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Advanced Principles > Anesthetic Considerations for Orthopedic Procedures > Flashcards

Anesthetic Considerations for Orthopedic Procedures Flashcards

1
Q

What is a common complication associated with orthopedic surgeries?

A

Major blood loss

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2
Q

What comorbidities are commonly associated with patients undergoing an orthopedic procedure?

A

CAD
Rheumatoid arthritis with systemic pulmonary, cardiac and musculoskeletal involvement
Osteoarthritis
Mental status (large population are elderly)

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3
Q

What is Rheumatoid arthritis?

A

Chronic inflammatory disease affecting multiple joints and organ systems

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4
Q

What are the most common joints rheumatoid arthritis affects?

A

C-spine, hips, shoulders, knees elbows, wrists and metecarpophalangeal joints

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5
Q

What are systemic effect of rheumatoid arthritis?

A

Anemia, pericarditis, cardiac tamponade, myoocarditis and pulmonary interstitial fibrosis

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6
Q

What affect does RA have on the immune system?

A

It impairs the immune system

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7
Q

What complications can occur when trying to intubate a patient with RA?

A

Cervical cord compression or compression of vertebral arteries from subluxating C2 at the odontoid process when flexing the neck

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8
Q

Why are patient with RA difficult to ventilate?

A

Restrictive lung disease from pulmonary fibrosis

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9
Q

What is ankylosing spondylitis?

A

Abnormal immobility of joint caused by fibrous growth in joint

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10
Q

What are common characteristics of ankylosing spondylitis?

A

Ossification of ligaments at attachment to bone
Progressive ossification
Seronegative for rheumatoid factor –> may go undiagnosed

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11
Q

What characteristic of ankylosing spondylitis is of interest to the anesthetic provider?

A

Axial skeleton disk space “bamboo spine”

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12
Q

What population is ankylosing spondylitis more common in?

A

Caucasian Males

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13
Q

What are symptoms of ankylosing spondylitis?

A

Low back pain, sacroilitis, multiplane rigidity of spine, chest stiffness and uveitis

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14
Q

Why are patients with ankylosing spondylitis difficult to intubate?

A

Atlantoaxial instability and spine fractures during airway manipulation

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15
Q

Why are patients with ankylosing spondylitis difficult to ventilate?

A

Rigid chest

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16
Q

What is the purpose of using a tourniquet in orthopedic cases?

A

Allows a bloodless field and minimizes blood loss

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17
Q

What is the maximum a tourniquet should be inflated?

A

100mmHg greater than systolic BP

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18
Q

What is known to occur if a tourniquet is inflated for longer than two hours?

A

Inflation greater than 2hrs routinely leads to transient muscle dysfunction and may be associated with permanent peripheral nerve injury

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19
Q

When does tourniquet pain usually begin to appear?

A

30-45min after inflation

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20
Q

What type of nerve fibers are thought to transmit tourniquet pain?

A

Unmyelinated C fibers

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21
Q

What is the definitive treatment for tourniquet pain?

A

Tourniquet release

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22
Q

What position are patients typically placed in for shoulder surgeries?

A

Beach chair position, flexed at hips and knees, 10 to 20 degree reverse trendelenburg

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23
Q

What nerve is at risk of injury in the beach chair position?

A

Brachial plexus injury

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24
Q

What occult blood loss can occur with a hip fracture?

A

Extracapsular and Subcapsular

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25
Q

Which type of fracture to the hip is associated with a higher occult blood loss?

A

Extracapsular fracture: femoral neck, intratrochanteric and subtrochanteric

26
Q

In what order does the most occult blood loss occur from injury to the hip?

A

Subtrochanteric > Intertrochanteric > base of femoral neck > transcervical > subcapital

27
Q

What syndrome is highly associated with a hip fracture?

A

Fat Embolism Syndrome

28
Q

What is the triad of symptoms seen with fat embolism syndrome?

A

Dyspnea
Confusion
Petechiae on chest, upper extremities, axilla & conjunctiva

29
Q

When is fat embolism syndrome most likely to occur?

A

72hrs following long bone or pelvic fracture

30
Q

What are the signs of fat embolism syndrome during general anesthesia?

A

Decreased EtCO2 and arterial saturation

31
Q

What is the treatment for fat embolism syndrome?

A

Early fracture stabilization and supportive care

32
Q

What position is a total hip replacement usually done in?

A

Lateral decubitus, higher degree of visibility and range of motion

33
Q

What is the most common indication for a total hip arthroplasty?

A

Osteoarthritis (Degenerative joint disease)

34
Q

What are the surgical steps to a total hip arthroplasty?

A

Dislocation and removal of femoral head
Reaming of acetabulum
Insertion of acetabular cup
Reaming of femur and insertion of femoral component

35
Q

What are the three life threatening complications of a total hip arthroplasty?

A

Bone cement implantation syndrome
Perioperative hemorrhage (reaming and insertion)
Thromboembolism

36
Q

What is bone cement implantation syndrome?

A

Hardening and expansion against components causes intramedullary HTN forcing embolization of fat, bone marrow, cement and air into femoral venous channels

37
Q

What effect does residual methylmethacrylate monomer produce?

A

Vasodilation and decreased SVR

38
Q

What can trigger platelet aggregation, and produce pulmonary microthrombi and CV stability in bone cement implantation syndrome?

A

Release of tissue thromboplastin

39
Q

What are the clinical manifestation of bone cement implantation syndrome?

A 
Hypoxia
HoTN
Dysrhythmias
Pulmonary HTN
Decreased CO
40
Q

How can the anesthetic provider intervene if bone cement implantation syndrome is suspected?

A

Increased FiO2
Maintain euvolemia
Ask the surgeon to perform a high pressure lavage of femoral shaft to remove debris

41
Q

What is a significant cause of morbidity and mortality in patients that undergo an orthopedic procedure?

A

Venous thrombosis

42
Q

What can be done to prevent venous thrombosis in the post operative period?

A

Regional anesthesia
Intermittent leg compression devices
Low-dose anticoagulant prophylaxis

43
Q

What can occur when the tourniquet is released after a total knee arthroplasty?

A

HoTN

44
Q

Why might the surgeon request muscle relaxation to facilitate a closed reduction?

A

Once fractured, the muscles tend to spasm and pull fracture together to try to heal. Does not heal properly

45
Q

What position are spine cases typically performed in?

A

Prone position

46
Q

What are some considerations with the prone position?

A 
Neck must be neutral
Shoulders abducted  less than 90 degrees
Ischemia to ears, eyes, nose, forehead female breasts or male genitalia
HoTN
Ventilation difficulties
47
Q

Why is it so important for a patient’s abdomen to be free from pressure while in the prone position?

A

If pressure on the abdomen it increases venous blood flow which increases after load causing an increase in blood loss

48
Q

What complications are associated with spinal surgery?

A

Large blood loss
Vision loss
VAE

49
Q

What two tests can be used for spinal cord monitoring?

A

Wake up test

SSEP, MEP monitoring

50
Q

What can cause vision loss after a spinal procedure?

A

Optic neuropathy
Retinal artery occlusion
Cerebral ischemia

51
Q

What changes are observed in SSEPs if spinal cord dysfunction occurs?

A

Changes in the latency and amplitude

52
Q

How do volatiles affect SSEPs?

A

Decrease amplitude and increase latency

53
Q

What anesthetics have no clinically relevant effect on SSEP signals?

A

Propofol, Ketamine and narcotics

54
Q

What is the most reliable monitoring tool for spinal procedures?

A

The wake up test

55
Q

When should volatiles be discontinued if planning to perform a wake up test?

A

An hour prior to wake up test

56
Q

If paralytic is used, what should be done in order to prevent interference with the wake up test?

A

Maintain 2-3 twitches on TOF/no reversal, the patient must have sufficient toe movement

57
Q

When is an anterior and posterior fusion performed on a patient with scoliosis?

A

If the curvature is greater than 90 degrees

58
Q

When is controlled HoTN required during an anterior and posterior approach for scoliosis?

A

Posterior portion, MAP should be 60mmHg or more to prevent blindness or cord ischemia

59
Q

Why does right ventricular hypertrophy and pulmonary HTN occur after an anterior and posterior approach for scoliosis?

A

Prolonged alveolar hypoxia due to hypoventilation and V/Q mismatch –> irreversible vasoconstriction and pulmonary HTN

60
Q

What are some considerations for patients undergoing limb reimplantation?

A

Keep the patient warm
Euvolemic
Anemia if tolerated
DO NOT use pressirs

Advanced Principles (16 decks)

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