臺灣博碩士論文加值系統

背景：
　　隨著醫療的進步，電刀、雷射刀、超音波刀等電外科儀器是目前外科手術常用之工具，其中電刀是使用率最高的儀器之一。使用電刀時常會伴隨著不完全燃燒，導致產生電刀煙霧，而這些煙霧已在許多研究中證實具有化學性與生物性方面的危害，主要造成醫護人員呼吸道、眼睛刺激等，而長期暴露下可能具有致突變或致癌等潛在傷害，因此本研究偵測電刀煙霧中六種常見之揮發性有機氣體，並探討手術科別、手術術式、電刀使用時間、電刀能量、病人之身體質量指數(Body Mass Index, BMI) 等相關因素是否影響特定化學物質之產量。
方法：
　　本研究在中部某醫學中心之手術房進行乳房外科手術及腹腔手術電刀煙霧的採樣，所偵測之揮發性有機氣體如下：甲苯(toluene)、乙苯(ethyl benzene)、二甲苯(xylenes)、苯乙烯(styrene)、呋喃甲醛(furfural)、酚(phenol)。分別使用SKC 226-01(活性碳管)採集苯環類及呋喃甲醛，SKC 226-95(XAD-7)採集酚。因為手術過程需為無菌狀態，無法將採樣泵直接配戴醫護人員身上，故先將手術電刀筆黏附上無菌抽痰管，抽痰管後端連接至體積為2.5 L之密封容器(chamber)，該容器之另一出口再連接至手術房的抽風系統作為抽氣動力，把手術產生的電刀煙霧抽進chamber中，再利用chamber中置放的採樣裝置採集電刀煙霧。採樣期間記錄電刀使用時間、手術診斷術式別、病人基本資料等，採樣結束後將樣本運回實驗室以氣相層析儀與火焰離子偵測器(GC-FID)進行樣本分析。

結果：
　　本研究收集了乳房外科手術及腹腔手術各15個個案，其中有27個樣本偵測到甲苯，其濃度範圍為0.031~0.463 mg/m3(0.008~0.120 ppm)，2個個案偵測到乙苯，其濃度為0.048及0.069 mg/m3(0.011及0.016 ppm)，2個個案偵測到苯乙烯，其濃度為0.455及0.627 mg/m3(0.104及0.144 ppm)。本研究所有採集之個案二甲苯、呋喃甲醛及酚則皆低於偵測極限。
手術科別、電刀能量、電刀的使用時間與電刀煙霧中之甲苯濃度皆具有統計上的顯著相關，由逐步迴歸分析得知電刀能量為主要影響甲苯濃度之因子。將結果依電刀使用能量高低分組後，電刀使用時間與BMI對電刀煙霧中甲苯濃度之影響，於散佈圖中發現皆有正向之趨勢，但並未達統計上的顯著意義。
結論：
　　本研究現有結果得知，電刀煙霧中主要成分為甲苯，主要影響甲苯濃度的因子為電刀能量，而電刀使用時間及病患BMI指數也可能為影響電刀煙霧中甲苯濃度之因子。

Introduction
Electrocautery, laser, and harmonic scalpel are widely used during surgeries. Especially, electrocautery is used more than others. In this process, tissue is heated to the boiling point of its constituent fluid causing cell membranes to rupture and often produces smoke. It contains bioaerosol of cellular constituents and chemicals. These chemicals cause headaches, irritation of the eyes, nose and throat, as well as potential long term health effects. This study intends to quantify certain volatile organic compounds with electrocautery smoke and further the correlation between the concentration and the factors included type of surgery, using electrocautery time, energy and patient’s BMI will be analyzed.
Method
The study was conducted in a medical center of central Taiwan and focused on breast and abdominal cavity surgeries. The investigated chemicals included toluene, ethyl benzene, styrene, o,m-xylenes, furfural and phenol. Toluene, ethyl benzene, styrene, o,m-xylenes and furfural were collected by SKC 226-01 (charcoal) sampler; and phenol was traped by SKC 226-95 (XAD-7) sampler. Because all surgery processes require the aseptic condition, the surgical team members were not able to wear the samplers. All samplers were put in a chamber system and gathering the smoke about 2 cm from the tip of diathermy pencil. For each sampling case, the type of surgery, using electrocautery time, energy and patient’s BMI were recorded. All samples were analyzed by gas chromatography and flame ionization detector (GC-FID).

Result
Thirty samples were collected, 15 from the breast surgeries and 15 form the abdominal cavity surgeries. Toluene was identified in 27 samples. The concentration ranges were 0.031~0.463 mg/m3 (0.008~0.120 ppm). Ethyl benzene was identified in 2 samples. The concentrations were 0.048 and 0.069 mg/m3 (0.011 and 0.016 ppm). Styrene was identified in 2 samples. The concentrations were 0.455 and 0.627 mg/m3 (0.104 and 0.114 ppm). The concentrations of m,o-xylene, furfural and phenol were lower than the limit of detection. The spearman’s correlations showed the concentrations of toluene were significantly correlated to type of surgery, energy, and using electrocautery time statistically. The energy was a major factor to determine the toluene concentration according to the results of stepwise regression analyses. The other two factors, using electrocautery time and patient’s BMI were not significant in affecting the toluene concentration if the results were categorized as high energy and low energy groups. However, the positive trends between the BMI versus toluene concentration and using electrocautery time versus toluene concentration were observed. More investigations should be addressed to verify the tendency statistically.
Conclusion
The energy was a major factor to determine the toluene concentration. The other two factors, using electrocautery time and patient’s BMI were possible factors to determine the toluene concentration.

摘要 I
Abstract III
誌 謝 V
目錄 VI
表目錄 IX
圖目錄 X
第一章 前言 1
第一節 研究背景 1
第二節 研究目的 2
第二章 文獻探討 3
第一節 電外科(electrosurgery)儀器種類 4
(一) 電刀(electrocautery、diathermy) 4
(二) 雷射(laser) 9
(三) 超音波刀(harmonic scalpel) 9
第二節 名詞定義 11
(一) 煙霧 11
(二) 手術術式 12
第三節 電刀煙霧中的組成及危害 14
(一) 微粒及生物性危害 15
(二) 化學性危害 19
第四節 可能影響電刀煙霧產生之相關因子 26
(一) 電外科儀器的種類 26
(二) 手術科別及術式 26
(三) 電外科儀器的模式及能量 27
(四) 病人之身體質量指數(body mass index, BMI) 27
(五) 電刀的使用時間 28
(六) 手術過程中是否使用抽吸裝置 28
第五節 電刀煙霧之採集與分析 29
(一) 電刀煙霧的採樣 29
(二) 電刀煙霧的分析儀器 30
第六節 研究物質之特性與法規標準 31
(一) 甲苯(toluene) 31
(二) 乙苯(ethyl benzene) 31
(三) 二甲苯(xylene) 32
(四) 苯乙烯(styrene) 33
(五) 酚(phenol) 33
(六) 呋喃甲醛(furfural) 34
第三章 材料與方法 36
第一節 研究設計 36
第二節 實驗設備與藥品 39
(一) 實驗設備 39
(二) 藥品 40
(三) 儲備溶液(stock solutions) 42
(四) 檢量線 43
第三節 採樣 44
(一) 採樣設備 44
(二) 採樣流程 46
第四節 分析 50
(一) 分析設備 50
(二) 脫附流程 50
(三) GC-FID分析條件 52
第五節 脫附效率及LOD(limit of detection) 55
第六節 統計方法 56
第七節 手術房環境特性 57
第四章 結果 62
第一節 乳房手術 62
(一) 個案基本資料 62
(二) 煙霧中的特定化學物質結果 62
第二節 腹腔手術 67
(一) 個案基本資料 67
(二) 煙霧中的特定化學物質結果 67
第三節 電刀煙霧成份之影響因子 71
(一) 各變項之間的相關性 71
(二) 手術科別 72
(三) 術式別之比較 72
(四) 電刀燒結能量 75
(五) 電刀使用時間 75
(六) 身體質量指數(BMI) 75
第四節 主要影響因子 78
第五章 討論 85
第一節 電刀煙霧成份之影響因子探討 85
(一) 不同手術科別 85
(二) 電刀燒結能量 85
(三) 電刀使用時間 85
(四) 身體質量指數(BMI) 86
第二節 主要因子之探討 87
(一) 身體質量指數(BMI) 87
(二) 電刀使用時間及頻率 87
第三節 相關文獻比較 89
(一) 電刀煙霧中揮發性有機化學物質之探討 89
(二) 相關因子之探討 90
第四節 研究限制 92
第五節 結論及建議 93
參考文獻 95
附錄 101

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