多模式镇痛在关节镜下肩袖损伤修复术中的临床应用观察

Efficacy of Multimodal Analgesia in Rotator Cuff Repair with Arthroscopic Surgery

目的观察多模式镇痛在关节镜下肩袖损伤修复术围术期疼痛管理中的镇痛效果。方法选取2014年1月至2015年6月新疆医科大学附属中医医院关节外科确诊为肩袖损伤行手术治疗的住院患者46例。按随机数字表法分为多模式镇痛组(22例)和静脉镇痛泵组(24例)。多模式镇痛组:1%罗哌卡因20 mL术前在切口周围行局部浸润麻醉+帕瑞昔布钠40 mg分别于术前及术后1、2 d静脉注射+术后肩峰下放置自控镇痛泵(1%罗哌卡因60 mL加0.9%NaCl注射液稀释至100 mL)。静脉镇痛泵组使用静脉自控镇痛泵(舒芬太尼100μg+托烷司琼5 mg+0.9%NaCl注射液稀释至100 mL)。记录两组患者术后不同时点静息痛及活动痛视觉模拟评分(VAS),静息VAS>7分时给予吗啡辅助镇痛,记录吗啡用量及相关不良事件。比较两组患者术后1、6周美国纽约特种外科医院肩关节功能评分(HSS)。结果两组患者术后4、8、12、24、36、48 h不同时点VAS在静息状态下均较平稳[多模式镇痛组:(1.3±0.2)分,(1.2±0.4)分,(1.3±0.3)分,(1.1±0.2)分,(1.0±0.3)分,(1.3±0.3)分;静脉镇痛泵组:(2.2±0.3)分,(2.4±0.6)分,(2.5±0.6)分,(2.6±0.4)分,(2.7±0.5)分,(2.8±0.6)分],多模式镇痛组较静脉镇痛泵组高,两组在组间、不同时点间、组间不同时点间交互效应差异有统计学意义(P<0.05)。在活动状态下,两组患者VAS[多模式镇痛组:(3.5±1.0)分,(3.7±1.8)分,(3.7±1.6)分,(3.5±1.4)分,(3.7±1.0)分,(3.6±1.4)分;静脉镇痛泵组:(4.6±1.0)分,(4.9±1.3)分,(4.7±1.0)分,(5.0±1.4)分,(4.8±1.0)分,(4.6±1.2)分],多模式镇痛组较静脉镇痛泵组高,两组在组间、不同时点间、组间不同时点间交互效应差异有统计学意义(P<0.05)。术后48 h内,多模式镇痛组吗啡用量及相关不良反应显著低于静脉镇痛泵组[(11.2±1.3)mg比(19.8±2.7)mg,23.7%(6/22)比62.5%(15/24),P<0.05];两组患者术前、术后1周、6周不同时点行HSS肩关节功能评分均较治疗前呈上升趋势[多模式镇痛组:(59±8)分、(78±7)分比(44±7)分;静脉镇痛泵组:(50±8)分、(77±11)分比(42±4)分],差异有统计学意义(P<0.05)。结论肩袖损伤修复术围术期采用多模式疼痛管理方案可有效控制术后疼痛,减少辅助镇痛药物吗啡的用量及不良反应的发生,使患者在术后早期便可积极进行关节功能的康复锻炼,提高临床满意度。

Objective To observe the effects of multimodal analgesia in patients receiving arthroscopic rotator cuff repair. Methods Total of 46 patients undergoing arthroscopic rotator cuff repair in the Department of Joint Surgery,Hospital of Traditional Chinese Medicine Affiliated to Xinjiang Medical University from Jan. 2014 to Jun. 2015 were divided into multimodal analgesia group（ 22 cases） and intravenous analgesia group（ 24 cases）. The multimodal analgesia group received local infiltration of 20 mL 1% ropivacaine surrounding incision and intravenous injection of 40 mg parecoxib before operation,40 mg parecoxib was given at the 1st day and the 2nd day after operation too. All patients received self-control analgesia after operation,multimodal analgesia group： 1% ropivacaine 60 mL ＋ physiological saline 40 mL; intravenous analgesia group： sufentanil 100 μg ＋ tropisetron 5 mg ＋ physiological saline 97 mL.Rest and exercise visual analogue scale（ VAS） values of the two groups were recorded at different time points. Morphine was available as a rescue analgesic when VAS 〉 7 at rest. The used amount of morphine and relevant adverse events were recorded. Patients were assessed by hospital for special surgery（ HSS） shoulder function scale 1 week and6 weeks after surgery. Results The postoperative 4,8,12,24,36,48 h VAS value of the two groups： more stable in the resting state[multimodal analgesia group：（ 1. 3 ± 0. 2） scores,（ 1. 2 ± 0. 4） scores,（ 1. 3 ± 0. 3） scores,（ 1. 1 ±0. 2） scores,（ 1. 0 ± 0. 3） scores,（ 1. 3 ± 0. 3） scores; intravenous analgesia group：（ 2. 2 ± 0. 3） scores,（ 2. 4 ±0. 6） scores,（ 2. 5 ± 0. 6） scores,（ 2. 6 ± 0. 4） scores,（ 2. 7 ± 0. 5） scores,（ 2. 8 ± 0. 6） scores],the multimodal analgesia group higher than the intravenous analgesia group with statistically significant differences between the two group,different time points and the interaction of groups and time points（ P 〈 0. 05）. Under the active state,the VAS data[multimodal analgesia group：（ 3. 5 ± 1. 0） scores,（ 3. 7 ± 1. 8） scores,（ 3. 7 ± 1. 6） scores,（ 3. 5 ± 1. 4） scores,（ 3. 7 ±1. 0） scores,（ 3. 6 ±1. 4） scores; intravenous analgesia group：（ 4. 6 ±1. 0） scores,（ 4. 9 ±1. 3） scores,（ 4. 7 ±1. 0） scores,（ 5. 0 ± 1. 4） scores,（ 4. 8 ± 1. 0） scores,（ 4. 6 ± 1. 2） scores],the multimodal analgesia group higher than the intravenous analgesia group with statistically significant difference（ P 〈 0. 05）,there were significant difference between the two groups,different time points and the interaction of groups and time points. The multimodal analgesia group consumed less morphine compared with the intravenous analgesia group,and showed lower incidence of side effects[（ 11. 2 ± 1. 3） mg vs（ 19. 8 ± 2. 7） mg,6 cases vs 15 cases,[23. 7%（ 6 /22） vs 62. 5%（ 15 /24）,P 〈 0. 05].The preoperative and postoperative 1 week and 6 weeks HSS score of both groups were on the rise[multimodal analgesia group：（ 59 ± 8）,（ 78 ± 7） vs（ 44 ± 7）; intravenous analgesia group：（ 50 ± 8）,（ 77 ± 11） vs（ 42 ± 4） ],the differences were statistically significant（ P 〈 0. 05）. Conclusion The multimodal management of pain leads to better analgesia efficacy,less morphine consumption and less morphine-related adverse effects and better recovery of shoulder function at early stage after shoulder arthroscopic surgery,thus improves the clinical satisfaction.