小剂量氯胺酮用于瑞芬太尼麻醉后痛觉过敏的临床研究

Effects of ketamine on the patients with postoperative hyperalgesia after remifentanil-based anaesthesia

目的观察小剂量氯胺酮是否能抑制瑞芬太尼复合吸入麻醉所致的痛觉过敏。方法腹腔镜下胆囊切除术患者60例,20～60岁,ASA分级I～II级,随机分为3组:对照组(C组)术中仅用吸入麻醉;瑞芬太尼组(R组)术中持续靶控输注靶浓度4μg/L的瑞芬太尼;氯胺酮组(K组)术中持续靶控输注靶浓度4μg/L的瑞芬太尼,缝皮时给予氯胺酮0.5mg/kg。记录3组患者拔管时间、拔除气管导管后的口述疼痛评分,拔管后2、4、12、24h的视觉疼痛模拟评分(VAS),4h内再次要求镇痛的人数和拔管后24h内的不良反应。结果R组和K组患者苏醒和拔管时间显著短于C组(P<0.05)。拔管15min时,R组患者疼痛评分显著高K组和C组(P<0.01),拔管后2、4h的VAS评分R组患者疼痛评分显著高K组和C组(P<0.05),12hR组和K组VAS评分显著高于C组(P<0.05)。术后4h内R组患者再次要求镇痛时间较K组和C组多。术后3组患者不良反应无显著差异。结论手术中大剂量应用瑞芬太尼会诱发术后痛觉过敏,氯胺酮对瑞芬太尼麻醉术后疼痛具有明显的抑制作用,且不增加不良反应。

Objective To evaluate the preventive effects of ketamine on the patients with postoperative hyperalgesia after large-dose remifentanil-based anesthesia.Methods 60 patients undergoing laparoscopic cholecystectomy were randomly assigned to 3 groups（n=20）,group R received intraoperative remifentanil by TCI at 4 μg/L,group K received intraoperative remifentanil by TCI at 4 μg/L and ketamine 0.5 mg/kg at skin closure,group C received no drug infusion.Anesthesia was maintained with sevoflurane.The four-level verbal rating scale after trachea extubation,VAS score at 2,4,12,24 hours after extubation were recorded.Results The emergence times were significantly shorter in the Group R and Group K than those in Group C（P〈0.05）.Pain scores in Group R were significantly higher than those in Group K and group C during the first 15 postoperative minutes（P〈0.01）.The VAS scores at 2,4 hours in group K were lower than those in group R（P〈0.05）.More patients in Group R required analgesia than those in Group C and Group K.The adverse drug reaction showed no significant difference in three groups.Conclusion Small dose ketamine can attenuate postoperative hyperalgesia after large-dose remifentanil-based anesthesia and without increasing the incidence of side effects.