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Advanced Anesthesia Test#2 > Ortho > Flashcards

Ortho Flashcards

1
Q

Polymethylmethacrylate

A
  • Bone cement
  • Frequently required for joint arthroplasties
  • Binds prosthetic device to the patients bone - causing an increase the intramedullary pressure
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2
Q

Complications when intramedullary pressure increases

A

o Fat, bone marrow, cement, or air emboli
o Vasodilation and ↓ in SVR
o Platelet aggregation and microthrombus formation
o Hypoxia
o Hypotension
o Dysrhythmias
o Pulmonary hypertension an increase in PVR
o ↓ CO

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3
Q

Interventions for increased intramedullary pressure (w/ bone cement)

A

o Increase FiO2
o Maintain euvolemia
o Treat arrhythmias
o Surgeon can create a vent hole in the distal femur to relieve intramedullary pressure

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4
Q

Pneumatic Tourniquets:

A

• Creates a bloodless field that facilitates surgery

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5
Q

Pneumatic Tourniquets: inflation pressure

A

100 mmHg over systolic blood pressure

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6
Q

Pneumatic Tourniquets:

Prolonged inflation of >2 hours can lead to

A

transient muscle dysfunction / myopathies / pain
o peripheral nerve injuries
o rhabdomylsis

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7
Q

Pneumatic Tourniquets:

Other potential problems

A 
o	Hemodynamic changes 
o	Pain 
o	Metabolic alterations 
o	Arterial thromboembolism
o	Pulmonary embolism
•	Tourniquet pain
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8
Q

Tourniquet pain

A

un-myelinated slow conducting C-fibers
o Pain usually begins 45-60 min into procedure
o Pain may become so severe that patients may require GA despite the regional block – Spinal Anesthetic
o Progressive sympathetic activation
o Cuff deflation immediately relieves tourniquet pain and associated hypertension

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9
Q

o When the tourniquet is released you will see….

A

cause ↑’s in PaCO2, ETCO2, serum lactate and potassium levels

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10
Q

When applying the tourniquet

A

Limb must be padded and the cuff must fit and be properly applied to the correct extremity

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11
Q

Fat Embolism Syndrome: presents in -

A

72 hours of long bone or pelvic fractures

o long bones = femur / humerus / pelvis

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12
Q

Fat Embolism Syndrome: Signs and symptoms:

A

o Dyspnea, hypoxia
o Confusion or agitation
o Petchiae on the chest, upper extremities, axillae and conjunctiva
o Fat globules may be found in the retina, urine or sputum
o During GA: ↓ ETCO2 and arterial O2 saturation, ↑ pulm artery pressure

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13
Q

Fat Embolism Syndrome: mechanism

A

not known but is thought to occur due to the release of fat globules from fractured bone which enter torn medullary vessels

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14
Q

Fat Embolism Syndrome: Treatment

A

o Early fracture stabilization
o Oxygen and intubation with continuous positive airway pressure ventilation
o If the patient is coding - Start ACLS protocol
o High dose corticosteroids may be of beneficial use

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15
Q

Deep Vein Thrombosis & Pulmonary Embolism

A
  • Most common after orthopedic surgery on the pelvis and lower extremities
  • Occurs due to venous stasis and a hypercoagulable state due to localized and systemic responses to surgery
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16
Q

Deep Vein Thrombosis & Pulmonary Embolism

- pts at risk

A 
Hip surgery or knee reconstruction patients
o	 Obese patients
o	 Over the age of 60
o	 The use of a tourniquet
o	 Greater than 4 days immobilization
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17
Q

how to decrease risk of DVT and PE -

A

• Prophylactic anticoagulation and use of pneumatic leg compression devices decreases incidence of DVT

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18
Q

• If patients are on anticoagulation prophylaxis, spinal or epidural needle placement or catheter removal should

A

not take place until 6-8 hours after heparin dose or 12-24 hours after LMWH

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19
Q

• Anticoagulants may be started after surgery -

A

o Heparin 5,000 units q8˚ or LMWH

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20
Q

Compartment Syndrome:

A

there is an increased pressure – typically caused by inflammation – within the facial compartment – which first impairs venous and lymphatic drainage and eventually arterial blood flow to the tissues – this decreased blood flow to the tissues can lead to nerve damage and muscle death

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21
Q

Compartment Syndrome:

Most commonly seen in

A

anterior and posterior compartment of the leg

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22
Q

Compartment Syndrome:

increased pressure impedes

A

venous, lymphatic and eventually arterial flow

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23
Q

Compartment Syndrome: reduction of blood flow causes

A

ischemia, pain, and may cause paresthesias

• Can lead to nerve damage and muscle death if severe and untreated

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24
Q

Compartment Syndrome: treatment

A

medical emergency and requires a fasciotomy

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25
Q

UTIMATELY the ____________ is responsible for the proper positioning of the patient on the OR table

A

CRNA

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26
Q

Surgical pause:

A

• Initiated by surgeon to identify correct limb or area of surgery before operation begins
o Correct patient / Correct procedure / Correct limb
o Initials marked on the site prior to surgery
• Used to prevent wrong site surgery

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27
Q

the most frequently used anesthetics for ortho

A

• Regional, General Anesthesia, and MAC with sedation and a local anesthesia (LA) field block

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28
Q

Factors that influence the type of anesthetic used:

A 
Patient preference
o	 Patient state of health
o	 Expertise of anesthetist
o	 Duration of Procedure
o	 Surgeon Preference
o	 Practice patterns of hospital - some hospitals may have more resources than other
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29
Q

Arthroscopy

A

• Examination of the interior of a joint with an endoscope

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30
Q

Arthroscopy: • Benefits

A 
o	↓ blood loss
o	↓ postoperative pain
o	↓ hospital time
o	↓ length of rehabilitation 
o	Equals decreased healthcare cost and improved patient satisfaction
31
Q

Arthroscopy: Complications

A 
o	Inadvertent extubation
o	Eye/corneal injury 
o	Nerve injury
o	Tourniquet complications  
o	Vascular injury 
o	Volume overload from fluid absorption
32
Q

Arthroscopy: If a patient does become volume overloaded

A

treat them with fluid restriction / oxygen / diuretics / monitor hemodynamics

33
Q

Knee arthroscopy:

A

Used for diagnosis and/or repair of the meniscus, loose body removal this could be from cartilage micro-fracture, or cruciate ligament repair mainly the anterior ligament repair

34
Q

Knee arthroscopy: position

A

Supine position with the foot of the bed lowered

35
Q

Knee arthroscopy: Anesthetic considerations

A

o Spinal anesthesia w/ MAC

o General anesthesia with a LMA and surgeon injects LA

36
Q

Shoulder Arthroscopy:

A

Used for repairs of the rotator cuff, labral tears, frozen shoulder and other shoulder complications

37
Q

Shoulder Arthroscopy: most commonly done for-

A

ROTATOR CUFF REPAIR (RCR)

38
Q

Shoulder Arthroscopy: position

A

lateral decubitus or beach chair

39
Q

Shoulder Arthroscopy: Complications

A

o Subcutaneous emphysema
o Pneumothorax
o Pneumomediastinum
o Hypoxic brain injury

40
Q

Hypoxic brain injury

A
  • Usually related to beach chair position & hypotension
  • Anesthetist will give a Propofol drip or beta-blocker to get systolic less than 100 mmHg, usually around 90 mmHg. Research shows controlled hypotension can contribute to hypoxic brain injury. Try to avoid this -
  • keep systolic > 100mmHg / don’t let it fall below 20% of baseline
41
Q

Shoulder Arthroscopy: Anesthetic considerations

A

o Positioning and airway access can be limited
o Maintain normothermia
o Put monitors in non-operative arm

42
Q

Shoulder Arthroscopy:

Combination interscaline block or HIGH brachial plexus block: Complications:

A

interscaline block - can lead to phrenic nerve paralysis -which would paralyze half the diaphragm or Horner’s Syndrome

43
Q

Horner’s Syndrome

A

pitosis
miosis
endopthalmus
anhydrosis

44
Q

Arthroplasty:

A

Surgical replacement of a joint to gain the return of natural range of motion and function of the joint
-Arthroplasty is used for restoration of the controlling function of the surrounding soft tissues - such as the muscles, ligaments and tendons

45
Q

Arthroplasty:
• Total arthroplasty
• Hemiarthroplasy

A
  • Total arthroplasty = total joint replacement

* Hemiarthroplasy = partial joint replacement

46
Q

Arthroplasty: Goals include:

A

o Pain relief
o Stability of joint motion
o Deformity correction

47
Q

Arthroplasty: Joints are replaced with

A

Prostheses made from strong metal alloys such as cobalt or titanium

48
Q

Complications of arthroplasty:

A

o Blood loss
o Infection
o Thromboembolism
o Nerve injury

49
Q

Most commonly replaced joints:

A

o Hip

o Knee

50
Q

Arthroplasty:

Anesthetic considerations:

A

o Spinals are used for sick patients - a lot of elderly patients who fall and fracture their hips
o General Anesthesia is reserved for those who do not consent to Regional
• Again, anesthesia is responsible for patient positioning and maintaining normothermia,
• Procedures can last from 1-4 hours

51
Q

Hip arthroplasty:

A

Also known as total hip replacement

52
Q

Hip arthroplasty: position

A

Supine can be used – on a FRACTURE TABLE

Lateral decubitus position

53
Q

Hip arthroplasty: general info

A
  • Large incision from iliac crest to mid thigh
  • Several large muscle groups are incised and dissected
  • Joint is disarticulated and femoral head and neck are excised leaving the femoral canal open
  • During reaming process venous sinuses can be opened and destroyed leading to significant blood loss
54
Q

Hip arthroplasty: Anesthetic considerations specific to hip arthroplasty:

A
  • Frequently are elderly patients with co-existing diseases
  • VOLUME DEPLETED
  • blood loss can be up to 6 units or 2-3 L
  • LATERAL DECUBITUS POSITION using a HYPERBARIC spinal
55
Q

pt on plavix

A

stop 7 days prior- put on aspirin

56
Q

Knee arthroplasty:

A
  • Also know and total knee replacement
  • Supine position w/ tourniquet
  • done for degenerative joint disease
57
Q

Knee arthroplasty: Anesthetic considerations

A

o Similar to THA
o Supine
o Spinal w/ MAC

58
Q

Open Reduction Internal Fixation:

A

• Known as ORIF

59
Q

ORIF: OPEN REDUCTION

A

open surgery to set bones - necessary for some fractures

60
Q

ORIF: INTERNAL fixation

A

refers to fixation of screws or plates to enable and facilitate healing. Keeping the bone in its normal position

61
Q

ORIF: RIGID fixation

A

prevents micro motion across lines of the fracture and helps to enable healing and prevent infection.

62
Q

ORIF: EXTERNAL fixation

A

is a surgical treatment used to set bone fractures in which a cast would not allow proper alignment of the fracture

63
Q

ORIF: Anesthetic considerations

A
  • Emergency cases are considered full stomachs and aspiration prophylaxis should be implemented
  • Consider that the patient may be acutely intoxicated with alcohol and/or drugs
64
Q

Depressants effect on MAC: alcohol and narcotics

  • acute
  • chronic
A

o Acute usage (acutely intoxicated) – DECREASED MAC

o Chronic usage - INCEASED MAC

65
Q

Stimulants effect on MAC: amphetamines / cocaine

A

o Acute usage- INCREASED MAC
o Chronic usage- DECREASED MAC
patients who are chronic uses of stimulants usually have decreased catecholamine stores - **some may need an increased MAC – due to enzyme induction, but essentially your going to treat the patient accordingly to what’s going on at the time

66
Q

Marijuana/Cannabis effect on MAC:

A

o Acute usage- DECREASED MAC

o Chronic usage- INCREASED MAC

67
Q

Anesthetic Management for Hand and Foot Surgery

A

• Foot surgery is usually done by podiatrists
• Tourniquets are frequently used
• Most hand procedures can be done under general anesthesia using short acting anesthetics (S.A.F.E.) with LMA
o S.A.F.E. – short-acting, fast emergence

68
Q

carpal tunnel release

A

usually done using a Bier Block or general anesthesia with an LMA

69
Q

Bier Block:

A

o IV REGIONAL anesthesia
o Start IV in hand, exsangunate the arm, inflate tourniquet, and inject 50 ml of 0.5% Lidocaine
- TQ up for at least 20-25 minutes

70
Q

ANKLE BLOCK

A

23-25 gauge needle and 5-8 ml of LA – Lidocaine or Marcaine is injected at the site after aspiration – your doing a type of a field block around where these nerves are

71
Q

ANKLE BLOCK: nerves

A
  • Femoral nerve terminal branch is the
    1- SAPHENOUS nerve – is at distal end of tibia - also known as the lateral malleolus
- Sciatic nerve terminal branches:
2- Posterior tibial nerve – back medial aspect. 
3-  Deep peroneal nerve
4-  Superficial peroneal nerve
5- Sural nerve
72
Q

Series of 5 different injections - essentially doing a circumferential block – AVOID…..

A

EPINEPHRINE in your local anesthetic.

73
Q

Brachial plexus nerves and where they originate

A
  • roots (C5-T1)
  • trunks: superior (C4-C6), middle (C7), inferior (C8 & T1)
  • Divisions: 3 ventral and 3 dorsal
  • cords: lateral, medial, and posterior
  • branches: axillary, musculocutaneous, radial, median, ulnar

Advanced Anesthesia Test#2 (4 decks)

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