王浩洋;康鹏德;裴福兴;杨静;沈彬;周宗科;马俊;黄强;

• 1:四川大学华西医院骨科

摘要(Abstract)：

[目的]前瞻性研究多模式镇痛(multimodal analgesia,MA)在全髋关节置换术(total hip arthroplasty,HTA)后镇痛的有效性和安全性。[方法]将60例拟行初次单侧全髋关节置换的患者随机分为2组:多模式镇痛组(MA组)和对照组。所有患者均于术前3 d开始口服塞来昔布(200 mg,2次/d),手术采用静脉、吸入复合麻醉。多模式镇痛组(n=30),于假体安置完成,缝合关节囊后于关节囊周围、切口周围浸润注射罗哌卡因2.5 g/L,80ml(含0.1 mg肾上腺素),逐层关闭切口;对照组(n=30),不做切口浸润直接缝合切口。两组患者均不使用静脉患者自控式镇痛泵。观察2组患者术后1、4、24、48、72 h和出院时的疼痛视觉模拟评分(visual analogue scale,VAS)和术后24、48、72 h及出院时术侧髋关节活动度,阿片类药物使用情况及镇痛相关不良反应发生率。[结果]多模式镇痛组(MA组)患者术后48 h内切口疼痛程度低于对照组,差异有统计学意义(P<0.05),48 h后MA组患者疼痛程度稍低于对照组,但结果差异无统计学意义(P>0.05)。术后髋关节屈伸、外展活动MA组优于对照组,差异有统计学意义(P<0.05);术后24 h内MA组16人要求使用补救性阿片类药物,显著低于对照组(26人)(P<0.05),恶心、呕吐等副反应发生率MA组低于对照组。两组患者均未出现切口感染、下肢深静脉血栓(deep vein thrombosis,DVT)等全髋关节置换术相关严重并发症。[结论]多模式镇痛能有效缓解THA术后疼痛,减少患者对阿片类药物的需求,利于患者术后早期康复的同时不增加THA术后严重并发症的发生率。多模式镇痛是THA术后安全、有效的镇痛方法。

关键词(KeyWords)： 全髋关节置换术;多模式镇痛;切口浸润镇痛

Abstract:

Keywords:

基金项目(Foundation): 卫生部行业科研专项基金(编号:201302007)

作者(Author): 王浩洋;康鹏德;裴福兴;杨静;沈彬;周宗科;马俊;黄强;

Email:

DOI:

参考文献(References)：

• [1]Singelyn FJ,Ferrant T,Malisse MF,et al.Effects of intravenous pa-tient-controlled analgesia with morphine,continuous epidural anal-gesia,and continuous femoral nerve sheath block on rehabilitation af-ter unilateral total-hip arthroplasty[J].Regional Anesthesia PainMed,2005,5:452-457.
• [2]Parvizi J,Miller AG,Gandhi K.Current concepts review:multimodalpain management after total joint arthroplasty[J].J Bone Joint SurgAm,2011,11:1075-1084.
• [3]Abdul-Hadi O,Parvizi J,Austin MS,et al.Nonsteroidal anti-in-flammatory drugs in orthopaedics[J].J Bone Joint Surg Am,2009,12:2020-2027.
• [4]Wheeler M,Oderda GM,Ashburn MA,et al.Adverse events associat-ed with postoperative opioid analgesia:a systematic review[J].JPain,2002,2:159-180.
• [5]Viscusi ER,Parvizi J,Tarity TD.Developments in spinal and epi-dural anesthesia and nerve blocks for total joint arthroplasty:what isnew and exciting in pain management[J].Instr Course Lect,2007,2:139-145.
• [6]Becchi C,Al Malyan M,Coppini R,et al.Opioid-free analgesia bycontinuous psoas compartment block after total hip arthroplasty.Arandomized study[J].Europ J Anaesthesiol,2008,5:418-423.
• [7]Singelyn FJ,Gouverneur JM.Postoperative analgesia after total hiparthroplasty:IVPCA with morphine,patient-controlled epidural an-algesia,or continuous"3-in-1"block?:A prospective evaluationby our acute pain service in more than 1,300 patients[J].J ClinAnesthesia,1999,7:550-554.
• [8]Biboulet P,Morau D,Aubas P,et al.Postoperative analgesia after to-tal-hip arthroplasty:comparison of intravenous patient-controlledanalgesia with morphine and single injection of femoral nerve or psoascompartment block.A prospective,randomized,double-blind study[J].Regional Anesthesia Pain Med,2004,2:102-109.
• [9]McQueen DA,Kelly HK,Wright TF.A comparison of epidural andnon-epidural anesthesia and analgesia in total hip or knee arthro-plasty patients[J].Orthopedics,1992,2:169-173.
• [10]Singh K,Phillips FM,Kuo E,et al.A prospective,randomized,doub-le-blind study of the efficacy of postoperative continuous local anes-thetic infusion at the iliac crest bone graft site after posterior spinalarthrodesis:a minimum of 4-year follow-up[J].Spine(PhilaPa 1976),2007,32:2790.
• [11]Lunn TH,Husted H,Solgaard S et al.Intraoperative local infiltrationanalgesia for early analgesia after total hip arthroplasty.A random-ized,double-blind,placebo-controlled trial[J].Regional Anes-thesia Pain Med,2011,5:424-429.
• [12]Specht K,Leonhardt JS,Revald P,et al.No evidence of a clinicallyimportant effect of adding local infusion analgesia administratedthrough a catheter in pain treatment after total hip arthroplasty[J].Acta Orthopaedica,2011,2:315-320.
• [13]Joo JH,Kim JS,Kim YH.Is intra-articular multimodal drug injec-tion effective in pain management after total knee arthroplasty[J].JArthroplasty,2011,7:1095-1099.
• [14]Maheshwari AV,Boutary M,Yun AG,et al.Multimodal analgesiawithout routine parenteral narcotics for total hip arthroplasty[J].Clin Orthop,2006,453:231-238.
• [15]Andersen LO,Husted H,Otte KS,et al.High-volume infiltrationanalgesia in total knee arthroplasty:a randomized,double-blind,placebo-controlled trial[J].Acta Anaesthesiol Scand,2008,10:1331-1335.
• [16]Fredrickson MJ,Price DJ.Analgesic effectiveness of ropivacaine 0.2%vs 0.4%via an ultrasound-guided C5-6 root/superior trunkperineural ambulatory catheter[J].Br J Anaesthesia,2009,3:434-439.
• [17]Young A,Buvanendran A.Recent advances in multimodal analgesia[J].Anesthesiol Clin,2012,1:91-100.
• [18]Axelsson K,Nordenson U,Johanzon E,et al.Patient-controlled re-gional analgesia(PCRA)with ropivacaine after arthroscopic subacro-mial decompression[J].Acta Anaesthesiol Scand,2003,47:993.
• [19]Martin F,Cherif K,Gentili ME,et al.Lack of impact of intravenouslidocaine on analgesia,functional recovery,and nociceptive painthreshold after total hip arthroplasty[J].Anesthesiology,2008,109:118-123.
• [20]Morin A,Wulf H.High volume local infiltration analgesia(LIA)fortotal hip and knee arthroplasty:a brief review of the current status[J].Anasthesiol Intens Notfallmedizin Schmerztherapie,2011,2:84-86.
• [21]Liu W,Cong R,Li X,et al.Reduced opioid consumption and im-proved early rehabilitation with local and intraarticular cocktail anal-gesic injection in total hip arthroplasty:a randomized controlled clin-ical trial[J].Pain Med(Malden,Mass),2011,3:387-393.