2. American College of Chest Physician, Society of Critical Care Medicin (1992).
American College of Chest Physician, Society of Critical Care Medicin consensus conference: Defi- nition for sepsis and organ failure in sepsis, ,Crit Care Med, 20, 864 - 874.
3. Carcillo J.A, Fields A. I, Task force com- mittee Members (2002). Clinical practice parameters for hemodynamic support of pediatric and neonatal patient in septic shock, Crit Care Med, 30, 1365-1378.
4. Dellinger R.P, Carlet J.M, Masur H et al (2004). Surviving sepsis campaign Guidelines for menagement of severe sepsic and septic shock.
Intensive Care Med, 30, 536 - 555.
TCNCYH Phu trwong 74 (3) - 2011 6. Marchant OR, Carlos EA, Jimenez O (2004). Septic shock of early or late onset: does it matter?. Chest, July 126 (1) 173 - 8.
7. Mayer TA (1992). Shock in the Pediatric Patient in Schwartz GR (ed): Principle and practice of Emergency Medecine, Philadelphia/London, Vol 112504-2515.
8. Praveen K (2005). Clinical management guidelines of Pediatric septic shock, Indian J Crit Care Med; 9; 164.
9. RimarJM (1986). Shock in infents and children:
assessement and treatment, March Vol 13 M.C.N: 98 -105 10. Dauger S, Llor J, Aizenfisz s (2004).
Approche therapeutique en 2003 du choc septique de I'enfant dans les deux premieres heures.
Archives de Pediatrie, 11, 1014-1017.
Summary
STUDY ON EARLY DIAGNOSIS OF PEDIATRIC SEPTIC SHOCK IN INTENSIVE CARE UNIT OF THE NATIONAL HOSPITAL OF PEDIATRICS
Objective: to find some clinical and laboratoy symptomes to diagnose early pediatric septic shock.
Patients and method: 67 patients were diagnosed septick shock treated in intensive care unit (ICU) of National hospital of peditries (NHP) from June 2003 to november 2006, createria of diagnosis septic shock base on ACCM/SCCM 2002, method: prospective description. Results: the clinical and laboratory symptomes following: the alternating mental with PPV 76%, Sn 91%, Sp73% and p < 0.001, quick and weak pulse with PPV 68%), Sn 88%, Sp58% and p < 0.001, oliguria with PPV 72%,Sn 76%, Sp 70% and p
< 0,001, prolong refill with PPV 74%, Sn91%, Sp 66% and p < 0.001,increasing blood lactate with PPV 62%, Sn 40%, Sp 76% and p < 0.05. Conclusion: It could use the alternating mental, quick pulse, less urine output,prolong refill and increasing blood lactat in early diagnosis of pediatric septic shock.
Keywords: pediatric septic shock, early diagnosis of septic shock
THU'C TRANG HUYET AP VA MOT S6 YEU TO A N H HU'O'NG
• • •
D^N HUYET AP CUA BENH NHAN NHOI MAU NAO GIAI DOAN CAP TAI BENH VIEN 121
Nguyin HQ'u Tue\ Pham Thing^
^Benh vien 121, ^Bdnh vidn L§o khoa Trung wang
Nhoi m6u nao la benh thwang g$p, cd ty le tw vong cao do dd vi$c kiim soat huyit ap trong nhung gid diu rit quan trQng. Muc tieu: danh gia thwc trang huyit ap va mot so yiu to anh hwang din huyet ap cua benh nhan nhoi mau nao giai do$n cip. Nghien cwu tren 106 benh nhan nhdi mau nao giai doan cip diiu tri tai khoa dpt quy, b^nh vi$n 121 duvc danh gia vi tiin sw tang huyit ap, con sd huyit ap trung binh luc nh$p vi$n, cac bi$n phip h$ ip trwdc khi nhip vien, kit qua diiu tri (theo Rankin). Kit qua: 52,8% benh nhan cd tiin sw tang huyit ip, 55,7%
.b^nh nhan da duvc dung thuoc h^ huyet ip trwdc khi nhap vien. Huyit ip trung binh luc nhip vi^n li 106 ±16,6 mmHg. Kit qua diiu tri dat tot chiim 50,9%; khdng thay doi 30,2% vi xiu 18,9%. Trong nhdm d$t kit qui tot cd 97,6% duvc xic dmh huyit ip d0ng mach tmng binh luc nhip vi^n > 110 mmHg. Kit luin: Cd moi liin quan giCra huyit ip trung binh khi nhip vien vdi tien luxyng benh.
Tir khoi: nhdi mau nao, tang huyit ap
I. DAT VAN O i
Tai biin mach nao (TBMN) l i nguyen nhan gay tu- vong thCp hai tren toin the gidi, sau benh tim mach. Tai Chiu Au, ty le tCr vong hing nim ting tip 63,5 d i n 273,4/100.000 trudng hgp [8]. Nhdi mau nio chiim 80 - 85%) eic trudng hgp TBMN l i bdnh ly giy ra do t i c nghen mach miu tai mdt khu vyc giy ngipng cung cip oxy v i glucose cho nao, d i n din giam q u i trinh trao doi chat cua khu vue nio bj thiiu miu.
Oiiu trj nhoi mau nao trong nhii-ng gid diu bao gdm vide kiim soit tdt tinh trang than kinh v i cie chCpc nang sdng nhu huyit i p , mach, dd bao hda oxy, dudng huyet v i nhiet dp [6]. Trong dd vide kiem soat huyit ap trong nhu-ng gid dau bj nhoi miu nio l i yiu to rit quan trpng doi vdi tien lugng benh. Nhiiu nghidn cu-u cho thay nhu'ng benh nhin cd huyit i p cao nhit v i thap nhit trong 24 gid diu sau nhoi miu nio ed tien lugng x i u han [7,10]. Huyet i p thip hoic binh thudng thip ICie khdi phit dpt quy l i bit thudng, v i ed t h i l i hau qua cua nhoi miu nio Idn, suy tim, thiiu miu cue bd, giam thi tich tuin hoin hoac nhiim khuan huyit.
Tren thye t i , vide kiem soat huyet i p trong nhii-ng gid diu trude khi nhip vien cdn nhiiu bit cip. Xuit phit tCp thye te dd, chung tdi tiin hinh nghien cu-u d i t i i : "Nghien eu-u thye trang huyet i p v i mdt so yiu td anh hudng d i n huyit i p eua bdnh nhin nhdi miu nio giai doan c i p tai Benh vidn 121" nhim muc tieu:
1. Md ta tinh trang huyit i p d benh nhin nhoi miu nio giai doan cip tai benh vien 121.
2. Phin tich cie yiu td anh hudng din huyit i p d nhdm nghien cu-u tren.
II.
D 6 ITU'QNG VA PHU'QNG
PHAP 1. Ddi tu'O'ng: Tat ca benh nhin dugc chin doin xic djnh la nhoi miu nio, diiu trj ndi trCi tai khoa Ddt quy, bdnh vidn 121 tii-10/2009 din 12/2010.1.1. Tieu chuan chon mau: phai du eic tieu chuin sau:
- NhPl miu nip thoa min tidu chuan chin doin cua TP chCPC y t i t h i gidi (WHO) (TCYTTG).
- Nhip vidn trong vdng 24 gid dau eua benh
tinh tip khi khdi phat.
Chup CT Scanner cd hinh anh nhoi miu nao (tieu chuan vang). Niu chua rd ton thuang trdn phim d giai doan sdm thi dya v i o lim sing chin doan sdm nhoi m i u nio, sau 24 gid chup lai de xac djnh chin doin.
1.2. Tieu chuan loai trCe - Nhoi mau nao dudi liu.
- Cie nguyen nhan g i y t i e mach nio.
- Cd kem benh suy thin man phai ipc miu, xa gan...
2. Phu'ang phap
- Md ta tiin CCPU, ngiu nhien, khdng doi chCpng.
Bdnh nhin nghien CCPU dugc c i p CCPU v i diiu trj til- luc nhip vidn den 3 tuin sau dd.
- Phuang phap dieu trj:
+ Dieu trj tridu chCpng v i theo ddi sat cie chi so sinh ton nhu huyet i p , hd hip, thin nhidt, nude, dien giai, dudng miu v i cac bleu hidn eua suy tim.
+ Huyit i p : Trong nhu-ng ngay diu, diiu chinh v i duy tri 110 mmHg ^ huyit i p trung binh < 130 mmHg.
+ Su- dung cie thuoc bao ve te bio than kinh.
+ Su- dung thude khang ddng niu ed chi djnh.
+ Phdng v i diiu trj cie biin chCpng: phii nio, trio ngugc, vidm phoi...
+ T i p van ddng sdm, dieu trj dy phdng cip 2.
2.1. So Iwang benh nhan: 106 benh nhin dugc tuyin chpn thep phuang phip tich luy ed chu dich.
2.2. Cac chi tieu theo doi va danh gia
- Dac diim bdnh nhin: tuai, gidi. Tiin SLP ting huyit i p . Khdi phit benh: cd ting huyit i p hay khdng; huyit i p luc v i o vidn; dao ddng eua huyet i p trung binh; ed SLP dung thude ha i p hay khdng.
Xet nghiem m i u : Na* K * ChCpc ning that trii: EF (%,)
- Kit qua diiu trj: (theo Rankin)
+ Tot: benh nhin cd tinh trgng cai thidn tot han so vdi luc v i o vien, tinh, i n udng dugc.
+ Khdng thay doi so vdi lOc nhip vidn.
+ Xau: Benh nhin nang han so vdi IGc vio vi$n, hdn me, tinh trang ddi song thye vit hoic tu" vong.
2.3. Thu thap va xir ly so lieu: So lidu dugc xu' ly tren phan mem SPSS 17.0. Cie so lidu so sinh d i u dugc quan t i m d i n dO tin eiy p.
TCNCYH Phu trwong 74 (3) - 2011
K^T QUA
Dac diem benh nhan
Tong so 106 bdnh nhin, dugc chin doin TBMN theo tieu chuan eua TCYTTG. Tuoi thip nhit l i 44, cao nhit l i 91. Tuoi trung binh l i 65,25 ± 11,43, ed 56 trudng hgp ed tiin SLP tang huyit i p , chiim 52,8%.
Thye trang huyit ap cua benh nhan
Cd 59 benh nhin dugc su- dung thude ha huyit ap trong cap cu-u ban diu, chiem ty Id 55,7%. Chu yiu l i su- dung thude dudng uong, 26 trudng hgp, chiim ty Id 44,07% (Bang 1).
Bang 1. Su' dung thude ha ap trong cip cdeu ban diu
Thuoc ha ap
Dudng diing
Cd Khdng Dudi ludi
Udng Lgi tieu TM
Phdi hgp
n 59 47 10 26 12 11
% 55,7 44,3 16,95 44,07 20,34 18,64
binh luc nhip vien < 110 mmHg, chiim 54,7%.
Dien giai do cho thiy cd 3 trudng hgp (2,8%) cd giam Na miu va 31 (29,2%)) ed giam K miu.
Kiem tra sieu i m tim thiy 12 trudng hgp cd EF
< 40%, chiim 13,1% (Bang 2).
Bang 2. Phan suit tdng mau thit trai tren sieu am tim
Huyit i p trung binh luc nhip vien l i 106,06 ± 16,5 mmHg. Cd 58 benh nhan cd huyit i p trung
EF (%)
<40
>40 X ± S D Min - max
n % 12 11,3 84 79,2
57,93 ±11,2 29-74 Phan tich cac yiu td anh hu'd'ng din huyit ap o- benh nhan TBMMN.
Bang 3. Lien quan giO'a xip tri ban diu vd'i HADMTB khi nhap vien
^^^.^^^^ HADMTB Thude HA ^""~^--~-^
Khdng diing Cd Tdng
'~~----..,...^^^ HADMTB K* ^ ^ ^ ^ ^
<3,5
>3,5 E
<110 n 16 42 58 Bang 4. Lien i
<110 n 23 35 58
mmHg
% 27,6 72,4 100
>110 mmHg n
31 17 48
% 64,6 35,4 100 quan giO'a rdi loan K^'mau vd'i HADMTB
mmHg
% 39,7 60,3 100
>110 n 8 40 48
mmHg
% 16,7 80,3 100
n 47 59 106
n 31 75 106
Tong
Tdng
% 44,3 55,7 100
% 29,2 70,8 100 x' = 6,708; p < 0,05; OR = 3,29. Dp tin cay: 95% CI: 1,3 - 8,27.
B$nh nhin nhip vidn cd huyit i p trung binh > 110 mmHg cd kit qua diiu trj tot dat 97,6% vdi p < 0,001 (X^ = 28,18; p < 0,001; OR = 0,018. Dp tin eiy: 99% CI: 0,002 - 0,151).
IV. BAN LUAN
Qua nghidn CCPU thye trgng huyit i p v i mdt so yiu t i inh hudng d i n huyit i p cua bdnh nhin
Benh vidn 121 tif 10/2009 din 12/2010, ehung tdi nhin thiy:
v i tuoi v i gidi: Bdnh nhin trong nghidn CCPU
cua Chung tdi cd tuoi trung binh l i 65,25; thip nhit
la 44 va cao nhit la 91. TCP 60 tuoi trd len gap 63,2%. Theo k i t qua Nguyin Van Thdng [9] ti Id niy l i 68,5%; Hoing Khanh [5] 58,26% v i Nguyin Cdng Hyu [4] 72,3%.
Ve thye trang huyit i p , k i t qua nghien cu-u cua ehung cho thiy ti Id benh nhin khdng biit cd ting huyit i p hay khdng la 47,2%). Theo Vu Ngpc Lien [7] ti Id nay la 63,8%; Hoing Khanh [5] l i 64,4%.
Trong nghien CCPU eua ehung tdi, ed 59 benh nhin (55,7%)) dugc su- dung cac thude ha huyit i p khi sa
CCPU ban diu. Trong dd ed 26 trudng hgp (44,07%i) diing thude udng, 12 trudng hgp (20,34%) diing Igi tiiu tTnh mach, 11 trudng hgp diing thude phoi hgp thuoc udng v i thude Igi tiiu tTnh mach. Ding ehCi y la cd 10 trudng hgp (16,95%)) diing thude ngim dudi ludi (tic dung nhanh), mac dii trong cac khuyin cio eua Hdi Tim mach Viet Nam da nhin manh khdng diing Nifedipine cung nhu bit CCP bien phap ha huyet ap manh nao de tranh gay tut huyet ap qua mCPC lam cho tinh trang nhdi mau nao nang len [6], diy cung la thye trang cin canh bio tai cac ca sd y t i .
Nghien CCPU cua chCing tdi cho thiy huyit i p trung binh la 106,06 mmHg. Theo Nguyen Cdng Hyu [4] con sd nay l i 123,6 mmHg. Trong so 106 benh nhin nhdi miu nio ed tdi 58 benh nhan (54,7%) ed huyit i p trung binh < 110 mmHg. &
nhdm benh nhin cd huyit i p trung binh luc nhap vien
< 110 mmHg, cd tdi 19 benh nhin (57,6%) ed tiin triin xiu. Trong khi dd d nhdm benh nhin cd huyit i p trung binh >110 mmHg, con so nay l i 1 (2,4%)), sy khac bidt cd y nghTa thing ke vdi p < 0,001. Rd ring vide ha huyit i p qua thip cd anh hudng x i u din tien lugng benh. Sinh ly bdnh cua nhdi miu nio da chi ra ring sau khi tac mach nio, chi trong vdng vii phut, trung t i m cua viing bj nhdi miu da xuit hien t i bio nao chit. Viing xung quanh trung tim gpi la viing tranh tdi tranh sing, v i mat ehCpc ning da bj suy yiu nhung te bao nao vin cdn Kha ning phuc hdi do he thing tuin hoin bang he.
Chinh vi viy da sd t i c gia cho rang vdi nhdi miu nio, chi nen diiu tri khi huyit i p > 220/120 mmHg.
Thim chi, d nhiiu trung t i m , ngudi ta chi xem xet viec dung thude ha i p trong trudng hgp benh nhin ed suy tim nang, suy thin cip, tach phinh quai ddng mach chu, hoac t i n g huyit ap i e tinh [10].
Khuyin cao 2008 cua Hdi Tim mach hpc Vidt Nam v i chin doin va diiu trj nhdi m i u nao c i p nen duy tri huyit i p a mCpc 180/100 105 mmHg (cd tiin SLP tang huyet i p ) v i d mCpc 160 -180/90 -100 mmHg (khdng cd tiin su- ting huyit ap) [6].
V. K^T LUAN
Qua nghien cu-u 106 benh nhan nhdi miu nao giai doan cip, diiu trj tai khoa Dot quy, Bdnh vidn 121 tip 10/2009 den 12/2010, ehung tdi nhin thiy:
52,8%) BN cd tiin SLP tang huyet i p , 55,7%
benh nhin da dugc dung thude ha huyet i p trud-c khi nhip vien. Huyit i p trung binh luc nhip vien la 106 ± 16,6 mmHg.
Kit qua diiu trj dat tot chiim 50,9%; khdng thay doi 30,2%) v i x i u 18,9%). Trong nhdm dat kit qua Tdt cd 97,6% dugc x i c djnh huyit i p dpng mach trung binh luc nhip vien > 110 mmHg.
- Cd moi lien quan giu-a huyit i p trung binh luc nhap vien vdi viec XLP tri ban diu bing cac thuoc ha i p , phan suit tdng mau thit trai tren sieu am va roi loan K*mau.
TAI LIEU THAM KHAQ
1. Le Quang Cu'd'ng (2004). Dieu tri nhoi mau nio. Thin kinh hpc lim sang - Nhi xuit ban Y hpc: 188.
2. Doan Van De, Trjnh Qudc Hu'ng (2004).
Nghien cu-u huyit i p eua benh nhin dot qui nao giai doan c i p bing miy theo ddi huyit i p lu'u ddng. Tap chi Y hpc Viet Nam, tap 301: 81 - 85.
3. Nguyin Cong Hyu v i CS (2004). Tim hieu sy thay doi huyet ap trong tuin diu tien d benh nhin tai biin mach m i u nao do tang huyit ip. Tap chi Y hpc Viet Nam. Tap 301: 222 - 227.
4. Hoang Khanh (2000). Tang huyit i p va the tai bien mach nao tai benh vien Trung U'ang Hui.
Tap chi Tim mach hpc so 4/2000: 208 - 213.
5. Vu Thj Ngoc Lien va Cong sy (2009). Tinh trang tang huyit ap d bdnh nhin dot quj cip thieu miu nao cue bd cd tang dudng miu diiu trj tai benh vidn Bach Mai.
6. Nguyin Van Thdng. Nhin xet die diim, tinh chit, ca c i u benh tai trung t i m Ddt qui bdnh vien Trung U'ang Quin ddi 108. Tap chi Y hpc Vi^t Nam, t i p 301: 3 - 1 1 .
TCNCYH Phu trwong 74 (3) - 2011 7. A.Chamorro, N.Vila, E.EIices et al (1998). g. Harold P, Adam Jr, MD Birgitte H et al Blood Pressure and Functional Recovery in Acute
(1993). Classification of Subtype of Acute Ischemic Stroke. TROKE 24; 3 5 - 4 1 .
Ischemic Stroke. STROKE 29; 1850 - 1853.
8. Guideline (2003). The Seventh report of the
Joint National Committee on Prevention, detection, 10. Mahon M; Chalmers J; Anderson C et al evaluation and treatment of high blood pressure. (1997). Blood Pressure and Stroke Prevention.
JNC 7, JAMA; 289; 2560 - 2571. Science Press Ltd 34 - 42.
Summary
EVALUATION THE ACTUAL BLOOD PRESSURE AND A NUMBER OF FACTORS AFFECT TO BLOOD PRESSURE OF PATIENTS WITH ACUTE ISCHEMIC STROKE
Acute Ischemic Stroke (AIS) is a common disease, with high mortality rates. The control of blood pressure (BP) in the first hours is important. Objective: to assess the actual BP and a number of factors affect to BP of patients with acute ischemic stroke. Subjects and Methods: 106 patients with AIS in stroke unit of hospital 121 were assessed for history of high blood pressure, the average blood pressure at admission, anti - hypertensive measures before admission, and treatment outcomes (by Rankin). Results:
52.8% of patients had a history of high blood pressure. 55.7% of patients were taking antihypertensive drugs before admission. Average BP at admission was 106 ± 16.6 mmHg. Treatment outcomes: good result (50.9%), unchanged (30.2%)) and bad result (18.9%). In group of good results, 97.6% had average BP > 110 mmHg at admission. Conclusion: There is an association between average BP at admis- sion and the prognosis of acute ischemic stroke.
Keywords: acute ischemic stroke, hypertension
TAC DUNG
G I A MDAU CUA MORPHIN - SUFENTANIL KHOANG DU'QI NHEN TREN BENH NHAN MO TIM HO
Nguyin Van M i n h \ Nguyin Qudc Kinh^ Bui DCFC Phu^
^Trwong Dai hoc Y Dwac Hui, ^Benh vien Viet Dwc, ^Bdnh vien Trung wang Hui Danh gii tic dung giam dau va tic dung khdng mong muon cua morphin va sufentanil tiem khoang dwdi nhen tren benh nhan mo tim hd. Nghien cwu can thiep lam sang, 75 benh nhan dwac mo tim hd di thay/swa van, vi lo thdng lien nhi thdng lien thit duvc chia thanh ba nhdm: nhdm 1 (nhdm chirng), nhdm 2 diing morphin khoang dwdi nh$n 0,3mg.
nhom 3 kit hap morphin 0,3mg va 25mcg sufentanil Sau mo tat ca benh nhan duvc giam dau bang morphin tinh m^ch qua miy PCA. Luvng morphin tieu thu trong 48 gia a nhdm 2va3 thip han a nhdm 1 (13,73 ±7,47 va 11,20 = 4,38 so vdi 29,26 ± 7,62mg). Diim dau VAS vao thdi diim 8 gid sau mo, so benh nhin cin morphin trong 6 gid dau, Iwang sufentanil dung trong mo a nhdm 3 it han cd y nghia thong ke so vai nhdm 1 va 2. Thdi gian riit npi khi quan khdng khac nhau giira cac nhdm vitu'7-9 gid, ty le tic dung khdng mong mudn thip a tit ca cac nhdm. Kit luin: morphin ket h(?p vdi sufentanil tiem khoang dwdi nh$n cho tie dung giam dau hieu qua tren benh nhan mo tim hd vi it tic dung khdng mong muon.
Tu- khoa: mh tim, sufentanil, morphin khoang du-o-i nh?n, giam dau
I. D A T V A N D £ j3| benh tim b i m sinh, 10000 ngudi bj benh van tim Nhu c i u m i tim h d tren t h i gidi cung nhu d m i c phai, g i n 50% trong sd dd c i n can thidp p h i u Vidt Nam n g i y c i n g t i n g . Tai My, ed khoang thuit [1]. Md tim hd, vdi dudng md xuang CPC, banh 666000 trudng hap d u g c mo tim h d trong n i m ngyc, phiu tich e i c mach m i u Idn v i d i t dan luu, 2003, eon s i n i y t i n g len 709000 v i o n i m 2006. gay dau r i t manh, nhit l i ngiy d i u tien sau mo. Dau