Delvecchio L, Bettinelli S, Klersy C, Allegri M, Cavalloro F, Braschi A
Anesthesia and Intensive Care Service, Città di Pavia Clinic, Pavia, Italy.
Minerva Anestesiol. 2008 Mar;74(3):69-76.
Ample evidence is now available showing the analgesic efficacy of a local anaesthetic-opioid combination to control postoperative pain. This retrospective study aimed to analyze any improvement in the ability of sufentanyl, a highly lipophilic opioid, and morphine, a poorly lipophilic opioid, to control postoperative pain at rest and in motion when combined with ropivacaine 0.2%.
In this retrospective study, 171 patients who underwent major abdominal or urological surgery were evaluated. The therapeutic protocol provided for continuous epidural perfusion (5 mL/h) of ropivacaine 0.2% + morphine 0.03 mg/mL or ropivacaine 0.2% + sufentanyl 0.75 mug/mL for 48 h. Pain at rest (numeric rate scale, NRS) and in motion (NRSm) was evaluated by means of the NRS upon waking and at 3, 6, 12, 24, 36, and 48 hs, providing for the administration of a rescue dose if NRS >4. The overall analgesic effect was evaluated by comparing the area under the NRS curve (AUC) of both treatments using the Mann Whitney U test. Any differences between treatments in terms of NRS and NRSm in time were evaluated using ordinal logistic regression. To compare the frequency of patients who reported NRS >4 at least once during the follow-up period, logistic regression was used. Finally, the frequency of patients who required at least one additional drug or reported side effects was compared using Fisher's exact test.
While both groups showed a comparable overall analgesic effect, the baseline values of NRS and NRSm were lower for the sufentanyl group (P<0.001), perhaps as a result of its quicker onset due to higher lipophilicity. No statistically significant difference was observed in the frequency of patients requiring administration of an additional analgesic drug (P=0.136) or in the incidence of complications (P=0.799).
Both protocols providing a combination of a local anaesthetic and an opioid demonstrated an excellent safety and efficacy profile. The differing lipophilicity of the opioids did not cause any clinically or statistically significant differences in terms of efficacy or safety, other than a reduced onset time of sufentanyl, ensuring better pain control upon waking. We therefore believe that morphine should be the standard opioid for neuraxial use, although these results must be confirmed in the setting of a randomized controlled clinical trial.
目前有充分证据表明局部麻醉药与阿片类药物联合使用对控制术后疼痛具有镇痛效果。这项回顾性研究旨在分析高亲脂性阿片类药物舒芬太尼和低亲脂性阿片类药物吗啡与0.2%罗哌卡因联合使用时，在控制静息和活动时术后疼痛能力方面的任何改善情况。
在这项回顾性研究中，对171例行腹部或泌尿外科大手术的患者进行了评估。治疗方案为持续硬膜外灌注（5毫升/小时）0.2%罗哌卡因+0.03毫克/毫升吗啡或0.2%罗哌卡因+0.75微克/毫升舒芬太尼，持续48小时。通过数字评分量表（NRS）在醒来时以及术后3、6、12、24、36和48小时评估静息时疼痛（NRS）和活动时疼痛（NRSm），若NRS>4则给予补救剂量。使用曼-惠特尼U检验比较两种治疗方法的NRS曲线下面积（AUC）来评估总体镇痛效果。使用有序逻辑回归评估治疗方法在不同时间的NRS和NRSm方面的差异。为比较随访期间至少有一次NRS>4的患者频率，使用逻辑回归。最后，使用Fisher精确检验比较需要至少一种额外药物或报告有副作用的患者频率。
虽然两组总体镇痛效果相当，但舒芬太尼组的NRS和NRSm基线值较低（P<0.001），这可能是由于其较高亲脂性导致起效更快。在需要额外给予镇痛药物的患者频率（P=0.136）或并发症发生率（P=0.799）方面未观察到统计学显著差异。
两种局部麻醉药与阿片类药物联合使用的方案均显示出良好的安全性和有效性。除了舒芬太尼起效时间缩短外，阿片类药物不同的亲脂性在疗效或安全性方面未引起任何临床或统计学显著差异，从而确保醒来时能更好地控制疼痛。因此，我们认为吗啡应作为神经轴使用的标准阿片类药物，尽管这些结果必须在随机对照临床试验中得到证实。
