全膝关节置换术后多模式镇痛中非选择与选择性COX-2抑制剂的对比应用研究

目的：评价全膝关节置换术后病人早期功能锻炼过程中应用选择性环氧化酶-2（COX-2）抑制剂帕瑞昔布钠与非选择性环氧化酶（COX）抑制剂氟比洛芬酯之间的镇痛效果是否存在差异,以及对早期功能锻炼结果的影响。方法：前瞻性、随机、双盲、平行对照研究,根据纳入/排除标准,连续选取2009年6月至2010年3月在我科行单侧人工全膝关节置换术的病人60名。手术均采用腰麻联合硬膜外阻滞麻醉,由同一组手术医师完成,术中假体安装前关节周围软组织注射＂鸡尾酒＂镇痛液（罗哌卡因注射液150mg＋肾上腺素（1：1000）0.5ml,由生理盐水稀释为100ml）。手术结束后进行病人自控静脉镇痛（PCIA）。术后当天患者在护士的指导下进行股四头肌收缩功能锻炼及直腿抬高功能锻炼。术后第一天起行膝关节被动伸屈功能锻炼（CPM）及主动伸屈功能锻炼。术后第3至5天患者停PCIA镇痛后,进行试验干预。帕瑞昔布钠组给予注射用帕瑞昔布钠40mg,静注1/12小时。氟比洛芬酯组给予氟比洛芬酯注射液100mg,静注1/12小时。观察病人术后第3至5天静息状态下和活动锻炼时膝关节最大主动屈曲时的疼痛强度（VAS评分）,手术侧膝关节的主动伸屈活动度及术后1月复查时的手术侧膝关节的主动伸屈活动度,KSS评分,术后第2天与第6天的血红蛋白值。结果：两组病人给药后在静息状态及膝关节最大主动屈曲时,在不同时间点的VAS评分、膝关节主动活动度及术后1月患者膝关节的主动活动度和KSS评分的差异均无统计学意义（P〉0.05）。应用抗凝治疗后,帕瑞昔布钠组患者血红蛋白下降值与氟比洛芬酯组存在差异（P=0.042）。结论：尚不能认为人工全膝关节置换术后多模式镇痛中同时抑制COX-1和COX-2与选择性抑制COX-2之间存在差异。但应用选择性COX-2抑制剂（帕瑞昔布钠）镇痛更安全,因其有利于减少全膝关节置换术后患者抗凝治疗过程中的隐性失血。

The Effect of Parecoxib Sodium Versus Flurbiprofen Axetil in Multimodal Pain Management in Patients Undergoing Total Knee Arthroplasty

Objective：To evaluate the pain relief effect of parecoxib sodium（selective cyclooxygenase-2 inhibitor） versus flur-biprofen axetil（non-selective cyclooxygenase inhibitor） used in patients undergoing total knee arthroplasty in early short-term fuctional recovery.Methods：This is a prospective,randomized,double-blind,parallel and controlled study.According to inclusion/exclusion crite-ria,60 patients undergoing unilateral total knee arthroplasty were randomly assigned to one of the 2 groups from June,2009 to March,2010.All the operations were performed by the same group of surgeons under combined spinal and epidural anesthesia.Before the knee prothesis were installed,the intra-articular ＂cocktail anagesic injection＂ was given to every patient,which contained 150 mg ropivacaine,0.5 ml epinephrine（1：1000）.All patients received patient-controlled intravenous analgesia（PCIA） at the end of the operation,and got the exercise training from the nurses after the operation.Clinical trial interventions were given from the third postoperative day to fifth post-operative day,when the PCIA was stopped.The trial group received parecoxib sodium（40 mg,every 12 hours）,while the control group received flurbiprofen axetil（100 mg,every 12 hours）.The pain score（visual analog scale,VAS） at rest and during activity,active range of motion（ROM） of the operated knee from the third to the fifth postoperative day,active ROM of the operated knee as well as Knee Society Score（KSS） on postoperative day 30 and the hemoglobin of the second and the sixth postoperative day were observed.Results：There were no significant differences in such outcome measures as VAS scores at rest and during activity,active ROM of the operated knee from the third to the fifth postoperative day,and active ROM of the operated knee as well as Knee Society Score on postoperative day 30.With anticoagulant therapy,the difference of hemoglobin between the second and the sixth postoperative day in the parecoxib sodium group was lower than that in the flurbiprofen axetil group.Conclusions：This study did not reveal that there is better pain relief effect of parecoxib sodium than flurbiprofen axetil used in patients undergoing total knee arthroplasty in early short-term fuctional recovery.But it is safer to use parecoxib sodium for pain management with anticoagulant therapy because it can decrease the risk of hidden blood loss.