- Clinical manifestations of bone cement implantation
syndrome include hypoxia (increased pulmonary shunt), hypotension,
dysrhythmias (including heart block and sinus arrest), pulmonary hypertension
(increased pulmonary vascular resistance), and decreased cardiac
- Pneumatic tourniquets are often used in knee
arthroscopic surgeries because they create a bloodless field, which
greatly facilitates the procedure. However, tourniquets are associated
with potential problems of their own, including hemodynamic changes,
pain, metabolic alterations, arterial thromboembolus, and even pulmonary
- Fat embolism syndrome classically presents within
72 h following long-bone or pelvic fracture, with the triad of dyspnea,
confusion, and petechiae.
- Deep vein thrombosis and pulmonary embolism can
be major causes of morbidity and mortality following orthopedic
operations on the pelvis and lower extremities.
- Neuraxial anesthesia alone or when combined with
general anesthesia may reduce thromboembolic complications by several
mechanisms, including sympathectomy-induced increases in lower-extremity
venous blood flow, systemic antiinflammatory effects of local anesthetics,
decreased platelet reactivity, attenuated postoperative increase
in factor VIII and von Willebrand factor, attenuated postoperative
decrease in antithrombin III, and alterations in stress hormone
- Placement of an epidural needle or catheter (or
removal) should generally not be undertaken within 6–8
h of a subcutaneous “minidose” of unfractionated
heparin, or within 12–24 h of low-molecular-weight heparin.
Although potentially less traumatic, spinal anesthesia may represent
a similar risk.
- Flexion and extension lateral radiographs of
the cervical spine should be obtained preoperatively in all patients
with rheumatoid arthritis severe enough to require steroids or methotrexate.
If atlantoaxial instability exceeds 5 mm, intubation should be performed
with neck stabilization and an awake fiberoptic technique.
- Pulmonary artery monitoring in patients undergoing
bilateral hip arthroplasties reliably signals embolization by a
rise in pulmonary vascular resistance. If pulmonary artery pressures
rise above normal (200 dyn × s × cm–5)
during the first hip arthroplasty, the contralateral surgery should
- Like bilateral cemented hip replacement, monitoring
during bilateral knee replacement should include pulmonary artery
and pulmonary artery occlusion pressure measurements.
- Effective postoperative analgesia is essential
for early physical rehabilitation to maximize postoperative range
of motion and prevent joint adhesions following knee replacement.
- The interscalene technique of brachial plexus
blockade is ideally suited for shoulder procedures. Even when general
anesthesia is employed, an interscalene block can supplement anesthesia
and provide good postoperative analgesia.
Orthopedic surgery challenges the anesthesiologist with its diversity.
The degree of surgical trespass varies from minor finger surgery
to hemipelvectomy. Orthopedic patients range from neonates with
congenital anomalies to healthy young athletes to immobile geriatric
patients with end-stage multiorgan failure. Long bone fractures
predispose to fat embolism syndrome. Patients may be at high risk
for venous thromboembolism, particularly following pelvic, hip,
and knee operations. Use of bone cement during arthroplasties can
cause hemodynamic instability. Limb tourniquets limit blood loss
but introduce additional risks. Neuraxial and other regional anesthetic techniques
play an important role in decreasing the incidence of perioperative
thromboembolic complications, providing postoperative analgesia,
and facilitating early rehabilitation and hospital discharges. Advances
in surgical techniques, such as minimally invasive ...