HIEU QUA LOC MAU LIEN TUC TRONG SOC NHIEIVI TRUNG BIEN CHUfNG SUY DA CO QUAN d TRE EM
TAI KHOA HOI SUC TiCH Cl/C - CHONG DOC BENH VIEN NHI DONG 1
Nguylo Minh Tifin', Vo Thanh Vu', Vun Thanh Tung'.
M^c tieu: Danh gia iiieu qua lpc mau lien tue va yeu td lien quan den ket qua dieu tri tre soc nhiem trung bien chung suy da ca quan, nhap Khoa Hdi sue tich cue - Chong doc Benh vien Nhi dong 1 tii 01/01/2006 - 30/09/2014. Doi tuang vd phuong phdp nghien cuu: hoi cihi, mo ta hang loat trudng hgp. Ket qud: 48 truang hop soc nhiem trung bien chung suy da ca quan, dugc chan doan dua tren lam sang va xet nghiem, dugc dua vao 16 nghien emi, tudi trung vi 14,5 thang, nhd nhat 3 thang. Nam ehiem ti le 58,3% Nir 41,7%, dugc loc mau lien tue phucmg thuc tmh - tinh maeh hoae phuang thiic Ige tham tach mau tinh - tTnh mach lien tue cho thay cai thien lam sang nhu tri giac, nhip tim, nhiet do, xanh tai, da noi bong, eiing nhu eai thien tinh trang toan mau, lactate mau. Ti le b> vong 39,6%. Cac yeu to lien quan den tu vong co y nghia thdng ke bao gom tinh trang soe sau, Hon me sau Glasow < 5 diem, tdn thuang gan nang. Ket ludn: Lgc mau lien tue la bien phap ho trg cuoi cung dieu tri soc nhiem triing bien chung suy da ca quan khi ma cac bien phap khac trdf nen khong hieu qua nhu thong khi ca hgc som, chong soc theo luu do hudmg ddn, cung nhu eac thudc van maeh.
Tir khoa: soc nhidm triing, hgi chung suy da ea quan, lgc mau tTnh - tTnh mach lien tiic, lgc tham tach mau tTnh - tTnh mach lien tue.
Nhiem trung huyet d tre em la benh ly cd ti le mac va b i vong cao dac biet khi cd bien chdng soc nhiem biing, hay ton thu'dng da cd quan. Nam 2003 Lien doan the gidi cac hiep hpi hoi sdc cap cyu nhi da phat ddng chu'dng trinh qudc te kiem soat nhiem trung huyet tre em, thdng qua cac hu'dng dan chan doan sdm va dieu tri hieu qua'^'.
Cho den nay cac hudng dan da du'dc cap nhat theo y hgc chutig cd qua cac nam 2007,2009"' va mdi day phdi hdp vdi chudng trinh kiem soat sdng cdn nhiem trung huyet (surviving sepsis campaign) nam 2012'^' da cap nhat xd tri nhilm tiung huyet neing va sdc nhiem bung d ca ngu'di
' Khoa Hoi sac tich cifc - Chong doc, Binh vi?n Nhi dong I. thdnh pho Ha Chi Mmh
Ngiy nhfin bii: 15/6/2015 Ngiy phan bi^o song; OS/7/2015.
Ngiy duyft d i n g : 31/7/2015
\guiA chju trach nhi^m ngi dung khoa hpc: Nguyen Minh Tien. Khoa Hm sucnchcvc- Chdng dpc. Bfiih vi^n Nhi dong I. thdnh phd Hd Chi Minh.
Diimhoai 090339179S. [email protected]
ldn va tre em. Tuy nhien van cdn khdng it cac tru'dng hdp nhiem trung huyet nang, sdc nhiem trung kem dap dng vdi dieu tri va bieu hien suy da cd quan a n dieu tri can tiiiep ho trd Ipc mau lien bjc. Cung tiieo chu'dng trinh kiem soat sdng cdn nhiem trung huyet (surviving sepsis cam- paign) nam 2012, hieu qua Ipc mau tinh tTnh mach lien hjc cho thay cai thien tinh frang dd djch va ton tiiu'dng cac cd quan trong nhiem trung huyet nang, sdc nhiem tnjng(5'. Cho tcfi nay cd che benh sinh trong nhiem bung huyet sdc nhiem trung cd lien quan den cac van de phdng thich cac ngi ddc td ciia vi khuan, kich hoat te bao npi mac mao mach, kich hoat cac te bao viem,...ma hau qua du^ den san xuat nhieu cytokine gay viem nhu* TNFa, IL - 1, IL - 2, IL - 6, IL - 8, IL - 12... t d do du^ den tdn thu'dng cac cd quan. Lpc mau lien tue ngoai dieu tri suy than cap, lay bdt dich phu khdi cd tiie, thai loai ure, a e - atinine, kali... cdn giup loai bd Cytokine gay viem va cac hda chat trung gian. Vi vay chung tdi tien hanh nghien ciili de tai Igc mau lien tue trong sdc nhiem bung bien
TRUY^NHliMVl6TNAM*s6 3(111 - ?nis - 67
chdhg suy da cd quan d tre em nham nit ra mdt sd kinh nghiem tiii/c tien de chia se vdi cac bac si cdng tac hoi su'c nhi, dac biet la trong iinh vi/c Igc mau, gdp phan nang cao chat lu'dng dieu b-j va cai thien t d vong. Muc tieu cua de tai nham: Muc tieu tong quat: Oanh gia hieu qua Ipc mau lien tue va yeu td lien quan den ket qua dieu tri tre sdc nhiem b-ung bien chutig suy da cd quan, nhap Khoa Hoi sdc tich CLTC - Chong dgc Benh vien Nhi ddng 1 t d 01/01/2006 - 30/09/2014. Muc tieu cu the: (1) So sanh ti le bieu hien lam sang, can lam sang midc sau Ipc mau tan thii nhat. (2) Xac djnh ti le dac diem ky tiiuat Ipc mau va bien chutig lien quan, ti le sdng cdn, sd lan loc mau lien tue, tiidi gian nam hoi sdc. (3) Nhan dinh cac yeu td lien quan den ket qua Ipc mau lien tijc.
0 0 1 TUONG VA PHU'ONG PHAP Phu'dng phap: Md ta hoi cdu loat tru'dng hdp.
Doi tu'dng nghien cihi: PhuUng phap chgn mau: chpn mau lien tiep khong xac suat.
Tieu chi chgn benh: Benh nhan < 15 tuoi, du'dc chan doan lam sang sdc nhiem tmng bien chuhg suy da cd quan bao gom cac beu chi (1), (2), (3), (4):
(1) Cd hoi chuhg dap utig viem toan than; Systemic In- flammatory Response Syndrome (SIRS): hien dien it nhat 2 trong 4 tieu chuan sau frong do it nhat cd mpt tieu chuan ve nhiet dd hay sd lu'dng bach cau:
Sdt > 38,5"C hoac ha than nhiet < 36°C.
Tim nhanh tiieo bJoi (*) hoac tim cham d tre du'di 1 tiJoi (**).
Thd nhanh tiieo tudi (***).
Bach cau tang hoac giam theo bJOi (*****) hay band neutrophile > 10%.
Nhdm tuoi
< 1 tuan 1 tuan - < I
thang 1 thang - < 1
nam 2 - 5 tuoi 6 - 1 2 tuoi 13 - < 18 tuoi
Nhjp tim Nhanh(*)
>180
>180
> 180
>140
> I 3 0
>110 Cham(")
<10fl
<I00
< 9 0
NA NA NA
Nhjp The
> 5 0
> 4 0
> 3 4
> 2 2
> 1 8
> 1 4 HAttftu (mmHg)
< 6 5
< 7 5
< 1 0 0
< 9 4
<10S
< 1 1 7 So liTcfng bach au x 103 ( " . * . )
> 3 4
> 19,5 < 5
> 17,5 < 5
> 15,5 < 6
> 13,5 < 4,5
> 11 < 4,5
(2) du'dc xac dinh hay gdi y tac nhan vi khuan qua mdt trong cac tieu chf sau:
Cay mau du'dng b'nh (mpc vi khuan gay benh).
Soi nhupm Gram hay PCR phat hien phan tu'di truyen vi khuan hoac cay moc vi khuan tren mau benh pham.
Tang bach cau trong dich cd the vd trung (dich 6 bung, mang phoi, djch nao tuy...).
Cd 6 nhiem trCing gdi: t d du'dng tieu hda, hd hap, tiet nieu, gan mat, da... tren lam sang hay chan doan hinh anh (X - quang, sieu am).
CRP tang (> 20mg/L) hay PCT (procalcitonin) tang (>
0,5ng/ml).
(3) Cd bieu hien hpi chuhg suy da cd quan theo tieu chuan Goldstein: khi cd 2 trong cac cd quan bj suy sau day trong dd cd cd quanbm mach (sdc nhiem trijng):
+ Cd quan tim mach: Tut huyet ap (****) khdng dap utig vdi bu djch > 40ml/kg/gid.
HA van tut hoac
Can van mach de duy tri huyet ap binh thu'dng (Dopamin > 5)ig/kg/ph hoac Dobutamin, Epineph- rine) hoac
Cd 2 tieu chuan sau (giam tu'di mau):
Toan chuyen hda (BE < - 5mEq/l) khdng giai thich dddc.
Lactate mau ddng mach > 2 lan trj sd binh thu'dng (>
4mmol/L).
Thieu nieu: < 0,5ml/kg/h.
CRT > 5 giay.
Chenh lech nhiet dp ngoai bien va trung tam > S^C.
+ Cd quan hd hap
Pa02/FI02 < 300 (khdng cd tim bam sinh tim hoac benh phdi tru'dc do).
PaC02 > 55 hoac baseline + 20mmHg.
Can FI02 > 50% de duy tri Sa02 > 92%.
Can thdng khi cd hgc.
+ Than kinh Glasgow < l i d . Glasgow giam > 3d.
+ Huyet hpc
Tieu cau < SO.OOO/mm^.
I N R > 2
+ Than: Creatinin > 2 lan gidi han tren theo tudi, tdc la
> 0,8mg% (70,8jjmol/L) tre < 1 tudi, > l,4mg%
6 8 -TRUYtniNHllMVlgTNAM*s63(11)-2015
(123,9Mmol/L), tre 1-8 tuoi, > 2mg% (176,9Mmol/L) he >
8 tudi. Bat thu'dng chdc nang ttian khi ure > 40mg%
(7,lmmol/L) hoac aeatinine > gidi han ti-en theo tuoi.
+ Gan
Bilirubin toan phan > 4mg/dl (khdng ap dung cho sd sinh).
ALT > 2 lan h i so binh thudng. Tdn thudng gan nang AST hoac ALT >1.000dv/L.
(4) cd chi dinh Igc mau lien tue:
Nhiem trung huyet suy da cd quan kem suy than cap hoac
Xem xet cac tru'dng hdp nhiem triing huyet suy da cd quan khdng kem suy than cap nhutig cd bieu hien phan utig viem manh (CRP tang cao > lOOmg/L), sdt cao lien tue kem dap dng vdi bien phap ha sdt tich CLTC, nhip tim tang > 180 lan/ph, ARDS...
Bien phap ha s6t tich ci/c bao gom Lau mat ha sdt b'ch cdc. Paracetamol 10 - 15mg/kg/lan TTM cham trong 15 phut. Neu than nhiet van cdn > 39°C sau 1 gid sd dung paracetamol TTI^: ket hdp Ibuprofen 10 mg/kg/lan (udng hay qua sonde da day). Khdng su* dung Ibuprofen neu cd xuat huyet tieu hda. Rda da day bang NaCI 0,9% lanh, ± ket hdp thut thao NaCI 0,9% lanh: khi cdn sdt > 40oC va khdng dap dtig vdi Paracetamol + Ibuprofen. Cach tao NaCI 0,9% lanh dung trong rd'a da day hay thut thao de ha sot: Dung djch Nad 0,9% de ngan 4 - lOoC cua bJ lanh hoac dung djch NaCI 0,9% ddp da lanh trong 30 phut hay de trong ng^n da tu lanh 10 - 1 5 phut trong cac tru'dng hdp khan cap nhutig khdng cd san NaCI 0,9% lam lanh.
Tieu diiloai tru": Cac trudng hdp benh nhan nhiem trung huyet khdng cd bien chutig sdc nhiem tmng du'dc Igc mau lien tue hay dddc dieu trj bang phu'dng phap khac nhu*
thay huyet tu'dng; Cd bat thu'dng benh ly khac di kem nhu"
benh tim bam sinh, b|nh ly than kmh, benh phoi man, hdi chutig than hu', da dl tat.
2. Thdi gian va dja diem nghien cuti: 01/01/2006 - 30/09/2014, tai Khoa Hoi sdc tich CLTC - Chong doc Benh vien Nhi ddng 1, thanh phd Ho Chi l^inh.
3. Cac bUdc tien hanh: Sau khi cd chi djnh loc mau, benh nhan se du'dc tien hanh Igc mau theo qui tiinh [pc mau lien tue cua khoa hdi sdc nhd sau:
May PRISMA flex hoac may Aquarius (da dddc tiang bi tai Khoa Hoi su'c).
Dich Igc sd dung: dung djch Hemosol.
Dat catheter tinh mach tmng tam 2 ndng so 6 - 7F hoac 8 - I I F (tuy benh nhan).
Mang Ipc cho may loc mau PRISMA FLEX loai M60 cho ti-e < 20kg hoac MlOO cho tre > 20 kg.
Toe dp Ipc hay tdc dp djch thay the: 40ml/kg/h, Tdc dp bdm mau 4 - 6ml/kg/ph.
Khang ddng: Heparin hda mau benh nhan bang lieu tan cdng 3 phut tru'dc khi bat dau (heparin 0 - 50UI/kg hoac fraxiparin lieu 0 - 20UI/kg ndu tieu cau
< 50.000/mm3) tiem tinh mach tuy tinh trang dong mau cua benh nhan, lieu duy tri du'dc pha vdi nati-i clorua 0,9% va tmyen vao chu trinh trudc mang Ipc (fraxiparin lieu 0 - lOUI/kg/gid hoac heparin 0 - 20UI/kg/gid) bang may bdm tiem ti/dpng. Benh nhan cd nguy cd chay mau (INR > 2) giam nu^ lieu. Neu benh nhan cd bieu hien xuat huyet va INR > 4, khdng diJng khang ddng. Ldu y theo doi chdc nSng ddng mau moi 4 - 6 gid de dieu chinh lieu khang ddng thich hdp.
Theo ddi: Benh nhan dddc theo ddi qua trinh Igc mau bang phieu theo ddi Ipc mau; Sinh hieu va theo ddi lu'dng xuat nhap du'dc theo ddi moi gid trong 6 gid dau, it nhat moi 4 gid trong 24 gid ke tiep.
Thu nhap so lieu: sdc nhiem tmng bien chutig suy da cd quan thugc Id nghien cud du'dc tien hanh thu thap sd lieu trong qua trinh Ipc mau, theo ho sd nghien cud kem theo bao gdm:
a. Dac diem benh nhan: tudi, gidi, dja chi, ngay xuat hien soc, ngay xuat hien bien chuhg thd bat thu'dng.
b. Bieu hien lam sang tru'dc luc va trong qua trinh Ipc mau lien tue tai thcfi diem tO, t6, t l 2 , t24: Mach/nhjp tim, nhiet do, huyet ap, tri giac (Glasgow), xanh tai, da ndi bdng, toan chuyen hoa, chi so van mach tang co (VIS vasoactive Inotropic Score = (dopamine + dobutamine) x 1 + (adrenaline + noradrenaline) x 100 + Milrinone x 15.
c. Xet nghiem luc Igc mau: CTM, Het, tieu cau, du'dng huyet, ion dd, lactate mau, khi mau dong mach, CVP, chu'c nang ddng mau toan bp tai thdi diem tO, t6, t l 2 , t24, xet nghiem chdc nang gan; SCOT, SGPT, chdc nang than, tai ttidi diem ti3, t l 2 , t24.
Xu* ly so lieu: Sir dung phan mem SPSS 18.0 de phan tich sd lieu, sd dung cac phep kiem Independent Samples
TRUYEN NHlilUI VIETNAM • S O 3(11) - 201R - ^ Q
T Test danh cho bien dinh lu'dng ddc lap, phep lyem paired - sample t test danh cho bien dinh lu'dng cap ddi, phep kiem x2 danh cho bien dinh b'nh so sanh 2 ti le dgc lap, phep kiem Wilcoxon Signed Ranks Test danh cho bien djnh tinh so sanh cap ddi, ngudng y nghia thdng ke P < 0,05.
KET QUA
Trong thdi gian gan 9 nam t d 01/01/2011 - 30/09/2014, cd 48 tre soc nhiem trung bien chutig suy da cd quan, thda tieu chi nhan vao, dddc du'a vao Id nghien cdu, vdi cac dac diem sau:
D|c diem djch te hoc, lam sang, vi sinh Bang 1 : Dac diem djch te hoc, lam sang, vi sinh
Dac diem Tuoi tnjng vj (thang)
<2tufii Can n^ng trung vi (kg) SlOkg GI6i: Nam/nff Dia phi/dng: ttianti pii5/tjnii 0ieu tri tuyen truSi^tLf den Urn sang Ngay vao soc Soc sau (HA tut, kiiong do difdc) DiiSrg vao/o nhiem trung Tieu hoa Hohiip Da Khong ro Biem PRISM Diem PELOD Hot chiing suy da cO quan Cin lam sang Hct(%)
Bach cau (/mm^) / reutrophile (%) Tieu cau (103/mm^) CRP (mg/L) AST/ALT (dv/L) Ton thuWng gan Ure (minol/L)/creatinine (pmol/L) Suy than cap Diem Glasgow
Pa02/Fi0Z ARDS (PaOZ/n02 < 2G0) OIC
Lactate mau (mmol/L) / ScvOZ (%)
Ket qua 14,5 (3 thang - 1 3 tuoi)
31 (M,6%) 10(5-37) 25 (52,1%) 26 (58,3%)/20 (41,7%) 16 (33,3%)/32 (66,7%) 31 (64,6%)/17 (35,4%)
1 - 4 (1 - Z: 70,8%) 34 (70,8%)
26 (54,2%) 7(14,6%) 5 (10,4%) 10 (20,3%) 20,1 ± 3,2 18,6 ± 2,4 48 (100%)
33,8 ± Z,9 21326 ± 3426/78,5 ± 4,5
78,2 ± 15,7 98,5 ± 26,2 1838,6 ± 74,3/759,2 i 63,6
38 (79,2%) 7,3 ± 2,4/129,5 ± 34,6
29 (60,4%) 9,8 ±1,4, 5-11:13 (27,1%),
< 5: 9 (18,8%) 226,5 ± 45,6 23 (47,9%) 28(58,3%) 5,B ± 1,2/66,7 ± 4,2
Lactate mau > 2,5 mmoi/L Na+/K+/Ca++ (mmol/L) Du'cing huyet (mmol/L) PH/HC03/BE
Toan chuyen hoa nang (pH < 7,2) Cay mau moc vi khuan gay benh Eschenchia coli Burkholderfa cepacia Klebsiella spp Staphylococcus aureus Acinetobactena spp
45(95,8%) 132,4 ± 4,5/5,4 ± 0,7/1,02 ± 0,06 6,3 ± 2,7/ < Z,5:14 (29,2%), > 10:11 (22,9%)
7,22 ± 0,06/11,4 ± 4,3/ - 8,5 ± 0,4 33 (68,7%) 13 (27,1%)
5 2 2 3 (2 ca sau chung ngii^)
PRISM pediatric risk of mortality: chi so nguy cd tu' vong tre em, PELOD: pediatric logistic organ dysfunction: chi so roi loan c/iiit nang cd quan tre em, ARDS acute respiratory distress syndrome:
hoi diuiig suy ho hap cap ben trien, DIC: disseminated intravascu- lar coagulation: dong mau noi mach lan toa.
Can thiep dieu trj ngoai loc mau lien tue Bang 2: can thiep ^ u trj ngoai loc mau lien tue
flac diem Bien phap lio ttif ho liap (tiid may)
Midazolam so ca/lieu toi da TB (mg/kg/giiJ) Fentanyi so ca/iieu toi da TB (mcg/kg/giil) Bien pliap iio trd tuan lioan (ciiSng soc) Tong dich trung binh (ml/kg) trong 6gic( dau Dai phan Htso ca/iuWng dich trung binh (ml/kg) Dopamine so ca/iieu toi da TB (mcg/kg/phut) Dobutamine so ca/iieu toi da TB (mcg/kg/phut) Adrenaline so ca/iieu tffl da TB (mcg/kg/phut) Noradrenaline so ca/lieu toi da TB (mcg/kg/phut) sat catheter tinh mach trung tam do CVP D3t catheter dfing mach do HADMXL Dat thong tieu
Ktiang sinli ban ^ u Cephaiosporine the he thif 3 Quinolone Kliang sinh tiep tiieo
Carbapenem Vancomycin Sii* dung gamagiobuline TTM Hydrocortisone TM Dieu trj Idiac
Dieu chinh toan diuyai hoa Dieu tri ha du'cing huyet Tnjyen mau (hong tau l&ig)
Ket qua 48 (100%) 48(100%)/0,26±0,12
26 (54,2%)/l,8 ± 0,5 48 (100%) 85,4 ± 15,5 39 (81,3%) 38,2 ± 9,6 48 (100%)/10,6 ± 1,4 48(100%)/11,8±1,5 23 (47,9%)/l,Z ± 0,23 17 (35,4%) /1,1 ± 0,12
43 (89,6%) 45 (93,8%) 48 (100%)
40 (83,3%) 8 (16,7%)
37 (77,1%) 3 (5,3%) 2(4,2%) 11 (22,9%)
45 (95,8%) 14(29,2%) 15 (31,3%)
7 0 - TRUYtNNHltMVieTNAM*S6 3(111
K d qua dieu trj ThM gian nSm klwa hoi sut (ngay) Song
Tir vong
14,8 ± 5,3 Z9 (60,4%) 19 (39,6%) Ci/P centr3l nervous pressure: Ap lu'c dnh madi trung tam, HADMXL:
buy& ap dong mach xam lin TB: trung binh, TTM: truyen b'nh madi, TM dnh mach.
Dac diem loc mau ddt dau
Bang 3: Oac diem loc mau ddt ^ u
PhuWng fiiLJ-c loc mau CWH/CWHDF Chi dinh loc mau
Suy da cd quan kem suy than cap Suy da cd quan khong kem suy than cap Sot cao > 390C lien tgc, nhip tim nhanh.
kh6ng dap iing bl?n phap ha sot tich c i ^ .Thci may + ARDS + nhjp tim nhanh > 180 l/ph Ngay benh luc loc mau (ngay) TlKli gian tif luc s6c - luc l)3t d i u loc mau (gitl)
41 (85,4%)/7 (14,6%)
Z9 (60,4%) 19(39,6%)
16 (33,3%) 3 (5,3%) Median 3 (3 - 4:83,3%)
28,6 ± 9,4 (18 - 96) Thcli gian tif luc a i chi dinh - ipc mau trung binh (gid) 1,9 ± 1,2 (1 - 4) Thcfi gian loc miu hung binh (gid)
The h'ch dich thay the trung binh (ml/kg/gicf) The tich djch ttiSm tach trung binh (ml/kg/gid) The tich d d i lay ra tmng t»nh (ml/kg/gid) Dich tiiay the itemosoi Toe do b(Jm mau (ml/kg/phiit) Chong dong Hepann
Tan cong (Ul/kg) Duy hi (Ul/kg/gicJ) Fraxiparin
Tan cong (Ul/kg) Duy tri (Ul/kg/gid) Cathela- 2 nong 6^.5F/7F/e-UF
Dat Z catiieter ding luc
Bien chuhg do can thi|p dieu tri loc mau lien Uic Oong mang loc
Tac catheter Khi he thong Tut huyet ap Ha than nhi§t Ha kail mau
S3 truSno hdP loc mau lien tue > Z Sn
31,6 ± 7,1 40,8 ± Z,4 Z4,7 ± 3,2 2,4 ± 1,3 48(100%) 5,3 ± 1,2
5 (12,5%) 50,6 ± 4,7 16,8 ± 2,4 42 (87,5%) 20,8 ± 0,6 11,5 ± 2,8 25 (52,1%)/18 (37,5%)/
5(10,4%) 13 (27,1%)
9 (18,8%) 11 (22,9%) 5 (10,4%) 18 (37,5%) 10 (20,8%) 14(29,2%) 17 (35,4%)
CWH Continuous veno - Venous Hemofiltrabon: toe mau dnh mach - dnh ma&i lien tue, CWHDF Ccmdnuous v&io - Venous Hemodi- afiltration: loc tham tach mau tinh mach - dnh math lien tue.
Diln tien ton thu'dng cac cO quan tru'dc va sau loc mau lan ^ u
Bang 4: Dien tien ton thu'dng cac cd quan tru'dc va sau loc mau lan dau
Ctf quan Nhip tim (l/p) Nhiet dp (•C Xanh tai Etarmlbong Hohap
Gan Than
Tn giac Chuyen hoa
Kiem toan
Chi so VIS D)an PRISM Diem PELOD
Pa02/FO2 AaDO;
flST(UI/L) ALT(UI/L) Ure (mmol/L) Creatinin (Ijmol/L) GCS(diem) Na+[mmol/L) K+ (nmol/L) Ca++ (mnul/L;
TO sau 19c mau
189,6 ± 10,5 39,2 ±0,6
23/48 17/48 226,5 ± 45,5 235,614,4 lB3e,6 ± 74,3 759,2 ± 63,6 7,3 ± 2,4
129,6 ± 34,6 9,B ± 1,4 132,4*4,6 5,4 ±0,7 1,Q2 ± 0,06 Lactate (mniol/L) 5,8*1,2 Sc:v02 {%) pH HC03- BE
66,7 ± 4,2 7,22 ± 0,06 11,4 * 4,3
•8,5*0.4 59,4 ± 12,6 20,1 t 3,2 18,5 ± 2,4
112 sau I9C mau
169,2*15,3 38,3 ±1,4 18/4S 10/48 255,2 ± 34,6 194,7 ± 11,5 1684,7*85,4 618,4*52,6 6,6 * 1.5 106,4 ± 23,8
10,5 ± 1,1 134,2*3,5 3,3 * 0,6 0,91 ± 0,02
3.4*2,2 70,3 ± 4,5 7,32 * 0,04 15,8 * 2,3 -5,8*0,9 46,7*9,3 18,1*2,5 17,5*1,7
T24 sau Ipc mau
154,7116/4 37,7 ± 0,4
11/48 6/48 302,3 * 32,5 125,4 ± 10,3 1526,5 * 72,4 542,2 ± 51,7
5,9*0,8 79,3 * 18,6
10,9 * 1,2 131,8 * 3,2 3,4 ±0,3 1,01 ± 0,03 2,3 ± 1,4 73,4 ± 3,8 7,36 ± 0,02 17,4 * 2,5
•4,4*0,6 38,2 ±10,1 15,4 ± 1,6 16,7 * 2,1
P
< 0,05-
<0,05*
<0,05"
< 0,05"
< 0,05*
< 0,05*
NS- HS- NS'
< 0,05*
NS' NS'
<0,05' NS*
< 0,05"
< 0,05'
< 0,05*
< 0,05-
< 0,05-
<0.05'
< 0,05' NS* Scv02: saturation of central oxygen: do ijao hoa oxy mau dnh maeh trung tam, BE: base excess: kiem dU, VIS: vasoactve inodopic score: chi so van mach tang co cd tim. *pbep kiem Paired Samples T Test, **phep kiem Wilayxon Signed Ranks Test, ngudng y nghia P
< 0,05, NS: non - significant
Cac y§^u to lien quan den ket qua loc mau Bang 5. So sanh d^c di€m nhom song va tu* vong
Yeu to FuS < 12 thang Gidl (Nam) S&sau Glasgow < 5 pH HC03
^
Lactate (mmol/L) ftST(dv/L) ALT(av/L) VISNhom song (n = 29)
13 15 17 2 7,25 ±0,01
12,6 * 2,2 - 7,8 ± 2,4 4,7 ± 1,3 1142,6 * 42,7 484,6 ± 53,2 46,3 ± 5,4
Nh6ni bjr vong (n = 19)
9 12 17 7 7,2 ± 0,02 11,1 * 2,4 -8,7 ±2,6 6,2 ± 1,1 2559,7 ± 61,2 1084,6 ± 72,5 71,4 * 6,3
P „ , „ . HS" NS"
< 0,05"
< 0,05"
NS' NS* NS*
< 0,05'
< 0.05'
< 0,05"
<0,05*
TRUY4NNHliMVI$TNAM*s6 3(11) - 2015 - 7 1
Y & l t o PRISM PELOO MODS khong suy Chan Thtfi gian tJJ'luc s 6 c - bSt dau loc mau (qtiS) TIHA gian b^ I l k d i i d i n h - Ipc man (gicO
N h o m SCM19 (n = 29)
16,8 * 3,1 15,7 ± 2,1 15 24,5*4,3
1,8*1,3
Nhom tilr vong (n = 19)
22,7*4,2 20,6 ±2,3 4 31,6 ± 6,4
3,1*0,6 P value
< 0,05*
< 0,05'
NS' NS*
MODS: Multiple organ dysfunction syndrome: hgi cbi^hg suy da cd quan, *phep kiem Independent Samples T Test, **phep kiem *2 Test ngu3ng y nghia P < 0,05, NS: non - significant BAN LUAN
Trong th6i gian gan 9 nam tir 01/01/2011 - 30/09/2014, CO 48 tre soc nhiem trung bien chLTng suy da cd quan, tuoi trung vi 14,5 thang, nho nhat 3 thang, I6n nhat 13 tuoi, phan i6n tre <id&\ 2 tuoi (64,6%) va co can nSng thap du'di 10 l<g (52,1%), Nam chiem tl le 58,3%, Nd 41,7%. Oa so tre 6 ngu 6 tinh (66,7%), chuyen vien tir tuyen tru'dc (64,6%).
Tat ca cac tre nhap vien trong tinh trang soc, trong do soc sau chiem ti le 70,8%. Cuiflng vao 6 nhiem triing da so tir du'dng tieu hoa 54,2%, ke den la du'dng ho hap 14,6%, da 10,4%, khong ro du'dng vao 20,8%. Tinh trang soc nhilm triing thu'dng xay ra vao ngay 1,2 (70,8%) vdi so lirdng bach cau tang cao, CRP cao, kem ton thu'dng cac cd quan nhu" gan (79,2%), than (60,4%), hoi chuhg suy ho hap cap tien trien (ARDS) 47,9%, roi loan tri giac vdi diem Glasgow trung binh 9,8, dong mau noi mach lan toa DIC 58,3%, roi loan chuyen hoa ha du'dng huyet (29,9%), tang du'dng huyet (22,9%), tang lactate mau (95,8%), toan chuyen hoa nang (68,7%). Diem so PRISM, PELOD trung binh lan lu'dt la 20,1 va 18,6 phan anh do n3ng cua benh va ton thu'dng cac cd quan dda den hgi chuhg suy da cd quan. Bang chutig vi sinh ghi nhan cay mau moc vi khuan gay benh trong 27,1% cac tru'dng hdp, trong do nhiem Escherichia coli chiem UXJ the. Cd 3 trudng hdp cay mau moc vdi tu cau vang staphylococcus aureus, trong 2 tru'dng hdp tir nhiem khuan sau tiem ngiTa vacxin 3 trong 1 Sdi - Quai bj - Rubella bieu hien hoi chutig soc doc to vdi bieu hien lam sang sot cao lien tue, 61 mu'a, tieu chay, tut huyet ap, do da, ket mac mat sung huyet, luSi dau, roi loan tri giac nhuhg khong co dau hieu than kmh khu trii.
Ve dieu tri, tat ca cac tru'dng hdp (100%) du'dc dat
npi khi quan giup thd, thd may vdi an than bang midazo- lam ddn thuan hoac phoi hdp fentanyi (54,2%). Theo hu'dng dan quoc te ve XLT tri nhiem triing huyet nang va soc nhiem trung cua Chudng trinh kiem scat song cdn nhiem triing huyet (surviving sepsis campaign) nam 2012(5', chi djnh dat ngi khi quan thd may sdm neu benh nhan thd khong hieu qua, soc khong on dinh, tri giac xau hdn, giup cai thien chong soc hieu qua hdn. Tat ca cac tru'dng hdp dUdc truyen djch chong soc vdi tong lu'dng djch trung binh trong 6 gid dau la 85,4ml/kg, cd 81,3%
cac tru'dng hdp khong dap uTig vdi dung dich dien giai, dUdc doi sang dung djch cao phan tu' vdi lu'dng cao phan tCr sir dung trung binh la 38,2ml/kg. Loai cao phan tu' chiing toi sirdung la gelatin hoac hoac HES130 6% hoac HES 200 6%. Tat ca cac tnj'dng hdp trong 16 nghien ciru cua chiing toi, deu sir dung thuoe van mach dopamine va dobutamine vdi lieu toi da trung binh tu'dng img la 10,6 va ll,8mcg/kg/ph trong khi adrenaline va noradrenaline chiem tl le 47,9% va 35,4% vdi lieu toi da trung binh la 1,2 va l,lmcg/kg/ph. Do va theo doi ap lUc tinh mach trung tam (CVP central nervous pressure) va huyet ap dpng mach xam lan (HADMXL) du'dc thi/c hien d 89,6%
va 93,8% cac tru'dng hdp va la ky thuat rat can thiet cho dieu trj hu'dng muc tieu sdm, giup hu'dng dan dieu chinh toe dp dich truyen va thuoe van mach cung nhu' lay mau xet nghiem™.
Chiing toi sir dung hydrocortisone li§u thap eho 11 (22,9%) tru'dng hdp soc khang vdi cathecolamine. Chi dinh corticoid trong soc nhiem triing d tre em theo eac tac gia bao gom tir ban toi cap do nao mo cau, ho3c tre cd tien su" sir dung corticoid gan day vi bat thu'dng true ha doi - tuyen yen - thu'dng than hay tre soc nhiem triing khong dap utig vdi cathecolaminef^'-'^'. Tat ca cac tru'dng hdp tuan thii sir dung khang sinh trong vdng 1 gid dau tien vdi khang sinh ban dau la cephaiosporine the he thif 3 (cefotaxime hoac ceftriaxone) 83,3%, quinolone (ciprofloxacine hoac pefloxacine) 16,7%'^). Tuy nhien, co 3 (6,9%) tru'dng hdp tre soc nhiem triing cd bieu hien nhiem triing da (nhpt da nung mu viing mong, lutig va canh tay trai sau tiem chimg) du'dc sir dung nhdm khang sinh di§u tri ty cau triing la vancomycin. Cac tru'dng hdp dien hen nang, kem dap irng khang sinh ban dau cephaiosporine the he thir 3 hoac quinolone, chung toi doi sang khang sinh pho rong nhom carbapenem 77,1%.
Theo hu'dng dan quoc te ve xir tri nhiem trung huyet nang
7 2 - T R U Y t N N H l 6 M V i e T N A M * s 6 3 ( 1 1 ) - 2 0 1 5
va soc nhiem trung ciia Chu'dng trinh kiem soat song cdn nhilm triing huyet (surviving sepsis campaign) nam 2012, dimg khang sinh thich hdp sdm cho nhiem tmng huyet nang hoac sdc nhiem triing cai thien tir vong hdn sir dung khang sinh tre, khdng thich hdp, sirdung khang sinh cang tre, cang lam tang ti le tu" vong'^'. Cd 95,8% cac tru'dng hdp dddc sir dyng bicarbonate dieu chinh toan chuyen hda mau. Tuy nhien c^n lull y rang toan chuyen hoa la do thieu t u ^ mau mo nen dieu can thiet la toi uli hda tu'di mau md hdn la sir dung bicarbonate. Ngoai ra cd 29,2%
cac tru'dng hdp dddc dieu chinh ha du'dng huyet va 2 tru'dng hdp du'dc truyen gammaglobulin (4,2%) la 2 tru'dng hdp hpi chirng soc dpc to to nhiem ty cau vang sau chiing ngiTa.
Mae dii du'dc dieu trj tfch cu'c vcfi tat ca eac bien phap can thiep tren nhuhg cac benh nhan trong 16 nghien a j l j van khdng dap iTng vdi dieu trj va dien tien nang bien chiihg ton thu'dng gan, than, hd hap... du^ den hpi chuhg suy da cd quan nen dUdc tien hanh Ipc mau lien tyc.
Cd 41 tru'dng hdp (85,4%) du'dc Ipc mau theo phuUng thirc tTnh - tTnh mach lien tyc (CWH) va 7 tru'dng hdp (14,6%) theo phu'dng thirc loc tham tach mau tTnh - tTnh mach lien tue (CWHDF) vdi cac chi djnh hpi chuhg suy da cd quan kem suy than cap (60,4%), khong kem suy than 39,6% (bang 3). Theo chu'dng trinh kiem soat song cdn nhiem triing huyet (surviving sepsis campaign) nam 2012, chi djnh Ipc mau lien tue trong nhiem triing huyet nang va soc nhiem triing la khi co bien chiitig suy da cd quan trong do ed suy than cap'^'. Cac chi djnh khac cdn ban cai, tuy nhien eac tae gia Nhat Ban da chi dmh va ap dyng Ipc mau lien tyc cho eae tru'dng hdp nhiem trimg huyet suy da cd quan khdng kem suy than nhu' ton thu'dng gan, ARDS, phan utig viem manh vdi sot cao lien tue, nhjp tim nhanh... cho ket qua kha quan va u^ chuong phu'dng thirc Ipc tham tach mau tTnh - tinh maeh lien tue (CWHDF)'3Wi"'. Da SO cae tru'dng hdp du'dc lpc mau lien tyc vao ngay thir 3,4 cua benh (83,3%). Thdi gian tir luc cd chi dinh loc mau den khi gan benh nhan vao may Ipc mau trung binh la 1,9 ± 1,2 gid. Day la thdi gian danh cho tiep can tTnh mach trung tam, eung nhu* khdi dong moi dich he thong may Ipc mau de may sin sang hoat dpng. Thdi gian nay cang ngan cang tot vi can thiep Ipc mau du'dc tien hanh nhanh chdng. Tuy nhien khong phai d l dat du'dc vi tiep can mach mau trung tam d tre nhd rat
khd dac biet d tre cd can nang < 10kg trong 16 nghien cull eiia chiing toi chiem 52,1% cac fru'dng hdp. De nit ngan thdi gian chuan bi, chung toi chia 2 nhom thu'c hien song song mdt nhdm thdc hien tiep can mach mau gom cac bac sT gidi ed kmh nghiem trong chich tTnh mach diii, tTnh mach canh trong phan ldn vdi catheter 6 - 6.5F (52,1%) va 7F 2 ndng (37,5%), mpt nhdm khdi ddng chuan bj may Ipc mau lien tyc gdm cac bac sT dieu du@ng gidi thuan thuc lap rap moi dich he thong may Ipc mau.
Thdi gian ngan nhat trong nghien ciili eiia ehung toi la 1 gid. Tuy nhien cung can lull y tiep tyc hoi su'c hd hap tuan hoan toi ulj cung nhd dieu chinh rdi loan dien giai, thSng bang kiem toan. Thdi gian tir luc soc - luc bat dau Ipc mau 28,6 ± 9,4 gid. Day la thdi gian can thiet cho mpi no l y t tich cdc de dat du'dc muc tieu trong hoi sure soc nhiem tmng tru'dc khi du^ ra quyet djnh Ipc mau. Chu^ cd bang chimg lpc mau sdm trong nhiem triing huyet n3ng, soc nhilm tmng cai thien ket qua dieu trp'-'^'. Thdi gian Ipc mau lien tyc trung binh 31,6 ± 7,1 gid. Chimg tdi sir dyng dich hemosol chda dien giai va cd chat dem la bicarbon- ate lam djch thay the eung nhu" djch tham taeh. The tich dieh thay the trung binh 40,8 ± 2,4ml/kg/gid. The tieh djch tham tach trung binh 24,7 ± 3,2ml/kg/gid. Cho tdi hien nay van chu'a cd dii bang chiitig Ipc mau vdi lieu cao
> 50ml/kg/gid cai thien ti le tir vong trong sdc nhiem triing'"'*^'. Cac khuyen cao lieu dich thay the thich hdp hien nay la 20 - 40ml/kg/gid'"'.
Chung tdi chong ddng he thong Ipc mau phan Idn (87,5%) bang fraxiparine (nadroparine) lieu tan cong trung binh 20,8 ± 0,6UI/kg, duy tri 11,5 ± 2,8UI/kg/gid, so edn lai (12,5%) du'dc chong ddng bang heparin vdi lieu tan cdng trung binh 50,6 ± 4,7UI/kg, duy tri 16,8 ± 2,4UI/kg/gid. Mac dii chdng dong lieu cao nhu" vay nhutig van ed bien chuhg dong mang loc (18,8%), tac catheter (22,9%) nen ehimg toi phai thay qua loc hay catheter hoac chich 2 catheter d 2 tinh mach diii trai, phai hoac chich them tinh maeh canh trong (27,1%) de Ipc mau lien tue dat hieu qua, giam dong mang Ipc va tac catheter. De phdng ngira dong mang loc, tac catheter ngoai theo doi chirc nang d6ng mau de dieu chinh khang d6ng, a n theo ddi sat ap li/c xuyen mang (TMP), ap li/c mau ra (access pressure), ap lu'c mau ve (return pressure) de dieu chinh th6ng catheter kip thdi, thUe hien thii thuat njei mang loc va chinh lieu thuoe khang dong thidi hdp. Ngoai ra d tre
< 10kg thu'dng cd van de mat mau ra tuan hoan ngoai cd
TRUYiNNHl6MVlgTNAM*s63(11) - 2015 - 7 3
tiie, tre de bj soe sau khi mt mau ra ngoai ed the vao he thong loc, hoac kem them mat mau khi chich tinh mach trung tam gap khd khan, nen trong nghien euU chiing tdi cd 15 tre a n truyen them mau ehiem ti le 31,3%.
Danh gia hieu qua Ipc mau qua thay doi lam sang va can lam sang (bang 4) cho thay mach, nhiet dp eai ttiien rd d thdi diem 12,24 gid sau khi bat dau lpc mau. Tu'dng tu" nhu" vay, ti le dau hieu da xanh tai, da noi bdng, roi loan van mach eai thien dan d thdi diem 12,24 gid sau khi bat dau Ipc mau. Cai thien eac chi sd hd hap nhd Pa02/n02, AaD02 cd y nghTa tiiong ke. Men gan cd eai thien sau loc mau nhu'ng khong cd y nghTa thong ke, Cre- atinine mau cai thien dang ke nhuhg edn d mirc a o . Cae trj so chirc nang gan than trong gidi han binh tiiu'dng trong suot qua trinh lpc mau. Cd tinh trang giam kali mau d thdi diem 12, 24 gid nen can bo sung kali trong dich thay the va dich nuoi an tinh mach. Ngoai ra loc mau lien hje eai thien tinh trang toan mau kiem du' (BE: base ex- cess), tinh trang nd oxy mau nhu" eai thien lactate mau va dd bao hda oxy mau tinh mach hung tam Sev02: satura- tion of central oxygen), dac biet cai thien chi so van maeh - tSng CO ed tim (VIS: vasoactive dmgs score), tdc la giam du'dc nhu cau diing thudc van mach'^J'^^', cai thien chi so benh nSng tre em PRISM, PELOD.
Trong nghien cijdi cua diiing toi khdng khao sat su' thay doi cac cytokine gay viem trong mau va djch loc trong qua trinh lpc mau, nhutig tiieo cae tac gia khad^'w, loc mau lien tue giiip thai loai cac cytokine gay viem nhU TNFa, ILlp, IL6, IL8, ILRa... Loc mau lien hJC qua mang ban tham dda tren nguyen ly doi lull lay di khdi cd the eae eytoldne gay viem tipng lu'dng phan tii trung binh nhu' TNFa, ILlp, IL6, IL8, ILIO, IFNy... la cac cytokine ddng
vai trd trong cd che benh sinh nhiem triing huyet, sdc nhiem triing, ngoai ra Ipc mau lien tyc cdn giam du'dc sir tang than nhiet qua mufc (sot a o lien tue khong dap utig thudc ha sdt) nhd tuan hoan ngoai cd the. Co 17 tnjftng hdp (35,4%) sau ipc mau lien tiJC ddt 1, tinh trang van edn nang: mach cdn nhanh, xanh tai, da noi bong, roi loan van maeh, ton thu'dng cac cd quan nen du'dc Ipc mau I3n 2 hoac hdn nite. Bien chiihg do a n thiep Ipc mau lien hjc ngoai dong mang Ipc, tac catheter, chiing tdi cdn ghi nhan khi he tiidng (10,4%), tut huyet ap (37,5%), ha than nhiet (20,8%), ha kali mau (29,2%) nhutig du'dc khac phyc xir ly kip thdi.
Thdi gian dieu trj tmng binh tai khoa Hdi su'c la 14,8 ngay, culi sdng 29 tre (60,4%), 19 tre tir vong (39,6%)'"'», trong benh canh soc keo dai, suy hd hap, hdn m&. Cac yeu td lien quan den tir vong cd y nghia thdng ke bao gom tinh trang sde sau, hdn me sau Glasgow < 5, ton thu'dng gan nang, ehi so VIS, PRISM, PELOD cao nen can a n thiep dieu trj tfch cu'c nhSm ciili sdng tirng benh nhan nang, giiip cai thien tir vong.
V. KET LUAN
- Lpc mau lien tue trong sdc nhiem trimg bien chiihg suy da cd quan, cho thay eai thien lam sang nhUtri giae, nhjp tim, nhiet dp, xanh tai, da noi bdng, cijng nhu" cai thien tinh trang toan mau, lactate mau, giam nhu cau sir dung van mach.
- T i l e tir vong 39,6%.
- Cae yeu td lien quan den tir vong cd y nghTa thong ke bao gom tinh trang sdc sau, H6n me sau Glasow < 5 diem, ton thu'dng gan nang, ehi sd van maeh - tang co ed tim (VIS) a o .
74 - TRUY^NHiiMVirrNAM*s63(11
TAI U E U THAM KHAO
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\ca\ Care Medicine. Crit Care Med; 37: 666 - 688.
2. Oark. E. et al (2014). High - volume hemofilb^tion for septic acute kidney injury: a systematic review and meta-analysis. Critial Care, 18: R7
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International guidelines for management of severe sepsis and septic shock. Int Care Med; 41: 580 - 637
4. D. Payen, J. Mateo, J. M. Cavaillon, F. Fraisse, C.
Floriot, E. Viaut (2009). Impact of continuous venove- nous hemofiltration on organ Allure during l^e early phase of severe sepsis: a randomized controlled trial. Crit Care Med 37: 03 - 1 0
5. Grootendorst AF, van Bommel EF, van der Hoven B etal (1992). High volume hemofiltration improves hemo- dynamics of endotoxin induced shock in the pig. J Crit
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142(1): 59 - 65.
7. Karvellas J, Maha R Farhat (2011). A comparison of early versus late initiation of renal replacement therapy in critially ill patients with acute kidney injury: a systematic review and meta-analysis. Critial Care, 15: R72
8. Leslie W. Hayes (2009). Outcomes of critically ill children requiring continuous renal replacement therapy.
Journal of Critial Care 24, 394 - 400.
9. Matsuda, K.; Moriguchi, T (2010) Effiacy of Con- tinuous Hemodiafiltration with a Cytokine-Adsorbing He- mofilter in the Treatment of Acute Respiratory Distress Syndrome.Acute Blood Purifiation, Vol. 166: 83 - 92.
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Acute Blood Purifiation, Vol. 166: 73 - 82.
CONTINUOUS VENO-VENOUS HEMOFILTRAHON ON MULTIPLE ORGAN DYSFUNCTION SYNDROME DUE TO SEPnC SHOCK I N CHILDREN ADMITTED AT PEDIATRIC INTENSIVE CARE UNIT
Summary
Objective: assess the effiacy of continuous veno-ve- nous hemofiltration (CWH) on treatment of multiple organ dysfunction syndrome (MODS) due to septic shock and fectors related to outcome in children admitted at Pe- diatiic Intensive Care Unit from January 1^ 2006 till Sep- tember 30* 2014. Methods: Reb-ospeetive descriptive study of ases series. Results: 48 ases of MODS due to septic shock diagnoesd by clinial findings and paraclini- a l tests, who were included, with age median of 14.5 month old, youngest of 3 month old, male accounting for 58.3%, female 41.7%, have been given CWH or CWHDF,
showing improvement on clinical findings such as level of consciousness, ardiac rate, temperatiire, pallor, mottled skin as well as betterment on metabolic acidosis, level of lactate. Mortality rate was 39.6%. Risk fectors related to mortality included profound shock, Glasgow coma score under 5 points, severe hepatic injury. Conclusion: CWH or CWHDF is the final supportive intervention for patients with MODS due to septic shock who felled to standard therapeutic protocol including eariy intubation, shock re- suscitation by flowchart protocol, inotrope or vasoactive dmgs.
Key words: Multiple organ dysfunction syndrome, septic shock, continuous veno-venous hemofiltration, continu- ous veno-venous hemodiafiltration.
TRUYENNHfiMVieTNAM*s63(11) - 5 n i < ; . 7 S
