treatment of post-surgical edema in the orthopedic patient - a case report.

The present study was aimed at evaluating the use of mechanical and manual lymphatic therapy as a treatment for lymphedema resulting from orthopedic surgery that became painful after an episode of erysipelas. Case Report. A 70-year-old male patient suffered direct trauma resulting in a compound fracture of the tibia and fibula of the left leg.

Full Answer

What are general edema management techniques used in postoperative orthopedic rehabilitation?

Limb elevation, frequent repositioning, sodium restriction, and diuretic use are general edema management techniques also utilized in postoperative orthopedic rehabilitation patients. However, several of these modalities are poorly understood or lack adequate support from the literature.

When is surgical intervention indicated in the treatment of malignant edema?

In cases of severe malignant edema with impending herniation, surgical intervention may be required in the form of decompressive craniectomy or lobectomy.

Is edema education necessary after orthopedic arthroplasty?

Clinical Relevance: Edema education is recommended for orthopedic patients in rehabilitation facilities. Keywords: Arthroplasty; edema; orthopedic; postoperative; rehabilitation.

How does lower extremity edema affect outcomes of orthopedic surgery?

Reduced functional performance in orthopedic patients related to postoperative lower extremity edema also negatively impacts length of stay and patient perception of surgical outcomes (Brock et al., 2015).

What is edema tracking?

An Edema Tracking Spreadsheetwas used to collect information on patient demographics(age, gender), type of surgery, health variables (body massindex [BMI], psychological history, Patient HealthQuestionnaire-Nine[PHQ-9] depression score), edemavariables ( edema documentation and edema manage-ment), and length of stay. The PHQ-9 was utilized bya residential services representative per facility protocolto assess depression severity by asking patients nine ques-tions with individual answers assigned points rangingfrom 0 to 3 in relation to severity of depressive symptoms,which were added to a total score ranging from 0 to27 per the U.S. Preventative Services Task Force (2005).Psychological comorbidities and traits are correlated withworsened function, pain, and surgical outcomes most no-tably in the knee replacement population in comparisonto the hip replacement population (Dowsey et al., 2014).Edema severity and the patient’s ability to psychologicallycope with edema-related adversities greatly influence ther-apy progression (Su et al., 2012). PHQ-9 scoring datawere included as a variable since internal stakeholdersnoted that depression is often prevalent in postoperativeTKA and THA patients, which can negatively impactpostoperative rehabilitation. BMI was calculated by a di-etician from patient height and weight data, with less than18.5 kg/m2categorized as underweight, 18.5–24.9 kg/m2categorized as normal weight, 25–25.9 kg m2categorizedas overweight, and 30 kg/m2or greater categorized as obeseas per the National Institutes of Health (n.d.). Lower ex-tremity peripheral edema is noted as a common postop-erative complication particularly in obese knee and hiparthroplasty patients (Friedman et al., 2013). BMI datawere included as a variable to analyze the prevalence ofobesity in this patient population and to observe howBMI affected other data variables, including edema sever-ity and length of stay.

What is pre and post intervention?

The project was conducted at a mid-sized freestanding rehabilitative nursing facility that providesphysical rehabilitation to orthopedic, neurologic, cardiac,and general medicine patients in the Chicago land area. Pa-tients were admitted to this facility from 10 local hospitalsor other skilled nursing facilities.Thisprojectwasprimar-ily conducted on two of the four nursing floors that spe-cialized in orthopedic nursing rehabilitation. Involvedstaff included registered nurses, licensed practical nurses,certified nursing assistants, restorative aids, and memorysupport coordinators from the four nursing floors.

What is postoperative edema?

Postoperative edema is an anticipated sequela of most facial surgery, including cosmetic blepharoplasty. Swelling exhibits extreme variability from patient to patient; some patients hardly swell while some develop remarkable postoperative edema. The preoperative consent and evaluation should definitively cover all common complications including swelling. Generally, perioral edema begins in the recovery area and will increase for 48 hours and maximize at about 72 hours. Ice, head elevation, and avoidance of strenuous activity are the first lines of defense against excessive swelling. It is not uncommon for some patients to develop chemosis (edema of the bulbar conjunctiva) from the inflammation of surgery (Figure 7-71 ). Occasionally patients can develop impressive chemosis, and this frequently occurs from a Valsalva incident such as sneezing or coughing or more frequently from overactivity in the early preoperative phase. This can be very disconcerting for the patient and family, and they must be reassured. Chemosis can be treated with dexamethasone and Neo-Synephrine 2.5% drops, but I usually prescribe oral steroids. Although very common, I have been unimpressed with the results of tapering-dose packs. I use a regimen of 60 milligrams of prednisone (three 20-mg tablets) once a day for 5 days. This has proved to be very safe and effective and generally abates severe chemosis in 48 hours. I also use this regimen in healthy individuals for other cosmetic-related edema. Warm compresses are also utilized to soothe the eyes and reduce swelling.

What is the best treatment for edema in the brain?

In moderate cases, osmotic agents like mannitol and hypertonic saline as well as diuretics like furosemide are used to decrease the brain's hydrostatic pressure. Mechanical ventilation in obtunded patients is usually helpful in reducing edema by improving brain oxygenation and cerebral vasoconstriction.

Why is edema common in the hand?

Postoperative edema is a common presentation in the hand due to the inflammatory response during tissue healing.33,34 During the fibroplastic stage of healing, edema is promptly addressed to prevent additional joint stiffness, pain, and delays in healing.

How long does perioral edema last?

Generally, perioral edema begins in the recovery area and will increase for 48 hours and maximize at about 72 hours. Ice, head elevation, and avoidance of strenuous activity are the first lines of defense against excessive swelling.

What is the hemodynamic change after thrombosis?

Hemodynamic changes after damage or thrombosis of draining veins , accompanied by cytotoxic changes of brain parenchyma due to direct damage or ischemia from prolonged retraction, form a vicious cycle that produce macroscopic cerebral edema.

Does swelling have to be preoperative?

Swelling has extreme variability from patient to patient, as some patients hardly swell and others develop remarkable postoperative edema. The preoperative consent and evaluation should cover all common complications, including swelling.

Can lymphedema persist for months?

The periorbital area is very rich in lymphatics and occasionally lymphedema can occur and persist for several months in rare cases. It is not uncommon for some patients to develop chemosis (edema of the bulbar conjunctiva) from the inflammation of surgery or overactivity in the early postoperative period ( Fig. 5.108 ).

Why does edema occur?

Edema is a normal response to injury ( Villeco, 2012) and develops when the microvascular filtration rate exceeds lymph drainage for a sufficient period either because the filtration rate is high or the lymph flow is low or a combination of the two.

What is edema in the interstitium?

Edema becomes a concern when it persists beyond the inflammatory phase or after two weeks, subsequently developing peripheral protein-rich edema in the interstitium ( Stout, 2002 ). Peripheral edema differs from chronic venous and lymphatic obstruction, emerging immediately after a fracture or soft tissue injury. This type of edema increases during immobilization affects the distal extremity at the site of the injury and does not react immediately to diuretics or anti-inflammatory drugs. In contrast, venous edema develops slowly and only marginally responds to diuretics ( Majewski-Schrage and Snyder, 2016 ). Untreated and persistent edema can exacerbate pain, and cause mobility and range of motion (ROM) difficulties. Furthermore, edema may increase the risk of infection in the affected area, decrease blood circulation and negatively affect the elasticity of the arteries - all complications that can delay wound healing ( Földi et al., 2018 ). Scar tissue may obstruct the normal lymph flow. Free flaps used in reconstructive surgery appear to have no normally functioning lymphatic vessels ( van Zanten et al., 2017 ).

How does compression therapy work?

Compression therapy is an important therapeutic tool causing: 1) displacement of fluid from the interstitium and reduction in venous pressure. The compression promotes lymphatic drainage, resulting in augmentation of the lymphatic pump; 2) reduction of the lymphatic preload; and 3) increased lymph flow in functioning lymph vessels, particularly when combined with exercise. Compression acts as a counterforce to muscle activity. The contraction and relaxation of the skeletal muscles lead to an increase of pressure, thus, providing the most powerful stimulus to lymph drainage ( Hobday, 2016; Rockson, 2018 ). All methods of compression found in the review are described in Table 2.

Does compression therapy help with edema?

Orthopedic injuries in conjunction with extensive damage to tissues, bones and blood vessels, usually require a long recovery. Associated consequences are pain, movement limitations, decreased function and occasionally, prolonged edema, which can delay or interfere with the healing process. Lymphatic and compression therapy have become increasingly common, intending to reduce edema and pain, thus, promoting the recovery process.

Introduction

Pulmonary embolism is a life-threatening condition, with a high mortality rate. Recent studies show that 30-day mortality is 4%, but may increase to 13% after 90 days (1). The risk of developing a PE increases during and after surgery and it depends from the type of surgery and patient risk factors.

Case Report

A 56- year old men arrived in the emergency department because of a brief episode of loss of consciousness. The patient was in good health. He reported that, two weeks before, had undergone a hip left arthroplasty and was in therapy with enoxaparin 6000 units once a day.

Discussion

Pulmonary embolism is a life-threatening condition that should be promptly recognized. Surgical patients are at increased risk of developing a PE, especially after orthopaedic hip and knee surgery, because of positioning during surgery and immobility, that contributes to an increase in venous stasis. Therefore the prophylactic therapy is essential.

Bibliography

Alotaibi GS, Wu C, Senthiselvan A, McMurthy MS. Secular trends in incidence and mortality of acute venous thromboembolism: The AB-VTE Population-Based Study. Am J Med 2016; 129: 879 e 819-825.