32 ORTO - Coluna Flashcards
Many orthopedic operations including total joint arthroplasties and spine surgeries are classi- fied as intermediate surgical risk, with 30-day cardiac death or myocardial infarction occurring with an incidence of 1% to 5%.
Since preoperative cardiac risk evaluation is often inconclusive in high-risk patients with limited mobility, a higher level of monitoring and perioperative ______ measurements should be considered to assess for perioperative cardiac events.
Troponin
Em que pacientes o uso de antifibrinoliticos deve ser evitado? (3)
- Historia de eventos tromboembolicos
- Stents coronarianos
- Disfuncao renal
Qual a classificacao de risco cirurgico d maioria dos procedimentos ortopédicos, como Artroplastias e Cirurgias de Coluna?
Risco intermediario, com mortalidade cardiaca ou IAM de 1-5% em 30 dias.
Principais escores de risco Cardiovascular
- RCRI
- Gupta
O que avalia o Gupta Scale e o quais os criterios (5)?
Gupta Perioperative Risk for Myocardial Infarction or Cardiac Arrest (MICA) in 30 days.
- Idade
- Status funcional
- ASA
- Creat
- Procedimento
In this study, the adjusted OR for myocardial infarction or cardiac arrest was estimated to be 2.22 (95% CI, 1.55-3.17) for orthopedic surgery and 1.24 (95% CI, 0.38- 4.00) for spine surgery, compared with an OR of 4.96 for aortic surgery.
With a growing geriatric population and an increase in elective noncardiac surgeries in these patients, the necessity of having accurate estimations of the cardiac risk for geriatric patients becomes obvious. For this reason, the new geriatric-sensitive perioperative cardiac risk index (GSCRI), derived solely from geriatric data, was developed in 2017.
- Quais as variáveis? (7)
https://qxmd.com/calculate/calculator_448/geriatric-sensitive-perioperative-cardiac-risk-index-gscri
- AVE
- ASA
- Cirurgia
- Status Funcional (dependente)
- Cr
- Falencia Cardiaca
- DM
The GSCRI has been shown to be a significantly better predictor of cardiac risk in geriatric patients under- going noncardiac surgery compared to the Gupta score and RCRI. In the GSCRI, the OR for myocardial infarction or cardiac arrest in orthopedic patients (OR, 2.99; 95% CI, 2.22-4.02) was higher than in the other two indices. The underestimated cardiac risk in geriatric patients resulting from these scores is likely due to estimates that were derived from a younger population.
Qual a definicao de Perioperative Myocardial Injury?
- Trop > 144ng/L ou mais das medias pre-op para pos-op em pacientes de alto risco com > 65a ou em pacientes > 45a e historia de doenca arterial cornariana pre-existente, doenca arterial periferica ou AVE.
In the most recent study on PMI, Puelacher and coauthors defined PMI as an absolute increase in high-sensi- tivity cardiac troponin of 14 ng/L or greater from preoperative to postoperative measurements in high-risk patients 65 years or older or in patients 45 years or older with a history of pre- existing coronary artery disease, peripheral artery disease, or stroke.
Patients with pulmonary hyperten- sion undergoing orthopedic surgery represent an especially vulnerable group.
A thorough clinical examination of a patient with pulmonary hypertension should focus on the nature of: (8)
- Progressao de sintomas
- Tolerancia a exercicios
- Sinais de falencia de VD
- FC
- PA
- ECG
- Rx Torax
- Biomarcadores - BNP + trop
Quais os 5 dominios de fragilidade, conforme Linda Fried?
- Perda de peso
- Forca de preensão
- Exaustao
- Atividade fisica baixa
- Marcha alentecida
While frailty is increasingly acknowledged as a marker of functional decline, it remains a potentially modifiable risk factor.
- Como modififcar?
- Programas de reabilitacao pre-op
The main risk factors for postoperative delirium are: (5)
- idade > 65a
- Declinio cognitivo cronico ou demencia
- Disturbio visual ou auditivo
- Doenca grave
- Infeccao ativa
In order to successfully prevent, predict, and manage postoperative delirium, differ- ent delirium risk scores were developed of which two were validated in orthopedic surgical patients.
- Quais sao? (2)
1) Kalisvaart
- Funcao cognitiva na admissao
- Disturb visual
- Acute physiologic and chronic health status
- BUN/Cr ratio
2) Delirium Elderly At-Risk (DEAR)
- Idade
- Disturbio visual ou auditivo
- Dependencia em mais de uma atividade de vida diaria
- Baixo Escore Mini-Mental ou episodio previo de delirium pos-op
- Abuso de Alcool ou Benzo
Principais fatores de risco independentes para Doenca Tromboembolica em pacientes submetidos a Artroplastia Total de Articulacoes: (4)
- Doenca CV
- Hx previa de TEV
- Doenca neurologica
- ASA
Two large studies published after the last update of the ACCP guidelines suggested ______ to be an effective, safe, con- venient, and inexpensive alternative to low-molecular weight heparin or to rivaroxaban for extended thromboprophylaxis after joint arthroplasties.
Aspirin
Principal escore de risco para Doenca Tromboembolica na População Cirurgica Geral
- Caprini
While the widely-used Caprini score risk assessment model for throm- boembolic disease in the general surgical population failed to provide clinically useful risk stratification information in total joint arthroplasty patients,76 a more individualized risk model improved the efficacy of preventing venous thromboembolism in these patients.77 In spine surgery, venous thromboembolism prophylaxis remains even more controversial.
In general, arthroplasties are considered as having a ___1___ risk of bleeding, whereas vertebrospinal surgery is associated with a ___2___ risk of bleeding.
- Moderate
- High
De maneira simplificada e breve, nas cirurgias de artroplastias e cx vertebroespinhais, quando suspender a Aspirina?
- 5-7 dias antes de cirurgias em pacientes com baixo-moderado risco cardiovascular (ex: profilaxia primaria)
- Elevado risco CV: nao suspender
Em que pacientes nao suspender Aspirina no pre-op de artroplastias e cx vertebroespinhais? (4)
- SCA > 12m
- Stent farmacologico > 6m
- Stent metalico > 1m
- Bypass cardiaco > 6m
Elective orthopedic surgery is not recommended without optimization in patients with a very high cardiovascular risk; such surgery should be delayed when possible.
- Quais sao esses pacientes? (5)
- SCA < 12m
- Stent farmacologico < 6m
- Stent metallic < 1m
- Bypass cardiaco < 6m
- AVE < 4s
Based on robust evidence in the literature, it is recommended that patients with an increased risk of bleeding complications are identified using ______ and, only if indicated, the measurement of platelet count, prothrombin time, activated partial thromboplastin time, PFA-100 platelet function ana- lyzer test, and von Willebrand factor.
- A standardized questionnaire
From Koscielny J, Ziemer S, Radtke H, et al. A practical concept for preopera- tive identification of patients with impaired primary hemostasis. Clin Appl Thromb Hemost. 2004;10(3):195–204.
Como fazer screening de desnutrição em cirurgias ortopédicas? (4)
- IMC
- Medidas antropometricas
- Laboratorio: linfopenia, albumina, pre-albumina, transferrina, zinco
- Mini Nutritional Assessment score
Principais tipos de fraturas de coluna relacionadas a trauma
- Compressao 54.8%
- Distracao 16.9%
- Rotacao 18.5%
Em que momento os BNM Despolarizantes devem ser evitados apos TRM?
48-72h apos lesao
Although it remains controversial, data from a Cochrane review support a 48-hour course of ______ initiated within 8 hours of injury to those patients with incomplete neuro- logic deficits
High-dose Steroids
Cuidados Pulmonares de pacientes com escoliose grave (3)
- Doenca pulmonar restritiva
- Hipertensao pulmonar
- Hipertrofia de VD
Correction of spinal deformities can be associated with large intraoperative blood loss, and measures to minimize blood transfusion should be considered.
- Em que pacientes a hipotensao deve ser usada com cuidado para minimizar as perdas sanguíneas? (4)
- Idade avançada
- Doenca Cardiovascular
- Risco de complicacoes isquemias
- Risco de Perda Visual Pos-Op
Quais fatores fisiológicos e anestesicos podem interferir e atenuar os potenciais de acao monitorizados em cirurgias de coluna? (5)
- Hipotensao
- Hipoxemia
- Hipotermia
- Hipocarbia
- Anestesia Inalatoria
Assuming that the anesthetic effects on these modalities remain unchanged and the patient’s physiologic parameters remain stable, an intraoperative loss of SSEPs or MEPs should warn the clini- cians of (2)
- 1) impaired conduction through the dorsal columns or 2) the corticospinal tracts;
Em cirurgias de coluna, A predetermined checklist for response to IONM changes can guide the cli- nicians and facilitate rapid interventions aimed at diagnos- ing and correcting any surgical or physiologic insults.
- Quais as condutas implementadas pelo anestesiologista? (2)
1) Otimizar perfusao espinhal
- hemodinamica
- Anemia
- Temperatura
- pH
- pCO₂
2) Preparar possivel wake-up test
the ASA Task Force on Perioperative Visual Loss identified risk factors for ION after spinal fusion surgery to be: (6)
- Homens
- Obesidade
- Wilson frame
- Tempo cirurgico prolongado
- Elevada perda sanguinea estimada
- ↓% coloide administrado
Medidas para prevenir NOI
- Monitorar Hb/Ht em pacientes de alto risco
- Evitar pressao ocular
- Posicionar cabeca no mesmo nivel ou mais alto do que o coracao
- Estagiar o procedimento de cirurgia espinhal
Principais analgésicos utilizado para dor pos-op em paciente submetido a cirurgia de coluna (5)
- Methadone is increasingly employed in this group of patients and is reported to improve postoperative pain control even when administered as a single bolus (0.2 mg/kg) before surgical incision.
- Ketamine can be used as an adjunct to perioperative opioids, and is dem- onstrated to reduce postoperative narcotic demand after spi- nal surgery.
- AINEs
- Corticosteroids are occasionally administered, as they are shown to reduce opioid requirements after certain spine procedures, possibly through their anti-inflammatory effects as well as the reduction in substance P release.
- 𝛂2-antagonistas - Dexmedetomidine is also reported to negate the opioid-induced hyperalgesia that may occur following intraoperative opioid treatment
Qual a limitacao dos AINEs em cirurgias de coluna e ortopédicas no geral?
- Concerns of their effects on bone metabolism and osteoblastic proliferation.
Evidence suggests, nevertheless, that impaired bone healing may only be caused by higher doses and longer duration of NSAID administration, and smaller doses for the immediate postoperative period can be considered
Other options for treating the intensive postoperative pain after spinal surgery include the administration of intrathecal opioids, which has been shown to reduce the cumulative opioid demand.
- Quais as limitações dessa modalidade?
- Risco de depressao respiratoria
- Afetam funções motoras e sensoriais, mascarando complicacoes pos-op potenciais
