Wk 12: Orthopedics Flashcards
(82 cards)
1
Q
Comorbidities and Presurgical Conditions for Orthopedic Surgery (4)
A
Osteoarthritis (OA)
Rheumatoid arthritis (RA)
Lupus
Ankylosing Spondylitis (AS)
2
Q
Ankylosing Spondylitis (AS): primarily affects the _____ ______ and ______ _____ joints
A
vertebral column
sacroiliac joints
3
Q
Osteoarthritis aka _____________
A
degenerative joint disease (DJD)
4
Q
What is the leading cause of joint replacement (99%): most common type of osteoarthritis?
A
Osteoarthritis
5
Q
Osteoarthritis
Prevelence: Age > ____ years
Women ___ men
A
60
>
6
Q
Osteoarthritis
Caused by: (5)
-_______ wear and tear on joint
-______ ______ sports
-_______ injury: bone on cartilage
-________: extra stress on joints
-Genetics: Affects severity of OA of the _____ and ______
A
Chronic
High intensity
Previous
Obesity
spine, hip
7
Q
Rheumatoid Arthritis
Etiology:
-Inflammatory ___________ rheumatic disease
-___% of women, ___% of men will develop RA
A
autoimmune
4, 2
8
Q
Rheumatoid Arthritis
Symptoms start: > ___ years of age
Characteristics: ______ swelling, joint _______, destruction of ______ ______
A
60
Joint, tenderness, synovial joint
9
Q
Rheumatoid Arthritis
Genetics and environment:
Smokers (>____pk/yrs.), ______, ______, and _______ infections
A
20
obesity
periodontitis
viral
10
Q
Is there a cure for RA?
A
No cure, treat the symptoms
11
Q
Rheumatoid Nodules
Causes chronic _________
-Cervical spine: Decreased _______
-TMJ (temporomandibular joint): limits ________ ________
-Larynx: _______ of vocal cords in________
-Pulmonary: _______
A
synovitis
ROM
mouth opening
Fixation, adduction
12
Q
Which type of arthritis affects multiple organs?
A
Rheumatoid arthritis
13
Q
Which type of arthritis is caused by autoimmune disease?
A
Rheumatoid arthritis
14
Q
What is the leading cause of joint replacement?
A
Osteoarthritis
15
Q
Airway management for those with RA include: (3)
A
Regional technique
Use smaller ETT
Consider fiberoptic
16
Q
Which rheumatologic disorder includes the characteristic bamboo spine on x-ray and a fixed neck flexion?
A
Ankylosing Spondylitis
17
Q
What is the timeframe for administering antibiotics for surgery?
A
Within 1 hour before incision
18
Q
What is the maximum time frame for a pneumatic tourniquet during orthopedic procedures?
A
2 hours
19
Q
Tourniquet deflation can result in the following (2)
A
Hypotension
Increase in EtCO2
20
Q
Which of the following procedures will a tourniquet be required?
A
Knee
21
Q
Which of the following positions is V/Q optimized?
A
Prone
22
Q
In RA, what is the most common cause of death due to?
A
CV disease
(valves- incompetence, arrhythmias)
23
Q
Who is ankylosing spondylitis more common in?
A
Men
24
Q
Ankylosing spondylitis
Characteristic _______ spine (on x-ray), _____ neck flexion, _________ back pain, __________
A
bamboo
fixed
inflammatory
osteoporosis
25
Ankylosing spondylitis
Cardiac: _________ insufficiency, ________ ( ____ block)
Aortic
arrythmias (AV block)
26
Ankylosing spondylitis
Respiratory: _________ lung disease, ____, spontaneous _________, normal ____
Restrictive
OSA
pneumothorax
PFTs
27
Airway management for RA
-________ airway
-Proper positioning important; ____ cervical mobility
Difficult
Decreased
28
Airway management for RA
RA patients taking ______, ______ therapy, or _________ need careful assessment of the airway, including _______ _______ x-rays
steroids
immune therapy
methotrexate
cervical spine
29
Airway management for RA
-Consider _________ technique vs GETA
-SAB (spinal anesthesia block) difficult, dermatome spread is _____ than normal
-Awake _________/Glidescope
-Use _____ ETT
regional
higher
fiberoptic
smaller
30
Age-specific Orthopedic Procedures
Young adult: _______
Older adult and elderly: ____ and ____
Children: _______, ________
shoulder
hip and knee
congenital, accidents
31
Perioperative Care
Current medications, Labs
-Current __________ status
-Total joints: baseline lab values ( _____, _____, ____)
-_______ screening
-COVID screening: test within ___ hours of surgery
anticoagulation
CBC
T & S
UA
MRSA
72 (just ask if have COVID symptoms)
32
Perioperative Care
Antibiotics: Administer within ___ hour of incision
Ancef __ gm is normal dose.
> 120kg = ___ grams
Redose every ___ hours
IF ALLERGY TO CEPHALOSPORIN, _______
1 h
2 g
3 g
4 h
Vancomycin
33
Surgical Care Improvement Program (SCIP)
Goal: Improve surgical care by defining common ______ that can be taken and provide appropriate ________ to decrease surgical site ______
Retired in 2015; new name is ORYX Performance Measures
measures
guidelines
infections
34
Joint Commission Measures
Temperature monitoring: > ___ degrees
Antibiotic administration: within ___ hour of incision
Beta blockers: Continue on _____
36
1 h
day of surgery
35
________ is the most common antibiotic inducing allergic reactions administered for surgical procedures. (PCN eradicated for surgery)
Was it administered before or after induction?
Ancef
36
Enhanced Recovery After Surgery (ERAS)
-ERAS protocols encompass a comprehensive range of perioperative therapies aimed at facilitating the _______ process following surgical procedures
-Enhance the overall health ______ of patients
-Mitigating medical _______ through a reduction in the hospital _____ of stay
-Aims to decrease postoperative _____ rates
healing
outcomes
expenses
length
death
(Recover quicker, go home sooner, decrease costs)
37
ERAS Society: Summary of recommended interventions for the perioperative care of hip and knee replacement (2019)
______ should be actively identified, investigated, and corrected preoperatively
Anemia
38
ERAS Society: Summary of recommended interventions for the perioperative care of hip and knee replacement (2019)
Preoperative fasting: Clear fluids should be allowed up to ___ h and solids up to __ h prior to induction of anesthesia
2
6
39
ERAS Society: Summary of recommended interventions for the perioperative care of hip and knee replacement (2019)
40
ERAS Society: Summary of recommended interventions for the perioperative care of hip and knee replacement (2019)
Standard anesthetic protocol: _______ anesthesia and ________ techniques may both be used as part of multimodal anesthetic regimes
General
neuraxial
41
ERAS Society: Summary of recommended interventions for the perioperative care of hip and knee replacement (2019)
Use of local anesthetics for infiltration analgesia and nerve blocks: Routine use of LIA is recommended for _____ replacement but not for _____ replacement
*Nerve block techniques have _____ shown clinical superiority over LIA*
knee
not
*LIA in knee replacement = HIGH*
42
ERAS Society: Summary of recommended interventions for the perioperative care of hip and knee replacement (2019)
PONV: Patients should be screened for and given _______ PONV prophylaxis and treatment
multimodal
43
ERAS Society: Summary of recommended interventions for the perioperative care of hip and knee replacement (2019)
Prevention of perioperative blood loss: _______ ____ is recommended to reduce perioperative blood loss and the requirement for postoperative allogenic blood transfusion
tranexamic acid (TXA)
44
ERAS Society: Summary of recommended interventions for the perioperative care of hip and knee replacement (2019)
Perioperative oral analgesia: A ________, ______- sparing approach to analgesia should be adopted
The routine use of ________ (paracetamol) and _______ is recommended for patients without contraindications
multimodal, opioid-sparing
acetaminophen, NSAIDs
45
ERAS Society: Summary of recommended interventions for the perioperative care of hip and knee replacement (2019)
Maintaining normothermia: ________ body temperature should be maintained peri- and postoperatively
Normal
46
ERAS Society: Summary of recommended interventions for the perioperative care of hip and knee replacement (2019)
Antimicrobial prophylaxis: Patients should receive ________ antimicrobial prophylaxis
systemic
47
ERAS Society: Summary of recommended interventions for the perioperative care of hip and knee replacement (2019)
Perioperative fluid management: _____ balance should be maintained to avoid over-and under-hydration
Fluid
48
Pneumatic Tourniquet
-________ intraoperative blood loss
-Aid ________ of vital structures
-_______ the procedure
Reduces
identification
Expedites
49
Non- Pneumatic Tourniquet
-______ ring tourniquet (SRT)
-For _______ procedures
-Application time is _____ _______
-Tourniquet _______ and ________ are same
-No device attached to monitor _____
Silicon
brief
more rapid
pain and exsanguination
time
50
Tourniquet Application
-Applied ________ anesthesia
-Inflation pressure is determined by patients ____ and ____/____ of the extremity
-_____of inflation should be documented (60, 120, 180 minutes)
after
BP, size/shape
Time
51
Tourniquet Application
-Interruption of blood supply leads to ______ _____ and ________
-Degree of ______/______ influenced by ______ of tourniquet time
-Maximum of __ hours is considered safe
tissue hypoxia, acidosis
hypoxia/acidosis, duration
2
52
Safety Measures for Tourniquets
The tourniquet should be used no longer than ___ hours
-Nerve conduction is abolished after ___ mins
-Tourniquet pain starts ___ - ____ minutes after application
2 hours
30 minutes
45-60 minutes
53
Safety Measures for Tourniquets
What things can occur after 2 hours of tourniquet time?
Postop neuropraxia
Endothelial capillary leak
54
Safety Measures for Tourniquets
Only the minimally effective pressure should be used:
-Upper extremity: ___- ___mmHg > patients BP
-Lower extremity: ____ the patients SBP
Will see in clinical:
_______mmHg for arm
_______mmHg for leg (usually inflated ____ -_____mmHg)
70-90
Twice
250
350, 250-275
55
Tourniquet Deflation
-Critical stage: _____ _____ has been reported
-Deflation will release ______ metabolites into the systemic circulation
Cardiac arrest
anaerobic
56
Tourniquet Deflation
Causes: (5)
-__________
-________ ______
-___________
-____________
-Possible ______ ______
Hypotension
Metabolic acidosis
Hyperkalemia
Myoglobinuria
renal failure
57
Tourniquet Deflation
Increase in _______ peaking at 1-3 mins, returns to baseline in ___-___ minutes
EtCO2
10-13
58
Tourniquet Deflation
Increase in _______ blood flow d/t increase in EtCO2; maintain normocapnia
Cerebral
59
Tourniquet Deflation
Increase in __________ activity: increased post-tourniquet ________, usually lasts for ___ minutes
fibrinolytic
15
60
Tourniquet Deflation
Takes about ___ minutes for metabolic changes to normalize
Transient ________ in temperature: redistribution of core temperature
30
decrease
61
Tourniquet pain
-Occurs ___ -____ minutes after inflation
-Pain resembles ________ vascular occlusion and _______
45-60
thrombotic vascular occlusion
PVD
62
Tourniquet pain
-Causes ____ heart rate, and ___ BP
-____ aching that progresses to _____ and ______ pain that may require general anesthesia
Increased, increased
Dull, burning, excruciating
63
Tourniquet pain
-The burning and aching pain (slow-conducting, unmylenated ____ fibers)
-The pinprick, tingling, and buzzing sensations (fast myelinated ___-____fibers)
C
A-delta
64
Local Anesthetics and Tourniquet Pain
-As the concentration of local anesthetic decreases, the activation of ___ fibers increases, but the ___ -____ fiber activation is still suppressed
-C fibers may be ___ ______ to anesthetize than A-delta fibers, and tournequet pain therefore seems more consistent with pain sensation carried by ____ fibers
C
A-delta
more difficult
C
65
Local Anesthetics and Tourniquet Pain
-Certain local anesthetics enhance the effect of the blockade in the presence of _________ stimulation of the isolated nerve fiber
-______ is enhanced by an increase in the rate of nerve stimulation and may offer an advantage by lowering the incidence of _______ _______
Increased
Bupivacaine
tourneiquet pain
66
Postoperative Tourniquet Paresthesia's
-Excessive tourniquet pressure causes _________ of the underlying nerves- the _______ may be stretched on one side of the node and invaginated on another
-Nerve ________ at the skin level at edge of tourniquet
-Nerve ______ due to rupture of the _______ cell membrane may be present
deformation
myelin
injury
damage
Schwann
67
Postoperative Tourniquet Paresthesia's
Prevention: ( )
-Proper _______
-Correct ________ size
-Limit time to __ hours
padding
tournequet
2
68
Anesthetist responsibility related to tourniquets
Caution in patients with _______, patients who are ______, and patients with a history of risk factors for ______ formation (prolonged bed rest or immobilization)
fractures
elderly
emboli
69
Anesthetist responsibility related to tourniquets
1. Proper ____ size and ____ (OR nurse)
2. Minimal effective ______
3.Tourniquet set at appropriate _______
4. Inform surgeon when tourniquet time > __ hours
5. Over 2 hours, deflate for ___ minutes for reperfusion
cuff, application
pressure
pressure
2 h
5 mins
70
Compartment Syndrome
-d/t prolonged ________ time
-Increased _________ ________, prolongation of _________
tourniquet
capillary permeability, clotting
71
Compartment Syndrome
-_______ and ______ pressure - pain
-Tense ____, ________, _______, ______
-Absent _____ - irreversible ________
Internal and external
skin, swelling, weakness, paresthesia
pulse, paralysis
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