Department of Anesthesiology and Perioperative Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania.
J Surg Res. 2019 Dec;244:15-22. doi: 10.1016/j.jss.2019.05.049. Epub 2019 Jul 3.
Intrathecal morphine (ITM) and peripheral nerve blocks are accepted techniques for analgesia after abdominal surgery, but their efficacy has not been evaluated in the context of an enhanced recovery pathway (ERP) in pancreatic surgery.
We retrospectively compared postoperative analgesia (pain scores and opioid requirements) after open or robotic pancreatoduodenectomy or distal pancreatectomy among ERP patients receiving either ITM or transversus abdominis plane/quadratus lumborum (TAP/QL) nerve blocks.
We identified 303 ERP patients who underwent pancreatectomy with either ITM (n = 251) or TAP/QL blocks (n = 52). Patient demographics and procedural variables were similar between groups. Few preoperative patient characteristics (preoperative stroke and pain medication intake) differed between the two groups. In an unmatched patient cohort, the median pain score on postoperative day (POD 0) zero was 4.5 (interquartile range [IQR] 2.3-5.8) in ITM patients compared with 5.7 (IQR, 3.4-6.9) in patients who received TAP/QL (P < 0.05). Median opioid consumption in intravenous morphine equivalents on POD 0 was 2.7 mg (IQR, 0-11.7) in ITM patients compared with 8.4 mg (IQR, 2.5-20.8) in TAP/QL patients (P < 0.001). After propensity matching for patient characteristics, pain scores and opioid consumption were significantly (P < 0.05) lower on POD 0 and POD 5 in patients who received ITM. The difference in quality of analgesia between ITM and TAP/QL was also maintained in the pancreaticoduodenectomy and distal pancreatectomy subgroups. Extubation in the operating room was achieved in a higher percentage of patients receiving ITM (92%) compared with those receiving TAP/QL (63%). The incidence of postoperative nausea and vomiting was similar in both groups.
ITM was associated with reduced pain scores and opioid requirements compared with peripheral nerve blocks in an ERP for pancreatic surgery.
鞘内吗啡（ITM）和外周神经阻滞是腹部手术后镇痛的常用技术，但在胰腺手术的加速康复通道（ERP）背景下，其疗效尚未得到评估。
我们回顾性比较了接受 ERP 的患者在接受 ITM 或腹横肌平面/腰方肌（TAP/QL）神经阻滞后行开腹或机器人胰十二指肠切除术或胰体尾切除术的术后镇痛（疼痛评分和阿片类药物需求）。
我们确定了 303 例接受胰切除术的 ERP 患者，其中 251 例接受 ITM，52 例接受 TAP/QL 阻滞。两组患者的人口统计学和手术变量相似。两组患者的少数术前患者特征（术前中风和疼痛药物摄入）存在差异。在未匹配的患者队列中，接受 ITM 的患者术后第 0 天（POD 0）零时刻的中位数疼痛评分为 4.5（四分位距 [IQR] 2.3-5.8），而接受 TAP/QL 的患者为 5.7（IQR，3.4-6.9）（P<0.05）。接受 ITM 的患者在 POD 0 时静脉注射吗啡等效物的中位数阿片类药物消耗量为 2.7mg（IQR，0-11.7），而接受 TAP/QL 的患者为 8.4mg（IQR，2.5-20.8）（P<0.001）。对患者特征进行倾向匹配后，接受 ITM 的患者在 POD 0 和 POD 5 的疼痛评分和阿片类药物消耗量均显著（P<0.05）降低。在胰十二指肠切除术和胰体尾切除术亚组中，ITM 和 TAP/QL 之间的镇痛质量差异也得到维持。接受 ITM 的患者在手术室拔管的比例（92%）高于接受 TAP/QL 的患者（63%）。两组患者术后恶心呕吐的发生率相似。
与 ERP 下的外周神经阻滞相比，ITM 与胰腺手术后疼痛评分和阿片类药物需求降低相关。
