胸段硬膜外镇痛对下尿路功能的影响：罗哌卡因与布比卡因的比较
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Effect of Thoracic Epidural Ropivacaine versus Bupivacaine on Lower Urinary Tract Function
背景与目的：布比卡因胸段硬膜外镇痛可导致临床相关的由于逼尿肌松弛而引起的尿液残留。本研究通过评估尿液残留量和最大流量速率，从而比较使用罗哌卡因与布比卡因对膀胱功能障碍的影响程度。我们的假设为罗哌卡因会导致较低水平的尿液残留，由于已证明罗哌卡因对运动神经阻滞的作用较小。
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方法：本研究为单中心、随机、双盲、平行对照试验，42例接受开放性肾脏手术的患者随机分配至两个组：布比卡因（0.125％）组和罗哌卡因（0.2％）组，最终完成所有试验的共36例。试验对象纳入标准是膀胱功能正常的患者。分别于术前和胸段硬膜外镇痛期间行尿液动力学检查。主要指标是术后尿液残余量和胸段硬膜外镇痛效果的差异。次要指标为尿液最大流速的变化。
结果：布比卡因组术后尿液残余量中位数为300ml（30～510ml; P <0.001），罗哌卡因组为125 ml（-30～350 ml; P = 0.011）；布比卡因组的尿液最大流速中位数变化显著（-28～3ml/s; P <0.001），罗哌卡因组为（-16～7 ml/s; P = 0.025），组间差异显著（95％CI：0～12; P = 0.028）；两组间疼痛评分相似，镇痛期间无不良事件发生。
结论：与布比卡因相比，罗哌卡因胸段硬膜外镇痛后尿液残留量较少，反映罗哌卡因对逼尿肌功能的影响相对较小。
Girsberger S A, Schneider M P, Löffel L M, et al. Effect of Thoracic Epidural Ropivacaine versus Bupivacaine on Lower Urinary Tract Function: A Randomized Clinical Trial[J]. Anesthesiology, 2017
Background:Thoracic epidural analgesia with bupivacaine resulted in clinically relevant postvoid residuals due to detrusor underactivity. This study aimed to compare the risk of bladder dysfunction with ropivacaine versus bupivacaine using postvoid residuals and maximum flow rates. Our hypothesis was that ropivacaine would result in lower postvoid residuals, because ropivacaine has been shown to have less effect on motor blockade.
Methods: In this single-center, parallel-group, randomized, double-blind superiority trial, 42 patients undergoing open renal surgery were equally allocated to receive epidural bupivacaine 0.125% or ropivacaine 0.2%, and 36 were finally included. Inclusion criterion was normal bladder function. Patients underwent urodynamic investigations preoperatively and during thoracic epidural analgesia. Primary outcome was the difference in postvoid residual preoperatively and during thoracic epidural analgesia postoperatively. Secondary outcomes were changes in maximum flow rate between and within the groups.
Results:Median difference in postvoid residual (ml) from baseline to postoperatively was 300 (range, 30 to 510; P < 0.001) for bupivacaine and 125 (range, −30 to 350; P = 0.011) for ropivacaine, with a significant mean difference between groups (−175; 95% confidence interval −295 to −40; P = 0.012). Median difference in maximum flow rate (ml/s) was more pronounced with bupivacaine (−12; range, −28 to 3; P < 0.001) than with ropivacaine (−4; range, −16 to 7; P = 0.025) with a significant mean difference between groups (7; 95% confidence interval 0 to 12; P = 0.028). Pain scores were similar. No adverse events occurred.
Conclusion:Postvoid residuals were significantly lower using ropivacaine compared to bupivacaine for thoracic epidural analgesia reflecting less impairment of detrusor function with ropivacaine.
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