快速康復(fù)外科在麻醉中應(yīng)用的研究進(jìn)展

田和，李雅蘭

（暨南大學(xué)附屬第一醫(yī)院麻醉科，廣東廣州510632）

快速康復(fù)外科在麻醉中應(yīng)用的研究進(jìn)展

田和，李雅蘭*

（暨南大學(xué)附屬第一醫(yī)院麻醉科，廣東廣州510632）

快速康復(fù)外科 （ERAS）被大量臨床循證醫(yī)學(xué)研究所證實(shí)，通過(guò)減少患者的應(yīng)激反應(yīng)和并發(fā)癥，達(dá)到改善患者預(yù)后和減少住院時(shí)間的目的。ERAS理念貫穿整個(gè)麻醉工作中，優(yōu)化與完善圍術(shù)期的麻醉管理。本文對(duì)ERAS在麻醉中的研究和應(yīng)用概況作一綜述。

快速康復(fù)外科；麻醉；進(jìn)展

快速康復(fù)外科 （enhanced recovery after surgery，ERAS）這一理念最早于1997年由丹麥醫(yī)生Kehlet［1］提出。隨著現(xiàn)代醫(yī)學(xué)的不斷進(jìn)步，ERAS逐漸受到關(guān)注。ERAS由麻醉醫(yī)生、外科醫(yī)生、護(hù)士緊密配合，與患者及其家屬溝通合作，通過(guò)減少患者圍術(shù)期醫(yī)療措施引起的應(yīng)激刺激，盡可能維持患者自身生理功能的平衡，達(dá)到加速康復(fù)、減少并發(fā)癥、縮短住院時(shí)間、降低醫(yī)療費(fèi)用的目標(biāo)。ERAS的理念貫穿整個(gè)麻醉工作中，優(yōu)化與完善圍術(shù)期的麻醉管理。本文對(duì)ERAS在麻醉中的研究和應(yīng)用概況作一綜述。

1 ERAS與術(shù)前麻醉教育

ERAS強(qiáng)調(diào)術(shù)前與患者的溝通。由于患者對(duì)麻醉的認(rèn)識(shí)程度不如外科手術(shù)［2］，對(duì)麻醉的認(rèn)知缺乏會(huì)使患者更容易產(chǎn)生焦慮和恐懼情緒［3］。 早期研究［4］發(fā)現(xiàn)， 對(duì)患者的溝通與教育可顯著緩解術(shù)前的焦慮和緊張，同時(shí)提高患者對(duì)治療的滿意度，有助于早期恢復(fù)。術(shù)前與患者溝通也能更好實(shí)施患者的術(shù)后鎮(zhèn)痛［5］。 有研究［6］表明，術(shù)前教育對(duì)減少患者的焦慮有一定作用，但沒(méi)有充分證據(jù)表明術(shù)前教育能減少術(shù)后不良事件、改善疼痛、促進(jìn)功能恢復(fù)和減少住院時(shí)間。從2012年開(kāi)始，陸續(xù)推出了擇期直腸／盆腔手術(shù)［7］、胰十二指腸切除術(shù)［8］、擇期結(jié)腸手術(shù)［9］、 根治性膀胱癌切除術(shù)［10］、 胃（部分） 切除術(shù)［11］、 婦科常規(guī)／腫瘤手術(shù)［12］、 減肥手術(shù)［13］和肝臟手術(shù)［14］的ERAS指南，這些指南建議醫(yī)護(hù)人員與患者進(jìn)行術(shù)前溝通，為緩解患者的術(shù)前焦慮，推薦使用短效抗焦慮藥。

2 ERAS與術(shù)前禁食

ERAS改變了傳統(tǒng)術(shù)前禁食禁飲的觀念。在傳統(tǒng)觀念中，擇期手術(shù)需要在午夜前禁食，以避免術(shù)中出現(xiàn)反流誤吸等情況。循證醫(yī)學(xué)研究中，并沒(méi)有證據(jù)證明長(zhǎng)期禁食的安全性［15］，從2009年開(kāi)始就有ERAS相關(guān)共識(shí)指南允許患者在麻醉誘導(dǎo)前6 h攝入固體食物和2 h攝入透明液體［16］。2011年，歐洲麻醉學(xué)會(huì)提出的成人與兒童圍術(shù)期禁食指南也推薦術(shù)前6 h禁固體食物，2 h禁水［17］。ERAS除了放寬術(shù)前禁食時(shí)限，還建議患者手術(shù)前2～3 h口服富含碳水化合物的液體300 mL［16］，臨床實(shí)驗(yàn)證明術(shù)前口服碳水化合物可減少患者焦慮情緒、術(shù)后患者蛋白質(zhì)分解［18］和胰島素抵抗［19］。 胰島素抵抗可引起高血糖，進(jìn)而導(dǎo)致免疫抑制，高血糖也是術(shù)后患者手術(shù)部位感染的重要危險(xiǎn)因素［20］。然而，術(shù)前口服碳水化合物的觀念并沒(méi)有得到普遍的接受。一項(xiàng)臨床隨機(jī)對(duì)照試驗(yàn)［21］中，相對(duì)于術(shù)前口服飲用水來(lái)說(shuō)，術(shù)前口服碳水化合物飲料并沒(méi)有顯示出葡萄糖代謝、胰島素抵抗、皮質(zhì)醇濃度和血流動(dòng)力學(xué)的差異，對(duì)術(shù)后并發(fā)癥以及患者的滿意程度也無(wú)顯著影響。

3 ERAS與麻醉方案的選擇

ERAS推薦使用聯(lián)合麻醉，重新認(rèn)識(shí)局部麻醉、神經(jīng)阻滯和椎管內(nèi)麻醉。傳統(tǒng)觀念中，麻醉醫(yī)生術(shù)中關(guān)注的重點(diǎn)是患者的疼痛、生命體征、血流動(dòng)力學(xué)穩(wěn)定等，ERAS的觀念增加了對(duì)提供最佳的鎮(zhèn)痛和減輕手術(shù)的應(yīng)激反應(yīng)的認(rèn)識(shí)。ERAS推薦聯(lián)合麻醉的應(yīng)用，即全身麻醉 ＋局部或區(qū)域麻醉，特別是神經(jīng)阻滯和椎管內(nèi)麻醉已經(jīng)被許多的基礎(chǔ)和臨床研究證實(shí)，其能夠減少手術(shù)應(yīng)激反應(yīng)、改善微循環(huán)和組織灌注、降低胰島素抵抗、減少膈肌活動(dòng)的抑制和提供良好的鎮(zhèn)痛效果［22］。一項(xiàng)關(guān)于膝關(guān)節(jié)表面置換的臨床研究［23］中，相對(duì)于全身麻醉，椎管內(nèi)麻醉的輸血率更低，同時(shí)可減少術(shù)后并發(fā)癥。特別是針對(duì)睡眠呼吸暫停綜合征、椎管內(nèi)麻醉下進(jìn)行手術(shù)的患者，其并發(fā)癥風(fēng)險(xiǎn)也更低，更安全［24］。此外， 麻醉和鎮(zhèn)痛管理并不是孤立的，需要在ERAS的概念下聯(lián)合應(yīng)用，改善術(shù)后鎮(zhèn)痛，減少阿片類藥物用量和相關(guān)的副作用。一項(xiàng)腹部外科手術(shù)后死亡率的薈萃分析［25］顯示，與單用全身麻醉相比，合并使用胸段硬膜外鎮(zhèn)痛后死亡率降低40%，同時(shí)減少了呼吸和心血管的并發(fā)癥，降低了深靜脈血栓的形成風(fēng)險(xiǎn)，加快了胃腸道功能恢復(fù)。

4 ERAS與術(shù)后鎮(zhèn)痛

ERAS優(yōu)化圍手術(shù)期的疼痛管理，減少阿片類藥物的使用。疼痛是圍術(shù)期不可避免的不良反應(yīng)，它是由創(chuàng)傷組織引起的局部炎性反應(yīng)，導(dǎo)致周圍神經(jīng)刺激［26］。良好的術(shù)后鎮(zhèn)痛能夠預(yù)防患者疼痛、促進(jìn)其恢復(fù)和提高滿意度。在傳統(tǒng)的術(shù)后鎮(zhèn)痛中，阿片類藥物是鎮(zhèn)痛藥的主體部分，但阿片類鎮(zhèn)痛有許多副作用與并發(fā)癥， 包括呼吸抑制、 激素和免疫功能紊亂［27］，有臨床研究［28］表明阿片類藥物的使用可增加術(shù)后腸梗阻發(fā)生率。因此，為了減少阿片類藥物的不良反應(yīng)，控制和減少阿片類藥物的使用，尋找和替代阿片類藥物已經(jīng)成為疼痛管理優(yōu)先考慮的問(wèn)題［29］。 有研究［30］推薦使用椎管內(nèi)麻醉鎮(zhèn)痛、 對(duì)乙酰氨基酚、加巴噴丁和環(huán)氧化物酶（cyclooxygenase，COX）抑制劑。 對(duì)乙酰氨基酚［31］和非甾體抗炎［32］藥物可應(yīng)用于術(shù)后鎮(zhèn)痛，減少阿片類藥物的使用，但單靠這些藥物是不夠的，需要多模式的術(shù)后鎮(zhèn)痛療法，包括硬膜外鎮(zhèn)痛、外周神經(jīng)阻滯和手術(shù)切口周圍局部浸潤(rùn)鎮(zhèn)痛。硬膜外鎮(zhèn)痛應(yīng)合理控制局麻藥濃度，減少局麻藥的不良反應(yīng)。通過(guò)在硬膜外添加阿片類藥物或可樂(lè)定可減少局麻藥濃度，但同時(shí)也會(huì)產(chǎn)生鎮(zhèn)靜和低血壓，影響患者恢復(fù)［33］。近年來(lái)，連續(xù)的周圍神經(jīng)阻滯已成為熱門研究方向，且被證實(shí)是有效的術(shù)后鎮(zhèn)痛方式［34］。周圍神經(jīng)阻滯中聯(lián)合應(yīng)用地塞米松等佐劑可延長(zhǎng)鎮(zhèn)痛時(shí)間，這可能與佐劑引起局部血管收縮，影響周圍神經(jīng)吸收和全身抗炎作用相關(guān)［35］。此外，臨床試驗(yàn)證明聯(lián)合口服使用抗驚厥藥物普瑞巴林［36］和抗抑郁藥物度洛西?。?7］也可減少疼痛和阿片類藥物的使用。冰袋［38］也可用于減少重大腹部手術(shù)術(shù)后疼痛，其使用簡(jiǎn)單、經(jīng)濟(jì)有效、無(wú)藥物毒副作用。

5 ERAS優(yōu)化圍手術(shù)期麻醉管理

ERAS認(rèn)為維持圍手術(shù)期的正常體溫是加速患者康復(fù)的關(guān)鍵［39］， 圍手術(shù)期低溫會(huì)影響血小板功能， 損害凝血酶功能，延長(zhǎng)麻醉藥物的持續(xù)時(shí)間，而且增加外科傷口感染風(fēng)險(xiǎn)［40］。因此，在術(shù)中應(yīng)維持患者的體溫，合理應(yīng)用加熱設(shè)備、預(yù)熱輸液［41］，避免患者體溫的波動(dòng)。術(shù)后的惡心嘔吐是患者最痛苦的不良反應(yīng)之一［42］。惡心嘔吐會(huì)使患者產(chǎn)生強(qiáng)烈的不適感，大量的嘔吐可引起患者的水及電解質(zhì)失衡、反流誤吸、傷口裂開(kāi)，進(jìn)而影響患者術(shù)后的恢復(fù)?？刂菩g(shù)后惡心嘔吐可通過(guò)避免全身麻醉、減少阿片類藥物的使用，必要時(shí)使用5－羥色胺受體拮抗劑和地塞米松［43］。 糖皮質(zhì)激素［44］的使用已被證明能夠有效減少嘔吐。術(shù)后的早期動(dòng)員也是ERAS的一個(gè)關(guān)鍵組成部分［45］?；颊咝g(shù)后長(zhǎng)期臥床休息會(huì)產(chǎn)生很多不良影響，包括胰島素抵抗、肺功能和消化功能下降、增加血栓形成的風(fēng)險(xiǎn)。良好的鎮(zhèn)痛管理和控制并發(fā)癥能夠促進(jìn)患者術(shù)后動(dòng)員。

綜上所述，麻醉作為ERAS中重要的組成部分，ERAS的理念不斷被國(guó)內(nèi)外麻醉醫(yī)生所接受。ERAS理念的提出也不斷優(yōu)化與完善圍術(shù)期麻醉的管理，以患者為中心，保障患者的健康安全，關(guān)注患者的預(yù)后。

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（責(zé)任編輯：肖婷婷）

Advances of Enhanced Recovery after Surgery in Application of Anesthesia//

TIAN He,LI Yalan*
(Department of Anesthesiology, the First Affiliated Hospital of Ji'nan University,Guangzhou 510632,China;*

LI Yalan,E-mail:tyalan@jnu.edu.cn)

Enhanced recovery after surgery(ERAS)has been evaluated in numerous evidence-based medicine and clinical trials, which can obtain the object of improving patients'prognosis and shortening postoperative hospitalization through reducing patients'trauma stress and complications.The concept of ERAS,throughout the anesthesia work,optimizes and improves perioperative anesthesia management.This paper reviewed the research and application of ERAS in anesthesia.

Enhanced recovery after surgery;Anesthesia;Advance

R614

：B

10.3969/j.issn.1674-4659.2017.03.0434

2016－12－04

：2017-02-23

田和 （1990-），男，碩士研究生，研究方向：心血管手術(shù)的麻醉。

*通訊作者：李雅蘭，女，主任醫(yī)師，醫(yī)學(xué)博士，博士研究生導(dǎo)師，E-mail：tyalan@jnu.edu.cn。