Banks Kian, Ely Sora, Hsu Diana S, Dominguez Dana A, Gologorsky Rebecca C, Wei Julia, Maxim Clara, Ashiku Simon K, Patel Ashish R, Velotta Jeffrey B
Department of Surgery, UCSF East Bay, Oakland, CA, USA.
Department of Thoracic Surgery, Kaiser Permanente Northern California, Oakland, CA, USA.
J Thorac Dis. 2022 Jan;14(1):18-25. doi: 10.21037/jtd-21-1583.
Intercostal nerve blockade (INB) for thoracic surgery analgesia has gained popularity in practice, but evidence demonstrating its efficacy remains sparse and inconsistent. We investigated the effect of INB with standard bupivacaine (SB) with epinephrine versus liposomal bupivacaine (LB) versus a mixed solution of the two on postoperative pain control and outcomes in video assisted thoracoscopic lobectomy patients.
Since 2014, our practice has shifted from using INBs with SB with epinephrine, to LB, to a mix of the two as the central component of multimodal analgesia after video assisted thoracoscopic surgery. The blocks are performed in a standardized fashion under thoracoscopic visualization consecutively from two rib spaces above to two below the outermost incisions. We retrospectively compared all minimally invasive lobectomies performed at our institution between January 2014 and July 2018 by type of local anesthetic used for INB. We examined median length of stay (LOS), opioid utilization, and subjective pain scores [0-10].
Out of 302 minimally invasive lobectomy patients, 34 received SB with epinephrine, 222 received LB alone, and 46 received the mixed solution. LOS was almost a full day shorter in the LB group than in the SB group (34.8 56.5 hours, P=0.01). There was nearly 25% lower median total morphine equivalent utilization in the mixed solution cohort compared to the LB cohort (-7.1 mg, P=0.02). Additionally, IV morphine equivalent utilization was over 50% lower in the mixed solution group than in the SB with epinephrine group (-10.0 mg, P=0.03).
Our study is by far the largest (N=302) to compare types of local anesthetic used for INB within a uniform case population. The reductions in LOS and opiate utilization observed in our study among patients receiving LB-based formulations were both statistically and clinically significant.
肋间神经阻滞（INB）用于胸外科手术镇痛在实践中已得到广泛应用，但证明其疗效的证据仍然稀少且不一致。我们研究了标准布比卡因（SB）加肾上腺素的INB、脂质体布比卡因（LB）以及两者的混合溶液对电视辅助胸腔镜肺叶切除术患者术后疼痛控制和结局的影响。
自2014年以来，我们的做法已从使用SB加肾上腺素的INB，转变为使用LB，再到将两者的混合溶液作为电视辅助胸腔镜手术后多模式镇痛的核心组成部分。阻滞在胸腔镜可视化下以标准化方式连续从最外侧切口上方两个肋间隙到下方两个肋间隙进行。我们回顾性比较了2014年1月至2018年7月在我们机构进行的所有微创肺叶切除术，根据用于INB的局部麻醉剂类型进行分类。我们检查了中位住院时间（LOS）、阿片类药物使用情况和主观疼痛评分[0 - 10]。
在302例微创肺叶切除术患者中，34例接受了SB加肾上腺素，222例单独接受了LB，46例接受了混合溶液。LB组的LOS比SB组短近一整天（34.8对56.5小时，P = 0.01）。与LB队列相比，混合溶液队列的中位总吗啡当量使用量降低了近25%（-7.1毫克，P = 0.02）。此外，混合溶液组的静脉注射吗啡当量使用量比SB加肾上腺素组低超过50%（-10.0毫克，P = 0.03）。
我们的研究是迄今为止在统一病例人群中比较用于INB的局部麻醉剂类型的最大规模研究（N = 302）。在我们的研究中，接受基于LB配方的患者中观察到的LOS和阿片类药物使用量的减少在统计学和临床上均具有显著意义。
