加速康复外科理念在儿童发育性髋关节发育不良围手术期管理中的应用

Application of enhanced recovery after surgery in perioperative period management of developmental dysplasia of the hip in children

目的:探讨加速康复外科(enhanced recovery after surgery,ERAS)理念在儿童发育性髋关节发育不良(developmental dysplasia of the hip,DDH)围手术期管理中的应用价值。方法:将60例DDH患儿随机分为2组,每组30例。2组患儿均采用骨盆截骨术联合股骨近端截骨术治疗。分别在ERAS理念指导下(ERAS组)和传统康复理念指导下(传统康复组)进行围手术期管理。记录并比较2组患儿的手术时间、术中失血量、术中输血情况、住院时间、髋关节疼痛视觉模拟量表(visual analogue scale,VAS)评分、切口周围肿胀程度、切口周围肿胀消退时间及并发症发生情况。结果:①一般结果。2组患儿手术时间、术中失血量及术中输血情况比较,组间差异均无统计学意义[(107.70±6.92)min,(107.47±6.91)min,t=0.131,P=0.896;(180.00±48.87)mL,(190.83±48.60)mL,t=0.861,P=0.393;χ^(2)=0.647,P=0.421];ERAS组患儿住院时间短于传统康复组[(7.57±1.65)d,(10.36±1.56)d,t=6.720,P=0.000]。②髋关节疼痛VAS评分。时间因素与分组因素存在交互效应(F=3.220,P=0.047);2组患儿髋关节疼痛VAS评分总体比较,组间差异有统计学意义,即存在分组效应(F=33.928,P=0.000);术后不同时间点髋关节疼痛VAS评分的差异有统计学意义,即存在时间效应(F=108.156,P=0.000);2组患儿髋关节疼痛VAS评分随时间变化均呈下降趋势,但2组的下降趋势不完全一致[(3.23±1.57)分,(2.17±1.15)分,(1.60±0.72)分,F=74.242,P=0.000;(4.57±1.07)分,(3.83±1.21)分,(3.32±0.87)分,F=37.134,P=0.000];术后6h、12h、24h,ERAS组髋关节疼痛VAS评分均低于传统康复组(t=14.768,P=0.000;t=30.083,P=0.000;t=77.440,P=0.000)。③切口周围肿胀情况。ERAS组患儿术后24h切口肿胀Ⅰ级22例、Ⅱ级8例,传统康复组术后24h切口肿胀Ⅰ级14例、Ⅱ级16例。ERAS组患儿术后24h切口周围肿胀程度低于传统康复组(χ^(2)=4.444,P=0.035),切口周围肿胀消退时间短于传统康复组[(3.50±1.11)d,(5.43±1.14)d,t=6.680,P=0.000]。④并发症发生情况。ERAS组术后3例发生早期发热、2例发生恶心呕吐、2例发生腹痛腹胀,传统康复组术后8例发生早期发热、4例发生恶心呕吐、3例发生腹痛腹胀。2组患儿均未发生切口感染、尿路感染等并发症。ERAS组患儿并发症发生率低于传统康复组(χ^(2)=4.593,P=0.032)。结论:在儿童DDH围手术期管理中应用ERAS理念,能够缩短住院时间、缓解髋关节疼痛及切口周围肿胀,提高手术安全性。

Objective:To explore the application value of enhanced recovery after surgery(ERAS)in perioperative period management of developmental dysplasia of the hip(DDH)in children.Methods:Sixty DDH children were randomly divided into two groups,with 30 cases in each group.All cases were treated with pelvic osteotomy combined with proximal femoral osteotomy.Perioperative period management was performed under the guidance of ERAS(ERAS group)and traditional rehabilitation(traditional rehabilitation group).The operation time,intraoperative blood loss,intraoperative blood transfusion,length of hospital stay,hip pain visual analogue scale(VAS)score,swelling around the incision site,reduction time of the swelling around the incision site,and the incidence of complications were recorded and compared between the two groups.Results:①General results.There were no significant differences in operation time,intraoperative blood loss,and intraoperative blood transfusion between the two groups(107.70±6.92 vs 107.47±6.91 min,t=0.131,P=0.896;180.00±48.87 vs 190.83±48.60 mL,t=0.861,P=0.393;χ^(2)=0.647,P=0.421).The length of hospital stay in the ERAS group was shorter than that in the traditional rehabilitation group(7.57±1.65 vs 10.36±1.56 d,t=6.720,P=0.000).②VAS score.There was an interaction effect between the time factor and the grouping factor(F=3.220,P=0.047).There was a statistically significant difference in hip pain VASscores between the two groups,which was indicative of grouping effect(F=33.928,P=0.000).There was a statistically significant difference in hip pain VAS scores between different time points after operation,which was indicative of time effect(F=108.156,P=0.000).The hip pain VAS scores of the two groups showed a downward trend over time,but the downward trend was not completely consistent between the two groups(3.23±1.57,2.17±1.15,1.60±0.72 points,F=74.242,P=0.000;4.57±1.07,3.83±1.21,3.32±0.87 points,F=37.134,P=0.000).The hip pain VAS scores of the ERAS group was lower than those of the traditional rehabilitation group at6,12 and 24 h after operation(t=14.768,P=0.000;t=30.083,P=0.000;t=77.440,P=0.000).③Swelling around the incision site.There were 22 cases of grade Ⅰ swlling and 8 cases of grade Ⅱ swelling around the incision site 24 hafier operation in the ERAS group,and 14 cases of grade Ⅰ swelling and 16 cases of grade Ⅱ swelling around the incision site 24 h after operation in the traditional rehabilitation group.The swelling level around the incision site 24 h after operation in the ERAS group was lower than that in the traditional rehabilitation group(χ^(2)=4.444,P=0.035),and the reduction time of the swelling around the incision site was shorter than that of the traditional rehabilitation group(3.50±1.11 vs 5.43±1.14 d,t=6.680,P=0.000).④Occurrence of complications.In the ERAS group,early fever occurred in three cases,nausea and vomiting in two cases,and abdominal pain and distension in two cases,while in the traditional rehabilitation group,eight cases had early fever,four cases had nausea and vomiting,and three cases had abdominal pain and distension.No incision infection,urinary tract infection,and other complications occurred in the two groups.The incidence of complications in the ERAS group waslower than that in the traditional rehabilitation group(χ^(2)=4.593,P=0.032).Conclusion:The application of ERAS in perioperative period management of DDH in children can shorten the length of hospital stay,relieve hip pain and swelling around the incision site,and improve surgical safelty.