Week 3 - Orthopedic Anesthesia Flashcards
What anesthetic techniques can be used for orthopedic anesthesia?
Multimodal analgesia
-NSAIDS, Anticonvulsants, Opioids, Peripheral nerve blocks, other adjuncts
Neuraxial Anesthesia
General Anesthesia (not ideal)
What are anesthetic considerations for spinal cord injury?
- Neurologic exam – be sure to check pupils
- Airway management
- Cardiac considerations
- Autonomic hyperreflexia – inability to regulate ANS
- Succinylcholine – induced hyperkalemia (due to increased receptors from SC injury – have larger release of K+)
- Temperature control
How is the severity of scoliosis determined?
by the Cobb Angle
> 60* you see respiratory compromise
What are anesthetic considerations with scoliosis patients?
Preop: pulmonary function studies, CV considerations
Periop: posterior vs anterior approach, surgeries T8 and above
Anesthetic management: hemodynamic monitoring, vascular access, respiratory support (depends on what levels are involved), hypothermia, replacement of blood and fluid losses
What are anesthetic considerations of degenerative spine disease?
- Preop assessment
- Pt positioning
- General vs Regional
- Spinal cord monitoring (wake up test, SSEP/MEP)
- Blood/Fluid management
- Venous air embolism (HoTN, precipitous fall in ETCO2)
- Visual loss
- Postop management
What are anesthetic considerations with shoulder surgery?
- Positioning (beach chair is associated with decreases in cerebral perfusion, blindness, stroke, and brain death)
- Regional: interscalene block
- General vs MAC (ETT vs LMA – pt population)
What are anesthetic considerations with arm/hand surgery?
Regional:
- Supraclavicular vs Infraclavicular vs Axillary block
- Infiltration
- Bier block (not as common anymore)
General vs MAC
- ETT vs LMA
- Pt comorbidities
What are anesthetic considerations with hip surgery?
Anesthetic technique varies according to:
- Elective vs Traumatic vs Revision
- Pt population
- Surgeon
Potential Complications include fat embolus and blood loss (regional, deliberate hypotension, dilutional anemia)
What are the benefits of using regional anesthesia in hip surgery over general?
- Less postop cognitive dysfunction
- Superior postop analgesia
- Decreased incidence of DVT/PE
- Rapid postop rehabilitation
- Reduced cost of medical care
*neuraxial and peripheral nerve blocks have been used effectively for management
What are anesthetic considerations for knee arthroplasty?
- Effective postop pain management is paramount to recovery —Opioids and neuraxial techniques both have limitations (Multimodal pain management – continuous peripheral nerve block)
- Pt population influences anesthetic technique
What is a fascia iliaca block?
Similar to an 3-in-1 lumbar plexus block
Targets: femoral, obturator, and lateral femoral cutaneous nerves
Increased volume (40mL LA) required to block all three nerves
US imaging similar to femoral nerve block
What are anesthetic considerations with ankle/foot surgery?
Supplied by the femoral and sciatic nerve
Elective vs traumatic
Either neuraxial or peripheral nerve blocks are appropriate in combo with general or MAC
Position dependent on procedure
What is an ankle block?
Indicated for surgical anesthesia and postop analgesia involving the foot
- Position: supine w/ foot elevated or extended over stretcher
- High frequency linear array transducer
- ID vascular structure first
- Needle inserted in-plane or out of plane
- 3-5 mL LA at each nerve
What are the general complications with orthopedic surgery?
- Pneumatic Tourniquet: minimize blood loss – tourniquet pain
- Polymethylmethacrylate: acrylic bone cement used in arthroplasty (associated w/ sudden HoTN, causing bone cement implantation syndrome)
- Fat Embolism: associated w/ traumatic injury/surgery to long bones (risk factors = male, 20-30yo, hypovolemic shock, bilateral total knee replacement, rheumatoid arthritis, intramedullary instrumentation)
- DVT/PE: major cause of death following LE trauma/surgery
What is Bone Cement Implantation Syndrome (BCIS)?
Sudden hypotension with placement of acrylic bone cement used in arthroplasty
-results in decreased SVR, HoTN, and hypoxemia
Treatment: (to help prevent)
- discontinuing nitrous during cementation
- maximizing inspired O2 concentration
- euvolemia
- creating a vent hole in distal femur
- high-pressure lavage
