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N931 Advanced Principles of Anesthesia I > Anesthesia for Orthopedic Surgery > Flashcards

Anesthesia for Orthopedic Surgery Flashcards

1
Q

anesthetic technique for ortho procedures

A
  • multimodal
  • neuraxial
  • general
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2
Q

multimodal analgesia involves…

A
  • NSAIDs
  • anticonvulsants
  • opioids
  • peripheral nerve blocks
  • other adjuncts
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3
Q

preoperative abx

A
  • decrease risk of SSI
  • cefazolin within 1 hour of incision time
  • vancomycin within 2 hours of incision time
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4
Q

CMS surgical care improvement project

A
  • post op thromboembolism
  • glucose management
  • core body temperature
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5
Q

spine surgery

A
  • most open procedures
  • minimally invasive techniques for non-complex procedures
  • supine or prone positioning
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6
Q

patient populations for spine surgery

A
  • spinal cord injury
  • scoliosis
  • degenerative disk disease
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7
Q

anesthetic considerations for spine surgery

A
  • general anesthesia - need a secure airway, muscle relaxation
  • anticoagulants should be d/c if possible
  • preop testing –> CBC, plts, coags, CXR, PFTs, ECG, and ECHO (as appropriate)
  • evoke potentials may be monitored
  • prone position considerations
  • difficult intubation (esp if worried about in line stability)
  • A LOT of blood loss
  • hypotensive
  • POVL if prone from venous pooling
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8
Q

evoked potentials + anesthetic management

A
  • SSEP
  • MEP
  • or both can also be monitored
  • techs will say the volatile anesthetics affect these however research doesn’t support this
  • BUT we still do a TIVA usually (LOL); or 0.5 MAC of gas with TIVA
  • PRO TIP –> if monitoring MEPs need 2 soft bite blocks between the molars, the patient will bite down and the blocks prevent them from biting on the tube!
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9
Q

POVL

A
  • occurs with venous pooling of blood in the prone position

- risk factors are surgery longer than 5 hours, anemia, and male gender

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10
Q

prone position

A
  • alignment and proper padding are IMPORTANT
  • head and neck must be aligned
  • eyes must be free of pressure
  • chest/breast and genitalia free of pressure
  • arms padded and positioned –> superman or tucked
  • a lot of beds will have a mirror under head so you can see ETT
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11
Q

supine (cervical surgery) position considerations

A
  • like with ACDF
  • shoulder roll to extend neck
  • monitor ETT position
  • arms tucked with traction
  • BP cuff
  • IV placement (a lot of times will have 2 PIV with arms tucked)
  • maybe art line just depends
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12
Q

spinal cord injury

A
  • approximately 11,000/year
  • half are cervical
  • cervical = head injury, thoracic fractures, pulmonary + CV injury
  • lumbar = abdominal injuries, long bone fractures
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13
Q

SCI anesthetic considerations

A
  • neurologic exam
  • airway management
  • cardiac considerations
  • autonomic hyperreflexiaa
  • succinylcholine induced hyperkalemia
  • temperature control
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14
Q

scoliosis

A
  • deformity of the spinal column resulting in lateral curvature and rotation of the spine and rib cage involvement
  • up to 25% of patients have concomitant neuromuscular disease and congenital abnormalities
  • severity determined by Cobb angle
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15
Q

Cobb angle

A
  • measurement of the degree of side-to-side spinal curvature
  • describes the maximum distance from straight a scoliotic curve may be
  • Cobb angle > 60 degrees means pulmonary and CV compromise
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16
Q

preop anesthetic considerations for scoliosis

A
  • pulmonary function studies

- cv considerations

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17
Q

periop anesthetic considerations for scoliosis

A
  • posterior vs anterior approach
  • surgeries T8 and above (cardiac accelerator fibers)
  • wake up test may be done - use propofol and remi
  • long and bloody
  • need to IVs and be prepared to transfuse
  • some autologous transfusions, cell saver, and hemodilution are possible solutions
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18
Q

scoliosis anesthetic management

A
  • hemodynamic monitoring
  • vascular access
  • respiratory support
  • hypothermia
  • replacement of blood and fluid losses
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19
Q

degenerative spine disease

A
  • involvement more common in lumbar and sacral regions
  • includes = spinal stenosis, spondylosis, spondylolisthesis
  • may occur singly or concomitantly
  • neurologic exam is critical in determining disease level
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20
Q

degenerative spine disease anesthetic considerations

A
  • preop assessment
  • patient positioning (anterior vs posterior approach)
  • general vs. regional
  • spinal cord monitoring (wake up test, SSEP or MEP)
  • blood/fluid management
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21
Q

potential complications with degenerative spine disease surgeries

A
  • VAE - hypotension and precipitous fall of ETCO2, mill wheel murmur may be heard
  • visual loss - in prone position; optic neuropathy, retinal artery occlusions, cerebral ischemia
  • postop management
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22
Q

upper extremity surgery

A
  • arthroscopic or open
  • procedures include = joint disorders, fractures, joint arthroplasty, entrapment syndromes
  • performed with general or regional
  • patient position dependent upon procedure
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23
Q

brachial plexus

A
  • ventral rami of the C5 to T1 nerve roots
  • C4 and T2 are often minor or absent alltogether
  • nerve roots exit veretebral foramen converging and diverging into trunks, divisions, cords, and finally terminal branches
  • supplies sensory and motor innervation to upper extremity (a few exceptions)
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24
Q

pneumonic for brachial plexus divisions

A
  • Randy - roots
  • Travis - trunks
  • Drinks - divisions
  • Cold - cords
  • Beer - branches (terminal branches)
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25
Q

shoulder surgery common procedures

A
  • subacromial impingement
  • rotator cuff tear
  • arthroplasty
  • clavicle fractures
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26
Q

shoulder surgery common positions

A
  • lateral

- beach chair

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27
Q

lateral position considerations shoulder surgery

A
  • patients in lateral position usually have a kidney rest and then traction holding their operative arm up
  • head/neck alignment
  • padding and position of non-surgical extremities
  • be mindful of cerebral perfusion
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28
Q

beach chair position considerations shoulder surgery

A
  • decreased cerebral perfusion - 2 mmHg difference for every inch in height above where the BP cuff is
  • blindness
  • stroke
  • brain death
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29
Q

beach chair positioning BP monitoring

A
  • cuff should be placed on upper arm
  • arterial pressure monitoring = transducer should be placed at least to patients heart but preferably to brainstem
  • gives you an idea of the cerebral perfusion
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30
Q

anesthetic considerations for shoulder surgery

A
  • regional anesthesia –> interscalene block (ISB); single shot vs catheter placement
  • general anesthesia vs MAC
  • ETT vs LMA
  • depends on patient
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31
Q

interscalene block (ISB)

A
  • root level block
  • the primary brachial plexus block for procedures involving the shoulder and proximal upper arm
  • nerve roots C5-C7 are found in the interscalene groove between the anterior and middle scalene muscles
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32
Q

ISB indications

A
  • shoulder procedures
  • proximal humerus
  • lateral two-thirds of clavicle
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33
Q

ISB landmarks

A
  • sternal head of sternocledomastoid
  • clavicular head of sternocledomastoid
  • upper border of cricoid cartilage
  • clavicle
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34
Q

ISB landmark technique

A
  • needle inserted between anterior and middle scalene muscles
  • needle not placed deeper than 2-3 cm in most patients
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35
Q

ISB common side effects

A
  • stellate ganglion block (aka horner’s syndrome) - ptosis, miosis, and anhydrosis
  • diaphragmatic hemiparesis
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36
Q

ISB block pearls

A
  • C8 and T1 may not be blocked in about 30% of patients
  • avoid injecting close to the transverse process
  • the vertebral artery enters at C6, increasing risk of intravascular injection
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37
Q

common procedures of arm/hand

A
  • surgical repair of fractures (humerus, radius, ulnar, hand)
  • arthroplasty
  • amputation
  • ulnar nerve transplantation
  • carpal tunnel release
38
Q

surgery of arm/hand positioning

A
  • depends on procedures
  • beach chair
  • lateral
  • supine with arm out
39
Q

surgery of arm/hand anesthetic considerations

A
  • regional - supraclavicular vs. infraclavicular vs axillary blocks (single shot vs catheter)
  • can also do infiltration at site or a bier block
  • general anesthesia vs MAC
  • ETT vs LMA
  • depends on patient… individualize!
40
Q

Supraclavicular block (SCB) pearls

A
  • common side effects = stellate ganglion block or diaphragmatic hemiparesis (phrenic nerve block)
  • suprascapular nerve often missed
  • increased risk of vascular puncture and pneumothorax
41
Q

SCB

A
  • performed at level of trunks
  • indications are upper extremity below the shoulder surgery
  • good choice for elbow and hand surgery
42
Q

SCB landmarks

A
  • lateral insertion of SCM in the clavicle
  • Clavicle
  • patient’s midline
43
Q

SCB landmark technique

A
  • semisitting position head turned away
  • lower shoulder, flex elbow, forearm on lap, wrist supinated
  • lateral border of SCM visible at level where external jugular vein crosses, trace caudally to where SCM meets clavicle
  • needle inserted cephalad to later insertion of SCM at a direction parallel to midline
  • nerve stimulator set to current 0.8 mA, desired response is muscle twitch of fingers
44
Q

infraclavicular block (IFCB)

A
  • cord level block
  • alternative to SCB in patients with severe COPD or respiratory insufficiency
  • the cords (lateral, posterior, and medial) are labeled by their relation to the axillary artery
45
Q

IFCB pearls

A
  • low frequency may be required depending on how much subQ tissue
  • subQ injection of LA may be warranted
  • sliding needle medially increases potential for pneumo or hemothorax
  • thoraco-acromial artery and pectoral veins pass between the pectoral muscles, doppler may be used to help ID these to prevent inadvertent puncture
46
Q

IFCB indications

A
  • block of arm below the shoulder
  • hand
  • elbow
  • forearm
  • av fistula
47
Q

IFCB anatomy

A
  • three cords surround the axillary artery
  • lateral cord is most superficial
  • posterior is next
  • medial cord is deepest and below the axillary artery
  • lateral and medial each contain half of the median nerve
  • posterior cord contains all of the radial nerve
  • musculocutaneous nerve often outside, but close to lateral cord
48
Q

IFCB landmarks

A
  • clavicle
  • jugular fossa or notch
  • arcomioclavicular joint
  • coracoid proccess
49
Q

IFCB landmark technique

A
  • semisitting head turned away
  • subclavian artery palpated where it crosses clavicle or midpoint of clavicle marked
  • brachial artery palpated and marked at lateral border of pectoralis muscle
  • line joining these points is made
  • insert needle 2.5-3 cm below midpoint of clavicle at 45-65 degree angle towards axillary artery
50
Q

axillary block

A
  • axillary block is directed at the terminal branches of the brachial plexus
  • excellent block for procedures below the elbow
  • US has made it less attractive
51
Q

axillary block anatomy

A
  • in apex of axilla, the three plexus cords form the main terminal nerves of the upper extremity
  • axillary and musculocutaneous nerves leave the plexus at the level of the coracoid process
52
Q

axillary block landmarks

A
  • pulse of axillary artery
  • coracobrachialis muscle
  • pectoralis major muscle
  • biceps muscle
  • triceps muscle
53
Q

axillary block landmark technique

A
  • arm abducted 90 degrees, elbow flexed
  • arterial pulse palpated at level of major pectoralis muscle
  • nerve stimulator to 0.5-1 mA
  • needle inserted above arterial pulse towards median nerve or below arterial pulse toward radial nerve depending on surgical site
  • as superficial fascia penetrated, click felt and current amplitude increased at 1 mA increments until desired twitch (flexion or extension of wrist and fingers)
  • needle advanced toward stimulated nerve while reducing amplitude
  • once stimulation obtained at current of 0.3-0.5 mA inject local
54
Q

axillary block pearls

A
  • perform pre-procedure scan to ID course of each terminal branch
  • find axis where all nerves can be blocked with a single needle insertion
  • the intercostobrachial nerve (T2) supplies cutaneous innervation of the medial UE
55
Q

lower extremity surgery

A
  • may be athroscopic or open
  • common procedures = athroplasty, fractures, cartilage and ligament repair
  • performed with general or regional
  • patient position dependent upon procedure
56
Q

lumbar plexus

A
  • arises from ventral rami of L1 - L4 (occassionally T12)
  • major nerves = femoral nerve, obturator nerve, lateral femoral cutaneous nerve
  • other nerves = ilioinguinal nerve, iliohypogastric nerve
57
Q

lumbosacral plexus

A
  • arises from L4/5 - S1/5

- major nerve = sciatic nerve

58
Q

hip surgery

A
  • 200,000 replacements annually
  • elective vs traumatic
  • most are frail and elderly (>65 yo) –> additional comorbidities, mortality 10% in hospital, 25% w/in first year
  • blood loss greater with extracapsular (femoral neck, intertrochanteric, subtrochanteric)
  • patients positioned lateral or supine
59
Q

lateral positioning for hip surgery

A
  • head/neck alignment
  • adequate padding of dependent extremities
  • prevention of non-operative extremity nerve injury
60
Q

supine positioning for hip surgery

A
  • IV just be aware of what position is and if you will have access to the arms
  • protection of genitalia
  • traction injury to lower extremities
61
Q

hip surgery anesthetic considerations

A
  • technique varies based on - elective vs traumatic vs revision, patient population, surgeon
  • potential complications = fat embolus, VTE, blood loss
62
Q

hip surgery anesthetic technique regional over general

A
  • less post op cognitive dysfunction
  • superior post op analgesia
  • decreased incidence of DVT and PE
  • rapid post-op rehab
  • reduced cost of medical care
  • neuraxial and peripheral nerve blocks have been used effectively for management
63
Q

regional techniques for hip surgery

A
  • can be used for primary anesthetic and post-op analgesia
  • neuraxial - spinal vs. epidural
  • peripheral nerve blocks - lumbar plexus block (psoas compartment block), single vs continuous, fascia iliaca block
64
Q

knee surgeries

A
  • more than 300,000 performed annually
  • patients most often elderly with comorbidities
  • regional preferred over general
  • complete anesthesia requires both lumbar and lumbosacral blocks
  • procedures associated with SIGNIFICANT post op pain
65
Q

knee arthroplasty anesthetic considerations

A
  • effective post-op pain management is paramount for recovery
  • opioids and neuraxial techniques both have limitations
  • ERAS protocols - multimodal pain management, continuous peripheral nerve block
66
Q

knee arthroplasty

A
  • relatively minor surgery, performed as outpatient
  • patient population will influence anesthetic technique and management
  • peripheral nerve block rarely indicated
67
Q

ACL repair

A
  • more involved than knee arthroplasty but still frequently done outpatient
  • may warrant a continuous peripheral nerve block
  • knee bolster allows lower extremity to hang freely opening joint space
  • non-operative leg support needed to reduce lower back stress
68
Q

Femoral nerve block (FNB)

A
  • targets major branches of lumbar plexus
  • largest branch of lumbar plexus
  • formed by dorsal divisions of anterior rami of L2, L3 and L4 spinal nerves
  • emerges from lateral border of psoas muscle and remains deep to fascia iliaca
  • provides anesthesia to anterior thigh, knee, and medial aspect of lower leg
  • nerve is lateral to artery and deep to fascia lata and iliaca, superior to the iliopsoas muscle
69
Q

FNB landmark

A
  • patient supine, leg abducted 10-20 degrees and externally rotated
  • site of insertion -femoral crease below inguinal crease and immediately lateral (1cm) to femoral artery
  • nerve stimulator - current 1 mA needle introduced at 30-45 degree angle in cephalad direction, advance needle through fascia lata and iliaca (feel pop) as quads muscle contractions are obtained, current decreased while needle advanced
  • adequate position of needle = patellar twitches elecited at current 0.3-0.5 mA
  • inject 15-20 mL LA
70
Q

FNB pearls

A
  • if two arteries seen, scan cephalad and ID single femoral artery
  • doppler used to ID presence or absence of vessels
  • experience suggests that if the needle and LA are placed below the fascia iliaca and lateral to artery, successful blocks occur despite lack of twitches
  • complications avoided by using US
  • caution because lymph nodes can appear as nerves (lymph nodes are not continous while nerves are)
71
Q

fascia iliaca block nerve targets

A
  • femoral n
  • obturator nerve
  • lateral femoral cutaneous nerve
72
Q

adductor canal block (ACB)

A
  • FNB considered gold standard for pain relief post knee arthroplasty, but risk of falls associated with quadriceps muscle weakness
  • ACB provides sensory nerve blockade with minimal motor involvement!
73
Q

ACB pearls

A
  • nerve branches may be located on both sides of the superficial femoral artery, pre-procedure scan will detect any aberrancy and increase block efficacy
  • mytotoxicity if LA is deposited in muscle
  • vastus medialis is consistently blocked too, and may provide greater innervation to knee than previously thought
74
Q

surgery to ankle/foot

A
  • innervation to ankle/foot supplied by femoral and sciatic nerves
  • elective vs traumatic
  • either neuraxial or PNBs are appropriate in combination with general or MAC
  • position depends on procedure
75
Q

saphenous nerve block (thigh)

A
  • saphenous nerve is terminal branch of the femoral nerve
  • distal to the adductor canal the saphenous courses superficially in the distal thigh
  • provides only sensory innervation to medial aspect of lower extremity below the knee
  • used in conjunction with other blocks for surgery involving ankle and foot
76
Q

lumosacral plexus

A

-provides sensory and motor innervation to posterior thigh, knee, and lower extremity below the knee with exception to sensory innervation provided by saphenous nerve

77
Q

popliteal nerve block

A
  • targets sciatic nerve slightly proximal to knee
  • provides anesthesia for procedures involving foot and ankle
  • in popliteal fossa, nerves are bordered superiorly and medially by the semi-tendinosus and semi-membranous muscles and superiorly and laterally by biceps femoris muscles
78
Q

five nerves that supply innervation to foot

A
  • tibial
  • deep peroneal
  • superficial peroneal
  • saphenous
  • sural
79
Q

pneumatic tourniquet

A
  • often used to minimize blood loss and provide bloodless surgical field
  • proper sizing and inflation critical for safe/effective use
  • pressure of inflation depends on patient BP and extremity
  • should not be used longer than 2 hours
  • interrupted blood supply leads to tissue hypoxia and acidosis
  • deflation of cuff - release of metabolic waste
  • tourniquet pain - occurs at 60 min (pain, HTN)
  • known complications
80
Q

polymethylmethacrylate

A
  • acrylic bone cement used in arthroplasty
  • exothermic reaction that results in expansion and hardening of polymer
  • common in elderly patients
  • placement of cement associated with sudden hypotension causing BCIS
81
Q

BCIS

A
  • Bone Cement Implantation Syndrome

- absorption results in - decreased SVR, hypotension, hypoxemia

82
Q

BCIS risk factors

A
  • pre-existing CV disease or pulm HTN
  • ASA class 3 or higher
  • pathologic fracture, intertrochanteric fracture or long-stem arthoplasty
83
Q

BCIS treatment

A
  • D/C nitrous during cementation
  • maximize FiO2
  • euvolemia
  • create vent hole in distal femur
  • high pressure lavage
84
Q

Fat embolism syndrome (FES)

A
  • associated with traumatic injury and surgery to long bones
  • incidence = 3-4%
  • occurs when fat enters the blood stream from the broken bone
85
Q

risk factors for FES

A
  • age 20-30
  • male
  • hypovolemic shock
  • bilateral total knee
  • RA
  • intramedullary instrumentation
86
Q

major S/S FES

A
  • petechia
  • hypoxemia
  • CNS depression
  • pulmonary edema
87
Q

minor S/S FES

A
  • tachycardia
  • hyperthermia
  • retinal fat emboli
  • urinary fat globules
  • decreased plts/Hct
  • increased sed rate
  • fat globules in sputum
88
Q

FES treatment

A
  • early recognitioin
  • reverse contributing factors
  • stabilization of fractures
  • aggressive pulmonary support
  • pharmacologic therapy
89
Q

DVT/PE

A
  • major cause of death following lower extremity trauma or surgery
  • without prophylaxis, DVT develops in 40-80% of patients
  • PE in up to 28%
90
Q

risk factors for DVT/PE

A
  • s/p hip fracture
  • advanced age
  • immobility
  • previous DVT
  • cancer
  • pre-existing hypercoagulable state
91
Q

complications of arthoscopy

A
  • SubQ emphysema
  • pneumomediastinum
  • tension pneumo
  • irrigation 3-5 L irrigating solution bags - make sure to compare fluid in/out; large volumes can lead to volume overload, CHF, pulmonary edema or hyponatremia

N931 Advanced Principles of Anesthesia I (19 decks)

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