胰腺手术中使用非阿片类药物麻醉与阿片类药物麻醉的比较

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胰腺手术中使用非阿片类药物麻醉与阿片类药物麻醉的比较

贵州医科大学麻醉与心脏电生理课题组  

翻译：吴学艳 编辑：陈锐 审校：曹莹

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背景

与阿片类药物麻醉(OBA)相比，非阿片类药物麻醉(OFA)可显著降低术后吗啡总使用量；但OFA是否可行、是否可能改善胰腺手术患者的预后仍不清楚。  

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方法

对77例胰腺切除术患者围手术期资料进行回顾性分析，接受OBA联合使用瑞芬太尼(n=42)或OFA(n=35)，OFA组包括持续输注右美托咪啶、利多卡因和艾司氯胺酮。在OBA组，患者还接受单次吗啡鞘内注射，所有患者术中均联合使用丙泊酚、七氟烷、地塞米松、双氯芬酸钠及肌松药。术后疼痛采用创面持续浸润镇痛和吗啡自控镇痛。主要观察指标为术后疼痛评分(疼痛数字评分表，NRS)。次要观察指标包括拔管后48小时内的阿片类药物使用量、住院时长、90天内发生的不良事件以及30天的死亡率；安全事件观察指标为需要药抢救物的心动过缓和低血压。

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结果

与OBA组相比，OFA组的NRS评分(3[2～4]vs 0[0～2],p<0.001)和阿片类药物使用量(36[24～52]vs10[2～24]，p=0.005)均明显降低；OFA组住院时长缩短4天(14[7～46]vs10[6～16]，p<0.001)；术后发生胰瘘(p=0.0002)和胃排空延迟(p<0.0001)是影响住院时长的独立因素；OFA组综合并发症指数(CCI)较低(24.9±25.5vs14.1±23.4，p=0.03)。两组患者在人口统计学、手术时长、出血量、心动过缓、血管活性药物的应用、拔管时长方面无明显差异。  

HOLIDAY 结论

在这一序列研究中，OFA在胰腺切除术中具有可行性，且预后更好，可降低术后疼痛评分。较低的术后并发症发生率可能为将来随机试验提供依据并验证OFA可改善患者预后和缩短住院时长的假设。

HOLIDAY   原始文献来源  

Hublet S, Galland M, Navez J, et al. Opioid-free versus opioid-based anesthesia in pancreatic surgery[J]. BMC Anesthesiol. 2022 Jan 4;22(1):9.DOI: 10.1186/s12871-021-01551-y. 

Opioid-free versus opioid-based anesthesia in pancreatic surgery

Abstract

Background: Opioid-free anesthesia (OFA) is associated with significantly reduced cumulative postoperative morphine consumption in comparison with opioid-based anesthesia (OBA). Whether OFA is feasible and may improve outcomes in pancreatic surgery remains unclear.

Methods: Perioperative data from 77 consecutive patients who underwent pancreatic resection were included and retrospectively reviewed. Patients received either an OBA with intraoperative remifentanil (n = 42) or an OFA (n = 35). OFA included a combination of continuous infusions of dexmedetomidine, lidocaine, and esketamine. In OBA, patients also received a single bolus of intrathecal morphine. All patients received intraoperative propofol, sevoflurane, dexamethasone, diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infiltration and patient-controlled morphine. The primary outcome was postoperative pain (Numerical Rating Scale, NRS). Opioid consumption within 48 h after extubation, length of stay, adverse events within 90 days, and 30-day mortality were included as secondary outcomes. Episodes of bradycardia and hypotension requiring rescue medication were considered as safety outcomes.

Results: Compared to OBA, NRS (3 [2-4] vs 0 [0-2],P< 0.001) and opioid consum- ption (36 [24-52] vs 10 [2-24], P = 0.005) were both less in the OFA group. Length of stay was shorter by 4 days with OFA (14 [7-46] vs 10 [6-16], P < 0.001). OFA (P = 0.03), with postoperative pancreatic fistula (P = 0.0002) and delayed gastric emptying (P < 0.0001) were identified as only independent factors for length of stay. The comprehensive complication index (CCI) was the lowest with OFA (24.9 ± 25.5 vs 14.1 ± 23.4, P = 0.03). There were no differences in demographics, operative time, blood loss, bradycardia, vasopressors administration or time to extubation among groups.

Conclusions: In this series, OFA during pancreatic resection is feasible and independently associated with a better outcome, in particular pain outcomes. The lower rate of postoperative complications may justify future randomized trials to test the hypothesis that OFA may improve outcomes and shorten length of stay.

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