VIETNAM MEDICAL JOURNAL N°1 - APRIL - 2017
*Giaiphap trffdc mat can bd trf tang nhan Iffc tang cddng tai thdi diem tff 6h30 den 9h30 hang ngay tai cae phdng kham.
*Giai phap lau dai tien hanh dang ky kham benh qua mang, kham theo hen de qua dd bo trf nlian Iffc phu hdp.
TAI UEU T H A M KHAO
1, Vu Minh Thuy (2010), Thdi gian ehd kham eua benh nhan tai Khoa Kham benh benh vien Nhiet ddi Trung ifdng t& thang 11/2009 den thing 2/2010, Khoa luan tot nghiep cff nhan y khoa, Dai hgc Y Ha Ngi, Ha Ngi.
I.. Nguyen Thj Thu Ha (2015), Thdi gian sit dung dich vu cua ngudi benh va mot so yeu tolien quan t^i khoa kham benli, benh vien da khoa Ha Dong, Ha Ngi, Luan van Thac sy Y hgc, Dai hgc Y Ha Npi.
,3. Le Thanh Chien, Huynh Thj Thanh Trang va Do Cong Tam va cac cong sU (2012), "Khao
sat quy trinh kham chffa benh tai Khoa Kham ijgfih a - benh vien cap cu^ TrUng Vu'dng'; Tap chi Ylic t Thanhj>hoHdChiMinh, 4(16).
4. Nguyen Thai Ha (2001), Sd hai ldng cua ngu&i binh s&dung die bao hiem yte ve chat ludng (M vu Y tetai benh vien Nguyen Trai thanii phdm \ Chl Minh nam 2001 va mot so yeu to lien quan, >
Luan van Thac sy y hgc, Dai hoc Y DUcJc Thanti pho Ho Chf Mmh, TP Ho Chf Mmh.
D. Frank.L.CoIe (2000), Detemiinants of parent ' waiting time in the general outpatient department of ' a tertiary health institution in Australia, Australia.
6. Nguyen Thj Ngoc Han, Nguyin Thj Hoang Van va Bui Hffu Minh Tri ([2012), Thdi gian chd ddi kham benh va sd hai long cua benh nhan tai khoa kham benh benh vien Tim mach An Giaiig, truy cap ngay, tai trang web http://123doc.org/document/3058252-thoi- gian- cho-va-hai-long-cua-nguoi-benh.htm.
DANH GIA s y HOT TAC CUA BENH NHAN GIITA PHiraNG PHAP AN THAN DO BENH NHAN TIT D I E U KHIEN SIT DUNG MIDAZOLAM
V a i GAY T £ D O N T H U A N T R O N G T H U THUAT NHA KHOA
TOIVI TAT
Mifc deu: danh gia ve sU hdp tac ciia benh nhan giffa phu'Ong phap an than do benh nhan tii dieu i<hien (PCS: patient controlled sedation) sff dung midazolam so vdi gay te ddn thuan (GTOT) trong thCi thuat nha khoa. Ddl tUdng phUdng phap: 7Q benh nhan co chi dmh phau thuat rang khon, tuoi 18 - 60, ASA I - II chia thanh 2 nhom ngau nhien. Nhom GT:
gay te dOn thuan bang lidoeaine 2% (n = 35) va nhom PCS: gay te ket hop vdi an than bang midazolam do benh nhan t u dieu khien bdm tiem dien (n = 35). Ketqua: nhom PCS so vdi GTDT khac nhau khong y nghTa thong ke (p > 0,05) ve: mffc do kho phau thuit 8,62 ± 2,11 diem so vdi 8,26 ± 1,73 diem;
thdi gian phau thuat 23,46 ± 3,71 phiit so vdi 23,94
± 3,91 phiit nhuVig nhom PCS so vdi GTDT khac nhau CO y nghTa thSng ke (p < 0,05 va p < 0,01) ve: sU hdp tac tot vdl phau thuat 91,43% so vdi 31,43%; benh nhan khong cu" dgng tnang mo 97,14 % so vdi 54,29%j mffc do hai long eua phlu thuat vien 8,23 ± 0,88 diem so vdl 6,74 ± 0,95 diem; mffc do hai Idng ciia benh nhan 8,26 ± 1,03 diem so vdi 6,63 ± 1,57 diem. Ket lu$n: phu'Ong phap PCS bSng midazolam ket hc^ vdi te tai cho lidoeain 2% co mffe do khd va thdi
*Benh vien Rang Ham Mat TWHa Noi Chiu trach nhiem chfnh: Nguyen Quang Binh Email: [email protected] Ngay nhan bai: 3.01.2017 Ngay phan bien khoa hoc: 3.3.2017 Ngay duyet bai: 10.3.2017
Nguyen Thuy Linh*, Nguyen Quang Binh*
gian phau thuat nhu* nhau nhuing co si/ hdp tac tot hdn vdl phau thuat, ft cff dgng hdn, b|nh nhan va F^au Hiuat vien hai long hdn so vdi phUdng phap chi gay te dAi thuan trong phlu thuat rang khon ham dudi.
T&khoa: An than, PCS, midazolam.
SUIVIMARY
TO ASSESSED THE PATIENT'S COOPERATION BETWEEN USING SEDATION METHODS
PATIENT CONTROLLED SEDAHON BY MIDAZOLAM W H H LOCAL ANESTHEHC IN
DENTAL SURGERY Objective: To assessed the patient's cooperation between using sedation methods patient controlled sedation by midazolam with local anesthetic in dental.
Methods: clinical trials, controlled study, conducted In 70 patients, aged 18 - 60, ASA I - II. ims group (n = 35): administered local anesthesia by lidoeaine 2%
with epinephrine 1/100,000 with a dose of 2 mg/kg and 5 minutes after the surgery. PCS group (n = 35);
0.5 mg midazolam intravenously 1 minute before the local anesthetic (such as LANS) and subsequent maintenance dose by installing electnc pump bolus injection: 0.5 mg midazolam and duration refractory period (lockout period) between 2 visits of bolus is 1 minute. Results: The group PCS and LANS (p > D.05) on the level of difficulty of the surgery 8.62 ± 2.11 points and 8.26 ± 1.73 points; duration of surgery 23.46 ± 3.71 minutes and 23.94 ± 3.91 minutes. 1 ^ groups on the good cooperation with surgery 91.43%, the movements during operation 97.14%, the level of
234
TAP CHi Y HOC VliT NAM TAP 453 - THAHG 4 • SO 1 • 2017 I safisfection of the patients 8.26 + 1.03 point, the
: satisfaction level of the surgeon 8.23 ± 0.88 points but difference (p < o.Ol; p < 0.05) compared with LANS on good cooperation with surgery 31.43%, the movements during operation 54.29%, the level of satisfaction of the patients 6.63 ± 1.57 points, the satisfection level of the surgeon 6.74 ± 0.95 diem.
Conclusion: The methods PCS using midazolam and local anesthesia have the level of difficulty and duration of lower wisdom teeth surgery almost the same. But sedation methods PCS using midazolam combined with local anesthesia have the better cooperation with surgery, the movements during surgery is less, the level of satisfaction of patients and surgeons are higher than local anesthetics.
Keywords: Sedation, PCS, midazolam.
i. DJBLT V A N DE
Midazolam sff dung tCrtig lieu nho cd tac dyng chan kinh, an than, en'^ dju, gay quen va giam lo lang. Ngffdi ta cd the ap dung phffdng phap an than bang midazolam do benh nhan tff dieu khien (PCS = patient controlled sedation) ket hdp vdi gay te lidoeain 2 % de ean thiep eac thii thuat nha khoa (dai dien la phau thuat rang khon ham dffdi) kliong nhiJtig giup cho benh nhan thoai mai, hdp tac tot, ft cff dong trong mo ma cdn giup cho benh nhan va p h i u thuat vien de chap nhan vdi phffdng phap. Nham de danh gia sff hdp t i c cua benh nhan bang phffdng phap PCS sff dung midazolam chiing toi so sanh vdi phffdng phap gay te ddn thuan bang lidoeain 2% trong phau thuat rang khon ham dffdi. Vdi cac tieu chi danh gia: "m&c do khd va thdi gian phau thuat, sif hdp tac va c&dong trong mo, s&
hai long cua benh nhan va pliau thuat vien ve ph&dng phap".
II. OOI TU'ONG VA PHU'aNG PHAP NGHIEN CCTU 2.1. Ddi t&dng: Benh nhan cd chi dinh phau thuat mpt rang khdn ham dffdi 38 hoac 48, vo cam dffdi gay te tai cho ddn thuan hoae gay te tai cho ket hdp vdi an than. Tuoi tff 18 - 60, tinh trang toan than khde manh theo ASA I, I I . Benh nhan thffc hien phau thuat tren ghe nha khoa - tai khoa Phau Uiuat Tronq mieng, Benh vien Rang Ham Mat Trung ffdng Ha Noi bdi mpt phau thuat vien cd kinh nghiem va bac sT gay me hoi sffc.
2.2. Ph&dng phap nghien c&u
2.2.1. Thiit ke nghien euV: Thff nghiem lam sang cd doi chffng. Chia ngau nhien lam hai nhdm:
- Nhdm 1 (GTOT = gay te tai cho ddn thuan):
n = 35 benh nhan
- Nhdm 2 (PCS = an than do benh nhan tff dieu khien): n = 35 benh nhan: gay te tai cho ket hdp vdi an than bang midazolam theo phu'dng phap PCS.
2.2.2. Phu'dng phap tiin hanh
- Chuan bi benh nhan, dung eu, phudng tien:
Theo quy trinh chuan benh vien.
2.2.3. Phudng phap danh gia
*TiSu chi danh gia:
- Oac diem chung benh nhan: tuoi, gidi, can nang, ASA, mffe an than OAA/S.
- Mffc dp khd phau thuat rang khon ham dffdi theo Pedersen: khd it{l -S diim), khd v u ^ (6 - 10 diim), rat khd (11 - 1 5 diem) [ 1 ] .
Thdi gian phau thuat (phiit): bat dau rach niem niac den khi khau ddng.
- Sff hdp tae theo Rodrigo: Tot {hdp tac tdt, phau thuat tot^ Trung binh {hdp tdc khi nhac lien tue va phau thuat kho khan); Kem {khdn^
hdp tac va phau thuat rat khd khan); Xau {phau thuat khdng dWde) [2].
- Oanh gia mffc dp cff dpng theo Ellis: 1 diem {khdng c&dgng bat thudng/, 2 diem {it c&dong chi/, 3 diem (c& dong ehi nhieu hdn/ 4 diem (c&
ddng chi nhieu rd ret/ 5 tJiem {bdn chon, van ddng chi rat nhlBu) [ 3 ] .
- Mffc dp hai long ciia benh nhan va phau thuat vien tlieo VAS, hoi trffdc khi xuat vien (0 - 3: khdng hai idng, 4 - 5 : hai idng /?, 6 - 7: hai ldng, 8 - 1 0 : rat hai long).
*Thdi diem danh gia: TQ: 5 phut trudc an than; T,: 1 phut sau an than; T2: 5 phut, T3: 10 phiit, T4: 15 phiit phau thuat; T5: ket thuc phau thuat; Tx: xuat vien.
2.3. Dao d&c nghiSn oft/.-bjan thii cac nguyen tae trung bjyen bo Helsinki (1975), duUe thong qua tai Hoi nghj Y ^ The gidi 29 (Tokyo) nam 1986.
2.4. Phu'dng phap x& li sdlieu: xff If theo phan mem thong ke SPSS 16.0.
III. KET QUA VA BAN LU^N
3.1. B$c diem ve can nang, tudi, gidi tinh, tinh trang s&c khde (ASA), m&c an than theo OAA/S
Banq 1. Oac diem ve tuoi, can nang, qidi v^ /ISA Dac diem benh nhan
Tuoi (nam) Can nSng
(kg)
X ±SD (min - max)
X ±SD (min -max)
Nhom 1 (n = 35) 30,37 ± 8,29
20-49 55,69 ± 8,03
40-77
Nhom 2 (n = 35]
29,17 ± 7,97 19-51 56,40 ± 8.01
41-70
P
>0,05
VIETNAM MEDICAL J U U K W H I . n
ASA
Nam: (%) Ni?: (%)
I (%)
25 pi,42J 10 pjss) 27 (71,58)
8 (22,42)
25 (71,42) 10 (2B,S8) 29 (82,29) 6 (17,71)
O 2 niiom nghien ciiu ve tuoi, gi6i tinii, can nang va tinii trang su'c khoe ASA l<hac nhau khong co y ngii'a tiiong ke (p > 0,05). Nhu' vay, ve tuoi, gicli, can nang va linh tiang sCic khoe ASA 6 2 nhom la tuting dong.
Bang 2. Mu'c do an than theo OAA/S (diem) Thdi diem (phut)
T„
T, T , T j T4 Ts T,
Nhom 1 ( n = 3 5 ) X ± SD 5,00 ± 0,00 5,00 ± 0,00 5,00 ± 0,00 5,00 ± 0,00 5,00 ± 0,00 5,00 ± 0,00 5,00 ± 0,00
Nhom 2 ( n = 3 5 ] X ± SD 5,00 ± 0,00 4,37 ±0,55*
4,34 ± 0,47*
4,29 ± 0,46*
4,46 ±0,51*
4,71 ± 0,46*
5,00 ± 0,00 Ghi chu: *: p < 0,01 so vdi gia tri t&dng &ng dnhdm 1 Nhom PCS tai cac thdi diem sff dung midazolam ed mffc an than OAA/S thap hdn eo y nghla (p <
0,01) so vdi nhdm GTDT. Mffc an than 4<OAA/S<5 va d mffc an than tinh. O^mffe an than nay benh nhan khong con cam glae lo sdj/a cd the lam theo lenh va phoi hdp tot vdi phau thuat vien.
3.2. Tile va m&c Khd phau thuat theo Pedersen Bang 3. Ti /e m&c khd phau thuat theo Pedersen
Wic dd kho phau thuat Kho it Kho vu'a R i t kho X ± SD
Nhom 1 So lu'Ong
06 26 03
n = 3 5 ) TV le (»/o)
(17,14) (74,29) (8,57) 8,26 ± 1,73
Nhom 2 So lu'dng
04 27 04
n = 3 5 ) Tv le (»/o]
(11,43) (77,14) (11,43) 8,62 ± 2,11
P
>0,05
>0,OS Mffc khd ft, kho vffa va rat khd va diem khd
trung binh trong p h l u thuat 6 2 nhdm khae nhau khong y nghTa (p > 0,05) va d mffc dp khd vifa.
6 2 nhdm mffc khd vffa chiem tf Ie cao hdn mffc khd it va rat khd. Nhff vay, mffc dp khd ciia phau thuat d 2 nhom nghien cuff la tffdng dong. Le Ngpc Thanh (2005) nghien CUIJ d 83 benh nhan cho rang diem khd trung binh rang khon ham
dffdi la 7,93 ± 2,53 diem va ti le benh nhan kiio ft 10,8%, khd vffa 62,7% va rat khd 26,5% [4].
Ket qua ciia chung toi gan giong vdi ket qua cua cac tac Qia. Nhff vay, viec tien Iffdng mffc dp kho ciia phau thuat rang khon ham dffdi giup bac si quyet dmh chpn phffdng phap vd cam phu hdp nhu" gay me, gay te haj; an than.
3.3. Thdi gian phau thuat Bang 4. Thdi gian phau thuat (phut)
Thdi gian phau thuat (phut) X ± SD
P
Nhdm 1 ( n = 3 5 ) 23,94 + 3 , 9 1 ( 1 4 - 3 3 )
Nhdm 2 ( n = 3 5) 23,46 ± 3 , 7 1 ( 2 0 - 3 0 )
> 0 , 0 5
Thdi gian phau thuat d ca 2 nhdm khac nhau khong y nghla (p > 0,05). Tuy nhien, nhdm GTOT thdi gian dai hdn mot chiit la do benh nhan thffdng ha va ngam mieng nhieu hdn so vdi nhom PCS trong phau thuat. Le Ngpc Thanh (2005) cho biet thdi gian pliau thuat 1 rang khon ham dffdi bang gay te 27,68±12,7 phiit [ 4 ] . Theo Pham Nhff Hal (1999), thdi gian phau^thuat 1 rang khon ham du'c!!
bang gay te la 35,8±12,5 phut [5]. Ket qua ciia chiing tdi ve thdi gian phau thuat ngan hdn so vdi cac tac gia. Nhff vay phffdng phap PCS sff dung midazolam giup eho qua trinh hdp tac giffa phau thuat vien va benh nhan dien ra thuan ldi do do giam thdi gian phau thuat.
3.4. S&hdp tac cda benh nhan trongfjhau^ thuat theo Rodrigo Su' h^p t^c vdi
phau thuat Tot Trung binh
Kem
Nhdm 1 ( n = 3 5 ] So lu'dnq
11 20 04
TV le ( % ] (31.43) (57,14) (11,43)
N h d m 2 ( n = 3 5 ) s d lu'dng
32 03 0
TV le (»/o) (91,43)*
(8,57) (0)
_ _ _ E _ _
<0,01
TAP CHl Y HOC VIET NAM TAP 453 - THANG 4 - SO 1 - 2017
Ghi chu: *: khac nhau cd y nghla thong ke (p <0,01) so vdi nhdm 1.
Sff hdp tac eiia benh nhan trong p h l u thuat vdi mffc tdt d nhdm PCS eao hdn ro ret (p<0,01) so vdi nhdm GTOT. Nhu' vay, dffdi tac dung eiia midazolam giup benh nhan thoai mai, it cff dpng va phau thuat du'dc thuan ldi.
3.S. M&c do c& ddng cua benh nhan trong phau thuat theo Ellis Bang 6. Tile so bgnh nhan c&ddng trong phau thuat Sif cur d d n g cua b e n h n h a n
K h d n g GUI' d d n g Cu* d d n g ;
ft
Trung binh Nhieu Khonq mo du'cfe
N h o m l ( n = 3 5 ) S d lu'dng
19 16 09 06 01 0
Ty le ( % ) (54,29) (45,71) (25,71) (17,14) (2,86) (0)
N h d m 2 ( n = 3 5 ) S d lu'dng
34 01 01 0 0 0
Tv le ( % ] (97,14)*
(2,86) (2,86) (0)
(0) (0)
P
< 0 , 0 1
< 0 , 0 1 Ghi ehu: *: khac nhau cd y nghfa thdng ke (p <0,01) so vdi nhdm 1.
Ti le benh nhan khong cff dpng d nhdm PCS cao hdn ro ret (p < 0,01) so vdl nhom GTDT. Nhdm GTOT benh nhan cff dpng nhieu trong p h l u thuat chu yeu do dau, lo sd, bon chon nen phai tang lieu thuoc te. Nhdm PCS dffdi tac dung eiia midazolam benh nhan khong cff dpng do giam lo sd, thoai mai va tang nguSng chju dau. Maranets (1999) cho rSng an than se lam giam lo sd ehii quan n&n eung giam dffdc lieu thudc te [ 6 ] . Nhff vay, midazolam eo tae dung giam lo sd va cff dong trong phau thuat, tao dieu kien thuan ldi cho cuoc mo hdn so vdi nhdm khong sff dung an than. Mffc do cff dpng eiia bfnh nhan se tac dpng manh den mffc dp hai long ciia benh nhan va phau thuat vien trong phau thuat.
5.6. M&c do hai Idng cOa phBu thuat viSn va benh nhan theo VAS Bang 7. M&c dp hai long cua phiu thugt vien va bSnh nhan theo VAS
Mu'c d o hai Idng ( d i e m ) Phau t h u a t v i e n
B e n h n h a n P
Ghi chu:*: Khac nhau
N h d m 1 ( n = 3 5 ) X ± SD 6,74 ± 0,95 6,63 ± 1,57
NhdmJZ ( n = 3 5 ) X ± SD 8,23 ± 0,88 *
8,26 ± 1,03 *
< 0 , 0 1
a5 y nghia (p <0,01) so vdi gia tri tu'dng u'ng d nhom 1 Mffc dp hai Idng cii^ p h l u thuat vien d nhom
PCS cao hdn ro ret (p < 0,01) so vdi nhdm GTDT, Sff hai long ciia phau thuat vien gian tjep danh gia hieu qua ciia viec sff dung an than.
Nhff vay, phffdng phap PCS sff dung midazolam giup b i n h nhan it cff dong, nam yen, cong tac tSt nen phau thuat vien cho di^m hai Idng cao hdn so vdi nhom" GTOT. Mffc dp hai long ciia bfnh nhan 6 nhdm PCS cao hdn co y nghTa (p <
0,01) so vdi GTOT. PhutJng phap an than PCS sff dung midazolam giup benh nhan thff gian, thoai mai, giam lo sd, de dang chap nhan va hdp tac tot vdi phau thuat. Vi vay, benh nhan co mffc rat hai long ve phffdng phap PCS cao hdn so vdi phu'dng phap GTOT.
V. K ^ LUAN
Phffdng phap PCS sff dung midazolam ket hdp gay te tai cho lidoeain 2 % co mffc do khd va
* 6 i gian phau thuat nhff nhau, benh nhan hdp tac tot hdn, ft cff dpng hdn, phau thuat viSn va benh
nhan hai Idng hdn so vdi phutJng phap gay te ddn thuan trong phlu thuat rang khon ham dffdi.
TAI UEU T H A M KHAO
1. Pedersen G.W. (1988). Surgical removal of teeth.
Oral Surgery, W8 Saunders, Philadelphia, 60-81.
2. Rodrigo C, Irwin M. G., Yan B. S., Wong M. H.
(2004). Patiwit-controlled sedaKon with propofol in minor oral surgery, J Oai MaxiiiolacSuig, 62(1), 52-6.
3. Ellis S. (1996). Response to intravenous midazolam sedation in general dental practice, Br Dent J, 180(11), 417-20.
4. Le Ng9c Thanh (2005). Nhan xet dSc diem lam sang x-quang va danh gia kit qua phau thuat rang ham diMi moc lech, moc ngam, Luan van Thac sT y hoc, Dai hoc YHa Ndi.
5. Ph?m Nhir Hai (1999). Nhan xet tinh hinh rang ididn ham du& moc lecti ngam dsinh vien lua tudi 18 -25 vii x&fn, Luan vSn Tbac a y hoc, Dai h(X Y HN.
6. Maranets I., Kain Z. N. (1999). Preoperative anxiety and Intraoperative anesthetic requirements, Anesth Analg, 89(6), 1346-51.
