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摘要: 加速康复临床路径(enhanced recovery pathways, ERPs)的引入促使围手术期医疗模式发生了巨大转变, 现已广泛应用于各外科中, 并取得了不俗成效。加速康复的原则为促进正常功能恢复、全面的围手术期干预、多学科参与和教育以及基于循证医学证据的干预。ERPs最先应用于结直肠和心脏手术, 现已被整形外科、泌尿外科和妇产科等各外科专业广泛采用, 但其在高龄、衰弱或急诊手术患者中的应用仍存在局限性, 可针对这些患者的实际情况进行改良。本文就ERPs的基本原则、应用现状及未来发展方向展开讨论。Abstract: The introduction of enhanced recovery pathways has led to a considerable shift in the paradigm of perioperative care, which are now widely implemented in a variety of surgical specialties with large positive results. The principles of enhanced recovery are promoting recovery of normal functions, comprehensive perioperative interventions, multidisciplinary involvement and education, and evidence-based intervention. Enhanced recovery pathways were initially introduced in colorectal and cardiac surgery, and have been adopted amongst orthopedics, urology, obstetrics and gynecology, and other surgical specialties. Limitations for older or more frail patients, or patients undergoing emergent surgeries should be considered, and the pathways could be modified for those patients. In this review, we discussed the principles and status of enhanced recovery pathways as well as the room for further development.
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Keywords:
- enhanced recovery /
- principle /
- development
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加速康复临床路径(enhanced recovery pathways, ERPs)指一系列的干预措施，一旦应用，可改善患者手术后的临床预后。尽管加速康复的概念在20世纪90年代就已提出[1-2]，但直到很久后，这种做法才获得广泛认可。鉴于加速康复项目获得的成功及其积极结果，以及来自加速康复学会的倡导[3-4]，ERPs现已广泛应用于各类手术中。本文主要讨论ERPs的基本原则、现状以及未来的发展方向。
1. 加速康复临床路径的基本原则
1.1 促进功能恢复至正常
加速康复的初心遵循一个基本认知——尽管手术成功具有显著的治疗获益，但也经常伴随严重的生理紊乱(呼吸循环、肾、胃肠道和免疫等)[5]和功能紊乱(经口进食、睡眠、活动和认知等)[6-7]。ERPs致力于最大限度地减轻上述问题并优化康复过程。
1.2 全方位的围手术期干预措施
加速康复中最重要的医疗模式的转变是将关注点从手术本身转移至更广泛的围手术期。这包括医疗优化、患者教育、最大限度地减少术前禁食和肠道准备，同时积极鼓励恢复功能至正常(如经口进食和术后活动)，并监测术后并发症[8-9]。
1.3 多学科参与和教育
实施ERPs最重要的是多学科团队的参与。这不足为奇，手术前优化患者健康和功能状态需要专业知识和技能；术中最大限度地减少手术应激；并最大限度地促进术后康复[10]。在更广泛的前提下，ERPs的实施还依赖于大量的非临床工作者，其中包括文职人员、管理人员和其他支持团队。
1.4 基于循证医学证据的干预措施
为了确保ERPs的实施能够改善预后并具有成本效益，仅选择可能有益的干预措施至关重要。ERPs的实施通常以患者预后为出发点，以临床试验数据、临床观察和专家共识作为指导[11]。除了基于“外部”证据外，几乎所有成功的ERPs都包括监测干预的依从性及其与预后相关性的分析系统[12]。使用“内部”数据，使加速康复计划能够将其资源分配重点放于最有效的干预措施和依从性差的措施中[13]。
2. 加速康复临床路径的应用现状
2.1 适用范围
ERPs最初仅应用于结直肠和心脏手术，由于观察到在其他外科应用后患者预后亦有改善，ERPs目前已应用于包括骨科、泌尿外科和妇产科等多个学科中[14-18]。
2.2 局限性
ERPs的前提是术后康复，这是一个可以通过积极干预进行优化的过程，但并不一定适用于所有手术患者。如年龄较大或虚弱的患者机体生理储备较少，康复时间较长，且可能无法遵从如早活动等体力要求较高的干预措施[19]；受限于术前准备时间，通常无法对急诊手术患者进行优化，有学者担心在这种情况下，某些加速康复干预措施可能无效，并可能导致更严重的后果，例如术后并发症和再入院率增加[20-21]。另一方面，这也进一步促成了这一特殊群体ERPs的发展。
2.3 特殊群体加速康复临床路径
2.3.1 高龄/虚弱患者
患者年龄是许多手术中的重要预后因素(年龄越大，预后越差)，这与高龄患者术前伴发合并症几率增加、机体生理储备降低以及功能下降相关(图 1)，与围手术期并发症发生率、死亡率增加均密切相关。此外，虚弱用于描述与衰老过程和机体储备能力丧失相关的健康状况，并通常采用功能量表进行评分[22-23]。高龄和虚弱均可导致术后康复显著减缓。研究显示，加速康复计划中纳入的老年患者，其住院时间显著延长[20, 24-25]，并发症发生率较高[20]且依从性更差。当然，可以认为这些观察性研究未考虑到高龄或虚弱患者较长的术后自行恢复过程，且与基线相比，ERPs仍可能改善预后。实际上，最新研究报道，高龄与ERPs干预的依从性显著降低无关[24, 26]。此外，与传统的术后管理相比，外科(骨科、结直肠和神经外科)老年患者的加速康复干预与住院时间显著缩短、并发症/再入院率不显著增加相关[27-30]。同样，Hampton等[31]报道，极度虚弱指数与患者对ERPs的依从性较低无关，同时加速康复干预与虚弱患者的住院时间显著缩短、并发症发生率降低相关。这表明无论患者的年龄和身体状况如何，ERPs均有益。
2.3.2 急诊手术患者
尽管通常术前优化时间有限，急诊手术患者仍可能在ERPs的术中和术后实施中获益。最新研究指出，进行简明的术前患者教育，同时采取ERPs术中和术后干预措施，如目标导向液体治疗、多模式疼痛、术后恶心呕吐预防、早期活动和进食等[32-33]。这些干预措施可显著缩短住院时间[33-34]，降低术后并发症发生率[33, 35]。
3. 展望
ERPs可以被认为是一种标准化、多学科合作和基于循证医学证据，以改善手术治疗和患者预后的方法。尽管ERPs传统上侧重用于能够耐受术后康复过程的择期手术患者，但越来越多的证据表明，该路径可以针对术后并发症风险更高的高龄/虚弱患者以及接受急诊手术的患者进行改良。当然，这仍然需要更多的研究以确定在这些患者中实施ERPs的具体需求和挑战。
利益冲突 无翻译: 赵梦芸, 裴丽坚 (北京协和医院麻醉科)审校: 黄宇光 (北京协和医院麻醉科) -
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