右美托咪定复合0.2%罗哌卡因股神经阻滞对髌骨骨折的镇痛效果及神经递质的影响

Analgesic effect and neurotransmitter effect of dexmedetomidine combined with 0.2%ropivacaine on femoral nerve block of patellar fractures

目的探讨右美托咪定复合0.2%罗哌卡因股神经阻滞对髌骨骨折患者镇痛效果与神经递质的影响。方法前瞻性研究四川省骨科医院2020年8月—2022年8月收治的70例髌骨骨折患者,男性39例,女性31例;年龄18~59岁,平均43.9岁;道路交通伤35例,摔伤26例,其他9例;左髌骨折36例,右髌骨折34例。患者行髌骨骨折切开复位内固定术,术后行股神经阻滞镇痛。按随机数字表法分成罗哌卡因组与复合组,各35例。罗哌卡因组采用0.2%罗哌卡因阻滞,起始剂量20mL,背景剂量2mL/h,自控药量2mL/次,锁定时间为15min。复合组采用右美托咪定复合0.2%罗哌卡因阻滞,即0.2%罗哌卡因+1μg/kg右美托咪定混合液,给药剂量、方法同罗哌卡因组。比较两组术后2、6、12、24、48h静息、活动状态的视觉模拟评分(visual analogue scale,VAS)。分别在患者术前及术后24h、48h检测血清β-内啡肽(β-endorphin,β-EP)、P物质(substance P,SP)、孤啡肽(orphanin FQ,OFQ)水平,并分别在术前及术后48h,检测血清神经肽Y(neuropeptide-Y,NPY)、前列腺素E2(prostaglandin E2,PGE2)、肿瘤坏死因子-α(tumor necrosis factor-α,TNF-α)水平。结果复合组术后6、12、24、48h的静息状态下VAS低于罗哌卡因组[(2.6±0.4)分vs.(3.5±0.3)分、(2.7±0.3)分vs.(3.4±0.3)分、(2.6±0.4)分vs.(3.4±0.3)分、(2.2±0.4)分vs.(3.0±0.3)分,P<0.05];复合组术后6、12、24、48h活动状态下VAS低于罗哌卡因组[(3.2±0.4)分vs.(3.8±0.5)分、(3.2±0.3)分vs.(3.8±0.5)分、(3.2±0.3)分vs.(3.8±0.4)分、(2.9±0.5)分vs.(3.3±0.3)分,P<0.05]。复合组术后24h血清β-EP、SP、OFQ水平低于罗哌卡因组[(17.5±2.8)ng/L vs.(20.2±3.5)ng/L、(32.4±2.1)ng/L vs.(38.5±3.5)ng/L、(10.1±1.7)ng/L vs.(12.6±1.1)ng/L,P<0.05]。复合组术后48h血清β-EP、SP、OFQ水平低于罗哌卡因组[(14.3±2.1)ng/L vs.(17.1±2.7)ng/L、(29.4±2.5)ng/L vs.(34.1±2.1)ng/L、(7.3±0.7)ng/L vs.(8.9±0.6)ng/L,P<0.05]。复合组术后48h的血清NPY、PGE2、TNF-α水平低于罗哌卡因组[(45.7±3.8)pg/mL vs.(49.8±3.6)pg/mL、(20.3±3.5)ng/mL vs.(24.5±2.0)ng/mL、(296.7±41.1)pg/mL vs.(363.3±39.8)pg/mL,P<0.05]。结论右美托咪定复合0.2%罗哌卡因股神经阻滞能提升髌骨骨折患者的镇痛效果,减轻对术后神经递质、疼痛介质以及炎症的影响。

Objective To investigate the effects of dexmedetomidine combined with 0.2%ropivacaine on analgesia and neurotransmitters by femoral nerve block in patients with patellar fractures.Methods Seventy patients with patellar fractures admitted to Sichuan Orthopedic Hospital from Aug.2020 to Aug.2022 were included in this prospective study,including 39 male and 31 female aged 18-59 years,mean 43.9 years.Among them,35 cases were injured by car accidents,26 by falls,and 9 by others,with 36 left patellar fractures and 34 right patellar fractures.All the patients underwent open reduction and internal fixation for patellar fractures and femoral nerve block for analgesia after surgery.Patients were randomly divided into ropivacaine group and compound group with 35 cases each.The ropivacaine group was treated with 0.2%ropivacaine:the initial dose was 20 mL,the background dose 2 mL/h,the automatic dose 2 mL every time,and the locking time 15 min.The compound group was given dexmedetomidine combined with 0.2%ropivacaine,that is,0.2%ropivacaine and 1μg/kg dexmedetomidine mixture,with the same dosage and method as the ropivacaine group.The visual analogue scale(VAS)at postoperative 2,6,12,24 and 48 h at both rest and active states was assessed for pain.Serum levels ofβ-endorphin(β-EP),substance P(SP)and orphanin FQ(OFQ)were detected before surgery and 24 and 48 h after surgery,and serum levels of neuropeptide Y(NPY),prostaglandin E2(PGE2)and tumor necrosis factor-α(TNF-α)were detected before and 48 h after surgery.Results Preoperative comparison showed no significant difference between two groups.Following analgesia,the VAS at rest state of the compound group was lower than that of the ropivacaine group at 6 h(2.6±0.4 vs.3.5±0.3),12h(2.7±0.3 vs.3.4±0.3),24 h(2.6±0.4 vs.3.4±0.3)and 48 h(2.2±0.4 vs.3.0±0.3)after surgery(all P<0.05);the VAS at active state showed similar result(3.2±0.4 vs.3.8±0.5,3.2±0.3 vs.3.8±0.5,3.2±0.3 vs.3.8±0.4,2.9±0.5 vs.3.3±0.3,all P<0.05).The serum levels(ng/L)ofβ-EP,SP and OFQ in the compound group were much lower than those in the ropivacaine group at 24 h after surgery(17.5±2.8 vs.20.2±3.5,32.4±2.1 vs.38.5±3.5,10.1±1.7 vs.12.6±1.1,all P<0.05)and 48 h after surgery(14.3±2.1 vs.17.1±2.7,29.4±2.5 vs.34.1±2.1,7.3±0.7 vs.8.9±0.6,all P<0.05).At 48 h after surgery,the compound group also revealed much lower levels of serum NPY(pg/mL,45.7±3.8 vs.49.8±3.6),PGE2(ng/mL,20.3±3.5 vs.24.5±2.0)and TNF-α(pg/mL,296.7±41.1 vs.363.3±39.8),compared with the ropivacaine group(all P<0.05).Conclusion Dexmedetomidine combined with 0.2%ropivacaine can improve the analgesic effect of femoral nerve block in patients with patellar fractures and reduce the influence on postoperative neurotransmitters,pain mediators and inflammation factors.