Luketich James D, Land Stephanie R, Sullivan Erin A, Alvelo-Rivera Miguel, Ward Julie, Buenaventura Percival O, Landreneau Rodney J, Hart Lee A, Fernando Hiran C
Division of Thoracic and Foregut Surgery, Cancer Institute, University of Pittsburgh, Pittsburgh, Pennsylvania, USA.
Ann Thorac Surg. 2005 Jun;79(6):1845-9; discussion 1849-50. doi: 10.1016/j.athoracsur.2004.10.055.
Pain control is an important issue after thoracotomy. Ideal methods should have a high success rate, with easy implementation and minimal complications. Debate exists over the optimal pain control method. This randomized trial was designed to compare epidural (EPI) and intercostal nerve catheter with patient-controlled analgesia (ICN-PCA) for pain control after thoracotomy.
The study included 124 randomized patients; 91 had sufficient data for analysis (44 EPI, 47 ICN-PCA). The primary endpoint was pain measurement using a composite of a visual analogue scale, numerical rating, and categorical rating. A second endpoint was the success rate of each method. Pulmonary function tests, antibiotics, intensive care unit (ICU), and hospital days, and use of nonprotocol pain medications were also compared.
There were 12 pain observations per patient (90% completed on days 1 to 5). The pain composite revealed an average postoperative pain score of 2.4 on a scale from 0 (no pain) to 10 (worst pain). There was no difference between the groups. Failures of the planned method of analgesia included 9 in the EPI group and 4 in the ICN group (p = 0.23). Another 20 patients were excluded (no difference between groups) due to unsuspected mediastinal metastases precluding thoracotomy (n = 13), and other miscellaneous factors precluding follow-up (n = 7). The EPI group had an increased number of urinary catheter days (2.5 days vs 1.7, p = 0.002) and increased narcotic supplements (p = 0.03) compared with ICN. Mean ICU days (0.9) and hospital days (6.2) were similar for both groups, and there were no differences in arrhythmias, pneumonias, transfusions, and antibiotic use. Significant differences were seen (p = 0.001) between preoperative and postoperative pulmonary function tests in both groups. However, there were no differences in pulmonary function when the groups were compared with each other.
Satisfactory pain control was achieved after thoracotomy using either EPI or ICN-PCA. The ICN-PCA achieved equivalent pain control compared with EPI, and was placed by the surgeon with no delays in surgery, and demonstrated a decreased requirement for Foley catheter duration.
开胸术后的疼痛控制是一个重要问题。理想的方法应具有高成功率、易于实施且并发症最少。关于最佳疼痛控制方法存在争议。本随机试验旨在比较硬膜外麻醉（EPI）和肋间神经导管联合患者自控镇痛（ICN - PCA）用于开胸术后的疼痛控制。
该研究纳入了124例随机分组的患者；91例有足够数据用于分析（44例EPI，47例ICN - PCA）。主要终点是使用视觉模拟量表、数字评分和分类评分综合评估的疼痛测量。第二个终点是每种方法的成功率。还比较了肺功能测试、抗生素使用情况、重症监护病房（ICU）住院天数、住院总天数以及非方案规定的止痛药物使用情况。
每位患者有12次疼痛观察记录（90%在第1至5天完成）。疼痛综合评分显示术后平均疼痛评分为2.4分（范围从0分（无疼痛）至10分（最剧烈疼痛））。两组之间无差异。计划镇痛方法的失败情况为EPI组9例，ICN组4例（p = 0.23）。另外20例患者被排除（两组间无差异），原因是意外的纵隔转移导致无法进行开胸手术（n = 13），以及其他杂项因素导致无法随访（n = 7）。与ICN组相比，EPI组导尿天数增加（2.5天对1.7天，p = 0.002），麻醉补充剂使用增加（p = 0.03）。两组的平均ICU住院天数（0.9天）和住院天数（6.2天）相似，在心律失常、肺炎、输血和抗生素使用方面无差异。两组术前和术后肺功能测试均存在显著差异（p = 0.001）。然而，两组之间比较肺功能无差异。
开胸术后使用EPI或ICN - PCA均可实现满意的疼痛控制。ICN - PCA与EPI相比能实现等效的疼痛控制，由外科医生放置，不延迟手术，且导尿管留置时间需求减少。
