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(Spring 2025) Advanced Principles A > Orthopedic Anesthesia > Flashcards

Orthopedic Anesthesia Flashcards

1
Q

What are the two biggest factors associated with development of osteoporosis?

A
  • Elderly age
  • Menopause
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2
Q

What hormonal changes are characteristic of osteoporosis?

A
  • ↑ PTH
  • ↓ Vit D
  • ↓ HGH
  • ↓ Insulin-like growth factors
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3
Q

What are the four most common meds used to treat osteoporosis?

A

dronate acid drugs
- Fosamax (Alendronate)
- Actonel (Risedronate)
- Boniva (Ibandronic Acid)
- Reclast (Zoledronate)

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4
Q

Differentiate between Bouchard’s nodes and Heberden’s nodes.

A
  • Bouchard’s = proximal interphalangeal joints
  • Heberden’s = distal interphalangeal joints
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5
Q

What drug is the most common chondroprotective agent that helps protect the articular joint?

A

Glucosamine

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6
Q

What anesthetic considerations should be given to glucosamine?

A

Glucosamine needs to be stopped two weeks prior to surgery due to PLT aggregation inhibition.

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7
Q

Arthritis characterized by morning stiffness that improves throughout the day is….

A

Rheumatoid arthritis

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8
Q

Arthritis that is characterized by worsening symptoms throughout the course of the day is…

A

Osteoarthritis

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9
Q

What labs are typically elevated in a patient with rheumatoid arthritis?

A
  • ↑ Rheumatoid factor (RF)
  • ↑ Anti-immunoglobulin antibody
  • ↑ C-reactive protein (CRP)
  • ↑ Erythrocyte Sedimentation Rate (ESR)
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10
Q

What common dose of stress dose glucocorticoid is used for RA patients?

A

50 -100 mg hydrocortisone (Solu-cortef)

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11
Q

What two TNFα inhibitors are commonly used to treat RA?

A
  • Infliximab (Remicade)
  • Etanercept (Enbrel)
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12
Q

Which of the following drugs treat RA?
- Methotrexate
- Hydroxychloroquine
- Sulfasalazine
- Leflunomide

A

Trick question. All of them do
- Methotrexate
- Hydroxychloroquine
- Sulfasalazine
- Leflunomide

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13
Q

What airway concerns should be considered with RA patients?

A
  • Limited TMJ movement
  • Narrowed glottic opening
  • Cricoarytenoid arthritis
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14
Q

Where is the most instability typically located in the cervical spine of RA patients?

A

Atlantoaxial Junction

(be careful not to displace the odontoid process and impinge on the c-spine/medulla or vertebral arteries)

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15
Q

What are the signs and symptoms of atlantoaxial subluxation?

A
  • Headache
  • Neck pain
  • Extremity paresthesias (especially with movement)
  • Bowel/bladder dysfunction
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16
Q

What are the signs/symptoms of vertebral artery occlusion?

A
  • N/V
  • Dysphagia
  • Blurred Vision
  • Transient LOC changes
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17
Q

What ocular syndrome is typical of RA patients?

A

Sjogren’s syndrome

(Dry eyes and mouth)

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18
Q

What pulmonary issues are associated with RA?

A
  • Interstitial fibrosis
  • Restricted ventilation
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19
Q

What type of ventilatory settings would be utilized for an RA patient exhibiting a restrictive ventilatory pattern?

A

Pressure Control @ 5mL/kg

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20
Q

What artery is typically injured due to pelvic fractures? Where is the bleeding located in this instance?

A

Iliac artery → retroperitoneal space bleeding

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21
Q

What is the typical worst complication of long bone fractures?

A

Bone marrow fat embolism

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22
Q

What technique is used for intubation of a patient who has c-spine concerns?

A

MILS

Manual In-Line Stabilization

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23
Q

Describe the MILS technique

A
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24
Q

What is the mechanism of action of warfarin?

A

Warfarin inhibits Vitamin K epoxide reductase and limits the availability of Vitamin K throughout the body (decreases factors II, VII, IX, X)

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25
Q

What is the mechanism of action of LMWH?

A

indirect thrombin inhibitor

LMWH binds to antithrombin (Enhancement of AT Activity) & Xa (Inhibition of Factor Xa) thus → no thrombin → no fibrinogen forming into fibrin

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26
Q

What are some typical triggers for delirium?

A
  • Hypoxemia
  • Hypotension
  • Hypercarbia
  • Sleep Deprivation (Circadian Rhythm disruption)
  • Hypervolemia
  • Infection
  • Electrolyte abnormalities
  • Pain
  • Benzos
  • Anticholinergics
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27
Q

FEV₁ decreases by ___% for each decade of life.

A

10%

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28
Q

What occurs with closing volume as we age?

A

Closing volume increases.

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29
Q

What is the goal of regional anesthesia vs general anesthesia?

A

Avoid:

  • DVT
  • PE
  • EBL
  • Respiratory complications
  • Death
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30
Q

With placement of what device is fat embolism syndrome most likely to occur?

A

intramedullary rod (IMR)

Femoral Medullary Canal Rod

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31
Q

What is the s/s Triad of fat embolism syndrome?
When do s/s typically present?

A
  1. Dyspnea
  2. Confusion
  3. Petechiae

Typically presents in 12 - 72 hrs

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32
Q

What lab findings are noted with fat embolism syndrome?

A
  • Fat macroglobulinemia
  • Anemia
  • Thrombocytopenia
  • ↑ ESR
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33
Q

What is ESR? What are normal values for males and females?

A
  • Erythrocyte Sedimentation Rate
  • Male: 0 - 22 mm/hr
  • Female: 0 - 29 mm/hr
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34
Q

What minor s/s can be construed to characterize fat embolization syndrome?

A
  • Fever (100.4 F / 38 C)
  • ↑HR >120
  • Jaundice
  • Renal Changes
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35
Q

What are the anesthetic management techniques for fat embolization syndrome?

A

Supportive Therapy
- 100% FiO₂
- No N₂O
- IV Heparin
- CV & Resp support

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36
Q

What factors contribute to the development of DVT’s?

A
  • Lack of Prophylaxis
  • Obesity
  • > 60yrs old
  • > 30min procedure
  • Tourniquet use
  • > 4 days immobilization
  • > Lower extremity fracture
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37
Q

Which three surgery types present the greatest risk for DVT formation?

A
  • Hip surgery
  • TKA
  • Lower extremity trauma
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38
Q

When does LMWH need to be initiated?

A

12 hours preop
or
12 hours postop

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39
Q

Can neuraxial anesthesia be done after LMWH has been given?

A

Yes, if 10 - 12 hours after the dose.

Delay next dose 4 hours.

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40
Q

Can an epidural be placed in a patient on LMWH anticoagulation therapy?

A

No. No indwelling catheters

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41
Q

Neuraxial catheters must be removed ___ hours before the intiation of LMWH therapy.

42
Q

Can a patient have neuraxial anesthesia if on warfarin?

A

Only if the INR is ≤ 1.5

43
Q

Flip card for Anticoagulation guidelines for Neuraxial procedures.

44
Q

Flip card for additional Anticoagulation guidelines for Neuraxial procedures.

45
Q

What advantages does neuraxial anesthesia present in the prevention of DVT’s?

A
  • ↑ extremity venous blood flow (sympathectomy).
  • LA systemic anti-inflammatory properties.
  • ↓ PLT reactivity
46
Q

What is the maximum dose of TXA? (Tranexamic Acid)

47
Q

What is typical dosing of TXA?

A

10 - 30 mg/kg

1000mg is typical

48
Q

Tourniquet pain typically begins ___ minutes after application.

49
Q

The width of a tourniquet must be greater than ____ its diameter.

50
Q

How long can tourniquets be placed on an extremity?

A
  • 2 hours is typically not exceeded
  • 3 hours is max.
51
Q

What mmHg is typically used for thigh tourniquets?

A

300 mmHg
(or 100 mmHg > SBP)

52
Q

What mmHg is typically used for arm tourniquets?

A

250 mmHg
(or 50 mmHg > SBP)

53
Q

When utilizing a double tourniquet, it is important to remember to…

A

inflate proximal → deflate distal

54
Q

What occurs with tourniquet deflation?

A
  • Transient lactic acidosis
  • Transient Hypercarbia (thus V̇T)
  • ↑ HR
  • ↓ pain
  • ↓ CVP, BP, & temp
55
Q

What are some important points of assessment necessary for upper body procedures preoperatively?

A
  • Baseline vitals
  • Airway
  • Pre-existing nerve conduction issues
  • Examine pupils
56
Q

What are the cardiac consequences of sitting/Beach Chair position?

A
  • ↓ CO & BP
  • ↑ HR & SVR

Due to pooling of blood in lower body.

57
Q

What are the respiratory consequences of sitting/Beach Chair position?

A
  • ↑ FRC & lung volumes
58
Q

What are the neurologic consequences of sitting/Beach Chair position?

59
Q

How is venous air embolism prevented in a beach chair patient?

A

↑ CVP (above 0) to prevent a “suction” effect

60
Q

In what percent of the population is a patent foramen ovale present?

61
Q

How does one treat venous air embolism?

Besides prevention…

A
  • Inform surgeon → irrigation & occlusive dressing
  • DC N₂O if being used
  • Bilateral compression of jugular veins (prevent neuro consequences)
  • Place patient in head down position to trap in right atrium
  • Withdraw air through right atrial catheter
  • CV & Resp support
62
Q

The ultrasound transducer is being utilized to located venous air embolism in a patient. Where do you place the probe?

A

2ⁿᵈ - 3rd ICS right of sternum

Over the Right Atrium

63
Q

Though ultrasound over the right atrium is the most sensitive indicator of VAE (venous air embolism), the most definitive is….

A

transesophageal echocardiogram (TEE)

64
Q

The characteristic sound of a VAE is a _____________ murmur.

A

“Mill-Wheel” murmur

65
Q

What would be an indicator of a sudden decreased perfusion to the lungs?

A

↓ EtCO₂

66
Q

________ of the neck in a sitting position patient can accidentally extubate them.

A

Hyperextension

67
Q

In a sitting position patient, where would one zero their art line?

A

Tragus / external auditory meatus (circle of Willis)

Establishes knowledge of brain BP & thus perfusion.

68
Q

What are ocular conditions do we want to avoid due to the hypotension inherent to the sitting position?

A
  • Retinal Ischemia
  • Ischemia Optic Neuropathy

Also avoid corneal abrasion.

69
Q

There is a 40cm distance from the patients heart to their brain. The patient’s BP measured on the arm is 120/70. What is the estimated BP in the brain?

A

40cm x 0.77mmHg = 30.8mmHg

120 - 30.8 = 89.2mmHg
70 - 30.8 = 39.2mmHg

The patient’s brain BP is 89/39. Consider pts baseline and cerebral blood flow autoregulation.

70
Q

A standing patient’s NIBP on the arm is 134/92. The distance between the patient’s knee and the NIBP cuff is 120cm. What is the BP in the patient’s knee?

A

120 x 0.77 = 92.4

134 + 92
92 + 92

Patient’s “knee” BP standing up is 226/184

“1.36 cm = 1 mmHg” - Schmidt

71
Q

What is the Bezold-Jarisch reflex?

A

Cardiac inhibitory reflex resulting in signification HoTN & ↓HR

72
Q

What are possible complications of a brachial plexus block?

A
  • Respiratory depression
  • Horner Syndrome
  • Hoarseness
  • Dysphagia
73
Q

Why can respiratory depression occur with brachial plexus blocks?

A

Hemidiaphragmatic Paresis from Phrenic nerve blockade.

74
Q

What is the triad of Horner Syndrome?

A
  • Ptosis
  • Miosis
  • Anhydrosis
75
Q

What are the respiratory consequences of a lateral decubitus position?

A

(VQ mismatch)
- ↓ ventilation of dependent lung.
- ↑ perfusion of dependent lung.

76
Q

During mechanical ventilation in left lateral decubitus patient, which lung is overventilated?

A

Right lung (nondependent lung)

77
Q

During mechanical ventilation in left lateral decubitus patient, which lung more perfused?

A

Left lung (dependent lung)

78
Q

Where is an axillary roll placed on a lateral decubitus patient?

A

Caudad to the axilla (displaces head of humerus) to avoid compression of the neurovascular bundle (brachial plexus).

79
Q

Where should a pulse oximeter be placed in a lateral decubitus patient?

A

Dependent hand to ensure that there is no neurovascular compromise

80
Q

Elbow surgeries need what additional block (in comparison to shoulder surgeries) ?

A

Musculocutaneous nerve

81
Q

Is a patient with a hip fracture induced on the OR table or on the bed/stretcher?

A

Bed/Stretcher to avoid pain from movement to OR table.

82
Q

What are the benefits of neuraxial anesthesia for hip fracture repairs?

A
  • ↓ delirium
  • ↓ DVT & 1 month mortality
  • ↓ hospital stay (less infections)
  • Better posto pain control
83
Q

What are the three life-threatening complications of total hip arthroplasty?

A
  • BCIS (bone cement implantation syndrome)
  • Hemorrhage intra- & postop
  • VTE (venous thromboembolism)
84
Q

What chemical is bone cement and possible SE?

A

PolyMethylMethAcrylate (PMMA)

  • releases heat (exothermic reaction)
  • systemic absorption (vasodilation, decreased SVR)
  • platelet aggregation (r/t tissue thromboplastin release
  • microthrombus in lungs
  • CV instability
85
Q

What does bone cement do when introduced to the intramedullary bone surface?

A

Intramedullary HTN >500mmHg

Possible embolization of fat, bone marrow, and cement.

86
Q

What is the anesthetic management of BCIS? (Prevention and treatment)

A

Prevention
- minimize↓BP and ↓Volume
- maximize↑ FiO₂ & SpO₂ (No N2O)
- vent hole in femur, lavage of femoral shaft, avoid bone cement lol

Treatment
- ↑ FiO₂
- keep pt euvolemic
- vasopressors for HypoTN

87
Q

What are the s/s of BCIS?

A
  • Hypoxia
  • Hypotension
  • Arrythmias
  • pHTN
  • ↓CO
88
Q

In a supine position, spontaneous ventilation favors _______ lung segments, whiled control ventilation favors ________ lung segments.

A

Dependent ; independent

Supine: FRC decreases about 800ml & may fall below closing volume. Exacerbated by obesity, pregnancy and ascites.

89
Q

The most common postoperative peripheral neuropathy is:
a. Ulnar neuropathy
b. Brachial plexus injury
c. Median nerve injury
d. Sciatic nerve compression

A

a. Ulnar Neuropathy

90
Q

Where are the two major sites of injury in ulnar nerve injury?

A

Elbow at the condylar groove (medial epicondyle of humerus & olecranon process of ulna) and cubital tunnel.

91
Q

How is ulnar nerve nerve injury avoided?

A

Supinate hands (palms up!)

92
Q

What common drugs are often used for “conscious sedation” of a hip dislocation?

A
  • Ketamine/Propofol Mix
  • Succinylcholine for potential RSI
93
Q

What are the possible complications of tourniquet placement for knee surgeries?

A
  • Blood loss on deflation (note for 24hrs)
  • Peroneal Nerve Palsy
  • post op pain
94
Q

What are the 4 components of a TKA (Total Knee Arthroplasty) ?

A
  1. Tibial Component
  2. Femoral Component
  3. Patellar Component
  4. Plastic Spacer
95
Q

What three conditions (that anesthesia can control) are most often associated with increase infection of knee replacements?

A
  • Peri-operative glucose control
  • Post-op hypoxia
  • Post-op hypothermia
96
Q

What medication classes can be used to treat phantom pain from amputation?

A
  • Neuroleptics
  • Antidepressants
  • Na⁺ channel blockers
97
Q

What nerve innervates the sensation of the plantar surface?

A

Posterior Tibial nerve

98
Q

What nerve innervates the medial malleolus?

A

Saphenous nerve

99
Q

What nerve innervates the interspace between the great & 2ⁿᵈ toes?

A

Deep Peroneal nerve

100
Q

What nerve innervates the space between the dorsum of the foot and the 2ⁿᵈ - 5th toes?

A

Superficial peroneal nerve

101
Q

What nerve innervates the lateral foot and lateral 5th toe?

A

Sural nerve

(Spring 2025) Advanced Principles A (11 decks)

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