Y HOC VIET NAM THANG 6 - SO 1/2015 ^
DANH GIA HIEU QUA TREN HUYET DONG (y BENH NHAN soc NHI6M KHUAN CUA PHU-CXNG PHAP LOG MAU LIEN TUC C W H
Nguyen Dang T u a n * , Dao Xuan Co*, T r a n T h a n h Cang***, Nguyen Gia Binh*, Nguyen Thi Du**
TOM TAT
Muc tieu nghien cu'u: Oanh _gia hieu qua tren huyet dpng 6 benh nhan soc nhiem khuan ciia phffdng phap loc mau lien tuc CWH. Ddi tffdng va phu'dng phap nghien cffu: 52 BN SNK di/dc chan doan va dieu tn theo khuyen cao chien IffOc kiem soat nhiem khuan toan cau 2008 (SSC 2008), dUdc dat catheter Swan-Ganz va loc mau lien tuc CVVH. Ket qua: Giam mach va tang HATB tru'dc loc mau 127 ± 19,6 lan/phiit va 71 ± 9,4 mmHg xuong 107 ± 26 l^n/phut va 83 ± 14,2 mmHg khi ket thuc loc mau (p
<0,001), tang SVR tff 840 ± 310 trffdc loc len 1091 + 399 dynes/giay/cm^ (p < 0,001), giam lieu noradrenalin 1,15 + 0,851 trffdc Ipc xuong 0,41 + 0,835 ng/kg/phut ket thuc Ioc mau (p < 0,001), on dinh CO, CI vS SV d nhom s5ng vdi CO, CI va SV fan Iffdt 6,6 ± 2,38 L/phut, 4,2 ± 1,54 L/phut/m^va 60,6 + 16,52 ml th6i diem trffdc loc va thdi diem ket thuc loc mau la 6,1 + 1,42 /phut, 4,0 ± 1,00 L/phiit/m^va 5819
± 15,78 ml (p > 0,05). Ti le thoat sdc 73,1%, thdi gian thoat soc 58 ± 31,7 gicJ. Ket luan: Loc mau lien tuc CWH giup cai thien mach, HATB, SVR, giam lieu van m?ch d cac BN SNK, giiip on dmh CO, CI va SV'd nhom BN so'ng.
TW khoa: soc nhiem khuan, loc man lien tuc trong soc nhiem khuan
SUMMARY
TO EVALUATE E F F E a S O N H E M O D Y N A M I C VARIABLES IN SEPTICSHOCK PATIENTS OF
CONTINUAUS VENO-VEUOUS HEAMOFILTRATION
Objective: To evaluate effects on some hemodynamic variables in septic shock patients of continuous veno-venous heamofiltration (CWH).
Subject: 52 septic shock patients were enrolled to study, was treated following SSC 2008 guidelines, inserted Swan-Ganz catheter and supported by CWH.
Study method: intervention and companson.
Result: The mean of pulse rate, mean blood pressure, SVR at the bme starting CWH were 127 ±
"Benh vien Bach Mai
** Tn/dng Dai hgc YHa Ngi
*** Benh vien Viet Tiep Hai Phong Chju trach nhiem chinh: Nguyen Dang Tuan Email: [email protected] Dt: 0913.310.691 Ngay nhan bai; 4/4/15
Ngay phan bien khoa hoc: 4/5/15 Ngay duyet bai; 20/5/15
19.6 beats/mm, 71 ± 9.4 mmHg, 840 ± 310 ± 399 dynes/sec/cm^ changing to 107 ± 26 beat/min, 83 ± 14.2 mmHg and 1091 ± 399 dynes/sec/cm^ at the time CWH finishing (p < 0.001). CO, CI and SV were maintained stably dunng the CWH process tn the survivor group with CO, CI and SV at the time CWH starting were 6.5 ± 2.38 L/min, 4.2 ± 1.54 L/min/m^
va 60.6 ± 16.52 ml changing to 6.1 ± 1.42 /mm, 4.0 ± 1.00 L/min/m^ va 58.9 ± 15.78 ml at the bme CWH Rnishing (p > 0.05), recovering time from shock was 58 ± 31,7 hours, recovering rate from shock was 71.3%. Conclusion: CVVH helps reducing high pulse rate, elevating mean blood pressure and SRV in septic shock patients, for the survivor group CWH helps maintaining CO, CI and SV stably.
Cac chiJ viet tat: CWH (continuous veno-venous haemofiltration) loc mau tien tuc tinh mach tinh mach, SSC (Surviving sepsis campaign), CO (cardiac output) cung lu'Ong tim, CI (cardiac index) chi so bm, SV (strol<e volume) the tich nhat bop, SVR (systemic vascular resistance) su'e can mach he thong.
Keywords: septic shock, CVVH, CW for septic shock
I. DAT VAN DE
Soc nhiem khuan (SNK) la mpt tinh trang benh li nang thu'cJng gap tai cac khoa hoi siTc cap cii'u vdi tl le tir vong cao do hau qua cua roi loan va suy chii'c nang da cO quan. Roi loan huyet dgng xuat hien sdm trong SNK va thu'dng la mat xich quan trong ciia rat nhieu cac roi loan thir phat khac, kiem scat du'dc roi loan huyet dpng sdm giup cai thien ti le tir vong [ 5 ] , [ 7 ] . Loc mau lien tyc (LMLT) du'dc cho la cd kha nang loai bo cac cytol<ine gay viem giup cai thien huyet dong d cac benh nhan (BN) SNK [ 3 ] , [ 6 ] . Xuat^phat td do chung toi tien hanh de tai nay nham muc tieu: Danh gii hieu qui cii thien huyet dgng d benh nhin sdc nhiem khui'n cua phWdng phap loc mau lien tuc CWH.
II. DOI Tl/prJC VA PHU'aNG PHAP NGHIEN CUU 2 . 1 . Doi tLftfng nghien cu'u
- Tieu chuan Ida chon BN: gom 52 BN SNK nhap khoa hoi su'e tfch cu'c (H5TC) benh vien Bach Mai td 4/2009 den 11/2013 du'dc dat catheter tTnh mach Swan-Ganz va loc mau hen tyc.
Tieu chu_an chan doan va dieu trj SNK: theo hu'dng dan quoc te ve chien Iu'dc quan If nhiem khuan 2008 (SSC 2008) [ 2 ] .
Y HOC VIET NAM THANG 6 - SO 1/2015 - Tliu chuan loai trW. BN nhap vien qua muon,
khong thu'c hien du'dc day dii cac phac do dieu t n hoac SNK d BN cd benh giai doan cudi hole gia dinh BN tir chdi LMLT hoac dat catheter Swan-Ganz.
2.2. Phu'dng phap nghien cu'u: can thiep, CO so sanh
2.3.1. Tien hinh nghien cWu:
* Cac dieu tri cd ban: BN du'dc chan doan SNK nhap khoa HSTC du'dc: dam bao ho hap (thd may khdng xam nhap hoac xam nhap) nham dam bao Pa02 > 60 mmHg; dam bao tuan hoan bang bien phap truyen dich va sir dung van mach (noradrenalin va/hoac dobutaminj nham duy tri huyet ap trung binh (HATB) > 65 mmHg.
* Dat catheter Swan-Ganz: thu thap cac thong so huyet dong, HATB, ap lu'c tTnh mach trung tam (CVP), ap lu'c mao mach phoi bft (ALMMPB), CO, a , SV va SRV.
* Loc mau lien tuc: theo quy trinh loc mau khoa hoi sire tich cu'c
Phu'dng thifc Ipc mau: C W H , mang loc AN69 hoac PS (polysuifone) toe do mau dich 180- 200mi/phut, dich thay the bicarbonate dfch 45ml/kg/gid, chdng dong heparin hoac citrate, co ket hdp hda loang tru'dc mang tiT 0 den 100%,
Tieu chuan ngirng loc mau; lactate ve binh thu'dng ya ngifng du'dc thuoc van mach ft nhat 12 gid van duy tri du'dc HATB > 65 mmHg.
2.3.2. Thu thap so' lieu: thu thap cac dD' lieu lam sang, du" lieu huyet dpng tir catheter Swan-Ganz va xet nghiem thdi diem ngay tru'dc khi LMLT (TO), gid thir 3 (T3), gid thir 6 (T6), gid thir 12 (T12), gid thir 24 (T24), gid thu'48 (T48), gid thir 72 (T72) va ket thiic LMLT (T ket thuc).
2.3. Xir ly so lieu: bang phu'dng phap thong ke y hpc
III. KET QUA
3 . 1 . Dac diem benh nhan nghien cu'u Bang 1 : Pac diem benh nhan
Thong sd'
Nam (n = 52, %)
Tuoi (n = 52, X ± SD, Min-Max, nam) Ti ie suy da tang (n = 52, %) SS tang suy (n = 52) (X ± SD) Oiem APACHE II (diem) (n = 30 ) (X ± SD) Oiem SOFA (diem) (n = 52) (X ± SD) CVP (n = 52, X ± SD,cmH20) ALMMPB (n = 52, X ± SO, mmHg)
Tlidi qian bat dau soc den LMLT (n = 52, X ± SD, qid) So van mach (n = 52, X ± SD, Min - Max, ioai) Ttioat soc (n = 52, %)
Tiidi gian tiioat soc (n=52, qid) Sonq (n =52, %)
Gia tri
35/52 (68,2) 56 ±18 (17-90)
52/52 (100) 4,7 ± 1,08 25,5 ± 7,04
l l j 9 ± 2,8 12 ± 4,5 13 ± 5,4 27,7 ± 19,69 1,7 ±0,63 ( 1 - 3 )
38/52 (73,1) 58 + 31,7 30/52 (57,7)
3.2. hfieu qua cai thien huyet dong cua C W HThay doi ye mach vi huyit ap trung binh qua cic thdi dii'm LMLT Bleu do 1: Thay doi ve mach va huyet ap trung binh qua cac thdi diem LMLT
.^'
• HATBchuilB MATS cong HATB diet
Nhin xet: Mach va huyet ap d hai nhom tru'dc LMLT khong cd sd khac biet va cai thien ro theo thdi gian Ipc mau cho den khi ket thiic Ipc mau.
Y HOC VIET NAM THANG 6 - S D 1/2015
• Thay ddi sWc cin mach he thdng (SVR) va lieu noradrenalin
Bleu do 2:Thay doi sire can mach he thdng va lieu noradrealin
.lyil^-, ,|l.iy Liii'i Nor: fig/kg/ph ' p < 0,05
" p < 0.01 ' " p < 0,001
1 5 .—.-^vRtluinci - « - S V R song
SVRth^t 1-1 c -" - - Men chiijun
TO T3 76 T12 T24 T4S T72 T ket
Nhan xet: SVR va lieu noradrenalin d ca hai nhdm sdng va tir vong khong khac biet tru'dc Ipc mau, tuy nhien lieu noradrenalin nhom song giam rd theo thdi gian Ipc mau trong khi do nhdm tir vong khong giam du'dc lieu, tu'dng Li'ng SVR cung tang ro theo thdi gian Li^lLT d ca hai nhdm tuy nhien nhdm sdng tang ro ret hdn.
- Thay doi cung IWdng tin? (CO) vi chi so tim (CI) trong qui trinh LML T Bieu do 3: Thay doi CO va CI qua cac thdi diem loc mau lien tyc
7
CO: L/phiJt
„ C I : L / p h i i t / m ^
« p < 0 , 0 5 5S vol TO
Nhin xet: Tru'dc LMLT CO va CI cua nhdm sdng va tir vong khdng cd stf khac biet, tuy nhien CO va CI d nhdm sdng cd xu hu'dng gii? on dinh trong khi CO d nhom tu" vong cd xu hu'dng giam dan rd nhat tir thdi diem loc mau gid 24 va CI giam sdm hdn tir gid thir 12 trd di.
• Thay doi the tich nhit bop qua cic thdi diem Igc mau
Bleu do 4: Thay dd'i the tich nhat bdp qua cac thdi diem loc mau
SV (mi)TO T3 16 112 T24 T48 T72 Tl<et
N
22 22 22 22 22 19 17 22
Chung
63,8 ± 29,65 65,7 ± 29.66 63,8 ± 25,18 61,6 ± 20,67 60,4 ±23,13 54,2 ± 17,15 57,5 ± 16,66 57,4 ± 22,48
N
13 13 13 13 13 13 12 13
Sdng
60,6 ± 16,52 67,5 ± 23,36*
69,0 ± 23,81*
66,4 ± 18,94 62,5 ± 16,96 68,7 ± 17,82 60,9 ± 14,70 58,9 + 15,78
N
9 9 9 9 9 6 5 9
Tu" vong
68,3 r 43,13 63,1 ±40,82*
56,3 ± 26,61 54,6 1 21,15 57,5 ± 30,93 44,5 ± 11,47 49,5 ± 20,02 55,2 + 30,73
P
0,56
0,76
0,26
0,19
0,63
0,09
0,21
0,71
(* p < 0,05, so sanh tai thdi diem trudc loc mau vdi cac thdi diem khac)Y HOC VIET NAM THANG 6 - SO 1/2015
Nhin xet: SV nhdm song va tir vong khdng cd SLf khac biet thdi diem tru'dc Igc mau, tuy^nhien SV cua nhdm song cd tang dang ke d thdi diem Ipc mau 6 gid va 12 gid va giii' on dinh cho den khi ket thuc loc mau, SV ciia nhom tir vong xu hu'dng giam dan, ro nhat thdi diem Ipc mau gid thir 6.
cung cd dien bien tu'dng tiT, SV khdng khac biet tru'dc thdi diem Ipc mau nhu'ng d nhdm song SV tang len sau gid thif 6 ciia Ipc mau sau dd giu'on dinh edn d nhdm tir vong xu hu'dng giam dan va giam ro vao thdi diem gid 48 t r d di. Dieu nay cijng phii hcfp vdi nhan dinh ciia mot sd tac gia rang CO, CI va SV ciia cac BN SNK ban dau thu'dng tang cao do bii trir nhu'ng khi da bu dii djch thi lai lam bde Id giam CO, CI va SV va tliudng phai diing dobutamin [ 4 ] , eijng ed tae gia cho rang LMLT da giiip dao thai mdt sd cytokine tac dyng tren su'e co bdp cd tim nhu' MDS, TNFa, IL-1|3 ... giiip cai thien su'e co bop cd tim, CO, a v a S V [ 3 ] , [ 4 ] .
IV. BAN LUAN
4 . 1 . Dac diem benh nhan nghien cu'u Cae BN SNK nhap khoa HSTC mudn (27,7 ± 19,69 gid), trong tinh trang nang vdi diem APACHE I I cao (25,5 ± 7,04 diem) va tat ca da cd suy da tang vdi sd tang suy trung binh 4 tang, tru'dc khi loc mau BN da du'dc bii du djch vdi CVP dat 12 ± 4,5 cmH20 va ALMMPB dat 12 ± 4,5 mmHg va du'dc dung van mach noradrenalin de duy tri HATB tru'dc LMLT > 65mmHg theo khuyen cao [ 2 ] .
4.2. Hieu qua t r e n huyet dong Tru'dc khi'LMLT cho cac BN SNK, cac chi sd;
mach, HATB ciia hai nhdm BN sdng va tir vong khong cd sy" khac biet nhu'ng qua cac thdi diem Ipc mau mach va HATB cua ca hai nhdm deu cai thien, cy the maeh ban dau nhanh sau dd giam dan ve mire binh thu'dng con HATB tang dan d ca hai nhdm. Nghien ciTu ciia Tran Van Tuan [1]
cung cho nhan dinh tu'dng td.
- Sire can mach he thong (SVR) ciia hai nhdm BN tru'dc Ipc mau d mii'c thap va khdng co sU khac biet va lieu noradrenalin tru'dc Ipc mau d ca 2 nhdm deu eao ddng deu giUa hai nhdm, theo thdi diem LMLT SVR tang dan tu'dng irng vdi lieu noradrenalin cung du'dc giam dan theo eac thdi diem loc mau. Tuy nhien cd sy' khac biet trong giam nhu cau suf dung noradrenalin giii'a nhdm sdng va nhdm tir vong, d nhdm song lieu noradrenalin giam cd y nghia ngay tir thdi diem Ipc mau gid thir 6 cho den khi ket thiic Ipc mau hau nhu' da cat du'dc noradrenalin, trong khi d nhdm tir vong lieu noradrenalin hau nhu' khdng thay dd'i. Nguyen nhan ciia cae thay doi tren du'dc giai thich do cac cytokine gay viem gay ra cac tac dung tren tim mach nhu' chat gay gian mach NO, TNFa, IL - 1 ... va LMLT da giiip dao thai cac cytokine dd giup cai thien maeh va HATB [3],[5].
- CO va CI tru'dc Ipc mau d 2 nhdm sdng va td vong deu d mire tren binh thu'dng va khong cd sd khac biet. Tuy nhien d nhdm sdng cac thdng so nay cd xu hu'dng giam dan ve mire binh thu'dng (khdng tao sir khae biet so vdi thdi diem tru'dc Ipc mau) va du'dc giu' on dinh cho den khi ket thiic Ipc mau, con d nhdm tir vong cac chi so nay giam nhieu tao ra s y khac biet so vdi thdi diem bat dau Igc mau. The tich nhat bdp (SV)
V. KET LUAN
Lpe mau lien tuc cho 52 benh nhan soc nhiem khuan eho thay phu'dng phap Igc mau lien tuc C W H giiip cai thien maeh, huyet ap trung binh va sire can mach he thdng (SVR) d cac BN SNK va giiip giam lieu noradrenalin, duy trl du'dc cung lu'dng tim (CO), chi so tim (CI) va the tfch nhat bdp (SV) d nhdm benh nhan sdng.
TAI LIEU T H A M KHAO
1. Tran Ngoc Tuan va Le The Trung,(2002), Nghien ciTu iTng dung_^ky thuat Ipc mau lien tuc dieu tri benh nhan nhiem khuan nhiem doc nang.
Tap chi thong tin YPu'OcSo chuyen de bdng: tr.
57-60. ^ - 2. Dellinger, R.P., et al.,(2008), Survivlrig~Sep!ils
Campaign: international guidelines for management of severe sepsis and septic shock;
2008. Intensive Care A/etf 34 (1): pp. 17-60.
3. Joannes-Boyau, O., et al.,(2004), Impact of high volume hemofiltration on tiemodynamic disturbance and outcome during septic shock.
As3ioj50 (1): pp. 102-9.
4. Ledoux, D., et al.,(2000). Effects of perfusion pressure on tissue perfusion in septic shock.
Critical Care Medicine 28 (8): pp. 2729-2732.
5. Nguyen, H.B., et al.,(2004). Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 32 (8): pp. 1637-42.
6. Ratanarat, R., et al.,(2005). Pulse high-volume haemofiltration for treatment of severe sepsis;
effects on hemodynamics and survival. CritCare9 (4): pp. R294-302.
7. Rivers, E., et al.,(2001), Early goal-directed therapy in the treatment of severe sepsis and septic shock. iVEngiJ Med3^5 (19): pp. 1368-77.
