10.1 Revision Hip + BCIS

Question 1

1. An 80-year-old patient is to undergo second stage revision of a total hip arthroplasty for treated deep
   joint infection.

a) Which specific preoperative considerations are relevant to this patient? (5 marks)

Answer 1

Treatment of infection:

> > Ensure adequacy of treatment by assessment of symptoms and signs of patient and by white cell count and CRP level.

> > Plan for perioperative antibiotics. Consider recent antibiotic treatment and causative agent. Liaise with microbiology.

Effects of chronic infection:

> > Check for anaemia and treat if necessary to reduce risk of need for perioperative blood transfusion.

> > Reduced mobility may have resulted in deconditioning. Early physiotherapy input should be planned.

> > Dietician input for nutritional assessment and management if weight loss has occurred or appetite compromised.

Advanced age of patient:
» Increased risk of comorbidities that will require assessment and management. Specifically assess for comorbidities such as respiratory disease, ischaemic heart disease, and valvular heart disease, which will
influence choice of anaesthesia.

Plan for postoperative care:
» Location dependent on discussion with surgeon regarding complexity of surgery, likelihood of blood loss, presence of comorbidities.

Question 2

b) Describe the important features of the intraoperative anaesthetic management of this case. (7 marks)

Answer 2

Risk of BCIS:
» Increased risk due to age and gender. Take steps to mitigate its effects,

Postoperative delirium:
» Increased risk due to patient age. Avoid long-acting sedative drugs.
Neuraxial or other regional techniques reduce need for long-acting opioid use

Deep vein thrombosis prophylaxis:
» Risks: elderly patient, lower limb orthopaedic surgery, prolonged duration of surgery. Mechanical prophylaxis intraoperatively and plan for mechanical and pharmacological prophylaxis postoperatively. Ensure adequate hydration.

Blood loss:

> > Ensure cross matched blood available.
Use cell salvage.
Ensure adequate starting haemoglobin.
Neuraxial technique.
Consider tranexamic acid use.
Invasive monitoring: arterial line and cardiac output monitoring.

Question 3

b) Describe the important features of the intraoperative anaesthetic management of this case. (7 marks)

Answer 3

Further risk of joint infection:
» Antibiotic prophylaxis as discussed in part (a).

> > Maintain normothermia.

Patient positioning:
» Elderly patient and prolonged surgery. Optimise pressure area care, padding of supports.

Risk of renal dysfunction:
» Risks: hypotension associated with blood loss and neuraxial techniques, as well as advanced age. Maintain adequate volume status, use vasopressor as directed by flow monitoring, avoid nephrotoxic drugs
including NSAIDs.

Duration of surgery:
» Spinal anaesthesia is commonly used for primary joint replacements but is unlikely to offer sufficient duration of anaesthesia for this operation.
» Prolonged period in lateral position may not be tolerated with combined spinal and epidural with sedation.
» A combination of general anaesthesia, sedation, combined spinal and epidural, and nerve blocks may be used.

Question 4

c) List the patient risk factors for bone cement implantation syndrome (4 marks)

Answer 4

Patient risk factors
» Increasing age.
» Significant cardiopulmonary disease.
» Diuretic treatment.
» Male gender.

Question 5

Steps that can prevent or minimise the effect of BCIS:

Answer 5

> > Avoid use of cement where surgically appropriate or where patient’s
physiological status dictates.
Communication: preoperative assignation of roles in the event of BCIS,
surgeon to inform anaesthetist before applying cement, anaesthetist to
acknowledge.
Surgical management:
• Wash and dry femoral canal.
• Apply cement in retrograde fashion using cement gun with a suction
catheter and intramedullary plug in the femoral shaft.
• Avoid vigorous pressurisation of cement in at risk patients.
Anaesthetic management:
• Ensure adequate resuscitation pre- and intraoperatively – aim for
blood pressure within 20% of pre-induction value.
• Monitor for cardiorespiratory compromise: blood pressure and etCO2
(if general anaesthesia).
• Prepare vasopressors in case of cardiovascular colla