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NA 1 > A for orthopedics > Flashcards

A for orthopedics Flashcards

1
Q

preoperative assessment

A

cardiovascular system: AHA recommendations for cardiac testing, mobility is an issue

respiratory system: decreases in SaO₂, increase in closing volume, hip fracture → decreased PaO₂

neurologic assessment: delirium and POCD-assess mental status

preoperative assessment: check coag status and baseline lab values, SSI- major concern with joint arthroplasty, large bore IVs

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2
Q

Surgical site infection

A

Major issue in orthopedic surgery
- destroys healing and repairs
- may lead to removal
- TKA has 2x infection rate of THA because of less soft tissue and muscle

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3
Q

thromboprophylaxis: highest risk of DVT

A

THA/TKA
hip/pelvic fx

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4
Q

surgical site infection prevention

A
  • patient antibacterial soap
  • laminar flow
  • prophylactic abx
  • meticulous skin prep
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5
Q

thromboprophylaxis: warfarin

A

INR > 2.5

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6
Q

orthopedic emergencies

A

dislocated hip
finger reimplantation
compartment syndrome

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7
Q

orthopedic emergencies: dislocated hip

A

general (usually)
NPO status
quick procedure

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8
Q

orthopedic emergencies: finger reimplantation

A

general with a block
VERY long procedure
NPO status

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9
Q

orthopedic emergencies: compartment syndrome

A

seen most often with tibial fx’s
treatment surgical decompression

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10
Q

advantages of regional anesthesia

A
  • less risk of DVT/PE
  • decreased blood loss
  • less respiratory issues
  • no need for airway manipulation
  • better postop pain management → less incidence of chronic pain
  • less N/V
  • excellent skeletal muscle relaxation
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11
Q

common comorbidities in orthopedic surgery

A

osteoarthritis: loss of articular cartilage, no systemic manifestations, positioning concerns

rheumatoid arthritis: systemic disease, autoimmune disease

ankylosing spondylitis: fusion of axial skeleton, kyphosis, difficult airway & regional

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12
Q

rheumatoid arthritis

A
  • possible difficult intubation
  • acute pericarditis
  • acute interstitial fibrosis
  • Sjoren’s syndrome
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13
Q

RA: difficult intubation

A
  • TMJ synovitis
  • decreased glottic opening
  • cervical spine immobility/pain
  • Atlanta occipital subluxation
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14
Q

RA: acute pericarditis

A
  • symptoms of right heart failure
  • 2D echo to evaluate
  • cancel case if acute – may need to be drained
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15
Q

RA: acute interstitial fibrosis

A

restrictive disease
dyspnea and chronic cough

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16
Q

RA: Sjoren’s disease

A

chronic dry eyes
use lubricant

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17
Q

orthopedic considerations

A

tourniquet
fat embolism
POVL
positoning

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18
Q

pneumatic tourniquet: preparation

A
  • widest cuff possible
  • 2 layers of padding
  • 2 fingers between pad and cuff
  • exsanguinate with esmarch (bandage)
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19
Q

pneumatic tourniquet: pressure/time

A
  • pressure: usually 100 mmHg > SBP
  • limit of 2 hours (some say 2.5-3 hrs)
  • deflation: 10-30 mins for time> 2 hrs
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20
Q

pneumatic tourniquet: tourniquet pain

A
  • occurs after 60 mins
  • tachycardia and HTN
  • only treatment → deflation
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21
Q

pneumatic tourniquet: complicaitons

A

local: nerve/muscle injury

systemic:
- cardiovascular: HTN & tachy
- cerebral: increased CBF
- hematologic: hypercoagulable & fibrinolytic
- metabolic: LA, hyperaklemia, hypoxic
- temperature: inflation vs. deflation

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22
Q

Myonephropathic metabolic syndrome

A
  • upon deflation
  • hypotension
  • metabolic acidosis
  • hyperkalemia
  • myoglobinuria
  • myoglobinemia
  • possible renal failure
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23
Q

fat embolism: pathogenesis (mechanical theory)

A
  • injury → vessels are torn. Fat emboli enter circulation through the torn vessels
  • traveling fat → respiratory system. enters pulmonary capillaries and obstructs them
  • arterial system → two mechanisms. microemboli, patent foramen ovale
  • unanswered questions? → why the wait? Symptoms don’t appear 24-72 hrs. FES with no fracture?
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24
Q

fat embolism: pathogenesis (biochemical theory)

A

THE PRODUCTION OF TOXIC INTERMEDIATES (with pro-inflammatory effects) of circulating fat
- FFA
- cytokines
- C-reactive proteins

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25
fat embolism: clinical presentation & differential diagnosis
- delayed presentation - pulmonary features are the most common presenting features differential diagnosis - PE - amniotic fluid embolus - air embolus
26
FES typically manifests __ to __ hours after initial insult
24-72
27
FES: respiratory
- usually presenting symptom - hypoxia, dyspnea and tachypnea - ARDS-like syndrome develops
28
FES: petechial rash
- found on non-dependent areas of the body: head, neck, anterior chest, thorax, axilla, sub-conjunctiva
29
FES: classic triad
hypoxemia neurologic abnormalities petechial rash
30
FES: clinical/lab findings
- anemia/thrombocytopenia - fever - fat in urine - coagulation disorders - myocardial depression
31
differential diagnosis
PE - same time frame - no neurologic symptoms or rash - PE will show up on CT amniotic embolus - pregnant? - presents with CV collapse, respiratory failure, and seizures Air embolus - rash in unusual - neurologic and respiratory symptoms will show immediately with AE
32
POVL: causes
central retinal artery occlusion ischemic optic neuropathy
33
POVL: timing/presentation
24-48 hrs bilateral painless, loss of pupillary reflex
34
POVL: risk factors
obesity Wilson frame use length of surgery blood loss decreased use of colloids
35
positioning-prone
- induce on a stretcher - head and neck supported & aligned with turn - check breath sounds after turning - arms < 90 degrees or tucked - abdomen must be hanging freely - avoid flexion/extension of neck - head above heart level - increased ICP, increased IOP - PSV vs. VCV
36
positioning-lateral
- dependent lung is under-ventilated and over-perfused - axillary roll - pulse ox on the dependent arm - "bean bag" - pad facial structures, breast, and genitalia
37
positioning-beach chair
- decreased BP & preload, from venous pooling - adequately hydrate - lighten anesthesia - watch for inadvertent extubation - support head, maintain a neutral position - VAE
38
arthroscopy-lower extremity: outpatient
- most done outpatient - GA usually done - pain control - (intraarticular injection/PNB)
39
arthroscopy-lower extremity: knee/hip & TNS
ACL repair - postop pain, muscle relaxation Hip scope - positioning with traction TNS - transient neurologic symptoms - seen after neuraxial - common with lithotomy, knee scope, lidocaine
40
hip fracture: mortality
1 year = 30% 50% have postop confusion/delirium
41
hip fracture: timing of surgery
- earlier is better - less pain - less complication - decreased LOS - beware of good Hct!
42
pelvic fracture: mortality
3 month mortality = 14% retroperitoneal bleeding
43
hip fracture: anesthesia
- fracture table - aline? - SAB - 4x greater risk for DVT with GA
44
pelvic fracture: timing of surgery
- earlier is better - other injuries may delay surgery - optimal time to repair = 1 week
45
pelvic fracture: anesthesia
- high risk of DVT &/or PE - GA with an epidural for postop analgesia - large bore IVs or possible central line - possible neuromonitoring
45
hip/knee arthroplasty: most important risk factor for adverse events are
ADVANCING AGE
45
hip/knee arthroplasty: anesthesia
- SAB is an ideal anesthetic - Hip: significant EBL - TXA - controlled hypotension - preop preparation
45
hip/knee arthroplasty: common complications
cardiac events PE pneumonia infection
46
hip/knee arthroplasty: methyl methacrylate
hypotension BCIS (bone cement implantation syndrome) treatment - supportive & O₂
47
GA with OET was found to be an independent risk for...
nonsurgical complications after a TKA
48
bone-cement implantation syndrome: when will it occur?
- femoral reaming - acetabular/femoral cementing - insertion of the prosthesis - after TQT release (rare)
49
bone-cement implantation syndrome: signs/symptoms
- hypotension/hypoxia - An abrupt decrease in ETCO₂ will be the first indication under anesthesia - awake patient: dyspnea & altered sensorium
50
bone-cement implantation syndrome: mechanism
- embolization of bone marrow debris - toxic effects of MMA - release of cytokines
51
bone-cement implantation syndrome: risk factors
- pre-existing cardiac/pulmonary dx - ASA 3 or higher - long stem arthroplasty (THA > TKA) - revision surgeries
52
TXA
- antifibrinolytic and plasminogen activator - stops the conversion of plasminogen to plasmin - stops the breakdown of fibrin clots has decreased the rate of transfusion in THA/TKA to < 5% dosing is still being investigated
53
foot/ankle surgery: common complications
- compartment syndrome: be careful with long-acting PNB - may mask signs of compartment syndrome
54
foot/ankle surgery: anesthesia
SAB or PNB need to block sciatic and femoral nerves (no thigh TQT)
55
shoulder surgery: Bezold-Jarish reflex
LV receptor senses low-volume → efferent signal → decrease sympathetic flow (hypotension) & increase vagal output (bradycardia
56
shoulder surgery: postioning
-beach chair/lateral - VAE - POVL
57
shoulder surgery: HBE (hypotensive bradycardic episode)
- get hypotensive and bradycardic when doing a shoulder scope under an interscalene block - bezold-jarish reflex - may progress to cardiac arrest
58
shoulder surgery: anesthesia
- watch for hypotension - cuff-location when sitting, not reading BP at circle of willis
59
spine surgery: positioning
prone POVL potential
60
spine surgery: neuromonitors
- SSEP (somatosensory evoked potentials) - MEP (motor evoked potentials) - EMG (electromyography)
61
spine surgery: anesthesia
- cervical procedures - glide scope - cervical instability - awake FOI - anterior/posterior repairs
62
SSEP
- monitor the posterior (sensory) portion of the spinal cord - impulse: periphery → brain
63
MEP
- monitors anterior (motor) portion of spinal cord - impulse: brain → periphery
64
EMG
monitors nerve root injuries during pedicle screw placement
65
amplitude and latency
- IA - reduce latency - nitrous: reduce amplitude
66
attenuate SSEP & MEP
- hypotension - hypothermia - hypocarbia - anemia - anesthetics
67
types of scoliosis
idiopathic congenital neuromuscular
68
scoliosis: large blood loss
- deliberate hypotension - cell saver - intraoperative normovolemic hemodilution - TXA - autologous blood
69
scoliosis: POVL/neuromonitoring
- POVL rare (0.1%) - SSEM/MEP - usual - "wake up" test
70
scoliosis: anesthesia
- large bore IVs - arterial line - TIVA? - watch EBL
71
anesthetic implications: positioning
- prone - POVL potential - decreased abdominal pressure (may lead to increased EBL)
72
anesthetic implications: large EBL
- cell saver - intraoperative nomovolemic hemodilution - TXA - autologous blood? - aline- yes
73
anesthetic implications: complicaitons
- postoperative neurological deficit - wake up test (if needed) - inadvertent extubation - air embolus - dislodgment of instrumentation
74
major risk factors for delirium
alcohol use preoperative dementia cognitive imapirment psychotropic medication multiple comorbidities
75
perioperative triggers for dementia
- hypoexemia, hypotension, hypervolemia - abnormal electrolytes - infection - sleep deprivation - pain - benzos - anticholinergics
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NA 1 (15 decks)

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