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1
Q

What can makes ortho surgeries complicated

A

Co morbidities like CAD, stents, anemia, COPD

Meds like beta blockers, anticoags, lisinopril

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2
Q

What are the challenges with venous access

A

Intraoperative positioning

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3
Q

What are some diseases that contribute to injury

A

osteoporosis

Osteoarthritis rheumatoid arthritis

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4
Q

What is osteoarthritis and the symptoms

A 
Loss of articular cartilage d/t INFLAMMATION
Symptoms:
Pain
Crepitance
decreased mobility
joint deformities
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5
Q

What is osteoporosis? Etiology?

A

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
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6
Q

What common injuries can occur w/ osteoporosis

A
  • Stress fractures
  • Spine fx (thoracic or lumbar compression fx)
  • Proximal femur/humerus
  • Wrist
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7
Q

What meds may ppl w/ osteoporosis take

A

fosamax
actonel
boniva
reclast

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8
Q

What joints does OA effect

A

weight bearing joints/spine

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9
Q

What medications do pts take for OA

A

NSAIDs, celebrex, opioids

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10
Q

What heberdon nodes vs bouchard nodes

A

swelling and spurring of DISTAL interphalangeal joints

swelling and spurring of PROXIMAL interphalngeal joints

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11
Q

What is the concern for ppl with heberdon or bouchard nodes

A

Can interfere w/ function, ADLs and surgical positioning

Take care w/ positioning

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12
Q

What are important considerations for the preop eval in pts w/ OA or osteoporosis (5)

A
  • What joints are involved
  • Neurovascular assessment
  • Functional pain level (chronic pain?)
  • Constraints on surgical positioning
  • Type of anesthetic
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13
Q

What is rheumatoid arthritis

A

Chronic & systemic inflammatory autoimmune dx w/ progressive tissue damage

Joint synovitis/connective tissue inflammation

  • bone erosion
  • cartilage destruction
  • impaired joint integrity & fxn
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14
Q

Where does RA commonly start

What are the symptoms

A

starts in hands and wrists

pain, stiffness (MORNING STIFFNESS = HALLMARK)

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15
Q

What signs may be present on examination of joints in pts w/ RA

A

SQ nodules surround joints & bony prominence

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16
Q

How is RA diagnosed & with what examines

A

Diagnosed w/ lab tests

ELEVATED LABS

  • rheumatoid factor
  • anti-IG antibody
  • C-reactive protein
  • Erythrocyte sedimentation rate (ESR)
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17
Q

What is first line treatment for RA and implications for anesthesia

A

CORTICOSTEROIDS

exogenous steroids suppress production of endogenous steroids
pt may need “stress dose” before surgery

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18
Q

What medications are used for RA

A 
Steroids
NSAIDs
Opioids
Methotrexate
Hydroxychloroquine 
infliximab
Entanercept
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19
Q

What are anesthesia concerns for pt w/ RA

A

-Limited TMJ movement
-Narrowed glottic opening
-AO instability or subluxation
-

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20
Q

Describe the complications of AO instability or subluxation in the RA pt

A

Can affect flexion of the neck:

  • ->spinous process displacement can impinge on SC and medulla
  • ->Shifting can occlude arteries
  • ->Perfusion can be interrupted
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21
Q

Describe specific symptoms w/ AO sublux

A

HA
Neck pain
Neuro symptoms in arms and legs w/ movement
Bowel/bladder dysfunction

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22
Q

Describe specific symptoms with vertebral artery occlusion

A

N/V
Dysphagia
Blurred vision
TRANSIENT LOC (MOST COMMON**)

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23
Q

Anesthesia preoperative concerns in the RA pt (7)

A 
>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
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24
Q

Preop considerations in the pt w/ RA

A

> Other orthopedic problems
Medications taken
CNS concerns

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25
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
26
What are risk factors for delirium in pt w/ RA (5)
``` Age EtOH use Preop dementia Cognitive impairment Anesthesia ```
27
List triggers for altered CNS in the pt w/ RA
``` Hypoxemia hypotension hypercarbia hypervolemia infection abnormal lytes pain benzos/anticholinergics ```
28
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 ```
29
What are overall benefits of regional vs GA
Improved pain mgmt single shot or cath Preemptive analgesia May INC therapy participation
30
What are some orthopedic complications
Emboli (fat, air) DVT PE
31
What are the most common causes of fat embolizatoin
long bone fx/trauma cement use bilat TKA hypovolemic shoxk
32
What is the source of fat embolism
The medullary canal release of Medullary bone (marrow) Yellow or red marrow (contains fat)
33
What is the fat embolism syndrome triad of symptoms | When may these symptoms present
Triad: dyspnea confusion petechia Present in 12 - 72 hours
34
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
35
What is the etiology of fat embolism syndrome
- capillary ENDOTHELIAL BREAKDOWN - BLOCKAGE of capillary CIRCULATION - Triggering of SYSTEMIC INFLAMMATORY CASCADE
36
What are general symptoms of fat embolism therapy
Hypoxemia Resp failure (pulm, edema, ARDS) Neuro impairment
37
What is the most common cause of mortality r/t fat embolism
ARDS
38
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
39
What are minor symptoms associated w/ FES
Fever (>100.4*F) Tachy (>120 bpm) Jaundice Renal changes
40
Management of FES
- TREATMENT (prompt surgery) - Early recognition - Stabilization of fx - Aggressive & early respiratory/circulatory support - Minimize stress response
41
How can the stress response be minimized in FEW
Address hypoxia, hypotension, DEC end-organ perfusion: - Oxygenate - Maintain BP - Maintain volume status
42
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)
43
Describe risk factors associated w/ DVT/PE (6)
``` Obesity Age >60 yo Procedure length >30 min Use of tourniquet Lower extremity fx Immobilization >4days ```
44
Which surgeries pose the greatest risk for DVT/PE (3)
Hip surgery TKA Lower extremity trauma
45
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 ```
46
How does neuraxial anesthesia affect DVT/PE
INC LE venous blood flow d/t sympathectomy LA have systemic anti-inflammatory properties DEC plateley reactivity
47
When preparing for neuraxial anesthesia, what pt medications should be considered
``` Antiplatelets Thrombolytics Fondaparinux Direct thrombin inhibitors Therapeutic LMWH ```
48
What medications and when should be considered for thromboprophylaxis
LMWH (IV/SQ) 12 hours preop or postop
49
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
50
When can neuraxial anesthetic be performed for a pt on warfarin
**When INR = 1.5**
51
What antifibrinolytic is commonly used in orthopedic surgeries
TXA (tranexamic acid)
52
Which orthopedic surgeries commonly use TXA | What is the rationale
TKA in THA To control BL and DEC blood transfusions
53
How is TXA a to administered ortho pts and WHEN
IV, topical, PO prior to incision
54
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
55
What is the dosing for TXA in orthopedic surgeries | MAX total dose
10 - 30 mg/kg | MAX 2.5 gm
56
What is the purpose of using a tourniquet during orthopedic surgeries
DEC intraop EBL Provides bloodless field for better visualization Exsanguination
57
What is the result of exsanguination of operative limb
INC BV into central circulation
58
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)
59
What are the documentation components of tourniquet use (5)
- inflation time - deflation time - TOTAL inflated time in minutes - inflation pressure - any pressure changes
60
What are complications associated w/ tourniquet use (4)
- Nerve injury - Rhabdomyolysis - ischemia - mechanical trauma
61
What are tourniquet risk preventative measures
Minimize risk by deflating tourniquet over 20 - 30 mins to allow for reperfusion SLOW deflation
62
Patient s/sx to be aware of during tourniquet use
- pain after 1 hr of inflation - INC HR & BP - Diaphoresis
63
What pain path is tourniquet pain associated with
May be r/t regression of regional unmyelinated C fibers firing
64
Describe the process of using double tourniquet during inflation & deflation
INFLATION -proximal 1st DEFLATION -distal 1st
65
What factors influence pain w/ tourniquet use
- tourniquet time - anesthetic technique - dermatomal spread (peripheral nerve coverage) - LA & dose (density) - tourniquet use
66
What are potential negative effects of tourniquet use
- metabolic acidosis - INC K+ - INC CO2 - INC HR - HTN
67
What can attenuate the negative effects of tourniquet use
SLOW deflation | -slow reperfusion decreases negative effects
68
What s/sx are present following tourniquet deflation
- pain relief at site - DEC CVP - DEC BP - DEC temp - Transient lactic acidosis - transient INC CO2
69
How can transient hypercarbia from tourniquet use be addressed
INC Vm (INC Vt or RR)
70
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
71
List emergency ortho surgery indications (5)
- vascular compromis - compartment syndrome - neuro impairment - bone infection/sepsis - unstable pelvic fx or hip dislocation
72
If ortho trauma is not surgically emergent, how is pt treated in the meantime
- analgesia | - immobilization of fracture/injury
73
When ortho surgery is delayed, what are 3 physiologic considerations that could affect pt
- INC inflammation - possible BL - infection potential
74
What are immediate airway management considerations for c-spine injury (3)
C-collar immobility nerve compromise
75
What alternate intubation strategies are used when c-spine is not cleared or is injured
Awake intubation | Video laryngoscopy
76
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
77
what important component of preoperative assessment should be charted r/t c-spine surgery
Upper extremity assessment
78
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
79
Considerations for the CRNA when c-collar is present
- MOBILITY IS LIMITED - Cannot open mouth as wide - Use video laryngoscopy
80
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
81
What pulmonary capacity may be affected w/ C5 - T7 injury and WHY
DEC VC 60% b/c C5-T7 manages accessory muscle fxn
82
General treatment for c-spine injury
- meds - immobility - traction - surgery (cervical decompression &/or lami)
83
What pt may pt be in for C-spine surgery
Supine Prone Seated
84
Postop considerations for c-spine surgery (5)
- dysphagia - dysphonia - airway compromise - airway edema - brace/halo
85
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**)
86
How can the CRNA assess risk for c-spine postop airway edema following prone positioning
presence of edema to tongue, lips, or eyes
87
List c-spine procedures
``` decompression laminectomy fusion foraminotomy discectomy disk replacement ```
88
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
89
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
90
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
91
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
92
Pain mgmt considerations for pre/postop c-spine pts
- opioids--> PCA/IV/PO - Chronic pain - Medication dependence or addiction considerations
93
What factors should be considered and influence delirium in postop c-spine pt
- Elderly - ->know baseline - Hemostasis
94
Associated fractures/trauma with lumbar spine injury
- long bone injuries - Pelvic fractures - abdominal injury
95
Neuro assessment for lumbar spine injuries
FOCUS ON LOWER EXTREMITIES - tolerable fxnl pain score - flaccid LE? - DEC ROM - neuropathies
96
Treatment for lumbar spine injuries
meds immobility 9braces) traction surgery
97
List lumbar spine procedures
- lumbar spine decompression - laminectomy - fusion - foraminotomy - discectomy - disk replacement
98
Airway managment for lumbar spine surgery
GETA
99
Surgical immobility considerations for lumbar spine sx
immobility? | could neuraxial ane fail
100
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
101
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
102
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
103
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
104
Airway Prone positioning complications
- ETT kinking - ETT Dislodgement - Airway edema
105
Complications r/t airway edema from prone positioning
- may delay postop extubation - longer surgery = more airway edema - LMA NOT indicated
106
General prone complications
Airway problems Abdominal pressure to epidural veins Head/neck malpositioning Ocular complications
107
Prone positioning concerns r/t abdominal pressure
Pressure transmitted to epidural veins can INC bleeding
108
Prone positioning concerns r/t head/neck perfusion
Can be even more DEC w/ hypotensive technique
109
Head and neck complications r/t prone position
- prevent hyperflexion/extension of neck - retinal injury - corneal abrasion - suborbital nerve injury - excessive neck rotation
110
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
111
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
112
2 ocular complications associated w/ prone positioning
- retinal artery or vein occlusion | - ischemic optic neuropathy
113
Describe retinal artery or vein occlusion complication
- unilateral visual field loss - painless - usually position related
114
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
115
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
116
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
117
What should be considered with potential BL in lumbar spine surgeries
need to have: t&c consents for blood autologous or cell saver use?
118
Preop VS assessment and considerations intraoperatively for shoulder surgery
- are HR & BP controlled - DEC BP intraop - CEREBRAL PERFUSION
119
Considerations for cerebral perfusion during shoulder surgery
- pt is in sitting position | - surgeon may request lower BP (map~60 mmhg)
120
Airway considerations for shoulder surgery
- GETA - may be difficult to access airway once draped - head is up and away - SECURE AIRWAY prior to start
121
Shoulder preop exam
- baseline VS - pre-existing nerve issues - examine pupils
122
Common positioning considerations for shoulder sx
- beach chair w/ headrest - lateral decub considerations: head neutral padding eye protections
123
General shoulder surgery considerations
eye protection upper arm NIBP invasive BP may be needed
124
Anesthetic technique for shoulder sx
combined - GETA - regional as adjunct
125
regional techniques for shoulder sx
brachial plexus block interscalene block supraclavicular block
126
complications of interscalene block
BEZOLD-JARISCH REFLEX - INC catecholamine release d/t: - -cardiac inhibitory reflex - -DEC VR
127
describe the bezold-jarisch reflex
- DEC BP/HR - venous pooling - DEC preload - hypercontractile ventricle - DEC intraventricular volume
128
Treatment considerations for bezold-jarisch reflex
FLUID to increase intraventricular volume
129
complications of brachial plexus block
``` HEMIDIAPHRAGMATIC PARESIS -respiratory depression HORNER SYNDROME hoarsness dysphagia ```
130
describe horner syndrome r/t brachial plexus block
- blockage of sympathetic stellate ganglion block - ipsilateral response - -drooping eyelid - -pupil constriction - -sinking eyeball
131
preop considerations for humerus/elbow surgery
- nerve injury present? - INC risk of nerve palsy d/t malpositioning - presence of arthritis
132
Positioning during humerus sx
supine or lateral
133
Types of RA for humerus sx
brachial plexus block infraclivicular block axillary block
134
Considerations for GA and humerus sx
positioning procedure length immobility
135
What nerve should be covered w/ RA for tourniquet use in upper arm surgery
MUSCULOCUTANEOUS NERVE
136
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 ```
137
Postop considerations for upper arm surgery
``` pain mgmt (systemic vs RA) immobility (splints/braces) ```
138
RA techniques for lower arm surgery
axillary block | bier block
139
Postop considerations for UE ortho sx
immobility pain control to aid in adls anesthetic to optimize recovery

Advanced principles (2 decks)

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