VAI TRO CUA PROCALCITONIN TRONG CHAN DOAN NHIEM KHUAN HUYET d BENH NHI
OIEU TRI TAI BENH VIEN TRUNG UONG HUE (02/2012 - 08/2013)
Tran Kiem Hao".
v T ^ r . S ' i t f I T S ' ' ' r * v ? ' f ^ ' f ' ^ t * « " ' t a ' ^ . * tie, ttong cio ta V, r,™ sm cap era rti. « « • « « / . Xac <l|nh nong d j procalcilonin (PCT) iron. NKH o M en, N ^ v t o S n , ^ 2 r * S ' . r ' S ' ' ? ' ' ' ' - ' » b«nh rf,l «l 2 Mng «,6i . 4 len d - w ehin doi^
nhan to son, ttong . i n g 24 gii, san khoi pha, bfnh d mie do I ^ T » g e.o n h l s m T i PCT
Ttf khda: Nhiem ichuan huyet, procalcilonin (PCT).
OAT VAN OE
Nhiim khuan huyet (NKH) l i mot hoi chiiYig ttiudng g?p trang lim sing, die bift frong cic ddn vj hoi siic cap ciiu nhi. NKH ttiudng diln bien nhanh, neu khong phat hifn v i dieu fri Iqp ttidi se gay tinh frang NKH ning, co tiie du^ den soc nhiem khuan, suy da ctJ quan va tii vongt'»i.
Chan doin stJm, dieu frj diing va kip tiidi NKH se lim giim ty If h i vong.
6 bfnh nhi, bieu hifn iam sang eiia NKH thudng khong hSng (Knh, ci5 ttif ttiieu eie frifu chiing v i dau hifu iam sing die hifu. Chan doin xic djnh nhiem khuan huygt dift vio cay miu, nhung kft qui cay miu ttiudng chim v i khong phii luc nio cung dUdng tinh.
"S<vi/i ufn da khoa Hung uang Hue.
Ngiy ntifn IM: :u/ll 2016 Ngiy ptian bifn long:
Ngiy dgy^ ding: 12/01/2017
Ngu*l c h j . irick . h i ^ „«| dang Icho. hyc: Trin Kifm Hdo. Bfnh yifn aa khoa Tntng uang Hue.
Difn Ihoai: 0914 002329 E-mail: haotrwihemii, yahoo.com
Hien nay co nhieu dil diem de ehan doan phan bift giii& nhilm khuan huyet v i hoi chiibg dap liHg viem hf ttiong do nguyen nhan khic, mot frong cie chl diem do l i procalcitonini^i. 6 nhthig benh nhin NKH ning co hpi chiiYig dap ting viem toan ttiin, procaidtonin tang cao, sdm hcJn so vdi cie xet nghifm khic va co y nghia tien ludng soc nhilm khuan").
Oiling toi ttiUc hifn nghien eiiti nay nhim muc tieu:
(1) Xic djnh nong do procaidtonin trong NKH is tie em.
(2) Gii fri ciia procaidtonin huyet thanh trong tien doin NKH ning, s & nhilm khuan v i hoi chiitig suy da cd quan.
OOI Tt/ONG VA PHl/ONG PHAP
Ooi bftfng: 55 Bfnh nhi ti/ 2 ttiing tiioi frd ien dUde ehan doan NKH vao dieu fri tai ddn vi Hoi siic cap ciiXi Nhi Benh vien da khoa Trong Udng Hue. Thdi gian nghien ciiu' hy ttiing 02/2012 den 08/2013.
Cac tiSu chuan ehan doan
Hpi diCfng dap ifng viem hf thong: Khi co it nhat 2/4
TUUY^»li&)IV«TNAM*s6 1(17) - 2017 - 23
tieu chuan sau (frong do 1 tieu chuan bat bupc phii co la bit ttiuicing nhiet dp hay bach cau):
Bang 1. Tieu diuan ehan doan hoi tiiifng dap ititg viem hf thong'-
Nlaetdo tnjng tam
Kaqua
> 38,5^ l\at<WC T3ng liok giam ttieo tuoi (Uung dung lua tri BactiQumau lieu gay giam bacti cau ttujrptiat), tnje trenlO%
1 l)adi cau non.
Nhip dm > 2S0 so vdi gia tri tiinh thuiitng theo tuoi hoac nhip diam d tre cWS ItuS
Nhip thd |>2SOsoyiili^tnl)inh thuicnig ttieo tuoi Nhiem khuan huyet = HC£)UVHT + bang chiing/nghi ngd nhilm khuani^:
- Cay miu vi khuan gay bfnh dudng tinh.
- Nhilm khuan dudng tieu: Co sU hifn difn ctia vi khuan gay bfnh ti^ng nudc tieu.
- Viem phoi: Hpi chiing suy ho hap, hlnh inh viem phoi ti^n fim X-quang phoi.
- Viem ming nio mii: Djch nao hiy bien doi. Soi cay vi khuin giy bfnh(+).
- Ap xe phin mem.
- Tieu chiy nhilm khuan: Soi, cay phin vi khuan gay benh(+).
Phuong phip: Nghien ciiu mo t i . Cic bu-dc tien hinh
BWicl: Khim lim sing
- Khai thac bfnh sii v i hoi tien sir bfnh ctia bfnh nhin.
- Binh gii toan ttiin: Tim cic dau hifu nhilm khuan ti^n lim sing (moi kho, Iu8i bin), tim cic ming tiiim ti'm dSu chi, dau xuat huyft dudi da, tinh frang y tiiiic (bat an, CO gift, ndi sing, hon me)...
• Khim eie trifu chiing toan ttiin.
- Thim khim eie cd quan chiic ning: gan, tim, tiian, phoi, ttian kinh, huyft hpe.
Btrtfc 2; Thyt hifn cic xet nghifm can lim sing (cong ttiiJt miu, CRP, cay miu, proeaktonin).
flirtte 3: Oanh gii kft qua.
Thu thfp va xii' ly so lifu: Theo phUdng phip ttiong ke yhgc.
KETQUA
Bien doi procalcitonin trong NKH
Bang 2. Ti If cac mij'c do bien doi doi n5ng do procalcitonin
Procalcitonin 0,05 - 2 (ng/ml)
> 2 - 10 (ng/ml)
> 10 (ng/ml) Tong
S d . t n i ^ h ^ (n) 30 11 14 55
Tilf(%)
54,5 20,0 25,5 100 Nhan xet: Tat c i eie biiicing hdp NKH co PCT ting vd!
cac miit dp: 0,05 - 2ng/ml chiem 54,5%; > 2 - lOng/ml chiem 20%; > lOng/ml chiem 25,5%.
Bang 3. Gii tri trung binh procalcitonin trong NKH
Phan lo^i NKH Nhilm khuan huyet NKH ning Soc nhiem khuSn Chung
— r — 1 — p n PCT trung binh
31 23 1 55
3,61 ± 0,31 7,31 ± 1,01
14,8 5,36 ± 2,03
Nhan xit: Nong dp PCT tioing binh 5,36 ± 2,03ng/ml, ting dan theo miic dp ning ciia NKH.
Bang 4. Nong dp procalcitonin trung binh theo thdi gian khdi bfnh.
Tbdi gian khdi b f n h
<24gid 25 gid - 48 gid
> 48 gifl P
PCT trung binh ( n g / m l )
13,02 3,24 1,24
Trung vj (ng/ml)
13,67 1,60 0,12
< 0,001
Nhan xet: Benh nhan den sdm frong vong 24 gid sau khdi phit bfnh eo miic dp PCT ting cao nhat, sau d6 PCT giam dan theo thdi gian.
2 4 • TPUy6tlNH6uiV<TNAIM*s6 1(17) -2017
c a w d a PCT trong tien doan nhilm khuan h u y a Gia tri d i a PCT t n « g tien doan
nfng va soc nhiem khuan qua„ hoi diihig suy da ctf
' t T - r - ^ ' • • • l l
Bieu do 1 . su'dng cong ROC cua PCT xac d|nh NKH n|ng va SNK
Nhan xet; PCT eo gii bj frong viec fren doin NKH ning v i SNK vdi AUC = 0,741; dp nhay 79,2% v i iM dac hif u 83,9% d dian cat PCT > 2,28ng/ml.
I
- P C TCRP
20 40 60 lOO-OitUctutu
Bieu dS 2. So sinh difn t k h du^di du-dng cong cua PCT vdi b9di cau va CRP trong xac « n h
NKH ndng va SNK
Nhan ret: PCT co difn tieh dudng cong ldn nhit (0,741) khi so sinh vdi CRP (AUC = 0,581) v i badi tau miu (ALC = 0,625) frong ehan doin v i ben luWng NKH ning v i SNK (p < 0,05).
Bioi do 3. Ou-dng cong ROC d i a PCT xac dfnh hoi diihig suy da ctf quan
Mian * * PCT CO gii fri frong vifc xic djnh hoi chuiig suy da ed quan. B u i ^ oong ROC biaj diln gii fri dian doin aJa PCT CO difn tidi dua dudng cong AUC = 0,747;
dp nhay 86,7% v i dp die hieu 72,5% d diem cat PCT >' 2,28ng/ml.
B i & do 4. So sanh dien t k h dtidi dtfdng cong cua PCT viM CRP va bach cau mau trong
x i c Anh suy da ctf quan
NhAi xit: PCT 00 difn tidi dudi dudng cong Idn nhat (0,747) khi so s i r * vdi CRP (AUC = 0,618) v i badl tau mau (AUC = 0,685) tiong xic djnh suy da cd quan.
BAN LUAN
Ttay a a nong do procaWtonin d tie nhilm khuan huyft
Ttong nghien aiu ouadning loi, tat eifru&hg hpp NKH (Ku 00 n5ng dp procddhmin ting hdn binh tiiudng (PCT >
0,05ng/ml), w« cic miit dp tftig nhu sau: 0,05 - 2ng/ml
* « a n H 5 % ; > 2 - 1 0 ng/ml diiem 20%; > lOng/ml
* « " 25,5%. Nong dp PCT frung binh 5,36 i 2,03ng/ml
T R U V ^ I M & i v e T N A I I * s 6 1(17) - 2017 - 2 5
_^^m^
Kft qui niy phu hdp vdi nghien diu Ctia Nguyen Thj Tbanh vdi 86,6% 00 PCT > 0,5ng/ml; frung binh 6,8ng/ml (95%
a : 3,5 -13,3).
Pourakbari v i cs nhin ttiay nong dp PCT tang cao khi nghien ctlu 158 bfnh nhi tir 2 thing - 1 0 tua bj nhiem khuan huyft"".
Theo nhom nghien oili d Diit aia Bainkhorst v i cs, nong dp PCT frung binh frong NKH la 0,4 ± 3,0ng/ml;
iwng dp PCT trung binh trong hpi chutig nhilm khuan bjin tiiin 0,5 ± 2,9ng/ml; trong hpi chiitig nhian khuan toin ttiin ning 6,9 ± 3,9ng/m|Pi. So sinh vdi nghien ciiu niy thi hi so ctia chiing toi kha phCi hdpP'.
Bfnh nhin den sdm bong vong 24 gid sau khdi phit bfnh CO miit dp PCT ting cao nhat, sau do PCT giim dan ttieo thdi gian. Dieu nay phii hdp vdi sinh ly v i dpng hpc ciia PCT. Trong 48 gid dau tien khdi bfnh thi rrong dp PCT ting cao v i giim dan sau 48 gid den 72 gid.
Vi the xet nghifm PCT huyft thanh bfnh nhan vio ngay dau tien rat hiiu ich cho cong tic ehan doin v i tien luHng bfnh.
IJfng dung dpng hpc ciia PCT, Charles PE da tien hinh djnh lupng PCT frong 3 ngay Hen tiep khi b i t d i u khdi phit nhiem khuan huyft. Kft qua cho tiiay nong dp PCT ting ro rft giuS ngiy tiiii nhat v i ngay thii hai chiing to lifu phip khing sinh khdng thich hpp. Neu giu^ ngiy tiiii hai v i thii ba nong dp PCT khdng giim xuong 30% tiii c3n phii dinh gii lai ehan doin va lifu phip dieu bi'^'.
So vtSi cic chat tien viftn khic, PCT on djnh hdn, ton t?l trong nhift dp phong toi thieu 24 gid v i ffin tai frong 1 hiSn d 4°C, khong thay doi neu bj dun nong hay lam dong hay ra dong v i c6 tiidi gian bin hiiy dai hdn. Sau 6 -12 gid nhiem khuan, PCT ting nhanh hdn CRP va chim hdn cyhikins khicIL - 6, IL -10, TNF, toy nhien PCT ton tai liu hdn cic chat n a / " .
GIa trj tien doin nhilm khuin huyet ning, soc nhilm khuin v i hfi chihig suy da ctf quan dia pro- caidtonin
Trong nghien ciiU chiing toi, cie mifc dp tang PCT huyft ttianh co lien quan vdi NKH v i NKH nang.
Kft qui niy ding phii hdp vdi nghien ciiu ciia Abahrani^dio ttiay vdi nong dp PCT > 2ng/ml, ty If bfnh nhin nhiem khuan huyft l i 12,1%; nhilm khuan huyft ning 40% v i soc nhilm khuan 53,3%. Chiing to ty If
nong dp PCT huyft ttianh tang dan theo milt dp ning ciJa bfnht'J. Thep Castelli v i CS, PCT trung binh ciia nhom nhilm khuan huyft l i l,5ng/ml, nhilm khuan huyft ning l i 4,5ng/ml va soc nhilm khuan la 13,lng/miw. Theo nghien cult ciia Harbarth, nong dp PCT huyft ttianh oia nhom bfnh nhan NKH ia 3,5ng/ml; NKH ning la 6,2ng/ml v i sSc nhiem khuin la 21,3ng/ml. So sanh nghien aili oia Meisner va CS. cung co kft q u i tuHng tii. Bfnh nhin NKH CO nong dp PCT huyft thanh la 2,lng/ml; NKH ning 5,68ng/ml va soc nhiem khuan l i 6,06ng/m|i". Nong dp PCT huyft thanh c6 khi nang xic djnh miic dp tiam frpng ctia bfnh nhan NKH.
Kft qui nghien ciiU eiia chting toi, PCT eo gia fri bong vife ehan doin v i tien IUdng NKH ning va/hoae SNK; d diem cat PCT > 2,28ng/ml eo dp nhay 79,2% va do die hifu 83,9%. DUdng cong ROC bieu diln g i i frj ehan doan ctia PCT CO difn tich dUdi dUdng cong AUC = 0,741. PCT CO difn b'ch dUdng cong Idn nhat (0,741) khi so sanh vdi CRP (AUC = 0,581) va bach cau mau (AUC = 0,625) tiong ehan doan NKH nang va, hoie SNK.
Theo Charles, PCT rat co g i i tri trong viee ehan doan NKH. DUdng eong ROC mo ta gia trj ehan doin ciia PCT xie dinh NKH eo difn tfch dUdi dUdng eong AUC = 0,934 (95% Q : 0,881 - 0,970)151.
PCT cung co gii trj trong viee xic djnh Hpi chutig suy da cd quan; d diem c i t PCT > 2,28ng/ml co dp nhay 86,7% v i dp die hieu 72,5%. DUdng cong ROC bieu dien gii hi ehan doan cua procalcitonin co dien ti'ch dUdi duftng cong AUC = 0,747. PCT eo difn tich dUdi dUdng cong Mn nhft (0,747) khi so sinh vdi CRP (AUC = 0,618) va badi cau mau (AUC = 0,685) frong xic dinh suy da cd quan.
Cac nghien eiili fren ttie gidi eho ttiay dp nhay ciia PCT ttiay doi hi' 83% den 100%, dp die hifu ciia PCT tii' 70 - 100%. Theo Hatheriii va CSi", Meisner v i CS, PCT co kha ning tien doan NKH va hpi chiibg suy da ed quan tot hdn CRP. SUting cao PCT c6 lien quan h5i roi loan chii'c ning cic cdquan dUdc xie djnh tiieo tiiang diem SOFA (Sepsis related Organ Failure Assesment) hoie APACHE I I (Acute Physiology And Chronic Healtti Evaluation).
K f r LUAN
f&ng do procalcitonin trong NKH
- Tat ca cic trudng hdp NKH deu ed PCT huyft ttianh tang: 0,05 - 2ng/ml chiem ti If 54,5%; > 2 - lOng/ml chiem 20%; > lOng/ml chian 25,5%.
2 6 - THUY6«||M&t|VtTNAIM*S6 1 ( 1 7 ) - 2 0 1 7
- Nong dp PCT bung binh 5,36 ± 2,03ng/ml, tang ttieo miic dp nang ctia NKH.
- Bfnh nhan den sdm tiong vong 24 gid sau khdi phit benh CO mtie dp PCT tang cao nhat, sau di5 PCT giam dan theo thdi gian.
6/a^fif tien doan nhiem khuan huyet nang, soc nhi&n khum va hgi chihig suy da cdquan cuapro- caldtonin:
- PCT CO gia til tiwg vifc ehan doin va tien luting NKH ning v i SNK; d diem cat PCT > 2,28ng/ml co'do nhay 79,2% va dp die hifu 83,9%.
- PCT CO gia fri frong vifc xic djnh hpi ehiihg suy da cd quan; d dian cat PCT > 2,28ng/ml co dp nhay 86,7%
v i dp die hifu 72,5%.
TAI UEU THAM KHAO 1. Alzahrani A.J et al (2009), Rapid delation of pro-
calcitonin as an early marka of sepsis in intensive care unit in a tettiary hospital, Intemational Joumal of Medidne and Medical Sdences, 1(11), pp. 515 - 522.
2. Bell K, Wattie M, Bytti K, Silvestrini R, Qarlc P, Sta- chowski E, Benson EM (2003), Procalcitonin: a marka of bacteremia in SIRS, Anaestii Intensive Care, 31(6) oo 629 - 36
3. Brunkhorst F M, Wegsdieida K, Fdrydci Z F, Bnink- horst R (2000), Procalctonin for eariy diagnosis and dif- ferentiation of SIRS, sepsis, severe sepsis, and septic shock. Intensive Care Medidne, 26(2), pp. S148 - S152.
4. Castelli G P, Pognani C et al (2004), Piocaldtonin and C-reactive protein during systemic inflammatory re- sponse syndrome, sepsis and organ dysftjnction. Critical Care, 8(4), pp. 234 - 242.
5. Charies PE, Ladoire S et al (2008), Impact of pre- vious sepsis on tiie accuracy of procalcitonin for ttie eariy diagnosis of blood sfream infection in critically ill patients, BMC Infect Dis, 8, pp. 1-10,
6. Gendrel RD. (2005), Procaidtonin: A useful bio- marica in ttie management of severe bacterial infections in pediafric practice, Biomerieux, pp. 1 -10.
7. Goldstein B, Giroir B et al (2005), International pe- diafric sepsis consensus conference: Definitions for sepsis and organ dysfiinetion in pediatiics, Pediati- Crit Care Med 6(1), pp. 2 - 6 .
8. Hattierill M (1999), Diagnostic markere of infection:
comparison of procalcitonin with C-reaetive protein and leucocyte count, Ardi Dis Child, 81(5), pp. 417 - 21.
9. Meisna M. (2000), Procalcitonin: a new, innova- tive infection parameter; bbchemical and clinical aspects, Thieme, New York.
10. Nystidm P 0 (1998), The systemic inflammatoiy response syndrome: definitions and aetiology, J. Antimi- crob. Chemotiier, 41 (S 1), pp. 1 - 7.
11. Poutakbari B, Mamishi S et al (2010), Evaluation of procakatonin and neopterin level in serum of patients witti acute bacterial infiection, Braz J Infed Dis, 14(3) DD 252 - 255.
TRUV6«»i&MV«TNAM*s6 1 ( 1 7 ) - 2 0 1 7 - 2 7
ROLE OF SERUM PROCALCITONIN FOR DIAGNOSIS OF SEPSIS I N PEDIATRIC PATIENTS TREATED AT HUE CENTRAL HOSPITAL
(02/2012 - 08/2013)
Summary
Sepsis patients ate commonly seen at ICU. Objective:
Detennine tiie ooncenfration of serum procakitDnin in sep- ticemia in chiWren. Vilue of senim procddhxiin in pnedfct- ing severe sepsis, septic shock and multiple organ failure syndrome. Subjects and Methods: 55 chikiren diagnosed septKania at PICU, Hue Caitial Hospital. Results: All eases with septicemia had increased PCT levels: 0.05 bo 2ng/ml accounted for 54.5%, > 2 - lOng/ml 20%, > lOng/ml ac- counted for 25.5%. Minimum PCT concentrations 0.059ng/ml, maximum 24.83ng/ml, mean 5.36ng/ml, me-
Key words: S ^ s , procalcitonin (PCT).
dian 1.23ng/ml. Patients were coming soon within 24 hoi«s after onset of illness is the highest level of PCT, ttien de- creases. High senjm procaldhDnin level can prognosis of se- vere septicemia and sepsis shock, at cut off of PCT >
2.28ng/ml has a sensitivity of 79.2% and a spedfidty of 83.9%. High serum procaidtonin can prognosis of MODS, at ttie cut off of PCT > 2.28ng/ml had a sensitivity (rf 86.7%
and a specificity of 72.5%. Condustons: High semm pro- cakjtonin ean predicting of severe septicemia, septic shodt and MODS.
