WikiAnesthesia - User contributions [en]

Duchenne muscular dystrophy

2022-06-02T06:14:29Z

Mitchel.DeVita: added content

{{Infobox comorbidity
| other_names = DMD
| image =
| caption =
| anesthetic_relevance = High
| anesthetic_management = High risk for hyperkalemia, rhabdomyolysis, arrhythmia, difficult airway, respiratory insufficiency, and cardiomyopathy
| specialty =
| signs_symptoms = Proximal muscle weakness, respiratory insufficiency, and cardiomyopathy
| diagnosis =
| treatment =
}}Duchenne Muscular Dystrophy (DMD) is an X linked recessive, progressive myopathy resulting form a dystrophin gene mutation. Despite the rarity of this disease it represents a significant anesthetic challenge for both pediatric and adult patients.

==Anesthetic implications==

===Preoperative optimization===
-Electrolyte normalization especially potassium

-Cardiac testing including ECHO and EKG

-Pulmonary testing if not mechanically ventilated including PFTs

-thorough airway exam

===Intraoperative management===
-Anticipate difficult ventilation and intubation due to macroglossia, micrognathia, and highly limited mandible/c spine mobility.

-Patients are at increased risk of hyperthermia, rhabdomyolysis, and hyperkalemia. This risk is theoretically increased with exposure to halogenated inhalational anesthetics.

-They have an '''absolute contraindication''' to succinylcholine due to hyperkalemia arrest risk

-Exposure to inhaled anesthetics should be minimized in order to decrease risk of rhabdomyolysis. The use of sevofluorane has been reported for anesthetic induction in patients with muscular dystrophy with no associated complications. <ref>Echeverry-Marín, Piedad Ceciliaa; Bustamante-Vega, Ángela Maríab Anesthetic implications of muscular dystrophies, Colombian Journal of Anesthesiology: July-September 2018 - Volume 46 - Issue 3 - p 228-239

doi: 10.1097/CJ9.0000000000000059 </ref> A cautious approach, especially in pediatric patients requiring an inhaled induction should be to switch to a TIVA based approach immediately following intubation and IV line placement to theoretically lower the risk of rhabdomyolysis.

-Regional/neuraxial anesthesia is considered safe, but can be significantly more challenging given anatomy.

-Propofol, ketamine, opiates, midazolam have all been utilized safely in these patients.

-Rocuronium is also considered safe however delayed onset of action and prolonged duration have been reported <ref>Bhutia MP, Pandia MP, Rai A. Anaesthetic management of a case of Duchenne muscle dystrophy with Moyamoya disease. ''Indian J Anaesth''. 2014;58(2):219-221. doi:10.4103/0019-5049.130843</ref>

-Sugammadex use has not been fully established however it has minimal adverse cardiovascular events. In direct contrast, neostigmine may trigger acute myotonia, rhabdomyolysis, and arrhythmia.

-The risk of malignant hyperthermia is similar to that of the general population <ref>Birnkrant DJ, Panitch HB, Benditt JO, et al. American College of Chest Physicians consensus statement on the respiratory and related management of patients with Duchenne muscular dystrophy undergoing anesthesia or sedation. ''Chest'' 2007; 132:1977–1986.</ref>. The clinical presentation can be similar to MH (muscle rigidity, hyperkalemia, arrhythmia, cardiac arrest) however it fails to respond to dantrolene.

===Postoperative management===
-High sensitivity to opiates and higher risk for post op respiratory depression

-NSAIDs should be used carefully due to the risk of triggering rhabdomyolysis

-Consider transporting to ICU intubated, delaying extubation 24 to 48 hours, or consider the use of non-invasive mechanical ventilation

==Related surgical procedures==
Surgical airway including tracheostomy

==Pathophysiology==
X linked recessive, progressive myopathy resulting form a dystrophin gene mutation. Located on chromosome Xp21. Typically diagnosed during the ages of 3 to 5 and most commonly in males.

== Signs and symptoms ==
Typically patients present with progressive proximal muscle weakness at a young age, first manifested as weakness and growth delay. This eventually develops into diaphragmatic weakness and subsequent respiratory distress.

Patients develop florid respiratory distress and cardiomyopathy in advanced stage of the disease.

The patients have associated difficult airway anatomy in the form of macroglossia and limited mobility of mandible and cervical spine. They also can develop contractures of bilateral upper and lower extremities.

==Diagnosis==

==Treatment==

===Medication===

===Surgery===

===Prognosis===
Survival of these patients is generally only 20 to 30 years, and they ultimately succumb to ventilatory failure or heart failure.

==Epidemiology==

==References==

[[Category:Comorbidities]]

Duchenne muscular dystrophy

2022-06-02T05:48:20Z

Mitchel.DeVita: added content

{{Infobox comorbidity
| other_names =
| image =
| caption =
| anesthetic_relevance =
| specialty =
| signs_symptoms =
| diagnosis =
| treatment =
}}Duchenne Muscular Dystrophy (DMD) is an X linked recessive, progressive myopathy resulting form a dystrophin gene mutation. Despite the rarity of this disease it represents a significant anesthetic challenge for both pediatric and adult patients.

==Anesthetic implications==

===Preoperative optimization===
-Electrolyte normalization especially potassium

-Cardiac testing including ECHO and EKG

-Pulmonary testing if not mechanically ventilated including PFTs

-thorough airway exam

===Intraoperative management===
-Anticipate difficult ventilation and intubation due to macroglossia, micrognathia, and highly limited mandible/c spine mobility.

-Patients are at increased risk of hyperthermia, rhabdomyolysis, and hyperkalemia. This risk is theoretically increased with exposure to halogenated inhalational anesthetics.

-They have an '''absolute contraindication''' to succinylcholine due to hyperkalemia arrest risk

-Exposure to inhaled anesthetics should be minimized in order to decrease risk of rhabdomyolysis. The use of sevofluorane has been reported for anesthetic induction in patients with muscular dystrophy with no associated complications. <ref>Echeverry-Marín, Piedad Ceciliaa; Bustamante-Vega, Ángela Maríab Anesthetic implications of muscular dystrophies, Colombian Journal of Anesthesiology: July-September 2018 - Volume 46 - Issue 3 - p 228-239

doi: 10.1097/CJ9.0000000000000059 </ref> A cautious approach, especially in pediatric patients requiring an inhaled induction should be to switch to a TIVA based approach immediately following intubation and IV line placement to theoretically lower the risk of rhabdomyolysis.

-Regional/neuraxial anesthesia is considered safe, but can be significantly more challenging given anatomy.

-Propofol, ketamine, opiates, midazolam have all been utilized safely in these patients.

-Rocuronium is also considered safe however delayed onset of action and prolonged duration have been reported <ref>Bhutia MP, Pandia MP, Rai A. Anaesthetic management of a case of Duchenne muscle dystrophy with Moyamoya disease. ''Indian J Anaesth''. 2014;58(2):219-221. doi:10.4103/0019-5049.130843</ref>

-Sugammadex use has not been fully established however it has minimal adverse cardiovascular events and is likely safe. In direct contrast, neostigmine may trigger acute myotony, rhabdomyolysis, and arrhythmia.

-The risk of malignant hyperthermia is similar to that of the general population <ref>Birnkrant DJ, Panitch HB, Benditt JO, et al. American College of Chest Physicians consensus statement on the respiratory and related management of patients with Duchenne muscular dystrophy undergoing anesthesia or sedation. ''Chest'' 2007; 132:1977–1986.</ref>

===Postoperative management===

==Related surgical procedures==

==Pathophysiology==
X linked recessive, progressive myopathy resulting form a dystrophin gene mutation. Located on chromosome Xp21. Typically diagnosed during the ages of 3 to 5 and most commonly in males. Survival of these patients is generally only 20 to 30 years, and they ultimately succumb to ventilatory failure or heart failure.

== Signs and symptoms ==
Typically patients present with progressive proximal muscle weakness at a young age, first manifested as weakness and growth delay. This eventually develops into diaphragmatic weakness and subsequent respiratory distress.

Patients develop florid respiratory distress and cardiomyopathy in advanced stage of the disease.

The patients have associated difficult airway anatomy in the form of macroglossia and limited mobility of mandible and cervical spine. They also can develop contractures of bilateral upper and lower extremities.

==Diagnosis==

==Treatment==

===Medication===

===Surgery===

===Prognosis===

==Epidemiology==

==References==

[[Category:Comorbidities]]

Duchenne muscular dystrophy

2022-06-02T05:25:48Z

Mitchel.DeVita: added page and content

Joint replacement surgery

2022-05-31T08:08:51Z

Mitchel.DeVita: Started page

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Provide a brief summary of this surgical procedure and its indications here.

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Dacryocystorhinostomy

2022-05-31T08:08:47Z

Mitchel.DeVita: Started page

Orbitotomy

2022-05-31T08:08:33Z

Mitchel.DeVita: Started page

Fixation of fractures and dislocations of the wrist and hand

2022-05-31T08:07:57Z

Mitchel.DeVita: Started page

Repair of laceracted nerves/tendons of the hand

2022-05-31T08:07:50Z

Mitchel.DeVita: Started page

Carpal tunnel release

2022-05-31T08:06:02Z

Mitchel.DeVita: started page and added information

{{Infobox surgical procedure
| anesthesia_type = Regional or MAC
| airway = natural airway
| lines_access = 1 PIV
| monitors = standard
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Surgical procedure that involves cutting the transverse carpal ligament to release median nerve compression at the wrist.

== Overview ==

=== Indications ===
Carpal tunnel syndrome

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===
Typically not required unless patient pathology dictates

=== Operating room setup ===
setup for MAC with possible sedation. Backup GA setup

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===
Case typically performed under regional (often axillary) or MAC

== Intraoperative management ==

=== Monitoring and access ===
1 PIV

Standard ASA monitoring

=== Induction and airway management ===
MAC with natural airway

=== Positioning ===
Supine

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===
Tendon/nerve laceration

Bleeding

Infection

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Hand or digit replantation

2022-05-31T07:59:59Z

Mitchel.DeVita: Started page

Ventriculocisternostomy

2022-05-31T07:59:29Z

Mitchel.DeVita: Started page

CSF aspiration, diversion, or shunt procedures

2022-05-31T07:59:18Z

Mitchel.DeVita: Started page

Anterior thoracic spine surgery

2022-05-31T07:58:56Z

Mitchel.DeVita: Started page

Craniotomy for resection of epileptogenic focus

2022-05-31T07:58:20Z

Mitchel.DeVita: Started page

Anterior cervical spine surgery

2022-05-31T07:57:50Z

Mitchel.DeVita: added info

{{Infobox surgical case reference
| anesthesia_type = General
| airway = ETT
| lines_access = PIV, possible arterial line
| monitors = Standard, possible invasive BP monitoring, possible neuromonitoring
| considerations_preoperative = Neck ROM, preoperative neurologic exam
| considerations_intraoperative = TIVA for neuromonitoring
| considerations_postoperative =
}}

Provide a brief summary of this surgical procedure and its indications here.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|Potentially limited neck ROM related to pain, trauma, or mechanical stabilization devices leading to more challenging airway. Potential unstable cervical spine, instrumentation could cause permanent paralysis. Consider awake intubation if high concern for unstable spine or difficult airway.
|-
|Neurologic
|Possible preexisting motor and/or sensory deficits, particularly in the upper extremities. These symptoms may be exacerbated by head/neck positioning. May have chronic pain.
|-
|Cardiovascular
|Intraoperative bradycardia related to traction on the carotid bulb.
|-
|Pulmonary
|Limited neck ROM related to pain or structural changes can cause difficult laryngoscopy. Recurrent laryngeal nerve potentially at risk of damage intraop.
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===
Potentially limited neck ROM related to pain, trauma, or mechanical stabilization devices leading to more challenging airway. Potential unstable cervical spine, instrumentation could cause permanent paralysis. Consider awake intubation if high concern for unstable spine or difficult airway. Consider neuro exam following awake intubation if concern for cervical spine injury.

=== Positioning ===
Positioned supine, typically on a doughnut gel pillow to facilitate neck positioning.

=== Maintenance and surgical considerations ===

* Neuromonitoring may be used to detect potential nerve/spinal cord injury. In these cases, surgical teams typically require no paralytic and frequently request TIVA techniques to minimize the affect of anesthetic on neuromonitoring.

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

* Neck hematoma
* Airway edema
* Injury to cranial nerves, recurrent laryngeal nerve, and/or superior laryngeal nerve
* Dural tear

== Procedure variants ==

{| class="wikitable"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Dental extraction

2022-05-31T07:53:30Z

Mitchel.DeVita: Started page

Craniotomy for trauma

2022-05-31T07:53:03Z

Mitchel.DeVita: Started page, added info

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = large bore PIV, arterial line, consider central line if poor peripheral access or long term infusions required, ICP drain/monitor
| monitors = Standard plus arterial line and ICP monitoring
| considerations_preoperative = Full stomach, preop neuro exam
| considerations_intraoperative = bleeding, ICP changes
| considerations_postoperative =
}}

Provide a brief summary of this surgical procedure and its indications here.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===
Preop: CBC for baseline hemoglobin, CMP for electrolytes including sodium and potassium, INR given possible anticoagulants use

Intraop: Serial hemoglobin. Consider frequent Na checks if utilizing hypertonic saline, K checks if hyperventilating. TEG/coagulation studies as needed for resuscitation

=== Operating room setup ===
General anesthesia setup including fluid warmer/blood tubing, arterial line monitoring/setup, multiple infusion pumps, and consider ICP monitoring/drain as guided by neurosurgery.

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===
Needs arterial line

Consider ICP monitoring as guided by neurosurgery

=== Induction and airway management ===
Avoid increased ICP during induction

=== Positioning ===

=== Maintenance and surgical considerations ===
ICP monitoring and possible reduction including:

* ICP draining
* Hyperventilation
* Steroids
* Antileptics
* Mannitol
* Hypertonic saline
* Head of bed position (as possible)

=== Emergence ===

== Postoperative management ==

=== Disposition ===
Neuro critical care unit

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Splenorrhaphy

2022-05-31T07:45:42Z

Mitchel.DeVita: Started page

Gastric or duodenal perforation repair

2022-05-31T07:45:35Z

Mitchel.DeVita: Started page

Percutaneous endoscopic gastrostomy

2022-05-31T07:45:27Z

Mitchel.DeVita: Started page

Open vertical sleeve gastrectomy

2022-05-31T07:44:23Z

Mitchel.DeVita: Started page

Laparoscopic adjustable gastric banding

2022-05-31T07:44:16Z

Mitchel.DeVita: Started page

Gastric restrictive surgery

2022-05-31T07:43:50Z

Mitchel.DeVita: Started page

Biliopancreatic diversion with duodenal switch

2022-05-31T07:43:29Z

Mitchel.DeVita:

Trauma surgery

2022-05-31T07:42:53Z

Mitchel.DeVita: started page

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = Large bore PIV (14, 16g), Sheath introducers (Cordis), triple lumen central line, arterial line
| monitors =
| considerations_preoperative = Full stomach, airway trauma, hypovolemia
| considerations_intraoperative = bleeding
| considerations_postoperative =
}}

Provide a brief summary of this surgical procedure and its indications here.

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Awake fiberoptic intubation

2022-05-31T07:39:41Z

Mitchel.DeVita: started page

Intubating an awake patient with a fiberoptic scope after tropicalizing and numbing the oropharynx and glottic structures. Typically performed for suspected or known difficult airways or an unstable cervical spine.

Can be done via oral or nasal approach guided by nature of surgery, nature of difficult airway, or provider preference. Oral approach has several benefits including less overall distance, less bleeding risk, no need to dilate the nares, and typically quicker.

Equipment and setup:

* lidocaine gel
* 4% lidocaine
* tongue blade wrapped in gauze, dipped in lidocaine gel.
* 10cc syringe with 4% lidocaine with a 22g needle for transtracheal block
* nasal cannula or face mask
* fiberoptic bronchoscope opened, tested, and set up
* glycopyrrolate or diphenhydramine to dry oropharynx
* consider sedation if neuro exam is less important, options include, midazolam, fentanyl, propofol, dexmedetomidine, or ketamine among others.

LMA Supreme

2022-05-31T07:29:40Z

Mitchel.DeVita: formatting

A laryngeal mask airway is a supraglottic airway device which allows for controlled ventilation and delivery of anesthetic gases without requiring laryngoscopy or instrumentation of the trachea. It is considered to be a less secure airway device than an [[endotracheal tube]].

LMA® Supreme™ Airway is advertised to increase efficacy and safety versus first-generation devices including decreased aspiration risk.

Features include:

* Elongated cuff to help with smooth insertion
* Distal tip with laryngeal and esophageal seals
* Integrated bite block
* Tab to help with securing device

Sizing chart:
{| class="wikitable"
|+
!LMA Size
!Weight (KG)
|-
|1
|<5
|-
|1.5
|5-10
|-
|2
|10-20
|-
|2.5
|20-30
|-
|3
|30-50
|-
|4
|50-70
|-
|5
|70-100
|}

LMA Supreme

2022-05-31T07:29:11Z

Mitchel.DeVita: added info

A laryngeal mask airway is a supraglottic airway device which allows for controlled ventilation and delivery of anesthetic gases without requiring laryngoscopy or instrumentation of the trachea. It is considered to be a less secure airway device than an [[endotracheal tube]].

LMA® Supreme™ Airway from is advertised to increase efficacy and safety versus first-generation devices including decreased aspiration risk.

Features include:

* Elongated cuff to help with smooth insertion
* Distal tip with laryngeal and esophageal seals
* Integrated bite block
* Tab to help with securing device

Sizing chart:
{| class="wikitable"
|+
!LMA Size
!Weight (KG)
|-
|1
|<5
|-
|1.5
|5-10
|-
|2
|10-20
|-
|2.5
|20-30
|-
|3
|30-50
|-
|4
|50-70
|-
|5
|70-100
|}

LMA Unique

2022-05-31T07:24:34Z

Mitchel.DeVita: added definition of LMA

A laryngeal mask airway is a supraglottic airway device which allows for controlled ventilation and delivery of anesthetic gases without requiring laryngoscopy or instrumentation of the trachea. It is considered to be a less secure airway device than an [[endotracheal tube]].

LMA (laryngeal mask airway)® Unique™ is a first generation LMA utilizing a silicone Cuff with integrated cuff pressure monitoring device. It is advertised to have better elasticity, seal pressures, and decreased sore throat risk vs PVC LMA cuffs.

Sizing chart:
{| class="wikitable"
|+
!LMA Size
!Weight (KG)
|-
|1
|<5
|-
|1.5
|5-10
|-
|2
|10-20
|-
|2.5
|20-30
|-
|3
|30-50
|-
|4
|50-70
|-
|5
|70-100
|}

LMA Unique

2022-05-31T07:23:45Z

Mitchel.DeVita: added info

LMA (laryngeal mask airway)® Unique™ is a first generation LMA utilizing a silicone Cuff with integrated cuff pressure monitoring device. It is advertised to have better elasticity, seal pressures, and decreased sore throat risk vs PVC LMA cuffs.

Sizing chart:
{| class="wikitable"
|+
!LMA Size
!Weight (KG)
|-
|1
|<5
|-
|1.5
|5-10
|-
|2
|10-20
|-
|2.5
|20-30
|-
|3
|30-50
|-
|4
|50-70
|-
|5
|70-100
|}

Deep extubation

2022-05-31T07:16:43Z

Mitchel.DeVita:

Intubation and extubation (Endotracheal tube (ETT) removal) represent a critically important phase of anesthesia care where multiple potentially catastrophic complications can occur. Therefore modern practice has focused on limiting adverse events during these stages. Intubation is accompanied with an algorithm designed to help providers navigate challenging airways. While extubation generally carries guidelines and practical measure to help guide extubation readiness, deep vs awake ETT removal is often left to provider discretion.

In general, patients are extubated when either under general anesthesia (GA) (deep) or awake and following commands, and not between these two states. Most adults are extubated awake while healthy pediatric patients are commonly extubated deep.

A few general exclusions that should preclude a deep extubation: difficult airway (mask or intubation), full stomach, severe OSA, or other pathology that limits adequate spontaneous ventilation.

Classic routine awake extubation is considered when patients are well oxygenated with adequate spontaneous ventilation including frequency, regularity, and tidal volume as guided spirometry and end-tidal carbon dioxide (CO2). In addition the awake extubation is performed after the patient demonstrates the ability to follow commands such as sustained head lift, tongue protrusion, hand grip and release, etc.

Deep extubation is defined as ETT removal while under full general anesthesia (no response to surgical stimulus). If on volatile anesthesia, 1.0 MAC or higher is typically required. Patient should have full paralytic reversal and adequate spontaneous ventilation including frequency, regularity, and tidal volume as guided spirometry, SaO2, and end-tidal carbon dioxide (CO2). Deep oropharyngeal suction to both remove any secretions and also identify breath holding or response to stimulus. If no grimace or breath holding, the patient is considered "deep" and extubation can proceed. Following ETT removal, supplemental O2 via face mask is applied and ventilation should be closely monitored to identify obstruction, spasm, or poor effort. Oral/nasal airways, jaw thrust, or other maneuvers may be required to overcome obstruction.

Benefits include:

* Decrease coughing, gagging, bucking on the ETT
* Potentially more calm and smooth emergence

Risks include:

* Potentially unprotected airway in an anesthetized patient
* Theoretical risk of laryngospasm
* Increased risk of airway obstruction

A meta analysis in 2018 with 17 randomized trials and a total of 1881 pediatric patients had several interesting findings:<ref>Koo CH, Lee SY, Chung SH, Ryu JH. Deep vs. Awake Extubation and LMA Removal in Terms of Airway Complications in Pediatric Patients Undergoing Anesthesia: A Systemic Review and Meta-Analysis. ''J Clin Med''. 2018;7(10):353. Published 2018 Oct 14. doi:10.3390/jcm7100353</ref>
{| class="wikitable"
|+
!Deep vs awake extubation
!Result
!Odds ratio
|-
|Overall complications
|No difference
|OR 0.5, 95% CI 0.23–1.11, ''p'' = 0.09
|-
|Airway obstruction
|'''Favors awake'''
|OR 2.67, 95% CI 1.03–6.94, ''p'' = 0.04
|-
|Cough
|'''Favors deep'''
|OR 0.25, 95% CI 0.10–0.60, ''p'' = 0.002
|-
|Desaturation (<96%)
|No difference
|OR 0.43, 95% CI 0.17–1.09, ''p'' = 0.08
|-
|Laryngospasm
|No difference
|OR 1.12, 95% CI 0.57-2.17, ''p'' = 0.75
|-
|Breath holding
|No difference
|OR 0.77, 95% CI 0.27–2.18, ''p'' = 0.62
|}

Deep extubation

2022-05-31T07:16:22Z

Mitchel.DeVita: added page, described deep vs awake, added study results

Intubation and extubation (Endotracheal tube (ETT) removal) represent a critically important phase of anesthesia care where multiple potentially catastrophic complications can occur. Therefore modern practice has focused on limiting adverse events during these stages. Intubation is accompanied with an algorithm designed to help providers navigate challenging airways. While extubation generally carries guidelines and practical measure to help guide extubation readiness, deep vs awake ETT removal is often left to provider discretion.

In general, patients are extubated when either under general anesthesia (GA) (deep) or awake and following commands, and not between these two states. Most adults are extubated awake while healthy pediatric patients are commonly extubated deep.

A few general exclusions that should preclude a deep extubation: difficult airway (mask or intubation), full stomach, severe OSA, or other pathology that limits adequate spontaneous ventilation.

Classic routine awake extubation is considered when patients are well oxygenated with adequate spontaneous ventilation including frequency, regularity, and tidal volume as guided spirometry and end-tidal carbon dioxide (CO2). In addition the awake extubation is performed after the patient demonstrates the ability to follow commands such as sustained head lift, tongue protrusion, hand grip and release, etc.

Deep extubation is defined as ETT removal while under full general anesthesia (no response to surgical stimulus). If on volatile anesthesia, 1.0 MAC or higher is typically required. Patient should have full paralytic reversal and adequate spontaneous ventilation including frequency, regularity, and tidal volume as guided spirometry, SaO2, and end-tidal carbon dioxide (CO2). Deep oropharyngeal suction to both remove any secretions and also identify breath holding or response to stimulus. If no grimace or breath holding, the patient is considered "deep" and extubation can proceed. Following ETT removal, supplemental O2 via face mask is applied and ventilation should be closely monitored to identify obstruction, spasm, or poor effort. Oral/nasal airways, jaw thrust, or other maneuvers may be required to overcome obstruction.

Benefits include:

* Decrease coughing, gagging, bucking on the ETT
* Potentially more calm and smooth emergence

Risks include:

* Potentially unprotected airway in an anesthetized patient
* Theoretical risk of laryngospasm
* Increased risk of airway obstruction

A meta analysis in 2018 with 17 randomized trials and a total of 1881 pediatric patients had several interesting findings:<ref>Koo CH, Lee SY, Chung SH, Ryu JH. Deep vs. Awake Extubation and LMA Removal in Terms of Airway Complications in Pediatric Patients Undergoing Anesthesia: A Systemic Review and Meta-Analysis. ''J Clin Med''. 2018;7(10):353. Published 2018 Oct 14. doi:10.3390/jcm7100353</ref>
{| class="wikitable"
|+
!Deep vs awake extubation
!Result
!Odds ratio
|-
|Overall complications
|No difference
|OR 0.5, 95% CI 0.23–1.11, ''p'' = 0.09
|-
|Airway obstruction
|Favors awake
|OR 2.67, 95% CI 1.03–6.94, ''p'' = 0.04
|-
|Cough
|Favors deep
|OR 0.25, 95% CI 0.10–0.60, ''p'' = 0.002
|-
|Desaturation (<96%)
|No difference
|OR 0.43, 95% CI 0.17–1.09, ''p'' = 0.08
|-
|Laryngospasm
|No difference
|OR 1.12, 95% CI 0.57-2.17, ''p'' = 0.75
|-
|Breath holding
|No difference
|OR 0.77, 95% CI 0.27–2.18, ''p'' = 0.62
|}

Deep extubation

2022-05-31T06:43:53Z

Mitchel.DeVita: Created page with "Intubation and extubation (Endotracheal tube (ETT) removal) represent a critically important phase of anesthesia care where multiple potentially catastrophic complications can occur. Therefore modern practice has focused on limiting adverse events during these stages. Intubation is accompanied with an algorithm designed to help providers navigate challenging airways. While extubation generally carries guidelines and practical measure to help guide extubation readiness, d..."

Sports surgery

2022-05-31T06:37:28Z

Mitchel.DeVita: Created page with "{{Infobox surgical procedure | anesthesia_type = | airway = | lines_access = | monitors = | considerations_preoperative = | considerations_intraoperative = | considerations_postoperative = }} Provide a brief summary of this surgical procedure and its indications here. == Overview == === Indications === === Surgical procedure === == Preoperative management == === Patient evaluation<!-- Describe the unique and important aspects of preoperative evaluation. Add..."

Spine surgery

2022-05-31T06:37:19Z

Shoulder surgery

2022-05-31T06:36:57Z

Orthopedic oncology surgery

2022-05-31T06:36:52Z

Knee surgery

2022-05-31T06:36:36Z

Hip surgery

2022-05-31T06:36:30Z

Hip arthroplasty

2022-05-31T06:35:30Z

Mitchel.DeVita:

{{Infobox surgical procedure
| anesthesia_type = General or spinal
± Regional
| airway = ETT if general
| lines_access = Large bore IV
± Arterial line
| monitors = Standard
± ABP
| considerations_preoperative =
| considerations_intraoperative = Risk for bone cement implantation syndrome (BCIS)
| considerations_postoperative = Multimodal analgesia
}}'''Hip arthroplasty''' ('''THA''') has become one of the most common orthopedic surgical procedures performed since 1960, and it is often one of the most successful. Indications for total hip arthroplasty include osteoarthritis, traumatic arthritis, avascular necrosis, post-proximal fracture arthrosis, and congenital hip dislocation. It is typically performed in patients ages 60 and over, but has been performed in patients of all ages depending on etiology. Older patients tend to require hip arthroplasty for indications like hip fracture and subsequent arthrosis/arthritis, osteoarthritis, while patients of all ages may require hip arthroplasty for indications such as traumatic arthritis and (juvenile) rheumatoid arthritis.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|RA pts: assess for cervical nerve root compression and antlanto-occipital instability. Imaging (lateral film XR) and exam performed as this will alter airway and positioning plans.

If regional planned: assess for presence of neurologic conditions (MS, neuropathies, existing nerve injuries) that may be relative contraindications
|-
|Cardiovascular
|Standard evaluation: more important for older patients with more cardiovascular risk factors. Often will need pharmacologic stress testing as pain and arthritis limit exercise capacity.
RA patients, consider increased risk for conduction abnormalities, valvular pathology (AR, valvular fibrosis), pericardial effusion.
|-
|Pulmonary
|Standard exercise capacity evaluation. In obese patients, evaluate for OSA and potential for resultant pHTN. In RA patients, consider pulmonary fibrosis, effusions, glottic narrowing. For all patients with arthritis, evaluate mouth opening (arthriticTMJ).
|-
|Gastrointestinal
|Standard evaluation including NPO status
|-
|Hematologic
|Consider patient anticoagulation status and direct for proper holding of anticoagulation, particularly as regional is used often in these cases. Preoperative hemoglobin should be obtained, as well as type and screen. Consider preoperative blood order (especially if revision).
|-
|Renal
|Preoperative kidney function (Cr, electrolytes) may be considered (effects on drug clearance; more important in geriatric populations).
|-
|Endocrine
|Standard evaluation, blood sugar control important for postoperative wound healing
|-
|Other
|Consider home pain medication regimen; will help guide perioperative analgesic plan.
|}

=== Labs and studies ===

* Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P.
* At a minimum, all patients should have a preoperative hemoglobin and type and screen on file prior to case start.
* If procedure is to be a revision, strongly consider ordering preoperative packed red blood cells (PRBCs).

=== Operating room setup ===
Standard operating room setup. Airway setup, suction, IV setup, induction medications, emergency drugs, analgesic agents should be prepared and readily accessible.

Tranexamic acid prior to incision and at closure being used in greater frequency for blood loss control<ref>{{Cite journal|last=Rajesparan|first=K.|last2=Biant|first2=L. C.|last3=Ahmad|first3=M.|last4=Field|first4=R. E.|date=2009-06|title=The effect of an intravenous bolus of tranexamic acid on blood loss in total hip replacement|url=https://pubmed.ncbi.nlm.nih.gov/19483232|journal=The Journal of Bone and Joint Surgery. British Volume|volume=91|issue=6|pages=776–783|doi=10.1302/0301-620X.91B6.22393|issn=2044-5377|pmid=19483232}}</ref><ref>{{Cite journal|last=Peng Zhang|first=M. M.|last2=Jifeng Li|first2=M. M.|last3=Xiao Wang|first3=M. M.|date=2017-07|title=Combined versus single application of tranexamic acid in total knee and hip arthroplasty: A meta-analysis of randomized controlled trials|url=https://pubmed.ncbi.nlm.nih.gov/28602763|journal=International Journal of Surgery (London, England)|volume=43|pages=171–180|doi=10.1016/j.ijsu.2017.05.065|issn=1743-9159|pmid=28602763}}</ref>

Antibiotics considerations: Beta-lactam (cefazolin) +/- glycopeptide (vancomycin)

=== Patient preparation and premedication ===

* Multimodal analgesic technique recommended.
* Preoperative COX-2 inhibitors, gabapentin, and acetaminophen can be considered.
* Enhanced recovery protocols<ref>{{Cite journal|last=Wainwright|first=Thomas W.|last2=Gill|first2=Mike|last3=McDonald|first3=David A.|last4=Middleton|first4=Robert G.|last5=Reed|first5=Mike|last6=Sahota|first6=Opinder|last7=Yates|first7=Piers|last8=Ljungqvist|first8=Olle|date=2020-01-02|title=Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations|url=https://doi.org/10.1080/17453674.2019.1683790|journal=Acta Orthopaedica|volume=91|issue=1|pages=3–19|doi=10.1080/17453674.2019.1683790|issn=1745-3674|pmc=PMC7006728|pmid=31663402}}</ref> are using PO multimodal medications with greater frequency

=== Regional and neuraxial techniques ===
Advantages to neuraxial and regional techniques:

* improved postoperative pain control

* decreased risk of DVT/PE
* decreased intraoperative blood loss.

Neuraxial techniques (particularly spinal anesthesia) have been used with success in patients undergoing THA and especially beneficial in patients who may have a complicated or difficult airway. See [[Topic:Wbvci9l4oaxluxwj|discussion on drug choice]].
{| class="wikitable wikitable-horizontal-scroll"
|+
!Drug
!Conc.
!Baricity
!Dose
!Duration*
(min)
!Unique
Side-Effects
|-
|Bupivicaine<ref name=":0">{{Cite journal|last=Frey|first=K.|last2=Holman|first2=S.|last3=Mikat-Stevens|first3=M.|last4=Vazquez|first4=J.|last5=White|first5=L.|last6=Pedicini|first6=E.|last7=Sheikh|first7=T.|last8=Kao|first8=T. C.|last9=Kleinman|first9=B.|last10=Stevens|first10=R. A.|date=1998-03|title=The recovery profile of hyperbaric spinal anesthesia with lidocaine, tetracaine, and bupivacaine|url=https://pubmed.ncbi.nlm.nih.gov/9570604|journal=Regional Anesthesia and Pain Medicine|volume=23|issue=2|pages=159–163|doi=10.1097/00115550-199823020-00008|issn=1098-7339|pmid=9570604}}</ref><ref name=":1">{{Cite journal|last=Malinovsky|first=J. M.|last2=Charles|first2=F.|last3=Kick|first3=O.|last4=Lepage|first4=J. Y.|last5=Malinge|first5=M.|last6=Cozian|first6=A.|last7=Bouchot|first7=O.|last8=Pinaud|first8=M.|date=2000-12|title=Intrathecal anesthesia: ropivacaine versus bupivacaine|url=https://pubmed.ncbi.nlm.nih.gov/11094000|journal=Anesthesia and Analgesia|volume=91|issue=6|pages=1457–1460|doi=10.1097/00000539-200012000-00030|issn=0003-2999|pmid=11094000}}</ref>
|0.75%
|Hyperbaric
|12-16mg
|90-120
|
|-
|Bupivicaine<ref name=":0" /><ref name=":1" />
|0.5%
|Isobaric
|12-16mg
|90-120
|
|-
|Lidocaine<ref name=":0" /><ref>{{Cite journal|last=Liam|first=B. L.|last2=Yim|first2=C. F.|last3=Chong|first3=J. L.|date=1998-07|title=Dose response study of lidocaine 1% for spinal anaesthesia for lower limb and perineal surgery|url=https://pubmed.ncbi.nlm.nih.gov/9717596|journal=Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie|volume=45|issue=7|pages=645–650|doi=10.1007/BF03012094|issn=0832-610X|pmid=9717596}}</ref><ref>{{Cite journal|last=Pawlowski|first=Julius|last2=Orr|first2=Kevin|last3=Kim|first3=Ku-Mie|last4=Pappas|first4=Ana Lucia|last5=Sukhani|first5=Radha|last6=Jellish|first6=W. Scott|date=2012-03|title=Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures|url=https://pubmed.ncbi.nlm.nih.gov/22342508|journal=Journal of Clinical Anesthesia|volume=24|issue=2|pages=109–115|doi=10.1016/j.jclinane.2011.06.014|issn=1873-4529|pmid=22342508}}</ref>
|1-2%
5%
|Isobaric;
hyperbaric
|60-80mg
|60-90
|TNS (7%)
|-
|Mepivicaine<ref>{{Cite journal|last=Pawlowski|first=Julius|last2=Orr|first2=Kevin|last3=Kim|first3=Ku-Mie|last4=Pappas|first4=Ana Lucia|last5=Sukhani|first5=Radha|last6=Jellish|first6=W. Scott|date=2012-03|title=Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures|url=https://pubmed.ncbi.nlm.nih.gov/22342508|journal=Journal of Clinical Anesthesia|volume=24|issue=2|pages=109–115|doi=10.1016/j.jclinane.2011.06.014|issn=1873-4529|pmid=22342508}}</ref><ref>{{Cite journal|last=Pawlowski|first=J.|last2=Sukhani|first2=R.|last3=Pappas|first3=A. L.|last4=Kim|first4=K. M.|last5=Lurie|first5=J.|last6=Gunnerson|first6=H.|last7=Corsino|first7=A.|last8=Frey|first8=K.|last9=Tonino|first9=P.|date=2000-09|title=The anesthetic and recovery profile of two doses (60 and 80 mg) of plain mepivacaine for ambulatory spinal anesthesia|url=https://pubmed.ncbi.nlm.nih.gov/10960380|journal=Anesthesia and Analgesia|volume=91|issue=3|pages=580–584|doi=10.1097/00000539-200009000-00015|issn=0003-2999|pmid=10960380}}</ref><ref>{{Cite journal|last=Zayas|first=V. M.|last2=Liguori|first2=G. A.|last3=Chisholm|first3=M. F.|last4=Susman|first4=M. H.|last5=Gordon|first5=M. A.|date=1999-11|title=Dose response relationships for isobaric spinal mepivacaine using the combined spinal epidural technique|url=https://pubmed.ncbi.nlm.nih.gov/10553828|journal=Anesthesia and Analgesia|volume=89|issue=5|pages=1167–1171|issn=0003-2999|pmid=10553828}}</ref><ref>{{Cite journal|last=Schwenk|first=Eric S.|last2=Kasper|first2=Vincent P.|last3=Smoker|first3=Jordan D.|last4=Mendelson|first4=Andrew M.|last5=Austin|first5=Matthew S.|last6=Brown|first6=Scot A.|last7=Hozack|first7=William J.|last8=Cohen|first8=Alexa J.|last9=Li|first9=Jonathan J.|last10=Wahal|first10=Christopher S.|last11=Baratta|first11=Jaime L.|date=2020-10-01|title=Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation|url=https://pubmed.ncbi.nlm.nih.gov/32852904|journal=Anesthesiology|volume=133|issue=4|pages=801–811|doi=10.1097/ALN.0000000000003480|issn=1528-1175|pmid=32852904}}</ref>
|1.5%
|Isobaric
|50-80mg
|100-120
|TNS (7%)
|-
|Chloroprocaine<ref>{{Cite journal|last=Goldblum|first=E.|last2=Atchabahian|first2=A.|date=2013-05|title=The use of 2-chloroprocaine for spinal anaesthesia: Chloroprocaine for spinal anaesthesia|url=http://doi.wiley.com/10.1111/aas.12071|journal=Acta Anaesthesiologica Scandinavica|language=en|volume=57|issue=5|pages=545–552|doi=10.1111/aas.12071}}</ref><ref>{{Cite journal|last=Lacasse|first=Marie-Andrée|last2=Roy|first2=Jean-Denis|last3=Forget|first3=Josée|last4=Vandenbroucke|first4=Franck|last5=Seal|first5=Robert F.|last6=Beaulieu|first6=Danielle|last7=McCormack|first7=Michael|last8=Massicotte|first8=Luc|date=2011-04|title=Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: a double-blind randomized trial|url=http://link.springer.com/10.1007/s12630-010-9450-x|journal=Canadian Journal of Anesthesia/Journal canadien d'anesthésie|language=en|volume=58|issue=4|pages=384–391|doi=10.1007/s12630-010-9450-x|issn=0832-610X}}</ref><ref>{{Cite journal|last=Kouri|first=Mary E.|last2=Kopacz|first2=Dan J.|date=2004-01|title=Spinal 2-Chloroprocaine: A Comparison with Lidocaine in Volunteers:|url=http://journals.lww.com/00000539-200401000-00020|journal=Anesthesia & Analgesia|language=en|pages=75–80|doi=10.1213/01.ANE.0000093228.61443.EE|issn=0003-2999}}</ref><ref>{{Cite journal|last=Smith|first=Kristin N.|last2=Kopacz|first2=Dan J.|last3=McDonald|first3=Susan B.|date=2004-01|title=Spinal 2-chloroprocaine: a dose-ranging study and the effect of added epinephrine|url=https://pubmed.ncbi.nlm.nih.gov/14693591|journal=Anesthesia and Analgesia|volume=98|issue=1|pages=81–88, table of contents|doi=10.1213/01.ane.0000093361.48458.6e|issn=0003-2999|pmid=14693591}}</ref>
|2%
|Hyperbaric
|30-60mg
|30-50 (2-level regression)
60-90 (motor)

100-130 (ambulation)
|Flu-like symptoms
and back ache with

epinephrine addition
|}
Standard consideration of patient factors as they related to absolute/relative contraindications should be undertaken. Additional considerations for post operative mobilization. Some surgical teams and fast tracking joint replacement centers may mobilize patients as early as 2-4 hours postoperatively to help prevent DVT. <ref>Chua, Matthew J et al. “Early mobilisation after total hip or knee arthroplasty: A multicentre prospective observational study.” ''PloS one'' vol. 12,6 e0179820. 27 Jun. 2017, doi:10.1371/journal.pone.0179820</ref>

Time of procedure should also be considered, as spinal anesthesia has a limited duration of action (typically 2-3 hours, depending on agents used).

Intrathecal long-acting morphine can be considered for postoperative pain control with an understanding that patient selection is important for administration of this medication given the risk for respiratory depression and long duration of action.

Single shot peripheral regional nerve blocks can be used to improve postoperative analgesia, but are not sufficient as a primary anesthetic. Patients must be able to assume the position required to place these blocks. Blocks can help reduce postoperative opiate requirements. Blocks used include:

* femoral
* lumbar plexus
* quadratus lumborum (QL)
* fascia iliaca

== Intraoperative management ==

=== Monitoring and access===
Standard ASA monitoring. Consider addition of intraoperative EEG monitoring (BIS or similar).

2 large-bore PIV should be obtained. Arterial line for hemodynamic monitoring should be considered for revision procedures, cases with predicted significant blood loss, and for patients with significant cardiopulmonary disease.

=== Induction and airway management===
Induction can be tailored to individual patient comorbidities and acuity. RSI induction is indicated for trauma patients or those without proper fasting per ASA guidelines. For patients with rheumatoid arthritis, special consideration should be given to the airway and potential for cervical (atlanto-occipital) instability. In these cases, videolaryngoscopy or fiberoptic intubation should be considered and utilized.

Induction and intubation on the preoperative bed prior to moving to the operating room table should be considered if possible for patients in whom it would cause significant pain (and resultant physiologic and emotional stress) to execute this move.

=== Positioning===
{| class="wikitable wikitable-horizontal-scroll"
|+
!Surgical Approach
!Lateral
!Posterior
!Anterior/Anterolateral
|-
|Position
|Lateral decubitus
|Lateral decubitus
|Supine
|-
|Special Equipment
|Axillary roll/bean bag
|Axillary roll/bean bag
|Hana Table
Traction boots attachment to Hana table
|-
|Positioning Concerns
|Brachial plexus injury
Neck positioning

Check PIV flow
|Brachial plexus injury
Neck positioning

Check PIV flow
|
|}
If lateral positioning, a beanbag and axillary roll are typically used. Additional blankets/pillows/foam will be needed for under the patients head (to ensure neutral positioning of cervical spine) and to cushion the upper extremities. Reassess padding of pressure points, eye/ear position, monitors, and PIV patency after positioning is complete and prior to case start.

=== Neuraxial vs General Anesthesia ===
Observations studies have suggested improved outcomes if neuraxial (particularly spinal) anesthesia is utilized as primary anesthetic over general anesthesia. A recent randomized trial out of NEJM with 1600 patients age >50 compared spinal anesthesia vs general anesthesia (GA) and found:

* Death or inability to walk independently at 60 days: 18.5% in spinal vs 18.0% in GA (RR 1.03, 95%CI .84-1.27, P=.83)
* Death by day 60: 3.9% in spinal vs 4.1% in GA (RR 0.97, 95%CI .59-1.57)
* Inability to walk at day 60: 15.2% in spinal vs 14.4% in GA (RR 1.06, 95%CI .82-1.36)
* New onset delirium: 20.5% in spinal vs 19.7% in GA (RR 1.04, 95%CI .84-1.30)
* Median time to discharge in US: 3 days in spinal vs 3 days in GA (RR 1.06, 95%CI .96-1.16)

In general according to this study, '''spinal anesthesia was not superior to general anesthesia''' with respect to 60 day survival and ambulation. Additional postoperative delirium was similar between spinal and GA. <ref>{{Cite journal|last=Neuman|first=Mark D.|last2=Feng|first2=Rui|last3=Carson|first3=Jeffrey L.|last4=Gaskins|first4=Lakisha J.|last5=Dillane|first5=Derek|last6=Sessler|first6=Daniel I.|last7=Sieber|first7=Frederick|last8=Magaziner|first8=Jay|last9=Marcantonio|first9=Edward R.|last10=Mehta|first10=Samir|last11=Menio|first11=Diane|date=2021-11-25|title=Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults|url=https://doi.org/10.1056/NEJMoa2113514|journal=New England Journal of Medicine|volume=385|issue=22|pages=2025–2035|doi=10.1056/NEJMoa2113514|issn=0028-4793}}</ref>

=== Evidence for TXA ===
Tranexamic acid (TXA) is an antifibrinolytic agent often used in cardiac and trauma surgery to reduce clot breakdown and subsequent bleeding. TXA has been introduced into procedures with bleeding risk and has been shown to help decrease transfusions and overall blood loss.

Meta analysis of TXA use in total hip arthroplasty reveled strong evidence to reduce blood loss and risk of transfusion.<ref>Yale A. Fillingham, Dipak B. Ramkumar, David S. Jevsevar, Adolph J. Yates, Peter Shores, Kyle Mullen, Stefano A. Bini, Henry D. Clarke, Emil Schemitsch, Rebecca L. Johnson, Stavros G. Memtsoudis, Siraj A. Sayeed, Alexander P. Sah, Craig J. Della Valle,

The Efficacy of Tranexamic Acid in Total Hip Arthroplasty: A Network Meta-analysis,

The Journal of Arthroplasty,

Volume 33, Issue 10,

2018,

Pages 3083-3089.e4,

ISSN 0883-5403,

<nowiki>https://doi.org/10.1016/j.arth.2018.06.023</nowiki>.

(<nowiki>https://www.sciencedirect.com/science/article/pii/S088354031830593X</nowiki>)</ref> When compared with placebo, IV administration of TXA reduced blood loss by 504 mL and decreased the number of units transfused per patient by 1.43 units. In this meta-analysis, 14 of 15 studies used low doses (10 to 50 mg/kg) of TXA, and the remaining study used a high-dose (150 mg/kg) regimen.<ref>Yang ZG, Chen WP, Wu LD: Effectiveness and safety of tranexamic acid in reducing blood loss in total knee arthroplasty: A meta-analysis. J Bone Joint Surg Am 2012;94(13):1153–1159.</ref>

=== Maintenance and surgical considerations ===
Standard maintenance. Neuromuscular blockade required if GA, as this facilitates good operating conditions and allows the surgical team to properly test and place the prostethic(s).

=== Emergence ===
Standard emergence. PONV prophylaxis dependent on patient risk factors, usually ondansetron 4mg IV.

== Postoperative management ==

=== Disposition ===
Typically PACU.

Specialty centers are conducting same-day discharge<ref>{{Cite journal|last=Amundson|first=Adam W.|last2=Panchamia|first2=Jason K.|last3=Jacob|first3=Adam K.|date=2019-06|title=Anesthesia for Same-Day Total Joint Replacement|url=https://linkinghub.elsevier.com/retrieve/pii/S1932227519300060|journal=Anesthesiology Clinics|language=en|volume=37|issue=2|pages=251–264|doi=10.1016/j.anclin.2019.01.006}}</ref><ref>{{Cite journal|last=Li|first=Jinlei|last2=Rubin|first2=Lee E.|last3=Mariano|first3=Edward R.|date=2019-10|title=Essential elements of an outpatient total joint replacement programme|url=https://journals.lww.com/10.1097/ACO.0000000000000774|journal=Current Opinion in Anaesthesiology|language=en|volume=32|issue=5|pages=643–648|doi=10.1097/ACO.0000000000000774|issn=0952-7907}}</ref> for pre-screened populations<ref>{{Cite journal|last=Ziemba-Davis|first=Mary|last2=Caccavallo|first2=Peter|last3=Meneghini|first3=R. Michael|date=2019-07|title=Outpatient Joint Arthroplasty—Patient Selection: Update on the Outpatient Arthroplasty Risk Assessment Score|url=https://linkinghub.elsevier.com/retrieve/pii/S0883540319300348|journal=The Journal of Arthroplasty|language=en|volume=34|issue=7|pages=S40–S43|doi=10.1016/j.arth.2019.01.007}}</ref> with low-comorbidities and with adequate home support structure

ICU disposition depending on acuity, co-morbidities, and procedure planned (consider this especially with trauma patients or revision cases that have the potential for massive transfusion.

=== Pain management ===
Multimodal regimen, consider long-acting opioid agents if no contraindications or risk factors (pulmonary status). Ketamine bolus at induction or low-dose continuous infusion can act as analgesic adjunct. Consider supplementing with single shot peripheral nerve block (fascia iliaca, QL, lumbar plexus, femoral) if no contraindications and patient can tolerate positioning required for block.

=== Potential complications ===

* Bone Cement Implantation Syndrome (BCIS)--if pressurized insertion of bone cement (methylmethacrylate) is used ( while hammering of femoral head into acetabulum). Signs can range from mild hypoxia and hypotension to full cardiovascular collapse. Pathophysiology is incompletely understood, but is likely multifactorial in nature consisting of microembolic showering (of air, fat, bone, cement), histamine release/hypersensitivity, complement activation. Treatment is supportive (fluids, vasopressor support, and ACLS in complete cardiovascular collapse), therefore immediate recognition and intervention is important.
* Venous Air Embolism (VAE)
* Venous Fat Embolism
* Blood Loss
* DVT
* Femoral Fracture

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
* Depending upon surgical approach. Anterior/anterolateral approaches are performed supine, while lateral or posterior approaches are usually performed in lateral decubitus.
!
!Unipolar or Bipolar
!Revision of THA
!Anterior Approach
|-
|Unique considerations
|'''unipolar''': only femoral head replaced

'''bipolar''': femoral and acetabular side are both replaced
|blood loss
|
|-
|Position
|supine vs lateral decubitus (surgical side up)*
| --
|
|-
|Surgical time
|2-3hrs
|3+ hours
|
|-
|EBL
|250-750cc
|>1000cc
|
|-
|Postoperative disposition
|PACU
|PACU vs ICU (depending on transfusion needs or acuity may need to remain intubated)
|
|-
|Pain management
|multimodal
|multimodal; if infected prosthetic, regional may be avoided depending on extent of infection, overlying infected tissue.
|
|-
|Potential complications
|see above
|see above
|Femoral artery injury
during dissection between vastus lateralis and sartorius
|}

=== Enhanced Recovery after Surgery (ERAS): ===

== References ==
<references />
[[Category:Surgical procedures]]
[[Category:Orthopedic surgery]]
[[Category:Hip surgery]]
[[Category:Joint replacement surgery]]

Hip arthroplasty

2022-05-31T06:26:49Z

Mitchel.DeVita:

{{Infobox surgical procedure
| anesthesia_type = General or spinal
± Regional
| airway = ETT if general
| lines_access = Large bore IV
± Arterial line
| monitors = Standard
± ABP
| considerations_preoperative =
| considerations_intraoperative = Risk for bone cement implantation syndrome (BCIS)
| considerations_postoperative = Multimodal analgesia
}}'''Hip arthroplasty''' ('''THA''') has become one of the most common orthopedic surgical procedures performed since 1960, and it is often one of the most successful. Indications for total hip arthroplasty include osteoarthritis, traumatic arthritis, avascular necrosis, post-proximal fracture arthrosis, and congenital hip dislocation. It is typically performed in patients ages 60 and over, but has been performed in patients of all ages depending on etiology. Older patients tend to require hip arthroplasty for indications like hip fracture and subsequent arthrosis/arthritis, osteoarthritis, while patients of all ages may require hip arthroplasty for indications such as traumatic arthritis and (juvenile) rheumatoid arthritis.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|RA pts: assess for cervical nerve root compression and antlanto-occipital instability. Imaging (lateral film XR) and exam performed as this will alter airway and positioning plans.

If regional planned: assess for presence of neurologic conditions (MS, neuropathies, existing nerve injuries) that may be relative contraindications
|-
|Cardiovascular
|Standard evaluation: more important for older patients with more cardiovascular risk factors. Often will need pharmacologic stress testing as pain and arthritis limit exercise capacity.
RA patients, consider increased risk for conduction abnormalities, valvular pathology (AR, valvular fibrosis), pericardial effusion.
|-
|Pulmonary
|Standard exercise capacity evaluation. In obese patients, evaluate for OSA and potential for resultant pHTN. In RA patients, consider pulmonary fibrosis, effusions, glottic narrowing. For all patients with arthritis, evaluate mouth opening (arthriticTMJ).
|-
|Gastrointestinal
|Standard evaluation including NPO status
|-
|Hematologic
|Consider patient anticoagulation status and direct for proper holding of anticoagulation, particularly as regional is used often in these cases. Preoperative hemoglobin should be obtained, as well as type and screen. Consider preoperative blood order (especially if revision).
|-
|Renal
|Preoperative kidney function (Cr, electrolytes) may be considered (effects on drug clearance; more important in geriatric populations).
|-
|Endocrine
|Standard evaluation, blood sugar control important for postoperative wound healing
|-
|Other
|Consider home pain medication regimen; will help guide perioperative analgesic plan.
|}

=== Labs and studies ===

* Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P.
* At a minimum, all patients should have a preoperative hemoglobin and type and screen on file prior to case start.
* If procedure is to be a revision, strongly consider ordering preoperative packed red blood cells (PRBCs).

=== Operating room setup ===
Standard operating room setup. Airway setup, suction, IV setup, induction medications, emergency drugs, analgesic agents should be prepared and readily accessible.

Tranexamic acid prior to incision and at closure being used in greater frequency for blood loss control<ref>{{Cite journal|last=Rajesparan|first=K.|last2=Biant|first2=L. C.|last3=Ahmad|first3=M.|last4=Field|first4=R. E.|date=2009-06|title=The effect of an intravenous bolus of tranexamic acid on blood loss in total hip replacement|url=https://pubmed.ncbi.nlm.nih.gov/19483232|journal=The Journal of Bone and Joint Surgery. British Volume|volume=91|issue=6|pages=776–783|doi=10.1302/0301-620X.91B6.22393|issn=2044-5377|pmid=19483232}}</ref><ref>{{Cite journal|last=Peng Zhang|first=M. M.|last2=Jifeng Li|first2=M. M.|last3=Xiao Wang|first3=M. M.|date=2017-07|title=Combined versus single application of tranexamic acid in total knee and hip arthroplasty: A meta-analysis of randomized controlled trials|url=https://pubmed.ncbi.nlm.nih.gov/28602763|journal=International Journal of Surgery (London, England)|volume=43|pages=171–180|doi=10.1016/j.ijsu.2017.05.065|issn=1743-9159|pmid=28602763}}</ref>

Antibiotics considerations: Beta-lactam (cefazolin) +/- glycopeptide (vancomycin)

=== Patient preparation and premedication ===

* Multimodal analgesic technique recommended.
* Preoperative COX-2 inhibitors, gabapentin, and acetaminophen can be considered.
* Enhanced recovery protocols<ref>{{Cite journal|last=Wainwright|first=Thomas W.|last2=Gill|first2=Mike|last3=McDonald|first3=David A.|last4=Middleton|first4=Robert G.|last5=Reed|first5=Mike|last6=Sahota|first6=Opinder|last7=Yates|first7=Piers|last8=Ljungqvist|first8=Olle|date=2020-01-02|title=Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations|url=https://doi.org/10.1080/17453674.2019.1683790|journal=Acta Orthopaedica|volume=91|issue=1|pages=3–19|doi=10.1080/17453674.2019.1683790|issn=1745-3674|pmc=PMC7006728|pmid=31663402}}</ref> are using PO multimodal medications with greater frequency

=== Regional and neuraxial techniques ===
Advantages to neuraxial and regional techniques:

* improved postoperative pain control

* decreased risk of DVT/PE
* decreased intraoperative blood loss.

Neuraxial techniques (particularly spinal anesthesia) have been used with success in patients undergoing THA and especially beneficial in patients who may have a complicated or difficult airway. See [[Topic:Wbvci9l4oaxluxwj|discussion on drug choice]].
{| class="wikitable wikitable-horizontal-scroll"
|+
!Drug
!Conc.
!Baricity
!Dose
!Duration*
(min)
!Unique
Side-Effects
|-
|Bupivicaine<ref name=":0">{{Cite journal|last=Frey|first=K.|last2=Holman|first2=S.|last3=Mikat-Stevens|first3=M.|last4=Vazquez|first4=J.|last5=White|first5=L.|last6=Pedicini|first6=E.|last7=Sheikh|first7=T.|last8=Kao|first8=T. C.|last9=Kleinman|first9=B.|last10=Stevens|first10=R. A.|date=1998-03|title=The recovery profile of hyperbaric spinal anesthesia with lidocaine, tetracaine, and bupivacaine|url=https://pubmed.ncbi.nlm.nih.gov/9570604|journal=Regional Anesthesia and Pain Medicine|volume=23|issue=2|pages=159–163|doi=10.1097/00115550-199823020-00008|issn=1098-7339|pmid=9570604}}</ref><ref name=":1">{{Cite journal|last=Malinovsky|first=J. M.|last2=Charles|first2=F.|last3=Kick|first3=O.|last4=Lepage|first4=J. Y.|last5=Malinge|first5=M.|last6=Cozian|first6=A.|last7=Bouchot|first7=O.|last8=Pinaud|first8=M.|date=2000-12|title=Intrathecal anesthesia: ropivacaine versus bupivacaine|url=https://pubmed.ncbi.nlm.nih.gov/11094000|journal=Anesthesia and Analgesia|volume=91|issue=6|pages=1457–1460|doi=10.1097/00000539-200012000-00030|issn=0003-2999|pmid=11094000}}</ref>
|0.75%
|Hyperbaric
|12-16mg
|90-120
|
|-
|Bupivicaine<ref name=":0" /><ref name=":1" />
|0.5%
|Isobaric
|12-16mg
|90-120
|
|-
|Lidocaine<ref name=":0" /><ref>{{Cite journal|last=Liam|first=B. L.|last2=Yim|first2=C. F.|last3=Chong|first3=J. L.|date=1998-07|title=Dose response study of lidocaine 1% for spinal anaesthesia for lower limb and perineal surgery|url=https://pubmed.ncbi.nlm.nih.gov/9717596|journal=Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie|volume=45|issue=7|pages=645–650|doi=10.1007/BF03012094|issn=0832-610X|pmid=9717596}}</ref><ref>{{Cite journal|last=Pawlowski|first=Julius|last2=Orr|first2=Kevin|last3=Kim|first3=Ku-Mie|last4=Pappas|first4=Ana Lucia|last5=Sukhani|first5=Radha|last6=Jellish|first6=W. Scott|date=2012-03|title=Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures|url=https://pubmed.ncbi.nlm.nih.gov/22342508|journal=Journal of Clinical Anesthesia|volume=24|issue=2|pages=109–115|doi=10.1016/j.jclinane.2011.06.014|issn=1873-4529|pmid=22342508}}</ref>
|1-2%
5%
|Isobaric;
hyperbaric
|60-80mg
|60-90
|TNS (7%)
|-
|Mepivicaine<ref>{{Cite journal|last=Pawlowski|first=Julius|last2=Orr|first2=Kevin|last3=Kim|first3=Ku-Mie|last4=Pappas|first4=Ana Lucia|last5=Sukhani|first5=Radha|last6=Jellish|first6=W. Scott|date=2012-03|title=Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures|url=https://pubmed.ncbi.nlm.nih.gov/22342508|journal=Journal of Clinical Anesthesia|volume=24|issue=2|pages=109–115|doi=10.1016/j.jclinane.2011.06.014|issn=1873-4529|pmid=22342508}}</ref><ref>{{Cite journal|last=Pawlowski|first=J.|last2=Sukhani|first2=R.|last3=Pappas|first3=A. L.|last4=Kim|first4=K. M.|last5=Lurie|first5=J.|last6=Gunnerson|first6=H.|last7=Corsino|first7=A.|last8=Frey|first8=K.|last9=Tonino|first9=P.|date=2000-09|title=The anesthetic and recovery profile of two doses (60 and 80 mg) of plain mepivacaine for ambulatory spinal anesthesia|url=https://pubmed.ncbi.nlm.nih.gov/10960380|journal=Anesthesia and Analgesia|volume=91|issue=3|pages=580–584|doi=10.1097/00000539-200009000-00015|issn=0003-2999|pmid=10960380}}</ref><ref>{{Cite journal|last=Zayas|first=V. M.|last2=Liguori|first2=G. A.|last3=Chisholm|first3=M. F.|last4=Susman|first4=M. H.|last5=Gordon|first5=M. A.|date=1999-11|title=Dose response relationships for isobaric spinal mepivacaine using the combined spinal epidural technique|url=https://pubmed.ncbi.nlm.nih.gov/10553828|journal=Anesthesia and Analgesia|volume=89|issue=5|pages=1167–1171|issn=0003-2999|pmid=10553828}}</ref><ref>{{Cite journal|last=Schwenk|first=Eric S.|last2=Kasper|first2=Vincent P.|last3=Smoker|first3=Jordan D.|last4=Mendelson|first4=Andrew M.|last5=Austin|first5=Matthew S.|last6=Brown|first6=Scot A.|last7=Hozack|first7=William J.|last8=Cohen|first8=Alexa J.|last9=Li|first9=Jonathan J.|last10=Wahal|first10=Christopher S.|last11=Baratta|first11=Jaime L.|date=2020-10-01|title=Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation|url=https://pubmed.ncbi.nlm.nih.gov/32852904|journal=Anesthesiology|volume=133|issue=4|pages=801–811|doi=10.1097/ALN.0000000000003480|issn=1528-1175|pmid=32852904}}</ref>
|1.5%
|Isobaric
|50-80mg
|100-120
|TNS (7%)
|-
|Chloroprocaine<ref>{{Cite journal|last=Goldblum|first=E.|last2=Atchabahian|first2=A.|date=2013-05|title=The use of 2-chloroprocaine for spinal anaesthesia: Chloroprocaine for spinal anaesthesia|url=http://doi.wiley.com/10.1111/aas.12071|journal=Acta Anaesthesiologica Scandinavica|language=en|volume=57|issue=5|pages=545–552|doi=10.1111/aas.12071}}</ref><ref>{{Cite journal|last=Lacasse|first=Marie-Andrée|last2=Roy|first2=Jean-Denis|last3=Forget|first3=Josée|last4=Vandenbroucke|first4=Franck|last5=Seal|first5=Robert F.|last6=Beaulieu|first6=Danielle|last7=McCormack|first7=Michael|last8=Massicotte|first8=Luc|date=2011-04|title=Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: a double-blind randomized trial|url=http://link.springer.com/10.1007/s12630-010-9450-x|journal=Canadian Journal of Anesthesia/Journal canadien d'anesthésie|language=en|volume=58|issue=4|pages=384–391|doi=10.1007/s12630-010-9450-x|issn=0832-610X}}</ref><ref>{{Cite journal|last=Kouri|first=Mary E.|last2=Kopacz|first2=Dan J.|date=2004-01|title=Spinal 2-Chloroprocaine: A Comparison with Lidocaine in Volunteers:|url=http://journals.lww.com/00000539-200401000-00020|journal=Anesthesia & Analgesia|language=en|pages=75–80|doi=10.1213/01.ANE.0000093228.61443.EE|issn=0003-2999}}</ref><ref>{{Cite journal|last=Smith|first=Kristin N.|last2=Kopacz|first2=Dan J.|last3=McDonald|first3=Susan B.|date=2004-01|title=Spinal 2-chloroprocaine: a dose-ranging study and the effect of added epinephrine|url=https://pubmed.ncbi.nlm.nih.gov/14693591|journal=Anesthesia and Analgesia|volume=98|issue=1|pages=81–88, table of contents|doi=10.1213/01.ane.0000093361.48458.6e|issn=0003-2999|pmid=14693591}}</ref>
|2%
|Hyperbaric
|30-60mg
|30-50 (2-level regression)
60-90 (motor)

100-130 (ambulation)
|Flu-like symptoms
and back ache with

epinephrine addition
|}
Standard consideration of patient factors as they related to absolute/relative contraindications should be undertaken. Additional considerations for post operative mobilization. Some surgical teams and fast tracking joint replacement centers may mobilize patients as early as 2-4 hours postoperatively to help prevent DVT. <ref>Chua, Matthew J et al. “Early mobilisation after total hip or knee arthroplasty: A multicentre prospective observational study.” ''PloS one'' vol. 12,6 e0179820. 27 Jun. 2017, doi:10.1371/journal.pone.0179820</ref>

Time of procedure should also be considered, as spinal anesthesia has a limited duration of action (typically 2-3 hours, depending on agents used).

Intrathecal long-acting morphine can be considered for postoperative pain control with an understanding that patient selection is important for administration of this medication given the risk for respiratory depression and long duration of action.

Single shot peripheral regional nerve blocks can be used to improve postoperative analgesia, but are not sufficient as a primary anesthetic. Patients must be able to assume the position required to place these blocks. Blocks can help reduce postoperative opiate requirements. Blocks used include:

* femoral
* lumbar plexus
* quadratus lumborum (QL)
* fascia iliaca

=== Neuraxial vs General Anesthesia ===
Observations studies have suggested improved outcomes if neuraxial (particularly spinal) anesthesia is utilized as primary anesthetic over general anesthesia. A recent randomized trial out of NEJM with 1600 patients age >50 compared spinal anesthesia vs general anesthesia (GA) and found:

* Death or inability to walk independently at 60 days: 18.5% in spinal vs 18.0% in GA (RR 1.03, 95%CI .84-1.27, P=.83)
* Death by day 60: 3.9% in spinal vs 4.1% in GA (RR 0.97, 95%CI .59-1.57)
* Inability to walk at day 60: 15.2% in spinal vs 14.4% in GA (RR 1.06, 95%CI .82-1.36)
* New onset delirium: 20.5% in spinal vs 19.7% in GA (RR 1.04, 95%CI .84-1.30)
* Median time to discharge in US: 3 days in spinal vs 3 days in GA (RR 1.06, 95%CI .96-1.16)

In general according to this study, '''spinal anesthesia was not superior to general anesthesia''' with respect to 60 day survival and ambulation. Additional postoperative delirium was similar between spinal and GA. <ref>{{Cite journal|last=Neuman|first=Mark D.|last2=Feng|first2=Rui|last3=Carson|first3=Jeffrey L.|last4=Gaskins|first4=Lakisha J.|last5=Dillane|first5=Derek|last6=Sessler|first6=Daniel I.|last7=Sieber|first7=Frederick|last8=Magaziner|first8=Jay|last9=Marcantonio|first9=Edward R.|last10=Mehta|first10=Samir|last11=Menio|first11=Diane|date=2021-11-25|title=Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults|url=https://doi.org/10.1056/NEJMoa2113514|journal=New England Journal of Medicine|volume=385|issue=22|pages=2025–2035|doi=10.1056/NEJMoa2113514|issn=0028-4793}}</ref>

== Intraoperative management ==

=== Monitoring and access ===
Standard ASA monitoring. Consider addition of intraoperative EEG monitoring (BIS or similar).

2 large-bore PIV should be obtained. Arterial line for hemodynamic monitoring should be considered for revision procedures, cases with predicted significant blood loss, and for patients with significant cardiopulmonary disease.

=== Induction and airway management ===
Induction can be tailored to individual patient comorbidities and acuity. RSI induction is indicated for trauma patients or those without proper fasting per ASA guidelines. For patients with rheumatoid arthritis, special consideration should be given to the airway and potential for cervical (atlanto-occipital) instability. In these cases, videolaryngoscopy or fiberoptic intubation should be considered and utilized.

Induction and intubation on the preoperative bed prior to moving to the operating room table should be considered if possible for patients in whom it would cause significant pain (and resultant physiologic and emotional stress) to execute this move.

=== Positioning ===
{| class="wikitable wikitable-horizontal-scroll"
|+
!Surgical Approach
!Lateral
!Posterior
!Anterior/Anterolateral
|-
|Position
|Lateral decubitus
|Lateral decubitus
|Supine
|-
|Special Equipment
|Axillary roll/bean bag
|Axillary roll/bean bag
|Hana Table
Traction boots attachment to Hana table
|-
|Positioning Concerns
|Brachial plexus injury
Neck positioning

Check PIV flow
|Brachial plexus injury
Neck positioning

Check PIV flow
|
|}
If lateral positioning, a beanbag and axillary roll are typically used. Additional blankets/pillows/foam will be needed for under the patients head (to ensure neutral positioning of cervical spine) and to cushion the upper extremities. Reassess padding of pressure points, eye/ear position, monitors, and PIV patency after positioning is complete and prior to case start.

=== Maintenance and surgical considerations ===
Standard maintenance. Neuromuscular blockade required if GA, as this facilitates good operating conditions and allows the surgical team to properly test and place the prostethic(s).

=== Emergence ===
Standard emergence. PONV prophylaxis dependent on patient risk factors, usually ondansetron 4mg IV.

== Postoperative management ==

=== Disposition ===
Typically PACU.

Specialty centers are conducting same-day discharge<ref>{{Cite journal|last=Amundson|first=Adam W.|last2=Panchamia|first2=Jason K.|last3=Jacob|first3=Adam K.|date=2019-06|title=Anesthesia for Same-Day Total Joint Replacement|url=https://linkinghub.elsevier.com/retrieve/pii/S1932227519300060|journal=Anesthesiology Clinics|language=en|volume=37|issue=2|pages=251–264|doi=10.1016/j.anclin.2019.01.006}}</ref><ref>{{Cite journal|last=Li|first=Jinlei|last2=Rubin|first2=Lee E.|last3=Mariano|first3=Edward R.|date=2019-10|title=Essential elements of an outpatient total joint replacement programme|url=https://journals.lww.com/10.1097/ACO.0000000000000774|journal=Current Opinion in Anaesthesiology|language=en|volume=32|issue=5|pages=643–648|doi=10.1097/ACO.0000000000000774|issn=0952-7907}}</ref> for pre-screened populations<ref>{{Cite journal|last=Ziemba-Davis|first=Mary|last2=Caccavallo|first2=Peter|last3=Meneghini|first3=R. Michael|date=2019-07|title=Outpatient Joint Arthroplasty—Patient Selection: Update on the Outpatient Arthroplasty Risk Assessment Score|url=https://linkinghub.elsevier.com/retrieve/pii/S0883540319300348|journal=The Journal of Arthroplasty|language=en|volume=34|issue=7|pages=S40–S43|doi=10.1016/j.arth.2019.01.007}}</ref> with low-comorbidities and with adequate home support structure

ICU disposition depending on acuity, co-morbidities, and procedure planned (consider this especially with trauma patients or revision cases that have the potential for massive transfusion.

=== Pain management ===
Multimodal regimen, consider long-acting opioid agents if no contraindications or risk factors (pulmonary status). Ketamine bolus at induction or low-dose continuous infusion can act as analgesic adjunct. Consider supplementing with single shot peripheral nerve block (fascia iliaca, QL, lumbar plexus, femoral) if no contraindications and patient can tolerate positioning required for block.

=== Potential complications ===

* Bone Cement Implantation Syndrome (BCIS)--if pressurized insertion of bone cement (methylmethacrylate) is used ( while hammering of femoral head into acetabulum). Signs can range from mild hypoxia and hypotension to full cardiovascular collapse. Pathophysiology is incompletely understood, but is likely multifactorial in nature consisting of microembolic showering (of air, fat, bone, cement), histamine release/hypersensitivity, complement activation. Treatment is supportive (fluids, vasopressor support, and ACLS in complete cardiovascular collapse), therefore immediate recognition and intervention is important.
* Venous Air Embolism (VAE)
* Venous Fat Embolism
* Blood Loss
* DVT
* Femoral Fracture

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
* Depending upon surgical approach. Anterior/anterolateral approaches are performed supine, while lateral or posterior approaches are usually performed in lateral decubitus.
!
!Unipolar or Bipolar
!Revision of THA
!Anterior Approach
|-
|Unique considerations
|'''unipolar''': only femoral head replaced

'''bipolar''': femoral and acetabular side are both replaced
|blood loss
|
|-
|Position
|supine vs lateral decubitus (surgical side up)*
| --
|
|-
|Surgical time
|2-3hrs
|3+ hours
|
|-
|EBL
|250-750cc
|>1000cc
|
|-
|Postoperative disposition
|PACU
|PACU vs ICU (depending on transfusion needs or acuity may need to remain intubated)
|
|-
|Pain management
|multimodal
|multimodal; if infected prosthetic, regional may be avoided depending on extent of infection, overlying infected tissue.
|
|-
|Potential complications
|see above
|see above
|Femoral artery injury
during dissection between vastus lateralis and sartorius
|}

=== Enhanced Recovery after Surgery (ERAS): ===

== References ==
<references />
[[Category:Surgical procedures]]
[[Category:Orthopedic surgery]]
[[Category:Hip surgery]]
[[Category:Joint replacement surgery]]

Hip arthroplasty

2022-05-31T06:11:50Z

Mitchel.DeVita:

{{Infobox surgical procedure
| anesthesia_type = General or spinal
± Regional
| airway = ETT if general
| lines_access = Large bore IV
± Arterial line
| monitors = Standard
± ABP
| considerations_preoperative =
| considerations_intraoperative = Risk for bone cement implantation syndrome (BCIS)
| considerations_postoperative = Multimodal analgesia
}}'''Hip arthroplasty''' ('''THA''') has become one of the most common orthopedic surgical procedures performed since 1960, and it is often one of the most successful. Indications for total hip arthroplasty include osteoarthritis, traumatic arthritis, avascular necrosis, post-proximal fracture arthrosis, and congenital hip dislocation. It is typically performed in patients ages 60 and over, but has been performed in patients of all ages depending on etiology. Older patients tend to require hip arthroplasty for indications like hip fracture and subsequent arthrosis/arthritis, osteoarthritis, while patients of all ages may require hip arthroplasty for indications such as traumatic arthritis and (juvenile) rheumatoid arthritis.

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Neurologic
|RA pts: assess for cervical nerve root compression and antlanto-occipital instability. Imaging (lateral film XR) and exam performed as this will alter airway and positioning plans.

If regional planned: assess for presence of neurologic conditions (MS, neuropathies, existing nerve injuries) that may be relative contraindications
|-
|Cardiovascular
|Standard evaluation: more important for older patients with more cardiovascular risk factors. Often will need pharmacologic stress testing as pain and arthritis limit exercise capacity.
RA patients, consider increased risk for conduction abnormalities, valvular pathology (AR, valvular fibrosis), pericardial effusion.
|-
|Pulmonary
|Standard exercise capacity evaluation. In obese patients, evaluate for OSA and potential for resultant pHTN. In RA patients, consider pulmonary fibrosis, effusions, glottic narrowing. For all patients with arthritis, evaluate mouth opening (arthriticTMJ).
|-
|Gastrointestinal
|Standard evaluation including NPO status
|-
|Hematologic
|Consider patient anticoagulation status and direct for proper holding of anticoagulation, particularly as regional is used often in these cases. Preoperative hemoglobin should be obtained, as well as type and screen. Consider preoperative blood order (especially if revision).
|-
|Renal
|Preoperative kidney function (Cr, electrolytes) may be considered (effects on drug clearance; more important in geriatric populations).
|-
|Endocrine
|Standard evaluation, blood sugar control important for postoperative wound healing
|-
|Other
|Consider home pain medication regimen; will help guide perioperative analgesic plan.
|}

=== Labs and studies ===

* Preoperative labwork, cardiac studies, and imaging will vary amongst patient populations. As in all cases, much of the preoperative studies will be based on individual patient H&P.
* At a minimum, all patients should have a preoperative hemoglobin and type and screen on file prior to case start.
* If procedure is to be a revision, strongly consider ordering preoperative packed red blood cells (PRBCs).

=== Operating room setup ===
Standard operating room setup. Airway setup, suction, IV setup, induction medications, emergency drugs, analgesic agents should be prepared and readily accessible.

Tranexamic acid prior to incision and at closure being used in greater frequency for blood loss control<ref>{{Cite journal|last=Rajesparan|first=K.|last2=Biant|first2=L. C.|last3=Ahmad|first3=M.|last4=Field|first4=R. E.|date=2009-06|title=The effect of an intravenous bolus of tranexamic acid on blood loss in total hip replacement|url=https://pubmed.ncbi.nlm.nih.gov/19483232|journal=The Journal of Bone and Joint Surgery. British Volume|volume=91|issue=6|pages=776–783|doi=10.1302/0301-620X.91B6.22393|issn=2044-5377|pmid=19483232}}</ref><ref>{{Cite journal|last=Peng Zhang|first=M. M.|last2=Jifeng Li|first2=M. M.|last3=Xiao Wang|first3=M. M.|date=2017-07|title=Combined versus single application of tranexamic acid in total knee and hip arthroplasty: A meta-analysis of randomized controlled trials|url=https://pubmed.ncbi.nlm.nih.gov/28602763|journal=International Journal of Surgery (London, England)|volume=43|pages=171–180|doi=10.1016/j.ijsu.2017.05.065|issn=1743-9159|pmid=28602763}}</ref>

Antibiotics considerations: Beta-lactam (cefazolin) +/- glycopeptide (vancomycin)

=== Patient preparation and premedication ===

* Multimodal analgesic technique recommended.
* Preoperative COX-2 inhibitors, gabapentin, and acetaminophen can be considered.
* Enhanced recovery protocols<ref>{{Cite journal|last=Wainwright|first=Thomas W.|last2=Gill|first2=Mike|last3=McDonald|first3=David A.|last4=Middleton|first4=Robert G.|last5=Reed|first5=Mike|last6=Sahota|first6=Opinder|last7=Yates|first7=Piers|last8=Ljungqvist|first8=Olle|date=2020-01-02|title=Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations|url=https://doi.org/10.1080/17453674.2019.1683790|journal=Acta Orthopaedica|volume=91|issue=1|pages=3–19|doi=10.1080/17453674.2019.1683790|issn=1745-3674|pmc=PMC7006728|pmid=31663402}}</ref> are using PO multimodal medications with greater frequency

=== Regional and neuraxial techniques ===
Advantages to neuraxial and regional techniques:

* improved postoperative pain control

* decreased risk of DVT/PE
* decreased intraoperative blood loss.

Neuraxial techniques (particularly spinal anesthesia) have been used with success in patients undergoing THA and especially beneficial in patients who may have a complicated or difficult airway. See [[Topic:Wbvci9l4oaxluxwj|discussion on drug choice]].
{| class="wikitable wikitable-horizontal-scroll"
|+
!Drug
!Conc.
!Baricity
!Dose
!Duration*
(min)
!Unique
Side-Effects
|-
|Bupivicaine<ref name=":0">{{Cite journal|last=Frey|first=K.|last2=Holman|first2=S.|last3=Mikat-Stevens|first3=M.|last4=Vazquez|first4=J.|last5=White|first5=L.|last6=Pedicini|first6=E.|last7=Sheikh|first7=T.|last8=Kao|first8=T. C.|last9=Kleinman|first9=B.|last10=Stevens|first10=R. A.|date=1998-03|title=The recovery profile of hyperbaric spinal anesthesia with lidocaine, tetracaine, and bupivacaine|url=https://pubmed.ncbi.nlm.nih.gov/9570604|journal=Regional Anesthesia and Pain Medicine|volume=23|issue=2|pages=159–163|doi=10.1097/00115550-199823020-00008|issn=1098-7339|pmid=9570604}}</ref><ref name=":1">{{Cite journal|last=Malinovsky|first=J. M.|last2=Charles|first2=F.|last3=Kick|first3=O.|last4=Lepage|first4=J. Y.|last5=Malinge|first5=M.|last6=Cozian|first6=A.|last7=Bouchot|first7=O.|last8=Pinaud|first8=M.|date=2000-12|title=Intrathecal anesthesia: ropivacaine versus bupivacaine|url=https://pubmed.ncbi.nlm.nih.gov/11094000|journal=Anesthesia and Analgesia|volume=91|issue=6|pages=1457–1460|doi=10.1097/00000539-200012000-00030|issn=0003-2999|pmid=11094000}}</ref>
|0.75%
|Hyperbaric
|12-16mg
|90-120
|
|-
|Bupivicaine<ref name=":0" /><ref name=":1" />
|0.5%
|Isobaric
|12-16mg
|90-120
|
|-
|Lidocaine<ref name=":0" /><ref>{{Cite journal|last=Liam|first=B. L.|last2=Yim|first2=C. F.|last3=Chong|first3=J. L.|date=1998-07|title=Dose response study of lidocaine 1% for spinal anaesthesia for lower limb and perineal surgery|url=https://pubmed.ncbi.nlm.nih.gov/9717596|journal=Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie|volume=45|issue=7|pages=645–650|doi=10.1007/BF03012094|issn=0832-610X|pmid=9717596}}</ref><ref>{{Cite journal|last=Pawlowski|first=Julius|last2=Orr|first2=Kevin|last3=Kim|first3=Ku-Mie|last4=Pappas|first4=Ana Lucia|last5=Sukhani|first5=Radha|last6=Jellish|first6=W. Scott|date=2012-03|title=Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures|url=https://pubmed.ncbi.nlm.nih.gov/22342508|journal=Journal of Clinical Anesthesia|volume=24|issue=2|pages=109–115|doi=10.1016/j.jclinane.2011.06.014|issn=1873-4529|pmid=22342508}}</ref>
|1-2%
5%
|Isobaric;
hyperbaric
|60-80mg
|60-90
|TNS (7%)
|-
|Mepivicaine<ref>{{Cite journal|last=Pawlowski|first=Julius|last2=Orr|first2=Kevin|last3=Kim|first3=Ku-Mie|last4=Pappas|first4=Ana Lucia|last5=Sukhani|first5=Radha|last6=Jellish|first6=W. Scott|date=2012-03|title=Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures|url=https://pubmed.ncbi.nlm.nih.gov/22342508|journal=Journal of Clinical Anesthesia|volume=24|issue=2|pages=109–115|doi=10.1016/j.jclinane.2011.06.014|issn=1873-4529|pmid=22342508}}</ref><ref>{{Cite journal|last=Pawlowski|first=J.|last2=Sukhani|first2=R.|last3=Pappas|first3=A. L.|last4=Kim|first4=K. M.|last5=Lurie|first5=J.|last6=Gunnerson|first6=H.|last7=Corsino|first7=A.|last8=Frey|first8=K.|last9=Tonino|first9=P.|date=2000-09|title=The anesthetic and recovery profile of two doses (60 and 80 mg) of plain mepivacaine for ambulatory spinal anesthesia|url=https://pubmed.ncbi.nlm.nih.gov/10960380|journal=Anesthesia and Analgesia|volume=91|issue=3|pages=580–584|doi=10.1097/00000539-200009000-00015|issn=0003-2999|pmid=10960380}}</ref><ref>{{Cite journal|last=Zayas|first=V. M.|last2=Liguori|first2=G. A.|last3=Chisholm|first3=M. F.|last4=Susman|first4=M. H.|last5=Gordon|first5=M. A.|date=1999-11|title=Dose response relationships for isobaric spinal mepivacaine using the combined spinal epidural technique|url=https://pubmed.ncbi.nlm.nih.gov/10553828|journal=Anesthesia and Analgesia|volume=89|issue=5|pages=1167–1171|issn=0003-2999|pmid=10553828}}</ref><ref>{{Cite journal|last=Schwenk|first=Eric S.|last2=Kasper|first2=Vincent P.|last3=Smoker|first3=Jordan D.|last4=Mendelson|first4=Andrew M.|last5=Austin|first5=Matthew S.|last6=Brown|first6=Scot A.|last7=Hozack|first7=William J.|last8=Cohen|first8=Alexa J.|last9=Li|first9=Jonathan J.|last10=Wahal|first10=Christopher S.|last11=Baratta|first11=Jaime L.|date=2020-10-01|title=Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation|url=https://pubmed.ncbi.nlm.nih.gov/32852904|journal=Anesthesiology|volume=133|issue=4|pages=801–811|doi=10.1097/ALN.0000000000003480|issn=1528-1175|pmid=32852904}}</ref>
|1.5%
|Isobaric
|50-80mg
|100-120
|TNS (7%)
|-
|Chloroprocaine<ref>{{Cite journal|last=Goldblum|first=E.|last2=Atchabahian|first2=A.|date=2013-05|title=The use of 2-chloroprocaine for spinal anaesthesia: Chloroprocaine for spinal anaesthesia|url=http://doi.wiley.com/10.1111/aas.12071|journal=Acta Anaesthesiologica Scandinavica|language=en|volume=57|issue=5|pages=545–552|doi=10.1111/aas.12071}}</ref><ref>{{Cite journal|last=Lacasse|first=Marie-Andrée|last2=Roy|first2=Jean-Denis|last3=Forget|first3=Josée|last4=Vandenbroucke|first4=Franck|last5=Seal|first5=Robert F.|last6=Beaulieu|first6=Danielle|last7=McCormack|first7=Michael|last8=Massicotte|first8=Luc|date=2011-04|title=Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: a double-blind randomized trial|url=http://link.springer.com/10.1007/s12630-010-9450-x|journal=Canadian Journal of Anesthesia/Journal canadien d'anesthésie|language=en|volume=58|issue=4|pages=384–391|doi=10.1007/s12630-010-9450-x|issn=0832-610X}}</ref><ref>{{Cite journal|last=Kouri|first=Mary E.|last2=Kopacz|first2=Dan J.|date=2004-01|title=Spinal 2-Chloroprocaine: A Comparison with Lidocaine in Volunteers:|url=http://journals.lww.com/00000539-200401000-00020|journal=Anesthesia & Analgesia|language=en|pages=75–80|doi=10.1213/01.ANE.0000093228.61443.EE|issn=0003-2999}}</ref><ref>{{Cite journal|last=Smith|first=Kristin N.|last2=Kopacz|first2=Dan J.|last3=McDonald|first3=Susan B.|date=2004-01|title=Spinal 2-chloroprocaine: a dose-ranging study and the effect of added epinephrine|url=https://pubmed.ncbi.nlm.nih.gov/14693591|journal=Anesthesia and Analgesia|volume=98|issue=1|pages=81–88, table of contents|doi=10.1213/01.ane.0000093361.48458.6e|issn=0003-2999|pmid=14693591}}</ref>
|2%
|Hyperbaric
|30-60mg
|30-50 (2-level regression)
60-90 (motor)

100-130 (ambulation)
|Flu-like symptoms
and back ache with

epinephrine addition
|}
Standard consideration of patient factors as they related to absolute/relative contraindications should be undertaken. Additional considerations for post operative mobilization. Some surgical teams and fast tracking joint replacement centers may mobilize patients as early as 2-4 hours postoperatively to help prevent DVT. <ref>Chua, Matthew J et al. “Early mobilisation after total hip or knee arthroplasty: A multicentre prospective observational study.” ''PloS one'' vol. 12,6 e0179820. 27 Jun. 2017, doi:10.1371/journal.pone.0179820</ref>

Time of procedure should also be considered, as spinal anesthesia has a limited duration of action (typically 2-3 hours, depending on agents used).

Intrathecal long-acting morphine can be considered for postoperative pain control with an understanding that patient selection is important for administration of this medication given the risk for respiratory depression and long duration of action.

Single shot peripheral regional nerve blocks can be used to improve postoperative analgesia, but are not sufficient as a primary anesthetic. Patients must be able to assume the position required to place these blocks. Blocks can help reduce postoperative opiate requirements. Blocks used include:

* femoral
* lumbar plexus
* quadratus lumborum (QL)
* fascia iliaca

== Intraoperative management ==

=== Monitoring and access ===
Standard ASA monitoring. Consider addition of intraoperative EEG monitoring (BIS or similar).

2 large-bore PIV should be obtained. Arterial line for hemodynamic monitoring should be considered for revision procedures, cases with predicted significant blood loss, and for patients with significant cardiopulmonary disease.

=== Induction and airway management ===
Induction can be tailored to individual patient comorbidities and acuity. RSI induction is indicated for trauma patients or those without proper fasting per ASA guidelines. For patients with rheumatoid arthritis, special consideration should be given to the airway and potential for cervical (atlanto-occipital) instability. In these cases, videolaryngoscopy or fiberoptic intubation should be considered and utilized.

Induction and intubation on the preoperative bed prior to moving to the operating room table should be considered if possible for patients in whom it would cause significant pain (and resultant physiologic and emotional stress) to execute this move.

=== Positioning ===
{| class="wikitable wikitable-horizontal-scroll"
|+
!Surgical Approach
!Lateral
!Posterior
!Anterior/Anterolateral
|-
|Position
|Lateral decubitus
|Lateral decubitus
|Supine
|-
|Special Equipment
|Axillary roll/bean bag
|Axillary roll/bean bag
|Hana Table
Traction boots attachment to Hana table
|-
|Positioning Concerns
|Brachial plexus injury
Neck positioning

Check PIV flow
|Brachial plexus injury
Neck positioning

Check PIV flow
|
|}
If lateral positioning, a beanbag and axillary roll are typically used. Additional blankets/pillows/foam will be needed for under the patients head (to ensure neutral positioning of cervical spine) and to cushion the upper extremities. Reassess padding of pressure points, eye/ear position, monitors, and PIV patency after positioning is complete and prior to case start.

=== Maintenance and surgical considerations ===
Standard maintenance. Neuromuscular blockade required if GA, as this facilitates good operating conditions and allows the surgical team to properly test and place the prostethic(s).

=== Emergence ===
Standard emergence. PONV prophylaxis dependent on patient risk factors, usually ondansetron 4mg IV.

== Postoperative management ==

=== Disposition ===
Typically PACU.

Specialty centers are conducting same-day discharge<ref>{{Cite journal|last=Amundson|first=Adam W.|last2=Panchamia|first2=Jason K.|last3=Jacob|first3=Adam K.|date=2019-06|title=Anesthesia for Same-Day Total Joint Replacement|url=https://linkinghub.elsevier.com/retrieve/pii/S1932227519300060|journal=Anesthesiology Clinics|language=en|volume=37|issue=2|pages=251–264|doi=10.1016/j.anclin.2019.01.006}}</ref><ref>{{Cite journal|last=Li|first=Jinlei|last2=Rubin|first2=Lee E.|last3=Mariano|first3=Edward R.|date=2019-10|title=Essential elements of an outpatient total joint replacement programme|url=https://journals.lww.com/10.1097/ACO.0000000000000774|journal=Current Opinion in Anaesthesiology|language=en|volume=32|issue=5|pages=643–648|doi=10.1097/ACO.0000000000000774|issn=0952-7907}}</ref> for pre-screened populations<ref>{{Cite journal|last=Ziemba-Davis|first=Mary|last2=Caccavallo|first2=Peter|last3=Meneghini|first3=R. Michael|date=2019-07|title=Outpatient Joint Arthroplasty—Patient Selection: Update on the Outpatient Arthroplasty Risk Assessment Score|url=https://linkinghub.elsevier.com/retrieve/pii/S0883540319300348|journal=The Journal of Arthroplasty|language=en|volume=34|issue=7|pages=S40–S43|doi=10.1016/j.arth.2019.01.007}}</ref> with low-comorbidities and with adequate home support structure

ICU disposition depending on acuity, co-morbidities, and procedure planned (consider this especially with trauma patients or revision cases that have the potential for massive transfusion.

=== Pain management ===
Multimodal regimen, consider long-acting opioid agents if no contraindications or risk factors (pulmonary status). Ketamine bolus at induction or low-dose continuous infusion can act as analgesic adjunct. Consider supplementing with single shot peripheral nerve block (fascia iliaca, QL, lumbar plexus, femoral) if no contraindications and patient can tolerate positioning required for block.

=== Potential complications ===

* Bone Cement Implantation Syndrome (BCIS)--if pressurized insertion of bone cement (methylmethacrylate) is used ( while hammering of femoral head into acetabulum). Signs can range from mild hypoxia and hypotension to full cardiovascular collapse. Pathophysiology is incompletely understood, but is likely multifactorial in nature consisting of microembolic showering (of air, fat, bone, cement), histamine release/hypersensitivity, complement activation. Treatment is supportive (fluids, vasopressor support, and ACLS in complete cardiovascular collapse), therefore immediate recognition and intervention is important.
* Venous Air Embolism (VAE)
* Venous Fat Embolism
* Blood Loss
* DVT
* Femoral Fracture

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
* Depending upon surgical approach. Anterior/anterolateral approaches are performed supine, while lateral or posterior approaches are usually performed in lateral decubitus.
!
!Unipolar or Bipolar
!Revision of THA
!Anterior Approach
|-
|Unique considerations
|'''unipolar''': only femoral head replaced

'''bipolar''': femoral and acetabular side are both replaced
|blood loss
|
|-
|Position
|supine vs lateral decubitus (surgical side up)*
| --
|
|-
|Surgical time
|2-3hrs
|3+ hours
|
|-
|EBL
|250-750cc
|>1000cc
|
|-
|Postoperative disposition
|PACU
|PACU vs ICU (depending on transfusion needs or acuity may need to remain intubated)
|
|-
|Pain management
|multimodal
|multimodal; if infected prosthetic, regional may be avoided depending on extent of infection, overlying infected tissue.
|
|-
|Potential complications
|see above
|see above
|Femoral artery injury
during dissection between vastus lateralis and sartorius
|}

=== Enhanced Recovery after Surgery (ERAS): ===

== References ==
<references />
[[Category:Surgical procedures]]
[[Category:Orthopedic surgery]]
[[Category:Hip surgery]]
[[Category:Joint replacement surgery]]

Mucosal sleeve resection

2022-05-31T06:06:22Z

Mitchel.DeVita:

Perineal rectosigmoidectomy

2022-05-31T06:06:08Z

Mitchel.DeVita:

Rectopexy

2022-05-31T06:05:52Z

Mitchel.DeVita:

{{Infobox surgical procedure
| anesthesia_type = General
| airway = ETT
| lines_access = PIV
| monitors = Standard
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Rectopexy is used for the treatment of rectal prolapse and for high-grade internal rectal prolapse, often performed through laparoscopic approach.

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Rectopexy

2022-05-31T06:02:43Z

Mitchel.DeVita:

Palmar and digital fasciectomy

2022-05-31T03:07:09Z

Excision of ganglion of the wrist

2022-05-31T03:07:02Z

Arthrodesis of the wrist

2022-05-31T03:06:50Z

Mitchel.DeVita: Created page with "{{Infobox surgical procedure | anesthesia_type = | airway = | lines_access = | monitors = | considerations_preoperative = | considerations_intraoperative = | considerations_postoperative = }} Arthrodesis of the wrist, or wrist fusion, is a surgical technique utilized with other treatment options have failed to control symptoms of advanced wrist arthritis, wrist fractures, or severe ligament trauma. The wrist joint is immobilized with fusions of the radius to the..."

{{Infobox surgical procedure
| anesthesia_type =
| airway =
| lines_access =
| monitors =
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

Arthrodesis of the wrist, or wrist fusion, is a surgical technique utilized with other treatment options have failed to control symptoms of advanced wrist arthritis, wrist fractures, or severe ligament trauma. The wrist joint is immobilized with fusions of the radius to the carpal bones.

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===
Hematoma formation, Nerve injury (most common dorsal sensory branch of the ulnar nerve and the sensory branch of the radial nerve), Vascular injury, Infection, and Hardware failure <ref>Jimenez A, Anand P. Wrist Arthrodesis. [Updated 2022 Apr 30]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: <nowiki>https://www.ncbi.nlm.nih.gov/books/NBK556015/</nowiki></ref>

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]

Darrach procedure

2022-05-31T02:59:54Z

Mitchel.DeVita: Created page with "{{Infobox surgical procedure | anesthesia_type = Regional | airway = Natural | lines_access = PIV | monitors = standard | considerations_preoperative = | considerations_intraoperative = | considerations_postoperative = }} The distal ulna head resection, also known as Darrach's procedure, is performed for the management of an open dislocation of the distal radial-ulnar joint. == Overview == === Indications === === Surgical procedure === == Preoperative management..."

{{Infobox surgical procedure
| anesthesia_type = Regional
| airway = Natural
| lines_access = PIV
| monitors = standard
| considerations_preoperative =
| considerations_intraoperative =
| considerations_postoperative =
}}

The distal ulna head resection, also known as Darrach's procedure, is performed for the management of an open dislocation of the distal radial-ulnar joint.

== Overview ==

=== Indications ===

=== Surgical procedure ===

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|
|-
|Endocrine
|
|-
|Other
|
|}

=== Labs and studies ===

=== Operating room setup ===

=== Patient preparation and premedication ===

=== Regional and neuraxial techniques ===

== Intraoperative management ==

=== Monitoring and access ===

=== Induction and airway management ===

=== Positioning ===

=== Maintenance and surgical considerations ===

=== Emergence ===

== Postoperative management ==

=== Disposition ===

=== Pain management ===

=== Potential complications ===

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]