Department of Anesthesiology, Perioperative and Pain Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Department of Orthopedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
Br J Anaesth. 2021 Jul;127(1):110-132. doi: 10.1016/j.bja.2021.02.036.
For most procedures, there is insufficient evidence to guide clinicians in the optimal timing of advanced analgesic methods, which should be based on the expected time course of acute postoperative pain severity and aimed at time points where basic analgesia has proven insufficient.
We conducted a systematic search of the literature of analgesic trials for total hip arthroplasty (THA), extracting and pooling pain scores across studies, weighted for study size. Patients were grouped according to basic anaesthetic method used (general, spinal), and adjuvant analgesic interventions such as nerve blocks, local infiltration analgesia, and multimodal analgesia. Special consideration was given to high-risk populations such as chronic pain or opioid-dependent patients.
We identified and analysed 71 trials with 5973 patients and constructed pain trajectories from the available pain scores. In most patients undergoing THA under general anaesthesia on a basic analgesic regimen, postoperative acute pain recedes to a mild level (<4/10) by 4 h after surgery. We note substantial variability in pain intensity even in patients subjected to similar analgesic regimens. Chronic pain or opioid-dependent patients were most often actively excluded from studies, and never analysed separately.
We have demonstrated that it is feasible to construct procedure-specific pain curves to guide clinicians on the timing of advanced analgesic measures. Acute intense postoperative pain after THA should have resolved by 4-6 h after surgery in most patients. However, there is a substantial gap in knowledge on the management of patients with chronic pain and opioid-dependent patients.
对于大多数手术而言，目前尚无足够的证据来指导临床医生选择最佳的超前镇痛方法，而超前镇痛方法的选择应基于急性术后疼痛严重程度的预期时间进程，并针对基础镇痛已被证明不足的时间点。
我们对全髋关节置换术（THA）的镇痛试验文献进行了系统检索，提取并汇总了各研究中的疼痛评分，并根据研究规模进行加权。患者根据基础麻醉方法（全身麻醉、脊髓麻醉）和辅助镇痛干预措施（神经阻滞、局部浸润镇痛、多模式镇痛）进行分组。特别关注慢性疼痛或阿片类药物依赖患者等高危人群。
我们共确定并分析了 71 项试验，涉及 5973 例患者，并根据可用的疼痛评分构建了疼痛轨迹。在大多数接受全身麻醉和基础镇痛方案的 THA 患者中，术后急性疼痛在术后 4 小时后消退至轻度水平（<4/10）。我们注意到，即使在接受类似镇痛方案的患者中，疼痛强度也存在很大差异。慢性疼痛或阿片类药物依赖患者通常被主动排除在研究之外，并且从未单独进行分析。
我们已经证明，构建特定于手术的疼痛曲线来指导临床医生选择超前镇痛措施的时机是可行的。大多数接受 THA 的患者在术后 4-6 小时后急性剧烈的术后疼痛应该已经缓解。然而，对于慢性疼痛和阿片类药物依赖患者的管理，我们的知识仍然存在很大的差距。
