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Ortho Flashcards

1
Q

What kind of anesthetic plan can be used for ortho procedures?

A

Regional
General
combination technique
IV sedation

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2
Q

what is the anesthetic technique chosen based on?

A

-what type of surgery is the pt having?
-how long will the procedure take?
-does the pt have preferences?
-does the pts airway present any challenges?
-what comorbidities are present?

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3
Q

Who will evaluate the pt for the presence of infection (including MRSA) to prevent surgical site infections (SSI)

A

the orthopedic surgeon

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4
Q

What is the purpose of the pneumatic tourniquet?

A
  • Maintains a relatively bloodless field during intraoperative blood loss

-aids in the identification of vital structures

-Expedites the procedure

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5
Q

What are the components of the pneumatic tourniquet?

A

-Inflatable cuff
-connective tubing
-a pressure device
-a timer

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6
Q

The tourniquet should not be used for ______

A

more than 2 hours

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7
Q

What size cuff should be used?

A

Use the widest cuff possible

(use lower cuff pressure to occlude the blood flow)

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8
Q

what is the minimum amount of layers of padding that should be placed around the extremity?

A

2

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9
Q

What should the tourniquet size be?

A

Half the limb diameter and the cuff should overlap 3-6 inches

-tourniquet size should allow placement of 2 fingers between the tourniquet and the cast padding

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10
Q

When possible, the extremity should be exsanguinated _____ to tourniquet inflation

A

When possible, the extremity should be exsanguinated prior to tourniquet inflation

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11
Q

How much pressure should be used for occluding blood flow in the upper extremity?

A

70-90 mmHg > SBP

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12
Q

How much pressure should be used for occluding blood flow in the lower extremity?

A

2x SBP

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13
Q

What are the neurologic effects caused by limb tourniquets?

A

-abolition of somatosensory evoked potentials and nerve conduction occurs within 30 mins

->60 tourniquet times cause pain and HTN

->2 hours may result in post-op neurapraxia

-evidence of nerve injury may occur at the skin level underlying the edge of the tourniquet

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14
Q

What are the muscle changes that can be caused by the tourniquet?

A

-cellular hypoxia develops within 2 mins

-cellular creatinine level declines

-progressive cellular acidosis occurs

-endothelial capillary leak develops after 2 hrs

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15
Q

What are the systemic effects of tourniquet inflation?

A

elevations in arterial and pulm artery pressure occur (usually slight to mod. if only one limb is occluded

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16
Q

What are the systemic effects of tourniquet release?

A

-Transient decrease in core temp

-transient metabolic acidosis

-transient decrease in central venous tension occurs, but systemic hypoxemia is unusual

-acid metabolites (ie thromboxane) are released into central circulation

-transient fall in pulmonary and systemic arterial pressure

-transient increase in end-tidal Co2

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17
Q

What is a non-pneumatic tourniquet?

A

-A silicone ring tourniquet (SRT) may be used for brief procedures

-Consists of a silicone ring wrapped in a sleeve, with 2 pull handles connected by straps

At the end of surgery, the silicone ring tourniquet is removed by cutting the silicone ring

These tourniquets are not electronic. Therefore, tourniquet time must be closely monitored.

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18
Q

what other pain is tourniquet pain similar to?

A

thrombotic vascular occlusion, and peripheral vascular disease (PVD)

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19
Q

when does tourniquet pain occur?

A

45-60 mins after inflation

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20
Q

what are the symptoms of tourniquet pain?

A

dull aching which progresses to burning and excruciating pain that may require general anesthesia

once pain begins- it is resistant to analgesics, and anesthetic agents regardless of the anesthesia technique

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21
Q

What are the nerve fibers responsible for transmitting pain impulses?

A

-Unmyelinated C fibers: small, slow-conducting fibers, responsible for burning and aching

Myelinated A-delta fibers:large and fast conducting, responsible for pinprick, tingling, and buzzing sensation

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22
Q

What wound nerve damage be caused by?

A

rupture of the Schwann cell membrane

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23
Q

How do you prevent post-op tourniquet paresthesias?

A

use of proper padding
-appropriate choice of tourniquet size
-following recommendation for appropriate tourniquet pressure and usage time minimizes the incidence of complications

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24
Q

How should a pt be positioned for ortho surgery?

A

-Optimal exposure of the surgical site
-Protect all body systems
-Enable appropriate monitoring throughout the procedure
-Provide good access to the patient’s airway
-Allow for comfort and warmth
-Minimize or prevent physiologic functioning compromise
-Protect all body systems.
-Maintain patient dignity

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25
What are the benefits of arthroscopy?
minimally invasive -reduced blood loss -less post-op discomfort -reduced length of rehabilitation
26
How is a pt positioned for lower extremity arthroscopy?
most often supine
27
How is a pt positioned for shoulder arthroscopy?
lateral decubitus or "beach chair"
28
What is the pt positioning for elbow arthroscopy?
supine lateral decubitus prone
29
What are the complications of arthroscopy?
-subcutaneous emphysema -pneumomediastinum -tension pneumothroax -fluid volume overload d/t irrigation fluid
30
What are the signs and symptoms of a tension pneumothroax?
-Sudden, inexplicable hypoxemia -Elevated central venous pressure (CVP) -Tachycardia -Absent breath sounds on the affected side -Cyanosis -Diaphoresis -Decreasing oxygenation -Tracheal shift -Agitation (may be observed in patients receiving regional anesthesia) -Hypotension -Jugular vein distention -Increased airway pressure -Asymmetric chest wall movement -Percussive hyper resonance over the affected side -Extreme anxiety (may be observed in patients receiving regional anesthesia
31
What are the position-related complications during shoulder arthroscopy? BEACH CHAIR:
Hypotensive bradycardic events w interscalene block cervical plexus and hypoglossal nerve neurapraxis air embolism/pneumothorax DVT ophthalmoplegia cerebral hypoperfusion
32
What are the position-related complications during shoulder arthroscopy? Lateral decubitus:
temporary paresthesia neurapraxias of the dorsal digital nerve of the thumb and the musculocutaneous, ulnar, and axillary nerves permanent neurapraxia risk of musculotendinous nerve injury post op stroke DVT fluid-related obstructive airway compromise
33
What is total arthroplasty?
Replacement of all of the joint?
34
Hemiarthroplasty
replacement of part of the joint
35
What are the joint materials?
originally stainless steel Currently use nonferrous metal alloys (cobalt or titanium)
36
What surgical approach for hip arthroplasty is most common?
Posterior approach Requires a large incision extending from near the iliac crest across the joint to the midthigh level -lateral decubitus
37
what does the direct anterior approach (DAA) to hip arthroplasty entail?
minimally invasive, muscle sparing approach benefits: shorter hospital stay, faster post-op recovery
38
What position will the pt be in for the anterior approach?
supine
39
what are pts undergoing knee or hip arthroplasty at an increased risk of ?
Venous thromboembolism (VTE) DVT PE
40
how long should treatment to prevent VTE, DVT and PE continue for?
up to 35 days
41
what medication and preventative measures are used to prevent VTE, DVT and PE?
anticoagulation (LMWH) intermittent pneumatic compression device (IPCD) for 10-14 days
42
what kind a block can be done for hip arthroplasty?
subarachnoid block (SAB)
43
what is bone cement implantation syndrome (BCIS)
methyl methacrylate (MMA) may be instilled into the femoral canal Usually occurs at the following stages of surgery: femoral canal reaming, acetabular or femoral cement implantation, insertion of prosthesis or joint reduction, and occasionally after tourniquet deflation
44
what are the signs of BCIS?
First sign: absence of EtCO2 in pt under GA in awake: dyspnea, altered sensorium
45
what is the treatment for BCIS?
increase fio2 to 100% aggressive fluid resuscitation Tx hypotension w alpha agonist
46
What are the risk factors for developing bone cement implantation syndrome?
-Preexisting cardiovascular disease -Preexisting pulmonary hypertension -American Society of Anesthesiologists class III or higher -New York Heart Association class 3 or 4 -Canadian Heart Association class 3 or 4 -Surgical technique -Pathologic fracture -Intertrochanteric fracture -Long-stem arthroplasty
47
in total knee arthroplasty (TKA) why is there a risk of BCIS?
-both femoral and tibial surfaces are covered w MMA cement -the high-density polyethylene patellar component is cemented and seated w a vise-like clamp
48
What are the most popular intraarticular procedures?
-osteochondral lesion -ankle or subtalar debridement -subtalar fusion -partial talectomy
49
what are the most common extraarticular procedures?
-Os trigonum excision -tenolysis of the flexor hallicis longus tendon -endoscopic partial calcanectomy
50
What blocks are sufficient for all surgeries below the knee that do not require a thigh tourniquet?
femoral and sciatic nerve blocks
51
what does the femoral nerve innervate?
the medial leg to the medial malleolus
52
What nerves innervates the leg below the knee, including the foot?
common peroneal and tibial nerve
53
what are the indications for total shoulder arthroplasty (TSA)/ reverse total shoulder arthroplasty (RTSA)?
-Posttraumatic brachial plexus injuries -Paralysis of deltoid muscle and rotator cuff -Chronic infection -Failed revision arthroplasty -Severe refractory instability -Proximal humerus fracture -Bone deficiency after resection of a tumor in the proximal aspect of the humerus
54
Why is shoulder arthroplasty associated with higher amounts of blood loss?
tourniquet cannot be used
55
What blocks can be done for elbow arthroplasty?
supraclavicular, infraclavicular, interscalene, brachial plexus positions: -supine, lateral, prone -tourniquet used
56
what are the indications for elbow arthroplasty?
rheumatoid arthritis traumatic arthritis ankylosis of the joint
57
what does the beach chair position increase the risk of?
venous air embolism Reaming of the shaft of the humerus leads to risk of fat or bone marrow embolism Cerebral ischemia can occur with hypotension
58
What are hypotensive bradycardic episodes? (HBE)
Decrease in HR of at least 30 bpm within a 5-minute interval, any HR < 50 bpm, and/or a decrease is systolic BP of more than 30 mm Hg in a 5-minute interval or any systolic BP < 90 mm Hg
59
What is the proposed mechanism of HBE?
Bezold-Jarisch reflex An inhibitory reflex mediated through cardiac sensory receptors with a vagal efferent limb In the beach chair position, venous pooling in the lower extremities leads to an increase in sympathetic tone and ultimately a low-volume, hypercontractile ventricle Cardiac hypercontraction leads to activation of the Bezold-Jarisch reflex with an abrupt autonomic withdrawal of sympathetic response and activation of increased vagal tone The combination of venous pooling and paradoxical increased vagal tone results in sudden, profound bradycardia and hypotension that can be difficult to reverse rapidly
60
Prophylaxis of HBE
aggressive tx of fluid deficits and blood loss minimize venous pooling in beach chair w support stockings w regional avoid use of locals using epi
61
What are the contraindications to laparoscopic spinal surgeries?
Abdominal adhesions Abdominal trauma Severe cardiac or pulmonary disease (may not tolerate hypercarbia from insufflation) Thoracic approach contraindicated in patients that cannot tolerate one lung ventilation Patients requiring extensive instrumentation of the anterior spine
62
what are the lung changes in spinal surgery? prone
Displacement of organs (including diaphragm) cephalad Reduced functional residual capacity (FRC) Reduced tidal volume (TV) Increased airway pressures
63
what is aortic injury in spinal surgery?
Due to proximity of aorta to spinal column Suspect with sudden, dramatic, unanticipated, sustained hypotension
64
what is post-op visual loss (POVL)?
main causes w nonocular surgery: -ischemic optic neuropathy -retinal vascular occlusion
65
What are the risk factors for POVL?
male obesity use of Wilson frame anesthesia duration >6 hrs large blood loss colloid as a percent of nonblood fluids
66
When does visual loss occur?
24-28 hours after surgery Usually bilateral Painless vision loss Afferent pupil defect or nonreactive pupil No light perception Decreased or absent color vision Elevated intraocular pressures (IOP) > 40 mm Hg
67
how often should you perform and document eye checks?
20 mins
68
what are the most common ankle procedures?
repair of ankle fractures ankle fusion Achilles tendon repair
69
most common foot procedures
bunionectomy hammertoe correction plantar fasciotomy
70
What are the indications for forearm and hand surgery?
fractures nerve compression (carpal tunnel release)
71
what blocks can be done for forearm and hand surgeries?
bier block brachial plexus block
72
What is Rheumatoid arthritis?
The most prevalent chronic systemic inflammatory disease Autoimmune disease
73
what are the S/S of RA?
Joint swelling Joint tenderness Destruction of synovial joints anesthesia concerns: Airway! Effects on cervical spine, temporomandibular joint, larynx, and pulmonary system Limited ROM Cricoarytenoid joints are common sites for rheumatoid nodule deposition
74
what is ankylosing spondylitis (AS)?
Chronic inflammatory process Primary target: Spinal column and surrounding tissues Additional effects: Cardiac valve dysfunction Conduction delays Bundle branch blocks Restrictive lung disease
75
what are the anesthesia considerations for AS?
Airway! Position patient so no neurologic symptoms are present prior to induction of anesthesia Cervical spine in neutral position Regional anesthesia is a safe approach

Principles-Other (6 decks)

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