Desai Amita, Alemayehu Hanna, Weesner Kathryn A, St Peter Shawn D
Department of Surgery, Children's Mercy Hospital, Kansas City, Missouri, United States.
Department of Anesthesia, Children's Mercy Hospital, Kansas City, Missouri, United States.
Eur J Pediatr Surg. 2016 Apr;26(2):160-3. doi: 10.1055/s-0034-1396414. Epub 2015 Feb 2.
We conducted a prospective randomized trial to evaluate the merits of two established postoperative pain management strategies: thoracic epidural (EPI) versus patient-controlled analgesia (PCA) with intravenous narcotics after minimally invasive repair of pectus excavatum. Pain scores favored the EPI group for the first two postoperative days only. Critics of the trial suggest that if the epidural failure rate was not so high, results may have favored the EPI group. Therefore, we performed a subset analysis of the EPI group to evaluate the impact of these failures.
Patients for whom epidural catheter could not be placed or whose catheters were removed early owing to dysfunction were compared with those with well-functioning catheters. Those with well-functioning catheters were also compared with the PCA group. A two-tailed independent Student t-test and a two-tailed Fisher exact test were used where appropriate.
Of 55 patients in the EPI group, 12 patients (21.8%) had failed placement or required early removal. Comparing those with failed placements with the rest of the group, there was no difference in daily visual analogue scale pain scores or measures of hospital course. Likewise, comparing those with well-functioning catheters only to those in the PCA group, the results of the trial are replicated in terms of pain scores, hospital course, and length of stay.
In patients with failed epidural therapy, there is no significant difference in postoperative hospital course. Comparing those with well-functioning catheters to those in the PCA group, trial results are replicated-that is, no significant difference in length of stay, time to regular diet, or time to transition to oral medications. Therefore, failure rate in the EPI group did not influence the results of the trial.
我们进行了一项前瞻性随机试验，以评估两种既定的术后疼痛管理策略的优点：在微创漏斗胸修复术后，胸段硬膜外阻滞（EPI）与静脉使用麻醉剂的患者自控镇痛（PCA）。仅在术后的前两天，疼痛评分有利于EPI组。该试验的批评者认为，如果硬膜外阻滞失败率没有那么高，结果可能会有利于EPI组。因此，我们对EPI组进行了亚组分析，以评估这些失败的影响。
将因功能障碍而无法放置硬膜外导管或导管过早拔除的患者与导管功能良好的患者进行比较。导管功能良好的患者也与PCA组进行比较。在适当的情况下使用双尾独立样本t检验和双尾Fisher精确检验。
EPI组的55例患者中，有12例（21.8%）放置失败或需要早期拔除。将放置失败的患者与组内其他患者进行比较，每日视觉模拟评分法疼痛评分或住院过程指标没有差异。同样，仅将导管功能良好的患者与PCA组患者进行比较，在疼痛评分、住院过程和住院时间方面，试验结果得以重现。
在硬膜外阻滞治疗失败的患者中，术后住院过程没有显著差异。将导管功能良好的患者与PCA组患者进行比较，试验结果得以重现——即住院时间、恢复正常饮食时间或改用口服药物时间没有显著差异。因此，EPI组的失败率并未影响试验结果。
