Departments of Neurological Surgery and.
Department of Neurosurgery, Brown University, Providence, Rhode Island.
Hosp Pediatr. 2020 May;10(5):447-451. doi: 10.1542/hpeds.2019-0298.
Multimodal analgesia (MMA) may reduce opioid use after surgery for Chiari malformation type I. An MMA protocol was implemented after both posterior fossa decompression without dural opening (PFD) and posterior fossa decompression with duraplasty (PFDD).
Scheduled nonsteroidal antiinflammatory drugs (ketorolac or ibuprofen) and diazepam were alternated with acetaminophen, and as-needed oxycodone or intravenous morphine. The primary outcome was total opioid requirement over postoperative days 0 to 2.
From 2012 to 2017, 49 PFD and 29 PFDD procedures were performed, and 46 of 78 patients used the protocol. Patients with PFD required less opioids than patients with PFDD. Among patients with PFDD, patients with MMA protocol usage had a lower mean opioid requirement than patients with no MMA protocol usage (0.53 ± 0.49 mgEq/kg versus 1.4 ± 1.0 mgEq/kg, = .0142). In multivariable analysis, MMA protocol usage status independently predicted a mean decrease in opioid requirement of 0.146 mg equivalents/kg ( = .0497) after adjustment for procedure and surgeon. Statistically significant differences were not demonstrated in antiemetic requirements, discharge opioid prescriptions, total direct cost, and length of stay.
A protocol of scheduled nonsteroidal antiinflammatory drugs alternating with scheduled acetaminophen and diazepam was associated with opioid use reductions.
多模式镇痛（MMA）可能会减少 Chiari 畸形 I 型手术后阿片类药物的使用。在未打开硬脑膜的后颅窝减压（PFD）和后颅窝减压伴硬脑膜成形术（PFDD）后，实施了 MMA 方案。
计划使用非甾体抗炎药（酮咯酸或布洛芬）和地西泮与对乙酰氨基酚交替使用，并按需使用羟考酮或静脉注射吗啡。主要结局是术后 0 至 2 天内的总阿片类药物需求。
2012 年至 2017 年，共进行了 49 例 PFD 和 29 例 PFDD 手术，78 例患者中有 46 例使用了该方案。与 PFDD 患者相比，PFD 患者的阿片类药物需求较少。在 PFDD 患者中，使用 MMA 方案的患者阿片类药物需求平均值低于未使用 MMA 方案的患者（0.53 ± 0.49 mgEq/kg 比 1.4 ± 1.0 mgEq/kg， =.0142）。在多变量分析中，MMA 方案的使用状态独立预测了术后阿片类药物需求的平均降低 0.146mg 当量/kg（ =.0497），调整了手术和外科医生的因素。在止吐药需求、出院阿片类药物处方、总直接成本和住院时间方面，未显示出统计学显著差异。
计划使用非甾体抗炎药与计划使用对乙酰氨基酚和地西泮交替的方案与阿片类药物使用减少相关。
