TAP CHl Y DL/CyC L A M S A N G 108 Tap 9 • S6 2 /2014
Danh gia tac dung cua gay te tuy song bang hon hop Bupivacain va Morphin trong phiu thuat cSt tir cung
Evaluating the Effect of Spinal Anesthesia Method with a Mixture of Bupivacaine and Morphine in Subtotal Hysterectomy
Pham Hung, Le Sau Nguyen Bo mon Gdy me hoi si'cc - Truong DH Y Dime Thdi Nguyen
Tom t S t :
Muc tieu: Gdnh gia tac dung giam dau cua gay te tuy sdng bang hdn hpp bupivacain va morphin trong phau thudt cdt tU eung va taC dung khdng mong mudn cua phuang phap. Doi tugng vd phuang phdp nghiin cdu: Thiet ke md td tien cUu, phdn tich tren 50 benh nhan eo ASA 1 -2, tudi tU 18 - 60, khong cd chdng ehi dinh vdi gay te tuy song, cd chi dmh phau thuat cat tU cung cd ke hoach tai benh vien Oai hpc Y - Dupe Thdi Nguyen. Cac benh nhan khdng dung thudc tien me, duac chi dmh choc kim gay te 6 khe L2-L3, dupc tiem hdn hppthudcBupivacain lieu 0,2mg/kg + 0,1 mg morphin. /Cef qud;Phuang phdp gay te tuy sdng bdng hdn hop bupivacain va morphin trong phau thuat cat tCf cung cho ket qua tdt. Thdi gian tiem tang Uc che cdm giac dau d mUcTlO la 3,26 ± 0,47 phut. Thdi gian vo cdm la 122,32 ± 15,5 phut, 100% benh nhan dat mUc gidm dau tdt de phau thuat. Thdi gian gidm dau sau mo cua nhdm nghien cUu la 23,06 ± 0,8 gid. Benh nhan budn ndn trong md 2%, run 4% ngUa 4%. Sau md khdng cd b^nh nhdn bj non vd budn ndn, 4% cd trieu"chUng ngUa, 2% benh nhan bi bi tieu.
TUkhda: Gay te tuy sdng, bupivacain, morphin
Summary:
Objectives: To evaluate the analgesic effect of spinal anesthesia with a mixture of bupivacaine and morphine and its side effects in prepared subtotal hysterectomy. Subjects and methods: A prospective observational study, analyzing on 50 patients with ASA 1-2, aged 18-60, without contraindication for spinal anesthesia, who had prepared subtotal hysterectomy at Thai Nguyen University of Medicine and Pharmacy Hospital. The patients were not taken premedication and indicated the needle at L2 - L3 slot, injected the mixture with the dose of bupivacaine 0.2 mg/kg + 0.1 mg morphine. Results: This method achieved good results. The analgesic latent duration at TIO was 3.26 ± 0.47 minutes. The insensitive duration was 122.32 ± 15.5 minutes. 100% of patients achieved a good level of analgesia for surgery. The pain-relief duration after the surgery was 23.06 ± 0,8 hours. During the surgery, the patients who had nausea took up 2%, with shakes - 4%, and itchiness - 4%. After the surgery, there was no patient suffering from vomiting or nausea; those with itchiness accounted for 4% and with urinary retention - 2%.
/feywords; Spinal anesthesia, bupivacaine, morphine
Ph^n bi^n khoa hpc: POSTS PHAN DINH KY
JOURNAL OF 108- CLINICAL MEDICINE AND PHARMACY Vol9-N°2/2014
1 . D a t van d e
Cdt tU eung la chi djnh ngoai khoa t h u d n g gap trong ede benh ly phu khoa n h u u xa td eung. Viec giam dau trong va sau m d ludn 6ddc cac nhd phdu thuat va gay me hdi sUe quan tdm. Gay te tuy sdng (GTTS) dupc ap dung trong gdy me tU nhUng nam dau the ky XIX, tuy nhien phdi tdi nhUng ndm gan day phuang phap GTTS mdi t r d thanh mdt trong nhilfng phUPng phap dupe Ua chudng trong phau thuat tU vung bung dudi t r d xudng.
Phuang phdp GTTS sU dung nhieu ede thuoc te khde nhau, trong d d bupivacain Id thudc te dupc cac bde si gay me sU d u n g t h u d n g xuyen, tuy nhien thudc cd ede tdc dung phu nhU: t u t huyet dp, mach cham, dpc eho ca tim. Chinh vi vdy cac nhd gdy me t h u d n g xuyen tim hieu nghien cUu cac loai thudc phoi hap vdi bupivacain de lam giam lieu va gidm cae tde d u n g phu eua thuoc. Cdc thuoc giam dau hp morphin duac sU dung phdi hpp vdi bupivacain vUa lam gidm tdc d u n g phu eua thudc, vUa cd tac dung tang thdi gian gidm dau sau m d cho benh nhdn.
M o r p h i n Id thudc it tan t r o n g m d , t h d i gian khdi phdt tde d u n g cham t h u d n g dat hieu qud giam dau tdi d a d v u n g b u n g dUdi sau t i e m khoang dUdi nhen . 3-4 g i d va cd the keo dai tac d u n g tdi 24 g i d sau mo, Cac nghien cUu gan day chi ra rdng neu tiem lieu M o r p h i n e > 0,3mg thi ehi lam gia t a n g ede tdc d u n g phu ma khdng lam tang hieu qua gidm dau,
6 Viet Nam ndi chung va dac biet d Thai Nguyen cae nghien cUu va bao eao ve phdi hpp bupivacain vdi morphin ddi vdi phau t h u a t cdt t U cung cdn han ehe, do vdy chung tdi thUc hien nghien cUu nay vdi cdc muc tieu:
1. Ddnh gid tdc d u n g giam dau cua gay te t u y sdng bang hon h o p bupivacain vd m o r p h i n t r o n g vd sau phau thudt cat tU eung.
2. Danh gid tde d u n g khong m o n g m u d n eua p h u o n g phap.
2. Ddi tupng va phUcrng phap nghien cufu
2.1. Doi tuang: Cae benh nhan ed ehi dinh phau t h u d t cdt tU eung, t u d i tU 18 - 60, ASA 1-2, khdng ed chdng chi dinh gdy te tuy sdng.
2.2. Thdi gian, dja diem: 04/2013 10/2013 tai khoa Ngoai - Gay m e hdi sUe Benh vien Y - Duoc Thai N g u y e n .
2.3. Phuang phap
2.3.1. Thiet ke nghien edu: M d ta tien cufu, phan tich.
2.3.2. Thuoc vd phuang tien ky thudt: May theo ddi Phillip, b d d u n g eu gay te t u y sdng. Thudc do diem dau VAS t U 0 - 10. Thuoc gay te : Bupivacain, M o r p h i n .
2.3.3. Phuang phdp tien hdnh:Ta'\ phdng mo: Cho benh nhan nam dau bdng, Idp mdy theo ddi nhip t i m , ECG, SpOj, t h d oxy qua mask 3-51/ph it nhat 5ph trude gay t e , truyen djch Natrielorid 0,9% trude gay te 500ml. Benh nhdn dupe gidi thich rd ve phuang phap gay te t u y sdng de phdu thuat. Cde benh nhan t r o n g n h d m nghien cUu khdng d u n g ede thudc an than, tien m e de d a n h gid chinh xdc tac dung gidm dau cua p h u a n g phdp n g h i e n cUu. Bdc si gdy me rifa tay, mac do di gang vd khuan va tien hdnh ky thuat gdy te t u y sdng. D a t t u t h e b e n h nhdn nam nghieng tren ban m d , dau cui, lung cong toi da. Sat trung v u n g chpe kim 3 lan bdng cdn iod.Chpe kim vitriL2- L3, khi ed nude nao tiJy chdy ra thi tiem hon hcfp t h u d c vdi lieu Bupivacain 0,2mg/kg vd 0,1mg m o r p h i n . Theo ddi benh nhdn sau khi gay te den het cupc m d va den khi b e n h nhdn cd nhu cdu sudung t h e m t h u d c gidm d a u .
2.3.4. Thu thap so lieu: Cde t h d n g tin thu thap:
Dac d i e m benh nhan (gidi, t u d i , ehieu eao (cm), cdn nang (kg), benh phdu thudt, ASA (1 hoac 2), chi so huyet d d n g (nhip t i m (l/ph), huyet dp (mmHg), SpO„
t h d i gian t i e m tang Uc che cam giac dT10,T12,thcJi gian v d cam, t h a i gian gidm dau sau m d . Cdc thdi diem nghien cUu: T l (trude gdy te), T2 (sau gdy te 5 phut), T3 (sau gay te 10 phut), T4 (sau gdy te 15 phut), T5 (trude khi ket d d n g da), T6 {sau ket thuc phau thuat), T7 (khi benh nhdn ed nhu cau sUdung thudc gidm dau}.
2.3.5. Xdly so lieu: Bdng phan m e m SPSS 16.0. Si/
khde biet cd y nghia vdi p<0,05.
TAP CHi Y DtrCC LAM S A N G 108 Tap 9 - S o 2/2014
3. Ket qua nghien cufu 64kg. Chieu cao t r u n g binh t r o n g nghien eUu la
„ ^,.. , . , , 148,82 ± 5,38cm, thap nhat Id 134em vd eao nhat la 3.1. Dac diem benh nhan
167em.
Tudi t r u n g binh t r o n g nghien cUu 45,08 ± 14,24 Benh nhan dUpc danh gia ASA 1 la 38 t r u d n g tuoi, thap nhat 31 t u o i , cao nhat 58 t u d i . Can nang hap, ASA 2 la 12 trUdng hpp mac benh nhe khdng trung binh 47,03 ± 3,4 kg, t h a p nhat 42 kg cao nhat dnh hUdng tdi nghien cUu,
3.2. Ket qua Uc che cam giac
Bang 3 . 1 : Bang d i e m d a n h gia m u f c d o v o c a m Thong so
(Thdi gian tinh bang phut) Thcri gian tiem tang u'c cheT12 Thdi gian tiem tang u'c che'TIO Thdi g i a n v 6 c a m d T 1 2 Thdi gian v o c ^ m d T l O Thdi gian giam dau sau mo (VAS <4)
Trung binh 2,57 ± 0,42 3,26 ±0,47 175,6 ±8,89 122,32±15,5 1383,6 ± 4 8
M i n - M a x 2 - 4,45 2,35-6 148-215
9 0 - 1 8 5 1200-1524
Whdn xef,-Thdi gian tiem tdng Ue che cam giac d 122,32±15,5, ngan nhat la 90 phut, ddi nhat la T12la2,57±0,42, nhanh nhat 2 phut, cham nhat 4,45 185 phut.
phut. Thdi gian tiem tang Uc che cdm giac 6 TIO la 100% ede t r u d n g hpp giam dau t r o n g md deu 3,26±0,47, nhanh nhat Id 2,35 phut, chdm nhat la dat ket qua tdt.
6 phut. Thdi gian gidm dau sau mo 1383,6±48, tdi thieu Thdi gian vo cam: d T l 2 la 175,6±8,89, ngan 1200 phut, toi da 1524 phut,
nhat 148 phut, ddi nhat 215 phut, d TIO la 3.3. Anh hudng cua phuang phap len huyet dgng
120 100 80 • 60 40 20 0
^^
^ ,
Tl T9 T3 T4 T5 T6 17
Nhjptim Huyet ap tam thu SpOj
Bieu do 1. Anh hddng len nhip tim, huyet dp tam thu vd Sp02
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol9-N°2/20H
A//)dn xef; Mach va huyet dp tdm t h u deu gidm 6 t h d i d i e m T7 tu'e la ngUdi b e n h can d u n g thuoc giam t h d i diem T2 tUc Id sau khi gay te 5 phut, nhUng vdn d a u . Dieu nay p h u h p p vi gay te t u y sdng cd tac t r o n g gidi han eho phep. SpO^ hau n h u khdng thay d u n g Ue che giao cam gay gian mach ha huyetdpva ddi t r o n g sudt qua t r i n h m d , sau m d cho den khi mach c h d m .
3.4. Tac dung khong mong muon
Bang 3.2. Tac dung khong m o n g m u o n t r o n g m o Tac dung
khdng mong muon Non, budn ndn Run Bau dau Ngda Bi tieu
Trong mo So luong
1 2 0 2 0
Tyle(%) 2 4 0 4 0
Sau mo So liidng
0 0 0 2 1
Tyle(%) 0 0 0 4 2
Nhan xet:
Trong mo co 1 benh nhan co cam giac b u o n non chiem 2%, 2 benh nhan run chiem 4%, 2 benh nhan ngCra chiem 4%, Khong cd cac tai bien khac cua gay te t u y song t r o n g nghien ciiu.
Sau mo CO 2 benh nhan ngtra chiem ty le 4%, 1 benh nhan bi tieu chiem 2%.
4 , B a n luan
Dac&iem benh nhan;50 benh nhan trong nhom nghien ciiu; D o tuoi, can nang va phan loai SLTC khoe theo ASA th'i deu cho thay benh nhan co sdc khde tdt, dn dmh ve tam ly, di dang hgp tac vdi bac sT gay me, dieu nay giup cho viec danh gia tac dung giam dau cua phdong phap cang t h e m chinh xac.
Thcri gian tiem tang Oc che cam giac dau d mtj/c TIO: Ket qua nghien cCru d bang 2 cho thay t h d i gian t i e m tang ijc che cam giac dau d mile TIO la 3,26 ± 0,47 phut ngan nhat la 2,35 phut, dai nhat la 6 phut. Ket qua cua chung toi phu h d p vdi ket qua nghien cilu cua Nguyen Hdang Ngpc [2] til 2-6 phut, 0 6 Van Ldi [IJ 2-5 phut. N h d vay khi p h o i h d p bupivacain vdi morphin thi sau gay te S p h u t cd the phau thuat duoc. Bieu nay phu h d p vdi mile cho phep t r o n g phau thuat.
Thdi gian vd cam: Trong nghien cdu t h d i gian vd cam til khi mat cam giac dau ngang miJc TIO cho
den khi xuat hien cam giac dau d mile nay la 122,3]
± 15,5 p h i j t , ngan nhat la 90 phut, dai nhat la 18;
phut. Ket qua cua c h u n g t o i t d d n g i l n g ket qua cii cac tac gia : D d Van Loi la 130,21 ± 15,02 phijt[l), Hoang Xuan Quan 140 ± 180 p h i i t [1], thdi gian ri) dam bao de vd cam t r o n g phau t h u a t cat t i l cung.
Mufc do giam dau
Ket qua cho thay 100% benh nhan dat mile Jo giam dau t d t de phau thuat. Ket qua ciia chiing toi phu h o p vdi ket qua n g h i e n cilu cua D o Van Loi HI va Hoang Xuan Quan[3].
Thcri gian giam dau sau mo
Ket qua d bang 3.2 cho thay thdi gian giam 4au sau mo eua n h d m nghien cufu la 1383,6±48 (23,06±W gid), tdi thieu 1200 p h d t va tdi da 1524 philt. Ket qui chiing tdi phu hdp vdi ket qua nghien eilu eua 06 Vai Loi [1] la 24,08+1,09 g i d va Hoang Xuan Quan [3JB 23,39±1,45 gid, Katsuyki Terajima[4] la 24 ± 0,2 gid.
Anh hudng ten tuan hoan vaho hap Gay te t u y s o n g ile che t h a n kinh giao can gay gian mach ha h u y e t ap, g i a m n h i p t i m . Tron) n g h i e n c d u eua c h u n g t o i c u n g cd hien tdong tren n h d n g g i a m k h d n g d a n g ke chi b a n g 5-6% va A t r o n g g i d i han c h o p h e p . N g h i e n c i l u eua chOnj
TAP CHi Y DUaC L A M S A N G 108 Tap 9 - S o 2/2014
tdi CO ket qud t U o n g t u cua 0 6 Van Lai [1], Hodng Xuan Quan [3],
Tac dung khong mong muon
Ket qua d bdng 4.1 ed 2 % benh nhan bj b u d n ndn, 4 % ngUa vd 4 % bi run t r o n g t h d i gian phau thudt va sau phau thuat cd 4 % benh nhan bj ngUa va 2% benh nhdn bi b i t i e u . Nghien eUu eua chung tdl cd ket qud t u a n g t u eua D d Van Lpi [1], Hoang X u d n Q u d n [ 3 ] .
5. Ket luan
Phuang phdp gay te t u y sdng bang hdn h a p bupivacain va m o r p h i n t r o n g phau t h u a t cdt tU cung cho ket qud t d t . T h d i gian tien^ t a n g Uc che edm gide dau 6 mUc TIO Id 3,26 ± 0,47 phut. Thdi gian vd cam la 122,32 ± 15,5 phut. 100% benh nhan dat mUe gidm dau t d t de phau t h u d t . Thdi gian gidm dau sau mo eua n h d m n g h i e n eUu la 1383,6 ± 48 p h u t (23,06 ± 0,8 gid), t d i t h i e u 1200 , phut va tdl da 1524 p h u t .
Ket qud nghien cUu, t r o n g m d chi cd 2% benh nhdn budn non t r o n g m d , 4 % ngUa. Sau m d khdng
cd benh nhdn bj ndn va b u d n ndn, 2% cd trieu chUng ngUa, 2% benh nhan bi bi tieu.
Tai lieu t h a m khao
1 Do Van Lpi {2007): "Nghien cUu phdi hap bupivacain vdi morphin hoac fentanyl trong gay te tuy song de md lay thai va giam dau", Luan van thac sT yhpc. Trudng dai hpcY Ha Noi, 2. Nguyen Hoang Ngoc (2003): "Danh gia gay te dUPi
mang nhen bdng bupivacain lieu thap ket hpp vpi Fentanyl trong md lay thai", Luan van tdt nghiep thac si y hpc, TrUdng Dai hpc Y Ha Ndi.
Hodng Xuan Quan (2006): "Danh gid tdc dung gdy te tuy sdng bang bupivacain 0,5% ket hop vdi morphin trong phau thuat bung dudi va ehi dudi", Luan van thac sT Y hpc. Hpc vien Quan y.
Kasyuki Terarima, Hidetaka Onodera, Masao Kobayashi, Hiroko Yamanaka (2003). "Efficacy of infrofheca/ morphine for analgesia following elective caesarean section: comparison with previuos delivery", J Nippon Med Sch 70 (4).
