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Rheumatoid Arthritis Immune-mediated joint destruction with chronic inflammation of synovial membranes NOT regular wear and tear Establishing venous access can be difficult in this population
Cardiovascular Pericardial thickening and effusion, myocarditis, coronary arteritis, conduction defects, vasculitis, cardiac valve fibrosis (aortic regurgitation) Pulmonary Pleural effusion, pulmonary nodules, interstitial pulmonary fibrosis
Hematopoietic Anemia, eosinophilia, platelet dysfunction (from aspirin therapy), thrombocytopenia Endocrine Adrenal insufficiency (from glucocorticoid therapy), impaired immune system
Dermatological Thin and atrophic skin from the disease and immunosuppressive drugs
Rheumatoid Arthritis contd Exercise tolerance can sometimes not be assessed due to limited mobility Use Dipyridamole thallium scanning or dobutamine ECHO for evaluation Odontoid process protrusion
May be seen in severe cases Risk of vertebral circulation compromise during induction May compress spinal cord or brain stem
Grade 1: moderate hypoxia (Spo2<94%) or hypotension [fall in systolic blood pressure (SBP) >20%].
Grade 2: severe hypoxia (Spo2<88%) or hypotension (fall in SBP >40%) or unexpected loss of consciousness. Grade 3: cardiovascular collapse requiring CPR.
Epidurals, spinals may also be used as well as typical LCDs and anticoagulants.
Revision Arthroplasty
In particular may be associated with moderate to severe surgical blood loss. Controlled HYPOtension combined with regional techniques may help decrease blood loss.
Thought behind this is redistribution of blood flow away from bone surface which improves prosthetic cementing and shortens duration of surgery. Autologous blood donation should be considered
High-dose aprotinin, a proteinase inhibitor of fibrinolytic activity and the intrinsic coagulation pathway by decreasing activation of plasminogen, may reduce intraoperative blood loss in patients undergoing revision surgery.
Does not seem to increase risk of PE/DVT
Can construct 3D images of bone and soft tissue based of pt radiographs, CTs, etc.
Allows for improved preop planning and simulation
Premedication with oxycodone 10 mg (orally), valdecoxib 20 mg (orally), and acetaminophen 500 mg (orally). Versed 1-2 mg Antiemetic prophylaxis Lido 2% epidural provides surgical anesthesia (addition of catheter allows for addition administration) Postop pain handled with hydrocodone and acetaminophen and NSAIDs.
Knee Arthroscopy
Typically outpatient Athletes to the elderly Arthroscope used to evaluate conditions such as torn floating cartilage, surface cartilage, ACL reconstruction, trimming of damaged cartilage.
Joint not fully opened (yay MIT) Usually 2 incisions
Consider placement of epidural catheter preoperatively. Knee procedures are typically much more painful than hip so addition of this may help to alleviate some postop pain and allow for more successful physical therapy earlier.
Especially useful for bilateral knee replacements
Femoral sheath catheter may have fewer side effects than epidural
Traumatic fractures Nerve entrapment (carpal tunnel, cubital tunnel) Joint arthroplasties (RA)
Shoulder Surgery
Can be open or arthroscopic Utilize beach chair position or lateral decubitus position Interscalene brachial plexus blockade is excellent for these procedures
Provides good postop analgesia Saves intense muscle relaxation commonly required if this blockade is not performed
Indwelling interscalene catheter can provide up to 48hrs of postop analgesia following major shoulder operations.
Ropivacaine 0.2% infused at 4-8 mL/h
Ketorolac at the end of the procedure and w/in first 24hrs can reduce postop opioid requirements
Hand Surgery
Carpal tunnel release
One of the most common operations in anesthetic practice
Brachial plexus block may be preferred for operations lasting 1h< General anesthesia with propofol, desflurane, and LMA may also be utilized.