Y HOC VIET NAM THANG 4 • S O D A C BIET;2Q12
NGHIEN CljrU HOAT TINH MOT SO YEU TO OONG MAU 0 BENH NHAN
SOC
N H I I M KHUANoirac
LOG MAU LIEN TUCNguyen Tuan Tiing*, Nguyin Gia Binh*, Pham Quang Vinh*
T O M TAT:
Lpc m^u lien tuc (LMLT) trong soc nhigm khuan (SNK) co the lam thay doi dong cSm mSu.
Muc tieu: Nghien cii'u s u thay doi hoat tinh mot so yeu t6 dong mSu va moi lien quan gilja thay doi hogt tinh yeu to nay v ^ i mijc dp bpnh va k^t qua di^u trj a bpnh nhan SNK duffc LMLT, D 6 i tu'O'ng va p h u c n g phap nghien CLKU 68 b^nh nhan SNK dupe LMLT tgi b?nh vien Bach Mai Nghien cifu tien ci>u - m6 ta, so sSnh/tu doi chCeng. Kk qua. cP s y phyc hoi hoat tinh mdt so yeu to dong mau: hoat tinh cac y^u to dPng m^u ngogi sinh II, V, VII, X v^ npi sinh IX, XI trudc Ipc giam lan lupt IS 42.01%; 47,85%; 41,08%; 56%, 53,72%; 68,49%; sau Ipc t3ng t6n tuang irng IS 47,12%; 61,44%; 51,19%; 63,51%; 56,57%;
80,88% Sau ipc mciu hoat tinh yeu to VII a nhdm b$nh nhan dupe ciru song la 62,34%, cao han so vd'i nhPm sau do ti> vong Id 43,86%, a nhPm bpnh nhan SNK n^ng thi hoat tinh yeu to Viii sau Igc Id 153,76%; cao han so vai nhom benh nhcin nhp IS 133,3%. K i t luan: Co s u phyc hoi hoat tinh mpt so yeu to dPng mSu khi LMLT a b^nh nhSn SNK,
Tip khoa: soc nhtSm khuan, loc mSu lien tyc, yeu to ddng mSu.
S U M M A R Y
Research activity of some coagulation factors In septic shock patients w i t h continuous veno-venous hemofiltration
Continuous veno-venous hemofiltration ( C W H ) in septic shock may induce hemostasis
* D?i hQC Y Hd N0i
Phan bien khoa hpc: PGS.TS Nguyin Thj Lan 74
disorders Objective: To study the activity of coagulation factors and the relationship between altered activity of those factors with the severe level of disease and treatment outcomes in septic shock patients vt/ith C W H , Subjects and Methods: 68 septic shock patients with C W H at Bach Mai hospital. Prospective study - descnbe, compare / seif-control. Results: The recovery of activated coagulation factors: before filtering, the activity of some the extrinsic factors II, V, VII, X and intrinsic factors IX, XI reduced respectively 42,01%, 47,85%, 41,08%, 56%, 53.72%, 68.49%, after filtration, the activity those factors increased respectively 47,12%, 61.44%, 51.19%, 63,51%, 56,57%, 80.88%. After finished C W H , the activity of VII in survived patients was 62,34%, higher than the mortality group (43 86%), the activity of factor Vlll of low-risk patients was 153.76%, higher than the high-risk group (133,3%). C o n c l u s i o n : There was the recovery of the activity of some coagulation factors in septic shock patients with C W H .
I. D^T VAN OE
S6c nhilm khuan la tinh trang benh nang, gap kha nhieu va dieu tri con kho khan.
Dpc to cua vi khuan va hau qua phan ung viem cua co thi do la cac cytokin, cac chSt hoa hpc trung gian hoat hoa te bao gay ra rdi loan a nhieu co quan khac nhau, dh\ din suy da tang va benh nhan nhanh chong tu vong nlu khong duoc xu ly tich cue. Lpc mau lien tuc trong diau tri SNK ia phuong phap giup can bing thi tich dich, chit dien giai va pH
Y HOC VIET NAM THANG 4 - SO PAC BIET/2Q12
mau, ddng thoi loai khoi ca the cac chat trung gian co nguy co khong co Igi cho co the nhu mpt so cytokin gay viem, cac yeu to hoat hoa dong mau. LMLT da dupe nhieu trung tan h6i sue tren thh giai cQng nhu mpt so trung tam h6i sire tai Viet Nam ung dung trong di^u tri SNK va cho thay c6 hieu qua t6t [2, [3].Tuy nhien, lpc mau lien tuc la cho mau tiep xiic vol mang lpc, vi vay cac yeu to dong mau tiep xuc voi mang Ipc la vat "la"
lai CO the khai phat qua trinh dong cam mau.
Nhu vay, LMLT trong SNK vira co the lam giam hoat hoa he thong dong mau lai vira co the tang hoat hoa theo mpt ca che khac. Vi vay chiing toi nghien cuu de tai nay nham muc tieu:
/. Nghien cuu su thay doi hop tinh m^t soyiu to dong mdu d benh nhdn SNK duffc lpc mdu Hen tuc.
2. Tim hieu mii liSn quan giira thay ddi hoat tinh yeu to dong mdu vdi mire do benh vd kit qua diiu tri d benh nhan SNK dupfc Igc mdu lien tuc.
II. o 6 l TJpNG VA PHUONG PHAP NGHIEN CGU
. 2.1. {>6i tu'tfng nghien cthi
* 68 benh "nhan SNK dupe LMLT lin diu tien tai khoa H6i sue tich cue, Benh vien Bach Mai tir thang 8 nSm 2008 din thang 3 nam 2011 voi tieu chudn: chan doan SNK theo tieu chuin nam 2003 cua hpi Hoi sue va L6ng nguc My [6]; LMLT theo qui trinh cua khoa H6i siic tich cue, Benh vien Bach Mai.
* 38 nguoi truong thanh khoe manh la nhom tham chieu truoc lpc, co ti le nam/niJ va dp tu6i tuong duong nhom benh nhan nghien cuu.
2.2. Vat lieu nghien cuu: mau ngoai vi d6 dinh lupng hoat tinh cac yeu to dong mau tai 3 thai dilm: Tl {ngay truoc LMLT), T2 (thai dilm lpc mau dupe 6 gia, T3 (ngay khi kit thiic lpc mau).
2.3, Phuffng phap nghien cmi: tien ciiu, mo ta, CO so sanh/ tu doi chiing.
- Cac thong so nghien cuu: dinh lugng hoat tinh cac yeu to dong mau II, V, VII, VIII, IX, X, XI, XII tai 3 thai dilm nghien cuu. Ghi nhan mpt so dac diem lam sang va lpc mau lien tuc.
- Cac xet nghiem dong mau duac thuc hien tai khoa Huyet hpc - Truyen mau, Benh vien Bach Mai trong vong 1 gio sau khi lay mau.
Thu thap va sii ly so lieu theo phan mem SPSS 16.0; so sanh hoat tinh cac yeu to dong mau truac LMLT vai nhom tham chieu, giiia cac thoi diem nghien ciiu. So sanh hoat tinh cac yeu to dong mau truoc va sau LMLT theo mpt so dac diem lam sang.
III. KET QUA NGHIEN COU
3.L Dac diSm nhom benh nhan nghien cuu - Tu6i trung binh nhom benh nhan (BN) la 55,79 tu6i, ti le nam/nu la 3,86/1.
- Dilm APACHE II trung binh la 20,62;
60,29% BN tir vong; 66,18% BN phan lap duac vi khuan.
- T6C dp bom mau trung binh la 170,88 ml/phiit, t6c dp dich thay the trung binh la 2424,85 ml/gicf, thai gian loc trung binh la 23,85 gio. Co 61,7% BN duac duy tri ch6ng dong trong qua hinh lpc mau voi lieu heparin tieu chuin duy tri trung binh la 332,14 Ul/gia.
3.2. Mot so thay doi ve hoat tinh ylu to dong mau
3.2.1, Kit qud hoat tinh cdc yiu td dong mdu ngoai sinh
Truoc lpc mau: hoat tinh yeu t6 II, V, VII, X lin lugt la 42,01 ± 20,16; 47,85 ± 28,43; 41,08 ± 20,95; 56,00 ± 23,16 thip hon ro ret so voi nhom tham chieu tuong ung la 101,99 ± 15,93; 101,15 ± 19,51, 104,63 ± 22,88; 95,35 ± 13,98. Trong do boat tinh ylu t6 VII thip nhit (p < 0,01).
Y HOC VIET NAM THANG 4 • s 6 DAC BIET/2012
Bang 3.1. So sanh hoat tinh ySu t6 II, V, VII, X truoc, trong va sau lpc r
Yeu t o ( % )
II
V
VII
X
Benh nhan (n =68) T1,„
42,01 ±20,16
47,85 + 28,43
41,08 + 20,95
56,00 + 23,16
T 2 „ , 41,10 ±22,34
48,19 ±28,32
39,40 ± 22,75
54,36 ±23,52
T 3 „ , 47,12 + 22,12
61,44 + 35,96
5 1 , 1 9 ± 2 8 , 1 4
63,51 + 35.77 P P(,.2, > 0,05 D„ 1, < 0,01 P„.2i > 0,05 D„ » < 0,01 p,i 2, > 0,05 P,is, < 0 , 0 1 Pd.a > 0,06 Pn 31 < 0,05
Nhdn xet: hoat tinh cac ySu t6 II, V, VII, X phuc hoi ro ret khi ket thuc Ipc so vol truoc Igc (p < 0,05).
3.2.2. Kh qud hoat tinh cdc yiu to dong mdu noi sinh
Truoc Ipc mau: hoat tinh ySu tS IX, XI, XII lin lupt la 53,72 ± 26,08; 68,49 ± 40,30;
17,65 ± 15,84 thjp hon so voi nhom tham chi6u tuong ilng la: 85,98 ± 17,33; 98,94 ± 11,23;
55,49 ± 26,32 (p < 0,01). Hoat tinh ySu t8 VIII la 108,54 ± 49,84 khac biet khong c6 y nghla so v6i nhom tham chiSu la 99,08 ± 31,12 (p > 0,05).
Bdng 3.2. So sanh boat tinh yeu to Vlll, IX, XI, Xll truoc, trong va sau loc mau
Yiu ta (%)
Vlll
IX
XI
XII
Benh nhan (n = 68 T 1 , „
108,54 ±49,84
63,72 ± 26,08
68,49 + 40,30
17.65 ±15,84
T2,2, 117,70± 55.97
48,01 ±25,02
72,00 ±44,91
17,29 ±15,02
T3,s, 137,67 ± 8 2 , 0 8
56,57 ± 33,70
80,88 ± 6 0 , 1 2
16,90 ± 1 3 , 2 1 P P„,2) > 0.05 p„,3,
< 0 , 0 5 P|,,2, < 0,05 P|,,3)
> 0 , 0 5 Pl,,2l > 0,05 p„,3,
<0.01 P|,,2, > 0,05 P|,,3|
> 0 , 0 5
Nhdn xet: hoat tinh y^u t6 Vlll tang va hoat tinh ySu to XI phuc hSi khi ket thuc lpc mau so voi truoc Ipc (p < 0,05).
3.3. So sdnh hoat tinh mpt sSySu td ddng mdu theo muc dp benh vd ket qud dieu tri 3.3.1. So sdnh hoat tinh yiu td VH theo tile tu- vong trudc vd sau LMLT
Y HQC VIET NAM THANG 4 - SO PAC BIET/2012
Bdng 3.3. So sanh boat tinh ylu to Vll truac va sau lpc mau theo ti le tu vong
Ket qua 6iku trj
Song , „ Tir vonq a
Hoat tinh y§u t6 VII (.Y + SD) n
27 41 P(1-21
T l 44,50 ± 24,08 38,82 ±18,57
>0,05
T3 62,34 + 31,01 43,86 + 23,71
<0,05
P(T1-T3)
<0,01
>0,05
Nhdn xet: ket thiic lpc mau hoat tinh yeu to VII phuc h6i so vai truoc Ipc t6t hem a nhom con song (p < 0,01).
3.3.2. So sdnh hoat tinh yeu td Vlll theo mire dp nang trudc vd sau LMLT Bdng 3.4. So sanh hoat tinh yeu to VIII truoc Ipc va sau Ipc mau theo APACHE II
APACHE II
< 2 0 20 - < 25
2 25 P
Hoat tinh y i u t6 Vlll ( . T ± SD) n
28 18 26
T l 121,21 ±55,91
96,9 ± 33,44 101,94 ±51,25
>0,05
T3 133,3 ±59,65 124.79 ±77,38 163,76+107,87
>0,05
P(T1-T3)
>0,05
>0,06
<0,05
Nhdn xet: kSt thuc loc mau hoat tinh yeu to Vlll tang ra ret hon so voi truoc lpc 6 nhom benh nhan co dito APACHE 11 > 25 (p < 0,05).
Ket qua nghien cuu cho thay trong SNK boat tinh cac yeu to dong mau ngoai sinh giam, trong do yeu to VII giam nhieu nhat.
Tuong tu boat tinh cac yeu to dong mau npi sinh IX, XI, Xir cung giam trong do yeu to XII giam nhigu nhat, tuy nhien boat tinh yeu t6 Vlll binh thuong.
IV. BAN LUAN
4.1. Dac dilm floi tuwng nghien cihi Khi so sanh kSt qua nghien cim nay ve mpt s6 dac dilm chung cua benli nhan (theo kSt qua pbiin 3.1) voi mpt s6 nghien cuu khac nhu nghien ciJu cita Nguyen Gia Binb a 54 b?nh nhan LMLT [1], Dtag Qu6c Tuin cr 54 benh nhan SNK iuoQ LMLT [3], cac nghien cijru truoc vS SNK nhu nghien ciiu cia Yaguchi [9], nghien cilu ciia Hartemink [4]
thi b?nh nhan SNK trong nghien cim nay co dSc aim vJ tuoi, giai; dilm APACHE II khi vao khoa; ti le phan ISp vi khuan; ti Ie tir vong va dac diem Ipc mau khong khac biet dang k6 so vai d^c diem chung ciia benh nhan SNK 6 Viet Nam.
4.2. Mot so thay doi ve boat tinh cac yeu to dong mau
Theo Schouten, sur boat hoa con duong dong mau ngoai sinh do cac cytokin gay viem tang se lie chS tong hpp glycosaminoglycan tren te bao npi mac dan din TFPI mit chitc nang ire che TF/Vlla va ylu tl chju anh huong diu tien la ylu tl VII [8]. Thep Hopper SNK co thi boat hoa dong mau npi sinh thpng qua he thing yeu tp tiep xuc do dpc tl vi khuan, hau qua tieu thy cac ylu tl dong mau npi sinh, nhat la yeu to XII [5]. Hoat tinh ylu tl VIII (108,54%) cao hon SP voi nhom tham chieu nhimg van nam trong giai ban binh thucmg c6 the con do PC 77
Y HOC VIET NAM THANG 4 - SO OAC BIET/2012 giam trong SNK din den giam uc che yhu td
Vlll. Neame nghien cuu hoat tinh y^u t6 XII va yeu to Vlll a benh nhan SNK ciing cho thay hoat tinh yeu to XII giam va yeu to VIII tang [7].
LMLT gop phan phuc hoi ro ret hoat tinh cac yeu to dong mau dac biet la cac yeu to theo duong ngoai sinh. Su phuc hoi hoat tinh cac yeu to nay khi ket thuc lpc co the do lpc mau da lay di cac chat hoat hoa dong mau ngoai sinh, ho tra chuc nang gan, do truyen HTTDL o nhiing benh nhan nang. Ben canh do, viec su dung heparin trong lpc mau cung CO the gop phan dieu tri DMRRTLM, do do CO the gop phan phuc hoi dong mau. Hoat tinh yeu to VIII sau lpc mau tang co th§ do su phuc hoi cua PC chua du de dieu chinh hoat tinh yeu t6 nay.
4.3. Lien quan giira ho^t tinh mot so yeu to ddng mau vol muc do benh va ket qua dieu tri
4.3.1. Lien quan giira ho(f.t tinh yeu td VII vdi ti le tir vong trudc vd sau LML T
6 benh nhan SNK hoat tinh y§u t6 VII giam nhieu han a BN tir vong. Khi LMLT hoat tinh yeu to VII phuc hoi tot hon a nhom BN con song so voi nhom benh nhan sau do tu vong. Hoat tfnh yeu to VII giam la do ylu to dong mau dupe hoat hoa do dpc t6, do chat trung gian gay viem. Benh nhan cang nang, cac yeu to hoat hoa cang nhieu do vay roi loan cang nang. Lpc mau co hipu qua tire la lay duac nhieu yeu to bat Igi do, vi vay r6i loan duoc phuc hoi tot. Di^u do cho thiy viec cai thien hoat tinh yeu to VII phan anh kht qua lpc.
4.3.2. Lien quan giU'a hoat tinh ySu to VIII vdi muc do nang ciia benh trudc vd sau LML T
0 benh nhan SNK hoat tinh yhu th Vlll khac biet khong dang kg giila cac nhom muc dp nang co thi do su tuong tac giila hai co che ngupc nhau anh huong dSn boat tinh yeu t6 VIII, do la giam hoat tinh do tieu thu boi tac dpng ciia dpc to vi khuan, cac cytokin va giam bi lie chS boat tinh do boat tinh PC giam. Khi LMLT boat tinh y6u t6 VIII tang ro ret o benh nhan nang co the la do lpc mau dieu chinh boat tinh PC chua tot a nhimg BN nang so voi BN con lai.
V. KET LUAN
Nghien ciru hoat tinh mpt so yeu to dong mau truac, trong va sau LMLT 6 68 benh nhan SNK co the dua ra mpt so ket luan:
1. C6 su-phuc hoi ho^t tinh m^t s6 yeu to dong mau
- Hoat tinh cac yeu to dong mau ngoai sinh 11, V, Vll, X truac lpc giam, Ian lupt la 42,01%; 47,85%; 41,08%; 56%; sau Ipc tang len tuong ung la 47,12%; 61,44%; 51,19%;
63,51%.
- Hoat tinh cac yeu to dong mau npi sinh IX, XI truoc lpc giam, \kn luat la 53,72%;
68,49%; sau lpc tang len tucmg img la 56,57%; 80,88%.
2. Co moi lien quan giira thay ddi hoat tinh mot so yeu to dong mau voi muc do benh va ket qua dieu tri.
- Sau lpc mau miic dp phuc h6i hoat tinh yeu t6 Vll t6t han 6 nhom benh nhan dupe Clhl song so voi nhom sau do tir vong:
62,34% so voi 43,86%.
- CJ nhom benh nhan SNK nang thi hoat tinh yau t6 VIII sau lpc la 153,76%; cao hon so voi nhom benh nhan nhe la 133,3%.
Y HOC VigT NAM THANG 4 • SO BAC BIET/2012
TAI LIEU THAM KHAO
1. Nguyin Gia Binh, Nguyin Manh Tu'ofng (2006), "Nghien cuu hieu qua chong dong ciia heparin trong Ipc mau lien tuc", 7 hoc lam sdng, 11, tr. 30-33.
2. Nguyen Dang Tuan, Nguyen Gia Binh (2008), "Nhan xet ky thuat loc mau lien tuc qua 190 lan Ipc mau tai khoa Dieu tri tich cue Benh vien Bach mai", Y hoc Idm rang, 34, tr. 51-56.
3. Dang Quoc TuSn, Biii Van Tam (2010),
"Danh gia hieu qua ciia Ipc mau lien tuc trong dieu tri soc nhiem khuan tai khoa Hoi sire tich cue Benh vien Bach Mai", Y hQC Vifl-Nam, 370(1), tr. 46-50.
4. Hartemink K.J., Hack C.E., Groeneveld A.B.J., e( al (2010), "Relation between coagulation/fibrinolysis and lactate in the course of human septic shock", J Clin Palhol, 63,'pp. 1021-1026.
5. Hopper Kate (2005), "The modem
coagulation cascade and coagulation abnormalities associated with sepsis", S6th Internationnal Congress SCIVAC, Rimini, Italia.
6. Levy M.M., Fink M.P., Marshall J.C. et al (2003), "Intemational sepsis definition conference ", Intensive Care Med. 29, pp.
530-538.
7. Neame P.B., Kelton J.G., Walker I.W., et al (1980), "coagulation thrombocytopenia in septicemia: the role of disseminated intravascular". Blood, 56(1), pp. 88-92.
8. Schouten M., Wlersinga W.J., Levi M., (2008), "Inflammation, endothelium, and coagulation in sepsis". Journal of Leukocyte Biology, 83, pp. 536-545.
9. Yaguchi A., Lobo F.L.M., Vincent J.L., Pradier O. (2004), "Platelet function in sepsis". Journal of Thrombosis and Haemostasis, 2, pp. 2096-2102.
