Exam 1 (part 2) Flashcards by Olivia Stovenour

when should nerve issues be assessed for?

Preop and post op

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what is the most common position for shoulder surgery?

beach chair
**lat decubitus less common

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safely positioning patients is the responsibility of ______ providers

All

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what are the cardiac changes seen with beach chair

lower extremity blood pooling=decreased central blood volume–>decreased CO and BP; HR and SVR rise to compensate

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what are the respiratory changes seen in beach chair?

increased FRC and lung volumes

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what are the neuro changes seen in beach chair?

decreased CBF

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what is a serious complication seen in beach chair, prone, and reverse T?

Venous air embolism

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how is a VAE prevented?

keeping venous pressure above 0 at the surgical site to decrease the risk of air intake into the venous system

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what % of the general population has a patent foramen ovale (PVO)?

20-30%

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what happens if air enters the right ventricle and then the pulmonary artery?

pulmonary edema and reflex bronchoconstriction

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what are 6 steps to help treat/prevent worsening from a VAE?

–tell surgeon to irrigate and apply occlusive dressing
–discontinue N2O
–bilateral jugular vein compression
place patient in a head down position to trap air in the R atrium
–withdrawal air through a R side catheter
–anticipate CV collapse

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where is an US probe placed to diagnose a VAE in a sitting patient?

over the right atrium
(2nd-3rd ICS right of the sternum)

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what is the most sensitive non-invasive diagnostic for VAE?

doppler ulktrasound

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what is the most definitive diagnostic tool for VAE?

TEE

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what is the characteristic sound of a VAE?

mill wheel murmur

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what standard monitoring tool can be used to determine a decrease in lung perfusion?

decrease in etCO2

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what is the name of the head rest used in beach chair?

allen head rest

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which 3 regional blocks are common for shoulder surgery according to lecture?

brachial plexus, interscalene, supraclavicular

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what are 3 possible injuries to the eyes in beach chair?

corneal abrasion
ischemic optic neuropathy
retinal ischemia
**last 2 are d/t decreased perfusion

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how many mmHg difference for each cm above/below where blood pressure is taken?

0/77 mmHg/cm

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what is the bezold-jarisch reflex?

cardiac inhibitory reflex resulting from venous pooling (decreased preload) and hypercontractile ventricle (decreased intraventricular volume)—>hypotension and bradycardia

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what are the 3 symptoms of horner syndrome?

ptosis
miosis
anhydrosis
**happens on the same side of B plexus injury

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what are 4 potential complications of brachial plexus block?

phrenic nerve paralysis
horner syndrome
dysphagia
hoarseness

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2 common positions for elbow surgery?

supine or lateral decubitis

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what are the 3 regional blocks good for elbow surgery

brachial plexus infraclavicular axillary

what are 2 cardiac changes seen in lateral decubitus?

--CO remains unchanged unless there is an obstruction (kidney rest) --arterial BP may fall d/t decreased vascular resistance (more common in R than L decubitis)

what are respiratory changes seen in lateral decubitus pts who are ventilated?

--decreased ventilation and increased perfusion (gravity) to dependent lung (increased V/Q mismatch) --nondependent lung overventilated **worsens with paralysis or open chest

what are respiratory changes seen in lateral decubitus pts who are spontaneously breathing?

increased ventilation of dependent lung (no V/Q mismatch)

axillary rolls are placed ____ in lateral decubitus to prevent neurovascular compression

caudad

axillary rolls displace the head of the ____ against the _____. this leads to which 2 types of nerve injury?

--humerus, brachial plexus --stretch and compression

how do you assess NV status to the dependent arm while in surgery?

can place pulse ox probe or check radial artery pulse periodically

what is the allen arm rest used for?

to rest the upper arm in lateral decubitus. can also just use pillows

if using a tourniquet for elbow surgery, which nerve could also benefit from a regional block?

musculocutaneous

what helps greatly with pain in the post op elbow/forearm/hand population?

immobilization

for forearm/hand procedures, what position is patient in?

supine arms out

hip fractures are generally considered _______ cases?

emergent

what is the % mortality in the initial hospitalization in hip fracture pts?

10%

gastric motility ____ when trauma occurs

stops/slows significantly

what is the positioning for hip fracture surgery?

supine on fracture table

what are 4 benefits to using neuraxial anesthesia for hip fracture?

--decreased DVT and 1 month mortality --shorter length of hospital stay --lower delirium incidence --improved post-op pain control

what are 3 potentially life threatening complications of total hip arthroplasty?

bone cement implantation syndrome intra/post-op hemorrhage venous thromboembolism

what is the positioning for total hip?

lateral decubitus--operative side up

what are the 2 parts that make up a hip replacement part? lol

acetabular and femoral parts

what are 3 benefits to neuraxial for total hip?

decreased EBL decreased DVT/PE incidence decreased post op delirium incidence

what is the cement used for total hip called?

PMMA or MMA polymethylmethacrylate

what can happen when cement is applied in total hip?

immobilization of fat, bone marrow or cement due to pressure exceeding 500 mmHg in the intramedullary space

PMMA releases:

heat

what 2 things result from systemic absorption of PMMA?

vasodilation and decreased SVR

what 3 things result from PMMA application?

platelet aggregation mircothrombus in the lungs CV instability

what are 5 ways to prevent bone cement implantation syndrome?

--minimize hypotension/hypovolemia --maximize FiO2 --vent hole in femur --lavage femoral shaft --avoid bone cement use if possible

what is the treatment for bone cement implantation syndrome?

increased FiO2, maintain euvolemia, manage hypotension with vasopressors

what is the positioning for hip arthroscopy?

supine with weighted traction

what are the 3 cardiac changes seen in supine with weighted traction?

--equalization of pressures throughout arteries --increased R sided filling and CO --decreased HR and PVR

what are the 4 respiratory changes seen in supine with weighted traction?

--increased perfusion to posterior lungs --diaphragm pushed cephalad --FRC decreases and may fall below closing volume in older pts --all things exacerbated by pregnancy/obesity/ascites

most common post-op peripheral neuropathy:

ulnar nerve

what are the 2 major sites of injury for the ulnar nerve?

condylar groove and cubital tunnel **these are where the nerve is most shallow

what 2 structures form the condylar groove?

medial epicondyle of humerus and olecranon process of ulna

is muscle relaxation required for hip arthroscopy?

yes

which type of hip injury requires a closed reduction?

dislocation

what is the typical anesthetic for a closed hip reduction?

conscious sedation (ex. ketamine and prop)

are hip dislocations painful after closed reduction?

what is the positioning for knee arthroscopy?

supine with knee flexed

is a tourniquet used in knee arthroscopy?

sometimes

what is the positioning for total knee?

supine

what is the preferred anesthetic for total knee?

neuraxial-->decreased 30 day mortality, decreased infection

what 2 nerve blocks are used for total knee?

femoral and sciatic

how do you assess if the peroneal nerve is intact?

dorsiflexion of foot

for a total knee, blood loss begins:

when the tourniquet is deflated and continues for 24 hours

what are the 4 artificial components of a total knee?

tibial femoral patellar plastic spacer

what are 2 common ways to manage pain post op total knee?

indwelling epidural catheter or continuous peripheral nerve block

traffic in the OR decreases the desired _____ flow of air

laminar

what 3 things can contribute to surgical wound infection?

poor glucose control perioperatively post-op hypoxia post-op hypothermia

how much ancef for <70 kg? 70-120 kg? >120 kg?

1G 2G 3G

what are 2 benefits to neuraxial in amputations?

decreased delirium decreased phantom pain

phantom pain onsets within a few ____ of amputation

days

3 triggers for phantom pain?

weather changes emotional stress pressure on remaining area

what are 5 potential causes of phantom pain?

--remapping on nerve signals --damaged nerve endings --scar tissue --physical memory --pain prior to amputation

4 non-Rx treatments for phantom pain

biofeedback relaxation massage TENS unit

3 Rx treatments for phantom pain

neuroleptics antidepressants sodium channel blockers

what are 2 positions common for achilles surgery?

lateral or prone

position for ankle/foot surgeries (other than achilles)?

supine

5 nerves that contribute to regional block for ankle

1. posterior tibial nerve 2. saphenous nerve 3. deep peroneal 4. superficial peroneal 5. sural nerve

what do these nerves serve as sensory for? 1. posterior tibial nerve 2. saphenous nerve 3. deep peroneal 4. superficial peroneal 5. sural nerve

1. plantar surface 2. medial malleolus 3. space b/w big & 2nd toe 4. dorsum of foot, 2nd-5th toes 5. lateral foot, lateral 5th toe