亚麻醉剂量艾司氯胺酮联合丙泊酚对腹腔镜结直肠癌根治术后患者认知功能的影响

The effect of sub-anesthetic dose esketamine combined with propofol on cognitive function in patients undergoing laparoscopic radical resection of colorectal cancer

摘要

目的: 探讨亚麻醉剂量艾司氯胺酮联合丙泊酚在腹腔镜结直肠癌根治术中的应用价值。方法 选取2022年6月至2024年12月行腹腔镜结直肠癌根治术的 110 例患者,采用信封法将患者分为观察组（n=55,予以亚麻醉剂量艾司氯胺酮联合丙泊酚麻醉）与对照组（n=55,常规麻醉）,对比分析两组不同时点平均动脉压、心率、手术时间、麻醉时间、术中失血量、机械通气时间、麻醉后监测治疗室停留时间、苏醒时间、蒙特利尔认知评估量表评分、术后认知障碍发生率、肿瘤坏死因子-α、 C 反应蛋白、白细胞介素 -6 等相关指标。结果 麻醉后 5 min 、麻醉后 30 min 、手术结束时,观察组平均动脉压高于对照组 （P<0.05）;麻醉后 5 min 、麻醉后 30 min 时,观察组心率低于对照组（P<0.05）。两组手术时间、麻醉时间、术中失血量、机械通气时间、麻醉后监测治疗室停留时间、苏醒时间差异无统计学意义（P>0.05）。术后 24 h,观察组血清肿瘤坏死因子 -α、 C 反应蛋白、白细胞介素-6 低于对照组（P<0.05）,蒙特利尔认知评估量表评分高于对照组（P<0.05）。观察组术后认知障碍发生率低于对照组（P<0.05）。术后 24 h 内,观察组镇痛泵有效按压次数、总按压次数少于对照组（P<0.05）。结论 亚麻醉剂量艾司氯胺酮联合丙泊酚用于腹腔镜结直肠癌根治术,可维持患者血流动力学稳定,减轻术后认知功能损伤,值得临床推广应用。

Abstract

Objective: To explore the application value of sub-anesthetic dose esketamine combined with propofol in laparosco- pic radical resection of colorectal cancer. Methods: A total of 110 patients who underwent laparoscopic radical resection for colorectal cancer from Jun. 2022 to Dec. 2024 were selected.The patients were divided into the observation group（n=55, receiving sub-anesthetic dose esketamine combined with propofol for anesthesia）and the control group（n=55, receiving conventional anesthesia）by envelope method.The related indicators of the two groups were compared and analyzed, including mean arterial pressure, heart rate at different time points, operation time, anesthesia time, intraoperative blood loss, mechanical ventilation time, post-anesthesia care unit stay time, recovery time, Montreal cognitive assessment scale score, incidence of postoperative cognitive impairment, tumor necrosis factor-a, C- reactive protein, and interleukin-6. Results: At 5 min after anesthesia, 30 min after anesthesia and at the end of the operation, the mean arterial pressure of the observation group was higher than that of the control group（P<0.05）; at 5 min after anesthesia and 30 min after anesthesia, the heart rate of the observation group was lower than that of the control group（P<0.05）.There was no statistically signifi- cant difference between the two groups in operation time, anesthesia time, intraoperative blood loss, mechanical ventilation time, post- anesthesia care unit stay time, and recovery time（P>0.05）. At 24 h after operation, the serum levels of tumor necrosis factor-α, C-reac-tive protein and interleukin-6 in the observation group were lower than those in the control group（P<0.05）, and the Montreal cognitive assessment scale score was higher than that in the control group（P<0.05）.The incidence of postoperative cognitive impairment in the observation group was lower than that in the control group（P<0.05）.Within 24 h after operation, the effective pressing times and total pressing times of the analgesic pump in the observation group were fewer than those in the control group（P<0.05）. Conclusions: The application of sub-anesthetic dose esketamine combined with propofol in laparoscopic radical resection of colorectal cancer can maintain the stability of patients' hemodynamics, reduce postoperative cognitive impairment, and is worthy of clinical promotion and application.

关键词

结直肠肿瘤 / 结直肠癌根治术 / 腹腔镜检查 / 艾司氯胺酮 / 丙泊酚 / 亚麻醉剂量

Key words

Colorectal neoplasms / Radical resection of colorectal cancer / Laparoscopy / Esketamine / Propofol / Subanesthetic dose

[1] 刘萌萌,李付广.MAD2L1 在结直肠癌中的表达及与免疫浸润关系的研究[J].临床研究,2024,32(5):5-9.
[2] Chungsamarnyart Y,Pairart J,Munjupong S.Comparison of the effects of intravenous propofol and propofol with low-dose ketamine on preventing postextubation cough and laryngospasm among patients awakening from general anaesthesia:A prospective rando- mised clinical trial[J].J Perioper Pract,2022,32(3):53-58.
[3] Wu QR,Zhao ZZ,Fan KM,et al.Pulse pressure variation guided goal-direct fluid therapy decreases postoperative complications in elderly patients undergoing laparoscopic radical resection of colorectal cancer:a randomized controlled trial[J].Int J Colorectal Dis,2024,39(1):33.
[4] Wang Y,Wang C,Guo H,et al.Evaluation and analysis of neurocognitive dysfunction in patients with colorectal cancer after radi- cal resection:A retrospective study[J].World J Gastrointest Surg,2024,16(9):2893-2901.
[5] Siripoonyothai S,Sindhvananda W.Comparison of postoperative delirium within 24 hours between ketamine and propofol infusion during cardiopulmonary bypass machine:A randomized controlled trial[J].Ann Card Anaesth,2021,24(3):294-301.
[6] Xu Y,He L,Liu S,et al.Intraoperative intravenous low-dose esketamine improves quality of early recovery after laparoscopic radical resection of colorectal cancer:A prospective,randomized controlled trial[J].PLoS One,2023,18(6):e0286590.
[7] Zhu QQ,Qu L,Su T,et al.Risk Factors of Acute Pain in Elderly Patients After Laparoscopic Radical Resection of Colorectal Cancer[J].Surg Laparosc Endosc Percutan Tech,2024,34（1):43-47.
[8] Zhao L,Li Z,Jin B,et al.Safety and efficacy of low-dose esketamine in laparoscopic cholecystectomy:a prospective,double-blind randomized controlled trial[J].BMC Anesthesiol,2024,24(1):47.
[9] Zaki H,Shallik N,Shaban E,et al.An Analytical Comparison Between Ketamine Alone and a Combination of Ketamine and Propofol(Ketofol)for Procedural Sedation and Analgesia From an Emergency Perspective:A Systematic Review and Meta-Ana-lysis[J].Cureus,2022,14(7):e27318.
[10] Kornilov E,Erdman HB,Kahana E,et al.Interleaved Propofol-Ketamine Maintains DBS Physiology and Hemodynamic Stability: A Double-Blind Randomized Controlled Trial[J].Mov Disord,2024,39(4):694-705.
[11] Wang J,Hu W,Zhao X,et al.Sedative effect and safety of different doses of S-ketamine in combination with propofol during gas- tro-duodenoscopy in school-aged children:a prospective,randomized study[J].BMC Anesthesiol,2022,22(1):346.
[12] Kang JM,Cho YS,Park S,et al.Montreal cognitive assessment reflects cognitive reserve[J].BMC Geriatr,2018,18(1):261.
[13] Cavus Z,Moralar DG,Gok AK,et al.The Effects of Ketamine-Propofol and Remifentanil-Propofol Combinations on Integrated Pulmonary Index During Sedation in Gastrointestinal System Endoscopy[J].Sisli Etfal Hastan Tip Bul,2024,58(2):189-196.
[14] Fukano K,Iizuka Y,Ueda T,et al.Comparison of Sedation With Ketamine-Propofol Versus Propofol-Fentanyl for Elderly Patients Undergoing Prostate Biopsy:A Retrospective Observational Study[J].Cureus,2023,15(7):e42650.
[15] Kakarla A,Senapati LK,Das A,et al.Intravenous Dexmedetomidine-Ketamine Versus Ketamine-Propofol for Procedural Sedation in Adults Undergoing Short Surgical Procedures :A Randomized Controlled Trial[J].Cureus,2023,15(6):e40676.
[16] Song N,Yang Y,Zheng Z,et al.Effect of Esketamine Added to Propofol Sedation on Desaturation and Hypotension in Bidirection- al Endoscopy:A Randomized Clinical Trial[J].JAMA Netw Open,2023,6(12):e2347886.
[17] Varley TF,Sporns O,Puce A,et al.Differential effects of propofol and ketamine on critical brain dynamics[J].PLoS Comput Bi- ol,2020,16(12):e1008418.
[18] Akingbola O,Srivastav SK,Nguyen M,et al.Comparison of Ketamine and Propofol-Based Regimens for Deep Sedation in Children Undergoing Esophagogastroduodenoscopy[J].J Pediatr Intensive Care,2020,11(1):19-25.
[19] Wan C,Hanson AC,Schulte PJ,et al.Propofol,Ketamine,and Etomidate as Induction Agents for Intubation and Outcomes in Critically Ill Patients:A Retrospective Cohort Study[J].Crit Care Explor,2021,3(5):e0435.
[20] Sepehri Nour M,Dabbagh A,Fani K.Comparative Assessment of Propofol and Ketamine on Hemodynamic Indices and Cerebral Oximetry of Pediatric Patients Undergoing Cardiac Catheterization[J].Anesth Pain Med,2022,12(6):e128763.
[21] Elsherbiny M,Hasanin A,Kasem S,et al.Comparison of different ratios of propofol-ketamine admixture in rapid-sequence induc- tion of anesthesia for emergency laparotomy:a randomized controlled trial[J].BMC Anesthesiol,2023,23(1):329.
[22] Atchley E,Tesoro E,Meyer R,et al.Hemodynamic Effects of Ketamine Compared With Propofol or Dexmedetomidine as Continu- ous ICU Sedation[J].Ann Pharmacother,2022,56(7):764-772.
[23] Elsaeidy AS,Ahmad AHM,Kohaf NA,et al.Efficacy and Safety of Ketamine-Dexmedetomidine Versus Ketamine-Propofol Combi- nation for Periprocedural Sedation:A Systematic Review and Meta-analysis[J].Curr Pain Headache Rep,2024,28(4):211-227.
[24] Duran M,Dogukan M,Tepe M,et al.Comparison of propofol-fentanyl and propofol-ketamine for sedoanalgesia in percutaneous endoscopic gastrostomy procedures[J].Niger J Clin Pract,2022,25(9):1490-1494.
[25] Efe Mercanoglu E,Girgin Kelebek N,Turker G,et al.Comparison of the Effect of Ketamine and Dexmedetomidine Combined with Total Intravenous Anesthesia in Laparoscopic Cholecystectomy Procedures :A Prospective Randomized Controlled Study[J].Int J Clin Pract,2022,2022:1878705.
[26] Ziqiang F,Keyu H,Yun X,et al.Effect of esketamine on the EC50 of remifentanil for blunting cardiovascular responses to endo- tracheal intubation in female patients under general anesthesia:a sequential allocation dose-finding study[J].BMC Anesthesiol, 2024,24(1):67.
[27] Wittwer ED,Cerhan JH,Schroeder DR,et al.Impact of ketamine versus propofol for anesthetic induction on cognitive dysfunc- tion,delirium,and acute kidney injury following cardiac surgery in elderly,high-risk patients[J].Ann Card Anaesth,2023, 26(3):274-280.
[28] Chen HY,Meng XY,Gao H,et al.Esketamine-based opioid-free anaesthesia alleviates postoperative nausea and vomiting in pa- tients who underwent laparoscopic surgery:study protocol for a randomized,double-blinded,multicentre trial[J].Trials,2023,24(1):13.
[29] Mohammad Khalil A,Makram Botros J,Boules ML,et al.Reliable and Rapid Smooth Extubation After＂Ketamine-Propfol Mix- ture＂for Induction of General Anesthesia in Laparoscopic Drilling of Polycystic Ovary :A Randomized,Double-blind,Compara- tive Study[J].Anesth Pain Med,2021,11(2):e113919.
[30] De Vries LJ,Veeger NJGM,Van Roon EN,et al.Low-dose ketamine or opioids combined with propofol for procedural sedation in the emergency department:a systematic review[J].Eur J Emerg Med,2023,30(4):244-251.

基金资助

沧州市科技计划项目（213106080）