Total hip arthroplasty

What the Anesthesiologist Should Know before the Operative Procedure

Total hip arthroplasty (THA) is considered to be a completely elective procedure. The most common surgical technique for a THA requires an incision along the posterolateral aspect of the proximal thigh, which requires a lateral decubitus position (operative side uppermost). Alternatively, the anterior approach is becoming more widely used because it is associated with decreased postoperative pain and more rapid return to ambulation and functional recovery. The most common indications for elective THA are severe hip joint pain, decreased mobility and functional status. Progressive osteoarthritis (OA) is the most common etiology.

1. What is the urgency of the surgery?

What is the risk of delay in order to obtain additional preoperative information?

THA is a completely elective procedure.

Emergent: THA is not considered an emergent procedure.

Urgent: THA is not considered an urgent procedure.

Elective: For elective THA, adequate time must be taken to identify and optimize clinically relevant comorbid conditions prior to surgery

2. Preoperative evaluation

The vast majority of patients presenting for elective THA are elderly with multiple comorbid conditions. THA patients with progressive osteoarthritis (OA) or rheumatoid arthritis (RA) may have multiple joints involved with chronic pain and potential for difficulty in positioning for the operative procedure.

Elderly patients often have coexisting cardiac (coronary artery disease, congestive heart failure due to either systolic and/or diastolic dysfunction, valvular heart disease, and hypertension), cerebrovascular (prior CVA or TIA), pulmonary (chronic obstructive pulmonary disease [COPD] or obstructive sleep apnea [OSA]), and metabolic conditions such as diabetes (with attendant complications) and morbid obesity.

Patients with RA are often on chronic immune modulating/anti-inflammatory medications (such as methotrexate, infliximab, etanercept, NSAIDS, or glucocorticoids that may have major effects on perioperative hemostasis, risk of infection, wound healing, as well as potential for gastrointestinal (GI) and renal complications.

a. Medically unstable conditions warranting further evaluation include: recent myocardial infarction, unstable angina, unstable cardiac dysrhythmias, poorly compensated congestive heart failure, severe symptomatic uncontrolled hypertension, severe valvular disease such as aortic stenosis, poorly controlled chronic or acute decompensated obstructive airway disease, active pulmonary infection, poorly controlled diabetes, and or signs or symptoms of acute cerebrovascular insufficiency.

b. Delaying surgery may be indicated if: any of the above conditions are not optimally evaluated for degree of severity/risk stratification and treatment. THA is an elective procedure and delaying the procedure until the patient’s medical conditions are optimized is recommended.

3. What are the implications of co-existing disease on perioperative care?

b. Cardiovascular system

• Acute/unstable conditions

  Acute myocardial infarction, unstable angina, decompensated congestive heart failure, symptomatic dysrhythmias and stenotic valvular lesions should be investigated and optimized prior to elective THA.

• Baseline coronary artery disease or cardiac dysfunction – Goals of management

  Preoperative evaluation prior to elective THA is indicated is based on identifying patients at increased risk of cardiac complications keeping in mind that THA is considered an intermediate-risk surgery. However, preoperative cardiac testing should be based on decreasing long-term cardiac complications. There is limited data to support that cardiac revascularization (with either coronary artery bypass grafting [CABG] or percutaneous coronary intervention [PCI]) will improve perioperative cardiac outcome. In patients with cardiac risk factors at risk for coronary artery disease or with stable coronary artery disease, hemodynamic stress reduction is the optimal approach. THA with the potential for associated moderate to severe perioperative pain and/or significant blood loss can negatively affect myocardial oxygen supply/demand balance. Left ventricular systolic or diastolic dysfunction may increase the risk of congestive heart failure, especially if large volumes of perioperative fluids (crystalloid, blood products) are required in the setting of acute blood loss. Most cardiac medications, especially beta-blockers should be continued preoperatively and throughout the perioperative period. ACE-inhibitors and angiotensin receptor blockers may be discontinued 24 hours prior to surgery to possibly decrease the incidence and severity of perioperative hypotension. If the patient has had a coronary artery stent placed within the last 12 months, the perioperative plan for continuation/discontinuation of dual antiplatelet therapy (aspirin and a thienopyridine derivative) should be decided upon between the surgeon, anesthesiologist, and the cardiologist. Typically, clopidogrel (Plavix) is stopped 7 days prior to surgery to decrease the risk of perioperative bleeding and allow placement of a central neuraxial anesthetic. Ideally, aspirin should be continued in order to decrease the risk of perioperative in-stent thrombosis.

c. Pulmonary

• COPD: Perioperative evaluation should include severity of disease, typically assessed with a preoperative assessment of symptoms (dyspnea, cough, wheezing, prior hospitalizations, exacerbations requiring hospital admissions/intubation and/or systemic steroid therapy), functional capacity, and recent pulmonary infections are key questions. Laboratory examination such as arterial blood gases, flow volume loops, or chest radiographs are rarely necessary unless they change management (rule out recent pneumonia or assess for reversibility with bronchodilator therapy). Perioperative risk reduction includes maintaining all chronic medications, aggressive pulmonary hygiene, and ideally avoiding instrumentation of the airway would decrease the risk of perioperative pulmonary complications.

• OSA: Patients with sleep apnea should have the severity of the disease assessed, and appropriate strategies developed to reduce the potential for post-operative exacerbation of their disease by opioid-induced respiratory depression. They should continue the use of their continuous positive airway pressure (CPAP) therapy in the peri-operative period.

• Reactive airway disease (Asthma): The perioperative evaluation and risk reduction strategies are similar to patients with COPD.

• Patients presenting for elective THA are at high risk for perioperative venous thromboembolism (VTE) and there should be appropriate VTE prophylaxis.

• Patients presenting for THA are also at risk for perioperative hypoxemia due to fat embolization syndrome. This must be considered in the differential diagnosis of acute hypoxemia, although treatment is primarily supportive.

d. Renal-GI:

Perioperative evaluation: a history of gastrointestinal or renal disease should be sought. Patients may have chronic renal insufficiency due to either the progressive decline in renal function with aging or due to complications from cNSAID therapy. Patients with end-stage renal disease on chronic dialysis should be managed in concert with their nephrologist, with special attention paid to volume status and acid-base/electrolyte homeostasis.

Chronic renal insufficiency may affect the excretion of key drugs in the perioperative period. In particular, the dosage of opioids that require renal excretion (morphine sulfate and oxycodone) should be adjusted based on estimated creatinine clearance. Possible coagulation abnormalities associated with hepatic insufficiency should be assessed with coagulation testing, as they may affect the decision to utilize a central neuraxial anesthetic technique.

Perioperative risk reduction: volume, acid-base and electrolytes should be optimized (timing of dialysis) in patients with ESRD. Severe coagulation abnormalities may need to be corrected with plasma to correct clotting factor deficiencies associated with liver disease and DDAVP to correct platelet function abnormalities associated with ESRD.

e. Neurologic:

i. Acute issues

Perioperative evaluation: Acute changes in neurological function should be assessed prior to THA. Cerebrovascular insufficiency should be assessed with a focused history and neurological and cardiovascular examination, and appropriate imaging/cardiac studies as indicated by the history, review of systems, and physical examination. Neurological consultation is warranted and deferring elective THA is appropriate until the patient’s status is optimized. One of the most common perioperative complications in THA is acute delirium. Acute perioperative delirium is associated with an increased length of stay, poorer functional recovery, and increased mortality.

Perioperative risk reduction: Elective procedures should be deferred until acute changes in neurological function are fully evaluated and optimized. Acute perioperative delirium may be decreased by optimization of pain control, appropriate management of perioperative intravascular volume, oxygenation, electrolytes, sleep management, and careful monitoring of perioperative administration of medications that have potential CNS effects.

ii. Chronic disease

Perioperative evaluation: Chronic diseases should be optimized prior to elective surgery. Identification of pre-existing central neuraxial disease (such as myasthenia gravis, multiple sclerosis, or spinal stenosis) or peripheral neuropathies may play a role in the choice of anesthetic technique, especially the choice of regional anesthesia.

Perioperative risk reduction: Recent exacerbations of chronic diseases should be optimized and all chronic medications should continue. Localization (and documentation) of chronic neurological deficits will guide the choice and type of regional anesthesia if appropriate.

f. Endocrine:

Perioperative Evaluation: Complete history and physical examination should look for a history of diabetes (common in obese patients), thyroid disorders, or adrenal dysfunction.

Perioperative Risk Reduction: In diabetes mellitus patients, the patient’s blood glucose should be evaluated on the morning of surgery. Oral hypoglycemic agents should not be continued the day of surgery. If the patient is taking insulin, a reduction in their usual dose should occur due to their NPO status. These patients generally resume normal diets on their first postoperative day and should return to their pre-operative regimen, recognizing that the state of surgery may create a hyperglycemic state, which could have a deleterious effect on wound healing.

Patients with either thyroid or adrenal dysfunction should be stabilized appropriately prior to surgery, which may potentially require an endocrine consultation. Patients with acromegaly should have detailed a detailed airway examination for potential difficulties with either mask ventilation or endotracheal intubation.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan

Perioperative evaluation: Common comorbid conditions in patients presenting for THA include chronic inflammatory polyarthropathies such RA or ankylosing spondylitis. In RA, the airway may be particularly affected due to chronic inflammation of the temporomandibular joints (limiting mouth opening), cricoarytenoid joints (decreased glottic opening manifested as hoarseness of even stridor) and cervical spine.

Anterior subluxation of C1 on C2 (atlantoaxial subluxation) may occur in up to 40% of patients with chronic RA with associated symptoms of neck pain, headaches, or even myelopathy. Flexion of the head in the presence of atlantoaxial instability could result in displacement of the odontoid process into the cervical spine cord. Extra-articular manifestations of RA that are of importance include pericarditis that may result in chronic constrictive pericardial disease, as well as diffuse interstitial pulmonary disease.

Signs and symptoms of chronic right heart failure and pulmonary hypertension should be identified and optimized prior to elective procedures. Patients with ankylosing spondylitis may have progressive ossification of the axial ligaments and resulting fusion of the axial skeleton. The reduction in axial mobility may limit cervical spine motion and difficulties with airway management. In addition, lumbar spine fusion may limit the access to central neuraxial space for either spinal or epidural anesthesia.

Perioperative risk reduction: If atlantoaxial instability is suspected, imaging studies (at least cervical spine flexion-extension radiographs and possibly CT scans) are indicated. If present, the patient should undergo awake fiberoptic intubation if a general anesthetic technique is chosen and a cervical collar should be placed (regardless of anesthetic) should be considered to limit perioperative movement of the cervical spine.

4. What are the patient’s medications and how should they be managed in the perioperative period?

Patients may be on variety of prescription medications and these should be continued (or discontinued if appropriate) through the perioperative period based on the surgical and anesthetic needs. Over the counter herbal medications that may affect the perioperative hemostasis should be discontinued preoperatively.

h. Are there medications commonly seen in patients undergoing this procedure and for which should there be greater concern?

There are no specific medications that patients having a THA are on with the notable exception of nonsteroidal anti-inflammatory medications for chronic arthritis. Patients on nonspecific NSAIDs will typically have these discontinued 1 week prior to surgery because of their possible effects on platelet function. In contrast, patients on selective COX-2 inhibitors (such as celecoxib) may continue their medication through the perioperative course, as they should not affect platelet function. Due to the high risk of potential DVT or PE postoperatively, an anticoagulation plan will be in place prior to surgery. There are numerous options available to the patient, which may potentially affect the use of a central neuraxial anesthetic technique. The ACCP Anticoagulation Guidelines must be consulted if the anesthesiologist intends to employ a central neuraxial technique. Generally, because of the elective nature of the procedure, patients with a coronary artery stent will not be on dual antiplatelet therapy at the time of the operation, but a “bridging” therapy may be in place.

i. What should be recommended with regard to continuation of medications taken chronically?

• Cardiac: Continue cardiac medications perioperatively, especially beta blockers. ACE inhibitors and angiotensin receptor blockers (ARBs) may be withheld 24 hours prior to surgery to decrease the incidence and severity of perioperative hypotension (especially with concomitant diuretic therapy).

• Pulmonary: Continue all medications perioperatively. In addition, smoking cessation is highly recommended.

• Renal: Continue all medications perioperatively.

• Neurologic: Continue all medications perioperatively.

• Anti-platelet: Aspirin is considered safe with any regional anesthesia technique. However, it is common surgical practice to discontinue aspirin because of increased risk of perioperative bleeding. Plavix is typically stopped 7 days preoperatively to decrease the risk of surgical bleeding and allow the use of perioperative central neuraxial anesthetic/analgesic techniques.

• Antithrombotic medications: Coumadin (warfarin) is typically discontinued 5-7 days prior to surgery depending upon the patient’s individual INR goal. In patients at high risk of preoperative thrombosis, patients may be bridged on subcutaneous low molecular weight heparin in the days prior to surgery. Direct thrombin inhibitors (such apixaban, dabigatran, or rivaroxaban) are typically discontinued 3-5 days prior to surgery, especially if a central neuraxial anesthetic technique is planned.

• Psychiatric: Continue all medications perioperatively. Note than discontinuation of monoamine oxide inhibitors (MAOS) is no longer recommended. If patients are on MAOIs, patients may be at risk for significant systemic hypertension with the administration of indirect-acting sympathomimetic drugs such as ephedrine. If vasopressors are need, directing-acting agents such as phenylephrine should be used and in lower initial doses.

• Blood conservation: Anti-fibrinolytic therapy (either systemic and/or topical) with tranexamic acid (TXA) has been consistently shown to decrease perioperative blood loss and more importantly, decrease perioperative allogeneic red blood cell transfusion requirements. Due to the overwhelming evidence basis for its efficacy, the perioperative administration of TXA should be considered for all TKA procedures (in the absence of contraindications that may potentially increase the risk of postoperative VTE).

j. How To modify care for patients with known allergies –

Avoid medications in which the patient has true allergic reactions. It is important to discriminate between true allergic reactions such as rash, hives, throat swelling, and anaphylaxis versus “drug intolerance” such as nausea and vomiting. Preoperative oral multimodal analgesia is recommended for THA. Sulfa antibiotic allergy should not be considered a contraindication to utilizing celecoxib as part of a perioperative oral multimodal analgesic regimen.

k. Latex allergy- If the patient has a sensitivity to latex (e.g., rash from gloves, underwear, etc.) versus anaphylactic reaction, prepare the operating room with latex-free products.

The OR staff must be prepared to treat any inadvertent latex exposure despite all preparations.

l. Does the patient have any antibiotic allergies-

First, ensure that the patient has true allergies versus drug intolerance. If the patient has a documented true allergic reaction, then type and severity of allergic reaction must be known: mild pruritus vs. rash vs. life-threatening reactions such as airway swelling/anaphylaxis. For elective THA, a 1st generation cephalosporin is typically administered to target common gram-positive skin flora.

If the patient has a mild allergic reaction to penicillin (rash), the use of a 1st generation cephalosporin (such as cefazolin) may be appropriate. In contrast, if there is a severe life-threatening reaction to 1st generation to cephalosporin, then vancomycin typically administered. If there are allergic reactions to both 1st generation cephalosporin and vancomycin, an appropriate alternative is clindamycin 600-900 mg.

m. Does the patient have a history of allergy to anesthesia?

i. Malignant hyperthermia

• Documented: avoid all triggering agents such as succinylcholine and inhalational agents:

  Proposed general anesthetic plan: total intravenous anesthesia with nondepolarizing neuromuscular blockers as needed.

  Ensure MH cart available:

  Prepare anesthesia machine by removing inhalational anesthesia vaporizers, replacing the CO2 absorbers, and flushing the system with high-flow oxygen.

• Family history or risk factors for MH: A thorough history should elicit the true nature of the suspected family history. Ideally, if there is high index of suspicion, the patient should be referred for testing. If testing is not possible, then it is prudent to treat the patient as if they were “MH positive”, and a nontriggering anesthetic (regional anesthesia or TIVA) should be used and ensure the immediate availability an MH cart.

ii. Local anesthetics/ muscle relaxants

There are two types of local anesthetics: esters and amides. Most allergies associated with local anesthetic agents are secondary to the metabolites (para-aminobenzoic acid) of the esters. True amide allergies are exceedingly rare. A thorough patient history can elucidate what the reaction was and what type of local anesthetic was used. If the patient is a poor historian, avoidance of regional anesthesia may be necessary (provided old records cannot be obtained). If the patient has allergies to neuromuscular blocking agents (the agents most commonly associated with anaphylaxis include succinylcholine or rocuronium), alternative neuromuscular blocking agents (such as cisatracurium) should be utilized, or alternatively a central neuraxial anesthetic technique should be used.

5. What laboratory tests should be obtained and has everything been reviewed?

There are no specific laboratory tests for patients undergoing elective THA. Laboratory testing is based on the patient’s medical history and physical examination. Given the most patients are elderly with many comorbid conditions, below are some commonly ordered laboratory tests:

• Hemoglobin levels: Optimal level will depend on specific patient and comorbid illness. Patients with ischemic cardiac disease may require higher hemoglobin levels to optimize myocardial oxygen demand/delivery. Aggressive preoperative treatment of anemia (with either iron supplementation and or erythropoietin depending on the hemoglobin and ferritin levels) decreases perioperative allogenic red cell transfusion rates and possibly hospital length of stay.

• Electrolytes: within the appropriate range.

• Coagulation panel: INR for patients on chronic coumadin therapy. Bleeding times are not considered sensitive nor specific for investigation of primary hemostasis.

• Imaging: no routine specific imaging.

• Other: cardiac testing such as ECG, echocardiography, stress-testing if indicated and ordered should be reviewed.

Intraoperative Management: What are the options for anesthetic management and how to determine the best technique?

The anesthetic options for THA include general anesthesia or regional anesthesia. THA is well suited for regional anesthesia and is associated with decreased postoperative pain, systemic opioid consumption, nausea and vomiting. In addition, recent data also demonstrates that neuraxial anesthesia (in comparison to general anesthesia) may also decrease the risk of surgical site infection.

Ultimately, the choice of general anesthesia of neuraxial anesthesia is made by the anesthesiologist based on the patient’s preference, comorbid conditions, potential anesthetic complications, and the experience of the anesthesiologist.

a. Regional anesthesia

1. Neuraxial

• Benefits: For THA, there is less postoperative pain and systemic opioid requirement, nausea and vomiting. There is substantial epidemiological data that central neuraxial anesthesia significantly decreases the incidence of postoperative complications and perioperative surgical site infection compared to general anesthesia. If spinal anesthesia is used, lower doses of local anesthetics in conjunction with small doses of lipophilic intrathecal opioids (fentanyl) decreases the risk of spinal-anesthesia associated hypotension. The addition of small doses of long-acting hydrophilic opioids (preservative free intrathecal morphine 100 micrograms) provides potent postoperative analgesia for up to 24 hours. Lumbar epidural analgesia may also be used for intraoperative anesthesia and has the same favorable effects of spinal anesthesia. The onset of anesthesia is slower (which may be an advantage in terms of titrating the level of central neuraxial blockade and thus decreasing the risk of hypotension). Although the epidural catheter may be used postoperatively for postoperative analgesia, the widespread use of systemic anticoagulation (for VTE prophylaxis) increases the risk of central neuraxial hematoma and postoperative lumbar epidural analgesia has generally fallen out common use.

• Drawbacks: Risks for postdural puncture headache with spinal or epidural anesthesia. Increased risk of hypotension due to sympathetic effects of neuraxial anesthesia. Contraindicated in patients therapeutic on systemic anticoagulants (coumadin, therapeutic doses of unfractionated or low molecular weight heparin) or potent platelet inhibitors such as clopidogrel. Central neuraxial anesthesia may prove difficult due to lumbar arthropathy and difficulty with optimal positioning. Single injection spinal anesthesia has a fixed duration based on choice and dose of local anesthetic. This choice should take into account the complexity of the planned procedure (primary or revision THA) and the experience of surgeon.

• Issues: Contraindications noted above. In addition, patients may not tolerate intraoperative positioning without general anesthesia. Low dose intravenous sedation is appropriate when indicated.

2. Peripheral Nerve Block: Use of peripheral nerve block as the primary anesthetic must into account that incision and operative site is supplied by both the lumbar plexus (femoral, obturator, lateral femoral cutaneous nerves) and the sacral plexus (sciatic nerve, inferior and superior gluteal nerves, and nerve to the quadratus femoris). Thus a combined lumbar plexus (psoas compartment) and a parasacral plexus block is required for complete anesthesia.

• Benefits: Same as for neuraxial anesthesia. The use of long-acting local anesthetic agents (bupivacaine or ropivacaine) or placement of continuous peripheral perineural catheters can provide extended duration postoperative analgesia. Less risk of hypotension compared with neuraxial anesthesia.

• Drawbacks: Require significant technical skills in regional anesthesia as both lumbar and parasacral blocks are located deeper compared to other peripheral nerve blocks. The higher doses of local anesthetics required for the combined blocks may increase the potential risk of local anesthetic systemic toxicity (LAST).

• Issues: Low risk of clinically significant neuropathy. Not all patients will be suitable, nor will all anesthesiologists have the experience or training to perform combined lumbar or sacral plexus blocks.

3. Local Anesthetic Infiltration

High volume local anesthetic infiltration (LAI) into the subcutaneous and periarticular tissues surrounding the hip joint capsule is a rather simple technique that should be routinely performed by the surgical team to reduce postoperative pain. Local anesthetic infiltration analgesia has become an integral part of multimodal perioperative analgesia.

b. General Anesthesia

• Benefits: Provides definitive control of the airway. The technique of choice in patients who refuse or have contraindications to central neuraxial anesthesia.

• Drawbacks: Associated increased postoperative pain, nausea and vomiting, as well as increased perioperative anesthetic costs (versus spinal anesthesia).

• Airway concerns: as for any general anesthetic. Associated cervical arthropathies and instability may require an awake fiberoptic intubation.

c. Monitored Anesthesia Care

N/A

6. What is the author’s preferred method of anesthesia technique and why?

The author’s preferred method of anesthesia for elective THA utilizing posterolateral surgical technique-approach is single-injection spinal anesthesia (utilizing plain bupivacaine [12-15 mg] 0.5% in either an isobaric or hypobaric fashion) with intraoperative intravenous sedation with propofol and or small doses of midazolam. For surgeons with a total operative time that is consistently less than 90-100 minutes, plain mepivacaine (50-80 mg) provides more rapid and predictable resolution of spinal anesthesia, which facilitates early ambulation (possibly on the same day as surgery). A single-injection femoral nerve block (either preoperatively [preferred] or in the recovery room provides extended duration analgesia of 16-20 hours without the possible drawbacks of intrathecal morphine (nausea/vomiting, pruritus, or rarely, respiratory depression). A lumbar plexus block may also be used perioperatively (with either a general or spinal anesthetic) but does not provide additional analgesic benefits beyond a single-injection femoral nerve block. Either a lumbar plexus or a femoral nerve block provide superior analgesia compared to systemic opioids alone, but a femoral nerve block is technically much easier to perform. More recently, femoral and lumbar plexus blocks have fallen out of favor due to concerns of quadriceps motor block and the potentially increased risk of postoperative falls and has largely been replaced with periarticular local anesthetic infiltration.

1 hour prior to surgery, all THA patients also receive oral Celebrex 400 mg, gabapentin 600-900 mg, and acetaminophen 1000 mg as part of a multimodal analgesic protocol. Celebrex (100-200 mg BID) and acetaminophen (650 mg QID) should be continued into the postoperative setting.

• What prophylactic antibiotics should be administered? –

  The appropriate antibiotic that covers skin flora should be administered within 30-60 minutes of surgical incision and redosed at the appropriate intervals based on the duration of the surgical procedure. Acceptable antibiotics include cefazolin 1-3 grams, vancomycin (500-1500 mg), or clindamycin (600-900mg). If these are all contraindicated, then consultation with infectious disease for alternative antibiotic coverage is warranted.

• What do I need to know about the surgical technique to optimize my anesthetic care?

  For elective THA, revisions (versus primary) hip arthroplasties may take significantly longer and be associated with significantly higher perioperative blood loss. Thus, appropriate preparation (in terms of anesthetic technique, intravenous access, choice of invasive monitoring, and availability of blood components must be considered. In contrast to the lateral decubitis position utilized for the posterolateral approach-technique, patients undergoing THA utilizing a direct anterior approach will be in the supine position. In addition, a specialized operating room table (Hana® table) that places the operative hip in various degrees of hyperextension, adduction, and external rotation is typically used to facilitate the anterior approach for THA.

• What can I do intraoperatively to assist the surgeon and optimize patient care?

  Adequate lower extremity muscle relaxation will facilitate placement of the arthroplasty components for THA.

• What are the most common intraoperative complications and how can they be avoided/treated?

  The most common perioperative complications are related to blood loss, perioperative ischemia or heart failure, venous thromboembolic disease (DVTs and PEs), pneumonia, and acute delirium.

  Cardiac complications- myocardial ischemia is the most common perioperative complication and the etiology is multifactorial due to increased myocardial oxygen demand (sympathetic/stress response to pain and release of inflammatory mediators) and decreased myocardial oxygen supply (due to decreased cardiac output from anemia [chronic or acute due to acute blood loss], tachycardia or dysrhythmias, and LV systolic dysfunction.

  Pulmonary- Perioperative DVTs/PEs, pneumonia, as well as perioperative hypoxemia due to either fat emboli or bone cement implantation syndrome (in those with cemented arthroplasty)

  Neurologic: Delirium due to multiple etiologies.

a. Neurologic:

• Unique to procedure: Embolic complications due to either fat emboli associated with bone cement implantation syndrome may be associated with CNS embolic resulting in cerebrovascular insufficiency contributing to delirium. In addition, bone cement implantation syndrome may also be associated with systemic hypotension further compromising cerebral perfusion.

b. If the patient is intubated, are there any special criteria for extubation?

No

c. Postoperative management

• What analgesic modalities can I implement? See anesthetic and analgesic technique as described previously.

• What level bed acuity is appropriate? Typically, patients are admitted to an orthopedic surgical floor, but admission to a higher acuity setting (telemetry, postoperative intensive care unit will be determined by the patient’s comorbid conditions, and the intraoperative course.

• What are common postoperative complications, and ways to prevent and treat them? See above for anesthetic and analgesic advantages of either regional anesthesia or general anesthesia.

What’s the Evidence?

Macfarlane, AJR, Prasad, GA, Chan, VWS, Brull, R. “Does regional anesthesia improve outcome after total hip arthroplasty? A systematic review”. Br J Anaesth. vol. 103. 2009. pp. 335-345.

Sibia, US, Turner, TR, MacDonald, JH, King, PJ. “The impact of surgical technique on patient reported outcome measures and early complications after a total hip arthroplasty”. J Arthroplasty. vol. S0883-5403. 2016. pp. 30759-8.

Connolly, KP, Kamath, AF. “Direct anterior total arthroplasty: comparative outcomes in contemporary results”. Word J Orthop. vol. 18. 2016. pp. 94-101.

Vijay, A, Grover, A, Coulson, TG, Myles, PS. “Perioperative management of patients treated with angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers: a quality improvement audit”. Anaesth Intensive Care. vol. 44. 2016. pp. 346-52.

Cheung, CC. “Predictors of intraoperative hypotension and bradycardia”. Am J Med. vol. 128. 2015. pp. 532-8.

Singh, JA. “Current tobacco use is associated with higher rates of implant revision and deep infection after a total hip or knee arthroplasty: a prospective cohort study”. BMC Med. vol. 13. 2015. pp. 283

Jimenez-Almonte, JH. “Is local infiltration analgesia superior to peripheral nerve blockade for pain management after THA: a network meta-analysis”. Clin Orthop Relat Res. vol. 474. 2016. pp. 495-516.

Ilfeld, BM, Duke, KB, Donohue, MC. “The association between lower extremity continuous peripheral nerve blocks and patient falls after knee and hip arthroplasty”. Anesth Analg. vol. 111. 2010. pp. 1552-4.

Frew, N, Alexander, D, Hood, J, Acornley, A. “Impact of a blood management protocol on transfusion rates and outcomes following total hip and knee arthroplasty”. Ann R Coll Engl. vol. 98. 2016. pp. 380-6.

Liu, J. “Neuraxial anesthesia decreases postoperative systemic infection risk compared with general anesthesia in knee arthroplasty”. Anesth Analg. vol. 117. 2013. pp. 1010-6.

Chang, CC, Lin, HC, Lin, HW, Lin, HC. “Anesthetic management and surgical site infections in total hip or knee replacement: a population base study”. Anesthesiology. vol. 1134. 2010. pp. 279-84.

Hallstrom, B. “The Michigan experience with the safety and effectiveness of tranexamic acid use in hip and knee arthroplasty”. J Bone Joint Surg Am. vol. 5. 2016. pp. 1646-1655.

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