B Y T TRNG I HC DC H NI DNG TH PHNG THO KHO ST THC TRNG S DNG
THUC GIM AU KIM SOT AU SAU MTI VIN NHI TRUNG NG KHA LUN TT NGHIP DC
S H NI 2013 B Y T TRNG I HC DC H NI DNG TH PHNG THO KHO ST THC TRNG
S DNG THUC GIM AU KIM SOT AU SAU MTI VIN NHI TRUNG NG KHA LUN TT
NGHIP DC S Ngi hng dn: 1. ThS. Nguyn Th Hng Giang 2. ThS. Nguyn Th
Thu H Ni thc hin: 1. B mn Dc lc 2. Bnh vin Nhi Trung ng H NI 2013 i
LI CM N Ti xin by t lng bit n chn thnh v su sc nht ti ba ngi thy
trc tip hng dn ti thc hin kha lun tt nghip ny: -ThS. Bs. Nguyn Th
ThuHBcsgymKhoaPhuthut-Gy m hi sc Bnh vin Nhi Trung ng. - TS. Bs.
Dng Th Ly Hng Ging vin khoa Y Dc i hc Quc gia H Ni. - ThS. Bs.
Nguyn Th HngGiangGingvinBmnYhccs- i hc Dc H Ni. Ti xin chn thnh cm
n cc thy c gio trong B mn Y hc c s v B mn Dc lc cng nh cc thy c gio
trong ton trng, cc bc s, iu dng ti Khoa Phu thut Gym hi sc v Khoa
NgoiBnh vin Nhi Trung ng quan tm, gip v to iu kin cho ti thc hin
kha lun ny. Cui cng, ti xin c gi li cm n ti gia nh, bn b nhng ngi
lun bn, chia s, ng vin gip ti hon thnh kha lun. H Ni, ngy 20 thng
05 nm 2013 Sinh vin Dng Th Phng Tho ii MC LC LI CM N
....................................................................................................i
MC LC
..........................................................................................................
ii DANH MC CC CH V K HIU VIT TT
........................................iv DANH MC CC BNG BIU
......................................................................
v DANH MC CC HNH V V TH
......................................................vi T VN
...................................................................................................
1 CHNG 1: TNG QUAN
............................................................................
3 1.1. SINH L CM GIC AU SAU PHU THUT .............................
3 1.1.1. nh ngha v au
.......................................................................
3 1.1.2. Gii phu hc ca au
................................................................ 3
1.1.3. Nguyn nhn au sau phu thut
................................................ 4 1.1.4. Nhng yu t
nh hng n au sau phu thut ...................... 4 1.1.5. nh hng ca
au sau phu thut i vi cc c quan ............ 5 1.2. NH GI AU
.................................................................................
7 1.2.1. Cc thang nh gi au
............................................................... 7
1.2.2. La chn cng c nh gi au trn tr em
................................ 9 1.3. IU TR AU SAU PHU
THUT................................................. 10 1.3.1.
Phng nga au sau phu thut
.................................................. 10 1.3.2. iu tr
au sau phu thut
......................................................... 11 CHNG
2: I TNG V PHNG PHP NGHIN CU ............ 19 2.1.I TNG NGHIN CU
........................................................... 19
2.2.NI DUNG NGHIN CU
.............................................................. 19
2.2.1. c im mu nghin cu
.......................................................... 19
2.2.2. Kho st v tnh hnh s dng thuc gim au
.......................... 19 2.2.3. Hiu qu gim au
......................................................................
20 iii 2.3.PHNG PHP NGHIN CU
...................................................... 20 2.3.1.
Thit k nghin cu
....................................................................
20 2.3.2. K thut tin hnh
......................................................................
20 2.3.3. X l s liu
...............................................................................
20 CHNG 3: KT QU NGHIN
CU....................................................... 21 3.1. C
IM MU NGHIN CU
....................................................... 21 3.1.1. c
im v tui, gii.
............................................................... 21
3.1.2. Tin s phu thut
......................................................................
21 3.1.3. Ch nh phu thut
....................................................................
22 3.1.4. Phng php v cm
..................................................................
22 3.1.5. Phng php phu thut
............................................................. 23
3.2. KHO ST TNH HNH S DNG THUC GIM AU .............. 24 3.2.1. Danh
mc thuc gim au
.......................................................... 24
3.2.2. Tnh trng s dng thuc gim au sau phu thut ....................
24 3.2.3. Thi im dng thuc gim au sau phu
thut........................ 25 3.2.4. Tng s ngy dng thuc gim au
sau phu thut.................. 26 3.3. KHO ST HIU QU GIM AU
................................................. 27 3.3.1. im au
ca bnh nhn ti cc thi im nh gi .................. 27 3.3.2. T l gp
tc dng khng mong mun ....................................... 28
CHNG 4: BN LUN
...............................................................................
29 4.1. C IM MU NGHIN CU
....................................................... 29 4.2. KHO
ST V TNH HNH S DNG THUC GIM AU........ 32 4.3. HIU QU GIM AU
......................................................................
34 KT LUN V KIN NGH
.........................................................................
36 TI LIU THAM KHO
...............................................................................
I PH LC
..........................................................................................................
VI iv DANH MC CC K HIU, CH VIT TT BNBnh nhnFEV1Th tch kh th ra gng
sc trong giy u tin (Forced Expiratory Volume in the First second)
GNVGim au ngoi vi GTWGim au trung ng NKQNi kh qun NSAIDsThuc gim au
chng vim khng steroid (Non-steroid anti-inflammatory drugs) PTPhu
thut PTNS Phu thut ni soi TD KMMTc dng khng mong mun TKTWThn kinh
trung ng v DANH MC CC BNG BIU Bng 1.1: Thang nh gi au FLACC
.............................................................8 Bng
1.2: La chn cc thang nh gi au theo tui trn tr em
....................9 Bng 1.3: S dng thuc theo thang gim au WHO
....................................... 12 Bng 1.4: Cc thuc gim au
trung ng s dng sau phu thut trn tr ..... 14 Bng 1.5: Cc thuc gim au
ngoi vi s dng sau phu thut trn tr .......... 16 Bng 1.6: Cc thuc an
thn s dng sau phu thut cho tr ............................ 17 Bng
3.1: Phn loi bnh nhn theo tui v gii tnh
.................................. 21 Bng 3.2: Phn loi bnh nhn theo
tin s phu thut .................................... 21Bng 3.3: Phn
loi bnh nhn theo ch nh phu thut ..................................
22Bng 3.4: Phn loi bnh nhn theo phng php v cm
............................... 23Bng 3.5: Phn loi bnh nhn theo
phng php phu thut .......................... 23 Bng 3.6: Danh mc
thuc gim au sau phu thut ........................................
24 Bng3.7:Tnhtrngsdngthucgimausauphuthuttiphnghi tnh
......................................................................................................................
24 Bng 3.8: Tnh trng s dng thuc gim au sau phu thut ti cc khoa
...... 25 Bng 3.9: Phn loi bnh nhn theo thi im dng thuc gim au
............... 26 Bng 3.10: Tng s ngy dng thuc gim au sau phu thut
........................ 26 Bng 3.11: im au ca bnh nhn ti cc thi im
nh gi ...................... 27 Bng 3.12: T l bnh nhn ghi nhn c tc
dng khng mong mun ......... 28 vi DANH MC CC HNH V V TH Hnh 1.1:
Thang nh gi au theo nt mt
Wong-Baker................................. 7 Hnh 1.2: Thang im au
hnh ng dng VAS .............................................. 9Hnh
1.3: Thang im au tr li bng s NRS
................................................ 9Hnh 1.4: Thang
gim au WHO
......................................................................
11Hnh 1.5: Gim au a phng thc multimodal analgesia
.......................... 12 Hnh 1.6: Dn truyn cm gic au v c ch cc
thuc gim au .................. 13 1 T VN au sau m lun l ni m nh ca
bnh nhn v bc s khi tin hnh cc th thut, phu thut v l mi quan tm hng
u ca cc bc s gy m hi sc cng nh cc bc s ngoi khoa. au sau m nu khng
c kim sot tt s nh hng rt ln n tm sinh l ca bnh nhn nh lm chm phc hi
chc nng sau khi m v tng nguy c tr thnh au mn tnh d lnh vt m [27].
Stinblnnhttrongiutrautremlnhnrarngaukhng
ciutrlnguynnhnngkgybnhvtvongsauchnthng,phu thut
[51].Vnausaumcbitntlu,nhnggnymicch trng v quan tm c bit. Tuy nhin,
kim sot au sau m tt, vn cn nhiu thch thc nh: thiu n v gim au, thiu
phng tin, nhn lc, thiu hiu bit v nh hng c hi ca au, s thiu hp tc ca
phu thut vin, s thiu hiu bit ca bnh nhn v nhn vin y t (s bin chng,
nh gi au) v do bn thn cc i tng c nguy c au cao: chn thng, huyt ng
khng n nh, ri loi tri gic, bnh nhn qu nh hoc qu gi ... Cc yu t ch
quan ln khch quan k trn gp phn ng k khin cho tnh trng au saum vn
cha c qun lmt cchthchng:ausaumvnmccaothmchcncxuhngtngln (39% au
nhiu n rt au nm 2003 so vi 31% nm 1995) [15, 53]. Tm quan trng ca
cc n v gim au c khng nh, tuy nhin trn
thct,ngaycccncphttrincngchacyccnvgimau
trongbnhvinvmtphnkhngnhtrongsccnvvnchapng c cc ch tiu cht lng. Theo
cc nghin cu, t l cc n v gim au trong bnh vin ca mt s nc pht trin ln
lt nh sau: Anh (83%) 69% trong s cha thc hin c y cc chc nng hoc
khng tn ti, c (50% n v
gimautchtiuchtlng),TyBanNha(30%),Thyin(32%),Hng 2 kong (iu tr 20%
bnh nhn m ln), Italia (gim au khng ti phng hi sc cp cu) [42], [48].
Vit Nam, vn qun l au sau m mi bt u c ch n, nhiu bnh vin cha c n v
gim au v vic nh gi au vn cn gp nhiu ro cn. Bnh vin Nhi Trung ng l
mt bnh vin tin phong trong vic xy dng n v gim au sau m, t vic thnh
lp n v gim au vi thnh vin l cc bc s gy m, phu thut, dc s v iu dng;
n cc hot ng ban u nh m lp tp
hunchoccbcs,iudngphnnolmtngschvtnghiubit
caccnhnvinytiviccvnauvkimsotausaumchobnh
nhn.ccinhntngqutvthctrngchngaubnhvinNhiTrung
ng,trncsaranhnggiiphpngnchovickimsotausau m, chng ti tin hnh ti ny
vi mc tiu:1.Kho st thc trng s dng thuc gim au kim sot au sau phu
thut ti phng Hi tnh vkhoaNgoi bnh vin Nhi Trung ng v: danhmc thuc,
ng dng, thi im dng. 2.S b nh gi hiu qu gim au ca thuc trn bnh nhn.
3 CHNG 1 TNG QUAN 1.1.SINH L CM GIC AU SAU PHU THUT 1.1.1.nh ngha v
auTheoHiphiquctnghincuau(InternationalAssociationforthe Study of
Pain IASP): au l mt cm nhn kh chu v cm gic v cm xc do m b e da vhoc
b tn thng thc th gy nn, hoc do cc tnh trng c ngi bnh cm nhn l au
[1]. 1.1.2.Gii phu hc ca auCc dy thn kinh ngoi bin ng dn truyn cm
gic au gm 3 neuron:-Neuron1:Dntruyncmgicautngoibinntysng,thnnmti
hch sng. -Neuron 2: Dn truyn cm gic au t ty sng ln i th, h li v
trung no; thng bt cho ti ty sng, i ln trong b ty i th bn. -Neuron
3: Dn truyn cm gic au t i th, h li, vng di i v h vin n v no cm gic.
Hthngith-vnocvaitrnhnbit,phntchcmgicau(tnhcht, cng , thi gian, khu
tr).H thng li, vng di i, i th, h vin c vai tr gy ch n cm gic au to
cm xc kh chu, thi thc c th phn ng. Cc th th au c 3 loi: th th c
nhit A, th th au a thc C v th th
audamicmtgny,ththnychbkchhottrongqutrnh vim. 4
-ThthA:dntruyncmgicaunhanh,linquannsinhmyelinA, p ng ch yu vi cc
kch thch c hc, dn truyn cm gic au nhanh. Kch thch th th A gy au nh
dao m. -Th th C: dn truyn cm gic au chm, lin quan n si C khng c
myelin vpngvinhiukchthchnguyhikhcnhau(nhhahc,nhit,c hc), dn truyn
cm gic au chm.-Th th au a thc: Kch thch th th au a thc C gy cm gic
au nh b bng.Ththnycngngvaitrgydakhivimdonguynnhnthn kinh [36].
1.1.3.Nguyn nhn au sau phu thut-Ct da v t chc di da -Ct m su, chn
thng, hin tng ng mu -Ti ch: chn p, co ko thn kinh -Ch tim truyn: tn
thng t chc, kch thch tnh mch, chch ven, t mu -ng dn: dn lu, xng d
dy, xng tiu -H hp: ni kh qun, ho, th su -C ng, di chuyn, liu php vt
l hi phc -Bin chng phu thut: xon, tc mch -Khc: nn, b tiu, bng qu
cht... [24]. 1.1.4.Nhng yu t nh hng n au sau phu thut Yu t thuc v
bnh nhn: tui, gii tnh, trnh vn ha, tm l s au, lo lng, tin s au trc
, cc bnh mc km, tin s lm dng thuc [14], [22], [44], [57]. Yu t thuc
v phu thut:-V tr v tnh cht ca phu thut:Mc au: bng trn > ngc >
bng di > chn tay.-Phng php phu thut, thi gian phu thut, k thut v
cm5 -Binchng:nhimtrngvtthng,nhimtrnghuyttrongbng,chng bng [14],
[22], [47]. Yu t khc:chunbtmlchobnhnhntrcm(giithchvthngtin
chobnhnhnbitvausaumvcchiutr),iutrdphngausau
m,chtlngqunlausaum:phngphpgimau,loithuc,liu lng[14], [47]. 1.1.5.nh
hng ca au sau phu thut i vi cc c quanp ng tm l au sau m l mt trong
nhng nguyn nhn chnh gy lo lng v s hi cho bnh nhn nm iu tr ti bnh
vin. au lm bnh nhn gin d, on ght, c biu hin i nghch vi cc nhn vin y
t trc tip iu tr. Bnh nhn thng mt ng, sau kh iu tr hi phc [13],
[16], [33]. p ng sinh l Ccpngsinhlivichnthngvstressbaogm:rilonchc
nng h h hp, h tim mch, h tiu ha v h tit niu; mt cn i trong chuyn
havchcnngc;nhngthayivthnkinhnititvchuynhanhcc
thnhphnpngvim.Phnlnnhngthayinycthcloibbng cc k thut gim au, thuc
gim au c sn [13], [16], [33]. H h hp
Phuthutlngngchocvngbngcaogyraccthayivhhp nh: gim dung tch sng, th
tch kh thng lu, th tch kh cn, th tch kh cn chc nng v th tch kh th
ra gng sc trong giy u tin (FEV1).
autvtrct,rchctrongkhiphuthutvngbngtrngytng
trnglccbngtrongththravgimchcnngchonh.Huqulgy gim sc nhi caphi, thiu
co c ng b dn n bnh nhn khng th th su hay ho mnh, trong mt s trng hp
gy thiu oxy mu, tha cacbonic mu, ng cht tit, xp phi v vim phi. Tng
trng lc c l mt nguyn nhn gp 6 phn lm tng tiu th oxy v sn sinh acid
lactic. Rut cng trng do lit rut sau m hoc bng qun cht cng lm thng
kh khng . au xut hin hoc tng ln khi ht th su hoc ho lm bnh nhn khng
dm thc hin nhng c ng ny. Thucnhmmorphindngvinhiungkhcnhaugimauvci
thin chc nng phi c th gy nn hoc gp phn vo tnh trng suy h hp. Cc
thuc gim au khc c th gy nn cc di chng h h hp [13], [16], [33]. H
tim mch augykchthchtbothnkinhgiaocmlm:tngnhptim,tngth tch mu th tm
thu, tng tiu th oxy c tim. Hu qu lm tng nguy c thiu mu v nhi mu c
tim. Mt khc, bnh nhn s au tng khng dm vn ng gy tr tnh mch v kt dnh
tiu cu dn n nguy c thuyn tc tnh mch [13], [16], [33]. H tiu ha v
tit niu Lit rut, bun nn v nn sau phu thut c th xut hin sau mt s
nhng xung ng thn kinh nguy hi xut pht t cc tng v cu trc c quan. au
cng gy gimtrng lc bng quang v niu o gy kh tiu. Nhng vn nylm cho bnh
nhn kh chu, nht l cc trng hp lit rut ko di thi gian nm vin [13],
[16], [33]. p ng stress: Thn kinh, ni tit v chuyn ha p ng chnh ca
thn kinh ni tit i vi au bao gm cc tng tc trc h i tuyn yn thng thn v
giao cm thng thn. Cc p ng phn x vi au gy tng trng lc giao cm, kch
thch vng h i, tng catecholamin v tng tit hormon d ha v gim hormon
ng ha. Nhng thay i ny gy ra tnh
trngncvmui,tngnghuyt,tngacidbotdo,thcetonvlactat.
Mcchuynhavtiuthoxycacthtngln.Tnhtrngdhavcn bng nit m xut hin nu qu
trnh ny ko di [13], [16], [33]. 7 1.2.NH GI AU tr em, nh gi au v o
lng cng au mt cch hiu qu l nhng thnh phn then cht kim sot aumt cch
tt nht (gip phng v gim au [17], [30], [49], [52]. Trnhnthcycthtnh
gimcaucabnthn [19]. 1.2.1.Cc thang nh gi au Thang khun mt
Wong-Baker Hnh 1.1: Thang nh gi au theo nt mt Wong-Baker [56] Thang
COMFORT: xem ph lc 2 Thang FLACC: 8 Bng 1.1: Thang nh gi au FLACC
[39] NGY/THI GIAN Khun mt (Face) 0-Khng biu hin r hoc ci 1-Thnh
thong nhn mt hoc cau my 2-Hm thng xuyn rung ln, quai hm nghin cht
Chn (Legs) 0-T th bnh thng hoc th gin 1-Kh chu, bn chn, cng thng
2-Chn ra hoc co li Hot ng (Activity) 0-Nm yn, t th bnh thng, di
chuyn d dng 1-Vn vo, ln qua ln li, cng thng 2-Un cong, cng nhc hoc
co git Khc (Cry) 0-Khng khc (thc hoc ng) 1-Rn r, tht tht, thnh
thong khc2-Khc lin tc, nc n, ht ln, thng xuyn ku ca An i
(Consolability) 0-Thoi mi, th gin 1-D bng cch v v, b hoc ni
chuyn2-Rt kh d TNG IM 9 Thang im au hnh ng dng VAS (Visual analogue
scale) Hnh 1.2: Thang im au hnh ng dng VAS [55] Thang im au tr li
bng s (NRS - Numberical rating scale) Hnh 1.3: Thang im au tr li
bng s NRS [37] 1.2.2.La chn cng c nh gi au trn tr em Bng 1.2: La
chn cc thang nh gi au theo tui trn tr em [17] TuiLoi thang nh gi nn
la chn Di 3 tuiThang COMFORT hoc FLACC 3-4
tuiThangkhunmtWong-Baker(sai)+COMFORThoc FLACC 5-7 tuiThang khun mt
Wong-Baker ( sa i) Trn 7 tuiThang VAS hoc NRS hoc thang khun mt
Wong-Baker ( sa i) 10 1.3.IU TR AU SAU PHU THUT1.3.1.Phng nga au
sau phu thutChun b tm l Nhng bnh nhn c chun b tm l tt v cuc m v c
gii thch v au sau m s t au hn v d iu tr au hn. Phu thut vin, bc s
gy m hi scvcciudngcnanibnhnhn,nivibnhnhnvqutrnhphu thut v au
saum.Bnh nhncn bit rng: nh gi aul iu chnhcch iu tr au hin ti. Gii
thiu cho bnh nhn cc phng php gim au sau m,
bnhnhnstholunviphuthutvinvbcsgymhisctmra phng php iu tr au ph hp
nht. nh gi au thng xuyn sau m
Dphngausaumbngcanthiptrcvtrongm(Preemptive Analgesia) Preempty
analgesia c ngha lgim au d phng [31]. Khi au hnh thnh th kh iu tr
hn rt nhiu so vi vic phng cn au xy ra, v iu tr t rt sm, ngay khi s
au n mi xut hin. Nhng bnh nhn b au lp i lp li nhiu ln nhn thy rng:
nu h iu tr au sm hn th au d dng thoi lui hn l khi cn au tng ln. iu
ny cng ng vi au sau m. Nhng bnh nhn tnh dy sau gy m trong au n dng
nh khng tr vi thuc gim au hn l
nhngbnhnhntnhdymi,thoimi.Nhngnghincugnycncho
thyiutrautrckhiauxuthincnlmgimlngthucgimausau
m.Trongmtsnghincukhcngitacnthycsgimaurrttrong au chi ma sau khi bnh
nhn c gy t ngoi mng cng trc m.Mc ch s dng thuc d phng trc v trong
phu thut -Gim liu lng thuc t, m -Gim liu thuc gim au sau phu thut
11 -Ci thin tnh trng bnh nhn: tinh thn (gim lo lng), gim t l mc sau
phu thut, thi gian nm vin ngn hn. Cc thuc d phng: -Ketamin: tim tnh
mch 1-2mg/kg [21], [23] -t fentantyl, thm morphin trong m [35].
-NSAIDs: pirocicam, diclofenac [11], [32], [40], [45].
-Dexamethason [29] -Dexmedetomidin [26] -Paracetamol trc hoc trong
m [38]. 1.3.2.iu tr au sau phu thutNguyn tc chung:-S dng thuc theo
thang gim au WHO -S dng phng php gim au a phng thc multimodal
analgesia:-Thuc gim au c tc dng phng nga cn au hiu qu hn gim au hnh
thnh, iu quan trng l phi dng thuc gim au u n [20]. Hnh 1.4: Thang
gim au WHO 12 Bng 1.3: S dng thuc theo thang gim au WHO Bc 1 au nh
im au 1-3 Thuc gim au n gin Vd:paracetamol,NSAIDsthngvc
chCOX-2;cthkthphockhngkt hpvithucgimauphtr(co-analgesics). Bc 2 au
trung bnh im au 4-6 Opioid yu V d: dihydrocodeine, dextroproxyphene
kt hpkhngkthpvithucgimauph tr nh gabapentin. Bc 3 au nng im au 7-10
Opioid mnh Vd:morphin,fentanylkthpkhngkt hpvithucgimauphtrnh
gabapentin. Trong thc hnh lm sng, thuc gimauphtrcthgpphngimau
mkhngphilthucgimaukinhin (nh tricyclic, thuc chng co git) Hnh 1.5:
Gim au a phng thc multimodal analgesia[55]13 Hnh 1.6: Dn truyn cm
gic au v c ch cc thuc gim au [25] 1.3.2.1.Thuc gim au trung ng
Nguyn tc s dng:-Chsdngtrongtrnghpaumcnngvvakhinhmgimau ngoi vi khng
hiu lc. -S dng n c hoc phi hp ty mc au. -Lu dng cc bin php h tr v
thuc gim tc dng khng mong mun. -Khng c tr hon vic bt u dng opioid
bi lo ngi kh nng mang tnh l thuyt v s ph thuc tm l (nghin) [5],
[21]. Cch:ccthucgimautrungngcchtrungtmaunovngncn ng dn truyn cm gic
au t ty sng ln no [5]. Tc dng khng mong mun (ADR): -To bn, bun nn v
nn -c ch h hp, gy nghin [5]. 14 Chng ch nh: -Tr em di 30 thng tui
-Suy h hp -Suy gan nng -Chn thng no hoc tng p lc ni s -Trng thi co
git -ang dng cc cht c ch monoaminoxidas (IMAO). -Triu chng au bng
cp khng r nguyn nhn. -Nhim c ru cp hoc m sng ru cp [1]. Bng 1.4: Mt
s thuc gim au trung ng dng trn tr nh [21] ThucLiu MorphinTr s
sinh0.02 mg/kg/8h Tr s sinh (truyn lin tc)5-15 gkgh Tr nh0.05-0.1
mg/kg/6h Tr nh (truyn lin tc)0-30 gkgh FentanylTheo phu thut2-10
gkg bnh nhn chm sc c bit2-5 gkgh Ko transmucosal fentanyl
citrate15-20 gkg RemifentanilPhu thut0.5-1 gkgmin Bnh nhn chm sc c
bit0.1-0.05 gkgmin CodeinCh yu s dng dng kt hp vi paracetamol (thuc
n hoc siro) 0.5-1 mg/kg/4h Phn nhm thuc gim au mnh v gim au trung
bnh da theo mc liu gii hn. Morphin c ly lm chun nh gi cc thuc gim
au trung ng khc. Vi mc liu 10mg dng tim, morphin lm ht au vi a s cc
trng hp au. c c kh nng gim au bng morphin, cc cht khc phi c mc liu
nh trong bng [5]. 15 ng ung: morphin c dng dng dung dch ung hoc vin
tiu chun (gii phng ngay lp tc) u n mi 4h, liu u ph thuc rt ln vo iu
tr trc . Liu 5-10 mg thay th thuc gim au yu hn (nh paracetamol),
liu10-20mghochncyucuthaythchothucgimaumnhhn(so
snhvibnthnmorphin).Nuliuucamorphinkhnghiuquhnthuc
gimautrc,liutiptheonntngthm30-50%,mcchchnliuthp nht c th nga cn au.
Liu phi c iu chnh bng cch nh gi au chnh
xcvxemxtvicsdngccthucgimauhtr(nhNSAIDs).Mcd thng liu morphin 5-20mg
l nhng khng nn do d trong vic tng liu bc thang theo png ti 100mghoc
i khi ln ti 500mghoc cao hn nu cn thit. c th b qua liu ban m nu trc
khi i ng dng liu gp i [20]. Cc ng dng: Tim bp hoc di da oLiu: 5-10
mg/2-4-6h ou im: r, n gin, tc dng t t oNhc im: hp thu km (co mch,
tt nhit ), chm so viyu cu, au do tim, nng huyt tng khng n nh, bt
tin v thi gian. Tim tnh mch oPh hp cho au ngay sau m o1-3 mg10 pht
cho n VAS < 4 oDng ketamin 0,1 -0,2 mg/kg nu p ng km Truyn tnh
mch lin tc oMorphin pha 1mg/ml, 1ml/h oNguy c c ch h hp (qu liu) v
au (liu thp) Cc ng khc ong ung, ng hu mn, qua nim mc oQua da:
fentanyl 40 mcg10 pht, 6 liu/h 16 1.3.2.2.Thuc gim au ngoi vi Nguyn
tc s dng: -Lu chn thuc ph hp vi ngi bnh: kh nng mn cm ca bnh nhn vi
thuc, iu kin kinh t -Trnh vt qu mc liu gii hn -Tn trng cc nguyn tc
phi hp thuc gim au -Lu cc bin php khng dng thuc hoc dng thuc gim tc
dng khng mong mun. C ch: cc thuc gim au ngoi vi c ch s to thnh
prostagladin cht trung
gianhahckhiphtphnngvimkhimovictoraccchttrunggian ha hckhc nh
serotonin, bradikinin, histamin... ngn si cmgic (ngoi vi) [5]. Tc
dng gim au: t nh n va, tc dng tt vi cc loi au, c bit l au
dovim;khnggimausutrongnitng,khnggycchhhpvkhng gy l thuc thuc khi
dng ko di [7]. Bng 1.5: Cc thuc gim au ngoi vi s dng trn tr nh [21]
ThucLiu DiclofenacUng, t trc trng1 mg/kg/8h I buprofenUng10
mg/kg/8h Ketorolac0.5 mg/kg/8h hoc truyn lin tc Paracetamolt trc
trng40 mgkg; sau dng 30 mgkg8h Ung20 mgkg; sau dng 30 mgkg8h Tr s
sinh, t trc trng20 mgkg v 30 mg/kg/12h Tr s sinh, ung30 mgkg v 20
mg/kg/8h ParacetamolvNSAIDscdngthngxuynththngkhngcns dng gim au
opioid na [20]. 17 1.3.2.3.Thuc an thn [21]
Nhngthucnycdnggimbtnishivlolngtronggiai on trc phu thut, gim au v
kh chu v tng tc dng ca thuc gy m. La chn thuc ph thuc tng tng i
tng, phng php gy m Nu c th nn s dng ng ung, ng trc trng ch s dng
trong trng hp c bit.Bng 1.6: Cc thuc an thn s dng gim au sau phu
thut cho tr ThucLiu Diazepamng ung (45 60 pht trc phu thut) 1 thng
12 tui 200-300 gkg (ti a 10mg) 12-18 tui200-300 g/kg (ti a 20mg)
Tim tnh mch (trong vng 2-4 pht ngay trc phu thut) 1 thng 12 tui
100-200 gkg (ti a 5mg) 12-18 tui100-200 g/kg (ti a 20mg) ng trc
trng (30 pht trc phu thut)1-3 tui5mg 3-12 tui5-10 mg 12-18 tui10 mg
Midazolamng ung (15 30 pht trc phu thut) 1 thng 18 tui 500 gkg (ti
a 20mg) ng trc trng (15 - 30 pht trc phu thut)6 thng 12 tui 300-500
g/kgTim tnh mch 12-18 tui25-200 gkg (ti a 5mg) LorazepamTim tnh mch
(trong vng 2-4 pht ngay trc phu thut) 1 thng 12 tui 100-200 gkg (ti
a 5mg) 18 12-18 tui100-200 g/kg (ti a 20mg) ng trc trng (30 pht trc
phu thut)1-3 tui5mg 3-12 tui5-10 mg 12-18 tui10 mg Temazepamng ung
(1h trc phu thut) 1-12 tui1 mg/kg (ti a 30mg) 12-18 tui20-30 mg 19
CHNG 2 I TNG V PHNG PHP NGHIN CU 2.1.I TNG NGHIN CU Tiu chun la chn
-TtcbnhnhncchnhcanthipphuthuttikhoaPhuthut Gy m hi sc sau nm vin ti
khoa A3, A5, A6 bnh vin Nhi Trung ng t 4/3/2013 n 12/4/2013. -Bnh
nhn, ngi nh bnh nhn ng tham gia nghin cu. Tiu chun loi tr -Bnh nhn
nh hn 3 tui-Bnh nhn chuyn vin -Bnh nhn khng hp tc trong qu trnh
nghin cu: c tin s hay hin ti mc bnh thn kinh, tm thn. -Bnh nhn c
tin s nghin hoc ph thuc opioid -Bnh nhn c tai bin hay bin chng v
phu thut v gy m. -Bnhnhnkhngtunthiutr:tthayiliu,tdngthmcc thuc gim
au khc khi khng c ch nh ca bc s. 2.2.NI DUNG NGHIN CU 2.2.1c im mu
nghin cu: -Bnh nhn: tui, gii, tin s phu thut.
-Phuthut:chnhphuthut,phngphpvcm,phngphpphu thut. 2.2.2.Kho st v tnh
hnh s dng thuc gim au: -Danhmcthucsdnggimau,ngdng,thigiandngsauphu
thut. -Phi hp thuc gim au sau phu thut. -Tng s ngy dng thuc gim au
sau phu thut. 20 2.2.3.Hiu qu gim au
-imauticcthiim:trckhiphuthut(T0)v5thiimsau phu thut T1 (4-6h), T2
(10-12h), T3 (16-18h), T4 (22-24h), T5 (48h). -T l gp tc dng khng
mong mun. 2.3.PHNG PHP NGHIN CU 2.3.1Thit k nghin cu: Nghin cu m t
tin cu. 2.3.2K thut tin hnh -Sau khi chn c bnh nhn ph hp vi tiu
chun th tin hnh thu thp s liu theo mu phiu iu tra xy dng sn.
-Ccthngsthuthptrckhiphuthut,gm:tui,gii,tinsphu thut, tin s d ng vi
thuc, im au trc phu thut.
-Sauphuthut:chnhphuthut,phngphpvcm,phngphp phu thut, cc thuc gim au
c s dng, ng dng, thi im dng, im au ti cc thi im t T1 n T5 theo
thang nh gi au ty theo tui bnh nhn, tc dng khng mong mun xy ra. -nh
gi mc au sau phu thut:oBnh nhn 3-6 tui: s dng thang nh gi au theo
nt mt Wong-Baker oBnh nhn >6 tui: s dng thang nh gi au cho im
bng s oHng dn bnh nhn cch dng thc gim au sau bnh nhn t nh gi mc au
ca mnh v ghi nhn li. 2.3.3.X l s liu Cc kt qu nghin cu thu c c x l
theo phng php thng k m t da vo phn mm SPSS 16.0 v Microsoft Excel
2010. 21 CHNG 3 KT QU NGHIN CU
Thngkccthngtinthuct128bnhnhntrongmunghincu, chng ti thu c cc kt qu
sau: 3.1.C IM MU NGHIN CU 3.1.1.c im v tui, gii Mt s c im v tui v
gii ca bnh nhn trong mu nghin cu c thng k trong bng 3.1. Bng 3.1:
Phn loi bnh nhn theo tui v gii tnh Nhm tuiNNamTng n%n%N%
3-61814,15845,37659,4 7-152317,92922,75240,6
Tng4132,08768,0128100,0 Tui trung bnh7,412,946,213,236,593,18
Nhnxt:DocthcavinNhivtiuchunlachn,tuicabnh nhn trong mu t 3-15 tui.
Tui trung bnh ca bnh nhn l 6,59 tui. T l bnh nhn nam (68,0%) cao hn
so vi bnh nhn n (32,0%).3.1.2.Tin s phu thut Bng 3.2: Phn loi bnh
nhn theo tin s phu thut Tin s phu thutS BNT l % Cha phu thut
11287,5% tng phu thut 1612,5% Tng128100% 22 Nhn xt: a s bnh nhn u l
phu thut ln u (87,5%), ch c 12,5 % bnh nhn tng phu thut. 3.1.3.Ch
nh phu thut Bng 3.3: Phn loi bnh nhn theo ch nh phu thut Ch nhS bnh
nhnT l % Ct rut tha4938,3 To hnh dng vt1914,8 Ct u86,2 H tinh hon
xung bu86,2 Trng li niu qun86,2 ng i trng64,7 H i trng53,9 t thanh
nng ngc53,9 Khc2015,6 Tng128100,0 Nhn xt: Ch nh phu thut chim t l
cao nht l ct rut tha (38,3%) sau n to hnh dng vt (14,8%), ct u, h
tinh hon xung bu, trng li niu
qun,ngitrng,hitrng,tthanhnngngc,cnlilccphuthut khc. 3.1.4.Phng php
v cm Phng php v cm cng l mt trong cc yu t nh hng n cng au sau phu
thut [47]. Nu c v cm tt, bnh nhn khng phi chu au trong qu trnh phu
thut th vic kim sot au sau phu thut s d dng hn.23 Bng 3.4: Phn loi
bnh nhn theo phng php v cm Phng php v cmS bnh nhnT l % Ni kh qun +
t cng ct3829,7 Ni kh qun + t ngoi mng cng1410,9 Mask + t cng
ct3325,8 NKQ4333,6 Tng128100,0 Nhn xt: t ni kh qun l phng php v cm
chnh c p dng ti khoa Phu thut - Gy m hi sc bnh vin Nhi trung ng,
trong 33,6% bnh nhnctnikhqunnthun.Mtphnkhngnhbnhnhncgy
mbngphngphpphihpnikhqunvigytcngct(29,7%)vvi
gytngoimngcng(10,9%).Ngoira,cn25,8%bnhnhncvcm bng phng php kt hp
mask vi gy t cng ct. 3.1.5.Phng php phu thut Bng 3.5: Phn loi bnh
nhn theo phng php phu thut Phng php phu thutS bnh nhnT l % M
thng7457,8 Ni soi5442,2 Tng128100,0 Nhnxt:
Tlbnhnhncphuthutbngphngphpnisoikh ln (chim t l 42,2%). 24 3.2.KHO
ST TNH HNH S DNG THUC GIM AU3.2.1.Danh mc thuc gim au Bng 3.6: Danh
mc thuc gim au sau phu thut c dng vin Nhi T Nhm thucTn quc tTn bit
dcDng dng Hm lng Gim au ngoi viParacetamolDafalganVin t hu mn 150
mg Vin t hu mn 300 mg EfferalganVin t hu mn 150 mg Vin t hu mn 300
mg PerfalganTruyn tnh mch chm 1000 mg Gim au trung
ngMorphinMorphinng tim 1ml (10mg/ml) Nhn xt: Cc thuc gim au sau phu
thut c dng vin Nhi Trung
ngchgmcparacetamol(vinthumnhoctruyntnhmchchm)v morphin tim bp.
3.2.2.Tnh trng s dng thuc gim au sau phu thutBng 3.7: Tnh trng s
dng thuc gim au sau phu thut ti phng hi tnh Thuc s dngS bnh nhn T l
% Morphin 32,3% Paracetamol truyn tnh mch2418,8% Paracetamol t hu
mn53,9% Tng3225% 25 Nhnxt:c32bnhnhn(25%)cdngthucgimaungaykhiht tc
dng gy m. Trong c 3 bnh nhn c tim morphin, 24 bnh nhn c truyn
paracetamol, 5 bnh nhn c dng paracetamol t hu mn. Sau khi tnh v c
theo di mt thi gian phng hi tnh, m bo khng
cbinchng,bnhnhncchuynvcckhoaiutr.Thctrngsdng thuc gim au cc khoa iu
tr c th hin bng 3.8. Bng 3.8: Tnh trng s dng thuc gim au sau phu
thut ti cc khoa Thi gian S bnh nhn (T l %) Paracetamol truyn tnh
mch chm Paracetamol t hu mn(Dafalgan hoc Efferalgan) Ngy th 126
(20,3%)99 (77,3%) Ngy th 210 (7,8%)105 (82,0%) Ngy th 37 (5,5%)69
(53,9%) Ngy th 42 (1,6%)14 (10,9%) Ngy th 52 (1,6%)2 (1,6%)
Nhnxt:Ccthucdnggimausauphuthutcckhoachc paracetamol (gim au ngoi
vi), khng s dng thuc gim au trung ng, gim au ph tr, khng dng bit dc
phi hp v khng phi hp thuc. asbnhnhncsdngparacetamolthumngimausau
phu thut,mt s bnh nhn c dng paracetamol truyntnh mch chm (ch yu ngy
u tin). 3.2.3.Thi im dng thuc gim au sau phu thut26 Bng 3.9: Phn
loi bnh nhn theo thi im dng thuc gim au Thi gian Thi im dng thuc S
bnh nhnT l % Ngy th nhtDng theo phc 3225 Dng khi au9372,7 Khng dng
thuc32,3 Tng128100,0 Ngy th 2Dng theo phc 107,8 Dng khi au 10588,0
Khng dng thuc1310,2 Tng128100,0 Nhn xt: T l bnh nhn c s dng thuc ng
thi gian theo phc cnthp,asbnhnhnchdngthuckhiau(72,7%ngythnhtv88%
ngy th 2), c bit, mt s bnh nhn khng dng thuc gim au (2,3% ngy th
nht v 10,2% ngy th 2). 3.2.4.Tng s ngy dng thuc gim au sau phu
thutBng 3.10: Tng s ngy dng thuc gim au sau phu thut Tng s ngy dng
thucS bnh nhnT l % 032,3 1107,8 23829,7 36147,7 4129,4 543,1
Tng128100,0 Trung bnh2,63 0,955 27
Nhnxt:Phnlnbnhnhncdngthucgimautrong3hoc2
ngyutinsauphuthutvitltngngl47,7%v29,7%.Tuynhin cng c 3 bnh nhn
(2,3%) khng c dng mt thuc gim au no trong sut qu trnh phu thut. y l
nhng bnh nhn c k n thuc gim au nhng ngi nh bnh nhn khng cho dng vi
l do tr khng au lm v s nh hng n chc nng gan ca tr. 3.3.KHO ST HIU
QU GIM AU 3.3.1.im au ca bnh nhn ti cc thi im nh gi Bng 3.11: im au
ca bnh nhn ti cc thi im nh gi Thi im nh gi S bnh nhn (%) im au
trung bnh Khng au (0) au nh (1-3) au trung bnh (4-6) au nng (7-10)
n%n%n%n% T012194,564,710,800 T14,621,45002318,09574,2107,8
T23,691,46006752,35341,486,3 T33,471,4321,67054,75341,432,3
T43,061,3621,67961,74535,121,6 T52,301,362015,68768,02116,400
Nhnxt:Trcphuthut,huhtccbnhnhnkhngau.Sauphu
thut,nhnchung,mcaucabnhnhngimdntheothigian.Tithi im T1 (4-6h sau
phu thut), a s bnh nhn au mc trung bnh, t thi im T2 tr i, s bnh nhn
au nh chim t l tng dn, s bnh nhn au trung bnh gim. n thi im T5 (48h
sau phu thut) s bnh nhn au nh chim t l cao nht. 28 3.3.2.T l bnh
nhn ghi nhn c tc dng khng mong mun (TD KMM) Bng 3.12: T l bnh nhn
ghi nhn c tc dng khng mong mun Tc dng khng mong munS bnh nhnT l %
Bun nn, nn75,5 au u43,1 Ho32,3 Tng s bnh nhn ghi nhn c TD KMM1410,9
S bnh nhn khng ghi nhn c TD KMM11489,1
Nhnxt:SbnhnhnghinhncTDKMMsauphuthutl14 (10,9%). Trong : 7bnh nhn b
nn hoc bun nn, 4 bnh nhn b au u, 3
bnhnhnbho.cbit,nhngbnhnhnbnn,bunnnvho,tcdng khng mong mun lm tng mc
au ca bnh nhn. 29 CHNG 4 BN LUN 4.1.C IM MU NGHIN CU c im v tui,
gii:Trong mu nghin cu ca chng ti, tui bnh nhn t 3-15 tui. y l
docthcavinNhi(chnhntrctui15tui)vdotiuchunla chn: khng la chn bnh
nhn di 3 tui v khng thi gian v nhn lc theo di mc au la tui ny.
Kimsotausauphuthuttr
