King Morgan, Stambulic Thomas, Hassan Syed M Ali, Norman Patrick A, Derry Kendra, Payne Darrin M, El Diasty Mohammad
Queen's School of Medicine, Kingston, Ontario, Canada.
Kingston General Health Research Institute, Kingston, Ontario, Canada.
J Card Surg. 2022 Nov;37(11):3729-3742. doi: 10.1111/jocs.16882. Epub 2022 Sep 13.
Inadequate pain control after median sternotomy leads to reduced mobilization, increased respiratory complications, and longer hospital stays. Typically, postoperative pain is controlled by opioid analgesics that may have several adverse effects. Parasternal intercostal block (PSB) has emerged as part of a multimodal strategy to control pain after median sternotomy. However, the effectiveness of this intervention on postoperative pain control and analgesic use has not been fully established.
We conducted a meta-analysis to assess the effect of PSB on postoperative pain and analgesic use in adult cardiac surgery patients undergoing median sternotomy. PubMed, Embase, Google Scholar, and the Cochrane database were searched with the following search strategy: ([postoperative pain] or [pain relief] OR [analgesics] or [analgesia] or [nerve block] or [regional block] or [local block] or [regional anesthesia] or [local anesthetic] or [parasternal block] and [sternotomy]) and (humans [filter]). Inclusion criteria were: patients who underwent cardiac surgery via median sternotomy, age >18 and parasternal block (continuous and single dose). Exclusion criteria were: noncardiac surgery, nonparasternal nerve blocks, and the use of NSAIDS in parasternal block. Quality assessment was performed by three independent reviewers via the Cochrane risk of bias assessment tool. Of 1165 total citations, 18 were found to be relevant. Of these 18 citations, 7 citations (N = 2223 patients) reported postoperative pain scores in an extractable format and 11 citations (N = 2155 patients) reported postoperative opioid use in an extractable format. For postoperative opioid use, morphine equivalent doses were calculated for all studies and postoperative pain scores were standardized to a 10-point visual analog scale for comparison between studies; both these were reported as total opioid use or cumulative score ranging from 24 to 72 h postoperative. All data analyses were run using a random effects model, using a restricted maximum likelihood estimator, to obtain summary standardized mean differences with 95% confidence interval (CI's). For studies which only reported median and interquatile range (IQR), the median was standard deviation was estimated by IQR/1.35. Following median sternotomy both postoperative pain (SMD [95% CI] -0.49 [-0.92 to -0.06]) and postoperative morphine equivalent use (SMD [95% CI] -1.68 [-3.11 to -0.25]) were significantly less in the PSB group.
Our meta-analysis suggests that parasternal nerve block significantly reduces postoperative pain and opioid use.
正中开胸术后疼痛控制不佳会导致活动减少、呼吸并发症增加以及住院时间延长。通常，术后疼痛通过阿片类镇痛药控制，而这类药物可能有多种不良反应。胸骨旁肋间阻滞（PSB）已成为正中开胸术后疼痛控制多模式策略的一部分。然而，这种干预措施对术后疼痛控制和镇痛药使用的有效性尚未完全确立。
我们进行了一项荟萃分析，以评估PSB对接受正中开胸的成年心脏手术患者术后疼痛和镇痛药使用的影响。使用以下检索策略在PubMed、Embase、谷歌学术和Cochrane数据库中进行检索：（[术后疼痛]或[疼痛缓解]或[镇痛药]或[镇痛]或[神经阻滞]或[区域阻滞]或[局部阻滞]或[区域麻醉]或[局部麻醉]或[胸骨旁阻滞]和[开胸术]）以及（人类[过滤器]）。纳入标准为：通过正中开胸进行心脏手术的患者，年龄>18岁且接受胸骨旁阻滞（连续和单次剂量）。排除标准为：非心脏手术、非胸骨旁神经阻滞以及在胸骨旁阻滞中使用非甾体抗炎药。由三名独立评审员通过Cochrane偏倚风险评估工具进行质量评估。在总共1165条引用文献中，发现18条相关。在这18条引用文献中，7条引用文献（N = 2223例患者）以可提取格式报告了术后疼痛评分，11条引用文献（N = 2155例患者）以可提取格式报告了术后阿片类药物使用情况。对于术后阿片类药物使用，计算所有研究的吗啡等效剂量，并将术后疼痛评分标准化为10分视觉模拟量表以便进行研究间比较；这两者均报告为术后24至72小时的阿片类药物总使用量或累积评分。所有数据分析均使用随机效应模型，采用限制最大似然估计器，以获得95%置信区间（CI）的汇总标准化均值差。对于仅报告中位数和四分位间距（IQR）的研究，中位数标准差通过IQR/1.35估计。正中开胸术后，PSB组的术后疼痛（标准化均值差[95%CI] -0.49 [-0.92至-0.06]）和术后吗啡等效使用量（标准化均值差[95%CI] -1.68 [-3.11至-0.25]）均显著降低。
我们的荟萃分析表明，胸骨旁神经阻滞可显著减轻术后疼痛和阿片类药物使用量。
