【罂粟摘要】关节镜下肩部手术关节内浸润镇痛的系统评价和meta分析
关节镜下肩部手术关节内浸润镇痛的系统评价和meta分析
贵州医科大学 高鸿教授课题组
翻译：佟睿 编辑：佟睿 审校：曹莹
肩关节手术中保留膈神经功能的镇痛技术更加可行。关节内浸润镇痛是一种易于保留膈神经功能的方法，但由于镇痛效果的证据和对软骨毒性的理论关注存在矛盾，其作用尚不清楚。这项系统回顾和meta分析评估了关节镜下肩部手术中关节内浸润与全身镇痛或肌间沟臂丛阻滞的优点及风险。我们进行了比较关节内浸润、肌间沟臂丛阻滞与全身麻醉镇痛(对照组)的随机对照试验。主要观察指标为术后24小时累计口服吗啡当量消耗量。次要观察指标包括术后24小时内的视觉模拟评分；首次要求镇痛的时间；病人满意度；阿片类药物相关副作用；阻滞相关不良事件；以及软骨毒性的任何指标。研究共纳入了15项试验(863例患者)。与对照组相比，关节内浸润减少了术后24小时的止痛药消耗量，加权平均差异(95%CI)为-30.9%(-38.9 ~ -22.9；p<0.001)。关节内浸润也降低了术后12h疼痛评分的加权平均差值(95%CI)，术后4h的疼痛评分为-2.2 cm[(-4.4 ~ -0.04) ; p<0.05]。与肌间沟臂丛神经阻滞相比，阿片类药物用量无明显差异，但肌间沟臂丛神经阻滞术后2、4、24h的疼痛评分明显更优。各组中阿片类药物或阻滞相关的不良事件没有差异，也没有试验报告软骨毒性效应。与全身麻醉镇痛相比，关节内浸润能更好地控制疼痛，减少阿片类药物的消耗，提高患者满意度，但镇痛效果可能逊于肌间沟臂丛阻滞。
E. M. Yung, T. C. Got, N. Patel，et al. Intra-articular infiltration analgesia for arthroscopic shoulder surgery: a systematic review and meta-analysis.[J]. Anaesthesia 2021 Apr; 76 (4): 549-558.
Intra-articular infiltration analgesia for arthroscopic shoulder surgery: a systematic review and meta-analysis
Summary
Phrenic-sparing analgesic techniques for shoulder surgery are desirable. Intra-articular infiltration analgesia is one promising phrenic-sparing modality, but its role remains unclear because of conflicting evidence of analgesic efficacy and theoretical concerns regarding chondrotoxicity. This systematic review and meta-analysis evaluated the benefits and risks of intra-articular infiltration in arthroscopic shoulder surgery compared with systemic analgesia or interscalene brachial plexus block. We sought randomised controlled trials comparing intra-articular infiltration with interscalene brachial plexus block or systemic analgesia (control). Cumulative 24-h postoperative oral morphine equivalent consumption was designated as the primary outcome. Secondary outcomes included visual analogue scale pain scores during the first 24 h postoperatively; time-to-first analgesic request; patient satisfaction; opioidrelated side-effects; block-related adverse events; and any indicators of chondrotoxicity. Fifteen trials (863 patients) were included. Compared with control, intra-articular infiltration reduced 24-h postoperative analgesic consumption by a weighted mean difference (95%CI) of -30.9 ([-38.9 to -22.9]; p < 0.001). Intra-articular infiltration also reduced the weighted mean difference (95%CI) pain scores up to 12 h postoperatively, with the greatest reduction at 4h (-2.2 cm [(-4.4 to -0.04]); p < 0.05). Compared with interscalene brachial plexus block, there was no difference in opioid consumption, but patients receiving interscalene brachial plexus block had better pain scores at 2, 4 and 24 h postoperatively. There was no difference in opioid- or block-related adverse events, and none of the trials reported chondrotoxic effects. Compared with systemic analgesia, intra-articular infiltration provides superior pain control, reduces opioid consumption and enhances patient satisfaction, but it may be inferior to interscalene brachial plexus block patients having arthroscopic shoulder surgery.