术后镇痛：镇痛模式叠加1+1＞2?

本文由“小麻哥的日常"授权转载

摘要译文(供参考)

在全膝关节置换术后建立的多模式镇痛方案中添加右美托咪定、氯胺酮、地塞米松和神经阻滞没有益处

背景：

一种用于治疗严重疼痛的最佳保留阿片类的多模式镇痛方案可以提高全膝关节置换术后的恢复。

假设在多模式镇痛方案中添加五种最近描述的静脉和区域干预措施可以进一步减少阿片类药物的消耗。

方法：

采用双盲法，78例择期全膝关节置换术患者随机分为（1）对照组（n=39），或（2）研究组（n=39），接受同一组镇痛治疗。

研究组加上5项额外干预：腘动脉和后膝关节囊之间的局部麻醉浸润、术中静脉注射右美托咪定和氯胺酮，一次额外的静脉注射地塞米松和两次额外的内收管阻滞。

主要结局指标是术后24小时累积阿片类药物消耗量，

次要结局指标是其他止痛药、患者康复、功能结果和不良事件。

结果：

术后24小时（口服吗啡当量，平均值M±标准差SD；研究组：23.7±18.0 mg vs对照组：29.3±18.7 mg；平均差异[95%CI]，-5.6 mg[-2.7至13.9]；P=0.189）。

所有其他时间点，两组之间的阿片类药物消耗量无差异。

在疼痛评分、恢复质量或达到康复关键点的时间方面没有显著差异。

在研究组中，低血压发作发生的频率更高（39例中有25例[64.1%]，而对照组39例中只有13例[33.3%]；P=0.010）。

结论：

在存在关节周围局部麻醉浸润、鞘内吗啡、单针内收肌管阻滞和地塞米松的情况下，增加5种镇痛干预措施，在腘动脉和后膝关节囊之间进行局部麻醉浸润，静脉注射右美托咪定、静脉注射氯胺酮，增加静脉注射地塞米松剂量，重复内收管阻滞注射不能进一步减少阿片类药物消耗或疼痛评分，也不能改善全膝关节置换术后的功能结果。

原文摘要

No Benefits of Adding Dexmedetomidine, Ketamine, Dexamethasone, and Nerve Blocks to an Established Multimodal Analgesic Regimen after Total Knee Arthroplasty

Background:

An optimal opioid-sparing multimodal analgesic regimen to treat severe pain can enhance recovery after total knee arthroplasty. The hypothesis was that adding five recently described intravenous and regional interventions to multimodal analgesic regimen can further reduce opioid consumption.

Methods:

In a double-blinded fashion, 78 patients undergoing elective total knee arthroplasty were randomized to either (1) a control group (n = 39) that received spinal anesthesia with intrathecal morphine, periarticular local anesthesia infiltration, intravenous dexamethasone, and a single injection adductor canal block or (2) a study group (n = 39) that received the same set of analgesic treatments plus five additional interventions: local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, intraoperative intravenous dexmedetomidine and ketamine, and postoperatively, one additional intravenous dexamethasone bolus and two additional adductor canal block injections. The primary outcome measure was 24-h cumulative opioid consumption after surgery and secondary outcomes were other analgesics, patient recovery, functional outcomes, and adverse events.

Results:

Opioid consumption was not different between groups at 24 h (oral morphine equivalents, mean ± SD; study: 23.7 ± 18.0 mg vs. control: 29.3 ± 18.7 mg; mean difference [95% CI], -5.6 mg [-2.7 to 13.9]; P = 0.189) and all other time points after surgery. There were no major differences in pain scores, quality of recovery, or time to reach rehabilitation milestones. Hypotensive episodes occurred more frequently in the study group (25 of 39 [64.1%] vs. 13 of 39 [33.3%]; P = 0.010).

Conclusions:

In the presence of periarticular local anesthesia infiltration, intrathecal morphine, single-shot adductor canal block and dexamethasone, the addition of five analgesic interventions-local anesthetic infiltration between the popliteal artery and capsule of the posterior knee, intravenous dexmedetomidine, intravenous ketamine, an additional intravenous dexamethasone dose, and repeated adductor canal block injections-failed to further reduce opioid consumption or pain scores or to improve functional outcomes after total knee arthroplasty.

原文：

Muñoz-Leyva F, Jack JM, Bhatia A, Chin KJ, Gandhi R, Perlas A, Jin R, Chan V. No Benefits of Adding Dexmedetomidine, Ketamine, Dexamethasone, and Nerve Blocks to an Established Multimodal Analgesic Regimen after Total Knee Arthroplasty. Anesthesiology. 2022 Oct 1;137(4):459-470. doi: 10.1097/ALN.0000000000004326. PMID: 35867857.

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编辑：Michel.米萱

校对：Mijohn.米江