艾司氯胺酮联合舒芬太尼术后自控镇痛对单次神经阻滞后暴发痛影响的随机对照研究

Randomized controlled study on the effect of esketamine combined with sufentanil for postoperative patientcontrolled analgesia on rebound pain after single nerve block

目的探讨艾司氯胺酮联合舒芬太尼术后患者自控静脉镇痛(patient controlled intravenous analgesia,PCIA)对单次神经阻滞后暴发痛的影响。方法纳入2021年1月—2022年12月在复旦大学附属金山医院以单次神经阻滞的麻醉方式进行上肢骨折手术的患者80例,按照随机数字法平均分为艾司氯胺酮联合舒芬太尼PCIA组(Ket组)和舒芬太尼PCIA(Ctrl组)两组,每组40例。记录术后8 h、12 h、24 h、48 h的疼痛评分,初次疼痛时间和疼痛评分,按压镇痛泵30 min后疼痛评分,术后24 h、48 h阿片类药物用量和患者按压镇痛泵自控按钮次数。患者术后突然感到从“不痛”到“异常疼痛”[疼痛数字评价量表(numerous rating scale,NRS)评分≥7],并且需按压镇痛泵自控按钮判定为发生暴发痛。结果Ctrl组17例(45.95%)发生暴发痛,Ket组12例(36.36%)发生暴发痛,差异无统计学意义。Ket组术后24 h舒芬太尼用量少于Ctrl组,PCIA按压次数少于Ctrl组,差异有统计学意义(P=0.007)。两组发生暴发痛的患者术后48 h舒芬太尼用量和PCIA按压次数差异无统计学意义。发生暴发痛的患者在暴发痛出现并按压PCIA按钮后30 min,Ket组有12例(100.00%),Ctrl组有3例(17.65%)患者NRS<4,差异有统计学意义(P=0.02)。结论与单纯使用舒芬太尼PCIA比较,联合使用艾司氯胺酮不能降低上肢骨折手术单次神经阻滞后暴发痛的发生率。联合使用艾司氯胺酮可能有更快缓解暴发痛的作用。

Objective To investigate the effect of esketamine combined with sufentanil for postoperative patientcontrolled intravenous analgesia(PCIA) on rebound pain after single nerve block. Methods From January 2021 to December 2022,80 patients undergoing upper limb fracture surgery in Jinshan Hospital, Fudan University with single nerve block anesthesia were included and randomly divided into two groups: the Ket group(esketamine combined with sufentanil PCIA) and the Ctrl group(sufentanil PCIA), with 40 patients in each group. Several indicators were recorded, including pain scores at 8 h,12 h, 24 h, and 48 h postoperatively, the time to first pain and its score, pain scores 30 min after pressing the PCIA pump self-control button, as well as opioid consumption at 24 h and 48 h postoperatively, and the number of PCIA button presses. Rebound pain was defined as a sudden transition from “no pain” to “severe pain”(NRS≥7) requiring pressing the PCIA self-control button.Results Rebound pain occurred in 17(45.95%) patients in the Ctrl group and 12(36.36%) patients in the Ket group, with no statistically significant difference. The Ket group had significantly lower sufentanil consumption and fewer PCIA presses at 24 h postoperatively compared to the Ctrl group(P=0.007). At 48 h postoperatively, there was no significant difference in sufentanil consumption and PCIA presses among patients who experienced rebound pain in the two groups. At 30 min after pressing the PCIA button for breakthrough pain, 12 patients(100.00%) in the Ket group had NRS<4, compared to 3 patients(17.65%) in the Ctrl group, with a statistically significant difference(P=0.02). Conclusions Compared with using sufentanil alone for PCIA, the combination of esketamine and sufentanil does not reduce the incidence of rebound pain following single nerve block in upper limb fracture surgery. However, the combination of esketamine and sufentanil may provide a faster relief of rebound pain.