TCNCYH Phu truung 80 (3A) - 2012
THAY OOI THE CHAT 6 BENH NHI TIM BAM SINH TRLPaC VA SAU DlEU TRI CAN THIEP
L e Wgoc Lan, Nguyen Thj Kim Cue Trwdng Oai hoc Y Ha Noi
Nghtdn c&u ttnh trang thd chat (cdn nang, chiiu cao) d 62 trudng hap tim bim smh dwdi 5 tudi dug'c didu th bdng can thiep phiu thuat tai bdnh vidn Nhi Trung wang Nghidn cwu nhdm danh gia can ndng, chidu cao d bdnh nhi tim bim sinh trwdc • sau diiu tn can thiep va bwdc ddu tim hidu mot sd yiu td lidn quan Kit qua nghien cwu cho thiy trudc can thidp cdn nang va chiiu cao trung binh Id -2,3 SD vd - 1,9 SD. 67,7 % sd tre suy dmh dwdng, trong dd 27,4 %> suy dmh dwang vwa vd 4,8 % suy dinh dudng ndng, 41.9 % tre cd chiiu cao < - 2SD. Sau can thidp, tinh trang dinh dwdng phuc hdi rit tdt, ty id suy dmh dwang 22,6%," trong do chi cdn 3,2% trd suy dinh dwdng vua va nang, tre cdi coc gidm cdn 32,3% l^/l&c dd ndng suy dmh dwang cd Hdn quan din chi do an khong du, tinh trang suy tim va Iwang mau'len phdi Sau can thiep. d nhdm khdng cdn tdn Iwu tinh trang dinh dwdng hdi phuc tdt hon so vdi nhdm cdn tdn luu (p < 0.05). Cd thi kit ludn tim bim smh gdy anh hwdng nang ni din tinh trang thi chit cua tre. Can thidp sda chda cai thidn rit tit tinh trang dinh dwdng.
Tip khoa: tim b i m sinh, suy dinh du'dng I. DAT V A N D £
Cung vdi phat triln n l n kinh te va y t l , benh suy dinh dudng ngay cang giam dan Tuy nhien d tre tim b i m sinh, suy dinh dudng v i n cdn la tinh trang rit pho biln. Suy dinh dudng lam nang them tinh trang benh, trong mdt s l trudng hgp can nang qua thip eung lam can trd cho viec dilu tri triet de benh. Do dd nghien ciru nay dugc tien hanh vdl eac muc tieu:
- Danh gia can nang, chiiu cao a benh nhi tim bam smh trwdc va sau dieu tri can thiep.
- Bwdc dau tim nieu mot so yeu td lien guan den tang trwang a benh nhi tim bam sinh
II. D 6 | TU'O'NG VA PHU'aNG PHAP 1. D6i tu'ang nghien cu'u: 62 tre < 5 tudi mic benh tim bdm sinh, ed chl' dinh va duac dilu th can thiep (28 tre duge phlu thuat va 34 tre dugc thdng tim) tai benh vien Nhi Trung uang, Thdi gian t i l n hanh nghien ciru tir thang 08/2010 d i n thang 01/2011
2. Phu'ang phap: mo ta, theo ddi doc.
- Phuang phap nghien ciru- md ta, theo ddi dge. Gdm hai phln.
Hdi cuu khai thac tiln sir dinh dudng, phat triln t h i chit va benh tat eiia tre tir khl sinh ra d i n thdi dilm tilp xuc vdi benh nhan
Tlln eiru: theo dol tinh trang dinh dudng va benh tat cua tre tir khl tilp xuc benh nhan d i n thdl dilm 3 thang sau dilu tn can thiep,
- Danh gia can nang va chilu cao cua tre dua tren bang can nang va chilu cao theo tull eua WHO 2006.
- S l lieu duge x u ly b i n g phuang phap thing ke y hgc va p h l n m i m SPSS 18,0.
III. K^T QUA
T u l i phiu thuat trung binh la 13 thang (18 ngay tull 53 thang), trong dd 40,3% dudi 6 thang tuoi, 62,9% dudi 12 thang tull Ty le nam/nijla 1,1.
Cac benh tim gap trong nhdm nghien ciru g i m : 44 (71%) tre tim b i m sinh shunt trai 92
TCNCYH Phu tnmng 80 (3A) - 2012 phai, 6 tre tim b i m sinh tim nhilu mau len
phoi, 9 tre tim b i m sinh it mau len phdi va 3 tre khdng cd shunt trong tim (bit thudng ddng mach vanh, tTnh maeh phdi) Trong s6 62 tre: tang ap phdi gap d 52 (83,9%) tre: 18/
62 (29%) tang ap phSi nhe, 23/62 (37,1%) tang ap phoi trung binh va 11/62 (17,7%i) tang ap phdi r i t nang. 64,6% so benh nhan bi suy tim d cac mirc dp. Suy tim gap nhieu d nhdm tre nhd < 12 thang (81%), d nhdm tre
12-24 thang va nhdm > 24 thang ty le suy tim thip han (50%) va 11,1%). T i n suit tigu chay va viem phoi gap nhilu hon d tre dudi 12'thang so vdi nhom > 12 thang (P < 0,05)
31/62 (50%) tre sinh ra can nang < 3kg, trong dd 9/62 (14,5%) tre dudi 2,5 kg. Can nang tang trung binh trong thang diu, thang 2 va thang 3 l l n luat la 790gr, 760 gr va 590gr.
Bang 1. Ty le suy dinh du'd'ng d thdi dilm can thiep theo nhom tudi
Can nang - Chilu cao Tudi (thang)
Can nang thap
Chieu cao < - 2SD . 2SD * - 3 S D - 3 S D - . - 4 S D < - 4 S D
< 6 thang (n = 25) 6-12 thang (n = 14) 12-24 thang (n = 14)
> 24 thang (n = 9) Tong (n = 62)
n, 8 6 4 4 22
%
32,0 42,9 28,6 44,4 35,5
ni 10 3 2 2 17
%
40,0 21,4 14,3 22,2 27,4
na 2 1 0 0 3
%
8,0 7,0 0 0 4,8
n 11 6 5 4 26
%
44,0 42,9 35,7 44,4 41,9 Suy dinh dudng gap nhilu d nhdm dudi 12 thang tuoi so vdi nhdm ldn han (p < 0,05) Suy dinh dudng ehu y l u d the nhe va vira, ehilm 62,9%. 26/62 (42%) benh nhi cd chilu cao < - 2SD. Ty le tre ed ehilu eao col epe khdng khac biet giira cac nhdm tuoi (p > 0,05),
Bang 2. Thay ddi can nang, chilu cao sau dieu trj can thiep
Thdi gian Can nang Chieu cao
Tang can (gram) Tru'dc dilu tn can thi
Sau dieu tri 1 thang Sau dilu tn 2 thang Sau dieu tn 3 thang
ep -2,4 -2,1 -1,5 -1,1
610 760 630
-1,9
-1,5
5cm/ 3 thang (4,4-5,5 cm, 0195%)
Can nang, chilu eao eua tre sau dilu tn can thiep thay ddi ro ret so vdi trudc dieu tn (p <
0,01) Ty le tre cdi coc (ehilu cao < -2SD) giam ro ret, tir 26/62 (42%) tre xudng con 20/62 (32,3%) sau 3 thang
3 thang sau dilu tri ean thiep chl con 14/62 (22,6%) tre suy dinh dudng, trong dd suy dmh duang vira va nang la 2/62 (3,2%j).
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TCNCYH Phu trwang 80 (3A) - 2012
Tinh trang dinh du'dng tru'dc va sau dieu trj can thiep 3 thang Bang 3. Can nang, chieu cao tru'dc dieu trj can thiep va mot so yeu to lien quan
Can nang, chieu cao
> -2SD (n = 20) Can -2SD - . -3SD (n = 22) nang .350 .-4SD (n = 17)
< -4SD (n = 3) P
Chilu cao > -2 SD (n = 25) An
n 4 9 12 2 15
khong du n, = 27)
%
20,0 41,0 70,6 66,7 p < 0,05
60,0 Suy (n2 = n 8 16 13 3
P<
17 tim
= 40)
%
40,0 72,7 76,5 100 0,05
68,0
Viem ph6i(*) (hj = 38) n % 10 50,0 14 63,6 12 70,6 3 100
p < 0,05 16 64,0 p < 0,05 -0,05 p > 0,05 Viem phdi(*) Sd lan viem phdi udc tinh/nam > 2 lan/nam
Ty le an khdng dii, suy tim va viem phoi tai phat (tren 2 l l n / nam) tang d i n rd ret theo mue dd nang eua suy dinh dudng (p < 0,05). Cdc y l u t l suy tim, viem phli It anh hudng d i n chilu eao,
s l l l n tieu chay ed anh hudng ro ret d i n phat t n l n t h i ehlt cua tre. Tre tieu chay trung binh tren 3 lan/nam cd chilu eao, can nang t h i p han rd ret (p < 0,05) so vdi tre tieu chay dudi 3 lln/nam (-2,4 SD va -2,8 SD so vdl -1.6 SD va -2,1 SD).
Can nang trung binh d nhdm TBS nhilu mdu len phil thip han rd ret (p < 0,05) so vdi nhdm It mau len phli (-2,4SD va - 1,7SD), Ty le SDD gja nhdm nhilu mau ien phli la 73,1 % (38/52 tre), cao han nhdm It mau len phdi la 33,3% (3/9 tre) (p < 0,05). Khdng cd su khae biet v l ty le tre cd chilu cao < -2SD giira hai nhdm nay
Bang 4. Mdi Men quan giQ'a can nang, chieu cao va ton lu-u sau dieu tn can thiep
Sau 3 thang can thiep
Theo SD Tang tru'dng
Ton lu'u (ni = 20)
Khong tdn lu'u (n2 = 42)
Tdn lu>u (ni = 20)
Khong tdn \wu (n2 = 42)
Can nang -0,9 620
gr/thang
690 gr/thang
-1,3 1,5
cm/thang
1,S cm/thang
TCNCYH Phu truung 80 (3A) - 2012 Ty lg cdn t i n luu ciia ca hai phuang
phap d i l u tn (phau thuat va thdng tim) la 32,3% (20/62 tre). Theo doi 3 thang sau d i l u tn thly ed su khac biet v l can nang, chilu cao gii>a hai nhdm edn va khdng cdn ton luu ( p < 0,05).
IV. BAN LUAN
1. Tinh trang dinh du'dng tru'dc d i l u trj can thiep
Tre mic tim b i m smh co can nang khi smh thip han tre binh thudng can nang khi sinh eiia tre trai Id 2,8 ± 0,45 kg, cua tre gal la 2,9 ± 0,42 kg, thip han (p < 0,01) tieu ehuin t l chirc Y te T h i gidi 2006 (can nang trung binh eiia be trai la 3,3 ± 0,15 kg va ciia be gai la 3,2 ± 0,14 kg). Trong 2 thang d i u tre v i n tang can trung binh trong gidi han binh thudng. Sau do toe do tdng can giam ro ret (p < 0,05) tir 760 -790 gram/thang cdn 590 gram/thang. Theo Abraham [6], d benh nhan tim bim smh shunt trai phai trong nhtrng tuin d i u sau sinh, sire can mach mau phli vin ehua glam hoan toan nhu tre khde manh Hien tugng nay da han e h i lugng mau d i n phli nen trong 2 thang d i u tre It mae viem phli, suy tim do dd It anh hudng din tang trudng. Nhung so vdi tre khde manh trong 3 thang d i u , can nang tang trung binh khoang Ikg/thang [2], t i c dp tang can cua tre tim b i m sinh v i n t h i p han dang k l .
Tre tim b i m sinh co ty le suy dinh dudng cao [4, 8]. Da s l tre tim b i m sinh ed khd thd, tre thd nhanh, manh, sir dung nhilu ca hd hip phu d i n d i n tieu thu nhieu nang lugng han tre binh thudng Nhilm triing, dac biet viem phoi tai diln, keo dai cung la mdt trong nhCrng nguyen nhan chinh khiln tre an uong kem, non trd d l d i n d i n suy dinh duang [3].
Theo Ackerman IP [7], nang lugng t i n du de tre tim b i m smh ldn ludn thip han binh thudng, ngay ca khi tre nhan nang lugng eao
han do muc tieu thu nang lugng cao.
Tal thdi dilm trudc phlu thuat, 67,7% tre SDD theo tieu chuin WHO - 2006 (can nang/
tull < - 2SD), eao han nhilu so vdi ty le SDD cua nudc ta nam 2010 la 17,5% [12]. Trong nghien euu ndy cd 20/62 (32,3%) tre SDD vira va nang (can nang <- 3SD). Trong khl so lugng tre SDD trung binh va nang phai nhap vien giam d i n (nam 2010 tai benh vien Nhi Trung uang ehi cd 136 tre nhap vien vi SDD - thing ke phdng k l hoach ting hgp), v i n cdn ty le ldn suy dinh dudng d khoa Tim mach.
O thdi dilm ean thiep, chilu cao trung binh ciia tre so vdi tieu chuin la -1,9 SD 26/62 (42%) tre cd chilu dal< - 2 SD. Ty le tre thap < - 2SD khong cd su khac biet (p >
0,05) giira eac nhdm tuol cho thly ngay ca d tre nhd < 6 thang tuli bi tim bam sinh tinh trang dinh dudng da bl anh hudng nang n l va lau dai (suy dmh dudng man tinh).
2. Tinh trang dinh du'dng sau d i l u trj can thiep
Can nang va chilu cao ciia tre sau dilu tn can thiep cd su cai thien rd ret, su khac biet cd y nghTa (p < 0,01) 3 thdng sau dieu tri can thiep, m l i thang trung binh tre tang duge 600 - 700 gram, cd tre tang 1200 gram/thang Chilu cao tre eung tang rd ret, sau 3 thang trung binh tre tang 5cm/ 3 thang. Tinh trang dmh dudng bat d i u phue hli. Trude phau thuat, can nang trung binh ciia tre la -2,4 SD, sau 3 thang tang can dat mirc -1,1 SD.
Tuang tu, chilu cao trudc phlu thuat la -1,9 SD, tang len -1,5 SD sau 3 thang Sau dilu tri can thiep 3 thang ehi edn 14/62 tre (22,6%) suy dinh dudng, trong do vira va nang chi gap d 2/62 tre (3,2%). Ty le tre cd chilu dai <-2 SD giam tir 42% trude phdu thuat edn 32,3% sau 3 thang Qua hci eac ba me, chimg tdi nhan thly tre an nhilu han, 95
TCNCYH Phu trwung 80 (3A) - 2012 ngon mieng han va it bi dm han sau dieu tn can thiep. Oilu do eho thay hieu qua eua phuang phap dieu tri tnet d l benh TBS da ed val tro rit ldn quylt dmh d i n kha nang phue hli dmh dudng.
3. Mgt sd y l u td lien quan den phat t r i l n t h i chat
Chi do dinh dwang: 35/62 tre duac nudi dudng vdi che dd an tuang d l i d i y du Tre dugc bu me hodn toan hoac su-a eong thire trong 4 - 6 thang d i u , tir 4 - 6 thang trd len duge eho an bd sung, dam bao ea v l lugng va chit, d i y du theo d vudng thirc an. Nhirng tre nay ed can nang va chilu cao trung binh ldn han (-1,9SD va -1,6SD) so vdl tre khdng duac nudi dudng day dii (-2,9SD va -2,4SD) (p < 0,05) Ty le tre duac nudi dudng khdng d i y dii thly ro d nhdm tre SDD vira va nang (> 60%)
Rdi loan tieu hoa.
- Trung binh mdi tre trong nghien cii'u mac 2,4 dgt tieu chay/nam, trong dd 24/62 (38,7%) tre mie tren 3 dat/ndm. NhQ'ng tre nay cd can nang va chilu cao trung binh thip han so vdi nhii'ng tre chf mie trung binh dudi 3 dot/nam (p < 0,05)
GiQ'a cdn nang va s l dat tieu chay/nam co tuang quan nghich biln (r = 0,4)
Tinh trang viem phoi va suy tim Viem phli anh hudng rd den ican nang, chilu cao cua tre, dac biet nhQ'ng tre ed > 2 dat viem phli/nam Tre cdng viem phdi nhieu thi tinh trang suy dmh dudng cang nang
Suy tim khiln tre khd thd, met mdi, kem dn.
Ty le suy tim tang d i n theo mirc do ndng ciia suy dmh dudng Tuy nhien giu'a cae nhdm cd chilu cao khac nhau, khdng cd su khae biet v l ty le suy tim (p > 0,05) Giu'a cdn nang (SD) va viem phdi, can nang (SD) va suy tim cung ed tuang quan tuyln tinh nhung khdng chat che
(r lan luot Id 0,3 va 0,45)
Luung mau len phoi Trong 62 benh nhan cd 52 tre thuoc loai nhilu mau len phoi, 9 tre thudc ioai it mau len phoi vd 1 tre khac mae benh tim bim smh khong ed luong shunt (ro dgng mach vanh) Lugng mau len phli nhilu la ylu t l tien luang nguy ca m i c viem phli keo ddl, suy tim d tre tim bim smh shunt trai phai [9] Qua so sanh chiing toi nhan thly d thdl dilm can thiep, tinh trang can nang thip
< - 2SD d nhdm it mau len phil (33%) It han h i n so vdl nhdm nhilu mau len phli (73,1%) (p < 0,05) Trong khi dd chilu cao lal bi anh hudng d 2 nhdm khdng ed su khae biet (55%
va 42% ed ehieu eao < - 2SD)
Ton iwu sau phau thuat K i t qua phlu thudt duae danh gia qua sieu am tim Mac dil dilu tn bang phuang phap thdng tim dat dung cu hay p h l u thuat triet d l thi v i n cd ty le nhlt dinh cdn t i n luu sau dilu tn, trong nghien euu eua chung toi la 32,3%.
Cae t i n luu dd thudng la edn lulng shunt nhd hay hd van tim Cdn nang, chilu eao sau 3 thang d i l u th d nhdm khong t i n luu han nhdm cdn ton luu (p < 0,05).
V. KET LUAN
Tim b i m sinh gay anh hudng nang n l den tinh trang the chit (can nang va ehilu eao) eiia tre Mirc dd nang suy dmh dudng ed lien quan den c h l do an khdng dil, tinh trang suy tim va luang mau len phli. Sau can thiep, can nang va ehieu cao ciia tre duac eai thien rd ret
TAI LIEU THAIVI KHAO 1. IMCI (6/2008). Hudng d i n xir tri ling ghep cae benh thudng gap d tre em. Oanh gia c h l dd nudi dudng tre, eae hudng d i n nudi dudng tre; 20 - 22
2. Nguyin Gia Khanh (2009). Tang trudng t h i chit d tre em Bai giang Nhi 96
TCNCYH Phu trwcyng 80 (3A) - 2012 khoa t a p l Nha xult ban Y hoc: 13 - 26.
3. Nguyin Gia Khanh (2009). Benh tim bam smh d tre em Bai giang Nhi khoa tap 2.
Nha xult ban Y hoc: 15 - 35.
4. Le Ngoc Lan, D6 Doan Lo'i, Le Nam Tra (2008). Thong lien thit dan thuln d tre em: Mot s6 dac dilm lam sang, sieu am va ylu td lien quan dgn tang ap ddng mach phdi Tap ehi nhi khoa tap 1 (11) 11/2008
5. Vien dinh du'd'ng qudc gia (http://
viendlnhduong.vn). Dien bign suy dmh dudng tre em dudi 5 tudi tren toan qudc (1999-2010).
6. Abraham M. Rudolph (2001). Ventricu-
lar septum defect. Congenital Disease of the heart. Clinical - Physiological considerations Fully revised and updates second edition.
197-244
7. Ackerman IP. Pediatrics (1998). 102 1172-1177
8. Hoffman JLE, Rudolph AM (1965).
The natural history of ventneular septal de- fects in infancy AM J Cardiol 16. 634 - 53.
9. Matthias Gorenflo, Hong Gu, Zhuoming Xu (2010). Peri Operative pulmonary hypertension in paediatric pa- tients Current strategies in children with congenital heart disease Cardiology, 116 1 0 - 17
Summary
PHYSICAL CHANGE IN CHILDREN WITH CONGENITAL HEART DISEASES AFTER INTERVENTIONAL TREATMENT
Our study was carried out to estimate physical changes (body weight, height) in 62 children with congenital heart diseases, treated with interventional treatment in National Hospital of Pedi- atnes, estimate body weight, height of patients before and after treatment and find some related factors. The results showed that before treatment, body weight and height were -2.3 SD and - 1.9SD respectively, 67.7% patients had malnutrition, included 27.4 % with moderate and 4.8%
with severe malnutrition; 41.9% children had height < -2SD. After intervention, nutrition status recovered dramatically, with malnutrition rate 22.6%, with only 3.2 % moderate and severe mal- nutrition, the stunting rate reduced to 32.3% The severity of malnutrition related to insufficiency in food intake, heart failure and blood volume from heart to lungs. After inten/ention. in group without residual shunt, the nutrition status recovered better than that in group without It (p <
0 05). In conclusion, congenital heart diseases severely affects physical development of pa- tients. Interventional treatment significantly improved body weight and height.
Keywords: congenital heart deseases, malnutrition
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