肝癌患者术后胃肠功能障碍预防和护理的循证实践

doi:10.3761/j.issn.0254-1769.2024.06.001

摘要/Abstract

摘要：

目的基于最佳证据构建肝癌患者术后胃肠功能障碍预防和护理的循证实践方案，并评价其应用效果。方法应用循证护理学方法，系统检索、评价、总结肝癌患者术后胃肠功能障碍预防和护理的最佳证据。2022年9月—10月，以知识转化模式为指导，结合临床情境对最佳证据进行筛选，制订循证实践方案，并于2022年11月—2023年3月在浙江省杭州市某三级甲等综合医院肝胆胰外科中心进行实施，比较证据应用前后医护人员各项审查指标的执行率、围手术期胃肠功能障碍管理知识合格率和肝癌患者术后胃肠功能障碍发生率、首次排气时间、首次排便时间、术后住院时间、出院BMI及血清白蛋白相关结局指标的差异。结果该研究制订了18项审查指标，循证实践后医护人员11项审查指标执行率提高、知识合格率提高，差异有统计学意义（P<0.05）。患者术后胃肠功能障碍的发生率从11.9%下降至4.0%（P=0.037），首次排气时间、首次排便时间及术后住院时间均缩短，差异具有统计学意义（P<0.05）。结论肝癌患者术后胃肠功能障碍预防和护理循证实践的开展为临床决策提供了支持，提高了医护人员的知识水平和审查指标的执行率，有效降低了肝癌患者术后胃肠功能障碍的发生率，加速了康复进程。

关键词: 肝癌, 肝切除术, 术后胃肠功能障碍, 知识转化模式, 循证护理学

Abstract:

Objective To develop an evidence-based practice program for the prevention and management of postoperative gastrointestinal dysfunction in patients with hepatocellular carcinoma，based on the best available evidence，and to evaluate the effectiveness of its application. Methods An evidence-based nursing approach was conducted for systematical search，appraisal and summary of the best evidence for the prevention and management of postoperative gastrointestinal dysfunction in postoperative hepatectomy patients. From September 2022 to October 2022，under the guidance of Knowledge to Action Framework，and in combination with clinical scenarios，the best evidence was screened and adjusted，and an evidence-based practice plan was formulated. From November 2022 to March 2023，the plan was implemented in the Department of Hepatobiliary and Pancreatic Surgery of a tertiary A hospital in Hangzhou City，Zhejiang Province，China. We compared the rate of implementation of the measures by healthcare personnel before and after the application of the evidence，the qualified rate of knowledge of perioperative management of gastrointestinal dysfunction，and the incidence of postoperative gastrointestinal dysfunction in postoperative hepatectomy patients，the first time to flatus and bowel，the length of hospital postoperative stays，the BMI and serum albumin level on discharge. Results After evidence-based practice，the implementation of 11 review indicators and knowledge pass rate increased，and the difference was statistically significant（P<0.05）.The incidence of postoperative gastrointestinal dysfunction in patients decreased from 11.9% to 4.0%（P=0.037）. First time to gas and bowel，and the length of hospital postoperative stays were shortened，and the differences were statistically significant（P<0.05）. Conclusion The implementation of clinical evidence-based practice for the prevention and management of postoperative gastrointestinal dysfunction in postoperative hepatectomy patients provided support for clinical decision-making，improved healthcare professional awareness and implementation of review entries. It effectively reduced the incidence of gastrointestinal dysfunction in postoperative hepatectomy patients and accelerated the recovery process.

Key words: Liver Cancer, Hepatectomy, Postoperative Gastrointestinal Dysfunction, Knowledge to Action Framework, Evidence-Based Nursing

郭雪娥, 卞丽芳, 李鹤, 李春艳, 施晓兰, 李琰, 陈佳萍, 卢芳燕, 张华芳. 肝癌患者术后胃肠功能障碍预防和护理的循证实践[J]. 中华护理杂志, 2024, 59(6): 645-653.

GUO Xue’e, BIAN Lifang, LI He, LI Chunyan, SHI Xiaolan, LI Yan, CHEN Jiaping, LU Fangyan, ZHANG Huafang. Evidence-based practice for the prevention and management of gastrointestinal dysfunction in patients with liver cancer after surgery[J]. Chinese Journal of Nursing, 2024, 59(6): 645-653.

图/表 4

表1 肝癌患者术后胃肠功能障碍预防和护理的证据内容及审查方法

Table 1 Evidence content and review methods for the prevention and management of gastrointestinal dysfunction in patients with liver cancer after surgery

表2 两组患者一般资料的比较

Table 2 Comparison of general data in 2 groups

表3 循证实践前后审查指标执行率的比较

Table 3 Comparison of process indicators in 2 groups

表4 循证实践前后患者结局指标的比较

Table 4 Comparison of outcome indicators in 2 groups

参考文献 26

[1]	李偲, 刘克玄, 邓小明, 等. 术后胃肠功能障碍防治专家共识[J]. 国际麻醉学与复苏杂志, 2021, 42(11):1133-1142.
	Li S, Liu KX, Deng XM, et al. Expert consensus on the prevention and treatment of postoperative gastrointestinal dysfunction[J]. Int J Anesth Resus, 2021, 42(11):1133-1142.
[2]	Arfa S, Turco C, Lakkis Z, et al. Delayed return of gastrointestinal function after hepatectomy in an ERAS program:incidence and risk factors[J]. HPB(Oxford), 2022, 24(9):1560-1568.
[3]	Kalaitzakis E. Gastrointestinal dysfunction in liver cirrhosis[J]. World J Gastroenterol, 2014, 20(40):14686-14695. DOI URL
[4]	王静, 唐小丽, 邹静, 等. 加速康复外科理念下肝癌患者围术期全程胃肠道管理[J]. 护理学杂志, 2019, 34(10):1-4.
	Wang J, Tang XL, Zou J, et al. Strategies for maintaining gastrointestinal function during enhanced recovery after surgery program on patients undergoing resection of hepatocellular carcinoma[J]. J Nurs Sci, 2019, 34(10):1-4.
[5]	王红丽, 陈玲, 徐春艳, 等. 加速康复外科肝癌病人围术期护理方案的构建及应用效果[J]. 护理研究, 2019, 33(23):4060-4064.
	Wang HL, Chen L, Xu CY, et al. Construction and application observation of perioperative nursing program in liver cancerpatients undergoing enhanced recovery after surgery[J]. Chin Nurs Res, 2019, 33(23):4060-4064.
[6]	宋剑平, 卢芳燕, 林小燕, 等. 肝切除术后患者早期活动的最佳证据应用[J]. 中华护理杂志, 2019, 54(8):1175-1179. DOI
	Song JP, Lu FY, Lin XY, et al. Implementation of best evidence on early mobilization among patients after liver resection[J]. Chin J Nurs, 2019, 54(8):1175-1179. DOI
[7]	刘欢. 电针对重症患者胃肠功能障碍的疗效观察[D]. 南京: 南京中医药大学, 2022.
	Liu H. Observation on the effect of electroacupuncture on gastrointestinal dysfunction[J]. Nanjing:Nanjing University of Chinese Medicine, 2022.
[8]	桂屏, 叶淑华, 谢玉英, 等. 子午流注择时穴位贴敷对妇科腹腔镜术后患者胃肠功能的影响[J]. 中华护理杂志, 2020, 55(9): 1376-1380. DOI
	Gui P, Ye SH, Xie YY, et al. Effects of acupoint application therapy based on midnight-noon ebb-flow for gastrointestinal function in patients undergoing gynecological laparoscopy[J]. Chin J Nurs, 2020, 55(9):1376-1380. DOI
[9]	Wang Y, Yang JW, Yan SY, et al. Electroacupuncture vs sham electroacupuncture in the treatment of postoperative ileus after laparoscopic surgery for colorectal cancer:a multicenter,randomized clinical trial[J]. JAMA Surg, 2023, 158(1):20-27. DOI URL
[10]	钟婕, 周英凤. 知识转化模式在护理实践中的应用进展[J]. 中华护理杂志, 2017, 52(11):1366-1370.
	Zhong J, Zhou YF. Advances in the application of knowledge translation models to nursing practice[J]. Chin J Nurs, 2017, 52(11):1366-1370.
[11]	Joliat GR, Kobayashi K, Hasegawa K, et al. Guidelines for perioperative care for liver surgery:enhanced recovery after surgery(ERAS) society recommendations 2022[J]. World J Surg, 2023, 47(1):11-34. DOI URL
[12]	吴健雄, 许建萍, 荣维淇. 肝癌肝切除围手术期管理中国专家共识(2021年版)[J]. 中华肿瘤杂志, 2021, 43(4):414-430.
	Wu JX, Xu JP, Rong WQ. Chinese expert consensus on the perioperative management of hepatectomy for liver cancer(2021 edition)[J]. Chin J Oncol, 2021, 43(4):414-430.
[13]	Hedrick TL, Mcevoy MD, Mythen MMG, et al. American society for enhanced recovery and perioperative quality initiative joint consensus statement on postoperative gastrointestinal dysfunction within an enhanced recovery pathway for elective colorectal surgery[J]. Anesth Analg, 2018, 126(6):1896-1907. DOI PMID
[14]	Gero D, Gié O, Hübner M, et al. Postoperative ileus:in search of an international consensus on definition,diagnosis,and treatment[J]. Langenbecks Arch Surg, 2017, 402(1):149-158. DOI URL
[15]	赵玉沛, 黄宇光. 中国加速康复外科临床实践指南(2021)(二)[J]. 协和医学杂志, 2021, 12(5):632-640.
	Zhao YP, Huang YG. Clinical practice guidelines for ERAS in China(2021)(Ⅱ)[J]. Union Med J, 2021, 12(5):632-640.
[16]	Kalff JC, Wehner S, Litkouhi B. Measures to prevent prolonged postoperative ileus[DB/OL]. (2022-09-22) [2022-09-30]. https://www.uptodate.cn/contents/zh-Hans/measures-to-prevent-prolonged-postoperative-ileus.
[17]	Chen KB, Huang Y, Jin XL, et al. Electroacupuncture or transcutaneous electroacupuncture for postoperative ileus after abdominal surgery:a systematic review and meta-analysis[J]. Int J Surg, 2019, 70:93-101. DOI URL
[18]	Chen J, Tu Q, Miao S, et al. Transcutaneous electrical acupoint stimulation for preventing postoperative nausea and vomiting after general anesthesia:a meta-analysis of randomized controlled trials[J]. Int J Surg, 2020, 73:57-64. DOI URL
[19]	Alsharqawi N, Alhashemi M, Kaneva P, et al. Validity of the I-FEED score for postoperative gastrointestinal function in patients undergoing colorectal surgery[J]. Surg Endosc, 2020, 34(5):2219-2226. DOI PMID
[20]	陈芬, 张小青, 何君燕, 等. 个体化营养干预对肠癌术后护理中患者营养状态的影响[J]. 浙江临床医学, 2022, 24(12):1871-1872,1874.
	Chen F, Zhang XQ, He JY, et al. The impact of individualized nutritional intervention on the nutritional status of postoperative patients with colorectal cancer in nursing care[J]. Zhejiang Clin Med, 2022, 24(12):1871-1872,1874.
[21]	Yao LY, Gough AE, Zaghiyan KN, et al. Prospective randomized trial of immediate postoperative use of regular diet versus clear liquid diet in major colorectal surgery[J]. Dis Colon Rectum, 2023, 66(12):1547-1554. DOI PMID
[22]	柳冉冉, 于航娜, 董蓓, 等. 腹腔镜治疗结直肠癌老年患者术后肠梗阻发生率及影响因素研究[J]. 实用癌症杂志, 2021, 36(1):112-115.
	Liu RR, Yu HN, Dong P, et al. Study on the incidence of intestinal obstruction after laparoscopy in elderly patients with colorectal cancer and its influencing factors[J]. Pract J Cancer, 2021, 36(1):112-115.
[23]	丁亚, 赵瑞, 于航娜, 等. 胃肠肿瘤患者术后进食与早期肠梗阻的关系及护理[J]. 解放军护理杂志, 2017, 33(1):61-63.
	Ding Y, Zhao R, Yu HN, et al. The relationship between postoperative diet of gastrointestinal tumor patients and early intestinal obstruction and targeted nursing[J]. Nurs J Chin PLA, 2017, 34(1):61-63.
[24]	王燕, 陈思思, 江海丽, 等. 中医外治法治疗消化道肿瘤术后胃肠功能障碍Meta分析[J]. 河南中医, 2021, 41(1):88-94.
	Wang Y, Chen SS, Jiang HL, et al. A meta analysis of the effect of external therapy of TCM on gastrointestinal function recovery after gastrointestinal tumor surgery[J]. Henan Tradit Chin Med, 2021, 41(1):88-94.
[25]	于王子. 中医药治疗腹部术后胃肠功能障碍研究进展[J]. 辽宁中医杂志, 2021, 48(9):218-220.
	Yu WZ. Research progress of traditional Chinese medicine in treatment of gastrointestinal dysfunction after abdominal surgery[J]. Liaoning J Tradit Chin Med, 2021, 48(9):218-220.
[26]	徐青丽, 洪鲜, 屠江锋, 等. 综合性医院应用中医适宜技术如何解决“三关”问题[J]. 中国中西医结合急救杂志, 2020, 27(5):620-623.
	Xu QL, Hong X, Tu JF, et al. Application of appropriate technology of traditional Chinese medicine to solve“three barriers” by general hospital nurses[J]. Chin J TCMWM Crit Care, 2020, 27(5):620-623.