Y HOC VIET NAM SO DAC BIET-THANG 11/2010 guided puncture in ventilated patients. J
Cardiothorac Vase Anesth. 2002 Oct; 16(5):
572-5. 6.
Malloy DL, McGee WT, Shawker TH, Brenner M, Bailey KR, Evans RG, Parker MM, Farmer JC, Parillo JE: Ultrasound guidance improves the success rate of internal jugular vein cannulation: sticks for successful cannulation A prospective, 7.
randomized trial. Chest 1990;98:157-160.
Pirotte T. Ultrasound-guided vascular access in adults and children: beyond the internal
jugular vein puncture. Acta Anaesthesiol Belg.2008;59(3): 157-66.
Schwartz AJ, Jobes DR, Greenhow DE, Stephenson LW, Carotid artery puncture with internal jugular cannulation using the Seldinger technique: Incidence, recognition, treatment and prevention. Anesthesiology
;979; 51: s 160.
Sznajder HI, Zveibil FR, Bitterman H, Weiner P, Busztein S: Central vein catheter- ization: Failure and complication rates by three percutaneous approaches. Arch Intern Med 1986;146:259-261.
KHAO SAT TINH TRANG TIEU SOI HUYET O BENH NHAN TIM BAM SINH MO TIM HO TAI BENH VIEN TRUNG UONG HUE ^
Dong ST Sang, Biii Dure Phu, Nguyin Duy Thang, Nguyin Ngoc Minh, Doan Dure Hodng, Ddng The Uyen, Duong Dang Hoa, Nguyin Tat Dung, Tran Hoai An, Le Quang Thiiru, Nguyin Thj Bach Yen (*)
TOMTAT
Dat van de. Mo tim hd dUdi tuan hoan ngoai cd the (THNCT) gay ra nhieu bat thudng cam mau dan den hau qua chay mau qua mirc sau mo.
MLJC tieu: Khao sat tinh trang tieu sdi huyet tru'dc - sau THNCT va chay mau sau mo.
Phu'dng phap: Nghien ciTu d 60 benh nhan tim bam sinh (TBS) gom 30 cd tim, 30 khdng tim va 30 ngUdi chiTng khoe manh. Cac xet nghiem dem te bao mau va tieu sdi huyet dUdc tien hanh 1 ngay trUdc md, 15 phut sau khi trung hoa heparin, 2 gid va 6 gid sau md d phong hdi siTc tim. Dan lUu dng ngUc trung that (DLONTT) du'dc do trong vong 6 gid dau hau phau.
Ketqua:Trifdc md, nhdm Fallot khac biet cd y nghia ve hong cau, Hb, Het, D-Dlmers, FDPs, von Kaulla so vdi nhdm TBS khdng tim va nhdm chiTng. Khdng cd sU khac biet ve fibrinogen trUdc md d ca 3 nhdm. Hau het cac chi sd huyet hoc giam cd y nghla va cac do dac tieu sdi huyet tiep tuc keo dai 6 gid sau md d ca hai nhdm TBS (p<0,05). Mau DLNTT khac biet cd y nghTa d hai nhdm TBS (p<0,01).
Ket luan: Nhom Fallot bieu hien tieu sdi huyet nhe trUdc md va tieu sdi huyet manh keo dai sau md cd the gdp phan vao bien chiTng chay mau qua miTc sau md.
Td khda: Tieu sdi huyet, tim bam sinh, md tim hd, chay mau qua miTc sau md.
(*) Trung tdm lim mgch - TT Huyet hQC truyin mdu - BV Trung vang Hui
CHUYEN DE: PHAU THUAT TIM MACH VA tONG NGUC VIET NAM
SUMMARY
INVESTIGATION OF FIBRINOLYTIC CONDITION IN PATIENTS WITH CONGENITAL HEART DISEASE UNDERGOING OPEN HEART SURGERY
AT HUE CENTRAL HOSPITAL
Background: Open heart surgery with cardiopulmonary bypass (CPB) causes hemostatic abnormalities which result in postoperative excessive bleeding.
Objectives: Investigation of fibrinolysis before - after CPB and postoperative bleeding.
Method: 60 patients with congenital heart disease (CHD) (30 cyanotic, 30 acyanotic) and 30 healthy people were recruited consecutively.
Blood cells count and fibrinolytic tests were tested 1 day before operation, 15 minutes after protamine administration, 2 and 6 hours after operation at the intensive care unit (ICU).
Mediastinal chest tube drainage (MCTD) was measured for the first 6 h at the ICU.
Results: Preoperative significant differences could be found in red blood cells, Hb, Het, D- Dimers, FDPs, von Kaulla bebween group of Tetralogy of Fallot and two groups of the acyanotic and control. There was no significant difference in fibrinogen before operation among 3 groups (p>0,05). Most hematology parameters decreased significantly and fibrinolytic measurements were persisted until 6h after operation in both groups of CHD (p<0,05). There was the significant difference in MCTD bebween 2 CHD groups (p<0,05).
Conclusion:Jhe. Fallot group had a low level of preoperative fibrinolysis and high level of postoperative prolonged fibrinolysis that could result in postoperative excessive bleeding.
Key words: Fibrinolysis, CHD, open heart surgery, postoperative excessive bleeding.
I. OAT VAN DE
Nhieu bat thudng cam mau da dugc ghi nhan d benh nhan tim bdm sinh (TBS) cd tim hoac khong tim bao gdm giam fibrinogen.
giam tieu cau, rdi loan chuc nang tieu c§u,j bat thudng \h ydu td von Willebrand... [6].J Nhung benh TBS cd tim co bing chung ho^ \ hoa ddng mau tren miic binh thudng vi ca D-1 dimer va PAI ddu tang trude md. M6 tim ha i dudi tuan hoan ngoai co th6 (THNCT) dan ^ den nhieu rdi loan cSm mau: giam tieu c^u, J roi loan chuc nang tilu c4u, tang tieu sgi \ huyet (TSH) vai chay mau qua muc va dong j
mau ngi mach rai rac. j Nghien cuu nay dugc tiSn hanh nhim \
khao sat tinh trang TSH trude va sau THNCT i d benh nhan TBS md tim hd va bilu hien !
chay mau sau mo. \
I I . DOI TU'O'NG VA PHU'ONG PHAP 2.1. Doi tu-OTig
60 benh nhan TBS md tim hd dudi ) THNCT gdm hai nhdm 30 cd tim va 30 \ khong tim va 30 ngudi nhdm chung khoe manh dugc lan lugt nghien cuu tir thang 01/2007 d8n 6/2007. Loai trir tk ca nhihig benh nhan cd sir dung cac thudc chdng dong, I thudc anh huong chiic nang tilu cha trong ! vong 7 ngay, hk thudng dong mau di tniyin I hoac mac phai, md lai hoac chuyin sang m6 | kin.
2.2. Phu-ong phap nghien cmi: Nghien i
cuu tien cuu cd ddi chung. i Chiing tdi chgn nhdm chung ngudi ldn i
khde manh vi cac chi so cSm mau d ngudi j lon va tre tren 1 thang khong cd su khac bi?t I de tien danh gia cac hk thudng d ca 2 nhom i
benh va dl \ky mau. i 2.3. Phu-ong phap tien hanh
Tat ca benh nhan chgn vao mau nghien | ciiu dugc xet nghiem huyit hgc qua 4 thdi \ dilm TO: 1 ngay truoe md, Tl: \S phiit sau i khi trung hda heparin bang protamin, T2: sau i mo 2 gid, T3: sau md 6 gid. Tk ca cac xet nghiem nay dugc tiln hanh tai Trung tam j
Y HOC VIET NAM SO DAC BIET-THANG 11/2010
Huyit hgc - Truyin mau - BVTl/ Hul. Mau duac lay bdi nhan vien phong dong mau chuyen lam xet nghiem mo tim, bao dam tieu chuan xet nghiem dong mau. Ddi vdi benh nhan co tim dieu chinh chit chong dong theo Hot. Dem te bao mau tren may Cell-Dyn 3200 (Abbott-USA), 3 xet nghiem dong mau thudng quy: thdi gian prothrombin (PT) (%), thai gian thromboplastin timg phan boat hoa (APTT) va fibrinogen tren may STA compact (Diagnostica Stago- Phap); xet nghiem tieu sgi huyet: D-Dimers va FDPs (ban dinh lugng - Stago) va von Kaulla theo ky thuat thudng quy. Mau DLONTT dugc theo doi hang gid trong 6 gid dau sau mo bdi nhan vien dieu duong phong hdi siic tim.
Chay mau qua DLONTT dugc tinh qua miic idii chay mau lien tuc hoac khi chay mau dot ngot nhung khong mo lai va cd it nhat > 1 ml/kg/gid trong 6 gid [8] hoac > 4 ml/kg trong 4 gid dau hau phau. Tat ca benh nhan deu dugc gay me, chay THNCT va mo cimg mot e kip cua Trung Tam Tim Mach - BVTLT Hue. Hdu hit benh nhan dugc su dung huyet tuang tuoi dong lanh (HTTDL) va khoi hong cau (KHC) (trir nhdm Fallot) dl duy tri Het trong THNCT tir 20-30%. Dilu tri sau mo g6m mau tuoi toan phin (MTTP) sau khi ngimg THNCT, HTTDL, HCK, mau toan phan luu trii...
S6 lieu thu thap theo benh an nghien ciiu da dugc thong nhat va chuan hda. Xii ly so Ii?u theo phuong phap thong ke y hgc bang phin mim SPSS phien ban 15.0.
III. KET QUA NGHIEN CU\J
Nhom nghien cim gdm 30 benh TBS cd tim (Fallot, khong gap loai khac) va 30 TBS khong tim (thong lien thit, thdng lien nhl, tim ba buong nhT va hep dgng mach phdi). Ti 1? nam nir bing nhau, tudi trung binh ca
nhdm 9,74 ± 7,74 (12 thang din 36 tudi).
Can nang trung binh 22,24 ± 14,20 kg (5,5kg - 55kg). Khong co su khac biet co y nghia ve tuoi, gidi va can nang giira hai nhom.
3.1. Cac dac diem roi loan cam mau Ci thdi diem TO, nhom Fallot khac biet CO y nghia ve hong cau, Hb, Het, von Kaulla 45 - 120 phut (p < 0,05), D-Dimers > 0,5 pg/ml (p < 0,01), FDP > 5 ^g/ml (p < 0,01) so voi nhom TBS khong tim va nhom chiing.
Nhdm Fallot co PT keo dai (85,43 ± 9,20) so voi nhdm chimg (95,79 ± 4,41) voi p<0,05.
Khong CO su khac biet ve so lugng tieu cau, APTT, fibrinogen (p > 0,05) d ca 3 nhom.
Nhieu su khac biet co y nghia thdng ke giiia hai nhdm Fallot va TBS khdng tim vl thdi gian THNCT, ha than nhiet, lieu heparin (p < 0,01), lieu protamin, axit tranexamic (p
< 0,05); mau va che pham mau (ml) sir dung trong va sau mo: huyet tuong giau tieu cau, MTTP (p < 0,01)... [s6 lieu khong trinh bay], tong the tich mau va che pham mau (ml) su dung sau mo d nhdm Fallot (1069,83 ± 432,70) khac biet co y nghia so vdi nhdm TBS khong tim (402,60 ± 247,46) (p < 0,01).
Cac chi so te bao mau giam ro ret, cac xet nghiem dong mau va tieu sgi huyet deu bi rdi loan vao thdi diem Tl. Cac chi so te bao mau deu khac biet co y nghia (p<0,01) giira hai nhdm d ca 3 thdi diem Tl, T2 va T3 tru hdng ciu Tl (p > 0,05); khong cd su khac biet cd y nghTa giiia hai nhom ve cac xet nghiem dong mau (p > 0,05) trir fibrinogen, D-Dimer (p<0,05) d Tl va T2; va FDP (p<0,05) d ca 3 thdi dilm Tl, T2 va T3. CJ moi nhom, cac chi so ddng mau giam ro ret d Tl (p<0,05) va cd xu hudng trd ve tren 50%
hoac gin bang trude mo a T2, T3; nhung con nhieu su khac biet co y nghTa giiia cac thdi diem {Bdng 3.1, 3.2 vd 3.3).
CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM B a n g 3 . 1 . Cac chi so hong cau va tieu cau trude va sau md Benh Thdi diem
FA LL OT TB S KH ON G Ti M
Honq cau Hb (q/dl) Het (%) Tieu cau
Hong cau Hb (q/dl) Het (%) Tieu cau
TO 6,11 + 3,21 (a)
16,48 ± 3,21 52,80 ± 10,05 250,18 ± 76,64 4,83 ± 0,44 12,51 ± 1,42 40,29 ± 4,45
278,30 + 49,92
T l 5,72 ± 6,04 (3)
12,34 + 1,44 40,29 + 4,62 118,0+41,54 (P)
3,84 + 0,64 9,88 ± 1,53 31,36 ± 4,96
155,43 + 41,20
T2 5,13 + 0,71 13,89 ± 1,46 44,81 ± 4,80 123,81+45,13 (v)
4,22 ± 0,82 10,91 + 2,21 35,80 ± 6,86
172,87 ± 48,89
1
T3 4,98 ± 0,77 13,50 + 1,78 43,75 ±5,59 ' 135,93+ 48,62
4,33 ± 0,62 11,19 ± 1,52 36,43 ± 0,62
180,07± 38,82
So sanh ghep cap giiia TO-Tl, T1-T2 va T3-T0 CO sir khac biet cd y nghTa, T2-T3 khong khac biet ngoai trir a) p > 0,05 so vdi Tl; P) p > 0,05 so vdi T2; y)p < 0,05 so vdi Tl Ti le chay mau qua miic d nhom Fallot la 21 trudng hgp (70%) khac biet co y nghTa
so voi nhdm TBS khong tim (26,7%) vdi p < ! 0,01; mau DLONTT trung binh (ml) sau 6 ! gid d nhdm Fallot la 151,33 ± 130,51 ml ? khac biet cd y nghTa so vdi nhdm TBS khong ' tim (58,50 ± 52,57 ml) (p < 0,01) (Bdng3.4-3.5). '•
Benh Fallot TBS khong tim
B a n g Thdi diem PT (%) APTT (qiay) Fibrinogen (g/L) PT (%)
APTT (giay) Fibrinogen (g/L)
3.2. Cac chi so dong mau tnrdc va sau mo TO
85,43 + 9,20 30,13 + 2,65 2,85 + 0,63 87,71 + 9,49 32,50 + 2,50 3,13 ± 0,77
T l 59,46 ± 12,59 41,98 ± 14,42 1,91 ±0,50 (3)
61,72 ± 9,15 39,24 ± 10,50
2,25 ± 0,61
T2 64,54 ± 9,03 33,18 ± 8,48 2,26 ± 0,46 66,33 ± 9,32 37,00±11,98 2,70+0,83 iy)
T3 71,82 ± 11,23
32,37 ± 6,20 2,94 ± 0,75 71,08±12,64 33,93 ± 7,00 3,21 ± 1,07(5)
So sanh ghep cap giira TO- khac biet ngoai trir P) p>0,05 so
Tl, T1-T2 va T3-T0 co su khac biet cd y nghTa, T2-T3 khong vdi T2; y)p<0.05 so v&i T3; 5) p>0,05 so vdi TO.
Bang 3.3. Cac chi so tieu sgi huyet tnrdc va sau md
Benh Thdi diem FAL
LOT T BS KT
Von Kaulla' (n, %) D-Dimers * * ( n , %) FDPs * * ( n , %) Von Kaulla* (n, %) D-Dimers * * ( n , %) FDPs * * ( n , %)
TO 12(40%) (0)
21 (70%) 21 (70%) 4 ( 1 3 , 3 % ) (a)
3 (10%) 3 (10%)
T l 4 (13,3%) 30(100%) (3) 30(100%) (3)
2 (6,7%) 2 4 ( 8 0 % ) (3) 23 (76,7%) (3)
T2 1 (3,3%) 30 (100%) 30 (100%) 2 (6,7%) 23 (76,7%) 23 (76,7%)
T3 1 (3,3%) 30 il00%) 30 (100%) 1 f3,3%) (6)_
25 (83,3%)_
24 (80%) _
Y HOC VIET NAM SO DAC BIET — THANG 11 /2010
(*) 45-120 phut; so sanh ghep cap giiia TO-Tl va T3-T0 cd su khac biet cd y nghTa, T1-T2,
! T2-T3 khong khac biet ngoai trir a) p > 0,05 so voi Tl; 5) p > 0,05 so voi TO.
; (**)P)p>0,05sovdiT2.
I • • • • ,
3.2. Dac diem xuat huyet d nhom benh nghien cmi
Bang 3.4: Bilu hien chay mau sau mo
^~~~~^-^hay mau Benh ^~~~'~---,_^^
Fallot
TBS khong tim
Binh thu'dng n (O/o) 9 (30) 22 (73,3)
Qua mu'c n (O/o) 21 (66,7)
8 (26,7)
Tong n (O/o) 30 (100) 30 (100)
P
<0,01 -
Bang 3.5: Lugng mau trung binh qua dan luu nguc sau 6 gid
—.____^ Nhom
DLN ^ - — - _ Sau 6 gid (ml)
Fallot (n = 30) 151,33 ± 130,51
TBS khong tim (n = 30) 58,50 ± 52,57
P
<0,01
VI. BAN LUAN:
Du phdng chay mau qua miic sau md tim ha vdi THNCT d tre em cd vai trd quan trgng trong viec cai thien ket qua phau thuat.
4.1. Bat thwong cam mau ff benh nhan TBS Nhieu khiem khuyet cam mau da dugc ghi nhan d benh nhan TBS cd hoac khong tim, nhat la d benh TBS cd tim khi Het >
60% [9]. Khuynh hudng chay mau d benh TBS cd tim thudng tir nhe den trung binh: de bam mau, xuat huyet dang cham va chay mau l9i[6].
Thieu oxy man kich thich than tang tiet erythropoietin gay da hong cau va hau qua ting do quanh mau. Benh TBS cd tim thuong c6 giam tong hgp cac yeu td dong mau d gan (II, V, VII, IX, X) do tdn thuang thilu khi d gan va li tre d vi tuan hoan do do quanh mau cao. Tilu cau co nhirng bat thuong ca ve sd lugrng va chdt lugng. So lugng tieu cau tuong quan nghich voi Het. Sd lugng tieu cki thdp do ddi sdng ngin hoac giam san xuat tieu cau vi cac mau tilu cau thoat khoi sir phan manh 0 phii do shunt phai - trai. Hon niia, tang do
quanh mau (lire xe cao - high shear stress) gay tang san xuat cac vi hat tieu cau, cac vi hat nay ddng mgt vai trd quan trgng trong nhiing bat thuong dong mau d benh TBS cd tim. Khiem khuyet chat lugng tieu cau gom giam ngung tap vai ADP, epinephrin va collagen, va cd lien quan true tiep den miic do da hdng cau... Nhiing bat thucmg cam mau do hau qua cua tinh trang benh ly ddng mau tieu thu bieu hien tang cao D-Dimer. Chan va nhieu tac gia khac da quan sat thay tinh trang tang sinh thrombin va dong mau tieu thu d benh TBS co tim hoac khong tim. 6 benh nhan co tim cd bang chiing tang boat hoa dong mau vi ca D-Dimer va PAl-1 tang cao trude md. Cl hau het benh nhan nay, cac xet nghiem sang lgc cho phep du doan mgt khuynh hudng chay mau, nhung cac ket qua binh thudng khong loai trir kha nang chay mau nang sau mo [6].
Trong nghien ciiu cua chiing toi, nhom benh TBS cd tim (Fallot) cd tinh trang tang hong cau, Hb, Het so vai nhom khong tim va nhom chirng (p <0,05). PT khac biet cd y
CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM
nghTa so vdi nhom chiing (p<0,05). Bieu hien TSH nhe trude ml d nhom Fallot phii hgp vdi y van: 40% ca TSH nhe (von Kaulla 45-
120 phiit), 70% ca c6 D-Dimers > 0,5 |ag/ml va FDP > 5 pg/ml so voi 2 nhom kia. Tuy nhien, chua thay su tuong quan ro ret giira hong cau va Het vdi tieu cau va cac xet nghiem dong mau c6 le do ti le benh Fallot the nang it. Ket qua von Kaulla cua chiing toi theo tieu chuan cua hai tac gia: Boneu trong
"Gidi thieu ve nghien ciru cam mau va huyet khoi" (1982), binh thudng von Kaulla khong dugc < 90 phiit va Nguyen Nggc Minh trong
"Cam mau dong mau-ky thuat va iing dung trong lam sang" (1997), TSH nhe khi von Kaulla tit 45-120 phiit. Ket qua nay khong phii hgp vdi tieu chuan ciia Nguyen Anh Tri ["Dong mau va ung dung lam sang" (2000)]
bieu hien TSH khi thdi gian tieu euglobulin xay ra trong vong 1 gid va ciing khong phii hgp vdi ket qua cua Ho Thi Thien Nga [3].
Ket qua D-Dimers va FDP khong phii hgp vdi nghien ciiu cua Nguyen Anh Tri d ngudi binh thudng [4, 5], tuy nhien D-Dimer ciing tang trude mo tuong tu ket qua ciia nhom TBS trong nghien ciiu cua Ho Thi Thien Nga
[3]. Tuy nhien, do xet nghiem ban dinh lugng nen khong so sanh dugc. Do do, van de nay can tiep tuc nghien ciiu vdi mau lon hon va vdi phuong phap dinh lugng de cd ket luan chinh xac.
4.2. Roi loan dong mau sau mo
Benh nhan TBS cd tim cd sin su hoat hda dong mau va TSH ciing nhu khiem khuyet tieu cau. Co che roi loan cam mau sau THNCT phiic tap, tuy nhien cd thi lien he den miic do thieu oxy, tang do quanh mau, boat hoa tiep xiic va bo the hoac tinh trang viem.
Nguyin Nggc Minh (2002) ghi nhan 46,5% benh nhan c6 PT keo dai, 51,1% benh
nhan co APTT keo dai miic do nhe va vira, [2]. H6 Thi Thien Nga (2007) cho thdy PT,' APTT va fibrinogen giam cd y nghTa sau THNCT (p <0,01) [3]. Kit qua ciia chung t6i|
cd su thay ddi ro ret vl PT, APTT va' fibrinogen giira 2 thdi diem TO va Tl (p
<0,05), do mau bi pha loang bdi dich moi r3t' ngheo cac yeu to dong mau nen co thi lam keo dai a miic do vira phai cac thdi gian dong' mau d giai doan cuoi THNCT [3]. Tuy nhien cac xet nghiem nay cd xu hudng hoi phuc tra' lai tren 50% hoac gan bang tnrdc mo o thai' diem T2, T3, cd le do truyen mau nhdt la su' dung nhieu huyet tuong tuoi ddng lanh nen' da cung cap nhieu yeu to dong mau [3].
4.3. Tinh trang tieu soi huyet sau tu^n' hoan ngoai co* the
Vao nam 1984, Stibbe va cs da bao cao' tinh trang TSH xay ra d nhiing benh nhan mo J tim hd. TSH cd lien quan den tinh trangj viem, di tru te bao va cd phan ddng gop ciial THNCT. TSH xay ra lien tuc trong qua trinh!
THNCT va md tim hd, ca d vet thuang^
quanh tim va vong THNCT [7]. \ Ve mat lich sir, chay mau sau THNCTj
dugc cho la do TSH qua miic sau khi md nguc, tang len trong qua trinh THNCT v^
keo dai 2- 4 gid sau THNCT. Ha nhi?t vJi thdi gian bom keo dai lam nang them tinh]
trang tang TSH. Mang phdi, mang ngoai timj mang xuong cd chiia cac chat giong chatj hoat hoa plasminogen Iam khdi phat TSH ...j Tuy nhien, nhirng nghien cim ve sau cho thayi tinh trang tang TSH thudng khdng la nguyei^
nhan chinh cua chay mau. Theo Levin, d cS hai nhom cd ndng do yeu td hoat hoa plasminogen to chiic (t-PA) tang cao co y nghTa sau THNCT, tang cao d nhdm TBS co tim hon nhdm TBS khdng tim va miic t-PA con duy tri cao it nhat 6 gid sau md. \
Y HOC VIET NAM SO DAC BIET — THANG 11/2010
TSH bilu hien ro vai 100% benh Fallot va 76,7% TBS khong tim cd D-Dimer va FDP duong tinh keo dai din 6 gid sau ml.
Tuy nhien, do xet nghiem ban dinh lugng nen khong phan biet dugc su khac biet giira hai nhom, chi ghi nhan cd tinh trang duong tinh manh hon d nhdm Fallot vl ca D-Dimer va FDP sau md nhung hau nhu it khi vugt qua 40pg/ml.
Ket qua cua chiing tdi cho thay d thdi diem Tl, chi co 4 ca Fallot va 2 ca TBS khong tim cd von Kaulla trong gidi han 45- 120 phiit, con lai deu trd ve binh thucmg d ca hai nhdm (> 3 gid). Theo Ho Thi Thien Nga CO 2% trudng hgp cd von Kaulla duong tinh sau mo. Ty 1^ benh nhan co von Kaulla duong tinh sau mo khac biet co y nghTa so vdi trude md. Tren thuc te, nghiem phap von Kaulla mac dii dac hieu nhung it cd gia tri chdn doan som vi thudng am tinh ngay ca khi D-Dimer tang rat cao. Theo tai lieu cua Desmont, Bick cho rang du tang hoat tinh TSH trong thdi gian THNCT nhung rat hiem khi phat hien dugc thdi gian tieu euglobulin nit ngan vao cuoi THNCT [3].
Ket qua nghien ciiu phii hgp vdi ket qua ciia Inglis: trong hai nhom benh Fallot, nhdm chet cd miic FDP cao hon nhimg khong khac bi?t ve mat thdng ke trong 20 gid dau. Nhiing ca song cd FDP tir binh thucmg den 40 Hg/ml. 4 ca tir vong cd FDP cao sdm tir 80- 160pg/ml vao thdi diem 2 gid sau mo [9].
Nghien ciiu cua Hd Thi Thien Nga cho thay ndng do D-Dimer trung binh sau md (310pg/l) tang cao ro ret so voi trude mo (156 pg/1). Trong THNCT cd hien tugng tang hoat tinh TSH do boat hoa plasminogen va bdt hoat cac chdt lie chi plasmin. Theo Horow, ndng do tPA tang trong suit qua trinh THNCT trong khi chdt lie chi cua nd (PAI-1) khong tang. Mac dii sir dung chdng
ddng bang heparin lieu cao trong THNCT nhung thuc te van co mgt lugng thrombin dugc hinh thanh. Mac khac, qua trinh TSH ciing dugc khdi phat bod he thong tiep xiic khi mau tiep xiic vdi be mat nhan tao lam boat hoa yeu to XII va prekallicrein [3].
TSH tao ra cac san pham thoai giang cua fibrin va fibrinogen. Binh thuong, TSH khong cd y nghTa lam sang vi cac san pham thoai giang se bi loai thai trong THNCT va tang boat tinh TSH dugc phuc hoi vai gid sau khi ngimg THNCT. Tuy nhien, boat hoa qua miic plasminogen se hinh thanh qua nhilu plasmin cd the gay hau qua sau mo. Hoat tinh TSH dugc do bang nong do D-Dimer huyit tuong cho thay miic do boat hoa TSH trong va sau THNCT. Nong do D-Dimer cd tuong quan dang ke vdi lugng mau mat sau md.
Theo Mouton va cs, cac san pham thoai giang fibrin va fibrinogen, D-Dimer va tPA CO the tang sau THNCT. Da so cac tac gia deu thay D-Dimer tang cao ngay sau THNCT, tuy nhien gia tri nong do D-Dimer rat khac nhau tuy theo timg nghien ciiu. Viec danh gia su bien doi c6 tinh dgng hgc ciia D- Dimer theo thdi gian la rat quan trgng. Binh thudng D-Dimer giam dan sau md. Neu D- Dimer khong giam cho thay tinh trang tang boat tinh TSH bdt thudng [3]. . •
Trong qua trinh THNCT, hoat hoa TSH dan den tang hoat tinh plasminogen va giam cac yeu to lie che plasmin hinh nhu dong vai trd quan trgng ddi vdi cac bien chiing chay mau sau mo. Ro rang la cd nhiing su tuong tac phiic tap giiia he thong dong mau/ TSH va phan ung viem cap nhu "hgi chimg sau truyin" sau mo vdi THNCT. Sir dung aprotinin cd hieu qua lie che sir hoat hoa thrombin, lie che TSH va co hieu qua bao ve ddi vdi tieu cau.
CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM
Nhimg benh nhan ldn tuoi cd nguy co cao chay mau qua mirc va mo lai sau mo tim, do do di kem vdi tang ty le benh va ty le bi vong. So vdi benh nhan tre, benh nhan ldn tudi CO tinh trang tang boat hoa he thong dong mau trong qua trinh phau thuat dgng mach vanh va dac biet c6 tinh trang TSH nhieu hon sau mo. Dieu nay dan den tieu thu tieu cau va cac yeu to dong mau gay hau qua tang chay mau sau mo.
Ket qua nghien cua Varghese cho thay miic tPA khong trd ve gidi ban binh thudng trong trudng hgp chay mau nang khi so sanh vdi nhdm khong co bien chiing. Thdi gian THNCT dai hon se khdi phat sinh thrombin thong qua heparin, dan den tang phiic hgp PAI-1 - tPA va se boat hoa tieu cau dugc phat hien qua su tang GMP-140 hay P- selectin. Dieu nay ggi y moi lien ket giiia thdi gian THNCT, chay mau, boat hoa tieu cdu va TSH. Theo doi miic GMP-140 va phiic hgp PAI-1 - tPA cd the du doan do nang chay mau.
Tom lai, nghien ciiu ciia chiing tdi chua danh gia dugc moi tuong quan giiia TSH vdi bien chiing chay mau sau mo do xet nghiem bang phuong phap ban dinh lugng tuy nhien theo mgt so tac gia thi TSH sau THNCT co the gdp phan vao bien chiing chay mau sau mo tim hd.
4.4. Bieu hien chay mau sau mo
Ti le xuat huyet do bat thudng dong mau thay ddi tiiy theo tieu chuan xac dinh, nhung thudng dugc bao cao chiem ti le tu 3-5%
trudng hgp. Theo Nguyen Quoc Anh, ti le chay mau kho cam chiem 3%, ti le chay mau trong va sau mo gap nhieu (6,3%) [1].
Ket qua nghien ciiu ciia Ho Thj Thien Nga cho thay ty le chay mau thap nhat d nhom TBS khong tim, ty le bien chimg chay mau va mo lai cao nhat d nhdm benh van tim
va 9,1% tii chiing Fallot chay mau nhilu sau mo nhung khong c6 benh nhan nao phai m6 '
lai [3]. ' Bieu hien chay mau qua miic sau m6
trong nghien cim cua chung toi gap chu ylu o nhdm Fallot (70?/o). Ket qua nay phii hop vdi y van la benh nhan cd tim chay mau nhieu hon va cd thdi gian mo dai han. Ti le chay mau qua miic ciia chiing tdi cao so vai y van CO le do nhom Fallot la nhom co nguy ca chay mau cao va sir dung tieu chuan chay mau qua DLONTT > 1 ml/kg /gid trong 6 gid. Chiing toi phoi hgp 2 tieu chuan danh gia chay mau qua mirc vi nhdm nghien ciiu ciia chiing toi cd ca benh nhan tre em va ngudi trudng thanh. Do vay, van de nay ciing can tiep tuc nghien ciiu de cd ket luan chinh xac hon.
V. KET LUAN:
- Benh TBS ed tim (Fallot) cd tinh trgng tieu sffi huyet nhe trude md: tieu sgi huyet nhe (40% trudng hgp cd von Kaulla 45-120 phiit, 70% trudng hgp cd D-Dimers >
0,5|ig/ml va FDP > Sp-g/ml vdi p < 0,05) so vdi nhdm tim bam sinh khong tim va nhom
chiing (p < 0,05). ; - Tieu Sffi huyet keo ddi sau tuan hoan
ngodi Cff thi: 100% benh Fallot va 76,7%
tim bam sinh khong tim co D-Dimer > 0,5 l^g/ml va FDP > 5 \iglm\ keo dai 6 gid sau mo mac dii von Kaulla trd ve binh thudng (>
3 gid).
- Benh Fallot ehay mdu qud miec sau mo nhieu hffn nhdm tim bam sinh khong tim: 21 ca Fallot (70%) so vdi 8 ca tim bdm sinh khong tim (26,7%) (p < 0,01); mau dan luu nguc trung that trung binh sau 6 gid 6 nhdm Fallot la 151,33 ± 130,51 ml so vdi nhom tim bam sinh khong tim la 58,50 ± 52,57 ml (p<0,01).
524
Y HOC VIET NAM SO DAC BIET — THANG 11/2010
TAI LIEU THAM KHAO 5
1. Nguyen Quoc Anh va cs (2006), "Nhan xet kit qua gay me ml tim duoi tuin hoan ngoai ca thi trong bon nam tai benh vien Bach mai", Y hoc
thirc hdnh, 10, tr. 2 5 - 2 8 . 6.
2. Nguyin Nggc Minh va cs (2001), "Nhan xet ve phac do dong mau danh gia hieu qua dilu tri khang dong trong ml tim ha tai Benh vien Trung uang Hul", Cdc bdo cdo khoa hoc- Hoi 7.
thdo ldn thd tu Huyet hoc Truyen mdu, tr. 20.
3. Ho Thj Thien Nga (2007), Nghien cuu mot s6 bien doi te bdo mdu vd chi so dong mdu tren 8.
b?nh nhdn duoc phdu thudt tim vdi tudn hodn ngodi ca the, Luan an Tien sT y hpc, Truang Dai hpc Y Ha Npi, Ha Npi.
4. Nguyen Anh Tri, Vu Due Binh va CS (2001), 9.
"Trj so nong dp FDPs, D-Dimers a ngudi binh thucmg", Yhoc thuc hdnh, 9, tr. 42-43.
Nguyen Anh Tri va cs (2003), "Ket qua nghien ciiu mpt so chi so xet nghiem cam mau - dong mau a nguai binh thuang", Y hoc thuc hdnh, 445 (3), tr. 20-23.
Aulucli A. et al (2004), "Unusual Post- Extraction Hemorrhage in a Cardiac Patient: A Case report", / Can Dent Assoc, 70 (11), pp. 769 - 73.
Edmunds L. H., Colman R. W. (2006),
"Thrombin During Cardiopulmonary Bypass", Ann Thorac Surg, 82, pp. 2315-2322.
Forestier F. et al (2002), "Platelet function point-of-care tests in post-bypass cardiac surgery: are they relevant ?", British Journal of Anaesthesia, 89 (5), pp. 715 - 721.
Inglis T. C. McN., Breeze G. R., Stuart J., Abrams L. D., Roberts K. D. (1975), "Excess intravascular coagulation complicating low cardiac output", J. din. Path., 28, pp. 1-7.
TINH HINH DE KHANG KHANG SINH C U A
VI KHUAN GAY VIEM PHOI BENH VIEN VA CAC PHUONG PHAP DIEU TRi
• • • .
t -./;•! ;,»•:, . ' ', I, i ' T r a n V a n N g o c *
TOM TAT:
Viem phdi benh vien (VPBV) thUc sU la mgt van de sifc khde nghiem trong va la ganh nang rat Idn ve chi phi trong dieu tn do da sd VPBV la do nhu'ng vi khuan khang thudc. Ti le tir vong do VPBV khoang 33 - 50%, lien quan den nhilm trung huyet, suy hd hap va soc nhiem triing, dac biet do Pseudomonas aeruginosa va Acinetobacter species.
Tai Viet Nam, trong mgt ngbien ciTu cat doc tai BV Chd Ray nam 2000, VPBV co ti le 27,3%
va tir vong tai ICU la 39- 51,9%
SUMMARY:
ANTIBIOTIC RESISTANCE OF BACTERIA
RESULT IN HOSPITAL ACQUIRED PNEUMONIA AND CURRENTLY SOLUTION
Hospital acquired pneumonia is really a serious medical problem and suffered a very big burden in the cost of treament because most of HAP is due to multidrug resistant pathogens.
Mortality from HAP is about 33-50%, related to bacteremia, respiratory failure and septic shock, especially pneumonia due to Pseudomonas aeruginosa and Acinetobacter species. In Viet Nam in a longitudinal study conducted in Chd ray hospital in 2000, prevalence of HAP was 27%
and mortality in ICU is from 39 to 51,9%
* Bfnh vi4n Cha Rdy