Year : 2002 | Volume
: 36 | Issue : 1 | Page : 10--11
Anaesthesia for surgical management of fractures of acetabulum
Lilavati Hospital, Mumbai, India
Lilavati Hospital, Reclamation, Bandra, Mumbai 400 050
|How to cite this article:|
Kulkarni S. Anaesthesia for surgical management of fractures of acetabulum.Indian J Orthop 2002;36:10-11
|How to cite this URL:|
Kulkarni S. Anaesthesia for surgical management of fractures of acetabulum. Indian J Orthop [serial online] 2002 [cited 2020 Jan 27 ];36:10-11
Available from: http://www.ijoonline.com/text.asp?2002/36/1/10/35914
At the outset it must be remembered that fractures of the acetabulum may be associated with major trauma with multiple injuries to limbs, head, thorax, abdomen, or spine.
A routine pre-anesthetic history of co-existing diseases, allergies, drug therapies and previous anesthetics and operations is essential. Fluid resuscitation for hypovolemic shock is important. These injuries are usually associated with retroperitoneal hematoma of variable degree and can be the cause of occult blood loss and hemorrhagic syndrome leading to variable systemic effects. This may also cause paralytic ileus or sub-acute intestinal obstruction, which needs nasogastric aspiration. Acetabular fractures may also be associated with pelvic and urinary tract injuries.
Along with optimisation and stabilisation of co-existing medical illnesses and blood volume replacement as required, pre-operative pain relief is equally important for patient comfort.
Preoperative epidural analgesia with an indwelling epidural catheter should be considered in the absence of any contraindications. (Clotting abnormalities, infection at the site of insertion, severe hypovolemia, systemic sepsis etc.)
Continuous epidural infusions of dilute solutions of local anaesthetics with or without narcotics give superior analgesia. We routinely use 0.1% bupivacaine by continuous infusion at a rate of 0-10 ml/hour titrated to the patients' response using a syringe driver. This provides excellent analgesia without significant hypotension or motor blockade. Addition of Fentanyl 2mg/ml further reduces the rate of infusion and the dose of bupivacaine required and improves the quality of analgesia.
Patient controlled analgesia (PCA) with Pethidine, Morphine, or Tramadol and intravenous/intramuscular/oral analgesics are an alternative and provide reasonable pain relief.
Preoperative preparation should include GI ulcer propylaxis, DVT prophylaxis and antibiotic prophylaxis as per the hospital protocol.
Between regional anesthesia with sedation, general anaesthesia, and combined general with regional (Epidural) anaesthesia, we prefer the latter in view of long surgical time and lateral decubitus position for patient comfort as it offers the advantages of both.
Along with routine monitoring of pulse, blood pressure, ECG, temperature, urine output, oxygen saturation and end-tidal CO2, invasive monitoring using a central venous catheter and intra-arterial blood pressure monitoring may be instituted if major blood loss and fluid shifts are anticipated and hypotensive anaesthesia is planned or if the patient is medically compromised.
Intraoperative problems to be specially addressed are:
Position Related: Lateral decubitus position causes patient discomfort (if awake), pressure injuries, hypoxemia from V/Q mismatch (more often with underlying lung disease) neurovascular problems because the dependent shoulder presses on the axillary artery and brachial plexus and the stabilisation post presses on the femoral triangle. Patients who are given hypotensive anaesthesia may be at greater risk of neurovascular injury, as less extrinsic pressure is required to compress a less tense vessel. Care while positioning and adequate padding will minimise these problems.
Blood Loss: Use of regional anaesthesia or hypotensive anaesthesia reduces the blood loss by approximately 30-50%.
Methods of blood conservation during surgery include
Perioperative isovolumic hemodilution and autotransfusionIntraoperative blood salvage with the use of cell savers and reinfusion after processing. This reduces the requirements of banked blood transfusions.Artificial blood substitutes with oxygen carrying capacity may have a role in the future.
Massive blood loss will require banked blood and blood component transfusions with inherent risks associated with transfusions.
Temperature Regulation: Prolonged exposure to a cold operating room, evaporative heat loss from the respiratory tract, infusion of cold fluids and the loss of heat production secondary to anaesthesia causes decreased core temperature in most patients.
All skin surfaces not in the surgical field should be covered to reduce radiation and convection heat loss. Humidification of inspired gases reduces evaporative heat loss from the lungs; all IV fluids should be warmed. Warming of operating room above 22°C, use of warming mattress and surface air warmer help in maintaining the body temperature. Post-operative discomfort and shivering because of hypothermia can thus be avoided.
High dependency care is preferable for postoperative care and stabilisation of patient's condition and monitoring of vital parameters. Fat embolism syndrome is a potential problem.
Ongoing blood loss in the form of excessive drainages should be replaced adequately.
Adequate control of pain can be achieved with the use of epidural analgesia for 24-72 hours and avoids the side effects with the use of systemic narcotics e.g. sedation, nausea and vomiting, respiratory depression.
Appropriate use of antibiotics, prophylaxis for DVT (pharmacological and non-pharmacological methods) and early resumption of enteral nutrition should be considered.