B GIO DC V O TO

TRNG I HC BCH KHOA H NI

---------------------------------------
NGUYN TH THU H

Nguyn Th Thu H
K THUT Y SINH

NGHIN CU TN HIU IN NO

LUN VN THC S KHOA HC

K THUT Y SINH
KHO 2009

H Ni 3/2012
 B GIO DC V O TO
TRNG I HC BCH KHOA H NI
---------------------------------------

Nguyn Th Thu H

NGHIN CU TN HIU IN NO

Chuyn ngnh : K thut y sinh

LUN VN THC S KHOA HC

( K thut y sinh)

NGI HNG DN KHOA HC

PGS. Nguyn c Thun

H Ni Nm 2012
 LI CAM OAN

Ti xin cam oan lun vn thc s khoa hc NGHIN CU TN HIU IN

NO l cng trnh nghin cu ca c nhn ti. Cc s liu trong lun vn l s liu
trung thc.

H Ni ngy 26 thng 03 nm 2012

NGUYN TH THU H
Hc vin cao hc kha 2009
Chuyn ngnh K thut y sinh
Trng i hc Bch khoa H Ni

2
 MC LC

................................................................................................................ Trang
TRANG BA PH1
LI CAM OAN.2
MC LC ..................................................................................................... 3
DANH MC CC K HIU, CH VIT TT ........................................... 5
DANH MC CC BNG ............................................................................. 6
DANH MC HNH V, TH .................................................................. 6
M U ....................................................................................................... 8
CHNG 1 : C S L THUYT V IN NO .................................... 9
1.1. Lch s. ................................................................................................ 9
1.2. C s sinh l thn kinh ca in no. ................................................. 10
1.2.1. Ngun in c bn. ..................................................................... 10
1.2.2. Dn truyn cc xung in............................................................. 11
1.2.3. Hot ha cc sng in no.......................................................... 12
1.3. K thut ghi in no . ........................................................................ 12
1.3.1. My ghi in no ......................................................................... 13
1.3.2. in cc ...................................................................................... 13
1.3.3. V tr cc in cc ngoi da u. ............................................... 13
1.3.4. Quy trnh ghi in no thng quy............................................... 19
1.3.5. Cc nghim php hot ha. (Activation Procedures) .................... 20
1.3.6. nh gi bn ghi in no............................................................ 23
1.4. Cc dng sng in no...................................................................... 23
1.4.1. Xc nh sng da vo tn s....................................................... 23
1.4.2. Xc nh sng da vo hnh dng. ............................................... 27
1.4.3. Cc dng sng phc hp. ............................................................. 27
1.4.4. Nhiu. .......................................................................................... 30
1.4.5. Cc bin th bnh thng. ............................................................ 32
1.5. Khc bit theo vng trn bn ghi in no.......................................... 34
1.6. Li ch ca in no ................................................................... 35
1.7. Ch nh ca in no ................................................................ 36
CHNG 2: IN NO V NG KINH ........................................ 38
2.1. Khi nim v ng kinh ..................................................................... 38
2.2. Gi tr thc t ca in no trong lnh vc ng kinh. ................... 38
2.3. in no bnh nhn ng kinh ................................................... 39
2.3.1. in no trong cn ng kinh ................................................. 39
2.3.2. in no ngoi cn ng kinh................................................. 43
2.3.3. in no v trng thi ng kinh............................................. 50
2.3.5. Tm li ........................................................................................ 51

3
CHNG 3 : SNG IN NO V GY M ......................................... 52
3.1. Gii thiu ...................................................................................... 52
3.2. Tn hiu in no trong gy m v hi sc tch cc....................... 53
3.2.1. Phn loi EEG ........................................................................ 53
3.2.2. Sng in no trong gy m ................................................... 53
3.3. Propofol v tn hiu in no ....................................................... 57
3.3.1. Tc dng chng co git ca propofol v tn hiu EEG ........ 57
3.3.2. Mi quan h gia liu lng propofol v tn hiu in no thu
c ...................................................................................................... 58
3.4. Php o entropy nh gi trng thi hot ng ca no b khi gy
m. 61
3.4.1. Nguyn l ..................................................................................... 61
3.4.2. Entropy ph tn hiu...................................................................... 63
3.4.3. Entropy ph cn bng thi gian tn s........................................ 67
3.4.4. Entropy trng thi v Entropy p ng.......................................... 68
3.4.5. Entropy trong qu trnh kh kch pht........................................... 71
3.5. ng dng trong thc t ................................................................. 72
3.6. Khi m tnh mch bng k thut TCI-propofol kt hp theo di
m bng entropy ....................................................................................... 75
3.6.1. t vn ............................................................................... 75
3.6.2. i tng v phng php nghin cu ................................... 76
3.6.3. Kt qu nghin cu ................................................................. 76
3.6.4. Phn tch ................................................................................. 77
3.6.5. Kt lun .................................................................................. 78
3.7. Li ch ca php o Entropy trong gy m.................................... 78
KT LUN.................................................................................................. 79
TI LIU THAM KHO ............................................................................ 81

4
DANH MC CC K HIU, CH VIT TT

Cc ch vit tt
BS Thnh phn kch pht - c ch
BSR T l kch pht - c ch
ECG in tm
EEG in no
EMG in c
Nleo B pht nng lng khng tuyn tnh
NLEO B pht nng lng khng tuyn tnh tng
OAAS Thang im nh gi su an thn
RE Entropy p ng
SE Entropy trng thi

Cc k hiu
Thnh phn Sng alpha trong tn hiu in no
Thnh phn Sng beta trong tn hiu in no
Thnh phn Sng delta trong tn hiu in no
Thnh phn Sng gamma trong tn hiu in no
Xc sut ca hai im gn hn khong cch r trong khng
gian pham chiu
C(r) Hm tng quan
f Tn s
fhigh Tn s cao nht ca ph
flow Tn s thp nht ca ph
h Chc nng o
P Ph cng sut
S Entropy ph
SE Entropy trng thi
RE Entropy p ng

5
DANH MC CC BNG

Bng 3.1. nh ngha cc sng EEG theo tn s ......Error! Bookmark not defined.
Bng 3.2 - nh hng ca gy m bng sevoflurane (qua cch ht vo) v propofol
(tim tnh mch) ti c tnh sng in no. ............Error! Bookmark not defined.
Bng 3.2. Thang im nh gi su an thn ( OASS)........ Error! Bookmark not
defined.
Bng 3.3.Ch s Entropy thu c theo thang im OAAS: .. Error! Bookmark not
defined.

DANH MC HNH V, TH

Hnh 1. 1. Cu to ca mt nron thn kinh........................................................... 10

Hnh 1. 2. C s hnh thnh in th mng t bo.................................................. 11
Hnh 1. 3. H thng t in cc ghi 10-20............................................................ 14
Hnh 1. 4. Cch t in cc theo kiu 21 knh ..................................................... 18
Hnh 1. 5 Cch t in cc theo kiu 36 knh ...................................................... 18
Hnh 1.6. Cch t in cc theo kiu 74 knh ...................................................... 19
Hnh 1. 7. Cc dng sng chnh ............................................................................. 25
Hnh 1. 8. Dng sng Alpha .................................................................................. 25
Hnh 1. 9. Dng sng Beta..................................................................................... 26
Hnh 1. 10. Dng sng Theta ................................................................................. 26
Hnh 1. 11. Dng sng Delta.................................................................................. 27
Hnh 1. 12. Dng gai v sng................................................................................. 28
Hnh 1. 13. Dng a gai v sng ............................................................................ 28
Hnh 1. 14. Dng PLEDS ...................................................................................... 29
Hnh 1.16. Dng bng n v c ch ....................................................................... 30
Hnh 1. 17. Nhiu do m hi ................................................................................. 30
Hnh 1. 18. Nhiu do in tm v do mch ....................................................... 31
Hnh 1. 19. Dng nhiu kiu POP .......................................................................... 31
Hnh 1. 20. Nhiu do dng c truyn v nhiu 60Hz.............................................. 31
Hnh 1. 21. Sng Lambda v Posts ........................................................................ 32
Hnh 1. 22. Phc b K ........................................................................................... 32
Hnh 1. 23. Sng V................................................................................................ 33
Hnh 1. 24. Hot ng in MU............................................................................. 33
Hnh 1. 25. Psychomotor Variant........................................................................... 34
Hnh 1. 26.Nhp 14Hz v 6Hz ............................................................................... 34
Hnh 2.1. S minh ha cc hot ng ghi c ngoi t bo, trong t bo v
in th khu vc ca mt lt ct hi hi m ngi b ng kinh............................. 38
Hnh 2.1. Bn ghi in no ca bnh nhi 12 tui, c tin s ghp thn lc 4 tui... 40
Hnh 2.2. Cn ng kinh cc b thy thi dng................................................... 42
Hnh 2.3. in no ngoi cn ................................................................................ 44

6
Hnh 2.4. in no ngoi cn ................................................................................ 46
Hnh 2.5. Nhn sng 2 -2,5 Hz khi kch thch nh sng ngt qung ....................... 47
Hnh 3.1 V d v thnh phn kch pht - c ch................................................. 55
Hnh 3.2 Tn hiu EEG minh ha cho tc dng chng co git ca propofol..57
Hnh 3.3 Minh ha mi quan h liu lng propofol v in no .............60
Hnh 3.4. Khi o Entropy ca hng Datex Ohmea ............................................... 62
Hnh 3.5. V tr t in cc o entropy................................................................. 62
Hnh 3.6. Sng sin hon ho ch gm 1 thnh phn khc khng, c chun ha ti
1 theo cc bc chun ha..................................................................................... 65
Hnh 3.7. Mt lng nhiu trng c a ln u sng sin .................................. 66
Hnh 3.8. Sng sin bin mt v ch c nhiu trng bn phi ................................ 67
Hnh 3.9. Cc ca s thi gian............................................................................... 70
Hnh 3.10. Ph cng sut in hnh ca mt tn hiu sinh th ................................ 70
Hnh 3.11. Thng s RE v SE hin th trn mn hnh theo di ............................. 71
Hnh 3.12. Tn hiu EEG cha cc thnh phn kch pht - c ch.......................... 72
Hnh 3.13. Hm spine............................................................................................ 74
Hnh 3.14. Tng quan Entropy vi Ce ................................................................. 77
Hnh 3.15. Tng quan Entropy vi OAA/S.......................................................... 77

7
 M U
Cho n nay, in no vn lun gi mt v tr khng th thiu trong thc
hnh thn kinh c th tham gia vo chn on, tin lng, iu tr nhng bnh
nhn b tn thng hoc c nghi ng tn thng no b. Nn php o tn hiu in
no l mt php o c bn v quan trng ca s sng trong lnh vc y hc. iu
c th hin trong hai ng dng c bn c quan tm hin nay l tn hiu in
no trong chn on bnh ng kinh v trong nh gi trng thi hot ng ca no
b khi gy m. Cc vn ny c nghin cu v s dng nh phng php
thng mi trong nhiu thp k qua. Tuy nhin cc nh khoa hc vn khng ngng
pht trin nhng nghin cu ny c c nhng thnh tu tt hn.

Ni dung lun vn thc hin gm 3 chng:

Chng 1: C s l thuyt v in no

Chng 2: in no v ng kinh

Chng 3: Sng in no v gy m

Lun vn c thc hin nhm mc ch cung cp mt s nhng hiu bit c

bn v in no ng dng trong lm sng thn kinh v tnh u n/phc tp ca
tn hiu in no trong cc trng hp bnh ng kinh. ng thi lun vn cng
cp n phng php nh gi hot ng no b trong gy m ph bin hin nay
c thc hin bng php o EntropyTM. Thng s ny gip cc bc s nh gi
ng tnh trng bnh nhn v s dng liu gy m chnh xc, an ton cho bnh
nhn. Hin ti phng php ny c trin khai ti mt s bnh vin nh: bnh
vin Vit c, bnh vin Bch Mai, bnh vin 103, bnh vin Xy Dng, v.v
Cc lun im v s liu chng minh c thc hin trong qu trnh tc gi lm
vic v nghin cu ti mt s bnh vin trn, ng thi tham kho cc nghin cu
ca cc tc gi khc.

8
CHNG 1 : C S L THUYT V IN NO

1.1. Lch s.

T u th k 18, nhiu tc gi nghin cu thc nghim chu u ghi c

hot ng in no ca ng vt. Sau , Hans Berger ghi in no ngi thnh
cng vo ngy 6-7-1924 bn cu tri ca bnh nhn nam 17 tui bng in cc
trc tip qua l khoan s. T 1924-1938 vi 14 cng trnh c gi tr ca H.Berger
c cng b bao gm in no sinh l v bnh l ngi. in no m ra
k nguyn mi trong nghin cu lm sng , cc nc c , Nga, M v Php...
My in no EEG ln u tin c gii thiu vi th gii bi Hans Berger vo
nm 1929. Berger, mt chuyn gia v tm thn hc thn kinh trng i hc Jena
ca c s dng thut ng ting c Elektrenkephalogramm m t dng biu
din th ca cc dng in do no sinh ra. ng xut quan im rng cc dng
in no thay i da trn cc trng thi hot ng ca no nh ng, hn m, v
ng kinh. l tng rt cch mng gip hnh thnh nn mt nhnh mi trong
nghin cu y hc l bnh hc thn kinh.
Gibbs ( 1933) xut in no lm sng l mt ngnh ring, lin quan cht
ch vi lm sng, m u bng nhng nghin cu bnh nhn ng kinh nm 1934
M.
Cng vi s pht trin v k thut hin i, k thut ghi in no lun c ci
tin , t my c 4 ng ghi tng ln 8,10,12,14,16,18,20...64 ng ghi vi cc
chng trnh khc nhau. Ghi bng bt nhit, bt mc... n ghi vi tnh, video hoc
ghi in no c vi tnh v camera, d liu c lu tr trong my tnh.
Vit Nam, in no c ng dng trong lm sng cc trung tm y t,
cc bnh vin, vin ca tnh thnh trong c nc, gp phn quan trng cho chn
on v theo di iu tr bnh nhn.

9
 1.2. C s sinh l thn kinh ca in no.

1.2.1. Ngun in c bn.

Nh mi t bo khc, t bo no cng sinh nhng thay i dng in i vi

nhng yu t ha hc, l hc v cc yu t khc km theo. D l loi t bo no
khc nhau v hnh dng, kch thc... nhng chc nng ca chng thng nht v
ging nhau v hot ng in sinh hc. C th ni mt cch i cng l mi t bo
thn kinh gm c hai cc :
- Cc vo hay cc tip thu l ui gai ( dendrite).
- Cc ra hay cc pht dn truyn l si trc (axon ).

Hnh 1. 1. Cu to ca mt nron thn kinh

Nhng nghin cu gn y chng minh y tnh cht bn thm chn lc
ca mng t bo hnh sao c tc dng duy tr, iu chnh th cn bng ca cc
ion trong v ngoi mng t bo.

10
 Hnh 1. 2. C s hnh thnh in th mng t bo
- trong t bo ch yu l K+ ( khong 150mEq ).
- ngoi mng t bo ch yu l Na+ (150mEq ) v Cl- (125mEq).
in th mng t bo lc ngh ngi bn ngoi dng so vi bn trong khong
+70mV gi l trng thi cc ha. Bt k mt yu t no c kh nng lm gim
in th mng khong 10mV, th ngay ti K+ t trong ra ngoi v ngc li.
Na+ t ngoi vo trong t bo gy hin tng kh cc. Hin tng kh cc ny
t lan ta khp mng t bo v dn truyn xung in qua si trc n cc t bo
k cn. Nu in th yu th hin tng lan ta mng t bo hoc qua si trc
ngng v t bo li tr v trng thi cc ha.

1.2.2. Dn truyn cc xung in.

+ Cu to ca h thn kinh trung ng gm 2 thnh phn c bn: cc nron v

cc t bo thn kinh m
+ Cu to ca mt nron bao gm mt thn t bo, mt si trc v nhiu ui
gai. Cc thnh phn ny ca cc nron tip xc vi nhau thng qua cc sinap.
+ Cc t bo thn kinh m nm xen k vo mng li cc nron v tip xc
khng ch vi cc nron m cn tip xc vi c h thng mch mu trong cc t
chc thn kinh
+ Khi c mt xung ng thn kinh i n v t ti ngng , xung ng ny s
khi pht mt in th hot ng ca mng nron. tp trung ca cc ion K+ ti
khong gian bo trong qu trnh kh cc nron tng ln s to ra mt in th hot
ng ca mng t bo thn kinh m nm xung quanh nron ny. in th hot
ng c to ra t bo thn kinh m c vai tr lm lan to cc in th hot
ng ca nron ra mt vng nht nh , ngi ta gi y l in th khu vc.
Khng phi bt k xung in no cng c truyn i, m cn ph thuc vo
mc xung in c th lm thay i c cc thnh phn ha hc to ra hin
tng kh cc cc khp thn kinh.

11
 S dn truyn xung in ch yu cc khp thn kinh.
- Mng tn cng ca si trc l mng trc khp (presynapse ).
- Mng ui gai hay thn t bo th hai l mng sau khp ( postsynapse).
Mt xung in ti kch thch trc khp gii phng cc cht trung gian tc
ng ln mng sau khp to hin tng kh cc ti v dng in xut hin dn
truyn qua khp v t bo tip theo b kh cc. Nu dng in yu khng truyn
qua khp c th nhanh chng tr li cc ha.

1.2.3. Hot ha cc sng in no.

Vic xut hin mt nhm nhng xung ng b trong h thng cc si hng

tm dn n hot ho cc cu trc mt ngoi ca v no v to nn cc sng in
no c bin cao, rt d phn bit gia sng ny vi sng kia. Nu cc tn s ca
cc phng lc hng tm xy ra thnh tng nhp th cc in th hot ng khu vc
s biu hin bng nhng dao ng hnh sin. Khi tn s ca cc dao ng hng tm
nhanh, ng b v ko di th cc in th khu vc ghi c bng bt ghi in no
thng thng s biu hin bng nhng sng bin v tn s cao.
+ Bin : l biu hin mc m mt xung ng in c to ra.
+ Tn s l s ln mt sng c lp li trong mt khong thi gian nht nh
(thng l giy).
+ Pha : khi mt dng in i vo c nhiu in t s to ra mt sng hng ln
pha trn gi l pha m ngc li ti u ca khuch i c t in t, bt ghi s v
mt sng hng xung pha di gi l pha dng
Bin v tn s cng nh thi khong ca cc dao ng in th khu vc di
dng sng in no thng khc nhau v ph thuc vo cc lp t bo m ngi ta
thm d.

1.3. K thut ghi in no .

Ghi in no l phng php ghi hot ng in hc ca no bng cc in

cc t b mt ca da u mt cch chun mc .Cc in cc ny c ni vi

12
nhau theo tng chuyn o n gin hoc phc tp. Sau y l cc nguyn tc c
bn ca ghi in no :

1.3.1. My ghi in no

Cc my ghi in no c sn xut da trn nguyn tc phi hp ca nhiu

chuyn o. Mi chuyn o c to nn bi:
+ Mt khuch i bin cho php khuch i mt cch trung thc cc in th
mc tng microvolt.
+ Mt b phn ghi c hc hoc s ho cho php tip nhn nhng tn hiu v th
hin chng trn giy hoc trn mn hnh vi tnh. Tc chy ca giy t 15mm/s
cho n 30mm/s tu theo tng tc gi.
Tu theo s lng ca cc thng tin cn phn tch m cc bn ghi c th t t
8,12, 16 n 20 chuyn o. Hin nay cc my ghi in no s ho dn dn thay
th h thng ghi trn giy. Cc tn hiu c ghi bng chuyn o n cc sau
c s ho v d tr trong cc b nh c dung lng cao ca cc my tnh

1.3.2. in cc

C nhiu loi in cc c sn xut thch nghi vi tng yu cu c th.

ghi in no trong 1 thi gian ngn, ngi ta thit k cc in cc bng bc
gn trong mt khung cht do. Mt u ca in cc c tm nc mui sinh l
(in cc ca Gray Walter). Cc in cc ny c c nh trn da u bng mt
m li bng cc si cao su. ghi in no trong mt thi gian di v ghi
c trc tip cc cn ng kinh, cc in cc thng c sn xut di dng
nhng cc nh bng bc c th dn trc tip ln da u nh h dn in.
Gn y , mt h thng in cc mi ra i , l cc in cc c gn kt v
ni vi nhau di dng chic m chp rt thun tin, c th gip ghi tr nh v
nhng bnh nhn giy gia

1.3.3. V tr cc in cc ngoi da u.

13
 H thng 10-20% ca Jasper, t 1981 c quc t cng nhn v thng dng
nht. l h thng gm cc in cc c t theo mt t l nht nh trn ton b
vng da u. Bng phng php ny ngi ta c th xc nh c nhiu nhm
chuyn o khc nhau : nh u ,thi dng, chm ngi ln, in no tiu
chun cho php ghi c ng thi 16 chuyn o. Trong trng hp cp cu hi
sc hay tr nh, s lng cc chuyn o ny c th gim xung 12,10,8.
Cc in cc cn t tht i xng, ging ht nhau 2 bn. u bnh nhn phi
sch v ti tt c cc v tr s t in cc phi bi cht dn in ( h dn in, nc
mui sinh l) lm gim ti da in tr da u ( theo quy nh chun l < 5k .
Sau y l trnh t cc bc xc nh v tr t in cc.

Hnh 1. 3. H thng t in cc ghi 10-20

H thng t in cc ghi 10-20 quc t (international 10-20 system) ghi in
no. C 3 ng ni chnh: d1- n 2 ng tai ngoi (thc ra l ngay trc tai -
preauricular points), d2- ni gc mi vi chm ngoi, c 2 ng ni ny u i
qua nh s, v d3- ng chu vi ca s kt ni 2 im tn cng nht trn s. Ba
ng ny c chia theo t l 10-20-20-20-20-10%, theo c trc trc giao (2
ng vung gc), ln theo vng trn chu vi, theo kiu chia i cc im ni. Khi
nghin cu gic ng, c th ngi ta khng dng ht cc v tr ghi ny, v ch t
in cc mt s v tr: trn hnh v l nhng ch c vng trn en.

14
 Thng thng chng ta s dng mt b 21 in cc gn trn da u theo h thng
t in cc 10-20 ca quc t (the 10-20 International System).
Ta ly cc im mc sau y:
- im gc mi (nasion), nm gia 2 chn lng my (glabella).
- im chm (inion).
- ng tai ngoi 2 bn.
Vi cc k hiu sau y:
- F l trn (Frontal).
- O l chm (Occipital).
- C l trung tm (Central).
- P l nh (Parietal).
nh s l nu l bn tri, v s chn nu l bn phi.
Ni 2 im gc mi v chm vi nhau, ta c ng dc gia. Ta chia chiu di
ca ng ny theo t l %: im cch gc mi 10% l F0 (hay Fpz), cch tip theo
20% na l Fz, tip 20% na l Cz. Cz chnh l im chnh gia nh u, tip sau
n 20% l Pz. Cch im chm 10% (tc cch Pz 20%) l O0 (hay cn gi Oz).
Ni 2 ng tai ngoi vi nhau, ta c mt ng ct ngang ng dc gia
im Cz. Cc ng tai ngoi 10% bn tri l T3, bn phi l T4. Cch thm 20%
(chnh gia T3 hay T4 vi Cz) l C3 (bn tri) v C4 (bn phi).
V ng ng tm vi ng chu vi ca u, ni cc im mc pha ngoi nht:
Fpz-T3-Oz-T4. Trn ng (gn nh l ng trn) ny, cng chia theo t l % nh
vy. Cch 10% pha trc c Fp1 bn tri v Fp2 bn phi, sau 20% l F7 v F8.
Cch Oz 10% t pha sau l O1 bn tri v O2 bn phi. Cch tip 20% (l chnh
gia O1 vi T3) l T5 bn tri v (l chnh gia O2 vi T4) T6 bn phi.
V tip ng vng cung pha trong, tip ni Fp1-C3-O1 bn tri, v Fp2-C4-O2
bn phi. khong cch 20% (chnh gia cc mc) l F3 pha trc bn tri, F4 pha
trc bn phi, P3 pha sau bn tri, P4 pha sau bn phi.
Vy ta c 1 mng ghi in no . V phng din in hc, ngi ta coi tai v
gc mi l 0, l in cc trung ha. Nh vy kiu kt ni 1 in cc trn mng ghi

15
in no vi tai, ta c kiu ghi n cc. Cn cch ni 2 in cc trn mng vi
nhau m khng ni vi tai, th gi l cch ghi lng cc.
V tr Oz v Fpz t c dng t in cc ghi trong in no , nhng li
hay c dng khi ghi in th gi (v d in th gi thnh gic thn no BAEPs
Brainstem Auditory Evoked Potentials ). Theo s in cc nh trn, ta c 19 v
tr t in cc ghi in no . Vi nhng cch ni in cc khc nhau, ta s c
nhiu knh ghi. My in no cn c ti thiu 24 knh. Ti mt s phng ghi
in no trn th gii, ngi ta cn chia tch ra t m hn t c nhiu in
cc ghi EEG hn, c th c s v tr t in cc ghi trn da u l 32, 64, thm ch
256).
in cc i chiu: Cng nh in tim v in c, ghi c 1 ng ghi trn
mn hnh, in cc ghi cn c 1 cp gm in cc hot ng v in cc i chiu.
in cc hot ng (active electrode) l in cc t trn da u theo cc v tr nh
m t trn mng ghi EEG. Nh vy c nhiu in cc hot ng. Cn in cc
i chiu (reference electrode) thng ch c 1, v c dng chung cho tt c cc
in cc hot ng, mi mt in cc hot ng (active) s c i chiu v mt
in tch so vi in cc i chiu. Thng thng n c t mt ni coi nh
khng c hot ng in, thng l di tai bn tri hoc bn phi. Tuy nhin c
th c chnh lch v in gia 2 bn cu khi t in cc i chiu 1 bn nh vy,
v bn ghi in no c th mt cn xng 2 bn. V vy ngi ta c th kt ni tt
c cc in cc hot ng li vi nhau, kt ni y to nn mt in cc trung bnh
ha ca tt c hot ng in ca cc in cc, v coi l in cc i chiu.
Cch ny gip trnh hin tng mt cn i gia 2 bn trn bn ghi EEG, nhng li
khng phn nh ng bin in th thc s. Nh nu trn, cch ghi n cc
l ni mi mt in cc hot ng trn mng vi in cc i chiu, cn cch ghi
lng cc l ni 2 in cc hot ng vi nhau.
B xung mi:
H thng t in cc 10-20 quc t, c ngh vo nm 1958, hin c dng
rng ri, v c coi l phng php chun (standard method) ghi in no trn

16
da u (scalp EEG). Gn y Hi in no Hoa K (The American EEG Society)
tn thnh mt bin i nh trong danh php theo s v ch ci nguyn thy. Trong
, trc y l T3, T4, T5 and T6 th nay chuyn thnh T7, T8, P7 v P8. Ci tin
ny nhm lm tng phm vi t in cc chun ha vo trong vng di thi
dng - subtemporal region (v d: F9, T9, P9, F10, T10, P10) v ch r tn ca v
tr in cc nm ng vng trung gian, gia cc ng vng chun (v d: AF7,
AF3, FT9, FT7, FC5, FC3, FC1, TP9, TP7, CP5, CP3, CP1, PO7, PO3 v v.v.).
Nhng in cc t thm v gn st nhau hn, cch t thm in cc chnh gia
cc in cc tiu chun ca h thng t in cc 10-20, tt c nhng cch t thm
in cc nh vy thng s gip cho nh khu cc bt thng tt hn (v d nh
khu pht sng dng ng kinh - epileptiform discharges bnh nhn b ng kinh
cc b - partial seizures). Cng c mt vi kiu in cc c ch ghi hot ng
in thy thi dng. Cc in cc xng bm (sphenoidal electrodes) cng c
bit hu ch pht hin cc phng in bt thng thi dng gia nn no
(mediobasal temporal discharges), chng c gm vo pha di khuyt xng
hm di (mandibular notch) khong 2.5 ti 3 cm pha trc ca g bnh tai
(tragus), v hng theo hng ln trn v ra sau v pha l bu dc (foramen ovale).
Cc in cc xng bm ny hin nay t ra u vit hn so vi cc in cc mi
hng (nasopharyngeal electrodes), v c th dng cch dn ng bng hunh
quang (fluoroscopic guidance) m bo l chng tin st. in cc g m
trc (anterior "cheek" electrodes) t trn xng hm trn v khong 2 cm trc
ch gm in cc xng bm, v in cc thi dng trc (anterior temporal
electrodes) t 1 cm pha trn ca im ni 1/3 ca khong cch t ng tai ngoi
(external auditory meatus) cho ti ui mt (external canthus) cng gip ch cho
vic tm kim cc phng in bt thng t thy thi dng v hiu qu c th so
snh c vi cc in cc xng bm.
Cch t in cc thng thng c th khng pht hin c sng dng ng
kinh khong 10% bnh nhn ng kinh thy trn, c th tng kh nng pht hin
trn nhng bnh nhn ny bng nhng in cc t khong cch gn st nhau

17
hn, kiu nh F1, C1, F2, C2 (t gia khong cch ca Fz/F3, Cz/C3, Fz/F4 v
Cz/C4), hoc in cc trn mt (supraorbital electrodes) 2.5 cm pha ngoi im
gc mi (inion) v trn g xng trn mt (supraorbital ridge).

Hnh 1. 4. Cch t in cc theo kiu 21 knh

Hnh 1. 5 Cch t in cc theo kiu 36 knh

18
 Hnh 1.6. Cch t in cc theo kiu 74 knh

1.3.4. Quy trnh ghi in no thng quy.

Trc khi ghi in no , cn thc hin vic o chun (calibration) m

bo l my s cho ng ghi chnh xc. Sng ghi chun cung cp cho ta gi tr
so snh bin cc sng in no. Ngi ta dng mt xung in hnh ch nht,
hnh tam gic, hay hnh sin, c bin bit trc, a vo u vo ca b phng i
ca my ghi in no . Nh vy tn hiu chun s i vo tt c cc ng ghi
EEG, to ra mt sng chun trn bn ghi. Cn c vo sng chun ny, ngi
ta nh gi cc sng in no v mt bin .

Hnh chun : nh nhn chng t

my nhy ghi c nhng
sng c tn s cao v bin nh; on
dc xung phi bng khong 2/3 tng
chiu cao

19
Trong qu trnh ghi in no, ngi bnh t th th gin, na nm na ngi hoc
nm. Bung ghi in no phi kn o, cch m, thong mt v c mn che nh
sng. Ngi bnh c yu cu thc hin nhiu ln m mt v nhm mt nh
gi p ng ca bn ghi. Tip theo lm nghim php th su trong 3 pht v cui
cng thc hin nghim php kch thch nh sng ngt qung ( mt ngun nh sang
ngt qung vi cc tn s khc nhau c chiu vo mt bnh nhn vi mc ch
hot ho cc hot ng kch pht tim n ). Ngoi ra, tu tng theo yu cu c th
c th tin hnh mt s nghim php hot ho khc. Thi gian ghi in no ko di
khong 20 pht.

1.3.5. Cc nghim php hot ha. (Activation Procedures)

Mc ch ca cc nghim php trong qu trnh ghi in no lm xut hin cc

sng bnh l hoc lm r hn, in hnh hn khi nghi ng m ghi iu kin khng
c hot ha hay cc kt qu cha p ng c yu cu chn on lm sng.
Cc nghim php hot ha gm:

1.3.5.1. Nghim php m v nhm mt: phn ng ngng alpha.

Berger thc hin t 1929: bnh nhn c ghi in no iu kin yn tnh,

nhm mt sng alpha xut hin in hnh vng chm hoc nh.
Bnh nhn m mt ko di 3-5 giy, ngay lc sng alpha mt i (ch cn sng
beta bin thp ) v xut hin tr li tc th khi nhm mt tr li vi sng alpha c
bin cao hn mt cht so vi trc m mt l phn ng ngng alpha (+) ngi
khe mnh bnh thng. Ngc li, phn ng (-) l bt thng khi sng alpha
khng thay i hoc thay i khc nhau v bin hay tn s mt bn hay khc
nhau hai bn bn cu. Cng c th gp sng bnh l mt vng hoc mt bn c
ngha bnh l r hn.
Mi chng trnh ch cn thc hin nghim php ny mt ln, khng m mt
qu lu, sng alpha xut hin tr li khng c ngha hoc nhc li nghim php
nhiu ln cng khng c gi tr. Cn ch bnh nhn m mt thc s ,hn ch

20
chp, rung mi mt hay nhn cu thay i. Tt nhin nghim php ny khng thc
hin c khi ghi bnh nhn ng, ri lon thc hoc khng hp tc.

1.3.5.2. Nghim php tng thng kh (hyperventilation HV) hoc th

nhanh su (hyperpnea).

C s ca nghim php l tng th dng mu qua no chm hn, c bit l o

thi CO2, pH trong mu kim ha kch thch t bo v no ng kinh v cc ri
lon khc xut hin r hn.
Tin hnh : Gibbs thc hin t 1934 , trong khi ghi in no bnh nhn th su v
nhanh hn bnh thng vi mc va phi, khong 20 ln trong mt pht, ko di 2-
4 pht v tip tc ghi 1-2 pht sau khi bnh nhn th trng thi bnh
thng.Cc dng sng bnh l xut hin thng pht th 2-3.
Kt qu tng 30-80% ty thuc loi bnh so vi kt qu ghi khng c hot ha
tng th. Mt s bnh nhn c th xut hin cn lm sng trong lc tng th, c
bit cn nh vng thc (absence petit mal) tr em. T phng php hot ha
ny tr thnh phng php thng quy trong EEG. Phng php ny c bit hu
ch tm kim cc phng in kiu ng kinh ton th ha (generalized
epileptiform discharges), nhng khong 10% bnh nhn b ng kinh cc b
(partial epilepsies) n cng c th hot ha c cc phng in dng ng kinh
cc b (focal epileptiform discharges). Kh nng d b kch thch ca cc neuron
trong khi tng thng kh c cho l do co tht mch no qua trung gian thn no
do tnh trng gim carbonic trong mu (hypocapnia) gy ra. ng lm nghim php
tng thng kh ny nhng bnh nhn c nguy c tn thng no do co tht mch
nh cao huyt p c tnh (malignant hypertension), chy mu di nhn
(subarachnoid hemorrhage), bnh hng cu hnh lim (sickle cell disease).

21
 1.3.5.3. Nghim php kch thch nh sng ngt qung (Intermitent photic
simulation IPS ).

Ch nh nghim php ny bnh nhn ng kinh ton th nguyn pht

(generalized epileptiform discharges) hoc ng kinh c lin quan n kch thch
nh sng (photic seizures) m ghi bnh thng khng c biu hin bnh l.
Ngun sng nhp nhy cch mt bnh nhn khong 20-30cm, cho nhp nhy vi
tn s tng dn tng nc, cho ti mc 30Hz, ko di 5-10 giy, ngh 5-10 giy sau
mi ln thay i tn s (iu khin bng tay hoc t ng ).
Ngi ta khuyn lm nghim php vi m mt, ri cho nhm mt li. Cho nhm
mt trong khi ang nhp nhy sng c bit hu ch lm tng phng in ng kinh,
v cn thc hin thng quy. Nhng phng in dng ng kinh (epileptiform
discharges - ED) m ko di lu hn kch thch nh sng (ngng nhp nhy, m vn
c cc ED) th s tc ng mnh m ti bnh ng kinh ton th ha (generalized
seizure disorder), trong khi nu nhng phng in gn lin vi chui kch
thch nh sng (ht nhp nhy th cng ht cc sng ngay) c th ch l nhng
biu hin ngu nhin tnh c ngi khng c bnh ng kinh, nht l trong trng
thi cai thuc (drug withdrawal) hoc bnh no do nhim c chuyn ha. Kch
thch nh sng c bit hu ch trong bnh ng kinh ton th ha nguyn pht
(primary generalized epilepsy) v cc sng dng ng kinh khi lm kch thch nh
sng c th c khong 40% bnh nhn. Ngi ta thy khong cho ti 1/3 bn
ghi in no c sng dng ng kinh lin quan vi kch thch nh sng th cng c
cc sng dng ng kinh t pht cc b hoc ton th ha ch khc trn bn ghi
EEG.

1.3.5.4. Nghim php thiu ng ( Sleep Deprivation).

Khi trn mt bnh nhn b ng kinh, nhng in no khng thy c sng

ng kinh, th bn ghi khi mt ng (sleep deprived recording) thng s c ch. Mt
s nghin cu chng minh rng kh nng tm c sng dng ng kinh s tng

22
ln khi dng nghim php ghi EEG lc thiu ng, cho c bnh ng kinh cc b ln
ton th ha, v mi la tui. Cc phng in dng ng kinh sau khi mt ng s
xut hin c phn EEG ghi lc tnh to, ln ghi lc ng. Rowan v cng s cn
thy EEG sau khi thiu ng th c nhiu kh nng c sng dng ng kinh hn l
EEG sau khi ung thuc an thn (sedation) vi cng mt di ghi.

1.3.6. nh gi bn ghi in no.

Bn ghi in no c ngha v gi tr cho chn on, theo di iu tr ca lm

sng, khi bn ghi c thc hin ng cc quy nh v k thut:
- V tr in cc da u ng h thng 10-20% hoc 10%.
- Hn ch hoc khng c nhiu trn bn ghi.
- Thi gian ghi in no t 15-30 pht cho mt ln ghi bnh nhn. C bit
c th lu hn.
- C cc phng php hot ha khc nhau.
- C cc chng trnh khc nhau: t nht 4 chng trnh gm :
+ Ghi n cc (unipolar): cc in cc ni vi in cc chung 2 tai (A1 v
A2) hoc tng tai mt bn.
+ Ghi lng cc ( Bipolar): cc in cc ni nhau theo cc chng trnh
khc nhau: dc hai bn cu, ngang hay vng trn hai bn cu ...

1.4. Cc dng sng in no.

1.4.1. Xc nh sng da vo tn s.

Tng qut: Nm 1924, nh tm thn hc ngi o tn l Hans Berger l ngi

u tin ghi c EEG. ng nhn thy trn bn ghi EEG bnh thng, nhp ca cc
sng in no gm c vi loi. Nhp sng d thy nht c Berger t tn cho l
nhp hay sng alpha (alpha wave, alpha rhythm). i khi ngi ta cng gi l nhp
Berger (Berger rhythm) nhm vinh danh ng. Cc sng ny thng c bin
khong 50 microvolts (mc d cng c th dao ng t 5 ti 100 microvolts) v

23
xut hin 8-13 ln trong 1 giy (8-13 Hertz). Sng ny thy r nht phn pha sau
ca no ngi, vn l ni x l cc tn hiu th gic, tc l vng chm (occipital
region). V vy, i khi ngi ta cn gi nhp alpha l nhp tri pha sau (the
posterior-dominant rhythm). Sng alpha tr nn r nht khi ta nhm mt li. N b
trit tiu khi ta m mt. Nh vy sng alpha l du hiu cho bit no ang tnh
trng khng ch (inattentive brain), v ang ch c kch thch. Thc t l c
mt vi tc gi gi n l nhp ch i ("waiting rhythm"). Ni mt cch hnh
nh, ta c th hnh dung n nh l mt ngi ang st rut ch i, vi biu hin
nhp 2 chn hay g ngn tay trn mt bn, ch i c vng ng dy lm mt
vic g . Khi m khng cn phi ch i na (bng cch m mt hay tnh nhm
trong u), th sng alpha cng bin mt.
cc phn vng trn ca no (frontal region), c mt sng nhanh hn, gi l
sng beta (beta wave). N xut hin 13-35 ln trong 1 giy, nhng c bin di
30 microvolts. Cn mt loi sng khc na, gi l sng theta (theta wave), th c tn
s 4-8 Hz, v thng thy khi ang trong tnh trng bun ng v trong cc giai on
ng nng (light stages of sleep). Dng sng th t l sng delta (delta wave) th
him khi ghi c trn ngi bnh thng ang thc tnh, nhng bnh thng vn
thy khi ng su (deep sleep) hoc vo lc tnh gic ca tr nh. Sng delta l sng
c bin cao nht trong tt c cc sng in no. Ni chung nu n xut hin trn
mt ngi ln (tr khi ang ng) th chng t no c vn no : v d u no,
ng kinh, tng p lc nt s, khim khuyt v tr tu, hay hn m. Khi xut
hin, th n c khuynh hng thay th cho nhp alpha. C sng beta ln sng delta
u khng b nh hng bi m mt hay nhm mt.
Chi tit: Tn s ca sng tc l s lng ca sng trong mt n v thi gian,
y l trong 1 giy. Tn s ca cc sng in no vo khong t 0,5/giy cho ti
vi trm/giy. Tuy nhin cc my ghi EEG thng ch ghi c cc sng c tn s
di 26/giy.

24
 Cc sng c phn bit bi tn s, v c chia thnh cc loi sau:
Alpha
Beta
Theta

Delta

Hnh 1. 7. Cc dng sng chnh

Alpha l nhng sng c tn s trong khong t 7,5 ti 13 sng/giy (Hz). Thng
thy r alpha nht l cc vng pha sau ca u, c 2 bn, nhng thng bn bn
cu u th th c bin (chiu cao) cao hn. Alpha thng r ln khi nhm mt v
th gin, v bin i khi m mt hoc thc tnh cnh gic bi bt c c ch no (suy
ngh, m). y l nhp sng ch yu thy c trn ngi ln bnh thng v th
gin sng hin din trong hu ht cc thi k ca cuc i, nht l khi trn 30
tui, khi y sng ny chim u th trn ng ghi EEG lc ngh ngi.

Hnh 1. 8. Dng sng Alpha

Beta l nhng sng nhanh. Tn s ca n l t 14 Hz tr ln. Sng beta thng
thy c 2 bn cu, phn b i xng hai bn, v r nht l vng trn. Sng s
ni bt ln khi dng thuc an thn gy ng, nht l khi dng benzodiazepines v
barbiturates. Sng c th mt hoc suy gim vng c tn thng v no. Nhp
beta thng c coi l nhp bnh thng. N l nhp chim u th nhng bnh
nhn ang thc tnh cnh gic hc lo s, hoc khi m mt.

25
 Hnh 1. 9. Dng sng Beta
Theta l nhng sng c tn s t 3,5 ti 7,5 Hz, v c xp vo loi sng
chm. N c coi l bt thng nu thy ngi ln ang tnh to, nhng li
coi l hon ton bnh thng tr di 13 tui v ang ng. Cng c th thy theta
to thnh 1 vng bt thng cc b trn nhng ni c tn thng di v cc b;
C th thy sng theta lan ta trong cc bnh l no lan ta hay bnh no do chuyn
ha, hoc bnh l ng gia nm su (deep midline disorders) hoc trong mt s
trng hp no nc (hydrocephalus).

Hnh 1. 10. Dng sng Theta

Delta l nhng sng c nhp t 3 Hz tr xung. N c xu hng l nhng sng c
bin cao nht v l nhng sng chm nht. N hon ton c coi l bnh thng
v l sng u th tr s sinh di 1 tui v giai on 3 hoc 4 (stages 3 and 4)
ca gic ng. N c th xut hin cc b khi c tn thng di v v phn b rng
khp khi c tn thng lan trn, trong bnh no do chuyn ha (metabolic
encephalopathy), bnh no nc (hydrocephalus) hay tn thng ng gia trong
su (deep midline lesions). N thng tri nht vng trn ngi ln (v d
FIRDA - Frontal Intermittent Rhythmic Delta sng delta c nhp cch hi vng
trn) v phn b tri cc vng pha sau trn tr em (v d OIRDA - Occipital
Intermittent Rhythmic Delta - sng delta c nhp cch hi vng chm).

26
 Hnh 1. 11. Dng sng Delta
1.4.2. Xc nh sng da vo hnh dng.
Mt s sng c hnh dng c trng, bt k l tn s ca chng l nh th no, v
do vy c th nhn bit c nh vo hnh dng ca chng. Ngoi ra, c th c 1
cp hoc 1 nhm cc sng c hnh dng c trng. Mt v d v nhng sng c hnh
dng c trng l cc gai (spikes) v cc sng nhn (sharp waves) cc sng ny c
ng dc ln gp ti nh ri dc xung tng i t ngt, nh vy nn (cnh
y) ca sng tng i nh so vi bin (chiu cao) ca sng. Mt s sng c
th nhn bit c nh vo hnh dng, bao gm 2 loi chnh sau y:
1. Nhng sng c hnh dng c bit
2. Nhng phc b sng c hnh dng c bit
Nhng sng c th nhn bit c nh vo hnh dng bao gm: cc gai (spikes)
hoc sng chm (slow waves). Cc gai l nhng sng c nn (cnh y) hp trong
khi c bin (amplitude - chiu cao) tng i cao, to cho sng c hnh dng cao
v hp vi 1 nh nhn. Sng nhn l sng c y hi rng hn mt cht so vi cc
gai, nhng ngha th cng ging ht n l ch im cho thy c hot ng in
gy cn kch pht (seizure activity) v n gi c phng in hay hot ng in
ng b a (multiple synchronous firing or activity) ca cc ui gai ca t bo
thn kinh (dendrites). Sng nhn c coi l biu hin ca mt phng in cch
v tr ghi mt khong no , cn gai c coi l do phng in nm rt gn vi v
tr ghi.
1.4.3. Cc dng sng phc hp.
- Gai v sng (spike and wave): Dng gai v sng thy c mi la tui, nhng
thng nht l tr em. N bao gm 1 gai (c th l ngun pht nm v no) v
mt sng chm (thng l delta) c bin cao, sng chm ny c coi l c

27
ngun pht cc cu trc ca i th, phc b ny lp i lp li. Chng c th xut
hin ng b (ng th synchronously) v cn i hai bn trong cc bnh ng
kinh ton th ha (generalized epilepsies) hoc khu tr trong bnh ng kinh cc
b. Trong nhng dng gai v sng ton th ha, cn vng thc s (true absense) hay
l cn nh (petit mal) c trng bng gai-sng 3 Hz, trong khi gai chm sng
(slow spike-wave) thng thy hn khi no b tn thng v trong hi chng
Lennox-Gastaut. Nhng gai v sng nhanh hn 3 Hz s c trnh by trong phn
v a gai v sng (polyspike-wave).

Hnh 1. 12. Dng gai v sng

- a gai v sng (polyspike and wave): l mt dng ca gai sng, trong mi

mt sng chm i km vi 2 hoc nhiu gai. Dng thng gp l dng gai v sng
c tn s nhanh hn 3 Hz thng l 3.5 ti 4.5 Hz. Dng ny thng i km vi
co git c (myoclonus) hoc cc cn kch pht git c (myoclonic seizures). ng
nhm ln n vi gai sng 6 Hz, vn c coi l gai sng khng thc (phantom spike
and wave) l mt bin th ca bnh thng.

Hnh 1. 13. Dng a gai v sng

- Cc phng in dng ng kinh lch bn theo chu k (PLEDS - Periodic
Lateralized Epileptiform Discharges): l mt dng phng in i km vi tn
thng hay chn thng no cp tnh. Ngi ta thy dng sng ny r nht khi tn
thng no cp tnh c kt hp thm vi ri lon chuyn ha. N khi u bng
nhng sng nhn xut hin mt cch u n, trn mt nn tng i bng phng,

28
1 vng hay 1 bn ca no. Sau nhp ca n chm dn li v xut hin cc sng
chm theo chu k, v hot ng in c s nm gia cc phng in dng ng
kinh ny cng kh dn ln. Cui cng cc sng dng ng kinh kiu ny cng bin
mt hon ton. Kiu PLEDS thng thy khi c triu chng nh khu nng, hoc l
trn mt bnh nng ang c xu hng kh dn ln.

Hnh 1. 14. Dng PLEDS

- Cc sng 3 pha (triphasic waves): Sng 3 pha l 3 sng to vin cho mu trng
trn hnh minh ha. Chng thng xut hin khi c cc hot ng in gi cn kch
pht (pseudoparoxysmal activity). Cc sng ny thy c trong bnh no do gan
(hepatic encephalopathy), nhng cng c th thy trong cc dng bnh no do
chuyn ha khc.

Hnh 1. 15. Dng sng 3 pha

- Bng n v c ch (burst supression): Bng n v c ch l mt dng bng n
cc sng chm v hn hp (mixed waves) thng vi bin cao, v xen k lun
phin bng ng ng in. Thng l c c hai bn, nhng khng phi lc no
cng cn i 2 bn. Loi sng ny thng thy sau mt tn thng no nng, nh
sau t qu thiu mu no (postischemia), hay sau trng thi thiu oxy (postanoxia).
Cng c th thy tm thi (thong qua) trong gy m su, trng thi trc khi
EEG tr nn ng in hon ton.

29
 Hnh 1.16. Dng bng n v c ch
1.4.4. Nhiu.
Nhiu l nhng sng hoc nhng nhm cc sng do li k thut hoc do cc li
khc gy ra, v khng phi do hot ng in ca no gy ra. Nhiu l cc ri lon
do khim khuyt k thut gy ra, thng l nhng li c tnh tm thi. Bao gm
do di ng cc in cc lm cho mt tip xc, cc hot ng in ca c che khut
in no , do c ng ca u, chy xc da u, ra m hi, v.v
Nu ta dng phng i ln, th tt c cc bin lon k trn u c phng i
ln, bao gm cc nhiu ca mch v in tm , ca in cc v cc c ng,
nhiu 60 Hz v nhiu do m hi, l loi nhiu biu hin c dung dch mui nm
gia cc in cc lm cho n b on mch.

Hnh 1. 17. Nhiu do m hi

- Nhiu do in tm v do mch (ECG and pulse artifacts): C 2 loi nhiu
ny u c th nhn bit c nh vo tnh cht c chu k ca chng. Nhiu in
tm cho thy r phc b QRS theo chu k, v in tm th c tn hiu in ln
hn nhiu so vi in no . Nhiu do mch l do mch p pha di ca in
cc lm cho n chuyn ng theo chu k. C 2 loi nhiu ny u d nhn din,
nhng cng c th gy kh khn cho c in no.

30
 Hnh 1. 18. Nhiu do in tm v do mch
- Nhiu do chuyn ng ca in cc v cc chuyn ng khc: nhiu do
chuyn ng ca bnh nhn th c ng biu th t ngt, v trong hu ht trng
hp n dc ngc t ngt. So vi cc sng EEG chun th cc nhiu c bin
cao v ko di v thi gian. Mt nhiu kiu POP l do chuyn dch in cc rt
ngn (nhanh), ngi mi vo ngh d nhm ln n vi mt gai (spike), tuy nhin
gai kiu ny ch thy 2 knh cnh nhau v khng thy knh th ba nh nhng
gai ng kinh.

Hnh 1. 19. Dng nhiu kiu POP

- Nhiu do dng c truyn tnh mch v nhiu 60 Hz: nhng nhiu ny thng
c thy trong khi ghi in no trong phng chm sc c bit (ICU) v c 2 u
l nhng giao thoa v in. Trn hnh v, nhiu do dng c truyn l nhiu c mu
; n c tnh cht chu k, c bin thp v d dng nhn bit. Nhiu su mi
Hz thy c nhng ni in cc tip xc km, ni t khng tt, v c mt thit b
in chuyn dng t gn . N gy nn nhng gai (spikes) c tn s 60 chu k
giy to thnh vt mc in trn giy chy vi tc thng thng.

Hnh 1. 20. Nhiu do dng c truyn v nhiu 60Hz

31
 1.4.5. Cc bin th bnh thng.

C mt s sng hoc hnh dng sng t khi thy xut hin, nhng chng khng c
ngha bt thng hay bnh l. Nhng chng c th lm cho ta din gii nhm ln v
bn ghi in no . Trong cc bin th bnh thng ny, thng gp nht l nhp
mu (mu rhythm), bin th tm thn vn ng (psychomotor variant), cc sng
lambda, POSTS, cc thoi (spindles), sng ca nh s (vertex waves) v phc b K
(K Complexes).
- Lambda v POSTS: Lambda v POSTS tng t nhau v hnh dng v c hnh
tam gic. Chng xut hin khu vc pha sau v cn xng hai bn. POSTS l biu
hin ca sng dng thong qua chm ca gic ng (positive occipital transients
of sleep) v xut hin trong gic ng giai on 2. Lambda xut hin bnh nhn
tnh to khi nhn trng trng vo mt b mt trng. C hai loi ny u l dng sng
bnh thng, v xut hin n c, hay ko di, hay thnh mt chui ngn.

Hnh 1. 21. Sng Lambda v Posts

- Phc b K: phc b K (K Complexes) xut hin khi ang ng m b nh thc
ta thy n khi c kch thch m thanh hay cc kch thch khc khi bnh nhn ang
ng. Tip sau phc b K thng c p ng thc tnh c th l mt chui cc
sng theta c bin cao. Tip sau phc b K, in no li cho thy biu hin
gic ng, hoc trng thi thc tnh.

Hnh 1. 22. Phc b K

32
 - Sng V (Vertex Waves): Sng V xut hin vng cnh dc gia (parasaggital
areas) ca 2 bn cu v c dng mt sng nhn (sharp waves) hoc thm ch l dng
gai (spikes), khu vc lng nh (biparietal regions), tc l nh u (vertex), vi
pha ngc o nhau ti ng gia, nhng o trnh bc ngang (tranverse
montages) hoc nh s trn cc o trnh trc - sau (front-to-back). Cc sng
ny thy c trong gic ng giai on 2 (stage 2 sleep), cng vi cc thoi (spindles),
phc b K, POSTS, v.v...

Hnh 1. 23. Sng V

- Hot ng in MU (MU activity): hot ng in MU l dng nhp trong
cc sng c hnh nhn ging nh hnh ro chn (wicket fence) vi nh nhn v
chn cong trn. Gia 2 knh, nhp MU c th c pha nghch o nhau. Tn s ni
chung vo khong mt na ca hot ng in nhanh hin c.

Hnh 1. 24. Hot ng in MU

- Bin th tm thn vn ng (Psychomotor Variant): l loi nhp him gp, n
xut hin ging nh l s ha nhp ca 2 hay nhiu nhp c bn vo vi nhau to
nn mt dng phc hp. Nh thy hnh di, n c bin cao hn so vi xung
quanh, v cc sng c hnh dng nh dy ni (nh cc kha to hnh ch V). Loi
nhp ny hon ton khng cn xng 2 bn v thng b nhm vi hot ng in
kch pht. Tuy nhin n l loi hot ng in lnh tnh.

33
 Hnh 1. 25. Psychomotor Variant
- Nhp 14 v 6 (Fourteen and Six Rhythm): Nhp 14 v 6 rt hay thy tr em v
thanh nin mi ln. Nh thy trn hnh, cc sng 6 Hz v 14 Hz i khi un ln
theo cng 1 hng (ln hoc xung), v i khi th li i theo hng ngc nhau.
Nhp kiu ny thy c in hnh trng thi ng hoc bun ng (ng g gt), v
thng thy c trn bn ghi n cc (monopolar recordings).

Hnh 1. 26.Nhp 14Hz v 6Hz

1.5. Khc bit theo vng trn bn ghi in no.
Khc bit theo vng (area diferentiation) l nhng phn b khc nhau ca cc loi
sng trn cc vng ghi ca in no . Sau y l phn b cc sng theo vng ghi
trn da u ngi bnh thng.
+ Vng trn trc (prefrontal in cc Fp1 v Fp2): hot ng bta thp v
khng u, cc nhm alpha thnh tng di, v cc sng delta b mt ri rc.
+ Vng trn ngoi (trn bn frontolateral in cc F7 v F8): hot ng bta
14-20 Hz thng xuyn, sng theta thp ri rc
+ Vng trn (frontal in cc F3 v F4): nhp bta 17-20 chu k giy, c cc
nhm sng MU
+ Vng thi dng sau (temporal posterior in cc T5 v T6): nhp alpha cch
hi, hot ng theta thp ri rc, hot ng bta khng u v hay b cc sng khc
chm hn nm chng ln.

34
+ Vng thi dng (temporal in cc T3 v T4): hot ng bta khng u v
cch hi, thng c cc hot ng in 14-16 Hz, cc sng theta ri rc, v cc sng
delta 2-4 Hz ri rc.
+ Vng thi dng (temporal in cc T3 v T4): hot ng bta khng u v
cch hi, thng c cc hot ng in 14-16 Hz, cc sng theta ri rc, v cc sng
delta 2-4 Hz ri r c
+ Vng trung tm (central in cc C3 v C4): nhp 20-25 Hz ko di, nhp MU.
+ Vng nh (parietal in cc P3 v P4): nhp alpha, i khi c bta 20-25 Hz
nm chng ln.
+ Vng chm (occipital cc in cc O1 v O2): nhp alpha 8-13 Hz.
Khi c mt bn in no, chng ta phi xem xt n s khc bit ca cc vng.
Chng ta quan tm n bin , tn s v tnh u n ca cc sng. Ni chung, cc
sng alpha xut hin u th vng pha sau (chm), cn sng bta u th vng
pha trc (trn) ca bn ghi in no .
So snh gia 2 bn cu:
+Tnh cn i gia 2 bn cu: cc sng tng i cn xng 2 bn, cc in cc i
din nhau qua ng gia th thng c cc sng ging nhau, vi bin gn bng
nhau. Chnh lch bin khng qu 50% gia 2 bn
+ Tnh ng b cnh ng gia: nhng ng ghi t cc in cc gn ng
gia th s ng b vi nhau gia 2 bn. V d dao ng ca ng ghi t F3 v F4,
P3 v P4 s cng i ln hay cng i xung ti cng 1 thi im.
+ Tnh khng ng b pha ngoi: nhng ng ghi EEG xut pht t cc in
cc t pha ngoi th dao ng ngc chiu nhau gia 2 bn. V d khi ng
ghi T3 i ln, th ng ghi T4 i xung, ngc chiu nhau.
1.6. Li ch ca in no
Phng php in no k : (EEG : Electroencephalgraphy) l phng php cn
lm sng c s dng trn nhiu quc gia trn th gii v nhng gi tr hu
dng trong cc trng hp sau :
Phn nh c chc nng sinh l bnh thng ca no.

35
 nh gi v tin lng s phc hi ca no trong cc trng hp : tai bin
mch mo no - sau chn thng s no.
c bit in no pht hin cc trng hp ng kinh, gip theo di v
nh gi kt qu iu tr ng kinh qua vic kim tra in no nh k.
Gip ch im pht hin mt s trng hp c khi chon ch ni s.
Mt s trng hp c ri lon tun hon no, thiu nng tun hon no.
Nhng du hiu lm sng cn c kim tra in no :
Nhng tnh trng ngt thong qua hoc xu c km theo mo ming, si nc
bt.
Nhng cn co git t c th xy ra t nhin hay trong gic ng.
Nhng trng hp au u ko di hoc mt ng hong s, lo lng v c.
Cc trng hp sau tai bin mch mu no, chn thng s no c ln cn
co git kiu ng kinh.
Cc trng hp ng kinh c bc s chuyn khoa thn kinh chn on
nguyn nhn cho kim tra in no nh k theo di qu trnh kt qu iu
tr.
1.7. Ch nh ca in no
in no (EEG) l mt cng c h tr cho lm sng. EEG c dng hu
ch nht trong nhng trng hp sau y:
- Ri lon thc: trng thi sng s (stuporous), bn hn m (semi-comatose)
hay hn m (comatose states).
- Cc bnh l c co git (seizure disorders), c bit l cc bin th co git
khng kinh in nhng bnh nhn c nhng triu chng nguy cp. in no
gip chn on c trng thi ng kinh b che khut (occult status
epilepticus) trn mt bnh nhn c ri lon thc. N gip chn on phn
bit mt cn nguyn lnh tnh vi cc cn nguyn nghim trng hn trn tr b
chng co git do st - infantile febrile convulsion (in no trong c bnh
thng th l cn nguyn lnh tnh; ngc li th in no c cc hot ng
in dng gai v sng chm bt thng).

36
- Nghi ng c khi u nu thy c mt khu tr sng chm.
- Trong chn thng s no, khi c cc sng chm hay tnh trng c ch in
th do dp no (contusion) hay do mu t di mng cng.
- au u, kiu nh cc hi chng au na u, khi c th c cc dng EEG
c tnh gi .
- (C) Chn on phn bit mt bnh l vim lan ta hay khu tr, kiu nh apxe
no.
- (C) nh gi kh nng di cn no.
- Bnh no do chuyn ha khi c cc sng chm 3 pha c trng.
- Chn on phn bit cc ri lon hnh vi do thc th hay do chc nng (tm
thn).

37
 CHNG 2: IN NO V NG KINH
2.1. Khi nim v ng kinh
ng kinh l mt bnh l biu hin bng s xut hin nhng cn ng kinh,
nhc i nhc li gn nh ko di trong sut c cuc sng ca ngi bnh.
Bn cht ca cc cn ng kinh l hin tng kh cc bt thng, kch pht
ca mt qun th nron (c th lm thay i in th ca mng nron t -85mV
thnh +30mV). Cc hot ng ny c th quan st thy bng cch ghi cc in th
trong t bo, ngoi t bo v da u (in no thng quy).

Hnh 2.1. S minh ha cc hot ng ghi c ngoi t bo, trong t bo

v in th khu vc ca mt lt ct hi hi m ngi b ng kinh.
Cc nhn kch pht ghi c ti nron khi c nhng kh cc bt thng
ngun gc ng kinh (ng ghi s 3). Bin cc nhn ny thp hn rt nhiu
nu in cc ghi t ngoi t bo (ng ghi s 2). in cc b mt t ngoi da
u ghi c sng in no (ng ghi s 1) l tp hp nhiu gai kh cc kch pht
ca t bo.
2.2. Gi tr thc t ca in no trong lnh vc ng kinh.
Thng tin thu c t bn ghi in no rt cn thit, khng ch phn
bit cc hi chng ng kinh m cn gip tin lng ng kinh v theo di qu
trnh iu tr ca bnh, quyt nh bt u hay dng iu tr. Cc bn ghi in no
gip thy thuc tr li cc cu hi sau: cn cc b hay ton b, hnh thi hot ng
ca in no trong v ngoi cn. in no c th khng nhng cung cp thng
tin phn bit cc dng cn, m trong mt s trng hp, cn gip xc nh c

38
bn cht ca cn nu nh cc hot ng ca in no nn c trng cho mt bnh l
ca no c th gy ng kinh.
2.3. in no bnh nhn ng kinh
Trong thc hnh lm sng ghi in no , i vi bnh nhn ng kinh,
ngi ta chia lm hai loi: bn ghi trong cn (ghi trong khi ang xy ra trong cn
ng kinh) v bn ghi ngoi cn (ghi gia cn ng kinh).
2.3.1. in no trong cn ng kinh
c im chung ca in no trong cn ng kinh:
+ Gim in th hot ng nn: lc khi u ca cn ng kinh, ngi ta thy
c hin tng gim t ngt v nhp hot ng in no nn v xut hin mt loi
nhp mi gm nhng nhn hoc khng c nhn. Cng vo giai on u ca cn,
tn s ca loi nhp mi xut hin tng ln. Sau , song song vi hin tng gim
tn s, bin ca hot ng in no c xu hng tng ln, cc nhn ngy cng
phn bit r hn.
+ Tng t ngt in th ca hot ng nn
Ngoi ra mt s trng hp cc cn khng phn loi c c im sau:
a. Cc cn ng kinh s sinh lnh tnh nguyn pht: cc cn thng ngn, t 1
n 2 pht, nh khu rt a dng c th mt hoc hai bn, thng lc bn ny, lc
bn kia, khng n nh. Trn bn ghi thy cc hot ng in no thnh nhp tn s
beta v/hoc delta. V nguyn tc, khng c hin tng suy gim hot ng nn sau
cn. giai on cui ca cn ng kinh lm sng, cc phng lc trong cn di
lm sng c th vn cn.
b. Cc cn co git s sinh lnh tnh c tnh cht gia nh: in no trong
cn c hnh nh gim bin lan ta ca cc hot ng in no tip theo l cc
sng chm thnh nhp mt bn hoc hai bn cc v tr rt khc nhau. Cc cn ko
di t 1 2 pht.
c. Cc cn ton b: Trong cc cn ton b, phng lc kch pht hu nh tc
ng ln ton b v no mt cch t pht. c trng ca in no trong cn l

39
nhng phng lc nhn, a nhn, a nhn-sng ng b hoc i xng c hai bn
cu.
- Cn vng: l cc cn ng kinh c thi khong ngn, c trng bng bin
i thc.
- Cn vng in hnh c in no trong cn khi u v kt thc t ngt
km theo cc phng lc c hai bn cu, ng b v i xng di dng cc nhn-
sng, tn s trn hoc bng 3Hz. Cc phc hp ny xy ra iu ha, bin ln,
trn mt hot ng nn bnh thng ( hnh 2.1).

Hnh 2.1. Bn ghi in no ca bnh nhi 12 tui, c tin s ghp thn lc 4 tui.
Cn vng in hnh: phng lc nhn sng 3Hz khi u v kt thc t ngt. Trn
lm sng c biu hin mt thc. Chuyn o I. Khuch i 150V v 1s.
- Cn vng khng in hnh gm nhng cn ng kinh dng vng thc khi
u v kt thc km t ngt hn, thi khong ko di hn v bin i thc km
in hnh hn. in no trong cn thy cc phng lc nhn-sng lan ta hai bn

40
km iu ha i khi khng ng b c tn s di 3Hz, c khi km vi cc du
hiu khc ca cc cn (cc nhp nhanh, nhn tuyn np, a nhn).
- Cn git c: c trng ca cc cn ng kinh git c l hin tng co t
ngt cc c ng vn v i vn dn n git t ngt v ngn ca cc c. in no
trong cn thng thy nhng phng lc a nhn-sng hai bn bn cu, i xng,
ng b.
- Cn co git: thng xut hin ch yu nhng tr nh, i khi trong bnh
cnh st cao co git. Trn in no trong cn: phng lc t nhiu u n di dng
cc nhn hoc a nhn-sng.
- Cc cn tng trng lc: c trng bng co cng cc c ko di t nht mt
vi giy km bin i thc, ngng th cng nh cc ri lon thc vt khc. in
no thng c cc phng lc tuyn np a nhn, ton b.
- Cc cn mt trng lc: c trng bng mt trng lc t th gy ng t
ngt v gy chn thng. Trn in no trong cn mt phng lc nhanh, bin
khng cao, nhp tuyn np hoc phng lc nhn sng chm khng u n. Trn
lm sng kh c th phn bit c loi ng kinh ny vi cn ng kinh trng
lc, cn ng kinh git c hoc vi cn ng kinh phi hp gia cc yu t va nu
vi nhau. Ch c ghi in no video mi c th phn bit c cc cn ny.
- Cc cn trng lc co git: ng kinh trng lc co git (ng kinh cn ln)
l loi ng kinh ton b hay gp. in no trong cn gm mt hot ng
nhanh, in th thp, tip theo l bin tng dn giai on tng trng lc. Sau
xut hin cc a nhn hay a nhn-sng vi tn s chm dn trong giai on co
git. Tuy nhin, trong giai on co git, cc hot ng in no phn ln b che lp
bi nhiu in c nn kh quan st. giai on sau cn, cc sng chm xut hin
nhiu ln, tn ti nhiu gi thm ch nhiu ngy.
d. Cc cn ng kinh cc b
Hot ng in no ca cc cn ng kinh cc b thng xy ra mt
bn v khu tr, t nht l giai on bt u ca cn. Cc phng lc c th khu tr

41
ti mt v tr hoc lan ta ra xung quanh, n ton b c bn cu thm ch c th lan
sang c bn cu bn i din gy ra mt cn ng kinh ton b ha th pht.
in no trong cn c trng bng s bin mt hot ng nn, thay vo
l gim bin cc hot ng nn hoc xut hin mt hot ng nhanh, bin
thp, t nhiu khu tr mt s chuyn o. Tip theo, xut hin cc phng lc bin
tng dn gm cc nhn, nhn sng v cc sng chm kt thc t ngt. nh
khu v hnh thi hc ca nhng bin i ny ph thuc vo v tr xut pht cc
phng lc ng kinh.
- ng kinh thy thi dng: xut hin mt hot ng nhanh in th thp.
Hot ng ny tng dn v bin v c biu hin bng cc nhn hoc cc sng
chm thnh nhp vng thi dng hoc cng mt lc nhiu thy no khc nhau
(hnh 2.2).

Hnh 2.2. Cn ng kinh cc b thy thi dng: nhp theta a dng tuyn np
vng thi dng tri (C3-T3; P3-T5) trn mt nn hot ng chm bin thp.

42
Bnh nhn nam 38 tui b lon sn thy thi dng tri. o trnh II, khuch i
50V v 1s.
- ng kinh thy trn: bin i in no tm thi giai on u ca cn
rt a dng. Trong mt s trng hp, cc bin i trn in no xy ra trc khi c
nhng triu chng lm sng v lc ny in no cung cp cc thng tin quan
trng khu tr tn thng: hot ng nhanh, bin thp, cc nhn (thnh nhp
hoc khng), cc nhn-sng hoc cc sng chm thnh nhp, nm vng trn hoc
nm nhiu vng khc nhau ca no, thng gp c 2 bn. Cc sng mt dc,
bin cao, theo sau l hin tng gim bin hot ng in no lan ta .
- ng kinh trung tm: biu hin in no trong cn nhng bnh nhn c
ng kinh vng trung tm thng kn o.
- ng kinh thy nh: in no trong cn c th xut hin bt thng
mt vng rt rng no (trung tm nh chm thi dng).
- ng kinh thy chm: cc phng lc trong cn i khi kh lan ta v thng
t khi khu tr. Tuy nhin, lu rng mt ng kinh nh c bit l nhng ng
kinh khng nh hng n thc c th khng thy biu hin bt thng trn in
no .
2.3.2. in no ngoi cn ng kinh.
a. ng kinh cc b nguyn pht.
in no c hot ng nn v cu trc gic ng bnh thng. Tuy nhin,
c th thy cc hot ng bt thng cc b, tn s cc bt thng ny tng ln
trong gic ng.
- ng kinh cc b lnh tnh vi cc nhn trung tm thi dng hay ng
kinh kch pht Rolando: in no ngoi cn thy nhng nhn chm, hai pha,
bin ln vng trung tm thi dng, tn s tng dn khi vo gic ng v tn ti
tt c cc giai on ca gic ng. Cc hot ng in no ny c khuynh hng lan
ta hai bn . Do cc loi ng kinh ny thng xut hin trong khi ng nn ghi in
no trong gic ng tra v nhiu khi ghi in no trng thi tnh khng pht hin
c bt thng (hnh 2.3).

43
Hnh 2.3. in no ngoi cn: nhn tip theo l cc sng chm mt dc, ton th
vi mt thi dng-trung tm phi (C4). Bnh nhi 6 tui c cc cn co git khng
c yu t khi pht. ng kinh kch pht Rolando. o trnh I. Khuch i: 100V
v 1s.
- ng kinh lnh tnh tr nh c hot ng kch pht vng chm: in no
ngoi cn c trng bng mt hot ng nn bnh thng vi nhng nhn hoc
nhn-sng vng chm, bin ln mt hoc hai bn. Cc hot ng ny ch
cut hin khi nhm mt v bin mt khi m mt.
b. ng kinh cc b triu chng
Ni chung, cc ng kinh cc b triu chng c c im in rt khc nhau
v lin quan ch yu n khu vc c ng kinh.
- ng kinh thi dng: in no ngoi cn c th bnh thng hoc mt
i xng nh ca hot ng nn ca cc mc khc nhau. Cng c th gp cc
nhn, cc sng sn dc v hoc cc sng chm, mt bn hoc hai bn thi dng
ng b hoc khng ng b khu tr n thun ti vng thi dng.

44
 - ng kinh thy trn: t thy biu hin bt thng, i khi c mt cn xng
hot ng nn, xut hin cc nhn, cc sng sn dc, cc sng chm vng trn
mt bn v thng l hai bn hoc nhng sng chm xut hin nhiu thy ca
mt bn bn cu.
- ng kinh trung tm: in no ngoi cn c th bt thng nhng kn
o.
- ng kinh thy nh: do v tr gii phu ca thy nh ht sc c bit, cc
bt thng trn in no ngoi cn cng nh trong cn c th lan ta ra nhng
vng rt rng: trung tm nh chm thi dng.
- ng kinh thy chm: hot ng kch pht ngoi cn thng phng chiu ra
pha sau v t nhiu tng ln khi nhm mt. Cc biu hin bt thng cng c th
quan st thy vng rt xa ng kinh nh vng thi dng hoc vng trn. Cc
phng lc kch pht i khi lan ta rt mnh nn kh khu tr c v tr tn thng.
c. ng kinh ton b nguyn pht : in no ngoi cn bao gm hot ng
nn bnh thng, cc phng lc ton b hai bn ng oboj v i xng vi cc
nhn, a nhn, nhn-sng v a nhn-sng vi tn s trn hoc bng 3Hz. Cc bt
thng c th c hot ha trong gic ng v nhy cm i vi cc kch thch nh
sng.
Sau y l cc dng lm sng ca ng kinh ton b nguyn pht ty theo
la tui:
- Co git s sinh lnh tnh: biu hin bng nhng cn git (khng bao gi c
cn trng lc), hoc ngng th, xy ra vo khong ngy th 5 sau . in no
ngoi cn hot ng theta nhn k tip nhau.
- ng kinh git c lnh tnh tr nh nhi: him gp, c nhng t git c
ton b xy ra trong nm u v nm th 3 ca cuc i. in no : nhn sng
nhanh ton b, ng b vi nhng cn git c trn lm sng.
- ng kinh vng thc tr nh: thng xy ra la tui hc ng, l
dng thng gp ca ng kinh ton b nguyn pht. in no trong cn trn
mt hot ng nn bnh thng, cc phng lc nhn- sng 3Hz u n hai bn

45
bn cu, ng b, i xng km theo biu hin vng thc ko di 4-5 giy. in
no ngoi cn i khi cng c th ghi c hot ng delta pha sau thnh nhp
(hnh 2.4).

Hnh 2.4. in no ngoi cn: hot ng delta (mi tn) bnh nhi 12 tui, c tin
s ghp thn, c cc cn vng lm sng in hnh. Chuyn o II. Khuch i:
100V v 1s.
- ng kinh vng thc tui thiu nin: cc cn vng him hn v xy ra
thnh tng chp vo bui sng khi ng dy. in no ngoi cn khng c hiu.
in no trong cn gm cc phng lc nhn sng khong 3Hz, i khi nhanh
hn (4-5hz). Cc cn ng kinh ton b trng lc co git c th phi hp vi cc
cn vng trong 80% cc trng hp.
- Cc cn ng kinh git c tui thiu nin: in no ngoi cn c cc
nhn-sng v cc a nhn-sng ton b, thng khng i xng. Cc hot ng ny
nhy cm vi kch thch nh sng. Git c thng bo trc bng mt phc hp a

46
nhn-sng trn in no . Cc hot ng kch pht nu trn c th ghi c vo
bui sng khi tnh dy hoc sau khi mt ng.
- ng kinh cn ln khi tnh gic: in no ngoi cn c th bnh thng
hoc thy nhng phng lc ton b cc nhn-sng, a nhn-sng nhanh, cbit
hay thy vo bui sng khi tnh gic (hnh 2.5).

Hnh 2.5. Nhn sng 2 -2,5 Hz khi kch thch nh sng ngt qung. Bnh nhi 13
tui c biu hin cn ng kinh ln u tin khi ngi xem v tuyn. ng kinh ton
b nguyn pht ton b nhy cm vi nh sng. Bn ghi ngoi cn. o trnh I.
Khuch i 150 V v 1s.
- Cc ng kinh ton b nguyn pht nhy cm vi nh sng: xut hin khi c
kich thch nh sng ca bn ngoi. Biu hin trn in no , ngoi s nhy cm
vi nh sng, c th thy nhng c im ging nh in no ca ng kinh ton
b nguyn pht.
d. ng kinh ton b triu chng

47
 Cc cn ng kinh ton b triu chng thng xy ra tr nh v c cc c
im lm sng in hc khc hn vi ng kinh ton b nguyn pht. Cc cn ng
kinh loi ny thng ph hp gia git c, trng lc, cc cn vng khng in
hnh trn cng mt bnh nhn. Loi ny c chia lm hai nhm c hiu v
khng c hiu.
+ ng kinh ton b triu chng c hiu:
- Bnh Kufs: nhng bnh nhn ny, bin i nhn thc di dng sa st tin
trin nhanh v hng nh. in no di kch thch nh sng ngt qung tn s
chm thy cc nhn, cc a nhn-sng ng b vi kch thch nh sng.
- Bnh Lafora: in no c cc phng lc cc b thy chm hot ha khi
c kch thch nh sng ngt qung, i khi a hoc ton b. Hot ng in no
nn chm li.
+ ng kinh ton b triu chng khng c hiu: bnh him gp gm hai hi
chng: bnh no git c sm v bnh no c ng kinh tr em (hi chng
Otahara). in no : hnh nh cc t bng pht dp tt.
e. ng kinh ton b nguyn cn n hoc ng kinh triu chng c bit.
- Hi chng West: hi chng ny xy ra tr di 1 tui vi tam chng: co
tht tui th, chm pht trin tm thn vn ng v lon nhp cao in th. in no
rt hn lon, bao gm cc nhn v cc sng nhn bin ln phn b v mt
khng gian v thi gian khng tun theo mt trnh t nht nh (hin tng lon
nhp cao in th). Cc co tht trn lm sng thng phi hp vi cc phc hp
chm a pha trn in no (hnh 2.6).

48
Hnh 2.6. Hi chng West. in no ngoi cn: hot ng in no hn lon bao
gm cc nhn v cc sng nhn c bin ln, phn b v khng gian, thi gian
theo mt trnh t nht nh (lon nhp cao in th). Bnh nhi 7 thng, c cc cn
ng kinh khi tnh gic vi cc c ng nhn cu o ngc v co tht t chi. o
trnh I, khuch i 35 V v 1s.
- Hi chng Lennox-gastaut: y l th nng nht ca ng kinh tr nh.
Trn lm sng, c s phi hp gia cc cn tng trng lc, cc cn mt trng lc
v cc cn vng khng in hnh. in no ngoi cn c hot ng in no nn
bt thng km theo phng lc ton b di dng cc nhn-sng chm bin ln
tn s di 2,5Hz phi hp vi cc hot ng nhanh, tuyn np (khong 10Hz)
trong gic ng chm i khi c km theo cc cn tng trng lc (hnh 7.25).
f. ng kinh khng xc nh.
- Cc cn ng kinh s sinh: in no giai on u thng l bnh thng.
giai on sau, hay gp nhng biu hin phng lc ton th, nhy cm vi nh
sng v a .

49
 - ng kinh vi cc nhn sng lin tc trong gic ng chm: hot ng nhn-
sng lin tc trong gic ng chm l du hiu c trng ca loi ng kinh ny.
- Hi chng Landau-Keffner: hay ri lon vn ngn km theo ng kinh l
bnh cnh ph hp ri lon vn ngn mc phi vi ng kinh. in no c hot
ng kch pht di dng cc nhn v nhn-sng a , xy ra vng thi dng
nh hai bn bn cu.
2.3.3. in no v trng thi ng kinh.
nh ngha: trng thi ng kinh l tnh trng cc cn ng kinh di, vi
khong cch ngn c th to nn mt tnh trng ng kinh c nh v bn
vng. Thng thng thi gian ca cc cn ng trong trng hp ny ko di trn
30 pht.
a. Trng thi ng kinh ton b
- Trng thi ng kinh ton b co git: in no c cc phng lc kch pht
xut hin hai bn mc d thng khng i xng.
- Trng thi ng kinh ton b khng co git: in no thng l a hnh
thi. Cc nhn- sng chm t 1 n 2Hz. Ton b hai bn cu to nn mt hnh nh
bt thng kh c hiu. Tuy nhin, cng c th gp nhng hot ng kch pht c
hai bn thnh nhp khng phn ng i vi nhm m mt.
b. Trng thi ng kinh cc b.
- Trng thi ng kinh cc b n gin vn ng: Triu chng lm sng l git
bn vng thnh nhp ca ton b na c th. in no c biu hin cc hot
ng kch pht bn vng, khu tr, tng ng vi mt tn thng nng n ca no
(bnh mch mu, khi u, chn thng).
- Trng thi ng kinh cc b n gin tht ngn : cc ri lon v ngn ng
tn ti dai dng gia cc cn. in no c cc phng lc kch pht vng thi
dng nm bn bn cu tri.
- Trng thi ng kinh cc b phc tp vng thi dng: l mt hi chng
in hc cn nhiu iu cha bit n v kt qu iu tr vn cn rt hn ch. in

50
no c nhng hot ng ng kinh cc b lp li hoc hot ng kch pht lin
tc vng thi dng.
- Trng thi ng kinh cc b phc tp vng trn: c trng bng du hiu
thc m m kn o phi hp vi ri lon chng trnh ha cc mnh lnh phc
tp. in no c cc phng lc kch pht, t nhiu lan ta vng cc trn.
2.3.5. Tm li
Qua trn ta thy, mc d in no khng c hiu v nhy khng cao,
nhng t lu phng php ny lun c coi nh l mt cng c quan trng i vi
cc nh ng kinh hc.

51
 CHNG 3 : SNG IN NO V GY M
3.1. Gii thiu

Vn theo di gy m da trn cc ch s c tnh t in no c

nghin cu trong nhiu thp k qua. Kt qu nghin cu thnh cng t c ng
ch u tin vo nm 1996 khi tp on Aspect Medical System (M) gii thiu
ch s Bispectral (BIS). BIS l mt php o kt hp nhiu phng php x l tn
hiu (tn s, nh ph v min thi gian) tnh chiu su v hng ca bin php
gy m (Rampil, 1998). Sau , mt s phng php thng mi nh gi m
su c pht trin v s dng. V d ch s trng thi bnh nhn (Patient State
Index PSI) ca tp on Physiometrix (M), ch s Narcotrend ca Monitor
Technik (c), v ch s Entropy ca Datex Ohmeda - GE Healthcare (Phn Lan).
Mc d thc t trn th trng c mt s phng php/ thit b theo di gy
m, nhng cc nghin cu v lnh vc ny vn ang c pht trin. iu ny do
hai l do chnh: u tin, cc phng php hin ti c nhng hn ch nht nh
khin h tht bi trong mt s trng hp, th hai, theo di tn hiu in no EEG
ngy cng ph bin trong khu vc hi sc tch cc (ICU) v cc php o theo di
gy m phu thut khng thu c kt qu tt nht trong khu vc ICU.
Mt mt, vic theo di m su c pht trin o v nh gi tc dng ca
thuc gy m ln chc nng no nhm gim t l trng thi nhn thc trong khi gy
m, ngha l trnh trng thi gy m qu nng. Mt khc, iu ny s gip cc bc
s gy m duy tr trng thi gy m mc ti u ngn chn s phc hi chm,
tc l trnh gy m qu su.
Theo di tn hiu in no trong khu vc hi sc tch cc ICU gip gim au ti
u, v do , khong thi gian th my cng nh tng thi gian trong khu vc
ICU v bnh vin c th gim. Gy m qu nng trong khu vc ICU c th c mt
s hu qu vi bnh nhn nh tng mc cng thng ton b, tng huyt p, v
tng mc hp th oxy. Mt khc gy m qu su c th bao gm vi ri ro nh vy.

52
V d, n c th lm gim huyt p, ko di thi gian th my, v hi chng cai
thuc an thn.
3.2. Tn hiu in no trong gy m v hi sc tch cc
3.2.1. Phn loi EEG
Cc tn hiu in no c chia ra 5 loi sng in hnh da theo di tn s ca
tn hiu. Cc sng v di tn s tng ng c ch ra trong bng 3.1. T l cc
nhp sng ny trong mt ln o EEG ph thuc vo tui v trng thi thn kinh.
Bng 3.1. nh ngha cc sng EEG theo tn s

Sng EEG Di tn s , Hz
Delta () <4
Theta () 47
Alpha () 8 13
Beta () 14 - 30
Gamma () > 30

Sng delta c thy in hnh trong sut gic ng su vi sng chm, v n

c bin tng i ln. Ngoi ra, cc nhp delta c th xut hin trong trng hp
chn thng no v hn m cng nh trong sut qu trnh gy m. Nhp theta c th
c thy trong sut cc giai on hin nhin ca gic ng v trng thi tp trung
hon ton nh khi suy ngh. Nhp alpha chim u th trong sut thi gian th gin
m nhm mt nhng vn thc. Nhp alpha c bin ln nht vng chm. Sng
beta lin quan ti cc trng thi tnh to bnh thng. Nhp beta bin thp thng
c khi hot ng tp trung hoc suy ngh. c bit, nhp beta vi tn s u th c
lin quan ti mt vi bnh l v tc dng ca thuc. Nhp gamma lin quan ti nhn
thc v thc. Hot ng sng gamma xut hin trong khi thc tnh hoc c hot
ng khi ng ging nh mt khong kch pht - c ch trong khi gy m.
3.2.2. Sng in no trong gy m
3.2.2.1. c tnh chung
Cc loi thuc gy m nh hng n c tn s v bin ca sng in
no EEG. Mc d thc t l mi loi thuc c nh hng n sng in no ph

53
 thuc vo liu c th, tt c cc loi thuc c chung mt s c im thng
thy. Trong bng 3.2 c so snh nh hng ca cc loi thuc sevoflurane v
propofol ln sng in no. i vi c gy m tnh mch v ng th vo, cc
liu gy m nh thng gy ra tng hot ng beta thy trn v trit tiu hot
ng alpha thng thy vng chm. Sau , sng in no chuyn thnh bin
ln, hot ng sng chm lan rng chng ln hot ng alpha. Tip tc tng
liu thuc gy m lm cho hot ng chm tng cc chu k phng ngn ca
sng in no ci gi l c ch - xut hin. Khong thi gian chu k c ch
tng ln dn dn, v chu k hot ng bin cao ci gi l kch pht b rt
ngn li. Nu liu tng tip tc tng, s xut hin ca cc kch pht gim i dn
dn cho n khi chng mt hn, v sng EEG b c ch lin tc.
Bng 3.2 - nh hng ca gy m bng sevoflurane (qua cch ht vo) v
propofol (tim tnh mch) ti c tnh sng in no.
Thuc gy m Mc gy m nh hng ln tn s in no
Sevoflurane Gy m liu nh Mt sng alpha
Sng beta thy trn
Gy m Hot ng thy trn 4 8Hz
Tng liu Ph bin sng theta v delta
Bng n c ch
Khng tn hiu
Propofol Liu thp Mt sng alpha
Sng beta thy trn
Liu trung bnh Sng delta thy trn
Tng/ gim alpha
Tng liu cao Ph bin delta
Bng n c ch
Khng tn hiu

54
3.2.2.2. Thnh phn Kch pht c ch

Kch pht c ch (burst suprression BS) l thnh phn tn hiu c bin

ln, cc kch pht hot ng hn hp tun theo cc giai on hot ng b c ch
c th xy ra nhiu ln. Thnh phn BS c th xut hin trong thi gian thiu mu
cc b, h thn nhit mnh, v gy m phu thut su. Thnh phn BS m t hot
ng v no bt thng m trong khong thi gian khong 95% t bo v no
khng hot ng. V vy, c th kt lun rng trong qu trnh xy ra BS, bnh
nhn trng thi bt tnh su. Quan trng hn, thnh phn BS mt bnh nhn
khe mnh c th ch c to ra bi nng ln ca mt loi thuc gy m. V
cc loi thuc gy m khc nhau gy ra cc thnh phn BS khc nhau, cho thy
rng c ch hot ng ca chng khc nhau.
V d cc thnh phn EEG in hnh trong khi gy m mc BS khi dng
thuc gy m propofol v sevoflurane c ch ra trong hnh 3.1. Quan st hnh
3.1, ta c th nhn thy rng so snh vi cc kch pht do propofol, th kch pht
do sevoflurane c cu trc phc tp hn. Cc kch pht gy ra do sevoflurane c
xu hng cha t l cc hot ng t ngt v bin ln cao hn, trong khi cc
kch pht do propofol ch yu cha hot ng sng chm vi hot ng tn s
cao hn trn ln chng ln nhau. Ngoi ra, hot ng con thoi c th xut hin
trong khi gy m bng propofol.

Hnh 3.1 V d v thnh phn kch pht - c ch in hnh trong khi gy

55
 m su bng propofol (a) v sevoflurane (b). Phn ng khung mu xm biu th
thnh phn con thoi c th xut hin trong khi gy m bng propofol. i vi c
2 trng hp u s dng in cc mt Fz vi o trnh tham chiu A1A2.

3.2.2.3. Thnh phn con thoi trong tn hiu EEG

Con thoi (spindle) l thnh phn EEG c th xut hin trong khi ng. Cc
con thoi c xc nh vi chu k tng t 1 ti 3 giy v gim dao ng t 7 ti
14 Hz, thng chng ln trn nh cc hot ng EEG khc. Dao ng con thoi
l kt qu tng tc gia cc t bo thalamocortical v thalamic reticular. Cc
con thoi cng c nghin cu trong sut gic ng sinh l bnh thng xc
nh cc giai on gic ng v ri lon gic ng. Kt qu nghin cu cho thy
rng tn s cc con thoi ca bnh nhn ngng th khi ng chm hn so vi bnh
nhn khe mnh. Cc nghin cu kt lun rng tn s con thoi thp hn c th
xc nh rng gic ng b quy ry v cc c ch thn kinh iu chnh gic ng b
bin i.
Ngoi gic ng sinh l cc thnh phn con thoi c th xut hin trong sut
qu trnh gy m su bng propofol. Cc thnh phn con thoi gy ra bi propofol
hu ht c th c nhn thy r rng trong qu trnh gy m su khi thnh phn
BS sn sng hot ng. Tn s con thoi thng nm trong di 13 15Hz v thi
gian trong khong 2 n 5 giy. Con thoi thng xut hin sau kch pht nhng
thnh thong chng c th xut hin trong sut cc khong c ch di hoc trong
sut cc khong kch pht di. Hnh 3.1(a) minh ho mt trng hp in hnh
khi cc con thoi xut hin sau kch pht trong sut qu trnh gy m su bng
propofol.
iu cho thy rng hot ng EEG ng b tng ng vi cc con thoi,
thc t, c pht hin thm ch trc khi BS bt u. giai on u hot ng
ny c tn s khong 20Hz, sau , gy m su, n dn dn gim xung khong
13Hz nh khi BS bt u.

56
3.3. Propofol v tn hiu in no
Propofol l cht thi min c hot tnh ngn duy nht vi mt s u im
so vi cc thuc gy m khc. V hin nay vic s dng propofol nh mt loi
thuc chng co git v cht an thn ngy cng tng. Do , cc nh thn kinh
hc, bc s gy m, nh sinh l hc thn kinh hoc cc chuyn gia chm sc sc
khe khc cng tham gia vo vic chn on iu tr cho cc bnh nhn nng v
bnh nhn phi tri qua gy m bng propofol, v vy chng ta cn nm r s
thay i in no do propofol gy ra.
3.3.1. Tc dng chng co git ca propofol v tn hiu EEG
Hin nay, vic truyn lin tc midazolam hoc propofol vo tnh mch, cng
vi theo di EEG lin tc, l mt phng php ph bin trong iu tr tnh trng
ng kinh ko di dai dng tr em v ngi ln. Tuy nhin, khng c bng
chng no ghi li rng thnh phn kch pht c ch (BS) ca tn hiu EEG
xut hin hoc c hiu qu trong vic chm dt tnh trng ng kinh. Nhiu
bnh nhn c th kim sot hon ton cn co git vi tn hiu c bn l hot
ng sng chm lin tc v khng phi chu ri ro nhiu khi s dng liu cao
hn cn thit thu c mt thnh phn kch pht c ch (BS) (Hnh 3.2).

Hnh 3.2. Tn hiu EEG minh ha cho tc dng chng co git ca propofol.

57
 Hnh trn l tn hiu EEG thu c ca mt bnh nhn nam, 23 tui c
tin s mc bnh ng kinh thy trn lu nm, nguyn nhn kh cha v khng
r rng. Anh ta nhp phng cp cu tng qut trong tnh trng ln cn ng kinh
co git bt u t 12 gi trc . Anh ta phi truyn propofol 2,5 mg/ kg/ h
trong khong 24 h. Php o EEG ny c thc hin trong 24 gi u tin
trong khi bnh nhn trng thi hn m (comate) do propofol. Sng EEG thu
c cho thy mt s chm chung, chm tp trung hai bn trn, cc nhp
nhanh trong di beta ln ln v thi thong c cc sng nh t bin vng hai
bn trn. Sau , bnh nhn co git t do trong 72 gi. Mt thnh phn BS
khng phi l cn thit kim sot tnh trng ng kinh. B lc thng thp
(LFF) 0.3 Hz, b lc thng cao (HFF) 70 Hz. nhy 101V / mm.

3.3.2. Mi quan h gia liu lng propofol v tn hiu in no thu c

C mt s nghin cu cho thy mi quan h gia liu lng propofol v s

thay i EEG trong sut qu trnh a thuc vo bnh nhn. Mt nghin cu
trn tr em (21 tr em, 7-8 tui), cho cc em s dng liu ngu nhin 3 mg / kg
hoc 5 mg/kg hoc thiopental 5-7 mg/kg. ng in no c bn xut hin
bnh thng tt c cc bnh nhn. Cc chui EEG lc a thuc vo tng
ng cho ba nhm nh sau: sau khi mt khong trung bnh l 12 s, cc vt cho
thy s gia tng tn s t 9 n 10 Hz (sng alpha) v n hn 14 Hz (beta
sng). S chuyn i ny ko di 2s, tip theo l sng delta (2-3 Hz) tip tc
trong 1-2 pht. Cui cng, sng beta xut hin tr li tng dn nhng khng
thay th sng delta hon ton trong 5 pht tip theo. Sng delta ph bin hn
cc vng thy trn gn mt. Bn cnh , chui EEG lc a thuc vo cng
tng t nh vy khi s dng liu 2,5 mg/kg.
Ngay sau khi a thuc gy m vo c th bnh nhn, c mt s suy yu
ng k ca hot ng thn kinh v mt in no. Sau , khi kt thc hu ht
cc sng EEG phng, mt con thoi hnh thnh, cc chui nhp sng xut hin,
v sau l cc thnh phn BS in hnh. Nhng sng con thoi 14 Hz vi bin

58
 tng gim xut hin ng thi trn mt vi knh. N ging nh sng con
thoi do gic ng v cc loi thuc an thn to ra trong i no v phn b duy
nht ti vng v no mi cng cc si trc thn kinh thuc vng i v no.
Cc thnh phn chnh ca kch pht do propofol l sng chm, xut hin r rng
ton b vng da u hoc cc in cc c lin quan ti cc in cc su v cho
mt bin cao nht in cc trc v thp nht cc in cc trung tm v
nh. Hn na, nhng sng sc cnh ca BS ging nh sng nh ca gic ng
sinh l v phn b ca chng tng t nh cc con thoi. Nhng im tng
ng vi gic ng sng chm c th c gii thch l do nh hng ca
propofol trn h thng kch thch.
Di liu propofol t 40 n 200 mg to ra cc kch pht - c ch (BS) tt
c bnh nhn, ngoi tr bnh nhn ang trong tnh trng ng kinh, trong
trng hp ny nhanh chng thu c BS ngay t ban u, nhng m bo
duy tr BS cn tng thm liu propofol (9,5 (8,2-11,0) mg/kg/h). Mc d dng
liu cao, nng propofol trong huyt tng cn li mc bng mc o c
trong sut qu trnh gy m phu thut. Th nghim trn ng vt cho kt qu
trong sut cc BS, EEG c xp x khong 95% t bo v no lun phin chuyn
sang chui phn cc pha (t bin) v tn hiu in gn nh khng c (cc chu
k bng phng, trong khi 30-40% ca cc t bo thuc i no vn tip tc gii
phng cc t bin nh theo nhp trong sut cc chu k bng phng cc t
bo thn kinh thuc vng v no mi. Tuy nhin, iu ny ch xy ra khi cc
giai on bng phng c gii hn trong khong 30 giy. Hot ng BS
vng v no mi do gy m, xut hin tham gia vo cc hot ng ni sinh
n vng v no mi, yu cu truyn dn glutamatergic cn nguyn vn, s
chuyn t trng thi BS sang hot ng EEG ng in l kt qu t vic gim
s dng thuc gy m do truyn dn synap kch thch qua cht trung gian
glutamate. Bn cnh , nghin cu trn chut ch ra rng cc c tnh in
sinh l ca BS gy ra bi propofol khc vi cc BS gy ra bi isofluorane hoc
thiopental, BS do propofol cho thy thi gian ngn hn v bin thp hn.

59
 Hnh 3.3. Minh ha mi quan h liu lng propofol v in no
Tn hiu trn l ca bnh nhn nam 52 tui b ng kinh thy trn phi
kh cha. ng ta c a vo phng cp cu vi cc cn co git thng
xuyn rt mnh v c ch nh theo di EEG trong thi gian di chp
nh MRI mi ca no khi dng propofol. A. Tn hiu EEG ban u chm
mc thng thng 7-8 Hz. Sau khi cho dng propofol (2.0 mg/kg; mi tn
mu xanh), thnh phn EEG ny c thay i bi mt nhp nhanh hn
trong di alpha, 10-12 Hz, ch yu l trn khu vc gia trn sau 2s truyn
propofol. B. 10 giy sau , in no cho thy mt hot ng chung c bn
nhanh hn ti 10-12 Hz. C. Sau , ti 12 giy l mt sng chm tn s 5-6
Hz, v xut hin nhiu hn sng chm delta trung tm trn vng. Lc thng

thp tn s 0,3 Hz, Lc thng cao 70 Hz. nhy 7V/mm (A v B) v

60
10V/mm (C).

3.4. Php o entropy nh gi trng thi hot ng ca no b khi gy m.

Trong qu trnh gy m, vic theo di lin tc hot ng in ca v no
c s dng o mc chc nng no v su gy m. Hin nay, entropy
l php o hiu qu trong vic d on nhng thay i trong khi gy m tng
ng vi d liu EEG thu c vng da u, v nhng php o ny gip gim
ng k tng liu lng propofol v liu a vo trong khi phu thut.
3.4.1. Nguyn l
C mt s khi nim v k thut phn tch nhm xc nh cc bt thng ca
tn hiu ngu nhin, chng hn nh tn hiu in no. Mt trong nhng khi nim
l entropy. Xt v khi nim vt l th entropy t l thun vi logarit ca cc trng
thi vi m xut hin trong h thng nhit ng, v do lin quan n s lng ri
lon trong h thng. Trong l thuyt thng tin, d liu ngu nhin (entropy) ln u
tin c nh ngha bi Shannon v Weaver vo nm 1949, v p dng xa hn cho
quang ph nng lng ca mt tn hiu bi Johnson v Shore vo nm 1984. Trong
vn ny, entropy m t cc c im bt thng, phc tp, hoc khng th tin
on ca mt tn hiu. Xt mt v d n gin, mt tn hiu vi cc gi tr lin tip
tun t lun phin ca mt bin c nh v sau l ca mt bin c nh
khc c gi tr entropy bng khng, tc l tn hiu c quy tc v hon ton d on
c. Mt tn hiu, dy gi tr c to ra bi cc s ngu nhin c entropy ln hn
v phc tp hn nhiu.
Entropy l mt tham s trc quan vi mt trong cc ngha ca n l c th
phn bit mt tn hiu thng xuyn t mt tn hiu bt thng. Entropy cng c

61
c tnh l c lp vi di gi tr tuyt i nh bin v tn s ca tn hiu: mt
sng sin n gin c quy tc u n cho d l nhanh hay chm. Trong ng dng
in no , y l c tnh r rt v n c lin bin th trong cc tn s tuyt i
ca nhp sng EEG.
C nhiu cch khc nhau tnh ton entropy ca mt tn hiu.Trong min thi
gian ta c entropy gn ng hoc Shannon entropy. Trong min tn s, ta c
entropy ph tn hiu. ti u ha tc m thng tin c ngun gc t cc tn
hiu, ta to ra s kt hp ca cc phng php tip cn min thi gian v s. Mt
thut ton c thc hin trong khi o EntropyTM Datex-Ohmeda (Datex- Ohmeda
Division, Instrumentarium Corp., Helsinki, Finland). Thut ton pht trin
t entropy ph tn hiu, trong c cc li th c bit ng gp cho entropy t bt
k phm vi tn s c th c th c tch ra mt cch r rng. i vi thi gian p
ng ti u, cc tnh ton c th c xy dng theo cch m chiu di ca ca s
thi gian cho mi tn s c th c la chn ring r. iu ny dn n mt khi
nim m chng ta s gi l entropy ph tn hiu cn bng thi gian - tn s.

Hnh 3.4. Khi o Entropy ca hng Datex Ohmea

Hnh 3.5. V tr t in cc o entropy

62
3.4.2. Entropy ph tn hiu

im khi u ca cc php tnh l ph tn hiu. C cc php bin i ph khc

nhau c c hm mt ph, y chng ta xt n bin i Fourier ri
rc. N cho php bin i mt tp hp cc gi tr tn hiu x (ti) c ly mu cc
khong thi gian ti vi mt mu tn hiu thnh mt tp s cn bng ca cc gi
tr phc hp X (fi) tng ng vi mt tp cc tn s fi:

Cc thnh phn ph X (fi) c th c nh gi bng cchs dng mt k thut

tnh ton hiu qu c gi l bin i Fourier nhanh (FFT).
Khi nim entropy ph c ngun gc t mt php o trong thng tin c gi l
Shannon entropy. Khi p dng cho ph nng lng ca mt tn hiu ta thu c
entropy ph . Cc bc sau y c yu cu phi tnh ton entropy ph cho on
tn hiu c th trong mt di tn s c th [f1, f2].
T bin i Fourier X (fi) ca tn hiu x (ti), ph nng lng P(fi) c tnh
bng bnh phng bin ca mi phn t X(fi) ca bin i Fourier:

trong X^(fi) l lin hp phc ca thnh phn Fourier X(fi) v '*' biu th php
nhn.
Sau ph nng lng c chun ha. Ph nng lng chun ha Pn(fi)
c tnh bng cch thit lp mt hng s tiu chun Cn v vy tng ca ph nng
lng chun ha trong vng tn s c la chn [f1, f2] c tnh nh sau:

Trong bc tnh cui cng, entropy ph tng ng vi di tn s [f1, f2] c

tnh bi php cng :

63
 Tip theo, gi tr entropy c chun ha nm trong di t 1 (bt quy tc ti a)
v 0 (hon ton theo quy tc). Gi tr c chia bi h s log(N[f1,f2]) trong
N[f1,f2] l tng cc thnh phn tn s trong di [f1,f2]:

Hnh 3.6-3.8 minh ha cc bc sau. Hnh 3.6(A), 3.7(A), v 3.8(A) biu

din ba on tn hiu tng ng vi cc gi tr entropy khc nhau. Trong v d n
gin ny, chng ta xt cc on tn hiu vi tm thnh phn ph, trong thnh
phn tn s 0 c b qua thnh phn tn s n = 7 c phn tch. Hnh 3.7(A)
cho thy mt sng sin hon ho, hnh 3.8(A) mt sng sin chng ln nhiu trng, v
hnh 3.8(A) mt tn hiu nhiu trng hon ton ngu nhin. Hm ph Fourier ri rc
ca nhng tn hiu ny c chun ha, v c v tng ng trong hnh 3.6(B),
3.7(B) v 3.8(B). Cc thnh phn ph chun ha Pn(fi) c nh x tip bng
cch s dng hm Shannon trong hnh 3.6(C), 3.7(C) v 3.8(C).

64
 Hnh 3.6. Sng sin hon ho ch gm 1 thnh phn khc khng, c chun
ha ti 1 theo cc bc chun ha. Trong php nh x Shannon, c hai gi tr 1 v
0 c a v 0 v tng ng vi entropy bng 0.

65
 Hnh 3.7. Minh ha mt lng nhiu trng c a ln u sng sin.Sau
khi chun ha, ph bao gm mt thnh phn cao tng ng vi tn s sng sin, v 6
thnh phn khc 0 nh hn.Trong nh x Shannon, c 2 loi thnh phn ng gp
cc gi tr khc khng cho entropy ca tn hiu, tng ng vi entropy tng = 0,12
+ 6*0,08 = 0,60.

66
 Hnh 3.8. Minh ha sng sin bin mt v ch c nhiu trng bn phi. Sau
khi chun ha, nhiu lm cho N=7 thnh phn bng Pn(fi)=1/7.
3.4.3. Entropy ph cn bng thi gian tn s.
Trong phn tch tn hiu thi gian thc, cc gi tr tn hiu x (ti) c ly
mu trong mt ca s thi gian hu hn (giai on) c chiu di c la chn
vi mt tn s ly mu c th. Ca s thi gian ny di chuyn tng bc c
c cc c tnh cp nht ca mt ph. Vic la chn chiu di on lin quan
ti s la chn di tn s c xt, nh ca s thi gian di cho php lp cc
bin s chm nht (tn s thp nht ) ca tn hiu.
Mt tn hiu EEG bao gm nhiu la chn cc tn s khc nhau, di t
delta chm (t 0,5 Hz) ln n tn s mc 50 Hz. tn s 0,5 Hz, mt ca s thi
gian di 30s s c yu cu c c 15 chu k y ca cc bin s
0.5Hz. i vi tn s 50 Hz, cng mt s chu k y c th ch thu c c
0.3 s d liu.
Mt ca s thi gian n nht c di c nh r rng khng phi
l s la chn ti u c c thng tin nhanh v ng tin cy nht c th.

67
 ti u ha gia thi gian v phn gii tn s, khi o Entropy s dng mt
tp hp cc di ca s c la chn theo cch nh vy m mi thnh phn tn
s thu c t mt ca s thi gian l ti u vi tn s c th. Bng cch ny, thng
tin c trch t tn hiu cng nhanh cng tt. Cch tip cn ny lin quan cht
ch vi khi nim chuyn i wavelet, vi wavelets l cc gi sng vi rng
bin i hu hn c cha mt hng s xp x ca cc bin s ti u ha gia thi
gian v phn gii tn s.Tuy nhin k thut la chn kt hp li th ny
ca phn tchwavelet vi phn tch Fourier nhanh, chng hn nh kh nng xt s
ng gp mt cch r rng t bt k phm vi tn s c th, v thc
hin hiu qu trong phn mm. tng c bn c minh ha trong hnh. 4.6.
Trong khi o entropy, mt tn s ly mu 400 Hz c s dng. Ca s thi
gian ngn nht l 1,92 s = 768 gi tr mu,v di nht l 60,16 s = 24064 gi
tr mu.Ca s thi gian ngn nht c s dng cho di tn
s t 32 Hz n 47Hz. Ca s thi gian di nht ch c s dng cho cc tn s
di 2 Hz. i vi cc tn s gia 2 Hz v 32 Hz, chiu di ca s gia hai
cc bin c s dng. Ca s rt ngn t hn 2 s vi phm vi tn s t 32 Hz n
47 Hz m bo rng gi tr entropy tng trng thi thc tnh.c bit, n cho
thy du hiu c hot ng in c EMG ngay lp tc.
3.4.4. Entropy trng thi v Entropy p ng.
Mt tn hiu sinh th c o t trn ca mt bnh nhn bao gm mt thnh
phn tn hiu in c EMG ng k, c to ra bi hot ng c. Tn hiu in c
EMG c mt ph rng ging nhiu v trong sut qu trnh gy m thng chim u
th tn s cao hn 30Hz. Thnh phn tn hiu EEG chim u th tn s thp hn
( ln n khong 30Hz) c trong cc sinh th tn ti cc in cc. tn s cao
hn, nng lng EEG gim theo hm m.
S xut hin t ngt ca d liu tn hiu EMG thng ch ra rng bnh nhn
ang p ng li mt vi kch thch bn ngoi, chng hn nh mt kch thch au,
tc l s cm nhn khng au, do mt s th tc phu thut. Nh mt phn ng c
th c kt qu nu mc gim au l khng . Nu kch thch tip v khng dng

68
thm thuc gy m, rt c kh nng mc thi min cui cng bt u gim nh.
Hn na EMG c th cho thy mt ch dn nhanh e da v s thc tnh. Quan
trng l, do tn s tn hiu d liu EMG cng cao, thi gian ly mu c th cng
ngn hn ng k so vi yu cu tn s d liu tn hiu EEG thp hn. iu ny
cho php d liu EMG c tnh ton thng xuyn hn v vy cc ch th chn
on tng th c th c xc nh s thay i trng thi bnh nhn nhanh chng.
N gip thu c nhiu thng tin khi xt hai ch s entropy, mt ch s trn di
tn EEG chim u th mt mnh v mt ch s khc trn ton b di tn, bao gm c
hai thnh phn EEG v EMG. Entropy trng thi ( State Entropy SE) c tnh
trn di tn t 0.8Hz n 32 Hz. N bao gm mt phn EEG chim u th ca ph
tn hiu, v v vy n ch yu phn nh tnh trng v no ca bnh nhn. Cc ca s
thi gian gip SE c chn ti u vi mi thnh phn tn s c th, di gi tr t
60s ti 15s. Entropy p ng (Response entropy RE) c tnh trn di tn t
0.8Hz ti 47Hz. Php tnh ny bao gm c hai thnh phn EEG chim u th v
EMG chim u th ca ph tn hiu. Ca s thi gian gip RE c chn ti u vi
mi tn s, vi ca s thi gian di nht l 15.36s v ca s thi gian ngn nht,
ng dng cho cc tn s t 32Hz ti 47Hz l 1.92s.
iu c li chun ha hai thng s entropy ny theo cch m RE tr nn
cn bng vi SE khi nng lng EMG (tng ca nng lng ph gia 32Hz v 47
Hz) l bng khng, cng nh s chnh lch RE-SE s dng nh ch s hot ng
EMG. Chng ta k hiu di tn t 0.8Hz ti 32Hz l Rlow v di tn t 32Hz ti
47Hz l Rhigh; di kt hp t 0.8Hz ti 47Hz c k hiu l Rlow+high. T phng
trnh 4-5 th khi cc thnh phn ph trong di Rhigh l khng, cc gi tr entropy
cha chun ha S[Rlow] v S[Rlow+Rhigh] trng nhau trong khi cc gi tr entropy
chun ha thu c mt bt ng thc: SN[Rlow]> SN[Rlow+Rhigh]. V vy SE c
tnh nh sau:

69
 i vi RE, gi tr entropy chun ha c tnh nh sau:

Do , RE thay i t 0 ti 1, trong khi SE thay i t 0 ti

log(N[Rlow])/log(N[Rlow+high]) < 1.

Hnh 3.9. Minh ha cc ca s thi gian c di khc nhau cho thy s cn

bng ti u gia thi gian v phn gii tn s. Ca s thi gian ngn c tn s
cao nht m bo thi gian p ng nhanh.

Hnh 3.10. Ph cng sut in hnh ca mt tn hiu sinh th c o t trn

ca mt bnh nhn. Tn hiu EEG chim u th ln ti tn s khong 30Hz, trong
khi tn hiu EMG chim u th di tn s cao hn. Thang chia trc ng l
logarit.
Hai gi tr entropy trng nhau khi P(fi) = 0 vi tt c gi tr fi trong di [Rhigh].

70
Khi c hot ng EMG, cc thnh phn ph trong di [Rhigh] khc bit ng k t
gi tr 0 v RE ln hn SE.
Vi nhng nh ngha ny, c hai gi tr SE v RE u phc v mc ch thng
tin c li cho cc bc s gy m. Entropy trng thi l ch s n nh ca tc dng
gy m trn v no. Ca s thi gian SE c la chn theo cch m cc dao ng
tm thi b loi b khi d liu. Mt khc entropy p ng phn ng nhanh chng
s thay i. Mt tnh hung in hnh trong cc vai tr khc nhau ca cc tham s
ny l c chng minh trong sut qu trnh thc tnh, khi RE tng ln u ng
thi vi s kch hot c v tip theo vi giy sau l SE.

Hnh 3.11. Thng s RE v SE hin th trn mn hnh theo di

3.4.5. Entropy trong qu trnh kh kch pht
Khi thnh phn kh kch pht thit lp (Hnh 3.12), v l thuyt cc gi tr
entropy RE v SE c tnh ton theo cch ging nhau cc mc gy m thp.
Thnh phn tn hiu c cha EEG b kh c coi l tn hiu hon ton c quy tc
khng c d liu ngu nhin entropy, trong khi entropy lin quan n cc kch
pht c tnh ton nh m t. Php tnh thng xc nh s loi b kch pht
bng cch m t s lng loi b tng i, c gi l t l loi b kch pht (
burst suppression ratio- BSR), trong vng mt pht c c php nh gi n
nh y . Mt ca s thi gian 1 pht gm mt mu tn hiu di ca c cc
kch pht v c ch cung cp ch s v s lng tng i tn hiu EEG b trit
tiu, trong khi ca s thi gian ngn hn nhiu s to ra cc gi tr BSR dao
ng cao. Vi cng l do, mt ca s thi gian 1 pht, thay v thit lp cc ca s
thi gian khc nhau, c dng cho tt c cc thnh phn tn s ca cc gi tr SE
v RE bt c khi no cc on b c ch c pht hin trc ca d liu.
S c ch cc kch pht c pht hin bng cch ng dng k thut c m

71
t bi Sarkela v cng s. loi tr cc dao ng c bn, mt tr s trung bnh
cc b c tr t mi mu tn hiu. Sau tn hiu c chia lm hai bng tn
bng cc b lc dng elip. Tn s ct ca cc b lc thng thp v lc thng cao
ny tng ng l 20Hz v 75Hz. im ny tn s ly mu tn hiu l 200Hz.
Bng tn thp c s dng pht hin thnh phn kch pht c ch v bng tn
cao pht hin nhiu. Mt b pht nng lng khng tuyn tnh (nleo) bt ngun
t c hai bng tn vi mi on 0.05s. Gi tr tng NLEO c ng dng nh
gi cng sut tn hiu t cc khung 1s xp chng v mc iu chnh bng 0.05s:

Hnh 3.12. Tn hiu EEG cha cc thnh phn kch pht - c ch

Trong sut cc giai on c ch, cc nhiu ECG c th phn loi gin on v v
vy nhiu ca chng b loi b. iu ny cho thy s thay th mi nleo hin ti
bng mt nleo trung bnh t khung 1s, nu cc quy tc sau y c p ng:
A- Bnh phng lch gia nleo hin thi t on 0.05 giy v gi tr nleo trung
bnh vi khung 1s ln hn ba ln so vi gi tr trung bnh ca tt c bnh
phng cc lch trong khung 1s,
B- Khung 1s bao gm hu ht 4 on p ng iu kin A.
Kch pht c pht hin nu tng NLEO di y l mt ngng c nh vi
chiu di t nht l 0.5s v nhiu khng th hin. BSR l phn trm ca cc on
0.5s trong khong 60s trc c coi l n p.
3.5. ng dng trong thc t
Cc thng s RE v SE c thit k s dng kt hp vi cc thng s quan

72
trng khc trn cng mt mn hnh theo di. Tp hp cc thng tin phc tp ny
c x l bi cc bc s chuyn khoa nh gi tnh trng bnh nhn. cung
cp cc thng tin d liu ngu nhin hiu qu nht c th, cc thng s c hin
th ti u nht.
Mt gi tr nguyn hai ch s, chng hn nh 56, trn mn hnh c th c
nhn thy nhanh hn l mt gi tr thp phn, chng hn nh 0,56 hoc mt s ba
k t nh 562. V l do ny, cc gi tr entropy ban u thay i lin tc gia 0 v 1
c bin i sang thang s nguyn y gia 0 v 100. S phn chia n gin
thang o ban u thnh cc gi tr nguyn u nhau t 0 ti 100 s
Mt phn tng i ln ca thang ton hc ban u ca cc gi tr entropy nm
trong di cc mc gy m c coi l qu su, v vy di quan tm nht ca gy m
y v tnh trng nguy kch nm gia 0,5 v 1. S phn chia n gin ca thang
o ban u thnh cc gi tr nguyn cch u t 0 ti 100 s dn n kt qu l vi
nhn t lm gim phn gii trong di quan tm v phn gii cao khng cn
thit cc mc rt su. V l do ny, s chuyn i t thang o entropy lin tc ban
u [01] sang thang gi tr nguyn [0100] c thc hin bng mt b chuyn
i tuyn tnh. S chuyn i ny c xc nh bi mt hm spine n c th nh
x t thang [01] n thang [0100].
Bt k hm spine no u c c tnh lin tc v o hm ca n bt k bc
no cng lin tc. V vy, mi hot ng chuyn i c xc nh bi mt hm
spine n iu l hon ton trn tru khng c s gin on hoc nt tht. Hm
F(S) thc hin s chuyn i c m t trong hnh 3.13. Nh c th thy trong
hnh 3.13, bp sng ca hm cao nht trong di gy m lm sng v cp cu
phn gii ti u trong di ny. Di entropy p ng t 0 n 100, trong khi SE thay
i gia 0 v 91.

73
 Hnh 3.13. Hm spine c ng dng chuyn i cc gi tr entropy ban u
thnh cc gi tr RE v SE c hin th trn mn hnh. Cc ng nt t phn
chia r di gia vi bp sng >1 so vi di cao v thp vi bp sng <1. phn
gii ca php o c tng cng trong vng gia bi php chuyn i.
Nu bin ca cc thnh phn tn s thp l rt cao, c th xy ra vng gy
m rt su, s khc bit gia RE v SE, khi cc gi tr ny thu c ban u t
phng trnh, c th gim xung thp hn phn gii s nguyn c s dng
trn mn hnh theo di. c du hiu pht hin hot ng in c EMG, nn iu
chnh vic x l cc thnh phn tn s trong di [Rhigh] = [32Hz, 47Hz]. Thay v
ng dng hng s chun ha Cn theo phng trnh trn vo tt c cc thnh phn
tn s, trong trng hp ny mt hng s chun ha s khc bit Cnhigh c s
dng trong di [Rhigh]. Ch cn Cn c mt gi tr di mt ngng ring Cnlimit,
Cnhigh c ly bng gi tr Crv, nhng nu Cn vt qu Cnlimit, th Cnhigh c ly
bng Cnlimit. S thay i ny m bo rng tn hiu EMG hot ng c pht hin
trn mn hnh bt k trng hp no.

74
3.6. Khi m tnh mch bng k thut TCI-propofol kt hp theo di m
bng entropy
3.6.1. t vn
minh ha cho ng dng thc t ca php o entropy trong php nh gi
hot ng in no, chng ta xt nghin cu Khi m tnh mch bng k thut
TCI-propofol kt hp theo di m bng entropy ca cc bc s Hong Vn
Bch, Nguyn Quc Knh v Cng Quyt Thng c thc hin ti bnh vin Vit
c. TCI-Propofol l mt k thut gy m mi, da trn m hnh dc ng hc
ca Marsh hoc Schnider, trong nghin cu ny tc gi s dng bm tim in
Diprifusor da trn m hnh ca Marsh. Gy m theo nng ch ti ni tc ng
l no (Ce), mc an thn ph thuc vo Ce.
V mt lm sng, cc tc gi da vo bng im OAAS (Observers Assessment
of Alertness/Sedation) nh gi mc an thn: OAAS5: Tnh hon ton, p
ng ngay khi gi tn bng ging bnh thng; OAAS4: p ng chm, m h khi
gi tn bng ging bnh thng; OAAS3: Ch p ng khi gi tn to hoc gi nhc
li; OAAS2: Ch p ng khi gi tn to v lay nh; OAAS1: Khng p ng khi
gi tn to v lay nh.
Entropy monitor (G.E) cng c a vo theo di m, Entropy l sng
in no v in ca cc c vng mt c tch hp s ho thnh 2 ch s RE v
SE; RE l ch s hot ng ca cc c vng mt, c gi tr: 0 - 100 ; SE l ch s
hot ng ca v no, c gi tr: 0 91. Gi tr ca Entropy: khi tnh: 100-85; an
thn: (84-65); khi gy m su: (64-40) v m su mt hon ton in no:
Entropy = 0.
Nghin cu c thc hin trong giai on khi m bng k thut TCI truyn
tnh mch propofol t lc bnh nhn tnh cho n khi mt p ng bng gi tn da
trn nh gi OAAS v theo di m Entropy nhm mc tiu:
1/ nh gi ch s Entropy, Ce v thay i v huyt ng trong giai on khi m
2/ Lin quan gia cc ch s OAAS, Entropy v Ce

75
3.6.2. i tng v phng php nghin cu

i tng: 21 bnh nhn, tui: (18 - 85), ASA: (I-II), m c chun b, thuc cc
chuyn khoa: Tiu ho, tit niu, ph khoa, tai mi hng.
Cch tin hnh: Tin m hypnovel 0,03mg/kg khi bnh nhn n phng m, 15
pht sau tin hnh khi m propofol (Diprivan PFS) vi k thut TCI, t nng
mu ch: 4g/ml, sau khi an thn t n OAAS1 th tim Fentanyl 2g/kg,
Esmeron 0,6mg/kg t NKQ v duy tr m. Cc thng s RE, SE, Ce, nhp tim,
SpO2 c theo di v ghi li ti cc thi im t OAAS5 n OAAS1, ring
HAMTB o 1 pht/ln. Sau m hi bnh nhn xem c hin tng thc tnh trong
lc khi m khng?
Cc s liu c x l thng k theo SPSS 13.0

3.6.3. Kt qu nghin cu

- Tui: 49,1918,88; Cn nng: 52,36,8 kg, Propofol: 63,9 27,4 mg; Ce:
2,781,07g/ml; HAMTB gim trong thi gian khi m: 7,575,55 mmHg;
Thi gian bm thuc: 15,34,2 giy; Thi gian t m OAAS1: 112,732,6
giy; khng c s thc tnh trong giai on khi m.
Bng 3.3. Thang im nh gi su an thn ( OASS)
im p ng
5 Phn ng sn sng, tr li tn mt cch bnh thng
4 Tr li tn mt cch th
Ch phn ng sau khi gi ln tn bnh nhn hoc nhc li
3
nhiu ln
2 Ch phn ng sau khi lc hoc thc nh vo ngi
1 Ch phn ng sau khi b kch thch au
0 Khng c phn ng ngay c sau khi b kch thch au

76
Bng 3.4.Ch s Entropy thu c theo thang im OAAS:
Entropy RE SE
OAA/S X SD min max X SD min max
5 92,82 7,46 79 99 85,09 5,72 74 91
4 82,38 4,37 76 90 76,13 5,19 70 86
1 38,52
23 59 36,19 10,96 17 57
10,68
Do thi im OAAS2 v OAAS3 xy ra qu nhanh, kh phn bit nn cc s
liu ny khng c a vo bng tnh ton.

RE = 103,443 - 22,281*CE

r = - 0,664 80
SE= 94,33 - 19,561*CE

80

r = - 0,628
p < 0,001
p < 0,001
60
RE

SE

60












40


40










20

1,50 2,00 2,50 3,00 3,50 1,50 2,00 2,50 3,00 3,50
CE CE

Hnh 3.14. Tng quan Entropy vi Ce

100,00


RE = 25,151 + 13,63*OAA/S
SE = 24,177 + 12,282 * OAA/S

r = 0,949




80 r= 0,946




p < 0,001

p < 0,001
75,00
60
SE
RE

50,00
40












25,00 20
1 2 3 4 5
1 2 3 4 5
OAA/S OAA/S

Hnh 3.15. Tng quan Entropy vi OAA/S

3.6.4. Phn tch
Cn nng trung bnh ca nhm nghin cu:52,36,8 kg tui:49,1918,88
vi k thut TCI khi m lm gim ng k lng thuc m propofol (63,9
27,4mg) so vi liu khuyn co 2-3mg/kg, do vy hn ch mc thay i
huyt p ng mch trong giai on khi m. Khi tnh ch s Entropy c gi tr: RE:
92,827,46 v SE: 85,095,72; khi m su mt p ng vi kch thch bng li
ni v lay gi th RE: 38,527,46 v SE: 36,1910,96
Cc mc m lm sng ca bnh nhn c lin quan rt cht ch vi cc ch s:

77
 - RE vi OAAS: r = 0,949 v p< 0,001
- SE vi OAAS: r = 0,946 v p< 0,001
Nng mu ch Ce c lin quan cht vi ch s Entropy:
- RE vi Ce: r = -0,664 v p < 0,001;
- SE vi Ce: r = -0,628 v p <0,001
Nh vy m cng su th ch s Entropy cng gim, nng thuc m ti ni
tc dng cng tng. Vi Ce: 2,781,07g/ml th tng ng vi thi im mt p
ng ca bnh nhn.

3.6.5. Kt lun
Ch s Entropy lin quan cht ch vi mc m lm sng v nng thuc
propofol ti ni tc dng (no), v vy c th da vo Entropy iu chnh lng
thuc m cho ph hp vi cc giai on m.
3.7. Li ch ca php o Entropy trong gy m
Li ch lm sng:
Cung cp thng tin v tnh trng thn kinh trung ng (CNS) trong gy m
Gim thuc gy m
Trnh gy m su khng cn thit v hi tnh khng gia chng
Gip p ng nhanh tnh trng nguy cp trong gy m
Li ch cho bnh nhn:
Tng tnh an ton v cht lng iu tr
To thoi mi cho bnh nhn
Gip chun thuc m theo tng bnh nhn
Li ch kinh t:
Gim s dng propofol trong 15 pht cui ca gy m trong nhm Entropy
gy ra mc tng Entropy v rt ngn thi gian hi phc.

78
 KT LUN
Thng qua ba chng ni dung v cc lun im trn, lun vn cp
n cc thng s c bn ca tn hiu in no v cc ng dng ca phn tch tn
hiu in no trong chn on bnh ng kinh v nh gi trng thi hot ng ca
no b trong gy m. Do vy ni dung lun vn gip chng ta nm c cc kin
thc tng qut v tn hiu in no v vai tr quan trng ca vic thc hin ghi in
no lm sng. T ngha m ngy nay php o ny tr nn ph bin v my
ghi in no l mt trong nhng trang thit b yu cu tiu chun ca mt bnh
vin.
Cng vi cc thng s o chc nng phi, tim, h tiu ha, chc nng c,
trao i cht, thng s o chc nng ca no EEG v mc an thn ca no b
(entropy) hon thin bn thng s sinh tn ca c th ngi nh di y:

79
 T bn trn, cc nh nghin cu hin i vn khng ngng pht trin cc
ng dng mi, quan trng trong y hc nhm mc ch cui cng l chm sc sc
khe con ngi tt hn.

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hc, H Ni.
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mch bng k thut TCI-Propofol kt hp theo di m bng entropy.
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entropy and bispectral index of EEG in propofol, sevoflurane and thiopental
anaesthesia, European journal of Anaesthesiology ; 23: A-92
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10. Nagata Osamu A/Prof (2008), Target-controlled infusion in daily practice,
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