NGHIN CU GI TR CA P LC BNG

TRONG PHN LOI MC NNG BNH NHN VIM TY CP

O XUN C

NGI HNG DN: PGS. TS. TRN DUY ANH PGS. TS. NGUYN GIA BNH

T VN

VTC l bnh gp kh ph bin

Bnh cnh LS a dng:

Nh: t bin chng, nm vin ngn ngy.

Nng: din bin phc tp, nhiu bin chng, TV 20 - 50% (do ST).

C ch bnh sinh phc tp.

Vai tr ca p ng vim h thng trong VTC ngy cng c sng t.

Tin lng sm mc nng khi BN nhp

vin rt cn thit la chn cch iu tr

ph hp gim bin chng

C nhiu bng im c xy dng:

APACHE II, Ranson, Imrie, Balthazar (CTSI)

Cc bng im ny phc tp

Ch nh gi lc nhp vin v trong 48 gi.

T VN

T cui thp k 90 nhiu tc gi u M cp

n hi chng tng ALOB trong VTC:

Vng xon bnh l lin quan gia VTC v tng

ALOB, v cn nguyn l do cc yu t gy

vim, cc cytokine.

C mi lin quan gia ALOB vi mc nng

ca VTC (mt vi NC trn th gii).

Theo di din bin v hiu qu iu tr.

T VN

MC TIU NGHIN CU

Nghin cu gi tr ca p lc bng trong phn loi mc nng bnh nhn VTC

NGUYN NHN

Nguyn nhn hay gp: si ng mt, lm dng ru (75%)

Nguyn nhn khc:

Sau phu thut quanh ty, ni soi mt ty ngc dng

Chn thng

Chuyn ha: tng tryglyceride

Gan nhim m cp thi k c thai

Sau ghp tng, do thuc, bnh h thng

Khng r nguyn nhn

TNG QUAN

C ch khi u

Tn thng t bo tuyn Hot ha TB

Gii phng cc cht trung

gian Hu qu

Gii phng cc enzym ca ty:

- Tripsin

- Elastase

- PhospholypaseA

- Cc enzym khc

IL-1

IL-6

IL-8

IL-11

TNF

NO

PAF

Hot ha

Tripsinogen trong

TB tuyn

- Ru

- Si mt

- Nguyn nhn khc

BC trung tnh

TB n nhn

TB lympho

TB ni m

Ti ch:

- p xe

- Hoi t

Ton thn:

- ARDS

- Sc

- Thot mch

C CH BNH SINH

Tm tt c ch bnh sinh ca vim ty cp (Frossard J.L)

CHN ON

Tiu chun Atlanta 1992 sa i 2007

LS: au bng thng v, au xuyn ra sau

lng, nn, bun nn.

CLS: Amyla v/hoc Lipase mu tng 3 ln

CHA: siu m v CT.

PHN LOI THEO TIU CHUN ATLANTA

SA I 2007

Phn loi theo Hi ngh Atlanta 1992: nhiu nhc im

Nm 2007, Hi ty hc th gii sa i:

Phn loi theo lm sng:

Giai on sm (1 tun): VTC nng c N khi BN c HC p ng vim h thng (SIRS) v/hoc pht trin thnh suy tng

Giai on sau 1 tun: VTC nng khi c suy t nht 1 tng v ko di 48 gi (thang im Marshall hoc SOFA).

TIN LNG

Da vo cc du hiu lm sng

Da vo cc bng im: Ranson, Imrie,

APACHEII, Balthazar

Da vo cc marker ch im sinh hc trong

huyt thanh: IL6, IL8, IL10, TNF, CRP,

Procalcitolin

p lc bng v gi tr ca n trong nh gi mc VTC

TIN LNG

nh ngha:

p lc bng (ALOB) l p lc trng thi cn bng ng trong khoang bng, tng ln khi ht vo, gim khi th ra. Dao ng t 0 - 5 mmHg (7cm H2O).

Tng ALOB l khi gi tr ca ALOB 16 cmH20 trong t nht 3 ln o cch nhau mi 4 - 6 gi.

TIN LNG

Hip hi khoang bng th gii nm 2006 a

ra bng phn tng ALOB nh sau:

I: 12 - 15 mmHg (16 - 20 cmH20)

II : 16 - 20 mmHg (21 - 27 cmH20)

III: 21 - 25 mmHg (28 - 34 cmH20)

IV: > 25 mmHg (> 34 cmH20)

1

2

3

nh hng ca tng ALOB ti cc c quan

TIN LNG

TIN LNG

NC trn TG: in hnh l NC ca De Waele

NC trong nc: Nguyn c Ca NC trn 36 BN VTC cho thy c lin quan gia tng ALOB v mc nng ca VTC

Tng ALOB trong VTC

Tng ALOB (n=20) Khng tng ALOB (n=6) p

Ranson 7 3 < 0,05

APACHE 21 10 < 0,01

CRP 34 34 > 0,05

Suy h hp 20(95%) 2 (33%) < 0,01

Suy tim 19 (91%) 1 (17%) < 0,01

Suy thn 18 (86%) 1 (17%) < 0,01

Thi gian nm vin 42 12 < 0,01

BN c chn on VTC tui 18 c iu tr ti Bnh vin Bch Mai (khoa Tiu ha, khoa Hi sc tch cc) t 6/2008 - 6/2011.

Tiu chun chn on VTC theo tiu chun Atlanta 1992 sa i 2007.

I TNG NGHIN CU

I TNG V

PHNG PHP NGHIN CU

BN hoc gia nh khng ng tham gia nghin cu;

c PT hoc DLOB;

Bnh l bt thng bng quang;

Bnh l khc gy tng ALOB;

Bnh l mn tnh: suy tim III, IV; ung th giai on cui; Lupus ban h thng; suy thn mn; x gan;

I TNG NGHIN CU

Tiu chun loi tr

Thit k nghin cu: NC tin cu, theo di dc,

c can thip

Chn mu v c mu:

S dng cng thc tnh c mu p dng cho

vic c tnh t l trong qun th.

PHNG PHP NGHIN CU

2

2

)2/1(

)1(

ppZn

n: c mu

: mc ngha thng k, chn = 0,05 (tng ng vi tin cy 95%)

Z(1-/2): tra gi tr t bng, tng ng vi cc gi tr ca nh trn c kt qu Z(1-/2) = 1,96

p: l t l xut hin tn sut VTC th nng da theo nghin cu ca tc gi Nguyn c Ca (2007) ti khoa HSTC Bnh vin Bch Mai l 66%

: l chnh lch tuyt i yu cu l 10% (0,10).

p dng cng thc trn thu c kt qu.

Trong nghin cu ny chng ti la chn c 133 BN

PHNG PHP NGHIN CU

120085,0

34,066,096,1

)1(2

2

2

2

2/1

ppZn

PHNG PHP NGHIN CU

Cc bc tin hnh nghin cu

Thu thp cc triu chng lm sng

Hi bnh

Tin s: nghin ru, si mt, giun chui ng mt, b VTC, tng m mu, i tho ng.

Din bin bnh: thi gian khi pht, mc th t xut hin cc triu chng.

Khm lm sng

Cc du hiu ton thn

Cc du hiu c nng

Cc du hiu thc th

PHNG PHP NGHIN CU

Cc bc tin hnh nghin cu

Thu thp cc triu chng cn lm sng

Cng thc mu; Ure, creatinin, billirubin, in gii mu; protein, albumin mu, triglycerid;

Amylase mu, Lipase mu

ng mu, Canxi mu

Kh mu, men gan, t l prothrombin, bilirubin, ure, creatinin mu

Cy mu, nc tiu, dch mng bng, t chc ty hoi t

Cc xt nghim v ng mu

PHNG PHP NGHIN CU

Cc bc tin hnh nghin cu

Thu thp s liu chung cho nghin cu

Chn on hnh nh:

Chp X-quang phi;

Chp CT bng.

Siu m bng: BN nhp vin v tin hnh hng ngy

ti ging bnh;

Chp MRI: ch nh khi SA ,CT bng khng r tn

thng.

K thut o ALOB theo Cheatham

PHNG PHP NGHIN CU o ALOB

PHNG PHP NGHIN CU

Cc bc tin hnh nghin cu

Phn tng ALOB

Phn loi VTC theo cc thang im nng:

Ranson, Imrie, Balthazar, APACHE II.

Phn loi VTC theo Atlanta 1992 sa i 2007.

PHNG PHP NGHIN CU

Cc bc tin hnh nghin cu

nh gi suy tng da theo thang im SOFA

nh gi suy tng theo thang im SOFA cho tng tng

bao gm phi, tun hon, thn, thn kinh, gan, mu, s

lng tng suy vi tiu chun suy tng l im SOFA

2 hoc tng 1 im so vi lc nhp vin.

Din bin lm sng ca suy tng trong thi gian iu tr

thu thp s liu 1 ngy mt ln.

S lng tng b suy

PHNG PHP NGHIN CU

Cc bc tin hnh nghin cu

nh gi hiu qu

Cc thng s s dng nh gi:

nng: im SOFA,theo di ALOB 8 gi/ln.

Tng suy: s tng suy, mc suy tng, thi

gian hi phc cc tng suy.

Thi gian iu tr.

T l t vong.

PHNG PHP NGHIN CU

X l s liu

Theo phng php thng k y hc.

Tui v gii C IM BNH NHN NC

X

KT QU & BN LUN

Gii

Tui

Nam N Tng

n % n % n %

Nguyn nhn n T l %

Ru 88 66,2

Si mt 12 9,0

Giun 6 4,5

Tng tryglycerid 12 9

Khng r nguyn nhn 13 10,3

Tng s 133 100

Nguyn nhn

V c nh (Ru 71,6%); Nguyn c Ca (Ru 50%)

Cc phn loi VTC nng

(n,%)

VTC nh

(n,%)

Thang im Imrie 70(52,6) 63 (47,4)

Thang im Ranson 79 (59,4) 54(40,6)

Thang im APACHEII 64 (48,1) 69 (51,9)

Thang im Balthazar 50 (37,6) 83 (62,4)

Phn loi theo Atlanta sa i 2007 71 (53,4) 62 (46,6)

Phn VTC theo cc thang im

Nguyn Trng Hiu (VTC nng 34%)

Phn loi n %

Khng tng ALOB 34cmH2O 7 5,3

Tng 133 100,0

T l tng ALOB lc nhp vin theo phn chia ca Hip hi khoang bng th gii 2006

Nguyn c Ca (69%); De Waele (84%)

Mt s c im gia hai nhm tng ALOB v khng tng ALOB

c im Tng ALOB (n=91) Khng tng ALOB (n=42) p

Ranson 6,50 3,85 3,71 1,58

2

3

T l % bnh nhn VTC nng, nh (phn loi theo Atlanta sa i 2007), theo mc tng ALOB

Nguyn c Ca, V c nh, Rosus. J

Lin quan p lc bng vi cc thang im nng

ALOB

Cch phn loi

X SD

(cm H2O) p

Nng Nh

Imrie 22,755,01 15,184,66

Mi tng quan Spearman gia ALOB lc nhp vin vi cc thang im nng

510

15

20

25

30

ALO

B

0 5 10Ranson

r = 0,72, p < 0,001

510

15

20

25

30

ALO

B

0 2 4 6 8Imrie

510

15

20

25

30

ALO

B

0 5 10 15 20APACHE II

r = 0,7, p < 0,001

r = 0,78, p < 0,001 510

15

20

25

30

ALO

B

2 4 6 8 10CT-Score

r = 0,15, p > 0,05

Nguyn c Ca (r=0,51); Paivi Keskinen, De Waele (r=0,6); Zilvinas D.

Ranson Imrie

ApacheII

CT-Score

Chen H.

Gi tr ca ALOB lc nhp vin trong d bo mc ca VTC

Thang im Cut - off

(cm H2O) nhy

c

hiu GTDB(+) GTDB(-)

T l

chnh xc

APACHEII 23,2 98,55 86,88 86,67 96,77 83,68

Ranson 22,7 96,3 74,43 79,09 95,56 81,43

Imrie 21,5 88,0 82,29 75,67 90,91 78,20

Balthazar 23,6 86,75 40,0 70,59 64,52 69,17

Atlanta sa i

2007 21,9 83,38 91,94 90,0 78,67 86,69

Zilvinas D., Paivi Keskinen

ng cong nhn dng ROC Curve ca p lc bng trong d bo cc trng hp VTC nng theo

thang im

S (AUC) = 0,95 S (AUC) = 0,87

S(AUC) = 0,71

S(AUC) = 0,86

S(AUC) = 0,87

APACHEII Ranson

Imrie

Atlanta sa i

2007 Balthazar

Zilvinas D.,

Paivi

Keskinen

Gi tr ca ALOB lc nhp vin trong d bo mc ca VTC

So snh gi tr din tch di ng cong nhn dng (ROC Curve) ca ALOB trong d bo mc VTC vi cc thang im nng (theo phn loi Atlanta sa i 2007)

Thang im Gi tr din tch di

ng cong S(AUC)

Ranson 0,91

Imrie 0,9

ALOB 0,87

APACHE II 0,85

Balthazar

(CTSI) 0,76

Zilvinas D. (ALOB 0,932, Imrie 0,921, Apache II 0,866)

T l suy tng 2 nhm tng ALOB v khng tng ALOB

Tng suy Khng tng

ALOB (n = 42)

Tng ALOB

(n = 91) p

H hp 5 (11,9%) 59/91 (64,8%) < 0,001

Tim mch 6 (14,3%) 55/91 (60,4) < 0,001

Thn 5 (11,9%) 60/91 (65,9%) < 0,001

Mu 3 (7,1%) 18/91 (19,8%) < 0,001

Gan mt 3 (7,1%) 15/91 (16,5%) < 0,001

Thn kinh 0 6/91 (6,6%)

Lin quan gia tng ALOB v suy tng ca BN VTC

Nguyn c Ca (HH 44%, TH 48%, thn 52%, ALOB), De Waele (HH 95%, TH 91%, thn 86%, ALOB)

Lin quan gia mc tng ALOB v suy tng

11,9

46,6

57,5

78,6

100

0

10

20

30

40

50

60

70

80

90

100

< 16 cm

H20 (n=42)

I (n=30) II (n=40) III

(n=14)

IV (n=7)

T l %

Mc tng ALOB

0

10

20

30

40

50

60

70

80

90

100

< 16 cm

H20

(n=42)

I (n=30)

II (n=40)

III (n=14)

IV (n=7)

14,3

40

57,5

92,8100T l %

Mc tng ALOB

Tun hon

Thn

0

10

20

30

40

50

60

70

80

90

100

< 16 cm H20(n=42)

I (n=30) II (n=40) III (n=14)

IV (n=7)

11,9

43,3

65

92,9100T l %

Mc tng ALOB

H hp

Nguyn c Ca, Chen H., De Waele, Zininas, Zhang, Gary, Sunzx

Lin quan gia ALOB vi s tng suy

8,3+7,13

8,4+5,20

8,5+5,235,9+5,28

0

5

10

15

20

25

30

35

40

0 suy tng Suy 1 tng Suy 2 tng 3 tng

ALOB (cmH2O)

S tng suy

Nguyn c Ca, Chen H., De Waele, Zininas, Zhang, Gary, Sunzx

Lin quan gia tng ALOB vi mc suy tng

1.2

1.8

2.2

3.1

3.5

1.1

1.7

2.3

2.9

3.6

1.4

1.8

2.1

2.8

3.3

0

1

2

3

4

Khng tng I II III IV

H hp Tun hon Thn

ALOB

im SOFA

Paivi Keskinen

Gi tr ALOB lc nhp vin trong d bo bin chng suy tng

Cut off

(cmH2O) nhy

c hiu

GTDB(+) GTDB(-) T l

chnh xc

18,9 100,0 44,0 81,82 100,0 82,0

0.0

00

.25

0.5

00

.75

1.0

0

Se

ns

itiv

ity

0.00 0.25 0.50 0.75 1.001 - Specificity

Area under ROC curve = 0.7296

Din tch di ng cong

ALOB lc nhp vin lin quan vi t l t vong BN VTC

100

0

100

0

77,5

22,5

64,2

35,842,9

57,1

0

10

20

30

40

50

60

70

80

90

100

Khng tng

ALOB

(n=42)

I (n=30) II (n=40) II (n=14) IV (n=7)

Sng

T vong

T l %

Chen H., De Waele, Zininas, Zhang, Gary, Sun ZX

So snh mc tng ALOB (trung bnh) nhm t vong v sng

Kt qu

T

Sng (n=115)

X SD

(cmH2O)

T vong (n=18)

X SD

(cmH2O)

Chung

(n=133)

X SD

(cmH2O)

ALOB 15,294,50 27,742,28 16,986,04

p p

Gi tr ALOB lc nhp vin trong d bo t vong

Cut -

off nhy

c hiu

GTDB(+) GTDB(-) T l

chnh xc

32 97,39 27,78 89,60 62,50 88,0 0

.00

0.2

50

.50

0.7

51

.00

Se

nsitiv

ity

0.00 0.25 0.50 0.75 1.001 - Specificity

Area under ROC curve = 0.8688

Din tch di ng cong ca gi tr ALOB trong tin lng t vong

Kt qu t vong theo s tng suy nhm BN c iu tr hi sc c bn kt hp cc bin php LMLT v DLOB

T l t vong

S tng suy

S bnh nhn t vong (n),

T l (%)

1 tng suy (n = 7) 0

2 tng suy (n = 23) 1(4,3%)

3 - 4 tng suy (n = 17) 2 (11,8%)

5 - 6 tng suy (n = 8) 5 (62,5%)

Chung (n = 55) 8 (14,5%)

Paivi Keskinen, De Waele, Sun ZX, Nguyn Quang Hi

KT LUN

1. T l tng ALOB bnh nhn VTC trong nghin cu l 68,4%.

2. ALOB tng quan tuyn tnh thun cht ch vi cc thang im (Ranson, Imrie, APACHE II r = 0,72; 0,7 v 0,78), khng tng quan vi thang im CTSI (r = 0,15).

3. ALOB ti cc im ct 23,2; 22,7; 21,5; 23,6; 21,9(cmH2O)- tng ng tng ALOB II c gi tr d bo mc ca VTC theo cc thang im phn APACHEII, Imrie, Ranson v cch phn loi Atlanta sa i 2007

4. ALOB ti cc im ct 18,9; 32 (cmH2O) c gi tr d bo bin chng suy tng ; t vong vi nhy cao, nhng c hiu thp

KIN NGH

o ALOB l mt k thut n gin r tin c gi

tr tin lng sm, mc ca VTC, theo di v

gi cc bin php iu tr cho BN VTC. V vy

nn trin khai p dng cho cc c s y t.

Cn tin hnh cc nghin cu ng dng ln hn

cc BN c tng ALOB ni chung trong mi

trng hi sc, cp cu v chng c.

Em xin trn trng cm n !