TAP CHt Y HQC VlgT NAM TAP 450 - THANG 1 - S 0 1 - 2017
BUCrC DAU DANH GIA KET QUA DIEU TRI
VIEM NOI TAM MAC NHIEM KHUAN BANG P H A U THUAT SffM TAI VIEN TIM MACH - BENH VIEN BACH MAI
T O M T A T .
M^c tieu nghien cuU. Danh gia hiiu qua ciia phau thuat s6m (ngay trong giai do?n nam vien, tri/cfc khi ket thuc lieu trinh khang sinh) de dieu trj cho cac b§nh nhan viem ngi tam mac nhiem khuan (VPJTMNK) CO chl djnh ngoai khoa ^ i Vien Tim mach Benh vien B^ch Mai. BdttUdng va phUdng phap: nghien culi hoi cu\j, quan sat mo ta tren 52 benh nhan da duWc phau thuat trong giai doan si3m de dieu tn VNTMNK tai Vien Tim mach trong thcJi gian tu" 01/2013 den 12/2014. Ket qua : 50% so benh nhan co tien trien thuan ldi art noi kht quan tn/6c 24h, 1tic(i gian thd may
^Srung binh d nhom mo cap cu'u la 23 ± 8 gi6, 6 nhom mo sdm la IS ± 6 gi6. Ty le tu" vong chu phau: 5,8%.
C i : bien diulig hay gap nhat ia: sot keo dai sau mo:
24,4%, viem phoi do tJid may lau 4,4%, mo lai 2,2%.
Ketluair doi vdi cac benh nhan VNTMNK cd chi dinh ngoai khoa, ket qua cua viec phau thuat sdm tai Vien Chung toi la kha quan, ty le tif vong quanh phau thuat d mii'c thap (5,8% so vdi ty le chung bao cao tren the gidi la 5 - 1 5 % ) .
SUMMARY
EFFECT OF EARLY SURGERY TREATMENT ON INFECTIVE E N D O C A R D I T I S PATIENT I N VIETNAM HEART I N S T I T U E - BACHMAI
HOSPITAL
Aim of the study, to asses the effect of eariy surgery (during initial hospitalization time before OTHipletion of full antibiotic course) to treat for infedSve endocarditis patient. Objective and method, retrospective, observe and analyse study on 52 infective endocarditis patients had surgeried in Vietnam Heart Institute - Bachmai Hospital, from 01/2013 to 12/2014. Resuiti 50% of pts had extubated on the first 24 hours after operation.
Average intubation time in emergency surgery group pte was 23 ± 8 h, in elective surgery group pts was 15
± 6h. The perioperative mortality rate was 5,8%. Most common event were: persisting fever after operation:
24,4%; pneumonitis 4,4%; reoperation 2,2%.
*Vien Tim m?ch - BV Bach Mai Qiju trach nhiem chinh: Du'dng Du'c Hung Eniail: [email protected] Ngay nhan bai: 7.11.2016 Ngay phan bien khoa hoc: 22.12.2016 Ngay duySt b4i: 30.12.2016
DiTffng Diic Hung*
Conclusion: for infective endocarditis pts which had surgery indication, early result post operation in ours centre quitely good. The perioperative mortality rates about 5,8% (overall the world was 5-15%)
\. DAT \lhi
D 1Viem npi tam mac nhiem khuan (VNTMNK) la tinh trang viem mang trong tim do vi khuan, vdi bieu hien dai the hay gap la ton thu'dng sui, loet d van t i m , tiiu'dng xay ra tren mot benh tim bam sinh hoac mac phai tu" tru'dc. Phau thuat thay van nhan tao la mgt trong nhffng giai phap dieu tri cho cac benh nhan viem noi tam mac nhiem khuan. Ty le phau thuat VNTMNK tu' 25-50% cac tru'dng hc/p trong giai doan cap tfnh, khoang 20- 4 0 % d giai doan on dmh va hoi phuc [ 1 ] . Mac du phau thuat da du'dc trien khai tir nhu'ng nam 60 cua the ky tru'dc, va cung da cd cac hu'dng dan chi djnh phau thuat dieu t n VNTMNK, nhuYig van con hang loat nhij'ng van de dat ra nhu" thdi diem phau thuat; nguy cd va bien chutig trong, sau mo; kha nang kiem soat nhiem khuan khi phai mo "nong"... De dam bao hieu qua toi u'u cua phau thuat, va cai thien ty le tu" vong do VNTMNK, ran co su" danh gia can than ve lam sang, can lam sang, yeu to nguy cd khi phau thuat, cung nhu' phu'dng phap phau thuat dy"
kien cho benh nhan [ 2 ] . Chung toi tien hanh nghien cii'u nham muc tieu;
Budi: dau danh gia kit qua phau thuat d cac tjenh nhan viim npi tam mac nhiem khuan dudc phau thuat tai Vien Tim mach Benh vien Bach Mai.
IL £>6l TUQWG VA PHl/CrNG PHAP NGHIEN CUTJ 2 . 1 . Doi tu'dng nghien cu'u: Doi tu'dng nghien cdu la cac benh nhan chan doan Viem noi tam mac nhiem khuan, du'dc dieu trj va phau thuat tai Vien Tim mach Viet Nam trong hai nam, tu" thang 1 nam 2013 den thang 1 nam 2015.
2.2. Phu'dng phap nghien cu'u: Nghien cull hoi ClJu, mo ta cat ngang. Phu'dng phap chon mau thuan tien.
2 . 3 . Cac so lieu nghien cu'u du'dc t h u t h a p t h e o m l u benh a n nghien cu'u cu t h e
VIETNAM MEDICAL JOURNAL M°1 - JAHUARY - 2017
bao gom: Die diem chung cua nhdm benh nhin nghien cud, mpt so dac (Jiem lam sang va can lam sang, ket qua cay mau, c3/ dich, cay lienh pham khi phau thuit, cac ket qua lien quan iJen phlu thuat: phan loai tinh trang hau phlu theo cac nhom tot (rut noi Vm quan trong 24 gi6), hon me - thd may tren 24 gB, viem phoi, sot ton tai sau phlu thuat, tai bien mach nao, suy tim nang, tian djch mang ngoai tim, loc than nhan tao.
Danh gia ty le tCf vong (xin ve) sau mo.
2.4. Xiif ti so lieu theo thuat toan thong l<e y sinh hoc phan mem STATA 3.0 va SPSS 16.0.
III. KET QUA NGHIEN CO'U
3.1. eac diem chung cua cac b$nh nhan nghien cihi.
Trong hai nam tii 1/2013 den 1/2015, chiing toi li/a chon du'dc 52 benh nhan dieu trj va phau thuat VNTMNK tai Vien Tim mach, trong do co 36 benh nhan nam (chiem 69,2%) va 16 benh
nhan nff (chiem 30,8%). Tuoi mac benh nho nhat 17, Idn nhat 73, dp tuoi trung binh 43,1 i 16,3 tuoi. Nhom benh nhan 41- 60 tuoi co ty le cao nhat. Co 9,6% benh nhan du'di 20 tuoi va 3,8% benh nhan tren 70 tuoi du'dc phlu thuat.
Tien sii benh tim mach xuat hien iS 40,5%
triTdng hdp. Cao nhat trong nhom nay la b|nh van tim vdi ty le 30,8%, van nhan tao 5,8%. Co 1 benh nhan trong nghien ziiu co tien sii" tiem chi'ch ma tuy (1,9%), nhu'ng tru'dc do Idiong phat hien tien sii benh tim.
3.2. Ket qua vi sinh cua BN nghien clhi:
Tat ca cac BN trong nghien cu'u deu dutfc cay mau va benh pham khac (benh pham trong mo, djch nu'dc tieu, ddm) de tim can nguyen. Co 16 benh nhan chi cay mau du'dng tfnh, 2 benh nhan cay ca mau va manh van sinh thiet duyng tlnh, 2 benh nhan chi cay du'dng t'nh manh van sinh thia. Ty le cay mau dutfng tfnh 32,7% (18 mau), cay benh pham khac duWng tfnh 7,7% (4 mau).
Bing liTvli nquven nhin tronq cac mau cay ditdng tinh (n=20).
Can nguyen
Chung
Streptococcus sanguis Streptococcus viridans Streptococcus mitis Streptococcus bovis Streptococcus gordonii
Tonq Enterococus feacalis Staphylococcus aureus
Candida tropicalis Stenotrophomonas maitophiiia
Tonq
n 3 2 2 1 1 7 3 6 1 1 20
Ty le % 15%
10%
10%
5%
5% :
55%
-*«u15%
30%
5%
5%
100%
3.4. T^ le thu'dng ton phSt hien tren sieu am tim: siii chiem da so (94,3%), diit day chang : 31,4 %, thung rach van tim: 22,9 %, abces van - vong van: 17,1 %.
3.5. €>ac diem ve phau thuat. Trong tong so cac ca phau thuat chung toi da thu'c hien thi so ca phau thuat scfm la 86,5%, so ca phau thuat cap cu'u la 13,5%.
3.6. Chi so tien lu'dng phlu thuat Euro SCORE I I :
Bang 3: Chi so diem Euro SCORE dnhdm binh nhan phau thuat;
Chung Phau thuat cap cu'u
Phau thuat sdm n 52
7 45
X ± S D 8,54 ± 11,62 15,83 ± 12,73 7,40 ± 11,17
min 1,07 2,98 1,07
max 68,70 31,96 68,70 3.7 Ket qua sdm sau phau thuat.
Ty le tu* vong sdm quanh phau thuat ia 5,8%. Thdi gian thd may trung binh 6 nhom phau thuat
cap cu'u la 23 ± 8 gid; d nhom phau thuat sdm la 15 ± 6 gid. Su" khac nhau nay cd y nghTa thong ke
vdi p < 0.05. Bien chu'ng hay gap nhat la sot sau phau thuat, viem phoi do thd may keo dai, mo lai.
TAP CHi Y HOC VIET NAM TAP 450 - THANG 1 - S 0 1 - 2017
IM7s?ra •M?o?pc?u
li.tyo
• 2 8 . 6 % „ , , m ,ii.i»^.^3./_
T?t Th? may tren S?t sau ph?u 24 gi? thu?t
IV. BAN LUAN
Phau thuat la mot trong nhu'ng bien phap tfch cu'c de dieu trj viem ngi tam mac nhilm khuan (VNTMNK). Tuy nhien luci chpn thdi diem phiJ hdp de tien hanh phau thu3t Iu6n la mot van de doi hoi ngu'di bac sT phai can nhac. Trong nghien culi cua chung toi co 13,5% tru'dng hdp du'dc chi djnh mo cap cu'u, 86,5% tru'dng hdp mo sdm. Mot so thong ke cua cac tac gia khac cong txidng td: Herko Grubitzch va cs: phau thuat cap cuTu 13,3%, phau thuat sdm 60,0%, phau thulit tri hoan 26,7% [3]. theo Dodge A.
va cs, ty le mo cap cuXi co the len tdi 27,8% [4]
Chi dinh phau thuat cap cutt: Co 7 benh nlian trong nghien cu'u du'dc chi djnh phau thuat cap cu'u, chi dinh mo do sui ldn co ty le cao nhat vdi 42,9%, do ap-xe Idn la 28,6%, 1 BN bloc nhT that cap III, 1 BN can nguyen vi sinh do nam.
Theo P. Tonos va cs, tnang phau thuat cap cii'u VMTMNK, suy tim nang chiem 60%, sui Idn 48%, nhiem khuan keo dai 40%, huyet khoi 18%, cac nguyen nhan khac 33% [5].
Phau thuat sdm: Trong nhom phau thuat sdm, chi djnh mo chu yeu la thu'dng ton van tim qua nang (do thung van, dut day chang ...), sau do ia do nguyen nhan siji Idn. Ttieo thong ke cua Sigurdur Ragnarsson tren 100 benh nhan phSu thuat, chi dmh mo do sui Idn du'ng dau vdi 64%, suy tim du'ng thu' hai 48%, ap-xe van - vong van 8%, phau thuat do huyet khoi 36% [6]. Tapas Raychaudhury va cs lai cho thay nguyen nhan gSy suy giam huyet dpng (suy tim va roi loan dong chay qua van) chiem 80%, nhiem khuan l<eo dai 10%, huyet khoi 10% [7].
Phan tich chi so tien lu'dng phau thuat tinh theo thang diem Euro SCORE II cua 52 benh nhan la 8,54 ± 11,62. So sanh cho thay nhom phau thuat sdm co chi so Euro SCORE tiiap hdn nhom phau thuat cap cuXi (p<0,05).
Cach thu'c phau thuat: Boi vdi cac van tim bj ton thu'dng nang do nhiem khuan, va vdi yeu cau phau thuat nhanh de kiem soat toi uU tinh
4.4% 0.0% 2.2%
0.0% 0.0% 0.0%
Viemph?i Suytimn?ng Ph?uthu?tl?i
trang nhilm khuan, thi phau thuat thay van du'dc khuyen cao hdn la sda van [4].
T/nh trang binh nhan sau phau thuat: da so cac benh nhan phlu thuat sdm co thdi gian hau phau tot, 82,2% rut du'dc n6i khi quan trong vong 24 gid. Trong khi 71,4% BN thupc nhdm mo cap cu'u phai thd may keo dai qua 24 gid. Ty le tu' vong chung trong giai doan sdm la 5,8%.
Cac BN tu" vong deu la nhifng BN co ton thu'dng van rat phu'c tap hoac vi van de khong khong che du'dc nhiem khuan sau mo. Ty le tu' vong cua chung toi nhu' vay cung d mu'c thap neu so vdi mot so tac gia da bao cao.
Ciii dinh phau thuat cho benh nhan VNTMNK phai du^ tren su" theo doi sat va chat che benh nhan. Neu phlu thuat ngay trong tuan dau khi BN chu'a du'dc dieu tn khang sinh thi ty le tii"
vong theo mgt so tac gia da bao cao la rat cao.
Theo nghien cu'u ciia chung toi nhom phau thuat cap cu'u CO chi so Euro SCORE cung nhu' ty le td vong cao hdn han so vdi nhom phau thuat sdm (co SLT chuan bi tru'dc md). Qua do chung toi nhgn thay khong nen day manh so lu'dng BN mo cap cull neu khong thi/c SLT can thiet. Tuy nhien cung can ton trgng nhij'ng chi dinh mo cap cu'u neu cd. £)ieu do ddi hdi su" theo doi sat benh nhan kip thdi phat hien nhffng thay doi ve cau true cung nhu" huyet dgng de cd bien phap dieu trj thich hdp.
V. KET LUAN
Qua nghien cu'u ciia minh chung toi thay phau thuat dieu tn viem ngi tam mac nhiem khuan trong giai doan sdm tai Vien Tim mach dem lai hieu qua kha quan, tuy nhien thdi diem phau thuat du'a ra can phai du'dc quyet djnh di/a tren sd theo doi chat che benh nhan ve cac ton thu'dng cau true cung nhu' huyet dpng cua tim.
TAI UEU THAIVI KHAO
1. D. R. Murdoch, G. R. Corey, B. Hoen et al.
(2009), "Clinical presentation, etiology, and
VIETHAM MEDICAL JOURHAL N°1 - JANUARY - 2017 outcome of infective endocarditis in the 21st
century: the International Collaboration on Endocarditis-Praspective Cohort Study", Ardi Intem Med, 169(5), tr. 463-73.
S. J. Head, M. M. Mokhles, R. L Osnabnigge.
(2011), "Surgery in cun-ent therapy for infechVe endocarditis'; VaseHea0iRiskManag, 7,tr.255-63.
H. Grubitzsch, T. Christ, C. Melzer et a l . (2016), "Surgery for prosthetic valve endocarditis:
associations between morbidity, mortality and costsdagger" Interact Cardiovasc ThoracSurg.
A. Dodge, M. Hurni, P. Ruchat et al. (1995),
"Surgery in native valve endocarditis: indications,
results and risk factors" Eur J Cardiothorac Surg, 9(6), tr. 330-4.
P. Tornos, B. I u n g , G. P e r m a n y e r - M i r a l d a i ^ al. (2005), "Infective endocanjitis in Europe:
l^sons fi-om the Euro heart survey'; H^it, 91(5), tr. 571-6.
S. Ragnarsson, J . Sjogren, M. Stagmo et al.
(2015), "Clinical Presentation of Native f^ilral Valve Infective Endocarditis Determines Long- Term Outcome after Surgery" J CanI Surg, 30 (9), tr. 669-76.
T. Raychaudhury, A. Faichney, E. W. Cameron et al. (1983), "Surgical management of native valve endocarditis" Thorax, 38(3), tr. 168-74.
TIM HIEU NGUYEN NHAN KHif N BENH N H A N P H A I TAI NHAP VIEN DIEU TRI N O I T R U SAU KHI P H A U THUAT THAY VAN TIM NHAN TAO
v A DE XUAT MOT SO GlAl P H A P
Do PhiTffng Anh*
T O M TAT
MifC tiiu nghien cdu. tim hieu nguyen nhan khien benh nhan mang van tim nhan tao phai nhap wen dieu tri noi tru va de xuift mot so giii phap. Dor tifdng ngiiien cdu. tst ca cac benh nhan c6 mang van tim nhan tao vao nam dieu tri ngi tru tai Vien Tim mach Benh vien Bach Mai trong thdi gian 1 nam tu"
1/2015 d§n 12/2015. PhUdng phap nghiSn ahr. hoi ci!ili, ph3n tich mo ta. Kit qua: trong 1 nam co 312 benh nhan phai nhap vien dieu trj n5i tr6, s6 benh nhan td vong la 18 (5,8 % ) . Trong do co 162 b§nh nhan nhap vien trong thdi gian 1 nam dau tien sau phau thuat (cfii^m 20% tong s5 cac binh nhln phau thuat); s6 benh nhan tuf vong la 12 ngifcfi (7,4%). Cac bien chiing hay gap nhat la: qua lieu thuoc chong dong (41,3%), trong s5 do co den hdn 40,74% cac benh nhan bj xuat huyet 6 cac mu'c do khac nhau, nang nhat la xuat huyet nao dan den tu" vong. Cac bien chuYig khac nhu': rot loan nhjp tim (16,7%), suy tim (15,17%); thai san, chan thu'dng hay phau thuat ngoai tim co chay mau keo dai, benh ly kem theo:
t3ng huyit ap, dai thao dU&ng... fi4,9%). Cac bien chCfrig g^p vdi ty- le it hdn la: nhiem tmng (5,98%), thuyen tac mach (3,98%), bien chtftig cd hoc (2,24%), tan mau (0,75%), cac bieu hien than kiiih sau mo (0,75%). Kit luan: Ty l i benh nhan mang van nhan tao phai nhap vien dieu tn ngi tru sau phau thuat kha cao (20% so benh nhin mo trong nam dau
* l^e/7 77m mach - Benh viSn Bach Mai Chju trach nhiem chinh: Oo Phu'dng Anh Email: [email protected] Ngay nhan bai: 8.11.2016 Ngay phan bien khoa hoc: 13.12.2016 Ngay duyet bai: 27.12.2016
tiin). Cac blen co hay gap nhat la roi loan dong rpau, xu§it huyet nang, suy tim, roi loan nhip tim. Trang:d6 qua lieu tiiuoc chong dong mau la nguyin nhan ph6 bien hang dau va la nguyen nhan, gay tu" vorig QO nhat. Be han che bien chiJng do chung toi de Mjat mgt so giai phap: xay di/ng mo hinh phong kham' khang dong vdi may Coagucheck, ca the hoa dieu tri vdi lieu phap gen, phat the ID card ve tinh trang siy dung chong dong cho benh nhan.
SUIVIIVIARY
C O M P L I C A T I O N S OF PROSTHETIC HEART VALVES I N PATIENT HAD REHOSPITALIZED AFTER OPERATION:
CAUSES A N D SOME SOLUTION Aim of the study, to find out tiie cause of patients with prosthetic heart valves were hospitalized after tJie operation and suggest some solutions.
Subjects, all inpatients w/ith prosthetic heart valves at the Institute of Cardiology of Bach I^ai Hospital during 1 year from 1/2015 to 12/2015. Method.
retrospective, observed analysis. The result, in one year 312 prosthetic heart valves patients had hospitalized, the 18 patients died (5.8%). Of whicii 162 patients admitted during the first 1 year after surgery (20% of the total number of surgical patients); the number of patients who died was 12 (7.4%). The most common complications are:
overdose of anticoagulants (41.3%), of which there are more tiian 40.74% of bleeding patients in different degrees, is the most severe brain hemorrhage leads deatii. Other complications, such as cardiac arrhytiimia (16.7%), heart failure (15.17%), oOier complications such as maternity, trauma or surgery in addition to prolonged bleeding heart, patliology
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