Difference between revisions of "Hip arthroplasty"
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|120 (motor) | |120 (motor) | ||
170 (sensory) | 170 (sensory) |
Latest revision as of 11:09, 12 July 2023
Anesthesia type |
General or spinal ± Regional |
---|---|
Airway |
ETT if general |
Lines and access |
Large bore IV ± Arterial line |
Monitors |
Standard ± ABP |
Primary anesthetic considerations | |
Preoperative | |
Intraoperative |
Risk for bone cement implantation syndrome (BCIS) |
Postoperative |
Multimodal analgesia |
Article quality | |
Editor rating | |
User likes | 1 |
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
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[1][2]
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[3] 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 discussion on drug choice.
Drug | Conc. | Baricity | Dose | Duration*
(min) |
Unique
Side-Effects |
---|---|---|---|---|---|
Bupivicaine[4][5] | 0.75% | Hyperbaric | 12-16mg | 90-120 | |
Bupivicaine[4][5] | 0.5% | Isobaric | 12-16mg | 90-120 | |
Lidocaine[4][6][7] | 1-2%
5% |
Isobaric;
hyperbaric |
60-80mg | 60-90 | TNS (7%) |
Mepivicaine[8][9][10][11] | 1.5% | Isobaric | 50-80mg | 100-120 | TNS (7%) |
Chloroprocaine[12][13][14][15] | 2% | Hyperbaric | 30-60mg | 30-50 (2-level regression)
60-90 (motor) 100-130 (ambulation) |
Flu-like symptoms
and back ache with epinephrine addition |
Ropivacaine[16] | 0.75% | Isobaric | 15-22.5 mg | 120 (motor)
170 (sensory) |
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. [17]
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
- lumbar ESP (Erector spinae plane) block
- PENG Block (Pericapsular Nerve Group Block/Hip Block)
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
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. [18]
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.[19] 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.[20]
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[21][22] for pre-screened populations[23] 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
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
- ↑ Rajesparan, K.; Biant, L. C.; Ahmad, M.; Field, R. E. (2009-06). "The effect of an intravenous bolus of tranexamic acid on blood loss in total hip replacement". The Journal of Bone and Joint Surgery. British Volume. 91 (6): 776–783. doi:10.1302/0301-620X.91B6.22393. ISSN 2044-5377. PMID 19483232. Check date values in:
|date=
(help) - ↑ Peng Zhang, M. M.; Jifeng Li, M. M.; Xiao Wang, M. M. (2017-07). "Combined versus single application of tranexamic acid in total knee and hip arthroplasty: A meta-analysis of randomized controlled trials". International Journal of Surgery (London, England). 43: 171–180. doi:10.1016/j.ijsu.2017.05.065. ISSN 1743-9159. PMID 28602763. Check date values in:
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(help) - ↑ Wainwright, Thomas W.; Gill, Mike; McDonald, David A.; Middleton, Robert G.; Reed, Mike; Sahota, Opinder; Yates, Piers; Ljungqvist, Olle (2020-01-02). "Consensus statement for perioperative care in total hip replacement and total knee replacement surgery: Enhanced Recovery After Surgery (ERAS®) Society recommendations". Acta Orthopaedica. 91 (1): 3–19. doi:10.1080/17453674.2019.1683790. ISSN 1745-3674. PMC 7006728. PMID 31663402.CS1 maint: PMC format (link)
- ↑ 4.0 4.1 4.2 Frey, K.; Holman, S.; Mikat-Stevens, M.; Vazquez, J.; White, L.; Pedicini, E.; Sheikh, T.; Kao, T. C.; Kleinman, B.; Stevens, R. A. (1998-03). "The recovery profile of hyperbaric spinal anesthesia with lidocaine, tetracaine, and bupivacaine". Regional Anesthesia and Pain Medicine. 23 (2): 159–163. doi:10.1097/00115550-199823020-00008. ISSN 1098-7339. PMID 9570604. Check date values in:
|date=
(help) - ↑ 5.0 5.1 Malinovsky, J. M.; Charles, F.; Kick, O.; Lepage, J. Y.; Malinge, M.; Cozian, A.; Bouchot, O.; Pinaud, M. (2000-12). "Intrathecal anesthesia: ropivacaine versus bupivacaine". Anesthesia and Analgesia. 91 (6): 1457–1460. doi:10.1097/00000539-200012000-00030. ISSN 0003-2999. PMID 11094000. Check date values in:
|date=
(help) - ↑ Liam, B. L.; Yim, C. F.; Chong, J. L. (1998-07). "Dose response study of lidocaine 1% for spinal anaesthesia for lower limb and perineal surgery". Canadian Journal of Anaesthesia = Journal Canadien D'anesthesie. 45 (7): 645–650. doi:10.1007/BF03012094. ISSN 0832-610X. PMID 9717596. Check date values in:
|date=
(help) - ↑ Pawlowski, Julius; Orr, Kevin; Kim, Ku-Mie; Pappas, Ana Lucia; Sukhani, Radha; Jellish, W. Scott (2012-03). "Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures". Journal of Clinical Anesthesia. 24 (2): 109–115. doi:10.1016/j.jclinane.2011.06.014. ISSN 1873-4529. PMID 22342508. Check date values in:
|date=
(help) - ↑ Pawlowski, Julius; Orr, Kevin; Kim, Ku-Mie; Pappas, Ana Lucia; Sukhani, Radha; Jellish, W. Scott (2012-03). "Anesthetic and recovery profiles of lidocaine versus mepivacaine for spinal anesthesia in patients undergoing outpatient orthopedic arthroscopic procedures". Journal of Clinical Anesthesia. 24 (2): 109–115. doi:10.1016/j.jclinane.2011.06.014. ISSN 1873-4529. PMID 22342508. Check date values in:
|date=
(help) - ↑ Pawlowski, J.; Sukhani, R.; Pappas, A. L.; Kim, K. M.; Lurie, J.; Gunnerson, H.; Corsino, A.; Frey, K.; Tonino, P. (2000-09). "The anesthetic and recovery profile of two doses (60 and 80 mg) of plain mepivacaine for ambulatory spinal anesthesia". Anesthesia and Analgesia. 91 (3): 580–584. doi:10.1097/00000539-200009000-00015. ISSN 0003-2999. PMID 10960380. Check date values in:
|date=
(help) - ↑ Zayas, V. M.; Liguori, G. A.; Chisholm, M. F.; Susman, M. H.; Gordon, M. A. (1999-11). "Dose response relationships for isobaric spinal mepivacaine using the combined spinal epidural technique". Anesthesia and Analgesia. 89 (5): 1167–1171. ISSN 0003-2999. PMID 10553828. Check date values in:
|date=
(help) - ↑ Schwenk, Eric S.; Kasper, Vincent P.; Smoker, Jordan D.; Mendelson, Andrew M.; Austin, Matthew S.; Brown, Scot A.; Hozack, William J.; Cohen, Alexa J.; Li, Jonathan J.; Wahal, Christopher S.; Baratta, Jaime L. (2020-10-01). "Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation". Anesthesiology. 133 (4): 801–811. doi:10.1097/ALN.0000000000003480. ISSN 1528-1175. PMID 32852904.
- ↑ Goldblum, E.; Atchabahian, A. (2013-05). "The use of 2-chloroprocaine for spinal anaesthesia: Chloroprocaine for spinal anaesthesia". Acta Anaesthesiologica Scandinavica. 57 (5): 545–552. doi:10.1111/aas.12071. Check date values in:
|date=
(help) - ↑ Lacasse, Marie-Andrée; Roy, Jean-Denis; Forget, Josée; Vandenbroucke, Franck; Seal, Robert F.; Beaulieu, Danielle; McCormack, Michael; Massicotte, Luc (2011-04). "Comparison of bupivacaine and 2-chloroprocaine for spinal anesthesia for outpatient surgery: a double-blind randomized trial". Canadian Journal of Anesthesia/Journal canadien d'anesthésie. 58 (4): 384–391. doi:10.1007/s12630-010-9450-x. ISSN 0832-610X. Check date values in:
|date=
(help) - ↑ Kouri, Mary E.; Kopacz, Dan J. (2004-01). "Spinal 2-Chloroprocaine: A Comparison with Lidocaine in Volunteers:". Anesthesia & Analgesia: 75–80. doi:10.1213/01.ANE.0000093228.61443.EE. ISSN 0003-2999. Check date values in:
|date=
(help) - ↑ Smith, Kristin N.; Kopacz, Dan J.; McDonald, Susan B. (2004-01). "Spinal 2-chloroprocaine: a dose-ranging study and the effect of added epinephrine". Anesthesia and Analgesia. 98 (1): 81–88, table of contents. doi:10.1213/01.ane.0000093361.48458.6e. ISSN 0003-2999. PMID 14693591. Check date values in:
|date=
(help) - ↑ Gadre, Akshay Kishore; Bandyopadhyay, Kasturi Hossain; Dutta, Chumki; Nag, Tulsi (2019-12). "A Comparative Study of Intrathecal Isobaric 0.5% Bupivacaine and Intrathecal Isobaric 0.75% Ropivacaine in Elective Lower Segment Cesarean Section". Journal of Pharmacology and Pharmacotherapeutics. 10 (4): 126–131. doi:10.4103/jpp.JPP_80_19. ISSN 0976-500X. Check date values in:
|date=
(help) - ↑ 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
- ↑ Neuman, Mark D.; Feng, Rui; Carson, Jeffrey L.; Gaskins, Lakisha J.; Dillane, Derek; Sessler, Daniel I.; Sieber, Frederick; Magaziner, Jay; Marcantonio, Edward R.; Mehta, Samir; Menio, Diane (2021-11-25). "Spinal Anesthesia or General Anesthesia for Hip Surgery in Older Adults". New England Journal of Medicine. 385 (22): 2025–2035. doi:10.1056/NEJMoa2113514. ISSN 0028-4793.
- ↑ 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, https://doi.org/10.1016/j.arth.2018.06.023. (https://www.sciencedirect.com/science/article/pii/S088354031830593X)
- ↑ 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.
- ↑ Amundson, Adam W.; Panchamia, Jason K.; Jacob, Adam K. (2019-06). "Anesthesia for Same-Day Total Joint Replacement". Anesthesiology Clinics. 37 (2): 251–264. doi:10.1016/j.anclin.2019.01.006. Check date values in:
|date=
(help) - ↑ Li, Jinlei; Rubin, Lee E.; Mariano, Edward R. (2019-10). "Essential elements of an outpatient total joint replacement programme". Current Opinion in Anaesthesiology. 32 (5): 643–648. doi:10.1097/ACO.0000000000000774. ISSN 0952-7907. Check date values in:
|date=
(help) - ↑ Ziemba-Davis, Mary; Caccavallo, Peter; Meneghini, R. Michael (2019-07). "Outpatient Joint Arthroplasty—Patient Selection: Update on the Outpatient Arthroplasty Risk Assessment Score". The Journal of Arthroplasty. 34 (7): S40–S43. doi:10.1016/j.arth.2019.01.007. Check date values in:
|date=
(help)