无痛病房模式在早期人工膝关节置换术后的效果评价

Effect of a Model of Nurses' Pain Management Practice after Total Knee Arthroplasty

【目的】运用随机对照的前瞻性方法观察无痛病房管理对全膝关节置换术后膝关节早期功能康复的影响。【方法】2009年2月至2010年9月共100例单侧人工全膝关节置换患者随机分为研究组和对照组各50例。研究组患者采用无痛病房管理模式的镇痛方案:术前48 h及术后第2天给予塞来昔布200 mg(2次/d,术后6 h 400 mg口服)、氨酚曲马多1片(3次/d)口服,连续使用14 d;术中安装膝关节假体组件后、缝合前在膝关节周围注射混合镇痛药物(10 g/L罗哌卡因20mL,吗啡5 mg,生理盐水60 mL);对照组患者术后6 h视疼痛情况予哌替啶注射,第2天给予塞来昔布200 mg(2次/d,术后6 h 400 mg口服)、氨酚曲马多1片(3次/d)口服,连续使用14 d。分别记录术前、术后6、12、24、48 h静止和活动时视觉模拟疼痛评分(VAS),分别录记术前、末次随访膝关节KSS评分及EuroQol(EQ-5D)生活健康质量调查表。随访时间1.5～2年。【结果】88例(实验组46例,对照组42例)患者最后获得随访进入统计学分析:①两组手术前静止、运动VAS结果比较无统计学差异(P>0.05);术后6、12、24、48 h静止、运动VAS结果比较有统计学差异(P<0.01);术后72 h静止、运动VAS结果比较无统计学差异(P>0.05);②术前KSS膝评分研究组、对照组平均(36±6)、(34±6)分(P>0.05),术后分别增加至(89±11)、(89±10)分(P>0.05);两组术前、后的结果比较无统计学差异。KSS膝功能评分术前研究组、对照组(34±7)分、(35±6)分(P>0.05),术后增加至(80±9)、(78±9)分(P>0.05)。③EQ-5D评分:术后末次随访研究组、对照组分别为(0.79±0.16)分、(0.77±0.21)分(P>0.05);④并发症:两组术后没有发现伤口感染、延期愈合及关节强直等并发症。【结论】无痛病房管理对全膝关节置换术后早期功能康复有帮助,但远期效果无明显改变。

【Objective】To evaluate the effect of a model of nurses＇ pain management practice after total knee arthroplasty（TKA）.【Methods】 Two cohorts of 100 TKA patients were selected from Department of Joint Surgery,the First Affiliated Hospital of Sun Yat-Sen University before and after the initiation of the protocol from February 2009 to September 2009.They were divided into study group（n = 50） and control group（n = 50）.Fifty patients of the study group received a model of nurses＇ pain management practice： All patients pro-operation 48 hours and post-operation 24 hours the next day for celecoxib（Celebrex） 200 mg bid（after 6 hours 400 mg orally）,paracetamol and tramadol a tid oral,continuous use of 14 days,and received intraoperative periarticular injection of multimodal drugs（consisting of 10 g/L ropivacaine 20 mL,morphine 5 mg,normal saline 60 mL）,drug injection around the joint not used in patients of the control group.Pethidine used in patients with pain after the first 6 h,the same dose given as the case once again.Activities and visual analogue pain score were recorded before and after surgery.Clinical follow-up included EuroQol（EQ-5D） scores,preoperative and postoperative KSS knee score.【Results】 A total of 88 patients involved in the result analysis.（1） Visual analogue pain score： The patients of the study group had significantly lower rest pain scores and activity pain scores at 6,12,24,and 48 h after operation than the control group.There were no significant differences at 72 h after operation;（P 0.01）;（2） Average KSS scores were 36 ± 6,34 ± 6 points preoperatively and 89 ± 11,89 ± 10 points at final follow-up（P 0.05）;（3） Average EQ-5D scores was 0.79 ± 0.16 points in study group and 0.77 ± 0.21 points in study group in control group at final follow-up.There were no significant differences between both;（3） There were no significant differences in complications such as wound healing,incidence rate of infection,stiffness and so on.【Conclusions】 A model of nurses＇ pain management practice was shown to safely provide excellent pain control and functional recovery after surgery early.