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Causes and Treatment of Osteoporosis

Describe about the Report for Acute Care Nursing.

1. Osteoporosis is mainly a disease of aged people and it occurred due to the more bone resorption as compared to the of bone formation. The central cause of occurrence of osteoporosis is deficiency of gonadal sex hormone like estrogen. Estrogen represses receptor activator of nuclear factor-κ B ligand (RANKL). RANKL is responsible for the osteoclast differentiation and survival, when it binds to the RANK on the cell surface of osteoclast cells. This RANKL is generally expressed on the osteoblast precursor cells and inflammatory cells like T & B cells. Also, estrogen stimulates the expression of osteoprotegerin which binds to RANKL before it binds to RANK and prevent capability of RANKL to promote ostoclast formation and bone resorption and hence suppresses its ability to increase bone resorption. Deficiency of vitamin D and calcium also leads to the bone loss. In response to low calcium levels, parathyroid glands secret more amount of parathyroid hormone and this hormone promotes bone resorption by increasing more absorption of calcium in the blood to maintain optimum level of calcium in the blood. Trabecular bone are present at the end of long bones and vertebrae which plays role in bone turnover and due to the microcrack in the trabecular bone, it replaced by weaker bones (Raisz 2005; Drake et al., 2015).  

Open reduction and internal fixation (ORIF) is used correct as a bone break. In this open reduction means restoring fractured bone in the original position and internal fixation means steel rods, screw and plate are used to fix bone fracture. A total hip replacement (THR) is a surgical procedure used in osteoporosis in which deformed cartilage and bone of the hip joint is substituted with plastic, ceramic and metal. In THR there is more percentage of ambulation reported after discharge. In case of ORIF there is more morbidity, less compliance in terms of inhibited weight bearing and inferior outcome. In osteoporosis, due to bone loss there is the reduced possibility of plate fixation in case of ORIF. There were more number of patients already underwent ORIF, tried to move to THR (Boelch eta l., 2016; Archdeacon et al., 2013; Daurka et al., 2014)  .

2. Hip replacement (THR)/arthroplasty surgery requires anesthesia for long duration. There is significant loss of blood during surgery of the patient. Reported loss of blood in THR patient is around 1500 ml with hemoglobin around 4.0 g. In Gianna also almost same amount of blood loss occurred. However there were confounding results available for the loss of blood in general and local anesthesia. Few studies showed there was no difference in the blood loss in general and local anaesthesia, on the other hand few studies showed there was more blood loss in general anaesthesia as compared to the local anaesthesia (Rozario et al., 2008; Durasek et al., 2010; Singh et al., 2012). Anaesthesia and THR leads to the hypotension in the patients undergoing surgery. Average blood pressure less than 95/50 was reported in THR surgery. In case of Gianna also blood pressure observed was 95/50. In case of THR, different studies gave different definitions for the hypotension. Hypotension considered in different studies for THR were fall in blood pressure more than 30 % systolic  blood pressure, 33 % overall blood pressure, 40 mmHg and 20 % fall from the baseline (Bigler et al., 1985; Berggren et al., 1987; Davis et al., 1987). Even though, there was different criteria for hypotension in different studies, overall it has been observed that fall in blood pressure was more observed in regional anaesthesia as compared to the general anaesthesia (Couderc et al., 1977). It has been reported that blood transfusion in THR over the preoperative and postoperative period in case of regional anaesthesia was in the range of 230 to 260 ml. In case of Gianna, blood transfusion was 200 ml. In case of general and regional anaesthesia number of patients required transfusions were same however volume of transfusion required in the regional anaesthesia patients were higher as compared to the general anaesthesia patients (Valentin et al., 1986; Bredahl et al., 1991; Juelsgaard et al., 1998). Most of the available data in case of blood transfusion was heterogeneous.      

Risks and Complications of THR Surgery

There was less percentage of O2 in the blood of patients undergoing THR. In such scenario, administration of oxygen is necessary to prevent hypoxia. This condition occurred in almost 98 % patients. Oxygen saturation (SpO2) between 90 to 95%, considered optimum in case of THR surgery patients. This SpO2 correspond to the oxygen tension (Pao2) of 60–80 mmHg. Oxygen saturation observed in case of Gianna was 93 %. This volume was in the adequate range considering age and THR surgery of Gianna. In earlier studies few patients were reported with Pao2 less than 60 mmHg (Couderc et al., 1977; McKenzie et al., 1984; Brown et al., 1994). Fall in the oxygen tension was reported to be different at different time points for general and local anaesthesia.  There was more fall in oxygen tension in case of general anaesthesia as compared to the local anaesthesia at one hour after surgery, however there was no difference in the oxygen tension between general and local anaesthesia one day after completion of surgery. However, in few studies there was no difference observed in oxygen and carbon dioxide tension between general and local anaesthesia.  To prevent hypoxia, it has been suggested that oxygen with flow rate of 5 L/min is sufficient in case of THR patients (Rozario et al., 2008; Singh et al., 2012). However, in case of Gianna oxygen was supplied with the flow rate of 6 L/min. This volume was sufficient for Gianna.     

Orthopedic theaters used in the THR surgery are generally cooler than any other operation theaters with temperature is in the range of 18-20°C and humidity more than 55 %. With the weakened temperature regulatory system in the THR patients and mentioned cool orthopedic theater, in case of patients undergoing THR surgery, there is rapid decrease in the body temperature of patients undergoing THR surgery (Akca et al., 2002; Moretti et al., 2009). There was very less literature available for recording of temperature, hence threshold temperature is not available. In case of Gianna, recorded temperature was 36oC which is less than the normal temperature. It was reported in the literature that there is no difference in the temperature due to the general and local anaesthesia.

Effect of analgesics on the vital signs mainly depends on the baseline values of the vital signs of the individual patient. In this case of Gianna, most of the vital signs were abnormal and there was no worsening effect on vital signs by the use of analgesics (Sporer et al., 2006).

Effects of Anesthesia on Patients Undergoing THR Surgery


3.
Dischrge plan for the Giana was prepared by a team of discharge planner, resident nurse and physician. Consent of the Giana and her family was taken for her diachrge.

A case of Gianna Rossi, 79 years old, female, was admitted to emergency department after collapse. In X-ray it was revealed that Gianna has fracture in the hip due to osteoporosis. She stayed in the orthopedic ward for four days and her daily activities like eating and drinking are normal. She can walk using four-wheeled walker under supervision. Her pain can be managed with paracetamol and tramadol.

Subjective : Gianna was concerned about her independence after her discharge.

Objective :

  • Giana and her family were seen packing their items.
  • Giana received instruction from the physician and surgeon.
  • All the payments of the hospital were done.

Complete Patient Assessment (Chin-Jung et al., 2012; Al-Maqbali, 2014):

Dischrge needs : Giana is doing her daily activities normally and walk on her own using four wheeled walker under supervision and gradually there is progress in this.

Screening: Vital signs of Giana, those were became abnormal during and after surgery are now normal. 

Complaints: Giana doesn’t have any complaint as such and her pain can be managed using paracetamol and tramadol.

Physical screening: Giana was evaluated for getting in and out of her bed, walking with walker under observation and walking to the bathroom. All these assessments showed promising outcome.   

Visit hospital after 2 weeks for clinical follow-up.

Change dressing twice a day and don’t disturb the stitches.

Referred to experienced physiotherapist after two weeks because rehabilitation and physical therapy is essential. 

Do not take shower upto 6 days after surgery because incision and stitches may get wet and this can lead to infection.

Do not allow anybody to touch incision without washing hands with antiseptic.

Take paracetamol and tramadol, if she feels pain otherwise she can stop it.

Call to the hospital in following situations:

More redness or drainage at the incision area.

If pain is not decreasing even after taking painkiller.

If temperature is increasing.

After the approval of discharge plan of Giana by physician and the surgeon, Giana was discharged to her home along with discharge planner, visiting nurse, physiotherapist and her family members.

References:

Akca, O., & Sessler, D.I. (2002). Thermal management and blood loss during hip arthroplasty. Minerva Anestesiologica, 68, 182–5.

Al-Maqbali, M. A. (2014). Nursing intervention in discharge planning for elderly patients with hip fractures. International Journal of Orthopaedic and Trauma Nursing, 18(2), 68–80.

Archdeacon, M., Kazemi, N., Collinge, C., Budde, B., & Schnell, S. (2013). Treatment of protrusio fractures of the acetabulum in patients 70 years and older. Journal of Orthopaedic Trauma, 27(5), 256–261.

Discharge Plan for the Patient

Berggren, D., Gustafson, Y., Eriksson, B., Bucht, G., Hansson, L.H., Reiz, S., & Winblad, B. (1987).  Postoperative confusion after anesthesia in elderly patients with femoral neck fractures. Anesthesia and Analgesia, 66, 497-504.

Bigler, D., Adelhoj, B., Petring, O.U., Pederson, N.O., Busch, P., & Kalhke, P. (1985). Mental function and morbidity after acute hip surgery during spinal and general anaesthesia. Anaesthesia, 40, 672-6.

Boelch, S.P., Jordan, M.C., Meffert, R.H., & Jansen. H. (2016). Comparison of open reduction and internal fixation and primary total hip replacement for osteoporotic acetabular fractures: a retrospective clinical study. International Orthopaedics, Aug 10. [Epub ahead of print].

Bredahl, C., Hindsholm, K.B., & Frandsen PC. (1991). Changes in body heat during hip fracture surgery: a comparison of spinal analgesia and general anaesthesia. Acta Anaesthesiologica

Scandinavica, 35, 548-52.

Brown, A.G., Visram, A.R, Jones, R.D.M., Irwins, M.G., & Bacon-Shone, J. Preoperative and postoperative oxygen saturation in the elderly following spinal or general anaesthesia - an audit of current practice. Anaesthesia and Intensive Care , 22, 150-4.

Couderc, E., Mauge, F., Duvaldestin, P., & Desmonts, J.M. (1977). Comparative results of general and peridural anesthesia for hip surgery in the very old patient.  Anesthesie, Analgesie, Reanimation. 34(5), 987-98.

Chin-Jung, Lin., Shih-Jung, C., Shou-Chuan, S., Cheng-Hsin , C., & Jin-Jin, T. (2012).  Discharge Planning. International Journal of Gerontology, 6(4), 237–240.

Daurka, J., Pastides, P., Lewis, A., Rickman, M., & Bircher, M. (2014). Acetabular fractures in patients aged > 55 years: a systematic review of the literature. Bone Joint Journal , 96, 157–163.

Davis, F.M., Woolner, D.F., Frampton, C., Wilkinson, A., Grant, A., Harrison RT, et al. (1987).  Prospective, multi-centre trial of mortality following general or spinal anaesthesia for hip fracture surgery in the elderly. British Journal of Anaesthesia, 59, 1080-8.

Drake, M.T., Clarke, B.L. and Lewiecki, E.M.  (2015). The Pathophysiology and Treatment of Osteoporosis. Clinical Therapeutics, 37(8), 1837-50.

Durasek, J. (2010). Factors affecting blood loss in total knee arthroplasty patients. Acta Medica Croatica, 64, 209–14.

Juelsgaard, P., Sand, N.P.R., Felsby, S., Dalsgaard, J., Jakobsen, K.B., Brink, O., et al. Perioperative myocardial ischaemia in patients undergoing surgery for fractured hip randomized to incremental spinal, single-dose spinal or general anaesthesia. European Journal of Anaesthesiology, 15(6), 656-63.

McKenzie, P.J., Wishart, H.Y., & Smith, G. (1984). Long-term outcome after repair of fractured neck of femur; comparison of subarachnoid and general anaesthesia. British Journal of Anaesthesia, 56, 581-4.

Moretti, B., Larocca, A.M., Napoli, C., Martinelli, D., Paolillo, L., & Cassano M, et al. (2009).  Active warming systems to maintain perioperative normrothermia in hip replacement surgery: A therapeutic aid or a vector of infection? Journal of Hospital Infection, 73, 58–63.

Pesce, V.,  Speciale, D., Sammarco, G., Patella, S., Spinarelli, A., & Patella, V. (2009).  Surgical approach to bone healing in osteoporosis.  Clinical Cases in mineral and bone metabolism, 6(2),  131–135.

Raisz, L. (2005). Pathogenesis of osteoporosis: concepts, conflicts, and prospects. Journal of Clinical Investigation, 115(12), 3318–25.

Rozario, L., Sloper, D., & Sheridan, M.J. (2008). Supplemental oxygen during moderate sedation and the occurance of clinically significant desaturation during endoscopic procedures. Gastroenterology Nursing, 31, 281–5.

Sporer, K.A., Tabas, J.A., Tam, R.K., Sellers, K.L., et al. (2006). Do medications affect vital signs in the prehospital treatment of acute decompensated heart failure? Prehospital Emergency Care, 10(1), 41-5.

Singh, S., Singh, S. P., & Agarwal, J. K. (2012). Anesthesia for bone replacement surgery. Journal of Anaesthesiology Clinical Pharmacology, 28(2), 154–161.

Valentin, N., Lomholt, B., Jensen, J.S., Hejgaard, N., & Kreiner, S. (1986). Spinal or general anaesthesia for surgery of the fractured hip? A prospective study of mortality in 578 patients. British Journal of Anaesthesia, 58, 284-91.

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