本文選題：快速康復外科 + 麻醉管理　； 參考：《南方醫(yī)科大學》2017年碩士論文

【摘要】：研究背景:快速康復外科(fast-track surgery,FTS)理念是針對進行擇期手術的患者,圍手術期聯(lián)合運用有循證醫(yī)學證據的一系列優(yōu)化措施,有效地避免或減輕患者的應激反應以此來加快患者的術后康復,同時降低術后的并發(fā)癥發(fā)生率以及死亡率。這一理念尤其適用于腹部外科手術,并且需要外科、麻醉科及護理團隊的多學科合作。這種多模式觀念致力于優(yōu)化患者的術后康復,并且通過一些措施來改善患者預后。這一轉變已在國外臨床普遍推廣應用,并取得了較好的成果,在這個過程中,麻醉科也發(fā)揮了十分重要的作用。基于快速康復外科理念的麻醉管理貫穿于整個圍術期,包括術前進行詳細的宣教與咨詢、對術前患者的用藥方案進行調整、術前禁食禁水時間的改變、麻醉方式的優(yōu)化、麻醉管理的細化和改進以及對術后不良并發(fā)癥的早期干預等。隨著麻醉相關技術的不斷進步與發(fā)展,麻醉科在進一步推動FTS理念在臨床各學科中的應用和發(fā)展將起到越來越重要的作用。然而,FTS理念并未在我國臨床得到廣泛應用,很多外科醫(yī)生和麻醉醫(yī)生對這一理念還不甚了解,僅有少數(shù)大型醫(yī)院真正開展研究和應用,FTS理念的開展仍然任重道遠。在我國,上消化系統(tǒng)腫瘤依然是我國常見的惡性腫瘤和主要的腫瘤死因,據統(tǒng)計我國2011年惡性腫瘤發(fā)病率中,胃癌在女性中排第三位,在男性中排第二位,在我國惡性腫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,探討基于快速康復外科理念的麻醉管理在胃腫瘤手術過程中的有效性、安全性以及相應的機理更具有現(xiàn)實意義和挑戰(zhàn)性。本文就基于快速康復外科理念的麻醉管理在胃腫瘤手術中的應用及作用進行闡述。研究目的及意義:FTS理念已經在國外得到了普遍應用,并且已經發(fā)展得相對成熟,但是在我國還未得到足夠重視。為了完善相關的基礎理論,需要進一步應用到臨床實踐中,并且需要大量樣本隨機對照研究,同時運用循證醫(yī)學方法客觀分析及綜合評價這一舉措。因此本文就基于快速康復外科理念(FTS理念)的麻醉方式相對于傳統(tǒng)麻醉方式在胃腫瘤手術中的治療效果的安全性與優(yōu)越性進行探討。研究內容和過程:我們共收集了 2016年8月至2016年12月于南方醫(yī)科大學南方醫(yī)院普外科進行腹腔鏡下胃部分切除或全胃切除術的60例患者為觀察對象,男34例,女26例,年齡18-65歲,體重45-80Kg,美國麻醉醫(yī)師學會麻醉分級(ASA)Ⅰ或Ⅱ級,手術時間為2-4小時,均取平臥位。納入標準為:①精神狀態(tài)正常的成年人(18歲≤年齡≤65歲);②肝腎功能正常;③術前未服用任何影響代謝的藥物;④擬行擇期手術。排除標準;①術前有高血壓、糖尿病、腸梗阻和嚴重心、肺、肝、腎功能損害患者;②患有中樞神經系統(tǒng)疾病患者;③孕婦和哺乳期;④有食物及藥物過敏史患者。采用隨機數(shù)字法分為FTS組和傳統(tǒng)組,每組30例。其中FTS組圍術期采用快速康復外科理念所規(guī)定的處理流程,傳統(tǒng)治療組則按照傳統(tǒng)治療方式進行處理。觀察所有病例圍術期各項參數(shù),并對以下指標進行統(tǒng)計:兩組患者入室后詢問口渴、饑餓情況;記錄麻醉誘導前(To)、肌松起效喉鏡置入前(Ti)及插管后 1min(T2)、3min(T3)、5min(T4)、1Omin(T5)、20min(T6)的心率(HR)、平均動脈壓(MAP);術后惡心嘔吐發(fā)生例數(shù);術后12h(t1)、24h(t2)、48h(t3)兩組患者的傷口VAS評分、按壓鎮(zhèn)痛泵次數(shù)、鎮(zhèn)痛藥物使用劑量;術后首次排氣時間、首次排便時間;患者術后的住院時間、住院費用等指標。結論:FTS組患者在麻醉前出現(xiàn)口渴、饑餓的發(fā)生率與傳統(tǒng)治療組相比明顯地降低;FTS組患者在誘導過程中與傳統(tǒng)組相比血流動力學相對穩(wěn)定;FTS組患者術后惡心以嘔吐的發(fā)生率較傳統(tǒng)組低;兩組患者在術后相同時間點的VAS疼痛評分無顯著性差異,但傳統(tǒng)治療組追加按壓鎮(zhèn)痛泵的次數(shù)比FTS組多;FTS組患者術后首次排氣時間、排便時間均較傳統(tǒng)治療組提前,且住院天數(shù)及住院費用均比傳統(tǒng)治療組減少�；贔TS理念的麻醉管理方式有助于加快患者的術后康復,有利于提升患者的滿意度。
[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.
【學位授予單位】：南方醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R735.2;R614

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本文編號：1942018