Anesthesia for Orthopedics (Part 2) Flashcards
Use of the ____ ____ is a method often used for control of blood loss in orthopedic surgery.
Pneumatic tourniquet
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.
-Alarm should be set for 60 mins
-A total time of 2 hours is considered safe
*Document these times (CYA!!)
If the safe time limit is exceed for the tourniquet inflation (2hrs) but the surgery is not done, what should we do?
Deflate for 15-20 mins and then it can be reinflated
What do we have to be careful with upon deflation of the tourniquet?
Causes massive release of metabolic waste into systemic circulation
-HoTN and hypoxia
-Acidosis
-HyperK
-Myoglobinemia
-Renal failure
The first signs of tourniquet pain are seen about how long after inflation?
45-60 mins
Tourniquet pain starts as a ___ pain due to activation of __ fibers. It progresses to ___ pain activated by __ fibers.
Dull, aching pain –> C fibers
Sharp, burning pain –> A delta fibers
How do we treat tourniquet pain?
Drop tourniquet
-Pain is resistant to pain meds and anesthetic agents
_____ events are the leading cause of M&M after orthopedic surgery.
Thromboembolic events
-THA, TKA, Pelvic fx highest risk of VTE / PE
Due to the high risk of VTE/PE we will use anticoagulation in orthopedics. This impacts our anesthetic use of what technique?
Regional and neuraxial anesthesia
-LMWH should be started >12 hrs preop or >12 hrs postop
Bone cement is used in THA, TKA, and vertebroplasty. What clinical features could alert us of bone cement implantation syndrome?
Hypoxia, HoTN, arrhythmias, unexpected LOC under regional anesthesia
What is our anesthetic management of issues with bone cement?
-Communicate with the surgical team
-Optimize these patients hemodynamically before cement installation
-Give 100% FiO2, pressors, IV fluids as needed
-Document cement time (CYA!!)
Fat embolic syndrome is a rare problem causing hypoxic respiratory failure due to what?
Long bone or pelvic fractures.
-3% for one bone
-33% if bilateral long bone fx
How does FES cause hypoxic respiratory failure?
The fat cells from the bone marrow enter venous circulation and lodge into the pulmonary circuit.
FES is typically seen __-__ hours after initial injury. What symptoms will we see?
24-72 hours
Hypoxemia, neurologic impairment, classic petechial rash
How do we care for FES pts?
- Surgical correction of fx ASAP but definitely within 12 hours
- Supportive care: vent if needed
- My benefit from corticosteroids IV
Direct benefits of regional anesthesia incude:
-Reduced DVT, PE, and blood loss
-Better perioperative pain management
-Possible reduction in opioid use
Choice of a specific local anesthetic depends on what three things?
- Type of peripheral nerve block
- Purpose of the block
- Duration of anesthesia needed for surgery
What are common additives to prolong our regional blocks?
Epinephrine, clonidine, dexamethasone, opioids
Interscalene PNB
Use and Risk
Use: Shoulder and upper arm block
Risk: Risk of ulnar nerve sparing
Supraclavicular PNB
Use and Risk
Use: Entire upper arm distal to shoulder
Risk: Risk of pneumothorax
Infraclavicular PNB
Use
Use: Elbow and below
Axillary PNB
Use and Risk
Use: Distal to elbow
Risk: Risk of vascular injection
Must also block musculocutaneous nerve
Periscapular Nerve Group (PENG) Block Use
Hip
Femoral/Adductor canal block (Saphenous)
Anterior lower extremity and knee
Medial lower leg
Fascia Iliaca block
Anterior lower extremity and knee
Anagelsia for the hip
IPACK block
Posterior knee
Sciatic/Popliteal block
Posterior lower extremity
Lateral below the knee
Foot
Ankle block
Foot
