The state of the hemostasis system during endoprosthetics of the joints of the lower extremities operated on under conditions of general anesthesia in people with high anesthetic risk

Scientific research results in pandemic conditions (COVID-19)

95

Gaziev Z.T. Avakov V.E. Rakhmankulov E.Zh., Tashkent Medical Academy

Uzbekistan Tashkent Department of Anesthesiology and Intensive Care

THE STATE OF THE HEMOSTASIS SYSTEM DURING ENDOPROSTHETICS OF

THE JOINTS OF THE LOWER EXTREMITIES OPERATED ON UNDER

CONDITIONS OF GENERAL ANESTHESIA IN PEOPLE WITH HIGH

ANESTHETIC RISK

Z. Gaziev, V. Avakov, E. Rakhmankulov

Endoprosthetics of the joints of the lower extremities is considered one

of the most successful orthopedic procedures and more than a million such
operations are performed every year in the world (4). It is predicted that by
2020, arthroplasty of the joints of the lower extremities will exceed more
than one million per year in the United States alone (2). Historically, general
anesthesia has been the gold standard in orthopedic surgery. At present, in
research practice and in discussing the timely prevention of cardiovascular
diseases, especially coronary heart disease, which occupies the first place
among the causes of population death worldwide, it is necessary to take into
account age-related changes that occur in the anatomical structures of the
heart and the vessels supplying it. In the References: there is evidence of age-
related changes in coronary vessels. According to (1), in people of the
second period of middle age and the elderly, age-related changes in the
vascular wall are noted. According to (5), there is a direct correlation
between the degree of tortuosity of the coronary vessels and the age of the
patient.

Vascular changes (including tortuosity) can lead to a deterioration in

the hemodynamic conditions inside the vessels, and possibly to a change in
the hydrodynamic parameters of the blood flow. An increase in the load on
certain sections of the vascular wall can lead to chronic inflammation and
the deposition of atherosclerotic plaques, which is the main link in the
pathogenesis of IHD. This can contribute to rupture of the atherosclerotic
plaque tire and blood clots due to turbulence in the bloodstream. One of the
formidable problems of the postoperative period when performing
orthopedic surgery is bleeding. Total blood loss can be significant, reaching
50-60% of the volume of circulating blood, with the development of a
complex of negative processes that accompany massive blood loss, which
exacerbates an already traumatic intervention (3.6).

Objective: to study the state of the hemostatic system in elderly and

senile patients operated on under conditions of general anesthesia, to
identify its side effects.

Material and research methods.
We analyzed the postoperative period in 50 patients. Patients were

hospitalized in the trauma department of the multidisciplinary clinic TMA.

Scientific research results in pandemic conditions (COVID-19)

96

All patients underwent total joint replacement (39-THA and 11-TKA). Men
- 22 (44%) 28 - women (56%). The age of patients in this group was in the
range of 68-81 years, i.e. it is mainly elderly (78%) and senile age (22%)
with a physical status of ASA 3 or higher. The right side of the lesion
prevailed (54%) according to the Ketle index indicator, trophological status
fell within the framework of normal elderly and senile age, which were
operated on for degenerative-dystrophic and traumatic injuries of the joints
of the lower extremities.

Induction in anesthesia was carried out with propofol at the rate of 1-2

mg / kg, fentanyl (2-3 mg / kg), midosalam (dormicum) (0.1-0.2 mg / kg),
relaxant-pipecuronium bromide (arduan) (0.06 -0.08 mg / kg). After
tracheal intubation, anesthesia was maintained by inhalation of 1.3-1.8
vol.% Isflurane and propofol infusion of 2.5-3.5 mg / kg / hour. Fentanyl was
administered at times. The total amount was 4-5 μg / kg.

In the preoperative period, an infusion program was carried out in the

range of 6-8 ml / kg (5% glucose solution and electrolyte solutions). In order
to prevent thrombotic-embolic complications in all patients, 10-12 hours
after admission, heparin (7,500 IU) was administered subcutaneously twice
a day. In patients receiving anticoagulant therapy per os, the latter was
canceled, before surgery, 5 mg of vitamin K (Vikasol) was administered
intravenously, followed by a triple administration of heparin (7,500 IU) sc
daily.

Anesthesia was monitored by us using the bispectral index (BIS) for a

thorough titration of the anesthetic.

At values (BIS) exceeding 60 (tracheal intubation, traumatic stages of

the operation), fentanyl infusion was increased to 0.5-0.7 μg / mg. All studies
in the GA process were performed at (BIS) values up to 40-60 recommended
for elderly patients.

In cases of the development of arterial hypotension, it was assessed as:

“moderate”, when the systolic blood pressure decreased to 20% of the initial
level, “pronounced” - a decrease in systolic BP was more than 30% of the
initial, and the mean BP (MBP) became less than 100 mmHg In such cases,
vasopressors (ephedrine, dopamine) were used, as well as fluid infusion
until restoration of the MBP.

In cases of the development of bradycardia, defined as a decrease in

heart rate <50 per minute, atropine 0.5 mg was administered intravenously.

Indicators of systemic and central hemodynamics, BIS, SpO2 and

pressor consumption were monitored every 5-10 minutes during the
operation and up to 120 minutes after it. Surgical blood loss was
compensated for by the infusion of crystalloid and colloid and, if necessary,
blood products.

Scientific research results in pandemic conditions (COVID-19)

97

Surgical blood loss during hip and knee arthroplasty was determined by

the gravimetric method. During the operation, changes in systemic BP, DBP,
MBP, heart rate, SpO2 were observed. Stages of registration of these
indicators: before, during anesthesia, 30, 60, 120 minutes after the
operation is completed.

Clinical and biochemical blood tests (erythrocytes, Hb, Нt, lymphocytes,

total protein, electrolytes, glucose, transaminases, nitrogenous slags,
bilirubin) were performed before the operation and 1.5.10 days after the
operation. Before surgery and on day 10, coagulogram data were analyzed
with a focus on: fibrinogen, prothrombin time, platelets, APTT. To assess the
functional state of the components of the hemostatic system and fibrinolysis,
the hemocoagulography method was used with the help of the blood
rheology analyzer of the portable ARP Mednord (Tomsk). At the same time,
duplex scanning of the deep veins of the lower extremities was performed
on both sides. Research stages: 1) upon admission to the operating room, 2)
after tracheal intubation, 3) joint implantation, 4) end of operation and
anesthesia.

Results and discussion

Table No. 1 Indicators of a general blood test in patients operated on in

conditions of GA before and after surgery.

Indicators

GA (n = 50)
Before operation

After operation

Red blood cells, 10

12

/l

4,19 ± 0,31

4,11 ± 0,42

Hemoglobin, g/l

13,2± 0,4

12,8 ± 0,5

White blood cells, 10

9

/l 5,32 ± 0,64

5,79 ± 0,71

Neutrophils, 10

9

/l

3,23 ± 0,41

3,69 ± 0,39

Lymphocytes, 10

9

/l

1,62 ± 0,27

1,44 ± 0,31

From the data presented, it can be noted that initially all peripheral

blood parameters were practically within the physiological values. But,
given the age of patients in this group, we can talk about some initial
hemoconcentration, as evidenced by high rates of red blood cells and Hb.
Despite the fact that during the operation 21 patients (42%) underwent
transfusion of 200 ml of erythrocyte mass, because blood loss exceeded 500
ml and averaged 625 ml, by the end of the operation these parameters were
lower than the initial ones by 2.1 and 2.3 % (p> 0.05). As for the indicators
of white blood, by the end of the operation there was a slight tendency to
increase them within 8.8% - 12.5% except for lymphocytes. However, due
to the relatively high scatter of numbers (m), the marked increase in white
blood cells and neutrophils was not statistically significant. At the end of the
operation, the number of lymphocytes decreased relative to the initial data
by 11.2%, which was also a trend (p> 0.05).

Scientific research results in pandemic conditions (COVID-19)

98

Table No. 2 Indicators of hemostasis in patients operated on in

conditions of GA (n = 50) before and after surgery

Indicators

GA (n = 50)
Before operation

After operation

Fibrinogen, g/l

3,84 ± 0,32

3,61 ± 0,27

Platelets, 10

9

/l

162,3 ± 4,7

176,4 ± 3,9

Prothrombin time, sec

11,8 ± 0,5

11,4 ± 0,4

APTT, sec

28,9 ± 0,3

30,9 ± 0,2

Initial indicators of blood coagulation in this group of patients also did

not go beyond physiological values. There was only a tendency towards a
decrease in fibrinogen levels by the end of operations by 6.4% (p> 0.05) and
an extension of APTT by 6.9% (p <0.05).

Despite the fact that the vast majority of patients have suffered from

hypertension for a long time, we did not note a special spread of blood
pressure indicators upon admission, in all likelihood due to the systematic
use of antihypertensive drugs. The level of blood pressure in them was
within 160/90 - 125/70 mm. Hg, averaging 138.9 / 87, 7 mm Hg.

The table below shows the indicators of systemic hemodynamics and

pulse oximetry in the implementation of GA.

Table No. 3 Indicators of systemic hemodynamics at the stages of GA (n

= 50).

Indicators Study Stages (GA)

Before
operation

After
operation

Joint
implant

End of
operation

In 30
minutes

In 60
minutes

Syst BP.
(mm. Hg)

138,6±
11,4

142,8±
9,3

151,5±
10,4

137,7±
9,1

145,4 ±
9,2

150,3 ±
11,2

Diast BP
(mm. Hg)

87,9 ±
5,0

90,1± 4,3 92,4 ±

3,7

89,4 ± 5,5 87,1 ±3,9

90,6 ± 4,1

MBP
(mm. Hg)

104,9±
8,2

107,6 ±
6,8

112.0±7,1 105,5±7,0 106,5±6,5 110,5±7,0

HR (per
minute)

76,3±4,4 80,2±3,0 89,3±2,1

84,0±3,2

87,2±4,3

88,4±3,1

CVP (cm
H2O)

7,4±0,4

10,2±0,3 10,1±0,2

8,7±0,3

9,1±0,4

8,8±0,3

SPO

2

(%)

92,4±1,0 93,6±0,9 92,9±1,2

93,7±0,7

92,4±0,5

92,1±0,5

Of the data presented in the table during GA, the studied circulatory

parameters underwent changes, especially at the stages of tracheal
intubation, joint implantation, and also, an hour after the operation, when

Scientific research results in pandemic conditions (COVID-19)

99

patients began to complain of pain in the area of the surgical wound. So for
intubation and for the most traumatic stage of the operation - implantation
of joints BP increased by 2.5% and 8.6%, and Diast BP - by 2.5% and 5.1%,
respectively, although these changes indicated only a tendency to increase
and are not statistically significant (p> 0.05). As for heart rate, according to
averaged data, we did not observe bradycardia or bradyarrhythmia. It
increased during the traumatic stage of the operation and 60 minutes after
the operation by 17.0 and 15.8%, respectively. In both cases, p <0.05.

The table below provides data on the magnitude, operational blood loss,

and temporal parameters in patients operated on under conditions of GA.

Table No. 4 The volume of blood loss, ITT and temporal parameters in

patients operated on in conditions of GA (n = 50).

Indicators

1

st

patient group

GA

THA blood loss volume, ml

518,6± 67,6

TKA, ml

668,8± 88,4

Total blood loss (ml)

593,7± 78,0

The volume of ITT, ml

2588,4± 120,6

Erythromass, ml

386,7± 63,0

Time to surgery, min.

34,1± 3,2

Operation time, min

132,7± 6,1

Postoperative time, min.

44,9 ±10,2

Harness application time, min.

85,7± 2,7

Extubation time, min

14,3± 3,2

Cognitive function recovery time,
min.

38,4± 2,6

The data presented indicate that the total blood loss during joint

replacement of the lower extremities is on average 7-8 ml / kg div weight
(with THA-6.82 ml / kg, with TKA-8.8 ml / kg). The volume of infusion-
transfusion therapy in the operating room is within 34-35 ml / kg div
weight; The volume of red blood cells is 5.1 ml / kg. In GA, perioperative time
intervals are quite long. The recovery time of cognitive functions was within
30-50 minutes after extubation, averaging 38.4 ± 2.6 minutes.

Conclusions
1.

Changes in the homeostasis system during arterial hypertension

were revealed, manifested by activation of the fibrinolysis system and an
increase in the level of antithrombin III, indicating latent hypercoagulation.

2.

The use of NSAIDs in combination with narcotic analgesics makes it

possible to obtain adequate analgesia, but due to the pronounced reotropic

Scientific research results in pandemic conditions (COVID-19)

100

effect due to the side effects of NSAIDs, the degree of postoperative bleeding
also increases.

3.

In elderly and senile patients, a physiological decrease in fibrinolytic

activity develops, an increase in the level of the natural anticoagulant of
protein C.

References:
1. Zagrekov V.I. The effect of the anesthesia method on blood loss during

hip replacement / V.I. Zagrekov (and others). Medical almanac. 2010; 2 (11):
p 210-212.

2. Obukhov V.A. The choice of anesthesia method for hip joint

prosthetics / V.A. Obukhov (and others). Xi. All-Russian Congress of
Anesthesiologists and Resuscitators: Sat. materials. SPb., 2008; p 235-236.

3. Reed A. P. Clinical cases in anesthesiology: trans. from English / A.P.

Reed, J.A. Kaplan. M .: Medicine, 1995.352 s. ; Difficulties with tracheal
intubation: trans. from English / ed. I.P. Latto, M. Rosen. M .: Medicine. 1989;
p 304

4. Untu F.I. Comparative analysis of anesthesia methods for total

endoprosthesis of the hip joint / F.I. Untu (and others). Regional anesthesia
and treatment of acute pain. 2008; II (2): p 33-42.

5. Memtsoudis SG, Sun X, Chiu YL, Stundner O, Liu SS, Banerjee S, et al

.

Perioperative comparative effectiveness of anesthetic technique in
orthopedic patients. Anesthesiology 2013;118:1046-58.

6. Sertoz. N., Aysel I., Uyar M. The effects of sufentanil added to low-

dose hyperbaric bupivacaine in unilateral spinal anaesthesia for
outpatients undergoing knee arthroscopy // Agri. – 2014. – Vol. 26(4). P.
158-164. doi: 10.5505/agri 2014.51422.