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從藥物層面看人工膝關節置換 手術後的照護 張志偉 醫師 成功大學附設醫院骨科部主治醫師 成大醫學院骨科部臨床助理教授 南部地區藥事人員繼續教育.

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Presentation on theme: "從藥物層面看人工膝關節置換 手術後的照護 張志偉 醫師 成功大學附設醫院骨科部主治醫師 成大醫學院骨科部臨床助理教授 南部地區藥事人員繼續教育."— Presentation transcript:

1 從藥物層面看人工膝關節置換 手術後的照護 張志偉 醫師 成功大學附設醫院骨科部主治醫師 成大醫學院骨科部臨床助理教授 南部地區藥事人員繼續教育

2 Osteoarthritis (OA)  A common disease- progressive deterioration and loss of articular cartilage; subchondral sclerosis; osteophyte formation  Radiographic knee OA in 1/3 > 60 y/o population (Framingham Osteoarthritis Study)  Symptomatic OA in Taiwan- 5.8%; 1/3 OA involved the knee (1994 J Rheu).

3 非藥物性治療   Patient education   Personalized social support   Weight loss (if overweight)   Aerobic exercise programs & modification of activities of daily life   Physical therapy Range-of-motion exercises   Muscle-strengthening exercises   Patellar taping   Appropriate footwear- i.e lateral-wedged insoles 、 bracing   Occupational therapy   Assistive devices for ambulation 、

4 藥物治療   Oral   Acetaminophen   COX-2-specific inhibitor; Non-selective NSAID+ misoprostol or a PPI   Non-acetylated salicylate   Other pure analgesics: Tramadol   Intraarticular - Opioids/ Glucocorticoids   Viscosupplement- Hyaluronan ( 玻尿酸 )   Topical   Capsaicin   Methylsalicylate

5 若還不到要換關節的地步 …  矯正切骨術  corrective osteotomy  軟骨再生術  chondroplasty  清創術  debridement

6 李 x 柱 M 70, OA Knee, Right  KSS: 39-> 85; FS: 25->80  Pre-op 0-90, Post-op 0-120

7 人工膝關節置換歷史沿革 人工膝關節置換歷史沿革   In the 1860s, resection arthroplasty for arthritic knee (Fergusson); the first interposition arthroplasty using joint capsule (Verneuil)   In the 1940s, the first artificial implants as molds fitted to the femoral condyles.   In the 1950s, tibial replacement, but with loosening and persistent pain.   In the 1950s, simple hinges combined femoral/ tibial articular surface replacements appeared- failed for the complex knee motion; high failure rates from aseptic loosening and postop infection.   In 1971, Gunston‘s polycentric knee replacement had early success with its improved kinematics but failed with inadequate fixation to bone.   In 1973, the Mayo Clinic introduced highly conforming and constrained Geomedic knee arthroplasty and a kinematic conflict arose.   In 1973, the total condylar prosthesis by Insall, concentrated on mechanics and not try to reproduce normal knee motion. A rate of survivorship of 94% at 15 years’ follow-up (Ranawat, 1993). At the same time, a cruciate ligaments-retained prosthesis was developed.   One theoretical way is with mobile tibial bearings

8 How to perform total knee arthroplasty ?

9 To now……  Most Commonly Performed Musculoskeletal-Related Procedures: > 650,000 total knee arthroplasties (TKAs) are performed annually in U.S. to alleviate OA –related knee pain and disability.- AAOS [2011 Jul 24]. sits.pdf. > 650,000 total knee arthroplasties (TKAs) are performed annually in U.S. to alleviate OA –related knee pain and disability.- AAOS [2011 Jul 24]. sits.pdf.

10 全人工膝關節置換的功能  The primary indication- to Significant and disabling pain. If knee dysfunction causing significant reduction in the patient's quality of life, this should be taken into account.  The primary indication- to relieve pain from severe arthritis( 減除疼痛 ). Significant and disabling pain. If knee dysfunction causing significant reduction in the patient's quality of life, this should be taken into account.  Correction of significant ( 矯正變形 ) is an important indication but is rarely used as the primary indication for surgery. Roentgenographic findings must correlate with a clear clinical impression of knee arthritis.  Correction of significant deformity( 矯正變形 ) is an important indication but is rarely used as the primary indication for surgery. Roentgenographic findings must correlate with a clear clinical impression of knee arthritis.  Post-traumatic arthritis and limited function in youth or the elder (inherent longevity).  Rarely, severe patellofemoral arthritis may justify arthroplasty because the expected outcome of arthroplasty is superior to patellectomy.

11 何時需要換人工膝關節 ?  疼痛厲害影響生活 (Disabling Pain).  疼痛症狀無法以保守療法改善.  輔具, 物理治療, 藥物治療 ( 止痛. 消炎 )  關節退化厲害無法矯正治療時. 健保規範 :  70 歲以下 :2/3 關節病變 *, 或 1/3 嚴重退化  70 歲以上 :1/3 關節病變, 保守治療 3 月無效 * 關節病變 ; 關節間隙小於二分之一以上 * 關節病變 ; 關節間隙小於二分之一以上

12 不適合開刀的病患(禁忌症) Absolute contraindications (絕對) Knee sepsisKnee sepsis A remote source of ongoing infectionA remote source of ongoing infection Extensor mechanism dysfunctionExtensor mechanism dysfunction Severe vascular diseaseSevere vascular disease Recurvatum deformity secondary to muscular weaknessRecurvatum deformity secondary to muscular weakness a well-functioning knee arthrodesisa well-functioning knee arthrodesis Relative contraindications: (相對) Medical conditions precluding safe anesthesia and demands of surgery and rehabilitation. 身體狀況 Medical conditions precluding safe anesthesia and demands of surgery and rehabilitation. 身體狀況 Skin conditions within the field of surgery (eg, psoriasis)Skin conditions within the field of surgery (eg, psoriasis) Prior knee osteomyelitis 難以控制的感染Prior knee osteomyelitis 難以控制的感染 Neuropathic joint 神經造成關節病變Neuropathic joint 神經造成關節病變 ObesityObesity

13 Expectations & Convalescence thereafter   The results of a TKA are often excellent. It relieves pain in over 90% of patients, and most need no assistance walking after recovery. Most prostheses last 10~15 years before loosening and requiring revision.   Most patients require a short stay (3-5 days) in hospital to become safely independent of daily activities.   Walking and ROM exercises will be started immediately. It may be necessary to use crutches or a walker for a few weeks or even months.   The total recovery varies from 2-3 months to a year.   Continue physical therapy after home until the strength and motion return. Avoid contact sports, but low impact activities, like swimming and golf, are usually possible after full recovery.

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15 術後照護 (1) Vital signs monitoring4 出血 Bleeding  Hemovac drainage monitoring  Fluid and blood replacement  Average blood loss: 400 – 1200 cc  NO Hemovac 止痛 Pain control  Regular IM narcotics  Patient Control Analgesics (PCA)  Epidural anesthesia

16 術後照護 (2) Joint Function Rehabilitation Muscle power Muscle power 肌力 Q setting, Straight leg raising Range of Motion Range of Motion 活動範圍  Continuous passive movement (postop day 2)  Active flexion, bed sliding  Active extension, passive flexion

17 開車都不出車禍 ??

18 術中或術後可能併發症 - be divided into 3 categories:Complications.- blood loss; fracture; embolismGeneral peri-operative complications (including anesthesia) –infection, DVT, pain, stiffnessOther medical complications (post-op complications) - be divided into 3 categories:Complications specific to op proc.- blood loss; fracture; embolismGeneral peri-operative complications (including anesthesia) –infection, DVT, pain, stiffnessOther medical complications (post-op complications)

19 3 strategies to improve TKR delivery: 1.Multi-speciality pre-surgery evaluation of TKR candidates and in-patient management teams including anesthesia, internal medicine, & orthopedic surgery; 2.dedicated OR teams in which TKR surgeons work with the same group of specialized arthroplasty scrub technicians and nurses; and 3. before admission to better manage patient expectations. 3.involving patients in discharge planning before admission to better manage patient expectations.  A Collaborative Of Leading Health Systems Finds Wide Variations In Total Knee Replacement Delivery And Takes Steps To Improve Value (Health Affairs, May 9) by Ivan M. Tomek, MD,

20 Infection 感染  Infection after total hip and knee replacement is a real concern since it can be fatal, though it is a rare occurrence (0.3~1.9%)  1~ 2 % of primary procedure; 3~ 4 % of revisions.

21  Radiographic findings  Similar to findings in loosening with progressive interface widening; no definitive radiographic signs to differentiate except soft tissue gas  Soft tissue gas (ulcer or sinus tract)  Laminated periosteal reaction (rare)  Diagnostic evaluation  Blood tests; Aspiration; Nuclear medicine  Treatment  Acute e.g. after dental surgery  Open surgical lavage  Subacute or chronic  Resection of hardware with flail hip (Girdlestone)  Resection of hardware and placement of cement spacer 

22 Recommendations for Prophylactic Antibiotics in Specific Surgery Procedure Likely pathogen Recommended antibiotics Alternative Duratio n Total hip arthroplasty S. aureus CoNS Cefazolin 1 gm iv then 1 gm q8h ivd Vancomycin 1 gm ivd < 2 days Total knee arthroplasty S. aureus CoNS Cefazolin 1 gm then 1 gm q8h ivd Vancomycin 1 gm ivd < 2 days Internal fixation for close reduction S. aureus CoNS Cefazolin 1 gm then 1 gm q8h ivd Vancomycin 1 gm ivd < 1 day SpineS. aureus CoNS Cefazolin 1 gm then 1 gm q8h ivd Vancomycin 1 gm ivd < 2 days Other selective, non-prosthesis bone procedures S. aureus CoNS Cefazolin 1 gm then 1 gm q8h ivd Vancomycin 1 gm ivd < 1 day J Microbiol Immunol Infect 2004;37: Administer weight-based combined antibiotics (cephalosporin and vancomycin) at least 30 minutes prior to surgical incision

23 When To Discontinue Prophylactic Antibiotics  be discontinued within 24 hours after the end of the operation (O)  Pre-blended antibiotic bone cements (?)  continuing antimicrobial agents until all catheters and drains (X)

24 J Bone Joint Surg Am. 2006;88:

25 預防勝於治療 !!  Considering the common pathogens from remote site (oral hygiene) or neighboring (UTI, URI)

26  一種實質,或潛在組 織傷害或與此傷害相關的 不快感和情緒體驗  定義 - 一種實質,或潛在組 織傷害或與此傷害相關的 不快感和情緒體驗 "Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage ". "Pain is an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage ". International Association for the Study of Pain, 1986 Pain control

27 不爽 ?!

28 Response to General Stress Response to General Stress Endocrine/ Metabolic   ACTH, cortisol, catecholamines, IL-1   insulin   H 2 O, Na + retention ACTH = adrenocorticotropic hormone Kehlet H. Reg Anesth.1996;21(6S):35–37. Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491. 痛 會惡化生理狀況 心跳 , 血壓 , 呼吸 , 血流 , 蠕動 

29 Cousins M, Power I. In: Wall PD, Melzack R, eds. Textbook of Pain. 4th ed; 1999:447–491. Anxiety Depression Sleep deprivation Acute Pain 痛 會惡化心理狀況 惡性循環

30 疼痛類型 : 急性 vs 慢性 急性疼痛 :  持續時間少於 1 個月  如果沒有妥善治療會演 變為慢性疼痛 慢性疼痛 :  傷後疼痛持續超過 1 個月  反覆發作超過 3 個月  接續在組織受傷之後發生 1Beers MH, Berkow R, eds. The Merck Manual. 17th ed.; 1999: Cousins M et al. Textbook of Pain. 1999: Acute pain Chronic pain 持續時間 Duration Hours/ weeks Months/ years 病因 Pathophysiology Identified Rarely known 預後 Prognosis PredictableUnpredictable 治療方式 Treatment AnagelsicsMultidiscipline

31 治療急性疼痛的目標與策略 1. 及時介入與適當調整藥物,以充分控制疼痛。 2. 達到可接受的疼痛程度。 3. 協助病人從原本的疾病或受傷恢復。 “ Acute and chronic pain have nothing in common but the four letter word ‘ pain ’. ” John D. Loeser, Univ. of Washington, Seattle, US “ Persistent pain should be considered a disease state of the nervous system, not merely a prolonged acute pain symptom of some other disease conditions. ” Basbaum AI. PNAS 1999; 96:

32  被視為是對藥物治療的補充治療措施;心理干預、針灸、電 刺激和物理治療都可能有效對某些急性疼痛有幫助。 藥物治療 可使用的藥物包括鴉片類藥物、非類固醇抗炎藥和局部麻醉劑, 及輔助藥物如抗鬱劑、抗癲癇藥和細胞膜穩定劑等。 非藥物治療 為獲得最好療效與同時最小副作用,許多止痛藥物要小心調 整與客制化 (individualization) 的劑量投與。 多模鎮痛 - 同時使用不同類鎮痛藥,增加治療急性疼痛效果。

33 Acute pain after TKA  One or more methods to control pain  Multimodal analgesia- 多模止痛 One or more methods to control pain  an anti-nociceptive treatment using one or more analgesics prior to an event to prevent sensitization or limit post-injury pain; Preop analgesia is thought more effective than an equal post- operative dose  Pre- emptive analgesia- an anti-nociceptive treatment using one or more analgesics prior to an event to prevent sensitization or limit post-injury pain; Preop analgesia is thought more effective than an equal post- operative dose  Local infiltration anesthesia 術中  Ice packing 術後  Patient control anesthesia 術後  Medication- still play a major role  Medication- parenteral narcotics still play a major rolenarcotics

34 對各種疼痛的治療選擇  NSAIDs 非類固醇抗發炎藥物  Nonselective Nonselective  COX-2 selective COX-2 selective COX-2 selective  Opioids 鴉片類止痛藥物  Local anesthesia 局部麻醉劑  Adjunctive therapy 輔助治療  Others 其他 對不同病患, 沒有所謂單一最有效的治療藥物 !!

35 Arachidonic Acid Cyclooxygenase Prostaglandins Inflammation and Pain Protect Gastroduodenal Mucosa Support Renal and Platelet Function Traditional NSAIDs: Anti-inflammatory Analgesic Gastrointestinal Toxicity Renal Toxicity X { 傳統 NSAID 作用機轉

36 Milestones in NSAIDs Development  1899: Aspirin  1949: Steroid  1951:Phenylbutazone  1963:Indomethacin  1965:Ibuprofen  1966:Diclofenac  1968:Naproxen  1970:Piroxicam  1990’s: COX-2 inhibitors * 1950: Acetaminophen From Aspirin to COX-2

37 Scheiman JM Gastroenterol Clin North Am 1996; 25(2):  Age >60 years  History of ulcer disease  Concomitant steroid use  High-dose or multiple NSAIDs  Concomitant anticoagulant use 使用 NSAIDs 引發 GI 副作用之危險因子

38 CONCERNS of NSAIDs  GI 胃腸道  CV 心血管  Kidney 腎功能 - hydration  Others- Money? >> Key point- 首先講求不傷身 ; 感冒藥使用觀念 感冒藥使用觀念

39 Blood loss  The blood loss in the TKR is from 1014 to ml (Kim et al JBJS-b).  Average- 400~1200 ml  Surgical trauma (soft tissue & bone cutting) induced  Coagulation vs fibrinolysis

40 Peri-operative Blood Loss Tourniquet Release for hemostasis Hemovac for Drainage Tourniquet ON for OP Intra-op blood loss Post-op Blood loss

41 Factors affecting blood loss after TKA   Patient age, sex, BMI, arterial blood pressure, preop Hb and Hb preceding transfusion, operation/ tourniquet time, blood loss and volume of blood transfused  patients with hypertension and lower pre-op Hb level as well as longer duration of surgery.

42 Strategies to reduce blood loss in TKA  Reduce operation time  surgeon’s experience, trained team  Reduce surgical trauma  less invasive approach, surgical method (guiding tech.)  Fibrin tissue adhesive (  Fibrin tissue adhesive (containing clot-forming components)   Transamine (tranexamic acid)- anti-fibrinolytic agent   Intra-operative injection- Epinephrine+ xylocaine, bupivacaine   Others? Anesthesia method

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44 Vein thromboembolism 靜脈血栓 Pulmonary embolism Migration Embolus Deep Vein Thrombosis Girard et al., Chest 1999

45 Venous Pulmonary embolism (PE) Clot migrates to the lungs where it becomes trapped Most of the clots from DVT Deep venous thrombosis (DVT) Clots are formed in the deep veins of the leg Risk factors include: Damage to blood vessel Stasis Too much clotting factors Arterial Atrial fibrillation (AF) can cause the development of clots, which can travel to the brain AF increases stroke risk ~5-fold Stroke Acute coronary syndromes (ACS) comprise unstable angina and MI – The underlying cause is clots Acute Coronary Syndrome Clotting- a key event in multiple vascular disorders

46 VTE/PE is often clinically silent, difficult to diagnose, and DEADLY !! Approx. 80% DVTs are clinically silent > 70% fatal PEs are only detected post mortem 1 1. Goldhaber SZ et al. Am J Med. 982;73:822–826; 2. Sandler DA, et al. J Royal Soc Med. 1989;82:203–205

47 血管結構的變化 Virchow‘s Triad of Thrombogenesis Endothelial antithrombogenicity 血流的變化 血液組成的變化 Immobilisation and congestion Activation of coagulation

48 Venous v.s. Aterial Thrombosis Venous Thrombosis / AF  Mechanism  Major  Low flow ( Stasis)  Hypercoagulability  Minor  Vessel wall injury  Clinical Features  Large thrombi  High levels of thrombi generation  Prolong period of coagulation activation Arterial Thrombosis  Mechanism  Major  High shear  Endothelial injury  Minor  Hypercoagulability  Clinical Features  Smaller thrombi  Less marked thrombi generation  Shorter duration of coagulation activation

49 VTE risk factors in surgical patients Level of riskDescription LowMinor surgery in young patients (<40 years) with no additional risk factors ModerateMinor surgery in patients with additional risk factors Surgery in patients aged 40–60 years with no additional risk factors Highaged >60 years, or 40–60 y/o with additional risk factors* Surgery in patients with multiple risk factors Total hip or knee replacement; hip fracture surgery *Additional risk factors: previous VTE, cancer, molecular hypercoagulability, obesity, hereditary thrombophilias, inflammation of infection and anaesthesia Geerts et al. Chest 2004; Lindblad et al. Br J Surg 1991

50 Epidemiology of VTE after orthopaedic surgery  Major lower limb surgery alone: a high VTE risk, irrespective of any additional risk factors Geerts et al. Chest 2008  TKA/ THA: Asymptomatic DVT- 40% to 60%; Proximal DVT- 15% to 25%; Fatal PE in 0.5% to 2%; Symptomatic and fatal PEs: THA> TKA.  Hip fracture surgery, multiple trauma patients, esp pelvic or lower extremity frx DVT- 20% to 60% prior pelvic trauma. VTE without prophylaxis% DVT (range) % fatal PE (range) Elective hip replacement42–570.1–2.0 TKR41–850.1–1.7 Hip fracture46–600.3–7.5

51 Exacerbated risk of VTE with primary or secondary hypercoagulable states OKU9 Chap 12 **Several risk factors- hypercoagulable states, advanced age, prior history, immobility, smoking, obesity, stroke cancer.

52 VTE after Major Orthopaedic Surgery Continues to be a Risk After Discharge  Symptomatic VTE events reported in 1.5–10.0% within 3 months after surgery. 1  Most events occur after discharge from hospital. 1  Risk of symptomatic VTE after major orthopaedic surgery continues to be higher than that in the general population for at least 2 months after surgery. 1  However, VTE is often clinically silent, and the first manifestation (which may be a fatal PE) often occurs after discharge from hospital. 1,2 1. Geerts WH et al. Chest 2004;126:338–400S. 2. Ferri F. Ferri’s Clinical Advisor 2004: 6th edn. St Louis: Mosby, Primary prevention of VTE is recommended for all patients undergoing major orthopaedic surgery of the lower limbs 1

53 亞洲人與白種人在靜脈栓塞發生率上的種族差異 ….. 預期 (Perception) 或 事實 (reality)? 19 centers in 7 countries; 407 patients ( )

54 The primary goal of prophylaxis in VTE is to prevent symptomatic and fatal PE 1.Mechanical Prophylaxis 2.Pharmacologic Prophylaxis 3.Others Pneumatic Compression Boot & Plantar Compression Device

55 A Brief History of Anticoagulant Therapy Alban. Eur J Clin Invest 2005 Convenience and clinical benefit 1930s 1940s 1980s 1990s 2000s UFH: multiple targets, parenteral VKAs: multiple targets, oral LMWHs: m ultiple targets, parenteral DTIs: single target, oral and parenteral Indirect Xa inhibitors: Dual target, parenteral Direct Xa inhibitors: Single target, oral Present DTIs, direct thrombin inhibitors

56 傳統抗凝藥物 Vitamin K antagonists, e.g. warfarin (oral)  藥效不易預期  Onset 慢 ; 需 bridging therapy  需密切監控其 international normalized ratio (INR) 與劑量調整  增加出血風險 Heparin (injectable)  須皮下或連續輸注給藥;不利居家使用  須密切定期監測 activated partial thromboplastin time 與時常調整劑量  Heparin 誘發血小板減少症 (HIT) LMWHs (injectable)  須皮下給藥;  Heparin 誘發血小板減少症 (HIT)  New, predictable, oral anticoagulants are needed

57 Conventional anticoagulant : Multi - target LMWH Fondaparinux Warfarin Emerging Single-target IX X II VII TF/VIIa IXa VIIIa XIa IIa XIIa Xa 作用於 Coagulation waterfall 單一關鍵點可產生可預測性之抗凝效果 Antithrombin III + Xa Antithrombin III + Xa Indirectly Proteins C and S + IIa +

58 新型的抗凝藥物  標的抗凝血劑, 包括 Xa 凝血因子抑制劑和凝血蛋白酶 直接抑制劑 (DTIs)  Xa 凝血因子抑制劑 1.Fondaxparinux (Arixtra ®; GlaxoSmithKline)- injection 2.Idraparinux - injection 3.Rivaroxaban (Xarelto®; Bayer)- oral  凝血蛋白酶直接抑制劑 1.Hirudin (Lepirudin ®)- injection 2.Bivalirudin (Angiomax ®; The Medicines Company)-injection 3.Ximelagatran (Exanta®; Astra-Zeneca )- oral 4.Dabigatran (Pradax®; Boehringer Ingelheim )

59 Factor Xa: Pivotal Point in the Coagulation Pathway Factor Xa Phospholipids FVa–FXa Ca 2+ Intrinsic pathway Extrinsic pathway Prothrombin Thrombin FibrinogenFibrin Prothrombinase complex INITIATION PHASE AMPLIFICATION / PROPAGATION PHASE Platelet aggregation CLOT > 1: 1000 Tissue factor

60 ACCP guidelines for VTE prevention after major orthopaedic surgery  Eighth ACCP conference on antithrombotic therapy ProcedureRecommendationDurationGrade Elective THRLMWH, fondaparinux, or adjusted-dose VKA At least 10 days and up to 35 days 1A Elective TKRLMWH, fondaparinux, or adjusted-dose VKA At least 10 days and up to 35 days 1A 2B Geerts et al. Chest 2008 ASA is not recommended as sole prophylaxis in any of these patients ACCP, American College of Chest Physicians; ASA, acetylsalicylic acid; LMWH, low molecular weight heparin; VKA, vitamin K antagonists

61  Arthritis 關節炎  M-S Trauma 創傷  Osteoporosis 骨疏鬆  Spinal disorders 背痛  Crippled children 小兒 Decade of Bone & Joint 公元兩千年. 骨骼關節年

62 Take home message  人工膝關節置換是目前最常施行的骨科手術之一 ,常用以治療嚴重膝關節病變  急性疼痛的控制在施行膝關節置換手術,不論術 前或術後都相當重要  為避免可能術後感染,需自個人衛生習慣著手預 防  為減少手術失血,抗凝藥物可於術前 7 至 10 天前 開始停藥  對術後可能血栓形成,除早期活動外,尚可考慮 藥物治療

63 Thank You

64 Brief test  ( ) 人工膝關節置換是目前最常施行的骨科手術之一,常 用以治療嚴重膝關節病變;台灣每年有近 2 萬例手術  ( ) 在施行膝關節置換手術術前或術後,急性疼痛的控制 都相當重要;目前多模止痛為主流  ( ) 為避免可能術後感染,需自個人衛生習慣著手預防 ; 特 別是口腔衛生與泌尿道清潔  ( ) 為減少手術失血,抗凝藥物可於術前 7 至 10 天前開始 停藥  ( ) 所有的 NSAID 都有造成心血管風險,不宜長期使用


Download ppt "從藥物層面看人工膝關節置換 手術後的照護 張志偉 醫師 成功大學附設醫院骨科部主治醫師 成大醫學院骨科部臨床助理教授 南部地區藥事人員繼續教育."

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