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术后加速康复学会推荐意见:乳房重建最佳围手术期处理共识

2017-04-28 整形重建外科 SIBCS


  2017年5月,美国整形外科医师协会《整形重建外科》将正式发表加拿大卡尔加里大学、汤姆贝克癌症中心、艾伯塔省卫生署癌症策略临床网络、多伦多大学、美国希望之城国家医学中心、纪念斯隆凯特琳癌症中心、比利时根特大学、瑞典厄勒布鲁大学起草的术后加速康复学会(ERAS)推荐意见:乳房重建最佳围手术期处理共识评估。


  由于术后加速康复可以通过引进循证措施实现,故该评估旨在对乳房重建手术患者最佳围手术期管理达成共识,并为围手术期加速康复方案提供循证推荐意见。


  本文对各个方案项目进行大样本前瞻队列研究、随机对照研究、荟萃分析的系统评估。仅当缺乏较高级别证据时,才考虑小样本前瞻队列和回顾队列研究。可用文献由乳房重建手术国际专家组进行分级,并用于每个主题形成共识推荐意见。专家组进行共识讨论后,再对各个推荐意见进行分级。这些推荐意见的制定获得ERAS批准。


  虽然某些推荐意见来自高质量的乳房重建患者随机对照研究数据,但是大多数推荐意见参考了相关人群的低水平研究、非乳房重建人群的高质量研究外推数据。


  本文针对18个独特的术后加速康复问题,制定了推荐意见并进行了讨论。


  关键推荐意见包括:围手术期避免使用阿片类药物、避免术前禁食、鼓励早期进食、使用减轻术后恶心呕吐和疼痛的麻醉技术、采取措施预防术中低温、鼓励术后早期活动。


  根据各个主题的最佳可用证据,本文提出乳房重建患者最佳围手术期处理共识评估推荐意见如下:


  1. 入院前知情、教育和咨询:患者应接受详细的术前咨询(证据级别:高,推荐强度:强)。

  2. 入院前优化:对于每日吸烟者,术前戒烟一个月可以获益(证据级别:中,推荐强度:强);对于肥胖患者,术前将体重减轻至体重指数≤30kg/m²可以获益(证据级别:高,推荐强度:强);对于酗酒者,术前戒酒一个月可以获益(证据级别:低,推荐强度:强);对于相应人群,应转诊至改变这些行为的专科(例如戒烟门诊、肥胖门诊、戒酒门诊)。

  3. 穿支皮瓣计划:如果需要术前穿支皮瓣血管定位,推荐CT造影(证据级别:高,推荐强度:强)

  4. 术前禁食:应避免术前禁食,应允许患者术前2小时饮水(证据级别:高,推荐强度:强)。

  5. 术前碳水化合物负荷:术前2小时应予患者麦芽糖糊精饮料(证据级别:低,推荐强度:强)。

  6. 静脉血栓栓塞预防措施:应评定患者静脉血栓栓塞风险。除非有禁忌证并权衡出血风险,高风险患者应接受低分子量肝素或普通肝素,直至可以下床或出院。应加入理疗(证据级别:高,推荐强度:强)。

  7. 抗菌预防措施:应予氯己定皮肤制剂,并在皮肤切开1小时内给予针对常见皮肤微生物的静脉抗生素(证据级别:高,推荐强度:强)。

  8. 术后恶心呕吐预防措施:术前和术中应予药物减轻术后恶心呕吐(证据级别:高,推荐强度:强)。

  9. 术前和术中镇痛:患者应接受多种模式镇痛以减轻疼痛(证据级别:高,推荐强度:强)。

  10. 标准麻醉方案:推荐使用全静脉麻醉(TIVA)进行全身麻醉(证据级别:高,推荐强度:强)。

  11. 预防术中低温:术前和术中措施,例如充气保温系统,防止体温过低。需要进行温度监测,确保患者体温维持高于36℃(证据级别:高,推荐强度:强)。

  12. 术前静脉液体管理:应避免液体过多或不足,并维持水电解质平衡。目标导向疗法是实现这些目标的有效方法。推荐使用平衡晶体溶液,而非盐水。推荐使用升压药支持液体管理,并且不要对游离皮瓣产生不良影响(证据级别:高,推荐强度:强)。

  13. 术后止痛:应使用多种模式术后疼痛管理方案,避免使用阿片类药物(证据级别:高,推荐强度:强)。

  14. 早期进食:应鼓励患者尽快口服液体和食物,最好在术后24小时内(证据级别:高,推荐强度:强)。

  15. 术后皮瓣监测:术后72小时内应经常监测皮瓣。临床评估足以进行监测,对于包埋皮瓣推荐使用植入式多普勒装置(证据级别:高,推荐强度:强)。

  16. 术后伤口管理:对于切口闭合,推荐使用常规缝合线(证据级别:高,推荐强度:强)。皮肤坏死后的复杂伤口可用清创和伤口负压疗法(证据级别:中,推荐强度:强)进行治疗。

  17. 早期活动:应鼓励患者在术后24小时内开始活动(证据级别:高,推荐强度:强)。

  18. 出院后家庭支持和理疗:出院后应开始进行早期理疗、监督锻炼计划以及其他支持治疗措施(证据级别:高,推荐强度:强)。


  对此,哈佛医学院、贝斯以色列女执事医疗中心整形外科专家 Samuel J. Lin 发表同期述评。


Plast Reconstr Surg. 2017 May;139(5):1056e-1071e.


Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations.


Temple-Oberle C, Shea-Budgell MA, Tan M, Semple JL, Schrag C, Barreto M, Blondeel P, Hamming J, Dayan J, Ljungqvist O; ERAS Society.


University of Calgary; Tom Baker Cancer Centre; Cancer Strategic Clinical Network, Alberta Health Services; City of Hope National Medical Center; University of Toronto; University Hospital of Ghent; Memorial Sloan Kettering Cancer Center; Faculty of Medicine and Health, Orebro University.


BACKGROUND: Enhanced recovery following surgery can be achieved through the introduction of evidence-based perioperative maneuvers. This review aims to present a consensus for optimal perioperative management of patients undergoing breast reconstructive surgery and to provide evidence-based recommendations for an enhanced perioperative protocol.


METHODS: A systematic review of meta-analyses, randomized controlled trials, and large prospective cohorts was conducted for each protocol element. Smaller prospective cohorts and retrospective cohorts were considered only when higher level evidence was unavailable. The available literature was graded by an international panel of experts in breast reconstructive surgery and used to form consensus recommendations for each topic. Each recommendation was graded following a consensus discussion among the expert panel. Development of these recommendations was endorsed by the Enhanced Recovery after Surgery Society.


RESULTS: High-quality randomized controlled trial data in patients undergoing breast reconstruction informed some of the recommendations; however, for most items, data from lower level studies in the population of interest were considered along with extrapolated data from high-quality studies in non-breast reconstruction populations. Recommendations were developed for a total of 18 unique enhanced recovery after surgery items and are discussed in the article. Key recommendations support use of opioid-sparing perioperative medications, minimal preoperative fasting and early feeding, use of anesthetic techniques that decrease postoperative nausea and vomiting and pain, use of measures to prevent intraoperative hypothermia, and support of early mobilization after surgery.


CONCLUSION: Based on the best available evidence for each topic, a consensus review of optimal perioperative care for patients undergoing breast reconstruction is presented.


CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.


PMID: 28445352


DOI: 10.1097/PRS.0000000000003242




Plast Reconstr Surg. 2017 May;139(5):1072e-1073e.


Discussion: Consensus Review of Optimal Perioperative Care in Breast Reconstruction: Enhanced Recovery after Surgery (ERAS) Society Recommendations.


Lin SJ.


Division of Plastic Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School.


PMID: 28445353


DOI: 10.1097/PRS.0000000000003292





















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