臺灣博碩士論文加值系統

背景及目的：硬脊膜外麻醉是目前麻醉醫師經常使用的一種區域麻醉方式，而意外硬脊膜穿破則是施行硬脊膜外麻醉時最常見的併發症，本研究目的即在探討影響意外硬脊膜穿破之可能因素，以避免發生此一意外。
方法：本研究採回溯性資料蒐集方法，研究國內一家教學醫學中心自民國89年10月至95年5月期間共有15,932例硬脊膜外麻醉。分析各種病人特質（基本特性：年齡、性別；疾病特性：手術種類、ASA體位、急診、使用侵入性生理監視器）與工作特質（時間特性：執行時間、工作時段、累計上班時間；經驗特性：麻醉醫師的職位；工作負荷特性：麻醉醫師同時照顧之麻醉單位數）對意外硬脊膜穿破機率之影響。
結果：較易發生意外硬脊膜穿破之情況包括：個案年齡較高、非產科接受硬脊膜外麻醉者、大夜班執行硬脊膜外麻醉、由第一年住院醫師或第二年住院醫師執行硬脊膜外麻醉。以邏輯迴歸計算其意外硬脊膜穿破勝算比：骨科病人、其他非產科或骨科病人分別為產科病人的3.53、2.81倍；大夜班為白天班的4.42倍；第一年住院醫師、第二年住院醫師分別為專科醫師的3.20、3.03倍。
結論：限制高風險醫師於高風險時段為高風險病患族群執行硬脊膜外麻醉、減少高風險時段病人、增加醫師施行硬脊膜外麻醉經驗，將有助於減少意外硬脊膜穿破之風險。

Background and Aim: Epidural anesthesia is one of the regional anesthesias that anesthesiologists usually perform for patients. Accidental dural puncture is the most frequently occurring complications while performing epidural anesthesia. The aim of this study is to explore the factors influencing the accidental dural puncture rate by anesthetists.
Method: We retrospectively analyzed 15,932 cases of epidural anesthesia collected from a teaching medical center since October 1990 to May 2006. The influence of patient factors (included: age, sex, type of operation, ASA classification, emergency, invasive hemodynamic monitors) and work factors (included: anesthesia time, work shifts, cumulative work hours, anesthetists’ experience, concurrency) to the rate of accidental dural puncture was analyzed.
Results: Old age, non-obstetric operation, late night shift, 1st year and 2nd year training resident were associated with higher rates of accidental dural puncture. By logistic regression, the odds ratios in terms of accidental dural puncture rates for orthopedic operations and non-orthopedic non-obstetric operations are 3.53 and 2.81 in comparison with obstetric operations. Late night shift is 4.42 times more than day shift. 1st year and 2nd year training resident are 3.20 and 3.03 times more than attending anesthesiologist.
Conclusion: In order to reduce the accidental dural puncture, we recommend the following policies: First, limiting the inexperienced doctors not to perform epidural anesthesia for high risk patients during late night shifts; Second, reduce the patient amount of late night shifts; Third, increase doctors’ epidural anesthesia experience.

誌謝 i
中文摘要 ii
英文摘要 iii
表目次 v
圖目次 vi
第一章 緒論 1
第一節 研究背景 1
第二節 研究動機 2
第三節 研究目的 3
第二章 文獻探討 4
第一節 國內外麻醉醫師人力概況 4
第二節 工作負荷對麻醉品質的影響 8
第三節 增加麻醉主治醫師同時間內照顧的床數對麻醉品質的影響 9
第四節 工作時間對麻醉品質的影響 10
第五節 工作壓力對麻醉品質的影響 12
第六節 工作經驗對麻醉品質的影響 13
第七節 影響意外硬脊膜穿破的病人因素 14
第八節 文獻總結 15
第三章 研究方法 21
第一節 研究架構 21
第二節 研究變項及其操作型定義 23
第三節 研究假說 27
第四節 研究對象 27
第五節 資料蒐集方法 27
第六節 資料處理方法 28
第七節 資料分析方法 30
第四章 研究結果 32
第一節 病人特質分析 32
第二節 工作特質分析 36
第三節 意外硬脊膜穿破之相關因素邏輯迴歸分析 40
第五章 討論 46
第一節 病人特質討論 47
第二節 工作特質討論 48
第三節 研究限制 49
第六章 結論與建議 51
第一節 結論 51
第二節 建議 51
參考文獻 54
中文部份 54
英文部份 55

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