伴合并症的80岁以上老年人的围手术期麻醉处理

2005年1月至2005年6月以来我院共为≥80岁老年人实施各类手术麻醉共34例，围手术期严密控制合并症，结果全组麻醉手术期间无死亡，现报道如下。     

老年髋部骨折患者围手术期Orem护理

2007年1月-2008年11月,本院共收治老年髋部骨折患者70例,围手术期实施Orem护理，效果良好。现报告如下。 临床资料：本组70例患者中，男32例、女38例，年龄60—92岁。股骨粗隆间骨折左侧23例、右侧15例；股骨颈骨折左侧20例、右侧12例。合并高血压22例、糖尿病8例、心功能异常10例、肝肾功能异常25例。     

80岁以上患者腹腔镜胆囊切除围手术期处理

目的探讨高龄（≥80岁）患者腹腔镜胆囊切除术（LC）围手术期处理原则。方法2001年6月至2006年6月解放军第451医院共行LC术13776例,对其中≥80岁的结石性胆囊炎病例共34份进行回顾性分析,对术前评估、降低并发症影响因素并减少其发生提出可行性依据。结果本组平均年龄82.1岁,26例有明确的术前合并症,占76.5%,合并有两种以上疾病者15例,占44.1%,胆囊炎急性发作17例,病理诊断为急性化脓性胆囊炎6例,急性发作患者起病48h内急诊手术7例,内科抗感染并治疗合并症后手术10例,住院时间（13.3±5.3）d,手术时间（28.4±8.6）min,全部病例均完成手术,术后第3天发生快速房颤并急性心衰1例,合并糖尿病切口延迟愈合1例,合并肝硬化急诊手术后出现肺部感染、肝功损害加重1例,其余患者均顺利治愈出院,无手术死亡。结论在高龄患者LC围术期,注意术前评估,慎重确定手术时机,充分术前准备,术中仔细处理,是保证高龄老人顺利度过LC围手术期的必要条件,从而降低高龄患者手术风险。     

高龄髋部骨折患者106例围手术期治疗分析

髋部骨折是老年人的常见骨折,是老年人致残甚至死亡的一个重要原因~[1,2].对于高龄患者来说,内科合并症的的增多及重要脏器功能的减退使承受麻醉和手术的能力下降,手术风险增大,故围手术期的处理尤为重要,其结果将直接影响到手术的安全和效果.     

关节置换术与内固定术治疗80岁以上老年髋部骨折的疗效比较

高龄患者多有全身性骨质疏松，轻微外力即可导致髋部骨折。对于此类骨折，虽然手术治疗能够取得良好的治疗效果，但随着患者年龄升高，各系统脏器衰退及多系统并存疾病都在增加，手术风险很高，使得骨科医生在下决心治疗时要面临巨大的心理压力。我们应用Zuckerman FRS功能恢复量表的骨折前功能评估和自行研制开发的手术风险评价系统（ORAS1）来实施病人生活质量和全身状态的评估，并对术后的相关情况进行预测以选择手术。     

80岁及以上患者髋关节置换术围手术期并发症预防和对策

目的 探讨老年高危患者关节置换术围手术期并发症的预防和处理对策.方法 80～94岁髋关节置换术患者42例,并存重度骨质疏松(Dorr Ⅲ期)24例,采用骨水泥柄双极股骨头置换术25例,非骨水泥柄双极股骨头置换术2例,7例骨水泥全髋关节置换术,3例全髋关节翻修术.结果术中无死亡,1例90岁女性患者术后第5天关节脱位,复位后次日死亡,1例全麻术后昏迷1周后苏醒,5例术后3 d内发生认知障碍.38例(90.5%)出院时可扶助行器行走,患髋关节疼痛缓解.结论 对于需要行髋关节置换术的老年患者,进行关节置换术必须经过围手术期多学科的紧密配合协作,采用对应的手术和治疗对策,这样可以降低手术并发症的发生率或减轻并发症的程度,保证手术的成功.     

39例老年髋部骨折合并糖尿病的围手术期治疗

目的探讨老年髋部骨折合并糖尿病患者进行围手术期治疗的临床效果。方法取该院2009年2月—2013年12月期间接收的老年髋部骨折合并糖尿病患者39例,对其采用围手术期治疗的方法进行处理,然后观察其治疗效果。结果 39例患者经围手术期治疗及回访记录显示,呈优的患者有25例（64.10%）,呈良的患者有9例（23.08%）,呈可的患者有4例（10.26%）,呈差的患者有1例（2.56%）,优良率为87.18%。结论对老年髋部骨折合并糖尿病患者,采取围手术期治疗的方法进行治疗,可以取得显著的临床治疗效果,值得临床推广和应用。     

老年人股骨粗隆间骨折的围手术期处理

股骨粗隆间骨折好发于老年人，目前多主张采用手术治疗。老年患者常并存多种内科疾病，围手术期处理是确保生命安全和手术成功的关键。1997年1月至2002年10月，我们采用手术治疗股骨粗隆间骨折90例，取得了良好效果。     

高龄老年人髋部骨折的围手术期治疗及康复

髋部骨折在老年人中是一种常见的创伤,以往多采用保守治疗,但并发症多,致残率和病死率高[1].随着手术技术水平的提高、内固定器材的发展,采取积极的手术治疗,加强术前准备、术中监护、术后积极康复训练可减少卧床时间,早期下床活动可减少患者痛苦,便于护理,降低并发症,提高生活质量,是一种效果可靠的治疗方法.目前关于手术治疗结合围手术期的康复功能训练缺乏系统的整理.我院对老年人髋部骨折患者加强围手术期治疗及术后系统康复训练获得了满意的疗效.     

80岁以上患者股骨转子间骨折手术治疗(附85例分析)

目的探讨８０岁以上患者股骨转子间骨折的手术方式及疗效。方法回顾性分析８５例８０岁以上患者股骨转子间骨折的临床资料。其中采用滑动加压鹅头钉固定２６例，麦氏鹅头钉２５例，Ｅｎｄｅｒ钉８例，双加压螺丝钉９例，单加压螺丝钉１７例。结果术中无死亡病例，随访平均２８个月，功能恢复优良者５９例，占６９％；功能尚可者１４例；活动受限、疼痛、不能下床者１２例。结论手术治疗８０岁以上患者的股骨转子间骨折是延长患者寿命、改善其生活质量的有效方法。     

老年髋部骨折围手术期合并疾病和并发症的分析和处理

目的 探讨老年髋部骨折的特点，分析其围手术期并发症、合并疾病及治疗措施，以提高手术效果，提高患者生存质量。方法 对217例75岁以上老年人髋部骨折围手术期治疗方法及结果进行回顾性总结。结果 本组病例术前有63．1％病人有内科合并疾病，患者均顺利度过手术期，术后发生并发症共30例，发生率为13．7％。手术治疗优良率82．7％。结论 高龄髋部骨折患者术前合并疾病多，根据病人情况，采取积极恰当的围手术期处理、不同的麻醉手术方法和康复治疗，可降低围手术期并发症的发生率和病死率，取得优良的治疗效果。     

髋关节置换治疗老年股骨颈骨折与股骨头坏死的临床效果观察

目的探讨股骨颈骨折与股骨头坏死老年患者行髋关节置换治疗的临床效果。方法对该院2015-07~2016-07收治的股骨颈骨折与股骨头坏死患者90例,按照临床所用不同治疗方案分成对照组和观察组两组,对照组45例患者行人工股骨头置换治疗,观察组45例患者行髋关节置换治疗,比较两组临床效果及预后情况。结果观察组治疗后Harris评分优良率(95.56%)比对照组(80.00%)高(P0.05);对照组手术时间比观察组短,术中出血量比观察组少(P0.05);两组总并发症率分别为2.22%、4.44%,比较差异无统计学意义(P0.05);观察组治疗后总体健康评分[(84.08±15.68)分]比对照组[(66.35±13.05)分]高(P0.01)。结论股骨颈骨折与股骨头坏死老年患者行髋关节置换治疗能够提高髋关节功能和生活质量,临床需加以合理利用。     

Best practices for elderly hip fracture patients

OBJECTIVES: To determine evidence-based best practices for elderly hip fracture patients from the time of hospital admission to 6 months postfracture. DATA SOURCES: MEDLINE, Cochrane Library, CINAHL, Embase, PEDro, Ageline, NARIC, and CIRRIE databases were searched for potentially eligible articles published between 1985 and 2004. REVIEW METHODS: Two independent reviewers determined studies appropriate for inclusion using standardized selection criteria, extracted data, evaluated internal validity, and then rated studies according to levels of evidence. Only Level 1 or 2 evidence was included in our summary of clinical recommendations. RESULTS: Spinal anesthesia, pressure-relieving mattresses, perioperative antibiotics, and deep vein thromboses prophylaxes had consistent evidence of benefit. Routine preoperative traction was not associated with any benefits and should be abandoned. Types of surgical management, postoperative wound drainage, and even "multidisciplinary" care, lacked sufficient evidence to determine either benefit or harm. There was little evidence to either determine best subacute rehabilitation practices or to direct ongoing medical issues (e.g., nutrition). Studies conducted during the subacute recovery period were heterogeneous in terms of treatment settings, interventions, and outcomes studied and had no clear evidence for best treatment practices. CONCLUSIONS: The evidence for perioperative practices is relatively robust and evidence-based perioperative treatment guidelines can be easily established. Conversely, more evidence is required to better guide the care of elderly patients with hip fracture during the subacute recovery period and convalescence.     

丙帕他莫联合静脉自控镇痛泵对75岁以上老年髋部骨折患者术后的镇痛效果

目的探讨丙帕他莫联合舒芬太尼静脉自控镇痛泵(PCIA)对75岁以上老年髋部骨折术后的镇痛效果及安全性。方法将本院2015年6月至2016年6月216例75岁以上接受髋部手术的患者随机分为观察组和对照组,每组各108例;对照组给予PCIA,观察组给予丙帕他莫联合PCIA。观察2组患者术后12 h内的镇痛效果、追加镇痛药物情况以及术后不良反应发生情况。应用视觉模拟评分法(VAS)和Ramsay镇静评分评估患者术后镇痛效果。采用SPSS 17.0软件对数据进行统计学分析。计量资料采用方差分析,计数资料采用X2检验。结果术后2 h,2组间VAS和Ramsay评分差异无统计学意义;术后6 h和12 h,观察组VAS评分低于对照组,Ramsay评分高于对照组,差异有统计学意义(P0.05)。观察组术后2、6和12 h的舒芬太尼追加量均小于对照组,6 h和12 h时差异有统计学意义(P0.05)。观察组患者术后不良反应发生率显著低于对照组,差异有统计学意义(8.70%vs 37.0%,P0.05)。结论 75岁以上老年髋部骨折术后患者联合使用丙帕他莫和PCIA可有效减轻术后疼痛,尤其显著减少因应用阿片类药物导致的不良反应。     

80岁以上股骨颈骨折髋关节置换术围手术期安全性和疗效观察

目的评价高龄（≥80岁）股骨颈骨折患者接受髋关节置换术围手术期的安全性和有效性。方法1997年11月至2007年11月,应用全髋关节置换术（11例）或半髋关节置换术（67例）治疗78例≥80岁股骨颈骨折患者,对其术前危险因素、围手术期并发症和术后2周临床效果等临床资料进行回顾性分析。结果本组患者平均年龄（83．7±3．59）岁,其中GardenⅢ型骨折42例、GardenⅣ型骨折36例。术前应用美国麻醉医师协会分级标准评价,80．8％为高危患者;采用统计死亡率和并发症发生率的生理学和手术严重程度评分系统预测主要并发症发生32例,术后实际发生24例,观察值与预测值之间无统计学差异（p=0．205）,全髋关节置换组与半髋关节置换组均无统计学差异;术后2周疼痛缓解满意率为96．2％,76．9％的患者独立或辅助下自行室内活动。结论在高龄股骨颈骨折患者,围手术期针对生理状况及手术操作的可改变指标进行有效的干预措施,采取髋关节置换术,可获得安全、有效的临床结果。     

Outcomes of lumbar spinal fusion in super-elderly patients aged 80 years and over: Comparison with patients aged 65 years and over,and under 80 years

Despite the increasing prevalence of spinal surgery in super-elderly (SE) patients, the outcomes and complication rates have not been fully elucidated. The purpose of this study was to compare the outcomes and complications of lumbar spinal fusion for degenerative lumbar spinal stenosis (DLSS) in SE patients aged 80 years and over with those in patients aged 65 years and over, and under 80 years.This study analyzed 160 patients who underwent spinal fusion for DLSS between January 2011 and November 2019. Thirty patients in the SE group (group SE, ≥80 years) and 130 patients in the elderly group (group E, ≥65 years and <80 years) were enrolled. The performance status was evaluated by preoperative American society of anesthesiologists (ASA) score. Visual analog scales for back pain (VAS-BP) and leg pain (VAS-LP), and Korean Oswestry disability index (K-ODI) were used to assess clinical outcomes preoperatively and 1 year postoperatively. Percent changes of VAS-BP, VAS-LP and K-ODI were also analyzed. Fusion rates were evaluated by computed tomography 6 months and 1 year postoperatively. Furthermore, bone mineral density, operative time, estimated blood loss, blood transfusion, hospital days, hospitalization in intensive care unit and postoperative complications were compared.The average age of group SE was 82.0 years and that of group E was 71.6 years. There were no differences in preoperative ASA score, preoperative or postoperative VAS BP and VAS-LP, bone mineral density, operative time, estimated blood loss, blood transfusion, hospital days, hospitalization in intensive care unit and fusion rates between the groups. Preoperative and postoperative K-ODI were higher in group SE than group E (all P < .05). However, percent changes of VAS-BP, VAS-LP and K-ODI showed no significant differences. Overall early and late complications were not significantly different between the groups; however postoperative delirium was more common in group SE than group E (P = .027). SE status was the only risk factor for postoperative delirium with odds ratio of 3.4 (P = .018).Spinal fusion surgery is considerable treatment to improve the quality of life of SE patients with DLSS, however careful perioperative management is needed to prevent postoperative delirium.     

Functional recovery after hip fracture in old-old elderly patients

Hip fracture is epidemic and prevalence increased with advanced age. Impact of comorbid and cognitive status, gender, type of fracture, operative delay and pre-fracture ambulatory levels on functional outcome was shown in previous studies. We studied functional outcome after rehabilitation for hip fracture in old-old elderly (85 years and older) and compared it to young elderly (65–74 years) community-dwelling patients. Before the fracture, old-old elderly patients were more functional dependent, has had more comorbid diseases, and more of them live alone than young elderly. The waiting time to surgery and mean length of stay in orthopedic ward were longer than in young elderly. On admission to rehabilitation treatment, old-old patients presented with more depressed mood, were more cognitive impaired, and more suffer from pain. Old-old patients presented with laboratory data of malnutrition (decreased serum levels of albumin, cholesterol, hemoglobin, hematocrit, lymphocyte count) and inflammation (increased of transferrin and C-reactive protein). Improvement in Functional Independence Measurement (FIM) scale was found in both groups but significantly better in young elderly than in old-old elderly. The change in FIM during the rehabilitation period (ΔFIM) were in FIM total and in those parts of FIM concerning locomotion. The mean duration of rehabilitation stay was significantly longer in old-old elderly patients. On discharge old-old elderly patients more suffer from pain and difference between the groups according to the laboratory and to the cognitive data increased. Age per se is indicator of frailty and determinate functional recovery after hip fracture.     

80岁以上老年人髋部骨折的手术治疗：附117例临床分析

目的通过对１１７例８０岁以上老年人髋部骨折手术治疗临床分析，探讨其手术的必要性、可行性、手术指征及禁忌证。方法回顾性分析１１７例患者的术前并存症、术前准备、手术方式、术中情况、术后处理及随访情况。结果本组无术中死亡病例，平均住院时间为２３天。１０７例获得随访，随访率９１．５％，平均随访２８个月。预后：良（疼痛消失，功能好，恢复生活自理能力）７７例，占７２．０％；尚可（恢复部分生活自理能力）２１例，占１９．６％；差（仍有疼痛，不能下地活动，生活不能自理）９例，占８．４％。结论８０岁以上老年人髋部骨折的手术治疗是安全可行的。