股骨粗隆间骨折和手术对老年患者心血管系统的影响及PPG无创监测

发布时间：2018-07-20 11:58

【摘要】：目的:股骨粗隆间骨折为老年患者最严重的骨折之一,具有高死亡率、高致残率等特点,心血管事件与肺部感染是该疾病最常见死亡原因。髓内钉内固定术是现在手术治疗老年股骨粗隆间骨折的金标准。老年人心血管系统与呼吸系统储备下降,插入髓内针可能对老年人心血管系统造成更大影响。因此,本实验探索非扩髓型髓内针术对老年髋部骨折患者心血管系统的影响,分析其是否为造成患者死亡的危险因素。方法:本实验采用临床前瞻研究,对2015年9月5日至2015年12月5日连续入住陆军总医院骨科的老年股骨粗隆间骨折患者行非扩髓型髓内钉内固定术,记录一般资料及入院血液化验结果,入院后第二日、插入髓针前后、术后第二日分别监测老年患者脉搏波3分钟并记录相关波形,术中桡动脉穿刺置管测量血压。术后分析对比前后数据,观察有创无创监测差异性,非扩髓型髓内钉内固定术对老年患者心血管系统影响。术后1年随访,分析影响患者死亡率的危险因素。结果:插入非扩髓型髓内针主针前桡动脉置管测量收缩压与舒张压比脉搏波测量高(P0.05)。插入前,桡动脉与脉搏波收缩压回归方程y=1.5x-45(r2=0.837),舒张压回归方程y=1.2x-40(r2=0.746),插入后收缩压回归方程y=1.2x-36(r2=0.807),舒张压回归方程y=1.2x-18,r2=0.745,P均小于0.05,具有统计学意义。插入主针后,全部患者收缩压平均变化为-6.97±10.35mm Hg(P0.05),舒张压变化为-2.50(-5.36-0.00)mm Hg(P0.05),心率变化为-1.78±5.088)4)9)-1(P0.05),心肌耗氧量平均变化-760.16±1187.97(mm Hg·8)4)9)-1)(P0.05)。麻醉后、插入髓内针主针前后,入院第二日与术后第二日血管阻力变化无显著统计学差异。根据患者是否死亡进行分组,两组一般资料、血液检测结果无明显差异,两组收缩压、舒张压、心率、心肌耗氧量、血管阻力及其变化无明显差异。部分患者插入髓内针主针后血管阻力变化显著,入院第二日血管阻力为其危险因素。未发现导致患者死亡的影响因素。结论:插入髓内针主针对老年股骨粗隆间患者心血管系统有一定影响,但具有一过性、可恢复的特点,该术式对于治疗股骨粗隆间骨折相对安全。但对于术前RI值较高的患者,选择应慎重。骨科手术中可应用PPG对心血管系统行无创监测。
[Abstract]:Objective: intertrochanteric fracture of femur is one of the most serious fractures in elderly patients with high mortality and high rate of disability. Cardiovascular events and pulmonary infection are the most common causes of death. Intramedullary nail fixation is the gold standard for the treatment of intertrochanteric fractures in the elderly. The cardiovascular system and respiratory system reserve decreased in the elderly, and the insertion of intramedullary needle may have a greater impact on the cardiovascular system in the elderly. Therefore, we investigated the effect of unreamed intramedullary needle on cardiovascular system in elderly patients with hip fracture and analyzed whether it was a risk factor for death. Methods: the clinical prospective study was performed on elderly patients with intertrochanteric fracture of femur who were admitted to the Department of Orthopaedics of Army General Hospital from September 5, 2015 to December 5, 2015, and were treated with unreamed intramedullary nail fixation. The general data and blood test results were recorded. On the second day after admission, before and after the insertion of the medullary needle, the pulse waves of the elderly patients were monitored for 3 minutes and the relevant waveforms were recorded respectively. The blood pressure was measured by radial artery puncture catheter during the operation. The data before and after operation were analyzed and compared to observe the difference of invasive and noninvasive monitoring and the effect of non-reamed intramedullary nail fixation on cardiovascular system in elderly patients. All patients were followed up for 1 year to analyze the risk factors of mortality. Results: the systolic and diastolic blood pressure were measured by insertion of the radial artery catheter before the main needle of the unreamed intramedullary needle was higher than that by the pulse wave (P0.05). Before insertion, the regression equation of systolic pressure of radial artery and pulse wave y=1.5x-45 (r20.837), diastolic pressure regression equation (y=1.2x-40), postinsertion systolic pressure regression equation (y=1.2x-36) and diastolic pressure regression equation yong 1.2x-18r2n 0.745p were all less than 0.05, which had statistical significance. The mean systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) were -6.97 卤10.35mm Hg, -2.50 (-5.36-0.00) mm Hg, -1.78 卤5.088) 4) 9) (P0.05) (P0.05) and -760.16 卤1187.97 (mm Hg) 4) 9) (P0.05). After anesthesia, there was no significant difference in vascular resistance between the second day of admission and the second day after operation before and after the insertion of intramedullary needle. There was no significant difference in blood test results between the two groups according to whether the patients died or not. There was no significant difference in systolic blood pressure, diastolic blood pressure, heart rate, myocardial oxygen consumption, vascular resistance and its changes between the two groups. Vascular resistance changed significantly in some patients after insertion of intramedullary needle, and vascular resistance was a risk factor on the second day of admission. No factors leading to death were found. Conclusion: the intertrochanteric femoral intertrochanteric fracture is relatively safe for the elderly patients with intertrochanteric fracture. But for patients with higher RI before operation, care should be taken. PPG can be used to monitor the cardiovascular system in orthopedic surgery.
【学位授予单位】：山西医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R687.3

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