BUraC DAU DANH GIA HIEU QUA CUA THAY HUYET TU'ONG TRONG DIEU TRI CON N H U O C CO NANG
TAI KHOA HOI SU'C TICH Cl/C BENH VIEN BACH MAI
Nguyen Cong Tin*, Nguyen Gia Binh*
T O M T A T - ' '
Muc tieu: 1. Nghien cuu hiiu qud cua phuang phdp thay huyit tuang trong cdp cuu can nhupe ca ndng.
2. Ddnh gid cdc bien chimg cua phuang phdp thay huyit tuang. Ddi tuang.' Tie 3/2008 din 7/2010 chung tdi tiin hdnh thay huyit tuang cho 14 binh nhdn nhuac ca nang ndm diiu tri tgi khoa Hdi siec tich cue - Binh viin Bgch Mai. Phuang phap: nghiin cim tiin cim cd can thiip, cdc binh nhdn duac ddnh gid ca luc vd xit nghiim theo protocol nghiin cieu, chung tdi sie dung huyet tuang tuai ddng lanh. Ket qua: cd 14 binh nhdn (5 nam, 9 nie), tudi trung binh 36,6 ±15,2 (21 - 61), cd 10 binh nhdn cdn phdi thdng khi nhdn tgo, lupng huyet tuang mdi ldn thay (34,6 ± 6,6 ml/kg), sd ldn thay huyit tuang trung binh 2,86 ±.95 (I -4 ldn). Cdc binh nhdn cdi thiin tinh trgng Hit ca sau mdi ldn thay huyit tuong, hdi phuc gdn nhu hodn todn cdc ca bi Hit khi ra vien, cdc biin chimg nhu phdn img di img (ndi mdn, ngira, dd da) chiim 15/40 (37,5%) tdng sd ldn thay huyit tuang, cd mpt binh nhdn phdi dieng thay huyit tuang khi cdn 1/4 thai gian vi ndi ban di ung nhiiu. Tuy nhiin, khdng cd binh nhdn nao bi sdc phdn vi, nhiem khudn mdu hoac tgi chd, thdi gian ndm viin trung binh 9,2 ± 2,94 (4 '14 ngdy).
Ket luan: thay huyit tuong cdi thiin ro ca luc a benh nhdn nhuac ca, do do rut ngdn thai gian thd indy vd ndm viin, hgn chi duac cdc biin chieng do ndm lau gdy ra, bien chimg hay gap nhdt la phdn img di ung.
L D A T V A N D E
Nhugc ca la benh Iy thin kinh co do nguyen nhan tu mien (thudng gap d benh nhan cd u tuyen lie), CO the tao ra khang the khang acetylcholin receptor lam giam acetylcholine receptor chiic nang d mang sau xi nap dan den su van ddng cua ca van yeu dan, cac ca van ddng nhieu cd xu hudng yeu nhanh, dac biet la ca hd hap (la dau hieu nang, can phai thdng khi nhan tao), su yeu co cd tinh chat tai phat [7].
Myasthenia gravis
Acelylchal)n«st«raM
Hinh 1. Phan A (khdp noi binh thu&ng); phan B (khdp noi & trong nhug'c ca)
* Benh vien Bgch Mai
Khi benh nhan bi liet nhieu nhdm co, dac biet c a hd hap, b^nh nhan phai dieu trj dai ngay, nam lau
^ ed nhieu btSn chung nhu: loet do t^ de, nhian khuan phdi lien quan den thd may, tac inach nhieu nai do nam bat ddng.
Cac bien phap dieu tri tich cue lam giam lugng khang the tu mien trong mau de cai thi^n dugc tmh trang Iam sang bao gdm: dimg thudc ire che mien dich lam giam san sinh ra khang the, lgc huyet tuong de loai bd khang the tu mien ra khdi ca the [I], [2], [4], [8].
Thay huyet tuong (Plasma exchange) la bien phap lay bd huyet tuong cua ngudi bj benh cd chiia khang the tu mien, sau dd bii lai the tich bang plasma tuai ddng lanh hoac albumin 5%o, giiip cho van ddng CO dugc hdi phuc nhanh chdng.
Tir 1976 den 1980, Marcelo va cdng su d Columbia da tien hanh phuong phap thay huyet tuong cho 21 benh nhan nhugc ca da cho ket qua rat tdt [5].
36 55 (Thang 08/2010) Y HOC LAM SANG | 39
d Viet Nam, budc dau da tien hanh thay huyet tuang cho benh nhan nhugc ca. Vi vay, chiing tdi tiln hanh nghien ciiu de tai nay nham muc tieu:
1. Nghien ciru hiiu qud cua phuang phdp thay huyet tucmg trong cdp cim can nhuac ca nang.
2. Ddnh gid cdc biin chimg ciia phuang phdp thay huyet tuang.
n . DOI TUONG VA PHU'CfNG PHAP NGHIEN CUtJ 1. Ddi tuong nghien ciiu
Tir 3/2008 din 7/2010, chiing tdi tiln hanh nghien ciru 14 benh nhan nam dieu trj tai khoa Hdi sire tich cue - Benh vien Bach Mai vdi chan doan con nhugc ca nang dua vao [7]
- Lam sang:
+ Tien sir benh: da dugc chan doan nhugc ca.
+ Cd yeu ca tiing luc, yeu tang len khi van ddng, hdi phuc khi nghi.
+ Thudng cd sup mi, cd the cd nhinh ddi, nudt khd, ndi khd.
+ Lam cac nghiein phap gang siic thay ca yeu di rd ret.
+ Test Prostigmin: (+) - Can lam sang:
+ Test kich thich dien ca: (+).
+ CT scaner nguc: cd the phat hien tuyen ire.
2. Phuong phap nghien ciru - Nghien cii'u can thiep tien ciiu
- Sd lieu dugc thu thap va ghi chep can than theo mau benh an nghien ciiu.
- Benh nhan dugc danh gia tinh trang liet ca theo tiing nhdm ca trudc va sau mdi lan thay huyet tuong va sau ket thiic dgt thay huyet tuong theo thang diem cang ca tren lam sang cua Hdi ddng nghien ciiu y hgc (Medical research council Scale for Muscle Strength) dang dugc ap dung tai khoa Dieu tri tich cue - Benh vien Bach Mai:
0: Khdng cd bieu hien co ca.
1: Co ca quan sat dugc nhung khdng cd van ddng.
2: Cd van ddng ca nhung khdng thang dugc trgng lire.
3: Van ddng ca thing dugc trgng luc nhung khdng thang dugc ddi khang.
4: Van ddng ca thing dugc trgng lire va doi khang.
5: Co luc boat ddng binh thudng.
- Benh nhan liet ca hd hip dugc do NIP, Vt tir thd trudc va sau khi thay huylt tuong.
- Benh nhan dugc lam cac xet nghiem mau tru'dc va sau mdi lan Igc huyet tuong: cdng thirc mau, ddng mau ca ban, dien giai dd.
- Benh nhan dugc lam dien ca khi cd dieu kien.
- Sd lan thay huyet tuang cho mdi benh nhan:
tuy thudc vao tinh trang lam sang va dap iing ciia benh nhan, tdi da 6 lan.
- Khoang each giua cac lan thay huyet tuong:
thay huyet tuong hang ngay each ngay.
* Cac bien cd khi thay huyet tuong (cd the phai diing cudc Igc) [3], [6].
+ Ddng mang va bau bay khi.
+ Tac hay tudt dng thdng tmh mach.
+ Dut day, va mang.
+ Khi Igt vao tuan hoan ngoai ca the.
+ Sdc phan ve.
3. Phuong tien nghien cuu
- May Igc mau: Diapact cua hang B/Braun, Prisma cua hang Gambro.
- Djch thay the: huyet tuai ddng lanh dugc tinh theo cdng thiic[8].
Vplasma = (I-Ht)x(0,065 x Wkg)
Hoac udc tinh 30 - 40ml/Kg/lin. Ca dgt khoang 200 - 250m l/kg.
- Them 2 gram canxicloma(tiem tTnh mach Igram sau 30 phiit chay va ngay trudc khi ket thuc 30 phiit).
- Ong thdng 2 ndng cd 12F.
- Thudc chdng ddng: heparin.
- Cac thilt bj cip ciin: bdng ambu, may thd, dng ndi khi quan, adrenalinlmg, dimedron, methylpresnisolon 40mg, monitoring, bom tiem dien.
- Dung cu do NIP, Vt.
4, Xu ly va phan tich so lieu: theo thuat toan thdng key hgc SPSS 17.0.
40 I Y HOC LAM SANG So 55 (Thang 08/2010)
Nghien CLPU khoa hoc
4-
III. KET QUA
Bdng 1. Dgc diem chung Thdng so
Tudi Gidi
Thd'i gian nam vien
Thdi gian bj den khi thay huyet tuong (ngay)
Sd lugng huyet tuong/lan (ml/kg) Sd lan thay huyet tuong
Heparin bolus (Ul/lan) Heparin duy tri (Ul/gid)
Chung ( n = 1 4 ) 36,6 ±15,2
(21 -61) 5 nam - 9 nu'
9,2 ± 2,94 (4 - 14) 21,1 ±38,5
(1 - 150) 34,6 ± 6,6
(20 - 44) 2,86 ± .95
( 1 - 4 ) 739,5 ± 267,66
(300- 1000) 479,0 ±93,56
(300 - 800)
Khdng TKNT (n = 4) 42 ±17,7
( 2 5 - 6 1 ) 2 nam — 2 nii
8 ± 3 , 9 ( 4 - 1 3 ) 8,25 ± 10,6
(1 - 24) 37,4 ±6,73
(29 - 43) 3,75 ± 0 , 5
( 3 - 4 ) 715,4 ±279,42
(300- 1000) 446,2 ±87,71
(300 - 500)
CdTKNT ( n = 1 0 ) 34,4 ± 14,5
(21 - 60) 3 nam - 7 nir
9,7 ± 2 , 5 ( 6 - 1 4 )
•26,3 ±44,7 ( 2 - 150) 32,8 ±6,06
(20 - 44) 2,5 ± 0,85
( 1 - 3 ) 752,0 ± 266,33
(300- 1000) 496,0 ± 93,45
(300 - 800) Thdi gian xuat hien trieu chiing den khi tien trien nang phai thay huyet tuong dao ddng nhieu, do dieu trj thudc khdng cai thien tinh trang liet.
Thdi gian nam vien tai khoa Hdi siic tich cue trong khoang 10 ngay.
Sd lan thay huyet tuong trung binh 3 Ian/1 benh nhan.
Bdng 2. Ddnh gid ca luc nhom cff ddu mat cd vd hd hdp Nhdm CO"
Nhdm ca dau mat cd
Co hd hap
Gap ddu lgi Qugy ddu 2 bin Nhdm mdt Hd mieng Nhaicdn
Vt (ml/kg) NIP (mmHg)
Trudc PEX 3,00 ±1,57 3,71 ±1,33 3,29 ±1,20 3,64 ± 0,93 3,50 ±0,94 3,89 ± 1,76 8,11 ±4,08
Trudc khi ra vien 4,64 ± 0,84
5,00 4,71 ±0,61 4,86 ± 0,63 4,64 ± 0,63 10,25 ±0,46 21,38 ±4,98
P
< 0,005
< 0,005
< 0,005
< 0,005
< 0,005
< 0,005
< 0,005 Cac nhdm ca diu mat cd va ca hd hap cai thien rd ret cd y nghia thdng ke trudc va sau khi thay huyet tuang (vdi P < 0,005).
Bdng 3. Ddnh gid cff luc nhom cff tir chi Nhdm cu
Nhdm ca chi tren
Ndng vai Dua vai ra trudc
Ndng cdnh tay Gdp cdng tay Quay sap cdng tay
Gdp/dudi cd tay Cdm but V/dpng ngdn tay
Trudc PEX 3,14±1,23 3,21 ±1,12 3,50 ±0,86 3,71 ±0,91 3,86 ±0,86 4,00 ± 0,96 4,00 ± 0,96 4,00 ± 0,96
Trudc khi ra vien 4,33 ± 0,58 4,33 ± 0,58 4,33 ± 0,58 4,33 ± 0,58 4,67 ± 0,58 4,67 ± 0,58
5,00 5,00
P
< 0,005
< 0,005
< 0,005
< 0,005
< 0,005
< 0,005
< 0,005
< 0,005
56 55 (Thang 08/2010)
YHOC LAM SANG j
41Nhdm cu
Nhdm ca chi dudi
Ndng & giie 2 chdn Gap diti vdo bung Gdp/dudi cdng chdn
Gdp dudi bdn chdn V/d ngdn chdn
Trud-c PEX 3,29 ±1,27 3,50 ±1,29 3,57 ± 1,28 3,86 ±1,41 3,93 ± 1,27
Trudc khi ra vien 4,33 ± 0.58 4,67 ±0,58 4,67 ± 0,58 4,67 ±0,58 4,67 ±0.58
P
< 0,005
< 0,005 . < 0,005
<0,01
<0,01 Cac nhdm ca chi tren va chi dudi cai thien rd ret cd y nghTa thdng ke trudc va sau khi thay huyet tuong (vdi P< 0,01).
Bdng 4. Thay ddi ve cdng thirc mdu Thong so
Hdng cau Hemoglobin Hematocrit Bach cau Tieu cau
Trudc PEX - 4,46 ± 0,64 126,8 ±22,38
37,0 ±5,84 11,2 ±3,54 222,3 ± 87,60
Sau PEX 4,5 ± 0,78 120,4 ±30,47
35,2 ±8,43 13,2 ±4,56 221,0 ±64,97
Sau PEX 6h 4,6 ± 0,77 122,8 ±30,73
35,7 ±8,25 12,7 ±4,12 252,8 ±144,74 Khdng cd sir thay ddi nhieu ve cdng thiic mau tai cac thdi diem trudc, sau va sau 6 gid khi thay huyet tuong cho benh nhan. i .?•.<• ?i lu
Bdng 5. Thay ddi ve dien gidi dd mdu i j i< ti .;
Thong so Natri
Kali Canxi Cio
Trudc PEX 139,3 ±3,68 3,55 ±#,284 2,253 ±«,2930
105,1 ±8,17
Sau PEX 139,5 ±3,49 3,62 ± 0,289 2,851 ±0,3709
103,8 ±4,11
Sau PEX 6h 137,5 ±2,85 3,71 ±0,240 2,276 ±0,1471
102,8 ±3,37 Khdng cd su I h ^ 4di nhieu vk d i ^ gi4i 46 mau tai cac thdi diem trudc, sau va sau 6 gid khi thay huyet tiir<«^.(Jhob?nhnhan, cac ^ t f i niy vand toHig gidi ban binh thudng. _ ' ' :
Mtmg 6. may ddi ve ddng mdu
Thfiagso Protein
Albumin PT%
aPTT Benh/chirng Fibrinogen
Trv&c PEX 63,86 ± 7,448 34,80 ± 3,457 91,15 ±14,552 32,13 ±10,932 1,170 ±0,4168 3,12±0,9I4
Sau PEX 63,00 ± 5,948 35,76 ±4,866 77,95 ±14,739 47,85 ± 27,633 1,763 ±1,291 3,09 ±0,831
Sau PEX 6h 64,70 ±5,915 37,26 ±3,938 90,34 ±12,121
29,60 ± 6,783 1,038 ±0,248 3,24 ± 0,976 Cd sir giam cua PT%) va aPTT tai thdi dilm ngay sau khi thay huylt tuong, nhung tai thai diem sau 6 'id cac gia trj nay trd vl binh thudng nhu trudc khi thay huylt tuong.
Bdng 7. Thay ddi ve mgch, huyet dp Thdng sd
Mach
Huyet ap tam thu Huyet ap tam truong
Trudc PEX 88,9 ±12,85 115,3 ±11,98
71,3±9,11
Sau PEX 92,1 ±11,61 114,8± 11,09
70,1 ±8,20
P
>0,05
>0,05
>0,05
42 I Y HOC L A M S A N G So 55 (Thang 08/2010)
Nghien CLPU khoa hoc
4-
Su thay doi nhe cua mach, huylt ap trudc va ngay sau khi thay huylt tuong khdng cd y nghTa thdng ke (vdi P > 0,05)
Cac bien chiing:
Do thay huylt tuong: dj irng: 15/40 (37,5%) Ian thay huyet tuong
Do benh ly: xep phdi 5/14 (35,7%)) benh nhan, viem phdi 5/14 (35,7%)) benh nhan.
IV. BAN LUAN
Trong sd 14 benh nhan cd 10 benh nhan bj liet ca hd hap kem theo can phai thdng khi nhan tao, cd 1 benh nhan dugc thdng khi nhan tao khdng xam nhap, cdn 9 benh nhan dugc thdng khi nhan tao xam nhap.
Cac benh nhan dugc thay huyet tuong vdi sd lugng mdi lan thay (34,6 ± 6,6 ml) tuong duong vdi lugng huyet tuong udc tinh dugc khuyen cao.
Chiing tdi sur dung huyet tuong tuai ddng lanh cho benh nhan. Vi vay, cac yeu td ddng mau khdng bj thay ddi nhieu so vdi trudc khi thay huyet tuong.
Cac benh nhan cai thien tinh trang liet ca sau mdi lan thay, dac biet benh nhan hdi phuc gan nhu hoan toan cac ca bj liet khi ra vien, cung phii hgp vdi ket qua nghien ciin cua Marcelo va cdng su d Columbia klii thay huyet tuong cho 21 benh nhan nhugc ca [5].
Sd Ian thay huyet tuang d benh nhan nhugc ca thap ( 1 - 4 lan) da sd benh nhan chi can thay 3 lan da hdi phuc tdt cac ca bj liet. Dac biet, trong nghien CU'U nay cd 2 benh nhan d nhdm thdng khi nhan tao chi thay huyet tuong 1 lan, sau 1 ngay da bd may thd va riit dugc dng ndi khi quan, do vay thdi gian thdng khi nhan tao ciia 2 benh nhan nay chi 2-3 ngay. Thdi gian nam vien 5 - 6 ngay.
Cac thay ddi ve cdng thiic mau, dien giai mau tai cac thdi diem xet nghiem trudc, ngay sau va sau 6 tieng thay huyet tuong khdng thay khac biet nhieu, cac gia trj nay van nam trong gidi ban binh thudng.
Cac thay ddi v l ddng mau cd tinh trang giam ddng ngay sau khi thay huyet tuong, tuy nhien cac xet nghiem nay trd ve gia trj binh thudng sau 6 tiing, sir thay ddi nay lien quan den lieu heparin
trong qua trinh thay huyet tuong. Sir giam ddng mau nay chiing tdi khdng thay tinh trang benh nhan chay mau hoac mat mau tren lam sang va xet nghiem.
Trong nghien cun ciia chiing tdi cd gap cac bien chiing nhu phan iing dj img (ndi man, ngiia, dd da) cdn cao, chiem 15/40 (37,5%)) tdng sd lin thay huylt tuong, bien chimg nay xuat hien mudn sau khi ket thiic hoac sap ket thiic thay huyet tuong, theo tac gia Nikolina Basic ty le nay chiem 5%o sd lan thay huyet tuong frong nhieu nhdm benh khac nhau [6]. Cd mdt benh nhan phai dimg thay huyet tuong khi cdn 1/4 thdi gian vi ndi ban dj ung nhieu. Cac benh nhan nay dugc dieu trj diphenhydramin hydroclorid 1 Omg va methylprednisolon 40mg tiem tTnh mach, sau 30 phiit thi het tinh trang dj img. Tuy nhien, khdng cd benh nhan nao bj sdc phan ve, nhiem khuan mau hoac tai chd dng thdng tTnh mach Igc mau do qua frinh thay huyet tuong gay ra.
Cac bien chiing khac do benh ly gay ra nhu xep phdi chiem 5/14 (35,7%)) benh nhan, tinh trang xep phdi cd trudc khi vao vien, cac benh nhan nay deu can phai thdng khi nhan tao va soi hiit phe quan.
Viem phdi chiem 5/14 (35,7%) benh nhan, trong dd cd 3 benh nhan cd tinh trang viem phdi trudc khi vao vien, 2 benh nhan viem phdi lien quan den thd may.
Tuy nhien, tinh trang hd hap cua cac benh nhan nay deu tien frien tdt khi dugc thd may, soi hiit phe quan va SU' dung khang sinh hgp ly.
Khdng cd benh nhan nao bj loet, tac mach do han che van ddng vi thai gian nam vien ngan ngay ( 4 - 1 4 ngay) trung binh (9,2 ± 2,94 ngay).
V. KET LUAN
Thay huyet tuong cai thien rd tinh trang yeu ca d benh nhan nhugc ca, do dd rut ngan thdi gian nam vien va thdi gian thdng khi nhan tao ciia benh nhan, ban che dugc cac bien chiing do nam lau gay ra.
Thay huyet tuong cd tinh an toan cao, bien . chiing hay gap nhat la phan ung dj img va tinh trang giam ddng mau, tuy nhien cac bien chiing nay khdng gay nguy hiem den tinh mang benh nhan va trd ve binh thudng sau vai tieng khi ket thiic.
56 55 (Thang 08/2010) Y H O C LAM SANG | 43
TAI LIEU THAM KHAO
1. Anna Paola Batocchi, Amelia Evoli, Chiara Di Schino, and Pietro Tonall (2000) "Therapeutic apheresis in myasthenia gravis". Therapeutic Apheresis 4(4): 275-279
2. Adnan /, Qureshi and M. Farced K. Suri. (2000)
"Plasmaexchangefor treatment ofmyastheniagravis:
pathophysiologic basic and clinical experience".
Therapeutic Apheresis 4(4): 280 — 286
3. Andre A Kaplan, Joy L Fridey. (2009),
"Complications of therapeutic plasma exchange ", UpToDate CD version 17.3
4. Agishi T, Kaneko I, Hasito Y, Hayasaka Y, Sanaka T, OtaK, etal (2000), "DoubleFiltrationPlasmapheresis ", Therapeutic Apheresis 4(1): 29 - 33.
5. Marcelo R. Olarte, RichardS. Schoenfeldt, Audrey 5. Penn, Robert E. Lovelace and Lewis P. Rowland (I98I), "Effect of plasmapheresis in myasthenia gravis 1978-1980", Annals of the New York academy of sciences. Vol 377(1): 725-728
6. Nikolina Basic-Jukic, PetarKes, Snjezana Glavas- Boras. "Complications of therapeutic plasma exchange: Experience with 4857 treatments". Ther Apher Dial Vol 9, No 5, 2005: 391-395
7. Shawn J Bird, MD (2009), "Clinical manifestations of myasthenia gravis" CD UpToDate version 17.3
8. Shawn J Bird, MD (2009), "Treatment of myasthenia gravis" UpToDate CD version 17.3
SUMMARY
PRELIMINARY RESULT OF PLASMA EXCHANGE FOR TREATMENT OF SEVERE MYASTHENIA Objectives.' 1-To study the efficacy of Plasma
exchange in severe myasthenia gravis. 2-To evaluate complications of the Plasma exchange method. Subjects: From 3/2008 to 7/2010 we performed plasma exchange for 14 patients with
severe myasthenia gravis at the Intensive Care Department of Bach Mai Hospital. Method.' prospective study with intervention. Patients
were evaluated according to the research protocol. Results.' 14 patients (5 male, 9 female),
average age 36.6 ± 75.2 (21 - 61), 10 patients required mechanical ventilation, plasma volume changes each time (34, 6 ± 6.6 ml/kg), number of times for each patient was 2.86 ± .95 on average (1-4 times). The patient's condition improved
after each change plasma. Muscular paralysis recovered almost completely at hospital discharge.
Complications such as allergic reactions (rash, itching, red skin) accounted for 15/40 (37.5%)) of the total number of episodes. One patient must stop plasma exchange because of severe allergic rash. However, any patient have anaphylaxis, infection or blood spot. The average hospital stay is 9.2 ± 2.94 (4-14 days). Conclusion.' plasma exchange improved weak muscles condition of patients, shortened the duration of mechanical ventilation and hospital stay, limiting the complications caused by long stay in bed. The most common complication is allergic reaction.
j l ' O ' j . S ' i '
: nw jfin fjit
44 I Y HOC LAM SANG So 55 (Thang 08/2010)
