Anesthesia for orthopaedic
replacement surgeries
Prof.Dr.K.BALAKRISHNAN,
Chennai.
Introduction
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Some of the common joint
replacement surgeries are
1. Hip replacement
2. Knee replacement
3. Shoulder replacement
4. Elbow replacement

Total knee replacement (TKR) and
hip fracture coming for
replacement are the two most
common surgical procedures after
the sixth decade of life.
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Most of the patients have
degenerative joint disease,
commonly osteoarthritis (OA).

Other conditions requiring knee
or hip replacement are injury to
the neck of femur or knee joint,
knee deformity, rheumatoid
arthritis and gout.

Joint replacement is performed to
relieve pain and morbidity.
The challenge….
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Decreased organ function and
reserve
Co-morbid conditions
Consequences of polypharmacy
Challenges have been
converted into good
outcomes…
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Better understanding on
pathophysiology of aging
Better pharmacotherapy
Safer anaesthetic techniques
Improvements in monitoring
Multimodal analgesia and site
specific analgesia
Physiotherapy and early
ambulation
Pain is the first enemy to
mankind….
And anaesthesiologists are
mankind’s guardian angels.
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 !
Pre-operative concerns
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Associated injuries
Cause for the fall
Difficulty in assessing cardio
respiratory reserve
Osteoarthritis- Medications-NSAIDs
Pre-operative concerns….
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Pre-renal azotaemia
DVT prophylaxis
Diabetes Mellitus
The emotional significance of
fracture to the geriatric patient must
also be considered.
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.

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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.
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 .
Intra-operative concerns
Regional

General anesthesia
The choice of anaesthesia is
determined by:
i) surgical factors
ii) Patients factors
iii) Estimates of risk associated
with anaesthesia techniques
Regional Anesthesia Advantages
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Stress response to surgery
Intraoperative blood loss
Post-operative hypoxia
PONV
DVT- early mobilization
Regional Anesthesia Advantages
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Preemptive analgesia
Post-operative analgesia
Hypostatic pneumonia
Pressure sores
Centri Neuraxis Block - Concerns
•Coagulopathy
•Conscious sedation
•Shivering
•Technical difficulty
Autonomic dysfunction
-Hypotension
•I.V. fluids,
•vasopressors,
Diastolic pressure 60 mm Hg
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).

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.
General anesthesia
-Pre-operative beta
blockade

CAD
Hypertension
Diabetes mellitus
Hypercholesterolemia
Renal dysfunction

Goal: Heart rate between 60-70.
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General anesthesia
-Pre-Oxygenation
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100% Oxygen
8 deep breaths
Oxygen flow 10 L per min
General anesthesia
-Choice of Anesthetic agent
Short acting and less lipid soluble drugs
• Propofol
• Fentanyl
• Rocuronium
• Atracurium
• Sevoflurane
• Isoflurane
Intra-operative monitoring
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Pulse Oximetry
5 lead ECG-ST analysis
Capnography
NIBP- IBP
Temperature
Neuromuscular
monitoring
Urine output
Blood Transfusion
Progressive
reaming of
femur and
resection of the
condyles is
associated with
steady blood loss
Bone CementHypotension
The placement of
the prosthesis
involve the use of
methylmethacrylate
( bone cement )
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The cementing can cause
hemodynamic fluctuations
These fluctuations are related to
the vasodilatory and mast-cell
degranulating properties of the
monomeric form of
methylmethacrylate
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.
Bone Cement 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.
Fat embolism

The high incidence of fat
embolism with femoral neck
fracture repair and cemented
endoprosthesis may contribute to
pulmonary dysfunction
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
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.
Post-operative concerns
Pain
Pain
Pain
Pain
Pain
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.
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
Post-operative concerns
• Post operative delirium
• Post operative hypoxemia
• Hyponatremia
• Hypoglycemia
Early Mobilisation
Psychological support
Peri-operative Sepsis
Peri- operative Antibiotics
Conclusion
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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.