- Clinical manifestations of bone cement implantation syndrome include hypoxia (increased pulmonary shunt), hypotension, arrhythmias (including heart block and sinus arrest), pulmonary hypertension (increased pulmonary vascular resistance), and decreased cardiac output.
- Use of a pneumatic tourniquet on an extremity creates a bloodless field that greatly facilitates the surgery. However, tourniquets can produce potential problems of their own, including hemodynamic changes, pain, metabolic alterations, arterial thromboembolism, and pulmonary embolism.
- 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 cause morbidity and mortality following orthopedic operations on the pelvis and lower extremities.
- Neuraxial anesthesia alone or 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 release.
- For patients receiving prophylactic low-molecular-weight heparin once daily, neuraxial techniques may be performed (or neuraxial catheters removed) 10-12 h after the previous dose, with a 4-h delay before administering the next dose.
- Flexion and extension lateral radiographs of the cervical spine should be obtained preoperatively in patients with rheumatoid arthritis severe enough to require steroids, immune therapy, or methotrexate. If atlantoaxial instability is present, intubation should be performed with inline stabilization utilizing video or fiberoptic laryngoscopy.
- Effective communication between the anesthesiologist and surgeon is essential during bilateral hip arthroplasty. If major hemodynamic instability occurs during the first hip replacement procedure, the second arthroplasty should be postponed.
- Adjuvants such as opioids, clonidine, ketorolac, and neostigmine when added to local anesthetic solutions for intraarticular injection have been used in various combinations to extend the duration of analgesia following knee arthroscopy.
- Effective postoperative analgesia facilitates early physical rehabilitation to maximize postoperative range of motion and prevent joint adhesions following knee replacement.
- The interscalene brachial plexus block using ultrasound or electrical stimulation is ideally suited for shoulder procedures. Even when general anesthesia is employed, an interscalene block can supplement anesthesia and provide effective postoperative analgesia.
Orthopedic surgery challenges the anesthesia provider. The comorbidities of these patients vary widely based on age group. Patients may present as neonates with congenital limb deformities, as teenagers with sports-related injuries, as adults for procedures ranging from excision of minor soft-tissue mass to joint replacement, or at any age with bone cancer. This chapter focuses on perioperative care issues specific to patients undergoing common orthopedic surgical procedures. For example, patients with long bone fractures are predisposed to fat embolism syndrome. Patients are at increased risk for venous thromboembolism 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 ...