艾司氯胺酮联合全身麻醉及超声引导下颈丛神经阻滞在经腋窝入路腔镜下甲状腺切除术中的应用效果观察

Observation on the effect of esketamine combined with general anesthesia and ultrasound-guided cervical plexus block in axillary endoscopic thyroidectomy

摘要:

目的 探讨艾司氯胺酮联合全身麻醉及超声引导下颈丛神经阻滞在经腋窝入路腔镜下甲状腺切除术中的应用效果及安全性。方法 选择2022年1月－2024年10月该院拟行经腋窝入路腔镜下甲状腺切除术治疗的女性患者112例，随机分为观察组和对照组，各56例。所有患者均给予超声引导下颈丛神经阻滞，完成神经阻滞后再行全身麻醉。其中，观察组于麻醉诱导前注射艾司氯胺酮0.1 mg/kg，并于术中以0.1 mg/（kg·h）的速率持续泵注艾司氯胺酮，直至缝皮后；对照组则给予等容量生理盐水进行相同操作。于入室建立心电监护后即刻（T₀）、气管插管前即刻（T₁）、气管插管后即刻（T₂）、切皮即刻（T₃）和术毕即刻（T₄），比较两组患者的生命体征指标［平均动脉压（MAP）、心率（HR）和经皮动脉血氧饱和度（SpO₂）］。比较两组患者丙泊酚用量、瑞芬太尼用量和拔管时间等手术相关指标。于术后1、6、12和24 h，采用视觉模拟评分法（VAS）评分，评估患者疼痛程度。于术前和术后1 d，采用40项恢复质量量表（QoR-40）评分，评估患者术后恢复质量。比较两组患者不良反应发生情况。结果 两组患者MAP和HR的时间效应比较，差异均有统计学意义（F = 24.63，F = 20.11，P < 0.05），两组患者MAP和HR的组间效应比较，差异均有统计学意义（F = 13.54，F = 11.49，P < 0.05），两组患者MAP和HR的交互效应比较，差异均有统计学意义（F = 4.10，F = 3.46，P < 0.05）。两组患者SpO₂的时间、组间和交互效应比较，差异均无统计学意义（P > 0.05）。观察组丙泊酚用量、瑞芬太尼用量和术后1 d引流量明显少于对照组，差异均有统计学意义（P < 0.05）。两组患者拔管时间和苏醒时间比较，差异均无统计学意义（P > 0.05）。观察组术后1、6、12和24 h疼痛VAS评分明显低于对照组，差异均有统计学意义（P < 0.05）。两组患者QoR-40评分中，身体舒适度、疼痛维度评分及量表总分：1）术后1 d均低于组内术前（P < 0.05）；2）术后1 d对照组均低于观察组（P < 0.05）。对照组术后1 d QoR-40评分中的情绪状态维度评分明显低于术前（P < 0.05），观察组则无明显变化（P > 0.05）。观察组拔管呛咳发生率明显低于对照组（14.29%和37.50%，P < 0.05），两组患者恶心呕吐、头晕头痛、呼吸抑制、苏醒期躁动和苏醒期谵妄的发生率比较，差异均无统计学意义（P > 0.05）。观察组不良反应总发生率明显低于对照组（25.00%和66.07%，P < 0.05）。结论 艾司氯胺酮联合全身麻醉及超声引导下颈丛神经阻滞应用于经腋窝入路腔镜下甲状腺切除术，能有效地稳定患者血流动力学，减轻术后疼痛，促进术后恢复。值得应用于临床。

Abstract:

Objective To investigate the effect and safety of esketamine combined with general anesthesia and ultrasound-guided cervical plexus block in axillary endoscopic thyroidectomy.Methods The subjects of this study, 112 female patients who underwent axillary endoscopic thyroidectomy in our hospital from January 2022 to October 2024, were randomly divided into an observation group and a control group, each with 56 cases. All patients were administered with ultrasound-guided cervical plexus block followed by general anesthesia. The observation group was injected with 0.1 mg/kg of esketamine prior to anesthesia induction and continuously pumped with esketamine at a rate of 0.1 mg/(kg·h) during the operation until sutures were completed, while the control group was administered with an equal volume of normal saline following the same procedure. The vital sign indicators [mean arterial pressure (MAP), heart rate (HR) and percutaneous arterial oxygen saturation (SpO₂)] immediately after establishing electrocardiogram monitoring (T₀), immediately before tracheal intubation (T₁), immediately after tracheal intubation (T₂), immediately after skin incision (T₃) and immediately after the operation (T₄) were compared between the two groups. Surgical related indicators such as propofol dosage, remifentanil dosage, and extubation time were also compared between them. Pain visual analogue scale (VAS) scores were performed on patients from the two groups at 1, 6, 12, and 24 h postoperatively. The 40-item quality of recovery score (QoR-40) was used before the surgeries and 1 d after surgeries to assess the patients. Adverse reactions were also compared.Results The difference was significant in terms of MAP, HR time effect in the two groups (F = 24.63, F = 20.11, P < 0.05) and inter-group MAP, HR values (F = 13.54, F = 11.49, P < 0.05). There were statistically significant differences in the interaction effects of MAP and HR between the two groups (F = 4.10, F = 3.46, P < 0.05). The difference was not statistically significant in time, inter group, and interaction effects of SpO₂ (P > 0.05). The dosage of propofol, remifentanil, and postoperative 1 d drainage in the observation group were less than those in the control group, the differences were statistically significant (P < 0.05). The differences were not statistically signiciant in extubation time and awakening time between the two groups (P > 0.05). The VAS scores at 1, 6, 12, and 24 h after operation in the observation groups were lower than those in the control group, the differences were statistically significant (P < 0.05). Physical comfort, pain dimension ratings, and total score of the QoR-40 scale: 1) those 1 d after operation were lower than those before operation in both groups (P < 0.05); 2) 1 d after operation: those in the control group were lower than those in the observation group (P < 0.05). The control group witnessed a remarkable decrease in QoR-40 emotional state rating 1 d after operation than it did before operation (P < 0.05), while no significant change was seen by the observation group in this regard (P > 0.05). The incidence of coughing after extubation in the observation group was lower than that in the control group (14.29% and 37.50%), the difference was statistically significant (P < 0.05). The differences were not statistically signiciant in the incidence of other adverse reactions such as nausea, vomiting, dizziness, headache, respiratory depression, awakening restlessness and awakening delirium between the two groups (P > 0.05). The total incidence of adverse reactions in the observation group was significantly lower than that in the control group (25.00% and 66.07%, P < 0.05).Conclusion The application of esketamine combined with general anesthesia and ultrasound-guided cervical plexus block in axillary endoscopic thyroidectomy can significantly stabilize hemodynamics in patients, reduce postoperative pain, and promote postoperative recovery. It is worthy clinical application.