E1 Flashcards
What can makes ortho surgeries complicated
Co morbidities like CAD, stents, anemia, COPD
Meds like beta blockers, anticoags, lisinopril
What are the challenges with venous access
Intraoperative positioning
What are some diseases that contribute to injury
osteoporosis
Osteoarthritis rheumatoid arthritis
What is osteoarthritis and the symptoms
Loss of articular cartilage d/t INFLAMMATION Symptoms: Pain Crepitance decreased mobility joint deformities
What is osteoporosis? Etiology?
Decreased bone density
Age-related or post-menopausal
Etiology:
- d/t HI parathyroid hormone
- d/t LOW vitamin D, groth hormone, insulin-like growth factor
What common injuries can occur w/ osteoporosis
- Stress fractures
- Spine fx (thoracic or lumbar compression fx)
- Proximal femur/humerus
- Wrist
What meds may ppl w/ osteoporosis take
fosamax
actonel
boniva
reclast
What joints does OA effect
weight bearing joints/spine
What medications do pts take for OA
NSAIDs, celebrex, opioids
What heberdon nodes vs bouchard nodes
swelling and spurring of DISTAL interphalangeal joints
swelling and spurring of PROXIMAL interphalngeal joints
What is the concern for ppl with heberdon or bouchard nodes
Can interfere w/ function, ADLs and surgical positioning
Take care w/ positioning
What are important considerations for the preop eval in pts w/ OA or osteoporosis (5)
- What joints are involved
- Neurovascular assessment
- Functional pain level (chronic pain?)
- Constraints on surgical positioning
- Type of anesthetic
What is rheumatoid arthritis
Chronic & systemic inflammatory autoimmune dx w/ progressive tissue damage
Joint synovitis/connective tissue inflammation
- bone erosion
- cartilage destruction
- impaired joint integrity & fxn
Where does RA commonly start
What are the symptoms
starts in hands and wrists
pain, stiffness (MORNING STIFFNESS = HALLMARK)
What signs may be present on examination of joints in pts w/ RA
SQ nodules surround joints & bony prominence
How is RA diagnosed & with what examines
Diagnosed w/ lab tests
ELEVATED LABS
- rheumatoid factor
- anti-IG antibody
- C-reactive protein
- Erythrocyte sedimentation rate (ESR)
What is first line treatment for RA and implications for anesthesia
CORTICOSTEROIDS
exogenous steroids suppress production of endogenous steroids
pt may need “stress dose” before surgery
What medications are used for RA
Steroids NSAIDs Opioids Methotrexate Hydroxychloroquine infliximab Entanercept
What are anesthesia concerns for pt w/ RA
-Limited TMJ movement
-Narrowed glottic opening
-AO instability or subluxation
-
Describe the complications of AO instability or subluxation in the RA pt
Can affect flexion of the neck:
- ->spinous process displacement can impinge on SC and medulla
- ->Shifting can occlude arteries
- ->Perfusion can be interrupted
Describe specific symptoms w/ AO sublux
HA
Neck pain
Neuro symptoms in arms and legs w/ movement
Bowel/bladder dysfunction
Describe specific symptoms with vertebral artery occlusion
N/V
Dysphagia
Blurred vision
TRANSIENT LOC (MOST COMMON**)
Anesthesia preoperative concerns in the RA pt (7)
>C-spine flexion/extension -perform neck ROM >Vasculitis/vascular dx >Pericarditis or effusion >Diffuse interstitial fibrosis >Sjorgen's sx (dry eyes/mouth) >Gastric ulcers >Renal insufficiency d/t NSAID use
Preop considerations in the pt w/ RA
> Other orthopedic problems
Medications taken
CNS concerns
What CNS concerns should be considered in the pt w/ RA
> Assess baseline
-prone to postop delirium
Risk factors for delirium
Triggers for altered CNS
What are risk factors for delirium in pt w/ RA (5)
Age EtOH use Preop dementia Cognitive impairment Anesthesia
List triggers for altered CNS in the pt w/ RA
Hypoxemia hypotension hypercarbia hypervolemia infection abnormal lytes pain benzos/anticholinergics
Physiologic benefits of regional vs GA
Decreases risk of complications DEC DVT DEC PE DEC EBL DEC resp complications DEC death risk improved pain management
What are overall benefits of regional vs GA
Improved pain mgmt
single shot or cath
Preemptive analgesia
May INC therapy participation
What are some orthopedic complications
Emboli (fat, air)
DVT
PE
What are the most common causes of fat embolizatoin
long bone fx/trauma
cement use
bilat TKA
hypovolemic shoxk
What is the source of fat embolism
The medullary canal release of
Medullary bone (marrow)
Yellow or red marrow (contains fat)
What is the fat embolism syndrome triad of symptoms
When may these symptoms present
Triad:
dyspnea
confusion
petechia
Present in 12 - 72 hours
What can cause fat embolism
1) long bone trauma causes release of fat droplets into the veins
2) Fx releases mediators affecting solubility of lipids in circulation
What is the etiology of fat embolism syndrome
- capillary ENDOTHELIAL BREAKDOWN
- BLOCKAGE of capillary CIRCULATION
- Triggering of SYSTEMIC INFLAMMATORY CASCADE
What are general symptoms of fat embolism therapy
Hypoxemia
Resp failure (pulm, edema, ARDS)
Neuro impairment
What is the most common cause of mortality r/t fat embolism
ARDS
What are the major features of the triad of symptoms in FES
RESP –> dyspnea, edema
NEURO –> drowsiness, confusion, obtundation, coma
RASH–> petechia in conjunctiva, oral mucosa, skin folds of neck/axillae
What are minor symptoms associated w/ FES
Fever (>100.4*F)
Tachy (>120 bpm)
Jaundice
Renal changes
Management of FES
- TREATMENT (prompt surgery)
- Early recognition
- Stabilization of fx
- Aggressive & early respiratory/circulatory support
- Minimize stress response
How can the stress response be minimized in FEW
Address hypoxia, hypotension, DEC end-organ perfusion:
- Oxygenate
- Maintain BP
- Maintain volume status
How long can FES symptoms last and what is the mortality rate of FES
Symptoms resolve in 3 -7 days
Mortality rate = 10 - 20% (usually w/ ARDS)
Describe risk factors associated w/ DVT/PE (6)
Obesity Age >60 yo Procedure length >30 min Use of tourniquet Lower extremity fx Immobilization >4days
Which surgeries pose the greatest risk for DVT/PE (3)
Hip surgery
TKA
Lower extremity trauma
What preventative measures can be taken to decrease DVT/PE (6)
Prophylaxis Early ambulation SCDs TED hose Augment limb flow (less tourniquet time) Perop anticoagulation
How does neuraxial anesthesia affect DVT/PE
INC LE venous blood flow d/t sympathectomy
LA have systemic anti-inflammatory properties
DEC plateley reactivity
When preparing for neuraxial anesthesia, what pt medications should be considered
Antiplatelets Thrombolytics Fondaparinux Direct thrombin inhibitors Therapeutic LMWH
What medications and when should be considered for thromboprophylaxis
LMWH (IV/SQ)
12 hours preop or postop
Describe LMWH QD & BID dosing and when neuraxial anesthesia needs to be held
ONCE DAILY LMWH
- Neuraxial okay 10 - 12 hours AFTER PREVIOUS DOSE
- -DELAY NEXT DOSE 4 HOURS
TWICE DAILY LMWH
- Neuraxial NOT okay
- -REMOVE 2+ HRS P/T 1ST DOSE
When can neuraxial anesthetic be performed for a pt on warfarin
When INR = 1.5
What antifibrinolytic is commonly used in orthopedic surgeries
TXA (tranexamic acid)
Which orthopedic surgeries commonly use TXA
What is the rationale
TKA in THA
To control BL and DEC blood transfusions
How is TXA a to administered ortho pts and WHEN
IV, topical, PO
prior to incision
What complication should be considered when using TXA
What pt populations may TXA be contraindicated in
Risk of thromboembolic event
Caution in cardiac & vascular pts
What is the dosing for TXA in orthopedic surgeries
MAX total dose
10 - 30 mg/kg
MAX 2.5 gm
What is the purpose of using a tourniquet during orthopedic surgeries
DEC intraop EBL
Provides bloodless field for better visualization
Exsanguination
What is the result of exsanguination of operative limb
INC BV into central circulation
What is that standard tourniquet inflation guideline and setting for upper and lower extremity
What is the max time
Guideline = ~1-- mmHg >SBP UE = ~250 mm Hg LE = ~300 mm Hg
MAX time = ~ 3 hrs (generally not >2 hrs)
What are the documentation components of tourniquet use (5)
- inflation time
- deflation time
- TOTAL inflated time in minutes
- inflation pressure
- any pressure changes
What are complications associated w/ tourniquet use (4)
- Nerve injury
- Rhabdomyolysis
- ischemia
- mechanical trauma
What are tourniquet risk preventative measures
Minimize risk by deflating tourniquet over 20 - 30 mins to allow for reperfusion
SLOW deflation
Patient s/sx to be aware of during tourniquet use
- pain after 1 hr of inflation
- INC HR & BP
- Diaphoresis
What pain path is tourniquet pain associated with
May be r/t regression of regional unmyelinated C fibers firing
Describe the process of using double tourniquet during inflation & deflation
INFLATION
-proximal 1st
DEFLATION
-distal 1st
What factors influence pain w/ tourniquet use
- tourniquet time
- anesthetic technique
- dermatomal spread (peripheral nerve coverage)
- LA & dose (density)
- tourniquet use
What are potential negative effects of tourniquet use
- metabolic acidosis
- INC K+
- INC CO2
- INC HR
- HTN
What can attenuate the negative effects of tourniquet use
SLOW deflation
-slow reperfusion decreases negative effects
What s/sx are present following tourniquet deflation
- pain relief at site
- DEC CVP
- DEC BP
- DEC temp
- Transient lactic acidosis
- transient INC CO2
How can transient hypercarbia from tourniquet use be addressed
INC Vm (INC Vt or RR)
What are general considerations for anesthesia during ortho surgery (6)
-What happens during the sx
-Anesthetic mgmt
-positioning
Pre/post-op assessment
-blood loss and related ocmplications
-abx admin p/t incision
List emergency ortho surgery indications (5)
- vascular compromis
- compartment syndrome
- neuro impairment
- bone infection/sepsis
- unstable pelvic fx or hip dislocation
If ortho trauma is not surgically emergent, how is pt treated in the meantime
- analgesia
- immobilization of fracture/injury
When ortho surgery is delayed, what are 3 physiologic considerations that could affect pt
- INC inflammation
- possible BL
- infection potential
What are immediate airway management considerations for c-spine injury (3)
C-collar
immobility
nerve compromise
What alternate intubation strategies are used when c-spine is not cleared or is injured
Awake intubation
Video laryngoscopy
If c-spine is not cleared or is injured, what considerations must the anesthetist take on intubation
- head/neck mobility is hindered
- full jaw mobility is hindered
what important component of preoperative assessment should be charted r/t c-spine surgery
Upper extremity assessment
Concerns w/ AO instability and intubation and anesthesia
Could promote SUBLUXATION or VERTERBRAL ARTERY OCCLUSION
can impede cerebral perfusion
can be worse w/ arthritic conditions
Considerations for the CRNA when c-collar is present
- MOBILITY IS LIMITED
- Cannot open mouth as wide
- Use video laryngoscopy
What s/sx can be present with C3-C5 injury and why
Inability to:
- cough
- handle secretions
- manage ventilation (MAY NEED VENT SUPPORT)
Why:
b/c C3-3C5 control DIAPHRAGM FXN
What pulmonary capacity may be affected w/ C5 - T7 injury and WHY
DEC VC 60%
b/c C5-T7 manages accessory muscle fxn
General treatment for c-spine injury
- meds
- immobility
- traction
- surgery (cervical decompression &/or lami)
What pt may pt be in for C-spine surgery
Supine
Prone
Seated
Postop considerations for c-spine surgery (5)
- dysphagia
- dysphonia
- airway compromise
- airway edema
- brace/halo
What should be considered If pt has postop airway edema following c-pine surgery
- May not be able to extubate
- Position may contribute to edema (prone**)
How can the CRNA assess risk for c-spine postop airway edema following prone positioning
presence of edema to tongue, lips, or eyes
List c-spine procedures
decompression laminectomy fusion foraminotomy discectomy disk replacement
describe each surgical procedure
decompression
laminectomy
fusion
decompression:
release pressure from spinal nerves
laminectomy:
cervical or lumbar d/t SPINAL STENOSIS of lamina
fusion:
intervertebral fusion of 2 bodies to stabilize vertebra
done WITH discectomies
describe each surgical procedure
foraminotomy
discectomy
disk replacement
foraminotomy:
widening of vertebral foramen
allows SN to exit spinal canal
discectomy:
removal of damaged or herniated disc
disk replacement:
remove disc & replace w/ artificial one
What are spinal disease processes that may require surgery (6)
- Arthritis
- bone spurs
- spinal tumors
- DJD
- spinal stenosis
- conditions causing spinal nerve or cord compression
What are pre/post-op considerations for c-spine surgery (5)
- Admission status (in/outpt)
- nerve injury assessment
- mobility assessment
- Pain mgmt plan
- possible delirium
Pain mgmt considerations for pre/postop c-spine pts
- opioids–> PCA/IV/PO
- Chronic pain
- Medication dependence or addiction considerations
What factors should be considered and influence delirium in postop c-spine pt
- Elderly
- ->know baseline
- Hemostasis
Associated fractures/trauma with lumbar spine injury
- long bone injuries
- Pelvic fractures
- abdominal injury
Neuro assessment for lumbar spine injuries
FOCUS ON LOWER EXTREMITIES
- tolerable fxnl pain score
- flaccid LE?
- DEC ROM
- neuropathies
Treatment for lumbar spine injuries
meds
immobility 9braces)
traction
surgery
List lumbar spine procedures
- lumbar spine decompression
- laminectomy
- fusion
- foraminotomy
- discectomy
- disk replacement
Airway managment for lumbar spine surgery
GETA
Surgical immobility considerations for lumbar spine sx
immobility?
could neuraxial ane fail
Is neuraxial anesthesia appropriate for lumbar spine sx
why
NO
Risk of neuraxial failure
risk of pt moving during sx
used as adjunct for postop pain if indicated
Pre/post-op lumbar sx considerations
- admission status can determine meds given
- nerve assessment pre vs postop
- mobility assessment pre vs postop
- pain mgmt
- delirum esp in elderly
Blood loss considerations in lumbar spine surgery
- > 50% pts get blood transfusion
- large bore IVs & a-line
- autologous donation
- cell saver
- hypotensive technique
- fluid mgmt
- possible fibrinolytics
Describe purpose/considerations of hypotensive technique in lumbar surgery
- DEC amount of blood loss
- MAP 50-60 mm hg ok in healthy pts
- Do they have comorbidities
- organ perfusion
Airway Prone positioning complications
- ETT kinking
- ETT Dislodgement
- Airway edema
Complications r/t airway edema from prone positioning
- may delay postop extubation
- longer surgery = more airway edema
- LMA NOT indicated
General prone complications
Airway problems
Abdominal pressure to epidural veins
Head/neck malpositioning
Ocular complications
Prone positioning concerns r/t abdominal pressure
Pressure transmitted to epidural veins can INC bleeding
Prone positioning concerns r/t head/neck perfusion
Can be even more DEC w/ hypotensive technique
Head and neck complications r/t prone position
- prevent hyperflexion/extension of neck
- retinal injury
- corneal abrasion
- suborbital nerve injury
- excessive neck rotation
Describe these head/neck complications r/t prone positioning
- retinal injury
- corneal abrasion
retinal injury:
-d/t external pressure and compression
corneal abrasion:
-d/t lack of lubricant or coverage
Describe these head/neck complications r/t prone positioning
- suborbital nerve injury
- excessive neck rotation
suborbital nerve injury:
-d/t headrest pressure
excessive head rotation can lead to:
- brachial plexus problems
- pressure on vertebral arteries
2 ocular complications associated w/ prone positioning
- retinal artery or vein occlusion
- ischemic optic neuropathy
Describe retinal artery or vein occlusion complication
- unilateral visual field loss
- painless
- usually position related
Describe the 2 types of ischemic optic neuroapthy
ANTERIOR
- anterior portion of optic nerve
- early onset (<24 hours)
- EDEMA
POSTERIOR
- Posterior portion of optic nerve
- late onset (>24 hrs)
- NO EDEMA
- less collateral blood supply
Causes and risk factors (7) for ION
causes:
DEC BF
DEC O2 delivery
risk factors:
- comorbidities don’t necessarily contribute
- > 1000 ml BL
- prone for >6 hrs
- wilson frame use
- obesity
- colloid fluid mgmt DEC risk
- male gender INC incidence
Important general considerations for lumbar spine surgery
- generally more bloody
- longer procedure time esp w/ multi-level/procedure
- anesthetic mgmt
- blood loss mgmt
- positioning and pressure points
- perfusion
What should be considered with potential BL in lumbar spine surgeries
need to have:
t&c
consents for blood
autologous or cell saver use?
Preop VS assessment and considerations intraoperatively for shoulder surgery
- are HR & BP controlled
- DEC BP intraop
- CEREBRAL PERFUSION
Considerations for cerebral perfusion during shoulder surgery
- pt is in sitting position
- surgeon may request lower BP (map~60 mmhg)
Airway considerations for shoulder surgery
- GETA
- may be difficult to access airway once draped
- head is up and away
- SECURE AIRWAY prior to start
Shoulder preop exam
- baseline VS
- pre-existing nerve issues
- examine pupils
Common positioning considerations for shoulder sx
- beach chair w/ headrest
- lateral decub
considerations:
head neutral
padding
eye protections
General shoulder surgery considerations
eye protection
upper arm NIBP
invasive BP may be needed
Anesthetic technique for shoulder sx
combined
- GETA
- regional as adjunct
regional techniques for shoulder sx
brachial plexus block
interscalene block
supraclavicular block
complications of interscalene block
BEZOLD-JARISCH REFLEX
- INC catecholamine release d/t:
- -cardiac inhibitory reflex
- -DEC VR
describe the bezold-jarisch reflex
- DEC BP/HR
- venous pooling
- DEC preload
- hypercontractile ventricle
- DEC intraventricular volume
Treatment considerations for bezold-jarisch reflex
FLUID to increase intraventricular volume
complications of brachial plexus block
HEMIDIAPHRAGMATIC PARESIS -respiratory depression HORNER SYNDROME hoarsness dysphagia
describe horner syndrome r/t brachial plexus block
- blockage of sympathetic stellate ganglion block
- ipsilateral response
- -drooping eyelid
- -pupil constriction
- -sinking eyeball
preop considerations for humerus/elbow surgery
- nerve injury present?
- INC risk of nerve palsy d/t malpositioning
- presence of arthritis
Positioning during humerus sx
supine or lateral
Types of RA for humerus sx
brachial plexus block
infraclivicular block
axillary block
Considerations for GA and humerus sx
positioning
procedure length
immobility
What nerve should be covered w/ RA for tourniquet use in upper arm surgery
MUSCULOCUTANEOUS NERVE
Tourniquet inflation and documentation for upper arm surgery
~100 mmHg >SBP
document: inflation time (exact) deflation time (exact) total inflation in minutes inflation pressure inflation changes
Postop considerations for upper arm surgery
pain mgmt (systemic vs RA) immobility (splints/braces)
RA techniques for lower arm surgery
axillary block
bier block
Postop considerations for UE ortho sx
immobility
pain control to aid in adls
anesthetic to optimize recovery
