Anesthesia for Orthopedics (Part 1)

Question 1

Normal preoperative tests before a total joint replacement

Answer 1

-Check current meds (especially anticoagulants)
-CBC, BMP, Type and Screen, UA

Question 2

For surgical site infection prevention we will give what? When do we give it?

Answer 2

Cefazolin (Ancef) 1-2g IVPB
Should be given within 1 hour of incision
-If over 100kg give 2g

Question 3

If they need to get another antibiotic due to allergy, it will be ____.

Answer 3

Vancomycin OR clindamycin Thanks Dana!!
-Give within 2 hours of cut time

Question 4

Osteoarthritis is what?

Answer 4

Degeneration of articular cartilage with inflammation and pain with joint motion

Question 5

T/F: Rheumatoid arthritis is the most common form of arthritis and effects 21% of US adults.

Answer 5

WRONGO.
-Osteoarthritis is actually the most common and it effects 21% of US adults.
-Prevalence is also going up due to aging population and obesity.

Question 6

Osteoarthritis is classified as being the leading cause of ____ ____ ____.

Answer 6

Lower extremity disability
-Knee highest risk at 46%
-Hip at 25%

Question 7

OA can be diagnosed ____, ____, and ____.

Answer 7

Radiographically, pathologically, or clinically.
-Radiographically most common (Kellgren-Lawrence grading system)

Question 8

OA defined by what symptoms?

Answer 8

Pain, stiffness, decreased ROM, NO SYSTEMIC involvement
-Knees, hips, first metacarpal, distal interphangeal joints most commonly affected

Question 9

____ is the main manifestation of OA that eventually causes the pt to seek care.

Answer 9

Pain

Question 10

OA management includes

Answer 10

Non-pharm and pharm interventions
-Weight loss, exercise, physiotherapy, bracing
-NSAIDs, opioids, local injections
-Surgery

Question 11

Huge part of OA history/physical for anesthesia

Answer 11

-C-spine involvement
-Chart existing deficits (CYA!!!)
-Look over current med regimen

Question 12

Rheumatoid Arthritis is what?

Answer 12

Autoimmune mediated SYSTEMIC inflammatory disease
-Pain and disability from destruction of synovial joints

Question 13

RA characterized by what big symptom?

Answer 13

Morning stiffness that improves over the course of the day

Question 14

___ and ____ play a role in RA pathogenesis.

Answer 14

Cytokines and B lymphocytes
-B cells –> rheumatoid factor
-Cytokines –> infllammation cascade

Question 15

RA Med Concerns
NSAIDs

Answer 15

D/c 2 days prior to surgery
Renal function, coags

Question 16

RA Med Concerns
DMARDs

Answer 16

Check CBC and LFT
-Due to pancytopenia and liver harm

Question 17

DMARD are the only drugs that have the capability to do what in RA patients?

Answer 17

Only drugs that can slow down progression and prevent deformities

Question 18

RA Med Concerns
Corticosteroids

Answer 18

Impair wound healing and maybe enhance surgical infection risk

Question 19

RA Med Concerns
Leflunomide (never heard of her)

Answer 19

Check CBC and LFT
-Due to hepatotoxicity and pancytopenia

Question 20

RA Med Concerns
TNF inhibitors (Etanercept)

Answer 20

Infection risk

Question 21

RA Med Concerns
IL-1 Antagonist (Anakinra)

Answer 21

Infection risk

Question 22

RA physical exam concerns

Answer 22

C SPINE INSTABILITY (can be asymptomatic in up to 80% of pts)
-Atlanto-axial instability
-Atlanto-occipital subluxation
-Cranial settling onto c1
-Ankylosis in late stages
TMJ disease
Arytenoid disease / VC dysfunction
Srojen’s

Question 23

T/F: As cord compression worsens in RA, so do the patient’s symptoms.

Answer 23

FALSE.
-A high percentage of these patients are asymptomatic and symptoms do not necessarily align with severity of compression.

Question 24

You knew it was coming - biggest difference between OA and RA?

Answer 24

OA has no systemic effects
-RA with fever, weight loss, fatigue, myalgias, decreased appetite, Srojen’s

Question 25

Ankylosing Spondylitis is what?

Answer 25

Chronic progressive inflammation of spine and thorax

Question 26

Ankylosing Spondylitis is characterized by what?

Answer 26

1. Lower back pain with morning stiffness (referred pain to butt)
2. Bamboo Spine radiograph
   -Affects sarcoiliac joints and progresses cephalad

Question 27

AS most commonly effects __-__ vertebrae

Answer 27

C5-C7 –> have multiple airway plans!

Question 28

Biggest AS symptom CV related:

Answer 28

Aortic valve insufficiency
-Seen in 40% of patients

Question 29

What are big anesthesia concerns for these joint conditions - AS, OA, RA:

Answer 29

-Airway management –> we need thorough preoperative exams and preparation for tough airway
-Positioning –> we should plan to position these patients comfortably AND THEN induce
-Tough neuraxial –> limited spinal flexion and increased ossification of ligaments
-If using regional anesthesia, first check for neuropathy and chart (CYA!!)

Question 30

Involvement of the cricoarytenoid joint, cricothyroid joint, temporomandibular joint, and associated structures in the larynx is found in ___% of RA patients.

Answer 30

90%
-This can lead to postoperative airway obstructions and also can make their initial airway placement more difficult.

Question 31

T/F: Early implementation of conservative measures have proven to be useful in preventing kyphoscoliosis patients from needing corrective surgery.

Answer 31

FALSE.
-Over 80% of these patients have an idiopathic form.
-Surgery is indicated to prevent long-term ventilatory compromise when curvature exceeds 40 degrees.

Question 32

Kyphoscoliosis causes severe ____ pulmonary disease.

Answer 32

Restrictive

Question 33

The most important preoperative anesthesia implication for kyphoscoliosis pts is what?

Answer 33

Optimization of cardiopulmonary status.
-Remove airway irritants, treat infections, steroids for inflammation, treat GERD
-Pulmonary prehabilitation is great but often not covered by insurance and can be expensive –> incentive spirometer is free!

Question 34

Some important intraoperative anesthesia implication for kyphoscoliosis pts is what?

Answer 34

-Good access and proper positioning
-Invasive monitoring
-SSEP and MEP use (no NMB with MEP)
-EDUCATE if possible wake up test
-Optimization of blood plan
-Prepare for ICU postop