超声引导下星状神经节阻滞复合艾司氯胺酮静脉注射在胸腔镜肺叶切除术中的应用

Application of ultrasound-guided stellate ganglion block combined with esketamine intravenous injection undergoing thoracoscopic lobectomy

目的评价星状神经节阻滞复合小剂量艾司氯胺酮多模式镇痛在胸腔镜肺叶切除术中的应用。方法收集2020年3月至2021年10月,于南通大学附属瑞慈医院择期行胸腔镜肺叶切除术患者48例,性别不限,年龄48~75岁,ASA分级Ⅱ或Ⅲ级。按随机数字表法将其随机分为星状神经节阻滞复合艾司氯胺酮组(复合组)和艾司氯胺酮组(非复合组),每组24例。两组接受相同的全身麻醉方案及术后静脉自控镇痛(PCIA)。非复合组仅于切皮前静脉给予艾司氯胺酮0.5 mg/kg,复合组在此基础上,于全身麻醉诱导前行超声引导下星状神经节阻滞,给予0.25%罗哌卡因3 ml。记录术中血液动力学不良事件发生情况、术中瑞芬太尼用量;记录术后首次按压镇痛泵时间、术后48 h内有效按压次数及术后镇痛相关不良反应发生情况;记录术后1、6、12、24、48 h静息及咳嗽时视觉模拟评分(VAS)及VAS评分0~3分的例数;记录两组患者术后早期恢复情况(包括全麻苏醒时间、拔管时间、苏醒期躁动评分、恢复室停留时间及术后下床时间、进食时间)。结果共46例患者完成本研究及随访,两组各23例。与非复合组比较,复合组患者术中瑞芬太尼用量较少(t=2.81,P=0.007),首次按压时间较晚(t=2.39,P=0.025),术后48 h内有效按压次数较少(t=2.62,P=0.013)。与非复合组比较,复合组患者麻醉期间高血压发生率、心动过速发生率均较低(t=4.97,P=0.026;t=6.07,P=0.014),患者术后1、6、12 h静息及咳嗽时VAS评分较低(P均<0.05),VAS评分0~3分的例数较多(P均<0.05),恶心呕吐发生率较低(P<0.05)。复合组患者术后苏醒时间、拔管时间短于非复合组(P均<0.05),复合组苏醒期躁动评分、恢复室停留时间短于非复合组(P均<0.05)。结论超声引导下星状神经节阻滞复合小剂量艾司氯胺酮静脉注射用于胸腔镜肺叶切除术,可明显增强围术期镇痛效果,减少阿片类药物用量,维持血液动力学稳定,并且可以缩短患者术后苏醒及拔管时间,减轻苏醒期躁动。

Objective To evaluate the application of ultrasound-guided stellate ganglion block combined with esketamine intravenous injection undergoing thoracoscopic lobectomy.Methods Forty-eight patients,unlimited gender,aged 48-75 years old,ASA Ⅱ or Ⅲ,underwent video-assisted thoracic surgery were enrolled in this study,from March 2020 to October 2021 in the Rich Hospital Affiliated to Nantong University.According to the random number table method,they were randomly divided into stellate ganglion block combined with esketamine group(combined group)and esketamine group(non-combined group),24 cases in each group.All patients were received the same general anesthesia and patient-controlled intravenous analgesia(PCIA)after the operation.The patients were received stellate ganglion block under ultrasound guided with 0.25% ropivacaine 3 ml before the anesthesia induction,and 0.5 mg/kg esketamine was given intravenously before cutting the skin in the combined group,while the patients were received only 0.5 mg/kg esketamine before cutting the skin in the non-combined group.The incidence of adverse hemodynamic events during operation were recorded in the two groups.The dosage of remifentanil during the operation and the first pressing time of the analgesic pump,the effective pressing times of analgesic pump with 48 h after operation were recorded.Visual analogue scale(VAS)and the cases of VAS 0-3 at resting and coughing were recorded at 1,6,12,24,48 h after the operation,the analgesic-related adverse events were recorded after the operation.The parameters of the early postoperative recovery were recorded in the two groups as following:recovery time,extubation time,the agitation score during the awake period and the time in post-anesthesia care unit stay,ambulation time,feeding time.Results Fouty-six patients fulfilled the study protocol and follow-up,23 cases in each group.The dosage of remifentanil was less during the operation in the combined group than that in the non-combined group(t=2.81,P=0.007),the first pressing time of the analgesic pump was significantly later in the combined group than that in the non-combined group(t=2.39,P=0.025),and the effective pressing time of analgesic pump was less in the combined group with 48 h after the operation than that in the non-combined group(t=2.62,P=0.013).Compared with the non-combined group,the incidence of hypertension and tachycardia were less in the combined group(t=4.97,P=0.026;t=6.07,P=0.014).VAS at resting and coughing were lower,the cases of VAS 0~3 were significantly more and the incidence of nausea and vomiting was lower in the combined group than those in non-combined group at 1,6 and 12 h after the operation(all P<0.05).The recovery time and extubation time were shorter in the combined group than those in the non-combined group(all P<0.05).The agitation score during the awake period and the length of post-anesthesia care unit stay were less in the combined group than those in the non-combined group(all P<0.05).Conclusions Ultrasound-guided stellate ganglion block combined with small dosage of esketamine undergoing thoracoscopic lobectomy can provide effective perioperative analgesic effect,reduce the dosage of opioids,maintain hemodynamic stability,shorten the recovery time and extubation time,and decrease agitation during the awake period.