Anesthesia for Orthopedics (Part 3) Flashcards by Collin Morris

What is arthroscopy?

Minimally invasive surgery performed to examine and sometimes repair damage to the interior of a joint
-Can use any type of anesthesia, pt dependent

How well did you know this?

Not at all

Perfectly

Pt positioning for arthroscopy

Lower extremity: supine
Hip: lateral or supine
Shoulder: modified fowler (beach) or lateral

How well did you know this?

Not at all

Perfectly

Arthroscopy uses fluid instilled under pressure for visualization. This can cause what?

Fluid overload, CHF, pulmonary edema, hyponatremia, hypothermia

How well did you know this?

Not at all

Perfectly

For each CM of head elevation above the heart we see a ___mmHg reduction in MAP

0.75 mmHg per cm
2 mmHg per inch

How well did you know this?

Not at all

Perfectly

The ___-____ reflex can cause issues in shoulder surgery with an interscalene block in the sitting position.

Bezold-Jarisch

How well did you know this?

Not at all

Perfectly

The Bezold-Jarisch reflex effects are seen as profound ____ and ____.

Hypotension and bradycardia

How well did you know this?

Not at all

Perfectly

What is arthroplasty?

Surgical replacement of a joint to restore motion and function

How well did you know this?

Not at all

Perfectly

Nearly ___% of hip arthroplasty patients are also obese.

50%
-This adds a whole new level of complication by bringing in all anesthesia obesity considerations.

How well did you know this?

Not at all

Perfectly

The ____ approach is most common for THA.

Posterior approach - involves incision from iliac crest across joint to midthigh (lateral position)
-A direct anterior approach is growing as it is available as minimally invasive (supine)

How well did you know this?

Not at all

Perfectly

The THA anesthetic plan usually includes ____ anesthesia unless contraindicated.

Regional

How well did you know this?

Not at all

Perfectly

The use of ____ ____ inhibits fibrinolysis and is used in THA to cut down blood loss.

Transexamic acid (TXA) 1-2g

How well did you know this?

Not at all

Perfectly

TKA are commonly done with the ___ ___ block and in what position?

Usually GA with adductor canal block in the supine position

How well did you know this?

Not at all

Perfectly

____ ____ is used for assisting in blood loss.

Transexamic acid (TXA) 1-2g
-Also the pneumatic tourniquet around the thigh

How well did you know this?

Not at all

Perfectly

Anesthesia options for ankle arthroplasty?

Tourniquet and spinal/epidural
Combination of regional techniques for intra and postop
Sciatic and femoral blocks - work for all below knee

How well did you know this?

Not at all

Perfectly

Some big issues with shoulder arthroplasty?

Cerebral ischemia
POVL
Bezold-Jarisch (sitting position, interscalene block)

How well did you know this?

Not at all

Perfectly

When surgery is performed in the sitting position, what are some things we need to take into account?

Lower venous return = lower BP
Can lead to cerebral ischemia and POVL (ION - Ischemic Optic Neuropathy)

How well did you know this?

Not at all

Perfectly

Civilian extremity injuries occur most often due to ___.

Falls (43%)
MVC second with 26%

How well did you know this?

Not at all

Perfectly

The highest risk of massive hemorrhage is with ___ fx.

Pelvic fx
-Risk of shock, fat emboli, thromboembolic hypoxic respiratory failure

How well did you know this?

Not at all

Perfectly

Ideal time for open fx repair is _____. It should be done with what type of anesthesia for greatest pt safety?

Within 12 hours. Done under GA for aspiration risk - possible full stomachs

How well did you know this?

Not at all

Perfectly

Mortality rates climb up to ___% with open pelvic fractures.

70%
-Huge risk for massive hemorrhage, remember TXA for these pts!

How well did you know this?

Not at all

Perfectly

Main role of the anesthetist in pelvic fx repair?

The anesthetist’s role at this time should focus on close monitoring of hemodynamic end-organ perfusion in addition to replacing blood loss using principles of damage control resuscitation.

How well did you know this?

Not at all

Perfectly

Blood Supply for spine includes:
__ Anterior Spinal Arterie(s)
__ Posterior Spinal Arterie(s)

-1 Anterior Spinal Artery: the Artery of Adamkiewicz @T10-11 –> disruption = paralysis
-2 Posterior Spinal Arteries

How well did you know this?

Not at all

Perfectly

Anesthetic challenges for spinal surgery:

-Airway management
-Fluid and blood management
-Hemodynamic control and monitoring
-Perioperative anaglesia

How well did you know this?

Not at all

Perfectly

Gold standard surgical approach for spinal stenosis

Bony decompression by laminectomy
-Can be alongside lumbar interbody fusion for stability

How well did you know this?

Not at all

Perfectly

For anterior spinal surgical approaches on thoracic segments, we will need what?

A double-lumen ETT for one lung ventilation

What will be much harder to do successfully in spinal fusion patients?

Subarachnoid blocks and epidurals at the level of the fusion

What surgical technique is used for scoliosis

Anterior, posterior, or combo -Anterior requires thoracotomy and double ETT

What is important for us as anesthesia in scoliosis surgery or any serious spinal surgery?

-Good IV access -Advanced BP monitoring -Access to blood products -Purposeful use of hypotensive technique

Why is a laparoscopic approach advantageous in the anterior approach?

-Better respiratory functioning -Diminished blood loss -Shorter LOS -Lower costs **Only appropriate for the right patients

What patients should NOT be a candidate for laparoscopic spinal surgery?

1. Previous abdominal surgery/trauma 2. Thoracic spine surgery that CANNOT tolerate one lung anesthesia 3. Internal fixation with extensive instrumentation

Spinal Surgery Anesthesia Management (putting it all together here)

-Good IV access -Advanced monitoring (ABP, SSEP, MEPs) -Proper positioning -Airway A/B/C -Can pt tolerate one lung anesthesia if that is the plan? -Hypotensive technique -Blood conservation strategies

What are some examples of blood conservation strategies?

-Predonation autologous blood -Cell saver -Surgical site infiltration with epi -Hypotensive anesthesia -TXA

What changes on EP can signify possible cerebral ischemia?

50% reduction in amplitude OR 10% increase in latency

SSEPs monitor what? Can we use NMB with SSEP?

Monitor the integrity of the neural structures along both the peripheral and central somatosensory pathways -We CAN use NMB

Anesthesia effects on SSEPs

Increase latency and decrease amplitude *Ketamine, etomidate, opioids the exception* Use narc-based, TIVA, 1/2 MAC Avoid N2O - depressant

____ and ____ increase cortical amplitudes and enhance SSEP/MEP waveforms.

Ketamine and etomidate

MEPs monitor what? Can we use NMB?

Monitor integrity of motor tracts (anterolateral spinal cord/corticospinal tract) -CANNOT use NMB

Anesthesia effects on MEPs

Narc-based, TIVA, 1/2 MAC Avoid N2O - depressant **NO NMBA**

What does an electromyography do? Can we use NMB?

Stimulates a motor nerve and monitors known innervated muscle groups *NO NMB*

Difference in EMG versus SSEP/MEP?

EMG cannot monitor for ischemia

A NIMS ETT allows for what?

Monitoring of the vocal cords Used in ACDF surgery

Prone positioining changes

-Decreased CO and BP unless torso in plane -Keep abdomen free floating -Decreased FRC and TLC -Increased abdominal pressures, PIP -Use pressure control ventilation

Wilson Frame table allows for what that may increase comfort and outcomes?

Natural curvature of spine is supported

The huge MUST for the rotisserie table

Ensure the top of the sandwich is secure!! *Chickens and sandwiches.. idk*

In a face down position we should check positioning of face how frequently?

q15-30 mins -Use mirror, maintain patent tube

Orthopedic extremity surgery uses ___ ___.

Pneumatic tourniquet

There are roughly _____ spinal cord injuries per year in the US.

10,000 with about 80% males

Spinal cord outcomes are dependent on what 3 factors?

1. Severity of acute injury 2. Prevention of exacerbation of injury during rescue, transport, and hospitalization 3. Avoidance of hypoxia and hypotension

T/F: >50% of all traumatic spinal cord injuries occur in cervical region.

TRUE.

Most common SCI types:

1. Incomplete tetraplegia (31%) 2. Complete paraplegia (25%) 3. Complete tetraplegia (20%) 4. Incomplete paraplegia (19%)

Tetraplegia results in:

Partial or total loss of all four limbs and the torso

Paraplegia results in:

Only lower extremities and torso affected

6 p's of SCIs:

1. Pain 2. Paralysis 3. Paresthesia 4. Priapism 5. Ptosis 6. Position

SCI pts should have spinal immobilization before being moved. What position will we obtain an airway in?

Manual in-line stabilized position

Radiologic evaluation should include which cervical vertabrae?

All 7 *C7 most commonly injured site*

An SCI above C-3 often results in what?

Apnea, rendered ventilator dependent

_____ could exacerbate a SCI due to fasciculations.

Succ

We will maintain a MAP of ~___mmHg for best patient perfusion in spinal cord injuries

~90 mmHg

What induction agents should be used on spinal cord injury patients: Propofol or ketamine?

Hemodynamically stable = Propofol Unstable = Ketamine, but expect increased ICP

3 main symptoms of spinal shock:

1. Hypotension 2. Bradycardia 3. Hypothermia *A turned of sympathetic system is the best way to think of these* -Worse as we move more cephalad above T6

What is autonomic dysreflexia?

Sudden activation of sympathetic response secondary to a noxious stimuli -Presents with extreme HTN -Possible seizure, pulm edema, MI, AKI, intracranial hemorrhage

Management of autonomic dysreflexia:

Determine the noxious stimuli and correct it Fix BP

Thats all she wrote. Enjoy the studying!

Spring break next week yee haw