成人髖部骨折.ppt

1、成人髖部骨折：NICE指南,英國國家衛(wèi)生與臨床優(yōu)化研究所（NICE，National Institute for Health and Clinical Excellence） 是英國國家醫(yī)療服務(wù)系統(tǒng)（NHS）的組織，設(shè)在倫敦和曼徹斯特。 NICE成立于1999年4月1日，目標(biāo)是確保每個(gè)英格蘭和威爾士人平等享有NHS醫(yī)療的機(jī)會(huì)。 NICE制定指南，設(shè)定質(zhì)量標(biāo)準(zhǔn)，管理國家數(shù)據(jù)庫，為NHS、當(dāng)?shù)貦?quán)威部門和其他組織提供指南。,.uk/,髖部骨折,入院時(shí),股骨頸骨折,入院時(shí),入院時(shí),轉(zhuǎn)子下骨折？,入院時(shí),術(shù)后,全髖,術(shù)后,術(shù)后,病房照片 病人助行器行走,這是我們所有

2、的臨床印象嗎？,術(shù)后,術(shù)后,術(shù)后,臨床棘手的問題： 醫(yī)生的困惑 護(hù)理的壓力 家屬的期望 燙手的山芋，考驗(yàn)著每個(gè)人的智慧,骨科醫(yī)師的職責(zé)在于選擇恰當(dāng)?shù)墓潭ㄆ鞑摹?zhǔn)確地復(fù)位并可靠地固定骨折或矯形 而手術(shù)之外的問題也同樣應(yīng)該引起我們的重視,糖皮質(zhì)類激素的 骨科臨床應(yīng)用,北京大學(xué)人民醫(yī)院關(guān)節(jié)中心,林劍浩,路在何方？！,髖部骨折,髖部骨折是指股骨近端骨折（proximal femoral fracture，PFF），指發(fā)生在股骨頭邊緣和小轉(zhuǎn)子遠(yuǎn)端5 cm之內(nèi)的骨折。,流行病學(xué)情況,在英國每年有大約70,000到75,000例髖部骨折患者, 醫(yī)療衛(wèi)生相關(guān)花費(fèi)每年高達(dá)20億英鎊。（折合約為30萬RMB/人）

3、 英國全國髖部骨折數(shù)據(jù)庫報(bào)道:約10%的髖部骨折患者 在1個(gè)月內(nèi)死亡，約1/3在12個(gè)月內(nèi)死亡。 大部分死亡是與并發(fā)癥相關(guān)。 因此，髖部骨折并不是單純的手術(shù)治療，需要內(nèi)科，外科，麻醉和康復(fù)等包括醫(yī)院到社區(qū)的多學(xué)科綜合治療。,指南,指南推薦的診療計(jì)劃,指南推薦的診療計(jì)劃,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,關(guān)鍵問題： 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. 評(píng)估疼痛 2.Offer immediate analgesi

5、a to patients with suspected hip fracture, including people with cognitive impairment 即時(shí)鎮(zhèn)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光陰性者，24h內(nèi)安排MRI，否則予CT檢查,2.When the patient presents at hospital,4.Offer all patients a formal, acute, orthogeriatric or orthopaedic ward-based Hip Fracture Programme. 髖部骨折治療計(jì)劃 包括以下方面： 骨科老年疾病專家的評(píng)估 早期確認(rèn)患者的康復(fù)愿望 持續(xù)的、協(xié)作的多學(xué)科會(huì)診 快速改善術(shù)前健康狀況,2.When the patient presents at hospital,5. Ac

7、tively look for cognitive impairment and keep reassessing patients to identify delirium. 評(píng)估認(rèn)知障礙、及早確認(rèn)譫妄 有記憶障礙的患者在譫妄、并發(fā)癥、死亡率、延長住院天數(shù)等方面面臨更高的風(fēng)險(xiǎn)。 譫妄，明顯增加住院天數(shù)及6個(gè)月內(nèi)的死亡率，同時(shí)，使患者本人、家庭成員、照顧者(醫(yī)護(hù)人員)及其他住院病人相當(dāng)苦惱。,2.When the patient presents at hospital,2.When the patient presents at hospital,減少譫妄發(fā)生： 1.中樞神經(jīng)系統(tǒng)足夠的氧供2

8、.液體/電解質(zhì)平衡3.治療重度疼痛4.消除不必要的藥物5.調(diào)節(jié)腸道/膀胱功能6.足夠的營養(yǎng)攝入量7.早期活動(dòng)和康復(fù)8.術(shù)后主要并發(fā)癥的防治9.適當(dāng)?shù)沫h(huán)境刺激10.譫妄的治療,2.When the patient presents at hospital,阿米替林,苯海拉明,氯氮卓（利眠寧）,氯丙嗪,地西泮,多慮平,羥嗪（安泰樂）,丙咪嗪,吲哚美辛,哌替啶,2.When the patient presents at hospital,譫妄的治療：（a）適當(dāng)?shù)脑\斷檢查/管理（b）平靜的安慰，家庭成員的存在，和/或臨時(shí)保姆（c）如果必要時(shí)，氟哌啶醇0.250.5mg(1/4片) q4h；若禁忌，使

9、用相同劑量勞拉西泮（氯羥安定）,6. If a hip fracture complicates or precipitates a terminal illness, consider the role of surgery as part of a palliative care approach. 臨終關(guān)懷 在髖部骨折的患者中，有相當(dāng)大的比例合并危及生命的心肺、腫瘤和惡性疾病晚期等疾病。 此外，經(jīng)受髖部骨折、骨科和內(nèi)科并發(fā)癥的傷害、制動(dòng)及手術(shù)的創(chuàng)傷，也可以使個(gè)人的健康狀況惡化。 指南優(yōu)先考慮是：減輕痛苦、恢復(fù)功能、回歸社區(qū),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: 溝通 診斷 麻醉方式的選擇 鎮(zhèn)痛及其他藥物的選擇 術(shù)式 可能的并發(fā)癥 術(shù)后如何護(hù)理 康復(fù)計(jì)劃 遠(yuǎn)期的臨床結(jié)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、時(shí)立即行疼痛評(píng)估 and 在初始鎮(zhèn)痛后30min內(nèi)評(píng)估and 每小時(shí)進(jìn)行1次疼痛評(píng)估觀察 and 疼痛評(píng)估應(yīng)作為住院期間常規(guī)護(hù)理監(jiān)測(cè)項(xiàng)目.,3.analgesia,30分鐘的時(shí)間間隔反映了嗎啡的藥動(dòng)學(xué)/藥效學(xué)概況及其活性代謝產(chǎn)物嗎啡-6 - 葡萄糖醛酸。 給藥15分鐘后起效，足夠的止痛反應(yīng)總是30分鐘來實(shí)現(xiàn)。 效果的持續(xù)時(shí)間各不相同，從2至24小時(shí)不等，反射嗎啡-6 - 葡糖苷酸清除和響應(yīng)中的個(gè)體間變異。 如果需要進(jìn)一步的鎮(zhèn)痛，隨后每小時(shí)需要重新評(píng)估是合理的，不僅需要確保一個(gè)滿意的答復(fù)，而且評(píng)估任何不良影響。每小時(shí)也有一定的間隔是務(wù)實(shí)的，符合安全，通用性好臨床實(shí)踐，并在與CEM的建議。 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. 無關(guān)于止痛干預(yù)時(shí)間的相關(guān)研究 3. Ensure analgesia is sufficient to allow movements necessary for investigati

15、ons and for nursing care and rehabilitation. 要求：能配合查體、日常護(hù)理及康復(fù),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. 神經(jīng)阻滯 干預(yù)的時(shí)間術(shù)前術(shù)后？方式？ 指南建議后續(xù)的研究：進(jìn)一步評(píng)價(jià)nerve blocks的臨床及經(jīng)濟(jì)學(xué)價(jià)值,The best form of analgesia is surgical repair,3.analgesia,4.surgery,4.surgery,1.Timing of surgery (關(guān)鍵問題 ) 手術(shù)時(shí)機(jī) one of the biggest challenges to a health

19、care system The surgery does not stand alone. 它涉及到多學(xué)科之間的協(xié)調(diào)，包括：事故本身、急診科、急性創(chuàng)傷骨科服務(wù)、骨科老年疾病專家、麻醉師，以及有可用的手術(shù)室、訓(xùn)練有素的工作人員和相關(guān)設(shè)備。,4.surgery,對(duì)于這個(gè)問題，10項(xiàng)研究符合納入標(biāo)準(zhǔn)，均是關(guān)于早期手術(shù)、延遲手術(shù)的危害的研究，總共193,793人。 研究數(shù)據(jù)提示重要的影響因素包括：合并癥和年齡（7項(xiàng)研究）。 如不包括不適合手術(shù)的病人，即對(duì)延遲的原因是由于缺乏合適的人員、手術(shù)室或設(shè)備不可用（3項(xiàng)研究）。 延遲手術(shù)中確定的因素是入院時(shí)間。,4.surgery,1.1 Perform sur

20、gery on the day of, or the day after, admission. 入院48小時(shí)內(nèi)手術(shù) The cut-off for delay to surgery in this analysis is 24, 36 and 48 hours. 指南建議的后續(xù)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?,傾向于36小時(shí)內(nèi)手術(shù)？,4.surgery,1.2 Identify and treat correctable comorbidities immediately to avoid delaying surgery. 目標(biāo):一旦穩(wěn)定，盡快手術(shù) 不穩(wěn)定因素？,4.surgery,術(shù)前需改善的合并癥： 1.貧血2.抗凝狀態(tài)3.血容量不足4.電解質(zhì)紊亂5.未控制的糖尿病6.不受控制的心臟衰竭7.可糾正的心律不齊或心肌缺血8.急性肺部感染9.慢性肺部疾病的惡化,experienced

22、physicians and anaesthetists are needed!,4.surgery,33.3mmolL,室上性心動(dòng)過速,竇性心動(dòng)過速,230umol/L,4.surgery,2.Planning surgery （關(guān)鍵問題） 2.1 Schedule surgery on a planned trauma list. 手術(shù)團(tuán)隊(duì)、設(shè)備等 2.2 Consultants or senior staff should supervise trainee and junior staff during hip fracture surgery. 制勝法寶 上級(jí)的指導(dǎo) 影響：二次手術(shù)、

23、骨折對(duì)位、術(shù)后并發(fā)癥、住院時(shí)間、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 ：與全麻相比，區(qū)域麻醉在降低早期死亡率（1月內(nèi)）方面有統(tǒng)計(jì)學(xué)及臨床意義 (LOW QUALITY). 與全麻相比，區(qū)域麻醉在減少術(shù)后意識(shí)紊亂及DVT方面有統(tǒng)計(jì)學(xué)意義，但在臨床上改善不明顯(LOW QUALITY). 兩者在住院時(shí)間、嘔吐、肺炎、心肌梗死和肺栓塞的差異無統(tǒng)計(jì)學(xué)意義 (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,進(jìn)一步對(duì)骨折分型亞組分析發(fā)現(xiàn)，粗隆間骨折患者采用區(qū)域麻醉可降低死

26、亡率及肺部并發(fā)癥發(fā)生率，但在股骨頸骨折患者中差異不明顯,4.surgery,3.2 Consider intraoperative nerve blocks. 超聲引導(dǎo)下進(jìn)行，以減少并發(fā)癥及麻醉藥的劑量 減少阿片類藥物和其他鎮(zhèn)痛應(yīng)用的必要性和副作用 然而，因?yàn)橐玫难芯坑^察的方式及結(jié)果各不相同，因此不能形成有意義的結(jié)果。因此，該建議為共識(shí)。,4.surgery,4.Surgical procedures （關(guān)鍵問題） （1）手術(shù)目的是使患者術(shù)后盡快完全負(fù)重。 （2）對(duì)移位的囊內(nèi)骨折行關(guān)節(jié)置換術(shù)（全髖或半髖置換術(shù)），建議對(duì)骨折前能獨(dú)立行走、無認(rèn)知障礙、身體情況適合手術(shù)的患者行全髖置換術(shù)。 （3）

27、不建議使用Austin Moore或Thompson柄假體。 （4）建議使用骨水泥假體。 （5）半髖關(guān)節(jié)置換時(shí)建議使用前外側(cè)入路。 （6）AO分型A1和A2型的轉(zhuǎn)子間骨折，建議使用髓外內(nèi)固定系統(tǒng)（如滑動(dòng)加壓螺釘），而不是髓內(nèi)系統(tǒng)。 （7）轉(zhuǎn)子下骨折建議使用髓內(nèi)內(nèi)固定系統(tǒng)。,4.surgery,Austin Moore及Thompson柄假體是什么？,5.multidisciplinary rehabilitation,5.multidisciplinary rehabilitation,1. Mobilisation strategies （關(guān)鍵問題） 活動(dòng)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. 康復(fù)治療；早期活動(dòng),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: （關(guān)鍵問題） 將早期出院作為多學(xué)科支持下的治療計(jì)劃的一部分 病情穩(wěn)定 經(jīng)與病人、照顧者和家庭成員討論，告知尚未實(shí)現(xiàn)完全其康復(fù)潛力 有參與持續(xù)康復(fù)治療的心理準(zhǔn)備 能夠轉(zhuǎn)移和活動(dòng)短暫的距離,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