腹腔内使用利多卡因改善了剖宫产术后镇痛效果：随机、双盲、安慰剂对照试验
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Intraperitoneal Instillation of Lidocaine Improves Postoperative Analgesia at Cesarean Delivery: A Randomized, Double-Blind, Placebo-Controlled Trial
背景与目的:剖宫产术广泛使用于全世界。尽管平衡多模式镇痛有所改善，但仍有一部分产妇术后疼痛缓解和满意度仍不足。研究表明腹膜内局部麻醉剂使用可有效减少腹部手术的术后疼痛。腹膜内使用利多卡因作为多模式镇痛方案的一部分，本研究主要探讨其对剖宫产术后疼痛的影响。
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方法：本研究纳入了于椎管内麻醉下行选择性剖宫产的产妇，用0.75%重比重布比卡因联合芬太尼和吗啡进行椎管内麻醉。剖腹产结束时，在壁层腹膜或筋膜闭合之前，患者随机接受利多卡因（2％利多卡因和肾上腺素20mL，1:200,000）或安慰剂（20m生理盐水20mL）滴注到腹膜腔中。主要结果为术后24小时运动时的疼痛评分。次要结果为术后休息2h、24h、48h休息和运动时的疼痛评分、产妇满意度得分、镇痛药用量，恶心、呕吐、瘙痒的发生率以及肠道功能。
结果：共纳入240名产妇。利多卡因组和安慰剂组的基础生命体征无区别。术后24小时运动时疼痛评分（参数估计=0.02；95％CI：-0.14～0.18；P = 0.823），术后24小时休息时疼痛评分（参数估计=0.00；95％CI： -0.32～0.33；P = 0.986），两组无明显区别；术后2小时运动时疼痛评分（参数估计=-0.58；95％CI ：-0.90～-0.26； P = .001），术后2小时休息时疼痛评分（参数估计=-1.00 ；95％CI ：-1.57～-0.43; P =0 .001），利多卡因组比对照组值相对较低；亚组分析显示，术后24小时运动时疼痛评分显着降低（参数估计值=-0.33；95％CI：-0.64～-0.03; P = 0.032）；利多卡因组术后使用阿片类药物治疗疼痛的人数明显低于安慰剂组（分别为40％和65％），显著性为0.59（95％CI ：0.43～0.81； P = 0.001）。
结论：腹腔内使用利多卡因可改善剖宫产术后早期疼痛。此外，它减少了产后立即需要使用阿片类药物缓解疼痛的产妇人数。产妇将会从此镇痛方案大大受益。
Patel R, Carvalho J C, Downey K, et al. Intraperitoneal Instillation of Lidocaine Improves Postoperative Analgesia at Cesarean Delivery: A Randomized, Double-Blind, Placebo-Controlled Trial[J]. Anesthesia & Analgesia, 2017, 124(2):554.
Background: Cesarean delivery is a commonly performed procedure worldwide. Despite improvements in balanced multimodal analgesia, there remains a proportion of women for whom postoperative pain relief and patient satisfaction are still inadequate. Intraperitoneal instillation of local anesthetic has been shown to be effective in reducing postoperative pain after abdominal surgery. We sought to investigate the effect of intraperitoneal instillation of
lidocaine on postcesarean delivery pain as part of a multimodal analgesia regimen.
Methods:
We studied women scheduled for elective cesarean delivery under spinal anesthesia.Spinal anesthesia was performed with 0.75% hyperbaric bupivacaine, fentanyl, and morphine.At the end of the cesarean delivery, immediately before parietal peritoneum or fascia closure, patients were randomized to receive either lidocaine (20 mL 2% lidocaine with epinephrine) or placebo (20 mL normal saline) instilled into the peritoneal cavity. The primary outcome was pain score on movement at 24 hours. Secondary outcomes were pain score at rest and on movement at 2, 24, and 48 hours; maternal satisfaction score; analgesic consumption; incidence of nausea, vomiting, and itching; and return of bowel function.
Results:
Two hundred four women were recruited. Baseline characteristics were similar between the lidocaine and placebo groups. Pain scores at 24 hours postcesarean delivery on movement (parameter estimate 0.02 [95% confidence interval {CI} −0.14 to 0.18]; P = .823)
and at rest (parameter estimate 0.00 [95% CI −0.32 to 0.33]; P = .986) were similar in both groups. Pain scores at 2 hours postcesarean delivery on movement (parameter estimate −0.58 [95% CI −0.90 to −0.26]; P = .001) and at rest (parameter estimate −1.00 [95% CI −1.57 to −0.43]; P = .001) were lower in the lidocaine group. Subgroup analysis of patients with peritoneum closure revealed significantly lower pain scores at 24 hours on movement (parameter
estimate −0.33 [95% CI −0.64 to −0.03]; P = .032) in the lidocaine group. The number of women requesting postoperative opioids for breakthrough pain was significantly lower in the lidocaine group compared with that of the placebo (40 [40%] vs 61 [65%], respectively, relative risk 0.59 [95% CI 0.43–0.81]; P = 0.001).
Conclusion:
The use of intraperitoneal instillation of lidocaine improves early postoperative pain management after cesarean delivery. Furthermore, it reduces the number of women requesting systemic opioids in the immediate postpartum period. Women undergoing peritoneal closure may particularly benefit from this intervention.
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