不一样的文献分享：剖宫产术后镇痛

腰方肌神经阻滞用于腰麻剖宫产术后镇痛的效果观察

关于这个话题我们已经知道的

⛳️椎管内注射吗啡是腰麻剖宫产术后镇痛的首选技术。

⛳️腰方肌神经阻滞可能有镇痛作用，但目前尚不清楚能用于哪类患者。

这篇文章告诉我们的是新的

⚡️腰方肌神经阻滞与椎管内注射吗啡相比或与椎管内注射吗啡合用对镇痛没有益处。

⚡️对于不接受椎管内注射吗啡的患者，腰方肌神经阻滞确实能提供镇痛和减少阿片类药物的用量

背景：

椎管内注射吗啡是麻醉后镇痛的主要方式。腰方肌神经阻滞最近被认为是椎管内注射吗啡的一种辅助或替代技术。作者评价了腰方肌神经阻滞在剖宫产术后有无椎管内注射吗啡时的镇痛效果。

方法：

随机试验评估腰方肌神经阻滞在腰麻下选择性剖宫产术中的益处。

三种比较：

椎管内注射吗啡与椎管内注射吗啡复合腰方肌神经阻滞比较；

椎管内注射吗啡与腰方肌神经阻滞比较；

无神经阻滞或椎管内注射吗啡与腰方肌阻滞比较。

两个主要结果是：

1）术后24小时累积口服吗啡当量消耗量和2）4至6小时疼痛。

次要结果包括：

疼痛曲线下面积、

止痛请求时间、

阻滞并发症

和阿片类药物相关副作用。

结果：

分析了12个试验（924例患者）。

椎管内注射吗啡与椎管内注射吗啡复合腰方肌神经阻滞相比，24小时吗啡消耗量和4至6小时疼痛的平均差异（95%可信区间）分别为0毫克（-2至1）和-0.1厘米（-0.7至0.4），表明没有益处。

椎管内注射吗啡与腰方肌神经阻滞的差异分别为7mg（-2～15）和0.6cm（-0.7～1.8），也表明没有益处。

无阻滞或椎管内注射吗啡与腰方肌神经阻滞相比，腰方肌神经阻滞可分别观察到-18 mg（-28至-7）和-1.5 cm（-2.4至-0.6）的改善。

最后，对于无阻滞或椎管内注射吗啡与腰方肌神经阻滞，腰方肌神经阻滞可使48小时疼痛曲线下的面积增加-4.4 cm·h（-5.0至-3.8），超过临床重要阈值（3.96 cm·h），但在其他比较中未观察到差异。

结论：

中等质量的证据表明，与腰方肌神经阻滞复合椎管内注射吗啡或单独椎管内注射吗啡相比，腰方肌神经阻滞不能提高镇痛效果。

然而，在没有椎管内注射吗啡的情况下，腰方肌神经阻滞可以改善术后镇痛。

这种阻滞的临床应用似乎仅限于不使用椎管内注射吗啡的情况。

Postoperative Analgesic Effectiveness of Quadratus Lumborum Block for Cesarean Delivery under Spinal Anesthesia

What We Already Know about This Topic

Spinal morphine is the preferred technique for analgesia after cesarean delivery performed under spinal anesthesia

Quadratus lumborum block may offer analgesic benefit, but it is unclear in which patients

What This Article Tells Us That Is New

Quadratus lumborum block does not provide analgesic benefit when compared with or in addition to spinal morphine for postcesarean analgesia

In patients who do not receive spinal morphine, quadratus lumborum block does offer analgesic and opioid consumption benefit

Background: Spinal morphine is the mainstay of postcesarean analgesia. Quadratus lumborum block has recently been proposed as an adjunct or alternative to spinal morphine. The authors evaluated the analgesic effectiveness of quadratus lumborum block in cesarean delivery with and without spinal morphine.

Methods: Randomized trials evaluating quadratus lumborum block benefits in elective cesarean delivery under spinal anesthesia were sought. Three comparisons were considered: spinal morphine versus spinal morphine and quadratus lumborum block; spinal morphine versus quadratus lumborum block; and no block or spinal morphine versus quadratus lumborum block. The two coprimary outcomes were postoperative (1) 24-h cumulative oral morphine equivalent consumption and (2) pain at 4 to 6 h. Secondary outcomes included area under the curve pain, time to analgesic request, block complications, and opioid-related side effects.

Results: Twelve trials (924 patients) were analyzed. The mean differences (95% CIs) in 24-h morphine consumption and pain at 4 to 6 h for spinal morphine versus spinal morphine and quadratus lumborum block comparison were 0 mg (-2 to 1) and -0.1 cm (-0.7 to 0.4), respectively, indicating no benefit. For spinal morphine versus quadratus lumborum block, these differences were 7 mg (-2 to 15) and 0.6 cm (-0.7 to 1.8), respectively, also indicating no benefit. In contrast, for no block or spinal morphine versus quadratus lumborum block, improvements of -18 mg (-28 to -7) and -1.5 cm (-2.4 to -0.6) were observed, respectively, with quadratus lumborum block. Finally, for no block or spinal morphine versus quadratus lumborum block, quadratus lumborum block improved area under the 48-h pain curve by -4.4 cm · h (-5.0 to -3.8), exceeding the clinically important threshold (3.96 cm · h), but no differences were observed in the other comparisons.

Conclusions: Moderate quality evidence suggests that quadratus lumborum block does not enhance analgesic outcomes when combined with or compared with spin

al morphine. However, the block improves postcesarean analgesia in the absence of spinal morphine. The clinical utility of this block seems limited to situations in which spinal morphine is not used.

  
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