吗啡关节周围联合药物注射和鞘内注射对人工全膝关节置换术后疼痛和关节功能的影响

doi:10.3969/j.issn.1009-976X.2020.03.014

摘要/Abstract

摘要： 目的比较吗啡关节周围联合药物注射（PMDI）和鞘内注射对人工全膝关节置换术（TKA）患者术后疼痛和关节功能的影响。方法回顾分析我院行TKA患者153例,按照麻醉方式分成对照组、PMDI组和鞘内注射组,每组51例。对照组患者接受常规腰麻及关节周围软组织注射,PMDI组患者关节周围额外注射10 mg盐酸吗啡注射液,鞘内注射组患者腰麻药物中额外加入0.1 mg盐酸吗啡注射液。记录三组患者术后疼痛视觉模拟量表（VAS）评分。记录三组患者术后追加曲马多用量和首次追加曲马多时间。记录三组患者术后患肢主动关节屈曲角度。记录三组患者术后呕吐次数和术后止呕药物使用次数。结果术后6、12和24 h PMDI组和鞘内注射组患者术后疼痛VAS评分显著低于对照组患者（P<0.05）,术后6、12和24 h鞘内注射组患者术后疼痛VAS评分显著低于PMDI组患者（P<0.05）。术后12 h和24 h PMDI组和鞘内注射组患者追加曲马多用量显著低于对照组患者（P<0.05）,术后12 h和24 h 鞘内注射组患者追加曲马多用量显著低于PMDI组患者（P<0.05）。PMDI组和鞘内注射组患者术后首次追加曲马多时间显著低于对照组患者（P<0.05）,鞘内注射组患者术后首次追加曲马多时间显著低于PMDI组患者（P<0.05）。术后12 h和24 h PMDI组和鞘内注射组患者术后患肢主动关节屈曲角度显著高于对照组患者（P<0.05）,术后12 h和24 h 鞘内注射组患者术后患肢主动关节屈曲角度显著高于PMDI组患者（P<0.05）。术后12 h、24 h和48 h PMDI组和鞘内注射组患者术后呕吐次数和术后止呕药物使用次数显著高于对照组患者（P<0.05）,术后12 h、24 h和48 h PMDI组患者术后呕吐次数和术后止呕药物使用次数显著高于鞘内注射组患者（P<0.05）。结论吗啡PMDI和吗啡Ⅱ均为有效的TKA术后镇痛方法,其中吗啡Ⅱ较吗啡PMDI可进一步缓解TKA术后患者疼痛,加快患者早期关节功能恢复。但吗啡PMDI和吗啡Ⅱ均会增加TKA术后呕吐发生率,需要临床医生重视。

关键词: 关节功能, 人工全膝关节置换术, 关节周围联合药物注射, 鞘内注射, 术后疼痛, 吗啡

Abstract: Objective To compare the effect of morphine periarticular multimodal drug injection （PMDI） and intrathecal injection on pain and join function after total knee arthroplasty （TKA）. Methods 153 received TKA patients were retrospectively analyzed and assigned to the control group, PMDI group and intrathecal injection group （n=51）. Patients in the control group received regular spinal anesthesia and PMDI. Patients in the PMDI group received morphine 10 mg PMDI, and patients in the intrathecal injection group received morphine 0.1 mg intrathecal injection. Patients' visual analog scale （VAS） pain scores, tramadol usage, first using tramadol time, range of active knee flexion, vomiting times, usage of anti-nausea drugs were recorded postoperatively. Results VAS pain scores were significantly lower in the PMDI group and the intrathecal injection group than those in the control group in postoperative 6, 12 and 24 h （P<0.05）, and they were significantly lower in the intrathecal injection group than those in the PMDI group （P<0.05）. Tramadol usages were significantly lower in the PMDI group and the intrathecal injection group than those in the control group in postoperative 12 and 24 h （P<0.05）, and they were significantly lower in the intrathecal injection group than those in the PMDI group （P<0.05）. The first using tramadol time was significantly lower in the PMDI group and the intrathecal injection group than that in the control group （P<0.05）, and it was significantly lower in the intrathecal injection group than that in the PMDI group （P<0.05）. The ranges of active knee flexion were significantly larger in the PMDI group and the intrathecal injection group than those in the control group in postoperative 12 and 24 h （P<0.05）, and they were significantly larger in the intrathecal injection group than those in the PMDI group （P<0.05）. Vomiting times and usages of anti-nausea drugs were significantly more than those in the control group in postoperative 12, 24 and 48 h （P<0.05）, and they were significantly more in the PMDI group than those in the intrathecal injection group （P<0.05）. Conclusion Morphine PMDI and Ⅱ are both effective analgesic methods, and morphine Ⅱ is more effective in relieving postoperative pain and increasing knee function than morphine PMDI. However, morphine PMDI and Ⅱ both could increase the incidence rate of vomiting after TKA, which needs more attention from doctors.

Key words: periarticular multimodal drug injection, total knee arthroplasty, join function, morphine, pain, intrathecal injection

中图分类号:

R684

刘明明, 许治强, 李国建. 吗啡关节周围联合药物注射和鞘内注射对人工全膝关节置换术后疼痛和关节功能的影响[J]. 岭南现代临床外科, 2020, 20(03): 328-332.

LIU Ming-ming, XU Zhi-qiang, LI Guo-jian. Comparison of effect of morphine periarticular multimodal drug injection and intrathecal injection on pain and join function after total knee arthroplasty[J]. Lingnan Modern Clinics in Surgery, 2020, 20(03): 328-332.

参考文献

[1] Parvizi J, Miller AG, Gandhi K.Multimodal pain management after total joint arthroplasty[J]. J Bone Joint Surg Am, 2011, 93(11): 1075-1084.
[2] Meng ZT, Cui F, Li XY, Wang DX.Epidural morphine improves postoperative analgesia in patients after total knee arthroplasty: A randomized controlled trial[J]. PLoS One, 2019, 14(7): e0219116.
[3] 刘莱莉, 龚琴, 余建华, 等. 双重引导连续股神经阻滞复合关节周围阻滞对全膝关节置换术后镇痛及早期功能康复的影响[J]. 广东医科大学学报, 2017, 35(3):287-290.
[4] 余建华, 廖荣宗, 刘莱莉, 等. 超声引导下患侧股神经阻滞在单侧腰麻全膝关节置换术后镇痛的应用[J]. 广东医学院学报, 2013, 31(4):456-457.
[5] Essving P, Axelsson K, Kjellberg J, et al.Reduced morphine consumption and pain intensity with local infiltration analgesia (LIA) following total knee arthroplasty[J]. Acta Orthop, 2010, 81(3): 354-360.
[6] Essving P, Axelsson K, Aberg E, et al.Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty: a randomized controlled trial[J]. Anesth Analg, 2011, 113(4): 926-933.
[7] Stein C.The control of pain in peripheral tissue by opioids[J]. N Engl J Med, 1995, 332(25): 1685-1690.
[8] Lombardi AJ, Berend KR, Mallory TH, et al.Soft tissue and intra-articular injection of bupivacaine, epinephrine, and morphine has a beneficial effect after total knee arthroplasty[J]. Clin Orthop Relat Res, 2004, (428): 125-130.
[9] Busch CA, Shore BJ, Bhandari R, et al.Efficacy of periarticular multimodal drug injection in total knee arthroplasty. A randomized trial[J]. J Bone Joint Surg Am, 2006, 88(5): 959-963.
[10] Ishida K, Shibanuma N, Matsumoto T, et al.Periarticular multimodal drug injection improves post-operative pain and functional recovery after total knee arthroplasty[J]. J Orthop Sci, 2016, 21(2): 178-183.
[11] 关贵超, 何斌, 王艳涛, 等. 膝关节置换术中关节周围注射镇痛药物的效果观察[J]. 临床误诊误治, 2016,33(6):92-95.
[12] 王波, 吴鹏, 王铁军, 等. 混合药物关节腔周围注射对人工全膝关节置换术后镇痛疗效的前瞻性研究[J]. 临床和实验医学杂志, 2018, 17(13): 1448-1452.
[13] Ritter MA, Koehler M, Keating EM, et al.Intra-articular morphine and/or bupivacaine after total knee replacement[J]. J Bone Joint Surg Br, 1999, 81(2): 301-303.
[14] Iwakiri K, Minami Y, Ohta Y, et al.Effect of Periarticular Morphine Injection for Total Knee Arthroplasty: A Randomized, Double-Blind Trial[J]. J Arthroplasty, 2017, 32(6): 1839-1844.
[15] Essving P, Axelsson K, Aberg E, et al.Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty: a randomized controlled trial[J]. Anesth Analg, 2011, 113(4): 926-933.
[16] 李登, 苏保华, 许杰, 等. 术中关节周围鸡尾酒注射在骨性关节炎患者初次全膝关节置换术后镇痛中的应用[J].岭南现代临床外科, 2018, 18(5): 499-503.
[17] Barreveld AM, McCarthy RJ, Elkassabany N, et al. Opioid Stewardship Program and Postoperative Adverse Events: A Difference-in-differences Cohort Study [J]. Anesthesiology, 2020 Mar 10. doi: 10.1097/ALN.0000000000003238.[Epub ahead of print]
[18] Runner RP, Luu AN, Thielen ZP, et al. Opioid Use After Discharge Following Primary Unilateral Total Knee Arthroplasty: How Much Are We Over-Prescribing? [J]. J Arthroplasty.2020 Feb 5. doi: 10.1016/j.arth.2020.01.078.[Epub ahead of print]
[19] King CA, Landy DC, Bradley AT, et al. Opioid Naive Surgeons and Opioid-Tolerant Patients: Can Education Alter Prescribing Patterns to Total Knee Arthroplasty Patients?[J]. J Knee Surg, 2020 Mar 4. doi: 10.1055/s-0040-1701449.[Epub ahead of print]
[20] Cole p J, Craske DA, Wheatley RG. Efficacy and respiratory effects of low-dose spinal morphine for postoperative analgesia following knee arthroplasty[J]. Br J Anaesth, 2000, 85(2): 233-237.
[21] Tan PH, Chia YY, Lo Y, et al.Intrathecal bupivacaine with morphine or neostigmine for postoperative analgesiaafter total knee replacement surgery[J]. Can J Anaesth, 2001, 48(6): 551-556.
[22] 南兴东,李水清,贾东林,等. 鞘内吗啡联合连续股神经阻滞用于全膝关节置换术后早期康复镇痛的临床观察[J]. 中国疼痛医学杂志, 2010, 16(4):215-219.