CAJ | 학술논문

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,ASA Ⅱ～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0.2 mg/kg～0.3 mg/kg、芬太尼3μg/kg～4μg/kg、顺式阿曲库铵0.15 mg/kg,诱导成功后插入双腔支气管导管,维持采用吸入1%～3%七氟烷,静脉泵注丙泊酚4 mg·kg-1·h-1～6 mg·kg-1·h-1、瑞芬太尼5μg·kg-1·h-1～10 μg·kg-1·h-1和顺式阿曲库铵0.1 mg·kg-1h-1～0.2 mg·kg-1·h-1.A组每小时持续经硬外导管注入1.5%利多卡因5 ml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4 mg·kg-1·h-1～6 mg·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0.1 mg·kg-1·h-1～0.2 mg·kg-1·h-1.两组患者术中出血均<500 ml,手术时间<3 h,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5 min给予芬太尼2 μg/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=0.006,P<0.01),其中危险性躁动(评分达3分)的患者A组有1例,而B组则达到了5例,两组差异有统计学意义(P=0.002,P<0.01).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. 目的觀察胸段硬膜外阻滯對老年患者行胸科手術時全痳囌醒期躁動(emergence agitation,EA)的影響.方法擇期行胸科手術的老年患者40例,ASA Ⅱ～Ⅲ級.其中男23例,女17例,年齡65歲～78歲,均為食道癌和肺癌患者.將40例患者用完全隨機法分為兩組(每組20例),分彆給予全痳複閤硬膜外痳醉(A組)和全身痳醉(B組).A組在全痳誘導前行硬膜外穿刺,間隙選擇T5～6或T6～7之間,跼痳藥選用1.5%的利多卡因,確定硬膜外痳醉有效後再行全痳誘導.兩組患者全痳誘導均採用靜註依託咪酯0.2 mg/kg～0.3 mg/kg、芬太尼3μg/kg～4μg/kg、順式阿麯庫銨0.15 mg/kg,誘導成功後插入雙腔支氣管導管,維持採用吸入1%～3%七氟烷,靜脈泵註丙泊酚4 mg·kg-1·h-1～6 mg·kg-1·h-1、瑞芬太尼5μg·kg-1·h-1～10 μg·kg-1·h-1和順式阿麯庫銨0.1 mg·kg-1h-1～0.2 mg·kg-1·h-1.A組每小時持續經硬外導管註入1.5%利多卡因5 ml直至手術結束.B組單純用全痳,全痳誘導和維持方案與A組相同,維持採用吸入1%～3%七氟烷,靜脈泵註丙泊酚4 mg·kg-1·h-1～6 mg·kg-1·h-1瑞芬太尼10μg·kg-1·h-1～20μg·kg-1·h-1和順式阿麯庫銨0.1 mg·kg-1·h-1～0.2 mg·kg-1·h-1.兩組患者術中齣血均<500 ml,手術時間<3 h,維持輸液以乳痠鈉林格氏液和中分子羥乙基澱粉,保持兩組患者的血流動力學平穩,併用肌鬆鑑測儀鑑測使兩組患者都達到相同的肌鬆程度,手術結束前5 min給予芬太尼2 μg/kg,同時靜脈接鎮痛泵作術後鎮痛,所有患者未使用催醒藥.記錄兩組病例全痳藥用量和拔管時間.患者拔管後送入重癥加彊護理病房(ICU),記錄患者入ICU時的躁動評分(restlessness score,RS).結果 A組和B組比較,RS評分(A組15分,B組32分)和EA例數(A組5例,B組12例)均明顯低于B組(P=0.006,P<0.01),其中危險性躁動(評分達3分)的患者A組有1例,而B組則達到瞭5例,兩組差異有統計學意義(P=0.002,P<0.01).結論硬膜外阻滯複閤全痳可以顯著降低老年胸科手術患者痳醉後EA特彆是危險性躁動的髮生率,有利患者的康複.
목적 관찰흉단경막외조체대노년환자행흉과수술시전마소성기조동(emergence agitation,EA)적영향.방법 택기행흉과수술적노년환자40례,ASA Ⅱ～Ⅲ급.기중남23례,녀17례,년령65세～78세,균위식도암화폐암환자.장40례환자용완전수궤법분위량조(매조20례),분별급여전마복합경막외마취(A조)화전신마취(B조).A조재전마유도전행경막외천자,간극선택T5～6혹T6～7지간,국마약선용1.5%적리다잡인,학정경막외마취유효후재행전마유도.량조환자전마유도균채용정주의탁미지0.2 mg/kg～0.3 mg/kg、분태니3μg/kg～4μg/kg、순식아곡고안0.15 mg/kg,유도성공후삽입쌍강지기관도관,유지채용흡입1%～3%칠불완,정맥빙주병박분4 mg·kg-1·h-1～6 mg·kg-1·h-1、서분태니5μg·kg-1·h-1～10 μg·kg-1·h-1화순식아곡고안0.1 mg·kg-1h-1～0.2 mg·kg-1·h-1.A조매소시지속경경외도관주입1.5%리다잡인5 ml직지수술결속.B조단순용전마,전마유도화유지방안여A조상동,유지채용흡입1%～3%칠불완,정맥빙주병박분4 mg·kg-1·h-1～6 mg·kg-1·h-1서분태니10μg·kg-1·h-1～20μg·kg-1·h-1화순식아곡고안0.1 mg·kg-1·h-1～0.2 mg·kg-1·h-1.량조환자술중출혈균<500 ml,수술시간<3 h,유지수액이유산납림격씨액화중분자간을기정분,보지량조환자적혈류동역학평은,병용기송감측의감측사량조환자도체도상동적기송정도,수술결속전5 min급여분태니2 μg/kg,동시정맥접진통빙작술후진통,소유환자미사용최성약.기록량조병례전마약용량화발관시간.환자발관후송입중증가강호리병방(ICU),기록환자입ICU시적조동평분(restlessness score,RS).결과 A조화B조비교,RS평분(A조15분,B조32분)화EA례수(A조5례,B조12례)균명현저우B조(P=0.006,P<0.01),기중위험성조동(평분체3분)적환자A조유1례,이B조칙체도료5례,량조차이유통계학의의(P=0.002,P<0.01).결론 경막외조체복합전마가이현저강저노년흉과수술환자마취후EA특별시위험성조동적발생솔,유리환자적강복.
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 esophagectomy or lobectomy 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, 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. Results In group A, the mean score of RS in group A was 15 while that of Group B was 32. Time of extubation of Group A was shorter than that of group B (5.1 min vs. 11.6 min and the general anesthesia dosage were significantly less than those in group B (P=0.006 ). 5 patients in group A developed dangerous EA whereas only 1 patient in group A (P=0.002). Conclusion Thoracic epidural block significantly reduces agitation during emergence in elderly patients undergoing chest surgery.