日间全髋关节置换术围术期管理1例

2020-08-11 覃兆军 周才胜 李时芹 麻醉安全与质控

日间手术是指患者入院、手术和出院在24h内完成的手术,特殊病情不超过48h,且不包括门诊手术。近年来,国家逐步重视这一高效益诊疗模式。我国髋关节置换术逐年增多,随着外科与麻醉技术的飞速发展,以及加速术

日间手术是指患者入院、手术和出院在24h内完成的手术,特殊病情不超过48h,且不包括门诊手术。近年来,国家逐步重视这一高效益诊疗模式。我国髋关节置换术逐年增多,随着外科与麻醉技术的飞速发展,以及加速术后康复理念的普及,髋关节置换日间手术成为现实。全髋关节置换日间手术已在国外普遍开展,但国内未见相关文献报道。现将我院近期成功开展的1例髋关节置换日间手术报道如下。

1.患者资料

患者,男,62岁,身高162 cm,体质量58kg,因“先天性右髋关节发育不良”行右全髋关节置换日间手术。既往无其他病史可载。查体:血压(BP)120/65mmHg(1mmHg=0.133kPa),心率(HR)70次/min,呼吸频率(RR)14次/min,心肺听诊无异常。术前血常规、血生化、心电图(ECG)、胸片及肺功能检查均未见明显异常。所有检查及麻醉评估均在入院前门诊完成。

在家术前准备内容:加强营养(适当摄入鱼肉、猪肉、鸡蛋等);不饮酒、不吸烟;适当运动;每天早晚吹气球,每次5min;多食蔬菜水果,保持大便通畅。术前6h禁食固体食物,术前2h口服250mL葡萄糖水。手术当天8:00入院,完善医疗文书、签署知情同意书,8:30入手术室、9:30切皮、11:00手术结束,送患者回日间病房继续观察。

麻醉过程:入室后常规监护BP、HR、ECG及脉搏血氧饱和度(SpO2),开放静脉通道,鼻导管吸氧(3L/min)。静脉注入咪达唑仑2mg、地佐辛5mg后,在超声引导下进行右股外侧皮神经阻滞(探头置于髂前上嵴中下方,采用平面内模式进针,注入0.25%罗哌卡因10mL),及闭孔神经阻滞(探头置于股动脉内侧平行于腹股沟褶,采用平面内模式进针,分别阻滞前后支,共注入0.25%罗哌卡因20mL)。再取患侧在上,L3-4行右侧单侧腰麻,蛛网膜下腔注入低比重罗哌卡因10mg,再向头端置入硬膜外导管4 cm,最高阻滞平面为T8,术中硬膜外腔未追加局麻药,右侧腰麻阻滞时间150min,术中右下肢运动阻滞改良Bromage评分3分、左下肢评分1分。

切皮前30min静脉滴入头孢美唑1g,切皮前10min静脉滴入氨甲环酸1g、帕瑞昔布40mg及地塞米松5mg,术中持续静脉泵注右美托咪定0.4μg/(kg·h),静脉输注复方氯化钠注射液6mL/(kg·h),未输血。缝合伤口时,切口局麻药逐层浸润麻醉(罗哌卡因100mg、地塞米松5mg、酮咯酸30mg加生理盐水共40mL)、局部注入氨甲环酸1g。手术历时90min,出血约200mL,留置伤口引流管,未置入导尿管。

术中麻醉效果佳、生命体征平稳,患者未述任何不适。术后患者入日间病房,监测BP、HR、ECG及SpO2,静脉补液。此时患者双下肢均已恢复运动功能(改良Bromage评分0分),活动时疼痛视觉模拟评分(VAS)评分0分,嘱患者饮少量清水;术后2h生命体征平稳,开始流质饮食;术后4h辅双拐下床走动,口服氨酚羟考酮镇痛;术后20h拔出引流管、恢复正常饮食、再次下床活动;术后29h出院评估量表评分10分,办理出院、回家康复。嘱其口服头孢克洛缓释胶囊3d(500mg/次)、利伐沙班片5周(10mg/d)、按需口服氨酚羟考酮(325mg/次)镇痛,并给予具体康复指导意见。术后第1、2、7天电话随访,伤口状况良好、活动时疼痛VAS评分2~3分,每日行走训练30min,饮食正常,未述其他异常情况。术后30d上门随访,伤口痊愈、辅单拐行走,未述不适。

2.讨论

日间手术是一种高质高效的诊疗模式,可在很大程度上缓解我国目前“看病难、看病贵、住院长”等的困境,近年来备受我国政府部门重视,众多传统手术开始以日间手术方式完成。传统全髋关节置换术,一般住院10~14d,而日间手术模式则将住院时间压缩至24~48h,住院时间和医疗费用大幅缩减,但得到同样的医疗质量和安全保障,同时,也得到患者认可。该病例为我院开展的首例全髋关节置换日间手术,其成功开展得益于便捷的日间诊疗模式、最新外科与麻醉技术及加速术后康复理念的应用。

纳入日间手术的基本原则是已证明能够保障医疗质量和患者安全的手术,且术中出血少、手术时间短、术后康复快。我院每年施行髋关节置换术约500例,技术成熟、均在2h内完成、术后恢复满意,因此,适合开展日间手术。如患者手术不复杂、身体条件好、无基础疾病,则适合接受日间手术。本例患者除存在右髋关节病变外,无其他基础疾病,营养状况良好,因此,我们选择为其实施日间手术。全麻或椎管内麻醉下均可实施髋关节置换术,但对于老年患者,特别是单侧下肢手术患者,单侧腰麻是最佳麻醉方法,其对全身血流动力学影响小、术后恢复快,因此,本例采取单侧腰麻,取得良好效果。本例采用后外侧入路微创全髋关节置换手术,与传统手术方法相比,创伤更小、出血更少、恢复更快,为早日下床活动创造了条件。

完善的镇痛是术后尽早下床活动的基础,也是日间手术患者早日出院的前提。本例采用围术期使用非甾体类镇痛药、术中切口局部浸润麻醉及超声引导下神经阻滞等多模式镇痛方法,为患者术后提供了完善的镇痛,确保患者术后尽早下床行走,与文献报道一致。患者在入院前1周通过饮食进一步改善自身营养状况。为减轻饥饿感、降低胰岛素抵抗,术前2h口服少量碳水化合物;术后回到病房即开始饮用清水、并逐步过渡到正常饮食,这些措施为患者早日下床活动提供了营养支持。术后规律运动和抗栓治疗有利于预防下肢静脉血栓形成。

术后30d内多次随访,未出现伤口感染、出血、血栓及关节活动异常,康复满意,表明该病例在日间手术模式下取得圆满成功。综上所述,选择合适的患者、采用最新外科与麻醉技术及加速康复外科理念,全髋关节置换日间手术安全可行,有利于减轻患者医疗负担、促进患者尽早恢复健康。

原始出处:

覃兆军,周才胜,李时芹,杜思雨,马广胜.日间全髋关节置换术围术期管理1例[J].麻醉安全与质控,2019,3(04):226-228.

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    2020-10-06 yxch48
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    2020-08-11 liangying

    我进来是想夸一下这个封面

    0

  8. [GetPortalCommentsPageByObjectIdResponse(id=1754223, encodeId=24cd1e5422307, content=<a href='/topic/show?id=7d3330135ac' target=_blank style='color:#2F92EE;'>#关节置换术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=40, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=30135, encryptionId=7d3330135ac, topicName=关节置换术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=050736663344, createdName=apoenzyme, createdTime=Tue Feb 23 22:23:09 CST 2021, time=2021-02-23, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1742723, encodeId=653a1e42723f3, content=<a href='/topic/show?id=39cae96626f' target=_blank style='color:#2F92EE;'>#置换#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=34, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79662, encryptionId=39cae96626f, topicName=置换)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=3a7c35056336, createdName=yxch48, createdTime=Tue Oct 06 10:23:09 CST 2020, time=2020-10-06, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=2022016, encodeId=3b2e20220168f, content=<a href='/topic/show?id=3d3929e567d' target=_blank style='color:#2F92EE;'>#全髋关节#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=39, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=29756, encryptionId=3d3929e567d, topicName=全髋关节)], attachment=null, authenticateStatus=null, createdAvatar=http://thirdwx.qlogo.cn/mmopen/vi_32/Q0j4TwGTfTKUdkK5dVTue7YQDvwqM1ugOuEpDZEzvXhoGClFiavehcrNAYDuPbks3MkKLPpyAEicgic80KguxwicYQ/132, createdBy=ec952500165, createdName=ms5187542471278033, createdTime=Thu Jun 03 21:23:09 CST 2021, time=2021-06-03, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1275466, encodeId=fe1212e54663b, content=<a href='/topic/show?id=6a39406551e' target=_blank style='color:#2F92EE;'>#围术期#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=37, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=40655, encryptionId=6a39406551e, topicName=围术期)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=5fca128, createdName=licz0423, createdTime=Thu Aug 13 00:23:09 CST 2020, time=2020-08-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1322683, encodeId=c932132268398, content=<a href='/topic/show?id=cb1a406e0fc' target=_blank style='color:#2F92EE;'>#围术期管理#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=45, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=40670, encryptionId=cb1a406e0fc, topicName=围术期管理)], attachment=null, authenticateStatus=null, createdAvatar=, createdBy=c3ae503, createdName=pps20019, createdTime=Thu Aug 13 00:23:09 CST 2020, time=2020-08-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=1576787, encodeId=23cf15e6787d0, content=<a href='/topic/show?id=48fee966468' target=_blank style='color:#2F92EE;'>#置换术#</a>, beContent=null, objectType=article, channel=null, level=null, likeNumber=25, replyNumber=0, topicName=null, topicId=null, topicList=[TopicDto(id=79664, encryptionId=48fee966468, topicName=置换术)], attachment=null, authenticateStatus=null, createdAvatar=null, createdBy=054816326830, createdName=ms117281293605716, createdTime=Thu Aug 13 00:23:09 CST 2020, time=2020-08-13, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=807495, encodeId=331b80e495e6, content=我进来是想夸一下这个封面, beContent=null, objectType=article, channel=null, level=null, likeNumber=87, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20211106/ea1e44326e0946358e849b176cb8f385/463bdae7ebb241129b21a5680b639742.jpg, createdBy=329c5121051, createdName=liangying, createdTime=Tue Aug 11 17:04:26 CST 2020, time=2020-08-11, status=1, ipAttribution=), GetPortalCommentsPageByObjectIdResponse(id=807431, encodeId=10ea80e4314c, content=学习了, beContent=null, objectType=article, channel=null, level=null, likeNumber=95, replyNumber=0, topicName=null, topicId=null, topicList=[], attachment=null, authenticateStatus=null, createdAvatar=https://img.medsci.cn/20201110/2d55d24dc5fd419d994b7b920c79731b/d3c8bdca983c4af1b90220a8192e353a.jpg, createdBy=e14e5296465, createdName=飞翔的乌龟, createdTime=Tue Aug 11 09:25:55 CST 2020, time=2020-08-11, status=1, ipAttribution=)]
    2020-08-11 飞翔的乌龟

    学习了

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