YaDeau Jacques T, Paroli Leonardo, Fields Kara G, Kahn Richard L, LaSala Vincent R, Jules-Elysee Kethy M, Kim David H, Haskins Stephen C, Hedden Jacob, Goon Amanda, Roberts Matthew M, Levine David S
From the *Department of Anesthesiology, Weill Cornell Medical College; †Hospital for Special Surgery; and ‡Department of Orthopaedic Surgery, Weill Cornell Medical College, New York, NY.
Reg Anesth Pain Med. 2015 Jul-Aug;40(4):321-9. doi: 10.1097/AAP.0000000000000254.
Sciatic nerve block provides analgesia after foot and ankle surgery, but block duration may be insufficient. We hypothesized that perineural dexamethasone and buprenorphine would reduce pain scores at 24 hours.
Ninety patients received ultrasound-guided sciatic (25 mL 0.25% bupivacaine) and adductor canal (10 mL 0.25% bupivacaine) blockade, with random assignment into 3 groups (30 patients per group): control blocks + intravenous (IV) dexamethasone (4 mg) (control); control blocks + IV buprenorphine (150 μg) + IV dexamethasone (IV buprenorphine); and nerve blocks containing buprenorphine + dexamethasone (perineural). Patients received mepivacaine neuraxial anesthesia and postoperative oxycodone/acetaminophen, meloxicam, pregabalin, and ondansetron. Patients and assessors were blinded to group assignment. The primary outcome was pain with movement at 24 hours.
There was no difference in pain with movement at 24 hours (median score, 0). However, the perineural group had longer block duration versus control (45.6 vs 30.0 hours). Perineural patients had lower scores for "worst pain" versus control (median, 0 vs 2). Both IV buprenorphine and perineural groups were less likely to use opioids on the day after surgery versus control (28.6%, 28.6%, and 60.7%, respectively). Nausea after IV buprenorphine (but not perineural buprenorphine) was severe, frequent, and bothersome.
Pain scores were very low at 24 hours after surgery in the context of multimodal analgesia and were not improved by additives. However, perineural buprenorphine and dexamethasone prolonged block duration, reduced the worst pain experienced, and reduced opioid use. Intravenous buprenorphine caused troubling nausea and vomiting. Future research is needed to confirm and extend these observations.
坐骨神经阻滞可为足部和踝关节手术后提供镇痛，但阻滞持续时间可能不足。我们推测神经周围注射地塞米松和丁丙诺啡可降低24小时时的疼痛评分。
90例患者接受超声引导下坐骨神经阻滞（25 mL 0.25%布比卡因）和收肌管阻滞（10 mL 0.25%布比卡因），随机分为3组（每组30例患者）：对照阻滞+静脉注射（IV）地塞米松（4 mg）（对照组）；对照阻滞+静脉注射丁丙诺啡（150 μg）+静脉注射地塞米松（静脉注射丁丙诺啡组）；以及含丁丙诺啡+地塞米松的神经阻滞（神经周围组）。患者接受甲哌卡因椎管内麻醉以及术后使用羟考酮/对乙酰氨基酚、美洛昔康、普瑞巴林和昂丹司琼。患者和评估者对分组情况不知情。主要结局为24小时时的运动痛。
24小时时的运动痛无差异（中位数评分，0）。然而，神经周围组的阻滞持续时间比对照组更长（45.6小时对30.0小时）。神经周围组患者的“最痛”评分低于对照组（中位数，0对2）。静脉注射丁丙诺啡组和神经周围组患者术后当天使用阿片类药物的可能性均低于对照组（分别为28.6%、28.6%和60.7%）。静脉注射丁丙诺啡后（而非神经周围注射丁丙诺啡）恶心严重、频繁且令人烦恼。
在多模式镇痛的情况下，术后24小时时疼痛评分非常低，添加药物并未改善。然而，神经周围注射丁丙诺啡和地塞米松延长了阻滞持续时间，减轻了所经历的最痛程度，并减少了阿片类药物的使用。静脉注射丁丙诺啡导致令人烦恼的恶心和呕吐。需要进一步的研究来证实并扩展这些观察结果。
