INTRODUCTION

Enhanced recovery after surgery[1] is an evidence-based, interdisciplinary approach for the care of surgical patients, and it was first proposed by Henrik Kehlet and colleagues more than 20 years ago[2,3]. The aim of ERAS is to optimize perioperative management strategies in order to improve prognosis, shorten perioperative hospital stay, and reduce complications, readmissions, and overall treatment costs[3]. The implementation of ERAS requires a multidisciplinary team that includes surgeons, anesthetists, and nursing staff[3]. ERAS has provided numerous recommendations to improve perioperative management of the patient, such as shortening the period of perioperative fasting, the use of minimallyinvasive surgical techniques, the careful maintenance of fluid balance, early oral feeding after surgery, minimal use of drains/tubes, and early mobilization[3,4].

（3）吃得越晚，吃得越少。正常時(shí)間吃晚飯，吃七八分飽為宜。想減肥的可以只吃五分飽。有人因?yàn)楣ぷ鞯脑?，到家都十點(diǎn)了，那么要不要吃晚餐呢？當(dāng)然要吃！如果不吃晚餐，那頭一頓飯和下一頓飯間隔的時(shí)間將近十八個(gè)小時(shí)，腸胃中雖然沒有食物，但是消化液卻是會(huì)分泌的。雖然不多，但是長此以往也足以傷害腸胃健康。

Another important focus of ERAS is the early introduction of oral nutrition postoperatively. The European Society of Anaesthesiology recommends restoring liquid intake within 3 h after surgery[13], and a recent consensus statement encourages the early oral intake of fluids and solids after abdominal surgery[20]. Indeed, allowing adult patients to eat normal food on the day of surgery has been reported to shorten the time to resumption of bowel function, reduce the length of hospital stay, and decrease the incidence of postoperative complications[21-24]. Postoperative fasting can induce discomfort and anxiety in children due to thirst and hunger. Furthermore, early postoperative feeding in children has been reported to reduce the levels of hunger, thirst, and pain, shorten the time to first flatus/stool, and decrease infection rates, without increasing the incidence of vomiting[25-27]. Nevertheless, most hospitals still abide by the strategy of restricting food intake until ≥ 6 h after surgery. Moreover, data are very limited regarding the potential benefits and safety of early postoperative feeding in children in China.

AVEVA在全球各地有成千上萬的裝置和場地，不斷的監(jiān)控著200億個(gè)工業(yè)領(lǐng)域當(dāng)中的參數(shù)，每天的交易量要達(dá)到10萬億，同時(shí)，AVEVA還有多元化的專業(yè)技能，即有1000多個(gè)行業(yè)專家提供服務(wù)，可以幫助企業(yè)實(shí)施解決方案。AVEVA還有非常多的運(yùn)營、計(jì)劃方面的能力，幫助企業(yè)排期，以最高效的方式來進(jìn)行生產(chǎn)規(guī)劃。在英國石油公司（BP）的項(xiàng)目上，AVEVA憑借著自身優(yōu)勢，幫助其打通了各個(gè)環(huán)節(jié)、節(jié)約了生產(chǎn)成本、提高了效率。

This prospective pilot study included children undergoing non-gastrointestinal surgery at the General Surgery Department/Surgical Endoscopic Center of the Children’s Hospital (Zhejiang University School of Medicine) between January 2020 and June 2020. The inclusion criteria were: (1) Age ≥ 3 mo of age; (2) Children undergoing elective non-gastrointestinal surgery; and (3) ASA grade I-II[28]. The exclusion criteria were: (1) Gastrointestinal dysfunction (such as gastroesophageal reflux or gastrointestinal tract obstruction); (2) Obesity; (3) Difficult airway; (4) Cerebral injury; (5) Intracranial hypertension; (6) Coma; (7) Anesthesia time > 3 h, which would result in drug accumulation that would require a longer period of postoperative food and water fasting; or (8) Cardiac or renal dysfunction. The study was approved by the Ethics Committee of the Children’s Hospital, Zhejiang University School of Medicine. All children and their guardians provided informed consent for the study.

MATERIALS AND METHODS

Study design and patients

Recently, the General Surgery Department of our hospital has cooperated with other departments, including the Anesthesia Department, Operating Room, and Information Department, to implement a series of strategies to align our pre-operative and postoperative fasting protocols with the ERAS recommendations. The aim of this prospective pilot study of children ≥ 3 mo of age undergoing nongastrointestinal surgery was to evaluate the effects of the new perioperative fasting protocols on preoperative and postoperative fasting times and the incidences of thirst, hunger, vomiting, aspiration, and postoperative fever. It is anticipated that the procedures and findings described in this study would facilitate the optimization of perioperative fasting strategies in other surgical departments, especially in China.

收集語料的途徑和方法很多，但側(cè)重不同，效用不同。方法本身沒有優(yōu)劣之分，但有各自的適用范圍，有是否合適、是否有效之別(Kasper,2000)。所謂“合適”、“有效”的方法，指的是能夠獲取目標(biāo)語料的方法；所謂“目標(biāo)語料”，指的是有助于解決研究問題、實(shí)現(xiàn)研究目的的語料。因此，一項(xiàng)研究具體應(yīng)該采用哪種(哪些)方法，要視研究問題和研究目的而定。除此之外，還要考慮可行性，兼顧時(shí)間、物力、人力等現(xiàn)實(shí)因素。真實(shí)性(authenticy)并非衡量語料質(zhì)量的唯一標(biāo)準(zhǔn)，我們不能簡單地在非真實(shí)(inauthentic)和無效(invalid)之間畫等號(hào)(Kasper,2000:318)。

Patient grouping

A total of 303 children were included in this study. Among the 151 children in the conventional group (median [range]: 2.2 [0.3, 13.1] years), 81 had an indirect inguinal hernia, 8 had a thyroglossal cyst, 10 had a branchial fistula, 32 had a local mass, and 20 had other disorders (lymphangioma, hydrocele of the tunica vaginalis,

). Among the 152 children in the ERAS group (median [range]: 2.3 [0.3, 14.7] years), 88 had an indirect inguinal hernia, 6 had a thyroglossal cyst, 12 had a branchial fistula, 24 had a local mass, and 22 had other disorders (lymphangioma, hydrocele of the tunica vaginalis,

). Age, gender, body mass index, anesthesia time, anesthesia method, and operation time did not differ significantly between the two groups (Table 1).

Prolonged fasting is uncomfortable for the patient[6] and can lead to discomfort and anxiety in children because of thirst and hunger. The present study found that shortening the duration of perioperative fasting reduced patient discomfort since the ERAS group reported a lower incidence of thirst than the conventional group (among patients aged ≥ 2 years). Furthermore, satisfaction with the fasting protocol was greater for the ERAS group than for the conventional group. Other published studies have also reported benefits of a shorter duration of perioperative fasting on patient comfort[25-27].

Perioperative fasting protocols

In the conventional control group, the traditional perioperative fasting plan was used. In order to meet the requirements of 8 h without food and 4 h without water before the operation, a "batch fasting" was implemented. The responsible doctor arranged the banned food/water at 00:00, 2:00, and 4:00 in batches according to the operating room planning. After the operation, food and water were prohibited for 6 h in accordance with the current nursing routine requirements, and anesthesia recovery and swallowing function were not routinely evaluated. After 6 h, small amounts of rice soup, porridge, and other soft foods were allowed, and the patients were gradually shifted to a normal diet.

For children in the ERAS group, pre-operative fasting was based on the current guidelines in the United States, Europe, and China: ≤ 5 mL/kg of clear fluids, up to a maximum volume of 300 mL, were permitted within the 2 h before surgery; fasting period of 4 h for breast milk; fasting period of 6 h for formula milk, non-human milk, and starchy solids; and fasting period of 8 h for solids such as fat and meat. In order to implement an individualized pre-operative fasting protocol, the estimated start time of the operation for each patient was calculated on the day before surgery according to the order of the surgical list (which was decided by the surgical team) and the mean duration of each type of operation (which had been calculated from data obtained from the surgical anesthesia system). The nurse on the night shift re-assessed any risk factors that might influence the timing or lead to the cancellation of the operation. On the day of surgery, the progress of the surgical list was continuously monitored from the information system by the chief nurse or another staff member, and any delays in surgery were reported to the appropriate nursing staff and patient/parents so that the fasting times could be adjusted accordingly. Postoperatively, the children in the ERAS group were allowed to have food intake from 1 h after surgery, provided that they passed a safety assessment requiring a Steward recovery score > 4[29] and a water swallow test score of 1-2,

, able to drink 2-5 mL (children aged < 1 year) or 5-10 mL (children aged ≥ 1 year) of water in one or two attempts within 5 s. Liquid food was provided initially, and semi-liquid food (such as porridge) was provided 15 min later. The volume of the initial diet was half the regular feeding volume. A return to a normal diet was made gradually.

The implementation of the individualized fasting protocol for children in the ERAS group involved the training of medical staff at departmental meetings, which was led by the investigators in charge of reviewing the available literature and creating the new strategy. A slide deck was prepared to facilitate the training sessions. The patients and their parents were also informed about the fasting protocol, and the advantages of drinking clear liquids within the 2 h before surgery were emphasized. A simplified slide deck was used to help convey the relevant information to the patients and parents.

Data collection

All data were collected by trained investigators from our department through face-to-face questioning, reviewing medical records, and observation. The pre-operative food fasting time (the time from the last intake of food to transfer to the theatre) and liquid fasting time (the time from the last intake of clear liquids to transfer to the theatre) were recorded by the nurse who transferred the child to the operating room through inquiry of the parents. A venous blood sample for the measurement of pre-operative blood glucose levels was obtained before the initiation of intravenous infusions at 9:00 on the day of surgery. Postoperative food fasting time (time from transfer to the ward to the first intake of liquid) was recorded by a nurse at the bedside. Postoperative thirst reported before the first intake of food by children aged ≥ 2 years was recorded by the nurse in charge. Intraoperative vomiting and aspiration were recorded by a trained data collector after reviewing the records on the day after surgery. Postoperative vomiting and postoperative fever (≥ 37.5°C) before discharge from the hospital were recorded by the data collector after review of the medical records and consultation with the parents. On the morning after surgery, the children and parents were asked to rate their satisfaction with the preoperative fasting protocol using a visual analog scale, where 0 indicated non-satisfaction and 10 indicated great satisfaction.

Statistical analysis

SPSS 23.0 (IBM Corp., Armonk, NY, United States) was used for statistical analyses. Categorical data are described as frequencies and percentages and were compared between groups using the chi-squared test or Fisher’s exact test. Continuous data are described as the mean ± SD or median (range) according to normal distribution or not. Normally-distributed continuous data were compared between two groups using the independent-samples

-test. Non-normally-distributed continuous data were compared using the rank-sum test.

< 0.05 was considered statistically significant.

RESULTS

Baseline data

The study participants were divided into two groups according to whether they had been enrolled before or after the implementation of the new perioperative fasting strategy. Children who underwent surgery between January 8, 2020 and April 5, 2020 were managed using a conventional fasting protocol (see below) and allocated to a conventional group. Children who underwent surgery between April 6, 2020 and June 20, 2020 were managed using a fasting protocol based on ERAS recommendations (see below) and allocated to an ERAS group. The study aimed to have at least 150 patients in each group.

Pre-operative clinical data

The ERAS group had a significantly shorter food fasting time [11.92 (4.00, 19.33)

13.00 (6.00, 20.28) h,

< 0.001] and liquid fasting time [3.00 (2.00, 7.50)

12.00 (3.00, 20.28) h,

< 0.001] than the conventional group (Table 2). The preoperative blood glucose level was significantly higher in the ERAS group than in the conventional group [5.6 (4.2, 8.2)

5.1 (4.0, 7.4) mmol/L,

< 0.001; Table 2].

Postoperative clinical data

The time to postoperative feeding was significantly shorter in the ERAS group than in the conventional group [1.17 (0.33, 6.83)

6.00 (5.40, 9.20),

< 0.001]. Among children aged ≥ 2 years, the incidence of thirst was significantly higher in the conventional group than in the ERAS group (74.5%

15.3%,

< 0.001), whereas the incidence of hunger was not significantly different between the conventional group (26.3%) and ERAS group (21.5%). No children in either group experienced intraoperative or postoperative aspiration, and the incidences of perioperative vomiting and fever were also not significantly different between groups (Table 2). Satisfaction with the fasting protocol was significantly higher for the ERAS group than for the conventional group [7 (0, 10)

8 (5, 10),

< 0.001].

DISCUSSION

In view of the current discrepancy between preoperative fasting guidelines and clinical practice, we carried out this study and hoped to enrich the research data on early postoperative feeding for nongastrointestinal surgery, offer scientific and accurate medical care for children, and improve the satisfaction of the children and their families. The main finding of this pilot study is that children ≥ 3 mo of age in the ERAS group had a shorter pre-operative food fasting time, shorter pre-operative liquid fasting time, higher pre-operative blood glucose level, lower incidence of thirst, shorter time to postoperative feeding, and greater satisfaction with the fasting strategy than the conventional group. Notably, no children experienced perioperative aspiration, and the incidences of perioperative vomiting and fever were not significantly different between groups. Taken together, our findings show that the implementation of ERAS-based fasting protocols can safely shorten perioperative fasting times and improve the comfort of children undergoing non-gastrointestinal surgery.

從食品立法的視角來看，有關(guān)部門在現(xiàn)階段就是要在根源上健全立法，通過運(yùn)用立法的途徑與方式來懲戒制售毒害食品的不良行為。具體在實(shí)踐中，關(guān)鍵舉措在于運(yùn)用全局觀來規(guī)制整個(gè)過程的食品流通與食品生產(chǎn)，確保食品消費(fèi)者都可以擁有更為放心的食品安全環(huán)境。針對(duì)當(dāng)前各個(gè)核心性的立法環(huán)節(jié)，應(yīng)當(dāng)將安全閥全面布置于食品安全立法，以便于開展綜合性的安全威脅防控。

Conventional opinions suggest that the laryngeal reflex is suppressed under anesthesia and that this increases the risk of aspiration. Therefore, it was generally recommended that patients abstain from food and liquids from midnight to ensure complete gastric emptying and safe anesthesia. However, gastric emptying occurs within 90 min[7], and consumption of a small amount of clear fluid 2 h before surgery has little effect on gastric volume or pH[8], suggesting that prolonged fasting for food and liquids before surgery is unnecessary. In the present study, the mean pre-operative liquid fasting time was 12.15 h in the conventional group but only 3.17 h in the ERAS group. Despite the large difference in pre-operative liquid fasting time, the incidence of intraoperative and postoperative vomiting was not significantly different between the two groups, and no children experienced aspiration. Our findings agree with previously published data that shortening the duration of pre-operative fasting is safe and does not lead to an increase in the incidence of aspiration or vomiting in children[10,30,31] or adults[9,11].

Since fasting from midnight increases insulin resistance and is uncomfortable for the patients[6], shortening the pre-operative fasting time has several potential benefits. The intake of carbohydratecontaining liquids could help patients to maintain energy levels before they are exposed to surgical trauma, potentially improving clinical outcomes. This study found that the blood glucose level before surgery was significantly higher in the ERAS group than in the conventional group, suggesting that shortening the pre-operative fasting time could help maintain the blood glucose levels near the upper limit of the normal range. Interestingly, the pre-operative consumption of a carbohydrate drink has been reported to decrease not only postoperative insulin resistance[32] but also postoperative nausea[33].

In adult patients, the consumption of normal food on the day of surgery was found to quicken the resumption of bowel function, decrease hospital stay, and reduce the incidence of postoperative complications[21-24]. Furthermore, a study in children reported that early postoperative oral intake of fluid was associated with reductions in postoperative vomiting incidence and opioid use[34]. In the present study, postoperative feeding for patients in the ERAS group was initiated at 1 h after surgery, following a safety evaluation based on the Steward recovery score and water swallow test. In the ERAS group, the water swallow test score was 1-2 in 148 of the 152 patients, with only two children scoring 4 due to the appearance of an irritating cough. Thus, the vast majority of children were able to begin eating semi-liquid food at 1 h after surgery, and the diet was then gradually switched to a normal diet. Notably, the incidence of vomiting did not differ between the two groups, indicating that shortening the duration of postoperative fasting does not increase the risk of nausea and vomiting.

Shortening the pre-operative fasting time is one of the focuses of ERAS. Traditionally, fasting from midnight before an operation has been recommended to minimize the risk of aspiration[5]. Nevertheless, fasting from midnight increases insulin resistance and is not comfortable for the patient[6]. Furthermore, complete gastric emptying occurs within 90 min[7], and the consumption of 300 mL of clear fluid 2 h before surgery does not affect gastric volume or pH[8]. Notably, meta-analyses of randomized controlled trials have found that shortening the pre-operative fluid fasting duration does not increase the risk of adverse outcomes such as aspiration or regurgitation in adults[9] and children[10]. Guidelines from the American Society of Anesthesiologists[11,12] and the European Society of Anaesthesiology[13] recommend that children undergoing surgery should fast from the intake of solid food, non-human milk, and infant formula for ≥ 6 h, breast milk for ≥ 4 h, and clear fluids for ≥ 2 h. The guidelines issued by the Chinese Society of Anesthesiologists are very similar, except that children can be given ≤ 5 mL/kg of clear fluids, up to a maximum volume of 300 mL, within the 2-h period before surgery. Importantly, several studies have indicated that the implementation of these guidelines is suboptimal, with many pediatric patients being fasted for longer time periods than those recommended. For example, a study of children in the United States described pre-operative fasting times of 14.1 ± 6.3 h for food, 9.3 ± 6.6 h for breast milk, and 12.6 ± 5.9 h for clear liquids[14], and comparable results have been reported by studies in Europe[15], Australia[16], and Africa[17]. Importantly, implementing specific strategies to reduce pre-operative fasting times can improve adherence to the current guidelines[18,19].

隨著我國城市化發(fā)展快速發(fā)展，路橋工程建能夠有效緩解城市交通壓力，為我國城市化發(fā)展奠定良好的基礎(chǔ)。同時(shí)，由于施工環(huán)境較為特殊，并且受多種因素的影響，路橋工程在實(shí)際施工中易出現(xiàn)裂縫問題，為市民出行安全帶來嚴(yán)重的不良影響。為此施工企業(yè)應(yīng)對(duì)裂縫問題采取必要的控制措施，以提高路橋工程質(zhì)量，避免交通安全隱患的發(fā)生，保障市民生命財(cái)產(chǎn)安全，保證道路與橋梁正常運(yùn)行。

Although the amount of data collected in this study was small, there are actually many original studies on clear beverages 2 h before surgery and early postoperative eating, and they all support that clear beverages 2 h before surgery are safe and beneficial, and that early eating is safe as long as the patients have recovered from anesthesia and swallowing function evaluation is done[1,36-41]. This study is characterized by the pre-operative personalized fasting and drinking protocol and postoperative innovative use of the water swallow test to assess the swallowing function, which can better solve the problem of uncertain clinical surgery time. In addition, the water swallow test does not increase the workload of the nurses.

This study has some limitations. Although this was a prospective study, we used a method of grouping based on the date of admission rather than randomization in order to avoid interaction between different groups of children in the same ward. Therefore, the findings may be prone to selection bias. Furthermore, the generalizability of the results is not known because the study was conducted at a single hospital, and the sample size was relatively small. Many of the children underwent laparoscopic surgery with CO

insufflation, but the association of abdominal distension with nausea and vomiting was not assessed as a possible confounding factor. In addition, outcomes such as duration of hospital stay and postoperative complications were not evaluated. Large-scale, multicenter studies are needed to verify our findings.

The conventional group had a pre-operative food fasting time of 13.25 ± 2.73 h and a pre-operative liquid fasting time of 12.15 ± 3.02 h, consistent with previous investigations[14-17]. A notable observation in the present study was that although the ERAS group had a shorter pre-operative food fasting time (11.67 ± 3.41 h) and pre-operative liquid fasting time (3.17 ± 0.93 h) than the conventional group, the fasting durations were still longer than the those aimed for by the new strategy. Similar data have been reported by several previous studies describing the implementation of new protocols to shorten perioperative fasting times[18,19,35]. Our multidisciplinary approach to implementation of the new fasting protocols involved an extensive literature review in establishing an evidence-based strategy, training of all relevant staff members, close cooperation between several departments, and a clear explanation of the new protocol and its potential benefits to patients and their parents. A key aspect of this strategy was to estimate the start time of each operation as accurately as possible, as this allowed individualization of the pre-operative fasting protocol for each patient. Although the order of the surgical list did not change in this study, the duration of the individual operations inevitably varied from the estimated values, particularly for surgery that was performed at a different department. Furthermore, the cancellation of operation also had a knock-on effect on the other scheduled operations. These factors inevitably introduced a degree of error that hampered the achievement of optimal fasting times, despite the coordinated efforts of staff members to make appropriate adjustments. Another factor that may have affected pre-operative fasting times is that some children scheduled for morning surgery did not feed at around 6 h before surgery, as advised, because they were asleep.

CONCLUSION

Through multi-disciplinary collaboration and information transformation, it is possible to optimize the fasting and clear fluid drinking process before non-gastrointestinal surgery in children ≥ 3 mo of age. Individualized fasting programs are worthy of clinical promotion. For children with nongastrointestinal surgery, it is also safe and feasible to start early eating after evaluating the recovery from anesthesia and the swallowing function. The water swallow test can be used for postoperative swallowing function evaluation, which is simple, practical, and operable, and has good clinical promotion value.

擬定此研究于2015年1月至2017年12月在我院進(jìn)行,以規(guī)定研究時(shí)段內(nèi)收治的150例急診內(nèi)科患者為研究對(duì)象,隨機(jī)均分對(duì)照組與觀察組,各75例。此次研究經(jīng)醫(yī)學(xué)倫理委員會(huì)審核通過,且所有患者家屬均知情同意。

ARTICLE HIGHLIGHTS

ACKNOWLEDGEMENTS

We would like to thank the hospital leaders for their support. We also thank the director, doctors, and nurses of the Information Department for their help, which allowed the study to be conducted successfully.

1.2 手術(shù)方法 三孔組采用傳統(tǒng)三孔胸腔鏡手術(shù)。單孔組采用單孔胸腔鏡手術(shù)，患者取側(cè)仰臥位，行雙腔氣管插管復(fù)合麻醉，單肺通氣，于患者腋中線第5肋骨間做一切口，長度約為4 cm。逐層切開皮膚及胸壁組織，置入胸腔鏡觀察各器官情況、腫瘤大小及粘連情況后，逐層剝離肺血管、支氣管、肺裂，分離胸腔粘連，再將肺門、肺裂依次解剖，游離肺葉靜脈及動(dòng)脈分支，切除并取出肺葉，閉合支氣管殘端，清掃淋巴結(jié)。

FOOTNOTES

Ying Y and Xu HZ were responsible for the manuscript conceptualization, methodology, resources, software, and supervision; Ying Y and Han ML took charge of data curation, investigation, and project administration; Ying Y was responsible for funding acquisition and manuscript writing, reviewing, and editing; Han ML was responsible for formal analysis, validation, and visualization.

the Health Science and Technology Plan of Zhejiang Province in 2022, No. 2022KY867.

The study was reviewed and approved by the Ethics Committee of the Children’s Hospital, Zhejiang University School of Medicine Institutional Review Board (Approval No. 2018-IRB-095).

藝術(shù)創(chuàng)作活動(dòng)分為3個(gè)環(huán)節(jié)。一是藝術(shù)體驗(yàn)，通過各種心理要素對(duì)審美對(duì)象進(jìn)行觀賞、品味、理解的過程；二是藝術(shù)構(gòu)思，經(jīng)過長時(shí)間的體驗(yàn)使有雛形的作品向更成熟的方向發(fā)展；三是藝術(shù)表現(xiàn)，將自己的構(gòu)思與想法通過技法表現(xiàn)出來。其中藝術(shù)體驗(yàn)與藝術(shù)構(gòu)思非常重要，因?yàn)闆]有生活的體驗(yàn)，藝術(shù)家就不會(huì)有創(chuàng)作的靈感來源；沒有在靈感的基礎(chǔ)上進(jìn)行構(gòu)思，藝術(shù)作品就會(huì)沒有生命。因此藝術(shù)體驗(yàn)和藝術(shù)構(gòu)思非常重要，經(jīng)過這兩個(gè)環(huán)節(jié)才會(huì)產(chǎn)生完美的藝術(shù)作品。

縱觀莫言的“狂歡化”敘事可以發(fā)現(xiàn)，莫言取材于高密東北鄉(xiāng)的歷史與當(dāng)下的生活，在“高密東北鄉(xiāng)”的這個(gè)文學(xué)舞臺(tái)上不斷地書寫著過去先人的故事和當(dāng)下人民的生存狀態(tài)，以“狂歡”為聚焦點(diǎn)，表現(xiàn)出了對(duì)后代的無能與孱弱的批判，透過游戲戲謔的故事情節(jié)傳達(dá)出了深刻嚴(yán)肅的立意企圖。莫言作品中呈現(xiàn)出所謂的“狂歡化”現(xiàn)象正是狂歡化理論與文學(xué)脫節(jié)或者說是不同文化“雜交”的一種異態(tài)、異形產(chǎn)物，但是反思我們中國的文化背景以及新時(shí)期以來文學(xué)發(fā)展的特點(diǎn)，莫言式的“狂歡化敘事”算是一種較為成功的“雜交”產(chǎn)物，在精神、文化方面還是有較為深刻的內(nèi)涵，是值得肯定的。

All children and their guardians provided informed consent for the study.

The authors of this manuscript have no conflicts of interest to disclose.

There is no additional data available.

This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BYNC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is noncommercial. See: https://creativecommons.org/Licenses/by-nc/4.0/

學(xué)生在學(xué)習(xí)議論文的過程中，往往會(huì)把很多史料作為論據(jù)去論證相應(yīng)的觀點(diǎn)，以提高議論文論點(diǎn)的真實(shí)性及可靠性。找準(zhǔn)歷史學(xué)科與語文學(xué)科的結(jié)合點(diǎn),可以激發(fā)學(xué)生創(chuàng)新能力,有效訓(xùn)練學(xué)生的創(chuàng)新思維和。例如，同學(xué)們在寫以“天道酬勤”為話題的議論文時(shí)，經(jīng)常會(huì)用到中外歷史名人勤奮努力的事例作為論據(jù)，比如居里夫人幾十年如一日探求化學(xué)元素鐳的執(zhí)著；蘇秦“頭懸梁，錐刺股”的勤奮；愛迪生一千多次失敗后依舊不餒的努力發(fā)明等等，這些歷史故事不僅讓學(xué)生在寫作文時(shí)運(yùn)用的得心應(yīng)手，而且使學(xué)生不再害怕寫作的同時(shí)，寫出更有涵養(yǎng)的文章。

China

Yan Ying 0000-0002-9041-7859; Hong-Zhen Xu 0000-0001-9485-1268; Meng-Lan Han 0000-0002-9996-5755.

Wu YXJ

Wang TQ

Wu YXJ

1 Okabe T, Terashima H, Sakamoto A. Determinants of liquid gastric emptying: comparisons between milk and isocalorically adjusted clear fluids.

2015 ; 114 : 77 -82 [PMID: 25260696 DOI: 10 .1093 /bja/aeu338 ]

2 Bardram L, Funch-Jensen P, Jensen P, Crawford ME, Kehlet H. Recovery after laparoscopic colonic surgery with epidural analgesia, and early oral nutrition and mobilisation.

1995 ; 345 : 763 -764 [PMID: 7891489 DOI:10 .1016 /s0140 -6736 (95 )90643 -6 ]

3 Ljungqvist O, Scott M, Fearon KC. Enhanced Recovery After Surgery: A Review. JAMA Surg 2017 ; 152 : 292 -298[PMID: 28097305 DOI: 10 .1001 /jamasurg.2016 .4952 ]

4 Parks L, Routt M, De Villiers A. Enhanced Recovery After Surgery. J Adv Pract Oncol 2018 ; 9 : 511 -519 [PMID:31086687 ]

5 Maltby JR. Fasting from midnight--the history behind the dogma. Best Pract Res Clin Anaesthesiol 2006 ; 20 : 363 -378[PMID: 17080690 DOI: 10 .1016 /j.bpa.2006 .02 .001 ]

6 Bilku DK, Dennison AR, Hall TC, Metcalfe MS, Garcea G. Role of preoperative carbohydrate loading: a systematic review.

2014 ; 96 : 15 -22 [PMID: 24417824 DOI: 10 .1308 /003588414 X13824511650614 ]

7 Lobo DN, Hendry PO, Rodrigues G, Marciani L, Totman JJ, Wright JW, Preston T, Gowland P, Spiller RC, Fearon KC.Gastric emptying of three liquid oral preoperative metabolic preconditioning regimens measured by magnetic resonance imaging in healthy adult volunteers: a randomised double-blind, crossover study.

2009 ; 28 : 636 -641 [PMID:19500889 DOI: 10 .1016 /j.clnu.2009 .05 .002 ]

8 Maltby JR, Pytka S, Watson NC, Cowan RA, Fick GH. Drinking 300 mL of clear fluid two hours before surgery has no effect on gastric fluid volume and pH in fasting and non-fasting obese patients.

2004 ; 51 : 111 -115 [PMID:14766684 DOI: 10 .1007 /BF03018767 ]

9 Brady M, Kinn S, Stuart P. Preoperative fasting for adults to prevent perioperative complications.

2003 ; CD004423 [PMID: 14584013 DOI: 10 .1002 /14651858 .cd004423 ]

10 Brady M, Kinn S, Ness V, O'Rourke K, Randhawa N, Stuart P. Preoperative fasting for preventing perioperative complications in children.

2009 ; CD005285 [PMID: 19821343 DOI:10 .1002 /14651858 .CD005285 .pub2 ]

11 Taniguchi H, Sasaki T, Fujita H. Preoperative management of surgical patients by "shortened fasting time": a study on the amount of total body water by multi-frequency impedance method.

2012 ; 9 : 567 -574 [PMID: 22991495 DOI:10 .7150 /ijms.4616 ]

12 American Society of Anesthesiologists Committee. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American Society of Anesthesiologists Committee on Standards and Practice Parameters.

2011 ; 114 : 495 -511 [PMID: 21307770 DOI: 10 .1097 /ALN.0 b013 e3181 fcbfd9 ]

13 Smith I, Kranke P, Murat I, Smith A, O'Sullivan G, S?reide E, Spies C, in't Veld B; European Society of Anaesthesiology.Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology.

2011 ; 28 : 556 -569 [PMID: 21712716 DOI: 10 .1097 /EJA.0 b013 e3283495 ba1 ]

14 Williams C, Johnson PA, Guzzetta CE, Guzzetta PC, Cohen IT, Sill AM, Vezina G, Cain S, Harris C, Murray J. Pediatric fasting times before surgical and radiologic procedures: benchmarking institutional practices against national standards.

2014 ; 29 : 258 -267 [PMID: 24365219 DOI: 10 .1016 /j.pedn.2013 .11 .011 ]

15 Dolgun E, Yavuz M, Ero?lu B, Islamo?lu A. Investigation of Preoperative Fasting Times in Children.

2017 ; 32 : 121 -124 [PMID: 28343637 DOI: 10 .1016 /j.jopan.2014 .12 .005 ]

16 Buller Y, Sims C. Prolonged fasting of children before anaesthesia is common in private practice.

2016 ; 44 : 107 -110 [PMID: 26673596 DOI: 10 .1177 /0310057 X1604400116 ]

17 Abebe WA, Rukewe A, Bekele NA, Stoffel M, Dichabeng MN, Shifa JZ. Preoperative fasting times in elective surgical patients at a referral Hospital in Botswana.

2016 ; 23 : 102 [PMID: 27222691 DOI:10 .11604 /pamj.2016 .23 .102 .8863 ]

18 Dennhardt N, Beck C, Huber D, Sander B, Boehne M, Boethig D, Leffler A, Sümpelmann R. Optimized preoperative fasting times decrease ketone body concentration and stabilize mean arterial blood pressure during induction of anesthesia in children younger than 36 months: a prospective observational cohort study. Paediatr Anaesth 2016 ; 26 : 838 -843 [PMID:27291355 DOI: 10 .1111 /pan.12943 ]

19 Newton RJG, Stuart GM, Willdridge DJ, Thomas M. Using quality improvement methods to reduce clear fluid fasting times in children on a preoperative ward.

2017 ; 27 : 793 -800 [PMID: 28675597 DOI: 10 .1111 /pan.13174 ]

20 Feldheiser A, Aziz O, Baldini G, Cox BP, Fearon KC, Feldman LS, Gan TJ, Kennedy RH, Ljungqvist O, Lobo DN, Miller T, Radtke FF, Ruiz Garces T, Schricker T, Scott MJ, Thacker JK, Ytreb? LM, Carli F. Enhanced Recovery After Surgery(ERAS) for gastrointestinal surgery, part 2 : consensus statement for anaesthesia practice. Acta Anaesthesiol Scand 2016 ;60 : 289 -334 [PMID: 26514824 DOI: 10 .1111 /aas.12651 ]

21 Lassen K, Kjaeve J, Fetveit T, Tran? G, Sigurdsson HK, Horn A, Revhaug A. Allowing normal food at will after major upper gastrointestinal surgery does not increase morbidity: a randomized multicenter trial.

2008 ; 247 : 721 -729[PMID: 18438106 DOI: 10 .1097 /SLA.0 b013 e31815 cca68 ]

22 Lewis SJ, Andersen HK, Thomas S. Early enteral nutrition within 24 h of intestinal surgery versus later commencement of feeding: a systematic review and meta-analysis.

2009 ; 13 : 569 -575 [PMID: 18629592 DOI:10 .1007 /s11605 -008 -0592 -x]

23 Zhuang CL, Ye XZ, Zhang CJ, Dong QT, Chen BC, Yu Z. Early versus traditional postoperative oral feeding in patients undergoing elective colorectal surgery: a meta-analysis of randomized clinical trials.

2013 ; 30 : 225 -232 [PMID:23838894 DOI: 10 .1159 /000353136 ]

24 Charoenkwan K, Matovinovic E. Early versus delayed oral fluids and food for reducing complications after major abdominal gynaecologic surgery.

2014 ; CD004508 [PMID: 25502897 DOI:10 .1002 /14651858 .CD004508 .pub4 ]

25 R?zalar S, ?zba? A. Effect of Early Postoperative Feeding on the Recovery of Children Post Appendectomy.

2018 ; 41 : 131 -140 [PMID: 29596127 DOI: 10 .1097 /SGA.0000000000000279 ]

26 Radke OC, Biedler A, Kolodzie K, Cakmakkaya OS, Silomon M, Apfel CC. The effect of postoperative fasting on vomiting in children and their assessment of pain.

2009 ; 19 : 494 -499 [PMID: 19453581 DOI:10 .1111 /j.1460 -9592 .2009 .02974 .x]

27 Canada NL, Mullins L, Pearo B, Spoede E. Optimizing Perioperative Nutrition in Pediatric Populations.

2016 ; 31 : 49 -58 [PMID: 26703960 DOI: 10 .1177 /0884533615622639 ]

28 Mayhew D, Mendonca V, Murthy BVS. A review of ASA physical status - historical perspectives and modern developments.

2019 ; 74 : 373 -379 [PMID: 30648259 DOI: 10 .1111 /anae.14569 ]

29 Steward DJ. A simplified scoring system for the post-operative recovery room. Can Anaesth Soc J 1975 ; 22 : 111 -113[PMID: 1109700 DOI: 10 .1007 /BF03004827 ]

30 Andersson H, Zarén B, Frykholm P. Low incidence of pulmonary aspiration in children allowed intake of clear fluids until called to the operating suite.

2015 ; 25 : 770 -777 [PMID: 25940831 DOI: 10 .1111 /pan.12667 ]

31 Jayasinghe V, Mahesh PB, Sooriaarachchi C, Jayalath J, Karunarathne W, Liyanage SN. Evaluation of the effect of preoperative over-fasting on post-operative vomiting in children undergoing bone marrow aspiration at a tertiary care setting in Sri Lanka: A prospective cohort study.

2018 ; 62 : 366 -370 [PMID: 29910494 DOI:10 .4103 /ija.IJA_727 _17 ]

32 Gawecka A, Mierzewska-Schmidt M. Tolerance of, and metabolic effects of, preoperative oral carbohydrate administration in children - a preliminary report.

2014 ; 46 : 61 -64 [PMID: 24858963 DOI:10 .5603 /AIT.2014 .0013 ]

33 Tudor-Drobjewski BA, Marhofer P, Kimberger O, Huber WD, Roth G, Triffterer L. Randomised controlled trial comparing preoperative carbohydrate loading with standard fasting in paediatric anaesthesia.

2018 ; 121 : 656 -661 [PMID: 30115264 DOI: 10 .1016 /j.bja.2018 .04 .040 ]

34 Chauvin C, Schalber-Geyer AS, Lefebvre F, Bopp C, Carrenard G, Marcoux L, Mayer JF, Schwaab C, Joshi GP,Diemunsch P. Early postoperative oral fluid intake in paediatric day case surgery influences the need for opioids and postoperative vomiting: a controlled randomized trial?.

2017 ; 118 : 407 -414 [PMID: 28203729 DOI:10 .1093 /bja/aew463 ]

35 Isserman R, Elliott E, Subramanyam R, Kraus B, Sutherland T, Madu C, Stricker PA. Quality improvement project to reduce pediatric clear liquid fasting times prior to anesthesia.

2019 ; 29 : 698 -704 [PMID: 31070840 DOI:10 .1111 /pan.13661 ]

36 Gillis C, Carli F. Promoting Perioperative Metabolic and Nutritional Care. Anesthesiology 2015 ; 123 : 1455 -1472 [PMID:26248016 DOI: 10 .1097 /ALN.0000000000000795 ]

37 Thomas M, Morrison C, Newton R, Schindler E. Consensus statement on clear fluids fasting for elective pediatric general anesthesia.

2018 ; 28 : 411 -414 [PMID: 29700894 DOI: 10 .1111 /pan.13370 ]

38 Jiang W, Liu X, Liu F, Huang S, Yuan J, Shi Y, Chen H, Zhang J, Lu C, Li W, Geng Q, Xu X, Tang W. Safety and benefit of pre-operative oral carbohydrate in infants: a multi-center study in China.

2018 ; 27 : 975 -979 [PMID:30272844 DOI: 10 .6133 /apjcn.052018 .08 ]

39 Qin Q, Wang Z, Dong X. [Study of early feeding after general anesthesia in school-age children after orthopaedic surgery].

2018 ; 53 : 399 -403 [DOI: 10 .1097 /00000658 -900000000 -95320 ]

40 Dalir Z, Manzari ZS, Kareshki H, Heydari A. Caregiving Strategies in Families of Children with Congenital Heart Disease:A Qualitative Study.

2021 ; 26 : 60 -67 [PMID: 33954100 DOI: 10 .4103 /ijnmr.IJNMR_19 _20 ]

41 Zhong J, Zhang S, Yang J. [Clinical study on early eating after non-gastrointestinal surgery in children].

2018 ; 17 : 48 -50 [DOI: 10 .7748 /ns.16 .8 .10 .s30 ]