Bakshi Sumitra G, Mapari Amol, Shylasree T S
Department of Anesthesia, Critical Care & Pain, Tata Memorial Hospital, Parel, Mumbai, India.
Department of Gynecological Oncology, Tata Memorial Hospital, Parel, Mumbai, India.
Can J Anaesth. 2016 Dec;63(12):1335-1344. doi: 10.1007/s12630-016-0732-9. Epub 2016 Sep 14.
Opioid-sparing pain management is important for Enhanced Recovery After Surgery. Rectus sheath (RS) blocks are emerging as a promising modality for pain relief following midline laparotomy; however, there are limited prospective clinical trials testing their efficacy. The purpose of this randomized-controlled trial is to assess the morphine-sparing effect of local anesthetic (LA) boluses through RS catheters following elective gynecological oncology surgery.
After patients' informed consent, bilateral RS catheters were placed intraoperatively in 74 females (American Society of Anesthesiologists physical status I-II) undergoing elective midline laparotomy under general anesthesia. The patients were randomized to receive 20-mL injections of either LA (0.25% bupivacaine) or normal saline (NS) postoperatively every six hours for 48 hr. Groups were compared for the co-primary outcomes of 24- and 48-hr morphine requirements. The secondary outcomes were numeric rating scale (NRS) scores for pain recorded at rest and with movement.
The mean (SD) morphine consumption was significantly reduced in the LA group compared with the NS group at 24 hr [8.8 (8.3) mg vs 27.3 (10.0) mg, respectively; mean difference, 18.5 mg; 95% confidence interval (CI), 14.3 to 22.8; P < 0.001] and at 48 hr [14.8 (11.0) mg vs 42.4 (16.8) mg, respectively; mean difference, 27.7 mg; 95% CI, 20.9 to 34.3; P < 0.001]. At 48 hr postoperatively, there was also a significant decrease in the median [interquartile range] NRS scores for pain in the LA group compared with the NS group, both at rest (3 [2-3] vs 5 [5-6], respectively; P < 0.001) and with movement (4 [4-5] vs 7 [6-8], respectively; P < 0.001).
The use of intermittent LA boluses through RS catheters is an effective morphine-sparing pain management strategy for females undergoing midline laparotomy for gynecological cancer surgery. This study was registered with the Clinical Trial Registry of India (CTRI/2013/10/004075).
减少阿片类药物使用的疼痛管理对促进术后康复很重要。腹直肌鞘（RS）阻滞作为一种有前景的缓解中线剖腹术后疼痛的方式正在兴起；然而，测试其疗效的前瞻性临床试验有限。这项随机对照试验的目的是评估择期妇科肿瘤手术后通过RS导管给予局部麻醉剂（LA）推注的吗啡节省效果。
在患者知情同意后，对74名接受全身麻醉下择期中线剖腹术的女性（美国麻醉医师协会身体状况I-II级）术中放置双侧RS导管。患者被随机分为术后每6小时接受20毫升LA（0.25%布比卡因）或生理盐水（NS）注射，共48小时。比较两组24小时和48小时吗啡需求量这两个共同主要结局。次要结局是静息和活动时记录的疼痛数字评分量表（NRS）分数。
与NS组相比，LA组在24小时时平均（标准差）吗啡消耗量显著降低[分别为8.8（8.3）毫克和27.3（10.0）毫克；平均差异为18.5毫克；95%置信区间（CI）为14.3至22.8；P<0.001]，在48小时时也显著降低[分别为14.8（11.0）毫克和42.4（16.8）毫克；平均差异为27.7毫克；95%CI为20.9至34.3；P<0.001]。术后48小时，与NS组相比，LA组静息时（分别为3[2-3]和5[5-6]；P<0.001）和活动时（分别为4[4-5]和7[6-8]；P<0.001）疼痛的中位数[四分位间距]NRS分数也显著降低。
通过RS导管间歇性给予LA推注是一种有效的吗啡节省疼痛管理策略，适用于接受妇科癌症手术中线剖腹术的女性。本研究已在印度临床试验注册中心注册（CTRI/2013/10/004075）。
