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Active Assessment and Intervention:Issues of Clinical Nutrition in Guidelines for Enhanced Recovery after Gastrointestinal Surgery
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摘要: 加速康复外科(enhanced recovery after surgery, ERAS)在胃肠外科领域开展已有20余年, 尤其在结直肠外科中应用较为广泛。胃肠外科领域已有多部ERAS指南发表, 近年来国内外对胃肠外科ERAS指南又作了多次修订与更新, 有助于进一步规范围手术期胃肠外科管理。临床营养是ERAS中必不可少的重要组成部分, 包括术前营养评估、口服营养补充预康复、术后早期肠内营养等内容, 在指南更新中得到越来越多的关注与重视, 本文就国内外最新更新的ERAS指南中的临床营养部分进行重点解读。Abstract: Enhanced recovery after surgery (ERAS) has been launched and implemented in gastrointestinal (GI) surgery for more than 20 years, especially in colorectal surgery. And several ERAS guidelines for GI surgery have been published. Recently, the ERAS guidelines for improving the standardization of perioperative management of GI surgery have been revised and updated several times in China and abroad. Clinical nutrition, which includes preoperative nutritional risk assessment, pre-rehabilitation such as oral nutritional supplement, and early postoperative enteral nutrition, is an indispensable and important component of ERAS and has been paid more attention. Here we mainly summarized the clinical nutrition part of the updated ERAS guides in GI surgery.
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表 1 胃肠加速康复外科基本环节及核心内容
基本环节 内容 证据质量/推荐强度 预康复 ·包括生活方式干预、运动建议、饮食指导等[9] 低/强 ·生活方式干预：戒烟戒酒至少4周，以减少术后并发症[15-16] 戒烟：高/强；戒酒：低/强 ·健康宣教：门诊及住院个体化病情咨询与解答[17-18] 低/强 术前准备 ·不常规行机械性肠道准备，以减少脱水等发生[19] 中/强 ·术前6 h内禁食固体食物，术前2~3 h口服糖盐(不超过400 ml)以改善术后胰岛素抵抗 低/强 ·不推荐术前麻醉用药(镇静类或抗焦虑药物)，宣教、心理干预和口服糖盐有助于改善 高/强 术前紧张焦虑[20] 术中管理 ·切开皮肤前30~60 min，预防性使用抗生素 高/强 ·全麻或联合硬膜外阻滞等多模式麻醉镇痛，检测麻醉深度 中/强 ·采用加温床垫、加热液体等方式维护体温 高/强 ·胃肠外科微创手术(腹腔镜、机器人系统)可减少手术创伤、缩短术后住院天数 结直肠外科：高/强；胃外科：中/强 ·限制性容量治疗，监测补液量和心输出量 结直肠外科：高/强；胃外科：中/强 ·不常规使用鼻胃管，若必须使用，建议术中留置，术后24 h内拔除[21] 高/强 ·避免或减少腹腔引流[22] 高/强 术后措施 ·导尿管建议术后1~2 d拔除 结直肠外科：低/强；胃外科：高/强 ·积极预防和控制术后恶心呕吐，术前缩短禁食禁饮时间、口服糖盐、减少使用阿片类药物、预防性应用止吐药等多模式 低/强 ·术后多模式镇痛：推荐使用非甾体类抗炎药为基础用药，减少使用阿片类药物，切开和缝合皮肤前局麻浸润等 中/强 ·术后血糖控制 低/强 ·预防术后肠梗阻：硬膜外麻醉、减少阿片类药物使用、避免过量体液输注、早期经口进食、咀嚼口香糖等促进肠蠕动 结直肠外科：高/强；胃外科：低/弱 ·早期下床活动，制定每天活动量计划 结直肠外科：低/强；胃外科：极低/强 ·出院后随访 低/强 
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表 2 营养风险筛查2002评分表
评估项目 赋分 标准 营养损害程度 0分(无) 营养状态正常 1分(轻度) 3个月内体重下降＞5%，进食量约为正常需求量50%~75% 2分(中度) 2个月内体重下降＞5%，或进食量约为正常需求量25%~50%，或BMI在18.5~20.5 kg/m2之间 3分(重度) 1个月内体重下降＞5%(或3个月内体重下降＞15%)，进食量约为正常需求量0~25%，或BMI＜18.5 kg/m2 疾病严重程度 0分(无) 无 1分(轻度) 盆骨骨折，慢性病合并急性并发症，如肝硬化、慢性阻塞性肺病、慢性血液透析、糖尿病、肿瘤等 2分(中度) 腹部大手术*、卒中、重症肺炎、血液透析、血液恶性肿瘤 3分(重度) 颅脑损伤、骨髓移植、重症监护患者(急性生理学和慢性健康状况评分＞10分) 年龄 0分 ＜70岁 1分 ≥70岁 *包括未来1周内计划手术者; BMI:体质量指数
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