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Principles II N517 > Orthopedic Surgery > Flashcards

Orthopedic Surgery Flashcards

1
Q

What patient populations have orthopedic surgery?

A

can range from neonates with congenital abnormalities to health young athletes to geriatric patients with end-stage multi-organ failure

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2
Q

What is rheumatoid arthritis?

A

chronic inflammatory disease affecting multiple joints and organ systems that’s immune-mediated

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3
Q

Does RA affect males or females more?

A

females 1:2-3

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4
Q

What joint are we most concerned with in someone with RA?

A

cervical spine, can also affect hips, shoulders, knees, elbows, wrists, and metacarpophalangeal joints

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5
Q

What are systemic secondary effects of RA?

A

anemia, pericarditis, cardiac tamponade, myocarditis, pulmonary interstitial fibrosis

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6
Q

What are perioperative risks of someone with RA?

A
  • atlantoaxial stability
  • occult pericarditis and myocardial dysfunction
  • pulmonary complications from pulmonary fibrosis/restrictive lung disease
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7
Q

What do we worry about atlantoaxial stability in someone with RA?

A
  • subluxation from erosion of ligaments by rheumatoid destruction of bursae around odontoid process of C2; occurs with neck flexion
  • can cause cervical cord compression
  • can cause compression of vertebral arteries
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8
Q

What is ankylosing spondylitis?

A
  • abnormal immobility of joint caused by fibrous growth in joint
  • ossification of ligaments at attachment to bone
  • progressive ossification (joint cartilage, axial skeleton disk space (“Bamboo spine”), hips, shoulders, and costovertebral joints
  • seronegative for rheumatoid factor (may go undiagnosed)
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9
Q

Is ankylosing spondylitis more common in men or women?

A

men 10:1

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10
Q

Is ankylosing spondylitis more common in caucasians or non-caucasians?

A

caucasians, but 18-50% incidence in native americans

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11
Q

What are some characteristics of ankylosing spondylitis?

A

low back pain, sacroilitis, multiplane rigidity of spine, chest stiffness, uveitis

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12
Q

What is the onset of ankylosing spondylitis?

A

insidious onset at

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13
Q

What are perioperative risks of someone with ankylosing spondylitis?

A 
inability to intubate
atlantoaxial instability
spine fracture during airway manipulation
rigid chest/difficult ventilation
myocarditis/conduction defects
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14
Q

What would you want to know from a patient that has CAD?

A 
exercise tolerance
presence of chest pain
if have pacemaker or ICD
current meds
cardiology consult if needed
other diagnostic tests
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15
Q

Why is a stress test beneficial to look over for someone with CAD?

A

will tell you max HR and BP patient can tolerate before they show signs of ischemia, will know what HR and BP to stay under

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16
Q

What would you want to know about someone that has arthritis?

A

Are they on steroids? Will they need a stress dose?
Will they be able to tolerate positioning?
How is their neck mobility?
What does their airway look like?
Is the patient obese?

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17
Q

What would you want to know about a patient’s mental status?

A

Do they ahve alzheimers or dementia?
Is the patient cooperative? (could affect decision for regional)
Does the patient have an advanced directive? Do they want to suspend it for surgery?
Is the family present?

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18
Q

What are the benefits of regional anesthesia in orthopedic surgery?

A
  • improved postoperative analgesia
  • decreased postoperative nausea and vomiting
  • less respiratory and cardiac depression
  • improved perfusion due to sympathetic block
  • reduced blood loss
  • decreased risk of thromboembolism
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19
Q

Why do surgeons use pneumatic tourniquets?

A

allows bloodless field and minimizes blood loss

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20
Q

What is the max pressure you should inflate a pneumatic tourniquet?

A

100 mmHg above systolic pressure

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21
Q

What are associated problems with tourniquets?

A
  • hemodynamic changes
  • pain
  • metabolic alterations; washout of metabolic wastes
  • arterial thromboembolism
  • pulmonary embolism
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22
Q

What is the longest you should keep a tourniquet inflated?

A

2 hours, longer leads to transient muscle dysfunction and may be associated with permanent peripheral nerve injury

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23
Q

When does tourniquet pain start?

A

30-45 minutes after inflation

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24
Q

What type of pain is tourniquet pain?

A

dull, aching pain that results from transmission via slow-conducting unmyelinated C fibers

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25
Q

What is the likelihood of tourniquet pain with regional, spinal, epidural, and general techniques?

A

regional > epidural > spinal > general

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26
Q

What is the definitive treatment for tourniquet pain?

A

tourniquet release

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27
Q

Who operates the tourniquet?

A

we do, so have the controls and visual display within reach

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28
Q

When should you report tourniquet times to the surgeon?

A

at 60 minutes and then 15 min increments after that, make sure to chart the times you reported to the surgeon

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29
Q

What anesthesia techniques can you use for shoulder/upper arm surgery?

A

regional +/- general, but often combined due to limited access to the airway

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30
Q

What regional techniques can be used for shoulder and upper arm surgery?

A

interscalene or supraclavicular blocks

31
Q

What position is usually used for shoulder and upper arm surgery?

A

“beach chair” position, flexed at hips and knees with 10-20 degree reverse trendelenburg; make sure head, neck, arm, and hips are secured; check eye and ear pressure points; prevent stretch injury to brachial plexus

32
Q

What complication is the patient at risk for in the “beach chair” position?

A

poor cerebral perfusion, need to keep BP higher so you know you are getting adequate cerebral perfusion

33
Q

What regional techniques can be used for surgeries on the elbow?

A

infraclavicular or supraclavicular approaches to brachial plexus

34
Q

What regional anesthetic techniques can be used for someone having surgery on their wrist or hand?

A

brachial plexus block via supraclavicular or axillary approach (no interscalene because ulnar nerve missed)
Bier block
local infiltration

35
Q

What are some pre-op considerations for someone having surgery to repair fracture of the hip?

A
  • usually frail and elderly
  • comorbidities
  • frequently dehydrated
  • occult blood loss
  • fat embolism syndrome
36
Q

What areas on the femur are at higher risk for bleeding?

A

extracapsular fractures that occur in femoral neck, intertrochanteric or subtrochanteric

37
Q

When does fat embolism syndrome occur?

A

within 72 hours following long-bone or pelvic fracture (10-20% fatal event)

38
Q

What are some of the signs and symptoms of fat embolism syndrome?

A

dyspnea
confusion
petechiae on chest, upper extremities, axilla, and conjunctiva
decreased EtCO2 and arterial saturation under GA

39
Q

What is the treatment for fat embolism syndrome?

A

early fracture stabilization and supportive care

40
Q

What should you remember if the patient is going to be placed on a trochanteric fracture/ORIF table?

A

they go to sleep on stretcher and then are moved onto table
very little padding
perineal post present that puts males at risk of testicular compression

41
Q

What position is a total hip arthroplasty usually done?

A

lateral decubitus, sometimes done supine

42
Q

What is the most common indication for total hip arthroplasty?

A

osteoarthritis aka degenerative joint disease

43
Q

What nerve is present in the area for a total hip arthroplasty and can be damaged by the surgeon?

A

sciatic nerve

44
Q

What are the surgical steps for a total hip arthroplasty?

A
  • dislocation and removal of femoral head
  • reaming of acetabulum
  • insertion of acetabular cup
  • reaming of femur and insertion of femoral component
45
Q

What are 3 life-threatening complications that can occur with a total hip arthroplasty?

A

bone cement implantation syndrome
perioperative hemorrhage
thromboembolism

46
Q

What is in the cement used for a total hip arthroplasty?

A

methylmethacrylate (MMA)

47
Q

What kind of reaction does MMA cement undergo to harden and expand against components?

A

mixing of polymerized powder with liquid MMA monomer causes exothermic reaction

48
Q

What is the mechanism behind bone cement implantation syndrome?

A

exothermic reaction results in intramedullary hypertension forcing embolization of fat, bone marrow, cement, and air into femoral venous channels

49
Q

What does residual MMA cause?

A

vasodilatation and decreased SVR

50
Q

What does the release of thromboplastin from MMA cause?

A

triggers platelet aggregation, pulmonary microthrombi, and CV instability

51
Q

What are the clinical manifestations of bone cement implantation syndrome?

A 
hypoxia
hypotension
dysrhythmias (including heart block and sinus arrest)
pulmonary hypertension
decreased cardiac output
52
Q

What are some anesthetic strategies for managing bone cement implantation syndrome?

A

arterial pressure monitoring
increasing inspired oxygen
maintain euvolemia
high pressure lavage of femoral shaft to remove debris

53
Q

What are some strategies to prevent venous thromboembolism?

A

regional anesthesia
intermittent leg-compression devices
low-dose anticoagulant prophylaxis

54
Q

What are some considerations for a redo hip arthroplasty?

A

longer procedure
increased blood loss
will regional technique last long enough
may be increased need for invasive monitoring (Aline, CVP)

55
Q

What are some implications for a total knee arthroplasty?

A
  • usually shorter duration than THA
  • patient remains supine
  • blood loss limited by use of tourniquet
  • patients can tolerate a regional technique with IV sedation
  • BCIS possible, but less likely
  • hypotension can occur with tourniquet release
56
Q

What anesthetic techniques can you use for a knee arthroscopy?

A
  • variety of regional techniques (depending on expected length of surgery)
  • local anesthesia with sedation if diagnostic arthroscopy
57
Q

What regional techniques can be used for a meniscal repair or ACL reconstruction?

A

spinal
epidural
lumbar plexus - sciatic
femoral

58
Q

What are common foot/ankle procedures you may see?

A 
ankle fracture (plate and screws)
bunionectomy
hammer toe correction
plantar fasciotomy
Achilles tendon repair
59
Q

What should you keep in mind with a closed reduction case?

A
  • could involve any fracture
  • could be a 5 minute case of a 2 hour case
  • surgeon may request muscle relaxation to facilitate the reduction
  • be prepared for ORIF
60
Q

What are some indications for spine surgery?

A
  • Most often nerve root or cord compression
  • Scoliosis
  • Decompress the cord
  • Stabilize the spine following trauma
  • Tumor resection
  • Vascular malformation
  • Abscess
  • Epidural hematoma
61
Q

What are intraoperative concerns during spine surgery while in the prone position?

A
  • neck must be maintained in neutral position
  • ischemia/pressure on globe, nose, ears, forehead, female breasts, or male genitalia
  • shoulders abducted
62
Q

Since spine surgery can involve multiple levels, fusion, and instrumentation, what should you keep in mind?

A
  • associated with large blood loss
  • vision loss can occur (optic neuropathy, retinal artery occlusion, cerebral ischemia)
  • VAE
  • spinal cord monitoring (“wake up test”, SSEP, MEP monitoring)
63
Q

What is the purpose of SSEP monitoring?

A

monitor ischemia and injury of posterior aspect of spinal cord/isolated anterior spinal injury may go undetected

64
Q

What are anesthetic implications for SSEP monitoring?

A

need to keep stable anesthetic depth to avoid any changes in SSEP’s attributed to surgical intervention, changes in the latency and amplitude alert surgeons to spinal cord dysfunction

65
Q

What do volatile agents do to SSEP monitoring?

A

increase latency and decrease amplitude

66
Q

What volatile can be used for SSEP monitoring and at what mac?

A

isoflurane at

67
Q

What other drugs will not interfere with SSEP monitoring?

A

propofol, ketamine, narcotics

68
Q

What is a “wake-up test” during spine surgery?

A

most reliable assessment of possible spinal cord injury, requires planning and need to discuss with patient pre-op

69
Q

What technique is preferred for a wake-up test during spine surgery?

A

nitrous-oxide and narcotic, DC N2O and ventilate with 100% O2 and within 10 minutes the patient should be able to wiggle toes on command

70
Q

Do you have to fully reverse someone during spine surgery for a wake up test?

A

No, maintain 2-3 twitches and should be sufficient for toe movement

71
Q

What are some considerations for limb reimplantation?

A
  • long procedure with microvasculature anastomosis of vessels and nerves
  • keep patient warm
  • euvolemic
  • anemia - only if tolerated
  • regional excellent for vascular anastomosis due to sympathectomy
  • no pressors
  • long tedious case with little blood loss
72
Q

What should you consider with a pediatric patient undergoing orthopedic surgery?

A
  • parent and child’s anxiety level
  • could child benefit from premed
  • check NPO status
  • child may be naive to hospital setting as well as parents
73
Q

What subsets in the pediatric population often suffer pain, disability, and social isolation?

A 
cerebral palsy
congenital spine deformities
juvenile rheumatoid arthritis
osteogenesis imperfecta
epiphyseal dysplasia
scoliosis

Principles II N517 (7 decks)

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