Orthopedics Hip and knee arthroplasty.pptx

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1. Anesthesia for Hip surgery Instructor: Adanech Shiferaw(BSc, MSc) College of medicine and health science Department of Anesthesia

2. Outline Objectives Functional Anatomy Introduction Anesthesia consideration for hip surgery Anesthesia for hip fracture Anesthesia for hip arthroplasty Summary 12/24/2023 Anesthesia for orthopedics surgery 2

3. Brain storming What are Geriatrics anesthesia challenges, concerns and anesthesia implications? Discuss the following Lumbar plexus Sacral plexus Lower extremity dermatomal distribution Femoral nerve block options Sciatic nerve block 12/24/2023 Anesthesia for orthopedics surgery 3

4. Functional Anatomy The innervation of the hip joint arises from both the lumbar and sacral plexuses . Hip Joint is innervated by: The nerve to the rectus femoris from the femoral nerve , Branches from the anterior division of the obturator nerve , and The nerve to the quadratus femoris from the sacral plexus 12/24/2023 Anesthesia for orthopedics surgery 4

5. Anatomy... 12/24/2023 Anesthesia for orthopedics surgery 5

6. Anatomy..... Femoral nerve: Innervate the anterior and lateral aspects of the hip capsule. Obturator nerve: Innervate the anterior and medial aspects Accessory obturator nerve : Supplies the inferomedial aspect of the hip capsule. 12/24/2023 Anesthesia for orthopedics surgery 6

7. A natomy... L ateral femoral cutaneous nerve (LFCN ): C utaneous innervation of the anterolateral S ciatic nerve and branches of the sacral plexus Innervated by posterior aspect of the hip joint 12/24/2023 Anesthesia for orthopedics surgery 7

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9. Introduction Common hip procedures performed in adults include: Repair of hip fracture, Total hip arthroplasty, and Closed reduction of hip dislocation . Studies have reported mortality rates following hip fracture of up to 10% during the initial hospitalization and over 25% within 1 year . 12/24/2023 Anesthesia for orthopedics surgery 9

10. Preoperative education and counselling Contributes to: Relieve anxiety and emotional stress before hip or knee replacement It may most benefit patients with depression, anxiety, unrealistic expectations, or those with limited social support Higher patient confidence, Greater patient satisfaction, and Early recovery and discharge 12/24/2023 Anesthesia for orthopedics surgery 10

11. Preoperative fasting and carbohydrate loading In addition to liberalized fasting guidelines, ERAS protocols recommend that patients consume up to 300 ml of a clear carbohydrate-rich drink 2–3h before surgery, with the goal of presenting the patient for surgery in a metabolically ‘fed’ state Prevention of PONV Postoperative nausea and vomiting (PONV) can be more distressing than pain 12/24/2023 Anesthesia for orthopedics surgery 11

12. Anemia and blood transfusion Preexisting anemia is common, and compounded by acute blood loss from the fracture and surgery. Anaemia can provoke organ ischaemia and delay functional recovery , particularly in frailer patients. However , transfusion is associated with well documented risks. 12/24/2023 Anesthesia for orthopedics surgery 12

13. Anemia and blood transfusion,... The Association of Anaesthetists guideline states that, Perioperative Hgb target of 9 g/dl should be adopted for frailer patients and Hgb 10 g/dl for patients with a history of ischaemic heart disease , or who are unable to mobilise because of fatigue or dizziness on the first postoperative day 12/24/2023 Anesthesia for orthopedics surgery 13

14. Blood conservation techniques Hypotensive epidural anaesthesia Minimizing operating time, Pharmacological interventions T he use of tranexamic acid . TXA considered in patients who are at higher risk of bleeding and complications of anemia . 12/24/2023 Anesthesia for orthopedics surgery 14

15. Avoiding cognitive complications Delirium affects 25% of people with hip fracture. It is an unpleasant experience ,with the potential for longlasting effects and mortality. The avoidance of brain hypoperfusion attributable to hypotension may have a protective effect. Avoid drugs that may worsen delirium 12/24/2023 Anesthesia for orthopedics surgery 15

16. Postoperative analgesia Elderly patients with hip fractures often possess comorbidities that increase the risks of complications when using NSAIDs and Opioids The use of peripheral nerve blocks for patients with hip fractures has the potential to reduce: Pain , Delirium , Respiratory complications, Hospital length of stay, and Healthcare costs. 12/24/2023 Anesthesia for orthopedics surgery 16

17. Postoperative analgesia.... Options for postoperative analgesic therapy : Patient-controlled epidural analgesia, Peripheral nerve block (either single injection or continuous), and Peri-articular injection/local infiltration analgesia. NSAIDs, acetaminophen are opioid sparing and promote efficient postoperative analgesia, but on their own are typically insufficient. 12/24/2023 Anesthesia for orthopedics surgery 17

18. Postoperative analgesia... A lumbar plexus block (LPB) or psoas compartment block is an anatomically deep block that provides a potent analgesic for hip surgery. Femoral nerve block (FNB) is a useful alternative ; however, quadriceps weakness may increase postoperative fall risk during rehabilitation 12/24/2023 Anesthesia for orthopedics surgery 18

19. Postoperative analgesia... The fascia iliaca compartment block (FICB), ( femoral nerve block and 3-in-1 block) Provide effective but incomplete analgesia in patients with hip fracture. This is because the innervation of the hip joint arises from both the lumbar and sacral plexuses . A multimodal strategy for analgesia is useful. 12/24/2023 Anesthesia for orthopedics surgery 19

20. Maintaining normothermia Maintaining perioperative normothermia with forced-air heating during total hip arthroplasty associated with: Reduced infection, Less cardiac complications, Reduced coagulopathy, and Reduced transfusion requirements. Lower intraoperative blood loss Reduced opioid need and Greater patient satisfaction 12/24/2023 Anesthesia for orthopedics surgery 20

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22. Preoperative Considerations The majority of hip fracture and arthroplasty patients are geriatrics and frail. Often presenting with comorbidities that are difficult to optimize. 12/24/2023 Anesthesia for orthopedics surgery 22

23. Preoperative Considerations Patients presenting with hip fractures are frequently dehydrated from inadequate oral intake . A normal or borderline low preoperative hematocrit may be deceiving when hemoconcentration masks occult blood loss. Another characteristic of hip fracture patients is the frequent presence of preoperative hypoxia 12/24/2023 Anesthesia for orthopedics surgery 23

24. Preoperative...frailty score The patient receives 1 point for each criterion met: •0-1 not frail •2-3 , intermediate frail (pre-frail) •4-5 , frail 12/24/2023 Anesthesia for orthopedics surgery 24

25. Intraoperative Management Study shows Regional anesthesia (MA and RCT) has: Decrease in postoperative DVT and Decreased 1-month mortality Lower incidence of postoperative delirium and cognitive dysfunction and Better postoperative pain control than GA . 12/24/2023 Anesthesia for orthopedics surgery 25

26. Intraoperative Management... Extra care should be taken when considering the impact of Regional Anesthesia: Sympathectomy and hypotension in patients with significant comorbidities , particularly severe aortic stenosis. Slow and controlled dosing through an epidural catheter can prevent rapid hypotension 12/24/2023 Anesthesia for orthopedics surgery 26

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28. Introduction Total hip replacement is a common orthopedic operation generally performed in elderly patients . The ends of the bones are covered with a layer of cartilage, which allows smooth movement. When the cartilage is damaged by arthritis , joints become stiff and painful . Joint replacement is performed to relieve pain and improve mobility . 12/24/2023 Anesthesia for orthopedics surgery 28

29. Introduction... Most patients undergoing total hip replacement suffer from: Osteoarthritis (degenerative joint disease), Autoimmune conditions such as rheumatoid arthritis Avascular necrosis. 12/24/2023 Anesthesia for orthopedics surgery 29

30. Introduction... Osteoarthritis It is a degenerative disease affecting the articular surface of one or more joints (most commonly the hips and knees). It may also involve the spine, Neck manipulation during tracheal intubation should be minimized 12/24/2023 Anesthesia for orthopedics surgery 30

31. Introduction... Rheumatoid arthritis: is characterized by immune-mediated joint destruction with chronic and progressive inflammation of synovial membranes RA is a systemic disease affecting multiple organ systems, not only joints 12/24/2023 Anesthesia for orthopedics surgery 31

32. RA... RA often affects the small joints of the hands, wrists, and feet causing severe deformity ; Intravenous and radial artery cannulation can be challenging . Hoarseness or inspiratory stridor Narrowing of the glottic opening caused by cricoarytenoid arthritis. Leads to postextubation airway obstruction TMJ limited mobility : intubation may be impossible 12/24/2023 Anesthesia for orthopedics surgery 32

33. RA... A tlantoaxial instability Atlanto-axial subluxation occurs in ~ 25% of patients with severe RA . Flexion and extension lateral radiographs of the cervical spine should be obtained preoperatively Excessive movement can result in cervical cord compression T racheal intubation with inline stabilization utilizing video or fiberoptic laryngoscopy 12/24/2023 Anesthesia for orthopedics surgery 33

34. RA... 12/24/2023 Anesthesia for orthopedics surgery 34

35. Cont... Renal function may be impaired due to age, hypertension or chronic use of non-steroidal anti-inflammatory drugs 12/24/2023 Anesthesia for orthopedics surgery 35

36. Intraoperative Management Total hip replacement (THR) involves several surgical steps:, Positioning (lateral decubitus position), Dislocation and removal of the femoral head, Reaming of the acetabulum and Insertion of a prosthetic acetabular cup (with or without cement), and R eaming of the femur and insertion of femoral head and stem into femoral shaft ( with or without cement). 12/24/2023 Anesthesia for orthopedics surgery 36

37. Intraoperative... THR is associated with three potentially life threatening complications: Bone cement implantation syndrome, Intra- and postoperative hemorrhage, and Venous thromboembolism . Thus , invasive arterial monitoring may needed 12/24/2023 Anesthesia for orthopedics surgery 37

38. Intraoperative... Position - commonly lateral There is a risk of excessive lateral neck flexion and pressure in the dependent limbs 12/24/2023 Anesthesia for orthopedics surgery 38

39. Choice of anesthetic Total hip replacement can be performed under general, spinal or epidural anaesthesia, and often a combination of techniques is used. There is no evidence of a difference in mortality between the techniques. However regional anaesthesia has significant advantages over general anaesthesia. 12/24/2023 Anesthesia for orthopedics surgery 39

40. Closed hip dislocation reduction There is a 3% incidence of hip dislocation following primary hip arthroplasty and a 20% incidence following total hip revision arthroplasty . Hip dislocations may be corrected with closed reduction facilitated by use of a brief general anesthetic and relaxant as indicated 12/24/2023 Anesthesia for orthopedics surgery 40

41. Summary 12/24/2023 Anesthesia for orthopedics surgery 41

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43. Out line Knee joint Anatomy/innervation Anesthesia for knee Arthroscopy Anesthesia for total knee Arthroplasty Post operative pain management Anesthesia for scoliosis 12/24/2023 Anesthesia for orthopedics surgery 43

44. Knee Joint Anatomy 12/24/2023 Anesthesia for orthopedics surgery 44

45. Knee... Knee innervation is obtained from branches from: F emoral, Obturator, and Sciatic nerves.  The femoral nerve supplies the anterior aspect of the joint. Obturator- medial aspect of knee joint Sciatic- posterior aspect 12/24/2023 Anesthesia for orthopedics surgery 45

46. Knee Arthroscopy Arthroscopy is a form of surgery used to diagnose and treat joint problems . 12/24/2023 Anesthesia for orthopedics surgery 46

47. Preoperative consideration In ASA I and II ambulatory patients its recommended to do: A routine preoperative visit, history and physical examination, Standard testing (as required per protocol) modified by medical conditions and age. Can be performed as Ambulatory/day case surgery 12/24/2023 Anesthesia for orthopedics surgery 47

48. Intra-operative Surgery begins with: The intra-articular insertion of two or more ports close to the patellar tendon. An irrigation system is then connected to the portals to improve intra-articular visualization and to wash debris and blood. To provide a bloodless field , a pneumatic tourniquet used on the thigh Surgery usually lasts less than 1 hour and is accompanied by little hemodynamic impact and fluid requirements . 12/24/2023 Anesthesia for orthopedics surgery 48

49. Intra-operative... Spinal anesthesia is one of the common anesthesia techniques for knee arthroscopy . It provides quick reliable, and profound anesthesia and short-term postoperative analgesia For fast recovery of the spinal anesthesia: Very low doses of long-acting local anesthetics (bupivacaine or ropivacaine, 4–9 mg) with or without opioids ( fentanyl ≤10 μg ) or Short-acting local anesthetics, such as lidocaine 12/24/2023 Anesthesia for orthopedics surgery 49

50. Intraoperative.... Intra-articular injections of local anesthetics S uccessfully used for short and purely diagnostic procedures with intravenous sedation. Peripheral nerve blocks can also be used alone or in combination with spinal anesthesia. Femoral nerve and lumbar plexus blocks are both suitable techniques for knee arthroscopy 12/24/2023 Anesthesia for orthopedics surgery 50

51. Postoperative Postoperative pain is better controlled with peripheral nerve blocks. Postoperative analgesia with continuous peripheral nerve blockades (CPNB) has been used , Particularly continuous femoral nerve block (CFNB). 12/24/2023 Anesthesia for orthopedics surgery 51

52. Anesthesia for total knee arthroplasty 12/24/2023 Anesthesia for orthopedics surgery 52

53. Anesthesia for total knee arthroplasty... TKA is indicated most frequently for patients with: Osteoarthritis , Rheumatoid arthritis, and Hemophilic arthropathy of the knee. TKA is associated with the highest DVT and PE incidence of all orthopedic procedures: Approximately (~ 80 % and 20%, respectively). 12/24/2023 Anesthesia for orthopedics surgery 53

54. Preoperative assessment The preoperative evaluation of these patients is similar to what is required for patients undergoing hip arthroplasty. TKA is considered an intermediate risk procedure . Emphasis should be placed on the cardiovascular and respiratory state, For Rheumatoid Arthritis patients, special focus on airway and cervical spine evaluation is advised. 12/24/2023 Anesthesia for orthopedics surgery 54

55. Anesthetic management TKA can be performed with general or regional anesthesia . Several studies have suggested lower mortality and morbidity after regional anesthesia Lumbar epidural anesthesia remains one of the preferred anesthetic choices. 12/24/2023 Anesthesia for orthopedics surgery 55

56. Anesthetic management.... Combined spinal–epidural anesthesia is common, It provide Fast onset , Adequate intraoperative anesthesia Profound motor block , and Excellent postoperative analgesia. 12/24/2023 Anesthesia for orthopedics surgery 56

57. Anesthetic management... Peripheral blocks are an alternative: But a challenging choice , requiring a motivated patient and an expert in regional anesthesia TKA takes approximately 1 to 3 hours Position is supine A thigh tourniquet is generally used, and intraoperative blood transfusion is rarely needed 12/24/2023 Anesthesia for orthopedics surgery 57

58. Anesthetic management... What are the Effect of tourniquet deflation???? What is the Complications of tourniquet? The patients are usually stable during surgery and before deflation of the tourniquet. 12/24/2023 Anesthesia for orthopedics surgery 58

59. Anesthetic management... Tourniquet may cause: Systemic effects due to ischemia and reperfusion, Local effects from the pressure applied to the tissues . Tourniquet injury is main cause for peroneal and tibial nerve palsies after TKA The incidence of tourniquet-induced paralysis is approximately 1 in 8000 operations. 12/24/2023 Anesthesia for orthopedics surgery 59

60. Anesthetic management... After cuff deflation, hemodynamic instability, bleeding, and hypoxia may occur 12/24/2023 Anesthesia for orthopedics surgery 60

61. Postoperative analgesia Continuous analgesic techniques have been preferred over single-shot peripheral nerve blockades . E pidural analgesia provides better coverage of the entire leg, But Compared to continuous femoral perineural analgesia, it has some disadvantages Disadvantages of epidural anesthesia?/ Side effects/ Complications of femoral block? 12/24/2023 Anesthesia for orthopedics surgery 61

62. Postoperative analgesia... Femoral nerve continuous catheters provide analgesia comparable to an epidural , with potentially fewer side-effects. Adductor canal block Adductor canal catheters and femoral catheters provide equivalent analgesia without quadriceps weakness . 12/24/2023 Anesthesia for orthopedics surgery 62

63. Postoperative analgesia... An adductor canal block anesthetizes the skin from the medial aspect of the leg and knee to the ankle joint and foot. The technique consists of: Injecting 10 mL of long acting LA(e.g., bupivacaine 0.25% or ropivacaine 0.5%) next to the femoral artery and around the saphenous nerve in the adductor canal.  12/24/2023 Anesthesia for orthopedics surgery 63

64. Adductor canal block 12/24/2023 Anesthesia for orthopedics surgery 64

65. Techniques of ACB Identify the femoral artery deep in the sartorius muscle. Identify the limits of the femoral triangle and adductor canal by scanning up and down until the medial border of the sartorius muscle meets the medial border of the adductor longus muscle. From this point, continue to scan distally until the adductor longus muscle becomes shorter and the artery is located in the middle of the sartorius muscle. This location is an adequate site for injection. 12/24/2023 Anesthesia for orthopedics surgery 65

66. Postoperative analgesia.... Combination of epidural analgesia with a single-injection nerve block for knee arthroplasty, Improve analgesia Reduced pain scores and improve physical therapy outcomes . 12/24/2023 Anesthesia for orthopedics surgery 66

67. Postoperative analgesia.... Adductor canal block combined with epidural analgesia: Provides analgesia similar to the combination of femoral nerve block plus epidural analgesia; With No quadriceps weakness FNB plus EA combination can limit rehabilitation and contribute to falls compared to ACB combined with EA. 12/24/2023 Anesthesia for orthopedics surgery 67

68. Postoperative analgesia... Local infiltration analgesia ( LIA) LIA is a recent technique for early postoperative analgesia after knee arthroplasty. It is administered by surgeons Provide 6–12 h of pain relief after knee arthroplasty 12/24/2023 Anesthesia for orthopedics surgery 68

69. Congenital orthopedic disorder 12/24/2023 Anesthesia for orthopedics surgery 69

70. Scoliosis Scoliosis is a lateral deviation of the spine by >10⁰ ( as defined by the Scoliosis Research Society) 70% of cases are idiopathic Occurs in up to 4% of populations. With male to female ratio of 1:4. (Ho R, Irwin MG,2018 ) 12/24/2023 Anesthesia for orthopedics surgery 70

71. Scoliosis… Severe scoliosis may result in Restrictive lung disease Scoliosis can also cause chronic hypoxia , hypercapnia , and pulmonary vascular constriction ; resulting in: Pulmonary hypertension 2ry to compression of pulmonary vasculature and arterial hypoxia. Cor-pulmonale and RHF 2 ◦ to restrictive lung disease 12/24/2023 Anesthesia for orthopedics surgery 71

72. Scoliosis… O ften associated with congenital heart conditions , including mitral valve prolapse, coarctation of the aorta, and cyanotic heart disease Surgery is indicated when Cobb’s angle is >40-50⁰ , The aim is to arrest the natural progression of the disease in order to prevent further cardio-respiratory deterioration Patients with evidence of pulmonary hypertension or severe cardio-pulmonary disease may require a pulmonary artery catheter. 12/24/2023 Anesthesia for orthopedics surgery 72

73. Scoliosis... Anesthetic considerations for surgical correction of scoliosis by spinal fusion and instrumentation include management of: Prone position, Hypothermia during long procedures with extensive exposure, and replacement of blood and fluid losses Adequate hemodynamic monitoring and venous access are essential. 12/24/2023 Anesthesia for orthopedics surgery 73

74. Intra-op considerations Patient positioning and its concern Concerns regarding conduct of Anesthesia Monitoring including neurophysiologic monitoring Bleeding and blood conserving mechanisms Pain management 12/24/2023 Anesthesia for orthopedics surgery 74

75. Patient positioning Common positions include: Prone Supine knee-chest and Lateral decubitus positions All of the major pressure points, including those of the face , eyes, chin, chest, limbs, iliac crests, etc., should be adequately padded . 12/24/2023 Anesthesia for orthopedics surgery 75

76. Discussion Considerations of prone position The effect of prone position on systems Interventions 12/24/2023 Anesthesia for orthopedics surgery 76

77. Considerations of the prone position Head, eyes and neck Maintain head and neck in a neutral position Pressure points, particularly over the ears, forehead and chin should be padded Eyes should be free of external pressure and closed to prevent corneal abrasions The ETT should be secured before turning prone 12/24/2023 Anesthesia for orthopedics surgery 77

78. ....Prone position Chest: Pressure points on the chest wall should be protected Reduced compliance of the chest wall may impair ventilation Abdomen: Organ dysfunction, epidural venous engorgement and increased bleeding Limbs: Careful positioning to avoid nerve injury Brachial plexus injury == Avoid excessive abduction (>90) Ulnar nerve injury == pad Elbows 12/24/2023 Anesthesia for orthopedics surgery 78

79. Monitoring Temperature monitoring is important , as hypothermia impairs spinal cord monitoring and coagulation. Invasive arterial BP monitoring may be considered for operations where considerable blood loss is anticipated, or duration of surgery is prolonged. Central venous catheter may be useful for monitoring fluid status and administration of drugs. A urinary catheter should be inserted and urine output measured. 12/24/2023 Anesthesia for orthopedics surgery 79

80. Neurophysiological monitoring Monitoring may reduce the incidence of motor deficits or paraplegia after scoliosis surgery from 3% - 7% to 0.5 %. There are three main methods of IOM: the wake-up test (if others are not available), somatosensory evoked potential (SSEP) monitoring, and motor evoked potential (MEP) recording . The spinal cord may be at risk if the amplitude of SSEPs are reduced to 50 % of baseline values. MEPs are generally described as being present or absent . 12/24/2023 Anesthesia for orthopedics surgery 80

81. Conduct of Anesthesia Cervical and thoracic spine surgery, performed under GA. For lower thoracic and lumbar spine surgery, either general or neuraxial anesthesia may be safely administered For prone approach, a reinforced endotracheal tube is safer 12/24/2023 Anesthesia for orthopedics surgery 81

82. Conduct of Anesthesia… Propofol-based TIVA is best ; Because it has the least effect on neuromonitoring. If MEP signals are also being monitored, muscle relaxation should be avoided as much as possible following intubation . Balanced multi-modal analgesic technique should be used. 12/24/2023 Anesthesia for orthopedics surgery 82

83. Blood loss Correction of spinal deformities can be associated with large intraoperative blood loss. A rare cause of bleeding during spine surgery is trauma to the aorta, vena cava, or iliac vessels . 12/24/2023 Anesthesia for orthopedics surgery 83

84. Blood loss… Measures to minimize blood loss and blood transfusion should be considered. Such as: Preoperative autologous donation, Proper positioning, Deliberate controlled hypotension Anti-fibrinolytic agents and TXA( Tranexamic acid) 12/24/2023 Anesthesia for orthopedics surgery 84

85. Specific complications Perioperative visual loss It usually presents as painless visual loss on awakening from anaesthesia It occurs in 0.03-0.2% of patients (rare) It can occur 2⁰ to central retinal artery occlusion (CRAO), ischemic optic neuropathy (ION) and cortical ischaemia Central retinal artery occlusion is caused by excessive mechanical pressure on the globe of the eye. 12/24/2023 Anesthesia for orthopedics surgery 85

86. Specific complications… Abdominal organ ischemia Excessive compression of the abdomen in the prone position may compromise BF to the abdominal viscera. result in ischemia and impaired function of the liver, pancreas and kidneys. Manifested by unexplained metabolic acidosis, rising lactate and cardiovascular instability. Management is mainly supportive and may require intensive care input postoperatively 12/24/2023 Anesthesia for orthopedics surgery 86

87. Specific complications… Airway complications Significant facial and airway edema may develop, due to prone position and the intraoperative administration of large volumes of intravenous fluid. Cervical spine surgery may result in local inflammation , edema and hematoma formation. risk of developing upper airway obstruction following extubation Endotracheal tube cuff-leak test may also be performed 12/24/2023 Anesthesia for orthopedics surgery 87

88. Specific complications... Venous air embolus (VAE) is a catastrophic event that is a particular risk during laminectomy because of: the large amount of exposed bone and location of the surgical site above the level of the heart. VAE presents as: unexplained hypotension with an increase in the end-tidal nitrogen concentration or a fall in the end-tidal carbon dioxide concentration . 12/24/2023 Anesthesia for orthopedics surgery 88

89. Specific complications... Prevention and management measures of VAE Intravascular volume expansion , Careful positioning, Positive end-expiratory pressure, and Jugular venous compression. 12/24/2023 Anesthesia for orthopedics surgery 89

90. Specific complications... Treatment of VAE Flooding the surgical site with saline, Controlling sites of air entry, Repositioning the patient with the surgical site below the right atrium, Aspiration of air from a multiorifice central venous catheter, Cessation of inhaled nitrous oxide, and Resuscitation with oxygen, intravenous fluids, and inotropic agents. 12/24/2023 Anesthesia for orthopedics surgery 90

91. Postoperative management Pain management A multi-modal approach is gold standard: local anesthetic infiltration, central neuraxial blockade, opioids, paracetamol , ketamine and adjuvant analgesics 12/24/2023 Anesthesia for orthopedics surgery 91

92. Postoperative management… Continuous epidural analgesia has been shown to provide superior analgesia with reduced opioid requirements compared to intravenous patient-controlled analgesia . Ketamine has also been shown to reduce opioid requirements and improve mood postoperatively . An intraoperative infusion of Dexmedetomidine improves the quality of recovery and reduces fatigue in the early postoperative perio d ( Roger Ho,2018 ) 12/24/2023 Anesthesia for orthopedics surgery 92

93. Summary Detailed preoperative assessment should be performed with an emphasis on Airway, Cardio-respiratory and Neurological systems. Any neurologic compromise should be assessed and recorded preoperatively A detailed informed consent regarding complications and outcome needed. Padding pressure areas during positioning is important to decrease injury Perioperative pain, temperature and fluid management should be our major concern. 12/24/2023 Anesthesia for orthopedics surgery 93

94. Reference Morgan 6 th edition Miller 9 th edition Barash 8 th and 9 th edition Essential Anesthesia Sommer M, de Rijke JM, van Kleef M, et al. The prevalence of postoperative pain in a sample of 1490 surgical inpatients. Eur J Anaesthesiol . 2008;25(4 ):267–274 . Ho R, Irwin MG, Anaesthesia for major spinal surgery, Anaesthesia and intensive care medicine (2018), https://doi.org/10.1016/j.mpaic.2018.01.012 12/24/2023 Anesthesia for orthopedics surgery 94

95. Question, Comment...??? Thank You!!! 12/24/2023 Anesthesia for orthopedics surgery 95