艾司氯胺酮对保留自主呼吸全身麻醉胸腔镜肺结节切除术中低氧血症的影响

Effect of esketamine on hypoxemia during thoracoscopic pulmonary nodule resection under general anesthesia with preserved spontaneous respiration

中文关键词: 艾司氯胺酮  胸腔镜  非气管插管全身麻醉  保留自主呼吸  炎性因子

英文关键词: Esketamine  Thoracoscopy  Non-tracheal intubation general anesthesia  Preserved voluntary breathing  Inflammatory factor

中文摘要:

      
目的 探讨艾司氯胺酮对保留自主呼吸全身麻醉下行胸腔镜周围性肺结节切除术患者呼吸、循环和急性期炎性因子的影响。

方法 选择择期拟在全身麻醉下行胸腔镜周围性肺结节楔形切除术的患者84例，男45例，女39例，年龄18～64岁，BMI 18～25 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（E组）和舒芬太尼组（S组），每组42例。两组麻醉诱导前 10 min分别恒速静脉泵注右美托咪定0.4 μg/kg，首量泵注结束后行胸椎旁神经阻滞（TPVB）。E组麻醉诱导给予艾司氯胺酮0.5 mg/kg，术中维持艾司氯胺酮0.5 mg·kg^-1·h^-1持续泵注。S组麻醉诱导给予舒芬太尼0.1 μg/kg，术中维持瑞芬太尼0.05 μg·kg^-1·min^-1持续泵注。两组其余麻醉诱导和维持药物一致。记录术中低氧血症、心动过缓、低血压和体动发生情况。记录麻醉诱导前（t0）、置入喉罩后（t1）、打开胸膜后30 min（t2）、拔除喉罩前（t3）、送返病房前（t4）的HR、MAP、SpO₂、PaCO₂和PaO₂。记录t1、t2、t3 时VT、RR。于t0 及术后24 h（t5）时抽取肘正中静脉血3 ml，检测TNF-α、IL-6浓度。记录术后恶心呕吐、幻觉、谵妄、噩梦发生情况，口腔分泌物量和术后住院时间。

结果 与S组比较，E组术中低氧血症、心动过缓、低血压和体动发生率明显降低（P＜0.05）。与t0 时比较，S组t1时HR明显减慢，MAP明显降低，t1、t2、t3 时SpO₂明显降低（P＜0.05）。与S组比较，E组t1、t2、t3时SpO₂明显升高（P＜0.05），t1、t2、t3、t4 时PaCO₂明显降低、PaO₂明显升高（P＜0.05），t1、t2 时VT明显增大、RR明显增快（P＜0.05）， t5 时静脉血TNF-α和IL-6浓度明显降低（P＜0.05），恶心呕吐发生率明显降低，术后住院时间明显缩短（P＜0.05）。两组幻觉、谵妄、噩梦发生率和口腔分泌物量差异无统计学意义。

结论 艾司氯胺酮可以降低保留自主呼吸全身麻醉下周围性肺结节切除术患者术中呼吸抑制的发生率，维持血流动力学稳定，减轻急性期炎症反应，缩短术后住院时间。

英文摘要:

      
Objective To investigate the effects of esketamine on respiration, circulation and acute phase inflammatory factors in patients undergoing thoracoscopic peripheral pulmonary nodule resection under general anesthesia with preserved spontaneous respiration.

Methods Eighty-four patients, 45 males and 39 females, aged 18-64 years, BMI 18-25 kg/m², ASA physical status Ⅰ or Ⅱ, who were scheduled to undergo thoracoscopic wedge resection of peripheral pulmonary nodules under general anesthesia were selected. The patients were randomly divided into two groups by random number table: esketamine group (group E) and sufentanil group (group S), 42 patients in each group. The two groups were injected with 0.4 μg/kg dexmedetomidine by constant velocity intravenous pump 10 minutes before anesthesia induction respectively, and thoracic paravertebral block (TPVB) was performed after the initial injection. Esketamine 0.5 mg/kg was given in group E for induction of anesthesia, and esketamine 0.5 mg·kg^-1·h^-1 was continuously pumped for intraoperative maintenance. In group S, sufentanil was given at 0.1 μg/kg for induction of anesthesia, and remifentanil at 0.05 μg·kg^-1·min^-1 for intraoperative maintenance. Other anesthesia induction and maintenance drugs in both groups were the same. Hypoxemia, bradycardia, hypotension and body movement during operation were recorded. HR, MAP, SpO₂, PaCO₂, and PaO₂ were recorded before anesthesia induction (t0), after laryngeal mask placement (t1), 30 minutes after pleura opening (t2), before laryngeal mask removal (t3) and before return to ward (t4). VT and RR were recorded at t1, t2, and t3. 3 ml of blood was extracted from the median cubital vein at t0 and 24 hours after surgery (t5) to detect the concentrations of TNF-α and IL-6. The incidence of nausea, vomiting, hallucinations, delirium, nightmares, the amount of oral secretions and the length of postoperative hospital stay were recorded.

Results Compared with group S, the incidence of hypoxemia, bradycardia, hypotension and motility were significantly decreased in group E (P < 0.05). Compared with t0, HR and MAP decreased significantly at t1, and SpO₂ decreased significantly at t1, t2, and t3 in group S (P < 0.05). Compared with group S, SpO₂ in group E was significantly increased at t1, t2, and t3 (P < 0.05). Compared with group S, PaCO₂ was significantly decreased and PaO₂ was significantly increased in group E at t1, t2, t3, and t4 (P < 0.05). Compared with group S, VT and RR in group E increased significantly at t1 and t2 (P < 0.05). Compared with group S, the concentrations of TNF-α and IL-6 in venous blood of group E at t5 were significantly decreased (P < 0.05). Compared with group S, the incidence of nausea and vomiting in group E was significantly reduced, and the length of postoperative hospitalization was significantly shortened (P < 0.05). There were no significant differences in the incidence of hallucinations, delirium, nightmares, and oral secretions between the two groups.

Conclusion Esketamine reduces the incidence of intraoperative respiratory depression, maintains hemodynamic stability, reduces acute inflammatory response, and shortens hospital stay in patients under general anesthesia with preserved autonomic breathing for peripheral pulmonary nodule resection.