多模式镇痛在终末期头颈部癌症患者开腹胃造瘘手术中的有效性和安全性

Effectiveness and safety of multimodal analgesia in open gastrostomy in patients with end-stage head and neck cancer

目的评估多模式镇痛在终末期头颈部癌症患者开腹胃造瘘手术中的有效性和安全性。方法随机对照试验。前瞻性选择2023年6至12月首都医科大学附属北京同仁医院择期行开腹胃造瘘手术的终末期头颈部癌症患者50例,根据不同麻醉方式,采用随机数字表法分为多模式镇痛组和局部麻醉组,每组25例。多模式镇痛组采用超声引导下腹壁神经阻滞(腹直肌鞘阻滞和腹横肌平面阻滞)+静脉注射羟考酮+静脉注射氟比洛芬酯和地塞米松;局部麻醉组采用罗哌卡因局部浸润麻醉。主要观察指标为两组患者术中疼痛数字等级量表(NRS)评分>3分的发生率。次要观察指标包括术中各时间点[麻醉前(T0)、切皮时(T1)、手术开始后10 min(T2)、牵拉胃体时(T3)和手术结束时(T4)]NRS评分、血流动力学情况[平均动脉压(MAP)和心率(HR)]、不良反应发生率、术后患者满意度评分及术后24 h内静息及活动状态(咳嗽时)的NRS评分。结果多模式镇痛组男21例,女4例,年龄(61.4±9.9)岁;局部麻醉组男19例,女6例,年龄(58.6±10.8)岁。多模式镇痛组患者术中NRS评分>3分的发生率以及补救镇痛发生率均为12.0%(3/25),均低于局部麻醉组的60.0%(15/25),差异均有统计学意义(均P<0.001);多模式镇痛组T3时刻的NRS评分[M(Q_(1),Q_(3))]为2(2,3)分,低于局部麻醉组的5(3,6)分(P<0.05)。多模式镇痛组术中MAP和HR的变异性均低于局部麻醉组(均P<0.05)。多模式镇痛组患者术中心动过速、手术牵拉反应和恶心发生率均低于局部麻醉组(均P<0.05)。多模式镇痛组患者术后满意度评分为(9.25±0.71)分,高于局部麻醉组的(7.33±0.87)分(P<0.001)。多模式镇痛组患者术后24 h内活动状态(咳嗽时)NRS评分为(2.36±0.75)分,低于局部麻醉组的(3.03±0.81)分(P=0.005)。两组患者术后均无尿潴留、恶心、呕吐、头晕等不良反应发生。结论与局部麻醉相比,多模式镇痛策略在终末期头颈部癌症患者开腹胃造瘘手术中可提供更好的镇痛效果和持续时间,血流动力学更稳定,术中不良反应更少。

Objective To investigate the effectiveness and safety of multimodal analgesia in patients with end-stage head and neck cancer in open gastrostomy surgery.Methods This was a randomized controlled trial.From June to December 2023,50 patients with end-stage head and neck cancer who underwent elective open gastrostomy surgery in Beijing Tongren Hospital Affiliated to Capital Medical University were prospectively selected.The patients were divided into multimodal analgesia group and local anesthesia group using the random number table method according to different anesthesia methods,with 25 cases in each group.In multimodal analgesia group,a multimodal analgesia regimen was adopted:ultrasound-guided abdominal wall nerve block(rectus sheath block and transverse abdominis plane block)+intravenous injection of oxycodone+intravenous injection of flurbiprofen axetil and dexamethasone.In local anesthesia group,local infiltration anesthesia with ropivacaine was adopted.The main outcome measure was the incidence of intraoperative pain numeric rating scale(NRS)score>3 points in the two groups.The secondary observation indicators included NRS score and hemodynamic indexes[mean arterial pressure(MAP)and heart rate(HR)]at various time points during surgery[before anesthesia(T0),at the time of incision(T1),10 minutes after surgery(T2),during gastric body traction(T3),and at the end of surgery(T4)],incidence of adverse reactions,postoperative patient satisfaction score,as well as the NRS scores at rest and activity(coughing)within 24 hours after surgery.Results The multimodal analgesia group included 21 males and 4 females,aged(61.4±9.9)years.There were 19 males and 6 females in the local anesthesia group,aged(58.6±10.8)years.The incidence of intraoperative NRS score>3 points and the incidence of salvage analgesia in the multimodal analgesia group were both 12.0%(3/25),which were lower than 60.0%(15/25)in the local anesthesia group,and the differences were statistically significant(all P<0.001);The NRS score[M(Q_(1),Q_(3))]at T3 in the multimodal analgesia group was 2(2,3)points,which were lower than 5(3,6)points in the local anesthesia group(P<0.05).There were smaller variabilities in MAP and HR in the multimodal analgesia group than those in the local anesthesia group(all P<0.05).The incidence of intraoperative tachycardia,surgical traction reaction,and nausea in the multimodal analgesia group was lower than that in the local anesthesia group(all P<0.05).The postoperative satisfaction score of patients in the multimodal analgesia group was(9.25±0.71)points,which were higher than(7.33±0.87)points in the local anesthesia group(P<0.001).NRS score during postoperative activity within 24 hours in the multimodal analgesia group were(2.36±0.75)points,which were lower than(3.03±0.81)points of the local anesthesia group(P=0.005).No adverse reactions such as urinary retention,nausea,vomiting and dizziness occurred in both groups.Conclusion Compared with local anesthesia,the multimodal analgesic strategy could provide better analgesic effect and longer duration,better hemodynamic stability,and fewer intraoperative adverse reactions in patients with end-stage head and neck cancer undergoing open gastrostomy.