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Guidelines for Perioperative Pain Management in Total Knee Arthroplasty in China (2022)
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摘要: 全膝关节置换术(total knee arthroplasty, TKA)是目前治疗终末期膝关节疾病的主要方法。TKA术后常伴有中度至重度的疼痛，严重影响患者术后康复、患者满意度和总体疗效。多模式镇痛被认为是缓解TKA术后疼痛的理想方案。目前尚无TKA围手术期疼痛管理指南。经中华医学会骨科学分会关节外科学组、北京医学会骨科专业委员会关节外科学组批准及专家讨论，采用推荐意见的分级评估、制定及评价方法及国际实践指南报告规范，遴选出最为关注的20个临床问题，通过证据检索、证据质量评价及确立推荐意见和强度，采用德尔菲法进行4轮函询，最终形成20条推荐意见。本指南的制定旨在提高TKA围手术期疼痛管理的规范化和标准化。Abstract: Total knee arthroplasty (TKA) is currently the main treatment for end-stage knee disease. Moderate to severe pain often occurs after TKA, which seriously affects postoperative rehabilitation, patient satisfaction and overall outcome. Multimodal analgesia is considered as the ideal solution. There is no guideline for perioperative pain management in TKA in China. On the basis of the discussions by experts from Joint Surgery Branch of Chinese Orthopaedic Association and Joint Surgery Branch of Beijing Orthopaedic Association, the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to rate the quality of evidence and the strength of recommendations. Reporting Items for Practice Guidelines in Healthcare (RIGHT) checklist was strictly followed to report the guideline. Finally, 20 evidence-based recommendations were formulated based on the 20 most concerning clinical problems among orthopaedic surgeons according to evidence retrieval, quality evaluation of body evidence, and establishment of direction and intensity of recommendations through four rounds of Delphi surveys. This guideline was developed to improve the standardization of perioperative pain management in TKA in China.
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Key words:
- total knee arthroplasty /
- perioperative period /
- analgesia /
- evidence-based medicine /
- guidelines
作者贡献：翁习生、王坤正牵头制订指南框架；彭慧明负责组建指南制订工作组；指南制订工作组成员负责查阅文献、撰写指南初稿；张丽帆负责方法学指导及文献评价；其他成员对指南内容进行审校、修订和补充。利益冲突：所有参与制订该指南的专家组成员均声明不存在利益冲突附：《中国全膝关节置换术围手术期疼痛管理指南(2022)》项目组成员指南指导委员组邱贵兴 中国医学科学院 北京协和医学院 北京协和医院裴福兴 四川大学华西医院王坤正 西安交通大学第二附属医院指南共识专家组 (以姓氏汉语拼音排序)蔡谞 清华大学附属北京长庚医院曹光磊 首都医科大学附属北京宣武医院曹永平 北京大学第一医院柴伟 中国人民解放军总医院骨科医学部陈继营 中国人民解放军总医院骨科医学部崔旭蕾 中国医学科学院 北京协和医学院 北京协和医院冯宾 中国医学科学院 北京协和医学院 北京协和医院关振鹏 北京大学首钢医院郭艾 首都医科大学附属北京友谊医院郭万首 中日友好医院黄迅悟 中国人民解放军总医院第九医学中心林剑浩 北京大学人民医院林源 首都医科大学附属朝阳医院马璐璐 中国医学科学院 北京协和医学院 北京协和医院梅丹 中国医学科学院 北京协和医学院 北京协和医院申乐 中国医学科学院 北京协和医学院 北京协和医院孙祯杰 北京市第六医院田华 北京大学第三医院翁习生 中国医学科学院 北京协和医学院 北京协和医院姚建华 中国人民解放军总医院第七医学中心张洪 中国人民解放军总医院骨科医学部张洪美 中国中医科学院望京医院张星火 首都医科大学附属北京潞河医院张耀南 北京医院张轶超 首都医科大学附属北京同仁医院周一新 北京积水潭医院指南制订工作组 (以姓氏汉语拼音排序)李曾 广东省人民医院李辉 西安交通大学医学院附属红会医院李涛 青岛大学附属医院崂山院区李子全 中国医学科学院 北京协和医学院 北京协和医院彭慧明 中国医学科学院 北京协和医学院 北京协和医院沈松坡 首都医科大学同仁医院孙洋 吉林大学第二医院王英杰 中国医学科学院 北京协和医学院 北京协和医院肖刻 四川大学华西医院徐溢明 中国医学科学院 北京协和医学院 北京协和医院朱威 中国医学科学院 北京协和医学院 北京协和医院指南外审组 (以姓氏汉语拼音排序)曹力 新疆医科大学附属第一医院胡懿郃 浙江大学医学院附属第一医院黄伟 重庆医科大学附属第一医院蒋青 南京大学医学院附属鼓楼医院雷光华 中南大学湘雅医院刘军 天津医院刘培来 山东大学齐鲁医院吕松岑 哈尔滨医科大学附属第二医院毛新展 中南大学湘雅二医院钱齐荣 海军军医大学第二附属医院(上海长征医院)尚希福 中国科学技术大学附属第一医院(安徽省立医院)沈彬 四川大学华西医院史占军 南方医科大学附属第一医院孙水 山东第一医科大学附属省立医院(山东省立医院)孙炜 深圳市第二人民医院王飞 河北医科大学附属第三医院王金成 吉林大学第二医院王英振 青岛大学附属医院夏亚一 兰州大学第二医院肖骏 华中科技大学同济医学院附属同济医院徐耀增 苏州大学第一附属医院许鹏 西安交通大学医学院附属红会医院许伟华 华中科技大学同济医学院附属协和医院严世贵 浙江大学医学院附属第二医院杨佩 西安交通大学第二附属医院姚振钧 复旦大学中山医院尹宗生 安徽医科大学第一附属医院郑稼 河南省人民医院郑秋坚 广东省人民医院周宗科 四川大学华西医院指南秘书彭慧明 中国医学科学院 北京协和医学院 北京协和医院李曾 广东省人民医院方法学专家张丽帆 中国医学科学院 北京协和医学院 北京协和医院刘晓清 中国医学科学院 北京协和医学院 北京协和医院执笔彭慧明 中国医学科学院 北京协和医学院 北京协和医院翁习生 中国医学科学院 北京协和医学院 北京协和医院 -
表 1 本指南中涉及的证据质量分级与定义
证据质量分级 定义 高(A) 非常有把握观察值接近真实值 中(B) 对观察值有中等把握: 观察值有可能接近真实值, 但也有可能差别很大 低(C) 对观察值的把握有限: 观察值可能与真实值有很大差别 极低(D) 对观察值几乎没有把握: 观察值与真实值可能有极大差别 
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表 2 本指南中涉及的推荐强度分级与定义
推荐强度分级 定义 强(1) 明确显示干预措施利大于弊或弊大于利 弱(2) 不能确定临床决策或干预措施的利弊或无论质量高低的证据均显示利弊相当 专家建议 基于非直接证据或专家意见、经验形成的推荐
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表 3 《中国全膝关节置换术围手术期疼痛管理指南(2022)》推荐意见
条目 推荐意见 推荐强度分级 证据质量分级 推荐1 现阶段无明确证据表明术前宣教可以减轻全膝关节置换术后疼痛, 但可以缓解患者围手术期焦虑, 改善关节功能, 故推荐术前开展健康教育以帮助全膝关节置换术后康复 1 C 推荐2 建议术前使用预防镇痛, 可以减轻全膝关节置换术后疼痛, 目前对于药物的构成尚无标准方案 2 C 推荐3 现阶段无明确证据表明术前预康复可以减轻全膝关节置换术后疼痛, 但其可能有助于术后膝关节功能的恢复, 故建议对患者给予预康复以利于全膝关节置换术后加速康复 2 C 推荐4 推荐尽量减少全膝关节置换术中应用止血带的时间, 以减少患者术后疼痛, 降低其他不良事件发生的风险 1 B 推荐5 推荐术中常规使用关节周围混合药物注射以减轻全膝关节置换术后疼痛及减少阿片类药物的使用 1 A 推荐6 对于无禁忌证的患者, 推荐在关节周围混合药物注射药物配方中添加长效糖皮质激素以减轻全膝关节置换术后疼痛, 并不增加围手术期并发症发生率 1 B 推荐7 单次股神经阻滞相比关节周围混合药物注射在术后镇痛效果、吗啡用量及并发症发生率方面无显著差异, 前者影响术后康复, 后者简便经济, 建议在相同条件下优先选择关节周围混合药物注射 2 C 推荐8 收肌管阻滞相比股神经阻滞在术后镇痛效果及并发症发生率方面无显著差异, 但收肌管阻滞对术后股四头肌肌力影响较小, 在加速康复外科背景下, 建议优先选择收肌管阻滞, 也可联合使用关节周围混合药物注射 2 C 推荐9 由于全膝关节置换术围手术期全身应用糖皮质激素镇痛的有效剂量及其安全性仍存在争议, 故不建议将其常规加入全膝关节置换术多模式镇痛方案 2 B 推荐10 对无禁忌证的患者, 推荐术后常规使用非甾体抗炎药镇痛, 优先选择环氧合酶-2抑制剂 1 A 推荐11 不建议常规将对乙酰氨基酚纳入全膝关节置换术后多模式镇痛方案 2 B 推荐12 不建议全膝关节置换术后常规使用静脉患者自控镇痛, 对于无条件开展区域阻滞镇痛或不适宜局部浸润镇痛的病例, 仍可选用静脉患者自控镇痛 2 B 推荐13 不推荐将加巴喷丁类药物(如加巴喷丁、普瑞巴林等)常规纳入全膝关节置换术后多模式镇痛方案 1 C 推荐14 不推荐全膝关节置换术后常规使用阿片类药物镇痛, 在补救镇痛情况下可使用阿片类药物 专家建议 无 推荐15 不建议将椎管内置管镇痛常规纳入全膝关节置换术后多模式镇痛方案 2 B 推荐16 建议仅在有条件开展耳贴镇痛的机构, 术后辅助使用耳穴贴以减轻全膝关节置换术后早期疼痛 2 D 推荐17 建议仅在有条件开展针灸镇痛的机构, 术后辅助使用针灸/电针灸以减轻全膝关节置换术后早期疼痛 2 D 推荐18 推荐在围手术期改善患者睡眠以减轻全膝关节置换术后早期疼痛 1 B 推荐19 建议在有条件开展冷疗的机构, 在全膝关节置换术后对术侧膝关节应用冷疗以减轻术后疼痛 2 B 推荐20 建议在有条件开展神经肌肉电刺激的机构, 在术后4~6周内当其他治疗不能获得满意镇痛效果时, 可辅助使用神经肌肉电刺激以减轻患肢疼痛 2 B
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表 4 本指南干预措施推荐意见及证据质量分级
强推荐 不推荐 建议使用 不建议使用 1.术前镇痛健康教育(C)
2.尽量减少应用止血带的时间(B)
3.常规使用关节周围混合药物注射镇痛(A)
4.关节周围混合药物注射配方中加入糖皮质激素(B)
5.常规使用非甾体抗炎药(A)
6.改善睡眠质量(B)1.常规使用加巴喷丁类药物镇痛(C)
2.术后常规使用阿片类药物镇痛(无)1.术前预防镇痛(C)
2.术前预康复(C)
3.收肌管阻滞镇痛(C)
4.耳穴镇痛(D)
5.针灸镇痛(D)
6.术后冷疗(B)
7.经皮神经肌肉电刺激(B)1.常规使用股神经阻滞镇痛(C)
2.常规全身应用糖皮质激素镇痛(B)
3.常规使用对乙酰氨基酚镇痛(B)
4.术后常规使用静脉患者自控镇痛(B)
5.术后常规使用椎管内置管镇痛(B)
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