連續(xù)股神經(jīng)阻滯用于全膝關(guān)節(jié)置換術(shù)后康復(fù)鎮(zhèn)痛的臨床觀察

1、連續(xù)股神經(jīng)阻滯用于全膝關(guān)節(jié)置換術(shù)后康復(fù)鎮(zhèn)痛的臨床觀察南興東北京大學(xué)第三醫(yī)院麻醉科，北京100083摘要目的:觀察連續(xù)股神經(jīng)阻滯用于全膝關(guān)節(jié)置換術(shù)后康復(fù)鎮(zhèn)痛的效果。方法:選擇ASA 級(jí)行單側(cè)全膝關(guān)節(jié)置換患者30例,隨機(jī)分為2組:股神經(jīng)阻滯組(FA,n=15) 和持續(xù)靜脈鎮(zhèn)痛組（IA，n=15）。所有患者均實(shí)施氣管插管全身麻醉。FA組患者術(shù)后通過(guò)留置導(dǎo)管間斷注射0. 5 % 鹽酸利多卡因鎮(zhèn)痛，IA組患者術(shù)后靜脈持續(xù)輸注曲馬多鎮(zhèn)痛，兩組患者均維持鎮(zhèn)痛3天。記錄靜息、主動(dòng)和持續(xù)被動(dòng)功能訓(xùn)練時(shí)的VAS疼痛評(píng)分,開(kāi)始下床活動(dòng)時(shí)間，鎮(zhèn)靜程度，肌力分級(jí)和并發(fā)癥發(fā)生率。結(jié)果:FA 組患者在術(shù)后6 h、24 h、

2、48 h及72h的靜息、主動(dòng)和持續(xù)被動(dòng)功能訓(xùn)練時(shí)的VAS疼痛評(píng)分均明顯低于IA 組患者（P < 0. 05或P < 0. 01）；兩組患者下床活動(dòng)時(shí)間無(wú)顯著性差異（25±2）h vs（27±4）h, P 0. 05；兩組患者鎮(zhèn)靜程度總體較滿意；兩組患者的術(shù)后24h72h肌力評(píng)分平均大于3級(jí)；與IA 組比較，F(xiàn)A組患者并發(fā)癥發(fā)生率明顯減少，差異具有顯著統(tǒng)計(jì)學(xué)意義（4 vs 12,P0.009）。結(jié)論: 連續(xù)股神經(jīng)阻滯鎮(zhèn)痛效果良好,對(duì)下肢肌力影響輕微，并發(fā)癥發(fā)生率低，是TKA術(shù)后較為理想的康復(fù)鎮(zhèn)痛方法。關(guān)鍵詞全膝置換；術(shù)后鎮(zhèn)痛；股神經(jīng)阻滯Clinical Obser

3、vation of Continuous Femoral Nerve Blockade for Postoperative Rehabilitation Pain After Total Knee Arthroplasty SurgeryNAN Xing-dong, JIA Dong-lin, ZHANG Li-ping, etal. Department of Anesthesiology, Peking University Third Hospital, Beijing 100083, China.Abstract Objective To observe the effect of c

4、ontinuous femoral nerve on postoperative rehabilitation pain after total knee arthroplasty(TKA) surgery. Methods Thirty patients , ASA III , undergoing unilateral TKA surgery , were randomly divided into two groups : group FA and group IA. All patients received general anesthesia with tracheal intub

5、ation. After operation patients were given nerve-bolcked analgesia with 0.5 % Hydrochloric acid Lidocaine injected through a catheter in Group FA (15ml, 26 h/prn) and continuous intravenous analgesia with tramadol in group IA. All patients were maintained analgesia for 3 days. VAS Pain scores during

6、 rest, initiative exercise and continuous passive movement (CPM), time of first walk, Rameasay sedation scores, muscle st rength grades and complications were recorded. Results The VAS pain scores during rest, initiative exercise and CPM at all timepoints except postoperative 1h in group FA were obv

7、ious lower than those in group IA. There werent significant difference about the time of first walk between two groups(27±4）h vs（25±2）h . In general ,it was satisfactory about sedation degree in two groups. Average muscle strength grades during postoperative 2472h in two groups were over g

8、rade 3. Compared with group IA, a significantly lower incidence of side effects was noted in group FA（4 vs 12,P0.009）. Conclusion After TKA surgery, the continuous femoral nerve block can provide better pain relief, slight impact on musclestrength of lower limb and fewer side effects. Therefore, it

9、should be considered the technique of choice.Key words Total knee arthroplasty；Postoperative analgesia；Femoral nerve block隨著人工全膝關(guān)節(jié)置換(total knee arthroplasty, TKA)病例的增加，技術(shù)不斷成熟,現(xiàn)已成為療效十分確切的手術(shù)方式。TKA術(shù)后應(yīng)早期進(jìn)行主動(dòng)和被動(dòng)功能訓(xùn)練,以最大限度地改善假體關(guān)節(jié)的功能1。但TKA術(shù)后60 %的患者伴有重度疼痛,會(huì)明顯降低康復(fù)訓(xùn)練的效果，為滿足臨床需要，我們對(duì)行單側(cè)TKA術(shù)的患者術(shù)后實(shí)施連續(xù)股神經(jīng)阻滯鎮(zhèn)痛，取得良好

10、效果，報(bào)道如下。資料與方法1. 一般資料選擇ASA III 級(jí)行單側(cè) TKA 術(shù)患者30例,年齡4971歲，體重5587Kg,隨機(jī)分為2 組: FA 組,連續(xù)股神經(jīng)阻滯；IA 組,持續(xù)靜脈鎮(zhèn)痛；每組15 例。2. 方法 2.1 麻醉方法 兩組患者均采取靜吸復(fù)合全身麻醉。靜脈快速全麻誘導(dǎo)氣管插管，麻醉維持以吸入異氟烷和N2O為主，間斷追加芬太尼和萬(wàn)可松。2.2 股神經(jīng)阻滯方法 患者于全麻誘導(dǎo)前在神經(jīng)刺激器（Stimuplex®HNS 11, B.Braun Melsungen AG, Germany）引導(dǎo)下于患側(cè)行股神經(jīng)阻滯?；颊咂脚P，雙腿略分開(kāi)，于腹股溝韌帶下2 cm、股動(dòng)脈外側(cè)1

11、cm處皮下浸潤(rùn)麻醉, 選用55 mm針長(zhǎng)連續(xù)神經(jīng)叢阻滯套件，穿刺針與皮膚成30°角,向頭側(cè)進(jìn)針,刺激電流為1 mA，觀察到股直肌明顯收縮或伴有膝蓋跳動(dòng)時(shí)，刺激電流降為0.3 mA，調(diào)整針尖位置，股直肌仍有明顯收縮，退出針芯同時(shí)向頭側(cè)置管1012 cm ，固定導(dǎo)管。2.3 術(shù)后鎮(zhèn)痛 患者術(shù)畢送麻醉恢復(fù)室前, FA 組通過(guò)導(dǎo)管注入0. 5 % 鹽酸利多卡因15 ml, IA 組靜脈給予負(fù)荷量曲馬多(德國(guó)格蘭泰公司）50100 mg和恩丹西酮4 mg?；夭》亢驠A 組患者根據(jù)需要間斷注入同等量和濃度的鹽酸利多卡因，時(shí)間間隔不短于2h。IA 組持續(xù)輸注曲馬多鎮(zhèn)痛,配方為曲馬多1200 mg

12、+ 恩丹西酮16 mg + 生理鹽水至150 ml , 2ml/小時(shí)。兩組患者均持續(xù)鎮(zhèn)痛3天,同時(shí)加服扶他林片25 mg，1天3次。3觀察指標(biāo)3.1 鎮(zhèn)痛效果 觀察兩組患者術(shù)后1 小時(shí)、6小時(shí)、24 小時(shí)、48 小時(shí)、72 小時(shí)靜息狀態(tài)VAS 疼痛評(píng)分(RVAS)，術(shù)后24小時(shí)、48 小時(shí)、72 小時(shí)主被動(dòng)功能訓(xùn)練時(shí)VAS 疼痛評(píng)分(IVAS)，以及術(shù)后第3天上午持續(xù)被動(dòng)功能訓(xùn)練(continuous passive movement, CPM)時(shí)VAS 疼痛評(píng)分(PVAS)。3.2 肌力 記錄各時(shí)間點(diǎn)病人患肢股四頭肌肌力:0 為完全癱瘓,1 為可收縮,2 為不能抗重力,3 為抗重力不抗阻力,

13、4 為可抗弱阻力,5 為正常。3.3 鎮(zhèn)靜程度 采用Rameasay 鎮(zhèn)靜評(píng)分:1為不安靜、煩躁,2 為安靜合作,3 為嗜睡能聽(tīng)從指令,4 為睡眠狀態(tài)、可喚醒,5 為不易喚醒,6 為深睡狀態(tài)不可喚醒。1 分為鎮(zhèn)靜不足,24分為鎮(zhèn)靜滿意,56 分為鎮(zhèn)靜過(guò)度。3.4 副作用 記錄患者開(kāi)始下床活動(dòng)時(shí)間，觀察術(shù)后是否出現(xiàn)惡心、嘔吐、尿潴留及加用其他鎮(zhèn)痛藥等情況。4. 統(tǒng)計(jì)學(xué)處理VAS 疼痛評(píng)分、肌力分級(jí)和下床活動(dòng)時(shí)間等計(jì)量資料采用均數(shù)±標(biāo)準(zhǔn)差( x±S) 表示, 組間比較采用獨(dú)立樣本 t 檢驗(yàn); 鎮(zhèn)靜滿意度和并發(fā)癥發(fā)生率等計(jì)數(shù)資料采用2檢驗(yàn); P < 0. 05 認(rèn)為差異有統(tǒng)

14、計(jì)學(xué)意義。結(jié)果兩組患者年齡、體重、手術(shù)時(shí)間、術(shù)中芬太尼用量和術(shù)后開(kāi)始下床活動(dòng)時(shí)間等無(wú)統(tǒng)計(jì)學(xué)差異均。鎮(zhèn)痛效果:FA 組患者在術(shù)后6 h、24 h、48 h及72h的RVAS評(píng)分、功能訓(xùn)練時(shí)的IVAS評(píng)分和PVAS評(píng)分均明顯低于IA 組, P < 0. 05或P < 0. 01，見(jiàn)表1。鎮(zhèn)靜程度:兩組患者鎮(zhèn)靜總體均較滿意, IA組鎮(zhèn)靜過(guò)度病例數(shù)多于FA組，差異無(wú)統(tǒng)計(jì)學(xué)意義，見(jiàn)表2。肌力分級(jí): 兩組患者的肌力差異無(wú)統(tǒng)計(jì)學(xué)意義，術(shù)后24 h72 h肌力均大于3級(jí)，不影響主動(dòng)功能訓(xùn)練的效果，見(jiàn)表3。并發(fā)癥發(fā)生率: 總體上，F(xiàn)A組并發(fā)癥發(fā)生率明顯少于IA 組，具有顯著性統(tǒng)計(jì)學(xué)差異（4 vs 1

15、2,P0.009），見(jiàn)表4。討論膝關(guān)節(jié)置換術(shù)后需及時(shí)進(jìn)行康復(fù)訓(xùn)練治療,患肢的股四頭肌收縮練習(xí)及CPM訓(xùn)練常伴有劇烈的疼痛和股四頭肌痙攣，從而限制患肢活動(dòng)的力度和角度，影響假體關(guān)節(jié)的康復(fù)治療效果。緩解疼痛的方法很多，如口服阿片類止疼藥、持續(xù)靜脈鎮(zhèn)痛、神經(jīng)阻滯 2-4 、連續(xù)硬膜外鎮(zhèn)痛5 等。良好的神經(jīng)阻滯，不僅能提供和硬膜外鎮(zhèn)痛同樣的效果，而且并發(fā)癥更低，減少嗎啡的使用量4。尤其是近年來(lái)神經(jīng)刺激器的使用大幅提高了神經(jīng)阻滯的成功率，使得術(shù)后常規(guī)神經(jīng)阻滯鎮(zhèn)痛成為可能。常用神經(jīng)阻滯有腰叢神經(jīng)和股神經(jīng)阻滯, 但腰大肌間隙距離椎管近，有出現(xiàn)雙側(cè)阻滯危險(xiǎn)6。本研究在神經(jīng)刺激器引導(dǎo)下，沿股血管神經(jīng)鞘向上置管1

16、012 cm，單次足量注入低濃度的局麻藥，理論上藥物向頭端可彌散至腰大肌間隙7，可同時(shí)阻斷股神經(jīng)、股外測(cè)皮神經(jīng)和閉孔神經(jīng)。由于閉孔神經(jīng)位于股神經(jīng)內(nèi)下側(cè)發(fā)出，其阻滯成功率相對(duì)高于股外側(cè)皮神經(jīng)。股神經(jīng)或聯(lián)合閉孔神經(jīng)的阻滯對(duì)膝關(guān)節(jié)的前面和內(nèi)側(cè)疼痛產(chǎn)生麻痹作用，能顯著緩解TKA術(shù)后患肢的靜息痛和運(yùn)動(dòng)痛。而且導(dǎo)管易固定，阻滯范圍相對(duì)局限，避免硬膜外和腰叢阻滯范圍過(guò)廣引起的低血壓和運(yùn)動(dòng)受限。膝關(guān)節(jié)置換老年患者居多，術(shù)中需使用止血帶，圍術(shù)期易出現(xiàn)下肢深靜脈血栓形成和肺栓塞等危險(xiǎn)8。為預(yù)防該并發(fā)癥，患者在術(shù)中和術(shù)后需皮下注射速碧凝等抗凝血藥物，增加了硬膜外操作和留置導(dǎo)管出血的風(fēng)險(xiǎn)，限制了術(shù)后硬膜外鎮(zhèn)痛的臨床使

17、用。靜脈鎮(zhèn)痛具有操作簡(jiǎn)便、不影響肌力、適用范圍廣等優(yōu)點(diǎn)，但藥物對(duì)患者全身產(chǎn)生作用,副作用較多。本研究結(jié)果表明：采用股神經(jīng)阻滯患者的術(shù)后鎮(zhèn)痛效果明顯優(yōu)于靜脈鎮(zhèn)痛患者，而患肢的肌力未出現(xiàn)明顯下降。雖然兩組患者鎮(zhèn)靜總體均較滿意, 但靜脈鎮(zhèn)痛組鎮(zhèn)靜過(guò)度病例數(shù)多于股神經(jīng)阻滯組。此結(jié)果也與Francois9關(guān)于TKA術(shù)后股神經(jīng)阻滯與連續(xù)硬膜外和嗎啡靜脈鎮(zhèn)痛比較應(yīng)為首選的結(jié)論相一致。 雖然兩組患者術(shù)后24 h72 h股四頭肌肌力均大于3級(jí)，但FA組中有1例患者因感覺(jué)肌力弱術(shù)后36h才開(kāi)始下床活動(dòng)，說(shuō)明0.5的鹽酸利多卡因也有抑制運(yùn)動(dòng)神經(jīng)的可能，以后可以考慮改用對(duì)運(yùn)動(dòng)神經(jīng)阻滯更輕微的低濃度羅哌卡因。FA組還有

18、1例患者術(shù)后第2天穿刺點(diǎn)部位出現(xiàn)皮下滲血，可能與術(shù)后使用速碧凝有關(guān),局部加壓包扎后漸好轉(zhuǎn)?？傮w上，神經(jīng)阻滯組患者惡心、倦睡和鎮(zhèn)痛不足等發(fā)生率明顯低于靜脈鎮(zhèn)痛組。綜上所述,連續(xù)股神經(jīng)阻滯鎮(zhèn)痛效果良好,對(duì)下肢肌力影響輕微，并發(fā)癥發(fā)生率低，是TKA術(shù)后較為理想的鎮(zhèn)痛方法，有利于患者早期康復(fù)訓(xùn)煉。參考文獻(xiàn)1 Lau SK, Chiu KY. Use of continuous passive motion after total knee arthroplasty. J Arthroplasty, 2001, 16: 336339.2 Hugh W , Spencer S , Paul D , et

19、al . Peripheralnerve blocks improve analgesia after total knee replacement surgery. Anesth Analg , 1998 , 87: 9397.3 姜陸洋，李彥平，李樹(shù)人.連續(xù)腰大肌間溝阻滯用于全膝關(guān)節(jié)置換術(shù)后鎮(zhèn)痛的臨床觀察.中國(guó)疼痛醫(yī)學(xué)雜志,2002，8：1491544 Szczukowski MJ, Hines JA, Snell JA,et al. Femoral nerve block for total knee arthroplasty patients: a method to control

20、postoperative pain. J Arthroplasty, 2004,19:720-55 Mahoney OM, Noble PC, Davidson J,et al. The effect of continuous epidural analgesia on postoperative pain, rehabilitation, and duration of hospitalization in total knee arthroplasty. Clin Orthop Relat Res, 1990 :30-76 林惠華,王瓊,孫曉雄. 后路腰叢阻滯后出現(xiàn)硬膜外阻滯4例報(bào)告.

21、臨床麻醉學(xué)雜志, 2004, 20:2257 Winnie AP, Ramamurthy S, Durrani Z. The inguinal paravascular technic of lumbar plexus anesthesia: the“3 in 1”block. Anesth Analg ,1973,52:989996.8 關(guān)振鵬,呂厚山,吳淳,等.人工關(guān)節(jié)置換術(shù)后肺栓塞的早期診斷和處理.中華外科雜志, 2003, 41: 3740.9 Francois J, Singelyn FJ, Deyaert M, et al . Effects of intravenous pati

22、ent - controlled analgesia with morphine , continuous epidural analgesia and continuous three in one block on postoperative pain and knee rehabilitation after unilateral TKA. Anesth Analg , 1998 ,87: 8892.表1 兩組患者VAS疼痛評(píng)分（n=15, X±S)Table 1 VAS value of patients with postoperative pain分組（Groups）1h

23、6h24h48h72h或上午RVASIA 組(Intravenous)3.1±1.62.9±1.11.6±0.81.3±0.71.2±0.8FA組(lumbar plexus)2.3±1.81.3±1.3*1.2±0.9*0.9±0.7*0.8±0.6*IVASIA組(Intravenous)4.6±1.72.8±1.22.4±0.9FA組(lumbar plexus)2.7±1.81.8±1.61.3±1.3PVASIA組(Intra

24、venous)4.1±0.9FA組(lumbar plexus)2.7±1.2§§*,*:與IA 組靜止時(shí)比較, Compared with IA group in rest P < 0.05 , P < 0.01 ;,:與IA 組主動(dòng)功能訓(xùn)練時(shí)比較, Compared with IA group in initiative movement P < 0.05 , P < 0.01;§，§§：與IA 組被動(dòng)功能訓(xùn)練時(shí)比較, Compared with IA group in CPM P < 0. 05 , P < 0. 01表2 兩組患者鎮(zhèn)靜滿意度（n=15,)Table 2 Degree of sedation ( cases)分組（Groups）鎮(zhèn)靜程度(Sedation)6h24h48h72hIA組Intravenous不足(