Effects Of Multimodal Analgesia On Enhanced Recovery After Surgery In Children With Developmental Dislocation Of The Hip

Objective To investigate the effects of multimodal analgesia on enhanced recovery after surgery in children with developmental dislocation of the hip.Methods Ninety patients,aged 1 to 7 years, with developmental dislocation of the hip undergoing surgery were randomly divided into 3 groups(n=30 each):patient controlled intravenous analgesia(group A), PCIA+caudal block group(group B),PCIA+caudal block+paracetamol group(group C). Group C patients rectally received paracetamol 30-35mg/kg at 15 min before operation.All patients received combined inhalation and intravenous anesthesia.After anesthesia induction,The caudal injection was given to group B and C patients.0.25% ropivacaine 1 ml/mg was used in cadual block. The patients received 48 h of PCIA after operation.PCIA pump was set up with a background infusion of 2 ml/h,and a bolus dose of 2 ml with lock-out interval 15 min after a loading dose 4 ml. HR, MAP, RR, Sp O2 was routinely monitored at surgery and 48 hours postoperation. Observed and recorded the indexes, such as HR, MAP, RR, Sp O2. These indexes were from different situations that were before anesthesia(T0), skin incision(T1),end of operation(T2), after extubation(T3), immediate recovery(T4), 4 hour(T5), 8 hours(T6), 12 hours(T7),24 hours(T8),36 hours(T9) and 48 hours(T10) after surgery. FLACC and Ramsay score were recorded respectively at immediate recovery(T4), 4 hour(T5), 8 hours(T6), 12 hours(T7),24 hours(T8),36 hours(T9) and 48 hours(T10) after the operation. PAED score at T4 was recorded. Then 3ml Radial artery blood samples were taken before surgery and at the end of surgery to detect concentration of Interleukin-6(IL-6), Tumor necrosis factor(TNF-α), epinephrine(E) and Norepin Ephrine(NE) by the method of ELISA. The dose of propofol and sevoflurane used during the operation and recovery room residence time and postoperative hospital stay were recorded respectively. Observed and recorded Side effects: such as restlessness after surgery, somnolence, respiratory depression, nausea and vomitting, pruritus.Results1.General materials:There was no statistical significant difference in three groups at age, sex ratio,weight, operative time, intraoperative fluid transfusion volume and hemorrhage volume..2.Changes of vital signs:There was no statistical significant difference in three groups at HR、MAP、RR and Sp O2 before anaesthesia(P>0.05); RR:Compared with group A, index of RR at T4-T9 was significantly decreased in group B and C. Compared with group B,index of RR at T7-9 was significantly decreased in group C(P<0.05).HR:Compared with group A, index of HR at T4-T8 was significantly decreased in group B and C(P<0.05). Compared with group B,index of HR at T7-9 was significantly decreased in group C(P<0.05).3.Analgesic score results:This is FLACC scale that is use to evaluate the effect of analgesic. Compared with group A, FLACC score at T4-T9 was significantly decreased in group B and C(P<0.05);FLACC score at T10 was decreased in group C. Compared with group B,FLACC score at T7,T8,T10 was significantly decreased in group C(P<0.05).4.Sedation score results:The result of sedation scale from Group A was lower than that from Group B and C at T4、T5(P<0.05) by Ramsay scale. There was no statistical significance at other time points after surgery(P>0.05)。5, Restlessness score results:By PAED scale, Restlessness score at T4 from Group B and C was lower than that from group A(P<0.05)。6.Changes of plasma inflammatory factors levelsThree groups of plasma levels of IL-6,TNF-α,E and AE at the end of operation was significantly higher than that before surgery(P<0.05). But the plasma level of IL-6,TNF-α,E and AE at the end of operation increasing amplitude in group A were significantly greater than that in group B and C(P<0.05). The plasma level of IL-6,TNF-α,E and AE at the end of operation increasing amplitude in group B were significantly greater than that in group C(P<0.05). Compared with group A, the plasma level of TNF-α was lower in group B and C(P<0.05). Compared with group B, the plasma level of TNF-α was lower in group C(P<0.05).7.Changes of intraoperation anesthesic dose:Compared with group A, the dose of propofol and sevoflurane was lower in group B and C(P<0.05).8.Changes of fast track surgery index:There was no statistical significant difference about postoperative hospital stay in three groups(P>0.05).9.postoperative complicationsThere was no excess sedation, hypotension,,respiratory depression and there was no statistical significant difference about nausea,vomitting and pruritus in the three groups(P>0.05).Conclusions All studies show that multimodal analgesia including caudal block,paracetamol and PCIA can improve postoperative analgesia,reduce the production of inflammatory factors,relieve stress responses,decrease the incidence of emergence agitation, increase children and their parents satisfaction and benefit to enhance recovery after surgery, and that the mechanisms may be involved in analgesia,stress and inflammation.