不同剂量艾司氯胺酮复合罗哌卡因臂丛上干阻滞对肩关节镜术后反弹性疼痛的影响

Effects of different doses of esketamine combined with ropivacaine on rebound pain after arthroscopic shoulder surgery under superior trunk brachial plexus block

目的探讨不同剂量艾司氯胺酮复合罗哌卡因臂丛上干阻滞对肩关节镜术后反弹性疼痛的影响。方法选择行肩关节镜下治疗的患者90例,男35例,女55例,年龄18~60岁,BMI 18.5~28.0 kg/m^(2),ASAⅠ或Ⅱ级,按照随机数字表法将患者分为三组:E1组、E2组和R组,每组30例。三组患者神经阻滞局麻药物分别按照以下方案配置,E1组予0.2%罗哌卡因、艾司氯胺酮0.25 mg/kg和生理盐水共10 ml;E2组予0.2%罗哌卡因、艾司氯胺酮0.5 mg/kg和生理盐水共10 ml;R组予0.2%罗哌卡因和生理盐水共10 ml。所有患者在神经阻滞麻醉起效后行全身麻醉。记录神经阻滞前(T_(1))、阻滞后30 min(T_(2))、置入喉罩(T_(3))、术中30 min(T_(4))时HR、MAP、手术体积描计指数(SPI)。记录术后6、8、12、24、48 h时静息和活动时NRS评分、反弹性疼痛的发生情况。记录神经阻滞麻醉后感觉和运动阻滞起效时间以及持续时间、阻滞前后镇静评分、术后24 h内睡眠情况、术后48 h内不良反应的发生情况。结果三组不同时点HR、MAP差异均无统计学意义。与R组比较,E1、E2组舒芬太尼用量明显减少,术后12~48 h静息和活动时NRS评分明显降低(P<0.05)。与R组比较,E2组反弹性疼痛发生率明显降低,神经阻滞后镇静评分明显升高,术后1 d睡眠时间明显延长,睡眠效率明显升高(P<0.05)。与R组比较,E1、E2组术后48 h内恶心呕吐、头晕头痛等术后不良反应发生率明显降低(P<0.05)。三组感觉阻滞起效时间和持续时间差异无统计学意义,且均未出现运动神经阻滞。结论艾司氯胺酮0.5 mg/kg复合罗哌卡因能降低臂丛上干神经阻滞肩关节镜术后反弹性疼痛的发生率,改善患者术后睡眠质量,但不能缩短臂丛上干神经阻滞的感觉阻滞起效时间和增加阻滞持续时间。

Objective To investigate the effects of different doses of esketamine combined with ropivacaine on rebound pain after arthroscopic shoulder surgery under superior trunk brachial plexus block.Methods Ninety patients,including 35 males and 55 females,aged 18-60 years,BMI 18.5-28.0 kg/m^(2),ASA physical statusⅠorⅡ,were selected for shoulder arthroscopy.According to the method of random number table,the patients were divided into three groups:group E1,group E2 and group R,30 patients in each group.Three groups of patients with nerve block local anesthetic drugs were allocated according to the following scheme.In group E1,0.2%ropivacaine,esketamine 0.25 mg/kg,and normal saline total 10 ml.In group E2,0.2%ropivacaine,esketamine 0.5 mg/kg,and normal saline total 10 ml.In group R,0.2%ropivacaine and normal saline total 10 ml.General anesthesia was implemented for all patients after the nerve block anesthesia.HR,MAP,and surgical pleth index(SPI)were recorded before nerve block(T_(1)),30 minutes after nerve block(T_(2)),laryngeal mask placement(T_(3)),and 30 minutes during surgery(T_(4)).The NRS scores and the occurrence of rebound pain were recorded at rest and exercise 6,8,12,24,and 48 hours after surgery.The onset time and duration of sensory and motor block after anesthesia,sedation score before and after anesthesia,sleep quality within 24 hours after surgery,and the occurrence of adverse reactions within 48 hours after surgery were recorded.Results There were no significant differences in HR and MAP among the three groups at different time points.Compared with group R,the dosage of sufentanil in groups E1 and E2 were significantly reduced,and the NRS score at rest and exercise 12 to 48 hours after surgery were significantly decreased(P<0.05).Compared with group R,the incidence of rebound pain in group E2 was significantly reduced,and the score of sedation after nerve block was significantly increased,the sleep time was significantly prolonged,and the sleep efficiency was significantly increased within 1 day after surgery(P<0.05).Compared with group R,the incidence of postoperative adverse reactions such as nausea,vomiting,dizziness and headache in groups E1 and E2 within 48 hours after surgery were significantly reduced(P<0.05).There were no significant differences in the onset and duration of sensory block among the three groups,and no motor nerve block occurred.Conclusion Esketamine 0.5 mg/kg combined with ropivacaine can reduce the incidence of rebound pain after shoulder arthroscopy with brachial plexus block,improve postoperative sleep quality,but cannot shorten the onset time of sensory block and increase the duration of block.