Harky Amer, Clarke Ciaran Grafton, Kar Ashok, Bashir Mohamad
Department of Vascular Surgery, Countess of Chester, Chester, UK.
School of Medicine, University of Liverpool, Liverpool, UK.
Interact Cardiovasc Thorac Surg. 2019 Mar 1;28(3):404-406. doi: 10.1093/icvts/ivy265.
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: In patients undergoing video-assisted thoracoscopic surgery, is paravertebral block (PVB) superior to epidural analgesia (EP) in terms of pain control and its postoperative complication rates? Altogether, 153 papers were found using the reporting search, of which 4 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. At present, there are a limited number of studies directly comparing pain control and postoperative outcomes between PVB and EP, and no large-scale randomized trials have been reported. Three of the 4 papers are small prospective randomized trials, with a small cohort study featuring as the final piece of literature. There is no conclusive body of evidence to recommend either route as more efficacious from a pain control perspective; one study demonstrated significantly lower levels of pain with EP (P = 0.01), with a second study demonstrating significantly better pain control with PVB (P < 0.01) and a third failing to demonstrate any significant difference (P = 0.899). The frequency of requiring supplemental analgesia was similar between the PVB and EP cohorts (56% vs 48%, P = 0.26). PVB is associated with lower rates of postoperative complications compared to EP, specifically urinary retention (64% vs 34.6%, P = 0.0036) and hypotension (32% vs 7%, P = 0.0031; 21% vs 3%, P = 0.02). In summary, PVBs appear to offer an equivalent level of analgesic effect following video-assisted thoracoscopic surgery, with a more favourable side-effect profile, compared to EP. This does need to be contextualized in light of the scarcity of published material, with the available studies each containing a small number of participants.
一篇心脏外科的最佳证据主题文章是按照结构化方案撰写的。所探讨的问题是：在接受电视辅助胸腔镜手术的患者中，在疼痛控制及其术后并发症发生率方面，椎旁阻滞（PVB）是否优于硬膜外镇痛（EP）？通过报告搜索共找到153篇论文，其中4篇代表了回答该临床问题的最佳证据。这些论文的作者、期刊、出版日期和国家、所研究的患者组、研究类型、相关结局和结果均列于表格中。目前，直接比较PVB和EP在疼痛控制和术后结局方面的研究数量有限，且尚无大规模随机试验的报道。4篇论文中有3篇是小型前瞻性随机试验，最后一篇文献是一项小型队列研究。从疼痛控制的角度来看，没有确凿的证据表明哪种途径更有效；一项研究表明EP的疼痛水平显著更低（P = 0.01），另一项研究表明PVB的疼痛控制显著更好（P < 0.01），第三项研究未显示出任何显著差异（P = 0.899）。PVB组和EP组需要补充镇痛的频率相似（56%对48%，P = 0.26）。与EP相比，PVB术后并发症发生率更低，特别是尿潴留（64%对34.6%，P = 0.0036）和低血压（32%对7%，P = 0.0031；21%对3%，P = 0.02）。总之，与EP相比，PVB在电视辅助胸腔镜手术后似乎能提供同等水平的镇痛效果，且副作用更小。鉴于已发表材料的稀缺性，这确实需要结合具体情况来看，现有研究每项都包含少量参与者。
