艾司氯胺酮用于患者自控静脉镇痛对胸外科手术老年患者术后慢性疼痛的影响

Effects of esketamine used for patient-controlled intravenous analgesia on chronic postoperative pain in elderly patients undergoing thoracic surgery

目的探讨艾司氯胺酮用于患者自控静脉镇痛(PCIA)在胸外科手术老年患者术后慢性疼痛(CPSP)中的作用。方法选择拟行电视胸腔镜下肺癌根治术的老年患者120例,随机均分为对照组和试验组,2组麻醉诱导和维持方案相同。所有患者术毕即刻连接PCIA泵,镇痛药对照组为舒芬太尼1.0μg·kg^(-1)+氟比洛芬酯2.0 mg·kg^(-1)+托烷司琼10 mg,试验组为艾司氯胺酮2.0 mg·kg^(-1)+氟比洛芬酯2.0 mg·kg^(-1)+托烷司琼10 mg,均以氯化钠注射液稀释至100 m L,且PICA泵参数设置相同。记录术后48 h内疼痛视觉模拟量表(VAS)评分和Ramsay镇静评分,及不良反应发生情况,检测患者术前1 d和术后1、3 d的血清肿瘤坏死因子(TNF)-α、白细胞介素(IL)-6和IL-8浓度。术后3、6个月电话随访,记录有无CPSP发生。结果术后48 h内,2组VAS评分和Ramsay镇静评分、镇痛补救率、PCIA泵总按压和有效按压次数比较,差异均无显著意义(P>0.05)。术后48 h内试验组恶心、呕吐发生率显著低于对照组(P<0.05)。与术前1 d相比,术后1、3 d时2组血清TNF-α、IL-6和IL-8浓度均显著上升(P>0.05),但试验组血清TNF-α、IL-6和IL-8浓度均显著低于对照组(P<0.05)。术后6个月内对照组失访2例,试验组失访3例。术后3个月对照组和试验组分别发生CPSP 18例(31%)和7例(12%),术后6个月分别发生15例(26%)和5例(9%),差异均有显著意义(P<0.05)。结论艾司氯胺酮用于PCIA可降低胸外科手术老年患者CPSP的发生率,可能与炎症反应受到抑制有关。

AIM To investigate the effects of esketamine used for patient-controlled intravenous analgesia(PCIA)on chronic postsurgical pain(CPSP)in elderly patients undergoing thoracic surgical procedures.METHODS A total of 120 elderly patients scheduled for video-assisted thoracoscopic radical resection of lung cancer were randomly divided equally into control group and trial group,with the same anesthesia induction and maintenance protocols in both groups.All patients were immediately connected to the PCIA pump after surgery.The analgesic drugs of the control group were sufentanil 1.0μg·kg^(-1)+flurbiprofen axetil 2.0 mg·kg^(-1)+tropisetron 10 mg,and of the trial group were esketamine 2.0 mg·kg^(-1)+flurbiprofen axetil 2.0 mg·kg^(-1)+tropisetron 10 mg,which were both diluted to 100 mL with sodium chloride injection,and the parameters of the PICA pump in the both groups were the same.The pain visual analogue scale(VAS)score and Ramsay sedation score was recorded within 48 hours after surgery,as well as the occurrence of adverse reactions.The concentrations of serum tumor necrosis factor(TNF)-α,interleukin(IL)-6 and IL-8 on preoperative 1 d and postoperative 1 d and 3 d were measured.Telephone follow-up was conducted 3 to 6 months after surgery to record the occurrence of CPSP.RESULTS There was no significant difference in the VAS score,Ramsay sedation score,the rate of analgesic rescue,the total number of compression and the number of effective compression of PCIA pump between the two groups within 48 hours after surgery(P>0.05).The incidence of nausea and vomiting in the trial group was significantly lower than that in the control group within 48h after operation(P<0.05).Compared with preoperative 1 d,the concentrations of serum TNF-α,IL-6 and IL-8 in the two groups were significantly increased(P<0.05)on postoperative 1 d and 3 d,but the concentrations of serum TNF-α,IL-6 and IL-8 in the trial group were significantly lower than those in the control group(P<0.05).Within 6 months after surgery,there were 2 cases of lost follow-up in the control group and 3 cases of lost follow-up in the trial group.At 3 months after surgery,CPSP occurred in 18 cases(31%)of the control group and 7 cases(12%)of the trial group,respectively(P<0.05).At 6 months after surgery,CPSP occurred in 15 cases(26%)of the control group and 5 cases(9%)of the trial group,with significant differences between the two groups(P<0.05).CONCLUSION Esketamine for PCIA can reduce the incidence of CPSP in elderly patients undergoing thoracic surgery,which may be related to the inhibition of inflammatory response.