胸段硬膜外阻滞对老年胸科手术患者苏醒期躁动的影响

The effects of thoracic epidural block on emergence agitation in elderly patients undergoing thoracic surgery

目的 观察胸段硬膜外阻滞对老年患者行胸科手术时全麻苏醒期躁动（emergence agitation，EA）的影响。方法 择期行胸科手术的老年患者40例，ASAⅡ-Ⅲ级。其中男23例，女17例，年龄65岁-78岁，均为食道癌和肺癌患者。将40例患者用完全随机法分为两组（每组20例），分别给予全麻复合硬膜外麻醉（A组）和全身麻醉（B组）。A组在全麻诱导前行硬膜外穿刺，间隙选择T5-6或T6-7之间，局麻药选用1．5％的利多卡因，确定硬膜外麻醉有效后再行全麻诱导。两组患者全麻诱导均采用静注依托咪酯0．2mg／kg-0．3mg／kg、芬太尼3μg／kg-4μg／kg、顺式阿曲库铵0．15mg／kg，诱导成功后插入双腔支气管导管，维持采用吸入l％-3％七氟烷，静脉泵注丙泊酚4mg·kg^-1.h^-1-6mg·kg^-1.h^-1、瑞芬太尼5μg·kg^-1.h^-1-10μg·kg^1.h^-1和顺式阿曲库铵0．1mg·kg^-1·h^-1-0．2mg·kg^-1.h^-1。A组每小时持续经硬外导管注入1．5％利多卡因5ml直至手术结束。B组单纯用全麻，全麻诱导和维持方案与A组相同，维持采用吸入1％-3％七氟烷，静脉泵注丙泊酚4mg·kg^-1.h^-1-6mg·kg^-1.h^-1瑞芬太尼10μg·kg^-1.h^-1-20μg·kg^-1·h^-1和顺式阿曲库铵0．1mg·kg^-1·h^-1-O．2mg·kg^-1·h^-1。两组患者术中出血均〈500ml，手术时间〈3h，维持输液以乳酸钠林格氏液和中分子羟乙基淀粉，保持两组患者的血流动力学平稳，并用肌松监测仪监测使两组患者都达到相同的肌松程度，手术结束前5min给予芬太尼2μg／kg，同时静脉接镇痛泵作术后镇痛，所有患者未使用催醒药。记录两组病例全麻药用量和拔管时间。患者拔管后送入重症加强护理病房（ICU），记录患者入ICU时的躁动评分（restlessness score，RS）。结果 A组和B组比较，RS评分（A组15分，B组32分）和EA例数（A组5例，B组12例）均明显低于B组（P=O．006，P〈O．01），其中危险性躁动（评分达3分）的患者A组有i例，而B组则达到了5例，两组差异有统计学意义（P=0.002，P〈O．01）。结论 硬膜外阻滞复合全麻可以显著降低老年胸科手术患者麻醉后EA特别是危险性躁动的发生率，有利患者的康复。

Objective To explore the effects of thoracic epidural block on emergence agitation （EA） in emergence period in elderly patients undergoing chest surgery. Methods Forty ASA II -Ⅲ patients （23 male, 17 female） aged 65 y-78 y undergoing esophageetomy or lobeetomy were randomized to receive either general combined thoracic epidural anesthesia （group A, n=20） and pure general anesthesia（group B, n=20）. Thoracic 5-6 or 6-7（T5-6 or T6-7） vertebral clearance for puncture and epidural catheter was placed before general anesthesia in group A.A test dose of 4 ml 1.5% lidocaine was given. When correct positioning of the epidural catheter was confirmed,general anesthesia was induced with etomidate 0.2 mg/kg-0.3 mg/kg, fentanyl 3μg/kg-4 μg/kg and synatracurium O. 15 mg/kg. Anesthesia was maintained with inhalation 1%-3% sevoflurane, pumping propofol 4 mg. kg^-l.h^-1-6 mg.kg^-1.h^-1 and remifentanil 5 μg.kg. h^1-10μLg.kg^-1.h^-1 and syn-atracurium 0.1 mg.kg^-l.h^-1-0.2 mg. kg^-1.h^-1. 1.5% lidocaine was continuously infused at a rate of 5 ml/h during operation. In group B, the patients received the same general anesthesia technique as group A and without thoracic： epidural block. The blood loss of each patient was lower than 500 ml and the time of operation was within 3 hours. Hemodynamics were maintained stable and muscle relaxation was the same in both groups. Patients of both groups received 2 ug/kg fentanyl intravenously before end of operation and patient controlled intravenous analgesia （PCIA）. The restlessness score （RS）, extubation time, general anesthesia dosage were recorded.