不同浓度罗哌卡因收肌管阻滞对全膝关节置换术后镇痛效果及股四头肌肌力的影响

Effect of different concentrations of ropivacainefor adductor canal block on postoperative analgesia and quadriceps strength after total knee arthroplasty

目的比较超声引导下采用不同浓度罗哌卡因行收肌管阻滞(ACB)对全膝置换术(TKA)后镇痛效果及股四头肌肌力的影响。方法选取拟在喉罩全麻下行单侧膝置换手术患者60例,男33例,女27例,年龄50~75岁,BMI 17~25 kg/m^2,ASAⅠ-Ⅲ级,随机分为三组:0.25%罗哌卡因组(R1组)、0.375%罗哌卡因组(R2组)和0.5%罗哌卡因组(R3组),每组20例。患者均于术毕即刻于超声下行术侧ACB。记录术后4、8、12、24、48 h静息和运动时的VAS评分,记录术前1 d、术后4、8、12、24、48 h的股四头肌肌力分级,记录术前1 d、术后24、48 h膝关节活动度(ROM),并记录术后48 h内PCIA内舒芬太尼使用量,补救镇痛次数,恶心呕吐、尿潴留等并发症的发生情况。结果与术后4 h比较,术后12、24、48 h R1组静息和运动VAS疼痛评分明显升高(P<0.05)。与R1组比较,术后12、24、48 h R2、R3组静息和运动VAS疼痛评分明显降低(P<0.05)。与术前1 d比较,术后4、8、12、24 h R1组、R2组股四头肌肌力明显降低(P<0.05);术后4、8、12、24、48 h R3组股四头肌肌力明显降低(P<0.05)。与R3组比较,术后48 h R1组、R2组股四头肌肌力明显升高(P<0.05)。与术前1 d比较,术后24、48 h三组ROM明显降低(P<0.05);与R1组比较,术后24、48 h R2、R3组ROM明显升高(P<0.05)。与R1组比较,R2、R3组术后48 h内PCIA内舒芬太尼使用量明显减少,补救镇痛率、恶心呕吐和尿潴留发生率明显降低(P<0.05)。结论全膝关节置换术后镇痛采用0.375%罗哌卡因收肌管阻滞较0.25%浓度镇痛效果明显,减少术后阿片类药物使用量及并发症,较0.5%浓度有更强的股四头肌肌力及更高的膝关节活动度,有助于患者的术后快速康复。

Objective To compare the postoperative analgesia and quadriceps strength among patients undergoing total knee arthroplasty(TKA)with different concentration ropivacaine by ultrasound-guided adductor canal block(ACB).Methods Sixty patients scheduled to undergo unilateral TKA with general anesthesia,aged 50-75 years,BMI 17-25 kg/m^2,ASA physical statusⅠ-Ⅲ,were recruited.They were randomly divided into three groups,0.25%ropivacaine(group R1),0.375%ropivacaine(group R2)and 0.5%ropivacaine(group R3).All patients were conducted ACB by ultrasound immediately after surgery.VAS pain scores of resting and active conditions at 4,8,12,24,and 48 h after operation were recorded.Grades of quadriceps strength were recorded at 1 d before and 4,8,12,24,and 48 h after operation.The joint activity range of motion(ROM)was recorded on preoperative 1 d and 24 h,48 h after operation.Sufentanil dosage within PCIA,supplement times of analgesia,complications such as nausea and vomiting,and urinary retention within 48 h after operation were recorded.Results Compared with 4 h after operation,VAS pain scores of resting and active conditions in group R1 were significantly increased at 12,24,48 h after operation(P<0.05).The VAS pain scores of resting and active conditions in groups R2,R312,24,48 h after operation were significantly lower than those in group R1(P<0.05).Compared with 1 d before operation,quadriceps muscle strength of group R1,R2 decreased significantly 4,8,12,24 h after operation(P<0.05).The quadriceps muscle strength of group R3 decreased significantly 4,8,12,24,48 h after operation(P<0.05).Quadriceps strength in group R348 h after operation were significantly lower than those in groups R1 and R2(P<0.05).The ROM in groups R1,R2,R3 at 24,48 h after operation were significantly lower than 1 d before operation(P<0.05).The ROM in groups R2,R324,48 h after operation were significantly higher than group R1(P<0.05).Amount of sufentanil dosage in PCIA,times of analgesia rescue,nausea,vomiting,and urinary retention within 48 h after operation in groups R2,R3 were significantly lower than group R1(P<0.05).Conclusion Compared with 0.25%ropivacaine,ACB with 0.375%ropivacaine produces better analgesic effect,less postoperative opioid use and adverse events in TKA.Additionally,it has better quadriceps strength and higher joint activity range of motion than 0.5%ropivacaine,which is conductive to the rapid postoperative rehabilitation.