The Improvement Effect Of S-ketamine On Comprehensive Application At The Quality Of Recovery In Patients Undergoing Thoracoscopic Surgery

Objective Early postoperative pain after video-assisted thoracoscopic surgery（VATS）due to incision injury,intercostal nerve injury,or thoracic duct irritation is significant,limiting postoperative recovery.Poor control of acute pain can also increase the risk of developing chronic pain（CPSP）.Compared with traditional ketamine,s-ketamine has stronger analgesic and anti-inflammatory effects,which can reduce postoperative acute pain,reduce inflammation and effectively control oxidative stress in patients.The purpose of this study was to investigate the optimal effect of s-ketamine on postoperative pain,oxidative stress and postoperative recovery in patients undergoing thoracoscopic lobectomy.Methods A total of 96 patients,aged 18-64 years,regardless of gender,BMI 18-28 kg/m²,ASA class I or II,were scheduled to undergo thoracoscopic lobectomy under general anesthesia.They were divided into 3 groups by random number table method:0.1mg/kg s-ketamine group（S1 group）,0.2 mg/kg s-ketamine group（S2 group）and control group（C group）.Before induction of anesthesia,groups S1 and S2 were intravenously injected with 0.1 mg/kg and 0.2 mg/kg s-ketamine respectively,while group C was not given s-ketamine.Then the three groups were induced by intravenous injection of 0.05 mg/kg midazolam,0.4μg/kg sufentanil,1.5～2.0 mg/kg propofol and 0.2 mg/kg cisatracurium.Group S1 was injected with 0.1 mg·kg^-1·h^-1 s-ketamine during operation,and group S2was injected with 0.2 mg·kg^-1·h^-1 s-ketamine during operation.The remaining anesthesia maintenance drugs in the three groups were the same.During the operation,3-6 mg·kg^-1·h^-1 propofol,0.1-0.25μg·kg^-1·h^-1 remifentanil and 0.1-0.2 mg·kg^-1·h^-1 were continuously administered.The BIS value is controlled between 40 and 60.The SPI was controlled between 30 and 50,and the intraoperative remifentanil dosage was adjusted according to the SPI value.Cisatracurium was stopped 30 minutes before the end of the operation,and propofol,remifentanil and s-ketamine were stopped when the skin was sutured.All patients were connected with intravenous analgesia pumps（PCIA）with different formulations after operation.Sufentanil 2μg/kg and s-ketamine 1 mg/kg in group S1,sufentanil 2μg/kg and s-ketamine 1 mg/kg in group S2,sufentanil 2μg/kg in group C,and the three groups were all diluted to 100ml with 0.9%normal saline,the dose of PCA was 1.5 ml,the locking time was 10min,and the analgesia lasted for 48h after operation.Record the total dosage of propofol and remifentanil during the operation;record resting and movement pain scores（NRS）when leaving PACU（T₁）,postoperative6 h（T₂）,postoperative 12 h（T₃）,postoperative 24 h（T₄）,Postoperative 48 h（T₅）and postoperative 72 h（T₆）;recorded postoperative PCA sufentanil consumption.The number of effective PCIA compressions from 0 to 24 hours and 24 to 48 hours after operation and rescue analgesia.Take 5 ml of venous blood before and after the operation to measure the serum IL-6 concentration,superoxide dismutase（SOD）and malondialdehyde（MDA）levels before and after the operation;record postoperative recovery indicators such as postoperative recovery time,hospitalization time,the time of the first meal and the time of getting out of bed for the first time.Record the incidence of postoperative respiratory depression,nausea and vomiting,dizziness,salivation and other complications;record the Qo R-15 index scores and total scores on the first day and the second day after operation.The incidence of chronic pain was followed up by telephone at 3 months after operation,and the incidence and level of treatment measures were recorded.Results1.Comparison of the general information and indicators of the three groups of patients:There were no significant differences in general data such as age,gender,BMI,ASA grade,operation time,one-lung ventilation time,total intraoperative fluid intake,blood loss,and urine output among the three groups（P>0.05）.2.Comparison of intraoperative dosage of propofol and remifentanil among the three groups:There was no significant difference in the dosage of propofol during the operation among the three groups（P>0.05）.Compared with group C,the total amount of remifentanil during operation in groups S1 and S2 was significantly reduced（P<0.05）.Compared with group S1,the total amount of remifentanil during operation in group S2was significantly reduced（P<0.05）.3.Comparison of the rest and exercise NRS scores of the three groups of patients at different times after operation:Compared with group C,the resting and exercise NRS scores in groups S1 and S2 were lower at the time of leaving PACU,6 h,12 h,24 h,48 h（P<0.05）,exercise NRS score decreased 72 h after operation（P<0.05）.There was no significant difference in resting NRS score 72 h after operation among the three groups（P>0.05）.In comparison between S1 and S2 groups,the resting and exercise NRS scores tended to be stable at all time points,and were mostly concentrated in 3 points or below.In group C,the changes of resting and exercise NRS scores were significantly different at each time point.4.Comparison of postoperative analgesic drug dosage and rescue analgesic rate among the three groups:Compared with group C,in groups S1 and S2,postoperative PCA sufentanil dosage, the number of PCIA compressions from 0 to 24 hours and from 24 to 48 hours,and the rate of rescue analgesia were all significantly reduced（P<0.05）.Compared with group S1and group S2,postoperative PCA sufentanil dosage,the number of PCIA compressions from 0 to 24 hours and from 24 to 48 hours,and the rate of rescue analgesia have no significant differences（P>0.05）.5.Comparison of serological indicators among the three groups:There were no significant differences in IL-6 concentration,SOD and MDA contents among three groups before surgery（P>0.05）.The IL-6 concentration in group C was significantly higher than that in groups S1 and S2（P<0.05）.Compared with S2 group,SOD content was more significantly decreased and MDA content was more significantly increased in C group（P<0.05）.Compared with the preoperative results,the serum IL-6concentration and MDA content of the three groups were increased,while SOD content was decreased（P<0.05）.6.Comparison of postoperative general recovery indexes among the three groups:The postoperative recovery time of S1 and C groups was less than that of S2 group（P<0.05）,and there were no significant differences in the length of hospital stay,first feeding time and first getting out of bed time among the three groups（P>0.05）.7.Comparison of the incidence of related complications and chronic pain among the three groups:None of the patients had respiratory depression.There were no significant differences in the incidence of complications such as dizziness,nausea,vomiting and salivation and the incidence of chronic pain among the three groups（P>0.05）.8.Comparison of postoperative chronic pain degree among the three groups:There were no significant differences in the effects of postoperative chronic pain on daily life and levels of management measures among the three groups（P>0.05）.9.Comparison of postoperative Qo R-15 recovery quality scores among the three groups:Compared with group C,the scores of each item and total score of Qo R-15 were significantly increased at 1 and 2 days after operation in S1 and S2 groups（P<0.05）.There was no significant difference in each item and total score of Qo R-15 between S1group and S2 group at 1 and 2 days after operation（P>0.05）.The scores of each item and total score of Qo R-15 in the three groups were significantly higher on the 2nd day after surgery than on the 1st day after surgery（P<0.05）.Conclusion1.Perioperative intravenous application of 0.1 mg/kg s-ketamine for patients undergoing thoracoscopic lobectomy can significantly improve postoperative 72 h acute pain and reduce opioid consumption.2.Perioperative intravenous administration of 0.2 mg/kg s-ketamine can improve oxidative stress in patients.3.Perioperative intravenous application of 0.1 mg/kg s-ketamine did not increase the adverse reactions of patients,improved the quality of postoperative rehabilitation,and improved patient satisfaction.