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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 10 - N°2 /2OI5,
Danh gia tac dung khong mong muon va tac dung dy phong non ciia phuong phap giam dau do benh nhan ty dilu khien (PCA) bang fentanyl duong tinh mach ket hop voi ondansetron sau phau thuat tuygn giap
Evaluating side effects and vomiting prevention of patient controlled analgesia by intravenous fentanyl combine with ondansetron after thyroidectomy
Nguyen Ngoc Thach Benh vien Qudny 103
Muc tiiu: Banh gia tac dung khong mong muon va dU phong n6n cua phi/ong phap giam dau benh nhan do benh nhan t u dieu khien {PCA) bSng fentanyl dudng tinh mach ket hop v6i ondansetron sau phau thuat tuyen giap. 061 tdang vd phdang phdp: 80 benh nhan co chi dinh phau thuat tuyen giap, vo cam b i n g gay te dam roi than kinh c6 tai phong mo Benh vien QuSn y 103 tCf thang 5-12/2013, dUOc chia thanh 2 nhom, moi nhom 40 benh nhan Nhom 1 (nhom PCA): Pha dung dich chay may PCA bang each lay lOOOmcg fentanyl va 12mg ondansetron pha vcfi NaCI 0,9% dupc tong the tich 100 ml, nhu vay trong dung dich chay PCA fentanyl co nong do lOmcg/ml va ondansetron co nong do 0,12mg/ml. Sau phau thuat khi diem dau (visual analogue score - VAS) > 4, chuan 66 va cai dat cac thong so tren may PCA: Lieu bolus 1 ml, thdi gian khda 15 phut, lieu nen truyen lien tuc I m l / h , tong lieu gidi han trong 4 g i i la 20ml. NgUng chay may PCA sau 48 gift tinh tir khi bSt dau thuc hien giam dau. Nhom 2 (nhom Chung): Sau phau thuat khi diem VAS > 4, tiem tinh mach cham 15mg ketogesic/lan each nhau moi 6 gid giam dau cho benh nhan den 48 gid sau phau thuat. Ket gud: Nhom PCA ty le buon ndn non sau mo 22,5%; dau dau 5%; dau bung 5% tUdng urng thap hon nhdm chilng 60%; 22,5%; 15% (p<0,05). Nhdm PCA ty le an than 0AA/S4 2,5%, chong mat 15%; ngila 2,5%, bi dai 12,5% khac biet khong cd y nghTa thong ke so vdi nhdm chilng (p>0,05). Ket ludn- GiSm dau do benh nhan tU dieu khien bang fentanyl dudng tTnh mach ket hop vdi ondansetron giam dang ke ty le budn ndn, non va cac tac dung khdng mong mudn sau phau thuat tuyen giap
Tdifhod: Ndn sau phau thuat tuyen giap, PCA, fentanyl, ondansetron.
Summary
Objective: To evaluate the side effects and nausea and vomiting prevention of the patient contrdlled analgesia method (PCA) by intravenous fentanyl combined with ondansetron after thyroidectomy Subject and method: SO patients v»ere performed thyroidectomy under cen/ical plexus anesthesia in the operating room of the 103 Hospital from May to December 2013. These patients were divided into two Phan bien khoa hoc: TS. NGUYEN MINH LY
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groups: - Group 1 (the PCA group) (n=40): 100 ml PCA solution was prepared by dilution of lOOOmcg fentanyl, 12mg ondansetron, and normal saline 0.9%. The concentrations of fentanyl and ondansetron In the PCA solution were lOmcg/ml and 0.12mg/ml respectively. After finishing thyroidectomy, when the visual analogue score (VAS) > 4, titrating and setting up PCA as follows: Bolus dose 1ml, lockout time 15min, background dose 1 ml/h and total 4 hour dose limit 20ml. PCA stopped after 48 hour of analgesia.
- Group 2 (the control group) (n=40): After thyroidectomy when VAS > 4, intravenous injection of ketogesic 15mg every six hours for 48 hour postoperation. Result In the PCA group, the postoperative nausea and vomiting (PONV) rate was 22.5%, headache 5% and abdominal pain 5%, lower than those in the controi group (60%, 22.5% and 15%, respectively) (p<0.05). The rate of sedation 0AA/S4 was 2.5%, dizziness 15%, pruritus 2.5% and urinary retention 12 5%, which were not statistically different from the control group (p>0.05). Conclusion: Patient controlled analgesia method by intravenous fentanyl combine with ondansetron reduced significantly postoperative nausea and vomiting and side effects after thyroidectomy.
Keywords: Vomiting after thyroidectomy, PCA, fentanyl, ondansetron.
I.Oatvande
Phau t h u a t tuyen giap t h u d n g gay dau cap sau mo, Mac d u co nhieu p h u o n g phap giSm dau sau phau thuat nay nhUng p h a o n g phap giam dau do benh nhan Xd dieu khien (PCA - Patient Controlled Analgesia) qua dUdng tTnh mach b§ng cac thudc giam dau t h u o c n h o m o p i o i d la p h u o n g phap kha pho bien lam gia tang sd hai long cua benh nhan sau phau t h u a t [3] [4]. Fentanyl la m p t thuoc gicim dau manh thuoc n h o m o p i o i d nhUng co tac d u n g phu gay b u o n non va non khi silr d u n g [1].
Ondansetron la thuoc t h u o c doi khang thu the 5- HT3 CO tac d y n g d u p h o n g b u o n non non hieu qua sau phau t h u a t [1]. Hien nay t r o n g nu'dc chua co nghien ciJu nao cong bo ve cac tac d u n g khong mong m u o n khi silfdung PCA t i n h mach fentanyl ket hgp ondansetron de giam dau sau phau t h u a t tuyen giap diidl gay te dam rdi than kinh co. Do do, chung tdi tlen hanh nghien ctru de tai nay vdi muc tieu:
Ddnh gid tdc dung khong mang muon vd tdc dung dd phong non sau phau thudt tuyen giap khi sd dung PCA tinh mgch fentanyl ket hap ondansetron.
2. Doi t u a n g va phUtfng phap 2.1. Doi tddng nghien cdu
2.hh Boi tddng: 80 benh nhan dUpc phau thuat tuyen giap du'di gay te dam roi than kmh cd tai phdng mo Benh vien Quan y 103 tC/thang 5-12/2013.
2.1.2. Tieu chuan Ida chon: Benh nhan d o n g y thuc hien ky thuat PCA, biet sif d y n g may PCA sau khi hudng dan, khdng cd chong chi dinh sis d u n g fentanyl, ketogesic, ondansetron, t u d i tren 16.
2.1.3. Tieu chuan logi trd: Benh nhan tCfchdi thUc hien ky thuat PCA, chong chi dinh sii d u n g fentanyl, ketogesic, ondansetron.
2.2. Phuang phdp nghiin cUu
2.2.1. Thiet ke nghien cdu: Nghien cu'u tien cufu, thCr nghiem lam sang, co so sanh.
2.2.2. Chia nhom doi tdpng nghien cdu: 80 benh nhan duoc chia thanh 2 n h d m ngau nhien, m o i n h o m 40 benh nhan:
- Nhom 1 (nhdm PCA): Pha d u n g dich chay may PCA b i n g each lay lOOOmcg fentanyl va 12mg ondansetron pha vdi NaCI 0,9% dugc t o n g t h e tich 100 ml, n h u vay t r o n g d u n g dich chay PCA fentanyl cd n d n g 66 l O m c g / m l va ondansetron co n o n g do 0,12mg/ml. Sau phau thuat khi d i e m dau (visual analogue score - VAS) > 4, chuan d d va cai dat cac t h d n g sd tren may PCA: Lieu bolus 1 ml, t h d i gian khda 15phut, lieu nen truyen lien t y c I m l / h , t o n g lieu gidi han t r o n g 4 g i d la 20ml. NgC/ng chay may PCA sau 48 gid tinh Xd khi bSt dau thUc hien gicim dau.
- Nhdm 2 (nhdm chu'ng): Sau phau thuat khi diem VAS > 4, tiem tTnh mach cham 15mg ketogeslc/lan each nhau moi 6 gid giam dau cho benh nhan den 48 gidsau phau thuat.
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2.3. Tien hanh 2.3.1. Chuan bi benh nhdn
Benh nhan duoc kham trudc mo, hUdng dan sCr dung thudc VAS, may PCA, nhjn an udng tn/dc mo 6 gid.
2.3.2. Chuan bi thuoc, dung cu, phdang tien Thuoc: Fentanyl ong 500 mcg/lOmI CLia hang Rotex - Medica {CHLB Ddc), ketogesic ong 30mg/1ml cua hang DexaMedica (Indonexia), ondansetron (biet duoc Prezlnton) dng 8mg/4ml hang DexaMedica (Indonexia).
Dung cu, phdong tien nghien cdu: Bom tiem dien PCA Perfusor Space cua hang B.Braun (CHLB DiJc), thudc do diem dau VAS cua hang B.Braun (CHLB OCfc).
2.3.3. Cdch tien hdnh
Tai phong mo: B a t dudng truyen tTnh mach truyen d u n g djch natriclorua 0,9%. Tiem tTnh mach trudc gay te 15 phut seduxen 0,1 mg/kg va fentanyl 50mcg. Gay te dam roi than kinh co hai ben bang hon h p p lldocain 5 m g / k g va bupivacain 0,8mg/kg.
Theo ddi cac chi sd sinh t d n 5 phut/Ian cho tdi khi phau t h u a t ket thuc, benh nhan on djnh chuyen ve khoa ngoai da chien.
Tai budng benh: Danh gia mu'c dp dau sau phau thuat. Neu VAS < 4 diem, chua tlen hanh giam dau va danh gia lai 15 phut/Ian. Neu VAS > 4 diem, tien hanh giam dau den 48 gid sau phau thuat theo quy trinh dtCmg nhdm.
2.4. Cdc chi tiiu nghien cdu
2.4.1. Dgc diem chung benh nhdn nghien cdu:
Tudi, gidi, can nang, chieu cao, diem Apfel danh gia cac yeu t o nguy ca gay b u o n ndn va.ndn sau phau t h u a t (BNN5PT)
Thang diem yeu t o nguy ctf Apfel [2]
Yeu to nguy ctf NU
Tien sCrndn va buon ndn sau mo hoac say t a u x e
Khdng hut thudc Dung opioid sau mo
Diem 1 1
1 1
2.4.2. Tdc dung khong mong muon sau phau thudt - Oc che h d hSp: Tan so t h d < 10 Ian/phut.
- Budn non va n o n : T^ le b^nh nhan buon non ndn va mtTc dp b u o n ndn non t r o n g 48 gid sau phia thuat. Phan loai mCrc d d b u o n ndn va non sau phay t h u a t n h u sau: Khdng b u o n n o n , b u o n ndn ft, buofi ndn nhieu, khong n d n , ndn dudi 2 lan, ndn tu'2 lan t r d len.
- An than: Danh gia dp an than theo thang diem OAA/S (Observer's Assessment of Alertness/Sedation).
0A/\/S5: Tinh hoan toan, dap Ung ngay sau khi goi t§n b^ng giong binh t h u d n g . 0AA/S4: Dap uYig cham, mo ho khi gpi ten b i n g glpng binh thudng.
- NgUa, chong mat, dau dau, dau bung, bf tieu.
2.5. XCtly ket qud nghien cdu
Ket q u ^ nghien cUu dUdc xCf ly b i n g phan mem SPSS 17.0; p<0,05 d u p c col la khac biet cd y nghia t h o n g ke.
3. Ket qua
(
^ v Nhom
Oiem ^ v Apfel ^ \
0 1 2 3 4
! i n g 1 . D i e m Nhom 1 (n = 40) So BN 0 0 2 8 30
%
0 0 5 20 75
Apfer Nhom 2 {n = 40) So BN 3 2 20 15 0
%
7,5 5 50 37,5
0 P
<0,05
<0,05
<0,05
<0,05
<0,0S
Nhdn xet Khac biet ve d i e m A p f e l glUa hai n h d m cd y nghTa t h d n g ke v d i p<0,05. Ty le benh n h a n n h d m 1 cd d i e m A p f e l 4 la 7 5 % cao hdn n h d m 2 la 0%.
BSng 2 . Cac tac dung Ithong mong muon t r o n g 4 8 g i d sau phau t h u a t
\ ^ Nhom Tac \ ^ dung \ ^ KMM \ (Icchehd h$p Buon non, non An t h i n 0AA/S5 An than 0AA/S4 Bau dau Chong mat Ngita Bidal Dau bung
Nhom 1 (n = 40) So BN 0 9 39
1 2 6 1 5 2
%
0 22,5 97,5
2,5 5 15 2,5 12,5 5
Nhom 2 (n = 40) So BN 0 24 38
2 9 4 1 6 6
%
0 60 95
5 22,5
10 2,5 IS 15
P
>0,05
<0,05
>0,05
>0,05
<0,05
>0,05
>0,05
>0,05
<0,05 Nhdn xet Ty le b u d n ndn, ndn d n h d m 1 la 22,5% thap hon n h d m 2 la 60% (p<0,05); ty le dau dau, dau bung 6 n h d m 1 t u o n g Ung la 5%; 5% t h a p hon nhdm 2 la 22,5% va 15% (p<0,05).
BSng 3. MuTc do buon non va non trong 48 gicf sau phau t h u a t
^ \ Nhom Buon \ ^ non, \ ^ non ^ ^ Khong buon non Buon non ft Buon non nhieu Khong non Non dadi 2 lan Non t(f2 lan trd len
Nh6m1 (n = 401 So BN 34 6 0 37 1 2
%
85 15 0 92,5
2,5 5
Nhom 2 (n - 401 So BN 27 7 6 28 3 8
%
67,5 17,5 15 70 7,5 20
<0,05
<0,05
<0,05
<0,05
<0,05
<0,05 Nhan xet Nhdm 1 ty- le ndn tU 2 lan t r d len chi cd 5% t u o n g L^ng t h a p hdn so vdi n h d m 2 la 20%
(p<0,05).
4.1. Buon non, non trong 48 gidsau phdu thuat BSng 2 cho thay t y le b u o n ndn va ndn t r o n g 48 g i d sau phau thuat d n h d m PCA la 22,5% thap hon n h d m chUng la 60%, khac biet cd y nghTa t h o n g ke vdi p<0,05. BSng 3 cho thay mUc dd ndn tCr 2 lan t r d len t r o n g 48 gid sau phau t h u a t d n h d m PCA la 5%
thap hon n h d m chUng la 20%, khac biet cd y nghTa t h d n g ke vdi p<0,05. Ly giSi cho sU khac biet nay la do t r o n g hon h p p chay may PCA chung tdi da sd d u n g ondansetron la m d t thudc dU p h d n g b u d n ndn va ndn cd dac tinh khang t h u t h e 5-HT3 do do mac d u d nhdm PCA t y le benh nhan cd d i e m Apfel 4 cao hon n h d m chUng (bSng 1) nhUng t^ le b u d n ndn va ndn sau phau thuat d n h d m PCA thap h o n . So Yeon Kim (2008) nghien cUu giam dau va dU p h d n g buon n d n , ndn sau phau t h u a t tuyen giap dudi gay me ndi khi quSn b§ng p h u o n g phap PCA tTnh mach fentanyl ket hdp ondansetron nhan thay ty le budn ndn va ndn 24 gid sau phau thuat la 57,8%) [3].
Buon ndn, non sau phau thuat van la nguyen nhan chinh khien benh nhan cham xuat vien bdi vi buon ndn, ndn cd the gay buc cac mdi chi khau, toac vet mo, chay mau, roi loan nUdc dien glal [5].
4.2. MUc dd an thdn theo OAA/S
BSng 2 cho thay ty le benh nhan dat mUc dp an t h a n 0AA/S5 d n h d m PCA va n h d m chUng tUOng Ung la 97,5% va 95%); mUc dp an than 0AA/S4 d n h d m PCA va n h d m chUng t u o n g tfng la 2,5% va 5%);
khac biet khdng cd y nghTa t h d n g ke gida hai n h d m (p>0,05). Ngoai ra d ca hai n h d m , chung tdi khdng gap trUdng hap nao bi Cfc che ho hap. Ket qua nghien cufu nay cho thay mdc dp an toan cua p h u o n g phap SLT d u n g PCA fentanyl dUdng tTnh mach giSm dau cho benh nhan sau phau t h u a t tuyen giap. Y. E. IVIoon va cdng sU (2012) n g h i e n cu'u giSm dau va d u p h d n g b u o n ndn, ndn sau phau t h u a t tuyen giap d u d i gay me npi khi quSn bSng PCA tTnh mach fentanyl ket h p p ondansetron nhan thay ty le an than 12% va cung khdng gap trUdng h p p nao Uc che hd hap [4].
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4.3. Cdc tdc dung khong mong muon khac BSng 2 cho thay ty le dau dau sau phau t h u a t tuyen giap d nhdm PCA la 5% va n h d m chu'ng la 22,5%; khac biet cd y nghTa t h d n g ke vdi p<0,05.
Trong khi dd ty le dau dau sau mo cua Y. E. M o o n va cdng su (2012) la 38% [4].
Trong nghien cUu nay ty le benh nhan ngUa, chdng mat va bi tieu d hai n h d m khac biet khdng cd y nghia t h d n g ke (p>0,05) (bang 2), day la cac tac d u n g khdng m o n g m u d n cd t h e bSt gap khi sii d u n g fentanyl, thuoc giam dau thudc n h d m opioid. Trong khi d d ty le chdng mat sau mo cua So Yeon Kim (2008) la 4 0 % [3]; cua Y. E. M o o n va cdng sU (2012) la 22% [4].
Trong nghien cUu nay ty le benh nhan bi dau dau, dau bung d n h d m chUng cao hon n h d m PCA khSc biet cd y nghia t h o n g ke vdi p<0,05 (bSng 2), day cd le la hai tac dung khdng m o n g m u d n cd the bat gap khi sU d u n g ketogesic, m d t thudc giSm dau chdng viem non-steroid.
5. Ket luan
GiSm dau do benh nhan t u d i e u khien (PCA) bSng fentanyl dudng tTnh mach ket hpp vdi ondansetron giSm dang ke Vy le budn ndn, ndn trong do ty le budn ndn, ndn d nhdm PCA la 22,5%i so vdi nhdm chUng la
60%, ty le benh nhan ndn tU 2 lan t r d len la 5% so vdi n h d m chUng la 20% va cac tac d u n g khong mong m u d n sau phau t h u a t tuyen giap.
Tai lieu t h a m khdo
1. Bd Y te (2011) Difpc thu Qudc gia Vi$t Nam. Uhh Xuat bSn y hpc Ha Ndi.
2. Apfel CC, Roewer N (2003) Risk assessment of postoperative nausea and vomiting, international Anesthesiology Clinics 41 (4): 13-32.
J. So Yeon Kim (2008) Postoperat/ve/ntravenousPaf/enf - Controlled Analgesia in thyroid surgery: comparision of fentanyl and ondansetron regimens with and without the nonsteriodal anti-inflammatory drug fceforo/ac Thyroid 18(12): 1285-1289.
t . Y.E.Moon, J. Joo, J.E.Kim and Y.Lee (2012) Anti- emetic effect of ondansetron and palonosetron in thyroidectomy: a prospective, randomized, double- blindstudy. British Journal of Anaesthesia 108 (3):
417- 422.
5. Yoshitaka Fujil (2008) The benefit and risks of different therapies in preventing postoperative nausea and vomiting in patients undergoing thyroid surgery. Current Drug Safety 3:27-34.
