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APA Foundations 2 > Orthopedics > Flashcards

Orthopedics Flashcards

1
Q

Bone cement

A
  • polymethylmethacrylate (MMA) cement fills in gaps in bone and binds firmly to prosthetic device
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2
Q

Signs and symptoms of Bone cement implantation syndrome

A
  • hypoxia (due to increased pulmonary shunt)
  • hypotension
  • dysrhythmias (heart block and sinus arrest)
  • pulmonary HTN (due to increased PVR)
  • decreased cardiac output
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3
Q

** When is embolization most frequent during orthopedic surgery?

A
  • prosthetic insertion
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4
Q

How do you minimize the effects of bone cement (MMA)?

A
  • increase inspired O2 prior to MMA
  • maintain euvolemia
  • vasopressor PRN
  • Surgical methods (vent distal femur, high pressure lavage of femoral shaft)
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5
Q

What type of reaction causes bone cement to harden?

A
  • exothermic reaction.
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6
Q

Complications associated with bone cement

A
  • embolization of fat, bone marrow, cement and air into femoral venous channels
  • residual MMA monomer produces vasodilation and decreases SVR
  • tissue thromboplastin release may cause platelet aggregation, microthrombus into lungs and CV instability
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7
Q

Pneumatic tourniquets

A
  • used on upper and lower extremities to create bloodless field and minimize blood loss.
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8
Q

What 7 problems are associated with pneumatic tourniquets?

A
  • hemodynamic changes
  • pain
  • metabolic changes
  • arterial thromboembolism
  • pulmonary embolism
  • muscle and nerve injury
  • limb cooling
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9
Q

What hemodynamic changes are associated with pneumatic tourniquets?

A
  • exsanguination of limb shifts blood volume to central circulation
  • cuff inflation: decreased core temperature, increased HR
  • prolonged cuff inflation (45-60 minutes): HTN, tachycardia, sympathetic stimulation, sweating
  • cuff deflation: decreased CVP, decreased MAP
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10
Q

Tourniquet pain

A
  • severe aching and burning after several minutes
  • supplemental analgesia required
  • ** slow conduction C-fibers are most affected
  • pain less common if regional anesthesia is used
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11
Q

Metabolic changes associated with tourniquets

A
  • metabolic waste products accumulate in the tissue
  • cuff deflation causes rapid wash out of waste products
  • increased PaCO2, etCO2, serum lactate, potassium
  • increased minute volume in spontaneous breathing patients
  • dysrhythmias
  • reperfusion injuries from free radical formation
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12
Q

What cuff pressures should you use to inflate a tourniquet?

A
  • typically cuff pressure is 100 torr above systolic pressure
  • upper extremity: 250 torr
  • lower extremity: 350 torr
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13
Q

Why does having the tourniquet inflated cause metabolic changes?

A
  • extremity switches to anaerobic metabolism

- vasculature in the extremity will vasodilate

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14
Q

When is a tourniquet contraindicated?

A
  • in an extremity with calcified arteries
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15
Q

Tourniquet ischemia, especially of the lower extremity, can lead to ____________

A
  • deep venous thrombosis
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16
Q

Muscle and nerve injury associated with tourniquet use

A
  • prolonged inflation (> 2 hours) can cause transient muscular injury, permanent nerve injury and rhabdomylosis
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17
Q

Who is responsible for monitoring tourniquet time?

A
  • anesthetist
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18
Q

Fat embolism syndrome - triad of symptoms

A
  • dyspnea
  • confusion
  • petechiae (chest, upper extremities, axillary and conjunctiva).
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19
Q

What is the classic timeframe for presentation of fat embolism syndrome?

A
  • within 72 hours of long bone or pelvic fracture
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20
Q

What types of injuries and procedures are associated with fat embolism syndrome?

A
  • long bone fractures
  • CPR
  • liposuction
  • IV lipids
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21
Q

Fat embolism syndrome is ___________ and ____________.

A
  • less frequent

- more fatal (10-20%)

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22
Q

Fat embolism syndrome - pathophysiology

A
  • fat globules are released by disrupted fat cells in fractured bone and enter circulation through tears in medullary vessel
  • increased fatty acid levels are toxic to capillary-alveolar membrane
  • causes release of vasoactive amines and prostaglandins
  • progresses to ARDS, cerebral capillary damage, edema
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23
Q

What 2 coagulation abnormalities are associated with fat embolism syndrome?

A
  • thrombocytopenia

- prolonged clothing times

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24
Q

What changes will you see in a patient with fat embolism syndrome who is under general anesthesia?

A
  • decline in etCO2 and SpO2

- increase in pulmonary artery pressure

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25
Q

Fat embolism syndrome - treatment

A
  • supportive
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26
Q

What are 6 risk factors for deep vein thrombosis and PE?

A
  • age > 60 years
  • obesity
  • tourniquet
  • procedures > 30 minutes
  • lower extremity fracture
  • immobilization > 4 days
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27
Q

What patients are at highest risk for DVT and PE?

A
  • patients having knee or hip replacements
  • ** TKA has the highest risk of all **
  • patients over 70
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28
Q

DVT and PE - pathophysiology

A
  • venous stasis
  • hypercoagulability from inflammation
  • highest incidence in patients over 70
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29
Q

DVT/PE and neuraxial anesthesia

A
  • can reduce risk of DVT and PE
  • sympathectomy that is induced actually INCREASES in venous blood flow
  • local anesthetics have anti-inflammatory effects
  • decreased platelet activity
  • decreased rise in factor VIII and Von Willebrand factor
  • less decrease in antithrombin III
  • less stress hormone release
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30
Q

Neuraxial anesthesia and prophylactic anticoagulation

A
  • risk of spinal or epidural hematoma formation after neuraxial anesthesia in patients who have been given mini-dose heparin or LMWH
  • placement of epidural needle or catheter (or removal) should not be done within 6-8 hours of a SQ mini-dose of heparin or 12-24 LMWH
  • do not place or removal an epidural needle or catheter in a fully anticoagulated patient
  • antiplatelet drugs increase risk of spinal hematoma
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31
Q

Joint manipulation - management

A
  • IV agents with short duration
  • general preferred to regional
  • can use LMA, mask or ETT
  • profound relaxation allows surgeon to distinguish anatomical limitations from patient guarding
  • muscle relaxant, succinlycholine or rocuronium may be needed
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32
Q

Closed reduction - management

A
  • usually brief, but can become prolonged
  • percutaneous pins
  • x-ray/fluoro
  • casting/splinting
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33
Q

Predictors of perioperative mortality in patients with hip fractures

A
  • age > 85 years
  • history of cancer
  • baseline/preoperative alteration in neuro status
  • postoperative chest infection
  • postoperative wound infection
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34
Q

Hip fractures - regional anesthesia

A
  • hypobaric technique utilized to keep patient off of fracture
  • reduces risk of DVT/PE
  • reduces blood loss
  • quicker return to baseline neurological status
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35
Q

What is the mortality rate associated with hip fractures?

A
  • 10% during initial hospitalization

- 25% in first year following surgery

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36
Q

What are 2 reasons that you would delay repair of a hip fracture?

A
  • coagulopathy

- uncompensated heart failure

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37
Q

Hip fractures - general anesthesia

A
  • consider arterial line and large bore IV for larger fractures
  • short acting drugs
  • use lower solubility agents
  • minimize postoperative cognitive impairment
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38
Q

Arthroscopy

A
  • done to examine interior of joint with endoscope and obtain definitive diagnosis
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39
Q

Arthroscopy - benefits

A
  • less EBL
  • less post-operative pain
  • less rehab time
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40
Q

Arthroscopy - anesthesia management

A
  • based on joint location, position of patient and tourniquet utilization
  • can do general, neuraxial or regional anesthesia
  • use LMA for knees and wrists
  • use ETT for shoulders
  • elbow airway management depends on the position of patient
  • pain management: toradol and/or IV Tylenol
  • intraarticular injection of bupivacaine and duramorph provide pain relief for early ambulation
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41
Q

What are the indications for a total hip arthroplasty?

A
  • osteoarthritis
  • rheumatoid arthritis
  • vascular necrosis (from injury or drug abuse)
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42
Q

Total hip arthroplasty - intraoperative management

A
  • position: lateral decubitus
  • use of bone cement (MMA)
  • DVT/PE prophylaxis
  • blood loss: 400-1500 mL, 2000 mL for revisions (have PRBC available, 2 IVs, cell saver or autologous blood donation, regional may be advantageous)
  • prevent heat loss
  • consider spinal opioids for postoperative pain control
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43
Q

Total knee arthroplasty - intraoperative management

A
  • similar patient population and consideration as hips
  • duration: shorter than hip arthroplasty
  • EBL: 100-200 mL during surgery due to tourniquet use, more blood loss in 24 hours postoperatively
  • less bone cement syndrome than hip
  • release of tourniquet can release emboli and increase hypotension (check BP after tourniquet goes down)
  • partial knee replacement less invasive but not always shorter duration
  • early mobilization
  • consider epidural for bilateral total knee arthroplasty
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44
Q

Upper extremity surgery

A
  • can be done open or arthroscopic
  • positioning: sitting (beach chair) or lateral decubitus
  • consider interscalene block of brachial plexus (very good for pain 80% of time)
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45
Q

Forearm/hand surgery - anesthesia considerations

A
  • length of procedure
  • tourniquet use
  • consider Bier block or axillary block
  • general is best option for lengthy procedures with LMA or ETT
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46
Q

Foot/ankle surgery - anesthesia considerations

A
  • excellent candidates for regional anesthesia
  • nerve blocks with IV sedation
  • tourniquet use
  • LMA with local injection for postoperative pain control
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47
Q

Amputations/re-implantations - anesthesia considerations

A
  • careful attention to positioning
  • maintain body temperature (want vasodilation)
  • Avoid pain, hypotension, hypovolemia (anything that produces vasospasm or vasoconstriction)
  • regulate fluids-go heavier to hemodilute
  • maintain blood flow (avoid vasoconstrictors, optimal Hct 28-30%)
  • –If you must use a vasoconstrictor, use ephedrine r/t less peripheral vasoconstriction than phenylephrine
  • – Dextran or heparin infusion post-op
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48
Q

Interscalene block

A
  • targets brachial plexus TRUNKS (upper arm and shoulder)
  • avoid in patients with compromised respiratory status
  • risks: pneumothorax, epidural/spinal/arterial injection
  • 100% phrenic nerve block on ipsilateral side
  • may see Horner’s syndrome, hoarseness (RLN involvement), decreased chest wall sensation
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49
Q

Supraclavicular block

A
  • targets brachial plexus DIVISIONS (upper and lower arms)
  • risks: pneumothorax, vocal cord palsy
  • 50% phrenic nerve block
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50
Q

Infraclavicular block

A
  • targets brachial plexus CORDS
  • useful for surgery of elbow and distal hand
  • risk: pneumothorax (1%)
51
Q

Axillary block

A
  • targets BRANCHES of brachial plexus (distal to elbow)
  • injected into the axilla and hits median, ulnar and radial nerve (misses axillary nerve and musculocutaneous nerve)
  • risks: hematoma, vascular injection
52
Q

Femoral nerve block

A
  • loss of quadriceps function increases fall risk
  • catheters should be in place for less than 48 hours to avoid infection
  • single shot block still increases fall risk
53
Q

Sciatic nerve block

A
  • can block anywhere along the sciatic nerve

- can affect hip, thigh, knee, lower leg and foot

54
Q

Popliteal sciatic nerve block

A
  • useful for foot and ankle surgery
  • spares hamstring so knee can flex
  • allows for easier ambulation
55
Q

What are hallmarks of spinal or epidural hematoma?

A
  • back pain

- lower extremity weakness

56
Q

Which type of neuraxial anesthesia has a lower risk of complications in patient’s who have received prophylactic anticoagulation?

A
  • spinal anesthesia (due to smaller needles used vs epidurals)
57
Q

When will you lose the benefit of regional anesthesia in patients with hip fractures?

A
  • oversedation

- hypoxia

58
Q

Is there any different in mortality in patients with hip fractures who received regional anesthesia versus general anesthesia?

A
  • no difference after 2 months
59
Q

What types of hip fractures are associated with the largest amount of blood loss?

A
  • subtrochanteric (greatest)
  • intertrochanteric
  • base of femoral neck
  • transcervical subcapital (least - because the capsule restricts blood supply by acting as a tourniquet)
60
Q

How can you minimize postoperative cognitive impairment in patients with hip fractures?

A
  • minimize use of midazolam
  • maintain oxygenation
  • maintain hemoglobin
  • maintain normal capnea
61
Q

How is an undisplaced intracapsular fracture of the hip treated?

A
  • cannulated screws
62
Q

How is a displaced intracapsular fracture of the hip treatment?

A
  • internal fixation
  • hemiarthroplasty
  • total hip replacement
63
Q

How is an extracapsular fracture of the hip treated?

A
  • extramedullary (sliding plate and screws)

- intramedullary implant (gamma nail).

64
Q

*** What orthopedic procedure has the highest rate of DVT occurrence?

A
  • total knee arthroplasty
65
Q

Anesthesia considerations for upper extremity surgery

A
  • surgical positioning (beach chair)
  • no tourniquet used so potential for large blood loss
  • bone cement
66
Q

What are 7 complications associated with upper extremity arthroplasty?

A
  • pneumothorax
  • injury to subclavian veins
  • inadvertent extubation
  • c-spine injury
  • venous air embolism
  • fat embolism
  • bone embolism
67
Q

What are 2 interventions that significantly reduce the risk of DVT and PE?

A
  • prophylactic anticoagulation

- pneumatic leg compression

68
Q

T/F

With pneumatic TQ’s, compartment syndrome can develop is the TQ is too tight

A

False

can get compartment syndrome if the TQ is NOT tight enough (arterial flow is blocked, but not venous so it builds up).

69
Q

Heat, expansion, and hardening lead to ____

A
  • Intermedullary HTN (>500 mmHg)
70
Q

What effects are produced by the residual MMA monomer?

A
  • Decreased SVR, vasodilation
  • Significant hypotension
  • Decrease in EtCO2
71
Q

*** Bone cement Implantation Syndrome is most commonly associated with which procedure?

A

Hip Arthroplasty

72
Q

What is the first indication of BCIS during general anesthesia?

What is the first indication of BCIS during regional anesthesia?

A
  • Decrease in EtCO2

- Dyspnea, altered sensorium

73
Q

What complication has the highest incidence with beach chair position for shoulder arthroscopy?

A
  • Hypotensive bradycardic event (HBE)
74
Q

What complication has the highest incidence with lateral decubitus position for shoulder arthroscopy?

A
  • Temporary paresthesia
75
Q

Can you use N2O during hip surgery?

A

No

76
Q

For CV collapse associated with BCIS, treat it the same as ____

A

Right-side heart failure ( Aggressive fluid resuscitation, alpha-agonist for hypotension)

77
Q

For a tension pneumothorax, the most desirable method to relieved increased thoracic pressure is _____

A
  • chest tube
78
Q

With limb TQ’s, abolition of SSEP’s and nerve conduction occurs within ____

A

30 mins

79
Q

With limb TQ’s, application of more than ___ causes TQ pain and HTN

A

60 mins

80
Q

With limb TQ’s, application of more than ___ may result in post-op neurapraxia

A

2 hrs

81
Q

With limb TQ’s, cellular hypoxia develops within ___

A

2 mins

82
Q

With limb TQ’s, endothelial capillary leak develops after ____-

A

2 hrs

83
Q

For cefazolin, the preoperative time allotment is within ___ of incision time

A

1 hr

84
Q

For vancomycin, the preoperative time allotment is within ___ of incision time

A

2 hr

85
Q

TQ size should be ____ size of the limb diameter and the cuff should overlap by ____

A
  • Half

- 3 to 6 inches

86
Q

Which is harder to anesthetize, mylenated A-delta fibers or unmylinated C fibers?

A

unmylenated C- fibers

87
Q

Burning, aching pain correspond to activation of _____

A

unmyelinated C-fibers (slow conducting)

88
Q

Pinprick, tingling, and buzzing sensations that frequently accompany TQ application corresponds to activation of _____

A

A-delta fibers (fast acting)

89
Q

TQ pain is most consistent with sensation carried out by ____

A

unmyelinated C-fibers

90
Q

The potency of bupivicaine is enhanced by ____

A

increase in HR

may be advantageous by lowering the incidence of TQ pain

91
Q

For TQ pain associated with leg surgeries, which is more important to block…. thoracic sensory level or the sacral roots?

A
  • Sacral roots
92
Q

In the lateral decubitus position, the uppermost lung is classified as zone __ and the dependent lung is classified as zone ___

A
  • 1

- 3

93
Q

In the lateral decubitus position, the alteration ventilation-perfusion distribution is accompanied by reductions in ___ and ___

A
  • Vital capacity

- Tidal volume

94
Q

For patients undergoing major orthopedic surgeries, intermittent pneumatic compression devices (IPCD) should be used for a minimum of ____

A

10-14 days

95
Q

For patients undergoing major orthopedic surgeries, thromboprohylaxis should be continued for up to ____

A

35 days

96
Q

TQ should be let down for _____ in between inflations

A

20 mins

97
Q

Definition fo hypotensive bradycardia episodes (HBE)

A
  • decrease in HR of at least 30 bpm within a 5 minute interval
  • HR less than 50 bpm
  • decrease in SBP of more than 30 mmHG within a 5 minute interval
  • any SBP below 90 mmHg
98
Q

The most common mechanism for HBE is activation of _____

A

Bezold-Jarisch Reflex

99
Q

What types of procedures are most common for LA toxicity?

A

Ortho

100
Q

First sign of LA toxixity

A

ringing in ears

101
Q

Late sign of LA toxicity

A

seizures (benz’s are preferred, avoid propofol)

102
Q

4 medications to avoid during LA toxicity

A
  • Vasopressin
  • CCB’s
  • Beta blockers
  • Additional LA
103
Q

Treatment protocol for lipid rescue

A
  • Give 1.5ml/kg bolus,if not effective give few minutes and give again
  • Cont infusion 0.25 ml/kg/min – double infusion to 0.5ml/kg/min if BP remains low
  • Continue infusion for at least 10mins after obtaining circulatory stability
  • Recommended upper limit: approx. 10ml/kg lipid emulsion over the 1st 30mins
104
Q

6 nerves of ankle/foot

A
  • Sural
  • Superficial peroneal
  • Saphenous
  • Deep peroneal
  • Plantar
  • Calcaneous (for heel)
105
Q

____ has the highest rate of DVT’s of all ortho procedures

A

Total Knee Arthoplasty

106
Q

The primary concern when caring for a patient with RA is ____

A

Airway, check neck mobility

  • Atlantoaxis (C1-C2) subluxation (main one)
  • TMJ involvement
107
Q

What part of the airway is the most common site for rheumatoid nodule depostion?

A

Cricoarytenoid joints

108
Q

T/F

TKA has less bone cement syndrome than hip, but release of emboli w/tourniquet deflation may increase hypotension

A

True

109
Q

When will you see the most blood loss from a total knee arthroplasty?

A

Within 24 hrs post-op

EBL is only 100-200ml, but will see a larger amount of blood loss w/i 24hrs post-op

110
Q

Which procedure is longer, a total knee arthroplasty or total hip arthroplasty?

A

THA

111
Q

What has greater loss, a total hip arthroplasty or a revision?

A

Revision

112
Q

Anesthesia concerns for amputations

A
  • Psychological trauma
  • Phantom limb pain (regional is best option to block this)
  • Regional v General (regional preferred)
113
Q

T/F

ASA ALONE IS NOT A CONTRAINDICATION TO NEURAXIAL ANESTHESIA

A

True

114
Q

Stimulating the lateral cord during a infraclavicular block would cause _____

A

forearm flexion

115
Q

Stimulating the posterior cord during a infraclavicular block would cause _____

A

Wrist extension

116
Q

Stimulating the medial cord during a infraclavicular block would cause _____

A

finger and thumb extension

117
Q

Stimulating the median nerve during a axillary block would cause _____

A
  • Forearm pronation

- Wrist flexion

118
Q

Stimulating the ulnar nerve during a axillary block would cause _____

A
  • Finger flexion

- Thumb opposition

119
Q

Stimulating the radial nerve during a axillary block would cause _____

A
  • Wrist extension
120
Q

The MC nerve runs through the ____, so ask patient to ____ to assess it

A
  • Bicep

- Flex arm

121
Q

T/F

Bilateral Total Knee Replacements are best served by an epidural

A

True

Consider a femoral sheath catheter

122
Q

** When will you see the effects of emboli occur?

A

When the TQ goes down

The emboli occurs during implantation, but the TQ is holding it in place. Once deflated, then you will see the effects of the emboli and hypotension occur

123
Q

Mixing polymerized MMA powder with liquid MMA monomer causes _____ and ________

A

polymerization and cross linking of polymer chains

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