艾司氯胺酮联合胸椎旁神经阻滞对胸腔镜肺癌根治术后恢复质量的影响

Effect of esketamine combined with thoracic paravertebral nerve block on the quality of early recovery after thoracoscopic radical resection of lung cancer

中文关键词: 艾司氯胺酮  胸椎旁神经阻滞  肺癌根治术  恢复质量  术后疼痛

英文关键词: Esketamine  Thoracic paravertebral block  Radical resection of lung cancer  Quality of recovery  Postoperative pain

中文摘要:

      
目的 探讨艾司氯胺酮联合胸椎旁神经阻滞（TPVB）对胸腔镜肺癌根治术后恢复质量的影响。

方法 选择2021年10月至2022年8月行胸腔镜肺癌根治术患者111例，男50例，女61例，年龄18～64岁，BMI 18～30 kg/m²，ASA Ⅰ或Ⅱ级。采用随机数字表法将患者分为两组：艾司氯胺酮组（S组，n=55）和对照组（C组，n=56）。术前30 min两组均行T4椎旁神经阻滞。S组在麻醉诱导后静注艾司氯胺酮0.1 mg/kg，术中泵注艾司氯胺酮0.12 mg·kg^-1·h^-1至缝皮，术后采用患者自控静脉镇痛（PCIA），镇痛泵配方：羟考酮50 mg、艾司氯胺酮25 mg，生理盐水稀释至100 ml。C组麻醉诱导后和术中给予与S组同等剂量的生理盐水，镇痛泵配方：羟考酮50 mg，加生理盐水稀释至100 ml。记录术前1 d、术后 1、2、3 d 15项恢复质量量表（QoR-15）评分，术中舒芬太尼、瑞芬太尼用量和呼气末七氟醚浓度，拔管时间和PACU停留时间，术后6、12、24、48 h静息和活动（咳嗽）时疼痛数字评分（NRS评分），术后24、48 h羟考酮用量，镇痛泵总按压次数和有效按压次数，术后48 h内头晕、恶心呕吐（PONV）、谵妄、幻觉、噩梦、嗜睡、便秘等不良反应发生情况和患者满意度。

结果 与C组比较，S组术后1、2、3 d QoR-15评分明显升高（P<0.05），术后24、48 h静息时NRS评分、术后6、12、24、48 h活动时NRS评分和羟考酮用量明显下降（P<0.05），术后镇痛泵总按压次数和有效按压次数明显减少（P<0.05），患者满意度明显升高（P<0.05）。两组术中舒芬太尼、瑞芬太尼用量、呼气末七氟醚浓度差异无统计学意义。两组术后48 h内头晕、PONV、谵妄、幻觉、噩梦、嗜睡、便秘等不良反应差异无统计学意义。

结论 在胸腔镜肺癌根治术中，麻醉后应用艾司氯胺酮0.1 mg/kg，术中以0.12 mg·kg^-1·h^-1泵注艾司氯胺酮并在镇痛泵中加入艾司氯胺酮0.25 mg/ml，联合胸椎旁神经阻滞可减轻术后急性疼痛且不增加术后不良反应，提升患者术后恢复质量。

英文摘要:

      
Objective To investigate the effect of esketamine combined with thoracic paravertebral nerve block (TPVB) on postoperative recovery quality of patients undergoing thoracoscopic radical resection of lung cancer.

Methods A total of 111 patients undergoing thoracoscopic radical resection of lung cancer were selected from October 2021 to August 2022, 50 males and 61 females, aged 18-64 years, BMI 18-30 kg/m², ASA physical status Ⅰ or Ⅱ. According to random number table method, patients were divided into two groups: esketamine group (group S, n = 55) and saline group (group C, n = 56). Both groups underwent T4 paravertebral nerve block 30 minutes before operation. In group S, esketamine 0.1 mg/kg was injected intravenously after induction of anesthesia, and esketamine 0.12 mg·kg^-1·h^-1 was injected intravenously to suture the skin, and patient-controlled intravenous analgesia (PCIA) was adopted after surgery. The formula of analgesia pump was as follows: oxycodone 50 mg, esketamine 25 mg, diluted to 100 ml of normal saline. Group C was given the same dose of normal saline as group S after anesthesia induction and during the operation. The formula of analgesic pump was as follows: oxycodone 50 mg, diluted to 100 ml of normal saline. 15-item recovery quality scale (QoR-15) scores 1 day before surgery and 1 day, 2 and 3 days after surgery were recored. Total consumption of sufentanil and remifentanil, the concentration of sevoflurane at the end of breath, extubation time and PACU residence time were recorded. Resting and active (at cough) pain numerical scores (NRS) at 6, 12, 24, and 48 hours postoperatively and oxycodone consumption at 24 and 48 hours postoperatively were recored. The total number of compressions and the number of effective compressions by the analgesia pump within 48 hours after surgery, the occurrence of adverse reactions including dizziness, nausea and vomiting (PONV), delirium, hallucinations, nightmares, drowsiness, constipation, and patient satisfaction within 48 hours after surgery were also recored.

Results Compared with group C, QoR-15 scores in group S increased significantly 1 day, 2 and 3 days after surgery (P < 0.05), the NRS score at rest 24 and 48 hours after surgery, the NRS score during movement 6, 12, 24, and 48 hours after surgery, and the dosage of oxycodone were significantly reduced (P < 0.05), the total and effective compressions of the postoperative analgesic pump were significantly reduced (P < 0.05), and patient satisfaction was significantly increased (P < 0.05). There were no significant differences in the dosage of sufentanil and remifentanil and the end expiratory sevoflurane concentration between the two groups. There were no significant differences in postoperative adverse reactions such as dizziness, PONV, delirium, hallucinations, nightmares, drowsiness, and constipation between the two groups within 48 hours after surgery.

Conclusion In thoracoscopic radical surgery for lung cancer, esketamine 0.1 mg/kg was used after anesthesia induction, and esketamine 0.12 mg·kg^-1·h^-1 pumped during the surgery and esketamine 0.25 mg/ml was added to the analgesic pump, which combined with thoracic paravertebral nerve block, can improve the quality of postoperative recovery and relieve postoperative pain.