一名患有帕金森病的九旬老人接受髋部骨折手术的麻醉挑战：一例病例报告

文献信息

中文摘要

背景： 患有多重合并症的九旬患者发生髋部骨折会带来重大的麻醉挑战。帕金森病（PD）通过运动症状、自主神经功能障碍以及必须不间断多巴胺能治疗而进一步增加复杂性。
病例介绍： 我们报告一名93岁男性患者的围手术期麻醉管理，该患者患有高血压、帕金森病、甲状腺功能减退和血脂异常，因股骨颈经颈型骨折接受了骨水泥型左侧半髋关节置换术。该病例还因显著的语言障碍而更加复杂，因为患者仅能流利使用尼瓦尔语。在L3-L4水平实施脊髓麻醉，使用3 mL 0.5%高比重布比卡因加5 µg鞘内右美托咪定，选择该方案是为了延长麻醉时间，这是在与骨科团队讨论后决定的；该给药策略的理由和局限性在讨论部分进行了批判性评价。术中，患者出现三次低血压发作，可能与交感神经阻滞和佐剂作用有关，使用间羟胺递增剂量进行管理。一次术中低血糖发作（血糖55 mg/dL）被及时用50%葡萄糖纠正。术后，患者因多巴胺能治疗暂时中断而出现短暂性低活动性谵妄，在术后第2天恢复肠内用药后缓解。术后第3天，尽管鼻胃管功能正常，家属仍开始经口喂养，随后患者发生吸入性肺炎。该情况通过抗生素和支持治疗进行管理。患者随后好转，并于术后第10天出院。
结论： 对于包括帕金森病在内的多重合并症九旬患者，脊髓麻醉是可行的。本病例强调了基于证据的剂量优化和主动预防并发症的必要性。它进一步强调了在非常高龄患者中使用低剂量布比卡因脊髓麻醉、细致的围手术期血糖监测、继续多巴胺能治疗、结构化谵妄预防策略、照护者教育以及在高风险老年患者中严格遵守吞咽安全喂养方案的重要性。

英文摘要

BACKGROUND: Hip fractures in nonagenarian patients with multiple comorbidities present substantial anaesthetic challenges. Parkinson's disease (PD) adds further complexity through motor symptoms, autonomic dysfunction, and the imperative for uninterrupted dopaminergic therapy.
CASE PRESENTATION: We report the perioperative anaesthetic management of a 93-year-old male with hypertension, Parkinson's disease, hypothyroidism, and dyslipidaemia who underwent cemented left hemiarthroplasty for a transcervical neck of femur fracture. The case was additionally complicated by a significant language barrier, as the patient was exclusively fluent in Newari. Spinal anaesthesia was administered at L3-L4 using 3 mL of 0.5% hyperbaric bupivacaine with 5 µg intrathecal dexmedetomidine, selected to prolong anaesthesia based on discussion with the orthopaedic team; the rationale and limitations of this dosing strategy are critically appraised in the Discussion. Intraoperatively, the patient developed three episodes of hypotension, likely related to sympathetic blockade and adjuvant effects, managed with incremental doses of mephentermine. An episode of intraoperative hypoglycaemia (blood glucose 55 mg/dL) was promptly corrected with 50% dextrose. Postoperatively, the patient developed transient hypoactive delirium due to temporary interruption of dopaminergic therapy, which resolved after resumption of enteral medications by postoperative day 2. On postoperative day 3, the patient developed aspiration pneumonia after oral feeding was initiated by family members despite a functioning nasogastric tube. The condition was managed with antibiotics and supportive care. The patient subsequently improved and was discharged on postoperative day 10.
CONCLUSION: Spinal anaesthesia is feasible in nonagenarians with multiple comorbidities, including Parkinson's disease. This case highlights the need for evidence-based dose optimisation and proactive complication prevention. It further emphasises the importance of low-dose bupivacaine-based spinal anaesthesia in very elderly patients, meticulous perioperative glycaemic monitoring, continuation of dopaminergic therapy, structured delirium prevention strategies, caregiver education, and strict adherence to dysphagia-safe feeding protocols in high-risk geriatric patients.