Department of Anesthesiology, UCSD Center for Pain Medicine, University of California-San Diego, 9300 Campus Point Drive, La Jolla, CA 92037-7651, USA.
Reg Anesth Pain Med. 2011 Jan-Feb;36(1):26-31. doi: 10.1097/AAP.0b013e318203069b.
Although the efficacy of single-injection supraclavicular nerve blocks is well established, no controlled study of continuous supraclavicular blocks is available, and their relative risks and benefits remain unknown. In contrast, the analgesia provided by continuous infraclavicular nerve blocks has been validated in randomized controlled trials. We therefore compared supraclavicular with infraclavicular perineural local anesthetic infusion following distal upper-extremity surgery.
Preoperatively, subjects were randomly assigned to receive a brachial plexus perineural catheter in either the infraclavicular or supraclavicular location using an ultrasound-guided nonstimulating catheter technique. Postoperatively, subjects were discharged home with a portable pump (400-mL reservoir) infusing 0.2% ropivacaine (basal rate of 8 mL/hr; 4-mL bolus dose; 30-min lockout interval). Subjects were followed up by telephone on an outpatient basis. The primary outcome was the average pain score on the day after surgery.
Sixty subjects were enrolled, with 31 and 29 randomized to receive an infraclavicular and supraclavicular catheter, respectively. All perineural catheters were successfully placed per protocol. Because of protocol violations and missing data, an intention-to-treat analysis was not used; rather, only subjects with catheters in situ and whom we were able to contact were included in the analyses. The day after surgery, subjects in the infraclavicular group reported average pain as median of 2.0 (10th-90th percentiles, 0.5-6.0) compared with 4.0 (10th-90th percentiles, 0.6-7.7) in the supraclavicular group (P = 0.025). Similarly, least pain scores (numeric rating scale) on postoperative day 1 were lower in the infraclavicular group compared with the supraclavicular group (0.5 [10th-90th percentiles, 0.0-3.5] vs 2.0 [10th-90th percentiles, 0.0-4.7], respectively; P = 0.040). Subjects in the infraclavicular group required less rescue oral analgesic (oxycodone, in milligrams) for breakthrough pain in the 18 to 24 hrs after surgery compared with the supraclavicular group (0.0 [10th-90th percentiles, 0.0-5.0] vs 5.0 [10th-90th percentiles, 0.0-15.0], respectively; P = 0.048). There were no statistically significant differences in other secondary outcomes.
A local anesthetic infusion via an infraclavicular perineural catheter provides superior analgesia compared with a supraclavicular perineural catheter.
尽管单次锁骨上神经阻滞的疗效已得到充分证实，但尚无连续锁骨上阻滞的对照研究，其相对风险和益处仍不清楚。相比之下，连续锁骨下神经阻滞的镇痛作用已在随机对照试验中得到验证。因此，我们比较了上肢远端手术后锁骨上和锁骨下入路的外周神经局部麻醉输注。
术前，受试者随机分配到使用超声引导非刺激导管技术的锁骨下或锁骨上臂丛神经周围导管。术后，受试者在家中使用便携式输液泵（400 毫升储液器）输注 0.2%罗哌卡因（基础输注率为 8 毫升/小时；4 毫升推注剂量；30 分钟锁定间隔）。通过门诊电话对受试者进行随访。主要结局为术后第 1 天的平均疼痛评分。
共纳入 60 例受试者，其中 31 例和 29 例分别随机分配到锁骨下入路和锁骨上入路导管组。所有外周神经导管均按方案成功放置。由于违反方案和数据缺失，未进行意向治疗分析；相反，仅纳入导管在位且可联系到的受试者进行分析。术后第 1 天，锁骨下组报告的平均疼痛中位数为 2.0（10 至 90 百分位，0.5-6.0），而锁骨上组为 4.0（10 至 90 百分位，0.6-7.7）（P=0.025）。同样，锁骨下组术后第 1 天的最低疼痛评分（数字评分量表）也低于锁骨上组（分别为 0.5[10 至 90 百分位，0.0-3.5]和 2.0[10 至 90 百分位，0.0-4.7]；P=0.040）。与锁骨上组相比，锁骨下组在术后 18 至 24 小时内用于缓解突破性疼痛的口服阿片类药物（羟考酮，毫克）需求更少（分别为 0.0[10 至 90 百分位，0.0-5.0]和 5.0[10 至 90 百分位，0.0-15.0]；P=0.048）。其他次要结局无统计学差异。
与锁骨上外周神经导管相比，锁骨下入路外周神经局部麻醉输注可提供更好的镇痛效果。
