地塞米松局部浸润镇痛在择期全膝关节置换术中的应用: 双盲随机对照试验

背景与目的：全膝关节置换术与明显的相关，而有效的镇痛有利于患者满意度和功能恢复。研究表明地塞米松可能对局部麻醉起到促进作用，但当将其添加到膝关节置换术患者的局部浸润镇痛（LIA）混合物中时，这种作用尚未得到充分的研究。我们的假设是在局部浸润麻醉剂中加入地塞米松可以改善全膝关节置换术后的镇痛效果。

方法：我们对140例择期行单侧全膝关节置换术患者进行了随机双盲对照试验。将患者随机分配到2mL 0.9%生理盐水组或2mL地塞米松4 mg/mL加入LIA混合液组。我们的主要观察指标是24小时口服吗啡等效剂量。我们的次要观察指标包括短期和长期镇痛和功能结果以及不良事件。

结果：生理盐水组72例，地塞米松组68例。我们发现生理盐水组和地塞米松组的24小时吗啡消耗量相当，中位数分别为60(IQR40-105(16-230))mg和56(IQR41-75(0-300))mg(p=0.096)。与生理盐水相比，地塞米松与住院阿片类药物的总用量、需要抢救患者自控镇痛的发生率、住院时间和术后恶心的发生率有统计学意义的减少。地塞米松组患者术后第1天关节活动范围和步行距离均大于生理盐水组。在休息或活动疼痛评分、起止时间和3个月结果方面没有差异。

ABSTRACT

Background and objectives： Total knee arthroplasty is associated with significant pain, and effective analgesia is beneficial to patient satisfaction and functional outcomes. Studies have demonstrated that dexamethasone may have a facilitatory role on the action of local anesthesia, but this effect, when added to a local infiltration analgesia (LIA) mixture for patients having knee arthroplasty, is underexplored. Our hypothesis was that the addition of dexamethasone to local anesthetic infiltration would improve analgesic outcomes following total knee arthroplasty.

Methods：We performed a double-blind, randomized controlled trial of 140 patients undergoing elective, unilateral, total knee arthroplasty. Patients were randomly allocated to receive either 2 mL of saline 0.9% or 2 mL of dexamethasone 4 mg/mL added to a LIA mixture. Our primary outcome was 24 hours of oral morphine equivalent consumption. Our secondary outcomes included short-term and long-term analgesic and functional outcomes and adverse events.

Results：A total of 72 patients were included in the saline group and 68 were included in the dexamethasone group. We found comparable 24 hours of morphine consumption between saline and dexamethasone groups, with a median of 60 (IQR 40–105 (range 16–230)) mg and 56 (IQR 41–75 (range 0–300)) mg, respectively (p=0.096). Dexamethasone was associated with a statistically significant reduction in total inpatient opioid consumption, incidence of requiring rescue patient-controlled analgesia, length of hospital stay, and postoperative nausea, compared with saline. Patients in the dexamethasone group had a greater range of joint movement and distance walked on postoperative day 1 than the saline group. There were no differences in rest or active pain scores, timed up and go or 3-month outcomes.

Conclusions：Dexamethasone 8 mg was associated with no improvements in 24 hours of morphine consumption but was associated with modest improvements in short-term analgesia, short-term function, length of stay and postoperative nausea. There were no long-term benefits in the use of dexamethasone in LIA for patients undergoing total knee arthroplasty.