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KEY POINTS

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KEY POINTS

  1. Orthopedic surgery is associated with high incidences of deep venous thrombosis and pulmonary embolism.

  2. The need for anticoagulation results in anesthesia issues specifically related to the potential for neuraxial hematomas.

  3. Unique complications in orthopedic surgery are related to tourniquet use and fat embolism.

  4. Regional anesthesia is associated with lower morbidity and mortality than is general anesthesia.

  5. Prone spinal surgery cases have unique complications related to patient positioning, such as nerve injuries, ventilation problems, and blindness.

  6. Multimodal analgesia offers superior pain relief and leads to improved recovery.

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INTRODUCTION

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Orthopedic anesthesia presents a wide variety of challenges to anesthesiologists. The patient population can range from infant to centenarian along with a myriad of comorbidities. Many orthopedic procedures are associated with significant postoperative pain. Surgery on isolated extremities can be performed using a variety of regional anesthetic techniques for surgical anesthesia and postoperative analgesia. Neuraxial techniques can be challenging, especially when deep venous thrombosis (DVT) prophylaxis with low-molecular-weight heparin (LMWH) is needed. This challenge has led to the development of many peripheral nerve block techniques and advances in the equipment used for these techniques, including continuous nerve catheters and ultrasonography for identification of nervous structures. Recent literature has shown, in some orthopedic procedures, a benefit of regional anesthesia over general anesthesia with respect to reduction in deep surgical site infection rates, hospital length of stay, and rates of postoperative cardiovascular and pulmonary complication.1 Ultrasound-guided regional anesthesia offers significant advantages compared to peripheral nerve stimulation. A meta-analysis has shown that ultrasound guidance has a higher success rate and a lower risk for an accidental vascular puncture compared with nerve stimulator technique, as well as lower postoperative pain scores.2 It also appears that the minimum amount of local anesthetic required to successfully perform the nerve block may be reduced by up to 70% using ultrasonography instead of the traditional nerve stimulation technique.3 This may be of great benefit in reducing the incidence of local anesthetic toxicity. This chapter considers the factors pertinent to anesthesia for orthopedic surgery and reviews the appropriate management.

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SPECIFIC PROBLEMS IN ORTHOPEDIC PATIENTS

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RHEUMATOID ARTHRITIS

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Rheumatoid arthritis (RA) is a chronic, inflammatory autoimmune disorder characterized by articular and systemic manifestations, which ostensibly has repercussions for orthopedic surgery.

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These patients can be extremely challenging to treat for a variety of reasons. Deformities of the extremities are common, which may make vascular access and positioning of the patient difficult. Great care must be taken when positioning patients, with adequate padding needed to prevent pressure necrosis of the patient’s skin. If possible, positioning patients while they are awake often is useful. Of major concern in any patient with rheumatoid arthritis is the possibility of cervical spine instability.4 Cervical spine involvement occurs in more than half of patients with rheumatoid arthritis, with atlantoaxial dislocation the most common abnormality. Pain ...

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