The Effect Of Different Doses Of S-ketamine On Postoperative Pain After Ambulatory Laparoscopic Surgery

Background:With the development of modern medicine,day surgery has been proved to be an efficient,economical and safe surgical mode.In recent years,it has also been vigorously promoted and developed in China.The occurrence of moderate to severe postoperative pain can directly lead to the failure of day surgery patients to leave the hospital on time,or increase the risk of postoperative readmission.Multimodal analgesia is an internationally recognized perioperative analgesia solution,which aims to combine drugs and techniques acting on multiple mechanisms to achieve effect integration and reduce adverse reactions.As an N-methyl-D-aspartate（NMDA）receptor antagonist,S-ketamine is an integral part of clear perioperative multimodal analgesia.It mainly inhibits the input of noxious stimuli from the central nervous system to achieve analgesic effects.Its advantages in perioperative analgesia are mainly manifested in improving postoperative acute pain,reducing opioid consumption,relieving visceral pain,reducing acute and chronic hyperalgesia,and reducing the incidence of postoperative chronic pain.However,the application of S-ketamine may cause adverse reactions including hallucinations,nightmares,diplopia and other mental types.Concerns about its adverse reactions also limit the clinical application of S-ketamine.Since the incidence of adverse drug reactions is dose-dependent,it is currently recommended to use conventional doses or lower doses of S-ketamine during anesthesia in order to reduce the incidence of adverse reactions.However,for patients undergoing day laparoscopic surgery,whether the application of conventional or lower doses of S-ketamine can provide a good analgesic effect without affecting the normal discharge of patients is still lack of data support.Objective:The purpose of this study was to investigate the postoperative analgesic effect and adverse reactions of conventional dose and low dose S-ketamine in patients undergoing day laparoscopic hernia repair and cholecystectomy.Methods:Approved by the Ethics Committee of the First Affiliated Hospital of Dalian Medical University[PJ-KS-KY-2022-159（X）]and registered in the Chinese Clinical Trial Center（Chi CTR2200062255）,195 patients（aged 18～65 years）undergoing ambulatory laparoscopic hernia repair and laparoscopic cholecystectomy were included.The patients were randomly divided into:conventional dose S-ketamine group（ES₁group）,low dose S-ketamine group（ES₂ group）and control group（C group）.All patients were intravenously injected with 0.01 mg/kg penehyclidine hydrochloride injection half an hour before anesthesia.All patients were treated with total intravenous anesthesia with the same regimen.Patients in ES₁ group were intravenously injected with S-ketamine 0.5mg/kg during anesthesia induction,patients in ES₂ group were intravenously injected with S-ketamine 0.25 mg/kg,and patients in C group were intravenously injected with sufentanil 0.1μg/kg 30 minutes before the end of surgery.The numerical rating scale（NRS）was used to evaluate the postoperative pain of patients.The NRS scores of patients immediately after recovery（0h）,3h,6h,12h,24h and 48h were recorded,including visceral pain,incision pain,shoulder pain and overall pain.At the same time,the consumption of analgesic drugs,hemodynamic indexes at each time point and the incidence of postoperative adverse reactions were recorded.Result:（1）There was no significant difference in age,gender,BMI,ASA classification,preoperative comorbidities and other general demographic characteristics among the three groups（P>0.05）.（2）There was no significant difference in the distribution of operation types,anesthesia time,recovery time,PACU retention time,anesthetic dosage and vasoactive drug dosage among the three groups（P>0.05）.（3）There was no difference in the incidence of severe pain among the three groups at each time point（P>0.05）.The scores of resting body pain at T1 and T6 and visceral pain at T1-T6 in ES₁ group were lower than those in ES₂ group and C group（P<0.05）.The overall pain and pain scores of patients in the ES₁ group at rest at T2 after surgery were similar to those in the ES₂ group,but were lower than those in the C group（P<0.05）.There was no significant difference in postoperative shoulder pain scores among the three groups.（4）The consumption of opioids in ES₁ group was lower than that in C group and ES₂ group（P<0.05）.（5）Subgroup analysis showed that in laparoscopic hernia repair,the overall pain incidence of T1 movement in ES1 group was lower than that in ES2 group and C group（P<0.05）.The overall pain scores of patients in ES1 group and ES2 group were lower than those in group C at T2（P<0.05）.In laparoscopic cholecystectomy,there was no significant difference in the incidence of postoperative overall pain and pain scores among the three groups.（6）Compared with group C,patients in group ES₁ had lower systolic and diastolic blood pressure at T4（P<0.05）.There was no significant difference in hemodynamics between the two groups at the other time points（P>0.05）.There was no significant difference between ES₂ group and C group,ES₁ group and ES₂ group（P>0.05）.（7）There was no significant difference in the incidence of postoperative nausea,vomiting,vertigo,blurred vision,drowsiness,hallucinations and delayed discharge among the three groups（P>0.05）.Conclusions:1.Preoperative single intravenous injection of conventional dose（0.5mg/kg）of S-ketamine can reduce the NRS score of body pain in the early（T1）and late（T6）of resting state and visceral pain in the whole cycle（T1-T6）of exercise state.However,there was no relevant advantage when low-dose（0.25mg/kg）S-ketamine was injected.2.The conventional dose and low dose groups of S-ketamine can reduce the NRS score of overall pain at the initial stage of resting state（T2）.3.The application of conventional dose（0.5mg/kg）of S-Ketamine reduced the consumption of opioids after day laparoscopic surgery.4.S-ketamine conventional dose and low dose group did not increase the incidence of postoperative adverse reactions.