小剂量艾司氯胺酮神经周围给药与静脉给药在老年患者全膝关节置换术中的应用对比

Comparison of perineural versus intravenous administration of low-dose esketamine in elderly patients undergoing total knee arthroplasty

摘要:

目的 比较小剂量艾司氯胺酮神经周围给药与静脉给药在老年患者全膝关节置换术中的应用效果。方法 回顾性收集2020年1月—2025年1月在东部战区空军医院行全膝关节置换术的89例老年患者的临床资料。患者均于腘动脉和膝后关节囊间隙阻滞及胫神经阻滞成功后行蛛网膜下腔阻滞。根据艾司氯胺酮给药途径不同分为神经周围给药组（43例）与静脉给药组（46例）。记录患者感觉阻滞起效时间及持续时间、48 h内镇痛泵按压次数，比较两组术前与术后24 h的炎症因子水平和应激指标，通过视觉模拟评分法（VAS）评估患者术后6、12、24及48 h静息与运动时的疼痛情况，并记录术后并发症情况。结果 神经周围给药组感觉阻滞起效时间和48 h内镇痛泵有效按压次数均低于静脉给药组，感觉阻滞持续时间则长于静脉给药组（P <0.05）。神经周围给药组术后白细胞介素-6（IL-6）、IL-8、肿瘤坏死因子-α（TNF-α）水平均低于静脉给药组（P <0.05），两组术后IL-8、IL-6及TNF-α水平均高于术前（P <0.05）。神经周围给药组术后肾上腺皮质激素（ACTH）、皮质醇（Cor）、乳酸水平均低于静脉给药组（P <0.05），两组术后ACTH、Cor、乳酸水平均高于术前（P <0.05）。神经周围给药组与静脉给药组术后6、12、24及48 h静息与活动状态下VAS评分比较，结果 ①不同时间点静息与活动状态下VAS评分比较，差异均有统计学意义（P <0.05）；②神经周围给药组与静脉给药组静息与活动状态下VAS评分比较，差异均有统计学意义（P <0.05），神经周围给药组静息与活动状态下VAS评分较低，相对镇痛效果较好；③两组静息与活动状态下VAS评分变化趋势比较，差异均有统计学意义（P <0.05）。神经周围给药组并发症总发生率低于静脉给药组（P <0.05）。结论 在老年全膝关节置换术中，小剂量艾司氯胺酮神经周围给药的阻滞效果优于静脉给药，可减轻术后炎症应激反应，有效缓解术后疼痛。

Abstract:

Objective To compare the clinical efficacy of low-dose esketamine administered via the perineural and intravenous routes in elderly patients undergoing total knee arthroplasty.Methods The clinical data of 89 elderly patients who received total knee arthroplasty in our hospital from January 2020 to January 2025 were retrospectively analyzed. All patients underwent subarachnoid block after successful popliteal artery-posterior knee capsular space block and tibial nerve block. Patients were divided into perineural administration group (n = 43) and intravenous administration group (n = 46) according to different administration modes of intraoperative esketamine. The onset time and duration of sensory block and the number of analgesic-pump presses within 48 h were recorded. Inflammatory factors and stress indicators before operation and 24 hours after operation were compared between the two groups. Visual Analogue Scale (VAS) was adopted to assess resting and exercise pain scores at 6, 12, 24 and 48 h postoperatively. The incidence of postoperative complications was recorded.Results The onset time of sensory block and the number of effective presses of the analgesic pump within 48 hours in the perineural administration group were lower than those in the intravenous administration group, while the duration of sensory block was longer in the perineural administration group (P < 0.05). Postoperative levels of IL-8, IL-6 and TNF-α were significantly lower in the perineural administration group compared with the intravenous administration group (P < 0.05); postoperative IL-8, IL-6 and TNF-α concentrations were elevated relative to preoperative baseline values in both groups (P < 0.05). Postoperative levels of ACTH, cortisol (Cor) and lactic acid in the perineural administration group were lower than those in the intravenous administration group (P < 0.05), and postoperative ACTH, cortisol and lactic acid levels were higher than preoperative levels in both groups (P < 0.05). Rest and dynamic Visual Analogue Scale (VAS) scores at 6, 12, 24 and 48 h postoperatively were compared between the perineural and intravenous administration groups, with the following results: (1) Statistically significant differences were observed in rest and dynamic VAS scores across different time points (P < 0.05); (2) Statistically significant intergroup differences were detected in both rest and dynamic VAS scores (P < 0.05), with lower VAS scores and superior relative analgesic efficacy noted in the perineural administration group; (3) The changing trends of rest and dynamic VAS scores differed significantly between the two groups (P < 0.05). The overall incidence of postoperative complications was lower in the perineural administration group than in the intravenous administration group (P < 0.05).Conclusion For elderly patients undergoing total knee arthroplasty, perineural administration of low-dose esketamine achieves a superior block effect, alleviates postoperative inflammatory stress response and relieves postoperative pain effectively.