艾司氯胺酮复合丙泊酚在老年患者非插管全麻下股骨近端防旋髓内钉内固定术中的应用

Application of esketamine combined with propofol in the internal fixation of proximal femoral nail antirotafion under non-intubation general anesthesia in elderly patients

中文关键词: 艾司氯胺酮  非插管全身麻醉  股骨近端防旋髓内钉  髂筋膜间隙阻滞  疼痛

中文摘要:

      
目的 观察艾司氯胺酮复合丙泊酚在老年患者非插管全麻下行股骨近端防旋髓内钉（PFNA）内固定术中的应用效果。
方法 选择2020年11月至2021年12月择期行PFNA内固定术老年患者57例，男33例，女24例，年龄≥65岁，BMI 18～25 kg/m²，ASA Ⅱ或Ⅲ级。将患者随机分为两组：插管全麻组（T组，n=28）和非插管全麻组（NT组，n=29）。麻醉诱导前20 min行超声引导下患侧髂筋膜间隙阻滞（FICB），注射0.375%罗哌卡因30 ml。T组采用气管插管全麻；NT组切皮前静注艾司氯胺酮0.5 mg/kg，术中静脉泵注艾司氯胺酮0.25 mg·kg^-1·h^-1和丙泊酚1.5 mg·kg^-1·h^-1进行麻醉维持，术中保留自主呼吸。记录术中低血压、托下颌和体动例数、术后苏醒时间、PACU停留时间、术后24 h内镇痛泵有效按压次数和总按压次数。记录术后6、12、24 h静息时VAS疼痛评分。记录术前1 d和术后1 d C-反应蛋白（CRP）浓度、中性粒细胞与淋巴细胞比率（NLR）。记录术后恶心呕吐、头晕、谵妄和肺部感染等并发症的发生情况。
结果 与术前1 d 比较，术后1 d两组CRP浓度和NLR明显升高（P＜0.05）。与T组比较，NT组术中低血压发生率、术后肺部感染和并发症总发生率明显降低，术后苏醒时间、PACU停留时间明显缩短，术后24 h内镇痛泵有效按压次数和总按压次数明显减少，术后12、24 h静息时VAS疼痛评分明显降低，术后1 d CRP浓度和NLR明显降低（P＜0.05）。两组托下颌和体动发生率、术后6 h静息时VAS疼痛评分、术前1 d CRP浓度和NLR差异均无统计学意义。
结论 在老年患者PFNA内固定术中，与气管插管全麻比较，艾司氯胺酮复合丙泊酚非插管全麻可缩短术后苏醒时间，减轻术后疼痛，减少术后并发症的发生。

英文摘要:

      
Objective To investigate the application of esketamine combined with propofol in the internal fixation of proximal femoral nail antirotafion (PFNA) under non-intubation general anesthesia in elderly patients.
Methods Fifty-seven elderly patients underwent internal fixation of PFNA from November 2020 to December 2021, 33 males and 24 females, aged ≥ 65 years, BMI 18-25 kg/m², ASA physical status Ⅱ or Ⅲ, were randomly divided into two groups: intubation general anesthesia group (group T, n = 28) and non-intubation general anesthesia group (group NT, n = 29). Ultrasound-guided modified fascia illiaca compartment block (FICB) was used 20 minutes before induction of anesthesia, and 0.375% ropivacaine 30 ml was injected. Group T received general anesthesia with endotracheal intubation and group NT received intravenous infusion of esketamine 0.5 mg/kg before skin incision, esketamine 0.25 mg?kg^-1?h^-1 and propofol 1.5 mg?kg^-1?h^-1 were maintained by intravenous pump, keeping spontaneous breathing during the operation. The intraoperative incidence of hypotension, mandibular support, and body movements, the postoperative recovery time, the post-anesthesia care unit (PACU) stay time, effective pressing times, total actual pressing times within 24 hours after operation were assessed. VAS pain scores 6, 12, and 24 hours after surgery were recorded. The serum concentrations of C-reactive protein (CRP) and neutrophil to lymphocyte ratio (NLR) were measured 1 day before surgery and 1 day after surgery. Postoperative adverse events including nausea and vomiting, dizziness, delirium, and pulmonary infection were also recorded.
Results Compared with 1 day before surgery, the concentration of CRP and NLR 1 day after surgery were significantly increased (P < 0.05). Compared with group T, intraoperative incidence of hypotension, postoperative incidence of pulmonary infection, and postoperative total incidence of adverse effectswere significantly reduced, postoperative recovery time, PACU stay time were significantly shortened, effective pressing times and total actual pressing times within 24 hours after operation were significantly reduced, VAS pain scores 12 and 24 hours after surgery were significantly decreased, the concentration of CRP and NLR 1 day after surgery were significantly reduced in group NT (P < 0.05). There were no significant differences in the number of mandibular support and body movements, VAS pain scores at rest 6 hours after surgery, the concentration of CRP and NLR 1 day before surgery between the two groups.
Conclusion Compared with intubation general anesthesia, esketamine combined with propofol non-intubation general anesthesia can shorten postoperative recovery time, relieve postoperative pain, and reduce postoperative complications in elderly patients undergoing internal fixation of PFNA.