围手术期应用小剂量艾司氯胺酮对胸腔镜肺癌根治术患者术后镇痛的影响

Efficacy of low-dose esketamine on postoperative analgesia in patients undergoing thoracoscopic radical resection of lung cancer

目的探讨行胸腔镜肺癌根治术患者围手术期应用小剂量艾司氯胺酮减轻术后疼痛的效果及安全性。方法行胸腔镜肺癌根治术患者80例,随机分为艾司氯胺酮组和对照组各40例。对照组采用静脉注射咪达唑仑0.05 mg/kg、丙泊酚1.5~2 mg/kg、舒芬太尼0.6μg/kg、罗库溴铵0.6 mg/kg进行麻醉诱导;艾司氯胺酮组麻醉诱导同对照组,诱导后静脉注射艾司氯胺酮0.1 mg/kg。对照组术中维持麻醉吸入体积分数1%~2%七氟烷,静脉泵注瑞芬太尼0.1~0.3μg/(kg·min),间断给予罗库溴铵0.3 mg/kg,艾司氯胺酮组同时持续泵注艾司氯胺酮0.12 mg/(kg·h)。艾司氯胺酮组术后自控静脉镇痛应用羟考酮50 mg+艾司氯胺酮25 mg+生理盐水100 mL,对照组应用羟考酮50 mg+生理盐水100 mL。记录2组术后48 h羟考酮用量及头晕、恶心、呕吐等不良反应发生情况,术后4、12、24、48、72 h时静息疼痛(numerical rating scale,NRS)评分及24、48、72 h运动NRS评分,术后24、48、72 h时15项恢复质量(15-item quality of recovery,QoR-15)评分,首次自控镇痛时间、镇痛泵应用次数、术后首次下床时间和进食时间。结果艾司氯胺酮组术后24 h静息NRS评分[(3.4±1.4)分]及术后24、48、72 h运动NRS评分[(5.3±1.8)、(4.5±1.5)、(3.7±1.8)分]均低于对照组[(4.6±1.4)、(6.5±1.2)、(5.6±1.7)、(4.7±1.8)分](P<0.05),术后24、48、72 h时QoR-15评分[(83.0±9.2)、(103.7±11.2)、(115.6±10.9)分]均高于对照组[(75.3±12.3)、(97.2±11.7)、(108.5±11.5)分](P<0.05),首次自控镇痛时间[(7.1±1.3)h]晚于对照组[(6.2±1.6)h](P<0.05),首次下床时间[(15.1±1.4)h]早于对照组[(15.9±1.7)h](P<0.05);2组术后4、12、48、72 h静息NRS评分,术后24、48 h羟考酮用量,术后首次进食时间,自控镇痛泵使用次数,术后头晕、恶心呕吐、幻觉发生率比较差异均无统计学意义(P>0.05)。结论胸腔镜肺癌根治术中及术后应用小剂量艾司氯胺酮可减轻术后运动性疼痛,促进术后快速康复,不增加不良反应。

Objective To investigate the efficacy and safety of postoperative analgesia with low-dose esketamine in patients undergoing thoracoscopic radical resection of lung cancer.Methods Eighty patients undergoing thoracoscopic radical resection of lung cancer were equally and randomly divided into esketamine group and control group.Both two groups received anesthesia induction with intravenous injection of 0.05 mg/kg midazolam,1.5 to 2 mg/kg propofol,0.6μg/kg sufentanil and 0.6 mg/kg rocuronium,and meanwhile esketamine group received intravenous injection of 0.1 mg/kg of esketamine.Both two groups received anesthesia maintenance with inhalation of 1%to 2%sevoflurane,intravenous pump of 0.1 to 0.3μg/(kg·min)remifentanil and intermittent intravenous injection of 0.3 mg/kg rocuronium,and meanwhile esketamine group was continuously pumped with 0.12 mg/(kg·h)esketamine.For postoperative patient-controlled intravenous analgesia,esketamine group was given 50 mg oxycodone+25 mg esketamine+100 mL normal saline,and control group was given 50 mg oxycodone+100 mL normal saline.The dosage of oxycodone,the incidence of adverse reactions such as dizziness,nausea and vomiting in 48 h after operation,the numerical rating scale(NRS)scores at rest in 4,12,24,48 and 72 h after operation,the NRS scores during movement in 24,48 and 72 h after operation,the first postoperative patient-controlled analgesia time and frequency,the first out-of-bed activity time and the first food intake time were recorded in two groups.The 15-item quality of recovery(QoR-15)score was used to evaluate the recovery of patients in two groups in 24,48 and 72 h after operation.Results The NRS score at rest in 24hpostoperatively and NRS scores during movement in 24,48and 72hpostoperatively were lower in esketamine group(3.4±1.4;5.3±1.8,4.5±1.5,3.7±1.8)than those in control group(4.6±1.4;6.5±1.2,5.6±1.7,4.7±1.8)(P<0.05).QoR-15scores in 24,48and 72hpostoperatively were higher in esketamine group(83.0±9.2,103.7±11.2,115.6±10.9)than those in control group(75.3±12.3,97.2±11.7,108.5±11.5)(P<0.05).The first use of patient-controlled analgesia was later in esketamine group[(7.1±1.3)h]than that in control group[(6.2±1.6)h](P<0.05),and the first out-of-bed activity was earlier in esketamine group[(15.1±1.4)h]than that in control group[(15.9±1.7)h](P<0.05).There were no significant differences between two groups in the NRS scores at rest in 4,12,48and 72hafter operation,the consumptions of oxycodone in 24and 48h after operation,the first food intake time after operation,the frequency of postoperative patient-controlled analgesia and the incidences of dizziness,nausea/vomiting and hallucination(P>0.05).Conclusion The application of low-dose esketamine during and after thoracoscopic radical resection of lung cancer can reduce postoperative motor pain and promote enhanced recovery after surgery without increasing the incidence of adverse reactions.