髌骨骨折切开复位内固定术后不同镇痛模式的效果比较

Comparison of the efficacy with different analgesic modalities after open reduction and internal fixation of patients with patellar fracture

目的评价不同镇痛模式在髌骨骨折切开复位内固定术后的镇痛效果。方法择期行髌骨骨折切开复位内固定术患者150例，根据不同镇痛模式，随机分为舒芬太尼组（A组）、舒芬太尼＋左布比卡因组（B组）和吗啡组（C组），每组50例。术后镇痛模式分别为：A组静脉注射舒芬太尼140μg（PCIA）；B组硬膜外注射左布比卡因0．28g＋舒芬太尼140Ixg（PCEA）；C组静脉注射吗啡14mg（PCIA），各组均用生理盐水稀释至140ml。比较3组患者术后各时点VAS评分、改良Bromage分级和布氏舒适（BCS）评分，记录患者恶心、嗜睡等不良反应。结果术后12、24h时，B组和C组VAS〈3的例数明显高于A组（P〈0．05）；术后24h时，B组和C组的BCS评分明显高于A组（P〈0．05）；术后2h和6h时，C组的Bromage分级明显高于A组和B组（P〈0．05）。B组在12、24h内实际按压次数、有效按压次数多于A组和C组（P〈0．05）。A组发生术后嗜睡12例，明显多于B组的4例和C组的2例（P〈0．05）。结论髌骨骨折切开复位内固定术患者，术后采用左布比卡因联合舒芬太尼行硬膜外自控镇痛效果较好，优于单纯静脉舒芬太尼与单纯吗啡术后镇痛。

Objective To investigate the efficacy with different analgesic modalities after open reduction and internal fixation of patients with patellar fracture. Methods One hundred and fifty patients undergoing open reduction and internal fixation of patellar fracture were divided into sufentanil group （group A）, sufentanil and levobupivaeaine group （group B） and morphine group （group C）, 50 cases in each group according to the mode of analgesia. Patients in group A were given intravenous sufentanil 140 p,g （PCIA）, while patients in group B received epidural analgesia with 0.2% levo bupivacaine and sufentanil 140 p,g （PCEA）. Patients in group C were given intravenous morphine 14 rag. All groups were diluted with normal saline to 140 ml. VAS, modified Bromage grading, BCS and adverse reactions were recorded. Results The number of cases with VAS〈3 was significantly higher in group B and C than that in group A at 12, 24 h after the operation （P〈 0,05）. BCS was significantly higher in group B and C than that in group A at 24 h after the operation （P〈0.05）. Compared with group A and B, Bromage grade was significantly higher in group C at 2, 6 h after the operation （P〈0.05）. The actual press times and effective press times were more in group B at 12, 24 h after the operation （P〈0.05）. There were 12 cases with postoperative drowsiness in group A, which was obviously more than that in group B （4 cases）and in group C （2 cases ）（P〈0.05）. Conclusion The analgesic efficacy of PCEA with levobupivacaine and sufentanil is better than that with intravenous sufentanil or morpline alone after open reduction and internal fixation in patients with patellar fracture.