Corso Ellena, Hind Daniel, Beever Daniel, Fuller Gordon, Wilson Matthew J, Wrench Ian J, Chambers Duncan
School of Medicine and Dentistry, University of Sheffield, Sheffield, UK.
Clinical Trials Research Unit, Regent Court, 30 Regent St, Sheffield, S1 4DA, UK.
BMC Pregnancy Childbirth. 2017 Mar 20;17(1):91. doi: 10.1186/s12884-017-1265-0.
The rate of elective Caesarean Section (CS) is rising in many countries. Many obstetric units in the UK have either introduced or are planning to introduce enhanced recovery (ER) as a means of reducing length of stay for planned CS. However, to date there has been very little evidence produced regarding the necessary components of ER for the obstetric population. We conducted a rapid review of the composition of published ER pathways for elective CS and undertook an umbrella review of systematic reviews evaluating ER components and pathways in any surgical setting.
Pathways were identified using MEDLINE, EMBASE and the National Guideline Clearing House, appraised using the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool and their components tabulated. Systematic reviews were identified using the Cochrane Library and Database of Abstracts of Reviews of Effects (DARE) and appraised using The Grading of Recommendations Assessment, Development and Evaluation (GRADE). Two reviewers aggregated summaries of findings for Length of Stay (LoS).
Five clinical protocols were identified, involving a total of 25 clinical components; 3/25 components were common to all five pathways (early oral intake, mobilization and removal of urinary catheter). AGREE II scores were generally low. Systematic reviews of single components found that minimally invasive Joel-Cohen surgical technique, early catheter removal and post-operative antibiotic prophylaxis reduced LoS after CS most significantly by around half to 1 and a half days. Ten meta-analyses of multi-component Enhanced Recovery after Surgery (ERAS) packages demonstrated reductions in LoS of between 1 and 4 days. The quality of evidence was mostly low or moderate.
Further research is needed to develop, using formal methods, and evaluate pathways for enhanced recovery in elective CS. Appropriate quality improvement packages are needed to optimise their implementation.
许多国家择期剖宫产（CS）的比率正在上升。英国的许多产科单位已经或正计划引入强化康复（ER），作为缩短计划性剖宫产住院时间的一种手段。然而，迄今为止，关于产科人群强化康复的必要组成部分的证据非常少。我们对已发表的择期剖宫产强化康复路径的组成进行了快速回顾，并对评估任何手术环境中强化康复组成部分和路径的系统评价进行了综合评价。
通过MEDLINE、EMBASE和国家指南交换中心识别路径，使用研究与评价指南评估（AGREE II）工具进行评估，并将其组成部分制成表格。通过Cochrane图书馆和效果评价摘要数据库（DARE）识别系统评价，并使用推荐分级评估、制定和评价（GRADE）进行评估。两名评审员汇总了住院时间（LoS）的研究结果摘要。
确定了五项临床方案，共涉及25个临床组成部分；所有五项路径共有3/25个组成部分（早期经口进食、活动和拔除尿管）。AGREE II评分普遍较低。对单个组成部分的系统评价发现，微创乔尔-科恩手术技术、早期拔除尿管和术后抗生素预防最显著地缩短了剖宫产术后的住院时间，缩短了约半天至一天半。对多组成部分的术后加速康复（ERAS）方案进行的十项荟萃分析表明，住院时间缩短了1至4天。证据质量大多为低或中等。
需要进一步研究，采用正式方法制定和评估择期剖宫产强化康复路径。需要适当的质量改进方案来优化其实施。
