硬膜外阻滞与椎旁神经阻滞用于肝切除术患者术后镇痛的随机临床试验

Epidural Versus Paravertebral Nerve Block for Postoperative Analgesia in Patients Undergoing Open Liver Resection: A Randomized Clinical Trial.

作者信息

Schreiber Kristin L, Chelly Jacques E, Lang R Scott, Abuelkasem Ezeldeen, Geller David A, Marsh J Wallis, Tsung Allan, Sakai Tetsuro

机构信息

From the *Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Boston, MA; Departments of †Anesthesiology and ‡Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA.

出版信息

Reg Anesth Pain Med. 2016 Jul-Aug;41(4):460-8. doi: 10.1097/AAP.0000000000000422.

DOI:10.1097/AAP.0000000000000422

PMID:27281726

Abstract

BACKGROUND AND OBJECTIVES

Although many studies have found no difference between thoracic epidural block and unilateral thoracic paravertebral block after thoracotomy, no previous studies have compared epidural block with bilateral thoracic paravertebral block (bTPVB) in patients undergoing open liver resection. We aimed to investigate whether there was a significant analgesic advantage of thoracic epidural over bTPVB after liver resection.

METHODS

This randomized, prospective, open-label study included adult patients undergoing elective open liver resection. Patients were randomized to receive either thoracic epidural block or bTPVB, through which ropivacaine (0.2%) was infused for 3 days. The primary outcome was pain Verbal Rating Scale (VRS) score (0-10) at rest and with postoperative incentive spirometry. Secondary outcomes included VRS at rest, inspired volumes during incentive spirometry, patient-controlled analgesia hydromorphone utilization, measures of hemodynamic stability, and postoperative bowel function.

RESULTS

Eighty patients completed the study and received thoracic epidural block (n = 41) or bTPVBs (n = 39). No catheter-related complications were noted. The primary outcome, pain (VRS) with incentive spirometry, was significantly lower in the epidural group (epidural vs bTPVB, mean [SD]) (4.5 [2.7] vs 5.4 [2.7] at 24 hours postoperatively, and 3.2 [2.1] vs 4.6 [2.4] at 48 hours postoperatively). Maximal inspired volumes at 24 hours postoperatively (917 [379] vs 1042 [468] mL) and cumulative utilization of patient-controlled analgesia hydromorphone during the first 48 hours postoperatively (10.7 [7.9] vs 13.6 [8.5] mg) were not significantly different between groups. Decrease in mean arterial pressure from baseline at 24 hours postoperatively was greater for the epidural group (-12.6 [15.8] vs -3.8 [16.2]; P = 0.016).

CONCLUSIONS

This study suggests that there is a modest analgesic advantage of thoracic epidural over bTPVBs for patients after open liver resection.

摘要

背景与目的

尽管许多研究发现开胸术后胸段硬膜外阻滞与单侧胸段椎旁阻滞之间无差异，但此前尚无研究比较开腹肝切除患者的硬膜外阻滞与双侧胸段椎旁阻滞（bTPVB）。我们旨在研究肝切除术后胸段硬膜外阻滞相较于bTPVB是否具有显著的镇痛优势。

方法

这项随机、前瞻性、开放标签研究纳入了接受择期开腹肝切除的成年患者。患者被随机分为接受胸段硬膜外阻滞或bTPVB，通过这两种方式输注0.2%的罗哌卡因，持续3天。主要结局指标为静息及术后进行激励肺活量测定时的疼痛视觉模拟评分（VRS）（0 - 10分）。次要结局指标包括静息时的VRS、激励肺活量测定时的吸气量、患者自控镇痛的氢吗啡酮用量、血流动力学稳定性指标以及术后肠功能。

结果

80例患者完成了研究，其中41例接受胸段硬膜外阻滞，39例接受bTPVB。未发现与导管相关的并发症。主要结局指标，即激励肺活量测定时的疼痛（VRS），硬膜外组显著更低（硬膜外组与bTPVB组，均值[标准差]）（术后24小时为4.5[2.7] vs 5.4[?2.7]，术后48小时为3.2[2.1] vs 4.6[2.4]）。术后24小时的最大吸气量（917[379] vs 1042[468] mL）以及术后48小时内患者自控镇痛氢吗啡酮的累积用量（10.7[7.9] vs 13.6[8.5] mg）在两组间无显著差异。术后24小时硬膜外组平均动脉压较基线的下降幅度更大（-12.6[15.8] vs -3.8[16.2]；P = 0.016）。