超声引导下经腰方肌阻滞用于髋关节置换术后的效果评价

Effects and safety of quadratus lumborum block in analgesia after hip arthroplasty

目的评价超声引导下经腰方肌阻滞复合非甾体抗炎药多模式镇痛对髋关节置换术患者术后镇痛效果。方法选择2017年1至6月佛山市第一人民医院择期行髋关节置换术患者60例，年龄55～75岁，体质量45～70 kg，美国麻醉医师协会（ASA）分级Ⅰ～Ⅲ级，采用随机数字表法，将其随机分为2组（n＝30）：对照组（N组）和腰方肌阻滞组（R组）。手术结束后R组患者患侧在超声引导下行腰方肌阻滞，注射0.33%罗哌卡因30 ml，N组不进行腰方肌阻滞，两组患者接舒芬太尼镇痛泵行静脉自控镇痛（PCIA）。于术后即刻（T0）、术后3 h（T1）、6 h（T2）、12 h （T3）、24 h （T4）、36 h （T5）和48 h（T6），记录患者静态视觉模拟疼痛评分（VAS）；于T4、T5和T6时，记录患者运动VAS评分。记录术后0～≤3 h、〉3～≤6 h、〉6～≤12 h、〉12～≤24 h、〉24～≤36 h和〉36～≤48 h各时段内舒芬太尼用量。评估术后12、24、36、48 h时患者髋关节最大屈曲和外展活动度。统计术后24、48 h两组患者需要使用静脉镇痛泵进行补救性镇痛的例数。记录两组患者术后不良反应和总体满意度。结果R组患者在T1～T6时静态VAS评分分别为（0.8±0.4）、（1.0±0.3）、（1.2±0.5）、（2.0±0.5）、（1.7±0.4）和（1.6±0.5）分，N组分别为（3.0±0.7）、（3.5±0.9）（3.8±0.9）、（3.3±1.1）、（3.3±0.7）和（3.0±0.7）分，与N组比较，R组患者在T1～T6时静态VAS评分均降低，差异均有统计学意义（F＝203.090、216.354、203.956、35.548、96.332、80.577，均P〈0.01）；R组患者在T4～T6时运动VAS评分分别为（2.7±0.9）、（2.9±0.7）和（2.0±0.6）分，N组分别为（6.0±1.5）、（5.8±1.1）和（4.5±1.0）分，与N组比较，R组患者在T4～T6时运动VAS评分均降低，差异均有统计学意义（F＝154.561、143.224、141.479，均P〈0.01）。R组患者术后12、24、36、48 h髋关节最大屈曲度分别为（61±12）°、（64±10）°、（69±15）°和（78±19）°，N组分别为（45±11）°、（49±10）°、（52±12）°和（60±14）°，与N组比较，R组患者在术后各时点髋关节最大屈曲度均增加，差异均有统计学意义（F＝34.981、35.575、52.106、41.681，均P〈0.01）；R组患者术后12、24、36、48 h髋关节最大外展活动度分别为（22±6）°、（26±6）°、（27±8）°、（28±7）°，N组分别为（14±5）°、（17±6）°、（20±6）°、（20±5）°，与N组比较，R组患者在术后各时点髋关节最大外展活动度均增加，差异均有统计学意义（F＝58.974、33.402、19.151、20.575，均P〈0.01）。R组患者术后24、48 h需要使用静脉镇痛泵进行补救性镇痛的比例分别为10%和16.7%，N组分别为100%和100%，与N组比较，R组患者在术后需要进行补救性镇痛的比例降低，差异均有统计学意义（χ2＝49.091、42.857，均P〈0.01）。R组患者术后恶心呕吐和瘙痒发生率分别为3.3%和3.3%，N组分别为23.3%和20.0%，与N组比较，R组患者术后恶心呕吐和瘙痒发生率均降低，差异均有统计学意义（χ2＝5.192、4.875，均P〈0.05）。R组患者术后总体满意度评分为（3.7±1.0）分，N组为（1.9±0.7）分，与N组比较，R组患者术后总体满意度评分增加，差异有统计学意义（t＝7.841，P〈0.01）。结论超声引导下经腰方肌阻滞复合帕瑞昔布钠进行多模式镇痛，镇痛效果佳，不良反应发生率低。

ObjectiveTo evaluate the efficacy of ultrasound guided quadratus lumborum block combined with non-steroidal anti-inflammatory drugs for postoperative analgesia in patients undergoing total hip arthroplasty.MethodsFrom January to June 2017, sixty American Society of Anesthesiologists （ASA） physical status Ⅰ to Ⅲ patients, aged 55-75 yr, scheduled for total hip arthroplasty, were randomly divided into control group（group N） and quadratus lumborum block （group R）. Ultrasound guided quadratus lumborum block was implemented on the affected side at the end of operation.Then 30 ml 0.33% ropivacaine were administrated in group R, while the control group did not receive the same block. A sufentanil patient-controlled analgesia pump was connected to the patient. The rest visual analogue score （VAS） were recorded at 0 h（T0）, 3 h（T1）, 6 h （T2）, 12 h（T3）, 24 h （T4）, 36 h （T5） and 48 h（T6） after sugery, the VAS scores on movement were evaluated at T4, T5 and T6 time points.The consumption of sufentanil within each period time were recorded.The maximal flexion and abduction degrees of the hip joint were evaluated at 12, 24, 36 and 48 h after operation. The number of patients for rescue pain relief by intravenous analgesia pump during 24 h and 48 h after surgery were counted in both groups. The postoperative adverse effects and overall satisfaction in the two groups were recorded.ResultsThe VAS at rest in group R were 0.8±0.4, 1.0±0.3, 1.2±0.5, 2.0±0.5, 1.7±0.4 , 1.6±0.5 at T1, T2, T3, T4, T5, T6 respectively, and those in group N were 3.0±0.7, 3.5±0.9, 3.8±0.9, 3.3±1.1, 3.3±0.7, 3.0±0.7 at the same time points. The VAS at rest were lower in group R than those in control group at all time points （F=203.090, 216.354, 203.956, 35.548, 96.332, 80.577, all P〈0.01）. The VAS on movement in group R were 2.7±0.9, 2.9±0.7 , 2.0±0.6 at T4, T5, T6 respectively , and those in group N were 6.0±1.5, 5.8±1.1, 4.5±1.0. The VAS on movement were also lower in group R than those in control group（F=154.561, 143.224, 141.479, all P〈0.01）. The maximum flexion degrees in group R were （61±12）degrees, （64±10）degrees, （69±15）degrees and（78±19）degrees at 12, 24, 36, 48 h after operation, and those were （45±11） degrees, （49±10）degrees, （52±12）degrees and（60±14）degrees at the same time points. The maximum flexion degrees in group R were increased more than control group at 12, 24, 36, 48 h after operation（F=34.981, 35.575, 52.106, 41.681, all P〈0.01）. The abduction degrees in group R were（22±6）degrees, （26±6）degrees, （27±8）degrees and（28±7）degrees at 12, 24, 36, 48 h after surgery, and those in group N were （14±5） degrees, （17±6）degrees, （20±6）degrees and（20±5）degrees. The abduction degrees in group R were increased more than those in group N（F=58.974, 33.402, 19.151, 20.575, all P〈0.01）. The rates of rescue analgesia for pain relief were 10% and 16.7% at 24 h and 48 h after operation respectively in group R, and those were 100% and 100% in group N. Compared to group N, the rates of rescue analgesia for pain relief in group R were significantly decreased （χ2=49.091, 42.857, all P〈0.01）. The incidences of postoperative nausea and vomiting, pruritus in group R were 3.3% and 3.3% respectively, and those in group N were 23.3% and 20.0%. The incidences of nausea and vomiting, pruritus in group R were lower than those in group N （χ2=5.192, 4.875, all P〈0.01）. The overall satisfaction scores in group R （3.7 ± 1.0 ） were higher than those （1.9±0.7） in the group N（t=7.841, P〈0.01）.ConclusionThe quadratus lumborum block combined with parecoxib sodium for multimodal analgesia after total hip arthroplasty is effective and provides satisfactory analgesia.