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LAS - RUSS > Septic Arthritis / Septic Physitis > Flashcards

Septic Arthritis / Septic Physitis Flashcards

1
Q

Broad causes of Septic Arthritis:
1
2
3

A
  1. Naturally ocurring
  2. Iatrogenic
  3. Infectious (usually bact, but can be viral, mycobacterial, fungal)
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2
Q

Two main ways Septic Arthritis can naturally occur?

A

Hematogenous or Traumatic

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3
Q

Iatrogenic causes of Septic Arthritis?

A

During arthroscopy, arthrocentesis, fracture repair, etc

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4
Q 
Pathogenesis Steps of Septic Arthritis:
1.
2.
3.
4. Creates cycle of \_\_\_\_\_\_\_
A
  1. Synovitis/capsulitis
  2. fibrin deposition
  3. Cellular infiltrates ie degraditive enzymes, cytokines
  4. Creates cycle of cartilaginous matrix destruction
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5
Q

The cycle of cartilaginous matrix destruction in Septic Arthritis leads to:

  1. Decreased ___ synthesis
  2. Loss of ____
  3. ____ of the joint
  4. (painful/not painful)?
  5. Compromised ________
A
  1. HA
  2. PG
  3. Effusion
  4. Painful
  5. synovial blood flow
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6
Q

Risk factors for Septic Arthritis in Foals

  1. Same as what other disease?
  2. ______ –> risk of _____.
A
  1. Foal septicemia

2. Failure of Passive Transfer —> risk of bacteremia. Leads to localization of bacteria and hematogenous spread.

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7
Q

Types of septic arthritis in foals:
1.
2.
3.

A
  1. S
  2. E
  3. P
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8
Q

S-Type Septic Arthritis:

  1. Affects what parts of joint?
  2. Age affected?
  3. More likely to affects joints that (smaller/larger)?
  4. More likely to affect (single/multiple) joint(s)?
  5. CxS: a) b) c)
A
  1. Synovial membrane/fluid
  2. < 1 week
  3. Larger, ie stifle/tibiotarsal
  4. Multiple
  5. Acute, severe lameness, effusion.
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9
Q

E-Type Septic Arthritis

  1. Affects what parts of joint?
  2. Rads will reveal ___-
  3. Age affected?
  4. Relevant History?
  5. Affects (single/multiple joints?
  6. Which bone(s) does it target?
  7. Initial CxS?
  8. Late CxS?
A
  1. bones adjacent to articular cartilage, particularly the expanding epiphysis
  2. Subchondral lysis
  3. Weeks old
  4. FPT, concurrent dz (pneumonia, diarrhea)
  5. Multiple
  6. Distal femur, talus, tibia, radius
  7. Mild intermittent lameness
  8. Acute exacerbation of lameness/effusion
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10
Q

P-Type Septic Arthritis

  1. Affects what part of bone?
  2. Age affected?
  3. Sites affected?
  4. (single/multiple) sites affected?
  5. Initial CxS?
  6. Late CxS?
  7. General CxS?
A
  1. Physis of long bones
  2. Weeks –> months
  3. Distal physis of MCIII/MTIII, radius, tibia
  4. ONE SINGLE SITE USUALLY
  5. Premonitory lameness
  6. Acute severe lameness/swelling
  7. Perarticular swelling without effusion
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11
Q

Diagnosis of P-Type Septic Arthritis

1.
2.
3. Possible ____
4. DO NOT _____. Why?

A
  1. Radiographs
  2. Aspirate of physis
  3. Bone Biopsy
  4. Debride: Will damage physis and can cause premature closure.
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12
Q

Septic Arthritis - Foals:

  1. __ and __ types are similar.
  2. CxS: a) b) c) +/-
  3. Synovial Fluid Analysis will reveal….
  4. Bloodwork will reveal..
  5. U/S will reveal ____
A
  1. S-type, E-type
  2. a) lameness, b) effusion, c) +/- fever
  3. > 50,00 cell count, >90% neutrophils, color: normal to cloudy, red, organge, pink
  4. Increased fibrinogen +/- leukocytosis.
  5. Hypercellular fluid
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13
Q

Septic Arthritis in Foals:

  1. Be sure to identify…..
  2. Be sure to U/S the ____
  3. Prognosis for survival = ___%
A
  1. ALL JOINTS INVOLVED
  2. Umbilicus
  3. 77%
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14
Q

Septic Arthritis: Iatrogenic Risk Factors in Aduts:

1.
2.
3.
4. Usually what bacteria?

A
  1. Synovial Surgery
  2. Fracture repair
  3. Arthrocentesis
  4. Staphylococcus
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15
Q

Septic Arthritis: Risk Factors in Adult

  1. Most common bact that will be involved if traumatic cause?
  2. Bacteremia is (common/rare) in adults?
A
  1. Enterobacteriaceae (staph, pseudomonas, fungi)

2. rare

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16
Q

T/F

You should treat an open joint as an infected joint.

A

T

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17
Q

Septic Arthritis in Adults: CxS

  1. Similar to foals without _____
  2. (acute/chronic) onset of (mild/severe) lameness?
  3. Other signs:
    a)
    b)
    c) +/- ____
A
  1. bone involvement
  2. acute severe lameness
    3.
    a) synovial effusion
    b) peri-articular heat and swelling
    c) +/- Fever
18
Q

Diagnosis of Septic Arthritis in Adults

  1. Gold standard?
  2. Gross exam to evaluate ___, ____ and ____.
  3. ___/___
  4. Clinpath: evaluate a) b) c)
A
  1. Microbiology
  2. color, clarity, viscosity
  3. Clinical Signs/Hx
  4. a) total protein
    b) Cell count/differential
    c) staining of smears
19
Q

Diagnosis of Septic Arthritis in Adult Horses

Culture and sensitivity:

  1. Use what kinds of media? Why?
  2. Can submit for ____ culture.
  3. Do what if initial sample is negative?
  4. Foals - Aspirate ___ if suspect physitis
A
  1. Enrichment Media / Blood culture media. MUCH BETTER YIELD
  2. Fungal
  3. Repeat culture
  4. Physis
20
Q

Septic Arthritis Cytology:

  1. Color?
  2. Clarity?
  3. WBC count?
  4. Cell differentials?
  5. TP?
A
  1. Serosanguinous, orange
  2. Turbid
  3. Thousands +
  4. > 90% neuts, usually degenerated
  5. > 3.5g/dL
21
Q

Septic Arthritis Diagnosis:

  1. Most common isolate?
  2. Culture (before/after) antibiotics?
  3. Take tap (towards/away) from wound.
  4. Why?
A
  1. Staphylococcus
  2. Before
  3. AWAY
  4. So if there’s a chance that it doesn’t get through to the joint yet you don’t want to inadvertently introduce the bacteria into the joint.
22
Q

Imaging of Septic Arthritis:

Radiographs will reveal
1.
2.
3.

A
  1. Marked effusion
  2. Soft tissue swelling
  3. Osseous involvement
23
Q

Imaging of Septic Arthritis

benefits of ultrasound:
1.
2. Reveals what characteristic sign?
3. For foals?

A
  1. Guides fluid aspirate (esp. in difficult structures
  2. Hypercellular fluid
  3. FOALS - check umbilicus
24
Q

For successful treatment of Septic Arthritis, you must have _______ and ________

A

Rapid recognition of disease
and
Immediate aggressive treatment

25
Q

Possible Consequences of Septic Arthritis:

1.
2.
3.
4.

Complications:
1.
2.

A
  1. Acute synovitis with supuurative effusion
  2. Cartilage destruction via cellular and bacterial enzymes and cytokines
  3. Capsular fibrosis/ankylosis
  4. DJD
  5. Contralateral Limb Laminitis
  6. Euthanasia
26
Q 
Treatment Goals of Septic Arthritis:
1. Return \_\_\_\_\_\_\_ to normal environment.
Accomplished by doing what three things?
a) 
b)
c)

Can result in what if not accomplished:
2.
3.

A
  1. Cartilage
    a) eradicate infection
    b) eliminate inflammation
    c) minimize matrix loss and cartilage damage
  2. Irreversible structural damage and decreased prognosis for return to function
  3. contralateral limb laminitis
27
Q

Treatment of Septic Arthritis after sample acquisition:

  1. Begun treatment with what kind of drugs? Which ones specifically?
  2. _____ is a mainstay of treatment. When? How much?
A
  1. Broad spectrum antibiotics.
    Pencillin/gentamycin
  2. LAVAGE! Early and often, and in large volumes (5-10 L)
28
Q

Lavage of Septic Arthritis:

1. \_\_\_\_\_ lavage ideal.  
Benefits of this method: 
a)\_\_\_\_\_\_\_\_ delivery
b) Removal of \_\_\_\_\_
c) Allows \_\_\_\_\_\_\_\_
  1. ______ method is also fine.
    a) Downside: Sometimes ______
    b) Needle Size?
    c) Place needles in (infected compartment/all compartments)
A
  1. Arthroscopic
    a) Rapid and accurrate delivery
    b) removal of fibrin clots
    c) targeted debridement
  2. Needle (through and Through Lavage)
    a) frustrating
    b) large! 18-16G
    c) all compartments
29
Q

Lavage of Septic Arthritis:

  1. Sedation and local anesthesia: Use what drug?
  2. Use general anesthesia for what two procedures?
A
  1. 2% Mepivacaine

2. Arthroscopy and arthrotomy

30
Q

Lavage of Septic Arthritis: Lavage Solutions:

Options:
1. _______s like ____ or _____

  1. DO NOT ADD _____ or ______.
    Why?
    a)
    b)
  2. Can consider adding ___ instead, but it’s not required
A
  1. Balanced Electrolye Solution: ie LRS, Normosol
  2. Chlorhexidine or Povidone-iodine
    a) Cytotoxic! Will cause inflam
    b) Doesn’t work! It doesn’t do anything beneficial!
  3. DMSO
31
Q

Lavage of Septic Arthritis:

1.Lavage how often?

2. Stop when there is resolution of :
a)
b)
c)
d)
A
  1. Daily initially if not fully responsive

2)
a) Lameness
b) Effusion/swelling
c) WITH D/C of NSAIDs, analgesics
d) Synovial fluid SAA levels

32
Q

Treatment of Septic Arthritis: Antibiotics

  1. Start with what drugs?
  2. If it’s iatrogenic?
  3. T/F: Systemic Admin is vital to successful outcome.
A
  1. Broad spectrum ie Pen/Gen.
  2. 100% local treatment because results are as good or better vs systemic. Don’t make that big of a difference.
  3. F: Local is vital.
33
Q

When is it ok to stop admin of antibiotics in septic arthritis case?

A

Minimum 30 days and 2 weeks beyond resolution of CxS

34
Q

Treatment of Septic Arthritis: Local Antibiotics:

  1. Admin Methods: a) b) c) d)
  2. CRI vs Intermittent bolus determined by ____
  3. Sensitive to what drug? Why use it?
A
  1. a) Intra-articular
    b) RLP
    c) IO
    d) Antibody impregnated biomaterials
  2. C/S
  3. Aminoglycosides. MIC is very high, most bacteria cannot survive.
35
Q

Intra-articular admin of antibiotics:

  1. Instill when?
  2. Benefit of this method of admin?
  3. 500 mg Amikacin provides ___hr concentration > MIC for most pathogens.
  4. Be cautious of : a)
    b)
A
  1. After completion of lavage
  2. Very high conc of drugs at site of sepsis, 10-100x systemic admin
  3. 72 hr
  4. a) using in multiple joints.
    b) exceeding daily systemic dose.
36
Q

Regional Limb Perfusion:

  1. Performed how often?
  2. Technique:
    a) Proper _____ placement is essential. Describe it.
    b) catheter size?
    c) Inject (slowly/quickly)?
    d) Apply ____ topically
A
  1. QOD

2.

a) tourniquet. Above and below if possible, using Esmarch tourniquet. After injection, leave on for 30 min
b) 25-27 G
c) Slowly, over 5-10 min
d) Surpass

37
Q

Regional Limb Perfusion - Dosage

General Rule of Thumb:

  1. ____ of systemic dose
  2. For distal limb?
  3. For above carpus/tarsus?
  4. Cattle: Admin method? Benefit?
  5. Caution:
A
  1. 1/3rd
  2. qs to 30 mL
  3. qs to 60 mL
  4. RLP with Florfenicol. High tissue conc effective against F. necrophorum and A. pyogenes
  5. DO NOT EXCEED TOTAL DAILY SYSTEMIC DOSE
38
Q

IO antibiotic administration:

  1. before injection:
    a)
    b)
    c)
    d)
  2. Inject (slowly/quickly)?
  3. Leave tourniquet for how long?
A
  1. a) Sedation/local anesthetic
    b) Drill 4 mm hole
    c) Male end of luer tip extension set fits
    d) Apply esmarch tourniquet
  2. Slowly
  3. 30 min
39
Q

Septic Arthritis: Analgesia

  1. (is/is not) reccomended? Why/Why not?
2. Options:
a)
b)
c)
d) Hindlimbs: 
e)
A
  1. Is, because it’s extremely painful and will be accompanied by contralateral limb laminitis. Also they will spend excessive time recumbent which can result in decubital ulcers, resp dz, or weight loss.
  2. a) NSAIDs - be sure to monitor for toxicity though.
    b) Opiates
    c) CRI - lidocaine or ketamine
    d) Epidural catheter with opiates or detomidine
    e) GI protectants like omeprazole AND sucralfate
40
Q
  1. What is the most reliable and important measure to asses response to tx of septic arthritis?
  2. Beware false positive response from…..
  3. Avoid confusion how?
A
  1. Clinical lameness and pain
  2. NSAIDs and other analgesics
  3. By never d/c any antibiotic or lavage until horse is evaluated AFTER analgesics have been reduced or d/c.
41
Q

Adjunct Treatment of Septic Arthritis:

IA ___, ___, ____ are all reasonable, but which is most plausible.

A

HA, ACS, PRP.

HA.

LAS - RUSS (32 decks)

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