TAP CHI Y Dt/QC HQC CAN THg

TAP CHI Y Dt/QC HQC CAN THg - S6 11-12/2018

Hong, M.. Zha, L.. Fu, W.. Zou, M., Li. W., & Xu, D. (2012). A modified visual loop- mediated isoUiermal amplification method for diagnosis and differentiation of main pathogens from Mycobacterium tuberculosis complex. World Journal of Microbiology' and Biotechnology'. 2H{2), 523-531.

(Ngdynhdnbdi: 17/11/2017-Ngdy duyet ddng: 04/01/2018)

H I E U Q U A D ^ T M A Y T A O N H I P T ^ M THOfI Q U A DlTOfNG T I N H M ^ L C H T R O N G C A P C t r u L O ^ N N H I P C H A M T ^ I B ? N H V I E N DA K H O A

T H A N H P H 6 C A N T H O

Nguyin Tdm Thoai, Trinh Thf Bich Liin, Phgm Thi Kim Hoa, Le Quang Vo, Nguyin Vdn Nghia, Li Vdn Dgt, Vo Vift Thdng, Tran Back Ngan, Le Tan To Anh, Ho Hodng Kim, Trinh Thanh Tam Email: mickeyandntlt@yahoo.com TOM T A T

Bat van di: Dgt mdy tgo nhip tam th&i la mgt thu thugt rdt cdn thiit di diiu tri cdc rdi logn nhip chgm. Mgc tieu nghien cAu: Ddnh gid hi^u qud ciia dgt mdy tgo nhip (am then qua du&ng tinh mgch trong cap cuu logn nhip chgm tgi BV DKTP Cdn Tha tu 11/2012-11/2016. Dii tuffng va phuang phdp: Nghien cuu md td cdt ngang, dugc tien hdnh tren 51 binh nhdn ngi tru dugc dgt mdy tgo nhip tgm th&i qua du&ng tinh mgch cdp cuu tgi BVDKTP Cdn Tha. Ket qud: ty li thdnh cong cua thu thugt la 98% v&i ngir&ng kich thich cd ddn nhip on dinh Id 0,94± 0,44 V, thdi gian ludn diin cyrc tim vj tri ddn nhip tdt la 29,92 ± 12,46phut. Bien chung trong qud trinh thgc hien thu thugt: biin chiing chung & mdc 8%; trong do rdi logn nhfp keo ddi phdt diiu trj khi ludn dien cue la 3,9%, sut ddy dien cue trong th&i gian luu mdy tgo nhip la 2%. Hieu qud dgt mdy tgo nhip tgm th&i: ty 1$ thdnh cong Id 98%, thdnh cong cua thii thugt thdng qua hu&ng ddn cua siiu dm tim 2D: 97,7%, cdi thien huyet dgng: 90,9%, cdi thien trieu chimg: 92,5% binh nhdn dugc cuu song: 72,5%. Trong sd do cd 39,2% tu hoi phuc hit nhfp chgm, khdng cdn dgt mdy tgo nhip vtnh viin. Ket lugn: cd hieu qud cao trong buac ddu dat mdy tgo nhjp tgm th&i qua du&ng tinh mgch trong cdp ciru logn nhip chgm tgi b$nh vi$n da khoa thdnh phd Cdn Tha.

Tir khda: rdi logn nhip chgm, may tgo nhip tgm th&i.

E F F I C A C Y O F I N T R A V E N O U S T E M P O R A R Y P A C E M A K E R IH E M E R G E N C Y B R A D Y C A R D I A A R R H Y T H M I A A T C A N T H O G E N E R A L

H O S P I T A L

Nguyen Tam Thoai, Trinh Thi Bich Lien, Pham Thi Kim Hoa, Le Quang Vo, Nguyen Van Nghia, le Van Dat, Vo Viet Thang, Tran Bach Ngan, Le Tan To Anh, Ho Hoang Kim, Trinh Thanh Tam Background: Placing a temporary pacemaker is a very necessary procedure for the treatment of bradycardia arrhythmias. Objective: Evaluate the efficacy of intravenous temporary pacemaker in the emergency bradycardia arrhythmia in Can Tho general hospital from 11/2012- 11/2016. Materials and method: Cross sectional description, the study was conducted on 51 inpatients who were placed on a temporary pacemaker at Can Tho general hospital Results: The success rate of the procedure was 98% with the stimulus threshold of 0.94 ± 0.44V, time to find good conductor position is 29.92 ± 12.46 minutes. Complications during the procedure: common complications at 8%; arrhythmias due to electrode acquired treatment was 3.9% and electrode 84

TAP CHI Y Dl/QC HQC CXN T H Q - s 6 11-12/2018

loss during pacemaker maintenance was 2%. Efficacy of a temporary pacemaker: success rate of 98%, success of the procedure through the guidance of 2D echocardiography: 97.7%, hemodynamic improvement: 90.9%, improvement symptoms: 92.5%. patients were rescued:

72.5%. Of these, 39.2% recovered their slow rhythms without the need for a permanent pacemaker. Conclusion: it is highly effective in initial setting of intravenous temporary pacemaker in emergency management of patients with bradycardia arrhythmias in Can Tho general hospital

Keywords: bradycardia arrhythmia, temporary pacemaker.

L D i ^ T V A N D E

Rdi loan nhip chdm (RLNC) cd thS gdy rli loan huySt dOng va dua dSn tii vong neu khdng dugc cap ciiu kip thdi. D^t mdy tgo nhip tam thdi (DMTNTT) Id mdt thii thuat rdt can thiet de diSu tri cac rdi loan nhjp chdm cd trieu chufng tren lam sdng. Paul Zoll Id ngudi ddu tien thuc hien thdnh cdng thii thuat nay vao nam 1952. Tai Viet Nam, may tgo nhip da dugc Vien Tim mach - BV Bach Mai dp dung dau tiSn tu nam 1973, sau dd den nhieu tiomg tdm khdc trong cd nude nhu BV Thdng Nhdt, BV Chg Rdy, Vien Tim TP Hd Chi Minh. BV DKTP Cdn Tha da thuc hi?n thii thugt ndy tii tiidng 11/2012. Tao nhip ndi chung la linh vuc tuong ddi mdi vdi nhieu thdch thiic ddi vdi Ngdnh Y tS Can Tha. Hien tai Cdn Tha chua cd bat ky cdng trinh nghien cuu ndo ve linh vuc tao nhip, vdi mong mudn tim hieu vS ky thuat, biSn chiing va hieu qua cua dgt mdy tgo nhip tam thdi qua dudng tiiih mgch trong cdp ciiu RLNC, chiing tdi tien hanh nghien ciiu dS tdi vdi muc tieu nhu sau:

1. Khdo sat cac dac diim vl ky thu$t dat mdy, cac bien chiing trong ddt mdy tao nhip tam thdi qua dudng tinh mach trong cdp ciiu.

2. Danh gid hieu qua cua ddt may tao nhip tam thdi qua dudng tmh mgch trong cap ciiu loan nhip cham.

II. D6i TlTONG VA PHlTOfNG PHAP NGHIEN CLTU 2.1. Doi tirgng nghien cihi

2.1.1. Ddn s6 nghien ciru

Tdt ca benh nhan RLNC cd chi dinh DMTNTT cap cuu tiieo khuyin cao cua ACC/AHA tir thang 11/2012 din tiidng 11/2016 tgi BV Da khoa tiidnh Phd Cdn Tha.

2.2.2. Tieu chi chpn benh

Tdt ca benh nhdn bj rdi loan nhip chdm cd chi dinh dat may tgo nhip tam thdi cdp ciiu theo khuyen cao cua ACC/AHA.

2.1.3. Tieu chi logi trir

Benh nhdn khdng ddng y hogc thu thdp khdng dii cdc biin sd tiieo mdu.

2.2. Phu-ong phap nghiSn cuu

2.2.1. Thiet kl nghiSn cmi: Nghien ciiu md td, tiin ciiu.

2.2.2. Co- mau va phuong phap chon mau:

Day Id benh hilm nen chiing tdi dp dung phuang phdp ldy trgn mau trong sudt thdi gian nghien ciiu.

2.2.3. Noi dung nghien cuu

Khdo sdt cac dac diim vS kj thugt DMTNTT bao gim dudng dua dien cue vao, cdc thdng sd cdi dat may, thdi gian ddt dugc dien cue d vi tri tdt, qua do ciing ghi nhdn hieu qua dat dugc va cac bien chiing xdy ra.

TfllP CHI Y Dl/QC HQC CAN THO - SO 11-12/2018 III. KtT QUA NGHIEN CtfXJ

3.1. Dgc diem k j thuat thu thudt flat mdy TNTT 3J.1. Phmmg tiin hir&ng ddn vi tridi^n circ

Benh nhdn dugc tgo nhip qua hudng ddn ciia sieu am tim la 90,2%. Ldm thu thugt

"md" khdng cd hudng dan ciia XQ sieu am la 7,8%, chi cd 2% (1 trudng hgp) vdi tinh trang lam sang cho phdp di chuyin chiing tdi lam thii thugt tgi phdng phdu thi4t dudi hudng dan cua XQ tdng sang C-arm.

3.1.2. Dir&ng vdo cua day diin cue

Benh nhdn DMTNTT qua dudng tinh mach canh trong (TMCT) phai nhilu nhdt chiim 98% m l u nghien ciiu, cdn lgi 2% qua dudng ti^nh mgch dudi ddn (TMDD) phdi.

3.1.3. Vi tridhu ddy diin arc

51 benh nhdn DMTNTT qua dudng TM cd vj tri ddy vd ddu dien cue dat ySu cdu chiim 96% trong mdu nghiSn ciiu.

3.1.4. Phan logi kiiu dgt va ngtr&ng kich thich Bdng 1 • Kilu tgo nhip

Ky thuat dat may

KiSu tao nhip W I

voo ^

T8ng

n 42 9 51

Ti IS (%) 82,4 17,6 100 Cd 82,4 % benh nhdn dugc tao nhip budng that phdi kieu VVl Bdng 2. Nguang kich thich vd tdn s l tao nhip

Ky thuat dat may (50BN) Tan so

Tah.htH. 1 Ngu&ng 1 Cai dat OP

Don vi Chu Icy/phut

Voh Volt

TB±BLC 75,80 ±11,62

0,94 ±0,44 3,33 ±0,77 Tdn sd tao nhip trung binh Id 75 (chu ky/phiit) thap nhdt la 50 cao nhat la 100 ck/ phiit.

Bdng 3. Tdng thai gian ldm thii thugt va thdi gian tgo nhip Thai gian lini may (50BN)

Thoi gian lam thu thuat (5IBN) Thai gian chuan bi lam thii thuat (51BN)

Dona vi Ngay

phot phfit

TB±DLC 4,08 ±2,44 29,92 ±12,46 26,94 ±17,49 Benh nhan cd thdi gian tao nhip trung buih la 4,08 ngay, thap nhat 1 ngdy, cao nhdt 12 i ^ y .

3.2. Hieu qua vd biin chihig sau dgt mdy TNTT 3.2.1, Hi^u qua sau dgt mdy TNTT Bdng 4. Hieu qua sau dgt may TNTT trong nghiSn cuu

Hieu qua sau dat may Thanh cong cua thu thuat Chua thanh cong (may khfing dan) , , . ^ , j . „ 1 Dung vi tri va ho^c dp dai day phii hop

1 Chua dat yeu cau

n 50/51

1/51 49/51

2/51

98,0

%

2 96,9

3,9 86

TAP CHf Y Dl/QC HQC CAN THff - SO 11-12/2018

Ty phuc hoi 39,2

Chuyin sang djit may tgo nhip vinh viln | 17/51 33,3 Thanh cdng thii tiiugt 98%, tu phuc hdi la 39 %, chuyen sang dgt mdy vihh vien la 33,3%.

Bdng 5. HuySt dp vd nhip tim sau ddt may TNTT trong nghiSn ciiu Trudc d^t may

X±SD

Sau dat may TB ± DLC

Huyet ap 112.84± 25,53

Nhip tim 34,60 ± 8,67 75,80 ±11,62 <0,001

Huyet ap vd nhip tim ciia benh nhdn d nhdm sau dat may cao ban so vdi trudc dgt may va khac biSt ndy cd y nghia thing kS vdi p <0,001.

Bdng 6. Cdi thien huySt dp tdm thu sau d^t mdy TNTT trong nghien ciiu

Roi loan huyet dong Cai thien HATh

Truoc dat may n

22

Tyle(%) 43,1

Sau dat mdy n 2

Tyle(%) 3,9 20/22(90,9%)

P

<0,001 Nhdm benh nhdn cd rdi logn huySt ddng trudc dat may la 43,1% cao hon rdt nhiSu so vdi sau dat may vd khdc biet nay cd y nghia thing ke vdi p <0,001.

Bang 7. Cdi thien trieu chiing sau dgt may TNTT trong nghiSn ciiu

Roi loan y thurc Ngat Cai thien trieu chiing

Trudc dat may n{l)

33 37

Ty le (%)

Sau dat mdy n(2) 64,7 1 4 72,5 1 0

Tyle(%) 7,8

0 37/40 (92,5%)

p(l)&(2)

<0,001

<0,001 Nhdm benh nhdn cd rdi logn y thiic vd nhdm benh nhdn cd ngat trudc dat may cao hon so vdi sau dgt mdy va khdc biet ndy cd y nghia thdng ke vdi p <0,001.

Bang 8. Tu vong sau ddt mdy TNTT trong nghiSn ciiu Dac diSm

Tit vong

Phan nhdm Tii vong that bgi tao nhjp Tu vong do b^nh

lynen

Nguyen nhan tim mgch Nguyen nhan khac Tdng

n 1 8 4 13

Tyle(%) 2 15,7

7,8 25,5 Nhdm benh nhan tii vong kem tgo nhip khdng hieu qud chi 2%. Tii vong do benh ly nSn chiSm ti IS cao 12 trudng hgp trong dd nguySn nhdn tim mach chien 15,7%.

Bang 9. Tu vong trong nghien ciiu STT

1 2 3 4

B^nh canh chung

Nhip cham QT dai, nhanh that da dgng, rung that, viem phoi nang suy hd hap nang.

Suy tim iV nhdi mau ca tim cap khong ST chenh len ngay 2, ngimg xoang nhip thoat thdt chdm, phii phoi cdp tut huyit dp keo dai.

Viem CO tim, vo tam thu sau diiu trj nhanh thdt mng thdt.

Nhdi mdu co tim thanh duoi block AV dp III, dai thao dudng type 2, choang tim tut huyit dp keo ddi.

Tii vong Suy ho hap nang Choang tim, tut huyet dp Vd tam thu Choang tim, tgt huyet ap

T»P CHI Y Dl/QC HOC CAN THg - s 6 11-12/2018 STT

5 6 7 8 9 10 11

12

13

Benh canh chung

Suy tun 111 benh tim thilu mau cue bg, suy niit xoang nhjp thoat bd ndi cham tyt huyit dp, dai thao dudng type 2, xuat huyet giam tiiu ciu vo can.

Choang tim suy tim III benh tim thilu mdu cue bg, b$nh mach vanh CABG, ngimg xoang nhip thoat that c h ^ , xa gan child C.

Nhdi mau ca tim trudc rgng killip IV ngay 1, ngimg tim tai dien, rung thdt.

Nhoi mdu ca tim trudc rOng killip IV ngay 1 block AV dp III, nhip thoat thdt ch^m

Nhoi mau ca tim khong ST chenh len, suy tim 111, dai thao duong type 2 nhjp chgm xoang tut huyit dp, choang tim.

Viem phoi nang suy ho hap, suy tim lU, thieu mau eye bp ca tim, block AV cao do, nhip thoat that cham tut huyet dp.

Nhoi mau ca tim type 2, ngimg xoang nhjp thoat bg nii chgm, viem phoi, COPD nhom III, suy thin man

Nhli mau ca tim thanh dudi killip 111, nhjp bg noi chgm, dai thao dudng type 2, suy than man, choang tim suy da ca quan

Nhoi mau ca tim thanh hoanh that phai gid thii 17 killip IV, ngimg xoang keo dai, suy th|n mgn, xa gan child C xuat huyet tieu hoa, dai thao dudng type 2

Tii vong Chodng tim tyt huyet ap.

Chodng tim, tyt huyet ap Choang tim, tut huyet ap Choang tim, tut huyet ap Chodng tim, tyt huyit ap Suy hd hap/

viem phii ngng Suy ho hip, tut huyet ap keo dai

Suy da ca quan, choang tim, tut huyet dp k^o ddi.

Hon me gan, xuat huyet tieu hda B^nh nhdn tu: vong do benh 1^ nen phiic tgp nhieu benh ly qua nang kem theo, tao nhip tgm thdi chi giai quyet dugc tinh trgng nhip cham.

3.2.2. Cdc bien chung sau dgt mdy tgo nhip Bdng 10. Cac dang biin chiing trong mau nghiSn ciiu Bien chiing

Slit day di$n cue

Roi loan nhip trong va sau khi d^t Nhiem khuan tai cho Tran khi mang phoi Ting

n (50BN) 1 4 0 0 5

2%

%

8%

0%

0%

10%

Cd 8% cd rdi loan nhip trong liic ludn diSn cue va 1 trudng hgp bong day dien cue, 1 trudng hgp do benh nhdn ty nit day (dd hdi phuc, may da tdt).

IV. Ban ludn

4.1. Dgc diem ky thugt trong DMTNTT 4.1.1. Dirafng vdo vd dgng cu hu&ng ddn

Da s l cdc tiirdng hgp bdo cdo DMTNTT di vdo qua TMCT dl ludn dien cue vi dudng tilp can nay diSn cue vao tiidt phai de ddng ban, dgc biet khi khdng cd su hudng dan cua XQ tdng sdng [3],[24], ngoai ra cdn nhilu vi tri tilp cgn d l dua dien cue vdo thit phdi nhu TMDD, tinh mgch diii. Tuy nhien vdi moi vi tri tilp cgn se cd nhflng nguy co bien chiing khac nhau. Quyet dinh chgn dudng tinh mach nao d l tgo nhip can xem xet tinh cdp ciiu ban ddu, kha ndng dn dinh ciia ddu di|n cue va dung cy hudng dan nao (sieu dm tim 2D, XQ tang sang) hay dat "md" xdc dinh bdng DTD. iTu tien theo thii ty; TMCT

TAP CHI Y D i r g e HQC CAN THQ - SO 11-12/2018

phai, TMDD phdi, TMCT trdi, TMDD trdi, tiiih mach diii phai,...(tinh mach dui dS gdy thuyen tdc, nhiSm trimg,...) [2].

Hien nay ddi vdi DMTNTT qua dudng tinh mgch khi luon dien cue vao budng tim can cd hudng ddn cua XQ tang sang hogc DTD trong budng tim, hoac qua hudng din ciia siSu dm tim 2D de chgn dugc vi tri dau dien cue thich hgp. Trong khi tiSn hanh ludn day phdi cd 1 mdy pha rung ludn ludn sdn sang trong thao tdc di chuySn ddy dien cue [2]. Khi ludn day dien cue XQ tang sdng la tieu chudn vang d l thuc hien nhung can nhilu thai gian dS chuan bi vd khdng thS dat tai giudng khi cdp curu. Rieng dudi hudng ddn ciia monitoring hay sieu dm thi ca ddng hon cd thi thyc hien tai giudng benh. Tuy nhien d l thyc hien ky thugt nay tai giudng thi phdi dugc tap hudn ddy du ky thugt [3],[4],[33].

4.1,2. Kieu dgt may

Kieu tao nhip trong tgo nhip tgm thdi cap ciiu thudng la W I (tgo nhip budn^ thdt, nhan cam buong that, ddp iing ddi vdi nhan cam kiSu itc chS bdi QRS ndi tai) ddi vdi trudng hgp can phdu thugt cd dimg dao dien thi tgo nhip kilu VOO (chi kich thich budng that vd khdng c6 nhgn cdm de tranh may nhdn cdm nhdm ddng di?n tir dao dien). Trong ddt mdy tgo nhip ngudng tao nhip ly tuong d nhi khodng 1,5 V va d thdt khoang 1,0V d do rdng cua xung la 0,5 ms [2].

Tat ca cac trudng hgp DMTNTT qua tinh mgch cua chiing tdi dIu tgo nhip kilu W I (82,4%) vi hdu hSt benh nhdn dSu hi block nhi that, nhip chgm xoang vd suy niit xoang. Chi cd 17,6 % chiing tdi chgn VOO vi b?nh nhan cd nhanh that rung thdt do nhip ch$m hogc QT dai gay logn nhip. Da sd benh nhan dat may tgo nhip tgi giudng benh nhd hudng dan cua sieu am tim 2D chiing tdi da thanh cdng (j 98% benh nhan vdi ngudng kich thich thdt cd hieu qud la 0,94 ± 0.4V, thdp han miic 2V chirng td vi tri kich tgo nhip rat tdt.

Duy nhdt 1 trudng hgp vdi tinh trang benh nhdn viSm ca tim, ngimg tim sau shock dien diiu tri nhanh thdt, tim khdng ddp feig vdi kich thich cua mdy tao nhip (dau dien cue da tilp xiic vdi thanh thdt phdi thdy tren sieu dm tim 2D, vd tim nhilu vi tri khdc nhau nhung khdng tao dugc khu cue tim). Cac tdc gid khdc ghi nhdn ket qua deu cao ban so vdi chiing tdi nhu: Mai Phgm Trung Hilu va cgng su, tgo nhip 6 trudng hgp cd ngudng kich thich

<3V[1], Bostan OM va cdng su [5] cung cd kSt qua tuong ty (3,1±1,3 V).

4.2. Ket qua sau d^t mdy tao nhip tam thdi 4.2.1 Kit qud sau dgt mdy

Trong 51 ca dat may tgo nhip tgm thdi qua dudng tinh mgch, 50 (98%) ddt thdnh cdng, mdy dan tit, nguong kich thich <2V trong thdi gian trung binh 29.92 ± 12,46 phiit, ti IS thanh cdng nay la khd cao khi so sanh vdi cdc nghiSn ciiu khdc [1],[7],[8] ca biSt cd trudng hgp nghiSn ciiu cua Austin vd cgng sy [4] ti IS thanh cdng tao nhip khd thip 63%, thdt bai khdng tao nhip tit 37%, phdi dat lai 13 ldn (37%). Thdi gian chuan hi va thdi gian dat mdy keo ddi hem so vdi cac nghiSn cim khac [1],[7],[8] la do mdy siSu dm tim khdng cd sdn tai cho, phdi lien h? d l mugn may. Dac diim v l mat huyet ddn^ khi tao nhip tim da dugc cdc nhd lam sang va cac nhd sdn xudt may tao nhip chii y vdo ddu thgp niSn 60, sau khi ghi nhan tir mgt sd thii nghiSm cho thdy nhftng phuang thiic tao nhip khdc nhau se dan dSn hieu qua tren huyet dgng khac nhau [11].

Trong nghien cim cua chiing tdi sau dat mdy huySt dp tdm thu trung binh cai thien tii 96,37±37,63mmHg leri 112,84±25,53 mmHg, nhip tim tiimg bmh 34,60 ± 8,67lln/phut tang ISn 75,80 ± 11,62 Idn/phiit vd cd hai sy khac biet ndy cd y nghia thdng ke vdi i)<

0,001. Tinh trgng roi loan huyit ddng (huyit dp tam thu < 90mmHg) cimg cai thiSn din 89

TAP CHi Y Dirge HQC CAN THO - SO 11-12/2018

90,9% (20/22 trudng hgp), ttieu chiing ngdt va/ hodc rdi loan y thiic cdi tiiien ngay sau ddt may (92,5%). Nhu vdy vdi viec DMTNTT cd vai trd quan trgng trong viec ho trg cdc thudc van mgch d l cdi thien rdi loan huyet dgng do nhip ch§m. Tuy nhien cd 2 cas (9,1%) vdi tinh trang benh nen ndng ne vdn rdi loan huyet dgng keo dai dii may tao nhip dd dan nhip, tan sd tim da cai thien, b^nh nhan khong gidm dugc cdc thuoc van mach dang dimg vd benh nhan van tii vong sau dd vi choang tim tut huyit dp keo ddi.

Thu thuat DMTNTT thanh cdng nhung benh nhan van tir vong trong benh cdnh bSnh 1^ nln nang n l khdng thi gidi quySt la khd trdnh khdi, Jowett [6], troi^ nghiSn ciiu cua chiing tdi cd 12/51 benh nhdn tit vong mdc dii tao nhip da thdnh cdng va nhip tim tang diing tdn sd cdi dgt. Trong dd 8/51 benh nhdn tir vong do nguyen nhan tryc tilp tir tim nhu; suy tim sau nhdi mdu ca tim dien rdng, tut huyet dp keo dai dan den suy da ca quan... va cd 4/51 benh nhdn tu vong trong benh cdnh suy hd hdp nang do viSm phdi benh vien, nhiem khuan huyit nang truac dd, hdn me gan xo gan xudt huyit tiSu hda...

Trong s l 50/51 benh nhan dugc tgo nhip thanh cdng, 37/51 benh nhan dugc cim song cd 20/51 trudng hgp (39,2%) ty phuc hdi, 17/51 trudng hgp (33,3%) khdng hdi phuc phai dat mdy tgo nhip vinh vien. Benh nhdn ciia chiing tdi cd thai gian luu mdy tao nhip trung buih Id 4,08 ngay, thdp nhdt 1 ngay, cao nhat 12 ngdy.Tdt cd cdc trudng hgp phuc hdi dSu xdy ra sdm trong vdng 6 ngay sau dat mdy, c6 1 trudng hgp xudt hiSn lgi nhip cham sau khi dd hoi phuc phai chuyen di dat may tao nhip vinh vien.

4.2.2, Biin chiing

Biin chiing DMTNTT qua tinh mach lien quan den dudng vao, thao tdc ddy di^n eye vd sy duy tri di$n eye trong mgch mdu. Trong nhung bdo cao ldn ty le bien chiing thudng la 0% ddi vdi tgo nhip du phdng thyc hien tgi phdng md cd XQ tang sang va 20%

trong cac don vi cham soc mgch vanh. Bien chiing thudng gap nhdt la dudng vao d canh tay va ben. Chan thuang ddng mgch, thuyen tac khi hoac tran mau, trdn khi trung thdt, phdi cd thi gap trong 1-2%. Chay mdu cd y nghia xdy ra trong 4%. Jowett nhdn xet c6 32/162 trudng hgp cd biSn chiing xdy ra trong liic dat mdy tao nhip [6]. Mdt trong nhihig biSn chiing thudng ggp nhdt Id loan nhip thdt, nhip nhanh thdt hodc rung thdt (20%). Trong nghiSn ciiu cua chung tdi cd 4 ca (8%) nhanh thdt trong liic ludn dien eye vdo that, phdi shock dien chuyen nhip 2 ca, 1 ca hi siit day dien cue va 1 benh nhan lii lan tudi gid ty nit day khi benh nhdn dd hoi phyc nhip xoang (mdy tgo nhip d l d chi do off theo ddi). RiSng 1 ca Slit ddy diSn eye trong liic chuyen benh di dgt mdy tgo nhip vinh vien, may mdn benh nhan khdng le thudc may tao nhip, van cdn nhip tu thdt chdm khi mdy tao nhip tam thdi mat dan. Benh nhdn dugc chinh lgi ddy tgo nhjp tgm thdi va dat mdy tgo nhip vTnh vien ngay sau do. Cdc bien chirng khdc nhu tran khi, tran mdu mdng phdi, trung thdt, thuyen tdc phdi, kich thich co hoanh, nhiem triing... chiing tdi chua g§p phdi.

Theo Austin vd cOng su [4] logn nhip thit trong liic dat mdy khodng 6%. Theo Lumia vd cdng sy [8] ti le nhip nhanh tiiat la 14/128 ca (8.4%) ti-ong dd 9/142 (6.3%) cabi rung thdt.Trong cdc trudng hgp ddt mdy tgo nhip tam thdi cua chiing tdi, cd 4/50 (8%) ca hi nhanh that khi dua diSn eye vdo thit phai. Nhu vdy khi so sdnh vdi cdc tdc gia khdc, ti 1$ logn nhjp ciia chiing tdi khi DMTNTT qua dudng tinh mgch cd thdp ban d 1 s l bdo cdo diing nhieu logi dien cue khdc nhau. Diiu nay cd thi do chiing tdi diing dien cue loai cd bdng d dau. Theo Lang R va cgng su [7] nlu dimg dien eye cd bdng d dau khi DMTNTT khdng cd hudng dan ciia XQ thi ti le rli logn nhip nguy hiSm se it ham nhilu so vdi loai dien cue thdng thudng (1.5% so vdi 20.4%). BiSn chirng siit ddy dien eye sau ddt mdy ciing khdc nhau d cac nhdm tdc gid khdc nhau, tiiy thudc vdo ky thu^t vd kinh nghiem ciia 90

TAP CHI Y DITQC HQC CAN THg - SO 11-12/2018

ngudi dgt may. Trong nghien ciiu ciia chung tdi cd 1/51 chiSm (2%) trudng hgp siit ddy dien cue voi bieu hien mdt dan timg liic vd thay ddi vi tri ddu dien cue so vdi trudc dd khi chiSu dudi man tang sdng.

4.2.3. Hiiu qud

Da cd nhilu nghiSn cim vdi nhilu dudng tilp can va nhieu thiSt bi hudng ddn nhu:

Rosenberg vd cgng sy [9J, Weinstein vd c^ng sy [12], Lumia & Rios [8], Lang va cgng sy [7], Autin vd cgng su [4],... Viec dat mdy tgo nhip tgi giudng qua dudng tinh mach da dugc nhiSu tdc gia bao cdo. Nam 1964, Volgel va cgng sy [10] md ta ddu tiSn ky thudt ddt may tgo nhip qua dudng tinh mgch khdng cd hudng ddn cua XQ. Sau 1 nam Kimball va Killip dp dung ky thuat nay vd thdnh cdng, chi cd 20% cdc trudng hgp gap khd khdn. Theo Rosenberg AS vd cdng su [9] 80% cdc trudng hgp DMTNTT qua dudng tinh mgch thanh cdng nSu chi cd hudng ddn ciia DTD, trong do 72% cdc trudng hgp thanh cdng trong trung binh 18 phiit, 30% thdnh cong trong 5 phiit nSu khdng cd hudng ddn cua XQ.

Do thdnh cdng cua phuang phap tao nhip khdng cd hudng ddn ciia man XQ tdng sang phu thudc nhieu vao kinh nghiSm va hudng din cua DTD vd siSu dm tim 2D [2]. Vdi dieu kien hien tai nhd su hudng ddn cua DTD, sieu dm tim 2D liSn tuc trong thdi gian ludn dien eye, chiing tdi thyc hien thu thult ngay tgi giudng benh vdi ty IS thdnh cdng cao 50/51 trudng hgp (98%) tuang ty cdc nghien cihi khdc nhu: Bostan OM va cdng sy [5].

Cu thS vdi 51 benh nhdn chiing tdi thyc hien dgt mdy 45 truang hgp qua hudng ddn cua sieu am tim 2D liic lam thu thuat, so sanh vdi cdc n ^ e n ciiu khdc thdnh cdng cua thu thuat cua chiing tdi Id 97,7% (44/45 benh nhan), cao ban so vdi tac gid Rosenberg vd Dd NguySn Tin (vdi ty IS thdnh cdng Id 72% vd 85,7%). Ty IS thanh cdng trong nghien ciiu cua chiing tdi vcri hudng dan bdng sieu dn tim 2D so vdi hudng dan ciia XQ tang sdng cua Weinstein [12] tuong duong nhau. Diiu nay cd y nghia rdt quan trgng trong thyc hdnh cdp ciiu loan nhip chdm nguy hiem khi ca sd y te khdng trang bi du cdc phuong tien XQ tang sang hogc tinh trgng b?nh nhdn ndng can ldm thu thugt ngay. Tuy nhiSn, cac trudng hgp tinh trgng qua ngng, rli logn huyit ddng k^o dai, ti le tir vong cdn cao.

V. KET LUAN

Qua nghien ciiu d 51 benh nhan rli logn nhip cham dang dieu tri bdng ky thu^t dat mdy tao nhip tam thdi, chiing tdi ghi nhan:

5.1. Danh gia cac d^c diem vl 1^ thuat dat may

- v l ky thuat: ty le thdnh cdng cua thii thu|t l^i 98% vdi ngudng kich thich c6 ddn nhip In dinh la 0,94 ± 0.44V, thdi gian ludn dien eye tim vi tri din nhip tdt la 29.92 ± 12,46phiit.

- VS biin chiing trong qud trmh thyc hien thu thu|it: biSn chiing chung d miic 8%;

trong do rli logn nhip keo dai phai dieu tri khi ludn dien eye Id 3,9%, siit ddy dien cue trong thdi gian luu may tao nhip la 2%.

5.2. Hieu qua dat may tgo nhip tgm thM - T } I? thdnh cdng la 98%.

- Tiianh cdng cua thu thugt thdng qua hudng ddn cua sieu am tim 2D; 97,7%.

- Cdi tiiien huyit ddng: 90,9%.

- Cdi thien trieu chimg: 92,5%.

- Benh nhan dugc ciiu sdng: 72,5%. Trong sd dd cd 39,2% ty hdi phuc het nhip cham, khdng cin dgt mdy tgo nhip vtnh viln.

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TAP CHI Y Dl/QC HQC CAN THO - S6 11-12/2018 TAI LIEU T H A M K H A O

1. Mai Pham Trung Hieu, Le Thi Huynh Mai (2008) "Kinh nghiem ddt mdy tgo nhjp tgm thdi qua du&ng tinh mgch v&i ddy diin cue cd bong tgi binh viin tim mach An Giang". Tim Mach Hgc, 28 (8), tr 6.

2. Trdn Van Huy, Tran 06 Trinh (1997) Roi logn nhip cham tir b?nh hgc din diiu tri cdp ciiu va lau dai, NXB YHgc, TP H6 Chi Minh.

3. Adam Fitzpatt-ick, Richard Sutton (1992) A guide to temporary pacing, BMI, 22, p 09-11.

4. Austin JL, Preis LK, Crampton RS, et al (1982) "Analysisof pacemaker malfiinction and compiicationsoftemporary pacing in the coronary care unit".^mJ'Car</io/, 49, p301- 306.

5. Bostan OM (2002) "Dual chamber cardiac pacing in children: Single chamber pacing dual chamber sensing cardiac pacemaker or dual chamber pacing and sensing cardiac pacemaker". Pediatr Int, 44 (4), 635.

6. Jowett NI, DR Thompson and J.E.F.Pohl (1989) "Temporary transvenous cardiac pacing:

6 years experience in one coronary care unit". Postgraduate MedicalJournal, p 65.

7. David D Lang R, Herman HO, et al (1983) "The use of the balloon-tipped floating catheter in temporary transvenous cardiac pacing". PACE, 4, p 491.

8. Rios JC Lumia FJ (1973) "Temporary transvenous pacemaker therapy: An analysis of complications". Chest 64, p 604.

9. Grossman JI Rosenberg AS, Escher DJW, et al (1969) "Bedside transvenous cardiac pa.cing".Am Heart Jn,p 697.

10. Tabari K Vogel JHK, Averill KH, et al (1964) "A simple technique for identifying P waves in complex arrhythmias. ". Am Heart J 67 p 158.

11. Wienecke MM (\995) Hemodynamics of cardiac pacing". Pediatric cardiac pacing, Futura Publishmg,NYUSA

12. Z. Weinstein, J. Gnoj, J. T. Mazzara, S. M. Ayres, W. J. Grace (1973) "Temporary transvenous pacing via the percutaneous femoral vein approach. A prospective study of 100 cases". Am Heart J, 85 (5), p 695-705.

(Ngdynhdnbdi: 11/11/2017-Ngdy duyet ddng: 08/01/2018)

NGHIEN CUtJ GIA T R | CUA D I E N T A M D 6 G A N G SlTC T R O N G C H A N DOAN BENH M ^ C H V A N H 6 BENH N H A N D A U N G ^ C T f 40 T U 6 l

TROf L E N

Dgng Li Trang Thanh ' * Trin ViitAn\

1. BVDK Trung ucmg Can Tha 2. Tru&ng Dgi hoc Y Dugc Cdn Tha

*Email: trangthanhbaby@gmail. com TOM T A T

Bgt van di: Binh mgch vanh Id b^nh ly lim mgch thu&ng ggp v&i triiu chung chii yiu la dau thdt nggc va tieu chudn "vdng" la chup dgng mgch vanh. Di^n tdm do gang sdc la mgt phuang phdp chdn dodn cd dd nhgy, dg ddc hi^u dao dgng, m&i dugc triin khai tgi Binh viin Dgi hgc Y Dugc Can Tha. Mgc tiiu nghiin ciru: Nghien cuu gid tri cua dien tdm dd gdng site trong chdn dodn benh mgch vanh. Bii tuffng vd Phutmg phdp nghiin cuu: Nghien cuu md td cdt ngang, tien cdu 40 binh nhdn dau nguc tir 40 tudi tr& lin dugc chi djnh diin tdm dd gdng sue vd chup dgng mgch vanh tgi B4nh viin Dgi hge Y Dugc Can Tha tit thdng 7/2015 din thdng 7/2017.

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