靜脈注射Ketorolac及Fentanyl合併Midazolam於體外震波碎石術之止痛及副作用

Effects of Intravenous Ketorolac and Fentanyl Combined with Midazolam on Analgesia and Side Effects during Extracorporeal Shock Wave Lithotripsy

背景：體外震波碎石術經常用於門診病人之治療，因此使得適當的止痛且併發較少的副作用成為必要考量。本研究是比較靜脈注射ketorolac及fentanyl合併midazolam於體外震波碎石術之止痛及副作用。方法：將60位病患隨機分為兩組，K組30位病患在接受體外震波碎石術之前30分鐘靜脈注射ketorolac 60毫克及F組30位病患在接受體外震波碎石術之前3分鐘靜脈注射fentanyl 100 μg。所有的病患在接受體外震波碎石術之前3分鐘靜脈注射2.5 mg midazolam。疼痛程度則由分數評估疼痛等級(NRS)的方式評估。若止痛程度不恰當，使疼痛等級大於3分，則注射25 μg fentanyl作為補足的止痛劑。若是血氧飽和度小於94％則戴上氧氣面罩。然後記錄術中或術後副作用（噁心，嘔吐，頭暈）的產生及從麻醉後恢復室離開的時間。而從麻醉後恢復室離開的指標則定義為病患沒有任何不舒服甚至站立時也同樣。結果：在年齡，性別，體重，身高，碎石時的震波次數，碎石術的時間長短及止痛劑的補充方面，兩組之間沒有差異。需要戴氧氣面罩的情形ketorolac組(1/30)比fentanyl組(20/30)少，P< 0.01。發生頭暈的的機率ketorolac組(1/30)比fentanyl組(25/30)少，P< 0.01。其中fentanyl組有 3位病患抱怨噁心，而ketorolac組則沒有。從麻醉後恢復室離開的時間ketorolac組(14.7 ± 8.4 min)明顯比fentanyl組(49.5 ± 14.6 min)短，P< 0.01。結論：靜脈注射ketorolac及fentanyl合併midazolam對於體外震波碎石術，兩者都可提供良好的止痛作用。然而，ketorolac合併midazolam顯示有較少的副作用，及在較短的時間內從麻醉後恢復室離開。我們建議靜脈注射ketorolac合併midazolam在體外震波碎石術的麻醉處理上，是一種安全有效的藥物，尤其是應用於門診的病患。

Background: Extracorporeal shock wave lithotripsy (ESWL) is usually carried out on ambulatory or outpatient basis, and thus an appropriate anesthesia with minimal side effects is required. This study was to compare the analgesic and side effects of intravenous ketorolac with that of intravenous fentanyl, in combination with midazolam in ESWL. Methods: Sixty patients were randomly divided into two groups; group K (n = 30) received 60 mg ketorolac i.v. 30 min before ESWL and group F (n = 30) received 100 μg fentanyl i.v. 3 min before ESWL. All patients received 2.5 mg midazolam i.v. 3 min before ESWL for intraoperative sedation. The pain intensity was evaluated by a numeric rating scale (NRS). A supplemental analgesia with intravenous fentanyl 25 μg was given when inadequate analgesia occurred (NRS > 3). Oxygen supplement through a face mask was given when the SpO2 fell below 94%. Side effects (nausea, vomiting, dizziness) and the time of discharge from post-anesthesia room (PAR) were recorded. The criterion of discharge from PAR was absence of any discomfort especially when the patient held upright. Results: There was no difference between two groups in the demographic data, number of shock waves, duration of ESWL procedure, and fentanyl supplement. The incidence of oxygen supplement was lower in ketorolac group (1/30) compared with that of fentanyl group (20/30), P< 0.01. The frequency of dizziness was lower in ketorolac group (1/30) than that in fentanyl group (25/30), P< 0.01. Three patients in fentanyl group complained of nausea, but none did in ketorolac group. The discharge time from PAR was significantly shorter in ketorolac group (14.7 ± 8.4 min) than that in fentanyl group (49.5 ± 14.6 min), P< 0.01. Conclusions: Both intravenous ketorolac and fentanyl in combination with midazolam could provide good anesthesia for ESWL. However, ketorolac plus midazolam had less side effects and allowed shorter discharge time from PAR. We suggest that intravenous ketorolac combined with midazolam is a safe and effective anesthetic regiment for ESWL, particularly on ambulatory basis.