anaesthesia for replacement surgeries nitasha
TRANSCRIPT
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Anaesthesia for jointreplacement surgeries
Consultant:
Dr. Kajal jain
Presenters:
Dr. Sujith
Dr. Nitasha
Dr. Poorna
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Introperative anaesthetic concerns Patient position
Blood loss
Cement reactions
Thromboembolism
Use of tourniquet
Hypothermia
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Blood loss in joint replacement surgeries
High risk:
Total arthroplasties
Revision surgeries
Inexperienced surgeon
Bilateral knee arthroplasties Cementless hip replacements
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Blood loss can be minimised by:
Preop intraop postop
Bleeding history anaesthetic: regional anaes reduced phlebotomy
CBC, coagulation euthermia careful anticoagulat
Eliminate antiplatelet pharmacological: fibrin nutrition
Anticagualants bone wax, Adr sponges, thrombin
PAD systemic antifibrinolytics, wound
compression
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Options for blood management
Allogenic blood transfusion
Preoperative autologous blood donation
Salvage procedures
Acute normovolaemic hemodilution
Increase hemetopoeisis: iron/ erythropoeitin
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DVT AND PULMONARY EMBOLISM
Without prophylaxis 40-60% have DVT after THR , 60- 80% after TKR*
Rarely fatal PE
Pathophysiology( Virchows triad):
stagnant blood flow through veins
damage to vein walls
coagulation encouraged by the debris
Intraooperatively: 1. Activation of the clotting cascade occurs during
instrumentation of the medullary canal/ distal part of femur
2.Stasis in femoral venous flow: extremes of position
use of tourniquet
3.Endothelial injuiny during kinking of the femoral vein
Ref:Chest 2004;126;338S-400S
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Guideline recommendations
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Preoperative care:
1. All patients should be assessed preoperatively for elevated risk of PE( LOE III
B)
- hypercoagulable states
- H/O PE
2. All patients to be evaluated preoperatively for elevated risk of major bleeding(
III C) -h/o recent stroke
- recent gastrointestinal bleed
- bleeding diasthesis
Intraoperative care: 1. Patients should be considered for intra-operative and/or
immediate postoperative mechanical prophylaxis( LOE III B)
2. In consultation with the anesthesiologist, patients should be considered for
regional anaesthesia( LOE IIIC)
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Postoperative care:1 Post-operatively, patients should be
considered for continued mechanical prophylaxis until discharge to
home.( LOE IV C)
2. Post-operatively, patients should be mobilized as soon asfeasible to the full extent of medical safety and comfort( LOE VC)
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Chemopropylaxis:
1. Patients at standard risk of both PE and major bleeding should be
considered for one of the chemoprophylactic agents
a.Aspirin, 325 mg 2x/day (reduce to 81 mg 1x/day if gastrointestinal symptoms
develop), starting the day of surgery, for 6 weeks.
b. LMWH, dose per package insert, starting 12-24 hours post-operatively (or
after an indwelling epidural catheter has been removed), for 7-12 days .
c. Synthetic pentasaccharides, dose per package insert, starting 12-24 hours
postoperatively(or after an indwelling epidural catheter has been removed)
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Patients at elevated (above standard) risk of PE and at standard risk of major
bleeding should be considered for one of the following:
a. LMWH, dose per package insert, starting 12-24 hours post-operatively (or after an
indwelling epidural catheter has been removed), for 7-12 days
b. Synthetic pentasaccharides, dose per package insert, starting 12-24 hours
postoperativel(or after an indwelling epidural catheter has been removed), for 7-12
days
c. Warfarin, with an INR goal of 2.0, starting either the night before or the night after
surgery, for 2-6 weeks
Routine screening for DVT or PE post-operatively in asymptomatic patients is
not recommended
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Bone cement implantation syndrome
characterized by hypoxia, hypotension or both and/or unexpected loss of
consciousness occurringaround the time of cementation, prosthesis
insertion, reduction of the joint or, occasionally, limb tourniquet
deflation
Proposed severity classification
Grade 1: moderate hypoxia (SpO2,94%) or hypotension[fall in systolic
blood pressure (SBP) .20%].
Grade 2: severe hypoxia (SpO2,88%) or hypotension(fall in SBP .40%) orunexpected loss of consciousness.
Grade 3: cardiovascular collapse requiring CPR
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Risk factors
old age
poor preexisting physical reserve
impaired cardiopulmonary function,
pre-existing pulmonary hypertension
osteoporosis
bony metastases
concomitant hip fractures ,particularly pathological or inter
trochanteric fractures
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Aetiology and pathophysiology
Monomer mediated model: MMA monomer induced vasodilation
Emboli model: high intramedullary pressures
exothermic reaction
trapping air and medullary contents
temperature can increase as high as 96C 6 min after mixing the
components.
Hemodynamic effects: can embolise to lungs, heart and even coronary
and cerebral circulation in cases of paradoxical emboilsm
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Anaesthetic risk reduction
Proper preoperative assesment / evaluation /optimisation of co
morbidities
Discussion with surgeon regarding use of cemented prostheses
The anaesthetic technique and the type of prosthesis
avoidance of nitrous oxide
Increasing the concentation of inspired oxygen during cementation
Avoid intravascular volume depletion
invasive monitoring /CO monitoring
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Surgical risk reduction
Medullary lavage
Good hemostasis before cement insertion
Minimising the length of prosthesis
Use of non cemented prosthesis, venting the medullaion
Use of guns and retrograde insertion technique for cement insertion causes
even distribution of medullary pressure
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Management
Good communication b/w surgeon and anaesthetists
Clinical alerts: a fall in etCO2
Oesophageal doppler
Increase Fio2 to 100%
Inotropic support
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Hypothermia
Haemostatic mechanisms are reduced with old age;
anaesthesia-induced peripheral vasodilatation,
large wound surface area,
high-flow laminar theatre circulation systems,
major fluid shifts or
prolonged surgery.
Warmed fluids and use of hot air warmers desirable
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Use of tourniquet
Dr. Harvey Cushing ( 1904)
Provide bloodless surgical field but not without risks and complications
Application of tourniquet: The diameter of the cuff used should be wider than
half the diameter of the limb. It should be applied furthest away from the
surgical site and preferably over an area with the most fat and muscle padding.
Inflation pressures for lower limbs: at least 100 mm Hg above systolic
arterial blood pressure (usually 300500 mm Hg).
Inflation pressures for upper limbs: at least 50 mm Hg above systolic
arterial blood pressure (usually 250300 mm Hg
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Recommendations for time limit
varies from 30 minutes to 4 hours,
should be deflated after 2 hours for 1520 minutes
tourniquet should be used for only a further 60 minutes.
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Effects of tourniquet
During inflation
Cardiovascular effect:
circulating blood volume (up to 15%) and SVR (up to 20%).
bilateral simultaneous inflation - rise in CVP may cause volume overload
or even cardiac arrest.
Tourniquet pain A sudden heart rate and systolic and diastolic blood
pressures may occur after 3060 minutes
Haematological effects: 1. Systemic hypercoagulability. 2. deep vein
thrombosis
Metabolic effects: After 30 minutes, anaerobic metabolism occurs
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After deflation
Cardiovascular effect:1.During limb reperfusion, a transient decrease in
systemic vascular resistance accompanied by a compensatory increase in cardiac
index may occur. This avoids a severe decrease in mean arterial pressure.
2. Reactive hyper-reperfusion and vasospasm
Metabolic effects:
Increase in lactate and PaCO2
Decrease in pH.
Increase in plasma K+ level
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Post operative pain management
Analgesia: 1. Neuraxial techniques
2. Nerve blocks( single shot/ continous)
3. NSAIDS
4 systemic opoids( PCA regimen)
5. PCEA regimen
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Systemic opioids
Morphine : oral: 10-30 mg qid
:injection: 2- 15 mg sc/im/iv
Fentanyl : injection 50- 100 g/dose
transdermal: 25 g/hr q 72 hrs
tramadol : oral: 50- 100 mg qid
injection: 0.25 mg/kg iv
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PCA REGIMENS
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Dosing of neuraxial opioids
drugIntrathecal
dose
Epidural single
dose
Epidural
continous
infusion
fentanyl 5-25 g 50-100 g 25-100 g/hr
morphine 0.1- 0.3 mg 1-5 mg 0.1- 1 mg/hr
sufentanyl 2- 10 g 10- 50 g 10-20 g/hr
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Epidural dosing of local anaesthetics for postop
analgesia
Bupivacaine: 0.125-0.166% 5- 10 ml intermittent boluses or
continous infusion @ 5-12 ml/hr
Ropivacaine: 0.2% with infusion @4-6 ml/hr for 48 hrs
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Adjuvants
Clonidine:- Epidural: 75-150 g single dose in a 10 ml solution
containing 2mg of morphine and 0.125% bupivacaine
Intrathecal: 300-400 g
Dexmedetomidine: both sedation and analgesia
morphine sparing effect
0.2-0.7 g/kg/hr iv infusion
1g/kg in epidural analgesic mixture
- did not reduce the onset time, but produces a dense sensory and motor
block
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PCEA
Lower doses, greater patient satisfaction, lower incidence of S/E
Analgesic
solution
Continous rate
( ml/hr)
Demand dose
(ml)
Lockout
interval
(mins)
0.05%bupivac
aine+4/ml
fentanyl
4 2 10
0.0625%bupiv
acaine+ 5/mlfentanyl
4-6 3-4 10-15
0.1%bupivaca
ine+5/ml
fentanyl
6 2 10-15
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Analgesic
solution
Continous
rate
Demand
dose(ml)
Lockout
interval
( min)
0.2%
ropivacain
e+5g/ml
fentanyl
5 2 20
0.125%
bupivacain
e+ 0.5/ml
sufentanyl
3-5 2-3 12
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Hip and knee arthroplasty
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Anaesthesia for hip and knee replacement
Preoperative preparation
optimisation of co-morbidities
cross-matched blood .
deep vein thrombosis (DVT) prophylaxis
ensure appropriate timing of low-molecular-weight heparin.
Antibiotic prophylaxis (usually cephalosporin or aminoglycoside)
Invasive monitoring significant cardiac disease or large blood loss .
Large bore intravenous access (sited in the non-dependent arm for
laterally positioned patients).
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Anaesthetic technique
Regional anaesthesia is the technique of choice:
Reduces blood loss
improve cement bonding,
reduces surgical time
avoidance of airway compromise and cervical movement during
instrumentation
Decreases the incidence of DVT and pulmonary embolism
Improved postoperative analgesia
Enhanced early postoperative rehabilitation / improved outcome (especially
shoulder and knee arthroplasty)
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Reduction in the effects of general anaesthesia and systemic opioid
analgesia on pulmonary function
reduced incidence of PONV
It may avoid the need for endotracheal intubation and the consequent
vasopressor response
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Regional anaesthetic techniques
Lower limb surgery:
Central neuraxial blockade: 1. spinal
2. epidural
3. CSE
Peripheral nerve blocks:
- provide long lasting analgesia
- improved mobility
Disadvantage: may be more difficult to perform
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Peripheral nerve blocks for hip replacement
Lumbar paravertebral
Lumbar plexus block
Sciatic nerve block + lumbar plexus block
PERIPHERAL NERVE BLOCKS FOR KNEE
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PERIPHERAL NERVE BLOCKS FOR KNEE
REPLACEMENT
total knee arthroplasty severe pain :extensive osteotomy and quadriceps
splitting
Continuous peripheral nerve blocks provide the most effective and long-
lasting analgesia with fewer side effects when compared with PCA
morphine or continuous epidural analgesia
Blocks for TKR: 1. femoral nerve block
2. sciatic nerve block
3. obturator nerve block
4. lumbar plexus block
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Lumbar plexus anatomy
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Lumbar plexus block
Indications:
Hip, anterior thigh and knee surgery
Landmarks: iliac crest
spinous process
Needle insertion 4-cm lateral to the intersectionof landmarks 1 and 2
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Position:The patient is in the
lateral decubitus position with
a slight forward tilt
Needle insertion
:The needle is inserted at a
perpendicular angle to the
skin. The nerve stimulator
should be initially set to
deliver 1.5 mA current.
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Sciatic nerve block
- posterior( Labats approach)- classical technique
- anterior
- lateral
require adequate set-up
resists local anesthetic penetration,leading to longer block onset times
saphenous nerve block, either directly or via femoral nerve block ;complete anesthesia of the leg below the knee
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Landmarks for sciatic
nerve block
1Draw a line between the greater
trochanter to the posterior superior
iliac spine (PSIS).
2.Draw a second line from the
greater trochanter to the patientssacral hiatus (Winnies
modification).
3.Determine the point of initial
needle insertion by drawing a line
perpendicular from the midpoint of
the first line to its intersection with
the second
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Needles:
21-gauge, 10-cm insulated needle for themajority of patients. For
obese patients, 15-cm needles may be needed
18-gauge, 10-cm insulated Tuohy needle for catheter placement.
Insert catheters 5 cm beyond the needle tip.
Successful needle placement in proximity to the sciatic nerve is
observed with plantar flexion/inversion (tibial nerve) or
dorsiflexion/eversion (common peroneal nerve) with 0.5 mA or
less of current.
Local Anesthetic: In most adults, 20 to 30 mL of local anesthetic
is sufficient to block the plexus
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Studies of this posterior approach have demonstrated that plantar
flexion of the foot (tibial nerve stimulation) resulted in a shorter onset
time and more frequent success of the block versus dorsiflexion
(common peroneal nerve)
The posterior approach with the lumbar plexus block provides complete
anaesthesia of the lower extremity
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Anterior approach to sciatic nerve block
A 22 gauge 12- 15
cm needle is inserted
at the point of
intersection between
two lines
At this point it meets
lesser trochanter.
Paresthesias elicited
at a depth of 5 cm
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Alternative techniques to sciatic nerve block
Posterior approach in
supine Parasacral technique
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Femoral nerve block( 3 in -1 block)
Indications: anterior thigh and knee surgery
Landmarks: 1. femoral crease
2. femoral pulse
Euipments: 22G 5 cm needle
18G Tuohy needle for catheter placement
Local anaesthetic: 20-40 ml
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Pearls
Commonly the anterior branch of femoral nerve encountered first(
contraction of sartorius)
Needle redirected slightly laterally and with a deeper direction (
contraction of quadriceps)
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Shoulder arthroplasty
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Monitoring and intravenous access
Standard full patient monitoring attached
A large intravenous access taken
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Regional technique for shoulder arthroplasty
Interscalene block
Continous interscalene block( anterior and posterior
approaches)
Suprascapular block: mainly acts as a supplement to
general anaesthesia for postoperative pain
I l bl k S fi i l l d k
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Interscalene block Superficial landmarks
Position: place the patient supine
with head turned towards opposite
side
Technique: palpate C6 ( CRICOID).
Palpate SCM posterior border and
feel the interscalene groove at C6
level. EJV crosses at this point.
Insert needle posterior to it.
Needle: 22G 5 cm needle
Local anaesthetic solution: 30-40
ml
Goal : contraction of deltoid or
pectoralis major
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USG guide interscalene blocks
Probe: high frequency ( 5-12 Hz),
linear
Position: The oblique plane gives the
best transverse view of the brachial
plexus; Position the probe on the neck
at the level of C6
Approach. To use the
posterior approach, begin the needle
insertion at the lateral aspect of the
probe; . For the anterior approach,
insert the needle at the medial aspect
of the probe, taking care to avoid the
carotid artery and internal jugular vein
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Continous catheter techniques
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Drug delivery
Initial bolus:0.25ml/kg ropivacaine (0.5%) or bupivacaine
(0.5%) as a bolus injection for intra- and postoperative
analgesia if the block is combined with general anesthesia [3].
Solely given 0.5 ml/kg
Continous infusion: 5ml/hr of 0.25% ropivacaine or 0.25%
bupivacaine
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Suprascapular nerve block
The suprascapular nerve ( C5-C6) arises from the superior trunk of the
brachial plexus and supplies the posterior part of the shoulder joint
Acts as a supplement to general anaesthesia and reduces opioid
requirements
Technique: insert the needle 1cm above scapular spine parallel to the
vertebral spine until it contacts the vertebral spine near the suprascapular
notch. 10 ml of local anaesthetic solution is given as field block
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Postoperative analgesia
1. systemic opiates
2. intraarticular administration of opiates
3. regional analgesia: epidural catheter
interscalene catheter
suprascapular catheter
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Elbow arthroplasty
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Regional techniques for elbow replacement
BRACHIAL PLEXUS BLOCK
Anatomy : performed at the level of divisions where the plexus passes
between the clavicle and the subclavian artery
Indications: surgeries below the mid humerus
advantage: SPINAL OF THE ARM
Equipments: 1. USG machine- 8-12 Mhz
2. needles
3.local anaesthetic
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Landmarks for USG guided approach
The USG probe positioned in
the supraclavicular fossa,
pointing caudad, and moved
lateral
Once the subclavian artery is
visualized, the area lateral and
superficial to it is explored
until the plexus is seen, with a
characteristic honeycomb
appearance laterally and
medially
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Right supraclavicular plexus
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Infraclavicular block
The infraclavicular block is performed at the level of the cords of the
brachial plexus.
Indications: Elbow, forearm, hand surgery
It also provides excellent analgesia for an arm tourniquet.
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Superficial landmarks
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USG guided landmarks
Probe Position. The
parasagittal plane gives
thebest transverse view of
the brachial plexus
The needle is typically
inserted in-plane at the
cephalad (lateral) aspect of
the probe, and will bevisualized at the lateral
border of the axillary artery
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Hemophilia
Hemophilia is an X- linked recessive disorder
Occurs only in males, females act as carriers
Characterised by deficient factor VIII , IX
Classified in severity by the factor VIII levels
Normally 1U/ml= 100% of factor
Severe < 1%, moderate 1-4% , mild 4- 50%
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Anaesthetic concerns
High risk of hepatitis C,HIV
The need to avoid i.m injections
Problems of venous access
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Joint replacement surgery in hemophiliacs
indications contraindications
It is usually not recommended
until endstage, bone-on-bone
joint disease is present
degenerative disease that is
painful and may have
associated stiffness and
deformity, which is causing
functional impairmentt
presence of an active infection
AIDS and liver disease
A history of non-compliance
with recommended hemophilia
care may be a warning of an
unsuccessful outcome
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Preoperative assessment
To maximise the possibility of good outcome the patient should be seen
a minimum of six weeks before the scheduled procedure
Preoperative screening tests:
Inhibitor status
HIV antibody, viral load, and CD4 count
Hepatitis C and viral load
Fibrinogen, prothrombin time/INR, platelet count
Cardiopulmonary status
Inspection of venous access
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Choice of factor: Hemophilia A:
plasma derived or recombinant factor
Cryoprecipitate
Hemophilia B:
Purified factor IX containing product
APTT should be monitored after factor replacement
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Other blood support product
Intraoperative cell salvage procedures
Oral / iv iron replacement
Fibrinogen should be maintained above 150 mg/dl, INR< 1.5,and
platelets >50,000 for the first couple of days.
Vitamin K can be given to improve hepatic synthesis
Postoperative considerations
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Postoperative considerations
Pain Management:
Regional anesthesia with epidural catheters can be quite useful in the
first 24-48 hours after surgery. There is, however, a risk of spinal
/epidural hematoma
PCA Regimens
Surgical considerations: The drains are removed at 24 hours following
surgery,and the first dressing is changed at 48 hours
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thankyou
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