本文選題：股神經(jīng)阻滯 + 膝關節(jié)置換術��； 參考：《鄭州大學》2014年博士論文

【摘要】：研究背景膝關節(jié)置換術(total knee arthroplasty,TKA)是嚴重膝骨關節(jié)病變最有效的治療方法。該手術創(chuàng)傷較大、術后疼痛劇烈且患者多為老年,因腰椎退行性病變較多及圍術期抗凝藥物的常規(guī)使用,全身麻醉已成為重要選擇之一。術后的劇烈疼痛嚴重影響著患者的功能鍛煉和康復效果,因此TKA術后良好的鎮(zhèn)痛對患者最終關節(jié)運動動能的恢復尤為重要。國內(nèi)外大量臨床研究顯示不論是單次還是連續(xù)股神經(jīng)阻滯股神經(jīng)阻滯都能有效改善TKA患者術后鎮(zhèn)痛的效果、降低圍術期阿片類藥物用量、加快患者術后功能鍛煉和恢復、降低不良反應的發(fā)生率等,由于操作簡便、安全性較高等特點,在TKA患者中應用廣泛。但是臨床上實施股神經(jīng)阻滯的時間并不一致,術前或術后都有。術前和術后不同時間的股神經(jīng)阻滯對TKA患者術后鎮(zhèn)痛的效果有無影響;如果在術前應用股神經(jīng)阻滯,對TKA患者是否具有超前鎮(zhèn)痛作用,目前尚不明確。研究指出骨科手術、術后疼痛和年齡60歲都是術后認知功能障礙(postoperative cognitive dysfunction,POCD)發(fā)生的危險因素之一,因此預防和減少全麻下TKA老年患者POCD的發(fā)生十分必要。炎性反應可能是POCD發(fā)生的關鍵環(huán)節(jié),早年曾有學者提出外周神經(jīng)阻滯技術可能給炎性反應的治療帶來新的希望,動物實驗和臨床研究已發(fā)現(xiàn)外周神經(jīng)阻滯能更好的改善術后疼痛和炎性反應。股神經(jīng)阻滯能否通過改善全麻下TKA老年的術后疼痛和炎性反應從而對術后早期認知功能產(chǎn)生影響,尚不明確。研究目的通過手術前后不同時間的股神經(jīng)阻滯對全麻下TKA老年患者術后鎮(zhèn)痛效果的影響,擬探討股神經(jīng)阻滯是否具有超前鎮(zhèn)痛作用;通過比較股神經(jīng)阻滯、閉孔神經(jīng)阻滯及對照組對全麻下TKA老年患者早期POCD發(fā)生率的影響,擬探討股神經(jīng)阻滯是否能改善全麻下TKA老年患者早期POCD的發(fā)生率;通過比較股神經(jīng)阻滯及對照組對全麻下TKA老年患者術后早期炎性反應和神經(jīng)損傷的影響,擬探討股神經(jīng)阻滯影響全麻下TKA老年患者術后早期認知功能的可能機制,為TKA老年患者的疼痛管理和POCD預防提供新的思路。研究方法 1.采用隨機數(shù)字表法,分為3組:對照組(Ⅰ組)不實施股神經(jīng)阻滯;術前股神經(jīng)阻滯組(Ⅱ組)于麻醉誘導前行超聲引導下單次股神經(jīng)阻滯;術后股神經(jīng)阻滯(Ⅲ組)于手術結束即刻行超聲引導下單次股神經(jīng)阻滯。術后三組患者均行PCIA鎮(zhèn)痛。分別記錄兩組患者術后2h、6h、12h、24h、48h、72h時靜息狀態(tài)VAS評分與術后12h、24h、48h、72h時運動狀態(tài)VAS評分,及術后24 h內(nèi)PCIA中的舒芬太尼用量、PCIA的有效按壓次數(shù)(D1)和實際按壓次數(shù)(D2),并計算D1/D2;記錄術后24 h內(nèi)不良反應發(fā)生情況。2.采用隨機數(shù)字表法,分為3組:對照組(Ⅰ組)、股神經(jīng)阻滯組(Ⅱ組)和閉孔神經(jīng)阻滯組(Ⅲ組)。Ⅱ和Ⅲ組患者分別于麻醉誘導前行患側股神經(jīng)和閉孔神經(jīng)阻滯,空白對照組不實施股神經(jīng)阻滯。分別記錄兩組患者術中的麻醉時間、麻醉藥用量、手術時間及出血量;并記錄入室、開始手術及隨后每30min患者的MAP及HR至手術結束;記錄每組患者術中血管活性藥使用率;分別測試3組患者在術前1d和術后3、7d的MMSE評分并計算術后3、7d的POCD發(fā)生率。3.采用隨機數(shù)字表法,將其分為2組:對照組(Ⅰ組)和股神經(jīng)阻滯組(Ⅱ組)。Ⅱ組于麻醉誘導前行患側股神經(jīng)阻滯。所有患者分別于麻醉開始前、手術結束時、術后2h時抽取動脈血樣1ml行血氣分析記錄PH值、lac值及血糖值;分別于術前1d(T0)、術后2h(T1)、術后6h(T2)、術后12h(T3)、術后1d(T4)時采集外周靜脈血5ml,由經(jīng)過培訓且不參與麻醉的同一測試者采用酶聯(lián)免疫吸附法檢測血漿TNF-α和IL-6水平;并于分別于術前1d(T0)、術后1d(T4)、術后3d(T5)和術后7d(T6)時采集外周靜脈血5ml,采用酶聯(lián)免疫吸附法檢測血清Aβ和Tau蛋白濃度。研究結果 1.與對照組比較,術前股神經(jīng)阻滯組和術后股神經(jīng)阻滯組術后2h、6h、12h靜息狀態(tài)VAS評分與術后12h運動狀態(tài)VAS評分降低、術后24 h內(nèi)PCIA的舒芬太尼用量減少、D1/D2升高、惡心嘔吐的發(fā)生率也降低(P0.05);但術前股神經(jīng)阻滯組和術后股神經(jīng)阻滯組兩組間比較,術后不同時點的靜息和運動狀態(tài)VAS評分、術后24 h內(nèi)PCIA的舒芬太尼用量及不良反應的發(fā)生率差異無統(tǒng)計學意義(P0.05)。2.與對照組比較,股神經(jīng)阻滯組患者麻醉時間、手術時間、出血量及術中丙泊酚的總用量差異無顯著性(P0.05),但術中瑞芬太尼的總用量顯著減少(P0.05),而閉孔神經(jīng)阻滯組的麻醉時間、手術時間、出血量及術中麻醉藥總用量差異無顯著性(P0.05);三組患者從麻醉開始到手術結束各時間點的MAP、HR的動態(tài)變化及術中血管活性藥物使用率比較差異無顯著性(P0.05);術后3d時,與空白對照組比較,股神經(jīng)阻滯組的MMSE評分顯著增高,POCD的發(fā)生率顯著降低,而閉孔神經(jīng)阻滯組的MMSE評分和POCD發(fā)生率差異無顯著性(P0.05);術后7d時,三組的MMSE評分和POCD發(fā)生率比較差異無顯著性(P0.05)。3.與對照組比較,股神經(jīng)阻滯組患者在手術結束及術后2h的血糖值顯著降低(P0.05),而兩組患者術前、手術結束及術后2h的血氣分析中PH值及l(fā)ac值比較差異無統(tǒng)計學意義(P0.05);與術前T0時刻比較,術后T1、T2、T3和T4時刻兩組患者的血漿TNF-α和IL-6水平均顯著升高(P0.05);與Ⅰ組比較,術前T0時刻兩組患者血漿TNF-α和IL-6水平差異無顯著性,但Ⅱ組患者在術后的T1、T2、T3和T4時刻血漿TNF-α和IL-6水平顯著降低(P0.05);兩組患者在術后T4和T5時刻血漿Aβ和Tau蛋白水平與術前T0時刻比較顯著升高(P0.05),但Ⅱ組患者在T4和T5時刻血漿的Aβ和Tau蛋白水平與Ⅰ組比較顯著降低(P0.05),而兩組患者在T6時刻血漿的Aβ和Tau蛋白水平差異無顯著性(P0.05)。研究結論 1.股神經(jīng)阻滯能改善全麻下TKA老年患者術后早期PCIA的鎮(zhèn)痛效果,降低術中和術后早期阿片類藥物用量,但是無超前鎮(zhèn)痛作用。2.股神經(jīng)阻滯能降低全身麻醉下TKA老年患者術后早期認知功能障礙的發(fā)生率。3.股神經(jīng)阻滯能抑制全麻下TKA老年患者術后早期炎性反應。4.股神經(jīng)阻滯能通過改善全麻下TKA老年患者術后早期的疼痛和炎性反應,從而減輕神經(jīng)損傷,改善術后早期的認知功能。
[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.
【學位授予單位】：鄭州大學
【學位級別】：博士
【學位授予年份】：2014
【分類號】：R614.2

【參考文獻】

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