Exam II: Anesthesia for Ortho Surgery Flashcards
common to ortho pts:
- many have _____ ____/____
arthritic joints/deformities
common to ortho pts:
- many have limited _____ in ____
ROM
neck
common to ortho pts:
- require careful _____
positioning
common to ortho pts:
- may need help moving to ___ ___
OR table
common to ortho pts:
- fracture pts may have ____ ____
full stomachs
common to ortho pts:
- may have increased ____
bleeding
common to ortho pts:
- increased risk for ____ emboli, ____, and ____
fat
DVT
PE
common to ortho pts:
- exposure to larges amounts of _____
radiation
RA is an immune related, ______ inflammation of _____ joints, not just wear and tear
progressive
synovial
RA has multiple joint involvement, ______
deformity
RA: _____ lines and _______ challenges
invasive
monitoring
RA: ____ and ____ issues - check neck ROM, ____ opening
cervical
TMJ
mouth
RA: atlantoaxial subluxation: ____ films to evaluate and determine if ____ ____ ____ is indicated if >5mm instability exists
c-spine
awake fiberoptic intubation
RA: _____ _____ - hoarseness, airway obstruction
cricoarytenoid arthritis
RA: r/t to chronic ____ use, ____ bleeding, ____ toxicity, ____ dysfxn
NSAID
GI
renal
platelet
RA CV: ____ thickening and effusions, _____, coronary arteritis, _____ defects, cardiac ____ _____
pericardial
myocarditis
conduction
valve fibrosis (AR)
RA pulm: ____ _____, pulm nodules, interstitial ___ ____
pleural effusions
pulm fibrosis
RA hematology: ____, ____ dysfxn, thrombocytopenia
anemia
platelet
RA endocrine: ____ insufficiency (steroid rx), impaired ____ system
adrenal
immune
RA derm: ____ ____ skin from skin and steroids
thin atrophic
Positioning: done mostly after pt is _____
anesthetized
Positioning: usually ____, sitting ____ ____ or prone
supine
lateral decubitis
Positioning: protect ____ from injury - ____ and ____, may require padding ____
face
eyes and nose
face
Positioning: sitting increases risk for ___ ____, ___ and ___ in neutral position, some recommend avoiding ____
air embolus
head and neck
N2O
Positioning: ____ over ____ may impede ventilation
arms
chest
Positioning: sitting can reduce ____ ____ pressure
cerebral perfusion
Positioning: ____ injuries
stretch
Regional anesthesia: excellent advantages but can be _____
unreliable
Regional anesthesia: supplement with ___ ___
IV opioids
Regional anesthesia: may be used for ____ extremity surgery
upper
Regional anesthesia: reduced ___ ___ in some surgeries
blood loss
Regional anesthesia: ____ block commonly utilized for many wrist and hand surgeries
bier
Regional anesthesia: inserted ____ or ____ nerve catheters allow continuous infusions in the post op period
neuraxial or peripheral
Shoulder Surgery: ____ or “____ ___” positions
lateral or “beach chair”
Shoulder Surgery: positioning challenge, ____, ____, ____ areas
ears, eyes, bony areas
Shoulder Surgery: may utilize ____ during procedure
[Airway]
LMA
Shoulder Surgery: controlled _____
hypotension
Shoulder Surgery: ____ pressure during arthoscopic surgery
irrigation
Shoulder Surgery: associated with ____ injury
nerve
Shoulder Surgery: ____ possible in “beach chair” position
VAE
Cerebral Perfusion Pressure: level of the ____ ____ ____ and tragus = circle of ____ that estimates CPP
external auditory meatus
willis
Cerebral Perfusion Pressure: ____ pressure than level of the heart due to the vertical column and _____ pressure difference
lower
hydrostatic
Cerebral Perfusion Pressure: formula: __ mmHg for each ____ cm
7.5
10
Arthroscopic Surgery: used for k___, s____, e____, w___, h___, a____
knee
shoulder
elbow
wrist
hip
ankle
Arthroscopic Surgery: ___ invasive with ____ blood loss
less
reduced
Arthroscopic Surgery: ___ surgical field
bloodless
Arthroscopic Surgery: ____ incision with ____ postop pain
minor
less
Arthroscopic Surgery: reduced ___ ___ on _____ joints optimizes surgical field
blood pressure
nontourniquet
Arthroscopic Surgery: irrigation fluid ___-___ ____ distends joint. ____ pressure with ____ duration associated with subq emphysema and tension pneumo
60-80 mmHg
High
long
Spinal Surgery: most often to _____ cord or nerve root
decompress
Spinal Surgery: ____ and ____ surgeons perform
neuro and ortho
Spinal Surgery: multilevel ______ with plates, ____, ____ for spinal instability
instrumentation
rods
screws
Spinal Surgery: GA with or w/o _____
paralysis
Spinal Surgery: _____ may need to deflate lung
transthoracic
Spinal Surgery: airway challenges - ____ position, ____ immobility
prone
cervical
Spinal Surgery: can be done ____ or ____ approach
posterior
anterior
Spinal Surgery: may develop a ____ leak requiring a ____
CSF
VCM
Cervical Spinal Surgery: ___, ___ or ____ position
prone
sitting
supine
Cervical Spinal Surgery: arthritic conditions may cause ____ issues
ROM
Cervical Spinal Surgery: ROM issues include -
_____ dysfxn, limited ____ opening
TMJ
jaw
Cervical Spinal Surgery: ROM issues include -
____ instability, limited neck ROM
atlantoaxial
Cervical Spinal Surgery: ROM issues include -
potential ____ mngmnt challenge
airway
Cervical Spinal Surgery: ROM issues include -
may require ____ ____ intubation
awake fiberoptic
Cervical Spinal Surgery: major ____ and ____ are nearby (check distal ____) can utilize ear probe ____
arteries and veins
pulse
oximeter
Cervical Spinal Surgery: potential _____ injury, some surgeons dont want MRs used
RLN
Cervical Spinal Surgery: airway swelling could be issue _____
post-op
Cervical Spinal Surgery: identify an document preexisting ____ deficits
neuro
Cervical Spinal Surgery: prevent too much ____ and ____ traction (pad)
head and neck
Cervical Spinal Surgery: ____ or ____ must be prevented, LTA kit indicated
coughing or bucking
Lumbar Spinal Surgery: can be minimally ____ or more extensive
invasive
Lumbar Spinal Surgery: prone position using prone chest rolls, ____ ____ at risk, ___/___ less than 90 degrees
brachial plexus
arms/shoulders
Lumbar Spinal Surgery: abdominal compression impedes ___ ___, diaphragm is ____ decreasing FRC and VT
venous return
cephalad
Lumbar Spinal Surgery: long procedures lead to ___ ___ loss
large blood
Spinal Fusion: fusion of ___ or more vertebra are indicaed
2
Spinal Fusion: ___ grafting autologous or cadaveric
bone
Spinal Fusion: artificial ____ is inserted into space
disk
Spinal Fusion: plates, rods, screws stabilize the ___ ___
2 vertebra
Spinal Fusion: restores the correct distance between vertebra as a “cage” is constructed to ___ the vertebra in ____ and prevent ____
hold
place
collapse
Spinal Fusion Implications: identify and document _____ _____ deficits
preexisting neuro
Spinal Fusion Implications: pressure off ___, ___, ____, ____. blindness can occur, ischemic nose or chin
eyes, ears, nose, breast, genitalia
Spinal Fusion Implications: limited access to ____, ____ leads
airway, monitoring leads
Spinal Fusion Implications: ____ procedures, warm patient, ___ monitors
longer
temp
Spinal Fusion Implications: greater ___ loss, ___ saver, T&CM
blood
cell
Spinal Fusion Implications: ____ pt may have restrictive lung dz
scoliosis
Spinal Fusion Implications: major vessels are in close proximity to the ____
spine
Both Anterior and Posterior Approach: ____ approaches during surgery
2
Both Anterior and Posterior Approach: supine, open ____ cavity, dissect down to ____ ____
abdominal
anterior vertebrae
Both Anterior and Posterior Approach: turn patient ___ and continue surgery posteriorly
prone
Both Anterior and Posterior Approach: ____ vs ____
ALIF vs PLIF
Both Anterior and Posterior Approach: can be done for ___, ____, and ___ spinal issues
cervical, thoracic, and lumbar
Both Anterior and Posterior Approach: _____ monitoring indicated d/t artery of Adamkiewicz
neuromuscular
Both Anterior and Posterior Approach: supine spinal sx may be done with O2 ____ ____ on ____ to monitor vessel occlusion by _____
saturation monitor
toe
retractors
Wilson frame:
spinal operation bed device that uses a convex saddle frame
Mirrored ___ ___ for prone positioning
face cradle
__-___ for spinal sx
O-arm
Hip Fracture: typically e____, f____, d____, d____ patients with pre-existing comorbid conditions
elderly, frail, debilitated, dehydrated
Hip Fracture: ____ postition
supine
Hip Fracture: ____ table
fracture
Hip Fracture: ____ is applied to the fracture
traction
Hip Fracture: ____ post
perineal
Hip Fracture: ____ arm is placed on chest
ipsilateral
Hip Fracture: hypo____ and hyper____ ____ can be used
hypobaric
hyperbaric
SAB
Hip Fracture: ___ embolism common
fat
Fracture table: the patient must be moved ____ with continuous ____ on the fractured limb. The ____ arm is positioned on an arm board or sling without stretching the ___ ____
carefully
traction
ipsilateral
brachial plexus
Hip Replacement: typical patient is ____, likely ___ hx
elderly
arthritic
Hip Replacement: blood ____ can be large
loss
Hip Replacement: ____ ___ position allowing greater ROM
lateral decubitis
Hip Replacement: ____ incision
large
Hip Replacement: prosthetic can be _____ or _____
cemented or uncemented
Hip Replacement: bilateral hip surgery contraindicated if declining ____ ____ occurs after first hip sx
pulm fxn
Hip Replacement: ____/____ roll
axillary/chest
Hip Replacement: ___ arm supported and stabilized
upper
Hip Replacement: down ____ should be flat or no pressure
ear
Knee Replacement: usually elderly, ____
arthritic
Knee Replacement: ____ position
supine
Knee Replacement: _____ utilized
tourniquet
Knee Replacement: more ____ than hip replacement
painful
Knee Replacement: high incidence of ____
DVT
Knee Replacement: many regional anesthetic options - ____ 3 in 1 block (____, ____, ___) combined with spinal. _____ catheter utilized for post op pain control
femoral
LFC, Obt, FN
Femoral
Knee Replacement: many times an older, at risk, out of shape population vs young, active, inshape ______ knee surgery
arthoscopic
Knee Replacement: prosthetics cemented to ____ and ____
femur and tibia
Closed Reduction: usually very ____ procedures
short
Closed Reduction: h____, s_____, w____, e_____, f____
hips, shoulders, wrists, elbows, fingers
Closed Reduction: shorting acting _____ usually required
paralysis
Closed Reduction: may be done with ____ ventilation
mask
Closed Reduction: done many times with _____ bolus since short time (usually mins) are required for reduction success
propofol
Methylmethacrylate Cement: used to bind _____ to bone
prosthetic
Methylmethacrylate Cement: ____ reaction occurs, hardens cement and expands, lysis of _____ _____ and marrow
exothermic
blood cells
Methylmethacrylate Cement: _____ HTN - embolization of air, fat, marrow, cement
intermedullary
Methylmethacrylate Cement: systemic absorption - decreased ____ leads to vasodilatory effects, release of tissue _____, plt aggregation, microemboli formation
SVR
thromboplastin
Bone Cement Implantation Syndrome: ___ migrate to pulmonary system
emboli
Bone Cement Implantation Syndrome: hypo____, hypo____, reduced ____, dysrhythmias, s____, PHTN, increase ____, adequate h_____.
hypotension
hypoxia
CO
shunt
FiO2
hydration
Pneumatic Tourniquet: utilized to minimize ___ ___ and optimize surgical field
blood loss
Pneumatic Tourniquet: exsanguination - ____ bandage, distal to proximal
esmarch
Pneumatic Tourniquet: cuff overlap should be i80 degrees from ___ ____
nerve bundle
Pneumatic Tourniquet: inflation pressure determined by ____, some tourniquets will have ____ sensor. Typically, ____ torr lower extremity and ____ torr upper extremity over SBP. Venous tourniquet can occur.
BP
pulse
100
50
Pneumatic Tourniquet: neuro damage may occur if _____ or if overlap is over ____ bundle
> 2 hrs
nerve
Physiologic effects of tourniquets: during inflation, initial rise in ____, ____, ____ d/t displaced blood volume (300-500 mL) exsanguination
SVR
CVP
PVR
Physiologic effects of tourniquets: during deflation you see metabolic ____ d/t increased K+ and increased CO2, ____ increase, ____ decrease, hypo____ (most common) d/t sudden reduction of SVR and PVR and wash out of ischemic metabolites (thromboxane)
acidosis
HR
Temperature
hypotension
physiologic changes caused by limb tourniquets
Tourniquet Pain: usually an ____ after tourn. inflation
hour
Tourniquet Pain: increase in ___ & ___
HR & BP
Tourniquet Pain: ischemia, ___ ___ compression
nerve fiber
Tourniquet Pain: burning, ____ aching, ____ pain
dull
throbbing
Tourniquet Pain: __-____ - unmyelinated, slow conducting
C-fibers
Tourniquet Pain: ___ analgesics minimally effective
IV
Tourniquet Pain: ____ added to the LA have been shown to help
opioids
Tourniquet Pain: deflation for __-__ ___ can help
10-15 mins
Tourniquet Pain: quality/intensity of block vs ____ of block
level
Tourniquet Pain: __-____ - pinprick, tingling after deflation
A-fibers
Long Bone Fractures: fracture of ____ and ____, fat is released into the circulation
femur and tibia
Long Bone Fractures: fat embolism syndrome (triad)
petechiae (axillary, subconjunctival), dyspnea, confusion (mental changes)
Long Bone Fractures: ____, ____, and ____ can occur
DVT
PE
VAE
Fat embolus: common in fractures of ____ and ____
femur and tibia
Fat embolus: fat globules are released into the blood and impair _____ perfusion, endothelial damage to ____ capillaries, ____ wall damage, ____ congestion
pulm
pulm
alveolar
pulm
Fat embolus: fat embolus syndrome triad occurs ___-___ hours later
12-24
(petechiae, dyspnea, confusion)
Fat embolus: tachycardia and/or ____ segment changes may also occur.
ST
Fat embolus: fat in the ____ and sputum, _____ may be present
urine
conjuctiva
Fat embolus: coexisting ____ disease at greater risk
lung
Fat embolus: treatment is (3)
- O2
- fluids
- steroids
Fat embolus: aggressive ____
ventilation
DVT and PE: more common after ____ and ____
THA and TKA
DVT and PE: mechanisms (3)
- venous stasis
- hypercoagulable state
- plt aggregation
DVT and PE: ____ greatly contributes to problem
tourniquet
DVT and PE: epidural or spinal anesthesia ____ DVT. Higher levels of ______ and _____ activators, hyperkinetic blood flow
reduces
plasminogen and plasminogen activators
DVT and PE: may be attributed to allowing early _____
ambulation
DVT and PE: utilization of _____
anticoagulants
Orthopedic PE Case Study
58 y.o. male health hip replacement
During prosthetic rod placement sudden and profound drop in BP
ETCO2 = 5 mmHg, BP = 43/16, ETO2 = 95, SpO2 = 79%
10 minutes later ABG’s
pCO2 = 53, pH = 7.29, pO2 = 56, Sat = 81%
CO2 A-a gradient = 51, O2 A-a gradient 60
What has happened?
What are we intrapulmonary shunt or dead space ventilation?
Orthopedic PE Case Study cont’d
Why the odd pulmonary gas numbers?
Large amount of embolic material wedged in pulmonary artery blocking perfusion to lungs
Ventilation without perfusion = dead space ventilation
Blood CO2 unable to diffuse to lungs b/c of a reduced perfusion to gas-exchanging alveoli units
Mathematically, more CO2 being produced than can be eliminated
Lung O2 unable to diffuse to blood b/c of reduction in perfused gas exchanging alveoli units
Mathematically, more O2 in blood consumed than replenished by the lungs
Orthopedic PE Case Study cont’d
Why the hemodynamic numbers?
Venous return cut in half
Decreased preload = decreased stroke volume = decreased cardiac output = decreased BP
Decreased BP results in inadequate perfusion combined with a decreased PO2(hypoxemia) results in tissue hypoxia results in anaerobic cellular respiration and lactic acid buildup = decreased pH.
Hyperkalemia or hypokalemia?
PVCs and dysrhythmias occurring.
Post Op Pain Mgmt - ____ and IV ____
NSAIDs and IV opioids
Post Op Pain Mgmt: systemic opioids via PCA device leads to (3)
- improved anesthesia
- decreased total opioid consumption
- increased pt/nurse satisfaction
Post Op Pain Mgmt: intra-articular injection is a combo of ____ and ____s.
opioids and LAs
Post Op Pain Mgmt: continous post-op neuraxial and peripheral analgesia allows for (3)
- better pain relief/lower pain scores
- faster ambulation/rehab
- better post-op joint mobility
