探討點滴式標靶麻醉與傳統麻醉的臨床結果及成本分析
-以南部某區域教學醫院為例

研究目的台灣於2010年1月正式實施TwDRG，對住院手術而言，如何縮短留置時間 (Length of Stay) 是重要的議題，而麻醉後恢復照護單位在醫療機構傳統上是一個高花費及高勞力的重症單位，傳統麻醉方式的恢復因術後發生噁心嘔吐等副作用帶來照顧上耗時而增加人力成本。本研究希望透過比較不同麻醉方式(傳統麻醉與標靶麻醉)對於開刀病人的成本分析及術後出現噁心嘔吐與麻醉恢復時間長短之情形，已期達到以下之研究目的如下：目的一、比較傳統麻醉組及標靶麻醉組之住院手術病人成本的差異並探討病人特質及麻醉特質是否為其影響因子。目的二、比較傳統麻醉及標靶麻醉對拔管時間及麻醉恢復室置留時間，並探討病人特質及麻醉特質是否為影響因子。目的三、比較傳統麻醉及標靶麻醉法對病人術後出現噁心嘔吐，並探討病人特質及麻醉特質是否為其影響因子。研究方法本研究採前瞻性之研究設計，以立意取樣法，針對南部某一區域教學醫院之婦產科手術病人為研究對象共140位，依照病人接受麻醉方式將之分為兩組：傳統麻醉組(SEV)或標靶麻醉組(TCI)各70位。使用麻醉科記錄單收集病人基本特質及拔管時間、麻醉恢復室置留時間以及術後是否出現噁心嘔吐、藥物成本等資料，收案時間為2011年3月至2011年5月。研究結果總費用包含麻醉藥物成本及術後噁心嘔吐照護人力成本，結果顯示SEV組總成本(NT 619)明顯高於TCI總成本(NT 381)(P<0.001)；在麻醉恢復室時間方面TCI組較SEV組短(分別為47.6和52.2 min)(P=0.006)、術後噁心嘔吐的次數與麻醉恢復室時間成中度正相關(r=0.610、0.644，p<0.001)。SEV組相較於TCI組在術後容易出現噁心的機率(OR=6.97，95%CI=2.42~20.09)、同樣的SEV組在術後也較容易嘔吐(OR=13.14，95%CI=3.64~47.30)。疼痛分術方面兩組並沒有統計上顯著差異。結論與建議採用TCI組進行麻醉相較於傳統麻醉，在PACU時間明顯較短，進而對手術排程較滿的開刀房運作能夠更有效率，成本也相對較低。同樣地TCI組能夠有效減少術後噁心嘔吐次數，使得麻醉恢復室的置留時間縮短，幫助病人減少生理上不舒服也能提升手術病人的滿意度。本研究指出中度肥胖者、傳統麻醉方式、過去有噁心嘔吐病史者為噁心嘔吐次數多之高危險群。此結果將提供給醫院做為開刀房策略之參考，未來可針對高危險病患，在術前選擇預防性投予止吐藥等，以降低恢復室的延遲出院或非預期住院，減少醫療成本花費，將手術麻醉對日常生活機能及生活品質影響降至最低。

關鍵字

標靶麻醉；術後噁心嘔吐；成本分析

並列摘要

Objective:. The aim of this study was to compare costs and clinical outcome of TCI-based anesthesia with standard regimens using sevoflurane.Length of Stay in the hospital is an important healthcare issues especial after the implementation of TwDRG . An overall cost analysis of new anesthetic regimens must balance the direct cost of anesthetic regimens and beneficial effects leading to improved patient’s comfort including postoperative nausea vomiting side effects and time stay in PACU period. Methods: Total 140 surgical patients performed at a teaching hospital in Southern Taiwan undergoing elective gynecologic laparoscopic surgery .The study was prospective,randomized in design. All patients were ramdomly divided into two groups.:i.e. TCI-based anesthesia group and standard regimens using sevoflurane group . The aim of thesis was to evaluate clinical outcomes including time from stopping administration of anesthetic until treacheal extubation ,stay in the postanesthetic care unit and incidence of postoperative nausea vomiting and cost analysis between these two groups. All cases scheduled from March/2011 to May /2011 were collected . The study belongs to cross sectional study design. Results: The total cost was significantly higher in the SEVO group than in the TIVA group (NT 619,NT 381,respectively)(P<0.001) .In addition,Faster recovery was seen in the TIVA group than in the SEVO group(47.6 min,52.2 min respectively)(P=0.006) Incidences of postoperative nausea, and vomiting were significant higher in sevo group (OR=6.97,95%CI=2.42~20.09);(OR=13.14,95%CI=3.64~47.30 respectively), In addition,Incidence of postoperative pain was not significantly different among 2 groups. Conclusion: Faster recovery at PACU was seen in the TIVA group than in the SEVO group ,and therefore has more efficiency in the operating theatre and it also considered cost saving . In addition,episodes of postoperative nausea and vomiting and stay in the PACU were lesser and shorter in TCI group than in the other group, beneficial effects leading to improved patient’s comfort.