骨科老年患者手术损害控制的临床应用与初步实验研究
|
摘要
研究背景:手术是一种特殊形式的创伤,随着年龄的增长,人体各器官功能会逐渐出现衰退,尤其是伴有内科慢性疾病的老年患者对手术的耐受能力逐渐降低,在面对手术与否的情况下如何抉择成为临床医生、患者家属及患者本人左右为难的突出问题,是放弃手术治疗还是积极调整全身生理状况后进行手术,是按照常规进行手术还是采取损害控制性手术?是临床需要亟待研究的关键问题。
“损害控制(damage control)”技术最早起源于腹部外科,是针对腹腔内脏器严重损害后无法一期完成确定性手术而采取的分阶段、分步骤的手术策略,以避免伤者因出血过多导致生理状态的不可逆转。同样道理,为确保骨科老年病人手术的顺利进行,我们提出了“手术损害控制”的理念。所谓“手术损害控制”是指需要手术治疗的老年患者因其脏器储备功能差,对常规手术的耐受能力不足,围手术期易出现并发症甚至死亡危险,为此而采取的一种相对安全、可以接受的治疗措施。并不是所有的老年患者均有机会采取损害控制手术,哪些患者不需要采取损害控制就可以直接进行常规手术?哪些需要采取损害控制性手术?哪些患者即使采取损害控制也无法完成手术?针对上述问题,建立骨科老年患者手术风险评分系统,以此作为客观衡量工具,对高风险患者实施手术损害控制,以达到降低围手术期并发症和死亡率的目的。
目的:1、找出影响骨科老年患者围手术期死亡或并发症的风险因素;2、建立大坪骨科老年患者手术风险评分系统;针对评分系统开发软件;将软件应用于回顾性研究;3、将该评分系统软件应用于前瞻性研究,对高风险患者采取手术损害控制;4、探讨手术风险评分、老年患者围手术期应激反应与术后并发症的相关性;5、建立老年大鼠多发伤动物模型,证明损害控制手术方法能够改善老年大鼠存活率、降低并发症,为临床应用奠定理论基础。
方法:1、筛选风险因素:自行设计制作住院患者详细信息登记表。通过回顾近7年来在我科住院行手术治疗的760例老年患者的详细资料,将相关信息填入表格内。将出现死亡或并发症的患者作为实验组;无并发症的患者作为对照组,然后对两组相关内容进行统计学分析,筛选出影响手术预后的相关风险因素;2、经统计学分析对各风险因素进行权重赋值,参照APACHⅡ、POSSUM评分系统建立的方法,初步建立大坪骨科老年患者手术风险评分系统(Daping orthopedics operation risk scoring system for senile patient,DORSSSP);针对评分系统开发制作便于临床应用的软件;应用软件对260例老年髋部骨折进行回顾性研究,观察其预测的效价;3、应用评分软件对100例骨科老年患者进行前瞻性研究,对高风险的患者实施手术损害控制策略,观察术后预后情况;
4、应用DORSSSP对20例老年患者进行术前评分,按照评分高低分成A、B两组,于术后不同时相点采血检测白细胞GR蛋白表达和T淋巴细胞亚群的变化情况,观察术前评分、术后应激与不良预后的相关性;5、建立老年大鼠多发伤动物模型,观察不同组别外周血炎性细胞因子IL6、TNF-α、IL-10浓度的变化、白细胞GR蛋白表达的高低,判断手术损害控制策略对老年多发伤大鼠治疗的效果。
结果:
1.760例老年患者中56.7%的存在不同程度的并存症,术后死亡率为2.1%,出现1个或1个以上的并发症占23.3%。经统计学分析发现术前心、肺功能2级以上、营养不良、高血压病、糖尿病、神志异常、肾功能不全、电解质紊乱、手术大、术中出血量多、手术耗时过长是手术后不良预后的主要原因。
2.在第一部分760例患者信息资料基础上经统计学分析,对各因素分别给予权重赋值,初步建立大坪骨科老年手术风险评分系统,评分赋值结果见表2-1;针对评分系统开发的软件在windows系统上运行稳定、快捷,应用该软件对260例老年髋部骨折进行回顾性研究。结果低风险组100例,平均评分为12.5±0.8分,住院期间无死亡病例,出现并发症10例;中度风险组80例,平均评分为17.6±2.2分,住院期间无死亡病例,出现并发症21例;高风险组50例,评分为23.3±2.9分,住院期间死亡2例,出现并发症27例;极高风险组30例,评分为33.8±4.7分,住院期间死亡4例,出现并发症26例。DORSSSP预测并发症发生合计92例,POSSUM预测并发症发生合计119例,实际发生84例;DORSSSP预测死亡率为9例,P-POSSUM预测死亡人数10例,APACHEⅡ预测死亡人数12例,实际死亡6例。
3.应用DORSSSP评分对术前评分处于高风险的患者实施手术损害控制措施。入院后首次检查PS为12-42分,平均21.4±6.7分,OS为12-24分,平均15.2±4.5;术前PS为12-30分,平均18.3±6.2分;术前OS为5-18分,平均9.1±3.4分。根据入院时PS及拟行手术OS预测并发症发生率为46%,死亡率为11%,实施损害控制后预测并发症发生率为34%,死亡率为5%;术前POSSUM和P-POSSUM预测并发症和死亡发生率分别是39%和6%;APACHEⅡ预测死亡率为8%;实际并发症发生率为32%,死亡率为3%。
4.A组患者术后出现1例并发症,无死亡患者发生;B组术后出现1例死亡,3例并发症。患者术后外周血GR蛋白的变化结果是:两组病人手术创伤后外周血白细胞中GR蛋白的表达均不同程度表现为下降,术后第1天达到低峰,随着时间的推移表达逐渐升高,A组于术后第7天恢复至接近术前水平,14天恢复至正常。B组病人在术后第5天开始明显恢复,但恢复较A组缓慢,至术后14天时仍未恢复到术前水平,两组间比较存在显著性差异(p<0.01),表明其GR蛋白下降时间随着手术风险评分的增高而低表达水平持续时间延长。术后T细胞亚群的变化结果是:A、B两组CD3、CD4值在术后第1、3、5天均明显低于术前对照组( P<0.05) ,尤其术后第1天降低最明显( P<0.01),于术后第5天逐渐回升,A组于术后第7天恢复接近正常,14天恢复正常,而B组14天时仍呈较低水平;A组CD8在术后1、3、5天呈下降趋势,而B组显示没有降低反而呈现增高,T4/T8较长时间维持低水平。
5.老年多发伤大鼠术后血浆IL-6、IL-10及TNF-α含量的变化结果是:伤后第1天两组动物血浆IL-6、IL-10和TNF-α含量持续急剧升高到达高峰,与伤前及正常对照组比较相差非常显著(P<0.01),随后呈逐渐下降趋势,C组老年大鼠下降趋势明显优于B组,至术后14天C组恢复接近正常水平,而B组仍呈较高水平,两组之间存在显著性差异(P<0.05)。老年大鼠术后外周血白细胞GR蛋白的表达结果是:手术创伤后大鼠外周血白细胞中GR蛋白的表达均不同程度表现为下降,术后第1天达到最低峰,随着时间的推移,表达呈逐渐增高趋势。C组大鼠在术后第10天GR蛋白表达接近正常水平,而B组仍呈较低表达,至术后14天表达才接近正常水平,两组之间存在显著性差异(p<0.01)。表明其GR蛋白下降时间随创伤的严重程度增加而低表达水平持续时间延长。
结论:
1.老年患者术前心肺功能2级以上、营养不良、高血压病、糖尿病、神志异常、肾功能不全、电解质紊乱、手术大、术中出血量多及手术耗时过长是手术后出现死亡及并发症的主要原因。术前正确评估患者生理及手术方面存在的风险,并积极调整其生理状态或者改变手术方式,是避免出现术后并发症及死亡的重要措施。
2.DORSSSP是老年患者术前风险评估的重要工具,针对其开发的软件在windows系统下运行稳定,临床上使用方便、快捷;经临床回顾性研究发现能够很好的预测术后并发症和死亡率,与APCHEⅡ、POSSUM评分系统相比具有评估指标少、容易获得、计算简便、预测准确、可操作性强等优点。
3.应用DORSSSP评分系统评估出具有较高手术风险的老年患者实施手术损害控制后,明显降低了术后并发症及死亡率的发生,与POSSUM、P-POSSUM和APACHEⅡ评分系统比较有很好的一致性,前瞻性研究显示三种手术风险评分系统均存在一定的误差,所以该评分系统仍然要随着外科学的发展不断更新。
4.老年人手术风险评分与围手术期应激引起的外周血白细胞GR及T淋巴细胞亚群变化存在明显的相关性,术前评分高的老年患者术后GR表达呈持续低水平,CD3、CD4在低水平持续时间更长,CD4/CD8下降更加明显,术后发生并发症的几率明显增加。通过术前的风险评分结合手术前后外周血GR和T淋巴细胞亚群的变化,能够更好的预测手术后并发症和死亡的发生率,为临床上治疗老年高风险患者提供指导。
5.损害控制性手术的实施能够改善老年大鼠的生理状态,以最简单、微创、快速的方法稳定骨折断端,早期有效的液体复苏,减少术中出血,提高了外周血白细胞GR的表达,降低了局部炎性介质向血浆内的释放,避免了“瀑布样效应”的发生,从而降低了老年大鼠死亡率和发生并发症的比率,该方法是治疗老年大鼠多发伤的有效措施,为临床救治老年多发伤患者提供了有利的证据。
Research background: As a special kind of trauma, surgical procedures has been receiving more and more attentions. With the increasing of age, human organ function gradually decayed. For those with chronic internal diseases, the operation tolerance is more decreased. This problem makes it difficult for clinician, patients and their families to decide whether or not to have operation. So the problem on disclaiming operation therapy or having operation till the patient’s physiological function gets properly adjusted, routine operation or damage control operation, which of them should be carried out, remains to be a critical clinical issue to be resolved urgently.
The concept of damage control and its related techniques originated from the abdominal surgery. If the abdominal viscera get severely damaged, it is impossible to get one-stage operation. The step-by-step operation strategy is adopted to avoid the irreversible stage of physiological functions caused by mass hemorrhage or others. So it should make the same sense while we are tackling with senile patient in orthopedics. Damage control operation is a relative secure and receptive therapeutic measure for those with poor organ function reserve, low tolerance to routine operation and easy facility to complications or even mortality perioperatively. Not all senile patients should take damage control operation and indications are needed to make selection on direct routine operation, damage control operation and sometimes the operation still can not be accomplished with damage control.Therefore, an operation risk scoring system for senile patient in orthopedics need to be established to make objective evaluation to reduce perioperative complications or mortalities when taking damage control operation.
Objective:1.To find risk factors influencing perioperative complications or mortalities of senile patients in orthopedics. 2. Reference the method of APACHE and POSSUM scoring system to establish Daping orthopedics operation risk scoring system for senile patients and to develop an associated scoring system software for retrospective study. 3.To make prospective study with this software and take damage control operation on patients with high risk factors.4.To explore the perioperative relevance among operation risk scoring system, stress reaction of senile patients and postoperative complications. 5. To establish senile rat model with multiple injury and get fundamental research basis for damage control operation so as to improve survival rate and reduce perioperative complications.
Methods: 1. Screening for risk factors: to design and make registration forms about the inpatients’detailed information. data of 760 senile patients after operation in our orthopaedics department in the recent 7 years were filled into the forms and retrospectively studied. The experimental group included those with mortality or complications while the control group included those having no complications. Statistical analysis was made and the possible correlated risk factors and those having effect on postoperative prognostications were screened out. 2. Weight assignment was given to each risk factor according to statistical analysis and Daping orthopedics operation risk scoring system for senile patient (DORSSSP)was established with its related software developed. Retrospective study on this software was taken to 260 senile patients with fractures of hip and the software potency for prognostication was observed. 3. Prospective study of 100 senile patients in the department of orthopaedics was undertaken with this software, operation damage control strategies were carried out on patients with high risk factors and the information about their postoperative prognostications was recorded at the same time. 4. Twenty senile patients were scored preoperatively with DORSSSP and divided into A and B groups according to the score. Haemospasia at different postoperative phases were taken to detect the expression of GR protein and the diversification of T lymphocyte subpopulation. The correlation among preoperative scores, postoperative stress and poor prognosis was observed. 5.To establish senile rat model with multiple injuries and observe diversification of inflammatory cytokines such as IL-6, TNF-αand IL-10 in peripheral blood. The expression of GR protein on leukocytes was also detected to evaluate the therapeutic effect of operation damage control on rats with multiple injuries.
Results: 1. Among the 760 senile patients, the complications rate and the mortality rate was 56.7%, 2.1% respectively, and 23.3% of them had 1 or more complications. After statistical analysis we found that heart and pulmonary function were above grade 2, malnutrition, hypertension, diabetes, mind abnormality, renal inadequacy, electrolyte disturbance, big operation trauma, mass hemorrhage during operation and excessive operation time were main causes of poor postoperative prognostications.
2. Weight assignment was given to each factor after statistical analysis based on the prior part of work and DORSSSP was initially established (table2-1). The related software had been proved to run fast and stably on windows operating system. Retrospective study on 260 senile patients with hip fracture was taken with this software. There were 100 cases in low-risk group with score of 12.5±0.8 and no mortality was reported in their duration of hospital. While 10 cases had complications;there were 80 cases in mid-risk group with score 17.6±2.2,no mortality and 21 patients having complications;there were 50 cases in high-risk group with score 23.3±2.9, 2 mortalities and 27 patients having complications. For the ex-high-risk group we got 30 cases with score 33.8±4.7, 4 mortalities and 26 patients having complications in their duration of hospital. A total of 92 cases were predicted to have complications with DORSSSP. With POSSUM, 119 cases had complications with the actual number of 84.With mortality DORSSSP got the result of 9 cases, while P-POSSUM 10 cases and APACHEⅡ12 cases, the actual number was 6.
3. Operation damage control was taken for those in both high-risk and ex-high-risk group with DORSSSP. On these patients’first day of admission, physiology score (PS) was from 12 to 42 with average of 21.4±6.7 and operation risk score (OS) was from 12 to 24 with average of 15.2±4.5. The preoperative PS was from 12 to 30 with average of 18.3±6.2,while OS was from 5 to 18 with average of 9.1±3.4. The complication incidence was 46% with mortality rate of 11% according to the prediction based on PS and OS and operation schedule. After operation damage control, the predicted rate of complication cases was 34% with mortality of 5%. With the preoperative prediction using POSSUM and P-POSSUM, the complication rate and mortality rate was 39%, 6%respectively. For APACHEⅡthe predicted mortality rate was 8% while the actual complication rate was 32% and mortality rate 3%.
4. One patient appeared complication in group A, three patients presented complications and one patient died in group B. The peripheral blood GR protein expression of senile patients decreased to different extent. In group A, GR protein was decreased and reached the the lowest point on the first day after surgery .Though GR expression increased later, it was significantly lower than the preoperative level(p<0.01)until the 7th day, Restore normal till 14th day.In group B, GR protein was also decreased and reached the lowest point on the first day, lower than the preoperative level until the 14th day. There was significant difference between the two groups(p<0.01), which meant the prolonged low level expression of GR protein was statistically associated with DORSSSP. For the diversification of T lymphocyte subpopulation, CD3 and CD4 levels of two groups got significantly lower than the preoperative ones (P<0.05) on the 1st ,3rd and 5th day with the level of the first day lowest. CD3 and CD4 levels increased on the 5th day. For group A, CD3 and CD4 expression returned to their normal level on the 7th day while group B stayed at a relatively low level. CD8 level from the 1st , 3rd and 5th day detection showed decrease in group A after surgery while it increased in group B. In conclusion, CD3 and CD4 expression decreased shortly after surgery and returned to their normal value on the 7th day from its lowest point on the 1st day. With DORSSSP score the higher, CD3 and CD4 expression decrease the more and return to their normal value the slower. 5. Results of IL-6, IL-10 and TNF-αdiversification in blood plasma of senile rat with multiple injuries: IL-6, IL-10 and TNF-αlevel sharply increased to their peak on the 1st day after trauma and was significantly different from the control group(P<0.001).The fall-off tendency of IL-6, IL-10 and TNF-αwas more significant in group C than in group B. On the 14th day, group C almostly got the normal level while group B stayed at a fairly high level which indicated a significant difference between them(P<0.05). Results of GR protein expression on leucocytes in senile rat: Peripheral blood decreased to different extent after surgery trauma. GR expression in group C decreased on the first day and reached the lowest point on the 5th day. The expression got higher later,but it was still lower than its preoperative level(p<0.01)until the 14th day. GR expression in group B reached the lowest point on the 7th day and didn’t return to its preoperative level till the 14th day(p<0.01). Low level expression of GR protein may be prolonged in relation to the trauma severity.
Conclusions:
1. Heart and pulmonary function above grade 2, malnutrition, hypertension, diabetes, mind abnormality, renal inadequacy, electrolyte disturbance, big operation trauma, mass hemorrhage during operation and excessive operation time are main causes of poor postoperative prognostications for senile patients. Using PS and OS to evaluate the possible danger and positively adjusting their physiological functions state or altering operation modus are important measures to avoid postoperative complications and mortalities.
2. DORSSSP can work as an important preoperative risk assessment tool for senile patients and our software based on it can run stably on windows operating system. It is convenient and fast in clinical and can well predict postoperative complication and mortality rate in our clinical retrospective study. It is easier to obtain, simpler to calculate with less indexes and can predict more accurately than APCHEⅡa nd POSSUM scoring system.
3. Operation damage control was taken to those senile patients with high relatively surgery risk score under DORSSSP evaluation and this can significantly reduce incidence of postoperative complications and mortalities.DORSSSP showes good consistency with POSSUM, P-POSSUM and APACHEⅡscoring system. Though there was prediction error in these three operation risk scoring systems, the system could get better with the renewal of surgery knowledge.
4. Changes of GR protein expression on peripheral blood leucocytes and T lymphocyte subpopulation diversifications have conspicuous correlations with the operation risk scoring and perioperative stress of senile patients. For those senile patients with high preoperative score, GR protein expression stays at a persistent low level while the low level expression time of CD3 and CD4 is even longer. CD4/CD8 expression decreases quite significantly and the probability of postoperative complication remarkably increases. Through DORSSSP plus GR protein expression on peripheral blood leucocytes and T lymphocyte subpopulation diversifications, we can better predict the incidence rate of postoperative complications and mortalities and use this as a clinical therapy guide for senile patients with high risks.
5. The practice of operation damage control could improve senile rats’physiological function state. Simple, micro-invasive and fast measures to stabilize bone fracture,early effective liquid transfusion resuscitation and less hemorrhage in the operation can improve GR protein expression on peripheral blood leucocytes , reduce the release of local inflammatory cytokines into blood and avoid the happening of waterfall effect. The postoperative complication and mortality rate of senile rats could get effectively decreased. In conclusion, operation damage control is validly effective for senile rats with multiple injuries and this can provide us favourable clinical evidence for senile patients with the same trauma in orthopaedics.
“损害控制(damage control)”技术最早起源于腹部外科,是针对腹腔内脏器严重损害后无法一期完成确定性手术而采取的分阶段、分步骤的手术策略,以避免伤者因出血过多导致生理状态的不可逆转。同样道理,为确保骨科老年病人手术的顺利进行,我们提出了“手术损害控制”的理念。所谓“手术损害控制”是指需要手术治疗的老年患者因其脏器储备功能差,对常规手术的耐受能力不足,围手术期易出现并发症甚至死亡危险,为此而采取的一种相对安全、可以接受的治疗措施。并不是所有的老年患者均有机会采取损害控制手术,哪些患者不需要采取损害控制就可以直接进行常规手术?哪些需要采取损害控制性手术?哪些患者即使采取损害控制也无法完成手术?针对上述问题,建立骨科老年患者手术风险评分系统,以此作为客观衡量工具,对高风险患者实施手术损害控制,以达到降低围手术期并发症和死亡率的目的。
目的:1、找出影响骨科老年患者围手术期死亡或并发症的风险因素;2、建立大坪骨科老年患者手术风险评分系统;针对评分系统开发软件;将软件应用于回顾性研究;3、将该评分系统软件应用于前瞻性研究,对高风险患者采取手术损害控制;4、探讨手术风险评分、老年患者围手术期应激反应与术后并发症的相关性;5、建立老年大鼠多发伤动物模型,证明损害控制手术方法能够改善老年大鼠存活率、降低并发症,为临床应用奠定理论基础。
方法:1、筛选风险因素:自行设计制作住院患者详细信息登记表。通过回顾近7年来在我科住院行手术治疗的760例老年患者的详细资料,将相关信息填入表格内。将出现死亡或并发症的患者作为实验组;无并发症的患者作为对照组,然后对两组相关内容进行统计学分析,筛选出影响手术预后的相关风险因素;2、经统计学分析对各风险因素进行权重赋值,参照APACHⅡ、POSSUM评分系统建立的方法,初步建立大坪骨科老年患者手术风险评分系统(Daping orthopedics operation risk scoring system for senile patient,DORSSSP);针对评分系统开发制作便于临床应用的软件;应用软件对260例老年髋部骨折进行回顾性研究,观察其预测的效价;3、应用评分软件对100例骨科老年患者进行前瞻性研究,对高风险的患者实施手术损害控制策略,观察术后预后情况;
4、应用DORSSSP对20例老年患者进行术前评分,按照评分高低分成A、B两组,于术后不同时相点采血检测白细胞GR蛋白表达和T淋巴细胞亚群的变化情况,观察术前评分、术后应激与不良预后的相关性;5、建立老年大鼠多发伤动物模型,观察不同组别外周血炎性细胞因子IL6、TNF-α、IL-10浓度的变化、白细胞GR蛋白表达的高低,判断手术损害控制策略对老年多发伤大鼠治疗的效果。
结果:
1.760例老年患者中56.7%的存在不同程度的并存症,术后死亡率为2.1%,出现1个或1个以上的并发症占23.3%。经统计学分析发现术前心、肺功能2级以上、营养不良、高血压病、糖尿病、神志异常、肾功能不全、电解质紊乱、手术大、术中出血量多、手术耗时过长是手术后不良预后的主要原因。
2.在第一部分760例患者信息资料基础上经统计学分析,对各因素分别给予权重赋值,初步建立大坪骨科老年手术风险评分系统,评分赋值结果见表2-1;针对评分系统开发的软件在windows系统上运行稳定、快捷,应用该软件对260例老年髋部骨折进行回顾性研究。结果低风险组100例,平均评分为12.5±0.8分,住院期间无死亡病例,出现并发症10例;中度风险组80例,平均评分为17.6±2.2分,住院期间无死亡病例,出现并发症21例;高风险组50例,评分为23.3±2.9分,住院期间死亡2例,出现并发症27例;极高风险组30例,评分为33.8±4.7分,住院期间死亡4例,出现并发症26例。DORSSSP预测并发症发生合计92例,POSSUM预测并发症发生合计119例,实际发生84例;DORSSSP预测死亡率为9例,P-POSSUM预测死亡人数10例,APACHEⅡ预测死亡人数12例,实际死亡6例。
3.应用DORSSSP评分对术前评分处于高风险的患者实施手术损害控制措施。入院后首次检查PS为12-42分,平均21.4±6.7分,OS为12-24分,平均15.2±4.5;术前PS为12-30分,平均18.3±6.2分;术前OS为5-18分,平均9.1±3.4分。根据入院时PS及拟行手术OS预测并发症发生率为46%,死亡率为11%,实施损害控制后预测并发症发生率为34%,死亡率为5%;术前POSSUM和P-POSSUM预测并发症和死亡发生率分别是39%和6%;APACHEⅡ预测死亡率为8%;实际并发症发生率为32%,死亡率为3%。
4.A组患者术后出现1例并发症,无死亡患者发生;B组术后出现1例死亡,3例并发症。患者术后外周血GR蛋白的变化结果是:两组病人手术创伤后外周血白细胞中GR蛋白的表达均不同程度表现为下降,术后第1天达到低峰,随着时间的推移表达逐渐升高,A组于术后第7天恢复至接近术前水平,14天恢复至正常。B组病人在术后第5天开始明显恢复,但恢复较A组缓慢,至术后14天时仍未恢复到术前水平,两组间比较存在显著性差异(p<0.01),表明其GR蛋白下降时间随着手术风险评分的增高而低表达水平持续时间延长。术后T细胞亚群的变化结果是:A、B两组CD3、CD4值在术后第1、3、5天均明显低于术前对照组( P<0.05) ,尤其术后第1天降低最明显( P<0.01),于术后第5天逐渐回升,A组于术后第7天恢复接近正常,14天恢复正常,而B组14天时仍呈较低水平;A组CD8在术后1、3、5天呈下降趋势,而B组显示没有降低反而呈现增高,T4/T8较长时间维持低水平。
5.老年多发伤大鼠术后血浆IL-6、IL-10及TNF-α含量的变化结果是:伤后第1天两组动物血浆IL-6、IL-10和TNF-α含量持续急剧升高到达高峰,与伤前及正常对照组比较相差非常显著(P<0.01),随后呈逐渐下降趋势,C组老年大鼠下降趋势明显优于B组,至术后14天C组恢复接近正常水平,而B组仍呈较高水平,两组之间存在显著性差异(P<0.05)。老年大鼠术后外周血白细胞GR蛋白的表达结果是:手术创伤后大鼠外周血白细胞中GR蛋白的表达均不同程度表现为下降,术后第1天达到最低峰,随着时间的推移,表达呈逐渐增高趋势。C组大鼠在术后第10天GR蛋白表达接近正常水平,而B组仍呈较低表达,至术后14天表达才接近正常水平,两组之间存在显著性差异(p<0.01)。表明其GR蛋白下降时间随创伤的严重程度增加而低表达水平持续时间延长。
结论:
1.老年患者术前心肺功能2级以上、营养不良、高血压病、糖尿病、神志异常、肾功能不全、电解质紊乱、手术大、术中出血量多及手术耗时过长是手术后出现死亡及并发症的主要原因。术前正确评估患者生理及手术方面存在的风险,并积极调整其生理状态或者改变手术方式,是避免出现术后并发症及死亡的重要措施。
2.DORSSSP是老年患者术前风险评估的重要工具,针对其开发的软件在windows系统下运行稳定,临床上使用方便、快捷;经临床回顾性研究发现能够很好的预测术后并发症和死亡率,与APCHEⅡ、POSSUM评分系统相比具有评估指标少、容易获得、计算简便、预测准确、可操作性强等优点。
3.应用DORSSSP评分系统评估出具有较高手术风险的老年患者实施手术损害控制后,明显降低了术后并发症及死亡率的发生,与POSSUM、P-POSSUM和APACHEⅡ评分系统比较有很好的一致性,前瞻性研究显示三种手术风险评分系统均存在一定的误差,所以该评分系统仍然要随着外科学的发展不断更新。
4.老年人手术风险评分与围手术期应激引起的外周血白细胞GR及T淋巴细胞亚群变化存在明显的相关性,术前评分高的老年患者术后GR表达呈持续低水平,CD3、CD4在低水平持续时间更长,CD4/CD8下降更加明显,术后发生并发症的几率明显增加。通过术前的风险评分结合手术前后外周血GR和T淋巴细胞亚群的变化,能够更好的预测手术后并发症和死亡的发生率,为临床上治疗老年高风险患者提供指导。
5.损害控制性手术的实施能够改善老年大鼠的生理状态,以最简单、微创、快速的方法稳定骨折断端,早期有效的液体复苏,减少术中出血,提高了外周血白细胞GR的表达,降低了局部炎性介质向血浆内的释放,避免了“瀑布样效应”的发生,从而降低了老年大鼠死亡率和发生并发症的比率,该方法是治疗老年大鼠多发伤的有效措施,为临床救治老年多发伤患者提供了有利的证据。
Research background: As a special kind of trauma, surgical procedures has been receiving more and more attentions. With the increasing of age, human organ function gradually decayed. For those with chronic internal diseases, the operation tolerance is more decreased. This problem makes it difficult for clinician, patients and their families to decide whether or not to have operation. So the problem on disclaiming operation therapy or having operation till the patient’s physiological function gets properly adjusted, routine operation or damage control operation, which of them should be carried out, remains to be a critical clinical issue to be resolved urgently.
The concept of damage control and its related techniques originated from the abdominal surgery. If the abdominal viscera get severely damaged, it is impossible to get one-stage operation. The step-by-step operation strategy is adopted to avoid the irreversible stage of physiological functions caused by mass hemorrhage or others. So it should make the same sense while we are tackling with senile patient in orthopedics. Damage control operation is a relative secure and receptive therapeutic measure for those with poor organ function reserve, low tolerance to routine operation and easy facility to complications or even mortality perioperatively. Not all senile patients should take damage control operation and indications are needed to make selection on direct routine operation, damage control operation and sometimes the operation still can not be accomplished with damage control.Therefore, an operation risk scoring system for senile patient in orthopedics need to be established to make objective evaluation to reduce perioperative complications or mortalities when taking damage control operation.
Objective:1.To find risk factors influencing perioperative complications or mortalities of senile patients in orthopedics. 2. Reference the method of APACHE and POSSUM scoring system to establish Daping orthopedics operation risk scoring system for senile patients and to develop an associated scoring system software for retrospective study. 3.To make prospective study with this software and take damage control operation on patients with high risk factors.4.To explore the perioperative relevance among operation risk scoring system, stress reaction of senile patients and postoperative complications. 5. To establish senile rat model with multiple injury and get fundamental research basis for damage control operation so as to improve survival rate and reduce perioperative complications.
Methods: 1. Screening for risk factors: to design and make registration forms about the inpatients’detailed information. data of 760 senile patients after operation in our orthopaedics department in the recent 7 years were filled into the forms and retrospectively studied. The experimental group included those with mortality or complications while the control group included those having no complications. Statistical analysis was made and the possible correlated risk factors and those having effect on postoperative prognostications were screened out. 2. Weight assignment was given to each risk factor according to statistical analysis and Daping orthopedics operation risk scoring system for senile patient (DORSSSP)was established with its related software developed. Retrospective study on this software was taken to 260 senile patients with fractures of hip and the software potency for prognostication was observed. 3. Prospective study of 100 senile patients in the department of orthopaedics was undertaken with this software, operation damage control strategies were carried out on patients with high risk factors and the information about their postoperative prognostications was recorded at the same time. 4. Twenty senile patients were scored preoperatively with DORSSSP and divided into A and B groups according to the score. Haemospasia at different postoperative phases were taken to detect the expression of GR protein and the diversification of T lymphocyte subpopulation. The correlation among preoperative scores, postoperative stress and poor prognosis was observed. 5.To establish senile rat model with multiple injuries and observe diversification of inflammatory cytokines such as IL-6, TNF-αand IL-10 in peripheral blood. The expression of GR protein on leukocytes was also detected to evaluate the therapeutic effect of operation damage control on rats with multiple injuries.
Results: 1. Among the 760 senile patients, the complications rate and the mortality rate was 56.7%, 2.1% respectively, and 23.3% of them had 1 or more complications. After statistical analysis we found that heart and pulmonary function were above grade 2, malnutrition, hypertension, diabetes, mind abnormality, renal inadequacy, electrolyte disturbance, big operation trauma, mass hemorrhage during operation and excessive operation time were main causes of poor postoperative prognostications.
2. Weight assignment was given to each factor after statistical analysis based on the prior part of work and DORSSSP was initially established (table2-1). The related software had been proved to run fast and stably on windows operating system. Retrospective study on 260 senile patients with hip fracture was taken with this software. There were 100 cases in low-risk group with score of 12.5±0.8 and no mortality was reported in their duration of hospital. While 10 cases had complications;there were 80 cases in mid-risk group with score 17.6±2.2,no mortality and 21 patients having complications;there were 50 cases in high-risk group with score 23.3±2.9, 2 mortalities and 27 patients having complications. For the ex-high-risk group we got 30 cases with score 33.8±4.7, 4 mortalities and 26 patients having complications in their duration of hospital. A total of 92 cases were predicted to have complications with DORSSSP. With POSSUM, 119 cases had complications with the actual number of 84.With mortality DORSSSP got the result of 9 cases, while P-POSSUM 10 cases and APACHEⅡ12 cases, the actual number was 6.
3. Operation damage control was taken for those in both high-risk and ex-high-risk group with DORSSSP. On these patients’first day of admission, physiology score (PS) was from 12 to 42 with average of 21.4±6.7 and operation risk score (OS) was from 12 to 24 with average of 15.2±4.5. The preoperative PS was from 12 to 30 with average of 18.3±6.2,while OS was from 5 to 18 with average of 9.1±3.4. The complication incidence was 46% with mortality rate of 11% according to the prediction based on PS and OS and operation schedule. After operation damage control, the predicted rate of complication cases was 34% with mortality of 5%. With the preoperative prediction using POSSUM and P-POSSUM, the complication rate and mortality rate was 39%, 6%respectively. For APACHEⅡthe predicted mortality rate was 8% while the actual complication rate was 32% and mortality rate 3%.
4. One patient appeared complication in group A, three patients presented complications and one patient died in group B. The peripheral blood GR protein expression of senile patients decreased to different extent. In group A, GR protein was decreased and reached the the lowest point on the first day after surgery .Though GR expression increased later, it was significantly lower than the preoperative level(p<0.01)until the 7th day, Restore normal till 14th day.In group B, GR protein was also decreased and reached the lowest point on the first day, lower than the preoperative level until the 14th day. There was significant difference between the two groups(p<0.01), which meant the prolonged low level expression of GR protein was statistically associated with DORSSSP. For the diversification of T lymphocyte subpopulation, CD3 and CD4 levels of two groups got significantly lower than the preoperative ones (P<0.05) on the 1st ,3rd and 5th day with the level of the first day lowest. CD3 and CD4 levels increased on the 5th day. For group A, CD3 and CD4 expression returned to their normal level on the 7th day while group B stayed at a relatively low level. CD8 level from the 1st , 3rd and 5th day detection showed decrease in group A after surgery while it increased in group B. In conclusion, CD3 and CD4 expression decreased shortly after surgery and returned to their normal value on the 7th day from its lowest point on the 1st day. With DORSSSP score the higher, CD3 and CD4 expression decrease the more and return to their normal value the slower. 5. Results of IL-6, IL-10 and TNF-αdiversification in blood plasma of senile rat with multiple injuries: IL-6, IL-10 and TNF-αlevel sharply increased to their peak on the 1st day after trauma and was significantly different from the control group(P<0.001).The fall-off tendency of IL-6, IL-10 and TNF-αwas more significant in group C than in group B. On the 14th day, group C almostly got the normal level while group B stayed at a fairly high level which indicated a significant difference between them(P<0.05). Results of GR protein expression on leucocytes in senile rat: Peripheral blood decreased to different extent after surgery trauma. GR expression in group C decreased on the first day and reached the lowest point on the 5th day. The expression got higher later,but it was still lower than its preoperative level(p<0.01)until the 14th day. GR expression in group B reached the lowest point on the 7th day and didn’t return to its preoperative level till the 14th day(p<0.01). Low level expression of GR protein may be prolonged in relation to the trauma severity.
Conclusions:
1. Heart and pulmonary function above grade 2, malnutrition, hypertension, diabetes, mind abnormality, renal inadequacy, electrolyte disturbance, big operation trauma, mass hemorrhage during operation and excessive operation time are main causes of poor postoperative prognostications for senile patients. Using PS and OS to evaluate the possible danger and positively adjusting their physiological functions state or altering operation modus are important measures to avoid postoperative complications and mortalities.
2. DORSSSP can work as an important preoperative risk assessment tool for senile patients and our software based on it can run stably on windows operating system. It is convenient and fast in clinical and can well predict postoperative complication and mortality rate in our clinical retrospective study. It is easier to obtain, simpler to calculate with less indexes and can predict more accurately than APCHEⅡa nd POSSUM scoring system.
3. Operation damage control was taken to those senile patients with high relatively surgery risk score under DORSSSP evaluation and this can significantly reduce incidence of postoperative complications and mortalities.DORSSSP showes good consistency with POSSUM, P-POSSUM and APACHEⅡscoring system. Though there was prediction error in these three operation risk scoring systems, the system could get better with the renewal of surgery knowledge.
4. Changes of GR protein expression on peripheral blood leucocytes and T lymphocyte subpopulation diversifications have conspicuous correlations with the operation risk scoring and perioperative stress of senile patients. For those senile patients with high preoperative score, GR protein expression stays at a persistent low level while the low level expression time of CD3 and CD4 is even longer. CD4/CD8 expression decreases quite significantly and the probability of postoperative complication remarkably increases. Through DORSSSP plus GR protein expression on peripheral blood leucocytes and T lymphocyte subpopulation diversifications, we can better predict the incidence rate of postoperative complications and mortalities and use this as a clinical therapy guide for senile patients with high risks.
5. The practice of operation damage control could improve senile rats’physiological function state. Simple, micro-invasive and fast measures to stabilize bone fracture,early effective liquid transfusion resuscitation and less hemorrhage in the operation can improve GR protein expression on peripheral blood leucocytes , reduce the release of local inflammatory cytokines into blood and avoid the happening of waterfall effect. The postoperative complication and mortality rate of senile rats could get effectively decreased. In conclusion, operation damage control is validly effective for senile rats with multiple injuries and this can provide us favourable clinical evidence for senile patients with the same trauma in orthopaedics.
引文
1. Evers BM,Townsend CM Jr,Thompson JC.Organ physiology of aging[J].Surg Clin North Am.1994,74(1):23-39.
2. Leung JM, Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients [J].Am Geriatr Soc.2001, 49(8):1080-1085.
3.《老年人权益保障法》第2条.1996年8月29日第八届全国人民代表大会常务委员会第二十一次会议通过.
4. Mohamed K, Copeland GP.An assessment of the POSSUM system in orthopaedic surgery [J].J Bone Joint Surg Br. 2002, 84(5):735-739.
5. McLaughlin MA, Orosz GM, Magaziner J, et al.Preoperative status and risk of complications in patients with hip fracture [J].J Gen Intern Med.2006, 21(3):219-25.
6.王福权,骆燕禧,黄公怡,等.老年四肢骨折的内固定治疗(附438例报告) [J].中华骨科杂志.1991,11(4):242-245.
7. Copeland GP, Jones D, Walters M, et al.POSSUM: a scoring system for surgical audit [J].Br J Surg. 1991, 78(3):355-360.
8. Jin F, Chung, F.Minimizing perioperative adverse events in the elderly [J]. Br J Anaesth. 2001, 87(4):608-24.
9.丕焕,编.医用统计方法[M].第1版,上海:上海医科大学出版社.1993,370-387.
10. Le Gall JR.Modeling the severity of ICU patients:a system update[J].JAMA. 1994, 273(13):1049-1055.
11.朱维铭.手术前重要器官功能评估与手术危险性预测[J].中国实用外科杂志.2005,25(1):17-19.
12. Goldman L, Caldera D L, Nussbaum S R, et al.Multifactorial index of cardiac risk in noncardiac surgical procedures [J]. N Engl Med. 1977, 297(16):845-50.
13. Torrington KG, Henderson CJ.Perioperative respiratory therapy (PORT).A program of preoperative risk assessment and individualized postoperative care [J].Chest.1988, 93(5): 946-951.
14. Elie M, Rousseau F, Cole M, et al. Prevalence and detection of delirium in elderlyemergency department patients[J]. CMAJ.2000, 163(8):977-981.
15. Martin S Bitsch, Nicolai B Foss, Billy B Kristensen,et al.Pathogenesis of and management strategies for postoperative delirium after hip fracture [J].Acta Orthop Scand. 2004, 75(4):378-389.
16. Gerson MC, Hurst JM, Hertzberg VS, et al. Prediction of cardiac and pulmonary complications related to elective abdominal and noncardiac thoracic surgery in geriatric patients [J].Am J Med. 1990, 88(2):101-107.
17. Mustafa Aldemir, Sakir Ozen, Ismail H Kara, e t al. Predisposing factors for delirium in the surgical intensive care unit [J].Critical Care.2001, 5(5): 265-270.
18. Buckwalter KC, Fan RN, Buckwalter JA .Seeing older perioperative patients in 32-D: when your patient is demented, delirium, or depressed [J].J Operative Techniques in Orthopaedics. 2002, 12(2):64-71.
19. FormigaF, Chivite D, Mascaro J, et al. No correlation between mini-nutritional assessment (short form) scale and clinical outcomes in 73 elderly patients admitted for hip fracture [J]. Aging Clin Exp Res. 2005, 17(4): 343-346.
20. Ronnie A, Rosenthal, Stephen M Kavic.Assessment and management of the geriatric patient [J]. Crit Care Med. 2004, 32(4): 92-105.
21. Zimmet P, Mccarty D. The NIDDM epidemic: Global estimates and Projections-a look into the crystal ball [J]. IDF Bulletin.1995, 40:8-16.
22.吕厚山,周殿阁,袁燕林.糖尿病患者的人工膝关节置换[J].中华外科杂志. 1997, 5(8): 462-464.
23. Guyton JL.Fractures of hip, acetabulum and pelvis [M].Cnanle ST.Campbell’s operative orthopaedics, 9th ed.Mosby, St. Louis. 1998, 2181-2183.
24. Lyons AR. Clinical outcomes and treatment of hip fractures [J].Am J Med. 1997 103(2):51-63.
25. Bredahl C, Nyholm B, Hindsholm KB, Mortensen JS, Olesen AS. Mortality after hip fracture: results of operation within 12h of admission [J].Injury. 1992, 23(2):83-86.
26. Davis FM, Woolner DF, Frampton C, et al. Prospective, multi-center trial of mortality following general or spinal anaesthesia for hip fracture in the elderly [J].Br J Anaesth.1987, 59(3):1080-1088.
27. Forster MC, Calthorpe D. Mortality following surgery for proximal femoral fractures incentenarians [J].Injury, 2000, 31(7):537-539.
28. Fox HJ, Pooler J, Prothero D, Bannister GC.Factors affecting the outcome after proximal femoral fractures [J].Injury.1994, 25(5):297-300.
29. Hamlet WP, Lieberman JR, Freedman EL, e t al.Influence of health status and the timing of surgery on mortality in hip fracture patients [J].Am J Orthop.1997, 26(9):621-627.
30. Hoerer D, Volpin G, Stein H .Results of early and delayed surgical fixation of hip fractures in the elderly: a comparative retrospective study.Bull Hosp Jt Dis.1993, 53(1):29-33.
31. Todd CJ, Freeman CJ, Camilleri-Ferrante C, et al. Differences in mortality after fracture of hip: the East Anglian audit [J].BMJ.1995, 310(6894):904-908.
32. Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH.Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip [J].J Bone Joint Surg. 1995, 77(10):1551-1556.
33. Eiskjaer S, Ostgard SE. Risk factors influencing mortality after bipolar hemiarthroplasty in the treatment of fracture of the femoral neck [J].Clin Orthop Relat Res.1991, 270:295-300.
34. Hamilton BH, Hamilton VH, Mayo NE. What are the costs of queuing for hip fracture surgery in Canada [J]? J Health Econ.1996, 15(2):161-185.
35. Kenzora JE, McCarthy RE, Drennan Lowell J, et al.Hip fracture mortality.Relation to age, treatment, preoperative illness, time of surgery, and complications [J].Clin Orthop Relat Res.1984, 186:45-56.
36. Mullen JO, Mullen NL. Hip fracture mortality.A prospective, multifactorial study to predict and minimize death risk [J].Clin Orthop Relat Res.1992, 280:214-222.
1. Jain R, Basinski A, Kreder HJ.Nooperative treatment of hip fractures [J]. Int Orthop. 2003, 27(1):11-17.
2. Knaus WA, Wanger DP.APACHEⅡ: aseverity of classfication system [J].Crit Care Med.1985, 13(13):818-829.
3. Copeland GP, Jones D, Walters M, et al. POSSUM: a scoring system for surgical audit [J].Br J Surg. 1991, 78(3):355-360.
4. Evers BM, Townsend CM Jr, Thompson JC. Organ physiology of aging [J].Surg Clin North Am. 1994, 74(1):23-39.
5.罗朝盛,主编.Visual Basic 6.0程序设计实用教程(第2版)[M].清华大学出版社, 2008.
6. Le Gall JR, Lemeshow S, Saulnier F.A new Simplified Acute Physiology Score (SAPS II) based on a European-North American multicenter study [J].JAMA.1993, 270(24): 2957-2963.
7. Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system [J]. Crit Care Med. 1985, 13(10):818-829.
8. Shaw NJ, Dear PR. How do parents of babies interpret qualitative expression of probability [J]? Archives of Disease in childhood.1990, 65(5):520-523.
9. Gall JR, Loirat P, Alperovitch A, et al.A simplified acute physiology score for ICU patients [J].Crit Care Med. 1984, 12(11):975-977.
10. Sauaia A, Moore F A, Moore E E, et al. Early risk factors for postinjury multiple organ failure [J].World J Surg. 1996, 20(4):392-400.
11. Jones DR, Copeland GP, d e Cossart L. Comparison of POSSUM with APACHE II for prediction of outcome from a surgical high-dependency unit [J].Br J Surg. 1992, 9(12):1293-1296.
12. Whiteley MS, Prytherch DR, Higgins B, et al.An evaluation of the POSSUM surgical scoring system [J]. Br J Surg. 1996, 83(7):812-815.
13. Ramkumar T, Ng V, Fowler L, et al.A comparison of POSSUM, P-POSSUM and colorectal POSSUM for the prediction of postoperative mortality in patients undergoing colorectal resection [J]. Dis Colon Rectum. 2006, 49(3): 330-335.
14. Kuhan G, Abidia A F, Wijesinghe L D, et al. POSSUM and P-POSSUM overpredict mortality for carotid endarterectomy [J]. Eur J Vasc Endovasc Surg. 2002, 23(3): 209-211.
15. Treharne G D, Thompson M M, Whiteley M S, et al. Physiological comparison of open and endovascular aneurysm repair [J]. Br J Surg. 1999, 86(6):760-764.
16.尹志康,何梓铭,苟欣,等.生理学和手术侵袭度评分预测泌尿外科高龄患者术后并发症的价值[J].中华泌尿外科杂志. 2002, 23(1):43-45.
17.饶忠,黄谦,周红菊.改良POSSUM评分系统预测老年烧伤患者术后并发症的价值[J].广西医科大学学报. 2004, 21(1):94-95.
18. Mohamed K, Copeland GP.An assessment of the POSSUM system in orthopaedic surgery [J]. J Bone Joint Surg. 2002, 84 (5):735-739.
19.张博皓.改良生理学和手术严重度评分系统(POSSUM)预测髋部骨折手术并发症发生率及死亡率的价值[M].吉林大学硕士学位论文.2004.
20.张德宝. POSSUM和P-POSSUM评分系统预测髋关节置换术后死亡率和并发症率的价值[M].吉林大学硕士学位论文.2005.
21. Goldman L, Caldera DL, Nussbaum SR, et al.Multifactorial index of cardiac risk in noncardiac surgical procedures [J].N Engl J Med.1997, 297(16):845-850.
22. Hung, Patrick D, Sterling, Richard K. Predicting Outcome of Critically Ill Patients With Cirrhosis Admitted to the Intensive Care Unit: Who's Keeping Score [J]? Journal of Clinical Gastroenterology.2003, 37(3):203-205.
23.王玮,沈惠良,曹光磊,等. 65岁以上老年骨科患者手术风险因素评估[J].中国矫形外科杂志. 2006, 14(6):425-427.
24.郑永克,戴新建,郑纪阳,等.残气肺总量比对老年矽肺患者肺功能损伤分级合理性的初步探讨[J].温州医学院学报. 2006, 36(4):372-374.
25.兰秀夫,王爱民,孙红振,等.骨科手术风险评分在我院老年髋部骨折患者中的初步应用研究[J].创伤外科杂志. 2008, 10(2):124-127.
26.兰秀夫,王爱民,孙红振,等. 760例骨科老年病人手术风险因素分析[J].重庆医学. 2008, 37(5): 493-495.
27.金丕焕,主编.医用统计学方法[M].第1版,上海:上海科技大学出版社.1993, 370-387
28. Lemeshow S, Le Gall JR.Modeling the severity of illness of ICU patients. A systems update [J]. JAMA.1994 5, 272(13):1049-1055.
1. Emily VA,Finlayson MD.Operative Mortality with Elective Surgery in Older Adults[J].Eff Clin Pract.2001, 4(4):172-177.
2. Rixen Dieter, Grass Guido, Sauerland Stefan, e t al. Evaluation of Criteria for Temporary External Fixation in Risk-Adapted Damage Control Orthopedic Surgery of Femur Shaft Fractures in Multiple Trauma patients:“Evidence-Based Medicine”versus“Reality”in the Trauma Registry of the German Trauma Society [J]. The Journal of Trauma.2005, 59(6):1375-1395.
3. Frank Hildebrand, Peter Giannoudisb, Cristian Krettek, et al. Damage control: extremities [J]. Injury.2004, 35(4):678-689.
4. Pape HC, Giannoudis P, Krettek C.The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery [J]. Am J Surg 2002, 183(6): 622-629.
5.高辉,刘午阳,赖光松,等. 70岁以上股骨颈骨折患者全髋置换围手术期风险因素分析[J].中国老年学杂志. 2007, 4(27):365-366.
6.罗永忠,李佩佳,赵汉平,等.人工关节置换治疗高龄股骨粗隆间骨折[J].中国矫形外科杂志. 2005, 13(20):1542-1544.
7. Mary Ann McLaughlin, Gretchen M Orosz,Jay Magaziner,et al.Preoperative Status and Risk of Complications in Patients with Hip Fracture [J]. J Gen intern Med.2006, 21(3):219-225.
8. Lawrence VA, Hilsenbeck SG, Noveck H, et al. Medical complications and outcomes after hip fracture repair[J]. Arch Intern Med. 2002, 162(18):2053-2057.
9. Mark C, Denis C.Mortality following surgery for proximal femoral fractures in centenarians [J].Injury. 2000, 31(7): 537-539.
10. Brandt SE, Lefever S, Janzing HMJ, et al. Percutaneous compression plating (PCCP) versus the dynamic hip screw for pertrochanteric hip fractures: preliminary results [J]. Injury. 2002, 33(1):413-418.
11.王福权,骆燕禧,黄公怡,等.老年四肢骨折的内固定治疗(附438例报告) [J].中华骨科杂志. 1991, 11(4):242-245.
12. Mohamed K, Copeland GP.An assessment of the POSSUM system in orthopaedic surgery[J].J Bone Joint Surg. 2002, 84(5):735-739.
13. Copeland GP, Jones D, Walters M, et al. POSSUM: a scoring system for surgical audit [J].Br J Surg.1991, 78(3):355-360.
14. 14.M McLaughlin, Gretchen M, Orosz, MD et al. Preoperative Status and Risk of Complications in Patients with Hip Fracture [J]. J Gen Intern Med. 2006, 21(3):219-225.
15.钱礼.手术风险性与得益率的评估[J].中国实用外科杂志.1999,19(3):181.
1. Urban M K, Jules Elysee K M, Beckman J B, et al. Pulmonary injury in patients undergoing complex spine surgery [J].J Spine. 2005, 5(3): 269-76.
2.王军平,赵景宏,粟永萍.糖皮质激素受体调控与创伤应激紊乱关系的研究进展[J].中华创伤杂志. 2001, 17(8):508-510.
3.秦荣,周艳红,刘都户,等.大鼠严重烫伤早期应激反应中肝脏糖皮质激素受体变化的实验研究[J].第三军医大学学报.2002, 24(8):895-897.
4. Meaney M J, Diorio J, Francis D, et al. Early environmental regulation of forebrain glucocorticoid receptor gene expression: implications for adrenocortical responses to stress [J]. Dev Neurosci.1996, 18(1-2):49-60.
5. Perreau V, Sarrieau A, M ormede P. Characterization of mineralocorticoid and glucocorticoid receptors in pigs: comparison of Meishan and Large White breeds [J].Life Sci.1999, 64(17):1501-1515.
6.李大培,王浩丹,赵奇煌.严重脑外伤患者外周血淋巴细胞糖皮质激素受体的研究[J].山东医科大学学报. 1994, 32(2):114 -117.
7. Bledsoe R k, Montana VG, Stanley TB.Crystal structure of the glucocorticoid receptor ligand binding domain reveals a novel mode of receptor dimerization and coactivator recognition [J]. Cell.2002, 110(1): 93-105.
8.徐仁宝.休克时糖皮质激素受体的变化及大剂量糖皮质激素抗休克治疗的受体机制[J].基础医学与临床.1998,18(1):5-10.
9. Auphan N, DiDonato J A, Rosette C, et al. Immunosuppression by glucocorticoids: inhibition of NF-kappa B activity through induction of I kappa B synthesis [J].Science. 1995, 270(5234):286-290
10. Johnson JW, Beck JC, Haberkern CM.Glucocorticoids and the respiratory distress syndrome [J].Obstet Gynecol Annu.1984,13:99-129.
11.王庆松,王正国,朱佩芳.大鼠创伤后应激障碍模型的建立及其海马糖皮质激素受体的变化[J].第三军医大学学报. 2002, 24(8):895-897.
12. WANG QS, WANG ZG, ZHU PF. Establishment of PTSD model in rats and expression of glucocorticoid receptor in the hippocampi [J].Acta Academiae Medicinae Militaris Tertiae.2002, 24(8):895- 897.
13.李思齐,白祥军,王海平,等.多发伤患者外周血白细胞糖皮质激素受体α、β的表达及其意义[J].中华创伤杂志. 2005, 21(10):729-732.
1. Leung JM, Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients [J].Am Geriatr Soc.2001, 49(8):1080-1085.
2. Zedler S, Bone RC, Baue AE, et al.T-cell reactivity and its predictive role in immunosuppression after burns [J]. Crit Care Med. 1999, 27(1):66-72.
3. Pellegrini JD, De AK, Kodys K, e t al.Relationships between T lymphocyte apoptosis and anergy following trauma [J]. J Surg Res. 2000, 88(2):200-206.
4. Menges T, Engel J, Welters I, et al. Changes in blood lymphocyte populationns after multiple-trauma: association with posttraumatic complications [J]. Crit Care Med. 1999, 27(4):733-740.
5. Walsh DS, Siritongtaworn P, Pattanapanyasat K, et al. Lymphocyte activation after non-thermal trauma [J]. Br J Surg. 2000, 87(2):223-230.
6. Deveci M, SengezerM, Bozkurt M, et al.Comparison of lymphocyte populations in cutaneous and electrical burn patients [J].Clinical study. 2000, 26(3):229-232.
7. Dalton H J.T-cell responses in burn infection [J].Crit Care Med. 2001, 29(12):2386-2387.
8. Hashimoto T, Hashimoto S, Hori Y, et al. Epidural anaesthesia blocks in perpheral lymphocytes subpopulation during gastrectomy for stomach cancer [J].Acta Anaesthesiol Scand.1995, 39(3):294-198.
9.孟海东,赵晓东,陈晓光,等.老年人严重创伤后免疫抑制的研究[J].第三军医大学学报. 2005, 7(27):1509-1511.
10.林飞卿,余传霖,何球藻,主编.医学基础免疫学[M].上海:上海医科大学出版社.1992, 45-47.
11.黄锡全,刘恭植.衰老与免疫.内科免疫学[M].第1版.武汉:湖北科学技术出版社.1998, 22-25.
12.单颖,姜东,李淑云,等.老年人T细胞亚群的Meta分析[J].中国老年学杂志. 2007,19:1905-1907。
13. Axel Franke, Wolfgang Lante, Edmond Kurig, et al. Hyporesponsiveness of T cell subsets after cardiac surgery: a product of altered cell function or merely a result of absolute cellcount changes in peripheral blood [J]? Eur J Cardiothorac Surg. 2006, 30:64-71.
14.李艳芳,杨清,郭永和,等.不同心功能患者T淋巴细胞亚群的变化[J].中华老年心脑血管病杂志. 2006, 8(2):76-78.
1. Goris RJ, Gimbrere JSF, Niekerk JLM, et al.Early asteosynthesis and prophylactic mechanical ventilation in the multitrauma patient [J].JTrauma. 1982, 22(11):895-903.
2. Seibel R, LaDuca J, Hassett JM, et al. Blunt multiple trauma (ISS36), femur traction, and the pulmonary failure-septic state [J].Am Surg. 1985, 202(3):283-295.
3. Bone LB, Johnson KD, Weigelt J, Scheinberg R.Early versus delayed stabilisation of fractures: a prospective randomized study [J].J Bone Joint Surg Am. 1989, 71(3): 336-340.
4. Rotondo MF, Schwab CW, Mcgonigal MD, et al. Damage control: an approach for improved survival in exsanguinating penetrating abdominal injury [J].J Trauma.1993, 35(3):375-382.
5.王伟雄,冯骏,刘坚义,等.不同年龄段严重创伤患者特点与救治[J].中华急诊医学杂志. 2006, 15(12):1075-1078.
6.盛志勇.多发伤.黎鳌主编.现代创伤学[M].北京:人民卫生出版社.1996, 834-837.
7. Roberts CS, Pape HC, Jones AL,et al. Damage control orthopaedics:evolving concepts in the treatment of patients who have sustained orthopaedic trauma [J].Instr Course Lect. 2005, 54:447-462.
8. Hildebrand F, Giannoudis P, Kretteck C, et al. Damage control:extremities[J]. Injury. 2004, 35(7):678-789.
9.王爱民,蒋耀光.以骨关节损伤为主的严重多发性损伤的救治[J].创伤外科杂志. 2006, 8(4):382-385.
10. Menges T, Gngel J, Welters I, et al. Changes in blood lymphocyte populations after multiple-trauma: association with postt-raumatic complications [J]. Crit Care Med. 1999, 27(4):733-740.
11. YaoY M, Redl H, Bahrami S, et al.The inflammatory basis of trauma.shoch-associated multiple-organ failure [J]. Inflamm Res.1998, 47(5):201-210.
12. Majetschak M, Borgerman J, Waydhas E, et al. Whole blood tumor necrosis factor-alpha production and its systemic concen-trations of interleukin-4, interleukin-10, and transforming growth factor-beta in multiple injured blunt trauma victims [J].Crit CareMed. 2000, 28(6):1847-1853.
13. Shimonkevitz R, BarOr D, Harris L, et al. Granulocytes, including neutrophils, synthesize IL-10after traumatic pancreatitis: case report [J].J Trauma. 2000, 48(1):165-168.
14. Taniguchi I, Koido Y, Aiboshi J, et al.The ratio of interleukin-6 to interleukin-10 correlates with severity in patients with chest and abdominal trauma [J].Am J Emerg Med. 1999, 179(6):548-551.
15. Roumen RM, Redl H, Schlag G, et al.Inflammatory mediators in relation to the development of multiple organ failure in pa-tients after severe blunt trauma [J]. Crit Care Med. 1995, 23(3):474-480.
16. Gebhard F, Pfetsch H, Steinbach G, et al. Is interleukin-6 an early marker of injury severity following major trauma in human [J]. Arch Surg. 2000, 135(3):291-295.
17. DeBosscher K, Vanden Berghe W, Haegeman G. Mechanisms of anti-inflammatory action and of immunosuppression by glucocorticoids: negative interference of activated glucocorticoid receptor with transcription factors [J].J Neuroimmunol.2000, 109(1):16-22.
18.张芳,钱桂生,钱频,等.大鼠糖皮质激素受体变异体cDNA序列克隆和表达及功能研究[J].西北国防医学杂志.2005,26(1):1-3.
1. Evers BM,Townsend CM Jr,Thompson JC Organ physiology of aging[J].Surg Clin North Am,1994,74(1):23-39.
2. Schein M, Assalia A, Bachus H. Minimal antibiotic therapy aftet emergency abdominal surgery: a prospctive study [J].Br J Surg 1994, 81(7):989-991.
3.杨开锦,高堂成,王力群.高龄患者股骨粗隆间骨折的围手术期处理[J].第四军医大学学报. 2006, 27 (6): 515-517.
4. Jones HJS, de Cossart L. Risk scoring in surgical patients [J].Br J Surg, 1999, 86:149-157.
5. Ohnen JM, M ustard RA, Oxho lm SE, et al. APACHE score and abdominal sepsis: aprospective study [J]. Br Arch Surg.1988, 123:225-229.
6. BruneliA, Fianchini A, Gesuita R, et al.POSSUM scoring system as an instrument of audit in lung resection surgery [J]. Ann Thorac Surg.1999, 67: 329-331.
7. Knaus WA, Draper EA, W agner DP, et al. APACHEⅡ: a severity of disease classification system [J].Crit Care Med.1985, 13(10):818-829.
8. Committee on Medical A spects of Auto motive Safety .Rating the severity of tissue damage.The abbreviated scale. JAMA, 1971, 215:277-280.
9. Osler T,Baker SP,Susan P,et al.Amodification of the injury severity score that bothim prove saccuracy and scoring. JTrauma, 1997, 43:922-925.
10.孙俊,江学成.急诊室创伤患者创伤评分与并发症和救治的关系[J].中国危重病急救医学. 2006, 18(1):36-38.
11. Malone DL, Kuhls D, N apolitano LM, e t al.Back to basics: validation of the admission systemic inflammatory response syndrome score in predicting outcome in trauma [J].J Trauma.2001, 51(3):458- 463.
12. Copeland GP, Jones D, Walters M, et al. POSSUM:a scoring system for surgical audit [J] .Br J Surg.1991,78(3):355-360.
13. Copeland GP, Jones D. Comparative vascular audit using the POSSUM scoring system [J].Ann R Coll Surg Engl.1993, 75:175-177.
14. Copeland GP, Sagar P , B rennan J, et al. Risk-adjusted analysis of surgeon performance: a 1 year study [J].Br J Surg. 1995, 82(3): 408-411.
15. Brosens R P, Oomen J L, Glas A S, et al. POSSUM predicts decreased overall survival in curative resection for colorectal cancer [J].Dis Colon Rectum.2006, 49(6): 825-832.
16. Gotohda N, Iwagaki H, Itano S, e t al.Can POSSUM, a scoring system for perioperative surgical risk, predict postoperative clinical course [J]? Acta Med Okayama.1998, 52(6): 325-329.
17. Yii M K, Ng K J.Risk-adjusted surgical audit with the POSSUM scoring system in a developing country: Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity [J]. Br J Surg. 2002, 89(1):110-113.
18. Sommer F, Ehsan A, Klotz T, et al.Comparison of individual urologists' performance [J]. Eur Urol. 2001, 39(4): 369-374.
19. Ramkumar T, Ng V, Fowler L, et al.A comparison of POSSUM, P-POSSUM and colorectal POSSUM for the prediction of postoperative mortality in patients undergoing colorectal resection [J]. Dis Colon Rectum. 2006, 49(3): 330-335.
20. Whiteley M S; Prytherch D R; Higgins B, et al.An evaluation of the POSSUM surgical scoring system [J]. Br J Surg. 1996, 83(6): 812-815
21. Kuhan G, Abidia A F, Wijesinghe L D, e t al. POSSUM and P-POSSUM overpredict mortality for carotid endarterectomy [J]. Eur J Vasc Endovasc Surg. 2002, 23(3): 209-211.
22. Treharne G D, Thompson M M, Whiteley M S, et al. Physiological comparison of open and endovascular aneurysm repair [J]. Br J Surg.1999, 86(6): 760-764.
23.尹志康,何梓铭,苟欣,等.生理学和手术侵袭度评分预测泌尿外科高龄患者术后并发症的价值[J].中华泌尿外科杂志.2002, 23:43-45.
24.饶忠,黄谦,周红菊.改良POSSUM评分系统预测老年烧伤患者术后并发症的价值[J].广西医科大学学报.2004, 21:94-95.
25.张博皓.改良生理学和手术严重度评分系统(POSSUM)预测髋部骨折手术并发症发生率及死亡率的价值[M].吉林大学硕士学位论文,2004.
26. Ramanathan T S, Moppett I K, Wenn R, et al. POSSUM scoring for patients with fractured neck of femur [J].Br J Anaesth. 2005, 94 (4): 430-431.
27. Tekkis P P, Kocher H M, Bentley A E, et al.Operation mortality rates among surgeons: comparison of POSSUM and p-POSSUM scoring systems in gastrointestinal surgery [J]. Dis colon Rectum.2000, 43:1528-1534.
28. Midwinter MJ, Tytherleigh M, Ashley S. Estimation of mortality and morbidity risk in vascular surgery using POSSUM and Portsmouth predictor equation[J].Br J Surg.1999, 86:471-474.
29. Hosmer DW Ir, Lemeshow S.A goodness of fit test for the mutipleogistic regreesionmodels [J]. Community Statistics.1980, 10:1043-1069.
30. Hosmer DWIr, Lemeshow S. Applied Logistic Regression [J]. NEW YORK: wiley 1989.
31. Hemant M Kocher, Paris P Tekkis, Palepu Gopal, Ameet G. Risk-adjustment in hepatobiliarypancreatic surgery [J].World J Gastroenterol. 2005, 11(16):2450-2455.
32. Gocmen E, Koc M,Tez M,et al.Evaluation of P-POSSUM and O-POSSUM scores in patients with gastric cancer undergoing resection[J].Hepatogastroenterology. 2004, 51(60):1864-1866.
33. Tekkis PP, McCulloch P, Poloniecki JD, et al. Risk-adjusted prediction of operative mortality in oesophagogastric surgery with O-POSSUM [J].Br J Surg. 2004, 91(3): 288-295.
34. Mohil RS, Bhatnagar D, Bahadur L, et al. POSSUM and P-POSSUM for risk-adjusted audit of patients undergoing emergency laparotomy[J].Br J Surg. 2004, 91(4):500-503.
35. Prytherch D R, Sutton G L, Boyle J R.Portsmouth POSSUM models for abdominal aortic aneurysm surgery [J]. Br J Surg. 2001, 88(7):958-63.
36. Harris J R, Forbes T L, Steiner S H, et al. Risk-adjusted analysis of early mortality after ruptured abdominal aortic aneurysm repair [J]. J Vasc Surg. 2005, 42(3):387-91.
37. van der Sluis CK, Timmer HW, Eisma WH, e t al. Outcome in elderly injured patients: injury severity versus host factors [J]. Injury. 1997, 28(9-10):588-92.
38. Mohamed K, Copeland G P. An assessment of the POSSUM system in orthopaedics surgery [J].J Bone Joint Surg. 2002, 84(5):735-739.
39. McLaughlin MA, Orosz GM, Magaziner J, et al.Preoperative status and risk of complications in patients with hip fracture [J].J Gen Intern Med.2006, 21(3):219-25.
40. M J Brooks, R Sutton and S Sarin.Comparison of Surgical Risk Score, POSSUM and p-POSSUM in higher-risk surgical patients [J]. British Journal of Surgery.2005, 92: 1288-1292.
41. Gu GS, Zhang DB, Zhang BH, et al.Evaluation of P-POSSUM scoring system in predicting mortality in patients with hip joint arthroplasty[J].Chin J Traumatol.2006, 9(1): 50-55.
42. Young W,Seigne R,Bright S,et al.Audit of morbidity and mortality following neck of femur fracture using the POSSUM scoring system [J]. NZ Med J. 2006, 119(1234): U1986.
1. Rotondo MZ, Schwab CW, McGonigal MD, et al.“Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury [J]. J Trauma. 1993, 35(3):375-382.
2. Sagravaes SG, Toschlog EA, Rotondo MF. Damage control surgery the intensivist`s role [J].J Intensive Care Med. 2006, 21(1):5-16.
3. Henry SM, Tornetta P 3nd,Scalea T M. Damage control for devastating pelvic and extremity injuries [J] . Surg Clin North.1997, 77(4):879-895.
4. Marius K, Ludwing L, Otmar T.“Damage Control”in Severely Injured Patients [J]. J European Journal of Tauma.2005, 3:212-221.
5. Giannoudis PV. Surgical priorities in damage control in polytrauma [J]. J Bone Joint Surg . 2003, 85(4): 478-483.
6. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy [J].Ann Surg. 1983, 197(5):532-535.
7.陈国庭,刘中民.损伤控制外科的理论与实践外科理论与实践[J].2005, 10(2):197-198.
8.赵晓刚.极端状态创伤病人实施损伤控制外科策略的哲学思考[J].医学与哲学.2002,23(11):54-55.
9. Pape H C, Giannoudis P, Krettek C.The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery [J]. J Surg. 2002, 183(6): 622-629.
10.刘中民.普及损伤控制外科技术,提高严重创伤救治水平[J].中华急诊医学杂志. 2004, 13(4):221-222.
11.李喆,华积德.损伤控制外科理念在严重创伤和多发伤救治中的应用[J].中华创伤杂志. 2006,22(5):321-323.
12. Mikhail J.The trauma triad of death: hypothermia, acidosis, and coagulopathy [J].ACCN Clin Issues. 1999, 10(1):85-94.
13. John B. Holcomb, Don Jenkins, Peter Rhee. Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma [J].J Trauma.2007, 62:307-310.
14. Karen J, Brasel, John A, Weigelt. Damage control in trauma surgery[J].Current Opinion inCritical Care.2000, 6:276-280.
15. Hamill J. Damage control surgery in children [J]. injury.2004, 35(3): 708-712.
16.王爱民,陈辉,孙红振等.骨关节型严重多发伤的损害控制治疗[J].中华创伤杂志.2007,23(2):143-146.
17.赵小纲,江观玉.多发伤救治的损伤控制策略[J].中华创伤杂志.2006, 22(5):334-336.
18. Friedl HP, Ttentz O. Multiple trauma: definition, shock, multiple organ failure [J]. Unfallchirurgie.1992, 18(2):64-68.
19. Border JR: Death from severe trauma: Open fractures to multiple organ dysfunction syndrome [J]. J Trauma. 1995, 39(1):12-22.
20.王爱民,蒋耀光.以骨关节损伤为主的严重多发性损伤的救治[J].创伤外科杂志,2006,8(4):382-385.
21. Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries[J]. Injury. 2004, 35(7):671-677.
22.杨俊,高劲谋,赵山弘.严重多发伤时损伤控制骨科应用4l例[J].中华创伤杂志. 2006, 22(5):331-333.
23. Krishna G, Sleigh JW, Rahman H. Physiological predictors of death in exsanguinating [J]. Aust N Z J Surg. 1998,68(12):826-829.
24. Asensio JA, Petrone P, Roldan G, et al. Has evolution in awareness of guidelines for institution of damage control improved outcome in the management of posttraumatic open abdomen [J]? Arch Surg, 2004, 139(2):209-214.
25. Sharp KW, Locicero RJ.Abdominal packing for surgically uncontrollable haemorrhage [J]. Ann Surg. 1992, 215(5): 467-474.
26. Carrillo C, Fogler RJ, Shaftan GW.Delayed gastrointestinal reconstruction following massive abdominal trauma [J].J Trauma. 1993, 34(2): 233-235.
27. Rotondo MF, Zonies DH.The damage control sequence and underlying logic [J]. Surg Clin North Am. 1997, 77(4): 761-777.
28. Shapiro MB, Jenkins DH, Schwab CW, et al. Damage control: collective review [J].J Trauma. 2000, 49(5):969-978.
29. Pape HC, Giannoudis PV, Krettek C, et al. Timing of fixation of major fractures in blunt polytrauma– the role of conventional indicators in clinical decision making [J].J Orthop Trauma. 2005, 19(8): 551-562.
30.王一堂.积极开展损伤控制性手术[J].中国急救医学. 2004, 24(1):46.
31. Asensio JA, Petrone P, Roldan G,et al. Has evolution in awareness of guidelines for institution of damage control improved outcome in the management of posttraumatic open abdomen [J]? Arch Surg. 2004, 139(2):209-214.
32. Pape HC, Hildebrand F, Pertschy S, et al. Changes in the management of femoral shaft fractres in polytrauma patients: from early total care to damage control orthopedic surgery [J].J Trauma. 2002, 53(3):452-462.
33. Rixen Dieter,Grass Guido,Sauerland Stefan,et al. Evaluation of Criteria for Temporary External Fixation in Risk-Adapted Damage.Control Orthopedic Surgery of Femur Shaft Fractures in Multiple Trauma Patients:"Evidence-Based Medicine" versus "Reality" in the Trauma Registry of the German [J]. J Trauma. 2005, 59(6):1375-1395.
34. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics [J]. J Trauma. 2000, 48(4):613-623.
35. Oztuna V, Ersoz G, Ayan I, et al.Early Internal Fracture Fixation PreventsBacterial Translocation [J]. Clin Orthop Relat Res. 2006, 446: 253-258.
36. Jurkovich GJ, Greiser WB, Luterman A, Curreri P W. Hypothermia in trauma victims: an ominous predictor of survival [J].J Trauma.1987, 27:1019-1024.
37. Johnson JW, Gracias VH, Schwab CW, et al. Evolution in damage control for exsanguinating penetrating abdominal injury [J].J Trauma. 2001, 51(2):261-271.
38. Pape H C, Giannoudis P, Krettek C.The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery [J]. J Surg. 2002, 183(6): 622-629.
39. Zacharias SR, Offner P, Moore EE, et al.Damage control surgery [J].AACN Clin Issues. 1999, 10(1): 95-103.
40. Roberts CS, Pape HC, Jones AL. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma [J]. Instr Course Lect. 2005, 54:447-62.
41. Taeger Georg, Ruchholtz Steffen, Waydhas Christian.Damage Control Orthopedics in Patients With Multiple Injuries Is Effective, Time Saving, and Safe [J].Journal of Trauma-Injury Infection & Critical Care. 2005, 59(2):408-415.
42. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures:damage control orthopaedics[J].J Trauma.2000, 48(4):613-623.
43. Harwood PJ, Giannoudis PV, Probst C, et al.The risk of local infective complications after damage control procedures for femoral shaft fracture [J] J Orthop Trauma. 2006, 20(3):181-189.
44. Pape HC, Regel G, Dwenger A, et al.Influences of different methods of intramedullary femoral nailing on lung function in patients with multiple trauma [J].J Trauma. 1993, 35(5):709-716.
45. Pape HC, Dwenger A, Grotz M, et al. Does the reamer type influence the degree of lung dysfunction after femoral nailing following severe trauma [J]?An animal study.J Orthop Trauma. 1994, 8(4):300-309.
46. Pape HC, Dwenger A, Regel G, et al. Pulmonary damage after intramedullary femoral nailing in traumatized sheep—is there an effect from different nailing methods [J]? J Trauma, 1992, 33(4):574-581.
47. McBride WT, Armstrong MA, McBride SJ.Immunomodulation: an important concept in modern anaesthesia [J]. Anaesthesia. 1996, 51(5): 465-73.
48. Norman JG, Fink GW.The effects of eidural anesthesia on the neuroendocrine response to major surgical stress.A randomized prospective trial [J].Am Surg.1997, 63(1):75-80.
49. Sato A, Kuwabara Y, Sugiura M et al.Intestinal energy metabolism during ischemia and reperfusion [J]. J Surg Res.1999, 82(2):261-267.
50. KoikeK, YamamotoY.Splanchnic hypoperfusion and distant organ injury [J]. Nippon Geka Gakkai Zasshi.1999, 100(5):357-360.
51. Meek RN. The John Border memorial lecture:delaying emergency fracture surgery-fact or fad[J].J Orthopaedic Trauma. 2006, 20 (5):337-340.
52. Pape HC Immediate fracture fixation-which method? comments on the john border memorial lecture Ottawa 2005 [J].J Orthop Trauma. 2006, 20(5):341-50.
[1] Jain R, Basinski A, Kreder HJ. Nonoperative treatment of hip fractures [J]. Int Orthop. 2003, 27 (1):11-17.
[2] Knaus WA, Wanger DP. APACHE: aseverity of classfication system [J].Crit Care Med.1985, 13(13):818-829.
[3] Copeland GP, Jones D, Walters M, et al. POSSUM: a scoring system for surgical audit [J].Br J Surg. 1991, 78(3):355-360.
[4] Evers BM, Townsend CM Jr, Thompson JC. Organ physiology of aging.Surg Clin North Am.1994,74(1):23-39.
[5] Higgins TL, McGee WT, Steingrub JS, et al. Early indications of prolonged intensive care unit stay: Impact of illness severity, physician staffing, and pre-intensive care unit length of stay [J]. Crit Care Med. 2003, 31(1):45-51.
[6] Neary W D, Heather B P, Earnshaw J J. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) [J].Br J of Surg. 2003, 90:157-165.
2. Leung JM, Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients [J].Am Geriatr Soc.2001, 49(8):1080-1085.
3.《老年人权益保障法》第2条.1996年8月29日第八届全国人民代表大会常务委员会第二十一次会议通过.
4. Mohamed K, Copeland GP.An assessment of the POSSUM system in orthopaedic surgery [J].J Bone Joint Surg Br. 2002, 84(5):735-739.
5. McLaughlin MA, Orosz GM, Magaziner J, et al.Preoperative status and risk of complications in patients with hip fracture [J].J Gen Intern Med.2006, 21(3):219-25.
6.王福权,骆燕禧,黄公怡,等.老年四肢骨折的内固定治疗(附438例报告) [J].中华骨科杂志.1991,11(4):242-245.
7. Copeland GP, Jones D, Walters M, et al.POSSUM: a scoring system for surgical audit [J].Br J Surg. 1991, 78(3):355-360.
8. Jin F, Chung, F.Minimizing perioperative adverse events in the elderly [J]. Br J Anaesth. 2001, 87(4):608-24.
9.丕焕,编.医用统计方法[M].第1版,上海:上海医科大学出版社.1993,370-387.
10. Le Gall JR.Modeling the severity of ICU patients:a system update[J].JAMA. 1994, 273(13):1049-1055.
11.朱维铭.手术前重要器官功能评估与手术危险性预测[J].中国实用外科杂志.2005,25(1):17-19.
12. Goldman L, Caldera D L, Nussbaum S R, et al.Multifactorial index of cardiac risk in noncardiac surgical procedures [J]. N Engl Med. 1977, 297(16):845-50.
13. Torrington KG, Henderson CJ.Perioperative respiratory therapy (PORT).A program of preoperative risk assessment and individualized postoperative care [J].Chest.1988, 93(5): 946-951.
14. Elie M, Rousseau F, Cole M, et al. Prevalence and detection of delirium in elderlyemergency department patients[J]. CMAJ.2000, 163(8):977-981.
15. Martin S Bitsch, Nicolai B Foss, Billy B Kristensen,et al.Pathogenesis of and management strategies for postoperative delirium after hip fracture [J].Acta Orthop Scand. 2004, 75(4):378-389.
16. Gerson MC, Hurst JM, Hertzberg VS, et al. Prediction of cardiac and pulmonary complications related to elective abdominal and noncardiac thoracic surgery in geriatric patients [J].Am J Med. 1990, 88(2):101-107.
17. Mustafa Aldemir, Sakir Ozen, Ismail H Kara, e t al. Predisposing factors for delirium in the surgical intensive care unit [J].Critical Care.2001, 5(5): 265-270.
18. Buckwalter KC, Fan RN, Buckwalter JA .Seeing older perioperative patients in 32-D: when your patient is demented, delirium, or depressed [J].J Operative Techniques in Orthopaedics. 2002, 12(2):64-71.
19. FormigaF, Chivite D, Mascaro J, et al. No correlation between mini-nutritional assessment (short form) scale and clinical outcomes in 73 elderly patients admitted for hip fracture [J]. Aging Clin Exp Res. 2005, 17(4): 343-346.
20. Ronnie A, Rosenthal, Stephen M Kavic.Assessment and management of the geriatric patient [J]. Crit Care Med. 2004, 32(4): 92-105.
21. Zimmet P, Mccarty D. The NIDDM epidemic: Global estimates and Projections-a look into the crystal ball [J]. IDF Bulletin.1995, 40:8-16.
22.吕厚山,周殿阁,袁燕林.糖尿病患者的人工膝关节置换[J].中华外科杂志. 1997, 5(8): 462-464.
23. Guyton JL.Fractures of hip, acetabulum and pelvis [M].Cnanle ST.Campbell’s operative orthopaedics, 9th ed.Mosby, St. Louis. 1998, 2181-2183.
24. Lyons AR. Clinical outcomes and treatment of hip fractures [J].Am J Med. 1997 103(2):51-63.
25. Bredahl C, Nyholm B, Hindsholm KB, Mortensen JS, Olesen AS. Mortality after hip fracture: results of operation within 12h of admission [J].Injury. 1992, 23(2):83-86.
26. Davis FM, Woolner DF, Frampton C, et al. Prospective, multi-center trial of mortality following general or spinal anaesthesia for hip fracture in the elderly [J].Br J Anaesth.1987, 59(3):1080-1088.
27. Forster MC, Calthorpe D. Mortality following surgery for proximal femoral fractures incentenarians [J].Injury, 2000, 31(7):537-539.
28. Fox HJ, Pooler J, Prothero D, Bannister GC.Factors affecting the outcome after proximal femoral fractures [J].Injury.1994, 25(5):297-300.
29. Hamlet WP, Lieberman JR, Freedman EL, e t al.Influence of health status and the timing of surgery on mortality in hip fracture patients [J].Am J Orthop.1997, 26(9):621-627.
30. Hoerer D, Volpin G, Stein H .Results of early and delayed surgical fixation of hip fractures in the elderly: a comparative retrospective study.Bull Hosp Jt Dis.1993, 53(1):29-33.
31. Todd CJ, Freeman CJ, Camilleri-Ferrante C, et al. Differences in mortality after fracture of hip: the East Anglian audit [J].BMJ.1995, 310(6894):904-908.
32. Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH.Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip [J].J Bone Joint Surg. 1995, 77(10):1551-1556.
33. Eiskjaer S, Ostgard SE. Risk factors influencing mortality after bipolar hemiarthroplasty in the treatment of fracture of the femoral neck [J].Clin Orthop Relat Res.1991, 270:295-300.
34. Hamilton BH, Hamilton VH, Mayo NE. What are the costs of queuing for hip fracture surgery in Canada [J]? J Health Econ.1996, 15(2):161-185.
35. Kenzora JE, McCarthy RE, Drennan Lowell J, et al.Hip fracture mortality.Relation to age, treatment, preoperative illness, time of surgery, and complications [J].Clin Orthop Relat Res.1984, 186:45-56.
36. Mullen JO, Mullen NL. Hip fracture mortality.A prospective, multifactorial study to predict and minimize death risk [J].Clin Orthop Relat Res.1992, 280:214-222.
1. Jain R, Basinski A, Kreder HJ.Nooperative treatment of hip fractures [J]. Int Orthop. 2003, 27(1):11-17.
2. Knaus WA, Wanger DP.APACHEⅡ: aseverity of classfication system [J].Crit Care Med.1985, 13(13):818-829.
3. Copeland GP, Jones D, Walters M, et al. POSSUM: a scoring system for surgical audit [J].Br J Surg. 1991, 78(3):355-360.
4. Evers BM, Townsend CM Jr, Thompson JC. Organ physiology of aging [J].Surg Clin North Am. 1994, 74(1):23-39.
5.罗朝盛,主编.Visual Basic 6.0程序设计实用教程(第2版)[M].清华大学出版社, 2008.
6. Le Gall JR, Lemeshow S, Saulnier F.A new Simplified Acute Physiology Score (SAPS II) based on a European-North American multicenter study [J].JAMA.1993, 270(24): 2957-2963.
7. Knaus WA, Draper EA, Wagner DP, et al. APACHE II: a severity of disease classification system [J]. Crit Care Med. 1985, 13(10):818-829.
8. Shaw NJ, Dear PR. How do parents of babies interpret qualitative expression of probability [J]? Archives of Disease in childhood.1990, 65(5):520-523.
9. Gall JR, Loirat P, Alperovitch A, et al.A simplified acute physiology score for ICU patients [J].Crit Care Med. 1984, 12(11):975-977.
10. Sauaia A, Moore F A, Moore E E, et al. Early risk factors for postinjury multiple organ failure [J].World J Surg. 1996, 20(4):392-400.
11. Jones DR, Copeland GP, d e Cossart L. Comparison of POSSUM with APACHE II for prediction of outcome from a surgical high-dependency unit [J].Br J Surg. 1992, 9(12):1293-1296.
12. Whiteley MS, Prytherch DR, Higgins B, et al.An evaluation of the POSSUM surgical scoring system [J]. Br J Surg. 1996, 83(7):812-815.
13. Ramkumar T, Ng V, Fowler L, et al.A comparison of POSSUM, P-POSSUM and colorectal POSSUM for the prediction of postoperative mortality in patients undergoing colorectal resection [J]. Dis Colon Rectum. 2006, 49(3): 330-335.
14. Kuhan G, Abidia A F, Wijesinghe L D, et al. POSSUM and P-POSSUM overpredict mortality for carotid endarterectomy [J]. Eur J Vasc Endovasc Surg. 2002, 23(3): 209-211.
15. Treharne G D, Thompson M M, Whiteley M S, et al. Physiological comparison of open and endovascular aneurysm repair [J]. Br J Surg. 1999, 86(6):760-764.
16.尹志康,何梓铭,苟欣,等.生理学和手术侵袭度评分预测泌尿外科高龄患者术后并发症的价值[J].中华泌尿外科杂志. 2002, 23(1):43-45.
17.饶忠,黄谦,周红菊.改良POSSUM评分系统预测老年烧伤患者术后并发症的价值[J].广西医科大学学报. 2004, 21(1):94-95.
18. Mohamed K, Copeland GP.An assessment of the POSSUM system in orthopaedic surgery [J]. J Bone Joint Surg. 2002, 84 (5):735-739.
19.张博皓.改良生理学和手术严重度评分系统(POSSUM)预测髋部骨折手术并发症发生率及死亡率的价值[M].吉林大学硕士学位论文.2004.
20.张德宝. POSSUM和P-POSSUM评分系统预测髋关节置换术后死亡率和并发症率的价值[M].吉林大学硕士学位论文.2005.
21. Goldman L, Caldera DL, Nussbaum SR, et al.Multifactorial index of cardiac risk in noncardiac surgical procedures [J].N Engl J Med.1997, 297(16):845-850.
22. Hung, Patrick D, Sterling, Richard K. Predicting Outcome of Critically Ill Patients With Cirrhosis Admitted to the Intensive Care Unit: Who's Keeping Score [J]? Journal of Clinical Gastroenterology.2003, 37(3):203-205.
23.王玮,沈惠良,曹光磊,等. 65岁以上老年骨科患者手术风险因素评估[J].中国矫形外科杂志. 2006, 14(6):425-427.
24.郑永克,戴新建,郑纪阳,等.残气肺总量比对老年矽肺患者肺功能损伤分级合理性的初步探讨[J].温州医学院学报. 2006, 36(4):372-374.
25.兰秀夫,王爱民,孙红振,等.骨科手术风险评分在我院老年髋部骨折患者中的初步应用研究[J].创伤外科杂志. 2008, 10(2):124-127.
26.兰秀夫,王爱民,孙红振,等. 760例骨科老年病人手术风险因素分析[J].重庆医学. 2008, 37(5): 493-495.
27.金丕焕,主编.医用统计学方法[M].第1版,上海:上海科技大学出版社.1993, 370-387
28. Lemeshow S, Le Gall JR.Modeling the severity of illness of ICU patients. A systems update [J]. JAMA.1994 5, 272(13):1049-1055.
1. Emily VA,Finlayson MD.Operative Mortality with Elective Surgery in Older Adults[J].Eff Clin Pract.2001, 4(4):172-177.
2. Rixen Dieter, Grass Guido, Sauerland Stefan, e t al. Evaluation of Criteria for Temporary External Fixation in Risk-Adapted Damage Control Orthopedic Surgery of Femur Shaft Fractures in Multiple Trauma patients:“Evidence-Based Medicine”versus“Reality”in the Trauma Registry of the German Trauma Society [J]. The Journal of Trauma.2005, 59(6):1375-1395.
3. Frank Hildebrand, Peter Giannoudisb, Cristian Krettek, et al. Damage control: extremities [J]. Injury.2004, 35(4):678-689.
4. Pape HC, Giannoudis P, Krettek C.The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery [J]. Am J Surg 2002, 183(6): 622-629.
5.高辉,刘午阳,赖光松,等. 70岁以上股骨颈骨折患者全髋置换围手术期风险因素分析[J].中国老年学杂志. 2007, 4(27):365-366.
6.罗永忠,李佩佳,赵汉平,等.人工关节置换治疗高龄股骨粗隆间骨折[J].中国矫形外科杂志. 2005, 13(20):1542-1544.
7. Mary Ann McLaughlin, Gretchen M Orosz,Jay Magaziner,et al.Preoperative Status and Risk of Complications in Patients with Hip Fracture [J]. J Gen intern Med.2006, 21(3):219-225.
8. Lawrence VA, Hilsenbeck SG, Noveck H, et al. Medical complications and outcomes after hip fracture repair[J]. Arch Intern Med. 2002, 162(18):2053-2057.
9. Mark C, Denis C.Mortality following surgery for proximal femoral fractures in centenarians [J].Injury. 2000, 31(7): 537-539.
10. Brandt SE, Lefever S, Janzing HMJ, et al. Percutaneous compression plating (PCCP) versus the dynamic hip screw for pertrochanteric hip fractures: preliminary results [J]. Injury. 2002, 33(1):413-418.
11.王福权,骆燕禧,黄公怡,等.老年四肢骨折的内固定治疗(附438例报告) [J].中华骨科杂志. 1991, 11(4):242-245.
12. Mohamed K, Copeland GP.An assessment of the POSSUM system in orthopaedic surgery[J].J Bone Joint Surg. 2002, 84(5):735-739.
13. Copeland GP, Jones D, Walters M, et al. POSSUM: a scoring system for surgical audit [J].Br J Surg.1991, 78(3):355-360.
14. 14.M McLaughlin, Gretchen M, Orosz, MD et al. Preoperative Status and Risk of Complications in Patients with Hip Fracture [J]. J Gen Intern Med. 2006, 21(3):219-225.
15.钱礼.手术风险性与得益率的评估[J].中国实用外科杂志.1999,19(3):181.
1. Urban M K, Jules Elysee K M, Beckman J B, et al. Pulmonary injury in patients undergoing complex spine surgery [J].J Spine. 2005, 5(3): 269-76.
2.王军平,赵景宏,粟永萍.糖皮质激素受体调控与创伤应激紊乱关系的研究进展[J].中华创伤杂志. 2001, 17(8):508-510.
3.秦荣,周艳红,刘都户,等.大鼠严重烫伤早期应激反应中肝脏糖皮质激素受体变化的实验研究[J].第三军医大学学报.2002, 24(8):895-897.
4. Meaney M J, Diorio J, Francis D, et al. Early environmental regulation of forebrain glucocorticoid receptor gene expression: implications for adrenocortical responses to stress [J]. Dev Neurosci.1996, 18(1-2):49-60.
5. Perreau V, Sarrieau A, M ormede P. Characterization of mineralocorticoid and glucocorticoid receptors in pigs: comparison of Meishan and Large White breeds [J].Life Sci.1999, 64(17):1501-1515.
6.李大培,王浩丹,赵奇煌.严重脑外伤患者外周血淋巴细胞糖皮质激素受体的研究[J].山东医科大学学报. 1994, 32(2):114 -117.
7. Bledsoe R k, Montana VG, Stanley TB.Crystal structure of the glucocorticoid receptor ligand binding domain reveals a novel mode of receptor dimerization and coactivator recognition [J]. Cell.2002, 110(1): 93-105.
8.徐仁宝.休克时糖皮质激素受体的变化及大剂量糖皮质激素抗休克治疗的受体机制[J].基础医学与临床.1998,18(1):5-10.
9. Auphan N, DiDonato J A, Rosette C, et al. Immunosuppression by glucocorticoids: inhibition of NF-kappa B activity through induction of I kappa B synthesis [J].Science. 1995, 270(5234):286-290
10. Johnson JW, Beck JC, Haberkern CM.Glucocorticoids and the respiratory distress syndrome [J].Obstet Gynecol Annu.1984,13:99-129.
11.王庆松,王正国,朱佩芳.大鼠创伤后应激障碍模型的建立及其海马糖皮质激素受体的变化[J].第三军医大学学报. 2002, 24(8):895-897.
12. WANG QS, WANG ZG, ZHU PF. Establishment of PTSD model in rats and expression of glucocorticoid receptor in the hippocampi [J].Acta Academiae Medicinae Militaris Tertiae.2002, 24(8):895- 897.
13.李思齐,白祥军,王海平,等.多发伤患者外周血白细胞糖皮质激素受体α、β的表达及其意义[J].中华创伤杂志. 2005, 21(10):729-732.
1. Leung JM, Dzankic S. Relative importance of preoperative health status versus intraoperative factors in predicting postoperative adverse outcomes in geriatric surgical patients [J].Am Geriatr Soc.2001, 49(8):1080-1085.
2. Zedler S, Bone RC, Baue AE, et al.T-cell reactivity and its predictive role in immunosuppression after burns [J]. Crit Care Med. 1999, 27(1):66-72.
3. Pellegrini JD, De AK, Kodys K, e t al.Relationships between T lymphocyte apoptosis and anergy following trauma [J]. J Surg Res. 2000, 88(2):200-206.
4. Menges T, Engel J, Welters I, et al. Changes in blood lymphocyte populationns after multiple-trauma: association with posttraumatic complications [J]. Crit Care Med. 1999, 27(4):733-740.
5. Walsh DS, Siritongtaworn P, Pattanapanyasat K, et al. Lymphocyte activation after non-thermal trauma [J]. Br J Surg. 2000, 87(2):223-230.
6. Deveci M, SengezerM, Bozkurt M, et al.Comparison of lymphocyte populations in cutaneous and electrical burn patients [J].Clinical study. 2000, 26(3):229-232.
7. Dalton H J.T-cell responses in burn infection [J].Crit Care Med. 2001, 29(12):2386-2387.
8. Hashimoto T, Hashimoto S, Hori Y, et al. Epidural anaesthesia blocks in perpheral lymphocytes subpopulation during gastrectomy for stomach cancer [J].Acta Anaesthesiol Scand.1995, 39(3):294-198.
9.孟海东,赵晓东,陈晓光,等.老年人严重创伤后免疫抑制的研究[J].第三军医大学学报. 2005, 7(27):1509-1511.
10.林飞卿,余传霖,何球藻,主编.医学基础免疫学[M].上海:上海医科大学出版社.1992, 45-47.
11.黄锡全,刘恭植.衰老与免疫.内科免疫学[M].第1版.武汉:湖北科学技术出版社.1998, 22-25.
12.单颖,姜东,李淑云,等.老年人T细胞亚群的Meta分析[J].中国老年学杂志. 2007,19:1905-1907。
13. Axel Franke, Wolfgang Lante, Edmond Kurig, et al. Hyporesponsiveness of T cell subsets after cardiac surgery: a product of altered cell function or merely a result of absolute cellcount changes in peripheral blood [J]? Eur J Cardiothorac Surg. 2006, 30:64-71.
14.李艳芳,杨清,郭永和,等.不同心功能患者T淋巴细胞亚群的变化[J].中华老年心脑血管病杂志. 2006, 8(2):76-78.
1. Goris RJ, Gimbrere JSF, Niekerk JLM, et al.Early asteosynthesis and prophylactic mechanical ventilation in the multitrauma patient [J].JTrauma. 1982, 22(11):895-903.
2. Seibel R, LaDuca J, Hassett JM, et al. Blunt multiple trauma (ISS36), femur traction, and the pulmonary failure-septic state [J].Am Surg. 1985, 202(3):283-295.
3. Bone LB, Johnson KD, Weigelt J, Scheinberg R.Early versus delayed stabilisation of fractures: a prospective randomized study [J].J Bone Joint Surg Am. 1989, 71(3): 336-340.
4. Rotondo MF, Schwab CW, Mcgonigal MD, et al. Damage control: an approach for improved survival in exsanguinating penetrating abdominal injury [J].J Trauma.1993, 35(3):375-382.
5.王伟雄,冯骏,刘坚义,等.不同年龄段严重创伤患者特点与救治[J].中华急诊医学杂志. 2006, 15(12):1075-1078.
6.盛志勇.多发伤.黎鳌主编.现代创伤学[M].北京:人民卫生出版社.1996, 834-837.
7. Roberts CS, Pape HC, Jones AL,et al. Damage control orthopaedics:evolving concepts in the treatment of patients who have sustained orthopaedic trauma [J].Instr Course Lect. 2005, 54:447-462.
8. Hildebrand F, Giannoudis P, Kretteck C, et al. Damage control:extremities[J]. Injury. 2004, 35(7):678-789.
9.王爱民,蒋耀光.以骨关节损伤为主的严重多发性损伤的救治[J].创伤外科杂志. 2006, 8(4):382-385.
10. Menges T, Gngel J, Welters I, et al. Changes in blood lymphocyte populations after multiple-trauma: association with postt-raumatic complications [J]. Crit Care Med. 1999, 27(4):733-740.
11. YaoY M, Redl H, Bahrami S, et al.The inflammatory basis of trauma.shoch-associated multiple-organ failure [J]. Inflamm Res.1998, 47(5):201-210.
12. Majetschak M, Borgerman J, Waydhas E, et al. Whole blood tumor necrosis factor-alpha production and its systemic concen-trations of interleukin-4, interleukin-10, and transforming growth factor-beta in multiple injured blunt trauma victims [J].Crit CareMed. 2000, 28(6):1847-1853.
13. Shimonkevitz R, BarOr D, Harris L, et al. Granulocytes, including neutrophils, synthesize IL-10after traumatic pancreatitis: case report [J].J Trauma. 2000, 48(1):165-168.
14. Taniguchi I, Koido Y, Aiboshi J, et al.The ratio of interleukin-6 to interleukin-10 correlates with severity in patients with chest and abdominal trauma [J].Am J Emerg Med. 1999, 179(6):548-551.
15. Roumen RM, Redl H, Schlag G, et al.Inflammatory mediators in relation to the development of multiple organ failure in pa-tients after severe blunt trauma [J]. Crit Care Med. 1995, 23(3):474-480.
16. Gebhard F, Pfetsch H, Steinbach G, et al. Is interleukin-6 an early marker of injury severity following major trauma in human [J]. Arch Surg. 2000, 135(3):291-295.
17. DeBosscher K, Vanden Berghe W, Haegeman G. Mechanisms of anti-inflammatory action and of immunosuppression by glucocorticoids: negative interference of activated glucocorticoid receptor with transcription factors [J].J Neuroimmunol.2000, 109(1):16-22.
18.张芳,钱桂生,钱频,等.大鼠糖皮质激素受体变异体cDNA序列克隆和表达及功能研究[J].西北国防医学杂志.2005,26(1):1-3.
1. Evers BM,Townsend CM Jr,Thompson JC Organ physiology of aging[J].Surg Clin North Am,1994,74(1):23-39.
2. Schein M, Assalia A, Bachus H. Minimal antibiotic therapy aftet emergency abdominal surgery: a prospctive study [J].Br J Surg 1994, 81(7):989-991.
3.杨开锦,高堂成,王力群.高龄患者股骨粗隆间骨折的围手术期处理[J].第四军医大学学报. 2006, 27 (6): 515-517.
4. Jones HJS, de Cossart L. Risk scoring in surgical patients [J].Br J Surg, 1999, 86:149-157.
5. Ohnen JM, M ustard RA, Oxho lm SE, et al. APACHE score and abdominal sepsis: aprospective study [J]. Br Arch Surg.1988, 123:225-229.
6. BruneliA, Fianchini A, Gesuita R, et al.POSSUM scoring system as an instrument of audit in lung resection surgery [J]. Ann Thorac Surg.1999, 67: 329-331.
7. Knaus WA, Draper EA, W agner DP, et al. APACHEⅡ: a severity of disease classification system [J].Crit Care Med.1985, 13(10):818-829.
8. Committee on Medical A spects of Auto motive Safety .Rating the severity of tissue damage.The abbreviated scale. JAMA, 1971, 215:277-280.
9. Osler T,Baker SP,Susan P,et al.Amodification of the injury severity score that bothim prove saccuracy and scoring. JTrauma, 1997, 43:922-925.
10.孙俊,江学成.急诊室创伤患者创伤评分与并发症和救治的关系[J].中国危重病急救医学. 2006, 18(1):36-38.
11. Malone DL, Kuhls D, N apolitano LM, e t al.Back to basics: validation of the admission systemic inflammatory response syndrome score in predicting outcome in trauma [J].J Trauma.2001, 51(3):458- 463.
12. Copeland GP, Jones D, Walters M, et al. POSSUM:a scoring system for surgical audit [J] .Br J Surg.1991,78(3):355-360.
13. Copeland GP, Jones D. Comparative vascular audit using the POSSUM scoring system [J].Ann R Coll Surg Engl.1993, 75:175-177.
14. Copeland GP, Sagar P , B rennan J, et al. Risk-adjusted analysis of surgeon performance: a 1 year study [J].Br J Surg. 1995, 82(3): 408-411.
15. Brosens R P, Oomen J L, Glas A S, et al. POSSUM predicts decreased overall survival in curative resection for colorectal cancer [J].Dis Colon Rectum.2006, 49(6): 825-832.
16. Gotohda N, Iwagaki H, Itano S, e t al.Can POSSUM, a scoring system for perioperative surgical risk, predict postoperative clinical course [J]? Acta Med Okayama.1998, 52(6): 325-329.
17. Yii M K, Ng K J.Risk-adjusted surgical audit with the POSSUM scoring system in a developing country: Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity [J]. Br J Surg. 2002, 89(1):110-113.
18. Sommer F, Ehsan A, Klotz T, et al.Comparison of individual urologists' performance [J]. Eur Urol. 2001, 39(4): 369-374.
19. Ramkumar T, Ng V, Fowler L, et al.A comparison of POSSUM, P-POSSUM and colorectal POSSUM for the prediction of postoperative mortality in patients undergoing colorectal resection [J]. Dis Colon Rectum. 2006, 49(3): 330-335.
20. Whiteley M S; Prytherch D R; Higgins B, et al.An evaluation of the POSSUM surgical scoring system [J]. Br J Surg. 1996, 83(6): 812-815
21. Kuhan G, Abidia A F, Wijesinghe L D, e t al. POSSUM and P-POSSUM overpredict mortality for carotid endarterectomy [J]. Eur J Vasc Endovasc Surg. 2002, 23(3): 209-211.
22. Treharne G D, Thompson M M, Whiteley M S, et al. Physiological comparison of open and endovascular aneurysm repair [J]. Br J Surg.1999, 86(6): 760-764.
23.尹志康,何梓铭,苟欣,等.生理学和手术侵袭度评分预测泌尿外科高龄患者术后并发症的价值[J].中华泌尿外科杂志.2002, 23:43-45.
24.饶忠,黄谦,周红菊.改良POSSUM评分系统预测老年烧伤患者术后并发症的价值[J].广西医科大学学报.2004, 21:94-95.
25.张博皓.改良生理学和手术严重度评分系统(POSSUM)预测髋部骨折手术并发症发生率及死亡率的价值[M].吉林大学硕士学位论文,2004.
26. Ramanathan T S, Moppett I K, Wenn R, et al. POSSUM scoring for patients with fractured neck of femur [J].Br J Anaesth. 2005, 94 (4): 430-431.
27. Tekkis P P, Kocher H M, Bentley A E, et al.Operation mortality rates among surgeons: comparison of POSSUM and p-POSSUM scoring systems in gastrointestinal surgery [J]. Dis colon Rectum.2000, 43:1528-1534.
28. Midwinter MJ, Tytherleigh M, Ashley S. Estimation of mortality and morbidity risk in vascular surgery using POSSUM and Portsmouth predictor equation[J].Br J Surg.1999, 86:471-474.
29. Hosmer DW Ir, Lemeshow S.A goodness of fit test for the mutipleogistic regreesionmodels [J]. Community Statistics.1980, 10:1043-1069.
30. Hosmer DWIr, Lemeshow S. Applied Logistic Regression [J]. NEW YORK: wiley 1989.
31. Hemant M Kocher, Paris P Tekkis, Palepu Gopal, Ameet G. Risk-adjustment in hepatobiliarypancreatic surgery [J].World J Gastroenterol. 2005, 11(16):2450-2455.
32. Gocmen E, Koc M,Tez M,et al.Evaluation of P-POSSUM and O-POSSUM scores in patients with gastric cancer undergoing resection[J].Hepatogastroenterology. 2004, 51(60):1864-1866.
33. Tekkis PP, McCulloch P, Poloniecki JD, et al. Risk-adjusted prediction of operative mortality in oesophagogastric surgery with O-POSSUM [J].Br J Surg. 2004, 91(3): 288-295.
34. Mohil RS, Bhatnagar D, Bahadur L, et al. POSSUM and P-POSSUM for risk-adjusted audit of patients undergoing emergency laparotomy[J].Br J Surg. 2004, 91(4):500-503.
35. Prytherch D R, Sutton G L, Boyle J R.Portsmouth POSSUM models for abdominal aortic aneurysm surgery [J]. Br J Surg. 2001, 88(7):958-63.
36. Harris J R, Forbes T L, Steiner S H, et al. Risk-adjusted analysis of early mortality after ruptured abdominal aortic aneurysm repair [J]. J Vasc Surg. 2005, 42(3):387-91.
37. van der Sluis CK, Timmer HW, Eisma WH, e t al. Outcome in elderly injured patients: injury severity versus host factors [J]. Injury. 1997, 28(9-10):588-92.
38. Mohamed K, Copeland G P. An assessment of the POSSUM system in orthopaedics surgery [J].J Bone Joint Surg. 2002, 84(5):735-739.
39. McLaughlin MA, Orosz GM, Magaziner J, et al.Preoperative status and risk of complications in patients with hip fracture [J].J Gen Intern Med.2006, 21(3):219-25.
40. M J Brooks, R Sutton and S Sarin.Comparison of Surgical Risk Score, POSSUM and p-POSSUM in higher-risk surgical patients [J]. British Journal of Surgery.2005, 92: 1288-1292.
41. Gu GS, Zhang DB, Zhang BH, et al.Evaluation of P-POSSUM scoring system in predicting mortality in patients with hip joint arthroplasty[J].Chin J Traumatol.2006, 9(1): 50-55.
42. Young W,Seigne R,Bright S,et al.Audit of morbidity and mortality following neck of femur fracture using the POSSUM scoring system [J]. NZ Med J. 2006, 119(1234): U1986.
1. Rotondo MZ, Schwab CW, McGonigal MD, et al.“Damage control”: an approach for improved survival in exsanguinating penetrating abdominal injury [J]. J Trauma. 1993, 35(3):375-382.
2. Sagravaes SG, Toschlog EA, Rotondo MF. Damage control surgery the intensivist`s role [J].J Intensive Care Med. 2006, 21(1):5-16.
3. Henry SM, Tornetta P 3nd,Scalea T M. Damage control for devastating pelvic and extremity injuries [J] . Surg Clin North.1997, 77(4):879-895.
4. Marius K, Ludwing L, Otmar T.“Damage Control”in Severely Injured Patients [J]. J European Journal of Tauma.2005, 3:212-221.
5. Giannoudis PV. Surgical priorities in damage control in polytrauma [J]. J Bone Joint Surg . 2003, 85(4): 478-483.
6. Stone HH, Strom PR, Mullins RJ. Management of the major coagulopathy with onset during laparotomy [J].Ann Surg. 1983, 197(5):532-535.
7.陈国庭,刘中民.损伤控制外科的理论与实践外科理论与实践[J].2005, 10(2):197-198.
8.赵晓刚.极端状态创伤病人实施损伤控制外科策略的哲学思考[J].医学与哲学.2002,23(11):54-55.
9. Pape H C, Giannoudis P, Krettek C.The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery [J]. J Surg. 2002, 183(6): 622-629.
10.刘中民.普及损伤控制外科技术,提高严重创伤救治水平[J].中华急诊医学杂志. 2004, 13(4):221-222.
11.李喆,华积德.损伤控制外科理念在严重创伤和多发伤救治中的应用[J].中华创伤杂志. 2006,22(5):321-323.
12. Mikhail J.The trauma triad of death: hypothermia, acidosis, and coagulopathy [J].ACCN Clin Issues. 1999, 10(1):85-94.
13. John B. Holcomb, Don Jenkins, Peter Rhee. Damage Control Resuscitation: Directly Addressing the Early Coagulopathy of Trauma [J].J Trauma.2007, 62:307-310.
14. Karen J, Brasel, John A, Weigelt. Damage control in trauma surgery[J].Current Opinion inCritical Care.2000, 6:276-280.
15. Hamill J. Damage control surgery in children [J]. injury.2004, 35(3): 708-712.
16.王爱民,陈辉,孙红振等.骨关节型严重多发伤的损害控制治疗[J].中华创伤杂志.2007,23(2):143-146.
17.赵小纲,江观玉.多发伤救治的损伤控制策略[J].中华创伤杂志.2006, 22(5):334-336.
18. Friedl HP, Ttentz O. Multiple trauma: definition, shock, multiple organ failure [J]. Unfallchirurgie.1992, 18(2):64-68.
19. Border JR: Death from severe trauma: Open fractures to multiple organ dysfunction syndrome [J]. J Trauma. 1995, 39(1):12-22.
20.王爱民,蒋耀光.以骨关节损伤为主的严重多发性损伤的救治[J].创伤外科杂志,2006,8(4):382-385.
21. Giannoudis PV, Pape HC. Damage control orthopaedics in unstable pelvic ring injuries[J]. Injury. 2004, 35(7):671-677.
22.杨俊,高劲谋,赵山弘.严重多发伤时损伤控制骨科应用4l例[J].中华创伤杂志. 2006, 22(5):331-333.
23. Krishna G, Sleigh JW, Rahman H. Physiological predictors of death in exsanguinating [J]. Aust N Z J Surg. 1998,68(12):826-829.
24. Asensio JA, Petrone P, Roldan G, et al. Has evolution in awareness of guidelines for institution of damage control improved outcome in the management of posttraumatic open abdomen [J]? Arch Surg, 2004, 139(2):209-214.
25. Sharp KW, Locicero RJ.Abdominal packing for surgically uncontrollable haemorrhage [J]. Ann Surg. 1992, 215(5): 467-474.
26. Carrillo C, Fogler RJ, Shaftan GW.Delayed gastrointestinal reconstruction following massive abdominal trauma [J].J Trauma. 1993, 34(2): 233-235.
27. Rotondo MF, Zonies DH.The damage control sequence and underlying logic [J]. Surg Clin North Am. 1997, 77(4): 761-777.
28. Shapiro MB, Jenkins DH, Schwab CW, et al. Damage control: collective review [J].J Trauma. 2000, 49(5):969-978.
29. Pape HC, Giannoudis PV, Krettek C, et al. Timing of fixation of major fractures in blunt polytrauma– the role of conventional indicators in clinical decision making [J].J Orthop Trauma. 2005, 19(8): 551-562.
30.王一堂.积极开展损伤控制性手术[J].中国急救医学. 2004, 24(1):46.
31. Asensio JA, Petrone P, Roldan G,et al. Has evolution in awareness of guidelines for institution of damage control improved outcome in the management of posttraumatic open abdomen [J]? Arch Surg. 2004, 139(2):209-214.
32. Pape HC, Hildebrand F, Pertschy S, et al. Changes in the management of femoral shaft fractres in polytrauma patients: from early total care to damage control orthopedic surgery [J].J Trauma. 2002, 53(3):452-462.
33. Rixen Dieter,Grass Guido,Sauerland Stefan,et al. Evaluation of Criteria for Temporary External Fixation in Risk-Adapted Damage.Control Orthopedic Surgery of Femur Shaft Fractures in Multiple Trauma Patients:"Evidence-Based Medicine" versus "Reality" in the Trauma Registry of the German [J]. J Trauma. 2005, 59(6):1375-1395.
34. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures: damage control orthopedics [J]. J Trauma. 2000, 48(4):613-623.
35. Oztuna V, Ersoz G, Ayan I, et al.Early Internal Fracture Fixation PreventsBacterial Translocation [J]. Clin Orthop Relat Res. 2006, 446: 253-258.
36. Jurkovich GJ, Greiser WB, Luterman A, Curreri P W. Hypothermia in trauma victims: an ominous predictor of survival [J].J Trauma.1987, 27:1019-1024.
37. Johnson JW, Gracias VH, Schwab CW, et al. Evolution in damage control for exsanguinating penetrating abdominal injury [J].J Trauma. 2001, 51(2):261-271.
38. Pape H C, Giannoudis P, Krettek C.The timing of fracture treatment in polytrauma patients: relevance of damage control orthopedic surgery [J]. J Surg. 2002, 183(6): 622-629.
39. Zacharias SR, Offner P, Moore EE, et al.Damage control surgery [J].AACN Clin Issues. 1999, 10(1): 95-103.
40. Roberts CS, Pape HC, Jones AL. Damage control orthopaedics: evolving concepts in the treatment of patients who have sustained orthopaedic trauma [J]. Instr Course Lect. 2005, 54:447-62.
41. Taeger Georg, Ruchholtz Steffen, Waydhas Christian.Damage Control Orthopedics in Patients With Multiple Injuries Is Effective, Time Saving, and Safe [J].Journal of Trauma-Injury Infection & Critical Care. 2005, 59(2):408-415.
42. Scalea TM, Boswell SA, Scott JD, et al. External fixation as a bridge External fixation as a bridge to intramedullary nailing for patients with multiple injuries and with femur fractures:damage control orthopaedics[J].J Trauma.2000, 48(4):613-623.
43. Harwood PJ, Giannoudis PV, Probst C, et al.The risk of local infective complications after damage control procedures for femoral shaft fracture [J] J Orthop Trauma. 2006, 20(3):181-189.
44. Pape HC, Regel G, Dwenger A, et al.Influences of different methods of intramedullary femoral nailing on lung function in patients with multiple trauma [J].J Trauma. 1993, 35(5):709-716.
45. Pape HC, Dwenger A, Grotz M, et al. Does the reamer type influence the degree of lung dysfunction after femoral nailing following severe trauma [J]?An animal study.J Orthop Trauma. 1994, 8(4):300-309.
46. Pape HC, Dwenger A, Regel G, et al. Pulmonary damage after intramedullary femoral nailing in traumatized sheep—is there an effect from different nailing methods [J]? J Trauma, 1992, 33(4):574-581.
47. McBride WT, Armstrong MA, McBride SJ.Immunomodulation: an important concept in modern anaesthesia [J]. Anaesthesia. 1996, 51(5): 465-73.
48. Norman JG, Fink GW.The effects of eidural anesthesia on the neuroendocrine response to major surgical stress.A randomized prospective trial [J].Am Surg.1997, 63(1):75-80.
49. Sato A, Kuwabara Y, Sugiura M et al.Intestinal energy metabolism during ischemia and reperfusion [J]. J Surg Res.1999, 82(2):261-267.
50. KoikeK, YamamotoY.Splanchnic hypoperfusion and distant organ injury [J]. Nippon Geka Gakkai Zasshi.1999, 100(5):357-360.
51. Meek RN. The John Border memorial lecture:delaying emergency fracture surgery-fact or fad[J].J Orthopaedic Trauma. 2006, 20 (5):337-340.
52. Pape HC Immediate fracture fixation-which method? comments on the john border memorial lecture Ottawa 2005 [J].J Orthop Trauma. 2006, 20(5):341-50.
[1] Jain R, Basinski A, Kreder HJ. Nonoperative treatment of hip fractures [J]. Int Orthop. 2003, 27 (1):11-17.
[2] Knaus WA, Wanger DP. APACHE: aseverity of classfication system [J].Crit Care Med.1985, 13(13):818-829.
[3] Copeland GP, Jones D, Walters M, et al. POSSUM: a scoring system for surgical audit [J].Br J Surg. 1991, 78(3):355-360.
[4] Evers BM, Townsend CM Jr, Thompson JC. Organ physiology of aging.Surg Clin North Am.1994,74(1):23-39.
[5] Higgins TL, McGee WT, Steingrub JS, et al. Early indications of prolonged intensive care unit stay: Impact of illness severity, physician staffing, and pre-intensive care unit length of stay [J]. Crit Care Med. 2003, 31(1):45-51.
[6] Neary W D, Heather B P, Earnshaw J J. The Physiological and Operative Severity Score for the enUmeration of Mortality and morbidity (POSSUM) [J].Br J of Surg. 2003, 90:157-165.
© 2004-2018 中国地质图书馆版权所有 京ICP备05064691号 京公网安备11010802017129号 地址：北京市海淀区学院路29号 邮编：100083 电话：办公室：(+86 10)66554848；文献借阅、咨询服务、科技查新：66554700 |