加速康复外科理念在脊柱结核围手术期护理中的应用效果分析

doi:10.19982/j.issn.1000-6621.20220054

摘要/Abstract

摘要：

目的: 分析探讨加速康复外科(ERAS)理念在脊柱结核围手术期护理应用中的效果。 方法: 收集青岛市胸科医院外科2017年7月至2020年6月收治的147例脊柱结核患者。其中,2017年7月至2018年12月收治的68例脊柱结核手术患者围手术期应用常规护理,作为对照组;2019年1月至2020年6月收治的79例脊柱结核手术患者在常规护理措施基础上融入了ERAS理念,作为ERAS组。比较两组患者的引流管拔除、最初下床进行功能锻炼、最初自主排尿的时间,术后72h疼痛(采用视觉模拟评分法)评分,住院天数,恶心呕吐、肺部感染、药物性肝损伤的发生率,以及患者满意度的差异。 结果: 与对照组相比,ERAS组患者引流管拔除时间[6.00(4.00,8.00)d和8.00(7.00,8.00)d;W=4321.000,P<0.001]、最初下床进行功能锻炼时间[2.00(2.00,4.00)d和5.50(4.25,6.00)d;W=3376.000,P<0.001]、首次在床上自主排尿时间[5.00(3.00,6.00)h和9.00(7.00,9.00)h;W=3369.000,P<0.001]、术后72h疼痛评分[3.00(2.00,4.00)分和5.00(5.00,6.00)分;W=4078.500,P<0.001]、住院总天数[19.00(18.00,21.00)d和22.00(19.00,27.00)d;W=4791.500,P<0.001]均有所下降,差异均有统计学意义。与对照组相比,ERAS组术后恶心呕吐发生率[7.6%(6/79)和19.1%(13/68);χ²=4.311,P=0.038]、肺部感染发生率[2.5%(2/79)和11.8%(8/68);χ²=4.914,P=0.027]、药物性肝损伤发生率[1.3%(1/79)和13.2%(9/68),χ²=8.258,P=0.004]均有所下降,差异均有统计学意义。ERAS组患者满意度高于对照组[96.2%(76/79)和85.3%(58/68),χ²=7.100,P=0.008],差异有统计学意义。 结论: ERAS理念应用于脊柱结核围手术期护理可以加速患者的康复,减少并发症的发生,提高患者的满意度。

关键词: 围手术期医护, 康复, 结核,脊柱, 对比研究

Abstract:

Objective: To analyze the effect of enhanced recovery after surgery (ERAS) concept in perioperative nursing of spinal tuberculosis. Methods: A total of 147 patients with spinal tuberculosis treated in the Department of Surgical of Qingdao Chest Hospital from July 2017 to June 2020 were collected. Of them, 68 cases treated from July 2017 to December 2018 received routine nursing during the perioperative period (control group); 79 cases from January 2019 to June 2020 who underwent surgery were treated with the ERAS concept on the basis of routine nursing measures (ERAS group). The time of drainage tube extraction, first getting out of bed for functional exercise and initial spontaneous urination, pain score 72 hours after operation (using visual analog scoring (VAS) method), the length of hospital stay, the incidence of nausea and vomiting, the incidence of lung infection and drug-induced liver damage, and the patient's satisfaction were observed and compared between the two groups. Results: Compared with the control group, the drainage tube removal time, the initial time to get out of bed for functional exercise, the initial spontaneous urination time, VAS score 72 h after operation and the length of hospital stay in the observation group were all significantly shorter than those in the control group (6.00(4.00,8.00) d vs. 8.00 (7.00,8.00) d, W=4321.000, P<0.001; 2.00 (2.00,4.00) d vs. 5.50 (4.25,6.00) d, W=3376.000, P<0.001; 5.00 (3.00, 6.00) h vs. 9.00 (7.00, 9.00) h, W=3369.000, P<0.001; 3.00 (2.00, 4.00) vs. 5.00 (5.00, 6.00), W=4078.500, P<0.001; 19.00 (18.00, 21.00) d vs. 22.00(19.00,27.00) d, W=4791.500,P<0.001, respectively). The incidences of postoperative nausea and vomiting and pulmonary infection, and drug-induced liver damage in the observation group were significantly lower than those in the control group (7.6% (6/79) vs. 19.1% (13/68), χ²=4.311,P=0.038; 2.5% (2/79) vs. 11.8% (8/68), χ²=4.914, P=0.027; and 1.3% (1/79) vs. 13.2% (9/68), χ²=8.258, P=0.004, respectively). The patient satisfaction in the observation group was significantly higher than that in the control group (96.2% (76/79) vs. 85.3% (58/68), χ²=7.100, P=0.008). Conclusion: The application of ERAS concept in perioperative nursing of spinal tuberculosis can speed up the recovery, reduce the occurrence of complications, and improve the satisfaction.

Key words: Perioperative care, Rehabilitation, Tuberculosis,spinal, Comparative study

中图分类号:

蒋嫣, 龙雅琴, 王瑞兰, 田莉莹, 赵明伟, 刘加洪. 加速康复外科理念在脊柱结核围手术期护理中的应用效果分析[J]. 中国防痨杂志, 2022, 44(6): 555-558. doi: 10.19982/j.issn.1000-6621.20220054

JIANG Yan, LONG Ya-qin, WANG Rui-lan, TIAN Li-ying, ZHAO Ming-wei, LIU Jia-hong. Analysis of the effect of enhanced recovery after surgery in perioperative nursing of spinal tuberculosis[J]. Chinese Journal of Antituberculosis, 2022, 44(6): 555-558. doi: 10.19982/j.issn.1000-6621.20220054

图/表 4

表1

两组患者一般资料的比较

特征	ERAS组(79例)	对照组(68例)	统计检验值	P值
性别[例(构成比,%)]			χ²=0.004	0.763
男性	43(54.4)	38(55.9)
女性	36(45.6)	30(44.1)
年龄(岁, $x ¯$ ±s)	54.80±8.10	52.60±8.50	t=2.509	0.431
发病部位[例(构成比,%)]			χ²<0.001	0.872
颈、胸椎	29(36.7)	26(38.2)
腰椎	50(63.3)	42(61.8)

表1

表2

表3

表4

参考文献 17

[1]	Kehlet H. Fast-track surgery-an update on physiological care principles to enhance recovery. Langenbecks Arch Surg, 2011, 396 (5): 585-590. doi: 10.1007/s00423-011-0790-y. doi: 10.1007/s00423-011-0790-y URL
[2]	Kehlet H. Multimodal approach to control postoperative pathophysiology and rehabilitation. Br J Anaesth, 1997, 78(5): 606-617. doi: 10.1093/bja/78.5.606. doi: 10.1093/bja/78.5.606 URL
[3]	秦连菊, 杨九菊, 张秦平. 骨科患者术后护理干预体会. 河北医药, 2013, 35(23): 3653-3654, 3655. doi: 10.3969/j.issn.1002-7386.2013.23.073. doi: 10.3969/j.issn.1002-7386.2013.23.073
[4]	陈友雷, 徐小宏, 裘华森. 中西医结合快速康复外科方案治疗老年胃癌临床观察. 浙江中西医结合杂志, 2014, 24(12): 1082-1084. doi: 10.3969/j.issn.1005-4561.2014.12.016. doi: 10.3969/j.issn.1005-4561.2014.12.016
[5]	孙天胜, 沈建雄, 刘忠军. 中国脊柱手术加速康复--围术期管理策略专家共识. 中华骨与关节外科杂志, 2017, 10(4): 271-279. doi: 10.3969/j.issn.2095-9958.2017.04-01. doi: 10.3969/j.issn.2095-9958.2017.04-01
[6]	李元, 秦世炳. 重视在脊柱结核外科领域融入加速康复外科理念. 中国防痨杂志, 2021, 43 (5): 427-427. doi: 10.3969/j.issn.1000-6621.2021.05.002. doi: 10.3969/j.issn.1000-6621.2021.05.002
[7]	董雅娜. 健康教育路径在脊柱结核围手术期护理中的应用研究. 中国药物与临床, 2021, 21(11): 1992-1994. doi: 10.11655/zgywylc2021.11.085. doi: 10.11655/zgywylc2021.11.085
[8]	Barreiro E, Gea J. Respiratory and Limb Muscle Dysfunction in COPD. COPD, 2015, 12(4): 413-426. doi: 10.3109/15412555.2014.974737. doi: 10.3109/15412555.2014.974737 pmid: 25438125
[9]	Kling KM, Lopez-Rodriguez E, Pfarrer C, et al. Aging exacer-bates acute lung injury-induced changes of the air-blood barrier, lung function, and inflammation in the mouse. Am J Physiol Lung Cell Mol Physiol, 2017, 312(1): L1-L12. doi: 10.1152/ajplung.00347.2016. doi: 10.1152/ajplung.00347.2016
[10]	Sprung J, Gajic O, Warner DO. Review article: age related alterations in respiratory function-anesthetic considerations. Can J Anaesth, 2006, 53(12): 1244-1257. doi: 10.1007/BF03021586. doi: 10.1007/BF03021586 pmid: 17142659
[11]	Berger M, Acker L, Deiner S. Miller'sanesthesia. 9th ed. New York: Elsevier Health Sciences, 2019: 2102-2114.
[12]	中华医学会麻醉学分会, 老年人麻醉与围术期管理学组, 国家老年疾病临床医学研究中心, 等. 中国老年患者围手术期麻醉管理指导意见(2020版)(一). 中华医学杂志, 2020, 100(31): 2404-2415. doi: 10.3760/cma.j.cn112137-20200503-01406. doi: 10.3760/cma.j.cn112137-20200503-01406
[13]	Baldini G, Bagry H, Aprikian A, et al. Postoperative urinary retention: anesthetic and perioperative considerations. Anesthesiology, 2009, 110(5): 1139-1157. doi: 10.1097/ALN.0b013e31819f7aea. doi: 10.1097/ALN.0b013e31819f7aea URL
[14]	王倩, 张亚超, 张磊, 等. 加速康复外科理念在脊柱结核围手术期护理中的应用效果. 中国防痨杂志, 2021, 43(5): 463-467. doi: 10.3969/j.issn.1000-6621.2021.05.010. doi: 10.3969/j.issn.1000-6621.2021.05.010
[15]	Higashiguchi T, Hübner M, Klek S, et al. ESPEN guideline: Clinical nutrition in surgery. Clin Nutr, 2017, 36(3): 623-650. doi: 10.1016/j.clnu.2017.02.013. doi: 10.1016/j.clnu.2017.02.013 URL
[16]	中国医师协会麻醉学医师分会. 促进术后康复的麻醉管理专家共识. 中华麻醉学杂志, 2015, 35(2): 141-148. doi: 10.3760/cma.j.issn.0254-1416.2015.02.001. doi: 10.3760/cma.j.issn.0254-1416.2015.02.001
[17]	中国加速康复外科专家组. 中国加速康复外科围手术期管理专家共识(2016). 中华外科杂志, 2016, 54 (6): 413-418. doi: 10.3760/cma.j.issn.0529-5815.2016.06.004. doi: 10.3760/cma.j.issn.0529-5815.2016.06.004

处理方法	EARS组	对照组
术前
健康宣教床上排尿训练进行体位及呼吸功能锻炼禁食方案	入院后告知围手术期的各种相关事项及诊疗计划,以图册的方式告知手术室的环境,消除患者对陌生环境的恐惧术前1d在私密环境中指导患者床上排尿并实施入院后即进行手术体位的练习。指导患者腹式呼吸、吹气球、有效咳嗽咳痰,进行个体化腰背肌的功能训练术前6h禁食、2h禁饮	术前1d进行谈话签字、告知手术方式和手术风险,安抚患者的情绪术后指导患者床上排尿术前未系统规范练习,术后指导呼吸功能训练术前10h禁饮食
术后
体位及活动尿管管理进食时间疼痛管理功能锻炼	早期活动,待患者麻醉清醒后即给予半卧体位,术后第二日在支具保护下进行床边站立及下床锻炼术后麻醉清醒后6~24h内拔出导尿管自行排尿早期进食,术后麻醉,清醒后4h鼓励患者饮温水,评估无风险2h后逐步进流质饮食、半流质饮食、普通饮食术中采用罗哌卡因原液在切口、取髂骨处骨膜下、切口处肋间神经局部封闭,术后给予静脉自控式镇痛泵,帕瑞昔布钠40mg/次,1次/12h,静脉滴注,使用5~7d 根据病情及术式施行个体化的锻炼方案,如腰背肌功能训练、双下肢拉力带训练、术后第二日下床锻炼等	术后6h请患者去枕平卧,后每2h翻身一次,术后5d左右下床锻炼留置导尿管3d 术后6h禁饮食,第二天后改为流质饮食术后给予静脉自控式镇痛泵,对症处理,疼痛给药术后绝对卧床,5~7d后在支具保护下下床,逐渐行走,无其他功能锻炼