Liu M, Rock P, Grass J A, Heitmiller R F, Parker S J, Sakima N T, Webb M D, Gorman R B, Beattie C
Department of Anesthesiology, Johns Hopkins Medical Institutions, Baltimore, Maryland, USA.
Reg Anesth. 1995 Sep-Oct;20(5):418-25.
Thoracotomy is associated with pain and compromised pulmonary function. Intercostal nerve blocks (INB) and subarachnoid morphine (SM) act on different portions of the pain pathway. Each is effective for post-thoracotomy pain relief. The combination of these two modalities in relieving post-thoracotomy pain and improving postoperative pulmonary function has not been investigated.
In a double-blind study, 20 patients undergoing lateral thoracotomy for lung resection were randomized to receive 0.5 mg SM preoperatively and INB with bupivacaine (INB+) prior to wound closure or 0.5 mg SM with INB using saline (INB-). Visual analog scale pain scores at rest, with cough, and with movement of the ipsilateral arm, forced expiratory volume in 1 second (FEV1), and forced vital capacity (FVC) were measured at 4, 24, 48, and 72 hours after the operation. Opioid use was measured during the initial 24 hours after the operation.
At 4 hours, the INB+ group demonstrated better FEV1 (56.6% vs. 40.4% of baseline, P < .05) and FVC values (54.6% vs. 39.6% of baseline, P < .05) and less resting and cough pain (P < .05). However, FEV1 continued to decline in the INB+ group at 24 hours to lower than the INB- group although pain scores were similar beyond 4 hours. Opioid usage during the first 24 hours was similar (INB-, 16.7 mg vs. INB+, 13.2 mg, P = .7).
Although postoperative INB provided modest improvements in pain and pulmonary function when used as an adjuvant to 0.5 mg SM for post-thoracotomy analgesia, the benefits were transient. The authors do not recommend adding INB for patients undergoing lateral thoracotomy who receive 0.5 mg SM.
开胸手术会引发疼痛并导致肺功能受损。肋间神经阻滞（INB）和蛛网膜下腔注射吗啡（SM）作用于疼痛传导通路的不同部位。二者对开胸术后的疼痛缓解均有效。尚未对这两种方式联合用于缓解开胸术后疼痛及改善术后肺功能进行研究。
在一项双盲研究中，20例行肺切除侧开胸手术的患者被随机分为两组，一组在术前接受0.5mg SM，并在伤口缝合前接受布比卡因肋间神经阻滞（INB+），另一组接受0.5mg SM及用生理盐水进行的肋间神经阻滞（INB-）。在术后4、24、48和72小时测量静息、咳嗽及同侧手臂活动时的视觉模拟评分疼痛分数、第1秒用力呼气量（FEV1）和用力肺活量（FVC）。在术后最初24小时内测量阿片类药物的使用情况。
在4小时时，INB+组的FEV1（分别为基线的56.6%和40.4%，P <.05）和FVC值（分别为基线的54.6%和39.6%，P <.05）更好，静息和咳嗽时的疼痛更轻（P <.05）。然而，尽管4小时后疼痛评分相似，但INB+组在24小时时FEV1继续下降，低于INB-组。术后最初24小时内阿片类药物的使用量相似（INB-组为16.7mg，INB+组为13.2mg，P =.7）。
尽管术后肋间神经阻滞作为0.5mg SM用于开胸术后镇痛的辅助手段时，在疼痛和肺功能方面有适度改善，但益处是短暂的。作者不建议对接受0.5mg SM的侧开胸手术患者加用肋间神经阻滞。
