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随着我国社会步入老龄化,接受全膝关节置换术的老年患者逐年增多,而老年患者由于机体耐受力降低,且常常合并多种基础疾病,对手术、疼痛等刺激耐受力较差[1]。近年来,随着加速康复外科理念深入人心,如何减轻老年患者术后疼痛应激成为围术期医学关注的重点。超声引导下股神经阻滞技术是在超声可视化条件下将局麻药注射至股神经旁从而短暂阻断股神经的疼痛传导功能,发挥术后镇痛作用[2]。股神经阻滞麻醉对全膝关节置换术具有镇痛效果确切、对生命体征影响较小、减少阿片类镇痛药及不良反应少的优点,然而由于受局麻药物的半衰期影响其镇痛时间较短,尽管神经周围置管技术能为围手术期进行持续的镇痛管理,可由于导管移位、感染风险增加以及患者的管理具有困难性,使神经周围置入导管的应用受限[3]。研究发现,局麻药中添加佐剂能够延长周围神经阻滞时间,效果良好,包括肾上腺素、曲马多、咪达唑仑、碳酸氢盐、新斯的明、氯胺酮、可乐定等,但各类研究结论不一[4]。地塞米松作为一种类固醇类药物,在慢性疼痛治疗中被广泛应用于外周和中枢。右美托咪定为α2受体激动剂,通过激动突触前膜的α2受体,抑制去甲肾上腺素的释放发挥作用,有拟自然睡眠、镇痛等效果,在临床上得到广泛的应用。本研究旨在探讨地塞米松联合右美托咪定对罗哌卡因股神经阻滞,用于老年患者全膝关节置换术后镇痛效果及其优缺点,为股神经阻滞麻醉的实践提供临床参考。
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如表1所示,4组患者的性别、年龄、体重、MAP以及心率等指标均无统计学差异(P>0.05)。
表 1 4组患者的一般情况比较(n=24,
$\bar x $ ±s)组别 性别
(男/女)年龄
(岁)体重
(m/kg)MAP
(mmHg)心率 C 10/14 73.33±5.85 57.24±8.02 81.40±10.41 82.11±11.76 E1 11/13 69.50±6.09 60.32±10.56 83.28±12.86 83.28±16.15 E2 15/9 69.00±7.48 59.16±6.71 81.44±12.07 79.33±12.19 E3 13/11 69.83±3.06 55.42±10.08 80.22±13.01 80.06±10.82 χ2/F 2.459 0.684 0.437 0.129 0.165 P 0.483 0.572 0.606 0.903 0.925 -
如表2所示,4组患者的手术时间、出血量、输液量及诱导期咪达唑仑、舒芬太尼用量等手术指标均无统计学差异(P>0.05)。
表 2 4组患者手术情况比较(n=24,
$\bar x$ ±s)组别 手术时间 (t/min) 出血量 (V/ml) 输液量(V/ml) 诱导期咪达唑仑用量 (m/mg) 诱导期舒芬太尼用量(m/μg) C 127.33±21.39 195.72±29.38 900.00±141.42 1.99±0.16 26.53±2.14 E1 120.39±25.59 186.11±32.98 941.67±91.74 1.86±0.30 24.80±3.99 E2 108.61±16.35 213.33±19.15 916.67±213.70 1.92±0.28 25.60±3.72 E3 119.61±14.98 204.72±39.36 925.00±150.83 1.83±0.24 24.33±3.17 F 1.156 0.084 0.075 0.503 0.503 P 0.351 0.879 0.973 0.684 0.684 -
如表3所示,E2、E3组的术后6 h的VAS评分、Ramsay 评分显著低于C组,E3组的术后12 h的VAS评分显著低于C组(P<0.05),而4组术后24、48 h的VAS评分无统计学差异(P>0.05),说明地塞米松联合右美托咪定能够增强罗哌卡因的镇痛和镇静效果。
表 3 4组患者术后镇痛、镇静效果评价(n=24,
$\bar x $ ±s)组别 VAS评分 术后6 h
Ramsay 评分术后6 h 术后12 h 术后24 h 术后48 h C 2.60±0.55 2.40±0.55 1.20±0.84 0.40±0.55 1.17±0.41 E1 2.00±0.71 1.80±0.84 0.80±0.45 0.20±0.45 1.67±0.52 E2 1.60±0.55* 1.60±0.55 0.60±0.55 0.20±0.45 2.33±1.03* E3 1.20±0.45* 1.00±0.71* 0.60±0.55 0.20±0.45 2.5±0.55* F 5.487 0.027 1.067 0.222 5.062 P 0.009 3.963 0.391 0.879 0.009 *P<0.05,与C组比较。 -
如表4所示,E2、E3组的术后吗啡消耗量显著少于C组,且E1、E2、E3组的镇痛持续时间显著长于C组(P<0.05),说明地塞米松和右美托咪定均能够增强罗哌卡因的镇痛效果,延长镇痛时间,两者合用具有协同效应。
表 4 4组患者术后吗啡消耗量和镇痛时长比较(n=24,
$\bar x $ ±s)组别 术后吗啡消耗量(m/mg) 镇痛持续时间(t/min) C 10.50±1.87 556.67±56.10 E1 8.17±1.17 664.33±74.68* E2 5.50±1.38* 688.33±48.34* E3 4.67±1.37* 726.67±64.39* F 8.153 9.734 P 0.001 0.004 *P<0.05,与C组比较。 -
如表5所示,4组患者术后呼吸抑制、恶心、呕吐、头晕等不良反应的发生率无统计学差异(P>0.05),说明地塞米松和右美托咪定并未增加患者的不良反应的发生率,安全性较高。
表 5 4组患者术后不良反应发生率比较[例数(%),n=24]
组别 呼吸抑制 恶心 呕吐 头晕 C 0(0) 3(12.5) 2(8.33) 0(0) E1 0(0) 0(0) 0(0) 0(0) E2 1(4.17) 1(4.17) 1(4.17) 1(4.17) E3 1(4.17) 0(0) 0(0) 1(4.17) χ2 2.043 6.261 3.785 2.043 P 0.563 0.099 0.286 0.564
Analgesia effect of dexamethasone combined with dexmedetomidine on femoral nerve block with ropivacaine after total knee replacement in elderly patients
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摘要:
目的 观察地塞米松联合右美托咪定对罗哌卡因股神经阻滞用于老年患者全膝关节置换术后镇痛效果的影响。 方法 选取医院2019年1月至2020年12月关节外科收治的行全膝关节置换术的老年患者96例,术后均采用超声引导下股神经阻滞,按照神经阻滞药物配方分为对照组(C)、地塞米松组(E1)、右美托咪定组(E2)、地塞米松联合右美托咪定组(E3),收集患者的一般情况和手术情况,比较4组患者术后6、12、24、48 h的VAS评分和术后6 h的Ramsay镇静评分,分析各组患者术后吗啡消耗量及镇痛持续时间,观察术后6 h的不良反应发生率。 结果 4组患者的一般情况和手术情况均无统计学差异;E2、E3组的术后6 h的VAS评分、Ramsay 评分显著低于C组,E3组的术后12 h的VAS评分显著低于C组,而4组术后24、48 h的VAS评分无统计学差异;E2、E3组的术后吗啡消耗量显著少于C组,且E1、E2、E3组的镇痛持续时间显著长于C组;4组患者术后呼吸抑制、恶心、呕吐、头晕等不良反应的发生率不具有统计学差异。 结论 地塞米松联合右美托咪定能够增强老年患者全膝关节置换术后罗哌卡因股神经阻滞的镇痛效果,且不增加不良反应,更加安全有效。 Abstract:Objective To observe the analgesia effect of dexamethasone combined with dexmedetomidine on femoral nerve block with ropivacaine after total knee replacement in elderly patients. Methods 96 elderly patients undergoing total knee replacement with femoral nerve block analgesia from January 2019 to December 2020 in the hospital were enrolled in the study. Patients were divided into control group (C), dexamethasone group (E1), dexmedetomidine group (E2) and dexamethasone combined with dexmedetomidine group (E3) according to nerve block drug formulation. The general data and operation condition were collected, the VAS score at 6 h, 12 h, 24 h, 48 h and the Ramsay sedation score at 6 h after surgery were compared, the postoperative morphine consumption and duration of analgesia were analyzed, and the incidence of adverse reactions after operation was observed. Results Patients in four groups showed no significant differences in general data and operation time. The VAS score and Ramsay score at 6 h postoperatively in E2 and E3 were significantly lower than that in C, while there were no significant differences in VAS score at 24 h and 48 h postoperatively among four groups. Postoperative morphine consumption in E2 and E3 was significantly lower, and the duration of analgesia in E1, E2 and E3 was significantly longer than that in C. There was no statistical difference in the incidence of respiratory depression, nausea, vomiting, dizziness and other adverse reactions after operation among four groups. Conclusion Dexamethasone combined with dexmedetomidine could enhance the analgesic effect of femoral nerve block with ropivacaine in elderly patients after total knee replacement without increasing the adverse reactions, which would be both safe and effective. -
Key words:
- dexamethasone /
- dexmedetomidine /
- total knee replacement /
- femoral nerve block /
- analgesia
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表 1 4组患者的一般情况比较(n=24,
$\bar x $ ±s)组别 性别
(男/女)年龄
(岁)体重
(m/kg)MAP
(mmHg)心率 C 10/14 73.33±5.85 57.24±8.02 81.40±10.41 82.11±11.76 E1 11/13 69.50±6.09 60.32±10.56 83.28±12.86 83.28±16.15 E2 15/9 69.00±7.48 59.16±6.71 81.44±12.07 79.33±12.19 E3 13/11 69.83±3.06 55.42±10.08 80.22±13.01 80.06±10.82 χ2/F 2.459 0.684 0.437 0.129 0.165 P 0.483 0.572 0.606 0.903 0.925 表 2 4组患者手术情况比较(n=24,
$\bar x$ ±s)组别 手术时间 (t/min) 出血量 (V/ml) 输液量(V/ml) 诱导期咪达唑仑用量 (m/mg) 诱导期舒芬太尼用量(m/μg) C 127.33±21.39 195.72±29.38 900.00±141.42 1.99±0.16 26.53±2.14 E1 120.39±25.59 186.11±32.98 941.67±91.74 1.86±0.30 24.80±3.99 E2 108.61±16.35 213.33±19.15 916.67±213.70 1.92±0.28 25.60±3.72 E3 119.61±14.98 204.72±39.36 925.00±150.83 1.83±0.24 24.33±3.17 F 1.156 0.084 0.075 0.503 0.503 P 0.351 0.879 0.973 0.684 0.684 表 3 4组患者术后镇痛、镇静效果评价(n=24,
$\bar x $ ±s)组别 VAS评分 术后6 h
Ramsay 评分术后6 h 术后12 h 术后24 h 术后48 h C 2.60±0.55 2.40±0.55 1.20±0.84 0.40±0.55 1.17±0.41 E1 2.00±0.71 1.80±0.84 0.80±0.45 0.20±0.45 1.67±0.52 E2 1.60±0.55* 1.60±0.55 0.60±0.55 0.20±0.45 2.33±1.03* E3 1.20±0.45* 1.00±0.71* 0.60±0.55 0.20±0.45 2.5±0.55* F 5.487 0.027 1.067 0.222 5.062 P 0.009 3.963 0.391 0.879 0.009 *P<0.05,与C组比较。 表 4 4组患者术后吗啡消耗量和镇痛时长比较(n=24,
$\bar x $ ±s)组别 术后吗啡消耗量(m/mg) 镇痛持续时间(t/min) C 10.50±1.87 556.67±56.10 E1 8.17±1.17 664.33±74.68* E2 5.50±1.38* 688.33±48.34* E3 4.67±1.37* 726.67±64.39* F 8.153 9.734 P 0.001 0.004 *P<0.05,与C组比较。 表 5 4组患者术后不良反应发生率比较[例数(%),n=24]
组别 呼吸抑制 恶心 呕吐 头晕 C 0(0) 3(12.5) 2(8.33) 0(0) E1 0(0) 0(0) 0(0) 0(0) E2 1(4.17) 1(4.17) 1(4.17) 1(4.17) E3 1(4.17) 0(0) 0(0) 1(4.17) χ2 2.043 6.261 3.785 2.043 P 0.563 0.099 0.286 0.564 -
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