Anesthesia for Orthopaedic Surgery

Anesthesia for Orthopaedic Surgery

Anesthesia for Orthopedic Surgery Dr abdollahi 02/03/2020 1 Many orthopedic surgical procedures lend themselves to the use of regional anesthesia (intraoperative anesthesia and postoperative analgesia. 02/03/2020

2 Anesthesia for orthopedic surgery requires an understanding of special positioning requirements (risk of peripheral nerve injury), appreciation of the possibility of large intraoperative blood loss and techniques to limit the impact of this occurrence (intraoperative hypotension, salvage techniques). 02/03/2020 3

The risk of venous thromboembolism (emphasizing the need for the anesthesiologist to consider the interaction of anticoagulants and antiplatelet drugs with anesthetic drugs or techniques, especially regional anesthesia). 02/03/2020 4 Preoperative Assessment . A brief neurologic examination with documentation of any

pre-existing deficits is recommended. 02/03/2020 5 Pre-Existing Medical Problems Coronary artery disease (perioperative blockade should be considered) Rheumatoid arthritis (steroid therapy, airway management) Physical Examination Mouth opening or neck extension Evidence of infection and anatomic abnormalities at

proposed sites for introduction of regional anesthesia (peripheral techniques may be acceptable if a regional technique is contraindicated) Arthritic changes and limitations to positioning 02/03/2020 6 Choice of Anesthetic Technique Advantages of Regional versus General Anesthesia for Orthopaedic Surgical Procedures 1. 2.

3. 4. 5. 6. 7. 8. Improved postoperative analgesia Decreased incidence of nausea and vomiting Less respiratory and cardiac depression Improved perfusion because of sympathetic nervous system block Decreased intraoperative blood loss Decreased blood pressure

Blood flow redistribution to large caliber vessels Locally decreased venous pressure 02/03/2020 7 Surgery to the Spine Spinal Cord Injuries Spinal cord injuries must be considered in any patient who has experienced trauma. (Cervical spine injuries are associated with head and thoracic injuries, and lumbar spine injuries are associated with abdominal injuries and long bone fractures.)

02/03/2020 8 Tracheal Intubation 1. 2. 3. 4.

02/03/2020 Airway management is critical because the most common cause of death with acute cervical spinal cord injury is respiratory failure. All patients with severe trauma or head injuries should be assumed to have an unstable cervical fracture until proven otherwise radiographically. Awake fiberoptic-assisted intubation may be necessary, with general anesthesia induced only after voluntary upper and lower extremity movement is confirmed. In a truly emergent situation, oral intubation of the trachea with direct laryngoscopy (minimal flexion or extension of the neck) is the usual approach.

9 Respiratory considerations Respiratory considerations include an inability to cough and clear secretions, which may result in atelectasis and infection. 02/03/2020 10 Cardiovascular considerations

Cardiovascular considerations are based on loss of sympathetic nervous system innervation (spinal shock) below the level of spinal cord transection. (Cardioaccelerator fiber [T1T4] loss results in bradycardia and possible absence of compensatory tachycardia if blood loss occurs.) 02/03/2020 11 Succinylcholine-Induced Hyperkalemia Succinylcholine-Induced Hyperkalemia It is usually safe

to administer succinylcholine (Sch) within the first 48 hours after spinal cord injury. It should be avoided after 48 hours in all patients with spinal cord injuries. 02/03/2020 12 Temperature Control Loss of vasoconstriction below the level of spinal cord transection causes patients to become poikilothermic. (Body temperature should be maintained by increasing

ambient air temperature and warming intravenous [IV] fluids and inhaled gases). 02/03/2020 13 Maintaining Spinal Cord Integrity .An important component of anesthetic management is preservation of spinal cord blood flow. (Perfusion pressure should be maintained, and extreme hyperventilation of the lungs should be avoided.) Neurophysiologic monitoring (somatosensory or motor

evoked potentials), a wake-up test, or both are used to recognize neurologic ischemia before it becomes irreversible. 02/03/2020 14 Autonomic Hyperreflexia 1. Occurs in 85% of patients with spinal cord transection 2. 3. 4. 5.

6. above T5 Paroxysmal hypertension with bradycardia (baroreceptor reflex) Cardiac dysrhythmias Cutaneous vasoconstriction below and vasodilation above the level of transection Precipitated by any noxious stimulus (distention of a hollow viscus) Treatment is removal of stimulus, deepening of anesthesia, and administration of a vasodilator 02/03/2020

15 Scoliosis 02/03/2020 16 Pulmonary Considerations Postoperative ventilation of the patient's lungs is likely to be necessary if the vital capacity is below 40% of the predicted value. Prolonged arterial hypoxemia,

hypercapnia, and pulmonary vascular constriction may result in right ventricular hypertrophy and irreversible pulmonary hypertension. 02/03/2020 17 Surgical Approach and Positioning. The prone position is used for the posterior approach to the spine. (The hazards of the prone position, including brachial plexus stretch injury [the head

should be rotated toward the abducted arm and the eyes taped closed], should be considered. 02/03/2020 18 02/03/2020 The anterior approach is achieved with the patient in the lateral position, usually with the convexity of the curve uppermost. Removal of a

rib may be necessary. A double-lumen endotracheal tube is used to collapse the lung on the operative side. 19 A combined anterior and posterior approach in one or two stages yields higher union rates but is associated with increased morbidity, including blood loss and nutritional deficits. 02/03/2020

20 Anesthetic Management 02/03/2020 Respiratory reserve is assessed by exercise tolerance, vital capacity measurement, and arterial blood gas analysis. Autologous blood donation is often recommended (usually 4 U can be collected in the month before surgery).

21 There are specific anesthetic considerations for surgical correction of scoliosis by spinal fusion and instrumentation . 02/03/2020 22 Anesthetic Considerations for Surgical Correction of Scoliosis

1. Management of the prone position 2. Hypothermia (long procedure and extensive exposed 3. 4. 5. 6. area) Extensive blood and fluid losses Maintenance of spinal cord integrity Prevention and treatment of venous air embolism Reduction of blood loss through hypotensive anesthetic techniques

02/03/2020 23 Adequate hemodynamic monitoring and venous access are essential in the management of patients undergoing spinal fusion and instrumentation . 02/03/2020 24

Monitoring for Patients Undergoing Scoliosis Surgery 1. Cannulation of radial artery (direct blood pressure measurement and assessment of blood gases) 2. Central venous catheter (evaluates blood and fluid management and aspirate air if venous air embolism occurs) 3. Pulmonary artery catheter (pulmonary hypertension) 4. Neurophysiologic monitoring (prompt diagnosis of neurologic changes and early intervention) Somatosensory evoked potentials Motor evoked potentials Wake-up test 02/03/2020

25 Degenerative Vertebral Column Disease Spinal stenosis, spondylosis, and spondylolisthesis are forms of degenerative vertebral column disease that may lead to neurologic deficits necessitating surgical intervention. 02/03/2020 26 Surgical Approach and Positioning

02/03/2020 Cervical laminectomy is most often performed with patients in the prone position (Fig. 53-1). 27 Prone position with the patient's head turned and. the dependent ear and eye protected from pressure. Chest rolls are in place, the arms are extended forward without hyperextension, and the knees are .flexed

02/03/2020 28 02/03/2020 Fiberoptic-assisted intubation may be necessary in patients with severely limited cervical movement. The anterior approach places the surgical incision (anterior border of the sternocleidomastoid muscle)

near critical structures (carotid artery, esophagus, trachea [edema and recurrent nerve injury are possible]). 29 02/03/2020 The use of the sitting position for cervical laminectomy allows a more blood-free surgical field but introduces the risk of venous air embolism. The incidence is less than for sitting posterior fossa

craniotomy, but the patient still needs to be monitored with precordial Doppler. 30 Anesthetic Management 02/03/2020 General anesthesia is most often selected for spinal surgery because it ensures airway access and is acceptable for prolonged operations. Patients undergoing cervical laminectomy should be

assessed preoperatively for cervical range of motion and the presence of neurologic symptoms during flexion, extension, and rotation of the head. (Awake fiberoptic intubation of the trachea may be necessary.) 31 Sch should be avoided if there is evidence of a progressive neurologic deficit. 02/03/2020

32 Spinal Cord Monitoring Paraplegia is a feared complication of major spine surgery. The incidence of neurologic injuries associated with scoliosis correction is 1.2%. When patients awaken with paraplegia, neurologic recovery is unlikely, although immediate removal of instrumentation improves the prognosis. 02/03/2020

33 It is therefore essential that any intraoperative compromise of spinal cord function be detected as early as possible and reversed immediately. The two methods for detecting intraoperative compromise of spinal cord function are the wake-up test and neurophysiologic monitoring. 02/03/2020 34

wake-up The wake-up test consists of intraoperative awakening of patients after completion of spinal instrumentation. Surgical anesthesia (often including opioids) and neuromuscular blockers are allowed to dissipate, and the patient is asked to move the hands and feet before anesthesia is re-established. Recall may occur but is rarely viewed as unpleasant, especially if the patient is fully informed before surgery. 02/03/2020 35

Neurophysiologic monitoring Neurophysiologic monitoring (as an adjunct or an alternative to the wake-up test) includes : Somatosensory evoked potentials (SSEPs) (waveforms may be altered by volatile anesthetics, hypotension, hypothermia, hypercarbia), Motor evoked potentials (MEPs) (neuromuscular blocking drugs cannot be used), Electromyography. 02/03/2020

36 02/03/2020 SSEPs reflect the dorsal columns of the spinal cord (proprioception and vibration) supplied by the posterior spinal artery. 37

02/03/2020 MEPs reflect the motor pathways and the portion of the spinal cord supplied by the anterior spinal artery. The combined use of SSEPs and MEPs may increase the early detection of intraoperative spinal cord ischemia. 38

If both SSEPs and MEPs are to be monitored during major spine surgery, one might consider providing anesthesia with an ultrashort-acting opioid infusion with a low dose of inhaled anesthetic and monitoring the electroencephalogram to minimize the potential for intraoperative awareness 02/03/2020 39 Blood Loss A combination of IV hypotensive agents and volatile

anesthetics is frequently used in an attempt to decrease blood loss during surgery. Perioperative coagulopathy from dilution of coagulation factors, platelets, or fibrinolysis may be predicted from measurement of either the prothrombin time or activated partial thromboplastin time. 02/03/2020 40 .Visual Loss After Spine Surgery Most cases are associated with complex instrumented

fusions often associated with prolonged intraoperative hypotension, anemia, large intraoperative blood loss, and prolonged surgery (also present in patients who do not develop blindness). 02/03/2020 41 The American Society of Anesthesiologists' Closed Claims Registry concludes that patients at high risk for postoperative visual loss after major spine surgery are those in whom blood loss is 1000 mL or greater or

undergoing surgery lasting 6 hours or longer. 02/03/2020 42 .Venous Air Embolus Venous air embolism can occur in all positions used for laminectomies because the operative site is above the heart level. Presenting signs are usually unexplained hypotension and an increase in the end-tidal nitrogen concentration.

02/03/2020 43 Postoperative Care Most patients' tracheas can be extubated immediately after posterior spinal fusion operations if the procedure was relatively uneventful and preoperative vital capacity values were acceptable. The presence of severe facial edema may prevent prompt tracheal extubation. 2. Aggressive postoperative pulmonary care, including incentive spirometry, is necessary to avoid atelectasis and pneumonia.

3. Continued hemorrhage in the postoperative period is a concern. 1. 02/03/2020 44 Epidural and Spinal Anesthesia After Major Spine Surgery Postoperative anatomic changes make needle or catheter placement more difficult after major spine surgery .

02/03/2020 45 Changes After Major Spine Surgery That May Influence the Ability to Perform Epidural or Spinal Anesthesia 1. Degenerative changes (spondylothesis below level of fusion) that increase the chance of spinal cord ischemia and neurologic complications with regional anesthesia 2. Ligamentum flavum injury from prior surgery results in adhesions and possible obliteration of the epidural space or interference with spread of local anesthetic solution (patchy block)

02/03/2020 46 3.Increased incidence of accidental dural puncture if the epidural space is altered by prior surgery (blood patch is difficult to perform if needed) 4.Prior bone grafting or fusion may prevent midline insertion of the needle 02/03/2020 47

Spinal anesthesia may be a more reliable technique than epidural anesthesia if a regional technique is selected. The presence of postoperative spinal stenosis or other degenerative changes in the spine or pre-existing neurologic symptoms may preclude the use of regional anesthesia in these patients. 02/03/2020 48

Surgery to the Upper Extremities Orthopaedic surgical procedures to the upper extremities are well suited to regional anesthetic techniques . 02/03/2020 49 Regional Anesthetic Techniques for Upper Extremity Surgery 02/03/2020

50 Upper extremity peripheral nerve blocks may be used in the treatment and prevention of reflex sympathetic dystrophy. Continuous catheter techniques provide postoperative analgesia and facilitate early limb mobilization. 02/03/2020 51 The patient should be examined preoperatively to

document any neurologic deficits because orthopaedic surgical procedures often involve peripheral nerves with pre-existing deficits (ulnar nerve transposition at the elbow, carpal tunnel release of the median nerve at the wrist) or may be adjacent to neural structures (total shoulder arthroplasty or fractures of the proximal humerus). 02/03/2020 52 Improper surgical positioning, the use of a tourniquet,

and the use of constrictive casts or dressings may also result in perioperative neurologic ischemia. Local anesthetic selection should be based on the duration and degree of sensory or motor block required. (Prolonged anesthesia in the upper extremity in contrast to the lower extremity is not a contraindication to hospital discharge.) 02/03/2020 53 Surgery to the Shoulder and Upper Arm A significant incidence of neurologic deficits in patients

undergoing this type of surgery demonstrates the importance of clinical examination before regional anesthetic techniques are performed. 02/03/2020 54 02/03/2020 Total shoulder arthroplasty may be associated with a

postoperative neurologic deficit (brachial plexus injury) that is at the same level of the nerve trunks at which an interscalene block is performed. It is impossible to determine a surgical or anesthetic cause. Most of these injuries represent neurapraxia and resolve in 3 to 4 months. 55 Radial nerve palsy is associated with humeral shaft fractures, and axillary nerve injury is associated with proximal humeral shaft fractures.

02/03/2020 56 .Anesthetic Management Surgery to the shoulder and humerus may be performed under regional (interscalene or supraclavicular brachial plexus block) or general anesthesia. The ipsilateral diaphragmatic paresis and 25% loss of pulmonary function produced by interscalene block mean that this block is contraindicated in patients with severe pulmonary

disease. 02/03/2020 57 Surgery to the Elbow Surgical procedures to the distal humerus, elbow, and forearm are suited to regional anesthetic techniques. Supraclavicular block of the brachial plexus is more reliable than the axillary approach (which may miss the musculocutaneous nerve) but introduces the risk of pneumothorax (typically manifests 612 hours after

hospital discharge such that postoperative chest radiography may not be useful). 02/03/2020 58 surgery of the Wrist and Hand Brachial plexus block (axillary approach) is most commonly used for surgical procedures of the forearm, wrist, and hand. The interscalene approach is seldom used for wrist and hand procedures because of possible incomplete block of the ulnar nerve (15%30% of patients), and the supraclavicular approach

introduces the risk of pneumothorax. 02/03/2020 59 IV regional anesthesia (Bier block) permits the use of a tourniquet but has disadvantages of limited duration (90120 minutes), possible local anesthetic systemic toxicity, and rapid termination of anesthesia (and postoperative analgesia) on tourniquet deflation. 02/03/2020

60 Continuous Brachial Plexus Anesthesia Catheters placed in the sheath surrounding the brachial plexus permit continuous infusion of local anesthetic solution. (Bupivacaine 0.125% prevents vasospasm and improves circulation after limb reimplantation or vascular repair.) Indwelling catheters may be left in place for 4 to 7 days after surgery. 02/03/2020

61 Surgery to the Lower Extremities Orthopaedic procedures to the lower extremity may be performed under general or regional anesthesia, although regional anesthesia may provide some unique advantages . 02/03/2020 62

Lumbosacral Techniques for Major Lower Extremity Surgery 02/03/2020 63 Surgery to the Hip Surgical Approach and Positioning. The lateral decubitus position is frequently used to facilitate surgical exposure for total hip arthroplasty, and a fracture table is often used for repair of femur fractures. The patient must be carefully monitored for hemodynamic changes during

positioning when under general or regional anesthesia. (Adequate hydration and gradual movement minimize blood pressure decreases.) 02/03/2020 64 Care should be taken to pad and position the arms and to avoid compression of the brachial plexus. (A chest roll is placed caudad to the axilla to support the upper part of the dependent thorax.)

02/03/2020 65 Anesthetic Technique Spinal or epidural anesthesia is well suited to procedures involving the hip. Deliberate hypotension can also be used with general anesthesia as a means of decreasing surgical blood loss. 02/03/2020 66

Total Knee Arthroplasty (TKA) Patients undergoing TKA experience significant postoperative pain, which impedes physical therapy and rehabilitation. Regional anesthetic techniques that can be used for surgical procedures on the knee include epidural, spinal, and peripheral leg blocks. Spinal anesthesia is often selected, but an advantage of a continuous epidural is postoperative pain management. (Aggressive postoperative regional analgesic techniques for 4872 hours shorten the rehabilitation period more than systemic opioids.)

02/03/2020 67 Patients undergoing amputation of a lower limb often benefit from the use of regional anesthesia, although adequate sedation is imperative. 02/03/2020 68 Postoperative Analgesia after Major Joint

.Replacement Pain after total joint replacement, particularly total knee replacement, is severe. Single-dose and continuous peripheral nerve techniques that block the lumbar plexus (femoral nerve block) with or without sciatic nerve block provide excellent postoperative analgesia. 02/03/2020 69 Knee Arthroscopy and Anterior Cruciate Ligament (ACL) Repair

Diagnostic knee arthroscopy may be performed under local anesthesia with sedation. (A single dose or continuous lower extremity block is not warranted in most patients.) ACL repair requires postoperative analgesia (femoral nerve blocks should be considered). 02/03/2020 70 Intra-articular injection of local anesthetics (bupivacaine),

opioids (morphine), or both has become routine for perioperative management after arthroscopic knee surgery. 02/03/2020 71 Surgery to the Ankle and Foot Peripheral nerve blocks (femoral and sciatic nerve) provide acceptable anesthesia for surgery on the foot and ankle.

02/03/2020 72 Microvascular Surgery 02/03/2020 73 Anesthetic Considerations for Microvascular Surgery for Limb Replantation 1. Maintain blood flow through microvascular anastomoses 2.

3. 4. 5. 6. (critical for graft viability). Prevent hypothermia (increase temperature of operating room to 21C; warm IV solutions and inhaled gases). Maintain perfusion pressure. Avoid vasopressors. Use vasodilators (volatile anesthetics, nitroprusside) and sympathetic nervous system block (regional anesthesia). Consider normovolemic hemodilution.

Administer antithrombotics (heparin) with or without fibrinolytics (low-molecular-weight dextran). 02/03/2020 74

7.Remember positioning considerations associated with long surgical procedures. 8.Replace blood and fluid losses. 9.Consider the choice of anesthesia (often a combination of regional and general anesthesia) 10.Sympathectomy is helpful, but the long duration of surgery may limit use of single-shot techniques (another option is a continuous technique) 11.Ensure airway access and patient immobility. 02/03/2020 75

Pediatric Orthopaedic Surgery Regional anesthetic techniques are adaptable to pediatric patients, especially in those older than 7 years of age. IV regional anesthesia is particularly useful in pediatric patients for minor procedures such as closed reduction of forearm fractures. 02/03/2020 76 The use of local anesthetic creams minimizes patient

discomfort during placement of an IV catheter. The size of the upper arm often precludes the use of a double tourniquet in pediatric patients, thus limiting the duration of the surgical procedure to 45 to 60 minutes (tourniquet pain typically develops by this time). 02/03/2020 77 Other Considerations Anesthesia for Nonsurgical Closed Orthopaedic Procedures. Some minor procedures (cast and dressing

changes in pediatric patients, pin removal) require only light sedation, but procedures involving bone and joint manipulation (hip and shoulder relocation, closed reduction of fractures) usually require a general or regional anesthetic. 02/03/2020 78 Tourniquets Opinions differ as to the pressure required in tourniquets to prevent bleeding (usually 100 mm Hg

above patient's systolic blood pressure for the leg and 50 mm Hg above systolic blood pressure for the arm). Before the tourniquet is inflated, the limb should be elevated for about 1 minute and tightly wrapped with an elastic bandage distally to proximally. Oozing despite tourniquet inflation is most likely caused by intramedullary blood flow in long bones. 02/03/2020 79 The duration of safe tourniquet inflation is unknown

(12 hours is not associated with irreversible changes). Five minutes of intermittent perfusion between 1 and 2 hours may allow more extended use. Transient systemic metabolic acidosis and increased PaCO2 (18 mm Hg) may occur after tourniquet deflation. 02/03/2020 80 Tourniquet pain despite adequate operative anesthesia typically appears after about 45 minutes (may reflect

more rapid recovery of C fibers as the block wanes). During surgery, this pain is managed with opioids and hypnotics 02/03/2020 81 Fat Embolus Syndrome Patients at risk include those with multiple traumatic injuries and surgery involving long bone fractures, intramedullary instrumentation or cementing, or total knee surgery. The incidence of fat embolism syndrome

in isolated long bone fractures is 3% to 4%, and the mortality rate is 10% to 20%. 02/03/2020 82 Clinical and laboratory signs usually occur 12 to 40 hours after injury and may range from mild dyspnea to coma . Treatment includes early stabilization of fractures and support of oxygenation. Steroid therapy may be instituted

02/03/2020 83 Criteria for Diagnosis of Fat Embolism Syndrome MAJOR : 1. Axillary or subconjunctival petechiae 2. Hypoxemia (PaO2< 60 mm Hg) 3. 4.

CNS depression (disproportionate to hypoxemia) Pulmonary edema 02/03/2020 84 Criteria for Diagnosis of Fat Embolism Syndrome MINOR: 1. Tachycardia (>100 bpm) 2. Hyperthermia 3. Retinal fat emboli

4. Urinary fat globules 5. Decreased platelets 6. Increased ESR 7. DIC 02/03/2020 85 Methyl Methacrylate Insertion of this cement may be associated with hypotension, which has been attributed to absorption of the volatile monomer of methyl methacrylate or

embolization of air (nitrous oxide should be discontinued before cement is placed) and bone marrow during femoral reaming. 02/03/2020 86 Adequate hydration and maximizing oxygenation minimize the hypotension and arterial hypoxemia that may accompany cementing of the prosthesis. 02/03/2020

87 Venous thromboembolism is a major cause of death after surgery or trauma to the lower extremities. Without prophylaxis, 40% to 80% of orthopaedic patients develop venous thrombosis. (The incidence of fatal pulmonary embolism is highest in patients who have undergone surgery for hip fracture.) 02/03/2020 88

Antithrombotic prophylaxis is based on identification of risk factors . 02/03/2020 89 Antithrombotic Regimens to Prevent Thromboembolism in Orthopedic Surgical Patients Hip and Knee Arthroplasty and Hip Fracture Surgery LMWH* started 12 hours before surgery or 12 to 24 hours after

surgery or 4 to 6 hours after surgery at half the usual dose and then increasing to the usual high-risk dose the following day. Fondaparinux (2.5 mg started 6 to 8 hours after surgery) Adjusted-dose warfarin started preoperatively or the evening after surgery (INR target, 2.5; range, 2.03.0) Intermittent pneumatic compression is an alternative option to anticoagulant prophylaxis in patients undergoing total knee (but not hip) replacement. 02/03/2020 90

Spinal Cord Injury LMWH after primary hemostasis is evident Intermittent pneumatic compression is an alternative when anticoagulation is contraindicated early after surgery. During the rehabilitation phase, conversion to adjusted- dose warfarin (INR target, 2.5; range, 2.03.0). 02/03/2020 91

Elective Spine Surgery Routine use of thromboprophylaxis, apart from early and persistent mobilization, is not recommended. Knee Arthroscopy Routine use of thromboprophylaxis, apart from early and persistent mobilization, is not recommended. 02/03/2020 92 Possible Explanations for Decreased Incidence of Deep Vein

Thrombosis in Patients Receiving Regional Anesthesia Rheologic changes resulting in hyperkinetic lower extremity blood flow and associated decrease in venous stasis and thrombus formation Beneficial circulatory effects from epinephrine added to local anesthetic solution

Altered coagulation and fibrinolytic responses to surgery under neural blockade, resulting in decreased tendency for blood to clot Absence of positive pressure ventilation and its effects on circulation Direct local anesthetic effects (decreased platelet aggregation) 02/03/2020 93 Despite perceived advantages of neuraxial techniques for hip and knee surgery (including a decreased

incidence of DVT), patients receiving perioperative anticoagulants and antiplatelet medications are often not considered candidates for spinal or epidural anesthesia because of the risk of neurologic deficit from a spinal or epidural hematoma . 02/03/2020 94 Neuraxial Anesthesia and Analgesia in Orthopedic Patients Receiving Antithrombotic Therapy Low-Molecular-Weight Heparin Needle placement should occur 10 to 12 hours after a

dose. Indwelling neuraxial catheters are allowed with oncedaily (but not twice-daily) dosing of LMWH. It is optimal to place and remove indwelling catheters in the morning and administer LMWH in the evening to allow normalization of hemostasis to occur before catheter manipulation. 02/03/2020 95 Warfarin Adequate levels of all vitamin Kdependent factors

should be present during catheter placement and removal. Patients chronically on warfarin should have a normal INR before performance of the regional technique. PT and INR should be monitored daily. The catheter should be removed when INR <1.5. 02/03/2020 96 Fondaparinux Neuraxial techniques are not advised in patients who are

anticipated to receive fondaparinux. . 02/03/2020 97 Nonsteroidal Anti-Inflammatory Drugs No significant risk of regional anesthesia-related bleeding is associated with aspirin-type drugs. For patients receiving warfarin or LMWH, the combined

anticoagulant and antiplatelet effects may increase the risk of perioperative bleeding. Other medications affecting platelet function (thienopyridine derivatives and glycoprotein IIb/IIIa platelet receptor inhibitors) should be avoided. 02/03/2020 98 The patient should be closely monitored in the perioperative period for signs of paralysis. If a spinal hematoma is suspected, the treatment is immediate

decompressive laminectomy. (Recovery of neurologic function is unlikely if >1012 hours elapse.) 02/03/2020 99

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