anesthesia for orthopedic surgery อรุณชัย นรเศรษฐกมล
TRANSCRIPT
Anesthesia for Anesthesia for Orthopedic surgeryOrthopedic surgery
อรุ�ณชั�ย นรุเศรุษฐกมลอรุ�ณชั�ย นรุเศรุษฐกมล
ContentContent
General considerationGeneral consideration Age-specific orthopedic conditionsAge-specific orthopedic conditions Medical comorbiditiesMedical comorbidities Coexisting medicationCoexisting medication
Specific considerationSpecific consideration PositioningPositioning Bone cementBone cement Pneumatic tourniquetPneumatic tourniquet Fat embolismFat embolism Deep vein thrombosis & Deep vein thrombosis &
ThromboembolismThromboembolism
Age-specific orthopedic Age-specific orthopedic conditioncondition
Young adultYoung adult ACL reconstruction, Rotator cuffACL reconstruction, Rotator cuff
ElderlyElderly Hip, Knee arthroplastyHip, Knee arthroplasty Hip FractureHip Fracture
Children Children Congenital orthopedic surgeryCongenital orthopedic surgery
Medical comorbiditiesMedical comorbidities
Elderly patientsElderly patients Multiple organ dysfunctionMultiple organ dysfunction
Rheumatoid arthritisRheumatoid arthritis OsteoarthritisOsteoarthritis Ankylosing spondylitisAnkylosing spondylitis
Rheumatoid arthritis Rheumatoid arthritis problem should be awareproblem should be aware
Cervical spine instabilityCervical spine instability IV accessIV access Systemic involvementSystemic involvement Airway managementAirway management Spinal or epidural may be Spinal or epidural may be
difficultdifficult PositioningPositioning
Osteoarthritis
Joint usually involved in Osteoarthritis
Osteoarthritis ( OA)Osteoarthritis ( OA)problem should be awareproblem should be aware
Reduced joint movementReduced joint movement Airway managementAirway management IV accessIV access Spinal or epidural may be Spinal or epidural may be
difficultdifficult PositioningPositioning Concurrent analgesic therapyConcurrent analgesic therapy
Ankylosing spondylitis (AS)Ankylosing spondylitis (AS)problem should be awareproblem should be aware
Fix flexion deformityFix flexion deformity Regional anesthesia may be Regional anesthesia may be
difficultdifficult Abnormal spread of local Abnormal spread of local
anestheticsanesthetics
Coexisting medicationCoexisting medication
Antihypertensive drugsAntihypertensive drugs SteroidsSteroids AspirinAspirin NSAIDsNSAIDs Opioid analgesicsOpioid analgesics Immunosuppressive drugsImmunosuppressive drugs
Specific considerationSpecific consideration
PositioningPositioning
Supine Supine LateralLateral ProneProne Beach chairBeach chair Fracture tableFracture table
Why is positioning important?Why is positioning important?
Enable IV and catheter to remain Enable IV and catheter to remain patentpatent
Enable monitors to function properlyEnable monitors to function properly Facilitates the surgeon’s approachFacilitates the surgeon’s approach Patient safetyPatient safety
Supine Supine
Patient on backPatient on back Arms on arm boardsArms on arm boards
Arm < 90 degreesArm < 90 degrees Arm is supinated ( palm up)Arm is supinated ( palm up) Place padding under elbow if ablePlace padding under elbow if able
Arm tuckedArm tucked Check fingersCheck fingers Check IV lines and SaO2 probeCheck IV lines and SaO2 probe
LateralLateral
Body alignmentBody alignment Keep neck in neutral positionKeep neck in neutral position Always place axillary rollAlways place axillary roll Place padding between kneesPlace padding between knees Place padding below lateral Place padding below lateral
aspect of dependent legaspect of dependent leg
LateralLateral
Position arms to parallel to one Position arms to parallel to one anotheranother Place padding between arms or Place padding between arms or
place non-dependent arm on place non-dependent arm on padded surfacepadded surface
ProneProne
Face downFace down Head placementHead placement
Head straight forwardHead straight forward ET tube placement and patencyET tube placement and patency Check bilateral eyes/ears for pressure pointsCheck bilateral eyes/ears for pressure points
Head turnedHead turned Check dependent eye/ear, ETT placementCheck dependent eye/ear, ETT placement Be aware of potential vascular occlusionBe aware of potential vascular occlusion
ProneProne
Arm placementArm placement Tucked – similar to supineTucked – similar to supine AbductedAbducted
Check neck rotation and arm extension Check neck rotation and arm extension to avoid brachial plexus injuryto avoid brachial plexus injury
Elbow are paddedElbow are padded
Chest rollsChest rolls Iliac supportIliac support
Padding in placed under iliac crestsPadding in placed under iliac crests
Injury occuring from prolonged Injury occuring from prolonged positioningpositioning
Eye compression in prone Eye compression in prone positionposition
Skin breakdown due to Skin breakdown due to prolonged positioningprolonged positioning
Bone cement Bone cement Polymethylmethacrylate: Polymethylmethacrylate: MMAMMA
Bone cement implantation Bone cement implantation syndrome ( BCIS)syndrome ( BCIS)
Release of vasoactive and Release of vasoactive and myocardial depressant substancesmyocardial depressant substances
Intravascular thrombin generation in Intravascular thrombin generation in the lungsthe lungs
Direct vasoactive effects of Direct vasoactive effects of absorbed MMAabsorbed MMA
Acute pulmonary microembolizationAcute pulmonary microembolization
Clinical presentationClinical presentation
Fever Fever HypoxiaHypoxia HypotensionHypotension TachycardiaTachycardia DysrhythmiaDysrhythmia Mental status changeMental status change DyspneaDyspnea End tidal CO2 decreaseEnd tidal CO2 decrease Right ventricular failure and cardiac Right ventricular failure and cardiac
arrestarrest
ManagementManagement
Supportive careSupportive care Monitoring vital signsMonitoring vital signs O2 supplementO2 supplement IV fluidIV fluid VasopressorVasopressor
Pneumatic tourniquetPneumatic tourniquet
No more than 2 hoursNo more than 2 hours 100 mmHg above systolic blood 100 mmHg above systolic blood
pressurepressure 250 mmHg for arm250 mmHg for arm 350 mmHg for leg350 mmHg for leg
Pneumatic tourniquetPneumatic tourniquet
AdvantageAdvantage Eliminate intraoperative bleedingEliminate intraoperative bleeding
DisadvantagesDisadvantages Neurologic effectNeurologic effect Muscle changeMuscle change Systemic effects of the tourniquet Systemic effects of the tourniquet
inflationinflation Syeyemic effects of the tourniquet Syeyemic effects of the tourniquet
releaserelease
Neurologic effectsNeurologic effects
Tourniquet pain and Tourniquet pain and hypertension If > 45-60 minshypertension If > 45-60 mins
Neurapraxia if > 2 hoursNeurapraxia if > 2 hours Nerve injury at the skin level the Nerve injury at the skin level the
edge of the tourniquetedge of the tourniquet
Muscle changesMuscle changes
Cellular hypoxiaCellular hypoxia Cellular acidosisCellular acidosis Endothelial capillary leakEndothelial capillary leak Limb becomes colderLimb becomes colder
Systemic effect of tourniquet Systemic effect of tourniquet inflationinflation
Arterial pressure elevatedArterial pressure elevated
Systemic effect of tourniquet Systemic effect of tourniquet releaserelease
Transient fall in core temperatureTransient fall in core temperature Transient metabolic acidosisTransient metabolic acidosis Release of acid metabolites into Release of acid metabolites into
central circulationcentral circulation Transient fall in arterial pressureTransient fall in arterial pressure Transient increase in EtCO2Transient increase in EtCO2
PreventionPrevention
Select patients Select patients Wide, low-pressure cuffWide, low-pressure cuff Apply the lowest pressure to prevent Apply the lowest pressure to prevent
bleedingbleeding Limit time to 2 hoursLimit time to 2 hours Set maximum pressureSet maximum pressure
Arm 50-75 mmHg above systolicArm 50-75 mmHg above systolic Leg 75-100 mmHg above systolicLeg 75-100 mmHg above systolic
Adequate padding underneathAdequate padding underneath
Fat embolismFat embolism
The mechanical theoryThe mechanical theory The biochemical theoryThe biochemical theory
Clinical findingClinical finding
CardiovascularCardiovascular Persistent tachycardia, hypotensionPersistent tachycardia, hypotension
RespiratoryRespiratory Dyspnea hypoxia hemoptysisDyspnea hypoxia hemoptysis
CerebralCerebral Delirium stupor seizure comaDelirium stupor seizure coma
OphthalmicOphthalmic Retinal hemorrhageRetinal hemorrhage
CutaneousCutaneous petechiaepetechiae
OtherOther Jaundice feverJaundice fever
TreatmentTreatment
ProphylacticProphylactic Early stabilization of the fractureEarly stabilization of the fracture
SupportiveSupportive Respiratory careRespiratory care
Maximize O2, ventilationMaximize O2, ventilation Invasive monitorInvasive monitor
Volume statusVolume status Inotrope Inotrope High dose corticosteroidHigh dose corticosteroid
Deep vein thrombosis & Deep vein thrombosis & ThromboembolismThromboembolismlower extremities, pelvislower extremities, pelvis
Major pathophysiological Major pathophysiological mechanismmechanism Venous stasisVenous stasis Hypercoagulable stateHypercoagulable state Endothelial damageEndothelial damage
Risk FactorRisk Factor
ObesityObesity Age > 60 yearsAge > 60 years Procedure > 30 minsProcedure > 30 mins Use of tourniquetUse of tourniquet Lower extremities fractureLower extremities fracture Immobilization > 4 daysImmobilization > 4 days
PreventionPrevention
Prophylactic anticoagulantProphylactic anticoagulant Low dose heparinLow dose heparin WarfarinWarfarin LMWHLMWH
Intermittent pneumatic Intermittent pneumatic compressioncompression
Neuraxial anesthesia reduce Neuraxial anesthesia reduce thromboembolic complicationthromboembolic complication
Major orthopedic procedureMajor orthopedic procedure
Total hip replacementTotal hip replacement Fracture of the hipFracture of the hip Total knee replacementTotal knee replacement Spinal surgerySpinal surgery
Hip surgeryHip surgery
PatientPatient Limit ability to exerciseLimit ability to exercise Cardiovascular function can be Cardiovascular function can be
difficult to assessdifficult to assess Elderly with systemic disease, Elderly with systemic disease,
OA,RAOA,RA Blood lossBlood loss
Use of hypotensive technique or Use of hypotensive technique or reginal anesthesia reduces blood reginal anesthesia reduces blood lossloss
PositioningPositioning Mostly lateral decubitus positionMostly lateral decubitus position Ventilation perfusion mismatchVentilation perfusion mismatch Neurovascular problemNeurovascular problem
Potentially life-threatening Potentially life-threatening complicationcomplication
Bone cement implantation Bone cement implantation syndromesyndrome
Intra and postoperative Intra and postoperative hemorrhagehemorrhage
Venous thromboembolismVenous thromboembolism
Important factor of mortalityImportant factor of mortality
Very old ageVery old age Female>maleFemale>male Hip fractureHip fracture ObesityObesity SmokingSmoking MalnutritionMalnutrition Baseline cardiopulmonary functionBaseline cardiopulmonary function
Anesthetic concernsAnesthetic concerns
Invasive monitoringInvasive monitoring Blood lossBlood loss PositioningPositioning Cement fixationCement fixation Deliberate hypotensionDeliberate hypotension
GA or RAGA or RA
GAGA Decrease lung Decrease lung
functionfunction Depress coughDepress cough Increase Increase
secretionsecretion Depress cardiac Depress cardiac
functionfunction
RARA Reduce lung Reduce lung
complicationcomplication Reduce Reduce
thromboembolithromboemboli Reduce deliriumReduce delirium Reduce blood Reduce blood
lossloss
Revision hip arthroplastyRevision hip arthroplasty
Blood lossBlood loss Longer durationLonger duration Deliberate hypotension or Deliberate hypotension or
regional should be usedregional should be used
Total knee arthroplastyTotal knee arthroplasty
Preoperative considerationPreoperative consideration Same as THRSame as THR Severe rheumatoid arthritisSevere rheumatoid arthritis OsteoarthritisOsteoarthritis ObesityObesity comorbiditycomorbidity
Anesthetic managementAnesthetic management
ThromboembolismThromboembolism Fat embolismFat embolism CementCement Postoperative blood lossPostoperative blood loss Postoperative pain; more than Postoperative pain; more than
THRTHR