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Advanced Exam 1 > Upper and Lower Extremities > Flashcards

Upper and Lower Extremities Flashcards

1
Q

What are some important points of assessment necessary for upper body procedures preoperatively?

A
  • Baseline vitals
  • Airway
  • Pre-existing nerve conduction issues
  • Examine pupils
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2
Q

What are the cardiac consequences of sitting/Beach Chair position?

A
  • ↓ CO & BP (d/t decreased venous return)
    -will still fall despite increased HR & SVR
  • ↑ HR & SVR

Due to pooling of blood in lower body.

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3
Q

What are the respiratory consequences of sitting/Beach Chair position?

A
  • ↑ FRC & lung volumes
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4
Q

What are the neurologic consequences of sitting/Beach Chair position?

A

↓ CBF

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5
Q

How is venous air embolism prevented in a beach chair patient? How common is VAE in sitting position?

A

↑ CVP (above 0) to prevent a “suction” effect
up to 40% occurence in sitting position

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6
Q

In what percent of the population is a patent foramen ovale present?

A

20 - 30 %

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7
Q

How does one treat venous air embolism?

Besides prevention…

A
  • Inform surgeon → irrigation & occlusive dressing (bone wax if surgical site bone)
  • DC N₂O if being used
  • Bilateral compression of jugular veins (prevent neuro consequences)
  • Place patient in head down position to trap in right atrium
  • Withdraw air through right atrial catheter
  • CV & Resp support
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8
Q

The ultrasound transducer is being utilized to located venous air embolism in a patient. Where do you place the probe?

A

2ⁿᵈ - 3rd ICS right of sternum (Over the Right Atrium)
Most sensitive non-invasive indicator of VAE

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9
Q

What is the most definitive diagnostic test for VAE?

A

TEE

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10
Q

The characteristic sound of a VAE is a _____________ murmur.

A

“Mill-Wheel” murmur
IDs gas in chambers turbulent flow of blood mixed with gas

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11
Q

What would be an indicator of decreased perfusion to the lungs?

A

Sudden ↓ EtCO₂

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12
Q

________ of the neck in a sitting position patient can accidentally extubate them.

A

Hyperextension; ETT can migrate away from carina

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13
Q

In a sitting position patient, where would one zero their art line?

A

Tragus of the ear
-corresponds with Circle of Willis

Establishes knowledge of brain BP & thus perfusion.

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14
Q

Induced/intentional hypotension in shoulder surgery makes the patient prone to what ocular conditions?

A

Induced HoTN makes patient prone to
- Retinal Ischemia
- Ischemia Optic Neuropathy
may l/t temporary or permanent blindness
patients with baseline HoTN are especially at risk
Also avoid corneal abrasion.

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15
Q

There is a 40cm distance from the patients heart to their brain. The patient’s BP measured on the arm is 120/70. What is the estimated BP in the brain?

A

40cm x 0.77mmHg = 30.8mmHg

120 - 30.8 = 89.2mmHg
70 - 30.8 = 39.2mmHg

The patient’s brain BP is 89/39 Thus indicating hypotension and necessary correction.

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16
Q

A standing patient’s NIBP on the arm is 134/92. The distance between the patient’s knee and the NIBP cuff is 120cm. What is the BP in the patient’s knee?

A

120 x 0.77 = 92.4

134 + 92
92 + 92

Patient’s “knee” BP standing up is 226/184

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17
Q

What is the Bezold-Jarisch reflex? How is this reflex mediated?

A

Decreased ventricular filling sensed l/t slower HR to prolong filling time
5HT-3 Receptors in Vagus nerve and ventricular myocardium
Cardiac inhibitory reflex resulting in significant HoTN & ↓HR.

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18
Q

What are possible complications of a brachial plexus block?

A
  • Respiratory depression
  • Horner Syndrome
  • Hoarseness
  • Dysphagia
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19
Q

Why can respiratory depression occur with brachial plexus blocks?

A

Hemidiaphragmatic Paresis from Phrenic nerve blockade.

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20
Q

What is the triad of Horner Syndrome?

A
  • Ptosis (eyelid droop)
  • Miosis (pupil constriction)
  • Anhydrosis (inability to sweat)
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21
Q

What are the respiratory consequences of a lateral decubitus position?

A

(VQ mismatch) During mechanical ventilation
Ventilation:
- Dependent lung is under-ventilated d/t compression by weight of mediastinum and abd contents
-nondependent lung overventilated d/t increased compliance
Perfusion:
- Gravity causes pulmonary blood flow to favor dependent lung

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22
Q

Where is an axillary roll placed on a lateral decubitus patient?

A

Caudad to the axilla to avoid compression of the neurovascular bundle.

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23
Q

Where should a pulse oximeter be placed in a lateral decubitus patient?

A

Dependent hand to ensure that there is no neurovascular compromise

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24
Q

Brachial plexus block is utilized for elbow surgeries. Which approach is used for this block and what additional block is needed to ensure complete coverage?

A

Brachial Plexus approach: infraclavicular or axillary
Musculocutaneous nerve block is also needed

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25
Is a patient with a hip fracture induced on the OR fracture table or on the bed/stretcher?
Bed/Stretcher to avoid pain from movement to OR table.
26
What are the benefits of neuraxial anesthesia for hip fracture repairs?
- ↓ delirium - ↓ DVT & 1 month mortality - ↓ hospital stay - Better pain control
27
What are the three life-threatening complications of total hip arthroplasty?
- BCIS - Hemorrhage (long bone rich in blood supply) - VTE
28
What chemical is bone cement?
PolyMethylMethAcrylate
29
What does bone cement do when introduced to the intramedullary bone surface?
Release heat and pressurize (500mmHg!) Possible embolization of fat, bone marrow, and cement.
30
What is the anesthetic management of BCIS?
- maintain euvolumia -tx HoTN with pressors - ↑ FiO₂ & SpO₂
31
What are the s/s of BCIS?
- **Hypoxia** - **Hypotension** - Arrythmias - pHTN - ↓CO
32
In a supine position, spontaneous ventilation favors _______ lung segments, whilst closing volume favors ________ lung segments.
Dependent ; independent
33
The most common postoperative peripheral neuropathy is: a. Ulnar neuropathy b. Brachial plexus injury c. Median nerve injury d. Sciatic nerve compression
a. Ulnar Neuropathy
34
Where are the two major sites of injury in ulnar nerve injury?
Elbow at the **condylar groove** and **cubital tunnel**.
35
How is ulnar nerve injury avoided?
Supinate hands (palms up!)
36
What are the possible complications of tourniquet placement for knee surgeries?
- Blood loss begins with deflation (continues for 24hrs) - Risk of Peroneal Nerve Palsy
37
What are the steps to a TKA (Total Knee Arthroplasty) ?
1. Tibial Component 2. Femoral Component 3. Patellar Component 4. Plastic Spacer
38
What three conditions (that anesthesia can control) are most often associated with infection of knee replacements?
- Peri-operative glucose control - Post-op hypoxia - Post-op hypothermia
39
What medication classes can be used to treat phantom pain from amputation?
- Neuroleptics - Antidepressants - Na⁺ channel blockers (local anesthetic)
40
What nerve innervates the plantar surface?
Posterior Tibial nerve
41
What nerve innervates the medial malleolus?
Saphenous nerve
42
What nerve innervates the interspace between the great & 2ⁿᵈ toes?
Deep Peroneal nerve
43
What nerve innervates the space between the dorsum of the foot and the 2ⁿᵈ - 5th toes?
Superficial peroneal nerve
44
What nerve innervates the lateral foot and lateral 5th toe?
Sural nerve
45
Why is obtaining a baseline HR and BP especially important in shoulder surgery?
Shoulder surgery a tourniquet cannot be used. **HoTN techniques** used to decrease blood in field Bezold-Jarisch Reflex: l/t decreased HR in response to decreased ventricular filling (shoulder sx sitting position = decreased preload/venous return)
46
Describe the path of air and affected areas when VAE occurs?
Air enters wound and moves into circulation Air moves to Right ventricle via venous system Pulmonary blood flow is affected by air in RV -Pulmonary edema and reflex bronchoconstriction can occur Air may reach cerebral and coronary circulation via **patent foramen ovale** Death can result from acute CV collapse and arterial hypoxemia
47
To aspirate air trapped in right atria secondary to VAE the central line catheter tip should be placed where?
Junction of SVC and right atria
48
________ of the neck in a sitting position patient can lead to endobronchial migration of ETT
Hyperflexion; ETT migrates toward carina (tube moves deeper into airway)
49
Knowledge of the equipment used in sitting position is important. The beachchair back support is attached to what part of the bed?
The beachchair attachment is placed on the foot of the bed. This requires the bed to be turned 180 degrees. Must use head controls on bed remote to control the legs
50
What is the normal brain blood flow?
750-900 mL/min **750 mL/min is ≈ 15% of CO**
51
List and describe the Lower limit of autoregulation including the mechanisms utilized to maintain Cerebral blood flow?
LLA: 65-70 mmHG per Schmidt/50 mmHg per Castillo In response to ↓BP, vessels of brain dilate to maintain cerebral blood flow of 750 mL/min Limitations/adaptations: vessels can only dilate so much -LLA will shift to right as ULA shifts -This l/t ↓CBF if pt suffers ischemic event (MI/ischemic stroke)
52
List and describe the Upper limit of autoregulation (ULA) including the mechanisms utilized to maintain Cerebral blood flow?
ULA: ≈150 mmHg In respone to ↑BP sensed by baroreceptors, the vessels of brain will constrict, limited flow into the brain. Limitations/adaptations: ULA shifts to right when exposed to prolonged periods of HTN -this prevents overperfusion which ↑ hemorrhage risk -ULA right shift: patients more prone to brain damage if BP suddenly drops
53
How does the distance between the heart and brain affect the BP at the level of the brain?
For each 1 cm above the heart, the BP will decrease by 77% (↓ 0.77 mmHg/cm)
54
What is the preferred anesthetic management of a patient undergoing shoulder surgery?
GETA is preferred d/t muscle relaxation Regional: primary vs additive Most common block is brachial plexus block: either supraclavicular or Interscalene approach
55
Why is the Bezold-Jarisch Reflex triggered in shoulder surgery?
Sitting position decreases venous return (LE venous pooling) Hypercontractile ventricle: contracts harder to compensate for decreased volume -ventricle less relaxed and harder to fill
56
What is the cardiac impact of lateral decubitus position?
CO unchanged; unless venous return obstructed (kidney rest/jack knife position) ↓SVR Right lateral > left lateral -right lateral will ↓SVR more d/t less compression on heart -gravity effect on inferior vena cava will ↓SVR/↑ venous return Arterial BP: may fall d/t ↓SVR
57
Why is PVR decreased in the right lateral position?
PVR ↓ in right lateral is due to right lung being larger than left lung. -Gravity influence on blood flow to right lung will ↓PVR
58
How does the axillary roll work?
Ax roll displaces head of humerus against brachial plexus
59
What must the anesthesia provider ensure when Bean Bag used for lateral position
Besides ensuring adequate coverage for stability: Must ensure adequate abdominal and chest excursion -abd/chest compressed decreased expired Vt and therefore decreased inspired Vt -Peak pressures will increase if abd/chest compressed
60
What is the mortality rate of pt suffering hip fracture? What is the 1 year mortality and what factors influence this?
Initial hospitalizations mortality: 10% 1 year mortality: approx. 25-30% Factors influencing 1 yr mortality: -immobility/sedentary lifestyle -CV/resp conditions -DVT -delirium
61
What is the anesthetic plan for a patient undergoing total hip arthroplasty?
General **muscle relaxation required d/t leg/joint manipulation** Neuraxial additive d/t decreased EBL/DVT/PE/post op delirium
62
Systemic absorption of bone cement can lead to what consequences?
Vasodilation & decreased SVR CV instability anaphylactic shock
63
What are some methods to prevent bone cement implantation syndrome?
Minimize HoTN/hypovolemia Maximize FiO2 and SpO2 Vent hole in femur Lavage femoral shaft Avoid bone cement (some surgeons allow body to heal around implants)
64
What are the respiratory considerations for the supine patient?
Sponataneous ventilation favors dependent lung segments (no V/Q mismatch) Mechanical ventilation favors independent lung segments (V/Q mismatch) FRC decreases by approx. 800 mL -FRC air in lungs at end of expiration -in supine FRC may fall below closing volume in elderly, obese, & pregnant pts.
65
What are CV considerations for supine position?
Equalization of pressures throughout arterial system (vessels are level) Increased right side filling and increased CO (no blood pooling) Decreased HR and PVR
66
List the pressure points in the supine position?
Toes (from sheets) Heel, thighs, sacrum Elbow, humerus Vertebrae, occiput
67
What structures form the condylar groove?
Medial epicondyle of humerus Olecranon process of ulna
68
What is the typical anesthetic plan for a patient suffering a hip dislocation?
Pt requires closed reduction of hip dislocation (resetting the hip) -Conscious sedation is the typical anesthetic Ketamine/Propofol mix **RSI w/ GETA if suspecting full stomach**
69
What is the anesthetic plan for patients undergoing knee arthroscopy?
General with LMA (unless full stomach) Neuraxial vs regional: spinal may delay discharge (chloroprocaine: short acting) Sedation with extraarticular/intraarticular injections Possible tourniquet
70
Anesthetic for total knee arthroplasty?
General Neuraxial (preferred) -decreased 30 day mortality -decreased infection Peripheral block -femoral -sciatic
71
Describe the following types of wounds: clean, clean-contaminated, contaminated, dirty.
Clean: not inflamed or contaminated; no internal organ involvement Clean-contaminated: no evidence of infection; involves internal organ Contaminated: involve internal organ with spillage of organ contents Dirty: known infection at time of surgery
72
For patients scheduled for amputation what is an important preop assessment that must be conducted?
Full sensory assessment: to identify areas that may be involved in amputation that has sensory perception. Helps determine analgesia plan
73
For amputation surgery what is the anesthetic management
General anesthesia Neuraxial preferred: decreased delirium -potentially less phantom pain
74
When assessing a patient for phantom pain postop what must be documented
Onset of phantom pain: usually within a few days after surgery Pain description: intermittent, sharp, stabbing etc. Triggers: weather, stress, pressure on remaining area of limb
75
What are some causes of phantom pain?
MRI/PET scans can help identify -remapping of circuitry -damaged nerve endings -scar tissue Other causes: physical memory pain prior to amputation
76
Non pharmacologic Phantom pain treatments include
biofeedback relaxation massage TENS unit
77
What is the medical term for a bunion?
Hallux Valgus
78
Most ankle and foot surgeries are in supine position. Which ankle/foot surgery is the exception? What position may this be done in?
Achilles tendon repair Position: lateral or prone

Advanced Exam 1 (4 decks)

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