Ortho Flashcards
osteoporosis is caused by these 3 things:
age-related (elderly)
post-menopausal
hypothyroidism
increased risk of fractures in elderly is due to these hormonal changes:
increased PTH & cortisol
decreased vit D3, growth hormone, & insulin-like growth factors
______ compression fractures are most common with falls in the elderly
LUMBAR
Pts on fosamax, actonel, boniva, or reclast should hint to what pathophysiology?
osteoporosis
Arthritic disorder that is associated with inflammation, pain in weight bearing joints, and sx that worsen throughout the day (evening stiffness):
OA - osteoarthritis
swelling/spurring of DISTAL interphalangeal joints
Heberden’s nodes
swelling/spurring of PROXIMAL interphalangeal joints
Bouchard’s nodes
When should OA pts stop taking glucosamine prior to surgery?
2 wks – inhibits plt aggregation/risk bleeding
Arthritic disorder associated with morning stiffness that improves with activity:
RA - rheumatoid arthritis
What lab values are elevated in the RA pt?
rheumatoid factor
anti-immunoglobulin antibody
C-reactive protein (CRP)
erythrocyte sedimentation rate (ESR)
When reviewing home medications, you notice your elderly patient is taking methotrexate (MTX), what should you start thinking?
RED FLAG –> elderly + MTX = think RA, positioning & airway issues
What medications should the RA patient receive preop?
pain –> NSAIDs, opioids
Stress dose 100mg hydrocortisone IV
Airway considerations for RA pts:
limited TMJ movement, narrowed glottic opening, & cricoarytenoid arthritis = awake fiberoptic intubation &/or regional anes
What are some preop Qs to ask your RA pt to assess possible difficult airway (prior to the physical exam)?
hoarseness in voice, dysphagia, stridor, neck tenderness
Atlantoaxial instability in RA involves what 2 vertebrae?
C1 - atlas
C2 - axis
** displaces odontoid process (dens)
atlantoaxial instability in RA pts can result in impingement/compression of the:
C-spine, medulla, & vertebral arteries
Symptoms of atlantoaxial subluxation:
HA
neck pain
Upper & lower extremity paresthesia with movement
bladder/bowel dysfunction
vertebral artery occlusion/compression symptoms:
N/V
dysphagia
blurred vision
transient loss of consciousness
Sjogren’s syndrome is associated with RA and results in:
dry eyes & mouth
An RA patient has what type of ventilation issues? (obstructive or restrictive)
RESTRICTIVE – d/t diffuse interstitial fibrosis
What is a safe vent setting for the RA patient per Dr. Castillo?
PC-Volume guarantee
Vt = 5ml/kg IBW
RA + elderly + NSAID use can result in:
gastric ulcers & renal insufficiency
What does MILS/MILI stand for?
manual in-line stabilization/immboilization
If pt is confused or uncooperative, then this type of anes is not appropriate:
neuraxial or regional
Stabilization of head, neck, & torso in neutral position for pts who have not been cleared by x-ray is referred to as:
MILS/MILI
What airway maneuver is acceptable in trauma/c-spine pts?
chin lift – results in slight c-spine movement, but is allowed to open up airway
How does aging affect FEV1?
FEV1 decreases 10% for each decade
What is the target HR for elderly?
< 80 bpm
Which NMB reversal agent is safest for elderly?
sugammadex – avoids the HR changes seen with neostigmine & glyco)
When do symptoms of FES start to present?
12-72 hrs after trauma or surgery
FES symptoms triad:
dyspnea + confusion + petechiae 12-72 hrs after trauma or surgery
Which triad symptoms is the most definitive finding of FES?
PETECHIAE - conjunctiva, oral mucosa, skin folds of chest, neck, & axilla
Normal SED rate male:
0-22 mm/hr
Normal SED rate female:
0-29 mm/hr
long bone trauma (femur) and pelvic fractures can commonly cause:
FES - fat embolism syndrome
best preventative management of FES:
early recognition
fracture stabilization/immobilization ASAP
FES symptoms can resolve in _____ if managed appropriately.
3-7 days
When can you perform neuraxial anes after a patient has received LMWH (once daily dosing)?
10-12 hrs after previous LMWH dose (if there is no indwelling catheter)
if LMWH is given twice daily dosing, what should you consider with neuraxial anes?
NO indwelling catheter — must remove 2+ hrs before next LMWH dose
How soon after a neuraxial block can a patient resume LMWH dose?
4 hrs
without prophylaxis, risk of thrombosis is ____%
40-80%
Neuraxial anesthesia is ok if a patient is on warfarin as long as the INR is:
1.5 or less
What are the 3 advantages of neuraxial anesthetics in preventing VTE formation?
increased lower extremity venous blood flow (d/t sympathectomy)
LA = systemic anti-inflammatory properties
decreased platelet reactivity
When can neuraxial block be performed after aspirin & NSAIDs are stopped?
no additional precautions with these 2 medications
When can neuraxial block be performed after CLOPIDOGREL (PLAVIX) is stopped?
5-7 days
When can neuraxial block be performed after PRASUGREL (EFFIENT) is stopped?
7-10 days
When can neuraxial block be performed after TICLOPIDINE (TICLID) is stopped?
10 days
When can neuraxial block be performed after TICAGRELOR (BRILINTA) is stopped?
5-7 days
When can neuraxial block be performed after CANGRELOR (KANGREAL) is stopped?
3 hrs
When can neuraxial block be performed after ABCIXIMAB (REOPRO) is stopped?
24-48 hrs
When can neuraxial block be performed after TIROFIBAN (AGGRASTAT) is stopped?
4-8 hrs
When can neuraxial block be performed after EPTIFIBATIDE (INTEGRILIN) is stopped?
4-8 hrs
When can neuraxial block be performed after DIPYRIDAMOLE (PERSANTINE) is stopped?
24 hrs for ER formulation
When can neuraxial block be performed after CILOSTAZOL (PLETAL) is stopped?
2 days
Which antithrombotic agent is ok to give while indwelling neuraxial catheter is in place?
HEPARIN
How long should APIXIBAN (ELIQUIS) be held prior to neuraxial procedures?
48 hrs
What type of patients should TXA be avoided in?
hx of VTE events
recent coronary stents
severe ischemic heart dz
MI
CVA
renal impairment
pregnancy
binds reversibly to plasminogen by its lysin-binding site, inhibiting its association with fibrin & inhibits the proteolytic activity of plasmin
TXA - tranexamic acid
When should TXA be administered in an orthopedic case?
most commonly administered IV prior to incision (some providers like a continuous infusion throughout case, and some will like another bolus dose at end of case)
Max dose of TXA?
2.5 g
Variable IV dosing for TXA includes:
10 mg/kg
15 mg/kg
30 mg/kg
** common to give 1gm (the full 10ml syringe)
The width of a pneumatic tourniquet should be:
1/2 diameter of entire limb
How soon does tourniquet pain begin?
45 mins
What can be done to help tourniquet pain?
REGIONAL ANES
Tournique inflation pressures for thigh:
SBP + 100mmHg = inflation pressure
Tourniquet inflation pressures for arm:
SBP + 50mmHg = inflation pressure
Standard MAX time for tourniquet inflation:
3 hrs (180 min)
** generally not to exceed 2 hrs if possible d/t risk of nerve injury
Prolonged tourniquet inflation issues > 2 hrs can result in:
NERVE INJURY
Common upper extremity tourniquet inflation pressure?
~ 250 mmHg
Common lower extremity tourniquet inflation pressure?
~ 300 mmHg
What MUST the anes provider do when a tourniquet is being applied to a patient for an ortho case?
DOCUMENT ** even if OR nurse is already documenting it
- inflation time
- deflation time
- total inflated time
- inflation pressures & any adjustments
How can nerve injury be minimized if tourniquet time is exceeding the max time (3 hrs)?
deflating tourniquet for 20-30 min to allow for reperfusion –> then surgeon can resume case
Tourniquet pain is related to:
regression of neuraxial block –> unmyelinated C fibers firing
Ortho patient has had a tourniquet inflated for 45-60 min and starts to have an increased HR & BP + diaphoresis. What might be going on?
TOURNIQUET PAIN d/t regression of neuraxial block & unmyelinated C fibers firing
If a patient has a double tourniquet on a limb, what order should they be inflated & deflated?
inflate proximal
deflate distal
What are some additional negative effects that can occur once tourniquet is deflated?
metabolic acidosis
hyperkalemia
hypercarbia
tachycardia
HTN
** all d/t cellular metabolites being released once limb is reperfused
How can we treat the transient lactic acidosis & hypercarbia post tourniquet deflation?
Increase minute ventilation = blow off that extra CO2
______ programs can be useful in geriatric patients to reduce frailty & improve surgical outcomes.
Prehabilitation
Fractures of the ______ following falls are common in older patients & associated with high morbidity & mortality.
proximal femur
This surgical position offers superior exposure & access for most shoulder surgeries, less anatomy distortion, & less tension on the brachial plexus.
BEACH CHAIR > lateral decubitus
_____ can decrease by 15% in sitting patients (beach chair position) under general anesthesia.
Cerebral perfusion pressure (CPP)
** normal CPP = 60-80 mmHg
Intraop hypotension, hypoxia, & even cardiac arrest can occur following cemented fixation of the femoral prosthesis, this is known as:
bone-cement implantation syndrome
How should we manage bone-cement implantation syndrome?
potent inotropic agent – epi
invasive hemodynamic monitoring – art line & maybe CVP
** pulsatile lavage of femoral canal & drilling vent hole in femur before prosthesis can avoid the hemodynamic consequences
____ is probably the single most important cardiac risk factor in orthopedic patients.
CAD
The Doppler Ultrasound transducer is a sensitive non-invasive indicator of a venous air Embolism (VAE) in the sitting patient. Where do you place the probe on the chest?
over the right atrium - 2nd ICS @ right sternal border
For every cm distance between brain & heart, there is a ______ mmHg decrease in BP
0.77 mmHg
Normal distance between top of brain & heart:
10-30 cm
if cuff is 30 cm below the top of the brain & pts BP is 90/60, what is the approx. BP at top of the brain?
0.77 x 30cm = 23
90-23 / 60-23 = 67/37 mmHg
Induced hypotension is sometimes used in shoulder surgery to prevent bleeding and provide the surgeon with a better view, but this can lead to:
Retinal Ischemia
Ischemic Optic Neuropathy
cardiac inhibitory reflex that leads to hypotension + bradycardia R/T venous pooling (decreased preload) & hypercontractile ventricle (Decreased intraventricular volume)
Bezold-Jarisch Reflex
Most definitive treatment for venous air embolism (VAE)
Withdrawing air through a previously placed right atrial catheter/CVC
most sensitive non-invasive indicator of VAE
Placement of a doppler ultrasound transducer at the second or third intercostal space to the right of the sternum (over the right atrium)
Most definitive indicator of VAE?
TEE
a “mill-wheel” murmur is a characteristic sound of
VAE - venous air emobism
What actions can you take if a venous air embolism is suspected in your patient?
Placing the patient in a head-down position (to trap the air in the RA apex preventing entrance to the PA)
**Withdrawing air through a previously placed right atrial catheter/CVC
During elbow surgery, a spontaneously breathing patients dependent lung will have:
NO V/Q mismatch
** mech ventilation = V/Q mismatch in the dependent lung
If a patient has an axillary roll in place, where should the pulse be put on?
in the dependent hand
**periodically check radial pulse
For elbow procedures, tourniquets are typically inflated to:
100 mmHg > SBP
What lower extremity surgeries are considered emergent/urgent procedures?
hip fractures ORIF
How do you establish NPO time for a hip fracture patient?
gastric motility stops at “trauma” time so NPO time starts from the time the patient last ate to the time of trauma
Common complication in the sitting/beach chair position?
VAE - venous air embolism
If the surgical site is higher than the heart, then what can occur?
potential to entrain room air into open vessels and cause VAE
Ventilatory changes of the dependent lung on mechanical ventilation:
dependent (down) lung is underventilated d/t compression by the weight of the mediastinum & abdominal contents
ventilatory changes of the non-dependent (up) lung on mechanical ventilation:
non-dependent lung is overventilated b/c its compliance is increased
_____ causes pulmonary blood flow to favor the ______lung
GRAVITY
dependent lung
Ortho procedure that you should be prepared to potentially give blood transfusions?
hip fracture - ORIF
** large amt of extravasated/occult blood because its a closed fracture inside pt
Which physics law is responsible for IVF flow rate gravity drip?
Poiseulle’s Law
**increase ht of table = lose gravity drip of IVF = slower flow
3 potential life threatening complications of total hip arthroplasty (THA)?
- bone cement implantation syndrome (BCIS)
- intraop & postop hemorrhage
-VTE
Name of cement placed in acetabular & femoral stem in THA?
PMMA - polymethylmethacrylate
Cement used in total hip replacements can result in:
intramedullar HTN
** increases up to 500 mmHg d/t exothermic reaction (heat release)
Systemic absorption of fat emboli in venous circulation results in:
vasodilation = decreased SVR
Prepare to give _____ once surgeon starts cementing in total hip arthroplasty.
pressors – ephedrine or neo
** helps prevent BCIS
hypoxia, hypotension, arrhythmia’s, pulm HTN, decreased CO during total hip arthroplasty are a result of:
BCIS - bone cement implantation syndrome
List most common complications of total hip arthroplasty:
cardiac events
PE
pneumonia
respiratory failure
infection
When supine in a hip arthroscopy, what happens to your FRC?
decreases
To prevent ulnar nerve injuries when supine, how should the hands be positioned?
palms up (supinated)
The most common postoperative peripheral neuropathy is:
Ulnar neuropathy
Hip dislocation requires:
closed reduction internal fixation = no incision
Anesthesia mgmt for hip dislocations:
may be performed in ER or PACU, emergent - so have emergent equipment & anes cart ready.
Conscious sedation - ketamine & propofol pushes with succinylcholine for muscle relaxation + mask ventilation
For complete analgesic knee coverage, what regional blocks should be performed for a total knee arthroplasty?
femoral + sciatic nerve block
4 Artificial Components of the knee
- Tibial component
- Femoral component
- Patellar component
- Plastic spacer
Total knee arthroplasty’s are very painful postop, what’s the preferred and best pain mgmt option for this patient?
spinal with duramorph (morphine)
Neuraxial anesthesia is preferred in amputations because it results in:
less phantom limb pain
When does phantom limb pain onset occur post amputation?
within a few days of surgery
Phantom limb pain triggers:
weather changes
emotional stress
pressure on remaining area
What are some treatment medications used for phantom limb pain?
neuroleptics (antipsychotics)
antidepressants
Na channel blockers
When a patient receives an ankle block, what are the 5 nerves involved?
Posterior tibial nerve Sensation to plantar surface
Saphenous nerve Innervates medial malleolus
Deep peroneal nerve Interspace b/t great & 2nd toes
Superficial peroneal nerve Dorsum of foot & 2nd – 5th toes
Sural nerve Lateral foot & lateral 5th toe
Ankle block: Posterior tibial nerve provides sensation to
plantar surface (bottom of heel/foot)
Ankle block: saphenous nerve innervates
medial malleolus
Ankle block: deep peroneal nerve innervates
intersepace between great & 2nd toes
Ankle block: superficial peroneal nerve innervates
dorsum (top) of foot & 2nd-5th toes
Ankle block: sural nerve innervates
lateral foot & lateral 5th toe
Which arthritic disorder is generally NOT associated with thoracolumbar spine involvement?
RA - rheumatoid arthritis
