anesthetic considerations in orthopedic surgery.pptx

Anesthetic Considerations in Orthopedic Surgeries

1. ORTHOPEDIC SURGERY

2. Anesthesia for orthopedic trauma

3. Fat embolism syndrome –BJA 2021

4. BJA

5. BJA

6. BJA

7. 72-year-old female who presented to the Emergency Department following three weeks of worsening right hip pain, shortness of breath, and lower extremity edema. Her past medical history included hypertension, stage 3 chronic kidney disease, essential thrombocytosis progressing to myelofibrosis, osteoporosis, and hypothyroidism. Medications included anagrelide, aspirin, allopurinol, amlodipine, sevelamer, atenolol, levothyroxine, and alendronate. Vitals were stable except for hypertension (179/78 mmHg). Labs showed leukocytosis, elevated BUN and creatinine, high BNP, and troponin peaking at 598 ng/L; EKG was normal. MRI of the right hip without contrast revealed a pathologic basicervical hip fracture, extending into the femoral diaphysis with avascular necrosis

8. Patient received aspirin 325 mg, morphine 4 mg, and a heparin drip. Orthopaedic surgery and cardiology were consulted. Transthoracic echocardiogram showed normal left ventricular ejection fraction (LVEF) (60–65 %), Grade II diastolic dysfunction, severe left ventricular hypertrophy, moderate pulmonary hypertension, and mild-to-moderate tricuspid regurgitation (TR). Left heart catheterisation showed 50–70 % mid-LAD stenosis. Patient was cleared for surgery and designated as an “intermediate-high” risk. The anesthetic plan included general anesthesia with endotracheal intubation. A preoperative assessment revealed no complications from prior anesthesia for tubal ligations. Allergies included Ketorolac (anaphylaxis). Airway evaluation was unremarkable. The patient was ASA class IV and consented to right hip hemiarthroplasty with a long- cemented stem to bypass intramedullary lesions.

9. Preoperative medications included acetaminophen 1000 mg, gabapentin 300 mg, and labetalol 10 mg. Induction agents were midazolam 2 mg IV, fentanyl 25 mg IV, propofol 100 mg, and succinylcholine 60 mg. A phenylephrine infusion was initiated at 70 μg /min. Intubation was uneventful with a 7.0 cuffend a second large-bore peripheral intravenous catheter were placed.d endotracheal tube. A 20-gauge arterial line Following cement implantation, SBP dropped over 40 % from the starting pressure, meeting the criteria for Grade 2 BCIS. Consequently, the phenylephrine infusion rate was increased from 70 μ g/min to 90 μ g/ min, and two units of packed red blood cells ( pRBC ) were transfused. Despite these interventions, she continued to be unstable. A 9-Fr central venous catheter (CVC) was placed in the right internal jugular (IJ) vein, along with a Swan-Ganz, which reported pulmonary artery (PA) pressures of 70s/30s mmHg. In addition, a TEE was placed, indicating right ventricular (RV) failure and multiple pulmonary emboli (PE). As a result of the RV failure, the patient was started on a milrinone infusion at a rate of 0.5 μ g/kg/min.

10. Postoperatively, the patient remained intubated and was transferred to the intensive care unit (ICU). A chest computed tomography angiography (CTA) showed significant right upper and lower lobes pulmonary embolisms (PE). On postoperative day (POD) 1, patient remained intubated and on norepinephrine and milrinone drips. TTE showed hyperdynamic LV systolic function with LVEF >70 %, normal RV size and function, and moderate pulmonary hypertension. Milrinone and norepinephrine were weaned off as her pulmonary artery pressures decreased. By POD 2, patient was successfully extubated and transferred to the regular floor by POD 4. On POD 5, a pathology report from the right femur revealed a low-grade B-cell lymphoma with a pending subtype. On POD 14, the patient was discharged to a skilled nursing facility (SNF).

11. Discussion , conclusion The optimal anaesthetic technique for hip fracture surgery remains debatable. Studies show inconclusive results regarding mortality and outcomes. There is no consensus on the best anaesthetic method for hip arthroplasty to prevent the intraoperative frequency of BCIS Early detection and intervention are crucial in managing BCISThe severity of BCIS can range from hypoxia to cardiovascular collapse, necessitating immediate and appropriate interventions. The recommended approach involves treating cardiovascular collapse as RV failure with measures such as fluid administration, pulmonary vasodilators, inotropes, and alpha- adrenergic agonists. Preoperative assessment is vital for identifying high-risk patients, considering age, comorbidities, and medication history. Intraoperative monitoring should be comprehensive, addressing potential risk factors and ensuring hemodynamic stability.