老年髋部骨折围手术期相关问题ppt课件

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老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题1 1Pre-operativeTreatment strategySurgical fixation of fractured hips remains the standard of care老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativeTreatmentstrateg2 2Pre-operativeEvaluationComplete history,physical examination,laboratory examinationsAssessment of the surgical risksSystem deficits identified,and correctedThe American Association of Anaesthetists grading老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativeEvaluation老年髋部骨折3 3ASA Physical Status(PS)Classification System*:ASA PS CategoryPreoperative Health StatusComments,Examples*ASAPSclassificationsfromtheAmericanSocietyofAnesthesiologistsASAPS1NormalhealthypatientNoorganic,physiologic,orpsychiatricdisturbance;excludestheveryyoungandveryold;healthywithgoodexercisetoleranceASAPS2PatientswithmildsystemicdiseaseNofunctionallimitations;hasawell-controlleddiseaseofonebodysystem;controlledhypertensionordiabeteswithoutsystemiceffects,cigarettesmokingwithoutchronicobstructivepulmonarydisease(COPD);mildobesity,pregnancyASAPS3PatientswithseveresystemicdiseaseSomefunctionallimitation;hasacontrolleddiseaseofmorethanonebodysystemoronemajorsystem;noimmediatedangerofdeath;controlledcongestiveheartfailure(CHF),stableangina,oldheartattack,poorlycontrolledhypertension,morbidobesity,chronicrenalfailure;bronchospasticdiseasewithintermittentsymptomsASAPS4PatientswithseveresystemicdiseasethatisaconstantthreattolifeHasatleastoneseverediseasethatispoorlycontrolledoratendstage;possibleriskofdeath;unstableangina,symptomaticCOPD,symptomaticCHF,hepatorenalfailureASAPS5MoribundpatientswhoarenotexpectedtosurvivewithouttheoperationNotexpectedtosurvive24hourswithoutsurgery;imminentriskofdeath;multiorganfailure,sepsissyndromewithhemodynamicinstability,hypothermia,poorlycontrolledcoagulopathyASAPS6Adeclaredbrain-deadpatientwhoorgansarebeingremovedfordonorpurposes老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题ASAPhysicalStatus(PS)Class4 4Pre-operativePain：acetaminophen Approximately 40%of patients moderate renal dysfunction(eGFR 60 ml/min/1.73m2)Opioids：with caution NSAIDS:relatively contrindicated 老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativePain：acetaminophe5 5Pre-operativePreoperative tractionAbandoned老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativePreoperativetrac6 6Pre-operativePreoperative DVT prophylaxisPressuregradientstockings;LMWH:12hpriortosurgery;Aspirinwithheld老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativePreoperativeDVT7 7Pre-operativeHemoglobin(Hb)Pre-operativeanaemiainapproximately40%Pre-operativetransfusionconsideredif:Hb is 17*109/Lmayindicateinfection(usuallychestorurine).老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativeWhitecellcount9 9Pre-operativePlatelet countBelow50*109/Lnormallyrequirepre-operativeplatelettransfusion.老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativePlateletcount老年1010Pre-operativeAtrial Fibrillation(AF)Ventricularrateoflessthan100required.Factors:hypokalemia,hypomagnesemia,hypovolemia,sepsis,painandhypoxemia.Beta-blockerstocontrolHR老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativeAtrialFibrillati1111Pre-operativeDiabetes Hyperglycemia is not a reason to delay surgery unless the patient is ketotic and/or dehydrated.老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativeDiabetes老年髋部骨折围手1212Pre-operativeDialysis Surgery tailored around the dialysis;Urgent surgery may necessitate heparin-free dialysis老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativeDialysis老年髋部骨折围手1313Pre-operativeTime to surgery Earlysurgery(2436h)recommendedNodelayforpatientsmildtomoderatehypertension(systolic180mmHganddiastolic110mmHg)NoawaitingechocardiographyNodelayforminorelectrolyteabnormalities老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativeTimetosurgery老1414Pre-operativeReasons to optimise SevereanemiaHb8g/dl Severeelectrolyteimbalance,withplasmasodium150mmol/landpotassium6.0mmol/l.Uncontrolleddiabetes老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativeReasonstooptimi1515Pre-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 老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Pre-operativeReasonstooptimi1616Intra-operativeAntibiotics AntibioticsadministeredbeforeskinincisionHospitalantibioticprotocolsfollowed老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Intra-operativeAntibiotics老1717Intra-operativeAnaesthetic considerations Regional anesthesia recommended Keep intra-op diastolic60mmHg老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Intra-operativeAnaestheticco1818Intra-operativeIntravenous fluidsManypatientshypovolemicatthetimeofsurgeryColloidsreducehospitalstayandimproveoutcome老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Intra-operativeIntravenousfl1919Post-operativePain management Post-opepiduralanesthesialesscommonRegularacetaminophenthroughoutperioperativeperiod.NSAIDSusedwithextremecaution,andcontraindicatedinthosewithrenaldysfunction 老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Post-operativePainmanagement2020Post-operativePain management Opioids(andtramadol)usedwithcautioninpatientswithrenaldysfunctionOralopioidsavoided,andintravenousdoseshalvedwithahalvedfrequencyCodeineshouldnotbeadministered(constipating,emetic,perioperativecognitivedysfunction)老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Post-operativePainmanagement2121Post-operativeDVT prophylaxis LMWH;Warfarin;Rivaroxaban10-35days老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Post-operativeDVTprophylaxis2222Post-operativeOxygen Supplementaloxygenpost-operativelyforatleast24hoursSomeevidencesupportsoxygentherapyforthefirst72h老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Post-operativeOxygen老年髋部骨折围手2323Post-operativeFluid balance HypovolemiacommonEarlyoralfluidintakeencouragedUrinarycathetersremovedassoonaspossibleRoutinetransfusioninasymptomaticpatientswithahaemoglobinlevel80g/Lnotberequired.老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Post-operativeFluidbalance2424Post-operativePostoperative delirium Common(25%-50%)withhipsurgeryCommon(25%-50%)withhipsurgery Factors:hypoxia,hypoglycaemia,majorfluidandFactors:hypoxia,hypoglycaemia,majorfluidandelectrolyteimbalances,sepsisandmajororganelectrolyteimbalances,sepsisandmajororganimpairmentimpairmentProphylactic low-dose haloperidol may reduce severity Prophylactic low-dose haloperidol may reduce severity and duration of deliriumand duration of delirium 老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Post-operativePostoperatived2525Post-operativeNutrition Up to 60%of hip fracture patients clinically malnourished on admission The calorie and protein density of hospital food often poor 老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Post-operativeNutrition老年髋部2626Post-operative 1、热量：热氮比、热量：热氮比=100150:1 2、蛋白（按、蛋白（按0.15-0.2g氮氮/kg/d）计算（）计算（1g氮氮=6.25g氨基酸）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=4.1 kcal，1g脂脂肪肪=9.3 kcal老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题Post-operative1、热量：热氮比=1002727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/天天老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题实例男，88岁，股骨颈骨折半髋术后第4天老年髋部骨折围手术2828实例实例 血常规：血常规：WBC 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老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题实例血常规：WBC4.05109/L；RBC2.962929实例实例 1、每日氮需要量：、每日氮需要量：0.17555=9.6g，即，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：、补充脂肪：4809.352 g5、补充葡萄糖：、补充葡萄糖：7204.1175 g老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题实例1、每日氮需要量：0.17555=9.6g，即93030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).750ml0.9NaCL：500ml（4.5g钠）500ml糖用50%GS补入：17550%=350ml350ml老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题实例预计补液量：1750.1=1750ml（3L袋内糖浓3131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).750ml0.9NaCL：500ml（4.5g钠）500ml糖用50%GS补入：17550%=350ml350ml老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题实例预计补液量：1750.1=1750ml（3L袋内糖浓3232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老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题实例10KCL45ml（可另加口服“补达秀1.0/B3333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）老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题实例20%人血白蛋白50mlivbid；每次滴完后“速3434RehabilitationOsteoporosis treatment老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题RehabilitationOsteoporosi3535主要文献来源主要文献来源ManagementofProximalFemoralFractures2011:ManagementofProximalFemoralFractures2011:A national A national clinical guideline,Scotlandclinical guideline,ScotlandEvidence-basedguidelinesforthemanagementofhipfracturesinEvidence-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 proximal 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.Perioperative 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 老年髋部骨折围手术期相关问题老年髋部骨折围手术期相关问题主要文献来源ManagementofProximalF3636