DR.CHAVI SEHGAL ASSITANT PROFESSOR MLBMC JHANSI DR.ASHOK SINGH (JR)

CASE OF FRACTURE NECK FEMUR

HISTORY

*68 Year male with H/O fall 2 days back , H/O controlled hypertension for last 10 yrs taking Atenolol 25mg BD, Ecospirin 75 mg , Rosuvastatin 20 mg OD presents to ED

*Trauma was sustained by slipping in the bathroom which resulted in swelling of Rt. Hip area with excruciating pain , he was rushed to the casualty by his son within 1 hr of fall.

EXAMINATION & INVESTIGATIONS

*Patient conscious , B.P-170/100 mmHg,P.R-94/min, swelling in right lower extremity, Resp & CVS-WNL

*Inv-Hb-10gm/dl , TLC-10,400cell/mm3

*Platelet count -1.8 Lakh/μL , RBS-130mg/dl*Urea-60 mg/dl , creatinine-1.8mg/dl,*Na+ -134 Meq/L ,K+-4.2 Meq/L,*S.Albumin-3.9 mg/dl,*ECG-LVH(T-inversion v1-v4)*2D ECHO-diastolic dysfunction , EF-58%

Goals of management

*Immobilization at # site & prompt surgical fixation

*Two types of surgeries proposed- head conserving / replacement*Joint replacement - effective procedure for relief of disability d/t loss of function

*Growing demand , now performed as ambulatory Sx –’FAST TRACK SYSTEM’

PREOPERATIVE ASSESMENT

Patients posted for orthopedics with broad spectrum of problems Elderly /co-morbidities Young/associated

trauma

AGE IS NOT A DETERRENT FACTOR FOR SURGERY

Multidisciplinary approach is the key to handle ! Limited end organ reserve in elderly.

Age related osteoporosis

D/t high circulating PTH & low vitamin D , GHDisproportionate loss of Trabecular bone – high risk

for stress #- ( Minimal impact trauma)Bones at risk are-

Osteoarthritis M/CLoss of articular cartilage, inflammation.

C/F- pain, reduced mobility, deformed joints. Hands – swelling of -DIP (Heberden's nodes) - PIP (Bouchard's nodes).No systemic manifestationsImportant for surgical positioning of painful joints.

Rheumatoid ArthritisJoint synovitis - bone erosion, loss of joint integrity.

Systemic disease - exacerbations & remissions.C/F- pain/stiffness in multiple joints lasting >1 hr after

initiating activity.Boggy , tender joint

Patients on NSAIDs - assess for GI , renal C/CGlucocorticoids - need‘stress-dose’ for their operations.DMARD’S started early but risk of infection

ANKYLOSING SPONDYLITIS

Fusion of the axial skeleton- loss of spinal mobility.

Challenging airway -TMJ synovitis – limited MPG Damaged cricoarytenoid joints –narrow

glottis- interferes passage of ETT C-spine Arthritis - Flexion of head -Odontoid

process d/p into cervical spine- - Quadriparesis

Pre-op cervical flexion-extension radiographs required to plan for awake fiber-optic (AFOI)

Ossification of ligaments blocks access to CNB

Cardiovascular changes- Vascular – Atherosclerosis - SVR

Fibrotic myocytes - contractility. β-adr responsiveness -conduction delays, arrhythmias / ectopic LV SYSTOLIC/DIASTOLIC dysfunction coEXIST (HFpEF)

left ventricular compliance LVDP

Non compliant heart & blood vessels can neither tolerate hypovolemia nor exaggerated transfusion

! Consider fluid administration carefully!

RESPIRATORY Loss of elastic recoil. Barrel

Loss of height of the vertebrae/rib cage shaped chest.

Lung compliance early collapse of small airways air trapping. Chest wall compliance – work of breathing. Ventilatory responses to hypoxia, hypercapnia impaired.

Lung volume changes– Diffusing capacity , VC ,FEV1- TLC /FRC unchanged. RV - by 5% -10% / decade CC- with age & encroaches on FRCV/Q mismatch

Renal/Hepatic

STRUCTURAL- NephrosclerosisFUNCTIONAL- GFRNa+ handling, concentrating & diluting capacity – predisposes to dehydration and fluid overload.

STRUCTURAL- in liver size , hepatic blood flow 10%/decade

FUNCTIONAL-Phase I / Phase II metabolism slows down

Nervous

Aging causes memory decline to affect ADL Neuronal shrinkage & Neurotransmitters involved

COGNITIVE ISSUES

DEMENTIA-5-8% , >65 yrs Cause-ALZIEMERS with Agitation ,Depression ,Sleep changes DELERIUM- 10% , >65 yrs Fluctuating changes in level of consciousness accompanied by other mental symptoms

DEPRESSION-8-16%, >65 yrs

Ethical Issues-consent Diagnosis/Screening-NOT easy , use AD8

Questionnaire Informed consent- surrogate/Advanced directives Technique related -Patient co-operation is an issue for

R.A Pain management

FRAILITY

Refers to a loss of physiologic reserve that makes a person more vulnerable to disability during & after stress-(6.9%)

CRITERIA

Weight Loss   Exhaustion Physical Activity Walk Time Grip Strength

fatigue

Wt. loss

weakness

COMPONENTS

Investigations:Assessment of Co-morbidities

CBC- Hb / TLC / DLC / ESR / Platelet RBSCardiopulmonary - CX-R,PFTs, ABG, SPO2 , resting ECG - 2DEcho / Dobutamine stress tests Renal - Serum creatinine , Blood urea, - S.ElectrolytesMusculoskeletal Airway /Spine -Range of limb and neck movements Assessment for positioning on table and for regional blockade should be made

Risk(intermediate) Assessment

Done on factors:- (1) Age/comorbidity (2) Elective/ urgent (3) Blood loss /fluid shifts Risk more related with the presence of co-morbidities than with the age of the patient! Abnormal noninvasive cardiac testing pre-op rarely changes mx in orthopedic sx Morbidity not by coronary interventions. Restenosis is added risk if anticoagulants discontinued before sx

& peri-op bleeding if they are not stopped.

IDEAL TIME FOR SX

WHAT SHOULD BE DONE?*The answer is hemodynamic stress reduction*Use of β blockers should be continued /started in high risk patient {target H.R of < 80 bpm}

*Should be performed within 48 hours of admission* Optimization of co-morbidities should be done as early as possible, as delays morbidity

Preoperative PreparationPreoperative traction

O2 therapy - for first 48 hours , Hypoxemia!!Large bore I/V access (non-dependent arm for laterally positioned pt.) Cross-matched blood must be available DVT prophylaxis is required ( If CNB is planned )Antibiotic prophylaxisPrevention of pressure soresInvasive monitoring seldom indicated

INTRA OPERATIVE MANAGEMENT-THRAnterior / Lateral approach

*surgeons prefer lateral posterior approach , pt. in lateral decubitus position

*Compromises oxygenation-owing to V/Q mismatch *Prevent pressure on the axillary artery /brachial plexus by the dependent shoulder, place a roll /pad beneath the upper thorax

Techniques of Anesthesia

No anesthetic plan is superiorREGIONAL ANESTHESIA*Epidural space area *Permeability of duramater Dosage requirements of

* CSF volume anesthetics

* A given volume of epidural - more cephalic spread - shorter duration of block

RA-Advantages overweigh Disadvantages

ADVANTAGE DISADVANTAGE

1-MENTAL STATUS ASSESMENT 1-PATIENT REFUSAL

2- VASCULAR FLOW 2-SEDATION REQUIREMENT/O2

3- DVT( FIBRINOLYSIS) 3-HAEMODYNAMIC INSTABILITY

4- BLOOD LOSS(MAP-45-55 mmHg) 4-DELAYED ONSET

5- POCD (OPIOID SPARING), NO AIRWAY INSTRUMENTATION

5-EARLY WEARING OFF

6- POST OP ANALGESIA 6-MULTIPLE BODY REGION SX CANNOT BE DONE

7-EARLY MOBILIZATION

TYPES OF REGIONAL ANESTHESIA

*SUB ARACHNOID BLOCK(SAB)*EPIDURAL ANESTHESIA(EA)*CSE*PERIPHERAL NERVE BLOCKS(PNB) -For hip arthroplasty, 3-in-1 block (femoral/obturator /lateral cutaneous of thigh)

-A lumbar plexus block(LPB) also blocks the sciatic nerve, which has a component supplying the hip

SPINAL ANESTHESIA

*Profound block upto T-10 achieved by small amount of L.A*Main challenge is - control the intrathecal spread*Hyperbaric LA“sink” while hypobaric LA“swim” in a way that level of spread depends on interaction of density of LA with pt. posture

Midline approach/Sitting position-At L2-L3 interspace*3.5ml of 0.5% hyperbaric bupivacaine injected

Spinal anesthesia

Lateral position*When pt operated in lateral position S.A given with pt lying on their side in L2-L3 space (hip schedule for sx is upwards )

*hypobaric solution is created by adding 3.5ml isobaric bupivacaine + 1.5ml distilled water

EPIDURAL ANESTHESIA

*For EA ,sudden LOR as the needle passes through ligamentum flavum & enters the epidural space

*Introduce catheter with marked end in front through the Tuohy needle until the desired depth

*Catheter marking in cm-5.5-16.5(10.5cm- 2 ring,15.5cm-3 ring ,20.5cm-4 rings)

*Remove Tuohy needle holding catheter tightly

FEMORAL NERVE BLOCK

Nerve supply to hip joint -obturator, inferior /superior gluteal nerves Technique:1-Nerve stimulation Mark the inguinal ligament , Palpate FA about 2 to 3 cms below

Insert a 22 G , 3 inch needle perpendicular to skin lateral to FA and elicit paresthesias , Inject 10ml of L.A

USG GUIDED

*2-USG- USG transducer placed over inguinal crease , FA & FV visualized in C/S

*Just lateral to artery & deep to fascia iliaca FN appears as spindle shaped ’HONEY COMB’ texture

* Needle inserted lateral & cephalad to an angle of 450

* After careful aspiration 30-40 ml of L.A is injected

FASCIA ILIACA TECHNIQUE

*3-fascia iliaca technique- once inguinal ligament & FA identified , IL is divided into thirds,

*2 cm distal to the junction of the M2/3rd & L1/3rd, needle inserted in cephalad direction & 2 “pops” felt

* After careful aspiration 30-40 ml of L.A is given.

Lateral femoral cutaneous nerve block

*Patient positioned supine & a point 2 cm medial & 2 cm distal to ASIS is identified.

*A short 22 G needle inserted & directed laterally, observing for a “pop” as it passes through fascia lata.

*A field block is performed with 10-15 ml of L.A

Lumbar plexus block

* In Lat decubitus position palpate midline.* Draw a line through lumbar spinous processes & both

intercristal line identified & connected with a line at level of L4.* PSIS is then palpated & line is drawn cephalad parallel to 1st

line* A 10-15 cm needle is inserted at the point of intersection

between the transverse line & intersection of the lat & middle 3rd of the 2nd sagittal lines.

*Needle advanced (<3 cm past the depth at which transverse process contacted ) in an ant direction until a femoral motor response elicited (quadriceps contraction) & inject L.A

GENERAL ANESTHESIA ISSUESBALANCED GA WITH ETI-

Bleeding reduced by modest hypotensionDelayed Emergence from G.AMaintenance of Normothermia

ADVANTAGE DISADVANTAGE1-EARLY ONSET 1-AIRWAY INSTRUMENTATION2-AS LONG AS NEEDED 2-HAEMODYNAMIC ALTERNATION3-MULTIPLE SX AT 1 TIME 3-IMPAIRMENT OF NEURLOGIC

EXAMINATION4-PPV5-GREATER PT ACCEPTANCE

CONTROVERSY APOPTOSIS,APP GENE

Physiologic changes in elderly

Effect on pharmacokineticsPHARMACOLOGIC FACTOR

CHANGE WITH AGING IMPORTANCE

ABSORPTION GASTRIC PH GASTRIC EMPTYING ABSORPTION ABSORPTION SURFACE SPLANCHIC BLOOD FLOW

DISTRIBUTION BODY FAT VOD,LIPOPHILIC DRUGS

α1 GLYCOPROTEIN FREE FRACTION OF BASIC DRUGS

ALBUMIN FREE FRACTION OF ACIDIC DRUGS

BODY WATER CONC OF POLAR DRUGS

METABOLISM HEPATIC METABOLISM BIOTRANSFORMATIONELIMINATION GFR ELIMINATION ,pH &

ELECTROLYTE DISTURBSNCE

RENAL TUBULAR FUNCTION

Clinical Pharmacology of Anesthetic Agents in Elderly Patients

CHOICE OF ANESTHETIC AGENT

*Short acting & less lipid soluble drugs Propofol Fentanyl Rocuronium Atracurium Sevoflurane Isoflurane

INTRA OPERATIVE MONITORING

*SPO2, EtCO2, ECG, NIBP, Temp *Invasive arterial B.P monitoring-in pt with limited LVF/with massive blood loss

*CVP*Cardiac Output monitoring-is used to guide fluid therapy

*Cerebral O2 Saturation*Neuro muscular monitoring*Urine output

INTRA OPERATIVE PROBLEMS

Patient position: *In lateral position, risk of excessive lateral flexion/ pressure on

the dependent limbs Hypothermia: *Orthopedic O.T. colder, with a higher velocity airflow *Hypothermia causes poor wound healing , infection ,

coagulopathy Fluid warmers/blankets should be used routinely Blood loss: * Ranges from 300-1500 ml may double in the first 24 hours

postop *During TKR with an intra-operative tourniquet, most blood loss

occurs at recovery

Bone cement implantation syndrome

*Polymethylmethacrylate(PMMA) BCIS*Hypoxia, hypotension, unexpected LOC , cardiac arrest

occurs at time of cementation, prosthesis insertion, joint reduction, tourniquet deflation in a patient undergoing cemented bone sx

DEBRIS*Fat, marrow , cement particules , air , bone particules, & aggregates of platelets & fibrin

ETIOLOGY-Hypothesis1.Monomer absorbtion2.Embolisation - Cement undergoes exothermic reaction (72-120 0C) expands – intramedullary prdebris forced into circulation 3.Histamine release - type 1 hypersensitivity4.Complement factors – Anaphylatoxins

RISK FACTORS-

-Old age ,comorbidities,-Bony metastases,-Pathological #,-Intertrochanteric #

Risk reduction & Management*In high risk cases discuss risks-benefit of uncemented

/cemented arthroplasty* Avoid N2O & O2 concentration at the time of cementation

* PAC/TEE/Good haemostasis

* Medullary lavage* Venting the bone permits air to escape from the end of the cement plug

* If BCIS suspected, O2 concentration should be to 100% & continued in postoperative period

* Resuscitation with I/V fluids/Vasopressors/Inotropes

FAT EMBOLISM

*What are Fat Emboli? *Fat embolization and FES are not synonymous*FE-C/C of skeletal trauma/sx involving instrumentation of medullary canal

versus

*FES-physiological response to FE-multi system dysfunction (<1%)

*Onset within 24-72 hours, A/W long bone /pelvic #, > closed # Mortality: 10-20%

RISK FACTORS General factor- Males , 10-39 years Post traumatic hypovolemic state Reduced cardiopulmonary reserve Injury related factors- Multiple # , B/L femur #, lower extremity # Sx related factors- Intramedullary reaming/ nailing after femoral # , B/L procedure Joint replacement with high volume prosthesis

CLINICAL FEATURESTriad of- Dermatological Signs(rash)

Pulmonary Dysfunction Neurological (nonspecific)

(hypoxemia)-75%

Diagnostic Criteria

GURD’S CRITERIAMajor Features (at least 1)   *Respiratory insufficiency  *Cerebral involvement  *Petechial rashMinor Features (at least 4)   *Pyrexia ,Tachycardia ,Jaundice   *Retinal , Renal changesLaboratory Features   *Fat Microglobulinemia  *Anemia , Thrombocytopenia ,High ESR

Schonfeld Fat Embolism Syndrome Index

Sign ScorePetechial rash 5Diffuse alveolar infiltrates 4Hypoxemia -PaO2< 70 mm Hg 3Confusion 1Fever >38°C (>100.4°F) 1H.R >120 beats/min 1R.R > 30 / min 1

Score > 5/16 required for diagnosis of FES

Treatment & Management.

ProphylaxisImmobilization - Early fixationSupportive Medical Care*Maintenance of adequate oxygenation , ventilation*Maintenance of hemodynamic stability*Administration of albumin/blood products*Use of steroids controversial!*Prophylaxis of DVT*Heparin/LMW dextran/Ethanol

VENOUS THROMBOEMBOLISM

What is DVT? Clot in deep veins of the legs!

C/F- pain , swelling , tenderness, discoloration of surface veins

Adapted from: Greer IA. Bailliere’s Clin Obstet Gynaecol 1997;11:403-30.

Risk of DVT & PE : by several factors

Factors intrinsic to the patient

Factors related to underlying disease or

medical condition

Factors introduced by medical or surgical

treatment• Age• Obesity• Immobility• History of thrombosis• Thrombophilia

• Varicose veins• Venous insufficiency• Pregnancy• Trauma• Heart failure/MI• Malignancy

• Concomitant medication• Chemotherapy• Orthopaedic surgery• Major surgery• Caesarean section

PULMONARY EMBOLISMOccurs when blood clot breaks loose / travels to the lungs

C/F -shortness of breath, sharp rib/chest pain , occasionally hemoptysis, light-headedness, or collapse

Pt. with symptomatic PE have 18-fold higher risk of death than

with DVT alone

DiagnosisHISTORY/EXAMINATION

CHEST X-RAY/ECG/D-dimersDUPLEX ULTRASOUND/VENOGRAPHYSpiral CT chest/V:Q scan /Pulmonary Angiogram

COMPLICATIONS OF DVTShort-term- Prolonged Hospitalization, Bleeding C/C, Local extension, Long-term-Post-Thrombotic Syndrome, PHTN ,Recurrent DVT

Most hospitalized patients with DVT will

have NO SYMPTOMS or SIGNS!

Risk of VTE in Hospitalized Pt.

Geerts WT, et al. Chest 2008;358:381S-453S.

Patient Group DVT Prevalence (%)Medical Patients 10-20

General Surgery 15-40

Major Gynecologic Surgery 15-40

Major Urologic Surgery 15-40

Neurosurgery 15-40

Stroke 20-50

Hip and Knee Arthroplasty, Hip Fracture Surgery

40-60

Major Trauma 40-80

Spinal Cord Injury 60-80

Critical Care Patients 10-80

ProphylaxisMUST be given to all elderly pt under going orthopedic procedures confined to bed > a dayMechanical--Compression stockings-Intermittent pneumatic compression devices-IVC filters

PHARMACOLOGICAL

1. Antiplatelet (aspirin 50-100 mg/d)2. Coumarins (Warfarin)-Adjusted-dose started

preop or evening after sx (INR target-2.5 )3. UFH-5000 U S/C 8 hrly (monitor ApTT)4. LMWH (Enoxaparin)- started 12 hr before sx

or 4-6 hr after sx-40 mg S/C OD5. Fondaparinux (Factor Xa Inh)-2.5 mg OD S/C6. XIMELAGATRAN (DTI)-36 mg BD( oral)

NICE Guidelines - 2016

1-Anticoagulant -prophylaxis & treatment of DVT

LMWH - recommended over UFH (IV/SC) for initial therapy - do not require monitoring of coagulation - efficient when started preoperatively but risk of bleeding - continued for at least 10 days in LOW risk & extended to 28 to 35 days in high risk

2-Thrombolytics - severe, possibly fatal PE

ASRA - recommendations regard to use of anticoagulants & RA

Antiplatelet’s• Low dose aspirin / NSAID’S -No restriction • Clopidogrel/Ticlopidine- stop 7-10/14 days

respectively prior & continue 2 hrs after EC removal

• Tirofiban/Eptifibatide-stop 8 hr prior• Abciximab-stop 24-48 hr priorLMWH• An interval of 12 hrs after administration of usual

dose of LMWH and placement of CNB • With larger doses of LMWH - delay should be

extended to 24 hours • EC removal at least 8-12 hrs after last LMWH

dose, or 1 to 2 hrs before the next

recommendations regard to use of anticoagulants

& RA UFH S/C - No C/I If total daily dose <10,000 UUFH I/V- Delay CNB 2-4 hrs after last dose monitor ApTT

restart 1 hr after procedureWarfarin-Discontinue 4-5 days before CNB-Evaluate INR(2-3)Thrombolytics/FibrinolyticsNo available data ( follow fibrinogen level)

Postoperative Complications

Decision to initiate rehabilitation, depends on whether there is or not any perioperative C/C

Cardiac Complications*ACC/AHA guidelines recommend pre-op cardiac testing in pts at risk on basis of clinical risk / type of sx

*Older pts have risk of myocardial morbidity/mortality after orthopedic sx

Respiratory Complications  *Age related, exacerbated in arthritis*Embolization of bone marrow debris to the lungsNeurologic Complications-POCD

POST OPERATIVE COGNITIVE DYSFUNCTION

Short term deterioation of intellectual function ( memory / conc)-25-50%

Detected days to weeks after sx. Duration of several weeks to permanent.

Not affected -GA or RA Diagnosed by Neuropsychological testing

Risk factors Age/comorbidities, Alcohol Psychotropic medication, Preoperative cognitive impairment Perioperative hypoxemia, hypotension, abnormal electrolytes,infection, BZDs , Anticholinergic

Prevention

*Prophylactic continuation of medications.*Identifying at risk patient*Maintaining proper sleep cycle*IV Fluids & Electrolytes correction* exposure to- Antihistaminic, opioids, BZD,*Maintain Hct >30%,*Maintain O2 saturation > 90%*Pain control-Nerve Blocks, Gabapentin, opioids by rotation*Early rehabilitation

Post Operative ManagementOxygen: for the first 72 hours postoperatively.

Analgesia -Epidural / PCA / BLOCKS -Intra articular inj. Of L.A with opioids -Paracetamol- 1 g/6 hours, given orally/ rectally. -NSAIDs used with caution, in elderly -Midazolam infusions or baclofen- to ease quadriceps

muscle spasmFluid balance: Stringent monitoring is mandatory because blood loss

may double in the first 24 hours.

TKR -ISSUESTECHNIQUE

*Innervation of the knee -TN, CPN, ON, & FN.

*RA- SAB / CSE / femoral & sciatic block. *Advantages of SBTKR - exposure to risks of one anesthetic, one postoperative course of pain, reduced rehabilitation & an earlier return to baseline function.

*SBTKA however, has a higher incidence of perioperative complications, including MI ,FES, & thromboembolic events.

Patients Excluded for SBTKR*Age ≥ 75 yr

*ASA class III*Active ischemic heart disease (positive stress test)*Poor ventricular function (LVEF < 40%)*Oxygen-dependent pulmonary disease*IDDM* Renal insufficiency* Pulmonary hypertension* Steroid-dependent asthma* Morbid obesity (BMI > 40)* Chronic liver disease* Cerebrovascular disease

What is Tourniquet?

Compressing device applied over extremities to control circulation for a period of time to intra operative bleeding.

Better operating condition ”BLOOD LESS FIELD” Depends on following variables:-

Patient’s age Skin condition Blood pressure Shape/size of extremity

Tourniquet cuff ?

Cuff applied over limited padding. Cuff dimensions

large enough to comfortably encircle the limb for uniform pressure.

width of the inflated cuff should be > half the limb

diameter. Before inflation, limb should be elevated for approx. 1

min & tightly wrapped with an elastic bandage distally to proximally.

Optimal limb occlusion pressure(LOP)

Determined by gradually tourniquet pressure until arterial blood flow distal to cuff is interrupted

50-100 mmHg above Systolic B.P Upper limb-250 mmHg Lower limb-350 mmHg

Occlusion time kept minimum-Safe limit of 1-3 hours.

Asses operative situation at 2 hrs ,if anticipated duration >2hr

then deflate for 10 min & subsequently 1 hr interval.

CONTRAINDICATION

Prerequisites for application-Adequate hydration, Blood Volume , Normothermia

SCD PVD CRUSH INJURY DM NEUROPATHY H/O DVT PE

Local Effects of Tourniquet Inflation

Muscle change-due to compression / ischemia of the tissue over time.

Endothelial integrity disrupts tissue edema colder limbs D/t heat loss.

Problems -

Glycogen , ATP , NAD

CELLULARHYPOXIA ACIDOSIS

HAEMODYNAMIC RESPONSE

Inflation- Exsanguination of limb- venous/ arterial pressure.

in SVR, in HR,MAP, after 30-60 min of inflation. in PAP can occur in poor ventricular compliance.

prolonged inflation-systemic hypertension develops

reflecting cellular ischemia cannot be reduced by deepening anesthesia -use vasodilators Deflation- Reperfusion of ischemic limb- Sudden venous /arterial pressure Sudden in SVR Pooling of blood in extremities

METABOLIC RESPONSES

A washout of acidic by products occurs from ischemic limb to systemic circulation after Deflation

Transient metabolic acidosis leads to ( in EtCO2).

Changes reversed with in 30 min of deflation

in Lactic Acid, K+, PaCO2,

in PO2, in pH

NEUROLOGIC

COMBINATION OF NERVE COMPRESSION & ISCHEMIA Direct pressure of nerves beneath tourniquet

( shearing stress) leads to evidence of nerve injury

Upper limb- Radial>Ulnar>Median Nerve

Lower limb-Common Peroneal Nerve-

Implication in use of CNB – when tourniquet Inflation(> 2 hrs) causes post operative neuropraxia

Tourniquet pain

Poorly defined dull aching ,burning sensation at the site of application about 1 hour after inflation.

Correlates with degree of cellular acidosis.

Not relieved by narcotics , nerve blocks , EMLA.

Deflate the tourniquet for 10-15 min & reinflate it.

Temperature/Haematological change

Inflation- in core body temperatureDeflation- in core body temperature (0.7 0C)

Inflation- Hypercoagulable stateDeflation— Fibrinolytics activity –anticoagulation ( POST TOURNIQUET BLEEDING)

SHOULDER REPLACEMENT

Monitoring and I/V access*Standard monitoring is required*Large-bore I/V access on the non-operative side

*NIBP monitoring either on the non-operative side, or on the lower leg.

Anesthetic technique*1-G.A using an armoured tracheal tube and PPV

*2-Interscalene approach(ISB) to brachial plexus -improves operative conditions, blood loss, good muscle relaxation

Patient position

*Sitting / beach chair position*No excess strain on lumbar spine*Torso securely strapped/head ring*Access to airway difficult, ETT must be taped

Intraoperative problems*At start of operation, while positioning, drop in B.P , bradycardia accompany change from supine to sitting- vasopressors required

*At risk of air embolism from open veins at the operative site

REVISION ARTHROPLASTYMAIN INTRAOPERATIVE PROBLEM-

*Anticipated blood loss - depends on type of previous prosthesis and the number of components to be revised.

*Pre-donation of autologous blood when sx A/w with blood loss > 750-1500 ml

Acute Normovolaemic Haemodilution *Technique in which whole blood is removed through Phlebotomy while circulating volume maintained with acellular fluid

*Eliminates need for Allogenic B.T.* The blood requires no testing* risk of transfusion reaction/infections*Blood(2-4 U) kept at room temp for 4 hr at 6 0C

SPINE SURGERY

INDICATIONS*Neurologic dysfunction *Structural deformity / Pathologic lesionsEssential to discuss preoperatively stability of the CERVICAL SPINE with the surgeonNeurological assessment:- SHOULD BE DOCUMENTED * 1.Avoid further deterioration during intubation , positioning /

hypotensive anesthesia. * 2.Muscular dystrophies involve bulbar muscles, risk of

aspiration. * 3.Level of injury & time elapsed since insult are predictors of

physiological derangements which occur peri-operatively.

PRONE POSITION*Induction & intubation in supine position

*Turn prone as a single unit*Neck in neutral position*Head turned to the side / face on a cushioned holder

*Arms at the sides with the elbow flexed*Chest should rest on parallel rolls to facilitate ventilation

Anesthetic problems of prone position

Monitor disconnectsAirway: ETT kinking /dislodgement/Edema of upper airwayHead and Neck: Hyper flexion / hyper extension of neck Excess cervical rotation - kinking of vertebral arteryEyes: pressure over eyes:- retinal injury /corneal abrasion

Blood Vessels: Kinking of FV with marked flexion of the hip

Abdominal -epidural venous pressure bleeding

Nerves: Brachial plexus / Ulnar N/ CP/ LCNOT compression

WAKE UP TEST*Lightening anesthesia during procedure & observing patient’s ability to move to command. Evaluates functional motor integrity.

Anesthesia requirements: * Easy, rapid to institute , quickly antagonized * Awakening should be smooth* No pain/recall during the test Anesthetic techniques: Volatile/Midazolam/ Propofol / Remifentanyl -based anesthesia Disadvantages: * Risks of falling from the table / extubation * Provides information at the time of the wake-up only * Does not assess sensory pathways

CONCLUSION-CHALLENGES CONVERTED INTO GOOD

OUTCOMES*Better understanding of geriatric pathophysiology*Safer anesthetic technique*Multimodal / site specific analgesia*Better monitors*Physiotherapy & early ambulation