Complications in Total Knee Replacement Presented by SC

Complications in Total Knee Replacement Presented by SC 徐國祐, 李建霖 2005/05/31

Case Presenting n n n Case 1, 鍾OO, 66 y/o, M, Case 2 邱OO, 72 y/o, F, Case 3 柯李OO, 64, F,

Case 1 鍾OO n n n n 68 y/o, man. PH: 1. HTN, 2. DM, 3. PTCA in 93/2, 1 -VD, 4. Cervical stenosis s/p OP in 94/4, 5. Smoking (+) ASA class III Bilateral knee pain and soreness for 2 years simultaneous bilateral TKR on 5/20 severe wound pain with chest tightness and dyspnea were noted after transferred to general ward, EKG: no new ST-T change symptoms improved after O 2 supplement and pain control

Case 2 邱OO n n n 72 y/o, woman PH: 1. Cardiomegaly, 2. Denied other major systemic disease, 3. Smoking (-) ASA class II Bilateral knee pain for 10 years simultaneous bilateral TKR on 5/18 uneventful post-op course

Case 3 柯李OO n n n 64 y/o, woman PH: 1. HTN(+) and DM (+) under medical control, 2. Smoking (-) 3. Denied other major systemic disease and major OP ASA class II bilateral knee pain and swelling for 10 year simultaneous bilateral TKR on 5/23 uneventful post-op course

Discussion n n Perioperative Complication of Total Knee Arthroplasty Case Report Pulmonary Embolism Reperfusion Injury Intra-op monitor

Comparison of Staged TKR and Simultaneous Bilateral TKR Simultaneous Bilateral, Staged Bilateral, and Unilateral Total Knee Arthroplasty. A SURVIVAL ANALYSIS J Bone Joint Surg 85 A: 1533– 1537, 2003

Introduction to Simultaneous Bilateral TKR n Definition: n n Staged Total Knee Replacement. knee joints are replaced with total knee prostheses one at a time, at two separate operations, often several months apart. Simultaneous Bilateral Total Knee Replacement. both knees replaced with total knee prostheses during one operation seance, under one anesthesia.

Exsanguination in TKR Exsanguination of limb for decreased blood loss and a good operation field - Esmarch bandage distal to proximal for tissue and venous compression - Elevation of limb for 2~3 mins - Tourniquet for total tissue and artery compression n Ø Ø Esmarch tourniquet Pneumatic tourniquet (350 mm. Hg or 50~100 above BP)

Materials and Methods n n A total of 6200 total knee replacements, performed in 3998 patients between 1983 and 2000, consisted of 2050 simultaneous bilateral, 1796 unilateral, and 152 staged bilateral total knee replacements. A review of each group was conducted to compare the rates of morbidity and mortality, the survival of the prosthesis, and the clinical outcome.

Result n n n The simultaneous bilateral group had a significantly higher rate of thrombophlebitis than did the unilateral group (p = 0. 0326) No significant difference between the simultaneous bilateral and unilateral groups was found with respect to deaths within the first two weeks (p = 0. 5159), within three months (p = 0. 3299), or within one year (p = 0. 8863). The patients who died within one year after surgery were significantly older (average age, 75. 5 years) at the time of surgery than the patients who survived longer than one year (average age, 70. 2 years; p < 0. 0001).

Case Report Massive Pulmonary Embolism After Application of an Esmarch Bandage Chen-Wei Lu, MD*, Yi-Sharng Chen, MD†, and Ming-Jiuh Wang, MD, Ph. D‡ *Department of Anesthesia, Far Eastern Memorial Hospital, Taipei, Taiwan; and Departments of †Surgery and ‡Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan (Anesth Analg 2004; 98: 1187– 9)

Case Report n n n 71 y/o man, bil. TKR 8 year ago before this operation, experienced a left femoral periprosthetic supracondylar comminuted fracture. Spinal anesthesia with 10 mg of 0. 5% hyperbaric bupivacaine An Esmarch bandage was used to exsanguinate the lower limb, and the tourniquet was applied over the upper thigh region.

Case Report n n n 5 min after application of the Esmarch bandage, the patient complained of chest tightness, shortness of breath, and palpitation, and then he lost consciousness. ABP decreased from 136/80 to 60/30 mm Hg SPO 2 decreased from 98% to 79% HR decreased from 90 to 50 bpm ETCO 2 partial pressure decreased to 18 mm Hg within 1 min.

Case Report n n Endotracheal intubation Inotropic agents were given through CVP Emergent TEE revealed severely distended RA and RV, with a large embolus in the RA (Fig. 1). A large embolus was trapped in the foramen ovale, which seemed to be opened because of the greatly increased CVP (35 mm Hg)

Case Report

Case Report

Case Report n n n Cardiac surgeons performed embolectomy under CPB was converted to ECMO after operation. The patient was discharged 45 days after the operation and was generally well 6 mo after the operation.

Case Report -- Summary n n Preoperative anticoagulation and diagnostic workup should be performed to prevent the development of and exclude the possibility of venous thrombosis in patients with trauma of the lower extremities and delayed surgery. We recommend that TEE be used immediately during unexpected intraoperative cardiovascular collapse and suggest that ECMO is helpful in the treatment of massive pulmonary embolism and acute RV failure.

Case Report Risk assessment n Preoperative diagnosis: n n n Compression ultrasonography Venography Latex D-dimer assay

Thromboembolism in TKR n n n Incidence：< 1% Deep vein thrombosis(DVT) Pulmonary embolism(PE)--symptomatic

Pulmonary Emboli in TKR n n Previous conception：PE happened following tourniquet deflation, and could not occur during inflation phase. Sudden decreased Sa. O 2, Pa. O 2 and BP during tourniquet inflation was detected in some patient. Why? Influence of tourniquet on PE?

Tourniquet vs. Control n n Anesthesia - ETGA - Propofol, Fentanyl, Vecuronium - N 2 O, O 2, Sevoflurane Exsanguinated by Esmarch bandage and elevation Femur reaming by 20 cm intramedullary rod Implant 20 mm pegs with cement Tourniquet： 350 mm. Hg Anesthesiology 2002; 97: 1123 -8

n n n Arterial line, CVP (blood sampling) Monitor MAP, HR, Pa. O 2, Et. CO 2 at stable point (2. 5 mins, 10 mins) TEE - grade 0：no emboli - grade 1：a few fine emboli - grade 2：cascade of emboli or embolic mass<5 mm - grade 3：large embolic mass>5 mm Anesthesiology 2002; 97: 1123 -8

Grade 0 Grade 2 (<5 mm) Grade 1 (fine emboli) Grade 3 (>5 mm)

Anesthesiology 2002; 97: 1123 -8

1. Emboli exists during inflation phase (even grade 3) 2. Emboli：Deflation>Inflation 3. Significant Emboli：Tourniquet>Control Anesthesiology 2002; 97: 1123 -8

(2. 5 mins) 1. No difference in cardiopulmonary impairment compared with baseline except for tourniquet deflation. 2. Significant hemodynamic change after deflation and recovery in 5 minutes. Anesthesiology 2002; 97: 1123 -8

Tourniquet inflation phase Tourniquet compress femoral arteries and veins venous stasis, acidosis, endothelial injury, increased thromboplastin (hypercoaguable state) n Virchow triad of thrombus formation Anesthesiology 2002; 97: 1123 -8

Tourniquet inflation phase n Possible pathways of emboli enters IVC ü ü ü Through medullary cavity of femur drainage v. IVC Congestion side thromboembolism Insufficient compression of tourniquet Anesthesiology 2002; 97: 1123 -8

Tourniquet deflation phase Large thrombus in ischemic area enters circulation after deflation. 1. emboli exists before deflation 2. emboli peak within 1 mins after deflation 3. emboli area returns to pre-deflation level at 2~3 mis after deflation Acute PE may happen within 2 mins after deflation. Deflation Anesthesia & Analgesia 2001, 776 -80

Echogenic embolic materials (1) n n n Fat/Bone marrow Bone cement Thrombus Air Cold blood of ischemic limb Intra-op infusion fluid (from SVC) From IVC Anesthesiology 2002; 97: 1123 -8

Echogenic embolic materials (2) n Blood sample of emboli from PAC and femoral vein. shows no fat or bone marrow component. J. Bone Joint Surg. 80 A 389~396, 1998 n Large emboli thrombus Small emboli cold blood and air emboli Anesthesiology 2002; 97: 1123 -8

PE and hemodynamic change n Reduced at least 40% cross-section area of pulmonary arterial bed to produce hemodynamic changes. Mechanical obstruction (pulmonary emboli) Pulmonary vasoconstriction (by neuroendocrine substance, eg, serotonin) TEE is not good enough? n Anesthesiology V 99, No. 2 , Aug, 2003

Ischemic reperfusion(I/R) injury Definition： Secondary tissue damage inflicted when n blood flow is restored after an ischemic period. Cardiovascular surgery pp. 620 -31, 2002

Pathophysiology of I/R injury in limb (1) Critical tissue ischemic time Tissue Time n Muscle Nerve Fat Skin Bone 4 hrs 8 hrs 13 hrs 24 hrs 4 days most vulnerable to ischemia Cardiovascular surgery pp. 620 -31, 2002

Pathophysiology of I/R injury in limb (2) n During ischemic phase…. . - Muscle cells damage O 2 & ATP↓ muscle damage (injury or death) - Microcirculation change Endothelium injury (protrusion or swelling) disjunction of endothelium RBC compaction, WBC plugging, platelet aggregation along vessel wall increased leakage of plasma Cardiovascular surgery pp. 620 -31, 2002

Pathophysiology of I/R injury in limb (3) increased extravascular pressure compression of vessel - Increased thromboembolism venous stasis, acidosis, endothelial injury, increased thromboplastin (hypercoaguable state) Virchow triad of thrombus formation - No reflow phenomenon Cardiovascular surgery pp. 620 -31, 2002

Pathophysiology of I/R injury in limb (4) n n Reperfusion is followed by an inflammatory response to ischemic area. Cell level： - reoxygenation oxygen free radical↑ - mitochondria unable to use ATP - cytokine and mediators response remove damaged tissue and healing re-damage Robbins Pathologic basis of disease, pp 11 -13

Pathophysiology of I/R injury in limb (5) n Local inflammatory response Tissue damage (mostly, muscle cells) breakdown products(pro-coagulant) induce intrinsic clotting system cytokine and inflammatory mediators release inflammation response re-damage muscle cells and endothelium Cardiovascular surgery pp. 620 -31, 2002

Pathophysiology of I/R injury in limb (6) n Systemic inflammatory response Breakdown products flow into circulation inflammation response…. , esp. in lung damage of endothelium cells of vessels generally increased vascular permeability BP↓ shock…. Pulmonary vasoconstriction Cardiovascular surgery pp. 620 -31, 2002

I/R injury of tourniquet n n Tourniquet used < 2 hrs No obvious muscle damage Small I/R injury and little systemic inflammatory response in normal population Elders, autoimmune disease, neuromuscular disease……. Cardiovascular surgery pp. 620 -31, 2002

Propofol vs. Midazolam in TKR Reactive oxygen species I/R injury Midazolam 5 mg Propofol 0. 2 mg/kg and 2 mg/kg*hr continuous infusion Tourniquet deflation Anesthesia & Analgesia, 2002, pp. 1617~1620

Propofol n n n 2, 6 -diisopropylphenol Similar to phenol-based free radical scavengers. Small dose propofol still shows antioxidant effect on I/R injury of tourniquet. Anesthesia & Analgesia, 2002, pp. 1617~1620

Intra-op monitor for PE in TKR n n BP, HR, Sa. O 2 , Et. CO 2 TEE Pulmonary vascular resistance PVR/SVR ratio (drug effect) - embolic event：PVR↑, SVR may↓or no change PVRSVR ratio ↑ - drug effect：PVR and SVR change in same way PVR/SVR ratio changes little Pulmonary artery catheter(Swan-Ganz) Clinical Orthopedics and related research 2002, 396, 142 -51

Take home message PE still occurs during tourniquet inflation phase. n For intra-op PE - pre-op: compression ultrasonography, venography and latex D-dimer assay - Intra-op: TEE, PAC(PVR, PVR/SVR) n Small dose propofol has anti-oxidant effect on ischemic reperfusion injury. n

Thanks for your attention!!