TAP CHI Y Dl/CTC HQC CAN THa - SO 13-14/2018
9. Nguyen Trong Tuyen (2015), Nghiin eOu hiiu qud dieu tri hgi chimg tdng dp luc tinh mgch cira d b^nh nhdn xa gan bang phuang phdp tgo shunt eira-ehu trong gan, Luan an Tien sy Y hpc, Vi^n nghiSn ciiu Khoa hpc Y Dugc lam sang 108, tr. 59, 62.
10.A1 Traif 1 et al (1999), "Randomized trial of ligation versus combined ligation and sclerotherapy for bleeding esophageal varices", Gastrointestinal Endoscopy, 50(1), p. 1-6.
11 .Chalasani N et al (2003), "Improved patient survival after acute variceal bleeding: a multicenter, cohort study". The American Journal of Gastroenterology, 98(3), p. 653-659.
]2.E1-Saity W. M and Mourad F. A (2005), "Use of the Six-Shooter Ligation Device in the Management of Bleeding Esophageal Varices: A Developing-Country Experience", Digestive Diseases and Sciences, 50(2), p. 394-398.
13.Hassanien M et al (2015), "Predictors of In-Hospital Mortality in patients with hepatocellular carcinoma and Acute Variceal bleeding", Electronic Physician, 7(6), p.
1336-1343
l4.Jairath V et al (2014), "Acute variceal haemorrhage in the United Kingdom: Patient characteristics, management and outcomes in a nationwide audit". Digestive and Liver Disease, 46(5), p. 419-426.
15.LoG. H etal (2015), "A controlled trial of early versus delayed feeding following ligation in the control of acute esophageal variceal bleeding", Journal of the Chinese Medical Association, 78(11), p. 642-647.
16.Makhiouf N. A and Morsy K. H (2012), "Renal failure after upper-gastrointestinal bleeding among cirrhotic patients in Upper Egypt", Arab Journal of Gastroenterology, 13(3), p. 139-144.
n.Okasha H. H et al (2010), "Endosonography as a predictive tool for first oesophagogastric v?iriQcz[h\QGAm^\ArabJoia7ial of Gastroenterology, 11(3), p. 149-152.
(Ngdynhdnbdi: 10/11/2017-Ngdy duyet ddng: 02/01/2018)
D A C D I E M L A M S A N G , H I N H A N H H O C VA GIA TRI TIEN LU'QfNG TU* V O N G C U A T H A N G D i E M F O U R T R E N BENH N H A N HON M E DO
C H A N T H i r O N G SO N A O
Vd Hiin NhSn'*, Nguyin Duy Linh^
1. Benh vien Sdn Nhi An Giang 2. Tnrdng Dgi hgc YDugc Cdn Tha
* Email: vohiennhan2707(^gmail.com T O M TAT
Bgt vdn de: Thang diim Glasgow Coma Scale (GCS) dugc sir dgng rgng rdi di ddnh gid tri gidc binh nhdn. Tuy nhien qua thdi gian sir dgng nd cd mgt sd nhuac diim, vi thi ndm 2005, Wijdieks vd cgng sg de xudt thang diim mdi, the Full Outline of UnResponsiveness scale (FOUR), thang diem ndy khdc phue nhugc diim eua thang diim GCS vd cung cdp nhiiu chi tiit thdn kinh han Mue tiiu nghien du: Md td dde diim ldm sdng. hinh dnh hgc d binh nhdn hdn mi do chdn thucmg sg nao (CTSN). Xdc dinh gid tri tiin lugng tir vong cua thang diim FOUR so vdi thang diem GCS. Boi tirgng vd phuang phdp nghiin cuu: Cdt ngang md td tien ciru, binh nhdn hdn me do CTSN cd GCS nhd han bdng 8 diem vd tudi ldn han bdng 5. Nghiin ciru gid tii tien lugng tir vong cua thang diim FOUR Cdc biin sd thu thgp dugc xu tri bdng phdn mem thdng ki SPSS 18. ft
T»P CHf Y DUaC HOC CAN THO - s 6 13-14/2018
Kit qua:Tdng sd 118 binh nhdn, tudi trung binh 38,67, nam 87%. Tdng diim FOUR Id yeu td tien lugng dgc lap ddi vdi ty 14 lU vong. Do nhgyyd dg ddc hieu tdi uu tgi tdng diim FOUR bdng 5 (dd nhgy 86.5%, dg dgc hiiu 98,8%) vd tgi tdng diem GCS bdng 6 (dg nhgy 89.2%, dg dgc hiiu
76,5%). Kit lugn: Thang diem FOUR ed gid tri tiin lugng tir vong cao han so vdi thang diem GCS. Thang diim FOUR cung cdp nhieu chi tiet thdn kinh han thang diim GCS cho nen ed khd ndng tien lugng tie vong tdt han & nhung benh nhdn CTSN ngng.
Tir khda: Thang diim FOUR, thang diim GCS, tiin lugng tir vong. hdn mi, chdn thuang so ndo.
ABSTRACT
CLINICAL, IMAGING CHARACTERISTICS A N D VALIDITY IN THE MORTALITY PREDICTION OF T H E FOUR SCALE IN C O M A T O S E
PATIENTS WITH T R A U M A T I C BRAIN INJURY
Vo Hien Nhan, Nguyen Duy Linh Background: The Glasgow Coma Scale (GCS) is widely used to assess tiaumatic brain injury (TBI) patient's conciousness. But it still has some disadvantages. Therefore in 2005, Wijdieks et ai have proposed a new scale - the Full Outline of UnResponsiveness scale (FOUR), this scale modified the disadvantages when we used GCS scale and provided more neurological detail Objectives: Our aims were to desribe the clinical, imaging characteristics in patients with servere TBI, and to determine the mortality prognosis value of the FOUR scale compared with the GCS scale. Materials and method: This was a cross-sectional descriptive study, including TBI patients with a GCS of 8 points or smaller and an age greater than 5 years old. Mortality prognosis of the FOUR scale anh GCS was studied. Statistical analysis is done with SPSS 18.0 statistical software.
Results: 118 comatose TBI patientsunderwent to assess, the mean age is 38.67, male patients accounted for 87%. The FOUR score was an independent predictor of mortality. The sum of sensitivity and specificity was maximized at a FOUR total score was 5 (sensitivity 86.5%, specificity 98.8%) and total GCS score 6 (sensitivity 89.2%, specificity 76, 5%). Conclusion: The FOUR score is more valuable in predicting mortality than the GCS score. FOUR score provides more neurological details than the GCS score, so it is possible to predict mortality better in patients with severe traumatic brain injury.
Keywords: FOUR score, GCS score, protasis mortality, coma, tiaumatic brain injury.
I. D A T V A N DE
Ket qud diSu tri CTSN phy thudc phin ldn vao cdng tac quan ly va xii tii cip ciiu ban diu, nhdt la ddi vdi CTSN nang. Trong viec xir tri cdp ciiu ban diu viSc danh gid tri gidc ciia benh nhdn de ddnh gid miic do hdn mS gdp phin rit quan trgng trong viec chin doan, diSu tri, theo ddi, ciing nhu tien lugng bSnh nhan CTSN. Thang diim GCS dugc Jennet B vd Teasdale G de xudt tir rmm 1974, qua thdi gian tuy dugc sir dung rpng rai nhung din dan cac nhugc diem ciia nd da dugc phat hien. Nam 2005, Wijdieks dua ra mpt thang diim mdi. The Full Outline of UnResponsiveness, gpi la tiiang diim FOUR. Nam 2010, mdt hudng dan dya vao chiing cii d My ciing da cdng bd xdc nhdn dp tin cay v l viec dp dung thang diem FOUR dS danh gid miic dd hdn me la cd nhieu hita hen tdt. Tuy nhiSn viec danh gid tiSn lugng tir vong d nhihig benh nhan hdn me do CTSNchua dugc cdc tdc gid neu ra. Xuat phdt tir van de tren, chiing tdi tiin hdnh nghien ciiu dgc diim lam sang, can ldm sang, gid tri tien lugng tii vong cua thang diim FOUR tren benh nhdn hdn me do chdn thuong sp nao. Vdi cac muc tiSu cu the:Md ta dac diim lam sdng, hinh dnh hpc d
Tifl^P CHI Y Dl/ffC HQC CAN THO - s6 13-14/2018
bSnh nhdn hdn me do CTSN va xac dinh gia trj tien lugng tir vong cua thang diSm FOUR so vdi thang diSm GCS.
IL B 6 I TirgfNG VA PHU'ONG PHAP NGHIEN CUtJ 2.1. Soi tirong nghien cuu
TiSu chuan chpn mlu: Cdc benh nhdn dugc chin doan xdc dinh CTSN tgi Benh vien Da khoa Trung uong Cdn Tha tir thang 7 nam 2015 dSn thdng 1 ndm 2016, thida:
DiSm Glasgow cua bSnh nhdn < 8 va tudi benh nhdn > 5.
Benh nhdn dugc thyc hien khao sdt chan dodn hinh dnh bang chup cat Idp vi tinh sg nao.
Tieu chuan logi trir: BSnh nhdn hdn me do nguyen nhan khac hoac khdng logi trir dugc nguyen nhan hdn mS khac tren benh nhan CTSN.
Benh nhan khdng danh gia dugc thang diSm Glasgow la rdi logn tam thdn, cam diec, khong quan sdt dugc ddng tii.
BSnh nhdn dugc chin doan CTSN da dugc md d tuyen trudc sau dd chuyen den Benh vien Da Khoa Trung uong Cdn Tho.
Benh nhan va ngudi nhd khdng hgp tac, khdng tiiam gia nghien ciiu.
2.1. Phvtmg phap nghiSn cuu Thiet ke nghien cuu: Md ta cat ngang Co* mau va phirong phdp chon mau
Mdu duoc tinh theo cdng thiic : f^ ^ ^i-a/2 Ti a
Tir do, chiing tdi xdc dinh dugc cd mdu t6i thieu Id n = 92 b^nh nhdn.
Chgn mau thudn tien tir benh nhdn thda tieu chudn chgn mau vd khdng thudc tiSu chuan logi trir, den tdi thieu du ca mau da xdc dinh hogc nhieu hon.
No! dung nghien cuu:
Lam sang: So ciiu, nguySn nhdn, tinh trang nhdp vien, tdn thuong hdp sp, tri gidc (theo thang diim FOUR va GCS), diu hieu TK khu tni, tdn thuong phdi hgp.
Hinh anh hpc: CT scan sg nao.
Ket qua dieu tri: Phuong phdp diSu tri, phuong phap mo, sd Idn md, thai gian nim vien, tinh trang liic ra vien va sau mdt thang.
Trong phan tich da biin, biSn s6 ti le tit vong FOUR vd GCS dugc dua vdo phan tich hdi qui logistic da bien bing phep kiem dmh Mann-Whitney bdng cdch dua vdo mdt ldn dS tim yeu td tien lupng ddc lap ddi vdi ti IS tu vong. BiSn sd tdng diem FOUR va GCS dugc khdo sdt gid tri thdng qua phdn ti'ch dudng cong ROC (receiver operating characteristic) de xac djnh diSm cdt, dp nhay, dp dgc hieu, va diSn tich duoi dudng cong ROC.
IIL K E T QUA N G H I E N CUtJ 3.1. Dac diem mau nghiSn c ^
Mau nghien ciiu 118 benh nhan, trong dd cd 103 nam chiem 87%, tudi tnmg binh 36,67 ± 14,62. So cihi tiirdc nhap vipn 92%. Nguyen nhdn do lai nan giao thdng chiim 83,9%. GCS Iiic nhap vien 8 diem chiSm cao nhat 25,4%. GCS liic lay mau gap nhilu nhat Id 8 diem chiim 23,7%, FOUR Iiic lay mau nhiSu nhat la 11 diem chiem 14,4%. Dau hieu thin kinh khu tni:Ylu/IiSt chi chiim 37,3%, gian ddng tir chiSm 46,6%, mit phdn xa dnh sang chiem 53,4%.Tdn thuang phdi hgp ca quan khdc chiem 16,9%. Tdn thuong tien 17
Ti»iP CHi Y DUCfC HQC CAN THg - SO 13-14/2018
phim CTscan so nao: T6n thuong xuong chiem 73,7%, tu mdu ngoai mang cung chiem 22,9%, tu mau duoi mang ctog cip chiSm 55,9%, xudt huyit dircri nhen chiSm 78,8%, xujt huySt nao thjt chiem 11,9%, dap nao chiim 66,1%, duong gifta lech chiem 57,6%, phu nao chiSm 20,3%, tu mau trong nao chiem 8,55%.BiSu tri bang phuang phap m6 chiim 40,7%, diSu tri npi chiim 59,3%, trong sd BN ml thi phuang phap ml mo sp liy mau tu, giai ap chiim 81,3% phuang phap mo so lau mau tu, d$t lai nap sp chiem 18,7%, trong SIBN ml thi ml mot lin chiim 77,1%, ml hai lin chiim 22,9%. Thai gian nim vientrung buih la 13,02 ± 11,96 ngay, ngin nhit la 1 ngay, dai nhit la 62 ngay. Ty le tii vong trong nghign ciiru la 37 trucmg hop, chiem 31,4%.
3.2. Sir liin quan bien sl tong diim FOUR, GCS vi ty 1| tir vong
Bang 1. KSt qua phan tich hii qui da biin vl tuong quan gifta diim FOUR, GCS va ty le tu vong.
Cac bien s6 Diem FOUR Biem GCS
H | so hoi qui - 0,129
0,085
P
< 0,001
< 0,001
Khoang tin cay 9 5 % G H d u M
-0,155 0,035
GH tren - 0,103
0,135 Theo phep Idem dinh Mann-Whitney tong diem FOUR, tong diem GCS co tuong quan voi ty Ie tft vong co y nghia thing ke p < 0,05. Nhu vay bien so tong diem FOUR Ik yeu to tien luang dpc l^p dii voi tinh trang song va tu vong trong thai gian 30 ngdy k8 tu ngay nhap vien.
3.2. Gia tri tien lifffng tir vong ciia FOUR va GCS 3.3.1. Khao sat dien tich diroi dirong cong ROC
- G C S -rOTJR
S u i m g Oiam cbicu
0.0 0.2 0.4 0.6 0.8 1.0 1 - Dd dAr liirn
Bilu dl 1. Dien tich duoi duong cong ROC cfta FOUR va GCS Su phan bl cua biin so ting diim FOUR va GCS thoa dieu kien phan bl chuin.
Ket qua khao sdt dien tich du6i duong cong ROC vai gia tri thuc duong la tinh trang sing;
phin dien tich duoi duong cong ROC cua FOUR Id 0,981, (p < 0,001), khoang tin cay 95% tft 0,961 - 1,000. Diim cit tai FOUR bSng 5, dp nhay vd dp dac hieu tii uu nhit lin lupt la 86,5% va 98,8%. Tirong tu vdd thang diem GCS; dien tich dudi dutog cong ROC 18
TAP CHf Y Dirgrc HOC C&N THg - S6 13-14/2018
Id 0,913, (p < 0,001), khoang tin cay 95% tft 0,858 - 0,968. Diem cat tai diem GCS bang 6, thi thang diim c6 dp nhay vd dO dac hieu toi uu nhit lin lupt Id 89,2% va 76,5%
3.3.2. Diim FOUR, GCS va tien Iffffng tu- vong
•Si:
"1 10
I
S 6
T6ng mem GCS
2.
tl*.
. •.0 1 2 . > 4 - > 6 7 8 9 101112 Tong mim FOl^R BiSu dd 2: FOUR, GCS vd tinh trang sdng, tir vong Bang 2: Kha nang sdng va tii vong trong nghien cuu
Tinh trang benb nhan sing(%) Tir vong (%)
Tong diim FOUR
< 4 0 100
< 5 13,5 86,5
> 8 100 0
Tine di^m GCS
< 4 0 100
< 6 36,5 63,5
> 6 93,9
6,1 Bdng 2 the hien ket qua vS kha nang song va tft vong suy ra tijr gia tri tien doan ducmg (kha nang sing) cua hai thang diim FOUR vd GCS a cac mftc diem khdc nhau.
IV. BAN LUAN
Cac tac gia iiien nay dlu c6ng nhan vd ung hp gia tri cfta thang diim FOUR trong danh gia tri giac, cung nhu tien luong benh nhan hon me do CTSN. Ket qud nghien cftu cua chiing toi cung cho thiy thang diim FOUR la yiu to tien lupng tft vpng tit, cdc kit qua khdo sat dien tich duoi duang cong ROC tuong duong voi cdc kit qua nghien cuu Ididc (bdng 3).
Trong phan tich hIi qui logistic da biin a bdng 1, ket qud bi8n so tong diem FOUR thoa man dieu kien p < 0,05 vd GCS cung thoa man diiu kien p < 0,05. NSn FOUR vd GCS la yiu tl tien luong dpc lap trong nghi6n cun, kit qua nghien cuu cua chftng toi khong tuang ding vdi nghien cftu cua tdc gia Vo Thanh Dinh [1], Id bi6n so tong di6m FOUR la yiu to tien lupng dpc lap trong nghien ciiu vdi p < 0,05, con GCS thi khong phdi la yiu tl tien lupng d^c lap trong nghien cftu voi p > 0,05.
Theo bang 2, chung toi nhan thiy ring khi mftc dp b$nh rit nang, khi dd thang diim FOUR duoi 4 thi tit ca cdc bSnh nhan dlu tu vong, trong khi 6 inuc diim nho hom 5 cua thang diim GCS thi vin co benh nhan sing. Diiu nay chftng to ring ciu true chi tiet
TAP CHI Y Dl/pfC HQC CAN THCT - SO 13-14/2018
cua thang diSm FOUR cd bon thdnh phan thi cd uu the han thang di6m GCS cd ba thanh phdn, da giiip cho thang di8m cd kha nang tien lugng tur vong tdt han. Kdt qud nghien cuu nay ciia chung tdi ciing tuong ddng vdi nghien curu cua tdc gid V5 Thanh Dinh [1].
Bang 3. So sanh gia tri tien luong tu vong Tac gia
SaikaA[6]
Fugate JE [31 V o T D u i h [ l ) Gorii MA r41 Chung tdi
FOUR BC
7 8 8 6 5
BN 0,98 0,91 0,94 0,86 0,87
BDH 0,88 0,91 0,89 0,87 0,99
AUC 0,97 0,97
-
0,95 0,98
GCS BC
6 6 6 7 6
BN 0,98 0,91 0,87 1 0,89
B B H 0,82 0,87 0,88 0,61 0,77
AUC 0,95 0,95
-
0,91 0,91 (DC: diem cat, DN: dp nhay, DDH: dO dac hieu, A U C : dien tich duoi dudng cong ROC)
V. KET LUAN
Thang diem FOUR c6 gid tri tien luang tii vong cao ban so vdi thang diem GCS.
Khi diem FOUR bdng 5 thi thang diem cd do nhay va do ddc hieu tdi uu nhat lan luat Id 86,5% va 98,8%, vd dien tich duoi dudng cong ROC Id 0,98. Ddi vdi thang diSm GCS khi diem bang 6 thi thang diem cd do nhay vd dd d^c hi$u tdi uu nhat ldn lugt Id 89,2% va 76,5%, va dien tich dudi dudng cong ROC Id 0,91. Vdi k6t qud phan nhdm tien luong tu vong theo thang diem FOUR cho thdy khd nang tien lugng tur vong d miic dp benh rat nang cua thang diSm FOUR tdt han so vdi thang didm GCS.
TAI LI|;U THAM KHAO
1. Vo Thanh Dinh, Vu Anh Nhi (2011), "Nghien cun tien luang tii vong bdng thang diim FOUR d benh nhan hon me", Ludn dn tdt nghiip chuyen khoa II, Dai Hoc Y Dugc Tp. Hd ChiMinh, 17(1), ir 7 9 - 8 3
2. Phpm Dinh Kien va Nguyin Quoc Kinh (2013),"Danh gia su tuang quan giiJa diem Four vdi diem hdn me Glasgow trong chan thuang so nSo ndng", Tgp chi Y Dugc Ldm Sdng, 8(3), fr. 1-4.
3. Fugate JE et al (2010), "The FOUR score Predicts outcome in patients after cardiac arrest", Neuroerit Care 2010, 13(2), pp. 205-210.
4. Gorji MA (2014), "A comparison of the diagnostic power of theFullOutlineoflJnresponsivenessscale and the Glasgow coma scale in the discharge outcome prediction of patients with traumatic brain injury admitted to the intensive care unit", Original Article 2014,8(2), pp. 195 - 197.
5. Ledoux D et al (2009), "Full Outline of Unresponsiveness compared with Glasgow coma scale assessment and outcome prediction in coma", Critical Care 2009, 13(1), pp. 107.
6. Saika A (2015), "Prognostic value of FOUR and GCS scores in determining mortality in patients with traumatic brain injury". Acta Neuroehir (Wien), 157(8), pp. 1323 - 1328.
7. Wijdieks (2006), "Clinical Scales for Comatose Patients; The Glasgow Coma Scale in Historical Context and the New FOUR Score", Rev Neurol Dis 2006, 3(3), pp. 109 - 117.
8. Wijdieks et al (2005), "Validation of a New Coma Scale: The FOUR Score", Ann Neurol 2005, 58(4), pp. 585-593.
(Ngdynhdnbdi: 15/11/2017-Ngdy duyit ddng: 08/01/2018)
