Test 2 Ortho Flashcards
what is the leading cause of lower extremity disability among older adults in the US
osteoarthritis
what is the most common form of arthritis
osteoarthritis
_________________ is a degeneration of articular cartilage characterized by inflammation and pain with joint motion
osteoarthritis
what is the most common way that OA is defined
radiographically via the kellgren lawrence grading severity >/= 2
risk factors of OA
- age
- female
- obesity
- repetitive joint use
primary features of OA
pain, stiffness, and potentially decreased ROM in the absence of systemic features (fever)
anesthesia considerations with OA, RA, and ankylosing spondylitis
- difficult airway - video laryngoscope, C-spine neutral, awake fiberoptic intubation
- positioning concerns
- regional anesthesia: evaluate preoperative neuropathy
management of OA
- weight loss
- exercise
- physiotherapy
- bracing in certain cases
- tylenol and NSAIDs
- opioids
- local injections: LA +/- steroids
- viscosupplemntation
- arthroplasty surgery
why are pneumatic tourniquets used in orthopedic surgery?
- controls blood loss during extremity surgery
- maintain relatively bloodless field
- minimize intraoperative blood loss 4. aid identification of vital structures 5. expedites procedure
if a pneumatic tourniquet is going to be used for ortho extremity surgery, when should it be applied?
after induction of anesthesia
pneumatic tourniquets maximum time of ___________ hours is considered safe.
2
if a surgery needs a pneumatic tourniquet for > 2 hours, what should you do?
deflate for 15-20 minutes, then reinflate
why is the pneumatic tourniquet only allowed to be used for a max of 2 hours without interruption?
after two hours the interruption of blood supply –> tissue hypoxia and acidosis
when a pneumatic tourniquet is applied to the patient, you should document ____________, _________, and ________________
time of inflation; time of deflation; 60 min interval communication with the surgeon
pressure of the pneumatic tourniquet is dependent on ____________, __________/____________
Blood pressure; shape/size of extremity
when you deflate a pneumatic tourniquet it releases _________________ into systemic circulation
metabolic wastes
s/e of deflation of pneumatic tourniquet
- transient cardiopulmonary changes: HoTN, hypoxemia
- metabolic acidosis
- hyperkalemia
- myoglobinemia
- renal failure
____________ minutes after pressurization of pneumatic tourniquet, pts will start complaining of dull aching pain which progress to burning and excruciating pain that may require ________________
~45-60; general anesthesia
if a patient complains of dull, aching pain with pneumatic tourniquet, this is through _______________ fibers
unmyelinated C
if a pt complains of burning, tingling pain with pneumatic tourniquet, this is through _________ fibers
myelinated A-delta
T/F: tourniquet pain is often resistant to analgesic and anesthetic agents
true; need multimodal including regional anesthesia
what population of orthopedic surgery patients receive thromboprophylaxis ?
- total hip arthroplasty
- total knee arthroplasty
why would an orthopedic surgery need thromboprophylaxis
due to total hip and total knee arthroplasty having increased risk for VTE including DVT and PE
what is the most common agent used for VTE prophylaxis in certain orthopedic surgeries
low molecular weight heparin (lovenox)
what are the different thromboprophylactic techniques that can be used for certain ortho surgeries
- lovenox
- adjusted dose vitamin K antagonist 3. asprin
- intermittent compression device 10-14 days prior
T/F: hip/pelvic fracture patients will get low molecular weight heparin
FALSE
bone cementing is typically associated with what surgeries?
- total hip arthroplasty
- total knee arthroplasty
- vertebroplasty
what is the “cement” used in certain ortho procedures?
methyl methacrylate (MMA)
clinical features of bone cement implantation syndrome
- hypoxia
- hypotension
- arrhythmias
- CV collapse
- unexpected loss of consciousness under anesthesia
how do you manage bone cement implantation syndrome
- communication between surgical and anesthesia team
- optimize hemodynamic status (prior to cementing)
- 100% FiO2
- rapid fluid administration
- vasopressors
pts with one long bone fracture have approximately a _______ % chance of a fat emboli, but it goes up to _________% with bilateral long bone fracture
3; 33
massive fat emboli can produce _____________ and ______________
macrovascular obstruction; shock
fat cells produce _____________ reactions –> __________ and _________ lodging in the pulmonary arterial circulation
proinflammatory/prothorombic; platelet aggregation; fibrin generation
fat embolic syndrome is typically seen _______-_________ hours after injury
24-72
s/sx of fat embolism
- hypoxemia
- neurologic impairment
- classic petechial rash
fat embolic syndrome management
- ET intubation and mechanical ventilation
- some evidence of benefit from steroids IV
- surgical correction and stabilization of the long bone fracture ASAP
choice of local anesthetic depends on ?
- type of peripheral nerve block
- purpose (anesthesia vs postop pain) 3. duration of anesthesia required for surgery
additives to prolong regional blockade includes:
- epinephrine
- clonidine
- dexmethasone
- opioids
what are the different types of local anesthetics that can be used in a regional block
- lidocaine
- ropivicaine
- bupivicane
- liposomal bupiviciane
what are the different type of upper extremity peripheral nerve blocks?
- interscalene
- supraclavicular
- intraclavicular
- axillary
which PNB is the best for shoulder surgery?
interscalene
which PNB is the best for shoulder and upper arm surgeries
interscalane
with an interscalene block, you may miss which nerve?
ulnar
which PNB is the best for surgeries of the upper arm distal to the shoulder
supraclavicular
what are the risks with a supraclavicular block
pneumothorax
what type of block is best for a surgery at the elbow and below
infraclavicular
which PNB is best for surgeries distal to the elbow?
axillary
what are the risks with an axillary PNB
- risk of vascular injection
- may miss the musculocutaneous nerve
pros of regional anesthesia for orthopedic surgery
- may reduce risk of DVT, PE, and blood loss
- provides adequate perioperative pain management
- may reduce chronic pain issues and opioid use disorders
what is the disadvantage of doing regional anesthesia in ortho
time consuming because has to be done under ultrasound guidance
____________________ is a minimally invasive surgical procedure that is used to examine/dx and/or repair an interior joint
arthroscopy
arthroscopic surgeries are done on which joints
- hip
- knee
- shoulder
- wrist
- ankle
- foot
goals for arthroscopic surgery
- reduce blood loss
- reduce post op pain
- reduce length of rehab
__________________ is a surgical replacement of all or part of a joint to restore the natural motion and function of the joint
arthroplasty
what joints is an arthroplasty performed on?
- hip
- knee
- ankle
- shoulder
what are the goals of arthroplasty
- pain relief
- stability of joint motion
- deformity correction
anesthetic technique for athroscopy?
general, regional, combined GA/RA, or local MAC
what is the anesthetic technique use for a hip arthroplasty?
general, regional, or combo
what is the anesthetic technique used in knee arthroplasty
general, regional, or combo
what is the anesthetic technique used with ankle arthroplasty
general regional or combo (neuraxial = subarach block or epidural; SAB with PNB; or just PNB)
what anesthetic technique would be used for shoulder arthroplasty
general, regional, or combo (interscalene PNB +/- superficial cervical)
what position would a patient be in a for a lower extremity joint arthroscopy
supine
what position would a patient be in for a hip arthroscopy
lateral decubitus or supine
what position would a patient be in for a shoulder arthroscopy
lateral decubitus or modified fowler (beach chair)
what position would a patient be in for a hip arthroplasty
- lateral decubitus (posterior approach)
- supine (anterior approach)
what position would the patient be in for a knee arthroplasty
supine
what position would the patient be in for an ankle arthroplasty
supine
what position would the patient be in for a shoulder arthroplasty
- lateral decubitus
- modified fowler (beach chair)
which arthroplasty surgeries are pneumatic tourniquets used
knee and ankle
how much blood loss is typically seen with a knee or hip arthroplasty
~ 1 L
how much blood loss is typically seen with a shoulder arthroplasty
~ 500 mL
which arthroplasty surgeries is there a risk for bone cement implantation syndrome?
hip, knee, ankle, shoulder
which arthroplastic surgeries will thrombophylaxis of TXA 1-2 g be used?
hip, knee, shoulder
arthroscopic surgeries require irrigation of fluid under pressure for visualization, this can be absorbed causing what adverse effects?
- fluid overload
- CHF
- pulmonary edema
- hyponatremia
- hypothermia
what is TXA?
synthetic plasminogen activator that helps decrease blood loss through the inhibition of fibrinolysis and clot degradation
how is TXA use in orthopedic surgery/trauma
- decreases perioperative blood loss and transfusion requirements
- 1-2 g administered perioperatively
OA hx and physical
- Routine ROS
- what joints are involved? (C spine? any motor deficits? chronic pain?)
- evaluate functional capacity
- no specific diagnostic testing
ortho traumas are associated with significant ____________________.
hemorrhage
hemorrhage from ortho traumas are associated with what adverse events?
- shock
- fat emboli
- thromboembolic respiratory failure
what are the most common causes of ortho trauma
- Falls (43%) 2. MVC (26%)
with trauma, there is a high energy response, which should make providers highly suspicious of ___________________________
compartment syndrome
what is the ideal time to repair an open fracture?
within 12 hours of injury
if a trauma is taken for emergency surgery, they are considered _____________________; thus, __________________ is essential
to have full stomach; GI prophylaxis
open pelvic fractures have a mortality rate of _______%
70
which ortho fracture is affiliated with massive hemorrhage, and 1-2 g of TXA will be given perioperatively
pelvic
what is the CRNAs role during a pelvic fracture repair surgery
- focus on the hemodynamics, and end-organ perfusion
- replace blood loss using damage control resuscitation
when are minimally invasive techniques used in spinal surgery?
for non-complex spinal procedures
what are the anesthesia implications during complex spinal surgery?
- airway control and management
- fluid and blood management
- hemodynamic control
- postoperative analgesia
what are the 2 most common reasons for spinal surgery
- intervertebral disc herniation
- spinal stenosis
____________________ is the gold standard for bony decompression with spinal stenosis
laminectomy
bony spine decompression (like with spinal stenosis surgery) can lead to _____________________; therefore, ______________________ can be performed with the laminectomy
spinal instability; surgical lumbar interbody fusion (LIF)
what can surgical lumbar interbody fusions (LIF) be used in the tx of?
- spinal instability from bony spine decompression (laminectomy)
- spinal deformity
- spinal radiculopathy secondary to degenerative disc disease
what are the treatment options for degenerative disc disease
- lumbar interbody fusion
- disc replacement (younger patients)
laminectomy is done via __________________ approach
posterior
disc replacement is done via __________________ approach; and a may need assistance from ___________________ surgeons
anterior; general/vascular
during a disc replacement surgery, a ________________ type ETT may be used
double lumen
in an anterior-posterior approach to the thoracolumbar spine, what are the anesthesia considerations?
- GETA = safest
- consider evoked potential neurologic monitoring
- postop analgesia
- postitioning = major concern
- myelopathic, C-spine unstable, limited ROM –> intubate with video, FOB, or awake
- double lumen ETT and pt must be able to tolerate 1 lung anesthesia
- there is significant blood loss: IV access, HD monitoring, blood administration, blood conservation strategies
what are blood conservation strategies that can be used during thoracolumbar spine surgeries?
- predonation of autologous blood
- surgical site infiltation with epinephrine
- hypotensive anesthesia technique
- cell saver
- antifibrinolytics (TXA 1-2 g periop)
what is scoliosis
a lateral curvature of the lumbar spine > 10 degrees
what are the causes of scoliosis
- 80% = idiopathic
- cognential skeletal abnormalities
- neuromuscular dz
- neurofibromatosis
- spinal tumor –> spinal cord compression
surgical intervention of scoliosis
fusion of multiple joint spaces with or without anterior release
what are the different approaches that can be taken for scoliosis surgery
anterior, posterior, combination
if anterior approach for spinal surgery is taken, the patient must be able to handle _____________________________
one lung ventilation
CRNA role during scoliosis surgery
- hemodynamic control: IV access, ABP, blood products, HoTN technique 2. periop multimodal pain
SSEPs are monitored with what type of surgery?
- neurosurgical procedures (cerebral aneurysm and spine)
- aortic cross clamping 3. CEA with shunting
anesthetic technique with SSEPs
- narcotic only
- TIVA
- 1/2 MAC
can you use NMBA while monitoring SSEPs
yes
______________ potentiates the depressant effects of SSEPs
N2O
most anesthetic agents will increase latency or decrease amplitude of SSEPs except
- ketamine
- etomidate
- opioids
when would MEP monitoring be indicated?
either spine or intracranial surgery where the motor cortex or descending motor pathways are at risk
anesthetic technique of MEP monitoring
- narcotic base
- TIVA
- 1/2 MAC
- NMBA are CONTRAINDICATED
____________ potentiates depressant effects of MEPs and _____________ & ____________ increase cortical amplitudes and enhance MEPs
N2O; ketamine; etomidate
when would you monitor EMGs
- analysis of facial nerve during parotid gland surgery
- recurrent laryngeal nerve during head and neck surgery
- NIMS tube for ACDF surgery
anesthetic technique when monitoring EMG
unrestricted, but NMBA are contraindicated
what section of the spinal cord is most frequently injured?
Cervical region (specifically the craniocervical jx)
what is the most common C-spine vertebrae injured
C7
at what cervical level injury will respirations cease?
above the level of C3
airway management implications with C-spine injury
- avoid succ if have SCI
- technique dependent on the level of injury, level of cooperation, hemodynamic stability, and ability to protect the airway
- manual inline stabilization recommended
what is autonomic hyperreflexia/dysreflexia
sudden activation of sympathetic response as a result of noxious stimuli (colorectal or bladder distension)
autonomic dysreflexia will often present with _____________________
severe HTN
autonomic dysreflexia typically occurs in patients with SCI above ___________, and persists __________ to ______ post SCI
T6; weeks; months
how do you manage autonomic dysreflexia
- determine and correct the noxious stimuli
- reduce dangerous BP levels
why is succinylcholine not recommended in patients with SCI
- fasiculations can exacerbate SCI
- can precipitate sudden cardiac arrest secondary to massive muscle injury
so how should you intubate your patient with SCI without using succ?
- non-relaxant airway control techniques
- depolarizing NMBA - roc
acute SCI outcomes are dependent on what 3 factors?
- severity of acute injury
- prevention of exacerbation of injury during rescute, transport, and hospitalization
- avoidance of hypoxia and HoTN
there are about 10,000 spinal cord injuries at year, with 80% being __________ gender, with a median age of _____________
male; 25
what is the most common type of SCI?
incomplete tetraplegia
what precautions should be taken in any patient who comes in as a trauma to the head/face or c/o of pain in neck with or without palpitation or unconsicous?
- neutral C-spine; C-collar
- spinal backboard with movement
anesthesia approach to SCI
- early stabilization will improve outcomes
- maintain MAP ~ 90 mmHg for at least 7 days post injury
- document neurostatus before: induction of anesthesia, intubation, and positioning.
- consider awake intubation
- induction propofol vs ketamine or combo
- avoid N2O
- TXA administration
what are the considerations with propofol for induction in spinal cord injury patients/TBI
decreases cerebral blood flow (CMRO2); decreases CBF and ICP
which induction drug is preferred in the hemodynamically stable TBI patient
propofol
what are the considerations with ketamine as the induction agent for a pt with SCI/TBI
increases ICP, but avoids hypotension in hypovolemic trauma
SX of spinal shock
- Hotn 2. bradycardia 3. hypothermia
sx of spinal shock progress/intensify more _______________ from _________ vertebral level
cephalad; T6
__________________ is critical in the patient with spinal shock for resuscitation
invasive monitoring
what is the most common foot and ankle surgery
ankle fracture/joint fusion
T/F: ortho surgeries on the extremities do not use pneumatic tourniquets
false - they do use them
anesthetic technique in ortho extremity surgery
GA, regional, or combo
