超声引导下连续股神经阻滞对膝关节周围骨肿瘤全膝关节置换术患者镇痛及快速康复的影响

Effect of Ultrasound-Guided Continuous Femoral Nerve Block on Analgesia and Rapid Rehabilitation in Patients Undergoing Total Knee Arthroplasty

目的:探讨超声引导下连续股神经阻滞(ultrasound-guided continuous femoral nerve block, UGCFNB)用于全膝关节置换术(total knee arthroplasty,TKA)治疗膝关节周围骨肿瘤镇痛效果和对患肢康复功能的影响。方法:择期行TKA的膝关节周围骨肿瘤患者60例,ASAⅡ-Ⅲ级,随机分为UGCFNB组(N组)和静脉舒芬太尼组(I组),两组均采用蛛网膜下腔联合硬膜外麻醉。N组于腰硬联合麻醉前在超声引导下行股神经置管,两组均于假体安装后硬膜外给0.2%罗哌卡因5mL作为负荷剂量,并且安装镇痛泵。记录两组患者术后6h、12h、24h和48h不同时点的静息和运动时VAS评分,术后不同时点膝关节主动运动(active exercise,AE)角度和被动运动(continuoas passive motion,CPM)角度,股四头肌肌力评分,记录不良反应的发生情况。结果:术后6h、12h、24h和48h静息状态下,两组VAS评分差异无统计学意义(P>0.05);与I组相比,N组术后24h和48hCPM时VAS评分降低[(4.4±0.6)vs(6.3±0.7),(3.8±0.8)vs(6.5±0.6)](P<0.05);与I组相比,N组术后24h、48h和72h患肢AE角度增大[(45±5)°vs(30±4)°、(55±5)°vs(48±4)°、(76±5)°vs(69±3)°](P<0.05),CPM角度也增大[(66±3)°vs(46±5)°、(76±6)°vs(56±6)°、(88±5)°vs(80±7)°](P<0.05);术后6h、12h、24h、48h和72h两组患者各时点股四头肌肌力差异性无统计学意义(P>0.05);与I组相比,N组发生恶心呕吐、嗜睡、瘙痒副作用的比例少,差异性有统计学意义(P<0.05)。结论:与静脉镇痛比较,UGCFNB不仅静息状态下镇痛效果良好,而且降低CPM时疼痛,增加患肢AE和CPM角度,不影响股四头肌肌力,不增加术后并发症,有利于TKA骨肿瘤患者术后镇痛和快速康复。

Objective:To investigate the analgesic and rehabilitative effects of ultrasound-guided continuous femoral nerve block(UGCFNB)on patients undergoing the tota1 knee arthroplasty(TKA).Method:Sixty cases of patients with bone tumor around the knee(American Society of Anesthesiologists II-III)scheduled for total knee arthroplasty were randomly assigned to the UGCFNB group(Group N)and the venous sufentanil group(Group I).Both groups received combined subarachnoid-epidural anesthesia.Ultrasound-guided femoral nerve catheter was placed before combined spinal-epidural anesthesia in Group N.Both groups were given an epidural dose of 5ml 0.2%ropivacaine as a loading dose after the prosthesis was installed,and an analgesic pump was installed.Visual analogue scale(VAS)scores during rest and exercise were recorded 6 h,12 h,24 h and 48 h after operation in two groups.Muscle strength of quadriceps femoris and knee angle when doing active exercise(AE)and passive exercise,namely continuous passive motion(CPM),at different time points were recorded.The occurrence of adverse reactions was recorded.Results:There were no significant differences between the two groups in VAS scores in the resting state 6 h,12 h,24 h and 48 h postoperatively(P>0.05).The VAS scores in Group N were significantly lower than those in Group I in the state of CPM 24 h[(4.4±0.6)vs(6.3±0.7),P<0.05]and 48 h[(3.8±0.8)vs(6.5±0.6),P<0.05]after operation.The angles of affected limbs in Group N were significantly greater than those in Group I 24 h,48 h and 72 h after operation in the state of AE[(45±5)°vs(30±4)°,(55±5)°vs(48±4)°,(76±5)°vs(69±3)°,P<0.05]and CPM[(66±3)°vs(46±5)°,(76±6)°vs(56±6)°,(88±5)°vs(80±7)°,P<0.05].There were no significant differences in quadriceps muscle strength between the two groups 6 h,12 h,24 h,48 h and 72 h after operation(P>0.05).The proportion of side effects in Group N was smaller than that in Group I(P<0.05).Conclusion:Compared with intravenous analgesia,UGCFNB not only has good analgesic effect in resting state,but also reduces pain in the state of CPM.It can increase angles of affected limbs in the state of AE and CPM,does not affect quadriceps muscle strength,and does not increase postoperative complications.It is beneficial to postoperative analgesia and rapid rehabilitation in patients with TKA.