Y HQC VrgT NAM THANG 6 - s 6 2f2Q11 s y chenh lech KX sau tra hai loai thuoc
khong co y nghTa thong ke qua ca hai phu'dng phap do SBDT (0,195D) va KXKTO (0,883D). Ket qua cua chung toi cung phu hdp vdi nhan xet cua cac tac gia khac la Cyclogyl iioan toan cd the du'dc sir^dung de liet dieu tiet trong do KX 6 nhom tuoi nay [ 4 ] , [ 6 ] .
Cdng suat KX khong nhutig thay doi tru'dc - sau khi tra thudc va giO^ hai loai thuoc ma con thay doi theo dp tuoi va hinh thai tat KX. Nhom tuoi cang nho, cang vien thj thi s y chenh lech KX cang Idn, s y khac nhau cd y nghia thdng ke vdt p<0,01. Nen khi do KX tren nhom doi tu'dng nay nhat thiet phai sy dung thudc liet dieu fet. Oieu nay da duWc rat nhieu tac gia de cap den [3], [5].
Ben canh tac dung liet dieu tiet, Atnapin va Cyclogyl con cd tac dung gian (Kng t y . 9 7 % kich thydc dong t y khdng cd s y khac biet sau tra hai ioai thudc. Gian dong t y trong kham mat la yeu cau a n thiet trong do KX cung n h y soi day mat, tuy nhien neu ddng t y gian qua to cung anh hu'dng den ket qua do do hien tUdng cau sai.
Tac dung gSy gian dong t y cua ca hai loai thudc deu tot, chi khac nhau ve thdi gian do cd che du'dc ly khac nhau va day la mdt van de can can nhac khi dCing vao thdi diem ma tre di hpc.
3.3. P h a n vtng p h u : chung tdi thay sau tra Cyclogyl cd 2 tre do mat (0,47%) va trieu chyng nay hoan toan het sau 30 phut. Trong Ithi dd 15 tre do mat sau tra Atropin (6,52%), 2 tre bj sdt
<an chydm mat. NhU vay Cyclogyl sy dung an toan hdn Atropin va cd thdi gian hdi phuc ngan nen dUdc da sd cac tac gia ly^ chon [ 2 ] , [ 3 ] .
IV. KET IXJfyN
KX sau tra Atropin 0,5% vien thi hdn Ichi khong tra thuoc la 0,883D khi SBOT va 1,134D khi do KXKTO. Ket qua KX sau Atropin va Cyclogyl khdng cd sy khac biet. Sy khac biet ve KX tru'dc - sau va giiJa hai loai thudc cd lien quan vdi tuoi va the loai KX. Cyclogyl cd tac dung tu'dng t y Atropin nhyng an toan, tiet kiem thdi gian va chi phi cho gia dinh tre.
T A I L I E U T H A M K H A O
1. Nguyen Dufc Anh (1996), "Oanh gia hieu qua lam sang cua may tlo khuc xa t y dong", Tuyen t i p cong trinh nghien CLTU khoa MQC cua nghien citu sinh. Tap 2, Oai hoc Y Ha H6\ tr 203-208.
2. Bernard C.G, ( 1962), " Selection of a cydopegic ftjr refraction of children", Refraction in children, p8S5 3. Ingram R.M and Barr A., (1979)," Refraction in
1 year - old children after Cydoplegia with Cyclopentolate 1%; Comparison with finding after Atropinisation", B30, 63, pp 348 - 352.
t . Kawamoto K., Hayasaka S (1997), "Cycloplegic refraction in Japanese: A comparison of Atropin and Cyclopentolate'',Ophthalmologica, 211(2), pp.57-60.
5. Patricia M.K, (1979), "The effect of Cydoplegia on the determination of Refractive error by the Ophthalmetron", Amer. J. Optometry and Physiologicals optics, 56 (4), p 228 - 230.
6 Paul E.R and Diana J.S, (1986), "Atropine versus Cyclopentolate Cydoplegia reractions in school age myopia", Amer. OrtJioptic Journal, 36, p124-126.
DAC DIEM LAM SANG VA C A N LAM SANG VIEM PHOI VI KHUAN OT TRE EM TAI KHOA NHI BENH VIEN BACH MAI
Nguyen V a n B a n g * , Hocing Minh H a n g *
TOM T A T
Mgc tieu: Nghien cyu dSc diem lam sang, c§n lam sang trong viem phoi do vi khu^n d tre em dUdi 5 tuoi. Dot hr^ff, phu'dng phap: theo doi 146 benh nhan viem phoi (VP), 92 trai, 54 gai, tuoi t y 2 den 60 thang, co thdi gian bj benh trung binh tru'dc khi vao vi?n la 6,0±4,6 ngay, trong do co 46 benh nhan (31,5%) c6 kgt qua cay dich ty hau (DTH) du'dng tinh trong thdi gian t y 1/1/2010 den 30/9/2010 tjii khoa Nhi benh vien Bach Mai. Tfnh toan gia tri chan doan
* 0^1 hoc YHa Ngi
Phan biSn khoa hgc: PGS.TS. Nguyin Tien DQng
cua cac trieu chyng tam sang va can lam sang chu yeu dya vao tieu chuan vang la vi khuan (VK) nuoi cay djch ty hau tru'dc khi dieu trj. Kit qua. Moi kho-luQi ban hay gSp d tre viem phoi cd VK DTH(+) hdn 6 tre DTH(-) (p=0,01). NgUdc lai, nhip thd nhanh so vdi lya tuoi chiem t / I? 67% 6 nhom VK DTH(-) va chifm 50% d nhom VK DTH(+) (p=0,03). 6 diem cSt ludng BCal6,5 G/L, t / le benh nhi trong nhom VK DTH(+) cao hdn hSn trong nhom trong nhom VK DTH(-) (p=0,04). s y khac biet cang ro ret khi BC>17,5 G/L (p=0,02). Cac trieu chyng lam sang, can lam sSng
Y HQC VlgT NAM THANG 6 - SO 2/2011 khic khong c6 sy khSc biet rd r§t giCTa 2 nhdm nSn
khong th^ dijng d^ bift VP do vl khuS'n hay kh6ng do vl khuSn. Ketlugtt. Ket qui nghien cuU n ^ cho thSy c6 rft It t r i ^ diCihg iSm sing v i c§n ISm sing giup chS'n doSn phSn biit vi§m pha vi khuSin vdi (dc nguyfin nhSn viSm phoi khic
r d ' khoi. Dfc dlS'm, c^n ISm sAng, ISm sSng, vISm phSl, vi khuSn, d4 em
SUMMARY
Characteristics of dinical and laboratory findings In children suffering from bacterial infection admitted into Pediatric Department,
Bachmai Hospital
Objective: Research on characteristic of clinical and laboratory findings In children under 5 years old with pneumonia, suffering from bacterial. Population and methods. 146 children (92 males and 54 females) aged from 2 months to 5 years, with average time of sickness before admittance of 6.014.6 days, of which 46 (31.5%) with positive culUire for bacterial agents from nasopharyngeal secretions from 1/1/2010 to 30/9/2010 at Pediatric Oepartment, Bachmai Hospital. Assessment of bacterial diagnostic values of signs and symptoms mostly based on gold standard of using naso-pharyngeal secretions before treatment.
Results. Toxico-infectiuos signs are more frequently seen on children with pneumonia and positive culture for bactena in nasopharyngeal secretions than in those with negative culture (p=0,01). Dyspnea according to age seemed to be a dinical finding more frequently seen on children with pneumonia and negative culture for bacteria in nasopharyngeal secretions (67%) than on those writh positive culture (50%) {p=0,OS). At cut- off point of W8C>16,5 G/L, the rate of child patients In positive culture for bacteria in nasopharyngeal secretkxis are mudi higher than in those with negative culture (p=0,04). The difference is most significant when WBC>17,5 G/L (p=0,02). Other findings, either dinkal or laboratory ones did not show any interest in differentiating bacterial pneumonia from non-bacberial one. Condushn.
Our results showed that there were very few findings getting good diagnostic values in differentiating bacterial and non-bacterial pneumonia in childhood.
Key-wort^ Charactenstics, children, dinical, laboratory, pneumonia
I. O^T V A N o f
Viem phoi (VP) cho den nay van la mpt trong nhuTig b^nh thydng gSp nhat d tre em va la mpt trong nhihig nguyen nhan chfnh gay tu*
vong d tre nhd [1-4,6]. 6 cac nydc dang ohat trien, c3n nguyen chu yeu gay viem phoi van la
vl khuan, chiem khoang 75% [1-6,]. O Viet Nam, c^c nghidn cyu gBn day cQng cho thSy ty^l^ VP phdi dieu tr! bSng khang sinh van con rat cao [1,3,4]. M$t sd X&c gia da cd gSng tim kiem cac x6t nghiem thfch hdP cd gl^ trj phSn biet VP vi khuSn vdi cAc nguyen nhan khac [3,5,7,8]. Tuy
" nhlfin, cho den nay, cac thay thudc lam sang van phSl dya chu ySu vao kinh nghifm lam sang de ra quyet djnh dieu trj. Vi vay, chung tdi tien hanh d5 t i i nSy vdi myc tieu "Nghien cult dSc dim ISm sAng, c$n lim s^ng trong viem phoi do vi khuin d tr^ em dddl 5 tuoi" nhSm gdp phan giup cac th^y thudc lam scing them cd sd khoa hpc trong chSn do^n vifim phoi do cSn nguyen vi khuan d tr^ em.
II. f ) 6 l lOpNG VA PHUONG PHAP
2.1. E>5i t i r i n g la tat ca benh nhi tir 2 thdng den 5 tuoi dydc chan doan VP theo tiSu chuSn cua WHO dya vac tri?u chyng lam sang:
ho, sot, thd nhanh, co rut Idng ngyc, b'm tai, nghe phdi co ran am nho hat, co ket qua vl khuan hpc, dieu \x\ t^i khoa nhi benh viSn Bach Mai tiy 1/1/2010 den SQI'^IIQIO. Benh nhi bi VP nhyng kem theo cac benh If khac hoSc khdng co ket qua xet nghiem vi khuan dydc kiai khoi nghien ctfu.
2.2. Phu'tfng phap nghiSn cihi md ta, chpn mau thuan tien vdi c3 mau tdi da cho phep trong khoang thdi gian nghien cyu. Bien nghien cdy gom tudi, gidi, thdi gian bj benh, dieu trj khang sinh trudc khi tdi vien, trieu chutig lam sang thydng gSp (sot, tan sd thd, nit lorn long ngyc, ran am nho hat) va cac xet nghiem c$n lam sang pho bien (CRP, bach cau, bach cau da nhan trung tfnh).
2.3. Xu* ly 56 I t f u bSng thuat toan Khi-binti phuUng de so sanh sy khac nhau ve ty Ie cac trieu chyng trong hai nhdm 6o\ tutfng.
III. KlT QUA NGHIEN CCTU
Trong 146 benh nhan thu dude cd tudi trung binh la 14,7±12,'3 thang, thap nhat la 2 thang, cao nhat la 60 thang, pho bien nhat la nhdm tuS t y 2-12 thang (59,6%), nhdm 12-36 thang (36,3%), nhdm tren 36 den 60 thang tudi rat it (4,2%). Sd tr^ trai la 94 (64,4%) va sd tre gai la 52 (35,6%), ty le nam/nu' la 1,8:1 (p<0,05). Thcfi gian bj benh trung binh la 6,0 ± 4,6 ngay. Trong sd 146 mau b^nh gham djch ty hau lay tu* 1 ^ benh nhan cd 46 mau benh phSm cd ket qua cSy
Y HQC VlgT HAM THANG 6 • s d 2/2011
djch_^ty hau duBng tinh (31,5%), trong do vi
l<huSn H. Influenzae chiem ty le cao nhat vcfi 21 ttlflng hdp (45,6%); s; pneumonia 19 tri/cfng hdp (41,3%); M. catarrhallsl triTdng hdp (8,7%)
va thap nhat la S, aureus co 2 tru'dng hdp (5,4%). Trieu chCfng lam sang viem phoi theo k k qui vl khuan hpc du'dc trinh bay trong bang 1.
Bang J . So sanh trieu chuYiq lam sanq d benh nhan vien- Tri^u Chung
s a > 3 7 ' ' 5 C S5t > SS^SC Moi kho lu€i bS'n Djch mui dgc Ho CO nhieu ddm Nhjp thd nhanh Rut lom long ngUc Ran am nho hat
Nhom VK 3m tinh ( n = 1 0 0 ) n 74 34 17 13 81 67 50 80
%
74 34 17 13 81 67 50 80phoi theo ket qua vi khuan hoc dich tv hau.
Nh6m VK du'dng t i n h f n = 4 6 ) n 38 19 30 8 37 23 22 38
»/o 82,6 41,3 65,2 17,4 80,4 50,0 47,8 82,6
P 0,25 0,41 0,01 0,30 0,50 0,04 0,80 0,79
Trieu chyng mdi khd lydi ban g^p pho bien hdn d nhom benh nhan cd ket qua vi khuan dydng ti'nh trong DTH_ so vdi nhdm cd ket qua vi khuan UVr\ am tinh (p=0,01). Ngypc lai, thd nhanh hay gap hdn d nhdm benh nhan cd ket qua vi khuan DTH am tinh so vdi nhom cd ket qua vi khuan du'dng tirih trong DTH (p=0,04). Trieu chyng can lam sang d benh nhi viem phoi theo ket qua vi khuan hoc DTH dude binh bay trang bang 2 va 3.
^ Bang 2. So sanh trj sd bach cau (BC) va bach cau da nhan trung tfnh (BCTT) cila benh nhi viem phdi theo ket qua vi khuan hpc dich ty hau.
BC, BCTT (G/L)
BC S14,6 BC > 16,5 BC > 17,5 BCTT > 5,7 BCTT > 7,5 BCTT > 8,2
Nhom VK am tinh ( n = 1 0 0 ) N 30 19 16 33 23 19
»/o 30 19 16 33 23 19
Nhom VK dUo ( n = 4 6 N 21 16 15 23 13 11
ng ttnh
%
P 45.7 0,07 34.8 0,04 i 32,6 0,02 50,0
28,3 23,9
0,05 0,42 0,51
Ty Ie benh nhi ket qua vi khuan DTH dydng tinh co sd lydng bach cau trong mau ngoai vi >16,5 G/L cao hdn mot each cd y nghla so vdi nhdm benh nhi ket qua vi khuan hpc DTH am ti'nh (p=0,04).
Sy khac biet cang rd rang hdn khi trj sd bach cau mau ngoai vi >17,5 (p=0,02). Khdng thay sy khac biSt ve sd lydng tuyet ddi bach ^ u trung tfnh trong mau ngoai vi cua nhdm benh nhan cd ket qua vi khuan hpc DTH (+) so vdi nhom benh nhan cd ket qua vi khuan hpc DTH (-). Sy phan bd tn so CRP bong quan the nghien dSw va theo ket qua vi khuan hpc dydc trinh bay trong bang 3.
Bang 3. So sanh tri so CRP d benh nhi viem pho CRP (mg/l)
CRP > 5 • CRP >10 n ' CRP > 20 CRP > 30
Nhom VK am tinh (n=100) N 1 (•/») 63
• • 48 36 25
63 48 36 25
theo ket qua vi khuan hoc DTH Nhom VK du'dng tinh (n=461
N 32 28 23 14
(%)
69,6 60,9 50,034,3
P 0,4 0,1 0,1 0,5
Ty le benh nhi trong nhom benh nhi viem
pliol CO k a qua vi khuan hoc DTH du'dng tinh luon CO cac trj so CRP cao hdn trong nhom vi khuan hpc DThi am tfnh. Tuy nhien, s^f khac biet nay deu chuS flat den mu'c <i nghla thong ke.
IV. BAN IU$N
Trong nghien cuU nay, chung toi thay cd
76,7% benh nhi viem phoi cd sot, trong do so
benh nhi sot >38°5C chiem 36,6%. Ty le benh
nhi CO s5t va sot >3805C trong nhom co ket qua
Y HQC VlgT NAM THANG 6 - 36 2/2011
vi khuan DTH (+) cao hdn trong nhdm cd VK
DTH (-); tuy nhien, sy khac bi$t chu^ cd y nghia.
Do Thj Thanh XuSn thliy sdt chi^m t^ 1^ 56,7%
trong viem phdi d nhdm tre dudi 5 tudi. Theo Nguyen Tien Dung sdt chiem 52,6 % viem phdi d tr6 dydi 1 tud'i [3].
Chung tdi thay dau hl§u nhjp thd nhanh (so vdi lu^ tudi theo V^/HO) g§p d 67% benh nhi trong nhdm vi khucin DTH (-) v^ 50% benh nhi trong nhdm vi khuSn DTH (+). Nhy vay, thd nhanh la trieu chyng thu'dng gap trong viem phdi tr^ em Vei cd the chi cd gia trj trong chSn doin viem phdi. Stolz (2008) thay thd nhanh chiem ty le 38% [8]. Palafox (2000) khi nghien cyu 110 tre em Mexico ty 2 thang den 17 tudi thay trl^u chyng thd nhanh trong chan doan viem phdi cd dp nhay 72%, dp dSc hieu 67% (p=0,001) [7].
Theo Nguyen Tien Dung, trieu chyng thd nhanh cd d 88,3% d tre dydi 1 tudi viem phdi vdi dp nhgy 38,7% va dp dSc hieu 90,6%.
Ket qua nghien cyu nay cua chung toi cho thay trieu chyng ran am nhd hat chiem ty I?
80% d nhdm vi khuan dydng tinh va chiem 82%
d nhdm vi khuan am tfnh (p=0,79). Nhy vay, chung ta cd the thay khdng the dya vao ran am nhd hat de chan doan phan biet VP do vi khuan vdi VP khdng do VK. Ket qua nghien cyu cua chunq tdi phu hdp vdi ket qua nghien cyu cua Nguyen Tien Dung [3], ciia Stolz va cua Palafox.
Cac xet nghiem can lam sang cd gia tri chan doan rat cao trong viem phoi vi Wiuan, da dydc nhieu cdng trinh nghien cyu trong va ngoai nydc khang dinh [2,5,6,8], Tuy nhien, trong nghien cyu nay chung tdi chi de cap den trj sd bach caU, sd lUdng bach cau da nhan trung tinh va CRP ta nhii'ng xet nghiem cd the tien hanh thydng quy d nhieu benh vien.
Chung tdi thay 62,4% b?nh nhan cd trj sd CRP tang trong dd nhdm CRP>20 (mg/l) chiem 34,9%, khi tri sd CRP tang dan, dp dac hieu cung tcing dBn, nhyng dp nhay lat giam din tuy nhien sy khac biet Ididng cd y nghia thdng ke vdi (p=0,l). Chung tdi khdng thay sy khac biet ve cac trj sd CRP giUci 2 nhdm benh nhan VP cd va khdng cd vi khuan hpc tir DTH. Cd the la do benh nhan nghidn cCru cua chOng tdi da dung khang sinh dai ngay trydc khi den vien (118/146 benh nhi, chiem 81%), nhy nhan xet cua Adnet v^ cdng sy (1997) [Chest, 112:'466 - 471] cung nhy cua Don va Agarwal [2] la CRP rat cd gia trj trong chan doan viem phdi do vi khuan, CRP
thydng tang cao nhat sau khi nhiem khuan 48h v^ giSm dl rgt nhanh khi dieu trj khang sinh co k§t qua. Nhy vSy, mSc du dydc ky vong nhieu, nhyng qua ket qua nghien cull nay, chung ^ nh?n thay tri so CRP tSng chya cd gia tri djnh hydng cho chlfn do^n viem phdi do vi khuan.
V. KET LUiDiN
Qua nghlSn cyu so s^nh trieu chyng lam s^ng va c^n lam sang chu yeu cua tir 100 benh nhi cay DTH vd khuan va 46 tre cd VK DTH), chung tdi cho thay: mdi khd-!u8i ban tren lam sang, cdng vdi tSng sd lypng bach cau mdu
>16,5 G/L cd the giup chung ta dinh hydng nguyen nh3n viem phdi do vl khuan d tre em tiy 2 thing den 5 tudi. Ket qua nay mot lan nu^ cho thiy sy khd khSn ciia viec phan biet nguyen nhSn nhiem khuan va lam chung ta hieu tai sao cac thay thuoc Nhi khoa rat khd khSn khi quyet djnh diing khang sinh cho tre em viem phdi.
TA) LIEU THAM K H A O
1. D$ng DuTc A n h , T n i n Viin Nam va cs (2008]h>
Ty le mSc benh do phe a u d tre em dulS 5 tua nh?p vien t^i ThSnh phd Hai Phong. £ ^ tii nghien cuv cap bo, Vien Ve Sinh Dich Te Tnmg Udng, tr. 30 - 4 1 .
2. Don M, CancianI M, Korpi M ( 2 0 0 8 ) , "Qinksl and laboratory finding-in the diagnosis of bacterial pneumonia in children "Sw/ss. Medidy, 138-151.
3. Nguyen Tien Dung ( 2 0 0 2 ) . 03c diem lam s^ng va sy dung khang sinh trong dieu tri viem phoi 6 tre em dudi mot tudi. Ky yeu cSng dinh benh inen B?ch Mait%p 2, tr 318-328.
T. Pham Thj Minh Hong ( 2 0 0 4 ) . f ^ diem lam sang va vi sinh trong nhiem khuan ho hfp dp^
tinh d tre em dudi 2 tudi. Tap chi Y hoc thanh {iho Ho Chi Minh, tap 8, tr 116-117.
5 I a n C, Lurt P, Juanita Lozano, et al (2004).
Epidemiology and clinical charactenstics of community acquired pneumonia in hospitalized children. Pediatrics, 113 (4): 701-707.
6. Ngo Thj Tuyet Lan ( 2 0 0 9 ) . Nghien oiU <Sf.
diem lam sang, can lam sang va dieu tn benh viem phe quan phoi do vi khuan gram am djre tif 2 th^ng den 5 tuoi. Lmn vSn bac ^chuymikhoa ap II • TnJ^g D^i hgc y khoa Ha Ngi. j J 7 Palafox M, Guiscatre H, Reyes H, et ^ (2100(9.
DiagnoEticvaluecftadvpnea./VcAZ:^0^ 82:41-45.^
8. Stolz D, Christ-Crain M, Gencay M, a f l f ( 2 0 0 8 ) . Diagnosis values in lower respiratory tract infection. Swiss Medldy. 138 -151.
