Position: Supine, Left Lateral, Right Lateral, arms extended
Time: 1-2 hours (average)
Blood Loss: Very High (500+ ml)
Post-op Pain: Moderate (3-6)
Maintenance Paralytic: Ask surgeon

Blood Loss – Anticipate 200-900 ml of blood loss. You may be asked by the physician to keep blood pressures below a certain point (usually Systolic ~ 100 mmHg) to reduce potential blood loss. Anticipate administering TXA.

Sciatic nerve – Surgeons sometimes like to monitor the sciatic nerve. They monitor this by watching for movement of the lower extremities. When the cautery gets too close to this nerve, the leg will jump. With this preference, the surgeon will be requesting no paralytic.

Spinals – if you elect to perform a spinal for these cases, the addition of lidocaine (10 mg), epinephrine (15 mcg), and fentanyl (25 mcg) has been shown to be very effective at both reducing postoperative pain and discharge times.

Keep drapes HIGH – its these cases that will have blood coming over the drapes.

High Blood Loss (general considerations): Type and cross, CBC, and CMP should be done prior to the procedure. Consider having an A-line, blood tubing, and extra push-lines. Depending on the fragility of the patient, you may want to have blood in the room and available.

Lateral position (general considerations): If an ETT has been placed, make sure ETT is secure with extra tape.  Unhook anesthesia circuit while turning lateral and be especially careful to keep patient’s head neutral and aligned with body to avoid neck injury. Once lateral, use pillows/blankets/foam headrest to keep the patient’s head in neutral position. The most common nerve injury for orthopedic lateral procedures are neurapraxias of the brachial plexus. These are motor and/or sensory loss for 6-8 weeks due to pressure on the contralateral (dependent) axilla. To prevent this, place an axillary roll under the patient (caudad to the axilla, on the rib cage, and NOT in the axilla). Check routinely to make sure the axillary roll does not migrate into the axilla. If the non-dependent arm is placed on a board, check padding and reposition regularly to avoid radial nerve compression. If a bean bag is employed, check the hard edges to ensure that unnecessary pressure isn’t being put on soft tissues. Pad all dependent bony prominences such as the fibular head (to prevent peroneal nerve injury), and place pillows between the knees and ankles (to prevent saphenous nerve injury). If anterior hip supports are in place, ensure they are properly padded or neuropraxias and/or occlusions of large blood vessels may result.