5. Morclli A. , Rrtmcr C., Rchbcrg S. , Langc M . . Orccchioni A., Ladcrchi A., Bachcloni A., D'Alessandro M . , V;ui Akcn H., Pictropaoli P., Wcslplial M . (2008),
"PliciiN Icphrinc \crsus imicpiiicphrinc for iiiilial hcmodyiianiic support o f paticnt.s with scplic shock: a rnndoini/cd conlrollcd trial".
Critical Care. 12: R143.
6. Klouchc K., C avadorc P . , P o r t a k s P., C lot .1., Canaud B., B c r a u d J..I. (2002),
"Continuous \ciio-\cnous hcmofillralion improNcs hemodynamics in .scplic shock with acute renal failure without modifying TNI-
alpha and IL-6 plasma concentrations", Nephrol, 15: 150-157
7. K u m a r A. , Schupp E. , Bunnell E . , A l l , Milcarck B., Parrillo J.E. (200
"( aidiovarcular response to dobutami stress predicts outcome in severe sepsis a septic shock" Critical Care, 12:R35.
8. Ratanarat R. , Brcndolan A. , Piccinni 1 Dan M . , ct al. (2005), "Pulse high-volur haemoflltration for treatment of seve sepsis: effects on hemod\namics ai survival" Critical Care. 9: 294-30
OANH GIA HIEU QUA CUA THAY HUYET TUONG TRONG DIEU TRj SUY GAN CAP TAI BENH VIEN VIET TIEP HAI PHONG
Tran Thanh Gang
TOM TAT
Muc tieu: Oanh gia hieu qua ciia thay huyet tUOng trong dieu tri suy gan cap. Phu'cTng phap: 14 benh nhan suy gan cap tai benh vien Viet Tiep Hai Phong dUdc tien hanh thay huyet tUdng vdi mang loc TPE2000, toe dp mau 120 ml/phut, dich thay the la huyet tUdng tUdi dong lanh, chong dong heparin chuan, cac thong so dUdc danh gia tru'dc va sau PEX.
Ket qua: Cac thong so lam sang nhU diem Glasgow, mach, HA trung binh, nhip thd, nhiet do thay doi khong co y nghia thong ke trUdc va sau PEX (p>0,05).
Cac xet nghiem ure, creatinin, glucose, albumin sau PEX thay doi khong co y nghia so vdi tru'dc PEX. Chifc n§ng gan: GOT, GPT, GGT, bilirubin giam ro ret sau PEX (p<0,01). Chirc n§ng dong mau: Sau PEX PT tang, INR va APTT giam co y nghia thong ke (p<0,05).
Bien chu'ng phan iTng dj iTng chiem 14,3% so BN va 9,7% so lan PEX, khong g^p cac bien chu'ng nguy kich.
Ty le tir vong la 50,0%. Ket luan: Thay huyet tUdng lam cai thien chiTc nang gan, giiip dieu chinh roi loan dong mau. Ty le tir vong 50,0%. Bien chu'ng di iTng 9,7% so lan PEX, khong co bien chu'ng nguy hiem
ABSTRACT:
Objective: to evaluate the effects of plasm exchange in patients with acute liver failurf Methods: 14 patients with acute liver failure at th ICU of Viet Tiep hospital were treated with PEX wit TPE2000 membrane, blood flow rate was 120 ml/mir replacement fluid was fresh frozen plasme ultrafiltration rate was 1000 ml per hour, standarzide heparin was used for anticoagulation. Parameters wer measured before the beginning and efter of the PE>
Result: After PEX GOT, GPT, GGT, bilirubin decrease significantly (p<0,01), PT increased, INR and APT decreased significantly (p<0,05). More commo complication was allergic reactions accounted for 3/3 (9,7%) of the total number of episodes. However, an patient has anaphylaxis or infection. Conclusions PEX improves liver and coagulalion function in patient with acute liver failure. Allergic reactions were S,?"/
The mortality rate was 50,0%.
* Benh vien Hud nghi Viet Tiep, Hai Phdng
Y HOC VIET NAM THANG 10 - SO DAC BIET/2011 I. OAT VAN OE
Suy gan cip la mot tinh trang benh ly phuc tap xuat hien sau mot tac dong co hai den gan, dac trung bai vang da, r6i loan dong mau va benh ly nao gan tiln tri^n trong mot thai gian ngan a benh nhan (BN) truoc do chuc nang gan binh thuang. Ty le song sot thay doi tir 20-90% tuy tung nghien ciru[31.
Muc dich chinh cua dieu tri suy gan cap la kiem soat phu nao va dieu tri ho trg suy da ca quan cho den khi sir tai sinh gan xuat hien tro lai. Hien nay cac nuac phat trien ung dung bien phap loc mau hap phu phan tir (hemoperfusion hay MARS - molecular adsorbent recirculating s\stem)[2]. Bien phap nay khong nhung co kha nang loai tru doc chat ra khoi ca the ma con co tac dung dieu chinh lai can bang noi moi, ho trg da tang.
Tuy nhien, bien phap nay gia thanh rat dat va doi hoi ky thuat phiic tap, vi vay thay huyet tuang (PEX) da dugc nghien ctiu, ap dung.
PEX ciing c6 vai tro trong viec tao lap can bang noi moi va loai bo chat doc ra khoi ca the ma gia thanh re han rat nhieu so vai bien phap hap phu phan tir.
Muc tieu nghien cuu: Ddnh gid hieu qud cua thay huyet tuomg trong dieu tri suy gan cap.
II. 06l TUdNG VA PHUONG PHAP NGHIEN COU 1. Doi tu-oTig nghien ciiii.
* 14 BN suy gan cap dieu tri tai khoa H6i sue tich cue Noi, benh vien Viet Tiep Hai Phong, trong thai gian tu 01/2010 dhn 08/2011.
* Benh nao gan tu giai doan 2 tra len
* Bilirubin huylt thanh >300 |j,mol/lit Tieu chuin chdn doan suy gan cipm - Chan an, non, bu6n non, dau tuc ha suon phai, vang da va niem mac...
- Nong do bilirubin tang gap 3 lan binh thuang
Roi loan chuyen hoa: ha glucose mau, toan chuyen hoa
Roi loan dong mau (INR > 1,5)
Ticu chuan chan doan benh nao gan [7]
Giai doan 1: Tinh than cham chap, khong CO kha nang tap trung, tliay doi nhan each
Giai doan II: Ngii Hm, c6 hanh vi khong thich hgp, roi loan thi giac.
Giai doan 111: La ma nhung co kha nang danh tliuc, lu lan, noi nggng, tang phan xa
- Giai doan IV: Hon me sau, mat nao, hoac mat vo.
Tieu chuan loai tru: Suy gan cap tren BN CO benh giai doan cuoi; BN hoac gia dinh khong d6ng y thuc hien PEX, benh gan man tinh.
2. Phu-oDg phap nghien cihi.
2.7. PEX
May Prismaflex cua hang Gambro.
Catheter 2 nong ca 12F Duong vao tmh mach dui.
Mang loc TPE 2000 T6c do mau 120 ml/phut.
Plasma tuai, dong lanh cung nhom.
- T6c do thay huy^t tuong 1000 ml/gia - Thh tich huyk tuong mot \hn thay = (1- hematocrit BN) X (0,065 X trong lugng BN)
Sir dung chdng dong heparin theo phac do ciia cac tac gia Anh nam 2006.
2.2. Diiu tri suy gan cap.
Dieu tri ca ban:
+ Chong phii nao manitol 20% 0,4g/kg + Bii nuac, dien giai
+ Cung cap glucose
- Dilu tn nguyen nhan gay suy gan cap.
2.3. Cdc sS lieu chn thu thap - Tu6i, giai, dihm APACHE II.
Mach, HA trung binh, CVP, nhiet do, diem Glasgow
GOT, GPT, bilinibin toan phan, biliiiibin true tiep, protein tojui phiin, albiunin.
Ty Ic Prothrombin, INR, APTT, fibrinoecn.
Cac bien chirng
Ty II; tir vong.
Cac thai diem liy sd lieu: Truac PEX va sau PEX.
2.4. Xu ly .so lieu: Theo phuang phap thong kc y hgc.
I. KET QUA NGHIEN CCfU 1. Dac diem chun<j
Tirthang 01/2010 dCn 08/2011 co 14 BN suy gan cap vai 31 lan PEX.
Biing 1: Dac diC-m chung
Thong so Tuoi Gidi nam So lan PEX cho 1 BN The tich huyet tUdnq 1 fan PEX (ml)
Thdi gian 1 lan PEX (gid) Ty le tir vong
Gia tri 45,6 ± 16,8 (25-76)
57,1% ( 8 / H ) 2,2 ± 1 , 3 (1-4) 2753 ± 478 (2400-3500)
3,1 ± 0,5 (2,5-4,5) 50,0%(7/14)
Tuoi trung binh ciia BN suy gan cap la 45,6, giai nam nhieu hon nir chiem 57,1%. ty letu vong 50,0%.
2. So sanh tru*6c va sau PEX
Bang 2: Sir thay doi cac trieu chirng lam sang truac \ a sau PF.X
Thong so Tru'dc PEX Sau PEX
Diem Glasgow 31 12,5 ± 3,6 13,2 ± 3,9 >0,05
Mach (lan/phiit) 31 95,7 ± 16,3 96,4 ± 14.7 >0,05
Huyet ap trung binh (mmHg) 31 73,1 ± 10,3 71,6 ± 9, >0,05
Nhip thd (lan/phiit) 31 19,6 ± 6,7 21,3 ± 5,6 >0,05
Nhiet do (°C) 31 37,4 it: 1,6 37,1 ± 1,8 >0,05
Sau PEX diem Glasgow, mach, huyet ap trung binh, nhip tha, nhiet do thay d6i khong CO y nghTa thong ke (p>0,05).
Bang 3: Thay doi ure Thong so
Ure (mmol/l) Creatinin (pmol/l)
Glucose (mmol/l) Albumin (g/l)
creatinin, glucose, albiunin truac va sau PEX
n 31 31 26 23
Tru'dc PEX 7,7 ± 4,6 143,6 ± 98,7
6,8 ± 3,2 28,6 ± 8,9
Sau PEX 7,3 ± 4.1 137,3 ± 95.6
7,6 ± 4,3 29.9 ± 9,1
P
>0,05
>0,05
>0,05
>0.05 Khac biet ve ure, creatinin, glucose, albumin truac va sau PEX khong co y nghia th6ng ke (p>0,05)
Y HOC VIET NAM THANG 10 - SO DAC BIET/2011
Bang 4: Thay doi GOT, G Thong so
GOT (U/l) GPT (U/l) GGT (U/l)
Bilinjbin toan phan (umol/i) Bilimbin trUc tiep (umol/l)
n 31 31 20 31 31
^T, GGT, bilinjbin truac va sau PEX TrUdc PEX
936,7 ± 847,3 816,4 ± 743,5 98,7 ± 45,8 401,4 ± 236,5 298,6 ± 163,7
Sau PEX 451,3 ± 368,4 387,6 ± 314,5 43,6 ± 36,7 213,2 ± 116,4
110,3 ± 98,7
P
<0,01
<0,01
<0,05
<0,01
<0,01
GOT, GPT, GGT, bilinjbin toan phan, bilirubin tare tiep giam co y nghTa thong ke voi p-'O.Ol sau PEX.
Bting 5: Thay doi dong mau truac va sau PEX
Thong sd FT (%)
INR APTT (qiay) Fibrinogen (g/i)
n 31 22 31 31
Tru'dc PEX 36,7 ± 24,3 2,8 ± 1,7 56,3 ± 23,6
3,1 ± 2 , 1
Sau PEX 63,8 ± 23,5
1,4 ± 1,5 34,6 ± 18,7
3,4 ± 2,0
P
<0,01
<0,05
<0,05
>0,05
Sau PEX ty le prothrombin tang co y nghTa thong ke vai p<0,01, INR va APTT giam co y nghTa thong ke vai p<0,05, fibrinogen thay doi khong co y nghTa thong ke.
3. Bien chung
Bang 6:
Bien chuTng Phan iTng di iTng
Soc phan ve Chay mau Nhiem khuan huyet Nhiem khuan catheter
Tac mang
Bien chimg cua P E X S o B N ( n = 1 4 )
14,3% (2/14) 0%
0%
0%
0%
0%
So fan PEX ( n = 3 1 ) 9,7% (3/31)
0%
0%
0%
0%
0%
Bien chung di ung (do da, ngua) chiem 9,7% so lan PEX, chiem 14,3% so BN. khong gap bien chung soc phan ve.
IV. BAN LUAN
1. Hieu qua cua thay huyet tu-ong Trong nghien cuu cua chung toi co 31 lan PEX a 14 BN suy gan cap vai s6 lan PEX trung binh tren mgt BN la 2,2 ± 1,3, nhidu nhat la 4 l4n va it nhit la 1 Mn. Thai gian trung binh mgt cugc Igc PEX la 3,1 ± 0,5 gia, ng&i nhit la 2,5 gia, lau nhat la 4,5 gia.
Cdc trieu chihtg lam sdng: Co th^ thiy ro mgt dihu rSng cac chi so yh mach, huyk ap, dilm Glasgow, nhiet do, nhip tha khong
thay doi nhieu truac va sau PEX. Ket qua nay ciia chung toi ciing phii hgp vai nghien cuu cua cac tac gia khac nhu Nguyen Cong Tan nghien cim ve hieu qua cua PEX trong dieu tn hoi chung Guillain - Barre[4], Ngo Duy Dong nghien cuu hieu qua cua PEX va C W H trong tdn thuong gan cap do ngo doc [1], Akdogan trong nghien cuu hieu qua cua PEX trong suy gan cap [5].
Theo chung toi sa dT PEX it anh huang dhn lam sang cua BN la bai vi thai gian mot
lan PEX tuang doi ngan, h(rn nfra huycl tuang ciia BN dugc la\ ra sc dugc thay the
\ao ngay hang lunct tuang ciia nguai binh thuirng truoc khi Iro \c BN do vay sc bii lai tot cac the lich mat di ciing nhu cac thanh phan chirc nang can ihict ncn hau nhu khong anh huang den lui> cl dong.
Thay doi ve chirc ndng than: Uic, creatinin la nhung chi so dai diC"n cho sir thay doi chirc nang than truac \a sau PEX. Lh'c va creatinin co tha> doi truac \ a sau PEX nhirng sir khac biet nay khong co y nghTa thong kc.
Kcl qua na\ tirang tir nhu nghien ciru ciia Ngo Duy Dong [I], Akdogan [5|, Clemasscn
[6]. Theo chiing toi nhan thay rang the tich thay the huyet tuang thuirng chi la \ai lit (2.4 den 3.5 lit) \cVi so lugng nay thi khong co y nghTa gi trong vice thai trir ure, creatinin, so vai loc tham tach va loc lien tuc lugng dich
( hire nang dong mau: ty le prothrombin Cling la mgt yiu tt) quan trgng dc danh gia chirc nang gan. Ty le prothrombin tang ro ret sau PEX, INR giam c6 y nghTa thong ke sau PI'X. Tuy nhien vice tang ty Ic prothrombin khong dong nghTa vai viec cai thien chuc nang gan vi ban than huyet tuong tuai thay the CO nhieu yeu to dong mau \ i \ay ty le prothrombin tang la ket qua ciia sir pha trpn giira huyet tuang BN va huyet tuang thay the. Mac dii vay, \ ice tang ty le prothrombin cung CO mgt y nghTa quan trgng la dam bao qua trinh dong cam mau trong ca the, han che dugc cac bien chirng chay mau von rat hay gap trong su> gan cap nang. APTT giam ro ret sau Pl-X (p<0,050) dilu na> la do trong huyet tuang tuai tha\ the co nhieu yeu to dong mau nen sau khi Igc PEX thi boi phu lai dugc cac \cu to dong mau can thiet.
d6i luu va thay the r4t Ion va lien tuc theo Chung toi nhan thay fibrinogen co xu huang thai gian. Do vay PEX rit it c6 tac dung ho tang sau PEX nhirng su khac biet nay khong trg chirc nang than. co y nghTa thong ke (p>0,05).
Thay doi ve chirc nang gan: Chung toi 2. Cac bien chung
liy cac chi so bilirubin, GOT, GPT, GGT Trong nghien cim ciia chiing toi bien lam dai dien cho chirc nang gan. Ket qua a chimg chii yen ciia P1:X la phan img di img bang 4 cho thay bilirubin giam rat ro ret sau (do da, ngira). Co \A.y\^ (2/14) so BN co PEX (p<0,01). trung binh sau moi lan PEX phan img di img va co 9,7",, (3/31) so lan bilirubin giam tir 30% den 60% mire trong P1:X co phan img di img. Bien chimg nay huyet tuong, ket qua nghien ciru ciia chiing trong nghien ciru ciia chung toi thap hon toi cung giong vai nghien ciru ciia Ngo Duy nghien ciru ciia Ngo Duy Dong (21.7% so D6ng[l], Akdogan[5], Clemassen[6]. Day BN va 17,1% s6 lan PEX)[1] va Nguyen chinh la mot uu the tuyet doi ciia bien phap Cong Tan (85% so BN \ a 39,56% so lan PEX ma rat it phuang phap khac co dugc, PEX)[4]. Bien chimg nay trong nghien cmi ngay ca cac bien phap Igc mau lien tuc \ai ciia chiing toi thap hon co the do truac moi mang loc cai tien, dien tich 16 loc lan cung lan PEX chiing toi deu sir dung thuoc khang khong cai thien dugc tinh trang tang bilirubin histamin \ a 80 mg solu-Medron. Nguyen mau. Con cac enzyme lien quan nhieu den te nhan chinh ciia hien tugng nay la do ca the bao gan nhu GOT, GPT, GGT cung dugc cai ciia BN nhan mgt lugng kha Ion huyet tuong thien dang ke sau PEX (giam co y nghTa cua nguai khac vi vay rat de xay ra cac phan thong ke vai p<0,01). iimg di ung mien dich. Mgt bien chung nguy hilm CO thi xay ra trong qua trinh thay huyet
Y HOC VIET NAM THANG 10 - SO OAC BIET/2011
tuong la soc phan ve, tuy nhien trong nghien cuu cua chung toi khong gap truang hgp nao CO bien chung nay. Nhu vay dilu tri thay huyet tuong gan nhu khong co bien chimg nao nguy hiem xay ra.
V. KET LUAN
Thay huyet tuong trong dieu tri su\ gan cap giup: cai thien chirc nang gan (bilirubin, GOT, GPT, GGT giam co y nghTa thong ke) va dieu chinh roi loan dong mau (PT tang, INR, APTT giam co y nghTa thong ke).
Ty le tir vong 50,0%.
Bien chung di ung 9.7% so lan PEX, khong c6 bien chimg nguy hiem.
TAI LIEU THAM K H A O .
1. Ngo Duy Dong (2009), "Danh gia hieu qua ciia thay huyet tuong va loc mau lien tuc a benh nhan ton thuong gan cap do ngo doc", Luan van tdt nghiep thac sT HSCC, truang Dai hoc Y Ha Noi.
2. Do Quoc Huy (2006), "Lieu phap h6 trg gan", Hoi nghi khoa hoc chuyen de loc mdu lien tuc trong HSCC, Ha Noi 10/2006.
3. Suy gan cap, "Huong dan chan doan va dieu trj benh noi khoa", nhd xiidl hdn Y hoc-2011\
137-139.
4. Nguyen Cong Tan, Nguyen Gia Binh va CS (2007), "Danh gia hieu qua ciia thay huyet tuong trong hoi chirng Guillain - Barre" Tap chi Y hoc Idm sdng 4/2007, So dac san: 24-27.
5. Akdogan M., Camci C. , Guraka A., Gilcher R. , Alamian S. , Wright H. , Nour B., Sebastian A. (2006), "The Effect of Total Plasma Exchange on Fulminant Hepatic Failure" J Clin Apheresis, 21: 96 - 99.
6. Clemassen J . O . , Kondrup J., Nielsen L.B., Larson F.S., Ott P. (2001), "Effects of high - volume plasmapheresis on Ammonia, urea and amino acids in patients with acute liver failure". Am J Gas-troenterol, 96: 1217
1223.
7. O'Grady (1993), "Acute liver failure:
Rederfining the syndromes". Lancet, 342:
273-275.
8. Victor J., Navaro., John R., Senior. (2006),
"Drug Related Hepatotoxicity", N Engl J Med 2006,354:731 739.
