Jeremy Rainey, OMS-IV

Total Hip Arthroplasty

Preoperative Considerations Most patients suffer from
Osteoarthritis RA (which carries important considerations for us) Avascular Necrosis

Rheumatoid Arthritis Immune-mediated joint destruction with chronic inflammation of synovial membranes NOT regular wear and tear Establishing venous access can be difficult in this population

Table 401. Systemic Manifestations of Rheumatoid Arthritis. Organ System Abnormalities

Cardiovascular Pericardial thickening and effusion, myocarditis, coronary arteritis, conduction defects, vasculitis, cardiac valve fibrosis (aortic regurgitation) Pulmonary Pleural effusion, pulmonary nodules, interstitial pulmonary fibrosis

Hematopoietic Anemia, eosinophilia, platelet dysfunction (from aspirin therapy), thrombocytopenia Endocrine Adrenal insufficiency (from glucocorticoid therapy), impaired immune system

Dermatological Thin and atrophic skin from the disease and immunosuppressive drugs

Rheumatoid Arthritis contd Exercise tolerance can sometimes not be assessed due to limited mobility Use Dipyridamole thallium scanning or dobutamine ECHO for evaluation Odontoid process protrusion
May be seen in severe cases Risk of vertebral circulation compromise during induction May compress spinal cord or brain stem

 If atlantoaxial instability exceeds 5mm, awake fiberoptic intubation should be used.

Postextubation airway obstruction is also of concern due to cricoarytenoid arthritis.

RA/OA patients commonly treated with NSAIDs

Can cause GI bleeding, renal toxicity, platelet dysfunction COX-2 inhibition gives pain relief and antiinflammatory properties COX-1 inhibition generally responsible for SEs

Intraoperative mgmt THR

Involves several steps:
Positioning- usually lateral decubitus

Dislocation of femoral head

Reaming of acetabulum Insertion of prosthetic acetabular cup (w/wo cement) Reaming of femur and insertion of femoral head/stem into femoral shaft

Three potentially dangerous complications

Bone cement implantation syndrome Hemorrhage VTE

Intraop mgmt THR

BCIS
characterized by hypoxia, hypotension or both and/or unexpected loss of consciousness occurring around the time of cementation, prosthesis insertion, reduction of the joint or, occasionally, limb tourniquet deflation in a patient undergoing cemented bone surgery Severity

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%) or unexpected loss of consciousness. Grade 3: cardiovascular collapse requiring CPR.

Intraop mgmt THR

Invasive monitoring generally recommended Prior to cementing, increasing FiO2 may decreased risk of VTE Neuraxial anesthesia helps decrease risks.
Neuraxial anesthesia alone or when combined with general anesthesia may reduce thromboembolic complications by several mechanisms. These include sympathectomy-induced increases in lower-extremity venous blood flow, systemic antiinflammatory effects of local anesthetics, decreased platelet reactivity, attenuated postoperative increases in factor VIII and von Willebrand factor, attenuated postoperative decreases in antithrombin III, and alterations in stress hormone release. Intravenous lidocaine has been shown to prevent thrombosis, enhance fibrinolysis, and decrease platelet aggregation

Epidurals, spinals may also be used as well as typical LCDs and anticoagulants.

Bilateral Hip Arthroplasties

Bilateral hip arthroplasties can be safely performed during one anesthetic, assuming the absence of significant pulmonary embolization after insertion of the first femoral component.
Look for a rise in pulmonary arterial pressure with unchanged pulmonary arterial occlusion pressure with falling heart rate

An increase in pulmonary vascular resistance reliably signals embolization

Pressures above (200 dyn x s x cm5) require contralateral surgery to be postponed. NOTE: Bilateral UNCEMENTED HAs dont require PA pressure monitoring. Consider epidural for post-op pain.

Revision Arthroplasty
In particular may be associated with moderate to severe surgical blood loss. Controlled HYPOtension combined with regional techniques may help decrease blood loss.
Thought behind this is redistribution of blood flow away from bone surface which improves prosthetic cementing and shortens duration of surgery. Autologous blood donation should be considered

High-dose aprotinin, a proteinase inhibitor of fibrinolytic activity and the intrinsic coagulation pathway by decreasing activation of plasminogen, may reduce intraoperative blood loss in patients undergoing revision surgery.
Does not seem to increase risk of PE/DVT

Can also give EPO (increases RBC production)

Minimally Invasive Arthroplasty

Development of MIT for cementless hip replacement. In some setting may allow for robotic assisted surgery.

Computer-assisted surgery improves surgical outcomes

Can construct 3D images of bone and soft tissue based of pt radiographs, CTs, etc.
Allows for improved preop planning and simulation

CAS allows optimal placement with great accuracy of implants

MIT may reduce hospital length of stay to 24h or less.

Minimally Invasive Arthroplasty

Anesthetic plans
Epidural anesthesia Propofol infusion LMA May eliminate the need for parenteral opioids intraop!

Premedication with oxycodone 10 mg (orally), valdecoxib 20 mg (orally), and acetaminophen 500 mg (orally). Versed 1-2 mg Antiemetic prophylaxis Lido 2% epidural provides surgical anesthesia (addition of catheter allows for addition administration) Postop pain handled with hydrocodone and acetaminophen and NSAIDs.

Closed Reduction Hip Dislocation

3% incidence of hip dislocation following hip arthroplasty 20% following total hip revision Reduced with CAS

Less force required to dislocated implant

OR staff needs to be aware of extremes of positioning

Gen Anesthesia via facemask or LMA is usually sufficient

Succinylcholine may provide facilitation

Propofol may be enough

Confirm reduction with X-ray

Knee Arthroscopy
Typically outpatient Athletes to the elderly Arthroscope used to evaluate conditions such as torn floating cartilage, surface cartilage, ACL reconstruction, trimming of damaged cartilage.
Joint not fully opened (yay MIT) Usually 2 incisions

Intraop mgmt Knee Arthroscopy

Use of pneumatic tourniquet helps to reduce blood loss Pt usually supine General anesthesia performed in a majority of cases with LMA. Neuraxial anesthesia also used Femoral nerve, lateral femoral cutaneous nerve, and sciatic blocks commonly used for post operative anesthesia of knee. Epidural and spinal anesthesia produce equivalent pt satisfaction
Though roughly 30% of patients will complain of back pain following these procedures

Postop Knee Arthroplasty

Recovery depends on.. Patient GETTING UP AND MOVING
Adequate pain relief and PONV control also appreciated Systemic ketorolac + intraarticular steroid injectios an option Of course neuraxial blocks

Total Knee Replacement

Patients are of similar population to those undergoing total hip replacement
RA, OA, etc.

Intraop mgmt Total Knee Replacement

Shorter than hip replacement Supine position Blood loss reduced by tourniquet use If cooperative, patients can generally tolerate regional blockade with intravenous sedation BCIS is less likely to occur, but risk following insertion of femoral prosthetic is possible.
This may exaggerate any tendency for hypotension following tourniquet letdown. MONITOR PAOP.

Consider placement of epidural catheter preoperatively. Knee procedures are typically much more painful than hip so addition of this may help to alleviate some postop pain and allow for more successful physical therapy earlier.
Especially useful for bilateral knee replacements

Intraop mgmg TKR

Epidural ropivacaine 0.2% at 5-10 mL/h
Good analgesia

Minimal motor blockade for 48-72 hours

Femoral sheath catheter may have fewer side effects than epidural

Partial Knee Replacement

Limited approach has reduced muscle damage, more suitable for early ambulation, and may allow for discharge as early as 24hrs postop.

Anesthetic approach same for total knee or hip.

Surgery on Upper Extremity

Shoulder
Subacromial impingement

Rotator cuff tears

Traumatic fractures Nerve entrapment (carpal tunnel, cubital tunnel) Joint arthroplasties (RA)

Shoulder Surgery
Can be open or arthroscopic Utilize beach chair position or lateral decubitus position Interscalene brachial plexus blockade is excellent for these procedures
Provides good postop analgesia Saves intense muscle relaxation commonly required if this blockade is not performed

Indwelling interscalene catheter can provide up to 48hrs of postop analgesia following major shoulder operations.
Ropivacaine 0.2% infused at 4-8 mL/h

 Ketorolac at the end of the procedure and w/in first 24hrs can reduce postop opioid requirements

SHHHHHI promise its your Dilaudid!

Hand Surgery
Carpal tunnel release
One of the most common operations in anesthetic practice

Intravenous Regional Anesthesia (Bier Block) is ideal

Tourniquet placed on proximal arm of extremity (double cuff) IV catheter introduced into dorsum of patients hand Arm exsanguinated Lidocaine injected into IV. Diffusion of anesthetic from vessels to nerve provides analagesia. Pins and needles sign most common pt report within 5 minutes, though commonly missed in current practice due to Versed administration. Careful release of tourniquet must be taken to avoid systemic toxicity, hematomas, extremity engorgement, or subcutaneous hemorrhage.

Brachial plexus block may be preferred for operations lasting 1h< General anesthesia with propofol, desflurane, and LMA may also be utilized.