TAP CHi Y HOC VIET NAM T^P 450 - THAHG 1 • SO 1 - 2017 Fantanyl trong nghidn cffu cua chung toi cung
nhff nhieu nghien cffu khac da chi ra tac dung giam dau manh nhat^''*'^ bat dau nhanh, keo dai, kha nang eai thien diem dau gap 1,7 lan paracetamol va 1,3 lan Ultracet. Neu truyen tTnh mach cham eho hieu qua keo dai nen phan ldn benh nhan diang fentanyl deu de chju vdi tae dung cua thuoc. Chung tdi cd cijng ket qua nghien effu nhff Sudheer (2007)^: tac dyng phy eua thuoe kha cao, tffdng trf Ultracet nhrfng cac trieu chffng thffdng nhe, tham chf Sudheer^ con thay Ultracet gay buon non va non nhieu hdn fentanyl. Tuy nhien vdi thay d6i ve nhjp t h d , tan so maeh va suy ho hap, tang ap Iffc mach nao va tang ap Iffc npi sg thi fentanyl co ty le cao hdn nhieu, quan diem nay cijng dMc eac tac gia BeydonS Sudheer^ ung hg. Nen khuyen cao ehi nen diJng Fentanyl cho cac cdn dau nang hoac khong kiem soat 6Mc bang cac loai khae, loai trff can than cac nguy cd cho benh nhan trffdc khi chl dinh cho benh nhan va theo doi sat trong va sau kill benh nlian diiing thuoc.
V. Kfr LUAN
Dieu trj dau dau d benh nhan xuat huyet dffdi nhen gap nhieu khd khan do mffc do dau nang va keo dai. Paracetamol c6 tac dung nhanh nhffng tac dung yeu, tuy nhiSn ft tae dyng phu.
Codein va Ultracet co tac dyng chong dau tffdng dffdng tren lam sang va dffdc sff dung thffdng xuyen vi tac dung tot hdn paracetamol ddn thuan va ft tac dung phu hdn fentanyl. Fentanyl la thuoc cd tae dung chong dau manh nhat tren lam sang, nhffng vi nguy cd gay tac dung phy nhieu nen ehi diidc dung khi dau khong dap ffng
vdi cac lieu phap • khac. Cac tac dung khong mong muon thffdng gap la buon non; non;
chong mat.
T A I LIEU T H A M KHAO
1. Beydon L, Audibert G, Berre J et al (2005):
Pain management in severe subarachnoid haemorrhage; Ann Fr Anesth Reanim, 24(7):782-6.
2. Binhas M, Walleck P, EI Bitar N e t al (2006):
Pain management in subarachnoiid haemorrhage: a survey of French analgesic practices; Ann Fr Anesth Reanim', 25(9):935-9
3. M. H. Jeffrey, P. Charlton, D. 3. Mellor, E.
Moss, M. Vucevic (1999): Analgesia after intracranial surgery: a double-blind, prospective comparison of Codeine and tramadol; Br J Anaesthesia, 83(2):245-9.
4. Mahon P, Smith B, Brovirne J, Hawkshaw S, McEvoy L, Greene K, Rowan C, Markey F.
(2012): Effective headache management In the aneurysmal subarachnoid patient: a literature review; British Journal of Neuroscienee Nursing, 8(2): 89-93.
5. P. S. Sudheer, S. W. Logan, C. Terblanche, B.
Ateleanu and 3. E. Hall (2007):Comparison of the analgesic efficacy and respiratory effects of Fentanyl, tramadol and Codeine after craniptomy;Anaesthesia 62(6): 555-560.
6. Rachel Swope^ Keibf Glover, Yevgeniya Gokun, Justin F. Fraser, Aaron M. Cook (2014):EvaIuation of headadie severity after aneurysmal subaradinoid hernorrhage;Intetdisdplinary Neurosurgery,VoI 1,119-122.
7. Scott Y. Rahimi, Cargill H. Alleyne Jr., Eric Vernier, Mark R. Witcher, John R. Vender (2010): Postoperative pain management with tramadol after craniotomy: evaluation andcost analysis;J Neurosurg 112:268-272.
DAC DIEM LAM SANG, CAN LAM SANG VA D A N H G I A KET QUA DIEU TRI PHAU THUAT TU M A U TRONG NAO DO TAI BIEN MACH M A U NAO
Dirong Dai Ha*, Pham Tuan Dung**, Truong Quang Huy**
T O M TAT Nghien cdu benli^nhan xuat huyet nao do tai blen mach nao du'dc chan doan va phau thuat tai trung tam phau thuat Than kinh, benh vien Viet Dffc giai doan 7/2015^/2016. Nghien CLTH tien cdu ve d§c diem lam sang, can lam sang va ket qua dieu trj phau thuat mau tu trong nao do tai bien mach mau nao. Ty le nam/nff la 3 / 1 , chu yeu gap d ngu'di tren 50 tuoi (75%). Oa so benh nhan chi co 1 6 mau tu (97,2%), hay gap d tren leu (89%). Ket qua phau thuat; 50%
benh nhan tien trien tot, 44% tien trien xau.
*Trung tam phSu thuit thin kinh binh viin Viet Diic
**Tru&ng Dai hge YHa Ngi Chju trach nhiem chinh:
Email: [email protected] Ngay nhan bai: 7.10.2016 Ngay phan bien khoa hoc; 6.12.2016 Ngay duyet bai: 12.12.2016
VIETNAM MEDICAL JOURMAL H°1 - JANUARY - 2017
SUMMARY
THE CLINICALS SYMPTOMS, CLINICAL FIDING AND SURGICAL RESULTS OF INTRAPARENCHYMAL HEMATOMAS IN
STROKE PATIENT
Our study was carried out among 36 patients which were dignosed strDl<e hematomas intraparenchymai at Viet -Due hospitai from 7/2015 to 4/2016. Prospective observation was carried out at long time reseach. The objective of the study is to desaibe the dinicai signs, dinicai fiding and surgicai resuits of strolce intraparenchymai hematomas.Resuits shown that rate male/female was 3/1, primarily occurs in people over 50 years old (75%). Mainly patients had one hematoma (97,2%) and located in supratentorial region (89%). The good results after operation was 50% and got worsening 44%.
\. e^T VAN c l
Tai bien mach mau nao la nguyen nhan gay tCf vong thiJ tia sau ung thu' va cac benh tim m?ch, 4iJng thiJ nhat trong nhom cac benh If than kinh. Xuat huyet nao la mpt trong cac the benh eiJa tai blen mach nao chiem khoang 10- 15% tat ca cac tru'Sfig hdp dot quy nao (1){2).
Ty le tiJ vong va de lai di chiJng do xuat huyet nao la kha cao [3]. Ti le tir vong trong vong 30 ngay cua benh nhan xuat huyet nao dao dong tLf 13 den 61% [3] [4]. Vi vay, viec chan doan xac djnh , danh gia toan dien va tien lu'dng benh rat quan trpng, giup cho thay thuoc li/a chpn phu'dng phap ^ u tn thich hdp.
Hien nay co nhieu phu'dng phap de tien lu'dng ket qua dieu trj, trong do sii dung bang diem Hemphill la mpt phu'dng phap ddn gian, chinh xac. Bang diem Hemphill diTa tren 5 tieu chuan;
tuoi >80, diem danh gia y thiJc Glasgow, vj tri;
xuat huyet du'ctl leu tieu nao, kich thu'rSc khoi mau tu va si xuat hien cua chay mau nao that.
Mac du CO nhieu tien bp trong nghien cifu ve _ sirih benh hoc, chan doan va dieu tri nhu'ng iuS./
chpn phu'dng phap dieu tri phu hdp va tien Wdngf van con nhieu tranh cai. Do do, chung toi tienll hanh de tai "Bac diem lam sang, can lam sangl|
va danh gia ket qua dieu trj phau th_uat tii maDiS trong nao do tai bien mach mau nao" vdi cac muc tieu sau:
1. Nghien cdu mot so dac diem lam sing va can lam sang cua tu mau trong nao do tai bien' macli mau nao. ^
2. Banh gia ket qua dieu tri phau thuat iu mau trong nao do tai bien mach mau nao.
IL OOI TU'ITNG VA PHU'ONG PHAP NGHIEN CChj Doi tu'dng nghien cifu: Bao gom 36 benh nhan di/dc chan doan xac dinh la mau tu trong nao do tai bien mach mau nao theo To chifc Y te The Gi6i nam 1990, da du'dc dieu trj tai trung tam phau thuat than kinh Benh vien Viet Bifc tif thang 7/2015 den thang 4/2016.
Phu'dng phap nghien cifu: f^o ta lam sang, tien cifu.
III. KET QUA NGHIEN CU'U 1. Tuoi va gidi
- Ti le benh nhan nam gap nhieu hdn nif.
Nam/NCf la 3/1.
- Tuoi benh nhan xuat huyet nao do tai bien, mau nao hay gap nhat is nhom tren 50 tuoi, chiem 75%, tSp trung nhieu nhat d nhom 50 - 59 tuoi (30,6»/o).
2. Trieu chu'ng Ichdi phat.
Bang'l. Triiu chu'ng lim sang luc khdi phit Trieu chijing lam sang
Dau dau Non, buon non
Co qiat Liet nifa ngu'di Roi loan y thifc R6I loan ngon ngij'
So benh nhan 19 10 3 18 32 3
*
Ty le (»/o) 52,8 27,8 8,3 50 88,9
8,3
Bang 1 cho thay roi loan y thii'c la trieu chu'ng hay gap nhat, chiem 88,9%, tiep theo la dau dau (52,8%), liet nCra ngu'di chi bieu hien d 50% so benh nhan.
3. So lu'dng khoi mau tii
Trong nghien cu\i cua chung toi 35/36 benh nhan co 1 khoi mau tu trong so, chiem 97,2%.
4. Kich thu'dc khoi mau tu tren phim cat Idp vi tinh Kich thudc 6 tu mau
Nho (l-3cm) Trunq binhi 3-5cm)
Ldn (>5cm)
So benh nhan 1 16 19
Ty le (%) 2,8 44,4
52,8 1
TAP CHi y HOC VI&T NAH TAP 450 - THANG 1 - SO 1 • 2017
Bang 2. Kich thu'dc 6 mau tu tren phim chup cat ldp vi tfnh so nao d benh nhan mau tu trong sp do tai bien co chi (^nh phau thuat
Tii' bang 2, chung ta thay da so cac benh nhan du'dc phau thuat co du'dng ki'nh khoi mau td Idn hdn 3cm (97,2%). Trong dd, so benh nhan cd khoi mau tu ldn hdn 5cm chi§m 52,8%.
5. Vi Iri Ichoi mau tu
13%
W
' / ^
1 '^ L..
' ^
3%
8%
S^
^ ^
7i
19%
tf^^
mm^
{ 1
36%
• ban cau T
• ban cau T va nao that
• ban cau P
• ban cau P va nao that
• tieu nao
• tieu nao va nao that
Bieu do 1: Phan bo theo vj tri cua khoi mau tu do tai bien co chi dinh phau thuat Khoi mau tu thu'dng gap nhat d ban rau dai nao (89%), trong dd 55% d ban rau trai va 34% ban cau phai. Xuat huyet du'di leu gap d 11%.
6. f)ieu tri
- Cac phu'dng phap phau thuat: Md so lay mau tu la phu'dng phap chii yeu 75%, dan lull nao that chiem 16,7%, md sp va dat dan idu nao that chi chiem 8,3%.
- Trong so 36 benh nhan du'dc phau thuat, c6 18 benh nhan co tien trien tot (50%), 16 benh nhan tien trien xau (44%), 2 benh nhan tuf vong (tinh trang luc nhap vien rat nang Glasgow 3 diem - 6%).
Uen quan gi&a diem Glasgow luc vao vien va ket qua dieu trj,
10SoBN 5
1 5-8 diem 9-12 dilm
Diem Glasgow
• Tiln trien t6t • Tiln triln xiu a Td vong
Bleu dd 2: Liin guan giffs diem Glasgow IdC vao vien va kit gua dieu Cr/.
Nhom 3-5 diem cd 1/6 benh nhan tien trien tot sau phau thuat, t/ le nay d cac nhdm 6-8 diem, 9-12 ffiem, 13-15 dian lan lu'dt la 7/15; 4/8; 4/7. Oiem glasgow vao vien cang thap tien lu'dng cang xau.
- Lien quan gida the tich khoi mau tu va ket qua dieu tri: The tich trung binh 83,01±38,12. Nhom cd khoi mau tu tu" 30-60 ml cd 8/14 benh nhan tien trien tot hdn, nhom cd khoi mau tu > 60 ml chi cd 7/21 benh nhan cd tien trien tot.
Thdi gian td khi bj dot quy tdi khi phau thuat
150
Tru'dc 24h 1-7 ngay Thcri gian phau t h u | t
• Tien trien tot • Tiln t r i l n x i u a Ti> vong
Sau 7 ngay
Bii'u dS 3. Mdi liin guan giii'a thdiglan phau thuat va kit qua diiu tri
VIETNAM MEDICAL JOURNAL N'l - JAHUARY - 2017
Td bieu do 3, cho thay nhdm du'dc mo tru'dc 24h cd 4/15 b$nh nhan tien trien tot, nhdm du'o'E
phau thuat sau 1-7 ngay cd 11/20 benh nhan tien trien tot. 4 - Su' dung bang diem Hemphill trong tien lu'dng benh nhan sati mo:
Bdng 3. Lien guan giii'a dii'm Hemphill va 'ket gua diiu tri f)iem Hemphill
1 diem 2 diem 3 diem 4 diern 5 diem
Nhom SoBN
4 6 23
1 0
ra vien T / l e
100 100 100 100 0
Nhom tit vonq SofBN
0 0 0 0 2
Tyle 0 0 0 0 100
Ty le tu' vong 0 0 0 0 100-
1 1 i '1
Ty le song cua cac benh nhan co 1-4 diem la 100%, ty I^ tiT vong cua cac benh nhan 5 diem la 100%i|(
IV. BAN LUAN
Mau tu trong nao la mgt the clJa tai blen mach nao, chiem 15-20%, de lai nhieu di chimg nang ne. Co nhieu phu'dng phap dieu tri mau tu trong nao nhu dieu tri ngl l<hoa - bao td'n khong phau thuat, phau thuat. Muc di'ch cua phau thuat la cam mau, lay bo mau cue, giam hieu u'ng chen ep, giam anh hu'dng cua cac san pham giang hoa tu' mau nhanh chong.
Trong nghien ciJu cua chung toi, ty le nam mac cao hdn nff (nam/nif la. 3/1), cung tu'dng bi nhu' nghien ciJu cua Nguyen Quang Bai [5], Co le do nam mac tang huyet ap nhieu hdn nff. Phan ldn cac benh nhan deu tren 50 tuoi (chiem gan 75%).
Tlieo Trjnh Thi Khanh (2004) cac trieu chffng khi khdi phat berih gom: Roi loan y thffc (76,7%), dau dau (57,5%)[6]. Ket qua ciJa chung toi cho thay: roi loan y thffc la trieu chffng hay gap nhat (88,9%), kSt qua ciJa chung toi cao hdn Trinh Thi Khanh co le do benh nhan trong nghien cffu nang hdn d benh vien Hffu Nghi; tiep do la dau dau (52,8%) va liet nffa ngffdi (50%).
Ket^qua nghien cffu cua chiing toi cho thay dang ton thffdng hay gap nhat la mot 6 chay mau (97,2%), chay mau 2 S chi gap d 1 benh nhan, khong co benh nhan nao co 3 6 mau tu.
Theo Nguyen Quang Bai [5], chi dinh phau thuat is bat ky vi tri nao trong nao (trff viing cau nao, cuong nao, cu nao sinh tff), Broderick va cdng sff [7] nen han che phau thuat ban cau ffu the vi cho ket qua it kha quan. Da so benh nhan cCia chung toi thuoc nhom xuat huyet tren leu (89%), trong do gap nhieu hdn d ban cau trai (55%), hieu qua phau thuat d ban cau ben phai tot hdn ban cau ben trai. Mgt so nghien cull khuyen cao nen phau thuat cho cac benh nhan xuat huyet nao cd dffdng ki'nh khoi mau tu
>2cm, benh nhan cd khoi mau tu dffdng kinli
>5cm phau thuat cho ket qua khong tot [5], [7].
Theo Broderick va cong sff (2005) [7]: tong ket nghien cffu 1033 BN phau thuat xuat huyet nao d 83 trung tam cua 27 quoc gia, tac gia nhan thay: Cac thff nghiem khong noi len hieu qua phlu thuat sdm trong 12 gid dau, 26% cic, trffdng hdp dffdc phau thuat sau 60 gid (27-9? .' gidj, ket qua tot hdn nhdm phau thuat sdm, phau thuat khong nen dffdc thffc hien trong vdng 24 gid. Theo Nguyen Quang Bai, thdi gian dieu trj ngi khoa trffdc phau thuat thffdng la 5-8 ngay. Trong nghien cffu nay thdi gian chi djnh phau thuat gap nhieu nhat la 1-7 ngay (55,8%), phil hdp vdi cac tac gia tren.
Cd nhieu phffdng phap phau thuat dieu trj xuat huyet nao do tai bien mau nao nhff: Md so lay mau tu, dan Iffu nao that ra ngoai, dan lull nao that ra ngoai va lay khoi mau tu phia "salijg khoan sg va choc hut mau tu... Q Viet Nam cufig>i da tien hanh cac phffdng phap tren nhung^.;
phffdng phap md sg lay mau tu van dffdc su' dung nhieu nhatTrong nghien cuii nay co 27/36 benh nhan dMc thffc hien bang phffdng phap tren, chiem 75%; tiep theo la dan Iffu nao that ra ngoai 16,7%.
Theo Butcher K va cgng sff (2002), ty le tiJ vong trong vong 30 ngay ciia xuat huyet nao la;.
34-50%. Zuccarello cung khuyen cao chgn phau.
thuat cho cac benh nhan cd diem Glasgow tff 5- 15 va the tich khoi mau tu tren 10ml, sag: 3 thang ty le tff vong la 22%,, tien trien xau la, 44%. Theo Nguyen Thj Thoan (2008): 78 benh':
nhan xuat huyet nao dffdc phau thuat cd 29 benh nhan tien trien tot chiem 37,2%, tien then' xau cung chiem ty le 37,2%, tff vong chlem ty 18 25,6%. Trong 36 benh nhan nghien cihi cd 18 benh nhan tien trien tot (50%), 16 benh nhan' * tien trien xau (44%) va 2 benh nhan tff voiijg trong vong 30 ngay, ket qua cua chung toi phifiS
hdp vdi cac nghien cffu tren. ^i
TAP CHl Y HOC VIET NAM TAP 450 - THANG 1 - SO 1 - 2D17
€>iem Glasgow luc nhap vien cung la mpt yeu to fien iu'dng hieu qua phau thuat. Ty le benh nhan tien trien t o t sau mo d nhdm 3-5 diem la 16,67%, d nhdm 6-8 diem la 46,67%, d nhdm 9- 12 diem la 5 0 % va cao nhat d nhdm 13-15 diem 57,14%, sir khac biet cd y nghTa thdng ke vdi p<0,05. Nhu* vay diem Glasgow cang thap thi tien lu'dng hau phau cang toi.
Cd rat nhieu bang diem danh gia benh nhan xuat huyet nao nhu'ng khong cd s i / thong nhat trong viec su" dung bang diem nao trong danh gia ben lu'dng, dieu trj cung nhu" nghien cii'u.
Bang diem Hemphill vdi muc tieu ban dau tien lu'dng tu" vong d benh nhan xuat huyet nao trong vong 30 ngay sau tai bien mach nao. Bang diem Hemphill vdi muc tieu ban dau tien lu'dng tu' vong d benh nhan xuat huyet nao trong vdng 30 ngay sau tai bien mach nao. Theo Hemphill ( 2 ^ 1 ^ khi nghien cull tren cac BN xuat huyet nao tai 2 trung tam than kinh tai California trong 2 nam 1997-1998 da danh gia ty le td vong trong 30 ngay ciia BN xuat huyet nao tang dan theo so diem: Vdi Hemphill 3 diem ty le tu" vong 56-78%, Hemphill 4 diem ty le tir vong la 70- 100%, 5 diem thi ty le tu- vong la 100% va khong gap benh nhan 6 diem. Thang diem Hem phill da du'dc mot so tac gia ap dyng va cong nhan tinh ddn gian, thiet thu'c, hieu qua. TTieo nghien cu'u ciia chung toi tren 36 BN mau t u trong nao do tai bien; 4 BN diem Hemphill= 1;
6BN diem Hemphill 2; 23 BN diem Hemphill 3; 1 BN diem Hemphill 4 va 2 BN diem Hemphill 5, khong cd BN nao Hemphill 6 diem. Trong do vdi nhom BN cd diem Hemphill tu' 1 den 4 khdng cd ai tu'vong, 2 BN diem Hemphill 5 deu tu'vong, t / le tit vong vdi Hemphill 5 diem la 100%. Nhdm BN chil yeu du'dc phau ttiuat ia nhdm cd diem Hemphill bang 3 diem, dieu nay cd the giai thi'ch la do BN trong nhdm 1,2 diem Hemphill cd the can nhac dieu tri npi khoa nhieu hdn, BN trong nhdm diem Hemphill 4,5 ty l | tu'vong sau mo rat cao nen so lu'dng BN kha it. 2 BN diem Hemphill 5 diem van cd chi dinh mo la do nguyen vpng tha thiet tir gia dinh muon du'dc phau thuat cho BN mac du da du'dc nghe giai thi'ch rat kT td phia thay ttiuoc ve nguy cd t i r vong cu'c cao ciia BN sau mo.
V. KET L U A N
Mau t u frong nao do tai bien mach nao gap d nam nhieu hdn d nfi' (ty le 3/1), chii yeu gap d ngu'di tren 50 tuoi ( 7 5 % ) . Trieu chuTig lam sang khdi laenh hay gap nhat la roi loan y thiTc (88,9%), tiep theo la dau dau (52,8%). Dang ton tiiu'dng hay gap nhat la mot 6 mau t u (97,2%), mau tu chu yeu gap vj fri tren leu (89%).
Cd nhieu phu'dng phap phau thuat dieu tri mau tu trong nao do tai bien mach nao: Hd sp lay mau t u ; dan lull nao that ra ngoai; khoan sp, hut mau tu... Trong d d , m d sp lay mau tu la phu'dng phap du'dc sir dung nhieu nhat. Ket qua phau thuat con han che 5 0 % BN tien frien tot, 4 4 % tien trien xau, 6 % tu" vong sau phau thuat.
Bang diem Hemphill ia mot bang diem giup tien lu'dng benh nhan xuat huyet nao do tai bien mach nao trong vong 30 ngay dau ddn gian, chinh xac, giup tien lu'dng va chpn hu'dng dieu trj thich hdp.
TAI UEU T H A M KHAO
1. Sutherland GR, Auer RN(2006). primary intracerebral hemorrhage. Neurosci, pp. 551-7.
2. Albers GW, Amarenco P, Easton JD, Sacco RL, Teal P(2008). Antithrombotic and thrombolytic therapy for ischemic stroke: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines, chest.
3. Van Asch C33, Luitse MJA, Rinkel GJE, vander Tweel, Algra A, Klijin a M ( 2 0 1 0 ) . Incidence, case fatality, and functional outcome of ICH overtime, according to age, sex, and ethnic origin:
a systematic rGview and meta- analysis. Neurol, pp. 167-76.
4. Zhang L-F, Yang 3, Hong Z, et al[2003).
proportion of different subtypes of stroke in China.
Stioke, Bp. 2091-6.
5. Nguyen Quang Bai, N g u y i n Quang Long(2001). Nhan xet kit gua bddc <^u diiu tif xuat huyet nao do tai tiiih mach mau nao( tang huyit ap va di dang mach) bang khoan mot io xu'dng ^ chge hui khoi mau tu. pp. 131-137.
6. Trjnh Thj Khanh(2004]. Nghiin dki chan doan va dieu tii chay mau trong nao d nhO'ng ngudi tang huyet ap. Luan an tien sT y hoc tru'dng Oai hpc Y Ha Ngi.
' Broderick JP, Adam HP, Barsan W, et al(1999). Guideline for the management of Spontaneous Intracerebral Hemorrhage: A statement for Healthcare Professionals from a Special Writing Group Council, American Heart Asociation, Vol. 30, 4, pp. 905-915.
