局部浸润麻醉和股神经阻滞对全膝关节置换后镇痛作用和安全性比较的Meta分析

Local infiltration anesthesia versus femoral nerve block for pain control and safety after total knee arthroplasty: a meta-analysis

目的:局部浸润麻醉和股神经阻滞是全膝关节置换后常见的镇痛方法,但哪种是最佳的镇痛方法仍存在争议。有研究发现,由于局部浸润麻醉中各药物搭配的差异会导致结果存在较大偏倚,这可能是以往结果不统一的原因之一。文章系统评价使用固定药物成分(局麻药+非类固醇抗炎药+肾上腺素)的局部浸润麻醉与股神经阻滞在全膝关节置换后的镇痛疗效和安全性差异。方法:用检索词"Total knee arthroplasty,Local infiltration analgesia,Periarticular infiltration,Femoral nerve block"全面检索PubMed、EMbase、Cochrane Library、Web of Science和Viod数据库建库至2020-06-30关于局部浸润麻醉和股神经阻滞在膝关节置换镇痛中的随机对照临床试验。采用Cochrane风险偏倚表评估纳入文献质量。采用RevMan 5.3软件进行Meta分析,评价指标包括主要的疼痛结果、次要的功能结果和并发症。结果:①纳入9篇文献共514例患者,均为随机对照试验,文献质量评估提示纳入文献质量较高;②结果显示,两组患者在术后24 h静息、48 h静息、24 h运动和48 h运动的目测类比评分、48 h内阿片类药物消耗量、24 h和48 h膝关节活动度、住院时间、6周时6 min步行试验、感染发生率和恶心呕吐发生率方面差异无显著性意义(P> 0.05);但局部浸润麻醉组的24 h内阿片类药物消耗量明显低于股神经阻滞组(MD=-4.09,95%CI:-6.10至-2.08,P <0.000 1)。结论:局部浸润麻醉在全膝关节置换后急性期疼痛控制方面优于股神经阻滞,且膝关节功能恢复和并发症方面无显著差异,加上局部浸润麻醉操作简单、费用低廉,文章推荐其作为临床全膝关节置换后镇痛的最佳治疗方法。

OBJECTIVE:Local infiltration anesthesia and femoral nerve block are very prevalent anesthesia methods after total knee arthroplasty.However,which one was optimal in pain control was still controversial.The difference of components in local infiltration anesthesia led to great bias in outcomes,which may be one reason for the inconsistent results in the past.We took a systematic review to compare the efficacy and safety of femoral nerve block with the local infiltration anesthesia that use the fixed drug compositions(local anesthetics+nonsteroid anti-inflammatory drugs+epineph rines)for total knee arthroplasty.METHODS:Randomized controlled trials concerning local infiltration anesthesia and femoral nerve block on pain control after total knee arthroplasty from PubMed,Embase,Cochrane Library,Web of Science and Viod were sea rched until June 30,2020 by using the following terms"total knee a rthroplasty,local infiltration analgesia,pe riarticular infiltration,femoral nerve block".The quality of the included study was assessed using the Cochrane risk of bias to ble.The data were analyzed by RevMan 5.3 software for meta-analysis.The evaluation indexes contained main pain outcomes,secondary functional outcomes,and complications.RESULTS:(1)A total of 9 studies including 514 patients were included,all of which were randomized controlled trials.The lite rature quality evaluation indicated that the quality of the included literatures was relatively high.(2)The pooled data vndicated that there was no significant difference in visual analogue scale score at 24 hours on rest,48 hours on rest,24 hours on motion and 48 hours on motion,opioid consumption at 48 hours,range of motion at 24 and 48 hours,length of hospital stay,6-minute walk test at 6 weeks,rate of infection and rate of nausea and vomiting between two groups(P>0.05).However,the local infiltration anesthesia consumed significantly less opioid than fe moral nerve block at 24 hours(MD=-4.09,95%C/:-6.10 to-2.08,P<0.0001).CONCLUSION:Local infiltration anesthesia with the fixed compositions was superior to femoral nerve block in pain control of acute phase after total knee arthroplasty,and there was no significant difference in knee function recovery and complications.Considering that local infiltration anesthesia was easier to operate and less expensive,we recommended local infiltration anesthesia as the optimal pain management after total knee arthroplasty.