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

doi:10.3969/j.issn.1000-6621.2021.05.010

摘要/Abstract

摘要：

目的探讨加速康复外科(enhanced recovery after surgery,ERAS)理念在脊柱结核围手术期护理中的应用效果。方法采用前瞻性观察研究方法,按照就诊时间连续纳入2020年2月至2021年1月首都医科大学附属北京胸科医院收治的符合入组标准的159例脊柱结核患者作为研究对象,采用交替分组的方法分为观察组(79例,采用ERAS理念下的围手术期护理措施)和对照组(80例,采用常规围手术期护理措施)。比较两组患者术后首次进食时间、肛门排气时间、排便时间、首次下床时间、首次自解小便时间、尿管复插率、并发症发生率,以及疼痛数字评价量表(numerical rating scale,NRS)评分情况等。结果观察组术后首次进食时间、自解小便时间、肛门排气时间、排便时间、下床时间 [分别为12(7,15)h、5(3,6)h、(18.47±5.78)h、(54.41±3.89)h、(11.35±4.23)d]均明显早于对照组[分别为47(42,52)h、7(5,7)h、(45.54±7.94)h、(65.37±5.96)h、(14.57±5.63)d],差异均有统计学意义(Z=10.899,P<0.01;Z=5.307,P<0.01;t=24.600,P<0.01;t=13.748,P<0.01;t=8.364,P<0.01);尿管复插率(3.8%,3/79)明显低于对照组(15.0%,12/80),差异有统计学意义(χ²=5.838,P=0.016)。观察组术后并发症发生率(12.7%,10/79)明显低于对照组(36.3%,29/80),差异有统计学意义(χ²=11.951,P=0.001)。观察组术前24h及术后2、24、72h的疼痛NRS评分[分别为(3.72±0.67)分、(3.70±0.88)分、(4.10±0.89)分、(3.32±0.84)分]均明显低于对照组[分别为(5.41±1.09)分、(4.51±0.73)分、(5.76±0.83)分、(4.24±0.73)分],差异均有统计学意义(t值分别为11.794、6.320、12.165、7.374,P值均<0.01)。结论脊柱结核围手术期进行ERAS理念下的护理干预,可加快患者术后早期康复,减少并发症和减轻疼痛。

关键词: 结核,脊柱, 围手术期医护, 康复, 疗效比较研究

Abstract:

Objective To explore the application effect of enhanced recovery after surgery (ERAS) in perioperative nursing for spinal tuberculosis. Methods A prospective observational study was conducted in consecutive 159 spinal tuberculosis patients hospitalized in the Department of orthopedics, Beijing Chest Hospital from February 2020 to January 2021, all the patients were alternatively divided into observation group (n=79, treated with ERAS in perioperative nursing) and control group (n=80, treated with standard nursing in perioperative period). The first time of taking food, anal exhaust, defecation, getting out of bed and self-urination, the rate of catheter re-insertion, the incidence of complications, and the scores of numerical rating scale (NRS) were compared between the two groups. Results The first time of taking food, self-urination, anal exhaust, defecation, getting out of bed in the observation group were significantly earlier than those in the control group (12 (7,15) h vs. 47 (42, 52) h, Z=10.899, P<0.01; 5 (3, 6) h vs. 7 (5, 7) h, Z=5.307, P<0.01; (18.47±5.78) h vs. (45.54±7.94) h, t=24.600, P<0.01; (54.41±3.89) h vs. (65.37±5.96) h, t=13.748, P<0.01; (11.35±4.23) d vs. (14.57±5.63) d, t=8.364, P<0.01, respectively). The rate of re-insertion of urinary catheter and the incidence of complications in the observation group were both significantly lower than those in the control group (3.8% (3/79) vs. 15.0% (12/80), χ²=5.838, P=0.016; 12.7% (10/79) vs. 36.3% (29/80), χ ²=11.951, P=0.001). The scores of NRS 24 hours before operation, 2 hours, 24 hours and 72 hours after operation were significantly lower than those in the control group ((3.72±0.67) vs. (5.41±1.09), t=11.794; (3.70±0.88) vs. (4.51±0.73), t=6.320; (4.10±0.89) vs. (5.76±0.83), t=12.165; (3.32±0.84) vs. (4.24±0.73), t=7.374, respectively; all P<0.01). Conclusion The application of ERAS in perioperative nursing for spinal tuberculosis could promote the early recovery of patients after operation, reduce the postoperative complications and relieve the pain.

Key words: Tuberculosis, spinal, Perioperative care, Rehabilitation, Comparative effectiveness research

王倩, 张亚超, 张磊, 雷国华. 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[J]. 中国防痨杂志, 2021, 43(5): 463-467. doi: 10.3969/j.issn.1000-6621.2021.05.010

WANG Qian, ZHANG Ya-chao, ZHANG Lei, LEI Guo-hua. Application effect of enhanced recovery after surgery in perioperative nursing for spinal tuberculosis[J]. Chinese Journal of Antituberculosis, 2021, 43(5): 463-467. doi: 10.3969/j.issn.1000-6621.2021.05.010

图/表 4

表1

各临床特征在两组脊柱结核患者中的分布

临床特征	对照组(80例)	观察组(79例)	统计检验值	P值
年龄(岁, $x ˉ$ ±s)	54.82±14.79	53.20±15.82	t=0.667	0.506
性别[例(构成比,%)]			χ²=0.508	0.476
男	43(53.8)	38(48.1)
女	37(46.2)	41(51.9)
病变部位[例(构成比,%)]			χ²=1.554	0.460
颈椎	6(7.5)	4(5.1)
胸椎	31(38.7)	38(48.1)
腰椎	43(53.8)	37(46.8)

表1

表2

两组脊柱结核患者术后快速康复情况比较

组别	首次进食时间 [h,M(Q₁,Q₃)]	肛门排气时间 (h, $x ˉ$ ±s)	排便时间 (h, $x ˉ$ ±s)	首次下床时间 (d, $x ˉ$ ±s)	首次自解小便时间 [h,M(Q₁,Q₃)]	尿管复插 [例(发生率,%)]
观察组(79例)	12(7,15)	18.47±5.78	54.41±3.89	11.35±4.23	5(3,6)	3(3.8)
对照组(80例)	47(42,52)	45.54±7.94	65.37±5.96	14.57±5.63	7(5,7)	12(15.0)
统计检验值	Z=10.899	t=24.600	t=13.748	t=8.364	Z=5.307	χ²=5.838
P值	<0.01	<0.01	<0.01	<0.01	<0.01	0.016

表2

表3

两组脊柱结核患者围手术期并发症发生情况的比较[例(发生率,%)]

组别	压力性损伤	深静脉血栓	感染	合计
观察组(79例)	0(0.0)	3(3.8)	7(8.9)	10(12.7)
对照组(80例)	3(3.8)	10(12.5)	16(20.0)	29(36.3)
$χ 校正 2$ 值	1.334	-	-	11.951
P值	0.248	0.079	0.070	0.001

表3

表4

参考文献 17

[1]	Rajasekaran S, Khandelwal G. Drug therapy in spinal tuberculosis. Eur Spine J, 2013,22(Suppl 4):587-593. doi: 10.1007/s00586-012-2337-5.
[2]	中国防痨协会结核病临床专业分会骨关节结核学组. 脊柱结核手术治疗临床路径. 中国防痨杂志, 2016,38(8):609-614. doi: 10.3969/j.issn.1000-6621.2016.08.001.
[3]	吴茜, 马晶晶, 陈静娟, 等. 多学科协作快速康复外科护理在结直肠肿瘤手术中的应用. 护理管理杂志, 2015,15(11):800-802.
[4]	孙天胜, 沈建雄, 刘忠军, 等. 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.
[5]	中华人民共和国国家卫生和计划生育委员会. WS 288—2017 肺结核诊断, 2017-11-09.
[6]	兰汀隆, 秦世炳. 严格掌握脊柱结核手术指征并选择合适的手术时机和方式. 中国防痨杂志, 2017,39(4):327-328. doi: 10.3969/j.issn.1000-6621.2017.04.002.
[7]	Kondrup J, Rasmussen HH, Hamberg O, et al. Nutritional risk screening (NRS 2002): a new method based on an analysis of controlled clinical trials. Clin Nutr, 2003,22(3):321-336. doi: 10.1016/s0261-5614(02)00214-5. doi: 10.1016/s0261-5614(02)00214-5 URL pmid: 12765673
[8]	雷国华, 王倩, 陈向军, 等. 腰椎结核患者围手术期两种排便护理方法的对比研究. 中国防痨杂志, 2014,36(8):696-699. doi: 10.3969/j.issn.1000-6621.2014.08.019.
[9]	Dwyer AJ, Tarassoli P, Thomas W, et al. Enhanced recovery program in total hip arthroplasty. Indian J Orthop, 2012,46(4):407-412. doi: info:doi/10.4103/0019-5413.98829. URL pmid: 22912515
[10]	李小金, 曾丽雯, 王楚怀. 快速康复外科护理在重度脊柱侧凸行后路矫正术患者康复中的应用. 中国康复医学杂志, 2018,33(6):706-709. doi: 10.3969/j.issn.1001-1242.2018.06.017.
[11]	卫转, 郭锦丽, 李冰, 等. 骨科全麻下肢手术患者术后超早期拔除尿管临床研究. 护理学杂志, 2020,35(9):36-39. doi: 10.3870/j.issn.1001-4152.2020.09.036.
[12]	陈建东, 张晨, 苗瑞瑞, 等. 脊柱结核患者术后静脉血栓栓塞的发生状况及处理. 中国防痨杂志, 2018,40(5):490-493. doi: 10.3969/j.issn.1000-6621.2018.05.010.
[13]	王翠娴, 李萍, 陈建东. 护理干预对预防脊柱结核术后下肢深静脉血栓形成的意义. 中国中西医结合外科杂志, 2018,24(4):488-491. doi: 10.3969/j.issn.1007-6948.2018.04.025.
[14]	马皎洁, 雷国华, 李宝月, 等. 口服营养补充在围手术期脊柱结核患者中的疗效观察. 中国防痨杂志, 2016,38(4):257-261. doi: 10.3969/j.issn.1000-6621.2016.04.005.
[15]	张淑红. 综合护理干预对脊柱结核术后恢复和并发症的影响. 护士进修杂志, 2015,30(6):526-528.
[16]	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.
[17]	张丽娟, 陶晓, 夏丽莉, 等. 脊柱结核患者围手术期应用加速康复集束化护理临床路径表的价值. 中国防痨杂志, 2020,42(9):981-986. doi: 10.3969/j.issn.1000-6621.2020.09.017.