超声引导单次髂筋膜间隙阻滞联合艾司氯胺酮对髋部骨折手术老年患者术后谵妄的影响

Effect of ultrasound-guided single fascia iliaca compartment block combined with esketamine on postoperative delirium in elderly patients undergoing hip fracture surgery

目的评价超声引导单次髂筋膜间隙阻滞联合艾司氯胺酮对髋部骨折手术老年患者术后谵妄(POD)的影响。方法择期蛛网膜下腔麻醉下行髋部骨折手术患者62例,年龄60~85岁,BMI 18~30 kg/m^(2),ASA分级Ⅱ或Ⅲ级,性别不限。采用随机数字表法将患者分为2组(n=31):单次髂筋膜间隙阻滞组(FICB组)和单次髂筋膜间隙阻滞联合艾司氯胺酮组(FICB+E组)。于蛛网膜下腔麻醉前30 min行超声引导髂筋膜间隙阻滞;FICB+E组于切皮前5 min静脉注射艾司氯胺酮0.3 mg/kg,随后以0.25 mg·kg^(-1)·h^(-1)的速率静脉泵注至手术结束前30 min。术后采用PCIA,并采用曲马多进行补救镇痛。记录术后48 h内镇痛泵按压次数、补救镇痛次数和曲马多用量;于切皮时、手术开始后30 min、手术结束前30 min、手术结束时、离开PACU时采用Ramsay镇静评分评估镇静程度;采用意识模糊评估法(CAM)评估术后7 d内POD的发生情况;于入室、术后3 d、术后7 d时采用ELISA法检测血清TNF-α、IL-6、S100β和胶质纤维酸性蛋白(GFAP)浓度;记录药物相关不良反应发生情况。结果与FICB组比较,FICB+E组术后3 d内POD发生率降低,曲马多用量、镇痛泵按压次数、补救镇痛次数减少,各时点Ramsay镇静评分升高,术后血清TNF-α、IL-6、S100β和GFAP浓度降低(P<0.05),术后7 d总POD发生率差异无统计学意义(P>0.05)。结论超声引导单次髂筋膜间隙阻滞联合艾司氯胺酮可为老年髋部骨折患者围术期提供更完善的镇痛和镇静,降低术后早期(3 d内)POD的发生风险。

Objective To evaluate the effect of ultrasound-guided single fascia iliaca compartmentblock(FICB)combined with esketamine on postoperative delirium(POD)in elderly patients undergoing hip fracture surgery.Methods Sixty-two patients of either sex,aged 60-85 yr,with body mass index of 18-30 kg/m^(2),of American Society of Anesthesiologists Physical Status classificationⅡorⅢ,undergoing hip fracture surgery under subarachnoid anesthesia,were divided into 2 groups(n=31 each)using a random number table method:single FICB group(group FICB)and single FICB combined with esketamine group(group FICB+E).Ultrasound-guided FICB was performed on the operated side at 30 min before subarachnoid anesthesia.In FICB+E group,esketamine was intravenously injected as a bolus of 0.3 mg/kg at 5 min before skin incision followed by an infusion of 0.25 mg·kg^(-1)·h^(-1)until 30 min before the end of procedure.Patient-controlled intravenous analgesia was used for postoperative analgesia,and tramadol 1 mg/kg was given for rescue analgesia.The pressing times of patient-controlled analgesia,the number of rescue analgesia,and consumption of tramadol were recorded within 48 h after operation.The Ramsay sedation score was used to assess the degree of sedation at skin incision,30 min after the start of surgery,30 min before the end of surgery,at the end of surgery,and at discharge from the post-anesthesia care unit.Postoperative delirium(POD)occurred within 7 days after surgery was assessed using the Confusion Assessment Method.The serum concentrations of tumor necrosis factor-alpha,interleukin-6,S100βand glial fibrillary acidic protein(GFAP)were detected by enzyme-linked immunosorbent assay on admission to the operating room and at 3 and 7 days after surgery.The occurrence of adverse drug reactions(respiratory depression,nausea and vomiting,dizziness,somnolence,urinary retention)was recorded.Results Compared with group FICB,the incidence of POD was significantly decreased within 3 days after surgery,the consumption of tramadol,pressing times of patient-controlled analgesia and the number of rescue analgesia were reduced,Ramsay sedation score was increased at each time point,and the serum concentrations of tumor necrosis factor-alpha,interleukin-6,S100βand glial fibrillary acidic protein were decreased after surgery(P<0.05),and no significant change was found in the total incidence of POD at 7 days after surgery in group FICB+B(P>0.05).Conclusions Ultrasound-guided single FICB combined with esketamine can provide adequate analgesia and sedation in the perioperative period for elderly patients with hip fractures,reducing the risk of early postoperative(within 3 days)POD.