Anesthesia For Total Arthroplasty Of The Joints Of The Lower Extremities In Patients With A High Anesthetic Risk

Purpose: to determine the effect of unilateral spinal anesthesia on systemic and central hemodynamics, to identify its side effects in the elderly and senile, with total hip replacement. Materials and methods: 60 patients of geriatric age operated on under unilateral spinal anesthesia were examined. 44 patients underwent total hip arthroplasty (THA), 16 total knee arthroplasty (TKA). Inclusion criteria: elderly (from 60 to 75 years). For continuous monitoring of the vital functions of the patient, they used the "resuscitation and surgical" monitor UM 300 (LLC UTAS Company Ukraine). Conclusion: Unilateral spinal anesthesia is a safe and highly effective technique that can provide full intraoperative pain management for patients with total hip replacement in a high-risk group of patients.

The American Journal of Medical Sciences and Pharmaceutical Research (ISSN -2689-1026)

INTRODUCTION
Of all types of arthroplasty, hip replacement surgery is most often performed, which in patients of this age group is most often accompanied by the use of bone cements due to osteoporosis, the need for early activation in the postoperative period, or due to the developed aseptic instability of the endoprosthesis components (9,7).
To date, it is considered an established fact of the progressive aging of the population with an increase in the number of "storage diseases" requiring surgical treatment, which include a violation of the morphology and function of the musculoskeletal system (2,3). Often people over 65 are forced to maintain their ability to work and lead an active lifestyle.
In elderly patients, this intervention is performed practically for health reasons, since conservative treatment leads to deaths in 80% of cases due to hypostatic complications (1,6). Thus, safe and effective endoprosthetics is acquiring not only clinical but also social significance.
The safety and effectiveness of anesthetic management of this highly traumatic intervention seems to be a difficult task, given the mechanisms of its negative impact on the homeostasis of the elderly, which have fatal coincidences with some pathophysiological manifestations of aging, which increases the risk of surgery and anesthesia (4,5). First of all, this concerns the aggravation of the initial incompetence of central and peripheral hemodynamics, deficiency of circulating blood volume (CBV), catabolic direction of metabolism, tendency to thrombotic complications, and gas exchange disorders (8).
Purpose: to assess the effect of unilateral spinal anesthesia on systemic and central hemodynamics, to identify its side effects in patients with high anesthetic risk.

MATERIAL AND METHODS
The study is based on the results of examination of 63 patients who were treated in the department of orthopedics of large joints and hands of the multidisciplinary clinic of the Tashkent Medical Academy, who underwent primary arthroplasty of the joints of the lower extremities. Examined 63 patients of geriatric age, operated under conditions of combined spinal-epidural anesthesia. 44 patients underwent total hip arthroplasty (THA), 16 -total knee arthroplasty (TKA). Inclusion criteria: elderly (from 60 to 75 years old), pain syndrome for more than one year, no contraindications for regional methods of anesthesia, severe (grade 3 or 4) ostearthrosis (according to Kellgren-Zawrenee, 1957), resistant to conservative methods of treatment; Body mass index <40kg / m2; In 31.5% of the examined patients, physical status was assessed as class 1-2 according to ASA, in 68.5% of patients it corresponded to class 3-4.
The exclusion criteria from the study were: patient refusal from this type of pain relief, age less than 60 years, body weight less than 50 kg, history of allergic reactions to local anesthetics used, coagulopathy, neurological and neuromuscular diseases, severe liver disease, renal failure, the inability to cooperate with the patient.
The patients were diagnosed with from 2 to 6 concomitant diseases, among which IHD with chronic circulatory failure, atherosclerotic cardiosclerosis, hypertension of the 2nd degree with a high risk of cardiovascular and respiratory complications, arrhythmias prevailed. For continuous monitoring of the vital functions of the patient, we used the "resuscitation-surgical" monitor YUM 300 (LLC "Company UTAS" Ukraine).
The technique of unilateral (unilateral) spinal anesthesia to the patient in a lateral position (operated leg at the bottom) was performed with aseptic and antiseptic dural puncture with a Quincke 25-gauge needle (Spinocan, Brown, Germany) along the midline at the L3-L4 level. After the intrathecal puncture, the needle hole was turned downward (towards the operated lower limb) and 7.5 mg of a 0.5% hyperbaric solution of bupivacaine was injected for 60-80 seconds.
The lateral positions of the patients were maintained for 15-20 minutes, then they were transferred to the supine position with a raised head end. The dose of intrathecal administered hyperbaric 0.5% bipivacaine 7.5 mg for unilateral spinal anesthesia was deliberately chosen by us as the most frequently recommended dose without a combination with intrathecal administration of fentanyl (sufentanil), and also taking into account the fact that there are studies in the literature indicating that a decrease in the local anesthetic dose increases the incidence of failed unilateral spinal anesthesia) after intrathecal administration of 4mg and 6mg of hyperbaric bupivacaine.  4.9% (p> 0.05), then at the stage of joint implantation this difference was 6.1% (p <0.05). As for diastolic blood pressure and systolic blood pressure, they were remarkably stable at all stages of the operation. The same can be said about CVP and SpO2 indicators. As for the heart rate, at the beginning of the operation and by the time of joint implantation, it noted a tendency to decrease, but later it was at the level of age characteristics.

Results and discussion:
With a more detailed analysis of the period of the USA (injection of anesthetic) and before the operation and implantation of joint components, the dynamics of blood pressure and systolic blood pressure was as follows These indicators fit into the hypodynamic regime of blood circulation. Interesting, in our opinion, was the fact that with a decrease in blood pressure and systemic blood pressure at the stages of the beginning of the operation and implantation of the joint, it occurs not only due to the sympathetic block caused by a local anesthetic, but also due to a decrease in the one-time and minute productivity of the heart. But it was interesting that with a decrease in the indicators of systemic and central hemodynamics, there is a statistically significant increase in TPVR.  Time spent in the operating room after surgery, min 23,7 ± 2,9 The duration of the application of the tourniquet, min (n = 4) 88,3 ± 2,7 Recovery time of cognitive functions, min 16,8 ± 1,7 The total blood loss in this group of patients was 7 mg / kg, with THA -6.5 ml / kg, with TKA -7-8 ml / kg. The infusion volume in this group was 26.9 ml / kg, the volume of erythromass transfused -3.28 ml / kg.
The recovery time of cognitive functions was usually restored quickly within 15-20 minutes.

1.
Unilateral spinal anesthesia is a safe and highly effective technique that can provide full intraoperative pain relief for patients with total hip arthroplasty in a high-risk group of patients.

2.
The use of unilateral spinal anesthesia provides sufficient hemodynamic stability in older patients.

3.
The number of intraoperative complications among patients who underwent unilateral spinal anesthesia is significantly less than with the classical SA technique.