Ortho Flashcards
Arthrodesis
Surgical immobilization of a joint so bones may row together (fusion)
Arthroplasty
Surgical replacement of a joint
Arthrotomy
Incision into a joint
Intramedullary nail (rod)
Metal inserted into bone marrow canal to align and stabilize long bones (femur/tibia)
Osteotomy
Cutting or dividing a bone
Subluxation
Partial dislocation of two bones at a joint
Patient positioning in ortho
Arthritis prevalent
Consider access to patient
Mobility limitations due to injury
4 steps to tourniquet placement
Place over largest limb area
Protect skin
Exsanguinate limb
Inflate cuff
Inflation and maximum pressure for upper limbs with tourniquets
50mmhg> systolic BP
300mmhg
Lower limb tourniquet goal and maximum pressures
100mmhg> systolic BP
350mmhg
Safe duration of tourniquet use
90-120 min
-controversial max at 2-3 hours
Anesthetic considerations for tourniquets
Antibiotic- timing! Get in before tourniquet is up
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Documentation
Post tourniquet syndrome
Swollen, stiff, pallor, weakness/numbness
Resolves 1-6 weeks
Rare complications from tourniquets
Rhabdo
Compartment syndrome
PE
Vascular injury
Fibers involved in tourniquet pain
Unmyelinated C fibers
Describe tourniquet pain
Dull ache-burning pain-unbearable
Hypertension/tachycardia
Refractory to treatment
But resolves with deflation
Substance in bone cement
Methyl methacrylate- known teratogen, pregnant providers should not be in these cases
What is the primary concern with bone cement according to Andrea?
Increased intramedullary pressure
Physiologic effects of bone cement
Increased intramedullary pressure
Emboli
Vasodilation
Decreased SVR
Releases tissue thromboplastin
BCIS
Bone cement implantation syndrome
-vasodilation
-systemic hypotension
-arrhythmia
-RHF
-Arrest
When does BCIS occur?
CEMENTATION
PROSTHESIS INSERTION
Reduction of joint
Tourniquet deflation
Symptoms of BCIS
Hypoxia
Dyspnea
Hypotension
Low cardiac output
Arrhythmias
Confusion
Risk factors BCIS
Age
Bone cement
Pulm HTN
Osteoporosis
PFO/ASD
Preexisting card
Metastatic bone disease
BCIS- anesthesia risk reduction strategies
Discuss with surgeon
Avoid nitrous
100%O2 during cementation
Normovolemia
Surgical strategies to reduce BCIS
Medullary lavage
Hemostasis
Decrease prosthetic length
Non-cement prosthesis
Medullary vent
Common phrase about blood loss in ortho
The LARGER the bone the MORE it bleeds
Which is more vascular: cancellous or cortical?
Cancellous
Transfusion plan in ortho
COMMUNICATE!
Allowable blood loss goal/ crit
Hemodynamic stability
Up-to-date EBL
Comorbidities
Blood conservation strategies
Antifibrinolytics: TXA & aminocaproic acid
Autologous transfusion
Acute normovolemic hemodilution
Cell salvage
Deliberate hypotension
Preoperative autologous transfusion
May still require additional blood from blood bank-
2-4 wks ahead of time
Expensive
Maintain preop Hb 11 or hct 35%
Iron and epoetin supplements
Acute normovolemic hemodilution
EBL expected to be >20% blood volume
Blood withdrawn after induction…
Replace volume with crystalloid
Store at room temp for 6-8 hrs
Clotting factors intact/cardiac output maintained
Cell salvage
EBL of 1-1.5 L
Units have Hct- 50-60%
ABSOLUTE contraindication-septic wound
Relative contraindication- malignancy, clotting in field, fat in blood
Won’t contain clotting factors or platelets
Complications to deliberate hypotension
ISCHEMIC EVENTS
CVA, MI, ATN, hepatic necrosis
Contraindications to deliberate hypotension
Anemia
CAD
Cerebrovascular disease
Renal/hepatic insufficiency
Extremes of age
Uses of deliberate hypotension
Adult trauma
Cerebral tumor resection
Total hip
Jehovah’s Witness
Fat embolism syndrome (triad)
Classic triad (not always present)
Dyspnea/hypoxemia- 95%
Confusion- 60%
Petechial rash- 33%
Fat embolus
Fat droplets in systemic circulation
Long bone fractures
Detectable in blood and urine
SUBCLINICAL in many patients
Fat embolism syndrome (FES)
Fat particles embolism and deposit in pulmonary capillary beds, brain and micro vasculature
ARDS/multi-organ involvement
Risk factors for fat embolism syndrome
Hypovolemic shock
Rheumatoid arthritis
Intramedullary instrumentation
Total hip/cement
Concurrent bilateral knee replacement
Male>female
20-30 yrs old
Gurds criteria for FES
1 sign from major criteria
4 signs from minor criteria
And
Fat macroglobulinemia
Major GURD criteria
Axillary petechiae
Hypoxemia/SOB- pao2<60% on 0.4fio2
AMS- disproportionate to hypoxemia
Pulmonary edema
Minor criteria of GURD
Tachycardia<110
Pyrexia >38.5 C
Emboli present in retina….
Fat in urine
Sudden unexplainable drop in platelets
Type and screen
Blood type and antibodies
-ABO and RH
Type and cross
Crossmatch-comparing blood to donor blood to test compatibility
What happens on tourniquet deflation?
Hypotension
High etCO2
“Washing out of lactic acid”
End point of treatment for FES…
Ecmo
VTE as we age
Risk doubles each decade after 40
Risk for vte without prophylaxis
40-80% of cases
Fatal i up to 80% of those
Highest risk surgeries for thromboembolism
Total hip arthroplasty
Total knee arthroplasty
Traumatic injury to lower extremities
Risk factors thromboembolism
Obesity
Long procedure time
Immobility
> 60 years old
Tourniquet
Spinal cord injury
What compartment pressure requires fasciotomy?
> 30 mmhg
But really loss of pulses and obvious lack of perfusion
What is rhabdomyolysis?
Destruction of muscle cells releases myoglobin that clogs the glomerulus
Signs/symptoms of rhabdo
Increasing CPk-creatinine phosphokinase-indicator of tissue damage
Myoglobinuria
Red/foamy urine (casts)
Goal: prevent ATN
Baseline ortho preop assessment
Mobility-surgical position
CBC/ type&screen and cross
Document existing neuropathies
Examine site of block
Rheumatoid arthritis
Upper C-SPINE impacted in 80% of patients!!!
Assess level of systemic dysfunction
Multisystem disease! Could have subclinical cardiac/pulmonary
Frequently going to be a TKR
Benefits of regional
-Decreased cardiac depression
• Increased tissue perfusion and blood flow
• Decreased blood loss
• Decreased PONV
• Better pain control
Big consideration for hand/wrist surgery
Place the IV on the opposite side of the surgery
They will postpone!!
BIER block
IV distal to operative site on operative side
Exsanguinate the arm
Inflate distal cuff
Unwrap arm and administer local anesthetic through IV
Cuff must be inflated for 15-20 minutes MINIMUM
Minimum time for bier cuff to be inflated
15-20 min
4 options for brachial plexus block (diagram for areas affected)
Interscalene block
Roots
Supraclavicular block
Trunks/divisions
Infraclavicular block
Cords
Axillary block
Terminal branches
Visualize the brachial plexus variations and locations
Positioning concerns for upper arm/ shoulders
METICULOUS attention to eyes free from pressure- use goggles
Increased risk air embolism
Probably in beach chair
20cm rise in head causes what change in BP
15mmhg fall in cerebral MAP
This is difference between cuff and circle of Willis
EBL in humerus fracture
750
Concern for open repair rotator cuff
They are EXTREMEly painful
4 muscles involved in rotator cuff repair… SITS
-Supraspinatus
– Infraspinatus
– Teres Minor
– Subscapularis
Considerations for ACL repair
Very painful
Trocar after tourniquet could mask vessel injury
Large quantities of irrigating fluid-easy to overload
Blood loss in femur vs tibia/fibia fractures
Femur- 1500ml
TiB/fib-750
PPE in ortho procedures?
Lead
Frequent fluoro
Used to align bone fragments- think intramedullary rod
Blood loss in pelvic fracture
4L…
Or just everything
Easier repair sites for hip fractures
Above (neck) or below trochanters
Between trochanters can be quite difficult
Are older people harder to operate on for orthopedic surgery?
Not really
-no difference in pain scores and functional outcomes
Be more concerned about ASA status
Why is regional better in elderly population?
Increased Immobility = Increased 6 month mortality and decreased overall functionality 2 months post-op.
Pros and cons spinal vs epidural
Spinal- single shot, easier to place, dense block, NO post-op pain management
Epidural- more difficult to place, great post op pain management
What level spinal do we do for hips?
T10
Spinal needle considerations
Med delivery can be through a port so often people perform incomplete blocks since the needle isn’t advanced far enough
Hana ortho table
Steam punk
Provide traction and maintains alignment
Allows more angles for Fluoro
Watch the genitals
Hips are sometimes done laterally, what’s the consideration here
Heavy sedation+comborbitities??
Access to airway?
What’s the downside to minimally invasive hip surgery?
Technically challenging for the surgeon, otherwise its fucking fabulous
Biggest consideration for TKA + four nerves
Pain management
- we want them ambulating and going home
Femoral
Obturator
Sciatic
Lateral femoral cutaneous
Post op TKA considerations
Multimodal
Ice machines, local anesthesia
Early ambulating
Laminectomy and discectomy
Removal of the laminate or disc to relieve pressure on nerves
Blood loss in laminectomy
Should be very minimal!!
Most commonly injured area of spine
C5-c6
Least protected and most mobile segment of the spine
When do you use c-spine precautions in trauma?
Always
Until cleared
What’s type of injury is stabalization of cspine preventing?
Extending injury
Consideration for C5 or higher injury
Respiratory insufficiency
If deltoid/biceps are impaired then the diaphragm is impacted
C5-T7 injury consideration
Loss of accessory muscles- can decrease vital capacity up to 60%
Cardiac accelerator fibers
T1-T4
Bradycardia
No compensatory tachycardia with shock
Considerations for extubation after c-spine surgery
Pharyngeal edema
May need to be intubated over night
-neuro deficit
-EBL
-duration
Comorbidities
Why correct scoliosis and why not?
Restrictive pulmonary disease
V/Q mismatch
Pulm HTN
Cor-pulmonale
ONLY corrected when severe due to M&M
What’s the Cobb angle and who cares
Angle of vertebrae determines severity of scoliosis
> 40-50 degrees likely needs operative repair
2 systems we care about that are impacted by scoliosis
Cardiac and pulmonary
Anterior approach to scoliosis
Better correction
Higher complications
Deflate lung above T8
VATS
Video assisted thoracoscopy
Anesthesia considerations scoliosis
Long
Large EBL
All the monitors
POVL
Hypothermia
ICU after
What does ACL stand for
Anterior cruciate ligament
