Department of Anesthesiology, Hepatobiliary Service, Centre Hospitalier de l'Université de Montréal-Hôpital St-Luc, Montreal, Quebec, Canada.
Reg Anesth Pain Med. 2010 Jan-Feb;35(1):51-6. doi: 10.1097/AAP.0b013e3181c6f8f2.
Continuous epidural analgesia may be considered in liver resection but is often avoided because of possible coagulopathies and the risk of epidural hematoma in the postoperative period. On the other hand, there is no coagulation defect during the surgery. Effective prevention of postoperative pain may require continuous sensory ablation throughout the surgery event.
A prospective, randomized, double-blind study was conducted to evaluate the efficacy of intraoperative epidural anesthesia on postoperative morphine consumption via patient-controlled analgesia after liver surgery in 2 groups of patients. One group (epidural) received, intraoperatively, thoracic epidural bupivacaine perfusion (0.5% at 3 mL/hr) added to preoperative intrathecal morphine (0.5 mg) and fentanyl (15 microg). The other group (placebo) was administered the same intrathecal narcotics but with a sham epidural. Forty-four patients scheduled for major liver resection (> or =2 segments) were recruited. Patient-controlled analgesia morphine consumption, pain at rest and with movement, sedation, nausea, pruritus, and respiratory frequency were evaluated at 6, 9, 12, 18, 24, 36, and 48 hrs after intrathecal morphine injection.
Patients in the placebo group consumed twice as much morphine during each time interval than patients in the epidural group (at 48 hrs: 123 [SD, 46] vs 59 [SD, 25] mg; P < 0.0001). Pain evaluation on visual analog scale at rest and on movement was lower in the epidural group (P = 0.017 and P = 0.037).
Intraoperative thoracic epidural infusion of bupivacaine, added to intrathecal morphine, decreased postoperative morphine consumption with better pain relief compared with the placebo.
肝切除术中可考虑使用连续硬膜外镇痛，但由于可能存在凝血功能障碍以及术后硬膜外血肿的风险，通常会避免使用。另一方面，手术过程中不存在凝血功能缺陷。为了有效预防术后疼痛，可能需要在整个手术过程中持续进行感觉神经阻滞。
本前瞻性、随机、双盲研究评估了两组患者术中硬膜外麻醉对术后经患者自控镇痛（PCIA）使用吗啡的影响。一组（硬膜外组）术中接受胸段硬膜外布比卡因（0.5%，3ml/h）输注，同时给予术前鞘内吗啡（0.5mg）和芬太尼（15μg）。另一组（对照组）给予相同的鞘内麻醉药物，但给予假硬膜外麻醉。共纳入 44 例拟行肝切除术（>或=2 个肝段）的患者。术后 6、9、12、18、24、36 和 48 小时，通过 PCIA 评估吗啡消耗量、静息和运动时疼痛、镇静、恶心、瘙痒和呼吸频率。
对照组每个时间间隔的吗啡消耗量均是硬膜外组的两倍（48 小时时：123[SD，46]mg 比 59[SD，25]mg；P<0.0001）。硬膜外组的静息和运动时疼痛视觉模拟评分（VAS）较低（P=0.017 和 P=0.037）。
与对照组相比，鞘内吗啡联合术中胸段硬膜外布比卡因输注可减少术后吗啡用量，且镇痛效果更好。
