Galos David K, Taormina David P, Crespo Alexander, Ding David Y, Sapienza Anthony, Jain Sudheer, Tejwani Nirmal C
NYU Hospital for Joint Diseases, Langone Medical Center, 301 East 17th Street, Suite 1402, New York, NY, 10003, USA.
Clin Orthop Relat Res. 2016 May;474(5):1247-54. doi: 10.1007/s11999-016-4735-1. Epub 2016 Feb 11.
Distal radius fractures are very common injuries and surgical treatment for them can be painful. Achieving early pain control may help improve patient satisfaction and improve functional outcomes. Little is known about which anesthesia technique (general anesthesia versus brachial plexus blockade) is most beneficial for pain control after distal radius fixation which could significantly affect patients' postoperative course and experience.
QUESTIONS/PURPOSES: We asked: (1) Did patients receiving general anesthesia or brachial plexus blockade have worse pain scores at 2, 12, and 24 hours after surgery? (2) Was there a difference in operative suite time between patients who had general anesthesia or brachial plexus blockade, and was there a difference in recovery room time? (3) Did patients receiving general anesthesia or brachial plexus blockade have higher narcotic use after surgery? (4) Do patients receiving general anesthesia or brachial plexus blockade have higher functional assessment scores after distal radius fracture repair at 6 weeks and 12 weeks after surgery?
A randomized controlled study was performed between February, 2013 and April, 2014 at a multicenter metropolitan tertiary-care referral center. Patients who presented with acute closed distal radius fractures (Orthopaedic Trauma Association 23A-C) were potentially eligible for inclusion. During the study period, 40 patients with closed, displaced, and unstable distal radius fractures were identified as meeting inclusion criteria and offered enrollment and randomization. Three patients (7.5%), all with concomitant injuries, declined to participate at the time of randomization as did one additional patient (2.5%) who chose not to participate, leaving a final sample of 36 participants. There were no dropouts after randomization, and analyses were performed according to an intention-to-treat model. Patients were randomly assigned to one of two groups, general anesthesia or brachial plexus blockade, and among the 36 patients included, 18 were randomized to each group. Medications administered in the postanesthesia care unit were recorded. Patients were discharged receiving oxycodone and acetaminophen 5/325 mg for pain control, and VAS forms were provided. Patients were called at predetermined intervals postoperatively (2 hours, 4 hours, 6 hours, 12 hours, 24 hours, 48 hours, and 72 hours) to gather pain scores, using the VAS, and to document the doses of analgesics consumed. In addition, patients had regular followups at 2 weeks, 6 weeks, and 12 weeks. Pain scores were again recorded using the VAS at these visits.
Patients who received general anesthesia had worse pain scores at 2 hours postoperatively (general anesthesia 6.7 ± 2.3 vs brachial plexus blockade 1.4 ± 2.3; mean difference, 5.381; 95% CI, 3.850-6.913; p < 0.001); whereas reported pain was worse for patients who received a brachial plexus blockade at 12 hours (general anesthesia 3.8 ± 1.9 vs brachial plexus blockade 6.3 ± 2.4; mean difference, -2.535; 95% CI, -4.028 to -1.040; p = 0.002) and 24 hours (general anesthesia 3.8 ± 2.2 vs brachial plexus blockade 5.3 ± 2.5; mean difference, -1.492; 95% CI, -3.105 to 0.120; p = 0.031).There was no difference in operative suite time (general anesthesia 119 ± 16 minutes vs brachial plexus blockade 125 ± 23 minutes; p = 0.432), but time in the recovery room was greater for patients who received general anesthesia (284 ± 137 minutes vs 197 ± 90; p = 0.0398). Patients who received general anesthesia consumed more fentanyl (64 μg ± 93 μg vs 6.9 μg ± 14 μg; p < 0.001) and morphine (2.9 μg ± 3.6 μg vs 0.0 μg; p < 0.001) than patients who received brachial plexus blockade. Functional outcome scores did not differ at 6 weeks (data, with mean and SD for both groups, and p value) or 12 weeks postoperatively (data, with mean and SD for both groups, and p value).
Brachial plexus blockade pain control during the immediate perioperative period was not significantly different from that of general anesthesia in patients undergoing operative fixation of distal radius fractures. However, patients who received a brachial plexus blockade experienced an increase in pain between 12 to 24 hours after surgery. Acknowledging "rebound pain" after the use of regional anesthesia coupled with patient counseling regarding early narcotic administration may allow patients to have more effective postoperative pain control. It is important to have a conversation with patients preoperatively about what to expect regarding rebound pain, postoperative pain control, and to advise them about being aggressive with taking pain medication before the waning of regional anesthesia to keep one step ahead in their pain control management.
Level 1, therapeutic study.
桡骨远端骨折是非常常见的损伤，其手术治疗可能会很痛苦。实现早期疼痛控制可能有助于提高患者满意度并改善功能结局。对于桡骨远端固定术后哪种麻醉技术（全身麻醉与臂丛神经阻滞）对疼痛控制最有益，目前知之甚少，而这可能会显著影响患者的术后病程和体验。
问题/目的：我们提出以下问题：（1）接受全身麻醉或臂丛神经阻滞的患者在术后2小时、12小时和24小时的疼痛评分是否更高？（2）接受全身麻醉或臂丛神经阻滞的患者在手术时间和恢复室时间上是否存在差异？（3）接受全身麻醉或臂丛神经阻滞的患者术后使用麻醉剂的量是否更多？（4）接受全身麻醉或臂丛神经阻滞的患者在术后6周和12周桡骨远端骨折修复后的功能评估评分是否更高？
2013年2月至2014年4月在一家多中心大都市三级医疗转诊中心进行了一项随机对照研究。出现急性闭合性桡骨远端骨折（骨科创伤协会23A - C型）的患者可能符合纳入标准。在研究期间，40例闭合性、移位性和不稳定性桡骨远端骨折患者被确定符合纳入标准并被邀请入组和随机分组。3例患者（7.5%），均伴有其他损伤，在随机分组时拒绝参与，另有1例患者（2.5%）选择不参与，最终样本为36名参与者。随机分组后无脱落病例，分析按照意向性分析模型进行。患者被随机分为两组，全身麻醉组或臂丛神经阻滞组；在纳入的36例患者中每组18例。记录麻醉后护理单元使用的药物情况。患者出院时接受羟考酮和对乙酰氨基酚5/325mg用于疼痛控制，并提供视觉模拟评分（VAS）表格。术后按预定时间间隔（2小时、4小时、6小时、12小时、24小时、48小时和72小时）致电患者，使用VAS收集疼痛评分，并记录消耗的镇痛剂剂量。此外，患者在术后2周、6周和12周进行定期随访。在这些随访中再次使用VAS记录疼痛评分。
接受全身麻醉的患者术后2小时疼痛评分更高（全身麻醉6.7±2.3 vs臂丛神经阻滞1.4±2.3；平均差异5.381；95%可信区间，3.850 - 6.913；p < 0.001）；而接受臂丛神经阻滞的患者在12小时（全身麻醉3.8±1.9 vs臂丛神经阻滞6.3±2.4；平均差异 -2.535；95%可信区间 -4.0,28至 -1.040；p = 0.002）和24小时（全身麻醉3.8±2.2 vs臂丛神经阻滞5.3±2.5；平均差异 -1.492；95%可信区间 -3.105至0.120；p = 0.031）疼痛更严重。手术时间无差异（全身麻醉119±16分钟vs臂丛神经阻滞125±23分钟；p = 0.432），但接受全身麻醉的患者在恢复室的时间更长（284±137分钟vs 197±90分钟；p = 0.0398）。接受全身麻醉的患者比接受臂丛神经阻滞的患者消耗更多的芬太尼（64μg±93μg vs 6.9μg±14μg；p < 0.001）和吗啡（2.9μg±3.6μg vs 0.0μg；p < 0.001）。术后6周（两组数据，包括均值、标准差和p值）或12周（两组数据，包括均值、标准差和p值）的功能结局评分无差异。
在桡骨远端骨折手术固定的患者中，围手术期立即采用臂丛神经阻滞进行疼痛控制与全身麻醉没有显著差异。然而，接受臂丛神经阻滞的患者在术后12至24小时疼痛有所增加。认识到区域麻醉后的“反跳痛”并向患者咨询早期使用麻醉剂的问题，可能会使患者获得更有效的术后疼痛控制。术前与患者就反跳痛、术后疼痛控制进行沟通，并建议他们在区域麻醉消退前积极服用止痛药物以在疼痛控制管理中占得先机，这很重要。
1级，治疗性研究。
