JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 9-N°3/2Q14
iTng dung phirtfng phap gay me kiim soat nong do dich trong gay me ngoai trii
The Results of Using Target Controlled Infusion (TCI) Anesthesia Method for Outpatients
Nguyln Minh Ly, Nguyin Van Kien Benh vien Trung Qudn doi 108
Muc dich: danh gia hieu qua va dp an toan cua phUOng phap gay me kiem soat nong do dich vdi Propofol trong thu thuat ngoai trd Ddi tugng vd phuang phap: 6Q benh nhan {BN) co chi djnh ndi soi da day, ta trang va dai trang, tuoi tir 18 - 70, ASA I, II theo phan loai cua Hiep hpi gay me Hoa ky {American Society of Anesthesiologist) dugc gay me v6i nong do Propofol dich trong huyet taong khdi dau la 2.5mcg/ml, dieu chinh tang giam theo dap Lfng cua BN. Kitqud:lha\ gian lam thu thuat la 23,7 ± 11 phut, thdi gian gay me 28 ± 7,5phut, thdi gian khdi me 68 ± 12,4 giay, nong do dfch trung binh 2,9 ± 0,25mcg/ml. Lieu khcri me trung binh 58,8 ±15,5mg, tong liipng Propofol tieu thu 280 ± 80,5mg . Huyet ap va tan so tim giam nhe sau khdi me, tan so t h d va SpO; luon on dinh, it tac dung phu. BN tinh hoan toan sau 4,6 ± 3,5 phut va dugc tra ve sau 12,8 + 10,5phut vdi diem Aldrete 10 diem. Ket ludn: Gay me kiem soat nong do dich bSng Propofol la phu'Ong phap thich hdp cho cac thCi thuat npi soi da day va dai trang ngoai trii, thu thuat dugc tien hanh an toan, thuan loi. BN va bac sy hai Idng > 95 %.
TUkhda: Gay me kiem soat nong dp dich, Propofol, gay me npi soi ngoai t r u .
S u m m a r y :
Objective: The purpose of this study was to assess the anesthetic safety and effeaiveness of propofol administered for outpatients by Target - Controlled Infusion anaesthesia method (TCI). Subjects and methods:
the sample consisted of 60 patients aged from 18 to 70 years old with grade I or II in ASA classifications. All subjeas, who were sent for colonoscopy or esophagogastroduodenoscopy, were received initial dose of propofol TCI 2.5 ^tg/mi. The dose was then titrated according to clinical signs. Results: The complement time of the procedure was 23.7 ± 11 minutes and the anaesthesia lasted for 28 ± 7.5 minutes. The mean of plasma concentration {Cp) maintained during procedure was 2.9 + 0.25 ng/ml, onset time at loss of consciousness was 68 ± 12.4 minutes. Average doses of propofol, which were administered for induaion and total procedure, were 58.8 ± 15.5mg and 280 + BO.Smg, respeaively. Heart rate and blood pressure decreased slightly and shortly after induaion. The oxygen saturation, respiration rate were stable during procedures with minimal side efferts. Full consciousness returned after 4.6 ± 3.5 minutes and patients were discharged after 12.8 + 10.5 minutes with Aldrete score of 10. Conclusion: Using propofol TCI to induce and maintain anesthesia during colonoscopy and esophagogastroduodenoscopy was safe and convenient. 95 percent of surgeons and patients satisfied with the procedure.
Key words; Target Controlled Infusion, propofol, outpatients colonoscopy anesthesia
Phan bifn khoa hgc: TS. NGUYEN QUOC TUAN 102
TAP CHi Y DU'O'C LAM S A N G 108 T i p 9 - S o 3/2014
1, Dat van d e
Thong t h u d n g d nu'dc ta khi tien hanh cac thCi thuat n h u noi soi tieu hoa bao g o m da day, di trang tham chi ngay ca khi cat polyp dai true trang t h u d n g tien hanh khi benh nhan t i n h ma khong gay me.
Phuong phap nay nhanh, don gian, re tien, khong mat thdi gian gay me va t h o a t me, khong can cac trang thiet bi gay me hoi siJc chuyen sau. Tuy nhien BN t h u d n g bj am anh keo dai vdi cac khd chiu, dau, kich thich non va b u o n non t r o n g khi lam t h u thuat.
Mot so t r u d n g h g p khdng p h o i hop duoc hoac xay ra cac phan Ung cd hai n h u con cao huyet ap kich phat, tang nhjp t i m , cUdng phe vi t h a m tri cd t r u d n g hgp truy t i m mach nen dac biet nguy hiem cho cac BNcd nguy cacao.
Vdi sU ra ddi cCia cac loai thuoc me the he mdi Propofol cho phep khdi m e nhanh, thoat me nhanh, chat lugng hoi tinh t d t nen gay me cho cac thCi thuat ndi soi ngoai tru ngay cang dUdc Ung dung rong rai [5].
Ky thuat gay me kiem soat nong do dich {Target Controlled Infusion - TCI) co kha nang kiem soat nong dp thudc udc doan t r o n g co quan dich la huyet tUdng hoac nao mang lai nhieu tien ich trong kiem soat khdi me va duy tri me, nen rat cd loi trong gay me duy tri t u t h d va nhat la cho BN ngoai tru [2], [4]. BN me nhanh tinh nhanh va co the tra ve nha dUdc ngay, tuy nhien cac nghien cufu ve Idi I'ch va do an toan cua phuong phap gay me nay cho n h d m BN ngoai tru cdn rat it de cap, chinh vi vay chung tdi nghien cUu de tai vdi muc dich: Oanh gia hieu qu^, dp an toan khi gay me vdi Propofol cd kiem soat nong do dfch trong cac thu thuat npi sol d u d n g tieu hoa.
2. Doi tUofng va phucfng phap nghien cutj 2.1. Ddi tUgfng nghien cdu
60 BN CO chi dinh ndi soi da day va dai trang, tuoi tCr 18 - 70, ASA I, II theo phan loai cua Hiep hdi gay me Hoa ky (American Society of Anesthesiologist) tCr thang 6/2012 den thang 10/2013. Loai trU nhQng BN khdng du tieu chuan, BN cd chong chi dinh gay me vdi Propofol, BN cd roi loan t h d n g khf nang, cd cac benh 1)/ cJp tfnh d u d n g ho hap, COPD...
2.2 PhUcfng phip nghien cdu: Tien cu'u, thCf n g h i e m lam sang.
2.2.1 Chuan bi phuang tien, dung cu
- Monitor da t h d n g so Phillipe, may gay me, may hut, den va dng NKQ.
- Bam tiem kiem soat nong d p dich (TCI).
- Thuoc m e Propofol va cac thudc men phUdng tien gay me hoi sUc.
2.2.2. Phuang phap tien hanh
- BN duoc tay rugt, nhin an uong, do can nang chieu cao.
*Tgi phdng soi:
- L^p dat fvlonitor theo ddi cac t h d n g so, t h d oxy 2-3 I/phut.
- Lap m o t d u d n g truyen t i n h mach, ndi vdi d u d n g dan thuoc Propofol gan vdi BN nhat tranh khoSng chet. Chpn che dp kiem soat n d n g do dfch tren he t h o n g TCI-I. Nhap cac dU lieu chieu cao, can nang, t u o i cCia BN va chgn cai dat nong dp propofol dich huyet tUdng ban dau.
* Khdi me: - Benh nhan dugc nam t u the san sang, t h u d n g la nghieng 90°
- Xac nhan cac t h d n g sd tren may TCI vdi nong do dfch dao d o n g t d 2,5- 3,0Mg/ml, xac nhan va an n u t Start de may bat dau chay.
Dieu chinh thuoc me theo nong dd dfch can cU vao dap Ung cCia BN va cac thi soi. fVloi lan dieu chinh nong dp tang hoac giam 0,1 - 0,5 pg/ml, 2 p h u t / ian cho den khi dat yeu cau. Tang khi benh nhan cd dau hieu tinh, gi^m khi benh nhan cd dau hieu ngUng t h d , t u t ludi, t u t huyet ap hoac mach cham,
2.2.3. Cdc chi tieu theo ddi vd ddnh gid - Dac diem cua BN; t u o i , gidi, chieu cao va can nang
- T h d i gian lam thCi thuat, t h d i gian gay me.
- Thdi gian khdi me: dUdc tfnh t d khi b d m t i e m bat dau b a m thudc t d i khi BN mat y thOfc, hay mat p h a n x a mi mat.
- Thdi gian nong dp propofol dat tdi dfch {mdc cai dat de khdi me) dUdc tfnh tU khi an nut Start cho t h u o c chay den khi dat dugc n o n g dp Udc m u o n .
- LUdng propofol khdi me, lieu khdi m e t r u n g binh, t o n g lugng tieu t h u .
- Nong do dich trung binh duy tri trong thu thuat.
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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 9 - N"3 /2014
- Cac anh hudng ho hap khi khdi me: ngCrng thd, ho, CO that thanh quan...
- Tan suit dieu chinh do me theo dau hieu tinh tren lam sang: BN cua, tang mach va huyet ap, chSy nude mSt, va mo hoi, ho nac tang td 0.1 -0.5 n/ml.
- Thdi gian tinh: tinh til khi diJng thuoc tdi khi BN hoi phiJC phan xa mi mat hoac md mat theo lenh.
- Thdi gian BN dUdc tra ve va diem Aldrete: tinh til khi ket thiJc thu thuat den khi BN dij tieu chuan tra ve dat 10 diem: BN tinh tao hoan toan (2 diem), van dong binh thudng (2 diem), on dinh ve tim mach (2 diem), ho hap binh thudng (2 diem) va SpOj binh thudng {2 diem).
- Cac tac dijng khong mong muon: buon non, non, ret run,lo giac...
- Banh gia su hai Idng ciJa benh nhan va bac sy lam thij thuat.
- Tan so tim, HATB, SpO, tai cac thdi diem:
+ TO: Trudc khdi me +'T1: Sau gay me 5 phijt + T 2: Sau gay me 10 phijt + T3: Ket thuc thCi thuat + T4: Khi benh nhan ra khoi phdng soi
3. Ket qua
Nghien CLTU tren 60 benh nhan cd chi djnh soi da day ket hgp dai trang. Gom 32 BN nam 28 BN nO, tuoi thap nhat 18 cao nhat 78 tuoi, trung binh 50,3 tuoi. Can nang trung binh 52,7 kg, cao trung binh 160,2 cm.
Bang 3.1. Thori gian lam thu thuat, thdi gian gay me, thdi gian Ithdi me va thdi gian thuoc
Propofol flat nong do dfch trong mau
Chisd
X ± S D T/g thu
thuat phut) 2 3 , 7 ± 1 1
T/g gSy me phut) 28 + 7,5
T/g khdi me (giay) 68 ±12,4
T/g dat NB dich (giay) 185 ±15,8
Nhan xet: Thdi gian khdi me mat khoang 01 phut, tuy nhien khi thuoc dat nong do dich (khoJng 3 phijt) mdi cd the tien hanh lam thfl thuat ddgc
Bing 3.2. Lieu Ijhdi me trung binh, nong do dich trung binh, tong luomg propofol tieu thu
Chisd
X ± S D N/ddich
TB ( g / m l ) 2,9 ±0,25
Lieu khdi meTB
(mg) 58,8 ±15,5
Tongluong Propofol tieu thu (mg)
280 + 80,5
Bang 3.3. Tan suat dieu chinh do me trong qua trinh lam thi!i t h u a t
Chi so B i t dau soi Sau 5 phut Sau 10 phut Sau 15 phut
N/ddichTB
(ng/ ml)
2,9 ± 0,25 2,8±0,18 2,7±0,15 2,7±0,1Bleu chinh tang n(%) 12 (20)
0 0 0
Dieu chinh giam n (%) 2(3,3) 5 (8,4) 7(11,6) 4 (6,6)
Khdng dieu chinh n (%) 46 (76,6) 55(91,6) 53 (88,4) 56 (93,4)
Nhdn xet: Khi b^t dau soi thUdng ph^i tang do me (20%), gi^m cd 2 benh nhan (3,3%). Thdi gian sau chCi yeu la giam dp me,
Being 3.4. Thdi gian tinh, thcfi gian va diem Aldrete l<hi trS benh nhan
Chisd X ± S D
Thdi gian tinh 4,6 ± 3,5
Thdi gian benh n h i n ve 12,8 + 10,5
Diem Aldrete 1 0 ± 0 , 0
Nhdn xet: Thdng thudng sau khoang 12 phut la benh nhan hoan toan tinh tao, diem Aldrete dat 10 diem
va cd the tra ve.
TAP CHl Y DU-O'C LAM SANG 10 Tap 9 - So 3 /2014
Bang 3.5. Anh hudng ho hap va cac phan xa trong qua trinh lam thij thuat
Dau hi§u Ngdng t h d
Cddgng bat thudng L(dn CO, rudn Co that thanh q u i n Ho,sac
So benh n h i n (n = 60)
02 03 2 0 0
T y l e %
3,3 5 3,3 0 0 Nhdn xet: Cd-Z-benh nhan cd dau hieu ngUng t h d t h o a n g qua sau khi khdi me, cd 5 benh nhan cd nhUng cd" d g n g bat t h u d n g .
B^ng 3.6. TS t i m , HATB, SpO; trong cac thdi diem NC ' Chi sd
Thdi diem ~ — TO (trudc khdi me)
Tl (sau khdi me 5 phut) T2 (sau gay me 10 phut) T3 (Ket thiJc thO thuat) T4 (Khi t r i benh n h i n )
Tan so tim 85,1 ±10,3 72,6 ± 6,5*
78,2 ± 7,8 76,3 + 12,6 81,2±15,7
Huyet I p B M T B 90,6 ±14,7 70,2 ± 1 8 , 8 *
85,6 ±17,5 84,8+15,7 80,1 ±8,7
SpOj 100 ±0,0 97,4 ±2,5*
100±0,0 100±0,0 99,5 ±1,8
* p < 0,05
Nhdn xet: Sau khdi me 5 p h u t xu tan sd t i m , huyet ap t r u n g binh va do bao hoa oxy mau cd xu hUdng giam. cd y nghla t h d n g ke so vdi t h d i diem trUdc gay me. Cac t h d i diem sau cac ch! so t r d ve on dinh su khac biet khong cd y nghta t h o n g ke so vdi t h d i d i e m trUdc gay me.
Bang 3.7. Cac tac dung phu
Cac tac dung phu Dau dau Ndn buon ndn Ret run Buon ngO, ngu g l Hoa mat, chdng mat
Sd benh nhan
02 1 0 1 1
T y l e % 3,3 1,65 0 1,65 1,65 Nhdn xet: lac d u n g phu gap t y le t h a p dau dau nhe 02 benh nhan, 01 benh nhan ndn va buon ndn, 01 BN chdng mat.
BSng 3.8. SiT hai long cOa bac sy can thiep va benh nhan
Chi so Benh n h i n
Bacsy
Hal Idng SdBN
57 58
T>'le%
95 96,6
Khdng hai Idng Sd ngudi
03 02
T y l e % 5 3,4
Nhdn xet: Ty le BN va bac sy hai Idng vdi p h u o n g phap nay dat > 95%.
4. Ban luan
Nong d d dich udc m u o n Propofol t r o n g huyet t u a n g ban dau khdi me la chung toi dat la 2.5 [a/ml, day la lieu khuyen cao duac cho la benh nhan bat dau mat y thiTc, thap han vdi khuyen cao cua cac nghien cUu da t r u n g tam d Chau Au ve nong do dfch de khdi me cho Propofol tCr 4-8 p / m l cho nhufng benh nhan ASA l-ll [7], [8]. ThUc te cho thay vdi n o n g d p nay da so BN vao giac ngu nhanh va e m , chi cd 2 BN bj ngUng t h d va 46 BN khi dat n o n g dp nay da cd t h e tien hanh t h u t h u a t ma khong can tang t h e m n d n g dp m e (bang 3.5).
Propofol la t h u o c m e rat t d t ve chat lUdng hoi t i n h tuy nhien tac d u n g gian mach t u t huyet ap, mach cham, giam sdc co b d p c d t i m rat t h u d n g xay ra nhat la t r o n g giai doan khdi m e [6], [8]. Vdi t h i e t bj
JOURNAL OF 10 - CLINICAL MEDICINE AND PHARMACY Vol9-N°3/2014
TCI r i t cd Idi khi khdi me chinh la nhd kiem soat t o t ndng dp thudc trong mau va CO quan dich, ha huyet ap thudng nhe nhang hdn, t r i n h dugc ngdng t h d c l i thien huyet dong. Nhin vao ket q u i b i n g 6 cho thay:
tan sd tim, huyet apOIVlTB va dd bao hoa oxy mau sau khi gay me 5 phut deu giam cd y nghia thdng ke so vdi giai doan trudc khi khdi me. Huyet I p BMTB g i l m t i l 90,6 ± 14,7 mmHg trudc khdi me xudng 70,2 + 1 B,8 mmHg sau gay me 5 phiit, tuong tiJ do bao h o i oxy mau t d 100 + 0,0 % xudng 97,4 ± 2,5 %. Tuy nhien giai doan nay chi thoang qua nhanh va cac chi sd n l y t r d ve binh thudng trong cIc giai doan sau.
CIc nghien cdu cija Schnider TW [6], Servin F [7], [81, deu thay r i n g khi khdi mS bang each tiem thudc t h d n g t h u d n g de xay ra f m h trang q u i lieu g l y tinh trang ngUng t h d hoac t i j t huyet I p manh tham chi t u t huyet ap len den 50%, ket q u i nghien oJu cCia Chung tdi thay pha khdi me huyet ap g i l m 20,6%, nhjp tim g i l m 15,3% nhUng chi thoang qua va khdng cd BN n i o phai diJng thudc cap ci^ru nang huyet I p hole tang nhip tim. Trong gian doan duy tri me cd 2 BN (5%) cd ddng bat thudng v l dn dinh ngay sau khi dieu chinh tang lieu thudc Ket qua nghien cdu b I n g 2 cho thay vdi ndng do dich cua Propofol trong huyet tuong 2,9 ± 0,25 p/ml la phij hgp vdi BN trong thu thuat ndi soi da d l y , dai trang. Vdi phuong phap TCI - Propofol ta cd the dU d o l n kha chinh xac thdi gian hdi tinh. Trong nghien cdu cija chung tdi thdi gian tinh me trung binh ta 4,6 + 3,5 phut, thdi gian chd de t r i BN I I 12,8 ± 10,5 phut (BIng 4). Do Propofol t h I i t r d nhanh (do thanh thai cua co the 1,5 - 2 lit/phut) va khdng cd su tich luy thudc nen su hdi tinh sau g l y me thudng nhanh, chat lugng hdi tinh tdt, tinh me em diu va benh n h i n phLic hdi y thdc nhanh sau thij thuat [1], [5].
Nhdm nghien cdu khdng gap tai bien, bien chdng g) nguy hiem ngoai 2 BN cd dau hieu ngdng t h d t h o i n g qua va 1 BN cd buon ndn sau can thiep.
Tat c l BN deu dugc t r i ve nha an toan. Day la n h d m BN ndi soi ngoai tru, sau t h u thuat BN dUdc tra ve n h l nen viec danh gia t i n h trang hdi t i n h cua BN can ky Iudng va chat che, chung tdi b i t bugc p h l i chd cho BN t i n h tao h o l n t o l n dat 10 diem theo thang Aldrete mdi tra. Ket q u i dieu tra sau khi tinh cd 95%
sd benh nhan dugc hdi e l m thay rat h i i Idng. Benh nhan t r i i qua thu thuat nhe nhang v l hdi t i n h h o l n toan, BN khdng cd b a t e d cam nhan n i o v e t h d thuat
vda t r i i qua va nhieu BN tUdng minh chUa dugc lam thu thuat. T i c dung phu gap ty le thap, cd 1 BN bi ndn va buon non, 2 BN dau dau nhe ( b I n g 3.7) sau g l y me.
5. Ket l u a n
Gay m e TCI vdi Propofol cho cac t h i j t h u l t noi soi ngoai trd I I phUdng phap an toan va cd nhieu Uu diem. Thu thuat dude t i e n hanh thuan Igi, BN va ble sy hai Idng > 95 %. Tan sd t i m va HADM g i l m nhe ngay sau khdi me, khdng I n h hudng den chdc nlng hd hap, do b i o h o i oxy mau duy tri o n djnh trong c i c t h d i diem, t i c d i j n g phu it. Vdi ndng do Propofol t r o n g huyet t d o n g 2,9 ± 0,25 meg/ml la thich hgp eho t h d t h u l t nay, BN t i n h ngay sau 4,6 ± 3,5 phutva dddc tra ve n h l sau 12,8 + 10,5 phut vdi diem Aldrete dat 10 d i e m .
Tai l i e u t h a m k h a o
. Nguyen Qudc Khanh (2010), "Khdi m l bang propofol: kiem soat ndng do dich nao hay huySt tuong?". Tap chiy duac Idm sdng 108,5(6), tr. 80-84.
2. Demet Coskun; Berrin Gunaydin; Ayea Tas et all (2011) , ' A comparison of three different target- controlled remifentanil infusion rates during target- controlled propofol infusion for oocyte retrieval"
Clinics Vol.66 no.5Sao Paulo. Http//dx.doi.org 3. KJA- Korean Journal of Anesthesiology, "Modified
Aldrete Score (MAS)", Http://ekja.org 4. Kulling D, Rothenbuhler R, Inauren W (2003), "Safety of
nonanesthetist sedation with propofol for outpatient colonoscopy and esophagogastroduodenoscopy";
Endoscopy; 35(8). Pp. 679-82
5. Olinga/\, Ousmanou B, Cantraine F et al (2003),
"Comparition of effect - side propofol concentration at loss of consdousness and recovery", GlasgcM Meeting, Webside by RPD Publications, viww.RPD publicationeu 6. Schnider TW., IWinto C.S., Shafer S.L., Andresen C,
Goodale DB., Youngs EJ. (1999). 'The influence of age on propofol pharmacodynamics"./\nesf/7es/o/ogy, 90, pp.1502-1516.
7. Servin F (1998), "Anesthesie intraveneuse a objectif de concentration". Conferences d'actuafoat/on J99S, p. 35-48.
S. Servin F. (1998), "TCI compared w i t h manually controlled infusion of propofol: a multicentre stud/Mnest/iesM, 53(1), pp. 82-86.
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