【罂粟摘要】臂丛阻滞下桡骨远端骨折掌侧钢板固定术后静脉注射地塞米松镇痛效果的前瞻性双盲随机临床试验
臂丛阻滞下桡骨远端骨折掌侧钢板固定术后静脉注射地塞米松镇痛效果的前瞻性双盲随机临床试验
背景：臂丛神经阻滞后反跳痛的缓解和长期疼痛的发展是掌侧钢板固定治疗桡骨远端骨折的相关问题。这项双盲研究的目的是评估单次预防性静脉注射地塞米松在这种情况下的效果。主要观察指标是术后24小时内最高的疼痛评分。
方法：我们纳入了51名ASA分级为1-2级、拟接受有计划的桡骨紧急固定的成年患者。所有患者都接受了术前口服扑热息痛和依托昔布的药物治疗，并在术前使用罗哌卡因进行臂丛神经阻滞。患者被随机分成两组：地塞米松组在手术开始时静脉注射地塞米松16 mg，对照组注射4ml生理盐水。手术后，所有患者接受固定剂量的扑热息痛、依托昔布和羟考酮，并在前48小时内根据需要进一步追加羟考酮。记录患者术后1年内的疼痛、止痛药用量和日常功能。
结果：在术后首个24小时内，地塞米松组的言语疼痛评分(0~10)最高值的中位数(四分位数间距[区间])为4分(2~6分[0~7分])，安慰剂组为8分(5~8分[2~10分])，两组比较差异有统计学意义(P<0.001)。地塞米松组和安慰剂组的平均疼痛评分分别为2分(1 ~ 4[0-5])和5分 (3 ~ 6 [0-8])，p = 0.001，解救性羟考酮用量分别为5 (0 ~ 10 [0-35])mg和10 (5 ~ 15 [0-50])mg, p = 0.037，在术后8~24小时均显著低于对照组。地塞米松组臂丛神经阻滞时间延长69%，阻滞时间为21.5 (19.1-23.4[12.9-24.1])小时 vs 12.7(11.9-15.3[7.4-26.6])小时，P<0.001。地塞米松组有2名患者(9%)，而安慰剂组有12名患者(50%)在术后首个36小时内疼痛评分最高，为8-10分(p=0.002)。术后第3天和第7天，两组之间的疼痛评分或阿片类药物使用量没有显著差异。6个月后，27名患者(57%)报告手术部位疼痛，安慰剂组的平均疼痛评分(p=0.024)和最高疼痛评分(p=0.018)显著高于地塞米松组。一年后，地塞米松组有两名患者报告疼痛，而对照组有10名患者报告疼痛(p=0.015)。
结论：我们得出结论，静脉注射地塞米松可改善术后早期镇痛，并可改善6个月和12个月后的临床结果。
原始文献来源：A. Holmberg, S. S. Hassellund, T. Drægni, et al. Analgesic effect of intravenous dexamethasone after volar plate surgery for distal radius fracture with brachial plexus block anaesthesia: a prospective, double-blind randomised clinical trial.[J].Anaesthesia 2020 Nov; 75 (11): 1448-1460.
Analgesic effect of intravenous dexamethasone after volar plate surgery for distal radius fracture with brachial plexus block anaesthesia: a prospective, double-blind randomised clinical trial
Summary
Rebound pain after brachial plexus block resolution and development of long-lasting pain are problems associated with volar plate fixation for distal radius fractures. The aim of this double-blind study was to evaluate the effect of a single prophylactic intravenous dose of dexamethasone in this setting. The primary endpoint was highest pain score during the first 24 hours after surgery. We included 51 adults of ASA physical status 1–2 d u e to undergo planned acute fixation of the radius. All received premedication with oral paracetamol and etoricoxib, and a pre-operative brachial plexus block with ropivacaine. Patients were randomly allocated into two groups: a dexamethasone group receiving 16 mg dexamethasone intravenously at start of surgery and a control group receiving 4 ml saline. After surgery, all patients received fixed doses of paracetamol, etoricoxib and oxycodone, with further oxycodone added as needed in the first 48 hours. Pain, analgesic consumption and daily function were registered at predefined times up to 1 year after surgery. Median (IQR [range]) worst pain score in the first 24 hours, as assessed by verbal numeric rating scale (0–10), was 4 (2-6 [0–7]) in the dexamethasone group c o m p a r e d w i t h 8 ( 5–8 [ 2–10]) in the placebo group (p < 0.001). Average pain score, 2 (1–4 [ 0–5]) vs. 5 (3–6 [ 0–8]), p = 0.001 and rescue oxycodone consumption, 5 (0-10 [0-35]) mg vs. 10 (5-15 [0-50]) mg, p = 0.037), respectively, were both significantly lower in the dexamethasone group compared with control from 8 to 24 hours. Brachial plexus block duration was 69% longer in the dexamethasone group, 21.5 (19.1-23.4 [12.9 - 24.1]) hours vs. 12.7 (11.9 - 15.3 [7.4-26.6]) hours, p < 0.001. Two patients (9%) in the dexamethasone group compared with 12 (50%) in the placebo group experienced worst pain scores of 8-10 during the first 36 hours (p = 0.002). At 3 and 7 days postoperatively, there were no significant differences between groups for pain scores or opioid consumption. At 6 months, 27 patients (57%) reported pain at the site of surgery, with significantly higher average pain score (p = 0.024) and worst pain score (p = 0.018) in the placebo group. At 1 year, two patients in the dexamethasone group reported pain compared with 10 in the control group (p = 0.015). We conclude that intravenous dexamethasone improves early postoperative analgesia and may also improve clinical outcomes after 6 and 12 months.
翻译：佟睿 编辑：佟睿 审校：曹莹