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Advanced Principles of Anesthesia > Exam 3 > Flashcards

Exam 3 Flashcards

1
Q

What is a significant risk for poor outcomes after ortho surgery

A

Older age

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2
Q

What risks were addressed by the Surgical Care Improvement Project (SCIP)

A

Surgical site infection
Postop thromboembolism
Periop glucose management
Maintenance of normothermia

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3
Q

What is the timing for Ancef and Vancomycin

A

Ancef: within 1 hour of incision
Vanc: within 2 hours of incision

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4
Q

What are three things that are used to prevent surgical site infection

A

Sterile technique
Antibiotic irrigation
Antibiotic coated dressings

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5
Q

What makes older patients at increased risk for respiratory complications following orthopedic surgery

A

Decreased arterial O2 tension
Increased closing volumes
Decreased (around 10%) forced expiratory volume

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6
Q

What are 4 considerations for respiratory complications with ortho surgery

A

Elderly are at the highest risk
High rate of obesity and OSA
STOP-bang questionnaire and prudent postop management for OSA
Embolization of bone marrow debris to lungs after athroplasty

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7
Q

Who has a higher risk of periop myocardial morbidity and mortality

A

Older patients

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8
Q

What contributes to cardiac complications of ortho surgery

A

Systemic inflammatory response syndrome
Significant blood loss and fluid shifts
Stress response

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9
Q

What cardiac changes does the stress response from ortho surgery result in

A

Tachycardia
Hypertension
Increased o2 demand
Myocardial ischemia

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10
Q

What is a common complication seen in older patients after ortho surgery

A

Delirium

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11
Q

What factors influence an elderly patient’s development of delirium

A

Increased LOS
Poor functional recovery
ETOH
Pre-op dementia
Psychotropic medications
Multiple comorbid conditions

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12
Q

What are intraop risk factors for neurologic complications

A

Hypoxemia
Hypotension
Hypervolemia
Electrolyte imbalances
Pain
Benzos
Anticholinergic meds

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13
Q

What is the purpose of pneumatic tourniquet

A

Relatively bloodless field
Minimize blood loss
Identification of vital structures (improved visualization)

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14
Q

what is the max amount of time a tourniquet should be applied

A

Two hours

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15
Q

Necessary pressure for tourniquet in upper extremity

A

70-90 mmHg higher than SBP

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16
Q

Necessary pressure for tourniquet in lower extremity

A

Twice the patient’s SBP

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17
Q

How long does it take for abolition of somatosensory evoked potentials and nerve conduction to occur from pneumatic tourniquet

A

Within 30 min

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18
Q

What happens when tourniquet is inflated for >60 minutes

A

Pain and hypertension

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19
Q

What happens when tourniquet is inflated for >2 hours

A

Postoperative neuropraxia

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20
Q

What are the consequences of acid metabolites (thromboxane) being released into central circulation upon tourniquet deflation

A

Transient:
Fall in core temp
Metabolic acidosis
Fall in central venous oxygen tension
Fall in pulmonary and systemic arterial pressures
Increase in end tidal Co2

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21
Q

Which fibers are responsible for burning/aching pain

A

Unmyelinated C fibers

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22
Q

Which fibers are responsible for pinprick, tingling, and buzzing sensations

A

Myelinated A-delta fibers

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23
Q

What can be added to LA solutions for tourniquet pain

A

Opioids, ketorolac, melatonin, clonidine, precedex

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24
Q

Protein binding, clearance, half life of TXA

A

Minimally protein bound
Half life 2-3 hours
Cleared by kidneys

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24
Q

Dose of TXA

A

1 gram in 50ml of any crystalloid over 5-10 minutes, 5-20 minutes prior to incision

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25
Q

Side effects of txa

A

Minimal - nausea, vomiting, diarrhea

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26
Q

Contraindications of TXA

A

Clotting disorders
Acquired defective color vision
Subarachnoid bleed
Active clotting
Hypersensitivity to TXA

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27
Q

Relative contraindications to TXA

A

History of vascular occlusive events
Taking procoagulant
Prescription hormonal contraception

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28
Q

WHat should the BP be for deliberate hypotension

A

SBP between 80-90 or MAP between 50 and 65 in people without HTN
or
30% reduction of baseline MAP in patients with HTN

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29
Q

What patients should deliberate hypotension not be used in

A

history of cardiac, cerebrovascular, renal, or hepatic disease, or severe PVD

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30
Q

When is deliberate hypotension contraindicated

A

pts with uncorrected hypovolemia and severe anemia

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31
Q

What is a potential problem with deliberate hypotension

A

Vision loss

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32
Q

Which ortho surgeries have the highest incidence of thromboembolism such as DVT and PE

A

Pelvic fracture, hip fracture, total knee replacement

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33
Q

What is the leading cause of morbidity and mortality after orthopedic surgery

A

Thromboembolic events

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34
Q

How long should ortho patients receive DVT prophylaxis

A

up to 35 days post op

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35
Q

Risk factors for DVT/PE

A

advanced age, cancer, bed rest, prothrombotic conditions (factor V leiden), and prior DVT/PE

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36
Q

3 Major features of fat embolism syndrome

A

Respiratory insufficiency
Cerebral involvement
Petechial rash

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37
Q

5 Minor features of fat embolism syndrome

A

Pyrexia
Tachycardia
Retinal changes
Jaundice
Renal changes

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38
Q

Lab features of fat embolism syndrome

A

Fat microglobulinemia (required test for confirmation)
Anemia
Thrombocytopenia
High erythrocyte sedimentation rate

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39
Q

What are the consequences of acute extremity compartment syndrome

A

Infection
Muscle necrosis
Contractures
Nerve injury
Chronic pain
Amputation
Death

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40
Q

What are most diagnoses of compartment syndrome related to

A

Fractures, mostly in the lower leg

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41
Q

What is the most common fracture site associated with compartment syndrome

A

Tibial diaphysis: it is frequently injured and the fascial space is already tight

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42
Q

What are the 5 Ps of compartment syndrome

A

Painful onset
Pallor
Paresthesia
Paralysis
Pulselessness

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43
Q

Normal compartment pressures

A

Below 10 mmHg

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44
Q

When does significant injury occur from compartment syndrome

A

When absolute intracompartmental pressure exceeds 30-50

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45
Q

What is the definitive diagnostic tool for compartment syndrome

A

Intracompartmental pressure monitoring (sensitivity 94%)

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46
Q

how long should fasciotomy remain open for

A

at least 48 hours

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47
Q

How are crush injuries treated

A

adding hyperbaric O2

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48
Q

What is the main consequence of sitting/beach chair position

A

Cerebral hypo-perfusion

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49
Q

Where should bp be measured in sitting/beach chair position

A

At the level of the brain

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50
Q

Complications of beach chair/sitting position

A

hypotension/bradycardia
air embolism
pneumothorax
cerebral hypoperfusion

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51
Q

What position gives better limb stability during elbow surgery

A

Prone

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52
Q

What provides greater stability while traction is applied using either weights and counterweights

A

Fracture table

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53
Q

What are the benefits for the patients of arthroscopy

A

Reduced blood loss
Less postop discomfort
Reduced length of rehab

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54
Q

Complications from arthroscopy

A

Subcutaneous emphysema
Pneumomediastinum
Tension pneumothorax from shoulder arthroscopy

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55
Q

Patient positioning complications from arthroscopy

A

Inadvertent extubation
Eye or corneal injury
Visual loss from prone position
Nerve injury

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56
Q

What is the most desirable intervention for tension pneumo

A

Chest tube

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57
Q

How is needle compression done for tension pneumo

A

14 to 18 gauge iv angiocath inserted at the 2nd or 3rd intercostal space anteriorly
OR
the 4th or 5th intercostal space laterally

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58
Q

Advantages of regional (spinal) anesthesia for hip fracture

A

Avoids endotrachial intubation, airway manipulation, and medications that go along with that
Decreases total amount of systemic medication patient receives
May decrease risk of thromboembolism
Vasodilatory effect may help the patient with CHF

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59
Q

What is a cause of acute mortality from pelvic fractures

A

Retroperitoneal bleeding

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60
Q

What are common injuries accompanying pelvic fracture

A

Bladder and urethra

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61
Q

What is a significant risk associated with pelvic fractures

A

DVT and PE

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62
Q

Periop complications of femur fractures

A

MI, dysrhythmias, DVT, pulmonary embolism, delirium

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63
Q

Treatment of displaced femoral neck fracture

A

Replacement

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64
Q

Treatment of intertrochanteric/subtrochanteric fracture

A

Plates, screws, nailsat

65
Q

Treatment of nondisplaced femoral neck fracture

A

Closed reduction or percutaneous pinning

66
Q

What is the most common fracture in younger trauma patients or elderly patients with degenerative arthritis of the knee

A

Tibial plateau or proximal tibia fracture

67
Q

What must you monitor for with a tibial fracture

A

Compartment syndrome

68
Q

Preferred anesthetic techniques for tibia fractures

A

GA or spinal. Regional blocks for pain control if no compartment syndrome

69
Q

What type of regional blocks are appropriate for tibia fracture

A

Popliteal fossa
Sciatic
Femoral
Adductor canal

70
Q

What type of anesthesia is appropriate for upper extrem. fractures

A

GA, regional, or combo.
Brachial plexus block, interscalene

71
Q

What is the purpose of arthroplasty

A

Return motion and function of the joint and restore the controlling function of the surrounding soft tissues

72
Q

What are the goals of arthroplasty

A

Pain relief, stability of joint motion, correction of the deformity

73
Q

What are two risks of total knee arthroplasty

A

Thromboembolism
Bone cement implantation syndrome

74
Q

Anesthetic technique for TKA

A

GA and regional

75
Q

What blood loss can be expected from the femur

A

High blood loss of 500-1000ml
Highly vascular

76
Q

What surgery carries a high risk for venous thromboembolism including DVT and PE

A

Total Hip Arthroplasty

77
Q

Significant Risk factors for bone cement implantation sydrome

A

Pre-existing CV disease
Pre-existing pulmonary HTN
ASA class 3 or higher
Surgical technique (cemented hip arthroplasty)
Pathologic fracture
Trochanter fracture
Long-stem arthroplasty

78
Q

Clinical features of bone cement implantation syndrome

A

Hypoxia
Hypotension
Cardiac arrhythmias
Increased pulmonary vascular resistance
Unexpected loss of consciousness
Cardiac arrest

79
Q

What is the first indication of clinically significant BCIS under GA

A

A fall in ETCO2 concentration

80
Q

What are early signs of BCIS is awake/sedated patients with regional

A

dyspnea and change in consciousness

81
Q

What is the treatment for BCIS

A

Increase fio2 to 100%
Treat like right heart failure - aggressive fluid resuscitation and treat hypotension with alpha-agonists (phenylephrine)

82
Q

What is there a high incidence of with shoulder surgery

A

PONV
Pain
Long recovery time

There is also potential for damage to major vascular structures resulting in major blood loss

83
Q

Position for total shoulder arthroplasty

A

Lateral decubitus
or
modified Fowler (beach chair)

84
Q

What is an important risk to be aware of for shoulder arthroplasty

A

Potential for inadvertent extubation from patient positioning or from surgical manipulations near the patient’s head and neck

85
Q

Anesthetic management for total shoulder arthroplasty

A

GA and regional combo
interscalene block
Supraclavicular block

86
Q

What are consideration for hsoulder arthroplasty

A

Potential for cervical spine injury if excessive stretch or head becomes dislodged during manipulations.
Carefully monitor eyes for pressure.

87
Q

What is used for virtually all surgical procedures of hand and forearm

A

pneumatic tourniquet

88
Q

What anesthesia techniques can be used for forearm and hand surgery

A

brachial plexus blockade, iv regional block, or local with sedation for cases <1 hour.
GA if a longer, more complex case, comminuted fractures, reconstruction of vascular and nerve structures

89
Q

Posterior tibial nerve:

A

Sensation to the plantar surface

90
Q

Saphenous nerve:

A

Innervates the medial malleolus

91
Q

Deep peroneal nerve:

A

Supplies interspace between great and second toes

92
Q

Superficial saphenous nerve:

A

Supplies dorsum of foot and 2nd through 5th toes

93
Q

Sural nerve:

A

Supplies the lateral foot and lateral 5th toe

94
Q

What are the 2 most common reasons hospitalization after ambulatory surgery

A

PONV and pain

95
Q

Techniques for smooth emergence and preventing hematomas for extra thoracic surgery

A

Stable BP or slight hypotension
Prevent PONV
Lidocaine: IV, endotracheal, topical
Precedex bolus or infusion
Titrate opioids to minimize coughing and bucking

96
Q

What is the head angle in semi-fowlers

A

30-90 degrees above horizontal plane

97
Q

Where should the chin be in semi-fowlers

A

1-2 fingerbreadths off the chest to protect the cervical spine

98
Q

What impact does semi fowlers position have on the brain

A

Improved venous drainage from brain
Decreased ICP
Decreased cerebral perfusion

99
Q

Pulmonary impact of semi fowlers position on

A

Increased FRC
Increased compliance
Less access to airway

100
Q

Cardiac implications of semi fowlers position

A

Postural hypotension
Decreased MAP, CVP, SV and CO

101
Q

What nerves are impacted by semi-fowlers

A

sciatic
ulnar
cervical

102
Q

What are the clinical manifestations of venous air embolism

A

Hypoxemia
CO2 retention
Increased dead space
Decreased etco2

103
Q

Treatment for VAE

A

Flood and pack surgical site.
100% oxygen and d/c n2o
Valsava maneuver
T-burg positioning
Hemodynamic support

104
Q

How do you perform valsava maneuver on vent

A

Increase o2 flow, close apl valve, take off vent, squeeze bag for at least 10 seconds. This increases venous pressure and slows air entry

105
Q

What are common causes of pneumothorax

A

Breast surgery
Axillary node dissection
Nerve blocksS

106
Q

S/S of pneumothorax

A

Absent breath sounds on affected side
Hypoxia
JVD
Decreased BP
Increase airway pressure
Increased CVP
Increased HR

107
Q

Treatment of pneumothorax

A

100% o2, d/c n2o
Needle thoracostomy (emergent, unstable): ICS 2-MCL or ICS 4/5 - AAL
Chest tube insertion (definitive treatment if pneumo is large)
Hemodynamic stabilization

108
Q

Max dose lidocaine

A

4.5mg/kg
total max 300mg

109
Q

Max dose lido with epi

A

7mg/kg

110
Q

Max dose bupivicaine

A

2 mg/kg
Total max 175 mg

111
Q

Max dose bupivacaine with epi

A

3mg/kg
total max 500mg

112
Q

Max dose ropivacaine

A

3mg
total max 200mg

113
Q

What is the result of delayed systemic absorption for tumescent anesthesia

A

long lasting and less toxic than other LAs

114
Q

Preliminary max safe dosages for tumescent anesthesia

A

28mg/kg without liposuction
45 mg/kg with liposuction

115
Q

When are there peak serum concentrations of tumescent anesthesia

A

12-16 hours after injection

116
Q

What drugs should be avoided in treatment of LAST

A

Vasopressin
Ca channel blockers
Beta blockers
Sodium channel blockers
LAs
Any negative inotrope

117
Q

What potentiates LAST

A

hypoxia and acidosis

118
Q

Normal IOP

A

10-22 mmHg in the intact normal eye

119
Q

What can a sustained increase in IOP during anesthesia cause

A

Acute glaucoma
Retinal ischemia
Hemorrhage
Permanent visual loss

120
Q

What can cause increased IOP

A

Straining, retching, or coughing during induction increases venous pressure and can increase IOP by 40 mmHg or more

121
Q

What is the effect of hypoxemia and hypoventilation on IOP

A

Increase IOP

122
Q

What is the effect of hyperventilation and hypothermia on IOP

A

Decrease IOP

123
Q

What is a miosis-inducing anticholinesterase that interferes with the metabolism of succinylcholine

A

Phospholine iodide
Causes prolonged paralysis following a single dose of succ

124
Q

Why is topical anesthesia not always appropriate for eye surgery

A

It provides a lesser degree of analgesia and no akinesia of ocular muscles or eyelids

125
Q

How can you prevent systemic absorption of eye drops

A

Have pt close eyes for 60 seconds
Avoid blinking
Block the tear outflow canal by placing index finger over the medial canthus after the eye is closed

126
Q

What cranial nerves are anesthetized by a retrobulbar block

A

III
IV
V
VI
VII

127
Q

Where is a retrobulbar and peribulbar block performed

A

Orbital epidural space

128
Q

What are the risks of retrobulbar block

A

Optic nerve injury
Brainstem anesthesia
Retrobulbar hemorrhage

129
Q

Which occurs first in ocular block, analgesia or akinesia

A

Analgesia precedes akinesia of muscles

130
Q

When can effectiveness of retrobulbar and peribulbar blocks be evaluated

A

Retrobulbar: after 2 minutes
Peri: after 10 minutes

131
Q

If you have akinesia of the muscle do you have analgesia?

A

It is assumed yes, but not guaranteed

132
Q

What is the rarest but most devastating complication of ocular blocks

A

Ocular explosion

133
Q

Indications for GA in ocular surgery

A

Pediatric patient
Lack of patient cooperation
Severe claustrophobia
Inability to communicate
Inability to lie flat
Open-eye injuries
Procedures with durations greater than 2 hours

134
Q

Classes of medications for regional blocks during ocular surgery

A

benzos, narcotics, nonbarbiturates

135
Q

What is the danger of having a sleeping patient during ocular block

A

Sleeping patients can snore and have sudden head movements upon awakening

136
Q

What can cause expulsion of the eye contents

A

Choroidal hemorrhage - occurs when a vessel in the vascular choroidal layer of the eye ruptures, bleeding into the closed cavity and creating an acute rise in IOP

137
Q

What can cause an acute increase in IOP above 40 mmHg during induction

A

Coughing and retching

138
Q

Which induction agents lower IOP

A

Propofol and etomidate
Inhalational agents for infants and children

139
Q

What is the effect of nondepolarizing agents on iop

A

Decreases IOP

140
Q

What can cause EKG changes during ocular surgery

A

Oculocardiac reflex

141
Q

What do patients undergoing eye muscle surgery have an increased incidence of

A

Malignant hyperthermia
Postop nausea

142
Q

What helps to attenuate the increase in IOP caused by laryngoscopy

A

IV lidocaine 1/5-2 mg/kg given 1-1.5 minutes before

143
Q

Ophthalmic complications during regional and general anesthetics are most likely caused by:

A

Patient movement

144
Q

What can cause extrusion of globe contents and jeopardize vision regarding traumatic eye injuries

A

Increased IOP due to a tightly applied face mask, laryngoscopy, intubation, coughing/retching, bucking

145
Q

How do most complications of regional ocular anesthetics occur

A

From direct traumatization of the orbital vessels, globe, and optic nerve

146
Q

What is the initial intervention if the oculocardiac reflex is suspected

A

request that the surgeon release traction or pressure

147
Q

What are the signs and symptoms of globe puncture

A

Intraocular hemorrhage
Rapid increase in intraocular pressure with corneal edema

148
Q

What is a paravertebral block

A

targets spinal nerves on the side of the injection, can be performed at both thoracic and thoracolumbar levels; sympathetic fibers are blocked with less hemodynamic response than epidurals

149
Q

What is the level of block required for breast surgery

A

C7-T6

150
Q

What is the most effective pain management technique for breast surgery

A

paravertebral block

151
Q

What decreases epidural spread during paravertebral block

A

inject slowly, small volumes, and at low pressure

152
Q

What are complications of paravertebral blocks

A

Pneumothorax
Epidural spread (common, up to 40%)
Vascular, epidural, subarachnoid injection
Postdural puncture headache

153
Q

Pecs 1 block:

A

Medial and lateral pectoral branches of brachial plexus

154
Q

Pecs II block:

A

Long thoracic nerve
Lateral cutaneous branches of thoracic intercostal nerves (T2-T4)
Indicated for more extensive procedures involving chest wall and axilla

155
Q

Landmarks for Pecs blocks

A

Pectoralis major
Pectoralis minor
Serratus anterior
Thoracoacromial artery (pectoral branch)

156
Q

Serratus plane block:

A

Increases intercostal coverage from T2-T9
More lateral than Pecs II block.
Overlies 5th rib at the midaxillary line.
No coverage to pectoralis muscle

157
Q

Landmarks for Serratus block:

A

Latissimus dorsi muscle
Serratus anterior muscles
Thoracodorsal artery

158
Q

Complications of Pecs block

A

Large volume of LA causes risk for LAST.
Risk of vascular injection due to pectoral branch of thoracolumbar artery lying within the interfascial plane of the Pecs I injection.
Pneumothorax - intercostal space and pleura are just inferior to serratus anterior muscle

159
Q
A

Advanced Principles of Anesthesia (2 decks)

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