TAP CHf Y DdOC U M SANG 108 Tap12-S6l/2017
Dieu tri tim b i m sinh phu thuoc ong dong mach
A study of the treatment of duct dependent lesions
Tru-ffng Thi Mai Hong*, LI Anh Trong** *B^nh vien Trung uong Quan dpi 108
**Benh vien Nhi Trung uong
Muc tieu: Nhdn xet hieu qua cCia eae phuong phap d i l u tri duy tri dng ddng mach. Doi tuang vd phuang phdp: Mb td cat ngang, phan tfch 60 b i n h nhan t i m bam sinh phu thudc dng. Kit qud: Benh nhan phdi nhap v i l n ngay trong ngay dau sau sinh la 36,66%; chi djnh ngat oxy ehi 15%; sd dung PGEl Id 61,7% trong ngay dau tien. Sd b i n h nhdn phdi diJng PGEl lieu eao la 60%. Khf mau cdi thien rd ret sau khi sd dung. Kit ludn: Can phdi ngat oxy sdm vd dieu trj PGEl hieu qua trong duy tri dng ddng maeh.
TUkhod:T\m bam sinh phu thudc dng.
Summary
Objective: To assess the outcome of the treatment for maintaining d u a a l patency. Subject and method: A cross sectional study was conducted to analyze 60 patients w i t h duet dependent lesion.
Result: Patients w h o had t o hospitalize within one day old were 36.66%. 15% of participants were Indicated t o stop oxygen supply. 61.7% of children needed PGEl on the first day o f life. A total 60% o f the participants required PGEl with high doses. The blood gas saw a significant improvement after treatment. Conclusion: Prevention of oxygen use and early indications of PGEl were effective In maintenance of ductal patency.
Keywords: Duct dependent lesions.
I . O a t v a n d e
Benh t i m bam sinh (TBS) phu t h u d c d n g d d n g mach (ODM) la m o t n h d m benh dac b i e t t r o n g d d sU tdn tai eua OOM cd ^ nghTa song edn ddi vdi tre so sinh vd t r i nhd. Viec glCf cho mau luu t h d n g qua OOM dupe x e m n h u d i l u tri bdo t d n sinh mang benh nhdn [1]. T r I n t h i gidi, chan doan va dieu tri benh TBS phu thudc OOM da dupe bdt dau vd phat trien t d n h d n g nam bay m u o l cCia t h i ky trudc. Tai Viet Nam, t r o n g t h d i gian gan day, vdi su tien b d vupt bac v l ky t h u d t chan dodn, phau t h u d t cham sdc hdi sdc, va su cd mat cCia PGEl da cd nhieu hon
Ng&y nhgn bdi 21/11/2016, ngay ch&p nhan dang: 02/12/2016 Nguaiphan hdi: Tnamg ThiMaiHong.
Email: maihonghoa98@ gmail.com - Benh vien Nhi Trung uong
nhdng benh nhi cd chan doan benh t i m bam sinh p h u t h u d c C O M dupe dieu tri cdu song c h d can thiep n h d n g p h u o n g phdp hieu qua va t r i l t de h o n . Vi vay chung tdi t i l n hdnh de tai ndy vdi muc tieu Nhdn xit hiiu qud cua cdc phuang phdp dieu tri duy tri ong dong mach.
2. D d i t u p n g va phUOng phap
2.1.D6ititang
Tat ea n h d n g benh nhi dupe chan dodn xac d j n h benh TBS p h u t h u d c OOM bang sieu am t i m bdi bac sy chuyen khoa t i m maeh tai Khoa Cap cdu va Khoa So sinh Benh v i l n Nhi Trung u o n g t d ngdy 1/3/2013 d i n ngdy 1/9/2013.
2.7.7. Tieu chudn lUa chgn
Tat ca cdc benh nhan ed chan doan 6\Jac dieu trj duy tri dng d d n g mach bdng cae b i l n phap sau:
19
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N''1/201
Khdng t h d oxy ho t r p .
Duy tri m d d n g d d n g mach bdng PGEl.
2.12. Tiiu chudn loai trU
Nhdng benh nhan t d v o n g trUdc khi dugc chan doan TBS phu t h u d c OOM.
2.2. Phttc^g phdp
Phupng phap nghien cdu m d ta cd phan tfch, so sanh s d d u n g phdn m e m SPSS 16.
3. Ket quS
3.1. Dac diem c^a ddi f u'cAig nghien cCtu Trong t h d i gian n g h i l n cdu ed 60 benh nhi dupe chan doan xac d j n h benh TBS phu thudc d n g . Ode diem chung cOa mau n g h i l n cdu n h u s a u :
Bdng 1 . Phan bo b i n h nhan theo t u o i , gidi Nhom
tuoi S6luong T y l e % Gidi
< 1 ngay
22 36,66
1 - 7 ngay
13 21,67 Nam 37 (61,67%)
8 - 3 0 ngay 25 41,67
Tong 60 100 Ntt 23 (38,33%) Nhdn x l f ; Trong n g h i l n cuu cOa chung tdi cd d i n 36,66% t r i phdi nhap v i l n ngay trong ngay dau t i l n sau sinh, vd cd tdi 58,33% t r i phdi nhap v i l n ngay trong tuan dau t i l n sau sinh. T^- I I nam gap nhieu hon nd.
Bdng 2. Ty le cac benh TBS phu tiiudc dng dong mach
Nhdm
Nhdm cd cdn t r d mau cCia tuan hoan he thdng
Nhdm cd cdn trd mau cua tuan hoan phdi Nhdm cd bat thudng ca tudn hoan h i thdng va tuan loan phoi.
Benh
Hep eo, gian doan OMC Hep nang van OMC.
Hdi chdng thieu sdn that trd i.
Hep nang van Odng mach phdi OMP.
Thieu sdn OMP.
Thieu sdn van bald.
T h i l u s a n t h d t p h d i Fallot 4.
Chuyen gde ddng mach (CGOM)
Sd iUAig
(n)
16
29
15 T y l e
%
26,67
48,33
25
Nhdn xet: N h d m cd cdn t r d m d u cOa t u a n hoa p h d i cd t^ ll-eao nhat (48,33%).
3.2. Nhan xet dieu trj va kit qud
T r o n g nghien edu eua chOng t d i , cd t d i 51(8591 b e n h nhdn k h d n g dupe ngdt oxy, chi cd 9 (159(
benh nhdn duac ngat t h d oxy sau c h i n dodn.
Bdng 3 . Thay tfoi SpOz sau n g i t Oxy Thay doi
Sp02 Solaong Jf\e%
GiSm>
1 0 % 1 11,10
< 1 0 % 7 77,80
Kh6ng thay do!
1 11,10 Nhdn xet: 88,90% b e n h nhdn sau khi dUpc nga oxy ed Sp02 giam < 10% hoac k h d n g t h a y ddi.
Bang 4 . Thdi gian
Sd lupng T y l e %
tra l i l u lifdng sdrdung Thdi gian
Trong 24 gid 37 61,7
Sau 24 gid 23 38,3
PGEl Lieu lupng Binh thudng
24 40
Cao
36 60 Nhdn xet: Cd t d i 38,3% b i n h nhan dUpc sd dung PGEl sau 24 g i d vao v i l n . Oac biet cd trudng hpp dupe chan dodn vd sd d u n g PGEl sau 16 ngdy nam vien. 6 0 % b i n h nhan da phai diJng lieu PGEl eao de g i d 6 D M , ehi cd 4 0 % benh nhdn dupe dung l l l u t r o n g gidi han b i n h t h u d n g .
Hinh 1 . Bien chdng ngdng t h d sau dicing PGEl Nhdn xet. Cd 10 benh nhdn cd trieu chdng n g u n g t h d sau khi sd d u n g PGEl can dat ndi khi q u d n , e h i l m 16,67%. Cdn lai 50 benh nhdn, c h i l m 83,33% khdng gap trieu chdng ndy.
TAP CHf Y Dl/OC LAM SANG 108
Tapl2-S61/2017
Bdng 5. Thay doi khi mdu sau dung PGE1
Nhdm cd cdn trd mau cOa tudn hoan he thdng (nhdm 1).
Khi mau (nhom
1) PH PaOi PaCOj HCOj- Laaat
Trirdc ( M e a n ± S D )
7,29 ±0,03 65,93 ±13,51
39,5 ±3,16 19,57 ±1,78 9,17 ±1,61
Sau (Mean ± SD)
7,35 ± 0 , 0 4 48,071 ±7,38
49,36 ±1,99 27,55 ±2,51 6,31 ±1,38
P
0,03 0,26 0,00 0,00 0,01
Nhdm ed can trd mdu eua tuan hoan phdi (nhdm 2).
Khi mdu (nhom 2)
PH PaOj PaCOj HCO3- Lactat
TniiK ( M e a n ± S D )
7,32 ± 0,03 26,90 ±2,43 41,36 ±2,31 22,93 ±1,01 5,86 ± 0,91
Sau ( M e a n ± S D )
7,35 ±0,03 39 + 2,48 41,72 ±2,59 22,31 ±0,82 3,99 ± 0,50
P 0,58 0,00 0,85 0,68 0,01
Nhdm ed bat thudng cd tuan hoan he thdng va tuan hoan phdi (nhdm 3).
Khi mciu (nhom
3) PH PaOj PaCOi HCO,- Lactat
TrUorc (IHean±SD)
7,34 ±0,37 18,076 ±2,12
42,23 ±4,63 21,51 ±1;26 5,76 ±0,67
Sau (Mean ± SD)
7,3 ±0,29 23,307 ±2,16
49,76 ± 3,92 24,17 ±1,45 4,96 ±1,02
P
0,32 0,00 0,00 0,00 0,43 Nhdn xet: Sau khi sd dung PGEl:
Nhdm cd cdn trd mdu eCia tuan hoan he thdng dd ed sU gidm cd y nghTa cCia ehi sd Lactat td 9,17 ± 1,61 xudng cdn 6,31 ± 1,38 vdi p<0,05. Nhdm cd edn trd mdu cOa tudn hoan phdi da ed sU cai thiln rd ret Pa02 trong mau td 26,90 ± 2,43 len 39 ± 2,48 vdi
p<0,05. Nhdm cd bat thudng ed tuan hoan he thdng va tuan hoan phdi ed sU cdl thien ed ehi sd Laetat td 5,76 ± 0,67 xudng 4,96 ± 1,02 vd PaOi tdng td 18,076
±2,12 lln 23,307 ±2,16.
4. Ban luan
4.1. Dac diim chung cua mdu nghien citu
Trong nghiln cdu cOa chiing tdi, tuoi nhap vien cCia t r i trong ngdy ddu tiln (01 ngay) sau sinh la 36,66% vd sau ngay thd 8 Id 41,67%. T^' I I nay khae rat nhieu so vol nhdng nghien cdu khdc tren the gidi, theo nghiln culi cOa Aphrodite Tzifa vd edng sU [2] thi tuoi dupe chan dodn trung binh Id 01 ngdy (0,75 - 02 ngay). Theo Satoshi Hiraishi, Nobuyuki Fujino tuoi vao vien ciia t r i dao ddng trong thdi gian td 05 gid tuoi den 35 ngay, tuy nhien ehi ed mdt trUdng hpp duy nhdt dupe chan doan ngay thd 35 Id benh nhan hep eo ddng maeh ehCi, edn lai 76%
dupe chin doan trUde 05 ngay tuoi, nhung nghiln edu nay da lam td nam 1988 [3]. Oieu nay dupe hieu Id khd nang chan doan sdm cOa nhdm benh TBS ndi chung va TBS phu thudc dng ddng mach ndi rilng trIn the gidi cao hon han d Vilt nam, dac biet la chan dodn trude sinh.
Ve gidi tfnh cua benh nhdn, chOng tdi khdng thdy sU khae biet nhieu gida nghien cdu cCia chung tdi vdi nhdng nghiln cdu khdc. Ty I I nam trong cdc nghiln edu dIu Idn hOn nd; Nam/nd dao ddng td 1,2 - 1,8, cua chung tdi [a trong nghien cdu cOa
chOngtdila 1,6. * Ty le cac binh TBS phu thudc dng ddng maeh:
Chung tdi sd dung kit qud sieu am Doppler mau rim cua cae bac sT chuyin khoa Tim maeh, Benh vien Nhi Trung uong de dua ra eha'n doan xac dinh. Ty I I nhdm cd cdn trd mau cOa tuan hodn phdi cao nhat chiem 48,33%> nhdm ed can trd mau cCia tuan hodn he thdng vd nhdm cd bat thudng cd tuan hoan h i thdng va tudn hoan phdi cd ty I I tuong duong 26,67% vd 25%. T^ le cdc nhdm binh cung tUOng ddong trong nhdng nghiln cdu khac [1], [3].
4.2. Dieu tri vd hieu qud
Sau khi dupe chan dodn TBS phu thudc dng chi
ed 09 binh nhan (15%) cd chi dinh ngat oxy, ty I I
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY VoL12-N''l/201
nay qua t h a p so vdi nhiJng n g h i l n cdu khdc t r I n t h e gidi [4], [5], cd t h e la d o khi 6iiac chan dodn t h i t l n h trang cCia benh nhan da rat nang hoac cd t h e d o quan n l l m sai lam t r o n g d i l u t r i , cho t h d oxy d tdt ea cac benh nhdn cd t i m . Sau khi n g d n g cung cap oxy thi hau h i t cac b i n h nhan deu khdng cd chi sd Sp02 gidm dang ke. N h u vay khi cd chan doan benh TBS p h u t h u d c o n g d d n g mach t h i ehi d j n h ngat oxy se khdng lam dnh hUdng nhieu den Sp02 eua benh nhan va day la ehi d j n h can t h i e t
PGEl dupe sd d u n g t r o n g b i n h ly TBS p h u thudc dng d d n g mach d 61,7% benh nhdn eua chung t d i ngay t r o n g ngay dau t i l n nhap v i l n . Tuy n h i l n van cd t d i 23 benh nhan dUpc sd d u n g sau 24 gid, cd biet ed t r u d n g hpp dUpc ch^n dodn benh vd sd d u n g PGEl sau 16 ngdy nhap v i l n . Trong nghien cdu Satoshi H. cung cd m o t trUdng hpp dupe sd dung PGEl vdo ngay t h d 35 sau nhap vien, la t r u d n g hpp hep eo d d n g mach ehu [6]. Trong n g h i l n cdu cua Aphrodite Tzifa t h d i gian sd d u n g PGEl t r u n g binh la 3 g i d (2 d i n 6 gid) [2]. Ket qua ndy phu t h u d c k^aothdi gian va dja diem n g h i l n cdu.
Lieu lupng thudc: Cd tdi 36 b i n h nhan phdi sd dung lieu cao ngay t d dau chiem 60%, chi ed 4 0 % benh nhdn sd d u n g lieu binh t h u d n g . Ty I I nay eao i o n nhieu so vdi nhdng nghien cdu khac, ehi t r l n Judi 10% t r i phai sd d u n g l i l u eao [1]. Oieu nay la Jo benh nhdn t h u d n g dupe chan dodn m u d n , khi DOM da CO nhd. Cd t h e cd l i l n quan d i n khd nang :han dodn sdm eua chung ta edn han che va van :dn nhdng sai lam t r o n g d i l u t r i .
B i l n chdng ngung t h d : Cd 10 benh nhan, chiem 16,67% cd bien chdng ngung t h d sau khi sd d u n g 'GE1. T^ I I nay cung t u o n g d u o n g t r o n g n g h i l n edu :ua Garth D. Meckler la 12% [5]. Tuy n h i l n , t r o n g i g h i l n edu cCia chung tdi ed t d i 3 5 % tre khi sd d u n g 'GEl dang dupe dat noi khf qudn va t h d may, vl vdy hue t l khd danh gia tde d u n g khdng m o n g m u d n idyei!iaPGE1.
Thay ddi khf mau trude va sau khi sd d u n g PGEl;
N h d m CO edn t r d m d u eCia t u d n hoan h i t h d n da c d s d g i a m ed y nghia cCia chi sd Lactat t d 9,17 1,61 x u d n g c d n 6,31 ± 1,38 vdi p = 0 , 0 1 . N h d m cd cd t r d m a u cda t u a n hoan p h d i da cd sU edi t h i e n rd re PaOa t r o n g m d u t d 26,90 ± 2,43 l l n 39 ± 2,48 vc p<0,05. T r o n g n h d m cd bat t h u d n g ed t u a n hodn hi t h d n g va t u a n hoan p h d i ed t u y ehi sd Lactat gidm ti 5,76 ± 0,67 x u d n g 4,96 ± 1,02 khdng cd y nghl;
t h d n g k l (p=0,43) n h d n g ehi sd Pa02 t a n g len rd r l t d 18,076 + 2,12 l l n 23,307 ± 2,16 vdi p<0,05. Ke qud ndy c u n g rd r i t tUOng d U o n g v d i nhOng nghier cdu khdc t r l n t h i gidi [1], (7). H i l u qud cCia d i l u tr bang PGEl ddi vdi b e n h n h d n c d benh TBS p h i t h u d c d n g Id rat rd. Tuy n h i l n , chi sd Laetat ban dau t r o n g m d u cua b i n h nhan t r o n g n g h i l n cdu ciia c h u n g t d i eao h o n va PaOj t r o n g m d u eua b i n h nhan t h a p hon n h i l u so v d i n h d n g n g h i l n cdu khdc tren t h e gidi. Oieu ndy m o t Ian nda eho thay toan t r a n g cOa b e n h nhan t r o n g n g h i l n cdu eua chCing t d i khi vao vien Id rdt n a n g ne.
5 . Ket luan
Chi d i n h ngat t h d oxy t r o n g benh TBS phu t h u d c d n g d d n g mach ehi cd 15%; 61,7% benh nhan dupe s d d u n g PGEl t r o n g 24 g i d sau sinh; 60% so b i n h nhdn phai di^ng PGEl lieu cao. Khf mau dupe cai t h i e n rd r e t cd y tjghta t h d n g k l sau khi s d d u n g PGEl. Ody la m d t p h u o n g phdp dieu trj cd h i l u qua de d u y tri luu t h d n g 6 0 M d nhdng b i n h nhan co b e n h TBS p h u t h u d c d n g .
Tai l i e u t h a m khdo
/. William H, Fleming F.CCP, Lynne B, Sarafian, Roger H, Kobayashi (1982) Prostaglandin El Therapy Is It Associated with a Higher incidence of Wound infection in the Cyanotic Neonate?.
2. Aphrodite T, Claire B, Shane MT, John MS, Arch D, Child F, Neonatal E (2007) Published online 92(3):
199-203.
3. Satoshi H, Nobuyuki F (1988) Responsiveness of the ductus arteriossus to Prostaglandin El assessed by
TAPCH^YDl/QCLAM SANG 108 Tap 12 - Sfi 1 /2017
combined cross sectional and pulsed Doppler combined cross sectional and pulsed Doppler echocardiography. Br Heart J 62:140-147. echocardiography. Br Heart J 62:140-147.
4. Neonatal transfer service - London Kent Surrey 7. Lewis AB, Takahashi M, Lurie PR (1978) and Sussex (2008) Transfer of babies with duct Administration of prostaglandin El in neonates dependent congenital heart disease. with critical congenital cardiac defects. J Pediatr 5. Garth D (2005) To Intubate or Not to Intubate? 93:481-485.
Transporting Infants on Prostaglandin El 6. Satoshi H, Nobuyuki F (1988) Responsiveness of the
ductus arteriossus to Prostaglandin El assessed by
