Jjg>l NGHI KHOA H p c cCiA Hpl H 6 A SINH Y DUqC H A N Q I V A C A C T I N H P H ( A B A C IAH THCT XVIII
NGHIEN Cl)U Sff THAY otfl MOT SO CH! SO H 6 A SINH M A U VA T H ^ TfCH NUAC Tiiu A B|NH N H A N TIEU CO VAN CAP DO DA CHAN THUONG
TAI BfNH VllN HOU NGHj Vl|T Tl|P HAI PHONG.
Nguyin Thing Todn**, Tr^n HodiNam**, Ph^m Thi Thu Trang*, Luu Thl Thanh Duyin**
T 6 M TAT:
Nghidn ci>u 102 b$nh nhdn tidu ca vdn c4p do da chdn thu'o'ng ducrc di^u trf Igi khoa h6l BI>C Ngogi bdnh vi$n Vidt Tidp tu- thdng 12/2009 6hn thdng 12/2011. oAi luo'ng nghidn ci>u du'O'c Idm cdc xdt nghidm h i a sinh mdu:Urd. creatinin, CK, AST, Na*, K*, Can xi, Cl' ngay khi vdo vi$n, sau 66 Idm hdng ngdy cdc xdt nghi$m Ure, Creatinin vd CK cho d^n khi s6 luo'ng nui-c tiSu 24h trd Igi blnh thudrng. Kdt qu3 cho thdy N i n g dO CK todn phdn. AST, Ure, vd creatinin huydt Ihanh ddu tdng cao ngay sau 24 gi£r khi bdnh nhdn bj tai ngn. Protein mdu gidm, Na*. Can xi, Cl' thay ddi nhg, kali mdu tdng s d m . Cdc xdt nghi$m Ure, Creatinin vd CK todn phdn ddu gidm rdt nhanh khi thd tich nudc tidu duo'c cdi thi$n sau giai dogn vd mdu. Ridng Ure vd Creatinin trd vd blnh thudng sau 13 ngdy didu trj. Ddi vdi CK todn phdn sau 13 ngdy didu trj chua trd vd blnh thu'dng nhung dS gidm mgnh ti>ng ngdy.
S U M M A R Y :
CHANGES OF SOME BLOOD BIOCHEMICAL MARKERS AND URINE VOLUME IN ACUTE RHABDOMYOLYSIS
POLYTRAUMATIC PATIENTS TREATED AT THE VIET- TIEP HOSPITAL OF HAI PHONG We have studied 102 patients suffeving from polytraumatic acute rhabdomyolysis treated at the surgery Department of the Viet - Tiep hospital during the period of 12/2009 12/2011 The patients have been determined:
Urea, creatinine, CK, AST, and lonogram in blood just after hospitalization and daily then after (with urea, cregtinine, CK) just to the normalization of the 24h urine volume. The
* Truing DH y H^i phdng. *' B$nh vi$n Vi$t Ti$p 100
results showed that: high elevation of the concentrations of blood total CK. AST, urea and creatinine Just 24 hours after the trauma There were slight decreasing of proteinemia, slight changes of sodium, calcium and chloride, early elevation of kaliemia The concentrations of urea, creatinine and total CK decreased rapidly when the urine volume increased after anuria period Urea and creatinine concentrations returned to normal level after 13 days of treatment After this penod, the total CK concentration has not yet normalized but decreased every day.
I. OAT V X N OE:
Hpi chOmg tieu ca van cap (TCV): la mpt hpi chumg lam sdng, sinh hpc ban chat Id do ton thucmg c^c te bao ca van, dSn den gia!
phdng vdo mau cdc thdnh phan cua te biio:
myoglobin, cdc enzyme (CK, GOT), cac chat di^n giai, cac goc axit vd nhan purin, thromboplastin dan den cdc roi lo^n nudc • di^n giai, roi l o ^ dong mau npi mac rai rdc trong ldng mgch, suy th^n cap (STC).
STC do TCV d p n^u dupc phdt hien va dieu trj kjp thai sg nit ngSn thdi gian nSm vi?n. giam ty 1? tu vong, giam bien chung, nang cao chat lupng dieu tq. Vi vay chung toi tien hanh de tai nay vdi 2 myc tieu: I) Xghu'n ciru sif thay doi moi so chi so hoa sinh mdu a h^nh nhan tieu ca vdn cdp do da chdn thuang trong 24h ddu: 2) Bdnh gid su dien bien cdc chi so Ure. Creatinin vd CK toan phdn trong huyet thanh trong vai the lich nuac tieu.
Y HQC VIgT NAM THANG 8 - 2/2012 Tren co so d6 da xuat s\r can thiet cdc chi
s6 xit nghi$m quan trgng theo dai bfnh nhan da chin thirong tgi cdc co sa iiiu trj, II, Odi TUONG VA PHUONG P H A P NGHIEN CUU:
l.B6i tvflig nghien cmi (DTNC) l.l.Tleu chuan ckgn bfnh nkdn: 102 benh nhan da chan thuang dugc dieu trj tai Idioa h6i sue Ngofii b?nh vi?n Vi?t Ti$p tit thang 12/2009 den thdng 12/2011
- DTNC sa ldm cdc xit nghiam h6a sinh mdu:
• Ure, creatinin, CK dugc Idm ngay khi vao vian, sau do ldm hSng ngay cho dan khi enzym CK tra ve binh thu6ng hodc banh nhan tu vong.
• AST,
• Dien gidi dd (Na*, K*. Ca, Cl''
• Xet nghiam nuoc tieu: do s6 lugng nuoc tieu 3 gio dau de tinh ra ml/gio, sau do theo doi so lugng nuac tieu 24h, nhan xet mau sdc.
1.2, Tieu chudn logl Irir: ckc truang hgp trong b?nh canh khde nhu: co giat, ong dot, dong kinh, ngo dgc, uon van...
2.Phuviig phdp nghien cihi
2.1. Pkuang pkdp ngklln cim: mo Id cdt ngang
DTNC dugc bdc sy lam sang chan dodn da chan thucmg c6 suy than cdp vd dugc chia ldm ba nh6m;
- Nh6m 1 (nhdm n^g): kh5ng ddp img vdi Lasix, BN van v5 niju hodc thieu nifu vd c6 nhi^u bian chung: tdng K mau > 6 mmol/l, bien chimg tim suy tim, loim nhip tim, phii phoi cap, ngimg tim, hon ma, co gidt, phii to, trdn djch, can phdi lgc mdu ngoai th^n.
- Nhdm 2 (trung binh): cd ddp ling vdi Lasix, dd chuyen STC tha vd nieu sang STC thS cdn nudc tieu (2000-2500 mI/24 gid).
Kali mau < 6 mmol/l. Ura, creatinin mau tdng it chua cdn phdi lgc mdu, hodc lgc vdi sd lan it ban,
- Nhdm 3 (nhdm nhe): ddp img tdt vdi diau tri. Lugng nudc tiau tdng len nhanh chdng, duy tri lidu Lasix vd dich truyan dd nudc tiau > 150ml/gid. K< 5,5mmol/l, Khdng can phdi lgc mau
- Chdn dodn STC do TCV dya vao cdc tidu chudn sau: CK > 1000 U/I va Creatinin mdu > 150 nmol/L(banh nhan cd thd vd nieu, thiau nieu hoac cdn nudc tidu)
2.2. Xu- ly so lieu: phuffng pkdp thong key hoc SPSS 12.0,
III, KET QuA NGHIEN CCfU:
3,1, Dac dilm cua DTNC 3,1.1. Phdn bo ve lual
Bing 3.1. Phan bd theo tudi cua DTNC Tudi
15-19 20-29 30-39 40-49 50-59
>60 Tdnq Tuoi trung binh
Nhdm STC (n=102) 16(15,68%) 33 (32,36%) 30 (29,42%) 12(11,76%) 10(9,80) 1 (0,98%) 102(100%) 33,1 ±10,74
Hpl NGHI KHOA HpC CClA Hpl H 6 A SINH Y DUpC HA NQI VA CAC TINH PHIA BAC LAN THO XVIII Nk^n xit: H^u hit trong dd tuAi lao d^ng, trung binh Id 33,1 ±10,74 tu6i, khdng cd s(i khde biet ve ty If miic bfnh giOa cdc nhdm tu6i (p > 0,05),
3.1.2. Pkinbiv^glM
Bdng 3,2. Phiin bo theo gidi cuo cdc nhdm BN _Nam
NO
Nhdm STC (n-102) 77 (75,49%) 25(24,51%)
<0,05
;V/i(i» .vii: GOP cd nam vd nO. nhung cd khde bift (p < 0.05). nam gidi nhieu hon nO gidi.
.3.2. Dien bien cdi- t^iiii doiin siiy lh(in 3.2.1. Dlin bien giai dogn dhu (24 glir dhu):
* \i't nghifm hod sinh
X6t nghlfm UrS (mmol/l) Creatinin (umol/l) CK (lU/l) AST (lU/l) Protein mdu (q/L) Natn (mmol/l) Kali (mmol/l) Canxi (mmol/l) Cio (mmol/l)
Nhdm n$ng (n=43)(1) 27,77 ±13,28 448,6 1198,0 38294,9 ±
28787,5 2026,1 ±1471,2
49.9 ±11,1 133,3 ±13,4 6,01 ± 0.83 1.76 ±0.25 98.8 ±11,8
P (1)vd
(2)
>0,05
>0,05
<0,05
<0,05
<0,05
>0,05
<0,05
>0,05
>0,05
Nhdm trung binh (n=31)(2) 21.94 ±13,23
439,2 ± 250 24731,1 ±
17832.9 434,3 ± 348,7
55,9 ± 7,9 133,9 ±9 5,32 ± 0,78 1,85 ±0,38 101 8 ±7,6
P (2)v4
(3)
>0,05
>0,05
<0,05
>0,05
<0.05
>ao5
<0.05
>0,05
>0,05
Nhdm nhf (n=28) (3) 23,54 ± 8,52 336,6 ± 158,3 15352,1 ± 13087,5 767,9 ± 562,6
65,9 ±11.2 136.3 ± 14,4 4.84 ± 0.93 1.94 ±0,53 97,7 ±11,0 Nhdn xH:
- Nong dp CK toan ph5n cao nhat d^t t6i 67800 IU/1. chung to s\r huy hogi co rat Idn.
Tuy nhien ket qua NC ciia chung toi cho thu)' CK huyet thanh trong TCVC thap hon cac bao cao cua Gabow P (238000 IU/1 va Boies JM (236000 lU/l). Dieu nay cho thay ro rang trpng lupng ca the ngu6i vi?t nam thap. kh6i ca nho han so vai cac nuoc khac Iren thC gioi.
- Nong dp AST tSng nhung 6 nhom nSng tang nhieu han nhom trung binh \a nhom nh? (p<0.05). a nhom nang AST g5p khoang 50 lan binh thuong.
- Protein mau giam. nhom nSng giam nhiOu han nhom trung binh va nh? (p<0.05).
102
* C'lic thay doi ve difn giai: Giam Na mau mirc dp nh? va trung binh co a hau het cac BN. Gia trj Na* huyet thanh thap nhat la 125 mmol/i. Do te bao ca bj ton thuang. Na - K'-ATPase khong hogt dpng, mpt luang 1cm Na* chui vao te bao keo theo nuoc Iam phii trong tc bao \ a mat nuoc \ a Na* a long mach vit khoang ke. Giam can xi mau do can xi chui vao he thong luoi npi mo cua te bao day K' ra ngoai. Giam canxi mau cang lam tang tac d\ing dpc cua tang K* mau. Ket qua nay tuong tir NC cua cac tac gia Akma! M., Eric W.. KnocellJ.P.
Y Hpc VlgT NAM T H A N G 8 • 2/2012
3.2.2. Dien bien glai dogn vd nifu (Tir ngdy thir 2 dan khi cd Iji nudc tidu > 500ml/24 gid, Uung binh 14,5 ± 4,5 ngdy)
2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 IB 19
BlSu dd 3.1: Thd tich nudc tieu 24 gid cua DTNC giai doan vd nieu
* Cac xet nghif ni hoa sinh mau
—Nhim nang -Nn6mTB -Nn6ni nhe
Bleu do 3.2: Nong do urd huydt thanh TB ciia DTNC giai doan vd nieu
Nhdm nhe khdng tdng so vdi ngay ddu va ngay tii ngay thir 3 da bat dau giam nhanh. Nhdm benh nhan ndng vd trung binh, ure tdng keo ddi. sau 3 tuan mdi cd xu hudng vd binh thudng.
12 13 1,1 15 16 17 IB 19 20
Bd tki3.3: Ndng dd Creatinin huydt thanh TB cua DTNC giai doan vd nieu.
Nhdn xet: Ndng dd Creatinin nhdm nang liic ddu gdn tuong duong vdi cac nhdm khac va khdng khde biet d ca 3 nhdm thi d ngay thit 2 da tang them khoang 140 ^mol nhidu hon nhdm 103
Hpl NGHI KHOA HQC CCiA Hpl HpA SINH Y DUpC HA Npi VA CAC TJNH PHiA BAC LAM THO XVIII trung binh vd nh? (p<0.001), sau dd mile dCi dugc lgc mdu nhung nong dp Creatinin 6 nhdm ndy v5n ludn duy trl 6 mirc cao 700 - 800 junol/L, nhdm trung binh tSng ch$m hon, khodng 40 nmol (0,5 mg) mSi ngdy, dinh cao nhit d?il 500 (imol vdo ngdy thir 4 rAi gidm ddn,
- N6ng dO K* cua cdc BN * cd 3 nhdm diu trong gidi him binh thudmg khi lam xit nghidm hdng ngdy trong thdi gian v6 ni^u.nhd kit hgp diiu trj ndi khoa (dinh dudng) h o ^ kit hgp thu6c, lgc mdu.
>>
Ol
z 2 3 4 5 6 7 8 9 10 11 12 13 14
Bdng 3,4, N6ng d<l CK 1 Nhdm STC chung n
102 102 102 102 102 102 102 102 102 102 102 102 102
CK (U/l) 25119,6 ±
14963,9 24337,5 ±
17036,7 27681,6 ±
19663,2 23631,2 ±
14989,0 20706,0 ±
11183,2 17633,0 ±
16236,6 17999,7 ±
16826,3 13145,2 ±
15121,1 1540,0 ±
1050,7 6416,2 ±
2299,1 2099,7 ±
1932,3 1271,9 + 892,6
526,3 ±449,9 luyet tl
n 43 43 43 43 43 43 43 43 43 43 43 43 43
anh ciia cdc nhdt hdm nj^ng
CK (U/l) 30286,3 ±
27231,8 30230,8 ±
28285,0 27062,6 ±
50464,3 24680.0 ±
25317,5 24432,8 ± 102109,6 23863,5 ± 104866,3 23487,3 ±
2990,2 21407,6 ±
13567,4 21087,1 ±
1208,5 11874,8 ±
9057,6 7089,5 ±
1226,9 4897,4 ± 540.8 1640,0 ±501,6
nhinh nhdn sau 24h (nt Nhdm trung blnh n
31 31 31 31 31 31 31 31 31 31 31 31 31
CK (U/l) 27776,3 ±
12919,9 22535,4 i
19201,3 23723,7 ±
69083.3 36474.51
20825.8 17581,6 ±
11114,6 15178,3 ±
13176,7 14898,9 ±
13029,5 13183,8 ±
11926,9 12115.0±
11217.1 9188,8 ±
7718,6 5291,2 ±
6130.4 3179,0 ±
2759,6 958,0 ±321,9
dy):
Nhdm nh9 n 28 28 28 28 28 28 28 28 28 28 28 28 28
CK (U/l) 14914,6 ±
13456,8 10544,9 ±
9297,6 11968,51
9438,3 6200,7 ±
5375,9 5948,3 ±
1417,8 3577,8 ±
2068.7 3279,4 ±
3265.6 3144,2±
1818.2 1383,3 ±
526,7 1239,0 ±
828,9 623.0 ±
181,0 423,0 ±
91,0 403,0
±78,0 Nhgn xet:
- Ndng dg CK nhdm n$ng cd xu hudng cao hon rat nhidu so vdi nhdm nhe, nhdm tnmg binh. CK tdng cao gap hdng chyc lan thdm chi hdng tdm lan so vdi NMCT cap,
Tuy nhien ket qud xet nghidm CK todn phdn gidm rdt nhanh d cd 3 nhdm ngay sau khi benh nhan dugc cip ciru vd chdm sdc ddc bi$t. Kit qud ndy tuong tu kit qua cua Boles J,M„
Guidet B. vji CS, Montraver P.
104
Y Hpc VI$T NAM T H A N S 8 • 2/2012
* The tich nwi-c tieu 24 gidr vd cdc xit nghi$m hod sinh
Bdng 3.5. Thi tich nude tiiu 24 gid, ning dd ure vd creatinin huyit thanh ciia DTNC giai dogn cd Igi nudc tiiu
Ngdy 1 2 3 4 5 6 7 8 9 10 11 12 13
NuKi'c t i i u 24 g i d (ml) (n=32) 469,44 ± 1 5 1 , 6 9 6 1 , 1 1 1 4 7 2 , 9 6 1369,44 ±722.36 1962,78 ±776,20 2380,561672,82 2633,33 1 903,59 2961,11 ±1077,65
3130,561811,16 3056,251649,07 3260 ± 576,69 3496,67 ±1041,71
3380 ±705,29 3130,771630,32
Ure (mmol/l) (n=32) 26,74 ± 7,9 23,31 ± 6 . 3 20,76 ± 6 , 1 8 20.75 ±5,18 20,36 ± 7,42 18,98 ±4,17 18,6317,90 12,66 ±5,51 16,25 ± 2,61 10,47 ±6,19 11,1 ± 6 , 9 6 8,60 ± 0,85 7,80 ± 1 , 4 1
Creatinin (^mol/l) (n=32) 668 ±116,2 564,4 ± 1 7 6 473,6 ±213,7 458,0 ± 206,4 471,01187,9 362,91172,4 331,91218,3 237.4 ± 127,7 302.2 ±242,3 211.3 ±138,9 319,81191,2 2 0 8 , 8 1 8 3 , 7 93,7 1 20,6
Nhdn xet: Ure va creatinin mau giam nhanh khi lupng nudc tieu tang len va tra ve binh thuang sau 13 ngay.
IV. KET LUAN:
I. D^c diem c^n Iam s^ng suy than cap if b|nh nhan TCV cap do chan thu-ong
* Dac di^m Iam sang: tu6i trung binh:
33,7 ± 12,5 tu6i, ty le m4c benh 6 nam:
75,49%; niJ 24,51%.
*Bac diem can Iam sang: ngay tu dau n6ng dp CK da tang rdt cao, CK. tang theo muc dp t6n thuang tir nhe, trung binh den nang, ca bi ton thuang cang nhieu CK cang cao, n6ng dp CK a ca 3 nhom deu giam nhanh ngay khi benh nhan dupc cap cuu sau 24h.
- Nong dp ure va creatinin huyet thanh deu tang cao ngay sau 24 gia benh nhan bi da chan thuang va khong co sir khac biet ve n6ng dp ure va creatinin huyet thanh giua cac nhom.
- N6ng dp AST d^u tang nhung a nhom nang t3ng nhilu hem nhom trung binh va nhom nhe (p<0,05).
Protein mau giam. nhom nang giam nhieu hon nhom trung binh va nhe (p<0,05).
Dien giai d6:giam Na*, Ca, CI" mau mtJrc dp nhe va trung binh co a hau het cac BN. Tang kali mau co rat sam a ca 3 nhom mSc du gia tn trung binh ciia ca 3 nhom van <5 mmol/l.
2. Dien bien mpt so chi so hoa sinh vol the tich nu'o^c tieu:
- N6ng dp Ure, Creatinin va CK toan phan trong mau dSu giam rat nhanh khi the tich nuac tilu dupc cai thien sau giai doan vo ni?u. Rieng Ure va Creatinin tra ve binh thuang sau 13 ngay dilu tri (Benh nhan dupc dieu tri lai tieu va b6 sung djch truyen). Doi vai CK toan phan sau 13 ngay dilu tri chua tro ve binh thuang nhung da giam manh timg ngay.
Khuyen nghi: D I theo doi, tien luong benh nhan da chan thuang co suy than cap, cSn theo doi sat the tich nuoc tieu 24h va 105
Hpl NSHl KHOA H(?C CCiA Hpl HpA SINH Y DtJpC HA Npi vA CAC TINH PHIA BAC LAN THO XVIII theo ddi ning dd Ure, creatinin vd CK todn
ph^n trong huyit thanh hdng ngdy,
T A I U f U THAM K H A O :
1, Nguyin Chdnh (1993), Tin thuong do viii lap, Banh hge ngo^i khoa t$p II. Hge vian Qudn y, Irang 548-550,
2, v a Vdn Oinh (1998), Suy th$n cip, Hdi sire Ndi khoa II. Nhd xuit ban Y hyc.
trang 65-80.
3, T r i n Hfl-u ThonR (2001), Ddnh gid kcl qud ciia phuong phdp gdy bdi niau cudng buc trong du phdng vd diiu trj suy th§n
c i p do tidu c o van c i p , Luan vdn til nghidp iikc sy ngi trii b^nh vi^n, 4, Nguyen VSn Sang (2000). Suy than cap,
Bdch khoa thu Bdnh hge tjp I Irang 253-256, 5, Achard ,I,IVI., Dc Cagny B., Pruma A.,
Fourncir A. (1998), "Pathophysiology of acute tubular necrosis". Progress in acute renal failure. Euromed. pp. 23-46.
6, Akmal M., Goldstein D.A., Tdfcr N., Winkinson F.., Massuf S.G.(I978),
"Resolution of muscle calcification in the rhabdomyolysis and acute renal failure".
Annals of Internal Medicine, 89, pp. 928-30,
THliTA CAN BEO PHi VA ROI LOAN LIPID MAU CUA NGUUl 25-74 TUfil TAI KHU VUC NOI THANH THANH P H O VA NONG THON
U Thj Hgp*, Le Bach .Mai; Nguyen Tki Difp Anh*
Nguyen Cong Kkdn**, Vii Tkf Tku Hien*,
TOM TAT:
Muc tieu Ddnh gid tinh trang thira cdn bdo phi (TC-BP) vd rdi loan lipid mdu (RLLPM) d ngudi trudng thdnh tai ndi thdnh thdnh phd Idn vd ndng thdn. Ddi tu'g'ng vd phuo'ng phdp Nghidn ciru dieu tra cdt ngang Ddi tugng gdm 2420 trong dd 1162 nam vd 1258 nCr tudi tir 25- 74, dugc chia Idm 5 nhdm tudi tai 2 viing Thdnh phd (TP) gdm ndi thdnh TP Hd Ndi & ndi thdnh TP Hd Chi Minh vd ndng thdn (NT) gdm ddng bdng Bdc bd vd ddng bang sdng Cuu Long.
Ddnh gid llnh trang TC-BP bdng chi tidu nhSn trdc vd RLLPM bSng cdc chi sd hda sinh gdm Triglycerid, Cholesterol todn phdn (TC), LDL-C, HDL-C huydt tuong Kit qud O ndi thdnh TP 18,6% ddi tugng cd chi sd khdi co ttti (BMl) i 25 cao hon dang ke (p<0,001) so vdi ty Id ndy d NT Id 9,6% Ngudi trudng thdnh d thdnh phd cd ty Id
* Vien Dinh dmmg. ** Vu Khoa hoc Ddo lao 106
cholesterol cao don thudn Id 44.3%; tdng tnglycerid Id 49.3%. tdng LDL-C Id 43,5% cao hon so vdl cdc ty Id ndy d NT tucmg irng Id 27.3%, 39.3%, 21,4% vdi p<0,001. Ty 1$ dii tugng cd HDL-C Ihdp d TP Id 34,8 %. d NT IS 33,3% vdi p>0,06
Ttr khda: Thira c&n ddo phi. rii loan lipid mku. thknh phd. n6ng thdn. ngudi 25-74 tuii.
SUMMARY
OVERWEIGHT-OBESITY AND DYSLIPIDEMIA IN ADULTS FROM 25 TO 74 YEARS OLD IN
CITIES AND RURAL AREAS Objective: To investigate overweight-obesity and dyslipidemia status in adults in cities and rural areas. Subjects and methods A cross- sectional descriptive study was conducted among
