超高龄患者围术期.ppt

超高龄患者围术期麻醉并发症的防范与处置,芜湖市第一人民医院 牛居辉,超高龄患者的生理特点和病理生理特征,超高龄患者围术期的并发症及死亡原因分析,超高龄患者围术期的死亡率及影响因素,超高龄患者围术期的麻醉及管理,社会老龄化 科学技术进步 特别是麻醉学和外科学的发展,前言,超高龄手术患者越来越多,超高龄的概念,根据现代人的生理、心理特点，WHO将人的生命周期做了新的划分： 44岁以下为青年人； 4559岁为中年人； 6074岁为年轻老年人（the young old）； 7589岁为老老年人（the old old）； 90岁以上为非常老的老年人（the very old）或长寿老年人（the longevous）。 临床上将年龄超过90岁称为超高龄。,人口统计学特征：老龄化,2009年老年人口基本信息：2009年，全国60岁及以上老年人口达到1.6714亿，占总人口的12.5%。与上年度相比，老年人口净增725万，增长了0.5个百分点。2009年，80岁以上老年人口达到1899万，老年人口11.4%，2005年为1479万,10.2%。 65岁以上老年人口所占比重：有浙江、上海等7个省市超过10%，浙江省最高达到13.89%；全国其中65岁及以上人口为118831709人，占8.87%。上海老龄化进程呈现出高龄化态势上海80岁及以上高龄老年人口为58.78万人 。根据卫生部门资料，2010年上海平均期望寿命为82.13岁 我们医院超高龄手术量：,超高龄患者的生理特点和病理生理特征,超高龄患者生理特点-神经系统,中枢神经元数量减少 如到90岁，中枢神经元数量减少3050； 脑血管自动调节曲线因血管硬化和低血压而右移，容易脑缺血； 脑血流减少； 神经递质、受体减少； 脑灌流减少，脑氧代谢下降； 自主神经兴奋性下降 对循环系统调节减弱 ，对麻醉和手术应激的适应能力下降; 保护性喉反射迟钝。,超高龄患者生理特点-循环系统,心肌纤维化致弹性减退； 心肌肥厚； 心室舒张和充盈减少、CO、SV； 射血分数减少； 氧输送（DO2）等均减少动脉硬化，SVR升高，血压升高； 静脉弹性减退，顺应性下降，容量相对不足； 动脉硬化尤其是主动脉弓，压力感受器调节血压、心率功能减退窦房结功能减退 ； 副交感神经系统张力、受体反应下降； 左房、肺血管充盈增加，引起肺充血； 心室舒张功能减退 。,超高龄患者生理特点-呼吸系统,胸廓弹性减少； 肺顺应性下降； 呼吸肌减弱； 肺泡气体交换面积减解剖和生理死腔增加； 肺实质弹性组织减少，肺顺应性下降，肺活量（VC）减小，残余气量增加，FEV1下降，肺泡弹性回缩 ，通气/灌流下降； PaO2缺氧性肺血管收缩（HPV）反射对高碳酸血症和低氧血症的通气反应减弱。,超高龄患者病理生理特征,超高龄老人生理及组织的改变更为明显，麻醉的风险极大， 被称之fragile patients（易碎的病人）。主要原因有： 一是老人器官衰退，内环境稳态极度薄弱，麻醉手术耐受性差。如90岁，中枢神经元数量减少3050；交感神经活性水平在平时就提高，一旦麻醉阻滞，血流动力学变化剧烈，对血管活性物质反应差，受体反应性下降，应激情况下不能靠提高心率，而是更主要依赖前负荷和每博量的增加。脑血管自动调节曲线因血管硬化和低血压而右移容易脑缺血，维持正常的血压水平显得尤为重要。 二是基础疾病多，如高血压、糖尿病、心脑血管病等、贫血、营养不良等。老年痴呆在65岁以上发病率为5，75岁以上为15。 三是手术后恢复慢，老人手术后容易发生感染，导致肺炎，有的老年人还会出现静脉血栓等问题。日常活动量少；应激情况下，机体就会无力应付；内环境稳态极度薄弱，难以自动修复，脏器功能容易衰竭。,超高龄患者围术期死亡率及影响因素,超高龄患者围术期死亡率,麻醉手术相关死亡率: 术后30天内死亡 6070y 2.2. 7079 y 2.9 80y 以上 5.86.2 90 y以上 8.4%（Hosk MP ） 大手术，开胸，急诊剖腹，高达19.8 （Ackermann RJ ）,超高龄患者围术期死亡率,美国Warner MA 报道：31例100107岁世纪老人麻醉手术后30天的死亡率为16%，整体上发病率和死亡率似乎与麻醉类型无关。 英国Derby报道13例世纪老人30天的死亡率为31%，一年的死亡率56% 。 Mark C. The medical records of a consecutive series of 13 centenarians with proximal femoral fractures who presented to the Derbyshire Royal over a 20 year period were retrospectively reviewed. The majority of patients were female (M:F 2:11) and had suffere intertrochanteric fractures. The recorded incidence of surgical complications was low. The mortality at 30 days, 6 months and 1 year were 31%, 50% and 56%, respectively,影响超高龄患者围术期死亡率的因素-D.A Story,Table 1 Comparison of survivors and patients who died within 30 days of surgery. Values are number (proportion), mean (SD),or median (IQR range). Variable Survivors Non-survivors p value Patients 3942 (95%) 216 (5%) Age; years 78 (6) 81 (6) 0.001 Male 1982 (50%) 117 (54%) 0.001 Non-scheduled surgery 1279 (32%) 134 (62%) 0.001 ASA physical status 1, 2 1300 (33%) 15 (7%) 0.001 3 2081 (53%) 96 (44%) 4 450 (11%) 90 (42%) 5 21 (1%) 11 (5%) Comorbidities 0 1282 (35%) 31 (14%) 0.001 1 1255 (31%) 51 (24%) 2 771 (20%) 58 (26%) 3+ 634 (16%) 65 (35%) Complications 1 704 (18%) 131 (26%) 0.001 Length of stay; days* 6 (212 030) 30 (930 030) 0.001,Y. Kojima,影响超高龄患者围术期死亡率的因素,性别，女性好于男性。 日常生活依赖性（dependency in daily living，DDL） 低 DDL与术后并发症，住院时间及远期死亡率有关. 也是术后认知功能障碍post-operative cognitive dysfunction (POCD)的风险因素。 腹部手术 水、电解质紊乱，低温,呼吸抑制，术前贫血，营养不良，脱水，术后。卧床，低血容量。 急诊手术 定义，24h以内 手术时间与手术种类 如股骨颈骨折，可以PFN,DHS,锁定钢板，PCCP，全髋置换，全髋置换创伤大。采用PFN内固定相对创伤小、手术时间短（平均40分钟）、术中出血及术后引流量较小（平均约300毫升） 年龄 Hans等调查发现，与6579岁人群相比，80岁以上的患者关节成形术后心肌梗死的几率升高2.7倍，肺部感染的几率升高3.5倍，术后昏迷以及尿路感染的几率也有明显增高，死亡率更升高3.4倍。百岁以上高龄患者髋部骨折手术后30 d、6个月、1年死亡率分别为31、50、56，明显高于低年龄组患者术后死亡率。 蛋白 35,When compared with over 1000 hip fracture patients of all ages in previous prospective studies, the centenarians in this series were found to have a higher mortality during hospital admission ( p0.001) and at 1 year ( p=0.002). The treatment of hip fractures in centenarians poses a challenge. Optimal anaesthesia, expeditious surgery and a co-ordinated multidisciplinary approach to care is essential in these patients.,超高龄患者围术期的并发症及死亡原因分析,死亡原因及常见的并发症- D.A Story,Complication Mortality UnivariateOR p value AdjustedOR p value Systemic inflammation 305(7%) 46(15%) 3.9 (2.75.5) 0.001 2.5 (1.73.7) 0.001 Acute renal impairment 244(6%) 42 (17%) 4.4 (36.4) 0.001 3.3 (2.15.0) 0.001 Unplanned admission toICU173(4%) 34(20%) 5.0(3.37.6) 0.001 3.1 (1.94.9) 0.001 Acute pulmonary oedema 25(3%) 25(20%) 5.0 (3.17.9) 0.001 3.0 (1.75.0) 0.001 Return to operating theatre120(3%) 19 (16%) 3.6 (2.16) 0.001 2.5 1.44.4) 0.002 Acute myocardial infarction105(2%) 21 (20%) 5.0 (38.2) 0.001 2.9 (1.65.2) 0.001 Wound infection 85 (2%) 6 (7%) 1.4 (0.63) 0.4 0.8 (0.32.2) 0.57 Re-intubation 42(1%) 10(24%) 5.7(2.711.9) 0.001 5.0 (2.211.3) 0.001 Cardiac arrest 18(1%) 14(77%) 70(22.7214) 0.001 66.2(17.7247.2) 0.001 Pulmonary embolism 4 ( 1%) 1 (7%) 1.4 (0.39.4) 0.7 0.3 (0.03.9) 0.36 Stroke 10 ( 1%) 4 (40%) 12 (2.552.5) 0.001 Sample too small,Jovan L.,Mortality analysis in hip fracture patientsN. B. Foss Mortality related to cause,Mortality analysis in hip fracture patientsN. B. Foss,N. B. Foss 300 consecutive, unselected hip fracture patients were treated in a multimodal rehabilitation programme with continuous perioperative epidural analgesia and anaesthesia, early surgery, standardized fluid and transfusion therapy, enforced oral nutrition and early mobilization and physiotherapy. All deaths within 30 days of surgery or during primary hospitalization were analysed and classified according to whether death was unavoidable, probably unavoidable, or potentially avoidable. Results. Thirty-day mortality was 13.3% (40 patients) and the total perioperative mortality was 15.6% (47 patients). Death was definitely unavoidable in 28%, probably unavoidable in 15%, and in theory potentially avoidable in 57%. In the patients where death was potentially avoidable, active care was curtailed in 16 of 27 (59%) patients. Conclusion. About a quarter of the total mortality in hip fracture patients is definitely unavoidable, and death is probably only avoidable in about half of the unselected patients.,死亡原因及常见的并发症分析,术后并发症是导致患者住院期间及出院后死亡的最重要原因，导致患者死亡的严重并发症依次为心脏事件、肺部感染、肺栓塞、尿路感染。Seymam等调查发现肺部感染占老年术后并发症40，占可预防性死亡的20。,超高龄患者围术期的麻醉及管理,麻醉与管理,麻醉管理的最高目的是给病人提供一个适中的环境，保护心肌，维护血流动力学稳定，控制并存疾病，避免围术期不良事件 以并发症为切入点，结合患者自身特点，作术前评估和指导麻醉。 整体把握，风险管理, 贯彻始终。,麻醉与管理-术前检查,常规检查； 特殊检查 动态心电图， 心超，肌钙蛋白心肌酶术后3d； 颅脑核磁等检查，下肢深静脉超声检查，D二聚体。,麻醉与管理-术前评估与准备,呼吸系统 功能状况及危险因素 肝肾及其它体能状态 Duke Activity Status Index ，询问病人的日常活动能力来估计其心脏功能状态。通常可分优良（7 METS以上），中等（47 METS），差（4 METS以下）和不详(4 MET :4km/h 步行200500m 平路，作轻便家务如揩灰、洗碗等)。 水、电解质、酸碱等,麻醉与管理-术前评估与准备,ASA分级 中枢系统术前常规的核磁等检查，Soderqvist等调查发现，利用精神状况评分系统SSPMSQS(short portable mental status questionnaire score)对患者进行评分检查，如果患者评分26分相当于IV级。将心功能分级与CRI联合评估可有更大的预示价值。12导联ECG,动态心电图（如有必要），超声心动图。美国ACC/AHA（2002）围术期心血管危险性评估,Cardiac risk stratification for noncardiac surgical procedures. Risk=combined incidence of cardiac death and nonfatal myocardial infarction. Patients in this group do not generally require further preoperative cardiac testing. From reference 47 reproduced with permission,High risk(reported cardiac risk often more that 5%) Emergency major operations, particularly in the elderly Aortic and other major vascular surgery Peripheral vascular surgeryAnticipated prolonged surgical procedures associated with large fluid shifts orblood loss Intermediate risk (reported cardiac risk generally less than 5%) Carotid endarterectomy Head and neck surgeryIntraperitoneal and intrathoracic surgery Orthopaedic surgery Prostate surgery Low risk (reported cardiac risk often more that 1%) Endoscopic procedureSuperfical procedure Cataract removal Breast surgery,Cardiac risk index. From reference 62 reproduced with permission,Risk category Points Aged 70 yr 5 Myocardial infarction within last 6 months 10 S3 gallop or jugular venous distension11 Significant valvular stenosis3 Rhythm other than sinus or premature atrial contractions 7 Premature ventricular contractions 5/min 7 Poor general medical condition 3 Abdominal or thoracic aorta surgery 3 Emergency surgery 4 Total 53,Goldman multifactorial risk assessment. From reference 62 reproduced with permission,Risk class Points Risk Complication (%)Mortality (%) I 05 0.7 0.2 II 612 5.0 2.0 III 1325 11 2.0 IV 26 22 56,Risk factors for postoperative stroke in elderly,Preoperative factors: Preexisting cerebrovascular disease Ischaemic cardiac disease Atherosclerosis Carotid occlusionPreoperative vascular disease Hypertension Diabetes mellitus Physical inactivity Intraoperative and postoperativefactors Haemodynamic instability Hypoxaemia,麻醉与管理-术前评估与准备,麻醉医生与外科医生的沟通 麻醉医生与患者及其家属的沟通 通过患者及家属影响外科医生对术式的选择,麻醉与管理麻醉选择,尽量选对生理干扰少、安全、便于调节和麻醉效果确切的方法和药物. 连续腰麻，稳定的血流动力学参数，与缓慢阻滞交感神经有关，20分钟以后很少发生低血压，补偿机制 单侧腰麻 腰硬联合麻醉 神经丛阻滞 如有椎管狭窄，马尾综合症等，单侧腰丛阻滞加静脉麻醉 全麻复合连硬外麻醉，复合神经阻滞,麻醉与管理监测,BP，ECG，SpO2，尿量 有创血压、CVP。 全麻镇定患者脑电监测，麻醉药浓度监测、麻醉气体监测； 体温监测 肌松监测,Anaesthesia management for elderly patients undergoing major surgery,Preoperative assessment for identifying high risk patients Careful history Physical examination Twelvelead ECG Functional status assessment Nutrition assessment,Anaesthesia management for elderly patients undergoing major surgery,Preoperative preparation Effective control of coexisting disease Stopped smoking for 8 weeks Training in cough and lung expansion techniques Chest physiotherapy for elderly at risk of postoperative pulmonary complications Correct of malnutrition Routine precautions for major surgery Temperature monitor and control Ripple mattress DVT prophylaxis Intraarterial pressure monitoring Haemodynamic stability Combination of anaesthetic and vasopressor, betablockers or vasodilators Avoid fluid overloadQuick recovery from anaesthesia Use shortacting anaesthetic agents Combine epidural anaesthesia and GA for major abdominal and thoracic surgeryAntagonize neuromuscular blocking drugs,Anaesthesia management for elderly patients undergoing major surgery,Postoperative periodPrevent hypoxaemiaSupplemental oxygen, reversal of neuromuscular blocking drugs Prevent hypothermiaKeep warm perioperatively Effective postoperative pain controlMultimodal analgesia,麻醉与管理并发症的处理,低血压 N. KONTTINEN报道：术中低血压现象非常普遍，14例患者有10例需要血管活性剂苯肾和正性肌力多巴胺控制，低血压现象非常普遍，14例患者有10例需要血管活性剂苯肾和正性肌力多巴胺控制，维持血流动力学稳定对保证氧供需平衡至关重要。HR .BPH 20以内。特别舒张压。老年患者多合并心血管及肺部疾患，心肺功能储备不足，不能耐受剧烈的血液动力学波动。对于这类老年患者最好在术中常规准备静脉双通道，一路浅静脉，一路深静脉，以备紧急输液、输血。有创动脉血压监测。酌情给于麻黄碱或苯肾。术中管理关键之一是维持循环功能稳定,保持心肌氧供需平衡另外,老年病人术前常伴有血容量不足,这是常引起低血压和循环功能不稳定的重要因素之一,术者常认为老年人心肺功能不全,输液术中低血压.,Prevention of postoperative delirium. From reference 106 reproduced with permission. *MMSE, Digit Symbol Substituti