臺灣博碩士論文加值系統

本研究收集國軍高雄總醫院接受骨科膝關節鏡手術患者為對象，依美國麻醉協會分類為第一級病人(ASA class I；即身體健康並無任何系統性疾病者)，在取得病人同意後，於手術前三十分鐘依隨機取樣分為四組：即對照組、偽假電針組、術前電針組、術後電針組。實驗目的是藉由術前及術後電針穴位之止痛效果的比較，用以探討電針是否具有先機止痛的療效。本研究每組各二十位病人，於手術後記錄病患麻醉及手術時間，術後第一次要求止痛藥時間及二十四小時病患自控式止痛(Patient-Controlled Analgesia; PCA)所使用的嗎啡總量；並且觀察記錄病患的生命徵候(vital signs)、疼痛分數(VAS score)及藥物的副作用等，將收集之資料進行統計分析，以確認各組在統計學上是否有明顯差異(P<0.05)。
研究結果顯示，對照組、偽假電針組、術前電針組、術後電針組病人在術後第一次要求止痛藥的時間間隔平均值分別為9.90±0.59、22.10±2.26、47.25±2.47及57.30±1.75分鐘，且各組間在統計學上具有顯著的差異。在術後二十四小時內PCA嗎啡的使用總劑量上，對照組、偽假電針組、術前電針組、術後電針組分別為16.25±1.29 mg、11.35±0.87 mg、6.30±0.88 mg及4.65±0.64 mg，除了術前及術後電針組兩組間無明顯差異外，其餘各組間在統計學上具有顯著的差異。四組在疼痛分數的比較上，當手術結束麻醉清醒時(即第0小時)對照組及術後電針組的疼痛分數VAS score 皆高於偽假電針組及術前電針組，且具統計學上顯著的意義；而對照組在第0.5及1.0小時的疼痛分數VAS score高於其他三組，此亦有統計上的意義；至於其他時間點的疼痛分數，各組間並沒有差異。最後統計鴉片類藥物的副作用發生率，得知在術前電針組、術後電針組的術後噁心及眩暈的發生率都較對照組為低，且具有統計學上的意義。由本研究的結果發現：針刺鎮痛存在著安慰劑效應(placebo effect)，且術前及術後電針組的確更能延長術後第一次要求止痛藥的時間，及在術後二十四小時內PCA嗎啡的使用總需求量，達到更好的術後止痛。而在本研究結果中顯示：術後電針組較術前電針組有明顯延長第一次要求止痛藥的時間且有統計學上的意義；另外本臨床試驗亦發現術後電針組在PCA的嗎啡總需求量上較術前電針組為低，不過在統計學上並沒有明顯的差異。且此兩組皆比對照組有更好的術後鎮痛作用，可見電針的止痛作用具有預防由手術時所產生的中樞神經致敏化及術後發炎性傷害所造成的疼痛，亦即具有先機止痛的作用。根據本研究結果，關於術後止痛給予電針穴位的時機上，術前或術後電針之效果並無明顯的差異。

In the present study, we examined the effects of preemptive analgesia of electroacupuncture (EA) at classical acupuncture points (Yanglingquan and Yinlingquan) on postoperative pain. Eighty patients (ASA class I) undergoing arthroscopic surgery of knee were randomly assigned to four treatment regimens:
Group I (N=20), control group
Group II (N=20), sham-EA (needle intradermal insertion without electrical stimulation)
Group III (N=20), pre-operative EA (pre-op EA; needle insertion with 100 Hz electrical stimulation 30 min prior to anesthesia)
Group IV (N=20), postoperative EA (post-op EA; needle insertion with 100Hz electrical stimulation after the surgery)
All patients received patient-controlled analgesia (PCA) of morphine post-operation. Postoperative pain was evaluated by recording (1) the time of the first required analgesic, (2) the total amount of morphine required by PCA, and (3) Patients’ VAS score, (4) the opioid-related side effect. We found that the time of first analgesic required was 9.90±0.59、22.10±2.26、 47.25±2.47 and 57.30±1.75 minutes in the control, sham-EA, preoperative EA, and postoperative EA groups, respectively. There was significant in statistics by comparing with each other. During the first 24 hours, the total amount of morphine required was 16.25±1.29 mg、11.35±0.87 mg、 6.30±0.88 mg and 4.65±0.64 mg in the control, sham-EA, preoperative EA, and postoperative EA groups, respectively. There was significant in statistics by comparing with each other, except comparing with group III & IV. The incidence of nausea and dizziness during the first 24 hours after surgery was significantly reduced in both pre-op EA and post-op EA groups compared with the control group. We also found that sham-EA exerts a beneficial effect with respect to its pain relieving quality but not the side effect profiles. In conclusion, the present study showed that both pre-op EA and post-op EA group postpone the initial demand for pain control and decrease total PCA dosage within 24 hours. It also demonstrated that the electroacupuncture had the preemptive analgesia on the arthroscopic surgery of knee. And the post-op EA had the better analgesic effect than pre-op EA.

目錄 1
圖目錄 2
表目錄 3
謝辭 4
中文摘要 5
第一章 前言 7
第二章 文獻探討 9
第一節 痛覺神經的傳導路徑 9
第二節 手術後疼痛 10
第三節 先機止痛(preemptive analgesia) 12
第四節 手術後疼痛治療 14
第五節 針刺鎮痛的機轉 18
第六節 陰、陽陵泉穴的解剖位置及其功能 22
第七節 疼痛的測量工具 24
第三章 材料與方法 28
一、病患樣本選取 28
二、方法及步驟 28
三、統計分析 29
第四章 結果 30
一、四個治療組人口圖分析 30
二、術後首次要求止痛藥時間間隔比較分析 30
三、病人自控式止痛之嗎啡總需求量比較分析 30
四、術後二十四小時內VAS score比較分析 31
五、鴉片類相關副作用發生率比較分析 31
第五章 討論 37
第六章 結論 41
參考文獻 42
英文摘要 54

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