TCYHTH&B s6 2-2014 61
DIEU TR! THANH CONG BENH NHAN NHI
BONG 56% DIEN TICH CO THE (53% DIEN TICH BONG SAU), BIEN CHUfNG SOC NHUOC, NHIEM KHUAN HUYET
Nguyin Hai An, Trdn Dinh HiJng, Ngo TuIn Hvng Khoa Hdi sOc cip cOu- Vi$n Bdng Li HOu Trie
I.OiBhTVAND^
£)ilu trj bdnh nhdn t>dng didn r$ng, dd sdu Idn ludn Id thdch thirc trong dieu trj, dde bidt dli vdi bdnh nhdn bdng nhi, bdng idn hon 15% didn tich cc t h l tidn luong rit ndng, t^ fd tu" vong edn rit cao vdi cdc biln chirng ndng nl: soc bdng, nhiem khuin huylt (Blood Stream Infection), s6c nhilm khuin (Septic Shock), suy da tgng (Multiple Organ Failure - MOF), suy thdn. Soc bdng, nhilm khuin huylt Id nhOng biln chirng ndng n l nhit vd Id nhij'ng nguydn nhdn hdng dau gdy tu vong sau bdng d trd em. Didn tich bdng sdu ldn, Idm s6c bong ngdy cdng ndng, tdng nguy co nhilm khuin huylt trong giai dogn nhilm khuin nhilm ddc. Tuy nhidn, vdi nhO'ng tiln bd trong hli sirc djch thl, lidu phdp khdng sinh thieh hop, cit hogi tir sdm, ghdp da che phu vlt bdng, nudi dudng tich cyc dudng lidu hda k l l hop dudng tlnh mgch,,, dd gdp phin cii'u s6ng nhilu ca bdng nhi cd didn lich bdng sdu ldn hon 50% didn tich CO thl. Trong bdo cdo ndy chiing ldi xin gidi thidu mdt bdnh nhdn nhi bdng ndng vdi didn tich bdng 56% (53% didn tich bdng sdu), sic nhuoc ndng, nhilm khuin huylt &\s<?c dilu tri thdnh cdng.
2.Gl6lTHI$UB$NHNHAN
Bdnh nhdn: Phung Thj Huyin Tr., 6 tuli, s l bdnh dn 0005- VB- 3401.
Qud qudn: Vidt Ydn - Bdc Giang.
Tdm tit qud trinh bdnh si> vd dien biln qud trinh dilu trj: Bdnh nhdn bi bdng Ida Duyit bii: TS. Chu Anh Tuin
ngdy 03/12/2013. Sau bdng duoe so cdu tgi bdnh vidn da khoa tinh Bic Giang, tgi ddy duoe truyen dieh (200 ml ringeriaetat), giam dau, bdng bd. Chuyen Vidn Bdng Quoc gia sau 3 gid trong llnh trgng soc nhuoc ndng: li bi, mdi tdi, da nidm mgc nhot, ehi Ignh, thdn nhidt 36,2 dd C. Ty thd tin so 26 lln/phiit, Sp02: 99%. Mgch nhanh 170 lln/phOl, huylt dp 70/45 mmHg, chua bdi nidu tir luc bf bong, ddl sonde lieu khdng cd nudc tilu trong bdng quang. Tgi chl: ton thuong bdng 56% didn tich CO thl, trong dd cd 53% didn tich bong sdu d thdn, chi. Cdc xdt nghidm khi vdo vidn: hlng clu 5,81 T/l; huylt sdc t l 113 g/l; hematocrit 0,347 l/I; albumin 23g/l;
glucose 19,8 mmol/l; khi mdu nhilm toan ehuyin hda (pH 7,26; HCO3" 15,3 mmol/l;
BE-10,8 mmol/l); lactate: 4 mmol/l; kali 2,6 mmol/l; canxi 0,42 mmol/l. Cdc chT s6 khdc trong gidi hgn.
Bdnh nhdn duoc hii sCre tieh circ theo phdc d i ching sic: ii Im, thd oxy h i tro, Iruyen djeh ringerlactat, Iruyen djch keo, Iruyin huylt tuong (12 gid sau bdng), gidm dau, tro tim mgeh, khdng sinh lodn thdn. nudi dudng tieh cyc (nudi dudng sdm dudng tidu hdg). Sau 48 gid dilu trj tich cyc, cdc chl s l huylt ddng tam i n djnh, nude tilu duy trl 50 ml/gid. Cde ngdy tilp theo, todn thdn: dilu trj theo phdc do dy phdng nhidm khuin, ndng cao the trgng, dy phdng lodt dudng tidu hda,... Tgi cho: thay bdng, dip thulc silver- sulfadiazin 1% hdng ngdy,
Ngdy thir 3 (N3): phlu thudt cdt hogi ti>
sdm ghdp da ding logi, dj logi che phu vlt thuang (didn tich 13%). Sgu phlu thu$t diln biln Idm sdng tgm on djnh. cdc ch? s6 huylt ddng trong gidi hgn eho phdp.
62
Ngdy thCr 7(N7), elt hogi tCr Iln 2 (dign tich 5%), ghdp da ty thdn kieu tern thu 11%.
Vimg lung da ddng logi cdn bdm song. Sau mi, llnh tdo, thdn nhidt 37°5- 38°C, huyet ddng trong gidi han.
Ngdy thir 13, tgi eh5 edn 22% hogi lu khd, 25% md hat (da ty thdn dd ghdp Iln 1 chi bdm song 6%, da dong logi ghdp Iln 1 dd bong) Phdu thudt cdt hoai tu 11%, ghep da di loai che phu (Iln 2); ghep da ty thdn kilu tern thu 11% ldn md hgt. Sau mo ffnh, mdt, ede chi so huylt ddng trong gldi han cho phdp.
Ngdy thu 14: bdnh nhdn didn biln ndng, bilu hien birl rut khd chju, ndi sang nhieu, sdt cao nhieu can > 39 dd C, ha nhigt chdm, loan thdn phii nl, hd hip vd huylt dgng trong gidi hgn. Tai chl vet thuong; da ghdp nhot nhgt, nln tilt djeh nhieu, phin hogi lu ehua duoc ell bo chuyen hogi 10* udt, bd mdp vet ttiuong xung huylt mgnh, ely mu v l l thuang moc tn,rc khuan mO xanh vd tg edu vdng. Xet nghigm bgch cau ldng rat eao 33,7 G/l (xu hudng tdng tir N12), Cay mdu (lan 1, N14), dimg khdng sinh (vancomycin) theo hudng
nhidm khuin huylt tg elu vdng. Sau dimg khdng sinh 3 ngdy, didn bien lam sdng tot din idn: tinh tao, lilp xde tot, sit dao ddng 37,5-38 dd C, hd hap, huylt ddng trorig gidi hgn, tgi chd da ty thdn vd ding logi edn bdm sing, nen tilt it dich. Cay mdu Iln 2 ngdy thd 17.
Ngdy IhCr 20 (sau 6 ngdy dii khdng sinh), Todn thdn tinh tdo, hit sol, huydt^dng i n dmh. Tgi chd hogi tii' edn lai (11%) ehuyin khd, phdu thudt o i l hoai tif ghdp da tern thu 11%. N21, cd kit qua cly khuan mdu Iln 1:
nhidm khuin huyet K, pneumo/j/a, nhgy, cdm vdi Colistin. N23, cd kit qua cly.mdu lan 2:
dm tinh. Do dien bidn lam sdng thudn lyl, van tiep, tyc sir dyng. vaticomycin dot 14,ngdyf Bdnh nhan on djnh, chuyen khoa Phg? Hoi chirc ndng sau 55 ngdy dieultn tgi ICU (sau 9 lan phdu thudt).
Kit qua dieu In: Bdnh nhdn nlm dilu trj lgi khoa hoi sdc cap ciru 55 ngdy, ton thudng bdng khdi hodn todn, ting kinh phi, dieu trj 269.000.000 ding (bao hilm tra 193.000.000).
Ting luong huyel tuang da truyin 6500fiil, khii hing clu 5250ml. Thdi gian dimg khdng sinh dudng tTnh maeh 53 ngdy.
Bdng 1: Thdi diem, phucng phdp phlu thugt vd vj tri ldy da Ldn phiu thu|t
Lani Lan 2 Lan 3
Lan 4
Lan 5 Lan 6 Lan?
Lan 8 Lan 9
Ngdy phdu thu|it N3 N7 N13
N20
N24 N28 N35 N42 N48
Phuvng phap phlu thugt Cat hogi ti> todn I6p 13%
Gh^p da dong logi 8%, ghep d| lo^i 5%
Cat hogi ILP todn lap 5%
Gliepdati,Fthan 13%
Cat hoai ti> toan ldp 11 % Ghdpdatythan11%
clil hogi tir todn lap 11 %
Ghep da ly Itian 11%. ghep da dong logi 5%
Gti6pdati,i'than11%
Ghep da tuthan 11%
Ghepda ty than 11%
Ghep da ty than 11%
Gli6pdaty than7%
Vjtn'ldyda
Mgt ngodi 2 cang chdn Diu Mgt ngodi 2 cdnh lay M$t ngodi cSng chdn trdi
-t- 2 mu chdn Da diiu M$t ngodi 2 cing chdn
Da d i g •r' Mdt ngodi 2 cdnh tay
TCYHTH&B so 2 - 2014 63
S6 l^n phdi liy l^i da gh6p: da dau, m$t Tdn thuong bong sdu diroc che phu ngodi cing chan trdi; 3 iin; m^t ngodi d n g hodn toan sau 9 lan phliu thudt cdt hoai tir.
chdn phdi, mdt ngodi 2 cdnh tay: 2 lan, hai ghdp da tv thdn kieu tern thir (bdng 1).
mu chdn: 1 ldn.
Sau 3 lin liy da dau
3. BAN LUAN
Oieu trj bdnh nhdn bdng sdu didn tich rdng ludn Id thdch thire Idn trong dieu tii bdng ea giai doan sic bdng vd giai dogn nhidm khuan, nhilm dOc.
3.1. Dilu tri giai dogn sdc bong Trong giai dogn sic bdng, vin de ddt ra Id hii sirc djch the. Nhilu nghidn edu trdn thyc nghidm vd Idm sdng cho thiy, truyin djeh keo trong 12h diu sau bong cd hidu qua rit il vd cd t h l Idm tdng luyng nude trong phoi vd gdy ra cdc bien ehdng [9] [10].
Demling ehung minh ring phii n l dgt l i i da vdo gid Ihir 8- 12 sau bdng vd khdng phg thudc vdo loai djch duoc truyin [10]. Do vgy, djch keo duyc khuyin cdo ndn Iruyin sau 12h sau bdng.
Trdn bdnh nhdn, ting luyng dieh trong 24 gid diu Id 7000ml (5 ml/kg/%DTB) bao gim: ringerlactat, dich keo vd huylt tuong Iruyen sau 12h (gom: 1000ml Gelofusine 4%
vd 1000ml huyel tuang), thuic try tim:
Dobulamin lilu 8mcg/kg/phuL 12 gid diu truyin djch tinh thl, huylt dp dOng maeh chua on dinh (60-70/25-30 mmHg), so luong nudc tilu 0,3ml/kg/gid. Gid 15, sau truyin Gelofusine huyet dp on djnh d mO'c 95- 100/50-55 mmHg. Huyet dp i n djnh din sau dd Theo cdng thO-c Parland d Ire em, tong luong djeh trong 24 gid dau Id 4ml/kg/%DTB, tuy nhidn, luyng djch chiing ldl dieu trj Id 5ml/kg/%DTB mdi duy trl duoc huylt dp i n djnh, dam bao luyng nudc lieu 2ml/kg/gid.
Bdnh nhdn thodt sic on djnh sau 48 gid.
Luyng djch d bgnh nhdn ndy cao hon so vdi cdng thirc Parland cd t h l do bdnh nhdn cd didn bdng sdu Idn, iuong djch thodt ra gian bdo cQng ldn han. Nhu vdy, khi bgnh nhdn den vidn sdm Irong 6 gid dau. duyc hii sirc d]ch the day du, chiln thugt Iruyen dieh phii hyp se gdp phan ldm i n dmh ve huylt ddng, bgnh nhdn sdm thodt sic, gdp phan hgn che cdc biln chirng d giai doan sau
3.2. Didu trj giai do^n nhilm khuin, nhilm d$c
Trong giai dogn nhiem khuan, nhiem ddc bdng, nhilm khuin huyet Id mdt trong nhung biln chd'ng thudng gdp do cd nhieu ylu t l thudn lyl eho sy xdm nhdp cua vi sinh vdt tir vet thuang nhu: hidn tuyng suy giim midn djch trong bdng, da m i l chdc ndng bio vd, md hogi tD* Id mdi tm-dng 1;^ tudng cho vi khuan phdt triln, vimg t i n thuong kdm nudi dudng do phii ne, huyel lie, ty dd...[1].
Trdn bgnh nhdn, N14 khi cd tridu chirng Idm sdng vd cdn Idm sdng nghi do nhilm khuin huylt (NKH), d|c bidt, s i luyng bach clu ldng cao. Khi dyt cd kit qua xdt nghigm cly khuin mdu, chiing tdi dd dung Vancomycin sdm lilu 40mg/kg/24h. Sau dimg khdng sinh 3 ngdy theo hudng nhiem khuin huylt tg cau vdng, trigu chdng Idm sdng eai thidn rd: tinh, lilp xiic tit, sit dao ddng 37,5-38 do C, hd hip, huylt ddng trong gidi han, tgi chd da ghdp bdm sing, nln tilt it djeh. Sau 7 ngdy dilu trj Vancomycin, bdnh nhdn hit sot, tinh ldo, tgi cho hogi tii' edn Igi chuyin khd. Tuy nhien, kit qua cly khuin mdu Iln 1 (N14): nhidm khuan huyel K. pneumonia nhgy cam vdi Colistin; kit qua cly mdu Iln 2 (N17): khdng moc vi khuan. Sir dgng Vancomycin sdm khi chua cd k l l qua cly mdu do cdn ed vdo diln bien trdn Idm sdng vd xdt nghigm huylt hoc goi 9 nhiem khuan Gr(+), ding thdi, theo Surviving sepsis campain 2013, cin chu ddng sir dung khdng sinh cdng sdm cdng tot khi cd nghi ngd NKH, dung khdng sinh theo phuong phdp xuong thang khi cd kit qua cay khuin mdu. Sau sii' dgng Vancomycin, didn biln bdnh nhdn cli thi$n ddng k l , do dd, khi ed k i t qua cly mdu Iln 1, vdn tiep tgc lidu trtnh khdng sinh dang dimg, dilu ndy khing djnh rd han d k l l qui cly mdu Iln 2: khdng moc vi khuin. Oilu ndy cd thl do kit qua cly khuin mdu lan 1 chl Id vdng khuin hodc do ky thudt Ily mdu
TCYHTH&B s6 2-2014 65
xdt nghidm chua chuin. Didn biln trdn Idm sdng vd kit qud cly mdu Iln 2 (3 ngdy sau cly fln 1) dm tlnh dd Idm rd han gia thuyit ndy. Do vdy, vide theo ddl sdt dien bien Idm sdng, cdn ldm sdng, chu ddng dieu tn khdng sinh phO hop cdng sdm cdng t i t khi nghi ngd cd nhilm khuin huylt Id ylu l i quan trgng gdp phdn cuu song bdnh nhdn.
3.3. Phau thu$t dieu tii bdng sau Hidu qud cQa ell hogi tir bdng trong 72 gid sau bdng dd duoe nhilu tdc gia de cdp din gim [1] [3]: giSm nhilm dde, nhilm khuin; giam tinh trgng vidm hd thong d bdnh nhdn bdng (giam ning dd cytokine TNFa vd IL-6 huyet thanh, gidm mirc tdng hogt dd GOT vd GPT huylt thanh); hgn ehl mil mdu trong phau thudt...
Trdn bdnh nhdn chiing ldi phlu thudt cdt hogi tCi*, ghdp da dong logi sau 67 gid bj bdng. Sau phlu thudt, giam phii n l rd, giam sit ICr 1-2 dd, Sau cdt hogi tir bong, vide che phO vlt thuang sdm bing da dong loai vd d|
logi Id ylu t i quan trong dem Igi thdnh edng, Trdn bdnh nhdn, chOng tdi dd hai lan ghdp da ding logi, che phii trdn 20% didn bdng sdu.
Ghdp da kilu tern thu cOng gdp phan quan trpng cdu sing bdnh nhdn vl vung cho da didn tich hgn chl trong khi, nln md ghdp cin che phCi rit ring. Lin phlu thudt thd 2, vdi 5% da ghdp Ily lir mdt ngodi hai eing chdn, ChOng ldi dd ghdp cho 13% md hat bdng ghdp da kieu lem thu. Do didn tich vung cho da hgn ehl, nhilu vimg dd phai cho da 3 lan nhu: vOng da diu. vimg mdt ngodi cdng chdn (kit qud bdng 1) Trong thdi gian chd d l lay Igi da ghdp, ehdng tdi dd chu ddng xdy dyng chiln thudt Ily da xen kd gida cdc vitng cho da (vimg da diu vd mdt ngodi hai cdng chdn), kit hop ghdp da tern thu vd che phu tgm thdi bdng dg ding logi vd dj logi. Chien thudt ghdp da, uu tidn ghdp cho vimg dam bdo chdc chin thdnh edng trudc nhu vimg mdt tn/de thdn, mdt trudc ehi thl de sdm thu
hgp dign tich bdng, cai thign tinh trang todn thdn. Nhu vgy, vdi b$nh nhdn bdng sdu didn tich Idn trdn 50% DTCT, d n xdy dyng chien thudt phiu thudt tieh cyc vd hop ly eho ca qud trinh dieu trj nhu: thdi diem phau thudt, didn tfch cdt hogi tu, didn tich ghdp da. vj tri lay da, vi tri ghdp da...
Bgnh nhdn dilu tri lgi Khoa Hii sue d p ciru 55 ngdy, ton thuang bdng sdu duac che phO hodn todn qua 9 lan phdu thudt d t hoai lu, ghep da ty thdn kieu tem thu. Khdng sinh todn thdn vd kit hop nudi dudng sdm dudng tieu hda yd dudng Hnh mgch trong suit qud trinh dilu tri tgi ICU. Ting kinh phi dilu tn 269.000.000 dong. Ting luyng huyet tuang dd Iruyen 6500ml, khii hong d u 5250ml.
Thdi gian dimg khdng sinh dudng tlnh mgch 53 ngdy.
4. KtT LUAN
Oilu tri bdnh nhdn bdng nhi didn ring, dd sdu ldn Id thdch thirc Idn trong dieu tn, ty Id tir vong eao, chi phi didu tn ton kdm do cde bien ehung ndng n l Vi vdy, phai cd chiln thudt dilu trj hyp ly: ehing sic lich eye, chiln thudt sir dyng khdng sinh phu hyp vdi Ciiln bien Idm sdng vd cdn Idm sdng. Kit hop nudi dudng sdm todn Ihdn vd ed chiln thudt phlu thudt cy thl' d t hoai tir sdm (trong 72 gid sau bdng), che phii sdm sau d l hogi tir bdng cae vgt ligu thay the da, cd ke hogch Ily da vaghdpdahyply...
TAI LIEU THAM KHAO
1, Dinh Van Han (2004). Nghien ci>u phau Ihugl ck hogi li> som ghep da ngay Irong 72 gia diu sau bong, Lu$n an tien si, Ha Noi
2 Le The Trung (2003), "Bong v^ nhOng kien thiJc chuyen nganh", Nha xuat bin Y hQC - Thanh ph6 Ho Chi Mmh.
3 Nguyin Nggc Tuan vd CS (2001). Thau Ihudt d t hogi ti> sam. ghep da [\f thin cd cdi tien trong di4u In bong sau", Tgp chi y hQC tfiim hoa ra Wng - Vi$n Bong Quoc gia. (3), Ir 80-83.
66
4. Azzopardi EA., McVifilliams B., Iyer S.. WhJIaker IS.
(2009). "Fluid resuscitation in adults with severe burns al nsk of secondary compartment syndrome - An evidence based systemic review", BURNS.
vol 35. pp. 911-920.
5 Barret JP. (2005). "Initial management and resuscitation", in Principles and practice of bum surgery.pp. 1-32.
6. Blumetli J. Hunt JL, Amoldo BD, Parks JK, Purdue GF. (2008). 'The Parkland formula under fire: is Ihe criticism juslifled?" J Bum Care Res, V0l,29{1), pp. 180-186.
7. Boucher HW, Talbot GH, Bradley JS. Edwards JE, Gilbert D. Rice LB. et al (2009). Bad bugs, no drugs: no ESKAPE! An update from Ihe Infectious Diseases Society of America. Clin Infect Dis; vol 48:1-12
8. Chung KK., Wolf SE., Cancio LC. Et al (2009),
"Resuscitation of severely burned Millilary causuaties: Fluid begets more fluid", J Trauma, vol, 67, pp. 231-237.
9. Heminglon -Gorse SJ. (2005), "Colloid or cryslallokJ for resuscitation of major bums' J Wound Care, vol. 14(6), pp. 256-8.
10. Pham VT., Cancio LC, Gibran NS, (2008),
"/^erican Burn Association Practice Guideline Bum Shock Resuscitation", Joumal of Bum Care and Research, January/February, pp. 257- 267.
11. Rice L (2008), "Fedaral funding for the study of antimicrobial resistance in nosocomial pathogens no ESKAPE". The Joumal of Infectious Diseases;
vol 197:1079-81
