甲哌卡因对比布比卡因腰麻对患者术后早期活动的影响：随机对照实验
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甲哌卡因对比布比卡因腰麻对患者术后早期活动的影响：随机对照实验
翻译：任文鑫 编辑：冯玉蓉 审校：曹莹
背景:全髋关节置换术后早期活动预示着早期出院。腰麻在许多实践中是首选的，但其会延迟术后活动，特别是在使用布比卡因的情况下。甲哌卡因是一种中效局麻药，可比布比卡因更早下地活动。本研究旨在验证接受甲哌卡因的患者比接受重比重或等比重布比卡因用于初次全髋关节置换术的患者更早下地活动的假设。
方法：这项随机对照试验包括ASA健康状况分级I~III级接受初次全髋关节置换术的患者。患者按1:1:1随机接受52.5mg甲哌卡因、11.25mg重比重布比卡因或12.5mg等比重布比卡因腰麻。主要结果为麻醉后3~3.5h下地活动情况，次要结果包括运动和感觉功能恢复、术后疼痛、阿片类药物用量、一过性神经症状、尿潴留、术中低血压、术中肌张力、当天出院、住院时间和30d再入院。
结果：154例患者中，50例接受甲哌卡因腰麻，53例接受重比重布比卡因腰麻，51例接受等比重布比卡因腰麻。各组间患者的特征相似。麻醉后3~3.5h下地活动情况，甲哌卡因组50名患者中有35名（70.0%）达到目标终点，重比重布比卡因组53名患者中有20名（37.7%）达到终点，等比重布比卡因组51名患者中有9名（17.6%）达到终点（P<0.001）。使用甲哌卡因的患者运动功能恢复较早。仅在术后早期，甲哌卡因患者的疼痛和阿片类药物用量较高。日间手术中，50例甲哌卡因患者中有23例患者（46.0%），53例重比重布比卡因患者中有13例患者（24.5%）和51例等比重布比卡因患者中有11例患者（21.5%）当天出院（P=0.014）。甲哌卡因患者的住院时间最短。各组间在一过性神经症状、尿潴留、低血压、肌张力或头晕方面没有差异。
结论：与重比重布比卡因和等比重布比卡因组的患者相比，甲哌卡因组的患者术后活动更早，当天出院的可能性更大。如果腰麻是首选的麻醉类型，那么甲哌卡因对门诊全髋关节置换术患者可能是有益的。
原始文献来源：Eric S. Schwenk,Vincent P. Kasper, Jordan D. Smoker,et al.Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation:A Randomized Controlled Trial.Anesthesiology 2020; 133:801–11.
Mepivacaine versus Bupivacaine Spinal Anesthesia for Early Postoperative Ambulation
ABSTRACT
Background: Early ambulation after total hip arthroplasty predicts early discharge. Spinal anesthesia is preferred by many practices but can delay ambulation, especially with bupivacaine. Mepivacaine, an intermediate-acting local anesthetic, could enable earlier ambulation than bupivacaine. This study was designed to test the hypothesis that patients who received mepivacaine would ambulate earlier than those who received hyperbaric or isobaric bupivacaine for primary total hip arthroplasty.
Methods: This randomized controlled trial included American Society of Anesthesiologists Physical Status I to III patients undergoing primary total hip arthroplasty. The patients were randomized 1:1:1 to 52.5mg of mepivacaine, 11.25mg of hyperbaric bupivacaine, or 12.5mg of isobaric bupivacaine for spinal anesthesia. The primary outcome was ambulation between 3 and 3.5 h. Secondary outcomes included return of motor and sensory function, postoperative pain, opioid consumption, transient neurologic symptoms, urinary retention, intraoperative hypotension, intraoperative muscle tension, sameday discharge, length of stay, and 30-day readmissions.
Results: Of 154 patients, 50 received mepivacaine, 53 received hyperbaric bupivacaine, and 51 received isobaric bupivacaine. Patient characteristics were similar among groups. For ambulation at 3 to 3.5 h, 35 of 50 (70.0%) of patients met this endpoint in the mepivacaine group, followed by 20 of 53 (37.7%) in the hyperbaric bupivacaine group, and 9 of 51 (17.6%) in the isobaric bupivacaine group (P < 0.001). Return of motor function occurred earlier with mepivacaine. Pain and opioid consumption were higher for mepivacaine patients in the early postoperative period only. For ambulatory status, 23 of 50 (46.0%) of mepivacaine, 13 of 53 (24.5%) of hyperbaric bupivacaine, and 11 of 51 (21.5%) of isobaric bupivacaine patients had same-day discharge (P = 0.014). Length of stay was shortest in mepivacaine patients. There were no differences in transient neurologic symptoms, urinary retention, hypotension, muscle tension, or dizziness.
Conclusions: Mepivacaine patients ambulated earlier and were more likely to be discharged the same day than both hyperbaric bupivacaine and isobaric bupivacaine patients. Mepivacaine could be beneficial for outpatient total hip arthroplasty candidates if spinal is the preferred anesthesia type.
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