【作者】 李娟；

【导师】 王中玉；

【作者基本信息】 郑州大学 ， 麻醉学（专业学位）， 2022， 硕士

【摘要】 研究目的艾司氯胺酮为N-甲基-D-天冬氨酸(NMDA)受体拮抗剂,较氯胺酮具有更强的镇静镇痛效力,更少的不良反应。小剂量艾司氯胺酮对老年患者血流动力学、应激反应和术后谵妄、焦虑抑郁情绪的影响尚未得到评估。本研究拟评价小剂量艾司氯胺酮是否可以安全用于老年患者的麻醉诱导,为临床提供参考。资料与方法选择郑州大学第一附属医院择期全身麻醉下行单侧全膝关节置换术老年患者80例,患者随机分为2组(n=40):对照组(C组)和艾司氯胺酮组(K组)。艾司氯胺酮组静脉注射0.2mg/kg艾司氯胺酮、对照组静脉注射等容量的生理盐水,之后两组都复合依托咪酯、舒芬太尼和罗库溴铵进行麻醉诱导,术中采用静吸复合麻醉维持。记录麻醉诱导前(T0)、气管插管前即刻(T1)、气管插管后1 min(T2)、气管插管后5 min(T3)、切皮时(T4)、切皮后1 min(T5)、切皮后5 min(T6)时心率、收缩压、舒张压、平均动脉压(mean arterial pressure,MAP)、脑电双频指数(bispectral index,BIS)。于T0、T2、T3、T5、T6时采集血液样本,使用酶联免疫吸附法检测血浆去甲肾上腺素(NE)、肾上腺素水平(E)。记录麻醉诱导期间发生肌阵挛、呛咳的人数;麻醉诱导期间发生心血管不良事件的人数。苏醒时采用Ricker镇静-躁动评分(sedation-agitation scale,RSAS)评估患者躁动情况;术后3天内每天由评估人员采用CAM量表评估谵妄的发生情况;术前1天和术后1天采用医院焦虑抑郁量表(HADS)评估焦虑抑郁情绪;同时随访患者是否出现幻觉、噩梦等精神症状,术后3天内发生恶心呕吐的患者人数。结果1.一般资料:两组患者性别、年龄、BMI、手术时间、并存高血压人数、依托咪酯诱导量、舒芬太尼诱导量、ASA分级比较差异无统计学意义(P>0.05)。2.血流动力学和BIS值比较:与C组比较,K组在T1、T2、T3时的SBP、DBP、MAP及HR明显升高(P<0.05);两组在T4、T5、T6 时SBP、DBP、MAP及HR差异无统计学意义(P>0.05)。与T0时比较,两组在T1、T2、T3、T4、T5、T6时的SBP和MAP降低(P<0.05);C组T1、T2、T3、T4、T5、T6时DBP降低;K组在T1、T3、T4、T5时DBP降低(P<0.05);两组HR在T1、T3、T4、T5、T6时均低于T0 时(P<0.05)。与C组比较,K1组在T1、T2、T3时的BIS值明显偏高(P<0.05);两组在T4、T5、T6时的BIS值差异无统计学意义(P>0.05)。两组BIS值在T1、T2、T3、T4、T5、T6 时均低于T0 时(P<0.05)。3.E和NE水平比较:对照组和艾司氯胺酮组在T0、T2、T3、T5、T6时血浆肾上腺素、去甲肾上腺素水平比较差异均无统计学意义(P>0.05)。两组在T2、T5、T6时血浆肾上腺素、去甲肾上腺素水平均高于T0时(P<0.05),T3时血浆肾上腺素、去甲肾上腺素水平均低于T0时(P<0.05)。4.心血管不良事件比较:C组23例(57.5%)患者发生低血压,K组仅9例(22.5%)患者发生低血压,低血压发生率明显降低(P<0.05);两组诱导期其他心血管不良事件发生率差异无统计学意义(P>0.05)。5.呛咳和肌阵挛发生率比较:C组中8例(20%)患者发生呛咳,K组仅有1例(2.5%)发生呛咳,呛咳发生率明显降低(P<0.05);两组患者诱导期肌阵挛发生率差异无统计学意义(P>0.05)。6.术后躁动及情绪比较:与C组比较,K组术后的Ricker镇静-躁动评分、HADS评分差异无统计学意义(P>0.05)。两组患者术后1天的HADS的焦虑及抑郁评分较术前1天均有下降(P<0.05)。7.谵妄和术后不良反应比较:术后第2天,C组中一名患者出现了谵妄症状,K组在术后3天每天的随访中均未出现谵妄患者(P>0.05);两组患者术后3天内发生恶心、呕吐情况的人数,出现噩梦和幻觉的人数差异均无统计学意义(P>0.05)。结论1.小剂量艾司氯胺酮用于全膝关节置换术老年患者麻醉诱导,可使诱导期血流动力学更平稳,明显降低老年患者麻醉诱导期低血压、呛咳发生率,对刺激造成的应激反应无明显影响。2.围术期单次小剂量艾司氯胺酮在老年患者中应用,不增加术后不良反应的发生率,可以安全用于老年患者的麻醉诱导。更多还原

【Abstract】 ObjectiveEsketamine is an N-methyl-D-aspartic acid(NMDA)receptor antagonist,which has stronger sedative and analgesic effects and fewer adverse events than ketamine.The effects of low-dose esketamine on hemodynamics and postoperative delirium,anxiety and depression in elderly patients have not been evaluated.To evaluate whether low-dose esketamine can be safely for anesthesia induction in the elderly.Materials and methodsEighty elderly patients were selected for unilateral total knee replacement under general anesthesia in the first affiliated Hospital of Zhengzhou University.Patients were randomly divided into two groups(n=40):control group(C group)and esketamine group(K group).During induction of anesthesia,the control group was intravenously injected with normal saline of equal volume,and the esketamine group was intravenously injected with 0.2mg/kg esketamine.Both groups were induced by etomidate,sufentanil and rocuronium,and maintained by intravenous inhalation combined anesthesia during operation.HR,SBP,DBP,MAP and BIS values were recorded before induction of anesthesia(T0),immediately before endotracheal intubation(T1),1 min(T2)and 5min(T3)after endotracheal intubation,surgical skin incision(T4),1min(T5)and 5min(T6)after surgical skin incision,and blood samples were obtained to measure serum epinephrine(E)and norepinephrine(NE)concentrations at the time point(T0,T2,T3,T5,T6),which were determined by ELISA.During induction,the number of myoclonus,cough and the number of adverse cardiovascular events were recorded.During the recovery period after the patient woke up,agitation was assessed using the Ricker Sedation-Agitation Scale(RSAS);The Confusion Assessment Method(CAM)scale was used to evaluate the occurrence of delirium within 3 days after surgery by follow-up doctors.And Hospital Anxiety and Depression Scale(HADS)was used to evaluate anxiety and depression at 24h preoperatively and 24h postoperatively.Meanwhile,patients were followed up for hallucinations,nightmares and other mental symptoms,and the incidences of nausea and vomiting within 72 hours after surgery.Result1.Characteristics of clinical data:No significant difference was observed in sex,age,duration of surgery,number of hypertension,BMI,dosage of sufentanil and etomidate for induction American Society of Anesthesiologists physical status between the two groups(P>0.05).2.Hemodynamics and BIS:Compared with C group,SBP,DBP,MAP and HR of K group were significantly higher at T1、T2、T3(P<0.05).No significant differences was found in SBP,DBP,MAP and HR between the two groups at T4、T5、T6(P>0.05).Compared with T0,SBP and MAP of both groups at T1、T2、T3、T4、T5、T6 were decreased(P<0.05).DBP of K group at T2 was no significant difference with DBP at T0(P<0.05),but DBP of C group decreased from T1、T2、T3、T4、T5、T6(P<0.05).Compared with T0,HR in both groups decreased at T1,T3,T4,T5 and T6(P<0.05).Compared with C group,BIS in K group was significantly higher at T1、T2、T3(P<0.05).There were no significant differences in BIS value between the two groups at T4、T5、T6(P>0.05).Compared with T0,BIS of the two groups decreased at T1、T2、T3、T4、T5、T6(P<0.05).3.Epinephrine and norepinephrine:There were no statistical significances in NE and E concentrations between the two groups at five time points(P>0.05).Compared with T0,NE and E concentrations were significantly increased at T2,T5 and T6(P<0.05),and decreased at T3(P<0.05).4.Cardiovascular adverse events:Hypotension occurred in 23 patients(57.5%)in C group and only 9 patients(22.5%)in K group,and the number of hypotension was significantly lower in K group(P<0.05).There was no significant difference in the number of other cardiovascular adverse events between the two groups during induction(P>0.05).5.Cough and myoclonus:Eight patients(20%)in C group had cough,while only one patient(2.5%)in K group had cough,and the number of cough smaller significantly in K group(P<0.05).There was no significant difference in the number of myoclonus between two groups(P>0.05).6.Postoperative agitation and mood:Compared with C group,there were no significant differences in Postoperative Ricker sedation-agitation scale(RSAS)and Hospital Anxiety and Depression Scale(HADS)score in K group(P>0.05).Compared with 24h preoperatively,anxiety and depression scores in both groups decreased after HADS(P<0.05).7.Delirium and Adverse events:One patient in C group was identified as positive for delirium on the second postoperative day,while no delirium occurred from the first to the third postoperative day in K group(P>0.05).No statistically significant differences was found in the number of postoperative nausea,vomiting,nightmares and hallucinations between the two groups(P>0.05).Conclusion1.Low-dose esketamine for anesthesia induction in elderly patients undergoing total knee arthroplasty can make the hemodynamics more stable during induction and significantly reduce the incidence of hypotension and cough in elderly patients during anesthesia induction.It has no significant effect on the stress response caused by stimulation.2.The administration of single low-dose esketamine in the elderly does not increase the incidence of postoperative adverse reactions,and can be safely used for anesthesia induction in elderly patients.更多还原