全膝关节置换术围术期多模式超前镇痛的临床效果观察

Clinical Effect of Multi-mode Preemptive Analgesia on Patients Undergoing TKA during Perioperative Period

目的探讨多模式超前镇痛在全膝关节置换术(total knee arthroplasty,TKA)围术期应用的临床效果。方法选取我院2013年2月—2014年10月60例因膝关节骨性关节炎接受初次单侧TKA患者,随机分为鸡尾酒式局部浸润镇痛组(A组)、单次股神经阻滞镇痛组(B组)、传统静脉自控式镇痛泵镇痛组(C组),每组20例。3组均采用静脉吸入复合全身麻醉。A、B组术前2 d及术后均予塞来昔布200 mg,每日2次口服,术后切口周围局部冷敷,同时A组术中给予鸡尾酒式镇痛药物局部浸润(罗哌卡因150 mg+肾上腺素0.1 mg),B组给予单次股神经阻滞(0.375%罗哌卡因30 ml);C组仅术后给予静脉自控式镇痛泵(2μg/kg舒芬太尼+氟比洛芬酯100 mg)镇痛。记录3组术后6 h、12 h、1 d、2 d、3 d、5 d、7 d膝关节疼痛视觉模拟评分(visual analogue scale,VAS),术后6 h、12 h、1 d、2 d、3 d股四头肌肌力,术后1、2、3 d膝关节活动度,吗啡追加量及镇痛相关不良事件发生情况。结果 A组与B组在术后第6 h^5 d VAS评分均显著小于C组(P<0.05)。术后6 h和12 h,3组股四头肌肌力比较差异均无统计学意义(P>0.05);术后1~3 d,A组股四头肌肌力均显著高于B组(P<0.05),A、B组与C组比较差异均无统计学意义(P>0.05)。术后1 d,A组膝关节活动度显著大于C组(P<0.05),B、C组比较差异无统计学意义(P>0.05);术后1~3 d,A、B组膝关节活动度比较差异无统计学意义(P>0.05),但均显著大于C组(P<0.05)。A、B组术后吗啡追加量比较差异无统计学意义(P>0.05),但均显著少于C组(P<0.05)。A、B组镇痛相关不良事件发生率比较差异无统计学差异(P>0.05),且均显著低于C组(P<0.05)。结论多模式超前镇痛模式可以取得较传统静脉自控式镇痛泵更好的镇痛效果,且镇痛相关不良事件发生少,有利于患者术后功能恢复。

Objective To investigate the effect of multi-mode preemptive analgesia on patients undergoing total knee arthroplasty （ TKA） during perioperative period. Methods A total of 60 osteoarthrosis of knee patients undergoing the first unilateral TKA during February 2013 and October were randomly divided into local infiltration analgesia group （group A, n=20）, a single femoral nerve block analgesia group （group B, n=20） and traditional self-control venous pump analgesia group （group C, n=20）. All patients received complex intravenous inhalation anesthesia. Group A and B were treated with 200 mg Celecoxib （2/d） orally 2 d before and after the TKA, and then local incision cold compress was performed after the surgery;at the same time, group A was given local infiltration analgesia （150 mg Ropivacaine ＋0. 1 mg Epinephrine）;group B were given a single femoral nerve block analgesia （0. 375% Ropivacaine, 30 ml）;group C was given venous pump analgesia （ 2 μg/kg Sufentanil ＋ 100 mg Flurbiprofen Axetil ） . the visual analogue scale （ VAS） scores of knee joints at 6 h, 12 h, 1 d, 2 d, 3 d, 5 d and 7 d after the surgery, quadriceps femoris muscle power at 6 h, 12 h, 1 d, 2 d and 3 d after the surgery, genual range-of-motion （ ROM） at 1 d, 2 d and 3 d after the surgery, superaddition doses of Morphine and incidence rate of adverse events related analgesia in the three groups were recorded. Results The VAS scores at postoperative 6 h, 12 h, 1 d, 2 d, 3 d and 5d in group A and B were significantly decreased than those in group C （P〈0. 05）. The differences of quadriceps femoris muscle power at postoperative 6 h and 12 h were not statistically significant in the three groups （P〉0. 05）;the values of quadriceps femoris muscle power at postoperative 1 d, 2 d and 3 d in group A were significantly higher than those in group B （P〈0. 05）, but the differences in the values between group A and B with group C were not statistically significant （P〈0. 05）. The value of genual ROM at postopera-tive 1 d in group A was significantly higher than that in group C （ P〈0. 05 ） , but the difference in the value between group B and C was not statistically significant （P〉0. 05）; the differences in genual ROM values at postoperative 1 d, 2 d and 3 d between group A and B were not statistically significant （P〉0. 05）, but the values in group A and B were all significantly higher than those in group C （ P〈0. 05 ） . The difference in superaddition doses of Morphine between group A and B were not statistically significant （P〉0. 05）, and the values in group A and B were all significantly less than that in group C （P〈0. 05）. The difference in incidence rate of adverse events related analgesia between group A and B was not statistically significant （P〉0. 05）, and the rates in group A and B were all significantly lower than that in group C （ P〈0. 05 ） . Conclusion Multi-mode preemptive analgesia has better effective than traditional venous pump analgesia with lower incidence rate of adverse events and better post-operation function recovery.