超声引导下连续股神经阻滞在全膝关节置换术后镇痛及功能锻炼的意义

目的探讨单侧腰麻全膝关节置换（TKA）术后超声引导下连续股神经阻滞镇痛的效果。方法本组TKA手术123例,ASAⅠ-Ⅱ级,均选择L4/5间隙穿刺轻比重布比卡因单侧腰麻。Ⅰ组42例,Ⅱ组26例,术后均选用自控静脉镇痛（PICA）,PICA配方为（舒芬太尼100 ug＋氯胺酮50 mg＋咪唑安定1 mg＋托烷司琼6 mg）,用0.9%生理盐水稀释至100 ml,首剂量为3 ml静注后连接患者自控镇痛泵（PCA）,PCA泵维持量为1.5 ml/h、2 ml/PCA,锁定时间为60 min;Ⅱ组由术者于术毕加用0.375%左布比卡因20-30 ml行膝关节及切口局部浸润阻滞;Ⅲ组55例,于手术后床边超声引导下患侧股神经旁置管连续股神经阻滞镇痛,PCA泵配方为0.15%左布比卡因300 ml（含舒芬太尼100 ug）,首剂量15 ml后2 ml/h,8 ml/PCA,锁定时间为60 min。记录术后患者首次PCA时间,术后6 h、6-12 h、12-24 h、24-48 h舒芬太尼用量及其视觉模拟评分法（VAS）;术后48 h内膝关节的主动屈曲度,及48 h内膝关节被动屈曲90°时的VAS最大值;及患者的不良反应情况。结果（1）术后患者首次PCA时间,Ⅲ组〉Ⅱ组〉Ⅰ组,组间比较有统计学差异;（2）术后6 h和6-12 h舒芬太尼用量比较,Ⅰ组〉Ⅱ组〉Ⅲ组,组间比较有统计学差异;术后12-24 h及24-48 h舒芬太尼用量比较,Ⅰ组和Ⅱ组分别〉Ⅲ组,有统计学差异;（3）静息时VAS评分：术后6 h,Ⅰ组〉Ⅱ组和Ⅲ组,有统计学差异;6-12 h和术后12-24 h,Ⅰ组和Ⅱ组〉Ⅲ组,有统计学差异;24-48 h的VAS评分三组无统计学差异;（4）术后48 h内膝关节的主动屈曲度比较,Ⅲ组均明显大于及Ⅰ组和Ⅱ组,有统计学差异;（5）48 h内膝关节被动屈曲90°时的VAS比较,Ⅰ组和Ⅱ组均明显高于Ⅲ组,有统计学差异。结论超声引导下股神经旁置管TKA连续股神经阻滞镇痛的镇痛效果好,更有利于术后膝关节功能锻炼和膝关节功能的恢复。

Value of ultrasound-guided continuous femoral nerve block for postoperative analgesia and functional exercise after total knee arthroplasty

Objective To investigate the effects of the postoperative analgesia and functional exercise by ultrasound-guided continuous femoral nerve block after total knee arthroplasty（TKA）.Methods A total of 123 patients undergoing TKA of ASA Ⅰ - Ⅱ were randomized into three groups：group Ⅰ（n = 42）,group Ⅱ（n = 26） and group Ⅲ（n = 55）.All the patients had received unilateral spinal anesthesia by using hypobaric bupivacaine in the L4-L5 space.The postoperative patient-controlledanalgesia（PCA） for groupⅠ and group Ⅱwas performed intravenously.The PCA recipe for groupⅠandⅡwas as follows：sufentanil 100 ug ＋ ketamine 50 mg ＋ midazolam 1 mg ＋ tropisetron 6 mg.All these drugs were diluted in 100 ml of 0.9% saline;after the first intravenous dose of 3 ml,the PCA pump was connected,and the PCA parameters were set as follows：1.5 ml / h;2 ml / PCA,60 minutes of the lock time.All the patients in group Ⅱ had been intra-articularly injected 20-30 ml of 0.375%levobupivacaine by the surgeon before suturing.In group Ⅲ,the patients received ultrasound-guided continuous femoral nerve block for postoperative PCA after the surgery.The PCA formulation for group Ⅲwas as follows ：0.15% levobupivacaine 300 ml（containing sufentanil 100ug）;the PCA pump parameters were set as follows：first dose 15 ml;2 ml / h;8 ml / PCA;60 minutes of the lock time.The detection indicators included the first postoperative PCA time,the sufentanil dosage,the visual analogue scale（VAS）（during 0-6 h,6-12 h,12-24 h,24-48 h after the operation）,the maximum active flexion angle of the knee within postoperative 48 h,the maximum value of VAS when the knee was at 90° of passive flexion within the postoperative 48 h and the rate of adverse reactions.Results（1） There were significant differences,in the first postoperative PCA time between the different groups,group Ⅲ〉 group Ⅱ 〉group Ⅰ.（2） There were significant differences in the sufentanil dosage in the postoperative 6 h and 6-12 h,group Ⅰ