局部使用罗哌卡因预防成年人术后并发症
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Topical Ropivacaine in Prevention of Post-Tonsillectomy Pain in Adults
背景与目的
扁桃体切除后疼痛是术后疼痛最严重的1例。然而，最佳和充分的术后镇痛治疗仍不清楚。我们调查了局部罗哌卡因在160名成人门诊手术患者中的扁桃体切除术后两周的疼痛效果。
方 法
在扁桃体切除术结束时，将浸入1％罗哌卡因或盐水的2个拭子包装在扁桃体床中5分钟。我们使用布洛芬和对乙酰氨基酚（500mg） - 可待因（30mg）片剂的组合作为术后止痛剂2周。主要结果是在术后第一周时以数字评分量表（NRSs）测量的吞咽疼痛强度，表示为曲线下面积（AUC）。次要终点包括在麻醉后护理单位的2小时随访期间经历的最严重的疼痛，术后第二周的疼痛强度，以及术后2周内消耗的布洛芬和对乙酰氨基酚可待因片剂的数量。
结 果
在术后第一周，160例（75％）中有120例提供了完整的结果，包括根据说明使用止痛药的数据，并且每天完成并返回问卷。在术后第二周，共有101例（63％）患者相同。主要结局NRS（AUC）的中位数（四分位数范围[IQR]）为罗哌卡因组为38例（19）对照组在术后第一周（P = .77，-1.0估计差异; 95％置信区间[CI]为差异，-7.0〜5.0）;没有发现差异。罗哌卡因组NRS（NRSr）（NRSr）（AUC）的中位数（IQR）（AUC）为24.5（19），术后第一周为对照组为24（22）（P = .96，0.0估计差异; 95％CI差异为-5.0〜5.0）;没有发现差异。罗哌卡因组最差疼痛强度值（NRSs或NRSr）（AUC）的中值（IQR）为5（3），对照组为5（3）（P = .44，0.0估计差异; 95％CI为差值-1.0〜0.5）;没有发现差异。在术后第二周，罗哌卡因组NRS（AUC）中位数（IQR）为17（13），对照组为21（23）（P = 0.05，-4.0估计差异; 95％CI为差异，-9.0至0.0）和罗哌卡因组NRSr（AUC）10.5（10）和对照组11（13）的中位数（IQR）（P = .42，-1.0估计差异; 95％CI为差异，-5.0〜2.0）;没有发现差异。罗哌卡因组在第二次术后消耗的营救止痛药（对乙酰氨基酚可待因片）数量低于对照组（消费中值[IQR]为10 [12]]罗哌卡因组和对照组16例[12]; P = 0.0008，-7.0估计差异; 95％CI差异，-10〜-3.0）。这些组在扁桃体切除术后出血的风险总体上没有差异。然而，在局麻下需要止血的出血在罗哌卡因组中较常见（18％vs 8％，P = 0.48，10％估计差异; 95％CI差异，0％-21％）。
结 论
局部罗哌卡因在术后第一周未能减轻疼痛强度。我们没有观察到重大的不利影响。
原始文献摘要
Tolska HK1, Takala A, Blomgren K, Hamunen K, Kontinen V.Topical Ropivacaine in Prevention of Post-Tonsillectomy Pain in Adults.Anesth Analg. 2017 May;124(5):1459-1466.
BACKGROUND: Post-tonsillectomy pain is 1 of the most intense postoperative pain conditions. However, optimal and sufficient postoperative analgesic treatment remains unclear. We investigated the effect of topical ropivacaine for post-tonsillectomy pain in 160 adult outpatient surgery patients over 2 post perative weeks.
METHODS:At the end of tonsillectomy, 2 swabs soaked in either 1% ropivacaine or saline were packed into the tonsillar beds for 5 minutes. We used ibuprofen and a combination of acetaminophen (500 mg)-codeine (30 mg) tablets as postoperative analgesics for 2 weeks. The primary outcome was pain intensity on swallowing measured on a numeric rating scale (NRSs) during the first postoperative week expressed as area under curve (AUC). The secondary endpoints included the worst pain experienced during the 2-hour follow-up in the postanesthesia care unit, pain intensity during the second postoperative week, and the number of ibuprofen and acetaminophen-codeine tablets consumed during the 2 postoperative weeks.
RESULTS:During the first postoperative week, 120 patients out of 160 (75%) provided complete results, including data on their use of analgesics according to the instructions as well as completed and returned a questionnaire daily. A total of 101 patients (63%) did the same during the second postoperative week.Median (interquartile range [IQR]) of the primary outcome NRSs (AUC) was 38 (19) for the ropivacaine group and 37 (24) for the control group during the first postoperative week (P = .77, -1.0 estimated difference; 95% confidence interval [CI] for the difference, -7.0 to 5.0); no difference was found. Median (IQR) of NRS at rest (NRSr) (AUC) was 24.5 (19) for the ropivacaine group and 24 (22) for the control group during the first postoperative week (P = .96, 0.0 estimated difference; 95% CI for the difference, -5.0 to 5.0); no difference was found. Median (IQR) of the worst pain intensity values (NRSs or NRSr) (AUC) was 5 (3) for the ropivacaine group and 5 (3) for the control group (P = .44, 0.0 estimated difference; 95% CI for the difference, -1.0 to 0.5); no difference was found. During the second postoperative week, median (IQR) of the NRSs (AUC) was 17 (13) for theropivacaine group and 21 (23) for the control group (P = .05, -4.0 estimated difference; 95% CI for the difference, -9.0 to 0.0) and median (IQR) of the NRSr (AUC) 10.5 (10) for ropivacaine group and 11 (13) for the control group (P = .42, -1.0 estimated difference; 95% CI for the difference, -5.0 to 2.0); no difference was found.The number of rescue analgesics (acetaminophen-codeine tablets) consumed during the second postoperative week was lower in the ropivacaine group than in the control group (median [IQR] of the consumption [AUC] was 10 [12] for the ropivacaine group and 16 [12] for the control group; P = .0008, -7.0 estimated difference; 95% CI of difference, -10 to -3.0). The groups showed no differences in overall risk for post-tonsillectomy bleeding. However, bleeding requiring hemostasis under local anesthesia was more common in the ropivacaine group (18% vs 8%, P = .048, 10% estimated difference; 95% CI for the difference, 0%-21%).
CONCLUSIONS：Topical ropivacaine failed to reduce pain intensity during the first postoperative week. We observed no major adverse effects.
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