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Advanced Principles- Fall 2018 > Orthopedics > Flashcards

Flashcards in Orthopedics Deck (27)
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1

What should you focus on during the pre-op assessment of an ortho patient?

  • airway
  • neurologic exam- look for pre-existin deficits
  • assessing CV and Pulm function  can be difficult based on exercise tolerance in this population
    • may require a more advanced workup
  • Joint mobility issues
  • opioid use?  
    • could have tolerance
  • anticoagulation use?
    • often required post-op d/t risk of dvts after ortho surgeries
  • Chronic steroids
  • positioning issues

2

What are types of anesthesia that can be used for surgery to the hand and wrist?

  • Local w/ MAC (if no tourniquet required)
  • Terminal nerve blocks with three local injections
    • radial, ulnar, medial block (if no tourniquet required)
  • Brachial plexus block
    • axillary, infraclavicular, supraclavicular- all get elbow and below??
  • Bier block
  • General w/LMA or RSI w/ ETT if trauma

3

Refresher on Bier block

  • Limited to short procedures (about 1 hour)
  • Start IV on operative hand/wrist
  • Exsanguinate arm- elevate and wrap with super tight band
  • Double tourniquet- inflate upper cuff to 250 mmHg
  • Inject 50 ml 0.5% lidocaine
  • When pt begins complaining of discomfort in arm, inflate distal tournequet and deflate upper tourniquet
  • Complications: tourniquet failure causing LA toxicity
  • Record tourniquet times
  • must provide additional means for postop pain relief

4

What are the types of elbow surgeries?

How may the pt be positioned?

  • Types of surgeries:
    • cubital tunnel release
    • ulnar nerve transposition
    • ulnar collateral ligament reconstruction
    • ORIF fracture
  • Position
    • supine
    • lateral
    • prone

5

How can you do the anesthetic for an elbow surgery?

  • General w/LMA or RSI w/ETT if Trauma
  • brachial plexus block
    • infraclavicular, supraclavicular with intercostobrachial nerve block for tourniquet

6

Tourniquets:

Why are they used?

How should they fit?

Risks?

Settings?

Max duration?

What happens after deflation?

  • Used to minimize blood loss and provide bloodless surgical field
  • Cuff size- should completely encircle limb
    • width more than half the limb diameter
  • Risk- damage to underlying vessels, nerves, and muscles
    •  maker sure to pad it and dont pinch skin
  • Ideally, pressure set 100 mmHg above patients SBP for thigh and 50 mmHg for arm
  • Tourniquet pain develops over time
  • max duration 2 hours
  • Transient metabolic acidosis, increased CO2 levels and drop in BP with tourniquet deflation

7

Refresher on brachial plexus blocks:

What part of plexus they affect and indications

Interscalene

Supraclavicular

Infraclavicular

Axiallary

  • Interscalent
    • roots/trunks
    • Indicated for shoulder surgery and upper arm
  • Supraclavicular
    • Trunks/divisions (middle/inferior)
    • Indicated for surgery of upper arm to hand
  • Infraclavicular
    • Lateral, posterior, medial cords
    • indicated for surgery for elbow, forearm, hand
  • Axillary
    • median, ulnar, radial nerves
    • indicated for surgery below the elbow

8

What does intercostobrachial nerve come off of?

T2

9

Interscalene block:

Indications?

Goal?

What is not blocked?

  • Indications: Shoulder and upper arm
  • Goal: LA around superior and middle roots/trunks of C5, C6, and C7
  • Ulnar nerve NOT blocked

10

Interscalene block Complications

  • Ipsilateral phrenic nerve block with ipsilateral diaphragm paralysis (most common)
  • Intravascular injection
    • close to vertebral artery, carotid artery, and jugular vein
  • Hoarsness, dysphagia if recurrent laryngeal nerve blocked
  • Horner's syndrome (Horny Pam)
    • Ptosis
    • anhydrosis
    • miosis

11

Supraclavicular block:

Indications

Goal

What is not covered?

  • Indications- upper arm to hand
  • Goal- LA around blocks at trunks/divisions of plexus
  • Not covered- arm pit; may need intercostobracial block

12

Supraclavicular block:

complications

  • Pneumothorax- symptoms up to 6-12 hours after surgery
  • Vascular puncture
  • Phrenic nerve block with hemiparesis of diaphragm
    • less common than w/interscalene
  • Horner's syndrom
    • less common than w/interscalene

13

Infraclavicular block

Indications

goal 

frequently spares?

  • Indications: surgery of elbow, forearm, hand
  • Goal: LA blocks lateral, posterior, and medial cords
  • Frequently spares intercostobrachial nerve

14

Infraclavicular block

complications

  • vascular puncture (axillary
  • pneumothorax
  • painful block b/c needle goes through pectoralis minor and major

15

Axillary nerve block:

What is blocked?

  • Median nerve- superior (anterior) to axillary artery
  • Ulnar nerve- inferior to axillary artery
  • Radial nerve- posterior to axillary artery
  • Musculocutaneous nerve- often spared

*Remember "RUM-PIS":

Radial = Posterior

Ulner = Inferior

Median = Superior

16

Axillary block:

indications

  • Indicated for surgery below elbow
  • blocks terminal nerves: ulnar, radial, and median nerves
    • musculocutaneous nerve frequently not blocked.

17

What can you do if there is not tourniquet being used?

  • Terminal nerve blocks
    • ulnar, radial, median
  • for surgery of hand or wrist
  • pt doesnt need sling for arm

18

What are indications for shoulder arthroscopy?

  • Rotator cuff tear
  • torn labrum
  • repair of ligaments
  • severe refractory instability
  • removal of inflamed tissue
  • subacromial bursitis
  • arthritis
  • proximal humerus fracture

19

What nerve innervates about 70% of shoulder?

Suprascapular nerve- from brachial plexus C5 and C6 trunk

this is why interscalene works

20

Arthroscopy:

duration

position

anesthetic

  • 1 hour
  • sitting or lateral
  • GETA, GA w/LMA
  • +/- Interscalene or supraclavicular block (??) with MAC?

21

How is shoulder arthroplasty done?

Total joint replacement

 

22

Arthroplasty

Indications

duration

position

  • Indications:
    • arthritis- consider this while assessing airway
    • degenerative joint disease
  • duration- up to three hours
  • position: sitting or lateral

23

Shoulder arthroplasty anesthetic considerations:

  • Technique:
    • ETT
    • GA w/LMA
    • Interscalene or supraclavicular block
    • block with catheter (4-7 days)
  • Significant blood loss (up to 1 L)
    • tourniquet cannot be used
    • Need 2 or more large IVs
    • CBC pre-op
    • T & S
    • Hypotensive anesthetic technique
    • tranexamic acid (TXA)
  • Embolic syndromes
    • fat, air, or cement

24

What do you need to consider regarding lateral position with shoulder surgery?

  • Frequently reassess:
    • eyes
    • ears
    • head/neck alignment
    • legs
    • hips
  • Use axillary chest roll to protect brachial plexus
  • BP cuff pressure on lower arm- remember BP might reflect higher than actual

25

How does lung perfusion change in lateral position?

  • VQ mismatch
  • greater proportion of zone 1 in upper lung
  • greater proportion of zone 3 in dependent lung
  • Causes reduced zone 2 with more of it in dependent lung
  • **VQ mismatch is greater with controlled ventilation than with spontaneous ventilation

26

What are the potential injuries that can occur in beach chair position?

  • Cervical spine (head falling off headrest?)
  • Excess flexion of neck
    • may obstruct internal jugular vein causing venous engorgement
  • Excess extension of neck may impair CBF
  • Macroglossia- unusually large tongue
    • caused by lymph and venous drainage problems
  • Eye injury
    • avoid deliberate hypotensive technique
    • avoid pressure on eyes/ears

27

What are the hemodynamic challenges of beach chair position?

  • Hypotension
  • Venous pooling
  • decreased CO
  • Intrathoracic blood volume decreases
  • correctly monitoring BP is important
    • for ever 20 cm of height difference, there is 15 mmHg difference in BP