JOURNAL OF 108 - CLINICAL MEDICINE A N D PHARMACY Vol.12 - N=7/2017
Danh gia su thay doi ve tuan hoan, ho hap va cac tac dung khong mong mudn cua phuotig phap an th§n do benh nhan tu di^u khien b^ng propofol trong hut thai
The evaluation of circulatory respiratory changes and side effects of patient controlled sedation methode with propofol for abortion
Nguyin Du-c Lam*, *Trudmg Bgi hgc YHd Noi Hoing Ngpc Vinh**, **B$nh vi§n da khoa Ddng Anh Vu Van Du*** ***Benh vien Phu sdn Trung ucmg
Muc tiiu: Nghidn cQu sQ thay ddi ve tuan hoan, hd hap v l cac t i c dung khdng mong muon cua an than do benh nhan t u dieu khien (PCS - patient controlled sedation) b i n g propofol trong hut thai dudi 12 tuan. Bdi tuang vd phuang phdp: Jhd nghiem lam sang ngau nhien ed so sanh tren 100 b&nh nhan hilt thai CO tudi thai 1 0 - 1 2 tuan, chia hai nhdm: Nhdm an than do benh nhan tQ di^u khien (nhdm PCS), benh n h i n tU dieu khien bOm tiem dien, lieu bolus 20mg propofol, thdi gian khda la 60 giay; nhom gay me: Gay me tTnh mach b i n g propofol 2mg/kg. C l hai nhdm deu dupc gay te canh cd tQ cung bing 80mg lidocain. Ket qud: Tan sd tim, huyet ap ddng mach tam thu va huyet ap dpng mach tam trUang cCia cae benh n h i n d hai nhdm nghien cQu khdng cd sQ khac bi^t cd y nghTa thong ke d tat c l cac thdi diem nghien cQu, Tan sd thd eCia cac benh n h i n d nhdm gay me g i l m so vdi nhdm an than PCS tai cac thdi diem: T l , T2, T4, T6 v l T8 vdi p<0,05 nhUng SpOi khdng ed sU khIc biet giQa hai nhdm tai tat c l cac th6i diem. Nhdm an than it gap cle tae dung khdng mong mudn so vdi nhdm gay me: Gilm thd (6% so vdi 38%), chdng mat (30% so vdi 54%), dau cho tigm (12% so vdi 16%), nac (0% so vdi 2%). Kit lugn: PhUOng phIp an than do benh n h i n t u dieu khien bang propofol ft gay I n h hudng tren tuan hoan, hd hap va it gap cac t i e dung khdng mong mudn hOn so vdi phuang phap g l y me tTnh maeh bang propofol. Khdng gap eac bien chUng nang nhU: Suy hd hap, tut huyet I p , ndn trao ngupc...
Tdkhoa: An than do benh n h i n t u dieu khien, hut thai, propofol, tae dung khdng mong mudn.
Summary
Objective: To estimate the changes in circulation, respiration and side effects of propofol used in patient controlled sedation for abortion in women with under 12 weeks of pregnancy. Subject and method: A randomized controlled trial w/as performed in 100 patients with gestational age between 10- 12 weeks, these women were divided into two groups: The Patient Controlled Sedation group: Patient self-controlled sedation with a bolus dose of 20mg propofol, the block time was 60 seconds, and the
Ngdy nhan bdi. 24/5/2017. ngdy chdp nhdn ddng: 09/6/2017
Nguaiphdn hoi: Nguyin Due Lam. Email- [email protected] - Truang Bai hpc YHd Npi
TAP CHl Y DUgc LAM SANG 108 Tap 12-So 7/2017 anesthesia group: Intravenous anesthesia with propofol 2mg/kg. Both groups were given paraeervical block with 80mg lidoeaine. ftesu/t; There were non signifiean differences between 2 groups in heart rates, systolic and diastolic blood pressures. The respiratory rate of patients in the anesthetics group was lower than that of Patient Controlled Sedation group at T l , T2, T4, T6 and T8 {p<0.05), but the SpOj level remained the same in both groups. Patient Controlled Sedation group had less sides effects than anesthesia group: Hypopnea (6% versus 38%), dizziness (30% vs 54%), pain in injection site (12% vs.
16%), and pain hysteresis (0% vs. 2%). Conclusion: Patient Controlled Sedation propofol had less effects on respiratory, circulation and less sides effects than propofol induced intravenous anesthesia. No serious complications such as respiratory failure, hypotension, reflux... were recorded.
Keywords: Patient Controlled Sedation, abortion, propofol, side effects.
I . D a t v a n d e
Phuang p h I p an than do benh nhan tU dieu khien (Patient Controlled Sedation - PCS) bang propofol la phuang phap mdi cd nhieu Qu diem do benh nhan van tinh va cd the tham gia tfch eUc vao viec kiem soat mQc dp an than cua minh. Theo eae nghien eQu, phQOng p h I p nay giup g i l m lidu thudc me sU dung, benh n h i n tinh nhanh, xu^t vien sdm.
6 nude ta, phuong phap nay da dupe nghien cQu trong ndi soi dai trang, nhd rang k h d n . . . nhung chua cd nghien cQu nao ap dung phuong phap nay cho thu thuat hut thai, mdt t h u t h u l t s i n phu khoa rat phd bien, gay lo lang v l sp hai rat nhieu, dac biet d phu nQ trd nen can p h l i an than t d t eho bdnh nhan. Vi v l y , ehung tdi tien hanh nghien cQu de tai nay muc tidu: Nghiin cdu sd thay ddi ve tudn hodn, hd hdp vd cdc tdc dung khdng mong muon cda an thdn do binh nhdn td diiu khien bdng propofol trong hdt thai dudl 12 tudn.
2. Ddi tucAng va phUOng phap 2.7. Ddi tddng
Cac phu nQ cd thai, tuoi thai 1 0 - 1 2 tuan, cd yeu cau dinh chi thai nghen tai Benh vien Phu s i n Ha Npi.
77eu chudn Ida chgn: Tudi 16 - 50, ASA I, II, khdng CO chdng ehl djnh vdi propofol va lidocain, tinh nguyen tham gia nghien eUu.
Tieu chudn logi trd: Cd cae benh ly ndi khoa kem theo (benh t i m , phdi, gan than...), benh nhan dang sly thai, c h l y mau nhieu, t u t huyet I p , thidu khdi lupng tuan hoan...
2.2. Thiet kenghien cdu
ThQ nghiem lam sang, ngau nhien, ed so sanh.
2.3. Thdi gian, dia diem
Nghien cQu dUOc tien h l n h tQ t h i n g 12/2015 den t h i n g 6 nam 2016 tai Khoa Ke hoach hda gia dinh, Benh vien Phu san H I Ndi.
2.4. Cach thde tien hinh
Benh n h i n dUpc kham, lam cle xet nghiem huydt hpc, dUpc giai thfch ve phuang p h I p vd e l m va hudng dan sQ dung bam tiem dien tQ ddng (PCS).
Ddgc bdc tham ehia thanh 2 nhdm, moi nhdm 30 benh nhan:
Nhdm PCS: An than do benh n h i n t u d i e u khien, benh n h i n tU bam nut dieu khien bam tiem t u ddng de may bom vao tTnh maeh moi lan 20mg propofol (lieu bolux), thdi gian khda la 60 giay.
Nhdm gay me (GM): Gay me tinh maeh bang propofol lieu 2mg/kg.
C l hai nhdm deu dupe gay te canh eo tQ cung bang 80mg lidocain trUde khi tien hanh l l m thO t h u l t . Cac benh n h i n dupe theo ddi lien tuc trong qua trinh l l m t h d t h u l t : Cac chi sd ve tuan hoan, hd hap va cac t i e dung khdng mong muon. Cle thdi diem nghien cQu: T l - TIO tUdng Ung thdi gian tQ phut t h d 1 sau khdi me den phut thU 10. TKT: Thdi diem ket thuc thCi thuat. THT: Thdi diem benh n h i n hdi tinh. TXV: Thdi diem benh nhan dUOc xuat vien.
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3. K^t qua
Bang 1 . Dac diim chung cOa doi tUpng nghien cdTu
Tuoi (nam)
Chieu cao (cm)
Can nang (kg)
Chi so BMI ASA e o l B o l l
Tinhtranghonnhan Chua CO gia dinh f)a CO gia dinh Tien SLf hut thai Chua hut thai Da hut thai
Nhom 1 (PCS) (n = 50) 26,7 ± 7,3
(17-45) 158,1 ±5,4 (145-167) 47,8 ± 6,3 (39-65) 18,8 ±3,5
(17-23)
425 (84%) 8(16%)
11 (22%) 39 (78%) 31 (62%) 19(38%)
Nh6m2(GM) (n = 50) 27,2 ±6,7 (18-47) 157,8 ±6,2 (144-165) 48,3 ± 7,1 (38 - 63) 19,4 ±4,3 (18-24)
45 (90%) 5 (10%)
9(18%) 41 (82%) 29 (58%) 21 (42%)
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05 Thay doi vd tu^n h o l n : Tan sd tim, huyet l p ddng maeh t i m thu va huyet ap ddng mach tam trUang cua cae b^nh nhan d hai nhdm nghien cUu khdng cd sU k h I c biet cd 'ji nghla thdng ke d tat c l cac thdi diem nghien cQu (TO - T xv) vdi p>0,05.
Thay doi ve hd hap
25 20 15 10 5 0
19,1
18,4 18,7 16
V-4—4—«
\ ' '
19,5 \
11 3 ,6 r 17,6
1.
17,3 17,2
,5 12,6 13,2
1
r I
ri T
„ 15.3 17,5
4" 1
t
17,5
:^ \
16 IS
^
,1 1
18,4
TO Tl T2 T4 T6 - • - Nh6m 1
Te T10 - • - Nh6m2
TKT THT TXV
B i e u d o 1 . T h a y d d i v e t a n s d t h d
TAP CHl Y D l / O C L A M S A N G 108 Tap 1 2 - S o 7/2017
101 - 1 0 0 - 99 - 98 97 96 96 94 93 . 92
99.3 991 gg.3 99.4
_J i 1 -
99.2\J
r^ J
99.2 I
S W 99.1
98
99,1 99.3
99.3 99.3 99,1
99
96.6 96,3
TO T1 T2 T4
- • - Nh6m 1
T6 T8 T10
- • - Nhom 2
TKT THT TXV
B i e u d o 2 . T h a y d d i v e S p 0 2
Biing 2. Cac tac d u n g Ichdng m o n g m u o n
Dac d i ^ m Buon non, non Chong mat Nac Dau cho tiem Giam thcf
Nhom 1 (PCS) (n = 50)
0 (0%) 15(30%)
0(0%) 6(12%) 3(6%)
Nhom 2 (GM) (n = 50)
0(0%) 27 (54%)
1 (2%) 8(16%) 19(38%)
P
<0,05
>0,05
>0,05
<0,05
Cle dac diem chung cCia benh n h i n nhU: Tudi, ehieu eao, can nang, chi so BMI, phan loai sUc khde theo ASA d hai nhdm trong nghien eUu eua ehung tdi kha tuong ddng, d o dd, se khdng I n h hQdng den ket qua nghien eUu. £)a sd bdnh nhan deu da ed gia dinh va t / le hut thai lan d i u kha eao (62% d nhdm PCS, 58% d nhdm gay me).
Trong nghien cQu cua chung tdi, tan sd t i m cda cac benh nhan d hai nhdm nghien cQu khdng cd sU khac biet cd y nghla t h d n g ke d tat c l cac thdi diem nghien cdu. Huyet I p d p n g maeh t i m t h u va tam truong eua eac benh nhan d hai nhdm nghien eQu cOng khdng ed sQ khae biet cd y nghta thdng kd. Tuy nhien, d c l e thdi diem T l , T2, T4, T6 thi huyet ap t i m thu va huyet ap tam trQOng d nhdm gay me g i l m so vdi TO {p<0,05), dieu nay dQpc g i l l thfch do tac dung tren he tuan h o l n cda propofol khi dung lieu gay
me toan than 2mg/kg. Ket qua cua chdng tdi phu hop vdi TrUOng Minh Hai (huyet ap tam t h u v l tam trUong d benh nhan nhdm gay me bang propofol deu g i l m khi khdi me va keo dai trong va sau g l y me) [2]. Nhdm an than do benh n h i n tU ^ e u khien, huyet I p benh nhan dn djnh hon, khdng cd sU khac bidt so vdi TO d tat ca c l e thdi diem. Ket q u i eua ehung t d i cung phu hpp vdi da sd ele tae g i l , an than theo phuong phap PCS bang propofol don thuan hay phdi hpp vdi ele thude khac cho ket qua khdng g l y bien dpng ldn tren tuan hoan, t u t huyet ap thoang qua ma khdng can sQ dung den cac thude van maeh.
Bieu do 1 eho thay: Tan sd t h d eua eac benh n h i n d nhdm gay me g l i m so vdi nhdm an than PCS tai c l e thdi diem: T l , T2, T4, T6 va T8 vdi p<0,05, d l y la c l e thdi diem sau khi khdi me 1 phut, 2 - 8 phut dau tidn, d o d i e diem cua thude me propofol g l y Qe che hd h i p nen tan sd t h d cOa cac benh nhan nhdm 135
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gay me trong thdi gian n l y giam so vdi nhdm an than. Tuy nhien, khdng gap trUdng hpp nao tan sd t h d < 10 lan/phdt. Tan sd t h d g i l m d c l e thdi diem nay la do t i e dung Qc che hd hap cua propofol khi sQ dung lieu gay me tTnh mach 2mg/kg. 0 nhdm an than, do sQ dung lieu thap propofol (49,7 ± 14,2mg) nen ft Qe ehe hd hap, tan sd t h d on dinh han. Ket qua eua ehung tdi eung phu hpp vdi Nguyen Quang Binh, Tao Ngpe Son va Claudia Ceoimbra [1], [3], [4].
Theo ddi Sp02 eho thay: SpO; ed xu hQdng g i l m d thdi diem khdi me cCia nhdm g l y me (d thdi di^m T l , T2, T4), tuy nhien, sQ khIc biet khdng cd y nghTa thdng ke so vdi nhdm an than PCS (Bieu dd 2). G i l m b l o hda oxy mao maeh la do t i c dung Qc ehe hd hap eua thudc me propofol, tuy nhien, do cle bdnh n h i n deu dugc thd oxy nen vdi thdi gian Qe che hd hap ngan thl bao hda oxy ehUa thay ddi nhieu nen chua cd su khIe biet ed y nghTa thdng ke d hai nhdm nghien cQu. Trong nghien cQu nay, ehung tdi khdng gap trQdng hop nao SpOi g i l m < 92% va can hd hap ho trp. Trong nghien cQu cda Gillian Dean, khi an than sau de nao hut thai, ed gap mdt trQdng hpp suy hd hap p h l i dat ndi khi q u I n cap cQu [2]. Cd 3 mQc an than la: An than benh nhan van tinh; an than s l u v l g l y me toan the. MQc dp an than cang cao thi bdnh nhan cang bdt lo lang va thuan loi cho viec tien hanh thu thuat nhung cang lam tang bien chQng ve hd hap va tuan h o l n eijng nhU c h l m tinh va l l u dugc xuat vien. Day la Uu di^m cua phuong phap an than do benh n h i n tudieu khien.
Ve eae t i e dung khdng mong mudn cua hai phuang p h I p nly, chung tdi thay: Tie dung phu hay gap nhat la ehdng mat, nhdm g l y me (54%) cao ban nhdm an than (30%), su khac biet la ed y nghla thdng ke (p<0,05) va dau ehd tiem (lln lUOt I I 12% v l 16%) khdng cd su khac biet giQa hai nhdm {p>0,05), ed 1 benh nhan nl'c (2%). G i l m t h d la tac dung khdng mong mudn ed the g l y nguy hiem den tinh mang benh nhan trong qua trinh lam thu thuat. Trong nghien eUu cCia ehung tdi, ty le giam t h d d nhdm an
than do benh n h i n t u dieu khien ehi ehidm 6%, thap hon cd y nghTa thdng kd so vdi nhdm gay me tinii mach (38%). Oieu nay cd the dQpc g i l i thich la 6 nhdm an than do benh n h i n tU dieu khien, benh nhan van tinh nen chu ddng bam nut de thuoc truyen vao dUdng tTnh maeh, trong khi nhdm gay me tTnh mach, vdi lieu propofol 2mg/kg, mdt sd benh nhan da ed dau hieu g i l m thd, can p h l i sin sang theo ddi de ho trp hd hap khi can. Oay cung eho thay g i l trj cua phUong phap an t h i n do benh nhan tii ki^m soat, benh nhan van tinh nen khdng bj Qc che hd hap g l y giam t h d nhU trong gay me tTnh mach.
Khdng gap trUdng hpp nao cd ndn, budn ndn, mat djnh hudng hay cac tac dung phu khIc.
5. Ket luan
Phuong p h I p an than do benh nhan Xd dieu khien (PCS patient controlled sedation) bang propofol it g l y anh hUdng tren tuan hoan, hd hap va ft gap eac tac dung khdng mong mudn hon so v6i phuong phap g l y me tinh maeh bSng propofol:
G i l m t h d (6% so vdi 38%), chdng mat (30% so vdi 54%), dau cho tiem (12% so vdi 16%), nac (0% so vdi 2%)... Khdng gap eae trUdng hpp bien ehUng nang n h u suy h d h a p , t u t huyetap, ndn trao ngUpc...
Tai lieu t h a m k h a o
1. Nguyen Quang Binh (2010) Nghiin cdu phUang phdp an thdn bdng Propofol do binh nhan tddiiu khien trong phdu thudt rdng. Luin van Ti^n sy y hpc, Trudng Dai hpc Y Ha Ndi.
2. Truong Minh HIi 0999) Sddung Propofol trong ngo thai. Luan van Thac sy Y hpc, Hpe vien Quan y.
3. Tao Ngpe Son (2006) Bdnh gid tdc dung an than bdng propofol do benh nhdn tu diiu khiin trong thu thudt ndi soi dai trdng. Luin van Thac si y hoc, TrQdng Dai hoe Y Ha Npi.
4. Claudia C, Manon C, Thomas MH (2003) Patient- Controlled sedation using Propofol for dressing changes in burn patient: A Dose-Fiding study.
Anesth Anal 97:839-842.
