Y HQC VI$T NAM THAHG 4 - SO 1/2014 V. K ^ LUAN
Nhffng khd khan trong mo khi ean thiep phau thuat khoi dj dang dpng tinh mach nao vd la kich th\idc khoi Idn, vj t r i khoi d viing chffe n3ng va d sau, phii nao trong mo, chay mau trong mo va khd xae dinh ddng mach nuoi.
T A I L | | U T H A M KHAO
1, FerroJM (2006), "Update on intracerebral haemorrhage", J.Neurol, 253:985-999.
Fleetwood.IG, Steinberg.GK (2002),
"Arteriovenous malformations", 77?e Lancet, 359:
863-873.
Le Hong Nhan (2010) "Ket qua dieu trj ngoai khoa dl dang dong tinh mach nao" Y hoc thdc hanh, 733+734, 240-246.
Moussa.R, Harb.A, Menassa.L et al (2006),
"Hematoma intracerebral spontane du sujet jeune, Etiologies et rapports avec I'hypertension arterielle", Neurochirurgie, 52, 105-109.
Spetzler RF, Martin NA (1986) "A proposed grading system for arteriovenous malformations", J.Neurosurg, 65, 476-483.
XAC DINH HINH A N H VI KHUAN TRONG SOC NHIEM KHUAN TRE EM TAI BENH VIEN NHI TRUNG U-aNG
Tran Minh Oien*
T6MTAT
Myc tiSu: X^c djnh hinh anh vi khuan d benh nhi soc nhiem l^uSn. 061 tu'dng v i phifdng phdp:
Nghlfin ciiU mo tei tien culj 102 b-u'dng hpp benh nhi sSc nhiSm khu^n tai-Benh vien Nhi Trung u'dng, thdi gian 3 nSm 2006-2008, ti§u chuein chan doan soc nhlfim khuSn theo Hoi nghi quoc te thong nhat cac van rf§ nhlSm khuan nhi khoa 2002 (IPSCC 2002), xac dinh hinh Anh vi khuin qua cay mau tru'de diing khang sinh v i cSy c k chat d|ch, djnh danh vi khuan va lam khang sinh det. Kfft q u i : Ty 1^ cay m^u dUPng tinh la 14,7%, cSy miu du'dng tinh khong lien quan den ket qua dieu tri (s6ng/chet). Trong so 58 diung vi khuan phan lap dui^c tff meiu v i cac chat dich, ty le nhiem vi khuan Gr (+) l i 38%, Gr (-) l i 59%, cd 2 tofdng hpp nhiem nSm Candida Albicans. Hinh inh vi khuan gSp nhieu nhSl l i Klebsiella pneumonia, 22,4%, sau do la Tu cau ving 17,2%, tiep theo lan li/pt True khuan mu xanh, Ph€ d u , E.C0II, H.influenza... (12,1%, 10,3%, 8,6%, 6,8%...). Khing sinh do cd bieu hien tinh tr^ng khang khing sinh ciia cic vi khuan Gr am, d^c biet cac cephalosporin the h? 3, tu cau cdn nhay cam vdi hau hit cic khing sinh. K a luan: Tv- I? cay m i u duong itinh thSp 6 tr6 s6c nhiem kliuan (14,7%), vi khui'n Gr i m gip 59%, Gr duttng g i p 38%. Khang khang sinh . nhiSu vdl cic vi khuSn Gr am.
TW kMa: Soc nhiem khuan tre em, vi khuan,
! khing khing skih
, * S ^ tK^ Ntv Tmng uang
Phin bl$n khoa hga PGS.TS Kim Thj Khinh Dung
SUIVIMARY
BACTERIAL I D E N T I F I C A T I O N I N SEPTIC SHOCK CHILDREN Objectives: To define the kinds of bacteria in pediatric septic shock patients. Subjects and methods; a prospective descriptive study of 102 cases suffered from septic shock at the National Hospital of Pediatrics, dunng 3 years from 2006 to 2008, diagnostic critena for septic shock as the international pediatric sepsis consensus conference 2002 (IPSCC 2002), identified the bactena by blood culture before using antibiotics and culture body fluids, bactenal identification and do the antibiogram.
Results: The rate of positive blood cultures was 14.7%, a positive blood culture is not related to outcome (survival/non-survivor). Of the 58 stains of bactena isolated from blood and body fluids, rate of Gr (+) IS 38%, Gr (-) IS 59%, with 2 cases of Candida albicans infection. Image bacterias were: Klebsiella pneumoniae (22.4 % ) , and others prospectively are (17.2 %) of S. aureus, Pneumococcus, E.coli, H.influenza are 12,1%, 10.3% , 8.6% , 6.8%. On the antibiogram result, the Gr negative bactena are resistant to nearly all of antibiotics, especially, the third - generation cephalosponns, S. aureus are sensitive to almost antibiotics. Conclusions: The rate of positive blood cultures in children with sepdc shock is 14,7%, Gr negative bacteria have 59%, and 38% of Gr positive. The Gr negative bactena are nearly resistant to all of antibiotics.
Keywords: Pediatric septic shock, bacteria, antibiotic resistance.
8 ^
Y HOC VIET NAM THANG 4 - SO 1/2014
I. M a DAU
Sdc nhiem khuan la tinh trang suy tijan hoan cap gay giam tPdi mau cac tang, thuc day phan ffng viem he thong va rdi loan chuyen hoa keo dal, du'a den tinh trang suy da tang_va tff vong [3].
Ty le tff vong cua soc nhiem khuan (SNK) va nhiem khuan nang (NKN) va sdc nhiem khuan cdn cao, nam trong nhdm nguyen nhan tff vong hang dau d cac nu'dc dang phat trien va la nhom benh ngay eang tang d cac nu'dc phat trien [4].
Xac djnh can nguyen nhiem khuan la can thiet de dieu tri khang sinh kjp thdi. Hau het cae vi khuan (VK) deu cd the gay ra nhiem khuan mau, song nhiem khuan mau thi khdng nhat thiet tien trien thanh SNK. Cay mau dffdng tinh chi khoang 30-50% d benh nhan NKN. Vi khuan gram am (VK Gr am) la nguyen nhan chinh eua NKN, tuy nhien gan day qua cac nghien cffu quan sat va bang ehffng VK eho thay vi khuan gram du'dng (VK Gr du'dng) chiem ty le cao hdn [4].
Chung tdi thffc hien nghien effu nay nham muc t\eu: "Xac dinh hinh anh vi khuan dbenh nhi sdc nhiem khuan tai Benh vien hihi Trung u'dng".
W. eOl TU'qrNG VA PHU'aNG PHAP Ooi tu'dng nghien effu gom 102 benh nhan ed tuoi tff 1 ihang den 15 tuoi nhap khoa Hdi sffc cap cffu, Benh vien Nhi Trung ffdng vdi chan
doan soc nhiem khuan, thdi gian tff O1/O1/200S den 31/12/2007.
Tieu chuan chan doan soc nhiem khuan theo Hpi nghi quoc te thong nhat ve nhiem khuan nam 2002 (IPSCC-2002): benh nhan cd bieu hien suy tuan hoan + tinh trang nhiem khuan [6].
Loai trff: Benh nhan tuo'i sd sinh; Soc tim;
Sdc giam khoi lu'dng tuan hoan; Sdc phan ve.
Benh nhan du'de eay mau ngay khi vao vien tru'de sff dung khang sinh, cac chat djch cd the (djch nao tuy, mang bung, mang phoi, djeh noi khi quan) dffde thu thap trong qua trinh dieu tri.
Cay mau va cac chat dich theo quy trinh tai khoa Vi sinh, Benh vien Nhi Trung ffdng. Khang sinh do dffpc lam khi xac dinh dffdc chung vi khuan, danh gia mffe dp nhay cam/khang khang sinh theo quy trinh.
Nghien effu md ta, tien cffu.
Nhap va phan ttch so lieu theo phan mem SPSS 13.0
III. KETQUA
Nghien cffu xac djnh dffdc 102 benh nhi dii tieu chuan nghien cffu. Tre trai mac SNK nhieu hdn tre gai (59,8% so vdi 40,2%). Nhdm trediHii 12 thang tud'i ehiem ty le 65,7%.
Ket qua dieu tri ed 34,3% benh nhan song, 65,7% benh nhan tff vong, trong so tff vong c6 40,3% la tff vong tru'de 24 gid.
Bang 1: Ket qua cay mau va cac dich tim vi kiiuan Cay mau (+):
Cay dich noi l<hi quan (+):
Dich khac (+):
VKGr{+) VK Gr (•)
Nam Candida Abicans
Tru'de 48 gid n (%) 15 14 (52)
16 22 21 1
Sau 48 gict n ( % ) 0 13 (48)
0 0 13
1
Cliung n (°/o) 15(14,7)
27 (100) 16 (15,7) 22 {38,0) 34 (59,0)
2 {3,0) . Fihan xet: Cay mau dffdng tinh gap 15 trffdng hdp, ehiem 14,7%, trong vdng 48 gid nhap vien. Cac VK Gr (+) ehiem 38% deu eay trong vdng 48 gid nhap vien.
Bang 2: Hinh thai vi khuan Vi )(huan:
Klebsiella pneumonia:
Tu cau vang;
Tru'c khuan mu xanh:
Phe cau;
E.coli;
H. influenza;
Acinetobacter;
TrUdc 48 gid, n 9 10
3 6 4 4 0
Sau 48 gid, n 5 0 4 0 1 0 3
Cliung, 58 (100°/D)
14 (24,1)
10(17,2)
7 (12,1)
6(10,3)
5 (8,6)
4 (6,8)
3(5,2)
Y HOC VIET NAM THANG 4 - SO 1/2014
Candida albicans: 1 1 1 1 1 2 (3,5) Lien cau nhom A;
Enterovirus;
2 2 Khac; 1 2
0 \ 2 (3,5) 0 1 2 (3,5) 0 1 3 (5,2) Nh$n xet:l6r\q sd chung vi khuan gay benh la 58. Xae dinh vi khuan tru'de 48 gid thu'dng gap nhat la tucau vang{10 tru'dng hPp), Klebsiella pneumonia (9), phecau{6), H. tnfluenza{A), E.coli{A), lien cau nhom A (2). Cac vi khuan nhan dinh sau 48 gid vao vien ia: trdc khuan mu xanh (4 tru'dng hpp), Klebsiella pneumonia {'\), Acinetobacter {3), nam Candida abbicans{\).
Bang 3: Ket qua nhay cam khang sinh Khang sinh
Cephalotin;
Cefuroxim:
Cefotaxim:
Imipenem;
Ciprofloxaxin;
Amikacin;
Tazocin;
Vancomycin;
Cloxaxilin:
K.pneumonia (n=14)
1 2 5 11 10 5 7
TKMX (n=7) 2 2 3 4 5 2 5
Tu cau vang (n=10)
10 10 10 10 10 10 10 10 9
Phecau (n=6)
2 2 4 6 6 5 6
^ 1
5 i
Nh$nx4t:Klebsiella pneumonia va tr&c khuan mu xanh (TKt^X) khang khang smh nhieu, dac biet la cac cephalosporin. Cac khang sinh imipenem va ciprofloxaxin eung bi khang, imipenem ehi edn nhay cam 11/14 doi vdi K.pneumonia va 4/7 ddi vdi tr&c khuan mu xanh.
Td cau vang nhay cam hau het cae khang sinh, tinh trang khang cloxacixilm chi cd 1/10 chung vi khuan.
Phi cau nhay cam it vdl khang sinh cephalosponn the he 1,2, edn nhay cam 6/6 vdi cac khang sinh Imipenem, ciprofloxaxin, tazocin.
Bang 4: Uen quan giCa cay mau am Cay may
Am tinh;
Du'dng tinh;
Song 29 (82,9) 6 (17,1)
tinh va ket qua dieu tn.
Tiir vong 58 (86,6) 9 (13,4)
P 0,616 1
OR ( 9 5 % CI)
1,0 , 0,75 (0,24-2,31) ! ' M^nx4t:Cay mau du'dng tfnh khong anh hudng tdi ket qua dieu tn.
IV. BAN LUAN
Cay mau du'dng tinh chiem ty le 14,7%, dich n?l khi quan co 4 8 % (13/27 tru'dng hdp) du'dng tinh sau 48 gid lien quan den nhiem khuan benh ,vl?n. Ty le nhiem VK Gr ( + ) la 3 8 % , Gr j;-) la 159%, CO 3% nhiem nam. So lieu dich te hoc nhiem khuan d ngu'di Idn ciJa My giai doan 1979 '-2004 cho biet; tir nSm 1979 den n5m 1987 vi 'khuan Gram am chiem ty le chinh trong NKN, 'nhuTig glal doan sau dd den nSm 2003 thi ty le vi -khuSn Gram difdng cao hdn, tSng 26,3% hang -nSm. Qua cac vl khuan tim thay nSrii 2000 d ,b?nli nhin nhiem khuan n i n g thi vi khuan Gram
du'dng chiem 5 2 , 1 % , vi khuan Gram am la 37,6%, da vi khuan 4,7%, ki khi 1 % , nhiem nam 4,6%. Nhiem nam xu hirdng tang manh theo thdi gian, tang 207% tif nam 1979 so vdi nam 2000, cd tdi 16042 tru'dng hdp nhiem nam nang nam 2000 [7].
Trong nghien cdu nay chung toi danh gia lien quan giu'a cay mau du'dng tinh va ket qua dieu tri (song/chet) thay khong co lien quan. Nghien cdu cua Ayt Goh va cong sir trong nhdm tre em suy da tang co tinh trang nhiem khuan co ty ie cay mau du'dng tinh la 30%, benh nhan nhiem VK Gr
Y HOC VIET NAM THANG 4 - SO 1/2014 (-) trong mau hau het deu tff vong, chu yeu d
nhdm tre giam bach cau hat [ 5 ] .
Chung tdi xac dmh 6Mc 58 chung vi khuan.
Hinh thai vi khuan gap nhieu nhat la Klebsiella pneumonia, 22,4%, sau dd la Tu cau vang 17,2%, tiep theo lan lu'dt Tr&c khuan mu xanh, Phe cau, Ecoli, H.influenza ...(12,1%, 10,3%, 8,6%, 6,8%...). Cae vl khuan dffdc xac djnh tru'de 48 gid nhap vien nhieu nhat la Tu cau vang (10 trudng hdp), Klebsiella pneumonia (9), phi cau (6), H.influenza (4),..Vi khuan xae djnh sau 48 gid nhap vien la Tr&c khuan mu xanh (4), Klebsiella pneumonia (4), Aci'netobacter-{3), nam Candida abbicans (1).
Tren quan the tre em trong nghien effff d 7 bang cua My, hinh anh vi khuan hpe eua nhiem khuan nang va sdc nhiem khuan hau het la ty eau (17,5%), dac biet d nhdm tre dffdi 1 tuoi chiem 22,7%. Nhiem nao md eau it gap (1,2%) ehu yeu d nhdm tre khoe (2,2%) ft gap d nhdm tre cd benh phdi hdp (0,2%), sff khac biet nay cd y nghia thdng ke vdi p < 0,001. Ngffdc lai, nhiem nam lai hay gap d nhdm tre ed benh phoi hdp 14,9% so vdi tre khde 7,4% (p < 0,001), dae biet nhiem nam d tre cd HIV (47,4%). Ty le tff vong do nhiem khuan nang lien quan den vi khuan cao nhat d nhdm tre nhiem phe eau (14,5%) sau dd la nhiem nam (13%).
Tai Viet nam, trong nghien cffu theo ddi sff de khang khang sinh cua vi khuan hpc thu'dng gSp trong 6 thang dau nam 2006 tai 10 benh vien eua 3 mien Bae - Trung - Nam, td'ng so cd 12949 chiing vl khuan phan lap dffdc thi 5 vi khuan thu'dng gap nhat la : Klebsiella spp.
(17,8%), E.Coli (16,0%), Acinetobacter spp (12,2%), P.aeruglnosa (11,5%), Tu cau vang (9,8%). Cung trong nghien cffu nay, tai Benh vien Nhi Trung u'dng tren quan the tre em thi ty le phan bo vi khuan thu'dng gap nhat la : Klebsiella spp.{28,7%), E.Coli (12,5%), P.aeruglnosa (10,8%), S.viridan (9,6%), Enterococcus (5,6%). Cay mau dffdng tinh tai Benh vien Nhi Trung ffdng chiem ty le la 24,5%
[2]. T.M. Dien va cpng sff [1] trong nghien cffu ve nhiem khuan mau tre em 2 nam 1998-1999, tieu chuan chpn benh nhan la eay mau dffdng tinh tai khoa Hoi sffe cap cffu, Benh vien Nhi Trung u'dng thi hinh anh thffdng thu'dng gSp nhat la : Klebsiella spp (37,9%), P.aeruglnosa (20,7%), S. aureus{11,2%), £ a 7 / / ( 1 0 , 3 % ) .
V. KET LUAN
Nghien cffu 102 benh nhan SNK tai Benh vier Nhi Trung u'dng, chung toi thay t y le cay mau du'dng ti'nh la 14,7%. Trong so 58 chting vi khuan phan lap du'de, ty le nhiemx VK Gr (+) la 38%, Gr (-) la 5 9 % , cd 2 trffdng hdp nhi»n nam Candida Albicans. Hinh anh vi khuan gap nhiieu nhat la Klebsiella pneumonia, 22,4%, sau do la Tu cau vang 17,2%, tiep theo lan lu'dt T/i/t khuan mu xanh, Phe cSu, E.coli, H.in^uem . . . ( 1 2 , 1 % , 10,3%, 8,6%, 6,8%...).
TAI UEU T H A M KHAO
1. Tran Minh Dien, Lu'dng Thj SarV Ngd Th! Thi (2003), "Nhan xet tinh hinh nhiem khuSn huyftd tre em trong 2 nam 1997 - 1998 tgi khoa Hoi sut cap cffu, Benh vien Nhi Trung u'dng", Yhgcttwt hanh;'\e2:'ne • 119
2. Nguyen Thi Vinh, Nguyin Ode HiSn, Doan Mai Phu'dng vi cpng si^ (2006), "Bao cao ho^
dong theo doi sif de khang khang sinh oia vi khuan gay benh thu'dng g3p d Viet nam 6 thang dau nam 2006" Trk:h til http://www.moh.gov. vn/VNTD/ f^odtxis /Nghiencuu baocao /tabid/17 Z/pmType/ddii ProducdD/258/Default. Aspx
3. Carcillo J.A., Fields A.Z., American Collegfl o(
Critical Care Medecine Task Force Committee Members (2002), "Qinlcal pradice parameters for hemodynamic support of pediatric and neonatal patient in septic shock", Oit Care Med, 33: 855-859.
4. Deliinger R.P., Levy M.M., Carlet 3.M., etal for the International Surviving Sepsis Campaign Guidelines Committee (2008): "Surviving Sepsis Campaign: International guidelines for management of severe sepsis and septic shod:
2008", Crit care Med, 36: 296-327.
5. Goh-A.Y.T., Chan p. Lum L.C.5. (1999),
"Sepsis, severe sepsis, septic shock in pediatric multiple organ dysfunction", J. pediatr eft*
health; 35: 488 -492.
6. Goldstein B., Giroir B., Raldolph A., and member of the international consensu conference panel (2005), "International Pediatric sepsis consensus conference: Oeflnitiw for sepsis and organ dysfuncbon in pediatries', Pedlad Cnt Care Med, 6: 2-8.
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