DIEN DAN Y HOC
LOC MAU LIEN TUC KET HOP
• • •
CHOC HUT DAN LU'U DICH TIET DlSOI HU'O'NG D A N CUA SIEU AM TRONG OIEU TRI VIEM TUY CAP NANG
Dao Xuan Co*, Nguyen Gia Binh*
TOM T A T
Mue tieu: nghien ciru hieu qua cuu lgc mdu lien luc kit hgp vdi dun luu dich luy hogi lir dudi hirdng ddn cuu sieu dm. chup cut Idp Irong dieu Iri benh nhdn viem luy cup ngng tgi khou Diiu Iri lich cue. Benh vien Bgch Mui. Phuong phap: nghien ciru trin 78 binh nhdn dugc chia Idm 3 nhdm: nhdm I chf bao gdm cdc bien phdp hdi sire cir bun thudng quy: nhdm II cd kit hgp Igc mdu lien luc: nhdm III kei hgp lgc mdu liin luc vd chgc hiil ddn liru dich hogi lu luy dudi hudng ddn cuu siiu dm hodc chup cut lap vi linh. Ket qua: dd ngng cuu binh nhdn a bu nhdm theo cdc thung diem Apuche II Runson. Bullhazu Score khdng ed sir khde biei. ly li Igng suy luong dinmg a cu 3 nhdm khi nhdp vien. Kit qua diiu Iri: nhdm II vd III cai thien ldm sung vd cdn ldm sung nhunh hon. rd hem a nhdm I: (v le tu vong luang img a cue nhdm Id 53.13% (I): 27.27% (11) vd 12,5%, (III): sd ngdy dieu tri tinmg img nhdm 1 Id 25 ± 4.7: nhdm II: 19.5 ± 52: nhdm III: 14 ± 3.8. Ket luan.- Igc mdu lien luc kei hgp vdi chgc hut ddn hm dich hogi lu luy Idm giam rd ret ly le lu vong vd riit ngdn thai giun diiu Iri a benh nhdn viim tuy cdp ndng.
I.DATVANDE
Viem tuy cap (VTC) la mgt qua trinh viem cap tinh ciia tuy. benh eanh lam sang kha da dang, bieu hien b nhieu mirc do khac nhau: mire do nhe ehi can nam vien ngan ngay, it bien chirng. mirc do nang. benh dien bien phirc tap, nhieu bien chirng, ty le tir vong cao 20-50% [2, 3, 4, 8, 10, 14] trong benh canh suy da tang, nhiem trimg.
Co- che benh sinh cua VTC ngay eang sang td, cac nghien ciru gan day cho thay trong VTC cb tang cao nong do cac cytokin trong mau, tang phan irng ciia cac te bao bach cau va cae te bao ngi mac maeh mau dong ehinh la nguyen nhan dan den suy da tang trong VTC. Mat khae, eac nghien ciru gan day tir cubi thap nien 90 eiia eac tae gia Au, My da chi ra rang tang ALOB ty le thuan vbi do nang ciia
VTC va cung la hau qua ciia viec tang cac cytokin, cac yeu to gay viem trong VTC tao ra vong xoan benh ly dan den benh canh suy da tang nang ne trong VTC nang [7, 8, 14].
Nhirng hieu biet mdi ay da giiip eae nha nghien ciru va lam simg thay doi quan diem trong dieu tri VTC theo eo ehe benh sinh.
Lgc mail lien tyc (LMLT) la bien phap da dugc nhieu nghien eiru chirng minh cd kha nang lay duge cytokin, tii- db lam giam bien chung suy tang, giam ty le tii- vong trong VTC nang [7, 9, 14, 15, 20]. Bien phap ehge dan luu dieh hoai tu dubi hubng dan eiia sieu am da dugc nhieu tae gia nghien ciiu va chung minh cb hieu qua hon phau thuat ean thiep lay dieh ban trong hoai tir tuy vi tranh dugc hien tugng hoai tir lan tran (hoai tir rdng
Khoa Hdi sire lich cue - Binh viin Bach Mui
22 I Y HOC L A M S A N G S6 49 (Thang 02 / 201 0)
JMltciMM:WiP9iioc
ra sau phau thuat) va nhiem triing [9, 10. 20].
Khoa Dieu trj tich cyc (DTTC). Benh vien Bach Mai da va dang ap dung cac tien bg tren day trong dieu trj VTC nang. Chimg toi tien hanh danh gia, nhan xet bube dau ve: hieu qua cua bien phdp LMLT kit hgp chgc hiit ddn luv dich hogi tu luv dudi hmrng ddn cua sieu dm trong dieu tri VTC hogi lu.
II. DOI TUOTVG VA PHUOTVG PHAP NGHIEN Ciru
1. Dbi tircmg nghien ciru
- Cac benh nhan dugc chan doan VTC nang tai khoa DTTC, Benh vien Bach Mai, thdi gian tir nam 2002-2008.
- Tieu chuan chan doan VTC dya vao:
+ Diem Apache S 8.
+ Diem Ranson: neu co S 3 trong 11 yeu to la VTC nang.
+ Diem Balthaza sira dbi: ^ 7 diem la VTC nang (dya vao mirc do phii tuy + hoai tir tuy).
2. Phuong phap nghien cuu
- Nghien ciru mo ta hbi ciiu so sanh doi chimg.
- Chon mau - cd mau: chon mau thuiin tien.
- Cach thiic tien hanh: cac benh nhan du tieu chuan nghien ciru dugc chia lam 3 nhdm:
+ Nhdm dieu trj hoi sire ngi khoa.
+ Nhdm dieu trj hoi sire ngi khoa + Igc mau lien tue.
+ Nhbm dieu trj hoi sire nbi khoa + Igc mau lien tue va dan luu djch hoai tu dudi hudng dan ciia sieu am.
* Viec hdi sire npi khoa:
- Hbi sire hd hap, tuan hoan, chirc nang gan, than.
- Nudi dudng day dii: chi nhin an giai doan dau:
nuoi duong tTnh mach, hiit dich, giam tiet, cho an sdm trd lai khi benh nhan bot dau de han che nhiem khuan tii- catheter va tii- dudng tieu hda.
- Khang sinh toan than.
III. KET QUA
Til- thang 1/2002 - 9/2008 cb 78 benh nhan VTC nang dii tieu chuan nghien euu dugc dieu trj tai khoa DTTC - Benh vien Bach Mai, trong dd chi cb 32 benh nhan thugc nhbm I, 22 benh nhan thugc nhbm II va 24 benh nhan thube nhbm III.
Ket qua so sanh do nang eua 3 nhbm benh nhan trong bang 1.
^•"^"-^^ Nhbm so sanh Yeu to ^^^v^^
Tudi (ndm) Apache II (diem) Ranson (yeu td)
CT Score Balthaza (diem) Ap luc d hung
Bdng 1. So sdnh dp ndng giira 3 nhdm henh nhdn I (n=32)
hdi sire ca bdn)
50,5 ± 16,9 16,5 ±7,25
7 ±3,5 6 ±3,5 27 ±6,5
/ / (n=22) (hdi sue ca bdn+LMLT)
49.6 ±14,7 15.9 ±6.35
8 ±2,9 6 ±3,3 29 ±4,5
III (n=24) (hdi sire ca bdn+LMLT ± ddn luu)
48,5 ±13.63 16,2 ±5,58
7 ±4,25 6 ±4,1 28 ±4,8
P
>0,05
>0,05
>0,5
> 0,05
> 0,05 Nhdn .xel: do nang ciia cii ba nhbm benh nhan theo eae thang diem danh gia va ap lye b bung khbng cb su khae biet.
S6 49 (Thang 02 / 2010) Y HOC L A M SANG j 23
DIEN DAN Y HOC
f^ghien ciu'u khoa HQC
Bdng 2. Biiu hien suy tgng a 3 nhdm khi nhdp vien
Tang suy Tuiin hoim Ho hiip Than Gan Than kinh Mau
Nhbm I (n=32) 20 (62.5%)
8 (25.0%) 19(54.4%) 9(28,1%) 7(21,8%) 9(28,1%)
Nhom II (n=22) 14(63.5%) 6 (27.3%) 15(68.1%) 6 (27,3%) 5 (22,7%) 6 (27.3%)
Nhom HI (n=24) 1 5 (62.5%)
7 (29,2%) 16(66,7%) 8 (33,3%) 6 (25,0%) 7 (29,2%)
P
>0.05
>0,05
>0,5
>0,05
>0,05
>0,05 Nhdn xel: ty- le tang suy d 3 nhom khi nhap vien khong cd sy khac biet (p > 0.05).
Bdng 3. Su thay dai cdc hdng sd sinh tan a ha nhdm hinh nhdn theo thdi gian
\ L a m sang Thoi g i a n \
TO Tl T3 T5 T7 T14
Nhiet ao (t°) 1
37.9±0,9 38.l±0,7 38,3±0.5 37,6±0.9 37,7±0,8 37,5±0,8
I I 37,6±0,9 37.5±0.6*
37.3±0,6*
36.8±0.6 36,9±0,7 37.4±0.9
I I I 37,8±0.8 37.3±0.5*
37.2±0.7*
36,0±0.5 36.8±0.6 36.5±0.6
Mach (1/phut) 1
I28±25 I26±19 12l±23 119±2I I08±23 I05±17
I I 129±23 I I 4 ± 1 7 * 105±I9*
I 0 3 ± 2 1 * 96±17*
92±19 I I I I28±22 110+12 I 0 0 ± I 7 * * 9 5 ± I 2 * * 9 0 ± 1 4 * * 8 5 ± I 3 * *
H A T B (mmHg) 1
65±I0.5 66±8.5 70±6.8 76±4.2 77±5,8 78±6,9
I I I I I 63±9,8 64±29,7 74±9.2
76±7.2 81 ±3.9 84±4,5 85±7.8
75±8.8 78±6.8 8 U 5 . 3 84±5.8 84±4.9
Nhjp tho-(I/phut) 1
31±4 30±7 3 I ± 5 28±7 27±8 23±5
I I 32±3 26±6 23±4 22±5 22±4 22±6
I I I 32±4 23±4 20±5 20±4 I9±5 18±5
Nhdn xel: cac dau hieu sinh ton: mach. huyet ap, nhip thb. nhiet do dugc cai thien sdm hon d nhdm dugc dieu trj ket hgp LMLT. nhom co ket hgp dan luu 6 bung ± LMLT con cai thien ro ret hon (p < 0,05)
Bdng 4. Su thay ddi
Chi so Tho-i gian (ngay)
TO
T l
T3
1^
T7
T14
Amylase
1 450
±328 445
±348 450
±328 350
±128 190
±150 165
±89 I I 438
±315 451
±372 220
±181 180
±136 178
±1142 138
±95 I I I 462
±319 453
±308 220
±190 175
±163 169
±138 152
±85
cdc yeu td can ldm
PaOj /FiOj
1 146
±105 163
±117 162
±109 164
±98 178
±103 219 i l 0 9
I I 141
±112 162
±114 198*
±102 214*
±107 231
±109 253*
±112 I I I 143
±118 181*
±117 2 0 6 * *
±108 0 4 7 * *
±106
±89 2 6 8 * *
±106
sdng giua cdc nhdm benh nhdn theo thdi gian C R P ( m g % )
1 17.5
±4.6 16,3
±4,6 15,3
±8.2 14.7
±6.8 16.8
±6,2 5,2
±4.3 I I 16.7
±5,3 15,7
±4,7 12,3*
±5.2 9,6
±4.8 8.8*
±6.3 2.5
±1.8 I I I 17.2
±4,8 15,6
±4,8 10,3**
±5,1 8,5**
±3,6 6,8**
±3,7 2,6*
±1,2
Creatinin (mcmol/l)
1 255
±187 351
±242 428
±242 451
±251 372
±261 361
±186 i l 268
±192 185
±167 191
±168 167*
±128 158
±105 142 1 I I 2
I I I 270
±193 185*
±159 185*
±157 142*
±69 137*
±63 137**
±58
BachcSu (G/l)
1 16,2
±5,7 17,3
±5,2 16,4
±3,9 15,6
±4,7 13,4
±5,2 11,6
±3,9 I I 15,9
±5,3 16,2
±4,9 12,5*
±3,8 11,4
±3,8 10.3
±4,7 10,9
±3.7 I I I 17,2
±6,1 17,1
±6,2 11,5**
±3,6 11.2
±3,7 8,2
±3,6 9,1
±3,5
Nhdn xel: cac diiu hieu can lam sang a nhbm II vii nhom III cai thien.
24 I Y HOC L A M SANG S6 49 (Thang 02 / 2010)
Nghien CLPU khoa hpc
• Nhom 1 Nhom 2
• Nhom 3
Ngay T4 T5 T7 Bieu do 1. Su thay ddi ALOB giira 3 nhdm theo thdi gian
Nhgn xet: ap luc d bung b nhbm II va nhbm III giam nhanh ban so vbi nhbm I (p<0,05).
Bdng 5. So sdnh ty le tu vong d 3 nhdm Ty le tir vong
Tu vong chung Nhbm suy 1 tang Nhbm suy 2 tang Nhdm suy ^ 3 tang
Nhom I (n=32) 17/32(53,13%)
0 3/14(21,42%)
14/16(87,5%)
Nhom II (n=22) 6/22 (27,27%)
0 1/7(14,28%) 5/12(41,7%)
Nhbm HI (n=24) 3/24** (12,5%)
0 0/24 3/14 (21,4%)
P
<0,01
Nhdn xit: ty le tir vong chung cua nhbm II va nhbm III giam ro ret, nhbm III ty le tir vong ehi cbn 12,5%, nhbm suy ^ 3 tang d nhbm II va III ty le hi vong tuong ung ebn 41,7%) va 21,4%).
Bdng 6. So sdnh thdi gian dieu tri giu'a 3 nhdm Thoi gian
Thai gian dieu tri trung binh cua cac nhdm benh nhan Thai gian dieu tri nhbm benh nhan sbng
Nhbm I 17±4,5(n=32)
25 ±4,7(n=15)
Nhom II 16±5,3(n=22)
19±5,2(n=16)
Nhom III 14±4,8(n=24)
14±3,8(n=21)
P p>0,05
<0,01
Nhdn xit:
- Thai gian dieu tri: ngay dieu tri trung binh eua nhbm I va II khbng eb sy khac biet, ehi eb sb ngay dieu tn trung binh a nhbm sbng mbi eb sy khae biet.
- Ngay dieu trj trung binh eua nhbm III giam ro ret hon so vbi nhbm II, so ngay dilu tri trung binh eua benh nhan sbng nhdm III eiing giam rd ret hon nhbm II va nhbm I.
IV. NHAN XET VA BAN LUAN
1. Nhan xet ve do nang cua benh nhan khi nhap vien b ca 3 nhom
- 78 benh nhan VTC nang trong nghien euu eua ehung tbi (thai gian tir 2002-2008) duge chia
thanh 3 nhbm: nhbm I (khong lgc mau lien tue), II (eb ket hgp LMLT), III (LMLT kk hgp hiit dan luu dieh tuy hoai tir dubi hubng dan eua sieu am, dya theo eac thang diem danh gia do nang khbng eb su khae biet ve mire do nang khi nhap
S6 49 (Thang 02/2010) Y H O C L A M S A N G | 25
DIEN DAN Y HOC iNghien ct>u khoa hpc
vien (p > 0.05). (theo cac thang diem Apache II.
Ranson va Balthaza).
- Ty le tang suy khi nhap vien cung khong co sy khac biet a 3 nhdm nghien ciru: suy tuan hoan.
than, ho hap gap ty le cao nhat.
2. Nhan xet ve hieu qua dieu trj
2.1. Su thay ddi ldm sdng vd can ldm sdng trong qud trinh diiu tri
- Ket qua nghien cii-u d bang 3 cho thay cac diiu hieu song: maeh, huyet ap. trung binh. nhip thci, nhiet do dugc cai thien sbm hon d nhdm II va cai thien rd ret nhanh hon d nhdm III.
- Sy thay dbi ALOB giam nhanh trong 3 ngay dau b nhbm II va rd ret hon d nhbm 111.
- Ket qua nghien eiru d bang 4 cho thay nhdm II va III cac xet nghiem can lam sang: creatinin; PaO,/
FiO„ CRP, sd lugng bach cau ciii thien nhanh. sdm ban d nhdm III va rd ret hon b nhbm III la nhdm duge ket hgp LMLT va ket hgp dan luu djch b bung ( p < 0,05).
2.2. Ty'li tu vong
Ket qua nghien ciru cho thay d 3 nhom nghien cii'u khdng cb sy khac biet ve do nang theo cac thang diem danh gia va ty le tang suy khi nhap vien nhung theo bang 5 ty le tu vong d nhbm I (nhbm ehi dinh dieu tri hbi sire co- ban) la 53,13%, a nhbm II (nhbm dirge ket hgp Igc man lien tue) ty le tii vong ebn 27,27% trong khi nhbm III (nhbm dugc ket hgp LMLT va hiit dan luu dieh hoai tii' tuy dubi hubng dan eiia sieu am) giam tbi 12,5%. Ket qua nay phii hgp vbi nghien euu eiia Oda, Hirasawa (2005) [20].
Bien phap dan luu djeh hoai tir bang kim
nho dudi hudng d§n cua sieu am va chup cat lap dugc cac tac gia truong phai Hoa Ky khuyen eao [7,10,16,18] budc dau da dem lai kit qua dieu trj kha quan cho nhdm benh nhan nghien ciiu ciia chimg toi, dae biet vdi cac benh nhan trube day tuy hoai tu nhieu, ALOB tang rat cao, chimg tbi phai ean thiep ngoai khoa sau db ty le benh nhan song sdt rat thap do hien tugng hoai tii- tuy lan tran va nhiem khuan.
2.3. Thdi gian dieu tri
- Thdi gian dieu tri trung binh cua ba nhbm benh nhan cd sy khac biet, nhdm 11 va nhbm III dugc riit ngan ro ret. Sy ket hop LMLT vbi chgc hiit dan luu dich hoai tir tuy da lam giam sb ngay dieu trj cho benh nhan d nhbm nhiing benh nhan sbng rat nhieu theo bang 6. Trong nhbm I: 25 ngay; nhbm II: 19 ngay va nhdm III chi con 14 ngay. Viec ap dung LMLT tuy chi phi cb cao nhung rut ngan dugc thai gian dieu trj do db kinh phi eho dieu trj eiing khdng tang.
V. KET LUAN
Nghien ciru hieu qua bien phap LMLT ket hgp chgc hiit dan luu dieh tuy hoai tir dubi hubng dan ciia sieu am d benh nhan VTC nang hoai tii' chimg tdi thay:
- Nhbm benh nhan dugc LMLT, dae biet b nhbm ket hgp hiit dan luu dieh hoai tir sbm eai thien lam sang va can lam sang hon.
- Ty le til- vong giam ro ret b nhbm II (27,27%)) va giam nhieu hon nua b nhbm III (ket hgp LMLT vbi hut dan luu djeh hoai tir tuy).
- Riit ngan duge thai gian dieu tri.
TAI LIEU THAM KHAO
/. Tdn Thdl Bdch, Dd Thunh Long, Kim Vdn Vu (2002), "Mpt sd nhdn xil ve kit qua dieu tri viem tuy cdp hogi fu khdng do nguyin nhdn ca hgc Igi khoa Phdu ihudl cdp ciru bung, Binh viin Viet Dire ", Tap san ngogi khou, tr 18-24.
26 j Y HOC LAM SANG sa 49 (Thang 02 / 2010)
NgWen cijfu khoa hpc
2. Vu Vdn Dinh. Be Hdng Thu (2000). " Viem tuy cdp ", cdm nung cup ciru. NXB Y hgc. Hd Npi. tr 170- 174.
3. Trdn Giu Khdnh (2006). "Viem tuv cup ". Benh hgc ngogi dimg cho suu dgi hgc. tup I, NXB Yhgc, Hu Npi. tr 209-224.
4. Nguyin Dire Ninh (2001), "Viim tuy cdp ". Binh hgc ngogi suu dgi hgc. NXB Khou hgc vd Ky thudt (ldi ban Idn thir nhdt). tr 35 -58.
5. Hadng Trgng Thung (2002). "Viim luy cdp ". Benh lieu hdu gan mdi. NXB Y hgc Hd Npi.
6. Acosta J.M. Pellegrino C..4. Skinner D.B (1980). "Etiology und pulhogenesis of biliury pancreatitis".
Surgery 88. 118-125.
7. Avery B., Nalhens. J. Randul Curtis, el ul. (2004). 'Munugement of the crilicully ill patient with severe acute puncrealilis", Crit Cure med. Vol. 32. No. 12. 2524-2534.
8. Balthazar E.J. Freeny PC. Sonnenberg E. (1994). "Imaging and inter\'enlion in acule pancreatine", Radiology. 193. pp. 297-306.
9. Bellomo R.. Tipping P. (1996). "Tumor necrosis fuclor clearunce during veno - venous heamodicfillration in Ihe critically ill". ASAIO Ircms 37. 332-322.
10. Buchler MD., Gloo. B MD. und Wuldermu MD., Friess: MD.. C. Seller MD, "Acule necrotic puncrealilis:
treulmenl atratery accoding lo the status of infection ". Ann of surg. Vol 232. No5. 619-626.
11. Burch JM. Moore EE. Moore F4. et al (1996). "The ubdominul compurlment syndrome". Surg Clin North Am: 76:833—842.
12. Caldwell CB, Ricolla J,I (1987). "Changes in visceral blood flow with elevated inlrauhdominul pressure". J Surg Res: 43:14—20.
13. Castren M, Liukko K, Nurmi J. el ul (2004). "Measurement of the ubdominul circumference for ihe detection of inlra-ubdominal hemorrhage has no diagnostic value". Acta Anuesthesiol Scund:
48:592-594.
14. De Wciele el al (2005). "Inlru-ubdominul hypertension in patients with severe acule puncrealilis"
CrUicul Cure. 9:R452-R457.
15. Du W.. Zhangguo Wei Zhong Bing Jiu Vi Xue (2005). "Invesligulion on the relation between systemic inflammatory response syndrome and severity of acule puncreulitis", NIH/NLM MEDLINE, 17(5). 279-81.
1(5. Jeffrey Walker vp cs (2003). " Pathophysiology and munugemeni of ubdominul compartment svndrome". American jaurnul of crilicul care. Volume 12. No. 4: 367 - 371.
17. Malbruin M.L, Dries H Deeren (2006). "Effect ofbludder volume on measured intravesical pressure:
a prospective cohort study". Critical Care, 10:R98 (doi:10.I186/cc4962).
18. Malbruin M.L. (2005), "Intra ubdominul hypertension in the crilicully ill: il is lime lo pay attention ", Intensive care 11:156-171.
19. Maibrain ML. Cheulhum ML. KirkpaWick A. Siigrue M, Purr M. De Wuele J, Bulogh Z, Leppuniemi A, Olveru C, Ivuliiry R. D 'Amours S. Wendon ./ Hillmun K. Johunsson K. Kolkmun K, Wilmer A (2006).
"Results fi-om the Inlernulionul Conference of Experts on Inlra-ubdominal Hypertension and Abdominal Compartment Syndrome. I. Definilions". Intensive Care Med. 32:1722-1732.
20. Oda, Shigelo: Hirasawa. Hiroyuki: Shiga. Hideloshi: Matsuda. Kenichi: Nukumuru, Masuluka:
S6 49 (Thang 02 / 2010) Y HOC L A M S A N G | 27
DIEN DAN Y HOC
lM<3hi6ncW khoa hoc
Watcmabe. Eizo: Moriguchi. Takeshi (2005). "Management of Inlra-ubdominal Hypertension in Patients With Severe Acule Pancrealilis With Continuous HemodiufillrcUion Using u Polymethyl Melhacrylate Membrane Hemgfilter". TherapeuticApheresis d: Dialysis. 9(4):355-361.
21. Paivi Keskinen. Ari Leppuniemi. Ville Petlilu. Anneli Piilonen, Esko Kemppainen and Marju Hynninen (2007). " Intru-abdominul pressure in severe ucule pancrealilis ". World Journul of Emergency Surgery 2007. 2:2 doi: 10 1186/1749-7922-2-2.
SUMMARY
Objective: lo study the effectiveness of continuous veno-venuos heinofillrulion (CVVH) and drainuge of necrotic fluid under ECHO or CT guide on Ireulmenl of severe ucule puncreulitis in intensive care unit of Bach Mai Hospital. Methods: retrospective study conducted in 78 severe acute pancrealilis patients in ICU of Buch Mui Hospital: 32 SAP putients were treated with normal protocol for SAP (Group I) and 22 patients with and CVVH (Group II) and 24 patients were treated with CVVH and druinged necrosis fluid under ECHO guide (Group III). Results:
although no difference of degree of severity between 3 groups hul vital signs and laboratory pu- ruinelers of group 11 und III were improved more quickly ihun group I (p < 0.05). The morlulily rate of group I, II, III. were: 53.13%,: 27.27%o and 12.5%. Conclusions: CVVH and drange of necrosis fluid under ECHO guide are good methods for irealmenl of severe ucule puncreulitis.
28 j Y HOC L A M S A N G S6 49 (Thang 02 / 2010)
