锁骨上神经阻滞对肩部手术后急性疼痛的效果是否和肌间沟神经阻滞一样好？系统回顾与Meta分析
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Is Supraclavicular Block as Good as Interscalene Block for Acute Pain Control Following ShoulderSurgery? A Systematic Review and Meta-analysis
背景与目的
肌间沟神经阻滞（ISB）是治疗肩关节手术后急性疼痛的首选方法，但其对呼吸系统的不良副作用促使人们寻求替代方法。锁骨上神经阻滞（SCB）被认为是ISB的一种替代方法，但其相对镇痛和呼吸抑制的证据并不一致。我们比较了SCB和ISB对肩部手术的镇痛效果和呼吸抑制作用。
方 法
搜索比较ISB和SCB用于肩部手术的临床试验。我们预先设定，如果SCB对（1）术后24小时累积口服吗啡等效用量（主要结果，非劣效限度△=-25 mg）和（2）术后疼痛（次要结果，非劣效限度△=4.0 cm·h–1）无不良反应，并优于（3）阻滞后呼吸功能障碍（主要结果），则SCB是一个可接受的替代方案。并评估阿片类药物相关副作用和阻滞相关并发症。
结 果
本研究共分析了15项研究（1065例）。在单次注射阻滞中，SCB在24小时吗啡消耗量方面(SCB-ISB的平均差异，MD[95%CI]=-3.11mg[-9.42~3.19]，Δ=-25mg）、24小时疼痛评分方面 (MD = 0.78 cm·hour-1 [0.07~1.49], Δ = 4.0 cm·hour-1)并不差于ISB，并且降低了呼吸功能障碍的几率（OR[95% CI] =0.08[0.01~0.68]）。类似地，在连续阻滞中，24小时吗啡消耗量（MD=0.46 mg[-6.08~5.15]，Δ=-25 mg），SCB不差于ISB，并且降低了呼吸功能障碍的几率（OR=0.22[0.08-0.57]）。SCB还降低了发生轻微阻滞相关并发症的几率（单次注射和连续阻滞的OR分别为0.36[0.20-0.68]和0.25[0.15-0.41]）。因此，无效联合假设被否定，SCB被认为是可接受的ISB的替代方案。
结 论
对于肩部手术后的急性疼痛镇痛，高质量证据表明SCB可作为一种有效的ISB替代方案。SCB对术后阿片类药物消耗和急性疼痛无不良反应，并可降低阻滞后呼吸功能障碍的发生率。
原始文献来源及摘要
Nasir Hussain, Ioana Costache, Nicolas Kumar, et al.Is Supraclavicular Block as Good as Interscalene Block for Acute Pain Control Following Shoulder Surgery? A Systematic Review and Meta-analysis.Anesth Analg 2020;130:1304–19.
BACKGROUND: Interscalene block (ISB) is the acute pain management technique of choice for shoulder surgery, but its undesirable respiratory side effects have prompted seeking alternatives. Supraclavicular block (SCB) is proposed as an ISB alternative, but evidence of comparative analgesic and respiratory-sparing effects is inconsistent. We compared the analgesic and respiratory effects of SCB and ISB for shoulder surgery.
METHODS: Trials comparing ISB to SCB for shoulder surgery were sought. We decided a priori that SCB would be an acceptable alternative if it were noninferior for (1) postoperative 24-hour cumulative oral morphine equivalent consumption (primary outcome, noninferiority margin Δ = −25 mg) and (2) postoperative pain (secondary outcome, noninferiority margin Δ = 4.0 cm·hour–1); and superior for (3) postblock respiratory dysfunction (primary outcome). Opioid related side effects and block-related complications were also evaluated.
RESULTS: Fifteen studies (1065 patients) were analyzed. In single-injection blocks, SCB was noninferior to ISB for 24-hour morphine consumption (mean difference for SCB-ISB, MD [95% confidence interval {CI}] = −3.11 mg [−9.42 to 3.19], Δ = −25 mg); it was also noninferior for 24-hour pain scores (MD = 0.78 cm·hour–1 [0.07–1.49], Δ = 4.0 cm·hour–1); and decreased the odds of respiratory dysfunction (odds ratio [OR] [95% CI] = 0.08 [0.01–0.68]). Similarly, in continuous blocks, SCB was noninferior to ISB for 24-hour morphine consumption (MD = 0.46 mg [−6.08 to 5.15], Δ = −25 mg), and decreased the odds of respiratory dysfunction (OR = 0.22 [0.08–0.57]). SCB also decreased odds of minor block-related complications (OR = 0.36 [0.20–0.68] and OR = 0.25 [0.15–0.41] for single-injection and continuous blocks, respectively). Consequently, the null joint-hypothesis was rejected, and SCB can be considered an acceptable alternative to ISB.
CONCLUSIONS: For acute pain control following shoulder surgery, high-quality evidence indicates that SCB can be used as an effective ISB alternative. SCB is noninferior for postoperative opioid consumption and acute pain, and it reduces the odds of postblock respiratory dysfunction.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：任文鑫 编辑：冯玉蓉 审校：王贵龙