Nghiên cứu biến đổi các chỉ số khí máu động mạch và cơ học phổi khi áp dụng nghiệm pháp huy động phế nang trong gây mê phẫu thuật bụng ở người cao tuổi TT TIENG ANH

THE EDUCATION & TRAINING MINISTRY THE SCIENTIFIC AND MEDICAL STUDY INSTITUTION 108 LAI VAN HOAN RESEARCH ON THE VARIATIONS OF ARTERIAL BLOOD GASES AND PULMONARY MECHANICS DURING GENERAL ANESTHESIA APPLYING ALVEOLAR RECRUITMENT MANEUVERS FOR ABDOMINAL SURGERY IN THE ELDERLY Speciality: ANESTHESIOLOGY AND SICU Code : 62.72.01.22 THE SUMMARY OF MEDICAL PROJECT FOR DOCTORS HANOI – 2021 The project is completed at: THE SCIENTIFIC AND MEDICAL STUDY INSTITUTION 108 The scientific instructors: Vice Professor.Dr Cong Quyet Thang Vice Professor.Dr Le Thi Viet Hoa Reviewers: The project will be demonstrated with the institutional council examiners at THE SCIENTIFIC AND MEDICAL STUDY INSTITUTION 108 at 2021 The project can be mentioned at: The national Library of Vietnam The library of INSTITUTION 108 THE SCIENTIFIC AND MEDICAL STUDY INTRODUCTION Thanks to the development of modern medicine, the job of taking care of people’s health is increasing so that the average longevity is higher too Whereas, in Vietnam as well as in many other countries, the rate of elderly patients who need external medicine intervention is rising Besides, there is the rise of chronic diseases such as high blood pressure, heart failure, COPD,… That leads to a high rate of strokes and complications during the anesthesia and surgery of elderly people There are some emotionless methods in surgery, however, the method of anesthesia with the internal alveolus is still chosen for big surgery which is related to a lot of organs with long time such as abdominal surgery This is the emotionless method with such advantages, especially in the case of needing to control the moving blood and respiration of the patients However, the job of putting the internal alveolus pipes and breathing machine during the anesthesia will impact the breathing system because the ventilating in the machine is completely different from natural breathing The more time you use the breathing machine, the more changes will happen and this is the element which may cause complications in breathing after the surgery of the patients With other elements such as using the medicine in the opioid family, stretching muscles, this will lead to the hurt of the muscles in abdominal muscles, combining-side muscles because of the surgery … These are the main reasons for complications in breathing Any breathing complication can cause the lack of oxygen and increase CO2 in the blood system, decreasing the number of the functions in breathing such as the volume of moving air, the volume of crusted air, … A lot of methods which have been studied and applied to reduce the danger of collapsing lungs during the artificially ventilating The above methods have been studied by a lot of scientists and have given good results in preventing collapsing lungs in anesthesia with the internal putting alveolus and artificial ventilation, especially with long-time surgery or with the danger of high collapsing lungs Controlling the pressure in order to open lungs has been studied, with the opening pressure of +40 cmH2O which shows the ability of good alveolus, it helps to increase the rate of alveolus in participating in exchanging air As well as that, maintaining the level of PEEP +5cmH2O will help to mobilize alveolus by controlling the pressure better in the process of using a machine to breathe Mobilizing alveolus by pressure and other methods all influence the patients but it is not very clear, especially with elderly people In Vietnam, the methods of mobilizing alveolus (HĐPN) in anesthesia have been studied Therefore, we study the above methods with the following aims: Evaluating the changing of numbers in pressure of the blood artery and mechanical lungs when applying the method of mobilizing alveolus combined with PEEP +5cmH2O in abdominal anesthesia surgery of elderly people Comparing the changing of the numbers in pressure of the blood artery and mechanical lungs between the groups with and without mobilizing alveolus combined with PEEP +5cmH2O in abdominal anesthesia surgery of elderly people Investigating some unexpected uses in the circulation and respiration of the method of mobilizing alveolus combining with PEEP +5cmH2O in anesthesia surgery in the abdominal of elderly people Chapter Overall 1.1 Anatomizing the respiration system 1.1.1 Anatomizing the respiration system 1.1.2 Mechanical respirations 1.1.3 Moving and exchanging air 1.1.4 The change in respiration of elderly people 1.2 The influence of anesthesia-surgery abdominal on respiration 1.2.1 Abdominal Surgery 1.2.2 The influence of anesthesia on respiration 1.2.3 The mechanism causing the collapse of lungs in anesthesiasurgery There are a lot of different points of view in explaining the mechanism of the collapsing lungs in anesthesia-surgery but there are main types of mechanism which are most accepted: absorption mechanism, compression mechanism and the mechanism of reducing the surfactant [35], [67], [125] 1.2.3.1 Absorption mechanism Collapsing lungs because of absorption appears more often with anesthesia patients with two factors They are the increasing of blood oxidizing and reducing the rate of exchanging air-perfusion (V/Q) When the patients experience the duration of anesthesia, they are usually set up the maximum oxygen mode (100%) before setting up the artificial respiration [100] [19], [94] The second mechanism of the collapsing lungs is the low V/Q rate Basically, arteries are absorbing oxygen more quickly than the little alveolus which are supplying air This can happen easily in breathing pipes which are limited or blocked FRC continues to reduce more when patients are lying face up [60], [95] 1.2.3.2 Compression mechanism Collapsing lungs because of compression appears when the pressure at pleura is higher than the pressure inside the lungs, and the alveolus cannot maintain the open status longer The anesthesia patients are so sensitive with this kind of collapsing lungs for lots of reasons When lying face up, the anesthesia patients will have increasing pressure at pleura because the weight of the organs inside the abdominal is against the horizon muscles and the weight of the patients’ chests The both mechanisms have significant meanings in collapsing lungs when being compressed [46] [55], [61], [62] 1.2.3.3 Reduced Surfactant The last mechanism of collapsing lungs is reducing the surfactant in the alveolus sides The surfactant is produced by the pneumocystis cells type 2, it reduces the stretching surface and helps to increase the ability of lungs stretching When the surfactant reduces, the alveolus will have a lot of difficulty in closing-opening, and when they close, it will hardly be open again The appearance of collapsing lungs is the important element in the illness mechanism of complications about lungs after surgery such as the reduction of oxidizing blood, infected lungs and the reaction of inflammation The complications of infected lungs after surgery in the first hours are the main causes of the collapsing at the positions belonging to lungs [54], [103] 1.2.4 The strategy of reducing complications after surgery 1.3 The method of mobilizing alveolus 1.3.1 Definition 1.3.2 History 1.3.3 Methods of mobilizing alveolus * Mobilizing alveolus with the pressure +40 cmH2O Mobilizing alveolus with the continuous pressure 40 cmH2O in a period of 40 seconds This method has been proved that it is effective to improve oxidizing blood, easy to put in clinical practice and safe After mobilizing alveolus, we move to the method of breathing before mobilizing alveolus Watching: Before, during and after the surgery, watch the artery, SpO2 and the electrocardiogram [1], [92] Get again the X-ray of the lungs after the technique in order to check the complications of spilling the air pleura, mediastinum The films should be made at least 15 minutes after the mobilizing alveolus Blood test should be done before and after 15 minutes and hours after mobilizing alveolus The activity of the breathing machine, pressure of pipes, volume 1.3.4 Assignment 1.3.5 Anti-assignment 1.3.6 The time of mobilizing alveolus 1.3.7 Complications of mobilizing alveolus 1.4 Some studies about mobilizing alveolus 1.4.1 The study of mobilizing alveolus in the world 1.4.2 The study of using mobilizing alveolus in Vietnam Chapter THE OBJECTS AND METHODS OF STUDYING 2.1 The objects of the study 2.1.1 The standard of selecting patients: The patients who are 60 years old or over 60 who are assigned to have open abdominal surgery The whole body anesthesia with internal alveolus and artificial breathing Type of health ASA 1-3 The duration of anesthesia is 120 minutes or over Body mode number BMI less than 30kg per square metre The patient agrees to it 2.1.2 The standard of refusing Remove the patients who have one of the following standards: Chronic respiration: COPD (Type GOLD III or IV), serious or unable controlling asthma Used to have lung surgery before The X-ray of lungs has unusual pictures, injured lungs Lung cancer Deformed chest and chest diseases Serious nerve diseases Traumatic brain injury, increasing internal skull Serious heart failure (Type III, IV) Instant coronary artery syndrome Patients with arrhythmia Patients with kidney failure who have regular dialysis Patients with infected strokes or bleeding strokes Patients with the history of allergy to anesthesia medicine, stretching muscles medicine, and opioids 2.1.3 The standard of removing out of the study The cases with strokes in surgery have to be moved to the positive recovery units with a breathing machine for more than 24 hours 2.2 The method of the study 2.2.1 The study design Study-intervene random objects with comparison 2.2.2 The size of the study model The size of the model is assigned: n1 = n2 ≥ 37 Group 1: The ‘intervention’ with artificial breathing as well as controlling volume and carrying out the study of mobilizing alveolus with the pressure + 40cmH2O in 40 seconds and maintaining the level PEEP +5cmH2O Group 2: The ‘opposite’ with artificial breathing as well as controlling volume with the beginning setting up mode during the surgery 2.2.3 The time and the place of the study * The place of the study: Anesthesia-Recovery Department, Huu Nghi Hospital * The time of the study: From October 2016 to October 2019 2.2.4 Means of the study 2.2.5 The Procedure 2.2.5.4 The procedure of mobilizing alveolus with machine Avance CS2 After the patients have the average blood pressure higher than 65mmHg, mobilize alveolus with the procedure of using Vital Capacity with breathing machine Avance CS2 + Step 1: Choose menu Procedures on the right tab of the screen Choose Vital Capacity on the window + Step 2: Establish the number to carry out: - Pressure Hold: Pressure to keep opening lungs at 40cmH2O - Hold Time: The time to keep the pressure of opening lungs 40 seconds - PEEP on Exit: The level PEEP after mobilizing lungs 5cmH2O + Step 3: Touch Start Vital Capacity in order to run the program The lungs will be pumped with the setting up pressure, time then return to level PEEP chosen and continue ventilating for the patients as usual + Step 4: Repeat the procedure every 60 minutes At the moment of ‘mobilizing alveolus’ by keeping the pressure of breathing pipes at +40cmH2O, PEEP constantly +5cmH2O and maintaining in 40 seconds This procedure will be repeated after every 60 minutes until the surgery finishes Screen 2.4 The procedure of mobilizing alveolus 2.2.6 The number of the study 2.2.6.1 The main aims Changing mechanical lungs - Changing the exhaling volume (TVexp) - Changing the pressure of breathing pipes before and after mobilizing alveolus: Pmean, Ppeak, Plat - Changing the stretching of lungs (Compliance) - Changing the exhaling ventilation (Mvexp) - The number of times to mobilize alveolus: Group mobilizing alveolus * The changing of substance in blood artery: - Changing PaO2 - Changing the rate PaO2/FiO2 - Changing PaCO2 - Changing pH blood - Changing HCO32.2.6.2 Influence on circulation, respiration and unexpected symptoms - Changing about moving blood: Heart frequency (times/minute), HATT (mmHg), HATTr (mmHg), HATB (mmHg) - Changing SpO2 (%) - Taking notes all the unexpected effects related to artificial ventilation with the both groups: + Pressure Injury: Spilling air pleura, spilling air mediastinum, spilling air under skin + Moving blood: Going down pressure, slow heart frequency, disordered heart frequency + Respiration: Reducing the level of oxygen saturation bouncing artery (SpO2%) 2.2.6.3 The general standards of the patients * Characteristics of the two groups before surgery - Age (year), - Sex (male/female), - Health (ASA), - The BMI number = weight/(height)2, - History of the patient - Temperature - Breathing frequency (beat/minute) 11 Comments : After mobilizing alveolus, the level of stretching lungs is higher than that before the time of mobilizing alveolus 3.3 Changing the mechanical number of lungs in the two anesthesia groups 3.3.1 Changing the volume of the exhaling air of the two groups 3.3.2 Changing the stretching lungs of the two groups Chart 3.5: Changing compliance of the two groups in anesthesia Comments: The average value of the Compliance at the moment before mobilizing alveolus in the ‘opposite’ group and ‘intervention’ group is similar with p>0.05 After mobilizing alveolus, the Compliance of ‘intervention’ group is higher than the other one with p < 0.01 3.4 Changing the number of blood air artery 3.4.1 Changing the number PaO2 of the both groups Chart 3.6: Changing PaO2 of the both groups 12 Comments: The number PaO2 at the moment after mobilizing alveolus minutes and before finishing breathing machine is higher than that before mobilizing alveolus This improvement has its meaningful statistic with p < 0.05 3.4.2 Changing the rate PaO2/FiO2 of the two groups Chart̀ 3.7: Changing P/F of the two groups in anesthesia Comments: The average rate PaO2/FiO2 at the moment after mobilizing alveolus minutes is higher than that before mobilizing alveolus has its meaningful statistic with p < 0.01 3.5 Influence on circulation, respiration and unexpected symptoms 3.5.1 Changing in moving blood * Changing average blood pressure in mobilizing alveolus Chart 3.11: Changing average blood pressure in mobilizing alveolus Comments: The moment after mobilizing alveolus, the average blood pressure reduction has its meaningful statistic compared with that before 13 mobilizing alveolus The difference in blood pressure at the three moments above has their meaningful statistic with p 0.05 In the study of D Aretha [22], the top pressure Ppeak reduced at mobilizing group, pressure before mobilizing was 24 cmH2O went down to 20 cmH2O The reducing has its statistic Therefore, our results are different from those of the scientist We see that the pressure has changed but only a little and it doesn’t have its meaningful statistic between the two groups There is the difference maybe because of the difference between the two methods The scientist used the PEEP level increasing step by step to mobilize alveolus while we used high pressure continuously Therefore, the pressure of patients’ breathing pipes in the scientist’s study would have some changes with the PEEP level The studies with PEEP level increasing gradually in order to mobilize alveolus often have the level Ppeak which increases gradually and the limited of Ppeak is high 4.2.1 Changing the air blood level in artery Based on Table 3.22 and Chart 3.6, we find that the index number PaO2 of ‘intervention’ group is 207.5 ± 17.99 mmHg which is higher in statistic than the ‘opposite’ group, 9.4 ± 6,5 mmHg at the moment after the first time mobilizing alveolus minutes This is the time which has the most difference about PaO2 between the two groups Moreover, after taking out the internal alveolus pipes for 30 minutes, the PaO2 of ‘intervention’ group is higher than the ‘opposite’ group with the difference of p