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
How is shoulder arthroplasty done?
Total joint replacement
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
