Anesthesia for orthopedics procedures

Question 1

During orthopedic procedures, the chance for surgical site infection (SSI) prevention is decreased by

Answer 1

administration of appropriate PREOPERATIVE ANTIBIOTICS in a timely fashion

Question 2

Cefazolin pre-op time allotment for prevention of SSI

Answer 2

For cefazolin (a first-generation cephalosporin), the preoperative time allotment is within 1 hour of incision time;

Question 3

Vancomycin pre-op time allotment for prevention of SSI

Answer 3

Within 2 hours of incision time

Question 4

Organisms commonly associated with orthopedic procedures include

Answer 4

Staphylococcus aureus

gram-negative bacilli

coagulase-negative staphylococci (including S. epidermidis)

β-hemolytic streptococci

Question 5

Prophylactic antibiotics are not indicated in _______ procedures such as ______________ procedures and procedures not involving implantations.

_________surgery with or without instrumentation should be covered by an antimicrobial agent

Answer 5

Prophylactic antibiotics are not indicated in clean procedures such as diagnostic arthroscopic procedures and procedures not involving implantations.

Spinal surgery with or without instrumentation should be covered by an antimicrobial agent

Question 6

Recommended agent for antimicrobial prophylaxis for select orthopedic procedures

* None for orthopedic*

Answer 6

Cefazolin

Question 7

What alternative agents are recommended when patients have a b lactam allergy for antimicrobial prophylaxis for select orthopedic procedures

Answer 7

Clindamycin or vancomycin

Question 8

Why are tourniquets used during orthopedic surgery?

Answer 8

Tourniquets are often used in orthopedic surgery to minimize blood loss and provide a bloodless operating field.

Question 9

What is important to consider when using a tourniquet during orthopedic surgery?

Answer 9

Appropriate cuff size and inflation pressure is paramount in reducing the risk of neuromuscular injury related to tourniquet ischemia.

Question 10

Tourniquet inflation pressure for upper extremity surgery

Answer 10

70-90 mmHg above SBP

Question 11

Tourniquet inflation pressure for lower extremity surgery

Answer 11

2 times over SPB

Question 12

What is the duration of safe tourniquet inflation?

Answer 12

2 hours

Question 12

During tourniquet use the pain usually begins ___________minutes after inflation and is transmitted by ________fibers (slow pain)

Answer 12

usually begins 45-60 minutes after inflation and is transmitted by C fibers (slow pain)

Question 13

During tourniquet release for orthopedic procedures, the patient can manifest

Answer 13

Releasing the tourniquet produces transient changes including increased ETCO2,decreased body temperature, decreased blood pressure, decreased SVO2, and metabolic acidosis

Question 14

Safety measures for preventing tourniquet complications include

Answer 14

Question 15

Physiologic changes caused by tourniquets include

Answer 15

Question 16

What is the first indication of BCIS under general anesthesia?

Answer 16

An abrupt decrease in end-tidal carbon dioxide concentration may be the first indication of clinically significant BCIS under general anesthesia.

Question 16

What is Methyl methacrylate (MMA)?

Answer 16

A bone cement used during surgery

Question 16

Bone Cement Implantation Syndrome (BCIS), is characterized by several clinical features, including:

Answer 16

Hypoxia*

Hypotension*

cardiac arrhythmias*

increased pulmonary vascular resistance*

unexpected loss of consciousness when regional anesthesia is administered*

cardiac arrest

Question 17

Early signs of BCIS in the awake patient undergoing regional anesthesia:

Answer 17

dyspnea and altered sensorium

Question 17

To ensure blood supply to the brain it is prudent to maintain the patient’s head in a

Answer 17

a neutral anatomic alignment while in the prone position

Question 17

What is performed before cementing the patient with MMA ?

Answer 17

Blood pressure should be optimized.

The patient should be placed on a 100% fraction of inspired oxygen (FiO2),

pressure bags should be available for rapid intravenous (IV) fluid administration, and IV fluid bags should be full or nearly full.

It is also important to document the cement time on the anesthesia record.

Question 17

Management of BCIS

Answer 17

inspired oxygen concentration should be increased to 100%, and supplementary oxygen should be continued into the postoperative period.

It has been suggested that cardiovascular collapse in the context of BCIS is treated as right-sided heart failure.

Aggressive fluid resuscitation is recommended, and hypotension should be treated with α-agonists.

Question 17

Prone position complication

Answer 17

The increased intraabdominal or intrathoracic pressures resulting from being prone reduce venous return, and the cardiac output will be reduced.

In addition, placing a patient in the prone position increases systemic and pulmonary vascular resistance.

These increases lead to decreases in stroke volume and cardiac index.

Question 17

The use of ____________controlled versus ____________controlled ventilation may allow for lower peak pressure in the ___________position

Answer 17

The use of pressure-controlled versus volume-controlled ventilation may allow for lower peak airway pressure in the prone position.

Question 18

What support system allows a pressure-free abdomen and will minimize the effect on cardiac output?

Answer 18

the Jackson spine table or longitudinal bolsters for prone positioning,

Question 18

Even if no arterial or venous compression occurs, if the patient’s head rests ________ the level of the heart, this creates an increased risk _________

Answer 18

Even if no arterial or venous compression occurs, if the patient’s head rests below the level of the heart,this creates an increased risk for postoperative visual loss

Question 19

While turning the patient, special attention must be given to the __________ and __________.

Foam, gel pads, or head supports should be put in place ____________ turning.

Once the patient is turned, the first goal is to _____________and ________________

Answer 19

While turning the patient, special attention must be given to the head and the endotracheal tube.

Foam, gel pads, or head supports should be placed before turning.

Once the patient is turned,the first goal is to reconnect the breathing circuit and recheck the breath sounds to ascertain whether the tube is still in the correct place and has not migrated into the bronchus

Question 20

The potential for eye or corneal injury is high in _____________ position.

Answer 20

Prone

Question 21

Position related complications during shoulder arthroscopy- BEACH CHAIR position

Answer 21

Hypotensive bradycardic events
Cervical Plexus and hypoglossal nerve neurapraxias
Air embolism
Pneumothorax
DVT
Unilateral vision oss and ophthalmoplegia
Cerebral Hypoperfusion event

Question 22

Position related complications during shoulder arthroscopy- LATERAL DECUBITUS position

Answer 22

Temporary paresthesia

Neurapraxias of the dorsal digital nerve of the thumb, musculocutaneous, ulnar, and axillary nerve

Permanent neurapraxias

Postoperative Stroke

DVT

Fluid-related obstructive airway compromise

Risk of musculotendinous nerve injury (5-oclock portal) (rare)

Question 23

Tranexamic acid (TXA) MOA

Answer 23

TXA competitively blocks lysine receptors that activate plasminogen, preventing fibrin degradation.

In other words, it acts as an antifibrinolytic and maintains clot formation.

Question 24

Administration of tranexamic acid (TXA) to patients undergoing total joint replacement because it has been shown to:

Answer 24

Decrease perioperative blood loss and transfusion requirements with minimal risk of complications

Question 25

Administration dose and route for TXA

Answer 25

TXA (1–2 g) is administered perioperatively, either intravenously or topically at the surgical site.