anesthesia for orthopedic surgery Flashcards
1
Q
what are common characteristics seen with orthopedic patients?
A
- many have arthritic joints/deformities
- many have limited ROM in neck
- require careful positioning
- may need help moving to OR table
- fracture patients may have full stomachs
- may have increased bleeding
- increased risk of fat emboli, DVT, and PE
- exposure to large amounts of radiation
- 80% young and healthy; 20% old w/ fall or bad arthritis (inactive)
2
Q
describe rheumatoid arthritis
A
- immune related, progressive inflammation of synovial joints (not just joint wear and tear)
- systemic manifestations
- multiple joint involvement, deformity
- chronic NSAID use (GI bleeding, renal toxicity, platelet dysfunction)
3
Q
what are issues seen r/t joint deformity?
A
- invasive lines and monitoring challenges
- immobility and decreased endurance of patients
- cervical and TMJ issues: check neck ROM, mouth opening
- atlantoaxial subluxation: C-spine films to evaluate and determine if fiberoptic intubation is indicated if greater than 5 mm instability exists
- cricoarytenoid arthritis: hoarseness, airway obstruction
4
Q
what are CV effects of rheumatoid arthritis?
A
- pericardial thickening and effusions
- myocarditis
- coronary arteritis
- conduction defects
- cardiac valve fibrosis (AR)
5
Q
what are pulmonary effects of rheumatoid arthritis?
A
- pleural effusions
- pulmonary nodules
- interstitial pulmonary fibrosis
6
Q
what are hematological effects of rheumatoid arthritis?
A
- anemia
- platelet dysfunction
- thrombocytopenia
7
Q
what are endocrine effects of rheumatoid arthritis?
A
- adrenal insufficiency (on steroid treatment)
- impaired immune system
8
Q
what are dermatologic effect of rheumatoid arthritis?
A
thin atrophic skin
9
Q
describe positioning for orthopedic cases
A
- usu. done after pt. is anesthetized
- usu. supine, sitting lateral decubitus or prone
- protect face from injury: eyes/nose, pad face
- sitting increases risk for air embolus: head and neck neutral position; avoid N2O
- arms over chest may impede ventilation
- sitting can reduce CPP
- stretch injuries
10
Q
describe used of regional anesthesia for orthopedic cases
A
- excellent advantages but can be unreliable
- supplement w/ IV opioids
- may use more for upper extremity surgery
- may be used in combo w/ GA for post op pain control
- reduced blood loss in some surgeries
- bier block commonly w/ wrist and hand surgeries
- neuraxial or peripheral nerve catheters allow continuous infusions in the post op period
11
Q
describe shoulder surgery
A
- lateral or “beach chair” position (lateral is best)
- open or arthroscopic (90%) technique
- positioning challenge: ears, eyes, boney areas
- may use LMA
- interscalene block combine w/ GA
- controlled hypotension (low 90s systolic allows surgeon to see shoulder joint)
- irrigation pressure during arthroscopic surgery must be higher than systemic pressure (too high can lead to injury)
- associated w/ nerve injury
- VAE possible in “beach chair” position
12
Q
how can CPP be estimated?
A
- level of the external auditory meatus and tragus correlates w/ the Circle of Willis, where CPP can be measuered
- lower pressure than level of heart d/t the vertical column and hydrostatic pressure difference
- *each 10 cm distance from heart equals 7.5 mmHg lower
13
Q
describe arthroscopic surgery
A
- knee, shoulder, elbow, wrist, hip , ankle
- less invasive w/ reduced blood loss
- bloodless surgical field
- minor incision w/ less post op pain
- reduced blood pressure on non tourniquet joints optimizes surgical field
- irrigation fluid 60-80 mmHg distends joint
- high pressure w/ long duration associated w/ sub q emphysema and tension pneumothorax
- keep systemic BP as low as possible to still maintain CPP so surgeons won’t have to increase their pressure
14
Q
describe spinal surgery
A
- most often to decompress cord or nerve root
- neuro and ortho surgeons perform
- multilevel instrumentation w/ plates, rods, and screws for spinal instability
- GA w/ or w/o paralysis
- if transthoracic, may need to deflate the lung
- airway challenges: prone position, cervical immobility
- can be done posterior or anterior approach
- may develop CSF leak requiring a vital capacity maneuver (VCM or valsalva)
15
Q
describe cervical spine surgery considerations
A
- prone, sitting, or supine position
- arthritic conditions may cause ROM issues (may require FO)
- major arteries and veins are near by (check distal pulses; can use ear probe oximeter)
- potential recurrent laryngeal nerve injury (some surgeons don’t allow muscle relaxant use)
- airway swelling could be post op issue
- identify and document preexisting neuro deficits
- prevent too much neck and head traction (pad)
- coughing or bucking must be prevented (LTA kit)
16
Q
what arthritic conditions may cause ROM issues?
A
- TMJ dysfunction: limited jaw opening
- atlantoaxial instability: limited neck ROM
- potential airway management challenge, may require F/O intubation
