人工全膝关节表面置换术后连续股神经阻滞与经静脉患者自控镇痛的随机对照研究
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摘要
背景:全膝关节表面置换术(total knee arthroplasty,TKA)后重度疼痛的发生率高,患者自控镇痛(patient controlled analgesia,PCA)和连续股神经阻滞(continuous femoral nerve block,CFNB)是TKA后常用的镇痛方法。目的:比较CFNB与经静脉PCA在TKA围手术期镇痛中的有效性和安全性。方法:120例全身麻醉下行单膝TKA的患者,随机分成三组,分别接受CFNB(A组),静脉PCA(B组)和单次股神经阻滞联合静脉PCA(C组)作为术后镇痛方式。观察术后不同时间点静息和活动疼痛视觉模拟评分(VAS)及动态VAS评分与静态VAS评分差值(Δ_(动态VAS-静态VAS)),关节活动度(ROM)及术后吗啡的使用量。同时记录镇痛相关并发症。结果:术后各观察时间点内,A组及C组患者动静态VAS评分均显著低于B组,A组与C组术后VAS评分无差异。A组术后第3天,Δ_(动态VAS-静态VAS)最低。术后第6天,三组Δ_(动态VAS-静态VAS)无差异。C组吗啡使用量及PCA按压次数明显少于B组。术后第6天,三组膝ROM无统计学差异(A组114°,B组111°,C组114°)。A组有2例出现镇痛失败,1例出现术后导管脱落,行静脉PCA补救镇痛。B组术后恶心、呕吐发生率为42%,显著高于A组(8%)及C组(25%)。结论:TKA术后,CFNB镇痛可获得有效的静息镇痛及运动镇痛,有助于关节功能恢复,副作用小,但存在镇痛失败的可能。单次股神经阻滞联联合静脉PCA可减少镇痛不全,PCA用药次数和用量,降低单纯使用静脉PCA镇痛的并发症。
Background: There is a high ratio of postoperative pain after total knee arthroplasty(TKA). Both intravenous patient-controlled analgesia(PCA) and continuous femoral nerve block(CFNB) are common choices for postoperative analgesia. Objective: To compare the effects and safety of CFNB through a catheter versus PCA with intravenous morphine for analgesia after TKA. Methods: Totally 120 knee osteoarthritis patients who underwent unilateral TKA under general anesthesia were randomly allocated to three groups(n=40): group A(postoperative analgesia with CFNB), group B(intravenous PCA), and group C(bolus FNB plus intravenous PCA). Postoperative VAS score at rest(VAS-R) and during movement(VAS-M), difference between VAS-M and VAS-R(Δ_(VAS-M–VAS-R)), range of motion(ROM) during exercise, morphine consumption and complications related to pain control were recorded. Results: Both VAS-R and VAS-M in group A and C were significantly lower than those in group B at all observation time points, but there was no significant difference in the VAS scores between group A and C. Δ_(VAS-M–VAS-R)reached the lowest in group A on day 3 postoperatively. No significant difference was found in ΔVAS-M – VAS-Ron day 6 postoperatively between groups. Group C had significantly lower morphine consumption and PCA requirement than group B. There was no significant difference in the average ROM at postoperative 6-day between groups(group A: 114°, group B: 111°, group C: 114°). In group A, analgesia failed in 2 cases and femoral catheter dislodged in 1 case, who switched to intravenous PCA. The rate of postoperative nausea and vomiting(PONV) was 42% in group B,which was significant higher than that in group A(8%) and group C(25%). Conclusions: CFNB can achieve effective pain control both at rest and at movement after TKA, as well as satisfactory knee rehabilitation and less side-effect. Bolus FNB combined with intravenous PCA has less failed analgesia than CFNB, and can significantly decrease the complications as compared with only intravenous PCA.
Background: There is a high ratio of postoperative pain after total knee arthroplasty(TKA). Both intravenous patient-controlled analgesia(PCA) and continuous femoral nerve block(CFNB) are common choices for postoperative analgesia. Objective: To compare the effects and safety of CFNB through a catheter versus PCA with intravenous morphine for analgesia after TKA. Methods: Totally 120 knee osteoarthritis patients who underwent unilateral TKA under general anesthesia were randomly allocated to three groups(n=40): group A(postoperative analgesia with CFNB), group B(intravenous PCA), and group C(bolus FNB plus intravenous PCA). Postoperative VAS score at rest(VAS-R) and during movement(VAS-M), difference between VAS-M and VAS-R(Δ_(VAS-M–VAS-R)), range of motion(ROM) during exercise, morphine consumption and complications related to pain control were recorded. Results: Both VAS-R and VAS-M in group A and C were significantly lower than those in group B at all observation time points, but there was no significant difference in the VAS scores between group A and C. Δ_(VAS-M–VAS-R)reached the lowest in group A on day 3 postoperatively. No significant difference was found in ΔVAS-M – VAS-Ron day 6 postoperatively between groups. Group C had significantly lower morphine consumption and PCA requirement than group B. There was no significant difference in the average ROM at postoperative 6-day between groups(group A: 114°, group B: 111°, group C: 114°). In group A, analgesia failed in 2 cases and femoral catheter dislodged in 1 case, who switched to intravenous PCA. The rate of postoperative nausea and vomiting(PONV) was 42% in group B,which was significant higher than that in group A(8%) and group C(25%). Conclusions: CFNB can achieve effective pain control both at rest and at movement after TKA, as well as satisfactory knee rehabilitation and less side-effect. Bolus FNB combined with intravenous PCA has less failed analgesia than CFNB, and can significantly decrease the complications as compared with only intravenous PCA.
引文
[1]Singelyn FJ,Deyaert M,Joris D,et al.Effects of intravenous patient-controlled analgesia with morphine,continuous epidural analgesia,and continuous three-in-one block on postoperative pain and knee rehabilitation after unilateral total knee arthroplasty.Anesth Analg,1998,87(1):88-92.
[2]Capdevila X,Barthelet Y,Biboulet P,et al.Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery.Anesthesiology,1999,91(1):8-15.
[3]Chelly JE,Greger J,Gebhard R,et al.Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty.J Arthroplasty,2001,16(4):436-445.
[4]Paul JE,Arya A,Hurlburt L,et al.Femoral nerve block improves analgesia outcomes after total knee arthroplasty:a meta-analysis of randomized controlled trials.Anesthesiology,2010,113(5):1144-1162.
[5]张伟,胡焱,刘雪冰,等.持续股神经阻滞用于全膝关节置换术后镇痛的效果分析.北京医学,2013,35(11):942-944.
[6]Zinkus J,Mockut?L,Gelmanas A,et al.Comparison of 2analgesia modalities in total knee replacement surgery:Is there an effect on knee function rehabilitation?Med Sci Monit,2017,23:3019-3025.
[7]Wang F,Zhou Y,Sun J,et al.Influences of continuous femoral nerve block on knee function and quality of life in patients following total knee arthroplasty.Int J Clin Exp Med,2015,8(10):19120-19125.
[8]Momeni M,Crucitti M,De Kock M.Patient-controlled analgesia in the management of postoperative pain.Drugs,2006,66(18):2321-2337.
[9]于华鹏,刘朝晖,郭万首,等.连续股神经阻滞在全膝关节置换术后镇痛及早期康复锻炼中的作用.中国骨伤,2010,23(11):825-827.
[10]Dias AS,Rinaldi T,Barbosa LG.The impact of patients controlled analgesia undergoing orthopedic surgery.Braz J Anesthesiol,2016,66(3):265-271.
[11]Mc Nicol ED,Ferguson MC,Hudcova J.Patient controlled opioid analgesia versus non-patient controlled opioid analgesia for postoperative pain.Cochrane Database Syst Rev,2015,(6):CD003348.
[12]Ng FY,Chiu KY,Yan CH,et al.Continuous femoral nerve block versus patient-controlled analgesia following total knee arthroplasty.J Orthop Surg(Hong Kong),2012,20(1):23-26.
[13]Chan EY,Fransen M,Parker DA,et al.Femoral nerve blocks for acute postoperative pain after knee replacement surgery.Cochrane Database Syst Rev,2014,(5):CD009941.
[14]Moucha CS,Weiser MC,Levin EJ.Current strategies in anesthesia and analgesia for total knee arthroplasty.J Am Acad Orthop Surg,2016,24(2):60-73.
[15]Lavie LG,Fox MP,Dasa V.Overview of total knee arthroplasty and modern pain control strategies.Curr Pain Headache Rep,2016 20(11):59.
[16]Kim DH,Lin Y,Goytizolo EA,et al.Adductor canal block versus femoral nerve block for total knee arthroplasty:a prospective,randomized,controlled trial.Anesthesiology,2014,120(3):540-550.
[2]Capdevila X,Barthelet Y,Biboulet P,et al.Effects of perioperative analgesic technique on the surgical outcome and duration of rehabilitation after major knee surgery.Anesthesiology,1999,91(1):8-15.
[3]Chelly JE,Greger J,Gebhard R,et al.Continuous femoral blocks improve recovery and outcome of patients undergoing total knee arthroplasty.J Arthroplasty,2001,16(4):436-445.
[4]Paul JE,Arya A,Hurlburt L,et al.Femoral nerve block improves analgesia outcomes after total knee arthroplasty:a meta-analysis of randomized controlled trials.Anesthesiology,2010,113(5):1144-1162.
[5]张伟,胡焱,刘雪冰,等.持续股神经阻滞用于全膝关节置换术后镇痛的效果分析.北京医学,2013,35(11):942-944.
[6]Zinkus J,Mockut?L,Gelmanas A,et al.Comparison of 2analgesia modalities in total knee replacement surgery:Is there an effect on knee function rehabilitation?Med Sci Monit,2017,23:3019-3025.
[7]Wang F,Zhou Y,Sun J,et al.Influences of continuous femoral nerve block on knee function and quality of life in patients following total knee arthroplasty.Int J Clin Exp Med,2015,8(10):19120-19125.
[8]Momeni M,Crucitti M,De Kock M.Patient-controlled analgesia in the management of postoperative pain.Drugs,2006,66(18):2321-2337.
[9]于华鹏,刘朝晖,郭万首,等.连续股神经阻滞在全膝关节置换术后镇痛及早期康复锻炼中的作用.中国骨伤,2010,23(11):825-827.
[10]Dias AS,Rinaldi T,Barbosa LG.The impact of patients controlled analgesia undergoing orthopedic surgery.Braz J Anesthesiol,2016,66(3):265-271.
[11]Mc Nicol ED,Ferguson MC,Hudcova J.Patient controlled opioid analgesia versus non-patient controlled opioid analgesia for postoperative pain.Cochrane Database Syst Rev,2015,(6):CD003348.
[12]Ng FY,Chiu KY,Yan CH,et al.Continuous femoral nerve block versus patient-controlled analgesia following total knee arthroplasty.J Orthop Surg(Hong Kong),2012,20(1):23-26.
[13]Chan EY,Fransen M,Parker DA,et al.Femoral nerve blocks for acute postoperative pain after knee replacement surgery.Cochrane Database Syst Rev,2014,(5):CD009941.
[14]Moucha CS,Weiser MC,Levin EJ.Current strategies in anesthesia and analgesia for total knee arthroplasty.J Am Acad Orthop Surg,2016,24(2):60-73.
[15]Lavie LG,Fox MP,Dasa V.Overview of total knee arthroplasty and modern pain control strategies.Curr Pain Headache Rep,2016 20(11):59.
[16]Kim DH,Lin Y,Goytizolo EA,et al.Adductor canal block versus femoral nerve block for total knee arthroplasty:a prospective,randomized,controlled trial.Anesthesiology,2014,120(3):540-550.