加速康复外科应用于神经重症的探索与实践

doi:10.3969/j.issn.1674-8115.2025.09.002

摘要/Abstract

摘要：

神经重症医学是神经外科重要的亚专业，涉及神经外科各类疾病，特别是急危重症的临床诊断与治疗过程。该类患者的病情往往复杂多变，如何有效减轻中枢神经系统继发性损伤、降低手术及术后应激反应、预防和治疗严重并发症，是降低神经外科重症死亡率和致残率的关键环节，也是临床上面临的主要挑战。加速康复外科（enhanced recovery after surgery， ERAS）可以通过一系列基于循证医学的围手术期优化措施，减轻患者的手术创伤和应激，促进功能恢复，缩短住院时间和节省医疗费用，在多个外科领域展现出显著优势。然而，在神经重症高风险、复杂患者群体中，国内外尚缺乏系统化的ERAS实践经验和相关临床研究。因此，在神经重症患者中积极开展ERAS的临床探索与实践，对相关诊疗技术、管理措施和整体流程进行科学优化，并系统评估其安全性与有效性，具有重要的临床意义。该举措不仅为神经重症乃至神经外科ERAS共识的制定提供关键性循证医学依据，也将推动ERAS理念在我国神经外科领域的规范化应用与推广，最终改善患者预后，提升医疗质量。

关键词: 加速康复外科, 神经重症, 微创手术, 围术期管理

Abstract:

Neurocritical care is an important subspecialty in neurosurgery, engaged in the clinical diagnosis and treatment of various neurosurgical conditions, particularly emergencies and critical diseases. These patients often present with complex and dynamic conditions. Effectively mitigating secondary injuries to the central nervous system, reducing surgical and postoperative stress responses, and preventing and managing severe complications are critical to lowering mortality and disability rates in neurosurgical care, but remain major clinical challenges. Enhanced recovery after surgery (ERAS) employs a series of evidence-based perioperative optimization measures to reduce surgical injury and stress, promote functional recovery, shorten hospital stays, and lower medical costs, demonstrating significant advantages across multiple surgical disciplines. However, in the high-risk and complex neurocritical care patient population, there is still a lack of systematic ERAS practice and related clinical research, both domestically and internationally. Therefore, actively exploring and implementing ERAS in neurocritical care, scientifically optimizing diagnostic and therapeutic techniques, management measures, and overall clinical processes, and systematically evaluating its safety and efficacy, hold significant clinical importance. Such efforts will not only provide critical evidence-based medical support for the development of consensus on ERAS in neurocritical care and neurosurgery, but also promote the standardized application and dissemination of the ERAS concept in the field of neurosurgery in China, ultimately improving patient outcomes and enhancing the quality of medical care.

Key words: enhanced recovery after surgery (ERAS), neurocritical care, minimally invasive surgery, perioperative management

中图分类号:

R651

陈浩, 田恒力. 加速康复外科应用于神经重症的探索与实践[J]. 上海交通大学学报（医学版）, 2025, 45(9): 1099-1105.

CHEN Hao, TIAN Hengli. Exploration and practice of enhanced recovery after surgery in neurocritical care[J]. Journal of Shanghai Jiao Tong University (Medical Science), 2025, 45(9): 1099-1105.

图/表 4

参考文献 28

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Component	Content	Management principle
Vital signs assessment	Temperature, heart rate, blood pressure, respiratory rate, etc	Abide by the principles of damage control resuscitation (DCR)
Assessment of injury severity (AIS and ISS scores) and neurological status (GCS, NIHSS, and mRS scores)	AIS, GCS, NHISS, and mRS scores	Perform assessment jointly by the Department of Emergency Medicine and the Departments of Neurology and Neurosurgery
Coagulation function assessment and early intervention	Base on history of anticoagulant use, preoperative complete blood count, coagulation studies, etc	Administer hemostatic agents to prevent worsening of hemorrhage
Vomiting assessment	According to the PONV Simple Risk Assessment Scale	Initiate prophylactic antiemetic therapy and perform gastrointestinal decompression via nasogastric tube in patients with a risk score ≥3
Aspiration pneumonia assessment	Findings suggestive of aspiration pneumonia based on clinical history and chest computed tomography (CT) results	Administer prophylactic antibiotics in patients requiring endotracheal intubation and/or mechanical ventilation
Seizure risk assessment	High-risk factors: cerebral contusion and laceration, extensive subarachnoid hemorrhage (SAH), cortical hemorrhage, and anticipated severe postoperative cerebral edema or cerebral ischemia	Administer antiepileptic drugs (AEDs) routinely in patients with established epilepsy, and use prophylactically in patients at high risk for seizures

Component	Content	Management principle
Vital signs assessment	Temperature, heart rate, blood pressure, respiratory rate, etc	Abide by the principles of damage control resuscitation (DCR)
Assessment of injury severity (AIS and ISS scores) and neurological status (GCS, NIHSS, and mRS scores)	AIS, GCS, NHISS, and mRS scores	Perform assessment jointly by the Department of Emergency Medicine and the Departments of Neurology and Neurosurgery
Coagulation function assessment and early intervention	Base on history of anticoagulant use, preoperative complete blood count, coagulation studies, etc	Administer hemostatic agents to prevent worsening of hemorrhage
Vomiting assessment	According to the PONV Simple Risk Assessment Scale	Initiate prophylactic antiemetic therapy and perform gastrointestinal decompression via nasogastric tube in patients with a risk score ≥3
Aspiration pneumonia assessment	Findings suggestive of aspiration pneumonia based on clinical history and chest computed tomography (CT) results	Administer prophylactic antibiotics in patients requiring endotracheal intubation and/or mechanical ventilation
Seizure risk assessment	High-risk factors: cerebral contusion and laceration, extensive subarachnoid hemorrhage (SAH), cortical hemorrhage, and anticipated severe postoperative cerebral edema or cerebral ischemia	Administer antiepileptic drugs (AEDs) routinely in patients with established epilepsy, and use prophylactically in patients at high risk for seizures

Component	Content	Management principle
Assessment of anesthesia-related risk	Anesthesia classification (ASA classification)	Evaluate anesthesia-related risk and select appropriate anesthetic methods
Airway intervention	Respiratory status, arterial blood gas (ABG) results, etc	Administer intravenous expectorant drugs as primary therapy and use inhaled corticosteroids as indicated
Gastrointestinal intervention	Abdominal ultrasonography (US) and CT findings, etc	Administer antacids to reduce the incidence of stress ulcers
Formulation of surgical plan	Individualized surgical plan based on the location and severity of the patient's injury/hemorrhage	Formulate surgical plan according to patient condition and preoperative imaging; complete preparatory tasks including family communication and surgical consent documentation
Determination of the surgical site skin preparation method	Designed according to the surgical incision	Minimize the area of scalp shaving
Assessment of preoperative surgical incision status	Classification of cleanliness of surgical incision	Administer prophylactic antibiotics; perform wound debridement and achieve hemostasis

Component	Content	Management principle
Assessment of anesthesia-related risk	Anesthesia classification (ASA classification)	Evaluate anesthesia-related risk and select appropriate anesthetic methods
Airway intervention	Respiratory status, arterial blood gas (ABG) results, etc	Administer intravenous expectorant drugs as primary therapy and use inhaled corticosteroids as indicated
Gastrointestinal intervention	Abdominal ultrasonography (US) and CT findings, etc	Administer antacids to reduce the incidence of stress ulcers
Formulation of surgical plan	Individualized surgical plan based on the location and severity of the patient's injury/hemorrhage	Formulate surgical plan according to patient condition and preoperative imaging; complete preparatory tasks including family communication and surgical consent documentation
Determination of the surgical site skin preparation method	Designed according to the surgical incision	Minimize the area of scalp shaving
Assessment of preoperative surgical incision status	Classification of cleanliness of surgical incision	Administer prophylactic antibiotics; perform wound debridement and achieve hemostasis

Component	Content	Management principle
Formulation and implementation of the anesthetic plan	Implementation of an individualized anesthetic plan with intraoperative monitoring and management of anesthetic depth	Based on the patient's systemic status and surgical site requirements, minimize intraoperative administration of anesthetics and opioids, and implement goal-directed fluid therapy (GDFT)
Implementation of nursing care	Intraoperative nursing implementation according to surgical requirements	Position the patient according to anesthesia and surgical requirements; closely monitor patient condition during surgery, focusing on correct positioning and prevention of compression on limbs, nerves, and major blood vessels; maintain patency of urinary catheters, drainage tubes, and intravenous lines
Surgical procedure	Application of damage control surgery (DCS) techniques with strict adherence to minimally invasive principles	For patients with acute epidural/subdural hematoma combined with malignant intracranial hypertension or cerebral hernia, perform cranial drilling at the thickest part of the hematoma before traditional decompression and aspirate part of the hematoma to relieve intracranial pressure and achieve the golden treatment time for brain function; avoid injury to important blood vessels and functional brain areas; in cerebral hemorrhage surgery, perform long-axis minimally invasive procedures with white matter fiber bundles as the protection target
Suture	Closure of the dura, subcutaneous tissue, and skin using absorbable sutures	Prefer intradermal suturing for skin closure to avoid the need for suture removal
Insertion of drainage tube	Placement of drainage tubes in the subdural space, hematoma cavity, and cerebral ventricles	Determine drain placement according to the surgical plan and intraoperative findings; use antimicrobial-impregnated catheters whenever possible