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Danh gia phuang phap gay te dam roi than kinh canh tay ket hap vdi tien me (ketamin + seduxen) trong ph^u thuat chi tren 6
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Evaluating the efficacy of supraclavicular brachial- plexus anesthesia combined with pre-medication (ketamin + seduxen) on upper limb
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Nghien cdu tren 35 benh nhan (BN) tuoi td 7 - 13, can nang trung binh 33,74 + 7,89kg, phau thuat chi tren. Vo cam bSng gay te dam roi than kinh canh tay Lidocaine ket hop vdi tien te (ketamin + seduxen). Thoi gian phSu thuat trung binh: 49,54 ± 9,43; Thdi gian tac dung giam dau trung binh 82,36 ± 18 phut. Hieu qua vo cam tot: 82,85%, kha:11,45%, trung binh: 2,85%, kem: 2,85%. Khong gap tai bien, bien chiing va tac dung phu. Bdde dau nhan thay day la phUdng phap vo cam ddn gian, an toan, hieu qua vo cam tot, c6 the ap dyng cho cac phau thuat chi tren d tre em.
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Summary
We have studies 35 children ranging from 7 to 13 years of age, weigh average: 33.74 ± 7.89 kg who underwent upper limb surgeries. We applied Brachial- Plexus anesthesia with LiPocaine combined with pre-medicaeation (Ketamin+ Seduxen). Average duration of surgery and analgesia were 49.54 ± 9.43 min and 82.36± 18 min respectively. The excellent and good results were achieved in 82.85%, medium in 11.45% and failure were 2.85%. No serious complications and side effects. We concluded that Supraclavicular Brachial- Plexus anesthesia combined with pre- medicaeation (Ketamin-i- Seduxen) on upper limb surgery for childrens is simple, safe, effective and acceptable method. : ~
pnoVil CO iou r
L D a t v a n d e ' benh vien dia phuong cdn nhieu kho khan ve PhPOng phap gay te dam rdi than kinh canh phuong tien, trang thiet bi may moc va de khSc tay (DRTKCT) trong phau thuat chi tren d ngudi phuc nhu'ng nhupe diem cua gay me, chimg toi trudng thanh la phUOng phap vd cam dOn gian, an tien hanh nghien cdu gay te DRTKCT tren ddn toan, hieu qua, gia thanh re nen dope ap dung bang Lidoeain dOn thuan ket hpp tien te ketamin -i- rpng rai d trong nude cung nhu tren the gidi. Tren seduxen trong p h i u thuat chi tren d tre em nham 2 tre em, phUOng phap nay bUdc dau dupc ap dung muc dich:
d mpt sd benh vien nhi trung uong nhung con ft - Danh gia hieu qua vd cam cua phUdng phap nay.
nghien cdu ve no. Trong dieu kien ciia cac tuyen - Tim hieu cac tai bien, bien chLing,tac dung phu.
Phan bien khoa hpc: TS. NGUYEN MINH LY
2. Ddi ti/dng va p h i / d n g p h a p n g h i e n cufu 2.1. Ddi tugng nghien cdu
Gdm 35 Benh nhan (BN) phSu thuat chi tren tai Benh vien 2 1 1 , td thang 1/2009 den thang 6/2010, tudi 7-13, ASAl, ASAII, khdng cd chdng chi dinh TDRTKCT va dung cac thude ketamin, seduxen, lidoeain.
2.2. PhUdng phap nghien cUu
- Nghien edu tien cdu, md ta, cat ngang.
- Xd li so lieu theo phUOng phap thdng ke y hpc.
2.2.1. Ky thuat tien hanh
- Chuan bi BN: Tat ca cac BN phai dupc tham kham ky truPc md de' chpn dUa vao nghien cdu tren cO sd tieu chuan da dat ra.
- Dung cu, tbudc: Hop dung cu vd trung chuan bi cho gay te. Bom tiem 20ee. Thud'c te lidoeain 2%, ketamin, seduxen va cac thude hoi sde cap cdu.
- PhUOng tien may mdc cap cdu BN: den, dng ndi khi quan, may gay me...
- Ky thuat:
-r Dat dudng truyen, tiem tTnh mach ketamin 0,5mg/kg, atropinsunfat 5pg/kg, seduxen 0,1 mg/kg.
-I- Thd oxy 2 lit/phut.
-I- Gay te DRTKCT sau 2 phut theo ky thuat kinh dien cua Kulenkampff.
-I- Lieu thude te lidoeain 8mg/kg can nang -i- nuPc cat de the tich du 15 ml ddi vdi BN du'di 30kg, 20ml ddi vPi BN tu 30kg trd len.
-I- Sau gay te 7 phut thi!i test va tien hanh phiu thuat.
-I- Trong qua trinh phSu thuat benh nhan dupc ga ro tren vung md.
2.2.2. Theo ddi benh nhan
- Maeh (M), Huyet ap (H/A), tan sd hd hap, Sp02 trong sudt cupc md bang Monitoring da nang.
Ghi cac thong sd theo tOng thdi diem trUdc gay te (sau tien te): To, sau gay te: T l , T2, T3, T4, (Sau gay te d phut thO 10, 30, 50, 70 ). Rieng H/A, M chi dUa vao nghien cdu d hai thdi diem To va T2.
- Theo doi cac tai bien, bien chdng va tac dung phu (Ao giac, tdn thUOng than kinh, chpc vao dinh phdi, hdi chdng Claude- Bernard- Horner, liet day than kinh hanh, day than kinh quat ngppc, chpc vao mach m a u , ngd ddc thud'c) trong md va 6 gid dau sau m d .
2.2.3. Danh gia
- Thdi gian tac dung cua thude: td khi mat cam giac den khi cd cam giac dau tai vet md.
- Thdi gian phau thuat tfnh td bat dau rach da den khi ddng vet mo xong.
- Hieu qua vd c a m : DUa vao mdc dp vd cam cua Bromage (1967) va Kulkami (1998) chia thanh 4 mdc dp: tdt, kba, trung binh, kem.
3. Ket quS nghien cufu va ban luan
3.1. Dac diem cua ddi tugng nghien cdu 3.1.1. Tudi, can nang
B^ng 1: Phan bd tudi cua nhdm BN nghien cdu Tudi
7-8 9-10 11-13
Sd lupng (n=35 )
5 6 24
Tyle (%) 14,2%
17,2%
68,6%
A ' ± S D 10,94 ± 1,92
Can nang(kg)
18-25
B a n g 2: Can nang cua nhom BN nghien cdu Sd lupng
(n=35 ) 8
T y l e (%) 22,8%
A ' ± S D 33,74 ± 7,89
Y HOC VIET NAM SO PAC BIET THANG 10/2010
31-40 41-45
10 6
28,6%
17,2% •
- Tudi trung binh 10,94 ± 1,92, trong dd tudi td 7-10 chiem ty le thap (31,4%) do mpt sd BN trong nhdm tudi tren phai loai vi khong hpp tac vdi phuong phap vd cam. Benh vien khdng cd khoa nhi nen sd BN tren den vien cung ban che.
- Mac du tudi chu yeu 10-13 (68,6%) nhUng can nang trung binh ehi 33,74 ± 7,89 kg. Day la dieu kien thuan Ipi cho thpc hien ky thuat gay te.
3.1.2. Thdi gian phiu thuat
Thdi gian phSu thuat (phut)
30-40 41-50 51-60 61-70
B^ng 3: Thdi gian phau thuat Sd benh nhan
( n = 3 5 ) 6 13 12 4
T y l e (%) 17,2%
37,2%
34,2%
11,4%
X ± S D
49,54 ± 9 , 4 3
Thdi gian phau thuat ngan nha't: 30phut, dai nha't: 70 phut, trung binh: 49,54 ± 9,43 phut. Sd BN ed thdi gian phau thuat dai chu yeu la md gay phdc tap Idi cau xUOng canh tay, vdi thPi gian phau thuat tren phUdng phap vd cam cua chung tdi dap dng dupe yeu cau.
3.1.3. Vung phiu thuat
Bk
Vung phau thuat
Canh tay Khuy tay Cang tay Ban, ngdn tay
ng 4: Phan bd vung p h i u thuat Sd benh nhan
(n=35) 19
0 16
0
Ty le (%) 54,3%
0%
45,7%
0%
Ve mat benh chi gap phau thuat ket xUOng hoac lay phUOng tien ket xUOng d vung ckng tay (45,7%) va canh tay (54,3%) trong dd canh tay 100% la d Idi cau. Dieu nay cung phu hpp vPi benh ly chan thuong chi tren d tre em. NhU vay, vi tri phau thuat cua chung tdi la td 1/3 dudi canh tay trd xudng, day la vj trf thuan Ipi cho phi/Ong phap TDRTKCT tren ddn.
3.2. Hieu qua vo cam
Bang Hieu qua vd cam
Tdt Kha Trunq binh
Kem
5: Hieu qua vd cam Sd benh nhan (n= 35)
29 4 1 1
Ty le (%) 82,85%
11,45%
2,85%
2,85%
Thude tien te ketamin, vdi lieu va each dung trong nghien edu ve ly thuyet chi cd y nghTa giam dau, an than du de gay te va thdi gian chd tac dung eua tbudc te chd khdng anh hudng den viec danh gia hieu qua vd cam.
••• - Trong nghien cua cdu chung tdi, hieu qua vd cam tdt (82,85%), kha(11,45%), trung binh- kem (5,7%). Phil hpp vdi nghien cdu eua Dang Hanh Tiep [7] tren 222 BN 7-15 tudi md xd hoa eO deltoid bang TDRTKCT lidoeain 1 % (tdt: 82,9%, kha:
10,3%, trung binh - kem: 6,7%). Thap hon cac tac gia nghien cdu tren BN tru'dng thanh va cd sd
dung may do than kinh: Le Thi M S U Ddn [2] (tdt:
99%), Duong Van Doan [1] (tdt: 100%), Nguyen Van Hac [3] (tot: 95%), D6 Huy Hoang [5] (tot: 97%).
- 4 BN (11,45%) hieu qua vo cam kha, dau nhe d thi rach da chung tdi chi can dung them 4- 5ml lidoeain 1 % de te tai cho doe theo du'dng rach da, cupc md tien hanh thuan Ipi.
- 2 BN (5,7%) hieu qua vd cam trung binh- kem trong qua trinh gay te tim di cam khong ro rang. Cae BN nay phai chuyen phu'dng phap vo cam va khdng dUa vao nghien cdu: thdi gian tac dung vd earn va cac anh hudng ve hd bap, tuan hoan.
3.3. Thdi gian tac dung
B i n g 6: Thdi gian tac dung cua thuoc
O C - l H
oa-re
Thdi gian tac dung cua thud'c (phut)
40-60 61-80 81-100 101-120
Sd benh nhan (n= 33)
3 14 11 5
Ty le (%) 9 , 1 % 42,4%
33,3%
15,2%
X ± S D
82,36 ± 18,01
Thdi gian tac dung ngan nha't: 50 phut (1 BN), dai nha't: 120 phut, trung binh: 82,36 ± 18,01.
- ThPi gian tac dung cua chung toi ngan hOn cac tae gia: DUOng Van Doan [1] (168±7), Nguyen Van Hac [3] (150 ±7), Mai Van Thanh [8] (160,35 ±7,33), Bui Quang LUu [6] (178,2 ± 20,3), Dd Huy Hoang [5]
(138,63 ± 6,82). Tuy nhien, cac tac gia nay deu ket hpp giu'a lidoeain vdi eac thud'c: Adrenalin, prostigmine, fentanyl hoac Buplvacaine. ; • : .,
i. 3.4. Sl/thay doi huyet ap trung binh (HATB), tan sd tim ;• r v B i n g 7: Thay ddi HATB va tan sd tim
Thdi diem
TO T2 P
HATB (mmHg) n=33 Thap
nha't 40 35
Cao nha't 75 76
X ± S D 54,69 ±9,27
52,45±9,66
>0,05
Tan s d maeh (chu ky/phut) n=33 Thap
nha't 85 75
Cao nha't 130 105
A ' ± S D 96,84±14,6 84,79±10,73
<0,001
Khao sat HATB, tan sd mach d hai thdi diem: cam cua chung tdi n g l n nha't 50 phut, thdi gian TO, T2 nham danh gia anh hu'dng cua phuong phau thuat ngan nha't 30 phut va sau gay te 30 phap vd cam den tim mach vi thdi gian tac dung vd phut thi HA, mach cua BN dn dinh nha't .
Y HOC VIET NAM SOPAC BIET THANG 10/2010
- d nghien cdu chung toi HATB tai TO (54,69
±9,27) cd cao hOn T2 (52,45±9,66) nhUng sU khae biet khdng cd y nghTa thdng ke (p > 0,05). Tan sd mach tai TO (96,84±14,6 ) cao hdn co y nghTa thdng ke (p< 0,001) so vdi T2 (84,79±10,73 ).
- TrUdc gay te do tac ddng eua tam ly lo sp, dau d vung ton thUOng, tac dung cua ketamin, atropin nen tan sd tim tang cd y nghTa thdng ke, nhung HATB tang khong dang ke. Sau gay te nhd tac dung giam dau cua gay te, thuoc an than, BN thay thoai mai nen mach cham hon, HA dn dinh.
3.5. Danh gia'sd thay ddi tan sd thd, do bao hda oxy mau (SPO2) qua cac thdi diem Bang 8: SU thay ddi tan sd thd, Sp02 mau qua cac thPi diem
Thdi diem
(To) ( T l ) (T2) (T3) (T4)
So benh nhan (n= 33)
33 33 33 33 22
Tan sd thd X ± SD 18,70 ± 1,21 18,68 ± 1,21 18,71 ± 1,31 18,63 ± 1,21 1 8 , 6 2 ± 1,11
SpOa X ± S D 98,32 ± 0,26 98,87 ± 0 , 5 2 98,93 ± 0,69 98,17 ± 0 , 2 9 98,87 ± 0 , 8 7
P
>0,05
Tan sd thd, dp bao boa oxy trong mau trUdc gay te, sau gay te va d cac thPi diem khac nhau thay ddi khdng cd y nghTa thdng ke( p>0,05). Nhu vay, phaong phap vd cam cua chung toi khong. anh hu'dng den hd hap, phu hpp vPi nhan xet cua cac tac gia: Duong Van Doan [1], Le Thi Mau Ddn [2].
3.6. Tac dijng phy
Bang Tac dung phu
Ao giac Ngd ddc thud'c Ton thuong than kinh Liet day than kinh hoanh Liet day than kinh quat ngUpc Hdi chdng Claude - Bemard - Homer Choc vao dinh phdi
Chpc vao mach mau
9: Cac tac dung phu Sd benh nhan (n= 35)
2 0 0 0 0 0 0 2
Ty le (%) 5,7%
0%
0%
0%
0%
0%
0%
5,7%
Trong nhdm BN nghien cdu khdng gap liet day than kinh hoanh, day than kinh quat ngupc, hpi chdng Claude - Bernard - Horner. Cae tae gia khac: Dang Hanh Tiep [7] (khan tieng: 2,7%; hdi chbng Claude - Bernard - Horner: 68,4%), Mai Van Thanh [10] (khan tieng: 6,25%; hpi chufng Claude - Bernard - Horner: 9,4%), Bui Quang Luu [6] (khan tieng: 4,76%; hpi chdng Claude - Bernard - Horner:
7,14%). Cac tac gia nay deu TDRTKCT qua du'dng
gian cd bac thang va the tich thude te 20-30ml.
NhU vay vPi the tich 15 - 20ml thude te va DRTKCT qua diem tren xudng ddn cua chung tdi khdng cd bien chdng do lan toa thud'c.
- Khdng cd trudng hpp nao chpc vao dinh phdi, ngd dpc thuoc, tdn thudng than kinh. Du'dng Van Doan [1](2,5%) va Le Thi Mau Don (0,5%) giap tran khi mang phdi.
- 2 BN (5,7%) chpc vao mach mau phat hien khi hilt thCf bdm tiem xu ly bang each rut bdt kim ra, chinh lai hudngva bdm thud'c te, khdng ed trudng hpp nao bi mau tu tai chd, ty le nay tu'Ong dUdng vdi Dd Huy Hoang [5](5%), Bui Quang LUu [6](4,76%).
- 2 BN (5,7%) bi ao giac sau mo nhu'ng chi thoang qua la 2 BN hieu qua vd cam trung binh - kem. Kha nang do tae dung eua ketamin dung them khi chuyen phUdng phap vo cam.
- Nhu vay, phUdng phap vo cam cua chung tdi khong gap cac tai bien, bien chdng thong thudng va nghiem trpng nao.
4. Ket luan
Nghien cdu 35 BN tudi 7-13, can nang trung binh 33,74 ± 7,89, vo cam bang tien te ketamin -i- seduxen ket hpp gay te DRTKCT 8mg/kg can nang lidoeain ddn thuan de phau thuat chi tren (canh tay: 54,3%, cang tay: 45,75) thu dUpc ket qua sau:
- ThPi gian phSu thuat trung binh: 49,54±9,43.
Hieu qua vo cam tdt: 82,85%, kha: 11,45%, trung binh: 2,85%, kem: 2,85%. Thdi gian tac dung vd cam trung binh: 82,36 ± 18,01.
- Khong gap cac tai bien, bien chdng thdng thUPng cung nhU nghiem trpng nao.
Tai li^u tham khao
1. Duong van Doan (1986), Gay te DRTKCT eo hudng dan theo Kulenkamff. Luan vSn tdt nghiep Bae sy CKI gay me hdi sde - Benh vien Viet Oirc.
2. Le Thi Mau Don (1975), Kinh nghiem gay te DRTKCT tren xUdng ddn trong phau thuat chi tren Tap chf Y hpc thUc hanh, Bd Y te.
3. Nguyen Van Hac (2001), Oanh gia bleu qua cua phuong phap gay te DRTKCT qua dudng gian co bac thang, bang Lidocaine. Luan van thac sy Y hpc - Dai hpc Y Ha Npi.
4. Dd Xuan Hpp (1973), Day than kinh cua chi tren, giai p h i u thuc dung ngoai khoa td chi. Hpc vien Quany, t r . 6 8 - 7 1 .
5. Do Huy Hoang (2001), So sanh tac dung cQa lidoeain vdi bupivacain trong gay te dam rdi than kinh canh tay de p h i u thuat cSng ban tay. Luan van thac sTY hpc. Hpc vien Quan y.
6. Bui Quang Luu (2006), Danh gia tac dung gay te dam rdi than kinh canh tay qua dudng gian co bac thang bang buplvacaine ket hpp vdi lidocaine va prostigmine trong phau thuat chi tren. Luan van tdt nghiep bac sT chuyen khoa cap II, Hpc vien Quan y. ' . ' , '
7. Dang Hanh Tiep (2006), Nghien curu ap dung gay te dam rdi than kinh canh tay khe co bac thang bang lidoeain 1 % pha adrenalin 1/200.000 trong phau thuat xo hda co deltoid d tre em. Tap chi Y hpc thuc hanh, Bd Y te.
8. Mai van Thanh (2004), Gay te DRTKCT bang Lidocaine phd'i hpp vdi Neostigmine dudng gian CO bac thang, trong p h i u thuat chi tren. Luan van thac sy Y hpc, Hpc vien Quan y.
9. Kulenkampt f.f. D. (1998), Die anasthesierung des plexus brachial zentralble. Chir. 38, pp. 1337.
10. Bromage PR. (1967), Spread of analgesic solutions in the epidural space and their site of action a statistical study. Brit J. Anaesth. 734:161.
