I. Orthopedic Surgeries Flashcards
(93 cards)
1
Q
most abundant mineral in body
A
Calcium (98% deposited in bones)
2
Q
Skeletal system functions
A
- Support
- Storage
- RBC production
- Protection
- Leverage
HINT: Some Skeletons Look Really Porous
3
Q
Key preoperative considerations
A
- Mouth opening
- Neck extension
- Thyromental distance
- Dentition
- Regional site infection risk
- Brief neurologic assessment
- Positioning difficulties
- Tranexamic Acid Administration Required?
- Hbg
- Creatinine
4
Q
Tranexamic Acid (TXA)
A
- Anti-fibrinolytic agent: works by blocking the breakdown of blood clots, which will decrease bleeding (↑blood clots = ↓bleeding)
- works by inhibiting the activation of plasminogen to plasmin, which is an enzyme that plays a key role in breaking down fibrin clots. By inhibiting this process, tranexamic acid helps to stabilize blood clots and reduce bleeding.
5
Q
In what scenarios is TXA used?
A
- Hemorrhage/Trauma: it can be administered to reduce or prevent excessive bleeding, especially during surgeries or in patients with certain bleeding disorders.
6
Q
TXA Contraindications
A
- Recent Stroke
- Recent MI
- Recent Stents
- TXA increases the risk of thromboembolic events
- Tranexamic acid works by promoting clot stability, which could potentially exacerbate the risk of clot formation in individuals who have recently experienced a stroke.
7
Q
Hemoglobin (Hbg) normal range
A
Male: 13.5-17.5
Female: 12-16
HINT: for girl, 12ga maybe too much, try 16ga
8
Q
Hematocrit (HCT%) normal range
A
Male: 39-49
Female: 35-45
9
Q
Creatinine (CR) normal range
A
0.6-1.3
0.8 - 1.2
HINT: take just ONE scoop of creatine
10
Q
Which lab values are especially important to assess prior to a orthopedic/large fracture case?
A
Hemoglobin (Hgb) and Creatinine (Cr)
11
Q
3 locations neural structures may be blocked
A
- peripheral nerve
- nerve plexus
- neuraxial level
12
Q
Regional advantages over general
A
- Enhanced Rehabilitation
- Speedy Hospital Discharge
- Improved Post Op Analgesia
- Decreased PONV
- Less Respiratory & Cardiac Depression
- Improved perfusion via sympathetic block
- Reduced Blood loss
- decreased risk of thromboembolism
HINT: BRANDED P
13
Q
Variety of hip procedures
A
- Repair of hip fracture
- Total hip arthroplasty
- Closed reduction of hip dislocation
14
Q
Variety of knee procedures
A
- Arthroplasty
- Arthroscopy
- Total joint replacement
- Partial joint replacement
15
Q
Many patients present with Rheumatoid Arthitis. What are special considerations?
A
- Involvement of the cervical spine may result in limited neck ROM.
- Atlantoaxial instability
- Subluxation of the odontoid process can lead to spinal cord injury during neck extension
- These patients are normally on chronic steroid therapy, and therefore may require perioperative steroid replacement.
16
Q
why it is necessary to administer steroid therapy to adrenal insufficient patients:
A
Autoimmune disease = adrenal insufficiency = catecholamine depleted = hypotension = [these patients will not respond to adrenergic agents (Neo/Ephedrine) = treat with steroids (Prednisone [Cortisol]) perioperatively = facilitates a sympathetic response to stressors/pressers
increased cortisol response is associated with increased arterial contractile sensitivity to NE and vascular resistance
16
Q
What can be done to significantly reduce the incidence of would infection (osteomyelitis) for open wounds?
A
Minimizing the time between fracture and surgery
17
Q
Trauma patients are at risk for what type of respiratory complications?
A
hemothorax
pneumothorax
pulmonary contusion
fat embolism
aspiration
18
Q
what device is required in the presence of a hemo/pneumothorax?
A
Chest tube
19
Q
Pulmonary fat embolus occurs in ____% of patients with long-bone fractures.
A
10-15
20
Q
Symptoms of pulmonary fat emobli?
A
- hypoxemia
- tachycardia
- tachypnea
- respiratory alkalosis
- mental status changes
- conjunctival petechia (blood-shot eyes)
- fat bodies in the urine
- diffuse pulmonary infiltrates
symptoms of pulmonary aspiration are similar to those of a fat embolism
21
Q
What are a few preop considerations to help manage pulmonary aspiration and pulmonary fat emboli patients?
A
- Supplemental O2 to prevent hypoxemia
- Fluid management to prevent worsening of pulmonary capillary leak
- Early surgical stabilization of fracture sites
22
Q
What approximate amount of blood may be “hidden” in the thigh from a femur fracture?
A
2 liters (30 mL/kg)
23
Q
Increased HR, orthostasis or decreased BP may suggest what within the context of an orthopedic injury?
A
hypovolemia
24
how should hypovolemia be corrected?
10-40 mL/kg crystalloid, colloid, transfusion
25
What is indicated for any patient with prolonged loss of consciousness prior to anesthesia?
CT scan of head
26
what are a few areas to be assessed from a musculoskeletal perspective prior to intubation?
1. C-spine stability
2. Thoracic & Lumbar X-rays
27
Restore HCT to ____% prior to inducing anesthesia.
25%
28
Bone fracture patients are at **low/high** risk of DVT.
HIGH
*Rates as high as 50%, and PE rates 20%*
*Major cause of morbidity and mortality following ortho operations on pelvis and lower extremities*
29
Monitoring of ____ is mandatory to detect intraop compromise of the collecting system, and to monitor adequacy of renal perfusion
urinary output
Tests: UA, BUN, Cr
30
two main methods of anesthesia for hip procedures:
1. GETA
2. Regional
31
For lower and upper extremity, ____ anesthesia is more common if the procedure is short.
regional
32
for a long lower/upper extremity orthopedic procedure, what is a common anesthesia technique?
Regional + GETA
33
How should a trauma patient be extubated?
Fully awake
34
How should patients with pulmonary injuries (fat embolism, aspiration, contusion) be extubated?
They should NOT be extubated
*likely remain intubated for a couple days*
35
If large blood loss is expected:
IV:
Fluids:
Colloid: Y/N
Adjunct Devices:
18-16 ga x 2
NS/LR/Plasmalyte @ 8-12 mL/kg/hr
Colloids YES
Cell-Saver
36
What amount of blood must be lost IOT use the Cell saver?
400-600 cc
37
What blood contents are returned to the patient?
only RBC (NO plasma or platelets)
38
How much of the original blood content is returned to the patient?
1/3
39
when is the Cell Saver NOT used?
Cancer patients
40
What hemodynamic technique may be performed for patients with hip fractures (involving large blood loss), *unless the patient has severe CVD or carotid artery stenosis*?
moderate hypotension
41
methods of achieving moderate hypotension?
1. increase VA (*isoflurane 1-3% common*)
2. esmolol drip (lower HR, BP will follow)
3. SNP
4. NTG
5. Clevidipine
42
Esmolol dose for est. moderate hypotension
50-200 mcg/kg/min
43
Sodium Nitroprusside dose to achieve moderate hypotension?
0.25-3 mcg/kg/min
44
NTG dose to achieve moderate hypotension
0.25-2 mcg/kg/min OR 5-20 mcg/min
25-200 mcg Bolus
45
Clevidipine dose to achieve moderate hypotension
1-32 mg/min
46
what is the target reduction in BP when attempting to achieve moderate hypotension?
30% reduction in BP (but NOT < MAP 60)
47
what type of drug is clevidipine
Calcium Channel Blocker (looks like propofol - lipid emulsion)
48
what is the max time a tourniquet may be applied ("up") continuously?
2 hours
*it may be applied for 1.5 hours, down .5 hour, up 1.5 hours, etc*
49
What are the *standard* monitors for bone fracture patients?
+/- arterial line & CVP line
50
Patients with myocardial dysfunction should receive what kind of therapy? How should it be guided?
- Fluid and inotropic/presser therapy
- guided by continuous Central Venous Pressure (CVP) monitoring, PA catheter, and/or Transesophageal Echocardiogram (TEE)
51
What two other adjuncts may be helpful for monitoring bone fracture patients?
Clearsite or Flowtrac
52
Why is meticulous padding important for bone fracture patients?
- prevent nerve damage
- prevent ischemia of extremities
53
what hemodynamic event may increase risk of neurovascular injury?
decreased BP
54
Wahat are the major concerns intraopreatively for orthopedic cases?
- hypothermia
- damage to other organ systems
- Urinary
- Coagulopathy
- major blood loss
55
What are the concerns for post operative hip fracture patients?
- Pre-op/Intra-op damage to L4-S5 nerve roots and Cauda Equina (Equina Syndrome)
- Neuropathy of the femoral, genitofemoral, and lateral femoral cutaneous nerves
56
Neuropathy of the femoral, genitofemoral, and lateral femoral cutaneous nerves can result from pressure on the ____ ligament during surgery
ilioinguinal
57
____ affects articular surface of one or more joints, while ____ is characterized by an autoimmune-mediated joint destruction with chronic and *progressive inflammation* of synovial membranes; it also comes with systemic involvement.
- Osteoarthritis
- rheumatoid arthritis
58
Patients with rheumatoid arthritis frequently have associated ____ complications.
pulmonary
*pulmonary effusions are common*
*SOB on performing activities of daily living or exercise (e.g., climbing a flight of stairs) warrants further evaluation with PFTs*
*Inflammation in the lungs can lead to conditions such as interstitial lung disease (ILD), which involves inflammation and scarring of lung tissue*
*nodules can also develop in the lungs, causing inflammation and potentially leading to complications such as nodular lung disease*
59
Rheumatoid arthritis involvement of the cricoarytenoid joints may produce ____, (requiring ____ ).
- glottic narrowing
- small ETT
60
Rheumatoid arthritis involvement of the cricoarytenoid joints may manifest as ____.
hoarseness
61
Arthritic involvement of the TMJ limits mouth opening and may necessitate special techniques such as: (for ET intubation)
- fiber optic
- light wand
62
What may be used to assess cardiovascular status in arthritic patients?
Dobutamine Stress Echo
63
Rheumatoid Arthritis is associated with:
- pericardial effusion
- cardiac valve fibrosis
- cardiac conduction abnormalities
- Aortic Regurgitation (AR)
64
most common arrhythmia in elderly
A-Fib
65
what is a common neurological finding in RA patients?
cervical nerve-root compression
66
Further nerve root compression and/or cerebral ischemia can be evaluated by assessing what?
Full ROM of neck
67
While assessing ROM of neck, if cerebral ischemia occurs, what does this suggest?
vertebral artery compression
68
If ____ is present, a mandatory neurovascular evaluation must occur IOT plan intraop BP management.
cerebral ischemia
69
What hematologic pathology do RA patients commonly have?
Anemia
70
Anemia may present secondary to ____.
NSAID gastritis
71
What Hgb level is required IOT qualify for preop autologous blood donation?
Hgb >12 g/dL
72
T/F: patients on anticoagulants are candidates for regional anesthesia.
FALSE
73
Bone Cement chemical name
Methyl Methacrylate
74
Microemboli of air, fat, bone fragments, and cement may occur during pressurized cementing which may lead to ____ and ____.
hypotension
hypoxia
75
Significant pulmonary air emboli can result in decreased cardiac output, arterial hypotension, and cardiovascular collapse as a result of one or more of the following:
- Obstruction of peripheral pulmonary vessels by gas bubbles
- Air lock from gas in large pulmonary vessels or the heart
- Reflex pulmonary vasoconstriction
76
____ may be used to achieve a dry operating field, but with what precaution?
Hypotension
*significant hypovolemia must be avoided because this predisposes to a severe reaction to the pressurized cementing, causing decreased systemic blood pressure and pulmonary HTN*
77
List of potential complications with bone cement
- Hypotension
- hypoxia
- Severe Reaction
- Venous Air Embolus (VAE)
- Nerve injury
- Teratogenic: conflicting studies
77
what are some prophylactic anticoagulation measures to prevent DVT and Thromboembolism?
- Intermittent Pneumatic Leg Compression (IPC)
- Prohylactic Anticoagulants:
(1) Low Dose Molecular Weight Heparin (LDMWH)
(2) Warfarin
77
dose of LDMWH
5000 U every 8 hours
77
Reasons why tourniquet should not be used > 2 hours?
- hemodynamic changes
- Pain
- metabolic alterations
- arterial thromboembolism
- PE
77
T/F: Regional anesthesia decreases rates of embolic events.
TRUE
- regional blocks can cause sympathectomy (vasodilation)
- decreased stress response
77
A tourniquet is placed to a pressure of ____ above SBP. (typically default is ____)
100 mmHg
250mmHg
77
In order to decrease incidence of hematomas, epidural or spinal should not be undertaken within ____ hrs of (mini dose of heparin) or ____ hrs (LDMWH).
6-8
12-24
78
Symptoms of increased pain due to prolonged tourniquet usage?
- HTN
- ↑HR
- Diaphoresis
79
What can occur once the tourniquet is released?
- Significant drop in CVP & ABP
- Increase in plasma & EtCO2 due to lactic acid buildup
80
What should be done prior to tourniquet deflation?
5-10 mL/kg bolus NS/LR
*100mg Neo to blunt impending hypotension*
81
When deflating the tourniquet in pts with mod-to-severe lung dz, controlled ventilation should be continued until after the ____ that has accumulated in the leg has been metabolized (____ min), because these patients may be unable to increase ventilation to buffer this acid load.
lactic acid
3-5 min
*increase in lactic acid = decrease pH = increase CO2 = increase respiratory drive *(normally, but these patients may be respiratory depressed due to NMB or opioids)*
82
These patients are usually the victim of high-speed MVA (60-80%) and will likely have associated trauma.
Pelvic Fracture
83
Pelvic fracture associated traumas
1. disrupted abdominal viscera
2. fractured ribs
3. Contused lungs
4. closed head injuries
84
What is the biggest concern and principal motivator for early repairs of pelvic fractures?
Bleeding
85
blood loss greater than ____ units is common with ORIF of pelvic fractures.
4
86
