Shared Flashcard Set

Details

ORTHO
ORTHO
96
Nursing
Graduate
06/26/2011

Additional Nursing Flashcards

 


 

Cards

Term
What is the major risk factor for periop mortality with orthopedic surgery?
Definition
ADVANCED AGE
Term

In 2006...


_____ of pop. over age 65

_______ hip replacements

______ knee replacements

 

By 2030 number of ppl over 65 expected to ___?

Definition

In 2006...

1/8 of population over age 65

300,000 hip replacements

500,000 knee replacements

 

By 2030 number of ppl over 65 expected to double 

Term
What are the contributors to the increased risk of M&M in elderly patients?
Definition

Comorbidities

Limited functional capacity in many elderly

Many orthopedic procedures initiate a significant systemic inflammatory response

Potential for significant blood loss & fluid shifts

Difficulty in postop pain management

Term
What are the most frequent body systems affected by complications of orthopedic surgery? (3)
Definition

Cardiac

Pulmonary

Neurologic

Term

Is embolism of fat common?

 

It is found in almost 100% of _____ and _____ fractures.

Definition
embolism of fat is very common, found in almost 100% of femoral and pelvic fractures
Term
What is the incidence of fat embolism syndrome?
Definition
~1%
Term
What is FES?
Definition
a physiologic response to fat in the systemic circulation
Term

How does FES develop?

 

Does the quantity of fat correlate with severity of symptoms?

Definition

may develop gradually or acutely

 

no, quantity of fat in circulation doesn't correlate with severity of symptoms

Term
What are the 2 main aspects of the pathophysiology of FES?
Definition

mechanical obstruction of end-organ capillaries

 

trigger of systemic inflammatory response

Term
List the symptoms of FES (7)
Definition

petechial rash

diffuse alveloar infiltrates

hypoxemia (PaO2 <70 on 100% O2)

confusion

fever >38C

heart rate >120/min

respiratory rate >30/min

Term

Gurd's Diagnosis of Fat Embolism Syndrome:


Major Features (at least one)

List 3

Minor Features (at least four)

List 5

Lab findings

List 4

Definition

Gurd's Diagnosis of Fat Embolism Syndrome:


Major Features (at least one)

Respiratory insufficiency

Cerebral involvement

Petechial rash

 

Minor Features (at least four)

pyrexia

Tachycardia

Retinal changes

Jaundice

Renal changes

 

Lab findings

fat microglobulinemia (REQUIRED)

anemia

thrombocytopenia

High ESR

Term

What have multiple studies shown that RA has what benefits over GA with hip arthroplasty?

 

 

Definition

RA has following benefits over GA:

 

↓Blood Loss

↓ DVT

↓ PE 

Term

There is a _____ greater incidence of DVT with GETA over a RA.

 

The greatest risk of death following THA is d/t ______?

 

Besides the decreased BL & decreased risk for DVT or PE is there any other compelling differences between outcomes with regional & GETA?

Definition

 

There is a 4x greater incidence of DVT with GETA over a RA.

 

Greatest risk of death following THA is d/t PE


 

with the exception of pain management, there is no othercompelling difference between outcomes with RA and GETA

Term
What are the risk factors for postop PE/DVT? (5)
Definition

cancer

obesity

previous PE/DVT

prolonged bed rest (r/t pain mngmt)

advanced age

 

COPPA

Term
Do ASA and NSAIDs pose a problem with neuraxial anesthesia?
Definition
no apparent increase in risk of epidural hematoma following neuraxial anesthesia
Term
What does ASRA recommend with Warfarin?
Definition
recommends a central neuraxis anesthetic not be performed or an epidural catheter not be removed if        INR > 1.5
Term

What is the timing of neuraxial blocks with LMWH?

Usual dose?

Large dose?

 

What about removal of epidural catheter?

Definition

12 hrs after usual dose

24 hrs after larger dose (enoxaparin 1mg/kg)

 

epidural cath removed 8-12 hrs after and 1-2 hrs before next dose of LMWH

Term

What population are hip fractures common in?

 

1 year mortality for pts with hip fxs?

 

Highest risk of death with hip fracture is from _____?

Definition

common in elderly patients

1 out of 50 (pts over age 60)

 

1 year mortality ~30% 

 

highest risk of death is from PE

Term

With hip fractures, what type of anesthesia is advantageous?

 

Early surgery (within ___ hrs of injury) help reduce 3 things, what are they?

 

Though there is NO change in overall ______ with early surgery?

Definition

RA advantageous

 

12hrs 

 

Early Surgery

↓ Pain scores

↓ Length of hospital stay

↓ Periop complications

 

no change in overall mortality

Term

Pelvic fractures are usually caused by significant _______ and are associated with other _______?

 

What other injuries are common? (3)

Definition

significant trauma


other injuries

Chest 21%

Head 16%

Liver & Spleen 8% 

Term

What is the 3 month mortality rate with a pelvic fracture?

 

What is a major issue that may be see with a pelvic fracture?

 

When may repair/stabilization be done?

Definition

~14%

 

pts may have extensive retroperitoneal bleeding

 

may be done in combination with other procedures, or at least stabilization of other injuries

(best to do it within a week of injury but not always possible with other injuries that take priority per Miller)

Term

Traumatic injury to cervical spine requires great care with ________?

Definition
traumatic injury to cervical spine requires great care with intubation
Term
What methods of intubation should you consider with spinal surgery and traumatic injury to the spine?
Definition

Awake fiberoptic

-may consider positioning awake following intubation with confirmation of movement of extremities prior to induction


In-line traction with minimal movement of neck

-appropriate when C-spine has been radiologically cleared or when loss of life is imminent

Term
Blood loss may be enormous with _______ spinal surgery, what should you consider?
Definition

thoraco-lumbar


Consider pros and cons of:

Normovolemic hemodilution

Deliberate hypotension

Staging of the surgery

Term

What is critical with thoraco-lumbar spinal surgery?

 

What monitoring techniques can be used?

Definition

positioning & ongoing monitoring of position is critical

 

use of other monitoring techniques - eg. evoked potentials, wake-up test

Term
What is the most definitive test of an intact spine?
Definition
Wake-Up Test
Term

When is the wake-up test most commonly used?

 

Why?

Definition

most commonly used when repairing deformity

ie scoliosis kyphosis


straightening (distraction) of the spine can impair blood flow to anterior cord

Term

Why should the wake-up test be discussed with the pt preop?

 

What does the wake-up test require?

Definition

recall unlikely, but certainly possible

 

requires careful planning

Term
What is the typical wake-up test technique?
Definition
typically Nitrous-Narcotic technique with small amount of volatile
Term

Steps for wake up test:

 

Definition

1. VIA discontinued well before test planned

2. NMB doses titrated to achieve 2-3 twitches

(do not fully reverse NMB)

3. Discontinue nitrous

4. Begin asking pt to wiggle their toes 

(be patient, this may take a few minutes for them to get light enough)

5. When surgeon is satisfied, re-deepen the anesthetic (be sure another wake up wont be needed too soon)


Term
What other drug combo can be used for the wake-up test technique?
Definition
can also be done very effictively with VIA and a remifentanil infusion
Term
What is Methyl Methacrylate? 
Definition
acrylic bone cement
Term

What issues can placement of bone cement be associated with? Why?

 

What can you do prior to placement to prevent this issue? (4)

Definition

occasionally associated with sudden hypotension multiple mechanisms postulated

 

What you can do prior to placement:

ensure adequate fluid status

don't deepen anesthetic just before placement

maximize oxygenation

DC N2O before placement

Term
What are the inflation pressures of tourniquets for the thigh and arm?
Definition

~100mmHg > systolic BP for thigh

 

~50mmHg > systolic BP for arm

Term
What is bleeding from site after inflation of a tourniquet usually due to?
Definition
most likely due to long bone intramedullary blood flow rather than inadequate cuff pressure, but assess carefully
Term

What is the acceptable duration of inflation?

 

What must be done when this time period is up?

Definition

there is controversy but...

typically 1-2 hrs is considered acceptable

 

after this time there should be a 5 minute period of perfusion, then re-exsanguination & inflation

Term
What is your (oh crap thats me!) responsibility to do with a surgery involving a tourniquet? (3)
Definition

Record inflation/deflation times & inflation pressures

 

Notify the surgeon at 60 minutes and at least every 30 minutes after the initial 60 minutes

 

Document that surgeon has been notified

Term
What should you expect upon tourniquet release?
Definition

10-15% ↑ in HR

 

Slight increase in CO2 & serum K

only rarely do these present a problem

 

Potential release of emboli

Term

How is tourniquet pain described and when does it occur?

 

What is the mechanism?

Definition

dull, aching pain, restlessness

occurs after about 45 minutes (sometimes)

 

mechanism unclear

Term
How do you treat tourniquet pain with RA or GA?
Definition

RA - usual treatment = narcotics, hypnotics

 

GA = deepen anesthetic

Term

With central retinal artery occlusion what area becomes ischemic?

 

Branch retinal artery occlusion?

Definition

CENTRAL - decreases blood supply to entire retina

 

BRANCH - affects only a portion of the retina

Term
What are the 4 possible causes of periop vision loss with RAO?
Definition

External compression of the eye

Decreased arterial supply to the retina

Impaired venous drainage of the retina

Arterial thrombosis

Term
What are the clinical findings with RAO?
Definition
painless vision loss with an abnormal pupil reactivity
Term
*What is the most common cause of periop RAO?
Definition
improper patient positioning resulting in external compression of the eye
Term
What are the 2 causes of decreased arterial supply to the eye?
Definition

Embolic phenomenon

Hypotension

Term

How common is embolic phenomenon?

 

When is it common?

Definition

rare in most surgical procedures

 

have been reports of paradoxical emoblism from surgical site

 

retinal microemboli common during open heart surgery

Term
Hypotension (by itself) _______ seems to cause retinal ischemia.
Definition

Hypotension (by itself) rarely seems to cause retinal ischemia

 

multicenter questionnaire revealed only 3 cases of retinal ischemia in 27,930 hypotensive anesthetics

Term

What is imparied venous drainage from the eye due to?

 

Increased IOP is exacerbated by _______ and attenuated by ________ ?

Definition

studies on both normal and spine surgery pts show increased IOP in the prone position

 

-incr. in IOP exacerbated by head down position

-incr. in IOP attenuated by the head up position

Term

How does the retina recieve blood supply?

 

What may increase IOP enough to decrease blood flow through both?

Definition

retinal blood supply is from the retinal and choroidal vessels


external compression, may increase IOP enough to decrease both retinal & choroidal blood flow

Term
*How were most patients with CRAO positioned?
Definition
Most of patients with CRAO following prone surgery were positioned on a horseshoe headrest
Term
What is the prognosis of retinal ischemia?
Definition

Irreversible

 

yep, you are blind forever

Term

What is the treatment of retinal ischemia? (6)

 

*What is most important intervention?

Definition

Ocular massage to ↓IOP contraindicated if glaucoma not be ruled out

IV acetazolaminde may increase retinal blood flow

Inhalation of 5% CO2 in oxygen dilation

Thrombolysis by opthamologist

Localized hypothermia

Immediate opthalmology consult

Term
When does ischemic optic neuropathy primarily present?
Definition

present spontaneously

(only sometimes associated with surgery)

Term
Ischemic Optic Neuropathy is the leading cause of ______ in pts over _____ years old?
Definition
ION = acute vision loss in pts >50 
Term
What surgeries is ION reported? (4)
Definition

ION reported following:

Cardiothoracic surgery

Instrumented spinal fusion

Head and neck surgery

Nasal and sinus surgery

Term

ION Signs & Symptoms (2 possible)

 

ION usually presents within ___ hrs or on _____.

 

Is ION usually unilateral or bilateral?

What about with spine surgery?

Definition

painless vision loss with no light perception

or

just visual field defects

 

usually presents within 24-48 hrs or often upon awakening


may be unilateral or bilateral

most post-spine surgery cases are bilateral

Term
What are the possible contributing factors of ION? (9)
Definition

Blood Loss

Anemia or hemodilution

Altered venous hemodynamics

Abnormal autoregulation in optic nerve

Decreased blood pressure

Prone positioning

Use of vasopressors

Lengthy surgery for spinal fusion

Small cup-to-disc ratio

Term

What is corticol blindness?

 

Does it result in complete blindness sometimes? Is it common?

Definition

bilateral visual loss

and

absence of lid reflex response to threat

 

yes - complete blindness implies infarction of both the right and left occipital cortex

this is rare

Term

What is cortical blindness usually accompanied by?

 

*The majority (___%) of postop cortical blindness occurs with __________ or _________ surgery?

Definition

usually accompanied by signs of stroke in parieto-occipital area

 

~80% of postoperative cortical blindness occurs following cardiac or thoracic surgery

Term
What may cortical blindness result from? (9)
Definition

Ischemia

Cardiac arrest

Hypoxemia

Intracranial HTN

Hemorrhage

Vascular occlusion

Thrombosis

Intracranial hemorrhage

VasospasmEmboli

Term
What is the prognosis and treatment of cortical blindness?
Definition

Prognosis - healthy pts may show significant recovery of vision, but course may be prolonged

 

Treatment - prevention of progression of stroke

Term

T/F acute angle-closure glaucoma is common following anesthesia?

 

What population is acute angle-closure glaucoma most common in?

 

Symptoms? (2)

Definition

F - rare following anesthesia

 

most commonly in elderly women

 

symptoms:

painful red eye and cloudy or blurry vision

Term

*Is acute angle-closure glaucoma related to anesthetic technique?

 

*Is acute angle-closure glaucoma a big problem?

Definition

No association made between acute glaucoma and anesthetic technique!

 

This is an emergency requiring immediate opthalmologic consultation

Term

TURP

What type of cautery is used for a TURP?

 

What does the traditional method require to get rid of shavings?

Definition

unipolar cautery shaves slices off the prostate gland

 

requires use of irrigating fluid to distend the bladder & wash out shavings

Term

TURP

How does absorption of irrigation fluid with a TURP effect the pt?

Definition
absorption of irrigation changes in intravascular fluid volume and plasma solute concentrations
Term

TURP

As the gland is resected in a TURP ____ _____ are opened & irrigating solution is _______?

 

What is this dependent on? (3)

Definition

As the gland is resected in a TURP venous sinuses are opened & irrigating solution  is absorbed

 

Dependent on:

# of sinuses opened 

 duration of procedure

Ht of irrigating solution

Term

What pressure (ht) should be used for TURP?

 

What other surgery can cause similar fluid/electrolyte problems as the TURP?

Definition

<40 cm above pt

 

can see a similar problem w/ endometrial ablation when irrigating solution is used

 

-close record of I/O is kept in this procedure

Term
What do the initial fluid shifts in a TURP cause? (3)
Definition

Initially: excessive absorption of irrigant causes

 

HTN

Reflex bradycardia

baroreceptors

Pulmonary edema

Term
What is seen later with a TURP in regards to fluid shifts? (3)
Definition

3rd spacing 2ndry to hyponatremia & hypo-osmolality

 

hypotension - renal compromise

 

CV collapse

Term
What problems can be seen with hyponatremia due to absorption of Na-free irrigation in a TURP? (6)
Definition

confusion

agitation

seizure

visual disturbance

pulmonary edema

CV collapse

 

Term

What can TURP syndrome cause cerebrally? why?

 

Then the increased ICP causes reflex ______?

Definition

cerebral edema secondary to acute hypo-osmolality

 

increased ICP w/ subsequent reflex bradycardia

Term

What is the treatment of hyponatremia with TURP syndrome in an asymptomatic patient?

 

Symptomatic?

 

Complication of treatment in symptomatic pt?

Definition

asymptomatic hyponatremic patient with near normal osmolality - none

 

symptomatic or hypo-osmolar hyponatremia - 3% saline

 

Complication: central pontine myelinolysis (demylination)

Term
What metabolic problems may be seen with a TURP?
Definition

metabolic acidosis

and 

hyperammonemia

Term
How can hyperammonemia and acidemia result from TURP syndrome?
Definition
deamination of glycine irrigant to glyoxylic acid and ammonia
Term
What can hyperglycinemia cause with TURP syndrome? (2) Why?
Definition

Transient blindness - glycine is an inhibitory transmitter in the retina

 

Encephalopathy and seizures - potentiation of NMDA, an excitatory transmitter

Term
In general, what determines the effect of the wavelength on the target tissue?
Definition
degree to which a particular wavelength of light is absorbed and converted to heat determines the effect on the target tissue
Term

What laser is completely absorbed by water in the first few layers of cells; what nm?

 

What does this result in?

Definition

CO2 laser

10,600nm

 

results in explosive vaporization of surface tissue with little damage to underlying tissue

Term

What do excimer lasers allow?

 

What type of surgery is this laser used in?

 

nm?

Definition

allow extremely precise focusing of ultraviolet light

 

used extensively in photorefractive surgery (lasix etc)

 

200-400nm

Term

Describe the Nd:YAG laser...nm?

 

Types of surgeries (3)

Definition

less absorbed by water, therefore less vaporization and more thermal coagulation occurs (deeper "cooking" effects)

 

1064nm

 

TURP, laryngeal papilloma, laster uvulopalatoplasty

Term

Vaporization of tissue by a laser produces a Laser plume; what is it?

 

In rats what has it done?

Definition

smoke and fine particulate matter produced by vaporization of tissue

 

in rats has produced: pneumonia, inflammation, and emphysema

Term

What may the laser plume serve as?

 

Is there confirming data that viral transmission by a smoke plume is possible?

Definition

may serve as a vector for viral infection

 -have detected viral DNA in smoke plume from condyloma, and skin warts, but not laryngeal papilloma

 

No confirmation of viral transmission by a smoke plume has been shown

Term

Which lasers produce the most smoke?

 

What is employed at the surgical site to get rid of the smoke?

Definition

CO2

 

smoke evacuator

Term

Are ordinary OR masks ok with laser surgeries?

 

When do they need to be changed?

Definition

NO; ordinary OR masks don't filter small enough particles - special masks are required

 

need to be changed if damp b/c filtration becomes less effective

Term
List the laser hazards to the patient.(5)
Definition

Vessel perforation

Tissue injury

Venous gas embolism

Wrong target

Airway fires

Term

What size of vessels are not coagulable with laser?

 

What type of laser may produce more tissue injury?

Definition

vessels > 5mm

 

depth not well controlled with Nd:YAG

Term
Venous gas embolism is most common in ________ surgery?
Definition
hysteroscopic surgery
Term
What are the wrong targets that can be hit with the laser?
Definition

viable tissues

drapes

ETT

eyes

Term
What do you do to protect the pts eyes from lasers?
Definition

eyes taped

covered with opaque, saline soaked towel or metal shield

Term

How can the OR personnel protect their eyes?

Different lasers require different _____ lenses.

 

______ eyeglasses are adequate for CO2 lasers, but dont provide full coverage, WEAR THE __________.

 

Contact lenses provide _____ protection!

_______ to OR must be covered.  

Definition

Different lasers require different colored lenses

 

glass or plastic eyeglasses are adequate for CO2 lasers, but dont provide full coverage, WEAR THE GOGGLES.


Contact lenses provide no protection!

 

Windows to OR must be covered 

Term
What may produce local thermal injury with ETT and a laser?
Definition
ignition of outside of tube
Term
If the ETT cuff is punctured what can occur?
Definition
oxygen enriched environment at target site producing potential for ignition - airway fire
Term
What is the possible problem with perforation of the tube itself?
Definition
may produce a blowtorch type phenomenon and cause severe damage to pt
Term

Minimize _____ to avoid an ETT fire when using a laser and use _____ instead? 

 

Is N2O flammable? Helium?

 

What other measure may help eliminate airway fires?

Definition

Minimize FiO2 - use AIR (has less O2)

 

N2O is flammable

Helium?

 

ETT protection

Term
How can the ETT be protected from fire? (4)
Definition

pledgetts covering cuff

wrapping tube with metallic tape

specialized coated tube and saline-filled cuff

metal ETT

Term
List the steps for management of an airway fire.
Definition
  1. Remove source (ETT, packing)
  2. Stop ventilation
  3. If airway fire continues, flood the field
  4. Direct laryngoscopy/bronchoscopy to assess airway damage
  5. Reintubation following bronchoscopy
  6. Monitor for ≥24 hours
  7. Consider steroids and antibiotics
Term
List the characteristics of an ideal biologic agent.
Definition

Generate mass casualties

Would result in widespread M&M

Highly infectious and contagious

Inexpensive

No natural immunity

Easy large-scale dissemination

Easy to produce

GWHINEE

Supporting users have an ad free experience!