School of Medicine, Queen's University, Kingston, ON, Canada.
Department of Anesthesiology & Perioperative Medicine, Kingston General Hospital, Queen's University, Victory 2, 76 Stuart Street, Kingston, ON, K7L 2V7, Canada.
Can J Anaesth. 2017 Oct;64(10):1048-1058. doi: 10.1007/s12630-017-0937-6. Epub 2017 Jul 18.
Arthroscopic shoulder surgery can be performed with an interscalene brachial plexus block (ISBPB) alone, ISBPB combined with general anesthesia (GA), or GA alone. Postoperative pain is typically managed with opioids; however, both GA and opioids have adverse effects which can delay discharge. This retrospective study compares the efficacy of four methods of anesthesia management for arthroscopic shoulder surgery.
Charts of all patients who underwent shoulder surgery by a single surgeon from 2012-2015 were categorized by analgesic regimen: GA only (n = 177), single-shot ISBPB only (n = 124), or pre- vs postoperative ISBPB combined with GA (ISBPB + GA [n = 72] vs GA + ISBPB [n = 52], respectively). The primary outcome measure was the time to discharge from the postanesthesia care unit (PACU).
Mean (SD) time in the PACU ranged from 70.5 (39.9) min for ISBPB only to 111.2 (56.9) min for GA only. Use of ISBPB in any combination and regardless of timing resulted in significantly reduced PACU time, with a mean drop of 27.2 min (95% confidence interval [CI], 17.3 to 37.2; P < 0.001). The largest mean pairwise difference was between GA only and ISBPB only, with a mean difference of 40.7 min (95% CI, 25.5 to 55.8; P < 0.001). Use of ISBPB also reduced pain upon arrival at the PACU and, in some cases, upon discharge from the PACU (i.e., ISBPB only but not ISBPB + GA compared with GA). An ISBPB (alone or prior to GA) also reduced analgesic requirements.
Previously reported benefits of an ISBPB for arthroscopic shoulder surgery are confirmed. Postoperative ISBPBs may also be beneficial for reducing pain and opioid requirements and could be targeted for patients in severe pain upon emergence. A sufficiently powered randomized-controlled trial could determine the relative efficacy, safety, and associated financial implications associated with each method.
关节镜肩关节手术可以单独使用肌间沟臂丛阻滞（ISBPB）、ISBPB 联合全身麻醉（GA）或 GA 单独进行。术后疼痛通常采用阿片类药物治疗；然而，GA 和阿片类药物都有不良反应，这可能会延迟出院。本回顾性研究比较了关节镜肩关节手术四种麻醉管理方法的疗效。
对 2012 年至 2015 年间由一名外科医生进行的所有肩关节手术患者的图表，按照镇痛方案进行分类：仅 GA（n=177）、单次肌间沟阻滞（n=124）或术前-术后肌间沟阻滞联合 GA（ISBPB+GA[n=72]vsGA+ISBPB[n=52]）。主要观察指标是从麻醉后护理单元（PACU）出院的时间。
PACU 时间的平均值（标准差）范围为肌间沟阻滞仅 70.5（39.9）分钟至 GA 仅 111.2（56.9）分钟。任何组合形式使用肌间沟阻滞，无论时机如何，都显著缩短 PACU 时间，平均减少 27.2 分钟（95%置信区间[CI]，17.3 至 37.2；P<0.001）。最大的平均成对差异是 GA 与肌间沟阻滞，平均差异为 40.7 分钟（95%CI，25.5 至 55.8；P<0.001）。肌间沟阻滞也降低了到达 PACU 时的疼痛程度，在某些情况下，还降低了离开 PACU 时的疼痛程度（即肌间沟阻滞，而不是肌间沟阻滞+GA 与 GA 相比）。ISBPB（单独使用或在 GA 之前）还减少了镇痛需求。
关节镜肩关节手术中肌间沟阻滞的益处得到了证实。术后肌间沟阻滞也可能有助于减轻疼痛和阿片类药物需求，并可针对苏醒时疼痛剧烈的患者。一项足够大的随机对照试验可以确定每种方法的相对疗效、安全性和相关的经济影响。
