手術侵襲と麻酔管理 術後回復促進を目指し，手術侵襲の軽減を目的とした麻酔管理
「I はじめに」術後回復の阻害因子として, 手術侵襲による糖・たんぱく代謝の異常, 疼痛, 消化管機能不全および不動などがあげられる. これらの阻害因子は, 術後患者の早期離床および経口摂取を妨げる. 術後回復促進策におけるアウトカムである在院日数の短縮や合併症の発症率低減は, 早期離床および経口摂取の遅延によると言われている. 術後回復促進策においては, 手術侵襲への対策として, 適切な麻酔管理により侵襲を最低限に抑えることが推奨されている. 例えば, 麻酔管理では, 鎮痛による侵襲反応の軽減, 適正な輸液管理, 体温管理, および術前, 術中の炭水化物負荷などが実施される. 麻酔科医は,...
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| Published in | 外科と代謝・栄養 Vol. 50; no. 5; pp. 255 - 264 |
|---|---|
| Main Authors | , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
日本外科代謝栄養学会
15.10.2016
|
| Online Access | Get full text |
| ISSN | 0389-5564 2187-5154 |
| DOI | 10.11638/jssmn.50.5_255 |
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| Abstract | 「I はじめに」術後回復の阻害因子として, 手術侵襲による糖・たんぱく代謝の異常, 疼痛, 消化管機能不全および不動などがあげられる. これらの阻害因子は, 術後患者の早期離床および経口摂取を妨げる. 術後回復促進策におけるアウトカムである在院日数の短縮や合併症の発症率低減は, 早期離床および経口摂取の遅延によると言われている. 術後回復促進策においては, 手術侵襲への対策として, 適切な麻酔管理により侵襲を最低限に抑えることが推奨されている. 例えば, 麻酔管理では, 鎮痛による侵襲反応の軽減, 適正な輸液管理, 体温管理, および術前, 術中の炭水化物負荷などが実施される. 麻酔科医は, 麻酔管理の工夫により, 術後患者の早期離床および経口摂取を促し, 術後回復促進を目指す. 本稿では, 手術侵襲の軽減を目的とした麻酔管理に関して概説する. |
|---|---|
| AbstractList | 「I はじめに」術後回復の阻害因子として, 手術侵襲による糖・たんぱく代謝の異常, 疼痛, 消化管機能不全および不動などがあげられる. これらの阻害因子は, 術後患者の早期離床および経口摂取を妨げる. 術後回復促進策におけるアウトカムである在院日数の短縮や合併症の発症率低減は, 早期離床および経口摂取の遅延によると言われている. 術後回復促進策においては, 手術侵襲への対策として, 適切な麻酔管理により侵襲を最低限に抑えることが推奨されている. 例えば, 麻酔管理では, 鎮痛による侵襲反応の軽減, 適正な輸液管理, 体温管理, および術前, 術中の炭水化物負荷などが実施される. 麻酔科医は, 麻酔管理の工夫により, 術後患者の早期離床および経口摂取を促し, 術後回復促進を目指す. 本稿では, 手術侵襲の軽減を目的とした麻酔管理に関して概説する. |
| Author | 谷口, 英喜 牛込, 恵子 佐々木, 俊郎 藤田, 久栄 小林, 浩子 川崎, 理栄子 |
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| References | 12) von Dossow V, Luetz A, Haas A et al.: Effects of remifentanil and fentanyl on the cell-mediated immune response in patients undergoing elective coronary artery bypass graft surgery. J Int Med Res 36 (6) : 1235-1247, 2008 13) Winterhalter M, Brandl K, Rahe-Meyer N et al.: Endocrine stress response and inflammatory activation during CABG surgery. A randomized trial comparing remifentanil infusion to intermittent fentanyl. Eur J Anaesthesiol 25 (4) : 326-335, 2008 18) Basu S, Miclescu A, Sharma H et al.: Propofol mitigates systemic oxidative injury during experimental cardiopulmonary cerebral resuscitation. Prostaglandins Leukot. Essent. Fatty Acids 84 : 123-130, 2011 6) Holte K, Kehlet H : Epidural anaesthesia and analgesia-effects on surgical stress responses and implications for postoperative nutrition. Clin Nutr 21 : 199-206, 2002 11) Guggenberger H, Schroeder TH, Vonthein R et al.: Remifentanil or sufentanil for coronary surgery : comparison of postoperative respiratory impairment. Eur J Anaesthesiol 23 : 832-840, 2006 3) Feldheiser A, Aziz O, Baldini G et al.: Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2 : consensus statement for anaesthesia practice. Acta Anaesthesiol Scand. 2015 Oct 30. doi : 10.1111/aas.12651. [Epub ahead of print] Review. 16) Kawamura T, Kadosaki M, Nara N et al.: Effects of sevoflurane on cytokine balance in patients undergoing coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 20 : 503-508, 2006 14) El-Azab SR, Rossel PMJ, De Lange JJ et al.: Effect of VIMA with sevoflurane versus TIVA with propofol or midazolam-sufentanil on the cytokine response during CABG surgery. Eur J Anaesthesiol 19 : 276-282, 2002 31) Ljungqvist O, Nygren J, Thorell A : Modulation of post-operative insulin resistance by pre-operative carbohydrate loading. Proceedings of the Nutrition Society 61, 329-335, 2002 28) Gu CY, Zhang J, Qian YN et al.: Effects of epidural anesthesia and postoperative epidural analgesia on immune function in esophageal carcinoma patients undergoing thoracic surgery. Mol Clin Oncol 3 (1) : 190-196, 2015 33) Corcoran T, Rhodes JE, Clarke S et al.: Perioperative fluid management strategies in major surgery : a stratified meta-analysis. Anesth Analg 114 : 640-651, 2012 7) Jia Y, Jin G, Guo S et al.: Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. Langenbecks Arch Surg 399 (1) : 77-84, 2014 17) González-Correa JA, Cruz-Andreotti E, Arrebola MM et al.: Effects of propofol on the leukocyte nitric oxide pathway : in vitro and ex vivo studies in surgical patients. Naunyn Schmiedebergs Arch. Pharmacol 376 : 331-339, 2008 10) Sander M, von Heymann C, von Dossow V et al.: Increased interleukin-6 after cardiac surgerypredicts infection. Anesth Analg 102 : 1623-1629, 2006 9) Kapoor MC, Ramachandran TR : Inflammatory response to cardiac surgery and strategies to overcome it. Annals of Cardiac Anaesthesia 7 : 113-128, 2004 15) Baki ED, Aldemir M, Kokulu S et al.: Comparison of the effects of desflurane and propofol anesthesia on the inflammatory response and S100β protein during coronary artery bypass grafting. Inflammation 36 : 1327-1333, 2013 19) Lausevic Z, Lausevic M, Trbojevic-Stankovic J et al.: Predicting multiple organ failure in patients with severe trauma. Can J Surg 51 : 97-102, 2008 8) Butterworth JF, Mackey DC, Wasnick JD : Anesthesia for cardiovascular surgery. Morgan & Michail's Clinical Anesthesiology. 5th edition. United States : 435-486, 2013 24) Carli F, Halliday D : Continuous epidural blockade arrests the postoperative decrease in muscle protein fractional synthetic rate in surgical patients, Anesthesiology 86 : 1033-1040, 1997 4) Chrousos GP : The hypothalamic-pituitary-adrenal axis and immune-mediated inflammation. N Engl J Med 332 : 1351-1362, 1995 25) Fares KM, Mohamed SA, Hamza HM et al.: Effect of thoracic epidural analgesia on pro-inflammatory cytokines in patients subjected to protective lung ventilation during Ivor Lewis esophagectomy. Pain Physician 17 (4) : 305-315, 2014 30) Fearon KC, Luff R : The nutritional management of surgical patients : enhanced recovery after surgery. Proc Nutr Soc : 807-811, 2003 26) Chloropoulou P, Iatrou C, Vogiatzaki T et al.: Epidural anesthesia followed by epidural analgesia produces less inflammatory response than spinal anesthesia followed by intravenous morphine analgesia in patients with total knee arthroplasty. Med Sci Monit 28 ; 19 : 73-80, 2013 32) Smith MD, McCall J, Plank L et al.: Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev 14 ; 8, 2014 27) Zawar BP, Mehta Y, Juneja R et al.: Nonanalgesic benefits of combined thoracic epidural analgesia with general anesthesia in high risk elderly off pump coronary artery bypass patients. Ann Card Anaesth 18 (3) : 385-391, 2015 5) Wilmore DW : Metabolic response to severe surgical illness : Overview. World J Surg 24 (6) : 705-711, 2000 22) Ke JJ, Zhan J, Feng XB et al.: A comparison of the effect of total intravenous anaesthesia with propofol and remifentanil and inhalational anaesthesia with isoflurane on the release of pro-and anti-inflammatory cytokines in patients undergoing open cholecystectomy. Anaesth Intensive Care 36 (1) : 74-78, 2008 23) Taniguchi H, Sasaki T, Fujita H et al.: The Effect of Intraoperative Use of High-Dose Remifentanil on Postoperative Insulin Resistance and Muscle Protein Catabolism : A Randomized Controlled Study.Int. J. Med. Sci 10 (9) : 1099-1107, 2013 29) Carli F, Baldini G : Fast-track surgery : it is time for the anesthesiologist to get involved! Minerva Anestesiol 77 (2) : 227-230, 2011 2) Maessen J, Dejong CHC, Hausel J et al.: A protocol is not enough to implement an enhanced recovery programme for colorectal resection. British Journal of Surgery 94 : 224-231, 2007 1) White PF, Kehlet H, Neal JM et al.: Fast-Track Surgery Study Group. The Role of the Anesthesiologist in Fast-Track Surgery : From Multimodal Analgesia to Perioperative Medical Care. Anesth Analg 104 : 1380-1396, 2007 34) Yamasaki K, Inagaki Y, Mochida S et al.: Effect of intraoperative acetated Ringer's solution with 1% glucose on glucose and protein metabolism. J Anest 24 : 426-431, 2010 20) Kvarnström AL, Sarbinowski RT, Bengtson JP et al.: Complement activation and interleukin response in major abdominal surgery. Scand J Immunol 75 (5) : 510-516, 2012 21) Ihn CH, Joo JD, Choi JW et al.: Comparison of stress hormone response, interleukin-6 and anaesthetic characteristics of two anaesthetic techniques : volatile induction and maintenance of anaesthesia using sevoflurane versus total intravenous anaesthesia using propofol and remifentanil. J Int Med Res 37 (6) : 1760-1771, 2009 |
| References_xml | – reference: 10) Sander M, von Heymann C, von Dossow V et al.: Increased interleukin-6 after cardiac surgerypredicts infection. Anesth Analg 102 : 1623-1629, 2006 – reference: 5) Wilmore DW : Metabolic response to severe surgical illness : Overview. World J Surg 24 (6) : 705-711, 2000 – reference: 25) Fares KM, Mohamed SA, Hamza HM et al.: Effect of thoracic epidural analgesia on pro-inflammatory cytokines in patients subjected to protective lung ventilation during Ivor Lewis esophagectomy. Pain Physician 17 (4) : 305-315, 2014 – reference: 24) Carli F, Halliday D : Continuous epidural blockade arrests the postoperative decrease in muscle protein fractional synthetic rate in surgical patients, Anesthesiology 86 : 1033-1040, 1997 – reference: 27) Zawar BP, Mehta Y, Juneja R et al.: Nonanalgesic benefits of combined thoracic epidural analgesia with general anesthesia in high risk elderly off pump coronary artery bypass patients. Ann Card Anaesth 18 (3) : 385-391, 2015 – reference: 19) Lausevic Z, Lausevic M, Trbojevic-Stankovic J et al.: Predicting multiple organ failure in patients with severe trauma. Can J Surg 51 : 97-102, 2008 – reference: 30) Fearon KC, Luff R : The nutritional management of surgical patients : enhanced recovery after surgery. Proc Nutr Soc : 807-811, 2003 – reference: 2) Maessen J, Dejong CHC, Hausel J et al.: A protocol is not enough to implement an enhanced recovery programme for colorectal resection. British Journal of Surgery 94 : 224-231, 2007 – reference: 1) White PF, Kehlet H, Neal JM et al.: Fast-Track Surgery Study Group. The Role of the Anesthesiologist in Fast-Track Surgery : From Multimodal Analgesia to Perioperative Medical Care. Anesth Analg 104 : 1380-1396, 2007 – reference: 34) Yamasaki K, Inagaki Y, Mochida S et al.: Effect of intraoperative acetated Ringer's solution with 1% glucose on glucose and protein metabolism. J Anest 24 : 426-431, 2010 – reference: 7) Jia Y, Jin G, Guo S et al.: Fast-track surgery decreases the incidence of postoperative delirium and other complications in elderly patients with colorectal carcinoma. Langenbecks Arch Surg 399 (1) : 77-84, 2014 – reference: 12) von Dossow V, Luetz A, Haas A et al.: Effects of remifentanil and fentanyl on the cell-mediated immune response in patients undergoing elective coronary artery bypass graft surgery. J Int Med Res 36 (6) : 1235-1247, 2008 – reference: 6) Holte K, Kehlet H : Epidural anaesthesia and analgesia-effects on surgical stress responses and implications for postoperative nutrition. Clin Nutr 21 : 199-206, 2002 – reference: 20) Kvarnström AL, Sarbinowski RT, Bengtson JP et al.: Complement activation and interleukin response in major abdominal surgery. Scand J Immunol 75 (5) : 510-516, 2012 – reference: 29) Carli F, Baldini G : Fast-track surgery : it is time for the anesthesiologist to get involved! Minerva Anestesiol 77 (2) : 227-230, 2011 – reference: 11) Guggenberger H, Schroeder TH, Vonthein R et al.: Remifentanil or sufentanil for coronary surgery : comparison of postoperative respiratory impairment. Eur J Anaesthesiol 23 : 832-840, 2006 – reference: 16) Kawamura T, Kadosaki M, Nara N et al.: Effects of sevoflurane on cytokine balance in patients undergoing coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 20 : 503-508, 2006 – reference: 8) Butterworth JF, Mackey DC, Wasnick JD : Anesthesia for cardiovascular surgery. Morgan & Michail's Clinical Anesthesiology. 5th edition. United States : 435-486, 2013 – reference: 14) El-Azab SR, Rossel PMJ, De Lange JJ et al.: Effect of VIMA with sevoflurane versus TIVA with propofol or midazolam-sufentanil on the cytokine response during CABG surgery. Eur J Anaesthesiol 19 : 276-282, 2002 – reference: 32) Smith MD, McCall J, Plank L et al.: Preoperative carbohydrate treatment for enhancing recovery after elective surgery. Cochrane Database Syst Rev 14 ; 8, 2014 – reference: 31) Ljungqvist O, Nygren J, Thorell A : Modulation of post-operative insulin resistance by pre-operative carbohydrate loading. Proceedings of the Nutrition Society 61, 329-335, 2002 – reference: 21) Ihn CH, Joo JD, Choi JW et al.: Comparison of stress hormone response, interleukin-6 and anaesthetic characteristics of two anaesthetic techniques : volatile induction and maintenance of anaesthesia using sevoflurane versus total intravenous anaesthesia using propofol and remifentanil. J Int Med Res 37 (6) : 1760-1771, 2009 – reference: 4) Chrousos GP : The hypothalamic-pituitary-adrenal axis and immune-mediated inflammation. N Engl J Med 332 : 1351-1362, 1995 – reference: 28) Gu CY, Zhang J, Qian YN et al.: Effects of epidural anesthesia and postoperative epidural analgesia on immune function in esophageal carcinoma patients undergoing thoracic surgery. Mol Clin Oncol 3 (1) : 190-196, 2015 – reference: 17) González-Correa JA, Cruz-Andreotti E, Arrebola MM et al.: Effects of propofol on the leukocyte nitric oxide pathway : in vitro and ex vivo studies in surgical patients. Naunyn Schmiedebergs Arch. Pharmacol 376 : 331-339, 2008 – reference: 23) Taniguchi H, Sasaki T, Fujita H et al.: The Effect of Intraoperative Use of High-Dose Remifentanil on Postoperative Insulin Resistance and Muscle Protein Catabolism : A Randomized Controlled Study.Int. J. Med. Sci 10 (9) : 1099-1107, 2013 – reference: 9) Kapoor MC, Ramachandran TR : Inflammatory response to cardiac surgery and strategies to overcome it. Annals of Cardiac Anaesthesia 7 : 113-128, 2004 – reference: 26) Chloropoulou P, Iatrou C, Vogiatzaki T et al.: Epidural anesthesia followed by epidural analgesia produces less inflammatory response than spinal anesthesia followed by intravenous morphine analgesia in patients with total knee arthroplasty. Med Sci Monit 28 ; 19 : 73-80, 2013 – reference: 33) Corcoran T, Rhodes JE, Clarke S et al.: Perioperative fluid management strategies in major surgery : a stratified meta-analysis. Anesth Analg 114 : 640-651, 2012 – reference: 13) Winterhalter M, Brandl K, Rahe-Meyer N et al.: Endocrine stress response and inflammatory activation during CABG surgery. A randomized trial comparing remifentanil infusion to intermittent fentanyl. Eur J Anaesthesiol 25 (4) : 326-335, 2008 – reference: 15) Baki ED, Aldemir M, Kokulu S et al.: Comparison of the effects of desflurane and propofol anesthesia on the inflammatory response and S100β protein during coronary artery bypass grafting. Inflammation 36 : 1327-1333, 2013 – reference: 18) Basu S, Miclescu A, Sharma H et al.: Propofol mitigates systemic oxidative injury during experimental cardiopulmonary cerebral resuscitation. Prostaglandins Leukot. Essent. Fatty Acids 84 : 123-130, 2011 – reference: 3) Feldheiser A, Aziz O, Baldini G et al.: Enhanced Recovery After Surgery (ERAS) for gastrointestinal surgery, part 2 : consensus statement for anaesthesia practice. Acta Anaesthesiol Scand. 2015 Oct 30. doi : 10.1111/aas.12651. [Epub ahead of print] Review. – reference: 22) Ke JJ, Zhan J, Feng XB et al.: A comparison of the effect of total intravenous anaesthesia with propofol and remifentanil and inhalational anaesthesia with isoflurane on the release of pro-and anti-inflammatory cytokines in patients undergoing open cholecystectomy. Anaesth Intensive Care 36 (1) : 74-78, 2008 |
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