Namdari Surena, Nicholson Thema, Abboud Joseph, Lazarus Mark, Steinberg Dean, Williams Gerald
1Department of Orthopaedic Surgery, Rothman Institute, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania 2Department of Anesthesia, Sidney Kimmel Medical College at Thomas Jefferson University-Methodist Hospital Division, Philadelphia, Pennsylvania.
J Bone Joint Surg Am. 2017 Apr 5;99(7):550-556. doi: 10.2106/JBJS.16.00296.
Shortcomings of interscalene brachial plexus blockade include technical failure and rebound pain. Bupivacaine liposome injectable suspension, a sustained release preparation, is used for surgical-site administration. The purpose of this study was to evaluate these 2 postoperative pain management strategies in patients undergoing shoulder arthroplasty.
In a non-blinded, randomized controlled trial of participants undergoing primary shoulder arthroplasty, patients were randomized to interscalene brachial plexus blockade or intraoperative soft-tissue infiltration of bupivacaine liposome injectable suspension. The primary outcome variable was morphine equivalent units consumed over the first 24 hours postoperatively. Secondary outcomes included morphine equivalent units consumed intraoperatively and a visual analog scale (VAS) for pain at 0, 8, 16, and 24 hours.
Seventy-eight patients were randomized to interscalene brachial plexus blockade treatment (the blockade group) and 78 patients were randomized to bupivacaine liposome injectable suspension treatment (the suspension group). The mean total postoperative narcotic consumption (and standard deviation) over 24 hours after the surgical procedure was 14.8 ± 11.3 morphine equivalent units in the blockade group compared with 14.4 ± 16.8 morphine equivalent units in the suspension group (p = 0.849). Intraoperative narcotics were significantly lower (p < 0.001) in the blockade group (8.9 ± 4.1 morphine equivalent units) compared with the suspension group (16.2 ± 7.0 morphine equivalent units). The mean VAS pain score was significantly lower in the blockade group than in the suspension group at 0 hours postoperatively (0.8 ± 2.2 compared with 3.3 ± 2.7 points; p < 0.001) and at 8 hours postoperatively (1.4 ± 2.4 compared with 3.2 ± 2.2 points; p < 0.001), but it was not significantly different at 16 hours postoperatively (4.3 ± 2.8 compared with 3.8 ± 2.4 points; p = 0.348). The VAS pain scores were significantly higher (p = 0.021) in the blockade group (4.9 ± 2.7 points) compared with the suspension group (3.9 ± 2.3 points) at 24 hours postoperatively.
Patients treated with bupivacaine liposome injectable suspension required an equivalent amount of postoperative narcotics and greater intraoperative narcotics compared with patients treated with interscalene brachial plexus blockade. Although interscalene brachial plexus blockade provided improved pain scores for the first 8 hours after the surgical procedure, pain scores were worse at 24 hours. The optimal postoperative pain regimen for shoulder arthroplasty and the cost-effectiveness of analgesic techniques require further investigation.
Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.
肌间沟臂丛神经阻滞的缺点包括技术失败和反弹痛。布比卡因脂质体注射混悬液是一种缓释制剂，用于手术部位给药。本研究的目的是评估这两种术后疼痛管理策略在接受肩关节置换术的患者中的效果。
在一项针对接受初次肩关节置换术患者的非盲、随机对照试验中，患者被随机分为肌间沟臂丛神经阻滞组或术中布比卡因脂质体注射混悬液软组织浸润组。主要结局变量是术后头24小时内消耗的吗啡当量单位。次要结局包括术中消耗的吗啡当量单位以及术后0、8、16和24小时的视觉模拟疼痛评分（VAS）。
78例患者被随机分配至肌间沟臂丛神经阻滞治疗组（阻滞组），78例患者被随机分配至布比卡因脂质体注射混悬液治疗组（混悬液组）。手术操作后24小时内，阻滞组术后平均总麻醉药物消耗量（及标准差）为14.8±11.3吗啡当量单位，而混悬液组为14.4±16.8吗啡当量单位（p = 0.849）。阻滞组术中麻醉药物消耗量（8.9±4.1吗啡当量单位）显著低于混悬液组（16.2±7.0吗啡当量单位）（p < 0.001）。术后0小时（0.8±2.2分对3.3±2.7分；p < 0.001）和术后8小时（1.4±2.4分对3.2±2.2分；p < 0.001），阻滞组的平均VAS疼痛评分显著低于混悬液组，但术后16小时两组无显著差异（4.3±2.8分对3.8±2.4分；p = 0.348）。术后24小时，阻滞组的VAS疼痛评分（4.9±2.7分）显著高于混悬液组（3.9±2.3分）（p = 0.021）。
与接受肌间沟臂丛神经阻滞治疗的患者相比，接受布比卡因脂质体注射混悬液治疗的患者术后所需麻醉药物量相当，但术中所需麻醉药物量更多。尽管肌间沟臂丛神经阻滞在手术后的前8小时提供了更好的疼痛评分，但24小时时疼痛评分更差。肩关节置换术的最佳术后疼痛方案及镇痛技术的成本效益需要进一步研究。
治疗性II级。有关证据水平的完整描述，请参阅作者指南。
