Section of Thoracic Surgery, Department of Surgery, University of Miami, Miami, Fla.
Department of Anesthesia, University of Miami, Miami, Fla.
J Thorac Cardiovasc Surg. 2021 May;161(5):1689-1701. doi: 10.1016/j.jtcvs.2019.12.137. Epub 2020 Apr 3.
To evaluate differences in postoperative pain control and opioids requirement in thoracic surgical patients following implementation of an Enhanced Recovery after Thoracic Surgery protocol with a comprehensive postoperative pain management strategy.
A retrospective analysis of a prospectively maintained database of patients undergoing pulmonary resections by robotic thoracoscopy or thoracotomy from January 1, 2017, to January 31, 2019, was conducted. Multimodal pain management strategy (opioid-sparing analgesics, infiltration of liposomal bupivacaine to intercostal spaces and surgical sites, and elimination of thoracic epidural analgesia use in thoracotomy patients) was implemented as part of Enhanced Recovery after Thoracic Surgery on February 1, 2018. Outcome metrics including patient-reported pain levels, in-hospital and postdischarge opioids use, postoperative complications, and length of stay were compared before and after protocol implementation.
In total, 310 robotic thoracoscopy and 62 thoracotomy patients met the inclusion criteria. This pain management strategy was associated with significant reduction of postoperative pain in both groups with an overall reduction of postoperative opioids requirement. Median in-hospital opioids use (morphine milligram equivalent per day) was reduced from 30 to 18.36 (P = .009) for the robotic thoracoscopy group and slightly increased from 15.48 to 21.0 (P = .27) in the thoracotomy group. More importantly, median postdischarge opioids prescribed (total morphine milligram equivalent) was significantly reduced from 480.0 to 150.0 (P < .001) and 887.5 to 150.0 (P < .001) for the thoracoscopy and thoracotomy groups, respectively. Similar short-term perioperative outcomes were observed in both groups before and following protocol implementation.
Implementation of Enhanced Recovery after Thoracic Surgery allows safe elimination of epidural use, better pain control, and less postoperative opioids use, especially a drastic reduction of postdischarge opioid need, without adversely affecting outcomes.
评估实施胸外科加速康复后方案（含全面术后疼痛管理策略）后，接受胸腔镜或开胸肺切除术的患者在术后疼痛控制和阿片类药物需求方面的差异。
对 2017 年 1 月 1 日至 2019 年 1 月 31 日期间行机器人辅助胸腔镜或开胸肺切除术的患者前瞻性数据库进行回顾性分析。2018 年 2 月 1 日实施多模式疼痛管理策略（阿片类药物节约型镇痛剂、肋间注射脂质体布比卡因和避免开胸手术中使用胸段硬膜外镇痛）作为胸外科加速康复的一部分。比较方案实施前后的患者报告疼痛水平、住院期间和出院后阿片类药物使用、术后并发症和住院时间等结局指标。
共有 310 例胸腔镜和 62 例开胸手术患者符合纳入标准。该疼痛管理策略与两组患者术后疼痛显著减轻相关，总体上降低了术后阿片类药物需求。胸腔镜组术后住院期间阿片类药物使用（吗啡毫克当量/天）中位数从 30 降至 18.36（P=0.009），开胸组则从 15.48 微升至 21.0（P=0.27）。更重要的是，胸腔镜组和开胸组出院后处方阿片类药物中位数（总吗啡毫克当量）分别从 480.0 降至 150.0（P<0.001）和 887.5 降至 150.0（P<0.001）。两组在方案实施前后均观察到类似的短期围手术期结局。
实施胸外科加速康复后方案可安全消除硬膜外镇痛的使用，更好地控制疼痛，减少术后阿片类药物使用，尤其是大幅减少出院后阿片类药物需求，而不影响结局。
