| BackgroundThe concept of enhanced recovery after surgery(ERAS)was firstly proposed by a Danish surgeon,Professor Henrik Kehlet,in 1990s.It is a series of perioperative management program based on evidence-based medicine and coordinated by multidisciplinary health care workers,with the aim of minimizing patients’ perio perative stress response,reduce surgery-related complications,accelerate organ function recovery,and shorten hospital stay length.In recent years,the concept of ERAS has been promoted to a number of surgical fields,and is considered to be safe and effective;however,no study about pernicious placenta praevia and placenta accrete(PPP-PA)has been reported yet In 2014,two-child policy was completely im plemented in China,so the problem of re-pregnancy in scarred uterus is becoming increasingly prominent,and harms caused by PPP-PA has been paid more and more attention.Patients with PPP-PA may have ferocious intraoperative bleeding in cesarean section surgery,the intraoperative blood loss may cause hemorrhagic shock,and conventional hemostatic methods can’t effectively control the bleeding,so it’ll seriously threat patients’ lives and safety.Traditional hemostatic methods aim to strengthen the uterine contraction,local strap suture,or gauze packing,and if these conservative methods are invalid,hysterectomy is often necessary so as to control the bleeding.Hysterectomy results seriously affecting patients’ physical and mental health.However,cesarean section have big trauma,severe postoperative pain.Currently,there are a variety of methods for postcesarean section analgesia,but each method has some drawbacks.Therefore,targeting the features of suchpatients,how to reduce the intraoperative bleeding,reduce hysterectomy,perform full postoperative analgesia,promote patients’ early ambulation,reduce thrombosis,and reduce perioperative stress inflammatory response are the key steps to accelerate patients’rapid recovery.In recent years,intervention techniques have continuously developed in the field of obstetrics,and have opened up a new way in reducing obstetric hemorrhoea.In our hospital,intracesarean section abdominal aortic balloon occlusion technology has achieved certain effects in reducing intraoperative bleeding,hysterectomy,or other related complications against PPP-PA.Therefore,the first part of this paper retros pectively analyzed the safety and efficacy of abdominal aortic balloon occlusion in cesarean section in order to provide references for optimizing surgical programs,reducing surgical complications,and promoting patients’ rapid rehabilitation.In the second part,the PPP-PA patients performed abdominal aortic balloon obstruction and cesarean section were set as the study subjects for observing the impact of nabuphine combined ultrasound-guided continuous TAP block on postoperative stress response,analgesic effect,and maternal lactation;Furthermore,it was also compared with PCIA in order to explore more ideal postoperative analgesic patterns toward these patients.In the third part,based on the results of the first two parts and the existing research results of ERAS programs in other disciplines,the ERAS program for cesarean section surgeries in PPP-PA patients was preliminarily developed and compared with conventional perioperative measures,aiming to provide references for the clinical application and further studies of ERAS.Part 1 Retrospective analysis of efficacy and safety of abdominal aortic balloon occlusion in PPP-PA patients with cesarean sectionObjective:To investigate the efficacy and safety of abdominal aortic balloon obstruction in PPP-PA patients with cesarean section.Methods:The clinical data of a total of 113 PPP-PA patients hospitalized in the First Affiliated Hospital of Zhengzhou University from November 2015 to May 2016 were retrospectively analyzed.The patients were divided into two groups.Group A(n=54)underwent abdominal aortic balloon preset via the right femoral artery,and was injected saline into the balloon immediately after the delivery of the fetus in cesarean section so as to block the abdominal aorta;Group B(n=59)underwent routine cesarean section.The incidences of intraoperative blood loss,hysterectomy rate,the operation duration between the two groups were compared;The fetal radiation ex posure,neonatal Apgar score,balloon occlusion-associated complications(lower extremity deep vein thrombosis,femoral ischemic injury,etc.)and postoperative follow-up were also recorded.Results:The operation duration,intraoperative blood loss,blood transfusion volume,infusion volume,and hysterectomy rate were significantly lower in group A than that in group B,and the differences were statistically significant;The fetal radiation ex posure time was(5.17±1.91)s,and the dose was(4.26±2.34)mGy.There was no significant difference in the neonatal Apgar score between the two groups;No abdominal aortic balloon occlusion-associated complications occurred.The posto perative follow-up revealed no obvious abnormality in the uterine appendages of the two groups.Conclusions:The abdominal aorta balloon obstruction in PPP-PA patients with cesarean section can significantly reduce the intraoperative bleeding,reduce the amount of allogeneic blood input,and reduce the risk of hysterectomy.No abdominal aortic balloon occlusion-associated complications occurred.Part 2 Impact of nalbuphine combined continuous TAP block on postcesarean section analgesia,stress response and maternal lactationObjective:To investigate the impact of nabuphine comined ultrasound-guided continuous TAP block on postcesarean section analgesia,stress response,and maternal lactation.Methods:A total of 70 patients underwent abdominal aortic balloon occlusion and cesarean section under elective epidural anesthesia combined with general anesthesia were randomly divided into Group TAP and Group PCIA.Group PCIA was performed sufentanil PCIA,Group TAP was performed postoperative nabuphine combined ultrasound-guided continuous TAP block,and 20ml of 0.2%ropivacaine was administrated on each side after successful TAP block,followed by continuous administration of 0.2%ropivacaine(6-8 ml/h)until 48h after surgery.The observational index:① VAS score,and Ramsay sedation score at the postoperative 4h,8h,12h,24h,36h and 48h;② The analgesic remission rate during postoperative 48h,patient satisfactory degree,the adverse reaction related opiods;③ The levels of Cortisol(Cor),Interleukin-6(IL-6),and tumor necrosis factor-a(TNF-α)in the plasma at the postoperative 12h,24h and 48h were recorded;④ The serum prolactin concentration at the postoperative 24h and 48h was tested by ELISA;The puerperal colostrum was recorded and calculated the breastfeeding rate within puer peral 48 hours.⑤ The changes of TAP block plane and the incidence of related com plications(puncture-site hematoma infection,severe abdominal injury,or local anesthetic poisoning)were also recorded.Results:29 patients in Group TAP and 30 patients in Group PCIA finally com pleted the study.① The VAS scores of visceral pain in Group TAP were lower than Group PCIA at the postoperative 12h,24h and 36h.② There was no analgesic remission in two Groups,and incidence of nausea and vomiting within 48 hours of surgery were significantly lower in Group TAP.The patient satisfactory degree in Group TAP were significantly higher than Group PCIA.③ The concentrations of Cor,IL-6,and TNF-α in Group TAP at the postoperative 12h,24h and 48h were significantly lower than Group PCIA.④ The puerperal colostrum time in Group TAP was significantly shorter than Group PCIA,and the breastfeeding rate in Group TAP within puerperal 48 hours was significantly higher than Group PCIA(P<0.05).The serum prolactin concentrations in Group TAP postoperative 24h and 48h were significantly higher than Group PCIA(P<0.05).⑤The continuous TAP block plane was relatively fixed within 48 hours,and no TAP-associated complication was found.Conclusions:Nabuphine combined ultrasound-guided continuous TAP block can improve the post-cesarean section analgesia in PPP-PA patients,reduce the adverse reactions related opioid,reduce postoperative stress response,promote early maternal lactation,and improve the success rate of breast feeding and patient satisfaction,so it can be used as a choice for postoperative multimode analgesia.Part 3 Clinic study of ERAS protocol in patients with PPP-PAduring cesarean section:random prospective controlled studyObjective:To investigate the application of ERAS protocol in patients with PPP-PA during cesarean section,and to determine whether ERAS protocol can increase surgical trauma and stress,reduce the complications related surgery and promote posto perative recovery,compared with the traditional perioperative management.Methods:A total of 140 patients with PPP-PA underwent cesarean section in the First Affiliated Hospital of Zhengzhou University from April 2017 to April 2018,and randomly divided into ERAS Group and Control Group,70 cases per Group.The patients in the ERAS Groups received the protocol of ERAS and Control Group received conventional perioperative management.The major indicators were analyzed and compared as follows:①The operative duration,intraoperatve blood loss,fluid volume,blood transfusion,cases of hysterectomy;② Neonatal Apgar score 1 min and 5 min after birth;③The indicators of perio perative stress inflammatory response:level of blood glucose,blood insulin,homeostasis model assessment-insulin resistance(HOMA-IR),the concentration of C-reactive protein(CRP),Cortisol(Cor),Interleukin 1β(IL-1β),Interleukin 6(IL-6),tumor necrosis factor alpha(TNF-α)and Insulin-like growth factor binding protein 3(IGF-BP3)at T0(7am of operation day)、T1(the end of surgery)、T2(7am of 1st day after surgery)、T3(7am of 5th day after surgery).④The indicators of perioperative immune response at T0～T3:level of total complement activity(CH50),complement 3(C3)and C4.⑤ Gastrointestinal function recovery index(time of the first exhaust and defecation,time of the first fluidity intake)and length of postoperative hospital stay⑥The infectous complications,the complications of infrarenal abdominal aorta balloon block(angiorrhexis,thrombolysis of lower limbs and ischemic injury of femoral nerve),the complications of TAP block(hematoma formation,infection,toxicity of local anesthetics);Results:① The operative duration,intraoperatve blood loss,fluid volume and blood transfusion in ERAS Group were lower than those in control Group,and difference was statistically significant(P<0.05).There was no or 6 cases undergoing hysterectomy in ERAS Group or control Group,respectively,and difference was statistically significant(P<0.05).② There was no statistical difference in neonatal Apgar score 1 min and 5 min after birth(P>0.05).③There was no statistical difference in the level of blood glucose,blood Insulin,HOMA-IR,CRP and Cor from T0 to T3 between the two Groups(P>0.05).Compared with control Group,the concentrations of serum IL-1β from T1 to T3 were obviously lower(P<0.05),the concentration of serum IL-6 at T1 was higher(P<0.05),the concentrations of serum TNF-α from T1 to T2 were lower(P<0.05),and the concentrations of serum IGF-BP3 from T1 to T3 were lower(P<0.05)in ERAS Group.④There was no statistical difference in the levels of serum CH50 and C4 from T0 to T3 between the two Groups(P>0.05).Compared with control Group,the level of serum C3 from T1 to T3 was lower in ERAS Group(P<0.05).⑤Time of the first exhaust and defecation,time of the first fluidity intake was shorten significant in ERAS Group(P<0.05).The length of postoperative hospital stay in ERAS Group was shorter than that in control Group,and difference was statistically significant(P<0.05).⑥The infectous complications,the complications of infrarenal abdominal aorta balloon block,the complications of TAP block were not observed in the two groups.Conclusion:The protocol of ERAS can alleviate stress response induced by cesarean section in patients with PPP-PA,reduce the intraoperative bleeding and the risk of hysterectomy,enhance gastrointestinal function recovery,shorten postoperative the length hospital stay,with no increased incidence of complications.Therefore,the protocol of ERAS has certain feasibility and high security,thus being implemented gradually in clinical practice. |
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