艾司氯胺酮用于甲状腺切除术患者无肌松插管对诱导后低血压发生率的影响:一项随机对照研究

Effect of esketamine for endotracheal intubation in patients undergoing thyroidectomy without muscle relaxants on post-induction hypotension:a randomized controlled trial

目的探讨艾司氯胺酮用于无肌松插管对诱导后低血压(post-induction hypotension,PIH)发生率的影响。方法纳入2021年11月8日至2022年2月18日在复旦大学附属中山医院接受术中神经电生理监测的甲状腺切除术患者188例,随机分为艾司氯胺酮组(n=94,艾司氯胺酮1 mg/kg、瑞芬太尼4μg/kg和丙泊酚0.5 mg/kg)和丙泊酚组(n=94,丙泊酚2.5 mg/kg和瑞芬太尼4μg/kg)。记录气管插管前(T1:全部诱导药物后注射后30 s)以及气管插管后间隔1 min(T2~T6)的平均动脉压(mean arterial pressure,MAP)的变化;比较在T1时间点,两组方案PIH发生率的差异。结果两组患者的临床特征具有可比性。艾司氯胺酮组和丙泊酚组插管前PIH发生率分别为31.5%、79.8%(P<0.001)。在所有观察时间点,艾司氯胺酮组PIH发生率均显著低于丙泊酚组(P<0.001)。两组患者麻醉诱导后MAP较基线显著降低(F=256.78,P<0.001)。丙泊酚组MAP下降幅度大于艾司氯胺酮组(F=17.53,P<0.001)。艾司氯胺酮组插管条件满意为31例(33.7%),丙泊酚组为88例(93.6%);艾司氯胺酮组插管条件良好61例(66.3%),丙泊酚组6例(6.4%),差异均有统计学意义(P<0.001)。结论采用艾司氯胺酮1 mg/kg、瑞芬太尼4μg/kg、丙泊酚0.5 mg/kg的诱导方案进行无肌松插管可降低PIH的发生率,并提供临床可接受的插管条件。

Objective To explore the effects of esketamine and propofol on post-induction hypotension(PIH)for endotracheal intubation without muscle relaxants.Methods We enrolled 188 adult patients undergoing thyroidectomy under intraoperative electromyographic monitoring in Zhongshan Hospital,Fudan University from November 8th,2021 to February 18th,2022.Patients were randomly allocated into esketamine group(n=94,esketamine 1 mg/kg,remifentanil 4μg/kg and propofol 0.5 mg/kg)and propofol group(n=94,propofol 2.5 mg/kg and remifentanil 4μg/kg).The primary outcome was the occurrence of PIH before intubation(T1,30 s after all induction agents injection).Mean arterial pressure(MAP)was recorded before intubation(T1)and at 1-minute interval for 5 minutes(T2-T6)after endotracheal intubation.Results Patients in both groups had comparable clinical characteristics.The incidence of PIH before intubation was 31.5%in esketamine group and 79.8%in propofol group(P<0.001).MAP significantly decreased compared with the baseline in both groups(F=256.78,P<0.001).The decrease of MAP in propofol group was greater than that in esketamine group(F=17.53,P<0.001).Excellent intubation conditions were 31(33.7%)in esketamine group and 88(93.6%)in propofol group,while good intubation conditions were 61(66.3%)in esketamine group and 6(6.4%)in propofol group(P<0.001).Conclusions Induction with esketamine 1 mg/kg,remifentanil 4μg/kg and propofol 0.5 mg/kg can reduce the incidence of PIH with clinically acceptable intubation condition for endotracheal intubation without muscle relaxants.