全膝关节置换术后局部浸润镇痛与鞘内吗啡镇痛效果的比较：一项随机对照试验。

A comparison of the analgesic efficacy of local infiltration analgesia vs. intrathecal morphine after total knee replacement: A randomised controlled trial.

机构信息

From the Department of Anaesthesiology, Cork University Hospital and University College Cork, Cork, Ireland (DM, JM, JG, FL, GS, GI).

出版信息

Eur J Anaesthesiol. 2019 Apr;36(4):264-271. doi: 10.1097/EJA.0000000000000943.

DOI:10.1097/EJA.0000000000000943

PMID:30640244

Abstract

BACKGROUND

Local infiltration analgesia (LIA) is an effective pain management technique following total knee arthroplasty (TKA).

OBJECTIVE

To investigate if LIA provides better analgesia for patients undergoing unilateral TKA than intrathecal morphine.

DESIGN

Randomised controlled trial.

SETTING

Single tertiary referral centre.

PATIENTS

Consecutive American Society of Anesthesiologists Physical Status I to III patients scheduled to undergo unilateral TKA were randomised to two groups.

INTERVENTION

The control group received spinal anaesthesia with intrathecal bupivacaine and preservative-free morphine 0.3 mg. The intervention group received opioid-free spinal anaesthesia with bupivacaine, followed by intra-operative infiltration of the knee with levobupivacaine 2 mg kg and adrenaline 0.5 mg diluted to a volume of 100 ml with 0.9% saline. An intra-articular catheter was placed during surgery and used to give a bolus of 15 ml of levobupivacaine 0.5% on the morning of the first postoperative day.

MAIN OUTCOME MEASURES

Visual analogue scale (VAS) scores for pain were assessed repeatedly for 48 h postoperatively, at rest and on passive knee flexion to 30°. The primary outcome was VAS scores for pain at rest and on movement at 24 postoperative hours. Secondary outcomes were VAS scores at rest and on movement at 2, 6, 12 and 48 postoperative hours, opioid consumption, degree of active flexion of operative knee achieved in the first 48 h and the incidence of opioid-related side effects.

RESULTS

Forty three patients completed the study. Mean (± SD) VAS scores for pain at 24 h were lower in the intervention group than the control group at rest; 16.43 (± 20.3) vs. 37.2 (± 33.6), (P = 0.029). VAS scores for pain at 24 h on movement were also lower in the intervention group vs. the control group; 39.1 (± 22.8) vs. 57.0 (± 30.9), (P = 0.037). VAS scores were also lower on movement; 25.9 (± 16.8) vs. 40.5 (± 24.0), (P = 0.028) at 48 h.

CONCLUSION

We conclude that LIA conferred superior analgesia compared with intrathecal morphine 0.3 mg at 24 and 48 h following TKA.

TRIAL REGISTRATION

Clinicaltrials.gov identifier: NCT01312415.

摘要

背景

局部浸润镇痛（LIA）是全膝关节置换术后（TKA）一种有效的疼痛管理技术。

目的

研究 LIA 是否比鞘内吗啡更能为接受单侧 TKA 的患者提供更好的镇痛效果。

设计

随机对照试验。

地点

单一的三级转诊中心。

患者

连续接受美国麻醉师协会身体状况 I 至 III 级的单侧 TKA 患者，随机分为两组。

干预

对照组接受鞘内布比卡因和无防腐剂吗啡 0.3mg 的脊髓麻醉。干预组接受无阿片类药物的脊髓麻醉，然后在术中用左旋布比卡因 2mg/kg 和肾上腺素 0.5mg 对膝关节进行浸润，用 0.9%生理盐水稀释至 100ml。术中放置关节内导管，在术后第一天早晨给予 15ml 左旋布比卡因 0.5%的推注。

主要观察指标

术后 48 小时内反复评估视觉模拟评分（VAS）疼痛评分，在休息时和被动膝关节屈曲至 30°时评估。主要结局指标为术后 24 小时的 VAS 静息疼痛评分和运动时的 VAS 疼痛评分。次要结局指标为术后 2、6、12 和 48 小时的 VAS 静息和运动评分、阿片类药物用量、术后 48 小时内手术侧膝关节主动屈曲的程度以及阿片类药物相关副作用的发生率。

结果

43 例患者完成了研究。与对照组相比，干预组在休息时的 24 小时 VAS 疼痛评分更低，分别为 16.43（±20.3）和 37.2（±33.6），（P=0.029）。在运动时，干预组的 VAS 疼痛评分也低于对照组，分别为 39.1（±22.8）和 57.0（±30.9），（P=0.037）。在运动时，干预组的 VAS 疼痛评分也较低，分别为 25.9（±16.8）和 40.5（±24.0），（P=0.028），在 48 小时。