2023指南共识:胸外科患者术前和术中疼痛管理的临床建议：第1部分

以下文章来源于麻醉新超人，作者麻醉新超人

本文由“麻醉新超人”授权转载

该文章选自《麻醉与镇痛》2023年7月刊

翻译：张   丽   刘郁鋆   徐祗彪   徐医麻醉2022级硕士研究生

审校：赵林林  徐医附院麻醉科  

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

胸外科患者术前和术中疼痛管理的临床建议：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.

胸外科手术后疼痛为中至重度疼痛，可加重患者的术后不适并影响功能恢复。几十年来，阿片类药物一直是治疗胸外科术后疼痛的核心药物。使用多模式镇痛策略可以有效控制术后疼痛，并有助于减轻阿片类药物暴露，从而预防持续性术后疼痛的发生。本临床建议是美国心血管麻醉医师协会(SCA)质量、安全和领导(QSL)委员会阿片类药物研究组制定的一系列临床建议之一。本文系统回顾了与胸外科手术患者术前和术中疼痛管理相关的各种干预措施的现有文献，并为治疗胸外科手术患者的医师提供了建议：重点在于为患者制定个体化的疼痛管理策略，包括术前评估、疼痛管理、和以阿片类药物使用为重点的教育，以及围手术期使用多模式镇痛药和各种胸外科手术的区域镇痛技术。与该领域相关的文献正在涌现，并有望在未来提供更多关于改善临床相关患者预后和促进康复的方法。

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.

开胸术后疼痛的病因具有多样性，包括手术切口、肌肉挛缩、肋骨扩张、胸膜间隙开放等，可导致肋骨和肋椎关节、壁层胸膜、肺实质和肋间神经损伤。  

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.

胸外科手术后的中度至重度疼痛会增加患者的痛苦，并可能导致持续性术后疼痛。这可能会增加医疗保健成本，对生活质量和睡眠产生不利影响，并延迟正常的日常生活活动的恢复。胸外科手术后急性疼痛管理欠佳会损害正常的呼吸力学，这可能导致肺部并发症的发生并延长术后恢复时间。

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.

由于担心单纯依赖阿片类药物镇痛可能导致出院后持续使用阿片类药物，关于这些患者的围手术期疼痛管理措施一直在继续发展;这可能导致过去30年中阿片类药物相关死亡人数增加的重大公共卫生危机的发生。

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.

为了给治疗接受心脏和胸部手术患者的医师团队开发与围术期疼痛管理相关的教育资源，心血管麻醉医师协会（SCA）质量、安全和领导力（QSL）委员会的阿片类药物研究组总结了与这些患者围术期疼痛管理相关的文献，构成由四部分组成的一系列临床建议:

第一部分:胸外科手术患者术前及术中疼痛的管理。  

第二部分:心脏手术患者术前和术中疼痛的管理。  

第三部分:心胸外科患者术后疼痛的管理。  

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.

本项临床建议系统地制定了报告，旨在协助患者治疗领域的临床决策。通常，高质量研究的缺乏、证据的相互矛盾和/或无法评估干预措施在益处和风险之间的平衡，往往导致现有的证据不足。因此，声明及其建议是根据召集的专家小组对文献的集体共识制定的。  

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，临床建议总结了文献的现状，并报告了专家顾问的共识。它们不像标准或指南那样得到了科学文献同等程度的支持。临床建议应根据知识、技术和实践的发展进行定期修订。  

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.

本文件作为“临床建议第1部分：胸外科患者的术前和术中疼痛管理”，由SCA QSL委员会的阿片类药物研究组总结。  

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.  

临床建议中使用的术语的定义已包含在附录1中的补充数据文本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  

本临床建议旨在为胸外科患者围术期疼痛管理提供参考，这些患者可实现以下目标： 1.术前评估，包括:   a.教育和咨询，以建立患者对术后疼痛的现实期望，并就可用的疼痛管理方案进行教育;   b.风险因素评估，以识别存在胸外科手术后持续疼痛或持续使用阿片类药物风险的患者;   c.基于手术方法进行术后疼痛评估;   2.术中疼痛管理:   a.优化疼痛控制，促进患者的康复并恢复正常活动;   b.利用药物(非阿片类药物和阿片类药物)和非药物(区域镇痛)治疗进行个体化、以患者为中心的多模式镇痛策略;   3、安全使用阿片类药物治疗急性术后疼痛，同时降低过量用药和其他不良事件的风险。

FOCUS  

This practice advisory focuses on the preoperative and intraoperative pain management of opioid naïve 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.

焦点 

该实践咨询侧重于在全身麻醉（GA）下接受胸外科手术的无阿片类药物治疗史成人和青少年（12 岁以上）的术前和术中疼痛管理。解决阿片类药物耐受患者的复杂围手术期疼痛管理超出了本专题文章的范围。

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. 

适用人群  

本临床建议的目的是为麻醉医师、胸外科医师、重症监护医师、疼痛管理医师和其他治疗提供者（医师助理、高级执业护士、围手术期护士和重症监护室 [ICU] 护士）管理胸外科患者的术后疼痛提供参考。  

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.

研究团队成员和顾问

该研究团队是作为SCA QSL委员会阿片类药物研究组的一部分设立的。它包括了心脏手术后增强恢复(ERACS)、胸外科手术后增强恢复(ERATS)、区域镇痛技术、疼痛管理和方法方面的专家。有关工作组成员和顾问、证据模型、证据分级、用于评估文献中当前最佳实践证据的整个过程框架以及为制定咨询意见而采取的步骤的信息包含在附录2的补充数据文本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. 

科学证据 

该小组对与胸外科手术后疼痛的各种干预措施和管理策略相关的文献进行了系统的回顾。在评估了现有证据后，制定了临床建议，以传播知识并改进这一领域的临床患者治疗决策。   在对胸外科围手术期疼痛管理方式进行文献检索后，该小组使用改良德尔菲法制定了建议，以解决围手术期疼痛管理的各个方面，包括术前教育、影响胸腔手术后疼痛的危险因素评估、术后持续使用阿片类药物以及术后急性疼痛的药物治疗和区域麻醉技术。各种疼痛管理干预措施的证据主要来自于接受胸外科手术的患者。当数据有限或提供概括性结论时，例如在术前教育和咨询、加巴喷丁类药物、非甾体抗炎药（NSAIDs）和右美托咪定部分，还纳入了来自非胸外科手术患者的相关性研究。   临床建议的科学证据来自发表在同行评议期刊上的文献。

图1概述了基于类别、水平以及干预是否有益、有害或模棱两可(基于美国麻醉医师协会(ASA)的方法)的证据强度评估矩阵。   用于评估文献中当前最佳实践证据的总体过程框架和制定临床建议所采取的步骤包括附录2中的补充数据文本2。   文献检索方法，证据模型，关键词，以及用于构建临床建议的系统评价和荟萃分析(PRISMA)图的首选报告项目包含在附录3的补充数据文本3中。   附录4的补充数据文本4包括所有参考文献，研究类型，以及ASA分级。

PREOPERATIVE ASSESSMENT

术前评估 

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. 

术前评估、教育和咨询

文献研究结果

一些研究描述了术前疼痛教育和咨询的影响: 1.术后疼痛(A2-B类证据、B2-B类证据、A3-E类证据和B2-E类证据);   2.焦虑(A3-B类证据和B2-B类证据);   3.阿片类药物的使用(B1-B类证据、B2-B类证据和A2-E类证据);   4.功能恢复(B2-E类证据和A3-E类证据);   5.患者满意度(B2-E类证据);   6.早期停止阿片类药物使用(A3-E类证据)。

与对照组相比，发现术前认知教育干预可有效减少术后疼痛和/或焦虑（A2-B类证据）。一项荟萃分析显示，使用社会心理干预后，术后疼痛的减少无统计学意义(A1-E类证据)。 

当患者及其家属参与术后疼痛管理教育课程时，与对照组相比，术后疼痛的严重程度较低（B2-B类证据）。 

与对照组相比，使用交互式多媒体的术前教育课程在提高患者知识方面更有效27 (A3-B类证据)。当出院后继续使用多媒体疼痛管理教育工具时，与对照组相比，术后疼痛减轻，身体活动改善(A2-B类证据)。

图2A总结了围手术期疼痛教育和咨询的影响。

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). 

摘要及建议

评估术前疼痛教育和咨询的文献表明，对术后疼痛和阿片类药物消耗的影响各不相同。专家们对文献的共同评估认为，使用多媒体疼痛教育和咨询可能有助于减轻术后疼痛（推荐等级：A2-B）。术前认知或心理社会教育干预可能有助于减轻术后疼痛（推荐等级：A2-B）。出院后应继续使用多媒体工具进行疼痛管理教育，因为它可以减轻疼痛并促进患者的康复（推荐等级：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). 

用于胸外科术后持续性疼痛和阿片类药物的使用

开胸手术后疼痛综合征（PTPS）的发病率在 33% 至 70% 之间。患者通常出现轻度疼痛，并伴有身体功能下降的风险（A3-E类证据）。电视胸腔镜（VATS）手术与 25%-35% 的 PTPS 发病率相关。大约 30%-50% 接受开胸手术的患者和 18% 接受 VATS 的患者报告患有神经性PTPS;这种类型的疼痛更严重，需要更多的镇痛药，并且与睡眠障碍以及社会和身体功能限制有关（B2-H类证据）。研究发现，患者相关危险因素、手术因素和疼痛特征（图2B）与PTPS的发展之间存在关联（A3-E类证据，B1-H类证据/B1-E类证据和B2-H类证据/B2-E类证据）。

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). 

与持续性术后疼痛发展相关的患者相关危险因素

与PTPS相关的患者相关危险因素包括年龄小、女性、癌症诊断、慢性疼痛史、高血压、糖尿病、术前胸痛或胸痛(3-12个月)，以及催眠药物的使用(A3-E类证据、B1-H类证据/ B1-E类证据、B2-H类证据/ B2-E类证据)。   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). 

与持续性术后疼痛发展相关的手术因素 

与术后持续疼痛相关的手术因素包括大范围的手术、胸部手术、VATS、肋骨切除术、胸膜切除术、手术时间长、胸管引流时间长、引流管数量多、术后放疗、术后化疗(B2-H类证据/ B2-E类证据)。 

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). 

影响急性和/或持续性术后疼痛的手术因素

保护神经束的手术技术可以减轻急性疼痛、术后持续疼痛和镇痛药消耗，并促进早期恢复(A2-B类证据/ A2-E类证据，B2-B类证据/ B2-E类证据)。这些方法包括保留神经的开胸切口、肋骨复位、肋间肌瓣、单独或联合使用无压迫缝合技术以避免肋间神经压迫或受累。然而，一些研究表明，手术技术对术后急性或持续性术后疼痛的发生率没有影响(A2-E类证据)。   与接受开胸手术或电视辅助胸外科手术(VATS)的患者相比，接受机器人辅助胸外科手术(RATS)的患者在急性疼痛、阿片类药物使用和住院时间(LOS)方面报告的结果模棱两可(B1-E类证据和B2-E类证据)。然而，有2项研究表明，与开放手术相比，微创胸外科手术(MITS)与较低的急性术后疼痛和疼痛干扰评分相关(B2-B类证据)。   评价VATS在减少术后急性或持续性疼痛或阿片类药物使用以及促进早期功能恢复和改善生活质量方面作用的文献得出了不同的结果(A3-B类证据，B1-B类证据/ B1-E类证据，B2-B类证据/ B2-E类证据)。   

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). 

术后疼痛特征与持续性术后疼痛的关系  

术后第一周出现中度至重度疼痛或持续疼痛的患者，以及那些报告运动或移除硬膜外导管后疼痛增加的患者更有可能出现持续的术后疼痛(A3-H类证据，B1-H类证据和B2-H类证据)。他们在出院后和手术后首次门诊就诊时也报告了更高的疼痛评分，从第12周开始出现最显著的升高(A3-H类证据和B2-H类证据)。   

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 naïve 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). 

与新的持续性阿片类药物使用相关的危险因素   

据报道，阿片类药物不耐受患者肺切除术后新的持续阿片类药物使用发生率为14%至17% (B1类证据和B2类证据)。   

文献研究

几项研究发现，与胸外科手术后新的持续阿片类药物使用相关的多种患者相关、社会和手术相关因素(B2-H类证据/ B2-E类证据，B1-H类证据/ B1-E类证据)(图3B)。   

患者相关因素包括年龄较小、黑人种族、较高的Charlson合并症评分、关节炎、背痛、其他疼痛疾病、吸烟史、药物和药物滥用(B1-H类证据和B2-H类证据/ B2-E类证据)。   

手术因素包括开胸或开肺切除术、胃肠道并发症、术后LOS、辅助治疗或化疗、处方量大小(>450口服吗啡当量)、术前处方量和围手术期阿片类药物总剂量(B1-H类证据/ B1-E类证据和B2-H类证据/ B2-E类证据)。   

社会因素包括残疾状况、双重福利(医疗保险和医疗补助)、居住在与低教育相关的邮政编码地区(B2-H类证据)。   与不使用阿片类药物的人相比，新的持续阿片类药物使用者的总体生存率更低(B2-H类证据)。   

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). 

总结和建议

接受胸外科手术的患者可以筛查与PTPS相关的危险因素，以制定个性化的疼痛管理策略(推荐等级:B2-B)。采用保留肋间神经的开胸切口、肋骨复位和肋间肌瓣联合或不联合无压迫缝合技术减轻术后急性或持续性疼痛的益处尚不清楚(推荐等级:A2-E)。开胸闭合时的无压迫缝合技术可能有助于减轻急性和/或持续性术后疼痛(推荐等级:B2-B)(表1)。   术前筛查与持续阿片类药物使用相关的危险因素也可能有助于为患者量身定制镇痛，以减少阿片类药物暴露(推荐等级:B2-B)(表1)。  

INTRAOPERATIVE MANAGEMENT  

术中管理  

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). 

加巴喷丁类药物(加巴喷丁和普瑞巴林) 文献研究

评估围手术期加巴喷丁作为镇痛辅助药物的随机对照试验(RCTs)报告，胸外科手术后急性手术疼痛或肩部疼痛无差异(A2-E类证据)。加巴喷丁的使用并不能预防开胸术后持续疼痛(A3-E类证据)。加巴喷丁的使用与嗜睡和头晕等轻微副作用相关(B2类证据)。  

文献确实报道了使用加巴喷丁可以改善先前的术后持续性疼痛(B2-B类证据)。  

评估普瑞巴林在胸外科手术患者围手术期的随机对照试验报告了在VATS和开胸手术中急性术后切口疼痛和持续术后疼痛发生率的模棱两可的发现(A2-E类证据)。据一项观察性研究报道，普瑞巴林并没有减轻VATS后同侧肩痛(B2-E类证据)。   

总结和建议

围手术期使用加巴喷丁和普瑞巴林并不能减轻VATS或开胸手术后的急性疼痛。也没有发现它可以预防胸外科术后持续疼痛。因此，不建议术前给药以减少胸外科术后急性或持续性疼痛(推荐等级:A3-E)。这与Verret等人研究加巴喷丁和普瑞巴林在非心胸外科和心胸外科患者中的应用的meta分析结果一致，该分析报告了加巴喷丁和普瑞巴林在临床上无显著镇痛作用，两种药物均增加了头晕和视力障碍的发生率(A1-E类证据)。术后出现持续开胸后疼痛的患者可考虑加巴喷丁(推荐等级: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). 

对乙酰氨基酚  

文献研究

VATS或开胸行胸外科手术患者围手术期使用对乙酰氨基酚作为镇痛辅助药物的文献报道，当联合局部阻滞时，急性切口和肩部疼痛的减少没有达到统计学意义(A3-B类证据/ A3-E类证据和B2-E类证据)。然而，患者报告说，在胸廓开胸术和胸廓硬膜外镇痛(TEA)后的前16小时内，使用对乙酰氨基酚可以减轻肩部疼痛。另一项随机对照试验描述了与单独使用阿片类药物相比，静脉持续输注对乙酰氨基酚可减轻VATS手术后休息疼痛和咳嗽(A3-B类证据)。   静脉注射对乙酰氨基酚比口服给药具有更一致的药代动力学特征(B2类证据)。为证明静脉给药增加疗效而进行的系统评价显示口服和静脉给药之间没有差异。  

总结和建议

使用预定的围手术期对乙酰氨基酚作为多模式疼痛方案的一部分被发现提供关于急性术后疼痛好坏参半。Mac等人指出，TEA开胸术后定期服用对乙酰氨基酚可减少临床肩部疼痛。VATS后单独静脉输注对乙酰氨基酚的疼痛评分较低。   专家对文献的一致评价表明，胸外科手术患者的定期对乙酰氨基酚可能有利于不能接受局部镇痛的胸外科患者的急性疼痛控制(推荐等级: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).

非甾体抗炎药  

文献研究

评估围手术期使用非甾体抗炎药作为多模式镇痛策略一部分的随机对照试验报告了开胸和VATS手术后切口疼痛和肩部疼痛总体发生率的不同程度减少(A3-B类证据/ A2-E类证据)。  

一项研究发现，使用非甾体抗炎药可显著降低开胸术后中度至重度肩痛的发生率(A3-B类证据)。  

一项荟萃分析还报道，在接受心胸外科手术的患者中，使用非甾体抗炎药可以减轻疼痛并节省阿片类药物(A1-B类证据)。  

总结和建议

围手术期使用非甾体抗炎药作为多模式镇痛策略的一部分并不能持续减少胸外科患者的切口疼痛。然而，中度至重度肩痛的发生率有所下降。专家对文献的一致评价表明，在没有禁忌症的情况下，可以考虑将其用于胸外科急性疼痛患者(推荐等级: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). 

类固醇激素   

文献研究

随机对照试验报告围手术期静脉注射地塞米松不会降低VATS或开胸患者的疼痛评分或硬膜外患者自控镇痛(PCA)的使用(A2-E类证据)。   

总结和建议

静脉注射类固醇作为胸外科术后急性疼痛多模式镇痛策略的一部分，其益处尚不确定(推荐等级: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激动剂   

可乐宁

文献研究在接受开胸手术的患者中，围手术期静脉注射可乐定作为多模式镇痛方案的一部分的患者术后较少使用硬膜外局麻(LA) (B1-B类证据)。然而，可乐定的确切作用不能从研究设计中确定。   总结和建议没有足够的证据支持围手术期静脉注射可乐定作为减轻胸外科术后急性疼痛的镇痛辅助(推荐等级:D)(表2)。   

右美托咪啶

文献研究文献支持静脉注射右美托咪定作为经VATS和开胸胸外科手术患者术中和/或术后的镇痛辅助药物，因为它可以减少疼痛评分和/或阿片类药物的消耗(A2-B类证据)。   总结和建议右美托咪定围手术期可有效控制胸外科术后急性疼痛，可作为围手术期多模式镇痛策略的一部分(推荐等级: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-天冬氨酸受体阻滞剂   

氯胺酮

文献研究评估各种围手术期给药方案(包括术后持续输注氯胺酮)的研究报告了关于急性疼痛评分、阿片类药物消耗和PTPS发生率的模棱两可的结果(A2-E类证据)。与对照组相比，氯胺酮输注组患者的梦更生动(A3-E类证据)。 

总结和建议围手术期静脉注射氯胺酮作为胸外科术后急性疼痛多模式镇痛策略的一部分，其益处尚不确定(推荐等级: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). 

镁 

文献研究调查胸外科手术患者围手术期静脉注射镁作为镇痛辅助药物的研究得出了阿片类药物消耗和/或术后静息疼痛评分的混合结果(A3-E类证据和B2-B类证据)。关于慢性神经性疼痛的发生率(B2-E类证据)，结果也不明确。

总结和建议围手术期静脉补镁作为胸外科术后急性疼痛多模式镇痛策略的一部分，提供了不同的结果。围手术期使用的益处不确定(推荐等级: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). 

局麻药输注  

利多卡因

文献研究评估围手术期静脉输注利多卡因作为VATS手术患者镇痛辅助的文献尚无定论。研究报告术后6小时阿片类药物消耗和疼痛评分没有变化或下降。效果与血浆利多卡因水平直接相关，提示术后继续输注利多卡因可能是有益的(A2-E类证据)。   总结和建议围手术期静脉输注利多卡因作为胸外科术后急性疼痛多模式镇痛策略的一部分，其益处尚不确定(推荐等级: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). 

阿片类药物

文献研究

胸外科手术患者有几种相关的呼吸合并症，使用阿片类药物可导致呼吸抑制(B1类证据)。结合局部阻滞技术使用多模式镇痛可减少阿片类药物需求和相关副作用。在接受VATS和开胸手术的患者中，使用围手术期多模式镇痛和局部阻滞技术增强了恢复途径，减少了术后麻醉剂的使用、心肺并发症和LOS (B2-B类证据)。  

比较阿片类镇痛(OBA)与非阿片类镇痛联合局部阻滞的研究显示，在MITS手术后24至48小时内，阿片类药物的累积消耗有不同的影响(B1-B类证据/ B1-E类证据和B2-B类证据)。据报道，与接受非阿片类镇痛的对照组相比，接受OBA的患者在开胸后48小时内使用更多的硬膜外LA。(B2-B类证据)。  

总结和建议

胸外科手术应考虑围手术期阿片类药物节约、多模式镇痛方案，以减少术后阿片类药物暴露和潜在的心肺并发症(推荐等级:B2-B)(表2)。  

VARIOUS REGIONAL TECHNIQUES

各种区域阻滞技术

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). 

椎管内阻滞  

文献研究

在接受开胸手术的患者中，与GA单独或与胸膜下或切口镇痛联合相比，TEA提供了更好的镇痛效果和肺功能改善(A2-B类证据和B1-E类证据)。在VATS人群中，结果好坏参半。两项研究报告了TEA、全身镇痛和PCA提供的可比疼痛评分，而另一项研究显示TEA联合GA时的术后疼痛评分较低(A3-B类证据/ A3-E类证据和B2-E类证据)。使用TEA不影响VATS手术后持续术后疼痛的发生率(B2-E类证据)。   

在胸外科手术中使用TEA还与心脏和胃肠道并发症的减少以及更好地保护肺功能相关(A2-B类证据和B2-B类证据)。2项荟萃分析报告了类似的结果(A1-B类证据/ A1-E类证据)。   

预防性的术前TEA可能比术后单独使用具有更好的镇痛效果(A2-B类证据/ A3-E类证据)。在LA溶液中加入舒芬太尼、右美托咪定、地塞米松和镁等辅助药物以及硬膜外输注S+-氯胺酮可改善疼痛并减少镇痛需求(A2-B类证据/ A2-E类证据)。   

胸外科人群中与TEA相关的并发症为硬膜外血肿(0.34例/ 1000)和硬膜外脓肿(0.68例/ 1000)(B2类证据)。与对照组相比，TEA组恶心和呕吐的发生率更高(A3类证据)。一项荟萃分析报告低血压、尿潴留和瘙痒是最常见的副作用和7%的阻滞失败(A1类证据)。   

关于胸外科脊柱镇痛的数据很少，一项研究表明鞘内镁可减少阿片类药物的消耗，另一项研究报告与传统TEA相比，鞘内吗啡和环氧化酶抑制剂联合可改善疼痛评分(A2-B类证据)。   

总结和建议

与GA相比，围手术期TEA为胸外科患者提供了更好的疼痛控制和额外的益处；因此，应将其用于开胸患者的急性疼痛，以减少围手术期阿片类药物的使用(推荐等级:A2-B证据)。在VATS手术中，由于TEA和PCA提供了相同的镇痛效果，两种阻滞都可以用于VATS术后的急性疼痛管理(推荐等级:A3-B)。在LA输注中加入某些佐剂可增强镇痛作用(推荐等级:A2-B)。由于胸外科手术中使用脊髓镇痛的相关数据有限，目前暂无推荐(推荐等级: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). 

椎旁阻滞   

文献研究

在接受开胸手术的患者中，与全身镇痛相比，围手术期使用椎旁阻滞(PVB)可改善术后疼痛评分(A3-B类证据/ A2-E类证据)。  

比较开胸手术中PVB相关镇痛与TEA的研究显示，与术后疼痛控制相关的结果好坏参半(A2-B类证据/ A2-E类证据、B1-E类证据和B2-E类证据)。与TEA相比，PVB的使用具有更好的血流动力学稳定性和更少的副作用(A3-E类证据)。几项荟萃分析也得出结论，PVB的镇痛效果与TEA相当，但在尿潴留和低血压方面的副作用更有利(A1-E类证据)。  

在接受VATS的患者中，与无阻滞、伤口浸润或常规PCA的对照组相比，使用单部位或多部位胸椎PVB提供了更好或同等的镇痛效果(A2-B类证据/ A2-E类证据和B2-B类证据)。  

同样，与TEA相比，胸腔镜手术中使用PVB可获得更好的等效镇痛，且副作用更少(A3-B类证据/ A2-E类证据)。一项荟萃分析还报道，与对照组相比，PVB在胸腔镜手术患者中提供了质量更好的镇痛，副作用更少(A1-B类证据)。PVB也促进了VATS手术的自主通气(A3类证据和B1类证据)。  

在控制开胸患者急性疼痛方面，PVB优于预防性氯胺酮或经皮神经电刺激(TENS)装置(A2-B类证据)。  

同样，与肋间神经阻滞相比，接受VATS手术的患者报告PVB改善或非劣性疼痛控制(A3-B类证据/ A2-E类证据，B1-E类证据和B2-B类证据)。   在接受胸外科手术的老年人群中，与单独使用GA相比，使用PVB对术后认知功能和谵妄的发现模棱两可(A2-E类证据)。   一项系统评价发现，高剂量的LA(890-990毫克/ 24小时vs 325-472.5毫克/ 24小时)以及持续输注PVB可改善手术后48小时的疼痛评分(A1-B类证据)。左旋布比卡因和布比卡因脂质体可能比相同浓度的布比卡因具有更好的疼痛控制效果(A3-B类证据和B2-B类证据)。在LA输注中加入镁、右美托咪啶或可乐定可增强PVB的镇痛作用(A2-B类证据和A3-E类证据)。   虽然罕见，但放置在高位胸区的PVB可能导致同侧臂丛神经阻滞，导致膈肌麻痹、Horner综合征、暂时性四肢瘫痪或完全神经阻滞以及LA毒性(B3类证据)。如果在PVB输注中使用可乐定，患者可增加镇静作用和明显的低血压(A3-H类证据)。  

总结和建议

由于围手术期使用PVB可提供与TEA相当的镇痛效果，且副作用发生率较低，因此可考虑用于胸外科手术患者的急性疼痛管理，特别是有TEA禁忌症的患者(推荐等级:A2-E)。在LA输注中加入某些添加剂可以增强PVB的镇痛作用(推荐等级: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.

筋膜平面阻滞

筋膜平面阻滞(FPBs)根据解剖位置分为后胸壁、侧胸壁和前胸壁阻滞。这些阻滞已作为胸外科手术后疼痛控制的多模式镇痛方案的一部分。

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). 

竖脊肌平面阻滞

文献研究接受VATS或开胸手术的患者接受单次竖脊肌平面阻滞(ESPB)后，6 - 48小时内疼痛控制和/或累积镇痛需求降低，恢复增强(A2-B类证据)。ESPB也促进了VATS手术的自主通气(B3类证据)。

在用于ESPB的LA混合物中单独加入纳布啡或右美托咪定或与地塞米松联合可增强镇痛并延长阻滞持续时间(A2-B类证据/ A3-E类证据)。  

对于开胸患者，ESPB相关镇痛优于肋间神经阻滞(ICNBs)，不逊于PVB (A3-B类证据/ A3-E类证据)。与PVB相比，ESPB的不良反应、血肿和失败率更低(A3类证据)。ESPB联合前锯肌平面阻滞(SAPB)对开胸手术的镇痛效果与硬膜外阻滞相当(A3-E类证据)。   对于VATS手术患者，ESPB相关镇痛在术后疼痛和24- 48小时阿片类药物需求方面优于前锯肌平面阻滞(SAPB)，优于或不劣于肋间阻滞，不劣于或劣于PVB (A2-B类证据/ A3-E类证据和B1-B类证据)。 

然而，有ESPB和SAPB的MITS手术后的恢复质量是相同的(A3-E类证据)。  

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). 

前锯肌平面阻滞

文献研究与无阻滞、全身镇痛或PCA的对照组相比，接受VATS或开胸手术的患者单次或连续SAPB在降低疼痛评分和/或12至24小时阿片类药物消耗以及改善整体恢复方面更有效(A2-B类证据和B2-B类证据)。meta分析也报道了胸外科患者SAPB治疗后24小时疼痛控制的优势(A1-B类证据)。 

在连续SAPB混合物中加入右美托咪定或地塞米松可增强胸外科手术后的镇痛作用(A2-B类证据)。与PCA组相比，肺癌开胸术后持续SAP阻滞一周报告的切口后疼痛综合征发生率不明确(A3-E类证据)。  

对于接受MITS的患者，SAPB优于局部浸润，不逊于ICNB和PVB，在疼痛评分、阿片类药物消耗或改善恢复方面也逊于ESPB (A2-B类证据/ A2-E类证据和B2-B类证据)。在接受开胸手术的患者中，单次SAPB相关镇痛与PVB相当，低于TEA (A2-B类证据)。  

总结和建议虽然需要对各种FPBs的精确阻滞、镇痛可靠性和其他特性进行更多的研究，但某些阻滞可能提供更好的疼痛控制和胸外科手术后更低的阿片类药物消耗;因此，它们可以作为多模式阿片类镇痛方案的围手术期镇痛辅助药物(推荐等级: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). 

局部浸润阻滞  

切口镇痛

文献研究对于接受VATS或开胸手术的患者，与切口镇痛相比，SAPB、ESPB、PVB和TEA等局部阻滞与8至48小时疼痛评分较低和/或阿片类药物消耗减少相关(A2-B类证据/ A3-E类证据和B2-E类证据)。   总结和建议与其他区域阻滞相比，连续伤口浸润阻滞控制胸外科患者术后疼痛的效果较差；因此，目前不推荐(推荐等级: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). 

肋间神经阻滞

文献研究与之前讨论的其他局部和椎管阻滞相比，ICNB提供的镇痛效果较差。然而，对于接受开胸手术的患者，有证据表明ICNB联合PCA可能提供与TEA相当的镇痛效果(A2-E类证据)。  

与无阻滞或全身性镇痛相比，ICNB可在4 - 48小时内降低开胸和VATS患者的疼痛评分和/或镇痛用量，这表明对有椎管阻滞禁忌症的患者有利(A2-B类证据/ A3-E类证据和B2-B类证据/ B2-E类证据)。一项荟萃分析也报告了胸外科手术后24小时使用ICNB可减轻疼痛(A1-E类证据)。

在PVB或硬膜外镇痛中加入ICNB可能有减轻术后急性疼痛的作用，但目前可获得的证据是好坏参半(A3-B类证据/ A3-E类证据和B1-E类证据)。 

布比卡因脂质体(LB)已在说明书外用于RATS、VATS和/或开胸手术后的ICNB术后镇痛。 

研究报告胸外科手术患者肋间LB与普通布比卡因相比，疼痛评分或阿片类药物使用6至36小时无差异或减少(A3-E类证据，B1-B类证据，B2-E类证据/ B2-B类证据)。   当使用布比卡因脂质体进行麻醉时(B1-B类证据和B2-B类证据)，胸部手术后的LOS和肺部并发症发生率也有所下降。

与对照组相比，单独肋间阻滞镇痛或联合PCA或硬膜外镇痛可降低开胸患者术后疼痛评分和/或阿片类药物消耗(A2-B类证据/ A2-E类证据)。然而，在有或没有TEA的情况下使用阻滞镇痛会增加开胸术后严重疼痛或神经性疼痛的发生率(A2-E类证据)。 

总结和建议与全身镇痛相比，ICNB可降低胸外科手术患者的疼痛评分。因此，它可以作为这些患者多模式疼痛治疗方案的一部分，特别是那些有椎管阻滞禁忌症的患者(推荐等级:A2-B)。阿片类物质节约效应在普通LAs中未被LB复制；因此，现在不能推荐(推荐等级:C)。 

尽管肋间阻滞镇痛可以减轻开胸术后的疼痛和镇痛需求，但由于其与持续开胸后疼痛发生率增加相关，不推荐常规使用(推荐等级:C)(表3)。  

CONCLUSIONS 

结论

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. 

胸外科手术后疼痛管理不当可能导致持续的术后疼痛、残疾和生活质量下降。针对患者和手术过程定制的镇痛方法可能有助于有效的术后疼痛控制，并可能促进恢复。图3详细介绍了可用于择期或紧急胸外科手术患者的围手术期疼痛管理方法。

本建议基于现有文献和专家共识，为胸外科患者围手术期疼痛管理提供参考。然而，一些领域仍需要进一步研究。这些包括: 

1. 各种区域阻滞在促进功能恢复中的作用；

2. FPBs的最佳窗口和技术，各种LA辅助剂的使用，以及LA的时间、体积和剂量；

3. 影响LA在FPBs中扩散和吸收的因素； 

4. FPBs相关并发症；

5. 非阿片类镇痛药在预防术后持续疼痛和阿片类药物使用中的作用；

6. 非阿片类镇痛药的不良反应；  

7. 阿片类药物镇痛与单独非阿片类药物镇痛在改善术后疼痛中的比较；  

8. 考虑到持续性疼痛和阿片类药物使用的风险因素的个体化疼痛管理方法在影响结果中的作用；  

9. 围手术期多媒体教育及出院后辅助在术后疼痛控制及功能恢复中的作用；  

10. 临床结果侧重于恢复质量和生活质量的监测，而不是疼痛评分和阿片类药物的消耗。  

总之，寻求使用阿片类药物的多模式镇痛技术和FPBs进行围手术期疼痛管理仍然需要更多精心设计的试验，采用严格的方法来描述可能的益处和相关的不良反应。该领域的持续研究和进展可以继续为患者量身定制的镇痛提供未来指导，以改善临床相关结果，从而提高胸外科手术后的恢复和生活质量。

免责声明：

文中所涉及药物使用、疾病诊疗等内容仅供医学专业人士参考。

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编辑：Michel.米萱

校对：MiLu.米鹭