Ortho - Spine Flashcards by Kayla Dewberry

Most spine surgeries require what type of anesthetic?

GETA

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Long procedures (6-8 hrs) that are associated with decreased chest wall compliance + restrictive lung disease + risk of large blood loss

Scoliosis surgery

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What findings might be present on EKG in a patient with scoliosis?

RVH: V1-V4 R wave progression
RAE: wide P wave in lead II

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anticipate _______ with corrective scoliosis surgery

large blood loss

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______ ________ can occur If patient has received > 2 L crystalloids intraop

dilutional coagulopathy (need to give albumin or blood products)

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scoliosis surgery may require ________, but can have consequences if autoregulation/CPP not maintained.

intentional hypotension

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Expect partial paralysis of diaphragm & cervical spine injury if these 4 muscles are noted to be flaccid?

deltoid
biceps
brachialis
brachio-radialis
** innervated by C5

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Occurs with complete spinal cord transection above T5/T6

autonomic hyperreflexia

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C3,4,5 keeps….

the DIAPHRAGM alive

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SCI above the cardiac accelerator nerves leads to:

BRADYCARDIA
T1-T4

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SCI at T5 & higher leads to:

sympathectomy = hypotension
** DOC = midodrine (A1 agonist)

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What is the DOC for hypotension r/t SCI at or below T5?

midodrine (A1 agonist)

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Severe transient HTN, bradycardia, dysrhythmia’s, severe HA, vision changes, N/V, & anxiety are symtpoms of:

autonomic hyperreflexia

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Below the level of SCI, you would expect the patient to have cold, dry skin d/t:

autonomic hyperrelflexia (reflexive SNS response to pain)
cutaneous vasoconstriction & HTN BELOW level of injury

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Above the level of the SCI, you would expect the patient to have hot, diaphoretic skin d/t:

autonomic hyperreflexia (lack of PNS compensation)
cutaneous vasodilation ABOVE injury

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What are some causes of autonomic hyperreflexia in a patient with a SCI?

distended/full bladder or bowels
noxious stimuli (surgical)

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How can we prevent autonomic hyperreflexia?

deepen anesthetic
remove stimuli (drain bladder)

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If autonomic hyperreflexia does occur, how do we treat it?

deepen anesthetic + direct/fast acting vasodilators (nitroprusside, hydralazine, phentolamine)

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SCI at C3-C5 can result in:

diaphragm paralysis –> respiratory failure

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SCI at C5 - T7 can result in:

risk of infection from atelectasis & inability to cough d/t impairment of abdominal & intercostal support of respirations

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inability to maintain constant core temperature

poikilothermic

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inability to vasoconstrict BELOW level of SCI and disrupted temp sensations leads to:

poikilothermia

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How can we help a SCI patient maintain constant core temp?

warm IVF
warm air/bare hugger
increase OR temp if possible

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airway management issues are more common in _____ & _____ spine cases

cervical & thoracic

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severe kyphoscoliosis can result in:

CV compromise (pulm HTN~cor pulmonale)

flaccid deltoid & biceps can be a sign of:

cervical spine fracture

Recall the 6 P's of a neurovascular assessment:

- pain - poikilothermia - paraesthesia - paralysis - pulselessness - pallor

What type of X-ray may be required to better visualize atlanto-axial instability?

LATERAL x-ray **esp in RA pts

When is regional or neuraxial anesthesia good for spine pts?

- lumbar laminectomy 1-2 levels (if no upper level involvement) - disc surgery

How can we facilitate low venous pressure to surgical site (aka minimize blood loss) with positioning?

- maintaining a free abdomen - reverse trendelenburg

Position for a cervical spine surgery with an ANTERIOR approach?

SUPINE

Position for a cervical spine surgery with an POSTERIOR approach?

PRONE

This position is uncommon in spine procedures and is associated with what risk?

sitting = VAE

Which THORACIC surgical approach requires a DLT or bronchial blocker to drop a lung?

ANTERIOR approach

A patient undergoing an anterior thoracic surgery will require what airway equipment?

DLT or bronchial blocker

Placement of a DLT to collapse the lung on the operative side may be required for surgery above ____

A patient undergoing a posterior (prone) thoracic surgery will require what airway equipment?

single lumen ETT

What does supine laparotomy mean for an anterior lumbar spine procedure?

pt is supine + a surgical incision into the abdominal cavity

What preop medication should a patient receive if procedure requires the prone position?

anti-sialogogue - scope patch, glycopyrrolate glyco safer in elderly (does not cross BBB = less confusion)

After a patient has been turned prone and anes circuit is reconnected, what should you check?

assess for BL breath sounds

You notice the patient has periorbital &/or circumoral edema after being prone for the procedure, this may also indicate:

likely vocal cords also have edema --> caution with extubation (may need to go to ICU and keep intubated until edema subsides)

If using a wilson frame what should you check on the patient?

- males = genitalia - females = breasts **free from pressure

Where should arms be if patient is in the prone position?

superman or surrender position with <90 degree adduction

Abdominal pressure from prone position can lead to:

- increased intrathoracic pressure - decreased FRC & pulm compliance - decreased venous return - increased bleeding from epidural vein pressure

What's a major complication for pts when going prone?

POVL - postop visual loss

What are 3 causes of POVL?

- ischemic optic neuropathy (ION) - retinal artery/vein occlusio - cortical brain ischemia

Cause of POVL that can occur without any pressure on the eyes?

ION - ischemic optic neuropathy ** blood loss >1000mL, long surgery >6hrs, male, obese, decreased colloid use

How can we prevent ION (ischemic optic neuropathy)?

- head neutral/midline - blood transfusion/colloids - minimize intentional hypoT

Cortical brain ischemia can lead to POVL from:

intentional hypotension

Which 2 table frames allow the abdomen to "hang free" = no pressure on abdomen?

- andrew's frame - jackson spine table

Prone effects on the cardiovascular system:

- pooling of blood in extremities - compression of abdominal muscles - decrease VR/preload, CO, BP

Prone effects on respiratory system:

- compression of abdomen & thorax - decrease total lung compliance - increase WOB

Prone effects on neuro system?

extreme head rotation = decrease venous drainage & CBF

What is the most stable prone positioning device?

Mayfield tongs (pins in head)

What should you have ready to prepare for possible blood loss & transfusion in a spine case?

- 2 large bore PIVs - 2 units PRBCs in OR cooler - blood tubing primed & set up in blood warmer

What is a cell saver?

“Cell savers” are instruments that collect blood lost during surgery. The RBCs are washed with normal saline and concentrated to make an approximate 225 mL unit with a hematocrit of ~ 55%. RBC units can be either directly transfused into the patient or washed again and stored

What is the ABL formula?

(Initial Hct - target Hct) / initial Hct

When EBL is anticipated to be 500-1000mL, what can be done preoperatively?

autologous blood donation 2-4 wks prior

Autologous blood donation is contraindicated in:

significant cardiac disease & infection

Tranexemic acid (TXA) dosages:

10 mg/kg IV bolus gtt: 2 mg/kg/hr **max = 2.5g

Aminocaproid acid (Amicar) dosages: **not as common anymore

100 mg/kg IV bolus gtt: 10-15 mg/kg/hr

This is done in shoulder & hip surgeries but is not recommended for spinal surgeries d/t risk of end-organ ischemia:

intentional hypotension **surgeon may still request it

used to assess/preserve sensory & motor neurological function during spine procedures?

neurophysiologic monitoring - SSEP - MEP - EMG

SSEP stands for:

somatosensory evoked potential

MEP stands for:

motor evoked potential

What does SSEP monitor?

the dorsal (afferent) column pathways of the spinal cord that are responsible for proprioception & vibration **impulse comes from peripheral nerve & measured centrally

What does MEP monitor?

the anterior (efferent) portion of spinal cord **impulse triggered in brain and monitored in specific muscle groups

These are adverse effects of which neurophysiological monitoring: - cognitive defects - seizures - intraop awareness - scalp burns - cardiac arrhythmia's - bite injuries

MEPs

MEP monitoring should be avoided in what 3 main patients?

- active seizures - vascular brain clips (heat) - cochlear implants

monitors nerve root injury during pedicle screw placement & nerve decompression:

EMG - electromyogram

describes the signal strength

AMPLITUDE

the time it takes for a signal to travel through spinal cord

LATENCY

Name 6 cofounding factors that can affect amplitude & latency of neuro monitoring?

o Hypotension o Hypothermia o Hypocarbia o Hypoxia o Anemia o Anesthetics

How do volatile agents affect amplitude & latency of neuro monitoring?

dose dependent (keep at 0.5 MAC or less) - decrease in amplitude - increase in latency

Which anesthetic agent should be eliminated with MEP monitoring?

Nitrous Oxide

Best anesthetic option for procedures requiring neuro monitoring?

TIVA - opioids, ketamine, versed **but MEPs are depressed with propofol

If performing MEPs, what meds should be avoided?

- NMBA (but ok for induction) - propofol

If there are acute changes in amplitude/latency then:

STOP surgery

Spine surgery pts may require postop ventilation if:

- long case (>4 hrs = prone/airway edema) - thoracic cavity invasion - EBL >30ml/kg or > 2L - facial/laryngeal edema - preop VC < 30-35% of predicted

How do you assess for laryngeal edema if pt has facial swelling after being prone in a spine case?

deflate ETT cuff --> check for leak -- if no cuff leak = airway edema = keep intubated & go to ICU

Caution with this multimodal analgesic in postop spine cases:

NSAIDs = bleeding

What are some multimodal analgesics for postop pain mgmt for spine cases?

- multimodal - systemic opioids (PCA) - LA infiltration wound - intrathecal (spinal) morphine: 0.1-0.2 mg + LA - continuous epidural infusion - erector spinae block

What's the dose of epidural hydromorphone PF (preservative free)?

0.5 - 1 mg

What spine procedure has the highest risk for VAE?

LAMINECTOMY ** b/c large amount of exposed bone & surgical site is above heart

Signs of VAE intraop?

unexplained hypotension increased end-tidal nitrogen decreased ETCO2

Ortho - Spine Flashcards

(85 cards)