Y HOC VIET NAM THANG 5 - SO DAC Bl|T/2013
NGHIEN cull BIEN CHUUG HA DlTONG HUYET 0 BENH NHAN DAI THAO DlTOfNG NHAP VIEN TAI KHOA NOI TIET BENH VIEN VIET TIEP HAI PHONG NAM 2011 -2012
Tran Thi Mai*, Nguyen Thi Thiiy Ngan*
Dang Thj Kim Thanh* va CS
T O M TAT
Nghien citu 38 benh nhan (BN) dai thao dirdng(DTD) nhap vien vi ha diTdng huyet (HDH) tai Ithoa Npi Tiet - Benh vien Viet Tiep bang phu'dng phap mo ta cat ngang, chpn mau theo phu'dng phap thuan tien, tu' thang 08/2011- 07/2012, Chung toi thay: Nhom tuoi > 70 chiem 68,4%, trieu chu'ng run tay, va mo hoi lanh, doi 13,2%; 2 1 , 1 % va 18,4%; mat tap trung 10,5%;
co giat, id md va hon me sau gap 26,3%; 42,1 va 52,6%. Da so BN nhap vien d mu'c dp HDH nang: 68,4% . Du'dng huyet mao mach trung binh vao thcii diem BN nhap vien: 2,1 ± 0,86.
HbAlc trung binh la 7,1 ± 2,01. HDH do che do an 55,3%, do thuoc dieu trj co 26,3%, do chu'a du'dc chan doan xac djnh da dieu tr; co 13,2%.
76,3% BN Ithong theo doi du'dng huyet mao mach tai nha. 26,3% BN theo doi du'dng huyet deu dan tai cd scf y te. 73,7%. 7 1 , 1 % BN khong biet each t y xir iy l<hi co HDH;73,7% I<h6ng xir ly gi tru'dc khi nhap vien va 65,8% khong co hieu biet ve cac trieu chuhg HDH.
S U M M A R Y
Tile: Hypoglycemia during therapy in patients who had been diagnosed with diabetes hospitalized in Department of Endocrinology -Viet Czech Hospital Hal Phong from 2011-2012, Authors: Tran Thi Mai; Nguyen Thi Thuy Ngan;
Dang Thi Kim Thanh et al-Department of Endocrinology-Viet Tiep Hospital - Hai Phong- VietNam. Background: Hypoglycemia is a common complication in patients with diabetes, it can cause an increased risk of cardiovascular
disease (coronary heart desease located, myocardial infarction, etc.), and can cause severe brain damage and sequelae of brain death.In Endocrinology Dept.of Viet-Czech Hospital, the number of patients hospitalized for hypoglycemia, including severe hypoglycemia increased. To learning more about the complications of hypoglycemia in patients with diabetes, we studied this subject with two objectives. M e t h o d s : In a cross-sectional study was conducted in 2012, 38 patients hostitalized for hypoglecemia from 2011-2012 were collected by satisfaition theses creterias as follow: 1.
Patient had been diagnosed with diabetes and treated by a nti hyperglycemic and or Insulin;2.
Triage of Whipple: d. Clinical symptoms; b.
Glycemia inferior 4mm/l; c These symptoms disappeared after treatment.Blood glucose was calculated on fasting capillary blood;
Demographic, occupation, diet, glycemic control, HbAlc... were recorded too.Results:Patients aged > 70 was 68,4%; patients with severe hypoglycemia was on top with 68,4%; the mean capillary blood glucose was 2,1 ± 0,86; the mean HbAlc was 7,1 ± 2,01; hypoglycemia caused by poor diet was 55,3%; caused by overdose was 26,3%, hypoglycemia caused by antihyperglycemics in patients who had been missdiagnosed with diabetes was 13,2%.
Patients who did not monitor their blood glucose monthly at home was 76,3% and there was 26,3% patients who had been controlled their glycemia monthly at hospital. Patients who did not recognize symptoms of hypoglycemia was
C H U Y C N D E : HQI N G H | KHKT CAC TINH VUNG D U Y S N HAI BJC BO LAN THp NHAT
65,8%. Conclusion: Severe hypoglycemia was 68,4%; coma was the most frequent symptom with 52,6%; causes of hypoglycemia were; poor diet, overdose and missdiagnosis; related factors were: bad quality of the blood glucose control and of the education for diabetes patients and acute diseases.
I,
OAT VANoi
HDH la bidn chiing thudng gdp d BN DTD, nd ed thd gay tang nguy ca vd benh tim mach (BTTMCB, NIVICT...), tdn thuang ndo va nang cd thd gay di chimg vd nao va tir vong.
HDH thudng xuyen cdn anh hudng den tinh dpc lap va Idia nang sdng mot minh cua ngudi DTD.
Trong mdt nghien cuu thuan tap d BN DTD.
gap tren 50% ca HDH Ididng cd trieu chiing [7].
Tai khoa Ndi TiSt - Benh vien Viet Tiep Hai Phdng, sd BN nhap vien vi HDH, trong dd cd HDH nang ngay cang tang. De gdp phan tim hidu them ve bien chung HDH d BN DTD, chung tdi tidn hanh nghien cm dS tai nay nham hai muc tieu:
Mo Id dac diim ldm sdng vd can ldm sdng HDH tren BN BTD diiu tri Igi khoa nfi Tiit - Bfnh vien Viet Ti^p Hdi Phong lii Ihdng OS - 2011 din 07-20J2.
Xdc dinh nguyen nhdn vd mol .id yeu 16 Ihudn l(ri gdy HDH a nhom BN nghien cim. ^
II, D 6 | Tl/pNG VA PHUONG PHAP NGHIEN COU 2.1. Boi titmg nghien citu: BN duc«
chdn doan DTD cd bidn chung HDH vao'nhap vi^
tei khoa Ndi Tidt - Benh vien Viet Tiep Hai Phdng lit 01/08/2011 -31/07/2012thdaman tieu chuan sail
- BN da duac chdn doan DTD va dang dugc dieu tn
- Tieu chudn chdn doan HDH: Dua vao tam chimg Whipple [6]:
Trieu chung lam sang Duong huydt giam < 4 mmol/l Khi duang huydt tang cac trieu chimg giam va het
2.2. Phitffng phdp nghien citu: Theo phuang phap md ta cat ngang, mau thuan tien, ldy tdt ca cac BN du tieu chuan trong sudt thdi gian nghien ciiu.
2.3. Phan logi muc do HDH:
Bdng 2.1. Phan loai miic do HDH [6]:
Nhe Co the tu" dieu tri Run, nhip tim nhanh, va mo hoi, doi, met
Kich thich he Adrenergic
Trung binh Co the can ho trd Dau dau, tam trang thay doi, kem tap trunq
Neuroqiycopenic
Ning
Khonq the tu" dieu tri Ld md, co giat hoac hon me sau Neuroqiycopenic
2.4. Phdn tich vd xir ly so Heu: Phan mem thong ke y hoc SPSS 13.0.
III. KET QUA NGHIEN CCTU
3. 1. Dac diem chung cua doi tuo'ng nghien ciiu:
Tudi
3 0 - 4 9 5 0 - 6 9
> 7 0
S o B N ( n = 3 8 ) 4 8 26
Ty le {%) 10,5 21,1 68,4
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Y HQC VI$T NAM T H A H G 5 - S O B A C BlgT;2013
Gidi
Dja d l /
Nam NO Thanh thi Nonq thdn
16 22 31 7
42,1 57,9 81,6 18,4
Nhdm tudi > 70 co 26 BN chiem ( thanh thi la chu yeuchiemSl ,6%.
1,4%. BN nO nhieu han nam vdi 57,9%. BN sdng d
3,2, Bac diem lam sang, can Iam sang ciia nhdm nghien cu'u:
Bdng 3.2. Tri$u chimg lam sang HDH cua nhdm nghien cim
Run tav Va mo lanh Ddi Met Tronq nqUc Oau Oau Mat tap trung Coqiat L8m8 Hdn me
So BN Cn=38]
5 8 7 6 4 3 4 10 16 20
Vo 13,2 21,1 18,4 15,8 10,5 7,9 10,5 26,3 42,1 52,6
Trong 38 BN nghien cuu, trieu chimg run tay, va md hdi lanh, ddi chi gap d 13,2%;
21,1% va 18,4%. Trieu chimg mat tap trung gap 10,5%. Co giat, la ma va hdn me sau gap vdi ty le ldn hon vdi 26,3%; 42,1 va 52,6%.
gang J.J. Mirc do HDH
Nhe Trunq binh Nanq
S o B N ( n = 3 0 ) 8 4 26
Vo 21,1 10,5 68,4
Da so BN nhap vien a miic do HDH nang: 26 BN chiem 68,4%.
Bang 3.4. Dac diem can lam sang cua cac ddi tuang nghien cuu
Di/dnq huyet mao mach HbAlc
Trung binh 2,1 ± 0,86 7,1 ± 2,01
Max 4,7 14,3
Min 0,8 4,9 Duong huyet mao mach trung binh vao thai diem BN nhap vien rat thap: 2,1 ± 0,86.
CHUYBN DE: HQI NGHt KHKT CAC TJNH VpNC DUVeN HAI BAC Bq LAN THgNH^T
3,3, Nguyen nhan v:i mol so y i u to thuan loi gay H D H : Bang 3.5. Nguyen nhan HDH tren nhom BN nghidn ciru:
Cheddan(n=21;55,3%) Thudc dieu tri (n=10;26,3%)
An It hdn lUdnq can thiet BobOa
An mudn qid Khdnq theo ddn Oua lieu thudc Benh cap tinh
Chua chan doan xac dlnh da dieu tri Khdnq rd nquyen nhan
S6BN(n=3S) 14 3 4 4 6 1 5 1
Ty le (%) 36,9
7,9 10,5 10,5 15,8 2,6 13,2 2,6 HDH do che do an chiem 55,3%. do thuoc dieu tri co 26,3%. do chua duac chan doan xac dinh da dieu tri chiem 13.2%.
Bdng 3.6, Theo ddi dudng huyet ciia nhdm Tai nha bang may
mao mach Tai CO sd y te
Cd Khdnq Deu 1 thanq/lan Khdnq deu Khdnq theo ddi
BN nghien cim So BN (n==38)
9 29 10 11 17
Ty le (»/o) 23,7 76,3 26,3 28,9 44,8 Da so BN nghien cuu khong theo doi ducmg huyet mao mach tai nha (29 BN chi^m 76,3%). So BN theo doi duang huyet deu dan tai ca sa y tS chi co 10 BN chi^m 26,3%.
Bang 3.7, Hieu biet ve HDH va each tu xu ly truoc vao \ ien cua nlidni BN nghien cuu So BN fn=381
Tneu chirng HDH Tien sir HDH Biet tu xit ly khi cd HDH
TU xir ly d nha
Cd Khdnq Cd Khdnq Cd Khdnq Uonq nudc dUdnq Udnq sO'a cd dUdnq An banh keo nqot Khdnq xir ly qi
13 25 22 16 11 27 7 1 2 28
Ty le (»/o) 34,2 65,8 57,9 42,1 28,9 71,1 18,4 2,6 5,3 73,7 Cd 65.8% BN khdng cd hieu bidt vd cac bidt each tu xir ly khi cd HDH 73 7% BN tneu chirng HDH, 57,9% BN da tirng cd cac khdng xir ly gi trudc khi nhap vicn, con HDH trong tien su, 7 1 , 1 % BN khdng
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Y Hpc VIET MAM THANG 5 - SO D^C BIET/2013
IV. BAN LUAN
Trong 38 BN nghien cuu, trieu chumg run tay, va mo hoi lanh, doi chi gap a 13,2%; 21,1%
va 18,4% BN. trieu chung mat tap trung chi g5p 10,5%. Day la nhung trieu chimg som va thuang gap a BN HDH nhung chi gap voi ty le nho trong nghien cuu cua chiing toi cung nhu trong nhi^u nghien cuu khac nhu nghien cuu cua Nguyen Thi May Hong tai benh vien Chg Ray [1]. Ly do la vi phat hien mupn nen 6 thai di§m nhap vien, cac trieu chumg nang nhu giat.
lo ma, hon me sau gap nhieu hon voi ty le lan lugt la 26,3%; 42,1 % va 52.6%.
Da so BN nhap vien a muc do HDH nang chiSm 68,4% cao ban trong nghien cuu ciia Do Kim Phugng (2011) tai benh vien Thong Nhat [5]. Co sir khac biet la do doi tugng nghien cim cua tac gia bao gom ca nhung BN dang nSm ngi tni dugc xac dinh bang thu duang huyet mao mach hang loat nSn phat hien dugc nhung ca HDH nhe, con nhiJng BN ciia chimg toi da so la dugc nguai nha phat hien va dua vao cap cim trong tinh trang la ma. hon me sau. Do do, duang huyet mao mach tmng binh vao thoi diem BN nhap vien ciing rit thkp: 2,1 ± 0,86 mmol/l (thSp nhat 0,8 mmol/l). Trong khi HbAlctrung binh cua nhom nghien ciJTi la 7,1 ± 2,01 % van o trong nguang chap nhan dugc [3].
Ve nguyen nhan gay HDH. gap nhieu nhat la che do an khong phii hgp chiem 55,3%.
Nhom BN nay quan niem rang an la van de cua ca nhan trang khi diing thuoc la chuyen mon ciia bac sT. Hg khong biet phai giam lieu tham chi tam ngimg thuoc khi bo bua, an it han binh thudng va khong nen Sn mupn gia qua so voi gio quy dinh. Nghien ciin cua chiing toi cung phil hgp voi nghien ciiu ciia Ly Dai Luang (2008) tai benh vien Chg Riy [2].
Nguyen nhan thii hai che dp dimg thudc khong hgp ly chi^m 26,3%. Trong do, co nhimg
BN khi thay minh c6 cac trieu chung ciia DTD, tu nem nuac tieu thay ngpt thi tu mua thuoc uong, hoac lay thuoc ciia ngucri than bi DTD uong dSn den HDH, So khac, mac dii dugc bac sT ke don, khi dung thuoc khong dd thi tu y tang lieu thuoc dan den qua lieu gay HDH.
Nguyen nhan thii ba gay HDH dupc ghi nhan trong nghien cuu ciia chiing toi la HDH do chua dugc chan doan xac djnh da dieu tri (co 5 BN chiem 13.2%). Nhimg BN nay dugc chan doan tinh ca khi di kiem tra sire khoe dinh ky bai cac bac sT tuyen ca sa khong co chuyen khoa sau ve npi tiet. BN dupc xet nghiem mgt mlu duong huyet tuong, tham chi co BN khong phai llic doi, dugc chan doan va dieu tri ngay bang hai loai thuoc vien phoi hgp vai lieu trung binh den cao va HDH xay ra chi sau mpt den hai ngay dimg thuoc. Co BN da co nhiing bieu hien HDH nhe xay ra sau lieu thuoc dau tien song do khong dugc canh bao truac nen BN khong biet, van tiep tuc dung thuoc dan den HDH phai nhap vien.
Ve cac yeu to thuan lgi doi vai tinh trang HDH, chiing toi thay: Da so BN khong theo doi duang huyet mao mach tai nha chiem 76,3%.
Nhung van co toi 26,3% so BN dugc theo doi duong huyet deu dan tai ca sa y te chi ma van bj HDH. Ben canh do. sy hieu biet kem ciia BN ve HDH gop phan khong nho doi vai su xuat hien HDH khi CO tai 65,8% khong co hieu biet ve cac hieu chung HDH; dang ngac nhien la 57,9% BN da timg co cdc con HDH trong tien su; 71,1 % khong biet each tu xu ly khi co HDH;
73,7% khong xir ly gi miac khi nhap vien. Nhu vay, hieu biet cua BN va thai dp xir tri khi co HDH ciia nh6m BN cua chiing toi con rk han che. Dieu nay doi hoi can phai co nhieu hon nira cac buoi huyen thong, giao due hr cham soc dk
CHUYEN e6: HOI NGH! KHKT CAC TJNH VUNG DUY^N HAI BAC BQ LAN THfl NHAT
cung cap kien thirc cho BN DTD nhSm han che bien chimg HDH n ^ g can phai nhap vien.
V, KET LUAN
Qua nghien cu^i 38 BN DTD cd bien chung HDH nhap vi?n tai khoa Ngi Tidt - B?nh vien Viet Ti$p, chiing tdi rut ra 2 kdt Iu4n sau:
1, Ldm sdng vd can Idm sdng:
- Da sd BN nhap vien d mirc dd HDH nang (68,4%)
- Trieu chumg run tay, va md hdi, ddi gdp d 13,2%; 21,1% va 18,4%;
- Trieu chitng co giat, lo m o va hdn me sau gap ldn lucrt 26,3%; 42,1 va 52,6%.
- Dudng huydt mao mach trung binh luc BN nhap vien: 2,1 ± 0,86; HbAle trung binh la 7,1 ± 2,01%.
2, Nguyen nhan vdyiu ti lien quan:
- Nguyen nhan gay HDH hang ddu la do chd do an khdng dung: 55,3%; thu hai la do thudc didu tri khdng phu hpp: 26,3% ; do chua duoc chdn doan xac djnh da didu tri: 13,2%.
- Ydu td thuan lgi: 76,3% khdng theo ddi dudng huydt mao mach tai nha; 26,3% dugc theo ddi dudng huyet deu dan tai co sd y td.
Hidu biet cua BN DTD vd benh kem khi cd tdi 71,1% khdng bidt each tu xir ly khi cd HDH;73,7% khdng xir ly gi truoc khi nhap vien va 65,8% khong cd hieu bidt vd cac trieu chiing HDH. Ydu td thuan lgi it gap nhdt la cd benh kem theo 2,6%.
VI, KHUYEN NGHj
- Giao due BN va gia dinh, nhdt la nhihig BN 1cm tudi, vd kidn thuc didu tri benh DTD: Che dp an hprp Iy, diing thudc dung chi dinh cua bac sT, nhan bidt dugc bidn chiing HDH va bidt each tu xit tri tai nha.
- BN DTD nen theo ddi dudmg huyit mao mach tai nha de phat hien sdm, tranh di h^u qua ngng ne do HDH ngng gay ra.
- Dao tao mang ludi y te co sd vd chan dodn xac dinh benh DTD va dieu tri hgp iy di tranh tai bien HDH nguy hiem d BN DTD.
TAI LIEU THAM KHAO
1. Nguyen Thj IMay Hong, Nguyin ,Thy Khue (2008). Tan suat cic yeu to nguy co cua HDH tren BN DTD tai khoa Noi Tift benh vien Chp Ray. Luan an chuyen khoa cap II. Dai Hgc Y Dui?c Thanh pho Ho Chi Minh.
2. Ly Dai Lmmg, Nguyen Thy Khue (2008), Ty I? cac yeu to nguy co gdy HDH tren BN DTD dang dilu trj. Luan van tdt nghiep bac si noi tru. Dai hoc Y Dugc Thanh phd Hd Chi Minh.
3. Hpi Noi Tilt va DTD Viet Nam (2009), khuyin cao vl benh DTD, tr.94.
4. Nguyin Bich Phugng, Nguyen Thy Khue (1998). Mpt sd nhjn xet vl tinh hlnh HDH tren BN DTD tai benh vien Chg Ray. Luan an til nghiep Bac sT npi tru. Dai hpc Y Dupc Thanh phd Ho Chi Minh.
5. 0 6 Kim Phupng (2012). " Cac yeu td nguy co HDH tren ngudi cao tudi". Ky ylu Hdi Nghj Npi Tilt-DTD toan qudc lin thu VI.
6. Nguyin Thy Khue (2007). " Chin doan va dieu uj hon me HDH". Npi tilt hpc dai cuong.
Nha xuit ban y hpc chi nhanh Hd Chi Minh.
Trang6I3-62I.
7. American Diabetes Association, Chico A et al. Diabetes Care. 2003, 26(4): 1153-1157).
8. Fischer K and J, Lee (1986), Hypoglycemia in hospitalized patients. Causes and outcomes". The New England Journal of Medicine, 3i5. Pp I245-I250.
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