von Plato Hanna, Kontinen Vesa, Hamunen Katri
Division of Perioperative Care, Jorvi Hospital, Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, P. O. Box 800, 00029 HUS, Helsinki, Finland, Phone: +350504284471.
Division of Perioperative Care, Jorvi Hospital, Department of Anesthesiology and Intensive Care Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Scand J Pain. 2018 Jan 26;18(1):3-17. doi: 10.1515/sjpain-2017-0170.
Treatment of pain following major limb amputations is often a clinical challenge in a patient population consisting mainly of elderly with underlying diseases. Literature on management of acute post-amputation pain is scarce. We performed a systematic review on this topic to evaluate the efficacy and safety of analgesic interventions for acute pain following major limb amputation.
A literature search was performed in PubMed, Cochrane Central Register of Controlled Trials and Cochrane Database of Systematic Reviews using the following key words: [(amputation) AND (pain OR analgesi* OR pain relief)] AND (acute OR postoperative). Randomized controlled studies (RCTs) and observational studies investigating treatment of acute pain following major amputations for any indication (peripheral vascular disease, malignant disease, trauma) were included. The review was performed according to the standards described in the PRISMA statement. The Cochrane quality assessment tool was used to evaluate the risk of bias in the RCTs.
Nineteen studies with total of 949 patients were included. The studies were generally small and heterogeneous on outcomes, study designs and quality. There were 16 studies on epidural or continuous perineural analgesia (CPI). Based on five RCTs (n=268) and two observational studies (n=49), epidural analgesia decreased the intensity of acute stump pain as compared to systemic analgesics, during the first 24 h after the operation. Based on one study epidural analgesia caused more adverse effects like sedation, nausea and motor block than continuous perineural local anesthetic infusion. Based on one RCT (n=21) and eight observational studies (n=501) CPI seemed to decrease opioid consumption as compared to systemic analgesics only, on the first three postoperative days, and was well tolerated. Only three trials investigated systemic analgesics (oral memantine, oral gabapentine, iv ketamine). Ketamine did not decrease acute pain or opioid consumption after amputation as compared to other systemic analgesics. Gabapentin did not decrease acute pain when combined to epidural analgesia as compared to epidural analgesia and opioid treatment, and caused adverse effects.
The main finding of this systematic review is that evidence regarding pain management after major limb amputation is very limited. Epidural analgesia may be effective, but firm evidence is lacking. Epidural causes more adverse effects than CPI. The results on efficacy of CPI are indecisive. The data on adjuvant medications combined to epidural analgesia or CPI is limited. Studies on efficacy and adverse effects of systemic analgesics for amputation pain, especially concentrating on elderly patients, are needed.
在主要由患有基础疾病的老年人组成的患者群体中，治疗大肢体截肢后的疼痛通常是一项临床挑战。关于急性截肢后疼痛管理的文献稀缺。我们针对该主题进行了一项系统评价，以评估大肢体截肢后急性疼痛镇痛干预措施的疗效和安全性。
在PubMed、Cochrane对照试验中心注册库和Cochrane系统评价数据库中进行文献检索，使用以下关键词：[(截肢) AND (疼痛或镇痛*或疼痛缓解)] AND (急性或术后)。纳入了针对任何适应症（外周血管疾病、恶性疾病、创伤）的大截肢后急性疼痛治疗的随机对照研究（RCT）和观察性研究。该评价按照PRISMA声明中所述的标准进行。使用Cochrane质量评估工具评估RCT中的偏倚风险。
纳入了19项研究，共949例患者。这些研究在结局、研究设计和质量方面通常规模较小且存在异质性。有16项关于硬膜外或连续神经周围镇痛（CPI）的研究。基于5项RCT（n = 268）和2项观察性研究（n = 49），与全身镇痛药相比，硬膜外镇痛在术后头24小时内可降低急性残端疼痛的强度。基于一项研究，硬膜外镇痛比连续神经周围局部麻醉药输注引起更多的不良反应，如镇静、恶心和运动阻滞。基于一项RCT（n = 21）和8项观察性研究（n = 501），与仅使用全身镇痛药相比，CPI在前三天似乎可减少阿片类药物的消耗，且耐受性良好。仅有三项试验研究了全身镇痛药（口服美金刚、口服加巴喷丁、静脉注射氯胺酮）。与其他全身镇痛药相比，氯胺酮在截肢后并未降低急性疼痛或阿片类药物的消耗。与硬膜外镇痛和阿片类药物治疗相比，加巴喷丁与硬膜外镇痛联合使用时并未降低急性疼痛，且会引起不良反应。
该系统评价的主要发现是，关于大肢体截肢后疼痛管理的证据非常有限。硬膜外镇痛可能有效，但缺乏确凿证据。硬膜外镇痛比CPI引起更多的不良反应。CPI的疗效结果尚无定论。与硬膜外镇痛或CPI联合使用的辅助药物的数据有限。需要开展关于全身镇痛药治疗截肢疼痛的疗效和不良反应的研究，尤其要关注老年患者。
