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

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

THE SCIENTIFIC AND MEDICAL STUDY INSTITUTION 108

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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:

1 Vice Professor.Dr Cong Quyet Thang

2 Vice Professor.Dr Le Thi Viet Hoa

The project can be mentioned at:

1 The national Library of Vietnam

2 The library of THE SCIENTIFIC AND MEDICAL STUDY INSTITUTION 108

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:

1 Evaluating the changing of numbers in pressure of the blood artery and mechanical lungs when applying the method of mobilizing alveolus combined with PEEP +5cmH 2 O in abdominal anesthesia surgery of elderly people

2 Comparing the changing of the numbers in pressure of the blood artery and mechanical lungs between the 2 groups with and without mobilizing alveolus combined with PEEP +5cmH 2 O in abdominal anesthesia surgery of elderly people

3 Investigating some unexpected uses in the circulation and respiration of the method of mobilizing alveolus combining with PEEP +5cmH 2 O in anesthesia surgery in the abdominal of elderly people

Chapter 1 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 surgery

anesthesia-There are a lot of different points of view in explaining the mechanism of the collapsing lungs in anesthesia-surgery but there are 3 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 4 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 3 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 2 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 do 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

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:

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)

- Central Vein Pressure (CVP): cmH2O

Subclinical: Measuring the ventilatory lúng, X-ray the core lungs straight, blood formula: red blood cells, white blood cells, platelets , Hemoglobin

* Characteristics of Anesthesia and Surgery

- Surgical Organs

- Anesthesia time (minute)

- Surgery time (minute)

- Medicine using during anesthesia

- Changing the concentration of the least anesthesia gas in alveolus (MAC)

- Changing the concentration of exhaling CO2 (EtCO2)

2.2.7 The moment of collecting data

2.2.8 Some standards and definitions

2.2.9 Handling data

2.2.10 Morality in the study

2.2.11 The study charts

Chapter 3 THE RESULT OF THE STUDY 3.1 General characteristics

3.1.1 General characteristics of the patients

3.1.2 Clinical-subclinical characteristics before surgery

3.2 Ventilating characteristic and mechanical lungs in mobilizing alveolus

3.2.2 Changing the volume of exhaling breathing air before and after mobilizing alveolus

Chart ̀ 3.3: Changing of Tvexp after times of mobilizing alveolus Comments: With 6 times of mobilizing alveolus, the average value of

exhaling volume (TVexp) after mobilizing alveolus is higher than that before mobilizing alveolus With the 5 previous times, the difference

has its meaningful statistic p < 0.01

3.2.6 Changing of stretching lungs after mobilizing alveolus

Chart 3.4: Changing of stretching lungs after mobilizing alveolus

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