TAPCHlYDaOClAMSANGI 08 Tap 12 - So 2/2017
Nghien cmi gia tri cua lactate mau dong mach va bach cSu trong tien luong tu vong benh nhan ngo doc c4p paraquat tai Trung tam Ch6ng doc Benh vien Bach Mai
Study the value of several paraclinical factors in mortality prediction of paraquat poisoning patients at the poison control center Bach Mai Hospital
Ngo Dire Ngoc* ^ *TtTfffng Dgi hgc YHd Noi Nguyin Trung Nguygn" * *Binh vien Bgch Mai
Ngd doe e l p paraquat gay nen t i le tU vong va chi phi dieu trj cao, vl v l y mdt cdng cu hUu ich de tien lupng t d vong la rat c l n thiet. Cac xet nghiem paraquat huyet thanh khong pho bien d nhieu noi trong khi cae xet nghiem cO ban nhu khi mau ddng mach, sinh hda, huyet hpc thuc hien rat de va cd gia tn. Muc tiiu: Nghien cUu g i l trj mdt sd yeu t d can lam sang trong tien lupng tU vong benh nhan ngp dpc paraquat cap tai Trung tam Chdng ddc Benh vien Bach Mai. Ooi tugng vd phuang phdp: Md t l phan tich tren nhUng benh nhan ngp doe cap paraquat vao Trung tam Chdng dpc Benh vien Bach Mai. Kit qud:
Lactate mau ddng maeh ed gia trj tien doan tdt vdi AUC = 0,85 (95%Ci = [0,78 - 0,92]), bach cau cd gia tri tien d o l n k h i vdi AUC = 0,79 (95%CI = [0,72 - 0,87]). Lactate cut-off = 2,0mmol/lit dp nhay 80,7%, dp dac hieu 83,3% va OR = 20,9 (p<0,001). Bach eau cut-off = 14,9 dp nhay 75,9%, dp die hieu 68,7% va OR = 6,30 (p<0,001). Bach cau cao tren 23,2Giga/lit, lactate cao tren 7,2mmol/lit cd the tien lupng t d vong sdm trong 03 ngaydau./fet/i;on:Lactatemaud6ngmach va bach cau cd g i l trj tien lUpng ddc lap tUvong do ngd dde cap paraquat.
Tifkhda: Ngd ddc cap paraquat, tien luong, lactate, bach cau.
Summary
Acute paraquad poisoning leads to cost burden and mortality. Therefore, a useful tool to predict mortality is essential. The paraquat serum test is not common in many places while some basic tests like arterial blood gases, biochemistry, hematology are more common, easy and valuable. Objective:To study the value of several paraclinical factors in mortality prediction of paraquat poisoning patients at the poison control center Bach Mai Hospital. Subject and method: Interpretative observational study. This study included acute paraquat poisoning patients admitted to the Poison Control Center, Bach Mai Hospital. Result. Arterial blood lactate had good predictive value for AUC = 0,85 (95%CI = [0.78 to 0.92]), leukocytes had pretty good predictive value for AUC = 0.79 (95%CI = [0.72 to 0.87]). Lactate cut-off = 2.0mmol/L sensitivity 80.7%, specificity 83.3% and OR = 20.9 (p<0.001). WBC cut-off = 14.9, 75.9%
sensitivity, 68.7% specificity and OR = 6.30 (p<0.001). Leukocytosis > 23.2G/L, lactate levels above
Ngay nhdn bdi- 02/02/2017. ngdy chdp nhdn Sdng: 10/02/2017
Nguaiphdn hdi: Ngo Dice Ngoc, Email- [email protected] - Trudng Dgi hgc YHd Noi
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.12-N'2/3017 7.2mmol/L may prognosis premature death in the first 03 days. Conclusion: Arterial blood lactate and WBC have the independent prognostic value of mortality caused by paraquat acute poisoning.
Keyword: Acute paraquat poisoning, prediction, lactate, WBC.
1. Dat van de
Paraquat (1,1 '-dimethyK4'-bipyridinium) la thudc diet cd dUpc sU dung d nhieu qude gia tren the gidi tU nhOng n I m 1960, paraquat cd t i e dung didt ed rat tdt va dupc nhieu ndng dan d Viet Nam sd dung, ngd ddc d ngUdi thudng r l t tram trpng vdi ty le tU vong eao (40 - 90%) do chua tim ra phle dd dieu trj hieu q u i hay thude g i l i dpc dae hidu. Tuy nhien, ngd ddc paraquat hien nay khdng cd thudc g i l i dde d i e hidu. Ngd ddc d ngUdi thudng rat nang do ehUa tim ra thude g i l i dde dac hieu va bang chdng dieu trj thuyet phue [6]. Bdi vi viec diiu tri paraquat r l t khd khIn va it hieu qua, cho ndn viec tien lupng benh nhan ngd dpc cap paraquat la rat quan trpng. Viee tien lupng sdm bdnh n h i n tU vong se giup dUng ele ehi dinh dieu trj khdng can thiet v l tdn kem eho ngudi nha [2] va tUPng t u khi tien lUPng benh nhan tdt se tien tdi vide didu trj dung d i n cho benh nhSn. Do ndng dp paraquat huyet thanh dupe ehUng minh I I bien p h I p tdt trong viec d u d o l n ti Id sdng sdt eua benh nhan [3]. Tuy nhien d Viet Nam chi cd mdt sd ft trung t i m thuc hien dupc ki t h u l t nay. Ngoai ra cung ed cac chi sd can lam sang khIe nhu lactate mau dpng mach, bach eau m l u eung dupc chUng minh la ed y nghia trong vide tien lUpng xii vong d benh nhan ngd ddc d p paraquat [4,4] cac xet nghiem nay rat san cd d cae co sd y te va dac biet vdi lactate mau ddng maeh cung cd g i l tri tien lupng tU vong t d t . V; v l y chung tdi thue hidn nghien cUu: "Nghiin ctiU gid trj cua lactate mdu dgng mgch vd bgch cau trong viic dU bdo fu' vong 6 binh nhdn ngo dgc cdp paraquat tgi Trung tdm Chong dgc Binh viin Bgch Mai".
2. Doi tUtfng va phUtfng phap
Nghien cUu dupe tien h l n h tai Trung t i m Chdng ddc Bach Mai.
2.1. Doi tugng Tiiu chudn chgn binh nhdn
Tat c l benh n h i n dUpc chan d o l n xac djnh ngo dde paraquat tU 01/10/2015 -15/09/2016 dieu tn tai Trung tam Chdng dpc Bach Mai.
Tiiu chudn logi trif Ngd dde nhieu loai dde chat.
Benh nhan < 16 tudi.
Benh nhan nhap vien 72 gid sau ngp dpc.
Benh n h i n xin ve khdng xac minh duac (qua
^ e n thoai), khdng t l i kham.
2.2. Phuang phdp
Md t l cat ngang, ket hpp hdi cUu sd lieu san co eua tat e l ele benh nhan nhap vien va dupc chan d o l n ngd ddc paraquat v l dieu tn Xis 01/10/2015 - 15/09/2016.
Cdch thiyc tien hdnh
Tat ea c l e benh nhan du tieu chuIn ch^n doan dupc tham kham v l theo ddi trong sudt qua trinli dieu trj cho den khi xuat vien.
Cae xet nghiem m l u luc nhap vien: Bach cau, lactate m l u .
Theo ddi tinh hinh tUvong cda benh nhan trong 60 ngay.
XC/iysoliiu
Sd lieu dupe xd ly bang p h l n mem STATA 14.0, G i l tri a = 0,05 dugc col I I mUc cd y nghTa thdng ke, p = 0,2. Thuc hien hdi quy logistic dPn bien va da bien vdi eac yeu t d laetat m l u dpng mach, so li/Ong bach cau. Tinh didn tieh dUdi dUdng cong cua tC/ng yeu t d trong tien lUpng tU vong. Tim di^m cut-off eda tUng yeu t d dUa vao ehl sd Youden.
3. Ket q u d
Bien phap xii tri d tuyen trUdc chCi yeu la rifa da day cd 88 benh n h i n (67,1%), 83 benh nhan (63,3%) dupe sii dung than boat 11 bdnh nhan (8,4%) diicc si dung solu-medrol cd 7 benh n h i n duac Ipc mau (5,3%)-
TAP CHI Y DUOC LAM SANG 108 Tapl2-S62/2017
Bdng 1 . Dac diem chung nhom song va nhom tiJf vong
Yeu to
Gidi Nam (n,%) NO (n,%) Tuoi Thdi gian di^u tri
Nhdm s6ng n = 4 8 25 (52,1%)
23 (47,9%) 30,0 ±12,6 2,48 ±1,58
Nhom tilf vong n = 83 36 (43,4%)
47 (56,6%) 38,0 ±15,9 4,39 ±4,08
Nhom chung n = 131 70 (53,4%)
61 (46,6%) 34,7 ±15,3 3,18 ±2,91
P
X2=0,93 p=0,34
0,0009 0,0002 Nhdn xit: Khdng cd su khac biet ve t i le gidi tinh gida hai nhdm sdng va tU vong. Cd sU khae biet ed y nghia thdng ke gICa hai nhdm ve tudi.
Bdng 2. Dac diem can lam sang nhdm song va tijf vong
Xet nghiem
Bach cau (Giga/lit) Lactate (mmol/lit)
Nhom chung n = 131 X ± S D 17,3 ±7,3 4,03 ± 3,77
Nhom song n = 4S X ±SD 12,8 ±3,7 1,81 ±2,33
Nhom tijf vong n = 83 X ±SD 19,9 ±7,7 5,33 ± 3,89
P
0,001 0,001 Nhgnxit: Bach eau, lactate trung binh nhdm sdng va sU khae biet cd y nghTa thdng ke (p<0,05).
B i n g 3. Gia trj Cut-off cua bach cau, lactate
Xet nghiem
Bach cau (Giga/lit) Lactate (mmol/lit)
Cut-off
14,9 2
AUC
0,79 0,85
Dd nhay (%)
75,9 80,7
Do ctac hieu (%)
68,7 83,3
Nhdn xit: Bach cau gia tri tien luong tCf vong 6 benh nhan ngo idc cap paraquat vOi cto nhay 75,9% va dp dac hieu 68,7%. Lactate co do nhay 80,7% va do dac hieu 83,3%.
Being 4. Phan tich hoi quy logistic cac bi^n so bach cau, lactate
Bien lam sang
Bach cau Lactate
PhSn tich dam bien OR
6,30 20,9
95%CI 3,8-13,8 8,2 - 53,3
P 0,00 0,00
Phan tich da bi^n OR
3,36 7,65
95%CI 1,02-11,0 2,24 - 26,1
P 0,04 0,001 Nhdnxit: Lactate m l u ddng mach cd OR la 20,9, p h l n tich hoi qui da bien thay lactate mau ddng maeh ed g i l tri tien lUpng t d t ban bach cau.
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY Vol.l2-N"2/2i),7
- AUROC Bgch cau: 0.7974 - AUROC Laetat 0.8578
- - AUROC paraquat ni§u. 0 7873
— Dirirng eiam khao
Bieu do 1. Ndng d6 lactate mau ddng mach, bach cau va paraquat nieu trong tien lUpng tdvong qua phan tich dudng cong ROC
Nhdn xet: Dien tich dudi dUdng cong cOa bach eau la 0.7974 cd g i l t n tien lUpng tU vong d miKc M Lactate cd dien tich dudi dUdng cong la 0.8578 ed g i l t n tien lUpng t d v o n g tdt.
Bang 5. Bach cau va laetat t r o n g t i e n lUcfng thori g i a n tijr v o n g
Xet nghidm
Bach cau (Giga/lit) Laaate (mmol/lit)
Nhom tiJf vong
< 3 ngay n = 38 X ±SD 23,2 ± 7,1 7,2 ±4,0
4 - 7 ngay n = 31 X ±SD 18,1 ±7,1
4,0 ±3,1-
> 7 ngay n = 14 X ±SD 14,6 ±5,8 2,9 ±2,3
4f P
0,0001 0,0001 Nhdn xit: Bach cau, lactate trung binh d nhdm tU vong trong 03 ngay dau eao hOn rd r&t bach cau, lactate trung binh d hai nhdm tU vong mudn hOn va sU khIc b i | t cd y nghia thdng kd (p<0,001).
4 . Ban luan
Ty le tUvong do ngd ddc cap paraquat cdn cao 63,4%, cho thay c l n p h l i ed mdt edng cu de tidn luong tU vong do ngd ddc paraquat.
Gid tri bgch cau trong tiin lugng td' vong binh nhdn ngd cdp paraquat
Khi so sanh bach cau giUa nhdm sdng va nhdm Xis vong tai thdi di^m vao vien chung tdi nhan thay bach cau trung binh nhdm tUvong cao hon d nhdm
sdng lan lupt 19,9 ± 7,6Giga/lit so vdi 12,8 tifivksii khae biet ed y nghia thdng ke (p<0,001). Khi phan tieh bach eau d benh nhan tUvong trong 72 gici^au sau khi ngp doe ed g i l tri 23,2 ± 7,1 eao hOn hSn bach eau 02 nhdm tU vong mudn hOn cd ket quS la"
luot I I 18,1 ± 7,1 v l 14,6 ± 5,8 (p<0,001). Khi phSn tieh dudng cong ROC tidn lUpng XiS vong vdi bach c l u t h d i diem nhap TTCD chdng tdi nhin di/oc m q u i AUC 0,79. Oiem cut-off t d t n h l t la 14,9Giga/llt
52
•AP CHlY DUOC LAM SANG 108 Tap 12-So 2/2017
dp nhay 75,9%, dp d i e hieu 68,7%). Trong nghien :Uu eOa Cai khi phan tfch dUdng cong ROC eua sach cau t h l AUC la 0,73 t h a p hon nghien cUu cua :hung t d i n h u n g cut-off I I 15,9Glga/lit (dp nhay 59,2% v l d p d i e hieu 76%) [1].
Khi p h l n tich mdi tUPng quan giuei nhdm benh i h l n ed bach cau > 14,9Giga/lit so vdi nhdm benh nhan ed bach eau < 14,9Giga/lit ehung tdi nhan dUpc ket q u i OR = 6,3 (95%CI = [3,87 -13,78]; p<0,001).
Gid tri lactate mdu dgng mgch trong tiin lugng tCf vong benh nhdn ngo dgc cdp paraquat
Trong nghien eUu chung tdi da tien hanh so sinh glUa nhdm sdng va nhdm t d vong ndng dp lactate m l u ddng maeh nhdm t d vong eao hon ndng dp lactate m l u ddng mach nhdm sdng (5,38 ± 3,8 so vdi 1,8 ± 2,2mmol/lit va su k h I c biet cd y nghia thdng ke p<0,001).
Khi p h l n tich nhdm benh n h i n t d vong chung tdi nhan thay lactate nhdm benh nhan t d vong sdm trong 03 n g l y dau sau ngp ddc rat cao (7,2 ± 4,0mmol/lit) so vdi 02 nhdm t d vong mudn hOn (4,0
± 3,1 v l 2,9 ± 2,3mmol/lit) v l sU khIe bidt cd y nghia thdng ke (p<0,001). Trong nghien cUu cda Cai ndng dp lactate m l u d d n g maeh cung tang eao hon d nhdm bdnh nhan t d vong trong 03 n g l y dau sau ngd ddc so vdi n h d m tU vong mudn hon (6,7 so vdi l , 9 m m o l / L ) [ l ] .
Khi p h l n tfch dUdng cong ROC lactate cd g i l trj tidn lupng tU vong t d t vdi AUC = 0,85 (95%CI = [0,78 - 0,92]) vdi cut-off = 2,0mmol/lit gia trj dp nhay 80,7%, dd d i e hieu 83,3%. Nghien cUu cda Cai diem cut-off = 1,95mmol/litthap hon cCia nghien cUu cua chiing tdi, trong khi dp nhay cao hon dp nhay cua chiing tdi khdng dang ke, nhung dp d i e hieu thap 42,9% [1].
5. Ket luan
Lactate mau ddng maeh va bach eau cd the la yeu t d dde lap giup tien lUpng t d vong. Benh nhan ngd dde cap paraquat: Lactate m l u ddng mach vdi diem eut-offf = 2,0mmol/L ed g i l trj dp nhay = 80,7%, dp dac hieu = 83,3%. Bach eau vdi cut-off = 14,9G/L ed gia t n dp nhay = 75,9% va dp dac hieu = 68,7%.
Tai lieu t h a m k h I o
1. Cai Q, Liu Z (2014) An analysis of relevant factors of early death in acute paraquat poisoning. Zhonghua Wei, Zhong Bing Ji, Jiu Yi Xue 26(6): 379-382.
2. Eddlestone M, Wilks MF, Buckely NA (2003) Prospects for treatment of paraquat-induced lung fibrosis with immunosuppressive drugs and the need for better prediction of outcome: A, systemic revievir. QJM 96:809-824.
3. Hyo-Wook Gil, Mun-Soo Kang, Jong-Oh Yang, Eun- Young Lee&Sae-Yong Hong (2008) Association between plasma paraquat level and outcome of paraquat poisoning in 375 paraquat poisoning patients.
4. Kang C, Kim S C, Lee S H et al (2013) Absolute lymphocyte count as a predictor of mortality in emergency department patients with paraquat poisoning. PLoS One 8(10): 78160.
5. Liang Sun,Guo-Qiang Li, Peng-Bo Yan,Yang Liu,Guo-Feng Li and Lu-Qing Wei (2014) Prediction of outcome following paraquat poisoning by arterial lactate concentration-time data. Experimental and therapeutic medicine 8:652-656.
6. Senarathna L, Eddieston M, Wilks M F et al (2009) Prediction of outcome after paraquat poisoning by measurement of the plasma paraquat concentration. QJM 102(4): 251-259.
