骨科老年患者围术期心理干预对术后镇痛的影响

目的探讨骨科人工全膝关节置换术老年患者围术期心理干预对术后镇痛的影响。方法随机选择64例骨科拟行人工全膝关节置换术的老年患者,均于入院时应用焦虑自评量表和抑郁自评量表进行心理状态评估,根据自愿的原则,将患者随机分为对照组和干预组,对照组按常规进行治疗和护理,干预组根据患者的心理状况给予心理干预。于术前1 d和术后第4天再次进行心理状态的评估和手术后8、24 h对所有患者采用视觉模拟评分(VAS)及简化的McGill问卷(SF-MPQ)进行疼痛评分。结果两组患者入院时焦虑、抑郁状态评分无统计学差异(P>0.05),人工全膝关节置换术前1 d和术后第4日焦虑、抑郁状态评分有统计学差异(P<0.01)。两组患者入院时VAS无统计学差异(P>0.05),人工全膝关节置换术后8、24 h VAS评分有统计学差异(P<0.01)。两组患者入院时SF-MPQ评分无统计学差异(P>0.05),人工全膝关节置换术后8、24 h SF-MPQ评分有统计学差异(P<0.01)。结论围术期有效的心理干预能改善患者焦虑和抑郁的心理状态,从而降低术后疼痛程度,并可显著影响疼痛强度和持续时间。     

老年糖尿病患者骨科手术围手术期处理

目的　探讨老年糖尿病患者骨科手术围手术期血糖的控制和对手术的影响。　方法　回顾性分析 3 0例骨疾病并存糖尿病患者接受骨科手术治疗围手术期的血糖调控情况。　结果　 3 0例患者入院时空腹血糖 ( 1 3 .0± 1 .3 ) mmol/L,经术前用胰岛素控制血糖至 ( 7.0± 1 .0 ) mmol/L后 ,分别接受全髋关节置换、股骨头置换、颈椎后路双开门、颈椎前路椎间盘摘除、腰椎 Steeff钢板内固定、腰椎滑脱 CD及 RF脊柱内固定系统复位固定等复杂骨科手术治疗 ,术中及术后继续用胰岛素控制血糖至基本正常水平 ,本组术后血糖为 ( 8.0± 1 .1 ) mmol/L。 3 0例中 ,仅 1例 ( 3 .3 % )伤口愈合不良 ;与同期接受骨科手术的非糖尿病患者 4 0 3 9例中 3 3例 ( 0 .8% )伤口愈合不良比较 ,二者差异无显著性 ,未发生其他并发症。术后患者症状和体征均明显改善 ,肢体功能恢复良好。　结论　老年糖尿病患者经正确的围手术期处理 ,将血糖控制至基本正常水平 ,可耐受复杂的骨科手术。     

不同胸椎旁神经阻滞方式在胸腔镜肺叶切除术围术期镇痛效果比较

目的评价术前单次椎旁阻滞(thoracic paravertebral block,TPVB)复合静脉镇痛和术前椎旁置管连续阻滞对胸腔镜肺叶切除术(video-assisted thoracic surgery,VATS)患者围术期镇痛效果。方法纳入2018年4月至2018年8月在北京胸科医院行胸腔镜单一肺叶切除的肺癌患者99例,随机分为单次双点椎旁注射组(G1组,33例)、椎旁置管组(G2组,33例)和对照组(G0组,33例)。G0组术后采用静脉自控镇痛;G1组诱导前在超声引导下行单次双点TPVB,术后采用静脉自控镇痛; G2组诱导前在超声引导下椎旁置管,术后镇痛采用连续TPVB。随访记录3组患者术后1h、术后4h、术后24h和术后48h的视觉模拟疼痛评分(visual analogue score,VAS)、按压次数、镇静评分和镇痛补救次数;记录术中舒芬太尼、七氟烷和丙泊酚用量;记录苏醒时间、拔管时间;记录恶心、呕吐和苏醒期躁动等不良反应。结果与G0组相比:G1组和G2组在上述随访时刻静息时和咳嗽时的VAS评分明显降低(P 0. 05),术中舒芬太尼、七氟烷用量明显减少(P 0. 05),苏醒时间发生明显缩短(P 0. 05),上述指标在G1组和G2组却没有明显差异(P 0. 05);与G0组和G1组相比,G2组总不良反应发生率较低(P 0. 05)。结论术前单次双点TPVB复合静脉镇痛和术前椎旁置管连续TPVB均能有效缓解VATS术后急性疼痛,但连续TPVB具有较低的不良反应发生率,更推荐其为VATS围术期镇痛首选方案。     

糖尿病患者骨科手术69例围手术期治疗

目的探讨针对糖尿病骨科手术患者,观察围手术期治疗后获得的临床效果。方法选取该院2012年10月—2014年10月糖尿病骨科手术患者69例。针对所有糖尿病骨科手术患者研究有效方法加以围手术期治疗。观察完成治疗后获得的临床效果。结果所有糖尿病骨科手术患者均成功度过围手术期,未表现出心脑血管意外的情况。患者未表现出糖尿病严重并发症的情况。患者的住院时间为17~62 d,患者平均住院时间为(33.2±1.9)d。结论针对糖尿病骨科手术患者,针对其围手术期治疗需要给予高度重视,有效避免患者出现心脑血管意外的情况,避免患者出现严重并发症,最终显著将患者的生活质量提高。     

老年妇科手术患者的临床特点及围术期处理

目的总结老年妇科手术患者的临床特点及围术期处理措施。方法选取2015年1~12月在该院进行妇科手术的56例老年患者作为老年组(年龄≥60岁),同时选取同一时期采取妇科手术治疗的62例非老年患者作为非老年组(年龄<60岁),并分析两组手术前后临床特点,同时总结老年妇科手术患者围术期处理措施。结果两组恶性肿瘤疾病和术后合并疾病发病率比较差异有统计学意义(P<0.05),两组并发症发生率比较差异无统计学意义(P>0.05)。结论老年患者以妇科恶性肿瘤疾病为主,且多数术后合并各种并发症,因此掌握老年妇科手术治疗的临床特点,围术期做好术前准备和术后护理干预,有助于提高患者对麻醉和手术的耐受力,减少术后并发症的发生以及死亡率。     

围手术期干预对骨科老年患者术后认知功能障碍的影响

［摘要］　目的　探讨围手术期干预对骨科老年患者术后认知功能障碍（POCD）的影响。方法　将100例老年患者随机分为观察组和对照组各50例。观察组50例在予以相应的围术期常规护理的基础上，采取针对POCD的系统护理干预，对照组50例予以相应的围术期常规护理。分别记录两组患者术前、术后2 d、术后7 d简易精神智能状态量表（MMSE）评分及两组患者POCD发生率及情况等。结果　观察组患者术后POCD发生率低于对照组，术后2 d、7 d的MMSE评分明显高于对照组，差异有统计学意义（P<0.05）。结论　围手术期采取针对POCD的系统护理干预，能够有效避免或减少POCD的发生。     

双氯芬酸钠用于骨科术后镇痛80例效果观察

2002年3月至2003年9月，我科对80例骨科术后患者采用双氯芬酸钠缓释胶囊镇痛，效果良好。现报告如下。     

糖尿病患者骨科手术围手术期的临床护理与分析

目的探讨骨科糖尿病患者围手术期实施护理的方法和效果,使患者更快的恢复健康。方法选取该院2013年1月—2014年1月共收治的204例糖尿病骨科手术患者作为研究对象,实施围手术期的护理。结果在对204例骨科糖尿病患者实施了围手术期的护理后,患者均无发生感染或并发症,身体恢复较好。结论对骨科糖尿病患者实施围手术期的护理,不仅降低了术后并发症的风险,收到了满意的治疗效果,而且使患者心情乐观开朗,提高了患者的生活质量。     

Major orthopaedic surgeries for haemophilia with inhibitors using rFVIIa

Summary. Between 2000 and 2008, 11 major orthopaedic surgeries for 7 congenital haemophilia patients with inhibitors were performed by the first author as the primary doctor using recombinant activated factor VII (rFVIIa). Orthopaedic surgical treatments were performed for six surgeries for four high‐responder haemophilia A patients, three surgeries for two high‐responder haemophilia B patients and two surgeries for one low‐responder haemophilia B patient. This low‐responder patient is allergic to factor IX products, so he usually uses rFVIIa as a haemostatic agent. All of the surgeries were major, such as joint arthroplasty, arthroscopic synovectomy, and a combination of both, and excellent surgical results were achieved. Seven cases were controlled by bolus infusion of rFVIIa, and the other four cases were controlled by combined bolus and continuous infusion of rFVIIa. An anti‐fibrolytic agent was used for all cases. There were no thrombogenic adverse effects, only two bleeding episodes. As for haemostatic control, nine surgeries were excellent, one was good and one was fair. This report is the largest clinical report on major orthopaedic surgeries at a single institute. We have concluded that the combination of bolus and continuous infusion of rFVIIa is safe and effective, and more convenient to administer than simple bolus infusion therapy to achieve haemostasis at peri‐operative periods. In addition, our data also concurs with the data of several previous reports which showed that orthopaedic surgery for haemophilia patients with inhibitors by means of rFVIIa is safe and effective.     

Anaesthesiological problems in patients with rheumatoid arthritis undergoing orthopaedic surgeries

The article presents anaesthesiological problems in patients with rheumatoid arthritis (RA) scheduled for orthopaedic surgeries. Organ changes due to RA and related treatment were taken into account. The anaesthetic techniques used for patients with RA underwent orthopaedic procedures were presented.     

Artificial intelligence in perioperative management of major gastrointestinal surgeries

Artificial intelligence (AI) demonstrated by machines is based on reinforcement learning and revolves around the usage of algorithms. The purpose of this review was to summarize concepts, the scope, applications, and limitations in major gastrointestinal surgery. This is a narrative review of the available literature on the key capabilities of AI to help anesthesiologists, surgeons, and other physicians to understand and critically evaluate ongoing and new AI applications in perioperative management. AI uses available databases called “big data” to formulate an algorithm. Analysis of other data based on these algorithms can help in early diagnosis, accurate risk assessment, intraoperative management, automated drug delivery, predicting anesthesia and surgical complications and postoperative outcomes and can thus lead to effective perioperative management as well as to reduce the cost of treatment. Perioperative physicians, anesthesiologists, and surgeons are well-positioned to help integrate AI into modern surgical practice. We all need to partner and collaborate with data scientists to collect and analyze data across all phases of perioperative care to provide clinical scenarios and context. Careful implementation and use of AI along with real-time human interpretation will revolutionize perioperative care, and is the way forward in future perioperative management of major surgery.     

下肢术后患者输注氯诺昔康镇痛对血小板功能的影响

目的观察骨科下肢手术患者术后输注氯诺昔康对血小板功能的影响。方法将90例患者随机分为实验组（用氯诺昔康）、对照组（用芬太尼）及空白对照组,观察三组术前及术后24、48h的P-选择素（GMP-140）、血栓烷B2（TXB2）、血小板聚集率（PAgT）变化。结果实验组各指标均明显低于其他组（P〈0．01）;组内与术前比较,实验组各指标降低（P〈0．01）,空白对照组升高（P〈0．05）,对照组变化不大。结论术后输注氯诺昔康对血小板功能有抑制作用。     

Cost and occurrence of thrombocytopenia in patients receiving venous thromboembolism prophylaxis following major orthopaedic surgeries

Background Many factors impact the choice of anticoagulant used for venous thromboembolism prophylaxis following orthopaedic surgery. Thrombocytopenia (TCP) is an important factor from both clinical and economic perspectives, warranting assessment between the available agents. Thus, a retrospective cohort analysis was conducted to: (1) report the occurrence of TCP in a treatment and no treatment group, (2) evaluate the impact of anticoagulant choice on TCP within the treatment group, and (3) assess the clinical and economic implications of TCP in the treatment group. Methods Administrative claims from a hospital database were used to identify patients with hip replacement, knee replacement, or hip fracture surgery. The treatment group (n = 144,806) included patients receiving one of the following injectable anticoagulants post-operatively: dalteparin (n = 16,109); enoxaparin (n = 97,827); fondaparinux (n = 12,532); or unfractionated heparin (UFH) (n = 18,338). The no treatment group consisted of patients who did not receive one of the four injectable anticoagulants (n = 112,574) post-operatively. Outcomes were assessed for the hospitalization period plus 2 months post-discharge while controlling for relevant demographic and clinical characteristics. Results The occurrence of TCP was 1.0% in the no treatment group and 1.7% in the treatment group. Within the treatment group, patients who received dalteparin, enoxaparin, and UFH were significantly more likely to experience coded thrombocytopenia than those in the no treatment group. The risk of TCP among patients who received fondaparinux was not significantly different from the no treatment cohort (odds ratio [OR] = 1.15, 95% CI: 0.96–1.37, P = 0.13). Patients in the treatment group with coded TCP had 22% higher adjusted mean total healthcare costs (relative cost difference) compared to those without ($19,134 vs. $15,400, respectively, P < 0.0001), greater mean length of stay (LOS) (8.4 vs. 5.7, respectively), and a greater likelihood of experiencing a venous thromboembolic (VTE) event (6.1% vs. 2.4%, respectively). Conclusion Patients treated with fondaparinux did not have a significant increase in the risk of TCP compared to patients not on prophylaxis. In contrast, the risk was increased in those treated with enoxaparin, dalteparin, and UFH compared to the patients not on prophylaxis. Patients in the treatment group with coded TCP experienced more thrombotic events, incurred greater per patient healthcare costs, and experienced longer LOS than patients without coded TCP. Therefore, the risk of TCP should be considered when evaluating the profile of injectable anticoagulants since TCP may have important clinical and economic implications.     

中老年人骨科围手术期有关骨代谢指标变化的研究

目的 观察中老年骨科手术患者围手术期骨代谢变化特点,为临床治疗提供参考.方法 随机抽取年龄50岁以上的中老年患者共113例作为研究对象,分别于术前、术后一周测定静脉血中骨钙素(bone γ-carboxyglutamic acid protein,BGP)及Ⅰ型胶原交联C端肽(C-terminal telopeptides of type Ⅰ collagen,CTX)的水平.结果 手术后CTX值较术前明显升高(P<0.001),BGP值较术前明显降低(P<0.001).其中,骨质疏松症患者、骨折患者手术前后CTX值均变化较大;而骨折患者BGP值手术前后差异无统计学显著性(P>0.05),其余病人BGP值较术前明显降低(P<0.01).结论 中老年人在骨科手术前后存在骨代谢的变化,手术后CTX水平较术前升高,提示骨吸收过程活跃;BGP水平较术前降低,提示骨形成过程受到抑制.骨质疏松患者术后CTX升高程度较非骨质疏松患者明显.     

Use of perioperative epidural analgesia among Medicare patients undergoing hepatic and pancreatic surgery

BackgroundWe sought to characterize epidural analgesia (EA) use among Medicare patients undergoing hepatopancreatic (HP) procedures, identify factors associated with EA use and asses perioperative outcomes.MethodsPatients undergoing HP surgery were identified using the Inpatient Standard Analytic Files. Logistic regression was utilized to identify factors associated with EA receipt, and assess associations of EA with in-hospital outcomes and Medicare expenditures.ResultsAmong 20,562 patients included in the study, 6.7% (n =1362) had EA. There was no difference in the odds of complications (OR 1.05, 95% CI 0.93–1.19) or blood transfusions (OR 0.90, 95% CI 0.79–1.03) with EA versus conventional analgesia (CA). The odds of prolonged LOS (OR 1.16, 95% CI 1.03–1.30) were higher with EA; the odds of in-hospital mortality were higher with conventional analgesia (OR 1.90, 95% CI 1.28–2.83). Medicare payments for liver surgery were comparable among EA ($19,500) versus conventional analgesia ($19,300, p = 0.85) and slightly higher for EA ($23,600) versus conventional analgesia ($22,000, p < 0.001) for pancreatic procedures.ConclusionEA utilization among Medicare patients undergoing HP was low. While EA was not associated with morbidity, it resulted in an average additional one day LOS and slightly higher expenditures in pancreatic surgery.