膝关节周围注射镇痛在全膝关节置换术后多模式镇痛方案中的作用解析

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全膝关节置换术是治疗终末期膝关节疾病的 主要术式，而镇痛是围手术期处理最为关键的环节 之一。全膝关节置换术后疼痛明显，可严重影响患 者的康复进程及对手术的满意度［1］。
临床上有很多针对全膝关节置换术的镇痛方 案，但各有缺点。口服、肌内或静脉注射阿片类镇 痛药可能导致呼吸抑制、昏睡、肾功能损害、恶心、 呕吐及平滑肌抑制等并发症；周围神经阻滞、硬膜 外置管操作复杂，技术要求高，存在血肿、感染、神 经损害及术后跌倒的风险［2］，同时也限制了术后抗 凝措施的应用；持续关节内麻醉镇痛剂灌注有导致 细菌入侵的可能。而术中直接在手术区域注射麻 醉药的镇痛效果好，且技术要求低，被多数学者认 为是一种理想的人工膝关节置换术的镇痛选择。
中华骨科杂志 2016 年 4 月第 36 卷第 7 期 Chin J Orthop, April 2016, Vol. 36, No. 7
and reduce narcotic use compared with patients without it. It is simple and safe to use. 【Key words】 Arthroplasty, replacement, knee; Anesthesia and analgesia; Injections, intra⁃articular 【Fund program】 Beijing Science Committee Key Project Fund (D121100004212001)
【Abstract】 Objective To evaluate the additional efficacy of local anesthetic injection (LAI) as a part of multimodal anal⁃ gesia in patients undergoing total knee arthroplasty (TKA) with respect to pain, narcotic use, knee function and complications. Methods A multicenter randomized, controlled, double blind study was performed. A total of 101 patients undergoing unilateral TKA in two centers were randomly divided into injection group and control group. Injection group (50 cases) received local anes⁃ thetic injection of ropivacaine (200 mg), fentanyl (1 μg) and epinephrine (1∶1 000, 0.25 mg) in operation and control group (51 cas⁃ es) did not. All patients received standardized general anesthesia and postoperative intravenous patient controlled analgesia (PCA). Preoperative baseline data, surgery⁃related conditions, postoperative pain (on a 0 to 10 scale), knee function, time of open⁃ ing PCA, narcotic dosage in PCA and complications were compared respectively. Results The time of opening PCA in injection group (4-10 h, M=8 h) was longer than that in control group (2-5 h, M=4 h) (P<0.05). The 12 h, 24 h and total narcotic use of PCA in injection group (8.62±3.601 ml, 21.22±9.220 ml, 38.52±7.764 ml) was less than that in control group (18.43±9.671 ml, 35.30± 11.414 ml, 55.52±12.405 ml) (P<0.05). At post anesthesia care unit the mean VAS in injection group (2.40±1.927) was lower than that in control group (3.06±2.073) (P<0.05). There was no difference in mean VAS at other time points, knee function, length of stay between two groups (P>0.05). Conclusion LIA in TKA can relieve pain early after TKA, prolong the time of opening PCA
【关键词】 关节成形术，置换，膝；麻醉和镇痛；注射，关节内 【证据等级】 治疗性研究Ⅰ级 【基金项目】 北京市科委重大项目基金（D121100004212001）
A randomized controlled trial on additional efficacy of local anesthetic injection on multimodal analgesia in total knee arthroplasty Peng Huiming, Tang Qiheng, Qian Wenwei, Weng Xisheng, Zhou Yixin, Lin Jin, Jin Jin, Wang Wei, Feng Bin, Yin Xinghua, Wang Longchao, Tian Xue Peng Huiming and Tang Qiheng are the first authors who contributed equally to the article Department of Orthopaedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences, Beijing 100730, China (Peng HM, Qian WW, Weng XS, Lin J, Jin J, Wang W, Feng B, Wang LC, Tian X); Department of Orthopaedics, Beijing Jishuitan Hospital, Beijing 100035, China ( Tang QH, Zhou YX, Yin XH) Corresponding author: Weng Xisheng, E⁃mail: xshweng@; Zhou Yixin, E⁃mail: orthoyixin@
DOI: 10.3760/cma.j.issn.0253⁃2352.2016.07.004
【摘要】 目的 探讨术中膝关节周围注射镇痛在全膝关节置换术后多模式镇痛方案中的价值。方法 采用多中心 随机对照双盲研究，纳入 2014 年 7 月至 2015 年 6 月北京协和医院骨科和北京积水潭医院矫形骨科收治的初次单侧全膝关 节置换患者 101 例。随机分为两组：关节注射组 50 例，术中于膝关节周围浸润注射混合镇痛注射液 100 m（l 罗哌卡因 200 mg+芬太尼 1 μg+l∶1 000 肾上腺素 0.25 mg+生理盐水）；空白对照组 51 例。术后 48 h 内均统一配置静脉患者自控镇痛（pa⁃ tient controlled analgesia，PCA）泵。比较术后两组的疼痛视觉模拟评分（visual analogue scale，VAS）、开启静脉 PCA 泵的时 间和用药总量、膝关节活动范围、上消化道不良事件及术后并发症。结果 关节注射组 PCA 泵的开启时间为术后 4~10 h （M=8 h），空白对照组为术后 2~5 h（M=4 h），两组差异有统计学意义（Z=-4.201，P=0.000）。关节注射组术后 12 h、24 h 和 总的静脉 PCA 泵用药剂量分别为（8.62±3.601）ml、（21.22±9.220）ml、（38.52±7.764）ml，均少于空白对照组［分别为 （18.43±9.671）ml、（35.30±11.414）ml、（55.52±12.405）ml］，差异有统计学意义（P 均＜0.05）。关节注射组在麻醉恢复室时 疼痛 VAS 评分为（2.40±1.927）分，小于空白对照组的（3.06±2.073）分，差异有统计学意义（t=-2.760，P=0.007）。两组术前 一般资料、手术时间、术中出血量、术后引流量、异体输血率、术后其余时点疼痛 VAS 评分、膝关节活动范围、主动直腿抬高 时间、下地时间、住院时间的差异均无统计学意义（P 均＞0.05）。结论 膝关节周围注射镇痛可延长静脉 PCA 泵开启时 间、节省阿片类药物用量、缓解术后早期疼痛，且无明显并发症，是安全且有效的全膝关节置换术围手术期镇痛方法。
关节周围软组织混合镇痛药物注射在全膝关 节置换术中、术后早期有明显的镇痛效果，可以减 少阿片类药物的用量，没有明显的不良反应［2-9］。但 相关研究存在下列问题：①均为单中心对照研究， 且样本量较小，循证医学级别不高；②仅评价了膝 关节周围注射的镇痛效果，未评价其在多模式镇痛 方案中的作用，而多模式镇痛是目前膝关节置换围 手术期镇痛的主流选择；③混合镇痛药物的组成、 药品剂量、注射方式及部位存在一定差异，其中某 些药物也较难获取，许多方案不适宜在国内开展。