ERAS在普外科的应用.ppt

* Effects of preemptive analgesia on pain and cytokine production in the postoperative period. Anesthesiology 2003; 98:151–5 From preemptive to preventive analgesia. Current Opinion in Anaesthesiology 2006, 19:551–55  * * 预防镇痛该使用何种药物？效果如何？ 2005年，《麻醉与镇痛》杂志对术前采取镇痛措施进行术后镇痛的66篇RCTs （纳入3261位患者）进行的一项荟萃分析或许可以给我们答案。 该荟萃分析中，将患者随机分为5组，分别为——术前实施硬膜外麻醉组、局麻组、NMDA组、NSAID组和阿片组。 评价指标包括术后最初24-48h患者的疼痛强度、镇痛药物总需求量以及给予首次补救镇痛药物的时间3项指标； 研究表明： 术前预外周神经局部浸润和静脉注射NSAIDs可以减少镇痛药物需求量、延长首次补救镇痛药物的时间； 本实验证明：术前给予NSAIDs对于围手术镇痛临床获益明确（减少镇痛药物使用量以及延迟麻醉性镇痛药物给予时间） * * What is the Role of NSAIDs in Pre-emptive Analgesia?  * * * * The choice of incision is at the surgeon’s discretion, and should be of a length sufficient to ensure good exposure. * * * * * * Near-zero fluid balance as well as avoiding overload of salt and water results in improved outcomes. Perioperative monitoring of stroke volume with trans-oesophageal Doppler to optimize cardiac output with fluid boluses improves outcomes. Balanced crystalloids should be preferred to 0.9% saline * * * * * * NSAIDS are also an important part of multimodal analgesia. There have been clinical case series linking voltarol (150 mg, p.o. once a day) and celecoxib (cyclo-oxygenase (COX)-2 inhibitor) to an increased incidence of anastomotic dehiscence.173e 176 However, until more thorough studies addressing this question have been carried out, there is not sufficient evidence to stop using NSAIDS as a component of multimodal analgesia in the postoperative period. Tramadol is an alternative to NSAIDs * * thoracic epidural analgesia using low-dose local anaesthetic and opioids should be used in open surgery. For breakthrough pain, titration to minimise the dose of opioids may be used. In laparoscopic surgery, an alternative to TEA is a carefully administered spinal analgesia with a low-dose, longacting opioid. In connection with TEA withdrawal, NSAIDs and Paracetamol should be used. * * * * 快速康复外科理念主张术后早期活动。术后长期卧床会降低肌肉强度，损害肺功能及组织氧化能力、加重静脉淤滞及血栓形成 Optimizing