加速康复外科用于机器人辅助腹腔镜肾盂成形术患儿的效果

Efficacy of enhanced recovery after surgery for robot-assisted laparoscopic pyeloplasty in pediatric patients

目的评价加速康复外科(ERAS)用于机器人辅助腹腔镜肾盂成形术患儿的安全性和有效性。方法选择2018年3月至2019年4月行机器人辅助腹腔镜肾盂成形术的肾积水患儿60例,年龄3~12岁,性别不限,ASA分级Ⅰ或Ⅱ级。采用随机数字表法分为2组:对照组(C组,n=28)和ERAS组(n=32)。ERAS组采取术前ERAS宣教,缩短禁食禁水时间,并于术前2 h饮用葡萄糖水,优化麻醉方案,行保护性肺通气和目标导向液体治疗,术中采取保温和多模式止吐措施,术后采取多模式镇痛措施,早期经口进食进水,尽早下床活动。C组采取传统理念进行围术期管理。分别于气管插管后即刻、气腹建立后30 min、1、2 h和气腹结束后5 min和拔除气管插管后5 min时,记录气道峰压和潮气量,并行血气分析。记录术中心血管事件的发生情况。记录术后气管拔管时间、首次进饮进食时间、首次下地活动时间、首次排气时间、拔除尿管及引流管时间、住院时间。采用PAED评分量表评估苏醒期躁动情况。采用FPS-R量表评估术后72 h内的疼痛程度;当FPS-R量表评分≥4分时,静脉注射芬太尼0.25μg/kg补救镇痛。记录补救镇痛情况。采用Clavin-Dindo分级评估术后总的并发症情况,术后并发症包括:恶心呕吐、腹胀、腹痛、切口感染、腹腔感染、吻合口瘘及发热等。结果与C组比较,ERAS组术前禁食、禁饮时间缩短,术后气管拔管时间延长,术后住院时间、首次进饮、进食时间、首次下地活动时间、首次排气时间和拔除尿管缩短,气腹1和2 h时气道峰压降低,气腹各时点动脉血乳酸浓度降低(P<0.05或0.01),术后躁动、恶心呕吐、腹腔感染、切口感染和发热的发生率差异无统计学意义(P>0.05)。2组患儿术中均未见心血管不良事件发生,术后均未进行补救镇痛。结论ERAS可安全、有效地用于机器人辅助腹腔镜肾盂成形术患儿。

Objective To evaluate the safety and efficacy of enhanced recovery after surgery(ERAS)in robot-assisted laparoscopic pyeloplasty in pediatric patients.Methods Sixty pediatric patients of both sexes with hydronephrosis,aged 3-12 yr,of American Society of Anesthesiologists physical statusⅠorⅡ,undergoing robot-assisted laparoscopic pyeloplasty from March 2018 to April 2019,were divided into 2 groups using a random number table method:control group(group C,n=28)and ERAS group(n=32).In ERAS group,preoperative ERAS education was carried out,the time of preoperative food and water deprivation was shortened,pediatric patients drank glucose water at 2 h before surgery,anesthetic regimen was optimized,lung protective ventilation and target-directed fluid therapy were performed,and intraoperative warming and multi-mode antiemetic measures were carried out during operation,and multi-mode analgesic measures were taken after operation,and pediatric patients received water and food intake early through the mouth and got out of bed as soon as possible after operation.In group C,the traditional concept was adopted for perioperative management.Immediately after tracheal intubation,at 30 min and 1 and 2 h after establishing pneumoperitoneum,at 5 min after the end of pneumoperitoneum and at 5 min after extubation,the airway peak pressure and tidal volume were recorded,and blood gas analysis was performed.The occurrence of cardiovascular events was recorded during surgery.The postoperative time of extubation,time of first intake,the first postoperative off-bed time,the first flatus time,time of pulling out the ureter and drainage tube,and length of hospital stay were recorded.The Pediatric Anesthesia Emergence Delirium scale was used to assess the agitation during the recovery period.The Faces Pain Scale-Revised scale was used to assess the degree of pain within 72 h after surgery.When Faces Pain Scale-Revised scale score≥4,fentanyl 0.25μg/kg was intravenously injected as rescue analgesic.The requirement for rescue analgesia was recorded.The overall complications were evaluated by using Clavin-Dindo grading,and postoperative complications included nausea and vomiting,abdominal distension,abdominal pain,incision infection,abdominal infection,anastomotic leakage,fever,etc.Results Compared with group C,the preoperative food and water deprivation time was significantly shortened,the time of postoperative extubation was prolonged,the postoperative length of hospital stay,time of first intake,the first postoperative off-bed time,the first flatus time,and time of pulling out the ureter were shortened,airway peak pressure was decreased at 1 and 2 h of pneumoperitoneum,arterial blood lactate concentrations were decreased at each time point of pneumoperitoneum(P<0.05 or 0.01),and no significant change was found in the incidence of postoperative agitation,nausea and vomiting,incision infection,abdominal infection or fever in group ERAS(P>0.05).No intraoperative adverse cardiovascular events were found,and no pediatric patients required rescue analgesia after operation in two groups.Conclusion ERAS can be safely and effectively used for the pediatric patients undergoing robot-assisted laparoscopic pyeloplast.