徐阳 白伦浩

[摘要] 目的 观察帕瑞昔布钠术前预处理对全膝关节置换术（TKA）术后镇痛及炎性因子的影响。 方法 选择2014年1月～2015年6月间收治的104例行TKA的骨性关节炎患者随机分为观察组（54例）和对照组（50例），观察组麻醉诱导前30 min静脉注射40 mg帕瑞昔布钠，对照组不进行预处理，两组麻醉方法均为喉罩插管静吸复合全身麻醉。采用视觉模拟评分法（VAS法）评估患者术前与术后不同时点静息状态下疼痛程度，记录术后48 h内自控镇痛泵（PCA）按压次数与盐酸曲马多注射液使用量，此外，术前与术后不同时点采血检测外周血炎性因子水平。 结果 观察组术后4 h、8 h、12 h VAS评分均显著低于对照组（P<0.05）。术后24 h内，观察组PCA按压次数与盐酸曲马多使用量均显著低（少）于对照组（P<0.05），观察组术后48 h内曲马多用量明显少于对照组（P<0.05）。观察组术后6 h、12 h IL-6[（31.8±9.2） vs （43.4±11.5）pg/mL、（16.7±5.2） vs （22.8±6.8）pg/mL]、TNF-α[（59.2±15.1） vs （75.4±10.8）pg/mL、（47.3±11.2） vs （57.7±13.6）pg/mL]、CRP[（21.4±4.2） vs （28.2±5.0）mg/L、（15.2±3.5） vs （18.4±4.1）mg/L]水平均显著低于对照组（P<0.05）。两组术后不良反应发生率差异无统计学意义（P>0.05）。 结论TKA术前患者采用帕瑞昔布钠预处理能明显增强术后24 h镇痛水平，减少镇痛药用量，并能有效减轻术后炎性应激反应。

[关键词] 全膝关节置换术；帕瑞昔布钠；镇痛；视觉模拟评分；炎性因子

[中图分类号] R614；R687.4 [文献标识码] B [文章编号] 1673-9701（2016）09-0099-04

[Abstract] Objective To observe effects of preoperative parecoxib sodium pretreatment on postoperative analgesia and inflammatory factors for TKA patients. Methods A total of 104 osteoarthritis patients who underwent TKA from January 2014 to June 2015 were selected and randomly divided into the observation group （n=54） and control group （n=50）， and patients in the observation group were injected intravenously with 40 mg parecoxib sodium at 30 min before anesthesia induction， control group without pretreatment， the anesthetic method of two groups was Laryngeal mask intubation inhalation composite general anesthesia. Visual analogue scale（VAS） was used to evaluate patients' pain degree preoperatively and postoperatively under surprise status at different time points， and pump controlled analgesia（PCA） pressing frequence and tramadol hydrochloride usage within 48 h after operation were recorded. In addition， peripheral inflammatory factor levels on different observing point were examined and compared. Results The postoperative VAS scores of the observation group were significantly higher than those of the control group 4 h， 8 h， 12 h（P<0.05）. The PCA pressing frequencies and tramadol hydrochloride usage within 24 h postoperation of the observation group were significantly lower than those of the control group （P<0.05）， the tramadol hydrochloride usage within 48 h postoperatively in the observation group was significantly less than that in the control group either（P<0.05）. At 6 h and 12 h after operation， the levels of IL-6[（31.8±9.2） vs （43.4±11.5） pg/mL， （16.7±5.2） vs （22.8±6.8）pg/mL]， TNF-α[（59.2±15.1） vs （75.4±10.8）pg/mL， （47.3±11.2） vs （57.7±13.6）pg/mL] and CRP[（21.4±4.2） vs （28.2±5.0）mg/L， （15.2±3.5） vs （18.4±4.1）mg/L] in the observation group were significantly lower than those in the control group（P<0.05）. There were no statiatical significant differences in the incidence of postoperative adverse reactions between two groups（P>0.05）. Conclusion TKA patients received parecoxib sodium pretreatment can significantly enhance analgesic efficacy within 24 h postoperatively， reduce analgesics dosage， and can effectively reduce postoperative inflammatory stress response.

[Key words] Total knee arthroplasty； Parecoxib sodium； Analgesia； Visual analogue scale； Inflammatory factors

全膝关节置换术（total knee arthroplasty，TKA）是大型骨科手术，手术本身创伤大，会促使机体释放大量炎性物质，使外周和中枢神经系统痛觉敏化，术后会伴有剧烈疼痛，严重影响膝关节术后的早期功能锻炼和手术效果[1]。研究证实，术前超前镇痛能抑制交感神经的敏感化并减少炎症介质产生，达到减少术后疼痛的目的[2]。帕瑞昔布钠为新一代非甾体类高选择性环氧化酶（COX）抑制剂，临床研究证实[3，4]，帕瑞昔布钠在各种大中型手术后的多模式镇痛中效果显著，但对帕瑞昔布钠在大型骨科手术术前超前镇痛的报道较少，尤其是对术后炎性因子影响的报道更为罕见，笔者通过随机对照研究，对TKA患者术前采用帕瑞昔布钠预处理的镇痛效果及对血清炎性因子的影响进行了观察，现报道如下。……