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

INTRO DUC TIO N Limiting risks and complications when conduct ing anesthesia and intensive care for elderly patients is a topical issue because in reality the number of elderly patients

MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENCE

THE THESIS WAS DONE IN: 108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES

Supe rvisor:

1 Ass Prof Cong Quyet Thang

2 Prof Le Xuan Thuc

Day Month Year

The thesis can be found at:

1 Nat ional Library of Viet nam

2 Library of 108 Institute of Clinical Medical and Pharmaceutical Sciences

3 Central Institute for Medical Science Infomation and

T ecnology

INTRO DUC TIO N

Limiting risks and complications when conduct ing 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 ubat ion with anesthesia that sat isfies most surgeries It is accompanied by many ventilation complications, especially difficult intubat ion and artificial ventilation, which can easily cause lung complications Intubat ion 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, addict ive 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 long-lasting 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 sedat ion under the guidance of digitized electroencephalography via P SI is a t echnique that can limit intubat ion and the use of muscle relaxation However, currently, there is no research in the world and in Vietnam, conduct ing 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 conduct ed this st udy with three goals:

1 Evaluating the anesthesia effect of spinal anesthetic with bupivacaine 0.5% in combination with epidural anesthesia with bupivacaine 0.2% -sufentanil 0.5m cg/m l in lower abdom inal open surgery in the elderly

2 Evaluating the sedative effect of TCI-propofol on PSI digitized electroencephalography

3 Giving comments on the effects of spinal - epidural spinal anesthesia combined with sedation with propofol - TCI on respiration, circulation, and som e undesirable effects in lower abdominal surgery in the elderly

NEW CONTRIBU TIO NS O F TH E TH ESIS

1 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 dat a processing, large enough patient populat ion

2 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 sedat ion 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 Introduct ion: 2 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: 2 pages The t hesis has 8 figures, 13 charts, 32 tables, 228 references (28 documents in Vietnamese and 200 documents in foreign languages)

Chapte r 1 LITERA TUR E O VERVIEW 1.1 Anatomical and physiological changes i n el de rly people relate d

to anesthe sia and inten sive care

1.1.1 What is the elderly? The Viet nam Elderly Ordinance states t hat

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 t he 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 sedat ive 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 t one, stiffness of t he 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 characterist ic 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

conduct ing the spinal needle and needle epidural

1.1.6.2 Ligament system s: 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 relat ionship 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 wait ing 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 reduct ion 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 calculat ed based on the combination of time, frequency and spectrum of EEG and is digitized from 100 t o 0 When anesthetic, BIS index decreases from 100 to 0 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 <40 indicates deep maze, BIS <20 is too deep The

advantage is that we can calculate the right dose of anesthetic so that we can proactively allow patients to wake up early, avoid drug residues, avoid complications during the recovery period The downside is that only the funct ion of the cerebral cortex is expressed but does not directly reflect the subcort ical structure including t he spinal cord, so the BIS is less reliable for predicting response to pain stimulation

1.3.1.3 Assessment of anesthesia, sedation by ENTROPY

Entropy is a more accurate technique than BIS for detecting an outbreak of an electroencephalograph - quenching in anesthesia tracking Entropy has 2 indicators: RE and SE, RE can detect more quickly the state of consciousness in anesthesia Studies show that applying Entropy can save anesthetics to help patients wake up early

1.4 TC I propofol sedation method of coordination in re gional anesthesia In August 1996, T CI was introduced

In 1996, Mackenzie studied assessing sedation during regional anesthesia: indications, benefits and methods Research suggests that regional anesthesia is only a part It is necessary to use more techniques and other appropriate drugs to help patients relax quiet ly and cooperate well during surgery The concept of provincial sedation was born

In 2003, Villeret et al.determined which target concentrations to sedat e when anesthetized the area for elderly patients with ASA III undergoing vascular surgery The study showed that 100% of patients achieved sedation at 0.9mcg/ml, 94% at 1.1mcg/ml and 78% achieved at 1.3mcg/ml

Se dation with T CI propofol has two approaches One is to detect dose from low concentration after increasing gradually The second is to start from a high concentration and then gradually lower the

concentration through each t itration to determine sedation according to the appropriate PSI

1.5 Pharmacology of drugs use d in anesthesia and sedation

1.5.1 Bupivacain (Marcain)

CH3

NH

- When injecting anesthetic into the epidural space, it mainly acts on the spinal nerve roots The drug binds to the membrane of nerve conduct ion fibers, inhibits Na+ movement through t he cell membrane, reduces the rate and extent of depolarization of cells, thereby preventing the propagation of the action potential that inhibits conduct ion nerve Cardiovascular toxicity lidocaine 15 to 20 t imes in the experiments

1.5.2 Lidocain

- Lidocaine has a relatively low solubility in lipids compared to long-acting drugs like marcaine and tetracaine This reduces plasma protein binding, but it also reduces toxicity The rate of binding to plasma proteins of lidocaine is 70%

- Lidocaine at low plasma concentrations, this drug has an anticonvulsant effect at a concentration of 0.5-4mcg/ml, but conversely causes convulsions at a high concentration of 8mcg/ml

- On the cardiovascular system: Lidocaine inhibits almost selectively sodium channels, reduces both the amplitude and durat ion

of the action potential (PA) and prolongs t he rest time (PRA)

a good analgesic effect with low drug concentrations in plasma It causes morphine-like respiratory depression

1.6 Domestic and forei gn studies on spinal-e pidural spinal anesthesia in combination with TC I propofol sedation

In 2005, A Quinart and colleagues used T CI propofol for sedation during surgery to determine the target brain concentration and its correlation with BIS The BIS has a strong correlation with Ramsay's sedat ive score

In 2011, Thomas D and his colleagues also evaluated the use of SEDLine for its safety and effectiveness in sedat ion The results show

that this tracker is useful in assessing for sedation adjustment

Chapte r 2 RES EARC H SUBJEC TS AND METHO DS

2.1 Research subjects:

2.1.1 Selection criteria: The organs were operated in the lower

mesenteric mesenteric or posterior colon Age ≥ 60, status ASA I, ASA

II, has no contraindicat ions to spinal anesthesia such as: needle infection, spine deformity and spinal pathology Patients with coagulat ion disorders

2.1.2 Exclusion criteria: Patients have t he contraindicat ions t o spinal

anesthesia and epidural anesthesia, mental disorders, drug addict ion, and traumatic brain injury

2.1.3 The criteria for exclusion from the study group: T he patient

disagrees T here are complications during surgery: Bleeding great er than 500ml, shock T he incision must extend to the t ip of the breast The patients were not collected enough research data; endoscopic

- Objective 2: A clinical trial randomized controlled

2.2.2 Choosing the sample size: 100 patients divided into 2 groups 2.2.3 Time - place of the study: Department of Anesthesia and

intensive care - Friendship Hospital from January 2011 to March 2017

2.4.4 Process of conducting the research

- Group I has 50 patients and Group II has 50 patients with bupivacaine heavy 0.5%, with the same epidural catheter administration: The dose of bupivacaine heavy 0.5% 7mg/patient Mix bupivacaine plain 100mg + sufentanil 25mcg, mix 50ml with 0.9% NaCl solution and maintain an electric syringe of 5ml/h at the beginning of the incision T hen group I was sedat ed with 1% propofol

by T CI machine under Schnider target concentration control program 1mcg/ml, gradually increasing the target concentration to 0.5mcg after

Ce and Cp were balanced so t hat PSI index was within 70 ≤ P SI ≤80 and OAA/S = 3 points Allow the patient to breathe through natural channels When PRST score ≥ 3, pump through epidural catheter 10 ml

of 2% lidocaine solution to lower PRST score Meanwhile group II was sedat ed with 1% propofol by T CI under Schnider target

concentration control program 3mcg/ml, then gradually reduced target concentration to 0.5mcg after Ce and Cp were balanced so that PSI index within 70≤PSI≤80 and OAA/S = 3 points Patients are allowed to breathe naturally When PRST score ≥ 3, pump through epidural catheter 10 ml of 2% lidocaine solution to lower PRST score

2.5 Research crite ria

2.5.1 Evaluating the anesthesia effect of spinal anesthetic with bupivacaine 0.5% in combination with epidural anesthesia with a mixture of bupivacaine 0.2% -susfentanil 0.5mcg/ml in lower abdominal surgery in the elderly (Objective 1): Evaluating the sensory

inhibition immediately after injection of anesthetic into the spinal cord

by P inpricks method, motor paralysis with Bromage scale

Effects on sensory suppression: The time of occurrence of pain relief at

all levels T12, T10 , T6, T4,

Effects on motor inhibition: The t ime of occurrence of motor paralysis

at all levels, the number of paralyzed patients at all levels

2.5.2 Evaluating the sedative effects of TCI-propofol on PSI digitized electroencephalography: T ime to start determining the titration of

propofol sedat ion: Conduct ed 10 minutes before incision and is

calculated in mcg/ml; determ ine the Ce and Cp concentrations of

propofol through titrations so that 70 ≤ PSI≤80 and OAA/S = 3 points, determine the correlation between these Ce and Cp indexes with the

indexes PSI and OAA/S; determination of Ce and Cp concentrations of propofol and PSI index and clinical reliability

2.5.3 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

Continuously monitoring the respiratory frequency, SpO2, EtCO2, heart rate, blood pressure, nausea, vomiting, headache, back pain at the needle site Breathing slowly: Breathing frequency <10 breaths/minute

→ Squeeze the ball Bradycardia: <50 beats/minute atropine 0.25 mg intravenously slowly Repeat the injection after 2 minutes if the desired effect is not achieved If the blood pressure is low: Called mean blood pressure drop when reduced > 20% than the patient's baseline blood pressure, use ephedrine Repeat after 2 minutes if the desired effect is not achieved Fast infusion of gelofusin solution Itching, vomiting, and nausea: ondansetron 8mg x 1 slow intravenous syringe or naloxon

0.1mg slow intravenous injection, may be repeated if needed In case of ineffectiveness, combine the two drugs or use additional dexamethasone 4-8mg intravenously

RES EARC H CHART

Chapte r 3 RES EARC H RESULTS 3.1 Re sults of age, wei ght, height and type of surgery, consumption

of drugs and fluids, n umbe r of patients re quiring lidocaine in both groups Because in group II, one patient did not collect enough

research data, we excluded it from the study group in the first place So

group 1 has 50 patients and group 2 has 49 patients

3.1.1 Age, weight, height

Table 3.1 Age, weight, height

3.1.3 Types of surgery: Stat istics show that the surgery is

subcutaneous mesenteric surgery, lateral peritoneal

3.1.4 Time of surgery

Table 3.5 Surgical tim e (m inutes)

Value (minute ) Group I (50) Group II (49) p

3.2.1 Sensory suppression results