加速术后恢复 (ERAS) 护理计划

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In spite of continuous advances in anaesthesia, surgery and perioperative care, major surgery is still associated with undesirable sequel such as pain, cardiopulmonary, infective and thromboembolic complications, cerebral dysfunction, nausea and gastrointestinal paralysis, fatigue, and prolonged convalescence.1 Enhanced Recovery After Surgery (ERAS) was initiated by Professor Henrik Kehlet in the 1990s,1 and enhanced recovery programmes (ERPs) have become an important focus of perioperative management for most major surgeries. These care pathways are integrated as the patient moves from home through the pre-hospital/pre-admission, pre-operative, intraoperative, and post-operative phases of surgery and home again. ERAS represents a model of perioperative care in by re-examining traditional practices and replacing them with evidence-based good practices when necessary. It also covers each phase of the patient's journey through the surgical process. These programmes attempt to modify the physiological and psychological responses to major surgery,2 and have been shown to lead to a reduction in complications and hospital stay, improvements in cardiopulmonary function, earlier return of bowel function, and earlier resumption of normal activities.3,4 The key principles of the ERAS protocol include pre-operative counselling, pre-operative nutrition, avoidance of peri-operative fasting, and carbohydrate loading up to 2 h pre-operatively, standardised anaesthetic and analgesic regimens (epidural and non-opioid analgesia) and early mobilisation.5

One of the most important aspects is the ERAS team.6 It is an interdisciplinary team and refers to a group of healthcare professionals from diverse fields who work together in a cohesive and collaborative fashion with trust to share expertise, knowledge, and skills to engage and optimise the patient across the entire pathway.7,8 This includes pre-admission staff, dieticians, nurses, physiotherapists, social workers, occupational therapists, and doctors. All team members must be familiar with ERAS principles and be motivated to carry out the programme; they must be able to overcome traditional concepts, teaching, and attitudes towards perioperative care.6 For implementation to be successful, nurses were found to be key and play a central part of the team taking care of surgical patients by providing education, peri-operative care, and post-operative evaluation, as well as cost containment.9 They are at the forefront of daily patient care and have therefore a major impact on securing the adherence to ERAS pathway elements. Nursing within ERAS care implies a shift from traditional nursing to additional important tasks, including dedicated information (setting expectations), coaching of patients, and control, monitoring, and documentation of the recovery process.10 Systematic implementation of ERAS was associated with decreased nursing workload and higher compliance was associated with lower work burden for the nurses.11

Pre-admission phase

Information, education, and counselling help to set expectations about surgery and also about care plan in post op period. It also will help to reduce anxiety and increase patient satisfaction, which may improve fatigue and facilitate early discharge.12,13 Barriers like patients language, cultural and religious beliefs, health literacy, and nursing professionals attitudes, biases, behaviours, communication skills, and competencies may impact understanding of ERAS process and can make ERAS implementation challenging.

Ideally, the patient/family should meet with all members of the team including the surgeon, anaesthetist, dietician, and nurse. Studies have shown that patients prefer to be well informed, and support from a nurse at the time of diagnosis can reduce stress levels for up to six months14 However, to be effective in this area nurses should be skilled and willing to assess the individual's need for help with information, and managing their worry.14 Counselling helps to minimise anxiety by educating patients on what to expect post-surgery, pain management, post-operative phase are (deep breathing exercise, wound care), and addressing body image disturbance if any. Patients are also most successful when they are able to actively engage in lifestyle activities such as exercise to lose weight or stop smoking more than two weeks prior to surgery.15

Prehabilitation of patients with comorbidities is vital. The term ‘prehabilitation’ has been used to describe the process of optimising functional and nutritional capacity and preparing the patient to better cope with the stress of surgery.16 Inadequate nutrition, particularly for cancer patients undergoing surgery, is an independent risk factor for complications, increased hospital stay and costs.17 Therefore assessment and treatment of poor nutrition is an essential constituent of ERAS protocols. In terms of defining the problem, the European Society of Parenteral and Enteral Nutrition (ESPEN) defines “severe” nutritional risk as one or more of the following: weight loss > 10%–15% in six months, body mass index < 18.5 kg/m2 or a serum albumin of < 30 g/L.5

Pre-operative phase

Several randomised controlled trials (RCTs) have reported that clear fluids can be safely given up to 2 h, and a light meal up to 6 h, before elective procedures requiring general anaesthesia, in children and adults.18 Oral fluids including oral carbohydrates may not be administered safely in patients with documented delayed gastric emptying or gastrointestinal motility disorders as well as in patients undergoing emergency surgery.19 Decision on use of antihypertensive/hypoglycaemic agent need to be discussed. The ERAS programme needs to be discussed with patient/family and realistic goals need to be established for pain, nutrition, mobilisation, and length of stay (LOS).

Post-operative phase

Review findings highlights that ERAS protocols of post-operative care are beneficial for patients undergoing surgery.20 Nurses must note that several perioperative risk factors may contribute to post-operative morbidity. Risk factors include co-morbidities (diabetes, hypertension, chronic obstructive pulmonary disease immunosuppression, malnutrition), pain, nausea/vomiting, immobilisation, drains/naso-gastric tubes.1

Criteria for assessment, monitoring, and documentation interval need to be specified. Patient need to be assessed and evaluated for recovery status and return optimum function, for example: level of consciousness, ability to mobilise, etc. Patients are encouraged for early mobilisation and feeding.21 These activities should be supported by management of pain, preventing/minimising post-operative nausea/vomiting, surgical site care, IV fluids management, and early removal of IV catheter. Effective post-operative pain relief is a prerequisite to attain improved post-operative outcome, and when integrated into an active rehabilitation programme may reduce the surgical stress response, organ dysfunctions and improve gastrointestinal motility, to allow early oral nutrition and to facilitate early mobilisation.1 Involvement of family in care helps the family member to continue care post discharge confidently. Post-operative nausea and vomiting (PONV) risk assessment score (Table I) will help in management of PONV.22

Another aspect that nurses need to monitor is for surgical site infections (SSIs). SSIs are associated with increased patient morbidity, mortality, and healthcare expenditures. SSI reduction bundles have been demonstrated to decrease the risk of developing a surgical site infection and bundle elements include antimicrobial prophylaxis, skin preparation, avoiding hypothermia, avoiding surgical drains, and reducing perioperative hyperglycaemia.19

Discharge phase

Discharge planning begins during pre-operative phase and continues through discharge and return home. Time to recovery will vary depending on the type of surgery or symptom being measured.

Assessing patients readiness to discharge is an indispensable element of discharge planning and includes assessing functional status, re-emphasising on surgical site care, diet, exercise, lifestyle modifications, medications, and follow up. It is also essential to provide tailored information to meet the needs of the individual patient. A written information sheet will help in adhering to instructions, symptoms to report, when and how to obtain urgent care/assistance. Ensuring that patients’ informational needs have been met before hospital discharge sets the stage for successful self-management of recovery at home. With improved post-operative education and closer follow-up, it is estimated that 50% of hospital readmissions may be preventable.11,23

Conclusions

ERAS is now firmly established as a global surgical quality improvement initiative that results in clinical improvements,24 which in turn also has an impact on length of stay, and thus cost to patients. ERAS guidelines are freely available at ERAS society website and are based on the highest quality evidence.25 The effective implementation begins with the formulation of a protocol, carrying out each intervention, and gathering outcome data. The care of a patient is divided into three phases: before, during, and after surgery. Each stage needs active participation of few or all the members of the multi-disciplinary team. It is also the role of this team to keep abreast with the latest development in fast-track methodology and make appropriate changes to policy.21

Trained professional nurses remain indispensable evaluators, implementers, observers, and coordinators at all stages of ERAS programme.26 ERAS nursing pathway can be established across for all major surgeries incorporating best practices. This requires consistency across the care team, diligence to ensure compliance, and use of an audit tool for quality improvement.9 Patient reported outcomes, including symptom burden assessment, can also be tracked to guide individual post-operative care.19 Studies can also aim at improvement of hospitalisation conditions, reduction of patient stress, safer care, fewer complications, and cost effectiveness.20

Nursing professionals are well positioned as champion leaders and members of the patient-centered team for ERAS excellence.

全文翻译（仅供参考）

尽管在麻醉、手术和围手术期护理方面不断取得进步，但大手术仍然伴随着不良的后遗症，如疼痛、心肺、感染和血栓栓塞并发症、脑功能障碍、恶心和胃肠麻痹、疲劳和恢复期延长。1加速术后恢复 (ERAS) 由 Henrik Kehlet 教授在 1990 年代发起，1增强康复计划 (ERPs) 已成为大多数大型手术围手术期管理的重点。当患者从家中通过入院前/入院前、术前、术中和术后阶段以及再次回家时，这些护理途径被整合在一起。ERAS 通过重新审视传统做法并在必要时用循证的良好做法取代它们，代表了一种围手术期护理模式。它还涵盖了患者在手术过程中的每个阶段。这些计划试图改变对大手术的生理和心理反应，2并且已被证明可以减少并发症和住院时间、改善心肺功能、更早恢复肠道功能和更早恢复正常活动。3、4 ERAS方案的关键原则包括术前咨询、术前营养、避免围手术期禁食、术前 2 小时内的碳水化合物负荷、标准化麻醉和镇痛方案（硬膜外和非阿片类镇痛）和早期活动。5

最重要的方面之一是 ERAS 团队。6它是一个跨学科团队，指的是一群来自不同领域的医疗保健专业人员，他们以凝聚力和协作的方式相互信任，分享专业知识、知识和技能，以在整个路径中参与和优化患者。7 , 8这包括入院前工作人员、营养师、护士、物理治疗师、社会工作者、职业治疗师和医生。所有团队成员都必须熟悉 ERAS 原则并有动力执行该计划；他们必须能够克服对围手术期护理的传统观念、教学和态度。6为了使实施成功，护士被认为是关键，并通过提供教育、围手术期护理和术后评估以及成本控制，在照顾手术患者的团队中发挥核心作用。9它们处于日常患者护理的最前沿，因此对确保遵守 ERAS 途径要素具有重大影响。ERAS 护理中的护理意味着从传统护理转向额外的重要任务，包括专门的信息（设定期望）、对患者的指导以及对康复过程的控制、监测和记录。10系统实施 ERAS 与减少护理工作量相关，更高的依从性与降低护士的工作负担相关。11

入院前阶段

信息、教育和咨询有助于设定对手术的期望以及术后护理计划。它还有助于减轻焦虑并提高患者满意度，这可能会改善疲劳并促进早期出院。12 , 13患者的语言、文化和宗教信仰、健康素养以及护理专业人员的态度、偏见、行为、沟通技巧和能力等障碍可能会影响对 ERAS 流程的理解，并使 ERAS 的实施具有挑战性。

理想情况下，患者/家属应与团队的所有成员会面，包括外科医生、麻醉师、营养师和护士。研究表明，患者更愿意了解情况，并且在诊断时得到护士的支持可以减少长达六个月的压力水平14但是，要在这方面有效，护士应该熟练并愿意评估个人的需要寻求信息方面的帮助，并管理他们的担忧。14咨询通过教育患者手术后的预期、疼痛管理、术后阶段（深呼吸运动、伤口护理）以及解决身体形象障碍（如果有）来帮助减少焦虑。当患者能够在手术前两周以上积极参与生活方式活动（例如运动减肥或戒烟）时，他们也是最成功的。15

合并症患者的康复治疗至关重要。“预康复”一词用于描述优化功能和营养能力以及让患者更好地应对手术压力的过程。16营养不足，特别是对于接受手术的癌症患者，是并发症、住院时间增加和费用增加的独立风险因素。17因此，营养不良的评估和治疗是 ERAS 协议的重要组成部分。在定义问题方面，欧洲肠外和肠内营养学会 (ESPEN) 将“严重”营养风险定义为以下一项或多项：六个月内体重减轻 > 10%–15%，体重指数 < 18.5 kg/m 2或血清白蛋白 < 30 g/L。5

术前阶段

几项随机对照试验 (RCT) 报告说，在需要全身麻醉的选择性手术之前，儿童和成人可以安全地给予清澈的液体长达 2 小时，并在 6 小时内安全地给予清淡的食物。18对于有记录的胃排空延迟或胃肠动力障碍的患者以及接受紧急手术的患者，可能不安全地给予包括口服碳水化合物在内的口服液。19需要讨论使用降压药/降糖药的决定。ERAS 计划需要与患者/家属讨论，并且需要为疼痛、营养、活动和住院时间 (LOS) 建立现实目标。

术后阶段

审查结果强调，ERAS 术后护理方案对接受手术的患者有益。20护士必须注意，一些围手术期风险因素可能会导致术后发病率。风险因素包括合并症（糖尿病、高血压、慢性阻塞性肺疾病免疫抑制、营养不良）、疼痛、恶心/呕吐、制动、引流/鼻胃管。1

需要指定评估、监控和记录间隔的标准。需要评估和评估患者的恢复状态和恢复最佳功能，例如：意识水平、活动能力等。鼓励患者早期活动和进食。21这些活动应通过疼痛管理、预防/减少术后恶心/呕吐、手术部位护理、静脉输液管理和早期拔除静脉导管来支持。有效的术后疼痛缓解是改善术后结果的先决条件，当整合到积极的康复计划中时，可以减少手术应激反应、器官功能障碍并改善胃肠道运动，从而允许早期口服营养并促进早期活动。1家人参与护理有助于家人在出院后自信地继续护理。术后恶心呕吐（PONV）风险评估评分（表一) 将有助于 PONV 的管理。

护士需要监测的另一个方面是手术部位感染 (SSI)。SSI 与患者发病率、死亡率和医疗保健支出的增加有关。SSI 减少束已被证明可降低发生手术部位感染的风险，束元素包括抗菌预防、皮肤准备、避免低温、避免手术引流和减少围手术期高血糖。19

放电阶段

出院计划从术前阶段开始，一直持续到出院和回家。恢复时间会因手术类型或所测量的症状而异。

评估患者出院准备情况是出院计划不可或缺的要素，包括评估功能状态、重新强调手术部位护理、饮食、锻炼、生活方式改变、药物治疗和随访。提供量身定制的信息以满足个体患者的需求也很重要。书面信息表将有助于遵守说明、报告症状、何时以及如何获得紧急护理/援助。确保在出院前满足患者的信息需求，为在家中成功进行自我康复管理奠定了基础。随着术后教育的改进和更密切的随访，估计 50% 的再入院是可以预防的。11 , 23

ERAS 现在已被牢固确立为一项全球手术质量改进计划，可带来临床改善，24这反过来也会影响住院时间，从而影响患者的成本。ERAS 指南可在 ERAS 协会网站上免费获取，并且基于最高质量的证据。25有效实施始于制定方案、实施每项干预措施并收集结果数据。对患者的护理分为三个阶段：术前、术中和术后。每个阶段都需要多学科团队中少数或全部成员的积极参与。该团队的职责也是跟上快速通道方法的最新发展并对政策进行适当的更改。21

在 ERAS 计划的各个阶段，训练有素的专业护士仍然是不可或缺的评估者、实施者、观察者和协调者。26条 ERAS 护理路径可以针对所有包含最佳实践的大型手术建立。这需要整个护理团队保持一致，努力确保合规性，并使用审计工具来改进质量。9还可以跟踪患者报告的结果，包括症状负担评估，以指导个体术后护理。19研究还可以旨在改善住院条件、减轻患者压力、更安全的护理、更少的并发症和成本效益。20

护理专业人士处于卓越的 ERAS 卓越领导者和以患者为中心的团队的成员中。

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