Department of Anaesthesiology, Hvidovre University Hospital, Kettegård Allé 30, DK-2650 Copenhagen, Denmark.
Br J Anaesth. 2011 Feb;106(2):230-8. doi: 10.1093/bja/aeq333. Epub 2010 Dec 3.
Total knee arthroplasty (TKA) is associated with severe pain and inflammation despite an extensive multimodal analgesic approach, but the effect of high-dose glucocorticoid administration has not been studied.
Forty-eight patients undergoing unilateral TKA were included in a randomized, double-blind, placebo-controlled trial receiving preoperative methylprednisolone (MP) 125 mg i.v. or saline. All surgery was performed under lumbar spinal anaesthesia and patients received a standardized, multimodal analgesic regime. The primary endpoint was pain during walking 24 h after surgery, and secondary endpoints were pain at rest, pain upon hip flexion, and pain upon knee flexion. Pain assessments were performed repeatedly for the first 48 h after surgery, in a questionnaire from days 2 to 10, and at follow-up on days 21 and 30. Tertiary endpoints were postoperative nausea and vomiting (PONV), plasma C-reactive protein (CRP) concentrations, fatigue, sleep quality, and rescue analgesic and antiemetic requirements.
Pain during walking was significantly lower in the MP group up to 32 h after operation. Overall pain and cumulative pain scores (2-48 h) were lower for all pain assessments (P<0.04). Consumption of rescue oxycodone was lower from 0 to 24 h (P=0.02) and PONV, consumption of ondansetron reduced (P<0.05), and CRP concentrations were lower at 24 h (P<0.000001). Fatigue throughout the day of surgery was lower (P=0.02), but sleep quality was worse on the first night (P=0.002). No side-effects or complications were observed in other respects.
MP 125 mg before surgery improves analgesia and immediate recovery after TKA, even when combined with a multimodal analgesic regime. These findings call for further studies on safety aspects.
尽管采用了广泛的多模式镇痛方法，全膝关节置换术（TKA）仍伴有严重疼痛和炎症，但高剂量糖皮质激素给药的效果尚未得到研究。
48 例单侧 TKA 患者纳入一项随机、双盲、安慰剂对照试验，术前静脉注射甲泼尼龙（MP）125mg 或生理盐水。所有手术均在腰麻下进行，患者接受标准化多模式镇痛方案。主要终点为术后 24 小时行走时的疼痛，次要终点为静息时疼痛、髋关节屈曲时疼痛和膝关节屈曲时疼痛。术后前 48 小时反复进行疼痛评估，在第 2 至 10 天的问卷中进行评估，并在第 21 和 30 天的随访中进行评估。术后恶心呕吐（PONV）、血浆 C 反应蛋白（CRP）浓度、疲劳、睡眠质量以及解救性镇痛和止吐药的需求为三级终点。
MP 组在术后 32 小时内行走时疼痛明显降低。所有疼痛评估的总体疼痛和累积疼痛评分（2-48 小时）均较低（P<0.04）。从 0 至 24 小时解救性羟考酮的消耗较低（P=0.02），PONV 消耗减少（P<0.05），24 小时 CRP 浓度较低（P<0.000001）。手术当天全天的疲劳程度较低（P=0.02），但第一晚的睡眠质量更差（P=0.002）。在其他方面未观察到不良反应或并发症。
术前给予 125mgMP 可改善 TKA 术后的镇痛效果和早期恢复，即使联合多模式镇痛方案也是如此。这些发现需要进一步研究安全性方面。
