TRUNG TAM TIM MACH BENH VIEN E - HOI NGHj KHOA HOC LAN THlJf NHXT
DANH GIA SITTHAY DOI KHI MAU DONG MACH TRlTiOrC VA NGAY SAU TUAN HOAN NGOAI CO THE
Of TRE Dlrtn 10 KG TAI TRUNG TAM TIM MACH DENH VIEN E
Hoang Thi Phu-ong*, Nguyen Trung Hieu*
TOM T A T
Muc tieu: Danh gia siT thay doi khi mau dpng mach trUdc va ngay sau tuan hoan ngoai cd the d tre dUdi 10 kg tai trung tam tim mach benh Vien E. PhUtfng phap nghien cii'u: md ta, danh gia sii thay doi khi mau dpng mach tru'dc va ngay sau chay may tren 93 benh nhi mo tim md cd can nang du'di 10 kg. Ket qua: pH glam (TB: 0.03 ± 0.01), BE glam (TB: 1.48 ± 0.39), acid lactic tang (TB: 1.31 ± 0.1) va glucose mau tang (TB: 9.6 ± 0.83) cd y nghla thong ke vdi p<0.05. Cd su* tu'dng quan nghjch giii'a ALDMTB va nong dp acid lactic mau vdi r = 0.43 va p<0.d5. Ket luan: giam pH, BE, tang acid lactic va glucose, Glam ALDMTB lien quan vdi tang acid lactic mau.
SUMMARY
Objectives: Assessment of changes In arterial blood gases before and after cardio pulmonary bypass surgery in children under 10 kg body weight at the cardiovascular centre of E hospital.
Methods: description and evaluation of changes in arterial blood gases before and after cardio pulmonary bypass surgery over 93 patients who weigh less than 10 kg.
Results: the decrease of pH (mean ± sd:
0.03 ± 0.01), BE (mean ± sd: 1.48 ± 0.39), the increase of lactic acid (mean ± sd: 1.31 ± 0.1) and blood glucose (mean ± sd: 9.6 ± 0.83) are statistically significant with p < 0.05. Inverse correlation between mean arterial blood pressure and blood lactic acid concentration with r = 0.43 and p < 0.05.
Conclusions: decreased pH, BE, increased lactic acid and glucose. Reduced mean arterial
blood pressure can cause an elevation blood lactic acid.
I. OAT V A N o f
Trong phau thuat tim mach, tuan hoan ngoai ca the ddng vai trd rat quan trpng do anh hudng true tiep tdi dien bien trong md ciing nhu qua trinh hdi phuc cua benh nhan d phdng hdi siic sau md. Dieu nay cang rd rang han khi benh nhan la tre em, dac biet tre dudi 10 kg. Tai benh vien Hiiu Nghi Viet Diic tii trudc nam 2004 khi phiu thuat tim md cho tre dudi 10 kg thudng gap rdt nhieu khd khan lien quan tdi gay me hdi siic, trang thiet bi may mdc, ky thuat md va dac biet la tuan hoan ngoai ca the. Do dd nhumg tre hi benh tim bdm sinh chi dugc chi dinh phiu thuat khi cd can nang tren 10 kg. Nhiing nam trd lai day d Viet Nam da cd rdt nhilu tiln bp trong phiu thu^t tim bdm sinh d tre nhd cd can nang dudi 10 kg. Trong dd phai ke den nhiing tien bp cua tuan hoan ngoai ca the.
Tai trung tam tim mach benh vien E chiing tdi cung da tiln hanh phiu thuat kha nhieu tim bdm sinh tre dudi 10 kg. Viec danh gia tudn hoan ngoai ca thi chu yeu dua vao ket qua khi mau dpng mach dugc lam trudc, trong va ngay sau khi ngimg chay may. Tren thi gidi da cd rdt nhilu nghien ciiu ve s\r thay ddi khi mau dpng mach do tac dpng ciia man hoan ngoai ca thi [2], [4], [6], nhung tfii Viet Nam chiing tdi chua thdy cd nghien ciiu nao vl vdn dh nay. Do dd chiing toi tiln hanh nghien ciiu dl tai " danh gia su thay ddi khi mau dpng mach trudc va ngay sau tuan hoan
YHQC V|£T NAM THANG 8 - SO DAC BliT/2011
ngoai ca thi d tre dudi 10 kg tai trung tam tim mach benh vien E" nhdm hai muc tieu:
1. Danh gid su thay ddi Ichi mdu dong mach truac va ngay sau tudn hoan ngoai co the a tre dual 10 kg tai trung tdm tim mach benh vien E.
2. Tim hieu moi lien quan ciia mot sdyiu to trong qua trinh chay may vai su thay ddi cm Jchi mdu dong mach.
II. 001 TUONG VA PHUONG PHAP NGHIEN COU 1. Doi tiroug nghien cihi:
Tat ca cac benh nhan md tim, can nang dudi 10 kg cd sii dung tudn hoan ngoai ca thi.
Chiing tdi loai khdi nghien ciiu nhiing benh nhan khdng thu thap du sd lieu hoac thdng tin nghien ciiu khdng rd rang.
2. Phuong phap nghien cihi:
Nghien ciiu md ta cd su dung so lieu hdi ciiu va tien ciiu
Cach tien hanh nghien ciiu:
Tdt ca benh nhan dugc kham tdng thi trudc md bao gdm toan trang, tuan hoan, hd hap, chiic nang gan than, cac benh ly kem
theo khac, va cac yeu td lien quan nhu tudi, gidi tinh, tien su benh tat.
Xet nghiem sinh hoa, huylt hpc.
Tai phdng md benh nhan dugc khdi me theo phac do chung
Trudc khi chay may lam xet nghiem khi mau dpng mach lan 1
Benh nhan chay may:
+ Dich priming: hdng cau khdi cung nhdm 150 ml, plasma 200 ml
+ Luu lugng: 2.2 - 2.4 lit/m^/phiit -I- Ap luc ddng mach trung binh duy tri:
20 - 50 mmHg
+ Ndng dp oxy: 100%
-i- Dung dich liet tim: cardioplegia
Duy tri me trong chay may: fentanyl:
0.05 mcg/kg/h va propol: 6 mg/kg/h truyen tinh mach lien tuc.
Ngay sau khi ngiing may xet nghiem khi mau ddng mach lan 2.
3. Phan tich va xu* ly so lieu:
Sd lieu thu th^p dugc ma hoa va xii li bang phan mem SPSS 16.0
. KET QUA NGHIEN CQU
1. M9t so dac diem trong nghien cihi Bdng 1:
Dac diem T B ± S D Min Max
Tuoi (thang) 14.2 ± 11.6 1.5 60
Can nang (kg) 7.1 ± 2.2 9.5
Thdi gian cap chii (phut) 54.9 ± 38.1 10 246
Thdi gian chay may (phut) 74 ± 41.2 26 256
Khoang each diing cardioplegia (phut) 18.8 ± 3.2 15 32
So lan dung cardioplegia 2.9 ± 1.8 10
Ap li/c tu'dl mau (mmHg) 40.4 ± 2.3 30 55
Nu'dc tieu (ml) 114.4 ± 40.7 15 650
Het trong chav may (%) 29.4 ± 3.7 19 38
Nhiet dp trong chav may (°C) 36.1 ± 1.6 24
Can n^g < 5 kg: 15 benh nhan (16.1%), > 5 kg: 78 benh nhan (83.9%).
36.9
TRUNG TAM TIM MACH BENH VIEN E - HOI NGHj KHOA HOC LAN T H Q NHAT
Chdn doan: thdng lien thdt: 65 (70%), thdng lien nhT: 10 (10.7%), fallot4: 12 (12.9%), khac: 6 (6.4%)
Tang ap luc DMP trudc md: khdng tang: 18 (19.4%), tang nhe: 18 (19.4%), tang vua: 19 (20.4%), tang nang: 38 (40.9%).
2. Su thay doi cac yeu to trong khi mau dong mach Bdng 2:
Yeu t o pH(l) - pH(2) P02(2)-PO,(l) Sa02(2)-Sa02(l) P02/Fi02(2) - P02/Fi02(l)
BE(1) - BE(2) Lactic(2) - lactic(l) HCOJd) - HC03"(2) Glucose(2) - glucose(l)
TB±SD 0.03 ± 0.01 5.78 ± 17.66
1.53 ± 1.11 70.68 ± 22.56
1.48 ± 0.39 1.31 ± 0 . 1 4.29 ± 3.31
9.6 ± 0.83
t 3.86 0.33 1.37 3.13 3.82 13.3 1.32 11.6
P
<0.05
>0.05
>0.05
<0.05
<0.05
<0.05
>0.05
<0.05
TB: trung binh
Trong nghien ciiu ciia chiing tdi pH giam, BE giam, acid lactic tang va glucose mau tang rd ret vdi p < 0.05
3. Moi tvotig quan gifra nong do acid lactic va mot so yeu to khac
Chiing toi tim hieu mdi tuang quan giiia mpt sd ylu to trong qua trinh chay may nhu:
nhiet dp, thdi gian cap dpng mach chii, hematocrit, lugng nudc tieu, ap lire tudi mau trung binh vdi su thay ddi ndng do acid lactic trong mau.
Bdng 3:
Yeu t o
T° trong chay may va lactic Thdi glan cap chii va lactic Het trong chay may va lactic
Nu'dc tieu va lactic Tcardio va lactic ALDMTB va lactic
r -0.11
0.03 0.03 -0.05 -0.11 0.43
P 0.291 0.809 0.785 0.620 0.278 0.021
T°: nhiet dp Het: hematocrite
Tcardio: khoang each trung binh gifta 2 lan truyin dung dich cardioplegia ALTB: ap lire dpng mach trung binh trong sudt qua trinh chay may
Theo nhu bang tren chi thay cd mdi tuang quan nghich giiia ALDMTB va nong dp acid lactic mau vdi r = - 0.43 va p < 0.05.
Y HOC VIET NAM THANG 8 - SO DAC BIET/2011
IV. BAN LUAN
Trong nghien ciiu cua chung tdi pH mau sau chay may giam so vdi'trudc chay may cd y nghia thdng ke tuy nhien do phdn ldn benh nhan vdi chdn doan thdng lien thdt kem tang ap luc dpng mach phoi tu vua din nang (70%) do dd chiing tdi phai dilu chinh PCO2 cho phu hgp vdi tinh trang benh nhan khi gay me dac biet khi tim bdt ddu dap trd lai chiing toi phai dk hd hdp nhugc than nhdm lam tang luu lugng mau len phdi. Nhu vay pH se tang do kilm hd hdp va ca thi se tang thai HC03"
gay giam HC03" va BE. Mat khac nua hdu het benh nhan deu dugc sii dung thudc Igi tilu furocemide trong chay may vdi lilu 1 - 2 mg/kg can nang va lugng nudc tilu chiing tdi thu dugc trung binh la 16.8 ± 5.7 ml/kg/h, nen cang lam mdt HC03' va din tdi BE giam. Dilu dd giai thich cho su giam HC03"
trong kit qua nghien ciiu ciia chiing tdi, tuy nhien s\f thay ddi nay khdng cd y nghia thdng ke.
Acid lactic trong mau la yeu td gian tiep danh gia sir cung cdp oxy cho md va cac ca quan trong ca the. Trong nghien ciiu ciia chiing tdi cd tang acid lactic sau chay may nhu vay chiing td cd giam tudi mau, giam cung cap oxy cho md va ca quan trong qua trinh chay may. Mac dii tdt ca benh nhan diu dugc dam bao ap lire tudi mau trong toan bd qua hinh (HATB: 40.4 ± 2.3), hematocrit:
29.4 ± 3.7, trong dd chi cd 8 b?nh nhan chilm 8.6% hematocrit dudi 25% va oxy cung cdp cho may ludn la 100%. Trong nghien ciiu dugc thuc hien tren 9 tre md tim md cd can nang dudi 10 kg, tac gia Lichtenberg nhan thdy rdng sau md cd sir ting dang kl ndng dp acid lactic va glucose trong mau. Va theo dng thi su thay ddi ndng dp acid lactic va glucose mau nay bat ngudn tu djch priming may. Tuy nhien nong dp acid
24 gid va khdng cd su thay ddi nao dang kl trong vdng 48 gid tiep theo [5]. Khi chay may dap iing viem he thdng rat manh me keo theo viec giai phdng hang loat cac chdt trung gian hoa hpc nhu cytokine va interleukin, dan den su thay ddi ndi mdi. Theo Cremer vat cpng sir thi acid lactic mau tang trong qua trinh chay may la do dap iing viem he thdng va tiet cytokine. Dap iing viem he thdng gay giam sue can he thdng mach, giam tudi mau, tang chi sd tim, va keo theo toan lactic [3].
Dieu nay ciing dugc Thomas Ryan va cpng su chiing minh trong nghien ciiu cua minh [8]. Cdn tac gia Duke khi danh gia tien lugng tre nhd sau md tim vdi tinh trang toan lactic thi thay acid lactic tang cao lien quan vdi su tien trien nang len va tang ti le tu vong [4].
Tang glucose mau thudng xay ra trong chay may dac biet d tre nhd, do phan iing cua ca the ddi vdi nhiing thay ddi trong qua trinh chay may. Tuy nhien chiing tdi sir dimg dung dich ddy thudc khi su dung thudc trg tim, co mach ddi vdi tre dudi 10 kg la glucose 10%.
Do dd glucose mau thudng tang nhieu sau khi ngiing may, nghien cuu ciia chiing tdi tang trung binh la 9.6 mmol/l. Theo nghien ciiu cua Yates va cpng sir tren cac benh nhan sau md tim bam sinh d nhieu lira tudi thi tang glucose mau sau md cd lien quan vdi dien biln nang va tang ti le tu vong [9]. Steward va cdng sir thdy rang nhiing benh nhan cd tang dudng mau kem theo ha nhiet dp, ngiing tudn hoan thi thudng cd bieu hien xdu vl thdn kinh, tuy nhien ket qua lai khdng cd gia tri thdng ke [7]. Mpt nghien ciiu khac do Ballweg va cpng su thuc hien tren 188 tre nhd, tdt ca.deu dugc md tim vdi tuan hoan ngoai ca the khi 6 thang tudi va cd tang dudng mau trong vdng 48 h sau md. Ong danh gia tai thdi diem tre dugc 1 tudi va dng
TRUNG TAM TIM MACH BENH VIEN E - HOI NGHI KHOA HOC LAN THlf NHAT
khdng thay cd mdi lien quan giiia tang dudng mau va tinh trang nang ciia benh nhan [1].
V. KET LUAN
Khi mau dpng mach thay ddi: pH giam,.
BE giam, acid lactic tang va glucose mau tang cd y nghla thdng ke.
- Cd mdi lien quan nghich chieu giiia ap luc dpng mach trung binh trong chay may vdi su thay ddi ndng dp acid lactic mau.
TAI LIEU THAM KHAO
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Hyperglycemia after infant cardiac surgery does not adversely impact neurodevelopement outcome. Ann Thorac Surg. Dec 2007;84(6):2052-8.
2. Craig M. Cox, FRCA", Raimondo Ascione, MD^Alan M. Cohen, FRCA",Ian M.
Davies, FRCA%Ian G. Ryder, FRCA%Gianni D. Angelini, FRCS^ Effect of cardiopulmonary bypass on pulmonary gas exchange: a prospective randomized study.
Ann Thorac Surg. 2000;69:140-145.
3. Cremer J., Martin M., Redl H., et aL Systemic inflammatory response after cardiac operations.
AnnThoracSurg 1996;61:1714-1720.
4. Duke T., Butt W., South M., Karl T. Early markers of adverse events in children after cardiac operations. J Thorac cardiovasc Surg 1997;114:1042-1052.
Lichtenberg RC, Zeller WP, Goto M, Hurley RM, Sullivan HJ, Scanlon PJ.
Lactic acid changes during and after hypothermic cardiopulmonary bypass in infants. J Lab Clin Med. 1993 May;121(5):697-705.
MacNaughton P.D., Braude S., Hunter D.N., Denison D.M., Evans T.W. Changes in lung function and pulmonary capillary permeability after cardiopulmonary bypass.
Crit Care Med. 1992;20:1289-1294.
Steward DJ, Da Silva CA, Flegel T.
Elevated blood glucose levels may increase the danger of neurological deficit following profoundly hypothermic cardiac arrest.
Anesthesiology. Apr 1988;68(4):653.
Thomas Ryan, FFARCSI*", Joanna Balding, BA, Mod (Genetics)^ Eilis M.
McGovern, FRCSF, John Hinchion, FRCSr, Wendy Livingstone, PhD^ Zeb Chughtai, FRCSI', Owen P. Smith, FRCPl'' Lactic acidosis after cardiac surgery is associated with polymorphisms in tumor necrosis factor and interleukin 10 genes. Ann Thorac Surg. 2002;73:1905-
1909.
Yates AR, Dyke PC 2"^ Taeed R, et al.
Hyperglycemia is a marker for poor outcome' in the postoperative pediatric cardiac patient.
PediaW Crit Care Med. Jul 2006;7(4):351-