右美托咪定复合罗哌卡因联合收肌管阻滞用于全膝关节置换后镇痛
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摘要
背景:全膝关节置换后大部分患者会出现重度疼痛,对于这类患者如何缓解术后疼痛,减少术后并发症,是促进患者早期快速康复治疗的重点。目的:探讨B超定位下右美托咪定复合罗哌卡因用于收肌管阻滞在全膝关节置换术后的镇痛效果。方法:前瞻性观察2017年10月至2018年9月行单侧、初次全膝关节置换患者40例,随机分为2组,每组20例。罗哌卡因+右美托咪定组给予30 mL 0.375%罗哌卡因+1.5μg/kg右美托咪定,罗哌卡因组仅给予30m L0.375%罗哌卡因,2组均采用收肌管阻滞。治疗方案得到广州医科大学附属第三医院伦理委员会批准(医伦会审[2018]第170号,审批时间2018-10-31),且所有患者均签署知情同意书,手术科室和医生具有关节置换的资质及相关临床经验。2组患者术中均使用全身麻醉,记录手术时间及术中出血量;术后2,4,6,12,24,48 h测量平均动脉压、心率、血氧饱和度以及静息、运动状态下疼痛数字分级、镇痛评分;记录术后48 h内阿片类药物追加使用量、术后不良反应以及血清C-反应蛋白、白细胞介素6水平。结果与结论:①罗哌卡因+右美托咪定组术后2-48 h Ramsay镇静评分均显著高于罗哌卡因组(P <0.05);②在静息状态下2组疼痛数字评价量表评分均随术后时间延长而显著降低(P <0.05),且各时间点罗哌卡因+右美托咪定组疼痛数字评价量表评分较罗哌卡因组显著降低(P <0.05);③在运动状态下2组(12-48 h)疼痛数字评价量表评分均随术后时间延长而显著降低(P <0.05),且在12,24,48 h罗哌卡因+右美托咪定组疼痛数字评价量表评分较罗哌卡因组显著降低(P <0.05);④在心率方面罗哌卡因+右美托咪定组仅在术后48 h较罗哌卡因组显著降低(P <0.05);⑤术后24 h内追加盐酸哌替啶(100 mg/次)者,罗哌卡因组有6例,罗哌卡因+右美托咪定组有1例(P <0.05);术后24 h-48 h内追加者,罗哌卡因组有2例,罗哌卡因+右美托咪定组有3例(P>0.05),所有追加均为1次;⑥在术后不良反应方面,罗哌卡因组患者有1例出现术后恶心,另有2例出现口干;罗哌卡因+右美托咪定组有2例出现恶心及口干,另有1例出现心动过缓(心率=49次/min);⑦右美托咪定组术后血清C-反应蛋白水平显著低于罗哌卡因组(P <0.05),而血清白细胞介素6水平2组间差异无显著性意义(P> 0.05);⑧提示右美托咪定复合罗哌卡因用于收肌管阻滞对全膝关节置换术后的镇痛效果明显优于单独使用罗哌卡因,且不良反应少。
BACKGROUND: Most patients will suffer from severe pain after total knee arthroplasty. How to relieve postoperative pain and reduce postoperative complications is the key to promote early and rapid rehabilitation for patients.OBJECTIVE: To observe the analgesic effect of dexmedetomidine combined with ropivacaine for adductor canal block in patients undergoing arthroscopic total knee arthroplasty.METHODS: Forty patients who underwent primary unilateral total knee arthroplasty between October 2017 and September 2018 were randomly divided into two groups(n=20/group), followed by treated by 30 mL 0.375% ropivacaine, and 30 mL 0.375% ropivacaine + 1.5 μ g/kg dexmedetomidine, respectively. Both groups received adductor canal block. The study was approved by the Ethics Committee of the Third Affiliated Hospital of Guangzhou Medical University on October 31, 2018, approval number: [2018]170. All patients signed the informed consents, and the surgical department and surgeons had the qualifications for arthroplasty. General anesthesia was conducted, and the operation time and intraoperative blood loss were recorded. The mean arterial pressure, heart rate, oxyhemoglobin saturation, and Ramsay score and numeric pain rating scale score at rest and in activity at 2, 4, 6, 12, 24, and 48 hours after surgery were detected. Opioids consumption, anesthesia related adverse effects, the expression levels of C-reactive protein and interleukin-6 in the serum were detected at48 hours after surgery.RESULTS AND CONCLUSION:(1) The Ramsay score at postoperative 2-48 hours in the ropivacaine + dexmedetomidine group was significantly higher than that in the ropivacaine group(P < 0.05).(2) The postoperative numeric pain rating scale score at rest in both groups decreased with time(P < 0.05), and the score at each time point in the ropivacaine + dexmedetomidine group was significantly lower than that in the ropivacaine group(P < 0.05).(3) The postoperative numeric pain rating scale score in activity in both groups decreased with time(P <0.05), and the score at 12, 24 and 48 hours in the ropivacaine + dexmedetomidine group was significantly lower than that in the ropivacaine group(P < 0.05).(4) The heart rate at postoperative 24 hours in the ropivacaine + dexmedetomidine group was decreased significantly compared with the ropivacaine group(P < 0.05).(5) Six patients in the ropivacaine group and one patient in the ropivacaine +dexmedetomidine group acquired additional use of dolantin(100 mg/times) within postoperative 24 hours(P < 0.05). Two patients in the ropivacaine group and three patients in the ropivacaine + dexmedetomidine group acquired additional use of dolantin once within postoperative 48 hours(P > 0.05).(6) There was one patient who suffered nausea in the ropivacaine group, and two who reported xerostomia.Two patients in the ropivacaine + dexmedetomidine group experienced nausea and xerostomia, and one patient suffered sinus bradycardia(heart rate=49 beats/min).(7) The postoperative expression level of serum C-reactive protein in the ropivacaine + dexmedetomidine group was significantly lower than that in the ropivacaine group(P < 0.05), and there was no significant difference in the interleukin-6 level between two groups(P > 0.05).(8) To conclude, the analgesic effect of dexmedetomidine combined with ropivacaine on adductor canal block after total knee arthroplasty is significantly better than that of ropivacaine alone, and no significant adverse reactions are observed.
BACKGROUND: Most patients will suffer from severe pain after total knee arthroplasty. How to relieve postoperative pain and reduce postoperative complications is the key to promote early and rapid rehabilitation for patients.OBJECTIVE: To observe the analgesic effect of dexmedetomidine combined with ropivacaine for adductor canal block in patients undergoing arthroscopic total knee arthroplasty.METHODS: Forty patients who underwent primary unilateral total knee arthroplasty between October 2017 and September 2018 were randomly divided into two groups(n=20/group), followed by treated by 30 mL 0.375% ropivacaine, and 30 mL 0.375% ropivacaine + 1.5 μ g/kg dexmedetomidine, respectively. Both groups received adductor canal block. The study was approved by the Ethics Committee of the Third Affiliated Hospital of Guangzhou Medical University on October 31, 2018, approval number: [2018]170. All patients signed the informed consents, and the surgical department and surgeons had the qualifications for arthroplasty. General anesthesia was conducted, and the operation time and intraoperative blood loss were recorded. The mean arterial pressure, heart rate, oxyhemoglobin saturation, and Ramsay score and numeric pain rating scale score at rest and in activity at 2, 4, 6, 12, 24, and 48 hours after surgery were detected. Opioids consumption, anesthesia related adverse effects, the expression levels of C-reactive protein and interleukin-6 in the serum were detected at48 hours after surgery.RESULTS AND CONCLUSION:(1) The Ramsay score at postoperative 2-48 hours in the ropivacaine + dexmedetomidine group was significantly higher than that in the ropivacaine group(P < 0.05).(2) The postoperative numeric pain rating scale score at rest in both groups decreased with time(P < 0.05), and the score at each time point in the ropivacaine + dexmedetomidine group was significantly lower than that in the ropivacaine group(P < 0.05).(3) The postoperative numeric pain rating scale score in activity in both groups decreased with time(P <0.05), and the score at 12, 24 and 48 hours in the ropivacaine + dexmedetomidine group was significantly lower than that in the ropivacaine group(P < 0.05).(4) The heart rate at postoperative 24 hours in the ropivacaine + dexmedetomidine group was decreased significantly compared with the ropivacaine group(P < 0.05).(5) Six patients in the ropivacaine group and one patient in the ropivacaine +dexmedetomidine group acquired additional use of dolantin(100 mg/times) within postoperative 24 hours(P < 0.05). Two patients in the ropivacaine group and three patients in the ropivacaine + dexmedetomidine group acquired additional use of dolantin once within postoperative 48 hours(P > 0.05).(6) There was one patient who suffered nausea in the ropivacaine group, and two who reported xerostomia.Two patients in the ropivacaine + dexmedetomidine group experienced nausea and xerostomia, and one patient suffered sinus bradycardia(heart rate=49 beats/min).(7) The postoperative expression level of serum C-reactive protein in the ropivacaine + dexmedetomidine group was significantly lower than that in the ropivacaine group(P < 0.05), and there was no significant difference in the interleukin-6 level between two groups(P > 0.05).(8) To conclude, the analgesic effect of dexmedetomidine combined with ropivacaine on adductor canal block after total knee arthroplasty is significantly better than that of ropivacaine alone, and no significant adverse reactions are observed.
引文
[1]Hebl JR,Dilger JA,Byer DE,et al.A pre-emptive multimodal pathway featuring peripheral nerve block improves perioperative outcomes after major orthopedic surgery.Reg Anesth Pain Med.2008;33(6):510-517.
[2]王春光.收肌管内隐神经阻滞用于全膝关节置换术后镇痛的临床研究[D].苏州:苏州大学,2017.
[3]Danninger T,Opperer M,Memtsoudis SG.Perioperative pain control after total knee arthroplasty:An evidence based review of the role of peripheral nerve blocks.World J Orthop.2014;5(3):225-232.
[4]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.
[5]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.
[6]王海兰.术前股神经阻滞对全麻下全膝关节置换术老年患者的超前镇痛效果分析[J].川北医学院学报,2016,31(4):563-565.
[7]Feibel RJ,Dervin GF,Kim PR,et al.Major complications associated with femoral nerve catheters for knee arthroplasty:a word of caution.J Arthroplasty.2009;24(6 Suppl):132-137.
[8]Sharma S,Iorio R,Specht LM,et al.Complications of femoral nerve block for total knee arthroplasty.Clin Orthop Relat Res.2010;468(1):135-140.
[9]金姬延,姜伟,许蕊凤,等.连续股神经阻滞的安全隐患分析及护理[J].中国微创外科杂志,2015,15(10):958-960.
[10][Jaeger P,Nielsen ZJ,Henningsen MH,et al.Adductor canal block versus femoral nerve block and quadriceps strength:a randomized,double-blind,placebo-controlled,crossover study in healthy volunteers.Anesthesiology.2013;118(2):409-415.
[11]Krishnan C,Williams GN.Evoked tetanic torque and activation level explain strength differences by side.Eur J Appl Physiol.2009;106(5):769-774.
[12]Abdulatif M,Fawzy M,Nassar H et al.The effects of perineural dexmedetomidine on the pharmacodynamic profile of femoral nerve block:a dose-finding randomised,controlled,double-blind study.Anaesthesia.2016;71(10):1177-1185.
[13]Rancourt MP,Albert NT,C?téM,et al.Posterior tibial nerve sensory blockade duration prolonged by adding dexmedetomidine to ropivacaine.Anesth Analg.2012;115(4):958-962.
[14]Brummett CM,Hong EK,Janda AM,et al.Perineural dexmedetomidine added to ropivacaine for sciatic nerve block in rats prolongs the duration of analgesia by blocking the hyperpolarization-activated cation current.Anesthesiology.2011;115(4):836-843.
[15]杨淼,方华,章放香,等.七氟醚麻醉下右美托咪定复合罗哌卡因行髂腹下/髂腹股沟神经阻滞的效果[J].临床麻醉学杂志,2017,33(9):872-874.
[16]Weerink M,Struys MM,Hannivoort LN,et al.Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine.Clin Pharmacokinet.2017;56(8):893-913.
[17]Li A,Yuen VM,Goulay-Dufay S,et al.Pharmacokinetics and pharmacodynamics of dexmedetomidine.Drug Dev Ind Pharm.2016;42(12):1917-1927.
[18]Reuben SS.Preventing the development of complex regional pain syndrome after surgery.Anesthesiology.2004;101(5):1215-1224.
[19]Fowler SJ,Symons J,Sabato S,et al.Epidural analgesia compared with peripheral nerve blockade after major knee surgery:a systematic review and meta-analysis of randomized trials.Br JAnaesth.2008;100(2):154-164.
[20]Kent ML,Hackworth RJ,Riffenburgh RH,et al.A comparison of ultrasound-guided and landmark-based approaches to saphenous nerve blockade:a prospective,controlled,blinded,crossover trial.Anesth Analg.2013;117(1):265-270.
[21]Yao Y,Yu C,Zhang X,et al.Caudal and intravenous dexmedetomidine similarly prolong the duration of caudal analgesia in children:A randomized controlled trial.Paediatr Anaesth.2018;28(10):888-896.
[22]Brummett CM,Padda AK,Amodeo FS,et al.Perineural dexmedetomidine added to ropivacaine causes a dose-dependent increase in the duration of thermal antinociception in sciatic nerve block in rat.Anesthesiology.2009;111(5):1111-1119.
[23]Mangal V,Mistry T,Sharma G,et al.Effects of dexmedetomidine as an adjuvant to ropivacaine in ultrasound-guided supraclavicular brachial plexus Block:A prospective,randomized,double-blind study.J Anaesthesiol Clin Pharmacol.2018;34(3):357-361.
[24]Chen BS,Peng H,Wu SN.Dexmedetomidine,an alpha2-adrenergic agonist,inhibits neuronal delayed-rectifier potassium current and sodium current.Br J Anaesth.2009;103(2):244-254.
[25]Maruta T,Nemoto T,Satoh S,et al.Dexmedetomidine and clonidine inhibit the function of Na(v)1.7 independent of alpha(2)-adrenoceptor in adrenal chromaffin cells.J Anesth.2011;25(4):549-557.
[26]Kosugi T,Mizuta K,Fujita T,et al.High concentrations of dexmedetomidine inhibit compound action potentials in frog sciatic nerves without alpha(2)adrenoceptor activation.Br J Pharmacol.2010;160(7):1662-1676.
[27]Elliott D,Aitken LM,Bucknall TK,et al.Patient comfort in the intensive care unit:a multicentre,binational point prevalence study of analgesia,sedation and delirium management.Crit Care Resusc.2013;15(3):213-219.
[28]Wan Z,Wang J,Cao H,et al.Effects of different doses of dexmedetomidine on analgesic efficacy and inflammatory cytokines in patients undergoing laparoscopic surgery.Exp Ther Med.2018;16(3):1743-1746.
[29]Wang L,Zhang A,Liu W,et al.Effects of dexmedetomidine on perioperative stress response,inflammation and immune function in patients with different degrees of liver cirrhosis.Exp Ther Med.2018;16(5):3869-3874.
[30]Kong L,Lu XH.Effect of dexmedetomidine on perioperative inflammatory response and cellular immune in patients undergoing radical operation of thoracoscopic lung cancer.Zhonghua Yi Xue Za Zhi.2018;98(36):2929-2932.
[2]王春光.收肌管内隐神经阻滞用于全膝关节置换术后镇痛的临床研究[D].苏州:苏州大学,2017.
[3]Danninger T,Opperer M,Memtsoudis SG.Perioperative pain control after total knee arthroplasty:An evidence based review of the role of peripheral nerve blocks.World J Orthop.2014;5(3):225-232.
[4]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.
[5]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.
[6]王海兰.术前股神经阻滞对全麻下全膝关节置换术老年患者的超前镇痛效果分析[J].川北医学院学报,2016,31(4):563-565.
[7]Feibel RJ,Dervin GF,Kim PR,et al.Major complications associated with femoral nerve catheters for knee arthroplasty:a word of caution.J Arthroplasty.2009;24(6 Suppl):132-137.
[8]Sharma S,Iorio R,Specht LM,et al.Complications of femoral nerve block for total knee arthroplasty.Clin Orthop Relat Res.2010;468(1):135-140.
[9]金姬延,姜伟,许蕊凤,等.连续股神经阻滞的安全隐患分析及护理[J].中国微创外科杂志,2015,15(10):958-960.
[10][Jaeger P,Nielsen ZJ,Henningsen MH,et al.Adductor canal block versus femoral nerve block and quadriceps strength:a randomized,double-blind,placebo-controlled,crossover study in healthy volunteers.Anesthesiology.2013;118(2):409-415.
[11]Krishnan C,Williams GN.Evoked tetanic torque and activation level explain strength differences by side.Eur J Appl Physiol.2009;106(5):769-774.
[12]Abdulatif M,Fawzy M,Nassar H et al.The effects of perineural dexmedetomidine on the pharmacodynamic profile of femoral nerve block:a dose-finding randomised,controlled,double-blind study.Anaesthesia.2016;71(10):1177-1185.
[13]Rancourt MP,Albert NT,C?téM,et al.Posterior tibial nerve sensory blockade duration prolonged by adding dexmedetomidine to ropivacaine.Anesth Analg.2012;115(4):958-962.
[14]Brummett CM,Hong EK,Janda AM,et al.Perineural dexmedetomidine added to ropivacaine for sciatic nerve block in rats prolongs the duration of analgesia by blocking the hyperpolarization-activated cation current.Anesthesiology.2011;115(4):836-843.
[15]杨淼,方华,章放香,等.七氟醚麻醉下右美托咪定复合罗哌卡因行髂腹下/髂腹股沟神经阻滞的效果[J].临床麻醉学杂志,2017,33(9):872-874.
[16]Weerink M,Struys MM,Hannivoort LN,et al.Clinical pharmacokinetics and pharmacodynamics of dexmedetomidine.Clin Pharmacokinet.2017;56(8):893-913.
[17]Li A,Yuen VM,Goulay-Dufay S,et al.Pharmacokinetics and pharmacodynamics of dexmedetomidine.Drug Dev Ind Pharm.2016;42(12):1917-1927.
[18]Reuben SS.Preventing the development of complex regional pain syndrome after surgery.Anesthesiology.2004;101(5):1215-1224.
[19]Fowler SJ,Symons J,Sabato S,et al.Epidural analgesia compared with peripheral nerve blockade after major knee surgery:a systematic review and meta-analysis of randomized trials.Br JAnaesth.2008;100(2):154-164.
[20]Kent ML,Hackworth RJ,Riffenburgh RH,et al.A comparison of ultrasound-guided and landmark-based approaches to saphenous nerve blockade:a prospective,controlled,blinded,crossover trial.Anesth Analg.2013;117(1):265-270.
[21]Yao Y,Yu C,Zhang X,et al.Caudal and intravenous dexmedetomidine similarly prolong the duration of caudal analgesia in children:A randomized controlled trial.Paediatr Anaesth.2018;28(10):888-896.
[22]Brummett CM,Padda AK,Amodeo FS,et al.Perineural dexmedetomidine added to ropivacaine causes a dose-dependent increase in the duration of thermal antinociception in sciatic nerve block in rat.Anesthesiology.2009;111(5):1111-1119.
[23]Mangal V,Mistry T,Sharma G,et al.Effects of dexmedetomidine as an adjuvant to ropivacaine in ultrasound-guided supraclavicular brachial plexus Block:A prospective,randomized,double-blind study.J Anaesthesiol Clin Pharmacol.2018;34(3):357-361.
[24]Chen BS,Peng H,Wu SN.Dexmedetomidine,an alpha2-adrenergic agonist,inhibits neuronal delayed-rectifier potassium current and sodium current.Br J Anaesth.2009;103(2):244-254.
[25]Maruta T,Nemoto T,Satoh S,et al.Dexmedetomidine and clonidine inhibit the function of Na(v)1.7 independent of alpha(2)-adrenoceptor in adrenal chromaffin cells.J Anesth.2011;25(4):549-557.
[26]Kosugi T,Mizuta K,Fujita T,et al.High concentrations of dexmedetomidine inhibit compound action potentials in frog sciatic nerves without alpha(2)adrenoceptor activation.Br J Pharmacol.2010;160(7):1662-1676.
[27]Elliott D,Aitken LM,Bucknall TK,et al.Patient comfort in the intensive care unit:a multicentre,binational point prevalence study of analgesia,sedation and delirium management.Crit Care Resusc.2013;15(3):213-219.
[28]Wan Z,Wang J,Cao H,et al.Effects of different doses of dexmedetomidine on analgesic efficacy and inflammatory cytokines in patients undergoing laparoscopic surgery.Exp Ther Med.2018;16(3):1743-1746.
[29]Wang L,Zhang A,Liu W,et al.Effects of dexmedetomidine on perioperative stress response,inflammation and immune function in patients with different degrees of liver cirrhosis.Exp Ther Med.2018;16(5):3869-3874.
[30]Kong L,Lu XH.Effect of dexmedetomidine on perioperative inflammatory response and cellular immune in patients undergoing radical operation of thoracoscopic lung cancer.Zhonghua Yi Xue Za Zhi.2018;98(36):2929-2932.