Lalmand Manon, Wilwerth Madeleine, Fils Jean-François, Van der Linden Philippe
From the *Department of Anesthesiology, Université Libre de Bruxelles, Centre Hospitalier Universitaire Brugmann, Place Van Gehuchten, Brussels, Belgium; and †Ars Statistica, Nivelles, Belgium.
Anesth Analg. 2017 Sep;125(3):907-912. doi: 10.1213/ANE.0000000000001892.
After cesarean delivery, postoperative pain management allows early rehabilitation and helps prevent postpartum depression and chronic pain. Our present prospective, randomized controlled, double-blind study assessed the duration and effect of intrathecal analgesia and continuous ropivacaine wound infiltration versus a control group after cesarean delivery. The primary outcome was analgesia duration, defined as time to first morphine request. Secondary outcomes were cumulative postoperative morphine consumption, number of patients who did not require IV morphine, incidence of adverse effects, and time to first ambulation.
A total of 192 full-term parturients undergoing elective cesarean delivery were randomly allocated into 3 groups (control, morphine, and catheter). All patients received spinal anesthesia with 10 mg bupivacaine 0.5% hyperbaric bupivacaine (2 mL) + 5 μg of sufentanil (1 mL) and a multiholed catheter inserted into the wound. In the control group, NaCl 0.9% was administered intrathecally (0.1 mL) and through the catheter. The morphine group received 100 μg morphine (0.1 mL) intrathecally and NaCl 0.9% infused through the wound catheter. The catheter group received 0.1 mL NaCl 0.9% intrathecally and ropivacaine 0.2% infused in the catheter. Each patient received a 15-mL bolus of the dedicated solution through the catheter, which was connected to an elastomeric pump infusor delivering the same solution at a rate of 10 mL/h for 30 hours. All patients also received multimodal analgesia including acetaminophen and diclofenac. Analgesia duration was defined as the time from spinal injection (T0) to first IV morphine requirement (T1) administered via a patient-controlled IV analgesia pump. Statistical data analyses included use of the Kruskal-Wallis rank-sum test followed by the post hoc Tukey test and χ test.
The duration of postoperative analgesia was increased with intrathecal morphine (380 minutes; 215-1527) and ropivacaine wound infusion (351 minutes; 227-594) compared with the control (247 minutes; 182-338) with effect sizes of 0.171 (0.043-0.293) for morphine versus control and 0.164 (0.052-0.271) for catheter versus control. There was no difference between the morphine group and catheter group (effect size, 0.007; -0.118 to 0.132). Cumulative postoperative morphine consumption was also significantly lower in the morphine group and catheter group compared with the control group. The incidence of adverse effects did not differ between groups.
After elective cesarean delivery, 100 μg intrathecal morphine and ropivacaine wound infusion both increased the duration and effect of postcesarean analgesia without increased incidence of side effects.
剖宫产术后，有效的疼痛管理有助于产妇早期康复，并预防产后抑郁和慢性疼痛。本前瞻性、随机对照、双盲研究评估了剖宫产术后鞘内镇痛联合罗哌卡因持续伤口浸润与对照组相比的镇痛持续时间和效果。主要结局指标为镇痛持续时间，定义为首次要求使用吗啡的时间。次要结局指标包括术后吗啡累计用量、无需静脉注射吗啡的患者数量、不良反应发生率以及首次下床活动时间。
总共192例择期剖宫产的足月产妇被随机分为3组（对照组、吗啡组和导管组）。所有患者均接受腰麻，使用10mg 0.5%的重比重布比卡因（2mL）+5μg舒芬太尼（1mL），并在伤口处插入多孔导管。对照组经鞘内（0.1mL）及通过导管给予0.9%氯化钠注射液。吗啡组经鞘内给予100μg吗啡（0.1mL），通过伤口导管输注0.9%氯化钠注射液。导管组经鞘内给予0.1mL 0.9%氯化钠注射液，并通过导管输注0.2%罗哌卡因。每位患者通过导管接受15mL的专用溶液推注，导管连接弹性泵注入器，以10mL/h的速度持续输注30小时相同溶液。所有患者还接受了包括对乙酰氨基酚和双氯芬酸在内的多模式镇痛。镇痛持续时间定义为从腰麻注射（T0）至首次通过患者自控静脉镇痛泵静脉注射吗啡的时间（T1）。统计数据分析采用Kruskal-Wallis秩和检验，随后进行事后Tukey检验和χ检验。
与对照组（247分钟；182 - 338）相比，鞘内注射吗啡组（380分钟；215 - 1527）和罗哌卡因伤口浸润组（351分钟；227 - 594）的术后镇痛持续时间延长，吗啡组与对照组的效应量为0.171（0.043 - 0.293），导管组与对照组的效应量为0.164（0.052 - 0.271）。吗啡组和导管组之间无差异（效应量为0.007；-0.118至0.132）。与对照组相比，吗啡组和导管组的术后吗啡累计用量也显著降低。各组间不良反应发生率无差异。
择期剖宫产术后，鞘内注射100μg吗啡和罗哌卡因伤口浸润均可延长剖宫产术后镇痛的持续时间和效果，且不增加副作用发生率。
