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1 Korean J Women Health Nurs ( 여성건강간호학회지 ) Vol , 23-31, March 2015 pissn eissn 황윤정 1 박소미 2 원주세브란스기독병원 1, 연세대학교원주의과대학간호학과 2 Effects of Preoperative Dehydration on Postoperative Nausea and Vomiting in Gynecological Surgery Patients Hwang, Yunjeong 1 Park, SoMi 2 1 Wonju Severance Christian Hospital, Wonju 2 Department of Nursing, Wonju College of Medicine, Yonsei University, Wonju, Korea Purpose: The purpose of this study was to investigate the effect of dehydration from preoperative fasting on postoperative nausea and vomiting in patients who underwent gynecologic surgeries. Methods: Study design was a prospective descriptive study. A total of 75 patients in a university hospital were selected. Data were collected from March 17 to May 16, 2014 using self-report questionnaires and clinical electronic chart. Results: Factors influencing the development of postoperative nausea and vomiting were type of surgery (t=3.44, p=.001), use of PCA (t=-2.16, p=.034), and preoperative dehydration level (t=5.93, p<.001), and these variables accounted for 51.7% of postoperative nausea and vomiting. Among these variables, preoperative dehydration amount (β=.56) showed the largest influence in the difference in postoperative nausea and vomiting. Conclusion: Reducing dehydration during preoperative fasting can prevent occurrence of postoperative nausea and vomiting. Development of a clinical guideline is necessary to give directions for the prevention of dehydration during preoperative fasting and to ensure the proper duration of fasting according to patient characteristics, type of surgery and time of surgery. Key Words: Dehydration, Postoperative nausea and vomiting, Gynecology 서론 1. 연구의필요성수술전금식은마취유도로인한위내용물의역류를예방하기위해필요한절차로수술을받는환자들에게대부분행해지고있으며 [1], 우리나라는관례적으로수술당일자정이후부터금식을시행하고있다 [2]. 그러나수술 2시간전까지 내용물없는액체를섭취한환자와자정이후금식을한환자들의구토및폐내흡인의위험성을비교한결과차이가없었다 [3]. 또한우리나라사람들이즐겨마시는보리차 250 ml 정도를수술시작 3시간전에섭취하도록허용한뒤위내용물의양을측정한결과 [2] 별다른영향이없었고, 오히려환자의갈증을덜어주는긍정적인효과가있는것으로보고하였다. 이러한선행연구들의긍정적인결과를반영하여미국마취과학회에서는합병증이없는환자들에게있어서고형음식은수술 주요어 : 탈수, 수술후오심 구토, 부인과 Corresponding author: Park, SoMi Department of Nursing, Yonsei University, Wonju College of Medicine, 20 Ilsan-ro, Wonju , Korea. Tel: , Fax: , somi@yonsei.ac.kr - 이논문은제 1저자황윤정의석사학위논문의축약본임. - This manuscript is a condensed from of the first author s master s thesis from Yonsei University. Received: Feb 9, 2015 / Revised: Mar 16, 2015 / Accepted: Mar 17, 2015 This is an open access article distributed under the terms of the Creative Commons Attribution n-commercial License ( by-nc/3.0), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. c 2015 Korean Society of Women Health Nursing

2 황윤정 박소미 6시간전까지, 내용물없는액체의경우는 2시간전까지섭취를허용하는가이드라인을발표하였다 [4]. 수술전금식기간이길어질경우수술후오심 구토를증가시키는것으로보고되고있는데 [5], 이는오랜금식으로인한탈수와관련이있다 [6,7]. 수술전행해지는금식이세포내및세포외액의부족을초래하게되고, 이러한체액의부족은장허혈을유발하여세로토닌 (serotonin) 과같은오심유발인자들을유리시켜수술후오심 구토의발생률을증가시키기때문이다 [8]. 수술후오심 구토의관련요인을밝힌연구들은이미수천개에이르지만매년수백개의연구들이새롭게발표되고있듯이수술후오심 구토의관련요인은매우복합적이라고할수있다 [9]. 이러한복합적인관련요인은크게환자관련특성, 마취관련특성, 수술관련특성으로구분할수있다. 환자관련특성으로는남성보다는여성, 수술후오심 구토의과거력과멀미과거력이있는환자, 비흡연자가포함되며, 마취관련특성으로는휘발성흡입마취제의사용과아산화질소의사용, 수술중 후의아편제제의사용, 고용량의네오스티그민 (neostigmine) 의사용이포함된다. 마지막으로수술관련특성으로는수술시간이포함되는데수술시간이 30 분길어질때마다수술후오심 구토의위험이 60% 증가하는것으로보고되고있다 [9]. 모든수술환자에서수술후오심 구토의발생은 25~30% 로추정되지만 [10], 수술종류에따라이비인후과수술, 유방수술, 복강경수술, 부인과수술등이수술후오심 구토의발생을증가시키는것으로알려져있다 [11]. 특히부인과복강경수술환자의경우수술후오심 구토의발생률은 73% 까지증가하는것으로보고되고있는데 [12], 복강경수술이수술후오심 구토의발생률을증가시키는이유는복강경수술시흔히이루어지는두부하강자세와수술시야를확보하기위해복강내로주입하는가스로인하여복강내장기에발생한허혈이수술후오심 구토를증가시키는것으로알려져있다 [13]. 이에수술후오심 구토를예방하고관리하기위한약물요법 [14,15] 과함께아로마요법 [16,17], 내관지압 [18] 등의비약물요법의효과를검증하는연구들이진행되어왔으며, 오심 구토의유발요인이될수있는탈수를예방하기위하여수술전수액주입의효과를검증한외국의선행연구들도있다 [6,7,19]. 수술전환자의탈수량을계산하여수액을투여한결과투여하지않은군보다수술후오심 구토의발생률이유의하게낮았음을보고하였고 [7], 복강경담낭절제술과복강경부인과수술환자를대상으로한연구 [19] 에서는마취시작전 15 ml.kg -1 양의보충용수액을투여한결과수술후 1시간동 안의오심발생이보충용수액을투여하지않은군보다통계적으로유의하게낮았으며, 수술후 1시간부터 24시간동안의오심발생률또한통계적으로유의하게낮았음을보고하였다. 국내에서는복강경하자궁절제술환자를대상으로한연구 [20] 에서수술후오심 구토와수술전금식시간사이에는유의한차이가없었고, 수술중수액을 6.5 ml/kg/hr 미만으로투여받은그룹의수술후오심 구토의발생빈도가그이상으로투여받은그룹에비해유의하게높았음을제시하였다. 또한수술후오심 구토를예방하기위한약물요법과비약물요법의효과를검증한연구 [21-23] 들도많이이루어져있었다. 하지만수술전금식기간탈수량과수술후오심 구토와의관계를확인한연구는시도된적이없었다. 따라서본연구는수술후오심 구토의발생이비교적높다고알려져있는부인과수술환자를대상으로수술전금식기간탈수량이수술후오심 구토에미치는영향을확인하고자시도하였다. 2. 연구목적본연구는부인과수술환자를대상으로수술전금식기간탈수량이수술후오심 구토에미치는영향을확인함으로써, 수술전금식기간의탈수를예방하여수술후오심 구토의발생을최소화하기위한임상적용가이드라인의기초자료를제공하고자한다. 이를위한구체적인목적은다음과같다. 대상자의수술전금식기간탈수량과수술후오심 구토정도를파악한다. 대상자의일반적특성및수술관련특성을파악하고, 이에따른수술후오심 구토의차이를파악한다. 수술후오심 구토에미치는영향요인을확인한다. 연구방법 1. 연구설계본연구는부인과수술환자의수술전금식기간탈수량이수술후오심 구토에미치는영향을조사하기위한전향적서술적연구이다. 2. 연구대상본연구는 W시에위치한 Y대학병원의산부인과병동의입원환자중전신마취로복부절개또는복강경을통해자궁절 24 Korean Journal of Women Health Nursing

3 제술, 난소, 난관절제술을받은자이며, 악성종양진단을받은자, 응급으로수술이진행되었거나수술후합병증이발생한자는제외시켰다. 연구대상자의표출방법은편의표출을이용하였으며, 표본수산출은 G*Power 프로그램을이용하여수술전금식기간탈수량이수술후오심 구토에미치는영향정도를확인하는최종목적을위해위계적다중회귀분석방법으로유의수준 ( ).05, 중간정도의효과크기 (f).15, 검정력 (1-β).90, 예측변수 7개로설정한후산출한결과최소표본크기가 73명이었으며, 본연구의최종분석대상자수는 75명으로적절하였다. 3. 연구도구 1) 수술전금식기간탈수량본연구에서는수술전금식시작시간부터마취시작전까지발생한탈수량을탈수량계산공식 (1.5 ml kg -1 hr -1 body weight fasting time) 을이용하여 [24], 금식기간동안발생한탈수량에서정맥주사를통해실제투여된수액량을제하여산출하였다. 본연구에서수술전금식기간탈수량을산출한계산공식은다음과같다. [1.5 ml kg -1 hr -1 체중 수술전금식기간 -수술전금식기간동안주입된수액량 ] 2) 수술후오심 구토본연구에서수술후 24시간동안일어나는오심 구토는 Rhodes Index of Nausea, Vomiting and Retching (INVR) [25] 의한글번역도구 [26] 로측정한점수를의미한다. 도구의신뢰도는 Cronbach's =.84였고, 본연구에서는 Cronbach's =.88이었다. 본도구의구성은오심 3문항, 구토 3문항, 헛구역질 2문항으로되어있으며, 각각빈도와양, 불편감정도를측정하는총 8문항의 5점척도로구성되어있다. 증상이나불편감이가장높을때 4점, 증상이나불편감이전혀없을때 0점인최저 0점에서최고 32점으로점수가높을수록오심 구토의정도가심한것을의미한다. 4. 자료수집자료수집은 2014년 3월 17일부터 5월 16일까지 W시에위치한 Y대학병원의산부인과병동에서질문지를이용한면담및의무기록을통해수집하였으며, 구체적인절차는다음과같다. Y대학교대학병원산부인과병동에전신마취하자궁절제술또는난관 난소절제술을받을예정인환자의목록을연구자가매일체크하여대상자선정기준에합당한지를확인하였다. 기준에합당한대상자는불안을고려하여수술전정보제공및수술전수술동의서의작성여부를확인한뒤예비대상자에게연구자가연구목적을설명하였으며, 참여의사를밝힌환자에게서면으로동의를받았다. 자료수집은연구자와연구목적및자료수집과정에대해교육을받은연구보조원 1인이참여의사를밝힌대상자의수술시간을확인하고수술 8시간후 ( 수술을받고회복실에서마취상태로부터깨어난후병실로돌아와안정을보이는시기 ) 에방문하여 PCA 사용여부및약물종류, 수액의종류를의무기록지를통해조사하였고, 수술 24시간경과되었을때는오심및구토에대한자료를설문지를통해수집하였다. 5. 자료분석수집된자료는 IBM SPSS 20.0 프로그램을이용하여통계처리하였으며, 자료분석을위해사용한구체적인통계분석방법은다음과같다. 수술전금식기간탈수량과수술후오심 구토정도는평균과표준편차를이용하여분석하였다. 일반적특성, 수술관련특성은기술통계를이용하여실수와백분율로분석하였고, 환자관련특성, 수술관련특성에따른수술후오심 구토의차이는 Independent t-test와 One-way ANOVA, Scheffe 사후검정을이용하여분석하였다. 수술후오심 구토에미치는영향요인및영향정도를확인하기위해위계적다중회귀분석 (Hierarchical multiple regression) 을이용하여분석하였다. 6. 윤리적고려본연구를위하여연구계획서를 Y 대학윤리심의위원회에제출하여승인 (YWNR ) 을받은후병원의해당부서장에게연구목적과내용및윤리위원회통과내용을설명하고허락을받은후실시하였다. 연구대상자에게도연구목적과설문지내용을설명하고, 서면동의를받았으며, 연구참여는대상자의자율적인의지에따름을명시하였다. 수술환자의불편함을최소화하기위하여진료기록을통해조사할수있는자료는본인의동의후진료기록을통해조사하였다. 진료기 Vol ,

4 황윤정 박소미 록확인내용및응답한내용은연구목적으로만사용되며, 연구결과를분석한다음응답한설문지는폐기처분할것임을설명하였다. 연구결과 1. 대상자의수술전금식기간탈수량과수술후오심 구토정도대상자의평균수술전금식기간탈수량은 ± ml이었으며, 최소값은 ml, 최대값은 ml로나타났다. 또한수술후오심 구토의평균점수는 7.35±5.65 점이었고, 가능범위는 0~32점으로본연구에서는최소값은 0 점최대값은 25점이었다 (Table 1). 2. 대상자의일반적특성에따른수술후오심 구토의차이대상자의평균연령은 48.04±7.51 세이었고, 과거수술경험이있는대상자는 28명 (37.3%) 이었으며, 과거수술경험이있는대상자중과거수술후오심 구토를경험했던대상자는 8명 (28.6%) 이었다. 멀미경험이있는대상자는 31명 (41.3%) 이었다. 대상자의일반적특성에따른수술후오심 구토점수의차이를검정한결과유의한차이를보인특성은체중이었으며 (F=5.43, p=.002), 70 kg 이상인군이 50 kg 미만인군보다수술후오심 구토의점수가높은것으로나타났다. 또한과거멀미경험에따라수술후오심 구토의점수에유의한차이가있었는데 (t=2.88, p=.005), 과거멀미경험이있었던대상자의수술후오심 구토점수의평균은 9.48±6.24점으로과거멀미경험이없었던대상자의평균인 5.84±4.71점보다높게나타났다 (Table 2). Table 1. Level of Dehydration during Preoperative Fasting and INVR score during Postoperative 24 hour Period (N=75) Characteristics M±SD Measuring range Tool range Amount of preoperative dehydration (ml) ± ~1, INVR score 7.35±5.65 0~25 0~32 INVR=rhodes index of nausea, vomiting and retching. Table 2. Difference in Postoperative Nausea and Vomiting according to General Characteristics (N=75) Characteristics Age (year) (M±SD: 48.04±7.51) (Range: 35~68) Weight (kg) (M±SD: 63.04±11.54) (Range: 43.00~110.00) Categories <40 40~49 50~59 60 <50 50~<60 60~<70 70 PONV n(%) M±SD t or F p 8 (10.7) 42 (56.0) 18 (24.0) 7(9.3) 7(9.3) 27 (36.0) 20 (26.7) 21 (28.0) 10.50± ± ± ± ±4.51 a 5.14±5.21 b 7.80±4.95 c 10.76±6.19 d (a<d) BMI (kg/m 2 ) 18.5~< (30.7) 52 (69.3) 5.48± ± Smoking history 0(0.0) 75 (100.0) ±5.65 N/A N/A History of surgery 28 (37.3) 47 (62.7) 7.54± ± History of PONV 8 (28.6) 20 (71.4) 8.25± ± History of motion sickness 31 (41.3) 44 (58.7) 9.48± ± BMI=body mass index, N/A=t available, PONV=postoperative nausea and vomiting; Scheff'e test, Exclusion of non-relevant data. 26 Korean Journal of Women Health Nursing

5 3. 대상자의수술관련특성에따른수술후오심 구토의차이대상자중자궁절제술및난소, 난관절제술을시행받은대상자는 53명 (70.7%) 이었고, 난소, 난관절제술을시행받은대상자는 22명 (29.3%) 이었으며, 수술형태로는복부절개가 45명 (60.0%), 복강경이 30명 (40.0%) 이었다. 대상자의수술전평균금식기간은 ± 분으로최소 7시간 50분에서최대 16시간까지였으며, 수술전평균수액주입량은 ± ml이었다. 수술중투여된수액주입량의평균은 1,100.00± ml으로, 최소 550 ml에서최대 2,800 ml 까지의범위를보였다. 수술후통증자가조절장치 (Patient Controled Analgesia [PCA]) 를사용한대상자는 63명 (84.0 %) 이었고, 수술후오심 구토를호소하여추가진토제를투여받은대상자는 36명 (48.0%) 이었다. 수술후오심 구토점수에서통계적으로유의한차이를보인수술관련특성은수술형태였다. 복부절개로수술을받은대상자의수술후오심 구토점수의평균은 5.36±5.27 점, 복강경으로수술을받은대상자의평균은 9.83±6.67 점으로복 강경으로수술을받은대상자의수술후오심 구토의점수가복부절개로수술을받은대상자에비해통계적으로유의하게높았다 (t=-2.15, p=.040)(table 3). 4. 수술후오심 구토에미치는영향요인부인과수술후대상자들의오심 구토정도에영향을미치는요인을확인하기위해본연구결과및문헌고찰을통해수술후오심 구토에차이를보인변수를환자관련특성 ( 수술후오심 구토과거력, 멀미과거력 ), 마취 수술관련특성 ( 수술형태, 수술시간, 수술중수액주입량, PCA 사용여부 ) 으로범주화하고, 간호중재로조정가능한요인인수술전금식기간탈수량을포함시켜위계적다중회귀분석을실시하였다. 다중회귀분석에앞서문헌고찰에서제시된환자관련특성과마취 수술관련특성중탈수량에영향을줄수있는금식기간, 수술중수액주입량, 수술후추가진토제투여여부에따른수술전금식기간탈수량의차이를검정하였다. 이러한분석은수술전금식기간탈수량에영향을미칠수있는외생변수의영향여부를확인함으로써수술전금식기간탈수량이수술후 Table 3. Difference in Postoperative Nausea and Vomiting according to Anesthetic and Surgical related Characteristics (N=75) Characteristics Type of operation Categories Hysterectomy and oophorosalpingectomy Oophorosalpingectomy PONV n(%) M±SD t p 53 (70.7) 6.94± (29.3) 8.32±6.28 Type of surgery Abdominal incision Laparoscopic 45 (60.0) 30 (40.0) 5.36± ± Fasting time (minutes) < (56.0) 33 (44.0) 7.19± ± Administrated fluid amount during preoperative fasting (ml) < (60.0) 30 (40.0) 6.73± ± Inhalation agent Desflurane Sevoflurane 45 (60.0) 30 (40.0) 7.16± ± Duration of surgery (minutes) < (57.3) 32 (42.7) 8.21± ± Administrated fluid amount during surgery (ml) < (58.7) 31 (41.3) 7.61± ± Use of PCA 63 (84.0) 12 (16.0) 7.54± ± Use of additive anti-emetic 36 (48.0) 39 (52.0) 7.94± ± PCA=patient controlled analgesia. Vol ,

6 황윤정 박소미 오심 구토에미치는영향을명확히하고자분석하였다. 분석결과모든외생변수와수술전금식기간탈수량은통계적으로유의한차이가없어, 수술전금식기간탈수량이외생변수의영향을받지않음을확인하였다. 위계적다중회귀분석을한결과는다음과같다 (Table 4). 수술후오심 구토과거력, 멀미과거력, 수술형태, PCA 사용여부는가변수처리하여분석하였고, 공차한계는모두 0.1 이상의수치를보여다중공선성이없었으며, Durbin-Watson 은 1.95로기준값인 2에매우근접하고 0 또는 4에가깝지않기때문에잔차들간상관관계가없는것으로판단되어이회귀모형은적합하다고판단하였다. 첫번째단계에서환자관련특성만을포함하여분석한결과수술후오심 구토를설명하는정도는 11.0%(F=4.45, p=.015) 였으며, 통계적으로유의하게영향을주는변수는멀미과거력이었다 (t=-2.87, p=.005). 두번째단계에서는마취 수술관련특성을추가하여분석하였고, 수술후오심 구토를설명하는정도는 26.3%(F=4.05, p=.002) 로첫번째단계의모형에비해설명력이 15.3% 증가하였다. 두번째모형에서통계적으로유의하게수술후오심 구토에영향을주는변수로분석된요인은멀미과거력 (t=-3.20, p=.002), 수술형태 (t=3.32, p=.001) 와 PCA 사용여부 (t=-2.66, p=.010) 였다. 마지막으로세번째단계에서수술전금식기간탈수량을추가하여분석한결과수술후오심 구토를설명하는정도는 51.7%(F=10.23, p<.001) 로두번째단계의모형에비해설명력이 25.3% 증가하였다. 통계적으로유의한변수는수술형태 (t=3.44, p=.001), PCA 사용여부 (t=-2.16, p=.034), 수술 전금식기간탈수량 (t=5.93, p<.001) 으로나타났다. 수술후오심 구토에영향을주는변수들간의상대적영향력은금식기간탈수량 (β=.56) 이가장큰영향력을보이는변수로나타났으며, 두번째로수술형태 (β=.37), 세번째로는 PCA 사용여부 (β=-.23) 순이었다. 이에따라본연구에서는수술전금식기간탈수량이수술후오심 구토에가장큰영향을미치고있음을확인하였다. 논의본연구는부인과수술환자를대상으로환자관련특성과마취 수술관련특성에따른수술후오심 구토의차이를확인하고, 수술전금식기간탈수량이수술후오심 구토에미치는영향을검증하기위해시도되었다. 연구결과수술형태, PCA 사용여부, 수술전금식기간탈수량이통계적으로의미있는요인으로나타났다. 이들변수에의한설명력은 51.7% 였으며, 변수들간의상대적영향력은금식기간탈수량이가장큰영향력을보였다. 이는수술전탈수가화학감수체유발지역을자극하여수술후오심 구토를일으킨다는생리학적기전과일치하는결과를보여주는것이며, Lambert 등 [7] 의연구에서수술전금식기간탈수량을고려하여수액을투여한군에서수술후오심 구토의발생이유의하게감소한것과유사한결과이다. 그러므로수술이계획된환자들에게관례적자정이후금식보다는미국마취과학회에서발표한고형음식에있어서는수술 6시간전까지, 내용물없는액체의경우는 2 Table 4. Factors associated Postoperative Nausea and Vomiting in Gynecologic Surgery Variables Model 1 Model 2 Model 3 B β t B β t B β t History of PONV History of motion sickness ** ** Type of surgery ** ** Duration of surgery Administrated fluid amount during surgery (N=75) Use of PCA * * Amount of preoperative *** dehydration F(p) R 2 R 2 change 4.45(.015) (.002) (<.001) *p<.05, **p<.01, ***p<.001; Dummy variables: History of PONV (0:, 1: ); History of motion sickness (0:, 1: ); Type of surgery (0: Abdominal incision, 1: Laparoscopic), Use of PCA (0:, 1: ). 28 Korean Journal of Women Health Nursing

7 시간전까지섭취를허용하는가이드라인의적용을고려해볼필요가있으며, 본연구결과에서수술전금식기간탈수량이수술후오심 구토에가장큰영향력을보이는변수임을확인하였기때문에수술전탈수량을고려한수액요법이제공될경우수술후환자들이겪는불쾌한오심 구토증상을최소화할수있을것으로보인다. 환자관련특성중수술후오심 구토의점수에차이를보인변수는환자의체중으로 50 kg 미만인대상자에비해 70 kg 이상인대상자가수술후오심 구토의점수가높아통계적으로유의한차이를보였다. 체질량지수에따른오심 구토의차이연구를고찰하면, 체질량지수에따라오심 구토의차이를제시한연구 [27] 가있는반면체질량지수에따른수술후오심 구토의차이가없음을제시하는연구 [20] 도있는데, 본연구에서도또한수술후발생하는오심 구토의정도가체질량지수에따른차이는없었다. 하지만체중의경중에의해영향을받고있음을확인하였으므로추후이에대한연구가더필요할것이며, 환자의체중을고려한수술전탈수예방간호가필요하겠다. 또한멀미과거력의여부에따라수술후오심 구토에통계적으로유의한차이를보였는데멀미경험이있는대상자가멀미경험이없는대상자보다수술후오심 구토의점수가 2배정도높았다. 이는멀미경험이있는대상자가멀미경험이없는대상자보다수술후오심 구토발생이 2.47 배높게나타난연구 [12] 과유사한결과이다. 그러므로수술전멀미과거력의여부를간호사정요소에포함하여수술후오심 구토완화및예방을위한간호계획을세우는데활용할것을제안한다. 수술관련특성에따른수술후오심 구토정도의차이에서는수술형태에따라수술후오심 구토의정도가통계적으로유의한차이를보였고, 복강경을통해수술을시행한군이복부절개로시행한군보다수술후오심 구토의점수가높게나타났다. 이는복강경수술이수술후오심 구토에영향을주는변수로나타난연구결과 [27] 와유사하다. 그러므로복강경수술환자에게는수술후간호에오심 구토정도를체크하는간호를필수항목으로포함시켜대상자의불편감을완화시켜주는간호계획을제공하는것을제안한다. 한편 PCA의사용여부에따른수술후오심 구토의점수는통계적으로유의한차이가없는것으로확인되었는데, 이는이미 PCA 사용이오심 구토를증가시킨다는근거하에본연구가시행된병원에서는 PCA를사용한대상자들에게모두예방적으로진토제를투여하였기때문으로사료된다. 하지만위계적다중회귀분석모형에서는 PCA 사용여부가수술후오심 구토에영향을주는변수로확인되었으므로, 이러한결과는 PCA의사용이수술후오심 구토를증가시킨다는연구들 [28,29] 과도일치된결과를보여주고있다. 그러므로 PCA 사용시수술후오심 구토에대한지속적인사정이필요하겠다. 또한본연구에서는수술후오심 구토의정도를수술후 24시간동안경험한정도를 1회성으로측정하였는데추후에는수술후경과시간에따라세분화하여오심 구토정도의차이를확인할것을제안한다. 이는환자들이수술후오심 구토의정도가가장심하게나타난시간을확인하여대상자들의안위를높힐수있는중재가가능하다고사료되기때문이다. 또한수술전금식기간탈수량이수술후오심 구토의정도에가장영향을크게미치는변수로확인되었는데탈수량에영향을줄수있는수술중수액주입량에따른수술후오심 구토의정도는통계적으로유의한차이를보이지않았다. 이는 Yun [30] 의부인과수술환자를대상으로한연구에서수술중충분한수액의투여가수술후 2~6시간에서오심을감소시키는것으로나타났지만, 수술후 24시간동안의오심 구토에는유의한차이가없는것으로나타나수술후 24시간동안의오심 구토정도를측정한본연구의결과와유사하였다. 따라서수술중투여하는수액량보다는수술전충분한수액의투여가수술후오심 구토에더효과적이라고할수있겠다. 본연구결과는일대학병원부인과수술환자를대상으로시도되어일반화하는데제한점이있지만본연구결과에근거하여다음과같은제언을하고자한다. 첫째, 부인과수술환자만을대상으로시행하였으므로추후에는수술종류및대상자수를확대하여반복연구할것을제언한다. 둘째, 부인과수술환자에서수술전금식기간탈수량이수술후오심 구토에영향을주고있음을고려하여수술전탈수예방간호를적용한효과검증연구를제언한다. 셋째, 수술전금식기간탈수를예방하여수술후오심 구토의발생을줄이기위한근거기반의임상적용가이드라인의개발을제언한다. 결론본연구는생리학적기전에바탕을둔근거기반간호중재의기초자료를제시하기위해시도한연구로서수술전금식기간탈수량은수술후오심 구토의가장큰영향을주는변수임을확인하였다. 이에본연구는간호실무측면에서수술순서와상관없이일률적으로시행되고있는수술전불필요한장기간 Vol ,

8 황윤정 박소미 의금식및관습적으로이루어지고있는자정이후금식에대한재고가필요하다는토대를마련하였고, 수술전탈수를예방하여환자들이겪는불편감인수술후오심 구토의발생을줄이기위한임상적용가이드라인의기초자료를제공하였다. REFERENCES 1. Sendelbach S. Preoperative fasting doesn t mean nothing after midnight. American Journal of Nursing. 2010;110(9): Lee JH, Oh AY, Kim SD. Effect of preoperative NPO and oral fluid on gastric fluid volume and ph. Korean Journal of Anesthesiology. 1999;36(3): Somwanshi M, Tripathi A, Singh B, Bajaj P. Effect of preoperative oral fluids on gastric volume and ph in postpartum patients. Middle East Journal of Anesthesiology. 1995;13(2): American Society of Anesthesiologist. Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: A report by the American Society of Anesthesiologist task force on preoperative fasting. Anesthesiology. 1999;90(3): Tudor G. Fasting: how long is too long. Australian Nursing Journal. 2006;13(7): Adanir T, Aksun M, Ozqurbuz U, Altin F, Sencan A. Does preoperative hydration affect postoperative nausea and vomiting? A randomised controlled trial. Journal of Laparoendoscopic & Advanced Surgical Techniques. 2008;18(1): Lambert KG, Wakim JH, Lambert NE. Preoperative fluid bolus and reduction of postoperative nausea and vomiting in patients undergoing laparoscopic gynecologic surgery. American Association of Nurse Anesthetists Journal. 2009;77(2): Laer S, Scholz J, Ritterbach C, Laer C, Rahme E, Schulte AM, Esch J. Association between increased 5-HIAA plasma concentrations and postoperative nausea and vomiting in patients undergoing general anaesthesia for surgery. European Journal of Anaesthesiology. 2001;18(12): McCracken G, Houston P, Lefebvre G. Society of obstetricians and gynaecologists of canada clinical practice guideline: Guideline for the management of postoperative nausea and vomiting. Journal of Obstetrics and Gynaecology Canada. 2008; 30(7): Ho, KY, Chiu, JW. Multimodal antiemetic therapy and emetic risk profiling. Annals Academy of Medicine Singapore. 2005; 34(2): Stadler M, Bardiau F, Seidel L, Albert A, Boogaerts JG. Difference in risk factors for postoperative nausea and vomiting. Anesthesiology. 2003;98(1): Choi DH, Ko JS, Ahn HJ, Kim JA. A korea predictive model for postoperative nausea and vomiting. Journal of Korea Medical Science. 2005;20(5): Magner JJ, McCaul C, Carton E, Gardiner J, Buggy D. Effect of intraoperative intravenous crystalloid infusion on postoperative nausea and vomiting after gynaecological laparoscopy: Comparison of 30 and 10 ml. kg -1.British Journal of Anaesthesia. 2004;93(3): Antor MA, Uribe AA, Erminy-Falcon N, Werner JG, Candiotti KA, Pergolizzi JV, et al. The effect of transdermal scopolamine for the prevention of postoperative nausea and vomiting. Frontiers in Pharmacology. 2014;5(55): Chun HR, Jeon IS, Park SY, Lee SJ, Kang SH, Kim SI. Efficacy of palonosetron for the prevention of postoperative nausea and vomiting: A randomized, double-blinded, placebo-controlled trial. British Journal of Anaesthesia. 2014;112(3): Anderson LA, Gross JB. Aromatherapy with peppermint, isopropyl alcohol, or placebo is equally effective in relieving postoperative nausea. Journal of Peri-Anesthesia Nursing. 2004; 19(1): Ferruggiari L, Ragione B, Rich ER, Lock K. The effect of aromatherapy on postoperative nausea in women undergoing surgical procedures. Journal of Peri-Anesthesia Nursing. 2012; 27(4): Xu M, Zhou SJ, Jiang CC, Wu Y, Shi WL, Gu HH, et al. The effects of P6 electrical acustimulation on postoperative nausea and vomiting in patients after infratentorial craniotomy. Journal of Neurosurgical Anesthesiology. 2012;24(4): Ali SZ, Taguchi A, Holtmann B, Kurz A. Effect of supplemental pre-operative fluid on postoperative nausea and vomiting. Anaesthesia. 2003;58(8): Park SI, Ko YK, Yoon HS, Yoon SH, Lee WH, Lee JU. Analysis of factors related to postoperative nausea and vomiting after laparoscopic hysterectomy. Korean Journal Anesthesiology. 2005;49(2): Moon HY. Palonosetron and aprepitant for prevention of postoperative nausea and vomiting in patient undergoing laparoscopic gynecology surgery [master s thesis]. Seoul: Chung- Ang University; Jung HJ, Park SY. Combination effects of capsicum plaster at the korean hand acupuncture points K-d2 with prophylactic antiemetic on postoperative nausea and vomiting after gynecologic laparoscopy. Journal of Korean Academy of Nursing. 2013;43(2): Choi YK, Kim HJ, Park SW, Kim KS. The optimal anti-emetic dose of Ramosetron for prevention of postoperative nausea and vomiting following gynecologic surgery. Korean Journal of Anesthesiology. 2008;54(5): Aitkenhead AR, Moppett IK, Thompson JP, editors. Smith & Aitkenhead s Textbook of Anaesthesia, 6th ed. London, UK: 30 Korean Journal of Women Health Nursing

9 Churchill Livingstone; Rhodes VA, McDaniel RW. The index of nausea, vomiting, and retching: A new format of the index of nausea and vomiting. Oncology Nursing Forum. 1999;26(5): Kim YJ, Kim JY, Choi IR, Kim MW, Rhodes V. The index of nausea, vomiting, and retching Korean translation. Journal of Korea Academy of Adult Nursing. 2000;12(2): Lee YY. Prediction model on causing factors for the postoperative nausea and vomiting in patients using patient controlled analgesia [dissertation]. Seoul: Chung-Ang University; Song JW, Shim JK, Song Y, Yang SY, Park SJ, Kwak YL. Effect of ketamine as an adjunct to intravenous patient-controlled analgesia, in patients at high risk of postoperative nausea and vomiting undergoing lumbar spinal surgery. British Journal of Anaesthesia. 2013;111(4): Wang PK, Tsay PJ, Huang CC, Lai HY, Lin PC, Huang SJ, et al. Comparison of dexamethasone with ondansetron or haloperidol for prevention of patient-controlled analgesia-related postoperative nausea and vomiting: A randomized clinical trial. World Journal of Surgery. 2012;36(4): Yun JS. Effects of amounts of intraoperative intravenous fluid administration on postoperative nausea and vomiting [master s thesis]. Daejeon: Chungnam National University; Summary Statement What is already known about this topic? Preoperative fasting is prerequisite for all patients who are undergoing surgeries, but it is related to postoperative nausea and vomiting. Dehydration may affect postoperative nausea and vomiting. What this paper adds? Our research identified that the amountof dehydration from preoperative fasting is the most significant factor that affects the extent of postoperative nausea and vomiting. Implications for practice, education and/or policy This study shows preoperative fasting causes postoperative nausea and vomiting. Time of midnight should be reorganized into new timing system for patients who undergo a surgery in different time period. Vol ,

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