摘要
目的：Dexamethasone提供有效的止痛和止吐的作用，而麻醉氣體Sevoflurane相對於Propofol的藥物比較起來，與手術後的噁心和嘔吐相關性明顯增加。這個實驗的設計目的，就是評估預防性的使用dexamethasone是否能減少sevoflurane引起手術後噁心嘔吐的副作用，並且使病人在門診的直腸手術之後能夠提早恢復。
方法：四十個接受門診直腸手術的病患，被隨機的分成二組。實驗組有二十個病患在麻醉之前，接受dexamethasone 5 毫克靜脈注射，對照組二十個病患則以等量的生理食鹽水代替。所使用的麻醉誘導方式為揮發性的麻醉氣體Sevoflurane加上笑氣67%混合在每分鐘6公升氧氣流量之中，呼吸道的維持則以置入喉頭氣道呼吸管執行。麻醉的過程保持sevoflurane潮氣末端濃度為2%到4%，合併有50%笑氣在每分鐘3公升的氧氣流量之中。所有接受麻醉的病患手術過程都有自發性的呼吸。對手術後的噁心嘔吐的次數和疼痛指數以及滿意度作確實記錄。
結果：在用dexamethasone治療的病患相對於用食鹽水的對照組，其術後噁心嘔吐的次數和疼痛指數程度有明顯的降低。而所需要的恢復出院的時間也明顯縮短。除此之外，病人對麻醉的滿意度亦增加。但是在恢復過程中，眼睛打開的時間，開始對指令反應的時間，方向感及行動能力的恢復時間，並沒有顯著差異。
結論：在門診直腸手術的麻醉執行過程，用喉頭氣罩式呼吸道並使麻醉病患採行自發性呼吸的麻醉處置，預防性的給予Dexamethasone確實能減少手術後的噁心嘔吐機會及降低疼痛指數，並促進病人的恢復和提高對麻醉的滿意度。

ABSTRACT
Purpose: Dexamethasone provides potent analgesic and antiemetic effects. Sevoflurane are associated with an increased incidence of postoperative nausea and vomiting (PONV) and delayed patient discharge compared to propofol. This study was designed to evaluate whether the prophylatic use of dexamethasone with sevoflurane could minimize the incidence of PONV and facilitate early recovery after outpatient anorectal surgery.
Methods: Forty outpatients undergoing anorectal surgery were randomly assigned to receive either dexamethasone (5 mg IV; n=20) or an equal volume of saline (n=20) before the induction of anesthesia. Anesthesia was induced with sevoflurane 8% and N2O 67% in oxygen (at 6 L/min) followed by placement of laryngeal mask. Anesthesia was maintained with sevoflurane 2-4% end-tidal in combination with N2O 50% in oxygen 3 L/min. All patients were allowed to breathe spontaneously during the operation. The postoperative nausea and vomiting (PONV), VAS pain score and patient satisfaction were recorded.
Results: The incidence of PONV and VAS pain score were significant lower in dexamethasone-treated patients compared with saline-treated ones. The time required for discharge was significantly shorter in dexamethasone-treated patients. Above all, the dexamethasone-treated patients expressed higher satisfaction index. There was no significant difference in recovery time for eye opening, response to commands, orientation, and ambulatory.
Conclusions: The prophylactic administration of dexamethasone reduces the incidence of PONV andVAS pain score, promotes recovery to home readiness, and improves the satisfaction after the anesthesia with spontaneously breathing of sevoflurane through laryngeal mask in outpatients undergoing anorectal surgery.

感謝……………………………………………………3
縮寫表…………………………………………………4
中文摘要………………………………………………5
英文摘要………………………………………………7
介紹……………………………………………………9
方法……………………………………………………12
結果……………………………………………………15
討論……………………………………………………18
參考資料………………………………………………27
表格……………………………………………………33
圖………………………………………………………36

1. Smith I, White PF, Nathanson M, Gouidson R. Propofol: an update on its clinical use. Anesthesiology 1994;81:1005-43.
2. Nathanson MH, Fredman B, Smith I, White PF. Sevoflurane versus desflurane for outpatient anesthesia: a comparison of maintenance and recovery profiles. Anesth Analg 1995;81:1186-90.
3. Tang J, Chen L, White PF, Watcha MF, Wender RH, Naruse R, Kariger R, Sloninsky A. Recovery profile, costs, and patient satisfaction with propofol and sevoflurane for fast-track office-based anesthesia. Anesthesiology 1999;91:253-61.
4. Barison HL. Area postrema: chemoreceptor circumventricular organ of the medulla oblongata. Prog Neurobiol 1989;32:351-390.
5. Andrews PL, Davis CJ, Bingham S, Davidson HI, Hawthorn J, Maskell L. The abdominal visceral innervation and the emetic reflex: pathways, pharmacology, and plasticity. Can J Physiol Pharmacol 1990;68:325-345.
6. Aasboe V, Raeder JC, Groegaard B. Betamethasone reduces postoperative pain and nausea after ambulatory surgery. Anesth Analg 1998;87:319-23.
7. Splinter WM, Roberts DJ. Dexamethasone decreases vomiting by children after tonsillectomy. Anesth Analg 1996;83:913-6.
8. Liu K, Hsu CC, Chia YY. Effect of dexamethasone on postoperative emesis and pain. Br J Anaesth 1998;80:85-6.
9. White PF, Watcha MF. Postoperative nausea and vomiting: prophylaxis versus treatment. Anesth Analg 1999;89:1337-9.
10. Scuderi P, James R, Harris L, Mims III GR. Multimodal management eliminates postoperative nausea and vomiting (PONV) following outpatient laparoscopy. Anesthesiology 1999;91:A6.
11. White PF. Criteria for fast-tracking outpatients after ambulatory anesthesia. J Clin Anesth 1999;11:78-9.
12. Aldrete JA. The post-anesthesia recovery score revisited. J Clin Anesth 1995;7:89-91.
13. Lindley C, Blower P. Oral serotonin type 3-receptor antagonists for prevention of chemotherapy induced emesis. Am J Health Syst Pharm 2000; 57:1685-97.
14. Ortells MO, Lunt GG. Evolutionary history of the ligand-gated ion-channel
superfamily of receptors. Trends Neurosci 1995;18:121–7.
15. Watcha MF, White PF. Postoperative nausea and vomiting: Its etiology, treatment, and prevention. Anesthesiology 1992;77:162–84.
16. Suzuki T, Koyama H, Sugimoto M, Uchida I, Mashimo T. The diverse actions of volatile and gaseous anesthetics on human-cloned 5-hydroxytryptamine3 receptors expressed in Xenopus oocytes. Anesthesiology 2002;96:699-704.
17. Di Marzo V, De Petrocellis L, Fezza F, Ligresti A, Bisogno T. Anandamide receptors. Prostaglandins Leukot Essent Fatty Acids 2002;66:377-91.
18. Freund TF, Katona I, Piomelli D. Role of endogenous cannabinoids in synaptic signaling. Physiol Rev 2003;83:1017-66.
19. Parolaro D. Presence and functional regulation of cannabinoid receptors in immune cells. Life Sci 1999;65:637-44.
20. Schelling G, Hauer D, Azad SC, Schmoelz M, Chouker A, Schmidt M, Hornuss C, Rippberger M, Briegel J, Thiel M, Vogeser M. Effects of general anesthesia on anandamide blood levels in humans. Anesthesiology 2006;104:273-7.
21. Hechler A, Naujoks F, Ataman K, Hopf HB. The incidence of postoperative nausea and vomiting is not effected by routinely applied manual pre-oxygenation during induction of anesthesia. Anasthesiol Intensivmed Notfallmed Schmerzther 1999;34:684-8.
22. Bartamian M, Meyer DR. Site of service, anesthesia, and postoperative
practice patterns for oculoplastic and orbital surgeries. Ophthalmology.
1996;103:1628-33
23. Schultz Ls. Cost analysis of office surgery clinic with comparison to hospital
outpatient facilities for laparoscopic procedures. Int Surg 1994;79:273-7.
24. White PF. Ambulatory anesthesia advances into the new millennium. Anesth Analg 2000;90:1234-5.
25. Smith I, Nathanson MH, White PF. The role of sevoflurane in outpatient anesthesia.
Anesth Analg 1995;81:S67-72 .
26. Song D, Joshi GP, White PF. Fast-track eligibility after ambulatory anesthesia: a
comparison of desflurane, sevoflurane, and propofol. Anesth Analg 1998;86:267- 73.
27. Jokela RM, Kangas-Saarela TA, Valanne JVI, Koivuranta MK, Ranta PO, Alahuhta
SM. Postoperative nausea and vomiting after sevoflurane with or without
ondansetron compared with propofol in female patients undergoing breast surgery.
Anesth Analg 2000;91:1062-5.
28. Ashworth J, Smith I. Comparison of desflurane with isoflurane or propofol in
spontaneously breathing ambulatory patients. Anesth Analg 1998;87:312-8.
29. Saros GB, Doolke A, Anderson RE, Jakobsson JG. Desflurane vs. sevoflurane as
the main inhaled anaesthetic for spontaneous breathing via a laryngeal mask for
varicose vein day surgery: a prospective randomized study. Acta Anaesthesiol
Scand 2006;50:549-552.
30. Ghatge S, Lee J, Smith I. Sevoflurane: an ideal agent for adult daycase anesthesia?
Acta Anaesthesiol Scand 2003;47:917-31.
31. Baxendale BR, Vater M, Lavery KM. Dexamethasone reduces pain and swelling
following extraction of third molar teeth. Anaesthesia 1993;48:961-4.
32. Skjelbred P, Løkken P. Postoperative pain and inflammatory reaction reduced by
injection of a corticosteroid. Eur J Clin Pharmacol 1982;21:391-6.
33. Callery MP. Preoperative steroids for laparoscopic surgery. Ann Surg 2003;238:661–2.
34. The Italian Group for Antiemetic Research. Dexamethasone alone or in
combination with ondansetron for the prevention of delayed nausea and vomiting
induced by chemotherapy. N Engl J Med 2000;342:1554-9.
35. Ho ST, Wang JJ, Tzeng JI, Liu HS, Ger LP, Liaw WJ. Dexamethasone for preventing nausea and vomiting associated with epidural morphine: a dose ranging study. Anesth Analg 2001;92:745–8.
36. Henzi I, Walder B, Tramèr MR. Dexamethasone for the prevention of postoperative
nausea and vomiting: a quantitative systematic review. Anesth Analg 2000;90:186
-94.
37. Rich W, Abdulhayoglu G, Di Saia PJ. Methylprednisolone as antiemetic during
cancer chemotherapy: a pilot study. Gynecol Oncol 1980;9:193-8.
38. Harris AL. Cytotoxic-therapy-induced vomiting is mediated via enkephalin
pathways. Lancet 1982;1:714-6.
39. Sauerland S, Nagelschmidt M, Mallmann P, Neugebauer EA. Risks and
benefits of preoperative high dose methylprednisolone in surgical patients: A
systematic review. Drug Safety 2000; 23:449-61.
40. Sachiko T, Satoko O, Shuzo N, Toshimitsu U. Antiemetic effect of dexamethasone on cisplatin-induced early and delayed emesis in the pigeon. Europ J Pharm 2004;484:311–321.
41. Coloma M, White PF, Huber PJ, Tongier WK, Dullye KK, Duffy LL. The effect of ketorolac on recovery after anorectal surgery: intravenous versus local administration. Anesth Analg 2000;90:1107–10.