MINISTRY OF EDUCATION AND TRAINING MINISTRY OF DEFENSE
108 INSTITUTE OF CLINICAL MEDICAL AND PHARMACEUTICAL SCIENCES
NGUYEN THI LE MY
RES EARCH ON EFFICIENCY OF PAIN RELIEF OF PATIENT CONTROLLED EPIDURAL ANALGES IA WITH ROPIVACAIN OR BUPIVACAIN COMB INED FENTANYL AFTER HIP REPLACEMENT SURGERY IN THE ELDERLY
Spe cialty: Anesthesia and Critical Care
Code : 62.72.01.22
PhD. THESIS ABSTRACT
HANO I - 2021
TH E TH ESIS WAS DO NE IN: 108 INSTITUTE O F C LINICAL MEDICAL AND PHARMACEUTICAL SCIENC ES
Scientific Supervisors:
Prof. PhD. Cong Qu yet Thang
Re viewe r 1: ………………………………………………………….
Re viewe r 2: ………………………………………………………….
Re viewe r 3: ………………………………………………………….
The thesis is presented at the Council of 108 Institute of Clinical Medical and Pharmaceutical Sciences at: …. h …. Date …../…../…...
The thesis can be founde d at:
1. Vietnam National Library
2. Library of 108 Institute of Clinical Medical and
Pharmaceutical Sciences.
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INTRODUCTION
Hip replacement is a common surgery for the elderly to treat
conditions such as degenerative hip joints, hip fracture, and
intermittent fracture… T his is a major surgery that invades both the
bone and the t issue. Therefore, after hip surgery, patients often suffer
from severe and prolonged pain, while patients need to exercise early
to enhance recovery and prevent high-risk complications such as
embolism due to venous t hrombosis in deep circuit ...
There are many methods of pain relief after hip surgery that have
been studied and applied clinically such as epidural anesthesia,
neural body anesthesia, surgical site anesthesia, pain relief due to
patient self-controlled intravenous route ...
Epidural anesthesia
is an effective method of pain relief especially in major surgeries with severe and prolonged pain such as
thoracotomy, abdominal surgery, spinal surgery, and surgery big joints such as hip joints, knee joints ... Easy method of prolonging
pain relief time by placing catheter in the epidural space for continuous anesthetic infusion or intermitt ent injection. However,
epidural anesthesia also causes undesirable effect s such as hypotension, motor inhibition ... T he cause of the above problems is
due t o excess anesthetic used t o relieve pain. This leads to a blockage on motor and sympathetic nerves, thereby causing undesirable
effects.
PCEA: patient contronlled epidural analgesia (P CEA: patient
contronlled epidural analgesia) is an epidural analgesia in which the
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patient self-controls the amount of anesthetic introduced into the epidural space. This method helps to reduce the dose of drugs used,
thereby reducing the blocking area of the anesthetic, reducing undesirable effects.
Ropivapcaine is an anesthetic that belongs to the amino amid group. It has a good effect with less cardiotoxicity than bupivacaine. In
addition, the drug has a more inhibitory effect on sensation than a motor inhibitory effect. The drug is widely use d in clinical practice in
many different anesthetic methods such as spinal anesthesia, epidural anesthesia, plexus anesthesia and continuous infusion of anesthetic at
the incision.
Worldwide, there have been studies using ropivacaine in pain
relief by patients self-control epidural. However, in Vietnam, research on patient controlled epidural analgesia using ropivacaine
after hip replacement surgery in the elderly is few. T herefore, we conducted the above study with the following goals:
1. Compare the analgesic and motor block effects of ropivacaine 0.1% - fentanyl 1 mcg/ml with bupivacaine 0.1% - fentanyl 1
mcg/ml in the patient controlled epidural analgesia after hip replacement surgery in the elderly.
2. Evaluate the effects on circulation, respiration and the
undesirable effects of the two above pain relief methods.
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Chapte r 1 O VERVIEW
1.1 The elderly and problems relate d to anesthesia - surgery 1.2 Hip re placement surgery 1. 3 PCEA pain relief method 1.3.1 Epidural anesthesia
1.3.1.1 Anatomy of the epidural space 1.3.1.2 The effect of age on the distribution in the epidural space
1.3.1.3 The effect of epidural anesthesia 1.3.2 Self-controlled epidural pain relief
1.3.3 Principle of operation
Figure 1.1: Changes in drug concentration in blood Jeffrey A. Grass, Anesth Analg. Vol 101, pg. S44 – S61.
1.3.4 PCEA specifications 1.3.5 Unwanted effects
1.3.6 Some PCEA devices
1.4 Ropivacaine anesthetics
1.5 Some studies on PCEA 1.5.1 In Vietnam
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In 2017, the author Pham Xuan Hung performed the evaluation of the effectiveness of epidural analgesia for patients after hip surgery
of the levobupivacaine mixture with fentanyl. The author divided into 3 groups, each group has 45 patients.
Group 1: Levobupivacaine0,125% + 2μg/ml fentanyl 4ml/hour. Group 2: Levobupivacaine0.0625% + 1μg/ml fentanyl 8ml/hour.
Group 3: Levobupivacaine0.05% + 0.8μg/ml fentanyl 10ml/hour. The results showed that the group using levobupivacaine at
0.125% concentration had better analgesic effect, the number of pain rescues was less and patient satisfaction was higher than that of the
other t wo groups. However, the levobupivacaine group 0.125% also had a higher rate of motor inhibition of 22.2% compared with 8.9%
in the levobupivacaine group of 0.0625%.
In 2016, the author Tran Dac T iep studied the analgesic effect of
the epidural analgesic method of self-controlled patient using ropivacaine for patients after hip replacement surgery. In t he study,
the author compared t he effects of patient self-administered epidural anesthesia between the ropivacaine group and the ropivacaine group
combined with fentanyl. The parameters set on the PCEA are:
Required dose: 3 ml
T ime Locked: 10 minutes Maintenance dose: 3 ml/hour
Maximum total dose in 4 hours: 40 ml. The results of the method have good analgesic effect with lower
VAS score in the study 4. 1.5.2 In the world
The authors Francois J. Singelyn and Jean-Marie A. Gouverneur conducted a study on the comparison of pain relief effects after total
hip replacement surgery between three methods of pain relief. Pain
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relief by intravenous morphine P CA, P CEA and 3-in-1 anesthesia. In the study, the authors used 0.125% bupivacaine in combination with
sulfet anin 1mcg/ml. Maintenance dose is used 5-7 ml/h and automatic bolus dose of 2.5 ml every 30 minutes. Efficacy was assessed for 48
hours after surgery. All three methods of pain relief are equally effective.
Author Jan Maca (2020) and colleagues conducted a study with the goal of comparing the pain relief effects of PCEA with the relief
of common CEA pain after full hip replacement surgery. A total of 119 patients were enrolled in the study. After hip replacement
surgery the patient was admitted to the intensive care unit and randomized t o one of two groups (P CEA 61 patients and non-PCEA
58 patients).
The P CEA group was treated using a setting program with bolus
dose of 4 ml/time, lock-in time of 20 minutes, continuous background dose of 3 ml/h, total dose limit of 40 ml/4 hours . The
non-PCEA group received a continuous infusion of 5 ml/h and 8 ml bolus if the pain score was elevated. Total analgesic consumption,
intensity of pain, and pain relief-related
patient satisfaction, complications were recorded within 24 hours of surgery.
The results of the PCEA group with significantly lower total consumption of the pain relief mixture was 0.9 ± 0.3ml/kg/24h
compared with 1.3 ± 0.4 ml/kg/24h in the non-PCEA group with p < 0.001. There was higher patient satisfaction (p <0.001) in the P CEA
group. Average pain intensity over 24 hours post-surgery was similar for both groups (P = 0.14). There was no significant difference in the
rates of pain relief-related complications between groups.
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Chapte r 2
SUBJECTS AND METHO DS O F RESEARC H
2.1 Re search obje ct
The patients were assigned to surgery for hip joint surgery at Department B1C and Department of Resuscitation Anesthesia, 108 Military Central Hospital. 2.1.1 Criteria for selecting patients to study
Age ≥ 60. ASA I-III. Patients can work together for PCEA pain relief. There is no contraindicat ion to epidural anesthesia. Volunteer to participate in research
2.1.2 Exclusion standards
Patients with anesthesia and surgical complications during the
study period. 2.1.3 Criteria taken out of the study
The patient must have surgery again during the pain relief period. The patient must have prolonged mechanical ventilation after
surgery.
The patient was unable to insert the epidural catheter.
2.2 Re search Me thodology 2.2.1 Research design
Clinical, randomized, comparative clinical intervention study.
2.2.2 Research time and place
* Research time From October 2015 to October 2019 * Research location Department of Anesthesia and Resuscitation at 108 Military
Central Hospital
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Department B1C, Hospital Trauma Orthopedics – 108 Military
Central Hospital. 2.2.3 Sample size
From the above results, we chose to study a group of 52 patients. Patients were randomized to one of two groups.
Group B: Group B: PCEA analgesic group with Bupivacaine 0.1% combined with fentanyl 1mcg/ml.
Group R: Group R: group of pain relief P CEA by Ropivacaine
0.1% combined with fentanyl 1mcg/ml.
How t o group randomly Creat e 104 lottery tickets that are put into sealed envelope. Of which, 52 cards were writ ten "B", respectively, were the group using 0.01% bupivacaine in combination with fentanyl 1mcg/ml for pain relief and 52 cards with the letter "R" respectively were the group using ropivacaine 0.01%. with fentanyl 1 mcg/ml for pain relief. When the patient is selected for the study, the ballot will be drawn by himself, depending on t he lottery, the patient will receive the corresponding pain relief. 2.2.4 Conduct research 2.2.4.1 Research facilities 2.2.4.2 Drugs used in research 2.2.4.3 Patient examination before surgery 2.2.4.4 Conduct anesthesia * Epidural anesthesia Patient Placing: You can set the patient's five-leaned position or
sitting position. + Put the patient's posture lying on its side perpendicular to the
operating table, with the back of the shrimp.
+ Put the patient's posture to sit on the operating table, straighten the back, head slightly bowed, the legs drop down.
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Physicians wash sterile hands, wear sterile gloves, surgical gown, and a sterile mask. Disinfect t he back area to anesthetize with two times of iodine alcohol and one time of 70o white alcohol
Spread surgical chrysotile with sterile holes. - Poking position: can poke inter-joint slots L 1-2 to L 4-5. - T he landmark for determining the needle puncture position: The straight line connecting the lateral crest goes right above the L4- 5 vertebra .
- Anesthetize in place with lidocaine 1% solution. - Use NMC T uohy needle to poke in the direction of the needle up t o the head, bring the needle about 2-2.5 cm deep, stop to pull out the barrel. Use the resistance test to determine the position of the needle inlet to the NMC cavity. Using the pressure test pump, both insert the T uohy needle deep into the organization while keeping the pressure in the pump when the T uohy needle enters the epidural cavity will lose the pressure pump resistance.
- Insert t he catheter into t he epidural space on t he tip and let the length of the catheter in the epidural space correspond to the catheter tip level at position L1 or D12 .
- Fix the catheter with tape or opsite. - T est lidocaine 2% 2 ml (with adrenalin 1/200,000 via catheter to distinguish the catheter into t he epidural or subarachnoid cavity or blood vessel). Follow up the patient within 5 minutes if the heart rate> 20% can be catheter into the blood vessel, if the lower extremities can be injected into the subarachnoid space. Suspect ed patients were excluded from the study. - The retention time of catheter is 72 hours from the time of
epidural pain relief.
* Conducting spinal anesthesia for surgery
2.2.4.5 Conduct postoperative pain relief and postoperative follow- up
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Pain-relieving conditions: After the patient finishes the surgery and is t ransferred t o the recovery room, the patient is monitored and evaluated according to the criteria. When meeting the standards, it will reduce pain after surgery.
- Patient awake. - Pulse, blood pressure, SpO2 is stable. - Patient self-assesses pain level by pulling a corresponding pain
gauge.
+ If VAS <4, then follow up and reassess every 15 minutes. + If VAS> 4, the initial dose should be injected to relieve pain
after surgery, this is the time of H0 in the study.
* Initial dose Injecting drugs via epidural cat heters for both study groups,
calculate the injection volume as follows [57] :
Inje ction volume (ml) = Height (cm) - 100 10
After the initial dose is injected into the epidural space, the level of sensory suppression on the skin is checked by skin cold t est or skin prick method. Since then, the number of stools that inhibits the feeling of medulla of the anesthetic drug after injection into the epidural space has been determined .
* How to prepare the drug solution infused into the epidural
space:
Bupivacaine group: Take 03 vials of 0.5% 20ml bupivacaine with 03 ampoules of 0.1mg/2ml fentanyl mixed with 0.9% sodium chloride with volume 234ml. The mixture received consisted of 300 ml of which bupivacaine concentration 0.1% and fentanyl 1 mcg/ml. Ropivacaine group: T ake 7.5 vials of ropivacaine 0.2% 20ml together with 03 ampoules of 0.1mg/2ml fentanyl mixed with 0.9% sodium chloride with a volume of 144ml. The resulting mixture has a
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volume of 300ml in which the concentration of ropivacaine 0.1% and fentanyl 1mcg/ml.
PCEA Pain Relief Settings: Patients who started on self-administered pain relief after initial dose administration had a VAS score of <4.
- Use of drug mixtures for each study group as follows: + Group B: use a mixture of Bupivacaine 0.1% + fentanyl 1
mcg/ml.
+ Group R: use a mixture of Ropivacaine 0.1% + fentanyl 1 mcg/ml.
- Set machine parameters: Required dose: 3 ml. + Lock time: 15 minutes to suck. Maintenance dose: 3 ml/hour. + Total dose limited to 4 hours: 40 ml. During the study, if, after two consecutive presses of the required dose, the response has a VAS score> 4, the doctor injects an additional "pain relief" dose of 5 ml of pain reliever mixture corresponding to each study group. The machine parameters are kept the same. Patients were followed for evaluation every 15 minutes for the first 1 hour. If VAS score <4, continue with the study. If 15 minutes after the “rescue” dose, the patient still has pain, it is considered a failure of epidural pain relief and switch t o intravenous morphine PCA. - Withdrawing cat heter after 72 hours from epidural pain relief.
2.2.4 Monitoring times 2.2.5 Main evaluation criteria
* Goal 1 - Comparison of resting VAS pain scores at study t imes. - VAS pain points when in motion at the time of the study. - Poke position, block level of pain sensation.
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- T ime of onset of analgesic effect. - Blocking level after bolus dose, after 24 hours, after 48 hours,
after 72 hours.
- The need for PCEA pain relief and the need to take t he "pain relief" dose:
+ Number of requests (D = Demand and request success (A = Act ual, request success rate A/D (%)).
+ Number of injections of "rescue pain" doses + The volume of the initial dose anesthetic mixture. + Comparing the amount of bupivacaine and ropivacaine for pain relief in day 1, day 2, day 3 and total dose in three days of pain relief. - The time from t he onset of pain relief t o t he t ime t he patient
presses the first required dose.
* Goal 2 - Effects on circulation: changes in heart rate, blood pressure at
the time of the study.
- Effects on respiration: changes in breathing frequency, SpO 2 at research times.
- Effects on postoperative movement according to the Bromage score at 1 hour after bolus dose.
- Patient satisfaction when performing pain relief - Other Sedation. Vomiting undesirable
and effects: nausea. Urinary retention. Itching. Complications related to epidural anesthesia techniques
* Other evaluation criteria - Anthropometric characteristics of the patient: height (cm), weight (kg), age (years), sex.
Preoperative status: ASA, associated chronic pathology. Features anesthesia and surgery: + T ime of surgery: From t he start of skin incision t o the end of
skin closure.
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+ T he amount of drugs used in spinal anesthesia: bupivacaine (mg), fen tanyl (mcg).
Assessment of blood test status: Red blood cell count (T /L),
hemoglobin (g/L) and red blood cell volume (L/L). + Characteristics of surgery location, type of surgery,
preoperative diagnosis. 2.2.6 Some standards and definitions used in the study 2.2.7 Handling some unwanted effects 2.2.8 Data processing 2.2.9 Ethical issues in research
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2.2.10 Research Diagram
Select patients to study
104 patients
Conduct anesthesia, surgery
Bupivacain Group (52 patients): Pain reduction by bupivacain 0.1% combine fentanyl 1 µg/ml Ropivacain Group (52 patients): Pain reduction by ropivacain 0.1% combine fentanyl 1 µg/ml
PC EA installation
Bolus 3 ml/time Lock 15 minutes Limit: 40 ml/4h Base dose: 3 ml/h
Pain assessment based on VAS scale Record research indicators in data collection form
Stop pain reduction Withdrawal of the epidural catheter
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Chapte r 3
RES EARC H RESULTS
3.1 Characteristics of research patients
The mean age in our study was 71.6 ± 8.9, with the lowest age in the study being 60 and the highest at 98. The mean age difference between the two groups, but no difference statistical significance with p > 0.05.
The average height of the t wo groups in the study was different but the difference was not statistically significant with p> 0.05. In which the lowest height is 140 cm and the highest is 180 cm.
The average weight in the study was 54.4 ± 8.8kg, with the lowest being 36kg and the highest being 81kg. The difference in weight of the two groups in the study was not statistically significant with p > 0.05. 3.1.8 Surgical proce dures
Figure 3.2: Distribution of surgery type of two groups
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3.2 Effective postope rative pain relie f 3.2.1 VAS score at rest time at study times
Chart 3.3: VAS score change at break of two groups
Before the initiation of pain relief, the bupivacaine group had a mean VAS score of 5.3 ± 0.9, higher than that of the ropivacaine group of 5.1 ± 0.65 . In which the lowest is 4 points and the highest is 7 points. After the initiation of pain relief for 15 minutes, t he VAS score
of the bupivacaine group was 1.54 ± 0.8 lower t han the ropivacaine
group of 1.73 ± 0.84.
3.2.2 VAS score when moving at the research time
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Chart 3.4: VAS scores of two groups when moving
Prior to analgesia, the VAS score at motion of the two groups was high with the mean VAS score of bupivacaine was 6.25 ± 0.68 and that of the ropivacaine group was 6.15 ± 0.6. T he lowest is 5 points and the highest is 8 points.
At t ime H 0.25 , pain levels of the t wo groups decreased low with the mean of the bupivacaine group of 2.6 ± 0.66 and that of the ropivaca in group was 2.75 ± 0.84. 3.2.4 Characteristics related to the dose of anesthetic used First dose volumes of the two groups
p Group R (n = 52)
> 0.05 Min-Max 4 - 8
< 0.05 Min-Max Table 3.12: Characte ristics of the first dose of the two groups Group B (n = 52) 5.92 ± 0.71 5.9 ± 0, 92 4.8 - 7.5 10.8 ± 1.9 13.0 ± 1.6 10 - 16 7.1 ± 1.65 8 - 16 8.6 ± 1.5
< 0.05 Min-Max 5 - 13 4 - 13 Group Characte ristics First dose volume (ml) First dose onset time (minutes) T ime of patient pressing first required dose (hours)
Comm ent:
The first dose volume of the lowest two groups was 4 ml and the highest was 8 ml, the difference was not statistically significant with p> 0.05.
The onset time of bupivacaine group was 10.8 ± 1.9 minutes, which was short er than that of the ropivacaine group which was 13.0 ± 1.6. T he difference of the t wo groups was statistically significant with p < 0.05.
The t ime from the onset of pain relief to the t ime when patients pressed the first required dose of the bupivacaine group was 8.6 ± 1.5
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hours, which was 7.1 ± 1.65 hours longer than the ropivacaine group. The difference is statistically significant with p <0.05. 3.2.5 A/D ratio of two groups * A/D ratio of two groups
Figure 3.6: A/D ratios of the two groups during the study pe riod Review: Rate A/D of bupivacaine group ropivacaine group is higher than in the first day, the second and third. The difference was not statistically significant with p> 0.05. 3.4.7 Unexpected effects in research
Group R (n = 52) Group B (n = 52) Table 3.26: Une xpe cte d e ffe cts of two groups Total Group (n = 104) p n (%) n (%) n (%)
3 (5.7) 1 (1.9) 10 (19.2) 2 (3.8) 2 (3.8) 1 (1.9) 7 (13.4) 3 (5.7) 5 (4.8) 2 (1.9) 17 (16.3) 5 (4.8) >0.05
1 (1.9) 1 (1.9) 2 (1.9) Characte ristics Nausea Vomit Hypotension It ching Urinary retention 17 (32.7) 14 (26.9) 31 (29.8) Total
Review: Effects unexpected encounter the most in research Our research is at the rate of hypotension General met in the study was 16.3%. In particular, the bupivacaine group had a decrease in blood
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pressure of 19.2%, much higher than that of the ropivacaine group 13.4% (p> 0.05).
Chapte r 4 DISCUSSIO N
4.1 Gene ral Features 4.2 Effective postope rative pain relief 4.2.1 VAS-based assessment * VAS scores at resting time
From table 3.8, the resting VAS scores of the two groups at H0 were both 4 points higher with the mean of the two groups respectively 5.3 ± 0.9 in bupivacaine group and 5.17 ± 0.65 in ropivacaine group. After analgesia, the VAS score at rest of the t wo groups decreased significantly compared to the t ime of H0 , at t ime H0.25, the mean VAS score of bupivacaine group was 1.54 ± 0.8 and ropivacaine group was 1.73 ± 0.84. T hus, it can be seen that the VAS score of bupivacaine group decreased more than the ropivacaine group. The decrease of VAS score at rest of the two groups at H0.25 compared to H0 was statistically significant with p <0.05.
In the study by Do Trung Dung [5], the VAS score at rest of the epidural group at the time before pain relief was 4.02 ± 0.15, t his VAS score dropped to 0.53 ± 07.6 at the time of VAS1N. T his reduction is statistically significant with p <0.05. From chart 3.3 shows, the decrease from the time H0 to H0.25 of the bupivacaine group more than the ropivacaine group. At t he rest of t he study, the VAS score of the bupivacaine group was always lower than the ropivacaine group. After H0.25 time, VAS points at the time of the study of both research groups decreased gradually over time, but the reduction was not statistically significant compared to the time H0.25. In the study of author PA Kostamovaara [75] , PCEA group was inst alled with maintenance dose of 3 ml/h, bolus dose of 3 ml/time with lock time of 15 minutes. In the study of the author also showed that t he group using ropivacaine had a mean VAS score less t han 4. Also in the study of comparing pain relief PCEA compared with
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continuous infusion into the epidural space after hip replacement surgery of author Jan Maca [86], analysis in the first 24 hours of VAS score change showed that the VAS score level of the P CEA group was lo wer than that of the continuous infusion group. In which, at the 6th, 10th and 23rd hours, the difference of VAS scores between the two groups is statistically significant
In the author's study Shruti Shrikant Patil [134], the author using 0.125% ropivacaine with 0.125% bupivacaine in postoperative pain relief showed that the pain relief by epidural continuous infusion in both groups reached the level good with an average of <3 points. During the study period, the ropivacaine group had lower mean VAS scores than the bupivacaine group.
* VAS score when moving From Table 3.9, t he VAS score of movement of the t wo groups before starting to reduce pain decreased from 6.25 ± 0.68 to 2.6 ± 0.66 in the bupivacaine group and from 6.15 ± 0.6 down t o 2.75 ± 0.84 in t he ropivacaine group. There was no difference between the two study groups in terms of VAS scores before and after the init iation of pain relief. Also from chart 3.4, at the t ime of the study it can be seen that the average VAS score at the movement of the two groups were 4 points lower. T he mean VAS score decreased gradually over the study time of the two groups, this mean VAS score shows the analgesic effect of both groups as well.
In the study of Do Trung Dung [5] , in the epidural group, the VAS score at the movement time decreased from the background level of 4.44 ± 1.2 to 1.4 ± 1.3. The level of VAS score at the beginning of the author's study is lower than our study, the decrease in VAS score during the movement is also less but the average VAS score at 1 hour is lower than t he study. ours. However, the author's VAS score from 1 hour increased gradually and reached a maximum of 6 hours with an average of 2.78 ± 1.26 with the highest of 6 points. T he author Kethy M. Jules-Elysee [66] and partners compared the pain relief effect of PCEA with PAI showed that, the
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NRS score at movement from 6.1 ± 2.8 to 1.5 ± 1.3 . Then the NRS score increased on day 2 with an average of 2.4 ± 2.4 and decreased to day 3 with an average of 2.3 ± 0.8. Thus, the results of our study are similar t o those of the authors with the pain score when moving <4 points. This pain point level allows the patient to get active early. 4.2.2 Amount of epidural drugs 4.2.3 Anesthetic characteristics
* Waiting time for e ffe ct From table 3.12, t he waiting time for effects of the ropivacaine group was 13.0 ± 1.6 minutes, which was 10.8 ± 1.9 minutes longer than the bupivacaine group. The difference is statistically significant with p <0.05.
The waiting time for effects in our study is longer than that of author Tran Dac Tiep [26] , in the author's study, the waiting time for effects of the RF group is 9.0 ± 2.0 minutes. This difference may be due to the higher fentanyl concentration used by the author in our study. In the study of Mahendra Singh [110] , the onset time of 20 ml of ropivacaine 0.75% epidural was 15.43 ± 2.70 minutes, when combined with clonidine 75µg/ml, t he onset time was shorter than 10 , 55 ± 1.85. In the study, the author also evaluated the level of motor inhibition showing that the motor time of ropivacaine alone was 172.46 ± 6.32 minutes, shorter than that of ropivacaine combined with clonidine was 253.43. ± 8.32 minutes. * Time from start to first bolus dose From Table 3.12, the time for patients to press the first bolus dose in the bupivacaine group was 8.6 ± 1.5 hours, with the shortest t ime being 5 hours and the longest time being 13 hours. T his time interval of the ropivacaine group was 7.1 ± 1.65 hours, which was short er than that of bupivacaine group, this difference was statistically significant with p <0.05.
anesthetics the of
In the study of Stefania Leone [78] when comparing the pharmacokinetics bupivacaine, three levobupivacaine and ropivacaine, the T1/2 time of bupivacaine was
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the longest 210 minutes, levobupivacaine was 157 minutes and that of ropivacaine. is 111 minutes. 4.2.4 PCEA Setup Indicators
* Numbe r of clicks re queste d and response times From the results of table 3.17 and chart 3.10, our research results show that t he A/D ratios of the two groups in the study are above 90%. In particular, bupivacaine group A/D ratio higher than ropivacaine group. Although the difference was not statistically significant, it was found that bupivacaine's effectiveness level was higher than that of ropivacaine.
Research by author T ran Dac T iep [26], the number of clicks required by patients in the RF group is 4.4 ± 1 with the number of times at least 3 t imes and at most 6 t imes. Group R had more than 5.8 ± 0.8 required clicks during the first 24 hours. From 24-48 hours, the number of clicks requested increased in both groups in the study, in which group R had required clicks of 8.9 ± 1.2 and the RF group required wa s 6.0 ± 1.5. The author's required number of clicks is lower than in our study, however, in the study of author T ran Dac T iep, in addition to the first bolus dose, the author also used the epidural titration dose with the volume 2 ml/time, also in our study did not use the epidural titration dose. 4.3 Effects on movement, circulation and respiration 4.3.1 Influence on movement
From the results of table 3.19 and chart 3.8 shows that, bupivacaine group has higher level of motor inhibition according to bromage than ropivacaine group, the difference is statistically significant with p <0.05.
According to the author Do Trung Dung, the level of motor inhibition of the epidural group is high with 73.3% of patients having only slight leg contraction after removing body weight. Evaluation in Yuhong's study. Li showed that, age is one of the factors related to the level of blockade of motor when using epidural ropivacaine. In the study, the level of motor blockade in the age group ≥70 achieved
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at ropivacaine concentration is 0.383% compared with the group <70 to achieve with ropivacaine concentration of 0.536%, significant difference with p < 0.01. 4.3.2 Effects on circulation 4.3.3 Effects on respiration 4.4 Unwanted Effects
From table 3.26, the most common side effects in our study are hypotension, vomiting, nausea, prurit us, urinary retention. The difference of side effects between t he t wo groups in the study was not statistically significant with p> 0.05.
In the study of Do Trung Dung [5] , the epidural group experienced abdominal distension symptoms at the rate of 17.8%, tremor 15.6%, vomiting 13.3%, itching 17.8% and soreness. the first is 2.2%.
In Jan Maca's [86] study , hypotension and pruritus were t he t wo most observed adverse effects. The author did not find any unwanted effects such as slow rhythm, vomiting, nausea .
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CONCLUSIO N
Through a study comparing the efficacy of a mixture of ropivacaine 0.1% - fentanyl 1 mcg/ml with a mixture of bupivacaine 0.1% - fentanyl 1 mcg/ml in PCEA pain relief in 104 patients after hip surgery in the patient From October 2015 t o October 2019, at Military Central Institute 108, we draw t he following conclusion: 1. Effective pain relief
PCEA method has good analgesic effect after hip replacement surgery in the elderly. The mean VAS scores at exercise and at rest for both groups in the study were lower than 4. The total amount of anesthetic used for 72 hours was bupivacaine
280.0 ± 10.0 mg and ropivacaine was 282.9 ± 7.6 mg.
The A/D ratio of the bupivacaine group was higher than t hat of the ropivacaine group (98.7% vs 98.1% at day 1, 97% vs 95.8% at day 2 and 96.4% vs 95 , 7% at 3 days). 2. Effects on movement, circulation, respiration
The bupivacaine group had a wait time of 10.8 ± 1.9 minutes, which was short er than that of the ropivacaine group of 13.0 ± 1.6 minutes (p <0.05).
T ime t o press the first bolus dose of bupivacaine group of 8.6 ± 1.5 hours was longer t han t hat of ropivacaine group was 7.1 ± 1.65 hours (p <0.05). inhibition The bupivacaine group had an M 2 motor
level of 13.5%, higher than that of the ropivacaine group with no M 2 level motor inhibition (p <0.05). 3. Side effects
Side effect s encountered in the study of the two groups were equivalent with p> 0.05. Common side effects were hypotension 16.3%, nausea 4.8%, pruritus 4.8%, vomiting 1.9%.
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RECO MMENDA TIO NS 1. Application of PCEA pain relief method with ropivacaine 0.1% - fentanyl 1 mcg/ml in postoperative pain relief for hip replacement at facilities and facilities.
replacement pain the elderly in
2 . Conduct research with different P CEA settings for postoperative hip to make relief recommendations about the setting that has the best pain relief and least unwanted effects.
LIST O F RES EARC H WORKS
PUBLISHED R ELATED TO THE TH ESIS
1. Nguyen Thi Le My, Cong Quyet T hang (2020), Evaluation of
pain relief after hip replacement surgery in the elderly by the method of epidural anesthesia controlled by the patient. Journal
of Vietnamese Medicine, No. 1 & 2/2020, espisode 492, 97-101. 2. Nguyen T hi Le My, Cong Quyet T hang (2020), Comparing the
effectiveness of epidural anesthesia with Ropivacaine 0.1% with the Bupivacaine 0.1% after hip replacement surgery in
elderly. Journal of Vietnamese Medicine , No. 1 & 2/2020, espisode 492, 68-72.
3. Nguyen Thi Le My, Cong Quyet Thang (2020), Comparison of motor, sensory and circulatory effects of ropivacaine 0.1% and
bupivacaine 0.1% in postoperative epidural pain relief hip joints in the elderly, Journal of Clinical Medicine and Pharmacy 108 ,
espisode 13 - No. 7/2020, 57-63.
