Sangadala Priyanka, Talawar Praveen, Tripathy Debendra K, Kaushal Ashutosh, Gupta Amit, Raj Nirjhar
Department of Anaesthesiology, Pain Medicine and Critical Care, All India Institute of Medical Sciences, Rishikesh, Uttarakhand, India.
Department of Trauma and Emergency, All India Institute of Medical Sciences, Raipur, Chhatisgarh, India.
Indian J Anaesth. 2024 Mar;68(3):280-286. doi: 10.4103/ija.ija_729_23. Epub 2024 Feb 22.
Thoracic continuous spinal anaesthesia (TCSA) is emerging as the sole anaesthetic for major abdominal surgery due to its better perioperative outcomes. This study was designed to evaluate block characteristics and outcomes in 'opioid-free' and 'opioid-based' TCSA.
After ethical approval, trial registration and written informed consent, 50 adult patients undergoing major abdominal surgery were randomised into 'opioid-free' (bupivacaine alone) and 'opioid-based' (bupivacaine with fentanyl) groups. After confirmation of T4-L1 dermatome level of spinal anaesthesia, sedation by intravenous (IV) midazolam (0.02-0.05 mg/kg), ketamine (0.25 mg/kg) and dexmedetomidine (bolus dose of 1 µg/kg IV over 10 min followed by 0.2-0.7 µg/kg/h infusion) were started. The primary outcome measured was postoperative pain scores for 72 h in both groups. The secondary objectives were rescue opioid requirement, and the dose of bupivacaine required to achieve T4 level. Data were compared using the two-sided Student -test, Mann-Whitney and Fisher's exact tests.
The 'opioid-based' group performed significantly better compared with the 'opioid-free' group concerning pain scores at rest at 0 h ( = 0.023), 18 h ( = 0.023) and 24 h ( = 0.016) postoperatively, decreased intrathecal bupivacaine requirement [(induction ( = 0.012) and maintenance ( = 0.031)], postoperative rescue fentanyl requirement ( = 0.018) and patient satisfaction ( = 0.032) at the cost of increased postoperative nausea and vomiting ( = 0.049).
The 'opioid-based' TCSA provided better postoperative analgesia with significantly lesser postoperative pain scores when compared to the 'opioid-free' group in patients undergoing major abdominal surgery.
由于其更好的围手术期结局，胸段连续脊髓麻醉（TCSA）正逐渐成为主要腹部手术的唯一麻醉方式。本研究旨在评估“无阿片类药物”和“基于阿片类药物”的TCSA的阻滞特征和结局。
在获得伦理批准、进行试验注册并获得书面知情同意后，将50例接受主要腹部手术的成年患者随机分为“无阿片类药物”组（仅用布比卡因）和“基于阿片类药物”组（布比卡因加芬太尼）。确认脊髓麻醉的T4-L1皮节水平后，开始静脉注射（IV）咪达唑仑（0.02-0.05mg/kg）、氯胺酮（0.25mg/kg）和右美托咪定（10分钟内静脉推注剂量为1μg/kg，随后以0.2-0.7μg/kg/h输注）进行镇静。测量的主要结局是两组术后72小时的疼痛评分。次要目标是补救性阿片类药物需求以及达到T4水平所需的布比卡因剂量。使用双侧学生t检验、曼-惠特尼检验和费舍尔精确检验对数据进行比较。
“基于阿片类药物”组在术后0小时（P=0.023）、18小时（P=0.023）和24小时（P=0.016）静息时的疼痛评分、鞘内布比卡因需求减少[诱导期（P=0.012）和维持期（P=0.031）]、术后补救性芬太尼需求（P=0.018）和患者满意度（P=0.032）方面明显优于“无阿片类药物”组，但代价是术后恶心和呕吐增加（P=0.049）。
在接受主要腹部手术的患者中，与“无阿片类药物”组相比时，“基于阿片类药物”的TCSA提供了更好的术后镇痛效果且术后疼痛评分明显更低。
