老年髋部骨折围手术期相关问题.ppt

单击此处编辑母版标题样式,单击此处编辑母版文本样式,第二级,第三级,第四级,第五级,*,老年髋部骨折围手术期相关问题,Pre-operative,Treatment strategy,Surgical fixation of fractured hips remains the standard of care,Pre-operative,Evaluation,Complete history,physical examination,laboratory examinations,Assessment of the surgical risks,System deficits identified,and corrected,The American Association of Anaesthetists grading,ASA Physical Status(PS)Classification System*:,ASA PS Category,Preoperative Health Status,Comments,Examples,*ASA PS classifications from the American Society of Anesthesiologists,ASA PS 1,Normal healthy patient,No organic,physiologic,or psychiatric disturbance;excludes the very young and very old;healthy with good exercise tolerance,ASA PS 2,Patients with mild systemic disease,No functional limitations;has a well-controlled disease of one body system;controlled hypertension or diabetes without systemic effects,cigarette smoking without chronic obstructive pulmonary disease(COPD);mild obesity,pregnancy,ASA PS 3,Patients with severe systemic disease,Some functional limitation;has a controlled disease of more than one body system or one major system;no immediate danger of death;controlled congestive heart failure(CHF),stable angina,old heart attack,poorly controlled hypertension,morbid obesity,chronic renal failure;bronchospastic disease with intermittent symptoms,ASA PS 4,Patients with severe systemic disease that is a constant threat to life,Has at least one severe disease that is poorly controlled or at end stage;possible risk of death;unstable angina,symptomatic COPD,symptomatic CHF,hepatorenal failure,ASA PS 5,Moribund patients who are not expected to survive without the operation,Not expected to survive 24 hours without surgery;imminent risk of death;multiorgan failure,sepsis syndrome with hemodynamic instability,hypothermia,poorly controlled coagulopathy,ASA PS 6,A declared brain-dead patient who organs are being removed for donor purposes,Pre-operative,Pain：acetaminophen,Approximately 40%of patients moderate renal dysfunction(eGFR 17*10,9,/L may indicate infection(usually chest or urine).,Pre-operative,Platelet count,Below 50*10,9,/L normally require pre-operative platelet transfusion.,Pre-operative,Atrial Fibrillation(AF),Ventricular rate of less than 100 required.,Factors:hypokalemia,hypomagnesemia,hypovolemia,sepsis,pain and hypoxemia.,Beta-blockers to control HR,Pre-operative,Diabetes,Hyperglycemia is not a reason to delay surgery unless the patient is ketotic and/or dehydrated.,Pre-operative,Dialysis,Surgery tailored around the dialysis;,Urgent surgery may necessitate heparin-free dialysis,Pre-operative,Time to surgery,Early surgery(2436h)recommended,No delay for patients mild to moderate hypertension(systolic 180 mmHg and diastolic 110 mmHg),No awaiting echocardiography,No delay for minor electrolyte abnormalities,Pre-operative,Reasons to optimise,Severe anemia Hb 8g/dl,Severe electrolyte imbalance,with plasma sodium 150mmol/l and potassium 6.0 mmol/l.,Uncontrolled diabetes,Pre-operative,Reasons to optimise,Uncontrolled or acute onset left ventricular failure,Correctable cardiac arrhythmia,with a ventricular rate,120 bpm,Chest infection with sepsis,Reversible coagulopathy,Intra-operative,Antibiotics,Antibiotics administered before skin incision,Hospital antibiotic protocols followed,Intra-operative,Anaesthetic considerations,Regional anesthesia recommended,Keep intra-op,diastolic,60mmHg,Intra-operative,Intravenous fluids,Many patients hypovolemic at the time of surgery,Colloids reduce hospital stay and improve outcome,Post-operative,Pain management,Post-op epidural anesthesia less common,Regular acetaminophen throughout perioperative period.,NSAIDS used with extreme caution,and contraindicated in those with renal dysfunction,Post-operative,Pain management,Opioids(and tramadol)used with caution in patients with renal dysfunction,Oral opioids avoided,and intravenous doses halved with a halved frequency,Codeine should not be administered(constipating,emetic,perioperative cognitive dysfunction),Post-operative,DVT prophylaxis,LMWH;Warfarin;Rivaroxaban,10-35 days,Post-operative,Oxygen,Supplemental oxygen post-operatively for at least 24 hours,Some evidence supports oxygen therapy for the first 72h,Post-operative,Fluid balance,Hypovolemia common,Early oral fluid intake encouraged,Urinary catheters removed as soon as possible,Routine transfusion in asymptomatic patients with a haemoglobin level 80g/L not be required.,Post-operative,Postoperative delirium,Common(25%-50%)with hip surgery,Factors:hypoxia,hypoglycaemia,major fluid and electrolyte imbalances,sepsis and major organ impairment,Prophylactic low-dose haloperidol may reduce severity and duration of delirium,Post-operative,Nutrition,Up to 60%of hip fracture patients clinically malnourished on admission,The calorie and protein density of hospital food often poor,Post-operative,1、热量：热氮比=100150:1,2、蛋白（按0.15-0.2g氮/kg/d）计算（1g氮=6.25g氨基酸）,3、糖脂肪混合能源中：糖/脂=3/2,4、产热效能：1g糖=1g蛋白质=4.1 kcal，1g脂肪=9.3 kcal,实例,男，88岁，股骨颈骨折半髋术后第4天,体检：HR:90bpm，BP：120/70mmHg，T：36.5，W：55kg，SaO2 98%,精神稍微萎靡，神智清，认知能力好，贫血貌，,伤口干燥,，无红肿。双肺呼吸音清（CT提示：胸腔积液），阴囊水肿，入量400ml，尿量1900ml，可少量进食，保留尿管，大便通畅有腹泻7-8次/天,实例,血常规：WBC 4.05109/L；RBC2.96 1012/L，HGB 69g/L;Hct 0.198;Lymph:0.640109/L,血生化：,白蛋白：26.1 g/L，球蛋白：14.6 g/L，K：3.15 mmol/L,Ca 1.91 mmol/L,Iphos 0.56 mmol/L,实例,1、每日氮需要量：0.17555=9.6g，即9.66.25=60g氨基酸,2、每日需要热量：9.6125=1200 kcal,糖供热：12003/5=720 kcal/d,脂肪供热：12002/5=480 kcal/d4、补充脂肪：4809.352 g5、补充葡萄糖：7204.1175 g,实例,预计补液量：,1750.1=1750ml（3L袋内糖浓度10%）.2000ml,20%脂肪乳（力能）250ml（50g：488 kcal）补入.250 ml,氨基酸（法谱）（8.5%/250ml）：6021.53(约750 ml).750 ml,0.9NaCL：500ml（4.5g钠）500 ml,糖用50%GS补入：175 50%=350 ml350 ml,实例,预计补液量：,1750.1=1750ml（3L袋内糖浓度10%）.2000ml,20%脂肪乳（力能）250ml（50g：488 kcal）补入.250 ml,氨基酸（法谱）（8.5%/250ml）：6021.53(约750 ml).750 ml,0.9NaCL：500ml（4.5g钠）500 ml,糖用50%GS补入：175 50%=350 ml350 ml,实例,10KCL 45ml（可另加口服“补达秀 1.0/Bid”）,25%MgSO2 15ml,10%葡萄糖酸钙 1020ml+NS 3040ml 另外泵入（1h内）不可加入3L袋,甘油磷酸钠 10ml（缺货）,维他利匹特（脂溶性维生素）10ml,水乐维他（水溶性维生素）10ml或V佳林 1支,安达美（微量元素）10ml,纤维素,丙氨酰谷氨酰胺注射液（力太）100ml,胰岛素（G:I=8:1）：24u,实例,20%人血白蛋白50ml iv bid；每次滴完后“速尿”20mg iv，观察尿量能否达到200300ml/h。如果尿量大大多于上面数值侧可以下次使用速尿时减少用量（如10mg、5mg等），反之如果尿量不能达到200ml/h，则可以将速尿加量至40mg。对于少尿病人也可以使用24小时泵入速尿的办法来维持均匀尿量。,心脏：多巴胺0.1-0.2+普鲁卡因0.5+NS 50ml 24ml/h,贫血：输注CRBC:400ml（可提升2g Hb）,Rehabilitation,Osteoporosis treatment,主要文献来源,Management of Proximal Femoral Fractures 2011:,A national clinical guideline,Scotland,Evidence-based guidelines for the management of hip fractures in older persons:an update.,Jenson C S Mak,Ian D Cameron and Lyn M March,MJA 2010;192(1):37-41,Perioperative management of proximal hip fractures in the elderly:the surgeon and the anesthesiologist.,Minerva Anestesiol.2011 Jul;77(7):715-22.Epub 2011 Feb 1.,Perioperative considerations in geriatric patients with hip fracture:what is the evidence?,J Orthop Trauma.2009 Jul;23(6):386-94.,Best Practices for Elderly Hip Fracture Patients:A Systematic Overview of the Evidence.,J Gen Intern Med.2005 November;20(11):10191025,