【罂粟摘要】硬膜外超前镇痛在成人开胸术后急、慢性疼痛中的应用
硬膜外超前镇痛在成人开胸术后急、慢性疼痛中的应用
贵州医科大学 高鸿教授课题组
翻译：唐剑 编辑：佟睿 审校：曹莹
硬膜外镇痛是开胸术后疼痛管理的金标准，可在手术切开前或手术后开始。本研究针对此问题进行系统回顾和meta分析，探讨开胸手术前的超前硬膜外镇痛与开胸后再实施的硬膜外镇痛相比，是否能减轻成人开胸手术后的急性和慢性疼痛。
本研究检索了MEDLINE、Embase和Central数据库，进行随机对照试验，比较成人开胸操作前（试验组）和开胸操作后（对照组）的硬膜外镇痛效果。主要研究目标是术后72h内静息和咳嗽时的疼痛强度，以及术后1~6个月的疼痛发生率。将数据与随机效应meta分析相结合。本研究使用推荐、评估、发展和评价（等级）方法将证据质量分为高、中、低和极低。
本研究共计纳入了19项试验，1062例参与者，其中试验组529例试验组，对照组533例。术后72h内静息时疼痛强度明显低于对照组（19例，n=1062），术后48h内咳嗽时疼痛强度（11例，638例）明显低于对照组（11例，638例），术后1~6个月疼痛发生率明显低于对照组（6例，276例）。初步结果的证据质量为中等或低水平。
本项系统性回顾及meta分析结果表明硬膜外超前镇痛可降低成人开胸术后急性疼痛的强度和慢性疼痛的发生率，但研究中采用的证据质量较低。
Pre-emptive epidural analgesia for acute and chronic post-thoracotomy pain in adults: a systematic review and meta-analysis.
BACKGROUND AND OBJECTIVES: Epidural analgesia is the gold standard for post-thoracotomy pain management and can be started before or after surgical incision. This systematic review and meta-analysis investigated whether pre-emptive epidural analgesia before thoracotomy incision reduces acute and chronic post-thoracotomy pain in adults compared with epidural analgesia after incision.
METHODS: We searched databases including MEDLINE, Embase, and CENTRAL for randomized controlled trials comparing epidural analgesia initiated before (pre-emptive group) and after (control group) thoracotomy incision in adults. The primary outcomes were the pain intensity during rest and coughing within 72 hours after surgery and the incidence of pain 1 to 6 months after surgery. Data were combined with random-effects meta-analyses. We rated the quality of evidence as high, moderate, low, and very low using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method.
RESULTS: We included 19 trials with 1062 participants involving 529 in the pre-emptive group and 533 in the control group. The pain intensity was significantly lower at rest within 72 hours after surgery (19 studies, n=1062) and during coughing within 48 hours after surgery (11 studies, n=638), and the incidence of pain was significantly lower 1 to 6 months after surgery (6 studies, n=276) in the pre-emptive group than in the control group. The quality of evidence was moderate or low in the primary outcomes.
CONCLUSIONS: Our review provides low-quality evidence that pre-emptive epidural analgesia reduces the intensity of acute pain and the incidence of chronic pain after thoracotomy in adults.