超声引导下肋间神经阻滞、单点注射竖脊肌平面阻滞和多点注射椎旁阻滞对胸腔镜术后镇痛的影响：随机双盲临床试验
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超声引导下肋间神经阻滞、单点注射竖脊肌平面阻滞和多点注射椎旁阻滞对胸腔镜术后镇痛的影响：随机双盲临床试验
翻译：冯玉蓉 编辑：冯玉蓉 审校：曹莹
研究目的：探讨超声引导下肋间神经阻滞(ICNB)和竖脊肌平面单点注射阻滞(ESPB)对比椎旁多点注射阻滞(PVB)在胸腔镜手术后的镇痛效果。
设计：随机、对照、双盲研究。
设置：手术室、术后恢复室、病房。
患者：纳入75名患者，年龄18~75岁，ASA I~II，计划行择期胸腔镜肺部分切除术。72例患者留作最终分析。
干预措施：将患者随机分为三组(PVB组、ICNB组、ESPB组)。麻醉诱导后，由一名麻醉医师在超声引导下使用20 ml 0.375%罗哌卡因在T5-T7水平进行PVB，或在T4-T9水平进行ICNB，或在T5水平进行ESPB。术后病人使用患者自控吗啡镇痛装置。
测量指标：比较术后24小时吗啡累积消耗量作为主要结果。记录术后0、2、4、8、24、48h休息时和咳嗽时的视觉模拟量表疼痛评分，其他观察时间的吗啡累积消耗量和紧急镇痛需求量。
主要结果：三组患者术后24小时吗啡用量中位数[四分位范围IQR]有显著差异（PVB 10.5[9–15]mg；ICNB 18[13.5–22.1]mg；ESPB 22[15–25.1]mg；p=0.000）。PVB组与ESPB组（中位数差异 −7.5；95% CI −12~−4.5；p=0.000）、PVB组与ICNB组比较（中位数差异 −6；95%CI −9~−3；p=0.001）差异有统计学意义，但ICNB组与ESPB组比较（中位数差异 −3；95%CI −6~1.5；p=0.192）无统计学差异。PVB组在休息时和术后0、2、4、8 h咳嗽时的VAS评分明显低于ESPB组，在术后8 h咳嗽时的VAS评分明显低于ICNB组。ICNB组与ESPB组在各时间点的VAS评分均无显著差异。所有组在休息时和咳嗽时的VAS评分中位数均较低（<4）。ESPB组术后48小时内需要更多的紧急镇痛（PVB组vs ICNB vs ESPB 13%vs29%vs46%；p<0.05）。
结论：超声引导下多点注射PVB镇痛效果优于ICNB和单点注射ESPB，但ICNB和单点注射ESPB对胸腔镜手术后疼痛的缓解效果相同。
原始文献来源：Chen N, Qiao Q, Chen R, et al. The effect of ultrasound-guided intercostal nerve block, single-injection erector spinae plane block and multiple-injection paravertebral block on postoperative analgesia in thoracoscopic surgery: A randomized, double-blinded, clinical trial.[J].J Clin Anesth. 2020 Feb;59:106-111. doi: 10.1016/j.jclinane.2019.07.002.
The effect of ultrasound-guided intercostal nerve block, single-injection erector spinae plane block and multiple-injection paravertebral block on postoperative analgesia in thoracoscopic surgery: A randomized, double-
blinded, clinical trial
Abstract
Study objective: The study was to determine the analgesic effect of ultrasound-guided intercostal nerve block (ICNB) and single-injection erector spinae plane block (ESPB) in comparison with multiple-injection paravertebral block (PVB) after thoracoscopic surgery.
Design: Randomized, controlled, double- blinded study.
Setting: Operating room, postoperative recovery room and ward.
Patients: Seventy-five patients, aged 18–75 years, ASA I–II and scheduled for elective thoracoscopic partial pulmonary resection surgery were enrolled in the study. Seventy-two patients were left for final analysis.
Interventions: Patients were randomly assigned into the three groups (PVB group, ICNB group or ESPB group). After anesthesia induction, a single anesthesiologist performed PVB at T5-T7 levels or ICNB at T4-T9 levels or ESPB at T5 level under ultrasound guidance using 20 ml of 0.375% ropivacaine. Patients were connected to the patient-controlled morphine analgesia device after surgery.
Measurements: Cumulative morphine consumption at 24 h postoperatively as primary outcome was compared. Visual analog scale pain scores at rest and while coughing at 0, 2, 4, 8, 24 and 48 h postoperatively, cumulative morphine consumption at other observed time and rescue analgesia requirement were also recorded.
Main results: There was a significant difference in median [interquartile range, IQR] morphine consumption at 24 h postoperatively among the three groups (PVB, 10.5 [9–15] mg; ICNB, 18 [13.5–22.1] mg; ESPB, 22 [15–25.1] mg; p = 0.000). This difference was statistically significant for PVB group vs ESPB group (median difference, −7.5; 95% confidence interval [CI], −12 to −4.5; p = 0.000) and PVB group vs ICNB group (median difference, −6; 95% CI, −9 to −3; p = 0.001), but not for ICNB vs ESPB (median difference, −3; 95% CI, −6 to 1.5; p = 0.192). PVB group had significantly lower VAS scores at rest and while coughing than ESPB group at 0, 2, 4, 8 h postoperatively and than ICNB group at 8 h postoperatively. There was no significant difference in the VAS scores between ICNB group and ESPB group at all time. Median VAS scores at rest and while coughing at all time were low (< 4) in all groups. More rescue analgesia was needed in ESPB group during 48 postoperative hours (PVB vs ICNB vs ESPB; 13% vs 29% vs 46%; p < 0.05).
Conclusions: Ultrasound-guided multiple-injection PVB provided superior analgesia to ICNB and single-injection ESPB, while ICNB and single-injection ESPB were equally effective in reducing pain after thoracoscopic surgery.
贵州医科大学高鸿教授课题组
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