不同药物配方对全膝关节置换术局部浸润镇痛作用的影响

摘要

目的：比较局部浸润镇痛不同药物配方对全膝关节置换术患者术后镇痛效果。方法将150例拟行单侧膝关节置换术患者随机分为3组：R组、RF组与RM组，每组50例。3组患者均使用腰麻。R组配方为：罗哌卡因100 mg加生理盐水至50 mL。RF组配方为：罗哌卡因100 mg加芬太尼100μg加生理盐水至50 mL。RM组配方为：罗哌卡因100 mg+甲泼尼龙40 mg加生理盐水至50 mL。术毕连续股神经阻滞镇痛（CFNB）。镇痛不足时由医师根据患者疼痛程度给予肌内注射哌替啶50 mg。记录术后静息状态下4、8、12、16、24、36、48 h的疼痛视觉模拟评分（VAS）和术后24、36、48 h被动功能锻炼时疼痛VAS评分及并发症。结果3组疼痛VAS评分在静息状态下术后4、8 h时无显著性差异，术后12、24、36和48 h时RM组疼痛VAS评分均比R组和RF组低（P<0.01），而R组与RF组在各个观察时点疼痛VAS评分均无显著性差异。RM组功能锻炼时疼痛VAS评分均比R组和RF组明显低（P<0.01），而R组与RF组无明显差异。R组和RF组在术后静息状态下肌注补充镇痛药哌替啶的药量明显比RM组高（P<0.01）。结论膝关节置换术局部浸润镇痛配方建议使用罗哌卡因联合甲泼尼龙，不建议联合芬太尼。%Objective To compare the analgesic efifcacy of different formulas of local inifltration analgesia (LIA) after total knee arthroplasty (TKA). Methods 150 patients undergoing TKA under spinal anesthesia were randomized to three groups:group R (ropivacaine 100 mg dissolved to 50 mL with normal saline), group RF (ropivacaine 100 mg+fentanyl 100μg dissolved to 50 mL with normal saline) and group RM(ropivacaine 100 mg+methylprednisolone 40 mg dissolved to 50 mL with normal saline). Continuous femoral nerve block (CFNB) was established after spinal anesthesia and 20 mL of 0.5%ropivacaine was infused through the catheter placed near femoral nerve. Adjuvant analgesics were IM pethidine. The pain visual analogue scale (VAS) scores were assessed after operation at 4, 8, 12, 16, 24, 36 and 48 h at rest and after operation at 12, 36 and 48 h on passive mobilization by acute pain service blinded to analgesic treatment. Nausea and vomiting, dizziness and other side-effects were assessed postoperatively. Results The pain VAS scores at rest of three groups were not signiifcantly different 4 and 8 h after surgery. The pain VAS scores of group RM were signiifcantly less than group R and group RF at rest 12, 16, 24, 36 and 48 h after surgery (P<0.01), but there was no signiifcant difference between group R and group RF. A signiifcant difference in pain VAS scores was found in group RM vs. group R and group RF on passive mobilization 24, 36, 48 h after operation (P<0.01), but there was no signiifcant difference between group R and group RF. The postoperative pethidine consumptions of group R and group RF were more than that of group RM (P<0.01)at 48 h after operation. Conclusion CFNB combined with LIA was effective in controlling postoperative pain after TKA. The best formula for LIA was ropivacaine combined methylprednisolone and normal saline, but not combined fentanyl and normal saline.