两种镇痛方式对全膝关节置换术后患者凝血功能的影响

Effect of 2 postoperative analgesia methods on blood coagulation in patients after total knee arthroplasty

目的通过血栓弹力图(thrombelastogrophy,TEG)观察全膝关节置换术(total knee arthroplasty,TKA)后连续股神经阻滞(continuous femoral nerve block,CFNB)和静脉自控镇痛(patient controlled intravenous analgesia,PCIA)对患者凝血功能的影响。方法选取本院2014年12月至2015年5月间择期行单侧TKA、ASA分级Ⅰ级或Ⅱ级的60例患者(>18岁)随机分为CFNB组和PCIA组,每组30例,镇痛2 d。记录术后6、12、24、48 h视觉模拟疼痛评分(visual analogue scale,VAS)。分别于麻醉前(T0)、松止血带即刻(T1)、术毕(T2)、术后1 d(T3)、术后2 d(T4)行TEG检测,测定反应时间(R)、血凝块形成时间(K)、血凝块聚合形成速率(α角)及最大振幅(MA)。结果 CFNB组患者术后各时点的VAS评分均低于PCIA组(P<0.05)。同组内不同时点TEG各参数与T0时点相比,CFNB组T4时点的K值显著延长,T3、T4时点的α角和MA值显著减小(P<0.05);PCIA组T3、T4时点的R值与K值显著缩短,α角和MA值显著增大(P<0.05)。两组间同一时点TEG各参数比较,T3、T4时点CFNB组的R值和K值较PCIA组显著延长,α角和MA值较PCIA组显著减小(P<0.05)。结论 TKA术后CFNB镇痛效果优于PCIA,有助于改善TKA患者术后血液高凝状态。

Objective To investigate the effect of 2 postoperative analgesia methods on blood coagulation in the patients after total knee arthroplasty （TKA） with thrombelastography （TEG）. Methods Totally 60 patients （ 〉 18 years old） scheduled for elective unilateral TKA （ASA Ⅰ - Ⅱ ） in our department from December 2014 to May 2015 were enrolled in this study. They were randomly divided into continuous femoral nerve block （CFNB） group and patient-controlled intravenous analgesia （PCIA） group, with 30 cases in each group. Analgesia was maintained for 2 d. The visual analogue scale （VAS） scores were recorded at 6, 12, 24, and 48 h after surgery. The TEG parameters were measured at the time before anesthesia （TO） , the time when loosening the tourniquet （ T1 ）, the end of surgery （T2）, and in 1 d （ T3 ） and 2 d （T4） after operation. The VAS scores and TEG parameters at different times were compared between the 2 groups. Results The VAS scores were significantly lower after TKA at all time points in the CFNB group than the PCIA group （P 〈 0.05 ）. Compared with TO in CFNB group, the K values at T4 was significantly longer and the u-angle and MA values at T3 and T4 were significantly smaller （ P 〈 0.05 ）. However, in the PCIA group, the R and K values were significantly shorter and the α-angle and MA values were significantly bigger at T3 and T4 than those at TO （ P 〈 0.05 ）. Compared with PCIA group at T3 and T4, the R and K values were significantly prolonged and the α-angle and MA values were significantly smaller in the CFNB group （P 〈 0. 05）. Conclusion The patients receiving CFNB after TKA have better pain relief than those of PCIA, and may improve their hypercoagulability.