Test 1 Flashcards
Osteoporosis
Causes: (4)
Stress Fractures where at: (4)
Meds taken: (4)
Osteoporosis Causes:
1.) ^ Parathyroid hormone
2.) Decreased Vitamin D
3.) Decreased Growth hormone
4.) Decreased insulin-like growth factor
Fractures:
1.) Spine (thoracic/lumbar)
2.) Compression
3.) Proximal Femur/ Humerus
4.) Wrist
Meds:
1.) Fosamax
2.) Actonel
3.) Reclast
4.) Boniva
Osteoarthritis
What is it?
When does it get worse?
Symptoms?
Heberdon vs Bouchard nodes
Meds/ Treatment:
Loss of articular cartilage –> inflammation
Worse at night:
Crepitance, joint deformity, decreased mobility
-Heberdon nodes: Swell DISTAL interphalangeal joint
-Bouchard nodes: Swell PROXIMAL interphalangeal joints
Meds:
NSAIDS, COX2 (Celecoxib), Steroids at joint (intra-articular therapy), chondroprotective agents
Acu, weight loss, OT, TENS
Rheumatoid Arthritis
What is it?
Symptoms?
When is it worse?
What labs are elevated? (4)
Systemic inflammation
–> Destroy bone, cartilage, joint
–>Wrist/metacarpophalangeal joints + multiple joints
Symptoms:
Subcutaneous rheumatoid nodules
–>Morning stiffness
What labs are elevated?
-Rheumatoid factor
-Anti-immunoglobulin anti-body
-C-reactive protein
-Erythrocyte sedimentation rate
Rheumatoid arthritis anesthesia considerations
Airway:
Cervical spine:
Atlantoaxial subluxation symptoms?
Pulmonary?
Airway:
-Limited TMJ
-Narrow glottic opening
-Cricoartytenoid arthritis
Cervical spine:
-C1 Atlantoaxial instability
-Impingement on C-spine/medulla
-Vertebral artery occlusion
Atlantoaxial subluxation symptoms?
-Headache
-Neck pain
-UE/LE parasthesia with movement
-Bladder/bowel dysfunction
–> to do: X-ray, eval c-spine function
Pulmonary:
- Interstital fibrosis
-Restrictive ventilation pattern
Rheumatoid Arthritis Anesthesia Consideration:
Eyes:
Cardiac:
GI:
Renal:
Eyes: Sjogren syndrome
Cardiac:
-Vasculitis/ Vascular disease
-Peri-carditis/ Cardiac tamponade
GI:
-Gastric ulcers (NSAIDS)
Renal insuffieciency
Pre-op Considerations
General ortho repair?
Pelvic fractures?
Long bone fractures?
Ortho repair –>
-Bleed/shock
-Fat emboli
-Full stomach
Pelvic fractures –> iliac artery–>
-Retroperitoneal space bleeding
Long bone fracture –> bone marrow fat emboli into venous –> resp thrombus
Pre-op Ortho cardiac and respiratory considerations:
Cardiac:
Target HR?
Meds to consider?
Cardiac:
-Continue beta-blockers
-Initiate beta blocker if high risk
-Target HR <80
Consider if taking:
-BP meds
-Opioids/NSAIDS
-Anti-coagulation
Age-related respiratory changes:
1.)
2.)
3.)
1.) Progressive decreased PaO2
2.) Increased closing volume
3.) FEV1 decrease of 10% for each decade
Benefits of regional anesthesia over general anesthesia
LESS OF:
-DVT/PE
-Blood loss
-Respiratory complications
-Death
Fat embolism Syndrome (FES)
Symptoms present in ___ hrs.
Minor symptoms??
Major symptoms??
Labs:
12-72 hours
Minor Symptoms:
-Fever >100.4F
-HR> 120
-Jaundice/ Renal changes
**DYSPNEA
**CONFUSION
**PETECHIAE
LABS
-Fat macroglobulienemia
-Anemia and thrombocytopenia
-^SED rate
–> Male : 0-22 mm/hr (normal)
–> Female: 0-29 mm/hr (normal)
Patho of fat emboli
Resp impact of fat emboli?
Neuro?
Skin?
1.) Fat emboli –> Obstruct end organ capillaries
2.) –> fat metab to FREE FATTY ACIDS
3.) –> Systemic inflammatory response
4.) -Cytokines/ inflammatory invasion
RESP:
-Pulmonary endothelial injury
-Pulmonary edema
-ARDS (<10% cases)
-Mild hypoxemia
-Bilateral alveolar infiltrates
NEURO:
-Drowsy, confused, coma
SKIN:
-Petechial rash to mouth, eyes, chest skin folds, neck, axilla
Treatment for Fat emboli:
How long until symptoms resolve?
Heparin IV
NO N2O
FiO2= 100%
Aggressive resp/circulatory resuscitation. Decrease stress response
Resolves in 3-7 days
Fat emboli common in ____ surgeries? (2)
What do fractures release?
Pelvic fractures
Femoral fractures
Long bone trauma –> release fat droplets into venous system
Fracture: release mediators affecting solubility of lipids in circulation
DVT/ PE RISK FACTORS:
What kinds of surgery?
Length of surgery?
Immobile how long?
Size/Age?
How common?
Treatment?
40-80% without prophylaxis
Types of surgery:
HIP, TKA, Lower extremity trauma
-Surgery > 30 mins
-Immobile: >4 days
-Tourniquet use
Treatment:
-Prophylaxis/ SCD/TED/ Ambulate
-Reduce venous stasis/ augment limb blood flow
-PERI-OP anti-coagulation
For DVT, note if pt are taking these meds.
-Anti-platelet agents
-Thrombolytics
-Fonaparinux
-Direct thrombin inhibitors
-Therapeutic LMWH
Thromboprophylaxis for DVT:
LMWH initiation:
LMWH: 1x/day
LMWH: 2x/day
Warfarin
LMWH initiation: IV/SQ heparin 12 hrs pre-op OR 12 hrs post-op
LMWH: 1x/day
–> Neuraxial ok to do 10-12hrs after previous dose
–> Delay next dose 4 hrs
LMWH: 2x/day
–> Neuraxial catheter NOT OK
–>Remove 2hrs+ before 1st dose
Warfarin:
-Neuaxial anesthetic OK if INR </= 1.5
Effects of neuraxial anesthetic?
Blood flow:
Inflammation:
Platelet:
*Increased lower extremity venous blood flow d/t sympathectomy
*Systemic anti-inflammatory properties of local anesthetics
*Decreased platelet reactivity
- Tranexamic Acid (TXA)
Dose? MAX DOSE?
When to admin?
Frequently used in ____ & ____?
Benefits?
Cons:
DOSE IV: 10, 15, 30 mg/kg
(MAX 2.5g);
-All routes effective (oral/IV/Topical)
- Admin before incision
- Frequently used in TKA and THA
Decreased blood transfusion needed
CONS
* Risk of VTE? MI/ CVA/TIA?
* Many post-op CV complication related anemia and blood transfusion
Single vs repeated dose?
Tourniquet (Pneumatic)
Benefits ?
-When does tourniquet pain begin after ___ mins?
-What to do about Pain?
-Symptoms of the pain?
-Max time to inflate?
- Decrease intraop EBL
- Provides bloodless field
*Tourniquet Pain begins after 45 mins: Regional Anesthesia supplement
–> Pain: ^HR/^BP/diaphoresis related to regression of neuaxial block. Unmyelinated C fibers firing
MAX time: 3 hrs/180 mins
–>Generally not to exceed 2 hrs bc of Nerve damage
–> deflate 20-30 mins to allow for reperfusion
Tourniquent (Pneumatic) Inflation
How do you apply it?
How much pressure do you inflate?
*Apply over smooth padding
*Exsanguination with Esmarch®
–> Increase blood volume into central circulation
Thighs: ~100 mmHg >SBP
(~300 mmHg)
Arms: ~50 mmHg >SBP
(~250 mmHg)
How to use double tourniquet?
-Inflate proximal
-Deflate distal
Negative effects after deflating pneumatic tourniquet:
BP?
HR?
CVP?
Temp?
Minute ventilation?
Pain?
Acid/base?
K+?
CO2?
BP? Hypotension
HR? Increase
CVP? Decrease
Temp? Decrease
Minute ventilation? Increase
Pain? Relieved
Acid/base?
K+?
CO2?
* Metabolic acidosis
* Hyperkalemia
* Hypercarbia
* Transient lactic acidosis
* Transient hypercarbia..
ABCD’s of TRAUMA ANESTHESIA
MILS Manual In-Line Stabilization
Need 3 CRNAs
1 head, 1 shoulder, 1 intubate
DO NOT EXTEND NECK IN TRAUMA
-NO jaw thrust
-NO chin lift
-NO head tilt
OK:
-Cricoid pressure/ Sellick Maneuver
-Apneic ventilation (boyle’s law)
-Modified RSI (Ketamine/etom/ succ/roc)
Direct laryngoscopy after 3 attempts –> Combitube or LMA
