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POSTOPERATIVE MANAGEMENT OF ORTHOPEDIC PATIENTS. THE SURGEONS PERSPECTIVE ED SZALAPSKI JR., M.D. TWIN CITIES ORTHOEDICS. PHYSIOLOGIC RESPONSE TO TRAUMA. VASODILATION INCREASED MEMBRANE PERMEABILITY THIRD SPACING FLUID RETENTION. RESULT. PATIENTS REQUIRE VOLUME SUPPORT LOW BP

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POSTOPERATIVE MANAGEMENT OF ORTHOPEDIC PATIENTS


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    Presentation Transcript
    1. POSTOPERATIVE MANAGEMENT OF ORTHOPEDIC PATIENTS THE SURGEONS PERSPECTIVE ED SZALAPSKI JR., M.D. TWIN CITIES ORTHOEDICS

    2. PHYSIOLOGIC RESPONSE TO TRAUMA • VASODILATION • INCREASED MEMBRANE PERMEABILITY • THIRD SPACING • FLUID RETENTION

    3. RESULT • PATIENTS REQUIRE VOLUME SUPPORT • LOW BP • LOW URINE OUTPUT • ORGAN DAMAGE • RENAL FAILURE

    4. MODIFIERS • GENERAL HEALTH • MEDICATIONS • LOCATION OF SURGERY • MAGNITUDE OF DISSECTION • OUR INTERVENTIONS

    5. RECOVERY • AS PATIENTS RECOVER, THEY MOBILIZE/REABSORB FLUIDS • INCREASED URINE OUTPUT • OCCASIONAL FLUID OVERLOAD

    6. PRIMARY HIP REPLACEMENT CMS CHECKS BLOOD LOSS URINE OUTPUT/RENAL FUNCTION BLOOD PRESSURE (HTN MEDS!) DISLOCATIONS

    7. PRIMARY KNEE REPLACEMENT • PAIN MANAGEMENT!!!!! • BLOOD LOSS (250 TO 1250 ml) • URINE OUTPUT/RENAL FUNCTION • MOTION • VITAL SIGNS (HTN MEDS)

    8. PATELLA FRACTURE • MINIMAL DISSECTION • MINIMAL BLOOD LOSS • STRAIGHTFORWARD PAIN MANAGEMENT • MINIMAL THIRD SPACING • NON-WEIGHT BEARING • PATIENT STRENGTH & MOBILITY FACTORS

    9. TIB FIB FRACTURE • BLOOD LOSS IS USUALLY MILD • THIRD SPACING IS USUALLY MILD • PAIN MANAGEMENT • COMPARTMENT SYNDROME!!!!

    10. COMPARTMENT SYNDROME PRESSURE WITHIN THE FASCIAL COMPARTMENT RISES ABOVE PRESSURE WITHIN THE SMALL VESSELS ISCHEMIA RAPID ONSET OF PERMANENT DAMAGE TO MUSCLE AND NERVES

    11. COMPARTMENT SYNDROME • PAIN, PAIN, PAIN • LOSS OF ACTIVE MOTION • PAIN WITH PASSIVE MOTION • LOSS OF PULSE IS TOO LATE • LOSS OF PERFUSION IS TOO LATE • BEDSIDE PRESSURE MEASUREMENT • SURGICAL EMERGENCY

    12. INTERTROCHANTERIC HIP FRACTURE • BLOOD LOSS DEPENDS ON DISPLACEMENT AND COMMINUTION • BLOOD LOSS IS HIDDEN IN THIGH MUSCLES, NOT IN THE DRAIN, IF ANY • WATCH THE URINE OUTPUT • WATCH THE VITALS

    13. PERIPROSTHETIC FRACTURE • MODERATE BLEEDING AND THIRD SPACING • LOW CMS RISK • NON WEIGHT BEARING • MOTION • MODERATE PAIN

    14. PERIPROSTHETIC FRACTURE • EXTENSIVE DISSECTION • MAJOR BLOOD LOSS AND THIRD SPACING • GREAT DEAL OF DRAINAGE • WATCH URINE OUTPUT • THIRD SPACING

    15. SEPTIC TOTAL KNEE • 84 YO MALE • DIABETIC • HTN • VENOUS STASIS • SEVERAL WEEKS OF DENIAL

    16. REIMPLANTATION • QUADRICEPS TURNDOWN—RESTRICTED MOTION AND WEIGHT BEARING • THREE UNITS OF BLOOD • MILD ACUTE RENAL FAILURE • MILD CHF SEVERAL DAYS LATER

    17. SEPTIC TOTAL HIP • 60 YO MALE • PRIOR IM NAIL • 300+ POUNDS • MRSA INFECTION • VANCOMYCIN ALLERGY • THREE DEBRIDEMENTS TO ERADICATE INFECTION

    18. HIP REIMPLANTATION • 8 UNITS PRBC • 10 LITERS OF FLUID • PRESSORS FOR 12 HOURS • MILD RISE IN Creatinine—resolved • FULL WEIGHT BEARING

    19. SUMMARY • IT’S NOT JUST THE BONES • THINK ABOUT GENERAL PHYSIOLOGY OF SURGERY

    20. CONFLICT OF INTEREST I hereby certify that, to the best of my knowledge, no aspect of my current personal or professional situation might reasonably be expected to affect significantly my views on the subject on which I am presenting.