基于加速康复外科理念的多学科协作模式在糖尿病神经源性膀胱患者管理中的应用

Application of a multidisciplinary collaborative model based on the enhanced recovery after surgery concept in the management of patients with diabetic neurogenic bladder

摘要

目的：探讨基于加速康复外科（enhanced recovery after surgery，ERAS）理念的多学科协作模式在糖尿病神经源性膀胱（diabetic neurogenic bladder，DNB）患者管理中的应用价值。方法：采用前瞻性随机对照试验，将90例DNB患者随机分为对照组和试验组，每组45例。对照组接受常规管理模式，试验组接受ERAS多学科协作模式管理。主要观察指标为两组患者治疗前、治疗后3个月、6个月的血糖情况（糖化血红蛋白、空腹血糖、餐后2 h血糖）及尿动力学指标（残余尿量、最大尿流率、最大逼尿肌压力、最大膀胱容量）。次要观察指标包括住院时长与费用、并发症（尿路感染、结石、积水）、美国泌尿协会症状指数（American Urological Association symptom index，AUA-SI）、患者健康问卷抑郁量表（patient health questionnaire-9，PHQ-9）和生活质量测评量表（short form qualiveen，SF-Qualiveen）评分。采用重复测量方差分析与广义估计方程评估管理效果。结果：重复测量方差分析显示，除空腹血糖的交互效应无统计学意义外（P &gt; 0.05，时间效应显著），餐后2 h血糖、4项尿动力学参数及AUA-SI、SF-Qualiveen评分的时间、组间与交互效应均有统计学意义（P<0.05）；糖化血红蛋白及PHQ-9评分的时间与交互效应亦有统计学意义（P<0.05）。广义估计方程显示，尿路感染的时间与组间效应有统计学意义（P<0.05）；尿路结石、积水的时间效应有统计学意义（P<0.05）。试验组的住院时长和费用均低于对照组（P<0.05）。结论：ERAS多学科协作模式可改善DNB患者血糖控制、膀胱功能及生活质量，缩短住院时长和减少医疗费用，对减少部分并发症有积极作用。

Abstract

Objective：To explore the application value of a multidisciplinary collaborative model based on the enhanced recovery after surgery（ERAS）concept in the management of patients with diabetic neurogenic bladder（DNB）. Methods：This was a prospective randomized controlled trial. Ninety DNB patients were randomly assigned to a control group and an experimental group，with 45 cases in each group. The control group received routine management，while the experimental group received the ERAS multidisciplinary model. The primary outcomes were blood glucose levels[glycated hemoglobin（HbA1c），fasting plasma glucose（FPG），and 2-hour postprandial glucose（2hPG）]and urodynamic parameters[residual urine volume（RUV），maximum flow rate（Qmax），maximum detrusor pressure（Pdetmax），and maximum cystometric capacity（VMCC）]measured before treatment and at 3 and 6 months after treatment. Secondary outcomes included length of hospital stay and hospital costs，scores on the American Urological Association Symptom Index（AUA-SI），Patient Health Questionnaire-9（PHQ-9），and Short Form Qualiveen（SF-Qualiveen），and DNB-related complications（urinary tract infection，urolithiasis，hydronephrosis）. Repeated measures analysis of variance（ANOVA）and generalized estimating equations（GEE）were used to evaluate the management effects. Results：Repeated measures ANOVA showed that，except for the interaction effect of FPG（P &gt; 0.05，with a significant time effect），the time，group，and interaction effects for 2hPG，urodynamic parameters，and AUA-SI and SF-Qualiveen scores were all statistically significant（P<0.05）；the time and interaction effects for HbA1c and PHQ-9 scores were also statistically significant（P<0.05）. GEE analysis revealed that for urinary tract infection，both time and group effects were significant（P<0.05）；for urolithiasis and hydronephrosis，the time effects were significant（P<0.05）. The length of hospital stay and hospital costs in the experimental group were significantly lower than those in the control group（P<0.05）. Conclusion：The ERAS multidisciplinary model can improve glycemic control，bladder function，and quality of life in DNB patients，reduce length of hospital stay and medical costs，and has a positive effect on reducing certain complications.

关键词

神经源性膀胱 / 加速康复外科 / 多学科协作诊疗

Key words

neurogenic bladder / enhanced recovery after surgery / multidisciplinary collaborative management

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基金资助

国家卫生健康委医院管理研究所项目(NIHA25DM29)

淮安市卫健委科研项目(HABL2023096)

南京医科大学康达学院科研发展基金(KD2023KYJJ181)