Test 2: Orthopedics (pt 1/4) Flashcards
How do you prevent surgical site infections with orthopedic surgery?
Preoperative antibiotics within 1 hr of incision
What is the preferred antibiotic and dose to prevent SSIs?
Cefazolin (Ancef) 1-2 g IVPB (2g if >100 kg)
What are the normal preop lab tests done for orthopedics?
-Baseline CBC
-Type and Crossmatch (or T&S)
-BMP
-Urinanalysis (Arthroplasty - to detect presence of infection prior to surgery)
Degeneration of the articular cartilage characterized by inflammation and pain with joint motion
Osteoarthritis (OA)
What is the most common form of arthritis?
OA
____% of US adults have Arthritis, and ___% of those >65 years have it as well.
21%; 50%
What is the leading cause of lower extremity disability?
OA, given its predilection for lower extremity joints such as the knee and hip
How do you define OA via radiological criteria?
The Kellgren-Lawrence (KL) grading system.
Definite OA is a KL Grade of 2 or higher.
Graded on a scale of 0-4.
How do you characterize pathologic OA?
-Cartilage loss
-osteophytes
-subchondral bone marrow lesions and bone attrition
-meniscal lesions (in knees)
-synovitis
-effusion
Pain on weight-bearing activity at the early stages, with progression to more persistent pain punctuated by intermittent increases in pain that may or may not be predictable at later stages, as well as substantial functional limitations and disability.
Osteoarthritis
What are some risk factors for OA?
-Increased age
-Female sex
-Obesity
-Repetitive joint use
What are the primary symptoms of OA?
-Pain
-Stiffness
-Decreased ROM in the absence of systemic features such as fever (!!)
-Bone enlargement, particularly of the hand joints
-Intermittent swelling
-Crepitus
Which joints are most commonly involved in OA?
-Knees
-Hips
-First carpometacarpal or distal interphalangeal joints
How do you define symptomatic OA?
The presence of radiographic features of OA (KL or 2+)
AND
Knee symptoms attributable to OA
What is generalized OA?
Several joint areas are involved, such as the hand (e.g., distal interphalangeal, proximal interphalangeal, or first carpometacarpal joints), knee, and/or hip.
What is normally the primary reason people with OA seek medical care?
Pain
What is the management of OA?
-Weight loss, exercise, physiotherapy, bracing in certain instances, acetaminophen, non-steroidal anti-inflammatory drugs, opioids, and local injections (LA +/- corticosteroids) are the mainstays of treatment.
-Viscosupplementation (hyaluronic acid)
-Joint replacement is typically performed as a last option in late stages, with outcomes being better for hip than for knee replacement. (Arthroplasty)
What is the preop eval specific for OA?
-C spine involved? think airway
-Document any existing sensory/motor deficits
-If NSAIDs, consider BMP
-If taking herbal supplements, consider coags
-Is functional capacity limited by joint pain, or by heart/breathing?
An autoimmune-mediated, systemic inflammatory disease.
Rheumatoid Arthritis (RA)
Who is more commonly affected by RA, males or females?
Females are affected three times more commonly than males
What are the symptoms of RA?
-Morning stiffness that improves over the course of the day
-Painful synovial inflammation, swelling, and increased synovial fluid
-Progression to destruction of cartilage, periarticular osteopenia with pull-off of ligamentous insertions, leading to deformities and instability
-All organ systems can be involved
-Associated with other autoimmune diseases
What is the immune system pathology behind RA?
Activated endothelial cells stimulate T cells and B lymphocytes. B lymphocytes produce autoantibodies (rheumatoid factor) that enhance cytokine production. Cytokines (TNF, interleukin1, interleukin6) are released and accelerate the inflammatory cascade
A category of drugs used to slow down disease progression in RA.
-Target T and B cells
-Methotrexate is DOC
-Potential increased susceptibility to infection and cancer
Disease Modifying Antirheumatic Drugs (DMARDs)
Treatment modalities for RA may increase the risk for ____, and may require _________________.
Surgical infection; stress dose steroids
What are the adverse effects and preop mgmt associated with NSAIDs?
-Coag, GI, & renal dysfunction
-D/C 2 days before surgery
What are the adverse effects and preop mgmt associated with Methotrexate
-Pancytopenia, GI, abnormal LFTs
-Check CBC & LFTs. If abnormal, d/c prior to surgery
What are the adverse effects and preop mgmt associated with Corticosteroids?
-Impaired healing, glucose intolerance, infection risk, and adrenal suppression
-Continue; consider stress dose steroids
What are the adverse effects and preop mgmt associated with Leflunomide?
-Hepatotoxicity, HTN, pancytopenia
-Check CBC-P & LFTs; if abnormal, d/c prior to surgery
What are the adverse effects and preop mgmt associated with A-TNF agents (Etanercept)?
-Infection, malignancy
-Eval for risk of infection, severity of patient’s dz
What are the adverse effects and preop mgmt associated with IL-1 antagonists (Anakinra)?
-Skin irritation, risk of infection
-Eval for risk of infection, severity of patient’s dz
Drugs used to treat RA that either bind directly to TNF-alpha, or have decoy circulation receptor fusion proteins that bind to TNF-alpha with a greater affinity than the TNF-receptor.
TNF inhibitors (monoclonal antibodies)
What % of RA patients have asymptomatic C-spine instability?
50-80% are asymptomatic (!!)
Explain the pathology & implications behind C-Spine instability in RA patients?
-Commonly atlanto-axial, but can be subaxial
-More common in seropositive and early-onset RA, poorer functional status and severe peripheral joint disease
-Muscle tone is supportive in nonanesthetized patients, but when they’re anesthetized, stability goes away.
In RA, settling of occiput onto C1 with cephalad movement of odontoid into foramen magnum causes:
-HA
-Difficulty swallowing
-Cranial Nerve palsies
Late-stage RA disease, with fusion of the entire cervical spine, loss of mobility, and risk of fractures with osteopenic bone.
Ankylosis
What are other manifestations of RA that cause airway difficulty?
-Temporomandibular joint disease and limited mouth opening
-Arytenoid disease with deformity obstructing the glottic opening
-Sjögren’s is common, and chronic dry mouth leads to poor dentition
True/False: Degree of cord compression may not correlate with patient’s symptoms
True (!!)
What is the main difference between OA and RA?
No systemic manifestations with OA.
What are systemic symptoms associated with RA?
-fever
-weight loss
-fatigue
-myalgias
-decreased appetite because of the systemic inflammation
-secondary Sjögren’s syndrome (dry eyes and dry mouth)
A chronic progressive disease of the joints of the spine and thorax.
-Starts in early adulthood with inflammation of the sacroiliac joints and progresses cephalad to involve the entire spinal column and ribcage.
-Familial; associated with psoriasis, reactive arthropathy, and inflammatory bowel disease.
Ankylosing spondylitis
What are the symptoms of Ankylosing Spondylitis?
-Lower back pain with morning stiffness (Sacroiliac involvement causes referred pain to the buttocks)
-Progression with fibrosis and ossification of ligaments, leads to fusion and immobility of joints (risk of positioning injury and difficult intubation concerns)
-Risk for spinal fx with falls or careless moving
-Bamboo Spine on X-Ray
What are you most worried about when assessing pre-op Ankylosis Spondylitis patient?
-Degree of cervical and thoracic spine involvement
AS most commonly effects which vertebrae?
Most commonly effects C5-C7 (!!). Have airway plan A,B,C, etc
-Fixation of thoracic cage can lead to pulmonary dysfunction
What are eye implications involved with Ankylosing Spondylitis?
Eyes (40%):
-Uveitis/conjunctivitis (pain, visual disturbance, and photophovia)
-Usually unilateral
-Tx topical steroids
What are the cardiac implications involved with Ankylosing Spondylitis?
-Aortic Valve Insufficiency (40%)
-thoracic aortic involvement
-RBBB
What are the pulmonary implications involved with Ankylosing Spondylitis?
Restrictive physiology:
-dec compliance due to thoracic joint involvment
-dec TLC & VC
-Normal to increased Residual Volume and FRC
-Hoarseness from cricoarytenoid joint dz (rare)
What are systemic implications with AS?
-Malaise
-Fever
-Unintended weight loss
What are the MSK implications involved with Ankylosing Spondylitis?
-Hip involvement (33%)
-Inflammation of the extra-axial tendons and ligaments (40%)
-Peripheral arthritis
-Painful swelling of the fingers & toes
What is the treatment for Ankylosing Spondylitis?
-Stretching, exercise, PT
-NSAIDs and DMARDs (specificially infliximab (remicade) and etanercept (Enbrel) ).
What are the anesthesia implications r/t airway in patients with OA, RA, or AS?
-Careful airway exam, including eval of the C-Spine
-Assess for clicking/locking of jaw
-Hoarseness, difficulty swallowing, or hx of difficult intubation
-Increased incidence of difficult intubation:
-Video Laryngoscope, C-spine neutral, awake FOB
-Risk of neurologic deficit and postop obstruction
What is found in 90% of patients with RA that can lead to postop airway obstruction?
Involvement of the cricoarytenoid, cricothyroid, temporomandibular joint, and associated structures in the larynx.
Why does AS cause difficulty with patient positioning and intubation?
Limited C-Spine mobility and thoracic kyphosis
What is important to know regarding regional anesthesia and OA, RA, and AS?
-May be challenging to place, but not contraindicated
-May need US to place
-Document preop deficits
-May due difficult due to limited spinal flexion and ossification of ligaments. Paramedian approach may be useful.
An abnormal curvature of the spine, which if severe enough can result in rib cage abnormalities and cardiopulmonary compromise.
-Lateral curvature and anterior flexion of the thoracic and lumbar spine
-Can be normal. 80% of cases are idiopathic. Typically present in childhood (adolescence, males > females, genetic predisposition)
-Or secondary to underlying Neuromuscular disease (immobile, wheelchair bound, restrictive lung dz)
Kyphoscoliosis
Kyphoscoliosis is pathologic if anterior curvature of any region is >_____ degrees
45 degrees
A feature of normal aging with loss of intervertebral disc height, pathologic vertebral fractures, and can be found in association with scoliosis (lateral curvature)
Kyphoscoliosis
When is surgery indicated in kyphoscoliosis?
-To prevent long-term ventilatory compromise
-Restrictive lung Dz (severe risk of pulmonary HTN and CV failure)
-Cardiopulmonary sequelae
-Scoliosis curvature >40 degrees
Do conservative measures, such as PT and body braces, reduce the need for corrective surgery in kyphoscoliosis?
No
Does scoliosis alone cause sensory or motor impairment?
No, even if severe
Can induce spinal cord damage because of the sharp angulation of the spine
Kyphosis and kyphoscoliosis
What are the anesthesia implications r/t kyphoscoliosis surgery?
-Preop Cardiopulmonary optimization (remove airway irritants, tx bronchospasm, manage bronchial infection & inflammation)
-Anticipate difficult airway: A/B/C/D, etc. Video laryngoscope vs sleep/awake fiberoptic bronchospasm
How would you optimize a patient’s Cardiopulmonary status with Kyphoscoliosis preop?
-Remove airway irritants, tx bronchospasm, infection, and bronchial inflammation, and GERD
-Lung recruitment measures such as inspiratory muscle strengthening and training with IS
