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Anesthesia Principles I > Test 2 Ortho > Flashcards

Test 2 Ortho Flashcards

1
Q

what is the leading cause of lower extremity disability among older adults in the US

A

osteoarthritis

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2
Q

what is the most common form of arthritis

A

osteoarthritis

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3
Q

_________________ is a degeneration of articular cartilage characterized by inflammation and pain with joint motion

A

osteoarthritis

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4
Q

what is the most common way that OA is defined

A

radiographically via the kellgren lawrence grading severity >/= 2

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5
Q

risk factors of OA

A
  1. age
  2. female
  3. obesity
  4. repetitive joint use
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6
Q

primary features of OA

A

pain, stiffness, and potentially decreased ROM in the absence of systemic features (fever)

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7
Q

anesthesia considerations with OA, RA, and ankylosing spondylitis

A
  1. difficult airway - video laryngoscope, C-spine neutral, awake fiberoptic intubation
  2. positioning concerns
  3. regional anesthesia: evaluate preoperative neuropathy
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8
Q

management of OA

A
  1. weight loss
  2. exercise
  3. physiotherapy
  4. bracing in certain cases
  5. tylenol and NSAIDs
  6. opioids
  7. local injections: LA +/- steroids
  8. viscosupplemntation
  9. arthroplasty surgery
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9
Q

why are pneumatic tourniquets used in orthopedic surgery?

A
  1. controls blood loss during extremity surgery
  2. maintain relatively bloodless field
  3. minimize intraoperative blood loss 4. aid identification of vital structures 5. expedites procedure
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10
Q

if a pneumatic tourniquet is going to be used for ortho extremity surgery, when should it be applied?

A

after induction of anesthesia

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11
Q

pneumatic tourniquets maximum time of ___________ hours is considered safe.

A

2

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12
Q

if a surgery needs a pneumatic tourniquet for > 2 hours, what should you do?

A

deflate for 15-20 minutes, then reinflate

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13
Q

why is the pneumatic tourniquet only allowed to be used for a max of 2 hours without interruption?

A

after two hours the interruption of blood supply –> tissue hypoxia and acidosis

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14
Q

when a pneumatic tourniquet is applied to the patient, you should document ____________, _________, and ________________

A

time of inflation; time of deflation; 60 min interval communication with the surgeon

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15
Q

pressure of the pneumatic tourniquet is dependent on ____________, __________/____________

A

Blood pressure; shape/size of extremity

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16
Q

when you deflate a pneumatic tourniquet it releases _________________ into systemic circulation

A

metabolic wastes

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17
Q

s/e of deflation of pneumatic tourniquet

A
  1. transient cardiopulmonary changes: HoTN, hypoxemia
  2. metabolic acidosis
  3. hyperkalemia
  4. myoglobinemia
  5. renal failure
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18
Q

____________ minutes after pressurization of pneumatic tourniquet, pts will start complaining of dull aching pain which progress to burning and excruciating pain that may require ________________

A

~45-60; general anesthesia

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19
Q

if a patient complains of dull, aching pain with pneumatic tourniquet, this is through _______________ fibers

A

unmyelinated C

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20
Q

if a pt complains of burning, tingling pain with pneumatic tourniquet, this is through _________ fibers

A

myelinated A-delta

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21
Q

T/F: tourniquet pain is often resistant to analgesic and anesthetic agents

A

true; need multimodal including regional anesthesia

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22
Q

what population of orthopedic surgery patients receive thromboprophylaxis ?

A
  1. total hip arthroplasty
  2. total knee arthroplasty
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23
Q

why would an orthopedic surgery need thromboprophylaxis

A

due to total hip and total knee arthroplasty having increased risk for VTE including DVT and PE

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24
Q

what is the most common agent used for VTE prophylaxis in certain orthopedic surgeries

A

low molecular weight heparin (lovenox)

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25
Q

what are the different thromboprophylactic techniques that can be used for certain ortho surgeries

A
  1. lovenox
  2. adjusted dose vitamin K antagonist 3. asprin
  3. intermittent compression device 10-14 days prior
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26
Q

T/F: hip/pelvic fracture patients will get low molecular weight heparin

A

FALSE

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27
Q

bone cementing is typically associated with what surgeries?

A
  1. total hip arthroplasty
  2. total knee arthroplasty
  3. vertebroplasty
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28
Q

what is the “cement” used in certain ortho procedures?

A

methyl methacrylate (MMA)

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29
Q

clinical features of bone cement implantation syndrome

A
  1. hypoxia
  2. hypotension
  3. arrhythmias
  4. CV collapse
  5. unexpected loss of consciousness under anesthesia
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30
Q

how do you manage bone cement implantation syndrome

A
  1. communication between surgical and anesthesia team
  2. optimize hemodynamic status (prior to cementing)
  3. 100% FiO2
  4. rapid fluid administration
  5. vasopressors
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31
Q

pts with one long bone fracture have approximately a _______ % chance of a fat emboli, but it goes up to _________% with bilateral long bone fracture

A

3; 33

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32
Q

massive fat emboli can produce _____________ and ______________

A

macrovascular obstruction; shock

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33
Q

fat cells produce _____________ reactions –> __________ and _________ lodging in the pulmonary arterial circulation

A

proinflammatory/prothorombic; platelet aggregation; fibrin generation

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34
Q

fat embolic syndrome is typically seen _______-_________ hours after injury

A

24-72

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35
Q

s/sx of fat embolism

A
  1. hypoxemia
  2. neurologic impairment
  3. classic petechial rash
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36
Q

fat embolic syndrome management

A
  1. ET intubation and mechanical ventilation
  2. some evidence of benefit from steroids IV
  3. surgical correction and stabilization of the long bone fracture ASAP
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37
Q

choice of local anesthetic depends on ?

A
  1. type of peripheral nerve block
  2. purpose (anesthesia vs postop pain) 3. duration of anesthesia required for surgery
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38
Q

additives to prolong regional blockade includes:

A
  1. epinephrine
  2. clonidine
  3. dexmethasone
  4. opioids
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39
Q

what are the different types of local anesthetics that can be used in a regional block

A
  1. lidocaine
  2. ropivicaine
  3. bupivicane
  4. liposomal bupiviciane
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40
Q

what are the different type of upper extremity peripheral nerve blocks?

A
  1. interscalene
  2. supraclavicular
  3. intraclavicular
  4. axillary
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41
Q

which PNB is the best for shoulder surgery?

A

interscalene

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42
Q

which PNB is the best for shoulder and upper arm surgeries

A

interscalane

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43
Q

with an interscalene block, you may miss which nerve?

A

ulnar

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44
Q

which PNB is the best for surgeries of the upper arm distal to the shoulder

A

supraclavicular

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45
Q

what are the risks with a supraclavicular block

A

pneumothorax

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46
Q

what type of block is best for a surgery at the elbow and below

A

infraclavicular

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47
Q

which PNB is best for surgeries distal to the elbow?

A

axillary

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48
Q

what are the risks with an axillary PNB

A
  1. risk of vascular injection
  2. may miss the musculocutaneous nerve
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49
Q

pros of regional anesthesia for orthopedic surgery

A
  1. may reduce risk of DVT, PE, and blood loss
  2. provides adequate perioperative pain management
  3. may reduce chronic pain issues and opioid use disorders
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50
Q

what is the disadvantage of doing regional anesthesia in ortho

A

time consuming because has to be done under ultrasound guidance

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51
Q

____________________ is a minimally invasive surgical procedure that is used to examine/dx and/or repair an interior joint

A

arthroscopy

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52
Q

arthroscopic surgeries are done on which joints

A
  1. hip
  2. knee
  3. shoulder
  4. wrist
  5. ankle
  6. foot
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53
Q

goals for arthroscopic surgery

A
  1. reduce blood loss
  2. reduce post op pain
  3. reduce length of rehab
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54
Q

__________________ is a surgical replacement of all or part of a joint to restore the natural motion and function of the joint

A

arthroplasty

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55
Q

what joints is an arthroplasty performed on?

A
  1. hip
  2. knee
  3. ankle
  4. shoulder
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56
Q

what are the goals of arthroplasty

A
  1. pain relief
  2. stability of joint motion
  3. deformity correction
57
Q

anesthetic technique for athroscopy?

A

general, regional, combined GA/RA, or local MAC

58
Q

what is the anesthetic technique use for a hip arthroplasty?

A

general, regional, or combo

59
Q

what is the anesthetic technique used in knee arthroplasty

A

general, regional, or combo

60
Q

what is the anesthetic technique used with ankle arthroplasty

A

general regional or combo (neuraxial = subarach block or epidural; SAB with PNB; or just PNB)

61
Q

what anesthetic technique would be used for shoulder arthroplasty

A

general, regional, or combo (interscalene PNB +/- superficial cervical)

62
Q

what position would a patient be in a for a lower extremity joint arthroscopy

A

supine

63
Q

what position would a patient be in for a hip arthroscopy

A

lateral decubitus or supine

64
Q

what position would a patient be in for a shoulder arthroscopy

A

lateral decubitus or modified fowler (beach chair)

65
Q

what position would a patient be in for a hip arthroplasty

A
  1. lateral decubitus (posterior approach)
  2. supine (anterior approach)
66
Q

what position would the patient be in for a knee arthroplasty

A

supine

67
Q

what position would the patient be in for an ankle arthroplasty

A

supine

68
Q

what position would the patient be in for a shoulder arthroplasty

A
  1. lateral decubitus
  2. modified fowler (beach chair)
69
Q

which arthroplasty surgeries are pneumatic tourniquets used

A

knee and ankle

70
Q

how much blood loss is typically seen with a knee or hip arthroplasty

A

~ 1 L

71
Q

how much blood loss is typically seen with a shoulder arthroplasty

A

~ 500 mL

72
Q

which arthroplasty surgeries is there a risk for bone cement implantation syndrome?

A

hip, knee, ankle, shoulder

73
Q

which arthroplastic surgeries will thrombophylaxis of TXA 1-2 g be used?

A

hip, knee, shoulder

74
Q

arthroscopic surgeries require irrigation of fluid under pressure for visualization, this can be absorbed causing what adverse effects?

A
  1. fluid overload
  2. CHF
  3. pulmonary edema
  4. hyponatremia
  5. hypothermia
75
Q

what is TXA?

A

synthetic plasminogen activator that helps decrease blood loss through the inhibition of fibrinolysis and clot degradation

76
Q

how is TXA use in orthopedic surgery/trauma

A
  1. decreases perioperative blood loss and transfusion requirements
  2. 1-2 g administered perioperatively
77
Q

OA hx and physical

A
  1. Routine ROS
  2. what joints are involved? (C spine? any motor deficits? chronic pain?)
  3. evaluate functional capacity
  4. no specific diagnostic testing
78
Q

ortho traumas are associated with significant ____________________.

A

hemorrhage

79
Q

hemorrhage from ortho traumas are associated with what adverse events?

A
  1. shock
  2. fat emboli
  3. thromboembolic respiratory failure
80
Q

what are the most common causes of ortho trauma

A
  1. Falls (43%) 2. MVC (26%)
81
Q

with trauma, there is a high energy response, which should make providers highly suspicious of ___________________________

A

compartment syndrome

82
Q

what is the ideal time to repair an open fracture?

A

within 12 hours of injury

83
Q

if a trauma is taken for emergency surgery, they are considered _____________________; thus, __________________ is essential

A

to have full stomach; GI prophylaxis

84
Q

open pelvic fractures have a mortality rate of _______%

A

70

85
Q

which ortho fracture is affiliated with massive hemorrhage, and 1-2 g of TXA will be given perioperatively

A

pelvic

86
Q

what is the CRNAs role during a pelvic fracture repair surgery

A
  1. focus on the hemodynamics, and end-organ perfusion
  2. replace blood loss using damage control resuscitation
87
Q

when are minimally invasive techniques used in spinal surgery?

A

for non-complex spinal procedures

88
Q

what are the anesthesia implications during complex spinal surgery?

A
  1. airway control and management
  2. fluid and blood management
  3. hemodynamic control
  4. postoperative analgesia
89
Q

what are the 2 most common reasons for spinal surgery

A
  1. intervertebral disc herniation
  2. spinal stenosis
90
Q

____________________ is the gold standard for bony decompression with spinal stenosis

A

laminectomy

91
Q

bony spine decompression (like with spinal stenosis surgery) can lead to _____________________; therefore, ______________________ can be performed with the laminectomy

A

spinal instability; surgical lumbar interbody fusion (LIF)

92
Q

what can surgical lumbar interbody fusions (LIF) be used in the tx of?

A
  1. spinal instability from bony spine decompression (laminectomy)
  2. spinal deformity
  3. spinal radiculopathy secondary to degenerative disc disease
93
Q

what are the treatment options for degenerative disc disease

A
  1. lumbar interbody fusion
  2. disc replacement (younger patients)
94
Q

laminectomy is done via __________________ approach

A

posterior

95
Q

disc replacement is done via __________________ approach; and a may need assistance from ___________________ surgeons

A

anterior; general/vascular

96
Q

during a disc replacement surgery, a ________________ type ETT may be used

A

double lumen

97
Q

in an anterior-posterior approach to the thoracolumbar spine, what are the anesthesia considerations?

A
  1. GETA = safest
  2. consider evoked potential neurologic monitoring
  3. postop analgesia
  4. postitioning = major concern
  5. myelopathic, C-spine unstable, limited ROM –> intubate with video, FOB, or awake
  6. double lumen ETT and pt must be able to tolerate 1 lung anesthesia
  7. there is significant blood loss: IV access, HD monitoring, blood administration, blood conservation strategies
98
Q

what are blood conservation strategies that can be used during thoracolumbar spine surgeries?

A
  1. predonation of autologous blood
  2. surgical site infiltation with epinephrine
  3. hypotensive anesthesia technique
  4. cell saver
  5. antifibrinolytics (TXA 1-2 g periop)
99
Q

what is scoliosis

A

a lateral curvature of the lumbar spine > 10 degrees

100
Q

what are the causes of scoliosis

A
  1. 80% = idiopathic
  2. cognential skeletal abnormalities
  3. neuromuscular dz
  4. neurofibromatosis
  5. spinal tumor –> spinal cord compression
101
Q

surgical intervention of scoliosis

A

fusion of multiple joint spaces with or without anterior release

102
Q

what are the different approaches that can be taken for scoliosis surgery

A

anterior, posterior, combination

103
Q

if anterior approach for spinal surgery is taken, the patient must be able to handle _____________________________

A

one lung ventilation

104
Q

CRNA role during scoliosis surgery

A
  1. hemodynamic control: IV access, ABP, blood products, HoTN technique 2. periop multimodal pain
105
Q

SSEPs are monitored with what type of surgery?

A
  1. neurosurgical procedures (cerebral aneurysm and spine)
  2. aortic cross clamping 3. CEA with shunting
106
Q

anesthetic technique with SSEPs

A
  1. narcotic only
  2. TIVA
  3. 1/2 MAC
107
Q

can you use NMBA while monitoring SSEPs

A

yes

108
Q

______________ potentiates the depressant effects of SSEPs

A

N2O

109
Q

most anesthetic agents will increase latency or decrease amplitude of SSEPs except

A
  1. ketamine
  2. etomidate
  3. opioids
110
Q

when would MEP monitoring be indicated?

A

either spine or intracranial surgery where the motor cortex or descending motor pathways are at risk

111
Q

anesthetic technique of MEP monitoring

A
  1. narcotic base
  2. TIVA
  3. 1/2 MAC
  4. NMBA are CONTRAINDICATED
112
Q

____________ potentiates depressant effects of MEPs and _____________ & ____________ increase cortical amplitudes and enhance MEPs

A

N2O; ketamine; etomidate

113
Q

when would you monitor EMGs

A
  1. analysis of facial nerve during parotid gland surgery
  2. recurrent laryngeal nerve during head and neck surgery
  3. NIMS tube for ACDF surgery
114
Q

anesthetic technique when monitoring EMG

A

unrestricted, but NMBA are contraindicated

115
Q

what section of the spinal cord is most frequently injured?

A

Cervical region (specifically the craniocervical jx)

116
Q

what is the most common C-spine vertebrae injured

A

C7

117
Q

at what cervical level injury will respirations cease?

A

above the level of C3

118
Q

airway management implications with C-spine injury

A
  1. avoid succ if have SCI
  2. technique dependent on the level of injury, level of cooperation, hemodynamic stability, and ability to protect the airway
  3. manual inline stabilization recommended
119
Q

what is autonomic hyperreflexia/dysreflexia

A

sudden activation of sympathetic response as a result of noxious stimuli (colorectal or bladder distension)

120
Q

autonomic dysreflexia will often present with _____________________

A

severe HTN

121
Q

autonomic dysreflexia typically occurs in patients with SCI above ___________, and persists __________ to ______ post SCI

A

T6; weeks; months

122
Q

how do you manage autonomic dysreflexia

A
  1. determine and correct the noxious stimuli
  2. reduce dangerous BP levels
123
Q

why is succinylcholine not recommended in patients with SCI

A
  1. fasiculations can exacerbate SCI
  2. can precipitate sudden cardiac arrest secondary to massive muscle injury
124
Q

so how should you intubate your patient with SCI without using succ?

A
  1. non-relaxant airway control techniques
  2. depolarizing NMBA - roc
125
Q

acute SCI outcomes are dependent on what 3 factors?

A
  1. severity of acute injury
  2. prevention of exacerbation of injury during rescute, transport, and hospitalization
  3. avoidance of hypoxia and HoTN
126
Q

there are about 10,000 spinal cord injuries at year, with 80% being __________ gender, with a median age of _____________

A

male; 25

127
Q

what is the most common type of SCI?

A

incomplete tetraplegia

128
Q

what precautions should be taken in any patient who comes in as a trauma to the head/face or c/o of pain in neck with or without palpitation or unconsicous?

A
  1. neutral C-spine; C-collar
  2. spinal backboard with movement
129
Q

anesthesia approach to SCI

A
  1. early stabilization will improve outcomes
  2. maintain MAP ~ 90 mmHg for at least 7 days post injury
  3. document neurostatus before: induction of anesthesia, intubation, and positioning.
  4. consider awake intubation
  5. induction propofol vs ketamine or combo
  6. avoid N2O
  7. TXA administration
130
Q

what are the considerations with propofol for induction in spinal cord injury patients/TBI

A

decreases cerebral blood flow (CMRO2); decreases CBF and ICP

131
Q

which induction drug is preferred in the hemodynamically stable TBI patient

A

propofol

132
Q

what are the considerations with ketamine as the induction agent for a pt with SCI/TBI

A

increases ICP, but avoids hypotension in hypovolemic trauma

133
Q

SX of spinal shock

A
  1. Hotn 2. bradycardia 3. hypothermia
134
Q

sx of spinal shock progress/intensify more _______________ from _________ vertebral level

A

cephalad; T6

135
Q

__________________ is critical in the patient with spinal shock for resuscitation

A

invasive monitoring

136
Q

what is the most common foot and ankle surgery

A

ankle fracture/joint fusion

137
Q

T/F: ortho surgeries on the extremities do not use pneumatic tourniquets

A

false - they do use them

138
Q

anesthetic technique in ortho extremity surgery

A

GA, regional, or combo

Anesthesia Principles I (5 decks)

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