加速康复外科理念下老年髋部骨折术后重症监护病房快速通道建设的临床疗效初探  

Preliminary application of postoperative fast track transfer to intensive care unit for the geriatric hip fractures under enhanced recovery after surgery

作　　者：谢添 芮云峰[1] 刘松桥[2] 陈辉[1] 杨毅[2] 邱晓东[3] 李贺[1] 李卿[2] 陈闯 黄英姿[2] 马彬彬 鲁攀攀 亓一鸣 李儒雅 胡胜烨 石柳[1] 崔学良 孙杰 王臻[3] 陆新健[3] 崔颖[5] 张敏[6] 李荥娟[7] 任利群[7] 邹继红[7] 王宸[1] Xie Tian;Rui Yunfeng;Liu Songqiao;Chen Hui;Yang Yi;Qiu Xiaodong;Li He;Li Qing;Chen Chuang;Huang Yingzi;Ma Binbin;Lu Panpan;Qi Yiming;Li Ruya;Hu Shengye;Shi Liu;Cui Xueliang;Sun Jie;Wang Zhen;Lu Xinjian;Cui Ying;Zhang Min;Li Yingjuan;Ren Liqun;Zou Jihong;Wang Chen(Department of Orthopedics,Zhongda Hospital Affiliated to Southeast University,Nanjing 210009,China;Department of Critical Care Medicine,Zhongda Hospital Affiliated to Southeast University,Nanjing 210009,China;Department of Anesthesiology,Zhongda Hospital Affiliated to Southeast University,Nanjing 210009,China;Multidisciplinary Team(Mdt)for Geriatric Hip Fracture Management,Zhongda Hospital Affiliated to Southeast University,Nanjing 210009,China;Operation Room,Zhongda Hospital Affiliated to Southeast University,Nanjing 210009,China;Department of Blood Transfusion,Zhongda Hospital Affiliated to Southeast University,Nanjing 210009,China;Department of Geriatrics,Zhongda Hospital Affiliated to Southeast University,Nanjing 210009,China)

机构地区：[1]东南大学附属中大医院骨科,南京210009 [2]东南大学附属中大医院重症医学科(ICU),南京210009 [3]东南大学附属中大医院麻醉科,南京210009 [4]东南大学附属中大医院老年髋部骨折多学科综合诊疗协作组(MDT),南京210009 [5]东南大学附属中大医院手术室,南京210009 [6]东南大学附属中大医院输血科,南京210009 [7]东南大学附属中大医院老年科,南京210009

出　　处：《中华医学杂志》2020年第37期2897-2902,共6页National Medical Journal of China

摘　　要：目的建设加速康复外科(ERAS)理念下老年髋部骨折围术期高危患者术后转入重症监护病房(ICU)的快速通道,分析术后ICU快速通道建设的初步临床疗效。方法回顾性收集术后ICU快速通道建设前,即2014年1月至2017年12月于东南大学附属中大医院创伤骨科接受手术治疗的195例老年髋部骨折患者的临床资料,其中18例术后转入了ICU(非快速通道ICU组),采用多因素logistic回归分析筛查老年髋部骨折患者术后转入ICU的危险因素。参考筛选得到的危险因素和临床实际,建立老年髋部骨折患者术后ICU快速通道的转入标准。将2018年1月至2019年12月期间满足快速通道转入标准,术后转入ICU监护治疗的70例老年髋部骨折患者(快速通道ICU组)纳入研究,与快速通道建设前转入ICU的患者(非快速通道ICU组)的临床指标进行比较分析。结果美国麻醉医师协会(ASA)分级≥Ⅲ级(OR=4.260,95%CI:1.157~15.683,P=0.029)、院前时间≥48 h(OR=4.301,95%CI:1.212~15.266,P=0.024)、入院检查血红蛋白(Hb)<90 g/L(OR=7.979,95%CI:1.936~32.889,P=0.004)及合并冠心病(OR=6.063,95%CI:1.695~21.693,P=0.006)是快速通道实施前老年髋部骨折患者术后转入ICU的独立危险因素。快速通道建设前后两组转入ICU患者的基线资料在性别、年龄、骨折类型、入院时Hb浓度和院前时间方面的比较差异均无统计学意义(均P>0.05),但是在合并症数目方面,快速通道ICU组的患者显著高于非快速通道ICU组(Z=-1.995,P=0.046)。与非快速通道ICU组的患者相比,快速通道ICU组的患者术前等待时间、术后在院时间和总住院时长均显著缩短(Z=-2.121、-2.726、-3.130,均P<0.05),快速通道ICU组患者所需会诊数目及在ICU治疗时间≥2晚的患者比例也显著减少(均P<0.05),两组患者在再次ICU转科率、会诊数目≥4个的患者比例、手术时长、总住院费用及在院、术后1个月和3个月死亡率方面比较差异均无统计学意义(PObjective To develop a fast track transfer to intensive care unit (ICU) for the perioperative high-risk elderly patients after hip fracture surgery and analyze the preliminary clinical effect of the application.Methods From January 2014 to December 2017, before the application of postoperative fast track transfer to ICU, the clinical data of 195 elderly patients with hip fracture were included in a retrospective analysis. Among 195 hip fracture patients, 18 were transferred to ICU post operation (non-fast track group). Multivariate logistic regression analysis was applied to investigate relevant risk factors for transferring to ICU after hip fracture surgery. Based on risk factors acquired from the analysis and clinical experience, the fast track transfer to ICU for the perioperative high-risk elderly patients after hip fracture surgery was constructed according to the preliminary and experiential criteria. From January 2018 to December 2019, the clinical data of 70 patients (fast track group) who were transferred to ICU after hip fracture surgery through the fast track were collected and compared with non-fast track group.Results Multivariate regression analysis revealed that American Society of Anesthesiologists classification(≥Ⅲ) (OR=4.260, 95%CI:1.157-15.683, P=0.029), pre-hospital stage (≥48 h) (OR=4.301, 95%CI:1.212-15.266, P=0.024), hemoglobin concentration at admission(<90 g/L) (OR=7.979, 95%CI:1.936-32.889, P=0.004), coronary heart disease as one comorbidity(OR=6.063, 95%CI:1.695-21.693, P=0.006) were independent risk factors for transferring to ICU after hip fracture surgery. There were no significant difference in gender, age, fracture type, hemoglobin concentration at admission and time of pre-hospital stage between the non-fast track group and fast track group(all P>0.05). However, the number of comorbidities in the fast track group was significantly higher than that in the non-fast track group (Z=-1.995, P=0.046). The time to surgery, postoperative hospital stay, and length of hospital stay in

关 键 词：髋骨折 老年人 加速康复外科 重症监护 快速通道 

分 类 号：R473.6[医药卫生—护理学]