成人髋部骨折.ppt

1、成人髋部骨折：NICE指南,英国国家卫生与临床优化研究所（NICE，National Institute for Health and Clinical Excellence） 是英国国家医疗服务系统（NHS）的组织，设在伦敦和曼彻斯特。 NICE成立于1999年4月1日，目标是确保每个英格兰和威尔士人平等享有NHS医疗的机会。 NICE制定指南，设定质量标准，管理国家数据库，为NHS、当地权威部门和其他组织提供指南。,.uk/,髋部骨折,入院时,股骨颈骨折,入院时,入院时,转子下骨折？,入院时,术后,全髋,术后,术后,病房照片 病人助行器行走,这是我们所有

2、的临床印象吗？,术后,术后,术后,临床棘手的问题： 医生的困惑 护理的压力 家属的期望 烫手的山芋，考验着每个人的智慧,骨科医师的职责在于选择恰当的固定器材、准确地复位并可靠地固定骨折或矫形 而手术之外的问题也同样应该引起我们的重视,糖皮质类激素的 骨科临床应用,北京大学人民医院关节中心,林剑浩,路在何方？！,髋部骨折,髋部骨折是指股骨近端骨折（proximal femoral fracture，PFF），指发生在股骨头边缘和小转子远端5 cm之内的骨折。,流行病学情况,在英国每年有大约70,000到75,000例髋部骨折患者, 医疗卫生相关花费每年高达20亿英镑。（折合约为30万RMB/人）

3、 英国全国髋部骨折数据库报道:约10%的髋部骨折患者 在1个月内死亡，约1/3在12个月内死亡。 大部分死亡是与并发症相关。 因此，髋部骨折并不是单纯的手术治疗，需要内科，外科，麻醉和康复等包括医院到社区的多学科综合治疗。,指南,指南推荐的诊疗计划,指南推荐的诊疗计划,1.Key priorities for implementation 2.When the patient presents at hospital 3.analgesia 4.surgery 5.multidisciplinary rehabilitation,1.Key priorities for implementat

4、ion,1.Key priorities for implementation,关键问题： Timing of surgery Planning the theatre team Surgical procedures Mobilisation strategies Multidisciplinary management,2.When the patient presents at hospital,2.When the patient presents at hospital,Assess the patients pain. 评估疼痛 2.Offer immediate analgesi

5、a to patients with suspected hip fracture, including people with cognitive impairment 即时镇痛 3.Offer magnetic resonance imaging (MRI) if hip fracture is suspected despite negative anteroposterior pelvis and lateral hip X-rays. If MRI is not available within 24 hours or is contraindicated, consider com

6、puted tomography (CT). X光阴性者，24h内安排MRI，否则予CT检查,2.When the patient presents at hospital,4.Offer all patients a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme. 髋部骨折治疗计划 包括以下方面： 骨科老年疾病专家的评估 早期确认患者的康复愿望 持续的、协作的多学科会诊 快速改善术前健康状况,2.When the patient presents at hospital,5. Ac

7、tively look for cognitive impairment and keep reassessing patients to identify delirium. 评估认知障碍、及早确认谵妄 有记忆障碍的患者在谵妄、并发症、死亡率、延长住院天数等方面面临更高的风险。 谵妄，明显增加住院天数及6个月内的死亡率，同时，使患者本人、家庭成员、照顾者(医护人员)及其他住院病人相当苦恼。,2.When the patient presents at hospital,2.When the patient presents at hospital,减少谵妄发生： 1.中枢神经系统足够的氧供2

8、.液体/电解质平衡3.治疗重度疼痛4.消除不必要的药物5.调节肠道/膀胱功能6.足够的营养摄入量7.早期活动和康复8.术后主要并发症的防治9.适当的环境刺激10.谵妄的治疗,2.When the patient presents at hospital,阿米替林,苯海拉明,氯氮卓（利眠宁）,氯丙嗪,地西泮,多虑平,羟嗪（安泰乐）,丙咪嗪,吲哚美辛,哌替啶,2.When the patient presents at hospital,谵妄的治疗：（a）适当的诊断检查/管理（b）平静的安慰，家庭成员的存在，和/或临时保姆（c）如果必要时，氟哌啶醇0.250.5mg(1/4片) q4h；若禁忌，使

9、用相同剂量劳拉西泮（氯羟安定）,6. If a hip fracture complicates or precipitates a terminal illness, consider the role of surgery as part of a palliative care approach. 临终关怀 在髋部骨折的患者中，有相当大的比例合并危及生命的心肺、肿瘤和恶性疾病晚期等疾病。 此外，经受髋部骨折、骨科和内科并发症的伤害、制动及手术的创伤，也可以使个人的健康状况恶化。 指南优先考虑是：减轻痛苦、恢复功能、回归社区,2.When the patient presents at h

10、ospital,2.When the patient presents at hospital,7.Offer patients (or, as appropriate, their carer and/or family) verbal and printed information about treatment and care including: 沟通 诊断 麻醉方式的选择 镇痛及其他药物的选择 术式 可能的并发症 术后如何护理 康复计划 远期的临床结局,3.analgesia,3.analgesia,地位？ Fear of pain is a major concern to th

11、em and their relatives. The best form of analgesia is surgical repair, but there will usually be a period when assessment is taking place when some analgesia is needed. Pain relief is obviously important for simple humanitarian reasons and for acute nursing care, but also improves patients wellbeing

12、, reduces the risk of delirium, and facilitates the return to mobility and independence. Prompt and adequate relief of pain has long been identified as a major priority in the management of hip fracture, and one that has not always historically been achieved.,3.analgesia,Assess the patients pain: 入院

13、时立即行疼痛评估 and 在初始镇痛后30min内评估and 每小时进行1次疼痛评估观察 and 疼痛评估应作为住院期间常规护理监测项目.,3.analgesia,30分钟的时间间隔反映了吗啡的药动学/药效学概况及其活性代谢产物吗啡-6 - 葡萄糖醛酸。 给药15分钟后起效，足够的止痛反应总是30分钟来实现。 效果的持续时间各不相同，从2至24小时不等，反射吗啡-6 - 葡糖苷酸清除和响应中的个体间变异。 如果需要进一步的镇痛，随后每小时需要重新评估是合理的，不仅需要确保一个满意的答复，而且评估任何不良影响。每小时也有一定的间隔是务实的，符合安全，通用性好临床实践，并在与CEM的建议。 htt

14、p:/.uk/Publications/Publication%20Downloads/Sep2007PainAssessment.pdf,3.analgesia,2. Offer immediate analgesia to patients with suspected hip fracture, including people with cognitive impairment. 无关于止痛干预时间的相关研究 3. Ensure analgesia is sufficient to allow movements necessary for investigati

15、ons and for nursing care and rehabilitation. 要求：能配合查体、日常护理及康复,3.analgesia,4.Offer paracetamol every 6 hours preoperatively unless contraindicated. 5.Offer additional opioids if paracetamol alone does not provide sufficient preoperative pain relief. 7.Offer paracetamol every 6 hours postoperatively u

16、nless contraindicated. 8.Offer additional opioids if paracetamol alone does not provide sufficient postoperative pain relief. 9.Non-steroidal anti-inflammatory drugs (NSAIDs) are not recommended.,3.analgesia,3.analgesia,Cuvillion et. have shown that 2g of intravenous propacetamol (equivalent to 1g i

17、ntravenous paracetamol ) can be as effective as nerve blocks or morphine in the postoperative phase.,3.analgesia,3.analgesia,3.analgesia,6.Consider adding nerve blocks if paracetamol and opioids do not provide sufficient preoperative pain relief, or to limit opioid dosage. Nerve blocks should be adm

18、inistered by trained personnel. Do not use nerve blocks as a substitute for early surgery. 神经阻滞 干预的时间术前术后？方式？ 指南建议后续的研究：进一步评价nerve blocks的临床及经济学价值,The best form of analgesia is surgical repair,3.analgesia,4.surgery,4.surgery,1.Timing of surgery (关键问题 ) 手术时机 one of the biggest challenges to a health

19、care system The surgery does not stand alone. 它涉及到多学科之间的协调，包括：事故本身、急诊科、急性创伤骨科服务、骨科老年疾病专家、麻醉师，以及有可用的手术室、训练有素的工作人员和相关设备。,4.surgery,对于这个问题，10项研究符合纳入标准，均是关于早期手术、延迟手术的危害的研究，总共193,793人。 研究数据提示重要的影响因素包括：合并症和年龄（7项研究）。 如不包括不适合手术的病人，即对延迟的原因是由于缺乏合适的人员、手术室或设备不可用（3项研究）。 延迟手术中确定的因素是入院时间。,4.surgery,1.1 Perform sur

20、gery on the day of, or the day after, admission. 入院48小时内手术 The cut-off for delay to surgery in this analysis is 24, 36 and 48 hours. 指南建议的后续研究： What is the clinical and cost effectiveness of surgery within 36 hours of admission compared to surgery later than 36 hours from admission in mortality, mor

21、bidity and quality of life in patients with hip fracture?,倾向于36小时内手术？,4.surgery,1.2 Identify and treat correctable comorbidities immediately to avoid delaying surgery. 目标:一旦稳定，尽快手术 不稳定因素？,4.surgery,术前需改善的合并症： 1.贫血2.抗凝状态3.血容量不足4.电解质紊乱5.未控制的糖尿病6.不受控制的心脏衰竭7.可纠正的心律不齐或心肌缺血8.急性肺部感染9.慢性肺部疾病的恶化,experienced

22、physicians and anaesthetists are needed!,4.surgery,33.3mmolL,室上性心动过速,窦性心动过速,230umol/L,4.surgery,2.Planning surgery （关键问题） 2.1 Schedule surgery on a planned trauma list. 手术团队、设备等 2.2 Consultants or senior staff should supervise trainee and junior staff during hip fracture surgery. 制胜法宝 上级的指导 影响：二次手术、

23、骨折对位、术后并发症、住院时间、死亡率等等。,4.surgery,3. Anaesthesia 3.1 Offer patients a choice of spinal or general anaesthesia after discussing the risks and benefits. 3.2 Consider intraoperative nerve blocks.,4.surgery,3.1 Offer patients a choice of spinal or general anaesthesia after discussing the risks and benefi

24、ts. The GDG considered early mortality (up to 1 month) and patient preference to be the most important outcomes. Clinical evidence ：与全麻相比，区域麻醉在降低早期死亡率（1月内）方面有统计学及临床意义 (LOW QUALITY). 与全麻相比，区域麻醉在减少术后意识紊乱及DVT方面有统计学意义，但在临床上改善不明显(LOW QUALITY). 两者在住院时间、呕吐、肺炎、心肌梗死和肺栓塞的差异无统计学意义 (LOW QUALITY). In the absence

25、 of any strong evidence favouring one method over the other, the GDG decided that the choice of anaesthesia should be based on the patient preference after being given sufficient information about the options available and the expertise of the anaesthetist.,4.surgery,进一步对骨折分型亚组分析发现，粗隆间骨折患者采用区域麻醉可降低死

26、亡率及肺部并发症发生率，但在股骨颈骨折患者中差异不明显,4.surgery,3.2 Consider intraoperative nerve blocks. 超声引导下进行，以减少并发症及麻醉药的剂量 减少阿片类药物和其他镇痛应用的必要性和副作用 然而，因为引用的研究观察的方式及结果各不相同，因此不能形成有意义的结果。因此，该建议为共识。,4.surgery,4.Surgical procedures （关键问题） （1）手术目的是使患者术后尽快完全负重。 （2）对移位的囊内骨折行关节置换术（全髋或半髋置换术），建议对骨折前能独立行走、无认知障碍、身体情况适合手术的患者行全髋置换术。 （3）

27、不建议使用Austin Moore或Thompson柄假体。 （4）建议使用骨水泥假体。 （5）半髋关节置换时建议使用前外侧入路。 （6）AO分型A1和A2型的转子间骨折，建议使用髓外内固定系统（如滑动加压螺钉），而不是髓内系统。 （7）转子下骨折建议使用髓内内固定系统。,4.surgery,Austin Moore及Thompson柄假体是什么？,5.multidisciplinary rehabilitation,5.multidisciplinary rehabilitation,1. Mobilisation strategies （关键问题） 活动策略 1.1 Offer patie

28、nts a physiotherapy assessment and, unless medically or surgically contraindicated, mobilisation on the day after surgery. 1.2 Offer patients mobilisation at least once a day and ensure regular physiotherapy review. 康复治疗；早期活动,5.multidisciplinary,2.Consider early supported discharge as part of the Hi

29、p Fracture Programme, provided the Hip Fracture Programme multidisciplinary team remains involved, and the patient: （关键问题） 将早期出院作为多学科支持下的治疗计划的一部分 病情稳定 经与病人、照顾者和家庭成员讨论，告知尚未实现完全其康复潜力 有参与持续康复治疗的心理准备 能够转移和活动短暂的距离,5.multidisciplinary,3.Only consider intermediate care (continued rehabilitation in a commun

30、ity hospital or residential care unit) if all of the following criteria are met: intermediate care is included in the Hip Fracture Programme and the Hip Fracture Programme team retains the clinical lead, including patient selection, agreement of length of stay and ongoing objectives for intermediate care and the Hip Fracture Programme team retains the managerial lead, ensuring that intermediate care is not resourced as a substitute for an effective acute hospital Programme. 4.Patients admitted from care or nursing homes should not be excluded from rehabilitation programmes in the co