小儿腹腔镜结直肠手术中实施加强康复方案减少围手术期阿片类药物并未加剧术后疼痛
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Implementation of an enhanced recovery program in pediatric laparoscopic colorectal patients does not worsen analgesia despite reduced perioperative opioids: a retrospective, matched, non-inferiority study
背景与目的
加强康复方案（ERP）可加快肠道功能恢复，缩短术后住院时间和降低30天再入院的概率；但一味地追求减少术后并发症而牺牲适当的围手术期镇痛是非常不合理的。本研究旨在探讨小儿腹腔镜结直肠手术中实施加强康复方案减少围手术期阿片类药物对镇痛效果的影响。
方 法
收集的数据包括人口统计学信息、ASA分级和手术指征等。所收集的术中信息包括所执行的手术操作、采用的全身和区域麻醉技术、液体和药物管理、手术时间和并发症。收集的术后要素包括PACU疼痛评分、PACU阿片使用量、PACU留置时长、术后疼痛评分、术后阿片使用量、排便时间、术后总的住院时长、并发症和30天再入院率。
结 果
该研究分析了56名ERP前期患者和50名ERP患者。ERP组患者术中接受的静脉输液较（3.7±1.2ml/kg/h vs 7.5±3.7ml/kg/h，P<0.001）；ERP组术中阿片类药物使用量也显著降低（0[0，0.08]0.43 vs [0.31，0.69]，P<0.001）。尽管术中使用较少的阿片类药物，但ERP患者拥有非劣的平均疼痛评分（0[0，0.5] vs 0.38[0，1.5]，P值非劣性<0.001）；此外ERP队列中的患者术后使用较少的阿片类药物（0.01[0，0.03] vs 0.14 [0.07，0.21]，P<0.001），但术后4天也拥有非劣的平均疼痛评分（2.0±1.4 vs 2.3±1.3，P=0.003）。ERP队列还减少了术后住院时间（3[2，4]天vs 4[3，5]天，P<0.001）和30天再入院率（5.9% vs 25%，P<0.001）。
结 论
该研究发现对接受腹腔镜结直肠手术的患儿大量减少围术期阿片类药物使用并未显著加剧术后疼痛。
原始文献摘要
Edney J C , Lam H , Raval M V , et al. Implementation of an enhanced recovery program in pediatric laparoscopic colorectal patients does not worsen analgesia despite reduced perioperative opioids: a retrospective, matched, non-inferiority study[J]. Regional Anesthesia and Pain Medicine, 2019, 44(1):123-129.
BACKGROUND AND OBJECTIVES:
Enhanced recovery protocols (ERPs) decrease length of stay and postoperative morbidity, but it is important that these benefits do not come at a cost of sacrificing proper perioperative analgesia. In this retrospective, matched cohort study, we evaluated postoperative pain intensity in pediatric patients who underwent laparoscopic colorectal surgeries before and after ERP implementation.
METHODS:
Patients in each cohort were randomly matched based on age, diagnosis, American Society of Anesthesiologists classification, and surgical procedure. The primary outcome was average daily postoperative pain score, while the secondary outcomes included postoperative hospital length of stay, complication rate, and 30-day readmissions. Since our hypothesis was non-inferior analgesia in the postprotocol cohort, a non-inferiority study design was used.
RESULTS:
After matching, 36 pairs of preprotocol and postprotocol patients were evaluated. ERP patients had non-inferior recovery room pain scores (difference 0 (-1.19, 0) points, 95% CI -0.22 to 0.26 points, p valuenon-inferiority <0.001) and 4-day postoperative pain scores (difference -0.3±1.9 points, 95% CI -0.82 to 0.48 points, p valuenon-inferiority <0.001) while receiving less postoperative opioids (difference -0.15 [-0.21, -0.05] intravenous morphine equivalents/kg/day, p<0.001). ERP patients also had reduced postoperative hospital stays (difference -1.5 [-4.5, 0] days, p<0.001) and 30-day readmissions (2.8% vs 27.8%, p=0.008).
CONCLUSIONS:
Implementation of our ERP for pediatric laparoscopic colorectal patients was associated with less perioperative opioids without worsening postoperative pain scores. In addition, patients who received the protocol had faster return of bowel function, shorter postoperative hospital stays, and a lower rate of 30-day hospital readmissions. In pediatric laparoscopic colorectal patients, the incorporation of an ERP was associated with a pronounced decrease in perioperative morbidity without sacrificing postoperative analgesia.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：王贵龙 编辑：冯玉蓉 审校：王贵龙