加速康复外科指导下先天性脊柱侧凸患儿围手术期饮食及补液管理方案的制定及临床结果

Development of preoperative diet and fluid management protocol and postoperative follow-up results for children with congenital scoliosis under the guidance of enhanced recovery after surgery

目的制定加速康复外科(enhanced recovery after surgery,ERAS)指导下先天性脊柱侧凸患儿围手术期饮食及补液管理方案,探讨其临床效果,总结临床经验。方法回顾性分析2020年11月至2021年10月于首都医科大学附属北京儿童医院接受手术治疗的90例先天性脊柱侧凸患儿临床资料,其中男25例,女65例;年龄为(6.6±3.1)岁。患儿根据所接受的围手术期饮食及补液管理方案分为A组(45例)和B组(45例),A组予高蛋白饮食,缩短禁食水时间;B组予普食,术前禁食水6 h,术后1 d允许进食;两组患儿其他围手术期管理均遵循ERAS理念。比较两组患儿围手术期饮食、补液情况、术后消化道恢复情况、相关实验室检查指标、消化道并发症发生率和住院时间。组间比较根据数据类型对应采用独立样本t检验或Wilcoxon秩和检验或χ2检验或Fisher精确检验。结果A组患儿围手术期禁食水时间(10.2±4.6)h短于B组(31.1±7.9)h,差异有统计学意义(t=-10.213,P<0.001)。A组患儿术前、术后当日和术后1 d补液总量和含糖液量均少于B组(均P<0.001)。两组患儿围手术期餐前血糖差异无统计学意义(均P>0.05),但术前2 h和术后2 d内B组餐前血糖异常(<3.9 mmol/L或>6.1 mmol/L)的患儿明显多于A组(均P<0.05)。A组患儿术后3 d总蛋白高于B组[(59.7±4.5)g/L比(57.0±5.6)g/L,P=0.022],A组患儿术后3 d前白蛋白高于B组[(172.7±137.2)mg/L比(150.2±116.5)mg/L,P=0.010]。A组术后首次排气时间早于B组[16(9,17)h比25(21,43)h,Z=-5.725,P<0.001],A组术后首次排便时间也早于B组[20(13,30)h比44(24,81)h,Z=-3.162,P<0.001]。两组消化道并发症以轻度腹胀腹痛和恶心为主,多数未予处理自行好转,且A组发生率8.9%(4/45)低于B组的35.6%(16/45),差异有统计学意义(χ^(2)=7.779,P=0.005)。A组术后住院时间为(6.5±0.8)d,短于B组的(7.8±1.8)d,差异有统计学意义(t=-2.791,P=0.008)。结论ERAS理念下制定的先天性脊柱侧凸患儿围手术期饮食及补液管理方案可有效缩短患儿围手术期禁食水时间,可稳定血糖波动,促进胃肠道功能早期恢复并缩短住院时间,值得临床推广应用。

Objective To develop a preoperative diet and fluid management protocol for children with congenital scoliosis(CS)under the guidance of enhanced recovery after surgery(ERAS)and explore its clinical efficacy and summarize clinical experiences.Methods Retrospective analysis was performed for the relevant clinical data of 90 CS children operated from November 2020 to October 2021.Based upon preoperative diet and fluid management,they were assigned equally into two groups of A(n=45)and B(n=45).Group A received a high-protein diet and shorter fasting time for water intake while group B had a regular diet with 6 hours of water fasting pre-operation and eating on the first day post-operation.Other perioperative measures adhered to the principles of ERAS.Perioperative diet,fluid,postoperative digestive recovery,relevant laboratory parameters,occurrence of gastrointestinal complications and length of hospitalization stay were evaluated by independent sample t,Wilcoxon rank-sum,chi-square or Fisher's exact test depending on specific data types.Results Fasting duration was shorter in group A than that in group B[(10.2±4.6)h vs(31.1±7.9)h].There was significant statistical difference(t=-10.213,P<0.001).As compared to group B,group A had lower total fluid and sugar-containing fluid intake pre-operation,on the day of operation and on the first day post-operation(all P<0.001).No significant inter-group difference existed in preprandial blood glucose level(all P>0.05).However,group B had significantly more preprandial blood glucose abnormalities(<3.9 mmol/L or>6.1 mmol/L)than Group A within 2 hours pre-operation and during the first 2 days post-operation(all P<0.05).Total protein and pre-albumin levels at Day 3 post-operation were higher in group A than in group B[(59.7±4.5)g/L vs(57.0±5.6)g/L,P=0.022;(172.7±137.2)mg/L vs(150.2±116.5)mg/L,P=0.010].Time to initial passage of flatus post-operation[16(9,17)h vs 25(21,43)h,Z=-5.725,P<0.001]and time to initial bowel movement[20(13,30)h vs 44(24,81)h,Z=-3.162,P<0.001]were earlier in group A than those in group B.The major gastrointestinal complications of mild abdominal distensions,pain and nausea resolved spontaneously without treatment.The occurrence rate was lower in group A than that in group B[8.9%(4/45)vs 35.6%(16/45)].There was significant statistical difference(χ^(2)=7.779,P=0.005).Length of postoperative hospitalization stay was longer in group A than that in group B[(6.5±0.8)days vs(7.8±1.8)days].There was significant statistical difference(t=-2.791,P=0.008).Conclusions Perioperative diet and fluid management protocol under the concept of ERAS can effectively reduce perioperative fasting time,stabilize blood sugar fluctuations,promote early recovery of gastrointestinal function and shorten hospitalization stay in CS children.It is worthy of wider clinical promotions.