TAP CHI Y DLTOC LAM SANG 108 Tgp 6 - So 5/2011
Danh gia hieu qua cua lieu phap thay the than lien tuc dieu tri benh nhan bong nang
Evaluation of Effectiveness of Continuous Renal Replacement Therapy on Severely Burned Patients
Tran Ngoc Tuan Hoc vien Qudn y
Tom tat
Muc tieu: Oanh gia hieu qui cua lieu phap thay the than trong dieu trj benh nhan bdng nang. Tac gia da apdung lieu phap dieu trj cho 51 benh nhan bong nang (TU 1/2004 den 1/2008). P/?t/cngphdp; sUdung hai ky thuat: sieu Ipc lien tuc tinh mach- tinh mach va Sieu Ipc lien tuc ket hgp vdi tham tach mau. Kit qud thay rang : Tinh trang lam sang dugc cai thien di cung vdi sU thai Ipc cua cac cytokine sau khi dugc ap dung lieu phap thay the than lien tuc (p<0,01). Lieu phap gop phan cUu song nhQng benh nhan bong nang.
TUkhod: Cytokin; Lieu phap thay the than lien tuc.
Summary
Purpose: This prospective study investigated the effect of CRRT (Continuous Renal Replacement Therapy) on 51 severely burned patients admitted to Burned ICU National Institute of Burns from 1/2004 to 1/2008.
Methods: The use of two techniques: continuous veno - venous hemofiltration and continuous veno - venous hemofiltration dialysis. Results : The result showed that after CRRT, the plasma concentration of pro inflamatory cytokine including IL6, IL8 and TNFa significantly decreased (p < 0.01). In addition, the clinical improvement amounted to 50/51 patients (98.04%), and the mortality rate was 45.1%.
Keywords: Cytokin; Continuous Renal Replace Therapy.
1. Oat van de nhiem khuan bdng, lieu phip thay the than lien tue Dap Ung cua co the^ vdi chan thUdng bdng la bing (^^^^T: Continous Renal Replacement Therapy) dugc hdi ehUng dap Ung viem mang tinh he thdng (SIRS). ^ " 9 dung tai Viet Nam trong dieu trj bdng bang may Khi bdng, nhiem trung nang... de bj rdi loan ehUc nang ^^^^V^." ^ ^ " 9 1 ^ n i m 2003. Xult phit tU thUe tien tren, tang va neu khdng dugc eUu chUa kjp thdi v l dung thi ^^^ ^'^" *^"^ ^^ ^^' "^^ '^•
se chuyen sang trang t h i i rdi loan chUe ning da tang, D i n h g i l hieu q u i eua lieu p h i p thay the than suy da tang va ty le tUvong d nhUng benh nhin nay ed lien tue trong dieu trj benh nhan bdng nang.
the tdi 100%. Cle chat trung gian chuyen hda, cle 2. Doi tUgng va phUtfng phap nghien ciJu cytokines vUa la nguyen nhin, vUa la hau q u i cua rdi
loan benh ly. Nhieu t i e g i l da de xuat elc bien phip 2.1. Doi tuong nghiin cUu: 51 benh nhin dieu trj nhU: Dung cac chat trung hda cytokine, elc bdng nang nhiem ddc nhiem khuan ed rdi loan chUc phan tU ket dinh cung nhU loai thai cytokine. Lieu nang tang (45 benh nhan bdng nhiet khd, 3 benh phap thay the than la mdt trj lieu dap Ung dugc mue nhan bdng nhiet udt va 2 benh nhan bdng do vdi tdi dich nay. Trong eae bien phap dieu trj nhiem ddc ndng; tudi tU 19-45; 32 nam, 19 nU).
Phan bien khoa hgc: PGS.TS. LE THU HA
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JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY V i6-N°5/2011
2.2.PhUOng phap nghiin cUu: tien cUu ean thiep lam sang.
2.3. Thiit ki nghiin cUu: benh nhan dUgc Ung dung lieu phap thay the than lien tue dieu trj b i n g m i y Igc m l u Kimal v l m i y Igc m l u HF400 tai khoa Hdi sUe cap eUu Vien Bdng Qudc Gia tU 1/2004 - 1/2008. Cle benh nhan dugc trj lieu lien tue 01 lan (12h 24h thay m i n g Igc 1 lan): 36 benh n h i n sU dung ky thuat sieu Igc lien tue tinh mach - tinh mach (CWH), 15 benh nhan dUge I p dung ky thuat sieu Igc lien tue ket hgp vdi tham t i c h m l u (CWHD);
35/51 benh n h i n duge ap dung lieu p h i p ngay thU 4 den ngay thU 6 sau bdng; lugng djch trao ddi trung binh: SO lit/24h; thdi gian Igc trung binh: 36 gid. Ngoai Ung dung lieu p h i p thay the than lien tue, cle benh nhan dugc dieu trj tich cue nhU: thd may, thudc van mach, nudi dudng sdm dudng rudt, eac tri lieu tieh cUe tai cho... Khdng Ung dung lieu phap khi tinh trang benh n h i n ed dien tich bdng sau q u i Idn, rdi loan ddng mau nang. D i n h g i l tinh trang benh nhan b i n g l l m sing va cle xet nghiem, dinh lugng cle cytokine.
Lay mau huyet thanh eua benh n h i n trude thdi diem b i t dau Igc m l u v l sau trj lieu, djch Igc (khi ap
dung trj lieu dugc 06 gid) djnh lugng eae cytokine, Djnh lugng IL6, ILS trong huyet thanh b i n g phi/ang p h i p mien djch g i n enzym (ELISA) theo nguyen t^c Sandwich mdt giai doan, mdi xet nghiem sCf dung hai khing the don ddng. Oinh lugng TNFa trong djch Igc v l huyet thanh b i n g ky thuat RIA theo nguyen lycanh tranh.
3. Ket qud nghien cufu
Bing 1. Phan loai theo dien tich bdng chung
Tri lieu CRRT(n-51)
Dien tich bdng (% dien tich cotiie) 30-39
8
40-49 15
50-59 13
60-69 > 70 10 1 5 Benh n h i n dugc Ung dung lieu p h i p chu yeuco dien tieh bdng ehung 40-59 % dien tieh co the (DTCT) (28 benh nhin).
Bing 2. Phan loai theo dien tich bdng sau
Trj lieu CRRT(n = 51)
Dien tich bdng (% DTCT)
< 9 i 10-19 22 , 10
20-29 30-39 6 5
>40 8 Cd 8 benh nhan dien tich bdng sau tren 40- dugc Ung dung lieu p h i p .
Tir
Tmh trang ythUc
Tuan hoan (dung thuoc van mach)
Nude tieu
Thd may
Chuong bung Nhiet do
B i n g 3. Tmh trang suy tang trUde va sau khi CRRT
)h trang suy tang C6 roi loan Khong roi loan Phai dung thudc Giam lieu
Khong p h i i dung thuoc
< Iml/kg/h
> Iml/kg/h BN ph^i thd may
Thd may g i i m dugc FiOj va PEEP Khong g i i m
Giim
Trudc CRRT n
51 0 49
1
15
29
51
% 100%
0%
38,55 ± 0,18°C
Sau CRRT
n % 16
35
32 17 6 9 8
31,4%
68,6%
65,3%
34,7%
40%
60%
27,6% , 21 72,4%
22 29
43,1%
56,9%
37,35 ± 0,26°C
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TAP CHl Y DLTOC LAM S A N G 108 Tap 6-So 5/2011
|: Benh n h i n trUde khi dung lieu phap CRRT d l iugc dieu trj tich cue, thd may, dung elc thudc van mach... tinh trang y thUe vat va, la het rdi loan djnh nUdng hole li bl tren ca 51 benh nhin, p h i i dung :hude van mach la 49 benh nhin, sd lugng nude tieu
< Iml/kg/h la 15 benh nhan, p h i i thd m i y 29 benh nhan, chudng bung gap d tl't el 51 benh nhin. Ket q u i sau lieu p h i p CRRT ed 35 benh n h i n (68,6%) y thUe hdi phuc, tinh tao het vat v l kich thieh, 17 benh nhan (34,7%) trong nhdm phii dung thude van mach e l t dugc thudc van mach va 32 benh nhin giim lieu thude, 9 benh n h i n (60%) ed nUdc tieu trd lai (lugng nude tieu > Iml/kg/h), 21 benh nhin (72,4%) trong nhdm thd m i y g i i m dugc Fi02 v l PEEP, 29 benh n h i n (56,9%) g i i m chudng bung rd.
Bang 4. Ndng do elc cytokin trong djch igc d thdi diem gid thU6 eija trj lieu
Cytokin IL6 IL8 TNFa
Nong do
316,217 ±34,453 (Pg/ml) 599,262 ±163,585 (Pg/ml)
0,834 ±0,145 (ng/ml) Ndng do elc cytokine trong huyet thanh g i i m sau 6 gid trj lieu CRRT.
Bang 5. Ndng do cle cytokin huyet thanh sau khi Ung dung lieu p h i p thay the than
Cytiokine IL6 (Pg/ml) ILS (Pg/ml) TNFa (ng/ml)
Trudc CRRT 565,12 ± 158,65 1591,261516,74
2,1310,214
Sau CRRT 196,23144,3 352,951165,28
0,89210,253
P
<0,01
<0,01
<0,01 Ndng do cac cytokine trong huyet thanh g i i m 'd ret cd y nghia (p<0,01) sau trj lieu CRRT.
* Ty li tU vong: 23/51 (45,1%); tat ca eae benh nhan tien trien tdt sau CRRT nhung sau dd dien bien nang trd iai do tdn thUdng bdng sau Idn, khdng Jong kin dugc tdn thUdng, nhiem doe nhiem khuan
rd lai va tCr vong do suy da tang .
Biin chUng: khdng gap trUdng hgp nao rdi loan ddng mau sau Igc, t i c khi, sai sdt eIn bing djch...
4. Ban luan
Viec t i n g cao khdng kiem solt dugc boat ddng cua cle te bao viem, elc IVlediator viem sau chan thuang bdng, nhiem khuan II chia khda de phat trien rdi loan ehUe nang cle tang, hdi ehUng suy hd hap cap tien trien (Acute resspiratory distries syndrome: ARDS)... lam t i n g ty le tU vong. Mdt vai b i o cao d l ehi ra hieu q u i cua sieu Igc lien tue tren hd hap, tuan hoan d nhUng benh nhin nhiem khuan nang, rdi loan ehUe ning tang. \Ju diem eua phuong p h i p nay ed the d i o t h i i cle chat ed trgng lugng phin tU trung binh nhU cytokine, yeu td boat hda tieu cau, mdt sd ddc td, leukotrienes qua m i n g sieu Igc (Hemofilter), cle sin pham ddc ed trgng lugng p h i n tU Idn ban cd the dugc hap phu.
Ham lugng cle cytokine (IL6, 1L8, TNFa) giim mdt each cd y nghla sau lieu phip thay the than (p <
0,01) va cle cytokine tim thay trong djch Igc. Ket q u i nay phu hgp vdi nghien cUu eua mdt sd t i c g i l nhU:
Tran NggcTuan (2004), HoffmannJN, Eugen F.(2001) [1], [4]. Lgi diem quan trgng eua lieu p h i p thay the than lien tuc la dao t h i i lien tue cle sin pham ddc, sin phi'm cua q u i trinh chuyen hda v l mdt lugng Idn cle chat trung gian. Chinh sU thay ddi ndng do eua cytokine trong m l u II elch tdt nhl't chUng minh hieu q u i eua trj lieu. Da sd cle nghien cUu, deu khang djnh sU thanh cdng cua CRRT trong viec thanh t h i i IL6, IL8, cle ddc td vi khuan. Hieu q u i cua dao t h i i TNFa cdn nhieu ban cai, eae nghien cUu dUa ra nhUng ket q u i khic nhau, tU viec khang djnh lieu phap thay the than lien tuc khdng dao t h i i dugc TNFa den viec d i o t h i i dugc 52% ndng do TNFa.
De ly g i l i sU khic biet nay la do: TNFa boat ddng ed trgng lugng p h i n tU (TLPT) 52000 Daltons (gdm 3 TNFa khdng boat ddng), vdi TLPT nay TNFa boat ddng se khdng qua dugc mang sieu Igc (thii dugc tdi 30.000 Daltons). Tuy nhien, nhieu t i e g i l cho rang khi TNFa tiep xue vdi mang sieu Ige chung phan tach va giai phdng tao eae TNFa ddn cd the qua dugc mang sieu Ige t h i i ra ngoai. Chinh vl vay, ty le thanh t h i i TNFa khac nhau phu thudc vao sU 15
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol 6 - N°5/201' khac nhau eua mang Igc. Dieu nay chUng minh ket
q u i nghien eUu eua chung tdi I I CRRT t h i i Ige dugc TNFa. NhUng benh n h i n trong nghien cUu n i y dugc Ung dung lieu phap thay the than lien tue thi viec dao t h i i cle cytokine g i n lien eli thien ve lam sing (tinh trang huyet ddng, hd hap, than nhiet...). Viec cung cap dxy te bao dugc eli thien bdi Ige m l u lien tuc va nhd dd eli thien vi tuan holn, eli thien tinh trang huyet ddng va t o i n than.
IVldt sd t i c g i l eho ring Ige m l u lien tue tinh mach tinh mach (CWH) la mdt trong nhUng phuang p h i p chuan eua ky thuat thay the than lien tuc trong dieu trj benh n h i n nang l l m t i n g k h i n i n g cUu sdng va p h i i ket hgp chat che vdi nudi dudng dudng tieu hda cung nhu kiem solt eIn b i n g dich [5], [61.
HIadikm Tymonova J nhan mach hieu q u i eua Ige m l u lien tuc trong dieu trj bdng, tuy v l y cle t i e g i l eho r i n g bien ehUng ehly m l u cdn eao d nhUng benh n h i n bdng khi tien hanh ky thuat n i y [3]. Viec I p dung lieu phap thay the than lien tuc (CRRT) trong dieu trj nhiem ddc nhiem khul'n bdng dem lai kha quan, gdp phan n i n g eao ty le eUu sdng ngudi benh bdng.
Chung KK va cdng sU nghien eUu lieu phap thay the than lien tue d benh n h i n suy than cap tinh do bdng nghiem trgng q u i n ddi tai Iraq va Afghanistan eho ket q u i g i i m ty le tU vong trong 28 ngay (22%
so vdi 75%, p=0,002) va g i i m ty le tU vong trong benh vien (56%, so vdi 88%, p=0,04) d nhdm dung CRRT so vdi nhdm khdng dung lieu p h i p n i y [2].
Trong nghien cUu cua Tran Ngge Tuan (2004), ty le tU vong d nhdm benh n h i n ed rdi loan ehUe n i n g tang dugc Igc m l u la 38,71% thap ban rd ret so vdi nhdm khdng dugc Ige m l u 87,5%, (p < 0,01), ed y nghia thdng ke el khi hieu chinh cho tudi, dien bdng (p < 0,001) [1]. Trong nghien eUu nay, ty le tU vong d nhUng benh nhan dugc Ung dung lieu p h i p thay the than la 45,1%.
Chu truang la ufng dung lieu phap thay the than lien tuc sdm, du, an toan va hieu q u i . Trong tuang lai vdi sutien bd cua y hgc va phuang tien, lieu phap thay the than ket hgp nhieu phuang thiJe dieu trj
tieh cue ehung ta ed the eUu sdng nhieu ban nGfi benh n h i n bdng nang.
5. Ket luan
Qua nghien eUu tren 51 benh n h i n bdng nang dugc I p dung lieu phap thay the than lien tuc (CRRT) 1 lan ehung tdi rut ra ket luan sau:
Hieu q u i : Lieu p h i p thay the than lien tue cotac dung thanh t h i i cle cytokines 1L6, ILS, TNFa (p<0,001). Lieu p h i p gdp phan thuc day dien bien l l m sing thuan Igi d benh nhan bdng nang co roi loanchUe n i n g tang.
Bien chUng: Trong nghien eUu khdng thay cac tai bien v l bien chUng cua lieu p h i p .
Tai lieu tham khio:
1. Tran Ngoc Tuan. "Nghien cUu lam sang va Ung dung phuong phap Igc mau lien tuc gop phan dieu tri ngudi benh bdng trong thdi ky nhiem dpc nhiem khuan". Luan an tien sy y hgc ( 2004).
2. Chung KK, Juncos LA, Wolf SE. "Continuous renal replacement therapy improves survival in severely burned military casualties with acute kidney injury"
2008 feb;64(2 Suppl):Sl 79-85; discussion 5185-7.
3. HIadikm. TymonovaJ et al. (2001). Treatment by continuons renal Replacement therapy in Patients with burn injuries'
4. HoffmannJN, Eugen F.(2001). "Removal of Mediators by continues Hemofitration in septic patients'. World J Surg; 25:651 -659.
5. John A. K, Ravindra L. Mehta. Derek C. A et al.(2002).
'The first international consensus conference on continuous renal replacement therapy^Kidney International Vol 62 pp. 1855-1863.
6. Richard Tremblay et al.(2000). "Veno - Venous continous renal replacement therapy for burned patiens with acute renal failure". Burns: volume 26, issue 7,1 November page 638-643.
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