Is Local Infiltration Analgesia Superior to Peripheral Nerve Blockade for Pain Management After THA: A Network Meta-analysis
Is Local Infiltration Analgesia Superior to Peripheral Nerve Blockade for Pain Management After THA: A Network Meta-analysis
复制标题
DOI：
10.1007/s11999-015-4619-9
复制
发表时间：
2016-02-01
影响因子：
4.2
通讯作者：
Sierra, Rafael J.
中科院分区：
文献类型：
--
作者：
Jimenez-Almonte, Jose H.;Wyles, Cody C.;Sierra, Rafael J.
局部浸润镇痛和周围神经阻滞是THA术后疼痛管理的常用方法，但尚未进行直接头对头的随机对照试验（rct）。网络荟萃分析允许相对于共同比较物对个别治疗进行间接比较；在这种情况下，安慰剂（或无干预），硬膜外镇痛和鞘内吗啡，产生比较疗效的估计。我们的问题是，与安慰剂相比，(1)局部浸润性镇痛是否会降低患者疼痛评分和阿片类药物的消耗，(2)周围神经阻滞是否会降低患者疼痛评分和阿片类药物的消耗，以及(3)局部浸润性镇痛是否比周围神经阻滞更适合THA术后疼痛管理？我们检索了6个数据库，从建立到2014年6月30日，以确定比较THA术后患者局部浸润镇痛或周围神经阻滞的rct。网络荟萃分析共纳入35项低偏倚风险的rct，采用Cochrane协作推荐的风险评估工具（2296例患者）。本综述的主要结局是患者休息时疼痛评分和阿片类药物累积消耗，均在THA后24小时评估。由于在纳入的试验中存在大量异质性（研究之间的结果差异），因此使用随机效应模型进行meta分析，以估计加权平均差（WMD）和95% CI。灰色文献采用与已发表试验相同的纳入标准进行检索。只有一项未发表的试验（已发表的摘要）符合我们的标准并被纳入本综述。本系统综述中纳入的所有其他研究均为已发表的完整文章。贝叶斯网络荟萃分析包括所有比较局部浸润镇痛或周围神经阻滞与安慰剂（或无干预）、硬膜外镇痛和鞘内吗啡的随机对照试验。与安慰剂相比，局部浸润镇痛降低了患者疼痛评分（WMD, -0.61; 95% CI, -0.97至-0.24;p = 0.001）和阿片类药物消耗（WMD, -7.16 mg; 95% CI, -11.98至-2.35;p = 0.004）。与安慰剂相比，周围神经阻滞并未导致疼痛评分降低或阿片类药物消耗减少（WMD, -0.43; 95% CI, -0.99至0.12;p = 0.12； WMD, -3.14 mg, 95% CI, -11.30至5.02;p = 0.45）。然而，通过常用比较物比较局部浸润性镇痛与周围神经阻滞的网络meta分析显示，术后疼痛评分（WMD, -0.36; 95% CI, -1.06 ~ 0.31）和阿片类药物消耗（WMD, -4.59 mg; 95% CI, -9.35 ~ 0.17）之间没有差异，尽管秩序分析发现局部浸润性镇痛在更多模拟中排名第一，比周围神经阻滞更有效。采用新颖的统计网络meta分析方法，我们发现局部浸润镇痛和周围神经阻滞在THA后24小时的镇痛或阿片类药物消耗方面没有差异；根据秩序分析，周围神经阻滞有轻微的优势，但所讨论的效应大小可能不大。鉴于干预措施之间的细微差异，临床医生在讨论THA后使用哪种镇痛治疗时，可能会选择关注其他因素，如成本和干预相关并发症。第一级，治疗性研究。
Local infiltration analgesia and peripheral nerve blocks are common methods for pain management in patients after THA but direct head-to-head, randomized controlled trials (RCTs) have not been performed. A network meta-analysis allows indirect comparison of individual treatments relative to a common comparator; in this case placebo (or no intervention), epidural analgesia, and intrathecal morphine, yielding an estimate of comparative efficacy.We asked, when compared with a placebo, (1) does use of local infiltration analgesia reduce patient pain scores and opioid consumption, (2) does use of peripheral nerve blocks reduce patient pain scores and opioid consumption, and (3) is local infiltration analgesia favored over peripheral nerve blocks for postoperative pain management after THA?We searched six databases, from inception through June 30, 2014, to identify RCTs comparing local infiltration analgesia or peripheral nerve block use in patients after THA. A total of 35 RCTs at low risk of bias based on the recommended Cochrane Collaboration risk assessment tool were included in the network meta-analysis (2296 patients). Primary outcomes for this review were patient pain scores at rest and cumulative opioid consumption, both assessed at 24 hours after THA. Because of substantial heterogeneity (variation of outcomes between studies) across included trials, a random effect model for meta-analysis was used to estimate the weighted mean difference (WMD) and 95% CI. The gray literature was searched with the same inclusion criteria as published trials. Only one unpublished trial (published abstract) fulfilled our criteria and was included in this review. All other studies included in this systematic review were full published articles. Bayesian network meta-analysis included all RCTs that compared local infiltration analgesia or peripheral nerve blocks with placebo (or no intervention), epidural analgesia, and intrathecal morphine.Compared with placebo, local infiltration analgesia reduced patient pain scores (WMD, -0.61; 95% CI, -0.97 to -0.24; p = 0.001) and opioid consumption (WMD, -7.16 mg; 95% CI, -11.98 to -2.35; p = 0.004). Peripheral nerve blocks did not result in lower pain scores or reduced opioid consumption compared with placebo (WMD, -0.43; 95% CI, -0.99 to 0.12; p = 0.12 and WMD, -3.14 mg, 95% CI, -11.30 to 5.02; p = 0.45). However, network meta-analysis comparing local infiltration analgesia with peripheral nerve blocks through common comparators showed no differences between postoperative pain scores (WMD, -0.36; 95% CI, -1.06 to 0.31) and opioid consumption (WMD, -4.59 mg; 95% CI, -9.35 to 0.17), although rank-order analysis found local infiltration analgesia to be ranked first in more simulations than peripheral nerve blocks, suggesting that it may be more effective.Using the novel statistical network meta-analysis approach, we found no differences between local infiltration analgesia and peripheral nerve blocks in terms of analgesia or opioid consumption 24 hours after THA; there was a suggestion of a slight advantage to peripheral nerve blocks based on rank-order analysis, but the effect size in question is likely not large. Given the slight difference between interventions, clinicians may choose to focus on other factors such as cost and intervention-related complications when debating which analgesic treatment to use after THA.Level I, therapeutic study.