Total HIP

Question 1

Total hip replacement begins with positioning of the patient either.
L SFAP FTR

Answer 1

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

Question 2

After relocation of the new prosthetic hip joint and closure of the tissues, What is done next?

Answer 2

the patient may be given an abduction pillow to minimize the risk of dislocation. Mobilization takes
place over the ensuing days.

Question 3

Hip positioning

Answer 3

Position: Lateral decubitus for lateral or posterior approach use a beanbag or kidney rest (most common),
or Supine for anterior or anterolateral approaches

Question 4

CV concerns to THA
Most common population and their defect
CAT CC

Answer 4

Reumatoid arthritis (RA) is associated with pericardial thickening, cardiac valve fibrosis such as
aortic regurgitation, coronary arteritis, and cardiac conduction defects.

Question 5

Pt with RA concerns for Heart issues, Pt should

Answer 5

have ECHO if tamponade or cardiovascular disease is suspected and EKG in all RA patients.

Question 6

Another CV concern for RATx:

Answer 6

is bone cement implantation syndrome or BCIS from use of cement.

Question 7

Bone CEMENT IMPLANTATION SYNDROME Signs _

HHH AD

Answer 7

hypoxia(increased pulmonary shunt)
hypotension,
pulmonary hypertension (increase PVR)

arrhythmias (including heart block and sinus arrest), decreased cardiac output_

Question 8

Another intraop anesthetic concern other than CV and RESP

Answer 8

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.

Question 9

Resp: Pts undergoing total hip surgery often have RA and often have

Answer 9

pulmonary complications.

Question 10

RESP For hip, pt has RA what should you assess?

Answer 10

SOB on performing activities of daily living warrants assessment with PFTs.

Question 11

Common RESP issues with RA patients

Answer 11

Pulmonary effusions are common.
RA involvement of the cricoarytenoid joints may produce glottic narrowing, requiring smaller ETT, and
would manifest as hoarseness.

Question 12

Common airway issues with RA

Answer 12

Arthritic involvement of the TMJ limits mouth opening and may necessitate special techniques, like fiberoptic or glidescope for ET intubation.

Question 13

THA and Venous Air embolism: when is it a concern?

Answer 13

potential concern from air entering venous circulation with hip surgical site being above heart level.

Question 14

S/S of VAE (SIRI)

Answer 14

Sudden decrease in ETCO2,
Increase in PAP,
RV decrease in CO & BP
Increased dead space.

Question 15

Tx of VAE (FITLAPSA)

Answer 15

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.

Question 16

Neuro: Preop exam in RA reveals what?

Answer 16

ften reveals cervical nerve root compression.

Question 17

arthritis affects the pts ______ what test should be done? What is it assessing and you may need to do ?

Answer 17

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.

Question 18

Hip duration of surgery

Answer 18

Duration: 2-3 hrs

Question 19

EBL with hip

Answer 19

EBL: 250-750mL, potential for >1L

Question 20

Preoperative: .

Answer 20

Ancef 1-2 grams before incision, Versed 1-2mg unless contraindicated in older pts.

Question 21

THA PONV prophylaxis meds such as

Answer 21

Zofran 4mg, & dexamethasone 4mg

Question 22

How do you provide preemptive analgesia with

Answer 22

600mg Gabapentin
200mg Celebrex
1g Acetaminophen.

Question 23

Other pain management way for THA post op

Answer 23

Can do lumbar plexus block for pain

Question 24

Spinal option: OPTIMAL ANESTHETIC

.

Answer 24

12.5 –15 mg bupivacaine, 10–25 mcg of fentanyl and 100–200 mcg of morphine,

Question 25

If a spinal is done it will often be done

Answer 25

laterally while in the operating room.

Question 26

HOw should the patient be laying for the THA spinal anesthesia procedure?

Answer 26

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.

Question 27

Induction:

Induced

Answer 27

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).

Question 28

Maintenance:

Answer 28

standard maintenance.

Question 29

For maintenance NMBA facilitates the

Answer 29

placement and testing of prothesis.

Question 30

If NMBA monitor

Answer 30

TOF and Reverse pt. with

Question 31

Reversal dosing

Answer 31

neostigmine (0.5mg/kg IV) + glycopyrrolate (0.01mg/kg IV).

Question 32

Emergence for THA

Answer 32

_no special consideration

Question 33

THA how do you want the BP

Answer 33

Hypotension decrease BP 20%, decreases blood loss.

Question 34

THA and temp

Answer 34

Maintain normothermia with bairhugger and fluid

warmer.

Question 35

Post op issues with THA (PAC)

Answer 35

PCA with IV morphine or hydromorphone also
good option.
Acetaminophen (1g q 6 hr)
Celebrex (200mg/day).

Question 36

Full range of motion of the neck should be evaluated for

Answer 36

evidence of nerve root compression or cerebral

ischemia suggesting vertebral artery compression

Question 37

Cerebral ischemia mandates a

Answer 37

neurovascular evaluation to plan blood pressure management during
the case.

Question 38

Also potential for which nerve injury

Answer 38

sciatic nerve injury is evidenced by foot drop and inability to flex the knee

Question 39

Cementing time should be recorded in

Answer 39

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.

Question 40

THA If hypotension occurs use

Answer 40

alpha agonist – phenylephrine

for hypotension and aggressive fluid resuscitation

Question 41

Fat embolism – usually occurs

Answer 41

72 h following long-bone or pelvic fracture, with the triad of dyspnea, confusion, and petechiae.

Question 42

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,

Answer 42

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.