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Mar: Sem 5 - Adv. Principles A > Exam 1: Orthopedic Anesthesia > Flashcards

Exam 1: Orthopedic Anesthesia Flashcards

1
Q

What are the two biggest factors associated with development of osteoporosis?

A
  • Elderly age
  • Menopause/post-menopause
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2
Q

What hormonal changes are characteristic of osteoporosis?

A
  • ↑ PTH
  • ↓ Vit D
  • ↓ HGH
  • ↓ Insulin-like growth factors
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3
Q

What are the four most common meds used to treat osteoporosis?

A

dronate drugs
- Fosamax (Alendronate)
- Actonel (Risedronate)
- Boniva (Ibandronic Acid)
- Reclast (Zoledronate)

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4
Q

Differentiate between Bouchard’s nodes and Heberden’s nodes.

A
  • Bouchard’s = proximal interphalangeal joints
  • Heberden’s = distal interphalangeal joints
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5
Q

Medical management for Osteoarthritis

A
  • NSAIDS: meloxicam
  • COX2 inhibitor: celebrex
  • Topical treatment (voltarin is now a over the counter drug)
  • Intra-articular therpy (steroid injection)
  • Chondroprotective agents
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6
Q

What drug is the most common chondroprotective agent that helps protect the articular joint?

A

Glucosamine

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7
Q

What anesthetic considerations should be given to glucosamine?

A

Glucosamine needs to be stopped two weeks prior to surgery due to PLT aggregation inhibition.

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8
Q

Arthritis characterized by morning stiffness that improves throughout the day is….

A

Rheumatoid arthritis

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9
Q

Arthritis that is characterized by worsening symptoms throughout the course of the day is…

A

Osteoarthritis

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10
Q

What labs are typically elevated in a patient with rheumatoid arthritis?

A
  • ↑ Rheumatoid factor (RF)
  • ↑ Anti-immunoglobulin antibody
  • ↑ C-reactive protein (CRP)
  • ↑ Erythrocyte Sedimentation Rate (ESR)
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11
Q

What common dose of stress dose glucocorticoid is used for RA patients?

A

50 - 100mg hydrocortisone (Solu-cortef) or dexamethasone

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12
Q

What two TNFα inhibitors are commonly used to treat RA?

A
  • Infliximab
  • Etanercept
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13
Q

Which of the following drugs treat RA?
- Methotrexate
- Hydroxychloroquine
- Sulfasalazine
- Leflunomide

A

Trick question. All of them do
- Methotrexate
- Hydroxychloroquine
- Sulfasalazine
- Leflunomide

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14
Q

What airway concerns should be considered with RA patients?

A
  • Limited TMJ movement
  • Narrowed glottic opening
  • Cricoarytenoid arthritis
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15
Q

Where is the most instability typically located in the cervical spine of RA patients?

A

Atlantoaxial Junction

(be careful not to displace the odontoid process and impinge on the c-spine or vertebral arteries)

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16
Q

What are the signs and symptoms of atlantoaxial subluxation?

A
  • Headache
  • Neck pain
  • Extremity paresthesias (especially with movement)
  • Bowel/bladder dysfunction
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17
Q

What are the signs/symptoms of vertebral artery occlusion?

A
  • N/V
  • Dysphagia
  • Blurred Vision
  • Transient LOC changes
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18
Q

What ocular syndrome is typical of RA patients?

A

Sjogren’s syndrome

(Dry eyes and mouth)

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19
Q

What pulmonary issues are associated with RA?

A
  • Interstitial fibrosis
  • Restricted ventilation
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20
Q

Additional anesthesia concerns for RA:
- vascular
- cardiac
- GI
- Renal

A
  • Vasculiltis
  • Pericarditis or cardiac tamponade
  • Gastric ulcers
  • Renal insufficiency
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21
Q

Preop eval for RA

A
  • Joint involvment
  • neuro assessment (where is the numbeness and tingling)
  • pain level at BL
  • surgical positioning and mobility
  • consider the type of anesthetic (regional and pt comfort, ability to remain still for procedure, post ROM)

always establish the baseline in preop

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22
Q

What type of ventilatory settings would be utilized for an RA patient exhibiting a restrictive ventilatory pattern?

A

Pressure Control @ 5mL/kg

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23
Q

What artery is typically injured due to pelvic fractures? Where is the bleeding located in this instance?

A

Iliac artery → retroperitoneal space bleeding

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24
Q

What is the typical worst complication of long bone fractures?

A

Bone marrow fat embolism

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25
Q

ABCD’s of trauma anesthesia (how to do a trauma RSI)

A
  • MILS
  • preoxygenate (100% 10-15L/min for 3 mins minimum) can preoxygenate before putting on monitors in this case
  • cricoid pressure sellick maneuver/BURP (10lbs of pressure
  • induction with medications (ketamine of etomidate then muscle relaxation)
  • apenic ventilation (careful with modified RSI)
  • DL or LMA after 3 attempts
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26
Q

What technique is used for intubation of a patient who has c-spine concerns?

A

MILS

Manual In-Line Stabilization

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27
Q

Describe the MILS technique

A
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28
Q

What is the mechanism of action of warfarin?

A

Warfarin inhibits Vitamin K epoxide reductase and limits the availability of Vitamin K throughout the body

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29
Q

What is the mechanism of action of LMWH?

A

LMWH binds to antithrombin thus → no thrombin → no fibrinogen forming into fibrin

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30
Q

What are some typical triggers for delirium?

A
  • Hypoxemia
  • Hypotension
  • Hypercarbia
  • Sleep Deprivation
  • Hypervolemia
  • Infection
  • Electrolyte abnormalities
  • Pain
  • Benzos (Castillo says debatable)
  • Anticholinergics
  • Circadian Rhythm disruption
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31
Q

Pre-op eval of lungs

A
  • age related:
    • decreased PaO2
    • increased closing volume
    • FEV1 decreases
  • Obesity
  • OSA (stop-bang questionnaire)
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32
Q

FEV₁ decreases by ___% for each decade of life.

A

10%

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33
Q

What occurs with closing volume as we age?

A

Closing volume increases.

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34
Q

What is the goal of regional anesthesia vs general anesthesia?

A

Avoid:

  • DVT
  • PE
  • EBL
  • Respiratory complications
  • Death
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35
Q

With placement of what device is fat embolism syndrome most likely to occur?

A

Femoral Medullary Canal Rod (IM nail/rod)

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36
Q

What is the s/s Triad of fat embolism syndrome?
When do s/s typically present?

A
  1. Dyspnea
  2. Confusion
  3. Petechiae

Typically presents in 12 - 72 hrs

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37
Q

What lab findings are noted with fat embolism syndrome?

A
  • Fat macroglobulinemia
  • Anemia
  • Thrombocytopenia
  • ↑ ESR
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38
Q

What is ESR? What are normal values for males and females?

A
  • Erythrocyte Sedimentation Rate
  • Male: 0 - 22 mm/hr
  • Female: 0 - 29 mm/hr
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39
Q

What minor s/s can be construed to characterize fat embolization syndrome?

A
  • Fever
  • ↑HR
  • Jaundice
  • Renal Changes
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40
Q

What are the anesthetic management techniques for fat embolization syndrome?

A

Supportive Therapy early recognition
- stabilization of fracture
- 100% FiO₂
- No N₂O
- IV Heparin
- Aggressive and early CV & Resp support (could pregress to ARDS yikes)

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41
Q

What factors contribute to the development of DVT’s?

A
  • Lack of Prophylaxis
  • Obesity
  • > 60yrs old
  • > 30min procedure
  • Tourniquet use
  • > 4 days immobilization
  • > Lower extremity fracture
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42
Q

Which three surgery types present the greatest risk for DVT formation?

A
  • Hip surgery
  • TKA
  • Lower extremity trauma
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43
Q

When does LMWH need to be initiated?

A

12 hours preop
or
12 hours postop

Castillo hinted this would be on the test

44
Q

Can neuraxial anesthesia be done after LMWH has been given?

A

Yes, if 10 - 12 hours after the dose.

Delay next dose 4 hours and remove catheter 2+ hours before next dose

45
Q

Can an epidural be placed in a patient on LMWH anticoagulation therapy?

A

No. No indwelling catheters

46
Q

Neuraxial catheters must be removed ___ hours before the intiation of LMWH therapy.

A

2 hours

47
Q

Can a patient have neuraxial anesthesia if on warfarin?

A

Only if the INR is ≤ 1.5

48
Q

Flip card for Anticoagulation guidelines for Neuraxial procedures.

A
49
Q

Flip card for additional Anticoagulation guidelines for Neuraxial procedures.

A
50
Q

What advantages does neuraxial anesthesia present in the prevention of DVT’s?

A
  • ↑ extremity venous blood flow (sympathectomy).
  • LA systemic anti-inflammatory properties.
  • ↓ PLT reactivity
51
Q

What is the maximum dose of TXA? (Tranexamic Acid)

A

2.5 g

52
Q

What is typical dosing of TXA?

A

10 - 30 mg/kg

1000mg is typical

adminstered before incision (think about single dose vs repeated dose)

53
Q

Tourniquet pain typically begins ___ minutes after application.

A

45 min

54
Q

The width of a tourniquet must be greater than ____ its diameter.

A

½

apply over padding and exanguinate the limb before inflation

55
Q

How long can tourniquets be placed on an extremity?

A
  • 2 hours is typically not exceeded
  • 3 hours is max.
56
Q

What mmHg is typically used for thigh tourniquets?

A

300 mmHg
(or 100 mmHg > SBP)

57
Q

What mmHg is typically used for arm tourniquets?

A

250 mmHg
(or 50 mmHg > SBP)

58
Q

When utilizing a double tourniquet, it is important to remember to…

A

inflate proximal → deflate distal

59
Q

What occurs with tourniquet deflation?

A
  • Transient lactic acidosis
  • Transient Hypercarbia (thus V̇T)
  • ↑ HR
  • ↓ pain
  • ↓ CVP, BP, & temp
60
Q

Lecture 2 start

What are some important points of assessment necessary for upper body procedures preoperatively?

A
  • Baseline vitals
  • Airway
  • Pre-existing nerve conduction issues
  • Examine pupils
61
Q

What are the cardiac consequences of sitting/Beach Chair position?

A
  • ↓ CO & BP
  • ↑ HR & SVR

Due to pooling of blood in lower body.

62
Q

What are the respiratory consequences of sitting/Beach Chair position?

A
  • ↑ FRC & lung volumes
63
Q

What are the neurologic consequences of sitting/Beach Chair position?

A

↓ CBF

64
Q

How is venous air embolism prevented in a beach chair patient?

A

↑ CVP (above 0) to prevent a “suction” effect

If the surgical site is higher than the heart, its possible to entrain air into the open vessels and cause an air embolism

65
Q

Treatment for Venous air embolism

A
  • Tell surgeon so they prevent further entraning of air
  • apply occlusive dressing
  • D/C N2O
  • Bilateral compression of jugular veins
  • Tburg position to trap air in R atrial apex (prevents enterance to pulm. art.
  • withdraw air from central line if its already there (dont place a new one)
  • CV collapse will need pressors
66
Q

The doppler US transducer can be used to indicate a VAE in a sitting pt, where do you place the probe on the chest?

A
  • over RA
    at the 2nd or 3rd intercostal space to the right of the sternum (most sensative non-invasive indicator of VAE)

Most definative is still a TEE

67
Q

What is the characteristic sound of a VAE, and most characteristic monitor change?

A
  • sound = mill-wheel murmur
  • Monitor change = sudden decrease in EtCO2 (decreased perfusion to lungs)
68
Q

In what percent of the population is a patent foramen ovale present?

A

20 - 30 %

69
Q

____ of the neck in a sitting position patient can accidentally extubate them.

A

Hyperextension

70
Q

In a sitting position patient, where would one zero their art line?

A

Tragus of the ear

Establishes knowledge of brain BP & thus perfusion.

this is at the level of that damn Willis Suurkle

71
Q

Sometimes the hammer-dudes want us to lower the BP so they can see the surgical site better, what are ocular conditions do we want to avoid due to the hypotension inherent to the sitting position?

A
  • Retinal Ischemia
  • Ischemia Optic Neuropathy

Also avoid corneal abrasion.

72
Q

There is a 40cm distance from the patients heart to their brain. The patient’s BP measured on the arm is 120/70. What is the estimated BP in the brain?

A

Castillo’s way: 40cm x 0.77mmHg = 30.8mmHg

120 - 30.8 = 89.2mmHg
70 - 30.8 = 39.2mmHg

The patient’s brain BP is 89/39 Thus indicating hypotension and necessary correction.

Easier way: just remember 7.410pH i.e. for every 10cm change from the heart, the pressure changed by 7.4mmHg

40cm away = 4 x 7.4 = 29.6
120-29.6 ~90
70-29.6 ~ 40

73
Q

A standing patient’s NIBP on the arm is 134/92. The distance between the patient’s knee and the NIBP cuff is 120cm. What is the BP in the patient’s knee?

A

120 x 0.77 = 92.4

134 + 92
92 + 92

Patient’s “knee” BP standing up is 226/184

74
Q

What is the Bezold-Jarisch reflex?

A

Cardiac inhibitory reflex resulting in signification HoTN & ↓HR.

75
Q

How do we avoid the Benzold-Jarisch?

A

Increase preload and give zofran upfront

76
Q

What are possible complications of a brachial plexus block?

A
  • Respiratory depression
  • Horner Syndrome
  • Hoarseness
  • Dysphagia
77
Q

Why can respiratory depression occur with brachial plexus blocks?

A

Hemidiaphragmatic Paresis from Phrenic nerve blockade.

78
Q

What is the triad of Horner Syndrome?

A
  • Ptosis
  • Miosis
  • Anhydrosis
79
Q

What are the respiratory consequences of a lateral decubitus position?

A

(VQ mismatch)
- ↓ ventilation of dependent lung.
- ↑ perfusion of dependent lung.

80
Q

During mechanical ventilation in left lateral decubitus patient, which lung is overventilated?

A

Right lung (nondependent lung)

81
Q

During mechanical ventilation in left lateral decubitus patient, which lung more perfused?

A

Left lung (dependent lung)

82
Q

Where is an axillary roll placed on a lateral decubitus patient?

A

Caudad to the axilla to avoid compression of the neurovascular bundle. (Displaces the humeral head away from the brachial plexus)

83
Q

Where should a pulse oximeter be placed in a lateral decubitus patient?

A

Dependent hand to ensure that there is no neurovascular compromise

84
Q

Elbow surgeries need what additional block (in comparison to shoulder surgeries) ?

A

Musculocutaneous nerve

85
Q

Is a patient with a hip fracture induced on the OR table or on the bed/stretcher?

A

Bed/Stretcher to avoid pain from movement to OR table.

86
Q

What are the benefits of neuraxial anesthesia for hip fracture repairs?

A
  • ↓ delirium
  • ↓ DVT
  • ↓ hospital stay
  • Better pain control
87
Q

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

A
  • BCIS (bone cement implantation syndrome)
  • Hemorrhage
  • VTE
88
Q

What chemical is bone cement?

A

PolyMethylMethAcrylate

89
Q

What does bone cement do when introduced to the intramedullary bone surface?

A

Release heat and pressurize (500mmHg!)

Possible embolization of fat, bone marrow, and cement.

90
Q

What is the anesthetic management of BCIS?

A
  • Combat ↓BP and ↓Volume
  • ↑ FiO₂ & SpO₂
91
Q

What are the s/s of BCIS?

A
  • Hypoxia
  • Hypotension
  • Arrythmias
  • pHTN
  • ↓CO
92
Q

In a supine position, spontaneous ventilation favors ____ lung segments, whilst closing volume favors ____ lung segments.

A

Dependent ; independent

93
Q

The most common postoperative peripheral neuropathy is:
a. Ulnar neuropathy
b. Brachial plexus injury
c. Median nerve injury
d. Sciatic nerve compression

A

a. Ulnar Neuropathy

94
Q

Where are the two major sites of injury in ulnar nerve injury?

A

Elbow at the condylar groove and cubital tunnel.

95
Q

How is ulnar nerve nerve injury avoided?

A

Supinate hands (palms up!)

96
Q

What common drugs are often used for “conscious sedation” of a hip dislocation?

A

Ketamine/Propofol Mix
Succinylcholine

97
Q

What are the possible complications of tourniquet placement for knee surgeries?

A
  • Blood loss on deflation (note for 24hrs)
  • Peroneal Nerve Palsy
98
Q

What are the steps to a TKA (Total Knee Arthroplasty) ?

A
  1. Tibial Component
  2. Femoral Component
  3. Patellar Component
  4. Plastic Spacer
99
Q

What three conditions (that anesthesia can control) are most often associated with infection of knee replacements?

A
  • Peri-operative glucose control
  • Post-op hypoxia
  • Post-op hypothermia
100
Q

What medication classes can be used to treat phantom pain from amputation?

A
  • Neuroleptics
  • Antidepressants
  • Na⁺ channel blockers
101
Q

What nerve innervates the plantar surface?

A

Posterior Tibial nerve

102
Q

What nerve innervates the medial malleolus?

A

Saphenous nerve

103
Q

What nerve innervates the interspace between the great & 2ⁿᵈ toes?

A

Deep Peroneal nerve

104
Q

What nerve innervates the space between the dorsum of the foot and the 2ⁿᵈ - 5th toes?

A

Superficial saphenous nerve

105
Q

What nerve innervates the lateral foot and lateral 5th toe?

A

Sural nerve

Mar: Sem 5 - Adv. Principles A (11 decks)

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