目的：艾司氯胺酮（S-氯胺酮）是氯胺酮的S型对映异构体，具有立体选择性药理优势，其通过拮抗N-甲基-D-天冬氨酸受体（N-methyl-D-aspartate receptor, NMDAR）发挥抗中枢敏化、抗焦虑及神经重塑护作用，且较传统氯胺酮显著减少拟精神副作用。亚麻醉剂量艾司氯胺酮在保留自主呼吸与循环稳定的前提下，通过多靶点调控实现镇痛协同、抗术后抑郁及改善睡眠质量等综合获益，同时规避高剂量呼吸抑制风险。本研究旨在探讨亚麻醉剂量艾司氯胺酮（0.15 ~ 0.3 mg/kg/h）联合右美托咪定与瑞芬太尼在脂肪抽吸术中镇静镇痛的麻醉效果，为整形外科优化多模式麻醉方案提供理论依据。

方法：本研究为前瞻性、双盲、随机对照临床试验，研究于2023年12月30日至2024年3月30日在中国医学科学院整形外科医院麻醉科完成患者入组。共155例18～60岁ASA分级I ~II级择期行择期脂肪抽吸术的患者最终纳入分析，采用计算机生成的随机数字表按1∶1的比例随机分为试验组（艾司氯胺酮-右美托咪定-瑞芬太尼组，E组，n=78）和对照组（生理盐水-右美托咪定/瑞芬太尼组，C组，n=77）。患者入室后常规监测心电图（Electrocardiography, ECG）、血氧饱和度（Oxygen Saturation, SpO₂）、心率（Heart Rate, HR）、收缩压（Systolic Blood Pressure , SBP）、舒张压（Diastolic Blood Pressure, DBP）、平均动脉压（Mean Arterial Pressure, MAP）、呼吸频率（Respiratory Rate, RR）、呼气末二氧化碳分压（End-tidal CO₂ Pressure, PetCO₂）、脑电双频指数（Bispectral Index, BIS）及改良观察者警觉/镇静量表（Modified Observer's Assessment of Alertness/Sedation Scale, MOAA/S）。所有患者均使用具有呼吸末二氧化碳检测功能的鼻导管以5 L/min的流量吸氧。在建立外周静脉通路后进行麻醉诱导，主要麻醉药物方案为：E组静脉持续泵注艾司氯胺酮0.3 mg/kg/h，瑞芬太尼6 μg/kg/h，右美托咪定3 μg/kg/h，至患者改良观察者警觉/镇静量表（Modified Observer's Assessment of Alertness/Sedation Scale, MOAA/S）评分2分开始注射肿胀液，同时将艾司氯胺酮注射速度降至0.15 mg/kg/h。C组用生理盐水取代艾司氯胺酮，瑞芬太尼及右美托咪定用量同E组。术中根据镇静深度调整药物注射速度，维持MOAA/S评分3分，脑电双频指数（bispectral index, BIS）值65 ~ 80, 术后所有患者均转入麻醉后恢复室（Post-anesthesia Care Unit，PACU）至改良Aldrete评分≥ 9分后送回病房。主要结局指标为患者和手术团队对手术的满意度，次要结局指标为患者术后第1天阿森斯失眠量表（Athens Insomnia Scale, AIS）和术后第3天医院焦虑抑郁量表（Hospital Anxiety and Depression Scale, HADS）评分；患者基础状态（T0）、麻醉给药后15 min（T1）、手术开始时（T2）、手术开始1 h（T3）和手术结束时（T4）SBP、DBP、HR、RR、PetCO₂和SpO₂；麻醉诱导时间、术后恢复时间以及术中右美托咪定、咪达唑仑、瑞芬太尼、舒芬太尼的消耗量。采用有序logistic回归模型评估与患者满意度相关的预测因素。

结果：两组患者人口学资料差异均无统计学意义。E组患者和手术团队的满意度显著高于C组 (4.7 ± 0.6 vs 4.2 ± 0.7, P < 0.001；4.7 ± 0.5 vs 4.4 ± 0.7, P = 0.005)。E组术后第1天睡眠质量，第3天焦虑抑郁评分均显著低于C组 (4 [1, 6] vs 5 [2, 9], P = 0.012；1 [0, 3] vs 2 [0, 6], P = 0.012)。有序logistic回归结果显示，术后睡眠质量 (OR, 0.70; 95% CI, 0.62 - 0.79)、焦虑水平 (OR, 0.77；95% CI, 0.62 - 0.95) 和PACU恢复时间 (OR, 0.69；95% CI, 0.56 - 0.98) 是影响患者满意度的重要因素。术中呼气末二氧化碳分压在T1（43.9 ± 4.7 vs 46.0 ± 5.1, P = 0.008）、T2（45.1 ± 5.4 vs 48.6 ± 6.0, P = 0.002）、T3（46.0 ± 5.7 vs 49.0 ± 6.1, P = 0.002）、T4（43.9 ± 4.7 vs 45.9 ± 6.0, P = 0.022）时，E组均显著低于C组。与对照组相比较E组术中阿片类药物的消耗剂量减少，舒芬太尼和瑞芬太尼分别为(0 [0, 4] vs 5 [2.5, 7.7], P < 0.001) (700 [480, 900] vs 800 [500, 1200], P = 0.023)，均有统计学差异。关于围术期不良反应，E组术中心动过缓 [0 (0%) vs 11 (14.3%), P < 0.001] 和体动反应 [17 (21.8%) vs 32 (41.6%), P = 0.008] 发生率均明显低于C组。

结论：亚麻醉剂量艾司氯胺酮（0.15 ~ 0.3 mg/kg/h）可改善右美托咪定联合瑞芬太尼在脂肪抽吸手术中镇静镇痛的麻醉效果，提高患者和手术团队的满意度，同时降低患者术后的焦虑水平，改善患者术后睡眠质量。

Purpose: Esketamine (S-ketamine) is the S-type enantiomer of ketamine, which has stereoselective pharmacological advantages. It plays a protective role in central sensitization, anxiety and nerve remodeling by antagonizing N-methyl-D-aspartate receptor (NMDAR). Compared with conventional ketamine, it also significantly reduced the incidence of psychomimetic side effects. Under the premise of preserving spontaneous breathing and circulatory stability, sub-anesthetic dose of esketamine can achieve comprehensive benefits such as analgesic synergy, anti-postoperative depression and improvement of sleep quality through multi-target regulation, while avoiding the risk of high-dose respiratory depression. The aim of this study is to investigate the sedative and analgesic effect of subanesthetic dose of esketamine (0.15 ~ 0.3 mg/kg/h) combined with dexmedetomidine and remifentanil in liposuction, and to provide theoretical basis for optimizing multimodal anesthesia program in plastic surgery.

Patients and methods: This study was a prospective, double-blind, randomized controlled clinical trial. Patients were enrolled in the Department of Anesthesiology, Plastic Surgery Hospital, Chinese Academy of Medical Sciences from December 30, 2023 to March 30, 2024. A total of 155 American Society of Anesthesiologists physical status I-II patients, aged 18-60 years, scheduled for elective liposuction were included in the analysis. The patients were randomly divided into the experimental group (esketamine -dexmedetomidine -remifentanil group, group E, n=78) and the control group (saline -dexmedetomidine/remifentanil group, n=78) using a computer-generated random number table. Group C, n=77). Electrocardiography (ECG), Oxygen Saturation (SpO₂), Heart Rate (HR), Systolic Blood Pressure (SBP) were routinely monitored after the patients entered the room. SBP), Diastolic Blood Pressure (DBP), Mean Arterial Pressure (MAP), Respiratory Rate (RR), End-tidal CO₂ Pressure (PetCO₂), Bispectral Index (BIS) and Modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S). All patients received oxygen at a flow rate of 5 L/min using a nasal catheter with end-breath carbon dioxide detection capability. Anesthesia induction was performed after the establishment of peripheral venous access. The main anesthetic regimen was as follows: In group E, esketamine 0.3 mg/kg/h, remifentanil 6 μg/kg/h and dexmedetomidine 3 μg/kg/h were continuously pumped intravenously. When the patient's Modified Observer's Assessment of Alertness/Sedation Scale (MOAA/S) score was 2, the injection of swelling fluid was started. At the same time, the injection rate of esketamine was reduced to 0.15 mg/kg/h. In group C, esketamine was replaced by normal saline, and the dosage of remifentanil and dexmedetomidine was the same as that in group E. During the operation, the speed of drug injection was adjusted according to the depth of sedation, MOAA/S score was maintained at 3 and bispectral index (BIS) value was maintained at 65 ~ 80. All patients were transferred to the Post-anesthesia Care Unit (PACU) after the operation. PACU until modified Aldrete scores ≥ 9. The primary outcome measure was patient and surgical team satisfaction with the procedure. The secondary outcome measures were Athens Insomnia Scale (AIS) on the first day after surgery and Hospital Anxiety and Depression Scale (HADS) on the third day after surgery. SBP, DBP, HR, RR, PetCO₂ and SpO₂ at baseline (T0), 15 min after anesthesia administration (T1), at the beginning of surgery (T2), 1 h after surgery (T3) and at the end of surgery (T4); anesthesia induction time, postoperative recovery time, and intraoperative consumption of dexmedetomidine, midazolam, remifentanil, and sufentanil. Ordinal logistic regression models were used to evaluate predictors associated with patient satisfaction.

Results: There was no significant difference in demographic data between the two groups. The satisfaction of patients and surgical team in group E was significantly higher than that in group C (4.7 ± 0.6 vs 4.2 ± 0.7, P < 0.001; 4.7 ± 0.5 vs 4.4 ± 0.7, P = 0.005). The sleep quality on the first day after operation and the anxiety and depression score on the third day after operation in group E were significantly lower than those in group C (4 [1, 6] vs 5 [2, 9], P = 0.012; 1 [0, 3] vs 2 [0, 6], P = 0.012). Ordinal logistic regression showed that postoperative sleep quality (OR, 0.70; 95% CI, 0.62-0.79), anxiety level (OR, 0.77; 95% CI, 0.62-0.95) and PACU recovery time (OR, 0.69; 95% CI, 0.56-0.98) were important factors affecting patient satisfaction. Intraoperative end-tidal carbon dioxide partial pressure was significantly higher at T1 (43.9 ± 4.7 vs 46.0 ± 5.1, P = 0.008) and T2 (45.1 ± 5.4 vs 48.6 ± 6.0, P = 0.008). P = 0.002), T3 (46.0 ± 5.7 vs 49.0 ± 6.1, P = 0.002) and T4 (43.9 ± 4.7 vs 45.9 ± 6.0, P = 0.022) in group E were significantly lower than those in group C. Compared with the control group, the consumption of opioids during operation in group E was reduced. There were significant differences between sufentanil (0 [0, 4] vs 5 [2.5, 7.7], P < 0.001) and remifentanil (700 [480, 900] vs 800 [500, 1200], P = 0.023). The incidence of intraoperative bradycardia [0 (0%) vs 11 (14.3%), P < 0.001] and body movement [17 (21.8%) vs 32 (41.6%), P = 0.008] in group E were significantly lower than those in group C.

Conclusion: Subanesthetic dose of esketamine (0.15 ~ 0.3 mg/kg/h) can improve the sedative and analgesic effects of dexmedetomidine and remifentanil in liposuction surgery, improve the satisfaction of patients and surgical team, reduce the level of anxiety of patients after surgery, and improve the quality of sleep of patients after surgery.