腘动脉与后膝关节囊间隙联合隐神经阻滞及 “鸡尾酒”疗法在老年患者全膝关节置换术 中的应用效果观察

Application of ultrasound-guided interspace between the popliteal artery and the capsule of the posterior knee blocks combined with saphenous nerve block and"cocktail"therapy in analgesia after total knee arthroplasty in elderly people

目的探讨超声引导下腘动脉与后膝关节囊间隙(IPACK)联合隐神经阻滞及“鸡尾酒”疗法在老年患者全膝关节置换术(TKA)中的应用效果。方法前瞻性随机对照研究。纳入2020年10月—2021年9月蚌埠医学院第一附属医院60例择期行单侧TKA的老年患者,其中男19例、女41例,年龄60~85(69.0±6.1)岁。按照数字表法将患者随机分为3组,每组20例:IPACK联合隐神经阻滞及“鸡尾酒”疗法为A组,坐骨神经联合股神经及股外侧皮神经阻滞组为B组,单纯全身麻醉为对照组。观测指标:(1)比较患者年龄、性别、体质量指数、麻醉前生命体征(平均动脉压、心率、外科容积指数)等基线资料;(2)比较患者术中的生命体征变化;(3)比较患者术前和术后24 h炎性因子白细胞介素(IL)-1β、C反应蛋白(CRP)浓度;(4)比较患者术后6、12、24和48 h运动及静息数字评价量表(NRS)疼痛评分;(5)比较患者术后首次自主下床活动时间、术后住院时间,以及术后12、24和48 h膝关节活动度;(6)比较患者术后一般临床情况(苏醒时间、拔管时间、瑞芬太尼用量)、镇痛泵按压次数、镇痛的补救率及相关不良反应(恶心呕吐、嗜睡、心动过缓)的发生情况。结果(1)3组患者的基线资料比较差异均无统计学意义(P值均>0.05)。(2)术中切皮、扩髓及手术结束时,A、B组的平均动脉压、心率、外科容积指数均低于对照组,差异均有统计学意义(P值均<0.05)。(3)患者术后24 h的IL-1β、CRP浓度对照组均高于A、B组(P值均<0.05),A组与B组比较差异均无统计学意义(P值均>0.05)。(4)术后6、12、24、48 h,A、B组静息及运动NRS疼痛评分均明显低于对照组,差异均有统计学意义(P值均<0.05)。(5)术后12、24、48 h,A组患者的膝关节活动度(38.4°±8.9°、67.4°±8.2°、82.1°±8.8°)明显大于B组(29.5°±9.6°、61.3°±7.1°、72.3°±7.1°)和对照组(30.8°±6.8°、59.9°±7.6°、69.2°±7.4°),差异均有统计学意义(F=6.27、5.45、14.73,P值均<0.05),B组与对照之间差异均无统计学意义(P值均>0.05);术后住院时间和首次自主下床活动时间A组最短,为(27.0±5.8)h、(3.8±0.8)d,对照组为(39.6±6.4)h、(4.6±0.9)d,B组为(47.7±4.0)h、(5.2±0.8)d,差异均有统计学意义(F=71.33、11.71,P值均<0.001)。(6)A、B组的苏醒时间、拔管时间及瑞芬太尼用量、术后镇痛补救与不良反应均低于对照组,差异均有统计学意义(P值均<0.05);A、B组比较差异均无统计学意义(P值均>0.05)。结论老年患者TKA行IPACK联合隐神经阻滞及“鸡尾酒”疗法,术中及术后患者镇痛效果较好,住院时间短,运动功能干扰小,对TKA后老年患者的早期功能锻炼起到一定的积极作用。

Objective To investigate the effect of ultrasound-guided interspace between the popliteal artery and the capsule of the posterior knee(IPACK)blocks combined with saphenous nerve block and"cocktail"therapy in elderly patients undergoing total knee arthroplasty(TKA).Methods This study was a prospective study.The clinical data of 60 elderly patients undergoing unilateral TKA in the First Affiliated Hospital of Bengbu Medical College from October 2020 to September 2021 were included.There were 19 males and 41 females,aged 60-85(69.0±6.1)years.The patients were randomly divided into three groups:group A received IPACK combined with saphenous nerve block and"cocktail"therapy,group B received sciatic nerve combined with femoral nerve and lateral femoral cutaneous nerve block,and the control group received simple general anesthesia,with 20 cases in each group.Outcome measures including:(1)baseline data such as age,gender,body mass index,and vital signs before anesthesia(mean arterial pressure[MAP],heart rate,surgical pleth index[SPI]);(2)changes of vital signs;(3)expression levels of C reactive protein(CRP)and interleukin-1β(IL-1β)before operation and 24 h after operation;(4)Numerical rating scale(NRS)pain score at 6,12,24,and 48 h after operation;(5)patients'first time out of bed activity time after surgery,postoperative hospital stay,and knee joint activity at 12 h,24 h,and 48 h after operation;(6)general clinical conditions(recovery time,extubation time,dosage of remifentanil),effective pressing times of analgesic pump,recovery rate of analgesia,and incidence of related adverse reactions(nausea,vomiting,drowsiness,and bradycardia)were compared.Results(1)No significant difference was observed in baseline data among the three groups(all P values>0.05).(2)The changes of vital signs in the three groups were compared the heart rate(HR),MAP,and SPI in groups A and B were lower than those in the control group(all P values<0.05).(3)The levels of IL-1βand CRP in the control group at 24 h after surgery were higher than those in groups A and B(all P values<0.05),and no statistical significance was observed between group A and group B(all P values>0.05).(4)At 6,12,24,and 48 h postoperatively,the resting and exercise NRS pain scores in groups A and B were significantly lower than those in the control group,with statistical significance(all P values<0.05).(5)The range of motion of the knee joint in group A(38.4°±8.9°,67.4°±8.2°,82.1°±8.8°)was significantly higher than that in group B(29.5°±9.6°,61.3°±7.1°,72.3°±7.1°)and the control group(30.8°±6.8°,59.9°±7.6°,69.2°±7.4°),the differences were statistically significant(F=6.27,5.45,14.73,all P values<0.05).No significant difference was observed between group B and the control group(all P values>0.05).The postoperative hospital stay and the first independent ambulation time were the shortest in group A[(27±5.8)h,(3.8±0.8)days],followed by the control group[(39.6±6.4)h,(4.6±0.9)days]and group B[(47.7±4.0)h,(5.2±0.8)days].The differences were statistically significant(F=71.33,11.71,all P values<0.001).(6)The recovery time,extubation time,and remifentanil dosage of groups A and B were lower than those of the control group(all P values<0.05).The recovery rate of postoperative analgesia and the incidence of adverse reactions in groups A and B were lower than those in the control group(all P values>0.05).Conclusion IPACK combined with saphenous nerve block and"cocktail"therapy for elderly patients undergoing TKA surgery has good analgesic effect,short hospital stay,and small interference of motor function,which plays a positive role in early functional exercise of elderly patients with TKA.