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Orthopedic CRNA
Anesthesia for orthopedic surgery
| Question | Answer |
|---|---|
| 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
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