NGHIEN CLfU KY THUAT GAY ME NOI KHI QUAN MOT NONG TRONG P H A U THUAT CAT HACH
GIAO CAM NGLTC NO! SOI
TrSn Thi Thu Lanh, Hd Khd Cdnh, Ngi^in Van Minh BQ mon Gdy me hdi sue. Trudng Dgi hoc YDugc Hue T o m t a t
D a t v a n d e : T a n g ti8t mo hoi tay la benh hay gap cr nguoi tre, gay nhieu phien toai trong sinh hoat hang ngay, nhat la trong giao tiep. P h l u tiiuSt n0i soi long nguc c i t hach t h i n kinh giao cam la p h u a n g phap dieu tri hifu qua cao va de thuc hien. T r u o c day, de th\rc hien d u g c phau thuat npi soi long n g u c cat hach than kinh giao cam can phai gay m e v a i d3t npi khi quan hai n o n g , thong k h i tiing ben phoi, d|it bpnh nhan a t u thS nam nghieng, nam sap hay nam ngiia. P h u a n g phap n a y lam cho phau thuat kha phiic t^p, ton k e m , doi khi g l y t i n t h u o n g ducrng h o hSp khong c i n t h i i t . Hien nay, chung toi da nghi8n ciiu ap d u n g phuotig phap gay m e voi dat ong n6i khi quan mot n o n g , t u t h i n i m ngua n u a Fowler co b a m khi CO^ vao khoang m a n g p h i i . Ky thuat nay lam cho p h l u thuat tro nen thuan lgi, d o ton kem m a van dam bao an toan cho b$nh nhan. M u c tieu ciia nghien ciiu nay n h i m danh gia k i t qua cua k J thuat gay m^ n$i khi quan m g t n o n g trong phau thu|it cat hach giao cam ngirc npi soi va danh gia sv bien doi tan s l tim, huySt ap v i h6 hap trong qua trinh gay m e va phau thuat. P h i r a n g p h a p n g h i e n ciru: N g h i e n ciiu m o ta tien cuu trSn 43 benh n h a n , d u a c chan doan tang tiet md hdi tay, CO chi djnh phau t h u | t cat hach giao cam n g y c n6i soi. Benh nhSn d u g c g l y me ngi khi quan mpt nong thong t h u d n g , d ^ i t t u t h e nam ngiia nira dau cao 30°, b a m khi CO^ap lyc 5 - 6 m m H g vao khoang m a n g phdi. C i c chi s6 nghi&n ciiu gom: Tan so tim, huyet i p dpng m a c h , SpO^, EtCO^, ap lyc dinh d u d n g thd, thdi gian phau thu^t moi phdi, bien chiing cua gay me v i phau thuat, thdi gian n i m vi?n trung binh ciia b$nh nhan. K e t q u a : K J thuat gay me ndi khi quan mgt n o n g ket hpp b a m khi C O j v i o k h o a n g m a n g phoi de phau thu^t cat hach giao cam n g y c npi soi d u a c t h y c hien t h i n h cdng tren 43 benh nhan, tan so tim, huyet ap va ho hap on djnh trong qua trinh phau thuat tai c i c thdi diem trudc v i sau b a m CO^ ciia mdi phdi, SpO^ duy tri dn dinh tren 9 8 % trong qua trinh phau t h u | t , khdng c6 t r u d n g h a p nao d§t dan luu n g y c , khdng ghi nhan cd bien chiing x i y ra ve gay me v i phiu thuit, thdi gian n i m vien trung binh 2,84 ± 0,43 ngiy. K i t l u a n : K J thuat gay m e toan than vdi d n g npi khi quan m d t n d n g , t u the nam ngiia niia F o w l e r ket hop b a m CO^ v i o k h o a n g m i n g phoi trdng p h l u thuat c i t h^ch giao cam n g y c npi soi la mdt ky thuat an t o i n v i hieu qua, it gay bien ddi tan sd tim, h u y i t ap, h o h a p , tiet kipm cho bfnh nhan va c h u a ghi nhan cd bien chiing.
Tit khoa: Dgt npi khi qudn mpt nong. ong npi khi qudn hai nong, cdt hgch giao cdm nguc npi soi A b s t r a c t
A N E S T H E S I A W I T H S I N G L E - L U M E N E N D O T R A C H E A L I N T U B A T I O N F O R T H O R A C O S C O P I C S Y M P A T H E C T O M Y
, Tran Thi Thu Lanh, Ho Kha Canh, Nguyen Van Minh Hue Hue University of Medicine and Pharmacy
B a c l ^ r o u n d : Hyperhidrosis is frenquently present in young people, causes much trouble in daily life, especially in communication. Thoracoscopic sympathectomy is an effective and safe method to
- Dia chi lien he: Trdn Thi Thu Ldnh, email: thulanhdhyd@gmail com , ' . - , ' . ' " „ . ' - Ngay nhgn bai: 8/2/20J6 *Ngay ddngy dang: 13/4/2016 *Ngcr^ xudi b^n: 10/5/2016
Tap chf Y Dugc hgc - Trufrng Dai hgc Y Duyc H u i - So 32 5
treat palmar hyperhidrosis. Previously, double -lumen tube was used. This method was too complex, expensive, accompained pulmonary injuiy. We applied anesthesia with single -lumen endotracheal intubation and intrathoracic CO^ insufflation in supine position for thoracoscopic sympathectomy.
The objective of this study was to evaluate the resuh of anesthesia and change of heart rate, arterial blood pressure, the respiration and complications. Methods: A prospective study on 43 patients diagnosed with palmar hyperhidrosis. Thoracic sympathectomy was perfonned for the treatment of palmar hyperhidrosis. The single -lumen endotracheal intubation were carried out in supine position and intrathoracic CO^ insufflation at a rate 0.5 - 1 L.min'', sustained intrathoracic pressure at 5 - 6mmHg insufflation. Heart rate, arterial blood pressure, saturation of peripheral oxygen (SpO ), end-tidal carbon dioxide (EtCOj), peak airway pressure, surgery time for each lung, the complication of surgery and anesthesia and hospital stay were evaluated. Results: General anesthesia with single -lumen endotracheal intubation, and intrathoracic CO^ insufflation for treating palmar hyperhidrosis was performed successfully in all patients in semi Fowler with the mean age of 21.28 ± 5.65 (min 11 age -max 42 age). Heart rate, arterial blood pressure and respiratory were stable during surgegy and anesthesia. SpO^was over 98%, no complication occured, mean hospital stay was 2.84 ± 0.43 days (range 2-4days). Conclusions: Anesthesia with single - lumen endotracheal intubation and intrathoracic CO^ insufflation in supine position for thoracoscopic sympathectomy provided good surgery condition, guaranteed intraoperatively heart rate, arterial blood pressure and respiratory stability. This was an effective, safe, economic method with no complication.
Key words: Anesthesia, single - lumen, thoracoscopic sympathectomy.
1. DAT VAN DE
Tang tiet ml hdi li mdt benh thudng gap, nhit li d nhirng ngudi tre tudi. Tang tilt md hoi qua miic xuat hien d mat, long ban tay, ban chan, nich, lung... do tinh trang cudng giao cam gay ra, chiim khoang 1% dan sd. Tang tilt md hdi tay, nach khong gay nguy hiem din tinh mang nhung lai gay nhieu phien toil ddi vdi ngudi benh trong lao dpng, sinh ho^t va giao tilp xa hdi [8], [16]. Vdi su phat triln cua phau thu|it ngi soi, phau thueit cat hach giao cam nguc qua npi soi de dieu tri chirng tang tilt md hdi tay dugc thyc hien d hiu hit cac nude tren thi gidi vi tai cic benh vifn phau thuat ldng nguc tim m^ch d nude ta.
Nim 1992, phiu thu^t ngi soi da dugc ip dyng d Viet Nam. Tir nam 1996, phiu thuat ndi soi cat hach giao cam ngyc dupe iing dung d nhieu benh vien khac nhau mang lai kit qua tot. Diy la phuang phap dilu trj dugc ap dyng rgng rii vi tinh hieu qua cao, an toin, phiu thuit dan gian v i thim my. Phuang phap niy di thay the hoin toin cho phuang phap md ngyc kinh diln, cac thu thuit triet hach bing tiem cdn hay nude sdi qua thanh ngyc, lieu phap dien ion hda, botox, laser... trong dilu trj benh tang tilt md hdi. T^i Vift Nam, nhilu
nghidn ciiru bio cio ve cat h?ch than kinh giao cam ngyc qua ngi soi trong dieu tri tang tjet mo hdi tay vdi ty le thinh cdng rit cao, don giin vi it bien chirng [13].
Vf phuang dien gay me hdi sue, tnrdc day ngudi ta dat npi khi quan hai ndng vi thdng khi tirng ben phdi, dit tu the nim nghieng. Ky thuat gay mf toan than vdi dat dng ngi khi quin hai ndng Ii mgt ky thuit tuong doi phiic tap, eg nhieu tai bien, ky thuat nay ddi hdi ngudi gay me phii cd kinh nghiem dong thdi cd the ndi soi phe quin de xic dinh vj tri ong npi khi quin hai ndng khi can thiet. Vi vay, diy la mpt kJ thuat chi phi ton kem, mat nhieu thdi gian, ddi khi gay ton thuang dudng hd hap khdng can thiit.[2], [10], [12]. Giy md not khi quan thdng thudng (mdt ndng) ket hap bam COj, dat bfnh nhin nam ngua nua Fowler viia dam bio phau thuit vira tranh dugc bat Igi ciia dat ndi khi quan hai ndng. Hien nay cd it nghien ciiu ve van de niy. Chiing tdi tifn hinh nghien ciiu nay vdi myc tifu:
- Bdnh gid kit qud cita ky thudt gdy me npi khi qudn mpt ndng trong phdu thugt npi soi cdt hgch giao cdm nguc.
- Ddnh gid sy bien doi tdn so tim, huyet dp vd ho hdp trong qud trinh gdy me vdphdu thudt.
Tap chi Y Dugc hgc - Truong D?i hgc Y Dirge Hui - S6 32
2. DOI TU'gfNG VA PHU'ONG PHAP NGHltN CUU
2.1. Doi tuyng nghien cihi
Nghien ciiu dugc tien hinh trfn 43 benh nhan cd tinh trying sue khoe theo phan loai siic khde cua Hpi Gay mf Hoi sire Hoa K^ (ASA);
1,2. Bfnh nhin dugc chan doan mic chiing tang tilt md hdi tay, c6 chi dinh phiu thu^t npi soi cit hach giao cam ngyc.
Tieu chuin loai trii: Nhihig b$nh nhan cd chdng chi dinh phau thuat ngi soi ldng ngyc.
2.2. Dja dilm nghiSn cihi
D I tii dugc thuc hien tai khoa Gay mf Hdi siic, Bfnh vien Trudng Dai hgc Y Dugc Hue. Thdi gian nghifn curu tir thing 02 nam 2014 den thing 12 nam 2014.
2.3. Phinmg tien nghien ciru
Cac phuang tien, thudc diing trong gay mf thudng quy, may gay me, may phan tich khi mf, miy theo ddi hd h ^ , huyit ddng t^l phdng md Khoa Gay me Hdi siic, Bfnh vien Tmdng D^i hpc Y Dugc Hue.
2.4. Phuwng pbap nghien cihi Nghien ciru tiln cuu, md ta cat ngang.
2.5. Cac budc tien hanh nghifn curu Tit ci benh nhin deu dugc thim kham ky trudc md, danh gii bfnh nhin theo phin loai siic khde ciia Hgi Gay me Hdi siic Hoa Ky. Cac benh nhin dupe tifn hanh gay me hdi sire vi phau thuit nhu sau:
Bfnh nhin vao phdng mo dugc d§t catheter cd 18G d tTnh m^ch nin cd tay vi truyen dung djch NaCl 0,9% hole Ringer lactate. Benh nhan dugc gin monitor de theo doi mach, ECG, SpO^, do huyit ap khdng xim nhap, tin so hd hap, dat che dp ty dgng theo ddi lifn tuc 5 phut mdt lin. Tiln hinh khdi me: Khdi me bing fentanyl 3 ng/kg tifm tTnh mach, propofol 2,5 - 3 mg/kg, rocuronium 0,6 mg/kg va dat n^i khi quan mpt ndng thdng thudng.
Sau khi khdi mf cac benh nhan se dugc duy tri me bing sevofluran, fentanyl, rocuronium.
Sau khi gay mf benh nhan dugc thdng khi nhan t^o bing may mf Datex -Ohmeda, cac thdng so cii dit thd may Vt 8-1 OmI/kg, tin s6 thd 12 lin/ phut, I/E 1/2, d|t bpnh nhin d tu tiie nim ngiia diu cao 300, kd gdi dudi vai, hai tay d^ng dua len phia diu dugc kf tren gia dd.
Phiu thuit dupe tiln hinh tCtng bfn nguc, bfnh nhan dugc dit trocar diu tifn d gian sudn V dudng nach giiJa, khi dat trocar diu tien cin cho bfnh nhin ngung thd may va dl dng ndi khi quan thdng vdi khi trdi trong thdi gian dat trocar de trinh giy tin thuang phoi. Tiln hanh bam khi CO^ de lam xep phii vdi ap lyc thap tii 5 - 6 mmHg, luu lugng bom tiiip tli 0,5 -1 lit/phut. Tiep tuc d^t 2 trocar cdn lai d vi tri gian sudn in vi IV dudng nach tnrdc. Tien hinh cit hach T3, kilm tra vi fri cit khong chiy mau, sau cit hach cho nd phdi phiu thuat bang cich bdp bdng dull khi khoang mang phdi, vifc cho nd phdi dugc thyc hifn phoi hgp giita giy mf vifn va phiu tiiuat vien. Sau khi kiem iia phoi nd tit, ddng cic vj tri dat trocar khdng cin din luu khoang mang phdi khi khdng cd tran khi, trin mau mang phdi. Phau thuat tuang ty vdi bfn doi dipn.
Cac thdng so nghifn cuu:
- Tin sl tim, huyit ap dgng mach, SpO^ EtCOj, ip lyc dinh dudng thd dupe do cho timg phdi theo qua trinh phiu thuit vio cac thdi diem TO (trudc giy me), Tl (trudc bam CO^), T2 (sau bam CO^ 5 phiit), T3 (sau 10 phiit), T4 (sau 15 phiit), T5 (sau 20 phiit), T6 (sau 25 phiit), sau phlu thu^t. (Ap lyc dudng thd khdng do d thdi dilm TO).
- Cac bien chiing vl gay me phiu thuit.
- Thdi gian phiu thuit tiing bfn phii, thdi gian nam vien.
- Sd trudng hpp phai thay ong nOi khi quin hai ndng do khdng quan sat dugc phau tnrdng.
2.6. Xir ly $6 lifu
So lieu dugc xii ly bang phan mem SPSS 16.0 for Windows.
3. KtT QUA NGHIEN CtTU 3.1. Dac dilm chung cua nhom nghien ctru
Bang 1. Die diem chung benh nhan nghien ciiu Tbong so
Tuoi (nam) Giai (nam/nff), (n) Can nang (kg) ASA (1/2), (n) Mallampati (I/II/III)
Ket qua 21,28 ±5,65 (11-42) 20/23 (46,5%/53,5%) 49,09 ±6,82 (35-72) 43/0 (100%/D%) 23/19/1 (53,5% / 44,2% / 2,3%) Nhgn xet: Tudi trung binh li 21,28 ± 5,65 tuoi, thip nhit li 11 tuli, cao nhit li 42 tuoi. Hiu hit bfnh nhin cd sire khde binh thudng (ASA I) chiem 100%. Nu nhilu hgn nam.
T9P chi V Dug-c hgc - Tru*ng D^i hgc Y Duyc Hui - Sl 32
B a n g 2. Nghf nghiep Nghe n g h i i p
Hpc sinh, sinh vifn
C i n bd, cdng nhan, ky su phdng vien N " h e khac
Tdng c0ng
ciia nhdm nghien ciiu So lirtfng b e n h
26 9 8 43
T i le (%) 60,47%
20,93%
18,6%
100%
Nhdn xet: Nghe nghiep chu yeu cua nhdm nghien cihi l i hgc sinh, sinh vifn chiem ti If 60,47%, cic nghf nghipp khac chif m ti le t h i p hon.
3.2. C h i tieu n g h i e n c u u v e h u y e t d p n g , ho h a p
B a n g 3 . Thay ddi ve tan sd tim, huyft ap, SpO^ va EtCO^ ap luc dinh dudng thd d c i c thdi diem nghifn cim khi c i t hach giao cam p h i i p h i i
^^•^—^-X!*^ diem T h d n g so ^ - ^ ^ ^ TST
HATT HATTr HATB SpO,(%) EtCOj (mmHg) ALDDT ( c m H , 0 ) N
TO 79,98± 10,78
116±13,62 65,02±10,76 81,63±11,38 98,93±0.91
Tl 75,7O±ll,01 91,67±16,51 48,91±9,61 66,19±12,20
99,02±0,83 27,93±4,31»
15,63±1,39«
T2 77±13,82 101,42±9,25
57,09±9,09 75,33±8,77 98,67±0,60 28,93±4,40«
18,51±1,86«
T3 75.39±12,21 101,09±8,11 55,75±8,86 74,-12±S,47 98,57±0,55 30,59±4,63 19,59±2,48
33
T4 73,75±9,08 105,75±10,88 65,57±10,06 77,12±16,39 98,63±0,57 29,42±3,96 19,44±2,78
10
* p < 0,05: so sanh gia trj ETCO^ v i ap lyc dinh dudng thd d hai thdi d i l m trudc b a m CO^ va sau bom COj 5 phiit.
Nhgn xet: T i n sd tim, huyft ap dgng mach, SpO^ d c i c thai d i l m nghien ciiu khac biet khong cd y nghia t h i n g ke. CJ thdi d i l m T l v i T2 (trudc bom CO^ v i sau bgm CO^ 5 phut), EtCO^ va ap luc dinh dudng thd k h i c biet cd y nghta t h i n g kf (p < 0,05).
B a n g 4. Thay ddi v l t i n sd tim, h u y i t i p , SpO^ v a EtCO^
d c i c thdi diem nghifn cuu khi c i t h^ch giao c i m phdi trai
~ ^ ^ ^ ^
TST HATT HATTr HATB SpO,(%) EtCO,(mmHg) ALDDT (craHjO) N
Tl 77,91±13,48 95,33±14,32 5I,64±11,I4 69,05±I2,54 98,86±0,710 28,30±3,76«
16,44±1,81*
T2 78,51±13,33 104,88114,75 59,33±10,09 77,07±11,67 98,88±0,76 30,63±3.95«
19,21±2,17«
T3 79,77±15,01 100,44±13,77 55,49±11,61 72,85±12,46 98,63±0,62 31,10±3,86 20,08±2,41 35
T4 80,5Otl8,71 109,82111,61 64,50±12,15 81,36±I2,09 98,53±0,55 29,57±2,07 20,50±3,15
6
T5 82,36±15,63 112,67±15,77 S7,28±13,17 78,34±13,23 9S,76±0,39 32,55±3,38 21,18±2,15
2
Sau mo 81,67±I7,56 108,37±18,32 56,63±17,56 76,57± 11,78 98,51±0,63 29,32±3,18
18,57±2,25
Glli chu: TST: Tan s6 tim, HATT: huySt ap tam thu, HATTr: HuySt ap tam tnicmg, HATB: Huyet ap trung binh, ALDDT: Ap lire dinh duong tho.
* p < 0,05: so sanh gia trj E T C O , va ap lire dinh ducmg t h o o hai thoi diSm truoc bom CO^ va sau bcmi COj 5 phut.
Nhgn xel: Tan so tim, h u y i t ap dpng mach, SpO^ o cac thcri diem nghien ciiu khac biet khong c6 y nghia th6ng ke. d thoi di6m T l va T2 (trudc bom CO^ va sau bom CO^ 5 phut), EtCOj va ap lire dinh duong m khac biet co y nghTa tiidng ke (p < 0,05).
T^p chi Y Dugc h9c - T r u ^ g D?i hgc Y Dugc H H ^ - S6 32
3.3. Chi tieu nghien cuu ve thd^ gian cit hach giao cam va thdi gian nam vifn Bang 5. Thdi gian cit hach giao cam d ngyc phai va trii, thdi gian nam vien Thong so
Thdi gian phau thuit cat h^ch ben phii (phut) Thdi gian phau thuat cat hach bfn trai (phut) Thdi gian nim vifn (ngay)
Min 5 5 2
Max 18 25 4
Trung binh 10,42 ±3,14 10,45 ±3,86 2,84 ± 0,43 Nhdn xet: Thdi gian cat hach giao cim ngyc d hai phdi khac bift khdng cd y nghta, thdi gian nam vifn ngin, trung binh la 2,84 ± 0,43 ngay.
3.4. Ve cac bien chirng
Trong qua trinh nghien ciiu khdng ghi nhan cd trudng hgp nao cd biln chirng tran khi tran miu mang phdi, khdng cd trudng hpp nio phai d|t l^i dng ndi khi quin hai ndng de tiep tyc phiu thuit.
Ti le dat npi khi quin mgt ndng thanh cdng 100%, khdng cd trudng hgp nio phii dat lai dng ndi khi quin hai ndng de tiep tyc phau thuat.
Trong qua trinh nghien cihi khong ghi nhin co trudng hap nao cd bien chung trin khi trin miu mang phdi.
4. BAN LUAN
4.1. Ket qua cua ky thuait gay me npi khi quan mpt ndng trong phau thu^t cat hach giao cam ngyc npi soi
Nghien ciru cho thay giy me toan than dit npi khi quan mpt ndng thdng thudng kft hgp bom CO vao khoang ming phdi vi dit bfnh nhin d tu till nim ngira mia Fowler cho phau thuit cit hach giao cam ngyc la an toan, it giy roi lo^n tin sd tim, huyit ap, hd hip. Giy me vdi dit n^i khi quin mpt ndng dugc thyc hien nhanh han va xac djnh vj tri dit dng ndi khi quan de dang han, chi phi thap han so vdi dat ndi khi quan hai ndng. Mac dii cd nhii'ng uu difm nhung cung cd ti Ip that bai khi lam xpp phoi can phiu thuat, qui trinh bam CO^ cd the gdp phan lim ting nguy ca bien chiing ve hd hap vi huyit ddng. Khi gay me vdi ong n^i khi quan mpt ndng cin phii bam CO^ lien tyc vao khoang ming phdi, giiip xpp phii bdi ap lyc duong lifn tyc trong khoang mang phoi, tao phiu trudng thuan Igi cho phau thuit [4].
Trong nghifn ciiu niy, chiing tdi da thuc hifn thinh cdng vdi gay mf ngi khi quan mpt ndng, CO bam khi CO^ ip lyc thap 5 - 6 mmHg, luu lupng bam tir 0,5 - 1 lit/phiit vao khoang ming phii Ae lam x?p phii can phiu thuit, khdng cd
trudng hpp nao thit bai hay phai chuyfn sang dit npi khi quin hai ndng. Phiu thuit cit hach giao cam ngyc npi soi thao tac chu ylu d dinh phdi vi cic chudi hach giao cim tii T2 den T4 nam d phan dinh phdi, qui trinh phau thuit chi can lam xpp thiiy trfn cua phdi la cd the bdc Ip ro phau trudng, vi viy cd the dat ong npi khi quan mpt ndng kit hgp bom CO^ vio khoang ming phdi dl giiip xep phdi V^o phiu trudng Ah phiu thuat vien cd the thao tac viing dinh khoang mang phoi, phau thuit vin an toan va hifu qua, it giy rii loan vd huyit dpng va hd hap [1], [14]. Trong phau thuit long ngyc vindi soi long nguc, vifc dat Ing ndi khi quan hai ndng la mpt thach thurc Idn doi vdi giy me hoi siic khdng nhung ve ky thuit dat, lua chgn kich cd dng phii hgp vdi benh nhin, sang chin khi dat, tic dira dii ma cdn chi phi kha ldn cho Ing ngi khi quin hai ndng, ngoai ra vdi gay me ngi khi quin mpt ndng thdi gian chuan bi dupe riit ngan. Gay mf bang dng npi khi quan mot ndng giup cho viec gay raf "dgn giin" ban va da ton kem ban [8].
Ghi nhin nay cung phu hgp vdi mdt sd nghifn cuu cua cac tac gia khic [1], [8], [14].
Tu nam 2002 den nam 2005, Daniel va cpng sy cung da thyc hifn thanh cdng 205 ca cit hach thin kinh giao cim nguc ngi soi vdi gay mf n$i khi quin m^t ndng. Tac gii niy cung cho biit dieu kien bit Ipi vl ngi khi quan 2 ndng tai eg sd y tl la ly do dng nghien cihi dan gian hda ky thuat giy me vdi dat n^i khi quin mpt ndng [1].
Trong mgt nghifn ciru vdi so lugng Ion benh nhan, Huford ghi nhan 9% trudng hgp giim bag hda oxy, 9% cd tang ip lyc dudng thd, 7% sd bfnh nhan khd lim xpp phdi ben phiu thuit, 0,4% chin thuang dudng thd khi dit ngi khi quan hai ndng [7]. Cac bio cao ve nhung ton thuang khi phi quan, ngudi ta thiy ong ndi khi quan hai ndng giy T^p chi Y Dugfc hgc - Trirfrng Dai hgc Y Dirpc Hui - So 32
nhieu ton thuang hon loai mOt ndng thdng thudng.
Nhiing tin tiiuong nay nim d phin mang ciia khi quan gin chd chia ddi phi quin [10]. Lee va cpng sy ghi nhin ring sd bfnh nhan dau hgng vi khan tilng khdng khac nhau giu^ hai nhdm dit ngi khi quan mdt ndng hoac hai ndng [12], trong khi do Knoll vi cOng sy ghi nhan d nhdm diing ong ngi khi quin hai ndng, tj- le khan tilng vi dau hgng cao hon [10].
Trong nghien ciiu cua chiing tdi khdng cd sy khic biet vl tin s l tim, huyet ip ddng raach trung binh d hai phii trudc khi bom CO^ vi sau khi lam xpp phii d cac thdi dilm. Gia trj ciia EtCOj trung binh v i ap lyc dinh dudng thd trung binh d thdi dilm sau khi bam CO^ cao hon trudc khi bam CO^, sy khac bift cd y nghia vl mat thong kf. Tuy nhifn gia tri ETCO^ cung nhu ap lyc dinh dudng thd cdn nam trong gidi han binh thudng, khdng giy roi loan ve huyet dgng va hd hip nfn it c6 y nghta ve mit lam sing. Difu nay cd the giii thich la do chi lam xep thiiy trfn phoi chii khdng lam phii xpp hoan toin nhu khi gay me vdi dng ndi khi quan hai ndng, phan phdi cdn l^i van dugc thdng khi nfn hifn tupng tao shunt trong phdi giam so vdi cac tnrdng hgp thdng khi mdt phdi vdi npi khi quin hai ndng [2], [14]. Ngoai ra trong nghien ciiu cua chung tdi khi bam CO^ lam xep phdi phau thuit chi bom vdi ap lyc vi luu luang bom khi COj thip, thdi gian phau thugt tuang ddi ngan nfn miic dp hip thu CO^ khdng dang kf, gia trj trung binh vin nam trong gidi han binh thudng tai cac thdi dilm sau bam CO^. Vi thi kha nang trao doi khi vi oxy hda mau he thing dupe dam bio va it anh hudng den huyet ddng va hd hip. SpOj trudc khi bom CO^ va sau khi bam CO^ lim xpp phoi su khac bift khdng cd y nghta thing ke, SpO^ duy tri on djnh vdi gia tri trung binh d cac thdi diem tren 98%. Kit qua niy cung phii hpp vdi nghifn ciru ciia El- Dawlatly Abdelazeem [5].
Trong nghifn ciiu ciia chiing tdi, benh nhan dugc phiu thugt dat tu thi nira ngiia niia Fowler, tu thf nay cd uu dilm khdng xoay trd bfnh nhin, O tu the diu cao khi phdi xpp, phdi se co vl phia rdn phoi, dl dang thao tic d vimg dinh khoang ming phdi. Vdi tu thi nay phau thuit vien cd thf
tien hinh phau thugt d ca hai bfn mi khdng can phai chuin bj Igi bfnh nhan nhu khi dit dtu thi nim nghif ng. Ngoai ra, tu thi nim ngda it gay inh hudng din huyit dpng, thdi gian phiu thuat cQng ngin han [9]. Thdi gian md trung binh la 10,42 ± 3,14 phdt cho mdi ben, so vdi cac tic gia khac sir dyng mf ndi khi quan 2 ndng va sii dyng tir 2 din 3 trocar thdi gian phiu thuit c i hai bfn trung binh la 30 ± 6 phiit [5]. Khi cit hgch thin kinh giao cam ngyc cho 121 bfnh nhan d tu the nam ngira diu cao (semi-Fowler's), cd bam CO^vao khoang mang phii df lim x?p phii, Krasna ghi nhgn d tu the nay cd nhieu thuin lgi trong thao tic vung dinh khoang mang phdi nhat la hgch than kinh giao cam ngyc cao [11]. Nguyen Hoai Nam ap dyng phau thuat dgt bfnh nhan d tu the nim ngira, vdi Qii tien nay tac gia ghi nhin co nhilu thuin Igi vi rut ngin thdi gianmd [16].
Ket qua nghifn ciiu cho thay cat hach giao cim ngyc nOi soi vdi giy me ndi khi quan mpt ndng cd bom COj vao khoang ming phdi la mpt k5> thuit an toan va hifu qui.
4.2. Ve cac bien chung gay me phau thuat Nghien ciru khdng ghi nhgn cd trudng hpp nao cd bien chiing tran khi mang phoi, trin mau mang phdi, bfnh nhin sau phau thugt khong can dgt dan luu khoang ming phoi. Chiing tdi cung ghi nhan ti If dgt ndi khi quan m^t ndng thanh cdng 100% khdng cd tnrdng hpp nio phii thay lai Ing ndi khi quin hai ndng df tiep tuc phiu thuit.
Bpnh nhan sau md dn dinh, hdi phyc tdt, it dau vi thdi gian nam vien ngan, trung binh khoang 2,84 ± 0,43 ngay, kit qui niy cung tuong duang vdi ket qua cua Huynh Quang Khinh [8]. Dilu nay cho thay phuong phap gay me toan than vdi dgt nOi khi quan mpt ndng cd bam khi COj lim xpp phoi trong phiu thugt cit hgch giao cam ngyc npi soi mang tinh an toin vi hifu qui.
5. KtT LUAN
Qua nghien ciiu trfn 43 bfnh nhan tang tiet md hdi dugc ap dung ky thuat gay me toan than vdi ong ngi khi quan mdt ndng, ket hgp bom CO^ vio khoang mang phdi de lim xpp phdi, dat bfnh nhan tu thi nim ngiia nua Fowler cho phiu thtigt cit hgch giao cim ngyc npi soi tgi khoa Giy me hdi siic tnrdng Dgi hgc Y Dugc Hui cho thiy day la
10 Tgp chi Y Dugc hgc - Trufrng Dgi hgc Y Duyc Hui - Sl 32
ky thugt an toan va hifu qua, tinh trang huyet dpng phiu tiiugt c i t hach giao cam ngyc npi soi l i mpt ky va hd h i p on djnh frong s u i t qua trinh gay me phiu tiiuat tiiich hpp, it i n h hudng fren huyit ddng v i hd thugt. Ky thugt g i y me npi khi quan mgt ndng frong hap, chua ghi nhgn cd bien chiing.
TAI LIEU Arun P., Mudasir A., Sunil K. (2010), "Endoscopic thoracic sympathectomy for primary palmar hyperhidrosis", Surg Endosc, 24: 1952 - 57.
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ConacherI.D(2007), "Anesthesia for thoracoscopic sxagery", J Min Access Surg,^: 1 2 7 - 3 1 . Dias M.D.L, Burlamaque A.A, Bagatini A, Ribas F A , Gomes C R . (2005), "Thoracoscopic sympathectomy to treat palmar hyperhidrosis:
Anesthetic implications". Rev Bras Anestesiol, 55:
3 6 1 - 8 .
El-Dawl^ly A., Al-Dohayan A. (2002),
"Thoracoscopic sympathectomy: Endobronchial anesthesia vs endotracheal anesthesia with infralhoracic COj insufilation", J Anesth, 16: 13 - 6.
Haider A. (2005), "Focal hyperhidrosis: Diagnosis and management", CMAJ, 172(1): 69 - 75.
Huford W.E, AHille RH (1993), "A quality improvement study of the placement and complications of double-lumen endobronchial tubes", J Cardiolhoracic Vase Anesth, 7: 517 - 520.
HuJ'nh Quang Khinh, Nguyen Cong Minh, Hoing van Thiep, Ding Luu Ba (2006), "Phiu thuit noi soi cSt hach thin kinh giao cam ngyc vdi gay m6 ndi khf quan thudng, nim ngua v i sii dung I ngd vio", Yhgc Thanh pho H6 ChiMinh, tap 10, Phu b a n s l l , f r . 2 8 0 - 2 8 7 .
Huynh Quang Khinh, Nguyen Cong Minh, Hoing van Thifp v i cs (2004), " C i c biln chiing sdm trong phlu thuit npi soi ling ngyc", Hqi nghi not soi vd phdu thugt npi soi. DHYD TP. HCM, t r 4 1 8 - 4 2 5 .
T H A M K H A O
10. Knoll H., Ziegeler S., Schreiber J.U., Buchinger H., Bialas R, Semyonov K. et al (2006), "Airway injuries after one lung ventilation: A comparison between double-lumen tube and endobronchial blocker: A randomized, prospective, controlled U\aLY\ Anesthesiology, 105: 471 - 7 7 .
11. Krasna M.J., Jiao X. (2002),
"Thoracoscopic sympathectomy, CTSNET experts's techniques, general thoracic
experts" Thoracic Techniques, Section editor.
Mark K. Ferguson. MD: 1-4.
12. Lee K.H, Lim H.K, Lee K.M, Kim S.Y (1998),
"The incidence of sore throat and hoarseness after double - lumen endobronchial tube intubation", Korean J Anesthesiol, 35: 484 - 7.
13. Le Quang Dinh, Nguyin Hoii Nam (2010), "Kit qui phau thuat cit thin kinh giao cim ngyc npi soi vdi giy m i ngi khi quan mpt ndng trong dilu fri ting tiet m l hoi tay va nich", Yhoc Thanhph&Hd Chi Minh s6\: 1 3 5 - 8 .
14. Martin A., Telford R (2009), "Anestiiesia for endoscopic thoracic sympathectomy". Anesthesia Critical Care and Pain, 9,2: 52 - 9.
15. Miller D.L, Force S.D. (2007), "Outpatient microthoracoscopic sympathectomy for palmar hyperhidrosis", Ann Thorac Surg, 83: 1 8 5 0 - 3 . 16. Nguyin Hoii Nam (2003), "Nhttng cii tiln Ubng
dieu frj chiing ting tiet mo hoi tay bing phiu thuit npi soi ling nguc", Yhoc Thanh phd Hd ChiMinh, sl7,tr.31-5.
17. Vin Tin (2000), "Cii tiln phau tiiuat ndi soi ling nguc dl dilu frj chiy m l hdi tay", Toan van bdo cdo long liet nghien cieu khoa hgc va cdt tien ky thudt 10nam tgi B?nhvi4nBinhDdn,Xr. 157- 162.
Tgp chf Y Duyc hgc - Truftng Dai hgc Y Diryc Hue - So 32