心臟手術後疼痛軌跡與其相關因素之探討

Postoperative Pain Patterns and Its Related Factors in Patients Receiving Cardiac Surgery

李薇莉(Weillie Lee)

指導教授 ： 賴裕和

國立臺灣大學/醫學院/護理學研究所/博士(2012年)

https://doi.org/10.6342/NTU.2012.01374

摘要

目的：國外心臟手術後1-4年內有18-56% 病人發生手術後慢性疼痛，國內護理人員與研究者對國人心臟手術後急性疼痛如何發展成慢性疼痛的議題瞭解卻是有限。本研究的目的，旨在瞭解1) 手術後三個月時慢性疼痛的發生率，2)手術後三個月期間休息狀態下的次類型疼痛軌跡，3)手術後三個月期間活動狀態下的次類型疼痛軌跡，4)手術後三個月期間休息狀態疼痛之預測因素，5)手術後三個月期間活動狀態疼痛之預測因素。

方法：本研究採前瞻性縱貫性研究(prospective longitudinal study)。以病歷查閱、中文版疼痛自我效能問卷與口頭疼痛數字評量表，分別收集病人個人背景、治療性、心理性資料和手術後七個時間點的最大疼痛強度，七個時間點分別為手術後第三、四、七、三十、四十五、六十與第九十天。心理性資料則是在手術前與手術後第七天收集。研究資料以折線式成長模式(Piecewise Growth Model)描述手術後三個月期間兩個時段(手術後一週到四週)(手術後四週到十二週)疼痛軌跡的變化，且以邏輯斯廣義估計方程式(logistic Generalized Estimating Equation analysis)以逐步迴歸的向後法，分析手術後三個月期間疼痛變化的預測因素。

結果：符合收案條件者130位，完成調查者99位，有效樣本77位。手術後三個月時，休息狀態和活動狀態中重度疼痛的發生率分別為12%與4%。資料顯示個人的疼痛軌跡具有個別性變異，依手術後第三天疼痛與第七天疼痛間疼痛改變率的關係，分出四個次類型，為低升型(53%)、高降型(27%)、低降型(9%)與高升型(8%)。低升型是指術後第三天為輕度疼痛，但手術後第七天疼痛高於第三天；高降型是指術後第三天為中重度疼痛，但第七天疼痛低於第三天。低降型是指術後第三天為輕度疼痛，但第七天比第三天的疼痛更低。高升型是指手術後第三天為中重度疼痛，但第七天比第三天的疼痛更高。
休息狀態與活動狀態之次類型疼痛軌跡都分別顯示手術後疼痛隨時間下降的趨勢，並以手術後第四週做為疼痛變化之轉折點。休息狀態下之次類型疼痛軌跡：除高降型外，其它三個次類型都呈現有個體間疼痛變化的差異性。低降型在手術後一週內輕微疼痛，但在一週到一個月間疼痛上升，高升型在手術一週內有較多的疼痛，在一週到一個月疼痛快速下降。低升型與高降型呈現手術一週後疼痛持續、緩慢的下降。
活動狀態之次類型疼痛軌跡：除低降型外，其它三個次類型都呈現個體間疼痛變化具有差異性，主要表徵是手術後一週到一個月間疼痛快速下降，在手術一個月後疼痛緩慢的下降。低降型在手術後八週為輕度疼痛，緩慢的下降。性別與手術後疼痛自我效能是手術後三個月期間發生休息狀態疼痛的影響因素；手術後四到七天麻痛藥使用量與時間變項則是手術後三個月期間發生活動狀態疼痛的影響因素。

結論：研究內顯示，心臟手術後三個月期間的四個次類型疼痛軌跡都有隨時間下降的趨勢。然而，手術後三個月時休息和活動狀態仍分別有12%與4%的病人有中重度疼痛的發生率，手術後一個月疼痛是手術後疼痛變化的轉折點，而且出院前疼痛強度與手術後三個月期間疼痛變化有關。因此，在照顧心臟手術病人時，護理人員可在手術後不同時段（如手術前、手術後七天、手術後一個月與三個月），評估病人的疼痛狀態，依需要提供合適的建議與照護。未來研究可發展與測試提升手術後疼痛自我效能的護理措施，以利於病人更能有效處理疼痛，減少疼痛的發生，提升照顧品質。

關鍵字： 手術後疼痛軌跡、急性手術後疼痛、持續性疼痛、手術後慢性疼痛、影響因素、疼痛護理

關鍵字

手術後疼痛軌跡 ； 急性手術後疼痛 ； 持續性疼痛 ； 手術後慢性疼痛 ； 影響因素 ； 疼痛護理

並列摘要

Objectives: The literature has documented that 18% to 56% of patients experience chronic postoperative pain 1 to 4 years after cardiac surgery. Nursing professionals and researchers in Taiwan have limited understanding of how chronic pain develops from acute pain after cardiac surgery. The purposes of this study are to explore (1) the incidence of chronic pain 3 months after surgery; (2) the pain trajectory of pain subpatterns at rest 3 months after surgery; (3) the pain trajectory of pain subpatterns during activity 3 months after surgery; (4) the predictors of pain at rest 3 months after surgery; and (5) the predictors of pain during activity 3 months after surgery.

Method: This study adopted a prospective longitudinal design. Chart review, the Chinese version of the Pain Self-Efficacy Questionnaire, and the Verbal Numerical Rating Scale were used to collect patients’ demographics and therapeutic and pain belief. Data of the maximum level of pain at 7 time points, including day 3, 4, 7, 30, 45, 60, and 90 after surgery, were collected. Patients’ pain belief was collected before surgery and on the seventh day after surgery. Changes of the pain trajectory in 2 periods (week 1 to week 4 after surgery, week 4 to week 12 after surgery) within 3 months after surgery were captured using the piecewise hierarchical linear growth model. Finally, the logistic generalized estimating equation analysis was adopted to identify the predictors of changes in the pain pattern within 3 months after surgery.
Results: We contacted 130 patients who met the inclusion criteria. Of which, 99 patients completed the survey, and the number of valid samples was 77. The incidences of moderate to severe chronic pain at rest and during activity 3 months after surgery were 12% and 4%, respectively. Patterns of change in pain trajectories varied. According to the change rate between day 3 and day 7 after surgery, 4 subpatterns of pain at rest were generated and reported mild-increase (53%), severe- decrease (27%), mild-decrease (12%), and severe-increase (8%).

The mild-increase referred to a pattern of mild pain on the postoperative third day and more pain on the seventh day; the severe-decrease referred to a moderate to severe pain on the postoperative third day and a reduced level of pain on day 7. The mild-decrease referred a mild pain on the third day after surgery and a reduced level of pain on the seventh day. The severe-decrease referred to a moderate to severe pain on the third day after surgery and a reduced level of pain on day 7.

Both pain trajectories of subpatterns at rest and during activity demonstrated a trend of decrease over time, and the pain of fourth week after surgery was the turning point of pain changes. Regarding the subpatterns of pain at rest, except the severe-decrease, rest of the three patterns showed individual variabilities. Patients with the mild-decrease experienced a mild level of pain on day 7, and increased level of pain during first postoperative month. Patients with the severe-increase initially experienced moderate to severe pain on the seventh day after surgery, and then reduced rapidly during first postoperative month. Both patients with the mild- increase and the severe-decrease reduced a mild level of pain after Day 7, and since then reduced level of pain slowly. Regarding the subpatterns of pain during activities, except the mild decrease, the rest of patterns have individual variability and showed a rapidly decreased pain during first postoperative month, and turn to slow rate of pain decreased in one month. Patients with the mild-increasing and severe-decreasing pain pattern have similar pain changes with a high-mild pain at the day 7. Patients with the severe-increase have moderate to severe pain on the seventh day after surgery. Patients with the mild-decreasing pain experienced mild change of their pain level in first postoperative month. Gender and pain self-efficacy after surgery were related to pain at rest within 3 months after surgery. The accumlation amount and time of narcotic analgesic consumption within days 4 to 7 after surgery influenced changes in pain during activity within 3 months after surgery.

Conclusion: The study result indicated pain during three months after cardiac surgery tend to decrease over time. Yet, the incidence of moderate and severe pain three months after surgery were 12% and 4% for the rest and during activity respectively. The pain of fourth week after surgery was the turning point of pain changes, and pain before discharge was associated with the pain three months after surgery. Therefore, when taking care patients with cardiac surgery, caregivers should assess patients’ pain status at different time points (such as pre-operation, seven days post-operation, one month after surgery, and three months after surgery), and provide care as necessary. We also recommend improving patients’ self-efficacy in postoperative pain care to enhance their abilities to cope with pain, so that, the pain may be reduced and the quality of care may be ensured.

Keywords: Pain trajectory after cardiac surgery, acute pain, persistent pain, chronic postoperative pain, predictor, pain nursing

並列關鍵字

Pain trajectory after cardiac surgery ； acute pain ； persistent pain ； chronic postoperative pain ； predictors ； pain nursing

參考文獻

顏慧芳、邱麗文(2005)。急重症醫護人員的疼痛處理知識與態度及相關因素。實證護理，1(4)，292-301。

劉慧玲、洪美英、鐘貴春、陳堉玫、徐南麗(2004)。冠狀動脈繞道手術病患出院後自覺的健康問題及護理指導需求。慈濟護理雜誌, 3(1), 61-71.

陳淑美、劉立、陳益祥(2004)。預測不停跳冠狀動脈繞道手術醫療費用。中華民國急救加護醫學會雜誌, 15(4), 139-147。

謝麗鳳、林佳靜、賴裕和、鄒宗山(1998)。癌症家屬對止痛劑的擔心與病人疼痛控制的相關性。護理研究，6(4)，327-337。

何菊修、陳宗鷹(2005)。急性術後疼痛。慈濟醫學，17(Suppl 6)，43-50。