艾司氯胺酮联合纳布啡用于剖宫产术后镇痛对产后抑郁及镇痛效果的影响

Efficacy of esketamine combined with nalbuphine for postoperative analgesia on postpartum depression and analgesia in maternity undergoing cesarean section

目的观察艾司氯胺酮联合纳布啡用于剖宫产术后镇痛对产后抑郁及镇痛效果的影响。方法收集中国人民解放军联勤保障部队第九七〇医院2023年1月至4月妇产科行择期剖宫产术的产妇120例,年龄22~35岁,体重指数(BMI)20.9~35.1 kg/m^(2),ASA分级Ⅰ/Ⅱ级。采用随机数字表法将其随机分为两组:艾司氯胺酮联合纳布啡组(L组)和单纯纳布啡组(N组),每组60例。两组产妇均于L_(3~4)间隙行腰麻与硬膜外联合麻醉,腰麻给予0.5%布比卡因2 ml,阻滞平面控制在T_(4~6),统一向头端置入硬膜外导管,若麻醉效果欠佳,可经硬膜外腔给予0.5%罗哌卡因5~10 ml。两组产妇术后均给予静脉自控镇痛泵(PCIA),L组术后镇痛药物方案:盐酸艾司氯胺酮1 mg/kg+纳布啡0.5 mg/kg+托烷司琼10 mg,以生理盐水稀释至150 ml;N组用纳布啡0.6 mg/kg+托烷司琼10 mg,以生理盐水稀释至150 ml。记录两组产妇术后2、4、6、12、24、36、48 h的静息视觉模拟评分(VAS)和运动VAS评分;记录产妇术前1 d与术后2、4、6、12、24、36、48 h Ramsay镇静评分;记录两组产妇术后1、3、5、7 d爱丁堡产后抑郁量表(EPDS)的抑郁评分;记录两组产妇术后静脉自控镇痛泵追加按压次数;统计两组产妇术后VAS评分0~3分的例数及术后药物不良反应发生率。结果L组产妇术后1、3、5、7 d的EPDS抑郁评分依次为(5.4±0.8)、(6.0±0.6)、(6.2±0.8)、(6.8±0.8),N组组产妇术后1、3、5、7 d的产后爱丁堡产后抑郁量表抑郁评分依次为(6.0±0.9)、(8.4±1.8)、(8.6±1.6)、(8.7±1.4),L组产妇术后1、3、5、7 d的EPDS评分均低于N组,差异均具有统计学意义(P<0.01);L组术后4、6、12、24、36、48 h的运动VAS评分分别为(2.1±0.5)、(2.3±0.6)、(2.6±0.7)、(2.8±0.4)、(2.7±0.5)、(2.4±0.6),同时间点N组分别为(2.3±0.7)、(2.8±1.0)、(2.7±0.5)、(3.2±0.7)、(3.1±0.8)、(2.6±0.6),L组术后4、6、12、24、36、48 h的运动VAS评分均低于N组,差异均具有统计学意义(P均<0.05)。术后48 h内按压镇痛追加次数L组为(5.6±1.3)次,较N组的(7.8±1.7)次少,差异具有统计学意义(P<0.01)。产妇术后VAS评分0~3分的例数L组53例,N组37例,差异具有统计学意义(P<0.01)。两组产妇术后2、4、6、12、24、36、48 h的静息VAS评分差异均无统计学意义(P均>0.05)。L组产妇术后12、24、36、48 h Ramsay镇静评分高于N组,差异均具有统计学意义(P均<0.05)。结论艾司氯胺酮联合纳布啡用于产妇剖宫产术后镇痛,具有更好的镇痛、镇静作用,减轻产妇术后运动疼痛;艾司氯胺酮具有明显的抗抑郁作用,保护产妇心理健康,降低产妇术后抑郁的发生。

Objective To observe the efficacy of esketamine combined with nalbuphine for postoperative analgesia on postpartum depression and analgesic effect in maternity undergoing cesarean section.Methods One hundred and twenty maternities underwent elective cesarean section,aged 22 to 35 years,BMI 20.9 to 35.1 kg/m^(2)and ASAⅠ/Ⅱ,were divided into two groups,esketamine combined with nalbuphine group(group L)and nalbuphine group(group N),60 cases in each group according to the random number table,in the Department of Anesthesiology,970th Hospital of the PLA Joint Logistic Support Force from January to April 2023.In both groups,combined lumbar and epidural anesthesia was administered in the L_(3-4) interval,and the level of anesthesia was controlled at T_(4)-T_(6).PCIA were performed with esketamine 1 mg/kg+nalbuphine 0.6 mg/kg+tropisetron 10 mg+saline to 150 ml in the group L,and with nalbuphine 0.6 mg/kg+tropisetron 10 mg+saline to 150 ml in the group N.The cases of VAS between 0 and 3 were calculated.The Ramsay sedation scores were recorded before and after the surgery at 2,4,6,12,24,36 and 48 h.The Edinburgh postpartum depression scale(EPDS)was recorded at 1,3,5 and 7 d after surgery in both groups.The numbers of extra PCA pump presses and the incidence of adverse reactions were recorded.Results The EPDS at postoperative 1,3,5,and 7 d were(5.4±0.8),(6.0±0.6),(6.2±0.8),and(6.8±0.8)respectively in the group L,while those in the group N were(6.0±0.9),(8.4±1.8),(8.6±1.6),and(8.7±1.4)respectively.The EPDS of maternals in the group L were significantly lower than those in the group N(P<0.01).VAS in movement at postoperative 4,6,12,24,36,and 48 h were lower in group L than that in group N(all P<0.05).During the 48 h after the surgery,the maternities in group L required significantly fewer additional compression analgesia then that in group N(P<0.01).The numbers of VAS 0-3 were significantly higher in group L(53 cases)than that in group N(37 cases)(P<0.01).There was no statistical difference in the resting VAS between the two groups at postoperative 2,4,6,12,24,36 and 48 h(all P>0.05).Compared with the group N,the Ramsay sedation scores were increased significantly in group L at postoperative 12,24,36 and 48 h(all P<0.05).Conclusion Esketamine combined with nalbuphine for postoperative analgesia after maternal cesarean section has better analgesic efficacy and obvious antidepressant effects.