Exam 3 Flashcards
(160 cards)
1
Q
What is a significant risk for poor outcomes after ortho surgery
A
Older age
2
Q
What risks were addressed by the Surgical Care Improvement Project (SCIP)
A
Surgical site infection
Postop thromboembolism
Periop glucose management
Maintenance of normothermia
3
Q
What is the timing for Ancef and Vancomycin
A
Ancef: within 1 hour of incision
Vanc: within 2 hours of incision
4
Q
What are three things that are used to prevent surgical site infection
A
Sterile technique
Antibiotic irrigation
Antibiotic coated dressings
5
Q
What makes older patients at increased risk for respiratory complications following orthopedic surgery
A
Decreased arterial O2 tension
Increased closing volumes
Decreased (around 10%) forced expiratory volume
6
Q
What are 4 considerations for respiratory complications with ortho surgery
A
Elderly are at the highest risk
High rate of obesity and OSA
STOP-bang questionnaire and prudent postop management for OSA
Embolization of bone marrow debris to lungs after athroplasty
7
Q
Who has a higher risk of periop myocardial morbidity and mortality
A
Older patients
8
Q
What contributes to cardiac complications of ortho surgery
A
Systemic inflammatory response syndrome
Significant blood loss and fluid shifts
Stress response
9
Q
What cardiac changes does the stress response from ortho surgery result in
A
Tachycardia
Hypertension
Increased o2 demand
Myocardial ischemia
10
Q
What is a common complication seen in older patients after ortho surgery
A
Delirium
11
Q
What factors influence an elderly patient’s development of delirium
A
Increased LOS
Poor functional recovery
ETOH
Pre-op dementia
Psychotropic medications
Multiple comorbid conditions
12
Q
What are intraop risk factors for neurologic complications
A
Hypoxemia
Hypotension
Hypervolemia
Electrolyte imbalances
Pain
Benzos
Anticholinergic meds
13
Q
What is the purpose of pneumatic tourniquet
A
Relatively bloodless field
Minimize blood loss
Identification of vital structures (improved visualization)
14
Q
what is the max amount of time a tourniquet should be applied
A
Two hours
15
Q
Necessary pressure for tourniquet in upper extremity
A
70-90 mmHg higher than SBP
16
Q
Necessary pressure for tourniquet in lower extremity
A
Twice the patient’s SBP
17
Q
How long does it take for abolition of somatosensory evoked potentials and nerve conduction to occur from pneumatic tourniquet
A
Within 30 min
18
Q
What happens when tourniquet is inflated for >60 minutes
A
Pain and hypertension
19
Q
What happens when tourniquet is inflated for >2 hours
A
Postoperative neuropraxia
20
Q
What are the consequences of acid metabolites (thromboxane) being released into central circulation upon tourniquet deflation
A
Transient:
Fall in core temp
Metabolic acidosis
Fall in central venous oxygen tension
Fall in pulmonary and systemic arterial pressures
Increase in end tidal Co2
21
Q
Which fibers are responsible for burning/aching pain
A
Unmyelinated C fibers
22
Q
Which fibers are responsible for pinprick, tingling, and buzzing sensations
A
Myelinated A-delta fibers
23
Q
What can be added to LA solutions for tourniquet pain
A
Opioids, ketorolac, melatonin, clonidine, precedex
24
Q
Protein binding, clearance, half life of TXA
A
Minimally protein bound
Half life 2-3 hours
Cleared by kidneys
24
Dose of TXA
1 gram in 50ml of any crystalloid over 5-10 minutes, 5-20 minutes prior to incision
25
Side effects of txa
Minimal - nausea, vomiting, diarrhea
26
Contraindications of TXA
Clotting disorders
Acquired defective color vision
Subarachnoid bleed
Active clotting
Hypersensitivity to TXA
27
Relative contraindications to TXA
History of vascular occlusive events
Taking procoagulant
Prescription hormonal contraception
28
WHat should the BP be for deliberate hypotension
SBP between 80-90 or MAP between 50 and 65 in people without HTN
or
30% reduction of baseline MAP in patients with HTN
29
What patients should deliberate hypotension not be used in
history of cardiac, cerebrovascular, renal, or hepatic disease, or severe PVD
30
When is deliberate hypotension contraindicated
pts with uncorrected hypovolemia and severe anemia
31
What is a potential problem with deliberate hypotension
Vision loss
32
Which ortho surgeries have the highest incidence of thromboembolism such as DVT and PE
Pelvic fracture, hip fracture, total knee replacement
33
What is the leading cause of morbidity and mortality after orthopedic surgery
Thromboembolic events
34
How long should ortho patients receive DVT prophylaxis
up to 35 days post op
35
Risk factors for DVT/PE
advanced age, cancer, bed rest, prothrombotic conditions (factor V leiden), and prior DVT/PE
36
3 Major features of fat embolism syndrome
Respiratory insufficiency
Cerebral involvement
Petechial rash
37
5 Minor features of fat embolism syndrome
Pyrexia
Tachycardia
Retinal changes
Jaundice
Renal changes
38
Lab features of fat embolism syndrome
Fat microglobulinemia (required test for confirmation)
Anemia
Thrombocytopenia
High erythrocyte sedimentation rate
39
What are the consequences of acute extremity compartment syndrome
Infection
Muscle necrosis
Contractures
Nerve injury
Chronic pain
Amputation
Death
40
What are most diagnoses of compartment syndrome related to
Fractures, mostly in the lower leg
41
What is the most common fracture site associated with compartment syndrome
Tibial diaphysis: it is frequently injured and the fascial space is already tight
42
What are the 5 Ps of compartment syndrome
Painful onset
Pallor
Paresthesia
Paralysis
Pulselessness
43
Normal compartment pressures
Below 10 mmHg
44
When does significant injury occur from compartment syndrome
When absolute intracompartmental pressure exceeds 30-50
45
What is the definitive diagnostic tool for compartment syndrome
Intracompartmental pressure monitoring (sensitivity 94%)
46
how long should fasciotomy remain open for
at least 48 hours
47
How are crush injuries treated
adding hyperbaric O2
48
What is the main consequence of sitting/beach chair position
Cerebral hypo-perfusion
49
Where should bp be measured in sitting/beach chair position
At the level of the brain
50
Complications of beach chair/sitting position
hypotension/bradycardia
air embolism
pneumothorax
cerebral hypoperfusion
51
What position gives better limb stability during elbow surgery
Prone
52
What provides greater stability while traction is applied using either weights and counterweights
Fracture table
53
What are the benefits for the patients of arthroscopy
Reduced blood loss
Less postop discomfort
Reduced length of rehab
54
Complications from arthroscopy
Subcutaneous emphysema
Pneumomediastinum
Tension pneumothorax from shoulder arthroscopy
55
Patient positioning complications from arthroscopy
Inadvertent extubation
Eye or corneal injury
Visual loss from prone position
Nerve injury
56
What is the most desirable intervention for tension pneumo
Chest tube
57
How is needle compression done for tension pneumo
14 to 18 gauge iv angiocath inserted at the 2nd or 3rd intercostal space anteriorly
OR
the 4th or 5th intercostal space laterally
58
Advantages of regional (spinal) anesthesia for hip fracture
Avoids endotrachial intubation, airway manipulation, and medications that go along with that
Decreases total amount of systemic medication patient receives
May decrease risk of thromboembolism
Vasodilatory effect may help the patient with CHF
59
What is a cause of acute mortality from pelvic fractures
Retroperitoneal bleeding
60
What are common injuries accompanying pelvic fracture
Bladder and urethra
61
What is a significant risk associated with pelvic fractures
DVT and PE
62
Periop complications of femur fractures
MI, dysrhythmias, DVT, pulmonary embolism, delirium
63
Treatment of displaced femoral neck fracture
Replacement
64
Treatment of intertrochanteric/subtrochanteric fracture
Plates, screws, nailsat
65
Treatment of nondisplaced femoral neck fracture
Closed reduction or percutaneous pinning
66
What is the most common fracture in younger trauma patients or elderly patients with degenerative arthritis of the knee
Tibial plateau or proximal tibia fracture
67
What must you monitor for with a tibial fracture
Compartment syndrome
68
Preferred anesthetic techniques for tibia fractures
GA or spinal. Regional blocks for pain control if no compartment syndrome
69
What type of regional blocks are appropriate for tibia fracture
Popliteal fossa
Sciatic
Femoral
Adductor canal
70
What type of anesthesia is appropriate for upper extrem. fractures
GA, regional, or combo.
Brachial plexus block, interscalene
71
What is the purpose of arthroplasty
Return motion and function of the joint and restore the controlling function of the surrounding soft tissues
72
What are the goals of arthroplasty
Pain relief, stability of joint motion, correction of the deformity
73
What are two risks of total knee arthroplasty
Thromboembolism
Bone cement implantation syndrome
74
Anesthetic technique for TKA
GA and regional
75
What blood loss can be expected from the femur
High blood loss of 500-1000ml
Highly vascular
76
What surgery carries a high risk for venous thromboembolism including DVT and PE
Total Hip Arthroplasty
77
Significant Risk factors for bone cement implantation sydrome
Pre-existing CV disease
Pre-existing pulmonary HTN
ASA class 3 or higher
Surgical technique (cemented hip arthroplasty)
Pathologic fracture
Trochanter fracture
Long-stem arthroplasty
78
Clinical features of bone cement implantation syndrome
Hypoxia
Hypotension
Cardiac arrhythmias
Increased pulmonary vascular resistance
Unexpected loss of consciousness
Cardiac arrest
79
What is the first indication of clinically significant BCIS under GA
A fall in ETCO2 concentration
80
What are early signs of BCIS is awake/sedated patients with regional
dyspnea and change in consciousness
81
What is the treatment for BCIS
Increase fio2 to 100%
Treat like right heart failure - aggressive fluid resuscitation and treat hypotension with alpha-agonists (phenylephrine)
82
What is there a high incidence of with shoulder surgery
PONV
Pain
Long recovery time
There is also potential for damage to major vascular structures resulting in major blood loss
83
Position for total shoulder arthroplasty
Lateral decubitus
or
modified Fowler (beach chair)
84
What is an important risk to be aware of for shoulder arthroplasty
Potential for inadvertent extubation from patient positioning or from surgical manipulations near the patient's head and neck
85
Anesthetic management for total shoulder arthroplasty
GA and regional combo
interscalene block
Supraclavicular block
86
What are consideration for hsoulder arthroplasty
Potential for cervical spine injury if excessive stretch or head becomes dislodged during manipulations.
Carefully monitor eyes for pressure.
87
What is used for virtually all surgical procedures of hand and forearm
pneumatic tourniquet
88
What anesthesia techniques can be used for forearm and hand surgery
brachial plexus blockade, iv regional block, or local with sedation for cases <1 hour.
GA if a longer, more complex case, comminuted fractures, reconstruction of vascular and nerve structures
89
Posterior tibial nerve:
Sensation to the plantar surface
90
Saphenous nerve:
Innervates the medial malleolus
91
Deep peroneal nerve:
Supplies interspace between great and second toes
92
Superficial saphenous nerve:
Supplies dorsum of foot and 2nd through 5th toes
93
Sural nerve:
Supplies the lateral foot and lateral 5th toe
94
What are the 2 most common reasons hospitalization after ambulatory surgery
PONV and pain
95
Techniques for smooth emergence and preventing hematomas for extra thoracic surgery
Stable BP or slight hypotension
Prevent PONV
Lidocaine: IV, endotracheal, topical
Precedex bolus or infusion
Titrate opioids to minimize coughing and bucking
96
What is the head angle in semi-fowlers
30-90 degrees above horizontal plane
97
Where should the chin be in semi-fowlers
1-2 fingerbreadths off the chest to protect the cervical spine
98
What impact does semi fowlers position have on the brain
Improved venous drainage from brain
Decreased ICP
Decreased cerebral perfusion
99
Pulmonary impact of semi fowlers position on
Increased FRC
Increased compliance
Less access to airway
100
Cardiac implications of semi fowlers position
Postural hypotension
Decreased MAP, CVP, SV and CO
101
What nerves are impacted by semi-fowlers
sciatic
ulnar
cervical
102
What are the clinical manifestations of venous air embolism
Hypoxemia
CO2 retention
Increased dead space
Decreased etco2
103
Treatment for VAE
Flood and pack surgical site.
100% oxygen and d/c n2o
Valsava maneuver
T-burg positioning
Hemodynamic support
104
How do you perform valsava maneuver on vent
Increase o2 flow, close apl valve, take off vent, squeeze bag for at least 10 seconds. This increases venous pressure and slows air entry
105
What are common causes of pneumothorax
Breast surgery
Axillary node dissection
Nerve blocksS
106
S/S of pneumothorax
Absent breath sounds on affected side
Hypoxia
JVD
Decreased BP
Increase airway pressure
Increased CVP
Increased HR
107
Treatment of pneumothorax
100% o2, d/c n2o
Needle thoracostomy (emergent, unstable): ICS 2-MCL or ICS 4/5 - AAL
Chest tube insertion (definitive treatment if pneumo is large)
Hemodynamic stabilization
108
Max dose lidocaine
4.5mg/kg
total max 300mg
109
Max dose lido with epi
7mg/kg
110
Max dose bupivicaine
2 mg/kg
Total max 175 mg
111
Max dose bupivacaine with epi
3mg/kg
total max 500mg
112
Max dose ropivacaine
3mg
total max 200mg
113
What is the result of delayed systemic absorption for tumescent anesthesia
long lasting and less toxic than other LAs
114
Preliminary max safe dosages for tumescent anesthesia
28mg/kg without liposuction
45 mg/kg with liposuction
115
When are there peak serum concentrations of tumescent anesthesia
12-16 hours after injection
116
What drugs should be avoided in treatment of LAST
Vasopressin
Ca channel blockers
Beta blockers
Sodium channel blockers
LAs
Any negative inotrope
117
What potentiates LAST
hypoxia and acidosis
118
Normal IOP
10-22 mmHg in the intact normal eye
119
What can a sustained increase in IOP during anesthesia cause
Acute glaucoma
Retinal ischemia
Hemorrhage
Permanent visual loss
120
What can cause increased IOP
Straining, retching, or coughing during induction increases venous pressure and can increase IOP by 40 mmHg or more
121
What is the effect of hypoxemia and hypoventilation on IOP
Increase IOP
122
What is the effect of hyperventilation and hypothermia on IOP
Decrease IOP
123
What is a miosis-inducing anticholinesterase that interferes with the metabolism of succinylcholine
Phospholine iodide
Causes prolonged paralysis following a single dose of succ
124
Why is topical anesthesia not always appropriate for eye surgery
It provides a lesser degree of analgesia and no akinesia of ocular muscles or eyelids
125
How can you prevent systemic absorption of eye drops
Have pt close eyes for 60 seconds
Avoid blinking
Block the tear outflow canal by placing index finger over the medial canthus after the eye is closed
126
What cranial nerves are anesthetized by a retrobulbar block
III
IV
V
VI
VII
127
Where is a retrobulbar and peribulbar block performed
Orbital epidural space
128
What are the risks of retrobulbar block
Optic nerve injury
Brainstem anesthesia
Retrobulbar hemorrhage
129
Which occurs first in ocular block, analgesia or akinesia
Analgesia precedes akinesia of muscles
130
When can effectiveness of retrobulbar and peribulbar blocks be evaluated
Retrobulbar: after 2 minutes
Peri: after 10 minutes
131
If you have akinesia of the muscle do you have analgesia?
It is assumed yes, but not guaranteed
132
What is the rarest but most devastating complication of ocular blocks
Ocular explosion
133
Indications for GA in ocular surgery
Pediatric patient
Lack of patient cooperation
Severe claustrophobia
Inability to communicate
Inability to lie flat
Open-eye injuries
Procedures with durations greater than 2 hours
134
Classes of medications for regional blocks during ocular surgery
benzos, narcotics, nonbarbiturates
135
What is the danger of having a sleeping patient during ocular block
Sleeping patients can snore and have sudden head movements upon awakening
136
What can cause expulsion of the eye contents
Choroidal hemorrhage - occurs when a vessel in the vascular choroidal layer of the eye ruptures, bleeding into the closed cavity and creating an acute rise in IOP
137
What can cause an acute increase in IOP above 40 mmHg during induction
Coughing and retching
138
Which induction agents lower IOP
Propofol and etomidate
Inhalational agents for infants and children
139
What is the effect of nondepolarizing agents on iop
Decreases IOP
140
What can cause EKG changes during ocular surgery
Oculocardiac reflex
141
What do patients undergoing eye muscle surgery have an increased incidence of
Malignant hyperthermia
Postop nausea
142
What helps to attenuate the increase in IOP caused by laryngoscopy
IV lidocaine 1/5-2 mg/kg given 1-1.5 minutes before
143
Ophthalmic complications during regional and general anesthetics are most likely caused by:
Patient movement
144
What can cause extrusion of globe contents and jeopardize vision regarding traumatic eye injuries
Increased IOP due to a tightly applied face mask, laryngoscopy, intubation, coughing/retching, bucking
145
How do most complications of regional ocular anesthetics occur
From direct traumatization of the orbital vessels, globe, and optic nerve
146
What is the initial intervention if the oculocardiac reflex is suspected
request that the surgeon release traction or pressure
147
What are the signs and symptoms of globe puncture
Intraocular hemorrhage
Rapid increase in intraocular pressure with corneal edema
148
What is a paravertebral block
targets spinal nerves on the side of the injection, can be performed at both thoracic and thoracolumbar levels; sympathetic fibers are blocked with less hemodynamic response than epidurals
149
What is the level of block required for breast surgery
C7-T6
150
What is the most effective pain management technique for breast surgery
paravertebral block
151
What decreases epidural spread during paravertebral block
inject slowly, small volumes, and at low pressure
152
What are complications of paravertebral blocks
Pneumothorax
Epidural spread (common, up to 40%)
Vascular, epidural, subarachnoid injection
Postdural puncture headache
153
Pecs 1 block:
Medial and lateral pectoral branches of brachial plexus
154
Pecs II block:
Long thoracic nerve
Lateral cutaneous branches of thoracic intercostal nerves (T2-T4)
Indicated for more extensive procedures involving chest wall and axilla
155
Landmarks for Pecs blocks
Pectoralis major
Pectoralis minor
Serratus anterior
Thoracoacromial artery (pectoral branch)
156
Serratus plane block:
Increases intercostal coverage from T2-T9
More lateral than Pecs II block.
Overlies 5th rib at the midaxillary line.
No coverage to pectoralis muscle
157
Landmarks for Serratus block:
Latissimus dorsi muscle
Serratus anterior muscles
Thoracodorsal artery
158
Complications of Pecs block
Large volume of LA causes risk for LAST.
Risk of vascular injection due to pectoral branch of thoracolumbar artery lying within the interfascial plane of the Pecs I injection.
Pneumothorax - intercostal space and pleura are just inferior to serratus anterior muscle
159
