崔明達(dá), 蔡善保, 段 文, 孟祥暉, 張繼學(xué), 張伯康
(1.新鄉(xiāng)醫(yī)學(xué)院, 河南 新鄉(xiāng) 453003 2.安徽省腫瘤醫(yī)院, 安徽 合肥 230031)
丁丙諾啡聯(lián)合股神經(jīng)阻滯對(duì)膝關(guān)節(jié)置換術(shù)后快速康復(fù)的影響
崔明達(dá)1, 蔡善保2, 段 文2, 孟祥暉2, 張繼學(xué)2, 張伯康2
(1.新鄉(xiāng)醫(yī)學(xué)院, 河南 新鄉(xiāng)4530032.安徽省腫瘤醫(yī)院, 安徽 合肥230031)
目的觀察丁丙諾啡聯(lián)合股神經(jīng)阻滯,用于首次單側(cè)全膝關(guān)節(jié)置換術(shù)后患者的鎮(zhèn)痛效果及術(shù)后近期對(duì)功能鍛煉的影響。方法選擇我科2016年6月至2017年6月全膝關(guān)節(jié)置換術(shù)行股神經(jīng)阻滯62例,根據(jù)股神經(jīng)阻滯時(shí)是否使用丁丙諾啡分為A組(丁丙諾啡+羅哌卡因)和B組(羅哌卡因)。比較兩組患者術(shù)后12、24、36、48、60、72h靜息和活動(dòng)視覺(jué)模擬評(píng)分(Visual Analogue Score,VAS),術(shù)后3d的氨酚羥考酮使用量,術(shù)后7d膝關(guān)節(jié)關(guān)節(jié)活動(dòng)度(Range of motion,ROM) ,以及住院時(shí)間的情況。結(jié)果A組患者術(shù)后靜息狀態(tài)VAS評(píng)分在12、24、36、48h低于B組(P<0.05),在60、72h差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05);A組患者術(shù)后活動(dòng)狀態(tài)VAS評(píng)分在12、24、36、48、60、72h低于B組(P<0.05);術(shù)后氨酚羥考酮使用量在1、2d,以及總使用量A組小于B組(P<0.05)?;颊咝g(shù)后7d膝關(guān)節(jié)活動(dòng)度A組大于B組(P<0.05);兩組患者住院時(shí)間差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05)。結(jié)論使用丁丙諾啡聯(lián)合股神經(jīng)阻滯可改善術(shù)后短期鎮(zhèn)痛效果,減少鎮(zhèn)痛藥物使用,有利于患者早期功能鍛煉和快速康復(fù)。
全膝關(guān)節(jié)置換; 股神經(jīng); 丁丙諾啡; 鎮(zhèn) 痛
全膝關(guān)節(jié)置換術(shù)已經(jīng)逐漸成為治療嚴(yán)重膝關(guān)節(jié)骨關(guān)節(jié)病最普遍和有效的外科治療方法,隨著臨床快速康復(fù)理念的發(fā)展,在膝關(guān)節(jié)置換術(shù)后鼓勵(lì)患者早期進(jìn)行功能鍛煉[1],而全膝關(guān)節(jié)置換術(shù)后常會(huì)引起患者重度疼痛或極重度疼痛,因此有效術(shù)后鎮(zhèn)痛是實(shí)現(xiàn)患者早期功能鍛煉,快速康復(fù)的基礎(chǔ)[2]。隨著區(qū)域麻醉技術(shù)的發(fā)展和超聲在麻醉鎮(zhèn)痛領(lǐng)域的應(yīng)用,區(qū)域麻醉技術(shù)以其可靠的鎮(zhèn)痛效果和較少的全身不良反應(yīng)在術(shù)后鎮(zhèn)痛中的應(yīng)用比例逐漸提高[3~5]。在不增加副作用前提下如何延長(zhǎng)這種鎮(zhèn)痛效果成為全世界臨床研究的熱點(diǎn)。一些阿片類藥物??勺鳛橥庵苌窠?jīng)阻滯的的輔助藥物,例如芬太尼、舒芬太尼、嗎啡、哌替啶,但是其臨床效果并未得到統(tǒng)一認(rèn)可[6,7]。丁丙諾啡因具有獨(dú)特的藥理學(xué)作用引起了學(xué)者廣泛的興趣,丁丙諾啡是同劑量單獨(dú)作用持續(xù)時(shí)間最長(zhǎng)的阿片類藥物,它可以類似局部麻醉藥物阻斷神經(jīng)纖維Na+門控通道[8]。國(guó)外已有研究表明丁丙諾啡可有效增加區(qū)域鎮(zhèn)痛作用時(shí)間和效果[9~11],同時(shí)也有研究表明丁丙諾啡對(duì)區(qū)域鎮(zhèn)痛無(wú)正面作用[12]。本研究主要目的為觀察丁丙諾啡聯(lián)合股神經(jīng)阻滯對(duì)膝關(guān)節(jié)置換術(shù)后病人的疼痛控制效果,術(shù)后鎮(zhèn)痛藥物使用量,以及患者膝關(guān)節(jié)功能鍛煉情況。
1.1一般資料:選擇2016年5月至2017年6月,我科行全膝關(guān)節(jié)置換聯(lián)合股神經(jīng)阻滯患者62例,根據(jù)是否使用丁丙諾啡聯(lián)合股神經(jīng)阻滯分為兩組,A組使用丁丙諾啡0.3mg+0.375%羅哌卡因20mL股神經(jīng)阻滯,其中男性12例,女性20例,年齡65.4±9.0歲,體重64.3±8.6Kg,手術(shù)時(shí)間94.2±29.4min;B組使用0.375%羅哌卡因20mL股神經(jīng)阻滯組。其中男性12例,女性18例,年齡63.4±6.4歲,體重66.9±8.1Kg,手術(shù)時(shí)間92.9±29.6min;所有患者均采用氣管插管全身麻醉。經(jīng)比較,兩組患者一般資料差異無(wú)統(tǒng)計(jì)學(xué)意義(P>0.05),具有可比性。
1.2納入標(biāo)準(zhǔn):參與研究患者均符合以下標(biāo)準(zhǔn):①美國(guó)麻醉醫(yī)師協(xié)會(huì)分級(jí)Ⅰ~Ⅱ級(jí);②均為膝骨關(guān)節(jié)病首次行單側(cè)全膝關(guān)節(jié)置換術(shù);③年齡50~80歲
1.3排除標(biāo)準(zhǔn):符合以下任一標(biāo)準(zhǔn)則排除:①穿刺部位感染;②非首次手術(shù);③不能正確理解視覺(jué)模擬疼痛評(píng)分(VAS)的患者。
1.4治療方法:62例膝關(guān)節(jié)置換術(shù)均由我科同一高年資副主任醫(yī)師完成,在術(shù)前30min預(yù)防性應(yīng)用頭孢呋辛1.5g,手術(shù)開(kāi)始,抬高下肢排空靜脈后,止血帶充氣,壓力為45Kpa,定時(shí)90min。手術(shù)時(shí)間計(jì)為從排空下肢靜脈到縫皮。麻醉誘導(dǎo)后立即實(shí)施股神經(jīng)阻滯,在超聲定位和神經(jīng)刺激器引導(dǎo)下于患者患側(cè)行股神經(jīng)阻滯,患者平臥,在超聲定位后,腹股溝韌帶下2cm股動(dòng)脈外側(cè)1cm處作為穿刺點(diǎn),穿刺針朝向頭側(cè)與皮膚成30度進(jìn)針,刺激電流為1mA,觀察到股四頭肌明顯收縮,刺激電流降為0.2~0.3mA,仍可觀察到股四頭肌明顯收縮,表明穿刺部位正確,回抽無(wú)血后退出針芯,將針尖移到股神經(jīng)深面和和上表面注入藥物。A組注入0.3mg丁丙諾啡+0.375%羅哌卡因20mL,B組0.375%羅哌卡因20mL,使股神經(jīng)被藥物包繞。手術(shù)后病人均住骨科病房護(hù)理,并根據(jù)患者實(shí)際需求給予氨酚羥考酮應(yīng)用。
1.5主要觀察指標(biāo):①用視覺(jué)模擬評(píng)分(Visual analog scale,VAS)的方法來(lái)定量描述患者術(shù)后切口疼痛的程度。記錄三組患者術(shù)后12h、24h、36h、48h、60h、72h靜息和活動(dòng)狀態(tài)下VAS評(píng)分。②記錄術(shù)后3d病人氨酚羥考酮用量。③在術(shù)后7d每日測(cè)量患者膝關(guān)節(jié)活動(dòng)度(ROM)。④住院時(shí)間。
2.1術(shù)后兩組患者VAS評(píng)分比較:A組VAS評(píng)分在靜息狀態(tài)下較B組低,且在12h、24h、36h、48h差異有統(tǒng)計(jì)學(xué)意義(P<0.05),在活動(dòng)狀態(tài)下A組較B組低,在12h、24h、36h、48h、60h、72h差異均有統(tǒng)計(jì)學(xué)意義(P<0.05)。見(jiàn)表1、表2。
表1 兩組患者術(shù)后安靜狀態(tài)VAS評(píng)分比較
表2 兩組患者術(shù)后活動(dòng)狀態(tài)狀態(tài)VAS評(píng)分比較
表3 兩組患者術(shù)后氨酚羥考酮使用情況比較
2.2術(shù)后兩組患者氨酚羥考酮使用情況比較:A組使用量較B組低,在1d、2d和使用總量有統(tǒng)計(jì)學(xué)意義(P<0.05),見(jiàn)表3。
2.3兩組患者術(shù)后膝關(guān)節(jié)活動(dòng)度比較:術(shù)后7d患者膝關(guān)節(jié)活動(dòng)度(ROM)比較,A組大于B組,差異具有統(tǒng)計(jì)學(xué)意義(P<0.05)。見(jiàn)表4。
表4 兩組患者術(shù)后(ROM)比較
2.4兩組患者住院時(shí)間比較:A組患者住院時(shí)間10.68±2.67d,B組10.3±2.32d(P>0.05),兩組住院時(shí)間差異無(wú)統(tǒng)計(jì)學(xué)意義。
本研究的主要目的是丁丙諾啡聯(lián)合羅哌卡因行股神經(jīng)阻滯在初次膝關(guān)節(jié)置換術(shù)后的疼痛控制的影響。膝關(guān)節(jié)術(shù)后鎮(zhèn)痛對(duì)膝關(guān)節(jié)置換術(shù)后快速康復(fù)意義重大,隨著區(qū)域鎮(zhèn)痛技術(shù)的發(fā)展,為了達(dá)到更好的鎮(zhèn)痛效果,國(guó)內(nèi)外學(xué)者對(duì)區(qū)域麻醉時(shí)所使用輔助藥物展開(kāi)廣泛研究。而丁丙諾啡作為作用時(shí)間最長(zhǎng)的阿片類藥物被引起了學(xué)者注意,其應(yīng)用于區(qū)域鎮(zhèn)痛獲得了不同的效果。我們發(fā)現(xiàn)將0.3mg丁丙諾啡聯(lián)合羅哌卡因行股神經(jīng)阻滯可減輕病人術(shù)后疼痛,并且可減少術(shù)后氨酚羥考酮的用量,有利于患者的早期功能鍛煉。
Viel發(fā)現(xiàn)丁丙諾啡聯(lián)合臂叢神經(jīng)阻滯時(shí),可顯著增加神經(jīng)阻滯的效果,且有效時(shí)間可達(dá)35h[13]。Candido等[14]提出假設(shè)丁丙諾啡可作為局部麻醉藥輔助藥物以提高局域麻醉效果。分別將丁丙諾啡輔助臂叢神經(jīng)阻滯(組1),丁丙諾啡輔助肌肉內(nèi)麻醉(組2),不使用丁丙諾啡(組3)。對(duì)三組患者進(jìn)行VAS評(píng)分,組1評(píng)分最低,組3評(píng)分最高。組1鎮(zhèn)痛時(shí)間最長(zhǎng),組2其次,組3最短。作者得出結(jié)論丁丙諾啡可以顯著增強(qiáng)周圍神經(jīng)和臂叢神經(jīng)阻滯效果。當(dāng)丁丙諾啡作為下肢神經(jīng)阻滯的輔助藥物時(shí),也獲得了類似的結(jié)果[15]。有研究發(fā)現(xiàn)當(dāng)丁丙諾啡作為輔助藥物行坐骨神經(jīng)麻醉時(shí),實(shí)驗(yàn)組病人獲得了更加滿意的鎮(zhèn)痛效果和更長(zhǎng)的鎮(zhèn)痛時(shí)間[16]。Mehta等[17]對(duì)丁丙諾啡的外周效應(yīng)進(jìn)行評(píng)估,在腎切除后使用丁丙諾啡聯(lián)合羅派卡因進(jìn)行表面浸潤(rùn),術(shù)后患者VAS評(píng)分較單純使用羅哌卡因顯著降低,同時(shí)有效延長(zhǎng)了鎮(zhèn)痛時(shí)間,減少了術(shù)后鎮(zhèn)痛藥物的使用。我們的研究同樣證實(shí)了使用丁丙諾啡作為輔助用藥聯(lián)合股神經(jīng)阻滯在膝關(guān)節(jié)置換術(shù)可獲得更加理想的鎮(zhèn)痛效果。
膝關(guān)節(jié)置換術(shù)后早期的功能鍛煉可以促進(jìn)患者膝關(guān)節(jié)功能恢復(fù),但術(shù)后疼痛常會(huì)造成患者主動(dòng)功能鍛煉意愿降低。膝關(guān)節(jié)置換術(shù)使用股神經(jīng)阻滯鎮(zhèn)痛具有鎮(zhèn)痛效果好,副作用小等優(yōu)點(diǎn)。本次研究結(jié)果顯示,A組患者使用丁丙諾啡聯(lián)合股神經(jīng)阻滯后48h內(nèi)靜息狀態(tài)VAS評(píng)分顯著低于B組(P<0.05),活動(dòng)狀態(tài)72h內(nèi)VAS評(píng)分同樣顯著低于B組(P<0.05),這表明使用丁丙諾啡可增加膝關(guān)節(jié)置換術(shù)股神經(jīng)阻滯早期鎮(zhèn)痛效果。早期的鎮(zhèn)痛效果可以帶來(lái)良好的功能鍛煉效果,本次研究也證實(shí)了,A組患者使用丁丙諾啡聯(lián)合股神經(jīng)阻滯,在術(shù)后7d的膝關(guān)節(jié)活動(dòng)度(ROM)顯著大于B組。這表明丁丙諾啡聯(lián)合股神經(jīng)阻滯對(duì)患者術(shù)后功能恢復(fù)優(yōu)于單純股神經(jīng)阻滯。目前膝關(guān)節(jié)置換提倡快速康復(fù)理念,本次研究表明,膝關(guān)節(jié)置換術(shù)后使用丁丙諾啡聯(lián)合羅派卡因行股神經(jīng)阻滯可顯著提高鎮(zhèn)痛效果,減少鎮(zhèn)痛藥物使用,有利于膝關(guān)節(jié)功能鍛煉,從而達(dá)到快速康復(fù)的目的,值得在臨床推廣應(yīng)用。由于研究對(duì)象術(shù)前膝關(guān)節(jié)病變程度不同,術(shù)前疼痛以及病變程度不同,這些因素可能會(huì)影響術(shù)后疼痛評(píng)估。而且本次研究例數(shù)較少,可能會(huì)對(duì)結(jié)果造成部分偏差。因本研究隨訪時(shí)間較短,對(duì)患者遠(yuǎn)期功能鍛煉效果并未評(píng)價(jià),需要以后的研究進(jìn)一步完善。
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EffectofBuprenorphineCombinedwithFemoralNerveBlockonFast-trackSurgeryafterPrimaryTotalKneeArthroplasty
CUIMingda,etal
(XinxiangMedicalCollege,HenanXinxiang453003,China)
Objective: To observe the analgesic effect of buprenorphine combined with femoral nerve block for the primary total knee arthroplasty (TKA) and the short-term postoperative rehabilitation.MethodsSixty-three cases of total knee arthroplasty were retrospectively analyzed from June 2016 to June 2017. They were divided into two groups according to the method of femoral nerve anaesthetised. The patients in group A were given ropivacaine with the addition of 0.3 mg of buprenorphine. The patients in group B were given ropivacaine. Postoperative resting and activities of the visual Analogue Score(VAS)at 12、24、36、48、60、72 hours, the range of motion(ROM) in 7 days, the consumption of oxycodone acetaminophen in 3 days and the duration of the hospital stay were compared between two groups.ResultsThe resting state VAS in group A was significantly lower than that in group B at 12, 24, 36, 48 hours (P<0.05), and there was no significant difference in 60, 72 hours (P>0.05). The activities state VAS in group A was significantly lower than that in group B at 12, 24, 36, 48, 60, 72 hours (P<0.05); The consumption of oxycodone acetaminophen group A was significantly lower than group B in 1, 2 day and total consumption (P<0.05); The ROM of group A was significantly greater than that of group B in 7 days post-surgery (P<0.05); There was no significant difference in hospital stay between the two groups(P>0.05).ConclusionThe results showed that buprenorphine combined with femoral nerve block can improve the short-term analgesic effect and reduce the consumption of morphine drugs, which is beneficial to the functional exercise and rehabilitation of the patients.
Total knee arthroplasty; Femoral nerve; Buprenorphine; Analgesia
1006-6233(2017)11-1819-05
蔡善保
A
10.3969/j.issn.1006-6233.2017.11.017