老年髖部骨折圍手術(shù)期

相關(guān)問題.Pre-operativeTreatmentstrategySurgicalfixationoffracturedhipsremainsthestandardofcare

.Pre-operativeEvaluation

Completehistory,physicalexamination,laboratoryexaminationsAssessmentofthesurgicalrisks

Systemdeficitsidentified,andcorrectedTheAmericanAssociationofAnaesthetistsgrading

.ASAPhysicalStatus(PS)ClassificationSystem*:ASAPSCategoryPreoperativeHealthStatusComments,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,hepatorenalfailureASAPS5MoribundpatientswhoarenotexpectedtosurvivewithouttheoperationNotexpectedtosurvive>24hourswithoutsurgery;imminentriskofdeath;multiorganfailure,sepsissyndromewithhemodynamicinstability,hypothermia,poorlycontrolledcoagulopathyASAPS6Adeclaredbrain-deadpatientwhoorgansarebeingremovedfordonorpurposes.Pre-operativePain：acetaminophenApproximately40%ofpatientsmoderaterenaldysfunction(eGFR<60ml/min/1.73m2)Opioids：withcautionNSAIDS:relativelycontrindicated.Pre-operativePreoperativetraction

Abandoned.Pre-operativePreoperativeDVTprophylaxisPressuregradientstockings;LMWH:12hpriortosurgery;Aspirinwithheld

.Pre-operativeHemoglobin(Hb)

Pre-operativeanaemiainapproximately40%Pre-operativetransfusionconsideredif:

●Hbis<9g/dl.

●Hbis9–9.9g/dlandthereisahistoryofischaemicheartdisease.

.Pre-operativeWhitecellcount

Leucocytosisandneutrophiliacommon(45%,60%respectively)atpresentation;Markedleukocytosis>17*109/Lmayindicateinfection(usuallychestorurine).

.Pre-operativePlateletcount

Below50*109/Lnormallyrequirepre-operativeplatelettransfusion..Pre-operativeAtrialFibrillation(AF)

Ventricularrateoflessthan100required.Factors:hypokalemia,hypomagnesemia,hypovolemia,sepsis,painandhypoxemia.Beta-blockerstocontrolHR.Pre-operativeDiabetes

Hyperglycemiaisnotareasontodelaysurgeryunlessthepatientisketoticand/ordehydrated.

.Pre-operativeDialysis

Surgerytailoredaroundthedialysis;

Urgentsurgerymaynecessitateheparin-freedialysis.Pre-operativeTimetosurgery

●

Earlysurgery(24–36

h)recommended

●Nodelayforpatientsmildtomoderatehypertension(systolic＜180mmHganddiastolic＜110mmHg)●Noawaitingechocardiography●Nodelayforminorelectrolyteabnormalities

.Pre-operativeReasonstooptimise●SevereanemiaHb<8g/dl●Severeelectrolyteimbalance,withplasma[sodium]<120or>150mmol/land[potassium]<2.8or>6.0mmol/l.●Uncontrolleddiabetes.Pre-operativeReasonstooptimise●Uncontrolledoracuteonsetleftventricularfailure●Correctablecardiacarrhythmia,withaventricularrate＞120bpm●Chestinfectionwithsepsis●Reversiblecoagulopathy.Intra-operative

Antibiotics

AntibioticsadministeredbeforeskinincisionHospitalantibioticprotocolsfollowed.Intra-operative

Anaestheticconsiderations

RegionalanesthesiarecommendedKeepintra-opdiastolic≥60mmHg

.Intra-operative

Intravenousfluids

ManypatientshypovolemicatthetimeofsurgeryColloidsreducehospitalstayandimproveoutcome.Post-operative

Painmanagement

Post-opepiduralanesthesialesscommonRegularacetaminophenthroughoutperioperativeperiod.

NSAIDSusedwithextremecaution,andcontraindicatedinthosewithrenaldysfunction

.Post-operative

Painmanagement

Opioids(andtramadol)usedwithcautioninpatientswithrenaldysfunctionOralopioidsavoided,andintravenousdoseshalvedwithahalvedfrequencyCodeineshouldnotbeadministered(constipating,emetic,perioperativecognitivedysfunction)

.Post-operative

DVTprophylaxis

LMWH;Warfarin;Rivaroxaban10-35days

.Post-operative

Oxygen

Supplementaloxygenpost-operativelyforatleast24hoursSomeevidencesupportsoxygentherapyforthefirst72

h.Post-operative

Fluidbalance

HypovolemiacommonEarlyoralfluidintakeencouragedUrinarycathetersremovedassoonaspossibleRoutinetransfusioninasymptomaticpatientswithahaemoglobinlevel≥

80

g/Lnotberequired..Post-operative

Postoperativedelirium

Common(25%-50%)withhipsurgery

Factors:hypoxia,hypoglycaemia,majorfluidandelectrolyteimbalances,sepsisandmajororganimpairment

Prophylacticlow-dosehaloperidolmayreduceseverityanddurationofdelirium

.Post-operative

Nutrition

Upto60%ofhipfracturepatientsclinicallymalnourishedonadmissionThecalorieandproteindensityofhospitalfoodoftenpoor

.Post-operative

1、熱量：熱氮比=100~150:1

2、蛋白（按0.15-0.2g氮/kg/d）計算（1g氮=6.25g氨基酸）

3、糖脂肪混合能源中：糖/脂=3/2

4、產(chǎn)熱效能：1g糖=1g蛋白質(zhì)=4.1kcal，1g脂肪=9.3kcal

.實例男，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，SaO298%精神稍微萎靡，神智清，認(rèn)知能力好，貧血貌，傷口干燥，無紅腫。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，大便通暢有腹瀉7-8次/天.實例血常規(guī)：WBC4.05×109/L；RBC2.96×1012/L，HGB69g/L;Hct0.198;Lymph:<0.640×109/L血生化：白蛋白：26.1g/L，球蛋白：14.6g/L，K：3.15mmol/L,Ca1.91mmol/L,Iphos0.56mmol/L.實例1、每日氮需要量：0.175×55=9.6g，即9.6×6.25=60g氨基酸2、每日需要熱量：9.6×125=1200kcal糖供熱：1200×3/5=720kcal/d脂肪供熱：1200×2/5=480kcal/d

4、補(bǔ)充脂肪：480÷9.3≈52g

5、補(bǔ)充葡萄糖：720÷4.1≈175g.實例預(yù)計補(bǔ)液量：175÷0.1=1750ml（3L袋內(nèi)糖濃度≯10%）………….2000ml20%脂肪乳（力能）250ml（50g：488kcal）補(bǔ)入………………..250ml氨基酸（法譜）（8.5%/250ml）：60÷21.5≈3(約750ml)………….750ml0.9NaCL：500ml（4.5g鈉）…………………500ml糖用50%GS補(bǔ)入：175÷50%=350ml……350ml.實例預(yù)計補(bǔ)液量：175÷0.1=1750ml（3L袋內(nèi)糖濃度≯10%）………….2000ml20%脂肪乳（力能）250ml（50g：488kcal）補(bǔ)入………………..250ml氨基酸（法譜）（8.5%/250ml）：60÷21.5≈3(約750ml)………….750ml0.9NaCL：500ml（4.5g鈉）…………………500ml糖用50%GS補(bǔ)入：175÷50%=350ml……350ml.實例10KCL45ml（可另加口服“補(bǔ)達(dá)秀1.0/Bid”）25%MgSO215ml10%葡萄糖酸鈣10~20ml+NS30~40ml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纖維素丙氨酰谷氨酰胺注射液（力太）

100ml胰島素（G:I=8:1）：24u.實例20%人血白蛋白50mlivbid；每次滴完后“速尿”20mgiv，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。對于少尿病人也可以使用24小時泵入速尿的辦法來