预防性中等剂量地塞米松对高龄患者膝关节置换术后恶心呕吐及疼痛的影响

Effect of prophylactic moderate doses of dexamethasone on nausea and vomiting,and pain after knee arthroplasty in elderly patients

目的探讨围术期静脉注射中等剂量地塞米松对高龄患者膝关节置换术后恶心呕吐和疼痛的预防性作用。方法本研究为前瞻性、随机、对照试验。选择2021年1月至5月上海交通大学附属第六人民医院关节外科组收治的160例美国麻醉医师协会(ASA)分级Ⅰ级或Ⅱ级,拟行全麻下全膝关节置换的患者为研究对象。将患者随机分为地塞米松组(80例)和生理盐水组(80例),全麻诱导前20 min分别注射2 ml地塞米松(10 mg)(地塞米松组)或2 ml生理盐水(生理盐水组),其中6例患者手术时间超过200min,予以剔除,最终地塞米松组有78例患者,生理盐水组有76例患者纳入统计分析。主要观察指标为术后4、12、24、36h的视觉模拟评分法(VAS)评分及口头评分量表(VRS)评分;次要观察指标为止痛药和止吐剂的使用情况、血糖水平、住院天数和术后30d感染率。采用SPSS 21.0统计软件进行数据分析。根据数据类型,分别采用方差分析、t检验、χ^(2)检验或Fisher确切概率法进行组间比较。结果膝关节置换术后恶心呕吐和疼痛多发生于24 h以内,地塞米松组术后4、12、24h的VRS评分、术后恶心呕吐(PONV)发生率及VAS评分明显低于生理盐水组,差异均有统计学意义(P<0.05);术后36h,2组患者VRS评分、PONV发生率及VAS评分比较,差异无统计学意义(P>0.05)。术后第1天地塞米松组血糖水平明显高于生理盐水组[(8.5±1.7)mmol/L和(5.9±1.4)mmol/L,P<0.05];术后第3天2组患者血糖水平比较,差异无统计学意义(P>0.05)。2组患者平均住院天数比较,地塞米松组明显少于生理盐水组[(3.0±0.8)d和(4.8±1.5 d)],差异有统计学意义(P<0.05)。2组患者30d内感染率比较,差异无统计学意义(P>0.05)。结论术前预防性静脉注射10 mg地塞米松可有效缓解高龄老年患者全膝关节置换术后恶心呕吐的严重程度和发生率,并显著减轻术后疼痛,同时减少术后镇痛药和止吐药的使用率,并缩短住院天数。

Objective To evaluate the prophylactic effect of perioperative use of moderate-dose intravenous dexamethasone on postoperative nausea and vomiting,and pain after total knee arthroplasty in the elderly patients.Methods This study,a prospective,randomized,controlled trial,selected a total of 160 patients of American Society of Anesthesiologists(ASA)gradeⅠorⅡ,who were admitted to the Joint Surgery Department of the Sixth People′s Hospital Affiliated to Shanghai Jiao Tong University from January to May 2021 and scheduled for total knee arthroplasty under general anesthesia.They were randomly divided into dexamethasone group(n=80)and saline group(n=80).Intravenously,2 ml dexamethasone(10 mg)or 2 ml saline was injected 20 min before the induc-tion of general anesthesia.Six patients whose operation exceeded 200 min were excluded,leaving 78 cases in the dexamethasone group and 76 cases in the saline group for statistical analysis.The primary outcome measures were a visual analogue scale(VAS)at postopera-tive 4,12,24 and 36 h to assess the pain and a verbal rating scale(VRS)to assess the severity and incidence of nausea and vomiting.The secondary indicator were the use of analgesics and antiemetics,blood glucose levels,length of hospital stay,and infection rate at postoperative 30 days.SPSS statistics 22.0 was used for data analysis.Depending on the type of data,analysis of variance,t test,χ^(2) test,or Fisher′s exact test was used for intergroup comparison.Results Nausea,vomiting,and pain occurred mostly within 24 hours after total knee arthroplasty.The VRS scores,incidence of postoperative nausea and vomiting(PONV)and VAS scores in the dexamethasone group were significantly lower than those in the saline group at postoperative 4,12,24 h(P<0.05),but the difference was not signifi-cant at postoperative 36 hours(P>0.05).The blood glucose in dexamethasone group was significantly higher than that in saline group at postoperative 1 day[(8.5±1.7)vs(5.9±1.4)mmol/L;P<0.05],but the difference at postoperative 3 days was not significant(P>0.05).The mean postoperative hospitalization stay was significantly shorter in the dexamethasone group than in the saline group[(3.0±0.8)d vs(4.8±1.5)d;P<0.05].There was no significant difference between the two groups in the infection rate at postop-erative 30 d(P>0.05).Conclusion Preoperative prophylactic intravenous injection of 10 mg dexamethasone can effectively reduce the severity and incidence of nausea and vomiting in the elderly patients after knee arthroplasty,significantly alleviate postoperative pain,reduce postoperative use of analgesics and antiemetics,and shorten hospital stay.