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Application of Different Perioperative Anesthesia Plans and Multimodal Analgesia in Enhanced Recovery after Surgery for Open Pancreaticoduodenectomy
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摘要:
目的 评估不同麻醉与多模式镇痛在开腹胰十二指肠切除术加速康复外科(enhanced recovery after surgery, ERAS)策略中的安全性与有效性。 方法 采用回顾性队列研究, 收集2016年3月至2018年4月北京协和医院39例开腹胰十二指肠切除术患者的临床资料, 其中19例采用ERAS治疗方案(ERAS组), 20例采用常规治疗方案(对照组), 比较两组患者术中血流动力学相关指标、外周组织灌注情况及麻醉相关术后早期恢复指标、住院时间、ICU停留时间、住院费用的差异。 结果 ERAS组患者术中阿片药用量、出室前血乳酸浓度显著低于对照组(P均 < 0.05), 术后第一天外周血白细胞数量及中性粒细胞数量、血糖、术后早期阿片药用量、疼痛及恶心评分、镇痛满意度、拔除导尿管和胃管时间、术后首次下床活动时间、首次排气时间、住院费用各项指标均显著优于对照组(P均 < 0.05);两组患者手术时间、术中血流动力学相关指标、出血量无显著差异(P均>0.05)。 结论 应用不同ERAS麻醉与多模式镇痛策略可有效减轻开腹胰十二指肠切除术患者的手术应激、减少阿片药用量、促进术后早期恢复、缩短住院时间、降低住院费用。 Abstract:Objective This study aimed to evaluate the safety and effectiveness of different anesthetic approaches and multimodal analgesia in enhanced recovery after surgery (ERAS) when applied to open pancreaticoduodenectomy patients. Methods In this retrospective cohort study, we consecutively collected clinical data from 39 patients undergoing open pancreaticoduodenectomy in Peking Union Medical College Hospital from March 2016 to April 2018, among which 19 patients received ERAS strategy (ERAS group) and 20 traditional strategy (control group), and compared the differences in intra-operative hemodynamic changes, post-operative rehabilitation, length of stay, and costs between the ERAS group and the control group. Results The intraoperative opioid consumption and postoperative lactic acid in the ERAS group were lower than those in the control group (both P < 0.05). White blood cell and neutrophil counts on the postoperative day 1, blood glucose, pain score, postoperative nausea and vomiting, postoperative analgesia satisfaction, time to remove the transurethral catheter and nasogastric tube, time to exhaust and ambulation, and medical costs were all improved compared to the control group (all P < 0.05). Whereas operating duration, intraoperative hemodynamic changes, and intraoperative bleeding were comparable between the two groups (all P>0.05). Conclusion Different perioperative anesthesia plans and multimodal analgesia in ERAS strategy are safe when applied to open pancreaticoduodenectomy patients. It could effectively mitigate operative stress, decrease opioid exposure, expedite postoperative rehabilitation, shorten the length of hospital stay, and decrease medical cost. -
Key words:
- enhanced recovery after surgery /
- pancreaticoduodenectomy /
- perioperative
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表 1 两组开腹胰十二指肠切除术患者麻醉与多模式镇痛治疗方案
时间/方案 ERAS组 对照组 术前 麻醉评估 术前麻醉门诊评估心肺功能，指导调整术前用药，消除紧张焦虑；使用呼吸功能锻炼仪训练，持续至出院 术前1 d访视住院患者，评估心肺功能 胃肠道准备 无胃肠道动力障碍者术前禁食4 h，禁水2 h，术前2~4 h口服12.6%果糖+麦芽糊精200 ml 术前禁食水8 h 术中 麻醉方案 全麻复合胸段硬膜外镇痛(行T 7~9胸段硬膜外穿刺置管)，术中0.33%罗哌卡因4~6 ml/h持续泵入；丙泊酚镇静(靶控输入2~4 μg/ml，维持脑电双频指数于50左右)，辅以芬太尼、瑞芬太尼镇痛；吸入50% O2+50%空气 全麻，吸入七氟醚与50% O2+50%笑气混合气体(最低肺泡有效浓度0.8~1.3)，辅以芬太尼、瑞芬太尼镇痛 体温保护 入室至离开恢复室全程使用温毯机，使用加温冲洗液及静脉输注液体，调整手术室温度，并监测体温 不进行主动保温 目标导向液体治疗 入室后放置动脉导管，监测脉压变异量以指导术中输液，如果脉压变异量＞13%或血压低于基础值的30%，则在5 min内输液泵背景输注3 ml/kg乳酸钠林格氏液/羟乙基淀粉/琥珀酰明胶，如果脉压变异量仍＞10%或血压仍低于基础值的30%，则继续液体冲击，如果冲击2次后血压仍低，则使用血管活性药物 入室后放置动脉导管，监测有创动脉压，依据术中心率、血压变化及手术情况进行液体治疗 多模式镇痛 胸段硬膜外持续镇痛(手术切皮前给予帕瑞昔布40 mg或氟比洛芬酯50 mg；手术切皮前给予氯胺酮20~30 mg；辅以芬太尼、瑞芬太尼镇痛) 术中芬太尼、瑞芬太尼镇痛 预防恶心呕吐 对于术后恶心呕吐Apfel评分中危患者诱导前及手术前30~60 min增加一次血清素受体拮抗剂(昂丹司琼/格拉司琼)；对于术后恶心呕吐Apfel评分高危患者，手术结束前30~60 min予血清素受体拮抗剂和胃复安25~50 mg 所有患者诱导时予地塞米松及一次血清素受体拮抗剂(昂丹司琼/格拉司琼)预防恶心呕吐 术后 镇痛 0.2%罗哌卡因患者自控硬膜外镇痛；帕瑞昔布40 mg ×每12 h一次，必要时追加镇痛药物(曲马多、羟考酮)；维持患者疼痛评分低于2分 0.6 μg/ml舒芬太尼患者自控静脉镇痛，必要时追加镇痛药物(曲马多、羟考酮) ERAS：加速康复外科 
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表 2 两组开腹胰十二指肠切除术患者一般资料比较
组别 性别(例) 年龄(x±s，岁) BMI(x±s，kg/m2) ASA分级(例) 是否保留幽门(例) 手术时间(x±s，h) 术中失血量(x±s，ml) 男 女 Ⅰ级 Ⅱ级 Ⅲ级 保留 不保留 ERAS组(n=19) 11 8 57.8±2.3 22.4±2.4 3 15 1 5 14 5.4±0.4 671.1±88.8 对照组(n=20) 12 8 51.0±3.0 21.4±4.1 4 12 4 6 14 5.5±0.3 578.5±51.4 P值 0.894 0.077 0.352 0.157 0.798 0.870 0.362 ERAS：同表 1；BMI：体质量指数；ASA：美国麻醉医师协会
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表 3 两组开腹胰十二指肠切除术患者术中组织灌注指标及阿片药物暴露比较
组别 术中血流动力学指标 血乳酸浓度(x±s，mmol/L) 术中输液量(x±s，ml) 术中尿量(x±s，ml) 术中芬太尼用量(x±s，μg) 入室收缩压(x±s，mm Hg) 最高收缩压(x±s，mm Hg) 入室心率(x±s，次/min) 最高心率(x±s，次/min) 持续血管活性药支持(例) 入室 出室 晶体 胶体 异体血红细胞 异体血浆 总入量 ERAS组(n=19) 127.0±2.7 143.7±4.0 79.4±2.6 96.2±4.6 8 1.4±0.1 1.6±0.2 3258.0±291.5 1253.0±170.4 273.7±92.0 115.8±41.4 4900.0±453.8 894.7±115.3 234.2±35.3 对照组(n=20) 123.9±5.8 142.4±3.4 79.0±3.7 89.6±2.6 4 1.3±0.1 2.9±0.3 3305.0±193.8 700.0±105.1 200.0±68.1 80.0±39.5 4285.0±295.4 762.5±93.8 450.0±43.4 P值 0.634 0.790 0.926 0.212 0.176 0.539 0.002 0.893 0.008 0.521 0.535 0.259 0.377 0.001 ERAS：同表 1
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表 4 两组开腹胰十二指肠切除术患者术后镇痛、早期恢复指标、住院时间及费用比较(x±s)
项目 ERAS组(n=19) 对照组(n=20) P值 术后疼痛VAS评分 术后第1天静息状态 2.1±0.3 1.8±0.3 0.547 术后第2天静息状态 0.8±0.2 1.3±0.3 0.121 术后第1天活动状态 3.1±0.1 3.9±0.3 0.014 术后第2天活动状态 2.4±0.3 3.3±0.3 0.030 镇静评分 0.1±0.1 0.3±0.1 0.323 恶心评分 0.2±0.1 0.7±0.2 0.021 呕吐次数 0.1±0.1 0.6±0.2 0.012 镇痛满意度评分 0.1±0.2 0.6±0.1 0.001 术后阿片药用量(mg) 14.2±5.5 166.0±22.3 0.000 术后恢复指标(d) 拔除气管导管时间 1.0±0.0 1.1±0.1 0.336 导尿管拔除时间 1.2±0.1 1.9±0.2 0.004 胃管拔除时间 1.3±0.2 3.1±0.3 0.000 首次下床活动时间 1.3±0.1 2.0±0.2 0.004 首次排气时间 2.6±0.2 3.8±0.5 0.036 ICU停留时间(d) 1.1±0.1 1.0±0.2 0.447 总住院时间(d) 20.5±1.2 25.4±1.6 0.021 总住院费用(元) 70 799.5±3310.4 76 381.1±9350.5 0.585 ERAS：同表 1；VAS：视觉模拟疼痛评分
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