胸腔镜手术硬膜外镇痛与椎旁阻滞的比较

Epidural Analgesia versus Paravertebral Block in Video-Assisted Thoracoscopic Surgery

摘要: 在胸腔镜手术患者中，在疼痛控制和术后并发症发生率方面，多数研究结果表明，椎旁阻滞(paravertebral block, PVB)优于硬膜外镇痛(epidural analgesia, EP)。目前，直接比较PVB和EP在疼痛控制和术后结局方面的研究数量有限，尚无大规模的随机试验报道。但其中有4篇论文为此提供了最好的证据说明，四篇中有3篇是小型前瞻性随机试验，最后一篇文献是一项小的队列研究。从疼痛控制的角度来看，没有确凿的证据表明这两种方法谁更有效；一项研究表明EP显著降低了疼痛水平(P = 0.01)，第二项研究表明PVB明显改善了疼痛控制(P < 0.01)，第三项研究未能证明任何显著差异(P = 0.899)。PVB组和EP组需要追加镇痛的频率相似(56% vs 48%, P = 0.26)。与EP相比，PVB的术后并发症发生率更低，特别是尿潴留(64% vs 34.6%, P = 0.0036)和低血压(32% vs 7%, P = 0.0031; 21% vs 3%, P = 0.02) 。而在PVB组中，联合使用舒芬太尼的研究较少，其安全性和有效性值得我们深入研究。

Abstract: According to most research results, in patients undergoing video-assisted thoracoscopic surgery, paravertebral block (PVB) is superior to epidural analgesia (EP) in terms of pain control and its postoperative complication rates. At present, there are a limited number of studies directly com-paring pain control and postoperative outcomes between PVB and EP, and no large-scale random-ized trials have been reported. But, there were four papers that represented the best evidence to answer the clinical question. Three of the 4 papers are small prospective randomized trials, with a small cohort study featuring as the final piece of literature. There is no conclusive body of evidence to recommend either route as more efficacious from a pain control perspective; one study demonstrated significantly lower levels of pain with EP (P = 0.01), with a second study demon-strating significantly better pain control with PVB (P < 0.01) and a third failing to demonstrate any significant difference (P = 0.899). The frequency of requiring supplemental analgesia was similar between the PVB and EP cohorts (56% vs 48%, P = 0.26). PVB is associated with lower rates of postoperative complications compared to EP, specifically urinary retention (64% vs 34.6%, P = 0.0036) and hypotension (32% vs 7%, P = 0.0031; 21% vs 3%, P = 0.02). In the PVB group, there are few studies on the combined use of sufentanil, and its safety and effectiveness deserve our in-depth study.