艾司氯胺酮对青少年脊柱侧凸矫形手术中唤醒试验的影响

The effect of esketamine on the wake-up test in orthopedic surgery for adolescent scoliosis

目的评价术中使用艾司氯胺酮对青少年脊柱侧凸矫形手术唤醒试验的影响。方法选择择期行脊柱侧凸矫形手术患者80例, 采用随机数字表法分为2组:艾司氯胺酮组(SK组, 40例)和对照组(C组, 40例)。SK组麻醉诱导时给予艾司氯胺酮0.25 mg/kg, 继以0.25 mg·kg^(-1)·h^(-1)静脉输注;C组给予等容量的生理盐水。麻醉维持:两组均静脉泵注丙泊酚以5 mg·kg^(-1)·h^(-1)起始, 并根据BIS调整输注速率, 维持BIS值在45~55;瑞芬太尼以0.25 μg·kg^(-1)·min-1起始并根据血流动力学变化进行0.05 μg·kg^(-1)·min-1的梯度增减调节。记录唤醒时间, 评判唤醒质量, 同时评估和记录患者唤醒时的Ramsay镇静评分、Riker躁动评分, 唤醒前10 min(T0)、唤醒成功时(T1)、再次入睡后(T2)的MAP、心率, 计算T0~T1、T1~T2的MAP和心率变化(ΔMAP、ΔHR)。记录唤醒前麻醉时间、丙泊酚使用剂量及瑞芬太尼使用剂量、出血量、血管活性药物使用率, 记录手术全程总麻醉时间、总出血量、丙泊酚使用剂量及瑞芬太尼使用剂量、血管活性药物使用率;术后记录PACU内停留时间、气管拔管时间、VAS疼痛评分、Ramsay镇静评分和Riker躁动评分、恶心呕吐和噩梦等不良反应的发生情况。结果两组患者一般情况指标, 唤醒前的麻醉时间、丙泊酚使用剂量、出血量, 手术全程总麻醉时间、总出血量、丙泊酚使用剂量, 唤醒前和手术全程血管活性药使用率, 术后PACU内停留时间、气管拔管时间及不良反应发生情况比较, 差异均无统计学意义(P>0.05)。与C组比较, SK组患者唤醒质量分级Ⅰ级比例升高, Ⅱ级、Ⅲ级比例降低, 唤醒时间缩短, Ramsay镇静评分升高, Riker躁动评分降低, 唤醒前和手术全程的瑞芬太尼使用剂量减少, 差异均有统计学意义(P<0.05)。唤醒期间SK组T0~T1、T1~T2的ΔMAP和ΔHR均低于C组(P<0.05)。与C组比较, SK组术后苏醒时的Ramsay镇静评分升高, Riker躁动评分降低, VAS疼痛评分降低, 差异均有统计学意义(P<0.05)。结论使用艾司氯胺酮0.25 mg/kg麻醉诱导并以0.25 mg·kg^(-1)·h^(-1)静脉持续输注, 能有效提高术中唤醒质量, 缩短唤醒时间, 稳定唤醒期间的血流动力学, 减少术中瑞芬太尼使用剂量, 有利于提高麻醉安全和质量。

Objective To assess the effect of esketamine on the wake-up test in orthopedic surgery for adolescent scoliosis.Methods A total of 80 patients who were treated with selective orthopedic surgery for adolescent scoliosis were recruited.Using the random number table method,patients were divided into the esketamine group(SK group,n=40)and the control group(C group,n=40).When anesthesia induction was performed,0.25 mg/kg esketamine was additionally administrated in patients of the SK group,followed by intravenous infusion of 0.25 mg·kg^(-1)·h^(-1) esketamine;while those in the C group were given the same volume of normal saline.Anesthesia maintenance in both groups was performed by intravenous infusion of propofol and remifentanil.Propofol was given at the initial dosage of 5 mg·kg^(-1)·h^(-1),the infusion rate of which was adjusted to maintain the bispectral index(BIS)of 45-55.Remifentanil was given at the initial dosage of 0.25μg·kg^(-1)·min-1,and subsequently increased or reduced stepwise by 0.05μg·kg^(-1)·min-1 according to hemodynamic changes.The wake-up time was recorded and the wake-up quality was assessed.Ramsay sedation scores and Riker agitation scores at wake-up were recorded.This article recorded the mean arterial pressure(MAP)and heart rate 10 min before awakening(T0),at the time of successful awakening(T1),and after falling asleep again(T2),the MAP and heart rate changes of T0-T1 and T1-T2(ΔMAP,ΔHR)were calculated.The anesthesia time before wake-up and during the whole surgery,dose of propofol and remifentanil,blood loss,and the use of vasoactive drugs were also recorded.In addition,length of stay in the post-anesthesia care unit(PACU),time of extubation,Visual Analog Scale(VAS)scores,Ramsay sedation scores,Riker agitation scores,and the incidence of adverse events like nausea,vomiting,and nightmares after surgery were recorded.Results Baseline characteristics,anesthesia time before wake-up and during the whole surgery,dose of propofol,blood loss,use of vasoactive drugs,length of stay in PACU,time of extubation,and incidence of adverse events in the SK group and C group were comparable(P>0.05).Compared with C group,the quality of wake-up test in SK group showed an increase in the proportion of grade I and a decrease in the proportion of gradeⅡandⅢ,and the patients in SK group presented shorter wake-up time,higher Ramsay sedation scores,lower Riker agitation scores,and less dose of remifentanil before wake-up and during the whole surgery(P<0.05).ΔMAP andΔHR(T0-T1,T1-T2)during wake-up in the SK group were significantly smaller than those in the C group(P<0.05).In addition,patients in the SK group were graded significantly higher Ramsay sedation scores,lower Riker agitation,and lower VAS scores after postoperative recovery(all P<0.05).Conclusions Anesthesia induction by esketamine at 0.25 mg/kg and continuous intravenous infusion of 0.25 mg·kg^(-1)·h^(-1) esketamine effectively enhances the intraoperative wake-up quality,shortens the wake-up time,stabilizes hemodynamics during wake-up,and reduces the intraoperative dose of remifentanil,which is favorable to improve the safety and quality of anesthesia.