OAC DIEM LAW! SANG VA MOT SO YEU TO NGUY CO TU' VONG C O A B E N H SUY OA CO QUAN TAI KHOA HOl Sl>C CAP CU'U
BENH VIEN NHI TRUNG U'ONG
Dwong Thuy Nga, Pham Van Thang Trwdng Dai hoc Y Ha Noi Nghidn cwu nhdm md td mdt sd ddc diim tdm sang va xdc dmh yiu ti nguy co tu vong cua benh nhdn suy da ca guan tai khoa Hdi swc cip cwu, bdnh vidn Nhi Trung uong Kit qua cho thdy ty le benh nhan suy da ca quan Id 22,4%, ty Id tir vong suy da co quan a tre dudi 1 tudi (70%). nguydn nhdn chii yiu do nhiim trung (83,4%). Mdt sd yiu td nguy ca tu' vong la s l luong ca quan suy. tuii dwdi 12 thdng. didm PRISM s 20. cd tlin sd bdnh trwdc dd, suy da co quan xuit hien ngay ngay diu nhdp khoa va cd tinh trang nhiim khuin khi nhap khoa Tw dd cd thi kit luan suy da co quan Id bdnh ly tiin tridn nhanh va cd ty Id tir vong cao (70%)
Tip khoa: suy da cc quan, y l u t l nguy co-, dac diem lam sang I. DAT V A N D ^
Suy da ca quan la tinh trang benh nang thudng gap d khoa hll sire d p ciru, ty le suy da ca quan hien nay d cac khoa Hit sire d p ciru khoang 10,9 - 56,5% [4]. Ty le tir vong cdn rdt cao, tir 40 - 100% theo cac tac gia.
Vi vay suy da ca quan da va dang dugc nhieu cdng trinh trong va ngoai nudc nghien ciru. Tuy nhien cac d l tai chu y l u tap trung d ngudi Idn, nhii'ng nghien ciiu d tre em chua nhilu va chu y l u tren mdt benh cu t h i nhu nhilm triing huylt, sot xult huylt, s i c nhilm khuan. Do vay tiln hanh nghien ciru nay vdi muc tieu: Md ta mot s6 dac diim lam sang va xac djnh mot s6 yeu td nguy ca tw vong cua benh nhan suy da ca quan tai khoa Hdi sire cap cwu, benh vien Nhi Trung wang.
II. D6\ TU'gNG VA PHU'aNG PHAP 1. D6i tu'O'ng nghien CLPU
Cac b?nh nhan dugc chin doan suy da ca quan, 1 thang den 15 t u l i duac dilu tri tai khoa Hdi sire d p ciru, benh vien Nhi Trung uang; thdi gian dilu tn tai khoa > 24 gid.
Chan doan suy da ca quan theo tieu chuin ciia hdi Nhi khoa Quoc t l nam 2005 (lPSCC-2005) [2] Chin doan suy da ca quan khi cd suy ding thdi > 2 ca quan nhu tim mach, ho hip, huylt hoc, thin kinh, gan, than
Tieu chuin loai trw Benh nhan sa sinh;
benh nhan cd tinh trang mat nao khi nhap khoa (giai doan cull); benh nhan tu vong hoac xm v l trong vdng 24h ddu kht nhap khoa HSCC, benh nhan khdng du tieu chuan nhap khoa Hli sire d p ciru.
2. PhU'O'ng phap nghien CIFU 2.7. Thiet kS nghien cu'u:
Nghien ciru md ta tien ct^u.
- Cd m i u theo cdng thuc
'A ' 'F
Trong do a: sai s6 wdc tinh. a = 0,05 (do tin cay 95%), Z i-a/2 ^ 1,96 ,5- do chinh xac mong mudn Chon 6 = 0.1, p" ty le tCr vong chung cua benh nhan suy da ca quan.
Vdl p = 54% (ty le tir vong suy da ca quan
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TCNCYH Phu trwang 80 (3A) - 2012 theo tong ket khoa Hoi swc cap cwu - Benh ven Nhi Trung wang nam 2007) [1]. Cd mau toi thieu la 96 benh nhan
2.2.2 Npi dung nghien ciru
Dac diem lam sang suy da ca quan Tuli, gidi, tiln sir benh tat trudc dd (benh bam sinh hoac benh man tinh), dilm PRISM 24h dau nhap khoa, can nguyen suy da ca quan, ty le suy da ca quan, thai gian xult hien suy da CO quan tinh tir khi nhap khoa.
Mgf so yeu to nguy ca tw vong Ty le tu vong, s l CO quan suy, loai ca quan suy, dilm PRISM, tudi, benh trudc dd, thdi gian xuat hien suy da ca quan
III. KET QUA
1. Mot sd dac d i l m lam sang suy da c c quan: tir 11/2010 d i n thang 6/2011,cd 133 benh nhan suy da ca quan dupc thu thap vdi cac dac dilm chung sau'
- T u l i ; Trung binh 21,6 thang tuoi, dudi 1 tuli 70%, 1 - 5 tuoi 17,3%.
- Gidi Nam 53,4%; Nir- 46,6%
- Khoa chuyin benh nhan d i n hli sire cap cuu. d p ciru luu 67,7%, Hd hap 12,8%, Truyln nhilm 9%, Tim mach 5,3%,
Tlln sir benh trudc dd (benh man tinh hoac benh bim sinh): 35 benh nhan (27%), chit y l u nhdm benh tim mach 60%
Ty le benh nhan suy da ca quan cita khoa Hit sire d p ciru. 133/593 ^ 22,4%
Thdi gian xult hien suy da ca quan (tinh tir kht vao hll sire d p ciru)' ngay hgay d i u tien
la 97 benh nhan (73%.), tir ngay 2 den ngay thir 7: 34 benh nhan (25,6%), sau 7 ngay. 2 benh nhan (1,4%).
- Benh chinh dua d i n suy da ca quan Benh nhiem trung 111 benh nhan (83,4%), Tai nan, ngd ddc 9 benh nhan (6,8%), Benh ngoai khoa 3 benh nhan (2,3%), Benh he tao mau 3 benh nhan (2,3%) va nhdm benh khdng rd nguyen nhan 7 benh nhan (5,2%).
Trong 111 benh nhan nhilm triing cd 57 benh nhan viem phli (51,4%), 35 benh nhan nhilm triing huyet (31,5%o), 9 benh nhan viem nao (8,1%), 6 benh nhan viem ca tim (5,4%) va 4 benh nhan viem ruot hoai tiJ' 3,6%
- Dilm PRISM trung binh trong 24 gid khi vao hll sire d p ciru la 15,5 ± 7,5, chii ylu tir 16 - 20 dilm (24,1%), 21 - 25 dilm (22,5%)
- Cc quan suy chirc nang suy ho hip 100%, suy tudn hoan 92,5%, suy huylt hoc 51,1%), suy than 39,1%, suy gan 32,3% va suy thin kmh 28,6%
- So ea quan suy chire nang: suy 2 ea quan 27,8%; 3 ca quan 25,6%, 4 ea quan 24%; suy 5 ca quan 18,8%; suy 6 ea quan 3,8%
2. Mpt sd y l u td nguy ccr tie vong ciia benh nhan suy da c c quan
Kit qua dieu tn: cd 90/133 benh nhan tir vong, chiem ty le 70%
2.1. Lien quan giu-a tuoi, thdi gian xuit hien suy da ccy quan, tien su' mac benh, tinh trang nhiem i<huan khi nhap khoa vdi nguy co- tu' vong suy da co> quan
Bang 1. Mpt so Yeu to nguy co-
Tuoi
Benh tru'oc do
Thoi gian xuJit hien -
SDCQ
nhiim l<huan l<hi nhap l<hoa
< 12 thang
> 12 thang Co Khong Ngay thu' 1 Sau 1 ngay Dap Lfng viem he
th6ng (SIRS) Nhi§m l<huln Soc nhilm khuSn
ydu to nguy co' tiy vong Tu'vong S6ng
72 22 21 18 31 5 62 35 77 20 16 20 85 30 70 19 63 17 suy da
T6ng 94 39 36 97 97 36 115
89 80
cc quan OR 95%CI
2,81 (1,8-6,67)
3,5 (1,2- 11,3)
4,81 (1,9-11,9)
3,54 (1,16- 11,03)
3 36 (1,44-7,91)
2,84 (1,24-6,55)
P
<0,05
Tudi < 12 thang, tiln sir mac benh trudc dd (benh man tinh hoac benh bam smh), suy da ca quan xuat hien ngay ddu nhap khoa va cae mirc dd nhilm khuan cd lien quan nguy ca tir vong d benh nhan suy da ea quan (p < 0,05)
2.2: Lien quan giu'a ioai co- quan suy v&i nguy ca tiy vong
Bang 2. Lien quan g'lCea loai cc quan suy va nguy cc tir vong cua suy da cc quan Ccquan
Suy Thin l<inh Huylt hoc Than Tuin hoan
Gan Ho h i p
Tu- vong
n % 30 79 51 76 39 75 89 72,4 31 72 93 70 86 lu'ong
38 68 52 123
43 133
OR 1,9 1,6 1,5 3,9 1,2
95%CI 0,7-5,1 0,7-3,7 0,6-3,5 0,9-17,8
0,5-2,8 P 0,15 0,19 0,3 0,06
0,7
Su- l<hac nhau vS ty le tir vong cua cac loai co quan suy khong co y nghla thdng ke (p : 0,05)
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TCNCYH Phu trwang 80 (3A) - 2012
2.3. Lien quan giira s6 Iwmg co" quan suy va nguy co' tir vong
Bang 3. Lien quan giu'a so lu'ang co' quan suy va nguy co" tiy vong suy da cc quan
So ccquan Suy
TLP vong
%
67,7
100
(n = 133)
37 34 32 25 5
OR 1 3,75 10,27
13,2
0,36-2,8 1,2-11,8 2,7-43,4
1,0 0,009 0,00005
3,0-66,7 0,00003
So lugng ca quan suy cd Hen quan chat d i n kit qua dilu th ciia benh nhan suy da ca quan (p < 0,0001). Ty le tir vong tang d i n vdi s l ca quan suy
2.4. Lien quan giu'a diem PRtS!\^ v&i nguy c c tip vong cua suy da c c quan Bang 4. Lien quan giu>a dilm PRISM va nguy cc tip vong cua suy da cc quan Dilm PRISM Sdng Ti>vong
Tong 40 93
Tdng 77 56 n = 133
OR 95%CI
Ty le tir vong tang d i n theo mirc dilm PRISM. Dilm PRISM tren 20 cd lien quan chat che d i n tinh trang tir vong vdi OR: 11,4.
IV. BAN LUAN
Kit qua nghien ciru cho thly ty le suy da ca quan la 22,4%, phu hap cac nghien ciru trong va ngoai nudc, ty le xult hien suy da ca quan trong cac benh nhan dtlu tn tai khoa HSCC thay dit dao ddng tir 10,9 - 56,5%, ty le khac nhau phu thudc vao cac d l i tuang nghien ciru, trung tam hit sire, tieu chudn ehln doan hay each danh gia suy da ca quan [4]. Suy da ca quan thudng gap nhlt d nhdm benh ly nhilm trung 83,4%i. 0 nhilm khuln trong nghien ciru cija chung tdi chu y l u d hd h i p 51,4%. va nhilm khuan mau 31,5% Dii
CO nhilu tiln bp dilu tn nhung ty le tir vong suy da ea quan rat cao 70%. Ket qua nghien ciru cita chung tdi cao han so nghien ciru khac [3, 4, 5, 7]. Mdt phln do khi benh nhan d i n trong tinh trang muon, suy nhilu ca quan, tten lugng tu vong cao, dilm PRISM cita benh nhan rdt cao
Ty le tii' vong cua suy da ca quanca quan suy K i t qua nghien eiru eho thay suy 2 ca quan ty le tir vong 40,6%, suy 3 ca quan:
67,7%, suy 4 ca quan: 77,5%., suy 5 ca quan: 88%.. suy 6 ca quan thi ty le tir vong la 100%). Cung theo Wilkinson ty le t u vong khi suy 2 ca quan, 3 ca quan, va han 4 ca quan tuang ung la 26%., 62%. va 88% [7].
Y l u t l nhilm khuan khi nhap khoa cung
lam gia tang ty le tir vong cua suy da ca quan. Theo Proulx & cong su, nhdm s l e nhilm khuln tir vong 52%, nhdm nhiem khuln nang 25% [6] Trong nghien eiru eua chiing tol, ty le tir vong d benh nhan suy da ca quan ed SIRS, nhilm khuln va shock nhilm khuan lln luat la 74%, 78,5%, 78,6%
Ca 3 y l u t l SIRS, nhilm khuln va s i c nhilm khuln d i u cd lien quan chat che den k i t qua dtlu th benh nhan suy da ea quan (p < 0.05)
Qua trinh benh ly cita hot chirng suy da ea quan rdt phirc tap, tity muc dd t i n thuang ma bilu hien lam sang khac nhau Trong nghien ciru ciia chimg tdi, ca quan ton thuang hay gap nhat la tuan hoan va hd hip, 100% benh nhan eua ehiing tdi d i u cd suy hd hip, 92,5%) suy tudn hoan, suy thdn kmh It gap han. Tuy nhien loai ea quan suy khdng cd moi lien quan d i n kit qua dilu tri suy da ca quan (p > 0,05). K i t qua tren phii hap nghien ciru eua Tantaleau, Wilkinson [3, 7],
Thdl glan xuat hien suy da ea quan eiing la mot khia canh duae quan tam, cd tdi 73%
benh nhan xult hien suy da ca quan ngay ngay dau nhap khoa. Day la mdt y l u t l nguy ca den k i t qua dilu tri suy da ca quan vdi OR: 4,81 (95%o Ci: 1,96 - 11,9) Kit qua nay cung phu hgp nghien ciru cua Typpo [4]
Dilu do chirng td suy da ea quan tiln trien nhanh va tram trpng
Ngoai ra, tuli eang nhd benh tiln triln cang nang va de ti> vong. Theo nghien cuu cua ehung tdi tre dudi 12 thang tuit cd nguy ca tir vong gap 3 l l n so vdi tre tren 12 thang Tiln sir cd benh (man tinh hoac b i m stnh) tir trudc dac biet nhdm benh ttm maeh ed lien quan d i n k i t qua dtlu th suy da ca quan vdi OR la 3,5.
D i l m PRISM duge theo ddi d l danh gta tien lugng tir vong benh nhan suy da ea quan, dilm cang cao ty le ti> vong cang
nhieu Nghien ciru eho thly dilm PRISM tren 20 ed gia tn tien lugng tir vong Kit qua nghien ciru nay phu hap nghien eiru tac gia Ponce [5]
V. KET LUAN
Ty le suy da ca quan d benh nhan nhap khoa Hli sire cap eiru la 22,4%, ty le tir vong la 70% Suy da ca quan gap nhieu d tre dudi 1 tuoi (70%), nguyen nhan ehu y l u do nhiem triing (83,4%o) Ca quan t i n thuang gap nhilu nhlt la hd hap (100%), tudn hoan (92,5%)
Mdt sd ylu to nguy ca tir vong cua benh nhan suy da ca quan. tuli dudi 12 thang, dilm PRISM > 20, cd benh (man tinh, benh bam stnh) trudc dd, so lugng ca quan suy, suy da ca quan xult hien ngay dau nhap khoa va ed tinh trang nhilm khuln khi nhap khoa.
TAI LIEU THAIVI KHAO 1. Lu'cng Thj San, Phan Huu Phiic, Ta Anh Tuan (2006), Dac dilm lam sang va kit qua dilu th hdi chirng suy chire nang da ca quan tai benh vien Nhi Trung uang. Tap chi Nghien cu-u Y hoc. 44 (4) 86 - 92
2. Goldstein B, Giroir B, Ratdolph A ' (2005). International Pediatnc sepsis consen-
sus conference Definition for sepsis and or- gan dysfunction in pediatrics. Pediatnc Critical Care Med; (6) 2 - 8
3. Jose A. Tantalean. et al (2003). Multi- ple Organ Dysfunction Syndrome in Children Pediatric Critical Care Med 4 (2)
4. Katri V, Typpo, Nancy J. Petersen, et al (2009). Day One MODS is associated with poor functional outcome and mortality in the Pediatnc Intensive Care Unit, Pediatric Criti- cal Care Med 10(5): 5 6 2 - 5 7 0
5. Ponce De Leon A.L, Pomed - Gut- 215
TCNCYH Phu trwang 80 (3A) - 2012
terrez G (2005), Simplified PRISM 111 score Med 10(1): 1 2 - 2 2 and outcome in the pediatnc intensive care
unit, Pediatrics International. (47). 80 - 83. 7. Wilkinson JD, Pollack MM et al (1987). Mortality associated with multiple or- 6. Proulx F, Joyal JS, Mariscaico MM, et gan system failure and sepsis in pediatric in- al (2009). The pediatric multiple organ dys- tensive care unit Journal Pediatric. ( I l l ) : function syndrome. Pediatnc Critical Care 324 - 328.
Summary
CLINICAL FEATURES AND SOME FACTORS RELATED TO MORTALITY OF PEDIATRIC MULTIPLE ORGAN DYSFUNCTION SYNDROME
The study was conducted to describe the clinical characteristics and some factors related to mortality of pediatric multiple organ dysfunction syndrome (MODS). Results showed that the incidence of MODS was 22.4%; 70% with MODS were less than 1 year old. 83.4%, with MODS associated with sepsis. The mortality rate of MODS was 70%. Mortality prognosis factors were:
number of organs dysfunction, age < 12 month, PRISM score > 20, presence of sepsis, history medical disease ,the first day of multiple organ dysfunction In conclusion, the rate and the mor- tality of MODS were very high in the ICU There were some factors related with high mortality.
Keywords: Clinical feature, multiple organ dysfunction syndrome, risk factors related mortality
MOT SO Y ^ U TO ANH HU'DNG D^N TUOI MOC RANG
Nguyin Phu Dat, Nguyen Thi Yen Trwdng Dai hoc Y Ha Noi Qud trinh phdt thin rang cung Id mot vdn dd rdt quan trong trong qud trinh phdt thdn a trd em Cd nhiiu yiu td dnh hwdng tdi qud trinh phdt tnin rang cua tre em Di tdi dwac thwc hien nhdm nghien cdu mot sd yiu td dnh hwdng din tudi moc rang cua 1444 tre khod manh tudi td 6 thdng din 42 thdng tudi tai mdt sd nhd trd a Hd Ndi dwoc chon ngdu nhien trong thdi gian tw 01/10/2010 din 15/04/2011. Kit qud chi ra rdng trd em sdng trong khu vwc ndi thdnh Ha Ndl cd tudi kit thuc moc rang sua (trung binh Id 25 thdng tudi) sdm han tre sdng a ngoai thdnh (trung binh id 27 thang tudi). Nhu-ng tre nhe can khi sinh cd tudi moc rdng vd tudi kit thdc moc rang swa mudn han tre smh du cdn. Tu6i trung binh bdt ddu moc rang va tudi trung binh kit thdc moc rdng d nhdm tre dwac bd sung thdm vitamin D vd can xi hay chl vitamin D don thuin sdm han so vdi nhdm trd khdng dwac bd sung them (p < 0,05). Tuii trung binh kit thuc mgc rdng a nhdm tre dwac tdm ning hoac sdng a nai cd du dnh sang thi sdm han nhom trd khdng dwac tim ning (p < 0.01) Tdm lai. cdc yiu td anh hwdng din tudi bit diu moc rdng swa id cdn ndng cua tre khi sinh, sw bd sung them vitamin D. can xi cho trd Cdc yiu td anh hwdng din tudi kit thuc mgc rdng sCra Id dia dw. cdn ndng cua tre khi sinh. vide cho tre dn bd sung sdm. sw bd sung vitamin D va can xi cho trd, vide cho tri tim ning, diiu kidn dnh sdng nai d
TCr khoa: Tuoi moc rang, vitamin D, can nang khi sinh
