Y HOC VIET NAM THANG 2 - SO 1/2014
V - . ;
CHI SO HUYET DONG VA BIEN CHU'NG TRONG LOC MAU CHU KY 6f BENH NHAN SUY THAN MAN TAI BENH VIEN KIEN AN H A I PHONG
TOM TAT
Nghien cifu dUOc tten hanh tren 200 fan loc mau t?i benh vien Kien An Hai Phiing d 45 benh nhon suy thin'man (41 nam: 91,2%, 4 niJ: 8,8%), tuoi trung bdnh: 44,4 ± 10,4, dich loc Bicarbonat, qua loc Nipro FB 130T, toe do bdm mau tu" 180 - 250 ml/phyt,
Ket qua: Trong 4 gid loc mau, khong co sU bien dpng dang ke ve gia tn trung binh cua huyet ap tam thu, huyet ap tam tru'Png, tan so mach tai cac thdi diem do each nhau 1 gid, sir khac biet khong co y nghTa thong ke, Tuy nhien, tai cudi buoi loc, trung binh cua huyet ap tam thu, huyet ap tam trLlOng, tan so mach 6 mirc thap nhat va giam co y nghTa thdng ke so vdi liic ban dau (TO), (p<0,05), Ty le cac bien chirng tinh tren so (an loc mau gap nhU sau: tut huyet ap:
8%; non, buon non: 7%; loan nhip tim: 7%; chuot rut: 7%; dau ngi/c, ngira, sot it gap; khong gap cac bien chifng khac, Nhom co toe do bdm mau cao hoac the tich sieu loc Idn eo ty le bien chu'ng tut huyet ap cao hon nhom toe dp bom mau thap hoac the tich sieu Ipc nho (p<0,05). Nhom benh nhan tut huyet ap co ure mau trUdc Ipc eao hdn, hemoglobin thap hdn, that trai gian nhieu hOn so vdi nhom co huyet ap on dinh (p<0,05). Benh nhan co ure mau >34 mmol/l xuat hien non, buon non trong loc mau nhieu hOn so vdi nhom b?nh nhan co ure mau <34 mmol/l, (p < 0,01).
SUMMARY
HEMODYNAMIC I N D I C E S AND COMPLICATIONS D U R I N G HEMODIALYSIS
IN PATIENTS W I T H C H R O N I C RENAL FAILURE I N K I E N AN HOSPITAL H A I PHONG The study was conducted on 200 times of dialysis In Kien An Hospital Hai Phong in 45 patients with chronic renal failure (41 male: 91,2 %, 4 females: 8,8
%), mean age: 44,4 ± 10,4, solution Bicarbonate dialysis, filters Nipro FB 130T, speed of blood pumped from 180-250 ml/mm..,
Results: During 4 hours of Hemodialysis, the average of systolic blood pressure, diastolic blood pressure, frequency circuits were changed negligible, the difference of the measurement time interval 1 hour without statistical significance. However, at the end of the hemodialysis, the average of systolic blood pressure, diastolic blood pressure, frequency circuit were the most decreased and a statistically significant reduction compared with baseline (TO), (p<0.05).
'SdYte Hal Phdng
Phin bifn khoa hgc: PGS. TS Nguyen Lam Hda
Trinh Thi Ly* va cdng sy
The rate of complications during Hemodialysis' hypotension: 8%; nausea, vomiting: 7%, arrhythmias:7%; cramps; 7%; pain chest, cramps, fever were negligible; not having other complications. The group with high-speed pump or a large volume ultrafiltration had the rate of complications more than the group with low speed pump or small ultrafiltration volume (p<0,05). Hypotensive patients had blood urea higher before filtenng, lower hemoglobin, left ventricular larger compared with normal blood pressure group (p<0,05). Patients with blood urea >34 mmol/l appears nausea, vomiting during dialysis more than patients with blood urea <34 mmol/l (p<0.01), I. DAT VAN OE
Loc mau ehu ky co vai tro het sire quan trong thay the than thu'c hien chirc nang dao thai eae ehat chuyen hoa va giiT can bang noi moi, giai quyet nhu'ng roi loan co tinh chat de doa den tinh mang benh nhan. Tuy nhien, co nhieu yeu to co the gay ra bien chirng trong loc mau nhP: sieu lgc qua mirc lam giam khoi Itldng tuan hoan, dap irng hoat mach suy giam, thay doi tham thau mau, gian mach do dich lpc qua nong, phan ve vdi bp loc, thay doi tiTcfi mau do riit dich qua mirc v.v...
Chinh vi vay, nghien cifu chi so huyet dong va cac bien chirng trong qua trinh loc mau chu ky d benh nhan suy than man de theo doi sat, x\i tri kjp thcJi va dir phong cac bien chirng la rat can thiet, II. OOI TU'ONG VA PHUaNG PHAP NGHIEN CtJ'U
2 . 1 . Doi tu'dng nghien cii'u: Nghien ciru dyOc tien hanh tren 200 lan loc mau 6 45 benh nhan suy than man loc mau chu ky tai benh vien Kien An trong thdi gian tir thang 1/2009 den thang 8/2009. Chu ky Ipe theo quy dinh la 3 I- u'Pt/tuan, thdi gian moi lan Ipe la 4 gid.
2.2. PhiTdng phap nghien ciru: Nghien ciru tien ciru, cat ngang,
2.2.1. Tieu chuan chpn benh nhan vao nghien cii'u: Cac benh nhan suy than man co chi dmh loc mau chu ky, tire la suy than man giai doan 3b va giai doan 4.
2.2.2. Tieu chuan loai trit: Nhu'ng benh nhan suy than man kem cac benh ly khae: benh tim bam sinh, benh van tim mac phai, Basedow,
Y HOC VIET NAM THANG 2 - SO 1/2014 cae benh nhan loc mau khong deu, Ipc du'di 2
lan/tuan.
2.3. Cach tien hanh nghien cu'u - Kham lam sang, can lam sang tru'dc va sau lpc - Do huyet ap, tan so maeh tai cac thdi diem: TO (tru'dc loc), T60 (sau loc 60 phiit), T120 (sau loc 120 phiit), T180 (sau loc 180 phiit), T240 (cuoi buoi loc).
- Theo doi eae bien chiTng trong qua trinh lpc mau 2.4. Ky t h u a t loc mau
- Qua Ipc; Nipro FB 130T thuoc loai qua lgc sdi vdi chat mang cellulose eo dien tich mang la l,3m^ du'dc tai sir dung toi da 5 lan.
- Dich lgc: Bicarbonat, do hang AEONMED Co.
LTD san xuat.
- Chong dong: dung heparin vdi lieu 15UI/kg can nang/gid, diing lien tuc bang bdm dien va dirng tru'dc ket thue lgc mau 30 phiit.
- Toe do bdm mau tir 180 - 250 ml/phut tuy theo tinh trang ciia benh nhan.
- Nhiet do dich lpc 37°C
2 . 5 . Tieu chuan chan doan t u t huyet ap trong Ipc m a u ; Theo Emili va eong sir, benh nhan diTdc chan doan cd tut huyet ap trong buoi loc khi:
- Huyet ap tam thu giam >10mmHg so vdi huyet ap ban dau, kem theo trieu chirng tut huyet ap nhu' hoa mat, chong mat, buon non, non, va mo hoi...
- Huyet ap tam thu giam > 1 0 m m H g d nhuYig benh nhan eo huyet ap tam thu ban dau
<ioOmmHg.
- Huyet dp tam thu <100mmHg d nhu'ng benh nhan cd huyet ap tam thu ban dau <150mmHg.
- Huyet ap tam thu < l l O m m H g d nhUng benh nhan eo huyet ap tam thu ban dau >i50mmHg.
.KET QUA NGHIEN CU'U Bang 1 : Phan bo theo tuoi, gidi
Nhom tuoi 23-29 30-39 40-49 50-59
>60 Nam NO"
Tuoi trung binh
So BN (n = 45) 03 10 15 09 08 41 4 44,35 ± 10,4
Ty le»/(i 6,6 22,2 33,4 20,0 17,7 91,2 8,8
Nhan xet: Benh nhan cd tuoi trung binh la 44,35 t 10,4. Benh nhan tre nhat la 23 tuoi, Idn nhat 69 tuoi. Oo tuoi tir 30 den 60 ehiem ti le 75,6%. Nam ehiem da so: 91,2%.
Bang 2 : Thay doi huyet ap trong loc mau
Thdi dlem do HA
TO T60 T120 T180 T240 P
HA tam thu (X ± SD) 139,44 ± 16,33 137,21 ± 12,04 136,86 ± 14,47 134,64 ± 14,47 132,2 ± 12,27 p (0-240) < 0,05
p khac > 0,05
HA tam tru'dng (X ± SD) 80,12 ± 9,24 78,52 ± 8,26 78,04 ± 10,5 76,84 ± 8,04 76,25 ± 7,8 p (0-240) < 0,05
p khac > 0,05
Nhan A^ef.'Trong qua trinh lgc mau, huyet ap trung binh tam thu va trung binh tram tru'dng giao dpng khong dang ke, sir khac biet tai cac thdi diem do khong cd y nghia thong ke. Tai cuoi buoi lpc, huyet ap trung binh d mire thap nhat va giam cd y nghia thong ke so vdi liic ban dau (TO).
Y HOC V I ^ T NAM THANG 2 • SO 1/2014
3; Thay doi tan so Thdi diem
TO T60 T120 T180 T240 P
nach tronq ioc mau
Tan so mach (X ± SD) 78,62 ± 5,82 79,16 ± 4,16 80,12 ± 5,04 80,64 ± 5,27 81,72 ± 5,47 p (0-240) < 0,05
p khac > 0,05
Nhan xet:Trong qua trinh loc mau, tan so maeh trung bdnh giao ddng khong dang ke, sir khac biet tai cac thdi diem do khong cd y nghTa thong ke. Tai cudi buoi loc, tan sd mach trung binh d mirc thap nhat va giam cd y nghia thong ke so vdi liic ban dau (TO).
Bang 4: Cae bien chirng trong ioc mau Cac bien chu'ng Tut huyet ap Non, buon non Loan nhip tim Chuot riit Dau ngife Ngira Sot
Cac bien chiTng khac
So lu'dt BN loc mau
(n = 200) Ty leo/o
8,0 7,0
3,5
i^ac Dien cnung Knac | _ u __ ^ j u Nh^nxet'J^ le bien chirng tinh tren so lan lgc mau gap vdi ty le thap: tut huyet ap (8%), non, buon non (7%), loan nhip tim (7%), chuot rut (7%); dau ngi/c, ngiiS, sot it gap; khdng gap eae bien chirng khac.
Bang 5; Lien quan giu'a Toe do bcrm HA So lu'dt BN ioc mau
Ty ie BN tut HA
tut huyet ap vdi toe do bOm mau 1 8 0 - 2 0 0 m l / p h
100 4/100 (2%)
2 0 1 - 2 5 0 m l , ' p h 100 12/100 (6%)
P p < 0,05
Nh$n xet: Toe dp bpm mau cao (201 - 250 mi/ph) gay bien chu'ng tut huyet ap nhieu hdn toe dp bOm mau thap (180 - 200 mi/ph), (p < 0,05).
Bang 6; Lien quan giu'a tut huyet ap vdi the tich sieu Joc_
' The tich sieu loc T 1000 - 2000 \ 2001-3000 So itfdt BN igc mau
Ty ie BN tut HA~
50 2/50 (4%)
, < 0,05
5/80 (6,2%)
70 9/70(12,8%) , < 0,05
[ . , P I p < u,U3 p^ 5 U,U5 ^ _ ] Nh^n xit: The tich sieu ioc cang dn thfty'ie bien chirng tut huyet aptang cao, sU khac biet co y nghia thong ke (p < 0,05).
Bang 7: Lien quan qiiTa tut huyet ap vdi xet nghiem trifdc ipc Chi so XN tru'dc Ipc
Ure mau (mmol/l) (X ± s o r Hemoglobin (g/l) (X ± SD) Protein toan phan (q/l) (X ± SD) Albumin (g/i) (X ± SD) Dan that trai (X ± SD)
HA tut (n = 16) 34,26 ± 9,2 i,24 ± 19,6 72,18 ±5,6 37,12 ± 2,5 78,57 t 12,7
HA on dinh (n = 184) 26,23 I 6,4 < 0,01 78,51 1 21,3 < 0,05 38,45 t 2,63 58,13 ± 10,5
>0,05
<0,05
Nh$n xit: Nhom benh nhan tut huyet ap co ure mau tru'dc ipc cao hdn, Hemogiobin thap hdn, that
trai gian nhieu hdn so vdi nhdm cd huyet ap on dinh (p < 0,01 va p < 0,05).
Y HOC VIET NAM THANG 2 - SO 1/2014 Bang 8 : Lien quan giu'a bien ehirng non, buon non vdi ure mau tru'dc loc
Nong dp ure mau < 34 mmol/l Nong do ure mau > 34
mmol/l P
Tong so iUdt BN ioc mau Cd non, buon non
Ty ie % Tong so iu'dt BN loc mau
Cd non, buon non Ty ie %
177 8 4,52%
23 9 39,1%
<0,01
Nhan xet: Benh nhan ed nong dp ure mau > 34 mmol/l xuat hien non va buon non trong Ipe mau eao hdn rat nhieu so vdi benh nhan cd ndng do ure mau < 34 mmol/l (p < 0,01).
IV. KET LUAN
Qua nghien ciiu 200 lan lgc mau d 45 benh nhan suy than man lgc mau ehu ky tai benh vien Kien An Hai Phung, ehiing tdi riit ra mgt sd ket luan nhu'sau:
1. Benh nhan eo tuoi trung binh la 44,35 ± 10,4. Op tuoi tir 30 den 60 chiem 75,6%. Nam chiem 91,2%.
2. Trong qiia trinh lgc mau, khong cd sir bien dgng dang ke ve gia tri trung binh ciia huyet ap tam thu, huyet ap tam tru'dng, tan sd maeh tai cac thdi diem do each nhau 1 gid, sir khac biet khdng cd y nghia thdng ke. Tuy nhien, tai cudi budi Igc, trung binh ciia huyet ap tam thu, huyet ap tam tru'dng, tan so maeh d mirc thap nhat va giam cd y nghia thong ke so vdi liic ban dau (TO), (p < 0,05).
3. Ty le cac bien ehirng tinh tren so lan lpc mau gap nhu* sau; tut huyet ap: 8%; non, buon non; 7%; loan nhip t i m : 7 % ; chuot riit: 7%; dau ngirc, ngira, sot it gap; khdng gap cac bien chu'ng khae,.
4. Cae yeu to lien quan den ty le bien ehirng:
Nhdm cd toe dp bdm mau cao hoae the ti'ch sieu lpc Idn cd ty le bien chirng tut huyet ap cao hdn nhdm toe do bdm mau thap hoac the tich sieu lgc nhd (p < 0,05). Nhom benh nhan tut huyet ap cd ure mau tru'dc Ipc cao hdn, hemoglobin thap hdn, that trai gian nhieu hdn so vdi nhdm cd huyet ap on dinh (p < 0,05). Benh nhan ed ure mau > 34 mmol/l xuat hien non, buon non trong Igc mau nhieu hdn so vdi nhdm benh nhan ed ure mau < 34 mmol/l, (p < 0,01).
V. KHUYEN N G H I
Trong qiia trinh Ige mau chu ky d benh nhan suy than man, can theo roi sat benh nhan liic cudi budi Ipe vi dd ia thdi diem de gay bien dpi ehi sd huyet dgng,
Can theo doi sat hdn va de phdng bien chu'ng nhieu hon d benh nhan cd tdc do bdm mau cao hoac the ti'ch sieu lgc Idn, benh nhan ed ure mau eao, thieu mau nang va suy tim trai nang.
TAI LIEU T H A M K H A O
1. Nguyen Van Xang (2003), suy than man, Npi khoa Than tiet nieu va smh due, nha xuat ban Y hgc, tr 246 -258.
2. N g u y i n Tien Dung, Do Van Tiing (2011), Nghien ciru bien chu'ng tut huyet ap trong loc mau chu ky d benh nhan suy than man giai doan cuoi tai Benh vien Oa khoa Trung uong Thai Nguyen, Tap chi y du'dc Viet Nam, So thang 2/2011.
3. Hoang Biii Bao, Muynh Van Minh (2010), Nghien cu'u tinh trang suy tim va nong dp N- terminal pro B-type natriuretic peptide huyet tu'dng d Penh nhan dang Ipc mau chu ky. Tap chi Y hpc thanh pho Ho Chf Minh, Tap 14, so 1
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6. Lorincz I , Kakuk G (2001), Pressure changes within a chronic subdural hematoma during hemodialysis, Surg Neurol, 32 (4), pp 289-293.
7. Bregman H, Daugirdas JT, I n g TS (1999), Complications during hemodialysis. I n : Handbook of Dialysis, Dauugirdas JX, Ing TS (Eds), Little, Brown, New York, p. 149.
