艾司氯胺酮麻醉诱导用于腰椎手术的临床体会

目的　观察艾司氯胺酮麻醉诱导对血流动力学、腰椎手术术后拔管期的影响，探讨艾司氯胺酮麻醉诱导的临床效果。方法　选择解放军第970医院择期全身麻醉下行腰椎手术的患者60例，美国麻醉医师协会（American Society of Anesthesiologists，ASA）分级标准Ⅰ～Ⅱ级，采用随机数字法分为艾司氯胺酮组（E组）和芬太尼组（F组），各30例。E组男16例，女14例，年龄（58.0±7.5）岁；F组男18例，女12例，年龄（57.4±7.2）岁。麻醉诱导时，所有患者均静脉注射依托咪酯0.3 mg/kg、苯磺酸顺阿曲库铵0.3 mg/kg，E组伍用艾司氯胺酮0.5 mg/kg，F组伍用芬太尼5 μg/kg行麻醉诱导气管插管。观察并记录两组患者麻醉诱导前（T0）、诱导后气管插管前即刻（T1）、插管完成后1 min（T2）、5 min（T3）心率（heart rate，HR）和平均动脉压（mean arterial pressure，MAP）等血流动力学变化、术后拔管时间、术后准确活动双下肢时间及不良反应情况。采用单因素方差分析、独立样本t检验和χ²检验。结果　两组患者T0时HR、MAP比较，差异均无统计学意义（均P>0.05）；两组患者T1时MAP较T0时均显著降低［E组（90.5±7.9）mmHg（1 mmHg=0.133 kPa）比（99.6±8.2）mmHg、F组（89.0±9.8）mmHg比（97.5±5.7）mmHg，均P<0.05］；气管插管后，E组患者MAP快速回升，T2［（101.4±10.9）mmHg］、T3［（99.5±7.3）mmHg］时点同T0时比较，差异均无统计学意义（均P>0.05）；F组患者T2［（91.5±6.9）mmHg］、T3［（92.1±7.9）mmHg］时同T0时比较仍显著降低，差异均有统计学意义（均P<0.05）。麻醉诱导后，F组患者HR波动较为明显，T1时［（61.4±7.5）次/min］较T0时［（67.7±10.7）次/min］显著降低，插管后T3时［（73.1±10.1）次/min］较T0时显著升高，差异均有统计学意义（均P<0.05）；E组患者各时点HR均无显著变化（均P>0.05）。E组患者术后拔管时间及拔管后准确活动双下肢时间均显著低于F组［（10.3±0.8）min比（13.5±1.5）min、（7.9±2.3）min比（9.1±2.8）min］，差异有统计学意义（均P<0.05）。E组患者苏醒期躁动不良反应发生率显著低于F组［3.33%（1/30）比20.00%（6/30）］，差异有统计学意义（P<0.05）。结论　艾司氯胺酮麻醉诱导有利于患者血流动力学稳定及术后认知功能恢复，降低苏醒期躁动等不良反应发生率。

Clinical effects of esketamine in induction of general anesthesia forlumbar surgery

Objective　To observe the effect of esketamine in induction of general anesthesiafor lumbar surgery on hemodynamics and the extubation period. Methods　A total of 60 patients [American Society ofAnesthesiologists (ASA) Ⅰ or Ⅱ] who were scheduled to undergo lumbar surgery under general anesthesiaat 970th Hospital of the PLA were enrolled in this study. They were dividedinto an esketamine group (group E) and a fentanyl group (group F) by the randomnumber table method, with 30 cases in each group. There were 16 males and 14females in group E, and they were (58.0±7.5) years old. There were 18 males and12 females in group F, and they were (57.4±7.2) years old. During induction ofanesthesia, etomidate 0.3 mg/kg and atracurium 0.3 mg/kg were intravenouslyinjected in all the patients, and group E took esketamine 0.5 mg/kg and group Ftook fentanyl 5 μg/kg. The hemodynamic changes, such as heart rate (HR) andmean arterial pressure (MAP), were observed and recorded before anesthesiainduction (T0), immediately before endotracheal intubation (T1), and 1 min (T2)and 5 min (T3) after intubation. The extubation times and accurate activitytimes of both lower limbs, and postoperative adverse reactions in both groupswere recorded. One-way ANOVA, t test,and χ² test were applied. Results　There were no statistical differences in HR andMAP between two groups at T0 (both P>0.05).The MAP's in group E [(90.5±7.9) mmHg vs. (99.6±8.2) mmHg] and group F[(89.0±9.8) mmHg vs. (97.5±5.7) mmHg] at T1 were significantly lower than thoseat T0 (both P<0.05). The MAPrecovered rapidly in group E after endotracheal intubation, and the MAP's at T2[(101.4±10.9) mmHg] and T3 [(99.5±7.3) mmHg] were not statistically differentfrom that at T0 (both P>0.05). TheMAP's at T2 [(91.5±6.9) mmHg] and T3 [(92.1±7.9) mmHg] of group F weresignificantly lower than that at T0 (both P<0.05).After induction of anesthesia, the HR at T1 [(61.4±7.5) beats/min] wassignificantly lower and the HR at T3 [(73.1 ±10.1) beats/min] was significantlyhigher than that at T0 [(67.7±10.7) beats/min] in group F (both P<0.05). There were no significantchanges in HR of group E (all P>0.05).The postoperative extubation time and accurate activity time of both lowerlimbs in group E were significantly shorter than those in group F [(10.3±0.8)min vs. (13.5±1.5) min and (7.9±2.3) min vs. (9.1±2.8) min], with statisticaldifferences (both P<0.05). Theincidence of agitation during waking period of postoperative in group E wassignificantly lower than that in group F [3.33% (1/30) vs. 20.00% (6/30)]. Conclusion　Esketamine forinduction of anesthesia is benificial to stable hemodynamic change and recoveryof postoperative cognitive function and could reduce the incidence of adversereactions such as agitation during the waking period.