以下文章來源于麻醉新超人，作者麻醉新超人

本文由“麻醉新超人”授權(quán)轉(zhuǎn)載

該文章選自《麻醉與鎮(zhèn)痛》2023年7月刊

翻譯：張   麗   劉郁鋆   徐祗彪   徐醫(yī)麻醉2022級碩士研究生

審校：趙林林  徐醫(yī)附院麻醉科  

Practice Advisory for Preoperative and Intraoperative Pain Management of Thoracic Surgical Patients: Part 1

胸外科患者術(shù)前和術(shù)中疼痛管理的臨床建議：第1部分  

Pain after thoracic surgery is of moderate-to-severe intensity and can cause increased postoperative distress and affect functional recovery. Opioids have been central agents in treating pain after thoracic surgery for decades. The use of multimodal analgesic strategies can promote effective postoperative pain control and help mitigate opioid exposure, thus preventing the risk of developing persistent postoperative pain. This practice advisory is part of a series developed by the Society of Cardiovascular Anesthesiologists (SCA) Quality, Safety, and Leadership (QSL) Committee’s Opioid Working Group. It is a systematic review of existing literature for various interventions related to the preoperative and intraoperative pain management of thoracic surgical patients and provides recommendations for providers caring for patients undergoing thoracic surgery. This entails developing customized pain management strategies for patients, which includes preoperative patient evaluation, pain management, and opioid use-focused education as well as perioperative use of multimodal analgesics and regional techniques for various thoracic surgical procedures. The literature related to this field is emerging and will hopefully provide more information on ways to improve clinically relevant patient outcomes and promote recovery in the future.

胸外科手術(shù)后疼痛為中至重度疼痛，可加重患者的術(shù)后不適并影響功能恢復(fù)。幾十年來，阿片類藥物一直是治療胸外科術(shù)后疼痛的核心藥物。使用多模式鎮(zhèn)痛策略可以有效控制術(shù)后疼痛，并有助于減輕阿片類藥物暴露，從而預(yù)防持續(xù)性術(shù)后疼痛的發(fā)生。本臨床建議是美國心血管麻醉醫(yī)師協(xié)會(SCA)質(zhì)量、安全和領(lǐng)導(dǎo)(QSL)委員會阿片類藥物研究組制定的一系列臨床建議之一。本文系統(tǒng)回顧了與胸外科手術(shù)患者術(shù)前和術(shù)中疼痛管理相關(guān)的各種干預(yù)措施的現(xiàn)有文獻，并為治療胸外科手術(shù)患者的醫(yī)師提供了建議：重點在于為患者制定個體化的疼痛管理策略，包括術(shù)前評估、疼痛管理、和以阿片類藥物使用為重點的教育，以及圍手術(shù)期使用多模式鎮(zhèn)痛藥和各種胸外科手術(shù)的區(qū)域鎮(zhèn)痛技術(shù)。與該領(lǐng)域相關(guān)的文獻正在涌現(xiàn)，并有望在未來提供更多關(guān)于改善臨床相關(guān)患者預(yù)后和促進康復(fù)的方法。

Thoracotomy pain is multifactorial in origin due to surgical incision, muscle retraction, rib spreading, and opening of the pleural space, which can result in injury to sternocostal and

costovertebral joints, parietal pleura, lung parenchyma, and intercostal nerves.

開胸術(shù)后疼痛的病因具有多樣性，包括手術(shù)切口、肌肉攣縮、肋骨擴張、胸膜間隙開放等，可導(dǎo)致肋骨和肋椎關(guān)節(jié)、壁層胸膜、肺實質(zhì)和肋間神經(jīng)損傷。  

Moderate-to-severe pain after thoracic surgery increases suffering and may lead to persistent

postoperative pain, which can escalate health care costs, adversely affect quality of life and sleep, and delay the return to normal activities of daily living.Suboptimal acute pain management after thoracic surgery impairs normal respiratory mechanics, which may result in pulmonary complications and prolong recovery.

胸外科手術(shù)后的中度至重度疼痛會增加患者的痛苦，并可能導(dǎo)致持續(xù)性術(shù)后疼痛。這可能會增加醫(yī)療保健成本，對生活質(zhì)量和睡眠產(chǎn)生不利影響，并延遲正常的日常生活活動的恢復(fù)。胸外科手術(shù)后急性疼痛管理欠佳會損害正常的呼吸力學(xué)，這可能導(dǎo)致肺部并發(fā)癥的發(fā)生并延長術(shù)后恢復(fù)時間。

Perioperative pain management in these patients continues to evolve due to concerns that relying solely on opioid-based analgesia may contribute to persistent opioid use postdischarge; these issues may further contribute to the major public health crisis of increased opioid-related deaths seen over the past 3 decades.

由于擔(dān)心單純依賴阿片類藥物鎮(zhèn)痛可能導(dǎo)致出院后持續(xù)使用阿片類藥物，關(guān)于這些患者的圍手術(shù)期疼痛管理措施一直在繼續(xù)發(fā)展;這可能導(dǎo)致過去30年中阿片類藥物相關(guān)死亡人數(shù)增加的重大公共衛(wèi)生危機的發(fā)生。

To develop educational resources related to perioperative pain management for teams caring for patients undergoing cardiac and thoracic surgeries, the Society of Cardiovascular Anesthesiologists’ (SCA) Quality, Safety, and Leadership (QSL) Committee’s Opioid Working Group summarized the literature related to the perioperative pain management of these patients

in a 4-part series of practice advisories:

1. Part 1: Preoperative and Intraoperative Pain Management of Thoracic Surgical Patients.

2. Part 2: Preoperative and Intraoperative Pain Management of Cardiac Surgical Patients.

3. Part 3: Postoperative Pain Management of Cardiothoracic Surgical Patients.

4. Part 4: Post-Discharge Pain Management of Cardiothoracic Surgical Patients.

為了給治療接受心臟和胸部手術(shù)患者的醫(yī)師團隊開發(fā)與圍術(shù)期疼痛管理相關(guān)的教育資源，心血管麻醉醫(yī)師協(xié)會（SCA）質(zhì)量、安全和領(lǐng)導(dǎo)力（QSL）委員會的阿片類藥物研究組總結(jié)了與這些患者圍術(shù)期疼痛管理相關(guān)的文獻，構(gòu)成由四部分組成的一系列臨床建議:

第一部分:胸外科手術(shù)患者術(shù)前及術(shù)中疼痛的管理。  

第二部分:心臟手術(shù)患者術(shù)前和術(shù)中疼痛的管理。  

第三部分:心胸外科患者術(shù)后疼痛的管理。  

第四部分:心胸外科病人出院后疼痛的管理。  

The practice advisories systematically developed reports that are intended to assist decision-making in areas of patient care. Often, the available evidence is insufficient due to a lack of high-quality studies, conflicting evidence, and/or an inability to assess the balance between the benefits and risks of an intervention. Therefore, a statement and its recommendations are developed based on a collective consensus of the literature by the convened expert panel.

本項臨床建議系統(tǒng)地制定了報告，旨在協(xié)助患者治療領(lǐng)域的臨床決策。通常，高質(zhì)量研究的缺乏、證據(jù)的相互矛盾和/或無法評估干預(yù)措施在益處和風(fēng)險之間的平衡，往往導(dǎo)致現(xiàn)有的證據(jù)不足。因此，聲明及其建議是根據(jù)召集的專家小組對文獻的集體共識制定的。  

The practice advisories thus summarize the state of the literature and report the consensus of expert consultants. They are not supported by the scientific literature to the same degree as standards or guidelines. The practice advisories are subject to periodic revision as warranted by the evolution of knowledge, technology, and practice.

因此，臨床建議總結(jié)了文獻的現(xiàn)狀，并報告了專家顧問的共識。它們不像標準或指南那樣得到了科學(xué)文獻同等程度的支持。臨床建議應(yīng)根據(jù)知識、技術(shù)和實踐的發(fā)展進行定期修訂。  

This document serves as “Practice Advisory Part 1: Preoperative and Intraoperative Pain Management of Thoracic Surgical Patients,” developed by the SCA QSL Committee’s Opioid Working Group.

本文件作為“臨床建議第1部分：胸外科患者的術(shù)前和術(shù)中疼痛管理”，由SCA QSL委員會的阿片類藥物研究組總結(jié)。  

METHODS

方法  

Definitions of the terms used in the practice advisory have been included in Supplemental Digital Content 1, Appendix 1, http://links.lww.com/AA/E344.  

臨床建議中使用的術(shù)語的定義已包含在附錄1中的補充數(shù)據(jù)文本1中。  

PURPOSE  

This practice advisory is intended to serve as a resource for the perioperative pain management of thoracic surgical patients who enable the following: 1. Preoperative assessment, which includes: a. Education and counseling to set up the patients’ realistic expectations about postoperative pain and education about available pain management options, b. Risk factor evaluation for identification of patients who are at risk for persistent pain or persistent opioid use after thoracic surgery, and c. Assessment of postoperative pain based on the surgical approach; 2. Intraoperative pain management for: a. Optimal pain control to facilitate patient’ recovery and return to normal activities and b.With individualized, patient-centered, multimodal strategies utilizing pharmacological (nonopioid and opioid medications) and nonpharmacological (regional anesthesia) therapies; and 3. Safe use of opioids for acute postoperative pain management while reducing the risk of overdose and other adverse events.

目的  

本臨床建議旨在為胸外科患者圍術(shù)期疼痛管理提供參考，這些患者可實現(xiàn)以下目標： 1.術(shù)前評估，包括:   a.教育和咨詢，以建立患者對術(shù)后疼痛的現(xiàn)實期望，并就可用的疼痛管理方案進行教育;   b.風(fēng)險因素評估，以識別存在胸外科手術(shù)后持續(xù)疼痛或持續(xù)使用阿片類藥物風(fēng)險的患者;   c.基于手術(shù)方法進行術(shù)后疼痛評估;   2.術(shù)中疼痛管理:   a.優(yōu)化疼痛控制，促進患者的康復(fù)并恢復(fù)正?；顒?   b.利用藥物(非阿片類藥物和阿片類藥物)和非藥物(區(qū)域鎮(zhèn)痛)治療進行個體化、以患者為中心的多模式鎮(zhèn)痛策略;   3、安全使用阿片類藥物治療急性術(shù)后疼痛，同時降低過量用藥和其他不良事件的風(fēng)險。

FOCUS  

This practice advisory focuses on the preoperative and intraoperative pain management of opioid na?ve adults and adolescents (older than 12 years of age) undergoing thoracic surgery under general anesthesia (GA).

Addressing the complex perioperative pain management of the opioid-tolerant patients is beyond the scope of this Special Article.

焦點 

該實踐咨詢側(cè)重于在全身麻醉（GA）下接受胸外科手術(shù)的無阿片類藥物治療史成人和青少年（12 歲以上）的術(shù)前和術(shù)中疼痛管理。解決阿片類藥物耐受患者的復(fù)雜圍手術(shù)期疼痛管理超出了本專題文章的范圍。

APPLICATION

The purpose of the practice advisory is to serve as a resource for anesthesiologists, thoracic surgeons, intensivists, pain management physicians, and other care providers (physician assistants, advanced nurse practitioners, perioperative nurses, and intensive care unit [ICU] nurses) managing postoperative pain8 in thoracic surgical patients. 

適用人群  

本臨床建議的目的是為麻醉醫(yī)師、胸外科醫(yī)師、重癥監(jiān)護醫(yī)師、疼痛管理醫(yī)師和其他治療提供者（醫(yī)師助理、高級執(zhí)業(yè)護士、圍手術(shù)期護士和重癥監(jiān)護室 [ICU] 護士）管理胸外科患者的術(shù)后疼痛提供參考。  

TASK FORCE MEMBERS AND CONSULTANTS  

The task force was established as part of an Opioid Working Group of the SCA QSL Committee. It incorporated experts in enhanced recovery aftercardiac surgery (ERACS), enhanced recovery after thoracic surgery (ERATS), regional techniques, pain management, and methodology.

Information about task force members and consultants, evidence model, grading of evidence, the framework of the overall process used to assess the evidence from current best practices in the literature, and steps undertaken to develop the advisory is included in Supplemental Digital Content 2, Appendix 2, http:// links.lww.com/AA/E345.

研究團隊成員和顧問

該研究團隊是作為SCA QSL委員會阿片類藥物研究組的一部分設(shè)立的。它包括了心臟手術(shù)后增強恢復(fù)(ERACS)、胸外科手術(shù)后增強恢復(fù)(ERATS)、區(qū)域鎮(zhèn)痛技術(shù)、疼痛管理和方法方面的專家。有關(guān)工作組成員和顧問、證據(jù)模型、證據(jù)分級、用于評估文獻中當(dāng)前最佳實踐證據(jù)的整個過程框架以及為制定咨詢意見而采取的步驟的信息包含在附錄2的補充數(shù)據(jù)文本2中。  

SCIENTIFIC EVIDENCE  

The group conducted a systematic review of the literature related to various interventions and management strategies for pain after thoracic surgery. After evaluating the available evidence, a practice advisory was developed to communicate knowledge and facilitate decision-making in this area of patient care. After performing a literature search for perioperative pain management modalities in thoracic surgery, the group formulated recommendations using the modified Delphi process to address various aspects of perioperative pain management including preoperative education, the evaluation of risk factors that influence pain after thoracic surgery, and persistent postsurgical opioid use as well as pharmacological and regional anesthesia techniques for acute pain management after thoracic surgery. Evidence for various pain management interventions is primarily derived from patients undergoing thoracic surgery. When data were limited or provided generalized conclusions such as in the sections of preoperative education and counseling, gabapentinoids, nonsteroidal anti-inflammatory drugs (NSAIDs), and dexmedetomidine, pertinent studies from nonthoracic surgical populations were also included. Scientific evidence used in creating the advisory was derived from literature published in peer reviewed journals. Figure 1 outlines the matrix used to evaluate the strength of evidence based on categories, levels, and whether the intervention was beneficial, harmful, or equivocal based on the American Society of Anesthesiologists (ASA) methodology. The framework of the overall process used to assess the evidence from current best practices in the literature and steps undertaken to develop the advisory are included in Supplemental Digital Content 2, Appendix 2, http://links.lww.com/AA/E345. Literature search methods, evidence model, key words, and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) diagram used to construct the practice advisory are included in Supplemental Digital Content 3, Appendix 3, http://links.lww.com/AA/E346. Supplemental Digital Content 4, Appendix 4, http://links.lww.com/AA/E347 includes all the ref erences, type of studies, and their grading according to the ASA methodology. 

科學(xué)證據(jù) 

該小組對與胸外科手術(shù)后疼痛的各種干預(yù)措施和管理策略相關(guān)的文獻進行了系統(tǒng)的回顧。在評估了現(xiàn)有證據(jù)后，制定了臨床建議，以傳播知識并改進這一領(lǐng)域的臨床患者治療決策。   在對胸外科圍手術(shù)期疼痛管理方式進行文獻檢索后，該小組使用改良德爾菲法制定了建議，以解決圍手術(shù)期疼痛管理的各個方面，包括術(shù)前教育、影響胸腔手術(shù)后疼痛的危險因素評估、術(shù)后持續(xù)使用阿片類藥物以及術(shù)后急性疼痛的藥物治療和區(qū)域麻醉技術(shù)。各種疼痛管理干預(yù)措施的證據(jù)主要來自于接受胸外科手術(shù)的患者。當(dāng)數(shù)據(jù)有限或提供概括性結(jié)論時，例如在術(shù)前教育和咨詢、加巴噴丁類藥物、非甾體抗炎藥（NSAIDs）和右美托咪定部分，還納入了來自非胸外科手術(shù)患者的相關(guān)性研究。   臨床建議的科學(xué)證據(jù)來自發(fā)表在同行評議期刊上的文獻。

圖1概述了基于類別、水平以及干預(yù)是否有益、有害或模棱兩可(基于美國麻醉醫(yī)師協(xié)會(ASA)的方法)的證據(jù)強度評估矩陣。   用于評估文獻中當(dāng)前最佳實踐證據(jù)的總體過程框架和制定臨床建議所采取的步驟包括附錄2中的補充數(shù)據(jù)文本2。   文獻檢索方法，證據(jù)模型，關(guān)鍵詞，以及用于構(gòu)建臨床建議的系統(tǒng)評價和薈萃分析(PRISMA)圖的首選報告項目包含在附錄3的補充數(shù)據(jù)文本3中。   附錄4的補充數(shù)據(jù)文本4包括所有參考文獻，研究類型，以及ASA分級。

PREOPERATIVE ASSESSMENT

術(shù)前評估 

PREOPERATIVE EVALUATION, EDUCATION, AND COUNSELING Literature Findings Several studies described that preoperative pain education and counseling influence: 1. Postoperative pain(Category A2-B evidence, Category B2-B evidence, Category A3-E evidence and Category B2-E evidence); 2. Anxiety (Category A3-B evidence and Category B2-B evidence); 3. Opioid consumption (Category B1-B evidence, Category B2-B evidence and Category A2-E evidence); 4. Functional recovery(Category B2-E evidence and Category A3-E evidence); 5. Patient satisfaction(Category B2-E evidence); and 6. Early cessation20 of opioid use (Category A3-E evidence). Preoperative cognitive educational interventions were found to be effective in decreasing postoperative pain and/or anxiety compared to controls (Category A2-B evidence). A meta-analysis revealed a nonstatistical reduction in postoperative pain with the use of psychosocial interventions (Category A1-E evidence). When patient and their families were involved in educational sessions on postoperative pain management, lower severity of postoperative pain was reported compared to the control group (Category B2-B evidence). Preoperative educational sessions using interactive multimedia were more effective in improving patients’ knowledge27 compared to the controls (Category A3-B evidence). When the use of multimedia pain management educational tools was continued after discharge, decreased postoperative pain and improved physical activity were reported compared to the controls (Category A2-B evidence). Figure2A summarizes the impact of perioperative pain education and counseling. 

術(shù)前評估、教育和咨詢

文獻研究結(jié)果

一些研究描述了術(shù)前疼痛教育和咨詢的影響: 1.術(shù)后疼痛(A2-B類證據(jù)、B2-B類證據(jù)、A3-E類證據(jù)和B2-E類證據(jù));   2.焦慮(A3-B類證據(jù)和B2-B類證據(jù));   3.阿片類藥物的使用(B1-B類證據(jù)、B2-B類證據(jù)和A2-E類證據(jù));   4.功能恢復(fù)(B2-E類證據(jù)和A3-E類證據(jù));   5.患者滿意度(B2-E類證據(jù));   6.早期停止阿片類藥物使用(A3-E類證據(jù))。

與對照組相比，發(fā)現(xiàn)術(shù)前認知教育干預(yù)可有效減少術(shù)后疼痛和/或焦慮（A2-B類證據(jù)）。一項薈萃分析顯示，使用社會心理干預(yù)后，術(shù)后疼痛的減少無統(tǒng)計學(xué)意義(A1-E類證據(jù))。 

當(dāng)患者及其家屬參與術(shù)后疼痛管理教育課程時，與對照組相比，術(shù)后疼痛的嚴重程度較低（B2-B類證據(jù)）。 

與對照組相比，使用交互式多媒體的術(shù)前教育課程在提高患者知識方面更有效27 (A3-B類證據(jù))。當(dāng)出院后繼續(xù)使用多媒體疼痛管理教育工具時，與對照組相比，術(shù)后疼痛減輕，身體活動改善(A2-B類證據(jù))。

圖2A總結(jié)了圍手術(shù)期疼痛教育和咨詢的影響。

Summary and Recommendations

The literature evaluating preoperative pain education and counseling indicates a variable impact on postoperative pain and opioid consumption. The expert consensus evaluation of the literature concluded that the use of multimedia pain education and counseling may be useful for reducing postoperative pain (recommendation grade: A2-B). Preoperative cognitive or psychosocial educational interventions may be useful in reducing postoperative pain (recommendation grade: A2-B). Pain management education using multimedia tools should be continued after discharge as it can decrease pain and promote patient’s recovery (recommendation grade: A2-B) (Table 1). 

摘要及建議

評估術(shù)前疼痛教育和咨詢的文獻表明，對術(shù)后疼痛和阿片類藥物消耗的影響各不相同。專家們對文獻的共同評估認為，使用多媒體疼痛教育和咨詢可能有助于減輕術(shù)后疼痛（推薦等級：A2-B）。術(shù)前認知或心理社會教育干預(yù)可能有助于減輕術(shù)后疼痛（推薦等級：A2-B）。出院后應(yīng)繼續(xù)使用多媒體工具進行疼痛管理教育，因為它可以減輕疼痛并促進患者的康復(fù)（推薦等級：A2-B）（表1）。

FOR PERSISTENT PAIN AND OPIOID USE AFTER THORACIC SURGERY

The incidence of persistent thoracotomy pain syndrome (PTPS) is found to be between 33% and 70% after thoracotomy.Patients commonly reported mild pain and were at risk for diminished physical functioning (Category A3-E evidence). Videoassisted thoracic surgery (VATS) surgery is associated with 25% to 35% incidence of PTPS. Around 30% to 50% of patients undergoing thoracotomy and 18% of patients undergoing VATS30 reported having neuropathic PTPS; this type of pain was more severe intense, required more analgesics,and was associated with sleep disturbances and social and physical functional limitations (CategoryB2-H evidence).Studies found an association between patientrelated risk factors, surgical factors,and pain characteristics (Figure 2B) with the development of PTPS (Category A3-E evidence,Category B1-H evidence/Category B1-E evidence,and Category B2-H evidence/Category B2-E evidence). 

用于胸外科術(shù)后持續(xù)性疼痛和阿片類藥物的使用

開胸手術(shù)后疼痛綜合征（PTPS）的發(fā)病率在 33% 至 70% 之間?；颊咄ǔ３霈F(xiàn)輕度疼痛，并伴有身體功能下降的風(fēng)險（A3-E類證據(jù)）。電視胸腔鏡（VATS）手術(shù)與 25%-35% 的 PTPS 發(fā)病率相關(guān)。大約 30%-50% 接受開胸手術(shù)的患者和 18% 接受 VATS 的患者報告患有神經(jīng)性PTPS;這種類型的疼痛更嚴重，需要更多的鎮(zhèn)痛藥，并且與睡眠障礙以及社會和身體功能限制有關(guān)（B2-H類證據(jù)）。研究發(fā)現(xiàn)，患者相關(guān)危險因素、手術(shù)因素和疼痛特征（圖2B）與PTPS的發(fā)展之間存在關(guān)聯(lián)（A3-E類證據(jù)，B1-H類證據(jù)/B1-E類證據(jù)和B2-H類證據(jù)/B2-E類證據(jù)）。

Patient-Related Risk Factors Associated With Development of Persistent Postoperative Pain 

Patient-related risk factors associated with PTPS include younger age,female sex, diagnosis of cancer, history of chronic pain, hypertension, diabetes mellitus, preoperative chest pain or thoracic pain (3–12 months), as well as use of hypnotic medications (Category A3-E evidence,38 Category B1-H evidence/Category B1-E evidence, and Category B2-H evidence/Category B2-E evidence). 

與持續(xù)性術(shù)后疼痛發(fā)展相關(guān)的患者相關(guān)危險因素

與PTPS相關(guān)的患者相關(guān)危險因素包括年齡小、女性、癌癥診斷、慢性疼痛史、高血壓、糖尿病、術(shù)前胸痛或胸痛(3-12個月)，以及催眠藥物的使用(A3-E類證據(jù)、B1-H類證據(jù)/ B1-E類證據(jù)、B2-H類證據(jù)/ B2-E類證據(jù))。   Surgical Factors Associated With Development of Persistent Postoperative Pain

Surgical factors associated with persistent postoperative pain include more extensive surgery, thoracotomy, 3 port VATS, rib resection, pleurectomy, long duration of surgery, long duration of chest tube drainage, the number of drains, postoperative radiation therapy, and postoperative chemotherapy (Category B2-H evidence/Category B2-E evidence). 

與持續(xù)性術(shù)后疼痛發(fā)展相關(guān)的手術(shù)因素 

與術(shù)后持續(xù)疼痛相關(guān)的手術(shù)因素包括大范圍的手術(shù)、胸部手術(shù)、VATS、肋骨切除術(shù)、胸膜切除術(shù)、手術(shù)時間長、胸管引流時間長、引流管數(shù)量多、術(shù)后放療、術(shù)后化療(B2-H類證據(jù)/ B2-E類證據(jù))。 

Surgical Factors That Influence Acute and/or Persistent Postoperative Pain  

Surgical techniques that protect the nerve bundle may mitigate acute pain, persistent postoperative pain, and analgesic consumption as well as facilitate an earlier return to baseline activities (Category A2-B evidence/Category A2-E evidence, Category B2-B evidence/Category B2-E evidence). These include nerve-sparing thoracotomy incision, closure with rib approximation, intercostal muscle flap, or nocompression suture techniques alone or in combination to avoid intercostal nerve compression or involvement. However, some studies showed that surgical technique has no influence on the incidence of acute or persistent postoperative pain after surgery (Category A2-E evidence). Patients undergoing robotic-assisted thoracic surgery (RATS) reported equivocal results with regard to acute pain, opioid use, and hospital length of stay (LOS) compared to those undergoing  thoracotomy or video-assisted thoracic surgery (VATS) (Category B1-E evidence and Category B2-E evidence). However, 2 studies described that minimally invasive thoracic surgery (MITS) was associated with lower acute postoperative pain and pain interference scores compared to open surgery (Category B2-B evidence). The literature evaluating the role of VATS in reducing acute or persistent postoperative pain or opioid use as well as promoting early functional recovery and improving quality of life yielded mixed results (Category A3-B evidence, Category B1-B evidence/Category B1-E evidence, and Category B2-B evidence/Category B2-E evidence). 

影響急性和/或持續(xù)性術(shù)后疼痛的手術(shù)因素

保護神經(jīng)束的手術(shù)技術(shù)可以減輕急性疼痛、術(shù)后持續(xù)疼痛和鎮(zhèn)痛藥消耗，并促進早期恢復(fù)(A2-B類證據(jù)/ A2-E類證據(jù)，B2-B類證據(jù)/ B2-E類證據(jù))。這些方法包括保留神經(jīng)的開胸切口、肋骨復(fù)位、肋間肌瓣、單獨或聯(lián)合使用無壓迫縫合技術(shù)以避免肋間神經(jīng)壓迫或受累。然而，一些研究表明，手術(shù)技術(shù)對術(shù)后急性或持續(xù)性術(shù)后疼痛的發(fā)生率沒有影響(A2-E類證據(jù))。   與接受開胸手術(shù)或電視輔助胸外科手術(shù)(VATS)的患者相比，接受機器人輔助胸外科手術(shù)(RATS)的患者在急性疼痛、阿片類藥物使用和住院時間(LOS)方面報告的結(jié)果模棱兩可(B1-E類證據(jù)和B2-E類證據(jù))。然而，有2項研究表明，與開放手術(shù)相比，微創(chuàng)胸外科手術(shù)(MITS)與較低的急性術(shù)后疼痛和疼痛干擾評分相關(guān)(B2-B類證據(jù))。   評價VATS在減少術(shù)后急性或持續(xù)性疼痛或阿片類藥物使用以及促進早期功能恢復(fù)和改善生活質(zhì)量方面作用的文獻得出了不同的結(jié)果(A3-B類證據(jù)，B1-B類證據(jù)/ B1-E類證據(jù)，B2-B類證據(jù)/ B2-E類證據(jù))。   

Association of Postoperative Pain Characteristics With Persistent Postoperative Pain 

Patients who experienced moderate-to-severe pain or constant pain during the first postoperative week, as well as those who reported increased pain with movement or after removal of the epidural catheter were more likely to develop persistent postoperative pain (Category A3-H evidence, Category B1-H evidence, and Category B2-H evidence). They also reported higher pain scores after discharge and at first outpatient visit after surgery, with most significant elevations from week 12 onward (Category A3-H evidence and Category B2-H evidence). 

術(shù)后疼痛特征與持續(xù)性術(shù)后疼痛的關(guān)系  

術(shù)后第一周出現(xiàn)中度至重度疼痛或持續(xù)疼痛的患者，以及那些報告運動或移除硬膜外導(dǎo)管后疼痛增加的患者更有可能出現(xiàn)持續(xù)的術(shù)后疼痛(A3-H類證據(jù)，B1-H類證據(jù)和B2-H類證據(jù))。他們在出院后和手術(shù)后首次門診就診時也報告了更高的疼痛評分，從第12周開始出現(xiàn)最顯著的升高(A3-H類證據(jù)和B2-H類證據(jù))。   

Risk Factors Associated With Development of New Persistent Opioid Use   

The incidence of new persistent opioid use after thoracic surgery was reported to be 14% to 17% after lung resection in opioid na?ve patients (Category B1 evidence and Category B2 evidence). 

Literature Findings. 

Several studies found multiple patient-related, social, and surgery-related factors associated with new persistent opioid use after thoracic surgery (Category B2-H evidence/ Category B2-E evidence, and Category B1-H evidence/Category B1-E evidence) (Figure3B). Patient-related factors included younger age, Black race, higher Charlson comorbidity score, arthritis, back pain, other pain disorders, as well as history of tobacco use, and drug and substance abuse (Category B1-H evidence and Category B2-H evidence/Category B2-E evidence). Surgical factors included thoracotomy or open lung resection, gastrointestinal complications, postoperative LOS, adjuvant therapy or chemotherapy, prescription size (>450 oral morphine equivalents), preoperative prescription fills and total opioid dose used in the perioperative period (Category B1-H evidence/Category B1-E evidence and Category B2-H evidence/Category B2-E evidence). Social factors included disability status, dual-eligibility (Medicare and Medicaid), and residence in zip codes associated with lower education (Category B2-H evidence). New persistent opioid users had worse overall survivals compared to those who did not use opioids (Category B2-H evidence). 

與新的持續(xù)性阿片類藥物使用相關(guān)的危險因素   

據(jù)報道，阿片類藥物不耐受患者肺切除術(shù)后新的持續(xù)阿片類藥物使用發(fā)生率為14%至17% (B1類證據(jù)和B2類證據(jù))。   

文獻研究

幾項研究發(fā)現(xiàn)，與胸外科手術(shù)后新的持續(xù)阿片類藥物使用相關(guān)的多種患者相關(guān)、社會和手術(shù)相關(guān)因素(B2-H類證據(jù)/ B2-E類證據(jù)，B1-H類證據(jù)/ B1-E類證據(jù))(圖3B)。   

患者相關(guān)因素包括年齡較小、黑人種族、較高的Charlson合并癥評分、關(guān)節(jié)炎、背痛、其他疼痛疾病、吸煙史、藥物和藥物濫用(B1-H類證據(jù)和B2-H類證據(jù)/ B2-E類證據(jù))。   

手術(shù)因素包括開胸或開肺切除術(shù)、胃腸道并發(fā)癥、術(shù)后LOS、輔助治療或化療、處方量大小(>450口服嗎啡當(dāng)量)、術(shù)前處方量和圍手術(shù)期阿片類藥物總劑量(B1-H類證據(jù)/ B1-E類證據(jù)和B2-H類證據(jù)/ B2-E類證據(jù))。   

社會因素包括殘疾狀況、雙重福利(醫(yī)療保險和醫(yī)療補助)、居住在與低教育相關(guān)的郵政編碼地區(qū)(B2-H類證據(jù))。   與不使用阿片類藥物的人相比，新的持續(xù)阿片類藥物使用者的總體生存率更低(B2-H類證據(jù))。   

Summary and Recommendations. 

Patients undergoing thoracic surgery may be screened for risk factors related to PTPS for an individualized pain management strategy (recommendation grade:B2-B). The benefit of using intercostal nervesparing thoracotomy incision, rib reapproximation, and intercostal muscle flap with or without no-compression suture techniques for reducing acute or persistent postoperative pain is unclear (recommendation grade: A2-E). No-compression suture techniques during thoracotomy closure may be useful for reducing both acute and/or persistent postoperative pain (recommendation grade: B2-B) (Table 1). Preoperative screening for risk factors associated with persistent opioid use may also be useful for patient-tailored analgesia to reduce opioid exposure (recommendation grade: B2-B) (Table1). 

總結(jié)和建議

接受胸外科手術(shù)的患者可以篩查與PTPS相關(guān)的危險因素，以制定個性化的疼痛管理策略(推薦等級:B2-B)。采用保留肋間神經(jīng)的開胸切口、肋骨復(fù)位和肋間肌瓣聯(lián)合或不聯(lián)合無壓迫縫合技術(shù)減輕術(shù)后急性或持續(xù)性疼痛的益處尚不清楚(推薦等級:A2-E)。開胸閉合時的無壓迫縫合技術(shù)可能有助于減輕急性和/或持續(xù)性術(shù)后疼痛(推薦等級:B2-B)(表1)。   術(shù)前篩查與持續(xù)阿片類藥物使用相關(guān)的危險因素也可能有助于為患者量身定制鎮(zhèn)痛，以減少阿片類藥物暴露(推薦等級:B2-B)(表1)。  

INTRAOPERATIVE MANAGEMENT  

術(shù)中管理  

PHARMACOLOGICAL INTERVENTIONS Gabapentinoids (Gabapentin and Pregabalin)  

Literature Findings. 

Randomized control trials (RCTs) evaluating perioperative gabapentin as an analgesic adjunct reported no differences in acute surgical pain or shoulder pain after thoracic surgery (Category A2-E evidence). Gabapentin use did not prevent persistent postoperative pain after thoracotomy (Category A3-E evidence). Gabapentin use was associated with minor side effects such as somnolence and dizziness (Category B2 evidence). The literature does report improvement in preexisting persistent postoperative pain with gabapentin use (Category B2-B evidence). RCTs evaluating perioperative pregabalin in thoracic surgery patients reported equivocal findings for acute postoperative incisional pain and the incidence of persistent postoperative pain in both VATS and open thoracotomy procedures (Category A2-E evidence). Pregabalin did not reduce ipsilateral shoulder pain after VATS as reported by a single observational study (Category B2-E evidence). 

Summary and Recommendations. 

The use of perioperative gabapentin and pregabalin has not been shown to reduce acute pain after thoracic surgery via VATS or open thoracotomy. It was also not found to prevent persistent postoperative pain after thoracic surgery. Therefore, their preoperative administration is not recommended to decrease acute or persistent postoperative pain after thoracic surgery (recommendation grade: A3-E). This is consistent with the findings of a meta-analysis by Verret et al, which investigated gabapentin and pregabalin use in noncardiothoracic and cardiothoracic surgical patients, reporting a clinically nonsignificant analgesic effect and an increased incidence of dizziness and visual disturbances for both medications (Category A1-E evidence). Postoperative gabapentin may be considered for patients who develop persistent postthoracotomy pain (recommendation grade: B2-B) (Table2). 

加巴噴丁類藥物(加巴噴丁和普瑞巴林) 文獻研究

評估圍手術(shù)期加巴噴丁作為鎮(zhèn)痛輔助藥物的隨機對照試驗(RCTs)報告，胸外科手術(shù)后急性手術(shù)疼痛或肩部疼痛無差異(A2-E類證據(jù))。加巴噴丁的使用并不能預(yù)防開胸術(shù)后持續(xù)疼痛(A3-E類證據(jù))。加巴噴丁的使用與嗜睡和頭暈等輕微副作用相關(guān)(B2類證據(jù))。  

文獻確實報道了使用加巴噴丁可以改善先前的術(shù)后持續(xù)性疼痛(B2-B類證據(jù))。  

評估普瑞巴林在胸外科手術(shù)患者圍手術(shù)期的隨機對照試驗報告了在VATS和開胸手術(shù)中急性術(shù)后切口疼痛和持續(xù)術(shù)后疼痛發(fā)生率的模棱兩可的發(fā)現(xiàn)(A2-E類證據(jù))。據(jù)一項觀察性研究報道，普瑞巴林并沒有減輕VATS后同側(cè)肩痛(B2-E類證據(jù))。   

總結(jié)和建議

圍手術(shù)期使用加巴噴丁和普瑞巴林并不能減輕VATS或開胸手術(shù)后的急性疼痛。也沒有發(fā)現(xiàn)它可以預(yù)防胸外科術(shù)后持續(xù)疼痛。因此，不建議術(shù)前給藥以減少胸外科術(shù)后急性或持續(xù)性疼痛(推薦等級:A3-E)。這與Verret等人研究加巴噴丁和普瑞巴林在非心胸外科和心胸外科患者中的應(yīng)用的meta分析結(jié)果一致，該分析報告了加巴噴丁和普瑞巴林在臨床上無顯著鎮(zhèn)痛作用，兩種藥物均增加了頭暈和視力障礙的發(fā)生率(A1-E類證據(jù))。術(shù)后出現(xiàn)持續(xù)開胸后疼痛的患者可考慮加巴噴丁(推薦等級:B2-B)(表2)。  

Acetaminophen   Literature Findings.

The literature evaluating the perioperative use of acetaminophen as an analgesic adjunct in patients undergoing thoracic surgery via VATS or open thoracotomy reported findings that did not reach statistical significance for reduction in both acute incisional and shoulder pain when combined with regional techniques (Category A3-B evidence/Category A3-E evidence, and Category B2-E evidence). However, patients reported reduction in shoulder pain for the first 16 hours with scheduled acetaminophen after thoracotomy with thoracic epidural analgesia (TEA). Another RCT described decreased postoperative pain with rest and coughing after VATS surgery with intravenous continuous acetaminophen infusion when compared to opioids alone (Category A3-B evidence). Intravenous acetaminophen has a more consistent pharmacokinetic profile than oral administration (Category B2 evidence). A systematic review conducted to demonstrate increased efficacy of intravenous dosing revealed no difference between oral and intravenous administration. Summary and Recommendations. The use of scheduled perioperative acetaminophen as part of a multimodal pain regimen was found to provide mixed results with regard to acute postoperative pain. Mac et al noted that scheduled acetaminophen resulted in clinical reduction of shoulder pain after thoracotomy with TEA. Lower pain scores were reported with intravenous acetaminophen infusion alone after VATS. An expert consensus evaluation of literature suggests that scheduled acetaminophen in patients undergoing thoracic surgery may be of benefit for acute pain control in thoracic surgical patients, who cannot receive regional analgesia (recommendation grade: A3-E) (Table2). 

對乙酰氨基酚  

文獻研究

VATS或開胸行胸外科手術(shù)患者圍手術(shù)期使用對乙酰氨基酚作為鎮(zhèn)痛輔助藥物的文獻報道，當(dāng)聯(lián)合局部阻滯時，急性切口和肩部疼痛的減少沒有達到統(tǒng)計學(xué)意義(A3-B類證據(jù)/ A3-E類證據(jù)和B2-E類證據(jù))。然而，患者報告說，在胸廓開胸術(shù)和胸廓硬膜外鎮(zhèn)痛(TEA)后的前16小時內(nèi)，使用對乙酰氨基酚可以減輕肩部疼痛。另一項隨機對照試驗描述了與單獨使用阿片類藥物相比，靜脈持續(xù)輸注對乙酰氨基酚可減輕VATS手術(shù)后休息疼痛和咳嗽(A3-B類證據(jù))。   靜脈注射對乙酰氨基酚比口服給藥具有更一致的藥代動力學(xué)特征(B2類證據(jù))。為證明靜脈給藥增加療效而進行的系統(tǒng)評價顯示口服和靜脈給藥之間沒有差異。  

總結(jié)和建議

使用預(yù)定的圍手術(shù)期對乙酰氨基酚作為多模式疼痛方案的一部分被發(fā)現(xiàn)提供關(guān)于急性術(shù)后疼痛好壞參半。Mac等人指出，TEA開胸術(shù)后定期服用對乙酰氨基酚可減少臨床肩部疼痛。VATS后單獨靜脈輸注對乙酰氨基酚的疼痛評分較低。   專家對文獻的一致評價表明，胸外科手術(shù)患者的定期對乙酰氨基酚可能有利于不能接受局部鎮(zhèn)痛的胸外科患者的急性疼痛控制(推薦等級:A3-E)(表2)。  

Nonsteroidal Anti-inflammatory Drugs  

Literature Findings. 

RCTs evaluating perioperative use of NSAIDs as part of a multimodal analgesic strategy reported variable reduction in incisional pain and overall incidence of shoulder pain after thoracotomy and VATS surgeries (Category A3-B evidence/Category A2-E evidence). One study found a statistically significant reduction in the incidence of moderate-to-severe shoulder pain after thoracotomy with scheduled NSAIDs (Category A3-B evidence). A meta-analysis also reported a reduction in pain and an opioid-sparing effect with the use of NSAIDs in patients undergoing cardiothoracic surgery (Category A1-B evidence).

Summary and Recommendations.

The use of scheduled perioperative NSAIDs as part of a multimodal analgesic strategy did not consistently reduce incisional pain in thoracic surgical patients. However, there was a decreased incidence of moderate-to-severe shoulder pain. The expert consensus evaluation of literature suggests that their scheduled use may be considered for acute pain in thoracic surgical patients in the absence of contraindications (recommendation grade: A2-B) (Table 2).

非甾體抗炎藥  

文獻研究

評估圍手術(shù)期使用非甾體抗炎藥作為多模式鎮(zhèn)痛策略一部分的隨機對照試驗報告了開胸和VATS手術(shù)后切口疼痛和肩部疼痛總體發(fā)生率的不同程度減少(A3-B類證據(jù)/ A2-E類證據(jù))。  

一項研究發(fā)現(xiàn)，使用非甾體抗炎藥可顯著降低開胸術(shù)后中度至重度肩痛的發(fā)生率(A3-B類證據(jù))。  

一項薈萃分析還報道，在接受心胸外科手術(shù)的患者中，使用非甾體抗炎藥可以減輕疼痛并節(jié)省阿片類藥物(A1-B類證據(jù))。  

總結(jié)和建議

圍手術(shù)期使用非甾體抗炎藥作為多模式鎮(zhèn)痛策略的一部分并不能持續(xù)減少胸外科患者的切口疼痛。然而，中度至重度肩痛的發(fā)生率有所下降。專家對文獻的一致評價表明，在沒有禁忌癥的情況下，可以考慮將其用于胸外科急性疼痛患者(推薦等級:A2-B)(表2)

Steroids   Literature Findings.

RCTs reported that perioperative intravenous dexamethasone did not reduce pain scores or epidural patient-controlled analgesia (PCA) use in patients undergoing VATS or thoracotomy (Category A2-E evidence).

Summary and Recommendations.

The benefit of intravenous steroids as part of a multimodal analgesic strategy for acute pain after thoracic surgery is uncertain (recommendation grade: A2-E) (Table2). 

類固醇激素   

文獻研究

隨機對照試驗報告圍手術(shù)期靜脈注射地塞米松不會降低VATS或開胸患者的疼痛評分或硬膜外患者自控鎮(zhèn)痛(PCA)的使用(A2-E類證據(jù))。   

總結(jié)和建議

靜脈注射類固醇作為胸外科術(shù)后急性疼痛多模式鎮(zhèn)痛策略的一部分，其益處尚不確定(推薦等級:A2-E)(表2)。   

Alpha 2 Agonists   

Clonidine. 

Literature Findings. In patients undergoing thoracotomy, those who received perioperative intravenous clonidine as a part of multimodal analgesic protocol used less epidural local anesthetic (LA) postoperatively (Category B1-B evidence).However, the exact contribution of clonidine cannot be determined from the study design. Summary and Recommendations. There is insufficient evidence to support the use of perioperative intravenous clonidine as an analgesic adjunct for reducing acute pain after thoracic surgery (recommendation grade: D) (Table2). 

Dexmedetomidine. 

Literature Findings. The literature supports the use of intravenous dexmedetomidine as an analgesic adjunct intraoperatively and/or postoperatively for patients undergoing thoracic surgery via VATS and thoracotomy as it reduces pain scores and/or opioid consumption (Category A2-B evidence). Summary and Recommendations. Perioperative dexmedetomidine provides effective acute pain control after thoracic surgery and can be useful as part of a multimodal analgesic strategy in the perioperative period (recommendation grade: A2-B) (Table2). 

α 2激動劑   

可樂寧

文獻研究在接受開胸手術(shù)的患者中，圍手術(shù)期靜脈注射可樂定作為多模式鎮(zhèn)痛方案的一部分的患者術(shù)后較少使用硬膜外局麻(LA) (B1-B類證據(jù))。然而，可樂定的確切作用不能從研究設(shè)計中確定。   總結(jié)和建議沒有足夠的證據(jù)支持圍手術(shù)期靜脈注射可樂定作為減輕胸外科術(shù)后急性疼痛的鎮(zhèn)痛輔助(推薦等級:D)(表2)。   

右美托咪啶

文獻研究文獻支持靜脈注射右美托咪定作為經(jīng)VATS和開胸胸外科手術(shù)患者術(shù)中和/或術(shù)后的鎮(zhèn)痛輔助藥物，因為它可以減少疼痛評分和/或阿片類藥物的消耗(A2-B類證據(jù))。   總結(jié)和建議右美托咪定圍手術(shù)期可有效控制胸外科術(shù)后急性疼痛，可作為圍手術(shù)期多模式鎮(zhèn)痛策略的一部分(推薦等級:A2-B)(表2)。   

N-Methyl-d-Aspartate Receptor Blockers   

Ketamine. 

Literature Findings. Studies evaluating various perioperative dosing regimens including postoperative continuous infusion of ketamine reported equivocal results with regard to acute pain scores and opioid consumption and the incidence of PTPS (Category A2-E evidence). Patients in the ketamine infusion group experienced more vivid dreams compared to the control group (Category A3-E evidence). Summary and Recommendations.. The benefit of subanesthetic perioperative intravenous ketamine as part of a multimodal analgesic strategy for acute pain after thoracic surgery is uncertain (recommendation grade: A2-E) (Table2). 

N-甲基-D-天冬氨酸受體阻滯劑   

氯胺酮

文獻研究評估各種圍手術(shù)期給藥方案(包括術(shù)后持續(xù)輸注氯胺酮)的研究報告了關(guān)于急性疼痛評分、阿片類藥物消耗和PTPS發(fā)生率的模棱兩可的結(jié)果(A2-E類證據(jù))。與對照組相比，氯胺酮輸注組患者的夢更生動(A3-E類證據(jù))。 

總結(jié)和建議圍手術(shù)期靜脈注射氯胺酮作為胸外科術(shù)后急性疼痛多模式鎮(zhèn)痛策略的一部分，其益處尚不確定(推薦等級:A2-E)(表2)。   

Magnesium. 

Literature Findings. Studies investigating perioperative intravenous magnesium as an analgesic adjunct in patients undergoing thoracic surgery yielded mixed results for opioid consumption and/or postoperative pain scores at rest (Category A3-E evidence and Category B2-B evidence). The results were also equivocal regarding the incidence of chronic neuropathic pain (Category B2-E evidence). Summary and Recommendations. The use of perioperative intravenous magnesium supplementation as part of a multimodal analgesic strategy for acute pain after thoracic surgery has provided mixed results. The benefit of its perioperative use is uncertain (recommendation grade: C) (Table2). 

鎂 

文獻研究調(diào)查胸外科手術(shù)患者圍手術(shù)期靜脈注射鎂作為鎮(zhèn)痛輔助藥物的研究得出了阿片類藥物消耗和/或術(shù)后靜息疼痛評分的混合結(jié)果(A3-E類證據(jù)和B2-B類證據(jù))。關(guān)于慢性神經(jīng)性疼痛的發(fā)生率(B2-E類證據(jù))，結(jié)果也不明確。

總結(jié)和建議圍手術(shù)期靜脈補鎂作為胸外科術(shù)后急性疼痛多模式鎮(zhèn)痛策略的一部分，提供了不同的結(jié)果。圍手術(shù)期使用的益處不確定(推薦等級:C)(表2)。 

Local Anesthetic Infusions  

Lidocaine. 

Literature Findings. The literature evaluating the use of perioperative intravenous lidocaine infusions as an analgesic adjunct for patients undergoing VATS surgery was inconclusive. Studies reported no change or decreased opioid consumption and pain scores for 6 hours postoperatively. The effects were directly correlated to plasma lidocaine levels, suggesting that continuing lidocaine infusion into the postoperative period may be beneficial (Category A2-E evidence). Summary and Recommendations. The benefit of perioperative intravenous lidocaine infusion as part of a multimodal analgesic strategy for acute pain after thoracic surgery is uncertain (recommendation grade: A2-E) (Table2). 

局麻藥輸注  

利多卡因

文獻研究評估圍手術(shù)期靜脈輸注利多卡因作為VATS手術(shù)患者鎮(zhèn)痛輔助的文獻尚無定論。研究報告術(shù)后6小時阿片類藥物消耗和疼痛評分沒有變化或下降。效果與血漿利多卡因水平直接相關(guān)，提示術(shù)后繼續(xù)輸注利多卡因可能是有益的(A2-E類證據(jù))。   總結(jié)和建議圍手術(shù)期靜脈輸注利多卡因作為胸外科術(shù)后急性疼痛多模式鎮(zhèn)痛策略的一部分，其益處尚不確定(推薦等級:A2-E)(表2)。

Opioids

Literature Findings.

The use of opioids in patients undergoing thoracic surgery, who have several associated respiratory comorbidities, can lead to respiratory depression (Category B1 evidence). The use of multimodal analgesia with a regional technique reduces opioid requirements and associated side effects. Enhanced recovery pathways using perioperative multimodal analgesia and regional blocks in patients undergoing VATS and thoracotomy resulted in reduced postoperative narcotic use, cardiopulmonary complications, and decreased LOS (Category B2-B evidence). Studies comparing opioid-based analgesia (OBA) to nonopioid analgesia in combination with a regional block showed a variable influence on cumulative opioid consumption at 24 to 48 hours after MITS surgery (Category B1-B evidence/Category B1-E evidence and Category B2-B evidence). Greater epidural LA usage in the first 48 hours after thoracotomy was reported in patients who received OBA compared to the controls who received nonopioid analgesia. (Category B2-B evidence). 

Summary and Recommendation. 

A perioperative opioid-sparing, multimodal analgesic regimen should be considered for thoracic surgery to reduce postoperative opioid exposure and potential cardiopulmonary complications (recommendation grade: B2-B) (Table 2). 

阿片類藥物

文獻研究

胸外科手術(shù)患者有幾種相關(guān)的呼吸合并癥，使用阿片類藥物可導(dǎo)致呼吸抑制(B1類證據(jù))。結(jié)合局部阻滯技術(shù)使用多模式鎮(zhèn)痛可減少阿片類藥物需求和相關(guān)副作用。在接受VATS和開胸手術(shù)的患者中，使用圍手術(shù)期多模式鎮(zhèn)痛和局部阻滯技術(shù)增強了恢復(fù)途徑，減少了術(shù)后麻醉劑的使用、心肺并發(fā)癥和LOS (B2-B類證據(jù))。  

比較阿片類鎮(zhèn)痛(OBA)與非阿片類鎮(zhèn)痛聯(lián)合局部阻滯的研究顯示，在MITS手術(shù)后24至48小時內(nèi)，阿片類藥物的累積消耗有不同的影響(B1-B類證據(jù)/ B1-E類證據(jù)和B2-B類證據(jù))。據(jù)報道，與接受非阿片類鎮(zhèn)痛的對照組相比，接受OBA的患者在開胸后48小時內(nèi)使用更多的硬膜外LA。(B2-B類證據(jù))。  

總結(jié)和建議

胸外科手術(shù)應(yīng)考慮圍手術(shù)期阿片類藥物節(jié)約、多模式鎮(zhèn)痛方案，以減少術(shù)后阿片類藥物暴露和潛在的心肺并發(fā)癥(推薦等級:B2-B)(表2)。  

VARIOUS REGIONAL TECHNIQUES

各種區(qū)域阻滯技術(shù)

Neuraxial Analegesia   Literature Findings.

In patients undergoing thoracotomy, TEA provided superior analgesia and greater improvement in pulmonary function compared to GA alone or when combined with subpleural or incisional analgesia (Category A2-B evidence and Category B1-E evidence). In the VATS population, the results were mixed. Two studies reported comparable pain scores offered by TEA, systemic analgesia, and PCA, while another study demonstrated lower postoperative pain scores when TEA was combined with GA (Category A3-B evidence/Category A3-E evidence and Category B2-E evidence). TEA use did not affect the incidence of persistent postoperative pain after VATS surgery (Category B2-E evidence). TEA use for thoracic surgery was also associated with reduction in cardiac and gastrointestinal complications along with better preserved pulmonary function (Category A2-B evidence and Category B2-B evidence). Similar results were reported by 2 meta-analyses (Category A1-B evidence/Category A1-E evidence). Preventative preincisional TEA may have better analgesic efficacy compared to postoperative use alone (Category A2-B evidence/Category A3-E evidence). The addition of adjunctive medications such as sufentanil, dexmedetomidine, dexamethasone, and magnesium to LA solutions as well as epidural infusion of S+-ketamine may improve pain control and decrease analgesic needs (Category A2-B evidence/Category A2-E evidence). Complications associated with TEA in the thoracic surgical population were epidural hematoma (0.34 cases per 1000) and epidural abscess (0.68 cases per 1000) (Category B2 evidence). A higher incidence of nausea and vomiting was found in TEA group compared to the controls (Category A3 evidence). A meta-analysis reported hypotension, urinary retention, and pruritus as the most common side effects and 7% of technical failures (Category A1 evidence). Data on spinal analgesia for thoracic surgery were sparse, with one study demonstrating decreased opioid consumption with intrathecal magnesium and another reporting improved pain scores with combined intrathecal morphine and cyclooxygenase inhibitor compared to traditional TEA (Category A2-B evidence). 

Summary and Recommendations. 

Perioperative TEA offers superior pain control and additional benefits to patients undergoing thoracic surgery when compared to GA; therefore, it should be used for acute pain in patients undergoing thoracotomy to reduce perioperative opioid use (recommendation grade: A2-B evidence). In VATS surgery, because TEA and PCA provided equivalent analgesia, either technique can be offered for acute pain management after VATS (recommendation grade: A3-B). The addition of certain adjuvant agents to LA infusion enhances analgesia (recommendation grade: A2-B). As data related to the use of spinal analgesia in thoracic surgery are limited, no recommendations can be made at the current time (recommendation grade: D) (Table 3). 

椎管內(nèi)阻滯  

文獻研究

在接受開胸手術(shù)的患者中，與GA單獨或與胸膜下或切口鎮(zhèn)痛聯(lián)合相比，TEA提供了更好的鎮(zhèn)痛效果和肺功能改善(A2-B類證據(jù)和B1-E類證據(jù))。在VATS人群中，結(jié)果好壞參半。兩項研究報告了TEA、全身鎮(zhèn)痛和PCA提供的可比疼痛評分，而另一項研究顯示TEA聯(lián)合GA時的術(shù)后疼痛評分較低(A3-B類證據(jù)/ A3-E類證據(jù)和B2-E類證據(jù))。使用TEA不影響VATS手術(shù)后持續(xù)術(shù)后疼痛的發(fā)生率(B2-E類證據(jù))。   

在胸外科手術(shù)中使用TEA還與心臟和胃腸道并發(fā)癥的減少以及更好地保護肺功能相關(guān)(A2-B類證據(jù)和B2-B類證據(jù))。2項薈萃分析報告了類似的結(jié)果(A1-B類證據(jù)/ A1-E類證據(jù))。   

預(yù)防性的術(shù)前TEA可能比術(shù)后單獨使用具有更好的鎮(zhèn)痛效果(A2-B類證據(jù)/ A3-E類證據(jù))。在LA溶液中加入舒芬太尼、右美托咪定、地塞米松和鎂等輔助藥物以及硬膜外輸注S+-氯胺酮可改善疼痛并減少鎮(zhèn)痛需求(A2-B類證據(jù)/ A2-E類證據(jù))。   

胸外科人群中與TEA相關(guān)的并發(fā)癥為硬膜外血腫(0.34例/ 1000)和硬膜外膿腫(0.68例/ 1000)(B2類證據(jù))。與對照組相比，TEA組惡心和嘔吐的發(fā)生率更高(A3類證據(jù))。一項薈萃分析報告低血壓、尿潴留和瘙癢是最常見的副作用和7%的阻滯失敗(A1類證據(jù))。   

關(guān)于胸外科脊柱鎮(zhèn)痛的數(shù)據(jù)很少，一項研究表明鞘內(nèi)鎂可減少阿片類藥物的消耗，另一項研究報告與傳統(tǒng)TEA相比，鞘內(nèi)嗎啡和環(huán)氧化酶抑制劑聯(lián)合可改善疼痛評分(A2-B類證據(jù))。   

總結(jié)和建議

與GA相比，圍手術(shù)期TEA為胸外科患者提供了更好的疼痛控制和額外的益處；因此，應(yīng)將其用于開胸患者的急性疼痛，以減少圍手術(shù)期阿片類藥物的使用(推薦等級:A2-B證據(jù))。在VATS手術(shù)中，由于TEA和PCA提供了相同的鎮(zhèn)痛效果，兩種阻滯都可以用于VATS術(shù)后的急性疼痛管理(推薦等級:A3-B)。在LA輸注中加入某些佐劑可增強鎮(zhèn)痛作用(推薦等級:A2-B)。由于胸外科手術(shù)中使用脊髓鎮(zhèn)痛的相關(guān)數(shù)據(jù)有限，目前暫無推薦(推薦等級:D)(表3)。   

Paravertebral Block   Literature Findings. 

In patients undergoing thoracotomy, perioperative use of paravertebral block (PVB) resulted in improved postoperative pain scores compared to systemic analgesia (Category A3-B evidence/Category A2-E evidence). Studies comparing PVB-related analgesia with TEA for thoracotomy revealed mixed results related to postoperative pain control (Category A2-B evidence/Category A2-E evidence, Category B1-E evidence, and Category B2-E evidence). The use of PVB was associated with greater hemodynamic stability and fewer side effects than TEA (Category A3-E evidence). Several meta-analyses also concluded that PVBs have comparable analgesic efficacy to TEA with a more favorable side effect profile with respect to urinary retention and hypotension (Category A1-E evidence). In patients undergoing VATS, using single- or multiple-site injection techniques for thoracic PVB provided superior or equivalent analgesia compared to controls with no blocks, wound infiltration, or conventional PCA (Category A2-B evidence/Category A2-E evidence and Category B2-B evidence). Similarly, PVB utilization for thoracoscopic surgery resulted in superior equivalent, or inferior analgesia compared to TEA, with fewer side effects (Category A3-B evidence/Category A2-E evidence). A meta-analysis also reported that PVB provides better-quality analgesia with fewer side effects in patients undergoing thoracoscopic surgery compared to the controls (Category A1-B evidence).PVB also facilitated spontaneously ventilating VATS surgery (Category A3 evidence and Category B1 evidence). PVB was found to be superior to preventative ketamine or transcutaneous electrical nerve stimulation (TENS) units in thoracotomy patients with regard to acute pain control (Category A2-B evidence). Similarly, patients undergoing VATS surgery reported improved or noninferior pain control with PVB compared to intercostal nerve blockade(Category A3-B evidence/Category A2-E evidence, Category B1-E evidence, and Category B2-B evidence). In the elderly population undergoing thoracic surgery, the use of PVB reported equivocal findings for postoperative cognitive function and delirium compared to GA alone (Category A2-E evidence). A systematic review found that higher doses of LA (890–990 milligram [mg] versus 325–472.5 mg per 24 hours) as well as their continuous infusion for PVB led to improved pain scores up to 48 hours after surgery (Category A1-B evidence). Levobupivacaine and liposomal bupivacaine may provide better pain control than the same concentration of bupivacaine (Category A3-B evidence and Category B2-B evidence). Adding magnesium, dexmedetomidine, or clonidine to the LA infusion may enhance the analgesic effects of PVB (Category A2-B evidence and Category A3-E evidence). Although rare, PVBs placed in high thoracic regions may result in ipsilateral brachial plexus blockade, leading to hemidiaphragmatic paresis, Horner syndrome, temporary quadriplegia, or total spinal block as well as LA toxicity (Category B3 evidence). Patients can have increased sedation and significant hypotension if clonidine is used in PVB infusion (Category A3-H evidence). 

Summary and Reco mmendations. 

As perioperative use of PVB provides comparable analgesia to TEA with a decreased incidence of side effects, it can be considered for acute pain management in patients undergoing thoracic surgery, especially with contraindications to TEA (recommendation grade: A2-E). Certain additives to the LA infusion may be used to enhance the analgesic effects of PVB (recommendation grade: A2-B) (Table 3). 

椎旁阻滯   

文獻研究

在接受開胸手術(shù)的患者中，與全身鎮(zhèn)痛相比，圍手術(shù)期使用椎旁阻滯(PVB)可改善術(shù)后疼痛評分(A3-B類證據(jù)/ A2-E類證據(jù))。  

比較開胸手術(shù)中PVB相關(guān)鎮(zhèn)痛與TEA的研究顯示，與術(shù)后疼痛控制相關(guān)的結(jié)果好壞參半(A2-B類證據(jù)/ A2-E類證據(jù)、B1-E類證據(jù)和B2-E類證據(jù))。與TEA相比，PVB的使用具有更好的血流動力學(xué)穩(wěn)定性和更少的副作用(A3-E類證據(jù))。幾項薈萃分析也得出結(jié)論，PVB的鎮(zhèn)痛效果與TEA相當(dāng)，但在尿潴留和低血壓方面的副作用更有利(A1-E類證據(jù))。  

在接受VATS的患者中，與無阻滯、傷口浸潤或常規(guī)PCA的對照組相比，使用單部位或多部位胸椎PVB提供了更好或同等的鎮(zhèn)痛效果(A2-B類證據(jù)/ A2-E類證據(jù)和B2-B類證據(jù))。  

同樣，與TEA相比，胸腔鏡手術(shù)中使用PVB可獲得更好的等效鎮(zhèn)痛，且副作用更少(A3-B類證據(jù)/ A2-E類證據(jù))。一項薈萃分析還報道，與對照組相比，PVB在胸腔鏡手術(shù)患者中提供了質(zhì)量更好的鎮(zhèn)痛，副作用更少(A1-B類證據(jù))。PVB也促進了VATS手術(shù)的自主通氣(A3類證據(jù)和B1類證據(jù))。  

在控制開胸患者急性疼痛方面，PVB優(yōu)于預(yù)防性氯胺酮或經(jīng)皮神經(jīng)電刺激(TENS)裝置(A2-B類證據(jù))。  

同樣，與肋間神經(jīng)阻滯相比，接受VATS手術(shù)的患者報告PVB改善或非劣性疼痛控制(A3-B類證據(jù)/ A2-E類證據(jù)，B1-E類證據(jù)和B2-B類證據(jù))。   在接受胸外科手術(shù)的老年人群中，與單獨使用GA相比，使用PVB對術(shù)后認知功能和譫妄的發(fā)現(xiàn)模棱兩可(A2-E類證據(jù))。   一項系統(tǒng)評價發(fā)現(xiàn)，高劑量的LA(890-990毫克/ 24小時vs 325-472.5毫克/ 24小時)以及持續(xù)輸注PVB可改善手術(shù)后48小時的疼痛評分(A1-B類證據(jù))。左旋布比卡因和布比卡因脂質(zhì)體可能比相同濃度的布比卡因具有更好的疼痛控制效果(A3-B類證據(jù)和B2-B類證據(jù))。在LA輸注中加入鎂、右美托咪啶或可樂定可增強PVB的鎮(zhèn)痛作用(A2-B類證據(jù)和A3-E類證據(jù))。   雖然罕見，但放置在高位胸區(qū)的PVB可能導(dǎo)致同側(cè)臂叢神經(jīng)阻滯，導(dǎo)致膈肌麻痹、Horner綜合征、暫時性四肢癱瘓或完全神經(jīng)阻滯以及LA毒性(B3類證據(jù))。如果在PVB輸注中使用可樂定，患者可增加鎮(zhèn)靜作用和明顯的低血壓(A3-H類證據(jù))。  

總結(jié)和建議

由于圍手術(shù)期使用PVB可提供與TEA相當(dāng)?shù)逆?zhèn)痛效果，且副作用發(fā)生率較低，因此可考慮用于胸外科手術(shù)患者的急性疼痛管理，特別是有TEA禁忌癥的患者(推薦等級:A2-E)。在LA輸注中加入某些添加劑可以增強PVB的鎮(zhèn)痛作用(推薦等級:A2-B)(表3)。  

Fascial Plane Blocks 

Fascial plane blocks (FPBs) are classified into posterior, lateral, and anterior chest wall techniques depending on the anatomical location. These techniques have been included as part of a multimodal analgesic regimen for pain control after thoracic surgery.

筋膜平面阻滯

筋膜平面阻滯(FPBs)根據(jù)解剖位置分為后胸壁、側(cè)胸壁和前胸壁阻滯。這些阻滯已作為胸外科手術(shù)后疼痛控制的多模式鎮(zhèn)痛方案的一部分。

Erector Spinae Plane Block.

Literature Findings. Patients undergoing VATS or thoracotomy who received single-shot erector spinae plane block (ESPB) reported superior pain control and/or lower cumulative analgesic requirements for 6 to 48 hours along with enhanced recovery (Category A2-B evidence). ESPB also facilitated spontaneously ventilating VATS surgery (Category  B3 evidence). The addition of nalbuphine or dexmedetomidine alone or in combination with dexametha[1]sone to the LA mixture for ESPB may enhance analgesia and prolong the duration of the block (Category A2-B evidence/Category A3-E evidence). For patients undergoing thoracotomy, ESPB-related analgesia was found to be superior to intercostal nerve blocks (ICNBs) and noninferior to PVB (Category A3-B evidence/Category A3-E evidence). There were fewer adverse effects, hematomas, and failure rates with ESPB compared to PVB (Category A3 evidence). ESPB combined with serratus anterior plane block (SAPB) block delivered comparable analgesia to epidural for thoracotomy surgery (Category A3-E evidence). For VATS surgical patients, ESPB-related analgesia was found to be superior to serratus anterior plane block (SAPB) and superior or noninferior to intercostal block, as well as noninferior or inferior to PVB with regard to postoperative pain and 24- to 48-hour opioid requirements(Category A2-B evidence/Category A3-E evidence and Category B1-B evidence). However, equivocal quality of recovery was reported after MITS surgery with both ESPB and SAPB (Category A3-E evidence). 

豎脊肌平面阻滯

文獻研究接受VATS或開胸手術(shù)的患者接受單次豎脊肌平面阻滯(ESPB)后，6 - 48小時內(nèi)疼痛控制和/或累積鎮(zhèn)痛需求降低，恢復(fù)增強(A2-B類證據(jù))。ESPB也促進了VATS手術(shù)的自主通氣(B3類證據(jù))。

在用于ESPB的LA混合物中單獨加入納布啡或右美托咪定或與地塞米松聯(lián)合可增強鎮(zhèn)痛并延長阻滯持續(xù)時間(A2-B類證據(jù)/ A3-E類證據(jù))。  

對于開胸患者，ESPB相關(guān)鎮(zhèn)痛優(yōu)于肋間神經(jīng)阻滯(ICNBs)，不遜于PVB (A3-B類證據(jù)/ A3-E類證據(jù))。與PVB相比，ESPB的不良反應(yīng)、血腫和失敗率更低(A3類證據(jù))。ESPB聯(lián)合前鋸肌平面阻滯(SAPB)對開胸手術(shù)的鎮(zhèn)痛效果與硬膜外阻滯相當(dāng)(A3-E類證據(jù))。   對于VATS手術(shù)患者，ESPB相關(guān)鎮(zhèn)痛在術(shù)后疼痛和24- 48小時阿片類藥物需求方面優(yōu)于前鋸肌平面阻滯(SAPB)，優(yōu)于或不劣于肋間阻滯，不劣于或劣于PVB (A2-B類證據(jù)/ A3-E類證據(jù)和B1-B類證據(jù))。 

然而，有ESPB和SAPB的MITS手術(shù)后的恢復(fù)質(zhì)量是相同的(A3-E類證據(jù))。  

Serratus Anterior Plane Block.

Literature Findings. Single-shot or continuous SAPB in patients undergoing VATS or thoracotomy was more effective at lowering pain scores and/or opioid consumption for 12 to 24 hours as well as improved overall recovery compared to the controls with either no block, systemic analgesia,or PCA (Category A2-B evidence and Category B2-B evidence). Meta-analyses also reported superior pain control for 24 hours with SAPB in thoracic surgical population (Category A1-B evidence). The addition of dexmedetomidine or dexamethasone to LAs in a continuous SAPB mixture may  enhance analgesia after thoracic surgery (Category A2-B evidence). A continuous SAP block for a  week after thoracotomy for lung cancer reported equivocal findings for the incidence of postthoracotomy pain syndrome compared to the PCA group (Category A3-E evidence). For patients undergoing MITS, SAPB was superior to local infiltration, noninferior to ICNB and PVB, as well as inferior to ESPB with regard to pain scores, opioid consumption, or improved recovery (Category A2-B evidence/Category A2-E evidence and Category B2-B evidence). In patients undergoing thoracotomy, single-shot SAPB-related analgesia was comparable to PVB and inferior to TEA (Category A2-B evidence). Summary and Recommendations. While more investigation is needed regarding the precise technique, analgesic reliability, and other characteristics of various FPBs, certain blocks may provide superior pain control and lower opioid consumption after thoracic surgery; therefore, they can be used as perioperative analgesic adjuncts to a multimodal opioid-sparing pain regimen (recommendation grade: A2-B) (Table3). 

前鋸肌平面阻滯

文獻研究與無阻滯、全身鎮(zhèn)痛或PCA的對照組相比，接受VATS或開胸手術(shù)的患者單次或連續(xù)SAPB在降低疼痛評分和/或12至24小時阿片類藥物消耗以及改善整體恢復(fù)方面更有效(A2-B類證據(jù)和B2-B類證據(jù))。meta分析也報道了胸外科患者SAPB治療后24小時疼痛控制的優(yōu)勢(A1-B類證據(jù))。 

在連續(xù)SAPB混合物中加入右美托咪定或地塞米松可增強胸外科手術(shù)后的鎮(zhèn)痛作用(A2-B類證據(jù))。與PCA組相比，肺癌開胸術(shù)后持續(xù)SAP阻滯一周報告的切口后疼痛綜合征發(fā)生率不明確(A3-E類證據(jù))。  

對于接受MITS的患者，SAPB優(yōu)于局部浸潤，不遜于ICNB和PVB，在疼痛評分、阿片類藥物消耗或改善恢復(fù)方面也遜于ESPB (A2-B類證據(jù)/ A2-E類證據(jù)和B2-B類證據(jù))。在接受開胸手術(shù)的患者中，單次SAPB相關(guān)鎮(zhèn)痛與PVB相當(dāng)，低于TEA (A2-B類證據(jù))。  

總結(jié)和建議雖然需要對各種FPBs的精確阻滯、鎮(zhèn)痛可靠性和其他特性進行更多的研究，但某些阻滯可能提供更好的疼痛控制和胸外科手術(shù)后更低的阿片類藥物消耗;因此，它們可以作為多模式阿片類鎮(zhèn)痛方案的圍手術(shù)期鎮(zhèn)痛輔助藥物(推薦等級:A2-B)(表3)。 

Local Infiltrative Techniques Incisional Analgesia. 

Literature Findings. For patients undergoing VATS or thoracotomy, regional techniques, such as SAPB, ESPB,PVB, and TEA, were associated with lower pain scores for 8 to 48 hours and/or decreased opioid consumption compared to incisional analgesia (Category A2-B evidence/Category A3-E evidence and Category B2-E evidence). Summary and Recommendations. The use of continuous wound infiltration catheters for postoperative pain control in patients undergoing thoracic surgery has provided inferior results compared to other regional techniques; hence, it is not currently recommended (recommendation grade: C) (Table3). 

局部浸潤阻滯  

切口鎮(zhèn)痛

文獻研究對于接受VATS或開胸手術(shù)的患者，與切口鎮(zhèn)痛相比，SAPB、ESPB、PVB和TEA等局部阻滯與8至48小時疼痛評分較低和/或阿片類藥物消耗減少相關(guān)(A2-B類證據(jù)/ A3-E類證據(jù)和B2-E類證據(jù))。   總結(jié)和建議與其他區(qū)域阻滯相比，連續(xù)傷口浸潤阻滯控制胸外科患者術(shù)后疼痛的效果較差；因此，目前不推薦(推薦等級:C)(表3)。 

Intercostal Nerve Block.

Literature Findings. ICNBs provide inferior analgesia compared to the other regional and neuraxial techniques discussed previously. However, for patients undergoing thoracotomy, there is some evidence that ICNB with PCA may provide comparable analgesia to TEA (Category A2-E evidence). Compared to no block or systemic analgesia, ICNBs may decrease pain scores and/or lower analgesic use for 4 to 48 hours in patients undergoing thoracotomy and VATS, suggesting a benefit for patients with contraindications to neuraxial techniques (Category A2-B evidence/Category A3-E evidence and Category B2-B evidence/Category B2-E evidence). A meta-analysis also reported pain reduction with ICNB for 24 hours after thoracic surgery (Category A1-E evidence). There may be a role in adding ICNB to PVB or epidural analgesia to reduce acute postoperative pain, but the current available evidence is mixed (Category A3-B evidence/Category A3-E evidence and Category B1-E evidence). Liposomal bupivacaine (LB) has been used off-label for performing ICNBs for postoperative analgesia after RATS, VATS, and/or thoracotomy surgery. Studies reported either no difference or decreased pain scores or opioid usage for 6 to 36 hours when intercostal LB was compared to plain bupivacaine in thoracic surgical patients (Category A3-E evidence, Category B1-B evidence, and Category B2-E evidence/Category B2-B evidence). Decreased LOS and rate of pulmonary complications after thoracic surgery were also reported when liposomal bupivacaine was utilized for INCB (Category B1-B evidence and Category B2-B evidence). Intercostal cryoanalgesia alone or in combination with PCA or epidural decreased postopera[1]tive pain scores and/or opioid consumption in patients undergoing thoracotomy compared to the controls (Category A2-B evidence/Category A2-E evidence). However, there was an increased incidence of severe or neuropathic-type postthoracotomy pain with the use of cryoanalgesia with or without TEA (Category A2-E evidence). Summary and Recommendations..ICNB can decrease pain scores compared to systemic analgesia in patients undergoing thoracic surgery. Therefore, it can be used as part of a multimodal pain regimen in these patients, especially in those with contraindications to neuraxial techniques (recommendation grade: A2-B). The opioid-sparing effect seen with plain LAs has not been replicated with LB; hence, it cannot be recommended at this time (recommendation grade: C). Although intercostal cryoanalgesia reduces pain and analgesic needs after thoracotomy, its routine use is not recommended due to its association with increased incidence of persistent postthoracotomy pain (recommendation grade: C) (Table3). 

肋間神經(jīng)阻滯

文獻研究與之前討論的其他局部和椎管阻滯相比，ICNB提供的鎮(zhèn)痛效果較差。然而，對于接受開胸手術(shù)的患者，有證據(jù)表明ICNB聯(lián)合PCA可能提供與TEA相當(dāng)?shù)逆?zhèn)痛效果(A2-E類證據(jù))。  

與無阻滯或全身性鎮(zhèn)痛相比，ICNB可在4 - 48小時內(nèi)降低開胸和VATS患者的疼痛評分和/或鎮(zhèn)痛用量，這表明對有椎管阻滯禁忌癥的患者有利(A2-B類證據(jù)/ A3-E類證據(jù)和B2-B類證據(jù)/ B2-E類證據(jù))。一項薈萃分析也報告了胸外科手術(shù)后24小時使用ICNB可減輕疼痛(A1-E類證據(jù))。

在PVB或硬膜外鎮(zhèn)痛中加入ICNB可能有減輕術(shù)后急性疼痛的作用，但目前可獲得的證據(jù)是好壞參半(A3-B類證據(jù)/ A3-E類證據(jù)和B1-E類證據(jù))。 

布比卡因脂質(zhì)體(LB)已在說明書外用于RATS、VATS和/或開胸手術(shù)后的ICNB術(shù)后鎮(zhèn)痛。 

研究報告胸外科手術(shù)患者肋間LB與普通布比卡因相比，疼痛評分或阿片類藥物使用6至36小時無差異或減少(A3-E類證據(jù)，B1-B類證據(jù)，B2-E類證據(jù)/ B2-B類證據(jù))。   當(dāng)使用布比卡因脂質(zhì)體進行麻醉時(B1-B類證據(jù)和B2-B類證據(jù))，胸部手術(shù)后的LOS和肺部并發(fā)癥發(fā)生率也有所下降。

與對照組相比，單獨肋間阻滯鎮(zhèn)痛或聯(lián)合PCA或硬膜外鎮(zhèn)痛可降低開胸患者術(shù)后疼痛評分和/或阿片類藥物消耗(A2-B類證據(jù)/ A2-E類證據(jù))。然而，在有或沒有TEA的情況下使用阻滯鎮(zhèn)痛會增加開胸術(shù)后嚴重疼痛或神經(jīng)性疼痛的發(fā)生率(A2-E類證據(jù))。 

總結(jié)和建議與全身鎮(zhèn)痛相比，ICNB可降低胸外科手術(shù)患者的疼痛評分。因此，它可以作為這些患者多模式疼痛治療方案的一部分，特別是那些有椎管阻滯禁忌癥的患者(推薦等級:A2-B)。阿片類物質(zhì)節(jié)約效應(yīng)在普通LAs中未被LB復(fù)制；因此，現(xiàn)在不能推薦(推薦等級:C)。 

盡管肋間阻滯鎮(zhèn)痛可以減輕開胸術(shù)后的疼痛和鎮(zhèn)痛需求，但由于其與持續(xù)開胸后疼痛發(fā)生率增加相關(guān)，不推薦常規(guī)使用(推薦等級:C)(表3)。  

CONCLUSIONS 

結(jié)論

Inadequate pain management after thoracic surgery may lead to persistent postoperative pain, disability, and decreased quality of life. A customized analgesic approach for patients and procedures may facilitate effective postoperative pain control and may promote recovery. Figure3 details an approach to perioperative pain management that can be taken for patients undergoing elective or emergent thoracic surgery. This practice advisory provides recommendations for perioperative pain management for thoracic surgical patients based on the available literature and expert consensus. However, some areas still require further investigation. These include: 1. Role of various regional techniques in promoting functional recovery; 2. Optimal windows and techniques for FPBs, use of various adjuncts to LA, as well as timing, volume, and dosing of LA; 3. Factors that influence LA spread and absorption in FPBs; 4. Complications related to FPBs; 5. Role of nonopioid analgesics in preventing persistent postoperative pain and opioid use; 6. Adverse effects related to nonopioid analgesics; 7. Comparison of opioid-based analgesia versus nonopioid-based analgesia alone in improving postoperative pain; 8. Role of individualized pain management approach taking into consideration the risk factors for developing persistent pain and opioid use in influencing outcomes; 9. Role of perioperative multimedia-based education and counseling even after discharge in postoperative pain control and functional recovery; and 10. Clinical outcomes focused on quality-of-recovery and quality-of-life measurements rather than pain scores and opioid consumption. In summary, the quest to utilize opioid-sparing multimodal analgesic techniques and FPBs for perioperative pain management still warrants additional well-designed trials with rigorous methodology to delineate possible benefits and associated adverse effects. Sustained research and advancement in this field can continue to provide future guidance for patient-tailored analgesia to improve clinically relevant outcomes that may enhance recovery and quality of life after thoracic surgery. 

胸外科手術(shù)后疼痛管理不當(dāng)可能導(dǎo)致持續(xù)的術(shù)后疼痛、殘疾和生活質(zhì)量下降。針對患者和手術(shù)過程定制的鎮(zhèn)痛方法可能有助于有效的術(shù)后疼痛控制，并可能促進恢復(fù)。圖3詳細介紹了可用于擇期或緊急胸外科手術(shù)患者的圍手術(shù)期疼痛管理方法。

本建議基于現(xiàn)有文獻和專家共識，為胸外科患者圍手術(shù)期疼痛管理提供參考。然而，一些領(lǐng)域仍需要進一步研究。這些包括: 

1. 各種區(qū)域阻滯在促進功能恢復(fù)中的作用；

2. FPBs的最佳窗口和技術(shù)，各種LA輔助劑的使用，以及LA的時間、體積和劑量；

3. 影響LA在FPBs中擴散和吸收的因素； 

4. FPBs相關(guān)并發(fā)癥；

5. 非阿片類鎮(zhèn)痛藥在預(yù)防術(shù)后持續(xù)疼痛和阿片類藥物使用中的作用；

6. 非阿片類鎮(zhèn)痛藥的不良反應(yīng)；  

7. 阿片類藥物鎮(zhèn)痛與單獨非阿片類藥物鎮(zhèn)痛在改善術(shù)后疼痛中的比較；  

8. 考慮到持續(xù)性疼痛和阿片類藥物使用的風(fēng)險因素的個體化疼痛管理方法在影響結(jié)果中的作用；  

9. 圍手術(shù)期多媒體教育及出院后輔助在術(shù)后疼痛控制及功能恢復(fù)中的作用；  

10. 臨床結(jié)果側(cè)重于恢復(fù)質(zhì)量和生活質(zhì)量的監(jiān)測，而不是疼痛評分和阿片類藥物的消耗。  

總之，尋求使用阿片類藥物的多模式鎮(zhèn)痛技術(shù)和FPBs進行圍手術(shù)期疼痛管理仍然需要更多精心設(shè)計的試驗，采用嚴格的方法來描述可能的益處和相關(guān)的不良反應(yīng)。該領(lǐng)域的持續(xù)研究和進展可以繼續(xù)為患者量身定制的鎮(zhèn)痛提供未來指導(dǎo)，以改善臨床相關(guān)結(jié)果，從而提高胸外科手術(shù)后的恢復(fù)和生活質(zhì)量。

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文中所涉及藥物使用、疾病診療等內(nèi)容僅供醫(yī)學(xué)專業(yè)人士參考。

—END—

編輯：Michel.米萱

校對：MiLu.米鷺

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