硬膜外镇痛在胸腔手术后苏醒期的效果观察

目的 探讨硬膜外镇痛在胸腔手术后苏醒期的临床效果及安全性.方法 选择择期行剖胸肺大泡及单纯肺叶切除术90例,年龄25～55岁,ASAⅡ～Ⅲ级；将其随机分为硬外组(A),静脉组(B),对照组(C),每组30例.A组诱导前行T8～9硬膜外穿刺.三组均行双腔支气管插管,采用丙泊酚-瑞芬太尼-七氟醚静吸复合全身麻醉,维持PetCO2在35 ～ 45 mm Hg(1mm Hg=0.133 kPa)之间,血压波动在20％范围内.手术结束前20 min,A组硬膜外腔分次注入0.375％罗哌卡因10ml,B组静脉注射曲马多2mg/kg和昂丹思琼8 mg,C组静脉注射生理盐水10 ml.记录手术结束后自主呼吸恢复时间、意识恢复时间以及拔管时间.记录三组术前、清醒时和拔管后5 min的心率(HR)、平均动脉压(MAP)、呼吸频率(RR)、脉搏氧饱和度( SpO2).记录拔管后5min的镇痛,镇静及躁动评分.结果 A、B两组术后清醒时HR和MAP升高幅度均比C组小(P＜ 0.05),且A组比B组更低(P＜0.05).A组的疼痛评分和躁动评分最低(B＜C,P＜ 0.05;A＜B,P＜ 0.05).结论 硬膜外与静脉镇痛都能有效地抑制胸腔手术结束时停用麻醉药后苏醒期的各种不良反应,硬外镇痛效果更好.

Effect of epidural analgesia in recovery period of consciousness in thoracic surgery

Objective To explore the efficacy and safety of epidural analgesia in recovery period of consciousness in thoracic surgery. Methods 90 ASA Ⅱ-Ⅲ patients scheduled for lobectomy, aged 25 to 55 years, were randomly divided into epidural analgesia group （ group A ）, intravenous analgesia group （ group B ）, and control group （ group C ）, 30 for each group. Epidural acupunture was performed at T8-9 in group A before anesthesia induction. All the three groups received general anesthesia with remifentanil, propofol, and sevoflurane： PetCO2 was maintained between 35 and 45 mm Hg（ 1 mm Hg=0.133 kPa ）and blood pressure was controlled at a range of 20%. 20 minutes before the end of surgery, group A was administered 0.375% ropivacaine of 10 ml via the epidural space, group B received intravenous injections of tramadol of 2 mg/kg and ondansetron of 8 mg, and group C received 0.9% NS of 10 ml. Time to recovery of spontaneous breathing, time to recovery of consciousness, and time to extubation were recorded. HR, MAP, RR, and SpO2 were noted preoperatively and at recovery of consciousness and 5 min after extubation. Levels of analgesia and agitation were scored 5 min after extubation. Results Levels of increased HR and MAP were lower in groups A and B than in group C at recovery period of consciousness, group A had the lowest level （ P 〈 0.05 for all comparisons ）. Pain scores and agitation scores were lowest in group A, followed by group B, and then group C （ P 〈 0.05 for all comparisons ）. Conclusions Both epidural and intravenous analgesia are effective in inhibition of various adverse reactions after termination of anesthetics. Epidural analgesia had a better efficacy.