缺血预处理减轻全膝关节置换术患者术后早期疼痛的临床研究

摘要

Objective To evaluate the effect of ischemic preconditioning ( IPC ) on early postoperative pain in patients undergoing total knee arthroplasty. Methods A prospective randomized controlled trial of 40 patients undergoing elective total knee arthroplasty was performed in the First Affiliated Hospital of Anhui Medical University from October 2015 to April 2016.Patients (18 -65 years old) with ASA grade Ⅰ-Ⅲ( American Society of Anesthesiologists), were randomly divided into control group and ischemic preconditioning ( IPC ) group, 20 patients in each group. In the IPC group, ischemic preconditioning was performed before the operation of completely blood block to the lower limbs of the operation side, the tourniquet was inflated for 5 min and deflated for 5 min, for a total of 2 cycles. In the control group, only the tourniquet was attached without inflation or deflation before the surgery completely blocked the lower limb blood supply. The basic information of the general clinical data, tourniquet block time and operation time of the two groups were recorded and compared. The mean arterial pressure (MAP), heart rate (HR) and oxygen saturation ( SpO2 ) were measured before surgery, 30 minutes after the upper tourniquet, and at the end of the operation. Resting pain scores (VAS) were recorded at recovery time, 6 h after surgery, and 24 h after surgery. The number of pain remedies within 24 hours after surgery was recorded. Venous blood was collected 24 hours after surgery to detect the levels of creatine kinase(CK) and interleukin-6 (IL-6) in the blood. Results There were no significant differences in the general clinical data, tourniquet blockade time, and operation time between the two groups ( P >0.05). There were no significant differences in MAP, HR and SpO2 between two groups at each time point (P>0.05). The VAS score (3.10 ± 1.02) point in the IPC group was significantly lower than that in the control group (5.45 ± 0.99)point (t=7.394, P<0.05). VAS score had no significant differences between two groups at recovery room and 24 hours after surgery ( P > 0. 05 ). The number of pain remedies in the IPC group, was significantly lower than that in the control group at 24 hours after surgery (χ2 =4.803, P<0.05). There was no significant difference in serum CK between the two groups ( P>0.05). The serum IL-6 level was significantly lower in the IPC group ( 50. 11 ± 20. 39 ) pg/mL than in the control group ( 70. 80 ± 34.82) pg/mL ( t = 6. 628, P < 0. 05 ). Conclusions Ischemic preconditioning attenuates early postoperative pain and reduces the number of pain relief patients in total knee arthroplasty. The mechanism may be related to the reduction of inflammatory response by ischemic preconditioning.%目的 评价缺血预处理(IPC)对全膝关节置换术患者术后早期疼痛的影响.方法 前瞻性随机对照试验.选择2015年10月—2016年4月安徽医科大学第一附属医院择期行全膝关节置换手术患者40例,年龄18~65岁,美国麻醉医师协会( ASA)分级Ⅰ~Ⅲ级,按随机数字表法分为对照组及IPC组,每组20例. IPC组在手术完全阻断术侧下肢血供前,予以IPC,即止血带充气5 min、放气5 min,共2个循环.对照组在手术完全阻断术侧下肢血供前,仅缚上止血带而不进行充气或放气操作.记录并对比两组患者一般临床资料、手术期间止血带阻断时间和手术时间等手术基本信息,手术前、上止血带30 min后、手术结束时的平均动脉压( MAP)、心率( HR)、脉搏氧饱和度( SpO2 ).记录出恢复室时、术后6 h、术后24 h的静息疼痛评分(VAS),并记录术后24 h内疼痛补救例数.手术后24 h采集静脉血,检测血中肌酸激酶(CK)和白细胞介素6(IL-6)水平.结果 两组患者年龄、性别构成、体质量指数、术中止血带充气阻断时间以及手术时间比较,差异均无统计学差异(P值均>0.05).两组患者在观察各时点MAP、HR、SpO2 比较,差异均无统计学差异(P值均>0.05). IPC组患者术后6 h VAS (3.10 ± 1.02)分,明显低于对照组的(5.45 ± 0.99)分,两组比较差异有统计学意义(t=7.394, P<0.01);出恢复室时、术后24 h VAS 两组比较差异均无统计学意义(P 值均 >0.05). IPC组和对照组术后24 h疼痛补救例数分别为2例和8例,差异有统计学意义(χ2 =4.803, P<0.05 ).对照组和 IPC 组患者术后 24 h 血清 CK 分别为( 9.24 ± 4.97 ) ng/mL 和( 8.15 ± 4.03) ng/mL,差异无统计学意义(P>0.05);但IL-6水平IPC组为(50.11 ± 20.39)pg/mL明显低于对照组(70.80 ± 34.82)pg/mL,差异有统计学意义(t=6.628, P<0.05).结论 IPC能够减轻全膝关节置换术患者术后早期疼痛,减少镇痛剂的使用;其机制可能和IPC降低炎症反应有关.