ORTHOPEDICS

Question 1

Is rheumatoid arthritis (RA) just a disease of the joints and adjacent connective tissue

Answer 1

○ RA is a chronic inflammatory disease, which initially destroys joints and adjacent connective tissue and then progresses to a systemic disease affecting major organ
systems

Question 2

What are some of the clinical manifestations of RA?

Answer 2

○ Systemic manifestations of RA are widespread.
○ They may include pulmonary involvement with interstitial fibrosis and cysts with honeycombing, gastritis and ulcers from aspirin and other analgesics, neuropathy, nephropathy, muscle wasting, vasculitis, and anemia.
○ Ultimately the anatomy of the airway is damaged and
altered in patients with rheumatoid arthriti

Question 3

What are some airway abnormalities that can occur in patients with rheumatoid
arthritis?

Answer 3

○ Some airway abnormalities that can occur in patients with rheumatoid arthritis include decreased mouth opening, a hypoplastic mandible, cricoarytenoid arthritis, and cervical spine abnormalities.

Question 4

Why might the normal mouth opening be decreased in patients with rheumatoid arthritis?

Answer 4

○ Normal mouth opening may be decreased in patients with rheumatoid arthritis as a result of temporomandibular arthritis

Question 5

5. What occurs to the developing mandible in patients with juvenile rheumatoid
   arthritis that makes it more difficult to intubate the trachea in this patient
   population?

Answer 5

○ The patient with juvenile rheumatoid arthritis often has a hypoplastic mandible as a result
of early fusion.
○ This results in the noticeable overbite in some patients with RA

Question 6

What are some of the clinical manifestations of cricoarytenoid arthritis?

Answer 6

○ As with other joints, the cricoarytenoid joint may be affected by rheumatoid arthritis.
○ Cricoarytenoid arthritis may result in shortness of breath and snoring. RA patients have been misdiagnosed as having sleep apnea when in fact they have cricoarytenoid arthritis.
○ Patients with cricoarytenoid arthritis may present with stridor on inspiration.
○ This may present in the postanesthesia care unit (PACU) while the patient is recovering from anesthesia.
○ Acute subluxation of the cricoarytenoid joint, as a result of tracheal intubation, can cause stridor as well, and it is not responsive to racemic epinephrine.

Question 7

Can neck movement in patients with RA result in cervical spine injury?
What is the clinical implication of this?

Answer 7

○ Yes, movement of the neck in patients with RA can result in cervical spine injury.
○ The patient must be carefully evaluated for both the complexity and the risk of endotracheal intubation because of difficulty in visualizing the airway as a result of
the anatomic changes that occur. ○ Normal endotracheal intubation maneuvers with neck movement may result in an increased risk of cervical spine injury due to destruction of the bones and ligaments of the cervical spine.
○ These can place the cervical spinal cord at risk.
○ Many cervical spine abnormalities may occur in patients with RA

Question 8

What percent of patients with RA have involvement of their cervical spine?

Answer 8

The cervical spine is affected in up to 80% of patients with RA

Question 9

What are three abnormal movements of the cervical spine that may be manifest in
patients with rheumatoid arthritis?

Answer 9

○ Three abnormal movements of the cervical spine that may be manifest in patients with rheumatoid arthritis include atlantoaxial subluxation, subaxial subluxation, and superior migration of the odontoid

Question 10

10. What is atlantoaxial subluxation

Answer 10

Atlantoaxial subluxation is the abnormal movement of the C1 cervical vertebra (the atlas) on C2 (the axis).

Question 11

What pathology in RA patients can lead to atlantoaxial subluxation?

Answer 11

○ Normally, the transverse axial ligament holds the odontoid process, (also referred to as the dens), which is the superior projection of the vertebra of C2, in place directly behind the anterior arch of C1.
○ With destruction of the transverse axial ligament by RA, movement of the odontoid processis nolonger restricted.
○ As the neck is flexed and extended, the C1 vertebra can sublux on the C2 vertebra.
○ This can result in impingement of the spinal cord, placing it at risk for damage.

Question 12

How is the degree of atlantoaxial subluxation measured? What is this measurement
called?

Answer 12

○ Subluxation of C1 on C2, referred to as atlantoaxial subluxation, can be
quantified by a measuring the distance between the back of the anterior arch of C1 and the front of the dens or odontoid.
○ This distance is referred to as the
atlas-dens interval.

Question 13

What test can be used to determine the atlas-dens interval?

Answer 13

Flexion and extension radiographs of the cervical spine are obtained to determine the distance between the atlas and dens, or the atlas-dens interval, and thus the degree of subluxation.

Question 14

What degree of motion between the atlas and dens, or at what atlas-dens
interval, is the patient considered to be at risk for spinal cord injury?

Answer 14

○ If the atlas-dens interval is 4 mm or more atlantoaxial instability is present, the amount of subluxation is considered significant, and the patient is considered to be at risk for spinal cord injury

Question 15

In the case of pure transverse axial ligament disruption, does flexion or extension increase the atlas-dens interval?

Answer 15

○ In a situation in which the transverse axial ligament is disrupted, extension of the
neck minimizes the atlas-dens interval and increases the safe area for the spinal
cord.
○ Conversely, flexion of the neck increases the atlas-dens interval and decreases the safe area for the spinal cord, making flexion a more frequent risk position.
○ Still, rheumatoid arthritis affects more than just the transverse axial ligament; therefore, all neck movements in patients with rheumatoid arthritis have to be evaluated carefully as extension of the neck can also lead to problems.

Question 16

If a patient is asymptomatic with neck flexion and extension preoperatively
can the anesthesiologist be reassured of an atlas-dens interval of less than 4 mm?

Answer 16

○ Patients with rheumatoid arthritis can be asymptomatic with neck flexion and extension preoperatively while awake, and still have an atlas-dens interval of greater than 4 mm and be at risk for cervical spine injury.
○ These patients are able to
compensate for their cervical spine instability through local muscle.
○ Once anesthetized and the muscles are relaxed, atlantoaxial subluxation may occur.
○ Therefore the anesthesiologist should not be falsely reassured by asymptomatic flexion and extension in the awake patient.

Question 17

What is subaxial subluxation? What is its clinical significance?

Answer 17

Subaxial subluxation is the subluxation of 15% or more of one cervical vertebra
on another at any level below C2. Subaxial subluxation most commonly occurs at
the C5-C6 level. Patients with subaxial subluxation are at risk for spinal cord
impingement with neck movement. Minimal neck movement is recommended in
these patients

Question 18

What is superior migration of the odontoid? What are the potential clinical manifestations?

Answer 18

○ Superior migration of the odontoid is a condition where an intact odontoid process projects up through the foramen magnum and into the skull.
○ This occurs because of inflammation and bone destruction that results in cervical spine collapse with sparing of the odontoid process. ○ This can occur because not all areas of the cervical spine are equally affected in any given patient.
○ If the odontoid is spared, the
intact odontoid can impinge on the brainstem and patients may suffer
neurologic symptoms including quadriparesis or paralysis

Question 19

What is the surgical treatment for superior migration of the odontoid?

Answer 19

○ Surgical treatment for superior migration of the odontoid involves removal of the odontoid to decompress the spinal cord and brainstem.
○ A complicated surgical procedure, referred to as a transoral odontoidectomy, may be performed to accomplish this and involves an incision in the posterior pharyngeal wall, followed by removal of the arch of C1 and then removal of the odontoid and pannus, to relieve
neurologic symptoms.
○ With completion of the transoral portion of the procedure, the
cervical spine is very unstable, necessitating a posterior spinal fusion.

Question 20

What effect does rheumatoid arthritis have on the trachea?

Answer 20

○ Although the cervical spine is affected by rheumatoid arthritis and may collapse from bone destruction, the trachea is usually spared.
○ This results in the trachea
twisting in a characteristic manner as the cervical spine collapses, only serving to increase the difficulty of intubating the trachea of these patients.
○ Tracheal intubation aids such as a fiber optic bronchoscope, Glidescope, Airtraq, or intubating LMA should be available for assistance in endotracheal intubation of these patients should it be required

Question 21

21. What is the pathology in ankylosing spondylitis?

Answer 21

○ Ankylosing spondylitis is a rheumatologic disorder in which repetitive minute bone fractures followed by healing results in the characteristic bamboo spine, disease of the sacroiliac joint, fusion of the posterior elements of the spinal column, and fixed neck flexion that is characteristic of this patient population.

Question 22

What is the hallmark neck position in patients with ankylosing spondylitis?

Answer 22

○ The hallmark of patients with ankylosing spondylitis is a fused neck in flexion

Question 23

Ankylosing spondylitis is associated with which HLA type?

Answer 23

There is an association between ankylosing spondylitis and HLA-B27, although not
all HLA-B27 positive patients are affected with ankylosing spondylitis.

Question 24

What are some considerations for the anesthetic management of patients with
ankylosing spondylitis?

Answer 24

○ Patients with ankylosing spondylitis typically have a rigid cervical spine and neck
fused in flexion, which makes endotracheal intubation difficult.
○ Airway manipulation should be performed only after careful assessment, and an intubation
assist device can help secure the airway.
○ Patients with ankylosing spondylitis may also develop thoracic and costochondral involvement, which may result in a rapid shallow breathing pattern

Question 25

What are some considerations for the anesthetic management of patients undergoing spine surgery?

Answer 25

○ There are several considerations for the anesthetic management of patients undergoing spine surgery, and much depends on the level of the spine in which the
surgery will take place, as well as the surgical approach. ○ Preoperative assessment of the patient for underlying neurologic deficits and chronic pain issues are important.
○ For patients in whom the approach may be thoracic, pulmonary function tests may be indicated. In general, spine surgery can be long and complex with significant
blood loss and hemodynamic alterations. Intravascular access and intraoperative monitoring should be adjusted accordingly, and blood products may need to be ordered.
○ In the event that there will be intraoperative monitoring of the spinal cord with evoked potentials, the anesthesia administered for the surgery may need to be modified so as not to interfere with the acquisition of waveforms

Question 26

What are the various surgical approaches to spine surgery? What are the clinical implications of this?

Answer 26

Spine surgery may have anterior, posterior, lateral, and thoracic approaches. In
some cases, two approaches may be used during the same surgery. Preoperative
discussion with the surgeon is crucial: (1) to determine the surgical approach as
it may influence the location of intravascular access and monitoring placement,
(2) to ensure proper positioning and padding accessories, and (3) because there may
be a need to provide lung isolation and one-lung ventilation. A thoracic surgical
approach may involve open thoracotomy or thoracoscopic techniques. High
thoracic and thoracoscopic procedures frequently require one-lung ventilation
to ensure adequate visualization

Question 27

What kind of endotracheal tubes can be employed to provide one-lung ventilation for thoracic spine surgery?

Answer 27

A double-lumen endotracheal tube or a bronchial blocker can be employed to
provide one-lung ventilation for thoracic spine surgery

Question 28

What is an advantage of a bronchial blocker to provide one-lung ventilation for thoracic spine surgery?

Answer 28

○ A bronchial blocker can be used with a single-lumen endotracheal tube to provide one-lung ventilation for thoracic spine surgery.
○ An advantage of the bronchial blocker is the avoidance of the need to change the tube between different stages of the procedure or at the end of the operation. With the bronchial blocker, deflating
the cuff and withdrawing the catheter back into its casing and recapping the proximal end returns the endotracheal tube to its single-lumen tube characteristics.
○ If extubation of the trachea at the end of the surgical procedure is not indicated, the endotracheal tube does not have to be changed, thereby avoiding the issue of
changing an endotracheal tube in the presence of potentially significant airway edema. Make certain that the PACU staff is properly educated as to the various ports of the bronchial blocker

Question 29

What newer technique do surgeons employ during thoracoscopic spine surgery to
move the lung from the operative field that does not require one-lung ventilation?

Answer 29

Some surgeons are using carbon dioxide insufflation as the sole means of moving
the lung away from the surgical field even in high thoracic spine surgical
procedures. This obviates the need for one-lung ventilation, and allows for the
use of a single-lumen endotracheal tube for the entire procedure

Question 30

Why is intraoperative awareness a possible complication of spine surgery?

Answer 30

○ Patients undergoing spine surgery appear to be at an increased risk for intraoperative awareness as a result of the requirement that the anesthetic technique administered to them be modified to allow for obtaining adequate intraoperative neurophysiologic monitoring waveforms to assess spinal cord integrity.
○ Therefore, some advocate the use of brain function monitoring in these patients to help avoid intraoperative awareness.

Question 31

Is it mandatory to employ a monitor for intraoperative awareness in patients
undergoing spine surgery?

Answer 31

○ Awareness monitoring is not a standard and, as noted in the Practice Advisory for
Intraoperative Awareness and Brain Function Monitoring, a decision should be
made on a case-by-case basis by the individual practitioner for selected patients (e.g., light anesthesia).
○ There was a consensus in the advisory that brain function monitoring is not routinely indicated for patients undergoing general anesthesia as the “general applicability of these monitors in the prevention of intraoperative awareness had not been established.”
○ In fact, Avidan and associates demonstrated that awareness is not decreased with use of brain function monitoring. The need for brain monitoring is still not clear.

Question 32

Name some methods to help decrease blood loss in patients undergoing spine
surgery.

Answer 32

○ Methods to decrease blood loss in spine surgery patients include predonation,
hemodilution, wound infusion with a dilute epinephrine solution, hypotensive anesthesia techniques, red blood cell salvage, positioning to diminish venous
pressure, careful surgical hemostasis, and the administration ofantifibrinolytics.

Question 33

What pharmacologic methods exist to diminish blood loss in patients undergoing spine surgery? Why is aprotinin not used?

Answer 33

Medications to decrease blood loss during surgery include the antifibrinolytics
aprotinin, tranexamic acid, and E-aminocaproic acid. Aprotinin, a serine protease
inhibitor, effectively decreased blood loss in cardiac patients and has been
demonstrated to be efficacious in patients undergoing spine surgery as well. The
negative side effects of aprotinin in cardiac patients include an increased risk of
myocardial infarction (MI) or heart failure by approximately 55%, nearly double the
risk of stroke, increased risk of long-term mortality, and a higher death rate in
patients receiving aprotinin as demonstrated in a study over a 5-year period
comparing aprotinin and lysine analogs in high-risk cardiac surgery. The study was
terminated early and resulted in relabeling and ultimately withdrawing aprotinin
from the market so that it is no longer available. The synthetic lysine analogs,
tranexamic acid and E-aminocaproic acid, have also been employed in spine surgery
as well as in patients undergoing orthopedic surgery. Tranexamic acid can be
administered by an initial bolus injection of 10 mg/kg over 30 minutes followed by
a continuous infusion of 1 mg/kg/hr.

Question 34

What are some considerations for patients placed in the prone position?

Answer 34

Spine surgery is often performed with the patient in the prone position. Careful
positioning is crucial to avoid patient injury. Movement to the prone position
should be performed in a carefully coordinated manner with the surgical team. The
neck should not be hyperextended or hyperflexed but placed in the neutral position.
The endotracheal tube is positioned so it is not kinked, contact areas are padded, and
the face and eyes are protected. Pressure and stretch on nerves is avoided by proper
padding and avoiding any extension over 90 degrees. The abdomen needs to be
hanging free to avoid increased venous pressure and thereby increased venous
bleeding. The prone position alters pulmonary dynamics, so pulmonary function
must be reassessed in this position.

Question 35

Why is spinal cord integrity monitored during spine surgery?

Answer 35

Monitoring spinal cord integrity is an important component of major surgical
procedures involving distraction and rotation of the spine such as occurs with major anteroposterior spinal fusions and scoliosis surgery. Spinal cord monitoring is
employed to detect, and hopefully reverse in a timely manner, any adverse effects
on the spinal cord noted during the operative period.

Question 36

What are various methods used to monitor the spinal cord during spine surgery?

Answer 36

There are a variety of methods to monitor the spinal cord during spine surgery.
These include SSEPs; motor evoked potentials, including transcranial motor evoked
potentials, electromyograms (EMGs), or a wake-up test

Question 37

What are somatosensory evoked potentials (SSEPs)? What part of the spinal cord do
they monitor?

Answer 37

SSEPs are sensory evoked potential waves generated in the extremities by repetitive
stimulation that propagate up through the dorsum or sensory portion of the
spinal cord and into the brain, where these signals or waveforms are detected via
electrodes placed over the scalp. Specific areas on the scalp coincide with the brain’s
sensory areas for the upper and lower extremities and proper signal acquisition
obtained over these sites indicates an intact sensory or dorsal portion of the spinal
cord. The SSEP waveform generated from multiple repetitive stimulations is
analyzed for its latency and amplitude

Question 38

What changes in latency and amplitude are considered abnormal when monitoring
SSEPs during spine surgery?

Answer 38

An increase in latency of greater than 10% or a decrease in amplitude of 60% or more, as well as the inability to obtain a proper waveform or signal, may be indicative of spinal cord dysfunction or disruption.

Question 39

What anesthetic technique should be employed in patients being monitored with
somatosensory and/or motor evoked potentials?

Answer 39

9. If SSEPs alone are being monitored, an inhaled anesthetic, equivalent to a small
   percentage of 1 MAC, can be administered. Volatile anesthetics may interfere with
   signal acquisition in patients monitored with transcranial motor evoked potentials
   and may have to be discontinued, if used at all, if adequate signals cannot be
   obtained. Intravenous anesthetics will need to be administered in these surgical
   cases. While neuromuscular blockade may be used to facilitate tracheal intubation,
   paralysis should not be maintained if transcranial motor evoked potentials are being
   continuously monitored. If the patient is having pedicle screws placed, then the
   neuromuscular blockade needs to be terminated before the EMGs are obtained so
   that testing can be properly performed. A small dose of ketamine can be given in the
   perioperative period as an additional pain relief modality to provide analgesia for
   major surgery including spine surgery.

Question 40

What are some surgically related conditions that can interfere with spinal cord monitoring waveform acquisition?

Answer 40

Surgically related conditions that can result in interference of waveform acquisition
during spinal cord monitoring include direct injury or trauma to the cord or
impairment of the blood supply. Distraction, rotation, excessive bleeding, and severing or clamping of arterial blood supply can result in ischemia to the cord
and neurologic injury

Question 41

Why are some areas of the spinal cord more prone to ischemia?

Answer 41

41. Some areas of the spinal cord are more vulnerable and therefore more prone to
    ischemia because their blood supply is dependent on watershed blood flow. (505)

Question 42

During spine surgery, what is the time course in which changes in the SSEP waveforms manifest after the loss of spinal cord integrity?

Answer 42

○ Direct injury to the spinal cord results in immediate changes in SSEP waveforms.
○ In contrast, if surgery impairs blood supply and thus renders the spinal cord ischemic, the change in SSEP waveforms may take up to half an hour to manifest.

Question 43

What is the appropriate management of a patient during spine surgery once
significant changes are noted in the spinal cord monitoring waveforms?

Answer 43

Direct injury to the spinal cord results in immediate changes in SSEP waveforms. In
contrast, if surgery impairs blood supply and thus renders the spinal cord ischemic,
the change in SSEP waveforms may take up to half an hour to manifest.

Question 44

What is the appropriate management of a patient during spine surgery once
significant changes are noted in the spinal cord monitoring waveforms?

Answer 44

○ Once a significant change in intraoperative spinal cord monitoring waveforms is noted, specific maneuvers should be used to restore spinal cord blood flow, such as releasing the rotation and distraction of the spine if applicable.
○ In addition, as a result of spinal cord manipulation there may be insufficient blood supply to the spine.
⊙Therefore the mean arterial blood pressure should be increased in an effort to restore adequate blood flow to the spine. All variables such as hemoglobin,
temperature, arterial carbon dioxide concentration, and arterial blood pressure
should be considered. Once these are all evaluated, a wake-up test may be necessary if the waveforms do not improve.

Question 45

What area of the spinal cord is monitored by transcranial motor evoked potentials?

Answer 45

Transcranial motor evoked potentials allow for monitoring the patient’s spinal
cord motor pathways throughout the entire procedure. Stimulation over the motor
cortex of the brain generates a waveform, which is propagated down the motor
pathways and detected distally in the arm or leg. This stimulation results in a
characteristic waveform.

Question 46

How does paralysis with neuromuscular blocking drugs affect transcranial motor evoked potentials?

Answer 46

46. To generate transcranial motor evoked potentials, the patient cannot have residual
    neuromuscular blockade. (

Question 47

Why might masseter muscle contraction occur during transcranial motor evoked potentials monitoring? What is the clinical implication of this?

Answer 47

7. The electrical current causing the stimulus over the motor cortex during
   transcranial motor evoked potentials monitoring also stimulates muscles directly
   in the area of the electrodes placed in the scalp—the masseter muscle and muscles
   of mastication. This muscle contraction may result in a strong bite, which can
   potentially injure the tongue, lip, and endotracheal tube. Instances of significant
   tongue lacerations and damage to endotracheal tubes can occur and this can
   develop into emergency situations, especially with the patient in the prone
   position

Question 48

What special precautions should be taken for patients undergoing transcranial motor evoked potentials monitoring during spine surgery?

Answer 48

Special precautions should be taken for patients undergoing transcranial motor
evoked potentials monitoring during spine surgery. The tongue should not protrude
through the teeth. Placing a bite block made of tongue depressors and gauze in
the back of the mouth along the teeth line bilaterally will help prevent injury.
In the prone position, any motion may allow for the tongue to slip and fall between
the teeth, rendering it vulnerable to laceration. Each stimulus is associated with
a masseter muscle contraction, so the patient is at risk as long as waveforms
are being generated.

Question 49

How are intraoperative electromyelograms used to determine if a pedicle screw has
been placed too close to a nerve root?

Answer 49

Intraoperative electromyelograms are used to determine if a pedicle screw has
been placed too close to a nerve root. An electric current is sent through the screw
and the electromyelogram is measured distally. If a low milliamp current can
stimulate the nerve root, then the screw is too close to the nerve root. In general,
a current greater than 7 mA is considered safe enough to know that the pedicle
screw is not too close to the nerve root

Question 50

Can neuromuscular blockade bein effect when electromyelograms are being obtained?

Answer 50

For accurate electromyelogram testing, residual neuromuscular blockade must be
terminated or reversed.

Question 51

What is the role of the intraoperative wake-up test?

Answer 51

The wake-up test was traditionally used to assess spinal cord integrity in many
scoliosis cases. Development of sophisticated spinal cord monitoring is now
standard in many hospitals and the wake-up test is generally reserved for those
situations in which monitoring is unobtainable or a significant intraoperative
change in spinal cord monitoring waveforms is noted

Question 52

How is an intraoperative wake-up test performed?

Answer 52

The intraoperative wake-up test is performed as follows: turn off all inhaled
anesthetics, reverse any neuromuscular blocking drug present, and stop infusions
such as dexmedetomidine, propofol, narcotics, or ketamine. If spontaneous
respirations do not begin, inject naloxone, 0.04 mg at a time, to reverse any residual
narcotic effect. The patient’s head should be held to reduce the risk of self-extubation.
Prior to assessing lower extremity function, there should be confirmation of upper
extremity function. Patient compliance denotes adequate recovery from general
anesthesia. Then, while someone is observing the feet, ask the patient to wiggle his or
her toes. A rapid-acting anesthetic such as propofol should be ready to be
administered as soon as the assessment is complete, so the patient can rapidly be
reanesthetized. If the wake-up test is not successful in demonstrating adequate motor
movement, further surgical intervention may be warranted and the patient may
require transport to the radiology suite for additional imaging studies.

Question 53

Name potential complications of the intraoperative wake-up test

Answer 53

53. There are some potential complications of an intraoperative wake-up test. These
    include increased bleeding, venous air embolism, and even inadvertent extubation
    of the trachea in the prone position with the wound exposed

Question 54

What considerations are important at the conclusion of a spine procedure?

Answer 54

At the conclusion of a spine procedure, the patient is placed in the supine position. All
lines and tubes are secured so that intravenous line, arterial line, and airway access are
not lost at this crucial time. Carefully reassess the patient for hemodynamic status,
intravascular fluid volume status, hematocrit, blood loss, degree of fluid and blood
replacement, temperature, and the potential for airway edema. Premature extubation
must be avoided. Also, facial edema, respiratory effort, the amount of pain medication,
and the presence of splinting and pain should be evaluated before extubating the
trachea. After tracheal extubation, the patient may be transported to the PACU.
Supplemental oxygen should be administered in the PACU. Electrolytes, hemoglobin,
and clotting studies should be ordered as indicated.

Question 55

How can postoperative pain be managed in the patient after spine surgery?

Answer 55

Postoperative pain management may prove complicated after spine surgery
because some patients may have been taking pain medications preoperatively,
particularly opioids. Patient-controlled analgesia (PCA) may be effective, with the
dose tailored to the patient’s needs. Some centers use ketamine as an analgesic
adjunct. The use of nonsteroidal antiinflammatory drugs (NSAIDs), particularly
ketorolac, needs careful consideration because it is a medication that interferes with
bone formation and therefore should be avoided in patients who just underwent
spinal fusion. NSAIDs may be appropriate when bone healing is not a factor. Other
oral medications that are helpful may include acetaminophen, anticonvulsants
(e.g., gabapentin and pregabalin), antispasmodics that work at the spinal cord level
(e.g., baclofen, tizanidine), antiinflammatory medications, and opioids

Question 56

Which patients are at the greatest risk of postoperative visual loss? What are some
other possible factors that contribute to postoperative visual loss?

Answer 56

Although its etiology is unclear, patients undergoing prolonged spine surgery
(>6 hours) in the prone position who have large blood loss (>1 L) are particularly at
risk. Yet, patients with small blood loss and short procedures also have had visual
loss. Perioperative factors such as anemia, hypotension, prolonged surgery, blood
loss, increased venous pressure from positioning in the prone position, edema, a
compartment syndrome within the orbit, and resistance to blood flow, such as from
direct pressure on the eye, as well as systemic diseases such as diabetes,
hypertension, and vascular disease, are all possible etiologic factors. One recent
study entitled Risk Factors Associated with Ischemic Optic Neuropathy
(Anesthesiology 2012;116:15-24) has reported that that male sex, obesity, use of a
Wilson frame, longer cases, greater estimated blood loss, and a decreased percent of
colloid are associated with an increased incidence of postoperative visual loss

Question 57

What are some aspects associated with the prone position that may contribute to
postoperative visual loss?

Answer 57

There are several aspects of the prone position that may contribute to postoperative
visual loss. These include increased venous pressure from positioning in the
prone position, edema, a compartment syndrome within the orbit, and resistance
to blood flow such as direct pressure on the eye.

Question 58

58. How much of postoperative visual loss is due to ischemic optic neuropathy?

Answer 58

• Ischemic optic neuropathy is a major cause of postoperative visual loss.
• Variations in the blood supply to the optic nerve may play a role in the development of ischemic optic neuropathy including reliance on a watershed blood supply to
  critical areas of the optic nerve.

Question 59

What are the determinants of the ocular perfusion pressure? What is the clinical implication of this?

Answer 59

○ Ocular perfusion pressure (OPP), or the blood pressure supplying blood flow to the optic nerve, is a function of the mean arterial pressure (MAP) and intraocular pressure (IOP) such that OPP¼MAP IOP.
○ Increases in IOP or decreases in MAP can have a negative impact on the ocular perfusion pressure. The prone position is associated with increases in intraocular pressure, which can decrease the ocular perfusion pressure and lead to ischemia. ○ The prone position allows edema to develop in the orbit and this increase in venous pressure may impact arterial blood flow

Question 60

What intraoperative factors has the American Society of Anesthesiologists (ASA)
registry determined to be present in the vast majority of postoperative visual loss
patients?

Answer 60

○ A visual loss registry has been established by the ASA to facilitate establishing the etiology of postoperative visual loss
○ Also, an ASA practice advisory points to ischemic optic neuropathy as the most likely cause of postoperative visual loss
○ Of the 93 cases reported in the registry publication, 83 resulted from ischemic optic neuropathy, with the remainder attributed to central retinal artery occlusion.
○ Central retinal artery occlusion may be embolic in nature or the result of direct pressure on the eyeball and tends to be unilateral.
○ Most patients in the registry were
healthy and positioned prone for spine surgery. Blood loss of more than 1 L and procedures of 6 hours or longer were present in 96% of cases

Question 61

According to the ASA practice advisory regarding patients at high risk for
postoperative visual loss during spine surgery, is the use of deliberate hypotension associated with postoperative visual loss?

Answer 61

According to the ASA practice advisory regarding patients at high risk for postoperative visual loss during spine surgery, the use of deliberate hypotension has not been shown to be associated with postoperative visual loss.

Question 62

According to the ASA practice advisory regarding patients at high risk for
postoperative visual loss during spine surgery, what type of fluid should be
administered with crystalloid in these cases?

Answer 62

According to the ASA practice advisory regarding patients at high risk for postoperative visual loss during spine surgery, colloid should be administered in addition to crystalloid to maintain intravascular volume.

Question 63

According to the ASA practice advisory regarding patients at high risk for
postoperative visual loss during spine surgery, is there a defined transfusion trigger
at which the risk of postoperative visual loss is eliminated?

Answer 63

○ According to the ASA practice advisory regarding patients at high risk for postoperative visual loss during spine surgery, there is no defined transfusion trigger at which the risk of postoperative visual loss is eliminated

Question 64

ccording to the ASA practice advisory regarding patients at high risk for
postoperative visual loss during spine surgery, how should the patient’s head and
the operating room table be positioned when the patient is prone?

Answer 64

○ According to the ASA practice advisory regarding patients at high risk for postoperative visual loss during spine surgery, when in the prone position the patient’s head should be positioned level with or higher than the heart when possible.
○ Also, when possible, maintain the head in a neutral forward position without significant neck flexion, extension, lateral flexion, or rotation.

Question 65

What neurologic postoperative complications have been noted in patients who undergo surgery in the sitting position?

Answer 65

Postoperative complications that have been noted in the patient undergoing surgery
in the sitting position are rare but significant and devastating. These neurologic
complications include stroke, ischemic brain injury, and vegetative states.

Question 66

When devastating neurologic postoperative complications occur after surgery in the sitting position, what is the implicated cause?

Answer 66

○ When devastating neurologic postoperative complications occur after surgery in the sitting position, the implicated cause is a decrease in cerebral perfusion pressure resulting in insufficient blood supply to the brain

Question 67

s the systemic arterial blood pressure at the level of the heart the same as that at the
level of the circle of Willis when patients are anesthetized and placed in the sitting
position?

Answer 67

○ No, the systemic arterial blood pressure is not the same at the level of the heart as it is at the level of the circle of Willis when patients are anesthetized and placed in the
sitting position.
○ This is due to the arterial blood pressure gradient that develops
between the heart and brain in this position

Question 68

What calculation more accurately determines the arterial blood pressure at the level
of the circle of Willis when one knows the arterial blood pressure at the level of the
heart when patients are anesthetized and placed in the sitting position?

Answer 68

○ When patients are anesthetized and placed in the sitting position, one can more accurately determine the arterial blood pressure at the circle of Willis through the following calculation: for each centimeter of head elevation above the level of the
heart there is a decrease in arterial blood pressure of 0.77 mm Hg.
○ Therefore, arterial blood pressure measured at the level of the heart is not the blood and perfusion pressure at the brain.
○ Indeed, a 20-cm difference in height between the heart and the
circle of Willis calculates to approximately a 15- to 17-mm Hg gradient.

Question 69

69. What superficial landmark correlates with the circle of Willis?

Answer 69

○ A convenient point for measuring height difference between the heart and brain is the external auditory meatus, which is at the same level as the circle of Willis.
○ Even so, there is still a significant amount of brain tissue above this level

Question 70

What is the potential risk of hypotension in patients that are anesthetized and placed
in the sitting position?

Answer 70

When patients are anesthetized and placed in the sitting position, the mean arterial
blood pressure should be maintained to avoid decreases in the cerebral perfusion
pressure and to potentially avoid devastating neurologic injury. Thus, hypotension
in these patients should be avoided. This is particularly true in the elderly or in patients
with chronic hypertension in whom the cerebral autoregulatory curve is altered

Question 71

Name several factors that predispose a person to a hip fracture.

Answer 71

○ Factors predisposing a person to a hip fracture include medical comorbidities, osteoporosis, lower limb dysfunction, visual impairment, increasing age, Parkinson’s disease, previous fracture, stroke, female gender, dementia, institutionalized patients, excess alcohol or caffeine consumption, cold climate, and use of psychotropic medications.

Question 72

What is the mortality rate associated with a hip fracture?

Answer 72

Mortality rates can range up to 14% to 36% in the first year after fracture.

Question 73

How do comorbidities in the patient with a fractured hip affect their postoperative
outcome?

Answer 73

Medical status affects morbidity and mortality. One example is the number of comorbidities from which the patient suffers, as in one study the presence of four to six comorbidities is associated with increased mortality rate when compared to patients with less comorbidity.
○ Roche and associates, in studying 2448 patients, reported that the presence of three or more comorbidities was a strong preoperative risk factor with the postoperative development of chest infection or heart failure being associated with a high mortality rate. ○ White and associates reported that ASA I and II patients had mortality rates equal to age-matched control subjects, but ASA III and IV patients had higher mortality rates (49% vs. 8%) after a hip fracture.
○ Moran and colleagues, in a study of 2660 hip fracture patients with an overall mortality rate of 9% at 30 days, 19% at 90 days, and 30% at 12 months, noted that healthy patients did well as long as surgery was performed within 4 days.
○ Patients with comorbidities had a nearly 2.5 times increased mortality rate at 30 days as compared with healthy patients.

Question 74

Does it make sense to delay surgery in a patient with a fractured hip and significant comorbidity to improve the patient’s medical status prior to surgery?

Answer 74

○ Generally, when significant comorbidities that need correction exist, patients benefit from a delay in surgery while their medical status improves.
○The mortality rate in high-risk patients in one study decreased from 29% to 2.9% when time was taken to correct physiologic abnormalities.
○ This was also demonstrated by
Kenzora and co-workers, who noted a higher mortality rate (34% vs. 6.9%) in patients who went immediately into surgery as compared to those who were delayed 2 to 5 days to improve their medical status.
○ Also, patients admitted to the
hospital immediately after fracture did better than those admitted more than a day later

Question 75

When should patients with a recent myocardial infarction and a fractured hip be
scheduled for surgery?

Answer 75

○ The management of a patient with a recent myocardial infarction (MI) and hip fracture illustrates how evaluations and management have changed.
○ Previously, surgery was delayed up to 6 months following a myocardial infarction, but now the tendency is to risk-stratify patients based on the severity of their myocardial
infarction to determine wait time until surgery.
○ The recent MI needs to be evaluated on a risk-benefit ratio comparing the risk of surgery after a recent MI with the negative side effects of keeping a patient bed bound with its attendant risks of
pneumonia, pulmonary embolism, pain, loss of ability to walk, and decubitus ulcers.
○ Factors to consider are the extent of the MI, additional myocardium that may be at risk, if the patient suffers from postinfarct angina, and the presence of congestive heart failure (CHF).
○ Although ongoing angina or the presence of CHF may preclude
early surgery, a small subendocardial MI with a minimal increase in cardiac
enzymes and normal echocardiogram and stress test would allow consideration for
an earlier intervention.
○ A fractured hip usually prevents the patient from undergoing a normal exercise stress test. ○ Therefore, if indicated, a pharmacologic stress test may be needed

Question 76

What are some considerations for the anesthetic management of patients undergoing hip surgery?

Answer 76

○ Considerations for the anesthetic management of patients undergoing hip surgery include the patient’s intravascular fluid volume status and the potential for significant perioperative blood loss, patient positioning and proper padding on the fracture table, maintaining normothermia, and whatever additional comorbidities may be present as these patients are typically elderly.

Question 77

Does choice of anesthetic technique—spinal or general anesthesia—play a role in the outcome of patients who have fractured their hip?

Answer 77

○ For patients undergoing hip surgery, there is no clear advantage of one anesthetic technique over another.
○ Therefore, choice of spinal or general anesthesia should be
made on a case-by-case basis taking the patient’s specific medical issues into consideration

Question 78

What are the pros and cons of regional or general anesthesia in the patient with a fractured hip?

Answer 78

○ Although no one anesthetic technique has proven to be superior, the pros and cons of both spinal and general anesthesia must be considered when choosing the
anesthetic technique for a given patient.
○ Advantages of regional anesthesia, such as provided by a spinal anesthetic, are that
(1) it avoids endotracheal intubation and airway manipulation and the medications that need to be administered to accomplish this,
(2) it decreases the total amount of systemic medication the patient receives throughout the procedure, and
(3) it may play a role in decreasing
the risk of thromboembolism.
○ The vasodilatory effect of the spinal anesthetic may help the patient with CHF.
○ However, intravascular fluid still should be given cautiously because CHF may worsen as the intravascular vasodilatory effect of the spinal anesthesia recedes.
○ General anesthesia, in contrast, is easy to administer, particularly in patients in whom movement and positioning for a regional anesthetic may be painful.
○ In addition, in a patient who may be hypovolemic, general anesthesia may be preferred to avoid a precipitous decrease in arterial blood pressure that may occur as a result of the decrease in systemic vascular resistance that accompanies regional anesthesia

Question 79

How are the elderly affected by the use of narcotics in the perioperative period?

Answer 79

○ The dose and frequency of pain medication given to elderly patients in the perioperative period may need to be decreased, and should be given cautiously because of an increased circulation time, and the cumulative effect of administered opioids may become evident when not expected

Question 80

Use of methylmethacrylate cement is associated with what side effects?

Answer 80

○ The use of methylmethacrylate cement is associated with cardiopulmonary side effects such as hypoxia, bronchoconstriction, hypotension, cardiovascular collapse, and even death

Question 81

What is the etiology of the systemic reaction to methylmethacrylate cement?

Answer 81

○ The systemic reaction to methylmethacrylate cement may result from the liquid methylmethacrylate cement monomer itself, which is used in producing the cement for cementing the prosthesis, or may be due to air, fat, or bone marrow elements
being forced into the circulation.
○ The higher the liquid content of the liquid monomer in the mix with the polymer methylmethacrylate cement at the time of insertion, which occurs from not adequately mixing or not waiting long enough for mixing to occur, the more frequently side effects are noted.

Question 82

Which patients are at high risk for a systemic reaction to methylmethacrylate
cement?

Answer 82

Patients who are at high risk for a reaction to methylmethacrylate cement include those who are hypovolemic at the time of cementing, hypertensive patients, and patients with significant preexisting cardiac disease.

Question 83

What is an appropriate tourniquet inflation pressure for lower extremity surgery?

Answer 83

In the lower extremity surgery, the tourniquet is inflated to approximately 100 mm Hg above the systolic blood pressure, as this will prevent arterial blood from entering
the exsanguinated limb

Question 84

What is the upper limit of tourniquet time before it should be deflated?

Answer 84

As tourniquets render the limb ischemic, there is a limit to inflation time before the
ischemia can result in permanent limb damage.
○ The safe upper limit of ischemia time is considered to be 2 hours.
○ The surgeon should be informed of tourniquet inflation time at 1 hour and then as the tourniquet approaches the 2-hour limit so it
can be deflated in a timely manner

Question 85

If tourniquet time exceeds 2 hours and the procedure is not completed, then the
tourniquet should be deflated for how long before it is reinflated and why?

Answer 85

○ If the total tourniquet time will exceed the 2-hour limit, the tourniquet should be deflated at 2 hours for a period of at least 15 to 20 minutes before it is reinflated.
○ This will allow for the “wash-out” of acidic metabolites from the ischemic limb as the limb is reperfused with oxygenated blood.
○ Recirculation of the ischemic limb
with release of the tourniquet is noted by a decrease in blood pressure and anincrease in end-tidal carbon dioxide as the acid products recirculate.
○ The hypotension usually responds to intravascular fluid administration and vasopressors if necessary.

Question 86

What are some complications associated with tourniquet use?

Answer 86

○ Complications associated with tourniquet use include nerve damage, vessel damage especially in patients with atherosclerosis, pulmonary embolism, and skin
damage.
○ One source of skin damage is the antiseptic prep solution, if it is allowed to seep under the tourniquet and tourniquet padding at the time of skin prep, causing a chemical burn.
○ Additional concerns at the time of tourniquet deflation are pulmonary embolism and a decrease in core temperature as the isolated extremity is reperfused.

Question 87

When does the major amount of blood loss occur during total knee replacement surgery?

Answer 87

○ During total knee replacement surgery a tourniquet is used, and in the operating room blood loss is usually not significant.
○ However, if much blood loss occurs into drains in the PACU, hypotension may result.
○ Some surgeons do not deflate
the tourniquet until the wound is closed and the dressing is on the patient.
○ In this situation blood loss is usually less but there is a risk of bleeding

Question 88

What are current recommendations for performing a neuraxial block in patients who received enoxaparin?

Answer 88

○ Consensus statements from the American Society of Regional Anesthesia and Pain Medicine (ASRA) addressed the issue.
○ Recommendations included waiting at least 10 to 12 hours before neuraxial needle placement in a patient who received a preoperative dose of enoxaparin

Question 89

When can redosing of enoxaparin occur after removal of an epidural catheter?

Answer 89

○ Consensus statements from the American Society of Regional Anesthesia and Pain Medicine recommend waiting 2 hours prior to dosing enoxaparin after an
epidural catheter is removed.
○ Patients on warfarin should have their catheter removed only when the international normalized ratio (INR) is below 1.5, and care should be taken to avoid other anticoagulants and antiplatelet medications when low-molecular-weight heparin is being used and an epidural catheter is in place.

Question 90

What are the current recommendations for performing a neuraxial block in patients taking clopidogrel?

Answer 90

○ Current recommendations in the ASRA Practice Advisory, Anticoagulation, 3rd edition, 2010, suggest that clopidogrel be discontinued for 7 days prior to
performing a neuraxial block.
○ However, the article quotes labeling as recommending this while the PDR section for clopidogrel actually recommends that for elective surgery it only be discontinued for 5 days.
○ The executive summary for the Anesthetic Management of the Patient Receiving Antiplatelet Medication, as part of the third edition, states, “On the basis of labeling and surgical reviews, the
suggested time interval between discontinuation of thienopyridine therapy and neuraxial blockade is 14 days for ticlopidine and 7 days for clopidogrel.
○ If a neuraxial block is indicated between 5 and 7 days of discontinuation of clopidogrel,
normalization of platelet function should be documented.”
○ In patients who needs to be maintained on clopidogrel or who have not discontinued it for an
adequate time period, other anesthetic techniques should be considered.
○ The guidelines for some of the antiplatelet medications will probably undergo revision as physicians gain experience with the use of medications such as clopidogrel in the perioperative period