G Pelvic reconstruction
Pelvic reconstruction is a surgical procedure that involves open reduction of pelvic fractures, which are then maintained by the application of plates and screws. Bone grafting may be used to repair any defects of the pelvis. The surgical time for the procedure is 3 to 6 hours. These fractures may be caused by minor trauma, especially in elderly persons, but most result from high-impact trauma (i.e., motor vehicle trauma). Evaluation of the patient for potential coexisting trauma should include a thorough neurologic, thoracic, and abdominal assessment. The extremities may also be involved.
2. Preoperative assessment
a) History and physical examination: Obtain a verbal history from the patient or family member. Note any preexisting disease processes, social history, current medications, surgical history, and allergies.
(1) Cardiac: Assess for cardiac contusion or aortic tear. Tests include 12-lead ECG, creatine phosphokinase isoenzymes, and chest radiography (wide mediastinal silhouette suggests aortic tear). Transesophageal echocardiography or angiography is indicated if an aortic tear is suspected. Consult with a cardiologist if indicated.
(2) Respiratory: Assess for possible hemothorax, pneumothorax, pulmonary contusion, fat embolism, and aspiration. The patient may require supplemental oxygen or mechanical ventilation to correct hypoxemia. Coexisting trauma to the head or cervical spine may require fiberoptic intubation. Tests include chest radiography and arterial blood gases.
(3) Neurologic: A thorough neurologic evaluation including mental status and peripheral sensory examination. Note any preexisting deficits. Consult with a neurologist if necessary. For tests, computed tomography of the head is indicated before anesthesia for patients who experience a loss of consciousness.
(4) Renal: Renal injury is possible with high-impact trauma. Rule out a urethral tear before placing the Foley catheter. A suprapubic catheter may be necessary. Intraoperative monitoring of urine output is mandatory to assess adequate renal perfusion. Consult a urologist if necessary. Tests include urinalysis, blood urea nitrogen, serum creatinine, hematuria, and myoglobinuria.
(5) Musculoskeletal: Cervical spine clearance may be required before neck manipulation (i.e., laryngoscopy). Consider evaluating thoracic and lumbar radiographs to rule out any deformity or instability before anesthesia. Tests include cervical spine radiography and others as indicated from the history and physical examination.
(6) Hematologic: Large blood loss associated with traumatic injury may occur. The patient’s hematocrit should be restored to greater than 25% before induction of anesthesia. Type and crossmatch for 6 units of packed red blood cells. Consider the use of a cell saver intraoperatively.
(7) Gastrointestinal: Patients should be assessed for abdominal injury associated with trauma. The test used is diagnostic peritoneal lavage.
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