Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA -
Department of Anesthesiology, Critical Care and Pain Management, Hospital for Special Surgery, New York, NY, USA.
Minerva Anestesiol. 2018 Dec;84(12):1406-1412. doi: 10.23736/S0375-9393.18.12383-2. Epub 2018 May 28.
The demand for total knee arthroplasty (TKA) is rising worldwide. Controversy persists in the literature regarding the benefits of general versus neuraxial anesthesia and which anesthetic is associated with the best outcomes. Likewise, the abundance of analgesic options for post-TKA pain have led to debate regarding the safest, most effective regimens. In this paper, we evaluated a selection of recent publications regarding anesthetic and analgesic choices for TKA. High-quality studies and meta-analyses linking anesthetic agents and analgesic modalities to clinically important outcomes were chosen wherever possible. We included a range of clinical and population-based research, incorporating established and emerging techniques. Although not uniform, clinical and population-based data favor neuraxial anesthesia, and suggest less morbidity compared to general anesthesia. There is good evidence to support an opioid-minimizing, multimodal approach to post-TKA analgesia, featuring peripheral nerve blocks and/or peri-articular injection. The recently described IPACK (interspace between the popliteal artery and posterior capsule of the knee) block may address posterior knee pain after TKA. Ultrasound-guided regional analgesia techniques are cost and clinically effective. Liposomal bupivacaine represents an expanding topic of research in TKA-analgesia, but currently, data do not support routine use. Evidence to guide the creation of pathways of care for TKA abounds, but must be tailored to local practice to maximize chances of success. Recent data supports the use of neuraxial anesthesia and regional analgesia techniques for TKA. Recommendations for clinical practice and future research to improve the state of the art are provided.
全膝关节置换术（TKA）的需求在全球范围内不断增加。关于全身麻醉与椎管内麻醉的益处以及哪种麻醉与最佳结果相关，文献中仍存在争议。同样，TKA 术后止痛的大量止痛选择也引发了关于最安全、最有效的方案的争论。在本文中，我们评估了一些关于 TKA 麻醉和镇痛选择的最新出版物。只要有可能，我们就选择了将麻醉剂和镇痛方式与临床重要结果联系起来的高质量研究和荟萃分析。我们纳入了一系列临床和基于人群的研究，纳入了既定和新兴技术。尽管并不统一，但临床和基于人群的数据支持椎管内麻醉，与全身麻醉相比，发病率更低。有充分的证据支持使用阿片类药物最小化、多模式的 TKA 术后镇痛方法，包括周围神经阻滞和/或关节周围注射。最近描述的 IPACK（腘动脉和膝关节后囊之间的间隙）阻滞可能解决 TKA 后膝关节后部疼痛的问题。超声引导下的区域镇痛技术具有成本效益和临床效果。脂质体布比卡因是 TKA 镇痛中研究不断扩大的主题，但目前的数据并不支持常规使用。指导 TKA 护理途径创建的证据比比皆是，但必须根据当地实践进行调整，以最大限度地提高成功的机会。最近的数据支持使用椎管内麻醉和区域镇痛技术进行 TKA。为改善现有技术提供了临床实践和未来研究的建议。
