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Orthopaedics > Managing post-op care of orthopaedic patients > Flashcards

Managing post-op care of orthopaedic patients Flashcards

1
Q

what needs to be considered in fluid management for post op ortho patients 5

A

type of injury in trauma cases

amoint of fluid loss intra-op

type of fluid loss

level of dehydration/ overload

age and comorbidities

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2
Q

how is fluid loss assessed 3

A

clinical exam

urine output

CVP monitoring (rare)

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3
Q

define crystalloid fluids

A

saline
hartmans

freely pass thorugh endotheial barriers and easily metabolised

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4
Q

define colloids

A

albumin, FFP, Gelofusion

increase intravascular volume more than crystalised

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5
Q

common post-operative problems in ortho patients 4

A

delirium

pain

nausea

pyrexia

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6
Q

clinical assessment of delirium

A

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

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7
Q

who is it risk of developing delirium 4

A

elderly

hip fracture

poor pain management

alcohol withdrawal

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8
Q

describe the WHO pain ladder in treatment of post op pain

A

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.

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9
Q

common causes of nausea in post op patients

A
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10
Q

how can risk factors for PONV be classified 3

A

patient factors

surgical factors

anaethetic factors

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11
Q

patient risk factors for PONV 5

A

female

age (incidence declines throughout adult life)

previous PONV or motion sickness

use of opioid analgesia

non-smoker

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12
Q

surgical risk factors for PONV 6

A

intra-abdo laparoscopic surgery

intracranial or middle ear surgery

squint surgery

gynae surgery

prolonged operative times

poor pain control

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13
Q

anaesthetic risk factors for PONV 5

A

opiate analgesia or spinal anaesthetia

inhalation agents

prolonged anaesthetic time

intraoperatiev dehydration or bleeding

overuse of bag and mask ventilation

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14
Q

types of postoperative infection

A

superfical

deep

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15
Q

describe deep postop infection

A

-occurs within 30 days if no implant or 90 days if implant present
-infection involves deep soft tissue (fascia/muscle) with above features

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16
Q

describe superficial postop infection

A

-occur within 30 days of surgery
-involes only skin and subcut tissue with one of:
=purulent drainage, organism detected, erythema/pain/swelling

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17
Q

common organisms in postop infection 4

A

coagulase negative straphlococus

staph A incld MRSA

strep

E Coli

Others

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18
Q

risk factors for postop infection 9

A

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)

19
Q

management of post-op infection 4

A

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

20
Q

concern with post-op prosethtic joint infection

A

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

21
Q

considerations for post op pain mangement 6

A

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

22
Q

definiont of postop AKI

A

elevated creatinei

reduced urine output

reduced GFR

23
Q

pathogenesis for postop AKI

A

hypotension leads to pro-inflammatory state-> increase in vasocontrictive mediators-> tubular ischaemia and injury

24
Q

risk factors for post-op AKI procedure related 4

A

hypovolaemia

reduced systemic vascular resistance (caused by anaesthesia)

nephrotoxic agents (NSAIDs, contrast media)

prophlyyatic ABx- gentamicin, fluclox

25
Q

risk factors for post-op AKI patient related 6

A

older ptx

pre-exisiting CKD

DM

liver disease

HTN

use of ACEi

26
Q

Mx of post op AKI 3

A

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

27
Q

why are lower-limb ortho patients at high risk of VTE 3

A

blood stasis
-tourniquet
-immobilisation

endothelial injury
-surgical position
-manipulation of limb

hypercoagulability
-trauma increases
-thromboplastins
-blood loss

*-THESE ARE FEATURES OF VIRCHOWS TRIAD

28
Q

risk factors for thromboelbolic disease 9

A

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

29
Q

prevention of VTE in post op patients 2

A

considered for VTE prophylaxis

mechanical
-early mobilisation
-graduated compression stockings
-intermittent pneumatic compression devices

pharmacological
-warfarin
-heparine
-NOACs

30
Q

diagnosis of VTE 2

A

suspect if ptx have persisting pain and swelling after elevating limb

investigations- D-dimers, doppler US

31
Q

clinical features assoc w haemorrhages 4

A

altered consciousness

tachycardia

low urine output

hypotension

32
Q

define fat embolism syndrome

A

when fat enters the blood stream

33
Q

respiratory features of fat embolism syndrome 3

A

early persistent tachycardia

tachypnoea, dyspnoea, hypoxia usually 72hrs following injury

pyrexia

34
Q

dermatoligcal features of fat embolism syndrome 2

A

red/ brown impalpable petechial rach

subconjunctival and oral haemorrhage/ petechiae

35
Q

CNS features of fat embolism syndrome 2

A

confusion and agitation

retinal haemorrhage and intra-arterial fat globules on fundoscopy

36
Q

imaging for fat embolism syndrome

A

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

37
Q

management of fat embolism syndrome 3

A

prompt fixation of long bone fractures

DVT prophylaxis

general supportive care

38
Q

causes of fat embolism syndrome 5

A

result of fractures of bones like femur or pelvis

others:
-pancreatitis
-ortho surgery
-bone marrow transplant
-liposuction

39
Q

what ortho patients are at risk of fat embolism syndrome 4

A

polytrauma

long bone fractures

hip arhtorplasty

knee arthroplasty

40
Q

basic pathophys of fat embolism syndrome

A

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

41
Q

major criteria for fat embolism syndrome diagnoiss 4

A

axillary or subconjunctival petechia

hypoaemia PaO2<60mmHg

CNS depression disproportionate to hypoaemia

pulmonary oedema

42
Q

minor criteria for fat embolism syndrome diagnosis 9

A

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

43
Q

managemetn of fat embolism syndrome 4

A

ICU

central venous pressure monitoring

O2 (maybe CPAP)

fluid replacement + albumin

44
Q

prevention of fat embolism syndrome 3

A

proper immonilisation

rapid open reduction and internal fixation

? use of prophylactic steroids

Orthopaedics (15 decks)

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