超高齡患者圍術(shù)期.ppt

超高齡患者圍術(shù)期麻醉并發(fā)癥的防范與處置,蕪湖市第一人民醫(yī)院 牛居輝,超高齡患者的生理特點(diǎn)和病理生理特征,超高齡患者圍術(shù)期的并發(fā)癥及死亡原因分析,超高齡患者圍術(shù)期的死亡率及影響因素,超高齡患者圍術(shù)期的麻醉及管理,社會(huì)老齡化 科學(xué)技術(shù)進(jìn)步 特別是麻醉學(xué)和外科學(xué)的發(fā)展,前言,超高齡手術(shù)患者越來(lái)越多,超高齡的概念,根據(jù)現(xiàn)代人的生理、心理特點(diǎn)，WHO將人的生命周期做了新的劃分： 44歲以下為青年人； 4559歲為中年人； 6074歲為年輕老年人（the young old）； 7589歲為老老年人（the old old）； 90歲以上為非常老的老年人（the very old）或長(zhǎng)壽老年人（the longevous）。 臨床上將年齡超過(guò)90歲稱(chēng)為超高齡。,人口統(tǒng)計(jì)學(xué)特征：老齡化,2009年老年人口基本信息：2009年，全國(guó)60歲及以上老年人口達(dá)到1.6714億，占總?cè)丝诘?2.5%。與上年度相比，老年人口凈增725萬(wàn)，增長(zhǎng)了0.5個(gè)百分點(diǎn)。2009年，80歲以上老年人口達(dá)到1899萬(wàn)，老年人口11.4%，2005年為1479萬(wàn),10.2%。 65歲以上老年人口所占比重：有浙江、上海等7個(gè)省市超過(guò)10%，浙江省最高達(dá)到13.89%；全國(guó)其中65歲及以上人口為118831709人，占8.87%。上海老齡化進(jìn)程呈現(xiàn)出高齡化態(tài)勢(shì)上海80歲及以上高齡老年人口為58.78萬(wàn)人 。根據(jù)衛(wèi)生部門(mén)資料，2010年上海平均期望壽命為82.13歲 我們醫(yī)院超高齡手術(shù)量：,超高齡患者的生理特點(diǎn)和病理生理特征,超高齡患者生理特點(diǎn)-神經(jīng)系統(tǒng),中樞神經(jīng)元數(shù)量減少 如到90歲，中樞神經(jīng)元數(shù)量減少3050； 腦血管自動(dòng)調(diào)節(jié)曲線(xiàn)因血管硬化和低血壓而右移，容易腦缺血； 腦血流減少； 神經(jīng)遞質(zhì)、受體減少； 腦灌流減少，腦氧代謝下降； 自主神經(jīng)興奮性下降 對(duì)循環(huán)系統(tǒng)調(diào)節(jié)減弱 ，對(duì)麻醉和手術(shù)應(yīng)激的適應(yīng)能力下降; 保護(hù)性喉反射遲鈍。,超高齡患者生理特點(diǎn)-循環(huán)系統(tǒng),心肌纖維化致彈性減退； 心肌肥厚； 心室舒張和充盈減少、CO、SV； 射血分?jǐn)?shù)減少； 氧輸送（DO2）等均減少動(dòng)脈硬化，SVR升高，血壓升高； 靜脈彈性減退，順應(yīng)性下降，容量相對(duì)不足； 動(dòng)脈硬化尤其是主動(dòng)脈弓，壓力感受器調(diào)節(jié)血壓、心率功能減退竇房結(jié)功能減退 ； 副交感神經(jīng)系統(tǒng)張力、受體反應(yīng)下降； 左房、肺血管充盈增加，引起肺充血； 心室舒張功能減退 。,超高齡患者生理特點(diǎn)-呼吸系統(tǒng),胸廓彈性減少； 肺順應(yīng)性下降； 呼吸肌減弱； 肺泡氣體交換面積減解剖和生理死腔增加； 肺實(shí)質(zhì)彈性組織減少，肺順應(yīng)性下降，肺活量（VC）減小，殘余氣量增加，F(xiàn)EV1下降，肺泡彈性回縮 ，通氣/灌流下降； PaO2缺氧性肺血管收縮（HPV）反射對(duì)高碳酸血癥和低氧血癥的通氣反應(yīng)減弱。,超高齡患者病理生理特征,超高齡老人生理及組織的改變更為明顯，麻醉的風(fēng)險(xiǎn)極大， 被稱(chēng)之fragile patients（易碎的病人）。主要原因有： 一是老人器官衰退，內(nèi)環(huán)境穩(wěn)態(tài)極度薄弱，麻醉手術(shù)耐受性差。如90歲，中樞神經(jīng)元數(shù)量減少3050；交感神經(jīng)活性水平在平時(shí)就提高，一旦麻醉阻滯，血流動(dòng)力學(xué)變化劇烈，對(duì)血管活性物質(zhì)反應(yīng)差，受體反應(yīng)性下降，應(yīng)激情況下不能靠提高心率，而是更主要依賴(lài)前負(fù)荷和每博量的增加。腦血管自動(dòng)調(diào)節(jié)曲線(xiàn)因血管硬化和低血壓而右移容易腦缺血，維持正常的血壓水平顯得尤為重要。 二是基礎(chǔ)疾病多，如高血壓、糖尿病、心腦血管病等、貧血、營(yíng)養(yǎng)不良等。老年癡呆在65歲以上發(fā)病率為5，75歲以上為15。 三是手術(shù)后恢復(fù)慢，老人手術(shù)后容易發(fā)生感染，導(dǎo)致肺炎，有的老年人還會(huì)出現(xiàn)靜脈血栓等問(wèn)題。日?；顒?dòng)量少；應(yīng)激情況下，機(jī)體就會(huì)無(wú)力應(yīng)付；內(nèi)環(huán)境穩(wěn)態(tài)極度薄弱，難以自動(dòng)修復(fù)，臟器功能容易衰竭。,超高齡患者圍術(shù)期死亡率及影響因素,超高齡患者圍術(shù)期死亡率,麻醉手術(shù)相關(guān)死亡率: 術(shù)后30天內(nèi)死亡 6070y 2.2. 7079 y 2.9 80y 以上 5.86.2 90 y以上 8.4%（Hosk MP ） 大手術(shù)，開(kāi)胸，急診剖腹，高達(dá)19.8 （Ackermann RJ ）,超高齡患者圍術(shù)期死亡率,美國(guó)Warner MA 報(bào)道：31例100107歲世紀(jì)老人麻醉手術(shù)后30天的死亡率為16%，整體上發(fā)病率和死亡率似乎與麻醉類(lèi)型無(wú)關(guān)。 英國(guó)Derby報(bào)道13例世紀(jì)老人30天的死亡率為31%，一年的死亡率56% 。 Mark C. The medical records of a consecutive series of 13 centenarians with proximal femoral fractures who presented to the Derbyshire Royal over a 20 year period were retrospectively reviewed. The majority of patients were female (M:F 2:11) and had suffere intertrochanteric fractures. The recorded incidence of surgical complications was low. The mortality at 30 days, 6 months and 1 year were 31%, 50% and 56%, respectively,影響超高齡患者圍術(shù)期死亡率的因素-D.A Story,Table 1 Comparison of survivors and patients who died within 30 days of surgery. Values are number (proportion), mean (SD),or median (IQR range). Variable Survivors Non-survivors p value Patients 3942 (95%) 216 (5%) Age; years 78 (6) 81 (6) 0.001 Male 1982 (50%) 117 (54%) 0.001 Non-scheduled surgery 1279 (32%) 134 (62%) 0.001 ASA physical status 1, 2 1300 (33%) 15 (7%) 0.001 3 2081 (53%) 96 (44%) 4 450 (11%) 90 (42%) 5 21 (1%) 11 (5%) Comorbidities 0 1282 (35%) 31 (14%) 0.001 1 1255 (31%) 51 (24%) 2 771 (20%) 58 (26%) 3+ 634 (16%) 65 (35%) Complications 1 704 (18%) 131 (26%) 0.001 Length of stay; days* 6 (212 030) 30 (930 030) 0.001,Y. Kojima,影響超高齡患者圍術(shù)期死亡率的因素,性別，女性好于男性。 日常生活依賴(lài)性（dependency in daily living，DDL） 低 DDL與術(shù)后并發(fā)癥，住院時(shí)間及遠(yuǎn)期死亡率有關(guān). 也是術(shù)后認(rèn)知功能障礙post-operative cognitive dysfunction (POCD)的風(fēng)險(xiǎn)因素。 腹部手術(shù) 水、電解質(zhì)紊亂，低溫,呼吸抑制，術(shù)前貧血，營(yíng)養(yǎng)不良，脫水，術(shù)后。臥床，低血容量。 急診手術(shù) 定義，24h以?xún)?nèi) 手術(shù)時(shí)間與手術(shù)種類(lèi) 如股骨頸骨折，可以PFN,DHS,鎖定鋼板，PCCP，全髖置換，全髖置換創(chuàng)傷大。采用PFN內(nèi)固定相對(duì)創(chuàng)傷小、手術(shù)時(shí)間短（平均40分鐘）、術(shù)中出血及術(shù)后引流量較?。ㄆ骄s300毫升） 年齡 Hans等調(diào)查發(fā)現(xiàn)，與6579歲人群相比，80歲以上的患者關(guān)節(jié)成形術(shù)后心肌梗死的幾率升高2.7倍，肺部感染的幾率升高3.5倍，術(shù)后昏迷以及尿路感染的幾率也有明顯增高，死亡率更升高3.4倍。百歲以上高齡患者髖部骨折手術(shù)后30 d、6個(gè)月、1年死亡率分別為31、50、56，明顯高于低年齡組患者術(shù)后死亡率。 蛋白 35,When compared with over 1000 hip fracture patients of all ages in previous prospective studies, the centenarians in this series were found to have a higher mortality during hospital admission ( p0.001) and at 1 year ( p=0.002). The treatment of hip fractures in centenarians poses a challenge. Optimal anaesthesia, expeditious surgery and a co-ordinated multidisciplinary approach to care is essential in these patients.,超高齡患者圍術(shù)期的并發(fā)癥及死亡原因分析,死亡原因及常見(jiàn)的并發(fā)癥- D.A Story,Complication Mortality UnivariateOR p value AdjustedOR p value Systemic inflammation 305(7%) 46(15%) 3.9 (2.75.5) 0.001 2.5 (1.73.7) 0.001 Acute renal impairment 244(6%) 42 (17%) 4.4 (36.4) 0.001 3.3 (2.15.0) 0.001 Unplanned admission toICU173(4%) 34(20%) 5.0(3.37.6) 0.001 3.1 (1.94.9) 0.001 Acute pulmonary oedema 25(3%) 25(20%) 5.0 (3.17.9) 0.001 3.0 (1.75.0) 0.001 Return to operating theatre120(3%) 19 (16%) 3.6 (2.16) 0.001 2.5 1.44.4) 0.002 Acute myocardial infarction105(2%) 21 (20%) 5.0 (38.2) 0.001 2.9 (1.65.2) 0.001 Wound infection 85 (2%) 6 (7%) 1.4 (0.63) 0.4 0.8 (0.32.2) 0.57 Re-intubation 42(1%) 10(24%) 5.7(2.711.9) 0.001 5.0 (2.211.3) 0.001 Cardiac arrest 18(1%) 14(77%) 70(22.7214) 0.001 66.2(17.7247.2) 0.001 Pulmonary embolism 4 ( 1%) 1 (7%) 1.4 (0.39.4) 0.7 0.3 (0.03.9) 0.36 Stroke 10 ( 1%) 4 (40%) 12 (2.552.5) 0.001 Sample too small,Jovan L.,Mortality analysis in hip fracture patientsN. B. Foss Mortality related to cause,Mortality analysis in hip fracture patientsN. B. Foss,N. B. Foss 300 consecutive, unselected hip fracture patients were treated in a multimodal rehabilitation programme with continuous perioperative epidural analgesia and anaesthesia, early surgery, standardized fluid and transfusion therapy, enforced oral nutrition and early mobilization and physiotherapy. All deaths within 30 days of surgery or during primary hospitalization were analysed and classified according to whether death was unavoidable, probably unavoidable, or potentially avoidable. Results. Thirty-day mortality was 13.3% (40 patients) and the total perioperative mortality was 15.6% (47 patients). Death was definitely unavoidable in 28%, probably unavoidable in 15%, and in theory potentially avoidable in 57%. In the patients where death was potentially avoidable, active care was curtailed in 16 of 27 (59%) patients. Conclusion. About a quarter of the total mortality in hip fracture patients is definitely unavoidable, and death is probably only avoidable in about half of the unselected patients.,死亡原因及常見(jiàn)的并發(fā)癥分析,術(shù)后并發(fā)癥是導(dǎo)致患者住院期間及出院后死亡的最重要原因，導(dǎo)致患者死亡的嚴(yán)重并發(fā)癥依次為心臟事件、肺部感染、肺栓塞、尿路感染。Seymam等調(diào)查發(fā)現(xiàn)肺部感染占老年術(shù)后并發(fā)癥40，占可預(yù)防性死亡的20。,超高齡患者圍術(shù)期的麻醉及管理,麻醉與管理,麻醉管理的最高目的是給病人提供一個(gè)適中的環(huán)境，保護(hù)心肌，維護(hù)血流動(dòng)力學(xué)穩(wěn)定，控制并存疾病，避免圍術(shù)期不良事件 以并發(fā)癥為切入點(diǎn)，結(jié)合患者自身特點(diǎn)，作術(shù)前評(píng)估和指導(dǎo)麻醉。 整體把握，風(fēng)險(xiǎn)管理, 貫徹始終。,麻醉與管理-術(shù)前檢查,常規(guī)檢查； 特殊檢查 動(dòng)態(tài)心電圖， 心超，肌鈣蛋白心肌酶術(shù)后3d； 顱腦核磁等檢查，下肢深靜脈超聲檢查，D二聚體。,麻醉與管理-術(shù)前評(píng)估與準(zhǔn)備,呼吸系統(tǒng) 功能狀況及危險(xiǎn)因素 肝腎及其它體能狀態(tài) Duke Activity Status Index ，詢(xún)問(wèn)病人的日?；顒?dòng)能力來(lái)估計(jì)其心臟功能狀態(tài)。通?？煞謨?yōu)良（7 METS以上），中等（47 METS），差（4 METS以下）和不詳(4 MET :4km/h 步行200500m 平路，作輕便家務(wù)如揩灰、洗碗等)。 水、電解質(zhì)、酸堿等,麻醉與管理-術(shù)前評(píng)估與準(zhǔn)備,ASA分級(jí) 中樞系統(tǒng)術(shù)前常規(guī)的核磁等檢查，Soderqvist等調(diào)查發(fā)現(xiàn)，利用精神狀況評(píng)分系統(tǒng)SSPMSQS(short portable mental status questionnaire score)對(duì)患者進(jìn)行評(píng)分檢查，如果患者評(píng)分26分相當(dāng)于IV級(jí)。將心功能分級(jí)與CRI聯(lián)合評(píng)估可有更大的預(yù)示價(jià)值。12導(dǎo)聯(lián)ECG,動(dòng)態(tài)心電圖（如有必要），超聲心動(dòng)圖。美國(guó)ACC/AHA（2002）圍術(shù)期心血管危險(xiǎn)性評(píng)估,Cardiac risk stratification for noncardiac surgical procedures. Risk=combined incidence of cardiac death and nonfatal myocardial infarction. Patients in this group do not generally require further preoperative cardiac testing. From reference 47 reproduced with permission,High risk(reported cardiac risk often more that 5%) Emergency major operations, particularly in the elderly Aortic and other major vascular surgery Peripheral vascular surgeryAnticipated prolonged surgical procedures associated with large fluid shifts orblood loss Intermediate risk (reported cardiac risk generally less than 5%) Carotid endarterectomy Head and neck surgeryIntraperitoneal and intrathoracic surgery Orthopaedic surgery Prostate surgery Low risk (reported cardiac risk often more that 1%) Endoscopic procedureSuperfical procedure Cataract removal Breast surgery,Cardiac risk index. From reference 62 reproduced with permission,Risk category Points Aged 70 yr 5 Myocardial infarction within last 6 months 10 S3 gallop or jugular venous distension11 Significant valvular stenosis3 Rhythm other than sinus or premature atrial contractions 7 Premature ventricular contractions 5/min 7 Poor general medical condition 3 Abdominal or thoracic aorta surgery 3 Emergency surgery 4 Total 53,Goldman multifactorial risk assessment. From reference 62 reproduced with permission,Risk class Points Risk Complication (%)Mortality (%) I 05 0.7 0.2 II 612 5.0 2.0 III 1325 11 2.0 IV 26 22 56,Risk factors for postoperative stroke in elderly,Preoperative factors: Preexisting cerebrovascular disease Ischaemic cardiac disease Atherosclerosis Carotid occlusionPreoperative vascular disease Hypertension Diabetes mellitus Physical inactivity Intraoperative and postoperativefactors Haemodynamic instability Hypoxaemia,麻醉與管理-術(shù)前評(píng)估與準(zhǔn)備,麻醉醫(yī)生與外科醫(yī)生的溝通 麻醉醫(yī)生與患者及其家屬的溝通 通過(guò)患者及家屬影響外科醫(yī)生對(duì)術(shù)式的選擇,麻醉與管理麻醉選擇,盡量選對(duì)生理干擾少、安全、便于調(diào)節(jié)和麻醉效果確切的方法和藥物. 連續(xù)腰麻，穩(wěn)定的血流動(dòng)力學(xué)參數(shù)，與緩慢阻滯交感神經(jīng)有關(guān)，20分鐘以后很少發(fā)生低血壓，補(bǔ)償機(jī)制 單側(cè)腰麻 腰硬聯(lián)合麻醉 神經(jīng)叢阻滯 如有椎管狹窄，馬尾綜合癥等，單側(cè)腰叢阻滯加靜脈麻醉 全麻復(fù)合連硬外麻醉，復(fù)合神經(jīng)阻滯,麻醉與管理監(jiān)測(cè),BP，ECG，SpO2，尿量 有創(chuàng)血壓、CVP。 全麻鎮(zhèn)定患者腦電監(jiān)測(cè)，麻醉藥濃度監(jiān)測(cè)、麻醉氣體監(jiān)測(cè)； 體溫監(jiān)測(cè) 肌松監(jiān)測(cè),Anaesthesia management for elderly patients undergoing major surgery,Preoperative assessment for identifying high risk patients Careful history Physical examination Twelvelead ECG Functional status assessment Nutrition assessment,Anaesthesia management for elderly patients undergoing major surgery,Preoperative preparation Effective control of coexisting disease Stopped smoking for 8 weeks Training in cough and lung expansion techniques Chest physiotherapy for elderly at risk of postoperative pulmonary complications Correct of malnutrition Routine precautions for major surgery Temperature monitor and control Ripple mattress DVT prophylaxis Intraarterial pressure monitoring Haemodynamic stability Combination of anaesthetic and vasopressor, betablockers or vasodilators Avoid fluid overloadQuick recovery from anaesthesia Use shortacting anaesthetic agents Combine epidural anaesthesia and GA for major abdominal and thoracic surgeryAntagonize neuromuscular blocking drugs,Anaesthesia management for elderly patients undergoing major surgery,Postoperative periodPrevent hypoxaemiaSupplemental oxygen, reversal of neuromuscular blocking drugs Prevent hypothermiaKeep warm perioperatively Effective postoperative pain controlMultimodal analgesia,麻醉與管理并發(fā)癥的處理,低血壓 N. KONTTINEN報(bào)道：術(shù)中低血壓現(xiàn)象非常普遍，14例患者有10例需要血管活性劑苯腎和正性肌力多巴胺控制，低血壓現(xiàn)象非常普遍，14例患者有10例需要血管活性劑苯腎和正性肌力多巴胺控制，維持血流動(dòng)力學(xué)穩(wěn)定對(duì)保證氧供需平衡至關(guān)重要。HR .BPH 20以?xún)?nèi)。特別舒張壓。老年患者多合并心血管及肺部疾患，心肺功能儲(chǔ)備不足，不能耐受劇烈的血液動(dòng)力學(xué)波動(dòng)。對(duì)于這類(lèi)老年患者最好在術(shù)中常規(guī)準(zhǔn)備靜脈雙通道，一路淺靜脈，一路深靜脈，以備緊急輸液、輸血。有創(chuàng)動(dòng)脈血壓監(jiān)測(cè)。酌情給于麻黃堿或苯腎。術(shù)中管理關(guān)鍵之一是維持循環(huán)功能穩(wěn)定,保持心肌氧供需平衡另外,老年病人術(shù)前常伴有血容量不足,這是常引起低血壓和循環(huán)功能不穩(wěn)定的重要因素之一,術(shù)者常認(rèn)為老年人心肺功能不全,輸液術(shù)中低血壓.,Prevention of postoperative delirium. From reference 106 reproduced with permission. *MMSE, Digit Symbol Substituti