鞘内吗啡联合布比卡因脂质体收肌管阻滞对全膝关节置换术患者术后镇痛及阿片类药物节约效应的影响

doi:10.3969/j.issn.1006-5725.2025.19.019

Abstract

Abstract:

Objective To evaluate the effects of low-dose intrathecal morphine （ITM） combined with liposomal bupivacaine adductor canal block （LB-ACB） on postoperative analgesia and opioid-sparing efficacy in patients undergoing total knee arthroplasty （TKA）. Methods In this randomized， double-blind， controlled trial， 80 TKA patients were allocated to either an intervention group （ITM 0.1 mg + LB-ACB， n = 40） or a control group （intrathecal saline + LB-ACB， n = 40）. Primary outcomes included resting/movement visual analog scale （VAS） scores at 6， 12， 24， 48， and 72 hours postoperatively， 48-hour morphine consumption， time to first rescue analgesia， and incidence of complications. Results （1） The intervention group showed significantly lower resting and movement VAS scores at 6， 12， 24， and 48 hours postoperatively compared with controls （all P < 0.05）， except at 72 hours （P > 0.05）. （2） The intervention group had a significant reduction in 48-hour morphine consumption （4.58 ± 1.0 mg vs. 9.34 ± 4.8 mg， P = 0.027）， a significantly lower rescue analgesia rate （15.0% vs. 47.5%， P = 0.002）， and a significantly prolonged time to first rescue analgesia （48.8 ± 7.5 h vs. 14.5 ± 5.5 h， P < 0.001）. （3） The intervention group demonstrated a significant decrease in the incidence of nausea （from 15.0% to 35.0%， P = 0.039） and vomiting （from 10.0% to 27.5%， P = 0.045）， but no significant differences were observed in the incidences of pruritus， urinary retention， or motor block （all P > 0.05）. Conclusion Low-dose ITM （0.1 mg） combined with LB-ACB significantly enhances early postoperative analgesia， reduces opioid consumption， and decreases nausea/vomiting risk， without increasing the risks of other complications. This regimen aligns with enhanced recovery after surgery （ERAS） principles.

Key words: intrathecal morphine, liposomal bupivacaine, adductor canal block, total knee arthroplasty, multimodal analgesia, opioid-sparing effect

CLC Number:

R614.2

Chenglong LI,Lun WAN,Lisha HUANG,Yucheng ZHAN,Shiying LONG,Zheng. WANG. Effect of intrathecal morphine combined with liposomal bupivacaine adductor canal block on postoperative analgesia and opioid⁃sparing effect in patients undergoing total knee arthroplasty[J]. The Journal of Practical Medicine, 2025, 41(19): 3083-3088.

Figures/Tables 6

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References 30

[1]	PRICE A J， ALVAND A， TROELSEN A， et al. Knee replacement［J］. Lancet， 2018，392（10158）：1672-1682. doi:10.1016/s0140-6736(18)32344-4 doi: 10.1016/s0140-6736(18)32344-4
[2]	LO L W T， SUH J， CHEN J Y， et al. Early Postoperative Pain After Total Knee Arthroplasty Is Associated With Subsequent Poorer Functional Outcomes and Lower Satisfaction［J］. J Arthroplasty， 2021，36（7）：2466-2472. doi:10.1016/j.arth.2021.02.044 doi: 10.1016/j.arth.2021.02.044
[3]	YOU D， QIN L， LI K， et al. A meta-analysis on advantages of peripheral nerve block post-total knee arthroplasty ［J］. Korean J Pain， 2021，34（3）：271-287. doi:10.3344/kjp.2021.34.3.271 doi: 10.3344/kjp.2021.34.3.271
[4]	DOMAGALSKA M， WIECZOROWSKA-TOBIS K， REYSNER T， et al. Periarticular injection， iPACK block， and peripheral nerve block in pain management after total knee arthroplasty： A structured narrative review ［J］. Perioper Med （Lond）， 2023， 12（1）：59. doi:10.1186/s13741-023-00346-8 doi: 10.1186/s13741-023-00346-8
[5]	BERGESE S D， RAMAMOORTHY S， PATOU G， et al. Efficacy profile of liposome bupivacaine， a novel formulation of bupivacaine for postsurgical analgesia［J］. J Pain Res， 2012，5（3）：107-116.
[6]	CHEN C M， YUN A G， FAN T. Continuous Bupivacaine Infusion versus Liposomal Bupivacaine in Adductor Canal Block for Total Knee Arthroplasty［J］. J Knee Surg， 2022，35（11）：1268-1272. doi:10.1055/s-0040-1722661 doi: 10.1055/s-0040-1722661
[7]	郭小花，陈茜，赵晴，等. 布比卡因脂质体腹横肌平面阻滞在剖宫产术后镇痛中的疗效与安全性［J］. 实用医学杂志， 2025， 41（11）： 1724-1729.
[8]	WANG L M， ZHANG Z， YAO R Z， et al. The Role of Intrathecal Morphine for Postoperative Analgesia in Primary Total Joint Arthroplasty under Spinal Anesthesia： A Systematic Review and Meta-Analysis ［J］. Pain Med， 2021， 22（7）：1473-1484. doi:10.1093/pm/pnab089 doi: 10.1093/pm/pnab089
[9]	TAO Y， ZHENG S Q， XU T， et al. Median effective volume of ropivacaine 0.5% for ultrasound-guided adductor canal block［J］. J Int Med Res，2018，46（10）：4207-4213. doi:10.1177/0300060518791685 doi: 10.1177/0300060518791685
[10]	QUAYE A， MCALLISTER B， GARCIA J R， et al. A prospective， randomized trial of liposomal bupivacaine compared to conventional bupivacaine on pain control and postoperative opioid use in adults receiving adductor canal blocks for total knee arthroplasty［J］. Arthroplasty， 2024，6（1）：6. doi:10.1186/s42836-023-00226-y doi: 10.1186/s42836-023-00226-y
[11]	MYLES P S， MYLES D B， GALAGHER W， et al. Measuring acute postoperative pain using the visual analog scale： The minimal clinically important difference and patient acceptable symptom state［J］. Br J Anaesth， 2017， 118（3）：424-429. doi:10.1093/bja/aew466 doi: 10.1093/bja/aew466
[12]	国家卫生健康委加速康复外科专家委员会骨科专家组，中国研究型医院学会骨科加速康复专业委员会，中国康复技术转化及促进会骨科加速康复专业委员会. 骨科加速康复围手术期疼痛管理专家共识［J］. 中华骨与关节外科杂志， 2022，15（10）：739-745.
[13]	YAKSH T L， RUDY T A. Analgesia mediated by a direct spinal action of narcotics［J］. Science， 1976，192（4246）：1357-1358. doi:10.1126/science.1273597 doi: 10.1126/science.1273597
[14]	RAWAL N. Intrathecal opioids for the management of post-operative pain［J］. Best Pract Res Clin Anaesthesiol， 2023， 37（2）：123-132. doi:10.1016/j.bpa.2023.01.001 doi: 10.1016/j.bpa.2023.01.001
[15]	BROWN B， CHEOK T S， WORSLEY D， et al. Comparative efficacy of intrathecal morphine and adductor canal block in the knee arthroplasty population： A retrospective multi-centre cohort study［J］. BMC Anesthesiol， 2024， 24（1）：365. doi:10.1186/s12871-024-02740-1 doi: 10.1186/s12871-024-02740-1
[16]	TANG Y， TANG X， WEI Q， et al. Intrathecal morphine versus femoral nerve block for pain control after total knee arthroplasty： A meta-analysis［J］. J Orthop Surg Res， 2017，12（1）：125. doi:10.1186/s13018-017-0621-0 doi: 10.1186/s13018-017-0621-0
[17]	CAI A L， LIU S J， WU B， et al. Intrathecal versus local infiltration analgesia for pain control in total joint arthroplasty［J］. J Orthop Surg Res， 2020，15（1）：110. doi:10.1186/s13018-020-01627-4 doi: 10.1186/s13018-020-01627-4
[18]	GEHLING M， TRYBA M. Risks and side-effects of intrathecal morphine combined with spinal anaesthesia： A meta-analysis［J］. Anaesthesia， 2009， 64（6）：643-651. doi:10.1111/j.1365-2044.2008.05817.x doi: 10.1111/j.1365-2044.2008.05817.x
[19]	JANIAK M， KOWALCZYK R， GORNIEWSKI G， et al. Efficacy and Side Effect Profile of Intrathecal Morphine versus Distal Femoral Triangle Nerve Block for Analgesia following Total Knee Arthroplasty： A Randomized Trial［J］. J Clin Med， 2022，11（23）：6945. doi:10.3390/jcm11236945 doi: 10.3390/jcm11236945
[20]	KUKREJA P， STREETZEL C， SHORT R T， et al. Intrathecal Morphine Use Improves Postoperative Analgesia and Reduces Opioid Consumption in Patients Undergoing Total Knee Arthroplasty Under Spinal Anesthesia： A Retrospective Study［J］. Cureus， 2023，15（8）： e43039.
[21]	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. 中国全膝关节置换术围手术期疼痛管理指南（2022）［J］. 协和医学杂志， 2022， 13（6）：965-985.
[22]	TUBOG T D， HARENBERG J L， BUSZTA K， et al. Use of Nalbuphine for Treatment of Neuraxial Opioid-Induced Pruritus： A Systematic Review and Meta-Analysis［J］. AANA J， 2019， 87（3）：222-230. doi:10.1016/j.jopan.2018.06.098 doi: 10.1016/j.jopan.2018.06.098
[23]	OKUTANI H， VECCHIO S LO， ARENDT-NIELSEN L. Mechanisms and treatment of opioid-induced pruritus： Peripheral and central pathways［J］. Eur J Pain， 2024， 28（2）：214-230. doi:10.1002/ejp.2180 doi: 10.1002/ejp.2180
[24]	LAVAND'HOMME P M， KEHLET H， RAWAL N， et al. Pain management after total knee arthroplasty： PROcedure SPEcific Postoperative Pain ManagemenT recommendations［J］. Eur J Anaesthesiol， 2022， 39（9）：743-757. doi:10.1097/eja.0000000000001691 doi: 10.1097/eja.0000000000001691
[25]	ZHAO D， LI P. Efficacy of adding infiltration between the popliteal artery and the capsule of the posterior knee （IPACK） to adductor canal block and local infiltration analgesia in total knee arthroplasty： A retrospective cohort study［J］. J Orthop Surg （Hong Kong）， 2024，32（2）：1-9. doi:10.1177/10225536241265445 doi: 10.1177/10225536241265445
[26]	MCCARTHY D， MCNAMARA J， GALBRAITH J， et al. A comparison of the analgesic efficacy of local infiltration analgesia vs. intrathecal morphine after total knee replacement： A randomised controlled trial［J］. Eur J Anaesthesiol，2019， 36（4）：264-271. doi:10.1097/eja.0000000000000943 doi: 10.1097/eja.0000000000000943
[27]	ESSVING P， AXELSSON K， ÅBERG E， et al. Local infiltration analgesia versus intrathecal morphine for postoperative pain management after total knee arthroplasty： A randomized controlled trial［J］. Anesth Analg，2011，113（4）：926-933. doi:10.1213/ane.0b013e3182288deb doi: 10.1213/ane.0b013e3182288deb
[28]	SALWAN A， PISULKAR G L， TAYWADE S， et al. A Review on the Efficacy of Extraosseous Local Infiltration of Multimodal Drug Cocktail for Pain Management After Total Knee or Hip Arthroplasty［J］. Cureus， 2022， 14（10）： e30451.
[29]	HU D， ONEL E， SINGLA N，et al. Pharmacokinetic profile of liposome bupivacaine injection following a single administration at the surgical site［J］. Clin Drug Investig， 2013， 33（2）：109-115. doi:10.1007/s40261-012-0043-z doi: 10.1007/s40261-012-0043-z
[30]	GOVIL N， TRIPATHI M， GOYAL T， et al. Comparison of two different volumes of 0.5% ropivacaine used in ultrasound-guided adductor canal block after knee arthroplasty： A randomized， blinded， controlled noninferiority trial［J］. J Anaesthesiol Clin Pharmacol，2022，38（1）：84-90. doi:10.4103/joacp.joacp_112_20 doi: 10.4103/joacp.joacp_112_20

一般资料	对照组（n = 40）	观察组（n = 40）	t/χ² 值	P值
年龄（x ± s）/岁	66.6 ± 6.3	66.3 ± 6.5	0.244	0.808
性别/例			0.805	0.370
男	24	19
女	16	21
BMI（x ± s）/（kg/m²）	26.2 ± 1.9	25.6 ± 2.2	1.398	0.166
ASA分级/例			0.490	0.783
Ⅰ级	5	6
Ⅱ级	27	24
Ⅲ级	8	10

时间点		对照组（n = 40）	观察组（n = 40）	Z值	P值
6 h	静息	3.0（2.0，3.0）	1.0（1.0，2.0）	-5.17	0.000
6 h	运动	3.0（3.0，3.8）	3.0（2.0，3.0）	-3.05	0.002
12 h	静息	3.0（2.0，3.0）	2.0（2.0，2.8）	-2.35	0.019
12 h	运动	4.0（3.0，4.0）	3.0（3.0，4.0）	-2.07	0.038
24 h	静息	3.0（3.0，4.0）	3.0（2.0，3.8）	-2.07	0.019
24 h	运动	4.0（4.0，5.0）	4.0（3.0，4.0）	-2.07	0.038
48 h	静息	3.0（3.0，4.0）	3.0（3.0，3.0）	-3.48	0.001
48 h	运动	4.0（3.0，4.0）	3.0（3.0，4.0）	-3.33	0.001
72 h	静息	3.0（2.2，4.0）	3.0（3.0，4.0）	-0.387	0.669
72 h	运动	3.0（3.0，4.0）	4.0（3.0，4.0）	-0.828	0.408

并发症	对照组（n = 40）	观察组（n = 40）	χ² 值	P值
恶心	14（35.0）	6（15.0）	4.267	0.039
呕吐	11（27.5）	4（10.0）	4.021	0.045
皮肤瘙痒	3（7.5）	5（12.5）	0.556	0.456
尿潴留	2（5.0）	1（2.5）	0.346	0.556

Effect of intrathecal morphine combined with liposomal bupivacaine adductor canal block on postoperative analgesia and opioid⁃sparing effect in patients undergoing total knee arthroplasty

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