低剂量艾司氯胺酮对老年肩关节镜手术患者术后早期认知功能及疼痛的影响研究

Effect of low dose esketamine on early postoperative cognitive function and pain in elderly patients undergoing shoulder arthroscopic surgery

目的探讨低剂量艾司氯胺酮对老年肩关节镜手术患者术后早期认知功能、疼痛的影响。方法前瞻性纳入2021年3月至2023年6月徐州医科大学附属淮安医院收治的老年肩关节镜手术患者110例,按随机数字表法将其分为低剂量组(E组)与对照组(C组),每组各55例。两组患者均行气管插管全身麻醉,E组麻醉诱导方案为艾司氯胺酮0.2 mg/kg+舒芬太尼0.5μg/kg+丙泊酚1.0 mg/kg+依托咪酯0.2 mg/kg+苯磺酸顺式阿曲库铵0.2 mg/kg,C组麻醉诱导方案为等容量0.9%氯化钠溶液+舒芬太尼0.5μg/kg+丙泊酚1.0 mg/kg+依托咪酯0.2 mg/kg+苯磺酸顺式阿曲库铵0.2 mg/kg。比较两组患者术前、手术开始时、拔管时的心率、平均动脉压(MAP)水平;利用视觉模拟评分法(VAS)评估患者术后2、4、8、24 h的疼痛程度;比较两组术前及术后1 d的血清皮质醇、肾上腺素、去甲肾上腺素(NE)水平;利用简易精神状态检查量表(MMSE)评估两组术前及术后1、3 d的认知功能。结果两组手术开始时、拔管时的心率、MAP均低于术前,E组手术开始时、拔管时的心率分别为(69.95±6.52)、(70.15±5.78)次/min,MAP分别为(76.18±6.24)、(79.89±7.51)mmHg,均低于C组[(74.62±8.20)、(75.64±6.68)次/min和(80.36±7.96)、(82.80±6.14)mmHg],差异均有统计学意义(P<0.05)。E组术后4、8、24 h的VAS评分分别为(1.64±0.59)、(1.95±0.45)、(2.69±0.47)分,均低于C组[(2.49±0.50)、(2.98±0.53)、(3.42±0.71)分],差异均有统计学意义(P<0.05)。两组术后1 d血清皮质醇、肾上腺素、NE水平均高于术前,E组术后1 d血清皮质醇、肾上腺素、NE水平分别为(118.52±10.46)nmol/L、(202.14±27.32)nmol/L、(183.24±8.27)pg/mL,均低于C组[(130.45±11.87)nmol/L、(254.36±18.67)nmol/L、(201.88±15.65)pg/mL],差异均有统计学意义(P<0.05)。两组术后1 d的MMSE评分均低于术前及术后3 d,且E组术后1、3 d的MMSE评分分别为(26.22±1.03)、(27.62±1.45)分,均高于C组[(24.18±0.86)、(26.55±1.99)分],差异均有统计学意义(P<0.05)。结论0.2 mg/kg艾司氯胺酮在老年肩关节镜手术患者中能取得较好效果,可促进术后早期认知功能恢复,减轻术后疼痛程度。

Objective To investigate the effects of low dose esketamine on early postoperative cognitive function and pain in elderly patients undergoing shoulder arthroscopic surgery.Methods A total of 110 elderly patients with shoulder arthroscopic surgery admitted to The Affiliated Huai'an Hospital of Xuzhou Medical University from March 2021 to June 2023 were included and divided into low dose esketamine group(group E)and control group(group C)according to the random number table method with 55 cases in each group.General anesthesia was performed in both groups,and the anesthesia induction regimen in the group E was esketamine 0.2 mg/kg+sufentanil 0.5μg/kg+propofol 1.0 mg/kg+etomidate 0.2 mg/kg+cis-atracurium benzoate 0.2 mg/kg.The anesthesia induction regimen of the control group was equal volume normal saline+sufentanil 0.5μg/kg+propofol 1.0 mg/kg+etomidate 0.2 mg/kg+cis-atracurium benzoate 0.2 mg/kg.The heart rate and mean arterial pressure(MAP)levels of the two groups were compared before surgery,beginning of the surgery and extubation.Visual analogue scale(VAS)was used to evaluate the pain degree of the patients 2,4,8 and 24 h after surgery.The levels of serum cortisol,epinephrine and norepinephrine(NE)were compared between the two groups before and 1 day after surgery.The mini-mental state examination(MMSE)was used to evaluate the cognitive function of the two groups before and 1 and 3 d after surgery.Results The heart rate and MAP at the beginning of surgery and extubation in both groups were lower than before surgery,and the heart rates at the beginning of surgery and extubation in the group E were(69.95±6.52),(70.15±5.78)beats/min,and the MAP were(76.18±6.24)and(79.89±7.51)mmHg,respectively,which were lower than those in the group C[(74.62±8.20),(75.64±6.68)beats/min,(80.36±7.96),and(82.80±6.14)mmHg],and the differences were statistically significant(P<0.05).The VAS scores of the group E at 4,8,and 24 hours after surgery were(1.64±0.59),(1.95±0.45),and(2.69±0.47)points,respectively,which were lower than those of the group C[(2.49±0.50),(2.98±0.53),and(3.42±0.71)points],and the differences were statistically significant(P<0.05).The levels of serum cortisol,adrenaline,and NE levels in both groups at 1 day after surgery were higher than before surgery,and the levels of serum cortisol,adrenaline,and NE in the group E at 1 day after surgery were(118.52±10.46)nmol/L,(202.14±27.32)nmol/L,and(183.24±8.27)pg/mL,respectively,which were lower than those in the group C[(130.45±11.87)nmol/L,(254.36±18.67)nmol/L,and(201.88±15.65)pg/mL],and the differences were statistically significant(P<0.05).The MMSE scores of the two groups at 1 day after surgery were lower than those before surgery and the 3 days after surgery,and the MMSE scores of the group E at the 1 and 3 days after surgery were(26.22±1.03)and(27.62±1.45)points,respectively,which were higher than those of the group C[(24.18±0.86)and(26.55±1.99)points],and the differences were statistically significant(P<0.05).Conclusion 0.2 mg/kg esketamine can achieve good results in elderly patients with shoulder arthroscopic surgery,which can promote early postoperative cognitive function recovery and reduce postoperative pain level.