Y HOC V\tJ NAM THANG 8 - S6 1/2013 khai chffdng trinh PHCN dffa vao cdng ddng
cung da tang len 3 lan; sd TYT xa cd KCB bSng YHCT tang tff 24,76% len 29,7%.
TAI U E U T H A M K H A O
1. Bo Y t e , Nien giam thdng ki Y te 2000,2005,2010, Ha Npi.
2. Bo Y t e , Tong cue f h o n g ke (2003), Bio cao kit qua dieu tra y ti quoc gia 2001-2002, Nha xuat ban Y hoc. Ha Noi.
Dung, T.V. (2002), Nghien cuU theo doi dian (SENTINEL) M? b'nh hinh cung cap va ^dung didi vu y te^i 28 xa nong thon trong 2 nSm 20(X}-2001, Ddn vi chinh sach-Vu ke hoach Bo Y te. Ha Noi.
hi^nh, V.T.M., cpng su" (2002), Hi^u qua ho?t dong cua mang lu'di y te thon ban t^i huyen Tua Chua tinh Lai Chau, Vien chien {u'dc va chinh sach y te, Bo y te, Ha Npi.
Tr^n t h j Mai Oanh va cong si^ (2011), Danh gia viec thu'c hien chii'c nSng nhiem vu cua tr^m y texa khu vut mien nui. Ha Noi.
HIEU QUA CUA LOG MAU LIEN TUC TiNH MACH - TINH MACH (CWH) TRONG DIEU TRj BENH TAY CHAN MIENG CO BIEN CHUfNG SUY TUAN HOAN
VA SUY HO HAP CAP TAI KHOA HOI SUfC CAP CIJU
Ta Anh Tuan', Dau Viet Hung', Phan Hiiii Phiic', Nguyen Van Tii', Ngo Tien Dong', Chu Thanh Son', Nguyen Trgng Dung', Dao Huu Nam', Phung Thi Bich Thuy^, Khiic Thi Renh Hoa^
TOM TAT
Muc tiiu nghien cuir. Oanh gia hieu qua ciia Ipc mau lien tuc (CWH) trong dieu tri benh tay chan mieng cd bien chffng suy tuan hoan va suy ho hap cap. £>oi tu'dng nghien ait/: 31 tre tay chan mieng CO bien chuVi'^g suy tuan hoan va suy ho hap cap vao dieu tn tai khoa HSCC, Benh vien Nhi Trung u'dng.
Phifdng phap nghien c&u: Nghien cffu mo ta tien ciru can thiep tir doi chufng tru'dc sau. kit qua nghien czh/.-Tudi trung binh ciia nhom nghien cffu la 23,7 ± 13,6 thang (dao dpng t y 2- 59 thang), thdi gian mSc benh trung binh la 3,1 ± 0,6 ngay, 34,4%
I benh nhan chan doan mupn (chi du'dc chan doan khi
•v^o HSCC). Ty le EV du'dng tinh la 40,6%, du'dng tinh I vdi EV71 la 15,6%. So sanh vdi thdi diem tri/dc Igc
mau (TO) - sau loc mau: tai thdi diem 6h nhiet do cd
;the, mach, huyet ap tam thu giam co y nghTa thong 'ke, tai thdi diem 24h giam du'dc lieu Dobutamin, 'Adrenaline va tai thdi diem 48h giam dUdc lieu Nor-
•adrenalin co y nghia (P < 0,05). Tai thdi diem 24h sau -loc mau: cac chi so SLBC, BCTT, prothrombin, HC03', iglucose mau, lactate, phan sd tong mau (EF), nong do ilL-6 mau, Tai thdi diem 12h sau Ipc mau trong dich loc jtim thay cac cytokine: IFN-g, IL-6; IL-6r, IL-8, IL-
V Khoa Hoi s&c cap cuV
fKhoa smh hoc phan hy cac benh nhiem trung - Benh Wien Nhi TW
Phan bien khoa hpc: PGS.TS Pham Van Thang
12p40, TNF-r2, MCP-1 va lam giam nong do IL-6 mau giam tai tdi diem 24h sau loc. Ty le song la 68,8%, song cd di chutig la 15,6% va t y vong la 15,6%. Ki't luan: CWH cd hieu qua tdt trong dieu trj benh HFMD CO bien chutig suy ho hap va tuan hoan
Tiy khoa: CWH, suy tuan hoan va suy ho hap cap, HFMD
SUMMARY
THE EFFECT OF CONTINUOUS VENO-VENOUS HEMOFILTRATION (CWH) IN TREATMENT FOR HAND, FOOT AND MOUTH DISEASE WITH FULMINANT CARDIOPULMONARY FAILURE IN PICU
The aim study is to determine the role of continuous veno-venous (CWH) in treatment for HFMD with fulminant cardiopulmonary failure. The results indicated that from 9/2011 - 5/2012 there were 32 patients with fulminant cardiopulmonary failure caused by HFMD, who admitted in the PICU, Nabonal Hospital of Pediatrics.The average age was 23.7 ± 16.7 months. The average duration of critical life threatening signs and symptoms was 3.1 days (2 - 4 days). Before admission in PICU there were 18 patients (34.4%), who was not diagnosed HFMD. The mean number of used inotropes was 2.9 ± 0.7. The percentage of positive EV cases was 40.6% and positive EV71 cases was 15.6%. At 6 hours after inibabng CWH; temperature, heart rate, systonic blood pressure normallized. At 12 hours after CWH
Y HQC VigT NAM THANG 8 - S 6 1 /2013 Started: WBC, neutrophils and lactate decreased;
elevated EF and blood HC03'; reducing of dose of Dobutamine, Adrenaline, Nor-adrenallne. IFN-g, IL-6;
IL-6r, IL-8, IL-12p40, TNF-r2, MCP-1 were detected in ultrafitrate fluid, but only IL-6 decreased in blood at 24 after CWH starting. 68,8% pabents were survival without any sequelae, survival with neurological sequelae was 15.6% and the mortarity rate was 15.6%. Condusions: CWH can remove IFN-g, IL-6;
IL-6r, IL-8, IL-12p40, TNF-r2, MCP-1 from the ciculation and reduced IL-6 level in blood HFMD patients. Cardiovascular hemodynamics, metabolic to improve after induction of CWH in HFMD with fulminant cardiopulmonary failure
Keywords: CWH, fulminant cardiopulmonary failure, HFMD
L
OAT VANof
Benh Tay chan mieng (hand, foot, and mouth disease - HFMD) la benh truyen nhiem cap ti'nh do vi rut dffdng ruot thupc ho Picornaviridae gay ra (chu yeu la do 2 nhom Coxackie A va EV 71), trong do EV71 la tac nhan quan trpng nhat, vi co the gay ra cac bien chffng nang: bien chffng than kinh (khoang 10 -30%), suy tuan hoan va ho hap dan den tff vong nhanh chong, dac biet la cf tre nho [ 2 ] . Cho tdi nay chffa co bien phap dac hieu dieu t n HFMD, chu yeu la dieu tri ho t r d . Thffc te lam sang, tai cac trung tam Hoi sffc cap cffu, loc mau lien tuc da dffdc ap dyng rong rai de dieu tri cho cac benh nhan soc n h i l m khuan vi Igc mau lien tuc co kha nang loai bo ra khoi cd the cac cytokine (tac nhan gay ra nhffng roi loan nang ciia benh) dffdc giai phong trong qua trinh dap utig viem ciia cd the khi bj soc nhiem khuan. Mat khac Ipc mau lien tuc giup giff can bang djch 6 nhffng benh nhan nang luon co xu hffdng qua tai djch, tff do giup tranh ton thffdng cac cd quan [5], [ 7 ] . Cau hoi dffdc dat ra lieu Ipc mau lien tyc CO hieu qua trong dieu trj HFMD co bien chffng suy tuan hoan va suy ho hap cap hay khong?.
Dffa vao nguyen ly noi tren, de tai dffdc tien hanh vdi cac muc tieu: Danh gia hieu qua cua Iqc mau iien tuc tinh mach-tinh mach (CWH) trong dieu tri benh tay chan mieng co bien chiing suy tuan hoan va suy ho hap cap.
W. 0 6 l TUpNG VA PHUONG P H A P NGHIEN CCfU 2 . 1 . Ooi tytfng nghien cii'u: Gom 32 benh nhan mac HFMD co bien chuYig suy tuan hoan va suy ho hap cap dffdc dieu tri tai khoa Hoi sffc cap cdu, Benh vien Nhi Trung ffdng tff thang 9 nam
2011 den thang 05 nam 2012.
Tieu c h u a n chan d o a n : theo WHO - 2011 va ciia Bo y te n3m 2012 [ 1 ] .
Chan doan ca lam sang: trong vy djch HFMr benh nhan co sot, phat ban dien hinh cua beni tay chan mieng, suy ho hap a n ho hap ho tre hoSc suy tuan hoan can s y dung cac thuoc var mach, hoSc xet nghiem EV dffdng tinh.
Tieu chuan chpn b f n h nhan loc mau: benh nhan HFMD cd bien chirtig suy tuan hoan va ho h ^ cap ngoai viec da dffdc dieu tri theo phac do oia Bg Y te con dffdc dieu tri phffdng phap lpc mau lien tuc tinh mach - tlnh mach (CWH).
Tieu c h u a n loai t r i r benh nhan khoi nghien cufu: benh nhan d giai doan cuoi cua benh, cd roi loan dong mau n3ng, khdng thiet lap dffdc vdng tuan hoan ngoai cd the, gia dinh beiih nhan khdng dong y ap dung phffdng phap Ipc mau hoac benh nhan khdng dffdc theo ddi diy dii cac so lieu theo qui djnh.
2.2. Phu'dng p h a p nghien cu'u 2.2.1. Pliu'dng ptiap nghien cihi: phffdng phap nghien cdu tien cffli, md ta va phan tidi can thiep dieu t n , cd so sanh/ t y doi chffng.
* Cd mau nghien cdu: chpn mau thuan tien, gom 32 benh nhan mac HFMD cd bien chyng siw tuan hoan va hd hap cap du'dc dieu tri tai kh(
HSCC, BV Nhi Trung ffdng.
2.2.2. Npi dung va bien ngiiien cuV:
* Oac d i e m c h u n g ciia doi tffdngj nghien cu'u: tuoi, gidi, thdi gian mac benh, tinh, trang toan than (nhiet dp, mach, huyet ap, glasgow..). Nguyen nhan ciia HFT^D: ty le du'dng!
tfnh vdi EV va EV71 hoac cac vius dffdng rudt khac, [
* Oanh gia hieu qua ciia loc mau lien|
tuc tinh mach - tTnh m a c h ( C W H ) : so sanh cac chi sd: nhiet do, mach, huyet ap tam thu,' phan sd tong mau that trai (EF), thay doi so|
Iffdng bach cau, bach cau trung tinh,|
protjirombin, lactate, glucose mau, HC03", liaii thudc van mach sff dung, ndng do cytokine trong mau va djch Ipc cf thdi diem trffdc loc (TO) va sau I igc mau 6, 12, 24, 36, 48 gid (T6,T12, T24, T36,|
T48). Ty le tff vong, di chffng, ra vien. I 2.3. Quy t r i n h loc m a u lien tuc tinh - t l n h mach ( C W H )
Loc mau lien tuc C W H bang may l«
Prisma ciia hang Gambro, qua Ipc cau tao boi m^ang polyacrylonitril (AN69) phii hdp vdi can nang ciia benh nhan.
- Dffdng vao mach mau: catheter 2 nong ptiii hdp vdi can nang dat vao tJnh mach ben hoac find
Y HQC VIJT HAM THANG 8 - SO 1/2013
mach canh trong, tinh mach dffdi don. Djch Ipc:
hemosot B. Chong ddng bang Heparin: lieu bolus tff 10-40 Ul/kg, lieu duy tri 5 - 40 Ul/kg de dat ART sau mang Ipc gap 1,2 -1,5 gia tri binh thffdng, hoSc giff ACT trong khoang 145 -160.
- Cac thong sd cai dat cho Ipc mau: tdc dd rut mau 3- 7 ml/kg/ph, tdc do djch thay the 36 - 84 ml/kg/gid; tdc do rut djch khdi benh nhan phu thupc vao tinh trang benii nhan, rut djch de giff bang djch bang "0".
2.4. Sii* ly so lieu: Theo phffdng phap thdng ke y hqc, sff dung phan mem SPSS.16
III. KET QuA NGHIEN COU
3.1. Oac diem chung ciia ddi tu'dng nghien cu'u
Tuoi trung binh cua nhom nghien cirtj la 23,7
± 13,6th, thdi gian mac benh trung binh la 3,1 ± 0,6 ngay, cd 11/32 (34,4%) benh nhan chan doan muon (chi dffdc chan doan khi vao HSCC), 10/32 (68,8%) benh nhan cd yeu to djch te, sd thudc van mach sff dyng 2,9 ± 0,7 thudc, 13/32 benh nhan co EV dffdng tfnh (40,6%) va 5/32 benh nhan cd EV71 dffdng ti'nh (15,6%).
3 . 2 . Hieu qua ciia loc mau lien tuc C W H
Bangl:So sanh thay doi mot so chi so lam sanq tru'dc va sau loc mau Chi so
Nhiet do
Mach
HATT TO"
39,4 ± 0,8
205,6 ± 17,0
94,4 ± 14,5 T S ' 37,5 ± 0,6
173,0 ± 16,0
103,0 ± 19,6 T12' 37,1 ± 0,6
156,5 ± 25,6
104,3 ± 15,2 T24''
36,8 ± 0,6
148,6 ± 20,6
103,2 ± 11,8 T 3 6 ' 36,8 ± 0,5
147,4 ± 17,7
101,2 ± 13,6 P 0,0000"'»;
O.OOOO"';
0,0000'";
0,0000"
,0000"'»;
0,0000"'';
0,0000"''';
0,0000"
0.013*';
0,0000"'';
0,000"-'';
0,007*'
Ghi chu: * test Tghep cap
Ntian xet: Tai thdi diem 6h sau loc mau cac chi sd: nhiet dd, mach, huyet ap tam thu giam ro ret cd y nghTa thdng ke so vdi thdi diem trffdc loc mau (p < 0,05).
Bang 2: So sanh thay doi mot so Chi so
SL Bach C3U Bach cau TT Prothrombin Glucose mau i^ctat mau (mmol/i) HC03" mau EF (%)
TO"
19.409,2 ± 7.400,0 11.159,4 ±5.715,6 62,4 ± 22,2
12,6 ± 7,6
6,3 ± 3,7 20,7 ± 4,7 42,9 ± 9.5
chi so xet nqhiem tru'dc va sau loc mau T24''
13.038,7 ± 3786,4 8.728,1 ± 3.657,1 74,7 ± 21,3
6,3 ± 3,8
2,3 ± 1,5 23,6 ± 2,7 55,2 ± 5,8
T48'
11.488 ± 4.024,5 7.371,4 ± 3.327,1 97,8 ± 25,6
7,2 ± 5,9
1,2 ± 0,7 25,0 ± 3,6
P"
0,0001*», 0,0001«;
O.OOl"-' 0,024*'; 0,038*';
0,003*' 0,014*°; 0,001*';
0,0000*' 0,001*';
0,0000*';
0,028*' 0,0000*';
0,0000*';
0,0000*' 0,004*'; 0,001*';
0,0000"
0,0001*'
Ghi chu: * test Tghep cap
Y Hpc VigT NAM T H A N G 8 • S 6 1/2013
Nhan xet: tai thdi diem 24h sau ioc mau so lu'dng bach cau, bach cau trung tinh, glucose man, lactate iriau giam ro ret; ty le prothombin, HC03' va EF tSng hOn so vdi thdi diem tru'dc ipc mau co f nghia (P < 0,05).
Bang 3: So sanh thay dol ileu thuoc van mach tru'dc va sau lpc mau
13,8 ± 4,1 10,5 ± 7,3 7,5 ± 6,2
0,12*'0, 015*';
0,000*' 0,15 ± 0,38 0,001*'; 0,000"
0,000*' 0,72 ± 0,56 0,32 ± 0,66
0,93*';
0,43*';
0,012"
Ghi chu: * test Tghep cap Nhan x4t: Tai thdi diem 24h sau loc mau da giam du'dc Ileu Dobutamin, Adrenalin va tai ttiS diem 48h sau ioc mau giam du'dc iieu Nor-adrenaiin. Si/ khac biet cd y nghia thong ke so vdl tiiili diem tru'dc ioc mau (p < 0,05)
Bang 4.
Cytokine TNF-a
IL-lb IFN-q IL'6 IL-6r IL-8 IL-12P40 IL-12p70 TNF-r2 MCP-1
So sanh thay doi cytokine mau tai mot so thdi diem trirdc va sau ioc
T O ' ( n )87,9 i 326.8 (15) 39,6 ± 107,6 (15) 81,1 ± 5 1 , 3 ( 9 ) 795,3 ± 1589,5 (15) 8812,5 ± 1777,3 (9) 878.4 ± 1407,5 (15) 8766,8 ± 5332,0 (4) 4018,9 ± 1538,7 (4) 4659,9 ± 989,1 (9) 1313,8 ± 2554,6 (15)
T 1 2 ' ( n ) 1 1 . 6 ± 3 1 . 6 ( 1 2 )
4,9 ± 7 , 5 (12) 83.9 ± 103,4 (6) 128,6 ±122,6 (12) 6573,8 ±3550,0 (6) 561,9 ± 5 4 1 , 5 (12) 1082,3 ± 168,9 (3) 798,1 ± 970,5 (3) 4650,4 ± 987,4 (6) 535,3 ± 1092,0(12)
T 2 4 ' ( n ) 7,9 ± 21,1(12) 7,7 ± 18,6(12) 38,0 ± 54,5 (7) 95,3 ± 80.6 (12) 8215,6 ± 2137,5 (7)
414,7 ± 499,3 (12) 4696,8 ± 3348,9 (4) 1171,8 ± 1057,6(4) 3993,5 ± 1077,8 (7) 721,3 ± 1082,3 (12)
mau
P ' 0,34"
0,87"
0,68' 0,11*
0,75' 0,86' 0,11"
0,11"
0,35*
0,58' ' , 0 , 2 5 "
' ; 0 , 7 5 "
' ; 0,25"
; 0,008«
' ; 0 , 3 5 "
' ; 0 , 1 4 « b . 0 47.,e ' ; 0 , 1 4 "
; 0,075"
b. Q 5j..<
Ghi chu: * Wilcoxon rank sum test Niian xet: Tai thdi diem 24h sau Ipc mau nong do IL-6 giam hdn so vdi tai thdi diem trffdc Ipc mau CO y nghTa thong ke (p = 0,008). Khdng cd sff khac biet ve nong do ciia cac cytokine: T TNF-a, IL-lb, IFN-g, IL-6r, IL-8, IL-12p40, IL-12p70, TNF-r2, MCP-1 tai cac thdi diem trffdc va sau Ipc mau.
Bang 5: So sanh thay doi cytokine dich loc tai mot sd thdi diem sau loc mau Cytokin (pq/ml)
TNF-a IL-lb IFN-q IL-6 IL-6r IL-8 IL-12p40 IL-12P70 TNF-r2
MCP-1
T 1 2 " ( n ) 0(6) 0(6) 1,6 ± 3 , 9 (6) 26,8 ± 37,3 (6) 7,2 ± 7,9 (6) 4,1 ± 4,6 (6) 664,4 ± 428,2 (3)
0(3) 71,1 ± 77,9 (6) 95,2 ± 174,3 (6)
T24'' (n) 0(5) 0(4) 8,2 ± 18,2 (5) 11,2 ± 226 (5) 6,2 ± 8,5 (5) 4,9 ± 4,4 (5) 692,1 ± 375,3 (2)
0(2) 56,0 ± 76,6 (5) 21,9 ± 24,5 (5)
P'
0,37*' 0,18*' 0,67*»
0.32*' 0,66*' 0,66*' 0,32*'
Ghi chu: * Wilcoxon rani: sum test Nhan xet: tai thdi diem 12h va 24h sau lpc mau trong dich Ipc co SLT xuat hien cua cac cytokine: IFN-g, IL-6; IL-6r, IL-8, IL-12p40, TNF-r2 va MCP-1. Chu'a thay co sir khac biet ve nong do cua cac cytokine tai cac thdi diem 12h, 24h tai djch ipc sau loc mau.
Ket qua dieu trj: Cd 22/32 (83,4%) benh nhan song, trong do 5/32 (15,6%) benh nhan song
cd di chimg than kmh. 05/32 (15,6%) benh nhan tiJ vong.
Y HOC ViET NAM T H A N G 8 - SO 1/2013
IV. BAN LUAN
4 . 1 . S a c d i e m djch t e l a m sang: Nghien ciili thay tuoi mac benh cua benh nhan HFMD nhd, tuoi trung binh la 23,7 thang (giao ddng tff 2 thang den 59 thang). Ket qua nay cung phiJ hdp vdi cac nghien cffu khac nhff: Trffdng Hffu Klianh (2012 - Benh vien Nhi ddng 1) thay tudi trung binh mac benh la 20 thang (dao ddng tff 1- 4 tudi) [2] va nghien ciTu ciia Fu YC (Dai Loan - 2003) tren 34 tre viem nao tiiy do EV71 cd bien chimg phii phoi cap thay tuoi trung binh mac benh la 26,9 thang [ 4 ] . Tre nhd de mac benh do he mien dich chu^ hoan thien, khi mac benh thffdng nang, mat khac tre nhd de bi lay nhiem do trong chffa cd y thffc giff ve sinh [ 8 ] .
Thdi gian mac benh'. Trung binh la 3,1 ± 0,6 ngay da cho thay benh dien bien nhanh va cap tinh. Ket qua ciia nghien cuXi cung tffdng tff nhff nghien cffu ciia cac tac gia trong va ngoai nffdc [ 2 ] , [ 3 ] , [ 4 ] . Trong nghien cuti thay cd tdi 34,4% benh nhan dffdc chan mudn, dieu nay cd the dan tdi benh nhan khdng dffdc theo ddi va dieu t n thich hdp. Theo WHO benh nhan HFMD can dffdc theo ddi sat va dffdc ho t r d hd hap sdm khi cd nhjp thd bat thu'dng, co giat cd keo dai, nhjp tim nhanh keo dai, tdi mau kem, do bao hoa d xy khdng d'n dinh.
Nguyen nhan gay benh: Theo cac tac gia nhffng bien chffng than kinh va suy tuan hoan hd hap cap deu do EV71 gay ra [ 3 ] , [ 4 ] , [ 7 ] . Ty le dffdng tinh vdi EV trong nghien cifu la 40,6%, trong do EV71 {+) chiem 15,6%, thap hdn so vdi nghien cffu ciia Trffdng Hdu Khanh [2] tai BV Nhi ddng 1 (trong 174 benh nhan HFMD > dp 2b EV71 ( + ) 76%) va mgt sd tac gia nffdc ngoai ( d cac benh nhan HFMD the nang EV71 dffdng tinh tff 50 - 70%) [ 3 ] , [ 4 ] . Dieu nay cd the giai thich do chiing tdi khdng xet nghiem dong thdi d nhieu loai mau benh pham ( d e h ty hau, phan, djch npi khi quan, ndt phdng). Loai benh pham chinh diing chan doan EV trong nghien cffu la djch ndi khi quan (100%), chi cd 16/32 benh n l ^ n (50%) dudC lay mau phan, khdng cd mau benh^pham tff d p i not phdng. Theo WHO vai tro ciia cac mau benh pham dung trong chan doan EV la nhff nhau,
4 . 2 . Hieu qua ciia loc mau C W H : Nghien cffu thay (bang 1) cac chi so ve nhiet do va huyet ddng (mach, huyet ap) da giam j n d t each rd ret sau loc mau 6h. Nhffng thay ddi rd ret mdt so chi sd can lam sang sau Ipc mau bao gdm: so Iffdng bach cau, bach cau trung tfnh
giam mdt each rd ret; ty le prothombin, HC03', chi sd EF cung cai thien cd y nghTa so vdi thdi diem trffdc loc mau (laang 2). Sau lpc mau da giam dffdc lieu sff dung ciia cac thudc van mach cd y nghTa so vdi thdi diem trffdc Ipc mau: (bang 3- giam lieu Dobutamin va Adrenalin tai thdi diem 24h, Nor-Adrenalin tai thdi diem 48h).
Nghien cffu cung nhan thay tai thdi diem 24h sau Ipc mau ndng dp IL-6 mau da giam cd y nghTa so vdi thdi diem trffdc loc mau (bang 4) va GA/H cd the loc dffdc mdt sd cytokine dd la: IFN-g, IL-6;
IL-6r^ IL-8, IL-12p40, TNF-r2, MCP-1 da tim thay trong djch Ipc (bang 5). Tuy nhien do sd mau dffdc djnh Iffdng cytokine con it nen chffa thay sff khac biet giffa cac thdi diem trffdc va sau loc mau, vl vay can cd nhffng nghien cffu tiep theo vdl sd Iffdng mau Idn hdn.
Goldstein nhan thay Igc mau lien tuc trong dieu trj benh nhan soc nhiem khuan, suy da tang da giiip cai thien tinh trang huyet dgng (chi sd tdng mau, chi sd t i m , the tich tdng mau), sffc can mach he thdng giam cua benh nhan mdt each cd y nghTa so vdi thdi diem trffdc Ipc mau. Sau loc mau 24h cac chi sd huyet ddng t r d ve binh thffdng. Lpc mau C W H cd the lgc du'dc TNF-o.
Giam nong do ciia IL-6 va IL-8 lien quan mat thiet vdl cai thien cac tneu chffng lam sang tai thdi diem 2h sau Ipc mau nhff: chi sd d xy, tinh trang huyet ddng, giam ap Iffc dgng mach phdi [5].
Trong nghien cffu, de dieu trj HFMD cd bien chffng suy tuan hoan va hd hap ngoai viec ap dung theo phac do chung ciia Bd Y te, nghien cffu da ffng dung ky thuat Igc mau lien tuc C W H cho nhffng benh nhan nay do dffa tren cd che ciia Igc mau lien tyc C W H cd the giiip loai bd cac cytokine (la nguyen nhan gay ra cac rdi loan nang ne trong cd che benh sinh ciia benh), giiip giff can bang djch tdt, dac biet vdi nhffng benh nhan nang ludn cd xu hffdng qua tai dich, tff dd giam ganh nang cho tim va phdi giup benh nhan phuc hdi nhanh [ 5 ] , [ 6 ] . Ket qua thay b l n h nhan sdng la 83,4% (68,8% benh nhan l<hdng di chffng, 15,6% benh nhan cd dl chffng ve than kinh) va b/ le tff vong la 15,6%. Ket qua thu dffdc ciia nghien cffu la kha tdt, bdi vi ty le tff vong ciia benh rat cao va hau het benh nhan tff vong trong vong 24h [ 4 ] , [ 8 ] . Nghien ciTu ciia Chang va cdng sff thay trong 11 benh nhan tff vong do phii phoi cap cd 9 benh nhan tff vong trong 12h vao HSCC. Nghien cffu ciia Jan SL va cgng sff ap dung ky thuat tim phoi nhan tao (ECMO) trong dieu trj 13 benh nhan suy tim phoi
Y HQC VigT NAM THANG 8 - S61/2013 cap do EV71 cho thay 11 benh nhan song trong
dd cd 1 benh nhan vdi di chirng nSng va 02 benh nhan tff vong [ 7 ] . Cho tdi nay lgc mau C W H chffa dffdc ap dung dieu trj cho benh nhan HFMD cd bien chffng n5ng, vi vay ket qua bffdc dau ciia nghien cffu la klia tdt, da giiip lam giam ty l# tff vong ciia benh, tuy nhien day mdi chl la nghien ciTii md ta vi vay can cd nhffng nghien cffu ddi chffng tiep cd gia trj hdn.
V. KET LUAN
Lgc mau lien tuc C W H cd hieu qua tdt trong dieu tri benh HFMD cd bien chffng suy tuan hoan va hd hap cap do cd kha nang giam nhiet do cd the, on djnh huyet ddng, chuyen hda, cai thien chffc nSng tim, phoi, giam lieu cac thudc van mach, giam ndng do IL-6 trong mau va giam b/
le tff vong ciia benh.
Loc mau lien tuc cd the loc dffdc mdt sd cytokine: IFN-g, IL-6; IL-6r, IL-8, IL-12p40, TNF- r2, MCP-1.
TAI LIEU T H A M K H A O
1. Bg Y te (2012) "HUdng dan chan doan, dieu tn benh tay chan mieng".
2. Tru'dng HChi Khanh, Saraswathy Sabanathai^
Tran Tan Thanh, e t al (2012), "Enterovlnjs 71- associated Hand, Foot, and Mouth Disease Southern Vietnam, 2011", Emerging Infectious Diseases • www.cdc.gov/eid • Vol. 18, No. 12, pp.
2002 - 2005
3. Chang LY, Lin TY, Hsu KH, et al (1999), "Cllnicsl features and risk factors of pulmonary edema after enterovlrus-71-related hand, foot, and mouBi disease", Lancet 354, pp. 1682-1686.
4. Fu YC, Chi CS, Jan SL et al, 2003, "Pulmonaiy edfflna of enterovirus 71 encephalomyelitis is assodated witti lef venbicular failure: implkations ix p-eabnent". Pediatric Pulmonology 35, pp.263 -26a 5. Goldstein SL, Somers MJG, Baum MA et al
(2005), "Pediatric patients with multi-organ dysfunction syndrome receiving continues renal replacement therapy". Kidney Intemational, 67, pp.653 - 658.
6. Heering P, Morgera S, Schmitz FJ et al (1997]
"Cytokine removal and cardiovascub hemodynamics in septic pabents with continuou venovenous hemofilfratjon". Intensive Care Med 23 (3), pp. 288 - 296.
/ . Jan SL, Lin SJ, Fu YC et al (2010)
"Extracoporeal life support for treatment of chidrei with enterovirus 71 infection-relatH cardiopulmonary failure: Intensive Care med, 31 (3), pp. 520 - 527.
THUC TRANG TUAN THU DIEU TRj CUA BENH NHAN DIEU TRf METHADONE TAI c a s a lEU TRj METHADONE QUAN LE CHAN. HAI PHONG
Pham Van Han', Nguyen Thi Tham', Nguyen Thu Phirong
T O M T A TMuc tieu: (1) Dac diem dich te hpc ciia benh nhan tai cO sd dieu trj Methadone quan Le Chan, Hai Phong; (2) Mo ta mot so yeu td lien quan den tinh trang tuan thii dieu tri Methadone. Phu'dng phap:
Nghien cirU cat ngang mo ta, toan bp 394 benh nhan dieu tri tren 12 thang tff 2009-2011 tai cd sd dieu tn Methadone quan Le Chan du'dc Iffa chpn. Phong van benh nhan, thu thap thdng tin tff ho sd benh an va hd sd tu' van. Phan tich sd lieu tren phan mem SPSS, openepi 3.2.1 so sanh ty le bd tn giffa cac nhdm dift tren thuat toan khi-binh phu'dng.ket qua: Nghien cffu 394 benh nhan dieu tn Methadone tai quan Le Chan Hai phong cho thay chii yeu la nam gidi (97,7%), 6 dp tudi tff 30-50 tudi (89%), sdng doc than (49,5%), cd gia dinh (31,2%) va cd trinh dp vSn hda la tdt nghiep trung hoc cd sd (50%). Ty le bd dieu tri >5 ngay Ii4n
bep cua benh nhan la 22,1%. Benh nhan nhiem HW cd nguy cd bd tri cao hdn 1,71 IBn so vdi benh nhat khdng nhiem vdi p< 0,05. Benh nhan cd y dinh vi hanh vi tff sat va du'dc tu" van dieu trj < 10 lan d nguy co bd trj cao hpn 10,93 lan va 10,34 lan so vol benh nhan khdng cd hanh vi nay vdi p<0,001. Khong cd su khic biet va lien quan cd y nghTa thong ke giijs bi tn vdi yeu to gia dinh cd ngu'di nghien ma tuy, tat dung phu (tao bdn, ra md hdi). Ket luan: Benti nhan dieu tfl tai CO sd Methadone chu yeu la nam gl*
(97,7%), d dp tudi tff 30-50 tudi (89%), sdng doc »iar (49,5%) va cd trinh do van hda la tdt nghiep bung hffl Cd sd (50%). Ty le bd tn ciia benh nhan la 22,1%
Tru&ng Dai hgc YHai Phong
Trung tam phong chong HIV/AIDS Hai Phong Phan bi0n khoa hpc: PG5.TS Nguyen VSn Hung 42
