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AS - N931 Advanced Principles of Anesthesia > Orthopedic Surgery > Flashcards

Orthopedic Surgery Flashcards

1
Q

Spine Surgery

A

Commonly open procedures
Supine or prone positioning
Spinal cord injury, scoliosis, or degenerative disc disease

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2
Q

Spine Surgery

Anesthetic Considerations

A

General anesthesia - secure the airway & muscle relaxation
Discontinue anticoagulants
Preop testing: CBC, platelet, coagulation, CXR, PFTs, EKG, & Echo
SSEP or MEPs monitoring
Blood loss
Hypotension
POVL risk

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3
Q

Prone Considerations

A

Abdominal compression (dependent on OR table)
Difficult intubation after positioned & surgery starts
Secure the airway
Oral suction before flip
Alignment & proper padding
Head & neck neutral alignment
Eyes free from pressure to prevent POVL
Proper chest roll placement
Check genitalia positioning
Arms padded & positioned (superman or tucked)
Soft bite blocks w/ evoked potential monitoring
Headrest pins → surgeon coordinates the flip

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4
Q

Supine Considerations

A

Shoulder roll to extend the neck
Confirm correct ETT position
Arms tucked w/ traction
Place double BP cuffs or A-line

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5
Q

Spine Cord Injuries are Associated w/

A 
↑ICP
Cervical:
- Head injury
- Thoracic fractures
- Pulmonary & CV injury
Lumbar:
- Abdominal injuries
- Long bone fractures
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6
Q

Spinal Cord Injury

Anesthetic Considerations

A

Document thorough baseline neurological exam
Airway management (C-collar or limited ROM)
Cardiac considerations T4
Autonomic hyperreflexia
Succinylcholine induced hyperkalemia
Thermoregulation

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7
Q

Scoliosis

A

75% idiopathic

Severity determined by Cobb angle

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8
Q

Cobb Angle

A

> 60% → CV & pulmonary complications

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9
Q

Scoliosis

Anesthetic Considerations

A 
Preop:
- Pulmonary function studies
- CV considerations
Periop:
- Posterior vs. anterior approach
- Surgery above T8
- Hemodynamic monitoring
- Adequate IV access
- IVF replacement
- Blood products available
- Respiratory support
- Prevent hypothermia
- Wake-up test
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10
Q

Degenerative Spine Disease

A

Spinal stenosis
Spondylosis
Spondylolisthesis

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11
Q

Degenerative Spine Disease

Anesthetic Considerations

A 
Preop assessment
Anterior vs. posterior approach
General vs. regional
Spinal cord monitoring
Fluid & blood pressure management
Adequate IV access
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12
Q

Complications

A 
VAE
- Hypotension
- ↓ETCO2
- Millwheel murmur
POVL
- Optic neuropathy
- Retinal artery occlusion
- Cerebral ischemia
Postop pain management
- Multi-modal
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13
Q

Brachial Plexus

A

C5-T1 ventral rami
C4 & T2 are often minor or absent
Roots exit vertebral foramen converging & diverging into trunks, divisions, cords, & finally terminal branches
Supplies sensory & motor innervation to the upper extremity

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14
Q

Roots →

A

Roots → Divisions → Cords → Terminal Branches

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15
Q

Shoulder Surgery

A

Lateral or beach chair position

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16
Q

Lateral Considerations

A

Head & neck alignment
Pad non-surgical extremities
V/Q mismatch

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17
Q

Beach Chair Considerations

A

↓cerebral perfusion
Head elevated above heart
2mmHg difference per inch
BP cuff on upper extremity
A-line at tragus level to reflect cerebral perfusion
Complications: VAE, blindness/POVL, embolism, stroke, brain death

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18
Q

General Anesthesia vs. MAC

A

ETT vs. LMA
MAC w/ NC & ETCO2 monitoring
Consider patient position & ability to access/manipulate airway or intubate during surgery

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19
Q

Interscalene Block

A

ISB - root level
Nerve roots C5-7 located w/in interscalene groove b/w anterior & middle scalene muscles 2-3cm
Semi-sitting or supine w/ head turned away
1° brachial plexus block in procedures involving the shoulder & proximal upper arm
Single-shot vs. catheter placement
Classic technique (Winnie) 1.5” 22G insert @C6 15-20mL LA injected

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20
Q

ISB Complications

A

Stellate ganglion block aka Horner’s syndrome
- Ptosis, miosis, & anhydrosis
Diaphragmatic hemiparesis (phrenic nerve)
C8 & T1 note blocked 30% patients
Avoid injecting close to the transverse process
Vertebral artery enters at C6 ↑risk intravascular injection

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21
Q

Arm/Hand Surgery

A 
Fracture repairs (humerus, radius, ulnar, hand), arthroplasty, amputation, ulnar nerve transposition, carpal tunnel release, trigger finger
Position dependent on procedure - lateral, supine, or beach chair
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22
Q

Arm/Hand Surgery

Anesthetic Considerations

A

Regional - supraclavicular, infraclavicular, or axillary block
Single shot vs. catheter placement
Bier block
General vs. MAC
Consider patient comorbidities & procedure length

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23
Q

Supraclavicular Block

A

SCB - trunk level
Upper extremity below the shoulder (elbow or hand surgery)
Insert needle cephalad to lateral sternocleidomastoid muscle to the clavicle at direction parallel to midline <2.5cm
Semi-sitting w/ head turned away
Lower shoulder & flex elbow
Forearm in lap w/ wrist supinated

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24
Q

SCB Complications

A

Stellate ganglion block aka Horner’s syndrome
- Ptosis, miosis, & anhydrosis
Diaphragmatic hemiparesis (phrenic nerve)
Often miss suprascapular nerve
↑risk vascular puncture or pneumothorax

25
Q

Infraclavicular Block

A

IFCB - cord level
Alternative to supraclavicular block in patients w/ severe COPD or respiratory insufficiency
Block arm below the shoulder (hand, forearm, elbow, AV fistula)
Cords - lateral, posterior, & medial labeled via relation to the axillary artery
Supine or semi-sitting w/ head turned away
Place transducer in sagittal plane below clavicle medial to coracoid process (away from midline toward axilla)
Insert needle cephalad to caudal 2.5-3cm at 45-65°

26
Q

IFCB Complications

A

Sliding the needle medially ↑potential pneumothorax or hemothorax
Doppler useful to prevent inadvertent thoraco-acromial artery or pectoral veins puncture

27
Q

Axillary Block

A

Terminal branches
Procedures below the elbow
Supine w/ arm abducted & elbow flexed 90°
Place transducer in crease b/w biceps & pectoris major
Insert needle lateral to medial

28
Q

Lower Extremity Surgery

A

Arthroscopic or open

Arthroplasty, fractures, cartilage or ligament repair

29
Q

Lumbar Plexus

A

L1-L4 ventral rami

Femoral, obturator, lateral femoral cutaneous, ilioinguinal, & iliohypogastric nerves

30
Q

Lumbosacral Plexus

A

L4/5 - S1/5
SCIATIC nerve
Supplies sensory & motor innervation to the posterior thigh, knee, & lower extremity below the knee w/ exception to sensory innervation provided by the saphenous nerve

31
Q

Hip Surgery

A

Lateral - traditional approach
Supine - anterior approach (traction applied to lower extremities)
Incision from iliac crest to mid thigh
↑blood loss associated w/ extracapsular
- Femoral neck, intertrochanteric, subtronchanteric
Revision surgery - longer duration & ↑blood loss

32
Q

Hip Surgery

Potential Complications

A 
Fat embolus
Venous thromboembolus
- Heparin, ASA, anticoagulant treatment
Blood loss
- Regional, deliberate hypotension, dilutional anemia
- Surgeon skill level
33
Q

Hip Surgery

Anesthetic Considerations

A 
Regional > General
- Less postop cognitive dysfunction
- Superior postop analgesia
- ↓DVT/PE incidence
- Rapid postop rehab
- ↓cost
Spinal vs. epidural
Peripheral nerve blocks - lumbar plexus (psoas compartment block) or fascia iliaca block
34
Q

Knee Arthroplasty

A

TKA - total knee arthroplasty
Regional generally preferred over general
Complete anesthesia requires both lumbar & lumbosacral plexus blockade
Significant postop pain

35
Q

Knee Arthroplasty

Anesthetic Consideration

A 
Postop pain management essential to recovery
PO pre-medicate days → weeks
Opioids & neuraxial techniques
ERAS protocols
- Multimodal pain management
- Continuous peripheral nerve block
36
Q

Knee Arthroscopy

A

Diagnostic or therapeutic
General w/ LMA
Minor surgery performed as outpatient
Peripheral nerve block rarely indicated

37
Q

ACL Repair

A

Commonly performed as outpatient procedure
Continuous peripheral nerve block
Knee bolster allows lower extremity to hang freely opening joint space
Need to support non-operative leg to reduce lower back stress

38
Q

Femoral Nerve Block

A

FNB
Targets major branch lumbar plexus
Dorsal divisions anterior rami L2, L3, & L4 spinal nerves
Emerges from psoas muscle border & remains deep to fascia iliaca
Provides analgesia to anterior thigh, knee, & medial aspect lower leg
Nerve lies lateral to the artery, deep to fascia lata & iliaca, & superior to iliopsoas muscle
Two arteries noted, scan cephalad & identify singular femoral artery
Supine w/ external extremity rotation
Insert needle 30-45° lateral to medial & inject 20mL LA

39
Q

FNB Complications

A

Vascular puncture & LA injection avoided by observing the needle tip throughout the procedure
Lymph nodes potentially appear as hyperechoic nerves - scan proximal & distal to help distinguish (lymph nodes are not continuous)

40
Q

Fascia Iliaca Block

A

Targets femoral, obturator, & lateral femoral cutaneous nerve
↑volume 40mL to block all three nerves

41
Q

Adductor Canal Block

A

ACB
Gold standard - pain relief following knee arthroplasty
Associated w/ fall risk 2° to quadriceps weakness
Sensory nerve blockade w/ minimal motor involvement
Position supine w/ slight extremity external rotation
LA deposited in fascial plane separating the adductor longus & vastus medialis below the subcutaneous tissues
Inject 5mL up to 20mL LA

42
Q

ACB Complications

A

Myotoxicity d/t LA deposited w/in the muscle
Vastus medialis consistently blocked - may provide greater innervation to knee than previously thought (positive benefit)

43
Q

Ankle/Foot Surgery

A

Innervation supplied by femoral & sciatic nerve
Elective vs. traumatic
Neuraxial or peripheral nerve blocks are appropriate in combination w/ general or MAC
Position - supine, lateral, or prone
Thromboprophylaxis

44
Q

Saphenous Nerve Block

A

Saphenous nerve (thigh) = femoral nerve terminal branch
Distal adductor canal
Saphenous superficial in the distal thigh
Provides ONLY sensory innervation to the medial aspect lower extremity below the knee
Used in conjunction w/ other blocks for surgical procedures involving the ankle & foot

45
Q

Popliteal Nerve Block

A

Targets the sciatic nerve slightly proximal to the knee
Provides anesthesia for procedures involving the foot & ankle
Popliteal fossa nerves are bordered superiorly & medially by the semi-tendinosus & semi-mebranous muscles & superiorly/laterally by biceps femoris muscle
Supine w/ operative leg elevated
Tibial nerve superior to the popliteal artery & vein
U/S scan proximal to locate the bifurcation w/ the peroneal nerve
Anisotropy - angle transducer towards foot to improve nerve imaging

46
Q

Foot Innervation

A

FIVE nerves supply innervation to the foot

  1. Tibial
  2. Deep peroneal
  3. Superficial peroneal
  4. Saphenous
  5. Sural nerve

*See nerve innervation pictures (slide 91-92)

47
Q

Ankle Blocks

A

Routinely indicated for surgical anesthesia & postop analgesia
U/S improves block efficacy even w/ lower LA volumes
Supine w/ foot elevated or extended over edge stretcher
Identify vasculature first
3-5mL LA injected at EACH nerve

48
Q

Pneumatic Tourniquet

A

Often used to minimize blood loss & provide bloodless surgical field
Inflatable cuff, connective tubing, pressure device, & timer
Proper sizing & inflation are critical to ensure safe & effective use
Inflation pressure depends on patient BP & extremity
NO LONGER THAN 2 HOURS
Interrupted blood supply → tissue hypoxia & acidosis
Cuff deflation → metabolic waste release → metabolic acidosis, hyperkalemia, myoglobinemia, renal failure
Tourniquet pain - 60min (pain, HTN, tachycardia)

49
Q

Polymethylmethacrylate

A

Acrylic bone cement used in arthroplasty
- Exothermic reaction that results in expansion & hardening
Commonly used in elderly patients TJA
Cement placement associated w/ sudden hypotension causing bone cement implantation syndrome (BCIS)

50
Q

BCIS

A

Bone cement implantation syndrome
Exothermic reaction causes intramedullary hypertension
Absorption results in ↓SVR, hypotension, & hypoxemia

51
Q

BCIS Risk Factors

A 
Pre-existing CV disease or pulmonary HTN
ASA class 3 or higher
Pathologic fractures, intertrochanteric fracture or long-stem arthroplasty
52
Q

BCIS Treatment

A 
Discontinue nitrous during cementation
Maximize inspired oxygen concentration 100% FiO2
Euvolemia
Creating vent hole in distal femur
High pressure lavage
α agonist
53
Q

Fat Embolism

A

Fat embolism syndrome (FES) associated w/ traumatic injury & surgery to long bones
Incidence 3-4%

54
Q

Fat Embolism Risk Factors

A 
Age 20-30yo
Male
Hypovolemia shock
Bilateral total knee replacement
Rheumatoid arthritis
Intramedullary instrumentation
55
Q

Fat Embolism S/S

A 
Major:
- Petechia
- Hypoxemia
- CNS depression
- Pulmonary edema
Minor:
- Tachycardia
- Hyperthermia
- Retinal fat emboli
- Urinary fat globules
- ↓platelets/Hct
- ↑sed rate
- Fat globules present in sputum
56
Q

Fat Embolism Treatment

A 
Early recognition
Reversing contributing factors (hypovolemia)
Fracture stabilization
Aggressive pulmonary support
Pharmacologic therapy
SUPPORTIVE
57
Q

DVT/PE

A

Major cause death following LE trauma or surgery
DVT 40-80% ortho patients w/o prophylaxis
PE 28% w/o prophylaxis
Thromboprophylaxis based on risk factor identification
Risk factors - previous hip fracture, advanced age, immobility, previous DVT, cancer, pre-existing hypercoagulable state

58
Q

Arthroscopy Complications

A 
Subcutaneous emphysema
Pneumomediastinum
Tension pneumothorax
Irrigation 3-5L 
- Compare fluid in & out
- Large volumes → volume overload, CHF, pulmonary edema, or hyponatremia (sterile water)

AS - N931 Advanced Principles of Anesthesia (17 decks)

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