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The Concept of Evidence-based Medicine Leads to Better Clinical Outcomes: Guidelines for Enhanced Recovery after Surgery in Gynecologic/ Oncology 2019 Update and Interpretation
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摘要: 加速康复外科(enhanced recovery after surgery, ERAS)目前已在全球范围内明确成为一项能够改善医疗服务、降低医疗成本的手术质量改善倡议。妇科/肿瘤ERAS指南发表于2016年2月, ERAS协会以及国际ERAS妇科分会于2019年2月依据现有最高质量的文献证据进行了首次更新。其中新增预康复、预防手术部位感染策略、患者报告结局、盆腔廓清及腹腔热灌注化疗、出院路径、ERAS评估及报告等6条, 更新文献证据级别及推荐级别10条, 其他5条未发生变化。本次指南更新从围手术期管理方面为妇科/肿瘤临床实践明确了发展方向。Abstract: Enhanced Recovery After Surgery (ERAS) is now firmly established as a global initiative for the improvement of surgical quality, which results in both clinical improvements and cost benefits to the healthcare system. The ERAS Gynecologic/Oncology guidelines were first published in February 2016. It had been updated in February 2019, representing the joint efforts of the ERAS? Society (www.erassociety.org) and the authors from the international ERAS Gynecology chapters, to present an updated consensus review of perioperative care for gynecologic/oncology surgery based on the best current evidence. There are six new items for 2019 guidelines, including prehabilitation, surgical site infection reduction bundles, patient-reported outcomes, pelvic exenteration and hyperthermic intraperitoneal chemotherapy, discharge pathways, and audit and reporting. Compared with the 2016 guidelines, the currently updated guidelines have ten items with differences in the quality of evidence and recommendation grade and five items with no change. This updated ERAS guidelines aim to further disclose the direction of the perioperative clinical practice of gynecologic/oncology.利益冲突 无
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表 1 妇科/肿瘤加速康复指南2019年更新或新增内容
条目 更新/新增 入院前宣教及咨询 推荐级别相同，证据质量增加(由低至中) 预康复 2019年指南新增 术前肠道准备 推荐级别及证据质量相同，新增参考文献 术前禁食及碳水化合物应用 更新总结及推荐，新增参考文献 静脉血栓形成的预防 更新总结及推荐，新增化疗中静脉血栓的预防 减少手术部位感染的系列策略 2019年指南新增(包括预防性应用抗生素、备皮、预防低体温、不放引流/管、预防围手术期高血糖) 标准麻醉方案 更新总结及推荐 微创手术 推荐级别相同，证据质量增加(由低至高) 围手术期补液管理/目标导向液体治疗策略 目标导向液体治疗策略内容更新 去阿片类药物的多模式术后镇痛 新增几种阵痛方案的推荐级别及证据质量 围手术期营养 新增免疫营养内容 术后肠梗阻的预防 推荐级别及证据质量增加(现为强/高) 患者报告结局 2019年指南新增(包括功能康复) 盆腔廓清及腹腔热灌注化疗 2019年指南新增 出院路径 2019年指南新增 加速康复外科评估及报告 2019年指南新增 
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表 2 妇科/肿瘤加速康复指南2019年未更新内容(推荐级别及证据级别均无变化)
条目 内容 术前优化措施 术前4周戒烟戒酒 戒烟——证据级别：高；推荐级别：强 戒酒——证据级别：中；推荐级别：强 麻醉前用药 术前应避免常规应用镇静药物 证据级别：低；推荐级别：强 恶心呕吐的预防 妇科手术应采用两种以上止吐药物的多模式镇吐方案预防术后恶心及呕吐 证据级别：中；推荐级别：强 尿管 尽量24 h内拔除尿管 证据级别：低；推荐级别：强 术后早活动 鼓励患者术后24 h内活动 证据级别：低；推荐级别：强
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