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Unit 1 Flashcards

1
Q

What is osteoporosis and what are the two biggest factors associated with development of osteoporosis?

A

Osteoporosis- decreased bone density l/t increased fracture risk
- Elderly age
- Menopause

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2
Q

What hormonal changes are characteristic of osteoporosis?

A
  • ↑ PTH
  • ↓ Vit D
  • ↓ HGH
  • ↓ Insulin-like growth factors
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3
Q

What are the four most common meds used to treat osteoporosis? What class are these drugs and what is their MOA?

A

“BARF”
Bisphosphonates “dronate drugs”
MOA: inhibit bone resorption therefore increasing bone density
- Boniva (Ibandronic Acid)
- Actonel (Risedronate)
- Reclast (Zoledronate)
- Fosamax (Alendronate)

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4
Q

Differentiate between Bouchard’s nodes and Heberden’s nodes.

A

OA can l/t interphalangeal joint involvement
- Bouchard’s = proximal interphalangeal joints
- Heberden’s = distal interphalangeal joints

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5
Q

What drug is the most common chondroprotective agent that helps protect the articular joint?

A

Glucosamine

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6
Q

What anesthetic considerations should be given to glucosamine?

A

Glucosamine needs to be stopped two weeks prior to surgery due to PLT aggregation inhibition.

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7
Q

Arthritis characterized by morning stiffness that improves throughout the day is….

A

Rheumatoid arthritis

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8
Q

Arthritis that is characterized by worsening symptoms throughout the course of the day is…

A

Osteoarthritis

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9
Q

What labs are typically elevated in a patient with rheumatoid arthritis?

A
  • ↑ Rheumatoid factor (RF)
  • ↑ Anti-immunoglobulin antibody
  • ↑ C-reactive protein (CRP)
  • ↑ Erythrocyte Sedimentation Rate (ESR)
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10
Q

What common dose of stress dose glucocorticoid is used for RA patients?

A

50-100 mg hydrocortisone (Solu-cortef)

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11
Q

What two TNFα inhibitors are commonly used to treat RA?

A
  • Infliximab
  • Etanercept
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12
Q

Which drugs treat RA? (6)

A

DMARDs
- Methotrexate
- Hydroxychloroquine
- Sulfasalazine
- Leflunomide
DMARDs also TNF alpha inh
-Infliximab
-etanercept

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13
Q

What airway concerns should be considered with RA patients?

A
  • Limited TMJ movement
  • Narrowed glottic opening
  • Cricoarytenoid arthritis
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14
Q

Where is the most instability typically located in the cervical spine of RA patients?

A

Atlantoaxial Junction

(be careful not to displace the odontoid process and impinge on the c-spine or vertebral arteries)

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15
Q

What are the signs and symptoms of atlantoaxial subluxation?

A
  • Recurrent Occipital Headache
  • Neck pain/limited neck ROM
  • Extremity paresthesias (especially with movement) d/t cord compression
  • Bowel/bladder dysfunction
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16
Q

What are the signs/symptoms of vertebral artery occlusion?

A
  • N/V
  • Dysphagia
  • Blurred Vision
  • Transient LOC changes
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17
Q

What ocular syndrome is typical of RA patients? What anesthesia considerations must be taken prior to surgery?

A

Sjogren’s syndrome
-Keratoconjunctivitis sicca: drying of eyes d/t decreased lacrimal secretions
-xerostomia: dry mouth secondary to decreased salivary production
*protect and lubricate eyes.

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18
Q

What pulmonary issues are associated with RA?

A
  • Interstitial fibrosis
  • Restricted ventilation
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19
Q

What type of ventilatory settings would be utilized for an RA patient exhibiting a restrictive ventilatory pattern?

A

Pressure Control @ 5mL/kg

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20
Q

What are some bleeding concerns with pelvic injury? What artery is typically injured due to pelvic fractures? Where is the bleeding located in this instance?

A

-Pelvic injury: bleed may tamponade temporarily due to being in closed cavity
hemorrhage can occur when opening cavity
-Iliac artery → retroperitoneal space bleeding

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21
Q

What is the typical worst complication of long bone fractures? Why?

A

Bone marrow fat embolism d/t high concentration of bone marrow fat in long bones.

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22
Q

What technique is used for intubation of a patient who has c-spine concerns?

A

Manual In-Line Stabilization (MILS)
-3 providers stabilize and align head in neutral position w/o cephalad traction
-Stabilize shoulders
-cricoid pressure
Intubate

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23
Q

Describe the airway implications of MILS technique

A

MILS will likely decrease visibility of larynx (cannot use airway maneuvers: jaw thrust, chin lift, head tilt d/t cervical spine movement associated with those techniques)

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24
Q

What is the mechanism of action of warfarin?

A

Warfarin inhibits Vitamin K epoxide reductase and limits the availability of Vitamin K throughout the body

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25
What is the mechanism of action of LMWH?
LMWH binds to antithrombin -Antithrombin is active when bound Factor Xa inhibition - prevents conversion of prothrombin into thrombin (reducing fibrin clot formation)
26
What are some typical triggers for delirium?
- Hypoxemia - Hypotension - Hypercarbia - Hypervolemia - Sleep Deprivation - Circadian Rhythm disruption - Infection - Electrolyte abnormalities - Pain - Benzos (avoid in elderly/okay in ETOH) - Anticholinergics
27
FEV₁ decreases by ___% for each decade of life.
10%
28
What occurs with closing volume as we age?
Closing volume **increases**. -lung volume at which airway closure begins to occur
29
What are patient specific benefits of regional anesthesia compared to general anesthesia?
Improved pain management Preemptive analgesia -if blocked preop can prevent progression to chronic pain syndrome May increase participation in rehab/PT/OT
30
With placement of what device is fat embolism syndrome most likely to occur? What is the incidence and mortality of FES with this procedure?
Femoral Medullary Canal Rod -incidence: <1% -Mortality: 10-20%
31
What is the s/s Triad of fat embolism syndrome? When do s/s typically present?
1. Confusion 2. Petechiae 3. Dyspnea Typically presents in 12 - 72 hrs but can be immediate
32
What lab findings are noted with fat embolism syndrome? What are the limitations of relying on these labs for diagnosis?
FAT-E - **F**at macroglobulinemia - **A**nemia - **T**hrombocytopenia - ↑ **E**SR **These labs won't be elevated/present at time of insult as onset is 12-72 hours**
33
What is ESR? What are normal values for males and females?
- Erythrocyte Sedimentation Rate - Male: 0 - 22 mm/hr - Female: 0 - 29 mm/hr
34
What minor s/s can be construed to characterize fat embolization syndrome?
- Fever (>100.4) - ↑HR (>120 bpm) - Jaundice - Renal Changes
35
What are the anesthetic management techniques for fat embolization syndrome? How long does it usually take for symptoms to resolve?
Supportive Therapy - 100% FiO₂ - **No N₂O** - IV Heparin - Aggressive and early CV & Resp resuscitation -minimize stress response r/t hypoxia, HoTN, decreased end-organ perfusion **symptoms resolve in 3-7 days**
36
What factors contribute to the development of DVT's?
- **Lack of Prophylaxis occurs 40-80%** - Obesity - > 60yrs old - > 30min procedure - Tourniquet use - > 4 days immobilization - > Lower extremity fracture
37
Which three surgery types present the greatest risk for DVT formation?
- Hip surgery - TKA - Lower extremity trauma
38
When does LMWH need to be initiated?
12 hours preop or 12 hours postop
39
Can neuraxial anesthesia be done after LMWH has been given?
Yes, if **Once daily dosing, 10 - 12 hours** after the dose. *Delay next dose 4 hours*.
40
Can an epidural be placed in a patient on twice daily LMWH anticoagulation therapy?
No. No indwelling catheters
41
Neuraxial catheters must be removed ___ hours before the intiation of LMWH therapy.
2 hours or more
42
Can a patient have neuraxial anesthesia if on warfarin?
Only if the **INR is ≤ 1.5**
43
Flip card for Anticoagulation guidelines for Neuraxial procedures.
44
Flip card for additional Anticoagulation guidelines for Neuraxial procedures.
45
What physiologic responses make neuraxial anesthesia superior to general anesthesia in regards to DVT prophylaxis?
- ↑ extremity venous blood flow (sympathectomy/vasodilation). - LA systemic anti-inflammatory properties. - ↓ PLT reactivity
46
What is the maximum dose of TXA? (Tranexamic Acid)
2.5 g
47
What is typical dosing of TXA?
10 - 30 mg/kg **1000mg is typical**
48
Tourniquet pain typically begins ___ minutes after application.
45 min
49
The width of a tourniquet must be greater than ____ its diameter.
½
50
How long can tourniquets be placed on an extremity?
- 2 hours is typically not exceeded - **3 hours is max**.
51
What mmHg is typically used for thigh tourniquets?
300 mmHg (or 100 mmHg > SBP)
52
What mmHg is typically used for arm tourniquets?
250 mmHg (or 50 mmHg > SBP)
53
When utilizing a double tourniquet, in order to help with tourniquet pain it is important to remember to...
inflate proximal → deflate distal
54
What occurs with tourniquet deflation?
- Transient lactic acidosis - Transient Hypercarbia (thus V̇T) - ↑ HR - ↓ pain - ↓ CVP, BP, & temp
55
Describe the disease process of Osteoarthritis?
OA is an inflammation of the cartilage of bone. OA usually l/t a loss of articular cartilage which l/t inflammation (bone on bone)
56
Symptoms of OA include?
Pain Crepitance (grating sound caused by friction) Decreased mobility Joint deformity
57
Which medications are commonly used for OA?
NSAIDs Meloxicam, Voltaren (topical can still l/t GI issues if overused) COX 2 Inh. Celebrex Opioids Intra-articular tx (steroid injection) Chondroprotective agents: glucosamine (d/c 1-2 wks prior to sx)
58
Describe the disease process of RA?
RA is a chronic and systemic inflammatory dz. Joint **synovial tissue/connective tissue** inflammation Progression of dz l/t bone erosion, cartilage destruction, impaired joint integrity
59
What joints are involved in RA?
Most joints of the body -Wrists and metacarpophalangeal joints -Cervical spine (C1/C2 are synovial joints) **thoracic and lumbar spine are fibrocartilagenous joints and are not affected by RA**
60
What are some important assessments that should be conducted prior to surgery in a pt with RA?
Voice assessment: if hoarse may indicate narrow glottic opening. -RA l/t cricoarytenoid arthritis presents with hoarseness, dyspnea, and stridor with larynx tenderness Mouth opening: may be limited d/t synovitis of TMJ Neck mobility: Atlantoaxial subluxation (neck mobility assessment will ID extent of RA related C spine involvement
61
When is Atlantoaxial subluxation suspected? Besides physical assessment how may the extent of Atlantoxial subluxation be assessed?
Long-standing seropositive RA with extra-articular manifestations. Intervention: Xrays with neck extended and flexed to assess extent
62
What are some additional anesthesia concerns for the pt with RA?
Vasculitis/vascular disease Pericarditis w/ severe long-standing RA Cardiac tamponade Accelerated atherosclerosis GI ulcers (NSAIDs) Renal insufficiency
63
What are some considerations for patients with orthopedic injuries/trauma?
Considered full stomach (RSI) Associated with hemorrhage, shock, fat emboli
64
Ortho patients may be on ACE Inhibitors or ARBs, and therefore unresponsive to vasopressors. In this instance, what medication may be effective to increase blood pressure?
Vasopressin works due to V1 and V2 receptors which act independently of the Renin Angiotensin Aldosterone System V1a receptors: on vascular smooth muscle, counteracts vasodilation by increasing intracellular Ca²⁺ V2 receptors: in the kidney, promotes water reabsorption by increasing aquaporin-2 (AQP2) channels in the collecting ducts | Additional V1 and V2 receptor info from Clinical not in lecture
65
What are the ABCD's of trauma anesthesia?
RSI -MILS -Preoxygenate with 100%, 10-15 L/min for minimum of 3 mins -Cricoid BURP (Sellick Maneuver 10 lbs or 20 Newtons) until ETCO2 and bilateral lung sounds confirm -Induction with Ketamine or Etomidate & Sch or Roc -Apneic Ventilation vs Modified RSI (1 breath after paralysis) -DL 3 attempts max, combitube or LMA if unable to secure ETT
66
What are the recommendations for patients on Beta blockers scheduled for surgery?
Continue Beta blocker use -begin with short acting (Esmolol) -Convert to longer acting agent in maintenance (metoprolol) Target HR <80
67
What are some complications associated with GA that a regional anesthetic can prevent or limit?
Avoids: - DVT - PE - EBL - Respiratory complications - Death
68
What fractures are fat emboli common in? How does fat enter the circulation after bone trauma?
**Common in pelvic and femur fractures** Long bone trauma l/t release of fat droplets into venous system Fracture releases inflammatory mediators (cytokines etc) that increase vascular permeability therefore increasing the solubility of lipids into circulation
69
What is the pathology of Fat embolism syndrome?
-End organ capillaries obstructed by fat emboli and bone marrow particulates **PE is worst outcome** Fat released is metabolized to Free fatty acids which can l/t systemic inflammatory response
70
Describe the systemic inflammatory response that is seen with fat embolism syndrome?
Systemic inflammatory response l/t: -inflammatory cell invasion -cytokine release (bradycardia/HoTN) -Pulmonary endothelial injury/edema -ARDS (<10% of cases)
71
What are some complications seen when tourniquet inflated longer than 2 hours? If required to inflate longer than 2 hours how may these complications be minimized?
Nerve injury Risk of ischemia/rhabdo -metabolic acidosis, Hyperkalemia, tachycardia, hypercarbia Mechanical trauma Minimize risk by deflating for 20-30 mins after two hours to allow reperfusion to limb.

Advanced Exam 1 (4 decks)

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