第一部分  超声引导下神经阻滞在成人心脏外科ERAS中的应用：一项系统综述和meta分析

研究背景

超声引导下神经阻滞可以显著减少围术期阿片类用药量和降低患者术后疼痛评分。然而，有关其在改善成人心脏手术患者术后康复中的应用仍有待于进一步探究。本研究旨在探究超声引导下神经阻滞在促进成人心脏手术患者术后加速康复中的应用。

研究方法

通过检索Pubmed、Embase和Cochrane数据库中2018-2022年发表的有关超声引导下神经阻滞在成人心脏外科手术中应用的随机对照试验。研究结局为术后气管插管时间、重症监护室 (Intensive care unit, ICU) 停留时间和住院时间。采用Review Manager软件进行文献质量评价和研究结局的meta分析。

研究结果

本研究检索到RCT研究26篇，最终纳入符合标准文献8篇，共包含424例受试者。Meta分析结果显示，行超声引导下神经阻滞可显著降低患者术后气管插管时间[odds ratio (OR) =-2.16, 95% confidence interval (CI) (-3.05, -1.26), P <0.00001]，ICU停留时间[OR=-1.17, 95%CI (-1.40, -0.94)， P <0.00001]和住院时间[OR=-0.96, 95%CI (-1.64, -0.29)， P =0.005]。

研究结论

超声引导下神经阻滞可显著缩短成人心脏手术患者术后机械通气时间、ICU停留时间和住院时间，加速术后康复。

关键词

超声引导下神经阻滞；心脏外科；术后加速康复；Meta分析

 

第二部分  多模式镇痛管理策略在改善成人心脏手术患者预后中的应用：一项单中心前瞻性随机对照试验

研究背景

多模式镇痛管理策略可以显著减少围术期阿片类用药，降低患者术后疼痛评分，从而改善患者围术期结局，已被广泛应用于各类手术。神经阻滞作为多模式镇痛管理策略一部分，已被证实可以应用于心脏手术，但相关研究证据尚不明确。本研究旨在探究基于超声引导下神经阻滞的多模式镇痛管理策略在改善成人心脏手术患者术后结局中的作用。

研究方法

本研究为一前瞻性、单中心、随机对照试验。收集2024年6月1日至2024年7月3日在中国医学科学院阜外医院拟行心脏手术患者。80名接受心脏手术患者1:1随机分配到干预组或对照组。干预组采用多模式镇痛方案，对照组采用传统大剂量阿片管理方案。主要研究结局为术后24小时15项恢复质量量表 (15 items quality of recovery scale, QoR-15) 得分。次要研究结局包括术后72小时QoR-15量表得分、术后疼痛评分、拔除气管插管时间、住院时间、医疗费用和术后并发症。

研究结果

干预组术后24小时QoR-15得分为122.35±6.71，对照组术后24小时QoR-15得分为115.30±5.90 (P <0.001) 。干预组术后24小时恢复质量较好 (QoR-15≥118) 患者比例为77.5%，对照组为55.0% (P =0.033) 。干预组术后24小时NRS评分显著低于对照组 (P =0.008) 。干预组气管插管时间较对照组显著缩短 (P <0.001) 。两组患者在术后72小时QoR-15得分和其他研究结局方面差异不具有统计学意义。

研究结论

联合应用胸骨旁肋间筋膜阻滞和腹直肌鞘阻滞的多模式镇痛管理策略可以改善心脏手术后患者的恢复质量并缓解术后疼痛，有利于心脏手术患者术后加速康复。

关键词

多模式镇痛；超声引导下神经阻滞；心脏手术；加速康复

 

 基于多学科构建加速康复外科临床管理路径 (ERAS) 在成人

心脏手术中的应用：一项单中心回顾性队列研究

研究背景

加速康复外科 (Enhanced recovery after surgery, ERAS) 是一类包含术前、术中和术后多项措施在内的围术期管理策略，可以降低术后不良事件发生率和促进患者术后康复，然而有关其在心脏外科中的应用仍有待于进一步探究。本项研究旨在探究加速康复外科管理策略在改善成人心脏手术患者预后中的作用。

研究方法

本研究为一回顾性队列研究。纳入2023年8月至2024年12月于中国医学科学院阜外医院行择期行心脏手术患者。经倾向性评分将纳入受试者按1:1匹配分为ERAS方案组和传统方案组。ERAS组为患者接受术前、术中和术后一系列干预措施，对照组为患者接受传统干预措施。主要研究结局为术后24小时15项恢复质量量表(15 items quality of recovery scale, QoR-15) 评分，其他结局包括术后主要心脑血管不良事件、术后急性肾损伤、术后中重度肝损伤、术后肺损伤、术后谵妄、术后疼痛评分、一年再入院率和死亡率等。

研究结果

本研究共纳入2397名患者，经倾向性评分匹配后共纳入统计分析患者1490名。ERAS组术后24小时QoR-15得分为117.25±14.11，显著高于对照组112.88±16.02 (P <0.001) 。ERAS组患者术后急性肾损伤 (7.7% vs. 12.4%, P =0.003) 、术后中重度肝损伤 (3.9% vs. 6.3%, P =0.034) 和术后肺损伤发生率 (38.3% vs. 47.3%, P <0.001) 均显著低于对照组 。同时，ERAS组患者术后机械通气时间和重症监护室停留时间显著缩短 (P <0.05) 。

研究结论

ERAS干预措施显著改善心脏手术患者预后，在加速成人心脏手术患者应用中具有显著优势。

关键词

心脏手术; 加速康复外科; 预后

 

第四部分  成人心脏手术患者预后不良风险因素探究及预测模型初步构建

研究背景

心脏手术患者术后康复质量对其长期生存和预后至关重要。既往研究表明，年龄、合并症、手术类型和体外循环时间等均是影响患者预后重要因素。然而，有关心脏手术患者不良预后影响因素和预测模型构建目前仍有待于进一步探究。因此，本研究旨在基于患者自我报告15项恢复质量量表 (15 items quality of recovery scale, QoR-15) 评分，探究心脏手术患者预后不良危险因素并初步构建相应预测模型。

研究方法

本研究回顾性纳入2023年7月至2024年7月于中国医学科学院阜外医院接受心脏手术患者。收集患者一般人口学资料、基线资料、术前检查结果、手术资料及术后随访结局。术后恢复不良定义为术后24小时QoR-15评分< 118分。采用单因素及多因素logistic回归分析识别术后恢复不良危险因素，并将相应危险因素纳入预测模型构建。模型效能检验采用曲线下面积 (Area under the curve, AUC) 和校准图进行评估。

研究结果

本研究共纳入1768例成人心脏手术患者，术后恢复不良发生率为27.6%。年龄、性别、高血压、糖尿病、手术时间、体外循环时间、术中出血量、射血分数及术中使用右美托咪定等是影响心脏手术患者术后康复质量关键因素 (P <0.05) 。预测模型在训练集和测试集中AUC值分别为0.795和0.734，显示出良好预测效能。校准图显示预测概率与实际观察结果高度一致。

研究结论

年龄等是心脏手术预后不良危险因素，本研究构建心脏术后恢复不良预测模型有助于优化围术期管理方案和改善患者预后。

Chapter I. The Application of Ultrasound Guided Nerve Block in Enhanced Recovery after Cardiac Surgery in Adult: A Systematic Review and Meta Analysis

Background 

Ultrasound-guided nerve blocks can both reduce intraoperative opioid use and pain scores. However, its role in enhancing postoperative recovery for adult cardiac patients requires further investigation. This study aims to explore the impact of ultrasound-guided nerve block on postoperative recovery in cardiac surgery.

Methods 

We conducted a systematic search for randomized controlled trials (RCTs) published between 2018 to 2022, focusing ultrasoundguided nerve block in adult cardiac surgery. The outcomes analyzed included postoperative extubation time, intensive care unit (ICU) stay time, and length of hospital stay (LOS) using Review Manager software (Review Manager 5.4, The Cochrane Collaboration, 2020, Beijing, China) for data synthesis and analysis.

Results 

Out of 26 RCTs, 8 studies involving including 424 subjects were included in this meta-analysis. The results showed that ultrasoundguided nerve block significantly reduced postoperative extubation time [odds ratio (OR) = -2.16, 95% confidence interval (CI) : -3.05 to -1.26), P <0.00001], ICU stay [OR=-1.17, 95%CI (-1.40, -0.94), P <0.00001], and overall hospitalization duration [OR=-0.96, 95%CI (-1.64, -0.29), P =0.005].

Conclusions 

Ultrasound-guided nerve block significantly reduces the postoperative extubation time, ICU stay, and LOS, in adult cardiovascular surgery. These benefits contribute substantially to enhanced recovery after cardiac procedures.

Keywords

Ultrasound guided nerve block; cardiac surgery; enhanced recovery after surgery; meta analysis

 

Chapter II. The application of multi-modal analgesic management in improving outcomes for adult cardiac surgery patients: A single-center randomized controlled trials

Background 

Multi-modal analgesic management strategies are applied in surgeries. It can reduce intraoperative opioid use, improve postoperative pain, and accelerate recovery. Nerve block is one of multi-modal analgesic strategies, but the relative evidence is uncertain. This study aimed to explore the effects of multi-modal analgesic management strategies based on nerve block on postoperative recovery in cardiac surgery.

Methods

This is a prospective and randomized controlled trial at Fuwai Hospital from June 1, 2024 to July 3, 2024. Eighty patients undergoing elective cardiac surgery were randomized at a 1:1 ratio to be allocated in the intervention group or control group. Patients in the intervention group received a multi-modal analgesic protocol. Patients in the control group were managed with traditional high-dose opioid anesthesia. The primary outcome was the global score of the 15-item Quality of Recovery (QoR-15) questionnaire at 24h after surgery. Secondary outcomes included QoR-15 at 72h, postoperative pain scores, time to extubation, length of stay, medical expenses in hospital and postoperative morbidities.

Results 

The QoR-15 global score at 24h after cardiac surgery was 122.35±6.71 in the intervention group vs 115.30±5.90 in the control group (P <0.001). The proportion of patients experiencing better quality of recovery (Qor-15≥118) was higher in the intervention group (77.5% vs 55.0%, P =0.033). The intervention group showed significantly lower 24h NRS scores (P =0.008) and shorter intubation times (P <0.001) versus controls. No significant differences were found in 72h QoR-15 scores or other outcomes.

Conclusions

The administration of multi-modal analgesia management strategies based on nerve block could improve quality of recovery and relieve postoperative pain for patients following cardiac surgery.

Key words

Multimodal analgesia, ultrasound-guided nerve block, cardiac surgery, quality of recovery

Chapter III. The application of enhanced recovery after cardiac surgery in adult patients: A single-center retrospective cohort study

Background

Enhanced recovery after surgery (ERAS) is a bundle of strategies including preoperative, intraoperative, and postoperative measurements. It has been shown to reduce complications and enhance recovery in other surgical specialties, but its impact on cardiac surgery remains under investigation. This study aimed to evaluate the effectiveness of ERAS in improving outcomes for cardiac surgery patients.

Methods  

A retrospective analysis was conducted on patients who underwent elective cardiac surgery in Fuwai hospital from August 2023 to November 2023. Patients were divided into an ERAS group and a traditional group after propensity score matching (PSM)1:1 based on demographic characteristics and intraoperative data. The ERAS group received a set of multidisciplinary interventions across preoperative, intraoperative, and postoperative phases, while the control group received traditional care. Primary outcomes was the QoR-15 score at 24h after surgery. Other outcomes included postoperative complications including major adverse events of cardiovascular and cerebrovascular events (MACCEs), acute kidney injury (AKI)， liver injury, lung injury, delirium, number rating scale, and so on.

Results

This study enrolled 2397 patients and 1490 patients were matched after PSM.  Acute kidney injury was also significantly reduced (7.7% vs. 12.4%, P =0.003). The incidence of moderate to severe liver injury was lower in the ERAS group (3.9% vs. 6.3%, P =0.034). The incidence of lung injury was lower in the ERAS group compared to the control group (38.3% vs. 47.4%, P <0.001). ERAS shorten mechanical ventilation time and ICU stay duration (P <0.05).

Conclusion

ERAS protocols significantly improved postoperative outcomes in patients undergoing cardiac surgery. ERAS has advantages in improving postoperative recovery after cardiac surgery.

Key words

Cardiac surgery, enhanced recovery after surgery, prognosis

 

Chapter IV. Exploration of risk factors and construction of a predictive model for poor prognosis in cardiac surgery

Background

Postoperative recovery is crucial for long-term prognosis. Previous studies showed that age, comorbidities, surgery type, cardiopulmonary bypass duration, and so on were factors for outcomes. However, certain risk factors and the construction of predictive models for cardiac need further exploration. Therefore, this study aimed to investigate the risk factors and construct the predictive model for cardiac patients based on the self-reported 15-item quality of recovery (QoR-15) scores.

Methods

A retrospective study was conducted involving adult patients who underwent cardiac surgery from July 2023 to July 2024. Data collected included demographics, basic characteristics, preoperative examination results, surgery data, and postoperative follow-up outcomes. Poor recovery was defined as a QoR-15 score less than 118 at 24 hours postoperatively. Significant predictors of poor recovery were identified through univariate analysis and multivariate logistic regression analysis and were used to develop a predictive model. The performance of the model was evaluated using the area under the curve (AUC) and calibration plots.

Results

Of the 1768 patients included, the incidence of poor recovery was 27.6%. Key predictors of poor recovery included age, gender, hypertension, diabetes, operation time, cardiopulmonary bypass time, intraoperative blood loss, ejection fraction, and the application of dexmedetomidine (P <0.05). The predictive model showed strong discriminative capability, with an AUC of 0.795 in the training dataset and 0.734 in the testing dataset. Calibration plots indicated a high level of consistency between predicted and actual probabilities.

Conclusions

Age and others are risk factors for poor prognosis in cardiac surgery. The predictive model effectively predicts a poor recovery after cardiac surgery and can be useful in improving intraoperative management and postoperative prognosis.