Anesthesia Ortho

Front 1

Which hip fxs have higher blood loss?

Back 1

1. Subtrchanteric>
2. Intertrochanteric>
3. Base of neck>
4. Transcervical>
5. Subcapital

Front 2

Advantages to regional anesthesia in orthopedic procedures?

Back 2

-Vasodilation-improves perfusion/reduces blood loss/reduces the risk of DVT formation because mediators aren’t released
-Intrathecal analgesia-long duration of analgesia
-Avoidance of N/V
-Decreased risk of Thromboembolism

Front 3

Disadvantages to regional anesthesia?

Back 3

Take longer to setup/ analgesia to take effect. Require more than 1 person

Front 4

What is the #1 morbidity in orthopedic cases?

Back 4

DVT

Front 5

Describe the difference in MSO4 for Intrathecal and Epidural and give rational?

Back 5

Intrathecal-0.1-0.2mg = Epidural @ 5mg
-because it has to diffuse across the dura.

** MSO4 is hydrophilic (Ionized) and does not diffuse as fast as Fentanyl which is lipophillic (unionized)

Front 6

Complications to managing the elderly orthopedic patients?

Back 6

1. Complex medical regimens
2. Altered mental status-delirium
3. Kinetic ∆’s-Absorption time slower
4. Distribution-higher fat content/low plasma volume (Inc. volume of distribution)
Metabolism/Excretion- hang around longer

Front 7

Advantages to using a Neuroaxial block for orthopedic surgeries?

Back 7

--Dec. DVT/PE? (Morgan)
--Increased blood flow (vasodilation)
--LA = systemic anti-inflammatory effect
--Limits post-op Inc. of Factor VIII and vWf
--Limits post-op Dec in ATIII
--Decreased PLT activity
--Alteration in release of stress hormones

Front 8

Problem with neuroaxial blocks in ortho pts?

Back 8

Use of anticoagulation during postop recovery-- increased risk of epidural Hematoma

Front 9

What is the recommendations for epidural catheters use and LMWH use?

Back 9

Start LMWH after removal of catheter or wait 2 hr after removal before starting.

Front 10

What are the recommendations with the use of Heparin and Epidural catheters?

Back 10

Remove catheter 2-4 hr after last heparin dose, or if pt is on coumadin- when INR< 1.5.

Front 11

What are the four types of arthritis?

Back 11

Gouty Arthritis (ass w/ renal dis)
Osteoarthritis (noninflammator)
Infectious Arthritis (Bacteremia)
Rheumatoid Arthritis (AutoImmune, Inflammatory)

Front 12

What are the main concerns of Rheumatoid Arthritic patients?

Back 12

Airway-Cervical instability-consider awake intubation and usually difficult airway cart nearby
Joint limitations-Evaluate TMJ/Atlanto-occipital, crico-arytenoid dysfunction.
Severe deformities

Front 13

Your Rheumatoid arthritic patient presents with hoarseness and inspiratory stridor. What is the most likely cause?

Back 13

Cricoarytenoid joint dysfunction-no AD duction

Front 14

What is the basal steroid secretion per/day?

How much steroid is secreted under stress?

Back 14

25-30mg/day

Up to 300mg

Front 15

What should be considered in patients with atlantoaxial instability >5mm? (RA Patients)

Back 15

Awake Oral FiberOptic Intubation

Manual Inline Axial Stabilization

Front 16

What is the primary initiative in true orthopedic emergencies?

Back 16

Immobilization to prevent secondary injuries, fat emboli, and decrease pain

Front 17

What types of orthopedic cases are true emergencies?

Back 17

Dislocations of hip/digit reimplantation / compartment syndrome
Anything that threatens a neuro vascular structure
Loss of limb or life

Front 18

What may occur if 6 hrs or more has elapsed from injury time to surgical intervention?

Back 18

Infection may occur prior to closure.
Compartment syndrome will hamper reduction and may cause delay in closure

Front 19

What is the problem with use of NTG in induced HOTN in Orthopedic cases?

Back 19

Increased Risk of DVT from venous pooling

Front 20

Mobilized fat particles, which embolize and lodge in the pulmonary vasculature.

Back 20

Fat embolism-

Front 21

Where does Fat embolism mostly occur?

Back 21

Long bone fxs occurring as early as 12-48 after Injury (mostly 72 hrs after)
TJR and Multiple fxs involving pelvic injury

Also: CPR/
Liposuction/
Intrabdominal procedures/
BM transplt/
Burns/ Intralipid/Sickle Cell

Front 22

What are the s/s of FES?

Back 22

Triad of dyspnea/confusion/petechiae

Front 23

What are the CV s/s of FES?
Usually masked by GA, because the develop as pulmonary leading to hypoxemia

Back 23

#1 s/s: DEC PaO2 (Hypoxemia)
2. DEC PaO2 / INC. CO2 / DEC ETCO2
(gradient ∆ due to block of pulm arterioles)
3. INC. PA pressures due to block of pulm arterioles
4. Dyspena/Wheezing/Chest pain/ Hemoptosis
4. ARDS picture-capillary leakiness/alveolar collapse due to DEC surfactant / DEC compliance due to interstitial fluid accumulation and INC PA pressures

Front 24

What EKG ∆’s are noted with FES?

Back 24

Nonspecific ∆’s
Dysrhythmias/Tachycardia
Ischemic patterns

Front 25

What are the Neuro/Skin s/s of FES?

Back 25

--LOC ∆’s
-- Apprehension /seizures /coma
-- Fever-due to release of prostaglandins
-- Petichiae over axilla, chest /UE /Conjunctiva

Front 26

What lab tests help dx FES?

Back 26

Fat in sputum and urine
Anemia/Thrombocytopenia
DEC. Ca++ due to binding with FFA

Front 27

What is the fluid of choice in prophylaxis of FES?

Back 27

Albumin

Front 28

What actions will help prevent Fat emboli?

Back 28

--Early splinting
--Hydration
--Albumin-provides binding sites for Free fatty acids
--Steroids prophylactically may DEC likelihood (controversial

Front 29

What monitor observations will clue you in to an embolic event?

Back 29

--High-pressure alarms (INC PIP)
--Oximeter (DEC SaO2)
--Capnometer (DEC ETCO2 / abscent waveform)
--ES/PS-Rales/absence of breath sounds
--ABG-acidosis

Front 30

How do you tx FES?

Back 30

Prophylactic steroids
Mech ventilation/PEEP / INC FiO2
Albumin
Heparin-not proven effective

Front 31

Thrombus from distant sites migrating to the heart or Pulmonary Vasculature.
# 1 complication in ortho.
(This is why regional is so popular)

Back 31

PE

Front 32

What vessels are primarily involved in origination site of PE?

Back 32

Deep Calf / Popliteal / Ileofemoral Veins

Front 33

How long post op do most DVT’s develop?

Back 33

24-48 hrs

Front 34

Which procedures are commonly associated with DVT?

Back 34

Orthopedic Trauma- INC release of factors
Vascular Sx
Long Term lithotomy procedures (gyne, urological)
CABG
Hypothermia
Hepatic
INC PRBC replacement

Front 35

Classic Signs of Thromboemboli?

Back 35

Dyspnea
Pleuritic Chest pain
Hemoptosis
Hypoxemia
A-a gradient widens

Front 36

How can one note thromboemboli under anesthesia?

Back 36

Tachypnea, HOTN, and Tachycardia
DEC. ETCO2 (over 30min)
INC. PAP
R heart failure/Rales
EKG ∆’s including strain, ST ∆’s
EMD/Asystole

Front 37

What is the proposed MOA of thromboemboli?

Back 37

INC. Plt adhesiveness
INC. Coag/activation of clotting factors
Vessel Wall lesions
Venous stasis

Front 38

Which clotting factors are thought to primarily be responsible for Thromboemboli?

Back 38

INC’s in Factor VIII and vWF
DEC’s in AT III levels-Heparin therapy

Front 39

What EKG ∆’s are noted when under GA for Thromboemboli?

Back 39

Tachydysrhythmia
Pulmonale-biphasic p waves
Anterior lead (V3-V5) lead T wave inversion
RAD
RBBB

Front 40

What CXR signs will be noted with Embolism?

Back 40

Loss of vascular markings in a lung field
Pleural infiltrate
PA dilation
Atelectasis

Front 41

What is the tx of PE?

Back 41

Fluids- increase preload + inc. Contractility (Inotropes) will = forward flow!
Supportive-PEEP, Intubate, Inc. FiO2
Heparinization- will contribute to further EBL

Front 42

Air embolism in orthopedics may occur from what MOA?

Back 42

The cement used will force air into medullary vessels causing poorly soluble gas to enter the vasculature and travel to the microcirculation of the heart. A mass of foamy bubbles will block venous outflow tract.

Front 43

Which procedures will predispose to air emboli?

Back 43

Neuro
Ortho-
Shoulder sx from high pressure lavage powered by gas

Front 44

What contributing pathology will worsen air embolism?

Back 44

PPFO
Undiagnosed AVM

Front 45

Methylmethacrylate- What is it in Ortho?

Back 45

Self-polymerizing acrylic bone cement that interdigitates with bony lattices

Front 46

What problems will be seen with Methylmethacrylate use?

Back 46

HOTN and Desaturation

Front 47

What should be done when cementing is taking place?

Back 47

Inc. FiO2 to 50% and may need to hydrate well prior to and during cement use

Front 48

PE may also occur from what other possibilities in ortho cases?

Back 48

Reaming of the bone shaft

Front 49

Tourniquest should be inflated to what pressure?

Back 49

50-100mmHg> SBP

Front 50

How long can a TQ be inflated?

Back 50

1-2 hrs (some studies indicate 30min-4hrs)

Front 51

How soon will TQ pain begin?

Back 51

45 minutes after inflation

Front 52

What MOA is thought to cause the pain?

Back 52

C fibers-dull pain ( A-deltas are sharp pain)

Front 53

What actions can be taken to prevent/anticipate FES?

Back 53

Adequately hydrate early on
Use Albumin
Adjust O2 concentration
Adequate lavage