研究背景
術後噁心嘔吐與疼痛是手術麻醉後最常見的併發症，會造成延長恢復時間、住院天數以及降低病人滿意度。甲狀腺切除手術(thyroidectomy)通常需執行插管全身麻醉，術後噁心嘔吐的發生率高達63–84%。迪皮質醇(Dexamethasone)為一種合成腎上腺皮質荷爾蒙，具有強力的消炎作用，根據之前的研究認為可以預防術後噁心嘔吐。全身麻醉所使用插管工具可分為直視和影像輔助插管，研究指出使用影像輔助插管能夠降低執行插管時使用力道使插管更順利，減少喉頭的傷害，期望可以減少術後喉部的疼痛。

研究目的
援引ERAS(enhanced recovery after surgery)精神，先行導入對甲狀腺手術重要的噁心嘔吐及喉嚨痛之預防方法，並同時討論插管方式與迪皮質醇的影響，及兩者可能的交互作用。希望透過這次的研究，提升甲狀腺手術病患之整體快速恢復，有助於降低住院天數，降低醫療成本。

材料與方法
本研究為隨機雙盲對照試驗，採用多因子設計(factorial design)，兩個因子分別為:「是否術前給予迪皮質醇?」與「是否使用影像輔助插管系統?」，分配為四組。於2019年03月至2020年10月，收集了台南某醫學中心及台南某地區醫院接受甲狀腺手術的病患做為研究的族群，共112位。術後收集甲狀腺手術患者相關併發症，如頭暈、噁心嘔吐、疼痛等，分析其相關性與風險預測因子。

研究結果
雖然在是否使用迪皮質醇或是否使用影像輔助插管的四個分組內，沒有觀察到術後噁心嘔吐發生率或術後疼痛指數的差異。但是在女性患者中，使用影像輔助插管的分組在術後第一天有較低的術後噁心嘔吐發生率(31.1% vs 54.6%, p=0.0263)，而沒有使用迪皮質醇或影像輔助插管的對照組在術後第一天，有較高的術後噁心嘔吐發生率(66.7%, p=0.0354)。另外，發生術後第一天發生噁心嘔吐的病患，有較高的疼痛指數(3.9 vs 5.2, 9=0.0009)，術後也需要較多次數的止痛藥(2.78 vs 1.05, p<0.0001)。

結論
本次研究證實了影像輔助插管系統在有較高風險的女性，可以預防術後噁心嘔吐，建議可以常規使用。由於在本次研究的整體噁心嘔吐機率較先前的研究低，需要更大型的研究，來證實是否可以推論到所有的族群。另外術後噁心嘔吐的發生和疼痛指數有高度相關，並且影響到術後止痛藥的使用，所以更加證明了預防術後噁心嘔吐的重要性。

We try to use a factorial randomized trial to reveal the effects of dexamethasone and video-assisted intubation on Postoperative nausea and vomiting (PONV) and the pain after thyroidectomy. Aim to establish the clinical care protocol about thyroidectomy which is based on the goal of ERAS (enhanced recovery after surgery).
No statistically significant relation was noted of prophylactic dexamethasone and video-assisted intubation of prevent PONV or reduce pain after thyroidectomy in the basic study population. But in female patients, video-assisted intubation significantly reduces the rate of PONV, however, insignificant relation was noted in the pain score. We believe it seems to have benefits to use video-assisted laryngoscope for tracheal intubation for thyroidectomy patients to reduce PONV. We also found the strong association between PONV and pain score. It may support the idea of PONV prevention may reduce the pain, even reduce analgesic dose.

參考文獻
A. Currie, J. Burch, J. T. Jenkins et al., “The impact of enhanced recovery protocol compliance on elective colorectal cancer resection: results from an international registry,” Annals of Surgery, vol. 261, no. 6, pp. 1153–1159, 2015,
doi: 10.1097/SLA.0000000000001029

Adnet F, Borron SW, Racine SX, Clemessy J, Fournier, Plaisance P, Lapandry C: The Intubation Difficulty Scale (IDS): Proposal and evaluation of a new score characterizing the complexity of endotracheal intubation. Anesthesiology 1997; 87:1290-7. doi: 10.1097/00000542-199712000-00005

Ahmad R, Changeez M, Tameez Ud Din A, et al. (May 23, 2019) Role of Prophylactic Dexamethasone Before Thyroidectomy in Reducing Postoperative Pain, Nausea and Vomiting. Cureus 11(5): e4735. doi:10.7759/cureus.4735

Apfel CC, Laara E, Koivuranta M, Greim CA, Roewer N. A simplified risk score for predicting postoperative nausea and vomiting: conclusions from cross-validations between two centers. Anesthesiology 1999; 91: 693-700
doi: 10.1097/00000542-199909000-00022.

Atabak Najafi, Farsad Imani, Jalil Makarem et al., Postoperative Sore Throat After Laryngoscopy With Macintosh or Glide Scope Video Laryngoscope Blade in Normal Airway Patients, Anesth Pain Med. 2014 February; 4(1): e15136.
doi: 10.5812/aapm.15136

Barros A, Vale CP, Oliveira FC et al: Dexamethasone effect on postoperative pain and tramadol requirement after thyroidectomy. Pharmacology, 2013; 91(3–4): 153–57, doi: 10.1159/000346612

Chen CC, Siddiqui FJ, Chen TL et al: Dexamethasone for prevention of post-operative nausea and vomiting in patients undergoing thyroidectomy: meta-analysis of randomized controlled trials. World J Surg, 2012; 36(1): 61–68
doi: 10.1007/s00268-011-1343-9

De Oliveira GS Jr, Almeida MD, Benzon HT, McCarthy RJ: Perioperative single dose systemic dexamethasone for postoperative pain: a meta-analysis of randomized controlled trials. Anesthesiology, 2011; 115(3): 575–88, doi:10.1097/ALN.0b013e31822a24c2

Ewalenko P, Janny S, Dejonckheere M, et al, Antiemetic effect of subhypnotic doses of propofol after thyroidectomy. Br J Anaesth 1996;77:463-7. doi: 10.1093/bja/77.4.463
 
Eberhart LH, Seeling W, Staack AM, Georgieff M. Validation of a risk score for prediction of vomiting in the postoperative period. Der Anaesthesist 1999; 48: 607-12
doi: 10.1007/s001010050760.

Feroci F, Rettori M, Borrelli A, Lenzi E, Ottaviano A, Scatizzi M: Dexamethasone prophylaxis before thyroidectomy to reduce postoperative nausea, pain, and vocal dysfunction: a randomized clinical controlled trial. Head Neck 2010;33:840–846, doi: 10.1002/hed.21543

Hohlrieder M, Brimacombe J, von Goedecke A, Keller C. Postoperative nausea, vomiting, airway morbidity, and analgesic requirements are lower for the ProSeal laryngeal mask airway than the tracheal tube in females undergoing breast and gynaecological surgery. Br J Anaesth 2007; 99:576-580. doi:10.1093/bja/aem096

Hung, K. C., Tan, P. H., Lin, V. C. H., Wang, H. K., & Chen, H. S. A comparison of the Trachway intubating stylet and the Macintosh laryngoscope in tracheal intubation: a manikin study. Journal of anesthesia, 2013,27(2), 205-210.
doi: 10.1007/s00540-012-1491-6

J. D. Griffiths, M. Nguyen, H. Lau, S. Grant, D. L. Williams. A prospective randomised comparison of the LMA ProSeal™ versus endotracheal tube on the severity of postoperative pain following gynaecological laparoscopy, Anaesth Intensive Care 2013; 41: 46-50, doi: 10.1177/0310057X1304100109.

J. Lerman, Surgical and patient factors involved in postoperative nausea and vomiting, Br J Anaesth, 69 (1992), pp. S24-S32, doi: 10.1093/bja/69.supplement_1.24s

James M.Sonner MD,James M.Hynson MD, OrloClark M, Jeffrey A.Katz MD, Nausea and vomiting following thyroid and parathyroid surgery, Journal of Clinical Anesthesia, Volume 9, Issue 5, August 1997, Pages 398-402,
doi: 10.1016/s0952-8180(97)00069-x

Koivuranta M, Laara E, Snare L, Alahuhta S. A survey of postoperative nausea and vomiting. Anaesthesia 1997; 52: 443-9, doi: 10.1111/j.1365-2044.1997.117-az0113.x.

Li B, Wang H: Dexamethasone reduces nausea and vomiting but not pain after thyroid surgery: a meta-analysis of randomized controlled trials. Med Sci Monit. 2014, 20:2837-2845.doi:10.12659/MSM.891390

Li P., Fang F., Cai J., Tang D., Li Q., Wang D. Fast-track rehabilitation VS conventional care in laparoscopic colorectal resection for colorectal malignancy: a meta-analysis. World Journal of Gastroenterology. 2013;19(47):9119–9126. doi: 10.3748/wjg.v19.i47.9119.
 
L. Magill, Collaborators DT, Collaborative WMR: Dexamethasone versus standard treatment for postoperative nausea and vomiting in gastrointestinal surgery: randomised controlled trial (DREAMS Trial). BMJ. 2017, 357, doi:10.1136/bmj.j1455

Melnyk, M., Casey, R. G., Black, P., & Koupparis, A. J. (2011). Enhanced recovery after surgery (ERAS) protocols: Time to change practice?. Canadian Urological Association Journal, 5(5), 342. doi: 10.5489/cuaj.11002

Shih-Ming Huang , Chen-Hsen Lee, Fong-Fu Chou, Koung-Yi Liaw, Tain-Chen Wu, Taiwan Endocrine Surgeons Study Group, Characteristics of thyroidectomy in Taiwan, J Formos Med Assoc.2005 Jan;104(1):6-11, PMID: 15660170

Shin HC, Kang TW, Wu YH, Sun HS, Tseng CA. Validation of simplified postoperative nausea and vomiting intensity scale in Taiwan. Journal of clinical monitoring and computing 2017. doi: 10.1007/s10877-017-0084-1.

Suzuki K, Kusunoki S, Tanigawa K, Shime N. Comparison of three video laryngoscopes and direct laryngoscopy for emergency endotracheal intubation: a retrospective cohort study. BMJ Open. 2019 Mar 30;9(3).doi: 10.1136/bmjopen-2018-024927.

Zou Z, Jiang Y, Xiao M, Zhou R: The impact of prophylactic dexamethasone on nausea andvomiting after thyroidectomy: a systematic review and meta-analysis. PLoS One. 2014,9:e109582. doi:10.1371/journal.pone.01095822019