Sun Eric C, Bateman Brian T, Memtsoudis Stavros G, Neuman Mark D, Mariano Edward R, Baker Laurence C
From the *Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Stanford University, Stanford, California; †Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, Boston, Massachusetts; ‡Department of Anesthesiology, Hospital for Special Surgery, New York, New York; §Department of Anesthesiology and Critical Care, University of Pennsylvania, School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; ‖Anesthesiology and Perioperative Care Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California; ¶Department of Health Research and Policy, Stanford University School of Medicine, Stanford University, Stanford, California; and #National Bureau of Economic Research, Cambridge, Massachusetts.
Anesth Analg. 2017 Sep;125(3):999-1007. doi: 10.1213/ANE.0000000000001943.
Total knee arthroplasty (TKA) is associated with high rates of prolonged opioid use after surgery (10%-34%). By decreasing opioid use in the immediate postoperative period, perioperative nerve blockade has been hypothesized to decrease the risk of persistent opioid use.
Using health care utilization data, we constructed a sample of 120,080 patients undergoing TKA between 2002 and 2012 and used billing data to identify the utilization of peripheral or neuraxial blockade. We then used a multivariable logistic regression to estimate the association between nerve blockade and the risk of chronic opioid use, defined as having filled ≥10 prescriptions or ≥120 days' supply for an opioid in the first postsurgical year. Our analyses were adjusted for an extensive set of potential confounding variables, including medical comorbidities, previous opioid use, and previous use of other medications.
We did not find an association between nerve blockade and the risk of postsurgical chronic opioid use across any of these 3 groups: adjusted relative risk (ARR) 0.984 for patients opioid-naïve in the year before surgery (98.3% confidence interval [CI], 0.870-1.12, P = .794), ARR 1.02 for intermittent opioid users (98.3% CI, 0.948-1.09, P = .617), and ARR 0.986 (98.3% CI, 0.963-1.01, P = .257) for chronic opioid users. Similar results held for alternative measures of postsurgical opioid use.
Although the use of perioperative nerve blockade for TKA may improve short-term outcomes, the analyzed types of blocks do not appear to decrease the risk of persistent opioid use in the longer term.
全膝关节置换术（TKA）术后长期使用阿片类药物的比例较高（10%-34%）。围手术期神经阻滞通过减少术后即刻阿片类药物的使用，被认为可降低持续使用阿片类药物的风险。
利用医疗保健利用数据，我们构建了一个包含2002年至2012年间接受TKA的120,080例患者的样本，并使用计费数据来确定外周或神经轴阻滞的使用情况。然后，我们使用多变量逻辑回归来估计神经阻滞与慢性阿片类药物使用风险之间的关联，慢性阿片类药物使用定义为术后第一年开具≥10张阿片类药物处方或供应≥120天。我们的分析对一系列潜在的混杂变量进行了调整，包括合并症、既往阿片类药物使用情况以及既往其他药物使用情况。
在这三组患者中，我们均未发现神经阻滞与术后慢性阿片类药物使用风险之间存在关联：术前一年未使用阿片类药物的患者调整后相对风险（ARR）为0.984（98.3%置信区间[CI]，0.870-1.12，P = 0.794），间歇性阿片类药物使用者的ARR为1.02（98.3%CI，0.948-1.09，P = 0.617），慢性阿片类药物使用者的ARR为0.986（98.3%CI，0.963-1.01，P = 0.257）。术后阿片类药物使用的替代指标也得出了类似结果。
虽然围手术期神经阻滞用于TKA可能改善短期结局，但所分析的阻滞类型似乎并未降低长期持续使用阿片类药物的风险。
