Department of Anaesthesia, Austin Health, Heidelberg, Australia.
Department of Critical Care, The University of Melbourne, Austin Health, Heidelberg, Australia.
PLoS One. 2023 Sep 8;18(9):e0291108. doi: 10.1371/journal.pone.0291108. eCollection 2023.
The optimal analgesic modality for patients undergoing hepato-pancreato-biliary (HPB) surgery remains unknown. The analgesic effects of a multimodal intrathecal analgesia (MITA) technique of intrathecal morphine (ITM) in combination with clonidine and bupivacaine compared to ITM alone have not been investigated in these patients.
We performed a multicenter retrospective study of patients undergoing complex HPB surgery who received ITM, bupivacaine, and clonidine (MITA group) or ITM-only (ITM group) as part of their perioperative analgesia strategy. The primary outcome was the unadjusted oral morphine equivalent daily dose (oMEDD) in milligrams on postoperative day 1. After adjusting for age, body mass index, hospital allocation, type of surgery, operation length, and intraoperative opioid use, postoperative oMEDD use was investigated using a bootstrapped quantile regression model. Other prespecified outcomes included postoperative pain scores, opioid-related adverse events, major complications, and length of hospital stay.
In total, 118 patients received MITA and 155 patients received ITM-only. The median (IQR) cumulative oMEDD use on postoperative day 1 was 20.5 mg (8.6:31.0) in the MITA group and 52.1 mg (18.0:107.0) in the ITM group (P < 0.001). There was a variation in the magnitude of the difference in oMEDD use between the groups for different quartiles. For the MITA group, on postoperative day 1, patients in the 25th percentile required 14.0 mg less oMEDD (95% CI: -25.9 to -2.2; P = 0.025), patients in the 50th percentile required 27.8 mg less oMEDD (95% CI: -49.7 to -6.0; P = 0.005), and patients in the 75th percentile required 38.7 mg less oMEDD (95% CI: -72.2 to -5.1; P = 0.041) compared to patients in the same percentile of the ITM group. Patients in the MITA group had significantly lower pain scores in the postoperative recovery unit and on postoperative days 1 to 3. The incidence of postoperative respiratory depression was low (<1.5%) and similar between groups. Patients in the MITA group had a significantly higher incidence of postoperative hypotension requiring vasopressor support. However, no significant differences were observed in major postoperative complications, or the length of hospital stay.
In patients undergoing complex HPB surgery, the use of MITA, consisting of ITM in combination with intrathecal clonidine and bupivacaine, was associated with reduced postoperative opioid use and resulted in superior postoperative analgesia without risk of respiratory depression when compared to patients who received ITM alone. A randomized prospective clinical trial investigating these two intrathecal analgesic techniques is justified.
接受肝胆胰手术（HPB）的患者最佳镇痛方式仍不清楚。鞘内吗啡（ITM）联合可乐定和布比卡因的多模式鞘内镇痛（MITA）技术与单独使用 ITM 的镇痛效果在这些患者中尚未得到研究。
我们对接受 ITM、布比卡因和可乐定（MITA 组）或单独 ITM（ITM 组）作为围手术期镇痛策略一部分的接受复杂 HPB 手术的患者进行了多中心回顾性研究。主要结局是术后第 1 天未经调整的口服吗啡等效日剂量（oMEDD）。在调整年龄、体重指数、医院分配、手术类型、手术时间和术中阿片类药物使用后，使用 bootstrap 分位数回归模型对术后 oMEDD 使用进行了研究。其他预设结局包括术后疼痛评分、阿片类药物相关不良事件、主要并发症和住院时间。
共 118 例患者接受 MITA，155 例患者接受 ITM 单药治疗。术后第 1 天 MITA 组累积 oMEDD 使用中位数（IQR）为 20.5 mg（8.6:31.0），ITM 组为 52.1 mg（18.0:107.0）（P<0.001）。不同四分位组之间 oMEDD 使用差异的程度存在差异。对于 MITA 组，术后第 1 天，第 25 百分位数的患者需要减少 14.0 mg 的 oMEDD（95%CI：-25.9 至-2.2；P=0.025），第 50 百分位数的患者需要减少 27.8 mg 的 oMEDD（95%CI：-49.7 至-6.0；P=0.005），第 75 百分位数的患者需要减少 38.7 mg 的 oMEDD（95%CI：-72.2 至-5.1；P=0.041）与 ITM 组相同百分位的患者相比。MITA 组患者在术后恢复室和术后第 1 至 3 天的疼痛评分明显较低。术后呼吸抑制的发生率较低（<1.5%），且两组之间相似。MITA 组患者发生术后低血压需要血管加压支持的发生率较高。然而，主要术后并发症或住院时间无显著差异。
在接受复杂 HPB 手术的患者中，与单独使用 ITM 相比，采用 ITM 联合鞘内可乐定和布比卡因的 MITA 与术后阿片类药物使用减少相关，并导致术后镇痛效果更好，而不会增加呼吸抑制的风险。有必要进行一项随机前瞻性临床试验来研究这两种鞘内镇痛技术。
