鸡尾酒疗法联合硬膜外单次小剂量吗啡对全膝关节置换术后疼痛控制的研究
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摘要
目的研究鸡尾酒疗法联合硬膜外单次小剂量吗啡对全膝关节置换术(total knee arthroplasty, TKA)后疼痛的控制作用。方法采用随机双盲对照研究,选取2018年2月至2018年9月我院收治的拟行初次单侧TKA的膝骨关节炎病人160例,随机分为4组,每组40例,麻醉方式均采用硬膜外麻醉。A组病人给予鸡尾酒疗法(含激素)联合硬膜外单次小剂量吗啡;B组病人给予鸡尾酒疗法(不含激素)联合硬膜外单次小剂量吗啡;C组病人给予单纯鸡尾酒疗法(含激素);D组为对照组,给予单纯鸡尾酒疗法(不含激素)。记录4组病人术后2、6、12、24、48、72 h静息状态下及术后24、48、72 h活动状态下的疼痛视觉模拟量表(visual analogue score, VAS)评分,术后48 h、72 h、4 d、5 d的膝关节最大屈曲活动度以及术后不良反应。结果 4组病人术后静息状态下、活动状态下的VAS评分及膝关节活动度总体比较,差异均有统计学意义(F=10.798,P<0.001;F=6.220,P=0.001;F=6.075,P=0.001)。A、B、C组术后静息状态、运动状态下的VAS评分均显著低于D组,且其膝关节活动度均显著大于D组,差异均有统计学意义(P均<0.05)。C组病人静息状态下VAS评分的总体均数高于A组,差值为0.52,差异有统计学意义(P=0.005)。结论鸡尾酒疗法联合硬膜外单次小剂量吗啡在TKA术后显示出更强且更协同的镇痛效果,可更好地改善术后膝关节活动度;在无激素禁忌及不良反应的条件下,建议"鸡尾酒"混合镇痛药中添加糖皮质激素。
Objective To study the effect of cocktail therapy combined with epidural single low dosemorphine on pain control after total knee arthroplasty(TKA). Methods A randomized, double-blind,controlled study was conducted on 160 patients with knee osteoarthritis who were treated with unilateral TKA inour hospital from February 2018 to September 2018 for the first time. Epidural anesthesia was used in all cases.They were randomly divided into four groups, 40 patients in each group: group A was given cocktail therapy(hormone-containing) combined with epidural single low dose morphine; group B was given cocktail therapy(hormone-free) combined with epidural single low dose morphine; group C was given simple cocktail therapy(hormone-containing); group D was given simple cocktail therapy(hormone-free). Visual analogue score(VAS)of patients at rest state for 2, 6, 12, 24, 48 and 72 h and at active state for 24, 48 and 72 h after operation in fourgroups, maximum flexion range of motion of knee joint at 2nd, 3rd, 4th and 5th day after operation, andpostoperative adverse reactions were recorded. Results There were significant differences in VAS score andknee joint activity among the four groups(F=10.798, P<0.001; F=6.220, P=0.001; F=6.075, P=0.001). TheVAS scores in groups A, B and C at rest and active state were significantly lower, and the range of motion ofknee joint in groups A, B and C was significantly greater than those in group D(P<0.05 for all). The averageVAS score in group C at rest was significantly higher than in group A, with a difference of 0.52(P=0.005).Conclusion Cocktail therapy combined with epidural single low dose morphine showed stronger and moresynergistic analgesic effect after TKA, which could better improve the knee joint functional activity after TKA.Under the conditions of no hormone contraindication and adverse reactions, it was suggested that glucocorticoidshould be added to"cocktail"mixed analgesics.
Objective To study the effect of cocktail therapy combined with epidural single low dosemorphine on pain control after total knee arthroplasty(TKA). Methods A randomized, double-blind,controlled study was conducted on 160 patients with knee osteoarthritis who were treated with unilateral TKA inour hospital from February 2018 to September 2018 for the first time. Epidural anesthesia was used in all cases.They were randomly divided into four groups, 40 patients in each group: group A was given cocktail therapy(hormone-containing) combined with epidural single low dose morphine; group B was given cocktail therapy(hormone-free) combined with epidural single low dose morphine; group C was given simple cocktail therapy(hormone-containing); group D was given simple cocktail therapy(hormone-free). Visual analogue score(VAS)of patients at rest state for 2, 6, 12, 24, 48 and 72 h and at active state for 24, 48 and 72 h after operation in fourgroups, maximum flexion range of motion of knee joint at 2nd, 3rd, 4th and 5th day after operation, andpostoperative adverse reactions were recorded. Results There were significant differences in VAS score andknee joint activity among the four groups(F=10.798, P<0.001; F=6.220, P=0.001; F=6.075, P=0.001). TheVAS scores in groups A, B and C at rest and active state were significantly lower, and the range of motion ofknee joint in groups A, B and C was significantly greater than those in group D(P<0.05 for all). The averageVAS score in group C at rest was significantly higher than in group A, with a difference of 0.52(P=0.005).Conclusion Cocktail therapy combined with epidural single low dose morphine showed stronger and moresynergistic analgesic effect after TKA, which could better improve the knee joint functional activity after TKA.Under the conditions of no hormone contraindication and adverse reactions, it was suggested that glucocorticoidshould be added to"cocktail"mixed analgesics.
引文
[1]Tammachote N, Kanitnate S, Manuwong S, et al. Periarticular mul-timodal drug injection is better than single anesthetic drug in con-trolling pain after total knee arthroplasty[J]. Eur J Orthop SurgTraumatol, 2018, 28(4):667-675.
[2]Motififard M, Omidian A, Badiei S. Pre-emptive injection of peri-articular-multimodal drug for post-operative pain management in to-tal knee arthroplasty:a double-blind randomized clinical trial[J].Int Orthop, 2017, 41(5):939-947.
[3]Tammachote N, Kanitnate S, Manuwong S, et al. Is pain after TKAbetter with periarticular injection or intrathecal morphine[J]. ClinOrthop Relat Res, 2013, 471(6):1992-1999.
[4]Kim TW, Park SJ, Lim SH, et al. Which analgesic mixture is appro-priate for periarticular injection after total knee arthroplasty? Pro-spective, randomized, double-blind study[J]. Knee Surg SportsTraumatol Arthrosc, 2015, 23(3):838-845.
[5]Fu P, Wu Y, Wu H, et al. Efficacy of intra-articular cocktail analge-sic injection in total knee arthroplasty-a randomized controlledtrial[J]. Knee, 2009, 16(4):280-284.
[6]Lamplot JD, Wagner ER, Manning DW. Multimodal pain manage-ment in total knee arthroplasty:a prospective randomized con-trolled trial[J]. J Arthroplasty, 2014, 29(2):329-334.
[7]Karlsen AP, Wetterslev M, Hansen SE, et al. Postoperative paintreatment after total knee arthroplasty:A systematic review[J].PLoS One, 2017, 12(3):e0173107.
[8]Parvizi J, Miller AG, Gandhi K. Multimodal pain management af-ter total joint arthroplasty[J]. J Bone Joint Surg Am, 2011, 93(11):1075-1084.
[9]Busch CA, Shore BJ, Bhandari R, et al. Efficacy of periarticularmultimodal drug injection in total knee arthroplasty. A randomizedtrial[J]. J Bone Joint Surg Am, 2006, 88(5):959-963.
[10]Jiang J, Teng Y, Fan Z, et al. The efficacy of periarticular multi-modal drug injection for postoperative pain management in totalknee or hip arthroplasty[J]. J Arthroplasty, 2013, 28(10):1882-1887.
[11]Fu P, Wu Y, Wu H, et al. Efficacy of intra-articular cocktail anal-gesic injection in total knee arthroplasty-a randomized controlledtrial[J]. Knee, 2009, 16(4):280-284.
[12]Chaumeron A, Audy D, Drolet P, et al. Periarticular injection in knee arthroplasty improves quadriceps function[J]. Clin OrthopRelat Res, 2013, 471(7):2284-2295.
[13]Bilir A. Single dose epidural morphine instead of patient-controlledepidural analgesia in the second day of cesarean section; an easymethod for the pain relief of a new mother[J]. Clin Exp Obstet Gy-necol, 2013, 40(1):118-121.
[14]Agarwal K, Agarwal N, Agrawal VK, et al. Efficacy of single doseepidural morphine versus intermittent low-dose epidural morphinealong with bupivacaine for postcaesarean section analgesia[J].Anesth Essays Res, 2012, 6(1):25-28.
[15]Milan Z, Das S, Kocarev M, et al. Is single-shot epidural analgesiamore effective than morphine patient-controlled analgesia for do-nor nephrectomy[J]. Transplant Proc, 2011, 43(10):3588-3592.
[16]Yu PY, Gambling DR. A comparative study of patient-controlledepidural fentanyl and single dose epidural morphine for post-cae-sarean analgesia[J]. Can J Anaesth, 1993, 40(5 Pt 1):416-420.
[17]Li M, Wan L, Mei W, et al. Update on the clinical utility and prac-tical use of ropivacaine in Chinese patients[J]. Drug Des DevelTher, 2014, 8(10):1269-1276.
[18]Bhasin S, Dhar M, Sreevastava DK. Comparison of efficacy of epi-dural ropivacaine versus bupivacaine for postoperative pain reliefin total knee replacement surgeries[J]. Anesth Essays Res, 2018,12(1):26-30.
[19]Ikeuchi M, Kamimoto Y, Izumi M, et al. Effects of dexamethasoneon local infiltration analgesia in total knee arthroplasty:a random-ized controlled trial[J]. Knee Surg Sports Traumatol Arthrosc,2014, 22(7):1638-1643.
[20]Pang HN, Lo NN, Yang KY, et al. Peri-articular steroid injectionimproves the outcome after unicondylar knee replacement[J]. JBone Joint Surg Br, 2008, 90(6):738-744.
[21]Sean VW, Chin PL, Chia SL, et al. Single-dose periarticular ste-roid infiltration for pain management in total knee arthroplasty:aprospective, double-blind, randomised controlled trial[J]. Singa-pore Med J, 2011, 52(1):19-23.
[22]Ng YC, Lo NN, Yang KY, et al. Effects of periarticular steroid in-jection on knee function and the inflammatory response followingUnicondylar Knee Arthroplasty[J]. Knee Surg Sports TraumatolArthrosc, 2011, 19(1):60-65.
[23]Zhao X, Qin J, Tan Y, et al. Efficacy of steroid addition to multi-modal cocktail periarticular injection in total knee arthroplasty:ameta-analysis[J]. J Orthop Surg Res, 2015, 10:75.
[24]Kwon SK, Yang IH, Bai SJ, et al. Periarticular injection with corti-costeroid has an additional pain management effect in total kneearthroplasty[J]. Yonsei Med J, 2014, 55(2):493-498.
[25]Sundarathiti P, Thammasakulsiri J, Supboon S, et al. Comparisonof continuous femoral nerve block(CFNB/SA)and continuous fem-oral nerve block with mini-dose spinal morphine(CFNB/SAMO)for postoperative analgesia after total knee arthroplasty(TKA):arandomized controlled study[J]. BMC Anesthesiol, 2016, 16(1):38.
[26]Huang YM, Wang CM, Wang CT, et al. Perioperative celecoxib ad-ministration for pain management after total knee arthroplasty-arandomized, controlled study[J]. BMC Musculoskelet Disord,2008, 9(1):77.
[2]Motififard M, Omidian A, Badiei S. Pre-emptive injection of peri-articular-multimodal drug for post-operative pain management in to-tal knee arthroplasty:a double-blind randomized clinical trial[J].Int Orthop, 2017, 41(5):939-947.
[3]Tammachote N, Kanitnate S, Manuwong S, et al. Is pain after TKAbetter with periarticular injection or intrathecal morphine[J]. ClinOrthop Relat Res, 2013, 471(6):1992-1999.
[4]Kim TW, Park SJ, Lim SH, et al. Which analgesic mixture is appro-priate for periarticular injection after total knee arthroplasty? Pro-spective, randomized, double-blind study[J]. Knee Surg SportsTraumatol Arthrosc, 2015, 23(3):838-845.
[5]Fu P, Wu Y, Wu H, et al. Efficacy of intra-articular cocktail analge-sic injection in total knee arthroplasty-a randomized controlledtrial[J]. Knee, 2009, 16(4):280-284.
[6]Lamplot JD, Wagner ER, Manning DW. Multimodal pain manage-ment in total knee arthroplasty:a prospective randomized con-trolled trial[J]. J Arthroplasty, 2014, 29(2):329-334.
[7]Karlsen AP, Wetterslev M, Hansen SE, et al. Postoperative paintreatment after total knee arthroplasty:A systematic review[J].PLoS One, 2017, 12(3):e0173107.
[8]Parvizi J, Miller AG, Gandhi K. Multimodal pain management af-ter total joint arthroplasty[J]. J Bone Joint Surg Am, 2011, 93(11):1075-1084.
[9]Busch CA, Shore BJ, Bhandari R, et al. Efficacy of periarticularmultimodal drug injection in total knee arthroplasty. A randomizedtrial[J]. J Bone Joint Surg Am, 2006, 88(5):959-963.
[10]Jiang J, Teng Y, Fan Z, et al. The efficacy of periarticular multi-modal drug injection for postoperative pain management in totalknee or hip arthroplasty[J]. J Arthroplasty, 2013, 28(10):1882-1887.
[11]Fu P, Wu Y, Wu H, et al. Efficacy of intra-articular cocktail anal-gesic injection in total knee arthroplasty-a randomized controlledtrial[J]. Knee, 2009, 16(4):280-284.
[12]Chaumeron A, Audy D, Drolet P, et al. Periarticular injection in knee arthroplasty improves quadriceps function[J]. Clin OrthopRelat Res, 2013, 471(7):2284-2295.
[13]Bilir A. Single dose epidural morphine instead of patient-controlledepidural analgesia in the second day of cesarean section; an easymethod for the pain relief of a new mother[J]. Clin Exp Obstet Gy-necol, 2013, 40(1):118-121.
[14]Agarwal K, Agarwal N, Agrawal VK, et al. Efficacy of single doseepidural morphine versus intermittent low-dose epidural morphinealong with bupivacaine for postcaesarean section analgesia[J].Anesth Essays Res, 2012, 6(1):25-28.
[15]Milan Z, Das S, Kocarev M, et al. Is single-shot epidural analgesiamore effective than morphine patient-controlled analgesia for do-nor nephrectomy[J]. Transplant Proc, 2011, 43(10):3588-3592.
[16]Yu PY, Gambling DR. A comparative study of patient-controlledepidural fentanyl and single dose epidural morphine for post-cae-sarean analgesia[J]. Can J Anaesth, 1993, 40(5 Pt 1):416-420.
[17]Li M, Wan L, Mei W, et al. Update on the clinical utility and prac-tical use of ropivacaine in Chinese patients[J]. Drug Des DevelTher, 2014, 8(10):1269-1276.
[18]Bhasin S, Dhar M, Sreevastava DK. Comparison of efficacy of epi-dural ropivacaine versus bupivacaine for postoperative pain reliefin total knee replacement surgeries[J]. Anesth Essays Res, 2018,12(1):26-30.
[19]Ikeuchi M, Kamimoto Y, Izumi M, et al. Effects of dexamethasoneon local infiltration analgesia in total knee arthroplasty:a random-ized controlled trial[J]. Knee Surg Sports Traumatol Arthrosc,2014, 22(7):1638-1643.
[20]Pang HN, Lo NN, Yang KY, et al. Peri-articular steroid injectionimproves the outcome after unicondylar knee replacement[J]. JBone Joint Surg Br, 2008, 90(6):738-744.
[21]Sean VW, Chin PL, Chia SL, et al. Single-dose periarticular ste-roid infiltration for pain management in total knee arthroplasty:aprospective, double-blind, randomised controlled trial[J]. Singa-pore Med J, 2011, 52(1):19-23.
[22]Ng YC, Lo NN, Yang KY, et al. Effects of periarticular steroid in-jection on knee function and the inflammatory response followingUnicondylar Knee Arthroplasty[J]. Knee Surg Sports TraumatolArthrosc, 2011, 19(1):60-65.
[23]Zhao X, Qin J, Tan Y, et al. Efficacy of steroid addition to multi-modal cocktail periarticular injection in total knee arthroplasty:ameta-analysis[J]. J Orthop Surg Res, 2015, 10:75.
[24]Kwon SK, Yang IH, Bai SJ, et al. Periarticular injection with corti-costeroid has an additional pain management effect in total kneearthroplasty[J]. Yonsei Med J, 2014, 55(2):493-498.
[25]Sundarathiti P, Thammasakulsiri J, Supboon S, et al. Comparisonof continuous femoral nerve block(CFNB/SA)and continuous fem-oral nerve block with mini-dose spinal morphine(CFNB/SAMO)for postoperative analgesia after total knee arthroplasty(TKA):arandomized controlled study[J]. BMC Anesthesiol, 2016, 16(1):38.
[26]Huang YM, Wang CM, Wang CT, et al. Perioperative celecoxib ad-ministration for pain management after total knee arthroplasty-arandomized, controlled study[J]. BMC Musculoskelet Disord,2008, 9(1):77.