加巴喷丁改善剖宫产术后疼痛管理：一项随机对照试验

背景加巴喷丁能够预防和治疗术后急性疼痛和慢性疼痛，但是，在剖宫产手术中的应用研究尚未见报道。本研究假设术前使用加巴喷丁能够减少剖宫产后疼痛。方法择期剖宫产患者随机分为两组：一组术前使用加巴喷丁600mg；另一组为安慰剂对照。蛛网膜下隙麻醉采用0．75％高比重布比卡因12mg，芬太尼10μg和吗啡100μg。术后镇痛开始于术中使用酮咯酸和对乙酰氨基酚，并于术后使用双氯芬酸、对乙酰氨基酚和吗啡。采用视觉模拟评分量表（0-100ram）评估麻醉后6小时、12小时、24小时以及48小时的静息痛和活动痛，记录患者满意度、阿片类药物用量和副作用。并记录新生儿干预治疗、Apgar评分、脐动脉血气分析和母乳喂养困难等情况。慢性疼痛在分娩后3个月进行评估，测定试验亚组中产妇和脐静脉加巴喷丁血浓度。采用混合模型分析，比较组间24小时疼痛视觉模拟评分的主要结果。结果46例患者随机分组，2例在分析时被排除。加巴喷丁组24小时平均（95％可信区间）运动疼痛评分为21mm（13-28），安慰剂对照组为41mm（31-50），P=0．001。加巴喷丁组产妇满意度较高。两组阿片类药物的用量无差异，但是加巴喷丁组产妇重度镇静比安慰剂对照组更常见（发生率分别为19％和0％，P=0．04）。新生儿Apgar评分、干预治疗或脐动脉pH值组间比较无统计学差异。产妇静脉／脐静脉血浆加巴喷丁浓度比的平均值和标准差分别为0．86和0．12。术后3个月两组慢性疼痛发生率类似。结论多模式镇痛中，术前口服加巴喷丁600mg与安慰剂对照组相比，可降低剖宫产术后疼痛，提高产妇满意度。

BACKGROUND： Gabapentin is effective for preventing and treating acute and chronic postoperative pain; however, it has not been described for use in cesarean delivery. We hypothesized that preoperative gabapentin would reduce postcesarean delivery pain. METHODS： Women undergoing scheduled cesarean delivery were randomized to receive preoperative gabapentin 600 mg, or placebo. Spinal anesthesia was achieved with 0.75% hyperbaric bupivacaine 12 mg, fentanyl 10μg, and morphine 100 μg. Postoperative analgesia was initiated with intraoperative ketorolac and acetaminophen, and continued with postoperative didofenac, acetaminophen, and morphine. Patients were assessed at 6, 12, 24, and 48 hours after spinal anesthesia for pain at rest and on movement using a visual analog scale （0 to 100 ram）, satisfaction, opioid consumption, and side effects. Neonatal interventions, Apgar scores, umbilical artery blood gases, and breastfeeding difficulties were assessed. Chronic pain was assessed 3 months after delivery. Maternal and umbilical vein gabapentin plasma concentrations were measured in a subgroup of patients. Mixed-model analysis was used to compare the primary outcome of visual analog scale pain scores at 24 hours between groups. RESULTS： Forty-six patients were randomized, and 2 were excluded from analysis. The mean （95% confidence interval, CI） pain scores on movement at 24 hours were 21 mm （CI = 13 - 28） in the gabapentin and 41 mm （CI = 31 -50） in the placebo group （P = 0.001 ）. Maternalsatisfaction was higher in the gabapentin group. There was no difference in opioid consumption. Severe maternal sedation was more common in the gabapentin group （19% vs. 0%, P = 0.04）. There was no difference in neonatal Apgar scores, interventions, or umbilical artery pH. The mean （SD） maternal vein： umbilical vein plasma gabapentin ratio was 0. 86 （0. 12）. The incidence of pain at 3 months was similar in both groups. CONCLUSIONS： Preoperative gabapentin 600 mg in the setting of multimodal analgesia reducespostcesarean delivery pain and increases maternal satisfaction in comparison with placebo.