高剂量激素用于治疗全髋关节置换术后疼痛高反应患者的疗效： 一项随机双盲试验
贵州医科大学 麻醉与心脏电生理课题组
翻译：胡廷菊 编辑：张中伟 审校：曹莹
尽管已实施多模式镇痛，全髋关节置换术仍可引发中到重度疼痛。疼痛爆发或术前阿片类药物治疗可能增加术后疼痛。术前糖皮质激素治疗可改善全髋关节置换术后疼痛，但对于疼痛高反应患者激素使用剂量与疗效相关的研究甚少。
我们设计了一项随机双盲对照试验，术前使用1mg/kg高剂量地塞米松或0.3mg/kg中剂量地塞米松静脉注射，用于术前疼痛评分大于20或常规使用阿片类药物的88例拟行全髋关节置换的患者。主要结局是术后24小时行走5米发生中到重度疼痛的比例。次要结局包括夜间休息和被动抬腿时疼痛，C反应蛋白，阿片类药物使用，睡眠质量，恢复质量-15量表，阿片类药物相关抑郁量表，再入院和并发症。
高剂量组术后24小时步行中到重度疼痛减少（高剂量组vs中剂量组，49%vs79%，P<0.01），术后24小时及48小时抬腿时疼痛也减轻（14%vs29%，P=0.02，12%vs31%，P=0.03）。高剂量组24小时及48小时C反应蛋白减少（P<0.01）。恢复质量改善（P<0.01）。
比较术前使用0.3mg/kg或1mg/kg地塞米松静脉注射减少全髋关节置换术后患者24小时中到重度疼痛，改善高疼痛反应患者的恢复，没有明显不良反应。
原始文献来源：
Nielsen NI, Kehlet H, Gromov K, , et al.High-dose steroids in high pain responders undergoing total knee arthroplasty: a randomised double-blind trial.[J]Br J Anaesth. 2022 Jan;128(1):150-158. doi: 10.1016/j.bja.2021.10.001.
High-dose steroids in high pain responders undergoing total knee arthroplasty: a randomised double-blind trial
Abstract
Background: : Total knee arthroplasty (TKA) is associated with moderate-to-severe postoperative pain despite multimodal opioid-sparing analgesia. Pain catastrophising or preoperative opioid therapy is associated with increased postoperative pain. Preoperative glucocorticoid improves pain after TKA, but dose-finding studies and benefit in high pain responders are lacking.
Methods:A randomised double-blind controlled trial with preoperative high-dose intravenous dexamethasone 1 mg/kg or intermediate-dose dexamethasone 0.3 mg /kg in 88 patients undergoing TKA with preoperative pain catastrophising score >20 or regular opioid use was designed. The primary outcome was the proportion of patients experiencing
moderate-to-severe pain (VAS >30) during a 5 m walk 24 h postoperatively. Secondary outcomes included pain at rest during nights and at passive leg raise, C-reactive protein, opioid use, quality of sleep, Quality of Recovery-15 and OpioidRelated Symptom Distress Scale, readmission, and complications.
Results: Moderate-to-severe pain when walking 24 h postoperatively was reduced (high dose vs intermediate dose, 49% vs 79%; P<0.01), along with pain at leg raise at 24 and 48 h (14% vs 29%, P¼0.02 and 12% vs 31%, P¼0.03, respectively). Creactive protein was reduced in the high-dose group at both 24 and 48 h (both P<0.01). Quality of Recovery-15 was also improved (P<0.01).
Conclusion:When compared with preoperative dexamethasone 0.3 mg /kg i.v., dexamethasone 1 mg/ kgreduced moderate-to-severe pain 24 h after TKA and improved recovery in high pain responders without apparent side-effects.
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