序贯降阶梯式与常规持续股神经阻滞在全膝关节置换术后镇痛中的效果比较

Comparison of the postoperative analgesic effects of sequential descending and common practice of continuous femoral nerve block after total knee arthroplasty

目的比较序贯降阶梯式与常规持续股神经阻滞(continuous femoral nerve block,CFNB)在单侧全膝关节置换术(total knee arthoplasty,TKA)后镇痛中的效果。方法选取单侧TKA后行CFNB患者75例,男30例,女45例,年龄≥18岁,ASAⅠ-Ⅲ级,随机分为两组:序贯降阶梯式组(S组)和常规CFNB组(C组)。患者CFNB成功后接受统一的静-吸复合喉罩全麻方案及复苏流程。S组:术后24 h内镇痛泵持续输注0.5%罗哌卡因,术后24~48 h降为0.25%,48~72 h为0.125%;C组:术后72 h内罗哌卡因浓度一直为0.2%。记录术后0~24 h、24~48 h、48~72 h的NRS评分及辅助镇痛药布托啡诺的使用情况;采用改良的徒手六级肌力法评估术后股四头肌肌力(MQF);记录手术相关并发症。结果术后0~24 h、24~48 h,C组NRS评分明显高于S组(P<0.05),C组术后使用布托啡诺比例明显高于S组(51%vs 11%,P<0.05)。C组NRS评分在术后48~72 h明显低于术后0~24 h(P<0.05)。术后0~24 h及24~48 h,S组MQF明显低于C组(P<0.05)。术后48~72 h两组MQF差异无统计学意义。S组在术后48~72 h的MQF明显高于术后0~24 h(P<0.05)。两组患者术后均未发生坠床及跌倒等严重意外。两组无一例穿刺点感染。结论采用序贯降阶梯式CFNB管理策略既可满足患者术后早期对镇痛的需求,又可通过适时降低局麻药浓度使其达到早期康复锻炼的目的。

Objective To compare the postoperative analgesic effects of sequential descending and common practice of continuous femoral nerve block after total knee arthroplasty(TKA). Methods Seventy-five patients, 30 males and 45 females, aged ≥18 years, ASA physical status Ⅰ-Ⅲ, were randomly divided into two groups: the sequential descending group(group S, n = 38) and the conventional group(group C, n = 37). After CFNB, the patient received a unified intravenous-inhalational general anesthesia with laryngeal mask airway and resuscitation. In group S, 0.5% ropivacaine was continuously infused by the analgesia pump within 24 h after surgery, 0.25% at 24-48 h and 0.125% at 48-72 h respectively. In group C, the concentration of ropivacaine infusion was 0.2% during 72 h after operation. All the analgesic pump was withdrawn on the third day after operation. The NRS values and the use of butorphanol were measured at 0-24, 24-48, 48-72 hours after operation. Musculi quadriceps femoris(MQF) was assessed by modified bare-handed six-level muscle strength method. Results The NRS value of group C was significantly higher than that of group S at 0-24 hours and 24-48 hours after operation(P < 0.05), and the number of patients who used butorphanol as adjuvant analgesia was significantly higher than that of group S(51% vs 11%, P < 0.05). The NRS value of group C at 48-72 h after operation was significantly lower than at 0-24 h after operation(P < 0.05). MQF in group S was significantly lower than that in group C(P < 0.05) at 0-24 h and 24-48 h after operation. There was no significant difference in MQF between the two groups at 48-72 h after operation. The MQF of group S at 48-72 h after operation was significantly higher than at 0-24 h after operation(P < 0.05). Conclusion Not only can the management strategy of sequential descending CFNB satisfy the patients′ high demand for analgesia in the early stage after operation, but also achieve the goal of early rehabilitation exercise by reducing the concentration of local anesthetics timely.