摘要
目的 评价艾司氯胺酮围术期全程镇痛用于胸腔镜肺叶切除术患者的效果.方法 择期全麻下行胸腔镜肺叶切除术患者90例,性别不限,年龄18～64岁,BMI 18～30 kg/m2,ASA分级Ⅰ或Ⅱ级.采用随机数字表法分为3组(n=30):对照组(C组)和不同剂量艾司氯胺酮组(S1组和S2组).S1组和S2组于麻醉诱导前分别静脉注射艾司氯胺酮0.1和0.2 mg/kg.3组均常规麻醉诱导.麻醉维持时S1组和S2组分别静脉输注艾司氯胺酮0.1、0.2 mg·kg-1·h-1,3组其余麻醉维持药物相同.术后行PCIA,C组药物为舒芬太尼2 μg/kg,S1组和S2组在此基础上混合艾司氯胺酮1 mg/kg.采用酮咯酸氨丁三醇补救镇痛,维持静态疼痛NRS评分≤3分.记录术中丙泊酚和瑞芬太尼总量、术后0～24 h和＞24～48 h PCIA有效按压次数及补救镇痛情况;记录术后呼吸抑制、恶心呕吐、头晕、流涎等不良反应发生情况和苏醒时间.于术前30 min和术后30 min时采用ELISA法测定血清IL-6浓度,采用硫代巴比妥酸比色分析法测定血清MDA浓度.于术后1和2 d时采用15项恢复质量(QoR-15)量表评估术后恢复情况.于术后1～3个月电话随访慢性疼痛的发生情况.结果 与C组比较,S,组和S2组术中瑞芬太尼用量、术后0～24 h和术后＞24～48 h PCIA有效按压次数、补救镇痛率、术后血清IL-6浓度降低,QoR-15量表评分升高,S2组术后血清MDA浓度降低(P＜0.05);与S1组比较,S2组术中瑞芬太尼用量降低(P＜0.05),术后血清IL-6和MDA浓度差异无统计学意义(P＞0.05).与S2组比较,S1组和C组术后苏醒时间缩短(P＜0.05).3组术中丙泊酚用量、不良反应发生率、慢性疼痛发生率差异无统计学意义(P＞0.05).结论 艾司氯胺酮围术期全程镇痛(麻醉诱导前剂量0.1 mg/kg、麻醉维持剂量0.1 mg·kg1·h-1,术后PCIA剂量1 mg/kg)用于胸腔镜肺叶切除术患者可提高镇痛质量,改善术后早期康复质量.
Abstract
Objective To evaluate the efficacy of perioperative analgesia with esketamine in the patients undergoing thoracoscopic surgery.Methods A total of 90 patients of either sex,aged 18-64 yr,with body mass index of 18-30 kg/m2,of American Society of Anesthesiologists Physical Status classifica-tion Ⅰ or Ⅱ,scheduled for elective thoracoscopic lobectomy under general anesthesia,were divided into 3 groups(n=30 each)by a random number table method:control group(C group)and different doses of esketamine groups(S,group,S2 group).Before induction of anesthesia,esketamine 0.1 and 0.2 mg/kg were intravenously injected in S,group and S2 group,respectively,while esketamine was not given in group C.Anesthesia was routinely induced in all the three groups.During anesthesia maintenance,esketamine 0.1 and 0.2 mg·kg-1·h-1 were intravenously infused in group S,and group S2,respectively,and the remaining drugs used for anesthesia maintenance were the same in the three groups.Patient-controlled intravenous an-algesia(PCIA)was used after operation,and PCIA solution contained sufentanil 2 μg/kg in group C,and esketamine 1 mg/kg was mixed on the basis as previously described in S1 and S2 groups.Aminotriol ketorolac was given as rescue analgesia to maintain numeric rating scale score at rest ≤3.The total amount of propofol and remifentanil during operation,effective pressing times of PCIA in postoperative 0-24 h and＞24-48 h periods,and requirement for rescue analgesia were recorded.The occurrence of adverse reactions such as re-spiratory depression,nausea and vomiting,dizziness and salivation,and emergence time were recorded after surgery.The serum interleukin-6(IL-6)concentration was measured by enzyme-linked immunosorbent assay at 30 min before and after surgery,and the malondialdehyde(MDA)concentration in serum was measured by thiobarbituric acid colorimetric analysis.The postoperative recovery was assessed using the 50-item quali-ty of recovery scale at 1 and 2 days after surgery.The development of chronic pain was followed up by tele-phone within 1-3 months after surgery.Results Compared with group C,the intraoperative consumption of remifentanil,effective pressing times of PCIA in postoperative 0-24 h and＞24-48 h periods,rate of rescue analgesia,and postoperative serum IL-6 concentration were significantly decreased,and the 50-item quality of recovery scale score was increased in S1 and S2 groups,and the postoperative serum MDA concentration was significantly decreased in group S2(P＜0.05).Compared with group S1,the consumption of intraopera-tive remifentanil was significantly decreased(P＜0.05),and no significant change was found in postopera-tive serum IL-6 and MDA concentrations in group S2(P＞0.05).Compared with group S2,the postoperative emergence time was significantly shortened in S,and C groups(P＜0.05).There was no statistically signifi-cant difference in the intraoperative consumption of propofol,incidence of adverse effects and incidence of chronic pain among the three groups(P＞0.05).Conclusions Esketamine for perioperative analgesia(dose before anesthesia induction 0.1 mg/kg,dose for maintenance of anesthesia 0.1 mg·kg-1·h-1,dose for postoperative PCIA 1 mg/kg)can raise the quality of analgesia and improve the quality of early postoper-ative recovery in the patients undergoing thoracoscopic lobectomy.
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