RU2491045C2 - Method of improving preparation of old age patients for operation of total hip replacement - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: invention relates to medicine, namely to traumatology and orthopedics, and can be applied in carrying out of pre-operational preparation of old age patients for operation of total hip replacement. For this purpose patient is laid in horizontal position. Deep exhalation with breathing holding is made at the background of quiet breathing. Then, after maximal possible apnea, series of inevitable spontaneous inhalations is performed. After that, breathing is restored. Breathing maneuver is carried out trice with repetition of four cycles per day with four day preparation duration.

EFFECT: method makes it possible to improve pre-operational preparation of old age group patients by increase of reserve abilities of myocardium by creation of processes of hypoxia-hypercapnia in doing breathing exercises with breathing holding in specified mode, which in its turn, makes it possible to prevent possible postoperative complications from vital systems.

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Description

According to WHO, people over 60 are the fastest growing group in the world. The aging population of the planet and, in particular, Russia, creates a number of gerontological problems. One of them, which is of high importance, is fractures of the tubular bones of the lower extremities. And the most common are hip fractures in the elderly. Most scientists consider the increase in the number of femoral neck fractures to be a real epidemic, with high (up to 12-15%) primary mortality, treatment difficulties and progressive mortality in the near future [4, 6, 7].

Along with the high and increasing incidence of this pathology from year to year, the need to resolve it has medical and social significance. Medical problems are caused by a stressful situation for several months with pain, muscle tension, psychosomatic reactions - increased blood pressure, changes in the functions of the gastrointestinal tract and urinary system, as well as changes in psychological reactions with the state of "situational anxiety". This determines the extremely low quality of life of older people. [5, 3].

When comparing therapies for hip fractures, the mortality rate from operations is up to 19.7%. With conservative treatment, requiring a long bed rest, at least 40%. More effective tactics in relation to fractures of the proximal femur in the elderly, in the general opinion, is surgical treatment. [8, 13].

Despite the generally recognized optimality of surgical treatment, conservative technologies are often chosen for the treatment of this group of patients, even in specialized departments. The generally accepted tactics of refusing hospitalization. The proportion of patients with fractures of the proximal femur, transferred to the category of surgically incurable, is significantly overestimated. [10, 11].

High stationary mortality in fractures of the proximal femur in elderly and old individuals determines the reasons for the refusal of operations and is based on age-related changes in organs and systems of the senile organism with the formation of a whole complex of risk conditions. The main risk factor for surgery in the elderly is the formation of chronic heart failure, which is based on atherosclerotic lesions of all pools, cardiomyopathy and coronary pathology with myocardial remodeling. Heart failure causes an extremely high percentage of complications of the perioperative period and deaths. Thus, age is a risk factor for morbidity and mortality from cardiovascular diseases [16].

It should be noted that only methods for treating impaired functions and preventing complications are discussed in the literature. The basic preparation of gerontological patients is limited to the correction of chronically impaired functions and is not specific. Drug and non-drug methods are used.

Non-drug therapy of background diseases consists in improving the drainage ability of the lungs using various methods of physiotherapy, the use of inhalation, as well as methods of hypoxic or hypercapnic training (Buteyko, Frolova, etc.). As a component of preoperative preparation, these methods are not proposed. Drug therapy includes the use of (β-blockers, nitrates, diuretics, anabolics, heparins, cardioprotectors and drugs used by patients before hospitalization for the treatment of any chronic diseases. [2, 9, 12]. As a preoperative preparation for patients with compromised cardiac The vascular system suggests one of the most recently studied effects of ischemic preconditioning [14, 15, 17]. This effect is at the stage of experimental analysis, although it is potentially effective. To prevent critical ischemia in the various basins.

The aim of the invention is to improve the preoperative preparation of patients of an older age group by increasing the reserve capacity of the myocardium and preventing possible postoperative complications from the vital systems.

Methodology of preparation.

The patient is in a horizontal position. Against the background of calm breathing after a normal inspiration, a deep exhalation is made. Then, after the maximum possible breath holding, it is possible to restore breathing. The breathing maneuver is repeated twice more. Four such cycles are performed per day. The duration of the preparation is four days. It is important that breath holding is performed after a deep exhalation: after a pause, a series of forced breaths inevitably occurs. Presumably, the pathophysiological basis is the processes of controlled hypoxia-hypercapnia.

During breath holding after a deep exhalation, the induced processes of hypoxia and hypercapnia lead to an increase in the partial tension of carbon dioxide and a decrease in the pH of the blood. A decrease in pH causes a shift in the dissociation curve to the right. The pH value and the content of CO ₂ in the tissues of the body alter the affinity of hemoglobin for O ₂ . Their influence on the dissociation curve of oxyhemoglobin (Bohr effect): with an increase in the concentration of hydrogen ions and the partial voltage of CO ₂ in the medium, the affinity of hemoglobin for oxygen decreases. This effect has an important adaptive value: the blood is able to release more oxygen, while in the tissues (in particular, the myocardium), conditions are created for saturation with energy-intensive substrates. The latter circumstance creates conditions for the stability of the myocardium and other tissues in subsequent negative events.

The closest analogue of the proposed method is the method of volitional regulation of respiration K.P. Buteyko (Buteyko K.P. et al. The influence of volitional regulation of respiration on some physiological functions at altitude // Issues of Aviation Medicine. - M., 1966).

The advantages of our method:

1. lack of special methodological training;

2. short-term preparation;

3. ease of implementation;

4. good portability of maneuvers with the possibility of independent state control;

5. reliable clinical effect and the possibility of surgical intervention in patients recognized as inoperable;

6. the possibility of using the method as a test for functional operability;

7. The ability to minimize the pharmacological burden;

8. The possibility of early activation of the patient and reduction of the postoperative period.

Under our supervision there were 36 patients of the older age group with fractures of the head and neck of the femur and the proximal femur, as well as degenerative-dystrophic processes of the hip joints (aseptic necrosis of the femoral head, coxarthrosis of the III-IV stage, consequences of injuries of the hip joint), in need of hip replacement (n = 36).

Exclusion criteria from the observation groups were diseases that could lead to an aggravation of the condition even without surgery: severe diabetes mellitus, severe morbid obesity, a common oncological process, etc. Patients are divided into two groups. The first group included patients who, against the background of the standard one, underwent the preparation we proposed (n = 12). In the second (control) group (n = 24), therapy did not differ from generally accepted directions. Additionally, with the participation of exercise therapy practitioners, for the two weeks before surgery, the second group of patients used the Buteyko breathing method. The average age in the groups is shown in table 1.

Table 1 Age characteristics of patients Group Age 1 (n = 12) 84.3 ± 3.19 2 (n = 24) 65.4 ± 4.45

The age of all patients of the first group exceeded 80 years. Concomitant pathology in patients of this group: ischemic heart disease, functional angina III-IV of functional classes, ischemic and / or hypertrophic cardiomyopathy, atherosclerosis of the aorta, cerebral and coronary vessels, complicated course of arterial hypertension, H _II st .; emphysema, pneumosclerosis, DN _II Art. When assessing the clinical condition, complaints were noted of weakness, angina pain provoked by activation during hygiene measures; mixed cachexia, psychophysical asthenization, compensated nature of ventilation disorders, central and systemic circulation. Initial functional tests confirmed the high risks of developing cardiovascular system disorders: latent and / or overt myocardial ischemia, intraventricular conduction disturbances with blockade of the bundle of His on an ECG and Holter monitoring; hypertrophy and diffuse hypokinesia of two or more zones of the left ventricular myocardium with a decrease in ejection fraction and pulmonary hypertension II tbsp. on the echocardiography.

We consider it important that four patients, during the preparation, noted a worsening of the clinical condition, expressed in an increase in the occurrence of chest pains and a decrease in the tolerance of ongoing breathing exercises. These patients were found to be inoperable, excluded from the study group and discharged with the necessary recommendations for conservative therapy.

Patients of the first group were the most severe of all included in the study, and the identified risks justified their previous refusals to conduct the operation. Given the identified functional disorders and initial hypovolemia, drug therapy was limited to taking nitrates and ACE inhibitors. Along with taking drugs, patients of the first group performed breathing maneuvers according to the described technique for four days.

When monitoring before the operation of functional studies (table 2), the following data were obtained. When monitoring by Holter, a significant decrease in the frequency of episodes of myocardial ischemia and an improvement in the parameters of ischemia were recorded (only episodes of ischemia with ST segment depression> 100 μV were taken into account). The ejection fraction during ECHO KG (EF) tended to increase by 1.5-2 times, and the average value of pressure in the pulmonary artery (DLA _cf ) significantly decreased.

As a result, a decrease in the level of psychophysical asthenization was clinically observed (can be explained by the distraction of patients from their own state and active participation in the treatment process, enhanced by the work of systems associated with external respiration). A decrease in the intensity and frequency of chest pains was noted.

The control (second) group included patients who also had elderly and senile age (from 60 to 75 years). Patients were selected with a comparable concomitant pathology: coronary heart disease, functional angina I-II, ischemic and / or hypertrophic cardiomyopathy, atherosclerosis of the aorta, cerebral and coronary vessels, arterial hypertension, H _I st, moderate course; pulmonary emphysema, pneumosclerosis, DN _I st.

The clinical condition of patients of the second group was less disturbed: complaints of rare chest pains; moderate psychophysical asthenization, compensated nature of ventilation, central and systemic circulation. Initial functional tests confirmed the compensated nature of the impairment. The average values of the initial and control functional disorders - see table 2.

Table 2. Dynamics of functional tests before and after the preparation in both groups of patients. PV (%) Before preparation After preparation 1 group 38.75 ± 3.49 44.4 ± 2.59 p <0.05 2 group 56.7 ± 7.58 57.2 ± 7.26 p> 0.05 DLA _cf (mmHg) 1 group 48.3 ± 2.78 36.25 ± 3.67 p <0.05 2 group 37.7 ± 4.5 36.65 ± 3.8 p> 0.05 The average parameters of ischemic episodes in groups according to the Holter test 1 group 2 group The average number of episodes per patient Before preparation 28.9 ± 2.8 20.12 ± 7.049 After preparation 10.75 ± 2.4 * 18.5 ± 6.70 Episode duration (min) Before 6.675 ± 0.86 3.67 ± 0.7 after 1.25 ± 0.14 * 3.29 ± 0.76 ST segment depression (μV) Before 183.3 ± 15.36 121.9 ± 16.57 After 130.5 ± 7.97 * 113.58 ± 15.97 Maximum heart rate (bpm) Before 98.75 ± 8.57 86.87 ± 7.99 After 81.58 ± 3.88 * 84.29 ± 6.66 * - p <0.05

After preoperative preparation, all patients of both groups underwent heparin therapy in the form of injections of 0.3 mg fraxiparin one day and 12 hours before surgery. The operations on replacing the hip joint with cementless prostheses were of the same type and performed under spinal anesthesia with 0.5% ropivacaine solution in the volume of three milliliters in combination with sedation with 20 mg iv seduxen solution. After surgery, all patients were transferred to intensive care units. The criteria for evaluating the postoperative period were: complications of the cardiovascular system, thromboembolic complications, length of stay in the intensive care unit, length of hospital stay after surgery. There were no fatal outcomes. The data are presented in table 3.

All complications were successfully corrected, and the patients were discharged home. But in the first (most severe) group, complications arose half as much, which led to an almost significant reduction in the length of hospitalization in the ICU. The average time spent in the specialized department was different.

Table 3 Postoperative Evaluation Criteria Group 1 Group 2 abs % abs % Acute myocardial infarction one 4.17 Heart failure one 8.3 2 8.3 Tela one 4.17 Total complications one 8.3 four 16.67 Hospitalization in ICU (h) 17.66 ± 2.89 22.20 ± 14.58 n / a bed-day in the department (days) 9 ± 0.45 11.33 ± 1.4

Clinical example.

Patient P., 79 years old, was hospitalized with a diagnosis of DOS. Fracture of the neck of the left thigh, aseptic necrosis of the head of the left thigh; sop. Ischemic heart disease, functional class III angina, hypertrophic cardiomyopathy, atherosclerosis of the aorta, brain and coronary vessels, complicated course of arterial hypertension, N _IIA Art .; emphysema, pneumosclerosis, DN _II Art.

When assessing the clinical condition, complaints were noted of weakness, angina pectoris, provoked by activation during hygiene measures; morbid obesity (Quetelet index 37.6), psychophysical asthenization, compensated nature of ventilation, central and systemic circulation. Initial functional tests confirmed the high risks of developing cardiovascular system disorders: latent and overt myocardial ischemia (the average number of episodes of myocardial ischemia is 37.8 with a duration of 6.4 minutes and a depression of the ST segment of 180 μV and a maximum heart rate of 97 per minute with Holter monitoring), violation of intraventricular conduction with blockade of the left leg of the bundle of His on an ECG; myocardial hypertrophy, diffuse hypokinesia of the anterior and posterior zones of the left ventricular myocardium with a decrease in ejection fraction to 32.4% and pulmonary hypertension to 49 mm Hg on the echocardiography.

Preoperative drug therapy consisted of taking 10 mg / day of enalapril, four times a day, 20 mg of nitrosorbide inside. She performed breathing exercises 20 minutes after taking nitrosorbide. It should be noted a high degree of good faith in the implementation of recommendations, as previously, the patient was already denied surgical treatment. After four days of preparation, the dynamics was obtained in a subjective assessment of one's own condition in the form of a lack of complaints, a positive mental climate, and a slight decrease in the Ketle body mass index to 36.7. Objective indicators also changed: the average number of episodes of myocardial ischemia 21 with a duration of 1.5 min and a ST segment depression of 110 μV and a maximum heart rate of 88 per min during Holter monitoring), with an ejection fraction of 50.6% and pulmonary hypertension of 25 mm Hg on the echocardiography.

Patient P. underwent total endoprosthetics of the left hip joint under conditions of spinal anesthesia at the level of Th _XII and sedation with seduxen 15 mg fractionally with respiratory support as oxygen insufflation through the nasal cannula at a rate of 7 l / min. The duration of the operation was 70 minutes. The volume of blood loss did not exceed 500 ml. The postoperative period was uneventful. No critical changes in the hemodynamic and oxygen-dynamic profiles were noted. After 17 hours, the patient was transferred from ICU to the department and was discharged after 7 days.

Thus, comparing the results of treatment of patients with femoral fractures using traditional treatment and using the method we have proposed, it was found that by increasing the reserves of the cardiovascular system in a short time, it was possible to achieve improved indicators of heart functions: contractility, excitability, conductivity in patients in the group of maximum operational risk. As a result, the number of complications decreased compared with the group of less severe patients. It should be noted that preoperative preparation was much shorter.

Bibliography

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Claims (3)

1. A way to improve the preparation of senile patients for total hip arthroplasty by increasing the reserve capacity of the myocardium, which consists in creating episodes of a state of self-controlled hypoxia-hypercapnia in a patient who, being in a horizontal position, with calm breathing, exhales deeply with breath holding, then after the maximum possible apnea restores breathing; they perform a breathing maneuver three times, with a repetition of four cycles per day with a training duration of four days, characterized in that the breath is held after a deep exhalation with an inevitable series of spontaneous breaths, independent control of one’s condition. 2. The method according to claim 1, characterized in that they obtain a reliable clinical effect and the possibility of surgical intervention for elderly patients, recognized inoperable due to the high risk of developing cardiovascular complications. 3. The method according to claim 1, characterized in that at the same time they test functional operability in problem patients when it is impossible to conduct tests with physical activity.