艾司氯胺酮与硫酸镁用于腹腔镜胆囊切除术对老年患者血流动力学、应激反应及术后镇痛的影响比较

Effects comparison of esketamine and magnesium sulfate on hemodynamics, stress reaction and postoperative analgesia in elderly patients undergoing laparoscopic cholecystectomy

摘要:

目的 比较艾司氯胺酮与硫酸镁用于腹腔镜胆囊切除术（LC）对老年患者血流动力学、应激反应和术后镇痛的影响。方法 选择2021年6月－2023年10月于该院择期行LC治疗的老年患者156例，随机分为艾司氯胺酮组、硫酸镁组和生理盐水组，各52例。麻醉诱导前15 min，艾司氯胺酮组给予盐酸艾司氯胺酮注射液0.20 mg/kg静脉输注；硫酸镁组给予硫酸镁注射液50.00 mg/kg静脉输注；生理盐水组静脉输注等量生理盐水。分别于入室建立心电监护后即刻（T₀）、麻醉诱导后即刻（T₁）、气管插管后即刻（T₂）、气腹即刻（T₃）、胆囊切除即刻（T₄）和气管拔管前即刻（T₅），使用监护仪监测3组患者的心率（HR）和血压（BP）。分别于T₀、T₄和T₅时点，检测3组患者血清应激反应指标［皮质醇（Cor）和去甲肾上腺素（NE）］水平。比较3组患者术中麻醉药用量、阿托品和去氧肾上腺素使用情况、术后24 h舒芬太尼用量、苏醒时间、拔管时间和定向力恢复时间。分别于术后2、6、12、24 h评估患者疼痛程度。比较3组患者术后不良反应情况。结果 与T₀时点比较，硫酸镁组与生理盐水组T₁时点HR、收缩压（SBP）和舒张压（DBP）明显降低，差异均有统计学意义（P < 0.05）；生理盐水组T₂、T₃、T₄和T₅时点HR、SBP和DBP较T₀时点明显升高，差异均有统计学意义（P < 0.05）。与艾司氯胺酮组比较，硫酸镁组T₁和T₂时点HR明显降低，T₁时点SBP和DBP明显降低，差异均有统计学意义（P < 0.05）；生理盐水组T₁时点HR、SBP和DBP明显降低，T₂、T₃、T₄和T₅时点HR、SBP和DBP明显升高，差异均有统计学意义（P < 0.05）。与硫酸镁组比较，生理盐水组T₁、T₂、T₃、T₄和T₅时点HR、SBP和DBP明显升高，差异均有统计学意义（P < 0.05）。与T₀时点比较，3组患者T₄和T₅时点血清Cor和NE水平明显升高，差异均有统计学意义（P < 0.05）。艾司氯胺酮组和硫酸镁组T₄和T₅时点血清Cor和NE水平明显低于生理盐水组，差异均有统计学意义（P < 0.05）。艾司氯胺酮组和硫酸镁组T₄和T₅时点血清Cor和NE水平比较，差异均无统计学意义（P > 0.05）。艾司氯胺酮组和硫酸镁组术中丙泊酚用量和瑞芬太尼用量明显少于生理盐水组，且艾司氯胺酮组明显多于硫酸镁组，差异有统计学意义（P < 0.05）。3组患者术中阿托品和去氧肾上腺素的使用率比较，差异均无统计学意义（P > 0.05）。艾司氯胺酮组和硫酸镁组术后24 h舒芬太尼用量明显少于生理盐水组，差异均有统计学意义（P < 0.05）；但硫酸镁组与艾司氯胺酮组术后24 h舒芬太尼用量比较，差异无统计学意义（P > 0.05）。艾司氯胺酮组和硫酸镁组拔管时间和定向力恢复时间明显短于生理盐水组，差异均有统计学意义（P < 0.05），但艾司氯胺酮组与硫酸镁组比较，差异无统计学意义（P > 0.05）。艾司氯胺酮组和硫酸镁组术后2、6、12和24 h疼痛视觉模拟评分法（VAS）评分明显低于生理盐水组，差异均有统计学意义（P < 0.05），但艾司氯胺酮组与硫酸镁组比较，差异无统计学意义（P > 0.05）。3组患者术后不良反应发生率比较，差异无统计学意义（P > 0.05）。结论 艾司氯胺酮与硫酸镁用于行LC的老年患者，均能起到稳定术中血流动力学、抑制应激反应和减轻术后疼痛的作用。

Abstract:

Objective To compare the effects of esketamine and magnesium sulfate on hemodynamics, stress reaction and postoperative analgesia in elderly patients undergoing laparoscopic cholecystectomy (LC).Methods The subjects of this study, 156 elderly patients who underwent LC from June 2021 to October 2023, were randomly divided into 3 groups, each with 52 cases. 15 min prior to anesthesia induction, the esketamine group was administered with esketamine hydrochloride injection 0.20 mg/kg intravenously, magnesium sulfate group received intravenous infusion of magnesium sulfate injection 50.00 mg/kg, and physiological saline group received intravenous infusion of equivalent stroke-physiological saline solution. The heart rate (HR) and blood pressure (BP) of three groups were monitored using a monitor immediately after entering the room (T₀), immediately after anesthesia induction (T₁), immediately after tracheal intubation (T₂), immediately after pneumoperitoneum (T₃), immediately after cholecystectomy (T₄), and immediately before tracheal extubation (T₅). The levels of serum stress reaction indicators [cortisol (Cor) and norepinephrine (NE)] in three groups were tested at T₀, T₄, and T₅ respectively. Intraoperative anesthetic dosage and use of atropine and phenylephrine, sufentanil dosage 24 h after surgery, awakening time, extubation time, and directional force recovery time were compared among the three groups. Patients' pain level was assessed respectively 2, 6, 12 and 24 h after the operation. Adverse reactions were compared among the three groups.Results The magnesium sulfate group and physiological saline group saw much lower HR, systolic blood pressure (SBP), and diastolic blood pressure (DBP) at T₁ than they did at T₀, the differences were statistically significant (P < 0.05), while the physiological saline group had significant higher HR, SBP, DBP at T₂, T₃, T₄, T₅ than it did at T₀, the differences were statistically significant (P < 0.05). Compared with the esketamine group over the same period, the magnesium sulfate group showed a significant decrease in HR at T₁ and T₂, and a remarkable decrease in SBP and DBP at T₁, the differences were statistically significant (P < 0.05). At T₁, HR, SBP, and DBP in the physiological saline group were much lower, while the HR, SBP, and DBP in this group at T₂, T₃, T₄, and T₅ were obviously higher than those in esketamine group, the differences were statistically significant (P < 0.05). The physiological saline group witnessed much higher HR, SBP and DBP at T₁, T₂, T₃, T₄, T₅ as compared with the magnesium sulfate group over the same period, the differences were statistically significant (P < 0.05). All the three groups had significantly higher Cor and NE levels at T₄ and T₅ than they did at T₀ (P < 0.05). The serum Cor and NE levels at T₄ and T₅ in the esketamine group and magnesium sulfate group were significantly lower than those in the physiological saline group during the same period, the differences were statistically significant (P < 0.05). There was no significant difference in serum Cor and NE levels between the esketamine group and magnesium sulfate group at T₄ and T₅ over the same period, the differences were not statistically significant (P > 0.05). The intraoperative consumption of propofol and remifentanil in the esmketamine group and the magnesium sulfate group were significantly less than those in the physiological saline group, and the esmketamine group was significantly more than the magnesium sulfate group (P < 0.05). There were no significant difference in the utilization rate of intraoperative atropine and phenylephrine among the three groups (P > 0.05). Sufentanil dosage 24 h after surgery in magnesium sulfate group and esketamine group were less than that of physiological saline group, the differences were statistically significant (P < 0.05). However, there was no significant difference in the consumption of sufentanil dosage 24 h after surgery between the magnesium sulfate group and the esmketamine group (P > 0.05). Extubation time and directional force recovery time in magnesium sulfate group and esketamine group were shorter than those of physiological saline group, the differences were statistically significant (P < 0.05), but the differences were not statistically significant between the magnesium sulfate group and esketamine group (P > 0.05). The pain visual analogue scale (VAS) score at 2, 6, 12, and 24 h after the operation in the esketamine group and magnesium sulfate group were significantly lower than those in the physiological saline group, the differences were statistically significant (P < 0.05), but the differences were not statistically significant between the magnesium sulfate group and esketamine group (P > 0.05). There was no significant difference in postoperative adverse reactions among the three groups (P > 0.05).Conclusion In treating elderly people undergoing LC, esketamine and magnesium sulfate are alike in effects on stabilizing hemodynamics, inhibiting stress reaction, and mitigating postoperative pain.