非阿片类药物多模式疼痛管理与术后临床结局的关系：基于择期关节置换术的阻塞性睡眠呼吸暂停患者的一项回顾性研究
本公众号每天分享一篇最新一期Anesthesia & Analgesia等SCI杂志的摘要翻译，敬请关注并提出宝贵意见
Non-opioid analgesic modes of pain management are associated with reduced postoperative complications and resource utilisation: a retrospective study of obstructive sleep apnoea patients undergoing elective joint arthroplasty.
背景与目的
镇静剂和阿片类药物应用于阻塞性睡眠呼吸暂停(OSA)患者时增加围术期气道风险。为了减少阿片类药物在此类患者中的应用，目前OSA患者的围术期镇痛管理建议中推荐采取多模式镇痛。但多模式镇痛在此类患者中的有效性目前尚缺乏研究。
方 法
本研究选取从2006年1月到2016年12月美国高级医疗保健数据库(Premier Healthcare Solutions,Inc., Charlotte, NC, USA)中所有接受全髋关节置换(THA)或全膝关节置换(TKA)术的患者；多模式镇痛的定义为在手术当天或术后第二天添加非阿片镇痛模式，并按添加一种、两种或两种以上非阿片镇痛模式分组。非阿片类镇痛模式包括外周神经阻滞、对乙酰氨基酚、类固醇、加巴喷丁/普瑞巴林、氯胺酮、非甾体抗炎药或环氧化酶-2(COX-2)抑制剂；采取多水平、多变量回归模型分析多模式镇痛类别(与单一阿片类药物相比)和结果之间的关联；结果表示为校正后的优势比(OR)和Bonferroni校正的95%置信区间(CI)。
结 果
本研究共纳入181182例接受关节置换术的OSA患，其中88.5%(N =160,299)采用多模式镇痛；多模式镇痛组与对照组间的最大差异之一是PCA在前者使用率较低(单一阿片类镇痛者为26.6%，而增加一种、两种或多种镇痛模式者分别为19.2%、13.7%和7.7%，P<0.0001)。阿片类药物剂量、LOS、费用和并发症发生率均以单一阿片类药物组最高；阿片类药物处方剂量、医疗资源占用和术后并发症的校正后估计效应；随着镇痛模式的增加，术后第1天阿片类药物处方量逐渐减少：-14.9% (CI -17.0%; -12.7%)，LOS下降：-11.8% (CI -13.0%; -10.7%)；住院费用略有下降：-3.2%(CI-4.2%；-2.2%)。
结 论
在OSA围手术期并发症高危人群中，随着镇痛模式增多，阿片类药物处方剂量逐渐减少，可减少不良事件。
原始文献摘要
Cozowicz C,Poeran J,Zubizarreta N et al. Non-opioid analgesic modes of pain management are associated with reduced postoperative complications and resource utilisation: a retrospective study of obstructive sleep apnoea patients undergoing elective joint arthroplasty. [J] .Br J Anaesth, 2019, 122: 131-140.
Background: Studies on the effectiveness of multimodal analgesia, particularly in patients at higher perioperative risk from obstructive sleep apnoea (OSA), are lacking. We aimed to assess the impact of multimodal analgesia on opioid use and complications in this high-risk cohort.
Methods: We conducted a population-based retrospective cohort study of OSA patients undergoing elective lower extremity joint arthroplasty (2006-2016, Premier Healthcare database). Multimodal analgesia was defined as opioid use with the addition of one, two, or more non-opioid analgesic modes including, nonsteroidal anti-inflammatory drugs (NSAIDs),cyclooxygenase-2 inhibitors, paracetamol/acetaminophen, peripheral nerve blocks, steroids, gabapentin/pregabalin, or ketamine. Multilevel multivariable regression models measured associations between multimodal analgesia and opioid prescription (primary outcome; oral morphine equivalents). Secondary outcomes included opioid- and OSA-related complications, and resource utilisation. Odds ratios (OR) or % change and 95% confidence intervals (CI) are reported.
Results: Among 181 182 OSA patients included, 88.5% (n =160 299) received multimodal analgesia with increasing utilisation trends. Multivariable models showed stepwise beneficial postoperative outcome effects with increasing additional analgesic modes compared with opioid-only analgesia. In patients who received more than two additional analgesia modes (n =64 174), opioid dose prescription decreased by 14.9% (CI -17.0%; -12.7%), while odds were
significantly decreased for gastrointestinal complications (OR 0.65, CI 0.53; 0.78), mechanical ventilation (OR 0.23, CI 0.16;0.32), and critical care admission (OR 0.60, CI 0.48; 0.75), all P<0.0001.
Conclusions: In a population at high risk for perioperative complications from OSA, multimodal analgesia was associated with a stepwise reduction in opioid use and complications, including critical respiratory failure.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：王贵龙 编辑：何幼芹 审校：王贵龙