股神经阻滞对全麻下膝关节置换术老年患者术后镇痛和早期认知功能的影响

发布时间：2018-06-19 10:22

本文选题：股神经阻滞 + 膝关节置换术　；参考：《郑州大学》2014年博士论文

【摘要】：研究背景膝关节置换术(total knee arthroplasty,TKA)是严重膝骨关节病变最有效的治疗方法。该手术创伤较大、术后疼痛剧烈且患者多为老年,因腰椎退行性病变较多及围术期抗凝药物的常规使用,全身麻醉已成为重要选择之一。术后的剧烈疼痛严重影响着患者的功能锻炼和康复效果,因此TKA术后良好的镇痛对患者最终关节运动动能的恢复尤为重要。国内外大量临床研究显示不论是单次还是连续股神经阻滞股神经阻滞都能有效改善TKA患者术后镇痛的效果、降低围术期阿片类药物用量、加快患者术后功能锻炼和恢复、降低不良反应的发生率等,由于操作简便、安全性较高等特点,在TKA患者中应用广泛。但是临床上实施股神经阻滞的时间并不一致,术前或术后都有。术前和术后不同时间的股神经阻滞对TKA患者术后镇痛的效果有无影响;如果在术前应用股神经阻滞,对TKA患者是否具有超前镇痛作用,目前尚不明确。研究指出骨科手术、术后疼痛和年龄60岁都是术后认知功能障碍(postoperative cognitive dysfunction,POCD)发生的危险因素之一,因此预防和减少全麻下TKA老年患者POCD的发生十分必要。炎性反应可能是POCD发生的关键环节,早年曾有学者提出外周神经阻滞技术可能给炎性反应的治疗带来新的希望,动物实验和临床研究已发现外周神经阻滞能更好的改善术后疼痛和炎性反应。股神经阻滞能否通过改善全麻下TKA老年的术后疼痛和炎性反应从而对术后早期认知功能产生影响,尚不明确。研究目的通过手术前后不同时间的股神经阻滞对全麻下TKA老年患者术后镇痛效果的影响,拟探讨股神经阻滞是否具有超前镇痛作用;通过比较股神经阻滞、闭孔神经阻滞及对照组对全麻下TKA老年患者早期POCD发生率的影响,拟探讨股神经阻滞是否能改善全麻下TKA老年患者早期POCD的发生率;通过比较股神经阻滞及对照组对全麻下TKA老年患者术后早期炎性反应和神经损伤的影响,拟探讨股神经阻滞影响全麻下TKA老年患者术后早期认知功能的可能机制,为TKA老年患者的疼痛管理和POCD预防提供新的思路。研究方法 1.采用随机数字表法,分为3组:对照组(Ⅰ组)不实施股神经阻滞;术前股神经阻滞组(Ⅱ组)于麻醉诱导前行超声引导下单次股神经阻滞;术后股神经阻滞(Ⅲ组)于手术结束即刻行超声引导下单次股神经阻滞。术后三组患者均行PCIA镇痛。分别记录两组患者术后2h、6h、12h、24h、48h、72h时静息状态VAS评分与术后12h、24h、48h、72h时运动状态VAS评分,及术后24 h内PCIA中的舒芬太尼用量、PCIA的有效按压次数(D1)和实际按压次数(D2),并计算D1/D2;记录术后24 h内不良反应发生情况。2.采用随机数字表法,分为3组:对照组(Ⅰ组)、股神经阻滞组(Ⅱ组)和闭孔神经阻滞组(Ⅲ组)。Ⅱ和Ⅲ组患者分别于麻醉诱导前行患侧股神经和闭孔神经阻滞,空白对照组不实施股神经阻滞。分别记录两组患者术中的麻醉时间、麻醉药用量、手术时间及出血量;并记录入室、开始手术及随后每30min患者的MAP及HR至手术结束;记录每组患者术中血管活性药使用率;分别测试3组患者在术前1d和术后3、7d的MMSE评分并计算术后3、7d的POCD发生率。3.采用随机数字表法,将其分为2组:对照组(Ⅰ组)和股神经阻滞组(Ⅱ组)。Ⅱ组于麻醉诱导前行患侧股神经阻滞。所有患者分别于麻醉开始前、手术结束时、术后2h时抽取动脉血样1ml行血气分析记录PH值、lac值及血糖值;分别于术前1d(T0)、术后2h(T1)、术后6h(T2)、术后12h(T3)、术后1d(T4)时采集外周静脉血5ml,由经过培训且不参与麻醉的同一测试者采用酶联免疫吸附法检测血浆TNF-α和IL-6水平;并于分别于术前1d(T0)、术后1d(T4)、术后3d(T5)和术后7d(T6)时采集外周静脉血5ml,采用酶联免疫吸附法检测血清Aβ和Tau蛋白浓度。研究结果 1.与对照组比较,术前股神经阻滞组和术后股神经阻滞组术后2h、6h、12h静息状态VAS评分与术后12h运动状态VAS评分降低、术后24 h内PCIA的舒芬太尼用量减少、D1/D2升高、恶心呕吐的发生率也降低(P0.05);但术前股神经阻滞组和术后股神经阻滞组两组间比较,术后不同时点的静息和运动状态VAS评分、术后24 h内PCIA的舒芬太尼用量及不良反应的发生率差异无统计学意义(P0.05)。2.与对照组比较,股神经阻滞组患者麻醉时间、手术时间、出血量及术中丙泊酚的总用量差异无显著性(P0.05),但术中瑞芬太尼的总用量显著减少(P0.05),而闭孔神经阻滞组的麻醉时间、手术时间、出血量及术中麻醉药总用量差异无显著性(P0.05);三组患者从麻醉开始到手术结束各时间点的MAP、HR的动态变化及术中血管活性药物使用率比较差异无显著性(P0.05);术后3d时,与空白对照组比较,股神经阻滞组的MMSE评分显著增高,POCD的发生率显著降低,而闭孔神经阻滞组的MMSE评分和POCD发生率差异无显著性(P0.05);术后7d时,三组的MMSE评分和POCD发生率比较差异无显著性(P0.05)。3.与对照组比较,股神经阻滞组患者在手术结束及术后2h的血糖值显著降低(P0.05),而两组患者术前、手术结束及术后2h的血气分析中PH值及lac值比较差异无统计学意义(P0.05);与术前T0时刻比较,术后T1、T2、T3和T4时刻两组患者的血浆TNF-α和IL-6水平均显著升高(P0.05);与Ⅰ组比较,术前T0时刻两组患者血浆TNF-α和IL-6水平差异无显著性,但Ⅱ组患者在术后的T1、T2、T3和T4时刻血浆TNF-α和IL-6水平显著降低(P0.05);两组患者在术后T4和T5时刻血浆Aβ和Tau蛋白水平与术前T0时刻比较显著升高(P0.05),但Ⅱ组患者在T4和T5时刻血浆的Aβ和Tau蛋白水平与Ⅰ组比较显著降低(P0.05),而两组患者在T6时刻血浆的Aβ和Tau蛋白水平差异无显著性(P0.05)。研究结论 1.股神经阻滞能改善全麻下TKA老年患者术后早期PCIA的镇痛效果,降低术中和术后早期阿片类药物用量,但是无超前镇痛作用。2.股神经阻滞能降低全身麻醉下TKA老年患者术后早期认知功能障碍的发生率。3.股神经阻滞能抑制全麻下TKA老年患者术后早期炎性反应。4.股神经阻滞能通过改善全麻下TKA老年患者术后早期的疼痛和炎性反应,从而减轻神经损伤,改善术后早期的认知功能。
[Abstract]:Background knee arthroplasty (total knee arthroplasty, TKA) is the most effective treatment for severe knee osteoarthropathy. The operation has greater trauma, severe postoperative pain and more elderly patients. General anesthesia has become one of the most important choices because of more lumbar degenerative diseases and routine use of anticoagulants in the perioperative period. Pain seriously affects the functional exercise and rehabilitation effect of the patients, so good postoperative analgesia after TKA is of particular importance to the recovery of the final motion kinetic energy of the patients. A large number of clinical studies at home and abroad have shown that both single or continuous femoral nerve block can effectively improve the effect of postoperative analgesia in patients with TKA and reduce the perioperative period. The dosage of opioid drugs, accelerating the postoperative functional exercise and recovery, reducing the incidence of adverse reactions, and so on, is widely used in TKA patients because of its simple operation and high safety. However, the time of the clinical application of femoral nerve block is not consistent, before and after the operation, the femoral nerve block at different time before and after the operation is to TKA The effect of postoperative analgesia is not affected. If femoral nerve block is used before operation, it is not clear whether TKA patients have a preemptive analgesic effect. The study indicates that Department of orthopedics surgery, postoperative pain and age 60 are one of the risk factors for postoperative cognitive dysfunction (postoperative cognitive dysfunction, POCD). It is necessary to prevent and reduce the occurrence of POCD in TKA elderly patients under general anesthesia. The inflammatory response may be the key link in the occurrence of POCD. In the early years, some scholars suggested that peripheral nerve block may bring new hope for the treatment of inflammatory reaction. Animal experiments and clinical studies have found that peripheral nerve block can improve postoperative pain and inflammation better. It is not clear whether the femoral nerve block can affect the early postoperative cognitive function by improving the postoperative pain and inflammatory response of TKA aged under general anesthesia. The effect of preemptive analgesia; by comparing the effect of femoral nerve block, obturator nerve block and control group on the early POCD incidence of TKA elderly patients under general anesthesia, it is proposed to explore whether femoral nerve block can improve the early incidence of early POCD in TKA elderly patients under general anesthesia; by comparing the femoral nerve block and control group to the early post operation of TKA in the elderly patients under general anesthesia. The effects of inflammatory reaction and nerve injury were discussed. The possible mechanism of the early cognitive function of the TKA elderly patients under general anesthesia was explored to provide new ideas for the management of pain and the prevention of POCD in the elderly patients of TKA. Method 1. the study was divided into 3 groups by random digital table method: the control group (group I) did not carry the femoral nerve block; the preoperative femoral nerve block was not carried out. The nerve block group (Group II) was guided by ultrasonic guided single femoral nerve block before anesthesia induction, and the femoral nerve block (Group III) was guided by ultrasonic guided single femoral nerve block at the end of the operation. After the operation, the three groups were all treated with PCIA analgesia. The postoperative 2h, 6h, 12h, 24h, 48h, 72h, VAS score and postoperative 12h, 24h, and 4 were recorded in the two groups. 8h, 72h motor state VAS score, and the dosage of sufentanil in PCIA in 24 h after operation, PCIA effective press times (D1) and actual press times (D2), and calculated D1/D2. The incidence of adverse reactions within 24 h was recorded by random number table method, divided into 3 groups: Group (Group I), femoral nerve block group (Group II) and obturator nerve block group ( Group II and group III were treated with femoral nerve and obturator nerve block before induction of anesthesia, and the blank control group did not carry the femoral nerve block. The anesthesia time, the dosage of anesthetics, the operation time and the amount of bleeding were recorded in the two groups, and the admission, the hand operation and the subsequent MAP and HR to the end of each 30min patient were recorded. The use rate of vasoactive drugs in each group was recorded. The MMSE score of 3 groups of patients before and after the operation of 1D and postoperative 3,7d and the POCD incidence of 3,7d after operation were divided into 2 groups: the control group (group I) and the femoral nerve block group (Group II). Group II was induced by the femoral nerve block before anesthesia induction. At the end of the anaesthesia, at the end of the operation, the arterial blood samples were extracted at 2h after the operation to record the pH value, the lac value and the blood sugar value, respectively at the preoperative 1D (T0), 2h (T1), 6h (T2) after operation, 12h (T3) after operation, and the postoperative 1D. The same test was tested by enzyme linked immunosorbent assay. Plasma TNF- alpha and IL-6 levels were measured before operation 1D (T0), postoperative 1D (T4), postoperative 3D (T5) and 7d (T6) after operation. The serum A beta and protein concentration were detected by enzyme linked immunosorbent assay (ELISA). Results 1. compared with the control group, the pre operation femoral nerve block group and the postoperative femoral nerve block group were in the resting state. The score and the postoperative 12h motor state VAS score decreased, the dosage of sufentanil of PCIA decreased, D1/D2 increased, and the incidence of nausea and vomiting decreased (P0.05) in 24 h after operation, but compared with the postoperative femoral nerve block group and the postoperative femoral nerve block group, the resting and movement state VAS score of the postoperative different points and the sufentanil in 24 h after the operation were compared. There was no significant difference in the incidence of dosage and adverse reactions (P0.05).2., compared with the control group, there was no significant difference in the time of anesthesia, the time of operation, the amount of bleeding and the total dosage of propofol in the femoral nerve block group (P0.05), but the total amount of remifentanil in the operation was significantly reduced (P0.05), while the anesthesia time in the obturator nerve block group was in the hand. There was no significant difference in the time of operation, the amount of bleeding and the total amount of anesthetics in the operation (P0.05). There was no significant difference between the three groups from the beginning of anaesthesia to the time of the operation at the end of the operation, the dynamic changes of HR and the use rate of vasoactive drugs in the operation were not significant (P0.05), and the MMSE score in the femoral nerve block group was significantly higher at 3D after the operation. There was no significant difference in the incidence of POCD, but there was no significant difference in the MMSE score and the incidence of POCD in the obturator block group (P0.05). There was no significant difference between the three groups of MMSE scores and the POCD incidence in the three groups after the operation (P0.05).3. (P0.05).3. compared with the control group, the blood sugar of the femoral nerve block group was significantly reduced (P0.05) at the end of hand operation and in the postoperative 2H (P0.05), and the two groups were compared with the control group (P0.05). There was no significant difference between the pH value and the lac value in the blood gas analysis of 2H before and after the operation (P0.05). Compared with the T0 time before the operation, the plasma TNF- alpha and IL-6 water in the two groups of patients after T1, T2, T3 and T4 increased significantly (P0.05). The plasma TNF- alpha and IL-6 levels were significantly decreased at T1, T2, T3 and T4 (P0.05) at the postoperative time of operation (P0.05). The levels of plasma A beta and Tau protein in the two groups were significantly higher at the T4 and T5 levels after the operation, but the levels of serum beta and protein in plasma were significantly lower than those in group I at the time of T4 and T5. There was no significant difference in plasma A beta and Tau protein levels in the two groups at T6 time (P0.05). Conclusion 1. femoral nerve block can improve the analgesic effect of early PCIA in the elderly patients with TKA under general anesthesia and reduce the dosage of opioid drugs at the early stage of operation and after operation, but no preemptive analgesia effect of.2. femoral nerve block can reduce TKA under general anesthesia. The incidence of early cognitive impairment after operation in elderly patients with.3. femoral nerve block can inhibit early inflammatory response to.4. femoral nerve block in TKA elderly patients under general anesthesia by improving the early pain and inflammatory response of the elderly patients under general anesthesia, thus reducing nerve injury and improving early cognitive function after operation.
【学位授予单位】：郑州大学
【学位级别】：博士
【学位授予年份】：2014
【分类号】：R614.2

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