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加速康复外科(enhanced recovery after surgery,ERAS)是指采用一系列经循证医学证实有效的围手术期优化处理措施,尽量减少手术给患者带来的生理及心理创伤,达到令患者快速康复的目的[1]。ERAS理念在国内外外科领域推广应用多年,取得了较好效果。鉴于脊柱结核患者的特殊性,笔者将ERAS理念应用于脊柱结核患者围手术期护理中,以期发挥其促进快速康复的作用,提升患者康复效果。
资料和方法
一、研究对象
收集2017年7月至2020年6月青岛市胸科医院外科收治的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。
纳入标准:(1)通过临床症状结合影像学改变、病原学及病理(分子病理学)等确诊为脊柱结核;(2)术前评估能够在全身麻醉下顺利完成内固定术;(3)患者对治疗过程知情同意并签署知情同意书;(4)无心、肝、肾等重要脏器基础疾病,无活动性肺结核,凝血功能正常;术前血红蛋白(Hb)>100g/L。
排除标准:合并美国脊髓损伤协会(American Spinal Injury Association,ASIA)截瘫分级在四级以下的患者;其他未控制的严重的心脑血管疾病、呼吸系统疾病、恶性肿瘤及糖尿病等患者。
二、一般资料
ERAS组中,男性43例,女性36例;年龄12~79岁,平均(54.80±8.10)岁。包括颈椎结核9例,胸椎结核20例,腰椎结核50例。对照组中,男性38例,女性30例;年龄15~77岁,平均(52.60±8.50)岁。包括颈椎结核7例,胸椎结核19例,腰椎结核42例。两组患者在性别构成、年龄构成、病种构成上差异均无统计学意义,具有可比性。见表1。
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, | 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) |
三、护理方法
两组患者围手术期的护理方式见表2。
表2 两组患者围手术期的处理方式
| 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 |
四、统计学处理
采用SPSS 23.0软件进行统计学分析。计数资料以“例数”和“百分率/构成比(%)”描述,组间差异比较采用χ2检验。计量资料呈正态分布时以“
结果
一、两组患者术后恢复情况及总住院天数
ERAS组在引流管拔除时间、最初下床进行功能锻炼时间、首次床上自主排尿时间、术后72h疼痛评分(采用视觉模拟评分法)及总住院天数等方面均优于对照组,差异均有统计学意义。见表3。
表3 两组患者术后恢复情况及总住院天数情况的比较
| 组别 | 引流管拔除时间 [d,M(Q1,Q3)] | 最初下床进行功能锻炼 时间[d,M(Q1,Q3)] | 首次床上自主排尿 时间[h,M(Q1,Q3)] | 术后72h疼痛评分 [分,M(Q1,Q3)] | 总住院天数 [d,M(Q1,Q3)] |
|---|---|---|---|---|---|
| ERAS组(79例) | 6.00(4.00,8.00) | 2.00(2.00,4.00) | 5.00(3.00,6.00) | 3.00(2.00,4.00) | 19.00(18.00,21.00) |
| 对照组(68例) | 8.00(7.00,8.00) | 5.50(4.25,6.00) | 9.00(7.00,9.00) | 5.00(5.00,6.00) | 22.00(19.00,27.00) |
| W值 | 4321.000 | 3376.000 | 3369.000 | 4078.500 | 4791.500 |
| P值 | <0.001 | <0.001 | <0.001 | <0.001 | <0.001 |
二、两组患者术后并发症发生及满意度情况
ERAS组术后恶心呕吐、肺部感染、药物性肝损伤的发生率均低于对照组,差异均有统计学意义;出院时对两组患者进行护理满意度调查,ERAS组总体满意度为96.2%,明显高于对照组的85.3%,差异有统计学意义。见表4。
表4 两组患者术后并发症发生及满意度的比较
| 组别 | 恶心呕吐 | 肺部感染 | 药物性肝损伤 | 满意度 | ||||
|---|---|---|---|---|---|---|---|---|
| 例数 | 发生率(%) | 例数 | 发生率(%) | 例数 | 发生率(%) | 例数 | 发生率(%) | |
| ERAS组(79例) | 6 | 7.6 | 2 | 2.5 | 1 | 1.3 | 76 | 96.2 |
| 对照组(68例) | 13 | 19.1 | 8 | 11.8 | 9 | 13.2 | 58 | 85.3 |
| χ2值 | 4.311 | 4.914 | 8.258 | 7.100 | ||||
| P值 | 0.038 | 0.027 | 0.004 | 0.008 | ||||
讨论
一、ERAS术前宣教的意义
ERAS理念指导下的术前健康促进对于脊柱结核手术患者的快速康复具有重要意义[7]。对于ERAS组患者,在其入院后即讲解结核病的基本知识,消除其对结核病的神秘感及恐惧感,术前告知围手术期的各种相关事项及诊疗计划,用图册等方式展示手术室的环境,消除其对陌生环境的困惑,使患者术前能有一个良好的心态面对手术。
二、围手术期增加营养和疼痛管理的意义
综上所述,将ERAS理念引入应用于脊柱结核围手术期护理,可以加快患者康复的速度,值得在临床中推广应用。
利益冲突 所有作者均声明不存在利益冲突
作者贡献 蒋嫣:数据分析、论文撰写;龙雅琴、王瑞兰、田莉莹:数据采集、文献检索;刘加洪、赵明伟:论文撰写、文献检索、论文修改
参考文献
Fast-track surgery-an update on physiological care principles to enhance recovery
Multimodal approach to control postoperative pathophysiology and rehabilitation
骨科患者术后护理干预体会
中西医结合快速康复外科方案治疗老年胃癌临床观察
中国脊柱手术加速康复--围术期管理策略专家共识
重视在脊柱结核外科领域融入加速康复外科理念
健康教育路径在脊柱结核围手术期护理中的应用研究
Respiratory and Limb Muscle Dysfunction in COPD
In the next decade, Chronic Obstructive Pulmonary Disease (COPD) will be a major leading cause of death worldwide. Impaired muscle function and mass are common systemic manifestations in COPD patients and negatively influence survival. Respiratory and limb muscles are usually affected in these patients, thus contributing to poor exercise tolerance and reduced quality of life (QoL). Muscles from the lower limbs are more severely affected than those of the upper limbs and the respiratory muscles. Several epidemiological features of COPD muscle dysfunction are being reviewed. Moreover, the most relevant etiologic factors and biological mechanisms contributing to impaired muscle function and mass loss in respiratory and limb muscles of COPD patients are also being discussed. Currently available therapeutic strategies such as different modalities of exercise training, neuromuscular electrical and magnetic stimulation, respiratory muscle training, pharmacological interventions, nutritional support, and lung volume reduction surgery are also being reviewed, all applied to COPD patients. We claim that body composition and quadriceps muscle strength should be routinely explored in COPD patients in clinical settings, even at early stages of their disease. Despite the progress achieved over the last decade in the description of this relevant systemic manifestation in COPD, much remains to be investigated. Further elucidation of the molecular mechanisms involved in muscle dysfunction, muscle mass loss and poor anabolism will help design novel therapeutic targets. Exercise and muscle training, alone or in combination with nutritional support, is undoubtedly the best treatment option to improve muscle mass and function and QoL in COPD patients.
Aging exacer-bates acute lung injury-induced changes of the air-blood barrier, lung function, and inflammation in the mouse
Review article: age related alterations in respiratory function-anesthetic considerations
This review examines the effect of aging on pulmonary reserve. Special emphasis is placed on how anesthetic and surgical factors may impose substantial stresses on the respiratory system of elderly patients, leading to increased risk for postoperative pulmonary complications including respiratory failure.A MEDLINE-based English-language literature search was undertaken for the period 1966-2006, and an EMBASE search covered the overlapping period 1988-2006. Selected articles were limited to those applying to elderly subjects/patients.Age-related loss of the lung static recoil forces, stiffening of the chest wall and diminished alveolar surface area lead to a decrease in vital capacity, an increase in residual volume, decrease in expiratory flows and increased ventilation-perfusion heterogeneity. Respiratory muscle strength consistently declines with age further increasing the work of breathing. While gas exchange may be well preserved at rest and during exertion, pulmonary reserve is diminished, and under conditions of positive fluid balance, positioning for surgery, and increased metabolic demand, postoperative respiratory failure can occur. Increased sensitivity to respiratory depressants and muscle weakness pose additional risks for the development of postoperative respiratory complications in elderly patients. Regional anesthetic techniques provide for superior postoperative analgesia, without necessarily altering the frequency of postoperative pulmonary complications in the older surgical population.Alterations in respiratory physiology associated with aging must be appreciated to anticipate and minimize potential complications associated with surgery and anesthesia in the elderly. Individualized care to optimize preoperative cardiorespiratory function, minimize intraoperative respiratory pertubations, and to gently restore postoperative pulmonary function are essential anesthetic goals for elderly patients who require surgery.
中国老年患者围手术期麻醉管理指导意见(2020版)(一)
Postoperative urinary retention: anesthetic and perioperative considerations
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
ESPEN guideline: Clinical nutrition in surgery
促进术后康复的麻醉管理专家共识
中国加速康复外科围手术期管理专家共识(2016)
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