TCNCYH Phu trimng 80 (3A) -2012
10. Terry Reynolds, Yan Peng (2002). 12. Winterhalter Michael, MD, Simon The Pediatric echoeardiographer's Pocket Andre.MD, stafan Fischer, Hartmut Heck- Reference, 265 - 266, 338 - 340. er, PhD (2008). Companson of inhaled llo- prost and ntrie oxide in patients withh pulmo- 11. Wernovsky G, Mayer JE, Jonas RA, ^ ^ ^ hypertension during weaning from eardi- et al (1995). Factors influencing early and opuimonary bypass in cardiac surgery. A pro- late outeome of the arterial svntch operation spective randomized trial Juornal of cardio- for transposition of the great arteries J thoracic and vascular Anesthesia. 22 (39):
Thorae Cardiovase Surg; 109 289 - 302 406-413.
Summary
THE EFFECTS OF INTRAVENOUS ILOPROST IN THE TREATMENT OF PULMONARY HYPERTENSION IN THE PATIENTS AFTER OPEN HEART SURGERY
AT NATIONAL HOSPITAL OF PEDIATRICS
The objective of this study was to assess the effects of intravenous lloprost in the treatment of pulmonary hypertension in the patients after open-heart surgery al National Hospital of Pedi- atrics The results showed that systolic pulmonary artery pressure decreased after lloprost treat- ment: from 47.22 ± 9.76mmHg to 40.38 ± 9 61 mmHg (p < 0 001) after 4 hours of time and 35.25 ± 10 14mmHg (p < 0 001) after 24 hours, which had statistical significance Blood pres- sure was stable before and after lloprost therapy. The patient' respiratory improved with F/O2 gradually decreasing from 83 ± 22 1% to 52 97 ± 21.83 % with p < 0.001, Pa02/Fi02 increased from 189.65 ± 114.05 to 286.54 + 199 92 with p < 0.001 Diuresis increased from 2.36 ± 1.07 ml/kg/h to 3 36 ± 1.3 ml/kg/h and blood lactate decreased from 1.52 ± 0.76 to 1.00 ± 0.53 (p <
0.001). In conclusion. Intravenous lloprost combined with routine measures effectively in the treatment of perioperative pulmonary hypertension
Keywords: iloprost, Pulmonary hypertension, cardiac surgery
VIEM PHOl LIEN QUAN THO MAY O BENH NHAN SAU MO TIM M d TAI KHOA HOI SLTC NGOAI BENH VIEN NHI TRUNG U'aNG
Tran Minh Dien, Pham Anh Tuan, Dang Anh Dwong, Trinh Xuan Long, Pham Hong Son Benh vien Nhi Trung wang Nghidn cwu nhdm xdc dmh ty Id vidm phdi lidn quan thd mdy (VAP). can nguyen vi khuin vd cdc yiu td dnh hwdng din VAP d bdnh nhdn sau md tim md. Co 16 bdnh nhan VAP trong 125 benh nhdn md tim md, chiim 12.8% Ty suit mdi mdc VAP la 24.5/1if ngdy thd may Nguy ca mic VAP ngay thw 2 tang 8.9%. ngay thw 3.4 Id 14.5%, ngay thw 5,6 Id 18,46%; ngdy thw 7 din ngay thd 18 la 22.5%; twngdy 20la48,51% Tyldtwvongdo VAP trong sd benh nhdn sau md tim 1.6%. Phdn lap dwoc 8 loai vi khuin gdy bdnh Klebsiella pneumonia (37.5%), Pseudomonas aeruginosa (12,5%). Acinobacter baumanii (12.5%). Staphyloccocus aureus (12,5%), Escherichia coli (12,5%>). Stenotrophomonas maltophilia (12.5%) Cdc yiu td lidn quan tdi VAP bao gdm tudi. cdn nang. thai gian thd may. thoi gian luu catheter tinh mach trung tdm. thdi gian Iwu din Iwu trung thit. thoi gian ndm hdi swc. dung gidn ca, truyin mdu, ddt lai nQi khi qudn. di hd xwong ire
Tip khoa: Viem phli lien quan thd may, npi khi quan 86
I. DAT VAN DE
Viem phli lien quan thd mdy (ventilator- associated pneumonia - VAP) la nguyen nhan p h i biln nhlt trong nhilm khuln benh Vien d nhung tre bl benh nang va la nguyen nhan pho biln thir hai sau nhilm khuln huylt d tre em noi chung ]. NhQ'ng benh nhan dugc hd hip hd tra bing may thd cd ty le viem phli eao han 6 - 20 lln so vdl benh nhan khdng thd may nam trong dan vi hoi sii'c [1]
Cac nha phlu thuat tim maeh canh bao ring tre em sau mo tim md cd nguy ea cao viem phli lien quan thd may va cd kha ndng tang nguy ca khang thule d l i vdl vi khuln [3]. Nhii'ng nghien ciru g i n day cho thly t i n suit viem phil lien quan thd may d nhu'ng tre sau m l tim md tir 9 - 2 1 % va day la mdt trong nhii'ng nguyen nhan hang dau dan tdi tir vong d nhdm benh nhan nay [4, 5]
Nham xac dmh sdm d l tang eudng hieu qua dilu tn va phdng tranh VAP, dac biet d nhii'ng tre em sau m l tim md, de tai duae thuc hien vdi muc tieu: xac dinh ty te VAP, can nguyen vi khuan gay benh va xac dmh cac yeu td anh hwdng den viem phdi lien quan thd may a benh nhan sau md tim md II. D O I TU'O'NG VA PHU'aNG PHAP
1. D6I tu-gng nghien cipu: Bao gdm 125 tre dual 15 tuoi duac phlu thuat tim md tai benh vien Nhi Trung uang Nhu-ng benh nhan nay khdng bi viem phdi vd khdng thd may trudc phlu thuat.
Viem phli do thd may duae xae dmh bing bang dilm CPIS (clinical pulmonary infection score) do Pugin va cong su dua ra nghien eiru va irng dung ndm 1991 [6].
Nhung benh nhan cd dilm CPIS > 6 duae chin doan la cd VAP
2. Phuang phap nghien ciFu: Nghien eiru thuln tap tlln ciru, eac benh nhan du tieu chuin nghien cuu duac lua chon theo phuang phap chon mau thuan tien, cac dli tuang nghien cicu duac theo doi tir khi sau m l chuyin ra HSN din khi ra khdi khoa d l phat hien VAP So Heu duae thu thap theo mlu benh an thong nhlt Thdi gian thue hien tir thdng 4 - 2011 tdi thang 9 - 2011.
Phan tich kit qua
3. Xif ly so lieu: theo ehuang trinh STATA 11 So sanh 2 s l trung binh bing kilm dmh t So sanh 2 ty le bang kilm dmh X^ hoac kilm dmh chinh xac ciia Fisher Lien quan giu'a VAP va cae ylu t l khac duac phan tich bang hoi quy Logistic
III. KET QUA
Til'thang 4/2011 d i n thang 9/2011 ed 125 benh nhan duac phlu thuat tim md, chuyin ra khoa hoi sire ngoai va duac thd may h i tra, tit ea nhung benh nhan nay duae ehia thanh 2 nhdm VAP va khdng VAP
Cd 16 benh nhdn VAP ehilm ty le 12,8%.
Ty suit mdi mie VAP d benh nhan sau m l tim md la 24,5/10^ ngay thd may (16 benh nhan tren ting s l 653,06 ngay thd may)
Ty suat mdi mac tich liiy Trong nghien eiru thly nguy ca mac VAP ngay thir 2 tang 8,9%; ngay thir 3,4 la 14,5%; ngay thir 5.6 la 18,46%, ngay thir 7 d i n ngay thir 18 la 22,5%; til'ngay 20 la 48,51%
Ty ie tu vong Trong nghien eiru ed 2 benh nhantu vong do VAP, chilm ty le 1,6%
Vl khuln: Phan lap dugc 8 vi khuln gay benh. ty le vi khuln Gram (+) 12,5%, vi khuln Gram (-) 87,5%, trong dd Klebsiella pneumonia 37,5%
TCNCYH Phu truung 80 (3A) - 2012
Yeu to
TUOI
Bang
^ 1 thang 1 - 1 2 thang
> 12 thang
1. Cac y§u 16 djch te anh hu'O'ng VAP
VAP n, (%) Khong VAP n; (%) RR (95%CI) 4 (50) 4 (50)
8(13,1) 53(89,9) 4(7,14) 52(92,86)
P
< 0,05 Nam 7 (12,9) 47 (87,03)
Gioi ^—--' -—^— >0,05 NO 9(12,6) 62(87,4)
p < 5 k g 11(23,9) 35(76,1)
Cannang —^ —^-^ 3,8(1,4-10,2) < 0,05 p > 5kg 5 (6,3) 74 (93,7)
Bon gian 7(11,1) 56(88,9)
TBS ^—-^ ^—— > 0,05
Phl>ctap 9(14,5) 53(85,5) ^ ^ Tre mac VAP tu6i eang nho thi ty le mac cang cao (p < 0,05), can nang thap du'O'i 5 kg (p <
0,05), mirc do phCre tap cua tim bam smh khong lien quan d§n m i c VAP.
Bang 2. Cac yeu to thd'i gian anh hu'O'ng VAP Ydu to thd'i gian
Lu'u tmh maeh trung tam
Luu dan lu'u trung thit Cap dong mach ehu THNCT
Nam HSN
< 4 ngay
> 4 ngay
< 5 ngay
> 5 ngay
< 3 ngay
> 3 ngay
< 45 phiit
> 45 phiit
< 120 phut
> 120 phut
< 7 ngay
> 7 ngay
VAP n, (%) 0(0) 16 (50) 3 (3,2) 13(43,3)
8 (7,6) 8(40) 45 (95,5) 69(83,1) 68 (89,5) 41 (83,7) 2 (2,3) 14 (40)
Khong VAP n, (%) 93(100)
16 (50) 92 (96,8) 17(56,7) 97 (92,4) 12(60) 2 (4,7) 14(16,9)
8(10,5) 8(16,3) 87 (97,7)
22 (60)
RR (95%CI)
13,7 (4,2 - 44,9)
5,3 (2,2-12,3)
17,8 (43-743)
P
< 0,001
< 0,001
< 0,001
>0,05
>0,05
< 0,001 Cae y§u td anh huang dgn ty le mac VAP: thai gian tha may tren 4 ngay (p < 0,001), thai gian lu'u tinh mach trung tam tren 5 ngay (p < 0,001), dSn lu-u trung that keo dai tren 3 ngay (p <
0,001), va thai gian nam digu tri hdi sire tren 7 ngay (p < 0,001)
Cac ySu 16 trong qua trinh dlSu tri hdi sire anh hu'O'ng d i n ty le mac VAP la siJ dung thuoc gian ca (p < 0,001), cham dong xu-ang ire (p < 0,05), phai truySn mau (p < 0,05), ein dat lai ngi khi quan (p < 0,001), sir dung tren 3 loai thude van maeh (p < 0,001)
Yeu to Gian CO
Tang ap lue ddng mach phoi
Cham dong xuang ire Truygn mau Dat lai noi khi quan 86 thude van mach
Bang 3. Cac yeu to khac anh hu'O'ng VAP
Cd Khong Co Khong cd khong
CO
khong cd khdng
< 3 loai
> 3 loai
VAP n, (%) 29 (65,9) 80 (98,8) 79 (85,9) 30 (90,9) 7 (63,6) 102(89,5)
31 (72,1) 78(95,1) 5(50) 104(90,4) 108(91,5) 1(14,3)
Khong VAP n, (%) 15(34,1)
1 (1,23) 13(14,1) 3(9,1) 4 (36,4) 12(10,5) 12(27,9) 4 (4,9)
5(50) 11 (9,6) 10(8,5) 6(85,7)
RR (95%CI) 27,6 (3,8 - 202)
3,45 (1,3-8,9)
5,7 (1,9-16,6)
5,2 (2,3-12)
10,1 (5,2-19,7)
P
< 0,001
>0,05
<0,05
<0,05
< 0,001
< 0,001 Bang 4. Phan tich hdi quy da bi6n Logistic
cac yeu to anh hu'O'ng VAP Y6u t6 Odds ratio (95%CI) p
1,524(0,525-4,426) 0.439 So loai van
mach
Durggianco 4,282(0,389-47,14) 0,235 Thdl gian tho 1030(1,008-1,054) 0,008 may
Trong phan tich hdi quy da bign chi cdn ygu t6 thai gian tha may keo dai anh hud'ng den ty le m i c VAP (OR = 1,003 vai do tin cay 95% trong khoang 1,008 - 1,054)
IV. BAN LUAN
Ty le VAP trong nghien eiru la 12,8%, tuang tu so vdi Chia - Wan Tang 13% [7] va J E.Fischer cung cac cdng su 9,6% [8]
Ba s6 cac tac gia dgu cho rang ty suit mdi mic cua VAP vao khoang 2,9 - 21,6/10' ngay thd may [9] Tang va cong su 21,6/10' ngay tha may [7], P P Roeleveld 17,1/10' ngay tha may [10], Ravier Hortal 22,2/1000 ngay thd may [11]
Theo J.E.Fishcher [8], ty suit benh nhan md'i mac VAP trong vdng 3 ngay d i u sau phlu thuat tang len tU' 4 - 40% 6' nhii'ng tre
thd may keo dai tren 30 ngay, thap hon so vdl nghien ciru eua chiing tdi, trong vdng 3 ngay d i u la 8,9% va sau 20 ngay thi nguy ca nay tang 48,5%.
Ty le tu vong Cac tac gia dgu cho ring ty lg tir vong eiia VAP dirng thir 2 sau nhigm trung mau, theo Tang [7] ty le tir vong 38,5%
va nguy ca tir vong do VAP glp 12,9 lln so vdl benh nhan khdng VAP. Theo tac gia Tang thi su khac bigt giua cac kit qua la do tinh hinh VI khuln khang thudc cua tirng khu vue khac nhau, dac bigt la tinh hinh khang da khang sinh cua nhigu loai vi khuln dang c6 khuynh hudng phat trien manh, Vi khuln nhigm triing benh vien thudng gap la vi khuln gram (-), Klebsiella pneumonia 37,5%
Cac y l u td anh hudng VAP. Tuang tu nhu nhilu tac gia khac, nghien cuu eua chiing toi cung cho thly tre eang nhd tudi, can nang thip thi ty le nhigm triing benh vien cang cao (p < 0,05) Gidi tinh khong anh hudng dgn su phat tnen VAP
Cung nhu Tang, nhilu tac gia chi ra rang su phat trien VAP thudng lien quan vdi nhCrng bgnh nhan nang, trai qua nhu'ng cupc
TCNCYH Phu truung 80 (3A) - 2012 phlu thuat keo dai, sau m l c I n quy trinh hau phlu chat che [7]. Trong nghien eiru cua ehiing tdi tim b i m sinh dan glan vd phirc tap khdng Hen quan vdi ty le VAP (p > 0,05), cd t h i do nghien ciru cua chiing toi s l lugng benh nhan edn it
Thdi gian thd may keo ddi lam tang nguy ea viem phil lien quan thd may, nghien euu ciia Tang chia 2 nhdm thd may tren 5 ngay va dudi 5 ngay, ty le VAP giira 2 nhdm nay ed su khac biet ed y nghla thing ke (p < 0,001).
Theo Javier Hortal [11], nguy ca VAP tang len khl thdl gian thd may keo dai tren 9 ngay.
Sir dung catheter tinh maeh trung tam nd rit cd gia tri trong qua trinh hdi sire sau m l , nhung lai ddl hdi dilu kien vo khuln cao, ky nang thuc hanh tot Trong nghien ciru nay chung tdi thly ring thai gian luu tTnh mach trung tam cang keo dai thi nguy ca VAP cang cao (p < 0,001), nguy ca VAP tdng 13 lln nlu de catheter tren 5 ngay. Tac gia Tang nguy ca mac VAP tang g l p 18 lln khl luu catheter > 7 ngay [7].
Trong nghien ciru nay chimg tdi chia benh nhan thanh 2 nhdm thdi gian nam hll sire >
7 ngay va < 7 ngay, Ty te VAP va khdng VAP d 2 nhdm benh nhan nay ed su khac biet (p
< 0.05); RR = 17,8, 95%C1 (4,263 - 74,31) vdl thdl gian nam d khoa hll sire trung binh 6,28 ± 5,70 ngay Tuang tu ciia Chia-Wan Tang va P P Roeleveld [10].
Mot s l y l u t l khac nhu dung 3.loai van mach nguy ea VAP tang 10 l l n (p < 0,001);
thdl gian luu d i n luu trung thit tren 3 ngay lam tang nguy ca VAP 5,3 lan, su' dung thule gian ca, cham ddng xuang uc, truyln mau, dat lai ngi khi quan lam gia tdng nguy ca mac VAP
Phan tich da b i l n Logistic cac y l u t l anh hudng vdi VAP.
Trong nghien eiru nay qua phan tich hli quy
da biln Logistic chi thly ylu t l thdi gian thd may ed anh hudng rd ret din VAP (p *= 0,008).
Bang phan tich da biln Logistic eua tac gia Tang giOa cac y l u t l thdi gian THNCT, thdi gian thd may, thai d i n luu trung thit, thdi gian luu catheter tTnh mach trung tam thi ehi CO thdi gian thd may la cd anh hudng d i n VAP vdl p < 0,05, OR = 15,196, 95%Cl (2.158-107,2).
Theo nghien ciru eua P P.Roeleveld, phan tich da biln giira dilm PRISM > 10 (bang dilm tien luang mirc do nang cua benh nhan), truyln plasma tuai ddng lanh, thdl gian cap DM ehu va tuli vao vien, Thly diem PRISM >
10 anh hudng din ty le VAP vdl p < 0,05; OR
= 4,39(1.06-18,04).
Phdn tich h l l quy da biln Logistic eho thly duge y l u t l anh hudng thuc su, va nhtrng y l u t l gay nhilu, nhung kit qua khac nhau glCra cac tac gia la do thilt k l nghien ciru, thdl gian, khu vuc nghien ciru khac nhau, trang thilt bj, ddi ngu can bd bac sy.
V. K^T LUAN
Ty le VAP d tre thd may sau m l tim md (12,5%) edn cao, ty suit mdi mac VAP la 24,5/10^ ngay thd may. Nguy ca mac VAP trong 3 ngay d i u la 8,9% va tang d i n din ngay thu 20 la 48,9%. Ty le tCr vong d nhdm benh nhan VAP (1,6%).
Ty le VAP bj anh hudng bdi cac ylu t l dich t l (tuoi, can nang). Thdi gian thd may keo dai lam tang nguy ca VAP (tren 4 ngay), cae y l u t l : thdi gian luu catheter tTnh mach trung tam, luu d i n luu trung thit, thdi gian n i m hdi sire ngoai, thai gian nuoi dudng tTnh maeh hoan toan, gdp phln khdng nho den su phat triln VAP. Benh nhan ed truyln mau, diing gian ca, chdm ddng xuang wc, dung nhilu van maeh, dat lai noi khl quan cung la nhii'ng y l u t l anh hudng manh d i n ty le VAP.
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Ventilator-associated pneumonia after heart surgery a prospective analysis and the value of surveillance. Crit Care Med, 31(7): 1964 - 1970
5. Kollef MH, Sharpless L, Vlasnik J, Pasque C, Murphy D, Eraser VJ (1997).
The impact of nosocomial infections on pa- tient outcomes following cardiac surgery.
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Diagnosis of ventilator-associated pneumonia by bacteriologie analysis of bronehoseopie and nonbronchoscopic "blind" bronchoalveo-
lar lavage fluid. Am Rev Respir Dis. 143 (5 Pt 1): 1121 -1129.
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Delay of extubation in neonates and children after cardiac surgery impact of ventilator- associated pneumonia Intensive Care Med, 26 (7)- 942 - 949
9. Elward AM, Warren DK, Eraser VJ (2002). Ventilator-associated pneumonia in pediatric intensive care unit patients, nsk factors and outcomes Pediatrics; 109 (5)- 758 - 764
10. Roeleveld PP, Guijt D, Kuijper EJ, Hazekamp MG, de Wilde RB, de Jonge E (2011). Ventilator-associated pneumonia in chil- dren after cardiac surgery in The Netherlands Intensive Care Med, 37 (10): 1656 -1663,
11. Hortal J, Giannella M, Perez MJ, Bar- rio JM, Desco M, Bouza E et al (2009). Inci- dence and nsk factors for ventilator-associated pneumonia after major heart surgery. Inten- sive Care Med; 35 (9): 1518 - 1525.
Summary
VENTILATOR-ASSOCIATED PNEUMONIA
IN PATIENTS AFTER OPEN HEART SURGERY AT NATIONAL HOSPITAL OF PEDIATRIC The purpose of the study was to identify the rate of ventilator - associated pneumonia (VAP), bac- teria! ongin and factors affecting VAP in patients after open heart surgery. The result showed that there were 16 VAP out of 125 open heart surgery patients, which accounted for 12.8%. The rate of recent VAP was 24 5/10' days on ventilator The risk of getting VAP on the second day increased 8.9%. the 3rd and 4th day was 14.5%. the 5th and 6th was 18.46%; from 7th to 18th was 22.5%, from 20th was 48.51%. The motarlity rate due lo VAP among patients after open heart surgery ac- counted for 1.6%. After separating. 8 kinds of bateha were found including Klebsiella pneumonia (37 5%), Pseudomonas aeruginosa (12 5%), Acinobacter baumanii (12.5%), Staphyloccocus aureus (12 5%), Escherichia coli (12.5%), Stenotrophomonas maltophilia (12.5%) Factors relating to VAP consisted of age. weight, duration of ventilators, catheter TMTT saving time, mediastinal drainage time, time al SICU. taking mephenesin. blood transfusion, reseting endotrachea. openning steijium Keywords: ventilator - associated pneumonia (VAP), endotrachea
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