Chinese Journal of Tissue Engineering Research ›› 2017, Vol. 21 ›› Issue (3): 456-463.doi: 10.3969/j.issn.2095-4344.2017.03.024
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Zhu Shi-bai1, Zhai Jie2, Jiang Chao1, Ye Can-hua1, Chen Xi1, Weng Xi-sheng1, Qian Wen-wei1
Online:
2017-01-28
Published:
2017-03-14
Contact:
Qian Wen-wei, M.D., Associate chief physician, Associate professor, Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100005, China
About author:
Zhu Shi-bai, Studying for master’s degree, Department of Orthopedic Surgery, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Science, Beijing 100005, China
Supported by:
a grant from Peking Union Medical College Hospital of Chinese Academy of Medical Science, No. 81572110
CLC Number:
Zhu Shi-bai, Zhai Jie, Jiang Chao, Ye Can-hua, Chen Xi, Weng Xi-sheng, Qian Wen-wei. Application of “enhanced recovery after surgery” in the perioperative period of total knee arthroplasty[J]. Chinese Journal of Tissue Engineering Research, 2017, 21(3): 456-463.
2.1 术前措施 2.1.1 评估、宣教 首先从患者入院开始,对患者的现有疾病以及其他系统的疾病都要做出全方位的评估。其次就是关于纳入快速康复的标准。有文献指出,对于年龄较大、内科合并症较多、术前血压、血糖控制不佳的患者不适合纳入快速康复的实施方案[2-3]。但近期一篇前瞻性的研究分析了3 112例行初次全膝关节置换的患者,结果表明对于年龄较大、术前合并心肺疾病的患者,其术后并发症、出院时间、与再入院率等方面与对照组相比并无明显统计学差异[4]。而也有类似文献表明,对于吸烟、饮酒、糖尿病以及术前功能状态差的患者,快速康复方案同样可取得了优良的结果[5-7]。所以说,对于患者的纳入标准,并没有严格的限制,大多数患者通过快速康复都能获得较好的结果。关于术前健康教育、功能锻炼等对于减少患者住院天数已有大量文献报道,除此之外,还可起到改善减轻焦虑情绪、提高满意度、缓解术后疼痛、改善功能的作用[8-11]。同时,设立出院标准方法可以让患者感觉到一旦自己术后达到这种标准,就可以出院,从而弱化了患者的患者意识,在一定程度上加速了康复的过程,如独立的个人护理、辅助装置下能走50 m、膝关节屈伸活动度0°-90°、目测类比评分< 5分(口服药物可控制疼痛)等[12]。 2.1.2 禁食禁水 有研究表明,骨科择期手术患者术前禁食时间> 12 h,禁水> 4 h[13]。这种传统的禁食水方案不仅会造成患者产生口渴、饥饿、烦躁、头痛、脱水、血容量减少、低血糖等不适,而且加上手术的创伤, 会导致机体的消耗进一步增加。根据研究显示,术前禁食6 h是完全足够的,而水在胃肠道内的半排空时间仅为10-20 min,摄入1 h后有95%完全代谢[14]。而且有研究表明,术前2 h口服液体不仅不增加胃内容量,反而可刺激胃的排空[15]。同时,也有研究者指出术前口服糖水还可以起到减轻术后应激、改善预后的作用,从而加速患者康复过程,在一定程度上缩短住院时间[16]。在美国麻醉医师学会在重新修订的术前禁食指南也明确指出择期手术患者术前6 h可进食固体食物,术前2 h可进食不含乙醇、含少许糖的透明液体[17]。 2.1.3 超前镇痛 关于超前镇痛,已有许多研究指出其对于术后镇痛可起到优良的效果。其概念是在20世纪初由Crile[18]提出,原意是指在伤害性刺激发生前给予镇痛治疗,阻断伤害性传入刺激到达中枢神经系统,从而减轻伤害后疼痛。但是随着对疼痛分子机制的研究进展和临床经验的积累,人们逐渐认识到超前镇痛的实质其实应该是减少有害刺激传入所导致的外周和中枢敏感化,以抑制神经元可塑性变化,并不特指“切皮前”所给予的镇痛。目前临床应用最多的是非类固醇抗炎类药物,包括塞来昔布、双氯芬酸等,主要通过抑制环氧化酶来减少前列腺素的释放,抑制前列腺素介导的化学或机械感受器的增敏,从而预防中枢或外周敏化以实现超前镇痛。国外研究也表明,非类固醇抗炎药物超前镇痛可抑制前列腺素的早期产生,削弱痛觉过敏,减轻手术相关炎症[19]。已有大量文献证实,术前使用非类固醇抗炎药可减少术后目测类比评分,减少阿片类药物使用以及加快术后膝关节功能的恢复[20]。其次就是对乙酰氨基酚,作为传统的解热镇痛药物,通过抑制中枢神经系统前列腺素合成酶,同样可以减少前列腺素合成和释放达到镇痛的效果[21]。而加巴喷丁是一种新型的抗癫痫类药物,其结构与γ-氨基丁酸类似,可用于带状疱疹神经痛和多发性硬化引起疼痛,但国内外许多学者将其用于膝关节置换手术的超前镇痛,同样可取得了令人满意的结果[20,22]。但目前关于超前镇痛的使用药物种类、时间、剂量等方面均无同一标准,今后还需要更多的临床研究去指导超前镇痛的具体方案。 2.1.4 类固醇激素的应用 类固醇激素的应用现今成为临床工作中研究的热点之一,对于膝关节置换来说,围术期使用激素类药物不仅可降低术后恶心、呕吐的发生率,并能起到减轻炎症、术后镇痛的作用。Fujii等[23]将患者随机分为4组,术前分别予以地塞米松4,8,16 mg及安慰剂,结果表明随着剂量的增大,患者术后恶心、呕吐的发生率呈下降趋势,并且术后并无感染等并发症的发生。Backes等[24]在术中给予患者10 mg地塞米松也得出了同样的结论,并且还可显著减少术后患者的目测类比评分,降低C-反应蛋白水平,缩短住院时间。而一篇回顾性研究对6 294例行关节置换的患者进行了分析,其中557例在围术期使用了不同剂量的地塞米松,发现无论是切口感染还是深部组织的假体周围感染,其发生率与对照组相比差异并无显著性意义[25]。从研究看目前关节外科大夫所关心的并不是激素类药物的使用时间,而是使用激素是否会造成术后的感染,因为感染是关节手术灾难性的并发症。而对于其具体使用措施还没有明确的定论及标准。所以今后还需要更多的研究去分析围手术期激素类药物的具体使用时间、剂量以及给药方式,从而达到最优的效果。 2.1.5 是否放置尿管 对于初次膝关节置换,文献报道显示术后发生尿潴留的概率为0-75%[26]。临床当中普遍选择常规放置尿管来达到预防术后尿潴留的目的,而放置尿管的危害主要有尿路感染,尿道损伤、刺激,影响术后早期功能锻炼等。但根据2015年的一项随机对照试验研究,314例患者随机分为导尿组与非导尿组,结果表明术后发生尿潴留的概率无统计学差异,而不导尿组术后尿路感染、尿路刺激症状显著低于对照组[27]。通过分析尿潴留患者的特征,发现年龄、ASA等级、男性、前列腺增生、术中液体量、手术时间、椎管内麻醉等是发生尿潴留的危险因素[27-28]。所以除了危险因素较多的患者外,大多数患者行膝关节置换不需放置导尿管。 2.2 术中措施 2.2.1 麻醉方式 以往研究往往推荐采用腰硬联合的麻醉方式,主要是因为其对心肺功能影响小,而且通过硬膜外导管给予镇痛药物,可显著缓解术后疼痛,利于早期康复锻炼[29]。但是由于其尿潴留、硬膜外血肿、感染等风险,以及对下肢运动功能的阻滞延迟了术后早期下地活动时间等不利影响,往往与快速康复的理念有所出入,对患者的早期功能锻炼有较大干扰,所以目前针对采用全身麻醉或者腰硬联合等椎管内麻醉的两种麻醉方式出现了较大的争论。并且近期有多个随机对照试验研究比较了全身麻醉对比椎管内麻醉在膝关节置换快速康复过程中的应用,发现全身麻醉的患者术后出院时间与下地时间均早于椎管内麻醉组,并且其疼痛评分与恶心呕吐发生率等方面较椎管内麻醉组均无显著的提高,椎管内麻醉组的患者仅仅是在术后短期内的目测类比评分较低,之后便普遍高于全身麻醉组,并且通过调查,患者往往更加青睐于全麻这一麻醉方式[30-31]。总结来说,随着现代麻醉技术的提高以及术中丙泊酚、瑞芬太尼等应用以及镇痛模式的多样化,或许在临床当中要重新考虑应用全身麻醉这一传统的麻醉方法,同时,也需要更多的随机对照试验与前瞻性研究来对比两者在临床中应用效果的差异,进一步筛选出安全而更加适合快速康复方案的麻醉方式,加速患者康复过程[32]。此外,麻醉过程当中,在良好的镇痛、镇静及肌松的情况下,应尽量减低对胃肠道影响的药物用量,避免术后胃肠蠕动减慢以及恶心、呕吐等不良反应。 2.2.2 术中镇痛方式 周围神经阻滞的方法曾经被认为是膝关节置换术中的金标准。对比股神经阻滞与收肌管阻滞,虽然股神经阻滞术后镇痛效果明显,但其会损害股四头肌功能,延缓锻炼进展,并有一定增加跌倒概率的风险[33]。而收肌管阻滞与其相比,镇痛效果相当,其主要作用于感觉支,对运动支的影响较小,所以对术后的早期康复可起到至关重要的作用[34-35]。 关节周围浸润注射以镇痛药物为主的混合药物,即所谓的鸡尾酒疗法,同样可达到术后缓解疼痛的目的,目前也广泛运用到初次全膝关节置换手术之中,并且可以起到优于周围神经阻滞或硬膜外给药的镇痛效果[36-38]。但是目前鸡尾酒疗法的配方各个医院都不尽相同,但归根到底都是以罗哌卡因等局麻药物为主,之后再与肾上腺素、类固醇激素或者阿片类药物等制成的混合制剂,从而达到止痛的目的。近年来,随着快速康复在关节置换领域中的发展,关节周围浸润注射的方法甚至有替代周围神经阻滞之势,除了其镇痛效果明确以外,还可归因为操作简便,在术中可由手术医师独立完成,并且术后对股四头肌影响小,不会因额外的导管产生对患者早期功能锻炼的不便,更加符合快速康复的理念。 布比卡因脂质体在关节周围浸润注射中的应用现已成为临床研究中的热点之一,其主要原理是通过延长局部药物的作用时间来达到镇痛效果,甚至有研究指出,单次局部应用之后,其镇痛时间可长达96 h之久,并且在2013经美国FDA认证可作为外科软组织注射应用,起到减轻术后疼痛的作用[39-40]。但随着临床研究的深入,对布比卡因脂质体在膝关节置换术中的应用褒贬不一,有学者将其应用于关节周围浸润注射,发现可显著降低患者术后的疼痛水平以及减少阿片类药物的使用剂量,起到缩短住院时间,加速康复的作用[41-42],但也有研究者对比传统的罗哌卡因,指出布比卡因脂质体不仅不能达到理想的效果,甚至昂贵的药物费用大大增加了患者的经济负担[39,43]。虽然布比卡因脂质体理论上具有良好的应用前景,但其在注射过程中可能往往由于药物释放速度减慢,降低了在目标组织内的药物浓度等原因而使其作用效果远达不到预期水平,在日后尚需大量的临床研究来证实其效果,指导临床的应用。 2.2.3 氨甲环酸的使用 氨甲环酸主要通过保护纤维蛋白不被纤溶酶溶解达到止血效果。有研究表明,初次膝关节置换围手术期静脉使用氨甲环酸可降低失血量约500 mL,降低输血量1.43 U[44]。而国家卫计委统计了65家医院8 259膝关节置换患者,结果表明,不管是静脉还是局部应用,都可显著减少围术期的输血率,其中静脉+局部联合应用效果最好。但是氨甲环酸的使用方式、剂量、时间等方面都存在着较大的差异,并无统一标准。一篇近期的综述文献罗列出了多个随机对照试验研究中的氨甲环酸应用方案,虽然使用方法上都存在着不同,但是都能减少术后失血量,而不增加症状性的静脉血栓栓塞事件的发生率[45]。而这篇综述也对氨甲环酸的使用给出了一些指导性的建议,如下:①推荐剂量为10-20 mg/kg,或固定剂量1 g;②对于不使用止血带的患者,切开皮肤前给予固定剂量1 g,而使用止血带的患者,首次给药时间在松止血带前5-10 min为宜;③局部应用氨甲环酸,超过2 g的止血效果要好于低剂量;④术后2-4 h再静脉予以固定剂量的1 g;⑤高血栓风险患者,局部应用应该作为首选。而Shin等[46]通过荟萃分析指出局部与静脉应用氨甲环酸相比较在输血率、引流量、血红蛋白水平等方面并无明显差异,对于静脉应用,推荐两次给药时间分别是应用止血带前20 min与松开止血带前15 min,剂量10 mg/kg为宜,而对于高血栓栓塞风险患者,局部应用可作为首选方式,推荐剂量为2 g加入至100 mL生理盐水在缝合切口后经引流管注入。 2.2.4 是否放置引流管 关于初次膝关节置换是否常规放置引流管存在着较大的争议,以往支持的文献指出通过安放引流管可减少术后感染发生率、减少隐形失血、促进术后康复,不增加其他并发症[47-49];而不支持安放引流管的相关文献则指出安放引流会增加感染率、增加术后失血、不利于康复,同时不安放引流也不增加其他并发症[50-51]。而根据最近一篇meta分析结果,比较了安放与不安放引流管的差异,指出对于感染、静脉血栓形成、功能评分在两者中差异均无显著性意义,但是在输血率方面,引流组略大于非引流组,而非引流组切口渗液、伤口瘀斑的概率要高于引流组[52]。所以对于初次全膝关节置换来说,引流与不引流各有优势,放置引流可减少渗液、切口瘀斑,不引流可降低输血率。 2.3 术后措施 2.3.1 多模式镇痛 有研究表明,术后疼痛已成为延长患者住院天数与降低其满意度最为主要的原因。所以术后的疼痛管理对减少患者住院天数、加速康复过程起到决定性的作用,围术期有效地止痛不仅是膝关节置换术快速康复过程中的首要条件,也是有利于早期下床活动及功能恢复的必要前提。 静脉自控镇痛应用广泛,但往往因为阿片类药物的不良反应造成恶心、呕吐、呼吸抑制等不良反应,从而延长患者住院天数、不利于快速康复过程,不推荐作为膝关节置换术后的常规镇痛方案。持续硬膜外镇痛虽然镇痛效果强大,但其因尿潴留以及对下肢运动功能的影响从而不利于早期下肢功能锻炼等危害已逐渐被其他镇痛方式所淘汰。连续股神经阻滞由于损害股四头肌功能、增加跌倒风险等原因,在早期下地活动、早期功能锻炼的快速康复理念下,其应用相比于之前也有下降趋势。而持续收肌管阻滞对比于股神经阻滞,虽然在一定程度上弥补了股四头肌功能损害的缺陷,但由于其操作相对繁琐,且术后导管的刺激也会造成患者的疼痛,且佩戴导管下地活动增加患者的不适以及不便,患者的早期功能锻炼在一定程度上也受到一定的影响,也逐渐被关节周围浸润注射所取代。 关节周围组织浸润注射是近些年来兴起的镇痛方案,已成为全膝关节置换手术首选的镇痛措施。Beckmann等[53]通过文献回顾与自己的随机对照试验研究得出关节周围组织浸润注射方法是膝关节置换中最为具有优势的镇痛措施,显著优于目前临床上广泛应用的周围神经阻滞,而随着鸡尾酒配方药物的多样性以及布比卡因脂质体的进一步研究,相信其在今后的临床当中有着广阔的应用前景。 在多模式的镇痛方案中,止痛药物起到至关重要的作用,其中阿片类药物镇痛效果强,但其副作用较大,并有一定的痛觉敏化作用,即患者在接受阿片药治疗后出现的对伤害性刺激敏感性增高,出现异常疼痛或者是原有的疼痛加剧[54]。并且已有大量研究把减少术后阿片类药物的使用量作为其目的来进行[20-21,55]。非类固醇抗炎类药物已经逐渐成为全膝关节置换术后的主要镇痛药物,其抗炎、镇痛效果强,并有一定的抗敏化作用,有研究表明,非类固醇抗炎药可减少术后阿片类药物使用率50%-75%,而且也可以增强阿片类药物的镇痛作用[56-57]。除此之外,对乙酰氨基酚也广泛应用于术后的镇痛,2011年,FDA批准对乙酰氨基酚的静脉注射类药物(Ofirmev),从而可见其使用价值[58]。近年来已有学者将加巴喷丁用于膝关节置换后的镇痛,发现其不但可以减轻术后疼痛,并且具有镇静、抗焦虑作用,而且不良反应较少,有助于快速康复[59-61]。 除此之外,膝关节术后患肢抬高减轻肿胀、健康教育消除患者焦虑情绪以及膝关节冷敷也在一定程度上可起到缓解疼痛的作用。而类固醇激素的应用虽然已有大量文献报道可起到减轻炎症反应、降低疼痛的作用[23-24],但其安全性及使用方法都需要进一步的临床试验去证实。 2.3.2 功能锻炼 膝关节置换后,股四头肌功能均有不同程度的损害,主要可归因于疼痛、止血带的应用以及炎症反应等[62]。而以往对于术前功能锻炼的研究表明其对于膝关节术后的功能恢复并无明确的效果,或只有短期内功能的改善,甚至有文献指出其对于术后功能的恢复与对照组相比差异无显著性意义[63-65]。膝关节术后,有些外科医生往往把CPM作为常规锻炼方式,但已有学者指出,被动的持续锻炼仅仅只能帮助尽早达到出院要求的关节屈曲标准,而对关节最终的活动度无明显影响,并且还会造成关节内血肿、患者疼痛等不适,所以目前仅把术后CPM功能锻炼作为辅助措施的一种,更多的是强调早期、患者主动的锻炼模式。有研究表明,术后当天即开始进行膝关节功能锻炼对减少住院天数、促进快速康复可起到决定性的作用[66-68]。但美中不足的是,虽然多种物理锻炼干预措施已被临床研究者所尝试,但就目前国内外文献报道并没有系统、科学的康复锻炼方法,仅仅只是凭借经验来进行,并没有相应的理论支持。而在理想的情况下,术后的功能康复应该遵循基本的运动生理学原理来进行简单、少而精的锻炼以达到最优的效果[69]。而在国外的快速康复实施方案中,大部分都强调早期的功能锻炼,在麻醉恢复后即可进行,并且术后24 h内在良好的镇痛模式下有绝大多数的患者均可下地活动[12,20,22,55]。 2.3.3 早期进食水 国内临床工作中,多数医护人员仍然倾向于术后禁食水6 h的护理常规,而全麻术后进食往往以肛门排气为标准,这样的方式往往会给患者带来太多的不适,甚至造成低血糖、诱发消化道溃疡等严重不良反应[70]。但随着麻醉技术的改进以及对麻醉药物剂量的精确控制,多数医院的麻醉医生已能将患者的清醒时间控制在结束时,因此,传统的禁食水方案理应被废止。而国内第6版《外科学》教材也明确指出在患者清醒后,若无恶心、呕吐等不良反应,即可进食[71]。不仅如此,已有多项研究表明术后早期进食进水,可减少低钾血症发生率、加快肠道功能恢复,从而减少便秘,加快患者康复过程[72-74]。 2.3.4 恶心、呕吐的预防 有研究表明,患者术后恶心、呕吐发生率约为20%-37%,高危患者达到80%,持续时间可达5 d之久,处理术后恶心、呕吐的处方量仅次于镇痛药物,而且患者对此的关注度仅次于疼痛,成为延迟住院时间的第二大因素[75]。而其危险因素主要有术后恶心、呕吐病史、焦虑、麻醉、手术时间长、阿片类药物的使用等等。而对于术后恶心、呕吐的预防,近些年来类固醇激素类药物的应用逐渐成为临床上研究的热点。大量研究证实,静脉予以地塞米松,可减少术后恶心、呕吐的发生率约26%,其与昂丹司琼合用具有明显的效果[24,76]。 除此之外,胃复安、莫沙必利、昂丹司琼等也广泛用于术后的镇吐,但是注射的最佳剂量及时间并没有统一的标准。国内最新一期中国髋、膝关节置换术加速康复——围术期管理策略专家共识总结了全国各个医院关于术后恶心呕吐的预防方案,给出了一些指导性的建议,主要包括:地塞米松麻醉时静脉予以10 mg,术后6 h及次日再静脉予以10 mg;莫沙必利术前3 h口服5 mg,术后5 mg/次,3次/d;必要时予以昂丹司琼以及胃复安等药物。除此之外,东莨菪碱贴剂、头高脚高的预防体位、减少阿片类药物的使用、缩短手术时间也可起到一定的预防作用。"
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