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,TreatmentstrategySurgicalfixationoffracturedhipsremainsthestandardofcare,Pre-operative,EvaluationCompletehistory,physicalexamination,laboratoryexaminationsAssessmentofthesurgicalrisksSystemdeficitsidentified,andcorrectedTheAmericanAssociationofAnaesthetistsgrading,Pre-operative,Pain：acetaminophenApproximately40%ofpatientsmoderaterenaldysfunction(eGFR60ml/min/1.73m2)Opioids：withcautionNSAIDS:relativelycontrindicated,Pre-operative,PreoperativetractionAbandoned,Pre-operative,PreoperativeDVTprophylaxisPressuregradientstockings;LMWH:12hpriortosurgery;Aspirinwithheld,Pre-operative,Hemoglobin(Hb)Pre-operativeanaemiainapproximately40%Pre-operativetransfusionconsideredif:Hbis17*109/Lmayindicateinfection(usuallychestorurine).,Pre-operative,PlateletcountBelow50*109/Lnormallyrequirepre-operativeplatelettransfusion.,Pre-operative,AtrialFibrillation(AF)Ventricularrateoflessthan100required.Factors:hypokalemia,hypomagnesemia,hypovolemia,sepsis,painandhypoxemia.Beta-blockerstocontrolHR,Pre-operative,DiabetesHyperglycemiaisnotareasontodelaysurgeryunlessthepatientisketoticand/ordehydrated.,Pre-operative,DialysisSurgerytailoredaroundthedialysis;Urgentsurgerymaynecessitateheparin-freedialysis,Pre-operative,TimetosurgeryEarlysurgery(2436h)recommendedNodelayforpatientsmildtomoderatehypertension(systolic180mmHganddiastolic110mmHg)NoawaitingechocardiographyNodelayforminorelectrolyteabnormalities,Pre-operative,ReasonstooptimiseSevereanemiaHb150mmol/landpotassium6.0mmol/l.Uncontrolleddiabetes,Pre-operative,ReasonstooptimiseUncontrolledoracuteonsetleftventricularfailureCorrectablecardiacarrhythmia,withaventricularrate120bpmChestinfectionwithsepsisReversiblecoagulopathy,Intra-operative,AntibioticsAntibioticsadministeredbeforeskinincisionHospitalantibioticprotocolsfollowed,Intra-operative,AnaestheticconsiderationsRegionalanesthesiarecommendedKeepintra-opdiastolic60mmHg,Intra-operative,IntravenousfluidsManypatientshypovolemicatthetimeofsurgeryColloidsreducehospitalstayandimproveoutcome,Post-operative,PainmanagementPost-opepiduralanesthesialesscommonRegularacetaminophenthroughoutperioperativeperiod.NSAIDSusedwithextremecaution,andcontraindicatedinthosewithrenaldysfunction,Post-operative,PainmanagementOpioids(andtramadol)usedwithcautioninpatientswithrenaldysfunctionOralopioidsavoided,andintravenousdoseshalvedwithahalvedfrequencyCodeineshouldnotbeadministered(constipating,emetic,perioperativecognitivedysfunction),Post-operative,DVTprophylaxisLMWH;Warfarin;Rivaroxaban10-35days,Post-operative,OxygenSupplementaloxygenpost-operativelyforatleast24hoursSomeevidencesupportsoxygentherapyforthefirst72h,Post-operative,FluidbalanceHypovolemiacommonEarlyoralfluidintakeencouragedUrinarycathetersremovedassoonaspossibleRoutinetransfusioninasymptomaticpatientswithahaemoglobinlevel80g/Lnotberequired.,Post-operative,PostoperativedeliriumCommon(25%-50%)withhipsurgeryFactors:hypoxia,hypoglycaemia,majorfluidandelectrolyteimbalances,sepsisandmajororganimpairmentProphylacticlow-dosehaloperidolmayreduceseverityanddurationofdelirium,Post-operative,NutritionUpto60%ofhipfracturepatientsclinicallymalnourishedonadmissionThecalorieandproteindensityofhospitalfoodoftenpoor,Post-operative,1、热量：热氮比=100150:12、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=3/24、产热效能：1g糖=1g蛋白质=4.1kcal，1g脂肪=9.3kcal,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，SaO298%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：WBC4.05109/L；RBC2.961012/L，HGB69g/L;Hct0.198;Lymph:0.640109/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,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=1200kcal糖供热：12003/5=720kcal/d脂肪供热：12002/5=480kcal/d4、补充脂肪：4809.352g5、补充葡萄糖：7204.1175g,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：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,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：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,实例,10KCL45ml（可另加口服“补达秀1.0/Bid”）25%MgSO215ml10%葡萄糖酸钙1020ml+NS3040ml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）,Rehabilitation,Osteoporosistreatment,主要文献来源,ManagementofProximalFemoralFractures2011:Anationalclinicalguideline,ScotlandEvidence-basedguidelinesforthemanagementofhipfracturesinolderpersons:anupdate.JensonCSMak,IanDCameronandLynMMarch,MJA2010;192(1):37-41Perioperativemanagementofproximalhipfracturesintheelderly:thesurgeonandtheanesthesiologist.MinervaAnestesiol.2011Jul;77(7