Test 1: Anesthesia For Orthopedic Surgery: Osteoporosis, Osteoarthritis, and RA Flashcards
Considerations and Challenges for Orthopedic Demographics (65 years+).
- Increased comorbidities/ chronic disease processes
- IV access difficulties
- Intraoperative positioning challenge
- Prone to trauma (ie: falls)
- Acute and Chronic Pain
- Thrombus risk (sedentary life-style)
During pre-op assessment of an orthopedic geriatric patient. What can you do to assess frailty and movement?
Shake the patient’s hands.
What are the causes of osteoporosis?
- Usually age-related
- For women, post-menopausal
- ↑ PTH
- ↓ Vitamin D, GH, and Insulin-like growth factor
- Stress fractures
Where are the common places osteoporosis can occur?
- Spine: thoracic and lumbar (compression fx)
- Proximal femur and humerus
- Wrist
What are the common meds to treat and prevent osteoporosis?
- Fosamax
- Actonel
- Boniva
- Reclast
What disease process is the loss of articular cartilage that leads to inflammation?
- Osteoarthritis
What are the causes of osteoarthritis?
- Age (>65 years)
- Wear and tear on weight-bearing joints (knee, hip, neck, shoulders, etc)
What percentage of patients experience physical limitations with osteoarthritis?
- 8%
Common symptoms of Osteoarthritis?
- Pain
- Crepitance (grating sensation)
- Decrease mobility
- Joint deformity
What characteristics differentiate Osteoarthritis and Rheumatoid Arthritis?
- For Osteoarthritis patients, as the day progresses, activity level decreases d/t pain
- For Rheumatoid Arthritis, pain is alleviated throughout the day with mobility and ambulation
What are the most common medications used to alleviate patients with Osteoarthritis?
- NSAIDS
- Celebrex
- Opioids
What are the two types of joint deformities that can develop with osteoarthritis?
- Heberden’s Node: Swelling/spurring of distal interphalangeal joints
- Bouchard nodes: Swelling/spurring of proximal interphalangeal joints
What are some outpatient management of osteoarthritis to maintain activities of daily living?
- Occupational Therapy
- Weight Loss
- Acupuncture
- TENS (Transcutaneous Electrical Nerve Stimulation)
What are medication management of osteoarthritis?
- NSAIDS: Meloxicam
- COX-2 inhibitor: Celecoxib (Celebrex)
- Topical Treatment (Voltaren, NSAID: Diclofenac)
- Intra-articular therapy (steroid injection)
- Chondroprotective agents (Glucosamine)
Garlic, ginger, ginkgo, ginseng, and glucosamine can cause bleeding problems during surgery. When will a patient stop these herbal and natural supplements before surgery?
- 2 weeks before surgery
Pre-Op Evaluation for Osteoporosis and Osteoarthritis Patients.
- Joint Involvement
- Neurovascular Assessment (handshake)
- Pain Level
- Surgical positioning/ mobility ROM
- Consideration for the type of anesthetic (Regional vs. GA)
What is Rheumatoid Arthritis?
- Autoimmune and inflammatory disease causing inflammation (painful swelling) in the affected parts of the body.
- RA mainly attacks the joint synovial tissue, connective tissue
- RA can cause bone erosion, cartilage destruction, and impaired joint integrity
What areas are commonly affected by RA?
- Wrist
- Metacarpophalangeal joints
What are the symptoms of RA?
- Morning pain and stiffness that improves throughout the day
- Anorexia, fatigue, and weakness
- Subcutaneous (rheumatoid) nodules around joints, extensor surfaces, and bony prominences
What lab results correlate with rheumatoid arthritis?
- ↑ Rheumatoid factor
- ↑ Anti-immunoglobulin antibody
- ↑ C-reactive protein
- ↑ Erythrocyte sedimentation rate
What medications are used to treat patients with RA?
- Glucocorticoids
- NSAIDS
- Opioids
- Methotrexate (MTX) - anti-neoplastic
- Hydroxychloroquine - anti-malrial
- Sulfasalazine -anti-rheumatic
- Leflunomide - anti-rheumatic
- Infliximab (Remicade) - TNF inhibitor
- Etanercept (Enbrel) - TNF inhibitor
What should be considered from an anesthesia standpoint for an RA patient taking glucocorticoids who is about to undergo surgery?
- Make sure the patient receives a stress dose of steroids
Prolonged glucocorticoid use can cause HPA Axis suppression which will decrease natural cortisol release. Pts with suspected HPA Axis suppression should receive a high dose steroid in a stress state to maintain hemodyamic stablilty.
Airway considerations with RA patients
- Limited TMJ movement
- Narrow glottic opening (consider smaller ETT)
- Cricoarytenoid arthritis (consider fiberoptic laryngoscopy)
Cervical spine considerations with RA patients
- Atlantoaxial instability (C1 and C2) - can be displaced
- Neck flexion can displace the odontoid process (dens), which can cause impingement on the c-spine and medulla
- Vertebral artery compression
What are the symptoms of atlantoaxial subluxation?
- Headache
- Neck pain
- Upper/ Lower Extremity paresthesia with movement
- Bladder/ Bowel dysfunction d/t spinal cord impingement
How can you definitively evaluate the risk of atlantoaxial subluxation?
- Evaluate C-spine flexion and extension by X-ray
What are the symptoms of vertebral artery occlusion?
- N/V
- Dysphagia
- Blurred Vision
- Transient LOC
What are anesthesia concerns for the eyes with RA patients?
- Sjogren’s syndrome → dry eyes
What are pulmonary concerns with RA patients?
- Diffused interstitial fibrosis
- Restrictive ventilation patterns (Start Vt at 5 ml/kg)
What vent settings would be ideal for someone with a restrictive ventilation pattern?
- Pressure Control - Volume Guarantee
What are vascular concerns for RA patients?
- Vasculitis
- Vascular Disease
What are cardiac concerns for RA patients?
- Pericarditis
- Cardiac tamponade
What are GI concerns for RA patients?
- Gastric Ulcers (from NSAIDS use)
What are renal concerns for RA patients?
- Renal Insufficiency (most likely age-related)
