Nosotti Mario, Rosso Lorenzo, Tosi Davide, Palleschi Alessandro, Mendogni Paolo, Righi Ilaria, Marenghi Cristina, Santambrogio Luigi
Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy.
Thoracic Surgery and Lung Transplant Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, University of Milan, Milan, Italy
Eur J Cardiothorac Surg. 2015 Sep;48(3):428-33; discussion 434. doi: 10.1093/ejcts/ezu467. Epub 2014 Dec 18.
Preventive analgesia is defined as a treatment that is commenced before the surgical procedure in order to diminish the physiological consequences of afferent nociceptive transmission caused by the procedure and prevent central sensitization. The analysis of randomized studies of preventive analgesia is controversial. The aim of this study was to check the analgesic efficacy of preoperative administration of dextromethorphan associated with intercostal nerve block with levobupivacaine in thoracotomy patients who refused or had a contraindication to epidural analgesia.
This study was a four-arm, double-blinded, randomized placebo-controlled trial. Patients were allocated following close block randomization into four arms: 'Group A' preoperative dextromethorphan and preoperative intercostal block (IB), 'Group B' preoperative placebo and preoperative IB, 'Group C' preoperative dextromethorphan and postoperative IB, 'Group D' preoperative placebo and postoperative block. The primary end-point was the cumulative morphine consumption (CMC) within the first 14 days after surgery.
A total of 400 patients were enrolled and 395 completed the study. There were no statistical differences among the groups in terms of demographic and surgical data; in contrast, preoperative quality-of-life scores were heterogeneous. The mean CMCs were as follows: Group A 111.4 mg, Group B 121.5 mg, Group C 126.8 mg, Group D 138.3 mg. Group A mean was lower than the maximum (P = 0.0001). The CMC value did not correlate with age, sex, body mass index, education, type of surgery, length or width of the incision and rib fracture. Postoperative functional data and post-thoracotomy syndrome prevalence were homogeneous; female gender resulted predictive for post-thoracotomy syndrome.
Results indicate that preoperative administration of dextromethorphan associated with preoperative IB with levobupivacaine provided preventive analgesia, decreasing analgesic administration during the early postoperative period compared with placebo and/or postoperative IB. This study failed in detecting any effect of preventive analgesia on functional items and post-thoracotomy syndrome.
预防性镇痛被定义为在手术操作前开始的一种治疗，以减轻该操作引起的传入性伤害性感受传递的生理后果，并防止中枢敏化。预防性镇痛的随机研究分析存在争议。本研究的目的是检验在拒绝或有硬膜外镇痛禁忌证的开胸手术患者中，术前给予右美沙芬联合左旋布比卡因肋间神经阻滞的镇痛效果。
本研究是一项四臂、双盲、随机安慰剂对照试验。患者按照封闭区组随机化被分配到四个组：“A组”术前右美沙芬和术前肋间阻滞（IB），“B组”术前安慰剂和术前IB，“C组”术前右美沙芬和术后IB，“D组”术前安慰剂和术后阻滞。主要终点是术后14天内的吗啡累积消耗量（CMC）。
共纳入400例患者，395例完成研究。各组在人口统计学和手术数据方面无统计学差异；相比之下，术前生活质量评分存在异质性。平均CMC如下：A组111.4mg，B组121.5mg，C组126.8mg，D组138.3mg。A组均值低于最大值（P = 0.0001）。CMC值与年龄、性别、体重指数、教育程度、手术类型、切口长度或宽度以及肋骨骨折无关。术后功能数据和开胸术后综合征患病率是同质的；女性被认为是开胸术后综合征的预测因素。
结果表明，术前给予右美沙芬联合左旋布比卡因术前IB可提供预防性镇痛，与安慰剂和/或术后IB相比，可减少术后早期的镇痛药物使用。本研究未能检测到预防性镇痛对功能指标和开胸术后综合征的任何影响。
