Managing post-op care of orthopaedic patients Flashcards
what needs to be considered in fluid management for post op ortho patients 5
type of injury in trauma cases
amoint of fluid loss intra-op
type of fluid loss
level of dehydration/ overload
age and comorbidities
how is fluid loss assessed 3
clinical exam
urine output
CVP monitoring (rare)
define crystalloid fluids
saline
hartmans
freely pass thorugh endotheial barriers and easily metabolised
define colloids
albumin, FFP, Gelofusion
increase intravascular volume more than crystalised
common post-operative problems in ortho patients 4
delirium
pain
nausea
pyrexia
clinical assessment of delirium
CAM criteria
-confusion
-inattention
-disorganised thinking
-alterared level of consciousness
DSM-5 criteria
-disturbance in attention
-distrubance develop over short period of time
-addiotnal disturbance in cognition
4AT test
-altertness
-cognition (short test of orientation)
-attention (recitation of the months in backwards order)
-presenc of acute change or fluctuating course
who is it risk of developing delirium 4
elderly
hip fracture
poor pain management
alcohol withdrawal
describe the WHO pain ladder in treatment of post op pain
inital PCM or NSAIDs
if pain not controlled-> codiene or dextropropoxyphene together with appropriate agents to control and minimise side effects.
if pain not controlled final rung of the ladder is to introduce strong opioid drugs such as morphine. Analgesia from peripherally acting drugs may be additive to that from centrally-acting opioids and thus, the two are given together.
common causes of nausea in post op patients
how can risk factors for PONV be classified 3
patient factors
surgical factors
anaethetic factors
patient risk factors for PONV 5
female
age (incidence declines throughout adult life)
previous PONV or motion sickness
use of opioid analgesia
non-smoker
surgical risk factors for PONV 6
intra-abdo laparoscopic surgery
intracranial or middle ear surgery
squint surgery
gynae surgery
prolonged operative times
poor pain control
anaesthetic risk factors for PONV 5
opiate analgesia or spinal anaesthetia
inhalation agents
prolonged anaesthetic time
intraoperatiev dehydration or bleeding
overuse of bag and mask ventilation
types of postoperative infection
superfical
deep
describe deep postop infection
-occurs within 30 days if no implant or 90 days if implant present
-infection involves deep soft tissue (fascia/muscle) with above features
describe superficial postop infection
-occur within 30 days of surgery
-involes only skin and subcut tissue with one of:
=purulent drainage, organism detected, erythema/pain/swelling
common organisms in postop infection 4
coagulase negative straphlococus
staph A incld MRSA
strep
E Coli
Others
risk factors for postop infection 9
trauma cases
open wound pre-op (esp open fractures)
DM
obesity
vascular disease
prolonged procedure time
older patients
immune impairment
nutritional deficiencies (eg low albumin)
management of post-op infection 4
refer to treating team or on call ortho team
take wound swab and specimens for baseline inflammatory markers
do not commence ABx without wound swab/tissue culture
only commence ABx if evidence of systemic sepsis and specimen obtained
concern with post-op prosethtic joint infection
difficult to identify and some organisms difficult to culture
deep infection can lead to implant loosening and require several procedures to eradicate infection
best chance to isolate infection organism before ABx started
considerations for post op pain mangement 6
pre-op education
use oral over IV analgesia
IV PCA recommeneded when parenteral route needed for post-op systemic analgesia
monitor sedation and resp status if receiving opioids
local infiltration of would w Local anaetheic can be useful
regional aenatheic via nerve catheter or regional ernve block
-femoral nerve block
definiont of postop AKI
elevated creatinei
reduced urine output
reduced GFR
pathogenesis for postop AKI
hypotension leads to pro-inflammatory state-> increase in vasocontrictive mediators-> tubular ischaemia and injury
risk factors for post-op AKI procedure related 4
hypovolaemia
reduced systemic vascular resistance (caused by anaesthesia)
nephrotoxic agents (NSAIDs, contrast media)
prophlyyatic ABx- gentamicin, fluclox
risk factors for post-op AKI patient related 6
older ptx
pre-exisiting CKD
DM
liver disease
HTN
use of ACEi
Mx of post op AKI 3
use loop diuretics for fluid overload
maintina optimal haemodynamic state to perfuse kidney
use IV fluids, blood transfusion and inotropic agents to improve CO and O2 delivery
why are lower-limb ortho patients at high risk of VTE 3
blood stasis
-tourniquet
-immobilisation
endothelial injury
-surgical position
-manipulation of limb
hypercoagulability
-trauma increases
-thromboplastins
-blood loss
*-THESE ARE FEATURES OF VIRCHOWS TRIAD
risk factors for thromboelbolic disease 9
older ptx
obesity
varicose veins
FHx of VTE
thrombophilia
combined OCP/HRT
immobility
immobility due to travel
ortho:
-lower limb fracture
-spinal cord injury
-lower limb surgery
prevention of VTE in post op patients 2
considered for VTE prophylaxis
mechanical
-early mobilisation
-graduated compression stockings
-intermittent pneumatic compression devices
pharmacological
-warfarin
-heparine
-NOACs
diagnosis of VTE 2
suspect if ptx have persisting pain and swelling after elevating limb
investigations- D-dimers, doppler US
clinical features assoc w haemorrhages 4
altered consciousness
tachycardia
low urine output
hypotension
define fat embolism syndrome
when fat enters the blood stream
respiratory features of fat embolism syndrome 3
early persistent tachycardia
tachypnoea, dyspnoea, hypoxia usually 72hrs following injury
pyrexia
dermatoligcal features of fat embolism syndrome 2
red/ brown impalpable petechial rach
subconjunctival and oral haemorrhage/ petechiae
CNS features of fat embolism syndrome 2
confusion and agitation
retinal haemorrhage and intra-arterial fat globules on fundoscopy
imaging for fat embolism syndrome
may be normal
fat emboli tend to lodge distally
-therefore CTPA may not show vascular occlusion
-ground glass appearance may be seen at the periphery
management of fat embolism syndrome 3
prompt fixation of long bone fractures
DVT prophylaxis
general supportive care
causes of fat embolism syndrome 5
result of fractures of bones like femur or pelvis
others:
-pancreatitis
-ortho surgery
-bone marrow transplant
-liposuction
what ortho patients are at risk of fat embolism syndrome 4
polytrauma
long bone fractures
hip arhtorplasty
knee arthroplasty
basic pathophys of fat embolism syndrome
2 theories mechanical and biochemical
mechanicla
-trauma causes release of fat directly from bone marrow-> due to elevated pressure in medullary cavity cause release of fat globules
biochemical
-trauma causes inflammtion-> bone marrow to liberate fatty acids into venous circulation
-happens due to increased activity of lipoprotein lipase
major criteria for fat embolism syndrome diagnoiss 4
axillary or subconjunctival petechia
hypoaemia PaO2<60mmHg
CNS depression disproportionate to hypoaemia
pulmonary oedema
minor criteria for fat embolism syndrome diagnosis 9
tachy >110bpm
pyrexia >38.5
fat globules in urine
change in renal function
drop in HB and MCV
drop in platelets
increased ESR
fat globules in sputum
emboli present in retina on fundoscpy
managemetn of fat embolism syndrome 4
ICU
central venous pressure monitoring
O2 (maybe CPAP)
fluid replacement + albumin
prevention of fat embolism syndrome 3
proper immonilisation
rapid open reduction and internal fixation
? use of prophylactic steroids
