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