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Anesthesia Principles 1 > Anesthesia for Orthopedics (Part 3) > Flashcards

Anesthesia for Orthopedics (Part 3) Flashcards

1
Q

What is arthroscopy?

A

Minimally invasive surgery performed to examine and sometimes repair damage to the interior of a joint
-Can use any type of anesthesia, pt dependent

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2
Q

Pt positioning for arthroscopy

A

Lower extremity: supine
Hip: lateral or supine
Shoulder: modified fowler (beach) or lateral

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3
Q

Arthroscopy uses fluid instilled under pressure for visualization. This can cause what?

A

Fluid overload, CHF, pulmonary edema, hyponatremia, hypothermia

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4
Q

For each CM of head elevation above the heart we see a ___mmHg reduction in MAP

A

0.75 mmHg per cm
2 mmHg per inch

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5
Q

The ___-____ reflex can cause issues in shoulder surgery with an interscalene block in the sitting position.

A

Bezold-Jarisch

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6
Q

The Bezold-Jarisch reflex effects are seen as profound ____ and ____.

A

Hypotension and bradycardia

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7
Q

What is arthroplasty?

A

Surgical replacement of a joint to restore motion and function

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8
Q

Nearly ___% of hip arthroplasty patients are also obese.

A

50%
-This adds a whole new level of complication by bringing in all anesthesia obesity considerations.

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9
Q

The ____ approach is most common for THA.

A

Posterior approach - involves incision from iliac crest across joint to midthigh (lateral position)
-A direct anterior approach is growing as it is available as minimally invasive (supine)

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10
Q

The THA anesthetic plan usually includes ____ anesthesia unless contraindicated.

A

Regional

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11
Q

The use of ____ ____ inhibits fibrinolysis and is used in THA to cut down blood loss.

A

Transexamic acid (TXA) 1-2g

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12
Q

TKA are commonly done with the ___ ___ block and in what position?

A

Usually GA with adductor canal block in the supine position

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13
Q

____ ____ is used for assisting in blood loss.

A

Transexamic acid (TXA) 1-2g
-Also the pneumatic tourniquet around the thigh

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14
Q

Anesthesia options for ankle arthroplasty?

A
  1. Tourniquet and spinal/epidural
  2. Combination of regional techniques for intra and postop
  3. Sciatic and femoral blocks - work for all below knee
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15
Q

Some big issues with shoulder arthroplasty?

A

Cerebral ischemia
POVL
Bezold-Jarisch (sitting position, interscalene block)

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16
Q

When surgery is performed in the sitting position, what are some things we need to take into account?

A

Lower venous return = lower BP
Can lead to cerebral ischemia and POVL (ION - Ischemic Optic Neuropathy)

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17
Q

Civilian extremity injuries occur most often due to ___.

A

Falls (43%)
MVC second with 26%

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18
Q

The highest risk of massive hemorrhage is with ___ fx.

A

Pelvic fx
-Risk of shock, fat emboli, thromboembolic hypoxic respiratory failure

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19
Q

Ideal time for open fx repair is _____. It should be done with what type of anesthesia for greatest pt safety?

A

Within 12 hours. Done under GA for aspiration risk - possible full stomachs

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20
Q

Mortality rates climb up to ___% with open pelvic fractures.

A

70%
-Huge risk for massive hemorrhage, remember TXA for these pts!

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21
Q

Main role of the anesthetist in pelvic fx repair?

A

The anesthetist’s role at this time should focus on close monitoring of hemodynamic end-organ perfusion in addition to replacing blood loss using principles of damage control resuscitation.

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22
Q

Blood Supply for spine includes:
__ Anterior Spinal Arterie(s)
__ Posterior Spinal Arterie(s)

A

-1 Anterior Spinal Artery: the Artery of Adamkiewicz @T10-11 –> disruption = paralysis
-2 Posterior Spinal Arteries

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23
Q

Anesthetic challenges for spinal surgery:

A

-Airway management
-Fluid and blood management
-Hemodynamic control and monitoring
-Perioperative anaglesia

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24
Q

Gold standard surgical approach for spinal stenosis

A

Bony decompression by laminectomy
-Can be alongside lumbar interbody fusion for stability

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25
Q

For anterior spinal surgical approaches on thoracic segments, we will need what?

A

A double-lumen ETT for one lung ventilation

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26
Q

What will be much harder to do successfully in spinal fusion patients?

A

Subarachnoid blocks and epidurals at the level of the fusion

27
Q

What surgical technique is used for scoliosis

A

Anterior, posterior, or combo
-Anterior requires thoracotomy and double ETT

28
Q

What is important for us as anesthesia in scoliosis surgery or any serious spinal surgery?

A

-Good IV access
-Advanced BP monitoring
-Access to blood products
-Purposeful use of hypotensive technique

29
Q

Why is a laparoscopic approach advantageous in the anterior approach?

A

-Better respiratory functioning
-Diminished blood loss
-Shorter LOS
-Lower costs
**Only appropriate for the right patients

30
Q

What patients should NOT be a candidate for laparoscopic spinal surgery?

A
  1. Previous abdominal surgery/trauma
  2. Thoracic spine surgery that CANNOT tolerate one lung anesthesia
  3. Internal fixation with extensive instrumentation
31
Q

Spinal Surgery Anesthesia Management (putting it all together here)

A

-Good IV access
-Advanced monitoring (ABP, SSEP, MEPs)
-Proper positioning
-Airway A/B/C
-Can pt tolerate one lung anesthesia if that is the plan?
-Hypotensive technique
-Blood conservation strategies

32
Q

What are some examples of blood conservation strategies?

A

-Predonation autologous blood
-Cell saver
-Surgical site infiltration with epi
-Hypotensive anesthesia
-TXA

33
Q

What changes on EP can signify possible cerebral ischemia?

A

50% reduction in amplitude
OR
10% increase in latency

34
Q

SSEPs monitor what? Can we use NMB with SSEP?

A

Monitor the integrity of the neural structures along both the peripheral and central somatosensory pathways
-We CAN use NMB

35
Q

Anesthesia effects on SSEPs

A

Increase latency and decrease amplitude
Ketamine, etomidate, opioids the exception
Use narc-based, TIVA, 1/2 MAC
Avoid N2O - depressant

36
Q

____ and ____ increase cortical amplitudes and enhance SSEP/MEP waveforms.

A

Ketamine and etomidate

37
Q

MEPs monitor what? Can we use NMB?

A

Monitor integrity of motor tracts (anterolateral spinal cord/corticospinal tract)
-CANNOT use NMB

38
Q

Anesthesia effects on MEPs

A

Narc-based, TIVA, 1/2 MAC
Avoid N2O - depressant
NO NMBA

39
Q

What does an electromyography do?
Can we use NMB?

A

Stimulates a motor nerve and monitors known innervated muscle groups
NO NMB

40
Q

Difference in EMG versus SSEP/MEP?

A

EMG cannot monitor for ischemia

41
Q

A NIMS ETT allows for what?

A

Monitoring of the vocal cords
Used in ACDF surgery

42
Q

Prone positioining changes

A

-Decreased CO and BP unless torso in plane
-Keep abdomen free floating
-Decreased FRC and TLC
-Increased abdominal pressures, PIP
-Use pressure control ventilation

43
Q

Wilson Frame table allows for what that may increase comfort and outcomes?

A

Natural curvature of spine is supported

44
Q

The huge MUST for the rotisserie table

A

Ensure the top of the sandwich is secure!!
Chickens and sandwiches.. idk

45
Q

In a face down position we should check positioning of face how frequently?

A

q15-30 mins
-Use mirror, maintain patent tube

46
Q

Orthopedic extremity surgery uses ___ ___.

A

Pneumatic tourniquet

47
Q

There are roughly _____ spinal cord injuries per year in the US.

A

10,000 with about 80% males

48
Q

Spinal cord outcomes are dependent on what 3 factors?

A
  1. Severity of acute injury
  2. Prevention of exacerbation of injury during rescue, transport, and hospitalization
  3. Avoidance of hypoxia and hypotension
49
Q

T/F: >50% of all traumatic spinal cord injuries occur in cervical region.

A

TRUE.

50
Q

Most common SCI types:

A
  1. Incomplete tetraplegia (31%)
  2. Complete paraplegia (25%)
  3. Complete tetraplegia (20%)
  4. Incomplete paraplegia (19%)
51
Q

Tetraplegia results in:

A

Partial or total loss of all four limbs and the torso

52
Q

Paraplegia results in:

A

Only lower extremities and torso affected

53
Q

6 p’s of SCIs:

A
  1. Pain
  2. Paralysis
  3. Paresthesia
  4. Priapism
  5. Ptosis
  6. Position
54
Q

SCI pts should have spinal immobilization before being moved. What position will we obtain an airway in?

A

Manual in-line stabilized position

55
Q

Radiologic evaluation should include which cervical vertabrae?

A

All 7
C7 most commonly injured site

56
Q

An SCI above C-3 often results in what?

A

Apnea, rendered ventilator dependent

57
Q

_____ could exacerbate a SCI due to fasciculations.

A

Succ

58
Q

We will maintain a MAP of ~___mmHg for best patient perfusion in spinal cord injuries

A

~90 mmHg

59
Q

What induction agents should be used on spinal cord injury patients: Propofol or ketamine?

A

Hemodynamically stable = Propofol
Unstable = Ketamine, but expect increased ICP

60
Q

3 main symptoms of spinal shock:

A
  1. Hypotension
  2. Bradycardia
  3. Hypothermia
    A turned of sympathetic system is the best way to think of these
    -Worse as we move more cephalad above T6
61
Q

What is autonomic dysreflexia?

A

Sudden activation of sympathetic response secondary to a noxious stimuli
-Presents with extreme HTN
-Possible seizure, pulm edema, MI, AKI, intracranial hemorrhage

62
Q

Management of autonomic dysreflexia:

A

Determine the noxious stimuli and correct it
Fix BP

63
Q

Thats all she wrote. Enjoy the studying!

A

Spring break next week yee haw

Anesthesia Principles 1 (7 decks)

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