低劑量的Bupivacaine配合Midazolam為糖尿病患作脊椎麻醉進行足部手術有助改善術後恢復

Intrathecal Midazolam Combined with Low-dose Bupivacaine Improves Postoperative Recovery in Diabetic Meilitus Patients Undergoing Foot Debridement

背景：以往研究顯示脊椎麻醉內注射鴆片類或bupivacaine搭配使用midazolam可增進其麻醉的效果，而提供良好的術後止痛。本研究據此，針對糖尿病病患接受足部清創手術的患者設計臨床實驗，以較少量的bupivacaine搭配midazolam，觀察術中血行動力學、術後疼痛的指數、術後運動功能的恢復等多項指標的變化。方法=將病患分為兩組（每組各30人，兩組同樣於L3_4以27號脊椎麻醉針注射；M組注入1.5mL的0.5%hyperbaricbupivacaine，M+M組則注入1mL0.5%hyperbaricbupivacaine混合mgmidazolam+0.6mLN/S。麻醉藥物注入之後20分鐘，以pinpricktest測弒病患感覺神經阻斷的高度，術中並紀錄最高與最低血壓；並於術後於恢復室以VASscore（0-10）評估其術後疼痛的情形，同時每30分鐘，以Bromagescale（0-3）評估其運動功能恢復的情形；術後則紀錄24小時止痛藥的劑量與時間。結果=比較術中血壓變化兩組並無顯著差距。麻醉藥物注入之後20分鐘，病患感覺神經阻斷的高度，M組阻斷高度的中位數為T9，M+M組阻斷高度的中位數為T10（P>0.05）。術後6小時，疼痛指數大於5的病患人數，M組明顯較M+M組人數為多（3/30於M+M組，11/30於M組，P<0.05）;術後24小時，測試疼痛指數大於5的病患人數，M組明顯較M+M組人數為多（2/30於M+M組，12/30於M組，P<0.05），且使用止痛劑的病患人數M+M組明顯較少（4/30於M+M組，11/30於M組，P<0.05）。碓然在注入藥物20分鐘後至恢恢室30分鐘，M+M組的運動功能阻斷程度（Bromagescore）明顯較M組為差，但多數病患至恢復室後60分鐘後動作能力都已完全恢復。結論：低劑量的bupivacaine5毫克混合2毫克的midazolam作脊椎麻醉，可安全為糖尿病病患進行足部清創手術。同時明顯縮短術後運動功能恢復的時間，並減低術後嚴重疼痛的機率及止痛劑的用量。

Background: Intrathecal midazolam acts synergically with other anesthetics to relieve surgical pain, and the drug combination may decrease complications attributable to each component drug. This prospective study was to determine the spinal effects of low-dose of bupivacaine (5 mg) combined with intrathecal midazolam (2 mg) in diabetes meilitus (DM) patients undergoing foot debridement. Methods: Sixty diabetic patients were admitted for foot debridement under spinal anesthesia were equally di-vided into two groups. Group 1 (M) received 7.5 mg of hyperbaric bupivacaine; group 2 (M+M) received 5 mg of hyperbaric bupivacaine combined with 2 mg of midazolam intrathecally. The intensity of motor block was assessed with modified Bromage scale 20 minutes after injection, and at 0, 30, 60, 90 and 120 min after arriving at the post anesthesia care unit (PACU). Pain score was assessed with a 10cm visual analog scale (VAS, 0 = no pain and 10 = intolerable pain) at 0, 1, 2, 6 h and 24 h postoperatively. Results: Anesthesia was smooth in all patients except one in group M, whose analgesia was inadequate and gen-eral anesthesia was given to complete the surgery. The number of patients who sustained moderate to severe pain (VAS > 5) was significantly less in the M+M group than in M group as accessed 6 and 24 h postoperatively. The requirement of additional analgesic as reinforcement was significantly less in the M+M group than in the M group within the space of 24 h postoperatively. Recovery of motor function was significantly faster in the M+M group. Conclusions: The combination of intrathecal midazolam and bupivacaine was a safe and effective anesthetic technique, and it also provided early recovery of motor function and reduced the requirement of analgesics post- operatiyely.