Anesthesia for Orthopedic Surgery – Flashcards
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Potential airway difficulties
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-Rheumatoid arthritis: Cervical spine, TMJ -Steroid dependence
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Preoperative medications
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- Chronic opioid therapy, Anticoagulants, or Antihypertensives
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Anesthesia technique
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- Pt acceptance: Language barriers, Elderly -Infection -Coagulopathies
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Shoulder and Upper Arm
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-Total shoulder arthroplasty -Rotator cuff repair -ORIF humerus/clavicle fractures -Pectoralis reattachments
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Positioning For Shoulder and Upper arm procedures
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- "Beach chair" - Secure head, neck, hips!!! - Watch eyes - BP??? - Tourniquet??
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Upper extremity surgery: Anesthesia
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-General Anesthesia -Regional: Additive; Primary -SCIP -Radial nerve palsy (humeral shaft) -Axillary nerve/brachial plexus injury (proximal humerus)
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Elbow surgeries
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-ORIF distal humerus -ORIF epicondyle
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elbow sx:Positioning
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-Supine -Slight "beach chair"
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elbow sx: Anesthesia
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-General: Peds/Adults - Regional: Adults - SCIP
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Wrist and hand surgeries
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- ORIF radius - ORIF ulna - Finger pinning - Reimplantation - Carpal tunnel
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Wrist and hand: Positioning
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-Arm table: C-arm friendly - Supine
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Wrist and hand:Anesthesia
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-Tourniquet cases -General Anesthesia -Regional: Brachial plexus-ulnar nerve miss; Bier block -SCIP
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Axillary block
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Sx for forearm & hand; unsuitable for proximal humerus or shoulder surgery; pt. must be able to abduct the arm to perform
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Hip/femur surgeries
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- Arthroplasty - Femoral nailing - ORIF hip fracture: Bipolar, Pinning
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Hip/femur: positioning
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-Lateral decubitus -Fracture table (Maintenance of traction, C-arm access)
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Hip/femur: Anesthesia
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-Preop for the elderly..... - Regional!!: Placed before moving from stretcher; Ketamine?? - Propofol drip -Foley catheter -SCIP -Appropriate IV r/t blood loss
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Knees surgeries
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-Arthroscopy: Meniscus repair, ACL repair - Arthroplasty
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knee sx: positioning
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- Supine - "Knee break"- learn the bed!!!
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Arthroscopy: Anesthesia
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-General-LMA's are great!!!! -Regional may have longer post op time... - Titrate narcotic with spontaneous respiration - SCIP - Ice pack post-op!!!
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Arthroplasty: Anesthesia
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-Preop for elderly..... - Regional w/ Propofol drip! -Preemptive analgesia!; "The longest spinal known to man", epidural, indwelling femoral - SCIP -Tourniquet
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Tibia/ankle/foot surgeries
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- Amputations - Achilles tendons - Hallux valgus - ORIF malleolar fractures
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Tibia/ankle/foot positioning
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- Supine - Prone
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Tibia/ankle/foot:Anesthesia
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- Preop for elderly.... - General/Regional: Phantom pain; Little pain r/t neuropathy -Tourniquet?? -SCIP
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Tissue radio sensitivity:
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- Young organs, Eyes, Thyroid
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Contrast agents
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- Iodine molecules absorb x-ray - Concentration = radiopaque"ness" - Directly release histamine-no antibody presence: Warmth, N/V....hives, swelling....anaphylaxis - Renal toxicity: Serum creatinine; Extra fluids; Metformin
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Contrast via seafood???
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-Proteins in shrimp cause allergy -IgE antibodies present in allergic reactions
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Tourniquets
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- Minimize blood loss - Overlap of cuff should be 180 degrees from neurovascular bundle - Pressure: 100mmHg (thigh); 50 mmHg (arm) above systolic - Duration 2 hours
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Effects of prolonged occlusion
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- Metabolic acidosis - Hyperkalemia - Tachycardia - Hypercarbia - Tourniquet pain - *release of 2 tourniquets simultaneously not recommended
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Fat embolism syndrome
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-Associated with long bone fracture - Mortality 5-15%
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Fat embolism syndrome risk factors
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- Male -20-30 y/o -Hypovolemic shock -Intramedullary instrumentation - Bilateral total knee surgery
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FES symptoms: Major
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-Petechiae -Hypoxemia -CNS depression - Pulmonary edema
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FES symptoms: Minor
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-Tachycardia - Hyperthermia - Retinal/urinary/sputum fat globules - Unexplained decrease in platelets -Increased erthyrocyte sedimentation rate (ESR)
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FES:treatment
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-Early recognition -Reversal of precipitating factors (i.e. hypovolemic shock) -Stabilization of fracture -Respiratory support -Corticosteroids??
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Methyl Methacrylate
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-Acrylic bone cement -Treatment: No nitrous!!! Higher O2 concentrations. Hydrate
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Methyl Methacrylate - causes of Hypotension
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Absorption of volatile monomer Embolization of air and marrow Exothermic reaction Conversion to methacrylate acid
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Highest incidence of Venous Thromboembolism
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Hip fracture patients
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2012 College of Chest Physicians- which pts need DVT prophylaxis?
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- THA/TKA/Hip fracture
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Phantom Pain
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-Pain that occurs from a part of the body that is no longer there - Onset within few days of amputation -Intermittent -Affects part furthest from body -Shooting, stabbing, squeezing, throbbing, burning
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Phantom Pain triggers
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Triggered by weather changes, pressure on remaining part or emotional stress
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phantom limb pain: Causes
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-Unclear; MRI/PET show activity: Remapping of circuitry, Damaged nerve endings, Scar tissue, Physical memory, Pain prior to amputation.
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phantom limb: Treatment
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Biofeedback, Relaxation, Massage, TENS unit, Transcranial direct stimulation (Dr. Makin, Oxford, UK)
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Infraclavicular block
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Sx for elbow, forearm and hand; catheter site (near coracoid process) easy to maintain; no risk of hemo, pneumothorax
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Supraclavicular block
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Sx to mid-humerus, elbow, forearm & hand; risk of Pneumothorax*, unsuitable for outpatient procedures; phrenic nerve paresis in 30% of cases
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Interscalene block
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Sx to shoulder, proximal/middle humerus; Phrenic nerve paresis in 100% of patients for block duration; unsuitable for patients unable to tolerate 25% reduction in pulmonary function
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Safety practices:
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Time, Distance, Shielding
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Drugs for DVT prophylaxis
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- *LMWH, rivaroxaban, fondaparinux, IPCD
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When to initiate DVT prophylaxis
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-Start >12 hours pre/post rather then <4hours pre/post
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Inpatient DVT prophylaxis
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- While inpatient drug/IPCD combo
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Increased risk of bleeding- DVT prophylaxis
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use IPCD
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Not recommended for DVT prophylaxis
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-No IVC -No doppler -No prophylaxis for scopes or lower leg trauma
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Medications for Phantom limb pain
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Neuroleptics, antidepressants,Sodium channel blockers
