加速康复外科理念在多发肋骨骨折术后胸腔引流管管理中的应用  

Application of enhanced recovery after surgery in the management of thoracic drainage tube after operation

作　　者：向敏峰[1] 漆奋强[1] 蒋清柏[1] 韦福旺 覃骅晶[1] XIANG Min-feng;QI Fen-qiang;JIANG Qing-bo;WEI Fu-wang;QIN Hua-jing(Department of Cardiac and Thoracic Surgery, Liuzhou Worker Hospital, Liuzhou 545005, Guangxi, CHIN)

机构地区：[1]柳州市工人医院心胸外科,广西柳州545005

出　　处：《海南医学》2018年第12期1656-1660,共5页Hainan Medical Journal

基　　金：广西壮族自治区卫生和计划生育委员会自筹经费科研课题(编号:Z2016180)

摘　　要：目的探讨加速康复外科理念(ERAS)指导下胸腔镜多发肋骨骨折术后早期拔除胸腔引流管的可行性。方法选择2015年1月至2017年12月在柳州市工人医院心胸外科接受胸腔镜手术的118例多发肋骨骨折患者,采用随机数表法分为三组,A组40例,B组、C组各39例,三组均在ERAS理念指导下优化围手术期胸管管理措施,分别在胸腔引流液量≤100 m L/24 h、≤200 m L/24 h和≤300 m L/24 h时拔除引流管,观察三组患者术后胸管留置时间、术后住院时间、术后并发症、拔除胸管后胸片检查情况、拔除胸管后再次胸腔穿刺率及置管率、拔胸管后VAS疼痛评分,并观察术后24 h及拔胸管即刻的胸腔积液常规、生化指标。结果 B组和C组患者的术后胸管留置时间分别为(3.43±1.20)d、(2.11±1.07)d,住院时间分别为(8.16±2.25)d、(7.03±2.06)d,均比A组的(5.28±1.55)d、(10.83±2.72)d缩短,差异均有统计学意义(P<0.05);拔除胸管后第1天和第7天胸片复查,C组患者的胸腔积液和胸膜残腔的发生率分别为28.2%、10.3%,10.3%、2.6%,均高于A组的5.0%、2.5%,2.5%、0和B组的10.3%、2.6%,5.1%、0,差异均有统计学意义(P<0.05);拔除胸管后,C组患者的胸腔穿刺率为17.9%,均高于A组的2.5%和B组的5.1%,差异均有统计学意义(P<0.05);三组患者术后24 h、拔胸管即刻胸腔积液常规与生化指标比较差异均无统计学意义(P>0.05);疼痛评分,术后第4天A组、B组、C组分别为(4.3±0.7)分、(3.6±0.5)分、(3.2±0.5)分、术后第5天A组、B组、C组分别为(4.0±1.1)分、(2.5±0.7)分、(2.2±0.8)分,A组和B组、C组比较差异均有统计学意义(P<0.05)。结论多发肋骨骨折在借助胸腔镜微创技术前提下,术后引流量≤200 m L/24 h和≤300 m L/24 h时拔除胸管安全可行,对术后快速康复有利,且≤200 m L/24 h时拔管更加符合正常胸膜腔生理及创伤生理,是比较理想的拔管指征。各种护理措施的优化也有利于缩短术后胸管留Objective To explore the feasibility of removing thoracic drainage tube at early stage after thoracoscopic multiple rib fractures under the guidance of enhanced recovery after surgery（ERAS）. Methods From January2015 to December 2017, 118 patients with multiple rib fractures, who admitted to Department of Cardiac and Thoracic Surgery of Liuzhou Worker Hospital, were divided into the group A（n=40）, group B（n=39） and group C（n=39）. The perioperative management of thoracic duct were optimized in the three groups under the guidance of ERAS concept, and the drainage tube was removed at ≤ l00 m L/24 h, ≤200 m L/24 h and ≤300 m L/24 h. The retention time of the thoracic duct, the time of postoperative hospitalization, postoperative complications, the chest radiography after removal of the thoracic tube, the rate of thoracic puncture and intubation rate after removal of thoracic tube, and the VAS pain score after removal of the thoracic tube were observed. Routine and biochemical indexes of effusion were observed immediately after extubation and 24 hours after the operation. Results In group B and group C, the retention time of thoracic tube was（3.43±1.20） d and（2.11±1.07） d respectively, and the hospitalization time was（8.16±2.25） d and（7.03±2.06） d respectively, which were significantly shorter than（5.28±1.55） d and（10.83±2.72） d in group A（P〈0.05）. The incidence of pleural effusion and pleura residual cavity in group C on the first and seventh day were respectively 28.2% and 10.3%,and 10.3% and 2.6%, which were significantly higher than 5.0% and 2.5%, and 2.5% and 0 in group A and 10.3% and2.6%, and 5.1% and 0 in group B（P〈0.05）. The thoracic puncture rate of the group C was 17.9%, which was significantly higher than 2.5% in group A and 5.1% in group B（P〈0.05）. There was no significant difference in the routine and biochemical indexes between the three groups（P〉0.05）. The pain scores in group A, B and C on the fourth day after the operation wer

关 键 词：加速康复外科 多发肋骨骨折 胸腔引流 疗效 

分 类 号：R683.41[医药卫生—骨科学]