玻璃体视网膜手术(VRS)是眼科手术中执行最广泛的精确手术之一;大多数病例仅在区域麻醉(RA)下进行。然而,在特定情况下(例如当患者由于各种原因未能与操作员合作时),全身麻醉(GA),单独或与GA(联合全身区域麻醉,CGR),是执行VRS的唯一安全方法。虽然在手术过程中监测术中抢救阿片类药物镇痛(IROA)的疗效(评估麻醉(AoA)的充分性)可能具有挑战性,手术面积指数(SPI)是检测对伤害性刺激反应的有用工具,可在手术过程中合理滴定阿片类镇痛药(AO).当前的研究调查了基于SPI的芬太尼(FNT)滴定与各种先发制人镇痛(PA)技术相结合对在AoA下进行的VRS各个阶段的术中疼痛感知的影响。总共176名在GA下接受VRS的患者被纳入研究。他们被随机分配到以下五个研究组之一:GA组(对照组)-仅接受全身麻醉的患者;PBB-GA组和球周阻滞术前阻滞(含0.5%布比卡因和2%利多卡因);T-GA组预防性,外用2%丙美卡因;M-GA组,术前静脉输注1.0g的安乃近;P-GA组,术前静脉输注1.0g的对乙酰氨基酚。整个过程分为四个阶段:1期和2期-术前评估,PA管理,并诱导GA;3期-术中观察;4期-术后观察。在所有阶段监测SPI值。观察到在手术区域的各种操作期间发生伤害性感受(表示为ΔSPI>15),以及累积剂量的抢救镇痛,取决于PA管理。在VRS的过程中,抢救FNT剂量因手术阶段和研究组而异.大多数患者,不管他们的小组分配如何,在套管针插入期间需要补充镇痛,GA组患者需要最高剂量。同样,GA组内光凝时IROA的累积剂量最高.预防性多溴联苯和局部麻醉被证明最有效地削弱了对窥器安装的反应,虽然局部麻醉和扑热息痛输注被证明是比其他类型使用PA更有效的镇痛药。在进行的研究中,在整个手术过程中提供有效的镇痛方面,所使用的PA技术均不优于SPI下采用FNT给药的GA;对照组和研究组均有必要给予抢救性OA剂量.
Vitreoretinal surgery (VRS) is one of the most widely performed precise procedures in ophthalmic surgery; the majority of cases are carried out under regional anaesthesia (RA) only. However, in specific situations (such as when the patient fails to cooperate with the operator for various reasons), general anaesthesia (GA), alone or in combination with GA (combined general-regional anaesthesia, CGR), is the only safe way to perform VRS. While monitoring the efficacy of an intraoperative rescue opioid analgesia (IROA) during surgery (assessing the adequacy of anaesthesia (AoA)) may be challenging, the surgical pleth index (SPI) is a useful tool for detecting the reaction to noxious stimuli and allows for the rational titration of opioid analgesics (AO) during surgery. The current study investigated the influence of the SPI-based titration of fentanyl (FNT) in combination with various pre-emptive analgesia (PA) techniques on intraoperative pain perception during various stages of VRS performed under AoA. A total of 176 patients undergoing VRS under GA were enrolled in the study. They were randomly assigned to one of the five following study arms: Group GA (control group)-patients who received general anaesthesia alone; Group PBB-GA with preprocedural peribulbar block (with 0.5% bupivacaine and 2% lidocaine); Group T-GA with preventive, topical 2% proparacaine; Group M-GA with a preprocedural intravenous infusion of 1.0 g of metamizole; and Group P-GA with a preprocedural intravenous infusion of 1.0 g of paracetamol. The whole procedure was divided in four stages: Stage 1 and 2-preoperative assessment, PA administration, and the induction of GA; Stage 3-intraoperative observation; Stage 4-postoperative observation. the SPI values were monitored during all stages. The occurrence of nociception (expressed as ∆SPI >15) during various manipulations in the surgical field was observed, as were cumulative doses of rescue analgesia, depending on the PA administered. During the course of VRS, rescue FNT doses varied depending on the stage of surgery and the group investigated. The majority of patients, regardless of their group allocation, needed complementary analgesia during trocar insertion, with Group GA patients requiring the highest doses. Likewise, the highest cumulative doses of IROA were noted during endophotocoagulation in Group GA. Preventive PBB and topical anaesthesia were proven to be most efficient in blunting the response to speculum installation, while topical anaesthesia and paracetamol infusion were shown to be more efficient analgesics during endophotocoagulation than other types used PA. In the performed study, none of the PA techniques used were superior to GA with FNT dosing under the SPI with respect to providing efficient analgesia throughout the whole surgery; there was a necessity to administer a rescue OA dose in both the control and investigated groups.