快速康复外科在麻醉中应用的研究进展

田和，李雅兰

（暨南大学附属第一医院麻醉科，广东广州510632）

快速康复外科在麻醉中应用的研究进展

田和，李雅兰*

（暨南大学附属第一医院麻醉科，广东广州510632）

快速康复外科 （ERAS）被大量临床循证医学研究所证实，通过减少患者的应激反应和并发症，达到改善患者预后和减少住院时间的目的。ERAS理念贯穿整个麻醉工作中，优化与完善围术期的麻醉管理。本文对ERAS在麻醉中的研究和应用概况作一综述。

快速康复外科；麻醉；进展

快速康复外科 （enhanced recovery after surgery，ERAS）这一理念最早于1997年由丹麦医生Kehlet［1］提出。随着现代医学的不断进步，ERAS逐渐受到关注。ERAS由麻醉医生、外科医生、护士紧密配合，与患者及其家属沟通合作，通过减少患者围术期医疗措施引起的应激刺激，尽可能维持患者自身生理功能的平衡，达到加速康复、减少并发症、缩短住院时间、降低医疗费用的目标。ERAS的理念贯穿整个麻醉工作中，优化与完善围术期的麻醉管理。本文对ERAS在麻醉中的研究和应用概况作一综述。

1 ERAS与术前麻醉教育

ERAS强调术前与患者的沟通。由于患者对麻醉的认识程度不如外科手术［2］，对麻醉的认知缺乏会使患者更容易产生焦虑和恐惧情绪［3］。 早期研究［4］发现， 对患者的沟通与教育可显著缓解术前的焦虑和紧张，同时提高患者对治疗的满意度，有助于早期恢复。术前与患者沟通也能更好实施患者的术后镇痛［5］。 有研究［6］表明，术前教育对减少患者的焦虑有一定作用，但没有充分证据表明术前教育能减少术后不良事件、改善疼痛、促进功能恢复和减少住院时间。从2012年开始，陆续推出了择期直肠／盆腔手术［7］、胰十二指肠切除术［8］、择期结肠手术［9］、 根治性膀胱癌切除术［10］、 胃（部分） 切除术［11］、 妇科常规／肿瘤手术［12］、 减肥手术［13］和肝脏手术［14］的ERAS指南，这些指南建议医护人员与患者进行术前沟通，为缓解患者的术前焦虑，推荐使用短效抗焦虑药。

2 ERAS与术前禁食

ERAS改变了传统术前禁食禁饮的观念。在传统观念中，择期手术需要在午夜前禁食，以避免术中出现反流误吸等情况。循证医学研究中，并没有证据证明长期禁食的安全性［15］，从2009年开始就有ERAS相关共识指南允许患者在麻醉诱导前6 h摄入固体食物和2 h摄入透明液体［16］。2011年，欧洲麻醉学会提出的成人与儿童围术期禁食指南也推荐术前6 h禁固体食物，2 h禁水［17］。ERAS除了放宽术前禁食时限，还建议患者手术前2～3 h口服富含碳水化合物的液体300 mL［16］，临床实验证明术前口服碳水化合物可减少患者焦虑情绪、术后患者蛋白质分解［18］和胰岛素抵抗［19］。 胰岛素抵抗可引起高血糖，进而导致免疫抑制，高血糖也是术后患者手术部位感染的重要危险因素［20］。然而，术前口服碳水化合物的观念并没有得到普遍的接受。一项临床随机对照试验［21］中，相对于术前口服饮用水来说，术前口服碳水化合物饮料并没有显示出葡萄糖代谢、胰岛素抵抗、皮质醇浓度和血流动力学的差异，对术后并发症以及患者的满意程度也无显著影响。

3 ERAS与麻醉方案的选择

ERAS推荐使用联合麻醉，重新认识局部麻醉、神经阻滞和椎管内麻醉。传统观念中，麻醉医生术中关注的重点是患者的疼痛、生命体征、血流动力学稳定等，ERAS的观念增加了对提供最佳的镇痛和减轻手术的应激反应的认识。ERAS推荐联合麻醉的应用，即全身麻醉 ＋局部或区域麻醉，特别是神经阻滞和椎管内麻醉已经被许多的基础和临床研究证实，其能够减少手术应激反应、改善微循环和组织灌注、降低胰岛素抵抗、减少膈肌活动的抑制和提供良好的镇痛效果［22］。一项关于膝关节表面置换的临床研究［23］中，相对于全身麻醉，椎管内麻醉的输血率更低，同时可减少术后并发症。特别是针对睡眠呼吸暂停综合征、椎管内麻醉下进行手术的患者，其并发症风险也更低，更安全［24］。此外， 麻醉和镇痛管理并不是孤立的，需要在ERAS的概念下联合应用，改善术后镇痛，减少阿片类药物用量和相关的副作用。一项腹部外科手术后死亡率的荟萃分析［25］显示，与单用全身麻醉相比，合并使用胸段硬膜外镇痛后死亡率降低40%，同时减少了呼吸和心血管的并发症，降低了深静脉血栓的形成风险，加快了胃肠道功能恢复。

4 ERAS与术后镇痛

ERAS优化围手术期的疼痛管理，减少阿片类药物的使用。疼痛是围术期不可避免的不良反应，它是由创伤组织引起的局部炎性反应，导致周围神经刺激［26］。良好的术后镇痛能够预防患者疼痛、促进其恢复和提高满意度。在传统的术后镇痛中，阿片类药物是镇痛药的主体部分，但阿片类镇痛有许多副作用与并发症， 包括呼吸抑制、 激素和免疫功能紊乱［27］，有临床研究［28］表明阿片类药物的使用可增加术后肠梗阻发生率。因此，为了减少阿片类药物的不良反应，控制和减少阿片类药物的使用，寻找和替代阿片类药物已经成为疼痛管理优先考虑的问题［29］。 有研究［30］推荐使用椎管内麻醉镇痛、 对乙酰氨基酚、加巴喷丁和环氧化物酶（cyclooxygenase，COX）抑制剂。 对乙酰氨基酚［31］和非甾体抗炎［32］药物可应用于术后镇痛，减少阿片类药物的使用，但单靠这些药物是不够的，需要多模式的术后镇痛疗法，包括硬膜外镇痛、外周神经阻滞和手术切口周围局部浸润镇痛。硬膜外镇痛应合理控制局麻药浓度，减少局麻药的不良反应。通过在硬膜外添加阿片类药物或可乐定可减少局麻药浓度，但同时也会产生镇静和低血压，影响患者恢复［33］。近年来，连续的周围神经阻滞已成为热门研究方向，且被证实是有效的术后镇痛方式［34］。周围神经阻滞中联合应用地塞米松等佐剂可延长镇痛时间，这可能与佐剂引起局部血管收缩，影响周围神经吸收和全身抗炎作用相关［35］。此外，临床试验证明联合口服使用抗惊厥药物普瑞巴林［36］和抗抑郁药物度洛西汀［37］也可减少疼痛和阿片类药物的使用。冰袋［38］也可用于减少重大腹部手术术后疼痛，其使用简单、经济有效、无药物毒副作用。

5 ERAS优化围手术期麻醉管理

ERAS认为维持围手术期的正常体温是加速患者康复的关键［39］， 围手术期低温会影响血小板功能， 损害凝血酶功能，延长麻醉药物的持续时间，而且增加外科伤口感染风险［40］。因此，在术中应维持患者的体温，合理应用加热设备、预热输液［41］，避免患者体温的波动。术后的恶心呕吐是患者最痛苦的不良反应之一［42］。恶心呕吐会使患者产生强烈的不适感，大量的呕吐可引起患者的水及电解质失衡、反流误吸、伤口裂开，进而影响患者术后的恢复。控制术后恶心呕吐可通过避免全身麻醉、减少阿片类药物的使用，必要时使用5－羟色胺受体拮抗剂和地塞米松［43］。 糖皮质激素［44］的使用已被证明能够有效减少呕吐。术后的早期动员也是ERAS的一个关键组成部分［45］。患者术后长期卧床休息会产生很多不良影响，包括胰岛素抵抗、肺功能和消化功能下降、增加血栓形成的风险。良好的镇痛管理和控制并发症能够促进患者术后动员。

综上所述，麻醉作为ERAS中重要的组成部分，ERAS的理念不断被国内外麻醉医生所接受。ERAS理念的提出也不断优化与完善围术期麻醉的管理，以患者为中心，保障患者的健康安全，关注患者的预后。

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（责任编辑：肖婷婷）

Advances of Enhanced Recovery after Surgery in Application of Anesthesia//

TIAN He,LI Yalan*
(Department of Anesthesiology, the First Affiliated Hospital of Ji'nan University,Guangzhou 510632,China;*

LI Yalan,E-mail:tyalan@jnu.edu.cn)

Enhanced recovery after surgery(ERAS)has been evaluated in numerous evidence-based medicine and clinical trials, which can obtain the object of improving patients'prognosis and shortening postoperative hospitalization through reducing patients'trauma stress and complications.The concept of ERAS,throughout the anesthesia work,optimizes and improves perioperative anesthesia management.This paper reviewed the research and application of ERAS in anesthesia.

Enhanced recovery after surgery;Anesthesia;Advance

R614

：B

10.3969/j.issn.1674-4659.2017.03.0434

2016－12－04

：2017-02-23

田和 （1990-），男，硕士研究生，研究方向：心血管手术的麻醉。

*通讯作者：李雅兰，女，主任医师，医学博士，博士研究生导师，E-mail：tyalan@jnu.edu.cn。