TAPCHfYDUgc LAM SANG 108 T3p 11-S6 5/2016
Nghien cihi kit qua dilu tri soc nhigm kliuSn co ket hop loc mau tmh mach - tinh mach lien tuc ( C W H )
Resesarch the result of the treatment of septic shock combined with continuous venovenous hemofiltration
Hoang Cong Tinh*, Uokng C6ng Lirong* *Benh vien Da khoa tinh Hoa Binh Le Thi Viet Hoa**, Nguyin Phmmg D6ng** **^^«^ ^^^» ^'^"^ "''^^ 2"^« '^^^ ^^-^
Trln Dlc'xifp*** ***^^"'' ^'^" Qudny 103
Tdm tat
Muc tieu: So sanh ket qua dieu tri gida nhdm benh nhan soc nhi^m khuan co kdt hap Ipc mau tTnh maeh - tTnh maeh lien tuc vdi nhdm didu trj theo kinh dien. Doi tugng vd phuang phdp: 109 benh nhan
t
sdc nhiem khuan. Trong dd, 52 bdnh nhan dieu t n soe nhiem khuan cd ket hpp loe m l u tTnh mach - t m h mach lidn tuc (nhdm 1), 57 benh nhan dieu tri soc nhiem khuan theo kinh dien (nhdm 2). Ket qud: Lieu thudc van mach nhdm 1 giam co y nghTa thong kd t d thdi diem 24 gid va cCia nhdm 2 I I 48 gid so v d ! thdi diem Ti. Huyet ap trung binh cua nhdm 1 tang ed y^ nghia thdng ke tilf thdi ^ e m 24 gid va cCia nhdm 2 la 48 gid. Thdi gian t h o l t SNK nhom 1 trung binh la 78 gid, nhom 2 la 97 gid, k h i c biet cd y nghia thdng ke{p<0,01). Ngay dieu trj trung binh nhdm 1 la 11,5 va nhdm 2 la 12,7, khac biet c o y nghTa thdng kd(0<0,01).Kef/uan.Dieu tri soe nhiem khuan ed ket hpp Ipe mau tTnh mach-tTnh maeh lidn tue (nhdm 1) giijp giam l i i u thuoc v i n mach, cai thien huyet ap trung binh, rtit ngan thdi gian thoat sdc n h i l m khuan v^ giSm sd ngay dieu t n t d t hon so vdi dieu t n kinh dien (nhdm 2).TUkhoa: Soe nhiem khuan, Ipe mau tlnh maeh - tTnh maeh lien tue.
Summary
Objective: Comparing the result of the treatment between patient group of septic shock combined with continuous venovenous hemofiltration (CWH) and patient group of traditional treatment. Subject and method: 109 patients with septic shock. Of whom 52 was treated septic shock combined with C W H (group 1), 57 were treated septic shock using traditional method (group 2). Result: The dose of vasoactive drugs was statistically significantly declined from the 24"^ hour onwards in group 1 and t h e 48"^ hour onwards in group 2 compared with the time of T l . There was a statistically significant increase in mean blood pressure (MBP) in group 1 from the 24'^ hour onwards and the 48*'' hour onwards in group 2 compared with the time of T l . Mean shock escaping time in group 1 and group 2 was 78h and 97h respectively, the statistically signigieant difference (p<0.01). Mean number of day in hospital of groups 1 and groups 2 was 11.5 and 12.7 respectively, it was statistically significant (p<0.01). Conclusion:
Treating septic shock in combination with C W H (group 1) help to decrease the dose of vasoactive drugs, improve mean blood pressure, shorten septic shock escaping time and reduce number of day in hospital compared with those of traditional treatment (group 2).
Keywords: Septic shock, continuous venovenous hemofiltration.
Ng^ nhgn 1/8/2016. ngay chap nhgn 19/10/2016
Ngu&i pfidn hoi: Hoang Cdng Tinh, Binh vien Da khoa Tinh Hda Binh
JOURNAL OF 108-CLINICAL MEDICINE AND PHARMACY Vol.11-N-SQOie
1 . Oat Vein de
Soc nhiem k h u i n (SNK) t h i r d n g dan den suy da t a n g , la b^nh ly co t ^ le t i l v o n g cao tai cac Khoa Hoi sutc tfch ciic. ViSc chan doan s6m, dieu trj l!jp t h d i theo phac do h o p ly giup lam giam t J le til v o n g fl BNSNK[1],[5].
Loc mau t l n h mach - t m h mach lien tuc (OWH) duoc chlJng m i n h la giup dao thSi cac cytokine, c§n bang nuflc dien giai va rdi loan t o a n kiem, dieu chinh cac roi loan h u y f t d o n g , cai t h i 6 n lieu t h u d c van mach va huyet ap 6 BN SNK [2], [5], [7]. S e nghien cLiu hieu q u i cua Ipc mau t m h mach-tlnh mach liSn tuc t r o n g dieu tr| SNK, chung t d i nghien cufu de tai n^y nham muc tieu: So sdnh tt^t qua dieu tri gida nhom benh nhdn soc nhiem khudn co ket hap loc mau tinh mach - tinh mgch lien tuc (CWH) vdi nhom dieu tri theo kinh dien.
2. Doi tUtfng va phUtfng phap 2.1. Ooi tupng
109 BN SNK dieu trj theo SSC 2008 tai Khoa Hoi silc Tich cue - Benh vien Trung u o n g Q u i n ddi 108, Benh vien Bach Mai, Benh vien Ba khoa t i n h Hoa 3. Ket qua
3.1. Ddc diem benh nhdn
Binh t i r t h a n g 12/2011 den t h a n g 12/2014, 52 benh n h a n co ket h p p C W H , 57 b e n h nhan k h o n g C W H (khdng d d n g y C W H ) .
2.2. Phuang phdp Tien CLiu, m d ta cd so sanh.
2.3. Tiin hdnh
B i i u t n SNK t h e o khuyen cao Surviving Sepsis Campaign 2008 [6], * |
B a t catheter 3 n o n g t m h mach t r u n g t a m : Theo'^
ddi CVP, truyen djeh, d u n g t h u d c .
Dat catheter Ipc m a u 2 n d n g 12F t m h mach t r u n g ttm d i i i phai hoac dOi trai.
C W H vdi t h e t i c h djeh t h a y t h e Idn 45 m i / k g / g i d , sil d u n g d u n g djeh t h a y t h e Hemosol, siJ d u n g chdng d d n g heparin hoac citrate.
DCrng C W H khi BN t h o a t sdc nhiem khuan:
NgBng van mach dupc 12 g i d HATB s 6 5 m m H g . B a n h gia lam sang, c$n Iam sang tai cac thdi diem;T, (thdi diem chan do4n SNK), Tj (sau 24 gid), T, (48 gid), T. (72 gid), Ts (96 gid), trUdc C W H , sau CWH.
2.4. XUIfsd liiu
Theo phi^ong phap t h d n g ke y hpc.
Bdng 1 . Dac diem benh nhan nghien c i ^ Thdng so
Nam(n = 73,%)
Tudi (n = 109, X + SD, Min-Max, nam)
Tl le suy da tang (n = 109, %)
Sd tang suy ( n = 109) (X ±SD) Biem APACHE II (diem) (n = 109) (X + SD) Diem SOFA (diem) (n = 109) (X + SD)
Gia trj 73/109(67%)
59,3 + 17,1 ( 1 9 - 9 0 tudi)
109/109 (100%) 4,1 ± 0,9 25,1+3,6 11,0±1,2
^Ulk
TAP CHlY DUOC LAM SANG 108 TSpl1-S65/2016
3.2. So sdnh kit qud dieu tri giffa nhom 1 vdnhdm2 32.1. Dien bien veileu thuoc van mgch
3.2.1.1. Dien bldn ve lieu noradrenalin (micro^am/kg/phut)
^ ^ ^ ^ ^ Nhom Thdrigian ^ ~ ^ ^ ^
T, T;
Tj T, Ts Pl-2 J P,.3
P M Pi-s
Bdng 2 . D i l n bien noradrenalin cda nhom 1 va Nhdm T i n = 52)
X ± S D 0,88 + 0,78 0,75 ±0,71 0,41 ±0,68 0,25 ± 0,53 0,15 ±0,49
(^<aor>
<0,01
<0,01
<0,01
Nhdm 2 (n = 57) X ± S D 0,82 + 0,33 0,87 + 0,39 0,56 ± 0,45 0,41 ± 0,46 0,26 ± 0 , 4 9
>0,05
Cr<aor5
<0,05
<0,05 2
Chung (n = 109) X ± S D 0,85 ± 0,60 0,80 + 0,57 0,51 ± 0 , 5 7 0,30 ± 0,50 0,21 ± 0 , 5 0
>0,05
(^ <o,or>
<0,05
<0,01
Wftdn.)fet; Lieu noradrenalin cCia nhom 1 giam coy nghTa thong ke (p<0,01)ti^ thdi dilm T2. Trong khi do, noradrenalin cCia nhom 2 giim c6 y nghTa thong ke (p<0,05) ti^thdi diem T3.
3.2.1.2. Dien bien ve lieu dobutamin (microgam/kg/phut)
Bdng 3. Dien bien dobutamin cua nhom 1 va nhom 2
^ - - . ^ ^ ^ ^ ^ Nhom Thdi gian ^ . „ ^ ^
T, T2 Ts T4 Ts P.2 P H P M Pi-s
N h 6 m 1 ( n = 52) X ± S D 16.39 ± 4 1 1 14.70 ±4.86 12.57 ±6.20 9.13 ±5.31 7.43 ±5.15
<^^p<ao?>
p<0,01 p<0,01
<0,01
Nhom 2 (n = 57) m X ± S D 16.33 ±2.80 15.74 ± 3 . 5 9 12.93 ±5.15 10.86 ± 5 . 5 9 8.67 ±6.43
c;^p>o,or>
p<0,01 p<0,01 p<0,01
JOURNAL OF 108 - CLINICAL MEDICINE AND PHARMACY VoLll-N"5/2016
Nhdn xet: Lieu d o b u t a m i n n h d m 1 giam co y nghTa t h d n g ke (p<0,Q5) tit t h d i d i e m T i . Lieu dobutamin n h d m 2 giam cd y nghTa t h d n g ke (p<0,01) t d t h d i diem I s .
3.22. Dien bien vehuyetdp trung binh-HATB (mmHg).
S 6 0 -
T2 T3 Tlidldllm Bieu do 1 . Dien bien HATB cCia n h d m 1 va n h d m 2
Nhdnxet: HATB nhdm 1 tang cd y nghTa t h d n g ke (p<0,01) t i f t h d i diem Tj. Trong khi d d , HATB nhdm 2 tang cd y nghia t h d n g ke (p<0,05) t d thdi diem Tj.
3.2.3. Dien bien ve thdi gian thoat sdc (gid)
Nh6m1 Nhim2
150 Tlioi gian soc nhilm khuin
Bieu d o 2. Thdi gian thoat SNK (gid) cua n h o m 1 va n h d m 2 Nhan xet: Thdi gian thoat sdc cua n h d m 1
Khac biet c6 y nghTa t h d n g ke vdi p<0,01. t r u n g binh la 78 ± 32,6 (gift), cCia n h d m 2 la 97 ± 40,2 (gid). j
APCHlYDUOC LAM SANG 108 T5p 11-So 5/2016
3.2.4. Diln biin ve thdi gian dieu tri tgi Hoi sic tich cue
BSng 4. So ngay dieu trj t a i IHdi sl}c tich cue Nhdm
1 2 Tdng
N 52 57 709
X ± S D
10,52 ±3,837 12,70 ±4,067 17,65 ± 4 , 0 8 9
IVIinimum 2 2 2
IVIaximum 18 19 79
P
<0,01
Nhan xet: Sd ngay dieu trj t r u n g binh cua n h d m 1 la 10,52 ngay v& cua n h d m 2 1^ 12,70 ngay. Khac bidt :d y nghTa t h d n g ke vdi p<0,01.
3.2.5. Diln bien ve tyle song
Nh6m1 Nhim2
Bieu do 3. B d thj t y le sdng cCia nhdm 1 va nhdm 2 Nhdnxet:Ty le sdng cua n h d m 1 ia 61,5% va cda n h d m 2 la 54,3% (p>0,05).
k Banluan
4.7. Ode diim benh nhdn
BN cd d p t u o i t r u n g binh la 59,3 t u d i , nam gidi :hiem da sd vdi 67%; Sd BN cd suy da t a n g la 100%, d t a n g suy t r u n g binh la 4,1; Diem SOFA t r u n g binh 3 11, diem APACHE II t r u n g b i n h la 25,1.
4.2. Kit qud dieu tri cua nhdm 1 vdnh6m2 4.2.1. Diin bien velliu thuoc van mgch 6 bang 2, 3: Lieu noradrenalin va d o b u t a m i n ihdm 1 giam cd y nghTa (p<0,01) t d t h d i d i e m T2(sau 14 gid). Trong khi, lieu noradrenalin va d o b u t a m i n i h d m 2 giam cd y nghTa (p<0,01) t d Ts (sau 48 gid), IhiJng t d C W H glOp cai thiSn lieu thudc v i n mach d
BN SNK. Ket qua phCi h p p vdi cac n g h i e n ciJU khac [21, [8].
4.2.2. Diln bien vi huyet dp trung binh (HATB) HATB n h d m 1 t a n g cd y nghTa t h d n g ke (p<0,01) t d t h d i d i e m T2 (sau 24 gid), n h d m 2 t a n g cd y nghTa t h d n g ke (p<0,01) t d T j (sau 48 gid), cham hon n h d m 1 (bieu do 1). N h u v$y, dieu trj SNK ket h p p C W H g i u p cai thien HATB [2], [5],
4.2.3. Diln biin ve thdi gian thoat soc nhiem khudn d bleu d d 2: Thdi gian thoat SNK cCia n h d m 1 ngan hon nhdm 2, khac biet cd y nghTa thdng ke (p<0,01).
BI^u d d chdng t d , C W H giup BN thoat SNK sdm hon. Ket quS nay da dupc de cap trong 1 sd nghien cilu [2], [5].
JOURNALOF 108-CLiNtCAL MEDICINE AND PHARMACY Vol.11-N^S/lOie
4.3.4. Diin biin vi t^ li song, thdi gian dieu tri tgiHSTC
Tai b^ng 4 v^ bleu do 3: Thdi gian dieu tri tai HSCT cQa n h o m 1 ngan hem n h o m 2 , kh^c bidt eo y nghTa t h o n g ke (p<0,01). T;^ le song cQa n h o m 1 (61,5%) cao hon n h o m 2 (54,3%), mac dii khae bi$t khong co ^ nghTa t h d n g ke (p>0,05). NhU vay, ket h g p OA/H t r o n g d i l u trj SNK glOp rut ngein ngay dieu tri va co xu hUdng lam t a n g t y le sdng [2], [5].
5. Ket ludn
Lieu thudc van maeh cua n h o m 1 gieim co y nghTa t h o n g ke tilr t h d i ^ e m 24 g i d va n h o m 2 la sau 48 g i d sau SNK. HATB eua n h o m 1 tang co ^ nghTa t h o n g ke t i ^ t h d i diem 24 g i d va n h o m 2 tilrthdi d i e m 48 gid.
Thdi gian t h o a t SNK cCia n h o m 1 t r u n g binh la 78 g i d thap hon n h o m 2 la 97 gid, kh^c biet eo ^ nghTa t h o n g ki (p<0,01). Nhom 1 co so ngay dieu trj t m n g binh (10,5 ngay) ngan hon n h o m 2 (12,7 ngay), khae biet ed y nghTa t h o n g ke (p<0,01).
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chdn dodn vd theo doi dap Ung diiu tri nhiem khudn -i huyet, chodng nhiem khuan. L u i n in Tien sT Y hoc Bai hpc Y DUdc thanh phd Hd Chi Minh.
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Campaign: international guidelines for '}
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