【原】小兒腹腔鏡結(jié)直腸手術(shù)中實施加強康復方案減少圍手術(shù)期阿片類藥物并未加劇術(shù)后疼痛

罌粟花anesthGH 2021-07-21

展開全文

“海內(nèi)存知己，天涯若比鄰”

本公眾號每天分享一篇最新一期Anesthesia & Analgesia等SCI雜志的摘要翻譯，敬請關(guān)注并提出寶貴意見

Implementation of an enhanced recovery program in pediatric laparoscopic colorectal patients does not worsen analgesia despite reduced perioperative opioids: a retrospective, matched, non-inferiority study

背景與目的

加強康復方案（ERP）可加快腸道功能恢復，縮短術(shù)后住院時間和降低30天再入院的概率；但一味地追求減少術(shù)后并發(fā)癥而犧牲適當?shù)膰中g(shù)期鎮(zhèn)痛是非常不合理的。本研究旨在探討小兒腹腔鏡結(jié)直腸手術(shù)中實施加強康復方案減少圍手術(shù)期阿片類藥物對鎮(zhèn)痛效果的影響。

方法

收集的數(shù)據(jù)包括人口統(tǒng)計學信息、ASA分級和手術(shù)指征等。所收集的術(shù)中信息包括所執(zhí)行的手術(shù)操作、采用的全身和區(qū)域麻醉技術(shù)、液體和藥物管理、手術(shù)時間和并發(fā)癥。收集的術(shù)后要素包括PACU疼痛評分、PACU阿片使用量、PACU留置時長、術(shù)后疼痛評分、術(shù)后阿片使用量、排便時間、術(shù)后總的住院時長、并發(fā)癥和30天再入院率。

結(jié) 果

該研究分析了56名ERP前期患者和50名ERP患者。ERP組患者術(shù)中接受的靜脈輸液較（3.7±1.2ml/kg/h vs 7.5±3.7ml/kg/h，P<0.001）；ERP組術(shù)中阿片類藥物使用量也顯著降低（0[0，0.08]0.43 vs [0.31，0.69]，P<0.001）。盡管術(shù)中使用較少的阿片類藥物，但ERP患者擁有非劣的平均疼痛評分（0[0，0.5] vs 0.38[0，1.5]，P值非劣性<0.001）；此外ERP隊列中的患者術(shù)后使用較少的阿片類藥物（0.01[0，0.03] vs 0.14 [0.07，0.21]，P<0.001），但術(shù)后4天也擁有非劣的平均疼痛評分（2.0±1.4 vs 2.3±1.3，P=0.003）。ERP隊列還減少了術(shù)后住院時間（3[2，4]天vs 4[3，5]天，P<0.001）和30天再入院率（5.9% vs 25%，P<0.001）。

結(jié) 論

該研究發(fā)現(xiàn)對接受腹腔鏡結(jié)直腸手術(shù)的患兒大量減少圍術(shù)期阿片類藥物使用并未顯著加劇術(shù)后疼痛。

原始文獻摘要

Edney J C , Lam H , Raval M V , et al. Implementation of an enhanced recovery program in pediatric laparoscopic colorectal patients does not worsen analgesia despite reduced perioperative opioids: a retrospective, matched, non-inferiority study[J]. Regional Anesthesia and Pain Medicine, 2019, 44(1):123-129.

BACKGROUND AND OBJECTIVES:

Enhanced recovery protocols (ERPs) decrease length of stay and postoperative morbidity, but it is important that these benefits do not come at a cost of sacrificing proper perioperative analgesia. In this retrospective, matched cohort study, we evaluated postoperative pain intensity in pediatric patients who underwent laparoscopic colorectal surgeries before and after ERP implementation.

METHODS:

Patients in each cohort were randomly matched based on age, diagnosis, American Society of Anesthesiologists classification, and surgical procedure. The primary outcome was average daily postoperative pain score, while the secondary outcomes included postoperative hospital length of stay, complication rate, and 30-day readmissions. Since our hypothesis was non-inferior analgesia in the postprotocol cohort, a non-inferiority study design was used.

RESULTS:

After matching, 36 pairs of preprotocol and postprotocol patients were evaluated. ERP patients had non-inferior recovery room pain scores (difference 0 (-1.19, 0) points, 95%?CI -0.22 to 0.26 points, p valuenon-inferiority <0.001) and 4-day postoperative pain scores (difference -0.3±1.9 points, 95%?CI -0.82 to 0.48 points, p valuenon-inferiority <0.001) while receiving less postoperative opioids (difference -0.15 [-0.21, -0.05] intravenous morphine equivalents/kg/day, p<0.001). ERP patients also had reduced postoperative hospital stays (difference -1.5 [-4.5, 0] days, p<0.001) and 30-day readmissions (2.8% vs 27.8%, p=0.008).

CONCLUSIONS:

Implementation of our ERP for pediatric laparoscopic colorectal patients was associated with less perioperative opioids without worsening postoperative pain scores. In addition, patients who received the protocol had faster return of bowel function, shorter postoperative hospital stays, and a lower rate of 30-day hospital readmissions. In pediatric laparoscopic colorectal patients, the incorporation of an ERP was associated with a pronounced decrease in perioperative morbidity without sacrificing postoperative analgesia.

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