在胸腔镜手术患者中,在疼痛控制和术后并发症发生率方面,多数研究结果表明,椎旁阻滞(paravertebral block, PVB)优于硬膜外镇痛(epidural analgesia, EP)。目前,直接比较PVB和EP在疼痛控制和术后结局方面的研究数量有限,尚无大规模的随机试验报道。但其中有4篇论文为此提供了最好的证据说明,四篇中有3篇是小型前瞻性随机试验,最后一篇文献是一项小的队列研究。从疼痛控制的角度来看,没有确凿的证据表明这两种方法谁更有效;一项研究表明EP显著降低了疼痛水平(P = 0.01),第二项研究表明PVB明显改善了疼痛控制(P < 0.01),第三项研究未能证明任何显著差异(P = 0.899)。PVB组和EP组需要追加镇痛的频率相似(56% vs 48%, P = 0.26)。与EP相比,PVB的术后并发症发生率更低,特别是尿潴留(64% vs 34.6%, P = 0.0036)和低血压(32% vs 7%, P = 0.0031; 21% vs 3%, P = 0.02) 。而在PVB组中,联合使用舒芬太尼的研究较少,其安全性和有效性值得我们深入研究。
According to most research results, in patients undergoing video-assisted thoracoscopic surgery, paravertebral block (PVB) is superior to epidural analgesia (EP) in terms of pain control and its postoperative complication rates. At present, there are a limited number of studies directly com-paring pain control and postoperative outcomes between PVB and EP, and no large-scale random-ized trials have been reported. But, there were four papers that represented the best evidence to answer the clinical question. Three of the 4 papers are small prospective randomized trials, with a small cohort study featuring as the final piece of literature. There is no conclusive body of evidence to recommend either route as more efficacious from a pain control perspective; one study demonstrated significantly lower levels of pain with EP (P = 0.01), with a second study demon-strating significantly better pain control with PVB (P < 0.01) and a third failing to demonstrate any significant difference (P = 0.899). The frequency of requiring supplemental analgesia was similar between the PVB and EP cohorts (56% vs 48%, P = 0.26). PVB is associated with lower rates of postoperative complications compared to EP, specifically urinary retention (64% vs 34.6%, P = 0.0036) and hypotension (32% vs 7%, P = 0.0031; 21% vs 3%, P = 0.02). In the PVB group, there are few studies on the combined use of sufentanil, and its safety and effectiveness deserve our in-depth study.
胸腔镜手术,椎旁阻滞,硬膜外镇痛,舒芬太尼, Video-Assisted Thoracoscopic Surgery Epidural Analgesia Paravertebral Block Sufentanil摘要
在胸腔镜手术患者中,在疼痛控制和术后并发症发生率方面,多数研究结果表明,椎旁阻滞(paravertebral block, PVB)优于硬膜外镇痛(epidural analgesia, EP)。目前,直接比较PVB和EP在疼痛控制和术后结局方面的研究数量有限,尚无大规模的随机试验报道。但其中有4篇论文为此提供了最好的证据说明,四篇中有3篇是小型前瞻性随机试验,最后一篇文献是一项小的队列研究。从疼痛控制的角度来看,没有确凿的证据表明这两种方法谁更有效;一项研究表明EP显著降低了疼痛水平(P = 0.01),第二项研究表明PVB明显改善了疼痛控制(P < 0.01),第三项研究未能证明任何显著差异(P = 0.899)。PVB组和EP组需要追加镇痛的频率相似(56% vs 48%, P = 0.26)。与EP相比,PVB的术后并发症发生率更低,特别是尿潴留(64% vs 34.6%, P = 0.0036)和低血压(32% vs 7%, P = 0.0031; 21% vs 3%, P = 0.02) [1]。而在PVB组中,联合使用舒芬太尼的研究较少,其安全性和有效性值得我们深入研究。
关键词
胸腔镜手术,椎旁阻滞,硬膜外镇痛,舒芬太尼
Epidural Analgesia versus Paravertebral Block in Video-Assisted Thoracoscopic Surgery
Ji Zhao, Min Yang, Min Liu, Juying Li, Dan Wu
Affiliated Hospital of Yan’an University, Yan’an Shaanxi
According to most research results, in patients undergoing video-assisted thoracoscopic surgery, paravertebral block (PVB) is superior to epidural analgesia (EP) in terms of pain control and its postoperative complication rates. At present, there are a limited number of studies directly comparing pain control and postoperative outcomes between PVB and EP, and no large-scale randomized trials have been reported. But, there were four papers that represented the best evidence to answer the clinical question. Three of the 4 papers are small prospective randomized trials, with a small cohort study featuring as the final piece of literature. There is no conclusive body of evidence to recommend either route as more efficacious from a pain control perspective; one study demonstrated significantly lower levels of pain with EP (P = 0.01), with a second study demonstrating significantly better pain control with PVB (P < 0.01) and a third failing to demonstrate any significant difference (P = 0.899). The frequency of requiring supplemental analgesia was similar between the PVB and EP cohorts (56% vs 48%, P = 0.26). PVB is associated with lower rates of postoperative complications compared to EP, specifically urinary retention (64% vs 34.6%, P = 0.0036) and hypotension (32% vs 7%, P = 0.0031; 21% vs 3%, P = 0.02) [1]. In the PVB group, there are few studies on the combined use of sufentanil, and its safety and effectiveness deserve our in-depth study.
Kosinski [5] 等人对51例行胸腔镜肺叶切除患者进行了研究,比较硬膜外镇痛和经皮连续椎旁阻滞的镇痛疗效,主要观察指标为术后静态(休息时)和动态(咳嗽时)视觉模拟评分(VAS)、患者自控使用吗啡的情况和副作用。在PVB组,无论是24小时还是36小时,VAS评分都低于EP组,甚至在48小时时,PVB组仍然优于EP组;比较分析未显示术后对吗啡的需求有显著差异。结果显示:在EP组,术后尿潴留(定义为8小时内无自主排尿或者超声下探测到膀胱内尿液超过500 ml)发生率更大(64.0% vs 34.6%, P = 0.0036);在EP和PVB中低血压(定义为收缩压低于90 mmHg和/或与术前相比收缩压下降>20%)发生率分别为32.0%,7.7%, P = 0.0031,两组间肺不张发生率无显著差异(4.0% vs 7.7%, P = 0.0542)。相反,肺炎的发病率在PVB组中明显更高(3.8% vs 0%, P = 0.0331)。他们得出的结论为:对于胸腔进手术,PVB与EP都具有相似的镇痛效果,PVB比EP更安全,且术后并发症更少。
Okajima [6] 等人进行了一项随机试验,比较了90名接受PVB或EP的胸腔镜下行肺叶切除术、节段切除术或楔形切除术的患者术后补充镇痛的需求。主要观察指标是静息时的疼痛评分(数字评定量表:0 = 无,10 = 最大疼痛)、血压、副作用和与疼痛控制相关的总体满意度评分(1 = 不满意,5 = 满意)。对于中度疼痛需要补充镇痛药的发生率在两组中相似。低血压(定义为收缩压<90 mmHg)的发生率在EP组更高(21.2% vs 2.8%, P = 0.02);EP和PBV的其他副作用发生率无差异:瘙痒(3.0%对0%, P = 0.29)和术后恶心呕吐(30.3%对25.0%, P = 0.62)。采用匿名形式,两组间的VRS评分(5.0 vs 4.5, P = 0.36),与疼痛控制相关的总体满意度评分无统计学差异。总之,PVB在缓解疼痛方面与EP相似,并且术后血流动力学不稳定的发生率较低。
Kashiwagi [7] 等人进行了一项小型前瞻性随机试验,包括12名接受胸腔镜下肺癌根治术的患者,研究了术后疼痛缓解和术中血流动力学状况的差异。主要观察指标是:术后疼痛水平(数字评定量表(0 = 无疼痛,10 = 可能的最严重疼痛))、术中输液量和最低收缩压。PVB组和EP组均接受术后持续输注0.2%罗哌卡因6 ml/h镇痛。根据数值评分量表(0~10),在PVB组,患者NRS评分在术后12小时(4.5 vs 2.7, P < 0.01)和24小时(4.5 vs 2.7, P < 0.01)均高于EP组。PVB组与EP组相比,术中需要输血量(1,331 ml vs 1,693 ml, P < 0.01)更小。此外,PVB组收缩压高于EP组(87 mmHg vs 73 mmHg, P < 0.01)。Kashiwagi等人的结论是,尽管PVB对血流动力学有好处,但对于胸腔镜术后,EP在镇痛方面更好。
赵 集,杨 敏,刘 闵,李炬颖,吴 丹. 胸腔镜手术硬膜外镇痛与椎旁阻滞的比较Epidural Analgesia versus Paravertebral Block in Video-Assisted Thoracoscopic Surgery[J]. 医学诊断, 2020, 10(03): 164-167. https://doi.org/10.12677/MD.2020.103026
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