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NA 1 > A for orthopedics > Flashcards

A for orthopedics Flashcards

1
Q

preoperative assessment

A

cardiovascular system: AHA recommendations for cardiac testing, mobility is an issue

respiratory system: decreases in SaO₂, increase in closing volume, hip fracture → decreased PaO₂

neurologic assessment: delirium and POCD-assess mental status

preoperative assessment: check coag status and baseline lab values, SSI- major concern with joint arthroplasty, large bore IVs

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2
Q

Surgical site infection

A

Major issue in orthopedic surgery
- destroys healing and repairs
- may lead to removal
- TKA has 2x infection rate of THA because of less soft tissue and muscle

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3
Q

thromboprophylaxis: highest risk of DVT

A

THA/TKA
hip/pelvic fx

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4
Q

surgical site infection prevention

A
  • patient antibacterial soap
  • laminar flow
  • prophylactic abx
  • meticulous skin prep
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5
Q

thromboprophylaxis: warfarin

A

INR > 2.5

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6
Q

orthopedic emergencies

A

dislocated hip
finger reimplantation
compartment syndrome

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7
Q

orthopedic emergencies: dislocated hip

A

general (usually)
NPO status
quick procedure

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8
Q

orthopedic emergencies: finger reimplantation

A

general with a block
VERY long procedure
NPO status

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9
Q

orthopedic emergencies: compartment syndrome

A

seen most often with tibial fx’s
treatment surgical decompression

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10
Q

advantages of regional anesthesia

A
  • less risk of DVT/PE
  • decreased blood loss
  • less respiratory issues
  • no need for airway manipulation
  • better postop pain management → less incidence of chronic pain
  • less N/V
  • excellent skeletal muscle relaxation
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11
Q

common comorbidities in orthopedic surgery

A

osteoarthritis: loss of articular cartilage, no systemic manifestations, positioning concerns

rheumatoid arthritis: systemic disease, autoimmune disease

ankylosing spondylitis: fusion of axial skeleton, kyphosis, difficult airway & regional

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12
Q

rheumatoid arthritis

A
  • possible difficult intubation
  • acute pericarditis
  • acute interstitial fibrosis
  • Sjoren’s syndrome
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13
Q

RA: difficult intubation

A
  • TMJ synovitis
  • decreased glottic opening
  • cervical spine immobility/pain
  • Atlanta occipital subluxation
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14
Q

RA: acute pericarditis

A
  • symptoms of right heart failure
  • 2D echo to evaluate
  • cancel case if acute – may need to be drained
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15
Q

RA: acute interstitial fibrosis

A

restrictive disease
dyspnea and chronic cough

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16
Q

RA: Sjoren’s disease

A

chronic dry eyes
use lubricant

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17
Q

orthopedic considerations

A

tourniquet
fat embolism
POVL
positoning

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18
Q

pneumatic tourniquet: preparation

A
  • widest cuff possible
  • 2 layers of padding
  • 2 fingers between pad and cuff
  • exsanguinate with esmarch (bandage)
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19
Q

pneumatic tourniquet: pressure/time

A
  • pressure: usually 100 mmHg > SBP
  • limit of 2 hours (some say 2.5-3 hrs)
  • deflation: 10-30 mins for time> 2 hrs
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20
Q

pneumatic tourniquet: tourniquet pain

A
  • occurs after 60 mins
  • tachycardia and HTN
  • only treatment → deflation
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21
Q

pneumatic tourniquet: complicaitons

A

local: nerve/muscle injury

systemic:
- cardiovascular: HTN & tachy
- cerebral: increased CBF
- hematologic: hypercoagulable & fibrinolytic
- metabolic: LA, hyperaklemia, hypoxic
- temperature: inflation vs. deflation

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22
Q

Myonephropathic metabolic syndrome

A
  • upon deflation
  • hypotension
  • metabolic acidosis
  • hyperkalemia
  • myoglobinuria
  • myoglobinemia
  • possible renal failure
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23
Q

fat embolism: pathogenesis (mechanical theory)

A
  • injury → vessels are torn. Fat emboli enter circulation through the torn vessels
  • traveling fat → respiratory system. enters pulmonary capillaries and obstructs them
  • arterial system → two mechanisms. microemboli, patent foramen ovale
  • unanswered questions? → why the wait? Symptoms don’t appear 24-72 hrs. FES with no fracture?
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24
Q

fat embolism: pathogenesis (biochemical theory)

A

THE PRODUCTION OF TOXIC INTERMEDIATES (with pro-inflammatory effects) of circulating fat
- FFA
- cytokines
- C-reactive proteins

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25
Q

fat embolism: clinical presentation & differential diagnosis

A
  • delayed presentation
  • pulmonary features are the most common presenting features

differential diagnosis
- PE
- amniotic fluid embolus
- air embolus

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26
Q

FES typically manifests __ to __ hours after initial insult

A

24-72

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27
Q

FES: respiratory

A
  • usually presenting symptom
  • hypoxia, dyspnea and tachypnea
  • ARDS-like syndrome develops
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28
Q

FES: petechial rash

A
  • found on non-dependent areas of the body: head, neck, anterior chest, thorax, axilla, sub-conjunctiva
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29
Q

FES: classic triad

A

hypoxemia
neurologic abnormalities
petechial rash

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30
Q

FES: clinical/lab findings

A
  • anemia/thrombocytopenia
  • fever
  • fat in urine
  • coagulation disorders
  • myocardial depression
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31
Q

differential diagnosis

A

PE
- same time frame
- no neurologic symptoms or rash
- PE will show up on CT

amniotic embolus
- pregnant?
- presents with CV collapse, respiratory failure, and seizures

Air embolus
- rash in unusual
- neurologic and respiratory symptoms will show immediately with AE

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32
Q

POVL: causes

A

central retinal artery occlusion
ischemic optic neuropathy

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33
Q

POVL: timing/presentation

A

24-48 hrs
bilateral
painless, loss of pupillary reflex

34
Q

POVL: risk factors

A

obesity
Wilson frame use
length of surgery
blood loss
decreased use of colloids

35
Q

positioning-prone

A
  • induce on a stretcher
  • head and neck supported & aligned with turn
  • check breath sounds after turning
  • arms < 90 degrees or tucked
  • abdomen must be hanging freely
  • avoid flexion/extension of neck
  • head above heart level - increased ICP, increased IOP
  • PSV vs. VCV
36
Q

positioning-lateral

A
  • dependent lung is under-ventilated and over-perfused
  • axillary roll
  • pulse ox on the dependent arm
  • “bean bag”
  • pad facial structures, breast, and genitalia
37
Q

positioning-beach chair

A
  • decreased BP & preload, from venous pooling
  • adequately hydrate
  • lighten anesthesia
  • watch for inadvertent extubation
  • support head, maintain a neutral position
  • VAE
38
Q

arthroscopy-lower extremity: outpatient

A
  • most done outpatient
  • GA usually done
  • pain control
  • (intraarticular injection/PNB)
39
Q

arthroscopy-lower extremity: knee/hip & TNS

A

ACL repair - postop pain, muscle relaxation
Hip scope - positioning with traction

TNS
- transient neurologic symptoms
- seen after neuraxial
- common with lithotomy, knee scope, lidocaine

40
Q

hip fracture: mortality

A

1 year = 30%
50% have postop confusion/delirium

41
Q

hip fracture: timing of surgery

A
  • earlier is better
  • less pain
  • less complication
  • decreased LOS
  • beware of good Hct!
42
Q

pelvic fracture: mortality

A

3 month mortality = 14%
retroperitoneal bleeding

43
Q

hip fracture: anesthesia

A
  • fracture table
  • aline?
  • SAB - 4x greater risk for DVT with GA
44
Q

pelvic fracture: timing of surgery

A
  • earlier is better
  • other injuries may delay surgery
  • optimal time to repair = 1 week
45
Q

pelvic fracture: anesthesia

A
  • high risk of DVT &/or PE
  • GA with an epidural for postop analgesia
  • large bore IVs or possible central line
  • possible neuromonitoring
45
Q

hip/knee arthroplasty: most important risk factor for adverse events are

A

ADVANCING AGE

45
Q

hip/knee arthroplasty: anesthesia

A
  • SAB is an ideal anesthetic
  • Hip: significant EBL
  • TXA
  • controlled hypotension
  • preop preparation
45
Q

hip/knee arthroplasty: common complications

A

cardiac events
PE
pneumonia
infection

46
Q

hip/knee arthroplasty: methyl methacrylate

A

hypotension
BCIS (bone cement implantation syndrome)
treatment - supportive & O₂

47
Q

GA with OET was found to be an independent risk for…

A

nonsurgical complications after a TKA

48
Q

bone-cement implantation syndrome: when will it occur?

A
  • femoral reaming
  • acetabular/femoral cementing
  • insertion of the prosthesis
  • after TQT release (rare)
49
Q

bone-cement implantation syndrome: signs/symptoms

A
  • hypotension/hypoxia
  • An abrupt decrease in ETCO₂ will be the first indication under anesthesia
  • awake patient: dyspnea & altered sensorium
50
Q

bone-cement implantation syndrome: mechanism

A
  • embolization of bone marrow debris
  • toxic effects of MMA
  • release of cytokines
51
Q

bone-cement implantation syndrome: risk factors

A
  • pre-existing cardiac/pulmonary dx
  • ASA 3 or higher
  • long stem arthroplasty (THA > TKA)
  • revision surgeries
52
Q

TXA

A
  • antifibrinolytic and plasminogen activator
  • stops the conversion of plasminogen to plasmin
  • stops the breakdown of fibrin clots

has decreased the rate of transfusion in THA/TKA to < 5%
dosing is still being investigated

53
Q

foot/ankle surgery: common complications

A
  • compartment syndrome: be careful with long-acting PNB - may mask signs of compartment syndrome
54
Q

foot/ankle surgery: anesthesia

A

SAB or PNB need to block sciatic and femoral nerves (no thigh TQT)

55
Q

shoulder surgery: Bezold-Jarish reflex

A

LV receptor senses low-volume → efferent signal → decrease sympathetic flow (hypotension) & increase vagal output (bradycardia

56
Q

shoulder surgery: postioning

A

-beach chair/lateral
- VAE
- POVL

57
Q

shoulder surgery: HBE (hypotensive bradycardic episode)

A
  • get hypotensive and bradycardic when doing a shoulder scope under an interscalene block
  • bezold-jarish reflex
  • may progress to cardiac arrest
58
Q

shoulder surgery: anesthesia

A
  • watch for hypotension
  • cuff-location when sitting, not reading BP at circle of willis
59
Q

spine surgery: positioning

A

prone
POVL potential

60
Q

spine surgery: neuromonitors

A
  • SSEP (somatosensory evoked potentials)
  • MEP (motor evoked potentials)
  • EMG (electromyography)
61
Q

spine surgery: anesthesia

A
  • cervical procedures - glide scope
  • cervical instability - awake FOI
  • anterior/posterior repairs
62
Q

SSEP

A
  • monitor the posterior (sensory) portion of the spinal cord
  • impulse: periphery → brain
63
Q

MEP

A
  • monitors anterior (motor) portion of spinal cord
  • impulse: brain → periphery
64
Q

EMG

A

monitors nerve root injuries during pedicle screw placement

65
Q

amplitude and latency

A
  • IA - reduce latency
  • nitrous: reduce amplitude
66
Q

attenuate SSEP & MEP

A
  • hypotension
  • hypothermia
  • hypocarbia
  • anemia
  • anesthetics
67
Q

types of scoliosis

A

idiopathic
congenital
neuromuscular

68
Q

scoliosis: large blood loss

A
  • deliberate hypotension
  • cell saver
  • intraoperative normovolemic hemodilution
  • TXA
  • autologous blood
69
Q

scoliosis: POVL/neuromonitoring

A
  • POVL rare (0.1%)
  • SSEM/MEP - usual
  • “wake up” test
70
Q

scoliosis: anesthesia

A
  • large bore IVs
  • arterial line
  • TIVA?
  • watch EBL
71
Q

anesthetic implications: positioning

A
  • prone
  • POVL potential
  • decreased abdominal pressure (may lead to increased EBL)
72
Q

anesthetic implications: large EBL

A
  • cell saver
  • intraoperative nomovolemic hemodilution
  • TXA
  • autologous blood?
  • aline- yes
73
Q

anesthetic implications: complicaitons

A
  • postoperative neurological deficit
  • wake up test (if needed)
  • inadvertent extubation
  • air embolus
  • dislodgment of instrumentation
74
Q

major risk factors for delirium

A

alcohol use
preoperative dementia
cognitive imapirment
psychotropic medication
multiple comorbidities

75
Q

perioperative triggers for dementia

A
  • hypoexemia, hypotension, hypervolemia
  • abnormal electrolytes
  • infection
  • sleep deprivation
  • pain
  • benzos
  • anticholinergics
76
Q
A
77
Q
A

NA 1 (15 decks)

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