TAP CHl Y Dl/gC L A M S A N G 108 T i p 7 - Sd 3/2012
Nhan xet mot so su* co ky thuat, bien chung va each khac phuc trong qua trinh loc mau lien tuc & bfnh nhan ngo doc nang
Comments on the Correction of Technical Problems and Complications During Continuous Veno-venous Hemofiltration (CVVH) in Severely Poisoned Patients
Le Quang Thuan *, Pham Du§ * * B^nh vi^n Bach Mai Ngo Due Ng9C * * * * Truang Dgi hpc Y Ha Npi
Mijc ti&u: Md t i v i thdng k l nhO-ng b i l n chirng iiln quan tdi q u i trinh Ipc m i u liln tyc (LMLT) d b§nh n h i n ngd ddcn$ng. Ddituxyng: 139 i i n Igc m i u cho 106 b$nh n h i n ngd ddc n$ng vSo d i l u trj tgi Trung t i m Chdng ddc, B|nh v i | n Bgch Mai td- 1/2007 d i n 12/2011 Phuong phAp. Md t i c i t ngang Kit qui. Tudi tmng binh l i 35,6±14,1: Nam/Nu-1,46/1; 76,3% cd dd tudi tu- 20-59; 39,8% Id do ngd ddc hda chit; ty H td- vong 35,8%; chi dinh Igc m i u do d i o t h i i ddc chit l i 31,1%; sy c6 ky thu§t hay g i p nhit l i Idi b i o i p lye i m b^u trdn 28,8%, b i o i p lye i m du-dng m i u ra 21,6%; 7,2% cudc Ipc cd tyt i p , 3,6% b|nh nhan cd g i i m ti^u c i u . C i c sy cd ky thuit v i bidn chdng d i u duoc phit hi|n vd Ithic phyc kjp thdi Kit lu$n: C i c s y cd ky thuat hay gdp n h i t trong LMLT id Idi bdo i p luc am b i u trdn; b i l n chirng hay gdp Id tyt dp, giam ti4u c i u . Theo ddi, phit hi|n vd xu- tri sdm cAc sy c6 ky thudt, b i l n chdng cua LMLT gdp phan giam thtlu cdc nguy CO cho benh nhdn trong q u i trinh LMLT,
Tir khda. Lgc mdu Iiln tuc. biln chdng ipc m i u , ngd ddc, LMLT
Summary
Abstract- deaeration chamber Objective: To descnbe and count complications associated with continuous veno-venous hemofiltration (OWN) in severely poisoned patients Subjective- 139 times of C W H in 106 severely poisoning patients v/ere treated in the Poisoning Control Centre of Bach Mai Hospital from January 2007 to December 2011. Method This was a descriptive study. Results: The average age was 35.6 ± 14.1; Male/Female 1.46/1; 76 8% of patients were at the age from 20-59, 39 8% of causes for poisoning were chemical substances, the mortality rale was 35,8%; the mam indication for C W H was toxic elimination (31.1%); the most common technical error during C W H was "cannot detect return" error (28 8%). "wrong access pressure" error was 21 6%; 7,2% of C W H had hypotension during the first hour, thrombocytopenia was 3 6%; technical problems and complications were soon detected and corrected.
Conclusion: The most common technical problem was "cannot detect return" error, CWH-reiated complications were hypotension (5.7%) in the first hour and thrombocytopenia (3.6%) Stnct monitonng and controlling the technical problems and complications of C W H reduced nsks dunng C W H ' s progression.
Keywords. C W H , Complications of C W H , Poison
Phan bi|n kiioa h^ic: PGS.TS. LE THI VIET HOA
15
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 7 - N"3/2012
1.D$tvina6
Thu^t ngQ' iSl6u trj thay thd th$n I16n tgc (Continuous Renal Replacement Therapy - CRRT) hay LMLT thyd'ng d\jq/c si> dung dd midu td tdt cA cdc p h y a n g thd'c Igc mdu \/6f\ bdt kd d y d r i g vdo mach mdu Id dOng mach hay tTnh m^ch vd c6 djch thay thd hay khdng. K9 thudt ban ddu Id Igc mdu ddng mach-tTnh mach lidn tgc (Continuous Arterio- v e n o u s Hemofiltration - CAVH), ddi hdi phdi c6 mdt dng thdng ddng m^ch \(fn vd phM thuOc vdo huydt dp b$nh nhdn. S y phdt tridn cua k9 thudt, sdng chd ra cdc b c m mdu giiip cdi tidn thdnh phycrng thirc Igc mdu tTnh mach-tTnh mgch Ii6n tyc (Continuous Veno-Venous Hemofiltration - C W H ) Lpc mdu trd' thdnh mdt p h y o n g phdp didu trj rdt thdnh cdng, nhidu ca b$nh ndng dd dyg^c ciru sdng nhd* p h y a n g phdp ndy
O Vi$t Nam, trong khodng gdn chyc ndm trd ddy LMLT da trd- thdnh mdt k j thudt didu tn hOu hi$u gdp phdn ciru sdng nhidu bdnh nhdn ndng, ddc bidt Id cdc bfenh nhdn ngd ddc, Tuy nhidn, ngodi nhOng Ici thd khdng thd chdi cdi. LMLT cOng cd nhO-ng bdt Ig-i cua nd.
dd Id cdc sy c6 ky thudt bidn chCrng li&n quan tdi qud trinh Igc mdu. Thyc td s y dgng ky thudt ndy trong Idm sdng gdp It nhidu cdc s y c6 ky thudt vd bidn chirng nhung chua cd nghidn ci>u ndo tai Vi$t Nam thdng kd vd md ta. Vi vdy, chOng tdi tidn hdnh nghifin ciru dd tdi,
"Nghien c y u md ta cdc s y c6 ky thudt vd bidn chi/ng trong qud trinh LMLT", vdi myc ti&u md ta vd thdng kd cdc s u CO ky thudt, bidn chirng vd cdch xi> tri trong qud trinh Ipc mdu d" t)$nh nhdn ngd ddc ndng
2. Qdi tiF^ng va p h i r v n g phdp 2.1. Doi twqng
Ld 139 cudc LMLT d 106 b$nh nhdn, tgi Trung tdm Chong dOc, Bdnh vi$n Bach Mai, thdi gian tir 01/2007 den 12/2011 Vdi mire dd ngO ddc n$ng. diem PSS = 3 [1] Loai try cdc trudng hg-p ngirng ipc mdu do nguyfen nhdn chu quan cua gia d'inh ngudi b^nh
2.2. Phu<yng phdp Phuang phdp' md ta cat ngang 2.2.1. Thi4t k4 nghi6n cOv
Khi cd chi dinh LMLT, gia dinh b§nh nhdn vd b$nh nhdn (neu con tmh) dup'c giai thich \g\ ieh vd nhO'ng nguy eo eua LMLT vd dong y tien hdnh LMLT cho benh nhan
B$nh nhdn d u c c hdi b$nh 8i>. khdm Idm sdng, chi dinh xdt nghidm, theo ddi vd ghi chdp ty my cdc thdng sd 1dm sdng vd cdn Idm sdng theo bdnh dn nghidn ci>u.
+ Theo ddi cdc s y cd mdy Ipc trong sudt qud trinh tgc mdu,
+ Theo ddi cdc chf s d xdt nghi$m c a bdn chi>c ndng gan, thdn, cOng t h y c m d u , ddng mdu c a bdii mdi 6 gid", nhdn xdt s y thay ddi theo ndi dung nghien ci>u.
Kdt qud nghidn ci>u d y a c phdn tich, ddnh gid theo cdc ndi dung nghidn cCru
2.2.2. N^i dung nghidn cOv
+ Cdc s y cd k9 thudt. bidn phdp khde phyc. Ty 1$
gdp cua tCrng s y cd k9 thudt bdo dp lye dm d y d ^ g mdu ra, bdo dp lye dm bdu trdn. dp lye xuydn mdng tdng cao, bdo ddng khi trong dt/d'ng ddy Ipc. tdc qud. bdo ddng mdt cdn bdng djch Ipc
+ Cdc bidn ehCrng t h y d n g gdp vd bidn phdp khdo phgc ode bidn chirng chdy mdu. nhidm trung. d| irng, hg huydt dp, ha thdn nhidt, thay ddi tidu cdu. hdng cau, bach cdu...
+ Tinh trang dung nap vd-i mdy tpc. tai thdi didm ban ddu (TO) vd sau dd mdi 6 g i * ddn gid thir 60 (T60)
2 2.3. Phuong ti0n nghi6n ciru
+ Mdy iQC. Prismaflex hdng Gambro (Tbgy Oidn);
Diapact hdng B/Braun (Oirc),
+ Qud lpc CWH Diacap Acute vdi mdng loc polysulfon chay mdy Diapact vd qua Ipc Hemoselect vdi mdng Ipc polyacnionytnl chay mdy Prisma
+ Djch iQc cho CWH dieh Hemosol, Duosol vd djch pha
+ Catheter Certofix Duo HF (12F, 15cm) cua hdng B/Braun dung dd ddt dng thdng tTnh mach dui
+ Sir dgng qui trinh thay huydt t u a n g , phdc 66 s y dgng heparin trong LMLT. qui trinh theo ddi sy dung nap. bdng theo ddi thdng sd mdy Ipe theo cdc phdc dd thyd'ng qui tai Trung tdm Chdng ddc D6nh vidn Bach Mai
+ Theo ddi s y dung nap trong Ipc mdu bdng Ddng diSm SAS (Ricker Sedation Agitation Jcore) vd Thang
<3i6m <Jau Mankoski v6/\ 10 m y c dd khde nhau. Khdng dung nap ndu cd mOt trong ode ddu hidu' (1) Thang didm SAS ^ 5, (2) Thang didm Mankoski > 4.
+ Chdm didm mifc dd n^ng cua ngd ddc theo thang diem PSS [1]
16
TAP CHl Y DUOC LAM SANG 101 T a p 7 - S 6 3/:!012
3. K i t q u i
3.1. Mits6 a^c diem chung
B i n g 3 1 . M $ t s 6 d$c didm Chung cua n h 6 m b^nh nhSn nghidn ctFU
Thfing s6
Gidi
Ket qua Ipc
Chi dinh iQC
Nguyfen nhan NO Nam S6ng Ti> vong Lpc aOc c h i t Lgc h6i si>c Ph6i hpp
NgO dOc thu6c tan du-pc NgO dOc hOa c h i t bao vO thu'c vat Khac
n 106 43 63 68 38 33 57 16 49 42 15
Ty 10 % 100 40,6 59,4 64,2 35,8 31,1 53,8 15.1
46.2 1 39.6
14.2 Th&i gian IQC mAu trung binh 19,6 ± 6.3 (gii/)
Th&i gian ti> luc ngO dOc 16*1 l<hi du'cc Ipc m i u : 39,4 ± 40,0 {gib')
Nh$n xdf; Ty 1$ Nam/Ni> Id 1,46/1; ty 1$ tir vong Id 35,8%. 3 1 , 1 % chi djnh LMLT id lpc ddc chat, nguySn nhdn gdy ngd ddc can Ipc mdu hay gdp nhat Id ngd ddc thudc tdn dupe chiem 46,2%.
3.2. Su- CO ky thu$t thwdng g$p trong LMLT
Bang 3.2. T i le SIP c d ky thuat, nguyen nhan va each khac phuc Loai s u CO
ky thudt Tdc qua Bdo dp luc dm dudng mdu ra
Bdo dp luc dm tai bau trdn
Bdo ddng khi trong dudng ddy lpc Sdo ddng mat cdn bdng dich loc Bdo ddng dp luc xuydn mdng cao trong 6 gid dau
So luong 2/139
30/139 40/139 5/139
4/139
10/139
%
1,4
21,6 28,8 3,6
2,8
7,2
Nguyfen nhdn Khdng dung nap, ndng dd ddc chat cao
Khd hut mdu do vi tri dau catheter 15 phut dau chua du mdu Dudi khi ehua het Do dich riit ra khdng cdn bdng vdi dich thay the Ndng dd ddf chat qua cao, tar> mdu.
Khde phuc Pha iodng trudc mdng (Idm khi cd nguy co tdc) Didu chinh hodc ddt lai catheter
Tam bit dudng ve ciia mdu
Tien hdnh dudi khi
Dieu chinh lai cdc toe dd
Pha lodng trudc r- i n g
Ket qua khde phuc Kdo ddi dupe tudi thp mdng Net bdo dgng s u e d Het bdo ddng s u cd Het bdo ddng s y cd Het bdo ddng s u e d Het bdo ddng s u e d Nhan x^t: S u co ky thudt thudng gdp nhdt Id bdo dp lye dm tai bdu trdn, thudng chi g§p vdi mdy loc Diapact; bao dp luc dm dudng mdu ra gdp ca may Ipe Diapact vd Pnsma; trong 139 lan loc mdu cd 2 (1.4%) Idn gdp true trdc ve ky thudt gdy t i e qua, do benh nhdn kdm dung nap Khdng phai tat ca cae trudng hap sau khi khde phuc s u ed deu thdnh cdng, can tidn luang cdc s y co trudc khi xay ra de cd bidn phdp khde phuc so'm, kip thdi
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol7-N°3/20tt
3.3. Biin chirng cOa LMLT
B i n g 3.3. C i c b i i n chl>ng cila LMLT qua 139 c u f c I9C
Tut huyAt dp
Nhj^m tnjng chdn catheter Chdy mdu
Qua li^u heparin Ha du'O'ng huy^t Ha than nhiat Giam ti6u cdu
S6 lu'p'og
10 1 22 2 4 2 5
T } l «
%
7.2 0,7 16,8 1,4 2.9 1,4 3,6
K h i c phuc
B i t d i u vOi t,ic dO " I t mau t h i p , xCr tri theo nguySn nhan VO triing thii t h u i t , K h i n g sinh
Tlm v i x i i tn theo n g u y i n n h i n B i i u chinh l i i u heparin cho phii hp'p Cho i n h o i c t r u y i n du'O'ng l i i n tgc L i m i m dich thay t h i va u i m b i n h n h i n Theo dOi, diing heparin du. t r u y i n t i i u c i u
Nh$n x«( Chay mau (15.8% va tut huy4t ap (7.2%) la hai air l<i«n hay gap n h i t trong qua trinh Ke mau.
B i n g 3.4. R&l lof n h u y i t i p M m thu trong q u i trinh C W H
HATT (mmHg) Binh thiidrng (90-140) G i i m (<90) Tang(>140) T6ng Chung Tong RL HATT
To n 130
8 8 146
16
%
88,6 5,7 5,7 100 11.4
T , n 117
9 9 135
18
%
86.8 6,6 6,6 100 13,2 P(T„&T„) >
- T , j n 101
8 7 116
15 0,05
%
87.6 6,6 5,8 100 12.4
T , . n 71
3 2 76 5
%
93,7 3,8 2,5 100 6.3
T , , n 44
3 4 51 7
%
87.7 5.3 7 100 12.3
Nh$n xdt- Ty 1$ rdi loan huydt ddng trong LMLT gdp t u 6.3 ddn 13.2% LMLT it dnh hydmg tdi huyft ddng, bdng chirng cho thdy ty 1$ tyt huydt dp tdng Idn khdng ed y nghla thdng kd (P(TO4T!*) > 0,05). Tuy nhtdnofi 2 thdi didm tyt huydt dp cdn l y u y giai dogn ddu (To- Tg) vd giai doan mudn (T,B-T24).
3.4. Thay doi dung n^p cua bdnh nhdn vdi Igc m6u
mi
W)
HI
1) 7 M
71.4
TO Tft
Ti le dun}> nup {%) H4.2
55... ^"^tr^ 5«.,r ^
112 TIH T24 T.Ml T.tft 142 T48
--- -
.^5.4
IS4 T60
Bieu do 3.1. Ti id dung n$p theo th&i gian
Nh$n xdt- Dung nap Id BN nhdn cudc Ipc md khdng cdm gidc khd chju, khdng gidy dya Theo thdi gian,si benh nhdn dung nap vdi mdy lpc cd xu hudng giam xuong ddn
TAP CHl Y DLTgC LAM S A N G 108 Tdp 7 - S d 3/2012 4. Bdn lu$n
4.1. M^t s6 d^c diim chung
Ti le benh nhan nam bi ngd ddc nang cao hon niJ, 1^
di4u khd dac bi&t so vdi cdc nghidn eifu khSc v l tt 1^ gidi tinh trong c3c didu tra v l ngd ddc. C3c nghiin citu v l ngd ddc khde thudng cd t i 1^ nfl cao hon, nhd trong nghiin cdu ciia L& Thj Didm Tuylt, ty I I nOf gSp 1,5 I3n nam gidi [2].
Cd 139 cudc loc d 106 b&nh nhdn ngd ddc nSng, nhu vdy mdi benh nhdn Ipc 1,31 I3n vdi thdi gian Ipc trung binh khoang 1 ngay. Ddy khdng phdi Id khodng thdi gian ddng ke ciia mdt dot d i l u tn cho b i n h nhdn ngd ddc nang, tuy nhiln b^nh nhSn phdi nSm bS't ddng trong mdt thdi gian khd dh\ cung 1^ mot vile cSn luu y vh nguy CO
;biln chijfng xdy ra cung cd the se tang theo thdi gian. Qua isd lidu thdi gian trung binh dUoc loc mdu Id 43,4 gid tifc Id q u y l t dinh Ipc mdu duoc dua ra tuong ddi mudn sau khi da ddnh gid va can nhSc nhiiu y l u td. Vi&c q u y l t dinh Ipc .m^u sdm hay mudn phu thudc khd nhiiu vdo t i l n t r i l n iciia benh sau khi d i l u trj mdt thdi gian ng^n 1-2 ng^y.
Thdng thudng tinh trang nang cua bdnh nhSn khdng dd
•luc dd q u y l t dinh loc m i u mdi dupe dUa ra cd tinh thuyet .phuc. Nhieu tac gid cho rSng khdng nen d l loc mdu
mudn vi cac rdi loan se theo kieu vdng xo5n benh ly, rSt 'khd hdi phuc. LMLT hd tra tdt cho nhOng b&nh nhan -nang cd tdn thuong thSn hdn la gan, vi vay b i n h nhan thudng dUOc cht djnh LMLT neu cd tdn thuong than, tuy nhien neu benh nhan cd kem theo tdn thuong gan thl -cung khong phai la chdng chi dinh. Neu chi cd tdn .thuong gan don thuan thl LMLT c i n xem xet can than.
sTuy nhidn, r i t nhiiu chuyen gia cho ring ngay cd trong JrUdng hop cd tdn thuong gan don thuan ciing nen sir dung LMLT ngay sau khi thay huyet tUong hoac loc mau hap phu phdn xCi tdi tuan hoan - MARS (Molecular Adsorbents Recirculating System) [12].
V l nguyen nhan gay ngd ddc, cd mdt sd lucmg kha Idn chat ddc Id hda chat va thudc tay. Kha nhieu loai thudc va hda chat cd the duoc thdi trif qua mang loc cua ne thdng lpc lien tuc nen viec phat trien LMLT la mdt xu nudng can t h i l t trong y hoc ndi chung va linh vUc chdng ddc ndi rieng [10], [11].
Ve ket qua dieu tri, phdn anh rd ret ddi tUong nghien liru la benh nhan thudc nhdm nang. Nhieu nghien ciru :hay ring neu chi cd suy gan nang ty le tie vong da len tdi 50 - 90%. Tuy nhien, tifng nhdm benh nhan nhit dinh lai :d nhdng dac diem rieng va nguyen nhan gay t d vong
•i^ng vi vay cac sd lieu cd the rat khac nhau. Trong nghien :Lfu nay, ty le XCs vong d benh nhSn ngd ddc nang la i5,8% theo chOng tdi cung da la mdt thanh cdng budc lau. Ngd ddc nang thudng kem theo tdn thuong da co -•quan va viec dieu tn se vd ciing khd khan, LMLT cd y ighta hd tro chifc nang tang suy va lam giam ndng do Idc chat do do cd y nghTa ho tro rat Idn trong dieu tri
b i n h nhdn ngd ddc nSng. Nhdn djnh ndy cua chiing tdi cung gidng vdi tdc gid Holubek WJ. vd cs. [1], [11].
4.2. Cdc sUc6k9 thudt, biin chifng cda LMLT 4.2.1. Bdn ludn visi/cdlty thudt cOa LMLT - Sy c6 hay gdp nhSt Id bdo dp luc dm tai b5u trdn mdu gdp d 40 trong sd 139 cudc loc (28,8%), sU cd nay thudng chi gSp vdi mdy loc Diapact vci nguyin nhSn dUpc cho i^ trong nhiJfng phiit d3u do chua d i l n dii mdu trong dudng ddy loc vd thudng duoc xijf tr( don g i i n bSng each tam gdp day dUdng mdu v l Id cd t h l khSc phuc dupc trong h i u h i t cdc trudng hop.
- Bdo dp luc dm tai dudng mdu ra cung Id sU cd thudng gap, Id bdo ddng cd d cd mdy loc Diapact vd Prisma, chilm tdi 30/139 cudc loc (21,6%). Bdo ddng ap luc dm hay gay ra ICing tOng cho cdc ky thuat v i i n loc mau it kinh nghiim, n i u chdm xCf trf cd t h l gay t i c qud loc, phdi hiiy cudc loc gSy lang phi Idn. Nguyen nhdn bdo Idi b i o luc dm thudng do d i u hiit mdu ciia catherter cham vao thdnh mach, trudc khi xif tri Idi ndy, c i n dp dung cdc b i l n phdp de b i n h nhan dung nap vdi Ipc mau, tam thdi xir tri bSng each x l d|ch dudng cdu, sau dd d i l u chfnh vi tri d i u catheter d l khdng cham vao thanh mach, thdng thudng b i n g each rut catherter ra ngoai va xoay nhe mdt chut (tuyet ddi khdng day them catherter vao Idng mach).
- Bao ddng khf trong dUdng day loc gap 5 trong 139 cudc Ipc (3,6%), loi nay gap trong trudng hdp dudi chua h i t khf trong qua trinh moi dich, trudc khi t i l n hanh dudi khi, cac ky thuat vien Ipc mau c i n chu y de y mii'c mau trong cac bau trdn phu hop, tranh de mdc nay thap gay lot khi vao day Ipc.
- Bao ddng mat can b i n g djch Ipc gap 4 trong 139 cudc Ipc (2,8%), loi nay thudng khd xac dinh duoc nguyen nhan, cd y kiln cho rSng thudng do khdng phu hop giC^a tdc dp riit mau va tdc dp djch thay the, cd the xif tri b i n g each d i l u chfnh lai cdc tdc dp nay cho phii hop. Vdi may Prisma, cd the dat lai cac cam bien can djch b i n g each rut va dat lai cac can dich.
- Bao ddng ap lUc xuyen mang cao trong 6 gid dau, loi bao ap lUc nay rat dac biet, trong qua trinh lpc mau, chung tdi nhan thay hay gap d cac benh nhan ngd ddc (paraquat, gardenal). Nhan dinh ve dac diem nay thay ring vdi cac benh nhan ngd ddc paraquat, trong giai doan d i u cd the ngoai tinh trang cddac mau cdn do chit ddc g i n nhieu vao cac Id Ipc gay bit tdc. Trong qua trinh loc, ap luc xuyen mang giam dan cung vdi tdc dp biJ dich tang len, lam loang mau, giam hematocrit. NhU vay, cd the xCf tri bao ddng nay b i n g each pha loang trudc mang, vdi may Prisma cd the dieu chfnh b i n g tang ty le phan tram pha loang trudc mang; hoac tang tdc do truyen dich dong thdi van dam bao huyet ddng. Ddi vdi may loc
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY
Diapact c^n cdn cijf vdo tinh tr^ng Idm sdng (m<ic dd ngd ddc, phii, CVP, nudc t i l u , cdn n$ng) d l sir dyng blftn phdp truyin d'cb t h i i d d c 1dm lodng mdu cho phCi hpp trudc khi t i l n hdnh LMLT.
4.2.2. Bdn tudn v4biin chCeng cCia LMLT Phdn tich cdc b i l n chufng I i l n quan d i n LMLT Id vl$c Idm phCfc t?p, vl b$nh nhdn dupc lpc mdu nSm trong b$nh cdnh suy da t?ng n$ng n l , cic b i l n sd quan sdt thudng cd tdc ddng I5n nhau. Chiing tdi thdng k l vd bdn ludn nhang b l l n chiJfng rd rdng n h i t I i l n quan tdi qud trinh LMLT, Bdng 3.3. trinh bdy cdc b i l n chCtng dd gdp cOa LMLT d i l u tri BN ngd ddc nang.
- Biin chiyng chdy mdu hay gdp vd cung Id b l l n chiJng ddng ngai n h i t (chilm 15,8% tdng sd cudc loc). Nhidu loai ngd ddc cd b i l u h i l n suy da tang, ddc b i l t Id tinh trang suy gan d p do v i i m gan n h i l m ddc vdi b i l u h i | n rdi loan ddng mdu ndng n l . thudng k i m theo nhiiu tinh trang khde nhu suy thdn. toan chuyin hda... cd chi dinh Ipc mdu d l cdn b i n g ndi mdi ngodi chf dinh Ipc ddc chSt, chdy mdu trong nhOng trudng hpp ndy thudng khd trdnh khdi, Tuy nhiln d l gidm nguy co cho b i n h nhdn chung tdi ludn d l l u chinh tinh trang rdi loan gidm ddng trudc khi dat dng thdng tTnh mach diii. Tiiy theo nguyin nhdn b i n h ma sijf dung cdc b i l n phdp phu hop, nhu dung heparin n i u cd ddng mdu rdi rde trong Idng mach, k i t hop truyen cdc c h i pham mdu ( t i l u c i u hoac h u y l t tuong tuoi,..)... Mat khde, LMLT Idm gidm s6 luong t i l u cau gay dnh hudng tdi qud trinh ddng mdu. NgUdi ta cho rdng cd t h l do trong qud trinh loc, mdt sd y l u td nhu y l u td hoat hda t i l u c i u bi ddo thdi bdi mdy loc d i n Idi 1dm mat can b i n g cdc yeu td I n h hudng tdi t i l u c i u . Hon nCfa, trong qud trinh loc ddi hdi sif dung thudc chdng ddng truyen tinh mach lien tuc, mac du dUoc kilm sodt nhung cac nguy co do qua lieu heparin Id h i l n hCfu. Bdng 3.3 cho thay cd tdi 22/139 cudc tpc (15,8%) cd b i l n chdng chiy mau cd d 2 nhdm cd hoac khdng dung heparin. Tuy n h i l n bien chifng chdy mdu chu y l u xdy ra vdi nhdm b i n h nhdn cd nguy co cao va khdng diing chdng ddng, trong nhdm nay cd ti le bien chifng chdy mau tdi 76%, ngay tai thdi diem b i t dau loc mdu. Nhdm sit dung hepann cd 3 BN bi chay mau, trong dd cd 2/34 (5,9%) do diing heparin d l i i u truyen lien tuc 15 va 20Ul//kg/gid Trong hai b i n h nhdn cd bien chdng chdy mau tren Idm sdng, mdt b i n h nhdn thudc phan nhdm cd nguy co chdy mdu thdp, mdt b i n h nhan thudc phan nhdm khdng cd nguy co chdy mdu. Li do b l l n chifng nay xay ra cd le do khodng cich XN ddng mau 6 gid (cdng them 2 tieng chd k i t q u i la 8 gid), dii ddi de chuyen tir benh nhan trang thai an toan sang chdy mau. Thuc te, BN duoc phat hien chay mau chan catheter, 2 BN nay deu duoc tam ngifng heparin n I n h i t chdy mdu, khdng c6 bien chifng nang xay ra.
Vol7-N°3/2012
Thdi gian g$p b l l n chiJng cung cd y nghla guar trpng, cdc chifng x u i t h u y l t thudng g$p d gi^i thijf 6 d&i gid thiJ 12. Nghiin cijfu mdi ddy di/pc cdng bd t r i n tap chi Critical Care (2009), tdc gid Maria J. Santiago vd cs. dio b i l t b l l n chiing x u l t h u y l t trong qud trinh Ipc mdutt quan trpng, c h i l m tdi 10,8%, nhung khdng cd mdi li&i quan glOa t^ 1$ xuSt h u y l t vdi tudi, gidi, chSn dodn v l 6t ndng Idm sdng vd mdc du t i l u c^u gidm nhOng chUa cdsu khde b i | t d b i t ky thdi di^m ndo trong qud trinh lpc Dl Tuy n h i l n , d i l m chd y trong n g h i i n ctfu Id t i l u ciu vin dupc truyin trong mdt s6 trUdng hpp chdy mdu.
- Biin chung tut huyit ap trong LMLT. Cd 10/139 (7,2%) cdc cudc loc mdu cd tut h u y l t dp, vd d i u xdy ai phOt thd 30 d i n 60 sau khi bSt d i u cudc lpc, cd 1 ca xiyra d gid thd 24 cOa cudc loc. K i t qud d Bdng 3.4 chi ra ty |{
tyt h u y l t dp tdng l l n khdng cd y nghia thdng k l trons qud trinh Ipc mdu (Pno4Tj«) > 0,05). Oa sd tut huylt dp xiy ra 6 thdi d i l m b^t d i u Ipc, sau khi dupc d i l u chinh « nhanh chdng dn dinh. Bdn ludn v l n g u y i n nhdn glytu;
h u y l t dp, Chung tdi cho rdng trong giai doan khdi did m i y loc thudng rut mdt lucmg mdu Idn vdo mdy loc laora tinh trang t h i l u h y i v l t h l tich tudn hodn d i n tdi tut h u y l t dp nhanh chdng. Viec theo ddi huylt dp, cung luong tim, dp lUc tinh mach trung uong vd i^id nangtuB mdu cua co t h l giiip ieh r i t n h i i u cho vile duy tri hSng dmh the tich tudn hodn va huyet ddng. So vdi nghien c*
cua Maris J. Santiago vd cs. cho b i l t 30,4% b i n h nhdn to tut I p trong thdi gian d i u k i t ndi vdi mdy Ipc thl ti letir h u y l t dp do b i l n chijfng ky thudt ciia chung tdi khdng cac vd d i l n b i l n khdng ndng [4]. Khdng thSy duoc mdi lier quan ndo giiJfa tut h u y l t dp va cdc thdng sd khac (thl tfch dich thay t h l , lieu thudc vdn mach) vd cdc ddc diem dia mdy toe. Mdt s6 tdc gid nhu Brunet P. cho rdng tut aptc Iiln quan tdi vai trd cOa cdc phdn ijfng cua co t h l vi^
mdng loc [5].
- Sdn luan ve mdt sd biin chdng khac Nhu da bilt, ic mau Id mdt ky thudt phCfc tap, ddi hdi phuong tien Ic, thudt cao ddng thai phai cd ngudi vdn hdnh dUOc daot»
tdt. Cdc b l l n chLfng do Ipc mdu I i l n quan t<;n rat r\\\\k khia canh, t i / qud trinh ddt dng thdng tinh mach, dlntf"
k i t ndi vdi mdy Ipc vd k^t thuc cudc lpc. Cdc b i l n chiing cung cd t h l phdt sinh tC/ cdc thdnh p h i n phuc vu che cudc loc (dich loc, c h i t chdng ddng, ddy ndi, qud lpc],cic Idi ky thudt phdt sinh tCr mdy Ipc, cdch xif tri ciia ngUdi vir hdnh.,. h i l u b i l t dupc d i y du cdc ddc diem ndy se giiip ieh rat n h i i u cho vile c h i n dodn va xOf tri b i l n chOlig duoc thdnh thao. Hai b i l n chdng hay gap khde lien quan tdi LMLT dd la rdi loan dudng huyet va ha than nhiet
+ Rdi loan dudng huyet la mdt bien chijfng hay gaf trong loc mau. Trong nghidn eifu cua chiing tdi dCi vSnw nudi dudng chdng ha dudng mau da duoc chu y nhuftl van cd 4/139 (2,9%) cudc loc ha dudng mdu vao g i d ^
TAP CHl Y DUOC L A M S A N G 108 T$p 7 - S 6 3/2012
12 cua LMLT. Chung tdi cho r i n g vile k i l m sodt dUdng h u y l t d mCfc toi Uu cho cdc b i n h ipe mdu Id vdn d l quan trong. Cin theo ddi dUdng m l u , y thiJc vd dinh dUdng thich hop cho b i n h nhdn trong qud trinh LMLT. D i l u c i n luu y Id khi Ipc mdu cd t h l gdy ha dudng huylt do sif dung cac djch thay t h l khdng cd dudng, ddng thdi do khdng dupc cung d p dinh dUdng d i y dii trong khi Ipc [7], [8]. Vile theo ddi sat dudng h u y l t trong Ipc mdu I I cue ky quan trpng, tang dudng h u y l t cung c i n duoc tfnh d i n [9].
+ Hg than nhiet ta mdt b i l n chOrig cSn h i t siJc luu y itrong qud trinh Ipc mdu. N i u khdng dUOC 1dm I'm, nhilt d p ciia CO t h l se gidm xuong do hi&n tupng mdt n h i l t d vong tuan hodn ngodi co t h l . Nghiin cufu cua chung tdi t h i y 2 trudng hop ha thdn nhi&t vdo gid thCf 12 (1,4%).
iTdc gid Kenvin W. Finkel cho b i l t thdn nhi^t gidm 2,8 dd dm giam 26% nhu cdu oxy dan tdi m i t n h i l t tuong Suong 750 kcal/ngdy [4]. Do vdy ddi hdi cung cdp nang Upng vd ii I m cho b i n h nhdn. Cac mdy loc h i l n dai ngdy nay hau h i t d i u cd bd phan sudi I m . Cin luu y gidm than nhilt cd t h l lam Iu md phdn ifng sdt gdy khd n h i n b i l t
•inh trang nhiem khuan, tuy n h i l n mdt sd trudng hpp ha han nhiet lai duoc coi la loi t h l nhu vdi benh nhan sau igirng t u i n hoan.
Cac bien chu'ng khac nhu tac mach do khf, roi loan ."huyen hda vitamin va khodng chat... chung tdi chua ihao sat duoc trong nghien cdu nay.
4.2.3. Ban ludn vi mUc do dung nap trong LMLTcCia cdc iN ngd dgc ndng
Sy dung nap ciia benh nhan ddi vdi Ipc mau Id tinh Tang trong do benh nhan hop tac va chap nhan loc mau ndt each cd y thdc hoac vd y thilc n h i m dam bao qua rinh Ipc mau dien ra thuan loi. Trong nghien cu'u ciia hung tdi, benh nhan 6\igc theo ddi sU dung nap trong ua trinh Ipe mau, b i n g Bdng diem SAS (Ricker Sedation gitation Score) va Thang diem dau Mankoski vdi 10 mifc d khac nhau. Benh nhan duac coi la khdng dung nap eu ed mdt trong cac dau hieu sau: (1) Thang diem SAS >
; (2) Thang diem Mankoski > 4. Benh nhan khdng dung ap vdi may loc cung cd nguy co gay ra cac bien chifng guy hiem, tao ra sU mau thuan giu'a muc dich cua loc ,idu va mifc dp dung nap eiia benh nhan. Sddi chiing tdi .-an luan tdi mire do dung nap trong LMLT d cac benh
»han ngd ddc nang la vl sU dac thii trong Ipc mau d cae
•enh nhan ngd ddc, dae biet la cac ngd ddc thudc ngii, .iiuoe an than. Ket qua nghien ciJu d Bieu do 3.1, cho lay, theo thdi gian so benh nhan dung nap vdi loc mau dm d i n , trong vdng 6 gid dau 71,4% dung nap vdi may ,iC, sau loc 60 gid con sd nay la 35,4%. Cac benh nhan
ngd ddc nang dUpc Ipc mdu thudng trong trang thdi ndng, ed n h i i u tdn thuong gdy dau (ong ddt, rSn cin...), gSy rdi lo^in y thiJc (tiln hdn m l gan), vl vdy b i n h nhdn hay trong trang thdi vdt vd kich thfch hodc khd chiu, khd p h i n b i l t khdng dung nap do b i n h ly n I n hay nguyin nhdn khde. VI vdy ddnh gid dung nap trong nghiin ciJu ndy cOa chOng tdi khd chinh xdc. Nghiin cilu cho b i l t t^
le khdng dung nap vdi q u i Ipc chilm sd lupng cao trong 6 gid d i u (20,6%), tdng d i n l l n 58,3% d gid thiJ 30, Kmh nghiim cho t h i y loc mdu eho cdc b i n h nhdn ngd ddc thudc ngu, an t h i n , t;^ I I dung nap vdi may Ipc gidm d i n theo thdi gian do b i n h nhdn tinh ra d i n tdi kich thich, khdng dung nap vdi mdy lpc. Trong nhiJfng trudng hpp nhu vay, d l d i m bdo t i l p tuc loc ddc chit, trdnh h i l n tupng t i l phdn bd, chung tdi khuyin cdo cdc bdc sy Idm sdng n I n cdn nhic diing thudc an t h i n cd thdi gian ban t h l i n g i n d l d i m tinh trang dung nap giiip t i l p tuc loc ddc chit.
5. Ket ludn
Qua nghiin cu\j 136 cudc LMLT d 106 benh nhdn ngd ddc nang cho thay tudi trung binh la 35,6+14,1;
Nam/NU 1,46/1, 76,3% ed dd tudi tCr 20-59; 39,8% Id do ngd ddc hda chat; ty le tCf vong 35,8%; chf dinh Ipc mau do ddo t h l i ddc c h i t la 31,1%; sued ky thuat hay gap nhat la loi bao ap lye am bau trdn 28,8%, bao dp luc am dudng mau ra 21,6%; 7,2% cudc loc cd bien chiifng tut huyet ap;
3,6% benh nhan cd gi^m tieu cau, Cac su cd ky thuat va bien chifng deu duoc theo ddi phat h i l n va khic phuc kjp thdi, gdp phan gidm thieu cac nguy co cho benh nhan trong qua trinh Ipc mau, Vi the, loc m l u duoc coi la mdt phuong thdc dieu tri hien dai, an toan, ft bien chifng cho eac benh nhan ngd ddc nang.
Tai lieu tham khdo
1 Nguyen Thi f^flinh Tam (2001), "Danh gia mUc do nang ciia ngd doc cap bang bang PSS cua IPCS", Ludn van Tot nghlip bdc si chuyin l<hoa cdp II Trudng Bai hoc Y Hd Noi 2. Le Thl Diem Tuyet (1998), "Nhan xet tinh hinh ngo doc
thudc ngu va thudc an than tai khoa hoi sUc cap cu'u A9 benh vien Bach Mai tC/ 1/1995 - 6/1998", Cong trinh nghien cUu l<hoa hpc 1997- 1998, NXB Y hoc, tr 38 - 43.
3. Maria J Santiago, Jesus Lopez Herce et al (2009), 'Complications of continuous renal replacement therapy in critically ill children: a prospective observational evaluation study', Critical Care, Vol 13, No6,184-195,
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 7 - N°3/2012
Kenvin W. Finkel and Amber S. Podoll (2009), 'Complications of continuous renat replacement therapy". Seminars in Dialysis, Vol 22, No2,155-159.
Brunet P, Jaber K, Berland Y, Baz M: Anaphylactoid reactions during hemodialysis and hemofiltration: role of associating AN69 membrane and angiotensin I- converting enzyme Inhibitors, Am J Kidney DIsI 9:444- 447,1992,
Morimatsu H, Uchino S, Bellomo R, Ronco C: Continuous renal replacement therapy: does technique influence electrolyte and bicarbonate control? Int J Artif Organs 26:289-296, 2003.
Barenbrock M, Hausberg M, Matzkies F, de la Motte S, Schaefer RM: Effects of bicarbonate- and lactatr- buffered replacement fluids on cardiovascular outcome in CWH patients. Kidney Int 58:1751-1757, 2000.
Wooley JA, Btaiche IF, Good KL: Metabolic and nutritional aspects of acute renal failure in critically ill
patients requiring continuous renal replacemaii therapy. Nutr Clin Pract 20:176-191,2005.
9 Van den Berghe G, Wouters P, Weekers F, Venvaest C Bruynlnckx F, Schetz M, Vlassetaers 0, Ferdinande'f, Lauv/ers P, Bouillon R: Intensive Insulin therapy in t ^ critically iti patients. N Engl J Med 345:1359-1367,2oft 10. Baldwin IC: Training, management, and credentia^^
for CRRT in the ICU. Am J Kidney Dis 30:5n2-Slfti 1997,
Holubek WJ, Hoffman RS, Goldfarb DS et al. Use tf hemodialysis and hemoperfusion In poisoned pallei||l Kidney Int 2008; 74: 1327-1334,
Belli Schaefer, Franz Schaefer, Guido Engelmam, Jochen Meyburg, Karl Heinz Heckert,Mwi(
Zorn and Claus Peter Schmitt. Comparison of Motecufarj Adsorbents Recirculating System (MARS) dialysis i i # | combined plasma exchange and haemodlalysis ir children with acute liver failure. Nephrol. JXi Transplant (2011)26(11) 3633-3639.
11.
12.
