Barczyński M, Konturek A, Herman R M
Department of General Surgery, Jagiellonian University College of Medicine, 37 Pradnicka Street, 31-202 Kraków, Poland.
Surg Endosc. 2006 Jul;20(7):1088-93. doi: 10.1007/s00464-005-0458-1. Epub 2006 May 13.
This study aimed to evaluate the optimal timing of preemptive analgesia with bupivacaine peritoneal instillation in a prospective, randomized, double-blind, placebo-controlled trial.
In this study, 120 patients qualified for laparoscopic cholecystectomy were randomized to four groups. Group A received 2 mg/kg of bupivacaine in 200 ml of normal saline before creation of pneumoperitoneum. Group B received 2 mg/kg of bupivacaine in 200 ml of normal saline after creation of pneumoperitoneum. Group C received 200 ml of normal saline before creation of pneumoperitoneum. Group D received 200 ml of normal saline after creation of pneumoperitoneum. Local wound infiltration with bupivacaine was used before skin incisions. The primary end points of the study were postoperative pain intensity on a visual analog scale and incidence of shoulder tip pain. The secondary end points included the latency of nurse-controlled analgesia activation, the analgesia request rate, and analgesic consumption.
Significantly lower visual analog scores were observed in group A versus groups C and B versus group D during the initial 48 and 24 h, respectively. The patients in group A versus group B reported significantly lower pain at 4 h (p < 0.001) and 8 h (p = 0.003) postoperatively, but the difference was not significant after 12, 24, and 48 h. None of the group A patients reported shoulder tip pain, whereas it was reported by 3 patients in group B, 6 patients in group C, and 7 patients in group D (p < 0.01). The latency of nurse-controlled analgesia activation was 426.8 +/-57.2 min in group A, as compared with 307 +/- 39.8 min in group B, 109.3 +/- 51 min in group C, and 109 +/- 46.5 min in group D (p < 0.001). A significantly lower analgesia request rate was observed in group A versus C, as compared with group B versus D, throughout the entire study period (p < 0.05).
Preemptive analgesia with bupivacaine peritoneal instillation is much more effective for pain relief if used before creation of pneumoperitoneum. Although the effect of bupivacaine peritoneal instillation is also noticeable when used after creation of pneumoperitoneum, it confers significantly lower benefits.
本研究旨在通过一项前瞻性、随机、双盲、安慰剂对照试验，评估布比卡因腹腔内滴注进行超前镇痛的最佳时机。
本研究中，120例符合腹腔镜胆囊切除术条件的患者被随机分为四组。A组在建立气腹前，于200ml生理盐水中给予2mg/kg布比卡因。B组在建立气腹后，于200ml生理盐水中给予2mg/kg布比卡因。C组在建立气腹前给予200ml生理盐水。D组在建立气腹后给予200ml生理盐水。在皮肤切口前使用布比卡因进行局部伤口浸润。本研究的主要终点是视觉模拟量表上的术后疼痛强度和肩峰下疼痛的发生率。次要终点包括患者自控镇痛启动的潜伏期、镇痛需求率和镇痛药物消耗量。
在最初的48小时和24小时内，分别观察到A组与C组、B组与D组相比，视觉模拟评分显著更低。A组与B组患者在术后4小时（p<0.001）和8小时（p = 0.003）报告的疼痛显著更低，但在12、24和48小时后差异不显著。A组患者均未报告肩峰下疼痛，而B组有3例、C组有6例、D组有7例报告了肩峰下疼痛（p<0.01）。A组患者自控镇痛启动的潜伏期为426.8±57.2分钟，而B组为307±39.8分钟，C组为109.3±51分钟，D组为109±46.5分钟（p<0.001）。在整个研究期间，观察到A组与C组相比，镇痛需求率显著低于B组与D组（p<0.05）。
如果在建立气腹前使用布比卡因腹腔内滴注进行超前镇痛，对缓解疼痛更有效。虽然在建立气腹后使用布比卡因腹腔内滴注的效果也很明显，但带来的益处显著更低。
