TCYHTH&B so 1 - 2018 17
NGHIEN CUTU DAC DIEM LAM SANG, CAN LAM SANG VA DIEU TR! NGOAI KHOA BONG SAU TREN 10% DIEN TICH Cd THE 6 TRE EM
TA! VIEN BONG QUOC GIA
Hd Thj Xudn H u v n g Vidn Bdng Qude gia TOM T A T
Miic deu: Nghidn cdu d§c diim Idm sdng, e$n Idm sdng vd hidu qud phwang phdp phiu thu$t cit hogi td sdm, ghdp da ngay diiu tri bdng sdu tren 10 - 20% didn tich ca thi (DTCT) a trd em.
Phwang phdp: Nghidn ct>u tiin edu trdn 30 bdnh nhi. tudi tCr 6 thdng din 7 tudi diiu tri ndi trd tgi Vi$n Bdng Qudc gia td thdng 11/2010 din thdng 7/2012 cd didn bdng sdu tyi1% din 20% DTCT.
Kit qua: Hogi td udt cd tf 1$: 96.7%. vi khuSn trdn bi m$t vit thwang chd yiu Id tryc khuin mu xanh (60%) vd ty ciu vdng (23,3%). Tf 1$ sde, didn biin Idm sdng, cdn lam sdng cua thdi ki soc bdng vd nhiSm khuin nhlim dde tdng tf Id thudn vdi dign tich bdng sdu. Tgi vit thwang bdng sdu dwgic phiu thudt cit hogi td sdm, ghdp da ngay: tinh trgng phd ni gidm vd hit sau 1-2 ng^y;
gidm tin suit vd sd Iwc^ng tryc khuin md xanh trong lg md td chdc (tCr 53,3% xudng 23,3% tuang duang vdi 150,12 ± 27,41 xudng 52,88 ± 8,06) cung nhw ty cdu vdng (td 33.3% xudng 16,7%
tuang dwang vdi 148.89 ±24.91 xudng 51,5 ±6,86); gidm cdc tridu chdng thdi kf nhiim ddc nhiem khuin: rdi logn tinh thin td- 83,33% xudng 30%; sdt cao gidm td 100% xudng 30%; rdi logn tidu hda td 56,66% xudng 16.66%. Gidm ndng dg cytokine viem, tdng cdc yiu td miin dich: khi vit bdng sdu dwgc che phd hodn todn thi IL1. IL-6 vd TNF-a gidm vdi P <0.05 vd P <0.01; sau phau thudt sd lining CD4 tdng cdn IgM vd IgG chi tdng khi vit bdng sdu dag/c ghdp da che phu hodn todn vdi P< 0.01.
Tw khda: Bdng sdu; Ddc diim Idm sdng vd cdn Idm sdng; Cit bd hogi tw sdm vd ghdp da ABSTRACT
Aims: To study the clinical, paraclinical features and effectiveness of the early excision and skin graft for deep bums from 10% to 20 % of the total body sudace area (TBSA) in children.
Method: This prospective study was conducted on 30 pediatric patients aged from 6 months to 7 years at the National Institute of Burns from November 2010 to July 2012 who had area deep bums from 11 to 20% TBSA.
Results: Wet necrosis takes up 96.7%. The bactena on the wound surface was main P.
eruginosa (60%) and S. aureus (23.3%). The ratio of shock, clinical and paraclinical course in the period of burn shock and infection cases increased in direct proportion to the area of deep burns Deep bum wounds treated eady excision and skin graff: the edema reduce and go away after 1-2 days; reduction in both the frequency and amount of P. eruginosa in Igram of tissue (from 53.3%
to 23,3%. equivalent to 150.12 ± 27.41 down 52.88 ± 8.06} as well as S. aureus (from 33.30% to Nguuichiu trdch nhi$m chinh: Ho Thj XuSn Huong, Vifln Bdng Quoc gia - Email: [email protected]
18 TCYHTH&B so 1-2018
16.70% equivalent to 148.89 ± 24.91 down 51.5 ± 6.86). The symptoms of bacterial toxicity period reduced: mental disorder (from 83.33% to 30%); high fever (100% - 30%), digestive disorder from 56.66% - 16.66%. Inflammatory cytokine reduced, immune factor increased: when the deep bum wounds are fully covered, IL1, IL-6 and TNF-a (P < 0.05 and P < 0.01). Affer surgery, number of CD4 increased while IgM and IgG only increase with the only increase if the deep bum wound was fully covered with skin graff (P < 0.01).
Key words: Deep burn; Clinical and paraclinical features; Eady excision and skin graft
I.DATVANB£
Ton thuang bdng sdu Id edn nguydn gdy roi logn bflnh ly bdng. Mye dich dieu trj bdng sdu td logi bd hogi t u vd ghdp da t y than ehe kin t i n thuang cdng sdm cdng tit. Tgi Viflt Nam dd cd nhdng nghifln edu ve d l l u tn ngogi khoa tre em bj bdng sdu nhung chua todn difln v l d$c diem Idm sdng, d n Idm sdng cQng nhir hiflu qua eua phau thuflt e l t hoai t d sdm ghdp da ngay bdng sdu difln rflng tren 10% DTCT d tre em. Xuat phat t d thye t l ndy chiing tdi tien hdnh: "Nghien cdu ddc d i l m ldm sdng, c^n ldm sdng vd dieu tri ngogi khoa bdng sdu trdn 10% DTCT d tre em tgi Vifln Bdng QuIc gla° vdi muc tieu.
1. Nghifln cdu ddc diem Idm sdng, cfln Idm sdng bdng sdu t u 1 1 % d i n 20% DTCT d tre em 2. Nghifln edu hiflu qua phuang phdp p h l u thu^t d t hogi t d sdm, ghdp da ngay d i l u trj bdng sdu trdn 10% DTCT d tre em;
2. D 6 I TUX?NG V A PHira^NG PHAP NGHIEN CLTU 2.1. Ddi tuvng nghien c d u
30 bflnh nhi, t u l i t u 6 thdng d i n 7 t u l i dilu trj nfli tru tai hai khoa Bdng Ire em vd Khoa Hll sde cap cdu Vifln Bdng L6 Hdu Trdc t d thdng 11/2010 den thdng 7/2012 cd difln bdng sau td 1 1 % den 20% DTCT, tde nhdn gdy bdng: nhiflt udt, nhiflt khfl; ed s y dong y tham gia nghifln cdu cua ngudi gidm hp hdp phdp 2.2. P h u v n g phdp nghien ciVu
Phuang phdp nghien cdu tien cuu theo ddi dpc cd doi chdng so sdnh.
2.2.1. Sado thiet ke nghien c&u Bflnh nhdn nghifln cdu d u y c phdn bo theo sa d l dudi ddy:
30 BN Bong sau dfl IV DTBS: 11-20% DTCT
Theo doi ldm sdng, cgn lam sdng
VCing A3 cit HT gh6p da ngay
X
VCing B3 cit HT che phO ngay da OL, TBDL
Theo ddi v l t bdng, thdi gian khdi, hiflu qua dilu tri tren Idm sdng, cgn lam sing
I
TCYHTH&B so 1-2018 19
2.2.2. Phwomg phdp nghien cdu dieu tri phau thu^t vet bong sau
Tren mflt BN bdng sdu chia hai vung: vCing A3 dudc p h l u thu§t d t hogi t u sdm ghflp da ngay tgi; vCing B3 d t hogi t d sdm che phu ngay bdng da d i n g logi. trung bl da lyn.
+ Cde ChT tidu theo ddi sau m l : thay doi nhiflt dfl CO the trudc vd sau phau thuflt 48 gid; s l ngdy sot cao tru-de vd sau phau thuflt 1- 2 ngdy, thdi diem p h l u thuflt d t hogi t d ghflp da; hinh thdi da ghflp t y thdn; s l lan p h l u thudt d t hogi t d vd ghep da;
+ Theo ddi kha ndng bdm song cua manh da ghdp theo 3 mdc: T i t , khd (ty Ifl da ghdp song 70-100%); trung binh (50-70%); x l u (< 50%)
* Thdi gian l i l n v l t thuang bdng sdu Id tindi gian tfnh t d khi v l t bdng sdu dupe d t hogi tu, ghdp da cho den khi da ghflp bdm s i n g t i t . vet thuang liln;
' Thdi gian khdi ra vifln (dupe tinh t d khi bflnh nhdn vdo vifln eho d i n khi bflnh nhi chuyen khoa phyc h i i chdc ndng hodc ra vifln);
+ Dieu tri todn thdn: Theo phdc d l hifln dang dp dgng tai VB
Anh 1. Hinh anh viing A3 cat HT ghep da t y than, vung B3 dtrofc cat het HT cho* ghep da ddng loai
Anh 2. Hinh i n h vCing B3 sau cat h i t HT ghep da dong loai 30% (20%) dfl III, IV ngyc byng, td chi)..
Anh 3. Viing B3 dupe cat HT ghep trung bi da (BN Ngd Thi Phipang Th, 48 th, SBA: 5594, chan dodn bong Ida 25% (15%) dg III. IV mgt c6. 'o (15
than. tLF chi)
4. Hinh anh sinh thiet md Hl'bong s
d l xac djnh loSi va SLVK ~"
(BN VQ Thj D, 18 th, SBA: 1728, chan dodn bong nude sdi 15% (11%) do III, IV ngyc, bgng. Chan phai).
20 TCYHTH&B s6 1-2018
2.2.3. Phuxmg phdp xdt nghiem huyet hgc, sinh hda, mien djch vd cdc cytokin
Cdc xdt nghiflm cdn Idm sdng tdp trung tgi d c thdi d i l m :
- Mflt d i n hai ngdy trudc phlu thuflt d t hogi t u ghdp da,
- Sau p h l u thuflt d t hogi t d ghflp da 3 - 5 ngdy;
- Khi v l t bdng sdu dd dupe p h l u thuflt ghflp da t y thdn phQ kin.
Xdt nghiflm Cytokine TNFo, IL-1, IL-6: tgi Labo nghifln cdu dng dyng y sinh hpc cdng nghfl cao - Hpc Vifln Qudn y. Xdt nghiflm cdc yeu t l m i i n djch CD4, CDS, IgG, IgM tgi Vifln Huylt hpc truyin mdu Tnjng uong. Cdc XN thudng qui Idm tgi vifln Bdng Le Hdu Trdc.
2.3.4. Xd-If so ligu
s l liflu dup'c tinh ra gid tri Injng binh hay ty Ifl phin trdm. So sdnh cdc gid tn trung binh bing phuang phdp T - student, so sdnh hai hay nhilu ty Ifl b i n g tiflu chuln X^ Sy khdc biflt cd y nghTa thing kfl khi p < 0,05.
s l liflu dupe x d 11 b i n g p h i n m i m R Version.
3.2. Tri^u c h d n g Idm sang, cgn Idm sang tre em bdng sdu trdn 10% DTCT Bdng 1. Tri^u chCrng va b i l n chdng cua BN trong thdi ki s i c bong v^ NKNO
3. K £ T QUA NGHIEN CCrU
3.1. M$t Sd d | c diem djch t l d tre em bj bong sau tren 10 - 20% DTCT
Lda t u l i bj bdng nhilu n h l t t d 6 thdng d i n 5 tuoi c h i i m ty Ifl 28/30 = 93.3%, t u 6-7 t u l i cd 2 BN vdi ty Ifl 6.67%; ty Ifl trd trai Id:
60%, tre gdi: 40%. Nhiflt udt Id tdc nhdn gdy bdng chu y i u d tre chiem ty Ifl 80%, bdng Ida 20%. Cd 24/30 = 80% BN cd DTBC t d 20%
d i n 59% DTCT. Tre em bj bdng d nhieu vi tri k i t hyp: bdng d l u mdt co, chi dudi vd ehi trfln vdi ty Ifl tuang dng 21/30 = 70%, bdng viing ngye bgng Id 20/30 = 66,66%; bdng sinh dye ngodi cd ty Ifl cao 23/30 = 76,67%; lung mdng vdi ty Ifl 13/30 = 43,33%. Thdi gian tre em bj bdng tdp trung ehO y i u vdo cdc thdi diem td 17-22 gid vd 11 - 13 gid vdi ty Ifl 50% vd 26,7%. Nai x i y ra tai ngn bdng d tre chij y i u tai nhd chiem ty Ifl 96,7%. Bflnh nhi dupe x d ly dOng ngay sau bdng ed ty Ifl 43,3%, x u ly sai vd khdng x d ly cd ty Ifl eao 17/30 = 56,7%.
Chuyin den Vifln Bdng b i n g xe cdu thuang ed nhdn vien hfl t i n g ehilm ty Ifl 46.7%;
43,3% BN den b i n g dtd vd 10% BN bing xe mdy. Bflnh nhi vdo vifln sdm trong 24 gid d l u sau bdng ed ty Ifl: 21/30 = 70%.
Trilu chi>ng Tmh than
-V$tvShichthicfi -M^lmoi, there, libi Da niem m^c
• Chi l9nh Khdt niffrc Tu^n lio^n:
- HuySl 5p rfpng mgch giSm
• M^ch nhanh Tho- nhanti
Tho'i ki s6c bong N (n - 30)
5 23
22 23 22 10
%
16,7 76.7
73,3 76,7 73.3 33,3
Tho'i iti nhilm ithuin nhilm d$c N
25
30
30 30
%
83.3
100
100 100
TCYHTH&B s6 1-2018 21
Than nhi$l - Nhi^t dQ gi^m <37''C -S6ttr§n39^C - Sot cao CO gi9t
• So ngiy s6tcao> 39°
Roi loan tieu hoa - Won, chtiang bvng - la chiy Toan thSn ph£i ne Bien chi/ng
-Suy ho hip
•Xuathuyet TH - Viem phoi, PQ - Thieu nieu
5 30 3
9 11 14
3 1
16.7 100 10
30 36.7 46.7
10 3.33
30 12.9 ±2.6
17 15 12
4 3
100
66.7 50 40
13.3 10
Nh$n xdt thdi ky s l e bdng, cdc triflu chdng Thdi ky NKND t h i hifln: rdi logn tinh t h i n : g$p ty Ifl eao Id thd a. li bl chiem 76,7%; s i t eao 83,3%, s i t eao kflo ddi: 100% vdi so ngdy s i t eo gi§t 10%; Ta c h i y d p 36,7%. Biln chdng suy trung binh 12,97 ngdy. Biln chdng chij yeu Id hd h i p 10%; x u l t huylt tiflu hod 3,3%. viflm phoi p h i q u i n vdi ty Ifl 13,3%.
3.3.1. Cdc tri^u chOng cgn Idm sdng
Bang 2. D9c diem cSc chi s6 huylt hpc theo thdi gian
^ ^ ^ h m gian ChisI ^ ^ ^ - ^ HC(Tfl) HST(g/l) BC (G/l) BC tmng tinh (%)
3 ngay Q&u 5,89 ±0,81 161,36±24,53
20,15 ±8,54 63.78 ± 17,07
4-10 ngay 3.71 ±0.68 92.1 ± 15.33 13.81 ±3,97 52.58 ±18,13
11-20 ngay 3.65 ±0.84 93.59 ± 20.33
14,62 ±6,2 54.34± 15.18
21-30 ngiy 3.93 ±0.73 105,41 ± 18,08
11,98 ±2,99 50,6 ±16,56
Nhdn xdt So lupng HC vd HST trong 3 d nhdng ngdy d l u sau bdng, xu hudng trd v l ngdy d l u sau bdng tdng cao. s l lup'ng bgch binh thudng a thdi d i l m 21-30 ngdy.
e l u vd bgeh d u da nhdn tmng tfnh tdng ngay
f^s_
"^^^^ii^^^^MLgian Glucose (mmol/l) Protein (g/l) Albumin (g/l) NatriKali ^
^ ^
D$c diem cac chi s6 3 ngiy dlu 10,91 ± 5,73 52,66 ±7,94 26,08 ±4.88 132,52 ± 3,86
3.71 ±0.47
sinh hod v i dif n gia 4-10 ngiy 5,16 ±1,29 55,07 ±7.58 26,16 ±3.75 131,94 ±3,82 3,2 ± 0,53
mdu theo ihir'i gian 11-20 ngiy 5,03 ±0,92 54,08 ± 8,39 26,82 ± 7,82 133,13 ±2,22 3,7 ± 0,68
21-30 ngiy 5,16 ±0,8 60,07 ±4,83 29,25 ± 3,78 136,71 ±0.47 3,86 ± 0,43
22 TCYHTH&B so 1-2018
Nhdn xdt Glucose mdu 3 ngdy d l u tdng d l u sau bdng. Roi logn difln giai: natri giam cao han so vdi cdc ngdy t i l p theo, protein todn ngay nhdng ngdy d l u ; kali giam chu yeu tgi phan vd Albumin mdu giam ngay d nhdng ngdy thdi ^ I m 4-10 ngdy sau bdng.
3.3.2. Bgc diem VTbdng sdu
Bang 4. Tinh chit dam da ho^i t d bong v tre em bj bong sSu
~'~~~--~~~.^^__^^^ SLBN Tinh chit ho?i td '~~-^~-~...^___^^
Dam da tio?i tiF ^61 Dam da hogi ti> I<h6
Cpng
N=30 29
1 30
"A 96,67
3,33 100 Nhdn xdt Sdng sdu tre em bieu hifln dudi dang hoai t d udt cd ty Ifl cao (96,67%
Anh 5. Hinh anh hoai tu- kho Anh 6. Hinh anh hogi t d i f M
3.2. Phuo'ng phap d i l u trj ngogi khoa tre em bj bdng sdu trfln 10% DTCT
Bilu d l 1: Thdi gian cat bo hoai tdsau bong
Nhdn xdt Thdi gian trung binh d t bd HT trung t d 4 - 7 ngdy sau bdng cd 16/30 BN Id 5,9 ± 1,5 ngdy. Cdt trong ba ngdy d l u cd (53.33%), t d 8 - 1 4 ngdy ed 9/30BN (30%) do 5/30 = 16,67%; d t bd HT n h i l u n h l t tdp tinh trgng BN ndng.
TCYHTH&B so 1-2018 23
Bieu do 2: Vj tri cat bo hoai t d tren co" the tre
Nhan xdt Ghi di>'di va chi tren duac tien than sau la 12/30 f40%), a vung d m , co, ma hanh PT cSt bo hoa; td nhieu nhat vdi ty l§ ia 6/30 (20%)
24/30 (80%) va 18/30 (60%), d than trudc,
Bang 5. Dien tich bong sau ducrc cat bo moi lan phau thuat
^^~^~^--~^^_^^ V u n g DT c i i t ( % D T C T T ~ ~ ~ ~ ~ - — - , „ _ ^ ^ ^ ^ ^ ^
5-10 Cpr.g
A 3 | n = 3 0 )
30 30
B3 (n=30)
30 30
Nhin x6t Dien lich trung binh dirge cat bo HT 8,5% DTCT Toi thieu ojt. 5% DTCT, toi c cat 10% DTCT
Bang 6. D|c diem nen vet bong sau c i t HT o vung A3, B3
Dgc d i e m vet thu'OT?g'~~-~—,„,_^^^
Tinh trang xung huyel be mgt vet ihicong
Tinh Irang tiel dich
Thdi gian co to chi>c hgt Dgc d i l m TCH
- S e p - X a u
A3
Het sau c i i HT ghep da 1-2 ngay
Khong, da ghep bam ch^c vao nen ghep, VT l<h6
khong
B3
Giam sau 1-2 ngay
Giam v^ h i t sau 1-3 ngay, DDL, TBDL bam vao nen ghep
4 , 5 ± 1 , 3
2 8 ( 9 3 , 3 ) 2 (6,7)
Nhan xet Vung A3 tinh trgng phu ne giam, da ghep bam c h i c Viing B3 tmh trang phu ne, xung huyet, tiet dich giam ro ret
24 TCYHTH&B s6 1-2018
3.4. P h l u t h u | t ghSp da sau c i t ho^i td vi tho'i gian l i l n v l t bong sau Bang 7. S6 \in ghep va hinh thcii gh^p da t y thSn
Viing Lln gtiSp da
Hinh ttl§i ghdp da
llSn 2 lan Manli lern lihia IS Manh \\jiri ty 1^ 1/2 Manh tern thi/
Kit hpp mSnh vi tern thu Tfing
A3 (n=30) 30 2 0 30 0 2 32
B3 (n-30) 30 3 0 30 1 2 33
Nh$n xdt Gh6p da manh \ufd\ t j 1$ 1/2 fluffc dp dyng cho ca 2 vCing. Gh6p tern thif vS ki^u kk hep manh - tern thu- chf thyc hi$n khi gh6p da bo sung.
Bing 8. Th&i gian mdnh da ghep bam sdng t6t va thoi gian khdi ra vi$n
—____^_^ Vung Thd"! gian (ngay) " • _ _ Thdi gian manh da ghdp bdm s6ng t6t Thdi gian khoi ra vi^n
A3 (n = 30) 6,9±0,4
B3 (n = 30) 11,6±0,4 24,6±7,4
P
<0,05
Nh$n xdt Thd-i gian manh da gh6p bdm song tot sau cat HT vCing A3 ngSn han vDng B3, c6 •j nghTa vdi P < 0,05.
Anh 7. V l t thuvng bong s i u d$ IV, HT w&t ngaythu'4sau bdng
Anh 8. Cat HT theo phiFvng phap tiep tuyln bang dao Lagrot c6 garo ngdy thii' 4 sau bdng
Anh 8. Cit HT ghep da tir than vdng A3 vk cat HT ghep trung bi da lo'n vung B3 ngay thi> 4 sau bong
Anh 10. Treo chin t r i n h ti de, han che nhiim khuan VT sau cat HT ghep da
TCYHTH&B s6 1-2018 25
Anh 11. Da tir t h i n bam song tot d- viing A3 v i trung bi da Ip-n bim tot 6* vCing 83 (Trung bi da Ip-n
chi dap 1 lan duy nhat cho den khi c6 mo h^t)
Anh 12. Boc bd trung bi da Ig-n d- vCing 83 b^c I9 m6 hat d^p
3. Da ghep bam s6ng hoin toan [d- hai viJng A3, 83; cu6n bang chun h^n che seo
v i 8N t i p di l^i
3.5. Anh hu'O'ng cua p h l u t h u | t cSt ho^i t i f tdi d i l n bi&n toan than 8ang 9. Thay d6i mpt sd trif u chi>ng trueitc v i sau PT c i t HT ghep da
Tri?u Chiang R6I logn tinh thin (m$l mdi, 11 bi...)
Sot cao >38,5''c Roi logn tl6u hoa (Chudng
bung, la chiy) Da nigm mac nh^t Todn thdn phu n4 Thi^u ni$u
TruiJc cit HT Sau cit HT Trudc cat HT
Sau cit HT Tnjdc cat HT
Sau cit HT Trudc cat HT
Sau cit HT Trudc cit HT Sau cit HT Tn/dc cit HT Sau d t HT
n = 30 25
9 30 9 17 5 30 7 12 5 3 0
%
83,33 30,0 100 30 56,66 16,66 100 23,33 40.0 16,66 10,0 0 msn xit: Phau thuSt cSt HT ghSp da c6 hi§u qua r5 r^t trong vi^c giam cSo tri^u chiing NTNB.
26 TCYHTH&B s6 1-2018
3.6. Vi khucin v6t bdng tru'd'c vd sau phSu thu$t c i t ho^i ti> gh^p da
Bing 10. Tiin s u i t v i lo^i VK t r i n b i m$t v4t bdng s i u tru>d-c v i sau PT c i t HT
^ ^ ^ vang DT Sd miu (+) ^ ^ ^ ^ ^ So miu (*}
P.aeruginosa S.aureus Kpneumoniae Acinetobacter
A3 n=30 TPT
26 (93,3) 18 (60) 7 (23.3) 1 1
SPT 13 (43,3) 8(26,7) 5 (16,7) 0 0
P
<0,05
<0.05
<0.05
B3 n-30 TPT
28 (93,3) 20 (66,7) 10 (33,3) 1 0
SPT 12 (40,0) 8 (26.7) 4 (13.3) 0 0
P
<0.05
<0.05
<0.05
Nh$n xdt Sau d t HT s6 m i u (+) tr6n be m$t VT gi^m hen so vd\ tru-dc PT c6 J nghTa vdi P<0,05. TKMX \d loSi VK xuat hi$n nhi^u nh^t d ca 2 vCing A3, B3,
Bing 11. S6 l i ^ n g VK/cm^ t r i n b i m^it v l t bdng sau tru'dv v i sau PT c i t HT
— ^ ^ Vung DT S6 lup'ng VK/cm*—^^^
P.aewginosa S.aureus Acinetobacter
A3 TPT 310,7
±48,2 311,7
±36,8 150,0
SPT 123,3
±11,2 121.3
±4,9 0
P
<0,05
<0,05
B3 TPT 316,4
±41.1 310,2
±34.1 0
SPT 120,4
±8.8 131.1
±8,5 0
P
<0,05
<0,05
Chi chii: Thdi diim liy miu Idm x&t nghidm: trong phau thugt dt HTghdp da.
Nhdn xdt: SLVK TKMX/cm^ vd TCV/cm^ d be m|t v6t thuong ngay sau c^t hogi tCr deu giam ho-n b^ m0t hogi ti> tru-dc p h l u thuSt (c6 y nghia vdi p<0,05).
Bing 12. T i n suit v i s6 iu-^-ng VK/cm^ tren b4 m$t da ghip
"^ •—-.,,„^^^ Vung DT
ChitiSu — - - ^ ^ ^ S6 miu (+)
P.aenjginosa
S.atmtis
Til»%
SLVK/cm' T i l ^ % SLVK/cm'
A3 (n=30) 13(43,3)
8 (26,7) 135,8±12,1
5 (16,6) 128,6 ±3.4
B3 (n-30) 15 (50,0) g (30,0) 131,0 ±12,4
6 (20,0) 128,3 ±27,5 Chi chd: (") Tf 1$ % du^c so vdi s6 m§u dS ciy vi khuin d moi vung
Nhdn xdt Tn/c khuSn mO xanh vd ty cau v^ng \d hai loSi VK xuk hi$n tr§n b4 m5t da gh6p.
TCYHTH&B so 1-2018 27
Bing 13. Ty l# cac lodi vl khuin trong l g md t6 ch(rc vCing A3, B3 tnpoc va sau c i t HT
Loai VK ^ \ So mlu Paeruginosa S. auraus
Vung A3 (n = 30) MdHT trudc PT Mlu M
25 16 10
Tylf % 83.3 53.3 33,3
M6 lanh dudi HT Miu M
12 7 5
T } l » % 40,0 23,3 16,7
vang B3(n-30) MdHTtru^cPT Miu {*)
24 14 10
Ty 1? % 83,3 46,7 33,3
Md linh dudi HT Miu («)
13 8 5
TJI?%
43,3 26,7 16,7 Nhdn xdt Tdn suat xuiit hi#n vi khu^n d m6 ISnh sau c i t HT trfin ca hai vCing A3 vd B3 giam ra ret so vb-i mO HT vdi p<0,01. TKMX \d loSi vi khuin chi^m ty 1$ cao nhat 53.3% a vCing A3 vd 46,7% a vCing B3.
Bing 14. Sd lu^ng vi khuin tren l g md td chi>c.
^ ^ < T h d i dilm Loil V K " ^ ^ ^ SLVK Chung P. aeniginosa S. aureus
Vung A3 (n = 30) MdHT trudc PT
149.68 ±44,82 150,12 ±27,41 148,89 ±24,91
Md lanh dudi HT 62,42 ±7.39 52,88 ±8.06 51,5 ±6,86
Vung B3 (n=30|
MdHT trudc PT 150,24 ±25,66 150,13±28,15 150,4 ± 22,89
Md linh dudi HT 52,46 ±6,97 53,11 ±7.24 51± 6.38
P Pl.2
<0.01
<0.01
<0,01 p «
<0,01
<0,01
<0,01 Nhdn xdt SLVK trong m6 ISnh sau c i t HT & ca hai vCing A3 vd 83 deu giam ho-n so vdi mo HT, c6 J nghia vd\ p < 0,01.
3.7. Nghign ctpu s i ^ thay d6i ndng dp Cytokin huyM thanh
Bing 15. Thay ddi ndng d$ Cytokin huylt thanh tnr&c v i sau phiu thu|t Loai Cytokin
(pg/ml) IL-1 IL-6 TNF-a
Trudc phiu thu^t 105.76± 12,19 176,96 ±24,60 105,95 ± 15.46
Sau phlu thu|t 99,02 ± 15,76 163,09 ± 35,80 99,95 ± 18,39
Khi VB sau duQ'C ghep da che kin 72,49 ±14.15 98,78 ± 16,27 70,06 ±8.50
P P.-2
>0,05
>0,05
>0,05 P M
<0,05
<0.05
<0,01 Pi-j
<0,01
<0,01
<0,01 Nh$n xdt iL1, IL-6 vd TNF-a giam khSng cd y nghTa ngay sau khi cat hogi ti>. Chi khi vk thu-cng bong Sclu du'P'c che phii toSn bd thi ca 3 chi s6 nSy mdi giam rO r$t so vd\ irwdc vd sau c i t hogi li>. sy kh^c bi$t c6 y nghTa thong kd vd\ p <0,05 vd 0,01.
3.8. Nghien cCru s ^ thay d6i m$t s d y^u t d m i i n djch.
Bing 16. Thay d6i ndng dp CD4, CDS, IgG, IgM trudv v i sau PT c i t ho^i ti>
^ ^ ^ ^ d l ai^m C h i s l ^ ^ ^ ^ SLCD4(tb/iJm) SLCD8(tb/iJm) Ty l« CD4/CD8 IgG (mg/di) IgM (mg/dl)
Trudc phlu thu|t 928,20 ±493,64 809,60 ± 307.92 1,08 ±0,42 650,04 ± 103.44
105,41 ±8,27
Sau phlu thuat 1476,90 ±615,21
874,75 ±335,29 1,43 ±0,18 654.96 ±38.72
119.55 ±1,79
Khi VB sau ein?c ghep da che kfn
2400.80 ±219,12 906,15 ±156,77 1,69 ±0,84 690,45 ±25.01 152,02 ±38,83
P Pi.i
<0,06
>0,05
<0,05
>0,06
>0,05 P M
<0,05
>0,05
>0,06
<0,05
<0,05 Pi-j
<0,01
>0,05
<0,06
<0,05
<0,05
28 TCYHTH&B s6 1-2018
Nh§n xdt
- Sau p h l u thu$t c i t hogi tir vd sau khi v^t Uiu'O'ng bong sau dupe gh6p da che phu thi so lupng CCM tSng l§n rO r^t so vdi trudc p h l u thuat c i t hogi tCf (P < 0,05 va <0,01). S6 lup'ng CDS khfing c6 s y thay doi d cac thdi di^m trudc va sau khi can thi$p p h i u thuat;
- Ty 1$ CD4/CD8 a thdi diem trudc c i t va sau c i t hogi t u luOn d gidi hgn thap (nho hern 1,5), sau khi vet thuang bong sau dupe gh6p da che phu thi ty !§ ndy tang ISn (Idn ho-n 1,5) sy khac bi$t nay c6 y nghTa thong kg {vdi P<0,05);
- Ngay sau ph^u thuat c i t hogi iOf IgM va IgG khdng thay doi ngay (m^c dCi cd tang ISn nhung khdng c6 sy khac bi$t so vdi trudc p h l u thuat c i t hogi tu), khi vet thuo-ng bong sau dup'c ghdp da che kin thi IgM vd IgG tSng I6n rd r$t cd y nghTa so vdi trudc khi c i t hogi to ( P < 0,01).
4. BAN LUAN
4.1. D$c d i l m lam sdng, c^n lam sang tre em bj bdng sau tren 10% DTCT
Tgi ch5: V l t bong sau d t r i em bi§u hl$n dudi dgng hogi tO udt 29/30 = 96,67%, hogi t u khd 1/30 = 3,33%. Vi khuan trgn be m§t vet thuang chu y^u la tryc khuin mu xanh (60%) va ty c l u vang (23,3%). Hogi t u udt thudng tan rfra sdm, de nhiim khuan. Day la dac di^m n6i b$l lian quan tdi trpng lup'ng c c the tre chiem han 80% la nude.
Tri$u Chung toSn than thdi k j soc bong:
Di$n tieh bdng sau cSng Idn thi soc bdng cang nang, cd t h i x u l t hi$n soc nhup'c ngay t u gid d l u sau bdng. K i t qua nghidn euu trong thdi ky soc bdng cua chOng tdi thay noi bat cac tri$u chi>ng:
Rdi logn tinh thin: trgng thai hung p h i n bilu hi$n q u i y khdc, kich thfeh cd t j 1$ 16,7%, trgng thai i>c che: m0t mdi, thd a, li bi cd ty 1$
76,7%. s a c d i l m nay liSn quan tdi thdi gian tre nh$p vi$n sau bong va h$ t h i n kinh tre chua i n djnh do cac spi t h i n kinh ngogi vi chua myelin hda. [4,11]
Rdi logn tuin hodn: huyet Sp ddng mgch giam cd t j Ig 33,3%. Di$n tich bdng sau Idn, khoi lup'ng huylt tuang, nude, dign g i i i giSm thoat tdi 30 - 40%, thoat h u y l t tuang x u l t hign sdm 5 phiit sau va dgt mdc cao n h l t 8 - 12 gid. M i t djch cdn qua nhieu eon dudng khae nhu: boc hai nude qua v l t bdng, mat qua dudng hd hap, qua c h i t ndn, do sot cao [4].
Roi logn than nhigt: Tnjng tam d l l u chinh than nhi$t ehua hoan thi^n, d l phat sinh r6l loan than nhigt n$ng gSy co giat, tim tai. Nghign cdu cua chiing tdi cd k i t qua: nhigt dO giam <
37° cd ty Ig 16,7%, s6t cao> 39°c cd t} Ig 100%, s i t cao CO giat 10%,
Rdi logn tidu hda' ehudng byng, ndn la trigu chdng bao higu soc bdng nang hen, g l p 9/30 = 30,0% ; la chay cd t j Ig 11/30 = 36,7%.
K i t qua nay phCi hpp nghiSn cdu eOa eae tac gia trong va ngoai nude [2, 4, 6].
Ndng dd glucose mdu tang (10,91 ± 5,73 mmol/l) trong 3 ngay d l u sau bdng lidn quan tdi trgng thai strees vdi c c c h i than kinh t h i djch gay tang tiet cac hormon viljng dudi d i i - tuyln ygn - tuyln thup-ng than.
Biin chdng d thdi kf sde bdng: suy hd h i p c6 3/30 BN = 10%. Ci trgng thai binh thudng tre da phai thd g i n g SLTC, S6C bdng iam giam luu lupng mau gay thilu dxy md to chdc. Tim, phli phai tang hogt dOng d l bCi d i p lupng d xy thilu hyt. Tang tinh t h i m thanh mgch ngn s y gian nd cae phe nang bj hgn c h i dan den g i l m s y trao doi dxy trong vdng tuan hoan phli. Tat c l nhu'ng y i u to dd eOng vdi trgng thai stress iam tinh trgng b$nh nang idn [2. 4, 9, 15]. X u l t huyet tieu hda cd ty 1$ 3,33%, liSn quan ldi roi logn ehdc nang dieu tiet eua hg than kinh trung uang va giam k h i i lupng mau luu hanh gay hOi chO-ng lodt curling.
T r i l u chdng toan than thdi ky NKND:
nhilm khuin nhiim dOc tre bdng sau trdn 10%
DTCT t h i hign d cac trigu chdng sau:
Rdi logn tinh thin: Theo Kay M E[11]: r l i logn tinh than d tre em bj bdng x u l t hl§n sdm vai gid ngay sau bdng va kao dai 12 - 16 ngay vdi t f \$ dao dOng Idn 5% -85%.
c a c bieu hian r l i logn tinh t h i n d trd em ehO
TCYHTH&B s6 1-2018 29
yeu la vat va, li bi. Trgng thai Stress, dpc t l bdng, dgc to vi khuin, m#t mdi, dau, vidm mu v l t bdng, suy mdn... tae ddng x l u tdi hg t h i n kinh tre. K i t q u i nghign cdu cua chiing tdi: trd bi roi loan tinh t h i n cd ty Ig eao 83,3%.
Sdt Theo Gail.L s i t la trigu chdng x u l t hign s d m , gid t h d 16 sau bong va thudng xuyen nhat d thdi k j t h d hai cua benh bdng [10]. khi b| bdng 3% DTCT t h i y tre s i t tdi 40''C. Trong nghign c d u cua Chung tdi 100% tre cd sot cao kdo dai. S l ngay trung binh sot la 12,9 ± 2,6 ngay. Khi tre cd d i l n b i l n toan than x l u , s i t cao n h i l u can khd hg nhigt, s i t cao rdt run, dac biet d nhdng b$nh nhan cd dau hi$u nhiem khuin toan than n^ng.
Cdc biiu hidn bdnh If cda ca quan tidu hod: Lg T h i Trung nhan t h i y h | i chdng ligt e l p dg day, r u | t thudng g$p d bgnh nhan bdng nang cd n h i l m k h u i n toan than, lodt e l p ong tidu hda [4]. Nghidn cdu eua chOng tdi thiy: ehudng byng 17/30 tre c h i i m t j Ig 56,7%. Chudng byng, giam nhu dOng rudt iam vi khuin gay bgnh dudng rudt bam d$ng vao niem mgc, vup't qua barie xSm nhap vao mau gay NKH nOi sinh. Hal I byng day ca hoanh Idn cao, chdn dp l i n g ngyc c i n t r d hd h i p gdp p h i n iam tang suy hd h i p d p . la chay 15/30 b$nh nhi c h i i m 50%. Ia chay lam nang thSm roi logn nude, dign giai, can b i n g kiem toan, ldm tang tinh trgng nhiem k h u i n va suy mdn bong
Thiiu mdu vd suy mdn: Theo Donal.
D.H; Park.S thieu mdu d tre bdng sdu di$n rpng phat t r i l n sdm va nhanh [9]. K i t qua nghign cdu cua chiing tdi t h i y d ngdy t h d 4 d i n ngdy t h d 10 sau bong, s l lup'ng hdng c l u va h u y l t s i c t l trong mau ngogi vi g i l m rd r|t so vdi ngay d l u , cd xu hudng h i i phyc sau 20 ngay nhung v i n d mdc t h i p . Theo ddi chi s l h i n g c l u , h u y l t s i c t l cho tre la mOt trong nhdng chi tidu cd gia trj trong c h i n doan d i l u trj va tiSn lup'ng.
Rdi logn didn gidi: Baxter tinh s y m i t natri ra ngogi bSo tdi 4mmol/kg/% dign tich b6ng/24 gid, t h i tich mau luu hanh giam va thieu mau cgc bO tgi cac md ndn mdc ATPase cOa mang t l bao giam, c h i t nay c6 vj trf quan
trpng trong vigc gid can b i n g gradien di#n giai gida cac khoang n|i va ngogi t l bao [7]. S l e bdng gay giai thoat va chuyin djeh Kali d eae md t l bao bi ton thuang ra khoang gian bao, s y chuyen djch natri vao nOi bao va m i t natri do thoat djeh h u y l t tuang qua thanh mgch d i n tdi hau qua iam giam natri mau. Cac c h i t trung gian dudc hinh thanh va giai phdng (histamine, serotonine...) cang anh hudng d i n ca e h l gian vd tSng tinh t h i m thdnh mgch.
Tinh trgng u mau bgnh ly d hg mgch eae n|i tgng lam nang thdm cae r l i logn tuan hodn cang iam tang r l i logn can bang nude dign giai. VI vay, trong nghidn cdu cda chiing tdi t h i y r l i logn Na* xuat hign ngay nhdng ngdy d l u sau bdng. Tinh trang r l i logn dign giai cdn gap d thdi diem 4-10 ngay sau bong lidn quan tdi cae roi logn bgnh ly trong giai dogn NTND (sot cao kdo dai, roi logn tidu hda).
R l i logn kali x u l t hign chu y i u tgi thai diem 4- 10 ngay sau bdng b i l u hign trdn iam sdng b i n g tridu ehdng chudng bung. Trong qua trinh dieu trj phai thudng xuygn k i l m tra, d i l u trj can b i n g dien giai d l x d ly kip thdi 4.2. Hieu qua cua p h l u thu$t c i t hoai t d sdm - ghep da ngay
Hi$u qua cua p h i u thuat e l t hogi t d sdm, ghdp da ngay hoac che phu b i n g da d i n g logi;
trung bl da lo'n trong 7 ngay d l u sau bong d i n d i l n b i l n tgi ch5 t i n thuang bong sau: theo eae tdc gia, e l t hogi t d ghgp da sdm trudc 48 gid sau bdng la t i t n h l t hoac t d 3-5 ngay sau bdng khi ed sy phyc h l i tuan hoan. N l u c i t sau ngay thd 7 thi tinh trgng nhilm khuin tgi chd da tang
|gn, nguy ca nhiim khuan lan tran, m i n h da ghdp khd bam s i n g t i t . Djch phu bong la dung mdi chda cac chit trung gian vidm, eae san pham chuyin hda, trong dd cd cac c h i t gdy dau nhu Kalicrein, Histamin, Bradykinin, Prostaglandine (dac bi|t la PGE2), Leukotrienes, Serotonine, ion H* va c h i t P (substance pain- SP). Djch phli iam tang the tich phan b l , do dd phai tang liiu khdng sinh mdi cd tdc dyng dy phdng vd dieu trj. Djch phii eOng tgo d i l u ki$n eho vi khuin t d b l mat vet bdng xam nhap vao sau tdi md lanh quanh v l t bdng, lam giam ehdc nang midn djch cQa t l bao mien djch trong dap
30 TCYHTH&B s6 1-2018
dng chlng lgi vi khuin [1, 4, 9,16]. Nghidn cdu cDa chiing tdi cho t h i y thdi gian d t hogi t u ghdp da ngay trong 7 ngdy d l u cd tf Ig cao (70%) da tgo thuan Ip'i t i t cho tien triln cua bgnh: g i l m phii ne, xung huylt vd t i l t djch tgi v l t bdng sau 1-2 ngay d ea viing A3 va B3;
g i l m t i n s u i t x u l t hign cua tryc khuin mu xanh trudc p h l u thuat vOng A3- b3 la 83,3%
xuIng cdn 53,3% viing A3 vd 46,7% vung B3;
logi bd duac so lup'ng Idn vi khuan trong md lanh d nen v l t bdng sau c i t h i t hogi t d (150,12
± 27,41 so vdi 52,88 ± 8,06). Da ghdp t y thdn bam s i n g t i t kha vung A3 Id 93,3%, viing B3 la 90,0%. Vung B3 cd ty l | da ghdp t y than song cao la hi$u qua eua che phu tgm thdi b i n g da ding logi, trung bi da Ipn. Nhdng y i u t l dam bao da ghdp bdm s i n g cd ty 1$ cao: hogi t d dupe e l t bd trigt d l , khdng ed ty mau, dieh dudi m i n h ghgp, c l djnh tot- khdng xd Igeh, mat d | vi khuin < 10^/1 cm^. Toan than: cdc chi s l sing trong gidi hgn cho phdp, dup'c nudi dudng va cham sde tot Ddy ehinh Id nhdng yeu t l iam giam s l ngay lien vet bdng sau eung nhu s l ngay d i l u trj khdi ra vign cua bgnh nhi.
4.2. Hl^u qua ciia p h l u thuat c i t hoai t d ghSp da t y thSn ngay lam giam cac t r i f u c h i i n g t h d i ky NDNK, giam mirc do va t h d i gian sdt cua b^nh.
Trong nghign edu cua ehiing tdi, hogi t d bdng dup'c logi bd khdi ca the b$nh nhi m|t each chO dgng vd ghdp da t y than hoac che phu ngay b i n g da dong logi, trung bi da Ip'n.
Day la bi|n phap quan trpng cd tfnh quyit djnh d i n d i i n b i l n todn than ciia b|nh nhi. Sau e l t hogi t d ghdp da eae tri^u chdng thdi ky NDNK cua bgnh nhi giam ed y nghTa vdi p<0,05; tuy nhian s l b^nh nhi cd di|n bdng sdu 20% DTCT thi ede trigu ehdng NDNK cdn kdo ddi cho tdi khi hogi t d dup'c logi bd h i t khdi ea the vd ghdp da che phO kfn.
Sy thay doi nhigt dO ea the la m|t trong nhdng bing chdng rd r$t cua v'\$c cai thl|n tinh trgng NDNK trong bdng [42, 102]. Theo Parish R. A: tre em dudi 4 tuoi, nhdm bdng < 20%
DTCT, nhi$t do trd v l binh thudng sau 8 - 9
ngay. trdn 20% DTCT nhigt dO kdo ddi han 2 t u i n [13]. Vigc s d dyng khdng sinh d y phdng eung khdng thay d i i dudng bieu dien nht|t dO eua bgnh nhdn. K i t qua cOa ehiing tdi: Bgnh nhi sau phau thugt c i t bd hogi t d ghdp da vin cdn 9 bgnh nhi s i t eao t d 3-5 ngay bdi day l i nhung bgnh nhi ed dign bdng sdu trdn 20%
DTCT.
4.3. Hi^u qua cua p h l u thugt c i t hogi t d ghdp da d i n su? b i l n d i i Cytokin
Theo Mabrouk A: IL-6, TNF-o tang cao ty la thuan vdi dipn tich bdng, vdi t j 1$ BN nhiim khuin huyet vd ty l | t d vong. P h l u thuat e l t hogi t d ghdp da cdng sdm thi mdc d$ cac cytokine t i l n vidm cdng dupe giam t h i p va qua trinh vidm sau bdng cQng d i l n bien thuan Ipi han [12]. TNF-a It thay d l l ngay c l khi hogi t d bdng dup'c phau thuat c i t bd. Trong nghien cdu cua ehiiing tdi: IL1, IL-6 va TNF-o giam khdng cd y nghTa ngay sau khi e l t hogi t d . Chf khi v l t thuang bdng sau dupe che phu toan bO thi ea 3 chi so nay mdi g l i m r6 rgt so vdi trudc vd sau c i t hogi t d (sy khac bigt cd y nghTa thong kd vdi P <0,05 va 0,01), Ket qua nay eOng phii hp'p vdi nghidn cdu cua tac gia Abdel-Hafez N.M, Saleh Hassan Y vd c | n g s y khi nghidn cdu trdn 42 tre em bj bdng d Hy Lgp [5].
4.4. Hieu qua cDa p h l u thugt c i t hogi tu*
ghep da d i n s y b i l n d i i cdc y i u t d m i i n djch (CD4, CDS, IgG va IgM):
Tdc gia Mabnauk A, Mabrouk R.R nghidn cdu vai trd cua CD4 vd CDS d ngay thd 4 sau bdng trdn 40 BN da thu dudc k i t q u i : CD4 giam d BN cd dign bdng rgng; giam ty Ig thuan vdi ty 1$ t u vong. ty Ig BN bj suy ehdc nang gan, than. CD4 ddng vai trd quan trpng trong phdt then cdc p h i n dng mien djch va cac bilu hign iam sang trong bdng [12]. CD8 khdng thay d l l nhieu d BN bdng, khdng lidn quan cd y nghTa vdi dign tfch bdng. Tde gia L F Rioja theo ddi gid trj tign luang ty Ig CD4/CD8 d BN bong t d 11-36% DTCT nhan thiy: ngay thd 7 sau bdng CD4 giam vd CD8 tdng cao cd y nghTa d
TCYHTH&B s6 1-2018 31
nhung BN nhiim khuan huylt [14]. Nghidn cdu cOa chCing tdi trdn 30 BN cd dign bdng sau t d 11% den ti-gn 20% DTCT, dign bdng ehung Idn nhlt la 52% DTCT, khdng ed BN bj nhidm khuin huyet, chi ed BN vidm phli p h i quan ndn k i t qua so luyng CD4, CD8 cung phCi hpp vdi k i t q u i eiia hai tdc gia trgn.
Theo Behnam Sobouti (2012), khi nghidn cdu cdc yeu to m i i n d|ch trdn 50 tre em nhd han 6 tuoi bj bdng, tdc gia da nhan djnh: tre em bong nang mdc IgG, IgM thudng giam, dgt mde toi thieu d thdi d i i m 48h sau bdng va d i n trd Igi mdc binh thudng t d t u i n thd 2 den t u i n thd 4. N i n g dg IgM vd IgG lign quan mat thiet vdi mdc d | nghidm trpng b$nh bdng d tre em. Nong dg globulin m i i n djch giam la do r l i logn chuyen hoa, c i t hogi t d ghdp da sdm thi mdc IgM va IgG nhanh trd v l mdc cho phdp sau p h l u thuat [8]. Nghign cdu cQa chiing tdi eQng phCi hpp vdi nhan djnh cda cac tdc gia khi nong dO IgM vd IgG khdng thay d l l ddng k l d thdi diem trudc vd sau khi c i t hogi t d . Chi khi vet thuang da dup'c ghdp da t y thdn vd da ghdp bdm song thi IgM vd IgG mdi tdng cd y nghTa.
5. K £ T LUJB^N
Nghign cdu dac d i l m iam sang, can ldm sang vd d i l u trj ngogi khoa bdng sau trdn 10%
dign tich ca t h i d 30 trd em t d 6 thang den 7 tuoi tgi Vi$n Bong Ld Hdu Trac t d thang 11/2010 den thang 7/2012 chOng tdi riit ra m|t s l k i t ludn sau:
5.1. LSm s i n g b d n g s a u c 6 nhtpng d$c d i l m sau
Hogi t d udt cd ty 1$: 96,7%, vi khuin trdn be mat vet thuang ehO yeu Id tryc khuin mQ xanh (60%) vd ty c l u vdng (23,3%). Soc bdng:
100% vd s i c bdng nang. cac trl|u chdng thdi ky nhidm khuin nhiim dOe: r l i logn tinh t h i n : 83,3%, s i t eao kdo dai: 100%; s l ngdy s i t cao:
12,9 ngay, roi logn tidu hda: chudng byng:
56,7%; la chdy: 50%. S6 lupng h i n g e l u , huylt
s i c t l , bgch c l u tdng eao thdi ky s i c bong, giam t d ngdy thd 4 vd cd xu hudng phyc hoi nhung v i n t h i p d ngdy thd 21 d i n ngay thd 30. Glucosa mdu tang eao d thdi ky soc bdng vd trd v l binh thudng d ngay thd t u . R l i logn di$n giai: Na* mau gidm ngay d nhung ngay d l u ; Ka* mau t h i p d ngay thd 4 d i n 10 ngay sau bong Pnstein toan p h i n vd albumin giam ngay d thdi ky s i c bdng. Biln chdng viSm phoi c d t y l g . 13,3%.
5.2. P h l u thudt cat hoai td s d m , ghdp da ngay la bign phdp chii ddng da logi bd trigt de can nguydn gay r l i logn b^nh ly bdng; tinh trgng phCi n l giam vd het sau 1-2 ngdy; giam t i n s u i t vd so luang tryc khuin mCi xanh (trgn be mat t u 60% xuong 26,7% tuang duang vdi 310,7±48,2 xuong 123,3±11,2 vd trong l g md to chde t d 53,3% xuIng 23,3% tuang duang vdi 150,12 ± 27.41 xuIng 52,88 ± 8,06) eung nhu ty cau vang (trdn b l mgt t d 23,3% xuong 16.7% tuang duang vdi 311,7±36,8 xuong 121,3±4,9 va trong l g md t l chdc t d 33,3%
xuIng 16,7% tuang duang vdi 148.89 ± 24,91 xuong 51,5 ±6,86).
- Phau thuat e l t hogi t d sdm, ghdp da ngay cd tae dyng giam eae trigu chdng thdi ky nhiim dge nhilm khuin. cdc trigu chdng thdi ky nhiim dgc nhiim khuin cua b^nh nhi giam ed y nghTa vdi p< 0,05. (Roi logn tinh t h i n td 83,33% xuIng 30%; sot cao giam t d 100% xuIng 30%; r l i logn tieu hda td 56,66% xuIng 16,66%; toan than phD ne t u 16,66% xuIng 10%).
- P h l u thuat c i t hogi t u ghdp da cd tdc dyng giam ning d | cytokine vidm, tdng cac y i u t l m i i n djch: khi v l t bdng sau dup'c ehe phu hoan toan thi IL1, IL-6 va TNF-a g i l m vdi P <0,05 va P <0,01 (IL-1 t d 105,76 ± 12.19 xuIng 72,49 ± 14,15; IL-6 t d 176.96 ± 24.60 xuIng 98,78 ± 16,27; TNF-a t d 105,95 ± 15,46 xuIng 70,06 ± 8,50). Sau p h l u thuat s i ludng CD4 tang (td 928,20 ± 493,64 Ign 1476,90 ± 615,21) cdn IgM vd IgG chT tdng khi vet bdng sau dudC ghdp da che phu hodn todn vdi P <
0,01 (IgM t d 105,41 ± 8,27 Idn 152,02 ± 38,83;
IgG t d 650,04 ± 103.44 len 690,45 ± 25,01).
32 TCYHTH&B s6 1-2018
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