【罂粟摘要】胸腔镜手术后行奇静脉水平膈神经阻滞与对照组治疗后同侧肩痛的疗效比较：一项随机对照试验
胸腔镜手术后行奇静脉水平膈神经阻滞与对照组治疗后同侧肩痛的疗效比较：一项随机对照试验
贵州医科大学 高鸿教授课题组
翻译：潘志军 编辑：佟睿 审校：曹莹
同侧肩痛(ISP)是肺部手术后的常见问题。我们假设在手术操作位置附近的奇静脉水平处进行膈神经阻滞(PNB)可有效降低ISP。本研究的主要目的是评估PNB对胸腔镜手术(VATS)后ISP的影响。
这项前瞻性、随机、患者盲法、单机构试验在大学医院医疗信息网(UMIN000030464)上注册。入组的患者在硬膜外镇痛全身麻醉下行胸腔镜手术。我们将患者随机分配到接受10ml 0.375%罗哌卡因(PNB组)或0.9%生理盐水(对照组)，即在胸腔闭合前进行奇静脉水平的同侧膈神经阻滞。术后2、4、8、16和24小时患者静息时ISP使用数字评分量表(NRS，0-10)进行评估。ISP的发生率定义为术后24小时内至少报告一次NRS评分≥1的患者比例。在主要分析中，我们使用了χ2检验来比较PNB组和对照组之间ISP患者的比例。我们观察了患者24小时内ISP的NRS值和术后切口疼痛，以及术后镇痛药的使用频率。并在ISP评估时使用NRS评估患者切口疼痛。最后，我们还评估了患者术后恶心呕吐和肩部运动障碍的发生率。
本研究纳入了85例患者，随机分配到PNB组(n = 42)或对照组(n = 43)并对其进行数据分析。两组之间的人口统计学和手术概况没有临床相关差异。ISP的发生率无显著差异(对照组20/43 [46.5%]与PNB组14/42[33.3%]；P =0.215)。PNB组ISP的严重程度低于对照组(线性混合效应模型，主要治疗结果[组]：P < 0.001)。两组术后切口疼痛无显著差异。对照组术后镇痛药使用频率显著高于PNB组(Wilcoxon秩和检验，P <0.001)。两组术后恶心和呕吐无显著差异且肩关节活动范围无变化。
奇静脉水平PNB对VATS后ISP的发生率无明显影响。
Kaori Kimura Kuroiwa, Yuki Shiko, Yohei Kawasaki, et al. Phrenic Nerve Block at the Azygos Vein Level Versus Sham Block for Ipsilateral Shoulder Pain After Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial.[J]. Anesth Analg 2021;132:1594–602.
Phrenic Nerve Block at the Azygos Vein Level Versus Sham Block for Ipsilateral Shoulder Pain After Video-Assisted Thoracoscopic Surgery: A Randomized Controlled Trial
Abstract
Background: Ipsilateral shoulder pain (ISP) is a common problem after pulmonary surgery. We hypothesized that phrenic nerve block (PNB) at the azygos vein level, near the location of the surgical operation, would be effective for reducing ISP . Our primary aim was to assess the effect of PNB on postoperative ISP , following video-assisted thoracic surgery (VATS).
Methods: This prospective, randomized, patient-blinded, single-institution trial was registered at the University Hospital Medical Information Network (UMIN000030464). Enrolled patients had been scheduled for VATS under general anesthesia with epidural analgesia. Patients were randomly allocated to receive infiltration of the ipsilateral phrenic nerve at the azygos vein level with either 10 mL of 0.375% ropivacaine (PNB group) or 0.9% saline (control group) before chest closure. Postoperative ISP was assessed using a numerical rating scale (NRS, 0–10) at rest at 2, 4, 8, 16, and 24 hours. The incidence of ISP was defined as the proportion of patients who reported an NRS score of ≥1 at least once within 24 hours after surgery. In the primary analysis, the proportion of patients with ISP was compared between PNB and control groups using the χ2 test. NRS values of ISP and postoperative incision pain within 24 hours were investigated, as was the frequency of postoperative analgesic use. Incision pain was assessed using an NRS at the time of ISP assessment. Finally, the incidence of postoperative nausea and vomiting and shoulder movement disorders were also evaluated.
Results: Eighty-five patients were included, and their data were analyzed. These patients were randomly assigned to either PNB group (n = 42) or control group (n = 43). There were no clinically relevant differences in demographic and surgical profiles between the groups. There was no significant difference in the incidence of ISP (the control group 20/43 [46.5%] versus the PNB group 14/42 [33.3%]; P =0.215). The severity of ISP was lower in the PNB group than in the control group (linear mixed-effects model, the main effect of treatment [groups]: P < 0.001). There were no significant differences between groups in terms of postoperative incision
pain. The frequency of postoperative analgesic use was significantly higher in the control group (Wilcoxon rank sum test, P <0.001). Postoperative nausea and vomiting did not significantly differ between the 2 groups. There were no changes in the range of shoulder joint movement.
Conclusions: Azygos vein level PNB did not significantly affect the incidence of ISP after VATS.