高龄多处骨折合并重度肺动脉高压患者麻醉处理1例

A Case Report of Anesthetic Management of Elderly Patients with Multiple Fractures Complicated with Severe Pulmonary Hypertension

患者,女,84岁,诊断结果为左侧股骨粗隆间骨折,左侧肱骨外科颈粉碎性骨折并肱骨头前下移位,肺动脉收缩压80 mmHg,经骨科、心内科、老年科、呼吸内科以及麻醉科等多学科认真评估一致认为:患者高龄、多处骨折、心律失常、心功能IV级、重度肺动脉高压,手术风险较大,应进行积极术前准备,镇痛,抗感染,增强心肌收缩力,加强营养,经过两周的综合治疗患者情况明显好转,拟在在全麻下行左人工股骨头置换术、左肱骨外科颈骨折切开复位内固定术。麻醉常规动脉穿刺,静脉穿刺,微截流监测,麻醉前甲泼尼龙琥珀酸钠、去乙酰毛花苷注射液、盐酸多巴酚丁胺注射液静滴,术后左髂筋膜神经阻滞及左肌间沟臂丛神经阻滞,回病房继续抗感染、营养支持、抗凝、患肢功能锻炼、定时翻身拍背、避免患者下肢内收内旋。术后两周一般情况良好,饮食夜休可,下地活动及床上功能锻炼后自我感觉良好,顺利出院。

The patient is a female, 84 years old. The diagnosis reveals left intertrochanteric fracture of femur, comminuted fracture of surgical neck of left humerus with displacement of humeral head, and pul-monary artery systolic pressure of 80 mmHg. After careful evaluation by orthopedics, cardiology, geriatrics, respiratory medicine and anesthesiology, it is agreed that patients with advanced age, multiple fractures, arrhythmia, grade IV cardiac function and severe pulmonary hypertension are at greater risk of operation, so active preoperative preparation, analgesia, anti-infection, enhance-ment of myocardial contractility, and nutrition should be carried out. After two weeks of compre-hensive treatment, the patient’s condition improved significantly and a left artificial hip replace-ment and left humeral surgical neck fracture open reduction internal fixation surgery was planned under general anesthesia. The anesthesia routine included arterial puncture, venous puncture, mi-cro-flow monitoring, preoperative injection of methylprednisolone sodium succinate, acetylcysteine injection, and intravenous dobutamine hydrochloride injection. Postoperatively, the patient un-derwent left iliac fascia nerve block and left intermuscular arm plexus nerve block. The patient was then transferred to the ward for continued anti-infection, nutritional support, anticoagulation, func-tional exercise of the affected limb, turning and back patting at regular intervals, and avoiding in-ternal rotation of the lower limbs. Two weeks after operation, she was generally in good condition, taking a rest at night, feeling good after going to the field and exercising in bed, and was discharged smoothly.