全膝关节置换围手术期的镇痛:措施与对策

Perioperative analgesia in total knee arthroplasty: measures and countermeasures

背景:全膝关节置换术已成为全世界治疗终末期膝关节疾病最有效、最理想的方法。但是全膝关节置换创伤大,置换后常伴有剧烈的疼痛,以往资料表明,全膝关节置换后60%的患者感到严重疼痛,30%感到中等程度疼痛。疼痛的产生是一个多环节、多因素参与的极其复杂的过程,如何减少置换后疼痛并迅速恢复关节功能成为近年的研究热点。目的:对近年人工膝关节置换围手术期镇痛的研究进展以及发展趋势进行综述。方法:检索万方数据库、中国知网数据库及PubMed数据库中1990年1月至2017年12月的膝关节置换镇痛相关文献。中文检索词为:"膝关节置换,膝关节,镇痛,多模式镇痛,超前镇痛,快速康复,自控镇痛,COX-2抑制剂,股神经阻滞,收肌管阻滞,关节周围注射,冷疗";英文检索词为"knee arthroplasty,analgesia,knee joint,fast track,multimode analgesia,patient controlled analgesia,non-steroidal anti-inflammatory drugs,peripheral nerve block,periarticular injection,cold therapy"。共检索到文献2 306篇,经过阅读标题和摘要进行初筛,最终纳入59篇符合纳入排除标准的文献。结果与结论:(1)全膝关节置换后疼痛的病理生理学机制非常复杂,是由多种因素、不同环节所引起;(2)人工全膝关节置换围手术期镇痛理念包括快速康复、多模式镇痛和超前镇痛,已逐步在临床上开展实施;(3)全膝关节置换围手术期镇痛方法有患者自控镇痛、非类固醇类抗炎药、区域神经阻滞镇痛、关节周围软组织注射镇痛和冷敷疗法等,这些镇痛方法都存在着各自的优缺点;(4)目前多模式镇痛方案已被多数临床医生认可,但是最佳的疼痛管理方案仍然存有争议。此外,关于镇痛方式的选择,应根据患者个体特征以及现有技术手段进行综合考量。

BACKGROUND： Total knee arthroplasty has already become the most effective and ideal method for the treatment of end-stage knee disease worldwide. However, total knee arthroplasty is very traumatic and often accompanied by severe pain. The previous data indicate that 60% patients after total knee arthroplasty feel severe pain, and 30% patients feel moderate pain. The emergence of pain is a very complicated process with many factors involved. How to reduce postoperative pain and quickly restore joint function has become a hot research topic in recent years. OBJECTIVE： To review research progress and development trend of perioperative analgesia in total knee arthroplasty. METHODS： We retrieved the related literatures about the analgesia of knee arthroplasty from January 1990 to December 2017 in Wan Fang database, CNKI database and PubMed database by using the key words of ＂knee arthroplasty, knee joint, analgesia, multimode analgesia, preemptive analgesia, fast recovery, patient controlled analgesia, COX-2 inhibitor, femoral nerve block, adductor canal block, periarticular injection, cold therapy＂ in Chinese, and ＂knee arthroplasty, analgesia, knee joint, fast track, multimode analgesia, patient controlled analgesia, non-steroidal anti-inflammatory drugs, peripheral nerve block, periarticular injection, cold therapy＂ in English. Totally 2 306 articles were retrieved. After screening, finally 59 articles meeting the inclusion and exclusion criteria were included. RESULTS AND CONCLUSION：（1） The pathophysiological mechanism of pain after total knee arthroplasty is very complex and is caused by multiple factors and links.（2） There are many clinical analgesic ideas for total knee arthroplasty, including fast recovery, multimodal analgesia and preemptive analgesia, and these ideas have been gradually implemented in clinical practice.（3） There are many clinical analgesic methods for total knee arthroplasty, including patient-controlled analgesia, non-steroidal anti-inflammatory drugs analgesia, peripheral nerve block analgesia, periarticular multimodal drug injection and cold therapy. These analgesic methods have their own advantages and disadvantages.（4） At present, multi-mode analgesia has been approved by most clinicians, but the best pain management program is still controversial. Regarding the choice of the analgesic method, we should weigh the pros and cons, and take the individual characteristics of patients and the existing technical methods into consideration.