Y HQC VlgT NAM THANG S - SO 2g014 Sandahl TD, Jepsen P, Ott P, Vilstnip H
(2011): "Validation of prognostic scores for clinical use in patients with alcoholic hepatitis". Scand J Gasbventen^i, 49(9): 1127-32.
Altamirano, et al (2012): "Acute Kidney Injury Is an Early Predictor of Mortality for Patients With
Alcoholic Hepatits". Qin Gastroen^vl H&iatof.
10(1): 65-67.
Pafaniyappan, et al (2012): "The Utility of Scoring Systems in Predicting Eariy and Late Mortality in Alcoholic Hepatitis:Whose Srare Is It Anyway?". IntJHepatd; 2012: 624-675.
m m MAU NAO CHON LOC TRONG
PHAU THUAT QUAI DONG MACH CHO
T6MTAT
Tiy thdng 01 nam 2012 den thang 01 n3m 2014, CO 35 tru'dng hdp benh t^ d^ng mach chu ngu'c duWc phau thuSt tai ddn \4 phlu thu$t tim mach vi?n Tim m^ch qu5c gia trong dd cd 28 trudng hdp co lien quan tdl phSn quai dpng mach chD.Oiung toi sii dung ky thuSt tuSn hoin ngodi cd the (TKNCT): DSng nhiet vdi, h9 t i i ^ nhl|t 28 dd C, tdi mdu nao xudi dong chon iQcBdo v$ cd tim bdng mdu dSng nhiet trpn dung djch ldm 11^ tim (Cardioplegia). Ket qud biTdc dSu cho th3[y:
khdng c6 bien chirng lien quan d§n hoa loSng mdu, t- u'di mdu n3o xudi ddng r?t thudn ldi cho qud trinh phSu thu$t, bien chiihg va tH vong lien quan tdi tuan hodn ngodi cd the khi dp dung phu'dng phdp nay tu'dng duWng vdi cdc thdng k l khac tren the gidi.Tu"
ket qud thu du^c, chung tdi cho rdng tuan hodn ngoai cd the vdl k? thuat tdi mdu nao xudi ddng Id phu'dng phdp n§n du'dc lu^ chpn trong dieu ti*! b$nh ly dpng m^di chii ngi/c co ton thuWng lien quan tdl quai ddng mach chu
W khoi: Tuan hodn ngodi cd the, quai dpng m^ch chl}, tu'dt mdu nao.
SUMMARY
SELECTIVE ARTERIAL CEREBRAL PERFUSION I N A O R T I C ARCH SURGICAL
Cardiopulmonary bypass (GBP) in the surgical treatment for thoracic aortic disease From January 2012 to January 2014, 35 consecutive cases of thoracic aortic diseases were ( g r a t e d under cardiopulmonary bypass in the Cardiovascular Department of National Instltut of Heart and Vascular.
The method of CSP included: Selective arterial cerebral perfusion (SACP).28''C hypothennia. Nonnothermic and warm blood candloplegia. The first results showed;
no complication related to heamoddution. Technique
Dinmg Dire Hiing* va cs
of SACP brought good results; the operations were conducted eaaly, the operative complication and mortality were equal with other statistics. We thinh that thiu method of CPB should be use am a method of choice in surgical treatments for thoracic aorOc~arch
* l^<?/7 77/77 m?cA QUOC gia - B$nh vl0n Bach Mai Phin bl$n khoa hpa P6S.T5 TnitAig Thanh HiAAig
Keyword: Cardiopulmonary bypass, aortic~arch, arterial cerebral perfusion
L € ) i ( ^ T V A N D l
Oieu trj phau thuat benh ly dpng mach chii ngyc (Phong, Loc) vdi ton thdng quai dpng mach chil kem theo la mpt thach thii'c ldn dol vdi piiau thuat tim mach.Oay la mot phau thuat phu'c tap doi hoi nhom phau thu$t phai co trinh dp va kinh nghiem. Oe tranh cac tai bien dac biet la tai bien vS th3n kinh trung u'dng cd y nghia rat quan trpng vdi thanh cdng cua cuoc mo. Oa cd nhleu ky thuat trong tuan hoan ngoai cd the dUdc ap dung lam giam toi da cac bien chu'ng than kinh trung uWng nhu* ha than nhiet (Hypothermie), ha nhiet dp sau-ngiitig tuan hoan (Hypothermic profound and circulatory arrest); tdi mdu nao chpn Ipc xuoi ddng (Selective arterial cerebral perfusion), tdi mau nao ngu'dc dong (Retrograd Cerebral Peri'uslon). Muc dich ciia d ^ tai nay nham rut ra chien Iu'dc bao ve nao trong dieu tri phau thuatdpng mach chii ngi/c du'di tuan hoan ngoai cd the mot each thfch hdp nhat.
IL D d i l l / Q N G VA PHUONG PHAP N G H I I N C O U 2 . 1 . Ooi tu'dng nghiSn cuTu
Tat ca cac b^nh nhan du'dc phau thu$t dpng m?ch chil ngyc cd sir dung may tuan hodn ngoai cd the tai ddn vj phau thuat Tlm m^ch vl$n tlm mach quoc gia tir thang 01 nSm 2012 den thang 01 nam 2014. Chi djnh cho cac tru'dng hdP ton
Y HOC VlgT NAM THAHB 5 - SO M O M
thu'cfng dpng mach chu ngu'c a5 ton thu'dng den
qual dgng mach chu bao gom; Hpi chutig Marfan, Phong dpng mach chu ngu'c, Loc tach dong mach chu ngiTc typ A (Stanford). SCr dung may THNCT Sam System One (5 dau bdm), phoi nhan tao Capiox SX 18 CTerumo Japan), may trao doi nhiet Monitoring theo doi ap iu'c dpng mach, Hnh mach trung UOng, nhiet dp thirc quan & b-Uc trang, ECG.
2.2, Phu'dng phap nghien cihi Nghien cu'u siy dung thiet ke cat ngang mo ta vdi quy trinh nghien cull nhu sau
Dich mdi (Priming): Sit dung Ringer lactate (lOOOmI), Manltpl 20% (0,4 g/kg) va Heparin 40 mg
lap aSt h$ thdkg THNCT: DP thu'dng tpn CP lien quan tdl qual dpng mach chudu'dng ve cua tinh mach du'dc dam bap bdi canule2 tang d$t vap nhi phai. lu'di mau dUdc thUc hISn bdi canule dpng mach nach phai va i canule cd bdng d$t vap dpng mach canh gpc trai sau khi da md dpng mach chu
+ Chp cac thuoc gay me, chpng phu ne nap.
(Thippental)
+ Ch^ may ttian hoan ngoai cd theha nhiet dp
III.KitQUA
TCr thang 1/2012 den 1/2014, 28 b?nh nhan da dudc mp. Trpng sp nay, nam 15, nif 13, t trung binh 42,5 (cap nhat 73, thap nhat 35). Cac tpn thUdhg chu yeu bap gom (bang 1)
Bing l! Dgc diem ton thu'dnq
tdi 28°C va khi lam am lai benh nhan, chenh lech giiia nhiet dp mau cua benh nhSn va nudc aJa may trao doi nhia khong dutfc vu'dt qua 10°C.
- t d l mau nao xuoi dpng chpn Ipc (SACP):
(1) [Aau da dUdc tnao doi oxy du'dc tach ra tCr dudng dpng mach noi qua 1 bdm dpc lap va bdm len tdi mau nao. LUu y khi dat canule va c^p dpng mach chu cd the gay tai bien than kinh dp huyS ktioi va cac mang xd vOa; (2) Lull lu'dng tSi nao duy tri tir 10-15 ml/kg/phut, ap li/c duy bi khoang 60-80 mmhg; (3) DKU chinh kh! mau theo pH.
Bao ve cd tim: Chung tpi sii dung Net cO am (Caidipplegia) bang mau de tranh cac bien chung dp hda loang mau va bap ve cd tim duljc tPt hdn trpng mp. Khpang each glQS hai lan bao ve cd tim khpang IS phut/1 lan. Dat toe d6 triiyen cua cardipplegia la 200ml/m^ da cd the.
Lieu dau tien bang 200ml/mV da cd the, bdm trong 2 phut. Lieu sau bang 2/3 lieu dSu, bdm trpng 1 phut.
Menatocrit Duy bi Het trong c t i ^ may tCr 28%- 32% vdi dang nhiet 20%-24% vdi ha than nhiet
Ldu Iddng: Lull lu'dng duy tri 220^
2400ml/mVphCit.
HC Matfan
Bgnh IV
Plipn^ OMC len + (jual BMC
So lu'dng
I Lde tach DMC ngUc typ A (Stanfprd) _ I 1 7 '
Thddng ton chu yeu la loc tach dpng mach chu type A day ia thddng ton nang thddng b'en hanh ph&i thuat trong dieu kien cap cuti
Bang 2:1^11 gian phau thuat
Thdi gian I Thdi gian cSp THNCT (phiit) OMC
Quy trinh PT Thdi gian tita
mAu nao
OMC len + Quai
87(52-110)
63,5 (42-88)
72,3 (48-103)
PT Bental + Quai DMC
117(84-152)
96 (71-102)
112 (74-162)
Bing 2 the hien cac chi so liin quan den tuan hoan ngoai cd the sd dung dong nghien cud
Bang 3, Ket qua phau thuat Quy trinh phSu thu$t
DMC len + Quai DMC PT Bental + Oual DMC
Tpnqsp
S6f lu'dng
4 24 28
Tu* vong benh vi^n
0 2 2
Bien chQ'ng Than kinh
1 0 1
Chay mau (mo Ial)
0 0 0
Suy thSn
1
1
2
Y HOC VIET NAM T H A N G 5 - SO 2/2014
Bang 3 trinh bay bien chting vatyietu' vong Irong nghien cuU2 trUdng hdp td" vong 1 do suy than, 1 do viem phoi benh vien Bien diuhg than kinh chi gap & 1 benh nhan (benh nhan nam 69 tuoi mo cap ctiu tdc tich ddng mach chu Hit V2 ngu'di sau md)
Bang 4: Ket qua chunq Thdt gian thd may
(gid) 38 (6-187)
Lu'dng mau truyen Trung binh (ddn vi)
4,26 (2-8)
Thdi gian nam vien trung binh
12 (10-18)
iv. BAN LUAN
Qua 28 tru'dnq^ hdp thUdng ton dpng maeh ehCi ngut du'dc phau thuat chung tdi nhan thay;
Khpng ed sg' khac biet giiici ty le nam va nu\ Tudt cap nhat la 73 tupi va thap nhat la 36 tupi^ Hpi ehulig Marfan thu'dng g3p d nhom tre tuoi va trung niSn. Cae ton thu'dng dpng mach chu nguc d binh nhan Idn tupl da phan cd ting huyet ip kem thep
Tat ca cac benh nhan deu du'dc bao ve cd tim bang mau de tranh cac bien chulig do hoa ioSng mau gay nen va cd tlm dUde bao ve tot hdn.Tlidl gian tu3n ho4n ngoai ed thS va kep dong maeh chu d nhdm benh ly tpn thUdng can plial lam phau thuat Bental (Marfan, Ldc tach type A cd hd van dpng mach chu) dai hdn so vdi nhulig b?nh ly ton thUdng dong mach chu len va qual ddn thuSn.Thdi gian tdi mau nap trung binh khpang 72,3 phCit Tat ca cac truidng hdp deu sCr dung phulJng phap ha nhiet dp yiia 28*>C nhiet dp nay cho phep bap ve eae tang va dae biet chp nap vji eiing it gSy ra nhiilig bien toan ve sinh ly nhat la roi lean ddng mau sau mp. Tuan hoan ngpal ed the difde thiet lap mpt each thdng thudng giiia ddng mach naeh-nhl phai. Trpng 28 b'udng hdp diidc phau thuat cdl trudng hd^ tCr vong (3,3%) db bien ehiing suy than sau mp, 1 trUdng hpp dp viem phSl hau qui cua viee phai thd may kep dai. Ha nhiet dp 28°C na); lam giam tpl da cac bien chiihg dp ha than nhiet gay nen nhu' suy than, rei Ipan dong mau. Trong nghien cCili IuHng mau truyen trung binh__4,26 ddn vi khdng cd b?nh nhan nap phai mp Ial do ehay m4u. Oac bien chiing than kinh thu'dng do mang xd vOa cua thinh dong mach ehu khi kep ddng m?ch chu gSy nin. Ap lire hen duy tri d mCre 70- SOmmhg vlb^nh nhan thu'dng ed eaohuyet ap tr- uidc dddi dim bap tudi miu nap tdt trong mo.
H? nhift dd sau-ngCmg tuan hpin Prafpund Hypothemiic aiid circulatory arest(HCA) va tudi mau nio chpn Ipc xudi ddng Selective arterial cerebral perfusion (SACP). HCA la ky thuat dau tISn dupc i p dung trpng phau thuat c^uai dpng m?ch chu nggt,' day l i ky thuat ddn gian, de ap dgng, nd chp phep d i t canule de ding, tap
trudng mp thuan ldi chp phiu thuat vien, giam nguy ed chan thudng mach mau v i huyet khdi de ming xd vu^ gay ra dp cap dpng mach. Tuy nhien HCA co nhieu mat han che;(l) HCA khdng the bio ve nao mpt each hpin hao trong suat qua trinh phau thuat dp bj gidi han ve mat thdi gian (<40 phut), thee Svensen, d nhiet dp ed the tir 16°C den 18°C neu ngCmg tuan hpin ddi 40 phut thi ti le tu' vpng khpang 1 2% nhung neu
>40 phut thi b' le tu'vpng tang len 16%, cpn >60 phut thi ti le bJ vpng va tai bien than kinh la 100%. Mdt nghien cull khac cua Griepp chp thiy ti le tu' vdng khpang 15% v i tai bien than kinh la 19% [I I]; (2) Cic van de ve roi loan ddng miu do ha nhiet dd sau gay nen. Cac tai bien thudng ^xay ra khi bat dau tang nhiet dp trd lai v i ed till dejai di chCrng kep dai che benh nhan it nhat la 6 tuan sau mp dac biet l i d ngu'di gia nhu liet, ndi ngpng, roi Ipan tam than, tham chi l i tCr vong.
Iiidt phUdng phap khac ket hdp kl thuat HCA vdi tdi mau nap ngUdc ddng (RCP) dUdc mdt sS trung tam ap dung vdi mue dich han che thdi gian thieu mau nao do ngirng tu3n hjian. Miu du'dc bdm ngUdc vip TM chu tren de tdl mau nap, tuy nhien hd khdng the du luu lUdng de tdl mau nao, khdng sinh ly va khdng khie phuc d- Ude cac bien chu'ng do ha than nhiet gay nen, ky thuat thuc hien phiTc tap. RCP chi cd tie dgng tranh tac mach miu nap hdn la nudi dudng nap.
Thep nghien ciin cua Ueda ti le tCr vpng khpang 15% va tai bien tiian kinh l i 9% [14]. Okita va cdng su so sanh ti le tCT vong glD'a 2 phUdng phip RCP & SACP l i nhu nhau nhUng ti le tai bien than kinh d nhdm sd dung kl thuat RCP thi cao hdn han so vdi ki thuat SACP [9].
PhUdng phap SACP dudc chung tei ap dung ehp tat c i eac benh nhan. Trpng nhdm nay ed 2 benh nhan tCr vpng chiem ti le 6,5% trpng dp 1 dp suy Hian sau mp, 1 benh nhan ed tai bien ll?t 1/2 ngUdI sau me. v i Ibenh nhin bi bien chung viem phpi nhiem triing benh vien dp thd may kep dii.Theo Ueda thi ti le tii vong khoing 10%
Kazui cung cho ket qui td vpng l i 10% nhUng tai bien than kinh rat thap chi khping 3%. [2,7]. Ki Hiuat nay duoc thuc hien bing each diing mdt bdni doc lip tdl mau nap lien tue qua dpng
Y HOC VIET NAM THANG 5 - SO 2/2014 machnach phai; Va dpng mach canh goc trai
hoac trifc tiep vao 2 dong mach canh goc trong thdi gian ttiay quai dong mach chii tuy theo tutig tru'dng hdp cu the. Phu'dng phap nay cho ghep thiet lap he thong tuan hoan ngoai cd theddn gian tiiong thu'dng chung toi sir dung vong tuan hoan ngoai cd the dpng mach nach -nhT phai Trong phau th^uat lien quan tdi quai dong mach chil, thu'dng ton thu'dng phiTc^tap, thdi gian cap he thong dpng mach canh de thay quai thu'dng keo dai, khd tien iu'dng. SACP cho phep bao ve nao t&i \iu giam cac tai bien ve than kinh v) no khong gidi han ve mat thdi gian lull lu'dng va ap lut: tdi mau nao luon du'dc dam bao, giam toi da cac tai bien do ha than nhiet sau gay nen.
Ngoai ra nd cho phep bao ve tang, than va tiiy song do khonq phai ngimci tuan hoan. Mpt nghien ciiu Idiac cua Kamyia va c^ng su" cho ket qua ty le t i c mach mau nao khi sir dung ky thuat SACP la rat thap, chl co 0,6% so tru'dng hdp (4).
Day la ky thuat chunp toi su' dung^mot each thu'- dng qui cho cac phau thuat cd ton thu'dng hen quan bill quai dpng mach chil ngu'c.
V. K^T L U A N
Phlu UiuSt benh ly dpng m?ch c h i i n g y t co ton thu'dng qua! ddng mach chu la mpt phau thuat r§t phiic tap. Vdi 35 benh nhan du'dc phau thuat vdi ty I? t i f vong 6,5% , khong co benh nhan nao co bien diuYig than kinh thdi gian nam vl^n trung binh 12 ngay. Chung to! nhan thay ky thu$t tifdl mau nao chpn Ipc ket hdp ha nhiet dp v i i ^ bao v€ cd tlm bang djch mau dang nhiet la luei chpn thi'ch hdp
T A I LIEU T H A M K H A O
1 . Deborah K. H a r r i n g t o n , FeraaiMb Fragomeni and Robert Stuart Bonseft Cerebral Perfusion. Ann Thorac Sung 2007; 83:
799-804
2. Teruhisa Kazui, Katsushi Yamashita, Naold Washiyama, Hitoshi Terada, Abul Hasan, etaL Aortic Arch R^lacement Using Selective Cerdxal Perfusion. Ann Thorac Surg 2007;83:796-798. '•;.
3. Hiroliki Sasaki, Hitoshi Ogino, H i b ^ ' Matsuda, Kenji Minatoya, Motomi Ando SKI^
Soichiro Kitamura. Experience Integrated t o ^ Arch Replacement using Selective Cerebfal Perfusion: A 6-year. Ann Thorac Surg 2007; 83;
805-810.
4. Hiroyuki Kamiya, Uwe Klima, Christian Hagc Frank Logemann, Michael Winterhalter, et al. Cerebral Microembolizatlon During Antegra^l Selective Cerebral Perfusion Ann Thorac S ^ 2006; 81: 519-521.
5. Phau t h u | t d$ng m^ch chu n g y ^ t^f bfnh vien V i ^ t bii'c tiy ndm 2002 tfen n3m,2006i Difdng OiTc Hung va cong si/. T^p chi Y hoc ViS:
Nam 2006; 328-104.
6. Toshihiko Ueda^ Hideyuki Shimizu, KiaMM Hashizume, Kiyoshi Koizumi, H I t e i t f M Mori, Hankei Shin, and Ryohel Yozu. Nbi^^B and Morbidity After Total Arch Replacement I ^ B a Branched Arch Graft With Selective Antegffl|
Cerebral Perfusion. Ann Thorac Surg 2 0 0 3 ^ 1951-6.
7. Teruhisa Kazui, Katsushi Yamashita, Naold Washiyama, Hitoshi Terada, Abul Hasari,ir al. Usefulness of antegrade selective cerebral perfusion during aortic arch operations. ' ^ Thorac Surg 2002;74: 1806-1809.
TINH HINH r<r VONG TAI 7 T I N H / T H A N H PHd VA MOT SO YEU TO LIEN QUAN
T 6 M
TAT
Hien nay, t?i Viet Nam phan Idn c k tru'dng hdp tir vong xay ra tgi nha, vi?c cap giay chutig tCr cung nhu' xac djnh nguyen nhan tuf vong chua du'dc thyc hien day dii dSn den so li§u thdng ke ve tuT vong con thieu v^ chua chfnh xac. Myc t i e u : Mo ta mOt so yeu to lien quan 6Sn tii vong Vci ty suat ti^ vong tcii 7 tinh thuQc cdc khu ViTc dja ly k h k nhau. Phu'dng phdp:
* TnAi'ng 0^1 hpc YHa Npi
Phan bi0n khoa hpc: PGS.TS Ph^m Thi Lan
Nguyen Phu-oTig Hoa*, Pham Thj Ngpc Bich*
mo ta d t ngang. Thu thap thdng tin bSng phuBng phap phong van sir dyng b6 c3u hoi dieu tra cita WHO da dUdc chinh sCra. Sd lieu du^c thu th|ip tgi 7 tiri) thupc cac khu vu'c dja ly khac nhau. Ket qui: Ty siA tii vong chung ciia 7 tinh la 3,8%o, trong do ty suSttff vong tai khu vi/c mien niii cao hdn khu v\fc cao nguyen Cp<0,05). Ty le nhan giay chifng tir 1^ 74%
tuy nhien co su* khac nhau giu'a cac khu vut, th?p nhS la tai mien niii (52,6%), {p<0,001). PhBo ldn dc tru'dng hc?p tir vong tgi nhh (78,6%), cao nhSt tgi 1 ^ vi/c mign nui (84%), (p<0,01). Chi c6 14% s6 t n i f t l
