Fractures of a proksimalny hip at persons of advanced and senile age. H. 2
Performance on the 1st Congress of traumatologists-orthopedists of the capital. Moscow, on February 16-17, 2012.
The material is provided by the Medical CLINIC center +31.
The beginning read here.
5. Surgical tactics.
The change of proksimalny department of a hip at the patient of advanced and senile age is the indication to surgical treatment. Operation should be executed at most within 3 working days from the moment of arrival of the patient in a hospital. Thus the number of preoperative days depends on a somatic condition of the patient and need of use of these days for correction of accompanying pathology if it is obviously possible.
5.1. A sharp myocardial infarction or sharply developed violation of brain blood circulation;
5.2. An acute pneumonia with development of the respiratory insufficiency demanding artificial ventilation of lungs;
5.3. The acute surgical disease demanding urgent operative intervention;
5.4. Diabetes decompensation;
5.5. Coma of any etiology;
5.6. A sharp or chronic purulent infection with clinical manifestations in a zone of surgical intervention;
5.7. The terminal stage of any somatic disease which has led to loss of ability of the patient to movement still to the fact of approach of a trauma;
5.8. The expressed mental disorders which have led to loss of ability of the patient to movement, including by means of a wheelchair, to the fact of approach of a trauma.
The decision on refusal of surgical intervention or about its delay from above 3х is accepted the working days jointly by a consultation of experts with the corresponding registration of medical documentation. As it is necessary to consider that in case of the favorable course of diseases and recourse of the syndromes listed in points 5.1. – 5.6., operative treatment of a change of proksimalny department of a hip should be carried out to an extract of the patient from a hospital. If it is impossible, the decision on refusal of operative treatment of a change in the current hospitalization is accepted jointly by a consultation of experts with the corresponding registration of medical documentation.
In case of jointly accepted decision on existence of contra-indications to surgical treatment of a fracture of a proksimalny hip the patient, in the presence of the bases for continuation of stay in a hospital, passes treatment in that office on which profile there are contra-indications to surgical treatment of a fracture of a proksimalny hip either is written out home, or transferred to social medical care office.
At development of a vein thrombosis of the bottom extremities (extremity) in the patient of this group possibly carrying out both simultanny, and consecutive surgical interventions during one anesthesia. If similar owing to certain reasons it is impossible and the patient demands transfer to other hospital for treatment of vascular pathology, the change at first is, as a rule, fixed (the joint), as the reason of developing complication is replaced, then it is translated. Other decision is made out by a consultation.
6. Preoperative preparation and anesthesia.
Considering that circumstance that high-grade prevention of complications and recovery of this group of patients without fast restoration of impellent activity and knocking over of a pain syndrome are impossible, preoperative preparation should have the intensive, balanced character and to be limited in time from several hours to several days. The volume and quality of preparation are defined by a somatic condition of the patient and a type of the forthcoming intervention and should be based, it is rather on realistic attempts improve the general condition of the patient, than on aspiration to achieve "normal" indicators.
Preoperative preparation can be carried out directly in a preoperative (narcotic) room, a resuscitation hall, resuscitation unit, traumatologic or, in the presence of special indications, in psychosomatic office.
For the period of preoperative preparation for the purpose of reduction of painful feelings it should be used either an immobilization by situation, or temporary (disciplining) skeletal extension by small cargoes, especially at lateral extra capsular changes. Skeletal extension at changes of the B1 type is not carried out.
At development of the conditions listed in points 5.1. – 5.6. the present instruction, treatment of these complications, sharp diseases and syndromes and preparation for operation can be carried out in the relevant profile offices with preservation of one of ways of a temporary immobilization (an immobilization situation here more preferably). In all other cases transfer of the patient to somatic office with unstable surgically a change (not replaced joint) is allowed only by way of exception.
6.1. The method of anesthesia is defined together with the anesthesiologist. We accept any method which the doctor well owns. At the same time, a method of a choice is spinal anesthesia. The general anesthesia can be demanded, if regionarny anesthesia unsatisfactory or blockade is impossible (Ankiloziruyushchiya спондилит, adhesive process in the spinal channel, the expressed scoliosis and so on).
6.2. Infuzionny therapy. Patients usually are in a condition of dehydration which is often underestimated. It is desirable to establish peripheral канюлю 16G in that hand which during operation will be from below (in case of position of the patient "on one side"). Carrying out infuzionny preloading in the preoperative period in volume of 30-35 ml on kg of weight of a body is necessary. In case of an endoprotezirovaniye, especially total, it is necessary to order blood components. The question of need of a transfusion is solved individually.
6.3. Premedikatsiya. Need for a premedikatsiya arises seldom. It is necessary to remember that at this group of patients the premedikatsiya often leads to inadequate behavior. 6.4. Position of the patient on a table is defined by nature of the forthcoming operation and preferences of the surgeon. After laying of the patient on an operational table it is necessary to check all points of a potential sdavleniye as elderly patients are inclined to formation of decubituses.
6.5. Sedatsiya. During operation the sedatsiya can be demanded. Are for this purpose applied бензодиазепины short action (мидазолам) or пропофол. For elimination of item discomfort intravenous introduction фентанила can be demanded. At any method of anesthesia ensuring adequate gas exchange, hypoxemia prevention, normokapniya maintenance is important. At independent breath oxygen inhalation during all anesthesia is obligatory. At any doubts in adequacy of gas exchange installation of a laringealny mask and carrying out VVL is recommended.
6.6. The specific problems connected with implantation эндопротеза. Introduction of an artificial limb can be connected with falling the HELL and SpO2, and very expressed. The reasons can be an emboliya one or several substrata: fat, air, acrylic monomer, тромбопластинами. Maintenance of haemo dynamics is provided with the vazopressor, adequate volume of infuzionny therapy, and also application of high FiO2. Before cementation of a femoral component it is necessary to provide the adequate volemichesky status of the patient.
6.7. Cooling. During operation it is necessary to remember that elderly patients badly compensate
cooling. Thus the reason of this phenomenon can be: an exposure of a considerable part of a body of the patient, a microclimate in operational, evaporation from a surface of a wound, IVL, regionarny blockade with the subsequent peripheral vazodilyatatsiya. It is necessary to use all available means of warming of the patient, and also body temperature control in the perioperatsionny period.
6.8. Mikrotromboemboliya and actually tromboemboliya. The high risk of a tromboemboliya is caused by age of the patient, an immobilization, microcirculation violation in an extremity during operative intervention. Prevention should include: use of elastichesky stockings with a compression, adequate water loading, application of anticoagulants in the after and preoperative period.
6.9. Early postoperative period. At patients after the general anesthesia if they do not receive an oksigenoterapiya, the heavy gipoksemiya can develop. The first 5-10 minutes after the completion of anesthesia are the most dangerous. The etiology of this phenomenon is not quite clear. Emergence in the postoperative period and episodes of inadequate behavior is possible that as is connected with the transferred gipoksemiya. Therefore purpose of a respiratory giperoksichesky mix during not less than 6 h is necessary, and it is better – till 24 o’clock after the completion of operation. As a rule, a satisfactory analgeziya provide reasonable use опиатов or (and) blockade of the corresponding nerves. At elderly patients the urine delay therefore to 30 % of patients need a bladder kateterizatsiya often develops.
7. Operative intervention.
Actually the type of surgical intervention is defined by change type according to classification, a condition of a bone fabric and biological standards of the patient, in some cases – preferences of the surgeon.
7.1. For all changes of type 31А the osteosynthesis proksimalny femoral гвоздём, providing, in comparison with other technologies, a smaller invazivnost and duration of operation, and as possibility of early loading in weight of a body is preferable. At the same time, it is necessary to consider that at changes 31А1 and the dynamic femoral screw can be used with sufficient degree of mechanical efficiency. However, when using the dynamic femoral screw in cases of changes 31А2 and, especially, 31А3 it is necessary to restore a medial support and (or) to use the additional plate preventing a lateralizatsiya proksimalny отломка. As according to special indications, a thicket at changes 31А3, the dynamic myshchelkovy screw or predmodelirovanny plates with possibility of blocking of screws or without that can be used;
7.2. For type 31В1 changes (driven, linked), regardless of age of the patient, the osteosynthesis 3 kanyulirovanny screws in diameter 6,5мм or 7,3мм from skin or miniaccess punctures is preferable. Skeletal extension or repozitsiya attempts in this case are contraindicated. Operation is spent during the first hours after receipt as special preparation, as a rule, is not required. Primary endoprotezirovaniye in cases of changes 31В1 is an exception and is carried out according to special indications (for example, a combination of the driven fracture of a neck and the same joint deforming an osteoart rose (DOA) and so on) and demands, as a rule, longer and intense preoperative training.
7.3. At somatic healthy and active patients with changes of type 31В2 and high quality of a bone aged to 70-75 years the closed repozitsiya of a change and internal fixing, as a rule, by three kanyulirovanny screws in the first days after a trauma can be executed. Only in cases when the line of a change passes directly at the neck basis (so-called bazistservikalny damages), practically on border between medial and lateral changes, the osteosynthesis the dynamic femoral screw, as a rule, in a combination with the derotatsionny screw can be necessary. In other cases a preferable method of surgical treatment is the joint endoprotezirovaniye;
7.4. At somatic healthy and active patients with changes of type 31В3 and high quality of a bone aged to 65-70 years the closed repozitsiya of a change and internal fixing, as a rule, by three kanyulirovanny screws in the first days after a trauma can be executed. In other cases a preferable method of surgical treatment is the joint endoprotezirovaniye. In cases of sufficient mobility of the patient to a trauma, existence of signs of DOA of this joint the preference is given to a total endoprotezirovaniye. At inactive and hard somatic the burdened patients, for the purpose of reduction of time of operation unipolar prosthetics is carried out. Other things being equal the preference is given to bestsementny fixing;
7.5. At all operated patients it is carried out антибиотикопрофилактика. In osteosynthesis cases – by single introduction 1,0 гр. цефалоспоринов 1-2 generations directly ahead of operative intervention. In endoprotezirovaniye cases if there are no other indications, prevention is carried out during 3х days;
7.6. At all patients of advanced and senile age with fractures of a proksimalny hip prevention of tromboembolichesky complications is carried out. Application of elastichesky bandaging of extremities to, during time and after operation is obligatory. Introduction low-molecular гепаринов begins directly after arrival of the patient in a hospital and is carried out in doses and with duration of the introduction, recommended by producers.
8. Postoperative maintaining.
8.1. Depending on a somatic condition, first of all, and weights of actually operative intervention from operational the patient is translated in reanimatsionno – anesteziologichesky or traumatologic office. Besides correction of violations of a homeostasis by the main principle of postoperative rehabilitation faster activization of the patient is probably. The respiratory gymnastics is appointed directly after operation. Patients usually lift from a bed in time from 24 to 48 h after operative intervention. If for the prolonged anesthesia the epiduralny catheter was established, before activization it should be removed. Farther the volume and intensity of physiotherapy exercises extend day by day with finishing to preoperative level of activity of the patient;
8.2. The extract of the patient is carried out to terms and at achievement of the criteria established corresponding physician – economic standards. If necessary the aftercare of accompanying pathology in offices of the general profile, and rehabilitation – in special divisions or offices (hospitals) of the medikosotsialny help is possible.
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