Nghien cuu Y hoc Y Hoc TP. H o Chi Minh * Tap 20 * So 4 * 2016
NGU'dl HIHSf THAN TIM NGUlVG DAP (HI&4 THAN SAU Km C H ^ HAYNGU^^GTUANHOAN): NHAN TRUdNGHOPDAUTIENTAI VIEI NAM
Nguyen Truang San*, Nguyen Arih Tdi*, Li Thanh Liem*, Bui Pha Quang*, Phan Thi Xuan*, Trdn Quang Virdi*, Phifm Thi Ngoc Thdo*, Phqm Vdn Ddng*, Thdi Minh Sdm*, Chdu Quy Thuan*, LeMinh Him*, Bui Vdn Tudn*, Du Thi Ngoc Thu*, Hodng Khac Chudn*, Trdn Thi Bich Huong*, Trdn Nggc Sinh*
TOMTAT
Dat vdn de: Vdo thap ky 90, do cd su khan hiem tqng phii tr'am trong trin the gidi, ngu&i ta quay lai tan dung tqng him tie NHBD. Tqi Viet nam, tie 2 ndm qua, dd khai ddng chuang trinh ghip tqi binh viin Chg R&y, de tai mang ma so qud'c gia K.C.10.28/11-15. Tru&ng NHBD dau tien dugc thuc hiSn, sau day Id bdo cdo ve tru&ng hgp nay.
Benh nhdn vd phucmg phdp: Binh nhdn BVCR201500008, 65 tudi, nam. Sd'HS 50647; khdng BHYT.
Nhdp viin: 1 khoa ngi than kinh Idc ngay 16/6/2015, vi dot quy. Tien can tang dp huyel, Chan dodn khoa ngi than kinh: xuat huyei nao l&n bdn cau trdi ngdy thu 1, tdng huyei dp. tai bien mqch mdu nao, dot quy, iinh trqng choang khong Hdi phuc. Binh kem theo: xa gan do rugu. Nguai hien tqng tUm ndng (phdn loqi Maastricht III). Binh nh&n duac cdc BS chuyen khoa ihdn kinh dieu trf tich cue nhieng vo hieu, tien lugng diin tien se chei tuan hodn. Hdi ddng chei tim ddnh gid chii tim theo phdc dd da da dinh (Nghiin cdu KC.lO.^8/11-15). BN choang phdi duy tri van mqch (Adrenaline -Noradrenaline). Thang diem Wisconsin
>20 diem. Tien lugng tu vong. Hdi ddng chei tim hdi chdn, quyii dinh ngung cdc phuang tien Hdi siec va tri gidc khong hdi phuc, tim ngieng sau 3 phut. Tuyin tuyin bdchet tuan hoan hoan todn khong cdn thay tu&n hodn mau qua doppler. Kip md' dd san sdng, m& bung nhanh, truytn dung dich Cusiodiol 4 do Celcius vdo ddng mach chu. bung. Nh&n 2 than hiin va bdo qudn theo quy trinh, (th&i gian thieu mdu ndng la 17 phut). Chuyen phdng ghep vd bdo Phdng Cdng tdc xd hgi ho trg cham sdc co th^Ngudi hien tang vd to chiec li tang.
Ket luan: Ngu&i hiin tqng tim ngieng dap, la mgt trong 2 dqng him tqng khi chei. Cdi chei dugc dinh nghia trong dinh hu&ng hiin tqng nin khi tim ngieng hdn m&i lay tqng, khi do cdc tqng dd bi tdn thucmg nang rii. Cai chet ed djnh hu&ng hiin tqng khdng eh& deh khi tim chii sinh hoc hodn toan, vi nhu vay qua mudn cho viee hien tqng. Th&i gian gida luc ngieng Hdi sue din khi tim ngieng hdn rdt ngan (3 phdt), chieng to tien lugng vi su khong hdi phuc tudn hodn la chinh xdc.
Tie khoa: Ghep than, ngu&i cho tim ngdng dap (NHBD), hiin tqng sau khi tim ngieng dap, hien tqng sau khi chii tuan hodn (DCD), him tqng sau khi chei tim (DCD), hien tqng sau khi chei ndo (DBD).
ABSTRACT
KIDNEY DONATION FROM NON HEART- BEATING DONOR- THE FIRST CASES IN VIET NAM Nguyen Truong Son, Nguyen Anh Tai, Le Thanh Liem, Bui Phu Quang, Fhan Thi Xuan, Tran Quang Vinh,
I^iam Thi Ngoc Thao, Fham Van Dong, Thai Minh Sam, Chau Quy Thuan, Tran Trong Tri, Le Minh Men, Bui Van Tuan, Du Thi Ngoc Thu, Hoang Khac Chuan, Tran Thi Bich Huong, Tran Ngoc Sinh
* Y Hoc TP. Ho Chi Minh * Vol. 20 - No 4 - 2016: 28 - 31
*BVChaRay
Tdcgid hen lac: GS. TS. Tran Ngpc Sinh, DT: 0983723493, Email: tnsinhC'holmajLcon) 28
Y Hpc TP. H55 Chi Minh * Tap 20 * So 4 * 2016 Nghien cuu Y hoc
Background: Since the 90s, due to the severe shortage of donated organs in the world, organs from NHBDs have come back to view. In Vietnam, for the last two years, National Programme "Research and development for the new source of non hear-beating donor in Viet Nam", codes KC.10.28 / 11-15 has been started at Cho Ray Hospital. ThefoUawing is a report on the first NHBD case we performed.
Patients and methods: Patients BVCR201500008, 65, male. HS 50647; health record number 50 647;
no health insurance. Hospitalization on the date 16/06/2015, because of a stroke, admitted to internal neurology department. A history of high blood pressure, internal neurology diagnosis: Severe left cerebral hemisphere hemorrhage day 1, hypertension, stroke, cerebrovascular accident, unresponsive shock condition.
Morbid condition: alcoholic cirrhosis. Potential organ donor (Maastricht UI classification). The patient was under aggressive treatment, but to no avail. Prognosis: progression of cardiocirculatory death. Following an accepted guideline, a council evaluated cardiac death (Study KC.10.28 / 11-15). He zoas on mechanical ventilation, vasopressor-dependent shock (Adrenaline- Noradrenaline). Assess by the Wisconsin DCD Evaluation Tool:>20 points. Prognosis: non-survivable condition. The neurologists informed the family about the high risk of death. The councd evaluated cardiocirculatory death basing on the guideline (Study KC.10.28 / 11-15). The Council determined cardiac death, decided to stop resuscitation facilities and irreversible perception perception. The heart stops after 3 minutes. Cardiocirculatory death was declared. No sign of blood circulation on Doppler ultrasonography. Surgical team was ready, conducted laparotomy rapidly, infusing Custadiol 4 degrees Celsius to the abdominal aorta. The 2 kidneys were taken and put to storage process (hot ischemia time was 17 minutes). Transfer to the organ transplant theater. Then the staffs of Medical Society Departement will close cooperation with donor family to prepare for funeral.
Conclusion: The non-heart-beating organ donation is one of two forms of organ donation upon death.
Death as defined in the background organ donation orientation is when the heart stops totally. At that time, the organs are severely damaged to be transplanted. An organ donation oriented death is not defined as when the donor's heart completely biologically dead, because then it's loo late for organ donation. The time from resuscitation ceasing to heart stop was very short (3 minute), which proved the prognosis of
unrecoverable circulation zoas accurate.
Keywords: Kidney donation from non heart beating donor. Organ and tissue donation after cardiac death, non heart beating donor
DATVANDE '^^^ ^^^^ Nam, tu" 2 nam qua, da khoi dong chuong trinh ghep tuf nguoi cho tim ngimg Nguoi hien tang khi tim ngtmg dap da dap tai benh vien Cho RSy, de tai mang ma so duoc ihuc hien, tnxac nhung nam 1960, truoc ^^^^ ^-^ KC.10.28/11-15. Truong hop NHBD khi khai niim ehet nao H^n t?ng ra doi, dau tien duoe thue hien, sau day la bao cao ve nhung ket qua kem do phuong tien cham doan truong hop nay.
BENH AN chua cho phep ket luan cai chet khong the cuu
tren benh nhan. Nguoi ta tap trung vao nguoi
hien tang ch^t nao khi khai niem chet nao BN BVCR201500008. 65 hioi, nam. So HS dupe cong nhan nam 1968. Sau nam 1968, do 50647; khong BHYT. Nhap vien tai khoa noi nhimg thanh eong tuy^t voi cua ghep tir nguoi than kinh liic ngay 16/6/2015, vi dot quy. Tien cho chet nao, nguoi ta co khuynh huong tix bo can tang ap huyet, uong rugu hang ngay. Bach nguoi cho tim ngimg dap (NHBD). Vao thap eau: 8.06G/1 (N: 82%); Hong eau: 5.57T/L;
ky 90, do co su khan hiem tang phii tram Hemoglobin 140 g/L Het 46,8%. Tieu cau:
trpng tren the gioi, ngucri ta quay lai tan dung 95,2G/L. Duong huyet: 112mg/dl B.U.N tang hien tir NHBDf^-s-s-^'. 15mg/dl; Creatinin- huyet thanh: 0,89mg/dl;
29
Nghidn cuu Y hoc Y Hoc TP. Hb Chi Minh * T$p 20 * So 4 * 2016
eGFR: >60inl/p/l,73m2. SGOT: 48; SGPT: 24;
Biii TP: 0,79; TT 0,60; GT: 0,19, Protid: 4,8g/dl;
Albumin: 2,2g/dl; TPTNT: pH: 5,5; D: 1.000;
Protein-nieu am tinh; HC (-), BC (-), Nihit (), PSA: l,lng/ml.
Sieu am bung: 2 than bmh thuong, xo gan khong bang bung. Chain doan khoa cap cuu:
xuat huyet nao Ion ban cau trai ngay thii 1, tang ap huyet. Chan doan khoa npi than kinh:
xuat huyet nao Ion ban cau trai ngay thii 1, tang ap huy^t. tai bien mach mau nao, dot
quy, tinh trang choang khong hoi. Benh kem theo: xo gan do rupu. Nguoi hi&i tang ti(§m nang (phan loai Maastricht HI).
Benh nhan dupe eae BS chuyen khoa than kinh dieu tri tich cue nhung vo hieu, tien lupng dien hen se chet tuan hoan. Hpi dong chet tim danh gia chet tim theo phac do da djnh (Nghien cuu KC.10.28/11-15).
SO B 6 THV"C mpi Q I T TRiNH HrflN T H ^ TREN NGlTdl CHO TIM N G C N G D.fP (NHBD/DCD, Phan V.D. £5 taoi)
19:01 18:47 18:52
5 phiJt cho" dgi
iri gian thJeit mau nontl (theo ly »Hiy^) Thcri gtan Thd-i gian thi4u m^u n 6 n g (tht*chint.) ||ttii4u mJulgnhl
24 phOt 13:17gi& (Nguyfci van Th) 14:22 gi& (Nguyin Van v.)
So, ^ : Torn tdt kei qua thuc hiin quy trinh hien vd lay thdn tie ngu&i cho tim ngieng d&p (NHBD) tren tru&ng hgp ddu tiin tqi binh viin Chg Ray (NHBD: BVCR201500008, nam, 65 tudi, ngu&i nhan thqn:
Nguyen Vdn Th. 33 tudi va Nguyen Vdn V. 45 tudi) Benh nhan nhanh chong vao hon me sau, ngung thd sau vao vien, tho may, choang phai duy tri van maich (Adrenaline Noradrenaline). Thang diem danh gia tiem nang hien tgng sau chet tim cua Dai hgc Wisconsin <10 diem. Tien lupng tu vong. Bac si Khoa Npi than kinh bao cho gia dinh kha nang xau. H6i dong chet tim danh gia chet tim theo phae do da da dinh (Nghien ciiu KC.10.28/11-15). Don vi dieu phoi den trao doi v6i gia dinh ve kha nang hien tgng. Sau khi suy nghi 2 ngay gia dinh dong y hien tgng.
Cae thii tuc phap ly dugc ehuah hi. Benh nhan dupe chuyen sang khoa san soc tich cue (10 gio sang). Lue huy^t ap tut = 40mmHg, luc do hoi siic huyet ap l^n 90ininHg va giao dgng nhu vay den 20:30 gio huyet ap roi xu&ig 55mmmHg, doppler thay giam tuoi mau tram trpng 6- than va gan. Hpi dong chet tim hpi chain, quyet djnh ngung cac phuong tien hoi Stic va tri giac khong hoi phpc, tim ngimg sau 3 phiit. Tuyen tuyen hS chet tim, tuBn hoan hoan toan khong eon thay tuoi mau qua doppler. Kip mo da s5n sang, mo bung nhanh,
Y Hoc TP. H o Chi Minh * Tap 20 * So 4 * 2016 Nghien cuu Y hoc
truyen dung djch Custodiol 4 dp Celcius vao dgng mach chili bung. Nhan 2 than tu' Nguoi hien dieo quy trinh, bao quan theo quy trinh (thoi gian thieu mau nong la 17 phut). Riia den khi dieh ra trong han. Tien hanh nhan than, gan co xo dang dau dinh. Bao quan thaun 6 moi truong 4 do Celcius. Chuyen phong ghep. Sau do dong bung can than va bao Phong Cong tac xa hgi ho trp cham soc co flie Nguoi hien tgng va to chiic le tang. Ke't quii thue hien quy trinh thuc hien tren nguoi hi&i th$n dugc trinh bay qua so do 1
BANLUAN
Nguoi hien tang tim ngimg dap, la mpt trong 2 dgng hien tgng khi chet. Cai chet dupe dinh nghia trong djnh huong hi«i tang nen khi tim ngimg han moi lay tang, khi do cac tang da bj ton thuong ngng ne. Cai chet co djnh huong hien tang khong eho den khi tim chet sinh hpc hoan toan, vi nhu vay qua mupn eho viec hien tang. Tren the gioi trong 25 nam gan day da eo nhieu nghien ciiu, cac nuoc da phat trien Hnh vuc nay da cong bo nhieu phac do va luon dupe cap nhat*'-^^*.
Nhieu nghien eiiu ve thoi diem tuyen bo chet tim da dupe cong bo, the hien qua cac phac do huong dan hien hanh. Hien cai ehet dupe dinh nghia khi tuan hoan den mo khong con va CO du co so benh hgc de tien lupng khong hoi phuc, dii luc do tim eon dap nhung kh6ng hi^u qua va sap ngimg han. Do la ly do hien nay nhieu tae gia khong gpi la hien tang tim ngung dap (NHBD), ma dimg tir hien tang sau chet tuan hoan (donation after eireultory death, DCD), hien tang sau chet tim (donation after cardiac death, DCD)'^.^^'').
Truong hpp dau tien nay thuoc phan loai Maastricht IK'^', dien tien nhanlv nhung nho bg phan dieu phoi luon san sang, nen thuc hien ,v6i quy tririh kha hoan hao. Thoi gian giiia liic ngimg hoi siic d8h khi tim ngimg ban rat ngan (10 phut), chiing to tien lugng ve su khong hoi phuc tuan hoan la chinh xae, thoi
gian thieu mau nong dai hon trong lay than nguoi cho song (thucmg duoi 5 phut), nguoi cho chet nao (thudng 0 phiit).
KETLUAN
Hien tgng tir nguoi hien tang khi tim ngimg dap mac dii co thdi gian thieu mau nong dai hon ngudi cho chet nao hay ngudi cho sShg, nhung la mpt dang hien tang dupe md rpng nham tan dimg toi da nguon tang hien, CO the giiip phan nao viec can bang dupe su thieu hilt nguon tang hien va lam giam bot nan buon ban va ghep tgng trai phep.
TAIUEUTHAMKHAO
1 B n d s h Transplantation Society (2004). Guidelines relating to solid organ transplants from non-heart-beatmg donors.
2 Department ot Health of NSW (2011): Organ Donabon After Cardiac Death. NSW Guidelines. Public Health System, Divisions of General Practice, Government Medical Officers, NSW Ambulance Service, NSW Department of Health, Private Hospitals a n d Day Procedure Centres, Tertiary Education Institutes. Website:
h ltp://w w w.heal th.ns w.go v.au/pol icies/
3 Kimber. R M (2001). Use of non-heart-beating donors in renal Transplantation Postgrad Mud ] 2001;77:681-685 4 Kootstra, G.; Daemen, J.H,; Oomen, A P (1995),
"Categories of non-heart-beating donors,".Transplantation proceedings 27 (5): 2893
5 Lmd B et al.. B; Snyder, J; Kampschulte, S; Safar, P (1975),
"A review of total brain ischaemia models in dogs and original experiments on clamping the aorta" Resuscitation (Elsevier) 4(1) 1 9 - 31. 001:10.1016/0300-9572(75)90061-1 PMID 1188189 6 Minisby of Health, NSW (2014) Organ D o n a h o n After
Circulatory Death: NSW GuideUnes Document N u m b e r GL2014_008. Publication date ll-Iun-2014 66 7 Quoc Hgi Nirac C g n g Hoa Xa Hgi Chu Nghia Vigt N a m
(2006). Lu^it hien, lay, g h e p mo, bp p h a n co the n g u o i va hien, lay xac. Lugt so 75/2006/QHll, khoa XI, ky h p p thii 10, so 75/2006/qhll ngay 29 thang 11 n a m 2006.
8 Sanchez-Fruetuoso A, Dolores Peats D, Torrente J, Perez- Contin J, F e m a n d e z C, Alvarez J, B a m e n t o s A ' Renal Transplantation from Non-Heart Sealing Donors: A Promising Alternative to Enlarge the Donor Pool. J A m Soc Nephrol 11- 350-358,2000.
9 U.S Department of Health a n d H u m a n Service, Government Information on Organ a n d Tissue Donation a n d TrarKplantalion, T h e Need Is Real: Data http,//www.organdonor.gov/about/dala.html
Ngdy nhdn bdi bdo: 1/4/2016 Ngdy phan biin nhan xet bdt bdo- 16/4/2016 Ngdy bdi bdo dieac dang: 15/05/2016
