老年髋部骨折围手术期相关问题课件.ppt

老年髋部骨折围手术期相关问题,Pre-operative,Treatment strategySurgical fixation of fractured hips remains the standard of care,Pre-operative,Evaluation Complete history,physical examination,laboratory examinationsAssessment of 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 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(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 optimiseSevere 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 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%）.2000ml20%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 ml0.9NaCL：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%）.2000ml20%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 ml0.9NaCL：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 15ml10%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,ScotlandEvidence-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):37-41Perioperative 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,