TAP C H l Y H O C V I E T HAM TAP 464 • THANG 3 - SO 1 • 2013
NGHIEN c i r u T A C D U N G T R E N T U A N H O A N , H O H A P V A CAC TAC D U N G KHONG MONG M U 6 N COA GIAM DAU SAU MO NOI SOI CAT TU" CUNG HOAN T O A N BANG TIEM ROPIVACAIN 0,25% VAO VI TRI CHOC TROCAR Nguyen Dire Lam*, IVfai Van Tuyen**
T O M TAT
Muc tieu: Nghien ciiXi tac dung tren tuan hoan, ho hap va cac tac dung khdng mong mudn khac ciia phUdng phap hem tham dung dich thuoc te ropivacain 0,25% vao cac vi tri choc trocar d thanh bung de giam dau sau mo cat ty cung hoan toan qua npi soi. Dm tu'dng, phu'dng phap nghien cu'u: thy nghiem lam sang ngau nhien cd so sanh tren 60 benh nhan du'dc phau tiiuat cat t y cung hoan toan qua ngi soi, dUdc chia thanh hai nhom: nhdm nghien ciiu (nhdm ROPI):
bem tham 20 ml dung dich thuoc te ropivacain 0,25%
vao 4 VI tri choc trocar d thanh bung benh nhan sau khi ket thiic phau thuat; nhdm chyng (nhdm chyng):
khong tiem thudc te vao vj tri choc trocar. Ket qua:
Khong co sy khac biet c6 y nghTa thong ke ve tan so tim, huyet ap ddng mach, tan so thd va Sp02 giO'a hai nhom nghien ciili tai tat ca cac thdi diem nghien cyu.
Ty le non, buon non sau mo giUa hai nhom khac biet khong co y nghta thong ke. Ket luan: Tiem tham 5ml dung djch ropivacain 0,25% vao moi vi tri choc trocar (tong so 20 mi) khdng gay anh hu'dng tren tuan hoan, ho hap va it gay tac dung khong mong muon khi sy dung giam dau sau mo noi soi c3t ty cung hoan toan.
Td khda: npi sol cat t y cung hoan toan, tiem tham Idp thudc te thanh bung, ropivacain.
SUMMARY
RESEARCH THE EFFECT ON CARDIOVASCULAR, RESPIRATORY AND SIDE
EFFECTS OF LAPAROSCOPIC TOTAL HYSTERECTOMY OF INJECTION ROPIVACAINE
0.250/0 I N PUNCTURE TROCAR SUE Objective: To study the effect on cardiovascular, respiratory and side effects of laparoscopic total hysterectomy of method injection solution 0.25%
ropivacaine in the puncture trocar site in the abdominal wall. Subject and method: randomized clinical trial companng 60 patients lapanDSCopic hysterectomy completely, are divided intxj two groups: the study group (ROPI group): injecting 20 ml anesthetic ropivacaine 0.25% to 4 puncture trocar site in abdominal of patients after the end of surgery; the control group (control group): no anesthetic injection to puncture trocar site. Result: There was no statistically significant difference in heart rate, arterial blood pressure, respiratory rate and Sp02 between the two
*Tru&ng Dal hgc y Hi Ndi
**Benh vien Phu sin Tmng ddng Chiu frach nhiem chinh: Nguyen oyc Lam Email: [email protected] Ngay nhan bai: 14.12.2017 Ngay phan bien khoa hoc: 2.2.2018 Ngay duyet bill: 12 2.2(518
study arms at all study bme. The inddence of nausea and vomiting after surgery between the two groups was not statistically significant. Conclusion: Injections of 5 ml njpivacain 0.25% solution in each puncture trocar site (total 20 ml) did not affect on respiratory circulation and less side effects of postoperative analgesia of laparoscopic total hysterectomy.
Keywords: laparoscopic total hysterectomy, injection of anesthetic in the abdominal wall, ropivacaine.
I.
D^T VANDE
U xd t y cung la mdt benh phu khoa phd bien d phu nff Idn tuoi ma mdt trong cac phfftfng phap dieu tri ehu yeu hien nay la cat t y cung hoan toan. Ngay nay, ciing vdi sff tien bd ciia phau thuat ndi soi ndi chung, phau thuat cat t y cung hoan toan qua ndi soi ngay cang phd bien vi cae u'u diem ciia nd: Giam tdi da cac sang chan trong phau thuat, ft dau, phuc hoi cac chyc nang sau md nhanh, xuat vien sdm... Dau sau md npi soi eat t y cung hoan toan thu'dng la dau d eac Vj trf choc trocar vao 0 bung, vi vay, theo mdt sd nghien cyu, phu'dng phap tiem tham thudc te cd tac dung keo dai nhu' bupivacain, va dac biet la thudc te mdi ropivacain vao cac v| tri chan trocar d thanh bung la phu'dng phap gay te tai cho de giam dau sau md ddn gian va mang lai hieu qua giam dau tdt trong thdi gian dau sau md [2], [5]. Tuy nhien, chu'a cd nghien cyu nao d Viet Nam danh gia anh hu'dng tren tuan hoan, hd hap va cac tac dung khdng mong mudn ciia phu'dng phap nay. Vi vay, ehung toi tien hanh nghien cyu nay nham muc tieu: "Nghien cyu tac dung tren tuan hoan, hd hap va cac tac dung khdng mong mudn khac ciia phu'dng phap tiem tham dung dich thuoe te ropivacain 0,25% vao cac VI tri chpe trocar d thanh bung de giam dau sau md cat t y cung hoan toan qua ndi soi".
II. € » ! TU'ONG VA PHU'ONG PHAP NGHIEN CUU 2 . 1 . Doi tu'dng nghien cu'u: 60 benh nhan tudi 18-60, ASA I-II, du'dc chi dinh phau thuat cat t y eung hoan toan qua npi soi, md theo ke hoach tai Benh vien Phu san Trung u'dng du'dc chon vao nghien cyu, du'dc boc tham ngau nhien dechia thanh hai nhdm:
- Nhdm chyng: khdng tiem thudc te ropivacain vao vj trf trocar tren thanh bung.
- Nhdm ROPI: sau khi riit trocar, tiem tham idp 5 ml dung djch thuoc te ropivacain 0,25% tai
VIETNAM MEDICAL JOURNAL N°1 - MARCH - 2018 vi tri ehan trocar tren thanh bung.
*TiSu chuan loai trd: cac benh nhan khd khan trong giao tiep, bj dau man tfnh phai dung thuoc giam dau keo dai, cd tien sy di yng cac thuoe te nhdm amid, ed cac tai bien trong p h l u thuat hoac trong gay me.
2.2. Pliu'dng Qhap n g h i e n cu'u: t h y nghiem lam sang, ngau nhien, ed so sanh.
2.3. Phu'dng phap t i e n h a n h
*Kham benh nhan tru'dc md: cac benh nhan deu du'dc kham tien me tru'dc mo 1 ngay de giai thfch dio benh nhan ve cude md va phu'dng phap giam dau sau md, khai thac eae ben sy lien quan den gay me hoi sye, giai Wifch ve nghien cyu...
*Gay me: eae benh nhan d ca hai nhdm deu du'dc gay me toan than bang: propofol 2mg/kg,
fentanyl 3 mcg/kg, tracurium 0,5 mg/kg, duy hi me bang sevofluran 0,8-2%. Nhdm ROPI; sau khi_rut trocar, tai vi tri rach da tren thanh bung, phau thuat vien se tiem tham 5 ml dung didi thudc te ropivacain 0,25% cho moi vj trf, ti§ni vong trdn va tiem het dp day ciia thanh bung.
*Sau md: khi benh nhan dau, diem VAS > \ bat dau giam dau bang chuan dp morphin t'nh maeh (tiem ttnh mach tu'ng lieu nhd 2 mg cadi nhau 5 phiit den klii diem VAS < 3). Sau do duy tri bang truyen paracetamol 1 g/6 gid.
2.4. Cac chi t i e u t h e o doi va danh gia:
Cae benh nhan se du'dc theo ddi lien tue tai cac thdi diem nghien eyu trong vdng 24 gid dau sau md ve cac anh hu'dng tren tuan hoan, ho hap va cac tae dung khdng mong muon khac.
IM. KET QUA
Bang 3.1. Dac diem chung cua benh nhan, dac diem cua phiu thuat va gay me hoi sdc Thong so
Tudi (nam) Chieu eao (cm) Can nang (kg) ASA: Dd I (n %)
Od I I (n %) Tfen siir benh n h a n : Hiit thudc la
Say tau xe Tien sy ndn, budn ndn sau md
Thdi qian phau thuat (phiit) Ap lu'c bdm hdi d bunq (mmhq) Lu'dng thude sy dung trong gay me
Fentanyl (mg) Tracurium (mg)
Propofol (mg) Bang 3.2. Tan sd tim tai cac the Thdi diem
danh gia HQ H I H2 Ha H4 H, He H9
H„
H24 Nhan xet; TaNhom chu'ng(n = 3 0 ) 45,5 ± 5,0 156,3 ± 4,6 54,6 ± 5,0 26 (86,6%) 4 tl3,4%)
0 3 (10%) 2 (6,6%) 52,1 ± 8,7 10,6 ± 0,9 0,2 ± 0,03 32,1 ± 5,5 108, 2 ± 24,9
N h o m R O P I ( n = 30) 43,6 ± 3,7 155,9 ± 5,1
52,1 ± 4,8 27 (90%)
3(10%) 0 5 (16,6%)
1 (3,3%) 50,2 ± 9,1 10,3 ± 1,2 0,21 ± 0,03
32,7 ± 7,3 117,9 ± 31,8
P
>0,05
>0,0S
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05 ii diem nghien cii'u
Nhom chu'nq(n = 3 0 ) A ± S D 77,7 ± 11,2 77,8 ± 9,8 77,6 ± 10,0 80,4 ± 11,0 78,1 ± 9,1 79,2 ± 8,4 78,3 ± 7,7 79,3 ± 7,5 79,8 ± 7,7 80,5 ± 8,4 n sd tim cua cac
Min - Max 60 - 100
5 9 - 9 5 65 - 100 59 - 100 66 - 103 6 3 - 9 5 6 5 - 9 5 6 5 - 9 2 6 5 - 9 5 62 - 100 bs nh nhan 6 hai
Nhom R O P K n = 3 0 ) A ± S D 77,1 ± 9,8 72,7 ± 11,8 70,0 ± 10,5 71,6 ± 11,0 74,7 ± 8,9 73,0 ± 7,1 73,5 ± 6,8 71,4 ± 7,2 73,4 ± 7,2 73,4 ± 7,5 nhom ngh ien cifu
Min - Max 60 - 100 55 - 106 5 0 - 9 7 5 0 - 9 6 5 8 - 9 6 6 0 - 9 0 6 2 - 9 4 6 3 - 9 4 6 2 - 9 2 6 0 - 9 4 I<h6ng co sU \i\
P
>0,05
>0,OS
ac biet CO y nghTa thong l<e (p > 0,05).
^"g3.3. Hujretap dpng mach trungbinh tai cac thdi diem nghien cdu Thcli d i e m
danh gia
Nhom chC^ngfn = 3 0 ) A ± SD Min - Max
N h o m R O P K n = 3 0 ) A ± SD
i8,5 ± 11,1 91,2 ± 13,0
83,5 ± 9,2 34,7 ± 6,7
70 -114 93,7 ± 12,2
92,3 ± 8,9
90,5 ± 7,7 83^6 ± 5^8
>0,05
TAP CHI Y HOC VIET NAM TAP 464 - THANG 3 - SO 1 • 2018
H, Hs Hs H, Hl2 H?4
89,7 ± 7,4 90,1 ± 6,4 88,7 ± 6,4 90,2 ± 7,1 90,1 ± 7,3 89,5 ± 6,6
68 - 120 69 - 125 72 - 119 69 - 120 70 - 125 71 - 132
83,1 ± 5,4 82,8 ± 5,7 82,3 ± 4,9 82,9 ±4,5 82,2 ± 6,1 82,1 ± 4,5
70 - 117 75- 122 76 - 120 69 - 120 72 - 125 75 - 123
Nh0n xet: Sii khac biet ve huyet ap dpng maeh trung binh d hai nhdm tai thdi diem nghien eyu khdng cd y nghTa thdng ke (p > 0,05).
Bang 3.4. SpOz tai cac thdi diem nghiSn cdu Nhom chutig Thdi diem
danh gia
99,9 ± 0,4 99,5 ± 0,8 99,3 ± 0,9 99,2 ± 0,9 99,1 ± 0,9 99,2 ± 0,9 Jk. 99,4 ± 0,7
99,4 ± 0,7 98 - 100
98 - 100 99,2 ± 0,9 98 - 100 99,2 ± 0,9 - 100
HiA _ J 99,4 ± 0 , 7 1^ 9 8 - 1 0 0 ^ I 99,2 ± 0,9 [ 9 8 - 1 0 0 Nhan xet: Khong co su' khae biet ve SpOi eua cac benh nhan d hai nhom tai cac t nghien cyu (p > 0,05).Bang 3.5. Ndn va budn non
Tac dung khong mong muon Nhom chUngCn = 3 0 ) Nhom ROPI(n = 3 0 )
Khong non, buon non 26_(
29 (96,7%)
Budn ndn
3 (10%) 1 (3,3%)
Non
1 (3,3%) _
Nhan xet: l<hong co sd khae b e t ^da hai nhom ve tyj le non va buon non (p > 0,05). Sau phau thuat, khdng cd benh nhan nao cd bien chyng nhu"; nhiem trung vet mo, ap-xe tdn du' hoac viem phiie mae...
IV. BAN LUAN
Benh nhan d hai nhdm trong nghien eyu eiia ehiing tdi kha tu'dng ddng ve: Tudi, ehieu eao, can nang, phan loai sye khde theo Hdi Gay me Hoa Ky (ASA)... do do, se ft anh hu'dng den ket qua nghien eyu. Tien sy benh nhan chiing tdi can quan tam d day la: tien sd say tau xe, nghien thuoe la va tien sy ndn, budn ndn sau mo"
vi cae yeu t d nay lien quan den ty le ndn va buon ndn sau md theo thang diem Apfel. Thdi gian phau thuat, lu'dng thuoc me, thuoc hp morphin, thuoc gian cd sy dung trong mo ciia hai nhdm nghien cyu ciing khdng ed sy khae biet cd y nghTa thdng ke giya hai nhdm.
*Anh hudng tren tuan hoan: Chiing tdi theo ddi lien tuc tan sd tim va huyet ap ddng mach trung binh ciia cae benh nhan ciia hai nhdm tai cae thdi diem nghien eyu. Tan sd tim duy tri trong md tu'dng ddi dn dinh va khong ed sy khac biet giffa hai nhdm cho den khi ket thiie phau thuat. Tai thdi diem Ho tan sd tim d nhdm ehyng la '77,7'± 11,2 lan/phiit, d nhdm ROPI la 77,1 ± 9,8 lan/phiit. 6 thdi diem Hi, sau khi da diing ropivacain tiem gay te cac diem chpe
trocar d thanh bung thi tan sd tim trung binh d nhdm chyng la 77,8 ± 9,8 lan/phiit, d nhdm ROPI la 72,7 ± 11,8 lan/phiit khdng cd su' khac biet ve tan sd tim d thdi diem nay giya hai nhdm nghien cyu (p >0,05). Sy khac biet ve tan sd tim giO'a hai nhdm nghien cyu khdng cd y nghTa thdng ke d tat ea eae thdi diem nghien eyu khae.
Trong nghien eyu eiia ehiing tdi, huyet ap dpng maeh trung binh trong mo va sau khi gay te tai vi tri chan trocar ciia nhdm ROPI thap hdn so vdi nhom chyng, tuy nhien, sy khac biet khdng cd y nghTa thong ke giya hai nhdm nghien cyu (p>0,05). Huyet ap trung binh ciia hai nhdm van trong gidi han binh thu'dng, cd the giam huyet ap d cac benh nhan cd sy dung ropivacain gay te tai ehd rach da de giam dau sau md ndi soi la do tac ddng gian tiep tren tim mach ciia ropivacain do yc che than kinh giao cam bung [1]. Ngoai ra, tac dung giam dau tdt hdn trong nhyng gid dau d nhdm ed sy dung ropivacain cung cd the_ lam huyet ap giam hdn so vdi nhdm chyng.
*Anh hddng trSn hd hap: Trong nghien ciilJ nay, ehiing tdi theo ddi lien tuc Sp02 ciia cac benh nhan d hai nhdm tai tat ca cae thdi
VIETNAM MEDICAL JOURNAL N°1 • MARCH - 2018 diem nghien ciiu. Trong m d , benh nhan du'dc
thdng khi nhan t a o cung cap d§y d i i oxy nen Sp02 d ca hai nhdm ludn tren 9 9 % . Bat dau t y thdi diem nghien c y u , t y c la t y thdi diem phau thuat vien riit trocar khdi thanh bung va tiem gay'te chan trocar, Sp02 d ca hai nhdm ludn duy tri d m y c an t o a n , khdng c d tru'dng hdp nao xudng du'di 9 7 % . Tai phdng hoi tinh, benh nhan du'dc ho t r d t h d oxy 1 0 0 % va diidc riit ndi khf quan dya tiieo thang dieni danh gia Aldrete nen Sp02 d ea hai nhdm deu on dinh d m y c cao. Tai benh phdng, benh nhan d ca hai nhdm cd Sp02 dn djnh t y 9 7 % - 1 0 0 % . Oieu nay chyng t d phu'dng phap gay te tai vi t r i chan trocar giup giam dau t d t se lam benh nhan cd the t h d eham va t h d sau, se eai thien S p 0 2 [ 5 ] .
*Cac tie dung khdng mudn khac: Ndn va buon non sau md: Buon ndn va ndn sau mo cd nhieu nguyen nhan, do cac thude diing trong gay me, eae kfch thfch trong qua trinh phlu thuat, viec du'a khf CO2 vao 6 bung va tac dung khdng mong mudn ciia morphin de giam dau sau mo...
Trong nghien cyu cua ehiing tdi ed 3 benh nhan budn ndn va va 1 benh nhan ndn sau tiem morphin d nhdm ehyng can dieu tri bang 10 mg metoclopramid. Tuy ty le benh nhan bi ndn va budn ndn d nhdm chiitig nhieu hdn nhdm nghien eyu, nhuYig sy khac biet khdng ed y nghTa thdng ke, cd the do cd mau nghien eyu ciia chiing tdi edn nhd, can ed nhyng nghien cyu tiep theo. Ket qua ciia chiing tdi phu hdp vdi Scalia Catenacci S (10% benh nhan can dieu tri ndn va buon ndn d nhdm ropivacain giam hdn rat nhieu so vdi 43%
d nhom ehyng) [6]. T y eac ket qua nay eho thay viec tiem ropivacain gay te chan trocar cd hieu qua giam ty ie buon ndn va ndn sau md cd the do giam lu'dng morphin dung giam dau sau mo.
Trong nghien cyu cua chiing tdi, sau phau thuat, khdng cd benh nhan nao cd bien chyng nhu': nhiem trung vet mo, ap-xe ton du' hoae
viem phiic mac..Ket qua eua chiing tdi eiing phii hdP vdi cac ket qua nu'dc ngoai [2], [3], [4].
V. KET LUAN
Tiem thifm 5 ml dung dich ropivacain 0,25%
vao moi vj trf choc trocar (tong sd 20 ml) ktiong gay anh hu'dng tren tuan hoan, ho hap va ft gay tae dung khdng mong mudn khi sy dung giam dau sau md ndi soi cat t y cung hoan toan (buon ndn la 3,3% d nhdm tiem tham ropivacain soviS 10% d nhdm ehyng; ndn la 0% so vdi 3,3% d nhdm chyng).
TAI LIEU T H A M KHAO
1. Ghezzi F, Cromi A, Bergamini Vat al (2005).
Preemptive port site local anesthesia in gynecologic laoaroscoDv: A randomized, controlled trial. ] l^inim Invasive Gynecol May-Jun; 12(3):210-5, 2. Goldstein A., G r i m a u l t P., Henique A. et al
( 2 0 0 0 ) . Preventing postoperative pain by Ioal anesthetic instmabon after laparoscopic gynecologic surgery: a placebocontroiled comparison of bupivacaine and ropivacaine, Anesth. Analg, 9 1 : 403-407.
.>. Hiten M. P a t e l l , D.D. Duttaroyl, S.M.
Kacheriwala et al, (2014). Effectiveness of bupivacaine-soaked oxidized cellulose in the galibladder-bed vs port-site infiltration of bupivacaine for pain relief after laparoscopic cholecvstectomv. Suraicai Chronicles. 91-96.
4. Kong TW, Park H, Cheong JY et al (2014).
Efficacy of continuous wound infiltration of local anesthetic for oain relief after avnecalqate laparoscopy. Int J Gynaecol Obstet 124(3):212-jv a. Moiniche S., Jorgensen H.,Wetterslev J., Dahl J.B. (2000). Local anesthetic infiltration forpostoperative pain relief after laparoscopy: a qualitative and quantitativesystematic review of intraperitoneal, port-site infiltration ami mesosalpinx block. Anesth. Analg., 90: 899-912. ' 6. Scalia Catenacci S, Lovisari F, Peng S et al,
(2015). Postoperative Analgesia after Laparoscopic Ovarian Cyst Resection: DouMe- blind Muitieenter Randomized ContnDl Trial Companng Intra pentoneal Nebulization and Peritoneal Instillation of Ropivacaine. J Miniin Invasive Gynecol 22{5):759-66.
CAC YEU TO QUYET DINH T H A I DO DIEU TRI CHAN THU-ONG LACH ff TRE EM TAI BENH VIEN HU'U NGHI VIET DU'C
Nguyen Viet Hoa', Nguyin Xuan Hien
6 M TAT Muc tieu: Oanh gia cac yeu to quyet dinh thaidc dieu tn doi vdi chan thUdng lach d tre em tai benli vien Viit oyc ty 1/2013 den 12/2015. Phu'dng phap nghien cyu: Ty 1/2013 den 12/2015, 42 trUcJng h^f chan thUdng lach tii' 0 den 16 tuoi nhap vien Viet W Slide hoi eyu lai ho sd benh an. Benh nhan du'dc di^nhdm theo phUdng phap dieu tri "bao ton khong mc (BTKM) va phau tJiuat cat lach ngay (PTN). Phan tid ddn bien cac yeu td de tim ra yeu td nguy cd co lift quan den chi dinh cat lach. Ket qua: 42 benh nil
^Benh vien Viet Du'c
^Dai hoc Y Hi Ngi
Chiu trach nhieni chinh: Nguyen Viet Hoa Email: [email protected] Ngay nhan bai: 2.12.2017 Ngay ph^n bien khoa hoc: 28.01.2018 Ngay duyet bai: 8.2.2018