Anesthesia for Orthopedic Procedures - Final Wrap Up

Question 1

What are the special considerations for Orthopedic Surgery?

Answer 1

Bone Cement

Pneumatic Tourniquet

Fat Embolism

DVT

Question 2

How does Bone Cement work?

Answer 2

Powder Methylmethacrylate + Liquid Methylmethracrylate = Exothermic Hardening

Question 3

What are complications of Bone Cementing?

Answer 3

Intermedullary HTN > 500 mmHg

Fat, Bone Marrow, Cement, & Air Embolism

Residual MMA = Vasodilation

Tissue Thromboplastin Release = Microthrombus

Question 4

What are symptoms of Bone Cement Implantation Syndrome?

Answer 4

Hypoxia

Hypotension

Dysrhythmias

Pulm. HTN

↓CO

Embolization

Question 5

What are ways to minimize the negative effects of Bone Cementing?

Answer 5

↑FiO₂

Euvolemia

Vasopressors

Venting Distal Femur

High Pressure Lavage of Femoral Shaft

Question 6

What are problems r/t Pneumatic Tourniquets?

Answer 6

Hemodynamic & Metabolic Change

Pain

Embolus

Muscle/Nerve Injury

Limb Cooling

Question 7

What are the CV effects of having a prolonged tourniquet of 45 - 60 mins?

Answer 7

HTN

Tachycardia

Sympathetic Stimulation

Sweating

Question 8

What happens when a prolonged cuff/tourniquet is deflated?

Answer 8

↓CVP

↓MAP

↓Pain

↓Core Temp

↑HR

Question 9

How much pressure is applied by the Cuff/Tourniquet

Answer 9

100 mmHg above Systolic

Question 10

Which nerve fibers are affected by Tourniquets that cause pain?

Answer 10

Unmyelinated Slow C-Fibers

Question 11

What is Increased w/ Cuff /Tourniquet Deflation?

Answer 11

PaCO₂

EtCO₂

Lactate &Potassium

Metabolic Waste & Free Radicals

Minute Volume

Dysrhythmias

Question 12

When are Tourniquets Contraindicated?

Answer 12

Calcified Arteries

Question 13

Tourniquet Ischemia in the lower extremities lead to ______ & potentially Pulmonary Embolisms

Answer 13

Tourniquet Ischemia in the lower extremities lead to DVT & potentially Pulmonary Embolisms

Question 14

What can result if a Tourniquet stays inflated > 2 hours?

Answer 14

Transient Muscle Injury

Permanent Nerve Injury

Rhabdomyolysis

Question 15

What are the characteristics of Fat Embolism Syndrome?

Answer 15

Less Frequent, but more Fatal

Dyspnea

Confusion

Petechiae

Question 16

What is Fat Embolism Syndrome associated w/?

Answer 16

Long Bone Fractures

CPR

Liposuction

IV Lipds

Question 17

What is the Pathophysiology of Fat Embolism Syndrome?

Answer 17

1. Fat Globules enter circulation via medullary vessel tears
2. ↑Fatty Acid Release Vasoactive Amines & Prostaglandins
3. ARDS
4. Cerebral Capillary Damage/Edema

Question 18

How is Fat Embolism Syndrome diagnosed?

Answer 18

Petechiae

Fat in Retina, Urine, Sputum

Coagulopathy

Progressive Pulm. Decline

Question 19

What would Fat Embolism Syndrome look like under General Anesthesia?

Answer 19

↓EtCO₂

↓SpO₂

↑PAP

Question 20

What is the best way to Prevent & Treat Fat Embolism Syndrome?

Answer 20

Early Stabilization & Supportive Treatment

Question 21

Which type of procedures have the greatest risk for DVT/PE?

Answer 21

Knee & Hip Replacement

Question 22

What are Risk factors that contribute to DVT/PE?

Answer 22

> 60 y.o

> 30 min Procedure

> 4 Days Immobility

Obesity

Tourniquets

Lower Extremity Fx

Question 23

What causes a DVT/PE?

Answer 23

Venous Stasis & Hypercoagulability d/t Inflammation

Question 24

How does Neuraxial Anesthesia (Spinals/Epidurals) decrease the risk for DVT/PE?

Answer 24

↑Venous Blood Flow

Anti-Inflammatory

↓Platelet Activity

↓Factor VIII & VWF

↓Stress Hormone

Stable Antithrombin III

Question 25

Which type of Anesthesia is preferred for Joint Manipulation?

Answer 25

General w/ short acting meds along w/ Sux or Roc

Question 26

What would be appropriate reasons to Delay surgery for a Hip Fracture?

Answer 26

Coagulopathy & Uncompensated Heart Failure

Question 27

What are predictors of Peri-Op Mortality r/t Hip Repairs?

Answer 27

\> 85 y.o Cancer Hx Pre-Op Neuro Changes Post-Op Chest & Wound Infection

Question 28

What are the advantages of Regional Anesthesia for Hip Repairs?

Answer 28

Low Blood Loss ↓DVT/PE Risk Faster return to Neuro Baseline

Question 29

What technique can be used to keep a patient off the fracture pre-operatively?

Answer 29

Hypobaric Technique

Question 30

When does a Regional lose its benefit during a Hip Repair?

Answer 30

Oversedation & Hypoxia

Question 31

List the Hip Fracture location Blood Loss from Greatest to Least

Answer 31

Trochanteric \> Femoral Neck \> Transcervical & Subcapital

Question 32

How are Undisplaced Intracapsular Fractures repaired?

Answer 32

Cannulated Screw

Question 33

How are Displaced Intracapsular Fractures repaired?

Answer 33

Internal Fixation Hemiarthroplasty Total Hip Replacement

Question 34

How are Extracapsular Fractures treated?

Answer 34

Extramedulllary Sliding Plate/Screw Intramedullary Gamma Nail

Question 35

When is a Total Hip Repair indicated?

Answer 35

Osteoarthritis RA Vascular Necrosis

Question 36

What is the EBL for Total Hip Repairs?

Answer 36

400-2000 mL Have PRBCs, 2nd IV, Cell Saver

Question 37

What are the potential complications of Upper Extremity Arthroplasty?

Answer 37

Blood Loss PTX Subclavian Vein Injury Accidental Extubation C-Spine Injury Embolism Bone Cement Problems

Question 38

What procedures are used for Severed Parts?

Answer 38

Re-Implantation - Long, Staged procedures w/ Grafting & Re-Anastamosis

Question 39

Interscalene blocks target the _______ and should be avoided in patients w/ compromised ________ status

Answer 39

Interscalene blocks target the **Brachial Plexus Trunks** and should be avoided in patients w/ compromised **Respiratory** status

Question 40

What are risks associated w/ Interscalene Blocks?

Answer 40

Horner's Syndrome PTX Epidural, Spinal, Arterial Injection Complete Phrenic Block

Question 41

What does a Supraclavicular Block target?

Answer 41

Brachial Plexus *Divisions*

Question 42

What are the risks associated w/ Supraclavicular Blocks?

Answer 42

PTX Vocal Cord Palsy 50% Phrenic Block

Question 43

What kind of block targets the Brachial Plexus *Cords*?

Answer 43

Infraclavicular Block for Elbows & Hands has a small PTX risk

Question 44

Which nerves are blocked w/ an Axillary Block?

Answer 44

Medial, Ulnar, & Radial Nerves

Question 45

What are the risks associated w/ an Axillary Block?

Answer 45

Hematoma & Vascular Injection

Question 46

What is a concern when using a Femoral Nerve Block?

Answer 46

Falls d/t Loss of Quad Function

Question 47

Where can a Sciatic Nerve Block have its effect?

Answer 47

From Hip to Foot

Question 48

A Popliteal block can be useful for Foot & Ankle surgery, but spares the ______ & ______ for easier ambulation

Answer 48

A Popliteal block can be useful for Foot & Ankle surgery, but spares the **HAMSTRING** & **KNEE FLEXION** for easier ambulation