胰腺手术中无阿片类药物与阿片类药物的麻醉

本文由“罂粟花"授权转载

利多卡因贴片对术后疼痛的影响:一项随机对照试验的Meta分析

贵州医科大学 麻醉与心脏电生理课题组

翻译：文春雷  编辑：潘志军  审校：曹莹

背景：与阿片类药物的麻醉（OBA）相比，无阿片类药物麻醉（OFA）显著减少术后吗啡消耗量。OFA是否可行并可能改善胰腺手术的预后尚不清楚。

方法: 我们纳入了77例接受胰腺切除术的患者的围手术期资料，并进行了回顾性分析。患者术中接受瑞芬太尼（n=42）或OFA（n=35）。OFA包括连续输注右美托咪定、利多卡因和艾司氯胺酮。在OBA中，患者也接受了单次鞘内吗啡注射。所有患者术中均接受异丙酚、七氟醚、地塞米松、双氯芬酸钠、肌松剂。术后疼痛管理通过持续伤口浸润和患者控制吗啡实现。主要结局是术后疼痛（数值评分量表，NRS）。拔管后48小时内的阿片类药物量、住院时间、90天内的不良事件和30天的死亡率作为次要结局。需要抢救药物治疗的心动过缓和低血压发作被认为是安全结局。

结果：共与OBA相比，OFA组的NRS（3[2–4]vs0[0–2]，P<0.001）和阿片类药物消耗量（36[24–52]vs10[2–24]，P=0.005）均较低。OFA患者的住院时间缩短了4天（14[7–46]vs10[6–16]，P<为0.001）。OFA（P=0.03）伴有术后胰腺瘘（P=0.0002）和胃排空延迟（P<0.0001）被认为是住院时间的独立因素。OFA患者的综合并发症指数（CCI）最低（24.9±25.5 vs 14.1±23.4，P=0.03）。各组间在人口统计学、手术时间、失血量、心动过缓、使用血管升压药或拔管时间方面均无差异。

结论：在本研究中，胰腺切除术中的OFA是可行的，并且与更好的结局独立相关，特别是疼痛结局。较低的术后并发症发生率可能表明随机试验中OFA能够改善预后和缩短患者住院时间。

原始文献来源：

Hublet Stéphane , Galland Marianne, Navez Julie, Loi Patrizia, et al. Opioid-free versus opioid-based anesthesia in pancreatic surgery.[J]. BMC Anesthesiology (2022) 22:9.

英文原文     

Opioid-free versusopioid-based anesthesia inpancreatic surgery 

BACKGROUND: Opioid-free anesthesia (OFA) is associated with signifcantly 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, sevofurane, dexamethasone,diclofenac, neuromuscular blockade. Postoperative pain management was achieved by continuous wound infltration 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 consumption (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 fstula (P=0.0002) and delayed gastric emptying (P<0.0001)were identifed 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 diferences 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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编辑：MiLu.米鹭

校对：Michel.米萱

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