Orthopedics Week 13

Question 1

KEY POINTS

• Optimal anesthetic management for orthopedic surgery requires expertise in regional anesthesia and _______ (1) techniques.
• Regional anesthesia can provide physiologic benefits and facilitate recovery compared to _______ (2).
• _______ (3) is appropriate for surgeries not amenable to and/or patients with contraindications to regional techniques.
• Orthopedic surgery patients may have limited mobility and may require special attention to avoid _______ (4)-related injury.

Patients presenting for spine surgery should be evaluated carefully for potential _______ (5) challenges and/or impaired _______ (6) function.
- Major spine surgery frequently involves significant bleeding, and blood conservation techniques should be considered

Answer 1

Answers:

1. analgesia
2. general anesthesia
3. General anesthesia
4. positioning
5. airway
6. respiratory

Question 1

KEY POINTS

• Intraoperative monitoring of spinal cord function should be used for surgeries where the cord is at risk of injury.
• Catastrophic venous air embolism during spine surgery may present as unexplained _______(a) with high end-tidal _______ (1) and low end-tidal _______ (2).
• Nerve injury may result from surgical trauma and/or nerve blockade in the setting of pre-existing neurologic deficits.
• In the sitting position, for every ______(b) cm of difference in height of the head from the heart, there is a ______(c)-mmHg difference in mean arterial pressure.
• _______ (3), _______ (4), and _______ (5) should be available for management of hypotensive bradycardic events occurring during surgery in the beach chair position.
• _______ (6) blocks cause hemidiaphragmatic paresis and can cause respiratory compromise in patients with reduced pulmonary function.
• Venous thromboembolism is a common complication of _______ (7) extremity orthopedic surgery performed with inadequate thromboprophylaxis.
• The American Society of Regional Anesthesia has released guidelines for safe use of regional anesthesia in the setting of antithrombotic or thrombolytic therapy.

Answer 1

Answers:

1. nitrogen
2. carbon dioxide
3. Ephedrine
4. atropine
5. glycopyrrolate
6. Interscalene
7. lower

a. hypotension
b. 20
c. 15

Question 2

Introduction

Complications of orthopedic surgery includes/relate to:
- Nerve injury: Expertise in regional anesthetic techniques for both surgical anesthesia and postoperative analgesia is of _______(1) importance.
- _______(2) Blood Loss
- Stretch/Pressure _______(3)
- Hemodynamic _______(4)
- Tourniquet _______(5)
- controlled intraoperative _______(6)
- blood salvage _______(7)
- use of antifibrinolytics
- fluid _______(8)
- _______(9)

Answer 2

Answers:
1. paramount
2. Major
3. Injuries
4. Changes
5. use
6. hypotension
7. techniques
8. resuscitation
9. Transfusions

Question 3

Preoperative Assessment

• special attention to potential airway _______(1)
• considerations relating to mobility and intraoperative _______(2)
• medication history related to opioid _______(3)
• anticoagulation _______(4)
  
  • Common in elderly hip/knee patients with _______(5)

Overall, patients undergoing orthopedic procedures are considered at _______(6) risk for perioperative cardiac complications.

Answer 3

Answers:
1. difficulties
2. positioning
3. dependence
4. status
5. comorbidities
6. intermediate

Question 4

Rheumatoid Arthritis:
- often require orthopedic surgery and merit special _______(1)
- RA can affect the pulmonary, cardiac, and musculoskeletal _______(2)
- Airway management can be challenging in these _______(3)
- Involvement of the cervical spine and temporomandibular joints results in limited neck range of _______(4) and mouth opening
- Atlantoaxial instability, with subluxation of the odontoid process:
- can lead to spinal cord injury during neck _______(5)
- may require perioperative steroid replacement (Stress _______(6))
- If they are already on steroids for their _______(7)

Answer 4

Answers:
1. attention
2. systems
3. patients
4. motion
5. extension
6. Dose
7. RA

Question 5

Selection of Anesthetic Technique

Many orthopedic surgical procedures, because of their localized peripheral sites, lend themselves to regional anesthetic techniques

advantages over general anesthetics including:
- enhanced _______(1)
- accelerated hospital _______(2)
- improved _______(3)
- decreased nausea and _______(4)
- less respiratory and cardiac _______(5)
- improved _______(6)
- reduced blood _______(7)
- decreased risk of infection and _______(8)

The optimal regional technique and local anesthetic depend on factors including:
- surgery _______(9)
- indication for postoperative _______(10)
- degree & duration of postoperative sensory/motor block needed for active and passive physical _______(11)

General anesthesia is appropriate for orthopedic surgery:
- sites not amenable to _______(12)
- in patients with contraindications to regional techniques
- anticoagulation _______(13)
- infection at the needle insertion _______(14)
- pre-existing nerve injury or _______(15)
- You don’t want to be blamed for a nerve injury you didn’t _______(16)
- patient refusal: “They are allowed to say _______(17)”

Answer 5

Answers:
1. rehabilitation
2. discharge
3. analgesia
4. vomiting
5. depression
6. perfusion
7. loss
8. thromboembolism
9. duration
10. sympathectomy
11. therapy
12. regional
13. status
14. site
15. disease
16. cause
17. no

Question 6

Anesthesia for Spine Surgery

Preoperative Assessment
Preoperative evaluation for spine surgery should assess involvement of the:
* Respiratory system
* Cardiovascular system
* Neurologic system

Airway evaluation should focus on:
* restricted neck movement
o Ask the pt in pre-op: How high can you lift your chin before it starts to hurt?
* cervical spine stability
o Often times- you can just ask the surgeon how much wiggle room you have
* exacerbation of symptoms with movement or position

Securing the Airway:
* The decision to secure the airway awake, asleep, or with _______(1) airway devices should be made prior to surgery and the patient counseled accordingly
* Awake _______(2) tracheal intubation is preferred when assessing for neurologic function prior to use of a traction device.
o Numb the _______(3)
o Afrin in the nose to shrink the nasal mucosa
o Lidocaine _______(4): Prevent the Gag
o At The Ready with Propofol the second that tube goes in
* NEVER Place a HARD oral airway and then place a patient _______(5) (21:20)
o Can cause Lip _______(6)

Answer 6

Answers:
1. advance
2. fiberoptic
3. airway
4. updraft
5. Prone
6. Ischemia

Question 7

Respiratory Function
* Patients presenting for spine surgery often have impaired respiratory function.
* Scoliosis can cause _______(1) lung disease EXAM II QUESTION LOL
* neuromuscular diseases can be associated with recurrent _______(2) infections
* patients with spinal cord injury may already be _______(3) dependent
* Physical exam and history should focus on _______(4) impairment
* Chest radiograph, arterial blood gas, and pulmonary function tests may be indicated in patients with _______(5) pulmonary disease
* A preoperative vital capacity less than _______(6) of predicted is associated with prolonged postoperative ventilation after scoliosis surgery
* Optimization of pulmonary function targets treatment of _______(7) causes with the use of preoperative physical therapy, _______(8), and _______(9) as indicated

Answer 7

Answers:
1. restrictive
2. chest
3. ventilator
4. functional
5. restrictive
6. 30% to 35%
7. reversible
8. antibiotics
9. bronchodilators

Question 8

Cardiac dysfunction
* often associated with spine pathology and may be a primary manifestation of the disease as seen in muscular dystrophies
* Rarely, scoliosis can cause _______(1) secondary to chronic hypoxemia and pulmonary hypertension
o electrocardiogram (ECG) and echocardiogram should be obtained to assess left ventricular function and _______(2) pressures.
* Dobutamine stress echocardiography may be necessary to assess cardiac function in patients with limited _______(3) or mobility

Neurologic deficits
* Neurologic deficits of spine patients generally relate to the underlying disease and should be discussed in detail with the patient and surgeon and _______(4).
* cervical spine surgery:
o extra care must be taken to avoid _______(5) during tracheal intubation and positioning
* Neuromuscular diseases:
o increase risk of _______(6) during airway manipulation
* Patients with spinal cord injury:
o spinal shock and _______(7) are of particular concern.

Dr. H’s Key Words for Documenting
* Patient intubated in the neutral position Using Direct Laryngoscopy
* _______(8)
* No Neck Extension
* Dentition intact
* Positive End-Tidal
* Comment about the Neck Position (neutral, no extension, etc.)
* You HAVE to protect yourself- get in the _______(9)

Answer 8

Answers:
1. cor pulmonale
2. pulmonaryarterial
3. exercise tolerance
4. documented
5. injury
6. aspiration
7. autonomic dysreflexia
8. Atraumatic
9. habit

Question 9

Positioning for Spine Surgery
- Positioning for spine surgery depends on the level and approach of the procedure.
- Patients may be transitioned between supine, lateral, and prone positions intraoperatively (Rare)
- May be completely _______(1)
- Overall goals of positioning are to:
- _______(2) as needed to protect peripheral nerves, bony prominences, and the eyes
- _______(3) well
- Support _______(4) (not just dangling)
- _______(5) Position
- (protect brachial plexus; no pressure on olecranon processes)
- Support underneath the _______(6) and ankles
- (2) avoid displacement of unstable _______(7) during surgery
- (3) ensure low venous pressures—minimize blood _______(8) at the surgical site
- Low venous pressures can be facilitated by maintaining a free abdomen and _______(9) position.

Answer 9

Answers:
1. Prone
2. pad
3. Pad everything
4. Shoulders
5. Surrender
6. knees
7. fractures
8. loss
9. reverse Trendelenburg

Question 10

The posterior approach to spine surgery:
- requires _______(1) positioning
- Pressure on the abdomen causes _______(2) compression:
- increasing bleeding from _______(3) epidural veins
- ______(a) cardiac output
- increasing the risk of lower limb _______(4)
- Therefore, adequate foam padding should be placed under the chest (below the axillae) and the anterior superior iliac spines.
- Stretch and Pressure Injuries:
- The arms should not be abducted to more than 90 degrees and should be positioned with slight internal rotation to reduce the risk of brachial plexus stretching
- Elbow Flexion: _______(5) nerve is at particular risk of pressure-related injury and should be protected
- The eyes should be taped closed
- Be careful with the face _______(6)

The anterior approach to the thoracolumbar spine:
- achieved in the _______(7) position
- For scoliosis surgery:
- the ______(b) of the curve is usually uppermost
- removal of one or more _______(8) may be necessary for surgical exposure
- Placement of a ______(c) endotracheal tube to collapse the lung on the operative side may be required for surgery above _______(9)

Answer 10

Answers:
1. prone
2. inferior vena cava
3. valveless
a. reducing
4. thrombosis
5. ulnar
6. lashes
7. lateral
b. convexity
8. ribs
c. double-lumen
9. T8

Question 11

For cervical spine surgery:
- anterior approaches require the _______(1) position
- posterior approaches require _______(2) positioning
- patient may be positioned with the head away from machine to allow surgical access
- extensions may be needed for _______(3) circuits
- _______(4) minimizes venous bleeding
- A-Line: No longer _______(5) of care

Blood Conservation
- The frequency of transfusion in adult spine surgery ranges from _______(6) to 81%
- Most of the blood loss during spinal instrumentation and fusion occurs with _______(7)
- Proportional to the number of _______(8) levels involved.
- Rare cause of bleeding during spine surgery:
- trauma to the aorta, vena cava, or iliac vessels
- Unexplained rapidly evolving _______(9) with signs of _______(10) should alert the anesthesiologist to this possibility

Answer 11

Answers:
1. supine
2. prone
3. breathing
4. Reverse Trendelenburg
5. standard
6. 50%
7. decortication
8. vertebral
9. hypotension
10. hypovolemia

Question 12

Measures to decrease blood loss/transfusion requirements:
- preoperative _______(1) donation
- proper _______(2)
- the use of intraoperative _______(3) salvage
- administration of antifibrinolytics such as _______(4) (TXA)
- reduces surgical bleeding and transfusion requirements
- also does so without increased incidence of:
- _______(5) embolism (PE)
- _______(6) venous thrombosis (DVT)
- _______(7) infarction
- EXAM II QUESTION LOL

Answer 12

Answers:
1. autologous
2. positioning
3. blood
4. tranexamic acid
5. pulmonary
6. deep
7. myocardial

Question 13

Spinal Cord Monitoring
Intraoperative monitoring (IOM) of spinal cord function is now considered mandatory for all surgeries in which the cord is at risk of _______(1). Risk is incurred when corrective forces are applied to the spine, osteotomies are made, or the spinal canal is _______(2) invaded. There are three main methods of IOM: the wake-up test, somatosensory evoked potential (SSEP) monitoring, and motor evoked potential (MEP) recording.

The wake-up test
- involves intraoperative awakening of the patient after completion of spinal instrumentation in order to assess motor function of upper and lower _______(3)
- Dr. H: “This just doesn’t happen anymore with _______(4) and MEP as an option”
- ______(a) are (havenstein says _______(5) important tool) important for analgesia and tolerance of the _______(6) tube while the patient is awake
- Disadvantages including
- the risk that an _______(7) patient could move
- dislodge the endotracheal tube
- even fall from the table

Answer 13

Answers:
1. injury
2. surgically
3. extremities
4. SSEP
a. Opioids
5. most
6. endotracheal
7. uncooperative

Question 14

SSEPs: somatosensory evoked potential
- assess the _______(1) column pathways of proprioception and vibration that are supplied by the _______(2) spinal artery.
- SSEPs are altered by
- neural injury
- volatile anesthetics
- _______(3) co2?
- Hypoxia
- Hypotension
- _______(4) temp?

MEPs: motor evoked potential
- Motor pathways are supplied by the _______(5) spinal artery and are monitored by MEPs.
- MEPs are considered technically more difficult to use, in part because they are impeded by use of _______(6).

Answer 14

Answers:
1. dorsal
2. posterior
3. Hypercarbia
4. Hypothermia
5. anterior
6. muscle relaxants

Question 15

MEPs: motor evoked potential
- Motor pathways are supplied by the _______(1) spinal artery and are monitored by MEPs.
- MEPs are considered technically more difficult to use, in part because they are impeded by use of _______(2).

If both (MEP and SSEPs)
- SSEP and MEP are to be monitored during spine surgery, a suitable anesthetic regimen would include
- an ultrashort-acting ______(a) infusion (she says _______(3))
- a low-dose inhaled anesthetic (she says _______(4) MAC)
- total intravenous anesthesia (background _______(5))
- with monitoring of the electroencephalogram or _______(6)

• MEPs in combination with SSEPs may increase the early detection of spinal cord ischemia. Acute alterations in signal amplitude or _______(7) can signify spinal cord compromise and may be the result of direct trauma, ischemia, compression, or hematoma
  
  • If changes occur, it is recommended that surgery be discontinued → blood pressure returned to normal or _______(8) above normal→
  • volatile agents _______(9) or discontinued. →
  • ______(b) can help rule out a metabolic derangement. → If the signal does not return to normal, the surgeon should release distraction on the cord. →
  • A _______(10) can be performed at this time to definitely exclude neurologic deficits.
  • Summarized: _______(11) tests → anesthesia is blamed → ABG r/o anesthesia → still no return → surgeon releases pressure → wake up test

Answer 15

Answers:
1. anterior
2. muscle relaxants
a. opioid
3. Remi
4. 0.5
5. propofol
6. bispectral index
7. latency
8. 20%
9. decreased
b. Arterial blood gases
10. wake-up test
11. Motor and sensory evoked potential

Question 16

Spinal Cord Injury
- Patients with a suspected spinal cord injury should be examined immediately to assess for signs of respiratory insufficiency, airway obstruction, rib fractures, and chest wall or facial trauma.
- Spinal cord function above the level of the injury should be determined.
- If the muscles controlled by the C5 nerve roots (_______(1)) are flaccid, partial ______(a) paralysis should also be expected.
- C5 injuries “emphasis on _______(2) roots” CHART CHART CHART all deficiencies pre and post-op
- Patients requiring spine stabilization surgery may present with spinal shock, which occurs immediately after the injury and lasts up to _______(3).

• Injuries at or above T5 are associated with hypotension due to a physiologic _______(4) and loss of tone from the ______(b).
• Lesions above the cardiac accelerator fibers (______(c)) cause bradycardia.
  • Hypotension due to spinal injury is ______(d) responsive to intravenous fluids and vasopressors, and excessive fluid administration may contribute to the development of _______(5) edema
  • Be very cautious: If the patient has Low BP and they are NOT responding to Fluids… STOP the Fluid

Answer 16

Answers:
1. deltoid, biceps, brachialis, and brachioradialis
a. diaphragmatic
2. C5
3. 3 weeks
4. sympathectomy
b. splanchnic vascular beds.
c. T1 to T4
d. poorly
5. pulmonary

Question 17

With complete cord transection above T5
- Following recovery from spinal shock, ______(a) of patients go on to exhibit autonomic _______(1).
- The syndrome can also occur with injuries at lower levels and is characterized by
- severe paroxysmal hypertension with _______(2) from the baroreceptor reflex, dysrhythmias

• cutaneous_______(3) below and ______(b) above the level of the injury.
• Episodes are typically precipitated by distention of the _______(4) or rectum but can be induced by any _______(5) including surgery.
• Treatment involves
  
  • removal of the stimulus
  • deepening of anesthesia
  • administration of direct-acting _______(6).
• Untreated, the hypertensive crisis may progress to seizures, intracranial hemorrhage, or myocardial infarction.
• High cervical lesion that includes the diaphragmatic segments (_______(7)) results in respiratory failure and _______(8) without mechanical ventilation.
• Lesions between _______(9) cause significant alterations in respiratory function due to loss of abdominal and intercostal support.
  
  • Flaccid thoracic muscles can lead to paradoxical respirations and a vital capacity reduction of _______(10).
  • Inability to cough and effectively clear secretions causes an increased ______(c) and increased risk of infection.

Answer 17

Answers:
a. 85%
1. hyperreflexia
2. bradycardia
3. vasoconstriction
b. vasodilation
4. bladder
5. noxious stimulus
6. vasodilators
7. C3 to C5
8. death
9. C5 and T7
10. 60%
c. atelectasis

Question 18

Succinylcholine can be administered safely for the first ______(a) hours after spinal cord injury.
- After that time, a proliferation of _______(1) receptors in the muscle can cause hypersensitivity to depolarizing muscle relaxants leading to marked hyperkalemia.
- Maximal hyperkalemia risk from succinylcholine occurs between _______(2) and _______(3) after spinal injury.
- Serum potassium levels may rise as high as _______(4) mEq/L, causing ventricular fibrillation and cardiac arrest.
- Although succinylcholine should be avoided in all patients with spinal cord injury after 48 hours, _______(5) paralytic agents can be used.

Patients with spinal cord injury are _______(6) owing to disruption of sympathetic pathways carrying temperature sensation and subsequent loss of vasoconstriction below the level of injury.
- Normothermia can be achieved by applying exogenous heat to the skin, increasing ambient air temperature, warming intravenous fluids, and humidifying gasses.
- _______(7): Core temperature becomes dependent on ambient temperature; cannot maintain an independent core temperature
- This is the biological term for “Cold-Blooded” ie a lizard lol

Answer 18

Answers:
a. 48
1. acetylcholine
2. 4 weeks
3. 5 months
4. 14
5. nondepolarizing
6. poikilothermic
7. Poikilothermic

Question 19

Scoliosis
- Scoliosis involves a lateral and rotational deformity of the spine and occurs in up to _______(1) of the population.
- Most cases are idiopathic (_______(2)), with a male to female ratio of _______(3).
- Surgery is considered when the Cobb angle, a measure of curvature, exceeds:
- _______(4) degrees in the thoracic
- or _______(5) degrees in the _______(6) spine.

• can cause
  
  • _______(7) hypoxia
  • _______(8)
  • pulmonary vascular _______(9)→
    
    • resulting in _______(10) pulmonary vascular changes →
    • _______(11) hypertension→
    • eventually _______(12) ventricular hypertrophy and cor pulmonale.
• untreated idiopathic scoliosis can progress rapidly and is often fatal by the _______(13) or _______(14) decade of life.
• Scoliosis is also often associated with congenital heart conditions including
  
  • mitral valve _______(15)
  • coarctation of the _______(16)
  • cyanotic heart _______(17)
  • suggesting a common embryonic insult or collagen defect.
• scoliosis repair
  
  • is to halt the decline in respiratory function, pulmonary function acutely _______(18) for 7 to 10 days after surgery.
  • Preoperative vital _______(19) is a reliable prognostic indicator of respiratory reserve, and postoperative ventilator support is likely to be required for those with a vital capacity less than _______(20)% of predicted.

Answer 19

Answers:
1. 4%
2. 70%
3. 1:4
4. 50
5. 40
6. lumbar
7. chronic
8. hypercapnia
9. constriction
10. irreversible
11. pulmonary
12. right
13. fourth
14. fifth
15. prolapse
16. aorta
17. disease
18. deteriorates
19. capacity
20. 40

Question 20

Anesthetic considerations for surgical correction of scoliosis by spinal fusion and instrumentation include
- management in the _______(1) position, hypothermia during long procedures with extensive exposure, and replacement of blood and fluid losses.
- Adequate hemodynamic monitoring and venous access are essential.
- An arterial line allows for close hemodynamic monitoring and assessment of blood _______(2)
- whereas a central venous catheter may be helpful in evaluating blood and fluid management and can be used to aspirate air in the case of venous air _______(3).
- Patients with evidence of pulmonary hypertension or severe coexistent cardiovascular or pulmonary disease may require a pulmonary artery _______(4).

• Scoliosis CVP, _______(5), and PAC monitoring only for extremely sick _______(6)

Answer 20

Answers:
1. prone
2. gasses
3. embolism
4. catheter
5. A-line
6. patients

Question 21

Muscular Disorders
- Muscular dystrophy and cerebral palsy are important causes of _______(1)
- Patients with DMD are sensitive to _______(2) neuromuscular blocking agents, and _______(3) may occur with use of succinylcholine.

Degenerative Vertebral Column Disease
- Spinal stenosis, spondylosis, and spondylolisthesis are all forms of _______(4) vertebral column disease
- causing pain and/or progressive neurologic symptoms requiring surgical _______(5).
- A preoperative assessment of C-spine symptoms and the airway should be performed
- Intraoperatively, the _______(6) incision approximates the border of the _______(7) muscle, near critical anatomic structures.
- _______(8) retraction of the carotid artery may endanger cerebral perfusion, particularly in the elderly patient.
- Retraction of the _______(9) and _______(10) medially may cause pharyngeal laceration, laryngeal edema, and recurrent laryngeal nerve paralysis.
- Cerebrospinal fluid leaks and trauma to the vertebral artery have also been reported.
- General anesthesia is preferred for nearly all thoracic and cervical procedures because of the high spinal level that would be required with a regional technique
- Degenerative vertebral column disease: Thoracic/Cervical surgeries requires _______(11), because it would be hard to generate such a high spinal _______(12).

Answer 21

Answers:
1. scoliosis
2. nondepolarizing
3. hyperkalemia
4. degenerative
5. intervention
6. anterior
7. sternocleidomastoid
8. Lateral
9. esophagus
10. trachea
11. GENERAL ANESTHESIA
12. level

Question 22

Postoperative Care of the Spine Patient

Postoperative ventilation may be required in patients with:
- neuromuscular disorders
- severe restrictive pulmonary dysfunction with a preoperative vital capacity of less than _____(1) of predicted
- right ventricular failure, obesity, or sleep apnea
- Patients with prolonged procedures
- thoracic cavity invasion
- blood loss greater than _____(2)

Mentioned neurologic status should be _____(3) (vague)
- Neurologic status must also be monitored closely to determine appropriateness for _____(4).
- Neurologic status must be followed closely and bowel dysmotility is common.

Postoperative mechanical ventilation may be maintained for a few hours, with the head of the bed _____(5) when possible
- until hypothermia and metabolic derangements have been corrected and facial and _____(6) have improved.

______(a) analgesia postoperative pulmonary therapy (______(7)), including incentive spirometry, is necessary to avoid post extubation atelectasis and pneumonia

• Multimodal analgesia has become the gold standard for postoperative pain relief and can be useful after spine surgery.
• Completely strip the muscle off the _____(8) is what hurts; muscle spasm
• _____(9) her personal best pain relief was through drugs that stopped the pain

Do not expand but this table may be helpful

Answer 22

Answers:
1. 35%
2. 30 mL/kg-1
3. check/monitored
4. extubation
5. elevated when possible
6. airway edema
a. Multimodal
7. toileting
8. bone-THAT is what hurts
9. Her

Question 23

Complications of Spine Surgery

• Venous air embolus (VAE) is a catastrophic event that is a particular risk during laminectomy because of the large amount of _____(1) and location of the surgical site _____(2) the level of the heart.
  
  • presents as unexplained _____(3) with an increase in the end-tidal ______(a) concentration
  • OR a precipitous _____(4) in the end-tidal carbon dioxide concentration.
  • Prompt diagnosis and treatment increase patient survival with VAE.
• VAE Prevention and management measures include
  
  • intravascular volume expansion
  • careful positioning
  • positive end-expiratory pressure (______(5))
  • jugular venous compression (VAE Avoid _____(6))
• VAE Treatment includes
  
  • flooding the surgical site with saline
  • controlling sites of air entry
  • repositioning the patient with the surgical site below the right atrium
  • aspiration of air from a multiorifice central venous catheter
  • cessation of inhaled ______(b)
  • resuscitation with oxygen (______(7))
  • intravenous fluids
  • inotropic agents
  • Massive embolism may necessitate _____(8) and cardiopulmonary resuscitation.

Answer 23

Answers:
1. exposed bone
2. above
3. hypotension
a. nitrogen
4. fall
5. PEEP
6. Avoid JVD compression
b. nitrous oxide
7. 100% FiO2
8. supine repositioning

Question 24

Ischemic Optic Neuropathy

• Ischemic Optic Neuropathy is the most common cause of _____(1)
  
  • The etiology of vision loss can be optic neuropathy, _____(2), or cerebral ischemia.
• Most cases are associated with complex instrumented fusions, significant sustained intraoperative _____(3), anemia, large intraoperative blood loss, and prolonged surgery
• ischemic optic neuropathy after spinal surgery include
  
  • _____(4), obesity
  • ______(a) frame use
  • long anesthetic duration
  • _____(5)
  • use of _____(6) fluids.

Answer 24

Answers:
1. vision loss
2. retinal artery occlusion
3. hypotension
4. male sex
a. Wilson
5. large blood loss
6. non-colloid

Question 25

Upper Extremity Surgery
- Orthopedic surgical procedures to the upper extremity are well suited to regional anesthetic _______(1).
- The decision to perform regional anesthesia in a patient with pre-existing neurologic deficits or who is at risk for perioperative neurapraxia should be made on an individual basis after discussion with the patient and _______(2).
- She summarized as if there are present nerve injuries on assessment, regional at site is _______(3).

Surgery to the Shoulder and Upper Arm
- Reconstructive shoulder surgery, including total shoulder arthroplasty (TSA) and rotator cuff repair, presents unique management and positioning considerations to the _______(4).
- _______(5) block for shoulder surgeries.

Answer 25

Answers:
1. techniques
2. surgeon
3. C/I
4. anesthesiologist
5. Infra/supra clavicular

Question 26

Surgical Approach and Positioning
- Surgical procedures to the upper arm and shoulder are typically performed with the patient sitting in the “_____(1)” or _____(2) position (see Chapter 29).
- In either position, the patient’s head, neck, and hips must be secured to prevent lateral movement during surgical manipulation, with frequent reassessment throughout the case.
- Excessive rotation or flexion of the head _____(3) from the operative side results in stretch injury to the brachial plexus.
- Care must be taken to avoid pressure on the _____(4) and _____(5).
- The lateral position
- has been associated with increased rates of _____(6) from stretch injuries
- challenging position from which to convert from an arthroscopic to an open procedure should this become necessary
- _____(7) is the mildest form of traumatic peripheral nerve injury
- Chest roll for lateral decubitus position so they don’t stretch that _____(8)
- The beach chair position: _____(9) THE COCONUT
- Blood pressure at the head will be lower than at the arm or leg, with every ______(a) cm of height difference equating to approximately ______(b)-mmHg difference in mean arterial pressure
- Up to 25% of patients undergoing surgery in the beach chair position under general or regional anesthesia can experience hemodynamically significant _____(10) _____(11) events
- thought to be caused by ventricular underfilling and the _____(12) reflex.
- _____(13): _____(14): _____(15) describe the bj reflex process

Answer 26

Answers:
1. beach chair
2. lateral decubitus
3. away
4. eyes
5. ears
6. neurapraxia
7. Neuropraxia
8. Brachial Plexus
9. PERFUSE
a. 20
b. 15
10. hypotensive
11. bradycardic
12. Bezold–Jarisch
13. Apnea
14. Bradycardia
15. Hypotension

Question 27

Anesthetic Management
- Surgery to the shoulder and humerus may be performed under regional or general anesthesia
- She likes to have the Patient Position themselves pre-anesthetic, induce, then place _____(1)
- Ensures the patient is in a comfortable position And prevents _____(2) from un-seating with the move
- If a patient has Poor Pulmonary Function (ie _____(3)):
- interscalene blocks caused ipsilateral diaphragmatic paresis
- You may worsen this _____(4)

Surgery to the Elbow, Wrist, and Hand
- Surgery in the areas of the distal humerus, elbow, forearm, wrist, and hand can be performed with:
- _____(5), infraclavicular, or axillary nerve blocks
- Infraclavicular and supraclavicular approaches to the brachial plexus are:
- the most _____(6)
- provide consistent anesthesia to the four major peripheral nerves of the brachial plexus
- Medial aspect of the upper arm:
- supplied by the _____(7) nerve
- generally spared by infraclavicular and axillary blocks
- Instead: may be blocked by a subcutaneous injection of local anesthetic immediately distal to the axilla for the prevention of _____(8) pain
- Hand, Wrist and Finger Surgery:
- may require only local infiltration or peripheral blockade
- Intravenous regional anesthesia (Bier block)
- Decrease anesthetic requirement
- Minimal Postoperative Pain
- Quick Discharge Home

Answer 27

Answers:
1. LMA (Laryngeal Mask Airway)
2. LMA
3. COPD (Chronic Obstructive Pulmonary Disease)
4. situation
5. supraclavicular
6. reliable
7. intercostobrachial
8. tourniquet

Question 28

Lower Extremity Surgery
- 50/50 on General vs Regional
- Regional is a better option if the patient can _____(1)
- Neuraxial techniques for total hip arthroplasty (THA) and total knee arthroplasty (TKA) are associated with:
- lower 30-day _____(2)
- decreased incidence of thromboembolic events
- less blood _____(3)
- lower transfusion requirements
- decreased length of stay (_____)(4)
- A major complication of orthopedic lower extremity surgery is perioperative _____(5) formation and venous ______(a).

Hip Analgesia:
- A _____(6) or psoas compartment block is an anatomically deep block that provides a potent analgesic for hip surgery
- _____(7) is a useful alternative
- however, ______(b) weakness may increase postoperative fall risk during rehabilitation

Answer 28

Answers:
1. tolerate
2. mortality
3. loss
4. LOS
5. DVT (Deep Vein Thrombosis)
a. thromboembolism
6. lumbar plexus block (LPB)
7. Femoral nerve block (FNB)
b. quadriceps

Question 29

Ambulatory Hip Surgery
- Hip arthroscopy is a common procedure to repair:
- labral tears
- hip dysplasia
- femoroacetabular impingement.
- Patients are placed in either the _____(1) or _____(2) position
- ______(a) relaxation is necessary while the leg is placed in traction to facilitate dislocation of the femoral head from the _____(3) for access to the hip joint
- Relaxation can be achieved by spinal, epidural, or general anesthesia

Life-threatening complication of hip arthroscopy:
Intra-abdominal fluid extravasation (IAFE)
- extravasation of the arthroscopy fluid from the hip joint into the _____(4) cavity
- In extreme cases, intra-abdominal fluid extravasation (IAFE) can cause abdominal _____(5) syndrome
- resulting in hemodynamic instability, cardiovascular collapse, death

Treatment:
- ranges from clinical observation
- to _____(6)
- to abdominal laparotomy (Severe Cases)

Answer 29

Answers:
1. supine
2. lateral
a. Maximal
3. acetabulum
4. peritoneal
5. compartment
6. diuresis

Question 30

Total Knee Arthroplasty
- TKA involves the cutting and cementing of two _____(1)
- Extremely Common
- Neuraxial anesthesia should be used whenever possible
- The Esmarch (Giant Rubber Band) and work their way up above the knee, they will have you inflate the _____(2), and they will release the Esmarch
- thigh tourniquet will minimize bleeding and improve surgical visualization

Analgesia for Total Knee Arthroplasty
- The ______(a) nerves provide sensation to the knee joint
- Most commonly utilized peripheral nerve blocks are the:
- _____(3)
- fascia iliaca (_____)(4)
- _____(5)
- adductor canal (or _____)(6) nerve blocks

Answer 30

Answers:
1. long bones
2. tourniquet
3. LBP (lumbar plexus block)
a. femoral, sciatic, and obturator
4. 3-in-1 block
5. FNB (femoral nerve block)
6. saphenous

Question 31

Surgery to the Foot and Ankle
- Innervation of the foot and ankle is provided by the:
- ______(a) nerve (via the _____(1) nerve)
- and the _____(2) nerve (via the posterior tibial, sural, and deep and superficial peroneal nerves)

• Anesthesia for foot surgery can be performed with an:
  
  • ______(b) block (posterior tibial, sural, and _____(3) peroneal nerves)
  • _____(4) nerve block in the popliteal fossa with a ______(c) nerve block as needed for coverage of the medial foot and ankle

Not Covering Pediatric Orthopedics

Amputation
- many patients experience phantom limb pain, phantom limb sensations, and/or stump pain that can be chronic, debilitating, and difficult to manage
- The incidence of persistent phantom limb pain is approximately:
- ______(d) % with upper extremity amputation
- up to _____(5) after lower limb amputation
- Prolonged outpatient local anesthetic administration (median 30 days) via _____(6) catheter may prevent phantom limb pain

Answer 31

Answers:
a. femoral
1. saphenous
2. sciatic
b. ankle
3. superficial
4. sciatic
c. saphenous
d. 40
5. 85%
6. perineural

Question 32

Microvascular Surgery
- Often required for restoration of blood flow following orthopedic trauma
- can take many hours to perform
- often requires general anesthesia to maintain patient comfort and prevent movement
- Mechanical ventilation:
- can help avoid vasoconstriction caused by hyperoxia and hypocarbia
- as well as by hypercarbia-induced catecholamine release
- Optimal anesthetic management utilizes regional techniques that:
- provide _____(1) (maximizing vasodilation)
- and diminish the stress response (minimizing vasospasm and thrombotic risk)
- Maintenance of normothermia: essential to minimize vasoconstriction
- Volume replacement is recommended at a rate of _____(2) per hour
- Permissive hemodilution to a hematocrit of ______(a)% can be considered for optimization of blood viscosity, and oxygen-carrying capacity

• Surgeons generally discourage _____(3) except in emergency situations, so their use must be discussed with the surgical team prior to initiation.

Answer 32

Answers:
1. sympathectomy
2. 3.5 to 6 mL/kg
a. 30
3. vasopressors

Question 33

Acute Compartment Syndrome
- Occurs when soft tissue pressures in a closed extremity compartment exceed ______(a) perfusion pressure, resulting in ischemic tissue damage
- Most commonly seen following tibial and _____(1) fractures.
- ACS is often first heralded by symptoms of pain _____(2) to injury
- the benefits of regional analgesic techniques must be weighed against the risk of _____(3) diagnosis of compartment syndrome

Tourniquets
- Tourniquets are often used to minimize blood loss and provide a bloodless operating field for extremity orthopedic surgery
- The cuff should be large enough to comfortably encircle the limb, and the width should be more than _____(4) the limb diameter
- High Tourniquet Pressure: Damage to underlying vessels, nerves, and muscles
- Cuff pressure:
- _____(5) above a patient’s measured systolic pressure is adequate for the thigh
- ______(b) mmHg above systolic pressure is adequate for the arm
- The duration of safe tourniquet inflation is generally considered to be _____(6)
- however, a perfusion break followed by repeat exsanguination may be considered if longer total tourniquet times are required.

Answer 33

Answers:
a. capillary
1. forearm
2. out of proportion
3. delayed
4. half
5. 100 mmHg
b. 50
6. 2 hours

Question 34

Fat Embolus Syndrome
- Fat embolus syndrome (FES) is associated with:
- multiple traumatic injuries
- surgery involving _____(1) fractures
- bilateral arthroplasty
- The incidence of FES in isolated long-bone fractures is 3% to 4% and the associated mortality rate is significant, ranging from _____(2) to 20%
- Low Incidence but High Mortality
- Early ______(a) use in long-bone fracture patients may be beneficial in preventing the _____(3)
- Symptoms of FES usually occur ______(b) hours after the injury and can range from mild dyspnea to frank coma

Answer 34

Answers:
1. long-bone
2. 10%
a. corticosteroid
3. syndrome
b. 12 to 40

Question 35

Bone Cement Implantation Syndrome

• Bone cement implantation syndrome (BCIS) is a poorly defined syndrome of hypoxemia, hypotension, and/or altered mental status observed in patients undergoing fracture repair or arthroplasty with _____(1)
• The syndrome is defined as occurrence of these events in temporal proximity to cementation, prosthesis insertion, joint reduction, or tourniquet deflation, with its severity defined by degree of hypoxemia and _____(2)
• More likely to be associated with _____(3) than the circulation of methyl methacrylate cement monomers
• Such embolization can trigger a cascade of endothelial damage, _____(4) release, and ______(5) activation that contributes to the severity of FES and BCIS

Answer 35

Answers:
1. cementation
2. hypotension
3. FES (Fat Embolus Syndrome)
4. histamine
5. complement