6901 ortho Flashcards
1
Q
Podiatry is limited to study, diagnosis, and treatment of problems of the?
A
foot, ankle, and lower leg
2
Q
Ortho surgery involves procedures on what 4 things?
A
bones, joints, muscle, and related soft tissue
3
Q
Some implications of RA for anesthetists?
A
synovitis of cervical spine, TMJ, larynx, and pulmonary system; deposition of rheumatoid nodules causes inflammation of intervertebral discs and atlanto occipital subluxation
4
Q
If RA pt has limited TMJ opening use what intubation technique?
A
awake fiberoptic
5
Q
2 s/s which indicate narrowing and fixation of glottic opening d/t cricoarytenoid arthritis?
A
hoarseness, inspiratory stridor
6
Q
9 pulmonary lesions in RA pts?
A
pleural effusion, intrapulmonary nodules, rheumatoid pneumocoinosis, interstitial lung disease, vasculitis, obliterative bronchitis, upper lobe fibrosis, pulmonary infections, bronchogenic carcinoma
7
Q
Very prominent physical symptom in RA pt?
A
swanned fingers
8
Q
Difference between RA and OA?
A
RA is inflammatory disease of synovial membrane, which becomes thickened and there is BONE erosion; OA is where cartilages of articulating surfaces are eroded by disease or wear and tear and cartilage thins out and it is bone on bone
9
Q
In 3 words what is ankylosing spondylitis?
A
chronic inflammatory process
10
Q
Primary locus in ankylosing spondylitis?
A
spinal column
11
Q
2 cardiac and 1 pulmonary association with ankylosing spondylitis?
A
conduction delays, valve lesions; restrictive lung disease
12
Q
Huge issue with AS patients and intubation?
A
cervical spine mobility and TMJ opening
13
Q
4 anesthetic considerations for pts with OA?
A
NSAID use, cortisone injections, activity levels, and comorbidities
14
Q
Anesthetic selection in OA/RA/AS patients should consider what 5 things?
A
length of surgery, position of surgery, body habitus, general health, pt acceptance
15
Q
The bladder inside the pneumatic tourniquet should cover what % of the extremity?
A
50%
16
Q
Tourniquet use should not exceed how many minutes?
A
120
17
Q
Cuff overlap of the tourniquet should overlap away from what?
A
neurovascular bundle
18
Q
Exsanguination is done with? And what is exsanguination?
A
esmark; chasing the blood out of the extremity
19
Q
How long does it take for tourniquets to abolish SSEPs?
A
30 minutes
20
Q
Neurapraxia (loss of nerve function) occurs after how many minutes?
A
120
21
Q
Where does nerve injury usually occur in relation to the tourniquet?
A
edge of tourniquet
22
Q
Burning aching pain is d/t activation of what fibers?
A
c fibers
23
Q
Tingling, pins, and needles pain is due to activation of what fibers?
A
a-delta fibers
24
Q
Cellular hypoxia (tourniquet) occurs after how many minutes?
A
2; and acidosis occurs
25
What happens to creatinine values with tourniquet pain?
decrease
26
Endothelial capillary leak occurs after how long with use of tourniquet?
2 hours
27
How much blood does tourniquet release cause to be pushed in to systemic circulation?
300-500 mL
28
What pressures increase d/t tourniquet inflation?
systemic and pulmonary
29
What happens to the core temp when the cuff is deflated?
fall in core temp; is usually transient but if temp is low to begin with it might not rebound
30
What acid base disorder occurs after deflation of tourniquet?
metabolic acidosis
31
What happens to MVO2/MV after tourniquet deflation?
decreases
32
What happens to ETCO2 after tourniquet deflation?
transient increase
33
What happens to systemic and pulmonary pressures after tourniquette deflation?
transient decrease
34
Nerve damage reliably occurs after how many hours of tourniquet inflation?
4 hours
35
After 3 hours of tourniquet time, muscle power is reduced for how long?
full week
36
How long does it take for physiologic effects of tourniquet deflation to resolve after one hour of T time?
20 min
37
Most commonly used drug for IV regional anesthesia?
lidocaine
38
Example of dilute solution and concentrated solution of lidocaine?
dilute: 50 mL of 0.5% lido; concentrated: 12-15 mL 2% lido
39
What type of anesthesia is a bier block?
IV regional
40
3 indications for bier block?
short operative procedures for extremities, pain therapy, treatment of hyperhidrosis
41
LA concentration and amt for bier block?
12-15 mL of 2% lidocaine for upper extremities or 30-40 mL of 0.5% lido
42
Relative contraindications to bier block?
crush injuries, inability to access peripheral veins, infections, compound fractures, hx of allergy to LA, severe PVD, AV shunts, hepatic insuffiency, disrupted integrity of venous system, sickle cell disease
43
Some surgeries bier blocks are good for?
wrist or hand ganglionectomy, carpal tunnel release, dupuytren contractures, reduction of fractures and others
44
The duration of anesthesia for a bier block depends on?
the length of time the tourniquet is inflated
45
Typically discomfort from the tourniquet for a bier block occurs after how many minutes, which precludes its use for longer procedures?
30-45
46
2 disadvantages of bier blocks besides duration?
incomplete muscle relaxation and lack of post op pain relief
47
In a bier block, what area is anesthetized?
entire area beneath the tourniquet (and pick the most distal vein)
48
% lido used for bier block?
0.25-2%
49
catheter size for bier block?
18-20
50
In a bier block, where do you want the IV not used for the block?
on other arm
51
This med can prevent the potential CNS toxicity should the level of LA in a bier block raise?
benzo
52
For a bier block, how do you place the double pneumatic tourniquet?
on a padding layer of soft cloth with the proximal cuff high on the upper arm
53
Steps for bier block?
1) insert IV on contralat arm 2) place pneumatic tourniquet 3) insert IV as distally as possible 4) elevate arm for 1-2 min and wrap esmark bandage 5) while axillary artery is distally occluded, distal cuff (red inflated), inflate proximal (blue) cuff, deflate distal cuff 6) inject LA
54
How do you wrap the esmark bandage in a bier block?
spirally from the hand to the distal cuff of the double tourniquet
55
What is the point of the esmarch bandage?
exsanguinate the arm
56
Cuff pressure for bier block should be how much above SBP?
100 mm Hg
57
How fast do you inject the LA for bier block?
slowly
58
After injecting LA for bier block, what do you do?
lower the arm and remove IV from cannulated arm
59
Volume of LA injected for bier block depends on?
size of arm being anesthetized and concentration of anesthetic solution
60
Maximal dose of LA for bier block?
3mg/kg
61
Order of deflating cuffs in bier block?
distal cuff first then proximal cuff 25-30 min after beginning anesthesia
62
For IVRA what is used more commonly- small volume, larger concentration or large volume of dilute solution?
small volume, larger concentration
63
This LA is associated with formation of methemoglobin, but has less systemic and CNS side effects?
prilocaine
64
Anesthesia develops w/in how many min with bier block?
5 minutes
65
In a bier block, progressive numbness and complete insensitivity are followed by?
patchy decolorization of the skin and motor paralysis
66
Deflation of the wrong cuff in a bier block results in?
rapid loss of anesthesia and risk of systemic local toxicity
67
How do you check the pressure in the distal cuff for a bier block?
squeeze cuff and document oscillations on manometer
68
When the pt starts complaining of discomfort during a bier block, what can you do?
inflate distal cuff and deflate proximal. it provides immediate relief and the pt gets 15-30 more min of comfort
69
Which tourniquet should never be released before inflation of the other cuff?
proximal; distal
70
To prevent engorgement of the extremity in a bier block what can you do?
digital pressure on axillary artery, elevate arm, make sure there is no pulse
71
The proximal cuff for a bier block is near what?
axilla
72
At the end of a bier block, deflate the tourniquet for how long and then reinflate for how long to avoid risk of LA
10 sec; 2 min (1 min she says)
73
The surgeon should do what before release of tourniquet with bier block to prevent sudden oncoming pain?
infiltrate local anesthesia
74
4 complications of IVRA? Most common?
systemic toxicity, hematoma, engorgement, ecchymosis and SQ hemorrhage; systemic toxicity
75
Bier block: if surgery is finished w/in how many min after injection of LA what should you do to avoid systemic toxicity?
gradually release tourniquet w 2 min intervals between deflations
76
Engorgement as a complication of bier block can happen in pts with what health prob?
arteriosclerosis
77
Ensure that arterial pulse is absent in bier block to prevent?
engorgement
78
In upright position, ventilation and perfusion goes where?
perfusion to bottom of lungs and ventilation to top
79
Zone 1 is what part of lungs and Zone 2 is what part?
1: top; 3: bottom
80
In lateral position, perfusion and ventilation go to which part of lung?
perfusion goes to bottom lung and ventilation to top lung
81
What is hypoxic pulmonary vasoconstriction?
when pulmonary arterioles are exposed to alveoli with little O2 in them, they vasoconstrict and divert blood to alveoli where there is a closer VQ match
82
3 risks of injury in beach chair position?
potential for cervical neck injury d/t dislogement of head from holder, inadvertent extubation, brachial plexus injury on opposite side
83
4 advantages of beach chair position?
reduced rate of brachial plexus injuries, better resp mechanics, excellent access to shoulder, weight of arm distracts shoulder joint
84
What blunts the compensatory mechanisms in beach chair position?
volatile anesthetics
85
CPP decreases how much in beach chair?
15%
86
What happens to CVP, MAP, PAP, CO, PVR, and TPR in beach chair?
all but PVR and TPR decrease and they increase
87
What happens to venous return in beach chair?
can be hindered
88
Cerebral autoregulation is hindered with?
HTN
89
The distance between the arm cuff and the auditory meatus is how many cm and represents that much of a gradient between the BP in the brain versus the arm?
15 cm
90
There is a ___ mm Hg change in BP for every ___ cm or mm decrement in BP for each cm distance?
1; 1.25; 0.77
91
5 risk factors for vision loss after spine surgery in prone position?
atherosclerosis, CV disease, excessive blood loss, excessive crystalloid admin, excessive surgical length
92
Presentation of post op prone vision loss after spine surgery?
immediate post op vision loss
93
3 eye complications after prone surgery for spine surgery?
cortical blindness, central retinal artery occlusion, ischemic optic neuropathy
94
This occurs from major insult to vascular structures of the eye?
cortical blindness
95
Findings from cortical blindness?
visual field disturbances with normal retinal exam
96
Central retinal artery occlusion typically occurs from what 3 things?
direct pressure on globe, thrombosis, increased IOP
97
Findings in central retinal artery occlusion?
unilateral vision loss with periorbital edema. retina looks pale, ischemic, with pathgenomic cherry red spot at macula
98
10 suggestions for preventing POVL?
avoid direct pressure on globes, avoid periop hypotension, avoid periop anemia, consider 10 degrees of reverse Tburg during prone, lower transfusion threshold to keep hct >30% in at risk pts, avoid infusions of large amts of crystalloid, consider staging long spinal surgeries (>8 hours), maintain MAP at pt's baseline, avoid changes in any perfusion related meds shortly before surgery, perform post op vision exam as soon as possible in at risk pts
99
At risk pt for POVL is (4)
preexisting CV disease or metabolic disease, prolonged surgery in prone, increased blood loss expected
100
4 benefits of arthroscopy?
less blood loss, reduced post op pain, shorter or no hospitalization, shorter rehab course
101
Definition of arthroscopy?
examination and treatment of joint space with endoscope
102
What is arthroplasty?
total joint replacement
103
3 goals of arthroplasty?
pain relief, stability, deformity correction
104
What is the blood loss and over how long in knee arthroplasty?
up to 2 U over next 24 hours usually in drain
105
Most frequent arthroplasty?
knee
106
During component insertion for TKA what 3 consequences can occur?
HTN, hypoxia, CV collapse
107
Possible causes of complications during component insertion for TKA?
MMA cement, fat embolism, air embolism, marrow embolism, thromboembolism
108
What does MMA cement do to PVR, PCMP, SVR, CO, BP?
increases PVR, PCMP; decreases SVR, CO, and systemic BP
109
Since there is a high incidence of DVTs post op for TKA, they get either _______ or _______ post op?
LMWH, coumadin
110
Incidence of PE in TKA is?
1-5%
111
2 positions THA can be done in?
lateral decubitus, anterior
112
What 2 bones are richly perfused and make blood loss likely in THA?
femur, acetabulum
113
4 special considerations for THA?
MMA, blood loss can exceed 6 U, typically older with comorbidities, redos at MVAMC get a line and foley
114
What leads to hardening and expansion of MMA cement?
exothermic reaction
115
MMA can cause intramedullary HTN and result in embolization of what 4 things?
fat, air, bone, cement
116
Bone cement implantation syndrome 5 s/s?
hypoxia, hypotension, arrhythmias, pul HTN, decreased CO
117
Bone cement implantation syndrome usually occurs when?
femoral component placed
118
5 things to do to reduce MMA risk?
increase FiO2 prior to cementing, maintain euvolemia at time cement is ab to be placed, vent distal femur, high pressure lavage of femur shaft to remove debris, use of uncemented femoral components for hips
119
5 ways to reduce blood loss?
cell saver, autologous blood, induced hypotension, normothermia, spinal/epidural anesthetics
120
Clotting cascade does not work if temp is
35
121
What type of blood loss occurs in upper extremity arthroplasty?
more blood loss
122
3 special considerations about scoliosis surgery?
typically a/p surgery, requires thoracotomy to access thoracic spine, may have some restrictive lung disease d/t progress of disease
123
What is scoliosis?
lateral deviation in frontal plane associated with rotation
124
This type of bed frame supports the hip and thorax, some weight on elbows?
Relton adjustable pedestal frame
125
This frame is convex saddle frame and adjustable in width and length?
wilson frame
126
This frame is when only thorax is touching the bed and weight is borne by the knees. pad comes across butt
Andrews frame
127
Prob w andrews frame and tarcoff frame?
getting venous return in to systemic circulation
128
Good type of anesthesia for foot and ankle surgery?
regional
129
5 nerves which supply sensation to the foot?
superficial peroneal nerve, deep peroneal nerve, saphenous nerve, sural nerve, posterior tibial nerve
130
This ankle nerve is a branch of the common peroneal nerve. It descends toward the ankle in lateral compartment and enters the ankle just lateral to extensor digitorum. it provides cutaneous sensation to dorsum of foot and 5 toes. is most constantly located lateral to extensor digitorum longus at level of lateral malleolus superficially
superficial peroneal nerve
131
This ankle nerve runs in anterior leg as continuation of common peroneal nerve. innervates toe extensors, enters ankle between flexor hallus longus and extansor detorus longer tendons. provides sensation to medial half of dorsal foot, esp 1st and 2nd digits. has constant location just lateral to flexor hallus longus at level of medial malleolus. anterior tibial artery lies between this nerve and tendon
deep peroneal nerve
132
This ankle nerve is the terminal branch of femoral nerve. supplies superficial sensation to anterior medial foot and is most constantly located to just anterior to medial maleolus
saphenous nerve
133
Only nerve of foot not part of sciatic system?
saphenous nerve
134
This ankle nerve is a continuation of tibial nerve and enters foot between achilles tendon and lateral malleolus to provide sensation to lateral foot
sural nerve
135
This ankle nerve is a direct continuation of tibial nerve and it enters the foot of the posterior medial malleolus branching in to 2 diff branches. constantly located behind posterior tibial artery at level of medial malleolus and is sensory to heal, medial sole, and part of lateral sole of foot
posterior tibial nerve
136
This muscle moves your big toe?
extensor digitorum longus tendon
137
6 characteristics of hip fracture surgery?
typically elderly, typically on call/after hours, multiple comorbidities, blood loss thru all operative stages, lateral position, regional anesthesia is limited by pt comorbidities and conditions
138
Hip fracture surgery has a high incidence of post op complications. What are 4 risk factors for post op complications?
poor ASA, urgency of procedure, extent of procedure, duration of procedure
139
Major complication of ORIF of hip?
fat embolism
140
Fat embolism occurs in what % of femur fractures?
10-20%
141
When does fat embolism present after surgery?
within 72 hours of injury
142
3 physical symptoms of fat embolism?
confusion, petechiae, dyspnea
143
Diagnosis of fat embolism?
petechiae on chest, upper extremities, axilla, conjunctiva
144
Fat globules are in what 3 areas with fat embolism?
retina, sputum, urine
145
What happens to platelets in fat embolism?
thrombocytopenia
146
What happens to ETCO2, SaO2, and PAP in fat embolism?
increased PAP, decreased ETCO2, SaO2
147
What happens to ST segments in fat embolism?
suggestive of ischemia
148
Treatment of fat embolism?
stop surgery and mostly supportive care
149
Saphenous and superficial peroneal nerves are what kind of nerves?
small, unmyelinated c fibers (so don't need a lot of LA)
150
When doing ankle block, don't use what drug commonly added to LA if pt is diabetic?
epi
151
Needle size for ankle block?
22 g 1.5
