| Background:The hip joint is one of the largest joints in human body with fine mobility and is connected with extensive blood vessels and nerve muscle tissue. At present, clinical common joint arthroplasty includes hip arthroplasty and artificial knee joint replacement. Artificial hip replacement (hip arthroplasty, HA) is currently the most widely accepted and the most successful prosthesis replacement surgery, which has become one of the medical technology which is of most social benefit and economic benefits.The ages of patients receiving hip replacement surgery range from 20 to 80 years old. There is even a small number of patients can reach the 90-year-old. They may suffer from old femoral neck fracture, ischemic necrosis of femoral head, osseous arthritis, pain and dysfunction, and so on. For anesthesia, most of this kind of surgery can be done under anesthesia or nerve blockade intra-spinal canal. As for part of the surgery patients with other basic diseases or spinal canal anesthesia contraindications, tracheal intubation anesthesia was done. Artificial hip replacement surgery owns long-time duration, great trauma, large amount of intra-operative bfood loss, as well as vary intra-operative complications. These contribute to a significantly increased risk of anesthesia. Hip replacement has a large amount of haemorrhage and is time-consuming. Patients may suffer from vary postoperative complications, especially severe postoperative pain. Postoperative pain is most severe in the orthopaedic surgery, especially the hip joint replacement which is considered to be one of the most severe postoperative pains. Good postoperative analgesia is helpful to control and reduce the occurrence of postoperative complications, and is beneficial to patients. It enables patients to receive early functional exercise and thus earn early recovery of joint activities and greatly promote the patient recover process. Without the relief of postoperative pain, patients may limit the protective lower limb muscle movement. This may greatly affect early functional recovery of joints, and even lead to stiff joints, muscles disuse atrophy and other serious complications. Good postoperative self-control analgesia cankeep patients sustained pain-free states, and therefore is good for postoperative rehabilitation therapy, exercise, psychological stress, and reduce the postoperative complications and so on Therefore, choosing the right hip postoperative self-control analgesia mode is particularly important.Patient controlled analgesia is divided into patient controlled intravenous analgesia, (PCIA) and patient epidural controlled analgesia (PCEA), patient controlled nerveanalgesia (PCNA) and patient controlled subcutaneous analgesia (PCSA) according to different delivery way. For most time, clinical doctors may choose PCIA and PCEA, both of which have their own advantages and disadvantages. Both of them have been widely applied to postoperative analgesia for the limb joints, chest, abdominal cavity and pelvic surgery.PCIA is the earliest and the most widely used and accepted clinical postoperative PCA model. PCIA deliver drugs intravenously which can provide stable plasma concentration of analgesic drugs. Like as other PCA model, PCIA is set in advance by the anesthesiologist using microcomputer. It can limit the single largest dose, use the shortest time interval, and allow patients to adjust the input of analgesic drugs according to their own needs. Clinical research shows that PCIA is safer and more effective compared with traditional intramuscular injection of opioids analgesia. Pavy E has conducted a randomized controlled clinical study in which PCIA group was compared with model group (muscle note opioid analgesic). PCIA group has a better analgesic effect and higher patient satisfaction than muscle note opioid analgesia group. Hartrick CT conducted a randomized controlled clinical study showing that PCIA has a more perfect analgesic effect when compared with intramuscular injection, static note and subcutaneous injection of analgesic drugs. Moreover, PCIA does not increase the amount use of opioids and its side effects. The above two RCT studies have shown PCIA can provide a better analgesic effect and higher patient satisfaction.PCEA deliver drugs epidurally which can provide rapid analgesia effect and reduce the dosage of opioid. PCEA is often used in the chest, abdomen and orthopaedic surgery. Compared with PCIA, PCEA can not only use opioids, but also use a local anesthetic, which greatly reduced the amount of use of opioids. In particular, it can reduce the side effects of the opioid and can improve the better analgesic effect.Illgen RL conducted a research on patients after total hip and total knee replacement. The results showed that patients in experimental PCEA group demanded less amount of bupivacaine fentanyl than than those who were in the control group in which continuous epidural infusions of the drug was used. However, there was no significant difference in remedial medication and opioid side effects in both groups. Some other studies also showed that compared with continuous epidural infusion, PCEA could decrease the demand for analgesic and improved patient satisfaction. However, another studies insisted that PCEA which was done through the epidural local anesthetics can improve analgesia effect, but will also bring a higher incidence of complications such as hypotension, motor block and the retention of urine and so on.Effects of different methods of analgesia on stress reaction are different. Effective analgesia can relieve the postoperative stress reaction. Hip replacement surgery will inevitably lead to stress and the inflammatory reaction of the body due to surgical trauma and postoperative pain. It changes nerve endocrine immune regulation network, leading to the expression of inflammatory factors of stress waterfall inside the body. It cascades inflammatory response activation, leading to inflammatory response in injured tissues and cells. It even further leads to irreversible damages such as systemic inflammatory response syndrome, a threat to life. Postoperative pain is not only a secondary response to acute trauma, but also may be associated with the development of surgical trauma stress and maintain related. The main reason is as follows:various cytokines released from surgical site afferent nerve and tissue trauma after activation of the humoral cascade system through different pathways (humoral cascade systems), which make the nerve, endocrine and immune system as a whole, and also lead to more extensive and complex stress function.The inflammatory response can cause nonspecific damage to human tissue, which is a kind of cascade control through the regulation of pro inflammatory and anti-inflammatory cytokines multi mechanism.Inflammatory factors are divided into pro and anti inflammatory cytokines according to different functions. They both play a counter, and maintain the relative balance. The pathological state when pro inflammatory and anti-inflammatory cytokines balance is broken may induce inflammatory activity and immunological stress reaction. The pain experience can lead to increase of pro inflammatory cytokines, inhibition of anti-inflammatory factors, and further lead to inflammatory stimulation-the inflammatory cascade reaction.Patient controlled analgesia may suppress pro inflammatory cytokines and reduce inflammatory stress reactions by reducing pain. Different kinds of PCA may produce different analgesia effects on inflammatory stress reaction. Hip replacement operation has been mature, but after all, it is the biggest human body joint Hip replacement has a high incidence of postoperative complications and a high risk during the process of operation especial for elderly patients who are with poor tolerance. Thus, elderly patients receiving hip replacement may suffer from higher risk of postoperative inflammatory stress response. Pro inflammatory cytokines includes TNF-a, IL-6 and IL-8 while anti-inflammatory factors includes IL-10 and TGb-beta. Inflammatory reactions lead to extensive series of endothelial cell activation, diffuse vascular endothelial injury, organ dysfunction and even ultimately lead to systemic inflammatory response syndrome (Systemic Inflammatory Response Syndrome, SIRS). Research shows that, the peak of inflammatory cytokine cascade reaction was at the time point of 12 hours after operation. Therefore, our researches focus on the time point of 12 hours after the operation. We aim to figure out the effect of different analgesia on inflammatory response by comparing the difference in expressions of inflammatory factor 12 hours after operation.During the varied inflammatory cytokines, TNF-a and IL-6 is the ones earliest arrive in the early operation or trauma. They are the most sensitive markers of tissue damage. The elevated levels of them are closely related to the severe of tissue damage. IL-6 produces antibodies by stimulating B lymphocytes. It participated in systemic inflammatory response. Elevated levels of IL-6 may be found in patients with operation of hip. The level of IL-6 after pain stimulation may be closely related to the severe of intra-operative trauma operation. IL-8 also is a pro-inflammatory cytokine, participating in total hip arthroplasty in patients with immune stress. It is especially important in the inflammatory response of elderly patients. IL-10 and TGb-β, as anti-inflammatory factors, the decreased level of which may promote the occurrence of inflammatory reaction. Therefore, the expression levels of anti-inflammatory cytokines are also closely related to the inflammatory response intensity.Effective analgesia can relieve the postoperative stress response. There is a variety of methods of analgesia in clinic now to relief hip arthroplasty postoperative pain, including patient controlled intravenous analgesia, patient controlled epidural analgesia, nerve plexus analgesia patients and patients with percutaneous self controlled analgesia. Each has some defects. Effective analgesia method should have easy implementation, a relatively high success rate, less rate of complications and good effect. It is of importance to select the appropriate postoperative analgesia.A small number of researches on the comparison of spinal analgesia and patient controlled intravenous analgesia at home and abroad. Most of the researches focus on comparison among postoperative analgesia effect in the peritoneal, pleural and other operation. The other focuses more attention on comparison of analgesic effect. Little focus on comparison of postoperative side effects and complications. It is difficult to provide a comprehensive comparison of areas other than the analgesic effect. Our research pays much attention to the optimal management of analgesia after total hip replacement with the increasing number of total hip or semi hip joint operation.Considering the large scale, long during time, large amount of bleeding and postoperative serious complications such as pulmonary embolism, the selection of appropriate postoperative analgesia is of most importance. Choose the right kind of analgesia is a major problem for clinical workers. Our study is based on this basis, aiming to conduct a comparative study on effect of PCEA and PCIA, the two main types of PCA mode on analgesia after total hip arthroplasty. We observed a variety of different antalgic modes possible complications and side effects such as nausea, vomiting, itching, urinary retention, respiratory depression, consciousness disorder and so on. to make the evaluation and analysis. Based on the existing research at home and abroad, we should look for further and in-depth results which meet the clinical needs and solve practical problems, in order to lead to the development trend of scientific research.Which one is better for elderly patients receiving hip replacement, PCIA or PCEA? Currently there was not yet confirmed view and clinical evidence. Moreover, at present there is uncertain effect for the different analgesia methods on the expressions of inflammatory fectors after operation in and aboard. However, the two kinds of patient-controlled analgesia in the models have their advantages and disadvantages. For example, it has been reported that analgesic effect of PCEA compared with PCIA is more clear, which can achieve analgesia effect and patient satisfaction equivalent to PCIA using low doses of analgesic drugs. It is reported that the there is no significant difference beween PCEA and PCIA in the aspect of analgesic effect. Patients receiving PCEA may have greater probability of urinary retention as postoperative complications. In addition, the latest literature also reported that PCEA caused some rare complications, such as erectile dysfunction and so on. PCIA is a systemic kind of analgesia using intravenous analgesic drug with poor analgesic effect. It use a greater amount of analgesic drug more than PCEA, resulting in more systemic side effects such as nausea, vomiting, respiratory depression, disturbance of consciousness and so on. It has been reported that PCIA may lead to some serious respiratory depression cases, a direct threat to the lives of patients. How to evaluate the advantages and disadvantages of PCEA and PCIA, weighing advantages and disadvantages of both, so as to the select the suitable kind of patient-controlled analgesia in order to make patients free of pain and at the same time to avoid side effects. This is the actual clinical problem in today’s anesthesiologists’work, worthy to be researched in depth.Based on the above research background, this study intends to analyze case-control clinical research, using the VAS pain score, Ramsay sedation score scale, BCS comfort score scale to assess postoperative analgesia, sedation and patient perceived comfort degree. Besides, post-operative complications were recorded at the same time. We observed the different incidences of post-operative complications between PCIA and PCEA group. And comparison on comfort degree and comfortable degree between groups under the equivalent analgesic effect. Furthermore, on the aspect of inflammatory stress response, we aimed to figure out the difference in the analgesic effect in elderly patients receiving hip replacement between PCEA and PCIA group, so as to provide basis for clinical application of choice. Therefore, it has certain theoretical, practical significance of this study, and the clinical application value of actual operation.Objective:1. To observe the differences of analgesic Effect, comfort degree and sedation effect between intravenous patient-controlled analgesia (PCIA) and epidural patient-controlled analgesia (PCEA) in elderly patients after hip replacement surgery.2. It is defined as the equal anesthesia for those whose visual analogue scale (VAS) not higher than 2 at postoperative 12h. We aim to observe the differences of comfort degree and sedation effect as well as incidence rate of surgery complications in PCIA group and PCEA group under the equal anesthesia effect.3. Furthermore, we are supposed to figure out the differences in expressions of Inflammatory Cytokines in PCIA group and PCEA group under the equal anesthesia effect.Methods:1.152 elderly patients who had undergone hip replacement were included in our research. They were divided into two groups according to the different kinds of patient-controlled analgesia:patient-controlled analgesia group with 78 patients (PCIA group) and epidural patient-controlled analgesia group (PCEA group) with 74 patients. Visual analogue scale (VAS), Bruggrmann Comfort Scale (BCS) and Ramsay Sedation Score (RSS) were used to evaluate sedative effect and comfort degree in each group and incidences rate of postoperative complications were observed at 4h,8h,12h,24h and 48h after operation According to the figure of VAS, degree of pain was divided into three sections:I section (mild pain) with VAS ranged from 0 to 3; II section (moderate pain) with VAS ranged from 4 to 6; III section (severe pain) with VAS ranged from 7 to 10. Differences in the constituent ratio of the three sections were determined at each time point post-operation (12h,24h and 48h).2. Moreover, patients with a less than 2 VAS at 12hpost-operation were chosen into the second part of our research from the total 152 elderly patients receiving hip-replacement. Sixty patients were included. They were divided into PCIA and PCEA group with 30 patients each. Bruggrmann Comfort Scale (BCS) and RamsaySedation Score (RSS) were used to evaluate sedative effect and comfort degree in each group and incidences rate of postoperative complications were observed.3. Further research was conducted in the third part of our experiment Fifteen cases were randomly chosen in the two groups of the second part of our researches respectively. Blood from each patient was sampled for assays. Expressions of serum inflammatory cytokines including TNF-a, IL-6, IL-8, IL-10 and TGb-β were detected by ELISA, RT-PCR and Western-blot. Detection of each index in strict accordance with the reagent kit (Invitrogen company of America) within the operation standard.4. Analysis of variance was used when analyzing differences between groups on VAS, Ramsay and BCS scores. Bonferroni was further used when weighting the differences among sub-groups. As for the ratio of post-operative complications, chi square test was used to evaluate. Measurement data was shown using mean± standard deviation (x±s), differences among groups were compared by t test Count data was expressed as ratio, analyzed using χ2 test Statistical analysis was completed using SPSS 13.0 software, and using GraphPad Prism software to complete the results of composition.Results:1.4h,8h,12h,24h and 48h postoperative VAS of both groups in quiescent condition were (1.38±0.82 vs.2.06±0.83; t=5.122, P<0.001),(1.58±1.34 vs. 2.17±1.04;t=2.183, P=0.031),(1.26±0.85 vs.1.88±0.81;t=4.690,P<0.001) and (1.03±0.70 vs.1.41±0.71;t=3.345, P=0.001) respectively.12h,24h and 48h postoperative VAS of both groups in activity condition were (2.50±1.57 vs. 3.04±0.90;t=2.570, P=0.011), (1.54±1.05 vs.2.35±1.00;t=4.837, P<0.001), and (1.12±0.86 vs.1.63±0.64;t=3.900, P<0.001) respectively.2. There were not statistical differences between PCEA group and PCIA group at 4h,8h,12h,24h postoperative in quiescent condition (Wilcoxon W=5554.000, P=0.277); (Wilcoxon W=5866.500, P=0.428); (Wilcoxon W=5799.000, P=0.185); (Wilcoxon W=5926.000, P=0.530). There were not statistical differences between PCEA group and PCIA group at 12h,24b,48h postoperative in activity condition (Wilcoxon W=5493.500, P=0.383); (Wilcoxon W=5482.000, P=0.141); (Wilcoxon W=5889.000, P=0.145). And there were no significant differences between the two groups at other time point neither in quiescent state nor in activity condition.3.4h,8h,12h,24h and 48h postoperative RSS of both groups were (2.19±0.89 vs.2.58±1.04;t=2.480, P=0.014), (2.12±0.62 vs.2.51±1.03;t=2.858, P=0.005), (2.04±0.42 vs.2.37±0.84;t=3.101, P=0.002), (2.01±0.20 vs.2.19±0.69; t=2.206, P=0.030) and (2.04±0.26 vs.2.26±0.61;t=2.857, P=0.005), respectively.4.4h,8h,12h,24h and 48h postoperative BCS of both groups were (2.80±0.99 vs.1.54±0.98;t=7.881, P<0.001), (2.72±1.21 vs.1.77±0.85;t=5.550, P<0.001), (3.01±1.07 vs.2.37±1.00;t=3.838, P<0.001), (3.68±0.69 vs.2.86±0.75; t=6.994, P<0.001) and (3.72±0.63 vs.2.96±1.12;t=5.146, P<0.001) respectively.5.4h,12h,24h and 48h postoperative BCS of both group were (2.83±1.09 vs. 1.67±1.24;t=3.876, P<0.001), (3.37±0.67 vs.2.73±1.14;t=2.620, P=0.012), (3.73±0.45 vs.3.03±0.85;t=3.986, P<0.001)and (3.70±0.47 vs.3.00±1.08;t=3.252, P=0.002) under the equivalent analgesic score (12 h VAS≤2).8h,12h,24h and 48h postoperative RSS of both groups were (2.34±0.76 vs.2.93±1.20; t=2.179, P=0.034), (2.17±0.53 vs.2.70±1.02; t=2.536, P=0.015), (2.03±0.18 vs.2.40±0.81; t=2.408, P=0.022) and (2.03±0.18 vs.2.37±0.72; t=2.463, P=0.019). Rates of nausea and vomitting in PCIA group were higher than those of PCEA group (P=0.005). Rates of prolonged catheter retention in PCEA group were higher than those of PCIA group (P=0.024). There was not significance in the rates of other complications.6. Detected by ELISA, expressions of TNF-a as well as IL-6 in Group PCEA were lower and expression of IL-10 was higher than that in Group PCIA (t=2.389, P=0.024; t=2.696, P=0.012). Serum level of TGb-β was higher in Group PCEA detected by ELISA under the equivalent analgesic score (12 h VAS≤2). There was no significant difference in expression of IL-8 between groups (t=0.520, P=0.607); (t=1.685, P=0.107)Detected by RT-PCR, egressions of TNF-a as well as IL-6 in Group PCEA were lower (t=10.787, P<0.001;t=11.789, P<0.001) and egression of IL-10 was highe than that in Group PCIA (t= 12.349, P<0.001). There was no significant difference in expression of IL-8 and TGb-β between groups (t=1.320, P=0.198; t=1.076, P=0.291).Detected by Western-blot, expressions of TNF-a as well as IL-6 in Group PCEA were lower (t=6.981, P<0.001; t=5.752, P<0.001) and expression of IL-10 was highe than that in Group PCIA (t=7.543, P<0.001). There was no significant difference in the other factors between groups (t=1.917, P=0.065; t=1.946, P=0.062).Conclusions:According to the VAS score, the analgesic effect of PCEA is better than PCIA. Besides, sedation effect and comfort degree score of PCEA are also superior to those of PCIA. There was not significant differences between each group analyzing by section divided by VAS scores.Comfort degree and sedation effect in PCEA group were superior to those in PCIA group under equivalent VAS score. However PCEA might increase the risk of postoperative Catheter retention time prolonged. For elderly patients with hip replacement surgery, we need to choose the proper kind of postoperative self-control analgesia according to the merger disease situation of each patientOur research results showed that the serum content and protein expression level of TNF-α and IL-6 in PCEA group were lower than those in PCIA group. Level of mRNA and protein expressions of IL-10 in PCEA group were higher than those in PCIA group. Our results manifested that PCEA better promoted the expression of anti-inflammatory factors, reduce expression of pro-inflammatory factors, so as to maintain the balance of inflammatory factors, avoid postoperative inflammatory immune stress reaction, and reduce the immune stress on the body tissues.To conclude, PCEA is superior to PCIA in the maintainability of inflammatory cytokines balance and is beneficial for the recovery of postoperative immune function in elderly patients with hip surgery. Our study firstly focused on the influence of different analgesic methods on the immune function of patients with postoperative. We have provided more basises for the choice of the different kinds of analgesia. However, larger sample and more multicenter cohort studies are needed for the definition of relations between different analgesic way and the human immune function. Or we may further look deep into the potential mechanisms. |
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