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Advanced Principles A (Spring 2025) Cooper > 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 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

50-100mg hydrocortisone (Solu-cortef)
(Also Decadron)

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11
Q

What two TNFα inhibitors are commonly used to treat RA?

A
  • Infliximab
  • Etanercept
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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 (hoarseness)
  • 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 (C-spine)

(be careful not to displace the odontoid process and impinge on the c-spine 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 intervention could be done if atlantoaxial subluxation does occur?

A

Eval C-Spine and CXRs

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17
Q

RA

What are the signs/symptoms of vertebral artery occlusion?

A
  • N/V
  • Dysphagia
  • Blurred Vision
  • Transient LOC changes
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18
Q

What ocular syndrome is typical of RA patients?

A

Sjogren’s syndrome

(Dry eyes and mouth)

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19
Q

What pulmonary issues are associated with RA?

A
  • Interstitial fibrosis
  • Restricted ventilation
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20
Q

What issues with the following body systems are an anesthesia concern in RA patients?

Vascular:
Cardiac:
Renal:
GI:

A

Vascular: Vasculitis
Cardiac: Pericarditis, Tamponade
Renal: Insufficiency
GI: Gastric Ulcers (NSAID use)

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21
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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22
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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23
Q

What is the typical worst complication of long bone fractures?

A

Bone marrow fat embolism

Thromboembolic hypoxic resp. failure

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24
Q

How much cricoid pressure shoud we provide for trauma intubations?

A

10 lbs

aka Sellick Maneuver

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25
Q

What is the correct dose of Roc for a truama intubation?

A

1.2 mg/kg (RSI)

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26
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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27
Q

Describe the MILS technique

A
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28
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

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29
Q

What is the mechanism of action of LMWH?

A

LMWH binds to antithrombin thus → no thrombin → no fibrinogen forming into fibrin

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30
Q

What are some typical triggers for delirium?

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

SHIP BEACHHH

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31
Q

FEV₁ decreases by ___% for each decade of life.

A

10%

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32
Q

What occurs with closing volume as we age?

A

Closing volume increases.

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33
Q

What is the goal of regional anesthesia vs general anesthesia?

A

Avoid:

  • DVT
  • PE
  • Blood Loss
  • Respiratory complications
  • Death
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34
Q

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

A

Femoral Medullary Canal Rod

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35
Q

How likely is FES?
Mortality?

A

<1%

10-20%

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36
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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37
Q

What lab findings are noted with fat embolism syndrome?

A
  • Fat macroglobulinemia
  • Anemia
  • Thrombocytopenia
  • ↑ ESR
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38
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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39
Q

Based on the patho of FES, where are the fat emboli and bone marrow particulates specifically obstructing?

A

End organ capillaries

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40
Q

Pulmonary Complications d/t FES:

A

Pulm Endothelial Cell injury
Pulm Edema
Mild Hypoxemia
Alveolar Infiltrates
ARDS (<10%)

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41
Q

Where can a petechial rash develop with FES?

A
  • conjuctiva
  • Oral mucosa
  • skin folds of chest
  • neck
  • axilla
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42
Q

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

A
  • Fever
  • ↑HR
  • Jaundice
  • Renal Changes
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43
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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44
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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45
Q

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

A
  • Hip surgery
  • TKA
  • Lower extremity trauma
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46
Q

When does LMWH need to be initiated?

A

12 hours preop
or
12 hours postop

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47
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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48
Q

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

A

No. No indwelling catheters

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49
Q

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

A

2 hours

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50
Q

Can a patient have neuraxial anesthesia if on warfarin?

A

Only if the INR is ≤ 1.5

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51
Q

How long must we wait to perform a spinal injection after the last dose of:

Full dose SQ Heparin:
5-10 mg Fondaparinux:
40 mg SQ Lovenox:

A

Full dose SQ Heparin: When aPTT is <40 or 6 hrs
5-10 mg Fondaparinux: Contraindicated (36 hrs for 2.5 mg)
40 mg SQ Lovenox: 12 hrs

52
Q

How long must we wait to perform a spinal injection after the last dose of:

Dabigatran:
ASA:
Plavix:
Prasugrel:
Ticlopidine:

A

Dabigatran: 7 days
ASA: No wait time
Plavix: 7 days
Prasugrel: 7 days
Ticlopidine: 14 days

53
Q

How long must we wait to perform a spinal injection after the last dose of:

Tirofiban:
Eptifibatide:
Abciximab:
TPA full dose:

A

Tirofiban: 8 hrs
Eptifibatide: 8 hrs
Abciximab: 48 hours
TPA full dose: 10 days

54
Q

Flip card for Anticoagulation guidelines for Neuraxial procedures.

A
55
Q

Flip card for additional Anticoagulation guidelines for Neuraxial procedures.

A
56
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
57
Q

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

A

2.5 g

58
Q

What type of procedures were mentioned in lecture in which TXA is frequently used?

A

Total Knee and Total Hip

59
Q

What is typical dosing of TXA?

A

10 - 30 mg/kg

1000mg is typical

60
Q

Tourniquet pain typically begins ___ minutes after application.

A

45 min

C Fibers start to fire (slow)

61
Q

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

A

½

62
Q

How long can tourniquets be placed on an extremity?

A
  • 2 hours is typically not exceeded
  • 3 hours is max.
63
Q

What mmHg is typically used for thigh tourniquets?

A

300 mmHg
(or 100 mmHg > SBP)

64
Q

What mmHg is typically used for arm tourniquets?

A

250 mmHg
(or 50 mmHg > SBP)

65
Q

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

A

inflate proximal → deflate distal

*Bier Block

66
Q

What occurs with tourniquet deflation?

A
  • Transient lactic acidosis
  • Transient Hypercarbia (thus V̇T)
  • ↑ HR
  • ↓ pain
  • ↓ CVP, BP, & temp
67
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
68
Q

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

A
  • ↓ CO & BP
  • ↑ HR & SVR

Due to pooling of blood in lower body.

69
Q

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

A
  • ↑ FRC & lung volumes
70
Q

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

A

↓ CBF

71
Q

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

A

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

72
Q

Describe the process of venous air embolism from entrance into the system down to death.

A
  1. Surgical site higher than the heart = air will enter the RV
  2. Blood from the pulm. artery is interfered with, therefore pulmonary edema and reflex bronchoconstriction can occur
  3. Air could reach cerebral circulation via foramen ovale
  4. Death via CV Collapse and arterial hypoxemia
73
Q

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

A

20 - 30 %

74
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 support with pressors
75
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

76
Q

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

A

TEE

77
Q

The characteristic sound of a VAE is a _____________ murmur.

A

“Mill-Wheel” murmur

78
Q

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

A

↓ EtCO₂

79
Q

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

A

Hyperextension

80
Q

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

A

Tragus of the ear

Establishes knowledge of brain BP & thus perfusion.

81
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.

82
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 Thus indicating hypotension and necessary correction.

83
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

84
Q

What is the Bezold-Jarisch reflex?

A

Cardiac inhibitory reflex resulting in signification HoTN & ↓HR.

85
Q

How can we mitigate the effects of the Bezold-Jarisch reflex?

A

Increase Preload

Preemptive Zofran I guess..?

86
Q

What are possible complications of a brachial plexus block?

A
  • Respiratory depression
  • Horner Syndrome
  • Hoarseness
  • Dysphagia
87
Q

Why can respiratory depression occur with brachial plexus blocks?

A

Hemidiaphragmatic Paresis from Phrenic nerve blockade.

88
Q

What is the triad of Horner Syndrome?

A
  • Ptosis
  • Miosis
  • Anhydrosis
89
Q

Why might we see a decrease in CO with patients in Lateral Decubitis position?

A

Obstructed venous return d/t the use of a kidney rest

90
Q

What are the respiratory consequences of a lateral decubitus position?

A

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

91
Q

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

A

Right lung (nondependent lung)

92
Q

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

A

Left lung (dependent lung)

93
Q

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

A

Caudad to the axilla to avoid compression of the neurovascular bundle.

94
Q

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

A

Dependent hand to ensure that there is no neurovascular compromise

95
Q

What can be used to avoid brachial plexus stretching in upper arm procedures while in lat. decubitus.

A

Allen’s Arm rest

96
Q

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

A

Musculocutaneous nerve

97
Q

Regional methods for forearm to hand procedures?

A
  1. Axillary Block
  2. Bier Block
98
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.

99
Q

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

A
  • ↓ delirium
  • ↓ DVT
  • ↓ hospital stay
  • Better pain control
100
Q

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

A
  • BCIS
  • Hemorrhage
  • VTE
101
Q

What chemical is bone cement?

A

PolyMethylMethAcrylate

102
Q

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

A

Release heat and pressurize (500mmHg!)

Possible embolization of fat, bone marrow, and cement.

103
Q

Does the use of PMMA cause:

Increased or Decreased SVR?
Coagulation or Anticoagulation?

A

Decreased SVR

Coagulation (PLT Aggregation from thromboplastin release)

104
Q

What is the anesthetic management of BCIS?

What about things the surgeon can do?

A
  • Combat ↓BP and ↓Volume
  • ↑ FiO₂ & SpO₂

Surgeon:
- Vent Hole in femur
- Lavage of femoral shaft

105
Q

What are the s/s of BCIS?

A
  • Hypoxia
  • Hypotension
  • Arrythmias
  • pHTN
  • ↓CO
106
Q

Indications for a Hip Arthroscopy:

A
  1. Femoro-acetabular impingement
  2. Acetabular labral tears
  3. Loose bodies (fragments)
  4. Osteoarthritis
107
Q

Per Dr. Castillo, what are the pressure points we should know in the supine position?

A
  • Toes (from the bed sheets)
  • Heel
  • Thighs
  • Sacrum
  • Elbow
  • Humerous
  • Vertebrae
  • Occiput
108
Q

Cardiac changes that are possible in the supine position:

A
  1. increased CO, Right-sided filling pressures
  2. Bradycardia
  3. Decreased PVR
109
Q

In a supine position, spontaneous ventilation favors _______ lung segments, whilst closing volume favors ________ lung segments.

A

Dependent ; independent

110
Q

In the supine position, where does the diaphragm shift towards?

A

Cephalad

111
Q

FRC might ___ in older patients.

It may be drastically changed however, in these 3 patient populations.

A

DECREASE (below closing volume)

  1. Pregnant
  2. Obese
  3. Ascites
112
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

113
Q

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

A

Elbow at the condylar groove and cubital tunnel.

114
Q

How is ulnar nerve nerve injury avoided?

A

Supinate hands (palms up!)

115
Q

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

A

Ketamine/Propofol Mix
Succinylcholine

116
Q

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

A
  • Blood loss on deflation (note for 24hrs)
  • Peroneal Nerve Palsy
117
Q

What are the steps to a TKA (Total Knee Arthroplasty) ?

A
  1. Tibial Component
  2. Femoral Component
  3. Patellar Component
  4. Plastic Spacer
118
Q

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

A
  • Peri-operative glucose control
  • Post-op hypoxia
  • Post-op hypothermia
119
Q

Non-pharmacologic tx for phantom pain:

A
  1. Biofeedback
  2. Massage
  3. Relaxation
  4. TENS unit
120
Q

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

A
  • Neuroleptics
  • Antidepressants
  • Na⁺ channel blockers
121
Q

What nerve innervates the plantar surface?

A

Posterior Tibial nerve

122
Q

What nerve innervates the medial malleolus?

A

Saphenous nerve

123
Q

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

A

Deep Peroneal nerve

124
Q

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

A

Superficial saphenous nerve

125
Q

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

A

Sural nerve

Advanced Principles A (Spring 2025) Cooper (11 decks)

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