目的 观察胸段硬膜外阻滞对老年患者行胸科手术时苏醒期躁动（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-1~0.2mg•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2ug/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ICU，记录患者入ICU时的躁动评分（RS）。结果 和B组比较，A组RS评分和EA例数明显低于B组（P=0.006＜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，两组差异非常显著（P=0.002＜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苏醒期躁动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 elderly patients undergoing chest surgery. Methods Forty ASA Ⅱ~Ⅲ patients (23 male，17female) aged 65~78 yr undergoing esophagectomy or lobectomy were randomized to receive either general combined thoracic epidural anesthesia (group A,n=20) or pure general anesthesia(group B，n=20). In group A thoracic 5~6 or 6~7 (T5-6 or T6-7 ) vertebral clearance for puncture and epidural catheter was placed before general anesthesia.A test dose of 4ml 1.5% lidocaine was given.When correct positioning of the epidural catheter was confirm，general anesthesia was induced with etomidate0.2~0.3mg/kg, fentanyl3~4ug/kg and syn-atracurium0.15mg/kg. Anesthesia was maintained with inhalation 1%~3% sevoflurane, pumping propofol 4mg•kg-1•h-1~6mg•kg-1•h-1 and remifentanil 5μg•kg-1•h-1~10μg•kg-1•h-1 and syn-atracurium0.1mg•kg-1•h-1~0.2mg•kg-1•h-1. 1.5% lidocaine was continuously infused at a rate of 5ml.h-1 during operation. In group B, the patients received the same general anesthesia technique with group A and received only general anesthesia. All the patients loss blood lower than 500ml and the time of operation witnin 3 hours. Maintain the hemodynamics stable and the same muscle relaxation in two groups.The patients in group A and group B received 2ug/kg fentanyl byintravenous injection before end of operation and PCIA. The restlessness score (RS), extubation time, general anesthesia dosage were recorded. Result In group A, the score of restlessness score (RS), the time of extubation and the general anesthesia dosage were significantly less than those in group B（P=0.006＜0.01）.5 patients developed the dangerous EA whearas only 1 patient in group A and the difference between the two groups was signifycant （P=0.002＜0.01）. Conclusions Thoracic epidural block can significantly reduce the emergence agitation especially dangerous EA in elded patients who received chest surgery.
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