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研究生:莊富嵐
研究生(外文):Fu-Lan Chuang
論文名稱:胸腔內視鏡肺葉切除術與肺楔狀切除術使用靜脈自控式止痛之術後疼痛處置比較
論文名稱(外文):Comparison of postoperative pain management using intravenous patient-controlled analgesia between video-assisted thoracoscopic lobectomy and wedge resection
指導教授:林朝順林朝順引用關係
學位類別:碩士
校院名稱:臺北醫學大學
系所名稱:護理學研究所
學門:醫藥衛生學門
學類:護理學類
論文種類:學術論文
論文出版年:2015
畢業學年度:103
語文別:中文
論文頁數:93
中文關鍵詞:胸腔內視鏡手術肺葉切除術肺楔狀切除術靜脈式自控止痛術後止痛需求術後急性疼痛疼痛數字等級量表
外文關鍵詞:video-assisted thoracoscopic surgerylobectomywedge resectionintravenous patient-controlled analgesiapostoperative analgesia requirementpostoperative acute painnumerical rating scale
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目的:
分析比較胸腔內視鏡肺葉切除術與肺楔狀切除術的病人,使用靜脈自控式止痛(IVPCA),在手術後三天嗎啡使用量及疼痛程度的差異。次要目的是分別分析兩種術式,在術後三天不同天數之間,IVPCA嗎啡使用量及疼痛程度的差異。
方法:
採回溯性研究,收集北部某醫學中心102年5月至12月胸腔內視鏡手術患者資料。本研究的檢定方法為多元線性迴歸分析、多元羅吉斯迴歸分析與成對樣本t檢定。p<0.05代表具有統計顯著差異。
結果:
相比肺楔狀切除術病人,肺葉切除術病人的術後三天IVPCA嗎啡加總使用量高出5.893毫克(p<0.05),在個別天數亦有使用較多嗎啡的傾向。在術後第一至第三天的疼痛程度方面,肺葉切除術相比肺楔狀切除術病人於休息時,高出0.533、0.610與0.521分(p<0.05);於活動時,前者則是高出0.833、1.169與0.678分(p<0.05)。此外,在術後第二天與第三天活動時,肺葉切除術病人有較高風險發生不可忍受疼痛(NRS>3),其勝算比是肺楔狀切除術病人的10.48倍與4.6倍(p<0.05)。除了切除術式會影響病人的術後嗎啡使用量與疼痛程度外,年齡、性別、及體重也是顯著的影響因子。在休息時,肺葉切除術與肺楔狀切除術病人的疼痛程度,術後第二天比第一天少0.50與0.57分,第三天比第二天少0.35與0.20分(p<0.05);在活動時,術後第二天比第一天少0.63與0.77分,術後第三天比第二天少0.55與0.36分(p<0.05)。肺葉切除術與肺楔狀切除術病人的IVPCA嗎啡使用量也有逐天減少情形,術後第二天比第一天少使用8.23與7.52毫克(p<0.05),術後第三天比第二天少使用5.31與3.13毫克(p<0.05)。
結論:
胸腔內視鏡切除術式會影響病人術後疼痛處置的情形。肺葉切除術相比肺楔狀切除術病人,在術後三天,有顯著較高的IVPCA嗎啡使用總量,以及顯著較高的疼痛程度與較高風險發生不可忍受疼痛。在術後第一至三天,兩種切除術式皆有嗎啡使用量與疼痛程度逐天減少的情形。本研究建議在決定胸腔內視鏡手術術後疼痛處置方式時,應考量切除術式、年齡、性別、體重等影響因子,後續可探討適合不同切除術式的術後疼痛處置方式,以及分析影響胸腔內視鏡手術病人術後疼痛處置的因子與成本,供醫護人員評估病人PCA的需求。此外,術後PCA安裝天數大都以3天為標準,本研究結果可作為術前病人選擇PCA使用天數的參考依據,以避免醫療資源的浪費。


Objective:
We aimed to assess the differences of patients'' morphine consumption and pain intensity in postoperative day 1 to day 3 (POD1, to POD3) between video-assisted thoracoscopic surgery (VATS) lobectomy and wedge resection using intravenous patient-controlled analgesia (IVPCA). The second aim was to assess the differences of morphine consumption and pain level of both resection sugerys'' patients among POD1, POD2 and POD3.
Methods:
Data were retrospectively at one medical center in Taipei between May 1 and December 31 in 2009. Multiple regression analysis and paired t-test were used. The significance level of the test is p<0.05.
Results:
Compared with wedge resection, lobectomy surgical patients had 5.893 mg more of total morphine dose in the first 3 postoperative days(p<0.05). Lobectomy surgical patients also had higher numerical rating scale (NRS) of pain in POD1 to POD3 (0.533, 0.610 and 0.521 more, p<0.05) at rest as well as NRS at movement (0.833、1.169 and 0.678 more, p<0.05). Besides, Lobectomy surgical patients were more likely to have unbearable pain (NRS >3) at movement in POD2 (OR=10.48; 95% CI=3.10-35.49) and POD3 (OR=4.6; 95% CI=1.46-14.51). Lobectomy and wedge resection patients had less NRS score of 0.50 and 0.57 in POD2 than POD1, and less NRS score of 0.35 and 0.60 in POD3 than POD2 at rest. Lobectomy and wedge resection patients had less NRS score of 0.63 and 0.77 in POD2 than POD1, and less NRS score of 0.55 and 0.36 in POD3 than POD2 at movement. There was a decreased IVPCA morphine consumption from POD1 to POD3. Lobectomy and wedge resection patients used less morphine of 8.23 and 7.52 mg in POD2 than POD1, and less morphine of 5.31 and 3.13 mg in POD3 than POD2.
Conclusion:
Resection procedure is a factor to affect postoperative pain management in VATS. Compared to wedge resection patients, lobectomy patients have higher total IVPCA morphine consumption, higher pain intensity and more risk to occur unbearable pain in POD1 to POD3. We suggest that pain management in VATS should be adjusted to factors like resection procedure, age, gender and weight. A future study on suitable pain management in different VATS secection procedure and analyzing factors and cost affecting pain management after VATS are suggested to facilitate assessment of patients'' PCA requirement. Moreover, settling 3 days of PCA usage as a standard procedure is common, but the result of this study is a feasible reference for patients to adjust their number of days in using PCA to avoid waste of medical resources.


誌謝 I
中文摘要 II
英文摘要 IV
目 錄 VI
圖表目次 VIII
第一章 緒論 1
第一節 研究背景與動機 1
第二節 研究目的 6
第二章 文獻查證 7
第一節 胸腔內視鏡手術與傳統開胸手術 7
第二節 肺葉切除術與肺楔狀切除術 9
第三節 術後疼痛處置 10
第三章 研究方法 22
第一節 研究設計與研究架構 22
第二節 研究對象與資料收集 25
第三節 名詞界定與研究評量工具 27
第四節 研究假說 31
第五節 資料分析與處理 31
第四章 分析與結果 36
第一節 基本特性分析 36
第二節 術中變數分析 37
第三節 術後變數分析 37
第四節 術後主要結果分組資料比較 38
第五節 切除術式與術後IVPCA嗎啡使用量之相關 40
第六節 切除術式與術後疼痛程度之相關 41
第七節 術後IVPCA嗎啡使用量與疼痛程度在不同天數
之比較 43
第五章 討論 45
第六章 結論與建議 53
第一節 結論 53
第二節 建議 53
參考文獻 55
中文部分 55
英文部分 56
附錄 92


中文部分
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