加速康复外科管理模式对高龄髋部骨折患者护理效果评价

Evaluation of nursing effect of enhanced recovery after surgery model in elderly patients with hip fracture

目的探讨围术期加速康复外科(ERAS)管理模式对高龄髋部骨折患者的护理效果。方法采用回顾性病例对照研究分析2017年7月至2018年6月苏州大学附属第二医院收治的94例高龄髋部骨折患者临床资料,其中男24例,女70例;年龄76~98岁[(83.7±5.4)岁]。骨折类型:股骨转子间骨折54例,股骨颈骨折40例。患者行股骨近端防旋髓内钉(PFNA)固定或人工髋关节置换治疗。44例围术期采用ERAS管理模式(加速康复组),50例围术期采用传统护理模式(传统康复组)。比较两组术后骨折部位、骨密度、致伤原因不同患者的下床时间;术前及术后1,3,7 d视觉模拟评分(VAS);术后1个月并发症情况;术前、术后1周、1个月、3个月日常自理能力(ADL)评分;术后1周、1个月、3个月及末次随访时髋关节功能Harris评分;术后住院时间;术后3个月及末次随访时死亡情况。结果患者均获随访12~24个月[(17.7±6.2)个月]。加速康复组术后不同骨折部位(股骨颈、股骨转子间)、骨密度(>-2.5 SD、≤-2.5 SD)、致伤原因(摔伤、交通伤、其他)患者的下床时间较传统康复组显著缩短(P<0.01)。术前两组VAS差异无统计学意义(P>0.05),加速康复组术后1,3,7 d VAS[(3.4±0.9)分、(2.7±0.5)分、(1.7±0.6)分]较传统康复组[(4.3±1.1)分、(3.5±0.5)分、(2.7±0.9)分]显著降低(P<0.01)。术后1个月,加速康复组肺部感染发生率为0%,低于传统康复组的28%(14/50)(P<0.01);两组心血管系统、神经系统、尿路感染、下肢深静脉血栓、肝肾功能减退、贫血、电解质紊乱、低蛋白血症等并发症发生率差异均无统计学意义(P>0.05)。术前两组ADL评分差异无统计学意义(P>0.05),加速康复组术后1周、1个月、3个月的ADL评分[(37.0±6.6)分、(70.1±8.4)分、(86.2±9.3)分]均较传统康复组[(26.5±10.4)分、(50.1±11.4)分、(70.7±9.0)分]显著提高(P<0.01)。加速康复组术后1个月Harris评分为(80.9±8.6)分,较传统康复组的(71.1±9.2)分显著提高(P<0.01);术后1周、3个月及末次随访时两组Harris评分差异无统计学意义(P>0.05)。加速康复组术后住院时间为(4.7±2.4)d,较传统康复组的(7.8±3.9)d显著缩短(P<0.01)。加速康复组术后3个月内无死亡,至末次随访时死亡2例[5%(2/44)],传统康复组术后3个月内死亡4例[8%(4/50)],两组病死率至末次随访时差异无统计学意义(P>0.05)。结论对于高龄髋部骨折患者,围术期实施ERAS管理模式可缩短卧床时间,有效减轻术后疼痛,降低术后肺部感染发生率,加速髋关节功能恢复,改善生活质量,缩短术后住院时间,促进患者早日康复。

Objectives To investigate the nursing effect of perioperative enhanced recovery after surgery(ERAS)management model in elderly patients with hip fracture.Methods A retrospective case-control study was conducted to analyze the clinical data of 94 elderly patients with hip fracture admitted to Second Affiliated Hospital of Soochow University from July 2017 to June 2018,including 24 males and 70 females aged 76-98 years[(83.7±5.4)years].There were 54 patients with intertrochanteric fracture and 40 patients with femoral neck fracture.Surgical method was proximal femoral nail antirotation(PFNA)fixation or artificial hip arthroplasty.A total of 44 patients were managed by ERAS(enhanced recovery group)and 50 patients by traditional nursing(traditional rehabilitation group).The off-bed time was compared between the two groups from aspects of different fracture sites,bone mineral density and causes of injury.The visual analogue scale(VAS)was tested preoperatively and at postoperative days 1,3 and 7.The complications were recorded at postoperative 1 month.The activity of daily living(ADL)score was assessed preoperatively and at postoperative 1 week,1 month and 3 months.The Harris hip score was assessed at postoperative 1 week,1 month,3 months and at the last follow-up.The length of hospital stay and death at postoperative 3 months and at the last follow-up were recorded.Results All patients were followed up for 12-24 months[(17.7±6.2)months].In enhanced recovery group,the off-bed time of patients with different fracture sites(femoral neck,femoral intertrochanter),bone mineral density(>-2.5 SD,≤-2.5 SD)and causes of injury(falls,traffic accidents and others)were markedly shortened as compared with traditional rehabilitation group(P<0.01).There was no significant difference in VAS between the two groups before operation(P>0.05).However,the VAS in enhanced recovery group was(3.4±0.9)points,(2.7±0.5)points,(1.7±0.6)points at postoperative days 1,3 and 7,significantly lower than that in traditional rehabilitation group[(4.3±1.1)points,(3.5±0.5)points,(2.7±0.9)points](P<0.01).One month after operation,the incidence of pulmonary infection was 0%in enhanced recovery group and 28%(14/50)in traditional rehabilitation group(P<0.01).While there showed no significant differences in incidences of cardiovascular system,nervous system,urinary tract infection,lower limb deep vein thrombosis,impaired liver and kidney function,anemia,electrolyte disorder or hypoalbuminemia between the two groups(P>0.05).There was no significant difference in preoperative ADL score between the two groups(P>0.05).The ADL score in enhanced recovery group was(37.0±6.6)points,(70.1±8.4)points,(86.2±9.3)points at postoperative 1 week,1 month and 3 months,significantly higher than that in traditional rehabilitation group[(26.5±10.4)points,(50.1±11.4)points,(70.7±9.0)points](P<0.01).The Harris hip score in enhanced recovery group was(80.9±8.6)points at postoperative 1 month,significantly higher than that in traditional rehabilitation group[(71.1±9.2)points](P<0.01).There were no significant differences in Harris hip score between the two groups at postoperative 1 week,3 months and at the last follow-up(P>0.05).The length of hospital stay was(4.7±2.4)days in enhanced recovery group,significantly shorter than(7.8±3.9)days in traditional rehabilitation group(P<0.01).The enhanced recovery group showed no death within 3 months after operation and 2 deaths[5%(2/44)]at the last follow-up,while the traditional rehabilitation group revealed 4 deaths[8%(4/50)]within 3 months after operation.There was no significant difference in the mortality between the two groups until the last follow-up(P>0.05).Conclusion For elderly patients with hip fracture,perioperative ERAS management model can effectively shorten periods in bed,relieve postoperative pain,reduce incidence of postoperative pulmonary infection,accelerate recovery of hip function,improve quality of life,shorten length of hospitalization and promote early recovery.