TAP CHi Y DUOC LAM S A N G 108 Tap 10 - So 2 /2015
Danh gia chirc nang loc cua than tren benh nhan phiu thuat bung gay me vong kin Imi lu-ong thSp bSng sevofurane
To evaluate the filtration of renal function during abdominal surgery under low-flow sevoflurane
Nguyen Quoc Tuan Benh vien Trung uang Qudn doi 108
Tom tat
fi/luc tieu: B a n h gia chUc nang Ipc cua than tren benh nhan phau thuat bung gay me vdng kin luu lupng thap bang sevofurane. €>dl tdong vd phdang phdp: Nghien cUu thUc hien d 45 benh nhan phau thuat bung sU d u n g ky thuat gay me vdng kin luu lupng thap bang sevoflurane vdi lupng khi bu 1 lit/ phut. Oanh gia mUc loc cau than bang phUOng phap Udc t i n h dUa vao creatinine huyet tuong theo cdng thUc Cockroft-Gault va phUOng phap do bang dupc chat phdng xa Technetium - 99m - diethyenetriaminepentaacetic acid (Tc-99m - DTP A). Ket qua- ChUc nang loc cua than, mUc loc cau than binh t h u d n g . Ket luan: Gay me vdng kin lUu lUOng thap khdng nanh hUdng den than va chUc nang Ipc cua than.
Tdkhoa: LUu lUpng thap, thuoc me bdc hoi, chUc nang than, sevoflurane
Summary
Objective: To evaluate the filtration of renal function during abdominal surgery under low-flow sevoflurane. Subject and method: The study was conducted in 45 patients of abdominal surgery under low-flow sevoflurane at a fresh gas flow level of 1 L.min-1. Methods for the determination of Glomerular Filtration Rate (GFR): To estimate GFR by Cockroft-Gault's equation from serum creatinine and the method of nuclear medicine by using Tc'^'^-DTPA (diethylene triamine penta acetic acid) Result The postanesthetic renal function and Glomerular Filtration Rate studies did not change. Conclusion: Low- flow sevoflurane Inhalation anesthesia has no significant effect on the renal function.
Keywords: Low-flow, inhalation anesthetics, renal function, sevoflurane.
I.Oatvande cac hop chat A, B, C, D, E; t r o n g d d h p p chat A d ndng dp cao gay doc cho than do lam t d n t h u o n g va Sevoflurane dUpc danh gia la cd nhieu Uu diem
nhu khdi me nhanh, t i n h nhanh, de kiem soat dp anh hudng den chdc nang Ipc cua than khi gay me ., ,. ^ , , . , , ^ ^ . , v d l l U u l U 0 n g t h a p [ 5 ] , [6],[7], [8].
me, huyet ap, n h j p t i m on d m h , khong kich thich 6 Viet Nam, sevoflurane dUdc sCr d u n g tU nam dUdng hd hap, ly tUdng^de khoi me qua ^UOng^ho ^QOO cung vdi ky t h u a t gay me v d n g kin luu lUdng t h a p (GMVKLLT) va nhanh chong ddac pho bien d cac benh vien, t r u n g tam y te ldn cua ca na6c da cho thay sa hieu qua va an toan, cai thien chat lUcfng gay PhSn bien khoa hoc: TS. N G U Y E N M I N H L Y nne [1], [2], [4]. Mac dij da duoc sCr d u n g kha pho 87 hap dac biet d tre em [3]. Nhuoc diem cua
sevoflurane la qua t r i n h chuyen hoa thuoc smh ra
JOURNAL OF 108 - CLINICAL IVlEDICINE AND PHARMACY Vol10-N"2/201S
bien d Viet Nam, nhUng nghien cdu ve Snh hUdng den chUc nang cua than khi gay m e bSng sevoflurane chUa cd nhieu. VI vay, chung tdi tien hanh nghien cUu nhSm muc dich:
Ddnh gid chdc ndng loc cua thdn vd tdong quan gida cdc phdang phdp xac dinh mdc loc cdu than d benh nhdn ddac gdy me bang sevoflurane vong kin vdi Idu Idang thdp 1 lit/phut trong phdu thudt bung.
2. D o i tuong va phuong phap
Od; tupng; Gdm 45 benh nhan phau thuat bung theo chUdng trinh dUdl gay me hd hap b^ng sevoflurane, t u o i t d 16 den 60, ASA l-ll, khdng cd bat t h u d n g he tiet nieu, cac xet nghiem trudc mo t r o n g gidi han binh t h u d n g .
Phdang phdp: Nghien cdu dupc tien hanh theo phUdng phap nghien cdu lam sang quan sat, tlen cUu.
Phdang tien: Thuoc me boc hoi sevoflurane, monitor VEGA, may gay me Datex-Ohmeda Aespire, cac may xet nghiem khac...
Tien hdnh:
Tien me Midazolam: 0,1 m g / k g , Fentanyl:
5mcg/kg. Khdi me Propofol: 2,5 mg/kg TIVlC, tracrium: 5 m g / k g , Fentanyl: 2,5p.g/kg.
Duy tri me: Sevoflurane 3%, theo ddi, lUa chon MAC phu hpp, khi bu 1 lit/phut FiO? 40%. Duy tri giam dau Fentanyl lieu 2 | i g / k g / h . Gian c o t h e o yeu cau cua phau thuat. Ket thuc gay me: The tfch khi bu
> 4 lit/phut, danh gia mirc dp t i n h cua benh nhan de rut dng NKQ.
Theo ddi nhjp t i m , HA tai cac t h d i d i e m : To: trLfdc khi khdi me, T,: sau khi khdi me, T2: sau khi GMVKLLT 15 phut, T3: sau khi GMVKLLT 30 p h u t , T4: sau khi kit t h u c gay m e VKLLT chuyen sang gay m e ddng m d . , Xet nghiem: Ure, creatinin, glucose huyet tharifr^
sinh hoa nddc tieu 10 t h d n g sd (pH, specific gravity, urobilinozen, glucose, bilirubin, ketone, blood,, protein, nitrite, leucocytes) vao cac t h d i diem: No:
ngay trUdc phau thuat, N3: ngay t h d 3 sau phau thuat, N5: ngay t h d 5 sau phau thuat.
D o dp Ipc cau t h a n b^ng dUpc chat phdng xa (dcpx) tai: NQ, N5.
Nghien cUu nay da dupc Hdi d d n g Dao ddc t r o n g Nghien cUu Y sinh hpc cCia Vien nghien c&i Khoa hpc Y DUpc lam sang 108 va Benh vien Trung u o n g Quan ddi 108 chap t h u a n .
XU ly so lieu b^ng phan m e m SPSS 18.0 va Medcalc 9.6.2.0.
3. Ket qua
Dgc diem benh nhdn: 6 0 % nam va 40% nU, tuoi t r u n g binh la 39,4 t u o i . Chieu cao t r u n g binh 166,48 cm d n a m , 152,17 d n O . Can nang t r u n g binh la63,03 kg d nam, 48,56 kg d nU. BSA t r u n g binh 1,78 m^ 6 nam, la 1,43m^ d nU. ASA I: 51,1%, ASAII:49,9%. Phau thuat: gan mat 40%, thUc quan da day 13,3%, dai trang 26,7%, ta t u y 40%, benh khac 2,2%.
Chdc ndng loc cua than Xet nghiem d u d n g mau va dien giai
BSng 1 . Xet nghiem ure, creatinin HT va GFR Udc tinh theo creatinin t h d i diem No va N3 (n=45)
^~""~"~~--~-~-,„,^^^ Thcfi gian Chi so ^ ~ ~ ~ ~ ~ - - - , _ ^ ^ ^ Ure HT (mmol/L)
Creatinine HT (nmol/L) MLCTUt* (ml/phut/l,73m')
No 'X±SD
4 , 1 6 + 1 77,87 ±13,97 83,099 ±13,527
N3
X±SD
3,87 ± 0,83 84,25 ± 14,09 76,92 ±18,37
P
>0,1
>0,1
>0,1 ' IvILCT dt :B6 Ipc cdu thdn ddc tinh theo cong thdc Cockcrolf-Cault.
Nhan xet: Ure, creatinine va MLCTut Ns, Nj khong co sa khac biet (p>0,01).
TAP CHI Y DUQC L A M S A N G 10 Tap 10-S6 2/2015
Bing 2. Xet nghiem ure, creatinin huyet thanh va GFR UAc tinh theo creatinin thcii diem N„ va Ns (n=45)
— — — _ _ ^ ^ Thcri gian
Chi so — — — _ _ _ ^ Ure HT (mmol/L)
Creatinine HT (limol/L) MLCTUt (ml/phut/l,73m=)
No X±SD
4,16 ± 1 77,87 ±13,97 83,099 ±18,527
N , X±SD 4,53 ±1,02 82,98 ±12,87 77,53 ±16,19
P
>0,1
>0,1
>0,1 Nhgnxet Ure, creatinine va MLCTut NO, N3 khdng cd su khac biet (p > 0,01).
Bang 3. The tich n u d c t i e u
^~~"~~~-~~,..,„^^^ Thofigian Chi so ^~~"~~~~--..,^
The tich nt trung binh The tich nt (min - max) The tich nt trung binh nt ml/kg/gid
No 1381 ±247,5 1100-1800
1,25 N, 1661 ±212,1 1350-2050
1,25 N i 1571±1145 1350-1850
1,21 N , 1550 ±138,2 1300-1850
1,19 N l 1442± 117,7 1250-1650
1,11 Ns 1403±131,6 1650-1100
1,08
W/idn xef; The tich nddc tieu t r u n g binh t r o n g gidi han binh thudng.
Bang 4. Xet nghiem sinh hoa nUdc tieu (n = 45) Chi so
pH Tl trong Glucose Mau Protein
No 6,45 ±0,38 1,21 ±0,09 Am tinh Am tinh Am tinh
Ns 6,52 + 033 1,17 + 0,11 Am tinh Am tinh Am tmh
Ns 6,43 ±0,36 1,19 ±0,08 Am tinh Am tinh Am tinh
P
>0,1
>0,1
N / i d n x e f : M L C T d c p x N O v a N5 khdng cd sU khac b i e t ( p > 0 , l ) .
So sanh tUOng quan:
- D p pH nUdc t i e u , specific g r a v i t y t r u d c m o va sau mo ngay t h U 3, ngay t h U 5 k h d n g cd sU khac biet.
- Cac chi sd khac deu am t i n h , khdng cd bat thudng d nudc tieu cac benh nhan tal cac t h d i diem sau gay me ngay t h d 3 va ngay t h U 5.
B^ng 5. MLCT do bang DCPX thcri diem No va Ns
^ ^ ^ h d i gian Chi so ^^-^^^^^
MLCTdcpx*
(ml/phut) No
X±SD
79,15 ± 15,76
Ns
X±SD
77,258 ± 16,521
P
>0,1
^ MLCT dcpx: Mdc loc cou thdn do bong ddac chat phdng xg.
Do thj 1 . iVILCTdcpx trUdc mo va creatinin trudc mo
He sd tuong quan r - 0,825 (p<0,001), R? - 0,682 Phuong trinh hdi qui: Y = -1,02X + 162,04 MLCTdcpx trudc mo va creatinin trUdc mo cd mdi t u o n g quan nghich chat che.
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol10-N''2/2015:
0 6 thj 2. IVILCTdcpx va creatinin sau mo ngay t h U 5
He sd tuong quan r = 0,821 (p<0,001), R: = 0,675 PhUdng trinh hdi qui: Y = -1,1X + 175,87 IVILCTdcpx va creatinin sau m d ngay thU 5 cd mdi t u o n g quan nghich chat che.
4. Ban luan
Ket qua t h u dupc cho thay nude tieu cua 45 benh nhan cd pH, t i trpng va urobilinogen nSm t r o n g gidi han binh t h u d n g d tat c^ cac t h d i diem xet nghiem (No, N3, Ns), cac yeu t d cdn lai cung am tinh. The tich n u d c t i e u t r u n g b i n h / 2 4 g i d v a the tich nudc tieu t i n h theo m l / k g / g l d tai cac t h d i diem xet nghiem trUdc mo, sau mo ngay thU nhat va ngay thU nam d t r o n g gidi han binh t h u d n g va khdng cd su khac biet cd y nghia t h d n g ke.
Xet nghiem glucose huyet tUdng tai cac t h d i diem khdng cd sU khac biet cd y nghTa t h d n g ke. Xet nghiem dien glal (Kali, Natri, Canxi) tai cac t h d i diem cung khdng ghi nhan sU bat t h u d n g benh ly. Ket q u ^ nay cung khdng khac biet vdi nhieu tac gia khac.
Ure huyet tUdng gicim nhe sau mo ngay t h U 3 va t r d ve binh t h u d n g ngay thU 5. Creatinin huyet t u o n g d ba thdi diem No, N3, Ns khdng cd su khac biet (so sanh cap tai cac thdi diem).
Trong nghien cdu nay, MLCTUT tal cac thdi diem trudc gay me (No), sau gay me 3 ngay (N3), sau gay me 5 ngay (Ns) khdng khac biet va n^m t r o n g gidi han binh t h u d n g .
MLCT tai No va N5 khdng cd su khac biet cd y nghia t h d n g ke. Xet tren cac do thj ve mdi tUdng quan cCia MLCTdtp* vao ngay No, N5 vdi creatinin ndl sinh cd su tUdng quan nghich vdi he sd tUdng quan rat cao r > 0,8.
KhSo sat d o t h i bieu d i e n sU t U d n g q u a n cCia MLCTut Udc t i n h va MLCTdcpx NO va N5 deu c6 ket quS t u o n g d d n g va t U d n g q u a n t h u a n vdi ^
t u o n g q u a n cao. >
I
5. Ket luan ^ Qua nghi§n cdu 45 b^nh nhan phau thuat bum
duac gay me vdng kin lUu luong thap bang thuoc nf*' hd hap sevoflurane vdi lupng khi bu 1 lit/ phut, daiif gia mUc ioc cau than b^ng phUdng phap udc tinh du!a vao creatinine huyet tUong theo cdng thdc Cockroft- Gault va phuong phap do bSng dupc chat phdng ^ Technetium 99m - diethyenetriaminepentaacetic acid fTc-99m - DTPA) da cho thay:
ChUc nang Ipc cua than khdng bj anh hudng, mUc Ipc cau than danh gia b^ng phUdng phap udc t i n h theo cdng thUc Cockroi^-Gault va phUdng phap do being duoc chat p h d n g xa cho ket qua binh t h u d n g tren 45 benh nhan phau t h u a t bung dUOc gay me v d n g kin lUu lupng t h a p bang sevoflurane vdi t h e tich khi bu 1 lit/ phut.
Tai lieu t h a m kh^o
1. Phan Thj Hd H^i va cs (2005) Bddc dau sddung Sevoflurane trong gdy me hoi sdc tgi Benh vi§n Dgi hoc Y dugc tp. Ho Chi Minh. Y hpc t p . Hd Chi Minh, 9(1), tr. 29-33.
2. Tran Thi Bich Huong (2004) Vai tro cua Creatinine huye't thanh trong tham dd chdc ndng loc cdu thdn.
Y hpc tp Hd Chi Minh 8{2), tr. 43-49.
3 Bill ich Kim (2002) Du'gc ly hgc Idm sdng cdc thuoc m^
ho hdp. Bai giang g§y m& hdi sdc, Tap I, tr. 436-465.
4. Di Filippo A et al (2002) Sevoflurane low-flow anaesthesia: best strategy to reduce Compound A concentration. Acta Anaesthesiologica Scandinavica 46(8): 1017-1020.
J. Evan D. Kharasch et al (2001) Long-duration low- flow sevoflurane and Isoflurane effects on postoperative renal and hepatic function.
Anesthesia & analgesia (93): 1511-1520.
6. Robert F. Bedford, Harlan E. Ives (2000) The renal safety of sevoflurane. Anesthesia & Analgesia (90):
505-508.
' Shoukat Hussain Khan et al (2005) Tc - 99m DTPA renal scintigraphy and renal ectopia: A retrospective analysis. Indian Journal of Nuclear Medicine 20 (1):
9-13.
8. Thomas J. Ebert, Shahbaz R Aram (2000) Renal responses to low-flow desflurane, sevoflurane, and propDfo//npcif/enfs. Anesthesiology (93): 1401-1406,
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