Ortho Surgeries Flashcards
(104 cards)
1
Q
induction plan for any patient presenting for acute fracture repair
A
RSI - always consider full stomach
2
Q
why might arthritic pts be difficult intubations?
A
may have limited ROM of neck
3
Q
what is rheumatoid arthritis
A
immune-related, progressive inflammation of synovial joints
(not just normal wear & tear)
4
Q
airway concerns for a pt with rheumatoid arthritis
A
cervical mobility (atlantoaxial joint instability/subluxation), TMJ issues may make intubation difficult
5
Q
why do pts with rheumatoid arthritis need to have pre-op c-spine films?
A
to evaluate atlantoaxial subluxation and determine if awake fiberoptic intubation is indicated
6
Q
when is awake fiberoptic intubation indicated for pt with rheumatoid arthritis?
A
c spine film reveals > 5 mm instability
7
Q
s/s cricoarytenoid arthritis in pt with RA
A
hoarseness
8
Q
considerations for an RA pt on chronic NSAIDs
A
potential for GI bleeding, renal toxicity, platelet dysfunction
9
Q
CV effects of rheumatoid arthritis
A
- pericardial thickening, effusions
- myocarditis
- coronary arteritis
- conduction defects
- cardiac valve fibrosis
10
Q
heme effects of RA
A
- anemia
- platelet dysfunction
- thrombocytopenia
11
Q
endocrine effects of RA
A
- adrenal insufficiency r/t steroid use
- impaired immune system
12
Q
derm effects of RA
A
thin, atrophic skin from steroids
13
Q
position most associated with air embolus
A
sitting (beach chair)
14
Q
use of regional anesthesia in ortho surgeries
A
- more for upper extremity surgeries
- can be used with GA for postop pain control
- may result in less blood loss
15
Q
possible patient positions for shoulder surgeries
A
lateral or beach chair
16
Q
positioning challenge of shoulder surgery, regardless of position
A
padding and protection of ears, eyes, bony areas
~DuH~
17
Q
can LMA be used for shoulder surgeries?
A
DFort says yes
18
Q
regional anesthetic used in shoulder surgery for post op pain control
A
interscalene block
19
Q
risks assoc. with controlled hypotension in shoulder surgeries
A
- beach chair position - cerebral ischemia
- vision loss
20
Q
where does the art line need to be leveled to estimate CPP?
what is this area called?
A
level of external auditory meatus and tragus
circle of willis
21
Q
why is the pressure in the circle of willis lower than the pressure at the level of the heart?
A
d/t vertebral column and hydrostatic pressure difference
22
Q
1.25 cm = ____ mmHg drop in BP
A
1
23
Q
benefits of arthroscopic surgeries
A
- less invasive, less blood loss
- less post-op discomfort
- reduced length of rehab
24
Q
why is controlled hypotension used in arthroscopic surgeries?
A
to maintain bloodless field and reduce BP on non-tourniquet joints to optimize surgical field
25
why are irrigant fluids used in arthroscopic surgeries?
at what pressure are they instilled?
used to distend operative joint
60-80 mmHg
100-120 mmHg in beach chair
26
complications of high irrigation pressures with long duration
(in arthroscopy)
sub-q emphysema
tension pneumothorax
27
complications of irrigant absorption in arthroscopic surgeries
(book)
* fluid volume overload
* CHF
* pulmonary edema
* hyponatremia if sterile water used
28
most spinal surgeries involve what segments of the spine?
cervical & lumbar
29
anesthetic technique for spinal surgery
GA with or without paralysis
may do without paralysis to use SSEP
30
what aspects of spinal surgery can create airway challenges?
prone position
cervical immobility
31
why might the surgeon ask you to give VCM in the middle of a spinal surgery?
after CSF leak is repaired - increased transthoracic pressure allows the surgeon to test the seal of the dura
32
possible pt positions for cervical spine surgery
prone, sitting, or supine
| (Fort says most are supine now)
33
potential airway management challenge for c spine surgery pts
TMJ dysfunction, atlantoaxial instability (limited neck ROM)k
34
surgical approach for C1-C2 vs. C3-C6
C1-2: probably posterior
C3-6: anterior
35
why use an ear pulse ox in c spine surgery
major arteries and veins are nearby - retractors could occlude carotid
pulse ox waveform/reading can give clues about carotid occlusion
36
why is dexamethasone given prophylactically to c spine surgery pts
prevent post op airway swelling
37
possible nerve injury in c spine surgery
recurrent laryngeal nerve
38
why is an LTA kit indicated for c spine surgery pts?
to prevent coughing or bucking and prevent potential for airway hematoma
39
typical position for lumbar spine surgery
prone
40
potential nerve injury with positioning for lumbar surgery
how to avoid?
brachial plexus
arms/shoulders \< 90 degrees
41
why might you see decreased CO in a pt undergoing lumbar spine surgery?
abdominal compression (prone) can occlude IVC and impede venous return/stroke volume
42
why are FRC and Vt decreased in lumbar spine surgeries
prone position - diaphragm is cephalad
43
spinal surgeries assoc. with large blood loss
* lumbar spine
* spinal fusion
* hip replacement
44
respiratory concerns for a spinal fusion patient
scoliois pts may have restrictive lung disease
45
what is the artery of Adamkiewicz? (google)
why do we care
dominant thoracolumbar segmental medullary artery that supplies the lower spinal cord
need neuromuscular montioring in spinal fusion bc its v close to the spine
46
why use a toe pulse ox in a supine spinal surgery
to monitor vessel occlusion by retractors
47
typical patient population seen for hip fracture
elderly, frail, debilitated, dehydrated pts with existing comorbid conditions
48
positioning for hip fracture repair
* supine
* moved to fracture table after induction
* ipsilateral arm placed on chest
49
respiratory concerns related to positioning for a hip fracture repair
arm positioning creates restrictive lung conditions
50
ALIF vs. PLIF
* anterior or posterior lumbar interbody fusion
* can be done for cervical, thoracic, and lumbar spinal issues
51
if you give a hypobaric LA solution via spinal to a hip fracture pt, where will its effects be seen?
sorry prob a shitty way to word that
non-dependent (surgical) hip
is this supposed to say hypobaric- yup oopsie
52
fat embolisms are common for what procedures
hip fractures
long bone fractures (femur, tibia)
53
typical hip replacement patient
elderly, likely arthritic/degenerative joint disease
per the book, 50% are obese
54
positioning for hip replacement
lateral decubitus
55
why is a subarachnoid block particularly helpful in a hip replacement surgery?
(book)
several large muscle groups have to be cut/dissected to get to joint - muscle relaxation from block helps
56
why would a bilateral hip surgery be contraindicated?
if declining pulmonary function occurs after the first hip surgery
57
which is more painful - knee or hip replacement
knee, apparently
58
surgeries with high incidence of DVT
THA and TKA
| (total hip/knee arthroscopy)
59
regional anesthetic options for a knee replacement
* femoral 3 in 1 block combined with spinal
* femoral catheter for post-op pain control
60
which is probably better for a closed reduction - succs or roc?
succs - usually very short procedures but muscle relaxation needed bc muscle contraction can prevent reduction
but i guess if you have sugammadex it don't matta
61
anesthetic technique for closed reduction
can be done with propofol bolus
short-acting NMB
often done via mask ventilation w/o airway instrumentation
62
what is methylmethacrylate cement?
used to bind prosthetic to bone
63
what causes bone cement to harden against prosthetic components?
an exothermic reaction
64
what does intramedullary mean?
~google :)~
in the bone marrow
65
what can cause embolization of fat, bone marrow, cement, and air into venous channels?
intramedullary HTN
| (\>500 mmHg per M&M)
66
AEs of systemic bone cement absorption
* vasodilation
* decreased SVR
* release of tissue thromboplastin
* platelet aggregation
* microemboli formation
* embolic shock
67
what ortho surgeries should pregnant CRNAs not be involved in
ones that use bone cement
but prob all of em bc of the radiation
68
s/s of bone cement implantation syndrome
* hypotension
* hypoxia
* decreased CO
* dysrhythmias
* shunt
* pHTN
69
what might be the first sign of bone cement implantation syndrome under GA?
(book)
abrupt decrease in ETCO2
70
risk factors for bone cement implantation syndrome
(book)
* preexisting CV disease
* preexisting pHTN
* ASA 3+
* NY Heart Assoc. class 3 & 4
* intertrochanteric fracture
* long-stem arthroplasty
71
management of suspected bone cement implantation syndrome
100% FiO2
hydration
72
what is a pneumatic tourniquet
applied to an extremity proximal to surgical site to create a bloodless field
73
what is an Esmarch bandage?
*~\*google again*~\*
a soft rubber band used to expel venous blood from a limb (exsanguinate) that has had its arterial supply cut off by a tourniquet
74
AE of exsanguination of a lower extremity & tourniquet inflation
(M&M)
rapid shift of blood volume into central circulation
75
cuff overlap for pneumatic tourniquet
should be 180 degrees from nerve bundle
76
what determines inflation pressure of a pneumatic tourniquet?
what pressures are typically used
blood pressure
typically: lower ext. 100 mmHg & upper extremity **50 mmHg greater than SBP**
77
what is a venous tourniquet?
I think it is when BP gets higher and allows arterial blood to get back into the extremity that is supposed to be bloodless but then the venous pressure isnt high enough for it to get back out so it builds up in there
Very scientific words i know
78
risk factors for neurological damage from pneumatic tourniquet
* \> 2 hours tourniquet time
* overlap is over nerve bundle
79
physiologic effects of pneumatic tourniquet inflation
* autotransfusion = rise in SVR, CVP, PVR
* 300-500 mL displaced blood volume from exsanguination
* prolonged inflation = increased HR and BP
80
physiologic effects of pneumatic tourniquet deflation
* metabolic acidosis
* inc HR
* dec temp
* **hypotension**
81
why might you give neosynephrine prior to pneumatic tourniquet release
to prevent BP drop assoc. with anaerobic metabolites returning to tissues and into central circulation
82
why is tourniquet release assoc. with hypotension
sudden reduction of SVR (and PVR)
83
neuro effect of \> 60 min of tourniquet
box 38-1
tourniquet pain
HTN
84
neuro effect of \> 2 hours of tourniquet time
box 38-1
postop neuropraxia
85
how long does it take for cellular hypoxia to develop with a limb tourniquet?
box 38-1
within 2 min
86
what happens to cellular creatinine level with extremity tourniquet
box 38-1
decreases
87
when does endothelial capillary leak occur with limb tourniquet use?
box 38-1
\> 2 hours
88
systemic effects of tourniquet release
box 38-1
* transient fall in core temp
* transient metabolic acidosis
* acid metabolites released into central circulation
* transient fall in pulmonary and systemic arterial pressures
* transient increase in ETCO2
89
when does tourniquet pain usually begin?
an hour after inflation
90
do IV analgesics help with tourniquet pain?
what route do they work?
nope, sucks
work when added to LA
91
deflating the tourniquet for how long can help with pain
10-15 min
92
unmyelinated, slow-conducting fibers
C fibers
93
fibers responsible for pinprick, tingling after tourniquet deflation
A delta
94
describe the pain assoc. wtih pneumatic tourniquets
burning, dull, aching, throbbing
\*~so all the possible words to describe pain?~\*
95
fat embolism triad
petechiae - axillary, subconjunctival
dyspnea
confusion, AMS
96
what causes impaired pulmonary perfusion r/t a fat embolus?
fat globules released into the blood cause pulmonary congestion
97
when does the fat embolus triad occur?
12-24 hours later
98
CV changes that may be seen with fat embolus
tachycardia, ST segment changes
99
pts at greatest risk for fat embolus
coexisting lung disease
100
treatment of fat embolus
O2, aggressive ventilation, fluids, steroids
101
anesthetic technique that reduces the risk of DVT
why?
epidural or spinal
higher levels of plasminogen and plasminogen activators, hyperkinetic blood flow, earlier ambulation
102
why is dead space ventilation seen with fat embolus
embolic material can qedge in pulmonary artery and block perfusion to lungs
103
why might you see acidosis assoc. with fat embolus
decreased BP results in inadequate perfusion + decreasd PO2 and tissue hypoxia
all those things result in anaerobic cellular respiration and lactic acid buildup
104
electrolyte abnormality assoc. with fat embolus
hyperkalemia
