连续股神经阻滞联合浸润麻醉用于全膝关节置换术患者术后镇痛的效果

Effects of continuous femoral nerve block combined with infiltration anesthesia on postoperative an-algesia in patients undergoing total knee arthroplasty

目的：评价连续股神经阻滞联合浸润麻醉用于全膝关节置换术患者术后镇痛的效果。方法择期拟行单侧全膝关节置换术患者90例，ASA分级Ⅰ-Ⅲ级，年龄50～80岁，体重45～90 kg。采用随机数字表法，将患者分为3组（ n＝30）：连续股神经阻滞＋浸润麻醉组（ A组）、连续股神经阻滞组（B组）、连续股神经阻滞＋单次坐骨神经阻滞组（C组）。3组麻醉诱导前均放置股神经阻滞导管，之后C组行单次坐骨神经阻滞。 A组上假体之前，在关节囊后部注射混合药物20 ml，上完假体缝合之前，左右侧副韧带及切口处注射混合药物20 ml。混合药物为罗哌卡因2．5 mg∕ml、芬太尼2．5μg∕ml、甲泼尼龙琥珀酸钠1 mg∕ml。 B组依照上述方法注射生理盐水40 ml。术后行PCA，镇痛药物为0．2％罗哌卡因250 ml，背景输注速率5 ml∕h，PCA剂量5 ml，锁定时间30 min，持续镇痛48 h。采用口服曲马多进行补救镇痛，维持VAS评分≤5分。于术后4、8、12、24、48 h时记录静态VAS评分，于术后8、12、24、48 h时记录动态VAS评分。记录术后48 h内曲马多用量。于术后12、24、48 h时评价患肢运动功能，拔除股神经阻滞导管后72 h时评价患肢感觉和运动功能。记录置管处渗血∕液情况和不良反应的发生情况。结果与B组或C组比较，A组术后4～24 h时静态VAS评分、术后8～24 h动态VAS评分降低，曲马多用量降低（P＜0．05）；与B组比较，A组术后各时点患肢运动阻滞评分差异无统计学意义（ P＞0．05）；与C组比较，A组和B组术后12 h时患肢运动阻滞评分降低（ P＜0．05）。3组患者置管处渗血∕液、恶心呕吐发生率比较差异无统计意义（ P＞0．05）。结论连续股神经阻滞联合浸润麻醉可为全膝关节置换术患者提供更加充分的术后镇痛效果，且不影响感觉和运动功能恢复，安全性较好。

Objective To evaluate the effects of continuous femoral nerve block combined with in-filtration anesthesia on postoperative analgesia in the patients undergoing total knee arthroplasty. Methods Ninety patients, aged 50-80 yr, weighing 45-90 kg, of ASA physical status Ⅰ-Ⅲ, scheduled for elective unilateral total knee arthroplasty, were randomly divided into 3 groups （ n=30 each） using a ran-dom number table： continuous femoral nerve block ＋ infiltration anesthesia group （ group A）; continuous femoral nerve block group （ group B）; continuous femoral nerve block ＋ single sciatic nerve block group （ group C） . The femoral nerve was catheterized for block before induction of general anesthesia in the three groups, and then a single sciatic nerve block was performed in group C. In group A, 20 ml mixture was in-jected into the posterior part of the joint capsule before prosthesis implantation, and 20 ml mixture was in-jected around the collateral ligaments and incision sites after prosthesis implantation and before closing. The mixture included ropivacaine 2-5 mg∕ml, fentanyl 2-5 μg∕ml, and methylprednisolone 1 mg∕ml. In group B, 40 ml of normal saline was given as the method previously described in group A. Patient-controlled anal-gesia with 0-2% ropivacaine 250 ml was used for postoperative analgesia, lasting for 48 h. The patient-con-trolled analgesia pump was set up with a 5 ml bolus dose, a 30 min lockout interval and background infusion at a rate of 5 ml∕h. Tramadol was used as rescue analgesic and was given orally to maintain the VAS score ≤ 5. VAS scores at rest were recorded at 4, 8, 12, 24 and 48 h after surgery, and VAS scores during activity were recorded at 8, 12, 24 and 48 h after surgery. The total consumption of tramadol within 48 h after surgery was recorded. The motor function of the affected extremity was assessed and scored at 12, 24 and 48 h after surgery, and the sensory and motor function was evaluated at 72 h after removal of the catheter. The occurrence of bleeding or exudates from the site of catheterization and adverse effects were recorded. Results Compared with group B or C, VAS scores at rest at 4-24 h after operation, VAS scores during activity at 8-24 h after operation, and the total consumption of tramadol were significantly de-creased in group A. Compared with group B, no significant changes were found in motor block score of the affected extremity in group A. Compared with group C, the motor block score of the affected extremity was significantly decreased in A and B groups. There were no significant differences in the incidence of bleeding or exudates from the site of catheterization and nausea and vomiting between the three groups. Conclusion Continuous femoral nerve block combined with infiltration anesthesia can provide sufficient analgesia with-out influencing the recovery of sensory and motor function, and the safety is good for the patients undergoing total knee arthroplasty.