Hill Steven E, Keller Rebecca A, Stafford-Smith Mark, Grichnik Katherine, White William D, D'Amico Thomas A, Newman Mark F
Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
Anesthesiology. 2006 May;104(5):1047-53. doi: 10.1097/00000542-200605000-00022.
Although video-assisted thoracoscopic surgery for pulmonary resection is increasingly chosen over thoracotomy, the optimal analgesia regimen for thoracoscopy is unknown. The purpose of this trial was to compare the efficacy of analgesia from preoperative bupivacaine paravertebral nerve blockade with that from placebo injections.
Eighty adult patients undergoing unilateral thoracoscopic procedures were enrolled in a prospective, double-blinded, randomized clinical trial of preoperative, multilevel, single-dose paravertebral nerve blockade. Patients received six paravertebral injections with 5 ml of either 0.5% bupivacaine with 0.0005% epinephrine (treated, n = 40) or preservative-free saline (control, n = 40). Cumulative weight-adjusted intraoperative fentanyl and postoperative patient-controlled morphine usage, visual analog pain scores, and spirometry were used to compare efficacy of analgesia between groups.
The treated group received significantly less intraoperative fentanyl compared with the control group (P = 0.003) and had a 31% smaller cumulative patient-controlled morphine dose (P = 0.03) in the 6 h after block placement. Within 6 h, treated patients also reported lower maximum pain scores (P = 0.02) and demonstrated less pain score variability (P = 0.01). No statistically significant difference in cumulative morphine usage existed at 12 or 18 h after block placement. No significant difference in spirometry, cortisol levels, or cytokine production was found between treatments.
Single-dose paravertebral nerve blockade with bupivacaine is effective in reducing pain after thoracoscopic surgery, but only during the first 6 h after nerve blockade. Because of the limited duration of effect with currently available local anesthetic agents, the current data suggest that, at present, this technique is not indicated in the setting of thoracoscopic surgery.
尽管与开胸手术相比，越来越多的人选择电视辅助胸腔镜手术进行肺切除，但胸腔镜手术的最佳镇痛方案尚不清楚。本试验的目的是比较术前布比卡因椎旁神经阻滞与安慰剂注射的镇痛效果。
80例接受单侧胸腔镜手术的成年患者纳入一项前瞻性、双盲、随机临床试验，进行术前多节段单剂量椎旁神经阻滞。患者接受6次椎旁注射，每次注射5 ml 0.5%布比卡因加0.0005%肾上腺素（治疗组，n = 40）或无防腐剂生理盐水（对照组，n = 40）。使用累积体重调整的术中芬太尼和术后患者自控吗啡用量、视觉模拟疼痛评分和肺活量测定来比较两组间的镇痛效果。
与对照组相比，治疗组术中芬太尼用量显著减少（P = 0.003），在阻滞放置后6小时内，患者自控吗啡累积剂量小31%（P = 0.03）。在6小时内，治疗组患者的最大疼痛评分也较低（P = 0.02），疼痛评分变异性较小（P = 0.01）。在阻滞放置后12或18小时，累积吗啡用量无统计学显著差异。治疗之间在肺活量测定、皮质醇水平或细胞因子产生方面未发现显著差异。
布比卡因单剂量椎旁神经阻滞可有效减轻胸腔镜手术后的疼痛，但仅在神经阻滞后的前6小时有效。由于目前可用局部麻醉剂的作用持续时间有限，目前的数据表明，目前该技术不适用于胸腔镜手术。
