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N931 Advanced Principles > Week 4 Considerations for Ortho Surgery > Flashcards

Week 4 Considerations for Ortho Surgery Flashcards

1
Q

What are 3 components of preop teaching for orthopedic patients?

A
  1. procedure review
  2. anesthetic/analgesic options
  3. review of rehabilitation plan
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2
Q

Why is preop teaching so important for ortho patients?

A

*get the patient motivated to get home / go home.

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3
Q

What is included in a preop evaluation for ortho patients?

7

A 
– PMHx (previous surgeries, review of medications, anticoagulant status)
– Focused physical examination
– Laboratory
values
– Diagnostic studies
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4
Q

What lab is extremely important to get preop for spine patients?

A

type/screen & CBC

*check if patient takes blood thinners

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5
Q

What 4 labs are important to check in a total joint replacement?

A
  1. CBC
  2. pregnancy
  3. urinalysis
  4. type & screen
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6
Q

What is a major complication of total joint replacement?

A

surgical site infection

  • make sure antibiotics are given at the appropriate time
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7
Q

When should ancef be administered?

A

Should be IN within 1 hour of incision

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8
Q

When should vancomycin be administered?

A

Should be IN within 2 hours of incision

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9
Q

What could be included in a multimodal analgesia plan for ortho patients? (5)

A
  • NSAIDS
  • Anticonvulsants (gabapentin)
  • opioids
  • peripheral nerve block
  • other adjuncts
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10
Q

What are advantages of outpatient/arthroscopic surgery for ortho patients?

A
  • faster recovery
  • shorter LOS
  • fewer narcotics
  • faster return to work
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11
Q

What 2 services could perform spine surgery?

A
  1. ortho

2. neurosurgery

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12
Q

Spines are what type of procedure?

A

open, could be anterior or posterior

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13
Q

What are 3 patient populations that may need spine surgery?

A
  1. spinal cord injury
  2. scoliosis
  3. degenerative disk disease
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14
Q

How might scoliosis affect normal physiology?

A
  1. restrictive lung dz

2. hemodynamic changes d/t limited thoracic space

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15
Q

What kind of anesthetic is used during spine surgery?

A

TIVA; precedex, remifentanil

  • no more than 0.5 MAC if SSEPs are being monitored
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16
Q

What may be monitored during spine surgery?

A

SSEPs or MEPs

*evoked potentials

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17
Q

How are SSEPs change when volatile anesthetics are used?

A

decreased amplitude

↑ latency?

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18
Q

Preop testing for spine surgery includes, what?

textbook answer

A 
CBC (platelets)
coagulation studies
chest xray
PFTs
ECG
ECHO
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19
Q

What are some positioning considerations for spine surgery?

A
  1. Keep head/neck neutral during laryngoscopy

2. place BILATERAL bite blocks to the molars if evoked potentials are being monitored d/t risk of biting down

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20
Q

What 3 methods can combat blood loss during spine surgery?

A
  1. autologous transfusion
  2. hemodilution
  3. cell saver
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21
Q

What vital sign change may occur during spine surgery?

A

intentional or unintentional hypotension

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22
Q

What are risk factors for POVL?

[ischemic optic neuropathy]

A
  • prone
  • > 5 hours
  • pre-op anemia
  • male
  • obese
  • hypotension
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23
Q

What is paramount in prone positioning?

A

alignment and proper padding

  • head/neck alignment
  • eyes free of pressure
  • chest/breast and genitalia free of pressure
  • arms padded and positioned
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24
Q

If tucking arms, what do you need?

A

Have at least 2 IVs

PIVs and Aline should be in place before tucking arms

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25
Q

What is the position for anterior spine surgery?

A

supine,

  • shoulder roll to extend neck
  • ETT position, tubing should run over nose and forehead [make sure it is SECURE with tape]
  • arms tucked with traction

*have 2 BP cuffs in place or an aline

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26
Q

What percentage of spinal cord injuries are cervical?

A

~50%

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27
Q

What 3 injuries are cervical spinal cord injuries often associated with?

A
  1. head injury
  2. thoracic fractures
  3. pulmonary and cardiovascular injury
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28
Q

What 2 injuries are lumbar spinal cord injuries often associated with?

A
  1. abdominal injuries

2. long bone fractures

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29
Q

What are 7 anesthetic considerations of spinal cord injuries?

A
  1. neuro exam - get baseline!
  2. airway management - worry about C3,4,5
    [C5-T7 innervate the intercostal and abdominal respiratory muscles]
  3. cardiac considerations - loss of sympathetic tone below injury
  4. autonomic hyperreflexia - can occur if injury is complete and above T5
  5. succinylcholine-induced hyperkalemia - only if it has been >48H since injury
  6. Temperature control
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30
Q

What is the treatment of autonomic hyperreflexia?

A

remove the stimulus and support symptoms

  • deepen anesthetic + give vasodilators
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31
Q

Up to ___% of patients with scoliosis have concomitant neuromuscular disease and congenital abnormalities.

A

25%

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32
Q

How is the severity of scoliosis determined?

A

by measuring the COBB angle

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33
Q

What are 2 preoperative anesthetic considerations for scoliosis surgery?

A
  1. PFT

2. cardiovascular considerations

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34
Q

What are 3 perioperative anesthetic considerations for scoliosis surgery?

A
  1. posterior vs anterior approach
  2. surgeries T8 and above
  3. wake-up test? [TIVA with fast on/off drugs, remi/prop]
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35
Q

A cobb angle greater than ___ can have more pulmonary insult & complications.

A

60degrees

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36
Q

Scoliosis surgeries are often….

A

large, long, bloody

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37
Q

Anesthetic management of scoliosis surgery includes:

5

A
  1. hemodynamic monitoring
  2. vascular access
  3. respiratory support
  4. hypothermia
  5. replacement of blood and fluid losses
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38
Q

Why is there a risk of hypothermia during scoliosis surgery?

A

very long surgery, very involved & lots of blood loss

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39
Q

What portions of the spine are most commonly affected by degenerative spine disease?

A

lumbar or cervical

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40
Q

What are 3 examples of degenerative spine surgery?

A
  1. spinal stenosis
  2. spondylosis [wear & tear]
  3. spondylolisthesis [vertebrae slippage]
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41
Q

What pre-surgery test needs to be done if patient has degenerative spine disease?

A

MRI & thorough neurological exam

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42
Q

8 anesthetic considerations for degenerative spine disease?

A
  1. preop assessment
  2. patient positioning (post vs anterior)
  3. general vs regional
  4. spinal cord monitoring
  5. blood/fluid management
  6. venous air embolism
  7. visual loss
  8. postop management
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43
Q

What are 2 signs of a VAE?

A
  1. hypotension

2. drop in ETCO2

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44
Q

What are 3 possible causes of vision loss after degenerative spine surgery?

A
  1. optic neuropathy
  2. retinal artery occlusion
  3. cerebral ischemia
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45
Q

Why do you hyperventilate a patient who has a VAE?

A

to get the air out

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46
Q

What are 2 methods of performing upper extremity surgery?

A
  1. open

2. arthroscopic

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47
Q

What are 4 procedures included in upper extremity surgeries?

A
  1. joint disorders
  2. fractures
  3. joint arthroplasty
  4. entrapment syndromes (nerve impingement)
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48
Q

What are anesthetic techniques for upper extremity surgery?

A
  1. GETA

2. regional

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49
Q

The brachial plexus is derived from what nerve roots?

A

C5-T1

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50
Q

What part of C5-T1 nerves are included in the brachial plexus?

A

ventral rami

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51
Q

What is the order of nerve classifications?

A 
Roots
Trunks
Divisions
Cords
Branches (terminal branches)
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52
Q

What does the brachial plexus supply?

A

sensory and motor innervation to the upper extremity

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53
Q

What are the 5 terminal branches of the brachial plexus?

A
  1. median
  2. axillary
  3. musculocutaneous
  4. radial
  5. ulnar
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54
Q

What are 4 common shoulder surgeries?

A
  1. subacromial impingement
  2. rotator cuff tear
  3. arthroplasty (total shoulder)
  4. clavicle fracture
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55
Q

What is the position used during shoulder surgery?

A
  1. beach chair

2. lateral

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56
Q

3 challenges that can be faced in shoulder surgery due to positioning?

A
  1. head/neck alignment
  2. padding & positioning of non-surgical extremities
  3. cerebral perfusion
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57
Q

3 things to “worry about” during shoulder surgery?

A
  1. cerebral perfusion
  2. IV access
  3. airway access
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58
Q

The beach chair position has been associated with what 4 negative effects?

A
  1. decreased cerebral perfusion
  2. blindness
  3. stroke
  4. death
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59
Q

How can we better monitor patients in beach chair?

A
  1. BP cuff on upper arm

2. a-line transducer level with the circle of Willis

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60
Q

What is the surgeon going to ask for during shoulder surgery?

A

lower BP, hypotension

**we need to keep cerebral perfusion adequate by keeping BP up!

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61
Q

What kind of block can be used for shoulder surgery?

A

interscalene block (ISB)

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62
Q

What level block is an interscalene block?

A

root level

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63
Q

An interscalene block is the primary brachial plexus block for procedures involving…

A

the shoulder and proximal upper arm.

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64
Q

Where are the nerve roots of C5-T1 found?

A

Between the anterior and middle scalene muscles

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65
Q

What 3 procedure locations indicate an interscalene block?

A
  1. shoulder
  2. proximal humerus
  3. lateral 2/3 of clavicle
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66
Q

What are the landmarks for placement of an interscalene block? (4)

A
  1. sternal head of the SCM muscle
  2. clavicular head of the SCM muscle
  3. upper border of the cricoid cartilage
  4. clavicle
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67
Q

If placing a block with a landmark technique, what should also be used?

A

nerve stimulator

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68
Q

How is the needle inserted for an interscalene block?

A

between the anterior and middle scalene muscles,

no more than 2-3cm deep (in most patients)

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69
Q

What kind of transducer is used for an interscalene block?

A

high frequency linear array

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70
Q

Where do you start scanning to place an interscalene block?

A

supraclavicular fossa, scan cephalad

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71
Q

How is the needle inserted when placing an interscalene block?

A

lateral to medial

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72
Q

How much LA is injected when placing an interscalene bock?

A

20mL, but only administer 5mL at a time

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73
Q

What are 2 common side effects of an interscalene block?

A
  1. diaphragmatic hemiparesis d/t blockade of the phrenic nerve
  2. Horner’s syndrome [Ptosis, miosis, anhydrosis] → stellate ganglion blok
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74
Q

What nerve roots can be missed with an interscalene block?

A

C8 & T1

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75
Q

Where does the vertebral artery enter the spinal column?

A

C6

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76
Q

Who should not get an interscalene block?

A

resp insufficiency, COPD

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77
Q

What are 5 common surgeries of the arm/hand?

A
  1. surgical repair of fractures (humerus, radius, ulnar, hand
  2. arthroplasty
  3. amputation
  4. ulnar nerve transposition
  5. carpal tunnel release
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78
Q

What are 3 positions for surgery of the arm/hand?

A
  • beach chair
  • lateral
  • supine
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79
Q

What three blocks can be used for arm/hand surgery?

A
  1. supraclavicular
  2. infraclavicular
  3. axillary
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80
Q

What are 2 options for the type (not location) of blocks used in arm/hand surgery?

A

single shot vs catheter placement

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81
Q

What type of surgery can a Bier block be used for?

A

hand surgery

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82
Q

How is the patient positioned for a supraclavicular block?

A

supine

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83
Q

What type of transducer is used for a supraclavicular block?

A

high frequency linear array

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84
Q

Where is the transducer placed for a supraclavicular block?

A

supraclavicular fossa behind the clavicle

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85
Q

How is the needle inserted during a supraclavicular block?

A

lateral to medial

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86
Q

What is the volume of anesthetic used during a supraclavicular block?

A

~20mL

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87
Q

What nerve is often missed during a supraclavicular block?

A

suprascapular nerve

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88
Q

What are 2 common side effects of a supraclavicular block?

A
  1. stellate ganglion block (Horner’s syndrome)

2. diaphragmatic hemiparesis (phrenic nerve block?

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89
Q

What causes diaphragmatic hemiparesis?

A

phrenic nerve block

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90
Q

What is another name for Horner’s syndrome?

A

stellate ganglion block

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91
Q

A supraclavicular block has increased risk of what 2 complications?

A
  1. vascular puncture

2. pneumothorax

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92
Q

A supraclavicular block is performed at what level?

A

trunks

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93
Q

What is the indication for a supraclavicular block?

A

upper extremity surgery below the shoulder

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94
Q

What 3 landmarks are used to place a supraclavicular block?

A
  1. lateral insertion of the sternocleidomastoid in the clavicle
  2. clavicle
  3. patient’s midline
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95
Q

What position is a patient in during placement of a supraclavicular block?

A
  • semi-sitting, head turned away
  • lower the shoulder & flex the elbow
  • forearm on lap, wrist supinated
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96
Q

What level block is the infraclavicular block?

A

cord level

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97
Q

What is the infraclavicular block used for?

A

an alternative to the supraclavicular block in patients with severe COPD or respiratory insufficiency

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98
Q

How are the cords labeled?

A

by their relation to the axillary artery

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99
Q

What are the 3 cords labeled as/named?

A

lateral, posterior, medial

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100
Q

How is the patient positioned for an infraclavicular block?

A

supine

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101
Q

How is the transducer placed for an infraclavicular block?

A

in a sagittal plane below the clavicle, medial to the coracoid process

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102
Q

In what plane is the transducer placed for an infraclavicular block block?

A

sagittal

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103
Q

How is the needle inserted when placing an infraclavicular block?

A

cephalad to caudal

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104
Q

How much volume of LA is used for an infraclavicular block?

A

20-30mL

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105
Q

What kind of transducer is used for placement of an infraclavicular block?

A

either high or low frequency, linear or curvilinear array transducer

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106
Q

What additional step may needed when placing an infraclavicular block?

A

SQ injection of Lidocaine may be needed, this block can be painful!

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107
Q

What 2 vascular structures need to be considered when placing an infraclavicular block?

A
  1. thoraco-acromial artery
  2. pectoral veins

doppler will help identify & avoid these

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108
Q

Where do the thoraco-acromial artery and pectoral veins pass?

A

between the pectoral muscles;

doppler will help identify & avoid these

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109
Q

What are indications for an infraclavicular block?

A

block of the arm below the shoulder (hand, forearm, elbow, AV fistula)

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110
Q

What is the anatomy of the infraclavicular block?

A

3 cords that surround the axillary artery; lateral cord is the most superficial, posterior is next, medial cord is deepest and BELOW the axillary artery.

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111
Q

Where are the 3 cords in relation to the axillary artery?

A

surrounding the axillary artery.

lateral cord is the most superficial, posterior is next, medial cord is deepest and BELOW the axillary artery

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112
Q

Which cord contains the median nerve?

A

half is in the lateral cord and half is in the medial cord

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113
Q

What nerve is entirely contained within the posterior cord?

A

the radial nerve

114
Q

Where is the musculocutaneous nerve in relation to the cords?

A

outside of the cords but very close to the lateral cord

*so you may miss blocking this nerve

115
Q

Why does the anatomical location of the musculocutaneous nerve matter?

A

you might miss blocking it when performing an infraclavicular block!

116
Q

What are the 4 landmarks for the infraclavicular block?

A
  1. clavicle
  2. jugular fossa or notch
  3. acromioclavicular joint
  4. coracoid process
117
Q

What position is the patient in for placement of an infraclavicular block?

A

semi-sitting with head turned away

118
Q

What level block is an axillary block?

A

terminal branches

119
Q

An axillary block is good for what type of procedures?

A

procedures below the elbow

120
Q

Are axillary blocks becoming more or less popular?

A

less.

ultrasound has made other blocks more efficient with less complications

121
Q

Why is an axillary block not attractive?

A

multiple injections required

122
Q

What is the nerve anatomy of the apex of the axilla?

A

the three plexus cords form

the main terminal nerves of the upper extremity

123
Q

At the level of the coracoid process, what change in nerve anatomy occurs?

A

axillary and musculocutaneous nerves leave the plexus

at the level of the coracoid process

124
Q

Where does the axillary and musculocutaneous nerves leave the plexus?

A

at the level of the coracoid process

125
Q

Where do three plexus cords form

the main terminal nerves of the upper extremity?

A

the apex of the axilla

126
Q

Which nerve is frequently missed during an axillary block?

A

the musculocutaneous nerve

127
Q

How is the patient positioned for an axillary block?

A

supine

128
Q

Where is the transducer placed for an axillary block?

A

in the crease formed by the biceps and pectoris major

129
Q

How is the needle inserted for an axillary block?

A

lateral to medial

130
Q

What is the volume of LA used for an axillary block?

A

20-30mL

131
Q

What are the 5 landmarks of an axillary block?

A
  1. pulse of axillary artery
  2. coracobrachialis muscle
  3. pectoralis major muscle
  4. biceps muscle
  5. triceps muscle
132
Q

How is the arm positioned for an axillary block?

A

arm abducted 90 degrees, elbow flexed

133
Q

Where is the arterial pulse palpated when placing an axillary block?

A

at the level of the major pectoralis muscle

134
Q

How can lower extremity surgeries be performed?

A

open or arthroscopic

135
Q

What are 3 common lower extremity procedures?

A
  1. arthroplasty
  2. fractures
  3. cartilage and ligament repair
136
Q

Where does the LUMBAR plexus arise from?

A

from the ventral rami of L1-L4

occasionally T12

137
Q

What are 3 major nerves of the lumbar plexus?

and 2 others?

A
  1. femoral n
  2. obturator n
  3. lateral femoral cutaneous n
  4. ilioinguinal n
  5. iliohypogastric n
138
Q

Where does the LUMBOSACRAL plexus arise from?

A

L4/5 - S1-5

139
Q

What is the major nerve of the lumosacral plexus?

A

sciatic nerve

140
Q

Most common hip surgery patients:

A

frail & elderly

141
Q

How are patients positioned for hip surgery?

A

lateral or supine

142
Q

Hip surgery that is at greater risk of blood loss

A

extracapular

→ femoral neck, intertrochanteric, subtrochanteric

143
Q

Why can neuraxial anesthesia be beneficial in hip surgery?

A

it can ↓ blood loss

144
Q

Supine position considerations specific to hip surgery (3)

A
  1. IV site
  2. protect genitalia from pressure
  3. traction injury to lower extremities
145
Q

What are 3 things to consider when planning an anesthetic technique for hip surgery?

A
  1. elective surgery vs traumatic vs revision
  2. patient population
  3. surgeon
146
Q

3 major potential complications of hip surgery

A
  1. fat embolus
  2. venous thromboembolism
  3. blood loss [to help combat this →→ regional, deliberate hypotension, dilutional anemia]
147
Q

5 major benefits of regional over general for hip surgery

A
  1. less postop cognitive dysfunction
  2. superior postop analgesia
  3. decreased incidence of DVT & PE
  4. rapid postop rehab
  5. reduced cost of medical care (when you get up and moving you go home faster)
148
Q

2 reasons regional techniques are used in hip surgery?

A
  1. primary anesthetic

2. postoperative analgesia

149
Q

What kind of neuraxial block can be used for hip surgery?

A
  1. spinal

2. epidural

150
Q

What 2 kinds of peripheral nerve blocks can be used for hip surgery?

A
  1. Lumbar plexus block

2. Fascia iliaca block

151
Q

The lumbar plexus block is also called _____.

A

psoas compartment block

152
Q

The psoas compartment block is also called ____.

A

lumbar plexus block

153
Q

What are 2 kinds of lumbar plexus blocks?

A
  1. continuous

2. single

154
Q

Complete regional anesthesia for a knee arthroplasty requires ___.

A

lumbar & lumbosacral plexus blocks

155
Q

Is knee arthroplasty associated with a lot or little pain?

A

significant post-op pain

156
Q

Who is the average knee arthroplasty patient?

A

elderly with multiple comorbidities.

157
Q

What is paramount to post-op recovery from a knee arthroplasty?

A

post-op pain management

158
Q

What are 2 parts of an ERAS protocol for knee arthroplasty?

A
  1. multimodal pain management

2. continuous peripheral nerve block

159
Q

Anesthetic considerations for knee arthroplasty (3)

A
  1. Effective postoperative pain management is
    paramount to recovery
  2. Opioids and neuraxial techniques both have
    limitations
  3. Enhanced Recovery After Surgery (ERAS) protocols
160
Q

What is the usual anesthetic for knee arthroscopy?

A

peripheral nerve block is rarely indicated,

usually LMA

161
Q

Why is a knee arthroscopy done?

A

outpatient procedure, diagnosis

162
Q

What is the normal anesthetic technique for ACL repair?

A

same as a knee arthroscopy but peripheral nerve block is warranted for analgesic management

163
Q

What allows the lower leg to hang freely during an ACL repair procedure?

A

knee bolster,

will open the joint space

164
Q

What additional support is needed during ACL repair surgery?

A

non-operative leg support to reduce lower back stress

165
Q

What is special about the femoral nerve in the lumbar plexus?

A

it is the largest nerve

166
Q

What combines to form the femoral nerve?

A

dorsal divisions of the anterior rami of L2, L3, and L4 spinal nerves

167
Q

Where does the femoral nerve emerge from?

A

the lateral border of the psoas muscle, and remains deep to the fascia iliaca

168
Q

The femoral nerve provides sensory innervation to ___.

A

anteromedial leg

169
Q

The femoral nerve block provides anesthesia to ____.

A

anterior thigh, knee, and medial aspect of lower leg.

170
Q

Where is the femoral nerve located?

A

lateral to the artery and deep to the facia lata and iliaca and superior to the iliopsoas muscle

171
Q

What are the indications for a femoral nerve block?

A

anterior thigh

knee surgery

172
Q

How deep is the femoral nerve sheath?

A

2-3cm beneath skin

173
Q

What is the patient position for the femoral nerve block?

A

supine with external rotation of the lower extremity

174
Q

Where is the transducer placed for the femoral nerve block?

A

at the inguinal crease

175
Q

How is the needle inserted for the femoral nerve block?

A

lateral to medial

176
Q

How much volume is used for a femoral nerve block?

A

20mL

177
Q

What do you need to be UNDER for placement of the femoral nerve block?

A

the fascia iliaca

178
Q

What should be done if two arteries are noted when scanning for a femoral nerve block?

A

scan cephalad until a single femoral artery is identified

179
Q

Placement of LA ___ suggests successful femoral nerve block, even if no twitches are noted

A

below the fascia iliaca and lateral to the artery

180
Q

What structures appear as “nerves” when placing a femoral nerve block?

A

lymph nodes

181
Q

How are nerves and lymph nodes distinguished?

A

scan proximal and distal.

lymph nodes are not continuous and are only seen at specific locations

182
Q

After placement of a femoral nerve block, ambulation is prohibited for how long?

A

24 hours

183
Q

How do you avoid complications such as vascular puncture and local anesthetic injection when placing a nerve block?

A

observation of the needle tip throughout the procedure & aspiration

184
Q

What are indications for a fascia iliaca block? (4)

A

hip, anterior thigh, knee, femur fracture

185
Q

What is an alternative to a lumbar plexus block?

A

fascia iliaca block

186
Q

What are the three nerves targeted in a fascia iliaca block?

A
  1. femoral n
  2. obturator n
  3. lateral femoral cutaneous
    n
187
Q

How many nerves are targeted in a fascia iliaca block?

A

3

188
Q

How much volume is used for a fascia iliaca nerve block?

A

40mL

189
Q

What are the absolute contraindications for a fascia iliaca nerve block?

A

there are no documented absolute contraindications

190
Q

What are the 2 relative contraindications for a fascia iliaca nerve block?

A
  1. uncooperative patient/surgeon
  2. infection at site
    (3. patient refusal! -> from Dr. Pitman)
191
Q

What are 5 complications of a fascia iliaca block?

A
  1. block failure
  2. intraperitoneal injection (bowel perforation)
  3. femoral nerve palsy
  4. quadriceps weakness
  5. infection (increased with catheter)
192
Q

What roots does the femoral nerve originate from?

A

L2, L3, L4

193
Q

What roots does the lateral femoral cutaneous nerve originate from?

A

L2, L3, L4

194
Q

What does the lateral femoral cutaneous nerve carry?

A

sensory (afferent) information only

195
Q

What nerve roots does the obturator nerve originate from?

A

L2, L3, L4

196
Q

What does the obturator nerve innervate?

A

innervates a portion of the distal and medial thigh

197
Q

Where does the obturator nerve run?

A

cross iliacus muscle, deep to the fascia, to medial thigh

198
Q

It is important to block the obturator nerve along with what?

A

the THA (acetabular component)

199
Q

What is the key to the fascia iliaca block?

A

volume!
it is a compartment block

40-60mL

200
Q

How much volume is used for a fascia iliaca block?

A

40-60mL

201
Q

When using ultrasound to place a fascia iliaca block, how many “pops” will there be?

A

2

  1. fascia lata
  2. fascia iliaca
202
Q

What are the “pops” when placing a fascia iliaca block?

A
  1. fascia lata

2. fascia iliaca

203
Q

During placement of a fascia iliaca block, how should the LA spreak?

A

cephalad

204
Q

What has been the gold - standard for pain relief following knee arthroplasty?

A

femoral nerve block

205
Q

What negative effect has the femoral nerve block been associated with?

A

falls secondary to quadriceps weakness

206
Q

What is an alternative block to femoral nerve block, that can provide sensory blockade with minimal motor involvement?

A

adductor canal block

207
Q

What kind of block does an adductor canal block provide?

A

sensory blockade with minimal motor involvement

208
Q

What are indications for an adductor canal block?

A
  1. TKA
  2. ACL reconstruction
  3. anterior knee
    surgery

[if used with sciatic block, will achieve analgesia below the knee]

209
Q

What are contraindications for an adductor canal block?

A
  1. patient refusal
  2. infection at site
  3. allergy to LA
  4. anticoagulant therapy/coagulopathy
210
Q

What nerve is targeted in an adductor canal block?

A

the saphenous nerve

211
Q

The saphenous nerve is a branch of?

A

femoral nerve

212
Q

Where is the saphenous nerve found?

A

medial side of the knee and ankle

213
Q

What is the position when scanning for an adductor canal block?

A

pt is supine, scan at mid-thigh

**KEY: mid-thigh with femoral artery in middle of sartorius muscle

214
Q

What are the landmarks for location of the saphenous nerve?

A

nerve is below the sartorius muscle, lateral to the superficial femoral artery & femoral vein

215
Q

What is the patient position for placement of an adductor canal block?

A

Patient supine with slight external rotation of

extremity

216
Q

Where is the transducer placed for an adductor canal block?

A

distal thigh

217
Q

What kind of transducer is used for an adductor canal block?

A

high frequency linear array

218
Q

What kind of image is used for needle insertion to perform an adductor canal block?

A

short-axis image, in-plane needle insertion

219
Q

Where is LA placed when performing an adductor canal block?

A

in the fascial plane
separating the adductor longus and vastus medialis
below the subcutaneous tissue

220
Q

How much volume is used for an adductor canal block?

A

increments of 5mL up to 20mL

221
Q

Where may nerve branches be located when performing an adductor canal bock?

A

on both sides of the superficial artery

222
Q

What can happen if LA is injected into the muscle?

A

myotoxicity

223
Q

What additional muscle is blocked during an adductor canal block?

A

the vastus medialis

224
Q

What 2 nerves innervate the ankle and foot?

A

femoral nerve & sciatic nerve

225
Q

What kind of blocks are appropriate for ankle or foot surgeries?

A

neuraxial OR peripheral nerve blocks are appropriate in combination with general or monitored anesthesia

226
Q

What does the lumbosacral plexus supply?

A

sensory and motor innervation to the posterior thigh, knee, and lower extremity below the knee
(with the exception to sensory innervation provided by the saphenous nerve)

227
Q

What does the popliteal nerve block target?

A

the sciatic nerve, slightly proximal to the knee

228
Q

What does a popliteal nerve block provide?

A

anesthesia for procedures involving the foot and ankle

229
Q

How are the nerves bordered in the popliteal fossa?

A

superiorly and medially by the semi-tendinosus and semi-membranous muscles

superiorly and laterally by the biceps femoris muscle

230
Q

How is a patient positioned when placing a popliteal nerve block?

A

patient supine with operative leg elevated

231
Q

What kind of transducer is used for placement of a popliteal nerve block?

A

high frequency linear array transducer

232
Q

Where is the transducer placed for a popliteal nerve block?

A

in the popliteal crease

233
Q

What kind of image is used for placement of a popliteal nerve block?

A

short-axis image

234
Q

Where is the target location for the popliteal nerve block?

A

8-10cm above the popliteal fossa, the sciatic nerve is superficial and bifurcates into the tibial nerve and common peroneal nerve

235
Q

The sciatic nerve bifurcates into what 2 nerves?

A
  1. tibial nerve

2. common peroneal nerve

236
Q

How/where does the tibial nerve run?

A

midline

237
Q

How/where does the common peroneal nerve run?

A

courses laterally along superior

aspect of fibula

238
Q

What image is viewed when placing a popliteal nerve block?

A

short-axis image distal of the tibial and peroneal bifurcation

239
Q

How is the needle inserted when placing a popliteal nerve block?

A

Needle inserted
in-plane lateral
to medial

240
Q

How is the LA spread when placing a popliteal nerve block?

A

Circumferential spread around each nerve

[ensures a dense nerve block]

241
Q

How can the transducer be repositioned to gain a better view for the popliteal nerve block?

A

The transducer may have to be angled toward to the

foot to better image the nerves (anisotropy)

242
Q

When are ankle blocks indicated?

A

surgical anesthesia and

postoperative analgesia involving the foot

243
Q

What 5 nerves supply innervation to the foot?

A 
– Tibial n.
– Deep peroneal n.
– Superficial peroneal n.
– Saphenous n.
– Sural n. `
244
Q

How many nerves supply innervation to the foot?

A

5

245
Q

Why is it better to use ultrasound when placing a block?

A

Greater block efficacy even with lower volumes of

local anesthetic

246
Q

How is a patient positioned for an ankle block?

A

Supine with foot elevated or extended over the end of

the stretcher

247
Q

What transducer is used for an ankle block?

A

High frequency linear array transducer

248
Q

What is the first thing done when placing an ankle block?

A

identify vascular structures first

249
Q

How is the needle inserted when placing an ankle block?

A

in-plane or out-of-plane

250
Q

How much LA is used for an ankle block?

A

3-5mL at each nerve

251
Q

4 general considerations/complications for orthopedic surgery

important

A
  1. Pneumatic Tourniquet
  2. Polymethylmethacrylate
  3. Fat Embolism Syndrome
  4. Deep Vein Thrombosis and Thromboembolism
252
Q

When is a pneumatic tourniquet used?

A

to minimize blood loss and provide a

bloodless surgical field

253
Q

What are the components of a pneumatic tourniquet?

A
  1. inflatable cuff
  2. connective tubing
  3. pressure device
  4. timer
254
Q

What is critical when using a pneumatic tourniquet?

A
  1. proper sizing

2. proper inflation

255
Q

What determines the pressure of inflation of the pneumatic tourniquet?

A

patient’s blood pressure and the extremity

256
Q

What is the time limit for the pneumatic tourniquet?

A

2 hours

257
Q

What pathophysiology occurs when a pneumatic tourniquet is in use?

A

Interrupted blood supply leads to tissue hypoxia and
acidosis
• Deflation of cuff – release of metabolic waste –
metabolic acidosis, hyperkalemia, myoglobinemia,
renal failure

258
Q

When does tourniquet pain occur?

A

60 minutes: pain/HTN

259
Q

approximately 60 minutes after inflation of a pneumatic tourniquet, what occurs?

A

“tourniquet pain”; HTN & pain

^^do not “over treat” with opioids

260
Q

What is the maximum inflation pressure of the pneumatic cuff when on the upper extremity?
lower extremity?

other?

A

250mmHG

300mmHG

OR

100mmHg above the patient’s baseline

261
Q

What is important to document when the pneumatic tourniquet is used in the OR?

A

“up” time and “down” time

262
Q

What 5 things will the patient experience when the pneumatic cuff is deflated?

A
  1. metabolic acidosis
  2. hyperkalemia
  3. renal failure
  4. ↑ETCO2
  5. change in core body temperature
263
Q

What should happen when the pneumatic tourniquet has been inflated for 2 hours?

A

it should be released for 10 minutes

264
Q

What is polymethylmethacrylate?

A

Acrylic bone cement used in arthroplasty

265
Q

What is the acrylic bone cement used in arthroplasty?

A

polymethylmethacrylate

266
Q

What causes bone cement implantation syndrome?

A

Exothermic reaction that results in expansion and hardening of polymer ;

causes intramedullary hypertension

267
Q

What is cause of Bone Cement Implantation

Syndrome (BCIS)?

A

polymethylmethacrylate

268
Q

Absorption of polymethylmethacrylate results in: (3)

A

– Decreased systemic vascular resistance
– Hypotension
– Hypoxemia

aka: bone cement implantation syndrome

269
Q

What are the 3 risk factors for bone cement implantation syndrome?

A
  1. Pre-existing cardiovascular disease or pulm HTN
  2. ASA Class 3 or higher
  3. Pathologic fracture, intertrochanteric fracture or long-stem
    arthroplasty
270
Q

What is the treatment of bone cement implantation syndrome?

A
  1. Discontinuing nitrous during cementation
  2. Maximizing inspired oxygen concentration
  3. Euvolemia
  4. Creating a vent hole in distal femur
  5. High-pressure lavage
271
Q

What is fat embolism syndrome associated with?

A

traumatic injury and surgery to long bones

272
Q

What is the incidence of fat embolism?

A

3-4%

273
Q

What are the 6 risk factors for fat embolism?

A
  1. Age (20-30)
  2. Male
  3. Hypovolemic shock
  4. Bilateral total knee
    replacement
  5. Rheumatoid arthritis
  6. Intramedullary
    instrumentation
274
Q

4 major s/s of fat embolism:

A
  • Petechia
  • Hypoxemia
  • CNS depression
  • Pulmonary edema
275
Q

7 minor s/s of fat embolism:

A
  • Tachycardia
  • Hyperthermia
  • Retinal fat emboli
  • Urinary fat globules
  • Decreased platelets/Hct
  • Increased sed rate
  • Fat globules in sputum
276
Q

Treatment of fat embolism syndrome includes (5)

A 
– Early recognition
– Reversing contributing factors (hypovolemia)
– Stabilization of fractures
– Aggressive pulmonary support
– Pharmacologic therapy
277
Q

Without prophylaxis, DVT develops between __ of orthopedic patients

A

40-80%

278
Q

What are 6 risk factors for development of a DVT/PE?

A
  1. s/p hip fx
  2. advanced age
  3. immobility
  4. previous DVT
  5. cancer
  6. pre-existing hypercoagulable state
279
Q

What are 3 complications of arthroplasty?

A
  1. SQ emphysema
  2. pneumomediastinum
  3. tension pneumothorax
280
Q

What are the size of the irrigating solution bags?

A

3-5L

281
Q

What is important to remember when there is use of irrigating solution?

A

compare fluid in / out

282
Q

Large volumes of absorbed irrigation fluid can lead to:

A
  1. volume overload
  2. CHF
  3. pulmonary edema
  4. hyponatremia (if sterile water is used)

N931 Advanced Principles (3 decks)

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