Đánh giá hiệu quả giảm đau của ketamin liều thấp trong dự phòng đau sau mổ bụng trên

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ĐẶT VẤN ĐỀ
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 !"#$%&'()*+,
&-./)0 12$$3*4
5&677489:$;'<=&+$=
5$>6?$@,&-.A/)
BCDBED'
F+$"1@?&4G$H
-&$I+-66''F+$*
42=>">)*I+-"J%6$!A4G
24K$!?&"2$LM'<*$=+
$"1@L&7N6?$52$H=86?O
 2P$!+$+$6=Q
*$GP$6BRDBSDBTDBRD'
<*$=,>=4K,&+!/)
*$U>-*$GP$67&= *$V=?N'
W4/*$==4K+X7I$?Y$$&)
/$$=7&Z"5$+&[W\]$$&Y$
$747$&U+,&$-P^K,
6,_$&'`&H,K,*$="1
*_$&6$&=5*$=+$'a$^4/
=? 464K=5$A 4 4/*$=
&,4=5*$=+$BRDBbDBCRD'c&,V7;
*$=&4GK=$-=Q[IZ
]'a"7;$&?&"d&7
C
4K726.7"1$&$,'e6
4K.=+7;$& )=>+Z& %%&
`ce\"4/'
f%$,$72 7*$=&$6

&A'<="%$=4K7;&*$=7ZH
[%%$6%  %+]  7&  "%$  -  >%%& `3c%3e3\+
[`ce\]"4/[afag]'a=QA"%$
%%&`ce\$*$+Z*$Aafag6"VV=
7=>*$4K.*$=6*$4G=Q='h?
2"%$V 7"1$&$,$+=i
VG+Z$$MK=5$A6+X7"%$6$&=4G
5A$Q&,*$=$BCRDBCjDBkDBRCDBEjD'
a> ?19-&27*$
=A"%$?27;4$?&$7;+
$&">)**$=,6 V7BSDBlDBRDBbDBED
BklD'hm`$19-6?62=?H>'m9
6O1>=?0 Đánh giá hiệu quả giảm đau của ketamin
liều thấp trong dự phòng đau sau mổ bụng trên6C$0
1. Đánh giá hiệu quả giảm đau của ketamin liều thấp trong dự phòng đau
sau mổ bụng trên.
2. Đánh giá tác dụng không mong muốn của ketamin liều thấp và
morphin dùng giảm đau sau mổ bụng trên.
k
Chương 1
TỔNG QUAN
1.1. ĐỊNH KHU GIẢI PHẪU BỤNG TRÊN
1.1.1. Giới hạn bụng trên
n=4K/&V74$%&=
'
1.1.2. Thành phần các tạng trong bụng trên
W&&I$0=4G$&7
7o6BjD[L%$9']0
Hình 1.1. Định khu ổ bụng
R

1.2. SINH LÝ ĐAU SAU MỔ
1.2.1. Định nghĩa
a%&Q-,=),>[p\q lSb]=$Q
*$Q6?)6LO*$7&4/=I&
?$$16Q6&$-=QrA
4/2'a&= =$V+$=L2+
6I6GskBCD'
1.2.2. Đường dẫn truyền cảm giác đau'
 W*$==4K7?s&6Ji&1)
,>&"[L%$9'C]0
Hình 1.2. Sơ đồ dẫn truyền cảm giác đau
j
1.2.2.1. Đường dẫn truyền từ các receptor vào tủy sống
F7&?44/$1>$
&t/uW=&"VV/_
_& _=Q%%&*$==Z7&A
>&"=4K,Q1A76$1
&4$L4/=Q$$"$i& BCD'W
%%&*$*$=26$V'W%%&"1
 "*.V4K"N"VVN& 
$48=*$4Kv.*$=w
[%%+]64Kv7 w[x73]'F4K>
&"7?*$=s+s+A+,
*$"N"VV+y*$=/4BCjDBCSDBkD'`+
$6>$L*$Q&=6?57N4L2
*-6$[2&+7zu]%%&N"V
V+-.BCDBCDBlD'
W*$==4K?s%%&*$=6?>&
"-2+s+A+,%&+K\
δ

 $%6,=Q
b3kT${>=2%&+KW"1 $%6,=QTj|C
${&=$V BD'h$-A+,L=QA
4/2=&=L,3k=,A6;2L$+s
+'a+36>&"-+s+A+,+KW
>2?="22Q&%7"
 ==5$$=4K>6$N"X&7&=  5*
V69+&*$=$V V2.766HI
$QG+"==i>BlD'
b
1.2.2.2. Đường dẫn truyền từ tủy sống lên não
qKA>&"-td&+Qt43
=,767?*$=sA+,i&%&?=4G)
 3N 4 33=IN[L%$9'k]'
Hình 1.3. Sơ đồ chung của các đường nhận cảm tổn thương
\'aU+,0'(U}C'e+ }k'n 3N}R'n 34
n'ai&740j'W2&4
W'ai&@
e'`i&0b'`+}S'FIN}l'($'
E
1.2.2.3. Cảm nhận ở vỏ não
a>&"-s=IN=6;?i&66;*$
=A6Ji&'mJi& 6H&==6?$2669
?+3Q" L=N6NV=2/=
=&=$V'
W*$= 5tIs2-=5$&=4G7
?*$='F4G7?=i=4K>~6?$*'
a7 KA*$=*&6/5*$=2
*L-GO/5*-L=H
*$=$1&V2A"VV='`G6&6NVV

24G=QGL2$=-O•=&'
1.2.3. Những yếu tố ảnh hưởng tới đau sau mổ
1.2.3.1. Ảnh hưởng của phẫu thuật
3€&>,)>=N=+$'aG6$-
=Q=Q2?6&&4I
Z,=?2>%&
6;6Q+,BCDBCDBCTD'
3F"V6&++IZ67@7Q
2'W"6", 5=.7&+Z&/'
`4K1V=/'
3mNV$66G•*4=+
$'W=4Gd&=?/=4G‚)"y
+4G=/)=4G4L4/-'
3F?2sG-k=>G-b+$6=2
=*$7-6=V/s-k+$'
S
1.2.3.2. Các ảnh hưởng khác
3f=4K*V6•N,4$"*.N=A
+y,/'
3e;,*$=?&/&$9+$
4G=V/6"1=&R3bG=+$'
3F41ƒ7&4$4=4
>V6&+'''4>&=5=8=97,6*$="5
4K,*$=+$'
3W1.$+ +$'
34/*$=+$'
1.3. ĐAU SAU PHẪU THUẬT Ổ BỤNG
1.3.1. Nguyên nhân
1.3.1. 1. Đau nguồn gốc từ thành bụng
3F4G$&4G7t?

/4=4G$74+4G=4Gt=4Gt@u
fVV=s6>$=4K7?6&A+,%&=$
,'
3f6&7$Q4G&"d&
?=7@7Q+$'
3F4G7$Q4GQ=
+$'
l
1.3.1.2. Đau nguồn gốc từ tạng
F7&I,s$=2V=4G=Q6
G;%&-'`7&"VV
,746-$&"&$'F7&I,
$."V6&6"&=4>" N2
?&+$'
1.3.2. Ảnh hưởng của đau sau mổ bụng trên đối với các cơ quan trong
cơ thể
1.3.2.1. Trên tim mạch
F$.+,$.>.+-*&.
1/$7&.>%&$.&L/$7:>
$/$7&$2P6?3&LA/$'(/@=H
$=,$/)7:>",Y$+
7&"17$6=Q+$'n>-$$>$ƒ3
j„>-+$6=X6&+$
*$=,+y$*$>-'W*$=,+$
697"d$6*L&*$6)*A
 +Z&L/$BCED'
1.3.2.2. Trên hô hấp
qL2Q-12>7&*$
7V-.67V+,BED'
1.3.2.3. Trên tiêu hóa

F$*$=Q77Q"d&7G$^77'
1.3.2.4. Tiết niệu
<V='
T
1.3.2.5. Thần kinh nội tiết
F=-6=*"V$.%&$&+&
&&$&.4[<(]6+&%++7&+%&6+
.=4G$.@$,4& …&%65:$
;BbED'
1.3.2.6. Tâm thần
F&t+Ki$2A$*$'
†94/$1&"d&-t-"VV
%%&;"'W%%&N"VV$* 
^2&_A)96$62"VV&
*$=4K* &,7&"VV'F
-6"VV=$-,==&+$6
@*4/)'<*$=+$"1=A
6{&=*"V"1N->+y=
5$&1277QQ>$:7N
"4/'a2*@=7=>.U>-+
$BCTD'
1.3.3. Các phương pháp giảm đau sau mổ bụng
1.3.3.1. Gây tê vùng để giảm đau
3a&$-t4=4/*$=)*
+$'
3<*$=&$-=&t4=4/*$
=)*4 4K=5$" ".6?"‡=%%&
$-BkSDBEbD'

34/*$=7&Z"5$+&=4G&

$-[Wz\]4/*$=7&Z"5$+&
[%3W&&%7\%+0W\]$,6,_$&=4K
$6&"&&$-'a%&6.>4/*$
= 5$&$-$#dU+,$Q
>-$_6" I"6LXV$Q$
&$I+-t"ƒ=N4/BSD
BlDBDBCRD'
3<*$=PA+,$&?24/
*$=,7"d&7==4K-'
1.3.3.2. Dùng thuốc họ morphin đường toàn thân
3F4/=4K+X7?2'
3a&$$6IZ7;,_$&*
=4K*$?6%&7~y69>-+127:L*'(/
@)*6?4K,=@6%&s
G=5$+$BjDBkD'
3F4G7;$& 5$t$747$Y$
t)i$Y$7&Z"5$+&'
m+X7$&?&"1@.7"1
$&$,4I11->12$H$Q2K@
4K7$&.=+$BRCDBbkD'
1.3.3.3. Các kỹ thuật giảm đau khác
3ˆ*$='
3fVV=)7'
C
3f>K,*$="1*_$&4"6$
"1+%&7%…&$%$&BjRDBjjD'
‰f6$"1+%&7"1__"+X7"d&7
_&4GK.>6*$5V&'
‰f6$"1+%&7__WŠ‹3ppN,ƒ=N
+$"#$$6&*$=+$t

$6'
‰`%…&$6$7&=4K+X7_$
67&.+,$'
‰f%$?26%=4K">&+X7'(
?-6?"%$">K6,*$="09$?
6G=5$+X7=5 )*,2BRDBjED'
<*$=+$4G=4K7747=4/
--">K?,64/=5=)**$=
=IG*$7"1$&$,A$^4/$^,
BkbDBRkD'
1.3.4. Các phương pháp đánh giá đau sau mổ
1.3.4.1. Phương pháp khách quan 
3F&+Z=ƒ+,+ $4I=Q&$&
[%&$&+&u]'F4/,"d$">)*"1V
L69 ?>,*4">)*BCRD'
k
3F&+Z=ƒ124"V$5Vt+-
&=[Œzm]44K=ƒ[zŒ•]5V"V41
[m]5VV6&"V[%6%+&$%]'
3aV4K,*$=[$&&L&7&,u]$
=i7;),*$=W\Wz\BCbD'
1.3.4.2. Phương pháp chủ quan
Ža=5$=9=I7[m+\&q%3m\q]
a4=&=Q=$Q4 $7CT$'c)6?
V 94K5N$-=Q==57:
7+&+'c=,7)6?V, T6
=+,sT=>T'n=4K=N&J44/
-6$-=Q=A$9'f&*s=5$T=>6NV&J
ƒ=5$=m\q[$)6?V,]'a4
Ai\+3•%%BCDBCkDBClD'

Ž a =5$ =%&  +Z4K 6*GP +, [m%
`$%•q%3m`•q]
W="14=4K47
=5$=[=5$T4/-6"1==5$T=2]'n
=4K4K6*GP+,4/-6$-=Q=A
$9&&$-sT=>T'
Ža=5$=%&+Z4KP&[W%&•
q%3W•q]'
a,=4b$-=Q0"1==r=6s=7@7Q
=27@7Q="1N=Z=4K64K
$-=Q=A$9I*G'
R
1.4. DƯỢC LÝ MORPHIN
1.4.1. Cấu trúc hóa học và tính chất vật lý
c& 2&@)_2)>=N
V26!%%6 $-[IWk6%&
Wb]'W2O _A$&=i=4K•&&9$.$lCj'
c&,V&7 ,"?$>+,
7{4Pb_4KXCSj"El'a,tA>6
$BbD'
1.4.2. Dược động học
1.4.2.1. Hấp thu
f>=Q),&$$$•$$
'W5 )[CT3kT„]2+_)=4G 
N>BkD'
1.4.2.2. Phân phối
<t6&%>4/kj„?i&
$'aU,Q6&+,7{4'c&V
&7">$)&$i&$Y$
*$2jO$ 7BkD'

aUI=Q$&&i&6>4/{T$&">
K"d$6&%i&7:2$)&$i&AM%$2
M=M&67:2$)&'
c&5 A>ST„2"1&V
ET3ST„=&*)45H*)$6'b3T„
=4K*747"15&'
j
1.4.3. Dược lực học
1.4.3.1. Trên thần kinh trung ương
c&->afag*$=->12IA6
$Q+,=6?=i&'c&"VVafag-/I
16"*.&&4BjD'
3a7*$=0$& 7*$=$6=N
Q6&?4K+X7 72*&='
3a7"0&["=N=]&
"VV&t'
3a70$&$=+Z
"111$2 56?Q
$6?"VV=$$7;=i7;?4K$A
$&'
3a79*$0$&4G+*"&="#$6
->LO*$$4=1"" N6*$
)$&t$+*'
3c&$*$=-A6;(&$+6"V
V*$.>&$&"6*$4K4
5'c&.*+Z* \Wa(6&$&>'
1.4.3.1. Tác dụng trên hô hấp
3•>120$&$*$=-A$12
A6>ŠC6.WŠ
C

'a;Q6&?4K4+Z$2
*$A$L*?*$=J2'c&
->$12+,$"d&7G6
%&"‘"5W%%+3q&"%+'
b
3W&-Z0$& 5&-/L*4"
$2&=&Iƒ$+,iZ3*$
$7Q?+X76,=Q$'W/> y
$-A+,6746Ji&=6HA%%&>&
">,<\n\A=1'
3W&t>)*0$&7Z>//>)*
)=>* +$'
3•>*L&0L*?$&J2$.
/-=_=$i&!2=&+$'
1.4.3.4. Tác dụng lên tim mạch
’*4$$6>6?=?N'a&$Q+,
4GK$& 5"VV>+$i$r6
5*$>4>=&'
1.4.3.5. Tác dụng lên hệ thống tiêu hóa
3e70*$>7NLV.4/Z/77'
3•Q&0*$>7N6N67N$*$=QQ*$
+Z41AQ$.+Z24'
3F4G$0$.Z=4G$&t/6HŠ77'
1.4.3.6. Tác dụng lên hệ tiết niệu
€$.4/Z)**$+,4K45V5'
f"&; +X7$&4G2)$=>
7'
1.4.3.7. Tác dụng không mong muốn
c& $A-I11'
E

1.4.4. Tương tác thuốc
3m,A0$.+12.+Z$7N67:A/'
3m,0.7*$=./i$
7:>'
3m,U&*$7:>'
3m,$0$./+12'
1.4.5. Quen thuốc
†%,Q6&?7;6+Z7;'`4G)%
, 57;$&6?2T3CT?=6&/
?+&64G94G'(4K =4K*V 7&
%"%6*$&"VV%%&->* $Q+,2
&_->7%+%$*$+*L2\c6H'
f7;,=/5*-P.\c6H69
6?$&+=HJ./4=5%%&=-$4
•BRD'`&+Z&&%%&“A,*$=_$&
$."d&7)*A$6NV%%&`ce\'f%$-
>%%&`ce\*$4K)%,A,_$&
BblDBSkD'
1.5. DƯỢC LÝ KETAMIN
f%$,$Y$"1* 7t'
a,$Y$72 V2*$=BbD=i=4K+X7
Qi&?.$=4=5'a,=4K
K.$lbC7&1"%3e6+[W6q%6%+]=4K=46&
N4Gs.$lET6+X7&>m`$'
S
1.5.1. Tính chất lý học
f%$$QX 2O76H7L2A%7
6 &"1=,L-'`  7=I)_q[‰]6•
[3]3"%$&4fEj_4KXCkS6I74
7$,5'a$+"%$=4K9747$,

&(2LV=sjj=>kj;%&I=QA, BRD'
a,9777N„j„T„'”j$-jT$
77N„_T$-jTT$77Nj„'
f%$ 7=Ip+&q[‰]•[3]'e+X7
$+^KA=I6U'(=I
 774KZ_"'eq[‰]3"%$R$
/7/V*&/7$$•V/
7•[3]3"%$'eq[‰]3"%$$=4K+X7$Q+,4'
1.5.2. Dược động học
e&=V&$8,,6&i&'aG
7Q?6,"#$%&N=Q,6&-'
f%$=4K7;P?=4G0Y$$t$6&
A+,$&$-,6&$•"V)*'
a,t6&%$C„'aG2[a
{C•
]T3j
O'aG*s[a
{C–
]Cj3bTO4GST3CTO
M%$'aG"d&7"">K=IG6,_&%6
7—%$'
l
a5V,4Gl3CEV{"M%$k3CjV{"'
FQ*4GT3Rj${"{OM%$kj3CC${"{O'
a,)7&V&$8$'`I=Q&
26&G=5$j=>CO64G64KI=QA$r'
W5 lj„$%$&&&L%+%A&&$RjT
)*-$2 %7&L 6 &"> K'W5&
"%$&25 &=Q&"%$ =Q$
"&*{kA"%$'W2+= =4K*)6G

*C3kG4G'
f%$=4K*s)45lT„7475 R„
747"15 k„*s)'
f$Y$GG774kT7,=
+O"d&7j3jO'
1.5.3. Dược lực học
W/>7A"%$2-)=>?,
+_)&"1)%%&0
3a7%%&“δ˜A,_$&)=>
4K7,_$&'
3a7%%&&%'
3a7%%&A$&&$%"%$&&
,->=L,$&&$%[$&&$%7%+%7&
++%$][%"&%6q$lSC]=,V&=?ƒ)
9*$='
CT
3a=Q=,""1%%&`ce\27
?"VV")=>4K.=6
-'
1.5.3.1. Tác động lên thần kinh trung ương
a;Q6&?4K"%$9v$w7&
$Q$,->&=QA6Ji&66;74=I&"
"VV6?64'a$+/6&.
4/Z/*$=4A15$t$=IXi
i'*L$*L)**L,
6H'n 5&.>4_*4$t'q$
)>+Z"L*&$4$Q+,4GK
*&BbD'
™&L*"7;?&"$7;?
@'W 54KP&?$%—&7—%

&?$ BkD'e;7—%$,Tj${"&T${"Y
$4"$'W 5>P$7—&$TTj3T${"Y
$&&—%$C3R$Y$'&&…&&%•$*$
4KBkD'
1.5.3.2. Tác dụng lên tim mạch
a$$"%$ 7,+Z"VV&*$'
f%$$.>=Q$$6$4/.>
=Q$$?/$4/'a=Q$$Q
?4K,=Q$>=Q$6?N94G+"
$Y$"&*T3CO'a=Q$$7&=-A
7%%4/'qX7,?$_%—&7—%$*$
7BkD'
C
1.5.3.3. Tác dụng trên hô hấp
3f%$&=?"+X7$+V->*LA
$126WŠ
C
'q"$Y$C${"1"VO*$'
qX7?& 5s&)" ">K6
,_$&'qX7$Q$9"%$"1$="V$
=Q$'
3a$?t712*$/+&6?='
3f%$"1$$2*L*&6=4G'a
 77="$6*=?H/&4K'f%$
"1*,$Z_&4GK77='
3f%$ 7i>)*A>7&=V,&
*$'a,=4K+X7&%>)*'e=I•[3]
 7//=4G12$/7q[‰]69!7&
7^K=4K+X7& &t>)*'
1.5.3.4. Tác dụng như chất chống hiện tượng tăng đau và chống chất tiền viêm

f%$1)->%%&`ce\"1ƒ$*$
4K.=-7&4/$1$H$*$4K7
A,*$=_$&BjbDBETDBESD'
*-6$L*+)924/6>
5A:$;'a>%&+4/$1/5,P
"=Q$Q&*-$:7N67=>*-6$
6$=V79+ZP=N=5?+r&'a&*-6$6
HA2?6$[&3…$$&%]2)_'*-6$
+ZP@2"6$62,6$'f%$2&
+$7:>P'f%$*$$6+*L2
CC
&"?6$[&"%&3…$$&%]P6*$22
&)9+&dBCSD'
1.6. Nghiên cứu tác dụng giảm đau của ketamin
f%$?2/?$ 7*$="d$$&'
m&=QA"%$1)%%&`ce\$$
VG+Z66HA"%$$+'f%$=4K7;$
,*$ =^K$&'fVV=$&&%%&
`ce\4K."VVA>&"+s+U
+,$.*$4/4K7 6
*$='f%$$Q2=,""1A%%&
`ce\ 5.s4K*$4/"V
V=&•4.*4K7 BblD'qZ&
&%%&“A,*$=_$&$."d&7)*
A$6NV%%&`ce\'fƒ7;,*$=_
$&?&"d&7+y4K7=? 57
=>.=+$BbkD'f%$1)->%%&`ce\ 5
Hs+Z5A4K7'f$/
+&?-6?"%$4,^K$&&*$
==4/-BCjD'`I=Q>4/)*=5 7

CT3TT{$6=5==4KI=Q7;?=Tj${"
+= ?Y$6,=QTj3k${"{OBEDBRCD'
1.7. Các nghiên cứu về tác dụng giảm đau dự phòng của ketamin
3q6Q+Z[llE]=i>-CT
&&-$;=1$C $'` $
"%$Tj${""%$Y$47+= =4K?
Y$C${"{O&CRG6${"{O&RSG>
Ck
%&'` $-=4K$6?*74K[4$,+!]'f>)*
&26;.*$="$"$*$= !Y $
"%$6&-k6E+$'€4K$&6=5$=
m\q*$&@G=+$ $"%$'F5$H
 $"%$&/ $-'aU7"1$&$,
 $-&/+&6 $"%$BECD'
3<&6Q+Z[CTTk]-lk=4K
*$=P$&)W\"6?HIƒ'` $
"%$[R]Tj${""%$I=4K?Y$C
${"{O&CRG${"{O&CRG>%&'` $-
=4K?4$,+!'f>)*&2=5$=m\qOƒ6
O6=Q,@C $4K$&V/ $
"%$BklD'
3€%6Q+Z[CTTR]-lT=4Kt
$6=4KC $'` $"%$[RR]
q[‰]3"%$Ej${"+"$+= =4K?Y$
Cj${"{O&RSG>%&s"6?HI+-'` $-
=4K?4$,+!'n=4K*$=+$P
&L&7&)W\'f>)*4K&L&7&V/ $"%$=5$
=m\q""1 !Y@C $=QH $
"%$&/ $-UI161,C $
 R $"%$N*&&)BjkD'

3\7$6Q+Z[CTTj]-RT",
&Q=4K=%%&>"=;6?Tk
${"&6TEj„4$679T${"{G&6TC„
&RSG"&&'W=4KC
CR
 $'` $"%$=4K$Y$"%$Tj${"I=4K
?k${"{O&$6j${"{O&RSG>
%&'` $-=4K?4$,+!'f>)* $"%$
V$&/2,=>lT
T
/ $-BbD'
3•"%6Q+Z[CTTS]-7*$=A"%$
S=4K$k $'` $p
"%$Y$Tj$+"$IC${"{O&RSG'
` $pp;? $p4s"%$O">OQ$'
` $ppp=4K?4$,+!'f>)*24K$&
&CRG=2/ !Y," $p+&6 $pp6
ppp=5$=m\q2/ $ppp+&6 $pppU1 $ppp
&/ $p=5$"1"@ $"1
&N9=1*&BSkD'
<=[.$CTTS]$Q+,-&$"%$6&$&
=5*$=+$)W\'f>)**$4K$&>
=Q=N6"1.7"1$&$,BbDBbkDBERD'
W&=>4 -&+&+7;;?
"%$,&?&++= ?4G
=5$476+"6?HI+-'
1.8. Một số khái niệm và định nghĩa
3<*$=7ZH[%%$6%%+]+X7,s4
O7.*4K*$4/4/
7&64/7&6$&G$6=&=+

$BSDBkbDBRkDBRlD'
Cj
3(4K.=[%%+]=-)$-6"VV='
3(4K&74K$*$="
"VV"1='
3(4K7 [š73]4K>&"
+s+A+,*$"N"VV+y*$=/
4BblD'
3`*$4/[%+%+—&]@=+
4/6Iafag7=>.*$6"VV='
3a."VV4/[%%%L]=-"d&7
6)$-A>&"6"VV=+$BRlD'
3f%$?2[+$37&+%"%$%]=4K=NY?J
/C${">$tJ/${">$Y$&&
$-63k${"{O>?Y$&&
$-P/$$=BCjD'
3™&[(&]*$4 6?$Q+Z
6$Q4K"1? &Z")'™&L2
6$2="1Q6&!$,A 5"#$%&
"1"#$%&,&!-[$+*$$Q]&,&47[$2
6?+$A$9]'™& 5L2Q6+Z
6ZL2M'