中醫(yī)疼痛干預在老年髖部骨折圍手術期多模式鎮(zhèn)痛中的應用

沈思思　李剛　黃任水　戈勤妹　朱黎

[摘要] 目的 觀察中醫(yī)疼痛干預的多模式鎮(zhèn)痛方案在老年髖部骨折圍手術期鎮(zhèn)痛中的效果。 方法 2016年1月～2017年6月將60例擬行手術治療的老年髖部骨折患者，隨機分為治療組與對照組，每組30例。治療組采用中醫(yī)疼痛干預的多模式鎮(zhèn)痛方案，對照組采用常規(guī)多模式鎮(zhèn)痛方案，選擇術后12 h、24 h、48 h、72 h及術后1周作為時間觀察點，應用視覺模擬評分，靜脈自控鎮(zhèn)痛泵（patient controlled intravenous analgesia，PCIA）按壓人數(shù)，鹽酸哌替啶注射人數(shù)，惡心、嘔吐等藥物反應人數(shù)及髖關節(jié)主動屈曲外展活動度等指標評價治療前后疼痛程度、阿片類藥物需求、鎮(zhèn)痛藥物不良反應及髖關節(jié)功能等方面的差異。 結果 治療組28例、對照組29例成功完成治療及隨訪。術后12 h、24 h、48 h、72 h治療組VAS評分均低于對照組（P<0.05），術后1周兩組無差異（P>0.05）。術后12 h、24 h、48 h對照組PCIA按壓人數(shù)均多于治療組（P<0.05），對照組哌替啶注射人數(shù)均多于治療組（P<0.05）。術后12 h、24 h、48 h、72 h對照組鎮(zhèn)痛藥物不良反應人數(shù)均多于治療組（P<0.05），術后1周兩組無差異（P>0.05）。術后1周治療組髖關節(jié)屈曲活動度、外展活動度均大于對照組（P<0.05）。 結論 中醫(yī)疼痛干預的多模式鎮(zhèn)痛方案能有效減輕老年髖部骨折患者圍手術期的急性疼痛，減少阿片類藥物的需求量，降低鎮(zhèn)痛藥物的不良反應，有利于髖關節(jié)功能的早期康復，對創(chuàng)建中醫(yī)骨傷科無痛病房具有積極的意義。

[關鍵詞] 鎮(zhèn)痛；髖部；骨折；老年人；圍手術期

[中圖分類號] R683.42 [文獻標識碼] B [文章編號] 1673-9701（2017）36-0141-06

[Abstract] Objective To observe the effect of multimodal analgesic program of Chinese medicine pain intervention in perioperative analgesia of elderly patients with hip fracture. Methods A total of 60 elderly patients with hip fracture scheduled for surgical treatment from January 2016 to June 2017 were randomly divided into treatment group and control group， with 30 cases in each group. The treatment group was treated with multi-modality analgesia program of Chinese medicine pain intervention. The control group was given the conventional multimodal analgesia program. The 12 h， 24 h， 48 h， 72 h after surgery and 1 week after surgery were selected as time point. The indicators including visual analogue scale， the number of patients receiving controlled intravenous analgesia （patient controlled intravenous analgesia， PCIA） pressure， the number of patients receiving pethidine hydrochloride， the number of patients responding to nausea and vomiting， hip joint flexion and outreach activity were used to evaluate the differences in the degree of pain before and after treatment， opioids demand， analgesic drug adverse reactions and hip joint function. Results 28 cases in the treatment group and 29 cases in the control group were successfully treated and followed up. The VAS scores of the treatment group at 12 h， 24 h， 48 h and 72 h after operation were lower than those of the control group（P<0.05）. There was no difference between the two groups at 1 week after operation（P>0.05）. The number of PCIA compression in the control group was more than that of the treatment group at 12 h， 24 h and 48 h after operation（P<0.05）. The number of pethidine injection in the control group was more than that of the treatment group（P<0.05）. The number of patients with adverse reactions of analgesic drugs in the control group was more than that in the treatment group at 12 h， 24 h， 48 h and 72 h after operation（P<0.05）. There was no difference between the two groups after 1 week（P>0.05）. The flexion and outreach activities of the hip joint in the treatment group were greater than those in the control group at one week after operation（P<0.05）. Conclusion The multimodal analgesic program of traditional Chinese medicine （TCM） intervention can effectively reduce the perioperative acute pain in elderly patients with hip fracture， reduce the demand of opioids and the side effects of analgesic drugs. It facilitates the early rehabilitation of hip joint function， and has a positive meaning to create a painless ward orthopedic ward.

[Key words] Analgesia； Hip fracture； Elderly； Perioperative period

老年髖部骨折是骨科的常見病，多主張手術治療，骨折術后疼痛多為劇烈的急性疼痛，對機體刺激大。圍手術期疼痛控制可減輕患者痛苦，降低手術并發(fā)癥，提高術后髖關節(jié)功能。多模式鎮(zhèn)痛（multimodal analgesia，MMA）是一種新的鎮(zhèn)痛管理理念和方法，廣泛用于骨科術后鎮(zhèn)痛并取得了良好的效果，但阿片類藥物參與的多模式鎮(zhèn)痛，因易引起各系統(tǒng)不良反應而不能滿足病人舒適鎮(zhèn)痛的需求。中醫(yī)對疼痛的診療具有獨特的理論體系和豐富的治療方法，中藥內服、耳穴壓豆、穴位理療等中醫(yī)疼痛干預措施已在臨床中廣泛應用。……