A BAO CAO KHOA HOC
Tl le mdi mac, dac didm lam sang va kha nang hoi phuc cua benh nhan hoi sire CO benh than kinh co do mac benh tram trpng
TS. Nguyen The L u 3 n \ PGS. TS. Nguyen HuTu Cdng*»
*6^n/i wen Qa khoa Trung tam Tien Giang
** Trudng Dai hoc Ykhoa Phom Ngoc Thach
TOM TAT
Co sd nghien c i ^ : Benh than kinh cd do mac b^nh tram trpng (CINM) thddng xay ra tren benh nhan hdi sdc. Benh anh hddng d^n kha nang phuc hoi va lam tang ti le tOr vong nhung van chda co phuong phap dieu tri hdu hieu. Cac bao cao trong nudc ve benh li nay cdn tddng ddi it.
Muc ti€u: Xac djnh ti le cac dac diem lam sang, can lam sang, mdc do hdi phuc va ti 1^ mdi mac cOa CINM tren benh nhan hoi sure > 10 ngay.
Odi tddng va phddng phap: Md t^ cat ngang, cd theo ddi dpc 133 trudng hap tCr 10/2010 den 10/2012 tai B^nh vi^n Oa khoa Trung tam Tien Giang.
Ket qua: Ti le mdi mic cua CINM kha cao 54,89%. Trong do, the benh da day than kinh do mac benh tram trpng chiem cao nhat 47,95%, ke den la benh da day than kinh va benh cd do mac b@nh trim trpng 30,14%, thap nhat la benh cddo mac benh tram trpng 21,92%. Hau het cac dac diem I3m sang, can I3m sang tddng tuy van va cac nghien cdu khac. Gin 1/2 trddng hdp CINM tiJT vong trong benh vien (49%). Con lai, gan 1/4 hoi phuc van ddng hoan toan hoac mot phan sau 3 thang, hon 1/2 chua hoi phuc hoac nang hon va gan 1/4 tdvong sau ra vien.
Ket luan: Ti le CINM kha cao nhdng vin c6 th^ hdi phuc hoan toan. Do do, nen chu trpng phdt hien sdm cac trieu chumg cOa benh nham han che ti le va mdc dp nang.
Tir khda: benh than kinh co do mac benh tram trpng, benh da day than kinh, benh co, benh tram trong.
I. OAT VAN OE de dieu tn benh than kinh ca do mac benh tram Benh than kinh cd do mac benh tram trong " • ' " ^ " ' ^ ^'^" P^'^P ' " " * " '^ "9=" "9^^ ^^"'°
(critical illness neuro myopathy, CINM) thudng nguy eo, dieu trj tieh cUe benh li chinh va phuc xay ra tren benh nhan dieu tri tai dan vj hoi sdc ^ ° ' ^^^^ "^ng sdm.Tuy nhien, ca che benh sinh tieh cue Benh li nay co the lam keo dai thdi gian van chua duqe sang to, lam eho viee quan li benh nam vien, lam giam kha nang phuc hoi, tang chi gap nhieu khd khan. Vi vay, benh than kinh ca do phi dieu trj va tang ti le tdvong. rnae benh tram trong van la van de dang duac
Hien tai vin chUa co phuang phap hdu hieu quan tam, nghien cdu.
66 THAN KINH HQC VIET NAM I SO 10/2014 Website: hoithankinhhocvietnam.com.vn
BAO CAO KHOA HOC k.
Benh da day than kinh do mac benh tram trpng dUcfe mo ta dau tien vao nam 1984. TU do den nay cd nhieu bao cao ve benh than kinh ea do mac benh tram trong ddac cong bd tai cac nude phat trien nhu My, Phap, Ha Lan. Tai cae nude Chau A, trong dd ed Viet Nam, cac eong trinh nghien cdu ve benh than kinh ea do mac benh tram trpng eon tuong doi ft.
Vdi nhCfng li do tren, ehung toi tien hanh nghien eUu nay vdi muc tieu xac djnh ti le mdi mac, dac diem lam sang, can lam sang va mdc do hdi phue eua benh nhan hoi sdc > 10 ngay cd benh than kinh ea do mac benh tram trpng.
II. Dfil TUONG - PHU0NG PHAP NGHIEN CllU 1 .€)6i tiftfng nghien cufu
Tat ea benh nhan duoe dieu trj tai khoa Hoi sdc Tich cue - Chdng dpc, Benh vien Da khoa Trung tam Tien Giang tU thang 10/2010 den thang 7/2012 va ed du tieu ehuan ehon mlu nhd sau:
7.7. Tieu chudn chgn vao
Dieu trj tai khoa Hoi sde Tfeh cdc > 10 ngay.
Tong diem sde co MRC lue nhap vao khoa Hoi sde Tieh cdc > 48 diem.Tuoi > 15.
1.2. Tieu chdn logi ra
Cd benh than kinh co trude khi dieu trj tai khoa Hoi sUcTich cUc. Khong khao sat duae day du thong so can eho nghien eUu. Khong dong y tham gia nghien cdu.
1.3. C&mau
N = 133 trudng hc^^. ap ciung cong thde Ude lupng mpt tile:
N =
Z ( l - a 2 ) X P ( l - P )
a = 0,05, Zg,„ = 1,96, d = 0,08, P = 33% [5].
Website: hoithankinhhocviefriam.com.vn
2. Phi^cmg phap nghien cuXi
2.1. Thiet ke nghien cut/Mo ta cat ngang, co theo ddi doc.
2.2. Phuong phdp thu thgp so lieu
Phong van va quan sat true tiep. Kham tdng quat, kham than kinh, xet nghiem eong thUc mau, dudng mau, ure, creatmin, AST, ALT, ion do, CPK, khi mau dong mach.
Khao sat dien sinh ly than kinh ea 2 lan. Lan thu" nhat vao ngay 1 -3 de loai tru" benh than kmh CO CO trude khi vao khoa, lan thu" hai vao ngay 10-15 de xac djnh eo hay khong co benh than kinh CO mdi m^e khi dieu trj tai khoa Hdi sde Tfch
cdc. Khao sat day than kinh gida, tru, quay, chaysau va mac nong 2 ben. Khao sat dien ca kim cae ca delta, ca gian cot mu tay I, ca chay trude va ca thang dui 2 ben [8].
Chan doan benh than kinh ca do m^c benh tram trpng (CINM) khi eo mpt trong ba the benh gom: Benh da day than kinh do mac benh tram trpng (critical illness polyneuropathy, CIP) hoac benh co do mac benh tram trpng (critical illness myopathy, CIM) hoac benh da day than kinh va benh ea do mac benh tram trpng (critical illness polyneuromyopathy, CIPNM) theo tieu chan eua Stevens nam 2009 [9].
Danh gia kha nang hoi phyc theo thang diem Hughes va thang diem ban ehe toan dien benh than kinh ngoai bien (ONLS) tai cae thdi diem ngay 1, ngay 15, ngay 30 va ngay 90 [6].
3. Xii ly va phan tich so lieu
Nhap so lieu bang phan mem Epidata va xu' ly bang phan mem STATA.
Tinh ti le va trung binh eac gia trj. Dung phep kiem y;^ so sanh ti le va phep kiem t, Anova so sanh so trung binh gida cae nhom.
5(^10/2014 I THAN KINH HOC VIET NAM 67
A BAO CAO K H O A H O C
III. KET QUA NGHIEN COU
Trong 25 thang, chung toi t h u thap duoc 133 t r u i n g hop dCi tieu chuan chon mau.
1 .Ti le benh than kinh co do mac benh tram trong (CINM) tren benh nhan hoi siilc
1C6CINM KTC 95% 0,46-0,64 I Khong CINM
KTC 95% 0,36-0,54
2. H le cac the benh CINM tren BN hoi sijrc
T a n s o 35 30 25 20 -
10 - 5 0
KTC 9 5 % 4 7 , 9 5 %
Wk H m •
•
CIP 0,36-0,6
M n = 7 3
2 1 , 9 2 %
n til
B ^ ^ ^ ^ ^ H
^^^^^^v
CIM0,13-0,33
3 0 , 1 4 %
s •
CIPNM T h e b e n h C I N M 0,2-0,42
3. Tudi t r u n g binh CINM (n) Co (73)
Tuoi trung binh 70,58
Khong (60) 68,86 Mau (133) 69,62
D o lech 13,36 13,02 13,19
P
0,47
68 IHAN KINH HOC VIET NAM I SO 10/2014 Website: hoithankinhhocuietnam.com.vn
BAO CAO KHOA HOC Ik.
4. Phan bo gidi tfnh
GiOi
Nut Nam
TongMauNC N(%)
69(51,88) 64(48,12) 133(100)
Co CINM n ( % ) 36(49,32) 37 (50,68) 73(100)
Khong CINM n ( % ) 33(55) 27(45) 60(100)
P
0,72
5. Dac diem trieu chufng lam sang
Dac diem
RL tri giac Teoca Giam PXGC
RLCG(109) Tong so
M a u N C N (%)
24(18,05) 26(19,55) 47(35,34) 28(25,69) 133(100)
CINM
Co Khdng 12(16,44)
23(31,51) 35 (47,95) 26(42,62)
12(20) 3(5) 12(20) 2(4,17) 73(100) 1 60(100)
P
0,6
<0,01
<0,01
<0,01
PXGC: Phan xa gan co, RLCG: Rdi loan cam giac.
6. Tdng d i i m siJTc co MRC e i e m MRC
Lani
Lin 2
CINM
Co
Khong MauNCCo
Khong MauNCTrung binh 58,69 58,88 58,78 41,91 53,08 47,02
eaiSch
2,15 1,71 1,96 3,58 6,31 7,49
P
0,56
— 0,01
_1__J
Website' hoithankinhhocvietnam.com.vn 5 0 10/2014 I THAN KINH HOC Vl|T NAM 69
A BAO CAO KHOA HOC
7. Dac diem sinh hoa mau Bien so
Bach cau (xlOVmm')
CPK(U/L)
Dudng mau (mmol/L)
Ure (mmol/L)
Creatinin (nmol/L)
AST(U/L)
ALT(U/L)
Na* (mmol/L)
K* (mmol/L)
CINM
Co
KhongCo
KhongCo
KhongCo
KhongCo
KhongCo
KhongCo
KhongCo
KhongCo
KhongTrung binh 14,87 12,83 220,82 82,57 8,78 7,11 11,86 8,71 117,82 140,55 185,41 47,13 117,36
32,03 136,49 136,78 4,24 4,14
O a l # c h 8,1
5,67 445,05
83,12 8,4
2,84 18,61
5,55 81,07 116,58 915,48 39,86 478,86 21,06 10,48 5,35 0,84 0,85
P
0,09
0,01
0,14
0,17
0,20
0,25
0,13
0,84
0,49
8. Roi loan dien giai va thang bang kiem toan
Dac diem
Roi loan dien giai Roi loan kiem toan
M a u N C N ( % )
47 (35,34) 61 (45,86)
CINM
Co
34(46,58) 36(49,32)
Khong 13(21,67) 25 (41,67)
P
-a
0,03 0,38
70 THAN KINH HOC VIETNAM I SO 10/2014 Website: hoithankinhhocvietnam.com.vn
BAO CAO K H O A HOC k.
9. Dac diem cac tinh trang benh li
Dac diem
eovHT NTH S6c
SfXTQ Tong soM i u N C N ( % ) 86 (64,66) 36(27,07) 47 (35,34) 55(41,35) 133(100)
CINM
Co
58(79,45) 23(31,51) 33(45,21) 38 (52,05) 73(100)Khong 28 (46,67) 13(21,67) 14(23,33) 17(28,33) 60(100)
P
0,01
0,2
0,01 0,01DUVHT: hdi chdng ddp dng viem he thong.
HTH: nhiem trung huyet, SDCQ: suy da ca quan
10. Dac diem dieu tri va tuT vong
Dacdi^m
Thd may Steroid ChenTK-co
Tijrvong Tong so
M a u N C N ( % ) 66 (49,62) 47 (35,34) 83 (62,41) 54(40,6) 133(100)
CINM
Co
43 (58,9) 29 (39,73) 53 (72,6) 36(49,32) 73(100)
Khong 23 (38,33) 18(30) 30(50) 18(30) 60(100)
P
0,02 0,24 0,01 0,02
11.Thdi gian dieu trj hoi site va n i m vien Oac diem
Thdi gian hoi sufc (ngay)
Ihcli gian nSm vien (ngay)
CINM
Co
Khong MauNCCo
Khong MauNCTrung binh 20,34
14,3 17,62 25,07 18,58 22,14
0 6 lech 15,39
6,33 12,5 17,06
9,53 14,49
P
0,003
1
0,001
Website: Inoitliankinhlnocvietnam.com.vn 56lO/2014lTHANKINHHOCVrETNAM 71
A BAO CAO KHOA H O C
12. Khd nang hoi phuc cua benh nhan CINM 12.1.Trung binh diem Hughes va ONLS cua mdu
Tmng bmh diem Hughes P<0,D01
/X li-*
JK MiuNC —
P < 0,001 4,03 3,23
2.28
- C D C I N M — P< 0,001
_ ^ 3,28
2,4
-Khong CtNM
Ngay 1 Ngay IS jy 30 Ngay 913 4 -
3 -
2 - tlh diem ONLS
P< 0.001 4,02
/ l , * !
^JuT MluNC
Ngay 1 Ngay 15 P < 0,001
4.21
_ 1.27 ^
Co CINM
Ngay 30 P = 0,015
"V-if* •
" " " l ^ S KhSrig CINM
Ngay 90
12.2. Trung binh Siem Hughes va ONLS cua cdc the benh CIP, CIM, CIPNM Tnihg bmh Mm Huohes
^ 3 , 8 ff 3,55 f 3,41
4,53 4,15 3,74
'
4,47 4,05 3,79
a /
Ngay 15 Ngay 30
5 - tlh diem ONLS
P = 0,987 P = 0,843 P = 0,424
Z -
' 4 3.8B
4,67 \ . 4,19 3,33 ^ 2 , 9 4
2,67 ' / 1,6 f
0 -f- ^ Ngayl
-•-CIP Ngay IS
- • - C I M
Ngay 30 Ngay 90 CIPNM
12.3. Tile mUc 36 hoi phuc cua benh nhdn CINM
* Hoan toan • Mot phan *^ Chira • Nang hon ** TCr v o n g Mi/c d o hoi phuc
72 THANKINHHOCVIETNAMI SO 10/2014 Website, fioithanlonhtiocvietnam.com.vi
BAO C A O K H O A H O C k.
IV. BAN LUAN
Tl le benh than kinh cd do mac benh trann trpng (CiNM) t r o n g nghien cdu nay kha cao 54,89% ( l a c 95% 0,46-0,64). Trong do the benh da day than kinh d o m k benh trann trpng (CiP) chiem uU t h e 47,95%, ke den la the benh da day than kinh va benh c a do mac benh trann trpng (CIPNM) chiem t i le 30,14% va tinap nhSt la the benh ca do mac benh tram t r p n g (CIIVI) chiem 21,92%. Ti le CINM cua nghien cifu nay tLfcfng tir Bednarik (57,4%) [1], cao hon cua De Jonghe (25,3%) [4], CO t h e d o tieu chi chpn mau khac nhau.
Tuoi trung binh t r o n g mau nghien cufu la 69,62 ± 1 3 , 1 9 tudi. Thap nhat la 24 tudi va cao nhat la 87 tudi.Tt le nCf chiem 51,88% va t i le nam chiem 48,12%, gan bang nhau. Tl so nCf; nam la 1,08. Khong co sii khac biet ve tudi va gidi tfnh giCTa 2 nhom co va khong co CINM.
1 . Dac diem trieu chuTng Jam sang cua CINM Trong nghien cufu, t i le roi loan tri giac la 18,05%. Tfle t e o CO t r o n g nghien cu-u la 19,55%, 26 trUdng hpp. Tl le teo co cua n h o m co CINM (31,51%) cao hon n h o m khong co CINM (5%) co y nghTa (P < 0,05). Phan bo teo co chu yeu la d ngon chi doi xijfng 2 ben, chan nhieu han tay.
Mpt 50 teo ca n g o n lan gdc chi.
Tl le gicim phan xa gan co t r o n g nghien cufu la 35,34%, 6 n h o m co CINM la 47,95%, cao hOn CO y nghTa so vdi n h o m khong co CtNM la 20%
(P < 0,05). T i l e rdi loan cam giac la 25,69%, 6 cua nhom CINM cao hon n h o m con lai co y nghTa {P
< 0,001).
Trung binh t o n g d i e m sufc co MRC lan 1 la rat cao 58,78 ± 1,96 diem. Lan 2 giam nhieu chf con 47,02 ± 7,49, t h a p hOn lan 1 va 6 n h o m CINM (41,91 ± 3,58) thap hon n h o m khong c6 CINM (53,08 ±6,31) c o y nghTa.
Do do, can t h a m kham sufc cp, phan xa gan co.
c h u y tec c p v a r o i l o a n cam giac tren benh nhan hdi sure t h u d n g xuyen de phat hien sdm CINM.
2 . Oac diem can lam sang cua CINM Trung b i n h n d n g dp CPK cua mau la 158,45
± 304,44 U/L, d nhom cd CINM la 220,82 ± 445,05 U/L, cao hon n h d m khong CINM la 82,57 ± 83,12 U/L. Ket qua nay tUong tU nhU ket qua cua tac gia De Jonghe [4].
Cd 35,34% rdi loan dien giai, trong nhdm CINM la 46,58%, cao hon nhdm khong CINM (21,67%) cd y nghTa. NhU vay, rdi loan dien giai la bat t h u d n g can dupc chu trong. N h u vay, ket qu^ c$n lam sang cua chiing tdi tUOng tU vdi y van. Hau het cac xet nghiem sinh hda chua cd y nghTa trong chan doan CINM. Rieng CPK co the tang trong CIM hoai t d co cap [2].
3. Dac d i e m t i n h t r a n g b e n h If, d i e u trj va tiir v o n g b e n h n h a n hdi sii^c co CINM
Ti le cd hoi chUng dap Ung viem he t h d n g cua mau nghien cUu rat cao, chiem 64,66% cac trudng hpp, d nhdm CINM cung rat cao (79,45%), cao hon nhdm khdng CINM (44,67%) cd y nghTa (P < 0,001). Theo tac gia Bolton, My, hpi chUng dap Ung viem he thdng chiem t i le kha cao tren cac benh nhan hdi sUc, tU 30-50% [2]. Tinh trang nay cd the la nguyen phat do benh li chinh nhimg cung cd the thU phat tUnhUng thu thuat xam lan.
Ti le nhiem trung huyet trong nghien cUu la 27,07%, cua nhdm cd CINM la 31,51%, cao hdn n h d m khong cd CINM la 21,67%. Ti le sdc la 35,34%, d nhdm CINM la 45,21%, cao hon n h d m khdng CiNM chi 23,33% cd y nghTa.Tac gia Coakley, trong 25 trudng hop sdc nhiem trung, t i le CIP sau 12 ngay la 76% [3]. Ti le suy da co quan la kha cao, chiem 41,35%, d nhdm co CINM (52,05%) cao hon n h d m khdng CINM cd y nghta (P = 0,006). Suy da cd quan cd the gdp phan lam tang nguy cd t d v o n g va giam kha nang hoi phyc cua benh nhan.
Tl le t h d may trong nghien cUu kha cao, chiem
Website hoithankinhhocvietnam.com.vn 56lO/2014ITHANKINHHqCVIETNAM 73
A BAO CAO KHOA HOC
gan 1/2 cac trudng hop (49,62%), rieng nhdm cd CINM chiem den 58,9%, cao hon nhdm khdng CINM CO y nghia. Thd may cd the lien quan vdi CINM.Ti le benh nhan dUoc sd dung thudc chen than kinh cd chiem kha cao 62,41%, d nhdm CINM rat cao (72,6%), cao hon nhdm khong CINM edy nghTa[7].
Tl le tUvong trong benh vien kha cao chiem 40,6%, nhom cd CINM (49,32%) cao hdn nhom khdng cd CINM (30%) cd y nghTa. CINM cd the lam tang ti le tUvong trong vien.
Trung binh thdi gian dieu tri hdi sUc cua mau la 17,62 ± 12,5 ngay. Trung binh thdi gian nam vien kha dai 22,14 ngay. 6 nhdm cd CINM keo dai hdn nhdm khong cd CINM. CINM cd kha nang lam keo dai thdi gian dieu trj hdi sUc va thdi gian nam vien.
4. Kha nang hdi phuc cua benh nhan hoi su'c CO CINM
Trung binh diem Hughes cCia mau nghien cdu, cua nhdm CINM va cac the benh CIP, CIM, CIPNM cd khuynh hudng tang dan theo tdng thdi diem ngay 15, ngay 30 va giam mpt it vao ngay 90.
Trung binh diem Hughes cua nhdm cd CINM tai tdng thdi diem ngay 15, ngay 30 va ngay 90 cao hon nhdm khdng cd CINM cd y nghTa (P < 0,001).
Trung binh diem ONLS cua mau nghien cdu, cua nhdm CINM va cac the benh CIP, CIM, CIPNM cd khuynh hUdng tang len vao ngay 15, sau dd giam nhe vao ngay 30 va giam xudng rd ret vao
ngay90.Trung binh diem ONLS cua nhdm CINM theo tdng thdi diem ngay 15, ngay 30 va ngay 90 deu cao hon nhdm khdng cd CINM cd y nghTa (P
< 0,05).
Thang diem ONLS cd nhOng Uu diem la danh gia dupc mUc dp han che cija ca tay va chan, cd the danh gia mUc dp hdi phuc tdt hon thang diem Hughes.
Sau 90 ngay theo ddi 73 trudng hpp CINM, 49,32% trudng hpp tU vong trong benh vien, con lai 50,68% xuat vien. Trong sd nay, ti le td vong sau xuat vien la 16,22%.Tlle hdi phuc chdc nang van dpng hoan toan sau 3 thang la 8,11%, ti le hdi phuc khdng hoan toan la 16,22%. Sd trudng hpp chua cd bieu hien hdi phuc chiem 43,23%. Cac trUdng hpp cd bieu hien mat chUc nang nang hdn la 16,22%.
V. KET LUAN
Benh nhan hdi sdc td 10 ngay trd len co tl le benh than kinh co do mac benh tram trpng la 54,89%. Cac dac diem lam sang va can lam sang trong nghien cdu nay tuong tu vdi y van va cac nghien cdu khac.
Gan 1/2 trUdng hpp cd b#nh than kinh cd do m^c benh tram trpng tUvong trong benh vien.
Cdn lai, gan 1/4 trUdng hpp hdi phuc van ddng hoan toan hoac mpt phan sau 3 thang, hPn 1/2 trudng hpp chua hdi phuc hoac nang hon va gan 1 /4 trudng hpp td vong sau ra vien.
ABSTRACT
THE INCIDENCE, CLINICAL CHARACTERISTICS AND THE RESILIENCE OF ICU PATIENTS WITH CRITICAL ILLNESS NEUROMYOPATHY
Nguyen The Luan, Nguyen Huu Cong Background: Critical illness neuromyopathy (CINM) usually found occuring on ICU patients. This disease affects the resilience and increases mortality, w/hile there is no effective treatments available.
Reports on CINM in our country have been so far hardly found in medical media.
74 THAN KIMH HOC VIET NAM I SO 10/2014 Website: hoithankinhhocvietnam.com.vn
BAO CAO K H O A H O C k
Objeclive:This study will attempt t o g l v e a n identification of thecllnical.para-cllnlcal characteristic ratios, t h e resilience and the incidence of CINM found in patients having been treated in ICU within 10 days or more.
IMaterials and methods: The cross-section descriptive study with longitudinal observation was conducted on 133 patients from October 2010 through October 2012 at Tien Giang Hospital.
Results: The CINM incidence Is quite high reaching up t o 54.89%. Among these patients observed, critical illness polyneuropathy (CIP) were highest at 47.95%, Coming second was critical Illness polyneuromyopathy (CIPNM) at 30.14%, and critical Illness myopathy (CIM) at the lowest level with 21.92%. Most of t h e clinical, paracllnical characteristics detected was In fact similar t o those explained in medical textbooks and other studies. Nearly half of the 133 cases surveyed were dead at the hospital, reaching 49%. Nearly one-fourth of the other patients were partly or fully recovered after 3 months. More than half of these show no signs of recovery and some of t h e m whose conditions are seen t o get worse and nearly a quarter died after being discharged from hospital.
Conclusions: The Incidence of CINM is quite high but there is hope for a possibility of full recovery.
Thus, w e should attend t o detect its signs and symptoms as soon as possible to help limiting Its incidence and severity.
Keywords: critical Illness neuromyopathy, polyneuropathy, myopathy, polyneuromyopathy.
T A I L I I U T H A M K H A O
1. Bednarik, J., et al (2005). "Risk factors for critical illness polyneuromyopathy'; J Neurol, 252(3):p p.343-351 2. Bolton, CF. (2005). "Neuromuscular manifestations of critical Illness" Muscle Nerve, 32(2), pp.140-163.
3. Coakley, J.H., et al. (1993), "Preliminary observations on the neuromuscular abnormalities in patients with organ failure and sepsis" Intensive Care Med, 19(6), pp.323-328.
4. De Jonghe, B. (2002). "Paresis acquired in the intensive care unit: a prospective multicenter study" Jama, 238(22), pp.2859-2867.
5. De Letter, M.A., et al. (2001). "Risk factors for the development of polyneuropathy and myopathy in critically III patients'; Crit Care Med, 29(12), pp2281 -2286.
6. Graham, R.C., Hughes (2006)."A modified peripheral neuropathy scale: the Overall Neuropathy Limitations Scale"; J Neurol Neurosurg Psychiatry, 77(8), pp.973-976.
7. Lacomis,D.(20n)."Neuromusculardlsor-dersin critically III patients: review and update';j Clin Neuromuscul Dis,12(4),pp.197-218.
8. Nguyen Hijfu Cong (2013). "Chdn dodn dien vd dng dung ldm sdng", Nha xuat ban Dai hpc Quoc gia Tp. Ho Chi fvllnh, xuat bSn tan 1, tr.1-80.
9. Stevens, R.D., et al. (2009). "A framework for diagnosing and classifying intensive care unit-acquired weakness'; Crit Care Med, 37(10 5uppl), ppS299-5308.
Website: hoithankinhhocvietnam.com.vn 5 0 10/2014 I THAN KINH HOC VIET NAM 75
