甲狀腺功能減退癥患者髖或膝關節置換術圍手術期的處理_《華西醫學》

作者：

周程沛 , 何軍慧 ,  周宗科 , 楊靜 , 沈彬 , 康鵬德 , 裴福興

四川大學華西醫院骨科（成都，610041）;

關鍵詞：

甲狀腺功能減退癥全髖關節置換術全膝關節置換術圍手術期

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目的　探討髖或膝關節置換術（THR/TKR）并存甲狀腺功能減退癥（甲減）患者圍手術期的處理策略。方法　2009年1月－2011年12月收治30例行THR/TKR并存甲減患者，其中男8例，女22例，平均年齡62.4歲。處理要點包括術前糾正甲狀腺激素水平；術中縮短手術時間，減少出血量，選擇性應用糖皮質激素；術后補充甲狀腺激素，預防感染及深靜脈血栓形成，改善胃腸功能。評價指標包括圍手術期血壓、心率變化，胃腸功能狀況，切口愈合時間，甲狀腺功能水平，黏液性水腫昏迷等并發癥發生率；術前及術后Harris及特種外科醫院評分系統（HSS）評分等。結果　術后心率變化大，非致命性心律失常者20例；血壓控制平穩；術后甲狀腺功能變化不明顯，無黏液性水腫昏迷、心包積液及呼吸窘迫等嚴重并發癥發生。隨訪1個月，術前HSS評分平均28分，術后86分；術前Harris評分平均32分，術后87分。結論　術前控制血清促甲狀腺素在0.5～3.0 mU/L以內，總甲狀腺素、游離甲狀腺素至正常水平，是有效預防甲減患者THR/TKR圍手術期并發癥的關鍵；綜合應用左甲狀腺素片、糖皮質激素和抗凝治療是安全渡過圍手術期的重要保證。

引用本文： 周程沛,何軍慧,周宗科,楊靜,沈彬,康鵬德,裴福興. 甲狀腺功能減退癥患者髖或膝關節置換術圍手術期的處理. 華西醫學, 2012, 27(5): 665-669. doi: 復制

1.	中華醫學會內分泌學分會《中國甲狀腺疾病診療指南》編寫組. 甲狀腺疾病診治指南甲狀腺功能減退癥[J]. 中華內科雜志, 2007, 46(11): 967-971.
2.	Stathatos N, Wartofsky L. Perioperative management of patients with hypothyroidism[J]. Endocrinol Metab Clin N Am, 2003, 32(2): 503-518.
3.	Venkatesan T, Thomas N, Ponniah M, et al. Oral triiodothyronine in the perioperative management of central hypothyroidism[J]. Singapore Med J, 2007, 48(6): 555-558.
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6.	萬圣云, 朱宗超, 王光升. 外科病人并甲低的圍手術期處理 [J]. 醫師進修雜志, 1995, 18(10): 26-27.
7.	Devdhar M, Ousman YH, Burman KD. Hypothyroidism [J]. Endocrinol Metab Clin North (Am), 2007, 36(3): 595-615.
8.	Ringel MD. Management of hypothyroidism and hyperthyroidism in the intensive care unit [J]. Crit Care Clin, 2001, 17(1): 59 -74.
9.	Schiff R, Welsh GA. Perioperative evaluation and management of the patient with endocrine dysfunction [J]. Med Clin North Am, 2003, 87(1): 175-192.
10.	Bennett-Guerrero E, Kramer DC, Schwinn DA. Effect of chronic and acute thyroid hormone reduction on perioperative outcome [J]. Anesth Analg, 1997, 85(1): 30-36.
11.	Mercado DL, Petty BG. Perioperative medication management [J]. Med Clin North Am, 2003, 87(1): 41-57.
12.	Spell III NO. Stopping and starting medications in the perioperative period [J]. Med Clin North Am, 2001, 85(5): 1127-1128.
13.	Wellby ML, Kennedy JA, Barreau PB, et al. Endocrine and cytokine changes during elective surgery [J]. J Clin Pathol, 1994, 47(11): 1049-1051.
14.	Girvent M, Maestro S, Hernandez R, et al. Euthyroid sick syndrome, associated endocrine abnormalities, and outcome in elderly patients undergoing emergency operation [J]. Surgery, 1998, 123(5): 560-567.
15.	Wartofsky L, Burman KD. Alterations in thyroid function in patients with systemic illness: the “euthyroid sick syndrome” [J]. Endocr Rev, 1982, 3(2): 164-217.
16.	Stathatos N, Levatan C, Burman KD, et al. The controversy of the treatment of critically ill patients with thyroid hormone [J]. Best Pract Res Clin Endocrinol Metab, 2001, 15(4): 465-478.
17.	Connery LE, Coursin DB. Assessment and therapy of selected endocrine disorders [J]. Anesthesiology Clin North Am, 2004, 22(1): 93-123.
18.	Simone JV, Abildgaard CF, Schulman I. Blood coagulation in thyroid dysfunction [J]. N Engl J Med, 1965, 273(20): 1057-1061.
19.	Dalton RG, Dewar MS, Savidge GF, et al. Hypothyroidism as a cause of acquired von Willebrand’s disease [J]. Lancet, 1987, 1(8540): 1007-1009.
20.	Loeliger EA, van der Esch B, Mattern MJ, et al. The biological disappearance rate of prothrombin, factorsⅦ, Ⅸ, and Ⅹ from plasma in hypothyroidism, hyperthyroidism and during fever[J]. Thromb Diath Hemorrh, 1964, 10: 267-277.

1. 　中華醫學會內分泌學分會《中國甲狀腺疾病診療指南》編寫組. 甲狀腺疾病診治指南甲狀腺功能減退癥[J]. 中華內科雜志, 2007, 46(11): 967-971.
2. 　Stathatos N, Wartofsky L. Perioperative management of patients with hypothyroidism[J]. Endocrinol Metab Clin N Am, 2003, 32(2): 503-518.
3. 　Venkatesan T, Thomas N, Ponniah M, et al. Oral triiodothyronine in the perioperative management of central hypothyroidism[J]. Singapore Med J, 2007, 48(6): 555-558.
4. 　中華醫學會骨科學分會. 中國骨科大手術靜脈血栓栓塞癥預防指南[J]. 中華關節外科雜志(電子版), 2009, 3(3): 70-72.
5. 　Kohl BA, Schwartz S. How to manage perioperative endocrine insufficiency [J]. Anesthesiology Clin, 2010, 28(1): 139-155.
6. 　萬圣云, 朱宗超, 王光升. 外科病人并甲低的圍手術期處理 [J]. 醫師進修雜志, 1995, 18(10): 26-27.
7. 　Devdhar M, Ousman YH, Burman KD. Hypothyroidism [J]. Endocrinol Metab Clin North (Am), 2007, 36(3): 595-615.
8. 　Ringel MD. Management of hypothyroidism and hyperthyroidism in the intensive care unit [J]. Crit Care Clin, 2001, 17(1): 59 -74.
9. 　Schiff R, Welsh GA. Perioperative evaluation and management of the patient with endocrine dysfunction [J]. Med Clin North Am, 2003, 87(1): 175-192.
10. 　Bennett-Guerrero E, Kramer DC, Schwinn DA. Effect of chronic and acute thyroid hormone reduction on perioperative outcome [J]. Anesth Analg, 1997, 85(1): 30-36.
11. 　Mercado DL, Petty BG. Perioperative medication management [J]. Med Clin North Am, 2003, 87(1): 41-57.
12. 　Spell III NO. Stopping and starting medications in the perioperative period [J]. Med Clin North Am, 2001, 85(5): 1127-1128.
13. 　Wellby ML, Kennedy JA, Barreau PB, et al. Endocrine and cytokine changes during elective surgery [J]. J Clin Pathol, 1994, 47(11): 1049-1051.
14. 　Girvent M, Maestro S, Hernandez R, et al. Euthyroid sick syndrome, associated endocrine abnormalities, and outcome in elderly patients undergoing emergency operation [J]. Surgery, 1998, 123(5): 560-567.
15. 　Wartofsky L, Burman KD. Alterations in thyroid function in patients with systemic illness: the “euthyroid sick syndrome” [J]. Endocr Rev, 1982, 3(2): 164-217.
16. 　Stathatos N, Levatan C, Burman KD, et al. The controversy of the treatment of critically ill patients with thyroid hormone [J]. Best Pract Res Clin Endocrinol Metab, 2001, 15(4): 465-478.
17. 　Connery LE, Coursin DB. Assessment and therapy of selected endocrine disorders [J]. Anesthesiology Clin North Am, 2004, 22(1): 93-123.
18. 　Simone JV, Abildgaard CF, Schulman I. Blood coagulation in thyroid dysfunction [J]. N Engl J Med, 1965, 273(20): 1057-1061.
19. 　Dalton RG, Dewar MS, Savidge GF, et al. Hypothyroidism as a cause of acquired von Willebrand’s disease [J]. Lancet, 1987, 1(8540): 1007-1009.
20. 　Loeliger EA, van der Esch B, Mattern MJ, et al. The biological disappearance rate of prothrombin, factorsⅦ, Ⅸ, and Ⅹ from plasma in hypothyroidism, hyperthyroidism and during fever[J]. Thromb Diath Hemorrh, 1964, 10: 267-277.

《華西醫學》

甲狀腺功能減退癥患者髖或膝關節置換術圍手術期的處理

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《華西醫學》

甲狀腺功能減退癥患者髖或膝關節置換術圍手術期的處理

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