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6901 > Ortho/Podiatry > Flashcards

Ortho/Podiatry Flashcards

1
Q

Largest post operative problem for ortho/podiatry procedures

A

Post-op pain

-Regional anesthesia and multimodal analgesia utilized to address this

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2
Q

Rheumatoid arthritis

A

Chronic inflammatory process of uncertain etiology (autoimmune?)

  • Synovitis of cervical spine, TMJ, larynx, and pulmonary system
  • Rheumatoid nodules cause inflammation of intervertebral discs and atlanto-occipital subluxation (problem during intubation)
  • Can cause limited TMJ opening
  • Default=awake fiberoptic intubation
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3
Q

Hoarseness/inspiratory stridor indicates ___ for RA patients

A

Narrowing/fixation of glottis opening due to cricoarytenoid arthritis

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4
Q

RA pulmonary lesions

A

Can lead to many pulmonary diseases

  • Pleural effusion
  • Intrapulmonary nodules
  • ILD
  • Vasculitis
  • Pulmonary infections
  • Etc.
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5
Q

Osteoarthritis vs rheumatoid arthritis

A

Osteoarthritis -> bone on bone due to thinned cartilage
-“wear and tear” syndrome
RA -> Swollen/inflamed cartilage/synovial membrane -> bone erosion
-inflammatory disease of synovial membrane

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6
Q

Ankylosing Spondylitis

A

Chronic inflammatory process (primarily affects spinal column)

  • Spinal injury with little trauma
  • Conduction delays, valve lesions, restrictive lung disease
  • Airway concerns, cervical spine positioning for intubation/intraop/emergence
  • Many times C spine is fixed in flexed position -> awake fiberoptic intubation
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7
Q

Pneumatic tourniquet placement, inflation pressure, time of inflation

A

Should cover <50% of extremity and overlap away from superficial neurovascular bundle

  • Inflate to 90-100 mmHg above SBP
  • Notify surgeon at 60 minutes, shouldn’t exceed 120 minutes
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8
Q

Neurologic tourniquet hazards (30/60/120 minutes)

A

30 minutes: Abolish SSEP
60 minutes: Pain (even under deep anesthesia)
120 minutes: Neuropraxia (temporary loss of motor/sensory function due to blockage of nerve conduction)
-Nerve injury at edge of tourniquet can be permanent

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9
Q

Muscle tourniquet hazards (2 minutes, 2 hours)

A

2 minutes: Cellular hypoxia
-Creatinine values decrease
-Cellular acidosis
2 hours: Endothelial capillary leak

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10
Q

Systemic effects on tourniquet inflation

A

300-500mL blood pushed into systemic circulation -> increased systemic and pulmonary pressures

  • Exaggerated when 2 limbs are occluded
  • Potent anesthetic vapor blunts response more than balanced anesthetic technique
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11
Q

Systemic effects on tourniquet deflation

A

Decreased core temp
-Usually transient unless low to begin with
Transient metabolic acidosis
-Acidosis metabolites released into circulation
Decreased SvO2
Transient decreased systemic and pulmonary pressure
Transient increase in ETCO2

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12
Q

Tourniquet safety (2 hours, 4 hours, time to regain muscle power/sensation from 1 vs 3 hour T time)

A

2 hours: Shouldn’t exceed
4 hours: Reliable nerve damage will occur
3 hours: Muscle power of extremity reduced for a full week
1 hour: Physiologic effects of tourniquet deflation will resolve after 20 minutes

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13
Q

Complications of IV regional anesthesia

A
  • LAST (avoid with maintaining pressure in reliable tourniquet)
  • Hematoma (use a small IV and hold pressure for a long time after removing)
  • Engorgement of extremity (happens when arterial inflow without venous outflow, make sure there isn’t a pulse)
  • Exchymosis and subcutaneous hemorrhage (happens after engorgement, make sure theres padding under tourniquet)
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14
Q

Beach chair position complications

A

Cervical neck injury due to dislodgement of head from holder

  • Inadvertent extubation
  • Brachial plexus injury on opposite side
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15
Q

Advantages to beach chair position

A
  • Reduced brachial plexus injuries
  • Better respiratory mechanics
  • Excellent access to shoulder
  • Arm weight distracts shoulder joint
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16
Q

Hemodynamic hazards of beach chair position

A

CVP/MAP/PAP/CO decrease
-Inaccurate BP measurement if taken at arm (BP brain is 1mmHg less for every 1.25cm difference of auditory meatus from cuff site)

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17
Q

Vision loss after prone spine surgery (incidence, risk factors, presentation)

A 
Incidence: 0.028-0.2%
Risk factors:
-Atherosclerosis, CV disease
-Excessive blood loss
-Excessive crystalloid administration
-Excessive surgical length
Presentation: Immediate post-op vision loss due to:
-Cortical blindness
-Central retinal artery occlusion
-Ischemic optic neuropathy
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18
Q

How to avoid post-op vision loss

A 
Avoid:
-Direct pressure on globes
-Periop hypotension
-Periop anemia
Consider 10 degrees reverse Trendelenburg when prone
Lower transfusion threshold (Hct>30% in at risk patients)
Avoid large amounts of crystalloid
Maintain MAP at pts baseline
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19
Q

Arthroscopy

A

Examination/treatment of joint space with endoscope

  • Usually knee but also shoulder, wrist, hip, ankle
  • Less blood loss, post-op pain, short/no hospitalization, short rehab
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20
Q

Arthroplasty (what it is, goals, most common type)

A 
"Total joint replacement"
Surgical replacement of all/some joint
-Goal: Pain relief, stability, deformity correction
Knee=most common
-Use tourniquet
-Usual blood loss up to 2 units
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21
Q

Anesthetic for knee arthroplasty

A

General
Spinal
“Triple” block
-Femoral, sciatic, lateral femoral cutaneous nerves

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22
Q

TKA adverse events

A 
HTN, hypoxia, CV collapse during component insertion
Cases: 
-MMA cement
-Fat embolism
-Air embolism
-Marrow embolism
-Thromboembolism
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23
Q

CV effect of MMA cement

A

Increased PVR and PCWP

Decreased SVR, CO, BP

24
Q

PE incidence for TKA

A

1-5%

Very high, usually get LMW heparin and/or Coumadin post op

25
Q

Special considerations for THA

A

Blood loss can >6 units
MVAMC redo’s get a line and foley
Usually older patients with co-morbidities

26
Q

Methylmethacrolate cement (MMA)

A

Binds with patients bone and prosthetic parts
Hardens and expands due to exothermic reaction
Can cause intramedullary hypertension -> embolization of fat, bone, cement, and/or air

27
Q

Bone cement implantation syndrome (and risk reduction strategies)

A

-Hypoxia
-Hypotension
-Arrythmias
-Pulmonary hypertension
-Decreased CO
Usually occurs when femoral component is placed
Risk reduction strategies
-Increase FiO2 before cementing
-Maintain euvolemia
-Vent distal femur and do high pressure lavage of femur shaft to remove debris
-Use uncemented femoral components for hips
-Avoid hypothermia

28
Q

Methods to conserve blood during ortho surgery

A
  • Cell saver
  • Autologous blood
  • Induced hypotension (be careful)
  • Normothermia
  • Spinal or epidural anesthetics
29
Q

Indications for spinal surgery

A

Intervertebral disc herniation or spinal stenosis scoliosis

  • Herniated disc excised and foramen is enlarged
  • Vertebral fusion with bone grafts or vertebral cages
30
Q

Special considerations for scoliosis surgery

A

Typically anterior/posterior surgery

  • Requires thoracotomy to access thoracic spine
  • May have some restrictive lung disease depending on disease progression
31
Q

Foot and ankle surgery indications and anesthesia type

A

Ankle fraction, Achilles tendon rupture, bunions, hammer toes, plantar fasciotomy, toe/foot amputations
-Very amendable to regional anesthesia

32
Q

5 nerves for ankle blocks

A 
Branches of sciatic nerve:
-Superficial peroneal
-Deep peroneal
-Sural
-Posterior Tibial
Branch of femoral nerve:
-Saphenous
*All 5 must be accurately blocked for efficacious ankle block
33
Q

Hip fractures

A
  • Usually elderly with many co-morbidities
  • Usually off-shift
  • Blood loss pre- intro- and post-op
  • Lateral position
  • Use of regional anesthetics is limited by patient conditions and co-morbidities
  • High incidence of post-op complications
34
Q

2009 Article gerontology post-op complications correlated with ___

A
  • Poor ASA classification
  • Urgency of procedure
  • Extent of procedure
  • Duration of procedure
35
Q

ORIF major complication

A

Fat embolism
-10-20% of femur fractures, often fatal
-Due to fat globules released by the disruption in fat cells in bone fracture, enter the circulation through tears in venous sinuses in the bone
-Present in 72 hours of injury, sx: dyspnea, confusion, petechai
Dx: petechai on chest/UE/axilla/conjunctiva
-Fat globules in retina, sputum, urine
-Thrombocytopenia
-Decreased ETCO2, SaO2, increased PA pressures
-ST segment suggestive of ischemia
Treatment
-Stop operating on bone, supportive care

36
Q

On an upright CXR where should the end of the ETT be?

A

Where clavicles meet

37
Q

Bier block, what to check

A

Both sides of tourniquet are working (250mmHg and 270 mmHg)

-Distal and proximal cuffs and labeled and correctly correlate with box labels

38
Q

Onset of bier block

A

5 minutes

39
Q

Midazolam for bier block?

A

Yes, increases comfort and increases seizure threshold if tourniquet is inadvertently released and high lidocaine doses are released systemically

40
Q

Hypoxic pulmonary vasoconstriction

A

Alveoli without much O2 vasoconstrict, shunt blood flow to areas of lungs with better ventilation
-Normalizes V/Q mismatch

41
Q

What NOT to use in blocks for patients with diabetes

A

Epi

42
Q

Fracture table positioning considerations

A

Don’t forget about the unaffected leg that is raised above the body (BP will be decreased here compared to cuff reading), make sure it’s perfused

43
Q

Ankle block=block of the terminal branches of the ____ nerve

A

Sciatic nerve

Except 1 nerve branch of femoral

44
Q

Ankle block=block of 2 deep nerves __,__ and 3 superficial nerves __,__,__

A 
Deep
-Deep peroneal
-Posterior tibial
Superficial 
-Saphenous
-Sural
-Superficial peroneal
45
Q

Anesthetizing superficial vs deep nerves

A

Deep
-Anesthetized by injecting local anesthetic underneath the superficial fascia
Superficial
-Anesthetized by a simple subcutaneous injection of local anesthetic

46
Q

Sciatic nerve formed from __ through __ roots

A

L4-S3 roots

47
Q

1st split of sciatic nerve

A

To tibial nerve and common peroneal nerve

48
Q

Femoral nerve arises from ___ nerves, and what it’s positioned next to running down

A

L2-L4

Lateral and slightly deeper than femoral artery

49
Q

Ankle block provides anesthesia to:

A

Foot, but NOT the ankle itself

50
Q

Local anesthetics to use for ankle blocks (3)

A

1.5% Mepivicaine (with bicarb)
2% Lidocaine (with bicarb)
0.5-0.75% Ropivicaine
0.5% Bupivicaine

51
Q

Complications of ankle blocks

A 
Injection
Hematoma
Vascular injection
-Especially at saphenous vein at medial malleolus
Nerve injury
52
Q

Bezold-Jarisch reflex

A

Inhibitory reflex mediated through cardiac sensory receptors with a vagal efferent limb
-Beach chair position -> venous pooling in dependent extremities -> increased sympathetic tone, low-volume hypercontractile ventricle -> reflex activated -> abrupt automatic withdrawal of sympathetic response, activation of increased vagal tone
=sudden profound bradycardia and hypotension that’s difficult to rapidly reverse

53
Q

Blocks and hypotensive bradycardic episodes (HBE)

A

LA with epi for interscalene block might contribute to HBE (hypotensive bradycardic episodes) d/t increased cardiac contractility -> ventricular emptying -> increased HR (reduced cardiac filling) -> increased peripheral vasodilation and pooling (decreased afterload) -> ventricular hypovolemia with hypercontractions

54
Q

Prophylaxis to prevent HBE

A
  • Aggressive treatment of fluid deficits and blood loss
  • Support stockings: Minimize venous pooling in upright position
  • Avoid LA with epi
  • Consider using intraoperative beta-blockade in select patients
55
Q

Risk of developing ___ is increased with pneumatic tourniquet use

A

Thromboembolism

56
Q

Spine procedures more likely to be associated with major blood loss

A

Those involving the thoracic spine, particularly for malignancy or trauma

57
Q

TXA MOA

A

Inhibits fibrinolysis by blocking the activation of plasminogen resulting in clot stabilization -> reduced post-op bleeding

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