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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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slide2
Rheumatoid Arthritis
  • Total joint replacement
  • Total Knee replacement
  • The Patientswith a Hip Fracture
  • Anesthetic Technique
  • Scoliosis and Spinal Surgery
  • Regional Blocks
slide10
Most significant to anesthesiologist
    • changes that affect the airway
  • Tracheal intubation
    • Maybe difficult
  • Fiberoptic intubation
affectings the airway
Affectings the airway
  • Hypoplastic mandible
  • Receding chin
  • T-M jt. Ankylosis
  • Cricoarytenoid arthritis
  • Destructive change in jt. & ligament structure of C-spine
slide14
Subaxial subluxation
    • 15% displacement
  • Superior migration of the odontoid into the foramen magnum
caution
Caution
  • Procedure performed under general anesthesia
    • Avoid an aggressive jaw thrust that may cause excess neck motion
slide17
Providing 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
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
T.H.R. ( II )
  • Induced hypotension
    • Decreased blood loss
    • Diminish allogenic transfusion
    • Provide a dry surgical field & a dry cement-bone interface

⇒ 1970s ∼ 1980s

t h r iii
T.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 techniques

cementing i
Cementing ( I )
  • Cause – methylmetacrylate monomer
  • Complication
    • Fat & bone marrow embolement
    • Thromboplastic element
    • Air emboli

⇒ the more liquid,

the higher the incidence

cementing ii
Cementing ( II )
  • Higher risk patients
    • Hypertensive history
    • Hypovolemia
    • Preexisting cardiovascular disease
  • Cementing時
    • 100% supplemental oxygen should be administrated
post op t h r
Post-op T.H.R.
  • Intramuscular, intravenous PCA
  • Epidural narcotics

⇒ post-op pain relief

⇒ enhance rehabilitation

slide25
Performed 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 ↓
slide26
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 manage

predisposing factors
Predisposing 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
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
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
Proper Evaluation ( II )
  • Neurologic evaluation
  • Intravascular volume status
    • ∵ blood loss into the femur after fracture

→ result in significant hypovolemia

    • ∵diuretics medication pt. Pre-op

→severe

monitoring i
Monitoring ( 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 volume

monitoring ii
Monitoring ( 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
slide35
Many 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 & post-op concern
  • Positioning
    • Especially, perineal area
  • Post-op concern
    • Hypothermia
    • Neurovascular status
    • Pulmonary & cardiac state
    • Intravascular volume status
slide40
Provide
    • 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
slide42
Success rate improve

← Nerve stimulator use