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

Comparison of postoperative pain management using intravenous patient-controlled analgesia between video-assisted thoracoscopic lobectomy and wedge resection

莊富嵐(Fu-Lan Chuang)

指導教授 ： 林朝順

共同指導教授 ： 廖媛美

臺北醫學大學/護理學院/護理學研究所/碩士(2015年)

https://doi.org/10.6831/TMU.2015.00040

摘要

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。

關鍵字

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

並列摘要

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.

並列關鍵字

video-assisted thoracoscopic surgery ； lobectomy ； wedge resection ； intravenous patient-controlled analgesia ； postoperative analgesia requirement ； postoperative acute pain ； numerical rating scale

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