Anesthesia for Major Orthopedic Surgery

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Anesthesia for Major Orthopedic Surgery. R3 이 재 우. Rheumatoid Arthritis Total joint replacement Total Knee replacement The Patients with a Hip Fracture Anesthetic Technique Scoliosis and Spinal Surgery Regional Blocks. Rheumatoid Arthritis. Generalized chronic inflammatory disease
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Anesthesia for Major Orthopedic SurgeryR3 이 재 우Rheumatoid Arthritis
  • Total joint replacement
  • Total Knee replacement
  • The Patientswith a Hip Fracture
  • Anesthetic Technique
  • Scoliosis and Spinal Surgery
  • Regional Blocks
  • Rheumatoid ArthritisGeneralized chronic inflammatory disease
  • Genetic-asso. With HLA DR4
  • Asso. with T-cell immune response
  • Recent also infection
  • Most significant to anesthesiologist
  • changes that affect the airway
  • Tracheal intubation
  • Maybe difficult
  • Fiberoptic intubation
  • Affectings the airway
  • Hypoplastic mandible
  • Receding chin
  • T-M jt. Ankylosis
  • Cricoarytenoid arthritis
  • Destructive change in jt. & ligament structure of C-spine
  • Three major anatomic alteration in the C-spine
  • subluxation
  • Subaxial subluxation
  • 15% displacement
  • Superior migration of the odontoid into the foramen magnum
  • Caution
  • Procedure performed under general anesthesia
  • Avoid an aggressive jaw thrust that may cause excess neck motion
  • Total joint replacementProviding on infection-free environment
  • Adequate monitoring
  • ECG II & modified V5
  • Pulse oximetry
  • During long bone reaming & jt. Cementing
  • ETCO2
  • Detect episode of fat and pul. Emboli
  • Arterial or central line(if necessary)
  • Urinary catheter(controversial)
  • Position時 careful !!!
  • T.H.R. ( I )
  • Spinal, epidural, GA may be used
  • Spinal & epidural Ane.
  • Drier surgical field with lower blood loss than GA
  • Decrease the incidence of deep vein thrombosis and thromboembolism
  • ⇒ preferred techniques !!!T.H.R. ( II )
  • Induced hypotension
  • Decreased blood loss
  • Diminish allogenic transfusion
  • Provide a dry surgical field & a dry cement-bone interface
  • ⇒ 1970s ∼ 1980sT.H.R. ( III )
  • Current methods
  • To avoid allogenic transfusion
  • Pre-surgical blood donation
  • Intra-op cell salvage
  • Post-op wound drainage devices
  • Acceptance of lower post-op Hct.
  • ⇒ decrease the requirement for aggressive hypotensive techniquesCementing ( I )
  • Cause – methylmetacrylate monomer
  • Complication
  • Fat & bone marrow embolement
  • Thromboplastic element
  • Air emboli
  • ⇒ the more liquid, the higher the incidenceCementing ( II )
  • Higher risk patients
  • Hypertensive history
  • Hypovolemia
  • Preexisting cardiovascular disease
  • Cementing時
  • 100% supplemental oxygen should be administrated
  • Post-op T.H.R.
  • Intramuscular, intravenous PCA
  • Epidural narcotics
  • ⇒ post-op pain relief ⇒ enhance rehabilitationTotal Knee replacementPerformed under tourniquet(TQ)
  • Intra-op pain
  • Manifest as heart rate ↑ & BP ↑
  • d/t A delta & C fiber firing
  • TQ release
  • May become hypotensive
  • Massive pulmonary embolism ↑
  • Return of acidotic products
  • ETCO2 ↑
  • Core temperature ↓
  • Spinal & epidural anesthesia
  • Excellent methods for TKR
  • Useful to administration narcotics and to infuse of local anesthetics via epidural catheter
  • GA
  • PCA
  • → best alternative for post-op pain manageThe Patientswith a Hip FracturePredisposing factors
  • Lower limb dysfunction
  • Visual impairment leading to a fall
  • Previous stroke
  • Parkinson`s disease
  • Use of long-acting barbiturates
  • Increasing age
  • Psychotropic medication
  • Dementia
  • Osteoporosis
  • Cold climate
  • The Time of Operation
  • Preferable as soon as possible after hip fracture(in healthy patients)
  • Correctable pre-op medical condition or comorbidity
  • ⇒ Delay !!Proper Evaluation ( I )
  • Important
  • Respiratory evaluation
  • Baseline PaO2– 70 mmHg range
  • PaO2 significantly ↓
  • Pul. Embolism may be occurring from fat or deep v. thrombosis
  • Cardiovascular evaluation
  • In general, recent myocardial infarction
  • : Trend toward earlier operation- Risk-benefit ratio of operation Proper Evaluation ( II )
  • Neurologic evaluation
  • Intravascular volume status
  • ∵ blood loss into the femur after fracture
  • → result in significant hypovolemia
  • ∵diuretics medication pt. Pre-op
  • →severeMonitoring ( I )
  • Same as the aboves
  • Low PaO2 level
  • Carefully pulse oximetry
  • (especially, femur reaming & cement insertion)
  • Urinary catheter – should !!!
  • U.O.
  • : valuable monitor of intravascular volumeMonitoring ( II )
  • CHF patient
  • Significantly dehydrated state d/t
  • Blood loss into the fracture
  • Continued administration of diuretics
  • Attempt to keep pt. Fluid restricted
  • Central venous & pul. a. pressure monitor
  • Anesthetic TechniqueMany physicians – regional : safer
  • Outcome studies
  • No differences
  • Motality, age, sex, type of fracture,Dementia
  • Determining anesthetic technique
  • Pt. Factor, duration of surgery, type of fracture → important role
  • Intertrochanteric Fx.
  • Blood loss ↑
  • Surgical times ↑
  • Positioning & post-op concern
  • Positioning
  • Especially, perineal area
  • Post-op concern
  • Hypothermia
  • Neurovascular status
  • Pulmonary & cardiac state
  • Intravascular volume status
  • Scoliosis and Spinal SurgeryRegional BlocksProvide
  • pre-op pain relief, anesthesia and analgesia
  • Intra-op, post-op pain relief
  • Choose the specific pph. N. block based on surgical site
  • Interscalene block- For shoulder surgery
  • Infraclavicular block- for surgery below elbow
  • Axillary block-for ulnar side of the hand
  • Success rate improve ← Nerve stimulator use
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