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ANAESTHESIA FOR ORTHOPAEDIC SURGERY
Outline: Points of importance to the anaesthetist Anaesthetic techniques Special anaesthetic problems in orthopaedic surgery Management of a fractured jaw
to very long and complicated procedures such as hip replacements or spinal fusions. pneumothorax or haemothorax • Abdominal injuries. • A tourniquet is hazardous in old patients with cardiac failure. 3000. These injuries must be specifically looked for and either ruled out or treated wherever possible before commencing the anaesthetic. Blood loss may occur from open wounds. The sudden increase in venous return may embarrass the heart.GENERAL POINTS OF IMPORTANCE TO THE ANAESTHETIST Orthopaedic operations may range from simple procedures such as closed reduction of fractures. neck and upper airway injuries • Chest injuries. 162 .4000 ml A full stomach is a common problem associated with fractures and dislocations. or the bleeding may be concealed within the thigh or pelvis. • It may be associated with deep vein thrombosis. Blood replacement must be guided by the vital signs discussed under Shock in Chapter 52. Points of importance for all orthopaedic procedures The use of the tourniquet • This is not recommended in patients with sickle cell disease (See Chapter 33) and peripheral vascular disease. Blood loss must be replaced before surgery. Fractures and Blood Loss Fracture of foot with moderate swelling Fracture of lower leg Fracture of femoral shaft Fracture of knee joint (up to) Fracture of forearm Fracture of the humerus and shoulder (up to) Fracture of pelvis 250-500 ml 500-1000 ml 500-2000 ml 2000 ml 500 ml 2000 ml. SPECIAL PROBLEMS RELATED TO EMERGENCIES Emergency orthopaedic operations may be complicated by: Other injuries • Head injuries • Face. • The tourniquet produces ischaemia of the limb and a consequent acidosis.
The anaesthetist must be especially conscious of this. The patient must be supine. Repeated exposure to halothane over a short period of time should be avoided if possible. ANAESTHETIC TECHNIQUES Regional Anaesthesia This provides good analgesia and relaxation and minimal disturbance of bodily functions. General anaesthesia This is required when regional anaesthesia is contraindicated or when positioning for a regional anaesthetic causes too much pain. (This is usually the duty of the nursing staff). • Controlled ventilation Air or N2O/O2/relaxant/volatile + opioids or regional block. Abnormal positions carry certain hazards especially in patients with limited mobility. Wound infection is a very serious hazard in bone surgery. The patient may be placed in various positions. See more specialized anaesthetic textbooks. This is suitable for surgery on the limbs. However. The tourniquet time is less in older patients. There are more specific blocks for wrist. Posture. Radiation hazards are present because of the use of image intensifiers and X-Ray machines. Suggested regional techniques: • The upper extremities can be anaesthetised by an axillary block or Bier block. Take adequate precautions. • The lower extremities require a low spinal anaesthetic. hand. Supplement with opioids or a regional block. 163 . • Mask or LMA anaesthetic with spontaneous respiration (Air or N2O/O2/halothane). The need for repeated anaesthetics. foot and ankle. Suggested techniques: • Ketamine / diazepam may be used for short procedures such as reduction of fractures and dislocations. Many patients have restricted movement or instability of cervical joints making intubation difficult. It requires a competent anaesthetist and a co-operative patient. • The surgeon should be notified when the tourniquet has been inflated for one hour. Restricted movement. A ketamine infusion is useful. muscle tone is retained with ketamine and this may make reduction of fractures difficult. A maximum period of two hours should not be exceeded.• The time of application and release of the tourniquet must be noted.
SPECIAL ANAESTHETIC PROBLEMS IN ORTHOPAEDIC SURGERY Fractured femur • The patient with a hip fracture is usually old and may suffer from cardiovascular and/or respiratory disease. Added to this is a period of low fluid intake associated with the pain and transport to hospital. • The cement used is methyl methacrylate cement. hypotension and even cardiac arrest may follow. so pressure points must be carefully protected. • Blood loss is large. • The orthopaedic table is hard. 164 .Patients should be intubated in all major emergency operations (unless a spinal or regional technique can be used). When it is applied to the bone. • The patient may be hypovolaemic. • The patient may be brought into the operating theatre in traction. prepared by mixing a liquid and a powder. Prevent this complication by: − Maintaining adequate hydration − Replacing lost blood − Careful monitoring Surgery on the vertebral column This will not be discussed in detail as such operations will not be performed routinely in the hospitals for which this book is designed. having lost anything up to a litre of blood. • These patients are more prone to deep venous thrombosis and pulmonary embolism. Total hip replacement • Surgery for osteoarthritis or degenerative disorders of the hip joint is prolonged. This makes both regional and general anaesthesia difficult.
− Material such as blood clots. Unless there is a bony mechanical obstruction. − Wire cutters. mouth opening improves with anaesthesia. abdominal or orthopaedic injuries and assess blood loss. − A pharyngeal pack. Severe trauma is associated with a delayed gastric emptying time. ANAESTHETIC MANAGEMENT Pre-operative assessment • A fractured jaw is often associated with other injuries. pharynx and neck areas. food and vomitus in the upper airway. teeth. Premedication Avoid heavy sedation. • A full stomach. Examine the patient carefully for head. using a disposable plastic or 165 . caused by: − Tissue injury and swelling of the face. If it is at all possible this operation should be performed under local anaesthesia in order to avoid the dangers of general anaesthesia. • Carefully perform suction of the pharynx. • An anti-emetic (like promethazine) can be used in the premedication.MANAGEMENT OF A FRACTURED JAW A fractured jaw (mandible) is sometimes treated by wiring the jaws together. as swelling and muscle spasm associated with the fracture may limit movement. − The tongue falling back (in the semi-conscious or unconscious patient). neck. dentures. Intra–operative management • Establish a good intravenous line. • Measure and record cardiovascular and respiratory parameters. chest. • The patient must be awake at the end of the operation. − Expert post-operative nursing staff. The stomach contents include swallowed blood and food. • Assess ability to open the mouth. • A drying agent such as atropine or hyoscine is necessary especially if ether is used. The patient with a fractured jaw is in danger of regurgitation and aspiration of stomach contents. • Preparation requires: − A nasotracheal tube (this is contraindicated if there is a drainage of CSF from the nose which may occur if the base of skull has been fractured). to be available at the patient's bedside. Adequate rehydration with fluids and blood is necessary before the anaesthetic is started. • Check for airway obstruction.
rubber catheter. 166 .
167 . with atropine or glycopyrrolate and neostigmine. apply cricoid pressure and intubate. blind nasal intubation or even a tracheostomy (under local anaesthetic) before anaesthesia is induced.• If there is pre-operative evidence of airway obstruction. Post-operative care These patients need expert post-operative nursing. the following methods of anaesthesia are suggested: − An inhalational induction with air or N2O/O2 /volatile OR − Ether/air/O2. etc. a nasopharyngeal airway can be inserted if the patient can tolerate it. • Wire cutters must be available at the patient's bedside. secretions. Reversal is routine. The use of antibiotics. you may need to perform an awake intubation. • Observe the patient for the earliest signs of airway obstruction. • Take steps to prevent infection. or in those patients who have a limited ability to open their mouths (because of the fracture). • After extubation. • Suction the pharynx both before and after extubation using a suction catheter. Maintenance Air or N2O/O2/volatile/opioids/muscle relaxant. the general nursing care of the patient and chest physiotherapy are all-important. Once the patient is deep enough. OR Ether/air/oxygen/ opioids and muscle relaxant. which may be caused by the tongue falling back or by blood clots. Before the jaws are wired together: • Remove the pharyngeal pack. Teach the nursing staff how and when to use them. • If there is no pre-operative airway obstruction but the tissue injury and swelling in the facial and neck areas make it a likelihood when anaesthesia is induced. Monitor carefully. This may mean that the patient is extubated in the recovery ward. vomitus. • Pay close attention to the patient’s fluid intake (initially intravenous and later nasogastric or oral). • Suction the upper airway very carefully (don’t forget to look for blood clots behind the soft palate). Important points to remember • Leave the tube in place until the patient is fully awake. then give a dose of suxamethonium 1mg/kg. either intubate under deep inhalational anaesthesia (respiration may need to be assisted at this stage) or if the patient can be ventilated.
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