Chinese Journal of Tissue Engineering Research ›› 2018, Vol. 22 ›› Issue (23): 3716-3722.doi: 10.3969/j.issn.2095-4344.0287
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Dou Zhe, Yang Yun, Huang Jian
Online:
2018-08-18
Published:
2018-08-18
Contact:
Huang Jian, M.D., Chief physician, Department of Joint Surgery, Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010030, Inner Mongolia Autonomous Region, China
About author:
Dou Zhe, Master candidate, Physician, Department of Joint Surgery, Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010030, Inner Mongolia Autonomous Region, China
Yang Yun, Master, Associate chief physician, Department of Joint Surgery, Second Affiliated Hospital of Inner Mongolia Medical University, Hohhot 010030, Inner Mongolia Autonomous Region, China
Dou Zhe and Yang Yun contributed equally to this paper.
CLC Number:
Dou Zhe, Yang Yun, Huang Jian. Perioperative analgesia in total knee arthroplasty: measures and countermeasures[J]. Chinese Journal of Tissue Engineering Research, 2018, 22(23): 3716-3722.
2.1 全膝关节置换术后疼痛机制 全膝关节置换后疼痛的病理生理学机制非常复杂,是由多种因素、不同环节所引起,本质上是一种急性伤害感受性疼痛。全膝关节置换可以导致皮肤、肌肉、韧带、骨膜和滑膜等组织的损伤,以及在置换中应用止血带引起的血管损伤和组织缺血再灌注损伤,这些均可刺激局部组织内的感受器,从而产生疼痛信号,通过传入神经传入脊髓背角神经元,并最终传递到神经中枢和感觉皮质区,产生痛觉[10]。此外,疼痛中枢敏感化和外周敏感化也是术后疼痛产生的重要机制,它可以导致置换后痛觉过敏,进而使损伤部位和周围未损伤部位组织的痛阈降低,其意义甚至大于传统的痛觉神经传导机制[11]。因此,单一的止痛机制很难彻底的消除疼痛。随着多模式镇痛受到越来越多临床医生的关注,将会彻底解决这一难题,这也将会是今后围手术期镇痛的发展趋势。 2.2 现代治疗理念 2.2.1 快速康复 围手术期镇痛是现代快速康复的重要内容,快速康复外科理念是指通过对患者进行术前宣教、微创操作、围手术期镇痛及早期功能锻炼等一系列措施,最大程度地减轻手术创伤所引起的应激反应,从而加快患者术后康复过程,缩短住院时间的外科康复理念。近几年国内外关节外科医生逐渐引进了这一理念,并在髋膝关节置换术中获得明显疗效。张建等[5]对186例行髋膝关节置换的患者进行研究发现,快速康复外科理念在关节置换围手术期的应用,能够明显减轻患者围手术期的疼痛,减少置换后恶心、呕吐等并发症,并且可以明显缩短住院时间,提高患者满意度,促进患者的快速康复。朱诗白等[6]认为快速康复方案可以适用于绝大多数行膝关节置换的患者,包括高龄、置换前合并心肺疾病、2型糖尿病以及置换前吸烟、饮酒等患者。 值得一提的是,快速康复鼓励患者术后早期下床活动,但不提倡使用CPM机进行功能锻炼。已有研究表明CPM机对改善全膝关节置换术后的活动度、减轻疼痛无明显作用[7]。此外,快速康复方案不推荐全膝关节置换后使用负压引流以及导尿管,认为置换后负压引流会给患者带来额外费用,增加住院时间和输血的概率,但是置换后血肿形成率、切口裂开率和深静脉血栓的形成率与不使用负压引流的患者并无明显区别[12]。关于导尿管,Loftus等[13]指出,患者置换后不使用导尿管能够缩短住院时间,减少相关并发症,并且可以有效降低置换后30 d再入院率。快速康复后不留置引流管及导尿管,有利于患者早期下地活动以及功能康复锻炼。快速康复理念指导下全膝关节置换的疗效显著,有着良好的应用前景,但目前尚无统一的标准方案。 2.2.2 多模式镇痛和超前镇痛 疼痛的产生是一个多环节、多因素参与的复杂过程,使用单一的镇痛方法或药物常难以获得理想镇痛效果。近年来,多模式镇痛已经成为全膝关节置换围手术期管理的重要组成部分,并成为临床镇痛技术的主要发展方向,被认为是围手术期疼痛管理的理想方法[14]。多模式镇痛是联合应用多种作用机制不同的镇痛方法,包括外周神经阻滞、关节周围注射、病人自控镇痛和口服药物治疗等方法,通过阻断疼痛的感知或传导,充分发挥其协同作用缓解疼痛,并可减少单一药物的使用剂量,提高药物的耐受性,延长药物作用时间,从而为患者提供更为有效的置换后镇痛。同时尽可能减少麻醉药物过量会导致的恶心、呕吐、镇静、肠梗阻、呼吸抑制和皮肤瘙痒等不良反应。多模式镇痛方案在充分利用各种药物和镇痛技术优点的同时,尽可能减少其不良反应,希望达到一种理想的平衡状态。但要想真正拥有良好的术后镇痛效果以及安全性,目前临床上仍缺乏最为理想的全膝关节置换围手术期多模式镇痛方案。 全膝关节置换创伤可以引起疼痛中枢和外周敏感化,从而导致置换后出现痛觉过敏。因此,有效缓解疼痛的最佳方法是尽可能地避免置换前、置换中和置换后痛觉过敏的产生。超前镇痛是指在伤害性神经冲动形成之前,采用相关的镇痛方法来降低中枢和外周神经的敏感性,从而使疼痛得到缓解。它包括置换前超前镇痛、置换中超前镇痛以及置换后超前镇痛[15]。从理论上来说,最理想的镇痛方案是通过多阶段(置换前、置换中和置换后)、多途径(全身局部、外周中枢)以及多种药物(阿片类药、非类固醇类抗炎药和局麻药等)联合治疗,从而达到平衡镇痛,既可以获得理想的镇痛效果,又可以最大程度的避免因使用单一镇痛方法或药物所带来的不良反应。多模式镇痛和超前镇痛的理念已被大多数医生所接受,并逐步在临床上开展实施,具有良好的前景。 2.3 围手术期镇痛方法研究现状 2.3.1 患者自控镇痛 近年来,患者手术后疼痛治疗过程中采用药泵技术,即“患者自控镇痛”,其可以根据患者的自身情况来设定药物剂量,镇痛药物可在安全有效的范围里由患者自行控制给药。当患者置换后感到疼痛时,只需要按下镇痛泵运行按钮,即可起到镇痛作用,而且药物在体内可以保持相对稳定的血药浓度。临床上常用的患者自控镇痛技术包括硬膜外自控镇痛和静脉自控镇痛,其所用镇痛药物包括芬太尼、舒芬太尼和吗啡等阿片类药以及酮咯酸氨丁三醇等非类固醇类抗炎 药[16]。其中,阿片类药物可以通过不同的机制发挥镇痛作用,在硬膜外自控镇痛中阿片类药物直接作用于脊髓或脑相应节段后角区域的阿片受体上,促进内源性阿片肽的释放,从而提高机体痛阈;而在静脉自控镇痛中则是通过血液循环作用于脑干和大脑的疼痛中枢,并最终抑制下行疼痛的传导[17]。此外,在静脉自控镇痛不需要外置硬膜导管,可以快速起到镇痛作用,但是容易出现恶心呕吐、尿潴留以及呼吸抑制等不良反应;而硬膜外自控镇痛是通过硬膜外间隙来发挥药物的镇痛作用,术后较少出现恶心呕吐、嗜睡、呼吸抑制等不良反应[18]。二者均为目前临床上比较常用的置换后镇痛方法,具有良好的镇痛效果。 2.3.2 环氧化酶2抑制剂 传统的非类固醇抗炎药是通过抑制环氧化酶活性来抑制前列腺素生成,但因同时抑制了环氧化酶1而出现明显胃肠道反应。选择性环氧化酶2抑制剂避免了因抑制基础前列腺素合成所出现的副作用,因此可以有效降低置换后疼痛并且不良反应少。国内外许多学者相继研制出环氧化酶2抑制剂,并且把其作为辅助用药以增强阿片类药物的镇痛作用,包括塞来昔布、帕瑞昔布和伐地昔布等[19]。塞来昔布和帕瑞昔布应用于全膝关节手术围手术期均可以获得满意的镇痛效果,但使用帕瑞昔布的患者有更好的关节活动功能力且镇痛效果更佳[20]。计忠伟等[21]通过一篇Meta分析表明,患者在全膝关节置换前服用环氧化酶2抑制剂对控制置换后疼痛方面具有良好的安全性与有效性。Schroer等[22]的一项研究指出,全膝关节置换后给予患者每日口服400 mg塞来昔布,术后静息、活动时疼痛评分以及阿片类止痛药剂量明显减少,且关节活动度和功能评分增加。Dalury等[23]给予全膝关节置换患者出院后每日口服200 mg西乐葆,连续6周,患者膝关节疼痛得到明显缓解。塞来昔布与帕瑞昔布序贯疗法为近年所提出,能够有效减轻全膝关节置换围手术期疼痛,可在多模式镇痛中起到一定作用[24]。杨体敏等[25]通过随机双盲试验对60例全膝关节置换患者序贯应用帕瑞昔布+塞来昔布镇痛效果满意,能促进术后早期关节功能康复、减轻置换后早期炎症反应、缩短置换后住院周期及减少不良反应发生率,同时其对置换后凝血功能及关节引流量无明显影响。环氧化酶2抑制剂作为缓解全膝关节置换围手术期疼痛的口服药物,参与到多模式镇痛方案中,其作用时间长,镇痛效果好,同时能够减少其它药物用量,成为更加合理的用药方案。 2.3.3 股神经阻滞 股神经阻滞是目前临床上全膝关节置换后常用的镇痛方法,具有良好的镇痛效果。股神经阻滞分为单次阻滞和连续阻滞,超声引导下的连续股神经阻滞具有更好的镇痛效果,可作为全膝关节置换后镇痛较为理想的选择[26]。Santiveri等[27]对1 550例全膝关节置换患者进行了分析,将其分为硬膜外镇痛组、股神经阻滞组和股神经联合坐骨神经阻滞组,结果显示,联合阻滞组的镇痛效果要优于股神经阻滞组,而且吗啡使用量更少;而硬膜外阻滞组相对于其它2组存在着更多的不良反应。另外,Abdallah等[28]通过研究发现,与单纯股神经阻滞相比,股神经联合坐骨神经阻滞具有更好的镇痛效果,更少的阿片类药物用量且不良反应少。股神经阻滞虽然有着良好镇痛效果,但是其对股四头肌肌力的影响却是不可忽视的,应该引起广大临床医生的重视。有研究表明,股神经阻滞可能导致股四头肌内收肌肌力降低,会造成置换后跌倒事件发生率升高,这并不利于患者早期的功能恢复训练[29-30]。股神经阻滞用于全膝关节置换后镇痛的安全性优于阿片类药物静脉自控镇痛和硬膜外镇痛,但其与收肌管阻滞对比效果仍不明确。Li等[31]通过研究发现,收肌管阻滞组患者置换后 48 h膝关节屈曲至90°者的构成比要明显高于股神经阻滞组患者。由此可见,股神经阻滞对于肌力的影响可能直接关系到全膝关节置换患者置换后膝关节功能的锻炼以及恢复。 2.3.4 收肌管阻滞 全膝关节置换患者置换后尽早活动有利于膝关节功能快速康复,而连续股神经阻滞会影响到股四头肌肌力,不利于患者进行早期关节功能锻炼,有悖于快速康复理念。收肌管阻滞是近年来应用于全膝关节置换后镇痛的新方法,其靶神经为隐神经,但由于给药方式是局部浸润注射,其作用范围不只限于隐神经,因此许多学者常使用“收肌管阻滞”这一名称[32]。隐神经是纯感觉神经,具有不影响股四头肌肌力的优点,符合快速康复理念。此外,收肌管阻滞在临床上的操作技术已经逐渐成熟,其相关并发症很少见。Henningsen等[33]对97例应运收肌管阻滞镇痛的全膝关节置换患者置换后进行了随访,结果显示其镇痛效果良好,且并未发现有明确的收肌管阻滞相关神经损伤。 关于收肌管阻滞的给药方式,Shah等[34]研究发现使用连续收肌管阻滞组比单次收肌管阻滞组的镇痛效果更好,但患者置换后步行能力和早期关节功能恢复情况并没有明显差别。Kuang等[35]发现超声引导下的收肌管阻滞在提供同等有效镇痛的同时,其对股四头肌肌力影响较小,能够促进患者置换后关节功能恢复和早期下床活动,并且减少置换后恶心。因此,收肌管阻滞未来有可能替代股神经阻滞成为全膝关节置换后疼痛管理的黄金标准。 值得注意的是,这些研究大多是在多种镇痛方法联合使用的前提下进行的,所以其对收肌管阻滞和股神经阻滞镇痛效果评估的针对性相对较差[37]。Srensen等[38]指出,收肌管阻滞虽能较好的保留股四头肌肌力,但是否确实提高患者置换后的运动能力仍存有疑问。另有Sztain等[39]报道虽然应运收肌管阻滞镇痛的患者步行能力恢复时间较股神经阻滞有所减少,但总体上住院时间并没有缩短。目前对于收肌管阻滞的认识还不够,更大量的临床研究仍需广大医疗工作者去完成。 多模式镇痛在临床中的应用,可以充分利用收肌管阻滞的优点,在为患者提供有效镇痛的同时,能够减少其它镇痛方法可能引起的不良反应[40]。另外,环氧化酶2抑制剂序贯治疗有着镇痛效果好、不良反应少的优点,与收肌管阻滞联合应运可能在多模式镇痛中凸显其优势[41]。这种“各取所长”以及个体化的镇痛方案是目前全膝关节置换围手术期镇痛的目标,同时也会是今后的发展趋势。 2.3.5 鸡尾酒 关节周围软组织注射镇痛又被称作“鸡尾酒”疗法,使用吗啡、肾上腺素、局麻药、糖皮质激素等药物的混合液,注射到膝关节周围软组织中,通过不同药物作用机制和不同途径来减轻手术刀口周围骨与软组织的创伤反应,消除刀口周围疼痛信号的产生和传导,从而起到全膝关节置换后镇痛作用[42]。关节周围软组织注射既可避免全身给药所带来的不良反应,又可避免因采取股神经阻滞所引起的术后肌力较差等并发症。与其他镇痛方法相比,其优势在于可以直视下在关节周围神经支配丰富的区域注射药物,药物直达作用部位,局部组织药物浓度高,可以从根本上控制疼痛的产生和传导,在达到高效安全镇痛目的的同时,并不会影响到股四头肌肌力[43]。此外,关节周围软组织注射是通过药物的局部渗透作用逐渐起效,不会进入血液循环对中枢产生影响,并且延长了药物的镇痛时间。Ranawat等[44]认为,合适的患者使用“鸡尾酒”在关节周围组织注射,可以产生最好的镇痛效果,且不良反应最小。Vendittoli等[45]通过研究发现,全膝关节置换后使用静脉自控镇痛加罗哌卡因-酮咯酸-肾上腺素混合液在刀口周围浸润,镇痛效果确切,如果在关节局部置管,置换后24 h内可以追加给药,但总体上住院时间并无差异。Lombardi等[46]给予全膝关节置换患者置换中在关节周围组织注射布比卡因-肾上腺素-吗啡混合液,结果发现吗啡用量明显低于空白对照组。Lamplot等[47]研究发现,使用布比卡因-吗啡-酮咯酸混合液关节周围注射,能够减少麻醉药用量,提高患者满意度和疼痛评分,并且可以加快置换后早期的功能恢复。Tsukada等[48]将罗哌卡因-吗啡-肾上腺素-甲强龙-酮咯酸配方的混合液注入关节周围,与硬膜外镇痛相比,其在置换后第一个24 h内镇痛效果更好并且可以降低阿片类药物相关副作用。Kim等[49]通过研究发现,联合使用罗哌卡因、吗啡和酮咯酸丁三醇的“鸡尾酒”配方能够更为高效的起到更好的镇痛作用。鞠洪斌等[50]在关节假体周围注射吗啡-布比卡因-肾上腺素-甲强龙配方的混合液,与空白对照组相比,自控镇痛泵的使用频率明显减少,并且未见明显不良反应。国内外这些最新的研究证实了关节周围软组织注射镇痛的安全性与有效性,从而更好的丰富了多模式镇痛方案。 关于“鸡尾酒”混合药液,目前尚没有统一的配方,最佳的药物配比仍在不断探索与改进。值得一提的是,低浓度罗哌卡因具有感觉-运动阻滞分离的特点,能够根据药量来控制感觉与运动的阻滞程度,其中0.2%罗哌卡因可以达到最好的镇痛效果和最小的运动阻滞平 衡[51]。Kerr等[52]通过研究指出,在置换中给予关节周围组织注射罗哌卡因的安全有效剂量是300 mg。目前在临床上各类神经阻滞所使用的局麻药多为0.2%罗哌卡因,但一项最新的回顾性研究发现,使用长效脂体布比卡因能够在置换后72 h内为患者提供与0.2%罗哌卡因程度相当的有效镇痛,并且可以减少患者的医疗费用[53]。类固醇激素具有明显的抗炎作用,全膝关节置换中注射能够减轻手术局部的应激反应,进而有效减轻术后疼痛并促进早期膝关节功能恢复。岳海源等[54]通过一篇Meta分析指出,在关节周围组织注射类固醇激素能够降低术后疼痛,促进早期关节活动并缩短住院时间,且并不会增加置换后并发症的风险。Chia等[55]研究发现,使用高剂量糖皮质激素(80 mg曲安奈德醋酸)后,刀口会出现红肿和渗出,说明糖皮质激素使用剂量对全膝关节置换患者置换后恢复具有一定的影响。类固醇激素在关节周围注射的最佳剂量和远期效果仍需大样本量以及长期的随访来考证。 2.3.6 冷疗 冷敷疗法是通过低温刺激皮肤或黏膜来治疗疾病或缓解症状的物理方法,在临床上有着广泛的应用。冷疗在缓解患者置换后疼痛、肿胀、减少出血和改善关节活动度等方面起到积极作用。Morsi等[56]对双侧全膝关节置换患者的双侧膝关节置换后分别使用持续冷疗和一般常规处理,结果显示在关节活动度、出血量、镇痛药量和切口愈合等方面,前者均优于后者。Kullenbeg等[57]通过对比全膝关节置换患者置换后使用冷疗和硬膜外镇痛,结果得出两组在疼痛评分和镇痛药物用量上相近,但是在膝关节活动度以及住院时间方面冷疗组要优于硬膜外镇痛组。Ni等[58]通过Meta分析得出,冷疗能够使患者在置换后第2天疼痛得到明显缓解。陈松等[59]通过研究发现,连续24 h冷疗可以明显降低镇痛药物用量,并且能够推迟患者术后第1次使用镇痛药物的间隔时间。目前对冷敷治疗的持续时间以及适合温度仍需大量的临床研究来证实,未来或许能够成为全膝关节置换围手术期多模式镇痛方案中的一种有效辅助治疗手段,使患者得到更好的镇痛治疗。 中国组织工程研究杂志出版内容重点:人工关节;骨植入物;脊柱;骨折;内固定;数字化骨科;组织工程"
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