基于恢复质量轨迹的子宫内膜癌患者围手术期麻醉相关影响因素研究-现代医学

基于恢复质量轨迹的子宫内膜癌患者围手术期麻醉相关影响因素研究

单位：南京医科大学第一附属医院麻醉与围手术期医学科, 江苏南京 210029

分类号：R733.33;R614

出版年·卷·期（页码）：2026·54·第五期（778-785）

摘要：

目的：探讨子宫内膜癌根治术患者术后恢复质量(QoR)轨迹与围手术期麻醉管理因素的相关性。方法：采用回顾性队列研究设计，纳入2022年1月至2025年10月行腹腔镜下子宫内膜癌根治术的患者289例。所有患者术中均接受脑电双频指数(BIS)监测指导的全身麻醉，镇痛以舒芬太尼为主，并记录术中是否需追加其他镇痛干预。术后使用统一配方的舒芬太尼患者自控静脉镇痛(PCIA)。采用组基轨迹模型(GBTM)基于术后连续3 d的15项恢复质量量表(QoR-15)评分识别恢复轨迹类别，比较不同轨迹组围手术期指标，并采用多因素Logistic回归分析延迟恢复的相关因素。结果：GBTM分析识别出3类恢复轨迹：快速恢复组(126例，43.6%)、缓慢恢复组(112例，38.8%)和延迟恢复组(51例，17.6%)。这3组在术中舒芬太尼总用量分别为(0.5±0.2)、(0.7±0.2)、(0.8±0.2) μg·kg^-1，术中追加其他镇痛干预比例、BIS<40时间占比、术后24 h PCIA有效按压次数、术后恶心呕吐(PONV)发生率及术后追加使用格拉司琼及氟比洛芬酯占比差异均有统计学意义(均P<0.001)。多因素Logistic回归分析显示，术中舒芬太尼总用量每增加0.1 μg·kg^-1、术中需要追加其他镇痛干预、BIS<40时间占比每增加5%、术后24 h PCIA按压次数每增加5次、发生PONV以及术后追加使用格拉司琼与延迟恢复轨迹独立相关(均P<0.01)。结论：子宫内膜癌患者术后QoR呈现异质性轨迹。在以舒芬太尼为基础的常规镇痛方案中，其总用量增加、术中镇痛需追加其他干预、麻醉过深、术后早期镇痛需求高、发生PONV及需要追加止吐治疗，均与延迟恢复轨迹显著相关。优化上述围手术期麻醉与症状管理环节可能有助于改善患者术后QoR。

Objective: To investigate the correlation between postoperative quality of recovery(QoR) trajectories and perioperative anesthesia management factors in patients undergoing radical surgery for endometrial cancer. Methods:A retrospective cohort study was conducted involving 289 patients who underwent laparoscopic radical surgery for endometrial cancer between January 2022 and October 2025. All patients received general anesthesia guided by bispectral index(BIS) monitoring with sufentanil-based analgesia. Intraoperative additional analgesic interventions were recorded. Postoperatively, patients received standardized sufentanil-based patient-controlled intravenous analgesia(PCIA). Group-based trajectory modeling(GBTM) was applied to QoR-15 scores over the first 3 postoperative days to identify recovery patterns. Perioperative variables were compared across trajectory groups, and multivariable logistic regression was used to identify factors associated with delayed recovery.Results: GBTM identified three recovery trajectories: rapid recovery(126 cases, 43.6%), slow recovery(112 cases, 38.8%), and delayed recovery(51 cases, 17.6%). The total intraoperative sufentanil doses in these groups were(0.5±0.2),(0.7±0.2), and(0.8±0.2) μg·kg^-1, respectively. Significant differences were observed among the groups regarding the proportion requiring additional intraoperative analgesia, the proportion of time with BIS<40, the number of effective PCIA demands within 24 h, the incidence of postoperative nausea and vomiting(PONV), and the use of rescue granisetron and flurbiprofen axetil(all P<0.001). Multivariable logistic regression analysis indicated that the following factors were independently associated with the delayed recovery trajectory: each 0.1 μg·kg^-1 increase in intraoperative sufentanil dose, the need for additional intraoperative analgesia, each 5% increase in the time with BIS<40, each 5 additional PCIA demands within 24 h, the occurrence of PONV, and the postoperative use of granisetron(all P<0.01). Conclusion: Patients with endometrial cancer exhibit heterogeneous postoperative recovery trajectories. In a sufentanil-based analgesic regimen, higher total intraoperative sufentanil dosage, the need for additional intraoperative analgesic interventions, deep anesthesia(BIS<40), high early postoperative analgesic demand, occurrence of PONV, and the need for rescue antiemetic therapy are significantly associated with delayed recovery. Optimization of these perioperative anesthesia and symptom management protocols may improve postoperative recovery quality.

参考文献：

[1] CONCIN N, MATIAS-GUIU X, CIBULA D, et al.ESGO-ESTRO-ESP guidelines for the management of patients with endometrial carcinoma:update 2025[J].Lancet Oncol, 2025, 26(8):e423-e435.
[2] LJUNGQVIST O, DE BOER H D, BALFOUR A, et al.Opportunities and challenges for the next phase of enhanced recovery after surgery:a review[J].JAMA Surg, 2021, 156(8):775-784.
[3] NAGIN D S, ODGERS C L.Group-based trajectory modeling in clinical research[J].Annu Rev Clin Psychol, 2010, 6:109-138.
[4] KAYE A D, URMAN R D, RAPPAPORT Y, et al.Multimodal analgesia as an essential part of enhanced recovery protocols in the ambulatory settings[J].J Anaesthesiol Clin Pharmacol, 2019, 35(Suppl 1):S40-S45.
[5] KHALIL M, ALTAF A, WOLDESENBET S, et al.Long-term postoperative recovery trajectories among older individuals undergoing major operation[J].J Am Coll Surg, 2026, 242(2):366-376.
[6] 黄宇捷, 张健.舒芬太尼在静脉术后镇痛和临床麻醉中的应用效果及安全性[J].实用临床医药杂志, 2021, 25(25):109-111.
[7] JIANG Y Y, LI Z P, YAO M, et al.Standard opioid-containing versus opioid-sparing anesthesia on early postoperative recovery after video-assisted thoracic surgery:a propensity-weighted analysis[J].Front Surg, 2022, 9:1015467.
[8] LI Y, GU Y, LIU W, et al.Effects of intrathecal sufentanil at different doses on postoperative pain relief and opioid consumption in elderly patients undergoing lower limb orthopedic surgery:a randomized controlled trial[J].J Pain Res, 2025, 18:2439-2451.
[9] ZHANG T, YUE Z, YU L, et al.S-ketamine promotes postoperative recovery of gastrointestinal function and reduces postoperative pain in gynecological abdominal surgery patients:a randomized controlled trial[J].BMC Surg, 2023, 23(1):74.
[10] 陈庆丽, 葛卫斌, 吴刚, 等.舒芬太尼与芬太尼靶控输注对结直肠癌根治术患者麻醉苏醒质量、肺内氧合及氧化抗氧化系统影响的对比研究[J].世界华人消化杂志, 2024, 32(3):236-242.
[11] 胡双燕, 仲俊峰, 何锐, 等.右美托咪定复合舒芬太尼静脉镇痛对腹腔镜胃切除患者术后肠功能的影响[J].中国临床药理学与治疗学, 2016, 21(12):1409-1412.
[12] OU-YOUNG J, ROYSE C, CLARKE-ERREY S, et al.Recovery trajectories after major abdominal surgery:a retrospective pooled cohort study[J].Acta Anaesthesiol Scand, 2025, 69(2):e14576.
[13] MAYHEW D, MENDONCA V, MURTHY B V S.A review of ASA physical status-historical perspectives and modern developments[J].Anaesthesia, 2019, 74(3):373-379.
[14] COHEN J.Statistical power analysis for the behavioral sciences[M].2nd ed.Hillsdale, NJ:Lawrence Erlbaum Associates, 1988:20-26.
[15] NAGIN D S.Group-based trajectory modeling:an overview[J].Ann Nutr Metab, 2014, 65(2-3):205-210.
[16] 李新楠, 侯丹.患者术后恢复质量评估工具的研究进展[J].中华护理杂志, 2019, 54(10):1583-1587.
[17] STARK P A, MYLES P S, BURKE J A.Development and psychometric evaluation of a postoperative quality of recovery score:the QoR-15[J].Anesthesiology, 2013, 118(6):1332-1340.
[18] WEINBERG L, LI S Y, LOUIS M, et al.Reported definitions of intraoperative hypotension in adults undergoing non-cardiac surgery under general anaesthesia:a review[J].BMC Anesthesiol, 2022, 22(1):69.
[19] KARIM H M R, BANSAL V.Is research reporting intraoperative hypotension apt enough?[J].Indian J Anaesth, 2024, 68(5):496-499.
[20] FRANCK M, RADTKE F M, PRAHS C, et al.Documented intraoperative hypotension according to the three most common definitions does not match the application of antihypotensive medication[J].J Int Med Res, 2011, 39(3):846-856.
[21] LEE M, SILVERMAN S M, HANSEN H, et al.A comprehensive review of opioid-induced hyperalgesia[J].Pain Physician, 2011, 14(2):145-161.
[22] KOPPERT W, SCHMELZ M.The impact of opioid-induced hyperalgesia for postoperative pain[J].Best Pract Res Clin Anaesthesiol, 2007, 21(1):65-83.
[23] EVERED L A, CHAN M T V, HAN R, et al.Anaesthetic depth and delirium after major surgery:a randomised clinical trial[J].Br J Anaesth, 2021, 127(5):704-712.
[24] CHAN M T, CHENG B C, LEE T M, et al.BIS-guided anesthesia decreases postoperative delirium and cognitive decline[J].J Neurosurg Anesthesiol, 2013, 25(1):33-42.
[25] WICK E C, GRANT M C, WU C L.Postoperative multimodal analgesia pain management with nonopioid analgesics and techniques:a review[J].JAMA Surg, 2017, 152(7):691-697.
[26] GAN T J, BELANI K G, BERGESE S, et al.Fourth consensus guidelines for the management of postoperative nausea and vomiting[J].Anesth Analg, 2020, 131(2):411-448.
[27] JIN Z, HU J, MA D.Postoperative delirium:perioperative assessment, risk reduction, and management[J].Br J Anaesth, 2020, 125(4):492-504.
[28] MAN S, WU X, HUANG H, et al.Frailty in middle-aged and older adult postoperative patients with gynecological malignancies structural equation modeling[J].Front Public Health, 2024, 12:1431048.

服务与反馈：

【文章下载】【发表评论】【查看评论】【加入收藏】

提示：您还未登录，请登录！点此登录