Højer Karlsen Anders Peder, Geisler Anja, Petersen Pernille Lykke, Mathiesen Ole, Dahl Jørgen B
Department of Anaesthesia 4231, Center of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark Section of Acute Pain Management, Department of Anaesthesia 4231, Centre of Head and Orthopaedics, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark.
Pain. 2015 Jan;156(1):8-30. doi: 10.1016/j.pain.0000000000000003.
Treatment of postoperative pain should rely on results from randomized controlled trials and meta-analyses of high scientific quality. The efficacy of a particular intervention may depend on the type of surgical procedure, which supports the reporting of "procedure-specific" interventions. The aim of this systematic review was to document the procedure-specific evidence for analgesic interventions after total hip arthroplasty (THA). This PRISMA-compliant and PROSPERO-registered review includes randomized placebo-controlled trials (RCTs) of medication-based analgesic interventions after THA. Endpoints were postoperative opioid consumption, pain scores (rest and during mobilization), adverse events, and length of hospital stay. Fifty-eight trials with 19 different interventions were retrieved. High risk of bias, substantial differences in assessment-tools and criteria for pain, irregular reporting of adverse events, considerable differences in supplemental analgesic consumption, and basic analgesic regimens generally characterized trials. Meta-analyses of non-steroidal anti-inflammatory drugs, local infiltration analgesia, intrathecal opioids, and lumbar plexus block provided a 24-hour intravenous morphine-sparing effect of 14.1 (95 % confidence interval: 8.0-20.2) mg, 7.5 (3.7-11.3) mg, 19.8 (14.9-24.7) mg, and 11.9 (6.4-17.3) mg, respectively. Non-steroidal anti-inflammatory drugs and lumbar plexus block were demonstrated to provide reductions in postoperative pain scores. Intrathecal opioids increased pruritus, and lumbar plexus block reduced nausea and pruritus. The GRADE-rated quality of evidence ranged from low to very low throughout the analyses. This review demonstrated, that some analgesic interventions may have the capacity to reduce mean opioid requirements and/or mean pain intensity compared with controls, but the available randomized placebo-controlled trials does not allow a designation of a "best proven intervention" for THA.
术后疼痛的治疗应基于高质量的随机对照试验和荟萃分析结果。特定干预措施的疗效可能取决于手术类型，这支持了对“特定手术”干预措施的报告。本系统评价的目的是记录全髋关节置换术（THA）后镇痛干预措施的特定手术证据。这项符合PRISMA标准并在PROSPERO注册的评价纳入了THA后基于药物的镇痛干预措施的随机安慰剂对照试验（RCT）。观察终点为术后阿片类药物消耗量、疼痛评分（静息时和活动时）、不良事件及住院时间。检索到58项试验，涉及19种不同干预措施。试验的总体特征为偏倚风险高、疼痛评估工具和标准存在显著差异、不良事件报告不规范、辅助镇痛药物消耗量差异较大以及基础镇痛方案各异。对非甾体类抗炎药、局部浸润镇痛、鞘内注射阿片类药物和腰丛阻滞进行的荟萃分析显示，24小时静脉吗啡节省效应分别为14.1（95%置信区间：8.0 - 20.2）mg、7.5（3.7 - 11.3）mg、19.8（14.9 - 24.7）mg和11.9（6.4 - 17.3）mg。非甾体类抗炎药和腰丛阻滞可降低术后疼痛评分。鞘内注射阿片类药物会增加瘙痒，腰丛阻滞可减少恶心和瘙痒。在整个分析过程中，证据的GRADE分级质量从低到极低不等。本评价表明，与对照组相比，一些镇痛干预措施可能有能力降低平均阿片类药物需求量和/或平均疼痛强度，但现有的随机安慰剂对照试验无法确定THA的“最佳验证干预措施”。
