Trendelenburg体位达芬奇机器人辅助腹腔镜宫颈癌根治术中应用不同剂量艾司氯胺酮对颅内压的影响

Influence of different doses of esketamine on intracranial pressure in da Vinci robot-assisted laparoscopic radical resection of cervical cancer in Trendelenburg position

目的观察Trendelenburg体位(T位)达芬奇机器人辅助腹腔镜宫颈癌根治术中应用不同剂量艾司氯胺酮维持麻醉时颅内压变化,探讨艾司氯胺酮应用的安全性。方法择期全身麻醉下行达芬奇机器人辅助腹腔镜宫颈癌根治术患者60例,随机分为低剂量组、高剂量组和对照组各20例。3组麻醉诱导依次静脉注射丙泊酚2~4 mg/kg、舒芬太尼0.3~0.4μg/kg、罗库溴铵0.6 mg/kg;麻醉维持采用静脉泵注丙泊酚3~8 mg/(kg·h)、瑞芬太尼0.1~0.2μg/(kg·min),间断给予罗库溴铵维持肌肉松弛。低剂量组、高剂量组分别静脉泵注艾司氯胺酮0.125、0.25 mg/(kg·h)至手术结束,对照组静脉泵注等量生理盐水至手术结束。分别于麻醉诱导前即刻(T_(1))及T位后3 min(T_(2))、30 min(T_(3))、60 min(T_(4))、120 min(T_(5))、手术结束恢复平卧位后(T;)测定3组平均动脉压、心率、局部脑氧饱和度及视神经鞘直径(optic nerve sheath diameter,ONSD);记录围术期恶心呕吐、术后谵妄、苏醒延迟等不良事件发生情况。结果3组年龄、体质量指数、合并高血压比率、手术时间、丙泊酚诱导剂量、舒芬太尼诱导剂量、丙泊酚维持剂量、围术期不良事件发生率比较差异均无统计学意义(P>0.05)。低剂量组、高剂量组瑞芬太尼维持剂量[(1100±54)、(1070±85)μg]均少于对照组[(1350±93)μg](P<0.05),低剂量组与高剂量组比较差异无统计学意义(P>0.05)。低剂量组、高剂量组和对照组T_(2)[(5.06±0.22)、(5.21±0.18)、(5.03±0.20)mm]、T_(3)[(4.80±1.10)、(5.09±0.21)、(5.09±0.13)mm]、T_(4)[(5.25±0.14)、(4.98±0.22)、(5.14±0.16)mm]、T_(5)[(4.97±0.23)、(4.87±0.27)、(5.13±0.19)mm]时ONSD均大于T_(1)时[(4.73±0.17)、(4.63±0.15)、(4.61±0.24)mm](P<0.05),T_(6)时ONSD[(4.64±0.20)、(4.61±0.21)、(4.60±0.22)mm]与T;时比较差异均无统计学意义(P>0.05);3组各时间点ONSD组间两两比较差异均无统计学意义(P>0.05);3组不同时间点及组间平均动脉压、局部脑氧饱和度、心率比较差异均无统计学意义(P>0.05)。结论T位达芬奇机器人辅助腹腔镜宫颈癌根治术中静脉泵注0.125、0.25 mg/(kg·h)艾司氯胺酮均可维持血流动力学稳定,减少瑞芬太尼用量,且不增加患者颅内压,具有较高的安全性。

Objective To observe the change of intracranial pressure of da Vinci robot-assisted laparoscopic radical surgery of cervical cancer in Trendelenburg position,and to investigate the safety of esketamine.Methods Sixty patients undergoing da Vinci robot-assisted hysteroscopic cervical cancer under general anesthesia were randomly divided into lowdose group,high-dose group and control group,20patients in each group.Three groups received anesthesia induction with intravenous injection of 2-4 mg/kg propofol,0.3-0.4μg/kg sufentanyl and 0.6 mg/kg rouronium,anesthesia maintenance with intravenous pump of 3-8mg/(kg·h)propofol and 0.1-0.2μg/(kg·min)remifentanil,and muscle relaxation maintenance with intermittent administration of rocuronium.Low-and high-dose groups were given intravenous infusion of 0.125and 0.25 mg/(kg·h)esketamine,and control group was injected the equivalent volume of normal saline till the end of operation.The mean arterial pressure,heart rate,regional cerebral oxygen saturation and optic nerve sheath diameter(ONSD)were measured before induction(T_(1)),3min(T_(2)),30min(T_(3)),60min(T_(4))and 120min(T_(5))after head-down tilt,and after recovery of horizontal position(T;).The occurrence of adverse events as perioperative nausea/vomiting,delirium and delayed recovery were recorded.Results There were no significant differences in the age,body mass index,percentage of patients with hypertension,operation lasting time,induction dose of propofol,induction dose of sufentanil,maintenance dose of propofol,and the incidence of perioperative adverse events among low-dose group,high-dose group and control group(P>0.05).The maintenance dose of remifentanil was lower in low-dose group[(1100±54)μg]and high-dose group[(1070±85)μg]than that in control group[(1350±93)μg](P<0.05),and showed no significant difference between low-and high-dose groups(P>0.05).The ONSDs were longer at T_(2)[(5.06±0.22),(5.21±0.18),(5.03±0.20)mm],T_(3)[(4.80±1.10),(5.09±0.21),(5.09±0.13)mm],T_(4)[(5.25±0.14),(4.98±0.22),(5.14±0.16)mm]and T_(5)[(4.97±0.23),(4.87±0.27),(5.13±0.19)mm]than those at T_(1)[(4.73±0.17),(4.63±0.15),(4.61±0.24)mm]in low-dose group,high-dose group and control group(P<0.05),showed no significant differences at T_(6)[(4.64±0.20),(4.61±0.21),(4.60±0.22)mm]compared with those at T_(1)(P>0.05),and showed no significant differences in pairwise comparison among three groups at each time point(P>0.05).The mean arterial pressure,regional cerebral oxygen saturation and heart rate showed no significant differences at different time points and among three groups(P>0.05).Conclusion The application of esketamine at the dose of both 0.125and 0.25mg/(kg·h)can maintain hemodynamic stability and lower the dose of remifentanil in da Vinci robot-assisted laparoscopic radical resection of cervical cancer in Trendelenburg position,with not increasing intracranial pressure,therefore it has high security.