儿童矫正手术后增强快速康复治疗的前瞻性研究
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Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations
背景与目的
术后增强快速康复治疗(ERAS)方案是一套提高恢复速度的围手术期策略，在成人中已有很好的应用，但在儿童中还没有得到很好的研究。本研究的目的是确立小儿泌尿外科重建手术的安全性和有效性。与历史对照相比，ERAS可以缩短住院时间，减少并发症。
方 法
获得机构审查委员会批准，如果做了泌尿外科重建，包括肠吻合术，对年龄<18岁的患者进行前瞻性登记。ERAS包括：不做肠道准备，术前口服碳水化合物液体，避免阿片，局部麻醉，可行时腹腔镜，术后不做鼻胃管，早期喂食，早期静脉输液(IVF)。最近(2009-2014年)的历史对照者在年龄、性别、胃腹腔分流状态和患者是否正在接受膀胱扩大等方面的比例为2：1。结果是方案依从性，住院时间(LOS)，急诊(Ed)访问，30天内再入院，手术后90天内发生的再手术和不良事件。
结 果
共有26名历史患者和13名ERAS患者被包括在内。中位年龄分别为10.4(IQR 8.0~12.4)和9.9岁(IQR 9.1~11)，两组间差异无显着性意义(P>38%)，术前腹部手术38%例，脊柱裂扩大率88%例，脊柱裂原发率62%例，两组间差异无显着性(P>0.05)。ERAS可显著改善术前液体负荷(p<0.001)、避免类阿片(p=0.046)、早期终止IVF(p<0.001)和早期喂养(p<0.001)，实施ERAS后，协议依从性由术前的8/16(IQR4-9)提高到12/16(IQR11-12)。Los从8天下降到5.7天(p=0.520)，任何级别的并发症从2.1降至1.3(0.71，95%ci 0.51~0.97)。在所有ERAS患者中，有较少的并发症，但在急诊科(Ed)检查、再入院和再手术方面没有差异。
结 论
实施改进了医疗服务的一致性。ERAS改善的原则包括通过避免过多的液体、多模式镇痛和早期喂养来维持正常血容量。在不增加再入院、再手术或ED访视的情况下，儿童矫正手术后， ERAS减少了住院时间和90天并发症。
原始文献摘要
Rove KO, Brockel MA, Saltzman AF；Prospective study of enhanced recovery after surgery protocol in children undergoing reconstructive operations. J Pediatr Urol. 2018 Feb 1. pii: S1477-5131(18)30006-8. doi: 10.1016/j.jpurol.2018.01.001.
BACKGROUND:
Enhanced recovery after surgery (ERAS) protocol is a set of peri-operative strategies to increase speed of recovery. ERAS is well established in adults but has not been well studied in children.
OBJECTIVE:
The purpose of the current study was to establish the safety and efficacy of an ERAS protocol in pediatric urology patients undergoing reconstructive operations. It was hypothesized that ERAS would reduce length of stay and decrease complications when compared with historical controls.
STUDY DESIGN:
Institutional Review Board approval was obtained to prospectively enroll patients aged <18 years if they had undergone urologic reconstruction that included a bowel anastomosis. ERAS included: no bowel preparation, administration of pre-operative oral carbohydrate liquid, avoidance of opioids, regional anesthesia, laparoscopy when feasible, no postoperative nasogastric tube, early feeding, and early removal of intravenous fluids (IVF). Recent (2009-2014) historical controls were propensity matched in a 2:1 ratio on age, sex, ventriculoperitoneal shunt status and whether the patient was undergoing bladder augmentation. Outcomes were protocol adherence, length of stay (LOS), emergency department (ED) visits, re-admission within 30 days, re-operations and adverse events occurring within 90 days of surgery.
RESULTS:
A total of 26 historical and 13 ERAS patients were included. Median ages were 10.4 (IQR 8.0-12.4) and 9.9 years (IQR 9.1-11), respectively (P = 0.94) (see Summary Table). There were no significant between-group differences in prior abdominal surgery (38% vs 62%), rate of augmentation (88% vs 92%) or primary diagnosis of spina bifida (both 62%). ERAS significantly improved use of pre-operative liquid load (P < 0.001), avoidance of opioids (P = 0.046), early discontinuation of IVF (P < 0.001), and early feeding (P < 0.001). Protocol adherence improved from 8/16 (IQR 4-9) historically to 12/16 (IQR 11-12) after implementation of ERAS. LOS decreased from 8 days to 5.7 days (P = 0.520). Complications of any grade per patient decreased from 2.1 to 1.3 (OR 0.71, 95% CI 0.51-0.97). There were fewer complications per patient across all grades with ERAS. No differences were seen in emergency department (ED) visits, re-admissions and re-operations.
DISCUSSION:
Implementation improved consistency of care delivered. Tenets of ERAS that appeared to drive improvements included maintenance of euvolemia through avoidance of excess fluids, multimodal analgesia, and early feeding.
CONCLUSION:
ERAS decreased length of stay and 90-day complications after pediatric reconstructive surgery without increased re-admissions, re-operations or ED visits. A multicenter study will be required to confirm the potential benefits of adopting ERAS.
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