Mod10: Orthopedic surgery - Surgery on the Lower Extremities Flashcards

1
Q

Surgery on the Lower Extremities - Surgery to the Hip and Femur

Hip fractures

Patient population/Pre-op considerations:

A

Elderly

Many patients are frail and elderly

Morbidity and mortality

Mortality rate following hip fx up to 10% during initial hospitalization

25% within one year following fx

Co-morbidities

Many have a number of co-morbidities (CAD, cerebrovascular disease, COPD, DM, OSA)

Dehydrated

Many are dehydrated from inadequate oral intake

Hemoconcentration can lead to a deceptively normal Hct or Hgb preoperatively

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2
Q

Surgery to the Hip and Femur - Anesthetic techniques

GA versus regional (SAB or epidural):

A

Should take into consideration the type of reduction and fixation to be used

This depends on fx site, degree of displacement, preoperative functional status of patient, surgeon preference

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3
Q

Surgery to the Hip and Femur - Anesthetic techniques

Regional (SAB or epidural) technique:

A

15 RCTs showed decreased in postop DVT and 1-month mortality with RA…but these benefits do not persist past 3 months

You can see less postoperative delirium and postop cognitive dysfunction with RA if you use minimal sedation with the regional technique

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4
Q

Surgery to the Hip and Femur - Anesthetic techniques

Spinal anesthesia

advantage/ best LA & their benefits:

A

A spinal or epidural, with or without GA, has the advantage of enhanced postoperative pain control

If you use a spinal, hypobaric or isobaric local anesthetics are ideal for positioning, since the patient can lie on the nonoperative hip for the placement of the SAB and the surgery​

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5
Q

Surgery to the Hip and Femur - Hip Arthroplasty

Longer, more invasive procedures

include:

A

Hemi-arthroplasties & Total Hip Arthroplasties (THA)

are long and more invasive procedures

usually done in lateral decubitus position.

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6
Q

Surgery to the Hip and Femur - Hip Arthroplasty

Blood loss:

A

Both hemiarthroplasties and total hip arthroplasties have greater blood loss

Can result in significant hemodynamic changes, especially if cement is used

Make sure you have large bore IV and type and cross preop

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7
Q

Surgery to the Hip and Femur - Hip Arthroplasty

OA, RA, avascular necrosis

important intubation conerns:

A

Most patients having a THR has OA, RA, or avascular necrosis

Mentioned RA before – discussed their limited cervical range of motion

Atlantoaxial subluxation can be diagnosed with x-ray and during intubation

This can lead to protrusion of the odontoid process into the foramen magnum

=> this can impede vertebral blood flow and compress the spinal cord and brain

Flexion and extension lateral radiographs of the c-spine in patients with severe RA should be obtained before surgery

=> these would be patients who have RA that is severe enough to require methotrexate, steroids, or immune therapy

If atlantoaxial instability is present –> need to intubate with inline stabilization using a Glidescope, c-mac, or fiberoptic laryngoscopy

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8
Q

Surgery to the Hip and Femur - Hip Arthroplasty

THA consists of several steps:

A

Femoral head is dislocated and removed

There is reaming of the femur and insertion of a femoral component into the femoral shaft

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9
Q

Surgery to the Hip and Femur - Total Hip Arthroplasty (THA)

Positioning

A

Lateral decubitus or supine

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10
Q

Surgery to the Hip and Femur - Total Hip Arthroplasty (THA)

Potential for complications:

A

Bone cement implantation syndrome

Hemorrhage

Venous thromboembolism

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11
Q

Surgery to the Hip and Femur - Total Hip Arthroplasty (THA)

Types of specific procedures:

A

Hip surfacing arthroplasty

Bilateral arthroplasty

Revision arthroplasty

Minimally invasive arthroplasty

Hip arthroscopy

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12
Q

Surgery to the Hip and Femur - Total Hip Arthroplasty (THA) - Types

Bilateral arthroplasty

how does procedure on 1st hip influence second procedure?

A

Second procedure can be done safely as long as there is no occurrence of significant PE after the first femoral component is inserted

Be sure to be in good communication with the surgeon

If there are significant hemodynamic changes or instability during first hip, then the second hip should be postponed

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13
Q

Surgery to the Hip and Femur - Total Hip Arthroplasty (THA) - Types

Revision arthroplasty

blood loss compared to original procedure:

A

Can have much larger blood loss than original surgery

Can also take longer than routine arthroplasty

Depends on a number of factors, including surgeon skill

Consider preop autologous donation; and intraop salvage techniques

Some studies indicate decreased blood loss during hip surgery if regional rather than general technique used

Exact mechanism is not clear

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14
Q

Surgery to the Hip and Femur​- Total Hip Arthroplasty (THA) - Types

Closed reduction of hip dislocation

can be accomplished with which type of anesthetic?

A

Usually can be accomplished with very brief anesthetic

Often induce with Propofol and mask patient with gas

May need to use Sux to facilitate reduction if hip musculature severely contractured

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15
Q

Surgery to the Hip and Femur

Total Knee Arthroplasty

Position/How is blood loss minimized?

A

Supine position

Blood loss usually minimized with use of TQ

Not all surgeons use a TQ

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16
Q

Surgery to the Hip and Femur

Total Knee Arthroplasty

Anesthesia Techniques:

A

GA

Neuraxial

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17
Q

Surgery to the Hip and Femur - Total Knee Arthroplasty - Anesthesia Techniques

GA with LMA or ETT

choice based on:

A

As always, make sure your patient is a candidate for LMA

Evaluate risk for aspiration

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18
Q

Surgery to the Hip and Femur - Total Knee Arthroplasty - Techniques

Neuraxial:

A

If cooperative, patients can tolerate neuraxial technique plus sedation

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19
Q

Surgery to the Hip and Femur - Total Knee Arthroplasty

Postop pain

Facilitated by preop placement of:

A

Lumbar epidural or Perineural catheter

Post-op pain is typically more severe than pain following hip arthroplasty

Effective postop analgesia facilitates early physical rehabilitation to maximize postoperative ROM and prevent joint adhesions following knee replacement

Need to balance pain control and patient comfort with the need for patient who is alert and cooperative enough to start their postoperative rehab program

Epidural analgesia is useful for those patient having bilateral knee replacements

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20
Q

Surgery to the Hip and Femur - Total Knee Arthroplasty - Postop pain

Lumbar epidurals vs Femoral perineural

for unilateral knee replacement, what’s the difference?

A

Lumbar epidurals and femoral perineural catheters provide equivalent analgesia!!!

Femoral perineural catheters produce fewer SEs (itching, N/V, urinary retention, orthostatic light-headedness)

21
Q

Surgery to the Hip and Femur - Total Knee Arthroplasty - Postop pain

PNB catheters

benefits/consideration/complications:

A

In RCTs with continuous PNB catheters that are used postoperatively to deliver a continuous perineural infusion of LA have been shown to decrease the time it takes to meet d/c criteria following a TKR

However, remember that the use of these continuous PNB catheters takes a team approach – all members of HCT need to be involves (PT, nursing, surgery)

Complications can occur, including the major complication of falling!

Need a plan in place for preventing falls in the postop period for patients with these catheters

Important education piece anytime any type of regional anesthetic technique is used

22
Q

Surgery to the Hip and Femur

Knee Arthroscopy

intensity/population:

A

Relatively minor procedure

Usually performed on outpatient basis

Often thought of as being young and healthy

Many of these patients are elderly and have multiple co-morbidities

23
Q

Surgery to the Hip and Femur

Knee Arthroscopy

Position:

A

Supine

24
Q

Surgery to the Hip and Femur - Knee Arthroscopy

Choice of anesthesia techniques:

A

GA or neuraxial

PNBs using LAs with or without adjuvants + IV sedation

25
Q

Surgery to the Hip and Femur - Knee Arthroscopy

PNBs types of injections:

A

Periarticular injections

=> infiltration of local anesthetics around the join

Intraarticular injections

=> instillation of LA into the joint

Intraarticular LAs (bupivacaine or ropivacaine) usually allow for effective postop pain control for several hours​

Adjuvants to LAs include clonidine, opioids, ketorolac, epinephrine, and neostigmine for intraarticular injections are used to increase the duration of the analgesia​

26
Q

Surgery to the Hip and Femur - Knee Arthroscopy

Neuraxial vs GA

which is better?

A

SABs and epidurals seem to have same amount of success and patient satisfaction

But in ambulatory setting, GA is likely preferred as the others can delay d/c home

27
Q

Surgery to the Hip and Femur

ACL Repair

procedure intensity compared to knee arthroscopy/population basis:

A

More extensive than knee arthroscopy

Outpatient procedure

28
Q

Surgery to the Hip and Femur - ACL Repair

Anesthetic techniques:

A

GA

Neuraxial

PNB

Lumbar plexus block

(psoas compartment block)

29
Q

Surgery to the Hip and Femur - ACL Repair - Anesthetic techniques

Lumbar plexus block

(psoas compartment block)

benefits/risks:

A

Combined with spinal or sciatic block dramatically decreases postop opioid requirements

Lumbar plexus block: also known as psoas compartment block; this is an advanced block technique

Because placement of needle is deep in muscles, there is greater risk for systemic toxicity than there is with more superficial techniques

Proximity of lumbar nerve roots to the epidural space also carries risk of epidural spread of the LA

30
Q

Surgery on the Lower Extremities

Anatomy of the Lumbar Plexus

How many nerves? where do they originate? what do they innervate?

A

Lumbar plexus consists of 5-6 peripheral nerves that have origins in spinal roots L1-L4

The roots divide into the anterior and posterior branches

Small posterior branches supply innervation to skin of lower back and paravertebral muscles

Anterior branches form the lumbar plexus within the substance of the psoas muscle and emerge from the muscle as individual nerves in the pelvis

31
Q

Surgery on the Lower Extremities

Indications for Lumbar plexus block

benefits/potential complications:

A

Surgery on hip - Anterior thigh - Knee

Provides anesthesia or analgesia to entire distribution of the lumbar plexus, including the anterolateral and medial thigh, the knee, and the saphenous nerve below the knee

When combined with sciatic nerve block, anesthesia of the entire leg can be achieved

Very complex technique involved

Potential for complication and existence of simpler alternatives, weigh risk vs. benefits of lumbar plexus block

32
Q

Surgery on the Lower Extremities

Continuous peripheral nerve block system that slowly infuses local anesthetic near a nerve for effective pain relief:

A

ON-Q Outpatient Pain Pump

Portable system that delivers LA to surgical site

Pump connects to a catheter that delivers LA to relevant peripheral nerves

Can be used for multiple days

Ideally can reduce use of narcotics

33
Q

Surgery on the Lower Extremities - Surgery to the<strong> Ankle</strong> and<strong> Foot</strong>

Anesthetic techniques:

A

MAC and local from surgeon

GA

Innervation of foot provided by

<strong>(1)<em> femoral nerve</em></strong> (via <u>saphenous</u> nerve) and

(2) <strong><em>sciatic nerve</em></strong> (via <em>posterior tibial</em>, <em>sural</em>, and d<em>eep peroneal</em> nerves)

Can use PNB at the upper leg, knee or ankle

Can us neuraxial technique for foot surgery

34
Q

Surgery on the Lower Extremities - Surgery to the <strong>Ankle </strong>and <strong>Foot</strong>

Considerations for technique selection

based on:

A

Selection of regional technique based on surgical site, use of calf or thigh TQ, degree of wt bearing or ambulation, and need for postoperative analgesia

For example, TQ inflation > 15 to 20 minutes requires GA or neuraxial technique

Long-acting local anesthetics and the addition of epinephrine or clonidine allow prolongation of postop analgesia

Additional onset time required for bupivacaine and ropivacaine, so may take longer for block to set up

35
Q

Surgery on the Lower Extremities - Postoperative Analgesia

Systemic analgesics:

A

Simple

Safe

Non-opioid analgesics

PCA

36
Q

Surgery on the Lower Extremities - Postoperative Analgesia

PCA (patient-controlled analgesia)

benefits/concerns:

A

Improved analgesia

Decrease in total opioid consumption

Increased patient/nurse satisfaction

Patient education is key

(not okay for family member to use device for patient)

37
Q

Surgery on the Lower Extremities - Postoperative Analgesia

Non-opioid analgesics:

A

IV acetaminophen, ketorolac, ibuprofen

Gabapentin, clonidine, ketamine, esmolol (delays metabolism of opioids), dexmedetomidine

Improves analgesia, as multimodal approaches are more effective

Avoids side effects of opioids (resp depression, n/v, pruritis)

38
Q

Orthopedic surgery - Microvascular Surgery

Microvascular surgeries

Two types:

A

Replantation

(reattachment of a completely severed body part)

Revascularization

(restoring blood flow thru the severed body part)

Most replantation surgery involves the upper extremity

39
Q

Orthopedic surgery - Microvascular Surgery

Improving blood flow

How?

A

Perfusion pressure

Blood flow may be improved by increasing the perfusion pressure, preventing hypothermia, and using vasodilators and sympathetic blockade

Microvascular perfusion pressure depends on both adequate intravascular volume and oncotic pressure; may consider colloid

Blood loss

Blood loss is often continual and insidious

Unrecognized bleeding and third-spacing both reduce perfusion pressure but don’t overcorrect with crystalloid

=> can cause generalized edema (including the replanted body part) AND excess administration of blood products can increase blood viscosity and decrease BF)

Phenylephrine (+/-)

Evidence suggests that using phenylephrine to support BP doesn’t jeopardize blood flow to the tissue being re-implanted

BUT <u>ALWAYS ask surgeon</u> their preference!!!

Body temp

Body temperature impacts blood flow

Avoid hypothermia, as it causes peripheral vasoconstriction, sympathetic activation, shivering, increased O2 demand, altered coagulation, leftward shift of oxygen-hemoglobin dissociation curve (so Hgb less likely to release O2 into the tissues)

Vasospasm

Antithrombotics, fibrinolytics, and smooth muscle relaxants used to preserve blood flow in microvascular anastomoses thus helping to prevent vasospasm

40
Q

Orthopedic surgery - Microvascular Surgery - Improving blood flow

Perfusion pressure:

A

Blood flow may be improved by increasing the perfusion pressure, preventing hypothermia, and using vasodilators and sympathetic blockade

Microvascular perfusion pressure depends on both adequate intravascular volume and oncotic pressure; may consider colloid

41
Q

Orthopedic surgery - Microvascular Surgery - Improving blood flow

Blood loss:

A

Blood loss is often continual and insidious

Unrecognized bleeding and third-spacing both reduce perfusion pressure but don’t overcorrect with crystalloid

=> can cause generalized edema (including the replanted body part) AND excess administration of blood products can increase blood viscosity and decrease BF)

42
Q

Orthopedic surgery - Microvascular Surgery - Improving blood flow

Phenylephrine (+/-)

A

Evidence suggests that using phenylephrine to support BP doesn’t jeopardize blood flow to the tissue being re-implanted

BUT ALWAYS ask surgeon their preference!!!

43
Q

Orthopedic surgery - Microvascular Surgery - Improving blood flow

Body temperature:

A

Body temperature impacts blood flow

Avoid hypothermia, as it causes peripheral vasoconstriction, sympathetic activation, shivering, increased O2 demand, altered coagulation, leftward shift of oxygen-hemoglobin dissociation curve (so Hgb less likely to release O2 into the tissues)

44
Q

Orthopedic surgery - Microvascular Surgery - Improving blood flow

Vasospasm:

A

Antithrombotics, fibrinolytics, and smooth muscle relaxants used to preserve blood flow in microvascular anastomoses thus helping to prevent vasospasm

45
Q

Orthopedic surgery - Microvascular Surgery - Anesthetic type

RA techniques:

A

RA techniques have several advantages

They provide sympathectomy => vasodilation to the proximal and increased BF

46
Q

Orthopedic surgery - Microvascular Surgery - Anesthetic type

GA

benefits:

A

GA ensures airway is secure AND more likely to keep patient from moving

47
Q

Orthopedic surgery - Microvascular Surgery - Anesthetic type

Combination of GA and RA

Benefits/concerns:

A

Prolong intraoperative anesthesia and postoperative analgesia

Reduces the amount of INH agent needed

Increases patient’s tolerance of long procedure

Regardless of technique, avoid anything that stimulates vasospasm or vasoconstriction (pain, hypotension, hypovolemia)

48
Q

Orthopedic surgeries

Positioning considerations associated with long surgical procedure

A