艾司氯胺酮和右美托咪定作为超声引导下竖脊肌阻滞佐剂对胸腔镜肺手术术后镇痛的影响

Effects of esketamine and dexmedetomidine as adjuvants for ultrasound-guided erector spinae plane block on postoperative analgesia after thoracoscopic lung surgery

摘要:

目的 比较艾司氯胺酮和右美托咪定作为罗哌卡因佐剂用于胸腔镜手术中竖脊肌阻滞（ESPB）的效果。方法 选取2025年6月—2025年8月南京医科大学附属淮安第一医院纳入的105例接受胸腔镜术中行ESPB的患者，将其随机分为3组，RC组：0.75%罗哌卡因15 mL，用生理盐水稀释至30 mL。RE组：0.75%罗哌卡因15 mL，用生理盐水稀释至28 mL+0.1 mg/kg艾司氯胺酮2 mL。RD组：0.75%罗哌卡因15 mL，用生理盐水稀释至28 mL+1 μg/kg右美托咪定2 mL。所有患者术前在T₅椎体水平进行超声引导下ESPB。主要指标为镇痛持续时间；其他指标包括术后1、6、12、24、48 h的视觉模拟评分法（VAS），术中舒芬太尼、瑞芬太尼和丙泊酚消耗量，术中平均动脉压（MAP）和心率（HR），术中间羟胺消耗量，术中液体出入量，术后48 h内抢救性镇痛人数和镇痛泵按压次数、胸管留置时间，术后住院时间及术后不良反应发生率。结果 RD组和RE组镇痛持续时间长于RC组（P <0.05），RD组镇痛持续时间长于RE组（P <0.05）；RD组和RE组术后48 h内镇痛泵按压次数少于RC组（P <0.05），RD组术后48 h内镇痛泵按压次数少于RE组（P <0.05）。RD组和RE组血压开始降低时间早于RC组（P <0.05），RD组血压开始降低时间早于RE组（P <0.05）；RD组术中入液总量大于RC组和RE组（P <0.05），RD组术中间羟胺消耗量大于RC组和RE组（P <0.05），RC组术中间羟胺消耗量大于RE组（P < 0.05）。RC组、RD组与RE组术后1、6、12、24和48 h静息和咳嗽状态下VAS评分比较，结果 ①不同时间点静息和咳嗽状态下VAS评分比较，差异均有统计学意义（P <0.05）；②3组静息和咳嗽状态下VAS评分比较，差异均有统计学意义（P <0.05），RD组和RE组VAS评分较低，相对镇痛效果较好；③3组静息和咳嗽状态下VAS评分变化趋势比较，差异均有统计学意义（P <0.05）。RC组、RD组与RE组在入手术室后、神经阻滞后、麻醉诱导后、气管插管后、切皮时、缝皮时、手术结束时MAP、HR比较，结果 ①不同时间点MAP、HR比较，差异均有统计学意义（P <0.05）；②3组MAP、HR比较，差异均有统计学意义（P <0.05），RE组MAP最高，RC组次之，RD组最低；③3组MAP、HR变化趋势比较，差异均有统计学意义（P <0.05）。RC组、RD组和RE组手术持续时间、舒芬太尼消耗量、瑞芬太尼消耗量、丙泊酚消耗量和术中出液总量、术后住院时间及恶心呕吐、头晕、低血压、心动过缓发生率比较，差异均无统计学意义（P> 0.05）。RD组和RE组胸管留置时间短于RC组（P <0.05）。结论 艾司氯胺酮和右美托咪定作为罗哌卡因佐剂用于胸腔镜手术ESPB，可有效延长镇痛持续时间，降低术后疼痛评分，但右美托咪定在镇痛持续时间方面优于艾司氯胺酮。

Abstract:

Objective To compare the therapeutic effects of esketamine and dexmedetomidine as adjuvants to ropivacaine for erector spinae plane block (ESPB) in video-assisted thoracoscopic surgery (VATS).Methods A total of 105 patients who underwent ESPB during VATS at The Affiliated Huai’an No.1 People’s Hospital of Nanjing Medical University from June 2025 to August 2025 were enrolled. They were randomly divided into 3 groups: RC group with ultrasound-guided ESBP using 30 mL 0.375% ropivacaine, RD group with ultrasound-guided ESPB using 30 mL dexmedetomidine plus 0.375% ropivacaine, and RE group with ultrasound-guided ESPB using 30 mL esketamine plus 0.375% ropivacaine. All patients underwent ultrasound-guided ESPB at the T₅ vertebral level before operation. The primary outcome was the duration of analgesia. Secondary outcomes included Visual Analogue Scale (VAS) scores at 1, 6, 12, 24 and 48 h after operation, intraoperative consumption of sufentanil, remifentanil and propofol, intraoperative mean arterial pressure (MAP) and heart rate (HR), intraoperative consumption of metaraminol, intraoperative fluid intake and output, the number of patients requiring rescue analgesia and the number of patient-controlled analgesia (PCA) pump presses within 48 h postoperatively, chest tube indwelling time, postoperative length of hospital stay and incidence of postoperative adverse reactions.Results The duration of analgesia in the RD and RE groups was longer than that in the RC group (P < 0.05), and the duration of analgesia in the RD group was longer than that in the RE group (P < 0.05). The number of PCA pump presses within 48 hours postoperatively was lower in the RD and RE groups than in the RC group (P < 0.05), and it was lower in the RD group than in the RE group (P < 0.05). The time to onset of blood pressure reduction was shorter in the RD and RE groups than in the RC group (P < 0.05), and it was shorter in the RD group than in the RE group (P < 0.05). The total intraoperative fluid intake in the RD group was greater than that in the RC and RE groups (P < 0.05), and the intraoperative consumption of metaraminol in the RD group was greater than that in the RC and RE groups (P < 0.05). The intraoperative consumption of metaraminol in the RC group was greater than that in the RE group (P < 0.05). Comparison of VAS scores at rest and during coughing at 1, 6, 12, 24, and 48 hours postoperatively among the RC, RD, and RE groups showed that they were different across the time points (P < 0.05) and among the groups (P < 0.05), with the RD and RE groups having lower VAS scores, indicating relatively better analgesic effects. There were statistically significant differences in the change trends of VAS scores at rest and during coughing among the three groups (P < 0.05). Comparison of MAP and HR upon entering the operating room, after nerve block, after anesthesia induction, after tracheal intubation, at the time of skin incision, at the time of skin closure, and at the end of surgery among the RC, RD, and RE groups showed that they were different across the time points (P < 0.05) and among the groups (P < 0.05), with the RE group having the highest MAP, followed by the RC group, and the RD group the lowest. There were statistically significant differences in the change trends of MAP and HR among the three groups (P < 0.05). No statistically significant differences were observed among the RC, RD, and RE groups in terms of duration of surgery, consumption of sufentanil, consumption of remifentanil, consumption of propofol, total intraoperative fluid output, postoperative length of hospital stay, or the incidence of nausea and vomiting, dizziness, hypotension, or bradycardia (P > 0.05). The chest tube indwelling time was shorter in the RD and RE groups than in the RC group (P < 0.05).Conclusion Esketamine and dexmedetomidine as adjuvants to ropivacaine for ESPB in VATS can effectively prolong the duration of analgesia and reduce postoperative pain scores, but dexmedetomidine is superior to esketamine in the duration of analgesia.