CHUYSN Bi: Hpi NOH| KHOA HQC HUYgT HtfC • TRUYJN MAU TOAN QUO'C 2012
NGHllN Cliu S^THAY otil MOT SO CHI Sti HUVCT HOC ABeNHNHANTIMB^MSINH
TflM TAT
Tgn thuong bSm sinh cua tim cd th£ gdy mft sS thay dft tr«n cdc chi s5 tS bdo mdu vd ddng mdu cd bdn. Myc t i t u : Tim hlSu sif thay dSl cOa mft s6 chi sS mdu ngo^l vl d bfnh nhdn tim bUm sinh. efil tu'png vd PhU'dng phdp: 80 bfnh nhdn mic bfnh tim bSm sinh dUpc ti£n hdnh nghien ciu cdc chi sd tS bdo mdu ngogi vl vd ddng mdu cd bdn. KCt qud: 46.2% thifu mdu hdng ddu nhd, nhu^c sdc, 30% trUdng hpp tdng bgch cdu. Sd lutjtng tieu cdu binh thudng d 82.5% bfnh nhan. 11.25% so bfnh nhdn cd glam ty If prothrombin vd 33.75% cd chi so APTT bfnh/ching kdo ddl. K£t lu$n: Mft so thay doi chi sd te bao mau mau ngogf vi vd ddng mau cd ban da dupe md td d nhihig bfnh nhdn bi benh tim bam sinh.
Tu'khia: Tim bam sinh, te bao mdu ngogi vi, PT, APTT, Fibrinogen
SUMMARY
Study on peripheral blood cell Indices and coagulation tests in cardiac congenital diseases Congenital heart diseases can cause some changes on the Index of blood cells and coagulation test. Objective: Study on some changes of the peripheral blood Indices in patients with congenital heart diseases. Subjects and Methods: 80 patients writh congenital heart disease were studied on Indices of peripheralblood cells and coagulation tests.
Results: 46.2% hypochromic anemia, 30% of leukocytosis. Normal platelet counts in 82.5% of (*)DalhgcyHaNgl
Phan bl^n khoa hpc: TS. Tru'tfng Cong BuSn 226
Nguyin Quang Tiing, Tr4n Mai Hing(>|
patients. 11.25% and 33.75% of the patiofe with prolonged prothrombin time and yiPTT.
Conclusion: Some changes of peripheral bkxxj cells indices and coagulation tests have been described In patients with congenital heait disease.
Keywords. Congenital Heart Oiseasev F APTT, PT, Fibrinogen
I. O^T V A N o f
Bfnh tim bim sinh gdy nen do cdc djt|t bim sinh cua tim vd tn^ch mdu Idn xdy a trong thdi ky phdi thai. Cdc dj tft ndy thudng xdy ra sdm trong khodng 8 tuin le diu cua thai ky. Mpt sd d j tft nfng ni cd thi gfiy ti vong trudc khi trd ra ddi, cdn lai cdc dj t^
khdc khdng nfng vd tid ra ddi vdi cdc dj Ijt dd [3]. Tuy nhien neu khdng dupe phdt hifi vd dieu trj kjp thdi sd cd nhihig biin chiing ndng ne vd din den cdc nguy eo gdy hi vong tat cao cho trd.
Dj tft bim sinh eia tim vd cdc mgch mil Idn gdy nhieu roi lopn tren cdc hf co quan khde nhau, trong dd ed hf 190 mdu vd tuib ugng ddng mdu. Roi logn qud trinh luu thong ddng mdu ed thi dan din hifn tirpng pha Hfn giita mdu dpng mach vd tinh mach ldm toy ddi phdn dp oxy vd do vfy dnh hudng V tiep din khd ndng van chuydn vd trap doi oxy cia hdng cdu [4]. Nhiing thay ddi ve npi moi huyit tuang cd the gay cdc roi logn ve dong mdu. Ben canh do, tinh trgng tdng cao so luong cac hdng cdu va ti bdo mau cd the gay tinh trang cd ddc mdu tpm thdi va lifu dieu
Y HpC VIgT NAM T H A W G 8 • s g BAG BieT/2012
nay ciing cd thi ldm thay ddi cde ehi s6 ddng mau cia bfnh nhdn hay khdng? Cho din nay vin cdn kha ft cde cdng trlnh nghidn cuu cdng bd ve cdc dfc diim ti bdo mdu ngogi vi cung nhu cdc xet nghifm ddng mdu co bdn d nhihig benh nhdn nay. Chinh vi vfy, nghien cihi dupe tiin hdnh nhdm tim hiiu "Sp- thay Si mft si chi si huyit hpc& bfnh nhin tim bamsuth".
n. 061TUQNG VA PHUONG P H A P NGHIEN CCU
2.1. s i i tupng
80 bfnh nhdn dupe chin dodn Bfnh tim bim sinh (BTBS) tgi Trung tdm can thifp Tim mgch - Bfnh vifn Dai hpc Y Ha Nfi trong ndm 2011.
' 2.2. Phirong phdp nghiSn eihi Su dung phuang phdp nghien ciiu cdt ngang md td. Sd lifu dupe thu thfp theo benh in nghien ciru thdng nhit.
2.2.1. Cic chi si nghiin ciru Cdc bfnh nhdn dupe chpn vdo nghidn ciu diu dupe ldm xdt nghifm ti bdo mdu ngogi vi vd xdt nghifm dong mdu co bdn vdo thdi diim nhfp vifn, ttudc khi tiin hdnh can thifp.
Cdc ehi s6 ti bdo mdu dupe quan sdt kiim tta Igi trdn tidu bdn mdu ngogi vi.
2.2.2. Cic k^ thuft sir dpng Cac xdt nghifm diu dupe tiin hdnh tgi Khoa Xdt nghifm, Bfnh vifn Dgi hpc Y Hd Nfi, gdm:
Xdt nghifm ti bdo mdu ngoai vi dupe thyc hifn trdn mdy dim ti bdo ty dfng AVIDA 120 (Siemens, Die)
Cde chi s6 ddng mdu co bdn dupe thyc hifn tren mdy ddng mdu ty dpng ADVANCE ACL (IL, Italia).
2.2.3. Xu ly si llfu: Bdng phuang phdp thdng ke y hpc su dung phan mim SPSS 16.0.
k KET QuA NGHIEN CCru
Benh ly tim bdm sinh dupe thu thdp trong nghien eim bao gdm nhiiu thi khdc nhau, cu :he ttong bang 3.1 sau;
Bang 3.1. Bac diem ve the benh trong nhdm nghien ciu
Fallot IV
Hep van OMP/ TMP Benh TBS khac:
APSO typ IV
Teo van 3 la, tim 1 buong that TBS p h i c tap
Teo van 2 la, thieu san that P HC Williams
Teo van 3 la, thieu san that P Tonq
35,0
12,5 1,25 1,25 1,25 1,25 1,25 1,25 100
' Nhfn xet: Ty If mic TLT cao nhit (35%), tiip din la TLN va CODM (diu chiim :l,25%), hep van DM?/ TMP (12,5%) va cac thi bfnh hiim gdp khdc.
C H U Y E N Bi: Hpi NGHI KHOA HQC H U Y 6 T HQC • TRUVgN M A U T O A N Q U g c 2012
3.1. Thay dii cdc lof i ti bdo mdu a. Cic chi si hing ciu
Bing 3.2. Thay dAi cdc chi sA hong ciu
Chlsff SLHC (T/L) HGB (g/L) Hct(L/L) MCV(fL) MCHC RDW
)r±sD
4.77 ± 0.8 123 ± 1 8 0.38 ± 0.6
79 ± 8.8 330 ± 11.8 U . 3 ± 5.7
Min 3.66 95 0.29 54 285
10 Max
8.78 191 0.62 94 357 18
Ting 5 (6.2%) 7 (8.8%) 5 (6.2%)
0
.
21 (26,3%) 6 1 a m 8 (10.0%) 37 ( 4 6 . 2 % ) 13 (16.2%) 38 (47.5%) 34 (42.5%)
-
U n h thu'dii9 67 (83.6%)
36 (45%) 62 (77.5%) 42 (2.55%) 46 (57.5%) 59 (73.7%)
Nhfn xil:
Thiiu mdu chiim 46.2%, tdng sA lupng hAng ciu d 6.2% cdc trudng hpp.
Kich thudc hAng ciu nhd chiim 47.5%.
Phdn bA kich thudc hAng ciu khdng dAng diu chiim 26.3%.
*.Cii Binl Chi s o SLBC
BCTT
Lymph 0 BCua
acid BCila base BC m d n d
c chi si bpch ciu
• 3.3. Thay dAi cdc chi sA bgeh ciu
G/L
%
G/L
%
G/L
%
G/L
%
G/L
%
rC± SO 9.0 ± 2.75 3.93 ± 1.65 44.69 ± 14.36
3.98 ± 2.08 43.58 ± 14.05
0.363 ± 0.49 3.785 ± 3.71 0.55 ± 0.5 0.583 ± 0.373
0.61 ± 0.25 6.89 ± 2.14
Min 5,1 1.8 M.S
1.4 13.9 0.0 0.2 0.0 0.1 0.3 3.3
Max 17.1 10.5 77.8 10.6 74.7 2.5 21.4
0.2 1.5 1.3 13.7
Tdng 24 (30.0%)
2 (2.5%) 49 (61.25%)
0 3 (3.8%) 23 (28.75%)
24 (30.0%) 4 (5.0%) 12 (15%) 18 (22.5%) 28 (35.0%)
Giim 0 2 (2.5%) 4 (5.0%) 26 (32.5%) 37 (46.2%) 2 (2.5%) 11 (13.8%)
0 0 0 0
-
Binh thiliaiiJ 56 (70.0%]i 76 (95%) 1 27(33.8%) 54(67.5%) 40(50%) 55 (68.75%) i
45 (56.2%) i 76(95%) ' 68 (85.0%) 62 (77.5%
52 (65%) Nhpn xit:
Tdng sA lupng bgch ciu chiim 30%, trong dd tdng sA lupng bgch ciu hgt trung li chiem 61.25%. Khdng gfp trudng hpp ndo bj gidm bgch ciu.
Gidm sA lupng vd ty If lympho chiim lin Iupt Id 32.5% vd 46.2%.
Tdng sA lupmg vd ty If bgeh ciu ua acid chiim lin Iupt 28.75% va 30.0%.
c. Cic chi si tiiu ciu
Bing 3.4. Dfc diem sd lupng tiiu ciu sirc
< 150 G/L n 5
%
6.25
228
Y HQC VigT NAM T H A N G B • S 6 CAC Bif T/2012
150 - 400 G/L
> 400 G/L SLTC trung binh
66 82.5
Nhpn xit. Gidm tiiu ciu chiim 6.25% vd 11.25% ed biiu hifn tdng sA lupng tiiu ciu.
3.2. Thay dAi cdc chi si ddng mdu co ban Bang 3.5. Thay ddi cdc chi so ddng mdu cp ban
Chisd PT(%) rAPTT Fib (g/L)
rCiSD 92 ± 15 1.14 ±0.188
3.16 ±0.67 Min
59 0.76 1.31
Max 124 1.87 4.95
Tdng 5 (6.25%) 27 (33.75%)
6 (7.5%)
Gidm 9 (11.25%)
2 (2.5%) 2(2.5%)'
Binh thu'dng 66 (82.5%) 51 (63.75%) 72 (90%) Nh^nxit:
Chi s6 PT (%) binh thudng chi^m 82.5%, tang chi^m 6.25% vk gi6m chi^m 11.25%
cAc tnrfifng hi?p.
Chi so rAPTT tSng chiem 33.75% v^ g i ^ ij 2.5% c6c trudiig hgp..
Chi so Fibrinogen tSng chiem 7.5% v^ g i ^ 6 2.5% cdc tmdng hgp.
IV. BAN LUAN
HSu hk cSc the bat thuang cua b$nh tim ibSm sinh da dugc nhap vien chan dodn va idieu tri tai Benh vi?n Dai hgc Y H^ N^i.
Trong cac chi so mdu ngoai vi, so lugng :h6ng cAu tang chi yeu trong cac b?nh Fallot
•IV, TBS phuc t^p...V^ CO che, hi$n tugng
•tang s6 lugng h6ng chu co th6 do giam nong jd^ oxy trong mau gay phan iing tang nong do terythropoietin va doi khi can phai rut mau de )di^u tri. E>Sng Sy Sang va cgng sv ciing ghi [Ohan tinh trang tdng dang ke so lugng hong i^cau a cac b|nh nhan mac chung Fallot IV '(6,11 ± 3,21 T/L) so voi cac b^nh nhan mac 'TBS don thuJin khac [2]. Tuy nhien, tinh trgng thiiu mau la chii yiu vai 46.2%. Thi^u
"mau nay co the do nguyen nhan chii yeu la dinh duSng vi ty I? hdng cau nho, nhugc sac rdt cao 6 cac thi b?nh: 70.59% trong CODM, 62,5% trong cac BTBS khac, 60% trong cac b?nh ly vl Hep DM?/ TMP, va 41,18% vai tnrcmg hgp TLN. Theo Ritchey, co 40,6%
tmcmg hop CO MCV duoi 80fL va 21,7%
tnrcmg hgp co MCV duoi 75fL. 6 tre mSc
tim bam sinh thudng g$p tinh trang thieu sat do nhiiu nguyen nhan: (1) do nhu cSu tgo mdu cao hem binh thudng, (2) do cung cap thiiu vd (3) do hau qud diiu tri nit mau ho§c trao doi huyet tuong [7].
Ve sd lugng bach cau, Hd Thi Thi6n Nga cung ghi nhan cdc thdng so bach cdu d gidi han binh thudng trong da so cac benh nhan trudc mo tim bam sinh [1]. Tdng SLBC trong cdc thS b?nh co the do phan iing ciia co thi trudc tinh trang b?nh ly TBS gay nen hien tugng it huyet phoi, vi6m phoi tai diln nhiiu lan, ho^c co cac tdn thuong khdc ph6i hgp.
S6 lugng tieu cau tdng nhieu nhat trong cdc trudng hgp CODM (23,53%). Cac trudng hgp khdc khong tdng, ho$c tang khong dang kl vd khdng co s\r khdc bi?t vdi p > 0,05.
Mgt s6 tdc gia de cap den hien tugng giam so lugng tilu cau khi dg b3o hoa oxy dgng mgch giam, tuy nhien co chi chua dugc giai thich r6 rang [5,7].
Thay doi cac chi so ddng mdu co bdn thudng gap d cac the b?nh tim bam sinh cd
CHUYtN Bi: Hpi NOH| KHOA HQC HUYS'T Hqc • TBUYJN M A U T O A N QUgc 2012
tim nhiiu hon cde thi khdng tim. Nghidn cihi trdn nhdm bfnh nhi bj TBS ed tim, Ritchey vd cfng sv cdng bA thdi gian prothrombin kdo ddi gfp trong 19% vd chi sA rAPTT tdng d 20% trudmg hpp [7]. D i cfp din c o chi rAi logn ddng mdu 6 nhdm bfnh nhdn TBS tim, mft sA cdng trlnh nghidn ciiu cho ring do luu thdng mdu bj rAi logn gdy Or mdu d gan, dAng thdi tinh trgng gidm oxy d nhu md gan ldm gidm sdn xuit cac yiu to ddng mdu. Trong nghidn ciiu ndy, chiing tdi cQng dd ghi nhfn cd 11.25% sA bfnh nhdn cd gidm tJ- If prothrombin vd 33.75% bfnh nhdn cd chi sA rAPTT kdo ddi.
V. KE'T L U A N
Qua khdo sdt trdn 80 bfnh nhdn bj bfnh tim bim sinh, chung tdi rut ra mft sA kit lufn nhu sau:
Tinh trang thiiu mdu gfp d 46.2%
bfnh nhdn, chu y i u Id thieu mdu hAng c i u nhd. SA lupng bgch c i u tdng gfp 6 30%
trudng hpp, chii yiu Id tdng bgch c i u hgt trung tinh (61.25%) vd ua acid (28.75%).
82.5% bfnh nhan cd sA lupng tieu c i u trong gidi hgn binh thudng.
11.25% sA bfnh nhdn cd gidm ly If prothrombin vd 33.75% cd tdng chi sA APTT bfnh/chung. 90% bfnh nhdn ed nAng dp fibrinogen trong gidi hgn binh thudng.
TAI Llfu THAM KHAO
I H i Thj ThiSn Nga (2007) "Nghien am ti biin dii ti bio mdu va dong miu tren bpth nhdn lim ditpc phiu thuit vii tuin hoBi ngoii ca thi". Lufn dn Tien s j V hpc, Tnrdng Dgi hpc Y Hd Nfi.
2. Ding Sf s i n g , NguySn Ngpc Minh, Phan Th| Thiiy Hoa v4 cs (2007), "Khao salac rii lopn dong - cdm mau a bfnh nhm (An bdm sinh mo ha tpi Binh vifn TW Hue". Tfp chi Nghiin ciu Y hpc. i\(r\): Si-62. H 3. Li Nam Trd (2006). "Dpi cmmg vi lim M>
sinh", Bii giing Nhi khoa Ifp 2. NXB Yi hpc: 9 - 40.
4. Nguyin Lan Vift (2003). "Thi/c hanh timmpch",fl\B Yhpc.
5. LMI M.C., PerlofT J.K., Child SJ., (2006),
"Pathogenesis of thrombocytopei^Uiit Cyanotic congenital heart disease. Am I Carrf/o/, 98: 2 5 4 - 2 5 8 .
6. Mehmel TJL., Murslafa O., RuU O., el;
(2011), "Rate of abnormal coagulation lei result in patient with congfiniui hean disease". Journal of Contempoitm
Medicine \0): 6-\0. 1 7. Ritchey A.K, Keller F.G, O'Brien SA,
(2009), "Hematologic manifestations. ^ childhood illness", HofTman Hematology Basic principles and practice, Stb al:^
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