老年髖部骨折圍手術(shù)期相關(guān)問(wèn)題課件

老年髖部骨折圍手術(shù)期

相關(guān)問(wèn)題老年髖部骨折圍手術(shù)期

相關(guān)問(wèn)題Pre-operativeTreatmentstrategySurgicalfixationoffracturedhipsremainsthestandardofcare

Pre-operativeTreatmentstrategPre-operativeEvaluation

Completehistory,physicalexamination,laboratoryexaminationsAssessmentofthesurgicalrisks

Systemdeficitsidentified,andcorrectedTheAmericanAssociationofAnaesthetistsgrading

Pre-operativeEvaluationASAPhysicalStatus(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-deadpatientwhoorgansarebeingremovedfordonorpurposesASAPhysicalStatus(PS)ClassPre-operativePain：acetaminophenApproximately40%ofpatientsmoderaterenaldysfunction(eGFR<60ml/min/1.73m2)Opioids：withcautionNSAIDS:relativelycontrindicatedPre-operativePain：acetaminophePre-operativePreoperativetraction

AbandonedPre-operativePreoperativetracPre-operativePreoperativeDVTprophylaxisPressuregradientstockings;LMWH:12hpriortosurgery;Aspirinwithheld

Pre-operativePreoperativeDVTPre-operativeHemoglobin(Hb)

Pre-operativeanaemiainapproximately40%Pre-operativetransfusionconsideredif:

●Hbis<9g/dl.

●Hbis9–9.9g/dlandthereisahistoryofischaemicheartdisease.

Pre-operativeHemoglobin(Hb)Pre-operativeWhitecellcount

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

Pre-operativeWhitecellcountPre-operativePlateletcount

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

Ventricularrateoflessthan100required.Factors:hypokalemia,hypomagnesemia,hypovolemia,sepsis,painandhypoxemia.Beta-blockerstocontrolHRPre-operativeAtrialFibrillatiPre-operativeDiabetes

Hyperglycemiaisnotareasontodelaysurgeryunlessthepatientisketoticand/ordehydrated.

Pre-operativeDiabetesPre-operativeDialysis

Surgerytailoredaroundthedialysis;

Urgentsurgerymaynecessitateheparin-freedialysisPre-operativeDialysisPre-operativeTimetosurgery

●

Earlysurgery(24–36

h)recommended

●Nodelayforpatientsmildtomoderatehypertension(systolic＜180mmHganddiastolic＜110mmHg)

●Noawaitingechocardiography

●Nodelayforminorelectrolyteabnormalities

Pre-operativeTimetosurgeryPre-operativeReasonstooptimise●SevereanemiaHb<8g/dl●

Severeelectrolyteimbalance,withplasma[sodium]<120or>150mmol/land[potassium]<2.8or>6.0mmol/l.●UncontrolleddiabetesPre-operativeReasonstooptimiPre-operativeReasonstooptimise●Uncontrolledoracuteonsetleftventricularfailure●Correctablecardiacarrhythmia,withaventricularrate＞120bpm●Chestinfectionwithsepsis●ReversiblecoagulopathyPre-operativeReasonstooptimiIntra-operative

Antibiotics

AntibioticsadministeredbeforeskinincisionHospitalantibioticprotocolsfollowedIntra-operativeAntibioticsIntra-operative

Anaestheticconsiderations

RegionalanesthesiarecommendedKeepintra-opdiastolic≥60mmHg

Intra-operativeAnaestheticcoIntra-operative

Intravenousfluids

ManypatientshypovolemicatthetimeofsurgeryColloidsreducehospitalstayandimproveoutcomeIntra-operativeIntravenousflPost-operative

Painmanagement

Post-opepiduralanesthesialesscommonRegularacetaminophenthroughoutperioperativeperiod.

NSAIDSusedwithextremecaution,andcontraindicatedinthosewithrenaldysfunction

Post-operativePainmanagementPost-operative

Painmanagement

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

Post-operativePainmanagementPost-operative

DVTprophylaxis

LMWH;Warfarin;Rivaroxaban10-35days

Post-operativeDVTprophylaxisPost-operative

Oxygen

Supplementaloxygenpost-operativelyforatleast24hoursSomeevidencesupportsoxygentherapyforthefirst72

hPost-operativeOxygenPost-operative

Fluidbalance

HypovolemiacommonEarlyoralfluidintakeencouragedUrinarycathetersremovedassoonaspossibleRoutinetransfusioninasymptomaticpatientswithahaemoglobinlevel≥

80

g/Lnotberequired.Post-operativeFluidbalancePost-operative

Postoperativedelirium

Common(25%-50%)withhipsurgery

Factors:hypoxia,hypoglycaemia,majorfluidandelectrolyteimbalances,sepsisandmajororganimpairment

Prophylacticlow-dosehaloperidolmayreduceseverityanddurationofdelirium

Post-operativePostoperativedPost-operative

Nutrition

Upto60%ofhipfracturepatientsclinicallymalnourishedonadmissionThecalorieandproteindensityofhospitalfoodoftenpoor

Post-operativeNutritionPost-operative

1、熱量：熱氮比=100~150:1

2、蛋白（按0.15-0.2g氮/kg/d）計(jì)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

Post-operative1、熱量：熱氮比=100實(shí)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(wú)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(shí)例男，88歲，股骨頸骨折半髖術(shù)后第4天實(shí)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(shí)例血常規(guī)：WBC4.05×109/L；RBC2.96實(shí)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(shí)例1、每日氮需要量：0.175×55=9.6g，即9實(shí)例預(yù)計(jì)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(shí)例預(yù)計(jì)補(bǔ)液量：175÷0.1=1750ml（3L袋內(nèi)糖濃實(shí)例預(yù)計(jì)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(shí)例預(yù)計(jì)補(bǔ)液量：175÷0.1=1750ml（3L袋內(nèi)糖濃實(shí)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(lè)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(shí)例10KCL45ml（可另加口服“補(bǔ)達(dá)秀1.0/B實(shí)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(shí)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(duì)于少尿病人也可以使用24小時(shí)泵入速尿的辦法來(lái)維持均勻尿量。心臟：多巴胺0.1-0.2+普魯卡因0.5+NS50ml2~4ml/h貧血：輸注CRBC:400ml（可提升2gHb）實(shí)例20%人血白蛋白50mlivbid；每次滴完后“速Rehabilitation

Osteoporosistreatment

RehabilitationOsteoporosi主要文獻(xiàn)來(lái)源ManagementofProximalFemoralFractures2011:Anationalclinicalguideline,ScotlandEvidence-basedguidelinesforthemanagementofhipfracturesinolderpersons:anupdate.JensonCSMak,IanDCameronandLynMMarch,MJA2010;192(1):37-41Perioperativemanagementofproximalhipfracturesintheelderly:thesurgeonandtheanesthesiologist.MinervaAnestesiol.2011Jul;77(7):715-22.Epub2011Feb1.Perioperativeconsiderationsingeriatricpatientswithhipfracture:whatistheevidence?JOrthopTrauma.2009Jul;23(6):386-94.BestPracticesforElderlyHipFracturePatients:ASystematicOverviewoftheEvidence.JGenInternMed.2005November;20(11):1019–1025

主要文獻(xiàn)來(lái)源ManagementofProximalF后面內(nèi)容直接刪除就行資料可以編輯修改使用資料可以編輯修改使用后面內(nèi)容直接刪除就行主要經(jīng)營(yíng)：網(wǎng)絡(luò)軟件設(shè)計(jì)、圖文設(shè)計(jì)制作、發(fā)布廣告等公司秉著以優(yōu)質(zhì)的服務(wù)對(duì)待每一位客戶，做到讓客戶滿意！主要經(jīng)營(yíng)：網(wǎng)絡(luò)軟件設(shè)計(jì)、圖文設(shè)計(jì)制作、發(fā)布廣告等致力于數(shù)據(jù)挖掘，合同簡(jiǎn)歷、論文寫作、PPT設(shè)計(jì)、計(jì)劃書(shū)、策劃案、學(xué)習(xí)課件、各類模板等方方面面，打造全網(wǎng)一站式需求致力于數(shù)據(jù)挖掘，合同簡(jiǎn)歷、論文寫作、PPT設(shè)計(jì)、計(jì)劃書(shū)、策劃感謝您的觀看和下載Theusercandemonstrateonaprojectororcomputer,orprintthepresentationandmakeitintoafilmtobeusedinawiderfield感謝您的觀看和下載Theusercandemonstr老年髖部骨折圍手術(shù)期

相關(guān)問(wèn)題老年髖部骨折圍手術(shù)期

相關(guān)問(wèn)題Pre-operativeTreatmentstrategySurgicalfixationoffracturedhipsremainsthestandardofcare

Pre-operativeTreatmentstrategPre-operativeEvaluation

Completehistory,physicalexamination,laboratoryexaminationsAssessmentofthesurgicalrisks

Systemdeficitsidentified,andcorrectedTheAmericanAssociationofAnaesthetistsgrading

Pre-operativeEvaluationASAPhysicalStatus(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-deadpatientwhoorgansarebeingremovedfordonorpurposesASAPhysicalStatus(PS)ClassPre-operativePain：acetaminophenApproximately40%ofpatientsmoderaterenaldysfunction(eGFR<60ml/min/1.73m2)Opioids：withcautionNSAIDS:relativelycontrindicatedPre-operativePain：acetaminophePre-operativePreoperativetraction

AbandonedPre-operativePreoperativetracPre-operativePreoperativeDVTprophylaxisPressuregradientstockings;LMWH:12hpriortosurgery;Aspirinwithheld

Pre-operativePreoperativeDVTPre-operativeHemoglobin(Hb)

Pre-operativeanaemiainapproximately40%Pre-operativetransfusionconsideredif:

●Hbis<9g/dl.

●Hbis9–9.9g/dlandthereisahistoryofischaemicheartdisease.

Pre-operativeHemoglobin(Hb)Pre-operativeWhitecellcount

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

Pre-operativeWhitecellcountPre-operativePlateletcount

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

Ventricularrateoflessthan100required.Factors:hypokalemia,hypomagnesemia,hypovolemia,sepsis,painandhypoxemia.Beta-blockerstocontrolHRPre-operativeAtrialFibrillatiPre-operativeDiabetes

Hyperglycemiaisnotareasontodelaysurgeryunlessthepatientisketoticand/ordehydrated.

Pre-operativeDiabetesPre-operativeDialysis

Surgerytailoredaroundthedialysis;

Urgentsurgerymaynecessitateheparin-freedialysisPre-operativeDialysisPre-operativeTimetosurgery

●

Earlysurgery(24–36

h)recommended

●Nodelayforpatientsmildtomoderatehypertension(systolic＜180mmHganddiastolic＜110mmHg)

●Noawaitingechocardiography

●Nodelayforminorelectrolyteabnormalities

Pre-operativeTimetosurgeryPre-operativeReasonstooptimise●SevereanemiaHb<8g/dl●

Severeelectrolyteimbalance,withplasma[sodium]<120or>150mmol/land[potassium]<2.8or>6.0mmol/l.●UncontrolleddiabetesPre-operativeReasonstooptimiPre-operativeReasonstooptimise●Uncontrolledoracuteonsetleftventricularfailure●Correctablecardiacarrhythmia,withaventricularrate＞120bpm●Chestinfectionwithsepsis●ReversiblecoagulopathyPre-operativeReasonstooptimiIntra-operative

Antibiotics

AntibioticsadministeredbeforeskinincisionHospitalantibioticprotocolsfollowedIntra-operativeAntibioticsIntra-operative

Anaestheticconsiderations

RegionalanesthesiarecommendedKeepintra-opdiastolic≥60mmHg

Intra-operativeAnaestheticcoIntra-operative

Intravenousfluids

ManypatientshypovolemicatthetimeofsurgeryColloidsreducehospitalstayandimproveoutcomeIntra-operativeIntravenousflPost-operative

Painmanagement

Post-opepiduralanesthesialesscommonRegularacetaminophenthroughoutperioperativeperiod.

NSAIDSusedwithextremecaution,andcontraindicatedinthosewithrenaldysfunction

Post-operativePainmanagementPost-operative

Painmanagement

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

Post-operativePainmanagementPost-operative

DVTprophylaxis

LMWH;Warfarin;Rivaroxaban10-35days

Post-operativeDVTprophylaxisPost-operative

Oxygen

Supplementaloxygenpost-operativelyforatleast24hoursSomeevidencesupportsoxygentherapyforthefirst72

hPost-operativeOxygenPost-operative

Fluidbalance

HypovolemiacommonEarlyoralfluidintakeencouragedUrinarycathetersremovedassoonaspossibleRoutinetransfusioninasymptomaticpatientswithahaemoglobinlevel≥

80

g/Lnotberequired.Post-operativeFluidbalancePost-operative

Postoperativedelirium

Common(25%-50%)withhipsurgery

Factors:hypoxia,hypoglycaemia,majorfluidandelectrolyteimbalances,sepsisandmajororganimpairment

Prophylacticlow-dosehaloperidolmayreduceseverityanddurationofdelirium

Post-operativePostoperativedPost-operative

Nutrition

Upto60%ofhipfracturepatientsclinicallymalnourishedonadmissionThecalorieandproteindensityofhospitalfoodoftenpoor

Post-operativeNutritionPost-operative

1、熱量：熱氮比=100~150:1

2、蛋白（按0.15-0.2g氮/kg/d）計(jì)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

Post-operative1、熱量：熱氮比=100實(shí)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(wú)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(shí)例男，88歲，股骨頸骨折半髖術(shù)后第4天實(shí)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(shí)例血常規(guī)：WBC4.05×109/L；RBC2.96實(shí)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(shí)例1、每日氮需要量：0.175×55=9.6g，即9實(shí)例預(yù)計(jì)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(shí)例預(yù)計(jì)補(bǔ)液量：175÷0.1=1750ml（3L袋內(nèi)糖濃實(shí)例預(yù)計(jì)補(bǔ)液量：175÷0.1=1750ml（3L袋內(nèi)糖濃度≯10%）………….2000ml20%脂肪乳（力能）250ml（