Department of Anesthesiology, American University of Beirut-Medical Center, P.O. Box 11-0236, Beirut, Lebanon.
Anesth Analg. 2010 Aug;111(2):475-81. doi: 10.1213/ANE.0b013e3181e30b9f. Epub 2010 May 20.
BACKGROUND: Ultrasound-guided transversus abdominis plane block is an effective method of providing pain relief after cesarean delivery. Neuraxial morphine is currently the "gold standard" treatment for pain after cesarean delivery. In this study we tested the hypothesis that subarachnoid morphine would provide more prolonged and superior analgesia than would transversus abdominis plane block in patients undergoing elective cesarean delivery. METHODS: In this prospective, double-blind study, 57 patients were randomly assigned to receive either subarachnoid morphine (group SAM; n = 28) or transversus abdominis plane block (group TAP; n = 29). Patients received bupivacaine spinal anesthesia combined with morphine 0.2 mg in group SAM and received saline in group TAP. At the end of surgery, bilateral transversus abdominis plane block was performed using saline in group SAM or using bupivacaine 0.375% plus epinephrine 5 microg/mL in group TAP with 20 mL on each side. Postoperative analgesia for the first 24 hours consisted of scheduled rectal diclofenac and IV paracetamol; breakthrough pain was treated with IV tramadol. For the next 24 hours, scheduled rectal diclofenac was given; oral paracetamol and IV tramadol were administered upon patient request. Patients were assessed postoperatively in the postanesthesia care unit (time 0 hours) and at 2, 4, 6, 12, 24, 36, and 48 hours. The primary outcome measure was the time to first analgesic request. RESULTS: Median (range) time to first analgesic request was longer in group SAM than in group TAP [8 (2-36) hours versus 4 (0.5 to 29) hours (P = 0.005)]. Median (range) number of tramadol doses received between 0 and 12 hours was 0 (0-1) in group SAM versus 0 (0-2) in group TAP (P = 0.03). Postoperative visceral pain scores at rest and on movement during first the 4 hours were lower in group SAM than in group TAP, but were not different at any other time points. The incidence of moderate to severe nausea was higher in group SAM than in group TAP [13/28 (46%) versus 5/29 (17%) (P = 0.02)]. More patients developed pruritus requiring treatment in group SAM than in group TAP [(11/28 (39%) versus none (0%) (P < 0.001)]. CONCLUSION: As part of a multimodal analgesic regimen, subarachnoid morphine provided superior analgesia when compared with ultrasound-guided transversus abdominis plane block after cesarean delivery, yet at the cost of increased side effects.
背景：超声引导腹横肌平面阻滞是一种有效的剖宫产术后止痛方法。椎管内吗啡目前是剖宫产术后疼痛的“金标准”治疗方法。在这项研究中，我们假设蛛网膜下腔吗啡会比剖宫产术中接受腹横肌平面阻滞的患者提供更持久和更好的镇痛效果。
方法：在这项前瞻性、双盲研究中，57 名患者被随机分配接受蛛网膜下腔吗啡（SAM 组；n = 28）或腹横肌平面阻滞（TAP 组；n = 29）。SAM 组患者接受布比卡因脊髓麻醉加吗啡 0.2mg，TAP 组患者接受生理盐水。手术结束时，SAM 组双侧腹横肌平面阻滞采用生理盐水，TAP 组采用布比卡因 0.375%加肾上腺素 5μg/mL，每侧 20mL。术后前 24 小时采用直肠双氯芬酸和静脉扑热息痛进行术后镇痛；爆发性疼痛采用静脉曲马多治疗。接下来的 24 小时，给予直肠双氯芬酸；口服扑热息痛和静脉曲马多按需给予。术后患者在麻醉后恢复室（0 小时）和 2、4、6、12、24、36 和 48 小时进行评估。主要观察指标为首次镇痛请求时间。
结果：SAM 组首次镇痛请求时间长于 TAP 组[8（2-36）小时比 4（0.5-29）小时（P = 0.005）]。SAM 组 0-12 小时内曲马多剂量中位数（范围）为 0（0-1），TAP 组为 0（0-2）（P = 0.03）。SAM 组在前 4 小时内静息和运动时的术后内脏疼痛评分低于 TAP 组，但在其他任何时间点均无差异。SAM 组中度至重度恶心发生率高于 TAP 组[13/28（46%）比 5/29（17%）（P = 0.02）]。与 TAP 组相比，SAM 组需要治疗的瘙痒发生率更高[11/28（39%）比无（0%）（P<0.001）]。
结论：作为多模式镇痛方案的一部分，与剖宫产术中接受腹横肌平面阻滞相比，蛛网膜下腔吗啡提供了更好的镇痛效果，但副作用增加。
Anesthesiol Res Pract. 2025-3-16
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