Total HIP Flashcards
Total hip replacement begins with positioning of the patient either.
L SFAP FTR
Laterally or supine and making an incision over the hip.
Surgeon separates the muscles and ligaments to reach
the hip capsule.
Femoral head is dislocated and removed.
Acetabulum is reamed out to remove any damaged
bone
Prosthetic acetabular inserted with or without cement
Femur is then reamed out to accept a femoral component, which includes a femoral head and stem.
The femoral component is then inserted into the
femoral shaft, with or without cement
Range of motion is tested, and
placement is confirmed with an X-ray
After relocation of the new prosthetic hip joint and closure of the tissues, What is done next?
the patient may be given an abduction pillow to minimize the risk of dislocation. Mobilization takes
place over the ensuing days.
Hip positioning
Position: Lateral decubitus for lateral or posterior approach use a beanbag or kidney rest (most common),
or Supine for anterior or anterolateral approaches
CV concerns to THA
Most common population and their defect
CAT CC
Reumatoid arthritis (RA) is associated with pericardial thickening, cardiac valve fibrosis such as aortic regurgitation, coronary arteritis, and cardiac conduction defects.
Pt with RA concerns for Heart issues, Pt should
have ECHO if tamponade or cardiovascular disease is suspected and EKG in all RA patients.
Another CV concern for RATx:
is bone cement implantation syndrome or BCIS from use of cement.
Bone CEMENT IMPLANTATION SYNDROME Signs _
HHH AD
hypoxia(increased pulmonary shunt)
hypotension,
pulmonary hypertension (increase PVR)
arrhythmias (including heart block and sinus arrest), decreased cardiac output_
Another intraop anesthetic concern other than CV and RESP
Bleeding - Tranexamic acid 1-2 grams can be given intravenously or topically in the perioperative setting to
decrease blood loss and transfusion requirements. Also consider autologous blood transfusion depending
on preop Hgb level If < 12g/dL.
Resp: Pts undergoing total hip surgery often have RA and often have
pulmonary complications.
RESP For hip, pt has RA what should you assess?
SOB on performing activities of daily living warrants assessment with PFTs.
Common RESP issues with RA patients
Pulmonary effusions are common.
RA involvement of the cricoarytenoid joints may produce glottic narrowing, requiring smaller ETT, and
would manifest as hoarseness.
Common airway issues with RA
Arthritic involvement of the TMJ limits mouth opening and may necessitate special techniques, like fiberoptic or glidescope for ET intubation.
THA and Venous Air embolism: when is it a concern?
potential concern from air entering venous circulation with hip surgical site being above heart level.
S/S of VAE (SIRI)
Sudden decrease in ETCO2,
Increase in PAP,
RV decrease in CO & BP
Increased dead space.
Tx of VAE (FITLAPSA)
Flood area with saline
Inform surgeon,
Try to identify air entry, Try aspiration thru right atrial
catheter,
Lower preoperative sites if possible and support
hemodynamics with
Apply occlusive dressing to all bone edges
pressors and fluids, t
Stop nitrous if on and give 100% O2, and
Avoid PEEP.
Neuro: Preop exam in RA reveals what?
ften reveals cervical nerve root compression.
arthritis affects the pts ______ what test should be done? What is it assessing and you may need to do ?
spine,
lateral neck x-rays should be performed to determine the stability of the atlantooccipital stability
- may need to intubate with fiberoptic with decrease
ROM.
Hip duration of surgery
Duration: 2-3 hrs
EBL with hip
EBL: 250-750mL, potential for >1L
Preoperative: .
Ancef 1-2 grams before incision, Versed 1-2mg unless contraindicated in older pts.
THA PONV prophylaxis meds such as
Zofran 4mg, & dexamethasone 4mg
How do you provide preemptive analgesia with
600mg Gabapentin
200mg Celebrex
1g Acetaminophen.
Other pain management way for THA post op
Can do lumbar plexus block for pain
Spinal option: OPTIMAL ANESTHETIC
.
12.5 –15 mg bupivacaine, 10–25 mcg of fentanyl and 100–200 mcg of morphine,
If a spinal is done it will often be done
laterally while in the operating room.
HOw should the patient be laying for the THA spinal anesthesia procedure?
The pt should be laying broken hip down so the hyperbaric anesthetic can set during the block. During this time, sedation can be given with Propofol to help maintain pt. comfort during the procedure.
Induction:
Induced
monitors placed and standard induction on operating table (Fentanyl 25-50 mcg, Lidocaine 2%
1mg/kg, Propofol 2 mg/kg, and Succinylcholine 1 mg/kg if able to ventilate).
Maintenance:
standard maintenance.
For maintenance NMBA facilitates the
placement and testing of prothesis.
If NMBA monitor
TOF and Reverse pt. with
Reversal dosing
neostigmine (0.5mg/kg IV) + glycopyrrolate (0.01mg/kg IV).
Emergence for THA
_no special consideration
THA how do you want the BP
Hypotension decrease BP 20%, decreases blood loss.
THA and temp
Maintain normothermia with bairhugger and fluid
warmer.
Post op issues with THA (PAC)
PCA with IV morphine or hydromorphone also
good option.
Acetaminophen (1g q 6 hr)
Celebrex (200mg/day).
Full range of motion of the neck should be evaluated for
evidence of nerve root compression or cerebral
ischemia suggesting vertebral artery compression
Cerebral ischemia mandates a
neurovascular evaluation to plan blood pressure management during
the case.
Also potential for which nerve injury
sciatic nerve injury is evidenced by foot drop and inability to flex the knee
Cementing time should be recorded in
chart and communication at cementing time is crucial as prior to cementing, BP needs to be optimized,
FiO2 100% and pressure bags for fluids if needed.
THA If hypotension occurs use
alpha agonist – phenylephrine
for hypotension and aggressive fluid resuscitation
Fat embolism – usually occurs
72 h following long-bone or pelvic fracture, with the triad of dyspnea, confusion, and petechiae.
Treatment of Fat embolism
Fat embolism – usually occurs 72 h following long-bone or pelvic fracture, with the triad of dyspnea,
confusion, and petechiae. Treatment: stabilization and surgery on fracture, and also oxygen therapy
especially CPAP to prevent hypoxia, pressors for hypotension and vasodilators may help Pulm. HTN,
Stabilization and surgery on fracture
Oxygen therapy especially CPAP to prevent hypoxia Pressors for hypotension and vasodilators may help Pulm. Respiratory support, steroids are controversial, and heparin is not effective.
