后路QLB联合鸡尾酒疗法在关节镜ACLR术后镇痛中的效果分析

Analgesic effect of posterior quadratus lumborum block combined with cocktail therapy after arthroscopic anterior cruciate ligament reconstruction surgery

目的探讨超声引导下后路腰方肌阻滞(QLB)联合鸡尾酒疗法在关节镜前交叉韧带重建术(ACLR)后镇痛中的效果。方法选取北京大学第三医院延安分院(延安市中医医院)2021年2月至2023年4月接受关节镜下ACLR患者87例进行随机对照研究,采用随机数字表法将其分为A组(n=29)、B组(n=29)、C组(n=29)。A组采用超声引导下后路QLB,B组采用鸡尾酒疗法,C组采用超声引导下后路QLB联合鸡尾酒疗法。比较三组视觉模拟评分法(VAS)评分、膝关节功能、术中及术后一般情况、应激反应、炎症疼痛介质及不良反应。结果术后2 h、术后12 h、术后24 h,C组VAS评分分别为(3.25±0.41)分、(2.03±0.28)分、(0.65±0.09)分,均低于A组的(4.68±0.65)分、(3.28±0.39)分、(1.68±0.22)(t=10.02、14.02、23.34,均P<0.001)和B组的(4.79±0.72)分、(3.20±0.36)分、(1.72±0.24)分(t=9.49、13.82、22.48,均P<0.001)。术后1个月,C组的膝关节协会评分、特种外科医院膝关节评分分别为(92.02±3.33)分、(90.05±3.46)分,均低于A组的(81.85±2.27)分、(82.57±2.34)分(t=13.59、9.64,均P<0.001)和B组的(81.46±2.38)分、(83.22±2.40)分(t=13.89、8.73,均P<0.001)。三组术后72 h膝关节最大主动活动度、股四头肌肌力差异均无统计学意义(均P>0.05)。C组术后首次下床时间、术后首次直腿抬高时间、补救镇痛率、镇痛泵有效按压次数分别为(22.08±4.36)h、(2.26±0.30)h、3.45%、(0.75±0.16)次,均低于、少于A组(t=3.24、8.20,χ^(2)=7.73,t=19.29,均P<0.001)和B组(t=3.01、7.51,χ^(2)=6.44,t=17.34,均P<0.001)。术后24 h,C组血清血管紧张素Ⅱ、促肾上腺皮质激素、β-内啡肽、前列腺素E2均低于A组、B组(均P<0.05)。三组不良反应发生率差异无统计学意义(P>0.05)。结论鸡尾酒疗法联合超声引导下后路QLB可改善关节镜ACLR术后患者膝关节功能,镇痛效果确切,安全有效。

Objective To investigate the analgesic effect of ultrasound-guided posterior quadratus lumborum block(QLB)combined with cocktail therapy after arthroscopic anterior cruciate ligament reconstruction(ACLR)surgery.Methods A randomized controlled study was conducted on 87 patients who underwent arthroscopic ACLR surgery at the Yan'an Branch of Peking University Third Hospital(Yan'an Hospital of Traditional Chinese Medicine)from February 2021 to April 2023.The patients were randomly divided into three groups using the random number table method:Group A(n=29),Group B(n=29),and Group C(n=29).Group A received ultrasound-guided posterior QLB,Group B received cocktail therapy,and Group C received a combination of ultrasound-guided posterior QLB and cocktail therapy.Visual Analogue Scale(VAS)scores,knee function,intraoperative and postoperative general conditions,stress responses,inflammatory pain mediators,and adverse reactions were compared among the three groups.Results At 2,12,and 24 hours after surgery,VAS scores in Group C were(3.25±0.41)points,(2.03±0.28)points,and(0.65±0.09)points,respectively,which were significantly lower than those in Group A[(4.68±0.65)points,(3.28±0.39)points,(1.68±0.22)points,t=10.02,14.02,23.34,all P<0.001]and Group B[(4.79±0.72)points,(3.20±0.36)points,(1.72±0.24)points,t=9.49,13.82,22.48,all P<0.001].At 1 month after surgery,the Knee Society Score and Hospital for Special Surgery knee score in Group C were(92.02±3.33)points and(90.05±3.46)points,respectively,both of which were significantly higher than those in Group A[(81.85±2.27)points,(82.57±2.34)points,t=13.59,9.64,both P<0.001]and Group B[(81.46±2.38)points,(83.22±2.40)points,t=13.89,8.73,both P<0.001].There were no statistically significant differences in maximum active range of motion and quadriceps strength among the three groups at 72 hours after surgery(both P>0.05).The time to first ambulation,time to first straight leg raise,rate of rescue analgesia,and the number of effective activations of the analgesic pump in Group C were(22.08±4.36)hours,(2.26±0.30)hours,3.45%,and(0.75±0.16)times,respectively,all of which were significantly lower than those in Group A(t=3.24,8.20,χ^(2)=7.73,t=19.29,all P<0.001)and Group B(t=3.01,7.51,χ^(2)=6.44,t=17.34,all P<0.001).At 24 hours after surgery,serum levels of angiotensin II,adrenocorticotropin,β-endorphin,and prostaglandin E2 in Group C were significantly lower than those in Groups A and B(all P<0.05).There was no statistically significant difference in the incidence of adverse reactions among the three groups(P>0.05).Conclusion The combination of cocktail therapy and ultrasound-guided posterior QLB can improve knee function in patients after arthroscopic ACLR surgery and provides effective and safe analgesia.