不同剂量艾司氯胺酮对宫颈癌根治术患者视神经鞘直径的影响

Effect of different doses of ketamine on the optic nerve sheath diameter in patients with cervical cancer undergoing radical surgery

目的探讨不同剂量艾司氯胺酮对宫颈癌根治术患者视神经鞘直径(ONSD)的影响。方法前瞻性选取2020年1月至2022年12月在同济大学附属妇产科医院行宫颈癌根治术的女性患者120例作为研究对象,按照随机数字表法分为小、中、高剂量艾司氯胺酮组3组,每组40例。对3组患者麻醉平稳调整体位后,分别静脉输注0.125、0.2和0.3 mg/kg的艾司氯胺酮至手术结束。用便携式彩超测量3组患者麻醉诱导前即刻(T_(1)),麻醉诱导后10 min(T_(2))、60 min(T_(3))、120 min(T_(4)),手术结束平卧位10 min(T_(5))时双眼ONSD值;以血压计、近红外光谱血氧仪监测3组患者不同时间点平均动脉压(MAP)、局部脑氧饱和度(rSO_(2));疼痛视觉模拟评分法(VAS)观察3组患者不同时间点镇痛效果;比较3组患者手术结束时血清白细胞介素(IL)-6、IL-8、肿瘤坏死因子-α(TNF-α)含量;记录3组患者麻醉相关不良反应率。结果3组患者T_(2)、T_(3)、T_(4)时ONSD值均大于T_(1)时,差异均有统计学意义(P<0.05),T_(5)时ONSD值与T_(1)时比较,差异均无统计学意义(P>0.05);3组不同时间点ONSD水平组间两两比较,差异均无统计学意义(P>0.05)。3组患者组间MAP、rSO_(2)两两比较,差异均无统计学意义(P>0.05)。3组患者不同时间点VAS评分组间及时间存在交互作用(P<0.05),3组患者术后2、4、12 h的VAS评分均小于术前,差异均有统计学意义(P<0.05),而术后24 h的VAS评分与术前比较,差异均无统计学意义(P>0.05);术后4 h,高剂量艾司氯胺酮组VAS评分最低,差异有统计学意义(P<0.05)。从低到中、高剂量艾司氯胺酮组,患者的血清IL-6、IL-8、TNF-α水平依次降低,差异均有统计学意义(P<0.05)。低、中、高剂量艾司氯胺酮3组患者的不良反应发生率分别为5.0%、7.5%、12.5%,各组比较差异无统计学意义(P>0.05)。结论0.125、0.2、0.3 mg/kg的艾司氯胺酮可调控宫颈癌根治术患者的ONSD值,减轻炎症反应,增强镇痛效果,维持血流动力学稳定。上述作用随艾司氯胺酮的剂量增大而增加,可为术中颅内压的管理实践提供参考。

Objective To investigate the effect of different doses of Ketamine on the of optic nerve sheath diameter(ONSD)in patients with cervical cancer undergoing radical surgery.Methods A total of 120 female patients undergoing radical cervical cancer resection in Obstetrics and Gynecology Hospital,Tongji University from January 2020 to December 2022 were prospectively selected as the study objects and divided into three groups with low,medium and high doses of esketamine according to the random number table method,with 40 cases in each group.Patients in the three groups were given 0.125,0.2 and 0.3 mg/kg esketamine intravenously until the end of surgery after smooth adjustment of anesthesia.The ONSD in both eyes were measured by portable color ultrasound immediately before anesthesia induction(T_(1)),10 min(T_(2)),60 min(T_(3)),120 min(T_(4))after anesthesia induction,and 10 min(T_(5))after supine position.The mean arterial pressure(MAP)and local cerebral oxygen saturation(rSO_(2))at different time points were measured by sphygmomanometer and near-infrared spectrum oximeter.Pain visual analogue scale(VAS)was used to observe the analgesic effect of the three groups at different time points.Serum levels of interleukin(IL)-6,IL-8 and tumor necrosis factor-α(TNF-α)were detected by enzyme-linked immunosorbent assay.The rates of anesthesia-related adverse reactions were recorded in the three groups.Results The ONSD values at T_(2),T_(3)and T_(4)were higher than those at T_(1),the differences were statistically significant(P<0.05),and there was no statistically significant difference between the ONSD values at T_(5)and T_(1)(P>0.05).There were no statistically significant differences in the ONSD values at different time points and pairwise comparison of MAP and rSO_(2) among the three groups(P>0.05).There was interaction between groups and time in VAS ratings at different time points in the three groups,the differences were statistically significant(P<0.05).VAS scores at 2,4 and 12 h after surgery of the three groups were lower than those before surgery,the differences were statistically significant(P<0.05),while there was no statistically significant difference in VAS score between 24 hours after operation and before surgery(P>0.05);the VAS score of high dose esketamine group was the lowest at 4 h after operation,the difference was statistically significant(P<0.05).The levels of serum IL-6,IL-8 and TNF-αwere decreased in the low to medium and high dose esketamine groups,the differences were statistically significant(P<0.05).The incidence of adverse reactions in low,medium and high dose esketamine groups was 5.0%,7.5%and 12.5%,respectively,and there was no statistically significant difference among all groups(P>0.05).Conclusion Esketamine at 0.125,0.2,and 0.3 mg/kg can regulate the ONSD value of patients undergoing radical resection of cervical cancer,reduce the inflammatory response,enhance the analgesic effect,and maintain hemodynamic stability.The above effects increase with the increase of the dose of esketamine,which can provide reference for the management of intracranial pressure during operation.