三种院前镇痛方式老年髋部骨折患者术后转归临床研究

Effects of three pre-hospital analgesia methods on the prognosis of elderly patients with hip fracture

目的:对比不同院前镇痛方式对老年髋部骨折患者术后转归影响的差异。方法:选取老年髋部骨折患者180例,按随机数字表法分为3组(每组60例):非甾体药物镇痛组(N组)、髂筋膜阻滞组(F组)、腰丛阻滞组(L组),分别于急诊入院前行口服非甾体药物镇痛治疗、超声引导下髂筋膜阻滞镇痛治疗和腰丛神经阻滞治疗。于疼痛治疗前(T 0)、疼痛治疗后(T_(1))、术晨(T_(2))、术后24 h(T_(3))、术后72 h(T_(4))行VAS疼痛评分,于T_(2)、T_(3)、T_(4)时测定血清IL-6、TNF-α、P物质浓度。记录患者ICU入住率、住院时间、术后1个月及6个月病死率、并发症发生情况。术后1个月、3个月及6个月时电话随访患者,根据巴氏评分对其进行日常生活能力评估。 结果:F组和L组呼吸衰竭、心力衰竭发生率高于N组( P<0.05)。3组患者血清IL-6浓度随着时间的变化先升高后降低,TNF-α随着时间的变化逐步降低,F组、L组T_(2)时血清IL-6浓度低于N组( P<0.05),F组、L组T_(3)、T_(4)时血清IL-6、TNF-α浓度低于N组( P<0.05);T_(2)、T_(3)、T_(4)时F组、L组血清P物质浓度低于N组( P<0.05),T_(2)、T_(3)时L组血清P物质浓度低于F组( P<0.05),N组、L组患者的血清P物质指标随着时间变化先降低后升高,F组随时间变化逐渐降低。3组患者的静息VAS疼痛评分、运动VAS疼痛评分在T_(1)时较T 0明显下降,后随着时间的变化有不同程度改变;F组、L组T_(1)、T_(4)时静息及运动VAS疼痛评分低于N组( P<0.05),L组T 0时运动VAS评分高于F组和N组( P<0.05),L组T_(1)时运动VAS评分低于F组( P<0.05)。F组、L组术后至少发生一种并发症的发生率及谵妄发生率低于N组( P<0.05),F组住院天数短于N组、L组( P<0.05)。其余指标差异无统计学意义( P>0.05)。 结论:三种院前镇痛方案中,院前区域阻滞镇痛可降低患者围手术期静息痛及运动痛、围手术期炎性反应及谵妄的发生率,缩短住院时间。腰丛神经阻滞效果并不优于髂筋膜阻滞,院前区域阻滞镇痛对远期预后影响尚需进一步研究。

Objective To compare the effects of different pre-hospital analgesia on the prognosis of elderly patients with hip fracture after surgery.Methods A total of 180 elderly patients with hip fractures were enrolled.According to the random number table method,they were divided into three groups(n=60):a non-steroidal analgesia group(group N),a fascia iliaca block group(group F),and a lumbar plexus block group(group L).Before admission to the emergency department,the three groups underwent oral non-steroidal analgesia,ultrasound-guided iliac fascia block analgesia,and lumbar plexus block,respectively.Their Visual Analogue Scale(VAS)scores were assessed before pain treatment(T0),after pain treatment(T_(1)),in the early morning of the surgery day(T_(2)),24 h after surgery(T_(3)),and 72 h after surgery(T_(4)).The levels of serum interleukin(IL)-6,tumor necrosis factor(TNF)-αand substance P were measured at T_(2),T_(3),and T_(4).The intensive care unit(ICU)admission rate,the length of hospitalization stay,the mortality of 1 and 6 months after operation,and complications were recorded.Patients were followed up by telephone 1,3,and 6 months after surgery.According to the modified version of Barthel score sheet,their abilities of daily living were evaluated.Results The incidence of respiratory failure and heart failure was higher in groups F and L than group N(P<0.05).The serum IL-6 concentration of the three groups first increased along with time and then decreased,while TNF-αconcentration gradually decreased along with time.Groups F and L produced lower serum IL-6 concentrations than group N at T_(2)(P<0.05),and lower serum IL-6 and TNF-αconcentrations than group N at T_(3) and T_(4)(P<0.05).The serum substance P concentration was lower in groups F and L than group N at T_(2),T_(3),and T_(4)(P<0.05),while the serum P substance concentration was lower in group L than group F at T_(2) and T_(3)(P<0.05).The serum substance P index of group N and group L decreased first and then increased with time,while that of group F decreased gradually with time;The rest VAS pain score and exercise VAS pain score of the three groups decreased significantly at T_(1),and then changed with time.The VAS scores at rest and during movement were lower in groups F and L than those in group N at T_(1) and T_(4)(P<0.05);group L produced a higher VAS score during movement than groups F and N at T0(P<0.05),and a lower VAS score during movement than group F at T_(1)(P<0.05).Groups F and L presented a lower incidence of at least one postoperative complication than group N(P<0.05),and a lower incidence of delirium than group N(P<0.05).The length of hospitalization stay in group F was shorter than that in groups N and L(P<0.05).The difference in other indicators was not statistically significant(P>0.05).Conclusions Among the three prehospital analgesia methods,prehospital regional block analgesia can significantly relieve perioperative pain at rest and during movement,reduce perioperative inflammation and the incidence of delirium,and shorten the length of hospitalization stay to some certain extent;lumbar plexus nerve block is not superior to iliac fascia block;the effects of prehospital regional block analgesia on long-term prognosis needs further study.