集束化ERAS方案在肝移植术后恢复中的应用

Application of clustered ERAS regimen in recovery after liver transplantation

目的探讨集束化加速康复外科(ERAS)方案在肝移植术后恢复中的应用价值。方法本前瞻性研究对象为2019年3月至2021年12月在首都医科大学附属北京佑安医院诊治的250例肝移植患者。其中男150例,女100例;年龄22~67岁,中位年龄46岁。患者和(或)其监护人均签署知情同意书,符合医学伦理学规定。采用抽签法将患者分为ERAS组(130例)和对照组(120例)。ERAS组根据循证医学方法,构建肝移植术后集束化ERAS方案。观察两组患者的安全性指标、有效性指标和经济学指标。两组疼痛评分、术后住院时间等比较采用秩和检验,率的比较采用χ^(2)检验。结果ERAS组发生意外脱管、再次气管插管、气道误吸、急性尿潴留分别为6、17、1、2例,对照组相应为7、13、2、3例,差异无统计学意义(χ^(2)=0.188,0.297,0.005,0.008;P>0.05)。ERAS组发生呼吸机相关性肺炎、泌尿系统感染、口鼻腔黏膜压力性损伤、谵妄分别为13、4、1、10例,对照组相应为28、13、9、19例,差异有统计学意义(χ^(2)=8.091,5.924,5.713,4.033;P<0.05)。ERAS组和对照组术后10 d主观整体营养状况量表(PG-SGA)分级A级患者分别为45、28例,差异有统计学意义(χ^(2)=3.842,P=0.05)。ERAS组和对照组术后5 d疼痛评分分别为2(2)、5(1)分,术后10 d Barthel评分分别为70(25)、60(20)分,差异均有统计学意义(Z=-11.087,2.071;P<0.05)。ERAS组ICU住院时间、术后总住院时间和术后10 d住院费用分别为4(2)d、15(8)d、5.0(7.5)万元,对照组相应为5(2)d、17(10)d、9.3(5.6)万元,差异有统计学意义(Z=-4.967,-2.668,-3.230;P<0.05)。结论肝移植术后集束化ERAS方案安全性好,可有效促进患者康复,降低医疗成本。

Objective To evaluate the application value of clustered enhanced recovery after surgery(ERAS)regimen in the recovery after liver transplantation.Methods 250 patients undergoing liver transplantation in Beijing You'an Hospital Affiliated to Capital Medical University from March 2019 to December 2021 were recruited in this prospective study.Among them,150 patients were male and 100 female,aged from 22 to 67 years,with a median age of 46 years.The informed consents of all patients and(or)their guardians were obtained and the local ethical committee approval was received.All patients were randomly divided into the ERAS(n=130)and control groups(n=120)by the lottery method.According to the evidence-based medicine methods,the clustered ERAS regimen after liver transplantation was made in the ERAS group.The parameters related to the safety,efficacy and medical expense were observed between two groups.The pain score and length of postoperative hospital stay were compared between two groups by rank-sum test.The rate comparison was conducted by Chi-square test.Results In the ERAS group,accidental tube removal,tracheal re-intubation,airway aspiration and acute urine retention occurred in 6,17,1 and 2 patients,and 7,13,2 and 3 cases in the control group,respectively,and no significant difference was observed(χ^(2)=0.188,0.297,0.005,0.008;P>0.05).In the ERAS group,the incidence of ventilator-associated pneumonia,urinary tract infection,oral and nasal mucosal pressure injury and delirium was observed in 13,4,1 and 10 cases,and in 28,13,9 and 19 cases in the control group,respectively,where significant differences were observed(χ^(2)=8.091,5.924,5.713,4.033;P<0.05).At postoperative 10 d,Patient-Generated Subjective Global Assessment(PG-SGA)grade A were observed in 45 cases in the ERAS group and in 28 cases in control groups,where significant difference was observed(χ^(2)=3.842,P=0.05).In the ERAS and control groups,the pain scores at postoperative 5 d were 2(2)and 5(1),and the Barthel scores at postoperative 10 d were 70(25)and 60(20),respectively,where significant differences were observed(Z=-11.087,2.071;P<0.05).In the ERAS group,the length of ICU stay,the total length of postoperative hospital stay and 10-d hospitalization expense were 4(2)d,15(8)d and 5.0(7.5)×104 Yuan,and were 5(2)d,17(10)d and 9.3(5.6)×104 Yuan in the control group,where significant differences were observed(Z=-4.967,-2.668,-3.230;P<0.05).Conclusions The clustered ERAS regimen after liver transplantation is safe,which can effectively promote the postoperative recovery and lower medical expense.