CAJ | 학술논문

目的：探讨单侧腰麻全膝关节置换（ TKA）术后超声引导下连续股神经阻滞镇痛的效果。方法本组TKA手术123例，ASAⅠ～Ⅱ级，均选择L4／5间隙穿刺轻比重布比卡因单侧腰麻。Ⅰ组42例，Ⅱ组26例，术后均选用自控静脉镇痛（PICA），PICA配方为（舒芬太尼100 ug ＋氯胺酮50 mg ＋咪唑安定1 mg ＋托烷司琼6 mg），用0.9％生理盐水稀释至100 ml，首剂量为3 ml静注后连接患者自控镇痛泵（PCA），PCA泵维持量为1.5 ml／h、2 ml／PCA，锁定时间为60 min；Ⅱ组由术者于术毕加用0.375％左布比卡因20～30 ml行膝关节及切口局部浸润阻滞；Ⅲ组55例，于手术后床边超声引导下患侧股神经旁置管连续股神经阻滞镇痛，PCA泵配方为0.15％左布比卡因300 ml（含舒芬太尼100 ug），首剂量15 ml后2 ml／h，8 ml／PCA，锁定时间为60 min。记录术后患者首次PCA时间，术后6 h、6～12 h、12～24 h、24～48 h舒芬太尼用量及其视觉模拟评分法（ VAS）；术后48 h内膝关节的主动屈曲度，及48 h内膝关节被动屈曲90°时的VAS最大值；及患者的不良反应情况。结果（1）术后患者首次PCA时间，Ⅲ组＞Ⅱ组＞Ⅰ组，组间比较有统计学差异；（2）术后6 h和6～12 h舒芬太尼用量比较，Ⅰ组＞Ⅱ组＞Ⅲ组，组间比较有统计学差异；术后12～24 h 及24～48 h舒芬太尼用量比较，Ⅰ组和Ⅱ组分别＞Ⅲ组，有统计学差异；（3）静息时VAS评分：术后6 h，Ⅰ组＞Ⅱ组和Ⅲ
목적：탐토단측요마전슬관절치환（ TKA）술후초성인도하련속고신경조체진통적효과。방법본조TKA수술123례，ASAⅠ～Ⅱ급，균선택L4／5간극천자경비중포비잡인단측요마。Ⅰ조42례，Ⅱ조26례，술후균선용자공정맥진통（PICA），PICA배방위（서분태니100 ug ＋록알동50 mg ＋미서안정1 mg ＋탁완사경6 mg），용0.9％생리염수희석지100 ml，수제량위3 ml정주후련접환자자공진통빙（PCA），PCA빙유지량위1.5 ml／h、2 ml／PCA，쇄정시간위60 min；Ⅱ조유술자우술필가용0.375％좌포비잡인20～30 ml행슬관절급절구국부침윤조체；Ⅲ조55례，우수술후상변초성인도하환측고신경방치관련속고신경조체진통，PCA빙배방위0.15％좌포비잡인300 ml（함서분태니100 ug），수제량15 ml후2 ml／h，8 ml／PCA，쇄정시간위60 min。기록술후환자수차PCA시간，술후6 h、6～12 h、12～24 h、24～48 h서분태니용량급기시각모의평분법（ VAS）；술후48 h내슬관절적주동굴곡도，급48 h내슬관절피동굴곡90°시적VAS최대치；급환자적불량반응정황。결과（1）술후환자수차PCA시간，Ⅲ조＞Ⅱ조＞Ⅰ조，조간비교유통계학차이；（2）술후6 h화6～12 h서분태니용량비교，Ⅰ조＞Ⅱ조＞Ⅲ조，조간비교유통계학차이；술후12～24 h 급24～48 h서분태니용량비교，Ⅰ조화Ⅱ조분별＞Ⅲ조，유통계학차이；（3）정식시VAS평분：술후6 h，Ⅰ조＞Ⅱ조화Ⅲ
Objective To investigate the effects of the postoperative analgesia and functional exercise by ultrasound-guided continuous femoral nerve block after total knee arthroplasty ( TKA ) . Methods A total of 123 patients undergoing TKA of ASAⅠ~Ⅱ were randomized into three groups:group Ⅰ(n=42), group Ⅱ (n=26) and group Ⅲ (n=55).All the patients had received unilateral spinal anesthesia by using hypobaric bupivacaine in the L 4-L5 space.The postoperative patient-controlled-analgesia (PCA) for groupⅠand group Ⅱwas performed intravenously .The PCA recipe for groupⅠandⅡwas as follows:sufentanil 100 ug +ketamine 50 mg +midazolam 1 mg +tropisetron 6 mg.All these drugs were diluted in 100ml of 0.9%saline;after the first intravenous dose of 3 ml, the PCA pump was connected , and the PCA parameters were set as follows:1.5 ml/h;2 ml/PCA, 60 minutes of the lock time.All the patients in group Ⅱ had been intra-articularly injected 20 -30 ml of 0.375%levobupivacaine by the surgeon before suturing .In groupⅢ, the patients received ultrasound-guided continuous femoral nerve block for postoperative PCA after the surgery .The PCA formulation for group Ⅲwas as follows :0.15%levobupivacaine 300 ml ( containing sufentanil 100ug);the PCA pump parameters were set as follows: first dose 15 ml; 2 ml/h; 8 ml/PCA; 60 minutes of the lock time .The detection indicators included the first postoperative PCA time , the sufentanil dosage , the visual analogue scale ( VAS) ( during 0-6 h, 6-12 h, 12-24 h, 24-48 h after the operation ) , the maximum active flexion angle of the knee within postoperative 48h, the maximum value of VAS when the knee was at 90°of passive flexion within the postoperative 48 h and the rate of adverse reactions .Results (1) There were significant differences , in the first postoperative PCA time between the different groups , groupⅢ >groupⅡ>group I.(2) There were significant differences in the sufentanil dosage in the postoperative 6 h and 6-12 h, group Ⅰ >groupⅡ>group Ⅲ;the sufentanil dosage in the postoperative 12-24 h and 24-48 h, the sufentanil dosage of groupⅠand groupⅡwas higher than group Ⅲ;the difference was significant .(3) The VAS score (at rest) of groupⅠwas significantly higher than group Ⅱand groupⅢin the postoperative 6 h. The VAS scores of groupⅠand groupⅡwere significantly higher than group Ⅲin the postoperative 6-12 h and 12-24 h.There was no significant difference in VAS score among the three groups in the postoperative 24-48 h.( 4 ) The maximum active knee flexion angle of group Ⅲ within the postoperative 48 h was significantly higher than that of groupⅠand groupⅡ.(5) When the knee was at 90°of passive flexion within the postoperative 48 h, the VAS scores of groupⅠand groupⅡwere significantly higher than that of group Ⅲ;there was no significant difference between group Ⅰand group Ⅱ.Conclusion Postoperative analgesia by ultrasound-guided continuous femoral nerve block after TKA is the most effective one among the three methods , and more conducive to the exercise of knee function and knee function recovery .