全膝关节置换术后大容积局部浸润镇痛联合静脉或局部给予酮咯酸和吗啡与硬膜外镇痛的比较。
High-volume local infiltration analgesia combined with intravenous or local ketorolac+morphine compared with epidural analgesia after total knee arthroplasty.
机构信息
Department of Anaesthesia and Intensive Care,Asker and Bærum Hospital, Vestre Viken HF, Norway.
出版信息
Br J Anaesth. 2010 Nov;105(5):675-82. doi: 10.1093/bja/aeq232. Epub 2010 Aug 24.
BACKGROUND
Recently, high-volume local infiltration analgesia (LIA) in total knee arthroplasty (TKA) has been introduced, but dosage, timing, and effects of adjuvants are still debated.
METHODS
We randomized 102 patients undergoing TKA to receive either epidural analgesia (EDA group) or LIA (ropivacaine 150 mg and epinephrine 0.5 mg) combined with ketorolac 30 mg and morphine 5 mg given either locally (LIA group) or i.v. (LIAiv group). Epidural analgesia was maintained for 48 h. Intra-articular re-injection via a catheter with ropivacaine 142.5 mg and either intra-articular or i.v. ketorolac 30 mg was given 24 h after surgery. Pain scores, morphine consumption, side-effects, and readiness for hospital discharge were studied.
RESULTS
At discharge from the postoperative anaesthetic care unit, verbal pain scores were lower in the EDA group (P=0.004), but discharge was delayed [difference 101 min, 95% CI: (23, 178), P=0.007]. Group LIA reported lower pain scores at rest beyond 24 h after surgery [mean VAS (sd) at 24/48/72 h: LIA group 16/12/10 (14)/(13)/(11); LIAiv group 22/18/15 (17)/(15)/(12); EDA group 27/30/21 (21)/(29)/(19)]. Both the LIA and the LIAiv groups were mobilized faster and were earlier ready for hospital discharge [3.5 days (LIA group) vs 4 days (LIAiv group) vs 5.5 days (EDA group); P<0.001]. Cumulated morphine consumption (72 h) was lowest for the LIA group [80 vs 101 mg (EDA group) vs 118 mg (LIAiv group), P=0.007].
CONCLUSIONS
LIA with local adjuvants compared with epidural analgesia results in reduced opioid consumption, faster mobilization, and earlier readiness for hospital discharge. Ketorolac and morphine are more efficient when given locally than systemically. The study has been registered at clinicaltrials.gov (NCT00562627) before onset of participant enrolment: http://clinicaltrials.gov/ct2/show/NCT00562627?term=spreng&rank=2 (April 21, 2010).
背景
最近，在全膝关节置换术中引入了高容量局部浸润镇痛（LIA），但剂量、时间和佐剂的效果仍存在争议。
方法
我们将 102 例接受 TKA 的患者随机分为硬膜外镇痛（EDA 组）或 LIA（罗哌卡因 150mg 和肾上腺素 0.5mg）联合酮咯酸 30mg 和吗啡 5mg，局部（LIA 组）或静脉（LIAiv 组）给予。硬膜外镇痛持续 48 小时。术后 24 小时通过导管给予罗哌卡因 142.5mg 并给予关节内或静脉内酮咯酸 30mg 进行关节内再注射。研究疼痛评分、吗啡消耗量、副作用和出院准备情况。
结果
从术后麻醉护理病房出院时，EDA 组的口头疼痛评分较低（P=0.004），但出院时间延迟[差异 101 分钟，95%CI：（23，178），P=0.007]。LIA 组报告术后 24 小时后静息时疼痛评分较低[24/48/72 小时平均 VAS（标准差）：LIA 组 16/12/10（14）/（13）/（11）；LIAiv 组 22/18/15（17）/（15）/（12）；EDA 组 27/30/21（21）/（29）/（19）]。LIA 组和 LIAiv 组移动更快，更早准备出院[3.5 天（LIA 组）比 4 天（LIAiv 组）比 5.5 天（EDA 组）；P<0.001]。72 小时累积吗啡消耗量（LIA 组最低）[80 对 101mg（EDA 组）对 118mg（LIAiv 组），P=0.007]。
结论
与硬膜外镇痛相比，局部辅助剂的 LIA 可减少阿片类药物的消耗，更快地移动，更早准备出院。关节内给予酮咯酸和吗啡比系统内给予更有效。该研究在参与者招募开始前已在 clinicaltrials.gov 上注册（NCT00562627）：http://clinicaltrials.gov/ct2/show/NCT00562627?term=spreng&rank=2（2010 年 4 月 21 日）。
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