A CA LAM SANG
Nhan mot triT^g hdp: Nhoi mau ccT tim cap bien chuYig ngirng tuan hoan dUgfc cuU song nh5 phoi hdp chat che glflfa Khoa cap cuU- Ddn vj can thiep mach vanh- Khoa hoi siJc tich cUc
Nguyen Gia Binh* Dang Quoc Tuan*. Nguyen Bang Tuan', Bui V a n CLrang' Mai Van C u d n g ' . ^ i n Anh T o a i i " , Ngo Due Hung**N9Uven Lan H i e u ' " , Nguyen Ngoc Quang "
* K-Cc he i j c iic"i CJC - Be-r.n «ier, Bacri Iv'^
" ' V noa :ap c j u - 3epri via^ Bach Ma
•'-Tnj~gTa-n :ar :h=3 r'^". . a i " /^er T I T T.£Ch OL5C gte Vie: \i~
TOMTAT mod cho benh nhan bi;
Benh vien Bach Mai.
uy tuan hoan cap lai Ky thuat trao doi ox\ qua mang ngoai co
th6 (ECMO - Extracoporeal membrane 9ATVANBE ox\genation) co the duoc sir dimg de ho
trg cac tnidng hop su\ tuan hoan cap do cac ngu>'en nhan. Chung toi trinh bay mpt truong hop benh nhan nam. 63 tuoi, ngung tim trong benh vien 45 phut dugc cap cuu ngung tuin hoan thanh cong. can thiep mach vanh kip thoi: sau do benh nhan dugc ho trg tim phoi nhan tao ngoai CO the (ECMO) do tinh trang roi loan nhip va soc tim. Benh nhan hoi phuc din chuc nang tim \'a ngung ho trg ECMO sau 6 nga) va dugc xuit \ ien ma khong co thi^u sot than kinh. Mac du benh nhan bj ngung tim trong thoi gian dai nhung voi su ph6i hgp nhip nhang va chat che cua khoa cap cuu. phong can thiep mach \ anh \ a khoa hoi sue tich cue. benh nhan da hoi phuc hoan toan. Dieu nay mo ra mgt kha nang 42 iTAPCHiTIM MACH HOCVIET NAM-5063.2013
Nh6i mau ca tim (NMCT) cap nang co ti le tu vong rat cao dac biet a khi co bien chung ngung man hoan (NTH). De dat dugc thanh cwig can phai duoc chan doan \ a cap cuu som, vdi da> chuyen cap ciiu hgp ly \a k\' nang cua nhan \ien > te phai thanh ihao ket hgp voilrang bi can thiet. Sau day chung toi xin trinh ba} mot tmong hgp lam sang da Aigc cuu soDg mot each ngoan muc.
6101 THIEU BiNH AN
Benh nhan nam. 63 tuoi. tien su hiil thuoc la 30 bao nam. uong nrgu. cao hu> et ap, tang Iqrid mau dieu tri khong thuang xuyen. Ihinh thoang xuat hien con dau nguc thoang qua.
CA LAM S A N G ^
Vao khoa cSp cuu - Benh vien Bach Mai Iucl7h20 ngay 12/11/2012 vai li do dau ngirc trai. Vira tai khoa c4p ciiu benh nhan xuat hien m^t y thiic, tren dien tim la hinh anh v6 tam thu. Benh nhan duac cip ciiu ngirng tuan hoan, ep tim va dat noi khi quan, dat duong truySn tinh mach; tiem adrenalin Img m6i 3 phiit va tiem atropme 0,5mg.
Sau 15 phut va 30 phiit tren hinh anh dien tim vin la hinh anh v6 tam thu. Benh nhan duoc tigp tuc cap ciiu, d6n phiit 45 tim dap tra lai, dien tim la hinh anh nhip tu thit (Hinh 1)
Hinh 1: Biin tim sau cdp cHu ngirng tuan hodn
Sau do benh nhan dugc dat catheter tinh mach trung tam, truyen natrifaicarbonat 4,2%, duy tri adrenalin va dobutamin, huyet ap 60/40mmHg. Cac kSt qua xet nghiem cho thay cho thiy: co tinh trang toan chuyen hoa, troponin T cao, CK va CK-MB tang (Bang 1). Sieu am tim: Dpng mach chii binh thuang, co giam van dong dong deu cac thanh tim.
Bdngl: Cdc xet nghiem mdu sau cdp cdu ngUng tudn hodn Cong thuTc mau
Hong cau (T/l) Hemoglobin (g/1)
Hematocrit (1/1) MCV (fl)
M C H (pg)
4,6 (4,3-5,8)
147 (140-160)
0,447 (0,38-0,50)
97,2 (83-92)
32,0 (27-32)
Sinli h6a mau Ure (mmol/1)
Creatinin (umol/l) CK (U/l) CK-MB
(U/l) GOT (U/l) GPT (U/l)
5,2 (2,5-7,5)
145 (62-120)
422 (24-190)
102,2 (<24) 302,9 (<
37) 314,8 (<
40)
Khi mau dpng mach PH
PCOj HCO3 BE
PO, P/F
6,8 38 5,7 -25,3
195 195
TAP CHi TIM MACH HOC VIET NAM-SO 63.20131 43
. i C A LAM SANG
MCHC (g/1) Bach cau
(G/1)
Bilirubin toan (320-356) / '^..
8,16 Gldcose
^40-10,0) (mmoll)
% Trung dnh 1 44.3 , , „,
' (m^.'dl)
% Lympho
%Mono
Na- (mmol/l) (mmol 1) TWudn 89 Cl
(G/1) 1 (150-450) (mraolT) 3.5 (<17) lifii (3.9-6,4)
0,024 (<0,05)
145 (135-145)
4,0 ( 3 i - 5 )
974 (98-104)
DorE mau co ban
PT(%) P T I N R
62,- (70-140)
U9 .WTT 64i ioiy! ' 1283) .VTT
Benh chiip.e Fibnnogen
(eii"
125 (0.85-12)
U 3 (2-1) Benh nhan dugc chan doan: NMCT sau ducri cap co bien chiing NTH. \ a chuven d^n phong can thiep mach vanh sau 3h nhap vien. Ket qua chup dpng mach vanh cho thiv:
Co tac hoan toan doan lllll dpng mach vanh phai. da dugc dat mot stent vao dpng mach vanh phai va dat may tao nhip chcj trong bu6ng tim (Hinh 3)
J TKiy \==^
Hinhl: Ket qud chup maeh vdnh qua da vd ddt stent
Sau can th,ep mach vanh, benh nhan dugc chuv en khoa h6i sire tich cue- Trona linh ttang hon me. tha theo bop bong, mach: 1301 phut, huv et ap: 110 60 mmHa (dan. duv m to van mach. dobutamin lOug/kg/ph. adrenalin 0.6ugkgph. noradrenali;o.9u;ke ph).
D , ^ tun CO hmh anh nhip xoang xen ke vai cac nhip tu ,hi, (Hmh 3). Xe, ndiiem cho thay tmh ttang suy than toan chuyen hoa vaiactat mau tang (Bang 2^ ' ' 44 TAPCHiTIMMACHHOCVIETNAM-s6632013
CA LAM SANG i .
Hinh 3; Hinh dnh dien tim sau can thiep mgch vdnh qua da Bdng 2: Xet nghiem mdu sau can thiep mgch vdnh qua da
Khi mau d6ng m^ch PH
PCOj H C O j
BE
P C , P/F A-aDO,
Lactat
7,25 33 14,5 -11,7
94 235
11,5
Xet nghiem mdu Troponin T
(ng/ml) NT-ProBNP Ure (mmol/1) Creatinin (umol/l)
CK (U/l) CK-MB
(U/l)
>10 76 7,3 (2,5-7,5)
143 (62-120)
6650 (24-190)
504 (<24) Benh nhSn dugc chi dinh: H 5 trg tim
ph6i nhan tao ngoai co the cho tinh trang soc tim va roi loan nhip tim. Sau khi bit diu ehay ECMO: benh nhan dugc ngimg tit ca cac thu6c trg tim va van mach, huySt ap trung binh duy tri 70 - 90mmHg, tuai mau diu chi t6t, tiJu dugc 150 - 200ml/
gia, lactat mau giam din. Sau 4 ngay h6
trg ECMO, benh nhan tinh tao hoan toan, dien tim: hinh anh nhip xoang deu sieu am danh gia chiic nang tim hoi phuc dan, chirc nang than ve binh thucmg, hit toan chuyen hoa, lactate mau binh thuang, benh nhan cai dan ho trg va ket ECMO sau 6 ngay (114 gio) (Bang 3). Sau ngimg h6 tra ECMO. benh nhan tinh tao, huyet TAP CHI'TIM MACH HOC VIET NAM-SO 63120131 45
A CA LAM SANG
dpng 6n dinh, dugc nit npi khi quan tho ox> kinh. rut ma; tao nhip cho. su dung cac thudc lie chi men chuyin. Ngay 20/11/2012 benh nhan on dinh. khong co thilu sot thii kinh va ra vien sau 9 ngay dieu tri.
Bang 3: Difci him xet nghiem, chdc nang tim va hoira ECMO Ngay
Thong so PH PCO;
HCO, BE PC.
P/F Lactat
Ure/
Creatinm CK/CKMB Troponin T NT-ProBNP
EF%
13/11
-.33 35
m
-'.4 338 338 5.9 SO 134 8:so so- lo 126
14/11
"48
25 1 138 345
1
S.3 139 55-2 260
6.25 182
- 1
15/11 Diin bien can -33
16/11 lam sang
- 4 -
17/11
-41 30 31 , 33 25,1
2,9 109 270 1,6 10,1/184 2851/190 S,54
120 39
22.6 -11 126 315 13 SS 111 303 r
0 5 193 50
20,9 -J-
83 210 0.9 - ^ - 6 200/14
02 110
18/U
- 4 - 40 291 5 4 S9 230 OS 6- -3 140 13
01 90 5S HStitfECMOt
CI (I/ph/mO
KO, (%)
-
100
2.0-> 1,8 ->1,6
-0
l,4->ljl i : g a 60
m Jar, tet ECMO SO
BAN LUAN
Xii tri ngimg min hoan (NTH) tai khoa|ip cim: Ti le ngimg tira dot ngpt chiem 15"i tong so cac truong hpp tu vong a cac nuoc phat triln [8]. Thoi gian tii khi cip cim din khi CO tim dap tro lai 6 benh nhin ciia chiing toi la 45 phiit. trong mpt s6 nghien ciiu thiri gian na> la 3.8 - 5.1 phut cip ciiu ca ban va 8,4 - 9.0 phut cip cim chuv en sau trong nhihig nam tir 1977 din 2001 [5]. Nhuvay. Inronghap lam sang cua chung toi co thai gian cip ciiu ngimg tim dai ban v a benh nhan khong co di chimg thin kinh "khi ra v ien cho t h k Ky thuat cap ciiu ngimg tuin hoan(CPR) «l dugc thuc hien rit lit da diip cho dam bao tuan hoan toi thieu duy tri su sdng cuajisae^n g. v i vay cin CPR \ a, thiri gian lau hon va
46 ITAPCHI TIM MACH HOCVIET NAM-S6632013
CA LAM SANG i.
tich cue han a nhiing truong hgp ngimg tun dpt ngpt tai benh vien vi vin con ca hpi ciiu song benh nhan nhung cin dugc phat hien va cip ciiu ngay lap tiic, diiu nay doi hoi phai luon ehuin bi sin sang con nguai da dugc huin luyen thanh thao, khong mic sai sot va dung cu diy du.
Can tiiiep mach vanh: Vin co thi tiin hanh sau khi cip cim NTH. Thai gian tit khi bi NMCT din khi dugc can thiep mach vanh la 85 phiit. Theo cac tai lieu nuac ngoai sau cip ciiu ngimg tim tai ca so co hrang thilt bi, bien phap can thiep mach vanh qua da dugc lira ehpn. Benh nhan cua chung toi dugc chi dinh va can thiep mach vanh phii hgp vai cac nghien ciiu va thcri gian can thiep [4,7].
Sau khi da tai tuoi mau, co tim van con bi anh huong nSng ne chua the dam bao chirc nang cua minh, ke ca khi dung nhieu thuoc tang co bop co tim va thuoc van mach lieu cao, thi ECMO la lira chgn toi uu, no khong nhiing giiip chiic nang trpn oxy vai mau thay cho phoi ma con thay tim thuc hien chiic nang bom day dl cho tim co thai gian nghi ngai chcr hoi phuc, vi vay nay nay ECMO dupe chi dinli trong cac truong hgp suy ho hap cap nang ma may tha va cac thuoc khong hieu qua, hoac suy tuan hoan cap (NMCT, viem ca tim nang, sau phiu thuat tim, ghep tim... co biin chiing soc tim...)
Ci benh nhan nay cai dat ban dau dam bao chi s i tim (CI) 2,2 lifphut/m^ ngay sau do da ngimg het cac thuoc dobutamin, noradrenalm, adrenalin ma van duy tri huylt ap trung binli > 65mmHg, do lactate mau ngay sau van hanh may ECMO va
mSi 6 gio/lan thay giam dan , khi lactate mau tro ve binh thuong thi bat diu giam din su trg giiip ciia may cho den khi tun tu CO the dam nhiem dugc cong viec ciia mmh thi ngvmg hin.
Co mpt so yeu to: thai gian cip ciiu ngimg tuan hoan truoc khi ECMO, nguyen nhan ngimg tim va kha nang thay tim ho5c tai tuoi mau co the giiip danh gia benh nhan phii hgp cho ho trg ECMO [2,3,6].
Thoi gian cap ciiu ngimg tim tnrdc khi ho trg ECMO la yen to quan trgng anh huong den tien lupng song ciia benh nhan sau ngimg tim. Co mpt so nghien cim dua ra ket luan chi ho trg ECMO cho benh nhan ngimg tim trong benh vien vol thdi gian ngimg tim ngan [1]. Tuy nliien, ngudng thdi gian nay la bao lau van chua dugc thdng nhat. Benh nhan ciia chiing tdi hoi phuc than kinh hoan toan mac dii ngimg tim va dugc cap ciiu 45 phiit trudc khi hd trg ECMO. Thdi gian cap ciru ngimg tuan hoan ca ban tien lugng kha nang sdng hoac hdi phuc than kinh trung uong ciing khdng dugc thdng nhat [5]. Benh nhan cua chiing tdi tinh tao hoan toan va dugc cap ciiu diing quy each lien tuc khi ngimg tun va dugc tai tudi mau mach vanh sdm cung la li do cho tien lupng phuc hdi thin kinh tdt va dat thanh cdng dieu tri.
KETLUAN
Viec cap ciru thanh cdng trudng hgp NMCT cap cd bien chiing NTH nhd: chan doan va cap ciiu nhanh. chinh xac, ky thuat cap ciiu NTH tdt, phdi hgp nhip nhang cac khoa: cap cim - can thiep mach vanh va TAPCHITIMMACH HOC VIET NAM - 5063.20131 47
A CA LAM SANG
hdi siic tich cue nhd phucmg phap ECMO, (nhdi mau co tim, viem co tim cap cd biin da md ra mdt kha nang mdi trong viec ciiu chimg soc tim va rdi loan nhip tim nguy chiia nhiing trudng hgp suy tuin hoan cap hiem) d Benh vien Bach Mai.
ABSTRACT
Extracorporeal Membrane Oxygenation (ECMO) could be used for supporting patients in severe acute cardiogenic shock. We presented a 63-year-old male patient whose life was saved by primary PCI in combination with ECMO technique after having cardiac arrest for 45 minutes and then severe cardiogenic shock with several life-threatening arrhythmias as a result of acute myocardial infraction. The patient cardiac output improved significandy shortly after ECMO implementation. ECMO was discontinued after six days and the patient recovered without any neurological complication. Prompt multidisciplinary cooperation between the Emergency Department, the Vietnam Heart Institute and the Intensive Care Unit of Bach Mai hospital played an important role in the success of the case.
TAJ L i f U THAM KHAO
1. American Heart Association in collaboration with International Liaison Committee on Resucitation.
2010 AHA Guidelines for cardiopulmonary resuscitation and emergency cardiovascular care. Part 6:
CPR techniques and devices. Circulation 2010; 112 (Suppl. I): IV47-50
2. Morris MC, Wernovsky G, Nadkami VM. Survival outcomes after extracorporeal cardiopuhnonary instituted during active chest compressions following re&actory in-hospital pediatric cardiac arrest Pediatr Grit Care Med 2004i 5:440-6
3. Nagao K, Hayashi N, Kanmatsuse K, et al. Cardiopuhnonary cerebral resuscitation using emergency cardiopuhnonary bypass, coronary reperfiision therapy and mild hypothermia in patients with cardiac arrest outside the hospital. J Am Coll Cardiol 2000; 36:776 -83.
4. Nallamothu BK, Bates ER, Herrin J, et al. Times to treatment in transfer patients undergoing primary percutaneous coronary mtervention in the United States: National Registry of Myocardial hfarction (NRMI)-3/4 analysis. Circulation 2005; 111:761.
5. Rea TD, Eisenberg MS, Becker LJ, et al. Temporal trends in sudden cardiac arrest: a 25-year emergency medical services perspective. Circulation 2003; 107:2780
6. Schwan B, Mair P, Margreiter J, et al. Experience with percutaneous venoanterail cardiopulmonary bypass for emergency circulatory support. Grit Care Med 2003; 31:758-64.
7. Smith, SC Jr, Feldman, TE, Hirshfeld, JW Jr, et al. ACC/AHA/SCAI 2005 guideline update for percutaneous coronary intervention a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (ACC/AHA/SCAI Writing Committee to Update the 2001 Gmdehnes for Percutaneous Coronary totervention). J Am Coll Cardiol 2006; 47:el. AvaUable at:
www.acc.org/,ualityandscience/clinical/statements.htm (accessed September 18,2007)
8. ZhengZJ,CroftJB, Giles WH,MensahGA.Sudden cardiac deathmthe United States, 1989 to 1998.
Cuculation 2001; 104:2158.
48 I TAP CHf TIM MACH HOC VIET NAM-5063.2013
