Tolska Hanna Kaisa, Takala Annika, Blomgren Karin, Hamunen Katri, Kontinen Vesa
From the *Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, †Division of Otorhinolaryngology, Department of Head and Neck Surgery, and ‡Division of Pain Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Anesth Analg. 2017 May;124(5):1459-1466. doi: 10.1213/ANE.0000000000002015.
Post-tonsillectomy pain is 1 of the most intense postoperative pain conditions. However, optimal and sufficient postoperative analgesic treatment remains unclear. We investigated the effect of topical ropivacaine for post-tonsillectomy pain in 160 adult outpatient surgery patients over 2 postoperative weeks.
At the end of tonsillectomy, 2 swabs soaked in either 1% ropivacaine or saline were packed into the tonsillar beds for 5 minutes. We used ibuprofen and a combination of acetaminophen (500 mg)-codeine (30 mg) tablets as postoperative analgesics for 2 weeks. The primary outcome was pain intensity on swallowing measured on a numeric rating scale (NRSs) during the first postoperative week expressed as area under curve (AUC). The secondary endpoints included the worst pain experienced during the 2-hour follow-up in the postanesthesia care unit, pain intensity during the second postoperative week, and the number of ibuprofen and acetaminophen-codeine tablets consumed during the 2 postoperative weeks.
During the first postoperative week, 120 patients out of 160 (75%) provided complete results, including data on their use of analgesics according to the instructions as well as completed and returned a questionnaire daily. A total of 101 patients (63%) did the same during the second postoperative week.Median (interquartile range [IQR]) of the primary outcome NRSs (AUC) was 38 (19) for the ropivacaine group and 37 (24) for the control group during the first postoperative week (P = .77, -1.0 estimated difference; 95% confidence interval [CI] for the difference, -7.0 to 5.0); no difference was found. Median (IQR) of NRS at rest (NRSr) (AUC) was 24.5 (19) for the ropivacaine group and 24 (22) for the control group during the first postoperative week (P = .96, 0.0 estimated difference; 95% CI for the difference, -5.0 to 5.0); no difference was found. Median (IQR) of the worst pain intensity values (NRSs or NRSr) (AUC) was 5 (3) for the ropivacaine group and 5 (3) for the control group (P = .44, 0.0 estimated difference; 95% CI for the difference, -1.0 to 0.5); no difference was found. During the second postoperative week, median (IQR) of the NRSs (AUC) was 17 (13) for the ropivacaine group and 21 (23) for the control group (P = .05, -4.0 estimated difference; 95% CI for the difference, -9.0 to 0.0) and median (IQR) of the NRSr (AUC) 10.5 (10) for ropivacaine group and 11 (13) for the control group (P = .42, -1.0 estimated difference; 95% CI for the difference, -5.0 to 2.0); no difference was found.The number of rescue analgesics (acetaminophen-codeine tablets) consumed during the second postoperative week was lower in the ropivacaine group than in the control group (median [IQR] of the consumption [AUC] was 10 [12] for the ropivacaine group and 16 [12] for the control group; P = .0008, -7.0 estimated difference; 95% CI of difference, -10 to -3.0). The groups showed no differences in overall risk for post-tonsillectomy bleeding. However, bleeding requiring hemostasis under local anesthesia was more common in the ropivacaine group (18% vs 8%, P = .048, 10% estimated difference; 95% CI for the difference, 0%-21%).
Topical ropivacaine failed to reduce pain intensity during the first postoperative week. We observed no major adverse effects.
扁桃体切除术后疼痛是最剧烈的术后疼痛状况之一。然而，最佳且充分的术后镇痛治疗仍不明确。我们在160例成年门诊手术患者中，对术后两周内局部应用罗哌卡因治疗扁桃体切除术后疼痛的效果进行了研究。
在扁桃体切除结束时，将2块浸有1%罗哌卡因或生理盐水的拭子放入扁桃体窝5分钟。我们使用布洛芬以及对乙酰氨基酚（500毫克）-可待因（30毫克）片的组合作为术后镇痛药，持续2周。主要结局是术后第一周通过数字评分量表（NRS）测量的吞咽时疼痛强度，以曲线下面积（AUC）表示。次要终点包括麻醉后护理单元2小时随访期间经历的最严重疼痛、术后第二周的疼痛强度，以及术后两周内服用的布洛芬和对乙酰氨基酚-可待因片的数量。
术后第一周，160例患者中有120例（75%）提供了完整结果，包括按照说明使用镇痛药的数据，以及每天完成并返回问卷。术后第二周，共有101例患者（63%）做到了同样的事情。术后第一周，罗哌卡因组主要结局NRS（AUC）的中位数（四分位间距[IQR]）为38（19），对照组为37（24）（P = 0.77，估计差异为-1.0；差异的95%置信区间[CI]为-7.0至5.0）；未发现差异。术后第一周，罗哌卡因组静息时NRS（NRSr）（AUC）的中位数（IQR）为24.5（19），对照组为24（22）（P = 0.96，估计差异为0.0；差异的95%CI为-5.0至5.0）；未发现差异。罗哌卡因组最严重疼痛强度值（NRS或NRSr）（AUC）的中位数（IQR）为5（3），对照组为5（3）（P = 0.44，估计差异为0.0；差异的95%CI为-1.0至0.5）；未发现差异。术后第二周，罗哌卡因组NRS（AUC）的中位数（IQR）为17（13），对照组为21（23）（P = 0.05，估计差异为-4.0；差异的95%CI为-9.0至0.0），罗哌卡因组NRSr（AUC）的中位数（IQR）为10.5（10），对照组为11（13）（P = 0.42，估计差异为-1.0；差异的95%CI为-5.0至2.0）；未发现差异。术后第二周，罗哌卡因组服用的补救镇痛药（对乙酰氨基酚-可待因片）数量低于对照组（服用量[AUC]的中位数[IQR]，罗哌卡因组为10[12]，对照组为16[12]；P = 0.0008，估计差异为-7.0；差异的95%CI为-10至-3.0）。两组在扁桃体切除术后出血的总体风险方面无差异。然而，罗哌卡因组在局部麻醉下需要止血的出血情况更为常见（18%对8%，P = 0.048，估计差异为10%；差异的95%CI为0%-21%）。
局部应用罗哌卡因未能在术后第一周减轻疼痛强度。我们未观察到重大不良反应。
