多学科诊疗和"双下沉"在先天性肥厚性幽门狭窄围手术期加速康复外科管理中的应用  

Application of multidisciplinary treatment and Double Sinks policy during enhanced recovery after surgery for perioperative management of congenital hypertrophic pyloric stenosis

作　　者：黄寿奖[1] 秦琪[1] 吕成杰[1] 赵晓霞[1] 陈锐[1] 韩一江 王鹏[1] 胡艳[1] 王东披[1] 钭金法[1] Huang Shoujiang;Qin Qi;Lyu Chengjie;Zhao Xiaoxia;Chen Rui;Han Yijiang;Wang Peng;Hu Yan;Wang Dongpi;Tou Jinfa(Department of Neonatal Surgery, Affiliated Children's Hospital, Zhejiang University School of Medicine, Hangzhou 310052, China)

机构地区：[1]浙江大学医学院附属儿童医院新生儿外科,杭州310052

出　　处：《中华小儿外科杂志》2019年第9期784-789,共6页Chinese Journal of Pediatric Surgery

摘　　要：目的探讨多学科诊疗(MDT)和"城市医院下沉、医学人才下沉"(以下简称"双下沉")在先天性肥厚性幽门狭窄(CHPS)围手术期加速康复外科(ERAS)管理模式中的价值。方法回顾性分析2015年1月至2018年12月收治的先天性肥厚性幽门狭窄230例患儿的临床资料,按是否采用围手术期ERAS管理模式分为ERAS组(52例)和传统组(178例)。比较两组在日龄、病程、术前住院时间、营养不良、血气+电解质分析、术后第1天C反应蛋白和白细胞计数、术后住院时间、住院费用、出院日龄等方面的差异,及入院科室和居住地与各指标间的相关性。评价MDT和"双下沉"在围手术期ERAS管理模式中的价值。结果ERAS组和传统组日龄[(32.9±8.4)d比(41.4±18.2)d]、病程[(9.2±5.0)d比(13.7±10.8)d]、术前合并呼吸道感染率[3.85%比15.19%]、术前住院时间[(2.6±1.4)d比(3.7±2.2)d]、入院时pH值(7.48±0.09比7.52±0.11)、血氯[(101.31±8.02)mmol/L比(98.04±10.28)mmol/L]、术后住院时间[(3.91±1.13)d比(7.21±2.81)d]、住院费用[(11290.13±1725.19)元比(14676.21±4620.72)元]和出院日龄[(39.4±9.6)d比(52.4±18.2)d]等指标比较,前者均优于后者,且差异均有统计学意义(P≤0.001或<0.05)。采用ERAS管理模式前,入院科室和居住地与日龄(-0.273,P<0.001)、术前住院时间(0.324,P<0.001)、术后住院时间(0.205,P=0.006)、住院费用(0.399,P<0.001)、出院日龄(-0.201,P=0.007)相关,而与病程和营养不良无相关性。采用ERAS管理模式后,入院科室和居住地与这些指标均无相关性。结论围手术期ERAS管理模式可促进CHPS患儿加速康复,MDT可消除入院科室对诊疗的影响,"双下沉"可减少地域因素对诊疗的影响。MDT和"双下沉"作为ERAS实施的超前阶段可有效缩短患儿病程、术前住院时间,降低出院日龄,实现加速康复,是ERAS管理模式中的重要措施。Objective To evaluate the application of multidisciplinary treatment (MDT) and Double Sinks (DS, top-down hospital & talent services) policy during enhanced recovery after surgery (ERAS) for perioperative management of congenital hypertrophic pyloric stenosis (CHPS). Methods From January 2015 to December 2018, a total of 230 CHPS infants received traditional model (traditional group, n=178) and ERAS model (ERAS group, n=52) during perioperative management. Age at admission, time of disease course, nutritional status, incidence of preoperative respiratory infection, blood gas electrolyte analysis at admission, preoperative length of stay, leucocyte counts (WBC) and C-reactive protein (CRP) at postoperative Day 1, postoperative length of stay, hospitalization expenses and age at discharge were recorded and compared. Results Age at admission [(32.9±8.4) vs.(41.4±18.2) days], total length of stay [(9.2±5.0) vs.(13.7±10.8) days], incidence of preoperative respiratory infection [3.85% vs. 15.19%], preoperative length of stay [(3.91±1.13) vs.(7.21±2.81) days], postoperative length of stay [(3.91±1.13) vs.(7.21±2.81) days], hospitalization expenses [(11 290.13±1 725.19) vs.(14 676.21±4 620.72) RMB] and age at discharge [(39.4±9.6) vs.(52.4±18.2) days] in ERAS group were superior to those in traditional group and there were significant inter-group differences (P≤0.001 or <0.05). No significant inter-group difference existed in WBC/CRP at postoperative Day 1. MDT and DS were co-correlated with age at admission (-0.273, P<0.001), preoperative length of stay (0.324, P<0.001), postoperative length of stay (0.205, P=0.006), hospitalization expenses (0.399, P<0.001) and age at discharge (-0.201, P=0.007). Conclusions ERAS model may promote postoperative recovery and reduce hospitalization expenses. And MDT helps to shorten preoperative length of stay and DS may reduce age at admission and lower the incidence of preoperative respiratory infection. Both are indispensable and important components of ERAS measures dur

关 键 词：幽门狭窄 肥厚性 围手术期医护 加速康复外科 

分 类 号：R726.5[医药卫生—儿科]