加入局部浸润镇痛的多模式镇痛在全膝关节置换中的应用

 目的 探讨局部浸润镇痛在初次单侧全膝关节置换(total knee arthroplasty，TKA)术后多模式镇痛中的作用及安全性。方法 将60例拟行初次单侧TKA手术的患者随机分为局部浸润镇痛组与无局部浸润镇痛组，每组30例。两组均于术前3天给予塞来昔布口服(200 mg，2次/d)，于手术室进行术侧股神经阻滞(3.3 g/L罗哌卡因30 ml)。采用静脉吸入复合麻醉。局部浸润镇痛组于术中假体安放完毕后行切口局部浸润镇痛(2.5 g/L罗哌卡因60 ml+0.1 mg肾上腺素)；无局部浸润镇痛组不做切口局部浸润镇痛。术后均不使用静脉患者自控式镇痛泵。观察两组患者麻醉清醒后2、6、12、24、48、72 h及出院时的静息与活动疼痛视觉模拟评分(visual analogue scale，VAS)；术后24、48、72 h关节活动度、股四头肌肌力及镇痛相关不良反应发生率。结果 局部浸润镇痛组术后各时点的静息及运动VAS评分均低于无局部浸润镇痛组，术后2 h至48 h静息VAS及24 h以后运动VAS的差异有统计学意义。局部浸润镇痛组术后24、48、72 h及出院时膝关节活动度、股四头肌肌力优于无局部浸润镇痛组，首次直腿抬高时间早于无局部浸润镇痛组，对阿片类药物的需求(哌替啶35.0 mg/例)少于无局部浸润镇痛组(哌替啶66.7 mg/例)，镇痛相关不良反应发生率(2/30，6.7%)低于无局部浸润镇痛组(7/30，23.3%)，术后平均住院时间(5.4 d)少于无局部浸润镇痛组(6.8 d)，差异均有统计学意义。结论 以股神经阻滞联合局部浸润镇痛为主的多模式镇痛在初次单侧TKA术后有较好的镇痛效果。

Analgesic effects of local infiltration analgesia in multimodal analgesia for unilateral primary total knee arthroplasty

Objective To evaluate the efficacy and safety of local infiltration analgesia in the multimodal analgesia protocol. Methods Sixty patients who were scheduled to undergo TKA were randomly divided two groups: local infiltration analgesia (LIA) group (n=30) or the non-local infiltration analgesia (N-LIA) group (n=30). All patients were given Celecoxib 200 mg bid, 3 days preoperative, and a single-injection femoral nerve block (SFNB) half an hour before the surgery (ropivacaine 3.3 g/L, 30 ml). The LIA group was given local infiltration analgesia with ropivacaine (2.5 g/L, 60 ml) and 0.1 mg epinephrine before suture the operative incision. The N-LIA group didn't do the LIA. Both of the two groups didn't use the patient controlled analgesia. The VAS scores, the knee joint range of motion, the muscle strength of quadriceps femoris and the side effects and complications were recorded. Results The VAS scores were lower in LIA group than in the N-LIA group, these scores at 2 h to 48 h after surgery at rest and after 24 h at motion had statistical significance. The range of motion and the muscular strength of quadriceps femoris in the LIA group were better than in the N-LIA group. In the LIA group the use of opioids was less and the side effects were lower. The average length of hospital stay after the operation was shorter in the LIA group than the N-LIA group. Conclusion This multimodal perioperative analgesia protocol that include SFNB and LIA offered improved pain control and minimal side effects to patients undergoing TKA.