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S5 - Principles III - Test 2 > Ortho Surgeries > Flashcards

Ortho Surgeries Flashcards

1
Q

induction plan for any patient presenting for acute fracture repair

A

RSI - always consider full stomach

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2
Q

why might arthritic pts be difficult intubations?

A

may have limited ROM of neck

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3
Q

what is rheumatoid arthritis

A

immune-related, progressive inflammation of synovial joints

(not just normal wear & tear)

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4
Q

airway concerns for a pt with rheumatoid arthritis

A

cervical mobility (atlantoaxial joint instability/subluxation), TMJ issues may make intubation difficult

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5
Q

why do pts with rheumatoid arthritis need to have pre-op c-spine films?

A

to evaluate atlantoaxial subluxation and determine if awake fiberoptic intubation is indicated

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6
Q

when is awake fiberoptic intubation indicated for pt with rheumatoid arthritis?

A

c spine film reveals > 5 mm instability

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7
Q

s/s cricoarytenoid arthritis in pt with RA

A

hoarseness

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8
Q

considerations for an RA pt on chronic NSAIDs

A

potential for GI bleeding, renal toxicity, platelet dysfunction

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9
Q

CV effects of rheumatoid arthritis

A
  • pericardial thickening, effusions
  • myocarditis
  • coronary arteritis
  • conduction defects
  • cardiac valve fibrosis
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10
Q

heme effects of RA

A
  • anemia
  • platelet dysfunction
  • thrombocytopenia
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11
Q

endocrine effects of RA

A
  • adrenal insufficiency r/t steroid use
  • impaired immune system
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12
Q

derm effects of RA

A

thin, atrophic skin from steroids

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13
Q

position most associated with air embolus

A

sitting (beach chair)

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14
Q

use of regional anesthesia in ortho surgeries

A
  • more for upper extremity surgeries
  • can be used with GA for postop pain control
  • may result in less blood loss
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15
Q

possible patient positions for shoulder surgeries

A

lateral or beach chair

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16
Q

positioning challenge of shoulder surgery, regardless of position

A

padding and protection of ears, eyes, bony areas

~DuH~

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17
Q

can LMA be used for shoulder surgeries?

A

DFort says yes

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18
Q

regional anesthetic used in shoulder surgery for post op pain control

A

interscalene block

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19
Q

risks assoc. with controlled hypotension in shoulder surgeries

A
  • beach chair position - cerebral ischemia
  • vision loss
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20
Q

where does the art line need to be leveled to estimate CPP?

what is this area called?

A

level of external auditory meatus and tragus

circle of willis

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21
Q

why is the pressure in the circle of willis lower than the pressure at the level of the heart?

A

d/t vertebral column and hydrostatic pressure difference

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22
Q

1.25 cm = ____ mmHg drop in BP

A

1

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23
Q

benefits of arthroscopic surgeries

A
  • less invasive, less blood loss
  • less post-op discomfort
  • reduced length of rehab
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24
Q

why is controlled hypotension used in arthroscopic surgeries?

A

to maintain bloodless field and reduce BP on non-tourniquet joints to optimize surgical field

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25
Q

why are irrigant fluids used in arthroscopic surgeries?

at what pressure are they instilled?

A

used to distend operative joint

60-80 mmHg

100-120 mmHg in beach chair

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26
Q

complications of high irrigation pressures with long duration

(in arthroscopy)

A

sub-q emphysema

tension pneumothorax

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27
Q

complications of irrigant absorption in arthroscopic surgeries

(book)

A
  • fluid volume overload
  • CHF
  • pulmonary edema
  • hyponatremia if sterile water used
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28
Q

most spinal surgeries involve what segments of the spine?

A

cervical & lumbar

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29
Q

anesthetic technique for spinal surgery

A

GA with or without paralysis

may do without paralysis to use SSEP

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30
Q

what aspects of spinal surgery can create airway challenges?

A

prone position

cervical immobility

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31
Q

why might the surgeon ask you to give VCM in the middle of a spinal surgery?

A

after CSF leak is repaired - increased transthoracic pressure allows the surgeon to test the seal of the dura

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32
Q

possible pt positions for cervical spine surgery

A

prone, sitting, or supine

(Fort says most are supine now)

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33
Q

potential airway management challenge for c spine surgery pts

A

TMJ dysfunction, atlantoaxial instability (limited neck ROM)k

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34
Q

surgical approach for C1-C2 vs. C3-C6

A

C1-2: probably posterior

C3-6: anterior

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35
Q

why use an ear pulse ox in c spine surgery

A

major arteries and veins are nearby - retractors could occlude carotid

pulse ox waveform/reading can give clues about carotid occlusion

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36
Q

why is dexamethasone given prophylactically to c spine surgery pts

A

prevent post op airway swelling

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37
Q

possible nerve injury in c spine surgery

A

recurrent laryngeal nerve

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38
Q

why is an LTA kit indicated for c spine surgery pts?

A

to prevent coughing or bucking and prevent potential for airway hematoma

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39
Q

typical position for lumbar spine surgery

A

prone

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40
Q

potential nerve injury with positioning for lumbar surgery

how to avoid?

A

brachial plexus

arms/shoulders < 90 degrees

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41
Q

why might you see decreased CO in a pt undergoing lumbar spine surgery?

A

abdominal compression (prone) can occlude IVC and impede venous return/stroke volume

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42
Q

why are FRC and Vt decreased in lumbar spine surgeries

A

prone position - diaphragm is cephalad

43
Q

spinal surgeries assoc. with large blood loss

A
  • lumbar spine
  • spinal fusion
  • hip replacement
44
Q

respiratory concerns for a spinal fusion patient

A

scoliois pts may have restrictive lung disease

45
Q

what is the artery of Adamkiewicz? (google)

why do we care

A

dominant thoracolumbar segmental medullary artery that supplies the lower spinal cord

need neuromuscular montioring in spinal fusion bc its v close to the spine

46
Q

why use a toe pulse ox in a supine spinal surgery

A

to monitor vessel occlusion by retractors

47
Q

typical patient population seen for hip fracture

A

elderly, frail, debilitated, dehydrated pts with existing comorbid conditions

48
Q

positioning for hip fracture repair

A
  • supine
  • moved to fracture table after induction
  • ipsilateral arm placed on chest
49
Q

respiratory concerns related to positioning for a hip fracture repair

A

arm positioning creates restrictive lung conditions

50
Q

ALIF vs. PLIF

A
  • anterior or posterior lumbar interbody fusion
  • can be done for cervical, thoracic, and lumbar spinal issues
51
Q

if you give a hypobaric LA solution via spinal to a hip fracture pt, where will its effects be seen?

sorry prob a shitty way to word that

A

non-dependent (surgical) hip

is this supposed to say hypobaric- yup oopsie

52
Q

fat embolisms are common for what procedures

A

hip fractures

long bone fractures (femur, tibia)

53
Q

typical hip replacement patient

A

elderly, likely arthritic/degenerative joint disease

per the book, 50% are obese

54
Q

positioning for hip replacement

A

lateral decubitus

55
Q

why is a subarachnoid block particularly helpful in a hip replacement surgery?

(book)

A

several large muscle groups have to be cut/dissected to get to joint - muscle relaxation from block helps

56
Q

why would a bilateral hip surgery be contraindicated?

A

if declining pulmonary function occurs after the first hip surgery

57
Q

which is more painful - knee or hip replacement

A

knee, apparently

58
Q

surgeries with high incidence of DVT

A

THA and TKA

(total hip/knee arthroscopy)

59
Q

regional anesthetic options for a knee replacement

A
  • femoral 3 in 1 block combined with spinal
  • femoral catheter for post-op pain control
60
Q

which is probably better for a closed reduction - succs or roc?

A

succs - usually very short procedures but muscle relaxation needed bc muscle contraction can prevent reduction

but i guess if you have sugammadex it don’t matta

61
Q

anesthetic technique for closed reduction

A

can be done with propofol bolus

short-acting NMB

often done via mask ventilation w/o airway instrumentation

62
Q

what is methylmethacrylate cement?

A

used to bind prosthetic to bone

63
Q

what causes bone cement to harden against prosthetic components?

A

an exothermic reaction

64
Q

what does intramedullary mean?

~google :)~

A

in the bone marrow

65
Q

what can cause embolization of fat, bone marrow, cement, and air into venous channels?

A

intramedullary HTN

(>500 mmHg per M&M)

66
Q

AEs of systemic bone cement absorption

A
  • vasodilation
  • decreased SVR
  • release of tissue thromboplastin
  • platelet aggregation
  • microemboli formation
  • embolic shock
67
Q

what ortho surgeries should pregnant CRNAs not be involved in

A

ones that use bone cement

but prob all of em bc of the radiation

68
Q

s/s of bone cement implantation syndrome

A
  • hypotension
  • hypoxia
  • decreased CO
  • dysrhythmias
  • shunt
  • pHTN
69
Q

what might be the first sign of bone cement implantation syndrome under GA?

(book)

A

abrupt decrease in ETCO2

70
Q

risk factors for bone cement implantation syndrome

(book)

A
  • preexisting CV disease
  • preexisting pHTN
  • ASA 3+
  • NY Heart Assoc. class 3 & 4
  • intertrochanteric fracture
  • long-stem arthroplasty
71
Q

management of suspected bone cement implantation syndrome

A

100% FiO2

hydration

72
Q

what is a pneumatic tourniquet

A

applied to an extremity proximal to surgical site to create a bloodless field

73
Q

what is an Esmarch bandage?

~*google again~*

A

a soft rubber band used to expel venous blood from a limb (exsanguinate) that has had its arterial supply cut off by a tourniquet

74
Q

AE of exsanguination of a lower extremity & tourniquet inflation

(M&M)

A

rapid shift of blood volume into central circulation

75
Q

cuff overlap for pneumatic tourniquet

A

should be 180 degrees from nerve bundle

76
Q

what determines inflation pressure of a pneumatic tourniquet?

what pressures are typically used

A

blood pressure

typically: lower ext. 100 mmHg & upper extremity 50 mmHg greater than SBP

77
Q

what is a venous tourniquet?

A

I think it is when BP gets higher and allows arterial blood to get back into the extremity that is supposed to be bloodless but then the venous pressure isnt high enough for it to get back out so it builds up in there

Very scientific words i know

78
Q

risk factors for neurological damage from pneumatic tourniquet

A
  • > 2 hours tourniquet time
  • overlap is over nerve bundle
79
Q

physiologic effects of pneumatic tourniquet inflation

A
  • autotransfusion = rise in SVR, CVP, PVR
  • 300-500 mL displaced blood volume from exsanguination
  • prolonged inflation = increased HR and BP
80
Q

physiologic effects of pneumatic tourniquet deflation

A
  • metabolic acidosis
  • inc HR
  • dec temp
  • hypotension
81
Q

why might you give neosynephrine prior to pneumatic tourniquet release

A

to prevent BP drop assoc. with anaerobic metabolites returning to tissues and into central circulation

82
Q

why is tourniquet release assoc. with hypotension

A

sudden reduction of SVR (and PVR)

83
Q

neuro effect of > 60 min of tourniquet

box 38-1

A

tourniquet pain

HTN

84
Q

neuro effect of > 2 hours of tourniquet time

box 38-1

A

postop neuropraxia

85
Q

how long does it take for cellular hypoxia to develop with a limb tourniquet?

box 38-1

A

within 2 min

86
Q

what happens to cellular creatinine level with extremity tourniquet

box 38-1

A

decreases

87
Q

when does endothelial capillary leak occur with limb tourniquet use?

box 38-1

A

> 2 hours

88
Q

systemic effects of tourniquet release

box 38-1

A
  • transient fall in core temp
  • transient metabolic acidosis
  • acid metabolites released into central circulation
  • transient fall in pulmonary and systemic arterial pressures
  • transient increase in ETCO2
89
Q

when does tourniquet pain usually begin?

A

an hour after inflation

90
Q

do IV analgesics help with tourniquet pain?

what route do they work?

A

nope, sucks

work when added to LA

91
Q

deflating the tourniquet for how long can help with pain

A

10-15 min

92
Q

unmyelinated, slow-conducting fibers

A

C fibers

93
Q

fibers responsible for pinprick, tingling after tourniquet deflation

A

A delta

94
Q

describe the pain assoc. wtih pneumatic tourniquets

A

burning, dull, aching, throbbing

*~so all the possible words to describe pain?~*

95
Q

fat embolism triad

A

petechiae - axillary, subconjunctival

dyspnea

confusion, AMS

96
Q

what causes impaired pulmonary perfusion r/t a fat embolus?

A

fat globules released into the blood cause pulmonary congestion

97
Q

when does the fat embolus triad occur?

A

12-24 hours later

98
Q

CV changes that may be seen with fat embolus

A

tachycardia, ST segment changes

99
Q

pts at greatest risk for fat embolus

A

coexisting lung disease

100
Q

treatment of fat embolus

A

O2, aggressive ventilation, fluids, steroids

101
Q

anesthetic technique that reduces the risk of DVT

why?

A

epidural or spinal

higher levels of plasminogen and plasminogen activators, hyperkinetic blood flow, earlier ambulation

102
Q

why is dead space ventilation seen with fat embolus

A

embolic material can qedge in pulmonary artery and block perfusion to lungs

103
Q

why might you see acidosis assoc. with fat embolus

A

decreased BP results in inadequate perfusion + decreasd PO2 and tissue hypoxia

all those things result in anaerobic cellular respiration and lactic acid buildup

104
Q

electrolyte abnormality assoc. with fat embolus

A

hyperkalemia

S5 - Principles III - Test 2 (5 decks)

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