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157 Cards in this Set
- Front
- Back
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4 perioperative risks
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Patient
Provider Procedure Anesthesia |
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Formula for minimal risk c excellent outcome
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Complete H&P, Informed consent, Accurate diagnosis
Surgical planning, Lab tests c proper interpretation |
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ASA class I
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Normal healthy pt
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Class II
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Controlled mild systemic disease
smoker, anemia mildly obese |
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Class III
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Controled severe systemic disease;
CHF Stable Angina, MI HTN MOrbidly obese Bronchospastic dz |
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Class IV
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Severe life threatening disease
unstable angina COPD c sx CHF c sx Hepatorenal failure |
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CClass V
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Going to die soon
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CClass VI
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Brain dead organ donor
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Class E
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Emergency
Add it as a prefix |
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Bronchi spastic disease class
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Iii
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Chronic renal failure disease class
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Iii
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Anginas class
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Unstable IV
Stable III |
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Pre op tests------
CXR |
when pt shows signs of pulmmonary disease
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ECG
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MM>40
FF>>50 |
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chem profile
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HTN, Diuretics, COPD, Apnea, DM ,Renal Dx
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CBC
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Pt c hx of dyspnea on exertion, coagulopathy, blood loss, tachycardia
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Other tests that can be done
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LFT/RFT, vascular exam, imaging, respiratory, nutrition
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Coag studies
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PT, PTT, INR
Pt c coagulotherapy, bleeding dz, liver dz |
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CAD-----
Stats |
10x risk of MI
5% c CAD will have MI, Previous MI <3mo --> 30% reinfarct only do surgery on pt whose last MI was >6mo ago |
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AHA Major
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Intense MgMt-> delay or cancel sx
-<6mo post MI Severe Angina Recent Heart Surgery Arrhythmi |
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AHA Intermediate
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Requires further workup
Mild Angina Prior MI dx via ECG Decompensated HF DM |
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AHA Minor
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Increases risk is all
old abnormal ECG, non sinus rhythm decreased functionality |
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Surgical mgmt of pt c CAD
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Preop systolic <200, Dia <140... if not --> DELAY surgery
pacemaker- Call rep Hgb/Hct need to be sufficient for coronary perfusion |
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Pre- surgery Medical Management
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Platelets- 7-10 days out (ASA, Clopidogrel)
Lipids- 1D out Kidney- Hold Day Of Heart + Statins- take Day Of |
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Respiratory Disease ----------
Stats |
Pulmonary complication events are roughly equal to cardiac complications
Pneumonia is major complication McGlamry's= no increased pulm risk post-op if pt obese (difficulty during surgery though maintaining airway) |
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8 specific hx Qs
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MC- SPADE
Mechanical ventilator Cough (chronic or productive) Smoking Pneumonia Asthma Dyspnea Exercise intoleranc3e |
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6 risks of surgery on pt c pulm dz
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B- HILAR
Bronchoconstriction Hypoxia, Hypercapnea Innefective cough Latex allergy is very common Atelactasis Respiratory infection |
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RespDz pre op eval
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Total ROS
Total Meds review (ask about corticosteroid >2wks in past 6months) Measure Pulmonary Function |
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3 ways to increase pulmonary function
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8 wks out stop smoking
Deep breathing exercises and spirometry Corticosteroids to open airways |
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Inhaled pulmmonary meds
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Take (including DO procedure)
Stress dose corticosteroids |
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DM------------
Stats |
DM 5x risk of complications, 66% of complications are infection
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Surgery promotes what systemic signals?
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insulin inhibitory signals (increase glucose)
Cortisol (increase glucose) Catecholamines GH |
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The shugas
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Ideal is 80-100 or max <180
Cancel surgery at 200 (bc they will nave been NPO for 8 hours- something's wrong) or HgbA1C >8% Early admit pt with elevated glucose |
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Shuga levels c critically ill vs non
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Critical- keep <180
non- keep <140 control either way c insulin therapy |
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Oral control DM II- minor surgery
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Metformin stop 48hrs before
Stop all other orals DO Monitor Pre and every 1-2hrs post Tx HyperGlycemia c REGULAR insulin |
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Insulin controlled DMI - minor surgery
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Long acting insulin 1/2 dose
NO short acting insulin Treat hyperglycemia c SHORT or REg insulin |
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Emergency or High Risk DM
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Fusion of glucose, insulin, K
Balance Fluid, Sugar, Electrolytes |
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Acute renal failure------------------
Stats |
50% that develop ARF postop will die
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RF acute Risks
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Decreased Bvolume
Aminoglycosides, NSAIDS Sepsis Pigmenturia |
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RF chronic risks
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Renal Dz
HTN CHF DM PVD Increased Age Cirrhosis |
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Creatinine levels and cardiac complicaitons
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>2 pre-op --> increased risk of cardiac event in surgery (or shortly after)
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Why do full cardiac eval in Renal dz pt?
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if silent ischemia is seen on new ECG= major concern
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Surgery and dialysis
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Day before
Hold DO unless emergent |
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Diagnostic tests in RenalDz
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ECG, CBC, Serum chemistry
Newly dx add UA + electrolytes |
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Infectoin Tx
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Avoid aminoglycosides
Always prophylax implant? give Abx loooooon gtime |
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Avoid
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NSAID,
HOLD HEPARIN- Watch for anemia HGB needs to stay >11 or 12 |
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PVD----------------
5Ps |
Pulselessness, Pain, Pallor, Parasthesia, Paralysis
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Signs of chronic PVD
1-ABI 2- SLPs 3- PVR 4- TBI- 5- TcPO2 6- Toe Pressure |
ABI <.4
SLP 20-30mmHg change b/t segments PVR- flat waveforms (if see anything other than triphase wave- do ABI) TBI- <.65 TcPO2- <20mmHg Toes need at least 30-40mmHg to heal |
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DVT---------------------------
Stats |
Most preventable cause of death
Most common post-op cause of mortality and morbidity Venous Thrombus- no sx so goes undiagnosed frequently |
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Prophylactic Tx?
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Research authors say no, read on....
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Causes that would require prophylaxis
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>2hr Rearfoot procedure
Thigh or calf tournequet Long NWB Obese Elderly |
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Low risk category
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Minor surgery, <40
NO risk factors Tx: Early ambulation |
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Moderate Risk category
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Minor surgery, <40, + Risk factors
Minor surgery, >40, NO risk factors Major surgery, <40, No Risk factors Prophylaxis- LMWH Post-Op- LDUH |
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LMWH
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> bioavailability
more predictable |
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Warfarin
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INR 2-3
Weekly monitoring |
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ASA
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325 p/o BID starting c surgery and going until wt bearing
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RA---------------------------------
Pre-op workup |
32% complication rate
Consider pt rehab Cervical c1-c2 plain films lateral view extended and flexed |
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Methotrexate
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increases infection + wound healing complications
stop 2weeks out, resume when healing BEGINS |
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Rx Pre-OP
1. ASA 2. NSAID 3. COX2 |
1- 7d
2. 5 t1/2 3. No change |
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Kineret, Actvera
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IL1 inhibitors
Stop Prior to surgery and re-start after HEALING COMPLETION |
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RA Rx c Major Probs
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Penicillamine,
indomethacin, cyclosporin hydroxycloroquine prednisolone |
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Nutrition------------------------
1. Albumin 2. Prealbumin |
1- main transport in blood, most powerful antioxidant. >3.3g/dl
2 >16 g/dl (lower = sign of malnutrition) |
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Obesity-----------
Stats |
22x inflammation
13x infection 11x pain |
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increased risk of
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PE, wound infection, airway maintenance issue, DVT, Skin closure
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Pediatrics------------------------
increased riks of |
cardiac arrest
ariway mgm complications --> difficult intubation --> aspiration |
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Halothane
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Hypotension, arrhythmia
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Geriatrics---------------------
all factors considered |
not just age
comorbidities current meds activity level support at home, etc |
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Poor candidates
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if health limits physical activity
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Procedure guidelines
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match pt goal
min procedure for max results, hospital local anesthesia mobile quickly |
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PsychoSocial----------------------
Stats |
surgeon has 20-30% control of outcome
best outcomes when phsyician addresses pt c habitat |
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Predictors of outcome
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P-CHAD
Pain Complications prior Home Abuse Depression |
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CHARCOT
Etiology theories |
Neurovascular
Neurotraumatic Combined |
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Modern theory
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1- sensorimotor neuropahthy leads to
a- decreased sensation --> instability b- atrophy and equinus --> high risk foot 2- Autonomic neuropathy --> sympathetic failure --> increased bloodflow, a/v shunt --> osteolysis 3- throw in some trauma and you get a litteral hot mess |
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Classifications (names)
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Eicholtz and shiabata, Freikberg
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Eicholtz 1
tx |
Development- joint debris, fragmentation, capsular distension, subluxation, RESORPTOION OF BONE
TX: Limited wt bearing, TCC, Observation (Bisphosphonates) |
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Echenholtz 2
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Coalescense- Absorption, large fragments coalesce, sclerosis, REPAIR
Tx: TCC s WB |
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Eichenholtz 3
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Resoprtion: Chronic, bone ends orunded, fractures united, decreased sclerosis, DEFORMITY
Tx: TCC followed by CROW |
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Shiabata
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Zero- swelling and warmth, ligamentous instability
Imaging: silent bone stress injuires, MRI most sensitive, Marrow and pariosteal edema |
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Charcot progression Natural History
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Fracture due to repeptivive trauma s repair --> increase blod flow to bone --> increased resorption, inflamm --> decreased bone strenght, + mechanical destruction + desensitization --> failed attempts to heal --> deformity --> ulceration --> infection --> amputation, death
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Neuroptahty progression
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Automonic induced intraosseus hyperemia --> decrease mineral density --> decreased cortical strenght --> pathological fracture --> deformation --> ulceration
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Brodski
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pt 10min supine c leg elevated
gone - charcot |
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Freikberg
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1- forefoot
2- mid (lisfrank, intercun) 3- tarsal (choparts, N-C) 4- Ankle and subtalar 5- Calcaneus |
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OSTEOMYELITIS----------------------------
osteomyelitis |
ifnection progression to involve the medullary canal
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Osteitis
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infection of cortex of bone
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Brodis' abscess
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chronic abscess of bone surrounded by fibrous tissue and sclerotic bone
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Sequestration
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sequestration of dead bone from living bone (chronic osteo, ischemia, necrosis)
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Involucrum
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new bone formation around existing bone
periosteal reaction |
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cloaca
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opening formed at bone periosteum interface for extrusion of sequestrum
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OM classifications-----------------------
Waldvogel |
Pathogenesis
1.contiguous c vascular insufficiency (acute vs chronic in both) 2. contiguous s vascular insufficiency 3. Hematogenous |
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Cierny & mader
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Anatomy and physiology
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Anatomy
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1- medullary only (hematogenous
2- superficial, cortical 3- localized- part of a bone 4- diffuse- entire bone |
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Physiology
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A host- normal
B host (systemic vs local dz vs both) C host- treatment is worse than dz (sicko) |
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Burkholz
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Pathophysiology
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I
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wound induced
A- open fracture b- penetrating wound including uclers c post- surgery infection |
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II
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mechanogenic infection
A- implants B- unstable contact of bone |
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III
IV V VI VII |
iii- physical inocculation (?)
IV- ischemic limb dz V- any combo of above VI- osteo c septic arthritis VII- chronic osteitis/ myelitis |
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Causal organisms----------------------
Infant |
Staph
B strep Ecoli (involved in birthing process- Vag and Anus) |
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Child
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Staph
Strep H. Influenza |
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>16
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Staph Aureus + Epidermidis
G- Bacilli |
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Diabetic foot
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P-PASES
Proteus, Pseudomonas Anaerobes Staph Aureus Enterobactericiae Strep |
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Pathology of OM-------------------------
hematogenous infant |
metaphysis of long bone (recall process) --> can spread to epiphysis
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Hematogenous child
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metaphysis of long bone (can't spread anymore)
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Hematogenous adult
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starts at subchondral regions of long bones and vertebrae- advances to medulla --> joint
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Contiguous infection process
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Bacteria adhere to bone matrix --> response c acute inflammation rxn --> phagocyte toxins and radicals and proteolytic enzymes
increased intraosseus pressure sequestrum involucrum |
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Medical Mgmt of Osteo --------------------------
Infant clinical presentation |
lack of systemic and local findings
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Child classic
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abrupt fever, lethargy, irritable, inflammation
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Child actual
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vague complaints of pain ~3mo duration, minimal T change
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Adult hematogenous presentation
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same as child
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Adult contiguous presentation
local systemic |
Local- cellulits, wound, odor, exudates
Systemic- fever, malaise, fatique, chills |
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Early imaging Radiographic
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2 week lag
Perioseal thickening, elevation, focal osteopenia |
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Middle
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lucent area surrounded by sclerotic bone
lytic changes |
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Late
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Destruction of cortical bone, involucrim, sequestra, cloaca
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CT imaging OM
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pre surgery planning good for areas of necrotic bone
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MRI
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early change in marrow, soft tissue , tendon sheath, bursae
T1 positive- darker bone t2 postive- lighter bone |
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Tech 99
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non-specific
blood phase-inflammation delated- bony change |
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Indium iii
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specific to OM
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Antibiotic therapies---------------------------
vanco |
MRSA, Staph, Strep (G+ aerobes)
IV |
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Linezolid
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MRSA, VRE
ORAL |
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Zosyn
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Pseudomonal
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Unasyn
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Good G+
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nafcillin
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H. Influenzae, Ecoli
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Ciprofloxacin
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Penetrates bone
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Gentamycin
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Good G-
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Beads
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polymethymethacrylate
vanco/clinda/ genta |
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SEPTIC ARTHRITIS------------------------
risk factors |
systemic local and social
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Pathogenesis
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bacteria enters joint--> acute inflammation response --> cytokines, proteases -> cartilagge degreadation --> inhibition of cartilage synthesis --> irreversible bone loss
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G+ anaerobes
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staph + strep (vanco , chephazolin)
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G- bacilli
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Children <5, elderly, IVDU
H. Influenzae, EColi (3rd gen ceph + aminoglycoside) |
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N. Gonorrhea
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Chephtriaxone, quinalones
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Clinical presentation
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acute painful hot swollen joint
febrile bpt appears toxic |
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WBC count
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50-150
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DDX;
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gout, PA, Seroneg arthritis, Lyme dz
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Tx:
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ABx, I+D, Remove hardware
arthrodesis/amputation exfix |
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LIMB PRESERVATION----------------------------------
Amputation risk increases c |
increase wagner scale,
decreased ABI decreased albumin Decreased Hgb Increased WBC |
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Wegner ulcer scale
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1- superficial
2- deep s osteo 3- deep c osteo 4- forefoot necrosis 5- wholefoot necrosis |
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funcitonal considerations of amputation
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> E consumtpion c more proximal amp c significant decrease in mobility
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Factors for healing
1TcPO2 2Doppler skin perfusion test 3Pre-op toe pressure 4ABI 5Albumin 6 protein 7lymphocytes |
1>30mmhg
2>30 3> 40 4> .5 5>3.0 6>6.0 7>1500 |
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Amputation level final decision
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based on all research authors = Decision of when and where d/t clinical assesments
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Exostectomy
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subtotal calcanectomy (tibiocalc)
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Digital Amps
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Partial (terminal symes
Disarticulation |
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Partial Ray Amps
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Mid met shaft
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Complete ray amp
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met base
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1st ray amp
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medial drift of lesser toes c trasnfer ulcer
add reverse mortons and toe filler to increase propulsin |
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2-4 amputation
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functino well c acceptable cosmesis
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5th ray amp
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functions well
watch for lateral pressure |
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medial column amputation
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functions like hypermobile 1st= pronation c loss of function/propulsion
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>3 or 3 rays
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convert to TMA
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Transmet amp
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Bone cuts dorsal distal to plantar proximalk
1st and 5th beveled medially and laterally respectively maintain paraboly long plantar flap Rocker bottom shoe post-op |
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TMA equinovarus
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due to LOF of EHL and EDL leaving TA only antagnoist of Triceps S.
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Midfoot Amputation names
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chopart, lisfranc, boys, pirigroff
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Lisfranc amp
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maintain 5th and 2nd base,
TEV due to loss of peroneals and extensors breakdown under lateral cuboid STATT, TAL |
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Choparts
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midtarsal joint destruction, trasnfer TA to talar head,
Arch flap breakdown |
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Boyds
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retain calc for tibiocalc
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Pinograff or whatever
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maintain posterior calc for tibiocalc
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Symes
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preserves a longer stump for transfers,
difficult to fit prosthetic Must have intact heel pad Pts walk and live longer |
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Functional Ambulation scale 0-6
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0-bedridden
1- transfer 2- supervised mobility 3- limited household 4- unlimited household 5- limited community 6- errwhere errthang errday. |
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did you do the reading?
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then you can't get over an 80. Sorry.
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