RESOURCE PACK

This pack aims to give you an insight into the types of patients you will be caring for within ward 16. It has basic information on clinical observations, how and why we do them, types of common orthopaedic surgery and the anaesthetics used and some post op complications. We would strongly suggest after reading this pack you familiarise yourself in greater depth with common orthopaedic conditions.

This part of the induction pack should be retained for reference purposes.

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Author

CN Gillian Hirst

Contributors

CN Kate StephenSSN Anne BallieSN Nicci CrabbSN Susan LindsaySN Sharon McLellan

Critical Reviewers

SCN Marie Thomas

Review Date

November 2010

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List of Contents

Clinical Observations Resperations Page 4Pulse Page 5Blood Pressure Page 6Temperature Page 7

Oxygen Therapy Pages 8-12

Neurovascular Observations Pages 13-16

Immediate Post Operative Complications Pages 17-18

Hypotension Pages 19-20

Poor Urine Output Page 21

Hypovoleamia Pages 22-24

Types of Surgery Arthroscopy Pages 25-27Anterior Cruciate Ligament Repair Pages 28-30Hip Resurfacing Page 31Total Hip Replacement Pages 32-33Hip Revison Page 34Partial Knee Replacement Page 35Total Knee Replacement Page 36-37Knee Revison Page 38

Hip Precautions Page 39

Types of Anasethetic Spinal Anaesthetic Pages 40-41General Anaesthetic Pages 42-45Nerve Blocks Page 46

Wound Management Page 47

Pain Management Pages 48-52

Major Post Operative Complications DVT Page 54PE Page 55Compartment Syndrome Pages 56-57Fat Embolism Page 58Constipation Pages 59-60Spinal Headache Page 61

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Clinical Observations

.By following the SEWS chart, all clinical observations should be recorded. It is important to understand how to measure observations and what they tell you about what’s happening in the body. By recording observations regularly, they can show a pattern or trend of how well the body is functioning. These trends also allow you to see when the body is compensating or struggling to maintain its normal functionsRegular observations are carried out after patients have had major surgery and an anaesthetic. It is important for nursing staff to understand what they are looking for and not just carry out observations regularly because “that’s what we do”. This section aims to give you some insight into why we carry out regular observations on all patients and what significance it has and what care these patients may require.

Respirations

Respiration at rest should be effortless, regular and quiet. Respiration is the cycle of inspiration (breathing in) and expiration (breathing out). The main role of the respiratory system is gaseous exchange, which is getting oxygen into the body and excreting carbon dioxide. The anatomy used in this process consists of the upper respiratory tract (nose mouth, &throat) and lowers respiratory tract (lungs). The intercostal muscles (between ribs) and diaphragm (above abdominal cavity) are also used in respiration.

Respiration Patterns:The normal range of respirations is 14-20 per/min.

Bradypnoea – slow regular respirations less than 12 breathes/min, (alcohol consumption, metabolic and central nervous system disorders)Tachypnoea – rapid, regular respiration over 20 breathes/min (pneumonia, respiratory insufficiency, lesions in respiratory center in brain, fever).Apnea - cessation of breathing for more than 10 seconds. It may be intermittent, as in sleep apnea, or life threatening. Life threatening apnea requires immediate action.Prolonged expiration – expiration is longer than normal breathing (Chronic obstructive airways disease)Dyspnoea – difficult, labored and uncomfortable breathing (pleurisy, pulmonary embolism, pneumothorax, tumour, pericarditis and angina).Orthopnoea – dyspnoea is experienced in the recumbent position (lying down) (occurs in a number of cardiac and respiratory conditions).

Factors that can influence respiratory rate: Age Emotion Exercise Position Pain Disease O2 therapy Drugs – Timoptol eye drops can effect respiration.

Measurement:It is important to recognize that it is not just a simple matter of counting the number of breaths a patient takes but also the depth, pattern and sounds of respiration. It is good practice to also observe the patients colour whilst measuring respirations, are the lips, ears or tips of the patients nose blue or are they generally pale?

It is important that the patient is not aware that you are observing his breathing as the awareness of one’s own breathing can alter the rate, depth and regularity. Take the patient’s hand as if you were checking the radial pulse and observe the chest wall moving and count for 1 minute. Note depth of respirations. Note any irregular breathing patterns. Note any audible breathing sounds e.g. wheezing.

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Pulse

A pulse is the wave of expansion felt in artery walls every time blood is pumped out of the heart. The most common site used for measuring the pulse is the radial artery. The pulse rate of a healthy resting adult varies with age but as a guide the average rate for a healthy adult ranges between 50 and 90 beats per minute. It is not only the counting of the pulse rate that is important, the rhythm or regularity of the beats as well as their strength or volume should also be observed. A normal pulse should have a regular beat with the same time between each beat.

The strength of the beat should also be noted - a normal pulse should be strong and easily palpated. A range of disorders can cause an irregular beat or lowering / increase in the strength of the pulse for example: Hemorrhage Shock Heart conditions High blood pressure

A faster than normal pulse is referred to as a tachycardia and in adults this is considered to be above 100 beats per minute.

A tachycardia may be caused by a number of factors, however, it is important to appreciate that these factors are not necessarily associated with disease or disorders.For example; Emotion such as fear, anxiety, anger, exercise or activity

Tachycardia can be caused by a number of underlying disorders, disease, or conditions for example: Pain Shock Infection / pyrexia Heart problems Hemorrhage Anaemia Metabolic disorders - thyroid etc Drugs.

A slower than normal pulse is referred to as a bradycardia and in adults this is considered to be less than 60 beats per minute. Bradycardia can also be caused by factors other than disease such as relaxation or sleep.

Bradycardia can be caused by a number of disorders, disease, or conditions for example: Heart disease Drugs (such as beta blockers) Metabolic disorders Hypoxia (Lack of oxygen)

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Blood PressureBlood pressure is the pressure exerted by the blood (being pumped by the heart) upon the walls of blood vessels, it is measured in millimeters of mercury (mmHg) and is usually recorded in the arteries. The blood pressure measurement consists of two readings:

A higher reading called the Systolic Pressure – which measures the pressure within the arteries when the heart is contracting and pumping out blood.The second lower reading is called Diastolic Pressure – which measures the constant pressure within the arteries when the heart is relaxed.

Blood pressure can be affected by a number of factors, which can be generally grouped into two categories- Problems relating to cardiac output – (How efficiently the heart pumps out a

volume of blood during each beat) For example, the force of the contractions of the heart (this may be less if the heart is damaged by an MI), how fast the heart rate is, and the amount of blood circulating around the body.

The resistance - (exerted by the blood vessels – which expand and contract to control blood pressure) for example – the thickness or viscosity of the blood, the diameter of the blood vessels, the length of vessel the blood is traveling down.

High blood pressure or hypertension is defined as a Systolic pressure above 140mmHg and or a diastolic pressure above 90mmHg. Hypertension is often grouped according to severity into mild, borderline moderate or severe.

Common contributory factors in Hypertension Blood Vessel disease (hardening of the arteries) Obesity Renal problems Drugs

Low Blood pressure or hypotension is more difficult to define however as a guide a systolic pressure below 100 and diastolic below 60 may be considered as hypotensive.

Common contributory factors in Hypotension Shock Drug interaction (anti-hypertensive medications, anaesthetic drugs) Burns or dehydration Sudden failure of heart muscle

Other factors influencing Blood Pressure Emotion such as Fear Anxiety Anger Exercise or activity Relaxation Sleep

A patient is said to be normotensive if their blood pressure is within normal limits.

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TemperatureBody temperature is a useful indication of any change in body function. The normal range of body temperature is 35.8 – 37.2 centigrade and can vary slightly throughout the course of a day.

High temperature or pyrexia is considered to be a recorded body temperature above 37.2oc. Although, most thermometers now read “core” temperature, therefore a high reading would be above 37.5oc.

This may be caused by the following: Infection Neurological trauma Drug reaction Heat exhaustion.

Simply, a patient with a pyrexia will feel hot to touch other signs & symptoms which may also be observed include: Flushed /red appearance of skin Sweating Rigor (shivering).

Low temperature or hypothermia is considered to be a recorded body temperature below 35ocHypothermia can occur as a result of: Prolonged surgery Trauma Poor nutritional state Fall at home (elderly).

Simply a patient who is hypothermic will feel cold, other signs & symptoms whichmay also be observed include: Confusion Loss of consciousness.

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OXYGEN THERAPY

Oxygen is indicated in any acute condition causing inadequate tissue oxygenation; primarily within orthopaedics it will be used in the immediate post operative period as patients recover from their anaesthetic and blood loss.

When administering oxygen via a facemask you should ensure that it fits snugly around the nose, otherwise oxygen might blow into the patient’s eyes leading to discomfort and possible damage. Regular oral hygiene is essential and adequate hydration should be provided to minimize any discomfort or symptoms caused by oxygen therapy.

The oxygen transport pathway is a highly integrated series of steps designed to effect ventilatory -cardiovascular-metabolic coupling of external and internal respiratory processes. These steps include ventilation of the alveoli, diffusion across the alveolar capillary membrane, perfusion of the lung and extraction and utilisation of oxygen by the tissues. Oxygen delivery is defined as the total amount of oxygen delivered to the tissues. It is dependant on the volume of blood flowing through the veins and the amount of oxygen contained in the blood. The oxygen content of blood depends upon the amount of Haemoglobin (Hb) present in the blood. Maintenance of an adequate Hb concentration is therefore essential in critically ill patients. Tissue oxygenation is also dependant on blood flow. This in turn is determined not only by the cardiac output and its distribution but also by the viscosity of the blood, which depends largely on the packed cell volume ie if the patient is dehydrated then the blood will be more viscous, if the patient is overloaded with fluid then the blood will be more dilute.

Common clinical indications for using oxygen include;

• Acute/Chronic respiratory failure• Trauma• Acute myocardial infarction• Cardiac failure• Shock of any cause• Increased metabolic demands e.g. burns, multiple injuries and severe infections.• After surgery/anaesthetic• Carbon monoxide poisoning

Complications of Oxygen Therapy

C02 narcosis

A small percentage of patients with chronic obstructive pulmonary disease are at risk of ventilatory depression, if they are given uncontrolled (high concentration) oxygen. These patients have a high PaC02 (the amount of carbon dioxide being carried in the blood) even when well and may also be accustomed to lower than normal blood oxygen levels. These patients require careful monitoring when oxygen is used. The basis of therapy is to administer oxygen in sufficient concentration to normalise Pa02 (the amount of oxygen being carried in the blood) or at least to obtain a saturation of 90%. It is recommended that these patients are initially treated with 28% - 35% oxygen (using a venturi-type oxygen delivery system) and that the oxygen is increased incrementally whilst close monitoring occurs. The patient’s respiratory rate, depth and pattern, conscious level and Sa02 should be closely monitored.

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Oxygen Toxicity

Oxygen toxicity can occur when high concentrations of oxygen (>60%) are given for more than 48 hours continuously. Alveolar membrane damage can occur progressing to adult respiratory distress syndrome.If in doubt, it is better to administer a high concentration in the first instance and monitor the patient very closely. Conscious level, respiratory effort, heart rate, blood pressure and arterial blood gases should be frequently reviewed. Patients on high concentrations of oxygen for prolonged periods should be nursed in specialised areas ie High Dependency Units HDU where they can be closely monitored.

Oxygen Administration Methods

The goals of oxygen administration are to provide an inspired oxygen concentration sufficient to fully saturate available haemoglobin (Hb). This should decrease the work of breathing and the workload of the myocardium, as increases in ventilatory and myocardial activity are compensatory responses to hypoxaemia. Patients receiving supplementary oxygen may have specific needs relating to its delivery.The method of delivery will depend on certain factors, which are:• The expected duration of treatment.• The type of respiratory illness.• The pattern of breathing (high or low respiratory rate and drive)• The need for humidification.• The risk of carbon dioxide retention.

There is a wide range of oxygen delivery systems available, capable of delivering a range of oxygen concentrations from 24% to 100%. Oxygen delivery systems are classified into two main categories: variable systems, which deliver a proportion of the ventilatory requirements, and fixed performance systems that deliver the entire ventilatory requirements. The patient’s condition will dictate the oxygen device that is required.

Variable performance systems

These systems involve the entrainment of air by the patient. The oxygen concentration delivered to the patient’s lungs therefore depends upon the flow rate of oxygen delivered to the patient, his/her ventilatory pattern (e.g. inspiratory flow rate, respiratory rate) and the amount of air entrained. Variable performance devices include nasal cannula, simple facemasks (“hudson”) and non-rebreathing masks.

Nasal cannulaNasal cannulas come as single or twin. The single nasal cannula (nasal prong) consists of a length of tubing which has a small sponge attached to one end that sits in the patient’s nostril, through which oxygen is delivered. The twin nasal oxygen cannula consists of two separate prongs, one being inserted into each nostril, through which oxygen is delivered.

Indications• Used for low oxygen concentrations with a maximum flow rate of 6 litres per minute• Well tolerated by patients• Allows patients to eat, drink, and talk.• Less claustrophobic than conventional masks.• Unlikely to require humidification due to the efficiency of the nasopharynx

Possible complications• Local irritation and dermatitis may occur with higher flow rates.• Pressure sores on the top of the patient’s ears where the tubing of the twin nasal cannula lies.• Dry cracked mucous membranes in the nose.• Concentrations of oxygen administered to the patient are not precise especially if the patient mouth breathes.

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Simple face mask (Hudson mask)The prescribed percentage of oxygen is titrated according to litres/minute when using this mask. This allows one mask to be used at a number of different oxygen percentages (FiO2). Vents in the mask allow dilution of the oxygen, but if the flow rate is not sufficiently high, patients wearing these masks rebreathe exhaled carbon dioxide.

Indications• Short term oxygen therapy in the conscious patient.• 40% - 60% oxygen requirements. (5-6 litres per minute)• Typical use would be prophylactic O2 delivery e.g. postoperatively and angina therapy

Possible Complications• Has a drying factor, as oxygen flows straight into the facemask.• At low flow rates exhaled CO2 (carbon dioxide in exhaled air) is not adequately flushed from the facemask, thus significant re-breathing may occur potentially causing C02 retention. CO2 retention can lead to altered conscious level and possible death in extreme cases. A minimum of 5 litres per minute should be used to prevent this occurring.

Non-rebreathing mask

Non-rebreathing mask consists of a face mask and reservoir bag. The reservoir bag contains a one-way valve to prevent exhaled air entering the oxygen reservoir bag. On inhalation the one way valve opens which directs oxygen from a reservoir bag into the mask, thus the patient breathes air from the reservoir bag only. In addition, one-way valves are located in the side ports of the mask to prevent room air entering the mask. A tight seal is required, which can be difficult to maintain and uncomfortable for patients. The reservoir bag should be inflated before attaching the mask to the patient. It is important that the reservoir bag can expand freely and is not twisted or kinked. The oxygen flow rate should be sufficient to keep the bag inflated.

Indications• Used for higher oxygen concentrations Fi02 (concentration of oxygen) from 80% to 100% at 10–15 litres/minute.• Delivers oxygen and prevents re breathing of carbon dioxide.• As a safety mechanism a valve in the mask allows entrainment of room air if the patients tidal volume suddenly exceeds the oxygen flow.

Possible contraindications• A tight seal is required over the face although this may cause feelings of claustrophobia.

Fixed performance systems

These systems provide sufficient flow of gas to meet all of the patients minute ventilation requirements. The inspired oxygen concentration is determined by the oxygen flow rate and not the patients rate and depth of breathing. The type of fixed performance mask most used in hospital wards is the venturi mask.

Venturi mask system

This mask is connected to a venturi device, which mixes a fixed volume of air at a given oxygen flow. The venturi valves are colour coded and the flow rate of oxygen required to deliver a fixed concentration of oxygen

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is shown on each valve. The main advantage of these devices is that they can deliver accurate concentrations of oxygen despite the patient’s respiratory pattern. Oxygen passes through the narrow hole producing a high velocity stream that draws a constant proportion of room air through the valve, giving a precise delivery of oxygen percentage. Masks may be provided which deliver a single known concentration of oxygen (e.g.24%, 35%) or have interchangeable, often colour-coded, venturi heads with different entrainment apertures for different oxygen concentrations. Oxygen concentrations of between 24% and 60% can be delivered with this system.

Indications• Any patient requiring accurate delivery of a percentage of oxygen.

Possible Complications• Oxygen concentration can be altered if the mask is too loose or not correctly fitted.• Facemasks are more likely to be dislodged at night making compliance limited.• Use of humidification with venturi mask may alter the amount of oxygen the patient receives. If the water vapour becomes condensed at the jet hole it may delay oxygen reaching the patient at the correct level.

Management of a Patient Receiving Oxygen Therapy

All nurses have responsibilities in caring for patients receiving oxygen therapy.These include:• Understanding the purpose and reason for administration of the oxygen.• Selecting the appropriate oxygen mask/cannula e.g. nasal cannula or mask.• Monitoring the patient receiving oxygen therapy.• Addressing the discomfort that can be associated with the mask/cannula e.g. oral hygiene and skin care.• Providing appropriate and adequate humidification.• Encouraging compliance• Ensuring good communication: masks can make the patients voice muffled and oxygen flow is often loud.• Consider how the patient is going to eat and drink: changing to nasal cannula may be appropriate.• Awareness of infection control issues when the patient is receiving oxygen.

Monitoring the patient receiving oxygen therapy

Each patient should be individually assessed to determine how often his or her observations should be recorded. In addition to basic observations the following vital signs should be observed and documented according to the patient’s clinical condition.

Vital signs• Respiratory rate and depth• Patients colour• Level of Consciousness• Oxygen saturation• Sputum assessment• Arterial blood gases if clinically indicated

Oxygen related observations• Method of oxygen delivery• Oxygen flow rate/concentration review• Assessment for humidification• Patient compliance• Potential complications associated with oxygen therapy.• Ensure the holes on the mask are not blocked, as this will change the concentration of oxygen the patient receives.

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General ObservationsThe general signs of increasing hypoxaemia such as peripheral cyanosis especially of the lips, ears and nail beds, loss of concentration, mental confusion and drowsiness may occur over a relatively long period. They are therefore poor early indicators of developing problems and represent late manifestations that should have been treated much earlier.

Pulse Oximetry

Pulse oximetry is a simple non-invasive method of continuous monitoring of oxygenation.

Normal values for oxygen saturationThe normal range for oxygen saturation measurements is 95 – 100%, though lower measurements may be normal in selected patients. In the ward environment, pulse oximetry should be used to monitor the effects of changes in oxygen therapy. It can be used either intermittently or continuously. The aim is to identify hypoxaemia before it is detected by sight (i.e. cyanosis). But as with any aspect of technology, it is merely an aid to observation and should be used in conjunction with a through clinical assessment of the patient.

To ensure accurate monitoring of pulse oximetry, there has to be sufficient perfusion to the finger/toe or ear where the oxygen saturation probe would be placed. If the patient’s pulse is weak or absent then readings will be inaccurate. Nail polish may also cause inaccurate readings, so it is worth removing prior to monitoring. Aninflating blood pressure cuff proximal to the limb of the oxygen saturation probe will cause venous pulsation giving a false low reading.

When documenting a patient’s oxygen saturation it is important to also document the inspired oxygen concentration at the time of the recording. This allows the multidisciplinary team to assess/adjust the oxygen therapy according to patient need. Regular assessment of the patient receiving oxygen therapy is required. This includes monitoring of respiratory rate, oxygen saturation, oxygen requirements, appropriate device used and assessment for humidification.

For further information please read the Good Study Guide for Oxygen Therapy and Humidification which can be found on the intranet.

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NEUROVASCULAR OBSERVATIONS

Neurovascular assessment involves the evaluation of the neurological and vascular integrity of a limb. By using a systematic assessment, the recognition of any neurovascular deficit can lead to appropriate treatment and minimize the risk of complications which could lead to amputation of a limb, or even death of the patient. To identify patterns or changes in condition, it is important that neurovascular observations are documented in the Integrated Care Pathway (ICP). Within the orthopaedic setting, we use a CSM (Colour, Sensation and Movement) Chart. Limb temperature and wound assessments are also documented here.

Monitoring and recording of neurovascular observations is essential in all of the following;

Pre and post orthopaedic / plastic surgery

Bony or muscular trauma

Post spinal anaesthetic/local nerve blocks

Traction / plaster

Burns

Nerves are not renowned for their healing abilities and therefore any damage needs to be diagnosed and assessed promptly in order to reduce the risk of further damage.  Compartment Syndrome occurs from 2 hours to 6 days post injury/surgery but normally within 72 hours. With a compromised blood supply creating ischemia, irreversible muscle damage occurs within 4-6 hours and functional nerve damage within 12-24 hours, limb contractures can develop as early as 12 hours post insult.

Neurovascular observations must be analysed in conjunction with knowledge of the injury and other observations as documented complications may include

Loss of limb

Rhabdomyolsis (rapid breakdown of skeletal muscle due to injury to muscle tissue.)

Cardiac arrhythmias (as potassium may be released from damaged muscle)

Hypercalcaemia

The observations should be used in reference to each other and not as individual points of concern. Both limbs should be assessed simultaneously.

How to Perform Neurovascular Observations

It is important to remember that the majority of patients within the ward have had a planned spinal anaesthetic and may have nerve blocks as infusions, therefore we would expect altered sensation to be present in one or both limbs for several hours after surgery. CSM should be assessed and documented hourly initially along with the patients other routine observations. Both limbs should be assessed until the anaesthetic wears off, and CSM checked and documented daily throughout the patients stay in the ward.

All observations should be dated and timed when recorded. It is important to note any pre existing numbness, restricted movement or unusual colouring to the limbs to establish a baseline for all observations.

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Colour, Warmth, Swelling and Wound

Visually assess the naked foot/hand checking for colour, swelling and wound ooze. Check for warmth with superficial touch. Limbs should be pink and warm indicating a good blood supply. There may be some post operative swelling, but it should not be excessive and the limb should not be shiny, tense or painful to light touch. If the patients limb is cool to touch, pale, cyanotic (bluish discolouration of the skin) or mottled it may indicate there is a problem with the blood supply to the limb, especially if the unoperated side is unaffected. In these circumstances, it is important to get medical attention quickly. Both limbs should be fully exposed and assessed together so they can be visually inspected simultaneously for swelling and colour and temperature.

When assessing colour, sensation and movement of the limb, we also check the wound dressing. This will be discussed in more detail further on in the pack.

Pulse and Capillary Refill

Check foot/hand for presence and magnitude of pulses distal from the injury/affected area and venous return (capillary refill).

Capillary refill should be measured by pressing on the digit for 5 seconds then counting the seconds until the digit returns to its usual colour, normally taking less than two seconds.

Pain Score/Sensation

Sensation can be assessed by asking the patient if they are experiencing any altered sensation in the affected limb or if they feel sensation returning after the anaesthetic. By touching the limb, the patient can report to nursing staff how it feels and if it has changed since the last assessment. Again, both limbs should be assessed for comparison. A spinal anaesthetic will take about 6 hours to wear off, and nerve blocks longer, especially if used with a local infusion. Any new changes that result in decreased sensation, tingling, pins and needles, numbness or complete loss of sensation should be reported immediately to medical staff.

Pain Score should be done in conjunction with movement.

Patients positioning should also be documented on a turning chart. Patients who require neurovascular observations often have reduced mobility, and any altered sensation, especially in the lower limbs can put them at a higher risk of developing pressure sores as they are unable to move or feel the limb if it becomes uncomfortable.

Movement when limb is restricted:

Where movement is restricted by a cast or orthotics device the digits should still be flexed and extended, and the type of cast documented in the comments section.

Foot Movement

The foot should be actively dorsiflexed as far as mechanically possible. If active movement is not possible due to language or developmental barriers then full dorsiflexion should be carried out passively.

The patient should then actively plantarflex the foot as far as mechanically possible. Where this is not possible due to language or developmental barriers this movement should be carried out passively.

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Dorsiflexion                              Plantarflexion

             

It is imperative that the limb is fully flexed and extended in order to assess for compartment syndrome.

Hand Movement

The thumb and first digit should be made into an L shape and then extended upwards and backwards as far as mechanically possible. Active movement demonstrates nerve function. The L shape tests the Radial Nerve function.

The thumb brought to meet the index finger in an OK sign. The OK sign tests the Median Nerve function.

The fingers splayed and mild pressure applied to the external digits to ensure the position can be maintained. The splayed fingers tests the Ulnar Nerve function.

These should all be done actively, but where this is not possible due to language or developmental barriers this movement should be carried out passively.

It is imperative that the limb is fully flexed and extended in order to assess for compartment syndrome.

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Sensation

All touchable/visible surfaces (including in-between digits) should be checked for presence and type of sensation, and this should preferably be done with the patient’s eyes closed/not watching, as this leads to more accurate reporting of sensation. Absence of sensation or complaints of pins and needles/tingling can be indicative of nerve compromise and medical staff should be informed.

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Immediate Post Operative Complication

Postoperative complications may either be general or specific to the type of surgery undertaken, and should be managed with the patient's history in mind. Common general post-operative complications include post-operative fever, atelectasis, wound infection, embolism and deep vein thrombosis. The highest incidence is between 1 and 3 days after the operation. However, specific complications occur in the following distinct patterns: early postoperative, several days after the operation, throughout the postoperative period, and in the late postoperative period.

General Postoperative Complications

Immediate Signs Primary haemorrhage: either starting during surgery or following postoperative increase in blood pressure:

replace blood loss and may require return to theatre to re-explore wound. Basal Atelectasis: minor lung collapse more common after a general anaesthetic. Shock: blood loss, acute myocardial infarction, pulmonary embolism or septicaemia. Low urine output: inadequate fluid replacement intra and postoperatively

Early Signs Acute confusion: exclude dehydration and sepsis Nausea and vomiting: analgesia or anaesthetic related; paralytic ileus Fever (see below) Secondary haemorrhage: often as a result of infection Wound dehiscence DVT Urinary Tract Infection Postoperative wound infection

Postoperative fever

Days 0 to 2

Mild fever (T<38 C) (Common) Tissue damage and necrosis at operation site Haematoma Persistent fever (T> 38 C) Atelectasis: the collapsed lung may become secondarily infected. Specific infections related to the surgery: e.g. biliary infection post biliary surgery, UTI post urological

surgery

Days 3-5 Bronchopneumonia Sepsis Wound infection Drip site infection/ phlebitis

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After 5 days

DVT Specific complications related to surgery,

After the first week

Wound infection Distant sites of infection, e.g. UTI DVT, pulmonary embolus

Some of the most common post op problems are detailed below.

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HYPOTENSION

Blood pressure is a variable with a continuous variation. One can only consider normal and abnormal against the circumstances of the individual in question, with regard to age/sex, conditions in which it was measured, and other relevant factors. Hypotension is therefore a blood pressure that is much lower than usual, and which may be causing symptoms such as dizziness or lightheadedness. It is often defined as systolic 90/60 mmHg, but 100 mmHg may be more appropriate if the patient normally has hypertension.

It is important to remember when checking blood pressures using an automated measurement device (eg dynamap) that the condition of the machine, cuff size used, tubing and connections should be checked regularly. If during use a machine fails to detect BP, depending on the responsiveness of the patient in the bed, it may be a reflection on the patient’s condition, rather than a machine malfunction. If in doubt, check a blood pressure manually for a more accurate reading

Acute hypotension

In the acute form it can be a serious clinical feature that may cause renal, cerebral and myocardial hypoxic damage. It is often associated with the different forms of shock including:

Hypovolaemia - blood loss (haemorrhage), plasma loss (burns), dehydration (diarrhoea and/or vomiting), pooling of unavailable fluids (e.g. pancreatitis)

Cardiogenic - following MI Septic Anaphylactic Neurogenic - caused by trauma to spine or as an adverse effect of an epidural anaesthetic. Also, can

result from pain or fear via reflex vagal stimulation. Other causes include:

Vasodilatation - from antihypertensive drugs, heat exposure. Drugs such as: narcotic analgesics, alcohol, some antidepressants Cardiac dysfunction e.g. arrhythmia, MI, aortic regurgitation, tamponade. Pulmonary embolism. Micturition Syncope

Why is Hypotension Dangerous?

Organ perfusion depends upon blood flow, which relies on an adequate blood pressure. Most organs require mean blood pressure values above 70mmHg for normal perfusion and function. (the mean blood pressure is the number often in brackets at the side of the blood pressure on the monitor eg 122/82 (72)

For example; normal renal blood flow and glomerular filtration rates work at mean BP values for that patient. If a patient is normally hypertensive, they will filter waste products through the kidneys at a higher pressure than someone who has a normal BP. If blood flow to the kidneys is reduced due to a low BP, the filtration rate is decreased and urine output fails. Urine output is an easily measured marker in the post op patient of adequate renal perfusion and BP. If urine output falls below 0.5mls per kg per hour, you should be aware that blood pressure and renal perfusion may be inadequate.

The adverse effects of hypotension include

Decreased conscious level, leading to severe cerebral ischaemia Oliguria (no urine output) leading to renal failure Reduced gut perfusion leading to bowel ischaemia Reduced coronary blood flow leading to myocardial infarction and Decreased skin perfusion, leading to a reduced capillary refill time and ultimately possible digital

ischaemia.

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Management

Give O2 by mask Place patient head down if able (never tilt a patient with a running epidural) Administer IV fluids (0.9% saline) having excluded pulmonary oedema Treat underlying cause

This will depend upon the cause of the hypotension. For the majority of our patients early post operative hypotension is usually due to theatre loss and bleeding into drains or the joint, although, it may be simply due to insufficient IV fluid replacement. Patients who are fasted for long periods may be dehydrated before they go to theatre and require additional fluids.

A few days after surgery, hypotension, pyrexia and warm peripheries should raise the possibility of sepsis. The likely causes would include simple infections such as a chest or urine infection, but infection of the joint replacement should not be dismissed.

As hypovolaemia is the commonest cause of hypotension and shock you should give fluids. Medical staff will advise you how much you should give, but a bolus of 500 mls given quickly is an appropriate initial step. A good response to fluids will include a reduction in the patients heart rate, reduced capillary refill time (should be less than 2 seconds), improvement in conscious level and increased urine output.

Vasovagal Feint

Vasovagal faints are often associated with prolonged standing with resultant pooling of venous blood with reduced venous return to the heart. This can be common in orthopaedic patients who are up and out of bed for the first time since surgery as major surgery to the lower limbs will cause swelling in the legs and can impede venous return.Reduced cerebral perfusion causes loss of consciousness. Consciousness returns relatively quickly. May be brief period of sweating and pre-syncope symptoms before collapse.

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POOR URINE OUTPUT

In normal circumstances urine output ranges from 1.5 - 2 litres per day. As a minimum we generally look for a patient to produce 0.5-1ml of urine per kg of body weight per hour ie a patient weighing 50kg should produce 25mls/hr as a minimum and a patient of 90kg should produce 45mls/hr.

Normal urine production will only occur if the kidneys receive an adequate blood supply, the kidney function is normal and there is free flow of urine ie no obstruction between the kidneys and the urethra or catheter. It is important to check if a patient has normal blood pressure but decreased or no urine output that the problem is not with a blockage in the urinary catheter. A bladder scan or flushing the catheter may resolve this issue.

Urine output is influenced by multiple factors, many of which are not relevant in orthopaedics, but you may wish to study this topic further.

Common causes of decreased urine output include

Hypovolaemia Haemorrhage Severe or prolonged vomiting and or diarrhoea High output from stoma or NG tube Diuretic therapy Pulmonary oedema

Decreased Systemic Vascular Resistance Sepsis Antihypertensive medications Drug overdoses Some drug use e.g. gentamicin, non-steroidal anti-inflammatory Side effects of anaesthetic and sedative drugs

Cardiac Pump Failure Acute myocardial infarction Arrhythmias with poor cardiac output ie fast AF resulting in hypotension Cardiomyopathy Cardiac tamponade

When decreased urine output is due to a fall in blood pressure, renal blood flow or cardiac output it is potentially reversible provided the correct treatment is initiated urgently.

The initial treatment involves the administration of an IV fluid bolus with reassessment of blood pressure and urine output. Even patients with carcinogenic shock should receive a fluid challenge although in smaller volumes. The aim of fluid therapy is to increase circulating volume and renal perfusion. You should not permit a low hourly urine volume ie less than 0.5mls/hr to go untreated for more than 3 hours.

It is also essential that the renal team is informed if a patient has low urine output for a prolonged period of time. Hopefully this will prevent the patient developing Acute Renal Failure.

Management Treatment of any reversible causes. (as above) Restoration of intravascular volume. Strict fluid balance and correction of electrolyte abnormality. Input and output records, daily weights, physical examination, and serum sodium are used to determine

ongoing therapy.

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HYPOVOLEMIA

Hypovolaemia is a state of decreased circulating blood volume. The average adult has a blood volume of roughly 5 litres, composed of plasma and several kinds of cells. Red blood cells, white blood cells and platelets. Plasma comprises about 55% of blood fluid and is mostly water and nutrients. The most abundant cells in blood are the red blood cells which contain haemoglobin and transport oxygen around the body. White blood cells help to resist infections. Platelets are important in the clotting of blood.Blood is circulated around the body through blood vessels by the pumping action of the heart. Blood and fluid loss makes it difficult for the heart to pump enough blood around the body to maintain adequate blood pressure. Patients will develop hypovolaemic shock very quickly because of the inability to provide oxygen and nutrients to the tissues.

About 56% of the adult human body is fluid with two – thirds of the fluid contained in the cells. This is called intracellular fluid. The remaining third of the body fluid is in the spaces outside the cells and is called the extracellular fluid.

Loss of whole blood is the most common cause of circulation loss. A fracture to the femur will bleed 0.5 – 1Litre of blood. Bleeding will vary during hip replacement up to 1.5litres of blood Bleeding will normally be < 200mls during knee replacement as there is a tourniquet insitu above the knee Bleeding from wounds and in drains will vary with each patient. Drains can be used for both hip and knee

joint replacement but this is at the choice of the individual surgeon.

STAGES OF HYPOVOLAEMIC SHOCK

Stage 1 Up to 15% of blood volume loss (750mls) There is often no clinical changes Blood pressure will be normal Respiratory rate will be normal (14-20 per/min) Vasoconstriction will occur Circulation will be maintained but only for a short period Must be addressed now or will move onto next stage

Stage 2 15 – 30% blood volume loss (750-1500mls) Low blood pressure ( systolic <100, diastolic < 60) Increased respiratory rate ( >20per/min) Increased pulse ( > 100per/min ) Low urine output ( < 25ml/hr) There will be a lack of oxygen to the organs and tissues Patient may be mildly anxious/restless Needs rapid attention

Stage 3 30 – 40% blood volume loss (1500-2000mls) Low blood pressure ( systolic <100) Increased pulse ( >120per/min) Decreased pulse ( < 30per/min) Low urine output Patient will be anxious or agitated Skin sweaty, cool and extremely pale Needs rapid attention

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Stage four 40% blood volume loss (> than 2000mls) Very low blood pressure ( systolic < 70) Extreme Tachycardia No urine output Patient comatose Skin sweaty, cool and extremely pale By this stage there is too much damage. Cellular death occurs, vital organs fail and death occurs.Patients can progress through these stages very quickly so it is vital that hypovolaemia is treated in the early stages.

TREATMENT

Treatment of shock deals with the underlying cause.

Oxygen therapy to increase the efficiency of the patients remaining blood supply. Venous access (venflon) must be secured early. It is more difficult to obtain once circulatory collapse has

occurred. Preferably patients should have more than one cannula. IV fluids are a MUST to replace circulation volume. Fluid resuscitation will improve tissue perfusion and

meet cellular demands. In hypovolaemic states it is sometimes necessary to administer a combination of colloids and crystalloids.

CRYSTALLOIDS

0.9% NaCL (normal saline). When giving saline it must be 3 times the blood volume lost. Hartmans solution contains water and electrolytes 5% dextrose ( if risk of low blood sugar or > sodium)

Crystalloids are given to maintain fluid and electrolyte balance. They are mainly water with small molecules and provide hydration in the cells. They are unsuitable for persistent hypovolaemia and other forms of replacement should be considered.

Care must be taken as rapid infusion of large volumes of crystalloid can cause pulmonary oedema. Close monitoring is required and the use of an infusion pump.

COLLOIDS

Gelofusine is a gelatin Blood ( packed red cells) Blood products are used if patient requires clotting factors. Blood products will include Platelets, Fresh

Frozen Plasma (FFP) and Cryoprecipitate.

Colloids are plasma expanders and increase intravascular volume. They contain large molecules which remain in the blood vessels for longer. Patients will normally receive blood transfusion if haemoglobin < 9.

Administration of IV fluids is not just a mechanical task. It requires thought and professional judgement (NMC).

Complications of infusing large volumes of fluids are

Hypothermia - low body temperature which affects metabolism and body function Hyperkalaemia – high potassium levels in the blood which affects the heart

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Hypercalcaemia – high calcium level in the blood Clotting problems – coagulation is where blood forms a clot, problems with bleeding can occur if blood

fails to clot. Allergic reactions – the body’s response to a foreign substance, the immune system will try to protect the

body.

NURSING OBSERVATIONS

Know what surgery has been performed and any complications, blood loss should be recorded on the back of the anaesthetic chart.

Know type of anaestheticDrugs and analgesia should be recorded inside the anaesthetic chartFluids given in theatre should be recorded inside the anaesthetic chartDrainage and wound seepage should be recorded on fluid chartPeri operative vital signs should be recorded inside the anaesthetic chart

Surgeon’s post operative instructions should be recorded. Familiarise yourself with these – mobility status, x-rays, drain care, antibiotics, follow up.

Anaesthetist’s instructions should be recorded on the back of the anaesthetic chart. Familiarise yourself with these – monitoring of vital signs, wound checks, haemoglobin checks, other blood tests – U & Es, Anti coagulation therapy.

Monitor blood pressure, temperature, pulse, respirations, oxygen saturation levels on a SEWS chart.

Monitor input (oral and IV) and output (urine, vomit, blood loss, drainage, wound ooze) on a fluid balance chart.

Drains and wound sites should be checked regularly. Always inform the nurse in charge if the drain is filling up quickly or the wound is bleeding.

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TYPES OF ORTHOPAEDIC SURGERY

ARTHROSCOPY

Arthroscopy is a surgical procedure used to inspect and treat problems inside a joint. It allows a surgeon to look inside a joint and examine it closely so that they can determine what is wrong.

An arthroscope is a narrow tube with a light source attached to a tiny video camera, which transmits pictures back to a TV monitor. The arthroscope is passed through a small incision in the skin (arthroscopy is known as a keyhole procedure) and then used to light up and magnify the joint, so the surgeon can see any damage.

Arthroscopy can be used to investigate conditions such as arthritis; symptoms such as pain or joint weakness, and damage to cartilage or ligaments. Small instruments can be attached to the arthroscope to take a biopsy sample or to cut, trim or remove any loose fragments of tissue, bone or cartilage.

Arthroscopy is most often used to examine the knee joint, but techniques have been developed for using the procedure to examine other joints, including the shoulder, hip, ankle and wrist.

What is it used for? 

Arthroscopy is used when it is necessary to know exactly what is happening within a joint and what can be done to put it right.

In many cases, joint problems can be diagnosed using non-surgical methods such as MRI (magnetic resonance imaging), or treated with physiotherapy. However, X-ray and MRI are not always clear enough to make a proper diagnosis, particularly when the problem involves the soft tissues around a bone.

An arthroscopy may be done if:

there is a need to look inside a joint to find out exactly what is causing a problem such as pain, swelling or inflammation.

there is a tear in the cartilage of a joint (cartilage is the smooth, connecting tissue that covers the ends of the bones in a joint),

there is a tear in one of the ligaments in a joint (a ligament is a band of fibrous tissue that connects bones or cartilage together),

there is a loose piece of bone in a joint, the joint has become unsteady, or the joint has been affected by arthritis.

Arthritis can cause a thickening of a membrane within the joints called the synovium. This membrane can be easily removed with an arthroscopy.

Advantages of having an arthroscopy 

Arthroscopy allows a surgeon to look inside a joint, a place that would otherwise only be reachable by opening up the joint using traditional surgery. Surgeons don't like opening joints wide because they are particularly sensitive to the slightest infection. Joints can be seriously damaged by infection, so anything that reduces this risk is an advantage.

The keyhole technique of arthroscopy has a lower risk of complications than traditional surgery and usually results in less pain after the procedure, a shorter hospital stay and a quicker recovery.

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How is arthroscopy performed 

Arthroscopy can be performed using spinal or general anaesthetic and may last from 30 minutes to over an hour, depending on the amount of work to be done.

The skin over the affected joint will be cleaned with an anti-bacterial fluid and then two small incisions made - one for the arthroscope and the other for an examining probe or any attachment that is needed to assist with the procedure. The joint may be filled with a sterile fluid to make viewing the inside easier.

The surgeon will be able to see inside the joint using an eyepiece or a TV monitor and, if possible, will repair any damaged areas or remove any unwanted tissue during the procedure. Fluid is sometimes used to wash out a joint, particularly in joints affected by arthritis, as this can relieve symptoms for a few months.

At the end of the procedure the arthroscope and attachments are removed, any fluid is drained from the joint, and the incisions can closed with stitches, or some surgeons prefer just to leave them open as they heal within a few days. A sterile dressing is used to cover the incisions and the joint is often bandaged. Patients whose knees are bandaged are usually given small dressings away home with them and asked to reduce (remove) the dressing in 48 hours.

Recovery from the procedure 

The scars from an arthroscopy are usually tiny (around 5mm) and patients should hardly be able to notice them. Recovery after arthroscopic surgery is normally much quicker than after traditional surgery and patients will usually be able to go home the same day.

The incisions are normally pain-free but for a couple of weeks after surgery patients may experience some swelling and discomfort in the joint. This can sometimes last longer if the treatment has been for arthritis. Patients are usually given painkillers to take home to ease any discomfort.

Most people are able to return to work fairly soon after an arthroscopy, usually within a week, but it does depend on the job they do. For example, the time will be longer if their job involves bending, lifting or carrying, or if it will put increased pressure on the joint that has been examined.

The surgeon will advise whether the joint needs to rested or exercise it after the arthroscopy.

Complications of arthroscopy 

Arthroscopy is generally a safe procedure and the risks are lower than for traditional surgery. Some pain and stiffness around the joint are common after surgery, but complications are rare.

Complications from arthroscopy can include:

accidental damage to the joint, damage to the structures inside or near to the joint, infection of the joint, bleeding into the joint, unexpected reaction to anaesthetic, and loss of feeling in the skin around the joint.

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You should advise patients to see a doctor urgently if they:

have pain, swelling or tenderness in the joint which is getting worse, develop a high temperature, see fluid, pus or blood coming from the incisions, or develop numbness or tingling near to the joint.

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Anterior Cruciate Ligament Reconstruction (ACL)

Anatomy of the knee

The knee joint joins the thigh with the lower leg and consists of two articulations: one between the femur and tibia, and one between the femur and patella. It is the largest and most complicated joint in the human body. The knee is a mobile pivotal hinge joint which permits flexion and extension as well as a slight medial and lateral rotation. Since in humans the knee supports nearly the entire weight of the body, it is the joint most vulnerable both to acute injury and the development of osteoarthritis.

Ligaments

The ligaments surrounding the knee joint offer stability by limiting movements and, together with several menisci and bursae, protects the articular capsule. There are 4 ligaments within the knee;

Anterior cruciate ligament (ACL ) - controls rotational movement and prevents forward movement of the tibia in relation to the femur. Runs between attachments on the front (hence anterior cruciate) of the tibial plateau and the posterolateral aspect of the intercondylar notch of the femur.

Posterior cruciate ligament (PCL) - prevents forward sliding of the femur in relation to the tibial plateau. Runs between attachments on the posterior part (hence posterior cruciate) of the tibial plateau and the medial aspect of the intercondylar notch of the femur.

Medial collateral ligament - prevents lateral movement of the tibia on the femur when valgus (away from the midline) stress is placed on the knee. Runs between medial epicondyle of the femur and the anteromedial aspect of the tibia. Also has a deep attachment to the medial meniscus.

Lateral collateral ligament - prevents medial movement of the tibia on the femur when varus (towards the midline) stress is placed on the knee. Runs between lateral epicondyle of the femur and head of the fibula.

Menisci: the medial and lateral menisci are located within the knee joint, attached to the tibial plateau. They help to protect the articular surfaces by absorbing some of the forces transmitted through the knee. They also help to stabilise and lubricate the knee.

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The ACL is the most commonly injured knee ligament and is commonly damaged by athletes. The ACL attaches to the knee end of the Femur, at the back of the joint and passes down through the knee joint to the front of the flat upper surface of the Tibia. It passes across the knee joint in a diagonal direction and with the PCL passing in the opposite direction, forms a cross shape, hence the name cruciate ligaments. The role of the Anterior Cruciate Ligament is to prevent forward movement of the Tibia from underneath the femur. The Posterior Cruciate Ligament prevents movement of the Tibia in a backwards direction. Together these two ligaments are vitally important to the stability of the knee joint, especially in contact sports and those that involve fast changes in direction and twisting and pivoting movements. Therefore a torn ACL has serious implications for the stability and function of the knee joint.

A torn ACL or ACL injury is a relatively common knee injury amongst sports people. A torn ACL usually occurs through a twisting force being applied to the knee whilst the foot is firmly planted on the ground or upon landing. A torn ACL can also result from a direct blow to the knee, usually the outside, as may occur during a football or rugby tackle. This injury is sometimes seen in combination with a medial meniscus tear and MCL injury.

Anterior cruciate ligament injuries are more frequent in females with between 2 and 8 times more females suffering a rupture than males, depending on the sport involved and the literature reviewed. The reason for this is as yet unknown, however areas of current research include anatomical differences; the effect of oestrogen on the ACL and differences in muscle balance in males and females.

Symptoms of a torn ACL

There may be an audible pop or crack at the time of injury A feeling of initial instability, may be masked later by extensive swelling. A torn ACL is extremely painful, in particular immediately after sustaining the injury. Swelling of the knee, usually immediate and extensive, but can be minimal or delayed. Restricted movement, especially an inability to fully straighten the leg Possible widespread mild tenderness Tenderness at the medial side of the joint that may indicate cartilage injury.

Treatment options

Treatment for an ACL injury can either be nonsurgical or surgical depending on the extent of the injury.

Surgical options may be used if the knee gives way during typical daily activities, showing functional instability, or if the patient is unable to refrain from participating in high-risk activities ever again. Reconstructive surgery may also be recommended if there is damage to the meniscus (cartilage). This surgery is completed using arthroscopic techniques. Surgery involves either repairing or reconstructing the torn ACL. With a repair, the existing damaged ligament is sutured (stitched) if the tear is in the middle. If the ligament has detached from the bone (avulsed) then the bony fragment is reattached.

Surgical reconstruction of the torn ACL is performed using either an extraarticular technique (taking a structure that lies outside the joint capsule such as a portion of the hamstring tendon) or an intraarticular technique (using a structure from within the knee such as part of the patellar tendon) which will replace the anterior cruciate ligament.

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Surgery is performed more often than not following Anterior Cruciate ligament tears. The decision on whether to operate is based on a number of factors, including the athletes age; lifestyle; sporting involvement; occupation; degree of knee instability and any other associated injuries. Older people who are less active and perhaps injured their ACL following a fall as opposed to during sport would be unlikely to undergo surgery. A younger, fit person who regularly plays sport and would be more likely to adhere to a complex rehabilitation program is very likely to be offered surgery

If the surgical treatment is chosen there are also rehabilitation requirements. Physical therapy must be completed in three phases after the surgery is completed. With the use of the surgical treatment option, rehabilitation included, a patient can expect to be returning to previous and desired levels of activity in six to nine months

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TOTAL JOINT REPLACEMENTS

Ward 16 deals mostly with hip and knee replacements although ankle and shoulder replacements have occasionally been performed. Joint replacement consists of replacing the existing joint with an artificial joint. There are many reasons why a joint replacement is necessary, such as pain, osteo or rheumatoid arthritis or wear and tear of cartilage, there are many different ways in which surgery can be performed. A patients condition, age, lifestyle and how active they are can determine which type of surgery is better for them.

HIP RESURFACING

Hip resurfacing is an alternative method to the total hip replacement. It involves the diseased or damaged surfaces in the hip joint being replaced with metal plating. Only a small amount of bone has to be removed to accomplish this, then the new surface is re-shaped around the joint. Hip resurfacing can be considered for young patients with advanced hip disease. It offers less invasive treatment and less recovery time than a total hip replacement. It is unknown how long a resurfacing can last for, as it is a relatively new procedure, but will depend on the age and health of the patient, along with how much wear is placed on the hip. Resurfacings are becoming a popular choice for younger patients as they can be revised to a total hip replacement in later years. Therefore the patients can remain active for a longer period of time. The terms we use for this type of hip surgery is a ‘metal on metal hip resurfacing’ or a ‘Birmingham hip resurfacing’. The latter due to the fact it was 2 orthopaedic surgeons from Birmingham who have carried out the most modern research relating to this type of surgery. The expected length of stay in hospital is 5-7 days.

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TOTAL HIP REPLACEMENT

A total hip replacement consists of the hip joint, the socket and the ball; being replaced with artificial parts made of metal and a durable plastic material. The socket is used to replace the natural cup of the hip joint (acetabulum) and to house the ball portion of the joint (femoral head). The femoral component of the artificial hip consists of a metal rod or stem of which a metal ball is attached at an angle to mimic the shape of the top end of the thigh bone.

This type of replacement can be done in three different ways – cemented, un-cemented or a hybrid replacement.

CEMENTED

The cemented hip replacement implant is designed to be implanted using bone cement. The socket for this type of surgery is made of a special type of polyethylene which is tough and slippery, especially when wet. It has ridges on the outside that are designed to improve the fixation of the cup by the cement and also a wire marker that can be easily seen on x-ray. The implant is then inserted by first filling the cavity with the cement and then pushing in the artificial cup which is held still while the cement sets.

UN-CEMENTED

The un-cemented hip replacement is designed to be inserted into the prepared femoral canal without the use of bone cement. The socket for use without cement is made of metal and has a specially designed surface on its outer side that feels and looks like sandpaper. This is designed to fool the body into mistaking it for bone, therefore causing it to join up with the socket, similar to the way broken bones heal. The initial fit is achieved by machining the natural socket accurately and using an artificial socket that is slightly bigger. The metal socket is then forced into place and if needed, further fixation can be obtained by using additional screws. Lastly, a plastic insert is placed within the metal shell against which the artificial ball will form the joint. The ball and stem implant for use without cement also has a specially fabricated outer surface. This surface is spongier and encourages bone to grow into it. This is inserted by first machining the marrow cavity of the thigh bone with special drills and then jamming the component in, which is slightly larger, ensuring a secure fit.

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The surgeon will weigh up the advantages and disadvantages to both kinds of replacements by taking into account that each patient’s condition is unique.

HYBRID REPLACEMENT

A hybrid replacement is a combination of both a cemented and un-cemented fixation. The socket component is inserted without cement and is secured with screws and the ball and stem component is fixed with cement. This type of replacement is considered to be appropriate for younger patients as there is some evidence that an un-cemented socket may function longer than a cemented socket.

A total hip replacement, on average can last from 10 – 15 years. This again depends on contributing factors of the individual patient. The expected length of stay in hospital is 6 days.

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HIP REVISION SURGERY

Revision of a hip replacement is becoming more common due to a combination of younger people are having hip replacements, and older patients living longer. Revision surgery is more difficult than first time surgery so this will only go ahead if all other options have been explored. The difficultly can be due to which type of first replacement the patient had, such as a cemented is more difficult to remove as the cement must be removed before the new joint can be inserted, to get the cement out, often the length of the femur has to be split and opened up to allow the surgeon access. As the surgery is usually carried out through the previous incision line, this can weaken the muscles further, increasing the risk of dislocation after surgery.

The revision entails the original artificial joint being replaced with a new one. The decision can be based on medication or lifestyle changes that do not relieve pain or disability or if x-rays of the hip show that damage has occurred to the artificial hip. Other possible reasons can include fracture, dislocation or infection. Patients are expected to remain in hospital for 10 days following revision surgery.

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Knee replacement surgery is similar to hip replacement surgery in the reasons for it and also the different types that can be done.

PARTIAL KNEE REPLACEMENT

The knee is divided into three components which are – Medial – which is the inside of the knee

Lateral – which is the outside part

Patello-femoral – which is the joint between the kneecap and the thighbone

Partial knee replacement is required when the medial or lateral component has degenerated, which means there is no space between the femur (thigh bone) and the tibia (shin bone), therefore causing pain and restricted movement. It is more common to have the medial component replaced. This is done by the surgeon shaping the ends of the femur and tibia and then inserting a metal and plastic implant to act as a cushion to where the bone on bone contact occurred. Partial knee replacement is also known as a ‘unicompartment knee replacement’ or a ‘hemi knee replacement’. It has been reported that a partial knee replacement can last on average for 10 years. The expected length of stay is 5 days for this kind of procedure.

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TOTAL KNEE REPLACEMENT

The knee joint has three parts – The thigh bone – femur

The shin bone – tibia

The kneecap – patella

This type of joint is known as a hinge joint. Cartilage covers the surface where the bones meet allowing them to slide easily over each other. The whole joint is held together with tissue called ligaments and lubricated with natural fluid. When these surfaces get damaged, usually due to arthritis amongst other things, they need to be replaced with new parts. Two or three of the surfaces can be replaced as necessary. The knee replacement can be performed the same way as the hip – cemented, un-cemented and by hybrid procedure. The obvious difference being that the knee components are used.

CEMENTED

Knee replacement surgery initially involves the front of the knee being exposed and part of the quadriceps muscle being detached from the patella. The patella is then displaced to one side to allow exposure of the distal end of the femur and the proximal end of the tibia. This is so the ends of these bones can be accurately cut to shape and orientated to the axis of the bones. The cartilages and the anterior cruciate ligament are removed, and the posterior cruciate ligament may be removed but the tibial and fibular collater ligaments are preserved. Metal components are then impacted onto the bone or fixed using bone cement. A round ended implant is used for the femur, mimicking the natural shape of the bone and a flattened high density polyethylene surface is then inserted onto the tibial component so that the weight is transferred metal to plastic and not metal to metal.

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UN-CEMENTED

In an un-cemented procedure, the components of the implant are fixed to have a roughened surface designed to allow bone to grow into it, eliminating the need for cement. The implants are ‘press fit’ against the bony surfaces that are accurately cut to shape. Precise positioning is essential for bony attachment to occur with initial fixation by metal pegs and screws of the implant to bone. This implant relies on the bone to hold it in place, so this procedure requires good bone to be successful.

Cemented Un-cemented

As with the hip replacement, the surgeon will weigh up the advantages and disadvantages of each procedure before deciding which is more suitable.

HYBRID REPLACEMENT

The hybrid technique in a knee replacement consists of the femoral component being implanted without cement and the tibial and patellar component is cemented. This technique was introduced in the early 80’s and the long term results are just now being measured.

A total knee replacement can last, on average 10 – 15 years and the expected length of stay in hospital is 7 days.

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KNEE REVISION SURGERY

Knee revision surgery is a procedure in which a previously implanted artificial knee joint is replaced with a new one. The three major purposes for this surgery are to relieve pain, restore mobility and to remove a loose or damaged implant. Knee implants can become loose for two reasons. The first reason is mechanical and can be related to the fact that the knee joint bears a great deal of weight due to walking and running. It is unusual for the metal part to simply break but it can become loose. This can be due to the fact that the surgeon has removed the upper surface of the tibia to allow for the insertion of the implant and the bone tissue there is softer than the original bone. This can allow the metal implant to sink into the soft bone and gradually loosen. The second reason for loosening can be inflammation of the knee joint. The plastic part of the knee joint can form small particles of debris as a result of wear and tear over time. The amount of time can depend on if the patient has an uneven gait or pattern of walking. These tiny fragments of debris are absorbed by tissue cells around the knee joint and can become inflamed. This inflammatory response can dissolve the bone around the implant in a process called osteolysis. If this process continues, bone loss can accelerate and the implant eventually comes loose. Other reasons for knee revision surgery include infection and dislocation. The expected length of stay in hospital for this procedure is 10 days.

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Hip Precautions

Following hip replacement surgery, there is a high risk of disolocation. This is because the muscles and soft tissues surrounding the hip are less supportive as they have been cut through and the head of the femur dislocated to allow the surgeons access to the joint. To minimize the risk of dislocation, certain precautions must be followed.

The limb must be kept in abduction, ie away from the centre of the body rather than crossing over the middle.

When turning the patient in bed, three nurses must be available. Place a pillow or wedge between the patients legs and two nurses to turn the patient supporting the torso and legs whilst the third nurse carries out the care required.

No bending at the hip beyond 90 degrees.

No lifting the knees above the hips.

Patients chair and bed should be adjusted to the correct height for the individual patient.

Raised toilet seat should be available in all bathrooms.

No twisting.

Patients must not cross legs at knees or ankles.

Patients should be encouraged not to lie on their side for 6 weeks following surgery.

If possible, patients should favour the unaffected side to provide stability.

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TYPES OF ANAESTHETIC

Spinal Anaesthesia

Spinal anaesthesia is injecting small amounts of local anaesthetic into the cerebro-spinal fluid (CSF). The injection is usually made in the lumbar spine below the level at which the spinal cord ends (L2). Spinal anaesthesia has the potential to provide excellent operating conditions for surgery below the umbilicus.

AdvantagesSpinal anaesthetic patients can benefit from rapid recovery and absence of side effects.

Respiratory. Spinal anaesthesia produces few adverse effects on the respiratory system as long as unduly high blocks are avoided. The spinal anesthetic allows the patient to remain breathing independently throughout the surgery reducing the risk of chest infections post op. A high block can inhibit deep breathing in the patient.

Patent airway. As control of the airway is not compromised, there is a reduced risk of airway obstruction or the aspiration of gastric content as long as the patient is not over sedated. Diabetic patients. As the patient is awake there is a lesser risk of unrecognised hypoglycaemia. Diabetic patients can usually return to their normal food and diabetic medication regime soon after surgery as there is less sedation, nausea and vomiting.

Muscles. Spinal anaesthesia provides excellent muscle relaxation for lower abdominal and lower limb surgery.

Blood Loss. There is less bleeding than when surgery is performed under a General Anaesthetic due to the decreased blood pressure and heart rate, with improved venous drainage this has the effect of lessening blood loss.

Bowel. Spinal anaesthesia contracts the bowel and sphincters are relaxed however peristalsis continues. Normal gut function quickly returns.

Coagulation. DVT and PE less common following spinal anaesthesia.

Disadvantages of Spinal Anaesthesia

Spinal anaesthetics are not suitable for surgery lasting longer than approximately 2 hours. If an operation unexpectedly lasts longer than this, it may be necessary to convert to a general anaesthetic as the effects of the spinal anaesthetic will begin to wear off if not topped up.

There is a possible risk of introducing infection into the subarachnoid space and causing meningitis. This should not happen if equipment is sterilised properly and an aseptic technique is used.

A postural headache may occur postoperatively. This should be rare and will be discussed in more depth later in the pack.

Indications for Spinal Anaesthesia

Spinal anaesthesia is usually indicated for older patients and those with chronic respiratory disease, hepatic, renal and endocrine disorders such as diabetes. Almost all patients with mild cardiac disease benefit from the vasodilation that accompanies spinal anaesthesia except those with stenotic valvular disease or uncontrolled hypertension.

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It is suitable for managing patients with trauma if they have been adequately resuscitated and are not hypovolaemic.

ContraindicationsNon-availability of patient's consent, local infection or sepsis at the site of lumbar puncture, bleeding disorders, space occupying lesions of the brain, disorders of the spine and maternal hypotension. If the patient is on blood thinning medication, this is usually stopped a week before elective surgery, but if admitted as a trauma patient, and depending on the severity of the injuries, it may not be possible to reverse these agents prior to anaesthetic.

Complications

Can be broadly classified as immediate (on the operating table) or late (in the ward):

Spinal shock. Cauda equina injury. (The cauda equina is a structure within the lower end of the spinal column of most

vertebrates, that consists of nerve roots and rootlets from above. The space in which the cerebrospinal fluid is present is actually an extension of the subarachnoid space.

Cardiac arrest. Hypothermia. Broken needle. Bleeding resulting in hematoma, with or without subsequent neurological damage due to compression of

the spinal nerves Infection: immediate within six hours of the spinal anaesthetic manifesting as meningism or meningitis

or late, at the site of injection, in the form of pus discharge, due to improper sterilization of the LP set. Post dural puncture head ache or post spinal head ache

Local Anaesthetics used for spinal anaesthesia

Bupivacaine (Marcaine). 0.5% hyperbaric (heavy) bupivacaine is the best agent to use if it is available. 0.5% plain bupivacaine is also popular. Bupivacaine lasts longer than most other spinal anaesthetics: usually 2-3 hours.

Lignocaine (Lidocaine/Xylocaine). Best results are obtained with 5% hyperbaric (heavy) lignocaine which lasts 45-90 minutes. 2% lignocaine can also be used but it has a much shorter duration of action. If 0.2ml of adrenaline 1:1000 is added to the lignocaine, it will usefully prolong its duration of action. Lignocaine from multi-dose vials should not be used for intrathecal injection as it contains potentially harmful preservatives.

Cinchocaine (Nupercaine, Dibucaine, Percaine, Sovcaine). 0.5% hyperbaric (heavy) solution is similar to bupivacaine.

Amethocaine (Tetracaine, Pantocaine, Pontocaine, Decicain, Butethanol, Anethaine, Dikain). A 1% solution can be prepared with dextrose, saline or water for injection.

Mepivacaine (Scandicaine, Carbocaine, Meaverin). A 4% hyperbaric (heavy) solution is similar to lignocaine.

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General Anaesthetic

Definition

General anaesthesia is a state of total unconsciousness resulting from general anaesthetic drugs. A variety of drugs are given to the patient that have different effects with the overall aim of ensuring unconsciousness, amnesia and analgesia. The anaesthetist selects the optimal technique for any given patient and procedure. General anaesthesia is a complex procedure involving:

Pre-anaesthetic assessment Administration of general anaesthetic drugs Cardiorespiratory monitoring Analgesia Airway management Fluid management Postoperative pain relief

Pre-anaesthetic evaluation

Prior to surgery, the anaesthetist interviews the patient to determine the best combination of drugs and dosages and the degree to which monitoring is required to ensure a safe and effective procedure. Key factors of this determination are the patient's age, weight, medical history, current medications, previous anaesthetics, and fasting time.

Truthful and accurate answering of the questions is important so that the anaesthetist can select the proper anaesthetic drugs and procedures. For example, a heavy drinker or drug user who does not disclose their chemical uses could be undermedicated, which could then lead to anaesthesia awareness or dangerously high blood pressure. Commonly used medications such as Viagra can interact with anaesthesia drugs; failure to disclose such usage can endanger the patient.

An important aspect of this assessment is that of the patient's airway, involving inspection of the mouth opening and visualisation of the soft tissues of the pharynx. The condition of teeth and location of dental crowns and caps are checked, neck flexibility and head extension observed. If an endotracheal tube is indicated and airway management is deemed difficult, then alternative placement methods such as fiberoptic intubation may be required, after induction of anaesthesia.

General anaesthesia

General Anaesthesia implies loss of consciousness and of protective reflexes. General Anaesthesia is traditionally described as comprising of 3 components; Hypnosis, Relaxation and Analgesia

1 Hypnosis or sleep refers to being deeply asleep, unconscious, and totally unaware of events.

2 Relaxation implies abolition of reflex muscle tone, or specific block of nerve/muscle function, causing immobility and allowing easy surgical access.

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3 Analgesia refers to use of one or more of a wide range of pain reducing drugs from paracetamol to morphine, and perhaps local anaesthetics to block pain impulse transmission along nerves, in the hope of reducing heart rate and blood pressure responses to surgery.

Induction of anaesthesia

The general anaesthetic is administered in either the operating theatre itself or a special ante-room.

General anesthesia can be induced by intravenous (IV) injection, or breathing a gaseous anaesthetic through a facemask (inhalational induction).

Commonly used IV induction agents include propofol, etomidate, and ketamine. The most commonly-used agent for inhalational induction is sevoflurane because it causes less irritation than other inhaled gases.

The duration of action of IV induction agents is generally 5 to 10 minutes, after which time spontaneous recovery of consciousness will occur. In order to prolong anaesthesia for the required duration (usually the duration of surgery), anaesthesia must be maintained. Usually this is achieved by allowing the patient to breathe a carefully controlled mixture of oxygen, nitrous oxide, and a gaseous anaesthetic agent or by having a carefully controlled infusion of medication, usually propofol, through an IV. The inhalation agents are transferred to the patient's brain via the lungs and the bloodstream, and the patient remains unconscious. Inhaled agents are frequently supplemented by intravenous anaesthetics, such as opioids (usually fentanyl or a fentanyl derivative) and sedative-hypnotics (usually propofol or midazolam). Though for a propofol-based anaesthetic, supplementation by inhalation agents is not required. At the end of surgery the gaseous or intravenous anaesthetic is discontinued. Recovery of consciousness occurs when the concentration of anaesthetic in the brain drops below a certain level (usually within 1 to 30 minutes depending upon the duration of surgery).

Muscle relaxation / Neuromuscular blockade

"Paralysis" or temporary muscle relaxation with a neuromuscular blocker is an integral part of modern anaesthesia. Muscle relaxation allows surgery within major body cavities, eg. abdomen and thorax without the need for very deep anaesthesia, and is also used to facilitate endotracheal intubation.

Acetylcholine, the natural neurotransmitter substance at the neuromuscular junction, causes muscles to contract when it is released from nerve endings. Muscle relaxants work by preventing acetylcholine from attaching to its receptor.

Paralysis of the muscles of respiration, ie. the diaphragm and intercostal muscles of the chest requires that some form of artificial respiration be implemented. As the muscles of the larynx are also paralysed, the airway usually needs to be protected by means of an endotracheal tube. The effects of muscle relaxants are commonly reversed at the termination of surgery by anticholinesterase drugs.

Airway management

With the loss of consciousness caused by general anaesthesia, there is loss of protective airway reflexes (such as coughing), loss of airway patency and sometimes loss of a regular breathing pattern due to the effect of anaesthetics, opioids, or muscle relaxants. To maintain an open airway and regulate breathing within acceptable parameters, some form of "breathing tube" is inserted in the airway after the patient is unconscious. To enable mechanical ventilation, an endotracheal tube is often used (intubation), although there are alternative devices such as face masks or laryngeal mask airways.

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Monitoring intra operatively

Monitoring involves the use of several technologies to allow for a controlled induction of, maintenance of and emergence from general anaesthesia.

1. Continuous Electrocardiography (ECG): The placement of electrodes which monitor heart rate and rhythm. This may also help the anaesthetist to identify early signs of heart ischemia.

2. Continuous pulse oximetry (SpO2): The placement of this device (usually on one of the fingers) allows for early detection of a fall in a patient's hemoglobin saturation with oxygen (hypoxemia).

3. Blood Pressure Monitoring (NIBP or IBP): There are two methods of measuring the patient's blood pressure. The first, and most common, is called non-invasive blood pressure (NIBP) monitoring. This involves placing a blood pressure cuff around the patient's arm, forearm or leg. A blood pressure machine takes blood pressure readings at regular, preset intervals throughout the surgery. The second method is called invasive blood pressure (IBP) monitoring. This method is reserved for patients with significant heart or lung disease, the critically ill, major surgery such as cardiac or transplant surgery, or when large blood losses are expected. The invasive blood pressure monitoring technique involves placing a special type of plastic cannula in the patient's artery - usually at the wrist or in the groin.

4. Agent concentration measurement - Common anaesthetic machines have meters to measure the percent of inhalational anaesthetic agent used (e.g. sevoflurane, isoflurane, desflurane, halothane etc).

5. Low oxygen alarm - Almost all circuits have a backup alarm in case the oxygen delivery to the patient becomes compromised. This warns if the fraction of inspired oxygen drops lower than room air (21%) and allows the anaesthetist to take immediate remedial action.

6. Circuit disconnect alarm - indicates failure of circuit to achieve a given pressure during mechanical ventilation.

7. Carbon dioxide measurement (capnography)- measures the amount of carbon dioxide expired by the patient's lungs. It allows the anaesthetist to assess the adequacy of ventilation

8. Temperature measurement to discern hypothermia or fever, and to aid early detection of malignant hyperthermia.

9. EEG or other system to verify depth of anaesthesia may also be used. This reduces the likelihood that a patient will be mentally awake, although unable to move because of the paralytic agents. It also reduces the likelihood of a patient receiving significantly more amnesic drugs than actually necessary to do the job.

Postoperative care

Post-operative Analgesia

The anaesthesia should conclude with a pain-free awakening and a management plan for postoperative pain relief. This may be in the form of regional analgesia, oral, transdermal or parenteral medication. Minor surgical procedures are amenable to oral pain relief medications such as paracetamol and NSAIDs such as ibuprofen. Moderate levels of pain require the addition of mild opiates such as tramadol.

Major surgical procedures may require a combination of modalities to confer adequate pain relief. Parenteral methods include Patient Controlled Analgesia involving a strong opiate such as morphine. Here, to activate a

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syringe device, the patient presses a button and receives a preset dose or "bolus" of the drug e.g. one milligram of morphine. The PCA device then "locks out" for e.g.5 minutes, to allow the drug to take effect. If the patient becomes too sleepy or sedated, they make no more morphine requests. This ensures a fail safe aspect which is lacking in continuous opiate infusion techniques. It is important nursing staff check the PCA hourly to ensure the correct dose has been given.

Shivering

Shivering is a frequent occurrence in the post-operative period. Apart from causing discomfort and exacerbating post-operative pain, shivering has been shown to increase oxygen consumption, catecholamine release, cardiac output, heart rate, blood pressure and intra-ocular pressure. There are a number of techniques used to reduce this occurrence, such as increasing the ambient temperature in theatre, using conventional or forced warm air blankets eg bair paws and using warmed intravenous fluids.

Mortality rates

Overall, the mortality rate for general anaesthesia is about three to five deaths per million anaesthetic administrations. Death during anaesthesia is most commonly related to surgical factors or pre-existing medical conditions. These include major haemorrhage, sepsis, and organ failure (eg. heart, lungs, kidneys, liver). Common causes of death directly related to anaesthesia include:

aspiration of stomach contents suffocation (due to inadequate airway management) allergic reactions to anaesthesia (specifically and not limited to anti-nausea agents) and other deadly

genetic predispositions human error equipment failure

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Nerve Blocks

Lower Limb Block

Indications for specific nerve blocks The knee joint has significant contributions from femoral, obturator and sciatic nerves and significant injury or surgery to this joint will require that all these be blocked. (For the hip, it is nearly always sufficient to perform a 3-in-1 lumbar plexus block even though there is a small contribution from the sciatic nerve.) The following are some examples of the possible uses.

Femoral nerve blocks Pain relief for fractures of the shaft of the femur, particularly more proximal fractures. Following a total knee replacement.

Lumbar plexus (3-in-1) block:The lumbar plexus is formed from the L1-4 nerve roots. It can also be used as in all the uses of a femoral nerve block, plus the following:

Pain relief and anaesthesia for hip injuries such as dislocations and fractures of the neck of the femur. Anaesthesia for operations on the lateral thigh such as harvesting of skin grafts, or muscle biopsies. Pain relief for injuries and operations on the knee; extensive injuries and full knee anaesthesia require a

sciatic nerve block also .

Sciatic nerve block:The sciatic nerve is formed from the L-4, L-5 and S1, 2, 3 ventral rami pain relief or anaesthesia for injuries or operations on the sole of the foot or any of the toes, such as toe amputation

Combined sciatic and femoral or 3-in-1 block: With this combination pain relief and anaesthesia can be provided for almost any injury or operation

from the upper thigh downwards The blocks described will provide good postoperative analgesia for hip surgery

Upper limb Blocks

Supraclavicular Brachial Plexus Block

The supraclavicular block can be used for use for elbow, forearm, wrist, and hand procedures. One of the possible complications of this block is a pneumothorax. (a punctured lung)

Nerve blocks can be individual blocks given in the anaesthetic room as part of surgery, or can be given as an infusion for 48 hours post op via an infusion device.

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WOUND MANAGEMENT

Wound care is important as it prevents infection and promotes healing of the wound. Knee replacements usually come back from theatre with gauze, tegaderm/opsite dressings, velband and crep bandages. This makes a bulky, padded dressing which prevents the knee from bending immediately post op. This dressing should be reduced 24hrs post op and any drains present should be removed unless instructed not to by the surgeon.

Patients who have had knee replacements who have heavy blood staining on their dressing so that it is wet on the surface of the dressing should have their dressings changed. The wet dressing is compromised and a potential source of infection and therefore should be changed immediately. Patients within the first 24 hours post op should have the whole dressing reduced and redressed in the same way with padding and bandages. If we do not change the dressing, the blood will harden and stiffen within the dressing, causing discomfort to the patient and if the blood has run to the back of the dressing, it can cause a tourniquet effect as it hardens, potentially compromising the patients blood flow to the leg.

Patients with hip replacements have just gauze and tegaderm/opsite dressings in situ.

If the dressing is intact, ie not leaking or wet to touch, it should be left undisturbed, even if it is heavily blood stained. If the dressing is leaking, uncomfortable or blisters are forming underneath, it should be removed and redressed. Dressings can be left undisturbed for 4 or 5 days if they are not leaking, but should be removed prior to discharge.

Patient’s wounds should be dry before they are discharged home. If wounds are not dry, it must be a consultant or registrar who decides if the patient can go home or not.

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PAIN MANAGEMENT

Pain management is a big part of post op recovery. If patients are in pain, they are reluctant to mobalise. Each patient is prescribed paracetamol regularly along with Oxycontin.

For many years it has been recognised that the most important step in the management of pain is its formal assessment. There is a plethora of pain assessment tools available and the most commonly used in Tayside is the verbal rating scale using a 0-3 score. It has been shown to be valid and reliable in the assessmentof acute pain, with its main advantage being its ease of use by both staff and patients. The choice of pain tool used, however, is less important than the consistent and routine use by all the health professionals within a particular unit.

All patients who receive analgesia during their stay in Tayside hospitals will have their pain routinely assessed by staff. The frequency of assessment depends on many factors and it is the responsibility of ward staff to decide. However, it is strongly recommended that pain should be assessed whenever routine observations of pulse and blood pressure are carried out. If a patient needs rescue/ additional analgesia then it is important to ensure that their pain is reassessed within 60 minutes of administration, the effectiveness of the analgesia documented and further intervention taken if necessary.

The pain tool on the reverse of the SEWS chart should be used in the first instance to assess pain. The use of a pain tool avoids judgemental bias and provides consistency in pain assessment scoring throughout the team. The pain score is recorded on the bottom of the SEWS chart. Although a sedation and nausea score is also included on the SEWS chart, the recorded scores do not always reflect problems with pain or side effects. Hence, a separate pain assessment chart should be used for a minimum of 48hours following onset of problematic pain, initiation of analgesia or a change of analgesic plan for example stepping down from epidural analgesia or PCA. This will aid communication between healthcare providers and the patient and facilitate changes to treatment to meet individual patient’s needs.

Verbal Rating ScaleThe most commonly used pain assessment tool in NHS Tayside is the verbal rating scale. By having astandardised pain assessment tool printed on documentation it is hoped that staff become familiar with itand proficient with it’s use. This tool has been shown to be valid and reliable in the assessment of acutepain. The advantages are, that it can be verbally administered and is easy for both patients and staff to use. It allows patients to describe their pain in words rather than numbers. This tool has been recommended for use with older people and may be used with some success in patients with mild to moderate cognitive impairment.

Verbal rating scale.0 = No pain at rest, none on movement1 = No pain at rest, slight on movement.2 = Intermittent at rest, moderate on movement.3 = continuous at rest, severe on movement.

Ask the patient:- Do you have pain at rest? Ask the patient to make an appropriate movement. Do you have pain on movement? Is the pain constant or intermittent? Is the pain mild, moderate or severe?The response to these questions will provide the score to be recorded.

Pain score of 2 or 3 indicates inadequate analgesia and treatment should be offered.

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Nausea

Nausea and vomiting is a common post-operative problem and is also a common side-effect of opioid analgesia. Patients often quietly tolerate nausea, unaware, that treatment exists.

Formal assessment of nausea and vomiting, involving the patient, should be carried out and documented along with routine observations of pain assessment.

Nausea Score0 = No nausea or vomiting1 = Nausea only2 = Vomiting once3 = Vomiting more than once

For nausea score of 1 or more, see PONV treatment guideline.

SedationThe most feared side-effect of opioids is respiratory depression, however, over-sedation precedes this.

Sedation score is a more reliable indicator in detecting early opioid induced respiratory depression.

Sedation Score0 = None (patient alert)1 = Mild (occasionally drowsy, easy to arouse)2 = Moderate (frequently drowsy, easy to arouse)3 = Severe (somnolent, difficult to arouse)S = Sleep (normal sleep, easy to arouse)

Sedation score = 3 Shout for help.Check AirwayBreathingCirculationAdminister 10 litres oxygen therapy via non-rebreathing mask. Inform resident doctor. Discontinue opioid analgesia. Prepare Naloxone. (see guidelines for administration of Naloxone). Contact the Pain Team foradvice re- alternative analgesia prescription.

A SUGGESTED PAIN RELIEF POLICY

There are four important principles to remember. Analgesia should be:

Continuous - Prevent ‘breakthrough pain’ by continuous infusions of drug or regular administration of drug at pre-determined times. Do not wait for pain to occur before analgesia is given. ie Oxycontin at 06.00 & 18.00

Pre-Emptive - Try to anticipate pain whenever possible. Give analgesia before painful procedures begin. ie before physio.

Balanced - A combination of a) paracetamol, b) opioid, and c) local anaesthetic drug should be considered. The different drugs will act at three different parts of the acute pain pathway. This will help to prevent the side-effects that are associated with large doses of a single drug. ie paracetamol, Oxycontin and a local infusion device.

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Sequential - Pain after major surgery will still be present on the second or third day after the operation. Thepatient may not require an epidural or a patient-controlled analgesia device at this stage. It is important to step down to a less potent but effective method of analgesia.

To determine the effectiveness, pain assessment needs to be carried out at regular intervals.

Oxycontin Protocol

Side-effects of Oxycontin include- over-sedation- confusion/disorientation- RR <8CALL DOCTOR for further advice and inform acute pain team.

Guidance notes1. Step-down from epidural:- Stop epidural infusion 30 minutes after administration of Oxycontin.2. Discharge advice: - Reduce doses gradually - Ideally, Oxycontin should be stopped for full 24 hours priorto discharge.

If discharging a patient with Oxycontin, instruct the patient to make an appointment with GP as soon as possible. Give the patient the top copy of the discharge script to hand to the GP. Also, give the patient the Acute Pain Team discharge letter for the practice pharmacist. This is kept on the ward and basically asks the GP to review the patients pain and reduce or stop Oxycontin and replace with a weaker analgesic ie Tramadol or Codine.

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Breakthrough analgesia

Oramorph 10mg/5mls is the drug of choice within orthopaedics. If patients feel Oramorph is not effective this can be changed to Oxynorn 5mgs. Breakthrough analgesia should be 1/6th of the total daily dose. Eg Oxycontin 30mgs BD = 60mgs in 24hrs therefore you would give Oramorph 20mgs or 10mgs Oxynorm.

Oramorph Titration

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The full guidelines and further details about management of PCA’s and other methods of analgesia can be found on the intranet in the Pain Management Guidelines Book.

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MAJOR POST OPERATIVE COMPLICATIONS

No surgery is without risk. Patients should give “informed consent” for their surgery, ie the surgeon should discuss the surgery the benefits it will give the patient and the possible complications that could occur.

Below is some of the common and less common (but orthopaedic specific) postoperative complications that may affect our patients. It is important for nursing staff to recognise these problems and to act quickly in response to them.

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DVT and PE

All patients admitted to hospital with major trauma, for major surgery (ie surgery of 30 mins or more) or patients admitted with medical illness requiring 3 or more days of bed rest are at risk of developing a Deep Venous Thrombosis (DVT). Orthopaedic patients often fall into several of the risk categories for developing DVT ie Major lower limb surgery, aged 70 or over, having a BMI over 30 and reduced mobility for 3 days or being in a plaster cast. If a DVT is undiagnosed or untreated it can lead to a thrombus (or clot) becoming dislodged and travelling to the lungs causing a Pulmonary Embolism (PE)

DVT is the formation of a blood clot (thrombus) in a deep vein. It is a form of thrombophlebitis (inflammation of a vein with a clot formation)

DVT commonly affects the leg veins such as the femoral, popliteal veins or the deep veins of the pelvis.

DVT and PE’s are the most common cause of morbidity in orthopaedic patients.

According to Vichow’s Triad, venous thrombosis occurs via 3 mechanisms; decreased flow rate of the blood, damage to the blood vessel wall and an increased tendency of the blood to clot (hypercoagulability).

There are several factors which can increase a person’s risk of developing a DVT, including major surgery, immobilization for 3 days or more, having a lower limb in a plaster cast, smoking, obesity, age, certain drugs and pre-existing tendencies for clot formation.

Signs and Symptoms

DVT usually occurs in the legs but there may be no symptoms to the location of the DVT. Classic symptoms include pain, swelling, heat and redness of the leg, including dilation of the surface veins. Other clinical signs may include; pyrexia, raised white cell count,

DVT is usually diagnosed by an ultrasound scan, but it is worth remembering up to 25% of all hospitalised patients may have some form of DVT which often is undiagnosed. This is usually because either the clot is small or it starts around the knee and extends up the thigh causing no symptoms.

Treatment

Prophylaxic treatment includes; Good hydration, patient education, early post op mobilisation, foot/ankle exercises, and end of bed elevation to alleviate swelling of limbs.

Risk is reduced further when patients are treated with chemical and mechanical methods ie Low Molecular Weight Heparin (Fragmin) new oral drugs coming into treatment include riveroxabam, Graduated Elastic Compression Stockings and calf/foot pumps increase blood flow in the lower limbs.

If a DVT has been confirmed, anticoagulant treatment is commenced or increased. LMW Heparins ie fragmin are administered initially whilst warfarin is commenced. Once the patients INR is within therapeutic levels (as directed by the back of the warfarin prescription chart), the fragmin can stop and the patient is followed up at the warfarin clinic. Therapeutic levels for INR will depend on why warfarin was commenced.

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PULMONARY EMBOLISM (PE)

Pulmonary Embolism (PE) is a blockage of the pulmonary artery or one of its branches, usually occurring when a DVT becomes dislodged from its site of formation and travels through the circulation and becomes lodged in a smaller vessel.

Signs and symptoms

Symptoms of PE are sudden-onset dyspnea (shortness of breath), tachypnea (rapid breathing), and tachycardia (heart rate over 100bpm) and palpitations. Chest pain of a “pleuritic” nature (worsened by breathing), a cough, hemoptysis (coughing up blood)

Clinical signs include hypoxia (low saturation levels), this may lead to the patient appearing cyanosed. Severe cases of untreated PE can led to collapse, circulatory instability and sudden death.

PE’s are usually diagnosed with either a VQ scan (Ventilation & perfusion Scan) which shows that some areas of the lungs are being ventilated with air but not perfused with blood (due to the obstruction of the clot). This type of examination is now used less often due to the more widespread availability of a CTPA. However, a VQ scan may be useful in patients who have an allergy to CT contrast.

A CT pulmonary angiography (CTPA) is a pulmonary angiogram obtained using CT scan with contrast to highlight the areas in the lungs receiving blood.

Treatment for a PE is the same as for a DVT.

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Compartment Syndrome

Compartment syndrome occurs due to increased pressure within a confined space or compartment in the body. It can occur in the hand, forearm, upper arm, buttocks, leg, foot and abdomen.

Compartment syndrome most commonly occurs in the leg below the knee, if left untreated, it can affect the blood supply to muscles in the affected compartment and can result in necrosis (death) of the muscles. Rapid diagnosis and treatment to relieve the pressure can lead to recovery of the affected muscles, but if left untreated, the patient could lose the limb.

The connective tissue that defines the compartment does not stretch; a small amount of bleeding into the compartment, or swelling of the muscles within the compartment can cause the pressure to rise.

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Causes

A fracture of the bone is the most common cause of compartment syndrome, typically a fracture of the arm or leg bones.

Other causes include Penetrating injury such as stabbing or gunshot wounds. Crush injury Burns (as the skin is unable to expand) Bleeding from an injured vessel Plaster casts that are fitted too tightly IV drugs (usually given via a cannula) that accidentally leak into the arm around the vein.

Signs and symptoms

There are classically 5 "Ps" associated with compartment syndrome; Pain out of proportion to what is expected, Parasthesia, Pallor, Parasthesia and pulselessness of the limb. Of these only the first two are reliable in the latter stages of compartment syndrome.

Pain is often reported early and almost universally. The description is usually of severe, deep, constant, and poorly localized and is sometimes described as out of proportion with the injury. The pain is aggravated by stretching the muscle group within the compartment and is not relieved by analgesia including morphine.

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Parasthesia (altered sensation e.g. "pins & needles") in the cutaneous nerves of the affected compartment is another typical sign.

Paralysis of the limb is usually a late finding. The compartment may feel very tense and firm as well (pressure). In some cases, some find that their feet and even legs fall asleep. This is because compartment syndrome prevents adequate blood flow to the rest of the leg.

Note that a lack of pulse rarely occurs in patients, as pressures that cause compartment syndrome are often well below arterial pressures and pulse is only affected if the relevant artery is contained within the affected compartment.

Tense and swollen shiny skin

Nursing staff should be aware of a patient with lower limb surgery or injury that complains of severe pain which is not relieved by large amounts of analgesia ie several doses of IV Morphine. Removing bandages and dressings make no difference, neither does moving the affected limb.

Swelling may not be obvious initially; especially if it is the thigh, as this will hold a large amount of blood before it becomes visibly swollen.

Compartment syndrome is uncommon and most junior staff will not recognise it so it is important that nursing staff voice any concerns and seek senior advice if necessary.

Treatment

Early detection and treatment is vital to salvage the limb.

The aim of treatment is to relieve the pressure within the fascial compartment surrounding the muscles. This is done by performing an operation called a fasciotomy. In a fasciotomy, the skin and fascial compartment are cut open so that pressure is relieved.

Any dead muscle is removed during surgery and the wound is usually left open because if it was closed, the pressure could build up again.

The wound is usually closed several days later and skin grafting is common.

Common complications of compartment syndrome

Permanent nerve damage Permanent muscle damage and reduced function of the limb Permanent and often large scarring due to the fasciotomy procedure. In rare cases, loss of the limb Infection of the wound Kidney failure, as the muscle dies various chemicals are released by the muscle that can damage the

kidneys.

Prognosis for compartment syndrome

This depends on how quickly the compartment syndrome is diagnosed and treated. Complete recovery of nerves and muscles is possible if compartment syndrome is treated quickly. Quick treatment means that blood supply to the muscles can be restored before permanent damage occurs. Some experts say that compartment syndrome in the arm or leg needs to be treated within as little time as six hours to prevent muscle necrosis.

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FAT EMBOLISM

Fat emboli can occur whenever there is a chance for fat to enter the circulatory system such as during surgery or trauma.

The most common scenario is for fatty marrow to enter the circulation after the fracture of a long bone eg femur or trauma to the pelvis. Often caused by closed fractures of these bones.

Unlike emboli that come from blood clots, fat emboli are small and multiple causing widespread effects. Physical damage can be done to the brain, lungs and other tissues by the fat in the circulatory system.

Signs and Symptoms

Symptoms usually occur 1-3 days after the injury and are predominantly

Pulmonary ie shortness of breath and hypoxemia (lack of oxygen in the blood) Neurological ie agitation, confusion or coma. Dermatological ie a petechial rash. The petechia often occurs on the cheek, neck, auxilla, palate and

conjunctiva. Haematological ie anaemia and low platelets.

Early recognition is essential to prevent long term damage to the patient. Often fat emboli present as a mixture of hypoxia, confusion and a rash on the body.

Major changes as listed above are the main indicators of a fat embolism, but other minor signs can include

Fever Tachycardia Retinal changes Renal changes Tachypnoea Dyspnoea

The risk of fat embolism syndrome is thought to be reduced by early immobilization of fractures, especially by early operative correction. There is also some evidence that steroid prophylaxis of high risk patients reduces the incidence. Treatment is supportive. The mortality rate of fat embolism syndrome is approximately 5-15%.

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CONSTIPATION

Constipation is a symptom not a diagnosis and means different things to different people. Always ask patients exactly what they mean by the term constipation. There are various formal (and different) definitions of constipation. It is defined as defecation that is unsatisfactory because of infrequent stools (<3 times weekly), difficult stool passage (with straining or discomfort), or seemingly incomplete defecation. Stools are often dry and hard, and may be abnormally large or abnormally small.

Causes of constipation

A careful history helps to determine the possible cause. Ask about frequency, nature and consistency of the stool. Is there blood or mucus in/on the stools? Is there diarrhoea alternating with constipation? Has there been a recent change in bowel habit? Ask about diet and drugs. Most constipation does not need investigation, especially young, mildly affected patients.

Common Causes Low fibre diet or change in regular diet Inadequate fluid intake or dehydration Immobility (or lack of exercise) Irritable bowel syndrome Old age Post-operative pain Hospital environment (lack of privacy, having to use a bed pan)

Colorectal Disease Anal fissure Anal stricture Rectal prolapse

Drugs Opiate analgesics (eg morphine, codeine) Anticholinergics (tricyclics, phenothiazines) Iron

Metabolic / endocrine Hypothyroidism Hypercalcaemia Hypokalaemia

Neuromuscular Spinal or pelvic nerve injury Systemic sclerosis Diabetic neuropathyIntestinal Obstruction Strictures (eg Crohn's disease) Colorectal carcinoma Pelvic mass (eg fetus, fibroids) Diverticulosis (rectal bleeding is a commoner presentation) Congenital abnormalities Pseudo-obstruction

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Management Treat the cause Mobilise the patient Consider drugs only if above measures fail Try to use drugs for short durations only

Drugs for constipation

Bulk producers: Increase faecal mass, which stimulates peristalsis They must be taken with plenty of fluid Contraindications: difficulty in swallowing; intestinal obstruction; colonic atony; faecal impaction.Examples:

Bran powder 3.5g 2-3 times/day with food. eg Ispaghula husk Fybogel® 3.5g sachet in water after meals. Methylcellulose, eg Celevac® 3-6 500mg tablets/12h with water.

Stimulants: Increase intestinal motility and should not be used in intestinal obstruction. Prolonged use should be avoided as it may cause colonic atony and hypokalemia (but there are no good,

longterm follow up studies).Examples: Pure stimulant laxatives are bisacodyl tablets (5-10mg at night) or suppositories (10mg in the mornings) and

senna (2-4 tablets at night). Docusate sodium and danthron (dantron) have stimulant and softening actions; however danthron is

associated with colonic and liver tumours in animals - so reserve its use for the very elderly and terminally ill.

Glycerol suppositories act as a rectal stimulant.

Osmotic agents: Retain fluid in the bowel.Examples:

Lactulose, a semisynthetic disaccharide (sugar), which is primarily a stool softener. It is useful in constipation (dose: 15mL/12h) and hepatic encephalopathy (dose: 30-50mL/12h).

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Spinal Headache

Many people have epidurals or spinals for surgery. Uncommonly, a headache may develop following the procedure.

Headaches after surgery are common. A headache as a result of a spinal or epidural injection can occur between one day and one week after

having the epidural or spinal anaesthetic. It is usually a severe headache felt at the front or back of your head, which gets better when lying down and

worse on sitting or standing. Along with the headache the patient may experience neck pain, sickness and a dislike of bright lights.

The brain and spinal cord are contained in a bag of fluid. The bag is called the dura and the fluid is called the cerebro-spinal fluid (CSF). When an epidural is given, a needle is used to inject local anaesthetic just outside the dura. Occasionally the needle passes through the dura: the chances of this happening can vary.When a spinal is given, a fine needle is inserted into the dura deliberately to inject local anaesthetic into the CSF.

If too much fluid leaks out through the hole in the dura, the pressure in the rest of the fluid is reduced. When the patient sits up, the pressure around the brain is reduced even more. This decreased pressure can cause the symptoms typical of a post dural puncture headache.

Some patients describe it as like a very bad migraine, which is made worse when sitting or standing up.

Treatment

Lying flat and taking simple pain relieving drugs (such as paracetamol and ibuprofen) may help. You should encourage the patient to drink plenty of fluid (some people find tea or coffee especially helpful) and avoid lifting and straining.

Although the hole in the dura will usually seal over in a number of weeks severe headaches will require treatment. A post dural puncture headache can be treated with an ‘epidural blood patch’.

What is a blood patch?

The anaesthetist takes blood from your arm and injects it into your back, near to the hole in the dura. The blood will clot and tend to plug the hole. This feels similar to having the original epidural or spinal injection. It takes about half an hour to do.

In 60-70% people who have this kind of headache, the blood patch will cure the headache within 24 hours. After this, if you still have a headache, you may be advised to have a second blood patch. It is very rare to need more than two blood patches. In some people, the headache goes away, but it then returns. A second blood patch may then help.

After a blood patch, many anaesthetists recommend that you lie flat in bed for 4 hours and do not lift anything heavy for at least two days.

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Learning Disabilities

1.  LOCAL SERVICES RESOURCES/CONTACTSAcute Services  Lynda MurdachConsultant Nurse (Learning Disability)NHS TaysideNursing & Patient ServicesAshludie HospitalMonifieth Tel: 01382 527803

 

In Patient services  Learning Disability UnitCarseview CentreDundeeTel: 01382 878704SCN Gail Whyte

Admission and assessment unit, providing specialist assessment and treatment for people with learning disabilities across Tayside.

Craigowl CentreStrathmartine HospitalDundeeTel: 01382 831944SCN Hazel Lawrence

Specialist treatment centre for both day and residential clients who display extremes of challenging/offending behaviours.

Bridgefoot HouseStrathmartine HospitalDundeeTel: 01382 831947SCN Alison Irons

Challenging behaviour area split into 3 x 8 bedded areas, each dealing with a defined client group.

Day Hospital Services  Hawkhill Day HospitalPeddie StreetDundeeTel 01382 668300SCN Ritchie Harper Both services cater for individuals with challenging behaviour & are open Mon

– Fri only.Birch Avenue Day HospitalBirch AvenueSconePerthTel: 01738 553674SCN Sheila MarshallCommunity Learning Disability

Nursing Services 

Lunan Park Resource CentreFriockheimAngusTel: 01307 826940Team Leader AM Weir

 

Wedderburn House1 Edward StreetDundeeTel: 01382 346020CLDN’s Ann Pert, Shellie Connor & Alison Britton

 

Birch AvenueScone PerthTel: 01738 555420Health Team  Leader, CLD Service – Angie McManus

 

Forensic Team Tayside – wide cover.

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Craigmill CentreStrathmartine HospitalTel 01382 831975Team Leader Lesley Burnett

Further information regarding health team specialist services, are available in the, NHS Tayside Specialist Health Team for Adults with Learning Disabilities, Referral Guidelines & Information Pack.

SPECIALIST HEALTH TEAM FOR ADULTS WITH A LEARNING DISABILITYDUNDEE PERTH & KINROSS ANGUS

PSYCHIATRY OF LEARNING DISABILITY

Dr Sam Baldwin/Dr Eleanor Brewster

Consultant PsychiatristFlat 4Strathmartine CentreDUNDEE DD3 0PGTel: 01382 831981

Dr Fabian HautConsultant PsychiatristFlat 4Strathmartine CentreDundeeDD3 0PGTel: 01382 831981

Dr Phyllis WalkerConsultant Psychiatrist & Lead ClinicianFlat 4Strathmatine CentreDundeeDD3 0PGTel: 01382 831981

CLINICAL PSYCHOLOGYDr Sarah BroxholmeClinical Psychology DepartmentWedderburn House1 Edward StreetDUNDEE DD1 5NSTel: 01382 346025

Ms Shona McLarenClinical PsychologistBirch Avenue Centre55 Birth AvenueSCONE PH2 6LETel: 01738 555412

Dr Lucy PatersonClinical PsychologistWedderburn House1 Edward StreetDUNDEE DD1 5NSTel: 01382 346025

PHYSIOTHERAPYYvonne MiskellTeam Leader/PhysiotherapyDundee City Council Social Work

DeptBalmerino RoadDUNDEE 01382 307557

Sheila FrenzPhysiotherapy Team LeaderBirch Avenue Centre55 Birch AvenueSCONE PH2 6LETel: 01738 555416

Lynn JonesPhysiotherapy Team LeaderLinks Health CentreMarine AvenueMONTROSE, DD10 8YRTel: 01674 667152

SPEECH & LANGUAGE THERAPYCarol Sutherland/Bernie Brophy-ArnottSpeech & Language Therapy Managers

Wedderburn House1 Edward StreetDUNDEE DD1 5NSTel: 01382346005

Carol Sutherland/Bernie Brophy-ArnottSpeech & Language Therapy ManagersWedderburn House1 Edward StreetDUNDEE DD1 5NSTel: 01382 346005

Carol Sutherland/ Bernie Brophy-ArnottSpeech & Language Therapy ManagersWedderburn House1 Edward StreetDUNDEE DD1 5NSTel: 01382 346005

ART THERAPYJohn McCullochSenior Art TherapistCraigmill Skill CentreStrathmartine CentreDUNDEE DD3 OPGTel: 01382 831972

John McCullochSenior Art TherapistCraigmill Skill CentreStrathmartine CentreDUNDEE DD3 OPGTel: 01382 831972

John McCullochSenior Art TherapistCraigmill Skill CentreStrathmartine CentreDUNDEE DD3 OPGTel: 01382 831972

MUSIC THERAPYJeff HooperSenior Music TherapistCraigmill Skill CentreStrathmartine CentreDUNDEE DD3 OPGTel: 01382 831871

Jeff HooperSenior Music TherapistCraigmill Skill CentreStrathmartine CentreDUNDEE DD3 OPG

Tel: 01382 831871

Jeff HooperSenior Music TherapistCraigmill Skill CentreStrathmartine CentreDUNDEE DD3 OPGTel: 01382 831971

OCCUPATIONAL THERAPY

Astrid SmithSenior Occupational therapistCraigmill Skill CentreStrathmartine CentreDUNDEE DD3 OPGTel: 01382 831962

Sue YoungSenior Occupational TherapistBirch Avenue Centre55 Birch AvenueSCONE PH2 6LETel: 01738 555414

Ruth JeffriesSenior Occupational TherapistLunan Park Resource CentreGuthrie StreetFriockheim DD11 4SZTel: 01241 826952

 

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CHIROPODY/PODIATRYGerry Connor Senior podiatristPodiatry DeptWestgate Health CentreCharleston DriveDUNDEE DD2 4ADTel: 01382641154

No Specialist Adult Learning Disabilities Service.

Gerry ConnorSenior podiatristPodiatry DeptWestgate Health CentreCharleston DriveDUNDEE DD2 4ADTel: 01382641154

DIETETICSKirsty HamiltonClinical Specialist DietitianCraigmill Skill CentreStrathmartine CentreDUNDEE DD3 OPGTel: 01382 831976

Kirsty HamiltonClinical Specialist DietitianCraigmill Skill CentreStrathmartine CentreDUNDEE DD3 OPG

Tel: 01382 83197

Kirsty HamiltonClinical Specialist DietitianCraigmill Skill CentreStrathmartine CentreDUNDEE DD3 OPG

Tel: 01382 83197

LEARNING DISABILITY NURSINGCommunity Learning Disability Nursing Team

Wedderburn House1 Edward StreetDUNDEE DD1 5NSTel: 01382 346020

Community Learning Disability Nursing TeamBirch Avenue Centre55 Birch AvenueSCONE PH2 6LETel: 01738 555445

Community Learning Disability Services Lunan Park Resource Centre, Guthrie StreetFriockheim  DD11 4SZTel: 01241 826900

DELIVERY UNITLynda MurdachConsultant Nurse (Learning Disability)NHS TaysideNursing & Patient ServicesAshludie HospitalMonifieth, DD5 4HQTel: 01382 527803/07740 937309

Lynda MurdachConsultant Nurse (Learning Disability)NHS TaysideNursing & Patient ServicesAshludie HospitalMonifieth, DD5 4HQTel: 01382 527803/07740 937309

Lynda MurdachConsultant Nurse (Learning Disability)NHS TaysideNursing & Patient ServicesAshludie Hospital

Monifieth, DD5 4HQTel: 01382 527803/07740 937309