老年髋关节置换术病人围术期艾司氯胺酮应用的安全性及有效性分析

Analysis of safety and efficacy of perioperative esketamine in elderly patients undergoing hip arthroplasty

目的:观察老年髋关节置换术病人围术期艾司氯胺酮应用的安全性及有效性。方法:择期全麻下行髋关节置换术的老年病人90例,性别不限,随机分为对照组(S组)和观察组(E组),每组45例。S组接受超声引导下前路腰、骶丛神经阻滞,切皮前5 min静脉缓慢推注咪达唑仑和舒芬太尼注射液,术后使用舒芬太尼注射液配置成经静脉自控镇痛(PCIA)泵镇痛;E组同样接受超声引导下前路腰、骶丛神经阻滞,切皮前5 min静脉缓慢推注咪达唑仑和艾司氯胺酮,术后使用艾司氯胺酮配置成PCIA泵镇痛;分别观察比较2组病人切皮时(T_(1))体动反应例数、切皮后5 min(T_(2))MAP变化值(△MAP)以及术中呼吸抑制发生率,术前(T_(0))及术后6、12、24 h(T_(3)、T_(4)、T_(5))白细胞介素-6(IL-6)、皮质醇激素(Cortisol,Cor)的浓度变化;术后6、12、24 h(T_(3)、T_(4)、T_(5))视觉模拟评分(VAS)、Ramsay镇静评分;术后1、3 d(T_(5)、T_(6))简易智力状况评分法(MMSE),以及术后PCIA总按压次数和恶心呕吐发生率。结果:E组T_(2)时△MAP低于S组(P<0.05);2组T_(1)时体动反应比例、术中呼吸抑制发生率差异无统计学意义(P>0.05);术前2组病人IL-6以及Cor水平差异无统计学意义(P>0.05),术后各时间点E组水平低于S组(P<0.01);2组T_(3)时VAS评分差异无统计学意义(P>0.05),而T_(4)和T_(5)时E组低于S组(P<0.01);E组术后各时点Ramsay评分低于S组(P<0.01),T_(5)和T_(6)时认知状态MMSE评分均高于S组(P<0.01);E组病人PCIA总按压次数以及恶心呕吐发生率均低于S组(P<0.05)。结论:艾司氯胺酮应用于老年髋关节置换术病人,可显著减少围术期并发症,有效抑制炎症反应,提供良好的镇痛效果,且对病人术后认知功能影响轻微。

Objective:To observe the safety and efficacy of perioperative esketamine in elderly patients with hip arthroplasty.Methods:Ninety elderly patients scheduled for hip arthroplasty were randomly divided into group S and group E,45 cases in each group.The patients in group S received ultrasonic-guided anterior lumbar and sacral plexus nerve block,and midazolam and sufentanil injection were slowly injected intravenously 5 minutes before skin cutting,and sufentanil injection was used as patient-controlled intravenous(PCIA)pump for postoperative analgesia.The patients in group E received ultrasonic-guided anterior lumbar and sacral plexus nerve block,and midazolam and esketamine were slowly injected intravenously 5 minutes before skin cutting,and esketamine was used as a PCIA pump for analgesia.The number of cases of body movement reaction during skin cutting(T_(1)),the change value of MAP 5 min utes after skin cutting(T_(2))(△MAP)and the incidence of intraoperative respiratory depression were observed and compared between the two groups.The change of interleukin-6(IL-6)and cortisol(Cor)before operation(T_(0))and 6,12,24 h after operation(T_(3),T_(4),T_(5))were also tested.Visual analogue scale(VAS)and Ramsay sedation score at 6,12,24 h after surgery(T_(3),T_(4),T_(5)),the changes of Mini-mentul State Examination(MMSE),the total number of PCIA compressions and the incidence of nausea and vomiting at 1 and 3 days after surgery(T_(5)and T_(6))were recorded.Results:The△MAP at T_(2)in group E was lower than that in group S(P<0.05).There was no statistical significance in the incidence of the number of cases of body movement reaction at T_(1)and intraoperative respiratory depression between the two groups(P>0.05).There was no statistical significance in the concentration of IL-6 and Cor between the two groups before operation(P>0.05),however,both the concentration in group E was significantly lower than that of group S at each time point after operation(P<0.01).There was no significant difference in VAS score between the two groups at T_(3)(P>0.05),but the VAS score in group E was significantly lower than that in group S at T_(4) and T_(5)(P<0.01).Ramsay score in group E was significantly lower than that in group S at each time point(P<0.01),and MMSE score of cognitive state at T_(5)and T_(6) was significantly higher than that in group S(P<0.01).The total number of PCIA compressions and the incidence of nausea and vomiting in group E were lower than those in group S(P<0.05).Conclusions:Esketamine used in elderly patients with hip arthroplasty can significantly reduce perioperative complications,effectively inhibit inflammatory response,provide good analgesic effect,and also have slight effect on postoperative cognitive function of patients.