老年髖部骨折圍手術(shù)期相關(guān)問(wèn)題

1、老年髖部骨折圍手術(shù)期相關(guān)問(wèn)題,Pre-operative,,Treatment strategySurgical fixation of fractured hips remains the standard of care,Pre-operative,,Evaluation Complete history, physical examination, laboratory examinationsAssessment of

2、 the surgical risks System deficits identified, and correctedThe American Association of Anaesthetists grading,,Pre-operative,,Pain：acetaminophen Approximately 40% of patients moderate renal dysfunction (eGFR <60

3、 ml/min/1.73m2) Opioids：with caution NSAIDS: relatively contrindicated,Pre-operative,,Preoperative traction Abandoned,Pre-operative,,Preoperative DVT prophylaxis Pressure gradient stockings; LMWH: 12h

4、 prior to surgery; Aspirin withheld,Pre-operative,,Hemoglobin (Hb) Pre-operative anaemia in approximately 40% Pre-operative transfusion considered if: ●Hb is <9g/dl. ●Hb is 9 – 9.9g/dl and there is a his

5、tory of ischaemic heart disease.,Pre-operative,,White cell count Leucocytosis and neutrophilia common (45%, 60% respectively) at presentation; Marked leukocytosis > 17*109 /L may indicate infection (usually che

6、st or urine).,Pre-operative,,Platelet count Below 50*109/L normally require pre-operative platelet transfusion.,Pre-operative,,Atrial Fibrillation (AF) Ventricular rate of less than 100 required. Factors: hy

7、pokalemia,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 dehydrate

8、d.,Pre-operative,,Dialysis Surgery tailored around the dialysis; Urgent surgery may necessitate heparin-free dialysis,Pre-operative,,Time to surgery ● Early surgery (24–36 h) recommended ● No delay fo

9、r 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

10、Hb 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 ＞12

11、0 bpm ● Chest infection with sepsis ● Reversible coagulopathy,Intra-operative,,Antibiotics Antibiotics administered before skin incision Hospital antibiotic protocols followed,Intra-operative,,Anaesthetic consi

12、derations 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 outc

13、ome,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 d

14、ysfunction,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

15、not be administered (constipating, emetic, perioperative cognitive dysfunction),Post-operative,,DVT prophylaxis LMWH; Warfarin; Rivaroxaban 10-35 days,Post-operative,,Oxygen Supplemental oxygen post-operativel

16、y for at least 24 hours Some evidence supports oxygen therapy for the first 72 h,Post-operative,,Fluid balance Hypovolemia common Early oral fluid intake encouraged Urinary catheters removed as s

17、oon as possible Routine transfusion in asymptomatic patients with a haemoglobin level ≥ 80 g/L not be required.,Post-operative,,Postoperative delirium Common (25%-50%) with hip surgery Factors: hyp

18、oxia, 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

19、% of hip fracture patients clinically malnourished on admission The calorie and protein density of hospital food often poor,Post-operative,,1、熱量：熱氮比=100~150:1 2、蛋白（按0.15-0.2g氮/kg/d）計(jì)算（1g氮=6.25g氨基酸） 3、糖脂肪混合能源

20、中：糖/脂 =3/2 4、產(chǎn)熱效能：1g糖=1g蛋白質(zhì)=4.1 kcal，1g脂肪=9.3 kcal,實(shí)例,,男，88歲，股骨頸骨折半髖術(shù)后第4天體檢：HR: 90bpm，BP：120/70mmHg，T：36.5℃，W：55kg，SaO2 98% 精神稍微萎靡，神智清，認(rèn)知能力好，貧血貌，傷口干燥，無(wú)紅腫。雙肺呼吸音清（CT提示：胸腔積液），陰囊水腫，入量400ml，尿量1900ml，可少量進(jìn)食，保留尿管，大便通暢有

21、腹瀉7-8次/天,實(shí)例,,血常規(guī)：WBC 4.05×109/L；RBC2.96 ×1012/L，HGB 69g/L; Hct 0.198; Lymph: <0.640×109/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,實(shí)例,,1、每日氮需要量：0.175×55

22、=9.6g，即9.6×6.25=60g氨基酸 2、每日需要熱量：9.6×125=1200 kcal 糖供熱：1200×3/5=720 kcal/d 脂肪供熱：1200×2/5=480 kcal/d4、補(bǔ)充脂肪：480÷9.3≈52 g5、補(bǔ)充葡萄糖：720÷4.1≈175 g,實(shí)例,,預(yù)計(jì)補(bǔ)液量：175÷0.1=1750ml（

23、3L袋內(nèi)糖濃度≯10%）………………………….2000ml20%脂肪乳（力能）250ml（50g：488 kcal）補(bǔ)入………………………………..250 ml氨基酸（法譜）（8.5%/250ml）：60÷21.5≈3(約750 ml)………….750 ml0.9NaCL：500ml（4.5g鈉）…………………………………500 ml糖用50% GS補(bǔ)入：175÷ 50%=350 ml………………………………

24、……350 ml,實(shí)例,,預(yù)計(jì)補(bǔ)液量：175÷0.1=1750ml（3L袋內(nèi)糖濃度≯10%）………………………….2000ml20%脂肪乳（力能）250ml（50g：488 kcal）補(bǔ)入………………………………..250 ml氨基酸（法譜）（8.5%/250ml）：60÷21.5≈3(約750 ml)………….750 ml0.9NaCL：500ml（4.5g鈉）…………………………………500 ml糖用50

25、% GS補(bǔ)入：175÷ 50%=350 ml……………………………………350 ml,實(shí)例,,10KCL 45ml （可另加口服“補(bǔ)達(dá)秀 1.0/Bid”）25%MgSO2 15ml10% 葡萄糖酸鈣 10~20ml+NS 30~40ml 另外泵入（1h內(nèi)）不可加入3L袋甘油磷酸鈉 10ml（缺貨）維他利匹特（脂溶性維生素） 10ml水樂(lè)維他（水溶性維生素） 10ml或V佳林 1支安達(dá)美（微量元素） 10ml纖維

26、素丙氨酰谷氨酰胺注射液（力太） 100ml胰島素（G:I=8:1）：24u,實(shí)例,,20%人血白蛋白50ml iv bid；每次滴完后“速尿”20mg iv，觀察尿量能否達(dá)到200~300ml/h。如果尿量大大多于上面數(shù)值側(cè)可以下次使用速尿時(shí)減少用量（如10mg、5mg等），反之如果尿量不能達(dá)到200ml/h，則可以將速尿加量至40mg。對(duì)于少尿病人也可以使用24小時(shí)泵入速尿的辦法來(lái)維持均勻尿量。心臟：多巴胺0.1-0.

27、2+普魯卡因0.5+NS 50ml 2~4ml/h貧血：輸注CRBC: 400ml（可提升2g Hb）,Rehabilitation,,Osteoporosis treatment,主要文獻(xiàn)來(lái)源,,Management of Proximal Femoral Fractures 2011: A national clinical guideline, ScotlandEvidence-based guidelines for the

28、 management of hip fractures in older persons: an update. Jenson C S Mak, Ian D Cameron and Lyn M March,MJA 2010; 192 (1): 37-41Perioperative management of proximal hip fractures in the elderly: the surgeon and the anes

29、thesiologist. 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