低剂量艾司氯胺酮在胸腔镜肺段切除术中的应用效果

Effects of low-dose esketamine in video-assisted thoracoscopic surgery segmentectomy

摘要:

目的 评估低剂量艾司氯胺酮在胸腔镜肺段切除术的应用效果。方法 选取2022年2月—2024年2月在乐山市人民医院接受胸腔镜肺段切除术的106例患者。通过分层随机抽样法将患者分为试验组、对照组，各53例。试验组接受低剂量艾司氯胺酮与氟比洛芬酯的联合治疗，麻醉诱导后通过静脉给予氟比洛芬酯1 mg/kg，随后在手术切皮前给予艾司氯胺酮0.5 mg/kg，然后以0.25 mg/（kg·h）速度继续输注，直到皮肤缝合前停止。对照组在麻醉诱导后也接受氟比洛芬酯1 mg/kg静脉注射，但在切皮前改为注射同等体积的生理盐水，并持续输注直至缝合皮肤。对比两组血流动力学［麻醉诱导前（T₀）、进胸腔后5 min（T₁）和拔双腔管后10 min（T₂）的收缩压（SBP）、舒张压（DBP）、平均动脉压（MAP）、心率（HR）］、舒芬太尼和氟比洛芬酯用量、认知功能［术前和拔管后1、2、3 d简易精神状态检查量表（MMSE）评分］、血清生物标志物［白细胞介素-6（IL-6）、钙-钙调素依赖性蛋白激酶Ⅲ（CAMK Ⅲ）、5-羟色胺（5-HT）、脑源性神经营养因子（BDNF）］、恢复质量［40项恢复质量量表（QoR-40）评分］、情绪状况［医院焦虑-抑郁量表（HADS）评分］、不良反应（恶心、呕吐、呼吸抑制、眩晕、皮肤过敏）的变化。结果 两组患者T₀、T₁、T₂时SBP、DBP、MAP、HR比较，结果 ①不同时间点SBP、DBP、MAP、HR比较，差异均有统计学意义（F =19.904、29.923、22.524、13.769，均P <0.05）；②两组患者MAP比较，差异有统计学意义（F =20.099，P <0.05），试验组T₂时MAP高于对照组。两组患者SBP、DBP、HR比较，差异均无统计学意义（F =2.072、0.038、0.092，均P >0.05）；③两组患者MAP变化趋势比较，差异有统计学意义（F =36.736，P <0.05），两组患者SBP、DBP、HR变化趋势比较，差异无统计学意义（F =0.006、0.486、0.092，均P >0.05）。试验组术中和术后24 h舒芬太尼用量、术后24 h氟比洛芬酯用量均少于对照组（P <0.05）。两组患者术中氟比洛芬酯用量比较，差异无统计学意义（P >0.05）。两组患者术前和拔管后1、2、3 d MMSE评分比较，结果 ①不同时间点MMSE评分比较，差异有统计学意义（F =1830.314，P <0.05）；②两组患者MMSE评分比较，差异有统计学意义（F =382.161，P <0.05），试验组MMSE评分较高，相对认知水平较好；③两组患者MMSE评分变化趋势比较，差异有统计学意义（F =125.299，P <0.05）。试验组IL-6、CAMKⅢ水平均低于对照组（P <0.05），5-HT、BDNF水平均高于对照组（P <0.05）。试验组QoR-40评分低于对照组（P <0.05），HADS-A评分、HADS-D评分均高于对照组（P <0.05）。两组患者不良反应总发生率比较，差异无统计学意义（P >0.05）。结论 低剂量艾司氯胺酮联合氟比洛芬酯的少阿片化方案在胸腔镜肺段切除手术中有效减少了阿片类药物的使用，改善了认知功能和术后恢复，降低了炎症指标，提高了情绪和恢复质量，且不良反应无显著差异。

Abstract:

Objective To evaluate the effect of low-dose esketamine in video-assisted thoracoscopic surgery segmentectomy.Methods This study included 106 patients who underwent video-assisted thoracoscopic surgery segmentectomy at Leshan People's Hospital from February 2022 to February 2024. Patients were randomly assigned to two different treatment groups using stratified random sampling. The experimental group (53 patients) received a combination of low-dose esketamine and flurbiprofen axetil. After anesthesia induction, flurbiprofen axetil (1 mg/kg) was intravenously administered, followed by esketamine (0.5 mg/kg) before the skin incision. Esketamine was then infused at a rate of 0.25 mg/(kg·h) until skin suturing started. The control group (53 patients) received the same dosage of flurbiprofen axetil (1 mg/kg) intravenously, but instead of esketamine, the same volume of saline was administered before the skin incision and continued until suturing. We compared the two groups regarding hemodynamics [systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), and heart rate (HR) before anesthesia induction (T₀), 5 minutes after entering the thoracic cavity (T₁), 10 minutes after removal of the double-lumen tube (T₂) ], consumption of sufentanil and flurbiprofen axetil, cognitive function [Mini-Mental State Examination (MMSE) scores before surgery and 1 d, 2 d and 3d after extubation], serum levels of interleukin-6 (IL-6), calcium/calmodulin-dependent protein kinase Ⅲ (CAMK Ⅲ), 5-hydroxytryptamine (5-HT), and brain-derived neurotrophic factor (BDNF), quality of recovery [Quality of Recovery 40-item questionnaire (QoR-40) scores], emotional status [Hospital Anxiety and Depression Scale (HADS) scores], and adverse effects (nausea, vomiting, respiratory depression, dizziness, and skin allergies).Results Comparisons of SBP, DBP, MAP, and HR in the two groups at T₀, T₁, and T₂ showed that they differed significantly across time points (F = 19.904, 29.923, 22.524, and 13.769, respectively; all P < 0.05). A significant difference in MAP was observed between the two groups (F = 20.099, P < 0.05), with the MAP at T₂ being higher in the experimental group than in the control group. No significant differences were found between the two groups in SBP, DBP, or HR (F = 2.072, 0.038, and 0.092, respectively; all P > 0.05). The trend of MAP changes differed significantly between the two groups (F = 36.736, P < 0.05), whereas the trends of SBP, DBP, and HR changes did not differ significantly (F = 0.006, 0.486, and 0.092, respectively; all P > 0.05). Intraoperative and postoperative 24-hour sufentanil consumption, as well as postoperative 24-hour flurbiprofen axetil consumption, were lower in the experimental group than in the control group (all P < 0.05). No significant difference was observed in intraoperative flurbiprofen axetil consumption between the two groups (P > 0.05). Comparisons of MMSE scores before surgery and at 1, 2, and 3 days after extubation demonstrated that MMSE scores differed significantly across time points (F = 1830.314, P < 0.05) and between the two groups (F = 382.161, P < 0.05), with higher scores in the experimental group, indicating relatively better cognitive function. The trends of MMSE score changes differed significantly between the two groups (F = 125.299, P < 0.05). Levels of IL-6 and CAMK III were lower in the experimental group than in the control group (P < 0.05), whereas levels of 5-HT and BDNF were higher in the experimental group (P < 0.05). The experimental group had lower QoR-40 scores (P < 0.05) and higher HADS-A and HADS-D scores than the control group (both P < 0.05). There was no significant difference in the overall incidence of adverse reactions between the two groups (P > 0.05).Conclusion A low-dose esketamine combined with flurbiprofen axetil opioid-sparing regimen effectively reduces opioid consumption during video-assisted thoracoscopic surgery segmentectomy, improves cognitive function and postoperative recovery, lowers inflammatory markers, enhances mood and quality of recovery, and shows no significant difference in adverse reactions.