连续外周股神经阻滞用于老年肥胖患者全膝关节置换术后镇痛与功能康复的评价

Effects of continous feromal nerve block on postoperative rehabilitation pain after total knee arthroplasty in obese elderly patients

目的评价连续股神经阻滞用于老年肥胖患者全膝关节置换术(TKA)后镇痛与功能康复的效果,并与患者自控硬膜外镇痛(PCEA)进行对比。方法选择ASAⅠ～Ⅲ级行单侧全膝关节置换术的老年肥胖患者60例(BMI>30kg/m2),随机分为两组:股神经阻滞组(FA组,n=30)和患者自控硬膜外镇痛组(EA组,n=30),所有患者均接受蛛网膜下腔阻滞麻醉+硬膜外麻醉(简称腰硬联合麻醉)。FA组患者在实施腰硬联合麻醉前,在神经刺激器引导下放置股神经阻滞导管,并妥善固定,术后将股神经阻滞导管与术后镇痛泵连接,连续输注0.18%罗哌卡因(术毕单次15mL,背景量5mL/h,锁定时间30min,自控量5mL)行术后镇痛与功能康复,EA组患者术后给予硬膜外0.18%罗哌卡因复合吗啡自控镇痛(背景量5mL/h,锁定时间30min,自控量2mL),两组患者均维持术后镇痛72h。记录术后2、6、24、48及72h静息、主动功能训练时的VAS评分、镇静程度、肌力分级和不良反应发生率。结果两组患者术后2、6、24、48及72h静息、主动功能训练时的VAS评分、镇静满意度比较差异无统计学意义;FA组患者术后24h和48h肌力评分明显高于EA组(P<0.05);与EA组相比,FA组患者不良反应发生率明显减少(10%vs66.7%,P<0.01)。结论连续股神经阻滞术后镇痛效果良好,对下肢肌力影响轻微,不良反应发生率低,是老年肥胖患者TKA术后较为理想的镇痛与功能康复方法。

[Objective] To evaluate the effects of continuous femoral nerve block on postoperative pain and functional rehabilitation compared with Patient Controlled Epidural Analgesia （PCEA） after total knee arthroplasty （TKA） surgery in elderly obese patients. [Methods] The sixty elderly obese patients （ASA Ⅰ-Ⅲ, BMI〉30 kg/m^2） undergoing unilateral TKA surgery were randomly divided into two groups： Group FA and Group EA. All of them received combined spinal-epidural anesthesia （CSEA）. In Group FA before initiating CSEA, the femoral nerve block catheters were inserted by netve stimulator guidance and fixed appropriately, and then the catheter were cotmected with analgesia pumps postoperatively for pain relief and functional rehabilitation via continuously infusing 0.18% Ropivaeaine （bolus .njection 15 mL, background infusion 5 mUh, locking time 30min, PCA 5 mL）. The PCEA with 0.18% Ropivaeaine mixed with morphine （background infusion 5 mL/h, locking time 30 rain, PCA 2 mE） was performed in Group EA. All the patients were given postoperative analgesia for 72 h. The VAS pain scores during rest and initiative exercise, Ramessay sedation scores, muscle strength grades and adverse reactions were recorded at postoperative 2 h, 6 h, 24 h, 48 h and72 h respectively. [Results] There were no difference in the VAS scores during rest and initiative exercise at any time points and the satisfactory of sedation degree between two groups. The muscle strength grades at postoperative 24 h and 48 h in Group FA were significantly higher than that in Group EA （P〈0.05）. Compared with Group EA, a significantly lower ineidence of adverse reactions in Group FA was observed （10% Vs 66.7%, P〈0.01）. [Conclusion] As far as the continuous femoral nerve block is concerned, it ean provide not only better pain relief, but slight impact on muscle strength of lower extremity and fewer side effeets. Therefore, the eontinuous peripheral femoral nerve block is an ideal method for postoperative analgesia and functional rehabilitation for elderly obese patients after TKA surgery.