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
LOW URINE OUTPUT
ORGAN DAMAGE
RENAL FAILURE
MODIFIERS
•
•
•
•
•
GENERAL HEALTH
MEDICATIONS
LOCATION OF SURGERY
MAGNITUDE OF DISSECTION
OUR INTERVENTIONS
RECOVERY
• AS PATIENTS RECOVER, THEY
MOBILIZE/REABSORB FLUIDS
• INCREASED URINE OUTPUT
• OCCASIONAL FLUID OVERLOAD
PRIMARY HIP REPLACEMENT
CMS CHECKS
BLOOD LOSS
URINE OUTPUT/RENAL FUNCTION
BLOOD PRESSURE (HTN MEDS!)
DISLOCATIONS
PRIMARY KNEE REPLACEMENT
•
•
•
•
•
PAIN MANAGEMENT!!!!!
BLOOD LOSS (250 TO 1250 ml)
URINE OUTPUT/RENAL FUNCTION
MOTION
VITAL SIGNS (HTN MEDS)
PATELLA FRACTURE
•
•
•
•
•
•
MINIMAL DISSECTION
MINIMAL BLOOD LOSS
STRAIGHTFORWARD PAIN MANAGEMENT
MINIMAL THIRD SPACING
NON-WEIGHT BEARING
PATIENT STRENGTH & MOBILITY FACTORS
TIB FIB FRACTURE
•
•
•
•
BLOOD LOSS IS USUALLY MILD
THIRD SPACING IS USUALLY MILD
PAIN MANAGEMENT
COMPARTMENT SYNDROME!!!!
COMPARTMENT SYNDROME
PRESSURE WITHIN THE FASCIAL COMPARTMENT
RISES ABOVE PRESSURE WITHIN THE SMALL
VESSELS
ISCHEMIA
RAPID ONSET OF PERMANENT DAMAGE TO
MUSCLE AND NERVES
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
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
PERIPROSTHETIC FRACTURE
•
•
•
•
•
MODERATE BLEEDING AND THIRD SPACING
LOW CMS RISK
NON WEIGHT BEARING
MOTION
MODERATE PAIN
PERIPROSTHETIC FRACTURE
•
•
•
•
•
EXTENSIVE DISSECTION
MAJOR BLOOD LOSS AND THIRD SPACING
GREAT DEAL OF DRAINAGE
WATCH URINE OUTPUT
THIRD SPACING
SEPTIC TOTAL KNEE
•
•
•
•
•
84 YO MALE
DIABETIC
HTN
VENOUS STASIS
SEVERAL WEEKS OF DENIAL
REIMPLANTATION
• QUADRICEPS TURNDOWN—RESTRICTED
MOTION AND WEIGHT BEARING
• THREE UNITS OF BLOOD
• MILD ACUTE RENAL FAILURE
• MILD CHF SEVERAL DAYS LATER
SEPTIC TOTAL HIP
•
•
•
•
•
•
60 YO MALE
PRIOR IM NAIL
300+ POUNDS
MRSA INFECTION
VANCOMYCIN ALLERGY
THREE DEBRIDEMENTS TO ERADICATE
INFECTION
HIP REIMPLANTATION
•
•
•
•
•
8 UNITS PRBC
10 LITERS OF FLUID
PRESSORS FOR 12 HOURS
MILD RISE IN Creatinine—resolved
FULL WEIGHT BEARING
SUMMARY
• IT’S NOT JUST THE BONES
• THINK ABOUT GENERAL PHYSIOLOGY OF
SURGERY
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.