小剂量氯胺酮术后镇痛对全髋关节置换术患者细胞因子表达的影响

Effects of postoperative analgesia with small dose ketamine on plasma cytokines in patients undergoing total hip replacement

目的观察小剂量氯胺酮＋芬太尼用于全髋关节置换术患者术后镇静、镇痛的效果，以及对细胞因子肿瘤坏死因子-α（TNF-α）、白细胞介素-1β（IL-1β）的表达的影响。方法80例全髋关节置换术后患者随机分为两组行术后经静脉患者自控镇痛（PCIA），F组（40例）配方芬太尼20μg／kg＋昂丹司琼8mg＋生理盐水至100ml；FI潍（40例）芬太尼16μg／kg＋氯胺酮2mg／kg＋昂丹司琼8mg＋生理盐水至100ml。术后静脉持续泵注2ml／h，观察不同时间点视觉模拟评分（VAS）镇痛、镇静、呼吸血压变化、恶心呕吐等不良反应，血清TNF-α和IL-1β的表达。结果两组患者术后各时间点VAS镇痛、镇静评分、平均动脉压、血氧饱和度比较差异无统计学意义（P〉0．05）；KF组患者与F组比较，术后恶心、呕吐不良反应明显减少（P〈0．05）；术后0及4hIL-1β的表达差异无统计学意义（P〉0．05），术后12及24hIL-1βp表达明显降低（P〈0．05）；术后各时间点TNF-α的表达差异无统计学意义（P〉0．05）。结论小剂量氯胺酮复合芬太尼用于髋关节置换术患者术后镇痛，较传统的单用芬太尼术后静脉镇痛，能产生良好的镇痛效果，减少恶心、呕吐等不良反应，同时能抑制炎症因子IL-1β的表达，更有利于患者的康复。

[ Abstract ] Objective To investigate the analgesic effect of small dose ketamine, and its impact on the expression of plasma tumor necrosis factor-α （TNF--α） and interleukin-1β （IL-1β） in patients after total hip replacement. Methods A total of 80 patients （with age of 65 to 80 and ASA grade I to Ⅲ） after total hip replacement underwent patient controlled intravenous analgesia （PCIA） in our department. They were randomly divided into two groups： fentanyl and ondansetron group （F group, 20~tg/kg fentanyl ＋ 8mg ondansetron ＋ normal saline till 100ml, n = 40）, and small dose ketamine combined with fentanyl and ondansetron group （KF group, 16μg/kg fentanyl ＋ 2mg/kg ketamine ＋ 8mg ondansetron ＋ normal saline till 100ml, n = 40） at a continuous intravenous infusion of 2ml/h. Visual analogue scale （VAS）, mean aterial pressure （MAP）, blood oxygen saturation （SpO2）, side-effects during PCIA （such as nausea and vomiting）, and the plasma levels of TNF-α and IL-113 were recorded and compared between the two groups at different time points. Results There was no significant difference in the VAS, sedation score, MAP and SpO2 between the two groups at all time points （P 〉 0.05）, but the incidence of side-effects was significantly lower in KF group than in F group （P 〈 0.05）. No significant difference was found in the plasma level of IL-1β between the two groups in 0 and 4h after operation; but in 12 and 24h after operation, that in KF group was significantly lower （P 〈 0.05）. No significant difference was found in the level of TNF-α between the two groups at all time points. （P 〉 0.05）. Conclusion Small dose ketamine combined with fentanyl in PCIA has better analgesic effect than conventional method of using fentanyl alone for patients after total hip replacement. It also reduces the incidence of nausea and vomiting and inhibits the expression of inflammatory factor IL-1β, and thus is helpful to patient＇s recovery.