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Orthopedic CRNA

Anesthesia for orthopedic surgery

Advantages of neuraxial and peripheral regional anesthesia? Improved post op analgesia, decreased PONV, Less respiratory depression, decreased blood loss, decreased risk thromboembolism,
Contraindications to regional anesthesia include? Patient refusal, infection, systemic anticoagulation
Scolosis consists of what type of deformity? Lateral curvature/rotation of vertebrae, can also cause deformity of rib cage
What determines the severity of scoliosis? Cobb angle: Surgical correction formed for angles greater than 50 degrees.
scoliosis considerations from rib cage deformity? Impaired development of pulmonary vasculature, pulmonary HTN
Scoliosis of the spine considerations? Decreased compliance, decreased ventilatory response to CO2 can lead to arterial hypoxemia and hypercapnia causing respiratory failure.
Scoliosis of spine and rib cage deformity lead to what pulmonary conditions? Ventilation blood flow maldistribution which increases ventilatory requirements leading to respiratory failure. VQ mismatch can contribute to hypoxia.
Prolonged hypoxia, hypercapnia, pulmonary vascular constriction from scoliosis result in what irreversible pulmonary vascular changes? PHTN
Two Surgical approaches/positioning for scoliosis includes? Posterior approach done in prone positing, carefully pad pressure points. Anterior approach done in lateral positioning.
Degenerative vertebral column diseases what to assess pre-op? Cervical ROM, neurological symptoms during flexion, extension, rotation.
Cervical laminectomy positioning? prone
Lateral Laminectomy positioning? Supine
Thorocolumbar laminectomy positioning? Prone
Why Spinal Cord monitoring? Paraplegia feared, wake up test, neurphysiologic monitoring: SSEP MEP electromyography
Blood loss can be reduced through these 5 interventions? Proper positioning, use of intra-op blood salvage, induced hypotension, intra-op hemodilution, antifibrinolytics.
Visual loss risk factors from spinal surgery? Prolonged intra-op hypotension, anemia, large blood loss intra-op, prolonged surgery time
Diagnosis of visual loss post spinal surgery includes? Optic neuropathy, retinal artery occlusion, cerebral ischemia
Shoulder/Upper arm surgery stretch injuries from excessive rotation/flexion include? brachial plexus
Common upper arm/should position during surgery? "Beach chair"
Beach chair position complications during shoulder surgery? Hypotension, bradycardia. This can be decreased by gradual positioning to beach chair, hydration, and atropine if necessary.
Can a tourniquet be used for proximal upper extremity surgery? A tourniquet cannot be used because significant blood loss can occur
Considerations for good anesthesia outcomes following a shoulder surgery are? Interscaline supraclavicular block, a combined regional general. Toradol should also be considered to reduce opiod requirements.
Most reliable block for elbow surgery? Infraclavicular/supraclavicular approach to brachial plexus hits all four nerves.
Name the four nerves of the brachial plexus? Median, ulnar, radial, musculocutaneous
Axillary approach to brachial plexus decreases the risk of what complication? Pneumothorax
Most common surgery to the wrist/hand? Carpral tunnel release
IV regional anesthesia-Bier block? Double tourniquet, more extensive surgery, no postoperative analgesia
Pre-existing medical conditions common with a hip surgery include? CAD, CVD, COPD, DM. These patient are usually elderly.
Hip position for total hip surgery? Lateral decubitus position
Advantages of fracture table for femur fractures? Maintenance of traction, allows manipulation for closed reduction/fixation, access for XR in multiple planes
Hip fracture complications pre-op? these patients are frequently dehydrated due to poor PO intake. Hemoconcentration: May present with low HCT
Pre-op hypoxia for pt's undergoing hip surgery may be due to what conditions? Fat embolism, atelectasis from bed rest, pulmonary congestion/effusion from underlying CHF, consolidation due to infection
Common block with hip surgery? Central neuraxial blockade
Spinal considerations for hip surgery/position? hypobaric/isobaric to allow for easier positioning. Sitting lateral decubitus
Complications with spinal? Sympathectomy, hypotension occurs from peripheral vasodilation. Adequate hydration/ fluid bolus is essential.
What fracture is associated with the most blood loss? Extracapsular fx
What fracture is associated with the least blood loss intracapuslar fx are associated with less blood less than extra capsular.
Deliberate Hypotension with GA can do what to blood loss? Reduce surgical blood loss
What can be used to induce hypotension to decrease surgical blood loss? Diltiazem, SNP, B-blockers, NTG
Complications associated with total hip arthroplasty? Bone cement implantation syndrome, intra/post-op hemorrhage, venous thromboembolism.
Treatment for venous thromboembolism following total hip? low dose Anticoagulants, SCD's
Minimally invasive arthroplasty benefits? cementless, reduces tissue/muscle damage, less pain, early DC, faster recovery. Reduces hospitalization by 24 hours
Minimally invasive arthoplasty anesthesia considerations? Spinal/epidural/propofol infusion. LMA most often used. Epidural catheter withdrawn at end of case.
Knee arthroscopy positioning/anesthesia considerations? GA with LMA place pt in supine position. Simple outpatient procedure, minimal PONV.
Total knee arthroplasty complications? Failure to provide adequate analgesia interferes with rehab. Critical to maintain joint ROM, prevent joint adhesions.
Considerations for using a tourniquet for a total knee arthroplasty? A tourniquet requires a femoral block. Blockade of all four legs innervating leg: femoral, lateral femoral cutaneous, obturator, and sciatic.
Total knee regional anesthesia considerations? Regional anesthesia for 48-72 hours results in shorter rehab/ increased joint mobility. This can be done through a continuous peripheral technique or an indwelling femoral sheath catheter.
Hyperbaric/isobaric solutions in spinal anesthesia for a total knee can produce what complication? Higher block than is needed.
What type of regional anesthesia is considered for a total knee? Epidural offers advantage of continuous catheter for post-op period.
ACL repair block recommendations? Lumbar plexus block combined with sciatic block reduces opiod requirements/side effects. Pt can be DC home with indwelling femoral catheter to provide analgesia for up to 48 hours.
Ankle/foot surgery considerations? Regional anesthesia advantageous over GA.
Nerve innervations of foot are provided by what two nerves? Femoral nerver and sciatic nerve
More advantages of regional anesthesia for ankle block? Avoids CV effects, respiratory side effects, and urinary retention. Long acting local anesthetics with addition of dpi/clonidine prolong post op analgesia.
Disadvantages of ankle block? Expertise needed for consistent success.
Advantages of epidural analgesia/peripheral nerve blocks? Lower pain scores, better knee flexion/improved joint mobility, faster ambulation, shorter hospital stays.
What is Microvascular surgery? Reattachment of a completely severed body part, revascularization to reestablish blood flow through a severed body part.
Anesthesia management for microvascular surgery? Maintenance of blood flow through microvascular anastomoses Imperative to limb graft viability.
Positioning considerations microvascular surgery? Long cases pt must lie completely still
Replacement of blood/fluid loss for microvascular surgery? Can be extensive
How to improve blood flow through anastomoses during microvascular surgery? Increase perfusion pressure, prevent hypothermia, vasodilators/sympathetic blockade.
Determinants of microvascular perfusion pressure? Adequate intravascular volume/oncotic pressure
Drugs used in microvascular surgery to support BP? Phenylephrine
Drugs used in microvascular surgery to preserve blood flow anastomoses? Antithrombotics, fibrinolytics, low molecular weight dextran, smooth muscle relaxants.
Things to avoid during microvascular surgery? Vasospasm, vasoconstriction, pain, hypotension, hypovolemia.
Prior to inflation of tourniquet what needs to be done? Limb should be elevated/tightly wrapped with Esmarch bandage distally to proximally
Complications of tourniquet? How do you prevent these complications? Tournequet ischemia, this can be prevented by proper cuff size/inflation pressure
Adequate tourniquet pressures? Cuff pressure 100 mmhg above pt's measure SBP for thigh. 50 mmhg above SBP for arm.
Tourniquet safe length of time for inflation? time range 30 min to 4 hours
Inflation greater than 2 hours needs? What are the dangers of greater than 2 hours? Greater than 2 hours routinely leads to transient muscle dysfunction/may be associated with permanent peripheral nerve damage/rhabdomyolysis.
The tourniquet can cause damage to? Underlying vessels, nerves, skeletal muscles.
Deflation of a tourniquet can cause what complications? metabolic acidosis, increased arterial CO2 levels occur after deflation, serum lactate/potassium.
Symptoms a pt will experience from the tourniquet? Aching pain, dull, restless
What fibers does a tourniquet cause pain to? How long does it take for the pain appear? A delta/C fibers (AC for air conditioning) HA HA HA! 45 minutes it take for pain to appear
Tx for tourniquet pain? Release the tourniquet, during surgery opiods/hypnotics work well.
Associations of fat embolus? Multiple traumatic injuries/surgery involving long bones.
Risk factors of fat embolus? Male gender, age 20-30, hypovolemic shock, intramedullary instrumentation, RA, Total hip with cement, bilateral TKA
Fat embolus occurrence/symptoms? Occurs 12-72 hours after injury, classic triad is dyspnea, confusion, peteciae. Decreased arterial o2 is most consistent abnormal lab value.
Other triggering factors to fet embolism include? Shock, hypovolemia, sepsis, DIC can trigger conversion of fat emboli to fat embolism syndrome.
Treatment of fat embolism syndrome includes? Early recognition, reversal of aggravating factors-hypovolemia, early surgical stabilization of fracture sites, aggressive respiratory support, corticosteroid therapy may be beneficial for cerebral edema.
Diagnosis of fat embolus syndrome includes 1 of the following major symptoms. axillary/subconjunctival petechiae Hypoxemia (Pa02 <60 Fio2<.4) CNS depression Pulmonary edema
Diagnosis of fat embolus syndrome includes 4 of the following major symptoms? Tachycardia Hyperthermia Retinal fat emboli urinary fat gobbles Decreased PLT/HCT Increased ESR Fat globules in sputum
What is methyl methacrylate? Acrylic bone cement used during arthroplastic procedures.
Side effects of methyl methacrylate? Sudden onset of hypotension, vasodilation, decreased SVR
What causes the side effects of methyl methacrylate? Absorption of volatile monomer of drug embolization of air/bone marrow during femoral reaming lysis of RBC/marrow from an exothermic reaction Chemical reaction: Conversion methyl methacrylate to methacrylate acid
Clinical manifestations of methyl methacrylate? Hypoxia, increased pulmonary shunt, hypotension, heartblock/sinus arrest, pulmonary HTN, increased PVR, decreased CO.
Interventions to prevent clinical manifestations of methyl methacrylate? Adequate hydration, maximizing inspired o2 concentration minimizes hypotension/hypoxemia that can accompany cement prosthesis. Discontinue N20 several minutes before cementing occurs bc air can be trapped during this procedure.
What kind of cement is recommended in younger pt's? Cementless prostheses generally last longer and may be advantageous for younger active patients. Cementless implants are for healthy active bone formations.
Cement recommended for older pt's? Cemented prosthesis are preferred for older less active pt's who have osteoporosis/thin bones.
Risk factors for DVT and Thromboembolism? Obesity >60 years old procedures > 30 minutes Use of tourniquet lower extremity FX immobilization > 4 days
Highest risk procedures for DVT and Thromboembolism? Hip surgery and knee construction pt's
Multiple factors for DVT and thromboembolism? Positioning FX of long bones injection of cement predisposing medical conditions
Antithrombotic prophylaxis? Low dose heparin IPC Warfarin LMWH
When are anticoagulants started after surgery? Several hours after surgery to decrease intraop bleeding
How can you reduce thromboembolic complications? Neuraxial anesthesia causes a sympathectomy which increased lower extremity blood flow from vasodilation decreasing PLT reactivity
What are the benefits of lidocaine for Antithrombotic prophylaxis? Lidocaine has been shown to prevent thrombosis, enhance fibrinolysis, and decrease PLT aggregation.
When is it not safe to provide neuraxial anesthesia? Neuraxial anesthesia should not be done 6-8 hours after SQ dose of unfractionated heparin or with in 12-24 hours of LMWH.
What are the risk of providing neuraxial anesthesia if a pt received unfractioned heparin 6-8 hours prior of LMWH 12-24 hours prior? Risk of neurologic compromise from expanding spinal hematoma
Created by: evanrn1983