Brown Daniel R, Hofer Roger E, Patterson David E, Fronapfel Paul J, Maxson Pamela M, Narr Bradly J, Eisenach John H, Blute Michael L, Schroeder Darrell R, Warner David O
Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
Anesthesiology. 2004 Apr;100(4):926-34. doi: 10.1097/00000542-200404000-00024.
Previous studies suggest that intraoperative anesthetic care may influence postoperative pain and recovery from surgery. The authors tested the hypothesis that the addition of intrathecal analgesia to general anesthesia would improve long-term functional status and decrease pain in patients undergoing radical retropubic prostatectomy.
One hundred patients received either general anesthesia supplemented with intravenous fentanyl or general anesthesia preceded by intrathecal administration of bupivacaine (15 mg), clonidine (75 microg), and morphine (0.2 mg). Patients and providers were masked to treatment assignment. All patients received multimodal pain management postoperatively. Primary outcomes included pain and functional status over the first 12 postoperative weeks.
Patients receiving intrathecal analgesia required more intravenous fluids and vasopressors intraoperatively. Pain was well controlled throughout the study (mean numerical pain scores < 3 in both groups at all times studied). Intrathecal analgesia decreased pain and supplemental intravenous morphine use over the first postoperative day but increased the frequency of pruritus. Pain and functional status after discharge from the hospital did not differ between groups. Intrathecal analgesia significantly decreased the duration of hospital stay (from 2.8 +/- 2.0 to 2.1 +/- 0.5 days; P < 0.01) as a result of five patients in the control group who stayed in the hospital more than 3 days.
The benefits of improved immediate analgesia and decreased morphine requirements resulting from intrathecal analgesia must be weighed against factors such as pruritus, increased intraoperative requirement for fluids and vasopressors, and resources needed to implement this modality. Further studies are needed to determine the significance of the decrease in duration of hospital stay.
先前的研究表明，术中麻醉护理可能会影响术后疼痛及手术恢复情况。作者检验了以下假设：在全身麻醉基础上加用鞘内镇痛可改善耻骨后根治性前列腺切除术患者的长期功能状态并减轻疼痛。
100例患者分别接受静脉注射芬太尼辅助全身麻醉或鞘内注射布比卡因（15毫克）、可乐定（75微克）和吗啡（0.2毫克）后再行全身麻醉。患者及医护人员均对治疗分配情况不知情。所有患者术后均接受多模式疼痛管理。主要结局指标包括术后前12周的疼痛及功能状态。
接受鞘内镇痛的患者术中需要更多的静脉输液及血管升压药。在整个研究过程中疼痛均得到良好控制（在所有研究时间点两组的平均数字疼痛评分均<3）。鞘内镇痛在术后第一天可减轻疼痛并减少静脉补充吗啡的用量，但会增加瘙痒的发生率。两组患者出院后的疼痛及功能状态并无差异。由于对照组有5例患者住院时间超过3天，鞘内镇痛显著缩短了住院时间（从2.8±2.0天降至2.1±0.5天；P<0.01）。
鞘内镇痛带来的即时镇痛改善及吗啡需求量减少的益处，必须与瘙痒、术中对液体及血管升压药需求增加以及实施这种麻醉方式所需资源等因素相权衡。需要进一步研究以确定住院时间缩短的意义。
