Orthopaedics Flashcards
What is fat embolism syndrome
Uncommon but potentially fatal result of fat globules embolising to lung parenchyma and peripheral circulation after major trauma and long bone fractures
Occurs between 1 to 3 days after insult
Combination of direct mechanical effect and production of metabolites
Classic triad is hypoxaemia, axillary or subconjunctival rash and neurological signs (“HAN”)
Gurd’s criteria what makes diagnosis
2 major
OR
1 major and 4 minor
Gurd’s criteria major
Hypoxaemia
Pulmonary oedema
Neurological signs
Petechial rash
Gurd’s criteria minor
Tachycardia HR >110
Retinal change
Renal - oliguria/anuria
Pyrexia
Haematological - inc. ESR, sudden drop in haematocrit/plt
What is ankylosing spondylitis (AS)?
A rare inflammatory spondyloarthropathy that mainly affects the spine and sacroilliac joints
What would you focus on pre-operative assessment in patient with Ank Spond
Severity/stability of disease
When diagnosed
What treatmemnt
- Airway involvement
- May be v challenging
- Degree of kyphosis
- TMJ involvement and mouth opening - Severity of axial disease
- Will neuraxial be difficult due to ossified interspinous ligaments
- Is there any neurological deficit - Extra-articular disease
- Resp/CVS involvement
Ix:
Bloods - FBC,U+E,clotting/g+S
ECG
Echo
Lung Function
Issues of secondary joint surgery
Carried out when primary prosthesis needs revision due to
- Infection
- Recurrent dislocation
- Component loosening
Patients are older and more likely to have co-morbidities
Operations may be surgically complex and therefore
- Longer intra-operatively
- Longer post op recovery
- Potential for more blood loss
- Higher chance of significant post op pain
What are the 3 pillars of Patient Blood Management
- Optimisation of red cell mass and production (erythropoiesis)
- Minimisation of perioperative blood loss
- Managing anaemia
Can be applied pre-op, intra-op and post-op
WHO values for anaemia
<130g/L for men
<120g/L for women
Risks of perioperative anaemia
- Increased post op complications
- Increased mortality
- Increased L o S
Intraoperative strategies for PBM
- Optimising red cell mass
- Proceed when optimised (bloods 4-6 weeks pre-op) - Minimise perioperative blood loss
- Meticulous surgical techniques and haemostasis
- Intraoperative cell salvage
- Central neuraxial (some evidence is blood sparing)
- Goal directed management (use of TEG/ROTEM, clotting)
- Anti-fibrinolysis (TXA) - Managing anaemia
- Appropriate thresholds, 70g/L if no risk factors
- 80 in ischaemic heart disease
AAGBI recommendations with anaemia
FBC in all procedures >500ml EBL
Dx and management as early as possible
Major non urgent surgery should be postpones
Target >130g/L in M and F
Oral iron 40-60mg/day if 6-8weeks
IV iron if not tolerated or <6 weeks
What is rhabdomyolysis how is it confirmed ?
Muscle cell necrosis leading to leakage of intracellular contents (K+, PO4, CK, myoglobin, urate)
Confirmed with
CK >1000iu/L
Urine myoglobin
Complications
Serum K+, Ca++, PO4—
ECG changes
Causes of rhabdomyolysis
Crush injury
Compartment syndrome
Electrocution
Exertional (strenous exercise, seizures)
Malignant hyperthermia
Neuroleptic M.S
Drugs: statin, cocaine
Pre-operative management principles of patients on NOF pathway
Medical assessment
Frailty assessment
Cognitive assessment (AMTS)
Analgesia
- Multimodal
- Regional
Urgency - <36hrs
Transfusion thresholds pre NOF surgery
Association of Anaesthetists recommend
>90g/L no IHD
>100g/L with IHD
Best Practice Tariff in England for NOFs
Surgery in <36hrs
Assessed by elderly medicine physician <72hrs
Preop cognitive testing
Assessment for bone proctection, falls, nutrition
Postop delirium assessment
Assessed postop by physiotherapist
