艾司氯胺酮联合胸横肌平面阻滞对心脏瓣膜置换术患者应激反应和炎症水平的影响

Effect of esketamine combined with transversus thoracis plane block on stress response and inflammation level in patients undergoing cardiac valve replacement

目的 探讨盐酸艾司氯胺酮联合超声引导下胸横肌平面阻滞在全身麻醉下对心脏瓣膜置换术患者应激反应和炎症水平的影响。方法 选择择期体外循环支持下行正中开胸心脏瓣膜置换术的患者120例,采用随机数字表法分为4组:单纯全身麻醉组(G组)、全麻+静脉泵注艾司氯胺酮组(E组)、全麻+胸横肌平面阻滞组(T组)、艾司氯胺酮联合胸横肌平面阻滞组(ET组),每组30例。E组和ET组患者术中持续泵注0.2 mg/(kg·h)盐酸艾司氯胺酮注射液直至手术结束,G组和T组泵注等量生理盐水至手术结束。T组和ET组患者全麻诱导完成后,在超声引导下行双侧胸横肌平面阻滞,G组和E组患者不给予特殊处理。四组患者均接受相同的麻醉诱导和麻醉维持方案,且所有患者手术结束后均采用自控静脉镇痛泵。记录以下时间点:术前1天(T0)、麻醉诱导前(T1)、气管插管后1 min(T2)、胸骨正中锯开后1 min(T3)、体外循环开始前1 min(T4)、体外循环结束后1 min(T5)、手术结束后1 min(T6)、术后1天(T7)、术后2天(T8)、术后3天(T9)。于T1-T6记录患者的平均动脉压(mean arterial pressure,MAP)和心率(heart rate,HR);于T1、T4-T6检测并记录患者的血糖和乳酸水平;于T0、T7-T9记录患者的白细胞(white blood cell,WBC)和C反应蛋白(C-reactive protein,CRP)水平;记录四组术后不良反应的发生情况。结果 (1)四组患者血流动力学比较:与G组比,在T3时,T组患者的MAP、HR显著降低(P <0.05);在T5时点,ET组患者的MAP较E组降低,HR较T组升高(P <0.05);(2)四组患者体外循环转机后的乳酸、血糖水平均高于T1时点(P <0.05);与G组相比,E组患者在T5时点乳酸值降低、在T6时点血糖值降低(P <0.05);在T5、T6时点,E组患者的血糖值与T组相比更低(P <0.05),ET组患者的乳酸和血糖值与T组相比均更低(P <0.05);(3)与T0相比,四组患者术后的WBC,CRP水平均升高(P <0.05);在T7时点,E组和T组患者的WBC水平与G组相比均降低(P <0.05);与E组和T组相比,ET组患者在T7时点WBC水平更低,在T8时点CRP水平更低(P <0.05);(4)四组患者术后不良反应差异无统计学意义(P>0.05)。结论 全身麻醉下泵注小剂量盐酸艾司氯胺酮联合胸横肌平面阻滞在开胸心脏瓣膜置换术中,可以稳定患者的血流动力学,减少围术期应激反应和术后炎症水平,在临床上有实用价值。

Objective To investigate the impact of esketamine hydrochloride in combination with ultrasoundguided transverse thoracic muscle plane block on stress response and inflammatory levels in patients undergoing cardiac valve replacement under general anesthesia.Methods A total of 120 patients who underwent elective extracorporeal circulation-supported median open heart valve replacement were selected and randomly assigned into four groups using the random number table method:general anesthesia alone(Group G),general anesthesia with intravenous administration of esketamine(Group E),general anesthesia with transverse thoracic plane block(Group T),and esketamine combined with transverse thoracic muscle plane block(Group ET);each group consisted of 30 cases.Patients in group E and group ET received a continuous infusion of esketamine hydrochloride injection at a rate of 0.2 mg/kg-1·h-1 until the completion of the surgical procedure,while patients in group G and group T received an equivalent volume of saline solution until the completion of the surgical procedure.After the induction of general anesthesia,patients in group T and group ET underwent ultrasound-guided bilateral transverse thoracic muscle plane block,while patients in group G and group E did not receive any specific intervention.All four groups received identical protocols for anesthesia induction and maintenance,with self-controlled intravenous analgesic pumps administered to all patients postoperatively.The following time points were recorded:1 day prior to surgery(T0),pre-induction of anesthesia(T1),1 minute post-tracheal intubation(T2),1 minute post-median sternotomy(T3),1 minute prior to initiation of cardiopulmonary circulation(T4),1 minute after cessation of cardiopulmonary circulation(T5),1 minute after completion of surgery(T6),1 day post-surgery(T7),2 days post-surgery(T8),and 3 days post-surgery(T9).Mean Arterial Pressure(MAP) and Heart Rate(HR) were continuously monitored from T1 to T6.The levels of blood glucose and lactate were measured and recorded at T1,T4 to T6.The levels of White Blood Cells(WBC) and C-Reactive Protein(CRP) were assessed at T0,as well as at T7 to T9.The occurrence of postoperative adverse reactions was documented in all four groups.Results(1) Comparison of hemodynamics among the four groups:Compared with group G,there was a significant decrease in MAP and HR at T3 in group T(P < 0.05).At the T5 time point,MAP was lower in group ET compared to group E,while HR was higher in group ET compared to group T(P < 0.05).(2) The lactate and blood glucose levels of the four patient groups after extracorporeal circulation transfer were higher than those at the T1 time point(P < 0.05).Patients in group E had lower lactate values at the T5time point and lower blood glucose values at the T6 time point compared to group G(P < 0.05).Additionally,patients in group E exhibited lower lactate and blood glucose values at both the T5 and T6 time points compared to those in group T(P < 0.05).(3) Compared to T0,the levels of white blood cells(WBC) and C-reactive protein(CRP) were increased in all four groups after surgery(P < 0.05).At the T7 time point,the WBC levels in group E and group T were significantly lower than those in group G(P < 0.05).Furthermore,compared to group E and group T,the level of WBC in group ET was significantly lower at T7,while the level of CRP was significantly lower at T8(P < 0.05).(4) There were no significant differences observed in postoperative adverse reactions among the four groups(P >0.05).Conclusion Combining low-dose esketamine hydrochloride with transverse thoracic muscle plane block under general anesthesia during open heart valve replacement surgery can effectively stabilize the patient's hemodynamics,mitigate perioperative stress response and postoperative inflammation levels,thereby demonstrating significant clinical utility.