神经周围或静脉注射地塞米松对臂丛神经阻滞作用的比较
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Comparison of the effects of perineural or intravenous dexamethasone on low volume interscalene brachial plexus block: a randomised equivalence trial
背景与目的
局部佐剂的使用可延长肌间沟臂丛神经阻滞（ISB）镇痛时间；研究显示神经周围和静脉途径用药均可延长镇痛时间，但鉴于之前的研究设计，这两种给药方式的优越性都存在争议。由于神经周围使用地塞米松是一种超说明书使用，麻醉医生应充分了解临床作用差异。本研究旨在探讨神经周围或静脉注射地塞米松对臂丛神经阻滞作用。
方 法
随机选择182名计划在关节镜下进行肩关节手术并符合纳入标准的患者，接受低剂量ISB（0.5%罗哌卡因5ml）+神经周围或静脉注射地塞米松4mg。受试者、麻醉医生和研究人员都不知情。所有受试者接受标准化的全身麻醉和多模式镇痛。主要结果为镇痛持续时间。
结 果
神经周围和静脉注射地塞米松对镇痛持续时间影响不相等，90%可信区间的上下限分别为1h（P=0.12）和-2.5h（P=0.01）。观察到的平均阻滞时间差异无临床相关性（静脉注射地塞米松延长0.75小时）。两组间其他指标无显著差异。
结 论
罗哌卡因低ISB的情况下，神经周围和静脉注射地塞米松对阻滞时间的影并不相等。然而，神经周围静脉地塞米松在临床上没有明显的优势。
原始文献摘要
McHardy PG, Singer O, Awad IT,etal;Comparison of the effects of perineural or intravenous dexamethasone on low volume interscalene brachial plexus block: a randomised equivalence trial;Br J Anaesth 2020 01;124(1);PMID：31591018.
Background: Efforts to prolong interscalene block (ISB) analgesia include the use of local anaesthetic adjuvants such as dexamethasone. Previous work showing prolonged block duration suggests that both perineural and intravenous (i.v.) routes can both prolong analgesia. The superiority of either route is controversial given the design of previous studies. As perineural dexamethasone is an off-label use, anaesthesiologists should be fully informed of the clinical differences, if any, on block duration. This study was designed to test whether perineural vs i.v. dexamethasone administration are equivalent.
Methods: We randomised 182 eligible patients scheduled for arthroscopic shoulder surgery to receive low-dose ISB (0.5% ropivacaine 5 ml) with perineural or i.v. dexamethasone 4 mg. Subjects, anaesthesiologists, and research personnel were
blinded. All subjects also received a standardised general anaesthetic and multimodal analgesia. The primary outcome was duration of analgesia analysed as an equivalence outcome (2 h equivalency margin) using the two one-sided test (TOST) method.
Results: For the primary outcome, duration of analgesia, and perineural and i.v. administration of dexamethasone were not equivalent. The upper and lower bounds of the 90% confifidence interval were 1 h (P=0.12) and -2.5 h (P=0.01),respectively. The observed difference in mean block duration was not clinically relevant (0.75 h longer for i.v. dexamethasone). There were no other clinically signifificant differences between groups.
Conclusion: In the context of low-volume ISB with ropivacaine, perineural and i.v. dexamethasone were not equivalent in terms of their effects on block duration. However, there were no clinically signifificant differences in outcomes, and there is no advantage of perineural over intravenous dexamethasone.
麻醉学文献进展分享
贵州医科大学高鸿教授课题组
翻译：王贵龙 编辑：冯玉蓉 审校：王贵龙