ANAESTHETIC MANAGEMENT OF

JOINT REPLACEMENT SURGERIES

CONDUCTOR-DR NEETA VERMA MAAM

PRESENTOR-DR STUTI DUBEY
INTRODUCTION
➢Joint replacement – common, effective procedure for relief of disability due
to severe joint pain and loss of function.

➢ Most common joints replaced are the hip, knee and shoulder.

➢ Most patients for jt replacement have generalized degenerative joint

disease (eg.OA). Other conditions necessitating joint replacement surgery
include: › rheumatoid arthritis › osteoporosis and fracture › metastatic lesions
and pathological fractures › avascular necrosis of the femoral head.

➢ Most patients are elderly, with associated problems such as HTN, IHD, COPD
or renal disease.

➢Younger pts presenting for jt replacement surgery often suffer from

rheumatoid arthritis, severe osteoporosis or obesity.

➢ Presentation for revision of previous replacement is increasingly common.

 Preoperative assessment
➢ Problems in multiple systems are common because most patients are elderly.

➢ There are specific types of pts who are more likely to have orthopedic surgery and
are more likely to have perioperative complications.

➢ geriatric pts

➢ rheumatoid arthritis pts

➢ ankylosing spondylitis pts

 Geriatric Patients
➢ Postmenopausal, ageassociated osteoporosis higher risk of fractures.

➢ Ageassociated osteoporosis may be due to increased circulating

parathyroid hormone & decreased vitD, growth hormone.

➢ With osteoporosis disproportionate loss of trabecular (structural) bone –

thus at risk for stress fractures.

➢ Although all bones are at risk, thoracic and lumbar spine, proximal femur,
proximal humerus, wrist are at highest risk.
 Osteoarthritis
➢ Most common type of arthritis loss of articular cartilage, inflammation.

➢ Clinical manifestations pain, crepitance, reduced mobility, and deformity of involved joints.

➢ Hands – spurring, swelling of the distal IP jts (Heberden's nodes) and PIP jts (Bouchard's
nodes).

➢ No systemic manifestations of osteoarthritis should be aware of previous orthopedic

surgeries/ jt replacements / joints which are painful / limited mobility.

➢ Important for surgical positioning and the choice of an appropriate anesthetic.

 Rheumatoid Arthritis
➢ Chronic inflammatory form of arthritis, affects about 1% of adults, prevalence 23
times higher in women than men.

➢ Characterized by persistent joint synovial tissue inflammation leading to bone

erosion, destruction of cartilage, and loss of joint integrity.

➢ RA also a systemic disease, affecting multiple organ systems.

➢ often progresses through multiple exacerbations & remissions.

➢ Commonly present with pain and stiffness in multiple joints.

➢ Characterized by morning stiffness often lasting >1 hr after initiating activity.

➢ Usually wrists & MCP jts are involved (distinguishes RA from OA), boggy,
tender & warm.

➢May have prominent epitrochlear, axillary, & cervical LN enlargement.

➢SC rheumatoid nodules may surround joints, extensor surfaces, and bony
prominences.

➢ Patients taking NSAIDs should be assessed for GI SEs & renal

complications.

➢Glucocorticoids highly effective at relieving symptoms but used at low

doses & sparingly ( due to SEs of osteoporosis, cataracts, cushingoid
symptoms, hyperglycemia).

➢Pts taking glucocorticoids need stressdose steroids for their operations.

Airway management can be challenging
➢ TMJ synovitis limits mandibular motion & mouth opening.

➢Arthritic damage to cricoarytenoid joints diminished movement of VCs,

narrowed glottic opening; preop as hoarseness and stridor.

➢ During DLscopy, VCs may appear erythematous /edematous, reduced glottic

opening may interfere with passage of ETT.

➢ Increased risk of cricoarytenoid dislocation with traumatic intubations. ›

Arthritis of Cspine (atlantoaxial subluxation Flexion of head displacement of
odontoid process into cervical spine and medulla compression of vertebral
arteries precipitate quadriparesis, spinal shock, and death).

➢ Preop cervical flexionextension radiographs required to plan for awake

fiberoptic tracheal intubation, Cspine should be protected with collar.
Extraarticular manifestations of

➢ Restrictive pericarditis (dyspnea, RHF, fever, chest pain, pericardial friction rub,
pulsus paradoxus). ›
➢Pleural disease and intrapulmonary nodules.
➢ diffuse interstitial fibrosis with pneumonitis – PFTs restrictive ventilatory pattern
respiratory insufficiency, pulmonary HTN, RHF.
➢Overlapping CTDs Sjögren's syndrome, Felty's syndrome.

➢Airway Limited TMJ movement

➢ Narrow glottic opening

➢Cervical spine- Atlantoaxial instability
➢Cardiac Pericarditis
➢ Cardiac tamponade
➢Eyes- Sjögren's syndrome
➢Gastrointestina - Gastric ulcers secondary to ASA, steroids
➢Pulmonary -Diffuse interstitial fibrosis
➢Renal insufficiency secondary to NSAID
 Ankylosing Spondylitis
➢ Chronic inflammatory arthritic disease that results in fusion of the axial
skeleton.

➢ Ossification of axial ligaments progressing from sacral lumbar region

cranially, resulting in a significant loss of spinal mobility

➢ Significant challenge to us with regard to airway reduced movement of

their Cspines & TMJs.

➢ In most cases, awake fiberoptic endotracheal intubation is required for GA

➢ Increased rigidity of the thoracic spine in most cases also necessitates

intraoperative controlled mechanical ventilation.
➢ Although neuraxial anesthesia is better alternative to GA,
ossification of spinal ligaments closes intervertebral spaces,
blocking access to epidural space.

Extraskeletal manifestations

1. aortic insufficiency
2. cardiac conduction abnormalities
3. Iritis
4. upper lobe fibrobullous disease ,pleural effusions.

➢ Strict attention to positioning to avoid fracture of the fused

spine with concomitant spinal cord trauma.
 Assessment of co-morbidities
➢ Cardiopulmonary reserve
1. estimated by assessment of exercise tolerance.
2. may be impossible/ inaccurate (limited exercise).

In these circumstances the following may be used:

1. PFTs, ABG, RA SPO2
2. resting ECG (silent ischaemia / previous MI) 2DEcho (LV
function, WMA and valvular abnormality)
3. limited relevance information only about function of rested,
rather than stressed, cardiopulmonary systems.
4. Dobutamine stress tests provide information about cardiac
function under stress but they are not readily available.
Renal function

May be impaired owing to age, HTN or chronic use of NSAIDs.

Musculoskeletal

1. Other joint involvement is common

2. Range of limb and neck movements should be noted.
3. Obesity may be a cause or consequence of degenerative
joint disease.
4. Assessment for positioning on table and for regional
blockade should be made.
 Pts Excluded for Single Operation for Bilateral Total
Knee Arthroplasty
• Age ≥ 75 yr
• ASA class III
• Active ischemic heart disease (positive stress test)
• Poor ventricular function (LVEF < 40%)
• Oxygen-dependent pulmonary disease
• Patients considered at increased risk for morbidity and mortality
• IDDM
• Renal insufficiency
• Pulmonary hypertension
• Steroid-dependent asthma
• Morbid obesity (BMI > 40)
• Chronic liver disease
• Cerebrovascular disease
 Preoperative preparation
Preop assessment should be carried out as above.

➢ Optimization of co-morbidities is required.

➢ Cross-matched blood must be available.
➢ DVT prophylaxis is required. If a regional technique is planned,
ensure appropriate timing of low-molecularweight heparin.
➢ Antibiotic prophylaxis (usually cephalosporin or aminoglycoside) is
required.
➢ Invasive monitoring is seldom indicated unless there is significant
cardiac disease or large blood loss is anticipated.
➢ Large bore IV access is required (non-dependent arm for laterally
positioned patients
 Thromboprophylaxis in Orthopedic
Surgery
1) 1 of leading causes of morbidity after ortho surgery.
2) THR, TKR, hip and pelvic fracture surgery - highest incidence
of VTE, including DVT and PE
3) Patients with symptomatic PE have 18-fold higher risk of
death than pts with DVT alone.
4) Short-term complications of survivors of acute DVT and PE -
prolonged hospitalization, bleeding complications related to
DVT and PE treatments, local extension of DVT, and further
embolization.
5) Long-term complications include post-thrombotic syndrome,
pulmonary hypertension, and recurrent DVT.
6) As venous thrombi consist of fibrin polymers, anticoagulants
administered for the prevention and treatment of DVT.
7) Thrombolytics should be administered only in event of a
severe, possibly fatal PE.
8) LMWH is recommended over unfractionated heparin (IV/SC)
for initial therapy of DVT and PE.
9) LMWHs do not require monitoring of coagulation.
10) Although DVT prophylaxis may be more efficient when
started preoperatively, the risk of surgical bleeding also
increases.
11) LMWH should be continued for at least 10 days in routine
orthopedic procedures & in patients not considered high risk.
12) Extended prophylaxis to 28 to 35 days would be supported
in patients with evidence of a DVT or at higher risk for DVT.
➢ Risk factors for development of PE after surgery

1. Advanced age
2. Obesity
3. Previous PE and DVT
4. Cancer
5. Prolonged bed rest

➢ Warfarin - long-term treatment of DVT, with a target INR of 2.5

maintained for the duration of therapy.

➢Alternative to LMWH is fondaparinux, synthetic pentasaccharide

(selective inhibitor of factor Xa), prolonged half-life of 18 hours.

➢When administered OD, fondaparinux produces predictable

anticoagulant response.
➢ Use of periop anticoagulants has significant impact on use of RA, esp.
neuraxial anesthesia (risk of an epidural hematoma).

➢ASRA - updated consensus conference recommendations with regard to

the use of anticoagulants and RA. risk of epidural hematoma is
significantly increased with use of LMWH, so following recommendations
have been made:

1. An interval of 12 hrs after administration of usual dose of LMWH and

placement of a neuraxial block.

2. In patients receiving larger doses of LMWH (enoxaparin 1 mg/kg every

12 hrs), delay should be extended to 24 hours.

3. Epidural catheter removal at least 8-12 hrs after last LMWH

administration, or 1 to 2 hrs before the next.
 Intraoperative Management THR
• APPROACHES :
• anterior / lateral approach. -anterior approach - advantage
of exposure without violation of the muscles, but restricts full
access to the femur with the risk of lateral femoral cutaneous
nerve injury.
• lateral posterior approach - excellent exposure to the femur
and the acetabulum with minimal muscle damage, but
increases the risk of posterior dislocation.
• Most surgeons prefer lateral posterior approach, placing the
patient in lateral decubitus position, surgical side up, for
operation.
➢POSITIONING

1. Anesthesiologist must be aware that this position may compromise

oxygenation, esp in obese and severely arthritic pts, owing to V/Q
mismatch.

2. To prevent excessive pressure on the axillary artery and brachial plexus by

the dependent shoulder, an anterior roll or pad must be placed beneath
the upper thorax.

➢TECHNIQUE
1. Nerve supply to hip joint includes obturator, inferior gluteal, and superior
gluteal nerves - RA best achieved with SAB/ epidural anesthetic.

2. Lumbar paravertebral block may be used for postop analgesia when

postop anticoagulation requires removal of epidural catheter.
BLOOD LOSS
➢Can be significant.

➢Several studies have shown controlled hypotensive epidural anesthesia with

MAP of 60 mm Hg can reduce intraop blood loss for primary THRs to approx
200 mL.

➢Elderly patients able to tolerate this degree of blood pressure reduction

without cognitive, cardiac, or renal complications.

➢ Hypotensive anesthesia may improve the cement prosthesis to bone fixation

by limiting bleeding in the femoral canal.

➢Femoral prosthesis can be fixed to femoral canal through methyl

methacrylate cement or bony ingrowth.

➢ Cemented fixation of the femoral prosthesis has been complicated by “bone-

cement implantation syndrome,” which may result in intraop hypotension,
hypoxia, and cardiac arrest and FES postoperatively
Several mechanisms suggested
1. Embolization to circulation of bone marrow debris during pressurization
of femoral canal

2. toxic effects of circulating methyl methacrylate monomer

3.Release of cytokines during reaming of femoral canal promoting

microthrombus formation and pulmonary vasoconstriction.

4. Hypotension should be treated with epinephrine.

5. Risk factors for this complication include revision surgery, a long-stem

femoral prosthesis, THR for a pathologic fracture, preexisting pulmonary
hypertension, and the quantity of cement used.
 TOTAL KNEE REPLACEMENT
• TECHNIQUE
• innervation of the knee includes tibial nerve, common peroneal nerve,
posterior branch of obturator nerve, & femoral nerve.

• RA as SAB / CSE / combination of femoral & sciatic block can be provided

for the surgery.

• Single-injection femoral nerve blocks in combination with intravenous and

epidural patient-controlled analgesia have been employed to manage
postoperative pain and improve functional recovery.

• When LMWH has been instituted for the prevention of DVT, patient-
controlled epidural anesthesia cannot be continued postoperatively, and
instead continuous femoral nerve catheters are used
 TOURNIQUET APPLICATION
➢ Routinely inflated over thigh during TKA to reduce intraop blood loss,
provide a “bloodless” field for cement fixation of femoral and tibial
components.
➢ When deflated, blood loss usually continues for next 24 hours.
➢ Tourniquets are usually inflated to a pressure 100 mm Hg above pt's SBP
for 1 to 3 hours.
➢ Nerve injury after extended tourniquet inflation (>120 minutes) has been
attributed to combined effects of ischemia and mechanical trauma.
➢ Peroneal nerve palsy, a recognized complication of TKR caused by
combination of tourniquet ischemia and surgical traction.
➢ When prolonged tourniquet inflations are required, deflating the
tourniquet for 30 minutes of reperfusion may reduce neural ischemia.
➢ Cuff should be applied over limited padding.

➢Appropriate selection of tourniquet cuff size and inflation pressure

important to reduce risk of NM injury.

➢Cuff should be large enough to comfortably circle the limb to ensure

circumferentially uniform pressure.

➢Point of overlap should be placed 180 degrees from the

neurovascular bundle because there is some area of decreased
compression at the overlap point.

➢ Width of the inflated cuff should be >half the limb diameter.

➢Before tourniquet inflation, the limb should be elevated for

approximately 1 minute and tightly wrapped with an elastic bandage
distally to proximally.
➢ Duration of safe tourniquet inflation is unknown.
➢ Recommendations range from 30 min - 4 hours.
➢ 5 min of intermittent perfusion between 1- and 2-hour
inflations, followed by repeated exsanguination through
elevation and compression, may allow more extended use.
➢ Prolonged inflation / simultaneous release of 2
tourniquets - significant acidosis, particularly in patients
with an underlying acidosis due to other causes eg.DM.
➢ Even with RA, some pts complain of dull, aching pain or
become restless.
➢ During surgery, however, opioids and hypnotics are
usually effective.
➢ Postulated that tourniquet pain is caused by the
unblocking of unmyelinated C fibers during recession of a
neuraxial block
➢ Addition ofnarcotics to spinal or epidural anesthesia may
reduce tourniquet pain.

➢After tourniquet release, MAP falls significantly, partly owing

to release of metabolites from ischemic limb into circulation &
decrease in PVR.

➢ Advantages of TKR include exposure to risks of one

anesthetic, one postoperative course of pain, reduced
rehabilitation and hospitalization, and an earlier return to
baseline function.

➢TKA associated, however, with a higher incidence of serious

perioperative complications, including myocardial infarction,
fat embolization, and thromboembolic events.
 Anaesthetic technique
• General anaesthesia:
➢ if general anaesthesia is indicated, bleeding may be reduced
by modest hypotension in carefully selected patients, using
volatile agents.
➢ For hip arthroplasty, analgesia may be supplemented by the
use of a 3-in-1 (femoral/obturator/lateral cutaneous of thigh)
block.
➢ Some anaesthetists favour a lumbar plexus block because this
also blocks the sciatic nerve, which has a component
supplying the hip.
➢ For knee replacement, a 3-in-1 block combined with a sciatic
nerve block can be effective.
Regional anaesthesia :

Is technique of choice because it:

1. Reduce incidence of major periop complications with certain surgical

procedures, including DVT, PE, blood loss, respiratory complications.
2. Superior pain relief.
3. Peripheral nerve blocks employing long-acting anesthetics or
catheters may provide excellent intraop anesthesia and superior
postop analgesia.
4. Preemptive analgesia.
5. Manipulation of airway, & conscious patients can aid safest & most
comfortable positioning for surgery.
6. Suggested that epidural anesthesia reduces venous pressure, & this
is significant factor in determining surgical bleeding, decreased need
for bank blood and associated transfusion risks.
7. Sedation often desirable due to duration of operation, intraop noise.

8. Oxygen should be administered throughout the operative period.

9. As sedation deepens, airway obstruction or snoring may occur (not a

problem in the lateral position, but some supine patients may require a
nasopharyngeal airway).
 Intraoperative problems
• Patient position:
• in the lateral position, there is a risk of excessive lateral neck
flexion and pressure on the dependent limbs.

• Hypothermia:
• orthopaedic theatres colder than other theatres, with a
higher velocity airflow leading to more rapid patient cooling.
• Hypothermia causes poor wound healing, infection,
coagulopathy and CVS dysfunction.
• Fluid warmers, blankets and patient hats should be used
routinely.
Blood loss:
➢ Average blood loss in THR ranges from 300-1500 ml and may double in
the first 24 hours postop.
➢ During TKR with an intraoperative tourniquet, most blood loss occurs in
the recovery area.
➢Careful fluid balance is essential because compensation for hypovolaemia
is poor in the elderly.

Cement reactions:
➢ At the time of cementing, a drop in blood pressure and oxygen saturation
is often seen.
➢ Originally thought to be caused by a directly toxic effect of the methyl
methacrylate monomer component of the cement, but now known to be
caused by a shower of microemboli of blood, fat or platelets forced into
circulation by high intramedullary pressure during cement packing and
prosthesis insertion.
➢Subsequent embolisation to the lungs produces a raised
pulmonary vascular resistance and reduction in left ventricular
return, resulting in hypotension.
➢Microemboli are toxic to the lung parenchyma, causing
haemorrhage, alveolar collapse and hypoxia.
➢May be severe enough to cause cardiovascular collapse,
cardiac arrest and death.
➢Reactions are more common and more severe in bilateral joint
replacements
➢Therefore check vitals to ensure that the patient is not
hypovolaemic before cementing.
 Fat Embolism Syndrome
➢ Well-known complication of instrumentation of medullary canal.
➢ Physiologic response to fat within systemic circulation.
➢ Clinical manifestations of FES include respiratory, neurologic, hematologic,
and cutaneous signs and symptoms.
➢ Presentation of FES can be gradual, developing over 12 to 72 hours, or
fulminant leading to ARDS and cardiac arrest.
➢ Gurd and Wilson in 1974 suggested major and minor criteria to be used
for the diagnosis of FES.
➢ Presence of any 1 major + 4 minor criteria and evidence of fat
macroglobulinemia was required for diagnosis of FES.
➢ More recent investigations have indicated that quantity of fat in
circulation does not correlate with the severity of FES or development of
ARDS
 Gurd's Diagnosis of Fat Embolism
Syndrome
• Major Features (at least one)

➢ Respiratory insufficiency
➢ Cerebral involvement
➢ Petechial rash
• Minor Features (at least 4)
➢ Pyrexia
➢ Tachycardia
➢ Retinal changes
➢ Jaundice
➢ Renal changes Laboratory Features
➢ Fat microglobulinemia (required)
➢ Anemia
➢ Thrombocytopenia
➢ High erythrocyte sedimentation rate
Schonfeld Fat Embolism Syndrome Index
Sign Score
• Petechial rash 5
•Diffuse alveolar infiltrates 4
Hypoxemia Pao2<70 mm Hg
•Fio2 100%3Confusion 1
• Fever >38°C (>100.4°F) 1
Heart rate >120 beats/min 1
Respiratory rate >30 1

Score >5 required for diagnosis of fat embolism syndrome

➢Petechial rash is pathognomonic, usually present on
conjunctiva, oral mucosa, and skin folds of the neck and
axillae.

➢Mild hypoxemia and radiologic evidence of bilateral

alveolar infiltrates, <10% progress to ARDS.

➢ Neurologic manifestations – drowsiness, confusion,

obtundation and coma.

➢Treatment of FES is supportive with early resuscitation and

stabilization to minimize the stress response to hypoxemia,
hypotension, and diminished end-organ perfusion
 Deep Venous Thrombosis and Pulmonary Embolus

• VTE major cause of death after surgery or trauma to the lower

extremities.

• Incidence of fatal PE highest in THR for hip fracture.

• Effective thromboprophylaxis requires knowledge of clinical

risk factors in individual patients, such as advanced age,
prolonged immobility or bed rest, prior history of
thromboembolism, cancer, preexisting hypercoagulable state,
and major surgery.
 Antithrombotic Prophylaxis

• LMWH started 12 hr before surgery / 12-24 hr after sx, or 4-6

hr after sx at half usual dose & then increasing to usual high-
risk dose following day

• Fondaparinux (2.5 mg started 6-8 hr after surgery)

• Adjusted-dose warfarin started preop or the evening after
surgery (INR target, 2.5; INR range, 2.0 to 3.0)
• Intermittent pneumatic compression is an alternative option
to anticoagulant prophylaxis in patients undergoing total knee
(but not hip) replacement
 Neueraxial Anesthesia and Analgesia in the
Orthopaedic Patient Receiving Antithrombotic
Therapy
• LMWH
• placement should occur 10-12 hr after a dose.
• Indwelling neuraxial catheters are allowed with once, not twice daily) dosing of
LMWH.
• optimal to place/remove indwelling catheters in morning and administer LMWH in
evening to allow normalization of hemostasis to occur prior to catheter
manipulation
• WARFARIN
• Adequate levels of vit K-dependent factors should be present during catheter
placement and removal.
• Pts chronically on warfarin should have normal INR prior to performance of
regional technique.
• Monitor PT INR daily. Remove catheter when INR <1.5.
FONDAPARINUX
Neuraxial techniques not advised in pts who are anticipated to receive fondarinux
periop.

NONSTEROIDAL ANTI-INFLAMMATORY DRUGS

• No significant risk of RA-related bleeding is associated with aspirin-type drugs.

• pts receiving warfarin or LMWH, combined anticoagulant and antiplatelet effects may
increase risk of periop bleeding.

•other medications affecting platelet function such as thienopyridine derivatives and

glycoprotein IIb/IIIa platelet receptor inhibitors should be avoided.
 Postoperative Complications
• Cardiac Complications
• AHA guidelines recommend preop cardiac testing in pts at increased risk
on basis of clinical risk profile, functional capacity, and type of surgery.
• Orthopedic surgery - intermediate-risk
• Older pts have an increased risk of periop myocardial morbidity and
mortality after orthopedic surgery possible reasons for this increased risk
are as follows:
• multiple medical comorbid conditions
• limited functional capacity
• some ortho procedures initiate a systemic inflammatory response
syndrome,
• significant blood loss and fluid shifts
• postop pain is a major management problem after orthopedic surgery
• All
of these factors - stress response - tachycardia,
hypertension, increased oxygen demand, and myocardial
ischemia.

• In pts in whom percutaneous coronary intervention involved

placement of stents - added risks of restenosis and thrombosis

• if antiplatelet therapy discontinued before surgery -

increased periop bleeding if not discontinued.

• In elderly pts, β-blockers should be continued periop with a

target heart rate less than 80 beats/min.

• Decision to initiate postop physical therapy and

rehabilitation, depends on whether there has been a diagnosis
of a postoperative myocardial infarction.
Respiratory Complications
• elderly patients - progressive decrease in arterial oxygen
tension, an increase in closing volumes, decrease of approx
10% in FEV1 with each decade of life.

• Due to alterations in chest wall mechanics, exacerbated in

arthritis.

• hypoxia reflects respiratory changes caused by age or

embolization of bone marrow debris to the lungs in these
patients
Neurologic Complications
•confusion or delirium 3rd most common complication seen in elderly
patients

• associated with an increased length of hospital stay, poor functional

recovery, progression to dementia, and increased mortality.

• Postop delirium manifests as:

• attention and awareness deficits
• including acute confusion
•reduced ability to focus
•change in cognition
•irritability
•anxiety
•paranoia
• hallucinations.
• Develops acutely, but generally has a fluctuating course
over several days

• Major risk factors for postoperative delirium ›

•advanced age ›
•alcohol use ›
•preoperative dementia or cognitive impairment ›
•psychotropic medications ›
•multiple medical comorbid conditions.

•Perioperative events (hypoxemia, hypotension,

hypervolemia, abnormal electrolytes, infection, sleep
deprivation, pain, and administration of BZDs and
anticholinergic medications).
• Aging alters
pharmacokinetics and pharmacodynamics of
most medications, including anesthetics and analgesics.

•may have longer and more profound CNS effects on elderly

patients.

Strategies used to reduce incidence of postoperative

delirium –

•include identifying risk factors ›

•vulnerable and affected patients ›
•preserving orientation ›
•early mobilization ›
•adequate pain control ›
•maintenance of normal sleep cycles ›
•avoidance of psychotropic medications
 Postoperative management
• Analgesia
Epidural analgesia

• Excellent, particularly in reducing quadriceps muscle spasm following TKRs.

• Increased risk of urinary retention
• Catheterisation may cause a bacteraemia, increasing the risk of prosthesis
infection.

• Patient-controlled analgesia is the choice in many institu-tions. Intramuscular

opiates may also be considered.

• Regular paracetamol, 1 g/6 hours, should be given orally or rectally

NSAIDs used with caution, especially in elderly, owing to
increased risk of renal impairment.

Midazolam infusions or baclofen are sometimes required to

ease quadriceps muscle spasm.

Fluid balance: stringent fluid balance monitoring is

mandatory because blood loss may double in the first 24
hours. Nausea may reduce the patient’s oral intake.

Oxygen: perioperative ischaemia is common and generally

silent. Oxygen should be given for the first 72 hours
postoperatively.
 Conclusion
• Geriatric patients for joint replacement surgeries offer a
great challenge to the anaesthesiologists.

• A careful preoperative examination,preoperative

optimization, safe intraoperative anaesthetic techniques,good
postoperative pain relief, good postoperative followup with
rehabilitationwould aid in decreasing the morbidity in these
patients.
 REFERENCES
• Oxford handbook of anaesthesia; pg
443;chapter 18-Orthopaedic surgeries
• Kakar PN, Roy PM,Pant V, Das J.Anesthesia for
joint replacement surgery: Issues with
coexisting diseases .2011;27;315-22