1. Anesthesia for orthopaedic
replacement surgeries
Prof.Dr.K.BALAKRISHNAN,
Chennai.

2. Introduction
 Some of the common joint
replacement surgeries are
1. Hip replacement
2. Knee replacement
3. Shoulder replacement
4. Elbow replacement

5.  Total knee replacement (TKR)
and hip fracture coming for
replacement are the two most
common surgical procedures
after the sixth decade of life.

6.  Most of the patients have
degenerative joint disease,
commonly osteoarthritis (OA).

7.  Other conditions requiring knee
or hip replacement are injury to
the neck of femur or knee joint,
knee deformity, rheumatoid
arthritis and gout.

8.  Joint replacement is performed
to relieve pain and morbidity.

9. The challenge….
 Decreased organ function and
reserve
 Co-morbid conditions
 Consequences of polypharmacy

11. Challenges have been
converted into good
outcomes…
 Better understanding on
pathophysiology of aging
 Better pharmacotherapy
 Safer anaesthetic techniques
 Improvements in monitoring
 Multimodal analgesia and site
specific analgesia
 Physiotherapy and early
ambulation

12. Pain is the first enemy to
mankind….
And anaesthesiologists are
mankind’s guardian angels.

13. The straw that breaks the camel’s back may be
a very small one when the camel is nearing the
end of it’s journey !

14. Pre-operative concerns
 Associated injuries
 Cause for the fall
 Difficulty in assessing cardio
respiratory reserve
 Osteoarthritis- Medications-NSAIDs

15. Pre-operative
concerns….
 Pre-renal azotaemia
 DVT prophylaxis
 Diabetes Mellitus
 The emotional significance of
fracture to the geriatric patient must
also be considered.

16. Preoperative Preparation
 Evaluation of the functional
cardiovascular reserves may be
difficult due to the bedridden
state, the confusion
encountered, and the fracture.
Simple steps (e.g., auscultation,
ECG, and chest x-ray) can
detect acute decompensation.

17.  Echocardio­graphy if feasible at the
bedside and can give useful
information about left ventricular and
valvular function.
 Evaluation of electrolytes and blood
count is required; anemia or
electrolyte disturbances should be
addressed prior to anesthesia
induction.

18. Prophylaxis against DVT
 Prophylaxis against deep vein
thrombosis after lowerlimb joint
surgery is done with low
molecular weight heparin
starting either post operatively
or 12 hours preoperatively .

19. Intra-operative concerns
Regional

General anesthesia

20. The choice of anaesthesia is
determined by:
i) surgical factors
ii) Patients factors
iii) Estimates of risk associated
with anaesthesia techniques

21. Regional Anesthesia
-Advantages
 Stress response to surgery
 Intraoperative blood loss
 Post-operative hypoxia
 PONV
 DVT- early mobilization

22. Regional Anesthesia
-Advantages
 Preemptive analgesia
 Post-operative analgesia
Hypostatic pneumonia
Pressure sores

23. Centri Neuraxis Block - Concerns
•Coagulopathy
•Conscious sedation
•Shivering
•Technical difficulty
Autonomic dysfunction
-Hypotension
•I.V. fluids,
•vasopressors,
Diastolic pressure 60 mm Hg

24. Regional anesthesia
techniques
- Spinal
- Epidural anesthesia
- Combined spinal epidural
anaesthesia
- Femoral and Sciatic nerve blocks
(especially in patients with fixed
cardiac output in whom a neuraxial
block is not preferred due to possible
haemodynamic changes specifically
profound hypotension).

25.  The alternative option in fixed
cardiac output states include
segmental epidural, here the titrated
doses of local anaesthetic
administration and just blocking the
segments involved offers the benefits
of regional anaesthesia in critically ill
patients and at the same time
provides stable haemodynamics.

26. General anesthesia
-Pre-operative beta
blockade
 CAD
 Hypertension
 Diabetes mellitus
 Hypercholesterolemia
 Renal dysfunction
 Goal: Heart rate between 60-70.

27. General anesthesia
-Pre-Oxygenation
 100% Oxygen
 8 deep breaths
 Oxygen flow 10 L per min

28. General anesthesia
-Choice of Anesthetic
agent
Short acting and less lipid soluble drugs
• Propofol
• Fentanyl
• Rocuronium
• Atracurium
• Sevoflurane
• Isoflurane

29. Intra-operative monitoring
 Pulse Oximetry
 5 lead ECG-ST analysis
 Capnography
 NIBP- IBP
 Temperature
 Neuromuscular
monitoring
 Urine output

30. Blood Transfusion
Progressive
reaming of femur
and resection of
the condyles is
associated with
steady blood
loss

31. Bone Cement-
Hypotension
The placement of
the prosthesis
involve the use of
methylmethacrylate
( bone cement )

32.  The cementing can cause
hemodynamic fluctuations
 These fluctuations are related to
the vasodilatory and mast-cell
degranulating properties of the
monomeric form of
methylmethacrylate

33. Bone Cement
implantation syndrome
Bone cement implantation
syndrome (BCIS) is poorly understood.
It is an important cause of
intraoperative mortality and morbidity
in patients undergoing cemented hip
arthroplasty and may also be seen in
the postoperative period in a milder
form causing hypoxia and confusion.

34. implantation syndrome -
Treatment
BCIS may be reversible with prompt basic life
support and treatment to maintain both coronary
perfusion pressure and right heart function.
Administer fluid volumes to augment right
ventricular preload. Direct acting vasopressors,
such as phenylephrine and norepinephrine can
be titrated to restore adequate aortic perfusion
To improve ventricular contractility and function
administer inotropes such as dobutamine.

35. Fat embolism
 The high incidence of fat
embolism with femoral neck
fracture repair and cemented
endoprosthesis may contribute
to pulmonary dysfunction

36. Tourniquet in knee
replacement
Tourniquet inflation:
i) may precipitate heart failure
ii) may cause hypotension after release of
tourniquet
due to:
a) Release of acid products
b) Affected limb getting filled with blood
c) Blood loss

37. Post-operative care
 Immediate postoperative care
should be directed to supporting
oxygenation, controlling pain,
and facilitating the patient's
return to the baseline mental
status by emphasizing
orientation.

38. Post-operative concerns
Pain
Pain
Pain
Pain
Pain

39. Postoperative pain therapy is best a
multimodal approach.
- local anaesthetic infusions through
perineural catheters supplemented
with analgesics including a
combination of paracetamol, tramadol,
NSAID(when there is no
contraindication) and opioids.

40. PRINCIPLES
No.1: Start with low dose
Avoid long acting drugs
No.2: Use standing dose regimens
No.3: Repeated reassessment of pain relief
No.4: Repeated reassessment of side effects
No.5: Educate/inspire the care giver

41. Post-operative concerns
• Post operative delirium
• Post operative hypoxemia
• Hyponatremia
• Hypoglycemia

42. Early Mobilisation
Psychological support
Peri-operative Sepsis
Peri- operative Antibiotics

43. Conclusion
 Geriatric patients for joint
replacement surgeries offer a great
challenge to the anaesthesiologists.
 A careful preoperative examination,
preoperative optimization, safe
intraoperative anaesthetic
techniques, good postoperative pain
relief, good postoperative followup
with rehabilitation would aid in
decreasing the morbidity in these
patients.