股神经阻滞联合无止血带技术在全膝关节置换术中的应用及效果
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摘要
目的探讨股神经阻滞联合无止血带技术在全膝关节置换术(TKA)中的应用,并分析其在减轻术后疼痛中的作用及对术后认知功能的影响。方法本院2016年1月至2018年1月行TKA患者251例,男117例,女134例,年龄18～80岁,BMI 16.9～31.7 kg/m~2,ASAⅠ—Ⅲ级,随机分为四组:止血带下膝关节置换+静脉镇痛组(PT1组,n=56);止血带下膝关节置换+股神经阻滞镇痛组(PT2组,n=63);无止血带下膝关节置换+静脉镇痛组(P1组,n=56);无止血带下膝关节置换+股神经阻滞镇痛组(P2组,n=76)。分别于术前1 d、术后1、2、3 d测量术侧大腿中上1/3处周长,并于同时点采集外周静脉血测定白细胞计数(WBC)、中性粒细胞百分比(NEUT%)、C-反应蛋白(CRP)浓度。分别于术前1 d、术后1、2、3、7 d和3个月评测患侧膝关节活动度(AROM),采用视觉模拟疼痛评分法(VAS)评估静息和活动时的疼痛VAS评分。分别于术前1 d、术后1、2、3 d采用蒙特利尔认知评估量表(MoCA)评估患者认知功能,记录术后3 d内认知功能损害发生情况和恶心呕吐(PONV)发生情况。结果术后1、2、3 d PT1组和PT2组大腿周长增加值明显大于P1组和P2组(P<0.05)、CRP浓度明显低于P1组和P2组(P<0.05)。术后1、2 d PT1和P1组AROM明显小于PT2组和P2组(P<0.05),PT1组静息和活动时VAS评分明显高于PT2组、P1组和P2组(P<0.05),且P1组活动时VAS评分明显高于PT2组和P2组(P<0.05)。术后1 d PT1组和PT2组MoCA评分明显高于P1组和P2组(P<0.05)。术后3 d内PT1组和PT2组认知功能损害总发生率明显低于P1组和P2组(P<0.05),PT1组和P1组PONV的总发生率明显高于PT2组和P2组(P<0.05)。结论持续股神经阻滞联合无止血带技术用于全膝关节置换术,患者术后大腿肿胀及疼痛程度较轻,利于膝关节功能锻炼,关节活动度恢复快,但术后全身炎症反应较重且术后早期认知功能损害发生率增加。
Objective To observe the application of femoral nerve block combined with non-tourniquet technique in the total knee arthroplasty(TKA), and analyze the effects on relieving postoperative pain and the influence for postoperative cognitive function. Methods A total of 251 patients with 117 males and 134 females, aged 18-80 years, BMI 16.9-31.7 kg/m~2, ASA physical status Ⅰ-Ⅲ undergoing TKA were randomly divided into four groups: TKA under tourniquet plus intravenous analgesia(group PT1, n=56); TKA under tourniquet plus femoral nerve block analgesia(group PT2, n = 63); TKA without tourniquet plus intravenous analgesia(group P1, n = 56); TKA without tourniquet plus femoral nerve block analgesia(group P2, n = 76). The circumference of 1/3 mid-upper thigh was measured at 1 day before operation, 1, 2 and 3 days after operation. The white blood cell count(WBC), neutrophil percentage(NEUT%) and C-reactive protein(CRP) of peripheral venous blood were measured at the same time. The range of motion(AROM) of the knee joint was assessed at 1 day before operation, 1, 2, 3, 7 days and 3 months after operation, and the pain scores at rest and activity were also assessed by visual analogue pain score(VAS). Montreal Cognitive Assessment Scale(MoCA) was used to assess the cognitive function of patients at 1 day before operation, 1, 2 and 3 days after operation. The incidence of cognitive impairment and PONV were recorded within 3 days after operation. Results The increase value of thigh circumference in group PT1 and group PT2 were significantly higher than that in group P1 and P2 on the 1 st, 2 nd and 3 rd days after operation(P < 0.05), and the concentration of CRP was significantly lower than that in group P1 and P2(P < 0.05). The AROM of group PT1 and P1 was significantly lower than that in group PT2 and P2 on 1 st and 2 nd days after operation(P < 0.05), and the VAS score of group PT1 at rest and activity were significantly higher than that of group PT2, P1 and P2(P < 0.05), and the VAS score of group P1 at activity was significantly higher than that of group PT2 and P2(P < 0.05). MoCA scores of group PT1 and PT2 were significantly higher than those of group P1 and P2 on the 1 st day after operation(P < 0.05). The total incidence of cognitive impairment in group PT1 and PT2 were significantly lower than that in group P1 and P2 within 3 days after operation(P < 0.05), and the total incidence of PONV in group PT1 and P1 were significantly higher than that in group PT2 and P2(P < 0.05). Conclusion The patients undergoing TKA with continuous femoral nerve block combined with non-tourniquet technique have less thigh swelling and postoperative pain, which is more conducive to knee joint functional exercise and faster recovery of joint activity. However, the systemic inflammatory reaction after TKA with non-tourniquet technique may be more serious and the incidence of early cognitive impairment may increase.
Objective To observe the application of femoral nerve block combined with non-tourniquet technique in the total knee arthroplasty(TKA), and analyze the effects on relieving postoperative pain and the influence for postoperative cognitive function. Methods A total of 251 patients with 117 males and 134 females, aged 18-80 years, BMI 16.9-31.7 kg/m~2, ASA physical status Ⅰ-Ⅲ undergoing TKA were randomly divided into four groups: TKA under tourniquet plus intravenous analgesia(group PT1, n=56); TKA under tourniquet plus femoral nerve block analgesia(group PT2, n = 63); TKA without tourniquet plus intravenous analgesia(group P1, n = 56); TKA without tourniquet plus femoral nerve block analgesia(group P2, n = 76). The circumference of 1/3 mid-upper thigh was measured at 1 day before operation, 1, 2 and 3 days after operation. The white blood cell count(WBC), neutrophil percentage(NEUT%) and C-reactive protein(CRP) of peripheral venous blood were measured at the same time. The range of motion(AROM) of the knee joint was assessed at 1 day before operation, 1, 2, 3, 7 days and 3 months after operation, and the pain scores at rest and activity were also assessed by visual analogue pain score(VAS). Montreal Cognitive Assessment Scale(MoCA) was used to assess the cognitive function of patients at 1 day before operation, 1, 2 and 3 days after operation. The incidence of cognitive impairment and PONV were recorded within 3 days after operation. Results The increase value of thigh circumference in group PT1 and group PT2 were significantly higher than that in group P1 and P2 on the 1 st, 2 nd and 3 rd days after operation(P < 0.05), and the concentration of CRP was significantly lower than that in group P1 and P2(P < 0.05). The AROM of group PT1 and P1 was significantly lower than that in group PT2 and P2 on 1 st and 2 nd days after operation(P < 0.05), and the VAS score of group PT1 at rest and activity were significantly higher than that of group PT2, P1 and P2(P < 0.05), and the VAS score of group P1 at activity was significantly higher than that of group PT2 and P2(P < 0.05). MoCA scores of group PT1 and PT2 were significantly higher than those of group P1 and P2 on the 1 st day after operation(P < 0.05). The total incidence of cognitive impairment in group PT1 and PT2 were significantly lower than that in group P1 and P2 within 3 days after operation(P < 0.05), and the total incidence of PONV in group PT1 and P1 were significantly higher than that in group PT2 and P2(P < 0.05). Conclusion The patients undergoing TKA with continuous femoral nerve block combined with non-tourniquet technique have less thigh swelling and postoperative pain, which is more conducive to knee joint functional exercise and faster recovery of joint activity. However, the systemic inflammatory reaction after TKA with non-tourniquet technique may be more serious and the incidence of early cognitive impairment may increase.
引文
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[6] Barker T,Rogers VE,Brown KB,et al.Tourniquet use during total knee arthroplasty does not modulate the neutrophil-to-lymphocyte ratio,pain,or activity.J Orthop Traumatol,2017,18(3):283-287.
[7] 秦珮珮,彭丽桦,任力,等.连续股神经阻滞与患者自控静脉镇痛在全膝关节置换术后应用成本的比较.临床麻醉学杂志,2015,31(8):733-736.
[8] 张高峰,陈斐,孙立新,等.不同镇痛方式对全膝关节置换术后镇痛效果及炎性反应的影响.临床麻醉学杂志,2015,31(3):234-237.
[9] Memtsoudis SG,Valle AG,Jules-Elysse K,et a1.Perioperative inflammatory response in total knee arthroplasty patients:impact of limb preconditioning.Reg Anesth Pain Med,2010,35(5):412-416.
[10] Lu K,Xu M,Li W,et al.A study on dynamic monitoring,components,and risk factors of embolism during total knee arthroplasty.Medicine (Baltimore),2017,96(51):e9303.
[11] 王彬,张其亮,李军,等.老年患者髋关节置换术后谵妄和认知功能障碍的危险因素.临床麻醉学杂志,2013,29(8):785-788.
[2] Li Z,Liu D,Long G,et al.Association of tourniquet utilization with blood loss,rehabilitation,and complications in Chinese obese patients undergoing total knee arthroplasty.Medicine (Baltimore),2017,96(49):e9030.
[3] Muyskens JB,Hocker AD,Turnbull DW,et al.Transcriptional profiling and muscle cross-section analysis reveal signs of ischemia reperfusion injury following total knee arthroplasty with tourniquet.Physiol Rep,2016,4(1):e12671.
[4] Liu D,Graham D,Gillies K,et al.Effects of tourniquet use on quadriceps function and pain in total knee arthroplasty.Knee Surg Relat Res,2014,26(4):207-213.
[5] 阚金庆,李海涛,宋扬,等.全膝关节置换术后关节腔出血动态监测相关研究.中华关节外科杂志,2015,9(1):30-32.
[6] Barker T,Rogers VE,Brown KB,et al.Tourniquet use during total knee arthroplasty does not modulate the neutrophil-to-lymphocyte ratio,pain,or activity.J Orthop Traumatol,2017,18(3):283-287.
[7] 秦珮珮,彭丽桦,任力,等.连续股神经阻滞与患者自控静脉镇痛在全膝关节置换术后应用成本的比较.临床麻醉学杂志,2015,31(8):733-736.
[8] 张高峰,陈斐,孙立新,等.不同镇痛方式对全膝关节置换术后镇痛效果及炎性反应的影响.临床麻醉学杂志,2015,31(3):234-237.
[9] Memtsoudis SG,Valle AG,Jules-Elysse K,et a1.Perioperative inflammatory response in total knee arthroplasty patients:impact of limb preconditioning.Reg Anesth Pain Med,2010,35(5):412-416.
[10] Lu K,Xu M,Li W,et al.A study on dynamic monitoring,components,and risk factors of embolism during total knee arthroplasty.Medicine (Baltimore),2017,96(51):e9303.
[11] 王彬,张其亮,李军,等.老年患者髋关节置换术后谵妄和认知功能障碍的危险因素.临床麻醉学杂志,2013,29(8):785-788.