Anesthesia for Orthopedics (Part 2)

Question 1

Use of the ____ ____ is a method often used for control of blood loss in orthopedic surgery.

Answer 1

Pneumatic tourniquet

Question 2

A tourniquet is applied after induction of anesthesia and an alarm should be set for ___ mins for monitoring site. A total of ___ hours is considered a safe total time.

Answer 2

-Alarm should be set for 60 mins
-A total time of 2 hours is considered safe
*Document these times (CYA!!)

Question 3

If the safe time limit is exceed for the tourniquet inflation (2hrs) but the surgery is not done, what should we do?

Answer 3

Deflate for 15-20 mins and then it can be reinflated

Question 4

What do we have to be careful with upon deflation of the tourniquet?

Answer 4

Causes massive release of metabolic waste into systemic circulation
-HoTN and hypoxia
-Acidosis
-HyperK
-Myoglobinemia
-Renal failure

Question 5

The first signs of tourniquet pain are seen about how long after inflation?

Answer 5

45-60 mins

Question 6

Tourniquet pain starts as a ___ pain due to activation of __ fibers. It progresses to ___ pain activated by __ fibers.

Answer 6

Dull, aching pain –> C fibers
Sharp, burning pain –> A delta fibers

Question 7

How do we treat tourniquet pain?

Answer 7

Drop tourniquet
-Pain is resistant to pain meds and anesthetic agents

Question 8

_____ events are the leading cause of M&M after orthopedic surgery.

Answer 8

Thromboembolic events
-THA, TKA, Pelvic fx highest risk of VTE / PE

Question 9

Due to the high risk of VTE/PE we will use anticoagulation in orthopedics. This impacts our anesthetic use of what technique?

Answer 9

Regional and neuraxial anesthesia
-LMWH should be started >12 hrs preop or >12 hrs postop

Question 10

Bone cement is used in THA, TKA, and vertebroplasty. What clinical features could alert us of bone cement implantation syndrome?

Answer 10

Hypoxia, HoTN, arrhythmias, unexpected LOC under regional anesthesia

Question 11

What is our anesthetic management of issues with bone cement?

Answer 11

-Communicate with the surgical team
-Optimize these patients hemodynamically before cement installation
-Give 100% FiO2, pressors, IV fluids as needed
-Document cement time (CYA!!)

Question 12

Fat embolic syndrome is a rare problem causing hypoxic respiratory failure due to what?

Answer 12

Long bone or pelvic fractures.
-3% for one bone
-33% if bilateral long bone fx

Question 13

How does FES cause hypoxic respiratory failure?

Answer 13

The fat cells from the bone marrow enter venous circulation and lodge into the pulmonary circuit.

Question 14

FES is typically seen __-__ hours after initial injury. What symptoms will we see?

Answer 14

24-72 hours
Hypoxemia, neurologic impairment, classic petechial rash

Question 15

How do we care for FES pts?

Answer 15

1. Surgical correction of fx ASAP but definitely within 12 hours
2. Supportive care: vent if needed
3. My benefit from corticosteroids IV

Question 16

Direct benefits of regional anesthesia incude:

Answer 16

-Reduced DVT, PE, and blood loss
-Better perioperative pain management
-Possible reduction in opioid use

Question 17

Choice of a specific local anesthetic depends on what three things?

Answer 17

1. Type of peripheral nerve block
2. Purpose of the block
3. Duration of anesthesia needed for surgery

Question 18

What are common additives to prolong our regional blocks?

Answer 18

Epinephrine, clonidine, dexamethasone, opioids

Question 19

Interscalene PNB
Use and Risk

Answer 19

Use: Shoulder and upper arm block
Risk: Risk of ulnar nerve sparing

Question 20

Supraclavicular PNB
Use and Risk

Answer 20

Use: Entire upper arm distal to shoulder
Risk: Risk of pneumothorax

Question 21

Infraclavicular PNB
Use

Answer 21

Use: Elbow and below

Question 22

Axillary PNB
Use and Risk

Answer 22

Use: Distal to elbow
Risk: Risk of vascular injection
Must also block musculocutaneous nerve

Question 23

Periscapular Nerve Group (PENG) Block Use

Answer 23

Hip

Question 24

Femoral/Adductor canal block (Saphenous)

Answer 24

Anterior lower extremity and knee
Medial lower leg

Question 25

Fascia Iliaca block

Answer 25

Anterior lower extremity and knee
Anagelsia for the hip

Question 26

IPACK block

Answer 26

Posterior knee

Question 27

Sciatic/Popliteal block

Answer 27

Posterior lower extremity
Lateral below the knee
Foot

Question 28

Ankle block

Answer 28

Foot