【罂粟摘要】神经周应用布比卡因脂质体外周神经阻滞镇痛效果并不优于非脂质体：一项系统评价及Meta分析
神经周应用布比卡因脂质体外周神经阻滞镇痛效果并不优于非脂质体：一项系统评价及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
布比卡因脂质体在神经周给药时可以延长周围神经阻滞的镇痛时间。然而，神经周应用布比卡因脂质体临床疗效的证据是复杂性的。这项Meta分析旨在评估神经周应用布比卡因脂质体与非脂质体局部麻醉药相比在改善周围神经阻滞镇痛方面的有效性。
作者确定了评估周围神经阻滞止痛剂有效性的随机试验，这些试验比较了脂质体布比卡因和非脂质体局部麻醉剂。主要观察指标是汇集了24~72小时休息时疼痛程度评分的受试者围术期特征曲线下面积(AUC)差异。次要指标包括术后止痛药用量、首次止痛要求的时间、阿片类药物相关副作用的发生率、患者满意度、住院时间、布比卡因脂质体副作用和患者功能恢复。根据最小的临床重要性差异2.0 cm·h来解释AUC疼痛评分。
对9个试验(619名患者)进行了分析。纳入所有试验后，布比卡因非脂质体和脂质体在24~72h的AUC疼痛评分±SD分别为7.6±4.9 cm·h和6.6±4.6 cm·h。因此，神经周应用布比卡因脂质体与非脂质体相比，可将24~72h疼痛评分的AUC值(95%CI)提高1.0 cm·h(0.50~1.6cm.h；P=0.003)，这在临床上并无明显作用。排除一项行业赞助的试验，两组之间的差异无显著性意义(0.7cm·h[−0.1~1.5]; P=0.100)。次要指标的分析没有发现布比卡因脂质体在72h以内的各个时间点的疼痛严重程度、止痛剂用量、首次止痛要求的时间、阿片类药物相关的副作用、患者满意度、住院时间和功能恢复方面有任何额外的优势。没有布比卡因脂质体作用的报道。
与普通局麻药相比，神经周应用布比卡因脂质体在术后疼痛评分的AUC方面有统计学意义但其改善不具有较大的临床意义。此外，在排除了一项由行业赞助的试验后，这一益处变得不显著，并且发现布比卡因脂质体在术后疼痛和所有其他止痛和功能结果方面与普通局部麻醉剂没有什么不同。高质量证据不支持神经周应用布比卡因脂质体比非脂质体用于周围神经阻滞更加有优势。
原始文献来源：
Nasir Hussain, M.Sc., Richard Brull, Brendan Sheehy, et al. Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia: A Systematic Review and Meta-analysis.[J].Anesthesiology 2021; 134:147–64.
Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia: A Systematic Review and Meta-analysis
Background: Liposomal bupivacaine is purported to extend analgesia of peripheral nerve blocks when administered perineurally. However, evidence of the clinical effectiveness of perineural liposomal bupivacaine is mixed. This meta-analysis seeks to evaluate the effectiveness of perineural liposomal bupivacaine in improving peripheral nerve block analgesia as compared with nonliposomal local anesthetics.
Methods: The authors identified randomized trials evaluating the effectiveness of peripheral nerve block analgesic that compared liposomal bupivacaine with nonliposomal local anesthetics. The primary outcome was the difference in area under the receiver operating characteristics curve (AUC) of the pooled 24- to 72-h rest pain severity scores. Secondary outcomes included postoperative analgesic consumption, time to first analgesic request, incidence of opioid-related side effects, patient satisfaction, length of hospital stay, liposomal bupivacaine side effects, and functional recovery. AUC pain scores were interpreted in light of a minimal clinically important difference of 2.0 cm·h.
Results: Nine trials (619 patients) were analyzed. When all trials were pooled, AUC pain scores±SD at 24 to 72 h were 7.6±4.9 cm·h and 6.6±4.6 cm·h for nonliposomal and liposomal bupivacaine, respectively. As such, perineural liposomal bupivacaine provided a clinically unimportant benefit by improving the AUC (95% CI) of 24- to 72-h pain scores by 1.0 cm·h (0.5 to 1.6; P = 0.003) compared with nonliposomal bupivacaine. Excluding an industry-sponsored trial rendered the difference between the groups nonsignificant (0.7 cm·h [−0.1 to 1.5]; P = 0.100). Secondary outcome analysis did not uncover any additional benefits to liposomal bupivacaine in pain severity at individual timepoints up to 72 h, analgesic consumption, time to first analgesic request, opioid-related side effects, patient satisfaction, length of hospital stay, and functional recovery. No liposomal bupivacaine side effects were reported.
Conclusions: Perineural liposomal bupivacaine provided a statistically significant but clinically unimportant improvement in the AUC of postoperative pain scores compared with plain local anesthetic. Furthermore, this benefit was rendered nonsignificant after excluding an industry-sponsored trial, and liposomal bupivacaine was found to be not different from plain local anesthetics for postoperative pain and all other analgesic and functional outcomes. High-quality evidence does not support the use of perineural liposomal bupivacaine over nonliposomal bupivacaine for peripheral nerve blocks.