酮咯酸氨丁三醇静脉自控镇痛联合髂筋膜阻滞对全髋关节置换术糖尿病患者术后镇痛的效果

The effect of ketorolac tromethamine patient-controlled intravenous analgesia combined with fascia iliaca block on postoperative analgesia in diabetic patient after total hip joint replacement

目的探讨酮咯酸氨丁三醇联合髂筋膜阻滞对糖尿病患者全髋关节置换术后镇痛效果及炎症因子的影响。方法收集2021年5月至2021年9月在山西医科大学第二医院骨科择期行全髋关节置换术的糖尿病患者90例, 按随机数字表法分为阻滞组(A组)、酮咯酸氨丁三醇(B组)和联合组(C组), 每组30例。A组术毕行髂前上棘上水平髂筋膜阻滞, 药物剂量0.25%罗哌卡因30 ml。B组术毕给予患者静脉自控镇痛(PCIA)(酮咯酸氨丁三醇、舒芬太尼和生理盐水混合液, 酮咯酸氨丁三醇浓度为1.8 mg/ml, 舒芬太尼1.0 μg/ml, 背景输注剂量2 ml/h, PCA单次按压剂量0.5 ml, 锁定时间15 min), 持续用药48 h。C组术毕行髂前上棘上水平髂筋膜阻滞, 方法同A组, 然后连接PCIA泵, 方法同B组。评价指标包括:术毕未镇痛时(T0)、镇痛后24 h(T1)及镇痛后48 h(T2)患者的血压和心率;记录T0、T1和T2时刻患者血浆中IL-1β、IL-6、TNF-α表达水平以及T0、T1和T2时刻患者静息疼痛的视觉模拟评分(VAS)和血糖水平。结果 C组患者T1和T2时VAS评分(2.1±0.6、2.0±0.5)分均显著低于A组(3.6±0.9、3.8±0.8)分和B组(3.0±0.7、3.1±0.7)分;C组患者T1和T2时MAP为(86±7、83±7)mm Hg、HR分别为(83±8、82±8)次/min显著低于A组的MAP(94±4、90±6)mm Hg和HR(95±7、92±6)次/min(P均<0.05), C组患者T2时的MAP和HR[(83±7)mm Hg、(82±8)次/min]显著低于B组[(86±8)mm Hg、(88±6)次/min](P均<0.05);C组患者T1和T2时血糖水平(10.2±0.7、9.2±0.6)mmol/L显著低于A组(12.6±1.0、12.6±1.0)mmol/L和B组(12.0±0.8、10.9±0.8)mmol/L(P均<0.05);C组患者T1和T2时血清中的IL-1β(12.0±0.3、9.1±1.2)pg/ml、IL-6(63.0±6.9、53.3±5.2)pg/ml和TNF-α(113.6±9.1、93.4±6.2)pg/ml显著低于A组的IL-1β(15.3±1.3、12.0±0.3)pg/ml、IL-6(88.9±6.2、75.4±8.1)pg/ml和TNF-α(162.2±11.2、123.5±10.5)pg/ml以及B组的IL-1β(13.6±1.2、11.0±0.7)pg/ml、IL-6(80.3±7.3、65.3±5.8)pg/ml和TNF-α(142.2±11.3、110.4±9.3)pg/ml(P均<0.05)。结论酮咯酸氨丁三醇联合髂前上棘上水平髂筋膜阻滞可获得满意的术后镇痛效果, 维持血液动力学的稳定, 而且能降低患者的高血糖水平和炎症因子的表达, 显著改善患者预后。

Objective To investigate the effect of ketorolac tromethamine patient-controlled intravenous analgesia(PCIA)combined with iliac fascia block on postoperative analgesia and inflammatory factors in diabetic patients undergoing total hip joint replacement.Methods Ninety diabetic mellitus patients received total hip joint replacement in Second Hospital of Shanxi Medical University from May 2021 to September 2021 were collected and randomly divided into the block group(group A),the ketorolac tromethamine group(group B)and the combination group(group C)(n=30 each).In the block group,iliac fascia block with 30 ml of 0.25%ropivacaine was performed after the operation.In the ketorolac tromethamine group,PCIA was performed(ketorolac tromethamine 1.8 mg/ml,sufentanil 1.0μg/ml and normal saline mixture,background infusion dose 2 ml/h,single pressing dose of PCA 0.5 ml,and locking time 15 min)for 48 hours.In the combination group,patients were firstly given iliac fascia block in the same way as group A at the end of the operation,and then received PCIA pump in the same way as group B.The BP and HR were measured before starting analgesia(T0),24 hours after analgesia(T1)and 48 hours after analgesia(T2).The level of IL-1β,IL-6 and TNF-αin plasma at the time of T0,T1 and T2 were measured.The visual analogue scale(VAS)and blood glucose level were compared during the three groups at the time of T0,T1 and T2.Results The VAS were significantly lower at T1 and T2 in the combination group(2.1±0.6,2.0±0.5)than those in the block group(3.6±0.9,3.8±0.8)and in the Ketorolac tromethamine group(3.0±0.7,3.1±0.7)(all P<0.05).The MAP(86±7,83±7)mmHg and HR(83±7,82±8)beats/min were significantly lower at T1 and T2 in the combination group than MAP(94±4,90±6)mm Hg and HR(95±7,92±6)beats/min in the block group(all P<0.05),the MAP(83±7 mm Hg)and HR(82±8 beats/min)were significantly lower at T2 in the combination group than MAP(86±8 mm Hg)and HR(88±6 beats/min)in the ketorolac tromethamine group(all P<0.05).The blood glucose levels(10.2±0.7,9.2±0.6)mmol/L were significantly lower at T1 and T2 in the combination group than those in the block group(12.6±1.0,12.6±1.0)mmol/L and the ketorolac tromethamine group(12.0±0.8,10.9±0.8)mmol/L(all P<0.05).The serum levels of IL-1β(12.0±0.3,9.1±1.2)pg/mL,IL-6(63.0±6.9,53.3±5.2)pg/ml and TNF-α(113.6±9.1,93.4±6.2)pg/ml were significantly lower at T1 and T2 in the combination group than IL-1β(15.3±1.3,12.0±0.3)pg/ml,IL-6(88.9±6.2,75.4±8.1)pg/mland TNF-α(162.2±11.2,123.5±10.5)pg/ml in the block group and IL-1β(13.6±1.2,11.0±0.7)pg/ml,IL-6(80.3±7.3,65.3±5.8)pg/ml and TNF-α(142.2±11.3,110.4±9.3)pg/ml in the ketorolac tromethamine group(all P<0.05).Conclusion PCIA with ketorolac tromethamine combined with iliac fascia block can obtain satisfactory analgesic effect,maintain the stability of hemodynamics,and also reduce the blood glucose level and the expression of inflammatory factors,reduce the adverse reactions caused by stress response and blood glucose fluctuation in patients with diabetic mellitus,so as to improve the prognosis of the patients.