【摘要】：目的:股骨粗隆間骨折為老年患者最嚴(yán)重的骨折之一,具有高死亡率、高致殘率等特點(diǎn),心血管事件與肺部感染是該疾病最常見死亡原因。髓內(nèi)釘內(nèi)固定術(shù)是現(xiàn)在手術(shù)治療老年股骨粗隆間骨折的金標(biāo)準(zhǔn)。老年人心血管系統(tǒng)與呼吸系統(tǒng)儲(chǔ)備下降,插入髓內(nèi)針可能對老年人心血管系統(tǒng)造成更大影響。因此,本實(shí)驗(yàn)探索非擴(kuò)髓型髓內(nèi)針術(shù)對老年髖部骨折患者心血管系統(tǒng)的影響,分析其是否為造成患者死亡的危險(xiǎn)因素。方法:本實(shí)驗(yàn)采用臨床前瞻研究,對2015年9月5日至2015年12月5日連續(xù)入住陸軍總醫(yī)院骨科的老年股骨粗隆間骨折患者行非擴(kuò)髓型髓內(nèi)釘內(nèi)固定術(shù),記錄一般資料及入院血液化驗(yàn)結(jié)果,入院后第二日、插入髓針前后、術(shù)后第二日分別監(jiān)測老年患者脈搏波3分鐘并記錄相關(guān)波形,術(shù)中橈動(dòng)脈穿刺置管測量血壓。術(shù)后分析對比前后數(shù)據(jù),觀察有創(chuàng)無創(chuàng)監(jiān)測差異性,非擴(kuò)髓型髓內(nèi)釘內(nèi)固定術(shù)對老年患者心血管系統(tǒng)影響。術(shù)后1年隨訪,分析影響患者死亡率的危險(xiǎn)因素。結(jié)果:插入非擴(kuò)髓型髓內(nèi)針主針前橈動(dòng)脈置管測量收縮壓與舒張壓比脈搏波測量高(P0.05)。插入前,橈動(dòng)脈與脈搏波收縮壓回歸方程y=1.5x-45(r2=0.837),舒張壓回歸方程y=1.2x-40(r2=0.746),插入后收縮壓回歸方程y=1.2x-36(r2=0.807),舒張壓回歸方程y=1.2x-18,r2=0.745,P均小于0.05,具有統(tǒng)計(jì)學(xué)意義。插入主針后,全部患者收縮壓平均變化為-6.97±10.35mm Hg(P0.05),舒張壓變化為-2.50(-5.36-0.00)mm Hg(P0.05),心率變化為-1.78±5.088)4)9)-1(P0.05),心肌耗氧量平均變化-760.16±1187.97(mm Hg·8)4)9)-1)(P0.05)。麻醉后、插入髓內(nèi)針主針前后,入院第二日與術(shù)后第二日血管阻力變化無顯著統(tǒng)計(jì)學(xué)差異。根據(jù)患者是否死亡進(jìn)行分組,兩組一般資料、血液檢測結(jié)果無明顯差異,兩組收縮壓、舒張壓、心率、心肌耗氧量、血管阻力及其變化無明顯差異。部分患者插入髓內(nèi)針主針后血管阻力變化顯著,入院第二日血管阻力為其危險(xiǎn)因素。未發(fā)現(xiàn)導(dǎo)致患者死亡的影響因素。結(jié)論:插入髓內(nèi)針主針對老年股骨粗隆間患者心血管系統(tǒng)有一定影響,但具有一過性、可恢復(fù)的特點(diǎn),該術(shù)式對于治療股骨粗隆間骨折相對安全。但對于術(shù)前RI值較高的患者,選擇應(yīng)慎重。骨科手術(shù)中可應(yīng)用PPG對心血管系統(tǒng)行無創(chuàng)監(jiān)測。
[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 鹵10.35mm Hg, -2.50 (-5.36-0.00) mm Hg, -1.78 鹵5.088) 4) 9) (P0.05) (P0.05) and -760.16 鹵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.
【學(xué)位授予單位】：山西醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.3

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