• Extremes of age:  Experience a decrease in body system fxn, poor tolerance to anesthesia, broad med regimen, undiagonised pathologies
• Traumatic Injuries:  RSI (always considered full stomachs); Cervical collar injury (awake FOI); hidden injuries
• Arthritis:  Inability to lay flat; (arytenoid cartilage is affected by RA); DIFFICULT airway; polypharmacy

• General
• Regional
• Combination
• MAC with Local

1. Explain their options fully
2. Read their expressions
3. Be neutral
4. Have they had this procedure before?  What was done?  How did it work?
5. Never "sell"...without VERY good reason
6. Be a good patient advocate

Chest x-ray=8mrem

Head CT=170mrem

Abd CT=680mrem

FLUROSCOPY=>75,000mrem

5,000 mrem annual recommended exposure

Find fitting lead and thyroid shield!

1. To minimize blood loss
2. Improve surgical visualization
3. Contain local anesthetic in Bier Block

1. Cuff should be placed with limited padding underneath or none at all
2. Cuff needs to encircle entire limb
3. Point of overlap should be 180 degrees from neuromuscular bundle (overlap can cause decreased compression)
4. Width should be greater than 1/2 limb diameter

100mmHg > patient's SBP-for thigh or LE

50mmHg > patient's SBP-UE

• If patient's BP increases substantially, the tourniquet may need to be increased

Surgeons often use their own predetermined settings

350mmHg-LE

250mmHg-UE

20 minutes

(early release can cause local anesthetic toxicity)

1. Can damage underlying vessels, nerves, and muscles
2. Direct cuff pressure is more damaging than distal ischemia
3. All damage is completely REVERSIBLE if time limited to under 2 hours
4. Systemic metabolic acidosis and increased CO2 levels can occur after deflation
5. May see 10-15% increase in HR
6. 1-8mmHg increase in ETCO2
7. 5-10% increase in serum K+

45-60 minutes after inflation

• pt.'s c/o dull aching pain; or become restless and more difficult to sedate
• under GA, both HR and BP continue to increase, despite increased anesthetic and narcotic administered

• Where applied
• When inflated
• What pressure
• When deflated
• correlate with RN circulator

Site specific considerations for arthroscopies

Ankle, knee, hip, wrist and elbow:

1. Supine position
2. may or may not use tourniquet
3. General v. Regional (LMA v. ETT)-MR not typically needed
4. Low pain scores
5. Duration 20min.-2 to 3 hours

Shoulder

1. Beach chair or lateral position
2. ETT v. LMA (consider position)
3. Higher pain scores
4. Typically 1- 1.5 hours MINIMALLY

Joint reconstruction or replacement

1. Patients are usually older (heavier, unhealthy, HTN, DM, dec. activity)
2. Very HIGH pain scores-plan postop management ahead of time
3. Early postop ambulation
4. Positioning can be a challenge
5. Lengthy surgery
6. Keep pt. warm
7. May have high blood loss
8. METICULOUS INFECTION PREVENTION
9. Always have good IV access

• Hydrate
•  Oxygenate

• Anesthetic choices include:  Spinal, epidural, regional, GA or combo approach; depends on patient and surgeon fxs
• Typical time for primary total knee arthroplasty (2 hrs.); revisions (exctending 3-4 hours or more)
• EBL can range from 300-500ml in primary arthroplasty; revisions up to 1,000ml
• MOST common complications DVTs, dislocation of patella (20%), wound necrosis/infection, PE, loosening of components, peroneal nerve injury

50-75%

2-3%

10%

25%

• Anesthetic choices include:  Spinal, epidural, or GA (depends on patient and surgeon)
• Typical time for total hip can be 2-3 hours; redo being 3-6 hours
• EBL for initial hip replacement 250-750ml and 1,000ml for total hip revisions
• Both femur and acetabulum are reamed for implantation of prothetic components
• May have lost upto 1,000ml into fracture prior to incision

1. Care in positioning-both before and after induction
2. Expect hypotension and have fluids/pressors
3. Lots of noise and movement-adequate sedation
4. Room will be COLD-keep pt. WARM
5. Expect high EBL (preop and intraop)-may need volume expander such as HESPAN, cellsaver, or blood transfusion therapy

• Male
• 20-30 yo
• hypovolemic shock
• IM instrumentation
• total hip or knee arthroplasty

• Decreased ETCO2
• Decreased PaO2
• Increased pulmonary artery pressure

Long bone

Mechanical-fat droplets enter vascular system and act as microemboli in vascular beds

Biochemical

1. Toxic mechanism:  Free fatty acids released at time of trauma directly affect pneumocytes in the lung causing ARDS
2. Obstructive theory:  Mediators are released at the fracture site affecting lipid solubility resulting in embolization

• PREVENTION
• Preoperative methylprednisone may aid in preventing release of fat emboli
• O2 administration
• CPAP
• volume replacement
• overall support
• Albumin can bind to fatty acids and may aid in reducing lung damage

• LMW heparin therapy
• sequential compression devices
• antiembolism stockings
• early postop ambulation
• may be included in 'time out'
• continue anticoag. tx for 7-10 days postop or longer
• risk exists for up to 2 months postop
• S/S similar to Fat embolism (hypoxemia, tachycardia, tachypnea, respiratory alkalosis, mental status changes, petechia, fat globules in urine/sputum)

• placing a single cannulated screw under fluroscopy guidance from the anterolateral aspect of proximal femur
• Short
• minimal blood loss
• 10-16 yo
• low pain scores postop

1. Position-beach chair occasionally lateral
2. Possibility for VAE (venous air embolism)
3. Very HIGH pain score
4. Strongly encourage use of regional anesthesia block in addition to GA, interscalene block common
5. Prepared for hypotension (d/t position and possible use of MMA)
6. Minimal blood loss
7. Surgical time 2 hrs.
8. Intubation-difficulty reaching airway and pt. condition

Capnography, mass spectrometry, and left precordial doppler are all non-invasive ways to monitor VAE

• Surgeon irrigate site with NS
• decrease N2O
• 100% FIO2
• tilt pt. to LEFT side
• pressors
• if central line, withdraw air with 60cc syringe AGGRESSIVELY

• Regional, MAC v. GA, combo
• minimal blood loss; tourniquet typically used
• RARELY need ETT v. LMA (depends on pt.'s comorbidities)
• Ankle surgery can be lengthy/mult. incisions/medial and lateral repairs
• regional-popliteal, femoral, ankle, and digit blocks

• Regional, MAC or GA
• Supine position
• Bed rotated 90-180 degrees
• Specialized arm board on surgical side
• Minimal EBL w/ tourniquet use
• Damage to tendons and nerves; hand/palm area can greatly increase surgical times

• Extremely common outpt. procedure
• FAST (10-20 min)
• Skip Phase 1 PACU and go to Phase 2 recovery
• MAC-deep sedation for local block and enough sedation for light nap following local injection
• Open or endoscopically
• Trigger finger release procedures are FAST- surgeon may one pt. to WAKE towards end of case to follow commands and assess triggering

• insertion of pins into bone through skin to stabilize fx or joint that was realigned by closed reduction
• FAST
• Fluroscopy
• Low pain

Cervical Spine Surgery

(Anterior Approach)

• Herniated/degenerative disks, cervical tumors, some c-spine trauma
• GA with ETT always
• Trauma=difficult intubation r/t stabilization
• Supine (ext/flex of neck by surgeon)
• Document head/neck positioning specifically DURING intubation and again with positioning and WHO positioned head/neck
• Foam, Mayfield pins or horseshoe positioner
• Minimal blood loss
• 2 hours or less (fusion longer v. decompression)
• Warming pt.
• Arms will be tucked-consider IV access and add extensions if needed
• IF neck is unstable preop it is unstable postop
• PUT COLLAR BACK ON (document who took off and who put on)
• Prevent bucking/coughing on emergence (Narcotics, lidocaine, etc.)

Cervical Spine Surgery

(Posterior Approach)

• Same considerations for anterior approach
• PRONE position
• Emergence-head will most likely be in clamps/pins that need to be removed once in supine position
• Document surgeon in charge of head/neck in supine position placement of pins and again for the prone position change

• Anterior, lateral or posterior approach
• Anterior exposes:  great vessels, trachea, esophagus, lung parenchyma, sympathetic ganglia, lymphatic duct, and brachial plexus.
• Lateral exposes (thoracotomy ?rib resection):  great vessels, lung parenchyma, thoracic duct are at risk
• Anterior and lateral require one lung ventilation
• Spinal cord monitoring
• Awake extubation
• Blood loss  and surgical time vary greatly
• Arterial line (risk of sudden blood loss)
• Lumbar surgery w/ anterior approach=retraction of abdominal aorta and vena cava
• Permissive hypotension

• Most common
• Prone position
• Spinal cord monitoring
• Possibility of 'wake up' test-return to GA
• Arterial lines-risk for lg amount of blood loss, lengthy procedure, mult. comorbidities

• Lateral and/or rotation of vertebrae
• 75-90% idopathic; other causes include NM disease, congenital heart disease, trauma, and mesenchymal disorders
• Respiratory failure and death can occur by 45 yo if not corrected
• Decreased VC
• V/Q mismatch=hypoxemia
• Hypercapnia develops with age
• Freq. require postop ventilation (worse 7-10 days postop)
• Right ventricle hypertrophy common
• Increased pulmonary pressures
• Congenital heart disease (MVP, coarctation, and cyanotic heart disease)
• Commonly corrected in peds population

1. Likely pediatric population
2. Prone position
3. HUGE incision
4. Evaporative losses and blood loss are HIGH
5. Need for tight fluid management-balance losses with need for slight hypotension and prone position minimalization
6. MUST have good IV access (multiple), a-line, ?central line
7. Arms often accessible
8. Intubation may be difficult depending on curvature
9. Position challenges
10. Comorbidities (congenital heart, pulm. issues, etc.)
11. Spinal cord monitoring
12. Wake up test
13. Lengthy OR time (6, 8, 10 hrs.)
14. Post op pain control challenging-epidural catheters can be placed by surgeon prior to closing
15. VAE possible

Somatosensory Evoked Potential (SSEP) monitoring will show _______ in amplitude or an _______ in latency if damage is thought to be occuring?

Decrease

Increase

• Temperature (both hypo and hyperthermia)
• Hypotension-below the levels of cerebral autoregulation
• PaCO2 changes reflect changes in cerebral BF
• PaO2 changes reflect changes in O2 delivery to neural structures

Decrease

Increase

• 1/2 MAC of volatile with suplemental sedation gtt (propofol common, but can be dexmetatomidine, or narcotic gtt such as remifentanyl, sufenta, fentanyl)
• If MOTOR (anterior) monitoring-AVOID paralytics or limit to only intubation dose
• Huge implications for patient with fixed head pins (coughing and bucking can cause pt. to snap neck-aide on heavy anesthetics and ask how monitor looks)

• HTN
• DM
• Polycythemia
• Smoker
• RF
• Narrow-angle glaucoma
• Atherosclerotic vascular disease
• Collagen vascular disorders

• Hypotension
• Anemia
• Hypovolemia
• Prolonged surgical time
• Hemorrhagic hypotension

Ankylosing Spondylitis

• Inflammatory disease resulting in new bone formation in an attempt to heal (fusing of vertebral sections)
• Affects men more
• S/S begin in early adulthood
• Inflammation also occurs in eyes (pain, sensitivity to light, blurred) and aorta (aortic valve distortion)
• No cure; Tx aimed at decreasing pain and lessening symptoms
• Thorough airway assessment including neck ROM
• Plan on difficult intubation

• Long-term auto-immune disease that leads to inflammation of joints and surrounding tissues
• Affect other organs
• Affects woman more
• Cause UNKNOWN
• Early S/S:  Minor joint pains, stiffness, and fatigue

1. Immune mediated joint destruction
2. Chronic progressive inflammation of synovial membranes
3. Systemic involvement
4. Cardia:  Pericardial thickening and effusion, myocarditis, conduction defects, valvular fibrosis
5. Pulmonary:  Pleural effusion, nodules, interstitial fibrosis
6. Hematologic:  Anemia, thrombocytopenia, eosinophilia, plt. dysfunction
7. Endocrine:  Adrenal insufficiency, immunosuppression
8. Dermatologic:  Thin, dry, atrophic skin
9. Renal:  RF from vasculitis, amyloidosis, and/or meds used for therapy