T? LE VA CAC Y^U T 6 NGUY CO COA MIJC DQ DAU
SAU P H A U T H U A T Bl^NG
I>dn Xudn Yen', Nguyin Van Minh^
(1) L&p Y6E, Tne&ng Dgi hgc YDugc Hui (2) Bg mon Gdy me - Hdi sue Tru&ng Dgi hgc YDugc Hui
Tdm t i t
Dgt van de: Dau 11 mgt van dd ldn ciia y te, li mdi quan tam hlng diu cOa bgnh nhin sau phau thult.
Dau sau phlu thuat de lai rat nhieu hgu qui nghidm trong cho bgnh nhan khdng chi vd thd chit ma ca ve tim ly. Quyen dugc giam dau 11 quyen ca bin ciia con ngudi. Tuy nhidn, tf Id bdnh nhin phii chju dau tien lim sing van cdn cao, dgc biet ll cic bdnh nhin phii tiai qua phiu thuit. Mi^c tieu: XIc dinh ty 1? cac muc dd dau vi yeu td nguy ca ciia miutc d0 dau ngng sau phlu thult b\ing. Phuorng phip nghien curu: Nghien cim mo ta tidn ctiu. Ket qua: Nghien cihi tien 114 bgnh nhin trii qua phiu thult byng thiy sau phiu tfiuit cd 9,65% khong dau hoic dau nhg, 25,44% dau vira vl 64,91% dau n|ng. Phiu thuit hd cd nguy ca dau nang sau phiu thuat cao hon phiu tiiugt ndi soi (OR = 3,79; CI (1,69 - 8,51); p < 0,05).
Khdng tim thiy mdi lien quan giua tudi, gidi, chi sd khdi ca thd BMI (Body Mass Index), mure dd lo sg, xdp loai siirc khoe theo ASA (American Society of Anesthesiologists), miic dd dau du kien trudc phiu thugt, loai phlu tiiugt, phuang phap phau thugt, phuang phip v6 cim, v\ tii phlu thult, thdi gian phiu thugt va lugmg fentanyl da diing trong phiu thugt vdi muc dd dau nang sau phau thugt Ket Iu|n: Ty Ig bgnh nhan dau sau phau thugt byng cdn cao. Phlu thu§t hd lien quan din miic dd dau ngng sau phau thugt.
T& khda: Dau sau phdu thudt, phdu thugl bgng, yiu id nguy ca Abstract
INCIDENCE AND RISK FACTORS OF ABDOMINAL POSTOPERATIVE PAIN Tran Xuan Yen'. Nguyen Van Minl^
(1) Class Y6E of Hue Universily of Medicine cmd Pharmacy (2) Hue University of Medicine and Pharmacy
Background: Pain is a major health problem, it is the top concern of patients after surgery.
Postoperative pain causes serious consequence not only physically but also psychologically. Access to pain management is a fundamental human right. However, the proportion of patients suffering from pain clinically remains high, especially the patients operated. Objective: To determine the incidence of postoperative pain and risk factors of postoperative abdominal pain. Methods: A prospective study.
Results: The study on 114 patients underwent abdominal surgery showed absence or mild pain 9.65%, moderate pain 25.44% and severe pain 64.91%. Patients who underwent open surgery reported severe pain higher laparoscopic surgeiy (OR = 3.79; CI (1.69 - 8.51); p <0.05). There was no relationship between age, sex, BMI (Body Mass Index), ASA, level fear, pain level expected before surgery, type of surgeiy, surgical methos, anesthesia, surgical location, surgery time and amount of fentanyl used with severe postoperative pain level. Conclusions: The incidence of postoperative pain in abdominal surgical patients was high. Open surgical approach was related to severe postoperative pain level.
Keywords: Postoperative pain, abdominal surgery, riskfador
- Dfa chi USn hf: Nguyen Vdn Minh, email: [email protected] ' ' ~' -'*
Ng^ nhgn bdi: 25/3/2016 • Ngdy dSngy ddng: 12/4/2016 * Ngdy xudt bdn: 29/4/2016 . J
Tgp chf Y Dugc hgc - Trudng Dgi hgc Y Duyc Hue - So D|c bift 113
LD^^TVANDfc
Hgi ngWen cuu dau qudc te (Intemational Association for tiie Shidy of Pain - lASP) djnh nghia: Dau Id mgt cdm gidc kho chju vd trdi nghiim cdm xuc xudt hifn cimg luc v&i sg tdn thuang thgc sg hcry tiim ldng cua cdc md hodc dugc mo Id theo kiiu gidng nhu thi [12]. [13].
Dau la mgt vin de ldn ciia y te v l ciia xa hgi dii khdng mdi, li mdi quan tam hang dau ciia bdnh nhin trii qua phiu thugt [15].
Theo tuydn bd Montreal 2011: Quydn dugc giam dau la quydn ca bin ciia con ngudi [14].
Dau sau phau thugt se de Igi rit nhieu hgu qui nghidm trgng cho bgnh nhin khdng chi ve thd chit ml ci've tam \f ndu khdng dugc didu trt higu qui. Tuy nhien, tf Ig bgnh nhan chju dau sau phiu thuit cdn cao. Theo nghien cuu d Brazil (2009) 11 46%, or Anh (2002) la 67,2%, d Hdng Kdng (2003) li 84,7%, d Mf (2011) la 80%, phin Idn bgnh nhan phii chju dau tir muc dd trung binh ddn ning [6], [7], [8], [12]. 6 Vidt Nam chua cd nghien cuu nio ve van de niy.
Do dd, de dinh gii th^c trgng nhim cii thidn qui tiinh dieu trj v i chim sdc bgnh phan sau phlu thugt ndi chung v i sau phlu thuit byng ndi rieng, chung tdi th\rc hidn dd tli: "Ty 1$ vd cdc yeu ti nguy cff c&a m&c dg dau sau phdu th ugt
bitng", nhim hai myc tieu cy the sau:
1. Xdc dfnh ly If cdc mdc dg cua dau sau phdu thugtbyng
2. Xdc dfnh cdc yiu td nguy ca cua dem ngng scm phdu thugt bung
2. DOI TirONG VA PHlTONG PHAP NGHIEN c t r u
2.1. Doi tirgrng nghien cuu
Bgnh nhin cd chi djnh phlu thugt byng, dugc gay me hdi siic tiiudng quy tgi khoa Gay me - Hoi sire bgnh vi^n Trudng Dgi hgt Y Dugc Hue tii 5/2015 ddn 3/2016.
2.I.I. Hiu chain chgn b$nh
Bgnh nhan phlu timit byng tur 16 tudi trd ldn, dong y tham gia nghidn ciiu, hidu dugc phuang phap dinh gia dau tiieo VAS, bgnh nhin nim trong nhdm ASA I, ASA II, ASA UI tiieo tidu chuin dinh
gii siic khde bdnh nhin trudc md ciia Hdi Gay me Hoi siic My.
2.1.2. mu chudn logi trit
Bgnh nhin dudi 16tudi, bdnh nhin khdng ddng f tham gia nghien cihi, bgnh nhin cd roi logn cam giic, bgnh nhin cd rdi logn tam than.
2.2. Phuorng phip nghiSn ciru Nghien cihi mo t i tidn cihi
Chgn bdnh nhin theo tidu chuin chgn bgnh, dugc gay me hdi siic v l giim dau sau phlu thugt theo phic do thudng quy ciia khoa.
Sau phau thugt dinh gii miic dg dau bing thudc VAS (Visual Analogue Scale) liic nghi va liic vgn dgng tgi cic thdi diem 6 gid, 12 gid, 18 gid vi 24 gid: khdng dau ho^c dau nhg VAS tii 0 - 30 mm, dau viia VAS tii 31 - 69 mm, dau ngng VAS tii 70 - 100 mm. Miic dg dau cua bgnh nhin trong 24 gid diu sau phlu thugt li diem VAS cao nhit tiong ngiy.
Dinh gii miic dd hii Idng ciia doi tugng nghidn ciiu vd didu tri dau sau phiu thugt theo phic dd ctia khoa.
Ghi nh|n cic thdng sd vd tudi (nim), gidi, BMI (kg/m*), ASA, muc dO Io ling trudc md (Theo thang diem HADS - Hospital Anxiety and Depression Scale), miic dd dau d\i kien trudc mo (Theo VAS nhu trdn), logi phlu thugt, phucmg phip phlu thu$t, vi tri phlu thuit, phuang phip vd cim, thdi gian phlu thugt (phut), lugng fentanyl da dung trong phlu thugt (^g) dd phan tich mdi lien quan vdi miic dd dau n$ng sau phlu thu$t.
Xti ly sd ligu bing phin mdm thdng ke y hgc tiidng thudng, dd tin cgy 95%, p < 0,05 dugc xem cd y nghia thong ke.
3. K £ T QUA NGHIEN Ctitl 3.1. D$c didm chung
Bang 1. Die didtn gidri vi ASA ciia ddi tugng nghien cuu Thong
GiM ASA
Nam/Ntt
yarn
n 36/78 69/35/10
%
31,58/68,42 60,53/30,70/8,77 114 Tsp chl Y Diryc h(K; - 'n'ii*ng B»l hgc Y Diryc Hui - sS B}c bi|t
Bing 2. D|c diem tudi vi BMI eia ddi tugng nghidn cihi ThSag so
'nioi (nam) BMI (kg/m^)
(±SD) 45,76t 15,77 20,50± 2,40
Min 19 15,60
Max 79 28,40
Loai phau thu^t Phuorng phap phiu thu^t Vjtri
Phuorng pbap vo cam
Bing 3. Dgc diem gay me vi phau
Tidu hda/Tiet nidu/ Phy khoa Ngi soi/phau thugt hd Trdn rdn/ Dudi rdn/ Cl trdn va dudi ron
Gly md/ Gly td tiy sdng/ Gly md v l td ngoli ming ciing
thuit n 43/31/40
45/69 35/62/17
79/31/4
%
37,72/27,19/35,09 39.47/60,53 30,70/54,39/14,91
69,30/27,19/3,51 Bang 4. Thdi gian phau thuit va tugng fentanyl dl dung tiong phiu thugt
Thdng sd Thdi gian phau thu|it (phiit) Lugng fentanyl nhdm giy md (fig) Lirgng fentanyl nhom gay te (fig)
(±SD) 72,02 ±3,07 154,94 ±28,29
20,84 ± 9,6
Min 30,00
100 0
Max 180,00
250 30 3.2. Ty l | dau sau phau thuit
Bang 5. T^ Id cic muc dg dau trong 24 gid sau phlu thugt Mth: d9 dau
Khong dau vh dau nh^
Vira Nang
Tong
D
11 29 74 114
%
9,65 25,44 64,91 100
Bilu do 1. Ty Ig dau luc nghi
Tgp chf Y Dugrc hgc - TruJmg Dgi hgc Y Duffc Hui - So D$c bift 115
6 gio 12gid ISgid 24 gid
—Khong dau hoic dau nhe ~*—Dauviia —*—BaunSng
Bieu do 2. Ty Ig dau luc vgn ddng
so
70 60
«3 50
^ 40 30 20 10 0
69
* » _ — _ 6 i
^ an
6si6 12gio
—*—N^Ingca
ISgio
—•—VSndOng
24 gio
Bieu do 3 . Tnmg binh miic dd dau
33. Mac dg hai long v e dieu tr| dau sau phau thu^t cua doi tugng nghien cihi Bang 6. MOrc dg hii long
Mirc d$ hai long Hiildng Khong hai long
Tong
N 59 55 114
%
51,75 48,25 100 3.4. Cic yeu to nguy co* cua dau sau phSu thu^t bung
Bang 7. Cac yen td nguy ca
I^ioi (nam) Gioi BMI (kg/ni') ASA Lo lang
16-<60
>60 Nam '
Ntt
<18,5
>1S,5 I
II vara
Khong
ca
Dau n^g Co 56 18 27 47 13 61 40 34 62 12
Khong 32
8 9 31 11 29 29 11 31 9
P 0,60 0,13 0,21 0,05 0,41
T«p chi Y Diryc h?c - Tririrag B»i hgc Y Duvc Hoi - S6 D^c hlft
Mirc d9 dau dv kiin Loai phSu thu^t
Phirong phap phau thu^t
Vjtri
Phinmg phap vo cam
ThM gian phau tfau^t (phiit)
Lirgng Fentanyl da diing (fig)
Khong v^ vura N§ng Tieu h6a Tilt ni?u Phy khoa Npi soi Mohdr Tren ron Dudi ron Cii tren va duoi ron
Gay mS GSyte Gay me va gSy te ngoii
mang cihig
<60
>60
<150
>150
49 25 24 21 29 21 53 18 42 14 49 21 4 36 38 40 9
22 18 19 10 11 24 16 17 20 3 30 10 0 27 13 28 2
0,24 0,26
0,01 •
0,07
0,29
0,05
0,15
*OR = 3,79; CI (1,69-8,51) 4. BAN LUAN
Nghien cuu cua chiing tdi th\ic hign tren 114 doi tugng II bdnh nhin trii qua phiu thudt vio d byng thudc cic chuydn khoa tidu hoa, tiet nigu vi phy khoa. Dd tudi trung binh cua doi tugng nghien ciiu la 45,76 ± 15,77 tudi, nhd nhat 11 19 tudi vi I6n nhit la 79 tudi. T;^ Ig theo gicri, theo ASA ll khdng tucmg ducmg voi sd lugng nQ II78 nguai (68,42%) vi nam la 36 ngucri (31,58%), sd lugng ddi tugng nghien ciru theo ASA I, ASA II vl ASA III lin lugt l i 60,53%, 30,70%, 8,77%.
Nghien cuu cua chiing tdi c6 d?c diem chung ve tudi, gi6i tucmg ddng v<M nghidn cihi ciia Caumo, nghien cuu cua Gagliese v l nghien ciiru ciia Lau, d^c dilm vd ASA khdng tuorng ddng [4], [9], [14].
M|c dCi da c6 nhieu tidn bd trong dieu trj dau sau phlu thu9t nhung ty Id bdnh nhin phii chiu dau sau phSu thuit cdn cao, die bi$t la dau 6 mirc dd viJra vl n|ng. Van dd niy dl dugc de c^p nhieu trong y vin vi dugc md t l or nhieu nghien ciru khic nhau nhung cr Vidt Nam thi cdn h^n chd.
Myc dich nghien ciru ciia chung tdi cung cap ty Ig vd mflrc dg ciia bgnh nhin sau phlu thuit, ket qui
chiing tdi trinh biy d tren cho thay tf Id trong 24 gicr dau sau phiu thuit c6 9,65% khdng dau ho|c dau mure dd nhg, dau mirc dd vura li 25,44%, dau miic dg n|ng II 64,91%. Nghien ciiu cua chung tdi c6 kdt qui tuong duong vdi nghien ciiu cia Thai Hoing De (85,88%), Apfelbaum (80%), Chung (84,7%) [1], [2], [6]. Tuy nhidn, khic bigt so vdri nghidn cuu cua Cauceiro (46%), Caumo (43,4%), Beauregard (40%) [3], [4], [7]. Sy khac bidt nly CO the ll do ddi tugng nghien curu khdng hoin toln gidng nhau ve dd tudi, vd logi phiu thu^t, ve miic dd ning ciia bgnh, khic nhau ve chat lugng phlu thult, chat lugng chim soc hiu phlu, khac nhau ve didu trj giim dau da diing, bdn c^nh do thi holn cInh vi dieu kign nghidn curu khic nhau.
Ve mirc dd hii long ve ket qui didu trj dau, cd 59 ddi tugng (51,75%) hai long vi 55 ddi tugng (48,25%) khong hii Idng. Ket qui nay khdng phii hgp v6i 64,91% ddi tugng nghien ciiu phii chju mirc dg dau n|ng sau phSu thuit. Tuy nhien, cic nghien ciiru ciia Gan, cua Apfelbaum cilng cho ket qui tuong ty [2], [10]. Khdng c6 l;y' do giii thich ro ring cho sy khong tuong ddng giita miic dg dau vl mijrc dg hii long. Theo chung toi li do bgnh nhan T?p chi Y Dugrc hgc - IVu^g D^i hgc Y Dirge Hue - So D$c bift 117
hii long vdri thai d$ chim sdc cia nhan vidn y te hole do quan nigm phau thu^t 11 phii dau.
Ve cic yeu td nhan trie hgc gdm tudi, gidi, BMI, nghien ciiu ciia chiing tdi khdng tim thdy mdi lien quan c6 y^ nghTa thdng ke v6i miic dd dau n|ng sau phlu thulit byng. CIc ydu td niy, cic nghien ciiu khic nhau cho cic kdt qui cdn khic nhau. ASA II yeu td cd lien quan den miic dd dau sau phlu thuat is nhieu nghien curu nhu nghidn cihi cua Chung (ASA I c6 mirc dd dau n$ng hem ASA II, ASA III), nghien ciiru ciia Caumo (ASA III CO mirc dg dau viia ddn n$ng cao hon ASA I vi ASA II) [4], [5], [12]. Theo mgt nghien curu thdng kd cho th^y c6 mdi lidn quan giCfa tim \f bdnh nhin v l miic dO dau sau phau thu^t 615/15 nghien ciru dugc khio sit [U]. TIQ' nhidn nghidn ciiu chiing tdi khdng tim thay mdi Hen quan giO'a lo ling trudrc phlu thu|t, miic dd dau dy kl^n trud'c phau thu^t vdri miJrc dg dau n|ng sau phiu thu|it. Cic lo^i phlu thu^t chiing tdi nghien ciru gom: tieu hoa, tiet nigu vi phy khoa; cic vj tri phau thu|t gdm: trdn rdn, dudi rdn, ca trdn vl du6i ron. Nghidn cthi nay khong tun thay mdi lien quan giiia lo^i phlu thuit, vi tri phiu thu|t vdi miic dd dau sau phiu thuit, tuy nhidn tucmg ddng vcri ket TAILI|:U 1. Thii Hoing De, Duong Thj My Thanh (2011), Dinh gii tim 1;^ b^nh nhin trudc vl sau phSu thu§t t^i khao ngo^i b^nh vi^n huy^n An. Ky yeu Hgi nghf Khoa hgc binh viin An Giang, pp. 187-193.
1. Apfelbaum, J.L, et al. (2003), Postoperative pain experience: results trom a national survey suggest postoperative pain continues to be undeimanaged.
Aneslh Analg, 97(2), pp. 534-40.
3. Beauregard L, Pomp A, Choiniere M (1998), Severity and impact of pain after day-surgeiy. Can J Anaeslh, 45(4), pp. 304-11.
4. Caumo W, et al. (2002), Preoperative predictors of moderate to intense acute postoperative pain in patients undergomg abdominal suigery. Acta Anaesthesiol Scand, 46(10), pp. 1265-71.
5. Chung F, Ritchie -E, Su J. (1997), Postoperative pain in ambulatory surgery, Anesth Analg, 85(4), pp. 808-16.
6. Chung J.W, Lui J.C. (2003), Postoperative pain management: study of patients' level of pain and satisfaction with health care providers'
qui ciia Caumo vl ciia Cauceiro i^j, (./j. ITUIIUMJ^
phip phau thuit gdm ngi soi vi phiu thulit ha, ket qui cho thay phiu thudt h6 co nguy ea dau n§ng sau phiu thu^t gap 3,79 phlu thu^t ndi so!
(p < 0,05). Phuang phap vd clm gdm gly ml, gly te tiiy sdng, gay me vi gay te giim dau ngoai ming ciing. Chiing toi khdng tim thay mdi lidn quan gtfta phuang phip vd clm vl m^c d$
dau sau phlu thu^t, ket qui nly phii hgp vdri mdt sd tic gii cho ring phucmg phip vd clm khdng diing dd tidn lugmg vi nd phy thudc v l phuang phip phiu thu^t [5]. Thdi gian phlu thuit trung binh la 72,02 ± 30,79 phOt, lugng fentanyl di ding trung binh l i 154,94 ± 28,29 fig is nhom gly md ngi khi quin v i 20,84 ± 9,6 ^g. Ket qui nghien ciiru phii hgp v<M nghidn ciCru ciia Caumo li khdng c6 mdi lidn quan giira hai yeu td niy vdi miic dd dau sau phau thu^t [4],
5. KfeT L U ^
Sau phiu thuit byng, cac miic dg dau trong 24 gidr dau: khdng dau ho^c dau nhg li 9,7%, dau viia li 25,4 %, dau n^ng li 64,9%. C6 51,75% hai long v6i didu trj dau sau phlu thuit. Phlu thu^t hd la yeu to nguy ca cua dau ning sau phiu thuit T H A M K t t i O
responsiveness to their reports of pain, Nurs Health Sci, 5(1), pp. 13-21.
7 Couceuo T.C, et al. (2009), Prevalence and mfluence of gender, age, and type of surgery on postoperative pain, Rev Bras Anestesiol, 59(3), pp. 314-20.
8. Dolin S.J, Cashman J.N, Bland J.M. (2002), Effectiveness of acute postoperative pain management: I. Evidence from published data, Br JAnaesth, 89(3), pp. 409-23.
9. Gagliese, L, et al. ^008), Correlates of postoperative pain and intravenous patient-controlled analgesia use in younger and older surgical patients, Pain Met/, 9(3), pp. 299-314.
10. Gan T.J, (2014), Incidence, patient satisfaction, and perceptions of post-siugical pain: results from a US national survey, Curr Med Res Opin, 30(1), pp.
149-60.
11. Ip. H.Y, (2009), Predictors of postoperative pain and analgesic consumption: a qualitative systematic review, Anesthesiology, 111(3), pp.657-77.
12. Institute of Medicine Committee on Advancing 118 T^p chf Y Dugc hgc - TruJrag Dfi hgc Y Dirge Hui - Sd D^c bift
Pam Research and Education. (2011), The to pain management is a fundamental human National Academies Collection: Reports funded right, y Pain Palliat Care Pharmacother, 25(1), by National Institutes of Health, in Relievmg pp. 29-31.
Pain in America: A Blueprint for Transforming 14. Lau H, Patil N.G. (2004), Acute pain after Prevention, Care, Education, and Research, endoscopic totally extraperitoneal (TEP) inguinal National Academies Press (US) National hemioplasty: multivariate analysis of predictive Academy of Sciences, Washington (DC). f&ctois, Surg Enchsc, 18(1), pp. 92-6.
13. Intemational Pain Summit Of The Intemational 15. Rawal, N. (2005), Oiganization, fiinction, and Association For The Study Of Pain. (2011), unplementation of acute pain service, ,^nes//)efio/
Declaration of Montreal: declaration that access ClinNorthAmerica,2i{\),-pp.21l-25.
T9P chf ¥ Dirgrc hgc - Trudng D^i bgc Y Dugrc Hue - Sd D | c bift 119