Effects Of Low Dose Esketamine On Postoperative Pain And Early Cognitive Function In Elderly Patients With PFNA

ObjectiveThe purpose of this study was to observe the effect of intraoperative and postoperative low-dose esketamine on postoperative pain and early cognitive function in elderly patients with PFNA,and to provide reference for the clinical application of esketamine.MethodsA total of 90 elderly patients,aged 65 to 85 years,ASA grade I to III,were selected for PFNA surgery.The patients were divided into 2 groups randomly:esketamine group(group S)and control group(group C),with 45 cases in each group.In group S,0.2 mg/kg of esketamine was injected intravenously during anesthesia induction,and 0.2 mg·kg-1·h-1 of esketamine was injected intravenously during the operation.PCIA was analgesically diluted with esketamine 2 mg/kg+sufentanil 2μg/kg+azasetron 10 mg+0.9%normal saline to 100 ml.In group C,equal-volume normal saline was used to replace esketamine at each stage,and other medication regimens were the same as those in group S,After the operation,if the patient had more than moderate pain(VAS score≥4 points),the patient could press the analgesic pump to add additional dose.If the VAS score was still≥4 points after two consecutive presses on the analgesic pump,intravenous injection of flurbiprofen ester 50 mg was used for analgesic relief.Mean Arterial Pressure(MAP)and Heart Rate(HR)of the patient were recorded before anesthesia induction(T0),after anesthesia induction(T1),when endotracheal intubation(T2),when cutaneous resection(T3),30min after cutaneous resection(T4)and at the end of operation(T5).The dosage of propofol,remifentanil and vasoactive drugs were recorded.Time to surgery,time to recovery,time to extubation,length of stay in the Post-anesthesia Care Unit(PACU),blood loss,urine volume,and fluid replacement were recorded.Resting VAS scores and exercise VAS scores at 2 h(T6),6 h(T7),24 h(T8),and 48 h(T9)after surgery were recorded.The number of analgesic pump compressions and the dosage of flurbiprofen extranate were recorded within 48h after surgery.The occurrence of adverse reactions including Emergence Agitation(EA),Post-operative Nausea and Vomiting(PONV),dizziness,headache,diplopia and hallucination were recorded.At T0,T5,T8,and T9,3ml of the patients’ venous blood was withdrawn and measured for their Interleukin 6(IL-6),C-reactive Protein(CRP),and Cortisol(Cor)concentrations.Patients were assessed by MMSE respectively 1 day before surgery and 1,2 and 3 days after surgery.The MMSE scores and rates of postoperative cognitive dysfunction(POCD)were recorded.Results(1)There were no significant differences in age,sex ratio,ASA grading,body weight,BMI and years of education between 2 groups(P>0.05).(2)Comparison of postoperative pain between the two groupsCompared with group C,the resting VAS scores and exercise VAS scores in group S were significantly decreased at T6,T7,T8 and T9 time points(P<0.05),and the number of analgesic pump compressions and dosage of flubiprofen ester within 48h after surgery were significantly decreased(P<0.05).(3)Comparison of perioperative cognitive function between the two groupsIntra-group comparison:Compared with the 1 day before surgery,MMSE score of group C was significantly decreased(P<0.05),and the incidence of POCD was significantly increased(P<0.05),but MMSE score and the incidence of POCD were not significantly changed at 2 and 3 days after surgery(P>0.05).There were no significant changes in MMSE scores and the incidence of POCD in group S at 1,2 and 3 days after surgery(P>0.05).Comparison between groups:There were no significant differences in MMSE scores and incidence of POCD 1 day before surgery,2 days after surgery and 3 days after surgery between 2 groups(P>0.05).Compared with group C,the MMSE score of group S was significantly increased(P<0.05),and the incidence of POCD was significantly decreased(P<0.05).(4)Comparison of intraoperative hemodynamic indexes between the two groupsIntra-group comparison:Compared with T0,MAP at T1,T2,T3,T4 and T5 in both groups was significantly decreased(P<0.05);HR in group C was significantly decreased at T1,T3,T4 and T5(P<0.05),but had no significant change at T2(P>0.05).There were no significant changes in HR at T1,T2,T3,T4 and T5 in group S(P>0.05).Comparison between groups:Compared with group C,MAP and HR in group S had no statistical significance at T0(P>0.05),while MAP and HR were significantly increased at T1,T2,T3,T4 and T5(P<0.05).(5)Comparison of perioperative inflammation and stress indexes between the two groupsIntra-group comparison:Compared with T0,IL-6 and CRP concentrations in T5,T8 and T9 in 2 groups were significantly increased(P<0.05);The Cor concentration of group C was also significantly increased at T5,T8 and T9(P<0.05),and that of group S was only significantly increased at T8(P<0.05),but had no significant change at T5 and T9(P>0.05).Comparison between groups:Compared with group C,the concentrations of IL-6,CRP and Cor in patients S at To were not statistically significant(P>0.05),while the concentrations of IL-6,CRP and Cor at T5,T8 and T9 were significantly decreased(P<0.05).(6)Comparison of intraoperative drug use between the two groupsThere was no significant difference in intraoperative propofol dosage between the two groups(P<0.05).Compared with group C,the intraoperative dosage of remifentanil in group S was significantly decreased(P<0.05).There was no significant difference in the number of patients using the antihypertensive drug(uradil)between the two groups(P>0.05).Compared with group C,the number of patients in group S receiving hypertensive drugs(ephedrine,deoxyadrenalin)and atropine during the operation was significantly decreased(P<0.05).(7)Comparison of basic surgical information between the two groupsThere were no significant differences in operation time,recovery time,extubation time,PACU residence time,blood loss,urine volume and fluid replacement volume between 2 groups(P>0.05).(8)Comparison of postoperative adverse reactions between the two groupsNo diplopia or hallucination occurred between the two groups,and there was no significant difference in the incidence of EA,PONV,dizziness and headache(P>0.05).Conclusions1.Low-dose of esketamine can relieve pain within 48 h after PFNA in elderly patients,and will not affect the quality of recovery during anesthesia recovery or increase postoperative adverse reactions.2.Low-dose esketamine can improve early cognitive function after PFNA in elderly patients,which may be related to reducing postoperative pain,reducing intraoperative hemodynamic fluctuations,and inhibiting inflammation and stress response.