Anaesthesia for joint replacement surgeries

Consultant: Dr. Kajal jain

Presenters: Dr. Sujith Dr. Nitasha Dr. Poorna

Introperative anaesthetic concerns

Patient position Blood loss Cement reactions Thromboembolism Use of tourniquet Hypothermia

Blood loss in joint replacement surgeries

High risk: Total arthroplasties

Revision surgeries
Inexperienced surgeon Bilateral knee arthroplasties Cementless hip replacements

 Blood loss can be minimised by:

Preop Bleeding history CBC, coagulation Eliminate antiplatelet Anticagualants PAD

intraop postop anaesthetic: regional anaes reduced phlebotomy euthermia careful anticoagulat pharmacological: fibrin nutrition bone wax, Adr sponges, thrombin systemic antifibrinolytics, wound compression

Options for blood management

Allogenic blood transfusion Preoperative autologous blood donation Salvage procedures Acute normovolaemic hemodilution

Increase hemetopoeisis: iron/ erythropoeitin

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

Guideline recommendations

 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)

 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 as feasible to the full extent of medical safety and comfort( LOE VC)

 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)

 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

Bone cement implantation syndrome

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

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%) or

unexpected loss of consciousness.

Grade 3: cardiovascular collapse requiring CPR

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

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

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

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

Management

Good communication b/w surgeon and anaesthetists Clinical alerts: a fall in etCO2 Oesophageal doppler

Increase Fio2 to 100%

Inotropic support

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

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

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.

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

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

Post operative pain management

Analgesia: 1. Neuraxial techniques

2. Nerve blocks( single shot/ continous) 3. NSAIDS 4 systemic opoids( PCA regimen)

5. PCEA regimen

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

PCA REGIMENS

Dosing of neuraxial opioids

Intrathecal
dose

drug

Epidural single Epidural

dose continous infusion

fentanyl morphine

5-25 g 0.1- 0.3 mg

50-100 g 1-5 mg

25-100 g/hr 0.1- 1 mg/hr

sufentanyl

2- 10 g

10- 50 g

10-20 g/hr

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

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

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 0.0625%bupiv acaine+ 5/ml fentanyl 0.1%bupivaca ine+5/ml fentanyl

10

4-6

3-4

10-15

10-15

Analgesic solution

Continous rate

Demand dose(ml)

Lockout interval ( min) 20

0.2% ropivacain e+5g/ml fentanyl 0.125% bupivacain e+ 0.5/ml sufentanyl

3-5

2-3

12

Hip and knee arthroplasty

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).

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)

 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

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

Peripheral nerve blocks for hip replacement

Lumbar paravertebral

Lumbar plexus block

Sciatic nerve block + lumbar plexus block

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

Lumbar plexus anatomy

Lumbar plexus block

Indications: Hip, anterior thigh and knee surgery Landmarks: iliac crest spinous process Needle insertion 4-cm lateral to the intersection of landmarks 1 and 2

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.

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

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 patients

sacral 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

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

 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

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

Alternative techniques to sciatic nerve block Posterior approach in supine Parasacral technique

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

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)

Shoulder arthroplasty

Monitoring and intravenous access

Standard full patient monitoring attached

A large intravenous access taken

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

Interscalene block
Position: place the patient supine with head turned towards opposite

Superficial landmarks

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

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

Continous catheter techniques

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

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

Postoperative analgesia
1. systemic opiates
2. intraarticular administration of opiates
3. regional analgesia: epidural catheter interscalene catheter suprascapular catheter

Elbow arthroplasty

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

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

Right supraclavicular plexus

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.

Superficial landmarks

USG guided landmarks

Probe Position. The

parasagittal plane gives

the best transverse view of the brachial plexus The needle is typically inserted in-plane at the cephalad (lateral) aspect of the probe, and will be

visualized at the lateral

border of the axillary artery

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%

Anaesthetic concerns
High risk of hepatitis C,HIV The need to avoid i.m injections Problems of venous access

Joint replacement surgery in hemophiliacs

indications
It is usually not recommended

contraindications
presence of an active infection AIDS and liver disease A history of non-compliance

until endstage, bone-on-bone joint disease is present

degenerative disease that is

with recommended hemophilia care may be a warning of an unsuccessful outcome

painful and may have associated stiffness and deformity, which is causing functional impairmentt

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

 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

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
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

thankyou