两次小剂量地塞米松在高龄股骨颈骨折患者人工股骨头置换围手术期中的应用效果分析

Analysis of the application effect of two low-dose dexamethasone in the perioperative period of artificial femoral head replacement in elderly patients with femoral neck fracture

目的:探讨两次小剂量地塞米松在高龄股骨颈骨折患者行人工股骨头置换的围手术期中应用的临床疗效和安全性。方法:前瞻性随机对照研究。纳入2016年11月—2020年2月南京医科大学附属逸夫医院骨科高龄股骨颈骨折患者34例,其中男10例、女24例,年龄75~93岁,平均84.57岁。34例患者按数字表法随机分为地塞米松组和对照组,每组17例。地塞米松组入院后2 h内和术后第1天给予地塞米松10 mg静脉推注,对照组入院2 h内和术后第1天分别对应给予静脉生理盐水2 mL推注。比较两组患者入院后8 h及术后24、48、72 h静息状态及运动状态下患侧髋关节疼痛视觉模拟评分法(VAS)评分,术前及术后24、72 h的C反应蛋白(CRP)、白细胞介素-6(IL-6)表达水平,术后恶心呕吐(PONV)的发生率、术后患者使用镇吐药物甲氧氯普胺的情况。术前和术后第3天采用围手术期疲乏量表(ICFS)评估疲劳程度,术后第3天采用测角仪测量髋关节活动范围(ROM)以评估髋关节功能,对比两组患者疲劳程度、髋关节功能以及患者术后并发症发生情况。结果:地塞米松组在静息状态下术后24 h以及运动状态下术后24、48 h VAS评分[(2.85±0.90)、(4.12±0.76)、(3.12±0.93)分]低于对照组[(3.91±0.85)、(5.85±0.98)、(4.76±1.15)分],差异均有统计学意义( t=-3.528、-5.765、-4.603, P值均<0.01)。地塞米松组术后24、72 h CRP和IL-6均明显低于对照组,差异均有统计学意义( P值均<0.05)。地塞米松组PONV发生率为4/17,甲氧氯普胺用量(5.88±7.12)mg,均低于对照组的11/17、(10.59±5.56)mg,差异均有统计学意义( P值均<0.05)。术后第3天,地塞米松组ICFS评分(59.41±4.12)分,低于对照组的(67.76±5.36)分,髋关节ROM 101.29°±4.78°,高于对照组95.65°±5.21°,差异均有统计学意义( t=-5.095、3.294, P值均<0.01)。两组患者在院期间及出院1个月的随访中,仅地塞米松组发生浅表伤口感染1例,两组均未发现伤口深部感染、下肢深静脉血栓形成以及胃肠道出血。 结论:高龄股骨颈骨折患者行人工股骨头置换术围手术期应用两次10 mg地塞米松,能有效减轻患者手术后疼痛感,可降低术后CRP、IL-6水平,减少术后PONV发生率,降低术后疲劳程度,增加关节活动度,且不增加早期手术切口感染和消化道出血风险。

Objective This study aims to explore the clinical efficacy and safety of two low-dose dexamethasone in the perioperative period of the artificial femoral head replacement in elderly patients with femoral neck fracture.Methods This was a prospective randomized controlled study.From November 2016 to February 2020,34 elderly patients with femoral neck fracture(10 males and 24 females,average age=84.57 years[range:75-93 years])in the Department of Orthopedics,Sir Run Run Hospital,Nanjing Medical University were enrolled.A total of 34 patients were randomly divided into the dexamethasone and the control groups(17 cases in each group).The dexamethasone and the control groups were intravenously injected with 10 mg dexamethasone and 2 ml normal saline,respectively,within 2 h after admission and the first day after operation.The visual analog scale(VAS)of the hip joint pain in the resting and the exercise states at 8 h after admission and 24,48,and 72 h after operation,and the expression levels of the C reactive protein(CRP)and interleukin-6(IL-6)before and 24 and 72 h after operation,the incidence of postoperative nausea and vomiting(PONV),and the average use of metoclopramide were compared between the two groups.The degree of fatigue was assessed using identity consequence fatigue scale(ICFS).The range of motion(ROM)of the hip joint was measured using a goniometer on the third day after operation to evaluate the function of the hip joint and the incidence of postoperative complications.Results The VAS scores of the dexamethasone group were significantly lower than those of the control group([2.85±0.90],[4.12±0.76],[3.12±0.93]points)24 hours after operation under resting state and exercise state([3.91±0.85],[5.85±0.98],[4.76±1.15]points),and the differences were statistically significant(t=-3.528,-5.765,-4.603,all P values<0.05).The CRP and the IL-6 levels in the dexamethasone group were significantly lower than those in the control group at 24 and 72 h after the operation(all P values<0.05).The incidence of PONV and the dosage of metoclopramide in the dexamethasone group were 4/17 and(5.88±7.12)mg,respectively,which were significantly lower than those of the control group(11/17 and[10.59±5.56]mg;all P values<0.05).On the third day after the operation,the ICFS score of the dexamethasone group was 59.41±4.12,which was lower than that of the control group(67.76±5.36),and the ROM of the hip joint was 101.29°±4.78°in the dexamethasone group and 95.65°±5.21°in the control group.The differences were statistically significant(t=-5.095,3.294,all P values<0.01).During the hospital stay and one month follow-up,only one case of superficial wound infection occurred in the dexamethasone group.No deep wound infection,deep vein thrombosis,and gastrointestinal bleeding was found in both groups.Conclusions The administration of 10 mg dexamethasone twice in the perioperative period of the femoral head replacement in elderly patients with femoral neck fracture can effectively reduce the postoperative pain,rede the levels of CRP and IL-6,rede the incidence of postoperative PONV,and the degree of postoperative fatigue,increase joint mobility,which does not increase the risk of early surgical incision infection and gastrointestinal bleeding.