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目的 探索右美托咪啶复合罗哌卡因用于股神经连续阻滞术后镇痛能否改善老年单膝置换术后睡眠质量.方法 入选北京积水潭医院2016年11月至2017年6月160例60岁以上、拟行单膝置换术的老年患者.术中腰麻,术后随机接受0.2％罗哌卡因250 ml复合5μg/kg右美托咪啶连续股神经阻滞(持续输注5 ml/h,右美托咪啶输注速度0.1 μg·kg-1 h-1)镇痛(试验组)或单纯0.2％罗哌卡因连续股神经阻滞镇痛(对照组).观察术后4、24、48 h静息和运动时疼痛评分,术后前3天睡眠质量评分和术后谵妄发生情况.结果 试验组术后第1天、第2天睡眠质量评分分别为2(1～4)、2(1～4)分,对照组分别为4(2 ～8)、4(2 ～7)分,试验组明显低于(即优于)对照组,差异均有统计学意义(Z=-4.597、-4.183,均P＜0.05).试验组术后24、48 h静息时疼痛评分分别为2(1～2)、2(1～4)分,低于对照组的3(2 ～5)、3(2 ～6)分,差异均有统计学意义(Z=-6.671、-4.010,均P＜0.05).试验组术后4、24、48 h运动时疼痛评分分别为1(1～2)、3(2～4)、3(2 ～3)分,低于对照组的3(2 ～4)、5(3 ～6)、5(4 ～7)分,差异均有统计学意义(Z=-7.167、-6.824、-7.473,均P＜0.05).试验组术后前3天谵妄发生率为5％,低于对照组的15％,差异有统计学意义(x2 =4.444,P＜0.05).两组间不良事件发生率差异均无统计学意义(均P＞0.05).结论 对于单膝关节置换手术后老年患者,应用右美托咪啶复合罗哌卡因连续股神经阻滞可提高术后睡眠质量,改善镇痛效果、减少谵妄发生.

Objective To investigate the effect of dexmedetomidine adding to ropivacaine for continuous femoral nerve block on the improvement of postoperative sleep quality in elderly patients after total knee arthroplasty.Methods One hundred and sixty patients aged 60 years or older in Jishuitan Hospital scheduled for single total knee arthroplasty between Nov.2016 and Jun.2017 were recruited.All patients received spinal anesthesia and were randomized to receive either combined ropivacaine and dexmedetomidine (0.2％ ropivacaine 250 ml and 5 μg/kg dexmedetomidine,at a rate of 5 ml/h or 0.1 μg · kg-1 · h-1 dexmedetomidine,dexmedetomidine group) or only ropivacaine (0.2％ ropivacaine,at a rate of 5 ml/h,controlled group) for continuous femoral nerve block as postoperative analgesia after surgery.The severity of postoperative pain was assessed with numeric rating scale at 4,24,and 48 hours after surgery both at rest and with movement.Subjective sleep quality and delirium were evaluated daily during the first 3 days postoperatively.Results The subjective sleep quality scores were 2 (1-4),2 (1-4) and 4 (2-8),4(2-7) in dexmedetomidine group and controlled group respectively on the 1 st and 2nd days after surgery.The scores of dexmedetomidine group were much better than those of controlled group (Z =-4.597,-4.183,both P ＜ 0.05).The difference was statistically significant.The NRS pain scores at rest were 2 (1-2),2 (1-4),and 3 (2-5),3 (2-6) in dexmedetomidine group and controlled group respectively at 24 and 48 hours after surgery.The scores of dexmedetomidine group were lower than those of controlled group (Z =-6.671,-4.010,both P ＜ 0.05).The difference was statistically significant.The NRS pain scores with movement were 1(1-2),3(2-4),3(2-3) and 3(2-4),5(3-6),5(4-7)in dexmedetomidine group and controlled group respectively at 4,24 and 48 hours after surgery.The scores of dexmedetomidine group were lower than those of controlled group (Z =-7.167,-6.824,-7.473,all P ＜ 0.05).The difference was statistically significant.The incidence of 3-day delirium was lower in dexmedetomidine group (5％) than that in controlled group (15％) (x2 =4.444,P ＜ 0.05).The difference was statistically significant.There were no significant differences between groups regarding the incidences of adverse events.Conclusion Dexmedetomidine combined with ropivacaine for continuous femoral nerve block may improve subjective sleep quality,postoperative analgesia,and reduce delirium in the elderly after total knee arthroplasty.