Front Cover 1
OrthopedicAnesthesiology 2
Copyright 3
Contributors 4
Contents 8
Anesthesiology Clinics 11
Foreword 12
Preface 14
Evidence-Based Medicine for Ultrasound-Guided Regional Anesthesia 16
Key points 16
Introduction 16
Review of more recent evidence directly comparing ultrasound guidance to peripheral nerve stimulation for peripheral nerve ... 18
Review of more recent evidence for ultrasound guidance in central neuraxial anesthesia 19
Ultrasound-Assisted Technique 19
Real-Time Ultrasound-Guided Technique 19
Review of recent evidence for ultrasound guidance and patient safety 23
Evidence for ultrasound guidance and continuous peripheral nerve blocks 24
Evidence for optimal ultrasound-guided local anesthetic distribution 25
Summary 27
References 27
Role of Regional Anesthesia in Orthopedic Trauma 34
Key points 34
Introduction 34
Trauma and the Role of the Anesthesiologist 34
History of Pain Relief for Patients with Orthopedic Trauma and the Role of Regional Anesthesia in the Battlefield 35
Neurochemistry of Nociception in Trauma 36
Benefits of Regional Anesthesia and Analgesia in Orthopedic Trauma 37
Advantages of Regional Anesthesia in Orthopedic Trauma 37
Improved Outcomes in Patients Receiving Neuraxial Anesthesia Compared with General Anesthesia 38
Perioperative regional techniques in orthopedic trauma 38
Neuraxial Techniques 38
Paravertebral Block 38
Peripheral Nerve Blocks 39
Upper extremity nerve blocks 39
Lower extremity nerve blocks 40
Single-injection blocks versus continuous catheter techniques 40
Regional Analgesia for Crush Injuries 42
Local anesthetics and analgesic adjuvants for regional anesthesia 42
Neuraxial Blocks 42
Peripheral Nerve Blocks 43
The Risks of Regional Anesthesia in Orthopedic Trauma 43
Compartment syndrome 43
Infection 45
Peripheral nerve injury 46
Regional anesthesia in heavily sedated patients 47
Hemostasis in Trauma 49
Future considerations and summary 49
References 49
Which Outcomes Related to Regional Anesthesia Are Most Important for Orthopedic Surgery Patients? 54
Key points 54
Introduction 55
Pain management 55
Morbidity, mortality, and complications 56
Resource use: transfusion, critical care admission, ventilation 57
Patient comfort and satisfaction 58
Economic advantages 59
Length-of-stay earlier discharge 60
Improved functional outcome and inpatient fall risk 60
Summary 62
References 62
Optimizing Perioperative Care for Patients with Hip Fracture 68
Key points 68
The challenges 68
Preoperative risk consideration and optimization 69
Cardiac Consideration in Patients with Hip Fracture and Risk Stratification 69
Pulmonary Consideration in Patients with Hip Fracture and Risk Stratification 71
Risk of Venous Thromboembolism 74
Delirium 74
Other Preoperative Medical Considerations 74
Recommendation 76
Intraoperative considerations 76
Surgical Considerations 76
The Choice of Anesthesia 78
Postoperative care 79
Institutional guidelines 79
References 79
Regional Anesthesia-Analgesia 86
Key points 86
Introduction 86
The immune system and cancer 87
Surgical stress leads to immunosuppression via stress response 87
Opioids and the immune system 88
Regional anesthesia and local anesthetic effects on immunosuppression 88
Studies investigating the relationship between regional anesthesia and cancer recurrence 89
Regional Anesthesia Does Improve Cancer Recurrence 90
Regional Anesthesia Does Not Improve Cancer Recurrence 90
Regional Anesthesia May or May Not Improve Cancer Recurrence 92
Meta-analyses 92
Surgical site infections and regional anesthesia 92
Summary 93
References 93
Developing a Multidisciplinary Fall Reduction Program for Lower-Extremity Joint Arthroplasty Patients 98
Key points 98
Introduction 99
Current guidelines 99
Multidisciplinary approach 100
Assessment 101
Risk factors for total joint arthroplasty patients 101
Strategies and interventions 102
Implementation 103
Sustainability 103
An example of selecting interventions for a fall reduction program 103
Education 104
Fall Risk Assessment Tools 105
Alert System 105
Bed-Exit Alarm 106
Preliminary Results 106
Summary 106
References 107
Optimizing Perioperative Management of Total Joint Arthroplasty 110
Key points 110
Introduction 110
Trends in Primary and Revision Total Knee and Total Hip Arthroplasty 111
Deconstructing Clinical Pathways 112
Multimodal analgesia and peripheral nerve blockade or local infiltration analgesia 113
Preventing the transition from acute to chronic pain 115
Limiting blood transfusions with tranexamic acid 115
Treating anemia in the preoperative period 115
Tranexamic acid 116
Early and accelerated rehabilitation 116
Current Controversies in Preoperative Optimization 116
Malnutrition and morbid obesity 117
Tobacco abuse 118
Glycemic control 118
Patient education 118
Future considerations/summary 119
References 119
Preoperative Evaluation and Preparation of Patients for Orthopedic Surgery 126
Key points 126
Introduction 126
Risk stratification 127
Patients with hip (femur) fractures 128
Preoperative testing 129
Medical conditions that frequently require patients to undergo orthopedic procedures 129
Ankylosing Spondylitis 129
Scoliosis 130
Rheumatoid Arthritis 130
Hemophilia 131
Perioperative medication management 132
Blood conservation strategies 133
Patient education 133
Future considerations and summary 134
References 134
Setting Up an Acute Pain Management Service 138
Key points 138
Introduction 138
Multimodal approach to pain management 139
Structure and individual roles within an acute pain management service 139
Role of acute pain management service nurses and the use of protocols 141
Intravenous patient-controlled analgesia 141
Opioid-tolerant patients 143
Chronic Opioid Users 143
Patients with Opioid Abuse or Addiction 144
Neuraxial analgesia 145
Continuous peripheral nerve blocks 148
Potential Complications of Upper and Lower Extremity Nerve Blocks 148
Monitoring for Falls in Patients with Lower Extremity Blockade 151
The Role of Local Anesthetic Additives in Perineural Analgesia 152
The Role of the Acute Pain Management Service in an Ambulatory Continuous Perineural Catheter Service 152
Summary 152
References 153
Setting Up an Ambulatory Regional Anesthesia Program for Orthopedic Surgery 156
Key points 156
Introduction 156
Potential advantages of regional anesthesia 156
Regional Anesthesia Optimizes Analgesia 156
Regional Anesthesia Decreases Postoperative Nausea and Vomiting 157
Regional Anesthesia Can Prevent Unanticipated Admissions and Lead to Earlier Discharge 157
Regional Anesthesia Can Increase Efficiency 157
Regional Anesthesia Can Improve Patient Satisfaction 158
Surgeons May Prefer Regional Anesthesia 158
Practical details for organizing an ambulatory regional anesthesia service 158
Patient Education and Screening 158
Resources Including Equipment and Personnel 159
Techniques for Block Placement 159
Ambulatory Orthopedic Procedures Amenable to Perineural Blockade 160
Models of Practice 160
Multimodal Approach and Clinical Pathways 161
Postoperative Considerations 161
Postoperative considerations for ambulatory perineural catheters 163
Future considerations 163
References 164
Perioperative Management of the Opioid Tolerant Patient for Orthopedic Surgery 168
Key points 168
Introduction 168
Supraspinal mechanisms of opioids 170
Cellular mechanisms of tolerance 170
Background on clinical studies 171
Protocols for patient care in the postoperative period 172
Summary 174
References 174
Suggested reading 177
Index 178