艾司氯胺酮联合腰丛-坐骨神经阻滞对老年股骨颈骨折术后疼痛应激及认知功能的影响

Effect of esketamine combined with lumbar plexus-sciatic nerve block on postoperative pain stress and cognitive function in elderly patients with femoral neck fractures

摘要:

目的 评价艾司氯胺酮联合腰丛-坐骨神经阻滞对老年股骨颈骨折术后疼痛应激及认知功能的影响。方法 选取2023年5月—2023年12月中山市小榄人民医院94例择期接受切开复位内固定手术的股骨颈骨折老年患者为研究对象，随机分为艾司氯胺酮组与生理盐水组，每组47例。在腰丛-坐骨神经阻滞前，艾司氯胺酮组静脉注射0.2 mg/kg艾司氯胺酮，10 min内完成，随后以0.5 mg/（kg·h）速率静脉维持至手术结束；生理盐水组静脉注射生理盐水10 mL，10 min内完成，随后以与艾司氯胺酮组等容量、等速率的生理盐水静脉维持至手术结束。比较两组阻滞完成时间、起效及失效时间；比较两组穿刺前（T₀）、阻滞麻醉后10 min（T₁）、阻滞麻醉后20 min（T₂）、阻滞麻醉后30 min（T₃）、切皮时（T₄）、手术30 min（T₅）、术毕（T₆）时的心率（HR）和平均动脉压（MAP）；比较两组T₀、术后1 d（T₇）、术后3 d（T₈）、术后7 d（T₉）的P物质（SP）和前列腺素E₂（PGE₂）水平；比较两组T₀、T₇、T₈、T₉时的简易智能精神状态量表（MMSE）评分。结果 两组阻滞完成时间比较，差异无统计学意义（P >0.05）；艾司氯胺酮组阻滞起效时间较生理盐水组短，失效时间较生理盐水组长（P <0.05）。两组T₀～T₆时的MAP、HR比较，结果 ①不同时间点MAP比较，差异无统计学意义（P >0.05），不同时间点HR比较，差异有统计学意义（P <0.05）；②两组MAP比较，差异有统计学意义（P <0.05），艾司氯胺酮组MAP较低，血流动力学较为稳定。两组HR比较，差异无统计学意义（P >0.05）；③两组MAP变化趋势比较，差异有统计学意义（P <0.05），两组HR变化趋势比较，差异无统计学意义（P >0.05）。两组T₀、T₇～T₉时刻的SP、PGE₂水平及认知功能评分比较，结果 ①不同时间点SP、PGE₂水平及认知功能评分比较，差异均有统计学意义（P <0.05）；②两组SP、PGE₂水平及认知功能评分比较，差异均有统计学意义（P <0.05），艾司氯胺酮组SP及PGE₂水平较低，认知功能评分较高，相对镇痛效果较好，对认知功能影响相对较小；③两组SP、PGE₂水平及认知功能评分变化趋势比较，差异均有统计学意义（P <0.05）。结论 老年股骨颈骨折手术患者采用艾司氯胺酮联合腰丛-坐骨神经阻滞，阻滞起效时间短，失效时间长，可维持血流动力学稳定，降低术后疼痛应激，恢复认知功能。

Abstract:

Objective To evaluate the effect of esketamine combined with lumbar plexus-sciatic nerve block on postoperative pain stress and cognitive function in elderly patients with femoral neck fractures.Methods Ninety-four elderly patients with femoral neck fractures scheduled for open reduction and internal fixation at Xiaolan People's Hospital from May 2023 to December 2023 were enrolled and randomly divided into the esketamine group (n = 47) and saline group (n = 47). Prior to nerve block, the esketamine group received intravenous (IV) 0.2 mg/kg esketamine over 10 minutes, followed by continuous infusion at 0.5 mg/(kg·h) until surgery completion. The saline group received IV 10 mL saline over 10 minutes, followed by equivalent volume and rate saline infusion. Outcomes included block completion time, onset time, and regression time; heart rate (HR) and mean arterial pressure (MAP) at baseline (T₀), 10 min (T₁), 20 min (T₂), 30 min (T₃) after block, skin incision (T₄), 30 min intraoperatively (T₅), and surgery end (T₆); substance P (SP) and prostaglandin E₂ (PGE₂) levels at T₀, postoperative day 1 (T₇), day 3 (T₈), and day 7 (T₉); Mini-Mental State Examination (MMSE) scores at T₀, T₇, T₈, and T₉.Results No intergroup difference was observed in block completion time (P > 0.05). The esketamine group exhibited shorter block onset time and longer regression time versus the saline group (P < 0.05). HR and MAP analysis revealed: (1) No significant difference in MAP across time points (P > 0.05), but HR varied significantly (P < 0.05); (2) Intergroup MAP differed significantly (P < 0.05), with lower and more stable MAP in the esketamine group; (3) MAP trends differed significantly (P < 0.05), while HR trends did not (P > 0.05). SP, PGE₂, and MMSE analysis showed: (1) Significant temporal variations in SP, PGE₂, and MMSE (all P < 0.05); (2) Significant intergroup differences (P < 0.05), with lower SP/PGE₂ levels, higher MMSE scores, and superior analgesia in the esketamine group; (3) Significant intergroup trends (all P < 0.05).Conclusion Esketamine combined with lumbar plexus-sciatic nerve block in elderly femoral neck fracture surgery achieves rapid block onset, prolonged duration, hemodynamic stability, reduced postoperative pain stress, and preserved cognitive function.