發(fā)布時間：2018-06-16 13:36

  本文選題：喉罩 + 氣管插管��； 參考：《南方醫(yī)科大學》2017年碩士論文

【摘要】：開胸手術是現(xiàn)代胸外科所面臨的一項常規(guī)手術方式。但對于開胸手術,目前仍存在諸如術中切口大、并發(fā)癥較多以及對待患者機體創(chuàng)傷較大導致的患者康復難度大等弊端。然而隨著現(xiàn)代醫(yī)學的發(fā)展,成像技術的清晰化,光學設備的細致化,相關手術器械的專業(yè)化,使得胸腔鏡手術在胸外科這一領域得到快速發(fā)展。胸腔鏡技術在過往只是一種診斷技術,而現(xiàn)如今已成為了主要的新型外科治療手段,應用范圍之廣已覆蓋了胸外科醫(yī)療領域的多個方面,對于診斷評估以及治療具有重要幫助價值,其顯著的手術優(yōu)點在于手術時間無明顯限制�，F(xiàn)代胸腔鏡手術優(yōu)點甚多,其中存在諸多明顯優(yōu)勢,保證了術中患者生命體征的平穩(wěn),同時患者生理指標影響較小以及短時間內能夠恢復。雖然許多胸腔鏡手術(VATS)肺葉切除術已經進行了 12年,但第一次VATS肺葉切除術,該程序沒有得到廣泛接受。在美國每年進行的4萬例肺葉切除術中,約5%使用VATS進行。來自世界各地的各種作者已經出版了多份病例報告,報告了該手術的安全性及其巨大優(yōu)勢。然而,一些胸外科醫(yī)生更加關注該手術的安全性和相關的發(fā)病率和死亡率。在迄今為止最大的系列報告中,介紹了這一系列病例來評估這些問題。近年來,有不少臨床實踐顯示了氣管插管可引起諸多相關風險,為了規(guī)避這些風險,國內外相關領域學者報道了在患者硬膜外麻醉的有意識狀態(tài)下,行胸外科手術的一些經驗。這些研究結果最終表面:在患者的非單肺通氣下行硬膜外麻醉,同時可完整保留患者自主呼吸功能,此時可以行小型胸外科手術操作。國外學者Ambrogi,曾報道了八例采用新型胸腔鏡手術治療氣胸的患者,均采用側臥位喉罩通氣,保持自主呼吸,最終患者預后良好。但這種新型的胸腔鏡手術方法未完全證實其安全性,迄今缺乏關于術后生存質量的研究。因此,有必要對其術后相關效應與氣管插管麻醉對照組行相關臨床研究,闡明患者術后獲益。目的和意義由于之前文獻報道了許多非氣管插管條件下,患者行胸腔鏡手術的經驗,我們進行了這項臨床隨機對照實驗,主要將患者置于全麻條件下,行小型胸腔鏡手術,來治療患者非小細胞肺癌,通過患者預后等數(shù)據(jù),評估其手術方式的可行性及安全性。同時,為將來可進行喉罩與氣管插管全麻用于非小細胞肺癌根治術的臨床研究,提供一些相關經驗和相關臨床數(shù)據(jù)指導。另外,本次臨床研究創(chuàng)新性地使用了 FACT-L生存質量量表對患者術后生存質量進行評價,提高了實驗研究的可信度并且這一量表現(xiàn)已國際通用。研究方法回顧性分析我院2016年03月09日至2016年08月25日間40例非小細胞肺癌根治術患者的臨床資料,其中喉罩組20例,氣管插管組20例,比較兩組患者術后恢復情況、全身炎癥反應和術后生存質量等指標。1.患者麻醉1.1通過喉罩采用全麻組麻醉方式所有患者在知情同意后,采取30°半臥位進行麻醉,麻醉前,通過纖支鏡和支堵塞器等相關器械進行,目的是必要時可快速行氣管插管。麻醉前30分鐘霧化吸入2%利多卡因10毫升。進入手術室后持續(xù)監(jiān)測心電圖(ECG)、心率(HR)、血壓(Bp)、脈搏氧飽和度(Sp02)、呼吸頻率(RR)、腦電雙頻譜指數(shù)和尿量。麻醉誘導方式采用了:患者提前量泵入右旋美托咪啶(0.3微克/公斤),然后泵入異丙酚(維持維持血漿目標濃度為于2.5微克/毫升),以及瑞芬太尼(維持血漿目標濃度為于3納克/毫升)。麻醉維持處理:監(jiān)測患者的腦電雙頻指數(shù)(腦電雙頻譜指數(shù)),將其維持在40到60左右�；颊哽o脈內泵注:異丙酚藥劑(維持血漿1.5到3微克/毫升)以及瑞芬太尼(維持血漿目標濃度為2到4.5納克/毫升),切皮操作前,靜脈內給予舒芬太尼(0.15微.克/公斤)。胸腔鏡術中關閉胸腔前,再次給予舒芬太尼(0.1微克/公斤)。術后,判斷清醒時間,以呼喚患者可睜眼為標準,最終麻醉技師決定拔除喉罩的時機,并在復蘇室內拔除患者喉罩后,入住ICU進行維持處理。1.2氣管插管全麻組麻醉方式所有納入研究的患者,均取健側臥位行麻醉處理。麻醉監(jiān)測方法同喉罩組一致。麻醉誘導方法,采用了右旋美托咪啶(0.6微克/公斤)處理,然后再次分別泵入異丙酚藥劑(維持血漿目標濃度為3-3.5微克/毫升)以及瑞芬太尼藥劑(維持血漿目標濃度為4-6納克/毫升),順阿曲庫銨藥劑(0.2毫克/公斤)。患者氣管插管后將呼吸機設置為:潮氣量8到10毫升/公斤,呼吸頻率為15次/分鐘,吸呼比率為1:2,吸氧濃度50%,維持PetCO2在28到35毫米汞柱,手術后即立刻開始后行單肺通氣。麻醉維持時,腦電雙頻譜指數(shù)為40到60,患者靜脈泵注異丙酚(維持血漿目標濃度為2到4微克/毫升),瑞芬太尼(維持血漿目標濃度為4-6納克/毫升),切皮前追加舒芬太尼0.15-0.2微克/公斤。根據(jù)手術需要追加順阿曲庫銨0.05毫克/公斤,胸腔鏡術中關閉胸腔前,追加舒芬太尼0.1微克/公斤。手術期間,保持患者氧飽和度≥90%。術后,判斷清醒時間,以呼喚患者可睜眼為標準,最終麻醉技師決定拔除喉罩的時機,并在復蘇室內拔除患者喉罩后,入住ICU進行維持處理。2.胸腔鏡手術手術中設置胸腔鏡的觀察孔,主要位于患者腋前線的第7肋間,而常用的手術切口在3-4肋間,手術的輔助操作孔常位于腋后線的第9肋間。術側胸壁切口使肺萎陷并造成醫(yī)源性氣胸后,于肺表面噴灑2%利多卡因5-10毫升,術者在胸腔鏡直視下,迷走神經胸部干(右側位于奇靜脈弓上方氣管表面;左側位于肺根上方升主動脈表面縱隔胸膜下)、膈神經(左右兩側膈神經從縱膈胸膜與心包之間下行到達膈,最終于中心腱附近穿入膈)、切口肋間神經注射2%利多卡因2-3毫升;當考慮行肺葉切除或預計手術時間超過2小時,可使用0.5%羅哌卡因,且術中每2小時間中給藥。肺葉切除程序與常規(guī)胸腔鏡手術無異。手術關閉胸膜腔并縫合切口后,面罩輔助加壓通氣,并且輔助吸引器吸引胸管幫助肺組織膨脹。同時停止靜脈輸注藥物,轉送麻醉恢復室,待患者蘇醒后,即可安返病房。氣管插管全麻組手術過程按照普通雙腔氣管插管麻醉過程進行。3.術后止痛及護理對照組和實驗組的術后管理基本保持一致,其共同的施行方法為:術后止痛處理采用留置患者自控鎮(zhèn)痛泵以及非甾體類止痛藥處理。在患者術后當天,或者第一天清晨時攝X線胸正位片。對照組和實驗組患者全部允許在拔除喉罩或者氣管導管后,2到4小時內恢復進食及飲水。此外,胸腔的閉式引流順暢時,提示無漏氣,同時24小時內的引流量≤100毫升,便可拔除患者胸導管。研究內容及過程1.研究內容1.1術中部分記錄手術時間、術中失血情況以及血氣分析實時結果,術野暴露效果和麻醉效果評分均給予記錄。1.2術后部分返回病房后,記錄患者術后開始進食和下地活動的時間,術后使用抗生素時間(以無肺部感染癥狀、體征以及術后白細胞將至正常為標準,停用抗生素),胸管留置時間,術后住院時間,術后患者生存質量評分。手術前后72小時抽血檢測白細胞、中性粒細胞百分比、超敏C反應蛋白水平。麻醉滿意度評分:1分:麻醉非常完善:患者無痛感、表現(xiàn)安靜,手術過程良好,血流動力學一直保持相對穩(wěn)定;2分:麻醉欠完善,患者有輕度疼痛表現(xiàn),需術中用鎮(zhèn)靜劑處理,血流動力學有非病理改變引起的波動;3分:麻醉不完善,患者有疼痛明顯,呻吟躁動,在手術中輔助用藥處理后,情況才有所改善,但整體不夠理想,勉強完成操作;4分:需改用另外的麻醉方式,才能完成手術。手術視野滿意度評分:1分:術中野暴露充分滿意,便于完成手術;2分:手術視野比較充分且清晰,同時肺塌陷一般,但無需中斷手術另行處理;3分:手術視野暴露較差,患者肺塌陷不滿意,大部分時間需要中斷手術操作來處理手術視野:4分:手術視野暴露較差,以致無法進行相關手術,改行插管手術。本研究首次使用了評估肺癌患者的生存質量的FACT-L量表,FACT-L量表能對患者進行完整的術前、術后的生活質量進行可靠地評估[4,5]�；颊呤紫纫邮茚t(yī)師和護士的指導,隨后使用FACT-L量表,采取自填和問詢結合的方式,完整評估患者生存質量,包括情緒改變、角色類型、軀體功能和社會交往活動等情況進行相應的評分。得分與生活質量正相關,兩組患者在術后1周均全部進行問卷調查。2.研究過程2.1 一般資料本研究選取2016年03月09日至2016年08月25日于南方醫(yī)科大學南方醫(yī)院(以下簡稱“我院”)行肺癌根治術(肺葉切除+系統(tǒng)淋巴結清掃術)的患者共40例為研究對象,所有納入研究的患者麻醉評分(美國ASA評分標準)≥3分,BMI25,且無凝血障礙、心肺功能異常等。排除標準:患者有精神疾并、協(xié)作性差,血容量不足難以手術、血液系統(tǒng)疾病等難以手術的血液病患者。肺葉切除術入選標準按照陳進興報道標準[3]:術前或術中冰凍確診為非小細胞肺癌患者,腫瘤最大直徑小于6cm,并且無侵犯胸壁、隔肌、心包、主氣管等組織。按不同麻醉方式將患者分為使用喉罩全麻的研究組(20例)和使用氣管插管全麻的對照組(20例)。研究組男11例,女9例,平均年齡(54.6±15.2)。對照組男12例,女8例,平均年齡(51.6±12.0)。兩組患者的性別比、平均年齡、吸煙史、BMI值、ASA評分等的差異,無統(tǒng)計學意義(P值0.05),未顯示其明顯的患者個體差異性。2.2患者分組與手術進行采用Excel軟件進行患者隨時的分組,實驗組,行喉罩條件下(采用小潮氣量高頻雙肺通氣)全麻下行胸腔鏡手術,對照組,在雙腔氣管插管(全麻單肺通氣下),行胸腔鏡手術治療。記錄術中評估指標及術后恢復情況。2.3數(shù)據(jù)分析本次實驗所得的計量資料,均采用均數(shù)(Mean)±標準差(SEM)進行描述,兩組間的差異在方差齊性檢驗通過后,采用t檢驗的方法進行。計數(shù)資料用百分率表示,組間差異比較采用卡方檢驗。所有數(shù)據(jù),均采用SPSS軟件分析,a設置為0.05認為其差異有統(tǒng)計學意義。結果所以患者均手術順利無明顯事故出現(xiàn),無手術死亡患者,對照組和實驗組的手術時間、最低氧飽和度、最高呼氣末的二氧化碳分壓、手術視野和麻醉滿意度、失血量方面,無明顯的統(tǒng)計學差異。喉罩組患者術后進食時間、抗生素使用時間、術后住院時間均短于氣管插管組;喉罩組手術前后白細胞數(shù)量(計數(shù))、中性粒細胞百分比(%)和超敏C反應蛋白升高數(shù)值(計數(shù))均低于氣管插管組;喉罩組患者在術后生理狀況、附加狀況及生活質量總分等方面高于氣管插管組,兩組對比有統(tǒng)計學差異。結論:喉罩全麻胸腔鏡手術治療非小細胞肺癌具有良好的可操作性和安全性,同時在降低全身炎癥反應、加快術后康復、提高患者術后生存質量方面具有一定的優(yōu)越性。
[Abstract]:Thoracotomy is a routine surgical approach in the modern department of thoracic surgery. However, there are still disadvantages such as large incision, more complications and more difficulty in treating patients with greater trauma. However, with the development of modern medicine, the clarity of imaging technology and the meticulous of optical equipment With the specialization of related surgical instruments, thoracoscopic surgery has developed rapidly in this field in the Department of thoracic surgery. Thoracoscopy is a diagnostic technique in the past, and now it has become a major new surgical treatment. The wide range of applications has covered many aspects of the medical field in the Department of thoracic surgery, for diagnostic evaluation and The advantage of the treatment is that the operative advantage is that there is no obvious limitation on the operation time. There are many advantages of modern thoracoscopic surgery. There are many obvious advantages, which guarantee the stability of the vital signs of the patients during the operation, and the effect of the patient's physiological index is small and the short time can be restored. Although many thoracoscopic surgery (VATS) Lobectomy has been carried out for 12 years, but the first VATS lobectomy has not been widely accepted. In the United States, about 5% of the 40 thousand cases of lobectomy per year in the United States use VATS. Various authors from all over the world have published a number of case reports on the safety and great advantages of the operation. However, however, Some thoracic surgeons have paid more attention to the safety and associated morbidity and mortality of the operation. In the largest series of reports to date, this series of cases have been introduced to assess these problems. In recent years, many clinical practices have shown that tracheal intubation can cause many related risks to avoid these risks, related to these risks at home and abroad. The field scholars reported some experience in the Department of thoracic surgery operation in the conscious state of epidural anesthesia in patients. These findings finally surface: the patient's epidural anesthesia in the patient's non single lung ventilation and the complete retention of the patient's autonomic breathing function can be performed at this time in a small department of thoracic surgery operation. Foreign scholar Ambrogi, once reported Eight cases of pneumothorax treated by new thoracoscopic surgery were used in the lateral position of laryngeal mask ventilation to maintain self breathing and the patient had a good prognosis. However, this new method of thoracoscopic surgery did not completely confirm its safety. So far, there is no study on the quality of life after the operation. Therefore, it is necessary for the postoperative related effects and trachea intercalation. The clinical study of the anesthesia control group was conducted to clarify the postoperative benefit of the patients. Objective and significance, because of the previous literature on many non tracheal intubation conditions, patients underwent thoracoscopic surgery. We conducted this clinical randomized controlled trial mainly to put patients under general anesthesia and perform small thoracoscopic surgery to treat patients. For small cell lung cancer, the feasibility and safety of the surgical methods are evaluated through the patient's prognosis. At the same time, some relevant experience and related clinical data can be provided for the clinical study of laryngeal mask and tracheal intubation general anesthesia for non small cell lung cancer in the future. Moreover, this clinical study uses FACT-L students innovatively. The quality of life of the patients was evaluated by the memory quality scale, and the reliability of the experimental study was improved and the performance of this measurement was international. The clinical data of 40 patients with non small cell lung cancer from 09 to 08 month 2016 2016 were analyzed retrospectively, including 20 cases in the laryngeal mask group and 20 cases in the tracheal intubation group. The postoperative recovery, systemic inflammatory response and postoperative quality of life of the two groups of patients in the two groups were anaesthetized 1.1 through the general anesthesia of the laryngeal mask and all the patients in the general anesthesia group. After the informed consent, the anesthesia was taken in the 30 degree semi decubitus position, before anesthesia, through the fiberoptic bronchoscope and the branch blocker and other related instruments. Tube intubation. 30 minutes before anesthesia inhalation of 2% lidocaine 10 ml. After entering the operation room, continuous monitoring of electrocardiogram (ECG), heart rate (HR), blood pressure (Bp), pulse oxygen saturation (Sp02), respiratory frequency (RR), EEG bispectral index and urine volume. Anesthesia induction method was used: patients were pumped into dexmedetomidine (0.3 microgram / kilogram), and then pump Propofol (maintaining a plasma target concentration of 2.5 micrograms per milliliter) and remifentanil (maintaining a plasma target concentration of 3 ng / ml). Anesthesia maintenance treatment: monitoring patients' EEG bispectral index (EEG bispectrum index) and maintaining it at about 40 to 60. Intravenous infusion of propofol (maintaining plasma 1.5 to 3 micrograms) G / ml) and remifentanil (maintaining a plasma target concentration of 2 to 4.5 ng / ml) and sufentanil (0.15 microgram / kg) before the skin cutting operation. Before the thoracoscopy closed the thoracic cavity, sufentanil was given again (0.1 micrograms per kilogram). After the operation, the waking time was judged in order to call the patient to open the eyes as the standard, and eventually the anesthetist decision was made. The time to remove the larynx was determined, and after the laryngeal mask was removed in the resuscitation chamber, all the patients who were in the ICU and the.1.2 tracheal intubation group were all anaesthetized. The anesthetic monitoring method was the same as that of the laryngeal mask group. The anesthesia induction method was treated with dexamethodine (0.6 microgram / kg). Then pump the propofol (3-3.5 microgram / milliliter) and remifentanil (4-6 ng / ml) and CIS atracurium (0.2 mg / kg). After tracheal intubation, the ventilator was set up to 8 to 10 ml / kg, and the respiratory rate was 15 times per minute. The respiratory rate was 1:2, the oxygen concentration was 50%, and the PetCO2 was maintained at 28 to 35 mm Hg. After the operation, the single lung ventilation was immediately started. The EEG bispectral index was 40 to 60 when the anesthesia was maintained. The patient was injected with propofol (2 to 4 micrograms per milliliter in plasma target concentration), and rifentanil (maintenance of the plasma target concentration of 4-6 ng / ml) and the skin cut. 0.15-0.2 microgram / kg of sufentanil was added before the operation. According to the operation, 0.05 mg / kg of CIS atracurium was added, and 0.1 micrograms / kg of sufentanil before the thoracoscopy was closed, and 0.1 micrograms per kilogram were added to the sufentanil. During the operation, the patient's awake time was judged by keeping the patient's oxygen saturation more than 90%., so that the patient could open the eyes as the standard, and finally the anesthetist decided to pull out the anesthesia. In addition to the timing of the laryngeal mask, and after the removal of the laryngeal mask in the resuscitation chamber, the observation hole in the ICU for the maintenance treatment of.2. thoracoscopic surgery is located mainly in the seventh ribs of the frontline of the patient, while the common operative incision is in the 3-4 intercostal space, and the operative holes are often located in the ninth intercostal intercostal line of the posterior axillary line. The thoracic wall incision makes the lung After collapsing and causing iatrogenic pneumothorax, 2% lidocaine was sprayed on the lung surface, and 5-10 ml of lidocaine was sprayed on the lung surface. The pericardial nerve (the right was located on the surface of the trachea above the arch of the odd vein, and the left is located under the mediastinal pleural surface of ascending aorta above the root of the lung), and the phrenic nerve (the right and left phrenic nerve descended from the mediastinal pleura to the pericardium to the pericardium to the right. 2% lidocaine was injected into the intercostal nerve and 2-3 ml of lidocaine was injected into the intercostal tendon. 0.5% ropivacaine was allowed to be treated with 0.5% ropivacaine and was given every 2 small time during the operation. The lobectomy procedure was not the same as that of the conventional thoracoscopic surgery. The pleural cavity was closed and the incision was sutured after the operation. The cover assisted pressure ventilation, and the auxiliary suction apparatus attracted the chest tube to help the lung tissue expansion. At the same time, the intravenous drug was stopped and the anesthesia recovery room was transferred. After the patients woke up, the operation process of the tracheal intubation general anesthesia group was treated with the common double lumen tracheal intubation process for the pain relief and the nursing control group and the experimental group after.3.. Postoperative management was basically consistent, and the common method was: postoperative analgesic treatment was treated with a self controlled analgesia pump and a non steroidal painkiller. The X-ray chest radiographs were taken on the day after the operation, or at the morning of the first day. All patients in the control group and the experimental group were allowed to remove the laryngeal mask or trachea, 2 to 4 hours after the removal of the laryngeal mask or tracheal tube. In addition, when the closed drainage of the thoracic cavity was smooth, there was no air leakage, while the amount of drainage within 24 hours was less than 100 milliliters, the thoracic duct could be removed. The content and process of study and process 1. were studied in part 1.1, the operation time, the blood loss and the blood gas analysis in real time, the effect of the operation and the anesthetic effect of the operation field, the operation field and the anesthetic effect. The score of the fruit score was recorded after a partial return of the ward to the ward after.1.2, and the time for the patients to start eating and going down after the operation, the time of antibiotic use (with no pulmonary infection symptoms, signs and the standard of postoperative leukocytes to normal, the discontinuation of antibiotics), the retention time of the thoracic duct, the postoperative hospital stay, and the quality of life score of the postoperative patients. 72 hours before and after the operation to detect white blood cells, neutrophils percentage, hypersensitivity C reaction protein level. Anesthesia satisfaction score: 1 points: the anesthesia is very perfect: the patient has no pain, is quiet, the operation process is good, the hemodynamics remains relatively stable; 2: the intoxication is not perfect, the patient has mild pain performance, it needs the tranquilizer in the operation. Treatment, hemodynamics have non pathological changes caused by the 3 points: incomplete anesthesia, patients with obvious pain, moaning and restlessness, in the operation of adjuvant treatment, the situation is improved, but the whole is not ideal, barely complete the operation; 4 points: the need to use another way of anesthesia, to complete the operation. Visual field satisfaction score: 1 points: 1: In the operation, the operation was satisfactory, and the operation was easy to complete. 2 points: the operation field was full and clear, and the lung collapse was common, but there was no need to break the operation. 3 points: the operation field of vision was poor, the patients were dissatisfied with the lung collapse, and most of the time needed to break the operation to deal with the operation field of vision: 4 points: the operation field of vision was poor, so that there was no The first use of the FACT-L scale to assess the quality of life of the patients with lung cancer was first used in this study. The FACT-L scale was able to complete the patient's pre operation, and the quality of life after the operation was evaluated reliably for the [4,5]. patients first to receive the guidance of the doctors and nurses, and then the FACT-L scale was used to fill in and ask questions. A complete assessment of the quality of life of the patients, including emotional changes, role types, physical function and social interaction, was assessed. The score was positively related to the quality of life. The two groups were all surveyed in the 1 week after the operation in the.2. study process 2.1 general data from 09 to 2016 from 03 months of 2016. A total of 40 patients underwent radical resection of lung cancer (lobectomy + systematic lymphadenectomy) at the Southern Hospital of Southern Medical University (hereinafter referred to as "our hospital") on 25 days of 08 January. All the patients enrolled in the study (American ASA score standard) were more than 3, BMI25, without coagulation disorders, and abnormal cardiopulmonary function. The exclusion criteria: Patients There are mental disorders, poor cooperation, lack of blood volume and difficult operation, hematological diseases, and other Unoperable blood diseases. The standard of lobectomy for lobectomy is according to Chen Jinxing's standard [3]: Patients with non-small cell lung cancer diagnosed before or during the operation, the maximum diameter of the tumor is smaller than 6cm, and there is no invasion of the chest wall, septum, pericardium, and main trachea. The patients were divided into the study group (20 cases) using laryngeal mask general anesthesia (20 cases) and the control group using tracheal intubation general anesthesia (20 cases). The study group was 11 men and 9 women, with the average age (54.6 + 15.2). The control group was 12 men, 8 women, the average age (51.6 + 12). The average age, smoking history, BMI value, ASA score, and so on. The difference was not statistically significant (P value 0.05). The patients who had no distinct individual difference in.2.2 were divided into groups and operated by Excel software at any time, in the experimental group, under the laryngeal mask condition (using the high frequency and high frequency double lung ventilation) under general anesthesia under general anesthesia, the control group, and the double lumen tracheal intubation (the single lung ventilation with general anesthesia). Video-assisted thoracoscopic surgery. Intraoperative evaluation and postoperative recovery were recorded..2.3 data analysis.
【學位授予單位】：南方醫(yī)科大學
【學位級別】：碩士
【學位授予年份】：2017
【分類號】：R614;R734.2

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