唐燕紅，張 英，王旌晶，劉 慶△

(1.西南醫(yī)科大學(xué)附屬中醫(yī)醫(yī)院麻醉科，四川瀘州 646000；2.四川省瀘州市中醫(yī)院骨關(guān)節(jié)科 646000)

論著·臨床研究

全膝關(guān)節(jié)置換術(shù)后切口局部持續(xù)羅哌卡因浸潤(rùn)麻醉鎮(zhèn)痛的療效分析

唐燕紅1，張 英1，王旌晶2，劉 慶1△

(1.西南醫(yī)科大學(xué)附屬中醫(yī)醫(yī)院麻醉科，四川瀘州 646000；2.四川省瀘州市中醫(yī)院骨關(guān)節(jié)科 646000)

目的 評(píng)價(jià)全膝關(guān)節(jié)置換術(shù)后于手術(shù)切口局部行持續(xù)浸潤(rùn)麻醉鎮(zhèn)痛的有效性及安全性。方法 將2015年8月至2016年5月共48例于西南醫(yī)科大學(xué)附屬中醫(yī)醫(yī)院行初次單側(cè)膝關(guān)節(jié)置換的患者按系統(tǒng)隨機(jī)抽樣法分為3組：對(duì)照組16例患者術(shù)后未行手術(shù)切口的局部持續(xù)浸潤(rùn)麻醉及股神經(jīng)阻滯鎮(zhèn)痛，16例患者術(shù)后接受術(shù)側(cè)股神經(jīng)阻滯鎮(zhèn)痛(CFNB)組，16例患者術(shù)后行手術(shù)切口局部羅哌卡因持續(xù)浸潤(rùn)麻醉鎮(zhèn)痛(CWI)組。對(duì)比3組患者術(shù)前一般情況、術(shù)后1～3 d運(yùn)動(dòng)及靜息時(shí)手術(shù)部位的疼痛視覺模擬評(píng)分(VAS)、術(shù)后早期功能恢復(fù)情況及術(shù)后并發(fā)癥情況。結(jié)果 所有患者均獲得隨訪，3組患者在術(shù)前一般情況及術(shù)后并發(fā)癥方面差異無統(tǒng)計(jì)學(xué)意義(P>0.05)；術(shù)后1～3 d運(yùn)動(dòng)狀態(tài)下及術(shù)后第1天靜息狀態(tài)下VAS評(píng)分CWI組及CFNB組情況相似，均低于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)；CWI組患者術(shù)后早期功能恢復(fù)情況優(yōu)于對(duì)照組及CFNB組。結(jié)論 全膝關(guān)節(jié)置換術(shù)后于手術(shù)切口局部行持續(xù)浸潤(rùn)麻醉鎮(zhèn)痛可減少患者術(shù)后疼痛，促進(jìn)患者術(shù)后早期功能鍛煉及康復(fù)，提高患者滿意度。

關(guān)節(jié)成形術(shù)；傷口持續(xù)浸潤(rùn)；羅哌卡因

手術(shù)切口局部的浸潤(rùn)鎮(zhèn)痛技術(shù)近年來在關(guān)節(jié)置換術(shù)中得到了廣泛的重視。有研究提出，局部浸潤(rùn)鎮(zhèn)痛技術(shù)最大的優(yōu)勢(shì)在于起到鎮(zhèn)痛效果的同時(shí)，并不會(huì)引起患者股四頭肌肌力的下降，可更好地對(duì)患者功能康復(fù)訓(xùn)練起到輔助作用。目前使用的局部浸潤(rùn)鎮(zhèn)痛技術(shù)主要為術(shù)中鎮(zhèn)痛藥物的局部注射，但由于其中的一些常用鎮(zhèn)痛藥物如羅哌卡因或布比卡因，其藥物半衰期短，作用時(shí)間相對(duì)有限，故難以達(dá)到持續(xù)有效的鎮(zhèn)痛效果[1-2]。因此，是否可以將局部注射一次給藥改為手術(shù)切口部位的持續(xù)浸潤(rùn)鎮(zhèn)痛以達(dá)到更好的鎮(zhèn)痛效果。故筆者設(shè)計(jì)了本次研究，以驗(yàn)證持續(xù)手術(shù)切口部位浸潤(rùn)鎮(zhèn)痛是否可更好地進(jìn)行術(shù)后疼痛管理。

1 資料與方法

1.1 一般資料 將2015年8月至2016年5月共48例于西南醫(yī)科大學(xué)附屬中醫(yī)醫(yī)院行初次單側(cè)膝關(guān)節(jié)置換的患者納入研究。該研究方案已獲得西南醫(yī)科大學(xué)倫理委員會(huì)的批準(zhǔn)，所有試驗(yàn)對(duì)象均簽署知情同意書。48例患者按系統(tǒng)隨機(jī)抽樣法進(jìn)行分組，分為對(duì)照組、股神經(jīng)阻滯組(CFNB組)及持續(xù)切口浸潤(rùn)鎮(zhèn)痛組(CWI組)，每組各16例患者。納入標(biāo)準(zhǔn)：(1)符合全膝關(guān)節(jié)置換指征；(2)美國(guó)標(biāo)準(zhǔn)協(xié)會(huì)(ASA)評(píng)分小于或等于3分。排除標(biāo)準(zhǔn)：(1)嚴(yán)重肝、腎功能損害；(2)合并其他嚴(yán)重內(nèi)科基礎(chǔ)疾病；(3)對(duì)麻醉鎮(zhèn)痛藥物成分過敏者。

1.2 方法 術(shù)前2 d開始口服塞來昔布(西樂葆，美國(guó)輝瑞；200 mg，每天2次)及氨酚曲馬多片(陜西九州制藥；1片，每天3次)。所有手術(shù)操作過程為同一組醫(yī)師完成：取膝前正中切口，髕旁內(nèi)側(cè)入路，在截骨完成后于膝關(guān)節(jié)腔各部位注射羅哌卡因及甲強(qiáng)龍稀釋液50 mL，假體安放后，縫合關(guān)節(jié)囊，在膝關(guān)節(jié)外側(cè)置入一根硬膜外導(dǎo)管用于泵入鎮(zhèn)痛藥物，3組患者均常規(guī)安放引流管。CFNB組患者術(shù)前于腹股溝韌帶中點(diǎn)下方約2 cm股動(dòng)脈搏動(dòng)外側(cè)1 cm處定位，垂直進(jìn)針，以神經(jīng)刺激儀以0.4 mA電流刺激時(shí)看到股四頭肌收縮為達(dá)到股神經(jīng)周圍，置入硬膜外導(dǎo)管3～5 cm，術(shù)后予以1%氯普魯卡因5 mL/h鎮(zhèn)痛；CWI組患者用微量泵(艾普，江蘇如東；DDB-150)以5 mL/h持續(xù)將0.2%羅哌卡因(卓坦，齊魯制藥)泵入手術(shù)切口行局部持續(xù)浸潤(rùn)鎮(zhèn)痛，對(duì)照組患者術(shù)前不接受股神經(jīng)阻滯，術(shù)后用微量泵以5 mL/h持續(xù)將0.9%生理鹽水泵入手術(shù)切口。術(shù)后24 h拔除引流管，48 h后拔除連續(xù)股神經(jīng)阻滯及連續(xù)浸潤(rùn)鎮(zhèn)痛管道。術(shù)后繼續(xù)口服塞來昔布及氨酚曲馬多鎮(zhèn)痛，皮下注射低分子肝素鈉(齊魯制藥；0.4 mL，每天1次)預(yù)防深靜脈血栓。所有患者均采用美國(guó)施樂輝公司的人工膝關(guān)節(jié)假體，其中固定平臺(tái)12例，旋轉(zhuǎn)平臺(tái)20例。術(shù)后統(tǒng)計(jì)3組患者術(shù)后3 d的運(yùn)動(dòng)及靜息狀態(tài)下的視覺模擬疼痛評(píng)分(VAS)、膝關(guān)節(jié)功能恢復(fù)至出院標(biāo)準(zhǔn)(伸屈0°～90°)所需天數(shù)及圍術(shù)期并發(fā)癥情況。

2 結(jié) 果

2.1 患者術(shù)前一般資料比較 3組患者在年齡，性別組成，術(shù)前診斷及ASA評(píng)分方面比較，差異無統(tǒng)計(jì)學(xué)意義(P>0.05)，見表1。

表1 患者術(shù)前一般資料

OA：骨性關(guān)節(jié)炎；RA：類風(fēng)濕性關(guān)節(jié)炎；PVNS；色素沉著絨毛結(jié)節(jié)性滑膜炎。

2.2 術(shù)后患者運(yùn)動(dòng)及靜息狀態(tài)下VAS評(píng)分 CWI組在術(shù)后VAS評(píng)分方面，術(shù)后1～3 d運(yùn)動(dòng)狀態(tài)下及術(shù)后第1天靜息狀態(tài)下試驗(yàn)組VAS評(píng)分優(yōu)于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)，見圖1。

圖1 術(shù)后患者運(yùn)動(dòng)及靜息狀態(tài)下VAS評(píng)分

2.3 患者術(shù)后相關(guān)指標(biāo)比較 在術(shù)后早期功能恢復(fù)方面，CWI組短期功能恢復(fù)所需時(shí)間為(4.1±1.7)d,CFNB組為(6.7±1.8)d,對(duì)照組為(6.4±1.6)d,CWI組恢復(fù)時(shí)間少于對(duì)照組，差異有統(tǒng)計(jì)學(xué)意義(P<0.05)。

2.4 圍術(shù)期并發(fā)癥 除對(duì)照組有1例患者在術(shù)后常規(guī)雙下肢血管彩超中檢出無癥狀性深靜脈血栓外，其余患者均未出現(xiàn)如切口延遲愈合、切口感染等并發(fā)癥。

3 討 論

在膝關(guān)節(jié)置換術(shù)后，有效的疼痛管理可促進(jìn)患者術(shù)后早期主動(dòng)行功能鍛煉，在患者術(shù)后功能康復(fù)中可起到重要作用[3-5]。隨著多模式、多環(huán)節(jié)疼痛管理理念的引入，如何優(yōu)化這一系統(tǒng)疼痛管理方案中的每一步驟或環(huán)節(jié)成為研究者們關(guān)注的焦點(diǎn)。由于連續(xù)股神經(jīng)阻滯在全膝關(guān)節(jié)置換術(shù)后鎮(zhèn)痛中的廣泛應(yīng)用，在肯定其術(shù)后鎮(zhèn)痛效果的同時(shí)，也有關(guān)于該鎮(zhèn)痛方法所引起的如股四頭肌肌力下降、有效鎮(zhèn)痛范圍相對(duì)局限等不足見諸報(bào)道[6-7]。而在手術(shù)切口局部行適當(dāng)劑量的麻醉鎮(zhèn)痛藥物持續(xù)浸潤(rùn)麻醉鎮(zhèn)痛是一種新的鎮(zhèn)痛方法，相比在手術(shù)部位局部單次注射麻醉鎮(zhèn)痛藥物，它最大的優(yōu)勢(shì)在于可以在手術(shù)切口部位持續(xù)發(fā)揮鎮(zhèn)痛作用，減輕患者術(shù)后早期疼痛[8-11]。國(guó)外有少量關(guān)于該鎮(zhèn)痛方法應(yīng)用于某些外科術(shù)后疼痛管理的研究，其研究結(jié)果對(duì)該疼痛管理方法的有效性及安全性持樂觀態(tài)度。但目前在國(guó)內(nèi)外科領(lǐng)域中，其應(yīng)用仍少見報(bào)道，而膝關(guān)節(jié)置換術(shù)作為外科術(shù)后疼痛程度較重的手術(shù)之一，其術(shù)后如何安全有效進(jìn)行的疼痛管理一直是困擾臨醫(yī)師的一個(gè)難題，該疼痛管理方法是否可有效及安全的應(yīng)用于膝關(guān)節(jié)置換術(shù)后的疼痛管理。有鑒于此，筆者設(shè)計(jì)了本次研究，以分析評(píng)價(jià)全膝關(guān)節(jié)置換術(shù)后于手術(shù)切口局部行持續(xù)浸潤(rùn)麻醉鎮(zhèn)痛的有效性及安全性。

在麻醉藥物選擇方面，由于羅哌卡因具有阻斷痛覺但不干擾運(yùn)動(dòng)功能、心毒性小且具有收縮血管作用，同時(shí)還對(duì)金黃色葡萄球菌和大腸埃希菌有一定的殺菌作用[12-14]，其藥物特點(diǎn)更適宜于膝關(guān)節(jié)置換術(shù)后的疼痛管理。故本次研究選用該藥物作為局部浸潤(rùn)麻醉鎮(zhèn)痛的鎮(zhèn)痛藥物。

麻醉藥物的泵入劑量與疼痛管理效果也是密切相關(guān)，參考國(guó)外一些研究報(bào)道，大多傾向于2 mL/h或5 mL/h[15-16]，文獻(xiàn)[17-18]提出，在術(shù)后手術(shù)切口局部給予較大劑量的麻醉鎮(zhèn)痛藥物可有效減輕患者術(shù)后靜息和運(yùn)動(dòng)狀態(tài)下的疼痛，鎮(zhèn)痛時(shí)效最高可達(dá)32 h，且并無藥物不良反應(yīng)報(bào)道。故本次研究在麻醉藥物的泵入速度方面，選擇的泵入速度為5 mL/h。從對(duì)比分析結(jié)果來看，試驗(yàn)組患者在術(shù)后1～3 d運(yùn)動(dòng)狀態(tài)下及術(shù)后第1天靜息狀態(tài)下VAS評(píng)分均低于對(duì)照組，同時(shí)試驗(yàn)組患者在術(shù)后短期功能恢復(fù)所需時(shí)間方面，也短于對(duì)照組，且并無藥物不良反應(yīng)事件出現(xiàn)。證明該泵速及藥物劑量是安全有效的。

對(duì)于泵入麻醉鎮(zhèn)痛藥物的管道，其置管位置的選擇也是極為重要的。國(guó)外有研究報(bào)道，置管位置并不影響術(shù)后鎮(zhèn)痛效果[19-20]。但本研究從術(shù)后安全性考慮，將置管位置選擇為關(guān)節(jié)囊外，即待關(guān)節(jié)囊層縫合修復(fù)后，再行置管，以減少術(shù)后感染可能。從本研究結(jié)果來看，無論對(duì)照組還是試驗(yàn)組，均未出現(xiàn)術(shù)后切口感染或切口愈合不良。兩組患者術(shù)后并發(fā)癥方面無明顯差異。但本研究中也存在一些不足：(1)術(shù)后疼痛評(píng)價(jià)指標(biāo)采用VAS評(píng)分，為患者自評(píng)，存在個(gè)體差異及主觀干擾因素；(2)病例數(shù)量相對(duì)較少，更大樣本量的綜合分析值得期待。

綜上所述，全膝關(guān)節(jié)置換術(shù)后于手術(shù)切口局部行持續(xù)浸潤(rùn)麻醉鎮(zhèn)痛是安全有效的，該疼痛管理方法可減少患者術(shù)后運(yùn)動(dòng)及靜息狀態(tài)下的疼痛，同時(shí)不影響患者下肢肌肉力量，可促進(jìn)患者術(shù)后早期功能鍛煉及康復(fù)，提高患者滿意度。

[1]Garcia RM,Cassinelli EH,Messerschmitt PJ,et al.A multimodal approach for postoperative pain management after lumbar decompression surgery:a prospective,randomized study[J].J Spinal Disord Tech,2013,26(6):291-297.

[2]Kim SI,Ha KY,Oh IS.Preemptive multimodal analgesia for postoperative pain management after lumbar fusion surgery:a randomized controlled trial[J].Eur Spine J,2016,25(5):1614-1619.

[3]Wall PD,Sprowson AP,Parsons N,et al.Protocol for a single-centre randomised controlled trial of multimodal periarticular anaesthetic infiltration versus single-agent femoral nerve blockade as analgesia for total knee arthroplasty:Perioperative Analgesia for Knee Arthroplasty (PAKA)[J].BMJ Open,2015,5(12):e009898.

[4]Kelley TC,Adams MJ,Mulliken BD,et al.Efficacy of multimodal perioperative analgesia protocol with periarticular medication injection in total knee arthroplasty:a randomized,double-blinded study[J].J Arthroplasty,2013,28(8):1274-1277.

[5]Vendittoli PA,Makinen P,Drolet P,et al.A multimodal analgesia protocol for total knee arthroplasty.A randomized,controlled study[J].J Bone Joint Surg Am,2006,88(2):282-289.

[6]Morin AM,Kratz CD,Eberhart LH,et al.Postoperative analgesia and functional recovery after total-knee replacement:comparison of a continuous posterior lumbar plexus (psoas compartment) block,a continuous femoral nerve block,and the combination of a continuous femoral and sciatic nerve block[J].Reg Anesth Pain Med,2005,30(5):434-445.

[7]Brodner G,Buerkle H,Van Aken H,et al.Postoperative analgesia after knee surgery:a comparison of three different concentrations of ropivacaine for continuous femoral nerve blockade[J].Anesth Analg,2007,105(1):256-262.

[8]Fredman B,Shapiro A,Zohar E,et al.The analgesic efficacy of patient-controlled ropivacaine instillation after Cesarean delivery[J].Anesth Analg,2000,91(6):1436-1440.

[9]Horn EP,Schroeder F,Wilhelm S,et al.Wound infiltration and drain lavage with ropivacaine after major shoulder surgery[J].Anesth Analg,1999,89(6):1461-1466.

[10]Marino J,Russo J,Kenny M,et al.Continuous lumbar plexus block for postoperative pain control after total hip arthroplasty.A randomized controlled trial[J].J Bone Joint Surg Am,2009,91(1):29-37.

[11]Bianconi M,Ferraro L,Traina GC,et al.Pharmacokinetics and efficacy of ropivacaine continuous wound instillation after joint replacement surgery[J].Br J Anaesth,2003,91(6):830-835.

[12]Batai I,Kerenyi M,Falvai J,et al.Bacterial growth in ropivacaine hydrochloride[J].Anesth Analg,2002,94(3):729-731.

[13]Imani F,Zamani S,Etezadi F,et al.Effects of ropivacaine on postoperative pain and peak expiratory flow rate in patients undergoing percutaneous nephrolithotomy[J].Nephrourol Mon,2015,7(6):e30973.

[14]Niiyama Y,Yotsuyanagi T,Yamakage M.Continuous wound infiltration with 0.2% ropivacaine versus a single intercostal nerve block with 0.75% ropivacaine for postoperative pain management after reconstructive surgery for microtia[J].J Plast Reconstr Aesthet Surg,2016,69(10):1445-1449.

[15]Hoenecke HR,Pulido PA,Morris BA,et al.The efficacy of continuous bupivacaine infiltration following anterior cruciate ligament reconstruction[J].Arthroscopy,2002,18(8):854-858.

[16]Solovyova O,Lewis CG,Abrams JH,et al.Local infiltration analgesia followed by continuous infusion of local anesthetic solution for total hip arthroplasty:a prospective,randomized,double-blind,placebo-controlled study[J].J Bone Joint Surg Am,2013,95(21):1935-1941.

[17]Andersen LO,Husted H,Otte KS,et al.High-volume infiltration analgesia in total knee arthroplasty:a randomized,double-blind,placebo-controlled trial[J].Acta Anaesthesiol Scand,2008,52(10):1331-1335.

[18]Spreng UJ,Dahl V,Hjall A,et al.High-volume local infiltration analgesia combined with intravenous or local ketorolac+morphine compared with epidural analgesia after total knee arthroplasty[J].Br J Anaesth,2010,105(5):675-682.

[19]Andersen LO,Husted H,Kristensen BB,et al.Analgesic efficacy of intracapsular and intra-articular local anaesthesia for knee arthroplasty[J].Anaesthesia,2010,65(9):904-912.

[20]Dobrydnjov I,Anderberg C,Olsson C,et al.Intraarticular vs.extraarticular ropivacaine infusion following high-dose local infiltration analgesia after total knee arthroplasty:a randomized double-blind study[J].Acta Orthop,2011,82(6):692-698.

Analysis on efficacy of local incision continuous local ropivacine infiltration anesthetic analgesia after total knee arthroplasty*

TangYanhong1,ZhangYing1,WangJingjing2,LiuQing1△

(1.DepartmentofAnesthesiology,AffiliatedHospitalofTraditionalChineseMedicine,SouthwestMedicalUniversity,Luzhou,Sichuan646000,China;2.DepartmentofOrthopaedics,LuzhouMunicipalHospitalofTraditionalChineseMedicine,Luzhou,Sichuan646000,China)

Objective To investigate and evaluate the effectiveness and safety of continuous local incision infiltration anesthetic analgesia after total knee arthroplasty(TKA).Methods Forty-eight patients with initial unilateral TKA in the Affiliated Hospital of Traditional Chinese Medicine of Southwest Medical University from August 2015 to May 2016 were allocated to three groups according to systematic random sampling methods:16 cases in the control group

continuous local incision infiltration anesthesia and femoral nerve block analgesia,16 cases received continuous femoral nerve block analgesia after TKA(CFNB) and other 16 cases received local ropivacaine continuous local incision infiltration anesthesia analgesia(CWI).The preoperative general situation,visual analogue scale (VAS) score of operative site in movement and rest on postoperative 1-3 d,postoperative early function recovery and postoperative complication were compared among 3 groups.Results All cases were followed up.There was no statistically significant difference in the general situation postoperative complications among 3 groups(P>0.05).the VAS score under movement status on postoperative 1-3 d and rest status in the CWI group and CFNB group were similar,which were lower than those in the control group,the difference was statistically significant(P<0.05);the postoperative early function recovery in the CWI group was superior to that in the control group and CFNB group.Conclusion local incision infiltration anesthetic analgesia after TKA can relief postoperative pain,facilitate patient′s early function exercise and rehabilitation,and improves patient′s satisfaction.

arthroplasty；continuous wound infiltration；ropivacaine

10.3969/j.issn.1671-8348.2017.16.016

四川省衛(wèi)生廳科研課題(130274)；四川省瀘州市科研課題[2011-I-S41(4/4)]。 作者簡(jiǎn)介：唐燕紅(1987-)，在讀碩士,住院醫(yī)師，主要從事臨床麻醉工作?！?/p>

,E-mail：1105859368@qq.com。

R614.3+2

A

1671-8348(2017)16-2212-03

2017-02-04

2017-04-08)