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Pharm Final review > Anesthesia for Orthopedics and Podiatry > Flashcards

Anesthesia for Orthopedics and Podiatry Flashcards

1
Q

Purpose of the Pneumatic Tourniquet

A

Maintains a relatively bloodless field during intraoperative blood loss

Aids in the identification of vital structures

Expedites the procedure

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2
Q

Components of the tourniquet

A

Inflatable cuff
Connective tubing
A pressure device
A timer

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3
Q

Safety Measures for Preventing Tourniquet Complications

A

Tourniquet should be applied where the nerves are best protected in the underlying musculature

Test equipment for proper functioning before use

Tourniquet should not be used for > 2 hours

Use the widest cuff possible (use lower cuff pressure to occlude the
blood flow)

A minimum of 2 layers of padding should be placed around the extremity

Tourniquet size should be half the limb diameter and the cuff should overlap 3-6 inches

Tourniquet size should allow placement of 2 fingers between the tourniquet and the cast padding

When possible, extremity should be exsanguinated prior to tourniquet inflation

Only minimally effective pressure should be used for occluding blood flow:

Upper extremity: 70-90 mm Hg > SBP

Lower extremity: 2X the SBP

The pressure display must accurately reflect the pressure in the tourniquet bladder

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4
Q

Use the ____ cuff possible (use ___ cuff pressure to occlude the blood flow)

A

widest, lower

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5
Q

Tourniquet size should be ____ the limb diameter and the cuff should overlap ___to___ inches

A

half, 3-6 inches

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6
Q

Only minimally effective pressure should be used for occluding blood flow:
Upper extremity: __to__ mm Hg > SBP
Lower extremity: ___ the SBP

A

Upper extremity: 70-90 mm Hg > SBP

Lower extremity: 2X the SBP

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7
Q

Physiologic Changes Caused by Limb Tourniquets: neuro

A

Abolition of somatosensory evoked potentials and nerve conduction occurs within 30 minutes

> 60 minutes tourniquet time causes tourniquet pain and hypertension

> 2 hours tourniquet time may result in postoperative neurapraxia

Evidence of nerve injury may occur at the skin level underlying the edge of the tourniquet

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8
Q

Physiologic Changes Caused by Limb Tourniquets: muscle

A

Cellular hypoxia develops within 2 minutes

Cellular creatinine level declines

Progressive cellular acidosis occurs

Endothelial capillary leak develops after 2 hours

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9
Q

Systemic Effects of Tourniquet Inflation

A

Elevations in arterial and pulmonary artery pressure occur (this is usually slight to moderate if only one limb is occluded)

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10
Q

Systemic Effects of Tourniquet Release

A

Transient decrease in core temperature

Transient metabolic acidosis

Transient decrease in central venous oxygen tension occurs, but systemic hypoxemia is unusual

Acid metabolites (i.e., thromboxane) are released into the central circulation

Transient fall in pulmonary and systemic arterial pressure occurs

Transient increase in end-tidal carbon dioxide occurs

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11
Q

Non-Pneumatic Tourniquets

A

A silicone ring tourniquet (SRT) may be used for brief procedures

Consists of a silicone ring wrapped in a sleeve, with 2 pull handles connected by straps

At the end of surgery, the silicone ring tourniquet is removed by cutting the silicone ring

These tourniquets are not electronic. Therefore, tourniquet time must be closely monitored.

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12
Q

Tourniquet Pain

A

Tourniquet pain occurs 45-60 minutes after tourniquet inflation

Once the pain begins, it is resistant to analgesics and anesthetic agents, regardless of anesthetic technique

Ischemic pain of associated with tourniquet application is similar to the pain of thrombotic vascular occlusion and peripheral vascular disease

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13
Q

What are the symptoms of tourniquet pain?

A

Dull aching, which progresses to burning and excruciating pain that may require general anesthesia

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14
Q

The specific neural and metabolic factors responsible for tourniquet pain are still unknown, but researchers have identified the nerve fibers responsible for transmitting the impulses:

A

Small and slow unmyelinated C fibers:
Responsible for burning and aching

Large, fast myelinated A-delta fibers:

Responsible for pinprick, tingling, and buzzing sensations

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15
Q

Small and slow unmyelinated C fibers responsible for

A

burning and aching

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16
Q

Large, fast myelinated A-delta fibers are responsible for

A

pinprick, tingling, and buzzing

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17
Q

*True/False: Properly placed tourniquets inflated to appropriate pressures rarely cause injury

A

TRUE!

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18
Q

Prevention of post-op parasthesias

A

Use of proper padding

Appropriate choice of tourniquet size

Following recommendations for appropriate tourniquet pressure and usage time minimizes the incidence of complications

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19
Q

Goals of patient positioning

A

Optimal exposure of the surgical site

Protect all body systems

Enable appropriate monitoring throughout the procedure

Provide good access to the patient’s airway

Allow for comfort and warmth

Minimize or prevent physiologic functioning compromise

Protect all body systems

Maintain patient dignity

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20
Q

How is arthroscopy managed?

A

Can be managed by any available anesthetic technique:

General anesthesia

Combined regional and general anesthesia

Local blockade with sedation

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21
Q

Positioning for arthoscopy

A

Lower extremity arthroscopy:
Most often the supine position

Shoulder arthroscopy:
Lateral decubitus or “beach chair” position

Elbow arthroscopy:
Supine, lateral decubitus, or prone

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22
Q

What are the complications of arthoscopy?

A

Subcutaneous emphysema

Pneumomediastinum

Tension pneumothorax

Fluid volume overload due to irrigation fluid

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23
Q

What are the benefits of arthoscopy?

A

Minimally invasive, reduced blood loss, less post-op discomfort, reduced length of rehab

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24
Q

Signs and Symptoms of Tension Pneumothorax

A

Sudden, inexplicable hypoxemia

Elevated central venous pressure (CVP)

Tachycardia

Absent breath sounds on the affected side

Cyanosis

Diaphoresis

Decreasing oxygenation

Tracheal shift (away from the pneumothorax)

Agitation (may be observed in patients receiving regional anesthesia)

Hypotension

Jugular vein distention

Increased airway pressure

Asymmetric chest wall movement

Percussive hyperresonance over the affected side

Extreme anxiety (may be observed in patients receiving regional anesthesia)

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25
Q

Position related complications of beach chair

A

hypotension and bradycardia with interscalene blocks

air embolism/pneumo

DVT

unilateral vision loss

cerebral hypoperfusion

cervical plexus and hypoglossal nerve neurapraxias

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26
Q

Position related complications of lateral decubitus

A

temporary parasthesia

neurapraxis of the dorsal digital nerve of the thumb and musculoscutaneous, ulnar, axillary nerves

permanent neuropraxia

post-op stroke

DVT

fluid-related airway compromise

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27
Q

How to prevent position injuries with these..

A

beach chair - use level of brain systolic, attention to head positioning, prophylaxis for hypotensive bradycardic episodes

lateral decub - 45 degrees of forward flexion with 90 degrees abduction

45 degrees forward flexion with 0 degrees abduction

general anesthesia for longer cases

place anterior inferior portal out of traction

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28
Q

Arthroplasty terms

A

Total Arthroplasty:
Replacement of all of the joint

Hemiarthroplasty:
Replacement of part of the joint

Joint materials:
Originally stainless steel
Currently use nonferrous metal alloys (cobalt or titanium)

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29
Q

What is the most common approach for hip surgery?

A

Posterior approach

Requires a large incision extending from near the iliac crest across the joint to the midthigh level

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30
Q

What is the purpose of the direct anterior approach for hip surgery?

A

Minimally invasive, muscle-sparing approach with shorter incision

Benefits:
Shorter hospital stay
Faster postoperative recovery

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31
Q

What is the positioning for the two methods of hip surgery?

A

Posterior approach: Lateral decubitus

Anterior approach: Supine

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32
Q

Are hip surgery patients at an increased risk for VTE, DVT, and P.E’s?

A

Yes.

Treatment up to 35 days

Prevention of VTE:
Anticoagulation therapy (i.e, LMWH)

Intermittent pneumatic compression device (IPCD) for 10-14 days

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33
Q

What is the prevention for DVT/PE with hip surgery?

A

Anticoagulation therapy (i.e, LMWH)

Intermittent pneumatic compression device (IPCD) for 10-14 days

Treatment up to 35 days

34
Q

What facilitates the surgical process for hip arthroplasty?

A

The muscle relaxation produced by a subarachnoid block (SAB)

35
Q

What type of anesthesia is common for total hip arthroplasty?

A

Regional anesthesia is common

36
Q

What is bone cement implantation syndrome (BCIS)?

A

Hypoxia, hypotension, cardiac arrhythmias, increased pulmonary vascular resistance and cardiac arrest

Methyl methacrylate (MMA) may be instilled into the femoral canal

Usually occurs at the following stages of surgery: femoral canal reaming, acetabular or femoral cement implantation, insertion of prosthesis or joint reduction, and occasionally after tourniquet deflation

37
Q

*What is the first sign of clinically significant BCIS?

A

absence of EtCO₂ in a patient under general anesthesia

38
Q

What are the clinical features for BCIS in the awake patient under regional anesthesia?

A

dyspnea and altered sensorium

39
Q

What is the treatment for BCIS?

A

Increase FiO₂ to 100%
Aggressive fluid resuscitation
Treat hypotension with α-agonists

40
Q

What increases the risk of getting BCIS?

A

Preexisting cardiovascular disease

Preexisting pulmonary hypertension

American Society of Anesthesiologists (ASA) class III or higher

New York Heart Association class 3 or 4

Canadian Heart Association class 3 or 4

Surgical technique

Pathologic fracture

Intertrochanteric fracture

Long-stem arthroplasty

41
Q

Risk of BCIS increased by what during total knee arthroplasty?

A

Both FEMORAL and TIBIAL surfaces are covered with MMA cement

The high-density polyethylene patellar component is cemented and seated with a vise-like clamp

42
Q

Are tourniquets used during total knee arthoplasty and ankle arthroplasty?

A

Yes

DVT, PE and fat embolus are a risk of ankle arthroplasty thromboprophylaxis

43
Q

Most popular intraarticular procedures for ankle arthroplasty

A

Osteochondral lesion

Ankle or subtalar debridement

Subtalar fusion

Partial talectomy

44
Q

Most common extraarticular procedures

A

Os trigonum excision
Tenolysis of the flexor hallucis longus tendon
Endoscopic partial calcanectomy

45
Q

Anesthetic Management of Knee and Ankle Arthroplasty

A

Regional or General anesthetic (or a combination)

Regional anesthesia combining femoral and sciatic nerve blocks are sufficient for all surgeries below the knee that do not require a thigh tourniquet

The femoral nerve innervates the medial leg to the medial malleolus

The common peroneal and tibial nerve (branches of the sciatic nerve) innervate the rest of the leg below the knee, including the foot

46
Q

Regional anesthesia combining which nerve blocks are sufficient for all surgeries below the knee that do not require a thigh tourniquet?

A

Femoral and sciatic nerve blocks

47
Q

Upper Extremity Arthroplasty: Shoulder Arthroplasty

A

Reverse Total Shoulder Arthroplasty provides a better treatment option for more complex pathologies, rotator cuff tears, and revision of failed TSA

48
Q

Best for shoulders?

A

RTSA

49
Q

Indications for TSA/RTSA:

A

Posttraumatic brachial plexus injuries

Paralysis of deltoid muscle and rotator cuff

Chronic infection

Failed revision arthroplasty

Severe refractory instability

Proximal humerus fracture

Bone deficiency after resection of a tumor in the
proximal aspect of the humerus

50
Q

What are the two goals of TSA/RTSA?

A

Pain reduction and Improved range of motion

51
Q

Positions for shoulders

A

beach chair and lateral decubitus

52
Q

Why are shoulder associated with more blood loss?

A

Because you can’t use a pneumatic turniquet

53
Q

Elbow arthroplasty positions

A

supine, lateral, prone

54
Q

Indications for elbows

A

Rheumatoid arthritis
Traumatic arthritis
Ankylosis of the joint

55
Q

Goals for elbows

A

Pain reduction
Improved joint function

56
Q

What type of anesthesia do you use for upper extremity arthroplasty?

A

Supraclavicular block or interscalene block

Combined general/regional anesthesia commonly used

57
Q

Anesthetic considerations for upper extremity arthroplasty

A

Be vigilant re: the risk of extubation

Surgical manipulation can increase risk of cervical injury

Monitor patient’s eyes for pressure throughout the procedure - consider foam goggles

58
Q

Beach chair issues with upper extremity arthroplasty

A

Pulmonary function will resemble more “normal” function than lateral position

Increased risk of venous air embolism

*Reaming of the shaft of the humerus leads to risk of fat or bone marrow embolism

Cerebral ischemia can occur with hypotension

Significant hydrostatic gradient between the brain and the site of BP measurement
**Approximately 2 mm Hg per 1 inch of height differential

59
Q

*What is the difference between arm cuff measurement and brain pressure with beach chair?

A

**Approximately 2 mm Hg per 1 inch of height differential

60
Q

What leads to risk of fat or bone marrow embolism in beach chair position with upper extremity athroscopy

A

*Reaming of the shaft of the humerus leads to risk of fat or bone marrow embolism

61
Q

Postoperative visual loss

A

A result of intraoperative cerebral ischemia due to hypotension

62
Q

What defines Hypotensive bradycardic episodes (HBEs)

A

Decrease in HR of at least 30 bpm within a 5-minute interval, any HR < 50 bpm

and/or a decrease in systolic BP of more than 30 mm Hg in a 5-minute interval or any systolic BP < 90 mm Hg

63
Q

What is the most common mechanism of hypotensive bradycardic episodes?

A

The Bezold-Jarisch Reflex

64
Q

Hypotensive Bradycardic Episodes (HBEs) and the bezold-jarisch reflex

A

An inhibitory reflex mediated through cardiac sensory receptors with a vagal efferent limb.

Clinically, the Bezold-Jarisch reflex is an inhibitory reflex usually denoted as a cardioinhibitory reflex defined as bradycardia, vasodilation, and hypotension resulting from stimulation of cardiac receptors

In the beach chair position, venous pooling in the lower extremities leads to an increase in sympathetic tone and ultimately a low-volume, hypercontractile ventricle

Cardiac hypercontraction leads to activation of the Bezold-Jarisch reflex with an abrupt autonomic withdrawal of sympathetic response and activation of increased vagal tone

The combination of venous pooling and paradoxical increased vagal tone results in sudden, profound bradycardia and hypotension that can be difficult to reverse rapidly

65
Q

*Prophylaxis of HBEs

A

Aggressive treatment of fluid deficits and blood loss

Minimize venous pooling in the beach chair position with support stockings

With regional anesthesia, avoid use of local anesthetics using epinephrine
- Absorbed slowly, mimicking low-dose IV
epinephrine administration
- Increased cardiac contractility
- Resulting in ventricular emptying
- Increased heart rate (which reduces cardiac
filling)
- Increased peripheral vasodilation and pooling
(decreased afterload)
- Resulting in ventricular hypovolemia with
hypercontraction

Consider intraoperative β-blockade in select patients

66
Q

Most common position for spinals

A

prone

67
Q

Most Common Indications for spines:

A

Intervertebral disc herniation
Spinal stenosis
Scoliosis

68
Q

Laparoscopic approach
Contraindications for spinal surgery:

A

Abdominal adhesions

Abdominal trauma

Severe cardiac or pulmonary disease (may not tolerate hypercarbia from insufflation)

Thoracic approach contraindicated in patients that cannot tolerate one lung ventilation

Patients requiring extensive instrumentation of the anterior spine

69
Q

Anesthetic Challenges for spinal surgery

A

Airway control
Positioning
Fluid and blood transfusion management
Hemodynamic control
Postoperative analgesia

70
Q

Advantages for laparoscopy for anterior spinal surgery

A

Slide 30.

So many things.

Shorter rehab, better view, decreased infection, better cosmetics, etc.

71
Q

Anesthesia for spines

A

General

72
Q

Patient Positioning for spines

A

Prevent eye injury/corneal abrasions

Use rolls or positioning devices to prevent abdominal compression in the prone position to prevent:
- Displacement of organs (including diaphragm) cephalad
Reduced functional residual capacity (FRC)
Reduced tidal volume (TV)
Increased airway pressures

Engorgement of the epidural venous network
Contributes to increased blood loss

73
Q

Symptoms of aortic injury during a spine

A

Suspect with sudden, dramatic, unanticipated, sustained hypotension

74
Q

Main causes of post-op visual loss

A

Ischemic optic neuropathy
Retinal vascular occlusion

75
Q

Spinal Surgery: Postoperative Visual Loss (POVL) risk factors

A

Male sex

Obesity

Use of Wilson frame

Anesthesia duration > 6 hours

Large blood loss

Colloid as percent of nonblood fluids

76
Q

Spinal Surgery: Postoperative Visual Loss facts

A

Visual loss occurs 24 to 48 hours after surgery

Usually bilateral

Painless vision loss

Afferent pupil defect or nonreactive pupil

No light perception

Decreased or absent color vision

Elevated intraocular pressures (IOP) > 40 mm Hg

77
Q

Positioning to avoid visual loss during spines

A

Position patient’s head in a neutral position level with or above the heart

Use a foam headrest

Do NOT cover the eves with goggles when using a square foam headrest

Perform and document eye checks every 20 minutes

78
Q

Recommendations from task force for visual loss

A
  1. Consider informing patients who will undergo spine operations in the prone position anticipated to involve prolonged duration and/or substantial blood loss that they have a small but unpredictable risk of perioperative visual loss.
  2. Continually monitor systemic blood pressure.
  3. Colloids should be used along with crystalloids for maintaining euvolemia.
  4. Hemoglobin or hematocrit values should be monitored periodically during surgery, but no optimal transfusion threshold to prevent perioperative visual loss has been identified.
  5. The decision to use α-adrenergic agents should be made on a case-by-case basis.
  6. Direct pressure on the eye should be avoided to prevent central retinal artery occlusion.
  7. Position the head in a neutral position with the face down and the head level with or higher than the heart to minimize venous outflow obstruction.
  8. Consider staging very prolonged procedures in high-risk patients with careful consideration of the risk: benefit ratio.
  9. Assess vision when the patient becomes alert.
  10. An urgent ophthalmologic consultation should be obtained if there is concern for postoperative visual loss.
  11. Consider optimizing hemoglobin, hematocrit, hemodynamic status, and arterial oxygenation.
  12. Consider magnetic resonance imaging to rule out intracranial causes of visual loss.
  13. Antiplatelet agents, steroids, or intraocular pressure–lowering agents have not been shown to be effective for treatment of perioperative ION.
79
Q

Foot and Ankle Surgery

A

Most common ankle procedures:
Repair of ankle fracture
Ankle fusion
Achilles tendon repair

Most common foot procedures:
Bunionectomy
Hammertoe correction
Plantar fasciotomy

Anesthetic Management:
Regional anesthesia
MAC anesthesia
General anesthesia

80
Q

Forearm and Hand Surgery

A

Indications:
Fractures
Nerve compression (carpal tunnel release)

Anesthetic Management:
Full stomach? (traumatic injury)
Regional anesthesia
IV regional (Bier block)
Brachial plexus block
Tourniquet pain with prolonged procedure and regional anesthesia

MAC anesthesia

General anesthesia

81
Q

Rheumatoid Arthritis (RA):

A

The most prevalent chronic systemic inflammatory disease

Autoimmune disease

Signs and symptoms:
Joint swelling
Joint tenderness
Destruction of synovial joints

Anesthetic concerns:
Airway!
- Effects on cervical spine, temporomandibular
joint, larynx, and pulmonary system
- Limited ROM

*Cricoarytenoid joints are common sites for rheumatoid nodule deposition

82
Q

Ankylosing Spondylitis (AS):

A

Chronic inflammatory process

Primary target: Spinal column and surrounding tissues

Additional effects:
- Cardiac valve dysfunction
- Conduction delays
- Bundle branch blocks
- Restrictive lung disease

Anesthetic Management:
Airway!
- Position patient so no neurologic symptoms
are present prior to induction of anesthesia
- Cervical spine in neutral position

Regional anesthesia is a safe approach

Pharm Final review (24 decks)

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