Nghiên cứu tác dụng gây tê tủy sống ngoài màng cứng kết hợp an thần bằng tci propofol dưới hướng dẫn của điện não số hóa trong phẫu thuật bụng dưới ở người cao tuổi tt tiếng anh

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE 10 IN STI TU TE OF C LI NI C AL ME DI C AL A N D PHA RM A C EU TI C AL SC IE N CE S - NGUYEN MANH HO NG STUDY O N SPINAL - EPIDURAL SPINAL ANESTH ESIA EFFECT C O MBINED W ITH SEDA TIO N BY TCI PRO PO FO L UNDER TH E GUIDANCE O F DIGITIZED ELECTRO ENC EPHALO GRAPHY IN LOW ER ABDO MINAL SURGERY IN TH E ELDERLY Spe ciality: Resuscitation Anesthesia Code : 62.72.01.22 ABSTRAC T O F MEDICAL PHD THESIS Hanoi – 2020 THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES Supe rvisor: Ass Prof Cong Quyet Thang Prof Le Xuan Thuc Re viewe r: This thesis will be presented at Institute Council at: 108 Institute of Clinical Medical and Pharmaceutical Sciences Day Month Year The thesis can be found at: Nat ional Library of Vietnam Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences Central Institute for Medical Science Infomation and T ecnology INTRO DUCTIO N Limiting risks and complications when conducting anesthesia and intensive care for elderly patients is a topical issue because in reality the number of elderly patients requiring surgery is increasing The classic anesthesia is a generalized int ubation with anesthesia that satisfies most surgeries It is accompanied by many ventilation complications, especially difficult intubation and artificial ventilation, which can easily cause lung complications Intubation anesthesia must use muscle relaxants, so t he risk of residual muscle relaxants after surgery, to use central painkillers of the whole family morphine family leads to slow province, weak cough reflex, high risk of lung collapse and collapse Pulmonary is a serious complication after surgery, requiring mechanical ventilation to increase mortality All this leads to slow recovery of patients Classic postoperative analgesia is an opioid-intensive method But today it is proved that this method has many undesirable effects because it causes respiratory depression, addictive T hat's why multimodal anesthesia was born Central anesthesia (spinal + epidural) is popular, a simple and anesthesia method that provides high efficiency and quick onset t ime However, its disadvantage is that it is limited in time when used as a single dose so it does not meet long-term surgery Spinal anesthesia technique combined with epidural analgesia has overcome this disadvantage of spinal anesthesia alone because it is possible to add longlasting epidural drugs t o reduce pain and meet long-term surgery Spinal anesthesia combined with epidural analgesia for domestic and foreign gastrointestinal surgery is small, so we continue to research on this issue Multi-modal analgesia combined with adequate sedation under the guidance of digitized electroencephalography via P SI is a t echnique that can limit intubation and the use of muscle relaxation However, currently, there is no research in the world and in Vietnam, conducting a combination of epidural spinal anesthesia in combination with continuous analgesia in combination with sedation with target concentration controlled T CI propofol under instructions of electroencephalography digitized via PSI index for lower abdominal surgery in elderly patients So we conducted this study with three goals: Evaluating the anesthesia effect of spinal anesthetic with bupivacaine 0.5% in combination with epidural anesthesia with bupivacaine 0.2% -sufentanil 0.5mcg/ml in lower abdominal open surgery in the elderly Evaluating the sedative effect of TCI-propofol on PSI digitized electroencephalography Giving comments on the effects of spinal - epidural spinal anesthesia combined with sedation with propofol - TCI on respiration, circulation, and some undesirable effects in lower abdominal surgery in the elderly NEW CONTRIBU TIO NS O F TH E TH ESIS T he research is necessary and topical, especially when applying t he method of spinal anesthesia - epidural with T CI propofol sedation under the guidance of digitized elect roencephalography in human lower abdominal surgery elderly The topic has scientific and practical implications Proper, scientific and logical research design, reliable data and data processing, large enough patient population The technique of applying spinal-epidural anesthesia in combination with T CI sedation by propofol under the guidance of digitized electroencephalography P SI is a new technique It ensures t hat during the operation, the patient is sedated, does not know the operation is in progress, is of good insensitivity, early awareness, good quality of recovery and few unwanted effects suitable for lower abdominal surgery, especially in the elderly people This technique could completely replace t he classic endotracheal anesthesia method It helps determine the target brain concentration of propofol, with Cp = 1.98mcg/ml and Ce = 1.25mcg/ml just enough sedation with PSI = 75.27 just enough for this surgery This is the new point, the contribution of the topic to the scientific practice TH E TH ESIS STRUC TURE T he thesis consists of 124 pages Introduction: pages Chapter I Lit erature overview: 40 pages Chapter II - Research subject s and methods: 22 pages Chapter III - Results: 32 pages Chapter IV Discussion: 23 pages Conclusion: pages The t hesis has figures, 13 charts, 32 tables, 228 references (28 documents in Vietnamese and 200 documents in foreign languages) Chapte r LITERA TUR E O VERVIEW 1.1 Anatomical and physiological changes i n el de rly people relate d to anesthesia and intensive care 1.1.1 What is the elderly? The Vietnam Elderly Ordinance states that the elderly are 60 years of age or older 1.1.2 Changes in the nervous system: T he nervous system is the target organ for anesthesia In general, the brain size of the elderly decreases, the average brain weight decreases by 18% in t he 80s compared t o the 30-year-olds Decreased gray matter ratio as well as cranial index Micro, the number of nerve cells and the number of synapses, the concentration of neurotransmitters are reduced P ain thresholds increase, resulting in less need for opioid and sedative analgesics than younger people However, they are also more suscept ible to cognitive and respiratory depression 1.1.3 Changes in respiratory function: All measurable respirat ion indicators are decreasing The three mechanisms that alleviate pulmonary ventilation are: a sharp decrease in the ventilation function of the respiratory organs due to a decrease in respiratory muscle tone, stiffness of the chest (calcification of ribs joints, narrowing of t he cleft joints and variables) the form of vertebrae) reduces copliance of the chest and changes the characteristic elasticity of the lungs Ventilatory fraction imbalances and alveolar dispersion volume 1.1.4 Changes in cardiovascular function Cardiovascular function in the elderly is constantly changing: reducing vasoconstriction, reducing the number of cardiac muscle cells, reducing the response to stimulation by Beta-adrenergic, ventricular hypertrophy and reducing the number of cardiac muscle conduction cells A decrease in ventricular tone is associated with hypertrophic cardiomyopathy, making the flow of the heart very dependent on the ret urn circulation 1.1.5 Changes in renal function Renal blood vessels, glomerular filtration and altered t ubular function in the elderly For example, glomerular filtration rate drops by 50% at 80 years of age compared to at the age of 20 Elderly people are more likely to suffer from all kinds of acute kidney failure because - like other organs - kidney function is poorly adaptive with stress 1.1.6 Changes in the spine, ligaments and cerebrospinal fluid 1.1.6.1 Spine: The spine deteriorates over time Spinal degeneration is a chronic degenerative lesion of the vertebrae and disc discs and ligaments of the spine Scoliosis of the vertebrae, the edge of the medulla grows out of bone T he spinal edge muscles also contract, t he ligaments near the spine are pulled too much, making the spine deformed, making it difficult to identify the vertebrae and when conducting the spinal needle and needle epidural 1.1.6.2 Ligament systems: The intercostal ligament becomes thick and supple, making it difficult to poke T uohy needles In the elderly, the fibrous ligaments become fibrous, thickening making it difficult to puncture the spinal cord and epidural 1.1.6.3 Cerebrospinal fluid: T he amount of cerebrospinal fluid also decreases, thus slowing down t he diffusion of anesthetic 1.1.9 Pharmacological effects of drugs in the elderly: In general: Older people need a smaller amount of anesthetic than younger people This comment speaks to the relationship between age and pharmacodynamics and the pharmacokinetics of elderly anesthetics 1.2 Advantages of spinal-e pidural spinal anesthesia in surgery The technical advantage of anesthesia-epidural spinal anesthesia is Combining the advantages of both spinal anesthesia (short waiting time, strong anesthetic effect) with the advantage of epidural anesthesia (for pain relief) long) It can overcome t he case of spinal anesthesia that is not insensitive enough for surgery It meets long-term pain reduction requirements by placing catheters in epidural spaces to relieve postoperative pain, obstetric pain 1.3 Methods of assessing and controlling se dation and anesthesia 1.3.1.1 Several scales to assess sedative and clinical anesthetic OAA/S score Se dative scores for patients in intensive care room: Ramsay tranquilizer score, Cohen tranquilizer scale, Riker tranquilizer scale, RASS tranquilizer scale, Evans's PRST scale assesses clinical anesthesia sieve 1.3.1.2 Assess anesthesia, sedation by BIS BIS index is calculated based on the combination of time, frequency and spectrum of EEG and is digitized from 100 t o When anesthetic, BIS index decreases from 100 to and loss of tri cupping tends to occur when the BIS value is between 80 and 70 BIS between 40 and 60 is deep enough BIS 20%, but at this time there was and was treated with an infusion Crystalline and colloidal solutions with ephedrine But blood pressure is not sustainable It will be affected at a later stage by running an epidural electric syringe and sedating and especially adding epidural lidocaine 4.4.3 Some other undesirable effects of spinal and epidural anesthesia 4.4.3.1 Nausea and vomiting: As t he most common side effects, group I has cases accounting for 6%, group II with cases accounting for 4% T his symptom occurs in the first 25-30 minutes, t here is no case after surgery Itching: Itching is also common when using morphine drugs, we only patient has itching in group II (accounting for 2%) group I had no patients We observed patients of group I (6%) and cases of group II (4%) with pain at the needle site In both groups, there were no reported postoperative headaches Urinary retention: In our study, all patients underwent urethral catheterization immediately after anesthesia, so we could not assess urinary retention after surgery 4.5 The surgeon’s satisfaction about the anesthesia method: Good: In group I there are 48 cases accounting for 96%, group II cases have 47 cases 95.9% Fair: In group I, there are cases accounting for 4%, group II with cases 4.08% 23 4.6 Patient satisfaction: No patient felt pain and remembered during surgery and was very satisfied with this anesthesia method CONCLUSIO N Through the study on 99 patients who underwent spinal-epidural anesthesia combined with T CI sedation by propofol under the guidance of digitized electroencephalography for lower abdominal surgery in the elderly, we draw t he following conclusions.: On the anesthetic effect of spinal anesthetic by bupivacaine 0.5% in combination with e pidural ane sthesia with bupivacaine 0.2% sufentanil 0.5mcg which is sufficient for lower abdominal ope n surgery in the elde rly - 100% of patients have met the anesthetic requirements for surgery with the following anesthetic levels - T ime of sensory suppression on T12: 2.34 ± 0.69 minutes T ime of sensory suppression on T10 was 3.86 ± 1.28 minutes T he t ime of occurrence of sensory inhibition in T6 is 5.66 ± 1.35 minutes - The time of occurrence of motor inhibition in M1 was 2.92 ± 0.72 minutes T he time of occurrence of motor inhibition in M2 was 3.98 ± 0.92 minutes The t ime of occurrence of motor inhibition in M3 was 5.30 ± 1.17 minutes - T he method of anesthesia is good for surgery with 151 ± 53.32 minutes and 147.73 ± 56.22 minutes, the longest time is 270 minutes The sedative e ffe ct of TCI propofol on PSI digitizing ele ctroence phalography: afte r a comparative study of two titration methods, we conclude d: - T he level of sedation with an average PSI of 75.27 with a 95% confidence interval (74.76-75.78) is sufficient for lower abdominal surgeries Corresponding to that sufficient PSI, the average T CI propofol concentration is: Cp = 1.98mcg/ml (with 95% confidence interval: 1.87 - 2.09); Ce = 1.25mcg/ml (with 95% confidence intervals: 1.22-1.29) - Sedation should be carried out on a low to high t itration method to achieve the earliest sedation and reduce the number of titrations - Good quality of recovery: Immediately after the end of surgery, the average OAA/S score is and the painless patient with VAS scores immediately after surgery is 1.72 ± 0.4 (at rest in group I) and 1, 81 ± 0.5 (at rest in group II) 24 Effe cts of spinal-e pidural spinal anesthesia combining TCI propofol sedation on circulation, re spiration and some undesirable e ffe cts in lower abdominal surgery in the elderly: There were very few undesirable effect s reported in this study There is no special case of respiratory failure and circulatory failure during and after surgery Headache has 3% in group I and 2% in group II Nausea and vomiting have 4% in group I and 2% in group II Pain at the needle site was 6% in group I and 4% in group II Pruritus in group II has case accounted for 2%, group I has no cases PUBLISHED SCIENTIFIC RESEARC H WO RKS RELATED TO TH E TH ESIS Nguyen Manh Hong, Cong Quyet Thang (2018),“ Studying the anesthesia effects of spinal anesthesia method combined with epidural analgesia for lower abdominal surgery in elderly patients”, Vietnam Medical Journal, Issue No.2(462), January, p.29-32 Nguyen Manh Hong, Cong Quyet Thang (2018), “ Studying the adjustment of T CI propofol sedation by the targeted concentration under the digitized EEG guidance via PSI in combination with regional anesthesia for lower abdominal surgery in elderly patients”, Vietnam Medical Journal, Issue No.2(462), January, p.7-12 Nguyen Manh Hong, Cong Quye t Thang (2018) “ Combination of combined spinal-epidural (CSE) analgesia and T CI-propofol is that sufficient for lower abdominal surgery in the elderly patients?” th Wold Congress of SIVA-T CI 2018 15th to-18th August Kuala Lumpur Convention Centre Malaysia ... Sufent anil is 10-15 t imes stronger than fentanyl, less cumulative and has a short durat ion of action and 300 times the morphine Sufentanil has a stronger affinity on the receptor  than fentanyl... pidural spinal anesthesia in surgery The technical advantage of anesthesia-epidural spinal anesthesia is Combining the advantages of both spinal anesthesia (short waiting time, strong anesthetic... 1.16 minutes our results are slower than T ran Van Cuong's results is 3.39 ± 0.54 minutes but lower and lower t han some other authors like Nguyen Anh T uan at T6 is 11.96 minutes Achieving sensory