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Krista/ 2 Advanced Physical Assessment and foundation of Nursing Anesthesia 2 > Anesthesia for Orthopidic Surgery > Flashcards

Anesthesia for Orthopidic Surgery Flashcards

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1
Q

What are some special consideration in ortho surgery?

A
  • Bone cement
  • Pneumatic tourniquets
  • Fat embolism syndrome
  • Deep venous thrombosis
  • Thromboembolism
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2
Q

Characteristics of bone cement:

A
  • Exothermic reaction resulting in hardening
  • Heat, expansion and hardening lead to intermedullary hypertension (>500 mm Hg)
  • Residual mma monomer produces vasodilation, decrease in SVR
  • Tissue thromboplastin release may cause platelet aggregation microthrombus (lungs) and CV instability
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3
Q

What symptoms correlate with bone cement implantation syndrome:

A
  • Hypoxia (increased pulmonary shunt)
  • Pulmonary HTN (increase PVR)
  • Dysrthythmias (Heart blocks / Sinus arrest)
  • Hypotension
  • Decreased CO
  • Embolization most frequent during prosthetic insertion
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4
Q

What are the strategies to limit MMA (Bone Cement) effects:

A

-Increase inspired O2 prior to MMA (bone cement)
-Maintain euvolemia
-Vasopressor as needed
SUGICAL METHODS
-venting distal femur
-high pressure lavage of femoral shaft

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5
Q

What kind of hemodynamic changes will be seen with pneumatic tourniquets?

A
  • Increase B/P

- Increase HR

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6
Q

What are the problems with pneumatic tourniquets?

A
  • hemodynamic changes
  • Pain
  • Metabolic changes
  • Arterial thromboembolism
  • Pulmonary embolism
  • Muscle and nerve injury
  • Limb cooling
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7
Q

Prolonged cuff time of __ to __ minutes associated with HTN, ________, ___________ stimulation (sweating).

A

45 to 60
tachycardia
sympathetic

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8
Q

What will the deflation of the Pneumatic cuff do to the hemodynamics?

A
  • Decreases CVP

- Decreases MAP

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9
Q

T/F: The core temperature drops with the use of a pnuematic cuff.

A

TRUE

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10
Q

Pneumatic cuff pressure should be ____ torr above systolic pressure or the upper extremity should be ___ torr and the lower extremity ___ torr.

A

100
250
350

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11
Q

What kind of pain is associated with the tourniquet?

A

-Sever aching and burning (several minutes)
-Unmyelinated, slow conduction C fibers
Supplemental analgesia needed

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12
Q

T/F: Tourniquest pain is less common in general anesthesia then in regional anesthesia.

A

FALSE (…. less common in regional anesthesia then in general anesthesia.)

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13
Q

What metabolic changes are noticed with the tourniquet?

A
  • Waste accumulation in the tissue
  • Cuff deflation is rapid wash out which will increase PaCO2, ETCO2, serum lactate, and potassium.
  • With deflation an increase in spontaneous breathes and possible disrhythmias
  • Re-perfusion injuries from free radical formation
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14
Q

T/F: Tourniquet contraindicated in calcified artery.

A

TRUE

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15
Q

T/F: Tourniquet ischemia is NOT associated with upper/lower extremity that leads to a deep venous thrombosis.

A

FALSE (It is associated and is more common in the lower extremity)

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16
Q

Prolonged inflation of the tourniquet > _ hours leads to transient _______ and permanent _____ injury.

A

2
muscle
nerve

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17
Q

T/F: Rhabdomyolysis can be associated with prolonged tourniquet times.

A

TRUE

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18
Q

What is the triad of fat embolism syndrom:

A
  • dyspnea
  • confusion
  • petechiae (pathognomonic)
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19
Q

Classic presentation of fat embolism syndrome with in __ hours of ____ bone or ______ fracture.

A
  • 72
  • long
  • pelvic
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20
Q

What other modalities can cause fat embolism syndrome?

A
  • CPR
  • Liposuction
  • IV lipids
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21
Q

How do fat emboli enter into circulation:

A

medullary vessel

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22
Q

Increased fatty acid levels toxic to capillary alveolar membrane releasing vasoactive ______ and ____________.

A
  • amines

- prostaglandins

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23
Q

What type of coagulation effects will be seen with fat embolism syndrome.

A
  • Thrombocytopenia

- Prolonged clotting time

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24
Q

What kind of pulmonary symptoms will be seen with fat embolism syndrom?

A
  • Progressive pulmonary involvement from mild hypoxia and clear CSR to ARDS
  • Under GETA see decline in ETCO2 and SpO2 and rise in PAP
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25
Q

People with risk factor of Deep vein thrombosis are:

A
  • age > 60
  • obesity
  • Tourniquet
  • lower extremity fracture
  • immobilization > 4 days
  • procedure > 30 minute
26
Q

The highest risk for deep vein thrombosis are:

A

Knee replacement

Hip replacement

27
Q

Placement of epidural needle or catheter (or removal) should not be undertaken within ____hours of a SQ minidose of heparin or within ______ hour of LMWH.

A

6-8

12-24

28
Q

T/F: It is acceptable to place an epidural or needle in a fully anticoagulated patient.

A

FALSE (NEVER ACCEPTABLE)

29
Q

What are the hallmark signs of a hematoma due to a epidural needle or catheter?

A
  • back pain

- Lower extremity weakness

30
Q

____ and _______ that limit range of motion of a joint may require anesthesia for manipulation to occur.

A

Scars

Adhesion

31
Q

What does general anesthesia do for the management of joint manipulation?

A

The profound relaxation allows surgeon to distinguish anatomical limitations from patient guarding

32
Q

The management of a closed reduction may include:

A
  • surgery could either be short or long
  • percutaneous pins
  • Xray/fluoro
  • Casting/splinting
33
Q

What should be determined of the patient with a hip fracture?

A

Why did they fall?

  • Accidental
  • Neuro event
  • Cardio vascular
  • dementia
  • dehydration/electrolyte
  • ??Abuse??
34
Q

Hip fracture mortality is __ % during initial hospitalization and __% within the ____year.

A

10
25
first

35
Q

Other consideration of a hip surgery:

A
  • Surgery within 48 hours of injury
  • Time for medical evaluation and treatment of pathology
  • Type and Cross
  • evaluate hypoxia
36
Q

What are some reasons to delay a hip surgery:

A
  • Coagulopathy

- Uncompensated heart failure

37
Q

What are some predictors of peri-op mortality for hip fractures:

A
  • age > 85 years
  • History of cancer
  • Baseline/pre-op alteration in neuro status
  • Post op chest infection
  • Post op wound infection
38
Q

What are the benefits of regional anesthesia vs. general:

A
  • hypobaric technique can be utilized to keep patient off of fracture
  • reduced blood loss
  • Reduced DVT/PE
  • Quicker return to baseline neuro
39
Q

T/F: After two months no difference in mortality for regional vs general in hip repair.

A

True

40
Q

Will lose benefit of regional in hip surgery if:

A
  • patient oversedated

- patient becomes hypoxic

41
Q

How can blood loss be determined by location of hip fracture?

A
  • Greater blood loss occurs further distally from the hip.
  • From greater to less blood loss: subtrochanteric and intertrochanteric > base of femora neck > transcervical and subcapital
42
Q

What should be considered with hip fracture during general anesthesia:

A

-Bigger fracture (arterial line and size of IV)
-Use of short acting drugs
-Use lower solubility agents
-minimize postop cognitive impairment
{older patient less versed
{Maintain oxygenation
{Maintain hemoglobin
{Maintain normal capnea

43
Q

What are the benefits of a arthroscopy:

A
  • less estimated blood loss
  • less postop pain
  • less rehab time
44
Q

What is a arthroplasty good for:

A

Surgical replacement of all joint components to achieve return of natural motion and function of the joint.

45
Q

What are the goals of a arthroplasty:

A
  • pain relief
  • Deformity corrected
  • stability of joint motion
46
Q

What is the most common reason for a total hip arthroplasty (THA):

A

osteoartritis

47
Q

What are the factors that cause osteoarthritis: (THA indciation)

A

repetitive motion, obesity, often others areas of involvment (other joints)

48
Q

What are the factors that cause rheumatoid arthritis (RA): (THA indication)

A

immune mediated joint destruction with synovial inflammation systemic involvement with significant deformity atlantoaxis (C1-C2) subluxation and TMJ involvement use of steroids, anti-inflammatories, methotrexate

49
Q

What are the factor that cause vascular necrosis (THA indication)

A

injury

drug use

50
Q

Total hip arthroplasty (THA) intraop managment:

A
  • Position: lateral decubitus
  • Embolic event most frequent at insertion of femoral component
  • Use of MMA
  • Prophylaxis of DVT/PE
  • Blood loss
  • Heat loss
  • Periop infection
  • Postop pain control
51
Q

What is the estimated blood loss of a total hip arthroplasty?

A
  • 400 to 1200 mL

- Revision 2000 mL

52
Q

What has the highest rate of DVT of all ortho procedures?

A

Total knee arthroplasty (TKA)

53
Q

What is the estimated blood loss of total knee arthroplasty (TKA):

A

100 to 200 mL

54
Q

What should be remembered for upper extremity surgery?

A
  • Position is sitting (beach chair) or lateral decub (Maintain B/P MEAN)
  • Interscalene block of brachial plexus helpful
  • Cerebral oximetry
55
Q

What anesthsia consdieration of upper extremity arthroplasty:

A
  • surgical position
  • no tourniquet (large blood loss)
  • Potential pneumothorax
  • potential injury to subclavian veins
  • Potential in advertent extubation
  • Potential for C spine injury
  • Potential for VAE, fat or bone embolism
  • Effect of MMA
56
Q

What are the anesthesia consideration for a foot and ankle surgery:

A
  • candidates for regional anesthesia
  • nerve blocks with IV sedation
  • Use of tourniquet
  • LMA with local injection for postop pain control
57
Q

What are anesthetic concern for re-implantation of a limb/digit?

A
  • attnetion to positon
  • maintain body temp
  • regulation of fluids
  • Optimal HCT 28-30%
  • Avoid vasoconstrictors
  • Dextran or heparin infusion intraop
58
Q

What nerves consist of the interscalene block:

A

C5-T1

59
Q

Where does injection take place in an interscalene block:

A

Between scalene muscle at level of cricothyroid (C6)

60
Q

What are complications of Interscalene block:

A
  • CNS and CV toxicity from carotid artery, vertebral artery, and jugular vein
  • Respiration depression
  • Pneumothorax
  • Hoarseness,
  • Dysphagia
  • Horner’s syndrom
  • Ipsilateral phrenic nerve block most patient with hemidiaphram paralysis, 25 % decrease pulmonary function. Some may not tolerate.
61
Q

What are the S/S of local toxicity:

A
  • Ringing/buzzing in ears
  • Metallic taste or perioral numbness
  • Dysphasia, confusion
  • Orthostasis
  • PVC’s
  • Wide QRS/PEA/Asystole (BUPIVICAINE)
  • Brady/AV blocks/asystole (lidocaine)
62
Q

What is the procedure for lipid resuscitation of local anesthetic toxicity:

A
  • Stop infusion of local anesthetic
  • Bolus of 20% lipid solution at 1.5 mg/kg
  • Infusion of 0.25 mg/kg/min of 20% Lipid solution
  • Life support measures

Krista/ 2 Advanced Physical Assessment and foundation of Nursing Anesthesia 2 (8 decks)

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