75岁以上老年患者髋关节置换围术期合并症的处理及安全性评估

Management and safety evaluation of perioperative comorbidities in patients older than 75 years old undergoing hip arthroplasty

目的探讨75岁以上高龄患者行髋关节置换围术期合并症的处理方法，预防并发症，提高围手术期的安全性。方法回顾从2008年1月至2012年12月，行髋关节置换术75岁以上患者170例（179髋）。男61例，女109例，年龄75～93岁，平均78岁。全髋关节置换术98例，股骨头置换术33例，翻修术39例。记录患者的术前合并症及处理方法、术后并发症、输血量等。其中术前合并合并症的患者127例，合并症包括：高血压81例，心律失常18例，冠心病7例，慢性阻塞性支气管炎46例，糖尿病37例，肺部感染12例，免疫系统疾病（类风湿、系统性红斑狼疮、硬皮病）8例，肝功能不全3例，尿路感染7例，肾功能不全3例，早期老年痴呆症7例，脑梗塞后偏瘫1例，下肢静脉血栓11例。对这些合并症术前、术中及术后处理进行研究和总结并提出预防与治疗方法。结果170例患者平均住院15（7～62）天均顺利出院，无死亡病例。平均术中失血量300（200～800） ml，平均引流量250（50～350） ml，平均输血量400（0～2400） ml，输血103例（58%）。术后并发症：心衰2例，心律失常3例，肺部感染10例，脱位5例，术后谵妄16例，深静脉血栓8例，尿路感染5例，切口浅表感染1例，均经积极处理后治愈。结论高龄患者行髋关节置换术合并症多，术前积极处理各种合并症、术后积极防范及处理并发症是安全渡过围术期的重要措施。把握好手术时机及合并症的处理可有效降低死亡率及并发症发生率，提高手术的安全性。

Objective To investigate the management methods of perioperative comorbidities in the patients older than 75 years old undergoing hip arthroplasty so as to avoid the complications and improve the perioperative safety.Methods From January 2008 to December 2012, the clinical data of 170 patients （ 179 hips ） older than 75 years old who underwent hip arthroplasty were retrospectively analyzed. There were 61 males and 109 females, with a mean age of 78 years old （ range： 75-93 years ）. Total hip arthroplasty （ THA ） was performed on 98 patients, femoral head replacement on 33 patients and hip revision on 39 patients. The preoperative comorbidities and management methods, postoperative complications and volume of blood transfusion were recorded. There were 127 patients with preoperative comorbidities, including 81 cases of hypertension, 18 cases of arrhythmia, 7 cases of coronary disease, 46 cases of chronic obstructive pulmonary disease （ COPD ）, 37 cases of diabetes, 12 cases of lung infection, 8 cases of immune system diseases （ rheumatoid, systemic lupus erythematosus and scleroderma ）, 3 cases of hepatic dysfunction, 7 cases of urinary tract infection, 3 cases of renal insufifciency, 7 cases of early-onset Alzheimer disease, 1 case of hemiplegia following cerebral infarction and 11 cases of deep vein thrombosis. The preoperative, intraoperative and postoperative management methods were studied and summarized, and the ways of preventing and treating such comorbidities were put forward.Results All the patients were discharged successfully after an average hospitalization time of 15 days （ range： 7-62 days ） after the operation. No one died. The average volume of intraoperative blood loss was 300 ml （ range： 200-800 ml ）, and the average volume of drainage was 250 ml （ rang： 50-350 ml ）. The average amount of blood transfusion was 400 ml, （ range： 0-2400 ml, ） and 103 patients received blood transfusion. The postoperative complications included 2 cases of heart failure, 3 cases of arrhythmia, 10 cases of lung infection, 5 cases of dislocation, 16 cases of postoperative delirium, 8 cases of deep vein thrombosis, 5 cases of urinary tract infection and 1 case of incision infection. All the complications were cured by active treatment.Conclusions Elderly patients undergoing hip replacement often have comorbidities. It’s essential to manage the preoperative comorbidities and prevent the postoperative complications actively, in order to help the patients get through the perioperative period safely. The rates of mortality and complications can be effectively reduced with timely hip arthroplasty and good management of comorbidities, and the perioperative safety can be further improved.