Nghien CLPU khoa hoc
A N
NGHIEN CUtJ HIEU QUA CUA LOC MAU LIEN TUC TRONG DIEU TRI VIEM TUY CAP NANG CO BIEN CHUl^G SUY DA TANG
Dao Xuan Cu*, Nguyin Gia Binh*, Dang Qudc Tuan*
TOMTAT • Muc tieu: nghien cim hiiu qud cita he mdu liin tuc kit hpp vdi diiu tri thuang quy trong diiu tri viem
tuy cdp nang cd bien chimg suy da tgng. Ddi tuong va phuong phap nghien cuu: nghiin cim tiin cim cd ddi chimg duac thuc Men tren 48 binh nhdn viim tuy cdp ndng cd biin chimg suy da tgng tie ndm 2007 din 2009.
Benh nhdn duac chia thdnh hai nhdm: nhdm led 25 binh nhdn duac diiu tri thuang quy kit hpp he mdu liin tuc vd nhdm II cd 23 binh nhdn chi dp dung cdc biin phdp diiu tri thuang quy. Diim APACHEII, hpi chimg suy da tgng (MODS) ddnh gid thdng qua thang diem SOFA, lipase huyit thanh, CRP. Cdc biin chimg vd kit qua dieu tri sdng, chit duac thu nhgn. Ket qua nghien cuu: cd 48 binh nhdn duac nghiin cim theo dung quy trinh, diem Balthaza > 7, diim APACHE II> 8, diim Ranson > 3 trong II yiu td, diim SOFA > (vd cd it nhdt 2 tgng suy trong 72 gid ddu). Benh nhdn nhdm I cdi thien nhanh han, cdc tgng suy hdi phuc nhiiu han thdng qua diem suy tgng SOFA . Ty li sdng a nhdm I ciing cao han so vdii nhdm II. Ket luan: he mdu lien tuc la biin phdp diiu tri kit hap cd hiiu qud trong diiu h-i viim tuy cdp nang cd Men chimg suy da tgng.
I. DAT VAN DE
- Viem tuy cap (VTC) la mdt qua trinh viem cap tinh cua tang the, benh canh khdng chi diing lai tdn thuong viem d tuy, ma la mdt qua trinh dap ung viem he thdng (SIRS) dien bien tdi suy da tang (SDT)vatu'vong[l], [2],[5].
- Nhieu nghien cuu tren the gidi tap frung lam sang td dan ca che, sinh benh hgc ciia VTC va cho thay trong VTC nang cd tang cao ndng do cac Cytokin huyet thanh, dac biet la Interleukin 6; INF a tang phan img Clia cac te bao bach cau va cac te bao ndi mac mach mau. Dd chinh la nguyen nhan dan den suy da tang trong VTC [5].
- Mat khac, cac nghien cuu tii' cudi thap nien 90 Clia cac tac gia Au, My da chi ra rang tang ap lire d bung (ALOB) ty le thuan vdi do nang cua VTC va cung chinh la hau qua ciia viec tang cac cytokin, cac
* Benh vien Bgch Mai flfclU
yeu td gay viem trong VTC tao ra vdng xoan benh ly dan den suy da tang, nang ne trong VTC nang va la nguyen nhan dan den tii' vong [2], [4], [5].
- Viec dieu trj VTC, dac biet VTC nang da cd nhieu tien bd dua theo ca che sinh benh hgc, nhieu bao cao thanh cdng rd ret nhd vao ap dung cac tien bd trong chan doan va dieu trj.
- Lgc mau lien tuc (LMLT) la bien phap dugc nhieu nghien cuu chung minh la cd kha nang loai bdt cac cytokin va yeu td gay viem, tii' dd lam giam qua trinh viem dan den giam bien chirng SDT, ben canh dd hd trg cac tang suy, lam giam ty le tir vong.
Tuy nhien, cdn nhieu tranh cai tren the gidi ve hieu qua ciia bien phap nay [3], [6].
- Khoa HSTC Benh vien Bach Mai da va dang ap dimg bien phap LMLT trong dieu trj VTC nang.
Chiing tdi tien hanh nghien cii'u nay nham muc tieu danh gia hieu qua ciia bien phap LMLT trong dieu trj VTC nang cd bien chung SDT.
S6 55 (Thang 08/2010) Y HOC LAM SANG I 45
Nghien CCPU khoa hoc
n. DOI TirgfNG vA PHITONG PHAP NGHIEN ctru 1. Doi tuong nghien cuu
- 48 benh nhan dugc chan doan VTC nang cd biln chirng suy da tang dilu trj tai khoa HSTC Benh vien Bach Mai, thdi gian 2007 - 2009.
* Tiiu chuan chdn dodn VTC nang diea vdo - Dilm APACHE II > 8
- Dilm Ranson cd > 3 trong 11 yeu td
- Dilm Balthaza sira ddi > 7 (dua vao mirc do phii tuy + hoai tu tuy)
* Tieu chuan ddnh gid suy da tgng (MODS) theo thang diim SOFA cho timg tuy bao gdm: phdi, tuan hoan than, thin kinh, gan va mau. Sd lugng tang suy vdi tieu chuan suy tang la diem SOFA > 3 hoac tang >
4 diem so vdi liic vao khoa HSTC. Suy da tang dugc chan doan khi cd > 2 tang suy keo dai fren 24 gid.
2. Phuong phap nghien ciru - Md ta tien cu'u cd ddi chiing
- Chgn mau - cd mau: chgn mau thuan tien - Cach thirc tien hanh
* Cac benh nhan dii tieu chuan nghien ciiu dugc chia thanh 2 nhdm tien hanh dieu trj bao gdm:
2.1. Cdc bien phdp hdi sue tich cue dp dung cho cd hai nhdm
+ Hdi siic hd hap: dam bao dudng thd, dam bao oxy hda mau (thd oxy kinh, mat na, thd khdng xam nhap). Neu nang cd tdn thuong phdi ARDS —> thd may theo ARDS Net.
+ Hdi sire tuan hoan:
- Benh nhan dugc dat ong thdng tTnh mach trung tam
- Bii djch mudi dang truong, djch cao phan tir. Albumin dam bao CVP 10-15 cmUp. Nlu cd ARDS: duy tri CVP 6 - 8 cmUp.
- Thudc van mach, trg tim khi da bii dii djch.
- Giam djch tuy: Stilamin, Sandostatin.
- Giam dau: nhdm giam dau thdng thudng (paracetamol). Opiate.
+ Khang sinh: Imipenem, Quinolon.
+ Nudi dudng: chi nudi dudng tTnh mach 24 - 48 gid diu, sau dd kit hgp an sdm nhd gigt da day.
+ Cac phuong phap khac:
- Hut djch da day, thut hau mdn - Dan luu d bung, d djch quanh tuy
Dan luu bang dng thdng kich thudc 12 - 16 F dudi hudng dan cua sieu am hay CT.
2.2. Lgc mdu lien tuc (LMLT) chi dp dung cho nhom I
2.2.1. Chi dinh
LMLT dugc sdm ngay khi nhap vien neu benh nhan dugc danh gia la VTC nang cd bien chimg suy da tang.
2.2.2. Chdng chi dinh
Suy tim nang, HA tut (HA tam thu < 60mmHg) khdng khac phuc dugc rdi loan chay mau nang (cac chdng chi djnh chi mang tinh chat tuong ddi).
2.2.3. Ky thudt Ipc mdu
- May Prismeflex cua hang Gambro, mang Igc AN69 vdi djch tinh 0,9m^ djch thay the Hemosol pha san ciia hang Gambro.
- Chong ddng bing Heparin theo quy trinh cua khoa HSTC xay dung.
- Cac thdng sd cai dat: tdc do mau 180 - 200ml/
phiit tdc do djch thay the 45ml/kg/phut.
- Thdi gian keo dai I qua lgc 18 - 22 gid.
- Tieu chuan ngirng lgc mau: thoat sdc, ty le PaO2/FiO2>250...
NIU chi cdn suy than don thuan: cd the chuyen sang lgc mau ngat quang.
Theo ddi:
- L a m s a n g '"i:-^- - Ap lire d bung hang ngay.
- Diln biln suy tang theo thang diem SOFA.
- Cac bien chiing ciia VTC.
- Cac biln chiing ciia Igc mau lien tuc.
m . KET QUA N G H I E N C U U
Cd 48 benh nhan VTC nang du tieu chuin nghien ciiu tai khoa HSTC Benh vien Bach Mai, trong dd cd 25 benh nhan nghien ciiu thudc nhdm I, 23 benh nhan nghien cii'u thudc nhdm II.
46 I Y HOC L A M S A N G S6 55 (Thang 08/2010)
Ngiiien cuu l<iioa inoc
_-, „^ - p . .. ^., .-.--.,
Y e n t 6 ^~~~~~~^
rr Bang 1. So sanh dp nang giiea Nhom
Tudi
APACHE II (dilm) Ranson (yeu td) SOFA
CT Scan Ap luc d bung
I (n = 25) H6i sire cu ban
48,5 ± 13,7 15,5 ±4,7
10 ±4,2 8 ±3,5 7 ±2,5 25,5 ± 6,5
2 nhom benh nhan
II (n = 23) HSCBT loc man lien tuc
52,5 ±11,8 16,2 ±5,2
9 ±2,5 9,5 ±4,2
6 ±4,2 26,2 ± 7,5
P
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05 Do nang cua 2 nhdm benh nhan Iiic nhap vien khdng cd sir khac biet.
Bdng 2. Dgc diem suy tgng & 2 nhom khi nhap vien Tang suy
Tuan hoan Hdbap Than Gan Mau Than kinh
Nhom I (n = 15(60%) 17(68%) 120(40%)
7(28%) 8(32%) 5(20%)
Nhdm II (n = 23) 13(56,5%) 15(65,2%) 10(43,5%) 5(21,7%) 7(30,4%) 5(21,7%)
P
>0,05
>0,05
>0,05
>0,05
>0,05
>0,05 Nhdn xet: Ty Ie tang suy d 2 nhdm khi nhap vien khdng cd su khac biet (p > 0,05).
12 1 10
8 - 6 - 4 - 2 - 0 ^
Diem SOFA
ifn
1
Tl
/ ^ M O
•:,,: : •
1
T3 T5
" ~ ~ " — * ^
1
17
A >JlintTi T
* i>inonii
• IVhnm TT
• i^noni 11
^ ^ ^
' (ngry) T14 Xuat vien
Bieu dd 1. So sdnh sije thay ddi diem SOFA cua 2 nhom benh nhdn (chi so sdnh binh nhdn duac cim sdng)
Nhgn xet: Diem SOFA giam nhanh ban tir ngay thii 5 d nhdm dugc lgc mau lien tuc, khac biet cd y nghTa thdng ke (p < 0,05). ^_ ^ , .
86 55 (Thang 08/2010) YHOC LAM SANG j 47
Nghien ciru l<.[ioa hpc
CRP (mg/l) 20 -|
15 -
10 -
5 -
0
1 5 ^ 5 ^ 14.7
1
Tl
17.7
1
T3
N x l l . 2 l i ^ v
T5
5:^5.2
43^=^=5:::^
T7
— • — i N n o m I
—•—Nh6nin -
^ ^ . 4 1.4 l - = * ~ ~ - 5 O.S -Thdi plan
' ' (ngay) T14 Xuit vif n
Bieu do 2. Su thay ddi CRP & hai nhom
Nhgn xet: Su thay ddi CRP d 2 nhdm khdng cd su khac biet tai cac thdi diem so sanh (p > 0,05).
Lipase (UI/1) 3500
-»—n
*^50 , ™^>an
^ ^ ^ (ngay)
Bieu do 3. Su thay ddi Lipase & 2 nhom
Nhgn xit: Lipase giam nhanh ban d nhdm dugc Igc mau. Su khac biet cd y nghTa thdng ke vdi p < 0,05.
(cmH20) 30 25 20 15 10 5 0
-•—Nh6ml -ii—Nh6mn
Tl T2 T3 T4 T5 T7 Thdijgian
(ngay)
Bieu dd 4. Dien biin dp luc d bung & 2 nhom
48 I Y HOC LAM SANG S6 55 (Thang 08/2010)
Nghien cuu khoa hoc
Ap luc d bung giam nhanh ban d nhdm dugc Igc mau lien tuc. Su khac biet cd y nghTa thdng ke.
.'ji)] ••
Tylf %
501 40 30 20H 10
0
Nhom I Nhom n
50
Tif vong chung Nhom suy 2 Nhdm suy > 3 t^ng tsing
So tang suy
Bieu do 5. So sdnh ty le tu vong & 2 nhom
Ty Ie tu vong chimg cua nhdm I thap ban nhdm II, su khac biet cd y nghTa thdng ke.
Bdng 3. So sdnh th&i gian dieu tri giira 2 nhom Thdi gian
Thdi gian dieu tri
Thdi gian dieu tri nhdm benh nhan sdng
Nhom I 19 ±5,5 12 ±4,5
Nhom II 18 ± 6,5 21 ±5,5
P
>0,05 P<0,01 Nhdn xet:
- Ngay dieu tri tnmg binh ciia 2 nhdm khdng cd sir khac biet.
- Ngay dieu tri tmng binh cua benh nhan sdng d nhdm I thap ban d nhdm II cd y nghTa thdng ke (p < 0,01).
IV. NHAN XET VA BAN LUAN
I. Nhan xet ve do nang va dac diem benh nhan khi nhap vien
- 48 benh nhan VTC nang cd bien chiing suy da tang (thdi gian 2007 - 2009) dugc chia thanh 2 nhdm:
nhdm I (cd Igc mau lien tuc), nhdm II (khdng lgc mau lien tuc), khdng cd sir khac biet ve do nang theo cac thang diem danh gia do nang (thang diem APACHE II, Ranson, Balthaza, SOFA) va ap luc d bvmg.
- Tang suy khi nhap vien cung khdng cd sir khac biet ty Ie ve sd gid 2 nhdm. Suy tuan hoan, than va hd hip cd ty le cao nhat tuong ddi gidng nhau d 2 nhdm. ,
2. Nhan xet va ban luan ve kit qua dieu tri Ket qua nghien ciiu d bieu dd I, su dien bien cua diem SOFA md ta tien trien cua tang suy cho thay d nhdm I (dugc lgc mau lien tuc) cai thien nhanh ban so vdi nhdm dieu tri thdng thudng.
- Ap luc d bung (mdt yeu td so sanh ddc lap dang dugc nhieu nghien ciiu nhan xet la cd gia tri tien lugng va theo ddi dien bien ciia VTC nang) giam nhanh ban cd y nghTa thdng ke d nhdm dugc Igc mau lien tuc theo ket qua nghien ciiu d bilu dd.
- So sanh ve dien bien cua Lipase ket qua nghien ciiu d bieu dd 3 Lipase cQng giam nhanh ban d nhdm benh nhan dugc Igc mau lien tuc.
* Nhdn xit vi kit qud diiu tri
- Do nang theo cac thang diem danh gia ciia 2 nhdm benh nhan nhap vien khdng cd su khac biet.
Tuy nhien, ty Ie tu vong d nhdm dugc lgc mau lien tuc thap ban cd y nghTa thdng ke p <0,0I. Nghien ciiu cua chiing tdi cdn don le chua the khang djnh
56 55 (Thang 08/2010) YHOC LAM SANG | 49
Nghien CLFU khoa hpc
chac chan hieu qua cua Igc mau lien tuc trong dilu trj VTC nang cd bien chiing suy da tang. Kit qua nghien ciru nay phii hop vdi nhieu nghien ciru cua cac tac gia chau A (Nhat Ban, Trung Qudc...).
Trong nghien cuu cua chiing tdi d nhdm I cd 2 benh nhan suy 5 tang deu dugc ciin sdng, frong khi dd d nhdm n khdng cun sdng dugc benh nhan nao suy > 5 tang.
* Thdi gian diiu tri
Thdi gian dieu frj trung binh cua 2 nhdm khdng cd sir khac biet neu so sanh chung. Tuy nhien, neu so sanh thdi gian dieu trj cua benh nhan sdng (theo bang
3) d 2 nhdm thi benh nhan cd lgc mau lien tuc dugc nit ngin hon so vdi nhdm khdng lgc mau lien tuc.
V. KET LUAN
Nghien cim hieu qua bien phap LMLT d benh nhan VTC nang cd biln chimg suy da tang chiing tdi thay:
- Nhdm benh nhan dugc LMLT cai thien nhanh hon ve miic do suy tang, ap lire d bung va lipase...
- Ty le tir vong d nhdm dugc LMLT thap han nhdm dilu trj thdng thudng.
- LMLT rut ngin dugc thdi gian dieu trj.
TAI LIEU THAM KHAO
1. Vit Vdn Dinh, Be Hong Thu (2000), "Viim tuy cdp", Cdm nang cdp cim, NXB Y hpc, Hd Npi, tr 170-174.
2. Nguyin Duy Hue, Hd Tiin Quang (2003), " Viem tuy cdp, siiu dm hay chup cdt lap vi tinh ", Tgp chi Y hpc thuc hdnh, tap 439, ti: 26-28.
3. Den-QiangMao, Yao - QingJamy (2008), "Effects of time interval for hemoflltration on the prognosis of severe acute paucreatitis". World Journal of Gasti-oenterohgy, 9(2), pp. 373-376.
4. KJ, Girshman, J, Szejnfeld, D, et al CT-guided
percutaneous catheter drainage of acute necrotizing pancreatitis: clinical experience and observations in patients with sterile and infected necrosis. AJR Am J
Roentgenol 2009; 192:110.
5. Suresh T.Chari (2010): Acute pancreatitis.
UptoDate 2010. http://www.uptodate.com
6. PaiviKeskinen,AriLeppaniemi, VillePettila,Anneli Piihnen, Esko Kemppainen and Marja Hynninen (2007). "Intra-abdominal pr-essure in severe acute pancreatitis". World Journal of Emergency Surgery 2007, 2:2 doi:10.1I86/1749-7922-2-2.
SUMMARY •'.• ^-•••::•• •
THE EFFECTIVENESS OF CONTINUOUS VENO-VENUOS HEMOFILTRATION (CVVH) IN THE TREATMENT OF SEVERE ACUTE PANCREATITIS WITH MULTIPLE ORGAN FAILURE SYNDROM Objectivei To study the effectiveness of continuous
veno-venuos hemofiltration (CVVH) in the treatment of severe acute pancreatitis with multiple organ failure syndrom in Intensive Care Unit of Bach Mai Hospital. Subjects and Methods: Retrospective study was conducted in 48 patients with severe acute pancr-eatitis (SAP) with MOFS in ICU of Bach Mai Hospital: A total of 25 patients were treated with conventional pr-otocol and CVVH (Group I) and
23 patients were treated with only conventional protocol (Group II). Results: Although there was
no such difference of degree of severity between the two groups but SOFA score of Group I were improved more quickly than group II (p < 0.05) and the mortality rate of group I and II were 12%
and 30.4%. Conclusions: CVVH is good method for treatment of severe acute pancreatitis with MOFS complication.
50 I Y HOC LAM SANG S6 55 (Thang 08/2010)
