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【文献速递】2021年1月ANESTHESIOLOGY看点

2020

12/18

米勒之声

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腰方肌阻滞用于腰麻下剖宫产术后镇痛效果：系统评价和Meta分析

【文献速递】2021年1月ANESTHESIOLOGY看点

This month in anesthesiology

https://doi.org/10.1097/ALN.0000000000003638

【文献速递】2021年1月ANESTHESIOLOGY看点

This month in anesthesiology

https://doi.org/10.1097/ALN.0000000000003638

【文献速递】2021年1月ANESTHESIOLOGY看点

This month in anesthesiology

https://doi.org/10.1097/ALN.0000000000003638

本期《Anesthesiology》杂志的看点主要包括：72 腰方肌阻滞用于腰麻下剖宫产术后镇痛效果：系统评价和Meta分析。26 儿童动脉置管监护的主要短期并发症。35 γ-氨基丁酸A型受体激动剂ABP-700的激动对麻醉深度监测影响建模。61 阻隔设备的气溶胶滞留特性。52 椎管内分娩镇痛与阴道手术助产后新生儿发病率的关系：一项回顾性横断面研究。88 左旋布比卡因抑制大鼠周围和背角神经元的伤害性传递。111 围术期体温监测（临床焦点综述）。119 脉搏波分析估计心输出量（临床焦点综述）。

腰方肌阻滞用于腰麻下剖宫产术后镇痛效果：系统评价和Meta分析

72 Postoperative Analgesic Effectiveness of Quadratus Lumborum Block for Cesarean Delivery under Spinal Anesthesia: A Systematic Review and Meta-analysis

在腰麻下行择期剖宫产后，脊髓吗啡可提供长达12小时的有效、安全且经济高效的镇痛效果。这篇系统评价和meta分析的目的是阐述腰方肌阻滞在择期剖宫产的术后镇痛效果，评估腰方肌阻滞加腰麻有或没有脊髓吗啡的效果。这篇meta分析的主要结果是术后24小时内累积阿片类药物消耗量（口服吗啡毫克当量），以及术后4-6小时的视觉模拟量表静息疼痛得分。中等质量证据表明腰方肌阻滞对已经接受脊髓吗啡的患者没有镇痛益处，这体现在术后24小时内的静息疼痛评分和止痛药用量相似。当腰方肌阻滞作为镇痛替代方案与脊髓吗啡比较时，似乎也没有益处。然而，有证据表明，在没有脊髓吗啡的情况下，腰方肌阻滞与脊麻联合使用是有益的。

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原始文献

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 spinal 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.

儿童动脉置管监护的主要短期并发症

26 Major Short-term Complications of Arterial Cannulation for Monitoring in Children

儿童围手术期动脉置管是常规操作。在一项单中心，回顾性队列研究中，对2006年至2016年接受动脉置管监护的儿科手术患者，确定了与动脉置管围术期监护相关的主要短期并发症的发生率和使用模式。在111，934例18岁以下的外科手术患者中，有4178例患者进行了5142例动脉置管。动脉置管部位包括桡动脉（n=3395；66%），股动脉（n=1528，29.7%），尺，足，肱/腋动脉（n=216；4.2%）。总体主要短期并发症发生率较低（n=11；0.2%）。所有的并发症，包括血管并发症（n=8）和导管相关性血流感染（n=3），均发生在5岁以下儿童股动脉置管时，新生儿和婴儿并发症发生率最高。没有短期神经系统并发症，请参阅第7页随附的社论。

原始文献

Background

Perioperative arterial cannulation in children is routinely performed. Based on clinical observation of several complications related to femoral arterial lines, the authors performed a larger study to further examine complications. The authors aimed to (1) describe the use patterns and incidence of major short-term complications associated with arterial cannulation for perioperative monitoring in children, and (2) describe the rates of major complications by anatomical site and age category of the patient.

Methods

The authors examined a retrospective cohort of pediatric patients (age less than 18 yr) undergoing surgical procedures at a single academic medical center from January 1, 2006 to August 15, 2016. Institutional databases containing anesthetic care, arterial cannulation, and postoperative complications information were queried to identify vascular, neurologic, and infectious short term complications within 30 days of arterial cannulation.

Results

There were 5,142 arterial cannulations performed in 4,178 patients. The most common sites for arterial cannulation were the radial (N = 3,395 [66.0%]) and femoral arteries (N = 1,528 [29.7%]). There were 11 major complications: 8 vascular and 3 infections (overall incidence, 0.2%; rate, 2 per 1,000 lines; 95% CI, 1 to 4) and all of these complications were associated with femoral arterial lines in children younger than 5 yr old (0.7%; rate, 7 per 1,000 lines; 95% CI, 4 to 13). The majority of femoral lines were placed for cardiac procedures (91%). Infants and neonates had the greatest complication rates (16 and 11 per 1,000 lines, respectively; 95% CI, 7 to 34 and 3 to 39, respectively).

Conclusions

The overall major complication rate of arterial cannulation for monitoring purposes in children is low (0.2%). All complications occurred in femoral arterial lines in children younger than 5 yr of age, with the greatest complication rates in infants and neonates. There were no complications in distal arterial cannulation sites, including more than 3,000 radial cannulations.

椎管内分娩镇痛与阴道手术助产后新生儿发病率的关系：一项回顾性横断面研究

52 Association between Neuraxial Labor Analgesia and Neonatal Morbidity after Operative Vaginal Delivery: A Retrospective Cross-sectional Study

阴道手术助产的益处是避免产时剖宫产，但是增高了新生儿风险和产妇发病率。该研究假设椎管内分娩镇痛与新生儿发病率降低有关，因为它有助于受控的，无创伤的手术分娩，通过对2017年106，845名经阴道手术助产的女性，其中92,518接受了椎管内分娩镇痛的回顾性横断面研究来验证这一假设。接受椎管内镇痛的女性的新生儿综合发病率实际高于未接受椎管内镇痛的女性 (分别为10，409 [11.3%] vs. 1，271 [8.9%],相对危险度, 1.27 [95% CI, 1.20 - 1.34])。在调整混杂因素后，这种关联性减弱（校正后的相对危险度，1.19 [95% CI, 1.12 -1.26]）。在审稿人要求的事后分析中，从新生儿总体发病率中排除新生儿重症监护病房的入院和转院后，无论是在全模型还是倾向评分匹配模型中，都没有观察到椎管内镇痛与修改后的新生儿总体发病率之间的关系。

原始文献

Background

Up to 84% of women who undergo operative vaginal delivery receive neuraxial analgesia. However, little is known about the association between neuraxial analgesia and neonatal morbidity in women who undergo operative vaginal delivery. The authors hypothesized that neuraxial analgesia is associated with a reduced risk of neonatal morbidity among women undergoing operative vaginal delivery.

Methods

Using United States birth certificate data, the study identified women with singleton pregnancies who underwent operative vaginal (forceps- or vacuum-assisted delivery) in 2017. The authors examined the relationships between neuraxial labor analgesia and neonatal morbidity, the latter defined by any of the following: 5-min Apgar score less than 7, immediate assisted ventilation, assisted ventilation greater than 6 h, neonatal intensive care unit admission, neonatal transfer to a different facility within 24 h of delivery, and neonatal seizure or serious neurologic dysfunction. The authors accounted for sociodemographic and obstetric factors as potential confounders in their analysis.

Results

The study cohort comprised 106,845 women who underwent operative vaginal delivery, of whom 92,518 (86.6%) received neuraxial analgesia. The proportion of neonates with morbidity was higher in the neuraxial analgesia group than the nonneuraxial group (10,409 of 92,518 [11.3%] vs. 1,271 of 14,327 [8.9%], respectively; P < 0.001). The unadjusted relative risk was 1.27 (95% CI, 1.20 to 1.34; P < 0.001); after accounting for confounders using a multivariable model, the adjusted relative risk was 1.19 (95% CI, 1.12 to 1.26; P < 0.001). In a post hoc analysis, after excluding neonatal intensive care unit admission and neonatal transfer from the composite outcome, the effect of neuraxial analgesia on neonatal morbidity was not statistically significant (adjusted relative risk, 1.07; 95% CI, 1.00 to 1.16; P = 0.054).

Conclusions

In this population-based cross-sectional study, a neonatal benefit of neuraxial analgesia for operative vaginal delivery was not observed. Confounding by indication may explain the observed association between neuraxial analgesia and neonatal morbidity, however this dataset was not designed to evaluate such considerations.