The Clinical Study Of Lumbar Plexus Combined With Local Anesthesia For Unilateral Knee Arthroplasty Analgesia

Pain is the unavoidable trouble in Artificial joint surgery. Total Knee Arthroplasty is very effective means, it can effectively make patients after knee joint function restored,and the pain is eased in the late of the severe osteoarthritis joint disease.Early postoperative functional exercise after Total Knee Arthroplasty (TKA) is help for the patients’ early rehabilitation.however,there are 60% of postoperative with moderate severe pain and 30% with severe pain.Moreover, pain will cause flustered,elevation of blood pressure,disturbance of glucose metabolism, and be unhelpful for postoperative functional exercise,so good postoperative analge-sia is benifit for recovery. We should find a good maner for analgesia in unilateral knee replacement.There are many maners for TKA postoperative analgesia,such as Oral analgesics,patient controlled intravenous analgesia、continuous epidural analgesia、continuous subarachnoid analgesia、continuous epidural analgesia、 peripheral nerve blocks、peripheral nerve blocks and so on. But each kind of analgesic way has its insufficiency and side effects.Anteromedial knee is dominated by from the femoral nerve,cutaneous branches saphenous nerve,lower patellar branch of the saphenous nerve,posterolateral dominated by peroneal nerve, peroneal nerve articular branch,and posterior domin- ated by femoral cutaneous nerve,patellar from plexus.Beside the femoral cutaneous Nerve, peroneal nerve that from the bottom of the sacral plexus,others are sent from the lumbar plexus among the nerves above.From the side of innervation around the knee,it may be considered continuous plexus combined nerve block analge sia, but continuous sciatic nerve block has the risk of reducing lower extremity.Musc-le strength,damage to the sciatic nerve and so on, which combined nerve block analg-esia is still controversial.Single lumbar plexus combined sciatic nerve block can provide up to 8h postoperative analgesia, can also be used in fascia chamber indwelling catheter after continuous lumbar plexus block analgesia, both reducing the amount of systemic intravenous opioids, and can avoid analgesia for postoperative anticoagulation of intra-spinal canal hematoma intra-spinal canal risk.Local injection of the knee,as a relatively new way of total knee replacement analgesic,is less adverse reactions, effective,has and reduce the use of postoperative analgesics which reduce related adverse reactions.It is a promising approach for total knee replacement analgesic. Tissues injection around joints comparing with other with other analgesic injection mode can be looked straight bet, simple operation,selective injection according to the surgical lesion.since drug onset directly to the site of action,it can reduce the dosage to reduce adverse drug reactions, and improve the accuracy and effectiveness of injection that can prevent pain from the source to produce,preserve muscle, is cond-ucive to postoperative functional exercise, and reduce venous stasis of blood flow, reduce the probability of thrombosis.A single joint surrounded by local infiltration is conducive to compensate continuous lumbar plexus block, and can avoid to the risk of reducing lower extremity muscle strength damaging to the sciatic nerve.Therefore, the study of continuous Lumbar plexus block combined with local infiltration analgesia is a necessary way after TKA.In order to study the effect of lumbar plexus block combined with local infiltration anesthesia in unilateral knee replacement analgesia, which compared with intravenous analgesia, epidural analgesia, continuous lumbar plexus analgesia.Meanwhile, we can know the effect of long term pain control in half year for patients comparing with continuous lumbar plexus block combined with local anesthesia analgesia, simple continuous lumbar plexus block analgesia, intravenous analgesia, epidural analgesiaObjective:To study the effectiveness, safety, and the incidence of adverse reactions of lumbar plexus block combined with local infiltration anesthesia in unilateral knee replacement analgesia,which compared with intravenous analgesia, epidural analgesia, continuous lumbar plexus analgesia.Meanwhile, we can know the effect of long term pain control in half year for patients comparing with continuous lumbar plexus block combined with local anesthesia analgesia, simple continuous lumbar plexus block analgesia, intravenous analgesia, epidural analgesia.Methods:1)Subjects selected:The pharmacokinetic study was approved by the Guangzhou General Hospital Of Guangzhou Military Command Ethics Committee.The standards of subjects selected:120 patients for selective operation of unilateral knee replacement,55 male and 65 female,aged and body mass between 40～88 years old and 51～80kg, ASA Ⅰ～Ⅲ level.According to the digital method, the subjects are randomly divided into four groups of postoperative analgesia(n=30):continuous lumbar plexus combined with local infiltration analgesia group (LP+local infiltration), continuous lumbar plexus analgesia (LP), epidural analgesia (PCEA) and intravenous analgesia (PCIA).Gave their signed informed consent to participate in the study,subjects receive comprehensive physical examination, determination of liver and kidney function, and the ECG in the hospital before anesthesia.Subjects are selected in line with the conditions.The following conditions are excluded:preoperative nervous and mental diseases, ropivacaine allergy,opioid abusive or addicted history, obviously abnormal result of coagulation function test. 2)Selection of Anesthetic Methods:1. The subjects,seclected to groups of LP+local infiltration and LP, connect the MP30 (PHILIPS) in monitoring of pulse oxygen saturation (SpO2), electrocardiogram (ECG), a noninvasive blood pressure (NBP) in the operation room. The subjects are open peripheral vein,received infusion of lactated Ringer’s solution,have oxygen mask, inject dexmedetomidine hydrochloride 0.5～1 μg/kg in 10min through injection pump, and then to maintain calm by 0.2～0.7 μg/kg.h continuous infusion, until the end of operation. Guided by Stimuplex HNS 12 types of nerve stimulator (B.Braun company, Germany), we use 10cm catheter type electrical nerve stimulation needle length (B.Braun company, Germany) for lumbar plexus-sciatic nerve block. ① The lumbar plexus block:Patients with uninjured decubitus,bend knees in toward abdomen, take the intersection of the connection of iliac crest points and spine.The point that 3cm away to the caudal and 5cm to the affected side is puncture point. Needling slow vertically from the point, the musculi quadriceps femoris twitch, until below 0.3mA muscle don’t twitch,0.3～0.5mA muscle twitch, withdrawing without blood, injection volume of test don’t abnormal.After slow injecting 30ml 0.33% ropivacaine (no more than 1.5 mg. Kg -l), we fix indwelling catheter with catheter depth of 7～8cm in the LP+local infiltrationand LP group,which used for postoperative analgesia.②Sciatic nerve block:take the midpoint of the connection of posterior superior iliac spine and greater trochanter to do vertical line, the intersection of the vertical line and the connection of the greater trochanter and the sacral hiatus is the puncture site. Slowly vertically needling from this point, gastrocnemius twitchs until the muscle below 0.3mA don’t twitch,0.3～0.5mA have muscle trembling, withdrawing no blood, no abnormal amount after the test injection,then slowly inject 30ml 0.33% ropivacaine(no more than 1.5 mg. kg-1).2. Selected patients in epidural analgesia group with unilateral total knee replacement are connected MP30 (PHILIPS Company) monitor to monitor the pulse of blood saturation (SpO2), electrocardiogram (ECG), noninvasive blood pressure (NBP) after entering operation room,and open peripheral intravenous,infused Ringer lactate, oxygen mask, used the subarachnoid space-combined epidural block (CSEA), which choosed L3～4 puncture gap and injected to the head 1.8ml 0.5% bupivacaine in the subarachnoid space. After administration,routine post epidural catheter and regulate sensory block to T8-10, intermittent epidural give 3～5ml 2% lidocaine depending on the patient pain surgery recovery until the end of surgery.3.Selected injects in intravenous analgesia group,the patients in unilateral total knee arthroplasty is used inhalational combined with general anesthesia, which is connected MP30 (PHILIPS Company) monitor to monitor the pulse of blood saturation (SpO2), electrocardiogram (ECG), noninvasive blood pressure (NBP), end-tidal carbon dioxide partial pressure (PETCO2) after entering operation room. Open a peripheral vein, oxygen mask to remove nitrogen, respectively use Marsh, Minto mode to intravenous target-controlled infusion of 2～3 ng.ml-1 propofol and 3 ～4 ng.ml-1 remifentanil, intravenous injection of 0.15 mg.kg-1 cis-atracurium as anesthesia induction until unconsciousness, bave endotracheal intubation after muscle relaxation, anesthesia is maintained with continued sevoflurane (1～2MAC),3～5 ng.ml-1 remifentanil,an intermittent bolus of 5mg/times cis-atracurium, maintain the depth of anesthesia, anesthesia machine parameter settings are:tidal volume 8ml/ kg, respiratory rate 12 beats/min, respiratory parameters regulating the maintenance of end-tidal carbon dioxide partial pressure of 35-45mmHg, oxygen flequence of 21 /min, surgery awake extubation. 3)Analgesic Methods:Continuous lumbar plexus block combined with local infiltration anesthesia using disposable portable elastomeric infusion system infuse ropivacaine via lumbar plexus continuous and around the knee joint single topical block. After the lumbar plexus anesthesia,it is connected to the disposable catheter elastic portable infusion system within which the infusion pump of 0.2% ropivacaine 270ml, continuous infusion rate for 5ml.h-1. Local block recipe is ropivacaine 100mg, ketorolac tromethamine hydrochloride 30mg and adrenaline 1mg, with 0.9% sodium chloride injection diluted to 150ml,that compose cocktail analgesic mixture. The mixture analgesic in the posterior capsule, the medial and lateral collateral ligament total multi-point inject 60ml by the surgeon before the implants (Be careful not to inject popliteal artery);and multi-point inject altogether 50ml before closed the joint capsule in the distal quadriceps patellar ligament and joint capsule,the other 40ml multi-point injected in the synovium, periosteum and subcutaneous layers of tissue,pay attention to avoid skin injection around the incision.Continuous lumbar plexus block using disposable portable elastomeric infusion system infuse ropivacaine via lumbar plexus continuous. After the lumbar plexus anesthesia,it is connected to the disposable catheter elastic portable infusion system within which the infusion pump of 0.2% ropivacaine 270ml, continuous infusion rate for 5ml.h-1.Intravenous analgesia use patient-controlled intravenous analgesia(PCIA):Phar-maceutical formulations:fentanyl 18μg/kg+ droperidol 5mg+ saline, in total of 100ml. Load capacity:0.05mg fentanyl and lmg droperidol. Background dose is 2ml. h-1, an additional dose is 2ml/times, locking time is 15min.Loading dose slowly intravenous inject 30 minutes before the end of surgery.Epidural analgesia group is indwelling epidural catheter after epidural anesthesia.Epidural analgesia program (PCEA):Drug formulation:4mg morphine +3mg droperidol+200mg ropivacaine+ saline,in total of 100ml. Load capacity:lmg morphine and lmg droperidol. Background dose is 2ml/h, an additional dose is 2ml/ times, locking time is 15min. Load 30 minutes before the end of surgery slow. Loading dose slowly intravenous epidural 30 minutes before the end of surgery.All patients were open analgesia pump at the end of surgery. 4)Data processing:Each subject assess pain score at rest and in motion via VAS pain patient assessment at different time points (after 8 (T1),16 (T2),24 (T3),32 (T4),40 (T5) and 48h (T6)), use the modified Bromage score to assess the degree of lower extremity muscle strength, and calculate the mean and standard deviation,use SPSS 13.0 statistical software to analyze data. Measurement data depress as mean standard deviation (x±s),. Groups were compared using t test. Count data were compared with χ2 test, P<0.05 was considered statistically significant. ResultsThe modified Bromage score of muscle strength of lower limbs was 0 points during postoperative analgesia in the four group, which means no lower extremity block, comparison between groups wasn’t statistically significant (P> 0.05);the VAS score of the each observation point of rest and exercise in four group, LP+local infiltration group were less than 3, and lower than that of group PCIA, PCEA and group LP (P< 0.05); the LP+local infiltration analgesia group nausea (10%), vomiting (0%), urinary retention (0%), pruritus (0%), dizziness (0%) rates lower than that in PCIA group (30%,18%,18%,10%,30%) and PCEA (33%,27%,23%,7%, 30%) (P< 0.05) during Postoperative analgesia;And LP+local infiltration analgesia group nausea (10%), vomiting (0%), urinary retention (0%), pruritus (0%), dizziness (0%) incidence rate compared with LP (10%,0%,0%,0%,0%) was statistically significant (P> 0.05); at the same time the degree of pain control in half year long term,LP+local infiltration analgesia group was superior to the PCEA, LP and PCIA analgesia group (P< 0.05). Conclusion:The group of LP combined local infiltration analgesia can effectively control the resting pain and motion pain of the injured knee during postoperative analgesia. It can improve the satisfaction of patients, and do not reduce the muscle tension of lower limbs. The way not only to decrease the amount of opioid drugs, but also to reduce the incidence of headache nausea, vomiting, uroschesis, dizzy and itch of skin, etc. The degree of long-term pain control in six mount is also better than PECA,LP and PCIA.