Evidence-based control of stress response on intraoperative physiological indexes and recovery of patients undergoing gastrointestinal surgery

Abstract

BACKGROUND

Although the 2021 Chinese Clinical Practice Guidelines for Enhanced Recovery after Surgery (ERAS) provide recommendations for ERAS in gastrointestinal surgery, the clinical application of standard ERAS nursing models is challenging due to the variety of diseases involved in gastrointestinal surgery and the complex factors contributing to patient stress responses. Moreover, stress responses are more severe in older adult patients. Therefore, precision medicine is required to improve the quality of nursing care and promote postoperative recovery in gastrointestinal surgery.

AIM

To establish an evidence-based ERAS model based on stress response nursing care and demonstrate nursing benefits through clinical practice.

METHODS

This randomized clinical trial first established an evidence-based nursing ERAS protocol in older adult patients based on literature related to perioperative nursing measures for gastrointestinal surgery stress response. Next, 392 older adult patients who underwent gastrointestinal surgery and were admitted to our hospital between December 2021 and June 2023 were categorized into two groups to receive evidence-based (study group) or conventional (control group) ERAS nursing models, respectively. Intraoperative physiological parameters during surgery and postoperative recovery indicators were compared between the groups.

RESULTS

Among 64 domestic and international studies, the stress responses of older adult patients mainly included emotional anxiety, sleep disorders, gastrointestinal discomfort, physical weakness, pain, and swelling. The appropriate nursing interventions included comprehensive psychological counseling, pre- and postoperative nutritional support, temperature control, pain management, and rehabilitation training. Compared with the control group, the study group showed lower heart rate, mean arterial pressure, blood glucose level, and adrenaline level; shorter duration of drainage tube placement, time to first flatus, time to first ambulation, and postoperative hospital stay; lower anxiety scores on postoperative day 3; and lower incidences of postoperative infection, obstruction, poor wound healing, and gastrointestinal reactions were lower in the study group (all P < 0.05).

CONCLUSION

The evidence-based nursing measures targeting stress responses based on the conventional ERAS nursing model resulted in stable intraoperative physiological parameters during surgery, promoted postoperative recovery, and reduced the incidence of complications.

Key Words: Older adult patients; Gastrointestinal surgery; Stress response; Evidence-based nursing; Enhanced recovery after surgery

Core Tip: This study established an evidence-based enhanced recovery after surgery model with stress response nursing care as its foundation, and demonstrated nursing benefits through clinical practice, providing a reference and a guide for optimizing perioperative nursing protocols for older adult patients undergoing gastrointestinal surgery. Our results showed that patients who received the evidence-based nursing measures targeting stress responses showed more stable intraoperative physiological parameters, improved postoperative recovery, and a reduced incidence of complications compared with the control group that received the standard enhanced recovery after surgery nursing model.

INTRODUCTION

Gastrointestinal surgery is a common surgical procedure, and associated factors such as anesthesia, pain management, surgical trauma, and psychological stress inevitably lead to stress responses in patients, which adversely affect their postoperative recovery and quality of life[1]. Optimizing perioperative management measures can reduce the incidence of stress responses in patients and minimize the occurrence of complications, which positively impact patients’ postoperative recovery[2-5]. The 2021 Chinese Clinical Practice Guidelines for Enhanced Recovery after Surgery (ERAS) provided targeted recommendations for ERAS in gastrointestinal surgery. However, due to the wide variety of diseases involved in gastrointestinal surgery and the complex factors contributing to patient stress responses, the clinical application of standard ERAS nursing models is not ideal. In addition, stress responses tend to be more severe in older adult patients[6-9]. To improve the quality of nursing care in gastrointestinal surgery and promote postoperative recovery, our department has adopted precision medicine as a guiding principle. We collected relevant research literature from domestic and international sources to establish a precise ERAS nursing model based on evidence-based nursing for stress response in older adult patients undergoing gastrointestinal surgery. This model has been applied in clinical practice, yielding positive outcomes in terms of controlling patient stress responses, preventing complications, and facilitating postoperative recovery. The following report describes our findings.

MATERIALS AND METHODS

Evidence-based method

Using a combination of keywords, including “gastrointestinal surgery”, “stress response”, and ”nurse”, a systematic search was conducted across six electronic databases, namely, VIP, Wanfang, China National Knowledge Infrastructure, PubMed, Embase, and Cochrane Library. The search aimed to retrieve relevant literature published between January 2010 and September 2021. The inclusion criteria were: (1) Aged > 60 years undergoing gastrointestinal surgery; (2) Clinical research; and (3) Literature published in Chinese core and Science Citation Index journals. The exclusion criteria were: (1) Drafts, abstracts, reports, plans, reviews, case reports, and guide literature; (2) Non-availability of the full text of the literature; and (3) Studies that did not pass the literature quality evaluation. The Newcastle-Ottawa scale[10] was used for quality evaluation. This scale evaluates eight items across three major modules, with a total score ≤ 7 indicating that the literature does not meet the standard. Two researchers trained in systematic evidence-based research independently assessed and scored the studies. Discrepancies were resolved after consultation and discussion with a third researcher.

After screening, the English literature was translated into Chinese, and the included standard literature was cleaned to remove the abstracts and references, which were saved in text (txt) format. We used ROSTCM6 software for text segmentation and filtered out non-valuable words. Based on semantic association rule models, we established a visual semantic network diagram for nursing interventions in the stress responses of older adult patients undergoing gastrointestinal surgery and analyzed the precise nursing directions for stress responses. The research team identified evidence-based questions based on the clinical stress responses in this population, including emotional tension, sleep disorders, loss of appetite, nausea and vomiting, physical weakness, attentional abnormalities, bowel abnormalities, pain, and swelling. We designed structured data extraction forms and carefully read the literature to extract the targeted nursing measures. Nursing measures were classified, summarized, and organized to formulate a precise ERAS nursing plan.

Research methods

A randomized clinical trial was then conducted at our hospital from December 2021 to June 2023. Using the random number table method, a total of 368 patients who underwent gastrointestinal surgery patients were categorized into groups (n = 184 patients each). The research protocol was reviewed and approved by the hospital’s medical ethics committee. All patients and their families understood the trial protocol and voluntarily signed informed consent forms. The inclusion criteria were: (1) Age 60-79 years; (2) No known mental disorders; and (3) Complete imaging and pathological examination results and underwent gastrointestinal surgery in our hospital, including open and laparoscopic surgery. The exclusion criteria were: (1) Severe diseases of the heart, lungs, and other organs; (2) Extensive metastasis of malignant tumors; (3) Severe coagulation dysfunction; and (4) Severe immune system diseases. Additional exclusion criteria for the analyses were: (1) Patient drop-out; (2) Patients with insufficient compliance who could not cooperate with the treatment plan; and (3) Patients receiving other nursing programs.

Nursing approaches

The patients in the control group received routine ERAS nursing measures according to the 2021 Chinese Clinical Practice Guidelines for Accelerated Rehabilitation Surgery[11]. These measures included: (1) Strengthening preoperative education to establish a good doctor-patient relationship to ensure that patients understand the disease and surgical treatment precautions; (2) Comprehensive preoperative assessment of nutritional status, organ function, and psychological state and the scientific provision of preoperative nutritional support and preoperative rehabilitation training to enhance functional reserves; (3) Prophylactic administration of antibiotics and proper preoperative intestinal preparation; (4) Provision of necessary warming measures during surgery to avoid hypothermia; (5) Postoperatively, the administration of corticosteroids as the basic medication, with the implementation of multimodal pain management, while minimizing opioid analgesic use; (6) Monitoring patient fluid balance and tissue oxygenation; (7) Minimization and removal of catheters as early as possible; (8) Postoperatively, promotion of the early resumption of oral intake, early ambulation, rehabilitation training, and gastrointestinal function; and (9) Daily assessment of patient progress, prognosis, and compliance. The patients in the study group received evidence-based and precise ERAS nursing measures targeting stress responses compared with the control group.

The study group, based on the analysis of the included literature, primarily received the following nursing interventions: (1) Admission assessment: Based on the 2002 Nutritional Risk Screening[12] and the Self-Rating Anxiety Scale (SAS)[13] to assess the nutritional risk status and psychological state of the patients. Physicians evaluated the conditions and tailored targeted stress-response nursing plans based on individual patient characteristics; (2) Comprehensive psychological care throughout the process: The patients were provided with sufficient humanistic care, including psychological counseling to alleviate negative emotions, explaining clinical knowledge related to the disease and surgery, describing possible symptoms during the perioperative period and their solutions, answering questions raised by patients and their families, providing support to patients and their families as much as possible, guiding family members to collaborate in nursing, and reducing concerns for patients and their families; (3) Pre- and postoperative nutritional support was provided to the patients. The preoperative fasting time was shortened to fasting for 4 hours before surgery, no drinking for 2 hours before surgery, and administration of an appropriate amount of 12.5% glucose in warm water 2 hours before surgery[14]. After waking up postoperatively, patients were permitted to drink a small amount of water, and 4 hours postoperatively, the patients were allowed sugar-free chewing gum[15]. Early enteral nutritional support was provided along with reinforced postoperative nutritional guidance, emphasizing the gradual intake of small amounts of food multiple times; (4) Temperature control: The patient’s body temperature was maintained throughout the entire process, including adjusting the room temperature, intraoperative insulation, and controlling the temperature of irrigation fluids to minimize the impact of hypothermia on the patient’s neuroendocrine metabolism and coagulation mechanisms[16]; (5) Comprehensive pain management: The postoperative use of opioid analgesics was avoided as much as possible[17]. Instead, multimodal analgesia regimens combining oral medications, local infiltration, and patient-controlled analgesia were provided[18] to alleviate patient anxiety symptoms; and (6) Rehabilitation training: Rehabilitation training programs were developed based on the patient’s condition. After awakening from the surgery, the patients were allowed to engage in appropriate bed exercises. By the first postoperative day, the patients were permitted to move out of their beds[19]. Rehabilitation training and guidance were provided to patients and their family members to assist in the recovery process.

Observed indices

General baseline data, including patient age, sex, body mass index, systolic blood pressure, diastolic blood pressure, heart rate, type of surgery, and surgical method were recorded at admission. The SAS[13] was used to evaluate the emotional state of the patients. Intraoperative physiological indices, such as heart rate, mean arterial pressure, blood glucose level, and adrenaline index, were recorded. Postoperative recovery indicators, including the duration of postoperative drainage tube indwelling, first exhaust time, first time to get out of bed, length of postoperative hospital stay, SAS score 3 days postoperatively, complications, and related conditions, were recorded.

Statistical analysis

All statistical analyses were performed using IBM SPSS Statistics for Windows, version 26.0. If the measurement data conformed to a normal distribution, the mean ± SD was used to represent the measurement data, while medians and percentiles [m (P25, P75)] were used to represent skewed distributions. The independent samples t-test and rank-sum test, respectively, were used to compare normally distributed and skewed data between groups. Measurement data are expressed as frequencies and percentages [n (%)], and the χ²-tests was used for comparison between groups. Based on age, weight, type of surgery, and surgical method, the patients were categorized into 11 subgroups, and forest maps were drawn to analyze the complications of the two nursing modes. Statistical significance was set at P < 0.05.

RESULTS

Evidence retrieval

The searches of six electronic full-text databases identified 1162 relevant research articles. After removing 78 duplicate articles and 161 articles with low relevance based on titles, the abstracts and full texts were read. Sixty-four articles were selected based on the inclusion and exclusion criteria. Figure 1 illustrates the literature screening process.

Figure 1 Literature screening flow chart.

Evidence description analysis

Figure 2 shows the high-frequency semantic association network constructed from the segmented texts of the included research articles. According to this network, nursing interventions to manage stress responses in older adult patients undergoing gastrointestinal surgery should encompass the entire perioperative period, including pre-, intra-, and post-operative care. These interventions should focus on nutritional support management and gastrointestinal function recovery to reduce the incidence of complications. Additionally, appropriate measures, such as temperature management, fluid balance, and pain management, should be employed to decrease stress responses and improve patients’ adverse emotions, such as anxiety.

Figure 2 Older adult patients’ gastrointestinal surgery stress response nursing semantic association network diagram. This figure is a semantic association network diagram constructed by ROSTCM6 software to extract high-frequency words from research literature related to stress response nursing in elderly patients undergoing gastrointestinal surgery, based on word frequency and semantic association relationships. The black squares represent the conceptual nodes in the semantic association network. The line indicates the existence of semantic associations and interactive relationships between nodes. The absence of arrows indicates that the semantic association between nodes is a bidirectional relationship. The arrow indicates directional semantic associations between nodes, with the direction pointed by the arrow indicating the posterior node. The closer a square is to the center of the image, the higher the weight of the node, which has attracted more attention from relevant research literature. Nodes located at the center of the image are key nodes in the network.

Comparison of general data between the nursing treatment groups

Table 1 presents the results of the comparative statistical analysis of the general baseline data of the two treatment groups. Patient age, sex, body mass index, admission systolic blood pressure, diastolic blood pressure, heart rate, type of surgery, surgical approach, or admission SAS score did not differ significantly between the groups (all P > 0.05).

Table 1 The statistical results of general baseline data of the two groups of patients, n (%).

	Study group (n = 184)	Control group (n = 184)	t/χ2	P value
Age, years	66.8 ± 6.2	67.3 ± 6.6	-0.427	0.684
Male	102 (55.43)	98 (53.26)	0.917	0.338
BMI, kg/m2	23.1 ± 3.9	23.2 ± 3.9	-0.463	0.644
Systolic pressure, mmHg	120.7 ± 15.6	121.3 ± 16.2	-0.446	0.652
Diastolic pressure, mmHg	71.6 ± 10.8	71.9 ± 10.3	-0.219	0.882
Heart rate, times/minutes	72.4 ± 9.5	72.9 ± 9.8	-0.210	0.9884
Type of surgery
Radical gastrectomy	36 (19.57)	34 (18.48)	0.228	0.994
Perforation repair	38 (20.65)	38 (20.65)
Radical resection of rectal carcinoma	32 (17.39)	34 (18.48)
Colon cancer radical operation	50 (27.17)	48 (26.09)
Appendectomy	28 (15.22)	30 (16.30)
Surgical method
Laparotomy	86 (46.74)	90 (48.91)	0.174	0.676
Laparoscopic	98 (53.26)	94 (51.09)
SAS score	63.4 ± 12.8	64.2 ± 12.4	0.256	0.812

BMI: Body mass index; SAS: Self-Rating Anxiety Scale.

Comparison of intraoperative physiological indices between the nursing treatment groups

Table 2 shows the statistical results of intraoperative physiological indices of the two groups of patients. The average heart rate, mean arterial pressure, blood glucose level and adrenaline level in the study group were lower than those in the control group (all P < 0.05).

Table 2 The statistical results of intraoperative physiological indexes of the two groups of patients, mean ± SD.

	Study group	Control group	t	P value
Heart rate, times/minutes	75.2 ± 5.3	81.6 ± 6.8	-12.847	0.000
Arterial pressure, kPa	12.7 ± 1.4	15.2 ± 1.8	-12.714	0.000
Level of blood, mmol/L	5.8 ± 0.6	6.4 ± 1.2	-4.926	0.000
Epinephrine, ng/L	139.6 ± 18.3	168.4 ± 22.5	-14.274	0.000

Comparison of postoperative recovery between the nursing treatment groups

The study group had significantly lower durations of drainage tube placement, time to first flatus, time to ambulation, postoperative anxiety scores at 3 days, and length of hospital stay compared to the control group, with all P < 0.05. The intergroup differences were statistically significant (Table 3).

Table 3 The statistical results of postoperative recovery indexes of two groups of patients, mean ± SD.

	Study group	Control group	t	P value
Drainage tube indwelling time, hours	9.2 ± 3.6	14.8 ± 4.9	-14.437	0.000
First exhaust time, hours	19.5 ± 5.8	28.4 ± 7.2	-18.746	0.000
Ambulation time, hours	15.4 ± 4.6	24.2 ± 6.1	-22.325	0.000
Anxiety scores 3 days after operation	51.7 ± 15.2	74.6 ± 18.5	-27.429	0.000
Length of postoperative hospital stay, days	4.7 ± 1.3	6.5 ± 1.8	-8.792	0.000

Incidence of postoperative complications in the nursing treatment groups

Figure 3 presents the results of the subgroup analysis of postoperative complications, including infections, anastomotic leakage, obstruction, poor wound healing, abdominal distension, nausea, and vomiting in the two treatment groups. The incidence of postoperative complications was significantly lower in the intervention group than in the control group (P < 0.05). The occurrence of complications, including perforation repair and appendectomy, did not differ significantly between the two nursing methods (all P > 0.05). However, statistically significant differences were observed in the remaining subgroups (all P < 0.05). Female patients, patients with low body weight or overweight, those who underwent radical surgery for gastric, rectal, or colon cancer, and those undergoing open surgery could benefit from evidence-based control nursing for stress response.

Figure 3 Subgroup analysis of postoperative complications in the two nursing treatment groups. OR: Odds ratio; CI: Confidence interval; BMI: Body mass index.

DISCUSSION

Due to aging, the physical function of the older adult population itself declines, and their immune function, gastrointestinal function, etc., are not as good as those of the younger population. Moreover, due to various reasons, such as decreased physical function and autonomic nervous system function, their psychological quality is poor, and they are more likely to experience negative emotions, such as fragility, worry, terror, anxiety, and pain caused by diseases, surgical trauma, etc. Gastrointestinal surgery often involves significant abdominal disturbances due to exposure, suturing, traction, and tissue dissection. This can greatly affect the patient’s gastrointestinal function, leading to increased susceptibility to stress reactions such as nausea, anxiety, and pain. These reactions can adversely affect the postoperative recovery speed and may even trigger complications[20-22]. Additionally, older adult patients, due to their declining physical condition, weakened bodily function, and poor psychological resilience, are more prone to experiencing stress reactions following gastrointestinal surgery because of factors such as bodily trauma, environmental changes, and disease-related distress[23]. Therefore, providing targeted nursing interventions for stress response is crucial for older adult patients undergoing gastrointestinal surgery.

Although the routine ERAS nursing measures recommended by the guidelines can shorten the length of hospital stay and reduce the incidence of complications in older adult patients undergoing gastrointestinal surgery, their effectiveness is still not ideal. Severe stress reactions remain the primary cause of postoperative recovery in older adult patients[24-26]. The present study applied evidence-based research to establish a precise ERAS nursing model tailored to the stress responses in this population. Compared with routine ERAS nursing, precise ERAS nursing targeting stress responses achieved higher clinical benefits. The patients who received the targeted nursing model showed significantly better intraoperative physiological indicators and postoperative recovery outcomes, with a lower incidence of postoperative complications. Therefore, the precise ERAS nursing model established in the present study provides targeted nursing measures based on the characteristics of older adult patients through admission assessment. Psychological care throughout the process can enhance patient confidence, alleviate negative emotions, and reduce stress reactions caused by negative emotions[27]. Providing nutritional support and guidance to patients pre- and post-operatively can effectively improve their nutritional status during the perioperative period, reduce nutritional deficiencies or excesses, and enhance organ function to promote gastrointestinal recovery[28]. Comprehensive pain interventions and early rehabilitation training can reduce patient discomfort and positively affect patient sleep quality and other aspects[29]. Providing precise ERAS nursing tailored to the characteristics of the older adult population is more in line with the mechanism of stress responses in this population and can effectively reduce the level of stress responses in a targeted manner.

McAlee et al[30] reported that poor mood directly impacts patient postoperative recovery. Psychological interventions should be strengthened in older adult patients undergoing gastrointestinal surgery to the patient’s emotional state. The results of the present study demonstrated a significantly better psychological anxiety score in the study group than that of the conventional ERAS nursing group 3 days postoperatively. Older adult patients are prone to negative emotions, pessimism, anxiety, fear, and other serious negative emotions when undergoing gastrointestinal surgery, particularly radical gastrectomy and radical resection of rectal or colon cancer. Although young patients also experience negative emotions, they are more likely to maintain positive and optimistic attitudes[31]. In the present study, based on evidence-based research, a comprehensive perioperative nursing plan was established to provide targeted psychological counseling and humanistic care to patients pre- and postoperatively, in order to reduce patients’ negative emotions and improve their confidence in treatment. Emotional counseling was also provided to patients’ families, enabling them to provide better psychological support and improve the negative emotions of older adult patients. At the same time, multi-mode comprehensive pain relief measures were also provided, effectively reducing patients’ anxiety symptoms and discomfort caused by pain[32].

Panattoni et al[33] proposed the early promotion of intestinal function recovery after gastrointestinal surgery as a primary strategy for reducing postoperative hospital stay. Oral intake should be resumed as soon as the patient is awake postoperatively, and limited water intake should be allowed. The results of the present study demonstrated that the study group had lower first flatus time, drainage tube retention time, and postoperative hospital stay compared with the conventional ERAS care group; moreover, the study group also experienced fewer postoperative complications, such as infections, obstructions, abdominal distension, nausea, and vomiting. The early provision of limited water intake and chewing gum pseudo-feeding can stimulate the vagus nerve, promote gastrointestinal motility, and facilitate the earlier recovery of gastrointestinal function[34].

In addition, among older adult patients undergoing gastrointestinal surgery, those with older age, female sex, underweight or overweight status, or undergoing open surgery and radical surgery for gastric, rectal, and colon cancer exhibited higher incidence rates of postoperative complications. This conclusion is consistent with the findings reported by Kolarsick et al[35], indicating a higher risk of postoperative complications in these patient groups. The reasons for this association are likely related to the relatively weaker physiological functions or greater surgical stress in these patient populations. Implementing a precise ERAS care model with evidence-based stress response control can significantly reduce the incidence of postoperative complications and yield greater benefits.

However, the literature included in the present study involves patients undergoing surgery for various gastrointestinal diseases and does not provide further analysis of disease types, surgical methods, etc. Therefore, the control nursing plan established based on the literature may not be applicable to all gastrointestinal surgery patients. In the clinical value observation of applying evidence-based nursing programs for precision nursing control, only intraoperative physiological indicators, postoperative recovery, and postoperative complications were observed, and the long-term impact of implementing precision evidence-based nursing control on older adult gastrointestinal surgery patients was not observed. Further research and exploration are required to determine whether the proposed plan is suitable for older adult patients undergoing various gastrointestinal surgeries and its impact on patients in the medium to long term.

CONCLUSION

According to the characteristics of older adult patients, stress response is an evidence-based problem. Based on routine ERAS nursing measures for gastrointestinal surgery, evidence-based nursing intervention measures based on the stress response can effectively reduce the occurrence of negative emotions in patients, improve the recovery rate of gastrointestinal function in patients, and reduce the negative effects of discomfort, such as pain, abdominal distension, and nausea. This approach is beneficial for the postoperative recovery of patients by reducing the occurrence of postoperative complications and improving their quality of life during the perioperative period.