^ TAP CHl YDU-Crc LAM SANG 108 T^p g . 55 2 /2013
Danh gia tac dung khong mong mu6n giua cac liSu 7mg, 8mg va lOmg bupivacain ty trong cao 0,5% kSt hop vol 40^g fentanyl gay te tuy s6ng trong m6 l§y thai
The Assessment of the Side-effects with Doses of 7mg, 8mg and lOmg Heavy Bupivacain Combined with 40 ^g Fentanyl for Cesarean
Iran Van Cuwng*, •Q^^^ ^,^„ p^^ ^.^„ ^ ^ pj^^
Nguyen Thu "Nguyen Chu lich Hoi gay me hdi sue Viet Nam
Hien nay gay te tuy song ddng mdt vai tro quan trpng trong md lay thai, tuy nhien tac dung khdng mong mudn gida cac lieu thudc te van cdn khac nhau. Muc tieu nghien cdu: Danh gia tac dung khdng mong mudn gida cac iieu. Ddi tuang vd phuong phdp nghien cdu: gom 365 benh nhan dupc chia lam 3 nhdm, nhdm I va nhdm II deu la 122 benh nhan, nhdm III la 121 benh nhan gay te tuy sdng d t u t h e ngoi vi tri L2-3 Thiet ke thU nghiem lam sang ngau nhien tien cdu cd so sanh gida ba nhdm. Kit qud vd bdn ludn: Ty le tut huyet ap trong mo d nhdm III ludn cao hon d nhdm II vdi p<0,05, Nhdm I yeu cau diing thudc giam dau va thuoc me cao han nhdm II va nhdm III vdi p < 0,05. Ty le budn ndn, ndn trong md d nhdm III (37,2%) cao han han so vdi nhdm II (3,3%) va nhdm I (1,8%) su khac biet rat cd y nghia thdng ke (p < 0,001).
Ty le ret run tfong m o d nhdm III (40,5%) cao hon han so vdi nhdm II (4,1%) va nhdm I (0,8%) sU khac biet rat cd y nghia thdng ke (p < 0,001) Cac tac dung khdng mong mudn sau mo d ca ba nhdm khdng cd sU khac biet vdi p > 0,05. Nhu vay nhdm II cd it tac dung khdng mong trong mo it nhat so nhdm III (p <: 0,05). Nhung tac dung vd cam lai tdt hon d nhdm I (nhdm I la 84,6% va nhdm II 12,8%). Su khac biet cd y nghia thong ke vdi p < 0,05. Kit ludn- lieu 8mg bupivacain ty le tac dung khdng mong mudn trong mo thap hon lieu lOmg va lieu 7mg,
TUkhda: Gay te tuy song, mo lay thai, biplvacain 0,5% ty trong cao, fentanyl 40Mg.
Summary
Now/adays, spinal anaesthesia plays a very important role in Cesarean. However, side-effects betw/een doses and the appropriate dose of local anaesthesia are still different. Ojectives: This article is to assess the side-effects among doses. Suti/ecfsondn7ef/7ods.-The study included 365 parturients who w/ere divided into three groups: Group I with 122 parturients. Group N 122 parturients and Group II! 121 parturients. These patients underwent the spinal anaesthesia in sitting position and the puncture position IS L2-3. This research applies the retrospective random test study design, including the comparison among the three groups of I, II and 111. Results and discussions: The rate of hypotension during the operation in Group III is higher than that of Group II with p<0,05. The patients in Group I demands higher dose of fentanyl and ketamine. The rate of nausea, vomit in operations of Group III (37.2%) is much higher
Phan bi?n khoa hoc: TS NGUYEN DUG THIENG
Vol8-N"2/2013
than the rate of 3,3% in Group II and Group I (1,8%). This difference has the statistic meaning (p < 0.001). The rate of frisson during the operation in Group III (40.5%) is clearly higher than that in Group II (4.1%) and Group I (0.8%). This difference has the statistic meaning (p < 0.001). The post-operative adverse effects in three groups are not different with p > 0.05. Therefore, for the rate of vomit and frisson. Group I and Group II has the least undesired effects compared with Group III (p < 0.05), This difference has the statistic meaning with p
< 0 05. Conclusions: The dose 8mg bupivacain has lower rate of undesired effects during the operation than the doses of lOmg and 7mg.
Keywords: Spinal anaesthesia, cesarean, 0.5% heavy bupivacaine, 40pg fentanyl
I . D a t v a n d e
Phuang phap vd cam gay te tuy song de m d lay thai hien nay t d ra cd hieu q u i nhat. Tuy nhien, t i c d u n g khdng mong muon giUa c i c lieu 7mg, 8 m g va lOmg bupivacain ty trong cao gay te tuy sdng de md lay thai thi lai khac nhau.
Xuat phat tU ly do nay, chung toi tien hanh nghien cUu:
"Ddnh gid tdc dung khdng mong muon gida cdc lieu".
2. D o i tUtfng va phUcfng p h a p n g h i e n cOfu
2 . 1 . D o i tupfng: tren cac san phu ed chi dinh md lay thai lan dau tai benh vien Phu san Ha Ndi, trong thdi gian tUthang 8 nam 2010 den t h i n g 6 nam 2011.
* Tieu chuan: khong di Ung vdi thuoc te, ASA I - III, ddng y va hap t i c gay te tiiy song, khdng cd chdng chi dinh vdi gay te tuy song.
2.2. Phuang phap nghien cdu:
2.2.1. Thiet ke nghiin cdu: Nghien cUu nay sU d u n g thiet ke thU nghiem l i m sang ngau nhien tien cUu CO so s i n h gida 3 nhdm benh nhan I, II va \U Ung vdi 3 mUc dp gay te lieu bupivacain 7mg, 8mg va lOmg ket hap vdi 40pg fentanyl. Ca 3 n h d m duae choc kim d khe lien dot L2-3.
2.2.2. Phuang tien nglven cdu:
2.2.2.1. Monitor Nihon Kohden theo ddi HATB duac do t u ddng 2 phut/Ian trong 10 phut dau sau gay te tuy song, Sau dd cU 5 phut do lai m d t lan cho den ket thuc cudc mo.
2.2.2.2. Kim gay te 27G c u i hang B/Brawn 2.2.2.3. Thudc gay te: Marcain 0,5% dng 5ml (20mg) cua AstraZeneca, fentanyl 2ml (lOOpg), ketaminSOOmg.
2.2 3. Phuang phdp tien hdnh:
2.2.3.1. Chuan bi b e n h nhan: n h u qui trinh gay te tuy sdng t h d n g t h u d n g . Phau thuat vien thanh thao t r o n g mo lay thai.
2.2.3.2. Tien hanh ky that gay te tuy sdng d t i / the ngdi.
- Vj tri choc kim: d khe lien d d t L2-3 cho den khi thay djch nao tuy chay ra.
- Bom t h u d c te vao khoang d u d i nhen vdi 3 lieu 7mg, 8 m g va l O m g bupivacain 0,5% cung ket hpp vdi 40pg Fentanyl t u o n g Ung vdi cac lieu 1, 2,3. Toe dp bom thude t r o n g v d n g 30 giay.
- T4 la t h d i gian bat dau rach da; T6 la thdi gian lay thai.
2.2.4. Phuang phdp ddnh gid:
" Ddc diem benh nhdn: tn so BMt
* Chi tieu ddnh gid tdc dung khong mang muon:
* Trong mo:
Huyet ap tam t h u sau gay te tuy sdng - Huyet ap t i m t h u giam:
-I- Neu HATT g i i m > 20% so vdi HATT nen, sir d u n g ephedrin t i n h mach: 5-1 Omg.
+ Neu HATT g i i m > 30% so vdi HATT nen, sif d u n g ephedrin t i n h mach 10-40mg ket hop vdi truyen t h e m djch keo haes steril 6%.
- Danh g i i mUc dp giam dau phau thuat theo tieu chuan Abouleish g o m 3 mUc do: tdt, trung
binh, kem:
- Budn n d n , ndn - Run va ret run - Suy hd hap
* Sau mo:
- Budn ndn, ndn -NgUa - D a u dau
TAP CHi Y DU'Q'C L A M S A N G 108 Tap 8 - S o 2/2013
2.2.6. Xtlliso lieu: Nghien cilu auoc tien hanli tren 365 san piiu co H/la hoa, nhap va phan tich so lieu bSng phan chi d m h mo iay thai ian dau tai Benh vien Phu san mem SPSS 18.0 Ha Noi trong thdi gian tif thang 8 nam 2010 den
thang 6 nam. NhCrng l<etqu^ thu duac nhu sau:
3. Ket qua nghien ciJTu va ban luan 3.1. Dac diem cua nhom nghien cCtu
Bang 3 . 1 . Phan bo nhom doi tuong nghien cijru theo nhom tuoi
\ ^ NhomNC
Nliomtuoi ^ \ ^ ^ 1 8 - 2 2
• 2 3 - 3 0
>30 l o n g Mm-Max
1 ±SD
BMI
BMI
Nhom 1 {n=122) n 12 87 23 122
%
9,8 71,3 18,9 100 1 8 - 3 7 27,11 ±3,94
Mm - Max A' ±SD
<23
>23
Nhdm II (n=122) n 13 92 17 122
%
10,7 75,4 13,9 100 18-37 26,62 ± 3,73 19,95-31,57 26,01 ±2,57 13(10,7) 109(89,3)
Nhom III (n=121) n 8 81 32 121
%
6,6 66,9 26,4 100 19-36 27,66 ± 4,20 21,10-32,03 26,04 ± 2,74 18(14,8) 104(85,2)
Tong n 33 260 72 365
%
9,0 71,2 19,7 100 18-37 27,13 ±3,97 18,22-35,56 26,07 ± 3,23 22(18,2) 99(81,8)
P
>0,05
>0,05
>0,05
>0,05
Whdnxet.-Dac diem chung cua benh nhan khong cd gi khac biet vdi p > 0,05.
Chi sd BMI > 23 chiem phan Idn (85%) vdi p > 0,05.
Bang 3.2. Ty le tut huyet ap tam thu theo phan tram cua HATT nen
Ty le tut HATT
>20%
> 30%
Tong
Nhom II n 4 1 5
80,0
%
20,0 100
Nhom III n 15 36 51
29,4
%
70,6 100
Tong n 19 37 56
33,9
%
66,1 100
P
<0,05
M^^^l t 1
ro T2 T4 T6 Ta T i n TIS T2n Bieu do 1. HATB giOa cdc nhom nghien cii'u theo thai gian gay te
Nhan xet:
Ty le tut HATT > 20% n h o m 11 va n h o m III la 19 ca (33,9%), t r o n g do n h o m III cao hc(n n h d m II. Ty le tut HATT > 30% nhom II va n h o m III la 37 ca (66,1%), t r o n g do n h o m III luon cao hon n h o m II, SU khac biet nay deu CO y nghia t h o n g ke vdi p < 0,05.
Theo Pham Odng A va Nguyen Van Chiing, gay te tuy sdng bSng hon h o p bupivacain ket hop vrii fentanyl (20)ig) cho ket qua t u t huyet ap (58,3%) cao hon h i n so vdi n h o m III cua chung tdi vi lieu lirong bupivacain SLIdung cao hon 3 nhdm nghien cLru cua chung tdi [1],
Bang 3.3, So sanh viec dung t h e m cac thuoc g i i m dau va thuoc gay m e khi mo lay thai
Them thuoc giam dau va thuoc gay me an than
Dung Ihem fentanyl 50iig n=39) Dung them fentanyl va ketamin 50mg (n=30)
Nhom 1 n 33 30
%
84,6
too
Nhdm II n 5 0
%
12,8 0
Nhom III n 1 0
%
2,6
0 P
<0,0S
Nhdn xet:
Nhdm I phai dung thudc giam dau d c i c thdi diem rach da cd 33 ca (84,6%), t r o n g d o n h d m II ft hon chi c d 5 ca (12,8%), thap nhat la n h d m III duy nhat co 1 ca (2,6%).
T6: nhdm II va nhdm III khong cd BN nao p h i i d u n g e i thudc g i i m dau va thudc gay me, trong khi nhom I c d t d i 3 0 c a ( 1 0 0 % ) ,
Tuong duong vdi nghien cUu cua Cao Thi Bfch Hanh, Nguyen Thu [2] dat mUe g i i m dau trong mo tdt la 91,11%, trung binh la 8,89%, kem 0%.
Bang 4. C i c tac dung khong mong mudn trong m o
Tac dung khong mong muon trong mo
Buon ++ non, ndn
Ret run
Suy hd hap
Cd Khong
Cd Khong
Co Khdng
Nhdm 1 (n = 1221 n 2 120
1 121
0 122
%
1,8 98,2 0,8 99,2 0 100,0
Nhdm II (n = 122) n 4 118
5 117
0 122
%
3,3 96,7 4,1 95,9 0 100
Nhdm III (n = 121) n 45 76 49 72 0 121
%
37,2 62,8 40,5 59,5 0 100,0
P
Pi-j; p,., <0,001
p,j;p,.,<0,001
>0,05
• 8 u d n non, non: Nhdm I: 2 ca (1,8%); Nhdm II: cd 4 ca (3,3%); Nhdm III: cd 45 ca (37,2%). Sir khac biet la h o a n t o a n , vdi ( p < 0,001)
Chong JL [4] khi gay te tuy sdng vdi bupivacain don thuan ty le ndn va b u d n ndn la 11,8% cdn khi ket hdp vdi fentanyl la 22,2%. Trong khi dd thi Sheskey [7] t h d n g bao chi gap 1 benh nhan bi ndn va buon non trong 60 benh nhan nghien cCru.
'Retrun trong mo- Ket qua nghien cilu cua chung tdi n h u sau:
Nhdm I: cd 1 ca (0,8%), Nhom II' cd 5 benh nhan (4,1 %); Nhdm III: cd 49 (40,5%), sU khac biet giCra nhom I va n h d m II hoan loan vi khi benh nhan tut huyet ap c h i j n g tdi phai cho truyen dich nhieu va nhanh. Nhitvay,
TAP CHi Y DU'Q'C L A M S A N G 108 Tap 8 - S o 2/2013
tl le ret run 6 n h d m III cao hon rat nhieu so vdi nhdm I, trong m d . Cd the dUoe giai thich do tut huyet ap nhieu, phai truyen djch vdi tdc dp nhanh, ket hop vdi sU d u n g thudc co mach g d p phan lam tang ti le ret run cao hdn 6 n h d m III so vdi hai n h d m cdn lai.
Shende D va edng sU [6] run va ret run t h u d n g p h i n i n h q u i trinh mat nhiet do gian mach, do truyen djch lanh, do mat nhiet d vung m d ,
Bdng
Tac dung khdng mong muon sau md
Buon ndn, ndn
NgOa
£)au dau
Suy hd hap Cd Khong
Cd Khdng
Cd Khdng
Cd Khdng
3.5 .Cac tac dune Nhdm 1 (n = 122) n 1 121
20 102 4 118
0 122
%
0,8 99,2 16,4 83,6 3,3 96,7
0 100,0
Ithong mong muon sau mo Nhdm II
(n=122) n 2 120
17 105 5 116
0 122
%
1,6 98,4 13,9 86,1 4,1 95,9
0 100
Nhdm III (n=121) n 3 118
15 106 7 114
0 121
%
2,5 97,5 12,4 87,6 5,8 94,2 0 100
P
>0,05
>0,0S
>0,05
>0,05
Qua nghien cUu cCia chung tdi cho ket q u i ti le nhCfng t i c d u n g khdng m o n g m u d n cua 3 lieu nhu sau:
* Ti le buon ndn vd ndn: Nhdm I cd 1 benh nhan (0,8); Nhdm II cd 2 benh nhan (1,6%)); Nhdm 111 ed 3 benh nhan (2,5%). SU k h i c biet giUa cac nhdm khong cd y nghTa t h o n g ke (p > 0,05).
Theo nghien cUu cua Pham Dong An va Nguyen Van ChUng ti le ndn va buon ndn (10%) khi ket hpp 12mg bupivacain vdi 20pg fentanyl [1].
* Ty le ngda: Nhdm I cd 20 benh nhan (16,4%);
Nhdm II ed 17 benh nhan (13,9%); Nhom III cd 15 benh nhan (12,4%)). Ti le khac nhau giUa cac nhdm khong co y nghia t h d n g ke, vdi (p > 0,05).
Randalls B va cpng su [5] phdi hap fentanyl GTTS cho md lay thai thay tyle ngda la 2 1 % .
* Dau dau
Nhdm I CO 4 benh n h i n (3,3%); Nhom II cd 5 benh nhan (4,l%i); Nhdm III cd 7 benh nhan (5,8%), khac biet nay khdng cd y nghia t h d n g ke, vdi (p > 0,05).
Morewood GH [2] nghien cUu ty le dau dau (Post Dural Puncture Headache - PDPH) tren 366
benh nhan dUOc g i y te tuy sdng bang eae loai kim khac nhau da thu duac ket qua: 9% ddi vdi kim 25G, 8% ddi vdi kim 26G, Quincke va 1,5% ddi vdi kim 24G Sprotte. Mpt nda sd benh nhan dau dau nay duoc dieu trj bang ky thuat Blood Patch tren khoang ngoai mang cUng. Ong cdn ket luan rang ty le dau dau tha'p han d loai kim Sprotte (dau khdng nhon - Non Cutting Tip) so vdi kim Quincke dau nhpn (Cutting Tip) cd kich thude nho han. Rut ra ty le PDPH la 9,6% khi sU dung kim Sprotte 24G, ty le nay la 20% khi sU dung kim Quincke 26G.
5. Ket luan
Qua nghien cUu tren 365 san phu md lay thai lan dau tai benh vien Phu san Ha Noi chia ngau nhien thanh 3 nhdm gay te tuy sdng bSng bupivacain 0,5% ty trpng cao vdi c i c lieu 7,8 va 10 mg cung ket hop vdi fentanyl 40ng thUe hien d v j tri L2-3 chung tdi nhan thay tac dung khdng mong mudn gida cac lieu:
* Trong mo
- Cac bien ddng giam huyet ap t i m thu va huyet ap trung binh t h u d n g xay ra trong vdng 4-6 phut
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY dau sau khi tiem thudc te vao khoang dUdi nhen x i y ra sdm hon va chiem ty le cao nhat d n h o m III {pri <
0,05 ; P;-3 <0,05 ; p,-; >0,05).
Ty le buon ndn, ndn t r o n g mo d n h d m III (37,2%) cao han han so vdi n h d m I! (3,3%) va n h d m I (1,8%). SU k h i c biet rat cd y nghia t h d n g ke ( p < 0,001).
- Ty le ret run trong md d nhdm III (40,5%) cao hon han so vdi n h d m II (4,1%) va nhdm I (0,8%), SU khac biet rat cd y nghia t h d n g ke (p < 0,001).
* Sau mo
C i c tac d u n g khong m o n g m u d n d c i ba n h d m khdng cd sU k h i c biet vdi p > 0,05.
N h u vay nhdm II cd it t i c d u n g khdng m o n g trong mo it nhat so nhdm III ( p < 0,05). Nhu'ng t i c dung vd cam lai tdt hon d nhdm I (nhdm I la 84,6%
va nhdm II 12,8%). Su khac biet cd y nghia t h d n g ke vdi p < 0 , 0 5 ,
Tai lieu t h a m k h a o
1. Pham Dong An, Nguyen Van Chdng (2005), "Hieu qua gay te tuy sdng bang hon hop bupivacaine (marcaine) va fentanyl trong md lay thai", tr. 24 - 25
2. Cao Thj Bich Hanh, Nguyen Thu (2002), "GTTS bang Marcain 0,5% trong phau thuat chi difcfi", Tap chf thdng tiny duac, so 1, tr. 21 -23.
3. Morewood GH, (1993), "A rational approach to the cause, prevention and treatment of postdural punaure headache", CMAJ1993,149, pp. 1087-1093.
4. Ngiam 5KK., Chong JL. (1998), "The Addition of Intrathecal Sufentanil and Fentanyl to Bupivacaine for Cesarean Section", Sing med J, 39 (6), pp. 236-240.
5. Randalls B„ Broadway JW., Browne DA., Morgan 6M, (1991), "Comparison of four subarachnoid solutions ina needle-through needle technique for eleaive cesarean section", er J Anaesf/i 1991,66, pp. 314-318.
u, Shende D., Cooper GM., Bowden Ml. (1998). "The influence of intrathecal fentanyl on the characteristics of subarachnoid block for cesarean section". Anaesthesia, 53, pp. 706-710.
Sheskey M.C, Rocco AG, Edstrom H., Francs DM.
(1983), "A Dose - Response Study of Bupivacaine for Spinal Anesthesia",-4ne5f/iAna/g, 62, pp.931 -5.
