Y HOC VigT NAM THAHG 5 - SO 1/2014 I L - l p mau vcft mgt so chi so sinh hoa lien quan
den benh sinh o f f > typ 2 phu hdp vdi nhan djnli cua nhieu tac gia trong va ngoai nu'dc. Cac te bao md va te bao dinh cu" d mo md la nguon tong hdp va giai phdng cac adipokine nhu" TNF-o, IL-1, lL-6, day la nhutig dau an smh hoc cua viem cd lien quan tru'c tiep vdi khoi lu'dng md cd the. Mot 50 nghien cuTu cho thay nong dp cac adipokine cd lien quan vdi qua trinh trao doi chat va khang insulin, hoat tinh lipase, lipoprotein... va chtfc nang ciia cac te bao m d . Su" tang cao cua I L - l p cd the la b l n g chutig cho thay tinh trang viem tham gia vao cd che benh sinh BTO typ 2 va dac biet DTO typ 2 cd beo phi [5,6,7].NhDng ket qua trong nghien CLTU nay cd su" phu hdp vdi nhan djnh cua mot so tac gia khac ve su" thay doi nong do adipokine trong dd cd I L - i p [3-7].
IV. KET LUAN
Ket qua nghien CLTU cho thay nong do I L - l p huyet thanh tang cao rd ret d benh nhan DTO typ 2 CO beo phi va OTO typ 2 khong beo phi so vdi ngu'di khde manh (p< 0,001) va nong dp IL- l p cd tutfng quan thuan vdi nong dp glucose mau luc ddi va ty le HbAlc.
T A I LIEU T H A M K H A O
1. Thai Hong Quang ( 2 0 1 0 ) : Ttii/c hanh benh 6iA thao di/dng. NXB Y hoc. Ha Npi.
2. Nguyen Thj Phi Nga (2009): 'Nghien cu\j nong do TNF-a, CRP huyet thanh va lien quan vdi hinh thai, chu'c nang dong mach canh goc bang sieu am IDoppler mach d benh nhan dai thao 6iibt\g type 2". Luan an Tien sy Y hpc, Hpc vien Quan y.
3. American Diabetes Association (2011):
"Diagnosis and classification of diabetes mellitus".
Diabetes Care, Vol 33 (Supp. 1): S02-09.
^, Banerjee M, Saxena M. (2012): "Interleukin (rL)-l family of cytokines: role in type 2 diabetes".
Clin Chim Acta; 413(.15-16): 1163-70.
5. Donath MY, Shoelson SE (2011): "Type 2 diabetes as an Inflammatory disease". IVat Rev Immunoi,lU2): 98-107.
6. Gerner RR, Wieser V, Moschen AR, Tllg H.(2013). tabolic Inflammation; role of cytokines in the crosstalk between adipose tissue and liver.
Can J Physiol Pharmacol. 91(ll):867-72. - 7. Popko K, Gorska E, Stelmaszczyk-Emmel A,
Plywaczewski R, Stoklosa A, Gorecka D, Pyrzak B, Demkow U. (2010). Proinflammatory cytokines lL-6 and TNF-o and the development of inflammation in obese subjects. Eur J Med Res.
4;15 SuppI 2:120-2.
NONG DO NT-PROBNP (y BENH N H A N SOC NHIEM KHUAN Bui Thj Hir(mg Giang*, Binh Thi Thu Hu-ong*, B^ng Quoc Tuan*
T 6 M TAT
Muc t i e u : Oo nong dp NT-ProBNP d benh nhan soc nhiem khuin. Tim hieu moi lien quan gijj^ nong dp NT-ProBNP huyet thanh vdi chi so tim va vdi diem SOFA 6 benh soc nhiem khuan. Phu'dng phap:
Nghien citu tien culi. Benh nhan soc nhiem l^uan difijc do nong dp NT-ProBNP huyet thanh tai thdi diem nhap khoa Hoi SLTC. MiTc dp nSng cua benh tinh theo ttiang diem SOFA. Cung lu'dng tim do bang phu'dng phap hoa loang nhiet qua catheter dong mach phoi.
Tim hieu moi tu'dng quan giO^ nong dp NT-ProBNP huyet thanh vdi cung lu'dng tim va vdi diem SOFA. Ket qua: 39 benh nhan sdc nhilm khuan cd nong dp NT- ProBNP 1724.13 ± 1439.05 pg/ml, cung lu'dng tim 8.02 ± 4.211/ph va diem SOFA 8.02 ± 4.21. Cd moi
' Tni&ng Dai hgc YHa Ngi
Phan bign khoa hgc: GS.TSNguySn TMDu
tu'dng quan tuyen tfnh mirc d0 trung binh glD'a n3ng dp NT-ProBNP va diem SOFA {r=0,32, p<0,05) 6 b|nh nhan soc nhilm khuan. Cd moi tu'dng quan tuyen tinh giiJa nong do NT-ProBNP va chl so tim (r=-0,4^
p<0,05) d benh nhan soc nhilm khuan. Kfit Iu9n:
Nong dp NT-ProBNP cao d benh nh3n soc nhieffl khuan. Cd mS tUdng quan tuyen tinh giij^ nong dQ NT-ProBNP vdi chi so tim va vdi diem SOFA d b?fih nhan soc nhiem khuan.
Tit khoa: NT-ProBNP, cung lu'dng tlm, SOFA, s&
nhiem khuan.
S U M M A R Y
NT- PROBNP LEVELS I N SEPTIC SHOCK PATIENTS Objectives: To evaluate the relationship between NT-pn3BNP plasma concentrations and the Sepsis- related Organ Failure Assessment (SOFA). To evaluate
Y Hpc VtgT HAM THANG 5 - SO 1/2014 the relabonship between NT-proBNP plasma
concentrations and the cardiac output in septic patients. Methode: NT-proBNP, Cardiac output), SOFA score were evaluated in 39 septic shodt patients.
Bkxxl serum NT-proBNP concentrations were determined in each patient on admission. Cardiac output measurement determined by thermodilution with pulmonary artery cathetenzation. The severity of organ dysfunction was estimated according to the SOFA score. Results: The mean NT-proBNP concentration; cardiac output and the mean SOFA score were 1724.13 ± 1439.05 pg/ml; 8.02 ± 4.21 l/ph and 8.02 ± 4.21 points, respectively. The con-eiation between NT-proBNP level and cardiac output was r = - 0.48 (p<0.05). The correlation coefficient between NT- proBNP level and SOFA score was r = 0.32 (p<0.05).
Conclusions: NT-proBNP levels are increased in septic shock patients. NT-proBNP levels con-elate with the cardiac output; NT-proBNP levels correlate with SOFA score in septic shock patients. Abbreviations:
NT-proBNP: N-terminal pro brain natriuretic peptide.
SOFA score: Sepsis-related Organ Failure Assessment score. ACCP/SCCM: American College of Chest Wiysiclans/Society of Critical Care Medicine.
Keywords: NT-ProBNP, Cardiac output, SOFA, septic shock.
I. OAT V^N o l
Nhiem khuan huyet Vci sdc nhiem khuan la m§t \<i b^nh phii'c tap vdi bieu hien hpi chuVig d^p lirng viem he thong, cd the tien trien thanh hpi chChig suy da phu tang. Roi loan chu'c nSng tim thudng gap trong soc nhiem khuan. NhOng djnh nghla gan day ve soc nhiem khuan da de c$p den roi loan chu'c nSng tim la mot trong cac y§u t& W§n lu'dng nhiem khuan nSng [1]. De chan do^n roi loan chufc nang tim dyS vao kham lam sing, do cung lu'dng tim va sidu am tim. Tuy nhien, sieu am tim va do cung lu'dng tim khd thirc hl?n kjp thdt tai giu'dng, chmh vi vay mot test Chan do^n tai giu'dng giup chan doan va d^nh gia mii'c do nang la rat can thiet. B-type natriuretic peptide (BNP) du'dc te bao cd tim bai tl§t trong tinh trang thanh tam that gian qua mii'c ho$c h[?n tuyng thieu mau cd tlm, chinh vi the djnh luflng BNP va NT-ProBNP da du'dc nhieu c6ng trinh nghien ciili chiitig minh la 1 thdng so cd gid trj trong chan doan suy tlm. Trong soc nhilm khucin, sy" tSng nong dp BNP, NT-ProBNP c6 llSn quan d#n roi loan chiit nSng tim va phan litig viem h? thong, chi'nh vi v§y BNP, NT-ProBNP du^c sii" dyng nhu" m$t marker dy bao suy tim
thii" phat do nhiem khuan cung nhu' chi sd tien lu'dng ciia soc nhiem khuan [2,4,5].
Chinh vi vay chiing tdi tien hanh nghien cuXi nay vdi muctieu:
1. Nhan xet w nong do NT-ProBNP huyet thanh dbenh nhan soc nhiem khuan.
2. Tim hieu moi lien quan giiJB nong do NT- ProBNP huyet thanh vdi diem SOFA, cung ludng tim d benh soc nhiem khuan.
II. 061 nrpNG VA PHU'CTNG PHAP NGHIEN CUU Nghien ciiw du'dc thyc hien tai khoa Hoi site tich cu'c benh vien Bach mai.
2.1. Doi tu'dng nghien cu\i: gom cac benh nhan > 18 tuoi du'dc chan doan soc nhiem khuan theo tieu chuan cua ACCP/SCCM 2003.
Tieu chuan loai trir: soc tim, benh ly mach vanh, suy tim, benh nhan cd chong chi dinh dat catheter dong mach phoi.
2.2. Phu'dng phap nghien cuTu 2.2.1. PhWdng tien nghiin cihi: may do nong dp NT-ProBNP Cobas Elecsys ciia hang Roche, catheter catheter dpng mach phoi Corodyn TD Touch- Free ciia hang B/BRAUN, may theo doi benh nhan, may chup XQ t^i giu'dng, can benh nhan, thu'dc do chieu cao, benh an nghien cu'u, protocol nghien ciru va cac quy trinh cham sdc va dieu trj tai khoa Hoi sii'c tich eye, benh vien Bach Mai.
2.2.2. Phu'dng phap nghien cihi tien ciiXi: Tat ca benh nhan nghien cyu du'dc do nong dp NT-ProBNP huyet thanh. Xet nghiem NT-ProBNP bang phu'dng phap djnh lu'dng miSn djch dien hda phat quang phat, sy dung may Cobas Elecsys ciia hang Roche tai khoa Hda sinh, benh vien Bach mai. Xac djnh myc dp nang ciia binh theo thang diem SOFA. Cach do cung tu'dng tim bang phu'dng phap hda loang nhiet Do cung luUng tlm bang phu'dng phap pha loang nhiet sy dyng catheter dpng mach phoi, bdm nhanh trong vdng dudi 4 giay qua lo gan ciia catheter vj trf nhi phai 10ml dung djch natridorua 9%o cd nhiet do thap hdn than nhiet 7°C. Do cung lu'dng dm 5 lan, lay gia trj trung binh, ty dd tinh ra chi sd tim, syc can mach he tiidng va chi so the b'ch nhat bdp.
xy ly so lieu theo phu'dng phap thong ke y hpc 2.3. Dao dii'c nghlSn cihi:
Benh nhan du'dc chan doan va dieu tri soc
y HOC VIET NAM THANG 5 - SO 1/.^
nhiem khuan theo phac do cua khoa Hoi syc tich eye, benh vien Bach mai. Tru'dc khi du'dc \da chpn nghien cyu, benh nhan va gia dinh benh nhan du'dc giai thich ky viec can thiet phai lam chan doan, theo doi tinh trang huyet dong cung nhu' nguy cd cd the gap phai khi lam mot so tham dd (nhu" dat catheter Swan- Ganz: nguy cd roi loan nhjp tim, nhiem khuan...), khi gia dinh dong y se ky vao ban cam ket. Ket qua cua bien phap tham dd chi nham muc dich nghien cii\j va dieu tri cho benh nhan, moi thong tin du'dc giu" bi mat tuyet ddi.
III. KET QUA NGHIEN CU'U
3.1. Dac diem chung cua nhom benh nhan nghien cu'u
Nghien cyu tren 39 t)enh nhan soc nhiem khuan vao dieu trj tai khoa Hoi syc tfch eye benh vien Bach mai: tuoi 56 ± 16 nam; nam 64%, nff 36%; benh nhan phai thdng khf nhan tao: 96%;
procalcitonin tang cao 66.04 ± 37.15 ng/ml;
nong dp latat mau cao 5.23 ± 3.24 mmol/l; diem APACHEII 19.78 ± 6.78; diem SOFA 10.36 ± 3.47. Ty le benh nhan suy than 53% (creatinin 191.28 ± 109.99 pmol/l).Ty ie ty vong trong nghien cdu ciia chiing tdi la 54%,
Bing 1. Cac thonq so huyet donq tai th6i diem dat catheter dong mach phoi Mach (Ian/phut)
Huyet ap trunq binh (mmHq) Ap iu'c tTnh mach trunq tamCmmHq) Ap iuc donq mach phoi (mmHq) Ap iu'c mao mach phdi bit (mmHg) Cunq tUdnq tim (i/ph) Chi so tim (i/ph/m*) The tfch tonq mau (mt/nhip) Sut can mach he thong dyn.sec/cmVm'
120 ± 18 73.38 ± 9.27 10.96 ± 3.98 24.78 ± 6.79 13.36 ± 5.15 8.02 ± 4.21 5.09 ± 2.71 86.94 ± 37.41 758,32 ± 336,41
flh^n xet: Benh nhan nghien cdu co mach nhanh 120 ± 18 Ian/phut, huyet ap trung binh 73 mmHg, ap iuc tinh mach trung tam 10.96 ± 3.98 mmHg, chi so tim 5.09 ± 2.71 i/ph/m^ siJc can mach hj thong giam 758,32 ± 336,41.
3.2. Niong do NT-BNP t^i thdi diem nhap khoa HiSi sii'c
Trong nghien cdu ciia chijng toi, 80% benh nhan co nong do lfl"-ProBNP >300pg/mi, gia tri trung binh ciia NT^ProBNP la 1724.13 ± 1439.05 (pg/ml).
Bieu id 1. Moi tuBng quan gliJa nong do NT-ProBNP va cung ludng tim 6 benh nhan s&
nhiem iihuan
Nh$n xit: c6_mol tudng quan tuyen Unh gius nong do NT-ProBNP va cung lu'dng tim d benh nhSn
soc nhiem khuan (he so tudng quan r = -0,48: p<0,05).
Y HOC Vier NAM THANG 5 - s61/2014
Bieu do 2, M6i tUdng quan giu^ nong do fiT-ProBNP va chi so tim d benh nhan soc nhiem khuan
Nh$n xit: cd moi tu'dng quan tuyen tinh glDS nSng dp IfT-ProBNP va cung lu'dng tim d benh nhan s& nhiem khuSn (hS so tu'dng quan r = -0,46, p<0,05).
Chung toi sii' dung du'dng cong ROC de tim diem cat (cut off) NT-BNP de dU doan kha nSng benh nhan bj suy tim (di/a vao chi so tim CI <2.2i/ph/m^), ket qua dien tich du'di du'dng cong ROC <0,5.
Biiu do 2, VB. tuting quan giu& nong do MT-ProBNP va diem SOFA d benh nhan soc nhiem khuan.
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Nh$n xit: CO moi tu'dng quan tuyen tinh mii'c dp trung binh giOS nong dp NT-ProBNP va diem SOFA d b^nh nhan soc nhiem khuan (h$ so tu'dng quan r = 0,32, p<0,05).
IV. BAN LUAN
4.1. mng d$ NT-ProBNP tSng cao 6 b^nh nhSn sSc nhiem khuSn
Gl^ tri trung binh ciia NT-ProBNP trong nghiin ciru ciia chiing toi la 1724.13±
1439.05pg/ml, 80% benh nhan co nong dp NT- ProBNP >300pg/ml. Nghien cu'u ciia Varpula va c ^ SM' thay nong dp NT-proBNP thudng cao d nhihig b?nh nhSn nhiem khuan huyet nSng va s& nhilm khuan, cd lien quan den cac yeu to iJc
che cac te bao cd tim. Nong dp NT-ProBNP tSng la ket qua ciia viec gia tSng bai tiet hoSc giam d5 thanh thai. Suy chirc nang tim thir phat do nhiem khuan hoac qua trinh dap utig viem h$ thong \k nguyen nhan tang NT-ProBNP d benh nhan nhiem khuan [2]. Parker va cong sir thay 60-80%
BNP trong huyet thanh cd nguon goc tir te bao cd tam that va ap lire tam that qua cao, tinh trang qua tai the tich hoac gian tam that 1^
nhD'ng nguyen nhan chinh gay tJng BNP [3].
Y HOC VigT HAM THANG 5 - SO 1/2^4 Ngoai ra, s y giam bai tiet NT-ProBNP con do suy
chyc nang than. Nghien cyu ciia ehung toi eo 53% benh nhSn bi suy than. Nhu' vay sir tang nong do NT-ProBNP co the do suy chyc nang tim hoae suy than trong benh eanh soe nhiem khuan.
4 . 2 . Moi tu'dng quan giu'a nong do NT- ProBNP va cung lu'dng t i m d benh nhan soc nhiem khuan
Nghien cyu ciia chung toi thay co moi tu'dng quan tuyen tinh nghich bien giffa nong do NT- ProBNP vdi ehi so tim cf benh nhan soc n h i l m khuan (he so tu'dng quan r = -0,46, p<0,05).
Witthaut va eong s y thay nong do BNP co moi tu'dng quan tuyen tinh vc(i phan suat tong mau ciia that trai [ 4 ] . Post va cong SLT nghien cyu tren 93 benh nhan soc nhiem, chia lam 2 nhom benh nhan co phan suat tong mau > 5 0 % va nhom co phan suat tong mau < 5 0 % khuan thay nong dp BNP cao la mot marker de d y doan benh nhan co kha nang suy tim do yeu to yc che cd tlm do nhiem khuan [ 5 ] . Tuy nhien khi chung toi s y dyng du'dng cong ROC de tim diem cat (cut olT) NT-BNP de d y doan kha nang benh nhan bj suy tim (CI<2,2l/ph/m^), ket qua dien tieh du'di du'dng cong ROC <0,5, Nhu' vay khi benh nong do NT-ProBPN cao eo gia t n gdi y cae bac sy lam them cac xet nghiem tham do khac nhff sieu am tim hoac dat catheter dong mach phoi de xac djnh benh nhan roi loan chyc nang tim d benh nhan soc nhiem khuan.
4.3. Moi tu'dng quan giu'a nong do NT- ProBNP va diem SOFA d benh nhan soc nhiem Ithucin
Trong nghien cyu ciia chiing toi nong dp NT- ProBNP 1724.13±1439.05pg/ml, diem SOFA trung binh 10.36±3.47, co moi tffdng quan tuyen tinh yeu giffa nong dp NT-ProBNP va diem SOFA (r = 0,32, p<0,05). I^ariusz va cong sff [6]
nghien tren 20 benh nhan soc nhiem khuan, co nong dp trung binh ciia NT-proBNP la 140.80 ± 84.65 pg/ml, diem SOFA 6.31±3.75. Co moi tffdng quan co y nghTa thong ke giu'a nong dp NT-proBNP va diem SOFA vdi he so r=0.S164 (p<0.05). Kotanldou va cong sff nghien cffu tren 233 benh nhan nhiem khuan nang va soc nhiem
khuan khong co benh ly tim mach tff trffdc, ket qua nong dp NT-proBNP tang cao va co lien quan den cac cytokine viem khac. Nong dp NT-proBNP d nhom benh nhan tff vong cao hdn nhdm benh nhan song [ 7 ] .
V. KET LUAN
1. Trong nghien c y u ciia chung toi, benh nhan soc nhiem khuan co nong dp NT-ProBNP tang cao.
2. Cd moi tffdng quan tuyen tfnh giii:a nong dp NT-ProBNP vdi cung Iffdng tim va vdi diem SOFA d benh nhan soc nhiem khuan.
TAIUJU THAM KHAO
1. Dellinger RP, Levy MM, Rhodes A, Annae D, Gerlach H, et al {2013}. "Sun/lving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012". Intensive Care Med. 39 (2):165-228.
2. Varpula M, Pulkki K, Karlsson S (2007), Predictive value of N-terminal pro-brain natriuretic peptide in severe sepsis and septic shock. Qit Ca/e Med 35(5), 1277-B3.
3. Parker MM, McCarthy KE, Ognibene F P (1990). Right ventricular dysfunction and dilatation, similar to left ventricular Changes, characterize the cardiac depression of septic shock in humans. Chest97,126 - 1 3 1 .
4. Witthaut R, Busch C, Fraunberger P (2003).
Plasma atrial natriuretic peptide and brain natriuretic peptide are increased in septic shock:
Impact of interleukin-6 and sepsis as sociated left ventricular dysfunction. Intensive Care Med 29, 1696 -1702.
5. Post F, Weilemann LS, Messow CM (2008). B type natriuretic peptide as a marker for sepsis induced myocardial depression in intensive care patients. Cht Care i^ed 36(11), 3030-3037.
6. Marlusz P, Sanach M, Irzmanski R, et all (2006). NT-proBNP levels correlate with organ failure in septic patients: A preliminary report Postepy Hig Med Dosw. 60: 532-636.
7. Kotanldou A, Karsaliakos P (2009). PrognosDc importance of increased plasma amino-terminal pro-brain natriuretic peptide levels in a large noncardiac, general intensive care unit population.
5/?DC*31(4), 342-7.
