摘要
目的:通过比较冠状动脉多支病变的微创和常规旁路移植的术后疼痛,分析每组术后疼痛特点及影响术后疼痛的危险因素。方法:连续纳入2022年7月至2023年7月在北京安贞医院因多支冠状动脉病变择期接受非体外循环不停跳冠状动脉旁路移植术(OPCABG)的患者545例,其中常规旁路移植组397例(男289例、女108例,年龄35~77岁),微创旁路移植组148例(男121例、女27例,年龄37~84岁),倾向性评分匹配后两组各148例。使用数字等级评分(NRS)评估患者术后前5天(急性术后疼痛,APP)及术后3个月、6个月、12个月(慢性术后疼痛,CPSP)情况,并应用logistic回归分析两组患者术后3个月CPSP的危险因素。结果:常规组和微创组患者均在术后48 h内记录到静息时(NRS 4.0对6.0)和运动时(NRS 5.2对7.5)的最大NRS疼痛强度。两组患者静息时疼痛强度从术后第3天开始差异无统计学意义,运动时疼痛强度从术后第4天开始差异无统计学意义。常规组中60.2%的患者和微创组中92.6%的患者存在中-重度静息时疼痛(NRS≥4),常规组中83.5%的患者以及微创组中98.0%的患者出现中-重度运动时疼痛(NRS≥4)。围术期在拔除引流管后静息时疼痛强度微创组(拔管前NRS 6.0对拔管后NRS 2.7)较常规组(拔管前NRS 4.0对拔管后NRS 2.3)下降更为显著,运动时疼痛下降程度微创组(拔管前NRS 7.5对拔管后NRS 4.2)和常规组(拔管前NRS 6.0对拔管后NRS 2.7)差异无统计学意义。术后3个月时,常规组和微创组CPSP发生率分别为35.9%和35.1%。术后6个月时,两组患者CPSP发生率分别为(常规组8.7%对微创组6.8%),较3个月时发生显著下降(P<0.001)。在常规组中Europe SCOREⅡ评分高是术后3个月CPSP的独立危险因素;在微创组中BMI越大、术后需使用氟比洛芬酯补救性镇痛是术后3个月CPSP的独立危险因素。结论:微创组旁路移植手术患者术后早期的急性疼痛强度和发生率均高于常规组,拔除引流管后,两组患者静息时疼痛强度差异无统计学意义,运动时疼痛强度微创旁路移植仍然强于常规旁路移植。两组患者慢性疼痛发生率差异无统计学意义,均从术后3个月开始发生显著下降。术前Europe SCOREⅡ评分高的常规旁路移植患者、术前高BMI指数及术后急性疼痛剧烈的微创旁路移植患者往往术后慢性疼痛更显著。
Objective This study aimed to compare postoperative pain between minimally invasive coronary artery bypass grafting(MICS-CABG)and conventional CABG for multivessel coronary artery disease,comparing baseline characteristics and perioperative data between the two groups,and analyzing risk factors influencing postoperative pain.Methods A total of 545 patients undergoing elective off-pump coronary artery bypass grafting(OPCABG)for multivessel coronary artery disease at Bei-jing Anzhen Hospital from July 2022 to July 2023 were included.There were 397 patients in the conventional CABG group(289 males,108 females,aged 35-77 years)and 148 patients in the minimally invasive CABG group(121 males,27 fe-males,aged 37-84 years),with 148 patients in each group after propensity score matching.Pain levels were assessed using the Numeric Rating Scale(NRS)at the first 5 days postoperatively(acute postoperative pain,APP)and at 3,6,and 12 months postoperatively(chronic post-surgical pain,CPSP).Logistic regression was used to analyze risk factors for CPSP at 3 months postoperatively in both groups.ResultsWithin 48 hours postoperatively,both groups reported maximum NRS pain intensities at rest(NRS4.0 vs.6.0)and during activity(NRS 5.2 vs.7.5).From the third day after surgery,there were no significant diferences in resting pain intensity between the two groups,and from the fourth day afer surgery,there were no significant differences in pain intensity during movement.With 60.2%in the conventional group and 92.6%in the minimally invasive group experiencing moderate to severe pain at rest(NRS≥4),and 83.5%in the conventional group and 98.0%in the mini-mally invasive group experiencing moderate to severe pain during activity(NRS≥4).Immediately after drain removal,there was a significant reduction in pain intensity at rest in the minimally invasive group(pre-drain removal NRS 6.O vs.post-drain removal NRS 2.7),compared to the conventional group(pre-drain removal NRS 4.0 vs.post-drain removal NRS 2.3).How-ever,there was no significant difference in the reduction of pain intensity during activity between the minimally invasive group(pre-drain removal NRS 7.5 vs.post-drain removal NRS 4.2)and the conventional group(pre-drain removal NRS 6.0 vs.post-drain removal NRS 2.7).At 3 months postoperatively,the incidence of CPSP was 35.9%in the conventional group and 35.1%in the minimally invasive group.At 6 months postoperatively,the incidence of CPSP was significantly lower compared to 3 months in both groups(conventional group 8.7%vs.minimally invasive group 6.8%,P<0.001).In the conventional group,higher Europe SCORE II was identified as an independent risk factor for CPSP at 3 months postoperatively,while in the minimally invasive group,higher BMI and postoperative use of flurbiprofen for rescue analgesia were identified as independent risk factors.Conclusion In patients undergoing minimally invasive coronary artery bypass grafting(CABG),the early post-operative acute pain intensity and incidence were higher than those in the conventional CABG group.After drain removal,there were no significant differences in resting pain intensity between the two groups,but pain intensity during movement remained higher in the minimally invasive group compared to the conventional group.The incidence of chronic pain did not differ between the two groups but decreased significantly from 3 months postoperatively.Conventional CABG patients with high preoperative Europe SCORE I scores,high preoperative BMI and severe postoperative acute pain tend to have more chronic pain after mini-mally invasivebypass surgery.
作者
张宇霄
迟立群
马小龙
柳佳吉
梁林
Zhang Yuxiao;Chi Liqun;Ma Xiaolong;Liu Jiaji;Liang Lin(Department of Cardiac Surgery,Beijing Anzhen Hospital,Capital Medical University,Beijing 100029,China)
出处
《中华胸心血管外科杂志》
2025年第2期72-81,共10页
Chinese Journal of Thoracic and Cardiovascular Surgery
关键词
冠状动脉旁路移植术
微创手术
术后疼痛
危险因素
Coronary artery bypass grafting
Minimally invasive surgery
Postoperative pain
Risk Factors
