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1、老年髋部骨折围手术期老年髋部骨折围手术期相关问题相关问题Pre-operativeTreatment strategySurgical fixation of fractured hips remains the standard of carePre-operativeEvaluationComplete history, physical examination, laboratory examinationsAssessment of the surgical risksSystem deficits identified, and correctedThe American Assoc
2、iation of Anaesthetists gradingASA Physical Status (PS) Classification System*:ASA PS CategoryPreoperative Health StatusComments, Examples*ASAPSclassificationsfromtheAmericanSocietyofAnesthesiologistsASAPS1NormalhealthypatientNoorganic,physiologic,orpsychiatricdisturbance;excludestheveryyoungandvery
3、old;healthywithgoodexercisetoleranceASAPS2PatientswithmildsystemicdiseaseNofunctionallimitations;hasawell-controlleddiseaseofonebodysystem;controlledhypertensionordiabeteswithoutsystemiceffects,cigarettesmokingwithoutchronicobstructivepulmonarydisease(COPD);mildobesity,pregnancyASAPS3Patientswithsev
4、eresystemicdiseaseSomefunctionallimitation;hasacontrolleddiseaseofmorethanonebodysystemoronemajorsystem;noimmediatedangerofdeath;controlledcongestiveheartfailure(CHF),stableangina,oldheartattack,poorlycontrolledhypertension,morbidobesity,chronicrenalfailure;bronchospasticdiseasewithintermittentsympt
5、omsASAPS4PatientswithseveresystemicdiseasethatisaconstantthreattolifeHasatleastoneseverediseasethatispoorlycontrolledoratendstage;possibleriskofdeath;unstableangina,symptomaticCOPD,symptomaticCHF,hepatorenalfailureASAPS5MoribundpatientswhoarenotexpectedtosurvivewithouttheoperationNotexpectedtosurviv
6、e24hourswithoutsurgery;imminentriskofdeath;multiorganfailure,sepsissyndromewithhemodynamicinstability,hypothermia,poorlycontrolledcoagulopathyASAPS6Adeclaredbrain-deadpatientwhoorgansarebeingremovedfordonorpurposesPre-operativePain：acetaminophen Approximately 40% of patients moderate renal dysfuncti
7、on (eGFR 60 ml/min/1.73m2) Opioids：with caution NSAIDS: relatively contrindicated Pre-operativePreoperative tractionAbandonedPre-operativePreoperative DVT prophylaxisPressuregradientstockings;LMWH:12hpriortosurgery;AspirinwithheldPre-operativeHemoglobin (Hb)Pre-operativeanaemiainapproximately40%Pre-
8、operativetransfusionconsideredif: Hb is 17*109/Lmayindicateinfection(usuallychestorurine).Pre-operativePlatelet countBelow50*109/Lnormallyrequirepre-operativeplatelettransfusion.Pre-operativeAtrial Fibrillation (AF)Ventricularrateoflessthan100required.Factors:hypokalemia,hypomagnesemia,hypovolemia,s
9、epsis,painandhypoxemia.Beta-blockerstocontrolHRPre-operativeDiabetes Hyperglycemia is not a reason to delay surgery unless the patient is ketotic and/or dehydrated.Pre-operativeDialysis Surgery tailored around the dialysis; Urgent surgery may necessitate heparin-free dialysisPre-operativeTime to sur
10、gery Earlysurgery(2436h)recommendedNodelayforpatientsmildtomoderatehypertension(systolic180mmHganddiastolic110mmHg)NoawaitingechocardiographyNodelayforminorelectrolyteabnormalitiesPre-operativeReasons to optimise SevereanemiaHb8g/dl Severeelectrolyteimbalance,withplasmasodium150mmol/landpotassium6.0
11、mmol/l. UncontrolleddiabetesPre-operativeReasons 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-operativeAntibiotics AntibioticsadministeredbeforeskinincisionHo
12、spitalantibioticprotocolsfollowedIntra-operativeAnaesthetic considerations Regional anesthesia recommended Keep intra-op diastolic60mmHgIntra-operativeIntravenous fluidsManypatientshypovolemicatthetimeofsurgeryColloidsreducehospitalstayandimproveoutcomePost-operativePain management Post-opepiduralan
13、esthesialesscommonRegularacetaminophenthroughoutperioperativeperiod.NSAIDSusedwithextremecaution,andcontraindicatedinthosewithrenaldysfunction Post-operativePain management Opioids(andtramadol)usedwithcautioninpatientswithrenaldysfunctionOralopioidsavoided,andintravenousdoseshalvedwithahalvedfrequen
14、cyCodeineshouldnotbeadministered(constipating,emetic,perioperativecognitivedysfunction)Post-operativeDVT prophylaxis LMWH;Warfarin;Rivaroxaban10-35daysPost-operativeOxygen Supplementaloxygenpost-operativelyforatleast24hoursSomeevidencesupportsoxygentherapyforthefirst72hPost-operativeFluid balance Hy
15、povolemiacommonEarlyoralfluidintakeencouragedUrinarycathetersremovedassoonaspossibleRoutinetransfusioninasymptomaticpatientswithahaemoglobinlevel80g/Lnotberequired.Post-operativePostoperative delirium Common(25%-50%)withhipsurgeryCommon(25%-50%)withhipsurgery Factors:hypoxia,hypoglycaemia,majorfluid
16、andFactors:hypoxia,hypoglycaemia,majorfluidandelectrolyteimbalances,sepsisandmajororganelectrolyteimbalances,sepsisandmajororganimpairmentimpairmentProphylactic low-dose haloperidol may reduce severity Prophylactic low-dose haloperidol may reduce severity and duration of deliriumand duration of deli
17、rium Post-operativeNutrition 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、热量：热氮比=100150:1 2、蛋白（按氮、蛋白（按氮/kg/d）计算（）计算（1g氮氨基酸）氮氨基酸） 3、糖脂肪混合能源中：糖、糖脂肪混合能源中：糖/脂脂 =3/2 4、产热效能：、产热效能：1g糖糖=1g蛋白质蛋白质=4
18、.1 kcal，1g脂脂肪肪=9.3 kcal实例实例 男，男，88岁，股骨颈骨折半髋术后第岁，股骨颈骨折半髋术后第4天天体检：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，精神稍微萎靡，神智清，认知能力好，贫血貌，伤口干燥伤口干燥，无红肿。双肺呼吸音清（，无红肿。双肺呼吸音清（CT提示：提示：胸腔积液），阴囊水肿，入量胸腔积液），阴囊水肿，入量400ml，尿量，尿量1900ml，可少量进食，保留尿管，大便通畅有，可少量进食，保留尿管，大便通畅有腹泻腹泻7-8次次/天天实例实例 血常规：血常规：WB
19、C 4.05109/L；RBC2.96 1012/L，HGB 69g/L; Hct 0.198; Lymph: 0.640109/L血生化：血生化： 白蛋白：白蛋白：26.1 g/L，球蛋白：，球蛋白：14.6 g/L ，K：3.15 mmol/L, Ca 1.91 mmol/L , Iphos 0.56 mmol/L实例实例 1、每日氮需要量：，即、每日氮需要量：，即9.66.25=60g氨基酸氨基酸 2、每日需要热量：、每日需要热量：9.6125=1200 kcal 糖供热：糖供热：12003/5=720 kcal/d 脂肪供热：脂肪供热：12002/5=480 kcal/d4、补充脂肪：
20、、补充脂肪：4809.352 g5、补充葡萄糖：、补充葡萄糖：7204.1175 g实例实例 预计补液量：预计补液量：1750.1=1750ml（3L袋内糖浓度10%）.2000ml20%脂肪乳（力能）250ml（50g：488kcal）补入.250ml氨基酸（法谱）（8.5%/250ml）：6021.53(约750ml).750ml：500ml（钠）500ml糖用50%GS补入：17550%=350ml350ml实例实例 预计补液量：预计补液量：1750.1=1750ml（3L袋内糖浓度10%）.2000ml20%脂肪乳（力能）250ml（50g：488kcal）补入.250ml氨基酸（法谱
21、）（8.5%/250ml）：6021.53(约750ml).750ml：500ml（钠）500ml糖用50%GS补入：17550%=350ml350ml实例实例 10KCL45ml10KCL45ml（可另加口服（可另加口服“ “补达秀补达秀1.0/Bid”1.0/Bid”）25%MgSO215ml25%MgSO215ml10%10%葡萄糖酸钙葡萄糖酸钙1020ml+NS3040ml1020ml+NS3040ml另外泵入另外泵入（1h1h内）不可加入内）不可加入3L3L袋袋甘油磷酸钠甘油磷酸钠10ml10ml（缺货）（缺货）维他利匹特（脂溶性维生素）维他利匹特（脂溶性维生素）10ml10ml水乐
22、维他（水溶性维生素）水乐维他（水溶性维生素）10ml10ml或或V V佳林佳林11支支安达美（微量元素）安达美（微量元素）10ml10ml纤维素纤维素丙氨酰谷氨酰胺注射液（力太）丙氨酰谷氨酰胺注射液（力太）100ml100ml胰岛素（胰岛素（G:I=8:1G:I=8:1）：）：24u24u实例实例 20%人血白蛋白50mlivbid；每次滴完后“速尿”20mgiv，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
23、匀尿量。心脏：多巴胺0.1-0.2+普鲁卡因0.5+NS50ml24ml/h贫血：输注CRBC:400ml（可提升2gHb）RehabilitationOsteoporosis treatment主要文献来源主要文献来源ManagementofProximalFemoralFractures2011:ManagementofProximalFemoralFractures2011: A national A national clinical guideline, Scotlandclinical guideline, ScotlandEvidence-basedguidelinesforth
24、emanagementofhipfracturesinEvidence-basedguidelinesforthemanagementofhipfracturesinolderpersons:anupdate.olderpersons:anupdate.Jenson C S Mak, Ian D Cameron and Lyn Jenson C S Mak, Ian D Cameron and Lyn M March,MJA 2010; 192 (1): 37-41M March,MJA 2010; 192 (1): 37-41Perioperative management of proxi
25、mal hip fractures in the elderly: Perioperative management of proximal hip fractures in the elderly: the surgeon and the anesthesiologist. the surgeon and the anesthesiologist. Minerva Anestesiol. 2011 Minerva Anestesiol. 2011 Jul;77(7):715-22. Epub 2011 Feb 1.Jul;77(7):715-22. Epub 2011 Feb 1.Perio
26、perative considerations in geriatric patients with hip fracture: Perioperative considerations in geriatric patients with hip fracture: what is the evidence? what is the evidence? J Orthop Trauma. 2009 Jul;23(6):386-94.J Orthop Trauma. 2009 Jul;23(6):386-94.Best Practices for Elderly Hip Fracture Patients: A Systematic Best Practices for Elderly Hip Fracture Patients: A Systematic Overview of the Evidence. Overview of the Evidence. J Gen Intern Med. 2005 November; J Gen Intern Med. 2005 November; 20(11): 1019102520(11): 10191025
