Orthopedics Flashcards
What should you focus on during the pre-op assessment of an ortho patient?
- airway
- neurologic exam- look for pre-existin deficits
- assessing CV and Pulm function can be difficult based on exercise tolerance in this population
- may require a more advanced workup
- Joint mobility issues
- opioid use?
- could have tolerance
- anticoagulation use?
- often required post-op d/t risk of dvts after ortho surgeries
- Chronic steroids
- positioning issues
What are types of anesthesia that can be used for surgery to the hand and wrist?
- Local w/ MAC (if no tourniquet required)
- Terminal nerve blocks with three local injections
- radial, ulnar, medial block (if no tourniquet required)
- Brachial plexus block
- axillary, infraclavicular, supraclavicular- all get elbow and below??
- Bier block
- General w/LMA or RSI w/ ETT if trauma
Refresher on Bier block
- Limited to short procedures (about 1 hour)
- Start IV on operative hand/wrist
- Exsanguinate arm- elevate and wrap with super tight band
- Double tourniquet- inflate upper cuff to 250 mmHg
- Inject 50 ml 0.5% lidocaine
- When pt begins complaining of discomfort in arm, inflate distal tournequet and deflate upper tourniquet
- Complications: tourniquet failure causing LA toxicity
- Record tourniquet times
- must provide additional means for postop pain relief
What are the types of elbow surgeries?
How may the pt be positioned?
- Types of surgeries:
- cubital tunnel release
- ulnar nerve transposition
- ulnar collateral ligament reconstruction
- ORIF fracture
- Position
- supine
- lateral
- prone
How can you do the anesthetic for an elbow surgery?
- General w/LMA or RSI w/ETT if Trauma
- brachial plexus block
- infraclavicular, supraclavicular with intercostobrachial nerve block for tourniquet
Tourniquets:
Why are they used?
How should they fit?
Risks?
Settings?
Max duration?
What happens after deflation?
- Used to minimize blood loss and provide bloodless surgical field
- Cuff size- should completely encircle limb
- width more than half the limb diameter
- Risk- damage to underlying vessels, nerves, and muscles
- maker sure to pad it and dont pinch skin
- Ideally, pressure set 100 mmHg above patients SBP for thigh and 50 mmHg for arm
- Tourniquet pain develops over time
- max duration 2 hours
- Transient metabolic acidosis, increased CO2 levels and drop in BP with tourniquet deflation
Refresher on brachial plexus blocks:
What part of plexus they affect and indications
Interscalene
Supraclavicular
Infraclavicular
Axiallary
- Interscalent
- roots/trunks
- Indicated for shoulder surgery and upper arm
- Supraclavicular
- Trunks/divisions (middle/inferior)
- Indicated for surgery of upper arm to hand
- Infraclavicular
- Lateral, posterior, medial cords
- indicated for surgery for elbow, forearm, hand
- Axillary
- median, ulnar, radial nerves
- indicated for surgery below the elbow
What does intercostobrachial nerve come off of?
T2
Interscalene block:
Indications?
Goal?
What is not blocked?
- Indications: Shoulder and upper arm
- Goal: LA around superior and middle roots/trunks of C5, C6, and C7
- Ulnar nerve NOT blocked
Interscalene block Complications
- Ipsilateral phrenic nerve block with ipsilateral diaphragm paralysis (most common)
- Intravascular injection
- close to vertebral artery, carotid artery, and jugular vein
- Hoarsness, dysphagia if recurrent laryngeal nerve blocked
- Horner’s syndrome (Horny Pam)
- Ptosis
- anhydrosis
- miosis
Supraclavicular block:
Indications
Goal
What is not covered?
- Indications- upper arm to hand
- Goal- LA around blocks at trunks/divisions of plexus
- Not covered- arm pit; may need intercostobracial block
Supraclavicular block:
complications
- Pneumothorax- symptoms up to 6-12 hours after surgery
- Vascular puncture
- Phrenic nerve block with hemiparesis of diaphragm
- less common than w/interscalene
- Horner’s syndrom
- less common than w/interscalene
Infraclavicular block
Indications
goal
frequently spares?
- Indications: surgery of elbow, forearm, hand
- Goal: LA blocks lateral, posterior, and medial cords
- Frequently spares intercostobrachial nerve
Infraclavicular block
complications
- vascular puncture (axillary
- pneumothorax
- painful block b/c needle goes through pectoralis minor and major
Axillary nerve block:
What is blocked?
- Median nerve- superior (anterior) to axillary artery
- Ulnar nerve- inferior to axillary artery
- Radial nerve- posterior to axillary artery
- Musculocutaneous nerve- often spared
*Remember “RUM-PIS”:
Radial = Posterior
Ulner = Inferior
Median = Superior
Axillary block:
indications
- Indicated for surgery below elbow
- blocks terminal nerves: ulnar, radial, and median nerves
- musculocutaneous nerve frequently not blocked.
What can you do if there is not tourniquet being used?
- Terminal nerve blocks
- ulnar, radial, median
- for surgery of hand or wrist
- pt doesnt need sling for arm
What are indications for shoulder arthroscopy?
- Rotator cuff tear
- torn labrum
- repair of ligaments
- severe refractory instability
- removal of inflamed tissue
- subacromial bursitis
- arthritis
- proximal humerus fracture
What nerve innervates about 70% of shoulder?
Suprascapular nerve- from brachial plexus C5 and C6 trunk
this is why interscalene works
Arthroscopy:
duration
position
anesthetic
- 1 hour
- sitting or lateral
- GETA, GA w/LMA
- +/- Interscalene or supraclavicular block (??) with MAC?
How is shoulder arthroplasty done?
Total joint replacement
Arthroplasty
Indications
duration
position
- Indications:
- arthritis- consider this while assessing airway
- degenerative joint disease
- duration- up to three hours
- position: sitting or lateral
Shoulder arthroplasty anesthetic considerations:
- Technique:
- ETT
- GA w/LMA
- Interscalene or supraclavicular block
- block with catheter (4-7 days)
- Significant blood loss (up to 1 L)
- tourniquet cannot be used
- Need 2 or more large IVs
- CBC pre-op
- T & S
- Hypotensive anesthetic technique
- tranexamic acid (TXA)
- Embolic syndromes
- fat, air, or cement
What do you need to consider regarding lateral position with shoulder surgery?
- Frequently reassess:
- eyes
- ears
- head/neck alignment
- legs
- hips
- Use axillary chest roll to protect brachial plexus
- BP cuff pressure on lower arm- remember BP might reflect higher than actual
How does lung perfusion change in lateral position?
- VQ mismatch
- greater proportion of zone 1 in upper lung
- greater proportion of zone 3 in dependent lung
- Causes reduced zone 2 with more of it in dependent lung
- **VQ mismatch is greater with controlled ventilation than with spontaneous ventilation
What are the potential injuries that can occur in beach chair position?
- Cervical spine (head falling off headrest?)
- Excess flexion of neck
- may obstruct internal jugular vein causing venous engorgement
- Excess extension of neck may impair CBF
- Macroglossia- unusually large tongue
- caused by lymph and venous drainage problems
- Eye injury
- avoid deliberate hypotensive technique
- avoid pressure on eyes/ears
What are the hemodynamic challenges of beach chair position?
- Hypotension
- Venous pooling
- decreased CO
- Intrathoracic blood volume decreases
- correctly monitoring BP is important
- for ever 20 cm of height difference, there is 15 mmHg difference in BP
