BIEN CHUNG TIM MACH CAP O BENH NHAN PHAU THUAT NGOAI TIMTAI BENH VIEN BINH DAN TRONG 2 NAM (2005-2007)
Le Thi Hdng', Pham Thi Nga', Ho Thi Hoa Binh*, Nguyin Cao Thuy Hdng', Nguyen Manh Tien' T 6 M TAT
Van de va muc tieu nghien cihi: Sress gay me; phdu Ihuat; sau phdu thudt: dau, nhiem trung, chay mau, rdi loan nude, dien giai se kfch hoat nguy co bien chiing tim nhdt la tren benh nhan ldn tudi cd sdn benh tim.Muc dich nghien ciiu ddnh gia tan xudt biln chiing tim mach cdp va dm bien phap tdt nhat de han ehe tdi da bien chiing tim mach cap tren benh nhan phau thuat ngoai tim.
Ket qua va ban luan: Qua 2 nam nghien ciiu, chting tdi chi cd 28 trudng hgp co bien chiing tim mach cap nhu dot tir, nhdi mdu co tim, suy tim, phii phdi cdp, loan nhip tim ndng, bao gdm 12 phdu thudt chuong trinh va 16 phlu thudt cdp cuu, tii vong 13/28. Vdi 28 ca bien chiing tim mach cdp/2nam cho hon 20.000 benh nhan cd nguy co tim mach la rat thap, va trong nhiing bien chiing dd khdng cd benh nhdn nao cd chi sd nguy co tim mach cd dieu chinh
> 3 (nguy CO bien chiing tim mach cao), nhung cd lien quan din lpai phdu thuat cd nguy co bien chiing tim mach cao ll/28ca (>5%) nhu phdu thuat cdp ciiu dae biet ngudi gia, phau thudt mach mdu, phdu thudt nguc, phau thuat bung tren. Trong cdc biln chiing tim, bien chiing dot tir va nhdi mau co tim chiem 61,50 % tu vong do tim, cdc biln chiing lien quan den phau thuat nhu nhilm triing, mat mau la yeu td chinh kieh hoat bien chiing tim.
Han che cua nghien cuu la khdng ddnh gid tdn sudt bien chiing cho timg nhdm theo diem chi sd nguy ca tim mach va theo lpai phdu thudt tuy nhien nghien ciiu cung cho thdy chua cdn them xet nghiem thudng quy nhu ECG gang siic, sieu dm tim gang siic, chup ddng maeh vanh cho ddi tugng nguy ca cao. Dilu chinh yeu la theo ddi sdt cdc bdt thudng ve ddu hiiu sinh tdn va phdi tim hieu ngay tai sao nd bat thudng de tim nguyen nhdn ma ed kl hoach dieu tri thfch hop, tranh kich hpat biln chiing tim.
Tir khod: Bien chimg tim mgch cdp trong phdu thugt
ACUTE CARDIAC EVENTS IN PATIENTS UNDERGOING NONCARDIAC SURGERY IN BINHDAN HOSPITAL IN 2 YEARS (2005-2007)
Object: Assess frequency of acute cardiac events and find the best methods to minimize cardiovascular complications for the patients undergoing noncardiac surgery.
Design: retrospective, description, cross sectional study.
Result: Over two years of research, we only have 28 cases of cardiovascular complications such as sudden death, myocardial infarction, heart failure, acute pulmonary edema, severe arrhythmias, including 12 surgical elective and 16 emergency surgery, death 13/28.
Conclusion: In the heart events, sudden death cardiac and myocardial infartion by up 61.50%
fatal, complications related to surgery such as infection, blood loss is a major factor trigger heart complications. Limitations of the study is not evaluating the frequency of events for each group at the index and cardiovascular risk by type surgery but research also shows that more tests should not routinely as stress ECG, Ultrasound Stress heart, coronary arteriography for taking high-risk subjects. This major is closely monitored for vital signs of abnormal and to find out just why it is unusual to find causes that plan appropriate treatment, avoiding trigger of cardiac complications.
Key words: Surgical acute cardiac event DAT VAN DE
Trong 2 ndm benh vien phau thudt khdang 50.0(X)Oca, khdang 1/3 benh nhdn cd benh tim mach can phdu thuat cac benh ngoai tim, nhihig vdn de lien quan den phau thudt va gdy me ' B?nh vien Binh Dan
nhu: nhin ddi; dat, nit ndi khf quan; dau: chay mau; thieu mau; nhilm trung... la nh&ng yeu td khdi ddu sttess, viem, tdng ddng, tinh uang thieu oxy... tdt ca dieu nay cd the la yeu td lam kfch hpat thilu mdu cue bd co tun, va cd the gay cac biln chiing ve tim maeh cho phdu thuat ngoai tim. Vdi su tiln bd cCia gay me, phdu thuat xam ldn tdi thieu, cham sdc sau phdu thudt tdt hon dd lam ha thdp biln chiing tim mach hdu phdu. Benh vien Binh Dan da thuc hi?n kham ndi khoa chu phdu tir 1990 din nay, tuy nhien biln chimg tim mach cdp lien quan den phdu thudt ngdai tim la bao nhieu? chua cd nghien ciiu nao thuc hien de ddnh gia tan xuat biln chiing tim mach cdp sau phlu thuat ngdai tim. Do dd muc tieu cua nghien ciiu nay nham xdc dinh tdn xuat biln chiing tim mach cdp d benh nhdn phlu thudt ngdai tim, tir do nhin lai kham tim mach chu phlu nhu da tiln hanh hien tai da du chua? Cd can lam them xet nghiem hay test xam nhap nao dl danh gia tim mach trudc phdu thuat va tii nghien ciiu nay xac djnh nhirng ylu to thudng gap thiic ddy khdi phat bien chirng tim mach cap de : cd nhiing bien phdp theo ddi, dilu tri kip thdi, cung nhu de xuat them ve trang thiet bi theo ddi benh nhdn, nhdm han chl thap nhat bien chiing tim mach cdp ehu phdu.
THIET KE NGHIEN ClTU Nghien ciiu hdi ciiu, md ta, cat ngang.
Ddi tupng nghien cim: tdt ca nhirng benh nhdn cd phau thudt, hi bien chiing tim machj:ap nhu toan nhip, nhoi mau eo tim, suy tim- phii phdi cdp, xay ra trong vdng 30 ngay sau phdu thudt, tir 8-2005 din 8-2007.
Tieu chudn loai trir: benh nhdn cd biln chiing tim mach nhu tren, nhung chua phlu thuat, hoac phdu thudt tren 30 ngay.
Tdt cd benh nhdn dugc thdng ke theo: tudi, gidi, xep lpai yeu td nguy ca tim mach cd dieu chinh, bien chiing tim xay ra vao ngay hdu phau thii mdy, lpai bien chiing, yeu td thuan lgi xdy ra, ket qua ciia dilu tri, tu dd dua ra nhCrng khuyen eao cdn thiet dp dung tai benh vien de gdp phdn ha thdp nhdt ti le ttr vong hen quan den bien chiing nay.
Tong quan tai lieu
De ddnh gid nguy CO tim mach eho phdu thuat ldn dau tien 1977, Goldmann va cdng su da de ra cac chi sd nguy co tim mach cho phdu thudt ngdai tim, nhung chi sd do ed mdt sd ban che.
Sau dd 1986 Delsky va cdng su cd bo sung bao gdm tien hanh test de danh gia tim mach trude phdu thudt ngdai tim. Nam 1999 Lee va cdng su de nghj 06 chi sd nguy co tim mach ggi la chi sd nguy co tim mach da sii"a ddi dupc iing dung cho danh gia nguy ca tim mach cho phlu thudt ngoai tim, (mdi tham sd dugc 01 diem), nguy co cho bien chiing tim thdp: 0 diem (bien chiing tim: 0,4%), 1-2 diem:nguy co tmng binh (bien chiing tim:0,9%-1%). > 3 diem :nguy CO cao (bien chiing tim : 11 %) nhu sau'"'"^ ':
1. Phdu thuat cd nguy ca eao (phlu thudt trong phiic mac, phlu thuat mach mdu, phdu thuat trong Idng nguc).
2. Benh tim thieu mdu cue bd (tien su nhdi mau eo tim,nghiem phap gang siie duong ti'nh, hien cd con dau that nguc, su dung nitrate, sdng Q tren ECG).
3. Suy tim xung huyet (tien su suy tim, phii phdi, khd thd kjch phat vl dem, rale 2 phdi, gallop S3, tai phan bd tuan hdan tren phim x quang Idng nguc).
4. Tai bien mach mau nao (tien sir con thoang thieu mau nao hay dot quy).
5. Dai thao dudng dung insulin.
6. Creatinin mau trudc phau thudt > 2mg% (>177)im).
Phan tdng nguy ca bien chiing tim mach lien quan din loai phdu thudt ngoai tim:
Nguy ca cao (nguy co tim mach > 5%) Phdu thudt cap cim. ddc biet ngudi gia.
Phlu thuat dpng maeh chii hay mach mau ldn khde.
Phdu thudt mach mau ngpai bien.
Phdu thuat du dinh se keo dai vdi thay ddi dieh co the va hoac mat mau miic do dang kl.
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Nguy ca trung binh (nguy co tim mach < 5%):
-Phau thudt trong phiic mac, trong Idng nguc.
-Cdt bd npi mac dgng maeh canh.
-Phdu thuat viing ddu mat cd.
-Phau thuat chdn thuong chinh hinh.
-Phlu thudt tien tiet tuyln.
Nguy eo thdp (nguy co tim mach < l%):
Ndi soi.
Phdu thudt vii.
Phau thuat da.
Nhirng bien chihig tim mach cdp chu phdu: dot tir, nhdi mau co tim,suy tim cdp ; phii phdi cdp ;loan nhip sau phdu thudt.
K E T Q U A
Trong 2 nam, biln ehiing tim maeh cap bao gdm dot tir, nhdi mdu co tim, suy tim phii phdi, suy tim cap, Ipan nhip nhanh, chiing tdi chi cd 28 trudng hgp bao gdm 10 benh nieu, 18 benh tdng qudt, trong dd: tir vong 13 trudng hgp (chiem 46,43%), tudi cao nhdt 86, thdp nhdt 20 tudi; nam 17, nil 11. Phdu thuat chuong trtnh 12 ca, phdu thuat cdp ciiu 16 ea, bien chiing tim xay ra vao ngay hau phau 0: 06 ca, hau phlu 1: 07 ca, hdu phdu 2: 07 ca, hdu phau 3: 03 ca, hau phau 4: 02 ca, hau phau 7-17: 03 ca.
Bang 1: Phan bd theo tudi.
Tuoi Sobn (28)
11- 20 01
21- 30 00
31- 40 03
41- 50 02
51- 60 05
61- 70 07
71- 80 04
81- 90 06 Bang 2: Phan bd theo lpai benh rdng
qudt (18 ca) Ni?u (10 ca)
So ca r.vonp
So ca r.vong
PT mach
05 03 PT buou than 01 01
PT bung
09 02 Hep nieu dao 02 01
PT nguc
01 01 Than
it nuac
05 03
PT rupt thira 02 00 San than 02 01
PT bucfu
CO
01 01
Bang Ngay phdu Bien chirng tim
3: Phan bd bien chimg xdy ra vao ngay hdu phdu.
0
06
Bang 4: Phdn bd theo chi sd nguy co tim mach cd dieu chinh:
Sd ca
Dot tir mdu
So ca Tong so
ca 05 05
Ptcap Cliu
00 02
Pt chuang tiinh
05 03
Tu vong
05
catim Suy tim cap Khong phu phoi Phu phoi zap Loan nhip tim Loan nhip va phu phoi
05
07 05 01
04
05 04 01
01
02 01 00
03
02 00 00 NHAN XET VA BAN LUAN
Troiig 2 ndm vdi biln chimg tim mach cdp ehi ed 28 tiirdng hgp/ > 50.000ca (khdang 20.000ca cd cac van dl vl tim mach) la thdp va biln chirng tim khdng thdy lien quan den chi sd nguy co tim mach cao, chi cd 01 benh nhan cd dilm nguy ca tim mach tnrdc phlu tiiuat 3 dilm, 23 mrdng hgp 1-2 dilm, 04 trudng hgip 0 diem; nhung cd lien quan din phdu thuat cdp Cliu va Igai phlu thudt cd nguy co cao eho bien chiing tim (bung, nguc).
l.Ve 05 trudng hop ddt rii :chilm 38,46% tir vong do biln chimg tim, va 17,85% bien chiing tim mach cdp. Vi khdng cd tu thilt nen chdc chdn 05 ca diu do nguyen nhan tim mach, Chung tdi khdng chdc chdn, nhung trong 05 ca cd 02 ea khdng thude lpai phau thuiit cd nguy CO tim mach cao, va ca 05 ca khdng cd ca nao cd chi sd nguy co tim mach > 3 diem (tat ca diu phdu thudt chuong trinh, chi sd nguy co tim mach cd dieu ehinh: 01 ca: Odiem; 03 ca: 01 diem, 01 ca: 02 diem).
Cd 05 ca bien chiing diu xay ra d ngay hdu phau 0-3, trong do chae chan 02 ca (phau thudt phinh dpng mach chil bung) do nguyen nhdn tim mach, 01 ca hdu phdu 3 cat budu than 16n con rung thdt, ngung tim, dilm chi sd nguy co tim Id 1, (cd the do thuyen tac phdi?). 01 ca phau thuat cdt thiiy phdi do u, bien chiing tim xay ra chi 2h30 sau phlu thuat, luc benh nhdn dang thd jnay, cd mat mau va duge bii 2 dcm vi hdng cdu lang ngay sau md, dot tu khdi phdt bang vd tam thu, chi sd nguy co tim maeh benh nhan 2 diem. ECG trudc phau thuat ghi nhan sdng T dm d cac chuyen dao trudc tim trdi. Olea bien ehung tim xay ra vao ngay hdu phlu 1, ed tien can rdi loan nhip do benh van tim, chiic nang tam thu thdt trai bdo tdn, cd suy tim dp 2, phau thuat thupc lpai bien chiing tim mach miic dp thdp. Hdu phdu 1, benh nhdn khdi ddu dot ngpt bdng nhip nhanh, suy hd hdp sau dd rung thdt, phu ao khdat, Hb giam, hdi siic khdng hieu qua.dieu gi ki'ch hoat benh nhdn rung thdt? Do suy tira nang hon? Do chay mau sau phdu thudt tuyen giap gay chen ep trung that? trudng hgp nay cd khdm npi khoa va de nghi chua edn phlu thudt. Cd thieu sdt gi trong kham ndi khoa tren? Nhin lai cac budc cdn tien hanh de ddnh gid nguy ca tim, chiing tdi da hoan tdt, ft nhat trong 04 ca cd qua nhieu stress phau thudt nhu phdi phdu thudt 3 Idn trong 2ngay, phdu thudt mdt mau nhieu chfnh nh&ng deu nay kich hpat gdy bien ehiing rung thdt, ngimg tim cd the do co that dpng mach vanh hay trdc mang xo vua gdy nhdi mau co tim cap. Theo y van, nhung benh nhan benh ly mach mau, thudng cd nguy eo benh ddng mach vanh rat cao, vay 2 benh nay cd cdn lam test gang siic de chdn ddan benh mach vanh trudc phau thudt? Mac dii benh nhdn thudc nhdm phlu thudt cd nguy co bien chiing tim maeh cao > 5%, nhung chi sd nguy co lim mach benh nhan la 01, nen theo hudng dan khdng can lam them xet nghiem gi, neu phdu thuat khdng bi bien chimg Uen quan din cugc md cd the bien chiing tim khdng xdy ra?
Trong 05 trudng hgp tren khdng cd trudng hgp nao cd benh tim cdu tnic vi tdt ca deu dugc sieu dm tim. ghi nhdn chiic nang tdm tiiu that trai bao tdn.
Dot tii la tii vong khdng mong mudn tren benh nhdn biet hoac khdng biet benh tim, trieu chirng va tiJr vong khdang lh sau khdi phat trieu chiing'^'"'. Din 2005 chi cd 01 nghien Cliu ngimg tim sau phau tiiuat ciia Sprung va cdng su lugng gia 223 nguyen nhan ngimg tim sau phdu thuat xdc dinh lien quan den tim mach cd 98 ca, do chdy mdu 78 ca, do nguyen nhan 108
khac 47 ca'^'.
2. 05 Trudng hop nhdi mau co tim chiem 23,05% tii vong do tim va 17, 85% bien chimg tim mach cdp:
- 02 ea cdn sdng.
- Cd 02 ca phau thuat mach mau (phlu thudt cap ciiu):
-I- 01 xin ve vi viem phdi nhiem triing benh vien khdng dap iing dieu tri, chi sd nguy co tim mach 2 diem, nhdi mau co tim khdng sdng Q cd dap ling tdt vdi dieu tri, xay ra vao ngay h^u phdu 1.
-I- Trudng hgp 2 xay ra vao ngay hdu phdu 2, chi sd nguy co tim mach 01 diem.
-I- Ca 2 deu nhdi mau co tim khdng sdng Q, yeu td ki'ch hpat:
ca 2 deu thd may, deu cd bii hong cdu lang sau phau thuat, khdng cd huyet ap ha trong liie phdu thudt.
- 02 ca phlu thudt nieu (dat JJ, md bang quang ra da, phdu thudt chuong trinh) deu xin ve, mac du tudi tren 80, ca 2 cd chi sd nguy ca tim mach 0 diem.
+ Bien chiing tim xay ra vao ngay hdu phau 7, sdc nhiem triing; nhdi mdu ca tim ST chenh lenh, yeu td kfch hpat: nhiem trung huyet tCr nhiem trung nieu.
+ Ca cdn lai xdy ra vao ngay hau phdu 12, nhdi mau ST chenh lenh yeu td kich hpat: nhilm triing nieu.
+ Ca 2 deu cd tropomn I tang cao, cd chi djnh tai tudi mau dpng mach vanh, nhung khdng cd dieu kien, dien lien rung that, xin ve.
- 01 ea phlu thudt cdp ciiu, khdng cd tien can tim mach, diem chi sd nguy co tim mach 02 (suy than, phau thudt nguy co cao), tudi <50, benh nhan bi sdc nhilm trimg tir dudng tiin hda, dang dung van mach,lhd may bien chiing tim xdy ra vao ngay hdu phdu 3,ST chenh xudng, troponin I tang, cd the do co thdt dgng mach vanh gdy nhdi mdu co tim vung sau dudi, nhip chdm, benh nhdn cdn sdng.
Trong 05 trudng hgp tren chi cd 03 xdy ra vao ngay hdu phdu 1-3 (dieu nay phia hgp y van: >80% nhdi mau ca tim chu phdu la khdng irieu chiing, 66-100% nhdi mdu ca tim khdng sdng Q, thudng gap ST chenh xudng) va tii vong chu yeu do bien chirng phau thudt (sdc nhiem triing, suy hd hdp do viem phdi nhiem trung benh vien, chi ed 1 do nhdi mdu co tim) 02 trudng hgp nhdi mau co tim, xay ra d ngay hau phlu 7,12 deu cd ylu td kich hgat la nhilm trung nieu, dac biet la nhdi mdu co lim vdi ST ch6nh I8nh (ed 2 deu >80 tudi, phau thuat chuong trinh lpai phdu ihudt cd nguy co tim mach trung binh thdp, diem chi sd nguy co tim 0, deu vao vien vi nhiem triing tieu, mol sdc nhiem trung?) cd the benh nhdn tudi ldn cd xo vira mach mau mac dil ECG tru'dc phau thual binh thudng, nhung vi do tinh trang thay ddi nhip tim lien quan din hdi chiing ddp iing viem he thdng, tinh trang tdng ddng... gay kfch hgat trdc mang xo vira nen bien chiing xay ra vao ngay thir 7 ciia phdu thudt va vdi ST chenh lenh (khdng nhu y van thudng thdy da sd la nhdi mau khdng sdng Q va thudng ngay hdu phdu 1-3).
Nhdi mdu eo tim chu phlu: thudng xdy ra vao ngay hau phdu 0-3, da sd khdng sdng Q, yeu td ki'ch hpat cudi cugc phdu thudt, giai dpan tinh me, dau, mdi mau, ddi....
lam kfch thi'ch giao cdm gay tang : huyet ap, nhjp tim; nhilm triing sau phau thuat gay ki'ch hgat cac yeu td ddng mau...ldt cd nhihig dieu dd Iam tdng nhu cau oxy co tim gay hau qua eo that ddng mach vanh, vd mang xa viia gdy nhdi mau co tim''*^'^'. Trong nghien ciiu tii thiet d nhiing benh nhdn tii vong do tim sau phlu thuat ngdai tim ngudi ta nhan thay nguyen nhdn tdc ddng mach vanh do huylt khdi rdt I't"^'. Tieu chuan nhdn biet nhdi mau co tim chu phdu cd it nhdt 2/3 tieu chudn: su biln ddi ddng hgc men tim,
ihuat)'"'"^ '•^'. Dieu tri nhdi mau co tim chu phdu: gidng nhu dilu tri nhdi mdu ca lim d benh nhdn khdng phdu thudt tuy nhien viee diing thudc khdng ddng cdn can nhdc lgi ich va nguy co trudc khi dilng (phdi xem xet ban than lpai phlu thudt nhu mach mdu, bung, nguc, than kinh....)*^"^''*.
3.Cac ca rdi loan nhio nang: 05 ehilm 17,85 % biln chiing tim maeh cdp, khdng cd tu vong, 02 cd benh tim nen (thay van 2 la, ti-an mau mang tim, phdi), 01 cd cudng gidp, cd 03 ca cd Igan nhip Urrde phdu thuat.
02 phdu thudt chucmg trtnh.
03 phdu thuat cap eiiu.
Tdt ca deu Ipan nhjp uen that vdi dap ung thdt nhanh 150-189ldn/phut
Chi cd 01 ca cd ehi sd nguy co tim mach 02 diem, 04 ea edn lai, chi sd nguy ca chi cd 01 dilm. Bien chiing tim maeh xdy ra vao ngay hau phdu 1-3. Cd 04/05 ea yeu td kfch hpat loan nhjp la do nhilm hiing, vdi dii hdi chiing dap iing viSm he didng (cd 01 trudng hgp Igan nhip xay ra/ benh tim nen, nen dieu tii Ipan nhip cdn cdn nhae cd phai do benh tim nin hay khdng), va dieu chinh bang bii djch, ddi khang sinh thi'ch hgp, benh nhdn dn dinh. Vi 03 ca phai phau thuat cap ciiu nen khdng cd sieu dm tim trudc phau thudt, benh nhan bi loan nhip ngay sau phau thudt, benh vien khdng cd sieu am tim, nen trudc Igan nhip tren thdt vdi dap iing that nhanh, danh gia tinh trang tim:
chiing toi dua vao finh trang lam sang va phim x quang tim phdi, ca cdn lai cd sieu dm tim trudc phau thudt khdng cd suy chirc nang tdm thu cung nhu thrombus trong nhi trai.
Ca 05 trudng hgp tren khdng cd ca nao cdn phai dung thudc khang loan nhip, ngay ca ed 01 ea vdi Igan nhip kem rdi Igan huylt ddng nhung dieu tii la dieu tri benh nen cua benh nhan (do sdc nhiem uung, benh nhan dugc bii dieh theo CVP, dung van maeh noradrenalin, khdng sinh theo lieu phap xudng Ihang sau do benh nhdn dn). Dieu nay phu hgp vdi y van, lat cd cac loan nhip sau phau thuat ngdai tim cdn tim cac nguyen nhan trudc khi diing thude khdng Ipan nhjp, ai se la ngudi tim? Chi'nh phdu thuat vien, neu phau thudt vien khdng lam deu nay, bdc sT ndi khoa can phai hiit nhiing nguyen nhan gay Ipan nhjp sau phdu thudt da sd li8n quan den chinh cupc phdu Ihudt de tira nguyen nhan dieu tri kjp thdi, khdng mat thdi gian de tim thudc dieu tri Ipan nhip.
Lgan nhip sau phau thudt: can xem xet Igan nhjp cd trude phlu thudt hay loan nhip mdi xuat hien. Lgan nhip sau phau thuat la yeu td tien lugng nang, tuy nhien tir vong khdng lien quan den ban than lgan nhip ma lien quan din benh co ban eiia benh nhdn.
Thudng gap nhdt la lgan nhip tren thdt, tdn xudt phdt hien sau phlu thudt tiiy lpai phau thuat va theo ddi ECG lien tuc sau phdu thuat, nguy co Ipan nhip tang ddn so vdi tudi (tang 5,9% > 65 tudi)'^"*. Nhirng nguyen nhan Ipan nhip sau phau thudt do : benh cd sin benh tim cdu tnic trudc phdu thuat; mdi bi sau phdu thuat do: tang carboruc mdu ; thieu oxy ; roi loan nude dien giai; kfch thich co hgc nhu dng ndi khf qudn, dng din luu nguc....; gidm than nhiet; kich ihfch giao cam (gdy me khdng d u ) ; diilu mau eye bd CO lim ; nhiem triing ; sdc giam the tieh ; sdc nhiem triing ; qua tdi luan hdan...Biln chiing Ipan nhip sau phdu thuat xay ra nhilu nhdt ngay hdu phlu 1-5. Dilu uj loan nhjp quanh phau thuat trudc het can tim nguyen nhdn gay loan nhip, ngpai tni trudng hgp Ipan nhjp gay tdn thuang huylt ddng'^'^"'-"-^''*.
4.Ve nhuTig ca suv lim cdp khdng phii phdi cdp. cd tdng cdng 05 chilm 17,85% biln chirng tim mach cdp, va 15,46% tu vong do biln chiing tim.
03 ca cd ehi sd nguy ca tim maeh cd dieu chinh 2 diem (tii vong 02 ca), 02 ca cd dilm nguy CO tira 01 dilm.
Chi cd 01 ca phau thudt chuang fiinh, 04 ca phau thuat cap cuu.
Bien chimg suy tim cap xdy ra: 02 ngay sau phau thudt suy tim mdt bu, 02 hau phau 1, 01 hdu phdu 4.
110
Tir vong 03.
+ 02 ca tu vong ngay sau phdu thudt, do suy tim mdt bii:vi each phlu thudt, va do diing thudc trong liic phau thuat chua phu hgp, benh nhan khdng dugc dieu trj benh tim nen trudc phlu thuat. Ca 2, benh nhan cd suy than man, suy tim, than li nude 2 ben, benh nhan dugc phlu thudt 2 ldn each nhau 1 gid, ngay sau phdu thual benh nhan suy tim truy maeh.
-I- Ca tir vong cdn lai: do suy tim, viem phdi nhiem triing benh vien, suy hd hap.
Trong 05 ca tren, ehi cd 01 ca duge kham npi khoa tiirdc phdu thudt va vin tilp tuc udng thudc tri suy tim den sang ngay phlu thudt, 04 ca cdn lai ^d phlu thudt cdp ciiu va chua danh gid tim mach trudc phlu thudt, nen dieu tri ndi khoa suy tim tmdc phdu thuat chua dugc tiin hanh, them vao dd cd it nhdt 01 ca chua cd ehi dinh phau thuat, 01 ca phlu thuat chua dung thdi diem them vao dd dilng thuoc trong lue md khdng diing (cd chdng chi dinh) nen ca 2 benh nhdn deu bi suy tim cdp, khdng hdi phuc ngay sau phlu thudt (dilu nay hdan toan phii hgp vdi y van).Ca tii vong thii 3 do benh nhan bi suy dinh dudng suy hfl hdp do nhilm triing benh viin khdng dap iing dieu tri, thd may, vi yeu td nguy eo ldm suy tim ndng hon khdng dugc kiem sdat nen nhieu yeu td lam benh nhdn tu vong, khdng so duy nhdt benh tim. 02 ca cdn lai do Igai phdu thudt cd biln chiing tim mach thdp, thdi gian gdy me ngdn, d^ng dich truyen ft, benh nhan dugc diing thudc tim mach tdt nen khdng cd tii vong. Dieu nay cho thdy benh nhdn nin dugc kham ky trude phlu thudt trii trudng hgp vet thuong mach mdu ldn hodc phinh ddng mach chii bung vd nen khdng cd thdi gian dn djnh tim mach Irudc chan chdn se han chi bien chiing tim chu phdu.
Suy tim cap chu phdu thudng hin quan den cdc yeu td td nguy ca nhu :do benh nhan cd san : benh tim ; tieu dudng trudc phdu thudt, thera vao dd :thdi gian gay rae va phdu thu^t kdo dai (thudng la phdu thudt mach mdu, phdu thudt phdi truyen dich nhieu uong liic jjjgj(2.7.2i) -pj.Qjjg nghien eiiu ciia Mangano va cdng su 1990, tien sir rdi loan nhip tim, tieu dudng, thdi gian gdy me, thudc gay me, phdu thudt macb mau lien quan vdi suy tim sau phdu thuat, trong khi dd thilu mdu cue bd co tim thi khong. Ly do ciia phdu Ihudt mach mdu gdy suy tim sau phdu thu|t la phdu thudt keo dai va the tfch djch truyen nhieu. Charlon va cpng su tim thdy benh nhdn cd benh tim, viem ca tim* ', tieu dudng trudc phdu thuat nguy co suy tim sau phdu thudt*'*'^'. Y I U td khde cd the gdy suy tim sau phau thuat la benh nhdn khdng cd kha ndng dung thudc dieu trj suy tim bang dudng mieng sau phdu thudt. Thdi gian xdy ra suy tim chu phau: suy tira chu phau thudng xdy ra trong: ngay phdu thudt, do thdi gian phlu thuat kdo dai, thieu mdu cue bd co tim,su chuyen dich nhanh, hay ngay hdu phdu 2-3 do su tdi hdp thu dich khoang thii B.Trong nghien ciiu Mangano 48% suy tim xdy ra vdo ngay hau phlu 3. Dieu tri suy tim sau phau thuat giong nhu dieu tri d benh nhdn khdng phlu thuat, benh nhan suy tim vdi NYHA II-IV dilu tri vdi iic chl men chuyen gidm 16-31% tir vong. Thude gdy me, phuong phdp phlu thudt, mau mdt, vi tri benh nhan Iren ban md dnh hudng den he ludi ndi md va he thdng thdn kinh giao cdm, do dd dieu can luu y benh nhan cd tang huyet ap, suy tim, thieu mdu cue bp co tim, loan nhip...thudc dieu tri nen dugc udng den sang ngdy phdu thudt trir thudc lgi tieu, thudc lie che men chuyen vd iic che angiotensinogen II ngung sang ngay phau tiiuat'^-''".
5. NhuTig ea suv tim cd phu phdi: cd 07 trudng hgp phii phdi cap, tieu chuan chan doan: ldm sang khd thd, x-quang ed hinh anh cdnh budm 2 ben.
Chi cd 2 ca phdu thuat chuang irinh.
05 phdu thudt cap cim, cd 3 ca suy than mdn di kem.
Bien chimg tim xdy ra:
4- Ngay sau phlu thudt 01 ca, tren benh nhdn nir, 21 tudi dang ed thai thang thii 4, benh nhan cd huyet dp thdp trude phdu thudt, chan doan sdc nhilm triing n6n benh nhan dugc bii kha nhieu djch, hau qua ngay sau phdu thuat benh nhan bi suy hd hap do phii phdi
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