基于快速康复外科理念的麻醉管理在胃癌手术患者中的应用

发布时间：2018-05-27 12:14

本文选题：快速康复外科 + 麻醉管理　；参考：《南方医科大学》2017年硕士论文

【摘要】：研究背景:快速康复外科(fast-track surgery,FTS)理念是针对进行择期手术的患者,围手术期联合运用有循证医学证据的一系列优化措施,有效地避免或减轻患者的应激反应以此来加快患者的术后康复,同时降低术后的并发症发生率以及死亡率。这一理念尤其适用于腹部外科手术,并且需要外科、麻醉科及护理团队的多学科合作。这种多模式观念致力于优化患者的术后康复,并且通过一些措施来改善患者预后。这一转变已在国外临床普遍推广应用,并取得了较好的成果,在这个过程中,麻醉科也发挥了十分重要的作用。基于快速康复外科理念的麻醉管理贯穿于整个围术期,包括术前进行详细的宣教与咨询、对术前患者的用药方案进行调整、术前禁食禁水时间的改变、麻醉方式的优化、麻醉管理的细化和改进以及对术后不良并发症的早期干预等。随着麻醉相关技术的不断进步与发展,麻醉科在进一步推动FTS理念在临床各学科中的应用和发展将起到越来越重要的作用。然而,FTS理念并未在我国临床得到广泛应用,很多外科医生和麻醉医生对这一理念还不甚了解,仅有少数大型医院真正开展研究和应用,FTS理念的开展仍然任重道远。在我国,上消化系统肿瘤依然是我国常见的恶性肿瘤和主要的肿瘤死因,据统计我国2011年恶性肿瘤发病率中,胃癌在女性中排第三位,在男性中排第二位,在我国恶性肿瘤死亡率中胃癌在女性中排在第二位,在男性中排在第三位。因此,探讨基于快速康复外科理念的麻醉管理在胃肿瘤手术过程中的有效性、安全性以及相应的机理更具有现实意义和挑战性。本文就基于快速康复外科理念的麻醉管理在胃肿瘤手术中的应用及作用进行阐述。研究目的及意义:FTS理念已经在国外得到了普遍应用,并且已经发展得相对成熟,但是在我国还未得到足够重视。为了完善相关的基础理论,需要进一步应用到临床实践中,并且需要大量样本随机对照研究,同时运用循证医学方法客观分析及综合评价这一举措。因此本文就基于快速康复外科理念(FTS理念)的麻醉方式相对于传统麻醉方式在胃肿瘤手术中的治疗效果的安全性与优越性进行探讨。研究内容和过程:我们共收集了 2016年8月至2016年12月于南方医科大学南方医院普外科进行腹腔镜下胃部分切除或全胃切除术的60例患者为观察对象,男34例,女26例,年龄18-65岁,体重45-80Kg,美国麻醉医师学会麻醉分级(ASA)Ⅰ或Ⅱ级,手术时间为2-4小时,均取平卧位。纳入标准为:①精神状态正常的成年人(18岁≤年龄≤65岁);②肝肾功能正常;③术前未服用任何影响代谢的药物;④拟行择期手术。排除标准;①术前有高血压、糖尿病、肠梗阻和严重心、肺、肝、肾功能损害患者;②患有中枢神经系统疾病患者;③孕妇和哺乳期;④有食物及药物过敏史患者。采用随机数字法分为FTS组和传统组,每组30例。其中FTS组围术期采用快速康复外科理念所规定的处理流程,传统治疗组则按照传统治疗方式进行处理。观察所有病例围术期各项参数,并对以下指标进行统计:两组患者入室后询问口渴、饥饿情况;记录麻醉诱导前(To)、肌松起效喉镜置入前(Ti)及插管后 1min(T2)、3min(T3)、5min(T4)、1Omin(T5)、20min(T6)的心率(HR)、平均动脉压(MAP);术后恶心呕吐发生例数;术后12h(t1)、24h(t2)、48h(t3)两组患者的伤口VAS评分、按压镇痛泵次数、镇痛药物使用剂量;术后首次排气时间、首次排便时间;患者术后的住院时间、住院费用等指标。结论:FTS组患者在麻醉前出现口渴、饥饿的发生率与传统治疗组相比明显地降低;FTS组患者在诱导过程中与传统组相比血流动力学相对稳定;FTS组患者术后恶心以呕吐的发生率较传统组低;两组患者在术后相同时间点的VAS疼痛评分无显著性差异,但传统治疗组追加按压镇痛泵的次数比FTS组多;FTS组患者术后首次排气时间、排便时间均较传统治疗组提前,且住院天数及住院费用均比传统治疗组减少。基于FTS理念的麻醉管理方式有助于加快患者的术后康复,有利于提升患者的满意度。
[Abstract]:Background: the concept of fast-track surgery (FTS) is for patients undergoing elective surgery. A series of optimization measures with evidence-based evidence are combined in the perioperative period to effectively avoid or reduce the stress response of the patients in order to accelerate the postoperative recovery of the patients, and reduce the incidence of postoperative complications and death. This concept is especially suitable for abdominal surgery, and requires the multidisciplinary cooperation of surgery, anesthesiology and nursing teams. This multimodal concept is devoted to optimizing patients' postoperative rehabilitation and through some measures to improve the patient's prognosis. This transformation has been popularized and achieved good results in foreign countries. The anesthesiology department also played an important role in this process. Anesthesia management based on the concept of rapid rehabilitation surgery throughout the whole perioperative period, including detailed preoperation and consultation before the operation, the adjustment of the medication plan for the patients before the operation, the modification of the time of water prohibition, the optimization of anaesthesia, the refinement and modification of the management of anesthesia. Advance and early intervention for postoperative adverse complications. With the continuous progress and development of anesthesia related technologies, the anesthesiology will play an increasingly important role in further promoting the application and development of the FTS concept in clinical disciplines. However, the concept of FTS has not been widely used in clinical practice in our country, many surgeons and anesthesiologists. The concept of FTS is still a long way to go. In China, the cancer of the upper digestive system is still the common malignant tumor and the main cause of death in our country. According to the statistics of the incidence of malignant tumor in 2011, third of the women are in the female, and the male is in the male. In the middle row second, the mortality rate of cancer is second in women and third in men. Therefore, it is more realistic and challenging to explore the effectiveness, safety and mechanism of anesthesia management based on the concept of rapid rehabilitation surgery in the procedure of gastric cancer. The application and role of anaesthesia in the concept of complex surgery in the operation of gastric cancer. Purpose and significance: FTS concept has been widely used abroad, and has developed relatively mature, but it has not been paid enough attention in China. In order to improve the basic theory, it needs to be further applied to clinical practice, In addition, a large number of sample randomized controlled studies are needed and an objective analysis and comprehensive evaluation of evidence based medicine is used. Therefore, this paper discusses the safety and superiority of the anesthetic methods based on the concept of rapid rehabilitation surgery (FTS concept) relative to the traditional anesthetic methods in gastric cancer surgery. Process: We collected 60 cases of laparoscopic partial gastrectomy or total gastrectomy in the Department of general surgery, Southern Hospital of Southern Medical University from August 2016 to December 2016. 34 men, 26 women, 18-65 years old, 45-80Kg, and the American anesthesiologist's classification (ASA) I or class II, the operation time was 2-4 small. The standard was: (1) the adults with normal mental state (18 years of age < < < < 65 years of age); (2) normal liver and kidney function; (3) not taking any drugs that affect metabolism before operation; (4) to do elective surgery. Patients with systemic disease; (3) pregnant and lactation; (4) patients with a history of food and drug allergy. The patients were divided into group FTS and the traditional group, with 30 cases in each group. Among them, the perioperative period of group FTS was treated with the process of rapid rehabilitation surgery, and the traditional treatment group was treated according to the traditional treatment. All cases were observed in the perioperative period. All the parameters, and the following indexes were counted: two groups of patients were asked to ask for thirst and hunger after admission; before recording anesthesia induction (To), 1min (T2), 3min (T3), 5min (T4), 1Omin (T5), 20min (T6), mean arterial pressure, postoperative nausea and vomiting, and postoperative cases of postoperative nausea and vomiting. T3) the VAS score of the two groups of patients, the times of analgesic pump, the dosage of analgesic drugs, the first exhaust time after the operation, the time of the first defecation, the hospitalization time after the operation, the cost of hospitalization, and so on. Conclusion: the patients in group FTS were thirsty before anesthesia, the incidence of hunger was significantly lower than that in the traditional treatment group; the patients in group FTS were induced to be induced. In the FTS group, the incidence of nausea and vomiting after operation was lower than that of the traditional group. There was no significant difference in the VAS pain score between the two groups at the same time point after operation, but the times of the traditional treatment group were more than the FTS group; the first time after the operation and the time of defecation in the FTS group were the first time and the time of defecation. Compared with the traditional treatment group, the number of hospitalization days and hospitalization costs are less than those of the traditional treatment group. The anesthesia management based on the FTS concept can help to accelerate the postoperative recovery of the patients and improve the satisfaction of the patients.
【学位授予单位】：南方医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R735.2;R614

【参考文献】