1 / 30

CURRENT CONCEPTS IN PERI-OPERATIVE TKA MANAGEMENT

CURRENT CONCEPTS IN PERI-OPERATIVE TKA MANAGEMENT. MARIOS LYKISSAS, MD METROPOLITAN HOSPITAL. Kurtz S et al. Projections of primary and revision hip and knee arthroplasty in the US JBJS Am 2007;89:783. CONTENT. THROMBOPROPHYLAXIS BLOOD MANAGEMENT STRATEGIES

hlambert
Télécharger la présentation

CURRENT CONCEPTS IN PERI-OPERATIVE TKA MANAGEMENT

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. CURRENT CONCEPTS IN PERI-OPERATIVE TKA MANAGEMENT MARIOS LYKISSAS, MD METROPOLITAN HOSPITAL

  2. Kurtz S et al. Projections of primary and revision hip and knee arthroplasty in the US JBJS Am 2007;89:783

  3. CONTENT • THROMBOPROPHYLAXIS • BLOOD MANAGEMENT STRATEGIES • PROSTHETIC JOINT INFECTION PREVENTION • PERI-OPERATIVE ANALGESIA

  4. THROMBOPROPHYLAXIS

  5. PERI-OP TKA MANAGEMENT THROMBOPROPHYLAXIS • 88% DVT RATE IN UNTREATED PTS • 7-28% DVT RATE IN TREATED PTS • 0.5% IN MULTIMODAL APPROACH • MECHANICAL COMPRESSION DECREASES DVT RATE BY 15%

  6. RISK FACTORS FOR VENOUS THROMBOEMBOLIC EVENT

  7. PERI-OP TKA MANAGEMENT THROMBOPROPHYLAXIS • NO RCT STUDIES OUTLINE DURATION OF PROPHYLAXIS • PROPHYLAXIS FOR 4-6 WEEKS PO REDUCES DVT BY 70%

  8. 16 RCT STUDIES • 24,930 PTS • THA, TKA • 4-5 W PROPHYLAXIS VS 15 D PROPHYLAXIS + PLACEBO

  9. BLOOD MANAGEMENT STRATEGIES

  10. BLOOD MANAGEMENT STRATEGIES

  11. THRESHOLD VALUS BLOOD MANAGEMENT STRATEGIES PRE-OP ANEMIA SCREEN PTS 2-3 M BEFORE SURGERY IRON STUDIES IF Hb<12 g/dL IF IRON DEFICIENCY GIVE IRON MINIMUM 1M PRE-OP (250 MG/DAY FOR 1 M) IRON ORAL (NOT EFFICACIOUS IN MALABSORPTION, SLOW EFFECT) IRON IV IF DEFICIENT IRON STORESGIVE FERRITIN CARVOXYMALTOSE IV IV IRON IMPROVE Hb 1 g/dL OVER 10 DAYS 67% RESOLUTION OF ANEMIA

  12. BLOOD MANAGEMENT STRATEGIES PRE-OP ANEMIA EPO IS A POWERFUL BUT EXPENSIVE AGENT FOR CORRECTING ANEMIA INDICATED IN PTS WITH ANEMIA SECONDARY TO CRF PRE-OP AUTOLOGOUS DONATION IS ASSOCIATED WITH HIGH RATE OF WASTED BLOOD AND IS NOT COST EFFECTIVE

  13. 15 RCT STUDIES • 837 PTS • TXA vs PLACEBO • TXA RESULTED IN • FEWER BLOOD TRANSFUSIONS • LESS BLOOD LOSS • LESS CHANGE IN Hb • NO DIFFERENCE IN DVT • NO DIFFERENCE IN PE

  14. 15 STUDIES • 1495 PTS

  15. BLOOD MANAGEMENT STRATEGIES TXA VARIOUS REGIMENS 1 GR IV AFTER TOURNIQUET RELEASE (15 MG/KG) 1-3 GR INTRA-ARTICULARLY AFTER FASCIA CLOSURE 1 GR IV IN 5 H (2 H HALF-LIFE) CONTRA-INDICATIONS STROKE THROMBOEMBOLISM ALLERGY SEVERE CAD

  16. BLOOD MANAGEMENT STRATEGIES

  17. BLOOD TRANSFUSION • Hb> 8g/dL NO TRANSFUSION • Hb<6 g/dL TRANSFUSION IN ALL PTS • 6<Hb<8 TRANSFUSION BASED ON • ONGOING LOSSES • CARDIOVASCULAR RISK • SYMPTOMATIC ANEMIA

  18. PERI-OPERATIVE ANALGESIA

  19. PERI – OP ANALGESIA MULTIMODAL ANALGESIA MAXIMIZES POSITIVE ASPECTS WHILE LIMITING SIDE EFFECTS IV OPIOIDS NEGATIVELY IMPACT REHABILITATION & HOSPITAL DISCHARGE (DOSE DEPENDENT) AMERICAN SOCIETY OF ANESTHESIOLOGISTS RECOMMENDS 2 OR MORE ANALGETICS WITH DIFFERENT MECHANISMS OF ACTION

  20. MULTIMODAL ANALGESIA INTRA-OP POST-OP

  21. INTRA-OP MANAGEMENT BILATERAL TKA PRE-OP MANAGEMENT

  22. PROSTHETIC JOINT INFECTION

  23. POST-OP INFECTION MODIFIABLE VARIABLES ASSOCIATED WITH INFECTION

  24. POST-OP INFECTION MODIFIABLE VARIABLES ASSOCIATED WITH INFECTION ALBUMIN < 3.5 g/dL LYMPHOCYTE COUNT < 1500 CELLS/MM3

  25. POST-OP INFECTION 2nd GENERATION CEPHALOSPORIN CLINDA OR VANCO IN B-LACTAM ABX ALLERGY VANCO IN MRSA ADMINISTRATION 30-60 MIN BEFORE INCISION FINISHED >10 MIN BEFORE TOURNIQUET IV & CEMENT ABX MORE EFFECTIVE THAN EITHER ALONE ASYMPTOMATIC BACTERIURIA PRE-OP TREATMENT IS NOT NECESSARY MAJOR DENTAL PROCEDURES BEFORE TKA NASAL PRE-OP TREATMENT WITH MUPIROCIN OINTMENT FOR PTS WITH S. AUREUS CARRIAGE

  26. TKA IN PTS WITH INFLAMMATORY ARTHRITIS RA, PsA 4.2% 5-YEAR PROSTHETIC JOINT INFECTION RATE IN RA PTS (1.4% IN OA PTS) IN RA, RISK OF INFECTION IS ASSOCIATED WITH EXTRA-ARTICULAR DISEASE (RHEUMATOID NODULES, ESR-MARKERS FOR DISEASE SEVERITY) HIGHER RATES OF CARDIOVASCULAR DISEASE THAN GENERAL POPULATION RA PTS HAVE A 30-60% INCREASE IN CARDIOVASULAR MORBIDITY PULMONARY DISEASE COMMON IN PTS WITH RA ~40% OF RA PTS REFERRED FOR ARTHROPLASTY HAVE ASYMPTOMATIC C-SPINE INSTABILITY - NEED SCREENING WITH DYNAMIC C-SPINE XRAYS PTS WITH C1-2 OR SUBAXIAL INSTABILITY AND SAC <13 MM OR MYELOPATHY ON MRI REQUIRE C-SPINE DECOMPRESSION +/- FUSION PRIOR TO TKA

  27. TKA IN PTS WITH INFLAMMATORY ARTHRITIS ANTIRHEUMATIC THERAPY • INFECTION RISK STEROIDS > MTX (RISK INCREASES WITH DOSE) • STEROIDS HAVE NEGATIVE EFFECT ON WOUND HEALING AND INFECTION • PTS WHO D/C MTX HAVE HIGHER INFECTION RATE & FLARE RATE • MTX SHOULD BE CONTINUED THROUGH PERI-OP PERIOD • HYDROXYCHLOROQUINE IS NOT IMMUNOSUPPRESANT(SHOULD BE CONTINUED) • POST-OP ADRENAL INSUFFICIENCY AND DEATH IN STEROID-TREATED PTS • USE OF SUPRAPHYSIOLOGIC “STRESS DOSE” STEROIDS • (INTRA-OP SUPPLEMENTAL HYDROCORTISONE 100 MG) VISSER ET AL. ANN RHEUM DIS 2009;68:1086 HOES ET AL. ANN RHEUM DIS 2007;66:1560

  28. TKA IN PTS WITH INFLAMMATORY ARTHRITIS BIOLOGIC AGENTS • ASSOCIATION OF ANTI-TNF WITH PROSTHETIC JOINT INFECTION • HIGHER INFECTION RISK IN THE FIRST 6 M OF THERAPY • RESTART BIOLOGIC AGENTS 2 W PO

More Related