甲状腺日间手术中国专家共识(2021版)

日间手术经过60余年的发展,以高效、安全性和经济性在欧美等医疗发达国家广泛开展.国内日间手术发展起步较晚,目前只有少数三甲医院开展甲状腺日间手术.近年来随着加速康复外科(ERAS)理念在外科领域的不断深入应用,甲状腺外科ERAS也进入临床实践,成效显著.此外,多项新技术在甲状腺外科领域的应用提高了手术安全性,降低了术后...     

甲状腺日间手术可行性的研究进展

目的甲状腺日间手术目前在国外正逐步开展,但因甲状腺术后并发症的危险性较高,国内尚未大范围尝试。主要从甲状腺术后并发症的危险性来对甲状腺日间手术的可行性进行综述。     

观察心理与音乐干预对妇科手术患者术前心理应激反应的影响

目的 通过观察接受不同干预方法的患者,寻找有效降低术前心理应激反应的方法.方法 选择ASA Ⅰ或Ⅱ级、有相同音乐背景的妇科手术患者80例,随机分为心理干预组(P组)、音乐干预组(M组)和音乐与心理干预组(MP组)、对照组(C组),每组20例.对患者于术前1 d进行术前访视,了解音乐背景、讲明研究目的 及方法,评定患者焦虑水平,抽取血标本等.分别在入院后(T0)、入手术室动、静脉穿刺后5 min(T1)、研究结束时(T2)抽取血样,用放射免疫测定法检测血浆皮质醇(Cor)浓度、高效液相色谱仪检测去甲肾上腺素(NE)和肾上腺索(E)浓度.记录各组T1、T2时脑电双频指数(BIS)、MAP、HR.结果 与C组比较,T1、T2时P、MP组Cor、E、NE均降低(P<0.05);与T1时比较,T2时P、M和MP组MAP降低,HR减慢(P<0.05);与MP组比较,T1、T2时M组、T2时P组Cor、E、NE明显升高(P<0.05).与C组比较,T2时P、M和MP组MAP降低,HR减慢(P<0.05);与MP组比较,T2时P、M组MAP升高、HR增快(P<0.05).T2时M、MP组BIS明显低于C、P组(P<0.05).结论 心理干预复合个体化音乐疗法是降低患者术前心理应激反应较为有效的方法.     

腔镜甲状腺手术对患者创伤应激的影响

目的:探讨腔镜甲状腺手术对患者机体创伤应激的影响.方法:62例腔镜甲状腺手术患者按手术顺序分为A组25例,B组37例,分别与同期40例开放甲状腺手术(C组)对比,分析围手术期白细胞(white blood cell,WBC)、C反应蛋白(C reactive protein,CBP)、白介素-6(interleukin...     

心理支持和认知教育在青年女性甲状腺良性结节手术患者围术期护理中的应用效果

目的 探讨心理支持和认知教育干预在青年女性甲状腺良性结节手术患者围术期护理中的应用效果.方法 回顾性分析2019-01—2020-11在濮阳市中医医院行改良Miccoli腔镜辅助手术的60例青年女性甲状腺良性结节患者的临床资料.分为围术期常规护理组(常规护理组)和在常规护理基础上联合心理支持和认知教育干预组(联合干预组...     

甲状腺日间手术模式涉及的相关问题探讨

随着甲状腺癌发病率与手术量急剧增加,对24h内完成入、出院的甲状腺日间手术的需求也日益升高。目前日间手术已在国内外少数先进医疗单位实施,并认为是在严格控制适应证的情况下,具有安全高效、方便快捷的特点,能明显降低住院时间和住院费用,提高患者满意度的先进管理模式。然而在我国现有的医疗体制和医患环境下,真正建立和推广日间手术模式尚面临手术并发症、医保政策、医院管理制度、术后康复管理、医疗文书书写以及医学伦理等诸多问题。现阶段日间手术仅适合在有丰富外科经验的甲状腺诊疗中心进行有条件的临床探索。     

实施加速康复外科麻醉管理对甲状腺手术应激水平的影响

目的比较加速康复外科(enhanced recovery after surgery,ERAS)与传统围术期的麻醉管理对甲状腺手术围术期应激水平的影响。方法选择2016年5~8月择期行甲状腺手术的患者62例,男13例,女49例,年龄18~65岁,ASAⅠ或Ⅱ级,随机分为ERAS组(n=29)和对照组(C组,n=33)。ERAS组按照ERAS围术期流程操作,记录苏醒期和术后第1天VAS疼痛评分以及术后镇痛满意度评分,记录术前、术后当日和术后1d的C反应蛋白(CRP)、血皮质醇、IL-6、IL-8和TNF-α浓度。记录术后并发症的发生情况。结果苏醒期ERAS组VAS疼痛评分明显低于C组[(0.42±0.83)分vs(0.95±1.16)分,P0.05],术后1dERAS组VAS疼痛评分明显低于C组[(1.90±1.21)分vs(2.73±1.40)分,P0.05]。ERAS组术后第1天镇痛满意度评分明显高于C组(P0.05)。术后当日和术后1dERAS组CRP浓度明显低于C组;C组CRP浓度明显高于术前(P0.05)。两组术后咽痛、声嘶和饮水呛咳等并发症的发生率差异无统计学意义。结论 ERAS围术期操作系统在甲状腺手术中的应用安全、可靠,有效提高患者的满意度,提升舒适化围术期体验,同时减轻术后疼痛,促进患者快速康复。     

心理护理对妇科手术患者术前焦虑的影响

目的:观察心理护理干预对妇科手术术前焦虑及术后恢复的影响.方法:100例各种妇科疾病患者,用随机数字表法分为干预组和对照组,各50例,干预组采用一对一的个体化的心理护理干预;对照组采取常规心理护理,观察两组患者手术前后的焦虑自评量表( SAS)评分、收缩压、心率变化.结果:两组干预前SAS评分差异无统计学意义(P＞0.05),两组患者手术前和手术后SAS评分差别有统计学意义(P＜0.05);干预组术前10min收缩压、心率及入室后变化幅度低于对照组(P＜0.05);干预组术后住院间短于对照组(P＜0.05).结论:心理护理可缓解妇科手术患者术前焦虑情绪,减轻患者应激反应,促进康复.     

超前镇痛对高龄患者心理应激影响的临床研究

目的：探讨超前镇痛对高龄患者心理应激反应的影响。方法：选择择期下肢髋关节手术60例，随机分为超前镇痛组及对照组。分别观察患者入院时、手术前晚、麻醉前、切皮即刻、切皮后10min、30min、回病房30min和术后第一天、第二天的HR、SBP；应用放免法测定术前一日、术日、术后1、2、3日的皮质醇（Cor）、胰岛素（Ins）、血管紧张素Ⅰ（AⅠ）及血管紧张素Ⅱ（AⅡ）变化。结果：两组术前、术中HR、SBP无显著差异，术后对照组的变化与超前镇痛组比较有显著性差异（P〈0．05）。对照组Cor、Ins、AⅠ、AⅡ术后降低幅度均低于超前镇痛组，有显著性差异（P〈0．05）。对照组SAS、SDS、术后恐惧程度较超前镇痛组者显著性增高（P〈0．05）。麻醉效果两组比较无显著差异，但对照组术中辅助药用量和例数明显多于超前镇痛组。结论：超前镇痛可降低高龄患者的焦虑程度，改善心情，提高心理忍受力。维持较为正常的应激能力，避免过度应激反应。由此可减少围手术期并发症，增强手术安全性，利于患者早日康复。     

骨折患者由择期改为急诊手术时的生理应激与心理干预

目的 分析骨折患者由择期手术改为急诊手术时的生理变化．探讨心理干预对患者的影响。方法 将40例骨折患者分为三组．A组9例，为择期手术患者；B组14例、C组17例，均为择期改为第2天急诊手术患者。A、B组行常规护理．C组术前实施心理干预。在各时间段测量患者的血压、心率及皮质醇浓度。结果 入院时、术前1d晨三组血压、心率和皮质醇浓度比较．差异无显著性意义（均P〉0．05）。术前1d晚、术日晨、术后1～3dB组上述各指标均显著高于A、C组（均P〈0．05）。结论 择期改为急诊手术使患者的心理应激增加．心理干预可有效改善患者的应激状态。     

Outcome of ASA III patients undergoing day case surgery

Background. Day case surgery is becoming more acceptable, evenfor patients with complex medical conditions. Current recommendationssuggest that patients who are graded as American Society ofAnaesthesiologists physical status (ASA) III may be suitablefor this approach. There is only a small amount of publisheddata available to support this. We present a retrospective reviewof ASA III patients who had undergone day surgical proceduresin our unit. Methods. We carried out a retrospective case controlled reviewof 896 ASA III patients who had undergone day case proceduresbetween January 1998 and June 2002 using the existing computerizedpatient information system. The system records admission rates,unplanned contact with healthcare services and post-operativecomplications in the first 24 h after discharge. Results. We demonstrated no significant differences in unplannedadmission rates, unplanned contact with health care services,or post-operative complications in the first 24 h after dischargebetween ASA III and ASA I or II patients. Conclusion. With good pre-assessment and adequate preparationASA III patients can be treated safely in the day surgery setting. Br J Anaesth 2004; 92: 71–4     

对日间手术病房患者实施人文关怀的效果探讨

目的 探讨人文关怀措施对日间手术患者焦虑及术后康复的影响,为医护人员实施专业的人文关怀护理服务提供参考。 方法 将接受日间手术的110例腹股沟疝患者随机分为对照组与干预组各55例。对照组给予常规护理,干预组在常规护理的基础上实施人文关怀护理干预。比较两组术前焦虑评分、术后饮食与下床活动时间及护理满意度。 结果 干预组术前焦虑评分显著低于对照组,术后进食时间、下床活动时间显著早于对照组,护理满意度显著高于对照组（均P＜0.01）。 结论 为日间手术病房患者实施人文关怀服务可减轻其心理压力,加速术后康复,提高护理满意度。     

The perioperative dialogue reduces postoperative stress in children undergoing day surgery as confirmed by salivary cortisol

Aim: To evaluate the efficacy of ‘the perioperative dialogue (PD)’ by analyzing salivary cortisol, in 5‐ to 11‐year‐old children undergoing day surgery. Background: To deal with anxiety prior to investigations and/or procedures, children need to be confident and informed about what is going to happen. Therefore, intervention strategies should be initiated before admission to hospital. Methods and materials: Children (n = 93), 79 boys and 14 girls, scheduled for elective day surgery requiring general anesthesia were randomly recruited into three groups: (i) standard perioperative care (n = 31), (ii) standard perioperative care including preoperative information (n = 31), and (iii) the PD (n = 31). Saliva was sampled for cortisol analysis at specific time points during the pre‐ and perioperative procedures. Results: The children who received the PD had significantly lower (P = 0.003) salivary cortisol concentrations postoperatively. Moreover, it continuously decreased during the day of surgery compared with the other two groups (P < 0.01). Among the children who received analgesics, the PD group received significantly less morphine (P = 0.014) related to bodyweight: the mean dose was 0.1 mg·kg^?1 (n = 9) in the control group vs 0.04 mg·kg^?1 (n = 6) in the PD group. Irrespective of group, there was a positive correlation between the children’s morphine consumption and salivary cortisol concentration (r = 0.56; P = 0.038). The W‐B scale score was higher in the group that received morphine (median = 3 vs median=1; P = 0.001). Conclusions: The PD’s caring, continuity, and on‐going dialogues were associated with low concentrations of salivary cortisol postoperatively and reduced morphine consumption and thus appears to be a valuable complement to standard perioperative care in children undergoing day surgery.     

超声引导下筋膜平面阻滞联合局部浸润麻醉对乳腺外科日间手术患者的临床效果

目的：探讨超声引导下筋膜平面阻滞联合局部浸润麻醉在乳腺外科日间手术患者中的麻醉效果。方法：选择2019年12月—2022年3月我院乳腺外科收治的行日间手术的患者74例,按随机数字表法分为对照组与观察组,每组各37例。对照组采用局部浸润麻醉,观察组采用超声引导下筋膜平面阻滞联合局部浸润麻醉,手术24 h后评估患者麻醉效果,比较两组视觉模拟疼痛（VAS）评分、麻醉药物剂量、应激反应及并发症发生率。结果：两组术后16 h及24 h的VAS评分高于术后2 h(P <0.05);观察组术后16 h及24 h VAS评分低于对照组（P <0.05）;观察组最早起效时间、镇痛连续时间及局部麻醉药使用剂量少于对照组（P <0.05）;两组麻醉24 h后均伴有不同程度应激反应;观察组丙二醛（MDA）、隐性氧化蛋白产物（AOPP）水平高于对照组（P <0.05）;过氧化物酶（SOD）及谷胱甘肽过氧化物酶（GSH-Px）水平低于对照组（P <0.05）;两组麻醉期间呼吸抑制、寒战、注射部位肌肉痛、恶心呕吐及低血压发生率差异无统计意义（P>0.05）。结论：超声引导下筋膜平...     

实景动态教育对心脏手术患者术前心理状况的影响

目的探讨实景动态教育对拟行手术治疗心外科患者术前心理状况的影响。方法将心外科手术患者60例按照时间顺序分为对照组与观察组各30例。对照组按常规健康教育,观察组运用实景动态教育形式进行集中式多媒体授课。结果观察组术前1d焦虑评分显著低于对照组(P<0.05)。观察组对术前教育内容掌握程度及对护理工作的满意率显著高于对照组(均P<0.01)。结论实景动态教育有助于缓解心外科患者术前紧张情绪,提高知识水平及对护理工作的满意度。     

心理干预对整形美容外科手术患者紧张焦虑心理的影响

目的:探讨心理干预对整形美容外科手术患者产生紧张焦虑心理的影响。方法:将413例手术患者随机分为观察组(208例)和对照组(205例)。对照组接受一般心理护理,观察组接受依据准确期待而制定的干预措施,测定并比较两组患者紧张、焦虑程度,手术前中后的血压、心率波动情况,以及紧张、焦虑程度对手术时间的影响。结果:心理干预后观察组的血压、心率、紧张焦虑程度及手术时间显著低于对照组(P<0.05,P<0.01,P<0.05)。结论:心理干预可以缓解整形美容外科手术患者紧张、焦虑心理,降低血压波动范围及缩短手术时间。     

Systemic stress responses in patients undergoing surgery for benign prostatic hyperplasia

OBJECTIVE: To determine differences in systemic stress responses in patients undergoing three different types of surgery for benign prostatic hyperplasia (BPH), evaluated by measuring levels of stress variables, i.e. cortisol; acute-phase reactants, i.e. C-reactive protein (CRP) and fibrinogen; and antioxidants, i.e. total antioxidant status (TAS) and superoxide dismutase (SOD). PATIENTS AND METHODS: The study included 80 patients who fulfilled the inclusion criteria for surgery for BPH. Based on an ultrasonographic estimate of the prostate volume before surgery, all patients were allocated to one of three groups; group 1, prostate < or = 30 g and treated with transurethral incision of the prostate (TUIP); group 2, prostate 30-80 g, treated with transurethral resection of the prostate (TURP); and group 3, prostate >80 g, treated with a suprapubic transvesical prostatectomy (TP). Blood samples were taken from each patient on the day before and the day after surgery, and the acute-phase reactants and antioxidants measured; cortisol concentrations were also measured in 24-h urine samples the day before and 3 days after surgery. RESULTS: There were significantly higher levels of cortisol, CRP and TAS, and significantly lower levels of fibrinogen and SOD in all study groups after surgery than before. Surgery and associated conditions, e.g. excitement, fear, blood loss, etc., lead to traumatic and oxidative stress, followed by a strong systemic stress response during and after surgery. Low fibrinogen levels after surgery had a different pattern from the other acute-phase reactants, as a result of increased fibrinolytic activity after TURP and TP. CONCLUSION: The extent of the systemic stress response correlated fairly well with the degree of tissue damage, which differed in the three groups. Suprapubic TP caused the most tissue trauma and triggered the strongest systemic stress response. This response was moderate after TURP, while TUIP (a minor intervention) caused the least stress. Specific changes in stress markers could be used to improve surgery for BPH. Whether there is a benefit of antioxidant therapy during surgery for BPH should be evaluated in further studies.     

Perceived stress,psychological well‐being and the activity of neutrophils in patients undergoing cardiopulmonary bypass surgery

This study explored relationships, before and after surgery, between perceived stress and the activity of white‐blood cells (neutrophils) in 82 patients undergoing heart surgery involving cardiopulmonary bypass surgery (CPB). On the evening before surgery and at follow‐up, 6‐weeks after discharge, patients completed self‐administered standard psychological measures. Small peripheral blood samples were taken, from which neutrophil activity was quantified using nitro‐blue tetrazolium (NBT) and luminol‐dependant chemiluminescence (phagocytic capacity). There were consistent, statistically significant associations between stress and percentageNBT cells at baseline and at follow‐up. Regression analysis showed that perceived stress was a predictor of neutrophil activity at follow‐up suggesting that higher levels of stress are associated with higher levels of activity. Results from the phagocytic capacity data support and strengthen the NBT findings; in response to stimuli the phagocytic capacity of the neutrophils is reduced at baseline (high stress) and increased at follow‐up (lower stress). Significant decreases were found on perceived stress, anxiety, depression, negative affect and health‐related stress at follow‐up. Patients' self‐efficacy was high at baseline and remained high throughout the study. Results highlighted a consistent, significant relationship between perceived stress and the ‘activity’ of neutrophils. The implications of this finding are worthy of exploration given that stress‐activated neutrophils may adversely influence health outcomes. Copyright © 2006 John Wiley & Sons, Ltd.     

麻醉科医师术前受邀会诊与老年患者髋部手术后早期并发症的相关性

目的 探讨麻醉科医师术前受邀会诊与老年患者髋部手术后早期并发症的相关性。
方法 采用倾向性评分匹配（PSM）法回顾性分析2019年1—12月行髋部手术患者100例,男36例,女64例,年龄≥65岁,ASA Ⅲ或Ⅳ级。根据术前是否接受由外科医师提交会诊申请并由麻醉科高年资主治医师执行的正式会诊,将患者分为两组：受邀会诊组（会诊组）和非受邀会诊组（对照组）,每组50例。收集性别、年龄、BMI、ASA分级、年龄校正的Charlson合并症指数（aCCI）、麻醉方法、手术时间、麻醉时间、手术出血量、术前等待时间、术前住院时间、术后住院时间、总住院时间、术后1个月并发症等数据。比较两组一般情况、术中情况、住院时间和术后并发症等。
结果 两组性别、年龄、BMI、ASA分级和aCCI差异无统计学意义。会诊组椎管内麻醉比例明显高于对照组,术前等待时间、术前住院时间明显长于对照组,术后住院时间明显短于对照组（P<0.05）。两组手术时间、麻醉时间、出血量和总住院时间差异无统计学意义。会诊组术后并发症发生率明显低于对照组（P<0.05）。
结论 麻醉科医师术前受邀会诊与缩短老年患者髋部手术后住院时间及减少术后早期并发症相关。     

Trends in colorectal day case surgery in NHS Trusts between 1998 and 2005

Objective Day case surgery is safe and offers potential benefits to both patients and healthcare providers. This study aimed to describe national changes in colorectal day case workload between 1998 and 2005. Methods Admission data relating to Office of Population Censuses and Surveys Classification of Surgical Operations and Procedures (4th revision) (OPCS‐4) coloproctology operation codes were analysed using the Hospital Episode Statistics (HES) database. Day case rates (DCRs) were calculated as the proportion of elective cases performed on an ambulatory basis. Results In total, 3 119 058 colorectal admissions were recorded on the HES database between 1998 and 2005; 1 891 474 (61%) of these were for lower gastrointestinal endoscopies. Emergency cases accounted for 527 665 (17%), elective inpatient cases for 406 368 (13%) and elective day cases for 293 551 (9%) admissions. Throughout the study period the DCRs for five commonly performed elective colorectal procedures were: 0.70 for anal lesion excisions (OPCS‐4 codes: H48.1, H48.2 and H48.3); 0.16 for haemorrhoidectomy (OPCS‐4 code: H51.1); 0.63 for anal fissure procedures (OPCS‐4 codes: H56.2 and H56.4); 0.39 for elective procedures for anal fistula (OPCS‐4 codes: H55.1, H55.2, H55.3 and H55.4); 0.37 for elective pilonidal surgery (OPCS‐4 codes: H59 and H60.2). Two emergency operations, drainage of perianal and pilonidal abscesses (OPCS‐4 codes: H58.2 and H60.3 respectively), were identified as operations potentially amenable to day surgery. Over the seven study years, an annual average of 8559 (±SD 307) admissions were coded to drainage of a perianal abscess and 4676 (±SD 478) admissions to drainage of pilonidal abscess. The average annual bed usage associated with these procedures was 18 831 (±SD 718) and 7623 (±SD 436) bed days respectively. Conclusions Colorectal day case surgery is currently under‐exploited in the NHS. By lifting some of the barriers to day case surgery significant resource savings may be possible.