Y Hpc VigT NAM THANG 9 - SO 1/2014 T h u t hanh ciia CBYT eung rat han che, dac
biet d tuyen xa khi hau het CBYT tuyen xa ehu:a tiJtig thiTc hien sang Ipc UTCTC cho khach hang.
Do dd, cac CSYT can dao tao, tap huan cho CBYT cac tuyen ve cae ky thuat sang Ipc UTCTC.
Oao tao ky thuat tu" van, VIA, V I U , Pap smear, soi CrC, ADN HPV, ap lanh, LEEP cho tuyen tinh, ky thuat tu* van, VIA, ap Ianh cho tuyen huyen va tu" van, ky thuat VIA cho tuygn xa.
T A I L I I U THAM KHAO
1. Bp Y tS, (2011). Tai li^u hudng dan s^ng Ipc, dieu tri ton thuWng tien ung thiT de dy" phong ttiii"
cap ung thif co tuT cung.
2. Chu'dng trinh phong dmng ung thu" qufic gli cua To diiit Y te the gidi xuat ban Sn 2, nam 2002 3. Nguyen Tuan Hung, Tran Van ThuSn, Ket q u |
sang Ipc phat hien sdm ung thiT vu va ung thu* co tuf curig tai mot so tinh thanh giai doan 2008- 2010, Tap'chiy boc thuc hanh (815). sS 4/2012.
4. Allience for Cervical Cancer Prevention (ACCP). Cervical Cancer Prevention factsheet: 10 Key Findings and Recommendabons for Effective Cervical Cancer Screening and Treatment Programs, April 2007.
a. Feriay J . et a l . (2000), "Cancer inadence, mortality and prevalence worldwide". lARC Press, Version 1.0, lARC Cancer Base No.5, Lyon 2001.
6. WHO. "Strengthening cervical cancer prevention and control". Report of the GAVI-UNFPA-WHO meeting, 1 December 2009, Geneva, Switzerland.
7. WHO. Sexual and reproductive health; "Cancer of the cervix"
THONG KHI N H A N TAO 6* BENH NHAN BI RAN CAP NIA CAN CO SUY HO HAP
T 6 M TAT
Oe danh gia hieu c|ua thdng khi nhan tao (TKNT) vS mpt so bien churtig d benh nhan bj rSn cSn gay suy ho hap, nghien c i ^ da ben hanh tren 66 benh nhan (qom t>enh nhan hoi diu va tien cuU) bj rSn cap nia can CO suy ho hap, dieu tri tai Trung tam chong doc Benh vien Bach Mai Ha Nol vdi 2 phu'dng phap ho hap nfiSn tao t^i TKNT vdi Vt cao (12-15 ml/kg) va Vt trung binh (10 ml/kg) ket hdp vdi PEEP 5 cm H2O, trong thdi gian ttT thang 01/2012 den thang 10/2013, thu dudc ket qua nhu" sau:
- Thdl gian TKNT tmng binh la 9,8 ± 7,1 ngay.
- 2 phLfdng phap TKNT deu co hieu qua tren cai thien oxy mau va co tac dung diiu tri va dU phong xep phoi, tuy nhien SLT dung TKNT vdi Vt cao (12-15 ml/kg) dU phong xep phoi tot hdn Vt 10 ml/kg + PEEP 5 cm H^O.
- Bien chutig diu yeu la viem phoi lien quan den thd may (54,5%).
- CSn nguySn hay gap nhat gay vigm phoi la A.baumannii (45%), tiep den la P.aeruginosa, K.pneumonia, S.aureus va nam Candida albicans c^u chiem ty le 25%, tJiUdng g i p tren nhuTig benh nhan TKNT dai ngay (> 10 ngay).
Tv'AAda.'suy ho hap, rSn cap ma cSn, thdng khi nhSn tao.
* Hoi su'c cap CLTU, tru'dng Dai hpc Y Du'dc Thai Binh
** Trung tam Chong dpc, BV Bach Mai Ha Npi Chju trach nhiem chinh: N g u y e n D u y C u d n g Email; [email protected] Ot: 0932.393,678 Phan bien khoa hpc: TS Ha Tran Hutig Ngay nhan bai: 12.7.2014
Nguyen Duy Cu'dTig*^ Nguyen Kim Son**
S U M M A R Y
V E N T I L A T I O N I N RESPIRATORY FAIRLURE PATIENTS CAUSED BY BUNGARUS
M U L T I C I N T U S SNAKE BITE To evaluate the effectiveness of mechanical ventilation and a number of complications in respiratory depression patients caused by elapidea snake bite, study has conducted on 66 patients, bitten by bungarus multicintus snake, tieatmented on poison control center at Bach Mai Hospital in Hanoi with two methods of mechanical ventilation: high Vt (12-15 ml/kg) and average Vt (10 ml/kg) combinating with 5 cm H2O PEEP, obtained the following results:
- The average duration of ventilation; 9.8 ± 7.1 days - 2 ventilation methods are effective in improving blood oxygen and effects of treatment and prevention atelectasis, however ventilation with high Vt (12-15 ml/kg) atelectasis better reserve than Vt 10 ml/kg + 5 cm H20 PEEP.
- Complications of pneumonia is mainly related to mechanical ventilation (54.5%)
- The most common etiologic agent of pneumonia is A.baumannii (45%), followed by P.aenjginosa, K.pneumonia, S.aureus and Candida albicans are 25%
occupancy rate, common in patients with long-temi ventilation (>10 days)
Keywords: respiratory failure, scorpion snake bite nia, mechanical venblaPon
106
Y HQC VigT NAM THAHG 9 - SO 1/2D14
I. OAT V A N o l
Suy hd hap la dau hieu thu'dng gSp d BN bi ran cap nia cin do nhiem doc than kinh gay liet cd ho hap (LCHH). Thdi glaii hoi phuc liet cd hd hap thu'dng keo dai do do ddi hdl phai TKNT dai ngay cho b?nh nhan [1], [2]. Trong dieu kten hien nay khi ehu^ ed huyet thanh dac hieu khang noc fSn cap nia thi TKNT la bien phap dieu trj cd ban de duy tri chiit nang hd hap cho BN trong qua trinh chd cd ho hap hoi phuc. Liet cd ho hap cpng vdi TKNT dai ngay lam tSng nguy cd ton thudng phoi nhu" xep phoi va rat nhieu cac bien chultig khac kem trieo. Hien nay nganh Hoi su'c cap cuXi da ed ehl§n luidc thdng khi chdng xep phoi, ap dung de dieu trj cho nhutig BN suy lid hap do rSn cap nia eSn, tuy nhien ehuci cd nghien cihj niio danh gia hieu quii thdng khi nhan tao cung nhu" tjm hieu mpt sd bien chutig trong qua trinh thdng khi nhan tao cho benh nhan bj rSn dpc cin, vi vay chung tdi thi/c hien nghien CLTP niy vdi muc tieu: Oanh gia hieu qua thdng khi nhan t^o va mot so bien chimg d benh nhan bj r^n cap nia cSn cd suy hd hap.
II. odi TUPNG VA PHUUNG PHAP N G H I I N COU 2.1. Ool tu'dng Mhi£n CtJ'U
2.1.1. Tliu chuan Itfa chon BN Tat ca eae BN du'dc chan doan rSn cap nia
can dieu tri tai TTCD - BV Bach Mai tir thang 01/2012 den tliang 10/2013^
Tieu chuan chan doan ran cap nia can (khi cd 2/3 tieu ehuan)[l]:
- Bj ran can va ngu'di nha hoSc BN mang dPde eon ran den hoac nhin thay ran va ta Iai.
- Tai cho vet can: dau it, khdng sUng ne hoal tu", cd the tim thay mdc dpc.
- Toan than: cd dau hieu nhiem doe than kinh.
+ Dau hieu sdm: dau ngu'di, dau hpng, khd nudt, sup ml.
+ Mudn hdn: ha mieng han che, liet chi, liet cd hd hap, gian dong tir 2 ben phan xa yeu hoac khdng ed phan xa vdi anh sang, khdng eo Iai khi nhd pilocarpin.
2.1.2. Tiiu chuan lo^i ti'u'BN - BN bj rin cap nia can nhuTig mac nhDtig benh ly di kem cd the gay SHH nhu":
+ Benh ly hd hap: b?nh phe quan, phoi tif tru'dc, ton thu'dng hoac di dang Idng ngifc...
+ Benh ly tim mach: suy tim, benh van tim, loan nhjp tim...
- Suy gan, suy than nang.
- Tudi < 15, phu nff ed thai.
2.2. Phu'dng phap nghien cu\i
* Phu'dng phap: nghien CLTU md ta hoi culi ket hdp vdi tien cu'u.
• Quy trinh 7KMT cho BN ran cap nia can cd SHH RSn C9P nia can co SHH
can TKNT Chua cd tdn thircmg
Phdl
Da CO ton thutmg Phoi
TKNT vdi Vt cao
(12-15 ml/kg) TKNT vdi Vl
10 ml/kg +
P/F > 300
Tiep tye TKNT Vt 10 ml/kg + PEEPS
TKNT vdi ARDSnet
> Ket qua TKNT «
Y HQC VigT NAM THANG 9 . SO 1/2D14
* Cai dat ban dau:
- Bat phu'dng thirc VCV. Oat gidi han ap lire dudng thd : 10 < Ppk < 35.
- Cai dSt cac thong so ban dau: Vt: 10 ml/l<g; tan so thd (f): 14 - 16 Ian/phut; ty le I/E = 1:2; FI02
= 100% (sau 15 - 20 phut giam Fi02 = 30- 40%); PEEP = 0 cmH20.
- PhSn tich khi mau dong mach sau TKNT 30 phut
• Dieu chinh cac thong so tren may thd:
- Bleu chinh f theo khi mau dong mach.
- Neu TKNT vdi PEEP, dat PEEP = 5 cmH20 - TKUTT vdi Vt tang dan. Oieu kien cho phep t5ng Vt
+ I i m sang on djnh: BN tinh, khi Vt tang len khong g3y kho chiu.
+ Ppk < 35 cm H20, Pmean < 10 cm H20.
TSng dan Vt, khdi d5u 10 ml/kg rfii 11,12,13,14.15 (ml/kg) mol 8-12h.
Dieu chinh f theo khi mau va MV kh6ng doi.
Biiu do 1. Phan bo BN theo gidi
2.3. Phining phip xur ly so ll#u Sd lieu thu du'dc xir ly theo phu'dng phap thong ke Y hoc va' chu'dng trinh SPSS 18. So sanh 2 tri so TB cong bSng test T-student. So sanh 2 so quan sat bang kiem djnh A, viJi p<0,05 dUdc coi la co y nghia thong kS.
III. K ^ QUA NGHliN CO'U
Trong khoang thdi gian tir thang 1 nam 2012 den thang 10 nam 2013, co 66 BN du'dc chan doan ran cap nia cSn cd SHH can dat NKQ - TKNT nhap TTCO - BV Bf± Mai dieu tn, du tieu chuan du'dc chpn vao ngien ciru.
3.1. Bac diSm chung cua doi tu'dng NC.
3.1.1. Bac diim ve gidl, tiii), nghS nghli^p:
- Phan bo BN theo gidi tinh:
- Phan bo BN theo tuoi:
Bleu dS 2. Phin bo 6N theo nhom tuoi
Hau hit BN bl ran cap nia dn diu ii nam gidl (71,6%) vi rat treddd tuSl lao ddng 74,6%. Tuoi TS 33,5 ± 12,9 iuoi(nhd nhat 15 tuoi, cao nhat 71 tudi) Ket qua nay cdng tudng titdc nghien cuutmng vi ngoii nude [2], [3], [5].
3.1.2. Phan boBN theo mitc do n$ng
BliudSS. Phan bo BN theo mire dp nang Iiic nhap vien 80.3%
( ' " ^
bift-iiii. ^ V H M R ^ ^ B ^
13.6%
DNhv-
• I'rung hinh DNanii 1%
Ba soBN bl ran cap nia dn nhap vien trong tinh trang nang chiem ty ie 80,3%. Phan boBN tiieo mik dd ning tiong nghien cuUcua chung tdi cdng tWdng tU vdi ty ie trong nghien aiu cua Hi Tran Hung, cd den 83%BNd miit do nang. Nghien cuU cua Kularatne Sam 66% nhap vien d mut nang vi nguy kich Bieu nay^ ndi nen doc tinh aia rin cap nia ia rat doc (gap •! ian ran ho mang thu'dng [2]) vi tac dung gay nhiem ddc TK cua dc thinh phan trong noc ran [1], [2], [5].
Y HQC VigT NAM THAHG 9 - S6' 1/2014 3.2. Ket qua TKNT
3.2.1. Thdi gian thing khi nhin tao Bing 1. Thdi gian TKNT
D$ nang Nhe Nanq Thdi qian TB
Thai gian TKNT (ngay) Vt 12-15
2,6 ± 1,9 4,7 ± 2,9 10,5 ± 5,2 i,7 ± 5,5
Vtl0+PEEP5 2,8 ± 1,8 3,5 ± 3,1 12,1 ± 8,3 10,5 ± 7,8
2,7 ± 1,7 4,3 ± 2,7 11,3 ± 6,9
P I <0,01 I <0,01 I < 0,001 , Thai gian TKNTTBIi 9,8 ± 7,1 ngiy. Thdi gian TKNT dnhdm Vt 10 mi/kg + PEEP 5 cm H20 dii hdn so vdi nhdm du'dc TKNT vdi Vt 12-15 ml/kg (10,5 ± 7,8 ngiy so vdi 8,7 ± 5,5 ngay), tuy nhien sit khic biet khdng cd y nghia thong ke (p > 0,05). PSS miic dd nhe vi TB thdl glan TKNT ngan, PSS ning thdi gian TKNT dii hdn. Sit khic blit la cd y nghia thong ke vdi p < 0,001.
3.2.2. Phu'dng thdc thong Idtinhin tfio Bing 2. Cac phu'dng thu'c TKNT
TKNT PEEP (cmH20) Tan so (I/phut) Fi02 (%)
Vt 12-15 ml/kg
= 35 (53%) 8,2 ± 2,1 35,1 ± 10,3
Vt lOml/kg + PEEP 5 n = 29 (44%)
15,1 ± 1,5 40,2 ± 11,5
ARDSnet n = 2 ( 3 % )
21 ±1/4 55,5 ± 1,7 VtTB I 12,5 ± 2 , 4 I I 7,5 ± 0,8
44% BN ditdc TKNT vdi Vt 10 mi/i<g + PEEPS; 53% BN dUdC TKNT vdi Vt 12-15 ml/kg (trong dd 3 BN (8,6%) dimg dvtl2 ml/kg, 5 BN (14,2%) ddng dvtl3 rhi/kg, da so (25 BN chiem 77,1 %) dat dudc Vt 14-15ml/kg,
3.2.3, Cac Uin chitng thing Idyl nhin tao Bing 3. Ty le c^c bien chirng TKNT
Bien chihig VPLOTM VPLQTM b/cARDS VPLQTM b/c SNK TKMP Xep phoi
Vt 12-15 n = 35 16 (44,7%)
1 (2,8%) 0 0 1(2,8%)
VtlO+PEEPS n = 29 18 (58,1%)
3(10,3) 1 (3,4%) 0 5 (17,2%)
ARDSnet n = 2
2 0 0 0 0
TSng n 36
4 1 0 6
54,5
%
6^1 1,5 0 9,1 BiSn chdrng viem phSi lien quan d£n thd
mjy (VPLQTM)
Bien chihig chii yeu cua TKNT la VPLQ'TM chiem ty I? 54,5%. Ty \% nay d nhdm BN dUdc TKNT vdi Vt 10 ml/kg + PEEP 5 cao hdn d nhdm BN di/dc TKNT vdi Vt 12-15 ml/kg (58,1% so vdi 44,7%), tuy nhien sir khac biet khong c6 y nghia thong ke (p > 0,05)
Ty le VPLQTM trong nghien cijljciia chiing toi cao hdri so vdi nghien ciruciia Ahmed va cs (2011) (ty le VPLQTM la 8,7%). Oleu nay cc the giai thich rS'ng do trong nghien ci^uciia tac gia, cac BN b! Krait can deu dUdc sir dung huyet thanh kh^ng npc rSn nen rut ngan thdi glan TKNT , thdi glan TKNT TB rat ngan (2,3± 0,7 ngJy)[3]' ,
Bien chung xep phoi
Phan tich sau hdn, trong 6 BN xep phoi mdi, cd 5 BN trong nhom dudc TKUfT vdi 10 ml/kg + PEEP 5 cmH20 (17,2%), cao hdn nhom dugc TKNT vdi Vt cao (12 - 15 ml/kg) chi cd 1 BN (2,9%). Sir khac biet la cd y nghTa thong ke (p = 0,04).
Peterson va cs (1999) [7] cung thay rang ty le xep phoi mdi trong nhom BN du'dc TKNT vdi Vt cao thap hdn so vdi nhdm dutIc TKNT vdi Vt thap, SI/ khac biet la cd y nghia thong ke (5,2%
so vdi 52,2% vdi p < 0,05).
Tr^n khi mang ph6i
Trong nghien culjcua chung toi khong gap BN nao cd bien chij'ng tran khi mang phoi cung nhu' cac bien chirng tran khi khac cd le do ap lUc du'dng thd trong nghien ciruciia chijng toi luon du'di gidi han cho phep (Ppk < 35 cmH20).
3.3. C2IC nguySn nhSn chinh gay viem phoi
Y HQC VI|T NAM THAHG «- s61/2014 Bing 3. Ty le cSn nquyen gay benh phan lap dUdc
TKNT £ 1 0 ngiiy
( n = 3 8 ) TKNT > 1 0 ngay ( n = 2 8 ) Tong
Gram (-)
A.baumannii P.aenjqinosa K. pneumonia B.cepada S.pneumoniae
Gram(+ S.aureus 25
Candida.alblcans 25
P I , ' , . . < 0 . p 5 . . Trong nghien oiticua chung tdi thay cd 20 (31,3%) mau benh pham cho ket qui nudi cay du'dng bnh vi chu yiu d nhdm BN TKNT dai ngay (> 10 ngiy), stt khic blit cd y nghia thong ke vdip < 0,05.
Trong dd dn nguyen giy binh gap nhieu nhat li A.baumannil chiem ty le 45%, sau dd din Kpneumonia viS.aureus vi ham dnd'ida.aibk3ns diu chl&n ty le 25%.
3.4. KSt q u i dieu trj Bing 5 . Ket qua dieu tri
— — - — ^ J 1 < i f c do S H H K i t q u i fflSTBt"- - ^ _ Khdi hoan toan
Dl chutiq
Tu' vonq va xin ve de chet Tonq
Nh«
n 11 0 0 11
NSng n 49 0 1 50
Nguy kich n 2 2 1 5
TSng N 62 2 2 66
%
94 3 3 100Tit vong v i di chiTng chii yeu d nhdm SHH nguy kfch 3/4 BN ( 7 5 % ) , sir khac biet la cd y nghia thong kS vdi p < 0,01.
Nguyen nhan tu' vdng va bien chiJng TKNT (01 BN viim phdl sSc bien chijng ARDS ning va 01 BN VPLQTM bien chuhg soc nhiem khuan, suy da t^ng), 2 BN cd bien chirtig deu dd hau qua cua SHH keo dai. Oleu nay mot I3n n\ta hdl len vai trd cua cac BV tuyen cd sd trong viec Sep can va xij' tri l » n dSu SHH 6 BN b| ran cap nia can.
I V . K f T L U A N
Qua nghien cuU 66 BN cd SHH do rin cap nia cSn d i u tri tal TTCO - BV Bach Mai tir 01/2012 den thing 10/2013, chiing toi riit ra mpt so nhin xet sau:
- C i 2 phuBng phap TKNT la sij' diing Vt cao (12 -15 ml/kg) v i Vt 10 ml/kg + PEEP 5 cm H20 dSu hl|u q u i trln cai thl|n cxy hda m i u va co t i c dung dieu tri va di/ phong xep phoi, tuy nhiin s * dung TKNT vdi Vt cao (12-15 ml/kg) diT phong xep phoi tot hdn.
- Thdl glan TKNT TB la 9,8 ± 7 , 1 ngay. Bien chihig chii y i u la VPLQTM (54,5%), can nguyin phan lap di/dc thu'dng tren nhOhg BN TKNT dai ngiy ( > 10 ngay), cin nguyen hay gap nhat la A.baumannli chiem 4 5 % , Hep den l i
P.aeruglndsa, K.pneumonia, S.aureus va nam Candida.alblcans deu chiem ty le 25%.
- Kit qua dieu tri: khoi hoan toan 9 4 % , di chihig 3 % v i tir vong la 3 % . Di chiJng va tir vong chii yeu do bien chimg SHH va bien chiJhg TKNT.
TAI uf U THAM KHAO
1. WaneH, DJL (2010), Guidelines for the management of snake-bites. Guidelines for the management of snake-bites. WHO Regional Office for South-East Asia: p. 1-162.
2. Hung, H.T., ) . Hojer, and N.T. Du (2009), Qinical features of 60 consecutive ICU-treateo patients envenomed by Bungarus mutticinctiis.
Southeast Asian J Trop Med Publte Health. 40(3):
p. 518-24.
3. Ahmed, S.M., et al. (2012), Retrospective analysis of snake victims in Norlhem India admitted In a tertiary level institute, loumal of anaesthesiokigy, dinicaLphannacoiagy. 28(1): p. 45-50.
4. Njiuyin KIpi Sdn, Vu VSn Binh (2008), Nghiin culj d%: diem tam sang va dieu tri b^h nhan bl m$t so ran d§c tren can can thuoc hp rin ho (elapidae) 6 mien Bic Vift Nam, Lui'n an tien sy ¥ hpc, Tri/dng Bai hpc Y Ha Noi.
5. Nsiuyen Thii Hung (1997), Binh gia tac dung phong chong xep phoi d benh nhan liet cd h6 h ^ duyc TKNT ap ll/c dudng ngSt quang'vdi tlie trai lutJ thong cao, Luan vSn thac a Y hoc, Tru^no Oai hocYHaN6L " • 6. Peterson, W., et al. (1999), The effect of bdal
volumes on the time to wean persons with high tetraplegia from ventilators. Spinal Cord. 37f4V • 284-89. * '• ^'
