TAP CHl NGHIEN CLPU Y HQC -
HIEU QUA GIAM DAU SAU MO VA TAG DUNG KHONG MONG MUON CUA HAI LI^U MORPHIN TOrSONG
TRONG P H A U THUAT THAY KHOT HANG
Nguyin Q u i c A n h " , Nguydn Toan Thdng", Tidu Tidn Quan^
Trwang dai-hoc Y Ha Ngi, " Binh viin Bach Mai; ^Bpnh vien tinh Phii Thg Nghien cOv tien cOii, ngiu nhien, mu ddi nhim mijc tiiu so sanh hi$u qui giim dau sau mS va tac dijrtg khdng mong mudn cua hai lieu morphin tuy song 0,1 mg va 0,2 mg trong phiu thu$t thay khdp hang toan bp. Benh nhin dwgc chia lim hai nhom (nhom I, n = 30, 0.1 mg morphin va nhdm ll; n = 30. 0.2 mg morphin). Kit qua khong cd khac biet vi cic dac diim lien quan din b$nh nhan, gay me vi phiu thuat glOa hai nhom Thai gian giam dau sau mo. lieu thu paracetamol trong 48 gia dau a nhdm I va ll twang img la:
18.52 ± 3.14 va 23.86 ± 3.4 gia (p < 0.05), 7,57 ± 0.57 va 4,73 ± 0.45 gam (p > 0.05). Diem VAS tmng binh khi nam yen va v$n dpng tai cac thai diem sau mo ddu dwai 4 Ty Ip buon ndn vi ndn, ngwa va bl dai d nhdm I vi II twang Crng la 13,3% & 43.3%, 10% & 20% (p < 0.05). 16.8% & 26.7 % va 23,3% va 30%
(p > 0,05} Khdng co khic bl$t vi mwc an thin vi thoa man vdi giam dau, khdng gip wc ehi hd hip a hai nhom Kit luan' lieu 0.2 mg cd thai gian giam dau sau md dai han. tuy nhien ti 1$ ndn va budn ndn sau mo cab-han so vifn liiu 0,1 mg.
TLF khoa: morphin tuy sdng, giam dau sau mo, thay khwp hang loan bo
I. DAT VAN D&
Kiem soat hidu qua dau sau m l ludn Id mong muon cfla benh nhdn m l i khi phai phau thudt Ngodi yeu to nhdn dao, cdc anh hudng vd mgt tdm ly, giam dau khdng hieu qua edn cd the gdy ra nhieu roi loan tgi cac he t h i n g ca quan trong co the (ddc bidt Id hd hap, tudn hodn, ddng mdu, mien dich), tu' do gop phdn Idm tdng ti Id b i l n chfl'ng thdm tri Id tu vong lidn quan d i n phdu thudt [1] Thay khdp hang toan bp CO xu hudng ngdy cdng gia tang, neng tgi Hoa Ky hdng ndm cd khoang 244000 ca thay khdp hdng Ddy Id phSu thuat gay dau nhilu sau mo ddc bidt trong 24 gid ddu, cdn ly lieu phdp.vd phuc h l i chiic nang sdm do do
Dia chl liSn ti§: Nguyen Toan Thing, B^i mdn Gay m§ H6I sue. Truong D^i hoc Y Ha N(ii
Email thanggmhs@gmail com Ngay nhin 26/1/2015 Ngay duac chSp thuan 31/5/2015
giam dau hieu qua c6 vai trd hdt sfl'c quan trong [2]
Til' khi khdm phd ra hd thong opioid ngi sinh each day ba thap ky, si> dung cac opioid qua dudng tfly song cdng trd ndn pho b i l n han trong giam dau san khoa, k i l m soat dau man tinh vd dau cap tinh sau phdu thudt [3]
Nghien cfl'u tren ddng vdt thuc nghiem vd tren ngu'di cho thay cdc opioid u'a nu'de (hydrophilic) nhu hydromorphone vd morphin g i n vdi cdc thu the ddc hieu tai sung sau tfly s i n g manh han so vdi cdc opioid ua md (lipophilic) nhu' fentanyl hay sufentanil. Dilu nay giai thich cho su' khdc biet v l du-ac lifc hgc va d y a c ddng hgc cua hai logi opioid noi tren Cdc opioid ua m d khd dat d u g c vd duy tri n l n g dg dfl cao tai vj tri tdc dung do sy ling dgng t h u l c tai md m d ngodi mang cflng va thai tru' nhanh qua h u y l t t y a n g tfl" khoang ngoai mdng cfl'ng va tuy song, do dd giam dau
TCNCYH 94 (2)-2015
bi han c h l vd phgm vi cflng nhy thdi gian, trong khi cac tdc dung khdng mong m u l n tren tuy cOng x u l t hidn s d m han. Nguac lgi, morphin la t h u l c cd tinh kha dung sinh hgc (bioavailability) tai tfly s i n g cao han ndn cd tac dyng giam dau tot vd keo ddi sau m l , trong khi ty Id cdc tac dung khdng mong m u l n cd xu h u d n g nhidu han [3, 4 ] .
N h i l u nghien cu-u cho thdy su' dung mor- phin d u d n g tuy sdng cd tdc dung tdng cudng vd cam trong mo (tdc dung hiep d i n g vdi thuoc td) ddng thdi keo ddi giam dau sau mo.
Nhin chung, hieu qua giam dau cd "hidu fl'ng trdn" trong khi tdc dgng khdng mong m u l n ty le thuan vdi l i l u dflng, d l can bdng d i l u nay cdc lieu nhd morphin d u d i 0,3 mg thydng dug-c s u dung tren ldm sang. Bdn canh nguy CO gay fl'c c h l hd hap morphin tfly song cung lien quan d i n cac tdc dung khdng mong mudn khdc nhu buon ndn, ndn, ngira. an thdn sdu, bi dai[3]
Vdi phdu thudt thay khdp hang l i l u morphin d u g c sfl" dung thay d l i tfl' 0,05 - 0,3 mg, pho bien t u 0,1 - 0,2 mg, l i l u cao han cd the keo dai tdc dung giam dau nhu'ng lal ldm tang ti Id tac dung khdng mong m u l n [5; 6].
u l u t i l u u vdi hidu qua giam dau t i t va keo dai trong khi cdc tac dung khdng mong m u l n la t i l t h i l u vdn cdn khdc biet giu'a cac tac gia [3, 7, 8]. Morphin khdng cd c h i t bao quan cho gdy te tfly s i n g mdi cd tgi Viet Nam trong nhdng nam gdn day, do dd chua cd nhilu nghidn ciJu v l anh hudng cua l i l u thuoc len hidu qua giam dau cung nhu cdc tdc dung khdng mong m u l n trong phdu thudt thay khdp hdng. Chinh vi vdy chflng toi dgt van d l t i l n hdnh nghien cfl'u ndy nhdm muc tiduh so sanh hidu qua giam dau vd cdc tac dung khdng mong m u l n cua hai lieu morphin tuy s i n g 0,1 va 0,2 mg trong phdu thudt thay khdp hdng toan bg
TAP CHl NGHIEN CU'U Y HQC
II. D 6 | TU'Q'NG VA PHU'aNG PHAP
1. Odi t u ' g n g : bao gdm 60 bdnh nhan dug'c chi dmh thay khdp hdng cd chuan bi dap fl'ng du cdc tieu chuan
Tieu chuin chon benh nhan: Bdnh nhdn tu' 18 tuoi trd len, cd phdn logi sfl'c khoe theo ASA (American Society of Anesthesiologists) tfl' l-lll, dd du'ae giai thich vd dong y tham gia nghien cfl'u, cd phuang phap vd cam la gdy td tfly s i n g .
Tieu chuan loai trCr benh nhan Cac trydng hg'p c h i n g ch] djnh gay td tfly s i n g ( r l l loan dong mdu, nhidm trung tai nai choc kim, bdnh ly tim mgch ndng, khdng m u l n gdy td tfly s i n g . . . ) , suy giam y thfl'c. t i l n sfl' dung ma tuy va d i l u tn opioid keo ddi, dien b i l n b i t t h y d n g trong vd sau mo (ehuyin phuang phap vd cam, thdt bai phau thudt, khdng muon t i l p tuc tham gia) va di u-ng vdi cdc t h u l c sfl' dung trong nghidn cfl'u
2. Phu'ang phap
Nghien ciJu t i l n cfl'u ldm sang, ngdu nhidn, mfl ddi dug'c thyc hien tai khoa Gdy md h l i SU'C vd khoa Ngoai benh vidn Bach Mai tir thdng 3/2013 d i n thdng 9/2014
Ph ucng tien va th uoc dung trong nghien euu
Monitor da thong s l tgi phdng mo vd phdng h l i tinh, cac phyang tien, thuoc cap cfl'u can t h i l t T h u d c ddnh gia dau (VAS Visual Analog Scale) phdn dd tu' 0 d i n 10 Thuoc td tfly s i n g (Bupivacaine Heavy 0,5%
cua hdng Astra Zeneca), morphin khong cd chdt bao quan (Morphini sulfas WZF 0 , 1 % spinal cfla hang Polfa, Balan).
Cac famyc tien hanh
Bdc sT gay me thfl' nhdt thu'c hien thdm khdm trudc mo vd theo ddi ddnh gia benh TCNCYH 94 (2)-2015
TAP CHl NGHIEN CO-U Y HQC • nhdn sau mo (bao gom ca dau). Bdc sT gay me thfl' 2 la ngudi rut tham va thyc hidn gdy td tfly song.
- Thdm khdm, ddnh gid vd chuan bi benh nhan trudc mo duac thuc hien nhu thudng quy Bdnh nhdn dup'c giai thich v l nghien cfl'u, cdeh luang gid d i l m dau (thudc VAS) va xac nhdn d i n g y tham gia nghidn cfl'u.
- Tai phdng mo sau khi thidt lap dudng truyen, ldp cdc theo ddi didn tim, h u y l t ap, Sp02, tan s l thd bdnh nhdn duac tidn me dydng tTnh mach bdng 1 - 2 mg midazolam.
Cdc bgnh nhdn dug'c rut thdm ngdu nhien vdo hai nhdm, nhdm I (dung 0,1 mg morphin), nhdm ll (dflng 0,2 mg morphin). Dgt t u t h l ndm nghidng v l bdn phdu thudt, t i l n hanh gdy te tfly s i n g bdng kim 25G, vi tri chgc uu tidn L3 - 4 Sau khi xdc dinh djch nao tfly, tiem hdn hap thulc gdm bupivacaine (tfl' 6 - 7 mg) k i t hgp vdi mdt trong hai t i l u morphin d tren, T i l n hdnh ddt tu' t h l phdu thudt sau khi duy tri ndm nghieng 3 phut
- Theo ddi vd thu thap cdc thdng sd nghien cuu trudc, trong mo vd sau mo d eac thai d i l m td'ng gid trong 6 gid ddu, 2 gid mdt ldn trong 6 gid t i l p theo, 3 gid mgt lan trong 12 gid tiep theo vd 6 gid mgt ldn • trong ngay thfl' hai (quy u d c tfl' H I d i n H48) Bdnh nhdn du'p'c b l xung paracetamol 1 g/lan/mdi 4 - 6 gid khi diem VAS > 4 Bi ddi dug'c xdc dinh bdnh nhdn cd cdu bang quang can ddt xdng t i l u .
Cac thong so danh gia
Thdng so lien quan ddn benh nhdn (tuoi, gidl, can ndng, t i l n su), gdy md (hlu bupiva- caine, lieu morphin) vd phdu thuat (du'dng rach da, thdi gian mo)
Thdng so vd hieu qua giam dau sau mo d i l m VAS khi ndm ydn va vdn d$ng, thdi gian giam dau sau mo (thdi gian cho den khi diem VAS a 4) va tidu thu paracetamol trong 48 gid sau mo
Thdng s l lidn quan den thay doi ve hd hdp (tan s l thd, bao hda dxy), h u y l t ddng (mach, h u y l t ap trung blnh) vd cdc tdc dung khdng mong m u l n ; b u i n ndn, ndn, ngflra, bi dai, mfl'c dd an than (theo diem Ramsay), mflc dO thda man vdi giam dau (3 mdc: rat hdi long, hai long, khdng hdi ldng).
3. Xfl- ly s d lieu; s u dung phan mem SPSS 22.0, SU' dung test Mann-Whitney d l so sanh 2 gid tn trung binh, test khi binh phu'O'ng d l so sanh 2 ty Id, khac bidt d u g c coi la c6 J nghTa t h i n g ke khi p < 0,05.
4. Dao du'c n g h i e n cfl'u
Benh nhdn hoan toan t y nguyen tham gia vdo nghien cfl'u vd cd q u y i n rflt lui bat cfl luc ndo md khdng anh hydng d i n quyin lai dilu tn. Cdc thdng tin cfla bdnh nhdn dugc bao mat
111. K t T QUA
1. Dac d i l m lien quan den benh nhan, gay me va phdu t h u a t
Khdng cd khac bidt y nghTa giu'a hai nhom ve cdc ydu t l lidn quan den bdnh nhdn, gay me va phdu thuat (p > 0.05) (bang 1),
2. Hieu qua g i a m dau s a u m l 2.1. Diem dau trung binh tai eac thoi diem
Trong 48 gid ddu sau m l diem VAS trung binh d ca hai nhdm d i u d u d i 4 vd khong co khac biet giu'a hai nhom d mdi thdi d i l m ddnh gia ( p > 0,05) (bieu d l 1).
TCNCYH 94 (2) - 2015
• T A P S i H l NGHIEN CO'U Y HQC Bang 1 . B a c a i § m lien quan a j n b i n h n h a n , gay m e va phSu t h u a t Cac y e u t d Nhom I (n = 30) N h o m II (n = 30) Tuoi (nam)
GiCTi (Nam %) Can nang (l<g) ASA l-li (%) Ti^n siJ (%) Hutthu6c Say tau xe Benh l^hap hang (%) Hoai tu" vo l<huan Khac
Thai gian mo (phut) Ouffng rach da (cm)
51,2 ± 16.0 83.3 52,6 ± 6 , 2
53,3
60 16.7
93,3 3.7 70,2 ± 10,1
7,5 ± 1 , 2
47.8 + 15.5 80.0 53.6 ± 4 . 7
60
56.7 23.3
96,7 3,3 72,5 ± 10,3
7,8 ± 0 , 8 Lidu bupivacaine trung binh
Khi ndm yen Khi van ddng B i l u d d 1 . D i e m VAS t r u n g binh khi ndm yen va van d o n g ( N I = n h d m 1, N2 = n h d m 11) 2.2. Thai gian giam dau sau mo (thai gian cho den khi VAS > 4)
Thdi gian giam dau sau mo trung binh cua nhdm II (23,86 ± 3,4) dai han dang ke so vdi nhdm I (18,52 ± 3,14) (p < 0,05) (bieu d l 2).
2.3. Tieu thu paracetamol trung binh trong 48 gidr sau mo & nhom I va II tuceng irng IS 7,57 ± 0,57 va 4.73 ± 0,45 gram (p < 0,05)
TCNCYH 94 (2) - 2015
TAP CHI NGHIEN CU'U Y HQC -
23 86 :;: 3 4 18 52 + 3 14
Nhom 1 Nhom 2 B i l u d d 2. Thdn gian giam dau t r u n g binh sau m d ( g i d ) 3. Anh hu'dng tren h d hdp va tudn hoan
3.1. Thay doi ve ho hip
^
Tdn s l thd (Idn/phut) Sp02 (%) B i l u d d 3. T i n s d thd* va bao hda oxy (SpOz) trung binh ( N I = n h o m I, N2 = n h d m II) Thay doi v l tdn s l thd vd Sp02 trung blnh ddu trong gidi han blnh thudng, khdng cd khdc biet v l cdc gid tn nay giu'a hai nhdm d tdng thdi diem nghidn cfl'u {p > 0,05).
3.2. Thay doi ve tuan hoSn
\i. H'Z H'.y m-hZ' . • C i h - V ' H > H - : i ' l
Tdn s l tim (Idn/phflt) H u y l t dp trung binh (mmHg) Bieu d d 4. Tan s d tim va huyet ap t m n g binh tai cac t h d i d i d m
( N I = Nhdm I, N2 = Nhdm II)
TCNCYH 94 (2) - 2015
• TAP CHI NGHIEN cO'U Y HQC Cdc gid tri trung blnh cfla tan s l tim va huylt dp d i u trong gidi han binh thudng, khdng co khdc bi$t giu'a hai nhdm d tung thdi d i l m nghidn cfl'u, (p > 0,05).
4. Cac tac dung khdng mong mudn
Bang 2. Tac dung khong mong mudn
Nhdm I Nhdm II
Tac dung
khdng mong mudn % ni = 30
Ngira Bu6n non Non
5 4 3
16.8 13.3 10,0
8 13 6
26,7 43,3 20,0
>0,05
<0.05
Ramsay = 4
Bdnh nhan hai long 28
Ty Id buon ndn va non d nhdm I t h i p han cd y nghTa so vdi nhdm 11 (p < 0,05). Khdng cd khac biet giu'a hai nhom v l ti Id ngu'a, bi dai, d i l m Ramsay = 4 (khdng co d i l m 5 va 6) vd mdc do thda man vdi giam dau.
Khdng co trudng hap nao benh nhdn bi ngu-ng thd, t i n s l thd du'di 10 Idn/phflt hogc mach cham hay giam huyet dp c l n phai dflng t h u l c
IV. BAN LUAN
Kdt qua nghien cfl'u (bang 1) cho thdy khong co khdc bidt y nghTa giu'a nhdm I vd ll v l cac y l u t l tuoi, gidi, cdn ndng, phan loai sfl'c khoe (ASA), tidn sfl' hflt t h u l c , say tdu xe, nguyen nhdn ddn d i n thay khdp vd l i l u bupivacaine gay td tfly song Thdi gian p h l u thudt va dd ddi d u d n g rach da d hai nhdm cung t u a n g duong nhau. Day Id nhu'ng y l u to cd t h l anh hudng d i n cam nhdn dau, hidu qua cung nhu cac tdc dung khong mong m u l n cua phuang phdp giam dau [ 1 , 9; 10] S u d i n g nhdt nay d hai nhdm cho phdp so sdnh, danh gia khach quan va chinh xdc hon tdc dung cfla hai lidu morphin.
Thdi gian giam dau sau mo trung binh d nhom dflng morphin 0,1 va 0,2 mg trong nghien cfl'u cua chflng toi tu'ong fl'ng Id 18,52 ± 3 , 1 4 va 23,86 ± 3,4 gid (p < 0,05) (bieu 06 1), day Id khoang thdi gian trung vdi giai doan dau nhldu nhdt sau mo [2], K i t qua nay cung phu hgp vdi da s l cdc nghien cdu trudc day tren benh nhdn san phu khoa vd chinh hinh vdi thdi gian giam dau sau mo thay doi tu-15 - 24 gid vd thdi gian giam dau sau mo d nhdm dflng morphin hdu 0,2 - 0,3 mg dai han dang ke so vdi nhom dflng l i l u 0,1 mg hogc thdp hon [3, 6]. Tuy nhien, khi so sanh ba hlu morphin tuy song 50, 100 vd 200 meg trong phdu thudt thay khdp hang d cdc bdnh nhdn tren 65 t u l i Murphy khdng thdy khac biel v l thdi gian
TCNCYH 94 (2) - 2015
TAP CHI NGHIEN CU'U Y HQC • trung blnh cho d i n khi benh nhdn ydu cdu bo xung thdm giam dau gida hai hdu 100 va 200 meg (vdi thai gian giam dau trung binh khoang 1200 phflt) [7] Trdn thuc t l muc tieu keo ddi tae dung giam dau thudng bj han c h l bdi s y gia tang tdc dyng khdng mong muon khi sfl' dung l i l u tang ddn.
Chdt luang giam dau tdt the hidn d diem VAS trung binh khi ndm yen cung nhu- lflc van ddng ddu thdp ban 4 vd khdng cd khdc bidt giu'a 2 nhom d cac thdi diem ddnh gid trong 48 gid sau m l ( B i l u d l 2). D i l u nay cung tuong duong vdi k i t qua tu cdc nghien cfl'u cfla Murphy [7] vd Rathmell [8]. Mdc dfl vay, miJc dp tieu thu paracetamol d nhdm ll thap han ddng ke so vdi nhdm I vdi cdc gia tn tu'ong U'ng id 4,73 ± 0,45 vd 7,57 ± 0,57 gram (p < 0,05) T y a n g t u Rathmell vd cdng s y cung xdc nhdn tieu thu morphin qua giam dau do benh nhdn k i l m sodt (PCA) giam dan khi su' dung cdc hlu tang dan 100, 200 vd 300 meg morphin tuy song vdi cac phdu thuat khdp hang [8].
Bilu d l 3 vd 4 cho thay cac gia tn trung binh efla t i n so thd, SpOj, mach va huylt dp trung binh tai eac thdi d i l m sau mo deu trong gidi han binh thudng, khdng cd khac bidt giu'a hai nhdm d mdi thdi d i l m danh gid (p>0,05).
Mac dfl h i l m gdp nhung fl'c c h l hd hdp du'gc coi Id b i l n chi/ng nguy h i l m nhdt khi dung morphin tuy s i n g , vdi thdi d i l m xudt hien thu'dng mudn (pho b i l n tu" 6 - 12 gid vd co t h l tdi 19 gid sau dung morphin). T i le fl'c c h l hd hdp efla opioid tfly song d u g c cdng bo Id du'di 1 % vdi eac y l u to nguy c a Id bo xung opioid hodc an thdn tTnh mach, beo phi, ngu'ng thd khi ngfl [3] Trong nghidn cdu ndy chflng tdi khdng gap tru'dng hap ndo bj ngu'ng thd, Sp02 d y d i 90% hodc co tdn sd thd d y d i 10 Idn/phflt Mdt tong k i t 28 nghien ciiu ( g i m 790 benh nhdn dung morphin tuy s i n g va 524
bdnh nhan dflng gia dup'c) cho thay vdi lieu thdp hon 0,3 mg It cd nguy c a ire c h l hd hdp so vdi cac l i l u cao han [10]. Mfl'c dt an thin sdu d u g c coi Id mdt dau hidu bdo trydc tinh trang suy hd hdp va ludn dug'c theo ddi danh gid trong qud trinh d i l u tri dau cd sfl" dung opioid, chflng tdi khdng nhdn t h i y khdc bidtve ti le benh nhdn cd d i l m Ramsay = 4 giu'a hai nhdm {bang 2)
B u I n ndn vd ndn sau m l mac dfl khdng nguy hiem ngay d i n tinh mang nhung gdy khd chiu vd SCT hdi doi vdi bdnh'nhan. C a c h l gay ndn duac cho Id do tdc dung true t i l p cua t h u l c ldn trung tdm ndn tai hanh nao K i t qua cfla chung tdi eho t h i y ti Id b u I n ndn vd ndn d nhdm II cao han cd y nghTa so vdi nhdm I (vdi ti Id tyang ung' b u I n non 13,3% & 43,3%, ndn 10% & 20%. p < 0,05) (bang 2). K i t qua ndy phfl hgp vdi cac nghidn cfl'u trdn benh nhdn san khoa khi l i l u 0,1 mg cd ti le budn ndn va ndn thdp han so vdi l i l u 0,2 mg Tuy nhidn. Murphy vd Rathmell khdng thdy s u khac bidt vd ti Id ndn, budn ndn giija nhdm dung 100 va 200 meg morphin tuy s i n g [7; 8].
Ngda la mgt trong nhdng tac dung khdng mong m u l n thudng thdy nhat khi dflng mor- phin tfly s i n g ngay d l i l u thdp, vi tri xuat hidn thydng d vflng mgt co va ngyc. Chflng toi khdng thay s u khdc bigt y nghTa giu'a nhom I vd ll v l ti le ngu'a (16,8% & 26.7%. p > 0,05, bang 2). K i t qua nay thdp han so vdi nghien cfl'u cfla Slappendet (n = 143) vdi ti Id ngfl'a d l i l u 0,1 va 0,2 mg t u o n g iJng Id 48.6% vd 61,7% [9]. Mdt nghidn cfl'u khac cho thdy lilu 0,2 mg ldm tdng rd rdt ti Id ngfl'a so vdi l i l u 0,1 mg [7]. Anh h y d n g cua l i l u dung cflng du'ae xdc dinh trong mdt phdn tich gom 28 nghien CU'U vdi k i t qua Id lieu morphin £ 0,3 mg gay ngfl'a nhilu han so vdi cdc lilu t h i p (RR = 1.8, 95% Cl: 1 4-2.2 vdi l i l u < 0,3 mg vd RR = 5,0, 95% Cl 2,9 - 8,6 vdi h l u > 0.3 mg) [10].
30 TCNCYH 94 (2) - 2015
• TAP CHi NGHIEN cO'U Y HQC Bi dai CO the Id do giam chi phoi phd giao
cam dl ra gay gidn ca detrusor vd fl'c c h l gian ca thdt nieu dao (sphincter). Chflng tdi khong t h i y CO khdc bidt ve ty le bi ddi giO'a nhom 1 vd ll (tuang fl'ng la 23,3% vd 30%, p > 0,05, bang 2). D i l u nay cung phu hap vdi k i t qua cua Murphy va cdng s y [7], Chung toi cho r i n g viec lua chgn l i l u morphin tuy sdng nen can nhdc tren tu-ng benh nhdn cu t h l cdn d l i gida nhu cdu keo dai giam dau va nguy ca cud cac tac dung khdng mong m u l n Ndn SLP dung morphine h l u 0,1 mg vdi benh nhdn cd nguy c a cao b u I n non va non sau mo. Can cd them cac nghien cfl'u vdi c d mdu ldn hon va su' dung p h y a n g tien xac dinh nhu c l u bo xung giam dau khdch quan han (nhu' PCA) de khang dmh k i t qua cua nghien cfl'u
V. K£T LUAN
Nghien cfl'u trdn 60 benh nhan phdu thuat thay khdp hang cd chuan bi duac vd cam bdng gay te tuy s i n g su' dung bupivacaine k i t hap vdi hai l i l u morphin 0,1mg hoac 0,2 mg cho t h i y ddy la phuong phdp giam dau hieu qua va an todn L i l u 0,2 mg cd thdi gian giam dau sau mo ddi han nhyng ti le b u I n ndn va ndn cao hon so vdi hlu 0,1 mg Khdng co khac biet giu'a hai l i l u v l ti Id ngda, bi dai va mfl'c do an t h i n cung nhu- mfl'c dd hai long cua ngu'di benh
Lo'i c a m o-n
Chflng toi xin gyi ldi cam an chan thanh d i n cac bac sT, d i l u d y d n g khoa Gay me H l i SU'C, khoa Ngoai Benh vien Bach Mai va dac bidt cam an benh nhdn v l s u hap tac va flng hg cua ho trong qud trinh thyc hien nghien cdu nay
TAI LIEU THAM KHAO
1. Robert W Hurley, Jame D Murphy., Christopher L Wu (2014). Acute
Postoperative Pain, in Miller's anesthesia, R.D, Miller, Editor, 2974 - 2988.
2. Wiramus S, Delahaye D, Parratte S, et al (2014). Modern Anesthesia Techniques for Total Joint Arthroplasty From Blood Preservation to Modern Pain Control. Ann Orthop Rheumatol, 2(3), 1024.
3. Jamie D. Murphy, M., M. Harold J.
Gelfand, and M. Christopher L. Wu (2011).
Intrathecal Opioid Injections for Postoperative Pain, in Essentials of pain medicine, Honorio T Benzon and e t a l . Editor IM -212.
t . Bujedo, B.M (2014). Current evidence for spinal opioid selection in postoperative pain. Korean J Pain, 27(3), 200 - 209
5. Hassett, P., Ansari, B., Gnanamoorthy, P et al (2008). Determination Of The Efficacy And Side-effect Profile Of Lower Doses Of Intrathecal Morphine In Patients Undergoing Total Knee Arthroplasty.
BMC Anesthesiol 8, 5.
6. Bailey P.L, Rhondeau S, Sehafer P.G et al (1993). Dose-response pharmacology of intrathecal morphine in human volunteers Anesthesiology. 79(1), 49 - 59,
7. Murphy P.M, Stack D, Klnirons B et al (2003). Optimizing the dose of intrathecal morphine in older patients undergoing hip arthroplasty. Anesth Analg, 97(6), 1709 -1715
8. Rathmell J.P, Pino C. A, Taylor R, et al (2003). intrathecal morphine for postoperative analgesia a randomized, controlled, dose- ranging study after hip and knee arthroplasty Anesth Analg, 97(5), 1452 - 1 4 5 7
9. Slappendel R, Weber E. W, Benraad B et al (2000). Itching after intrathecal morphine Incidence and treatment. Eur J Anaesthesiol 17(10), 6 1 6 - 6 2 1 .
10. Gehling, M. and M. Tryba (2009).
Risks and side-effects of intrathecal morphine combined with spinal anaesthesia a meta- analysis Anaesthesia, 64(6), 643 - 651
TCNCYH 94 (2)-2015 31
TAP CHi NGHIEN COOJ Y HQC -
Summary
POSTOPERATIVE ANALGESIC EFFICACY AND ADVERSE EVENTS OF INTRATHECAL MORPHINE IN PATIENTS WITH TOTAL HIP
ARTHROPLASTY
This prospective, randomized double-blind trial was carried out to compare the postoperative analgesic efficacy and adverse profile of 0 1 mg and 0.2 mg intrathecal morphine in patients undergoing total hip arthroplasty. Patients were randomly divided into hwo groups' group 1 (n = 30) received 0.1 mg and group 11 (n = 30) received 0.2 mg The patient, anesthesia and surgery related charactenstics were comparable in two groups. The mean duration of analgesia (time to VAS = 4) and paracetamol consumption in group I and II were 18.52 ± 3,14 vs 23.86 ± 3,4 hours (p < 0.05) and 7.57 ± 0 57 vs 4,73 ± 0,45 gram {p > 0 05), respectively. Mean VAS scores at rest and active in both groups were less than 4 and similar at 48 hours after surgery. The frequency of nausea and vomiting, pruntus and urinary retention in group I and 11 were 13.3% vs 43 3%, 10%
vs 20% (p < 0.05), 16.8% vs 26 7 % and 23.3% vs 30% (p > 0 05), respectively. There was no significantly difference in patient satisfaction and sedation score between both groups and no case of respiratory depression was observed. In conclusion, 0.2 mg dose of intrathecal morphine produced longer postoperative analgesia but higher rate of nausea and vomiting than the 0,1 mg dose-
Key words; Intrathecal morphine, postoperative analgesia, total hip arthroplasty
TCNCYH 94 (2)-2015
