老年髋部骨折围手术期相关问题.ppt

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,Pre-operative,Pain：acetaminophen Approximately 40% of patients moderate renal dysfunction (eGFR 60 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 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 history 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 chest 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: 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 (2436 h) 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 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 72 h,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 80 g/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/d 4、补充脂肪：4809.352 g 5、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 anesthesiol