基于微血管自体组织的乳房再造中的加速康复通道：是否应成为标准治疗方法？
Enhanced Recovery Pathway in Microvascular Autologous Tissue-Based Breast Reconstruction: Should It Become the Standard of Care?
机构信息
Nashville, Tenn.; and Ann Arbor, Mich.
From the Departments of Plastic Surgery and Anesthesiology, Vanderbilt University Medical Center; and the Department of Surgery, Section of Plastic Surgery, University of Michigan.
出版信息
Plast Reconstr Surg. 2018 Apr;141(4):841-851. doi: 10.1097/PRS.0000000000004197.
BACKGROUND
Enhanced recovery pathway programs have demonstrated improved perioperative care and shorter length of hospital stay in several surgical disciplines. The purpose of this study was to compare outcomes of patients undergoing autologous tissue-based breast reconstruction before and after the implementation of an enhanced recovery pathway program.
METHODS
The authors retrospectively reviewed consecutive patients who underwent autologous tissue-based breast reconstruction performed by two surgeons before and after the implementation of the enhanced recovery pathway at a university center over a 3-year period. Patient demographics, perioperative data, and 45-day postoperative outcomes were compared between the traditional standard of care (pre-enhanced recovery pathway) and enhanced recovery pathway patients. Multivariate logistic regression was performed to identify risk factors for length of hospital stay. Cost analysis was performed.
RESULTS
Between April of 2014 and January of 2017, 100 consecutive women were identified, with 50 women in each group. Both groups had similar demographics, comorbidities, and reconstruction types. Postoperatively, the enhanced recovery pathway cohort used significantly less opiate and more acetaminophen compared with the traditional standard of care cohort. Median length of stay was shorter in the enhanced recovery pathway cohort, which resulted in an extrapolated $279,258 savings from freeing up inpatient beds and increase in overall contribution margins of $189,342. Participation in an enhanced recovery pathway program and lower total morphine-equivalent use were independent predictors for decreased length of hospital stay. Overall 45-day major complication rates, partial flap loss rates, emergency room visits, hospital readmissions, and unplanned reoperations were similar between the two groups.
CONCLUSION
Enhanced recovery pathway program implementation should be considered as the standard approach for perioperative care in autologous tissue-based breast reconstruction because it does not affect morbidity and is associated with accelerated recovery with reduced postoperative opiate use and decreased length of hospital stay, leading to downstream health care cost savings.
CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.
背景
在多个外科专业中，强化康复途径方案已证明可改善围手术期护理并缩短住院时间。本研究的目的是比较在实施强化康复途径方案前后接受自体组织乳房重建的患者的结果。
方法
作者回顾性分析了在大学中心，两位外科医生在 3 年期间实施强化康复途径前后连续接受自体组织乳房重建的患者。比较了传统标准护理（强化康复途径前）和强化康复途径患者的患者人口统计学，围手术期数据和 45 天术后结果。进行多变量逻辑回归以确定住院时间的危险因素。进行了成本分析。
结果
在 2014 年 4 月至 2017 年 1 月之间，确定了 100 名连续女性患者，每组 50 名。两组患者的人口统计学，合并症和重建类型相似。术后，强化康复途径组比传统标准护理组使用的阿片类药物明显减少，而对乙酰氨基酚的使用明显增加。强化康复途径组的住院时间中位数更短，这导致腾出住院病床并增加总体贡献利润率$279258 美元，增加$189342 美元。参与强化康复途径方案和总吗啡等效使用量较低是住院时间缩短的独立预测因素。两组之间的 45 天主要并发症发生率，部分皮瓣丢失率，急诊室就诊率，医院再入院率和计划外再次手术率相似。
结论
应将强化康复途径方案的实施视为自体组织乳房重建围手术期护理的标准方法，因为它不会影响发病率，并且与加速康复相关，减少术后阿片类药物使用和缩短住院时间，从而降低下游医疗保健成本。
临床问题/证据水平：治疗，III。
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