腰方肌后内侧阻滞能用于剖宫产术后镇痛吗？

无痛分娩是舒适化医疗的选择，减少分娩时的疼痛具有很多益处，比如让孕妇免受疼痛的折磨，减少分娩时的恐惧和疲倦等。剖宫产术后镇痛也必不可少，阿片类药物用于术后镇痛还是有诸多不足，探索其他有效镇痛方法来减少剖宫产术后疼痛和减少阿片类药物用量对促进产妇康复和促进母婴互动至关重要。现分享一篇最新发表在EJA杂志上的文章，看看腰方肌后内侧阻滞用于剖宫产术后镇痛的效果如何。该研究的亮点在于采用随机双盲对照性研究，减少了系统性误差，结果可信度更高。

剖宫产术后腰方肌后内侧阻滞与伤口浸润的比较：

一项随机、双盲、对照性研究

⛳️背景

减少剖宫产术后疼痛和减少阿片类药物用量对促进产妇康复和促进母婴互动至关重要。已实施各种技术来改善镇痛。

⛳️目的

该研究的目的是比较择期剖宫产术后腰方肌后内侧阻滞与伤口浸润的镇痛效果。

假设在多模式镇痛方法中，腰方肌后内侧阻滞由于有可能减轻内脏疼痛，与伤口浸润相比，术后24小时阿片类药物消耗减少15%。

⛳️设计

该研究为一项双盲、随机、安慰剂对照的临床研究。

⛳️实施

2019年8月至2020年5月的单中心临床研究。

⛳️患者

116名妇女被随机分为两组。

腰方肌组术后伤口注入0.9%生理盐水20ml，双侧腰方肌后内侧阻滞，每侧用0.25%左旋布比卡因20ml。

伤口浸润组术后伤口注射0.25%左旋布比卡因20ml，双侧腰方后内侧注射0.9%生理盐水20ml。

⛳️主要观察指标

主要结果为24小时阿片类药物（吡硝胺）的消耗量。

次要结果为48小时服用吡硝胺量、首次镇痛请求时间、休息和运动时的疼痛评分、手术至首次行走时间、手术至母乳喂养时间、镇静、瘙痒和并发症。

⛳️结果

腰方肌后内侧阻滞可显著降低吡硝胺在24小时内的消耗量：腰方肌组为1.5 ± 1.8毫克，而伤口浸润组为2.2 ± 1.7毫克，P=0.04。平均差值为-0.7毫克（95%可信区间为-1.3至-0.03）。

在需要吡硝胺的患者中，腰方肌后内侧阻滞组首次镇痛的时间明显长于伤口浸润，腰方肌组为11[7~14]h，而伤口浸润组为7[5~11]h（P=0.02）。

疼痛评分较低，但休息和运动时的疼痛评分组间没有差异。

两组之间的步行时间和母乳喂养时间没有差异。

⛳️结论

作为剖宫产术后多模式镇痛的一个组成部分，与伤口浸润相比，腰方后内侧阻滞与较低的24小时阿片消耗有关。

Posteromedial quadratus lumborum block versus woundinfiltration after caesarean section：

A randomised, double-blind, controlled study

BACKGROUND

Reducing pain and minimising opioids after caesarean section are crucialto enhancing maternal recovery and promoting mother-newborn interaction.Various techniques have been implemented to improve analgesia. We compared theanalgesic efficacy of posteromedial quadratus lumborum block with that of woundinfiltration following elective caesarean section.

OBJECTIVE

We hypothesised that within a multimodal analgesia approach,posteromedial quadratus lumborum block would, due to its potential to relievevisceral pain, result in a 15% reduction in 24-h postoperative opioidconsumption compared with wound infiltration.

DESIGN

A double-blind, randomised, placebo-controlled clinical study.

SETTING

A single-centre study between August 2019 and May 2020.

PATIENTS

One hundred and sixteen women were randomly allocated into two groups. Inthe quadratus lumborum group, 20 ml 0.9% saline was injected into the surgicalwound followed by bilateral posteromedial quadratus lumborum block using 20 ml0.25% levobupivacaine per side. In the wound infiltration group, 20 ml of 0.25%levobupivacaine was injected into the surgical wound followed by a bilateralposteromedial quadratus lumborum injection with 20 ml 0.9% saline per side.

MAIN OUTCOME MEASURES

The primary outcome was opioid (piritramide) consumption at 24 h.Secondary outcomes were piritramide consumption at 48 h, time-to-firstanalgesic request, pain scores at rest and with movement,surgery-to-first-ambulation time, surgery-to-breastfeeding time, sedation,pruritus and complications.

RESULTS

Piritramide consumption in 24 h was significantly lower withposteromedial quadratus lumborum block (1.5 ± 1.8 mg) than with woundinfiltration (2.2 ± 1.7 mg) (P = 0.04), mean difference of -0.7 mg, (95% CI-1.3 to -0.03). In those who required piritramide, time-to-first analgesicrequest was significantly longer with posteromedial quadratus lumborum block 11[7 to 14] h, than with wound infiltration 7 [5 to 11] h (P = 0.02). Pain scoreswere low, with no differences recorded at rest and with movement. There were nodifferences in time-to-ambulation and time-to-breastfeed between the groups.

CONCLUSION

As a component of multimodal postcaesarean section analgesia, posteromedial quadratus lumborum block was associated with lower 24-h opioidconsumption compared with wound infiltration.