题目：持续性罗哌卡因切口局部浸润与鞘内注射吗啡在剖宫产后镇痛效果中的比较：前瞻性、随机对照、双盲试验
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Continuous Ropivacaine Subfascial Wound Infusion Compared With Intrathecal Morphine for Postcesarean Analgesia: A Prospective, Randomized Controlled,Double-Blind Study
背景与目的
剖宫产后，术后疼痛管理可以促进早期康复，有助于预防产后抑郁症和慢性疼痛。目前的前瞻性、随机对照、双盲研究评估了剖宫产分娩后鞘内镇痛和连续罗哌卡因伤口浸润的持续时间和作用。主要结局是镇痛持续时间，其定义为首次增加使用吗啡的时间。次要结局是术后吗啡的累积用量，不需使用吗啡的患者数量，不良反应的发生率和首次下床活动的时间。
方 法
共有192名接受选择性剖宫产分娩的产妇，随机分为3组（对照组，吗啡组和导管组）。所有患者均接受椎管内麻醉，使用10mg0.5％高压布比卡因（2mL）+5μg舒芬太尼（1mL）以及插入伤口的多孔导管；对照组中，0.9％NaCl （0.1mL）通过硬膜下和导管施用。吗啡组通过伤口导管接受100μg吗啡（0.1 mL），0.9％NaCl（0.1mL）进行鞘内注射。导管组鞘内接受0.9％ NaCl（0.1mL），0.2％的罗哌卡因注射导管，每名患者通过导管接受15mL罗哌卡因，该导管连接到以10mL / h的速率泵注的弹性泵上，持续泵注30min。所有患者均进行多模式
结 果
与对照组相比，吗啡组和导管组的术后镇痛持续时间增加，分别为：（247分钟; 182〜338），（380分钟; 215〜1527）（351分钟; 227〜594）其效果大小为0.171（0.043〜 0.293），而对照组为0.164（0.052〜0.271）。吗啡组与导管组无差异（效果大小为0.007; -0.118〜0.132）。吗啡组和导管组与对照组相比，术后吗啡的使用量也显着降低。不良反应的发生率在组间无差异。
结 论
剖宫产术后，100μg鞘内吗啡的使用和持续性罗哌卡因切口浸润均增加了分娩后镇痛的持续时间和效果，且副作用的发生率并不增加。
原始文献摘要
Lalmand , Wilwerth , Fils J, et al. Continuous Ropivacaine Subfascial Wound Infusion Compared With Intrathecal Morphine for Postcesarean Analgesia: A Prospective, Randomized Controlled, Double-Blind Study.[J]. Anesthesia & Analgesia, 2017, 125(3):907-912.
BACKGROUND: After cesarean delivery, postoperative pain management allows early rehabilitation
and helps prevent postpartum depression and chronic pain. Our present prospective, randomized controlled, double-blind study assessed the duration and effect of intrathecal analgesia and continuous ropivacaine wound infiltration versus a control group after cesarean delivery.The primary outcome was analgesia duration, defined as time to first morphine request. Secondary outcomes were cumulative postoperative morphine consumption, number of patients who did not require IV morphine, incidence of adverse effects, and time to first ambulation.
METHODS: A total of 192 full-term parturients undergoing elective cesarean delivery were randomly
allocated into 3 groups (control, morphine, and catheter). All patients received spinal anesthesia with 10 mg bupivacaine 0.5% hyperbaric bupivacaine (2 mL) + 5 μg of sufentanil (1 mL) and a multiholed catheter inserted into the wound. In the control group, NaCl 0.9% was administered intrathecally (0.1 mL) and through the catheter. The morphine group received 100μg morphine (0.1 mL) intrathecally and NaCl 0.9% infused through the wound catheter. The catheter group received 0.1 mL NaCl 0.9% intrathecally and ropivacaine 0.2% infused in the catheter. Each patient received a 15-mL bolus of the dedicated solution through the catheter, which was connected to an elastomeric pump infusor delivering the same solution at a rate of 10 mL/h for 30 hours. All patients also received multimodal analgesia including acetaminophen and diclofenac. Analgesia duration was defined as the time from spinal injection (T0) to first IV morphine requirement (T1) administered via a patient-controlled IV analgesia pump. Statistical
data analyses included use of the Kruskal-Wallis rank-sum test followed by the post hoc Tukey
test and χ2 test.
RESULTS: The duration of postoperative analgesia was increased with intrathecal morphine
(380 minutes; 215–1527) and ropivacaine wound infusion (351 minutes; 227–594) compared
with the control (247 minutes; 182–338) with effect sizes of 0.171 (0.043–0.293) for morphine
versus control and 0.164 (0.052–0.271) for catheter versus control. There was no difference
between the morphine group and catheter group (effect size, 0.007; −0.118 to 0.132).
Cumulative postoperative morphine consumption was also significantly lower in the morphine
group and catheter group compared with the control group. The incidence of adverse effects did
not differ between groups.
CONCLUSIONS: After elective cesarean delivery, 100 μg intrathecal morphine and ropivacaine
wound infusion both increased the duration and effect of postcesarean analgesia without increased incidence of side effects.
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