小剂量艾司氯胺酮对老龄髋关节置换术患者术后谵妄的影响

任红; 周广伟; 付莉莉; 张咏晖; 胡斌; 张岚; 张满和; 王英

doi:10.12435/j.issn.2095-5227.2023.068

小剂量艾司氯胺酮对老龄髋关节置换术患者术后谵妄的影响

Effect of low-dose esketamine on postoperative delirium in elderly patients undergoing hip arthroplasty

摘要

摘要:
背景术后谵妄是老龄大手术患者常见的术后神经系统并发症，目前无有效的预防和治疗措施。
目的探究小剂量艾司氯胺酮对接受髋关节置换术老年患者术后谵妄发生情况的影响。
方法选取2020年9月 - 2021年10月因关节退行性变择期在唐山市工人医院全身麻醉气管内插管下行单侧全髋关节置换术的老年患者60例(年龄65 ~ 75岁)，随机分为两组：艾司氯胺酮组(A组)患者麻醉诱导静脉注射艾司氯胺酮0.2 mg/kg、咪达唑仑0.03 ~ 0.06 mg/kg、阿芬太尼20 ~ 40 μg/kg、依托咪酯0.1 ~ 0.3 mg/kg及罗库溴铵0.6 mg/kg；对照组(B组)患者麻醉诱导静脉注射与艾司氯胺酮等容量0.9%氯化钠注射液、咪达唑仑0.03 ~ 0.06 mg/kg、阿芬太尼20 ~ 40 μg/kg、依托咪酯0.1 ~ 0.3 mg/kg及罗库溴铵0.6 mg/kg。两组术中均采用静脉麻醉维持。记录两组患者麻醉诱导前(T₀)、诱导后5 min (T₁)、诱导后10 min (T₂)、手术开始(T₃)、手术结束(T₄)的平均动脉压(mean arterial pressure，MAP)及心率(heart rate，HR)。采用酶联免疫吸附法测定麻醉诱导前(T₀)、手术结束(T₄)、术后1 d (T₅)、术后3 d (T₆)静脉血中S100钙结合蛋白β(S100 calcium binding protein beta，S100β蛋白)及炎性因子肿瘤坏死因子-α(tumor necrosis factor-alpha，TNF-α)和白细胞介素-6(interleukin6，IL-6)、IL-10水平。采用3D-CAM量表评估术后5 d内谵妄的发生情况。
结果两组患者年龄、性别、ASA分级、体质量指数及手术时间差异均无统计学意义(P＞0.05)。两组患者MAP在T₁、T₂时刻较T₀时刻均显著升高(多重校正P＜0.013)，且在T₁和T₂时刻A组的MAP显著低于B组，差异有统计学意义(P＜0.05)。两组HR在T_1-3时刻较T₀时刻均显著升高(多重校正P＜0.013)，在T₁和T₂时刻A组HR显著低于B组，差异有统计学意义(P＜0.05)。两组患者血液中TNF-α、IL-6水平在T_4-6时刻较T₀显著增加(多重校正P＜0.017)，且T_4-6时刻A组显著低于B组，差异有统计学意义(P＜0.05)。两组IL-10水平在T_4-6时刻较T₀显著增加(多重校正P＜0.017)，且T_4-6时刻A组显著高于B组，差异有统计学意义(P＜0.05)。两组患者血液中S100β蛋白T_4-6时刻较T₀显著升高(多重校正P＜0.017)，且在T₄和T₅时刻A组S100β蛋白低于B组，差异有统计学意义(P＜0.05)。术后谵妄发生率A组为3.3％，B组为20.0％，但两组差异无统计学意义(P＞0.05)。
结论艾司氯胺酮可减少行髋关节置换术的老龄患者术后谵妄的发生，其机制可能与其抑制炎症反应、减轻脑损伤有关。

Abstract:
Background Postoperative delirium is a common postoperative neurological complication which has no effective preventive and therapeutic measures in elderly patients with major surgery.
Objective To investigate the effect of low-dose esketamine on the occurrence of postoperative delirium in elderly patients undergoing hip arthroplasty.
Methods Elderly patients with elective degenerative joint disease who underwent hip arthroplasty under general anesthesia from September 2020 to October 2021 in Tangshan Gongren Hospital, aged 65-75 years old, were randomly divided into esketamine group (group A) and control group (group B). Patients in group A were induced with intravenous injection of esketamine 0.2 mg/kg, midazolam 0.03-0.06 mg/kg, alfentanil 20-40 μg/kg, etomidate 0.1-0.3 mg/kg and rocuronium 0.6 mg/kg, while patients in group B were induced with intravenous injection of saline in the same volume as esketamine, midazolam 0.03-0.06 mg/kg, alfentanil 20-40 μg/kg, etomidate 0.1-0.3 mg/kg and rocuronium 0.6 mg/kg. Patients in both groups were maintained by intravenous anesthesia. The mean arterial pressure (MAP) and heart rate (HR) were recorded before anesthesia induction (T₀), 5 minutes after induction (T₁), 10 minutes after induction (T₂), at the beginning of surgery (T₃), and at the end of surgery (T₄). The levels of S100 calcium binding protein beta (S100β), the inflammatory factors tumor necrosis factor-alpha (TNF-α) and interleukin-6 (IL-6) in venous blood were measured by enzyme-linked immunosorbent assay at the following time points: induction of anesthesia (T₀), the end of surgery (T₄), 1 day after surgery (T₅), and 3 days after surgery (T₆). The 3D-CAM scale was used to assess the occurrence of delirium within 5 days after surgery.
Results There was no significance in age, sex ratio, ASA, BMI and operation time between the two groups (P>0.05). MAP increased significantly in both groups at T₁ and T₂ compared with T₀ (multiple correction, P<0.013), MAP decreased significantly in group A at T₁ and T₂ compared with group B (P<0.05); HR increased significantly in both groups at T_1-3 compared with T₀ (multiple correction, P<0.013), and the HR of patients in group A was significantly lower than that of group B at the time point of T₁ and T₂ (P<0.05); the levels of TNF-α and IL-6 in venous blood in both groups were significantly increased at T_4-6 compared with T₀ (multiple correction, P<0.017), and TNF-α and IL-6 levels in group A were significantly lower than those of group B at T_4-6 (P<0.05), the level of IL-10 in patients in both groups were significantly increased at T_4-6 compared with T₀ (multiple correction, P<0.017), and the level of IL-10 in group A increased significantly than group B at T_4-6 (P<0.05); S100β level in venous blood in both groups was significantly higher at T_4-6 compared with T₀ (multiple correction, P<0.017), and the S100β level in group A was significantly lower than group B at T₄ and T₅ (P<0.05); the incidence of postoperative delirium was 3.3% in group A and 20.0% in group B. Compared with group B, the incidence of postoperative delirium decreased in group A (P<0.05).
Conclusion Esketamine reduces the occurrence of postoperative delirium in elderly patients undergoing hip arthroplasty, and the mechanism may be related to inflammatory response suppression and brain injury reduction.

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