Orthopedics Week 13 Flashcards
KEY POINTS
- Optimal anesthetic management for orthopedic surgery requires expertise in regional anesthesia and _______ (1) techniques.
- Regional anesthesia can provide physiologic benefits and facilitate recovery compared to _______ (2).
- _______ (3) is appropriate for surgeries not amenable to and/or patients with contraindications to regional techniques.
- Orthopedic surgery patients may have limited mobility and may require special attention to avoid _______ (4)-related injury.
Patients presenting for spine surgery should be evaluated carefully for potential _______ (5) challenges and/or impaired _______ (6) function.
- Major spine surgery frequently involves significant bleeding, and blood conservation techniques should be considered
Answers:
- analgesia
- general anesthesia
- General anesthesia
- positioning
- airway
- respiratory
KEY POINTS
- Intraoperative monitoring of spinal cord function should be used for surgeries where the cord is at risk of injury.
- Catastrophic venous air embolism during spine surgery may present as unexplained _______(a) with high end-tidal _______ (1) and low end-tidal _______ (2).
- Nerve injury may result from surgical trauma and/or nerve blockade in the setting of pre-existing neurologic deficits.
- In the sitting position, for every ______(b) cm of difference in height of the head from the heart, there is a ______(c)-mmHg difference in mean arterial pressure.
- _______ (3), _______ (4), and _______ (5) should be available for management of hypotensive bradycardic events occurring during surgery in the beach chair position.
- _______ (6) blocks cause hemidiaphragmatic paresis and can cause respiratory compromise in patients with reduced pulmonary function.
- Venous thromboembolism is a common complication of _______ (7) extremity orthopedic surgery performed with inadequate thromboprophylaxis.
- The American Society of Regional Anesthesia has released guidelines for safe use of regional anesthesia in the setting of antithrombotic or thrombolytic therapy.
Answers:
- nitrogen
- carbon dioxide
- Ephedrine
- atropine
- glycopyrrolate
- Interscalene
- lower
a. hypotension
b. 20
c. 15
Introduction
Complications of orthopedic surgery includes/relate to:
- Nerve injury: Expertise in regional anesthetic techniques for both surgical anesthesia and postoperative analgesia is of _______(1) importance.
- _______(2) Blood Loss
- Stretch/Pressure _______(3)
- Hemodynamic _______(4)
- Tourniquet _______(5)
- controlled intraoperative _______(6)
- blood salvage _______(7)
- use of antifibrinolytics
- fluid _______(8)
- _______(9)
Answers:
1. paramount
2. Major
3. Injuries
4. Changes
5. use
6. hypotension
7. techniques
8. resuscitation
9. Transfusions
Preoperative Assessment
- special attention to potential airway _______(1)
- considerations relating to mobility and intraoperative _______(2)
- medication history related to opioid _______(3)
- anticoagulation _______(4)
- Common in elderly hip/knee patients with _______(5)
Overall, patients undergoing orthopedic procedures are considered at _______(6) risk for perioperative cardiac complications.
Answers:
1. difficulties
2. positioning
3. dependence
4. status
5. comorbidities
6. intermediate
Rheumatoid Arthritis:
- often require orthopedic surgery and merit special _______(1)
- RA can affect the pulmonary, cardiac, and musculoskeletal _______(2)
- Airway management can be challenging in these _______(3)
- Involvement of the cervical spine and temporomandibular joints results in limited neck range of _______(4) and mouth opening
- Atlantoaxial instability, with subluxation of the odontoid process:
- can lead to spinal cord injury during neck _______(5)
- may require perioperative steroid replacement (Stress _______(6))
- If they are already on steroids for their _______(7)
Answers:
1. attention
2. systems
3. patients
4. motion
5. extension
6. Dose
7. RA
Selection of Anesthetic Technique
Many orthopedic surgical procedures, because of their localized peripheral sites, lend themselves to regional anesthetic techniques
advantages over general anesthetics including:
- enhanced _______(1)
- accelerated hospital _______(2)
- improved _______(3)
- decreased nausea and _______(4)
- less respiratory and cardiac _______(5)
- improved _______(6)
- reduced blood _______(7)
- decreased risk of infection and _______(8)
The optimal regional technique and local anesthetic depend on factors including:
- surgery _______(9)
- indication for postoperative _______(10)
- degree & duration of postoperative sensory/motor block needed for active and passive physical _______(11)
General anesthesia is appropriate for orthopedic surgery:
- sites not amenable to _______(12)
- in patients with contraindications to regional techniques
- anticoagulation _______(13)
- infection at the needle insertion _______(14)
- pre-existing nerve injury or _______(15)
- You don’t want to be blamed for a nerve injury you didn’t _______(16)
- patient refusal: “They are allowed to say _______(17)”
Answers:
1. rehabilitation
2. discharge
3. analgesia
4. vomiting
5. depression
6. perfusion
7. loss
8. thromboembolism
9. duration
10. sympathectomy
11. therapy
12. regional
13. status
14. site
15. disease
16. cause
17. no
Anesthesia for Spine Surgery
Preoperative Assessment
Preoperative evaluation for spine surgery should assess involvement of the:
* Respiratory system
* Cardiovascular system
* Neurologic system
Airway evaluation should focus on:
* restricted neck movement
o Ask the pt in pre-op: How high can you lift your chin before it starts to hurt?
* cervical spine stability
o Often times- you can just ask the surgeon how much wiggle room you have
* exacerbation of symptoms with movement or position
Securing the Airway:
* The decision to secure the airway awake, asleep, or with _______(1) airway devices should be made prior to surgery and the patient counseled accordingly
* Awake _______(2) tracheal intubation is preferred when assessing for neurologic function prior to use of a traction device.
o Numb the _______(3)
o Afrin in the nose to shrink the nasal mucosa
o Lidocaine _______(4): Prevent the Gag
o At The Ready with Propofol the second that tube goes in
* NEVER Place a HARD oral airway and then place a patient _______(5) (21:20)
o Can cause Lip _______(6)
Answers:
1. advance
2. fiberoptic
3. airway
4. updraft
5. Prone
6. Ischemia
Respiratory Function
* Patients presenting for spine surgery often have impaired respiratory function.
* Scoliosis can cause _______(1) lung disease EXAM II QUESTION LOL
* neuromuscular diseases can be associated with recurrent _______(2) infections
* patients with spinal cord injury may already be _______(3) dependent
* Physical exam and history should focus on _______(4) impairment
* Chest radiograph, arterial blood gas, and pulmonary function tests may be indicated in patients with _______(5) pulmonary disease
* A preoperative vital capacity less than _______(6) of predicted is associated with prolonged postoperative ventilation after scoliosis surgery
* Optimization of pulmonary function targets treatment of _______(7) causes with the use of preoperative physical therapy, _______(8), and _______(9) as indicated
Answers:
1. restrictive
2. chest
3. ventilator
4. functional
5. restrictive
6. 30% to 35%
7. reversible
8. antibiotics
9. bronchodilators
Cardiac dysfunction
* often associated with spine pathology and may be a primary manifestation of the disease as seen in muscular dystrophies
* Rarely, scoliosis can cause _______(1) secondary to chronic hypoxemia and pulmonary hypertension
o electrocardiogram (ECG) and echocardiogram should be obtained to assess left ventricular function and _______(2) pressures.
* Dobutamine stress echocardiography may be necessary to assess cardiac function in patients with limited _______(3) or mobility
Neurologic deficits
* Neurologic deficits of spine patients generally relate to the underlying disease and should be discussed in detail with the patient and surgeon and _______(4).
* cervical spine surgery:
o extra care must be taken to avoid _______(5) during tracheal intubation and positioning
* Neuromuscular diseases:
o increase risk of _______(6) during airway manipulation
* Patients with spinal cord injury:
o spinal shock and _______(7) are of particular concern.
Dr. H’s Key Words for Documenting
* Patient intubated in the neutral position Using Direct Laryngoscopy
* _______(8)
* No Neck Extension
* Dentition intact
* Positive End-Tidal
* Comment about the Neck Position (neutral, no extension, etc.)
* You HAVE to protect yourself- get in the _______(9)
Answers:
1. cor pulmonale
2. pulmonaryarterial
3. exercise tolerance
4. documented
5. injury
6. aspiration
7. autonomic dysreflexia
8. Atraumatic
9. habit
Positioning for Spine Surgery
- Positioning for spine surgery depends on the level and approach of the procedure.
- Patients may be transitioned between supine, lateral, and prone positions intraoperatively (Rare)
- May be completely _______(1)
- Overall goals of positioning are to:
- _______(2) as needed to protect peripheral nerves, bony prominences, and the eyes
- _______(3) well
- Support _______(4) (not just dangling)
- _______(5) Position
- (protect brachial plexus; no pressure on olecranon processes)
- Support underneath the _______(6) and ankles
- (2) avoid displacement of unstable _______(7) during surgery
- (3) ensure low venous pressures—minimize blood _______(8) at the surgical site
- Low venous pressures can be facilitated by maintaining a free abdomen and _______(9) position.
Answers:
1. Prone
2. pad
3. Pad everything
4. Shoulders
5. Surrender
6. knees
7. fractures
8. loss
9. reverse Trendelenburg
The posterior approach to spine surgery:
- requires _______(1) positioning
- Pressure on the abdomen causes _______(2) compression:
- increasing bleeding from _______(3) epidural veins
- ______(a) cardiac output
- increasing the risk of lower limb _______(4)
- Therefore, adequate foam padding should be placed under the chest (below the axillae) and the anterior superior iliac spines.
- Stretch and Pressure Injuries:
- The arms should not be abducted to more than 90 degrees and should be positioned with slight internal rotation to reduce the risk of brachial plexus stretching
- Elbow Flexion: _______(5) nerve is at particular risk of pressure-related injury and should be protected
- The eyes should be taped closed
- Be careful with the face _______(6)
The anterior approach to the thoracolumbar spine:
- achieved in the _______(7) position
- For scoliosis surgery:
- the ______(b) of the curve is usually uppermost
- removal of one or more _______(8) may be necessary for surgical exposure
- Placement of a ______(c) endotracheal tube to collapse the lung on the operative side may be required for surgery above _______(9)
Answers:
1. prone
2. inferior vena cava
3. valveless
a. reducing
4. thrombosis
5. ulnar
6. lashes
7. lateral
b. convexity
8. ribs
c. double-lumen
9. T8
For cervical spine surgery:
- anterior approaches require the _______(1) position
- posterior approaches require _______(2) positioning
- patient may be positioned with the head away from machine to allow surgical access
- extensions may be needed for _______(3) circuits
- _______(4) minimizes venous bleeding
- A-Line: No longer _______(5) of care
Blood Conservation
- The frequency of transfusion in adult spine surgery ranges from _______(6) to 81%
- Most of the blood loss during spinal instrumentation and fusion occurs with _______(7)
- Proportional to the number of _______(8) levels involved.
- Rare cause of bleeding during spine surgery:
- trauma to the aorta, vena cava, or iliac vessels
- Unexplained rapidly evolving _______(9) with signs of _______(10) should alert the anesthesiologist to this possibility
Answers:
1. supine
2. prone
3. breathing
4. Reverse Trendelenburg
5. standard
6. 50%
7. decortication
8. vertebral
9. hypotension
10. hypovolemia
Measures to decrease blood loss/transfusion requirements:
- preoperative _______(1) donation
- proper _______(2)
- the use of intraoperative _______(3) salvage
- administration of antifibrinolytics such as _______(4) (TXA)
- reduces surgical bleeding and transfusion requirements
- also does so without increased incidence of:
- _______(5) embolism (PE)
- _______(6) venous thrombosis (DVT)
- _______(7) infarction
- EXAM II QUESTION LOL
Answers:
1. autologous
2. positioning
3. blood
4. tranexamic acid
5. pulmonary
6. deep
7. myocardial
Spinal Cord Monitoring
Intraoperative monitoring (IOM) of spinal cord function is now considered mandatory for all surgeries in which the cord is at risk of _______(1). Risk is incurred when corrective forces are applied to the spine, osteotomies are made, or the spinal canal is _______(2) invaded. There are three main methods of IOM: the wake-up test, somatosensory evoked potential (SSEP) monitoring, and motor evoked potential (MEP) recording.
The wake-up test
- involves intraoperative awakening of the patient after completion of spinal instrumentation in order to assess motor function of upper and lower _______(3)
- Dr. H: “This just doesn’t happen anymore with _______(4) and MEP as an option”
- ______(a) are (havenstein says _______(5) important tool) important for analgesia and tolerance of the _______(6) tube while the patient is awake
- Disadvantages including
- the risk that an _______(7) patient could move
- dislodge the endotracheal tube
- even fall from the table
Answers:
1. injury
2. surgically
3. extremities
4. SSEP
a. Opioids
5. most
6. endotracheal
7. uncooperative
SSEPs: somatosensory evoked potential
- assess the _______(1) column pathways of proprioception and vibration that are supplied by the _______(2) spinal artery.
- SSEPs are altered by
- neural injury
- volatile anesthetics
- _______(3) co2?
- Hypoxia
- Hypotension
- _______(4) temp?
MEPs: motor evoked potential
- Motor pathways are supplied by the _______(5) spinal artery and are monitored by MEPs.
- MEPs are considered technically more difficult to use, in part because they are impeded by use of _______(6).
Answers:
1. dorsal
2. posterior
3. Hypercarbia
4. Hypothermia
5. anterior
6. muscle relaxants
MEPs: motor evoked potential
- Motor pathways are supplied by the _______(1) spinal artery and are monitored by MEPs.
- MEPs are considered technically more difficult to use, in part because they are impeded by use of _______(2).
If both (MEP and SSEPs)
- SSEP and MEP are to be monitored during spine surgery, a suitable anesthetic regimen would include
- an ultrashort-acting ______(a) infusion (she says _______(3))
- a low-dose inhaled anesthetic (she says _______(4) MAC)
- total intravenous anesthesia (background _______(5))
- with monitoring of the electroencephalogram or _______(6)
- MEPs in combination with SSEPs may increase the early detection of spinal cord ischemia. Acute alterations in signal amplitude or _______(7) can signify spinal cord compromise and may be the result of direct trauma, ischemia, compression, or hematoma
- If changes occur, it is recommended that surgery be discontinued → blood pressure returned to normal or _______(8) above normal→
- volatile agents _______(9) or discontinued. →
- ______(b) can help rule out a metabolic derangement. → If the signal does not return to normal, the surgeon should release distraction on the cord. →
- A _______(10) can be performed at this time to definitely exclude neurologic deficits.
- Summarized: _______(11) tests → anesthesia is blamed → ABG r/o anesthesia → still no return → surgeon releases pressure → wake up test
Answers:
1. anterior
2. muscle relaxants
a. opioid
3. Remi
4. 0.5
5. propofol
6. bispectral index
7. latency
8. 20%
9. decreased
b. Arterial blood gases
10. wake-up test
11. Motor and sensory evoked potential
Spinal Cord Injury
- Patients with a suspected spinal cord injury should be examined immediately to assess for signs of respiratory insufficiency, airway obstruction, rib fractures, and chest wall or facial trauma.
- Spinal cord function above the level of the injury should be determined.
- If the muscles controlled by the C5 nerve roots (_______(1)) are flaccid, partial ______(a) paralysis should also be expected.
- C5 injuries “emphasis on _______(2) roots” CHART CHART CHART all deficiencies pre and post-op
- Patients requiring spine stabilization surgery may present with spinal shock, which occurs immediately after the injury and lasts up to _______(3).
- Injuries at or above T5 are associated with hypotension due to a physiologic _______(4) and loss of tone from the ______(b).
- Lesions above the cardiac accelerator fibers (______(c)) cause bradycardia.
- Hypotension due to spinal injury is ______(d) responsive to intravenous fluids and vasopressors, and excessive fluid administration may contribute to the development of _______(5) edema
- Be very cautious: If the patient has Low BP and they are NOT responding to Fluids… STOP the Fluid
Answers:
1. deltoid, biceps, brachialis, and brachioradialis
a. diaphragmatic
2. C5
3. 3 weeks
4. sympathectomy
b. splanchnic vascular beds.
c. T1 to T4
d. poorly
5. pulmonary
With complete cord transection above T5
- Following recovery from spinal shock, ______(a) of patients go on to exhibit autonomic _______(1).
- The syndrome can also occur with injuries at lower levels and is characterized by
- severe paroxysmal hypertension with _______(2) from the baroreceptor reflex, dysrhythmias
- cutaneous_______(3) below and ______(b) above the level of the injury.
- Episodes are typically precipitated by distention of the _______(4) or rectum but can be induced by any _______(5) including surgery.
- Treatment involves
- removal of the stimulus
- deepening of anesthesia
- administration of direct-acting _______(6).
- Untreated, the hypertensive crisis may progress to seizures, intracranial hemorrhage, or myocardial infarction.
- High cervical lesion that includes the diaphragmatic segments (_______(7)) results in respiratory failure and _______(8) without mechanical ventilation.
- Lesions between _______(9) cause significant alterations in respiratory function due to loss of abdominal and intercostal support.
- Flaccid thoracic muscles can lead to paradoxical respirations and a vital capacity reduction of _______(10).
- Inability to cough and effectively clear secretions causes an increased ______(c) and increased risk of infection.
Answers:
a. 85%
1. hyperreflexia
2. bradycardia
3. vasoconstriction
b. vasodilation
4. bladder
5. noxious stimulus
6. vasodilators
7. C3 to C5
8. death
9. C5 and T7
10. 60%
c. atelectasis
Succinylcholine can be administered safely for the first ______(a) hours after spinal cord injury.
- After that time, a proliferation of _______(1) receptors in the muscle can cause hypersensitivity to depolarizing muscle relaxants leading to marked hyperkalemia.
- Maximal hyperkalemia risk from succinylcholine occurs between _______(2) and _______(3) after spinal injury.
- Serum potassium levels may rise as high as _______(4) mEq/L, causing ventricular fibrillation and cardiac arrest.
- Although succinylcholine should be avoided in all patients with spinal cord injury after 48 hours, _______(5) paralytic agents can be used.
Patients with spinal cord injury are _______(6) owing to disruption of sympathetic pathways carrying temperature sensation and subsequent loss of vasoconstriction below the level of injury.
- Normothermia can be achieved by applying exogenous heat to the skin, increasing ambient air temperature, warming intravenous fluids, and humidifying gasses.
- _______(7): Core temperature becomes dependent on ambient temperature; cannot maintain an independent core temperature
- This is the biological term for “Cold-Blooded” ie a lizard lol
Answers:
a. 48
1. acetylcholine
2. 4 weeks
3. 5 months
4. 14
5. nondepolarizing
6. poikilothermic
7. Poikilothermic
Scoliosis
- Scoliosis involves a lateral and rotational deformity of the spine and occurs in up to _______(1) of the population.
- Most cases are idiopathic (_______(2)), with a male to female ratio of _______(3).
- Surgery is considered when the Cobb angle, a measure of curvature, exceeds:
- _______(4) degrees in the thoracic
- or _______(5) degrees in the _______(6) spine.
- can cause
- _______(7) hypoxia
- _______(8)
- pulmonary vascular _______(9)→
- resulting in _______(10) pulmonary vascular changes →
- _______(11) hypertension→
- eventually _______(12) ventricular hypertrophy and cor pulmonale.
- untreated idiopathic scoliosis can progress rapidly and is often fatal by the _______(13) or _______(14) decade of life.
- Scoliosis is also often associated with congenital heart conditions including
- mitral valve _______(15)
- coarctation of the _______(16)
- cyanotic heart _______(17)
- suggesting a common embryonic insult or collagen defect.
- scoliosis repair
- is to halt the decline in respiratory function, pulmonary function acutely _______(18) for 7 to 10 days after surgery.
- Preoperative vital _______(19) is a reliable prognostic indicator of respiratory reserve, and postoperative ventilator support is likely to be required for those with a vital capacity less than _______(20)% of predicted.
Answers:
1. 4%
2. 70%
3. 1:4
4. 50
5. 40
6. lumbar
7. chronic
8. hypercapnia
9. constriction
10. irreversible
11. pulmonary
12. right
13. fourth
14. fifth
15. prolapse
16. aorta
17. disease
18. deteriorates
19. capacity
20. 40
Anesthetic considerations for surgical correction of scoliosis by spinal fusion and instrumentation include
- management in the _______(1) position, hypothermia during long procedures with extensive exposure, and replacement of blood and fluid losses.
- Adequate hemodynamic monitoring and venous access are essential.
- An arterial line allows for close hemodynamic monitoring and assessment of blood _______(2)
- whereas a central venous catheter may be helpful in evaluating blood and fluid management and can be used to aspirate air in the case of venous air _______(3).
- Patients with evidence of pulmonary hypertension or severe coexistent cardiovascular or pulmonary disease may require a pulmonary artery _______(4).
- Scoliosis CVP, _______(5), and PAC monitoring only for extremely sick _______(6)
Answers:
1. prone
2. gasses
3. embolism
4. catheter
5. A-line
6. patients
Muscular Disorders
- Muscular dystrophy and cerebral palsy are important causes of _______(1)
- Patients with DMD are sensitive to _______(2) neuromuscular blocking agents, and _______(3) may occur with use of succinylcholine.
Degenerative Vertebral Column Disease
- Spinal stenosis, spondylosis, and spondylolisthesis are all forms of _______(4) vertebral column disease
- causing pain and/or progressive neurologic symptoms requiring surgical _______(5).
- A preoperative assessment of C-spine symptoms and the airway should be performed
- Intraoperatively, the _______(6) incision approximates the border of the _______(7) muscle, near critical anatomic structures.
- _______(8) retraction of the carotid artery may endanger cerebral perfusion, particularly in the elderly patient.
- Retraction of the _______(9) and _______(10) medially may cause pharyngeal laceration, laryngeal edema, and recurrent laryngeal nerve paralysis.
- Cerebrospinal fluid leaks and trauma to the vertebral artery have also been reported.
- General anesthesia is preferred for nearly all thoracic and cervical procedures because of the high spinal level that would be required with a regional technique
- Degenerative vertebral column disease: Thoracic/Cervical surgeries requires _______(11), because it would be hard to generate such a high spinal _______(12).
Answers:
1. scoliosis
2. nondepolarizing
3. hyperkalemia
4. degenerative
5. intervention
6. anterior
7. sternocleidomastoid
8. Lateral
9. esophagus
10. trachea
11. GENERAL ANESTHESIA
12. level
Postoperative Care of the Spine Patient
Postoperative ventilation may be required in patients with:
- neuromuscular disorders
- severe restrictive pulmonary dysfunction with a preoperative vital capacity of less than _____(1) of predicted
- right ventricular failure, obesity, or sleep apnea
- Patients with prolonged procedures
- thoracic cavity invasion
- blood loss greater than _____(2)
Mentioned neurologic status should be _____(3) (vague)
- Neurologic status must also be monitored closely to determine appropriateness for _____(4).
- Neurologic status must be followed closely and bowel dysmotility is common.
Postoperative mechanical ventilation may be maintained for a few hours, with the head of the bed _____(5) when possible
- until hypothermia and metabolic derangements have been corrected and facial and _____(6) have improved.
______(a) analgesia postoperative pulmonary therapy (______(7)), including incentive spirometry, is necessary to avoid post extubation atelectasis and pneumonia
- Multimodal analgesia has become the gold standard for postoperative pain relief and can be useful after spine surgery.
- Completely strip the muscle off the _____(8) is what hurts; muscle spasm
- _____(9) her personal best pain relief was through drugs that stopped the pain
Do not expand but this table may be helpful
Answers:
1. 35%
2. 30 mL/kg-1
3. check/monitored
4. extubation
5. elevated when possible
6. airway edema
a. Multimodal
7. toileting
8. bone-THAT is what hurts
9. Her
Complications of Spine Surgery
- Venous air embolus (VAE) is a catastrophic event that is a particular risk during laminectomy because of the large amount of _____(1) and location of the surgical site _____(2) the level of the heart.
- presents as unexplained _____(3) with an increase in the end-tidal ______(a) concentration
- OR a precipitous _____(4) in the end-tidal carbon dioxide concentration.
- Prompt diagnosis and treatment increase patient survival with VAE.
- VAE Prevention and management measures include
- intravascular volume expansion
- careful positioning
- positive end-expiratory pressure (______(5))
- jugular venous compression (VAE Avoid _____(6))
- VAE Treatment includes
- flooding the surgical site with saline
- controlling sites of air entry
- repositioning the patient with the surgical site below the right atrium
- aspiration of air from a multiorifice central venous catheter
- cessation of inhaled ______(b)
- resuscitation with oxygen (______(7))
- intravenous fluids
- inotropic agents
- Massive embolism may necessitate _____(8) and cardiopulmonary resuscitation.
Answers:
1. exposed bone
2. above
3. hypotension
a. nitrogen
4. fall
5. PEEP
6. Avoid JVD compression
b. nitrous oxide
7. 100% FiO2
8. supine repositioning
