Halawi Mohamad J, Grant Stuart A, Bolognesi Michael P
Orthopedics. 2015 Jul 1;38(7):e616-25. doi: 10.3928/01477447-20150701-61.
Optimal perioperative pain control for total joint arthroplasty remains a challenge. Whereas traditional regimens have relied heavily on opioids, newer multimodal pathways are increasingly gaining popularity as safer and more effective alternatives. The main premise of multimodal analgesia is decreased consumption of opioids, and hence lesser opioid-related adverse events. Other reported advantages include lower pain scores, faster functional recovery, higher patient satisfaction, and shorter length of hospital stay. Unfortunately, despite the advent of numerous analgesic techniques, the multimodal approach has remained widely variable, making direct comparison between studies difficult to interpret. This article provides an extensive review of traditional and modern perioperative interventions in pain management for total joint arthroplasty, including intravenous patient-controlled analgesia, epidural infusion, oral opioids, nonsteroidal anti-inflammatory drugs, acetaminophen, peripheral nerve blocks, periarticular infiltration, steroids, anticonvulsants, and long-acting local anesthetics. Emphasis is placed on pathophysiology, clinical evidence, and timing. A standardized multimodal analgesia protocol is also proposed based on best available evidence. In addition to pharmacologic interventions, patient education and interdisciplinary collaboration among the care teams play an important role in the success of any treatment pathway. With a growing demand for total joint arthroplasty in an era of bundled payments and accountable care, there has never been a greater need for a standardized multimodal analgesia pathway.
全关节置换术的最佳围手术期疼痛控制仍然是一项挑战。传统的治疗方案严重依赖阿片类药物，而新的多模式镇痛方法作为更安全、更有效的替代方案越来越受欢迎。多模式镇痛的主要前提是减少阿片类药物的使用，从而减少与阿片类药物相关的不良事件。其他报道的优点包括更低的疼痛评分、更快的功能恢复、更高的患者满意度和更短的住院时间。不幸的是，尽管出现了众多镇痛技术，但多模式方法仍然差异很大，使得不同研究之间的直接比较难以解释。本文对全关节置换术疼痛管理中的传统和现代围手术期干预措施进行了广泛综述，包括静脉自控镇痛、硬膜外输注、口服阿片类药物、非甾体抗炎药、对乙酰氨基酚、外周神经阻滞、关节周围浸润、类固醇、抗惊厥药和长效局部麻醉药。重点在于病理生理学、临床证据和时机。还基于现有最佳证据提出了标准化的多模式镇痛方案。除了药物干预外，患者教育以及护理团队之间的跨学科合作在任何治疗途径的成功中都起着重要作用。在捆绑支付和责任医疗时代，对全关节置换术的需求不断增加，因此对标准化多模式镇痛途径的需求从未如此迫切。
