Ilfeld Brian M, Madison Sarah J, Suresh Preetham J, Sandhu Navparkash S, Kormylo Nicholas J, Malhotra Nisha, Loland Vanessa J, Wallace Mark S, Proudfoot James A, Morgan Anya C, Wen Cindy H, Wallace Anne M
From the *Department of Anesthesiology, †Clinical Translational Research Institute, ‡Department of Ophthalmology, and §Department of Surgery, University of California San Diego, San Diego, CA.
Reg Anesth Pain Med. 2014 Mar-Apr;39(2):89-96. doi: 10.1097/AAP.0000000000000035.
BACKGROUND: We aimed to determine with this randomized, triple-masked, placebo-controlled study if benefits are afforded by adding a multiple-day, ambulatory, continuous ropivacaine paravertebral nerve block to a single-injection ropivacaine paravertebral block after mastectomy. METHODS: Preoperatively, 60 subjects undergoing unilateral (n = 24) or bilateral (n = 36) mastectomy received either unilateral or bilateral paravertebral perineural catheter(s), respectively, inserted between the third and fourth thoracic transverse process(es). All subjects received an initial bolus of ropivacaine 0.5% (15 mL) via the catheter(s). Subjects were randomized to receive either perineural ropivacaine 0.4% or normal saline using portable infusion pump(s) [5 mL/h basal; 300 mL reservoir(s)]. Subjects remained hospitalized for at least 1 night and were subsequently discharged home where the catheter(s) were removed on postoperative day (POD) 3. Subjects were contacted by telephone on PODs 1, 4, 8, and 28. The primary end point was average pain (scale, 0-10) queried on POD 1. RESULTS: Average pain queried on POD 1 for subjects receiving perineural ropivacaine (n = 30) was a median (interquartile) of 2 (0-3), compared with 4 (1-5) for subjects receiving saline (n = 30; 95% confidence interval difference in medians, -4.0 to -0.3; P = 0.021]. During this same period, subjects receiving ropivacaine experienced a lower severity of breakthrough pain (5 [3-6] vs 7 [5-8]; P = 0.046) as well. As a result, subjects receiving perineural ropivacaine experienced less pain-induced physical and emotional dysfunction, as measured with the Brief Pain Inventory (lower score = less dysfunction): 14 (4-37) versus 57 (8-67) for subjects receiving perineural saline (P = 0.012). For the subscale that measures the degree of interference of pain on 7 domains, such as general activity and relationships, subjects receiving perineural saline reported a median score 10 times higher (more dysfunction) than those receiving ropivacaine (3 [0-24] vs 33 [0-44]; P = 0.035). In contrast, after infusion discontinuation, there were no statistically significant differences detected between treatment groups. CONCLUSIONS: After mastectomy, adding a multiple-day, ambulatory, continuous ropivacaine infusion to a single-injection ropivacaine paravertebral nerve block results in improved analgesia and less functional deficit during the infusion. However, no benefits were identified after infusion discontinuation.
背景：我们旨在通过这项随机、三盲、安慰剂对照研究，确定在乳房切除术后单次注射罗哌卡因椎旁阻滞基础上，增加多日、门诊、持续罗哌卡因椎旁神经阻滞是否有益。 方法：术前，60例接受单侧（n = 24）或双侧（n = 36）乳房切除术的受试者分别接受单侧或双侧椎旁神经周围导管插入，导管置于第三和第四胸椎横突之间。所有受试者均通过导管接受初始剂量的0.5%罗哌卡因（15 mL）推注。受试者被随机分配使用便携式输液泵接受0.4%神经周围罗哌卡因或生理盐水[基础输注速度5 mL/h；储液器容量300 mL]。受试者至少住院1晚，随后出院回家，术后第3天拔除导管。在术后第1、4、8和28天通过电话联系受试者。主要终点是术后第1天询问的平均疼痛程度（0 - 10分）。 结果：接受神经周围罗哌卡因的受试者（n = 30）术后第1天询问的平均疼痛程度中位数（四分位间距）为2（0 - 3），而接受生理盐水的受试者（n = 30）为4（1 - 5）（中位数差异的95%置信区间为 - 4.0至 - 0.3；P = 0.021）。在同一时期，接受罗哌卡因的受试者突破性疼痛的严重程度也较低（5 [3 - 6] 对7 [5 - 8]；P = 0.046）。因此，使用简明疼痛量表测量，接受神经周围罗哌卡因的受试者疼痛引起的身体和情感功能障碍较少（得分越低，功能障碍越少）：接受神经周围生理盐水的受试者为57（8 - 67），而接受神经周围罗哌卡因的受试者为14（4 - 37）（P = 0.012）。对于测量疼痛对7个领域（如一般活动和人际关系）干扰程度的子量表，接受神经周围生理盐水的受试者报告的中位数得分比接受罗哌卡因的受试者高10倍（功能障碍更多）（3 [0 - 24] 对33 [0 - 44]；P = 0.035）。相比之下，输液停止后，各治疗组之间未检测到统计学上的显著差异。 结论：乳房切除术后，在单次注射罗哌卡因椎旁神经阻滞基础上增加多日、门诊、持续罗哌卡因输注可改善镇痛效果，并在输注期间减少功能缺陷。然而，输液停止后未发现有益效果。
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