多模式疼痛管理策略与围手术期结局和资源利用的关联：一项基于人群的研究。
Association of Multimodal Pain Management Strategies with Perioperative Outcomes and Resource Utilization: A Population-based Study.
机构信息
From Weill Cornell Medical College, New York, New York (S.G.M., C.C., E.E.M.); Department of Anesthesiology, Hospital for Special Surgery, New York, New York (S.G.M., C.C., E.E.M.); Department of Anesthesiology and Departments of Perioperative Medicine and Intensive Care Medicine (S.G.M., C.C., E.E.M.), Paracelsus Medical University, Salzburg, Austria; Institute for Healthcare Delivery Science, Department of Population Health Science and Policy (J.P., N.Z., M.M.), Department of Orthopaedics (J.P., N.Z.), and Department of Medicine (J.P.), Icahn School of Medicine at Mount Sinai, New York, New York; Veterans Affairs Palo Alto Health Care System, Palo Alto, California (E.R.M.); and Stanford University School of Medicine, Stanford, California (E.R.M.).
出版信息
Anesthesiology. 2018 May;128(5):891-902. doi: 10.1097/ALN.0000000000002132.
BACKGROUND
Multimodal analgesia is increasingly considered routine practice in joint arthroplasties, but supportive large-scale data are scarce. The authors aimed to determine how the number and type of analgesic modes is associated with reduced opioid prescription, complications, and resource utilization.
METHODS
Total hip/knee arthroplasties (N = 512,393 and N = 1,028,069, respectively) from the Premier Perspective database (2006 to 2016) were included. Analgesic modes considered were opioids, peripheral nerve blocks, acetaminophen, steroids, gabapentin/pregabalin, nonsteroidal antiinflammatory drugs, cyclooxygenase-2 inhibitors, or ketamine. Groups were categorized into "opioids only" and 1, 2, or more than 2 additional modes. Multilevel models measured associations between multimodal analgesia and opioid prescription, cost/length of hospitalization, and opioid-related adverse effects. Odds ratios or percent change and 95% CIs are reported.
RESULTS
Overall, 85.6% (N = 1,318,165) of patients received multimodal analgesia. In multivariable models, additions of analgesic modes were associated with stepwise positive effects: total hip arthroplasty patients receiving more than 2 modes (compared to "opioids only") experienced 19% fewer respiratory (odds ratio, 0.81; 95% CI, 0.70 to 0.94; unadjusted 1.0% [N = 1,513] vs. 2.0% [N = 1,546]), 26% fewer gastrointestinal (odds ratio, 0.74; 95% CI, 0.65 to 0.84; unadjusted 1.5% [N = 2,234] vs. 2.5% [N = 1,984]) complications, up to a -18.5% decrease in opioid prescription (95% CI, -19.7% to -17.2%; 205 vs. 300 overall median oral morphine equivalents), and a -12.1% decrease (95% CI, -12.8% to -11.5%; 2 vs. 3 median days) in length of stay (all P < 0.05). Total knee arthroplasty analyses showed similar patterns. Nonsteroidal antiinflammatory drugs and cyclooxygenase-2 inhibitors seemed to be the most effective modalities used.
CONCLUSIONS
While the optimal multimodal regimen is still not known, the authors' findings encourage the combined use of multiple modalities in perioperative analgesic protocols.
背景
多模式镇痛在关节置换术中越来越被认为是常规做法，但缺乏支持性的大规模数据。作者旨在确定使用的镇痛模式的数量和类型与减少阿片类药物处方、并发症和资源利用之间的关系。
方法
从 Premier 透视数据库（2006 年至 2016 年）中纳入了全髋关节/膝关节置换术（N=512393 和 N=1028069）的患者。考虑的镇痛模式包括阿片类药物、周围神经阻滞、对乙酰氨基酚、皮质类固醇、加巴喷丁/普瑞巴林、非甾体抗炎药、环氧化酶-2 抑制剂或氯胺酮。将组分为“仅使用阿片类药物”和 1、2 或 2 种以上的附加模式。多水平模型测量了多模式镇痛与阿片类药物处方、住院费用/时间长度和阿片类药物相关不良反应之间的关系。报告了比值比或百分比变化及其 95%置信区间。
结果
总体而言，85.6%（N=1318165）的患者接受了多模式镇痛。在多变量模型中，添加镇痛模式与逐步积极的效果相关：接受 2 种以上模式的全髋关节置换术患者（与“仅使用阿片类药物”相比）经历了 19%的更少的呼吸系统并发症（比值比，0.81；95%置信区间，0.70 至 0.94；未调整的 1.0%[N=1513]与 2.0%[N=1546]），26%的胃肠道并发症（比值比，0.74；95%置信区间，0.65 至 0.84；未调整的 1.5%[N=2234]与 2.5%[N=1984]），阿片类药物处方减少高达 18.5%（95%置信区间，19.7%至 17.2%；205 与 300 总口服吗啡当量），住院时间缩短 12.1%（95%置信区间，12.8%至 11.5%；2 与 3 中位数天）（所有 P<0.05）。全膝关节置换术分析显示出类似的模式。非甾体抗炎药和环氧化酶-2 抑制剂似乎是最有效的镇痛模式。
结论
虽然最佳的多模式方案仍不清楚，但作者的发现鼓励在围手术期镇痛方案中联合使用多种模式。
Zotero 插件