不同剂量艾司氯胺酮对产妇剖宫产术后镇痛和产后抑郁的影响

Effects of different doses of esketamine on analgesia and postpartum depression after cesarean section

目的观察不同剂量艾司氯胺酮复合舒芬太尼用于术后静脉自控镇痛(PCIA)对剖宫产术后镇痛效果及产后抑郁(PPD)的影响。方法选择择期行剖宫产术的产妇120例,单胎足月妊娠,年龄22~35岁,BMI 25~30 kg/m^(2),ASAⅡ级。所有产妇采用腰-硬联合麻醉,蛛网膜下腔使用0.5%布比卡因8~10 mg,硬膜外腔头端置管备用。采用随机数字表法将产妇分为四组:C组(n=29)、S_(1)组(n=28)、S_(2)组(n=30)和S_(3)组(n=29)。C组镇痛泵配方为舒芬太尼1.5μg/kg+托烷司琼4 mg,用生理盐水稀释至150 ml;S_(1)组、S_(2)组和S_(3)组分别在C组配方基础上加入艾司氯胺酮0.1、0.2和0.4 mg/kg。镇痛泵参数设置:负荷剂量5 ml,持续输注量2 ml/h,单次剂量1 ml,锁定时间15 min,镇痛持续时间48 h。记录术后48 h舒芬太尼用量、艾司氯胺酮用量、镇痛泵有效按压次数、总按压次数、术后镇痛补救例数、术后1周及6周爱丁堡产后抑郁量表(EPDS)评分情况和PPD的发生情况。记录术后48 h内恶心呕吐、皮肤瘙痒、噩梦等不良反应发生情况。结果与C组比较,S_(1)组、S_(2)组和S_(3)组术后48 h内舒芬太尼用量、镇痛泵有效按压次数、总按压次数明显减少(P<0.05)。S_(1)组、S_(2)组和S_(3)组术后48 h内舒芬太尼用量、镇痛泵有效按压次数、总按压次数差异无统计学意义。与C组比较,S_(1)组、S_(2)组和S_(3)组术后1周和6周EPDS评分与PPD发生率明显降低(P<0.05)。与S_(1)组比较,S_(2)组和S_(3)组术后1周和6周EPDS评分与PPD发生率明显降低(P<0.05)。与C组比较,S_(1)组、S_(2)组和S_(3)组产妇术后48 h内恶心呕吐发生率明显降低(P<0.05)。四组产妇术后48 h内补救镇痛比例和皮肤瘙痒、噩梦等不良反应发生率差异无统计学意义。结论剖宫产产妇术后PCIA复合使用艾司氯胺酮可减少阿片类药物的用量,提高术后镇痛效果,降低术后PPD的发生率,其中复合艾司氯胺酮0.2、0.4 mg/kg效果优于艾司氯胺酮0.1 mg/kg。

Objective To investigate the effect of different doses of esketamine combined with sufentanyl for patient-controlled intravenous analgesia(PCIA)on the analgesic effect after cesarean section and the incidence of postpartum depression(PPD).Methods A total of 120 parturients undergoing elective cesarean section,singleton term pregnancy,aged 22-35 years,BMI 25-30 kg/m^(2),ASA physical statusⅡwere selected.All parturients received a combined epidural with spinal anesthesia.A dose of 8-10 mg of 0.5%bubicaine was administrated in the subarachnoid cavity and the epidural tube was reserved.They were randomly divided into four groups according to random number table:group C(n=29),group S 2(n=28),group S_(2)(n=30)and group S_(3)(n=29).Group C was treated by sufentanyl 1.5μg/kg+totanisoltron 4 mg,diluted to 150 ml with saline.Group S_(1),S_(2),and S_(3)added 0.1,0.2,and 0.4 mg/kg,based on the formula of group C respectively.Parameter setting of analgesia pump:a bolus of 5 ml,continuous infusion amount of 2 ml/h,single dose of 1 ml,locking time of 15 minutes,and analgesia duration of 48 hours.The consumption of sulfentanyl and esketamine,times of effective and total press and remediate analgesia 48 hours after cesarean section,the Edinburgh postpartum depression scale(EPDS)and incidence of PPD 1 and 6 weeks after the operation were recorded.The adverse reactions such as nausea and vomiting,skin pruritus,and nightmares 48 hours after surgery were also recorded.Results Compared with group C,consumption of sufentanil,the times of effective presses,and total presses 48 hours after surgery were significantly reduced in groups S_(1),S_(2),and S_(3)(P<0.05),while there were no significant differences among groups S_(1),S_(2),and S 348 hours after surgery.The EPDS score and incidence of PPD 1 and 6 weeks in groups S_(1),S_(2)and S_(3)were significantly lower than those in group C(P<0.05),while those in groups S_(2)and S_(3)were lower than those in group S_(1)(P<0.05).Compared with group C,the incidence of nausea and vomiting were significantly decreased in groups S_(1),S_(2),and S 3(P<0.05).There were no significant differences of the rate of remedial analgesia cases and the occurrence of adverse reactions,such as pruritus and nightmares,among the four groups.Conclusion The use of PCIA combined with esketamine after cesarean section can reduce the consumption of opioids,improve postoperative analgesia and decrease the incidence of PPD 1 and 6 weeks after surgery,among which the combination of esketamine 0.2,0.4 mg/kg is better than esketamine 0.1 mg/kg.