- 學位論文
影像輔助胸腔鏡手術(VATS)病人術後疼痛照護品質相關因素探討
A Study of Factors Associated with Postoperative Pain Care Quality in Patients with Video Assisted Thoracoscopic Surgery
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摘要
研究背景：全球使用影像輔助胸腔鏡手術(VATS)的病例數逐年上升，台灣也已普遍使用此手術方式，由於術後傷口慢性疼痛及麻醉止痛副作用易導致病人疼痛照護品質不佳，因此探討影像輔助胸腔鏡手術(VATS)不同病人特性手術所產生的傷口慢性疼痛及麻醉止痛副作用，提供醫療人員臨床參考及管理人員品質目標建立。 目的：本研究目的為探討影像輔助胸腔鏡手術(VATS)病人術後疼痛照護品質相關因素，透過人口學因素包括(性別、年齡、身體質量指數(BMI))、潛在疾病因素包括(高血壓、糖尿病、術前疼痛分數、憂鬱分數)、手術相關因素包括(手術時間、止痛模式、術後24小時內中重度疼痛、手術種類、胸腔鏡孔數)對疼痛照護品質包括(傷口慢性疼痛、麻醉止痛副作用)的探討。 材料與方法：本研究為回溯性橫斷面研究，運用南部某區域教學醫院麻醉部疼痛科病人治療就診資料庫，收集於2022年7月26日(本資料庫第一例影像輔助胸腔鏡手術(VATS)手術日期)至2023年9月26日該醫院進行影像輔助胸腔鏡手術(VATS)之病人為研究對象，且根據國際疾病分類第十一次修訂本(ICD-11)慢性疼痛定義：「超過3個月持續性或復發性疼痛」，故術後電訪追蹤病人時間為2022年10月24日起至2023年12月25日止，共計184位。運用描述性統計包含次數分配表(frequency distribution table)、百分比、平均值(mean)及標準差(standard deviation)，推論性統計包含卡方檢定(Chi-Squared Test)及二元羅吉斯迴歸分析(Logistic Regression Analysis)探討自變項與依變項之相關性。 結果：男性102人(55.4%)、≦65歲有107人(58.2%)、BMI≧24有95人(51.6%)、無高血壓者有124人(67.4%)、無糖尿病者有151人(82.1%)、術前疼痛分數0分有159人(86.4%)；憂鬱分數平均值±標準差為0.59±1.97分、手術時間平均值±標準差為153.50±67.04分鐘、使用硬脊膜外腔病人自控式止痛(PCEA)有72人(39.1%)、無術後24小時內中重度疼痛有157人(85.3%)、肺葉手術部位者有160人(87.0%)、胸腔鏡孔數平均值±標準差為2.13±0.42孔。研究發現在二元羅吉斯迴歸分析中性別(AOR=0.38，P=0.040，95%CI 0.15-0.96)、手術時間(AOR=1.01，P=0.002，95%CI 1.0-1.02)及手術種類中的肋膜腔手術(AOR=91.51，P=0.006，95%CI 3.63-2304.96)對術後傷口慢性疼痛達統計顯著差異；身體質量指數(BMI)(AOR=0.40，P=0.046，95%CI 0.17-0.99)及止痛模式中的單次注射非類固醇類止痛藥(NSAIDs)、止痛醫囑給藥(non-opioid or opioid) (AOR=0.03，P=0.002，95%CI 0.004-0.30)對術後麻醉止痛副作用達統計顯著差異。 結論：性別、手術時間及手術種類為術後傷口慢性疼痛之預測因子；身體質量指數(BMI)及止痛模式為術後麻醉止痛副作用之預測因子。 建議臨床照護單位可針對女性、手術時間長及肋膜腔手術的病人進行更密集的術後疼痛追蹤，並積極給予術後疼痛緩解措施，如轉介疼痛科門診，以降低發生術後傷口慢性疼痛率。此外，針對身體質量指數(BMI)<24 kg/m2及使用硬脊膜外腔病人自控式止痛(PCEA)的病人，建議臨床照護單位可適時給予輔助藥物，以協助病人減緩噁心嘔吐及暈眩等麻醉止痛副作用。
並列摘要
Background: The number of cases using video-assisted thoracoscopic surgery (VATS) is increasing worldwide, and this surgical method has also been widely used in Taiwan. Since the wound chronic pain and side effects of postoperative anesthesia and analgesia can easily lead to poor quality of patient pain care, this study aims to explore the factors associated with the quality of wound chronic pain and postoperative anesthesia and analgesia side effects for patients undergoing video-assisted thoracoscopic surgery (VATS). Purpose: The purpose of this study is to explore the factors associated with the quality of postoperative pain care in patients with video-assisted thoracoscopic surgery (VATS), through demographic factors including (gender, age, body mass index (BMI)), underlying disease factors including (hypertension , diabetes, preoperative pain score, depression score), surgery-related factors including (operation time, analgesic mode, moderate to severe pain within 24 hours after surgery, type of surgery, number of thoracoscope holes), and quality of pain care including (wound chronic pain, anesthesia and analgesic side effects). Methods: This study is a retrospective cross-sectional study, using the patient treatment and consultation database of the department of anesthesia, a regional teaching hospital in southern Taiwan. We collected data from July 26, 2022 (the date of the first video-assisted thoracoscopic surgery (VATS) operation in this database ) to September 26, 2023, and according to the International Classification of Diseases, Eleventh Revision (ICD-11) chronic pain definition: "Persistent or recurring pain more than 3 months", so the postoperative telephone follow-up time for patients will be from October 24, 2022 to December 25, 2023, a total of 184 patients were the research subjects. The study use descriptive statistics including frequency distribution table, percentage, mean and standard deviation, and inferential statistics including chi-squared test and logistic regression analysis to explore the correlation between independent variables and dependent variables. Results: Male, ≦65 years old, BMI ≧ 24, did not have hypertension, did not have diabetes, had a preoperative pain score of 0, used patient-controlled epidural analgesia (PCEA), had no moderate or severe pain within 24 hours after surgery, and lung lobe surgery site are accounting for the majority. The mean ± standard deviation of the depression score was 0.59 ± 1.97, the operation time was 152.99 ± 67.21, and the number of thoracoscopic holes was 2.13 ± 0.42. Gender (AOR=0.38, P=0.040, 95%CI (0.15-0.96)), the operation time (AOR=1.01, P=0.002, 95%CI (1.0-1.02)) and pleural cavity surgery site (AOR=91.51, P=0.006, 95%CI (3.63-2304.96)) had a statistically significant difference in the chronic pain. Body mass index (BMI) (AOR=0.40, P=0.046, 95%CI (0.17-0.98)) and using NSAIDs, non-opioid or opioid (AOR=0.03, P=0.002, 95%CI (0.003-0.29)) had a statistically significant difference in the side effects of postoperative anesthesia and analgesia. Conclusions: Gender, operation time and type of surgery are predictors of wound chronic pain; body mass index (BMI) and analgesic mode are predictors of anesthesia and analgesic side effects. It is recommended that clinical care units conduct more intensive postoperative pain tracking for female patients, patients with long operation times, and patients with pleural cavity surgery , and actively provide postoperative pain relief measures, such as referral to pain clinics, to reduce the occurrence of chronic postoperative wound pain. For patients whose body mass index (BMI) is <24 and who use patient-controlled epidural analgesia (PCEA), it is recommended that clinical care units provide auxiliary drugs promptly to help patients alleviate the side effects of anesthesia and analgesia such as nausea, vomiting, and dizziness.
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