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局部浸潤麻醉 (LIA) 和選擇性初次髖關節和膝關節置換術後有效緩解疼痛的新技術 - 創新研究

穆罕默德·薩哈布

背景： 

選擇性全膝關節置換術 (TKR) 和全髖關節置換術 (THR) 後的急性疼痛控制通常很差，並且與長期持續性疼痛障礙有關。中度至重度疼痛通常在醫療程序後的最初 48 小時內進行，需要不同的疼痛方法，例如持續控制無痛和多模式鎮靜無痛。局部浸潤麻醉（LIA）策略是目前解決圍手術期不適感的一種既定方法；儘管如此，到目前為止，我們認為已經有詳細的衝突證據。在一項正在進行的 29 項檢查探索 LIA 在 TKR 中的應用的調查中，LIA 發展成為一種改善疼痛控制的受保護程序（Gibbs DMR 2012）。我們建立了 LIA 方法，結合關節內導管，允許注射新型混合物 (NM) 在術後持續混合。預防性止痛是一種抗傷害治療，是在醫療程序之前開始的治療，目的是防止醫療程序期間發生的割傷和火燒傷引起的疼痛加劇。除了在醫療程序之前進行指導之外，還可以在術後早期使用預防性止痛。這種防禦性影響是透過傷害性框架上先發制人地消除疼痛而產生的。為了緩解疼痛感，文字記錄了一些方法，包括藥物和課程。

Joint substitution medical procedures are considered as one of the most excruciating orthopedic techniques. This excruciating method is the aftereffect of lacking and inadequately rewarded postoperative torment after significant joint substitution medical procedure. This agony scene must be ideal tended to in light of the fact that not exclusively does this fundamentally drag out the restoration procedure, yet in addition purposes the expanded danger of different inconveniences. If not tended to inside time or without legitimate methodology, these postoperative excruciating scenes can advance into constant torment, which in the long run drags out the general length of hospitalization and cost. The excursion to accomplish the total and long haul help with discomfort starts before the medical procedure is performed. A significant premise to accomplish long haul help with discomfort and practical recuperation after the joint medical procedure includes adequate peri-employable absense of pain. One of the significant angles to accomplish effective result after joint medical procedure is the early joint preparation with the commencement of non-intrusive treatment. A few new medications and novel procedures to enhance the post-employable agony post-medical procedure are being presented each year, yet the greater part of the patients despite everything wind up experiencing extraordinary torment following medical procedure which frequently advances into constant torment.

Arthroscopic knee medical procedure has gotten progressively well known in present day orthopedics. In any case, the post-employable knee torment the board including early help and agony free postoperative consideration to the patient stays a test to a few clinicians. Now and again, torment the board in itself has become a need for the board as a childcare methodology. Tenacious agony after knee arthoplasty stays an uncertain issue for some patients. Torment is considered as an exceptionally emotional occasion since everybody has an alternate recognition and edge of agony. What's more, hence, it turns out to be hard to normalize any agony system for a specific medical procedure. A few factors that cause knee torment, which incorporate aggravation of free sensitive spots of the joint case, synovial tissue, front fat cushion.

The point of neighborhood penetration is to anesthetize sensitive spots in a limited territory of tissue by the infusion of neighborhood sedatives close by. This stands as opposed to fringe nerve obstructs, in which nerve axons are the objective and the infusion may occur in a region expelled from the careful site (eg, brachial plexus hinder for hand medical procedure). The profundity of the region to be worked on commonly decides the necessary degree of invasion. For shallow skin methods, for example, stitching of slashes and skin biopsies, subcutaneous or intradermal penetration is adequate. Increasingly broad tasks may request invasion into muscle, belt, and other profound tissues. Two general methodologies exist for anesthetizing skin and subcutaneous tissue. The first includes infusing neighborhood sedative legitimately into the line of cut and close by tissues, successfully flooding the individual nearby sensitive spots to deliver sedation. This can be exceptionally successful, yet may require huge volumes of neighborhood sedative to accomplish total inclusion.

Aims and Objectives:

In this study we find out the results on our experience using LIA in addition to the Novel Techniques and Proprietary NM developed in Leeds-Bradford and infiltrated at 4-5 mls/hour for 48 hours post surgery.

Materials and Methods:

Between October 2013 and October 2015, 62 patients undergoing primary TKR were prospectively followed up. Three groups of patients were studied. All patients studied had spinal anaesthesia (SA) with 300-400mcg diamorphine.

Group 1.  GA. No LIA and no NM. 20 patients.

Group 2.   SA plus NM for 48 hours post operatively with catheter placed anteriorly under the patella.  21 patients.

Group 3.  SA plus LIA plus NM for 48 hours post operatively with catheter placed posteriorly in the knee joint.  21 patients.

Between June 2011 and July 2014, 173 consecutive patients undergoing primary THR using the posterior approach were also prospectively followed up.

Results and complications: 

The patients without LIA or NM required more morphine in the initial 12 hours postoperative period than different gatherings. 70% (n=14) of these gathering 1 patients required 10mg morphine following TKR contrasted with just 2% (n=1) of patients requiring 10mg of morphine when LIA and NM were utilized. The expanded morphine necessity proceeded for 48 hours postoperatively in bunch 1, while none of the patients in bunches 2 or 3 required morphine following 36 hours. Factual investigation uncovered no distinction of morphine necessities with various catheter situation. Less patients experienced sickness and heaving or urinary maintenance in the gathering with LIA and NM (p-esteem <0.05, Mann-Whitney test). There were no contaminations DVT or different difficulties in any of the gatherings.

Conclusion:

這項研究表明，接受 TKR 治療的患者在 48 小時內接受 LIA 和 NM 治療後，在此期間所需的嗎啡量顯著減少。這種優勢一般在手術後的最初24小時內開始，並維持48小時。與其他組別相比，同時使用 LIA 和 NM 時，需要鎮靜止痛的患者較少。對於需要使用高達 20 毫克嗎啡的患者，最值得注意的中心性是在 0-12 小時（χ2(2) = 46.713，p = 0.000）；需要使用 30 毫克嗎啡的患者為 0-12 小時（χ2(2) = 46.310，p = 0.000）。