ERAS在骨科的应用.ppt

New Concepts inAcute Pain Therapy: Preemptive Analgesia * 注： 对术前采取镇痛措施进行术后镇痛的66篇RCTs （3261位患者）进行荟萃分析；----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?  * 骨科常见疼痛的处理专家建议 * 广义上，ERAS方案构成可大致分为术前、围手术期和术后干预。 术前 术前咨询和培训 缩短禁食时间及术前碳水化合物负荷 避免机械性肠道准备 深静脉血栓形成预防 预防性抗生素治疗 围手术期 高氧吸入 低体温预防 目标导向术中液体疗法 手术径路和切口 避免术后留置引流管和鼻胃管 短期硬膜外止痛和局部神经阻滞 术后 避免使用阿片类药物，应与对乙酰氨基酚和NSAIDS应用 术后早期进食 术后早期活动 限制静脉补液量 审查 * Marianne就髋关节置换患者术中保温问题进行了研究，通过将术中体温提高0．5℃，结果发现术中失血量显著减少。 * * 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 * 广义上，ERAS方案构成可大致分为术前、围手术期和术后干预。 术前 术前咨询和培训 缩短禁食时间及术前碳水化合物负荷 避免机械性肠道准备 深静脉血栓形成预防 预防性抗生素治疗 围手术期 高氧吸入 低体温预防 目标导向术中液体疗法 手术径路和切口 避免术后留置引流管和鼻胃管 短期硬膜外止痛和局部神经阻滞 术后 避免使用阿片类药物，应与对乙酰氨基酚和NSAIDS应用 术后早期进食 术后早期活动 限制静脉补液量 审查 Postoperative pain is still inadequately relieved despite substantial improvements in the knowledge of the mechanisms and treatment of pain [1]. Evidence suggests that inadequate relief of postoperative pain may result in harmful physiologic and psychologic consequences that lead to significant morbidity and mortality [2], which may delay recovery and the return to daily living [3]. In addition, the presence of postoperative symptoms, including pain, significantly contributes to patients’ dissatisfaction with their anesthesia and surgical experience [4]. Most importantly, it has been recognized that inadequately treated postoperative pain may lead to chronic pain, which is often misdiagnosed and neglected [5,6]. This article reviews the physiologic and psychologic consequences of inadequate