- 學位論文
探討於全身麻醉時以Granisetron併用氣體麻醉或併用標靶麻醉(TCI)病患術後之噁心嘔吐發生率-以膝關節置換術為例
Exploring the Incidence of Postoperative Nausea and Vomiting in Total Knee Replacement Patients under General Anesthesia with Concurrent Use of Granisetron, Inhalation Anesthesia, or Target-Controlled Infusion (TCI)
本文將於2028/07/01開放下載。若您希望在開放下載時收到通知，可將文章加入收藏。
摘要
研究動機：近年來由於全球老化以及民眾肥胖率上升，導致全身性關節炎成為常見的疾病。根據衛生福利部統計可知膝關節置換術在健保申報次數當中為全身關節置換術中比例為最高。然而，一般手術當中所使用全身麻醉，在手術後最初24小時內有30%病患將會產生噁心嘔吐的合併症。有研究指出，施行單側膝或髖關節置換術患者在手術後6小時內噁心發生率有14.73%、嘔吐發生率在手術後6至24小時內有7.52%。另有文獻指出膝關節置換術術後如無法早期下床將會影響個案術後肌肉力量與關節功能恢復功能，故應減少會使病患不適因素使病患早期下床參與復健活動。 筆者查閱現行對於術後噁心嘔吐的研究文獻對象大多數都是以術後噁心嘔吐高危險患者如年輕女性、耳鼻喉科手術、腹腔鏡手術等來進行相關研究，鮮少對於其他年齡患者或是其他手術別患者來進行。因此，引發筆者動機探討對於膝關節置換術患者使用止吐劑加上不同麻醉方法是否可以對其噁心嘔吐發生率有所改變，以期可以減少膝關節置換術術後噁心嘔吐發生率，促進病患減少不適早期參與復健維持術後良好的生理功能。 研究目的：探討膝關節置換術術後病患同樣使用止吐劑Granisetron之下併用吸入性氣體全身麻醉病患組或是併用靜脈標靶麻醉TCI propofol全身麻醉病患組，此兩組手術後的噁心嘔吐的發生率是否會有不同。 研究方法：研究對象為全身麻醉行膝關節置換術的病人，針對手術下刀前使用預防性止吐劑Granisetron合併採用不同的全身麻醉法：一、吸入性氣體麻醉。二、標靶麻醉TCI Propofol。比較兩種全身麻醉方法在術後噁心嘔吐的發生率是否有影響。研究使用病歷回溯法，收案場所為中部某區域醫院，回溯資料包含個案年齡、性別、BMI、有無抽菸、抽血肝腎功能、ASA分級、有無噁心嘔吐過去病史、手術時間、麻醉方法、使用止痛劑總量、術後噁心嘔吐評分等。收案期間為2023年6月13日至8 月31日。收得個案數共128人。當中未施打Granisetron個案數共29人，施打Granisetron共99位。99位個案當中使用吸入性氣體全身麻醉法共71人，靜脈標靶麻醉TCI propofol共28人。收得資料使用SPSS軟體進行描述性分析卡方統計及次數分配表百分比與單一因子T檢定做為資料分析。 研究結果：一、採用標靶麻醉TCI Propofol行膝關節置換術的病患噁心嘔吐發生率百分比(16.7%)低於吸入性氣體麻醉病患(83.3%)。二、兩組膝關節置換術病患病人皆使用Granisetron做為預防性止吐劑之下，經由單一因子T檢定統計結果顯示吸入性氣體全身麻醉病患與靜脈標靶麻醉TCI propofol病患有顯著性差異(P值0.001<0.05)。 結論：本研究探討了膝關節置換術病患在全身麻醉時使用止吐劑Granisetron併用吸入性氣體麻醉或是併用標靶麻醉TCI propofol對術後噁心嘔吐發生率的影響。結果顯示，術後噁心嘔吐發生率在標靶麻醉TCI propofol組顯著低於吸入性氣體麻醉組。然而，此研究為回溯性研究，僅能調查病歷上所記載的紀錄，可能存在病患自述病史方面的偏差。其次，由於臨床端並無強制規範全身麻醉需選擇標靶麻醉TCI作為膝關節手術麻醉方法，且吸入性麻醉在使用上較標靶麻醉TCI方便，因此兩組的病患數量並不平均。儘管如此，仍然可以藉由此研究發現單次注射5-HT止吐劑Granisetron併用標靶麻醉TCI propofol能有效地降低術後噁心嘔吐的發生率。將來可用來減少膝關節置換術病患術後噁心嘔吐發生率增加病患早期下床參與復健的意願。未來的研究建議可以進行前瞻性研究增加兩組病患人數以確定這些結果的一致性。
並列摘要
Background: In recent years, due to global aging and the rising obesity rates among the population, systemic arthritis has become a common disease. According to statistics from the Ministry of Health and Welfare, knee replacement surgery has the highest proportion of all joint replacement surgeries covered by health insurance. However, general anesthesia used in typical surgeries results in 30% of patients experiencing nausea and vomiting within the first 24 hours postoperatively. Studies have shown that patients undergoing unilateral knee or hip replacement surgery have a nausea incidence rate of 14.73% within the first 6 hours after surgery, and a vomiting incidence rate of 7.52% within 6 to 24 hours post-surgery. Additionally, literature indicates that if patients cannot get out of bed early after knee replacement surgery, their postoperative muscle strength and joint function recovery will be affected. Therefore, reducing factors that cause patient discomfort and encouraging early mobilization for rehabilitation activities are crucial. Upon reviewing current research literature on postoperative nausea and vomiting, it was found that most studies focus on high-risk patients for postoperative nausea and vomiting, such as young women, and those undergoing ENT or laparoscopic surgeries, with little research on patients of other ages or those undergoing different types of surgeries. This has motivated the author to explore whether the use of antiemetics combined with different anesthesia methods can alter the incidence of nausea and vomiting in patients undergoing knee replacement surgery. Purpose: Investigate whether there is a difference in the incidence of postoperative nausea and vomiting in patients undergoing knee replacement surgery who are given the antiemetic Granisetron, and either receive inhalation gas general anesthesia or Target-Controlled Infusion (TCI) Propofol general anesthesia. Method: The subjects of the study are patients undergoing knee replacement surgery under general anesthesia. The study investigates the impact of using prophylactic antiemetic Granisetron combined with different methods of general anesthesia: 1. Inhalation gas anesthesia. 2. Target-controlled infusion (TCI) Propofol anesthesia, on the incidence of postoperative nausea and vomiting. The study uses a retrospective chart review method. The cases were collected from the Anesthesiology Department of a regional hospital in central Taiwan. The retrospective data includes patient age, gender, BMI, smoking status, blood liver and kidney function, ASA classification, history of nausea and vomiting, surgery time, anesthesia method, total amount of analgesics used, and postoperative nausea and vomiting scores. The case collection period was from June 13, 2023, to August 31, 2023. A total of 128 cases were collected. Among them, 29 cases did not receive Granisetron, and 99 cases did. Of the 99 cases, 71 used inhalation gas general anesthesia, and 28 used intravenous target anesthesia TCI propofol. The collected data was analyzed using SPSS software for descriptive analysis, chi-square statistics, frequency distribution table percentages, and one-sample T-test. Results: 1.The incidence of nausea and vomiting in patients undergoing knee replacement surgery with Target-Controlled Infusion (TCI) Propofol anesthesia (16.7%) is lower than that in patients with inhalation anesthesia (83.3%). 2.Both groups of patients undergoing knee replacement surgery used Granisetron as a prophylactic antiemetic. The results of the one-sample T-Test showed a significant difference between patients with inhalation general anesthesia and patients with target-controlled infusion (TCI) of propofol (P value 0.001 < 0.05) Conclusion: This study investigated the effect of the antiemetic Granisetron in combination with inhalation anesthesia or target-controlled infusion (TCI) propofol on the incidence of postoperative nausea and vomiting (PONV) in patients undergoing knee replacement surgery. The results showed that the incidence of PONV was significantly lower in the TCI propofol group than in the inhalation anesthesia group. However, this study was retrospective and could only investigate the records documented in the medical history, which may have biases in the patient’s self-reported history. Furthermore, since there is no mandatory clinical guideline for choosing TCI as the anesthesia method for knee joint surgery, and inhalation anesthesia is more convenient to use than TCI, the number of patients in the two groups is not equal. Despite this, it was found that a single injection of the 5-HT antiemetic Granisetron combined with TCI propofol can effectively reduce the incidence of PONV. This can be used in the future to reduce the incidence of PONV in patients undergoing knee replacement surgery and increase the willingness of patients to participate in rehabilitation early postoperatively. Future research is suggested to conduct prospective studies to increase the number of patients in both groups to confirm these results.
參考文獻
丁曉嫻. (2019). ERAS術後噁心嘔吐之預防與處置 [ERAS Guideline for Postoperative Nausea and Vomiting (PONV) Prophylaxis]. 台灣醫學, 23(2), 223-232. https://doi.org/10.6320/fjm.201903_23(2).0010
林曉芳. (2020). 統計學：SPSS操作與應用. 楊榮川.
高傳真, & 高宗桂. (2017). 膝關節骨性關節炎的功能測評法 [Functional evaluation of knee osteoarthritis]. 臺灣中醫科學雜誌, 9(2), 20-30. https://doi.org/10.29810/sjttcm.201703_9(2).0003
張家穎, 洪明輝, 藍正妍, 王婷鈺, 許銘哲, 林宜樺, 吳長庭, & 王顥瑾. (2014). Miller大師引領您讀通麻醉學:麻醉學的基礎讀本. 合計圖書出版社.
陳伊伶, & 楊燦. (2021). 單側全膝關節置換術後與身體功能恢復之相關因素探討 [Factors Associated with the Recovery of Physical Function After Unilateral Total Knee Arthroplasty]. 澄清醫護管理雜誌, 17(1), 17-26.