本文選題：骨性關(guān)節(jié)炎 + 全膝關(guān)節(jié)置換術(shù)�。� 參考：《河北醫(yī)科大學(xué)》2017年碩士論文

【摘要】：目的:對(duì)照研究在全膝關(guān)節(jié)置換術(shù)中使用不同藥物配伍成兩種“雞尾酒”配方的術(shù)后鎮(zhèn)痛療效及術(shù)后膝關(guān)節(jié)早期功能恢復(fù)情況。方法:本研究選入自2014年05月開始到2015年06月期間的68例患者,男10例,女58例,全部患者均為骨性關(guān)節(jié)炎(OA)行首次全膝關(guān)節(jié)置換術(shù)(TKA),詳細(xì)記錄:患者年齡、性別、體重;術(shù)前依據(jù)視覺模擬疼痛評(píng)分標(biāo)準(zhǔn)對(duì)患者靜息狀態(tài)下、活動(dòng)后進(jìn)行VSA評(píng)分;術(shù)前依據(jù)美國膝關(guān)節(jié)外科學(xué)會(huì)標(biāo)準(zhǔn)對(duì)患者手術(shù)側(cè)膝關(guān)節(jié)進(jìn)行KSS評(píng)分。根據(jù)全膝關(guān)節(jié)置換術(shù)中應(yīng)用“雞尾酒”鎮(zhèn)痛配方的不同,隨機(jī)將所有入選68例患者分成兩組,每組各34例,均為單側(cè)膝。手術(shù)前3天所有患者均口服塞來昔布200mg,bid。研究組(A組)雞尾酒配方為:羅哌卡因225mg、酮咯酸氨丁三醇30mg、嗎啡5mg、腎上腺素0.3mg,加生理鹽水至100ml的混合液;對(duì)照組(B組)雞尾酒配方為:羅哌卡因225mg、腎上腺素0.3mg,加生理鹽水至100ml的混合液。注射部位包括:膝關(guān)節(jié)囊、膝關(guān)節(jié)內(nèi)、外側(cè)副韌帶、股四頭肌腱切開部分、髕韌帶、髕旁支持帶、皮下組織。待完成截骨及組織平衡后將藥液總量的2/5注入到關(guān)節(jié)囊后方,剩余3/5在即將關(guān)閉手術(shù)切口前注入到膝周其它組織當(dāng)中。記錄術(shù)中所有患者的手術(shù)持續(xù)時(shí)間,術(shù)中兩組患者的膝關(guān)節(jié)腔內(nèi)均放置一根負(fù)壓引流管,術(shù)后24h換藥拔管。兩組術(shù)后均行膝關(guān)節(jié)切口周圍持續(xù)冰敷24h、低分子肝素4100IU皮下注射2周抗凝及常規(guī)抗感染治療,術(shù)后第1天開始口服塞來昔布200mg,bid,如口服藥物的止痛效果不理想,視情況采用曲馬多100mg肌注進(jìn)行處理。記錄術(shù)后48h內(nèi)各時(shí)間段的曲馬多使用次數(shù);兩組術(shù)后惡心、嘔吐、皮膚瘙癢及呼吸抑制等藥物副作用發(fā)生的情況;記錄并對(duì)比兩組全部患者依次在術(shù)后8h、16h、24h、32h、40h、48h靜息狀態(tài)下與活動(dòng)后VAS評(píng)分分?jǐn)?shù)的差異;術(shù)后24h內(nèi)關(guān)節(jié)腔引流量的差別,評(píng)估是否能提高術(shù)后出血風(fēng)險(xiǎn);應(yīng)用KSS評(píng)分標(biāo)準(zhǔn)分別記錄下所有患者術(shù)后2周時(shí)的臨床和功能KSS評(píng)分。結(jié)果:1患者基本資料分析:本研究選入的68例患者,全部為單側(cè),男10例,女58例,入院后隨機(jī)分成A組與B組,A組患者中有男性4例,女性30例,年齡53~75歲,平均(61.58±11.27)歲,體重平均(66.43±7.15)kg。B組患者男性6例,女性28例,年齡54~73歲,平均(62.6±10.40)歲,體重平均(67.24±6.37)kg。手術(shù)時(shí)間:A組(101±8.56)min;B組(101±8.56)min。對(duì)比兩組中全部患者的性別比例、體重、年齡、手術(shù)持續(xù)時(shí)間等均不具有統(tǒng)計(jì)學(xué)意義,P0.05,保證了兩組其它數(shù)據(jù)具有可對(duì)比性。2靜息狀態(tài)下和活動(dòng)后VAS評(píng)分:術(shù)前對(duì)所有入選的患者行靜息狀態(tài)下、活動(dòng)后VAS評(píng)分,經(jīng)統(tǒng)計(jì)學(xué)方法分析后結(jié)果:術(shù)前研究組(A組)與對(duì)照組(B組)靜息狀態(tài)下VAS評(píng)分6.52±0.34,6.41±0.33;活動(dòng)后的VAS評(píng)分8.52±0.39,8.41±0.42,均無顯著差異,P0.05,具有可比性。術(shù)后A組8h、16h、24h、32h、40h、48h靜息狀態(tài)下VAS評(píng)分分別為:1.89±0.36,2.63±0.31,2.98±0.43,3.12±0.44,2.71±0.32,3.01±0.31;8h、16h、24h、32h、40h、48h活動(dòng)后VAS評(píng)分分別為:5.65±0.40,5.72±0.40,5.90±0.39,6.16±0.43,5.47±0.39,5.39±0.42。B組8h、16h、24h、32h、40h、48h靜息狀態(tài)下VAS評(píng)分分別為:2.14±0.39,2.90±0.42,3.23±0.31,3.41±0.34,2.82±0.36,3.14±0.39;8h、16h、24h、32h、40h、48h活動(dòng)后VAS評(píng)分分別為:5.92±0.34,5.99±0.38,6.14±0.36,6.42±0.32,5.61±0.32,5.52±0.35。A組在8h、16h、24h、32h靜息狀態(tài)下和活動(dòng)后的VAS評(píng)分與B組的進(jìn)行對(duì)比后,均低于B組,且差別較明顯,有統(tǒng)計(jì)學(xué)意義(P0.05),術(shù)后40h后A、B兩組靜息狀態(tài)下和活動(dòng)后的VAS評(píng)分進(jìn)行對(duì)比無明顯差別,無統(tǒng)計(jì)學(xué)意義(P0.05)。3術(shù)前、術(shù)后2周KSS評(píng)分:術(shù)前A組患者KSS臨床評(píng)分、功能評(píng)分分別為:42.61±14.32,40.16±10.78,術(shù)前B組患者KSS臨床評(píng)分、功能評(píng)分分別為:45.12±10.45,36.31±15.35,結(jié)果顯示P0.05,無統(tǒng)計(jì)學(xué)差異。術(shù)后2周A組患者KSS臨床評(píng)分及功能評(píng)分分別為:85.15±3.15,55.25±5.46,術(shù)后2周B組患者KSS臨床評(píng)分及功能評(píng)分分別為:79.45±9.98,42.89±11.08,結(jié)果顯示P0.05,研究組均優(yōu)于對(duì)照組。4術(shù)后兩組患者的藥物副作用出現(xiàn)概率:兩組患者出現(xiàn)惡心、嘔吐、皮膚瘙癢及呼吸抑制等藥物副作用無顯著差異,P0.05,無統(tǒng)計(jì)學(xué)意義。5術(shù)后24h引流量:術(shù)后24h引流量研究組與對(duì)照組分別為:154.52±29.63ml和152.46±29.26ml,兩組數(shù)據(jù)分析結(jié)果均為:P0.05,無統(tǒng)計(jì)學(xué)意義。6術(shù)后各時(shí)間段的曲馬多使用次數(shù):術(shù)后4h、8h、16h、24h、48h鹽酸曲馬多使用次數(shù)進(jìn)行對(duì)比無明顯差別,P0.05,不具有統(tǒng)計(jì)學(xué)意義。結(jié)論:1手術(shù)前后對(duì)入選的全部患者手術(shù)側(cè)膝關(guān)節(jié)功能和疼痛進(jìn)行分析對(duì)比,研究組和對(duì)照組這兩方面均獲得顯著改善,但鎮(zhèn)痛效果研究組相對(duì)更佳。2研究組“雞尾酒”配方鎮(zhèn)痛效果優(yōu)于對(duì)照組“雞尾酒”配方,可以有效減輕TKA患者術(shù)后膝關(guān)節(jié)周圍疼痛,有利于患者早期進(jìn)行膝關(guān)節(jié)功能康復(fù)鍛煉,使得患者盡早回歸家庭,恢復(fù)正常生活,提高患者對(duì)全膝關(guān)節(jié)置換手術(shù)各項(xiàng)的滿意度。
[Abstract]:Objective: To study the postoperative analgesic effect of two kinds of "cocktails" combined with two kinds of "cocktails" in total knee arthroplasty and to recover the early functional recovery of the knee joint. Methods: This study was selected from 68 patients from 05 months of 2014 to 06 months in 2015, 10 men and 58 women, all of them were osteoarthritis (OA). First total knee arthroplasty (TKA) was used to record the patient's age, sex, weight, and the preoperative VSA score on the patient's resting state according to the visual analogue pain score standard, and the KSS score of the knee joint of the patients before the operation according to the standard of the American Knee Surgery Society. All 68 patients were divided into two groups randomly, 34 cases in each group were divided into two groups. All patients in each group were single knee. All patients were treated with celecoxib 200mg at 3 days before operation. The formula of cocktail of bid. study group (group A) was ropivacaine, koropalic acid three alcohol 30mg, morphine 5mg, adrenaline 0.3mg, and mixed saline to 100ml. The formula of the cocktail of the control group (group B) was ropivacaine 225mg, adrenaline 0.3mg, and mixed solution of saline to 100ml. The injection site included the knee joint capsule, the knee joint, the lateral collateral ligament, the four head of the femoral tendon, the patellar ligament, the parampatellar support band, the subcutaneous tissue. The 2/5 injection of the total amount of the medicine after the osteotomy and tissue balance were completed. After entering the joint capsule, the remaining 3/5 was injected into the other tissues of the knee before the closure of the surgical incision. The duration of the operation of all the patients during the operation was recorded. A negative pressure drainage tube was placed in the two groups of patients during the operation, and the 24h changed the tube after the operation. The two groups underwent continuous ice compress around the knee joint and low molecular liver after the operation. 4100IU was subcutaneously injected with 2 weeks anticoagulant and conventional anti infection treatment, and celecoxib 200mg was orally administered on the first day after operation. The analgesic effect of bid, such as oral medicine was not ideal, was treated with tramadol 100mg intramuscular injection. The number of Tramadol Used in each time period of 48h after the operation was recorded, and the postoperative nausea, vomiting, pruritus and respiratory inhibition in the two groups were also recorded. Such as drug side effects, record and compare the two groups of all patients in order of postoperative 8h, 16h, 24h, 32H, 40H, 48h in the resting state and the difference in the VAS score after the resting state; the difference in the volume of intra-articular cavity flow in 24h after operation to evaluate the risk of postoperative bleeding; the 2 weeks after the operation of all patients were recorded with the KSS score standard. Results: clinical and functional KSS scores. Results: the basic data of 1 patients were analyzed: 68 patients were selected in this study, all were unilateral, 10 men and 58 women. After admission, they were randomly divided into group A and group B. In group A, there were 4 men, 30 women, age 53~75, average (61.58 + 11.27) years, average weight (66.43 + 7.15) kg.B, and female 28, average weight (66.43 + 7.15) kg.B. Age 54~73 years, average (62.6 + 10.40) years, weight average (67.24 + 6.37) kg. operation time: group A (101 + 8.56) min, B group (101 + 8.56) min. compared to all patients in the two group, the sex ratio, weight, age, and the duration of operation were not statistically significant, P0.05, to ensure that two groups of other data with comparable.2 resting state and live VAS score after the operation: before the operation, all the selected patients were resting in resting state and after the activity VAS score, and the results were statistically analyzed. The VAS score of the preoperative study group (group A) and the control group (group B) was 6.52 + 0.34,6.41 + 0.33, and the VAS score after the activity was 8.52 + 0.39,8.41 + 0.42. There was no significant difference between the group and the control group. There was a comparability of P0.05, and the 8h in the A group after the operation was 8h. The VAS scores of 16h, 24h, 32H, 40H and 48h were respectively 1.89 + 0.36,2.63 + 0.31,2.98 + 0.43,3.12 + 0.44,2.71 + 0.31. 4 + 0.39,2.90 + 0.42,3.23 + 0.31,3.41 + 0.34,2.82 + 0.36,3.14 + 0.39; 8h, 16h, 24h, 32H, 40H, 48h after activity, respectively. Statistical significance (P0.05), after 40H after operation, A, B two groups in resting state and after the activity of VAS scores were not significantly different, no statistically significant (P0.05).3 preoperative, 2 weeks KSS score: preoperative A group of KSS clinical score, the function score was 42.61 + 10.78, preoperative B group clinical score, functional score, respectively The results showed that: 45.12 + 10.45,36.31 + 15.35, the results showed no statistical difference. The clinical score and function score of KSS in group A after 2 weeks were 85.15 + 3.15,55.25 + 5.46 respectively. The KSS clinical score and function score of group B patients at 2 weeks after operation were 79.45 + 9.98,42.89 + 11.08, and the results showed P0.05. The study group were all better than the two group after.4 operation in the control group. There was a probability of drug side effects: there was no significant difference in side effects between two groups of patients, such as nausea, vomiting, skin pruritus and respiratory depression, P0.05, and no significant difference in 24h flow after.5: after the operation, the 24h flow rate study group and the control group were 154.52 + 29.63ml and 152.46 + 29.26ml respectively. The results of data analysis were: P0.05, no unification. The frequency of the use of tramadol at every time after.6: no significant difference between 4h, 8h, 16h, 24h, 48h tramadol after operation, P0.05, without statistical significance. Conclusion: 1 the two aspects of the knee joint function and pain of all the patients who were selected before and after operation were analyzed and compared, the two aspects of the study group and the control group were all compared. The analgesic effect of.2 research group is better than that of the control group "cocktail" formula, which can effectively reduce the pain around the knee joint of the TKA patients after operation, and help the patients to carry out the rehabilitation of the knee joint function early, and make the patients return to the family as soon as possible and restore the normal life. High patient satisfaction with total knee arthroplasty.
【學(xué)位授予單位】：河北醫(yī)科大學(xué)
【學(xué)位級(jí)別】：碩士
【學(xué)位授予年份】：2017
【分類號(hào)】：R687.4

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