DIEN BI^N LAM SANG VA CAN LAM SANG CUA BENH NHAN NGO DOC C A P N A N G TRONG QUA TRJNH LOC MAU LIEN TUC
TAI TRUNG TAM C H 6 N G DOC BENH VIEN BACH MAI
Ngd OiFC Ngpc\ Nguyin Thj Du^, Pham Due'
^Trwdng Dpi hpc Y Ha Ndi; ^Hpi Hdl sire Cip cim vi Ching ddc Hi Ndi
^Bpnh vipn Bpeh Mai
Lpc miu lien tuc la mdt phuong phap mdi ed trien vpng de dieu tri benh nhan ngd ddc eip mire dp nang.
Mijc ti6u: (1) Danh gia tiin trien lam sang ciia bpnh nhin ngd dpc cip tmng Ipe miu lien tue va (2) Dinh gli tiin triin c$n lim sang ciia bpnh nhan ngp dpc cip trong Ipe miu lien tijc. Ddi tuong vi phuong phap: 21 benh nhan ngd dpc cip, dliu tn tai Tmng tam Chong Dpc - Bpnh vipn Bpch Mai, dwQrc tiin hinh 28 lin lpc miu Tien tuc. Kit qua:
57,1% nguyen nhin ngd ddc do ti/ tir, tmng dd khoi benh 14 (67,3%), tir vong 7 (33,3%), thdi glan tir khi nhiim dpc tdi khi duoc Ipe miu 72 gid, thdi gian tmng blnh eua qua lpc 27,1 gid, sau Ipe 12 gid y thirc cii thipn rd ret, khdng cd roi loan huyit ddng trong qui trinh loc, ndng dp gardenal trong miu giam nhanh trong 12 gid diu, creatmin mau glam din trong qui trinh lpc. Kit luin: Lpc miu Tien tue cai thipn nhanh y thirc ciia bpnh nhin, giiip thai trir ddc chit, glam thdi gian thd may, ho trp tot chirc nang than va khdng lam rdi lopn huyit ddng.
Tir khoa: Loc mau lien tuc, ngp dpc cap nang, CWH
I. DAT
VANDt
Ngd ddc Id mdt benh ly thudng gap trong cap ciPU. Khoang 5% s6 bdnh nhdn din bdnh vidn elp ciPU Id do ngd ddc d p . Nam 2007, tai My cd 2,5 tridu ca ngd ddc [5]. O Viet Nam, ndm 2004, Trung tdm Chong ddc Bdnh vidn Bach Mai tilp nhdn tdi 1816 trudng hgp ngd ddc cap, trong dd tii' vong 0,49% [1]. Theo dd phdt triin eiia xd hdl, nhti'ng ndm gin ddy udc tinh s l ea mIe vd ty vong do ngd ddc elp ngdy cdng nhieu. Do vdy, ddi hdi phai ed hudng giai quylt nhanh chdng nhim giam ty Id mIe vd tu' vong. Tuy nhien, vin d i khd khdn d cho cde bidn phdp diiu tri ngd ddc elp ed nhilu han chl ddc bidt trong dilu kidn ciia mpt nude dang phdt triln nhu Vidt Nam, do thude khdng dOc ddc hidu khdng nhung hilm, md' edn rit ddt tiln, ede bidn phdp diiu tri mdi ddi hdi kinh phi Idn vd nguIn nhdn lye ehuyen mdn eao.
Thyc t l , dieu trj ngd ddc elp nang dd gap rit nhilu trd hggi. Vdi trdch nhiem tidn phong v l ching ddc, irng dyng thdnh tyu y hpc, Trung , tdm Ching ddc Bdnh vidn Bach Mai da triin khai nhilu ky thudt lpc mdu vdi mdng lpc tinh ndng eao vdo dieu trj bdnh nhdn ngd ddc d p . Hai trong s l dd Id lpc mdu tTnh mgch-tTnh mgch
lien tyc (Continuous veno-venous hemofiltration CWH) vd thay huylt tuang (Plasma Exchange - PEX). Lpc mdu lien tyc Id bidn phdp lpc cd nhilu Igi diim, tuy vdy vdi ede nhd Idm sang, gid tri cua CWH d mire dd ndo, dae biet Id vai trd eua nd trong diiu trj benh nhdn ngd ddc elp nang ra sao vdn Id cdu hdi chua ed Idi giai ddp. VI tfnh chit elp bdeh dd, ehiing tdi thyc hien nghidn ciru ndy nhdm muc tieu:
1. Ddnh gid tiln triln Idm sdng eiia benh nhdn ngd ddc d p trong Ipe mdu lidn tyc.
2. Ddnh gid tiln triln can Idm sdng cua bdnh nhdn ngd ddc elp trong Ipe mdu lien tyc.
II.
D 6 |TU'gNG VA PHU'QNG
PHAP 1. Ddi tu'angLa benh nhan duge ehln dodn ngd ddc d p mire dd ndng (PSS 3 diim) vdo dilu tri tai Trung tdm Chdng ddc, Benh vidn Bach Mai, duge tiln hdnh Ipe mdu lien tyc vd dong y tham gia nghidn ciPU.
Loai trip nhu'ng bdnh nhdn bj bdnh man tinh suy gan suy thdn tip trude, ede benh nhdn bj ngirng tuin hodn trude khi vdo vien.
2. Phu'ang phap
TAP CHI NGHIEN CLPU Y HOC -
Tiln CU'U ean thidp, so sanh cac thdi diem.
T i t ea benh nhdn deu dugc hdi ky tiin sir, thdm khdm vd theo ddi chat che trong qua trinh dieu trj. Benh nhdn duge theo ddi cdc thdng so Idm sdng vd can Idm sdng qua moi 6h: TO Id thdi diim bit d i u lpc mdu, T6 sau dd sau gid,
T12 sau 12 gid va tilp tyc nhu vdy cho din T30 Id sau 30 gid Ipe mdu lien tue.
Thdng tin thu nhdn dugc ghi trong mdu benh dn thong n h i t Nhap, xu ly so lieu bdng chuong trinh SPSS version 18.0 vd cdc thuat todn thing ke y hpe.
III. K^T QUA 1. Kit qua chung
Tong sd cd 21 bdnh nhan dugc dua vdo nghien ciru vdi 28 ldn lpc C W H . TI Id nam/nQ' gdn nhu nhau (1,1/1), tuoi trung binh (nam) Id 33,9 ± 14,3. Sd ngay diiu tri (ngdy): 10,0 + 8,7 (nhd nhit 1, Idn nhdt 42). Kit qua diiu trj: khdi 14 (66,7%), tip vong 7 benh nhan (33,3%).
Thai gian tip khi bj nhiim ddc din liic duge lpc mdu la: 72,2 ± 82,4 (gid). Nguyen nhdn ngd ddc: do ty tii' la eao nhit 57,1%, sau dd din tai nan 14,4%, cudi ciing Id do lam dung thuoc 28,6%. Tuoi thp trung binh eua qua lpc Id: 27,1
± 26,0 (gid). Thai gian thd may (ngdy): 2,9 ± 2,1 (nhd nhit 1, Idn nhat 7). Nam/nir: 1,1/1.
2. Diln biln lam sang Bang 1. So sanh dilm Glasgow o" thai dilm lpc mau Dilm Glasgows cac
tho'i dilm TO
Sd ldn lpc 26
Trung binh 8,2
SD 5,7 p > 0,05
T6 26 8,6 5,4
p < 0,05
T12 25 9,4 4,9
p < 0,05
T18 18 10,4 5,1
p<0,05
T24 13 12,1 4,5
p < 0,05
T30 9 11,7 4,5
Sy thay doi diim Glasgow rd rdt nhdt sau 18h Ipe mdu.
1 2 0 1
4 0 1
O - p>0,05
1 —
r~' »—
p>0,05 p>0,05
"- A—
p>0,05
-^
p>0,05
T O
- H u y e t a p t o i <3a ( m m H g )
- M g c h ( l a n / p h u t ) -Huye't a p t o i t h i e u
( m m H g )
- N h i e t <jp ( a a C )
Bilu dd 1. Cac thong sd lam sang c a bdn
Maeh, huyit dp, nhiet dp cd thay dpi giO-a cdc thdi diem trong qud trinh lpc mau, tuy vdy su khde bidt khdng cd y nghTa thong ke.
3. Diln biln can lam sang
Bang 2. Thay ddi v l cong th
Dilm Glassgows
Creatinin (Mmol/l) Billirubin (mmol/l) ALT (U/l/37°)
APTT (U/l/37°) Hong ciu
(T/l) Bach ciu
(G/l) Tieu cau
(G/l) Hb (g/l) Ht(l/I)
T0(n=
Trung binh 8,2 ± 5,7 239,1
+ 207,4 117,4
± 126,1 229,4 + 623,0 47,1 ±
22,1 4,1 ± 1,2 14,3 ±
7,1 160,8
± 130,2 111,9
± 29,9 0,33 ±
0,08
=24) P
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
T6(n=
Trung binh 8,6 ± 5,4 202,2
+ 148.4 141,5
± 177,9 265,8 + 468,1 57,5 ± 27,6 3,8 ± 1,0 13,8 ±
6,7 135,1
± 77,7 105,4
± 28,8 0,31 ±
0,08
=19) P
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
IPC mau T12(n Trung
binh 9,4 ±
4,9 182,0
± 129,4 193,5
± ' 235,3 217,6 + 386,3 51,2 ± 31,5 4,3 ± 1,0 14,8 +
6,0 150,7
± 103,5 113,9
± 24,4 0,3 3 +
0,07
trong qua trinh lpc
=16) P
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
T18(r Trung
binh 10,4 ±
5,1 138,9
+ 105,1 302,4
± 319,3 109,3 + 206,4 48,5 ±
19,1 3,4 ± 1,0 10,9 ±
3,5 136,2
+ 75,1 95,4 ±
19,1 0,28 +
0,06 1=8)
P
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
mau lien T24(n Trung
binh 12,1 +
4,5 153,3 ±
89,3 292,8 ±
331,8 266,9 ±
420,3 60,8 + 38,3 3,2 ± 1,0 16,8 ±
6,1 100,6 ±
73,7 99,7 ±
26,9 0,28 ±
0,08 tuc
=6) P
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05
>
0,05 T30 (n=5) 11,7±
4,5 151 ±
42,9 283,5
+ 178,2 99,6 ± 98,3 38,3 ±
10,0 3,4 ± 1,2 15,3 ±
5,4 94,2 ±
73,9 95,4 +
22,1 0,30 ±
0,05
Trong qua trinh Ipe mdu lien tyc, ede thdng so v i edng thirc mdu thay doi nhung sy khde bidt khdng cd ^ nghTa thong ke.
Ndng dp Gardenal mdu
Thai diem loe mdu
T O T 6 T 1 2 T 1 8 T 2 4
Bilu dd 2. SiP thay doi ndng dp gardenal trong mau Ning dd gardenal trong mdu giam rd rdt trong qud trinh Ipe mdu lien tyc.
TAP CHI NGHIEN CLPU Y HOC
IV. BAN LUAN
Dac d i l m chung: Nhdm benh nhdn cd tuoi ddi tuang ddi tre, trung blnh Id han 30 tuoi vd nguyen nhdn ngd doe Id do ty tii' chilm han mdt nira. Dac diim nay cung gap nhilu trong eae nghien ciPu trong nude eung nhu ngodi nudc khi tiln hdnh nghien cipu tren nhdm benh nhdn bj ngd doe nang. Nguyen nhdn la do d nhdm benh nhan eo tinh ty tip, ngudi ta thudng udng eae loai ddc ehIt vdi sd lugng Idn ddn din ngd doe nang [5]. Ty Id tip vong trong nhdm nghien ciru la 33,3%, sd dT cao nhu vdy la vi quin t h i chpn bdnh nhan trong nghien ciPu id nhdm benh nhdn ngp doe ndng vdi diim PSS > 3 [2]. Thdi gian tip khi bj nhiim ddc eho tdi luc dugc Ipe mau lien tye trung blnh Id 3 ngdy, diiu dd chirng td viee Ipe mdu edn irng dyng kha cham d benh nhan ngd ddc nang. Tren thue t l ehiing tdi thiy cd hai nguyen nhdn chinh gay nen tinh trang nay, thip nhit Id benh nhan dilu tri d tuyin dudi tdi khi tinh trang ndng roi mdi ehuyen len tuyin trdn, thip hai Id khi ipng dung mdt ky thudt mdi khd ton kem can phai ed sy ddng thudn eua gia dinh, do vdy hay mit nhieu thdi gian cho cdc nghi thiPC ehuan bj eho cupc lpc mdu. Thep chiing tdi eIn thilt phai tiln hdnh eude lpc mdu sdm han nu'a vdi cae benh nhdn ngd ddc d p nang, vi Ipe mau sdm giup thai ddc chit lam giam duge nguy ea chit ddc nglm them vao ca thi, trdnh duge nhung vdng xoln benh ly do dap ipng viem he thing gay ra.
Diln b i l n larii sang: Trong qua trinh theo ddi, dilm noi bat nhit trong nghien CLPU cua chiing tdi Id lpc mdu da giiip cai thien y thiPC rd ret. Tai thdi diem bit diu Ipe mdu, dilm Glassgew trung blnh la 8,2, sau dd 6 gid diem Glasgow hiu nhu khdng doi. Quan sat thdy ring, mdc du sau khi Ipe 6 gid, y thiPC eung khdng h i cai thien, nhung din gid thip 12 thi ed biin chuyin mdt each rd ret, vdi p < 0,05.
Nhipng gid sau tuang ty nhu vay, sau 18, 24
vd 30 gid y thirc tilp tue cai thien nhanh ehdng. Tham ehi sau 20 gid diim Glasgow trung blnh ldn d i n 12 diim. So vdi nhilu tdc gia k i t qua nay hoan toan trai nguge, trong suit qua trinh C W H benh nhdn khdng thiy cai thien y thirc mdt each rd ret [4,8]. Sd dT ed hien tugng nhu vay la vl trong nhdm nghien eiPU cua chung toi co kha nhiiu benh nhdn bj ngd doe gardenal (chilm tdi 40,9%). Tdc dyng cua dien tich Id lpc Idn va thdi gian lpc keo ddi, ma gardenal dugc thai trip kha nhanh, nen y thiPc duge eai thien mdt each nhanh chdng, nhu vdy rd rang C W H ed tdc dyng thai trir ddc chdt. Nhan xet nay cua ehiing tdi cung gidng vdi ede tae gia khde nhu Palmer [9], Chanehairujira [6].
Theo ddi chat ehe tinh trang huylt ddng cua benh nhan, v l cac thdng so huylt dpng ea ban tai eae thdi diim tip khi bit diu Ipe eho tdi khi kit thiic eho thay gan nhu khdng cd su bien ddng nhiiu. Kit qua nay phii hgp vdi nghien ciPU eua nhieu tac gia nudc ngoai, tat ca deu nhan djnh Ipe mdu lien tyc hdu nhu khdng anh hudng tdi huyit ddng ciia benh nhdn [4,7,10]. Nhu vay, C W H ed mdt uu dilm tuyet doi Id ed the dp dyng cho nhu'ng benh nhdn ngd dde cd roi loan huylt ddng, mdt tinh hudng rit hay gap d benh nhdn dde. Thai gian thd may eung Id mdt ehi sd gian tiep danh gia tde dyng thai trip dde chit eua eude Ipe mau lien tuc. Thdi gian thd may trong nhdm benh nhdn nghien ciPU ciia ehiing tdi ngin, trung blnh la 03 ngay. Trong khi dd benh nhdn ngd ddc gardenal mire dp ndng nlu khdng cd lpc mau thudng phai thd mdy khoang 01 tuin va cd rit nhieu biin chipng lidn quan, ddc biet la biln chipng nhiim trimg.
Diln b i l n can lam sang: De tim hiiu tdc ddng eua loe mau lien tye tdi ehiPC ndng gan va than, ehiing tdi ddnh gia ede thdng so nhu ure, creatinin, bilirubin, prothrombin...trong qua trinh Ipe. O i cap tdi ehiPC ndng thdn, kit qua cho thiy trong vdng 06 gid chiPC ndng than duge eai thien, creatinin mdu ed xu
hudng giam tuy chua cd y nghla, nhung tai ede thdi dilm sau dd cho thiy lpc mdu lien tue hd trg chu'c ndng thdn mdt cdch khd hidu qua bing vide lam giam lugng creatinin mdu nhanh ehdng mdt each cd y nghTa thing kd.
Theo nhiiu tde gia trong vd ngodi nudc, Ipe mdu lidn tye ft ed tde dyng ho trg cde rdi loan v l gan[3,6,7,8]. Kit qua nghidn ciru eiia chiing tdi cung phii hgp vdi nhu'ng nhdn xet dd. Cy thi nghien ciPu ehi ra ring, cde thdi diim tir luc bit diu lpc cho tdi gid thii' 30, bilirubin todn phin ed thay doi theo hudng giam nhung sy khde biet khdng cd y nghTa thing ke tit ca cdc phan tich diu eho p> 0,05. Chiing tdi eho ring bilirubin it qua 6ufac mdng Ipe, ngay ea khi mdng Ipe lidn tye da ed Id lpc Idn han rit nhiiu so vdi Ipe mdu thdng thudng. Nhu vdy, CWH it cd gid tri hd trg ton thuang gan d bdnh nhdn ngd dde nang. De chirng minh cho y kiln tren, ehiing tdi da khao sdt AST, ALT vd GGT, lly ALT ra lam dai didn thay ring theo thai gian Ipe mdu miPC ALT cd giam nhung khdng cd y nghTa thong kd d tit ea cdc thai dilm.
CWH dugc coi Id bien phdp giup dliu hda noi mdi, dde biet la diiu chinh nudc dien glal va thdng bing toan kilm. Trong nghien CLPU,
chiing tdi ddnh gia nhung thay doi v i dien giai dd, sy khde bidt khdng cd y nghTa thong kd v i su thay doi ciia bd 3 dien giai natri, kali, clo giii'a cdc thdi diim lpc mdu lien tuc cho thiy CWH hodn todn khdng gdy anh hudng tdi cdn bdng ndi mdi. Han nira, tren thyc t l nhii'ng rdi loan v l dien giai da chung tdi dliu ehinh tdt bing thay doi nong dd ehIt dien glal trong djeh thay thi. Kit qua ndy phii hgp vdi kit qua ciia rat nhiiu tdc gia trong vd ngodi nudc nhu B l Hong Thu, Palmer, Golper ..vv..[3,9,8].
V l ddng mau, ehiing tdi lly APTT Idm ehf so dai didn d l ddnh gid tinh trang ddng mdu d nhO-ng bdnh nhdn Ipe mdu lien tye. Diing thudc chong ddng d bdnh nhdn lpc mdu chii ylu anh hudng tdi APTT, vd chi so ndy lidn quan tryc
tilp tdi nguy ea t i c qua lpc. APTT duge coi Id ylu to ehinh de theo ddi tinh trang ddng mdu vd id ehJ sd d i diiu ehfnh liiu heparin trong qud trinh Ipe. Vdi phdc dd diing heparin hien tai, APTT d ede thdi diim khdng cd sy khde biet, han nu'a tuoi thp qua Ipe Id gin 30 gid Id dat yeu elu eua mdt eude lpc mdu lien tye. Tuy nhien dimg vd diiu chmh thudc chdng ddng trong CWH Id v i n d i edn ed nhiiu tranh cdi, Chung tdi khdng bdn ludn sdu han.
v i huyit hpc, trong nghien ciPU ehiing tdi quan sat thiy sd lugng hong elu, bach elu, tieu elu, eung nhu hemoglobin duge dam bao duy tri nhu nhau glQ'a cde thdi diem Ipe mdu.
Tuy nhung chf sd ndy edn phy thude vdo nhieu ylu td nhung eung ehipng tdCVMH khdng gay anh hudng nhilu tdi cdc chl sd huylt hpc.
Tren thue t i ed t h i kiim sodt, diiu chfnh dugc lugng djch vdo vd ra trong qua trinh CWH mdt each d i ddng. Trong qua trinh dilu tri, chiing tdi djnh lugng dugc mdt so ddc chit, nhung do nang lye han ehi eua phdng xet nghiem, ehiing tdi chpn gardenal 6e udc lugng kha ndng lpc bd ddc chit ciia CWH. Kit qua Id d 6 benh nhdn dugc djnh lugng nong dp gardenal ndng dd chit nay trong mdu giam nhanh trong 12 gid diu, Tuy nhien din gid 18 lai tang len ddi chut vd giam rit manh cho din thdi diem gid 24 va sau dd. Dilu dd chipng td Ipe mdu lien tyc cd hieu qua tot trong thai trip ddc chit, edn ed nhu'ng thdi dilm gardenal tang len mdt chiit chiing tdi cho ring dd Id do cd hien tugng tai phdn bo lai ddc chit tip md ma ra huylt tuang. Dilu nay eung dugc tdc gia Palmer de cap din, nhung tac gia vdn ddnh gid cao vai trd cua thim tdeh mdu do thai gian lpc mau ngin han md cung td ra khd hidu qua [9]. Theo ehiing tdi, Ipe mdu lien tyc cd uu viet han hln d i ehdng lai qud trinh tdi phan bo eiia dde chit do thai gian Ipe kee ddi suit ca ngdy, thdm ehi vdi ngdy. Tuy nhien eung eIn
TAP CHI NGHIEN CLPU Y HOC
ed nhii'ng nghidn ciru so sanh cy t h i han ve hieu qua eua hai phuang phdp.
V. K^T LUAN
Qua nghidn cii'u 21 trudng hgp benh nhdn dugc Ipe mdu tTnh mach-tTnh maeh lidn tye tai Trung tdm Cheng dde Bdnh vidn Bach Mdi, chiing tdi riit ra kit ludn nhu sau: Lpc mau tTnh mach-tTnh maeh lien tyc giup cai thien nhanh y thirc eua benh nhdn, giup thai trir ddc chit, giam thdi gian thd mdy, hd trg tot ehiPC nang than cai thien tdt can bing ndi mdi vd it anh hudng tdi huylt ddng eiia bdnh nhdn.
TAI
LIEU THAM
K H A O1. Bp Y t l (2002). Nien gidm thing ke y t l . Ha Ndi, 2002.
2. Nguyin Thj Minh Tam (2001). Ddnh gid miPC dp ndng eua ngd ddc elp theo bang dilm PSS cua ICPS, Luan van ehuyen khoa II, Trudng Dai hoc Y Ha Ndi, 2002.
3. B I Hdng Thu (2002). Nguydn ly va ky thudt tang thai trir chit ddc, Tdi lieu ddo tao elp eiru chdng dde, Bd Y t l Benh vien Bach Mai, Hd Ndi 5/2002, 230-240.
4. Andrew E. B. (2004). dialysis considerations in the patient with acute renal
failure: icu dialysis, chapter 29, principles and practice of dialysis, third edition, lippincott Williams & wilkins, 420-441.
5. Bronstein A, Kyper D., Louis C, Jody G., Barry R, Stuart H. (2007). 2007 annual report of the american association of poison control centers' national poison data system:
25th annual report, clinical toxicology (2008) 46,927-1057
6. Chanehairujira T, Mehta R (2004).
Continous dialysis therapeutic techniques, principles and practice of dialysis, third edition, lippincott Williams & wilkins, 162-180.
7. Chebrolu S, Sing T, Garella S (2004).
extracorporeal methods in the treatment of poisoning, principles and practice of dialysis, third edition, lippincott Williams & wilkins, chapter 38, 570-591.
8. Golper T(2006). Continuous renal replacement therapies: overview, up to date 18.1, http://www.patientuptodate.eom/.
9. Palmer P (2000). Effectiveness of hemodialysis in the extracorporeal therapy of phenobarbital overdose. Am J Kidney Dis.
36(3), 640-643.
10. Winchester J. (2004). Extracoporeal removal of toxic substances, chapter 7, critiealcare toxicology, elsevier mosby, 65-71.
Summary
CLINICAL AND LABORATORY PROGRESSION OF ACUTE POISONED PATIENT UNDER TREATMENT OF CONTINUOUS VENO-VENOUS
HEMOFILTRATION AT POISON
CONTROL CENTRE OF BACH MAI HOSPITAL
Continuous veno-venous hemofiltration (CWH) is a new hopeful therapy of acute severe poisoned patients. Objectives: (1) To evaluate the clinical courses of acute severe poisoned patients during C W H and (2) to detect the changes of laboratorial investigation during CWH.
Patients and methods: 22 acute severe poisoning patients were treated at Poison Control Center of Bach Mai hospital, 28 times of C W H were performed. Results: 57.1% suicidal patient, 14 (66.7%) patients totally recovered, 7 (33.3%) died, the time from being intoxicated to hemofiltrated was 72 hours, median time of a filter was 27,1 hours, 12 hours after hemofiltration, patient's consciousness cleariy got better, no hemodynamic disorder happened all the time of C W H , serum Gardenal concentration decreased rapidly during first 12 hours, serum creatinine decreased during CWH.
Conclusion: C W H improved patient consciousness, effectively eliminated toxins, decreased ventilation's time, assisted renal function and didn't cause hemodynamic disoders.
Keywords: Continuous veno-venous hemofiltration, C W H , acute severe poisoned patients
SU* DUNG VAT MACH XUYEN DONG MACH NGU'C LU'NG TRONG PHAU THUAT TAO HJNH
Tran Thiet San va CS Truong Dai hpc Y Hi Ndi
Vpt maeh xuyen cua ddng mach ngi/e lung thudc thi loai mdi trong phau thuat tao hinh va dwac ap dung tren lim sang tir han mdt thip ky nay. Muc tieu: 1. Md ta qui trinh phau tich vat da nhinh xuyen dpng mach ngwc lung. 2. Nhan xet mpt so chi djnh ciia vpt trong phiu thupt tao hinh. Ddi tuong va phuong phap: Tir thing 9/2008 din thing 1/2011, 5 bpnh nhan co cic khuyit ton phan mim rdng a cd ben, thanh ngwc, ban tay va ban chan dwpv phiu thuit tao hlnh bang vat mach xuyen ddng mach ngwc lung. Kit qua: Kich thudc vpt dii Idn (rpng nhit 10cm, dai nhit 18em). Cuong mpch nudi vat bao gom nhinh xuyen trong ea, nhinh ngoii va than ddng mpch ngwc lung dii tmng blnh 14,2 cm. Cic dpng vat dwpc sir dung: 2 vat cuong mpch liin, 3 vat tw do.
Thanh phin ciia vat: 3 vat da don thuin, 2 vat da ed kem mdt phin ca lung rdng. Cac vat che phii 100% khuyit phan mim cin tao hlnh. Tit ea cic vat diu song vi cho kit qua thim my tot a nai cho vat va nhin vat Nai liy vpt khdng cd hipn twpng dpng djch a tit ca cac trwdng hap. Kit luin: Vat nhinh xuyen ddng mach ngwc lung li mdt chat lieu dang tin ciy vi Tmh hoat cho muc dich tpo hlnh che phu cac khuyit Idn tren ca thi.
Tir khoa: phiu thu|t tao hinh, v^t da nhanh xuyen dpng mach ngyc lung I.
DAT
V A NDt
Vat da ea lung rdng cuong mach liin duge I.Tasini phdt hien vd sii" dyng tir nam 1896, nhung vat da khdng kdm ca lung rdng vdi cuong maeh nudi Id nhdnh xuyen tip dpng maeh ngyc lung gin ddy mdi dugc Angriglani vd CS lin diu tidn dua vdo dp dyng tren Idm sdng (1995). Lfu diim eua ky thudt SLP dung vat mgch xuydn ngyc lung (MXNL) Id bao tin khoi eg lung rdng, khdng Idm biin dang nai cho vat; vat duge huy ddng Idn vd vat ed cuong.
mach du ddi ddp u'ng tot eho mpi mye dich tao hlnh [1,7,8]. Vat MXNL dd dugc nhiiu tdc gia trdn thi gidi nghien ciPU vd dp dung thdnh edng trong tao hlnh, nhung eho din nay tai Vidt nam ehung tdi chua tim thiy ed mdt edng trinh ndo nghien eiru ve vat MXNL. Bdi bdo ndy gidi thidu nhu'ng kinh nghiem bude diu cua ehiing tdi v i ky thudt ngoai khoa vd ehf djnh SU' dung vat da MXNL trong phdu thudt tao hlnh che phii ede khuylt phin mim Idn.
Muc tieu:
1. Md ta quy trinh phdu tich vat mach xuyen ddng maeh ngyc lung.
2. Nhdn xet mdt so chf djnh eiia vat maeh xuyen ddng maeh ngyc lung trong phdu thudt tao hlnh.
II.
D6\TU'gNG VA PHU'aNG
PHAP 1. Ddi tu^p-ngNam benh nhdn (3 nam, 2 nu') cd ede khuylt phin mem Idn tai viing eo, ngyc, bdn tay vd bdn ehan da duac dliu trj tai Khoa Phdu thudt Tao hlnh, Benh vidn Da khoa Xanh Pdn, Ha Ndi tir thdng 9/2008 din thdng 1/2011. Tuoi cua cde benh nhdn tir 18-55 (trung blnh 29,8).
Nguyen nhdn gdy ton khuylt phin mim bao gom xa tri (2 trudng hgp), seo bdng axit (1 trudng hgp) vd do ehln thuang (2 trudng hgp). Kich thude eiia ede ton khuylt phin mim dao ddng tip 30em^ din 144em^ (trung binh 83.2em^). Vat MXNL duge sii' dyng d dang tu do (3 trudng hgp) vd dang vat ed