VlETHAM MEDICAL JOURNAL N°2 - DECEMBER • 2016
TIM HIEU M O T SO YEU TO LIEN QUAN DEN THE CHUYEN DANG CHAY MAU NAG d BENH NHAN NHOI MAU NAO CAP
DU-gC DIEU TRI BANG ALTEPLASE TINH MACH
T6MTAT
^ M^^tieu: Tim hleu mpt sd yeij to Hen quan den the diuyen dang chay mau nao d bpnh nhan nhoi miu nio cap dupc dieu tri bang atteplase dudng tinh madi. Phutfng phap: Mo t i 54 benh nhin nhoi mau nao rap dupc dieu bi bing alteplase dudng tinh mach CO biai diiihg diuyai dang diay mau nao ttf thing ll2010jSen tiling 10/2016. Ket qua: Cac ySu td anh dSh the chuyen dang dliy mau nao gom: tuoi > 70, ttldi gian khdi phat - ddng ttiufic, Huya i p tam tiiu >
140 mmHg, diem NIHSS > 12, dudng mau ben 10 mmol/I (OR 8,94; 95% a 1,51 - 52,73), mng nhi, Oen stf dii_ ttiio duftng, tien stf dung ttiu& chdng ddng, tiSn air nhSi mau nio, dau hleu nhdl mau nio sdm ben dipp cit ldp vi b'nh sp nio (OR 6,14; 95% a 1,01 - 39,93). Ket lu$n: Buftng miu tiin 10 mmoi/l v i dSu hleu nhoi miu nSo sdm trSn dipp phim cit Idp vl tihh so nao l i nhOhg y&i tS oo lien quan dai ttlS diuySi dang chiy miu nio ft bpnh nhin nhoi miu nao I3p dHu hi Seu huyft kha alteplasE duftng fnh madi.
W Khia: nhS miu nSo dp, biu huyet khS, chiy miu nSo chuy&, dang, yiiitd Ilin quan.
SUMMARY
UNDERSTANDINS SOME FACTORS RELATED TO SYMPTOMATIC INTRACEREBRAL HEMORHAGE AFTER T11R0MB0LYSING WITH
rt-PA I N ACinE ISCHEMIC STROKE Ohjective: to evaluate some fectois related to symptomatic Inbacerebral hemontiage due ta ttirombolysis wltti rt-PA In acute ischemic sboke Methods: Observational stiidy on 54 patients of Inbacerebral hemontiage after ttiey had a ttirombolyOc tieabnent for acute Ischemic sboke from lananry, 2010 ta Oaobre, 2016. Results: Factors related to symptixnatic Inbaoerebial hemontiage were (illkjwlng: age > 70 year-olds, time fhim onset to tieabnent, systolk: bkxxl pressure a 140 mmHg NIHSS soire above 12, glycemia above 10 mmol/i
Nguyen Binh Thuyen', Hoang Bui H4^^ Mai Duy Ton'
'BinhvlinE, 'Dglhoc rni ngl,
^ Bgnh vign Bach Mal
Chiu trich nhiSm dlinh: Nguyen Dinh TtiuySn Email: [email protected] Ngiy nh|n bil: 10.9.2016 Ngiy phan Mpn khoa hpc: 21.11.2016 Ngiy duylt bil: 30.11.2016
(OR: 8,94; 9S%a 1,51 - 51,73), flbrlliation ahn f i hlstoiy of diabete, current anticoagulation, histov oi la Ischemic stroke, sign of early ischemic stioke on n -i (OR: 6,14; 95% Q 1,01 - 39,93). Condiisk». ii Glycemia greater than 10 mmol/l and sign of ea* t ischemic sttoke on CT were signifirantty lelated b '*!
symptomatic intiaceiebral haemonfage alter -' tiiromboiytictherapy witii rt-PA in acute IschemKstnilce. '<'
Keywords: Stioke, Oirambolysis, related feaor - ' haemorrhage conversion. ' ..
I . B A T V ^ N O I ,3 Oleu trt^ HSu huyet khdi dtfdng Snh m?di i ^'''
phudng phap chinh trong dieu b| nhoi miu nao '^^
cap tfnh va cd hISu qua ca ve iam sang, chi plii ^-'^
dieu b l . Tuy nhlSn stf dpng tieu spl huya oi IHn '•
quan vdi nguy cd tSng ty lp chuySn dang dily • mau nao. Theo ket qua nghlSn ctfu ciia Vifn '- ^ nghien ctfu c i c Rdi loan thSn kinh va dpt qoy •"
nao qude gla (NINDS) thi ty IS chuySn dpng ciiiy " ' m i u nao x i y ra d 10,6% bpnh nhan [1]. " ' i *
Cac nghlSn ctfu frSnthS gidi da chi raySuB "«
dp' doSn nguy cd chuyin dang chiy miu nao vi **•
cd t h i giiip vipc luS chpn bpnh nhSn diSu tr( BSo »(
huya khdi dat ket qua tdt [2]. Tpi ViSt Nam, '•'' chiing toi chua tim thay cdng trinh nghiSn ohi — n i o dtfpc cdng bd danh gia cu thS cac yeu tf — IiSn quan den thS chuyen dpng chay mau nio 4 — bSnh nhan sau stf dung thudc alteplase trong — nhSi m i u nSo cap ti'nh. Chinh vi vay chiing ta — tien hanh nghien a i l i nhSm muc HSu: 77m hA —•
mgt sdyeu to Ilen quan dSn the chtiy&l # $ - ^ chay maud binh nhSn nhdi miu nao dp detldj —^
bing atteplase dnh mach.
II. o d l TU(?NG VA PHUONG PHAP NGHi&l OjU 1. Bo) t u ' f n g nghlSn c l i l i 061 ttfpng nghlSn ctfu gom cic benh nllJii da dudc dieu h i tai khoa CSp ciili Bpnh vljn Bpch Mal ttf tiling 1 n i m 2010 den thing 10 nam 2016 ttida man dong ttidl cic tieu thuJn dtfdl day:
1.1. C i c b ^ n h n h S n d u ' f c diilu tr| thutc alteplase dirdng S n h mach
•t- 'nSu d i u S n V a c i i f n : - Tuol ciia bpnh nhan ben 18 tudi.
Iiu
>«1
148
YH0CVieT||AIITAP445-THAMS12-s6?-Miii Kr . " ' ^ ^ . ' ^ ' ^ ' ^ W l * phat dia nhoi mau
".ij nao cue bp cap b'nh ro rang dudi 270 phiit titfdc ktv tiling thuoc alteplase.
- Dtfpc dimg ttiuoc atteplase ttieo lieu ]^. O,60ig/kg ti'nh mach.
' I. 4 TiSu chuan lo^i truT Ik ':.,' Bpnh an khdng (Hy du cic tiidng sd
% - Benh nhan khdng dtfoc theo ddi dii fronq 1., vdng 36 gid tai benh vien.
•ill 1.2. Djnh nghia mot so bidn nghien cihl
<i 1.2.1. Tliu chuan va phan loai chuygn
•i>i iang chiy mau nao [3].
la 1) XuSt huyet ttie nhe a - HI (Hemprrhage Infirction)
'5 - Hll: Chay mau cham nhd, vCing ria ciia 6 nhoi mau.
_ - HI2: Chiy mau dang cham frong d nhoi mau, khong cd hieu livig choan ch5.
It 2) XuSt huyet the nang
* H ^ " (Parenchymal Hemorrhage) J JSEi'-'"'^" ^ * " ™'' °^ ^^ *™g '^diSi .• S * ? ' ™ ™ " ' " 9 ' =d <:o say hISu tfng choan ll did nhp.
'• -1 ' / K '^ ""^^ ddng frSn 30% o nhdl mau, i 00 gay hISu uhg choan cho dang ke.
1.2.2. TISu ChuSn cAa dau hISu nhoi ' mau nao sdm tren CLVT S9 nSo
Kh] tren CLVT sp nao ciia bSnh nhan nhdl . miu nao den sdm cd 1 bdng 4 dau hiSu sau:
• Giim ty trpng nhan beo
• Xoa my bing thu^ dao
• Mat phan biet chat bang va xam cua nao
• Xoa cac ranh cupn nao
Phan tich cac yeu td USn ludng den Uie chuyen dang chay mau nao.
Cac sff lieu Uiu t h i p se dirtfc ytst \i ben phan mem STATA 12.0.
II. OOI TUQNG VA PHircmG PHAP NGHIEN CCru
• Thiet ke nghiSn cud: Md ta hoi ctfu - Phuang phap: Tat ca ho sd benh an benh nhan nhoi mau nao cap dtfdc dieu bl thudc lieu huya khdi alteplase dtfdng flnh mach va chup phim cat Idp vi b'nh sp nao bong vdng 36 gid iioac^bat cu- khi nao benh nhan cd bleu hiSn chuyen dang chay mau nao. Danh gla ket qua chup cat idp vi ti'nh sp nad tiieo phan loai ECASS I. Plian ti'ch cac yeu td tiSn IuBng ijen the chuyen dang chay mau nSd. Cac sd IISu thu ttipp se dudc xiy ly bdn phan mem STATA 12.0.
-_Phan ti'ch cac yeu td USn Itfpng ddn the chuyen dang chay mau nao. Cac sd IISu thu thpp se dtfpc xtf ly bSn phan mem STATA 12.0.
I I L K f t - Q u A N G H i e N C O U
3 . 1 . oac diem Chung: Ttf Uiang 1/2010 den ttiing 10/2016, co 54 bSnh nhSn phu hdp vdl tieu chuan chpn va leal tiir. Trong dd cd 21/54 (38,89%) xuat huyet UiS nhe v i 33/54 (61,11%) xuat huyel tile nSng.
ldi (nim) Thdl qian klidi phat - disu tri (philn
iiuveiap tam ttiu fmmliq) Diem NIHSS Qudng mau fmmnl/l)
Rung nhi ihni ...I.. .ji.r.S—
iu hleu nhoi rnau nao sdm tr^n phim Q V f s i i TTensof
Oal ttiao dtfdng Dunij chong donq
Nhoi mau nao
63,17 jL 12.38
172,41 ± 41,898143,24 ± 21,96 16,19 ± 3.85
8,73 ± 3.2529/54(53.7%) 41/54(75.9%) 10/54(18.5%) 6/54(11.1%)
. . . .. TheCDCMN i Xuathuvoh i ¥ „ » k.-.i:^ 1 ^=
YSutd
Tua
Xuat huyet
thg nhp XuSthuyet the nang
13
16
" 9 5 % a 0,159 - 7.770
1,99
0,280-14,17310.98 1,245-96,839
1.09
VlETHAM MEDICAL JOURNAL N°2 - DECEMBER - 2016
n e n su*
BTD Tien siir Nhoi mau n i o Tien suf dung
chong ddng Rung n h i Dau hidu sdm NMN
tren CLVT sp nao Nhin xit: Yeu to dtfdi bo vi ti'nh so nao trudc diet
< 1 6 Cd Kiidnq
Cd Khdnq
Cd Khdng
Cd Ktidnq Khdnq Cd
11 1 20 1 20 3 18 10 11 14 7 ig mau frSn 10 mmoi/l va dau
14 8 25 8 25 5 28 19 14 19 14 hieu nhoi mau nao
0,199 - 5 . 9 8 r B 8 , 9 4 ' - ^ 0,308-259,8^2
1.495 0,183-12.184 "
1,07 0,221 - 5,111
4,23 U,/09-12.184 "
6,14 1,014 - 39.931 sdm tren phim chup cat
IV. BAN L U A N
Qua nghlSn dru 54 benh nhan nhdi mau nao cap b'nh dudc dieu tri thudc "tieu huySt khdi alteplase dtfdng tinh mach cd bISn chtfng chuyen dang chiy mau nad chiing toi nhan thay: tuol tiung binh trong nghien a i d ciia chiing tdl la 63,2 ± 12,38 tuol, hiBng tp' nhtf ket qua ciia Mal Duy Tdn. Thdl glan khdi phat den liic dISu til ciia chiing tdl i i 172,4 ± 41,90 phut. KSt qua' cila Chung tdi cao hdn nhieu sd vdi cua Hacke W [3].
Diem NIHSS trung binh trong nghien ctfu cao hdn so vdl Maarten G [4]. Dudng mau tinh mach cua cac bSnh nhSn la 8,73 ± 3,25 mmol/l cao hdn so vdi so liSu cua Kimura vdi dtfdng mau khi nhpp vien la 8,0 ± 2,24 mmol/1 [5]
Dinh g i i ket qua chup cSt Idp vi ti'nh cho cic bSnh nhSn trong vdng 36 gid sau diSu b l tiSu huydt khoi dudng tinh mach hoSc bat ctf khi nao t d bleu hlSn chuyen dpng chiy mau cho thay: cd 6 1 % bSnh nhSn cd chuyen dang chay mau cd WSu chiihg (PH). Day chinh la Uie chuySn dang chiy m i u cd bleu hien iam sang ning ne, can cic bipn phap dieu trj b'ch cpt cd the la phau UiuSt lay khdi mau tu. Trong nghien ciiu ciia Chung tdl cd 2 bpnh nhSn cd bien chiilig chuyen dpng chay m i u ttiS ning nay. Ca 2 bSnh nhan nay deu phai du>Jc phau ttiuat md so glam ap va lay khdi mau tu.
Khi pMn tich ddn bien cac ySu td anh hudng dSi ChuySn dpng chay m i u nSo trang vdng 36 gld sau diing tiiudc tiSu huyet khdi alteplase dudng Bnh mach (bao gom cac yeu to: tuol, thdl glan khdi phit - dieu W, huySt ap tam Uiu, diem NIHSS, dudng m i u Bnh mpdi, tinh frpng rung nhi, cac dau hipu nhoi mau nao sdm tren phim chpp cSt ldp vl b'nh sp nao, tien stf dal Uiid dudng, nhoi m i u nao cu va tnln stf diing thudc chong ddng ma d day la aspirin), chiing toi thay:
Tuoi fren 70 la yeu td anh htfdng den chuyen
dpng chiy mau nao (PH2) cd y nghia tiiSng liS (OR 3,5; 95% a ; p - 0,04). Ket qua ciia dllijg tdi ttfdng ttf nhtf Mishra. Tuy nhien cic tic giS cho thay tuol khdng phai i i yeu to quan bpng nhat anh hudng den chuyen dang chay mao nao, vi vpy van cd ttie Iga chdn IJSnh nhSn ben 80 tudI de dieu tr| Heu huyet kh5i [6].
_ HuySt ap tSm ttiu tren 140 mmHg ding tt mpt yeu td IiSn quan den chuyen dang chiy mio nao vdi OR: 2,0 tuy nhiSn khong co <i nghii thdng kS vdi p > 0,05.
_ Dtfdng mau Bnh mach la mpt yeu to inh htfdng den chuyen dang chay m i u nao cd y nghTa thdng kS OR: 8,94 vdl p < 0,05. Kel qua nghien ctfu cua chiing tdi cQng tudng ti/ nhu nghiSn ciili ciia Mai Duy Ton [7] cung nhtf cila Mishra [61, khi dtfdng m i u t i n g cao sS lim ting the Uch 6 nhoi mau, dong nghTa vdi vISc ting nguy cd chuyen dpng chay m i u ttiS n?ng. • Oiem NIHSS trade dieu tri Ueu huySt khJI tren 16 se anh htfdng den USn Iming chuySn dpng chiy m i u nSo vdl OR 1,49 vdi p = 0,47, khdng cd <i nghia ttiong kS. Ket qui niy cijnj tudng Itf nhtf kel qua nghien ciili val bd oia dian NIHSS trong tiSn ludng dISu bi USu huyft khS dtfdng Hnh mpch bong 4,3 gld dau d benh nhin nhoi m i u nao cap do l i e dpng mach nao gliia [7].
Cac dau hieu sdm cua nhoi mau nao trSn phim chpp c i t Idp vl b'nh so nSo trtfdc khi dieo fri la mSt yeu td anh htfdng den chuySn dm chay mau nao cd <i nghia thdng kS vdl OR: 6,14 vdi p = 0,048.
Chiing tdl cung phSn b'ch sp' inh htfdng cua ' cic ySu t d tign stf: nhoi mau nSo dJ, dil ttiio ' dtfdng v i tien stf diing chdng ddng (aspirin), tuy ' nhien sy' i n h htfdng nay dSu khdng cd <i nghia ' ttidng ke vdl p > 0,05. Dudng m i u Bnh madi tren 10 mmoi/l (OR: 10,98, p = 0,013) v i tic ' dau hipu sdm fren phim chpp cSl Idp vl ti'nh sp
Y HQC Vl&T NAM TAP 449-THAHG 12-502-2016 i f nao (OR: 6,14, p = 0,048). Trong dd yeu Id
> dudng m i u tinh mach trSn 10 mmol/i l i yeu t d
^ inh htfdng cao hdn d i d HSn Itfdng chuyen dang
^i; dliy mau nao trong dieu tri thuoc Ueu huyet if' Idldl alteplase dtfdng Unh mach.
* V. K f r LUAN
> Hal yeu t d la dtfdng mau tinh mach > 10 V mmoi/l luc vao vien va cd cac dau hieu sdm aia
> nhoi miu nao tren phim chup cat idp vi b'nh sp
? rfiocd IiSn quan den chuyen dang chiy m i u nao
^ d benh nhan nhdi mau nao dtfdc dung thudc tiSu sdi huyet alteplase b'nh mach liSu 0,6mg/kg.
i: T A I U I U T H A M K H A O
! U NINDS rt-PA Stitike Study Group (1995).
^ Tissue plasminogen activator for acute ischemic stroke. N EnglJ Med, 333 (24), 1581-1587.
.: 2. William N. Whiteley, Karsten Bruins Slot, Fernandg Peter (2012). Risk Factors for
" ^ ^ ^ ^ Hemorrhage in Acute Ischemic Sboke _ _ ^ ^ ^ r e a t e d v^itti Recombinant Tissue
Plasminogen AcHvahir: A Systematic Review and
Mete-Analysis of 55 Studies. Stmke, 43, 2904- 2909.
3. Hacke W, Kaste M, C Fiesdil (1995).
Intravenous ttirombolysis with recombinant tissue plasminogen activator for acute hemispheric sboke. The European Cooperative Acute Sboke SbKly (ECASS). JAMA NeumI, 274,1017-1025.
4. Maarten G. Lansberg, Gregory W, Albeis , Wijman Christine A.C (2007). Symptomatic Intracerebral Hemorrhage following Thromboiyti'c Therapy for Acute Ischemic Sboke: A Review of the Risk Factors.
a. Yasuyuki Iguchi Kazumi Kimura, Kensaku Shibazaki (2010). Early sboke treatinent wiBi IV t-PA assodated witti early recanalization. J NeumI Sd, 295, 53-57.
». Nishant Kumar M ishra, H ans-Christoph DIener, Lyden Patrick D. (2010). Influence of Age on Ouhxime From Thrombolysis in Acute Sboke A Controlled Comparison In Patients From the Virtual International Stioke Trials Archive (VISTA). Sboke, 41, 2840-2848.
7. Mai Duy Tdn (2013). Cic yeu to tiSn Itfpng ket cyc xau aia dieu bj nhSI miu nSo cSp tiding 3 gid dau bang thuoc tiSu huyet khoi dudng Bnh mpch alteplase lieu tilSp. THoc Vigt Nam, 405, 81-85.
DANH GIA VAI TR6 COA K* THUAT DO AP u r c THITC QUAN TRONG LVA CHON MD'C PEEP <S BENH N H A N ARDS
Duong Due IM^nh', Ngo Trpng Toin^
Nguyin Cdng Tka', D i o Xuan Cff', Nguyin Gia Binh'.
T(3MTAT
Ttf khoa: Thong khi tiieo diien iu^c EPVent (Esophageal Pressure-Guided Ventilation), Ong tiiong thut quin cd bdng (esophageal baloon catheter). Hgc diu. Oanh gia thay doi mpt so chi so iam sang, khf miu v i cd hpc phoi khi cii d|t mtfc PEEP theo ap Itfc ttiuC quan. OH tugng. bpnh nhan dupc chan doin doin suy ho hap cap tien tiien (ARDS) ttieo tieu chuin cua Beriln 2012 (vdl mtfc dp bung blnh: 100< PaOj /HO; s 200 vdl PEEP a 5. 14* dp ning: PaOj/ROj S.
100 vdi PEEP a. 5). Thd miy tiieo ARDSnet vdl ( vt thap ) khdng cii ttiifn. PhuUng phip nghiin cdu.
Bfn cuu md t i , o3 mlu ttiuSn ti|n. BSnh nhin lay tei Bioa Hoi silt tich cpc Bach Hal. K» qui. ttf tiling 'Binh vifn da khoa Uing Bl
'Bfnl, viin Lio khoa B^ vign Bach Mal
Oiju trich nhISm chfnh: Dudng Dtfc Manh Email: [email protected] Hgiy nhin bil: 6.10.2016 figiy phan biSn khoa hpc: 30.11.2016 Ngiy duyet bii: 6.12.2016
10/2015 den 9/ 2016 iH cd 27 bpnh nhin dii tiSu chuan chpn vao nghien cilu vdl tiioi hung blnh l i 56 ± 16 tiioi, cao hiS nhat 83 hioi tiiSp nhSl l i 21 tijgi, nam gidi chiem 59%. Tnldc khi bSnh nhin dtfoc thd may tiieo chien luBc ttiong khi EPVent tSt c i ' blnh nhan dtfpc thong khi tiieo ARDSnet vdi Vt ttiap. Ket qua l i oxy hda miu khong cii ttiipn. Bpnh nhin sg dtfpc Uiong khi tileo chien Itfdc EPVent. Qua nghiSn ctfu benh nhan ARDS dutfc d|t ong ttidng tiitfc quan o i bong vio ttigt quin dS do i p Itfc ttitfc quin tileo qui binh chuan chung toi khong ghi nhin b i t k j mpt tai bien but ti^ nio xay ra lien quan. Quy ttinh Uiyc hipn ddn gian, d l lim. Kei luin: Ky UiuSt do i p itfc tiipc quan lya dipn mtfc PEEP toi tfu cho nhiitig bpnh nhan ARDS phy ttiuoc vao tiilig c i ttiS, co hpc phoi cila timg ngtfdi.
_ f e n Off*/'Ap dyng ky ttiuit niy cho t i t c i cic bpnh nhan c6 hpl chung suy hd hap cSp tiSn ttlSn.
SUIVIMARY
EVALUATING THE ROIC OF ESOPHAGEAL l>RE5SURE MEASUREMENT TECHNIQUE Tt] FIND
THE OPTIMAL l>SP IN PATIENT WITH ARDS
