About Orthopadeic Anesthesia
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What is orthopedic anesthesia?
This is a subspecialty of anesthesiology that focuses on providing anesthesia, sedation and pain management to patients with orthopedic trauma. Traumatic orthopedic injuries can range from isolated wounds to severe complex injuries. Patients with orthopedic injuries may need anesthesia for procedures to repair, damage control surgery or semi-elective procedures after stabilization.
Orthopedic anesthesia involves a wide range of techniques because the patients are at an increased risk for embolisms such as fat emboli and venous emboli. Bone cement can result in hemodynamic instability and tourniquets increase a unique set of considerations.
Preoperative EvaluationEvaluation before surgery should be thorough to the extent that the situation allows. Whenever possible, a review of the patient’s injuries, medical history, medications, allergies and last oral intake should be performed. An orthopedic anesthesiologist also performs and airway assessment and a directed physical examination. Sometimes the patient may be unable to provide an accurate medical history due to head trauma, illicit drug use, alcohol use, severe pain or dementia.
Laboratory tests results such as glucose, electrolyte, hemoglobin, coagulation parameters, platelet count and lactate should be reviewed.
Procedures which require orthopedic anesthesia include:- Emergency trauma
- Joint arthroplasty
- Hand surgery
- Oral and maxillofacial
- Pain medicine procedures
- Orthopedic oncology
- Pediatric surgery
- Sports medicine
- Spine surgery
Important ConceptsBone Cement
Bone cement is made by mixing methylmethacrylate powder and liquid methylmethacrylate monomer. This leads to an exothermic polymerization reaction and the formation of polymethylmethacrylate. This reaction can cause intramedullary hypertension which can result in embolization of fat, marrow, and cement.
Pneumatic Tourniquet
The tourniquet can be extremely painful. It is relatively resistant local anesthesia and can sometimes overcome regional anesthesia necessitating general anesthesia.
Specific Operations- Hip Operations
- Fracture repair: The choice between regional or general anesthesia is usually up to the anesthesiologist who makes a decision depending on your overall health, age, gender and existing medical problems.
- Total hip replacement (THR): This operation is associated with life-threatening complications such as profuse hemorrhage, VTE, and bone cement implantation syndrome. Therefore, invasive arterial monitoring is strongly considered. Most doctors conduct a regional anesthetic or add epidural analgesia on top of the general anesthetic.
- Knee Operations: These include knee arthroscopy are performed in outpatient procedures and general anesthesia is combined with a pneumatic tourniquet. Total or Partial Knee Replacement usually require a regional anesthetic combined with sedation. However, some patients require general anesthesia.
- Upper Extremity Operations: Shoulder Surgery and hand surgery are usually done under general anesthesia. The doctor may request controlled hypotension.
- Spine Surgery: Cervical spine, thoracolumbar spine, lumbar spine, allograft or autograft transplantation surgery, pelvic and sacral resections, pediatric orthopedic surgery, cerebral palsy, juvenile rheumatoid arthritis.
- Lower Extremity operations: Thigh/Leg, knee, ankle, and foot.
Postoperative AnalgesiaKnees are the most painful joints post-operative. Orthopedic anesthesiologists develop a pain management plan for the patient after surgery so that the pain can be controlled. Epidural analgesia, intra-articular injections, nerve catheters, NSAIDs and IV opiates are some of the options. The orthopedic anesthesiologist decides the type of postoperative analgesia according to individual cases.
Common Complications- Venous Thromboembolism: An orthopedic anesthesiologist has to carefully review and evaluate a patient before deciding on the type of anesthesia and administering it. Sometimes complications such as venous thromboembolism may occur
- Fat Embolism: This is a complication of using anesthesia and it is usually characterized by petechiae, dyspnea, and confusion.
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