脊麻下老年髋部骨折患者围术期出凝血功能的改变

Change of Perioperative Bleeding and Clotting in aged hip Fracture on Spinal Anesthesia

目的深入研究脊麻手术对老年髋部骨折患者围术期出凝血功能的影响。方法择期行髋部骨折手术老年患者30例,全部选用脊麻,术后常规应用PCIA泵。根据病情实施人工股骨头置换、闭合复位或切开复位内固定术。术后常规注射LMWH。采集患者入院后第一天清晨（术前）,麻醉后1 h（术中）,手术后第一天清晨（术后）静脉血样,共3次。监测出凝血检验指标9项、术后72 h患者DVT形成或肺栓塞临床表现以及伤口出血情况。结果本组患者男17例,女13例,年龄69~88岁,体重50~78 kg。诊断股骨颈骨折19例,股骨转子部骨折11例。行人工股骨头置换16例,闭合复位或切开复位内固定14例。本组患者皆选用0.12%轻比重布比卡因脊麻,术后皆使用PCIA泵。术后6 h常规皮下注射低分子肝素钙4100 IU一次。出凝血监测结果与术前比较,术中PT明显升高,AT-A明显降低;术后PT、aPTT、INR明显升高,TT、FDP、AT-A、D-D明显降低。与术中比较,术后aPTT明显升高,FDP、D-D明显降低。未发现有DVT形成或肺栓塞、亦未见伤口异常出血情况。结论老年髋部骨折患者机体血液系统处于高凝状态,脊麻、手术、PCIA和预防性使用LMWH对预防DVT形成及肺栓塞有益。

Objective Deep researches on spinal anesthesia and surgery effects of perioperative bleeding and clotting in aged hip fracture. Methods Thirty aged hip fracture patients of selective operation. All spinal anesthesia,undergoing surgery of artificial head of femur replacement、closed reduction or open reduction. Routinely using patient controlled intravenous analgesia（ PCIA） and preventive injecting low-molecularweight heparin（ LMWH） postoperatively. Gathering preoperative,intraoperative and postoperative venous blood sample,total 3 times. Monitoring our nine bleeding and clotting laboratory index,and observing clinical feature of deep venous thrombosis（ DVT）,pulmonary thrombo-embolism（ PTE） and wound abnormal bleeding. Results 17 male and 13 female,age ranging from 69 to 88 years,weight ranging from 50 to 78 kg,diagnosis 19 frature of neek of femur and 11 fracture of femoral interochanter. Undergoing 16 artificial head of femur replacements and 14 closed reduction or open reductions. 0. 12 % bupivacaine light proportion spinal anesthesia. PCIA postoperatively. After 6 hours they were subcutanneously injected low-molecular-weight heparin calcium injection 4100 IU routinely. Laboratory result was： Comparing with preoperation,intraoperative PT markedly raised,AT-A marked decline. And postoperative PT,aPTT and INR markedly raised,TT,FDP,AT-A and D-D marked decline. Comparing with intraoperation,postoperative aPTT markedly raised,FDP and D-D marked decline. There were no DVT,PTE and wound abnormal bleeding. Conclusion There was the hypercoagulable state in aged hip fracture patients. It is beneficial of preventing DVT and PTE that using spinal anesthesia,Surgery,PCIA and LMWH postoperatively.