不同镇痛方法对全膝置换术后疼痛控制和炎性细胞因子反应的影响

Effects of different analgesia protocols on postoperative pain control and inflammatory cytokine response after total knee replacement

目的:比较硬膜外、静脉和关节腔内3种镇痛方法,对减轻全膝置换术后疼痛和调控炎性细胞因子反应趋向平衡的效果差异。方法:将60例择期接受全膝关节置换术的患者随机分成3组,每组20例。硬膜外组:硬膜外腔推注负荷量吗啡,术毕接硬膜外镇痛泵;静脉组:静脉滴注负荷量曲马朵,术毕接静脉镇痛泵;关节腔组:关节腔内注射镇痛混合液,回病房后,按需静脉滴注阿片类镇痛药。记录3组患者术后6,18,24 h的视觉模拟疼痛评分(VAS)值。双抗夹心ELISA法检测麻醉开始即刻,术后6 h,18 h,24 h细胞因子TNF-α、IL-1β、IL-6和IL-8的浓度。结果:硬膜外组术后6,18 h的VAS评分明显低于其他两组,而静脉组又低于关节腔组。术后各组TNF-α、IL-1β、IL-6和IL-8浓度均升高,但术后6、18 h硬膜外组明显低于其他两组,且静脉组又明显低于关节腔组。术后24 h上述指标间无明显差异。结论:3种镇痛方法对全膝关节置换术后疼痛的控制和炎性因子反应的调控均有一定效果,其中硬膜外镇痛较其他两组效果更明显,静脉镇痛优于关节腔内镇痛。

Objective:To compare the effects of epidural analgesia,intravenous analgesia and intra-articular analgesia on reducing postoperative pain and modulating the inflammatory cytokine response to tend to balance after total knee replacement.Methods:A total of sixty patients were randomly divided into three groups (n =20).Epidural group:loading dose (morphine) was administrated by epidural injection,and patients controlled epidural analgesia after operation ; intravenous group:loading dose (tramadol) was administrated by intravenous drop,and patients controlled intravenous analgesia after operation; intra-articular analgesia group:a mixed solution was injected into articular cavity.When patients went back to the ward,opioids were administrated by intravenous drop as required.Visual analogue pain scale (VAS) scores were recorded at 6,8 and 24 h postoperation.Plasma levels of tumour necrosis factor-α,interleukin (IL)-1β 、IL-6 and IL-8 were measured immediately at anesthesia and 6,18,24 h postoperation.Results:Compared with the other two groups,VAS pain scores at 6 and 18 h postoperation were significantly lower in the epidural analgesia group.Compared with the intra-articular analgesia group,VAS pain scores at 6 and 18 h postoperation were obviously lower in the intravenous analgesia group.In the three groups,TNF-α,IL-1β,IL-6 and IL-8 levels increased significantly at 6,18,24 h postoperation compared with immediately at anesthesia,and the epidural analgesia group had significantly lower levels of the inflammatory cytokines compared with other two groups; the intravenous analgesia group had obviously lower levels of the inflammatory cytokines compared with intra-articular analgesia group.There was no difference at 24 h postoperation.Conclusion:Three analgesia protocols all reduced postoperative pain and attenuated TNF-α,IL-1 β,IL-6 and IL-8 production 24 h after total knee replacement surgery,but epidural analgesia was better than the other two protocols,and intravenous analgesia was better than intra-articular analgesia.