Sở y tế hà nội Bệnh viện tim hà nội Báo cáo kết Đề tài nghiên cứu khoa học cấp sở Năm 2011 Tên đề tài : ĐNH GI HIU QU HUYT NG CA DOBUTAMIN TRấN CC BNH NHN GIM LU LNG TIM SAU PHU THUT VAN TIM VI TUN HON NGOI C TH Chủ nhiệm đề tài: Ths Trn Mai Hựng Hà Nội, tháng 12/năm 2011 I T VN Phu thut can thip trờn van tim l phu thut chim t l ln cỏc phu thut tim vi tun hon ngoi c th c bit Vit nam, t l bnh nhõn tim mch cú bnh lý van tim l rt cao Theo thng kờ ti bnh vin, ca Vin Tim Mch- Bnh vin Bch Mai s bnh nhõn nm vin vỡ bnh van tim chim 2/3 [12] õy l hu qu ca cỏc tn thng van tim hu thp [4], bnh lý gp nhiu nht ti cỏc nc ang phỏt trin Phu thut tim vi s tr giỳp ca h thng tun hon ngoi c th (THNCT) l mt phu thut chuyờn khoa, ton b chc nng ca tim v phi c thay th bng mt h thng gi l tim phi nhõn to (Cardiopulmonary bypass: CPB) Mc dự ó cú nhiu tin b k thut m v bo v c tim, cng nh s dng cỏc thuc gõy mờ mi ớt nh hng n chc nng tim v sau m, cựng vi cỏc phng tin hi sc hin i, nhng gim lu lng tim sau m l thng gp [14],[32] Nguyờn nhõn nhiu yu t phi hp nhng luụn bao gm: bn thõn tim ó b suy trc m, bnh lý a van, thiu mỏu c tim kộo di thi gian cp ng mch ch, chn thng trc tip lờn tim cỏc can thip phu thut, tn thng tỏi ti mỏu, mt chc nng c tim gõy bi dung dch lm lit tim (cardioplegie), hot hoỏ h thng viờmgim lu lng tim gõy gim cung cp oxy cho cỏc c quan [29],[32] Tn thng cp tớnh chc nng tõm tht cú th tip din c giai on hi sc [14].Vic s dng thuc tr tim cú vai trũ ci thin lu lng tim, rt quan trng vic giỳp hi phc hot ng ca tim sau phu thut, rỳt ngn thi gian th mỏy, gim bt thi gian nm vin, gim t l t vong, ng thi giỳp cho bnh nhõn nhanh chúng tr li cuc sng thng nht v tit kim c nhiu chi phớ [32],[35] Cỏc yu t nguy c phi hp vi vic phi s dng thuc tr tim sau m thỡ ó c nghiờn cu nhiu [16],[47],[52] Cú nhiu loi thuc tr tim c s dng gii quyt ny (Dopamine, Dobutamine, Dopexamine, Epinephrine, Milrinone, Enoximone, Norepinephrine, Levosimendan,) [29],[30] Hin nay, Dobutamine l thuc tr tim c dựng ph bin ti cỏc trung tõm phu thut tim mch [30],[39],[40],[45],[48] Tuy nhiờn cho ti ti Vit Nam cha cú nghiờn cu no c cụng b v hiu qu ca Dobutamine iu tr gim lu lng tim sau phu thut van tim vi tun hon ngoi c th Vic dựng thuc tr tim cũn ph thuc nhiu vo kinh nghim riờng ca cỏc bỏc s gõy mờ hi sc, cha cú s thng nht v cỏc bng chng nghiờn cu Xut phỏt t thc t ú, chỳng tụi tin hnh nghiờn cu: ỏnh giỏ hiu qu huyt ng ca Dobutamine trờn cỏc bnh nhõn gim lu lng tim sau phu thut van tim vi tun hon ngoi c th Vi mc ớch: ỏnh giỏ hiu qu ci thin huyt ng ca Dobutamine trờn bnh nhõn gim lu lng tim sau phu thut van tim cú s dng tun hon ngoi c th ỏnh giỏ cỏc tỏc dng bt li ca Dobutamine trờn mt s ch s huyt ng ca bnh nhõn Chng I TNG QUAN TI LIU 1.1 Lch s gõy mờ - hi sc phu thut tim vi THNCT 1.1.1 Lch s gõy mờ- hi sc Phu thut tim i vo nhng nm cui th k 19.Na th k tip theo l giai on phỏt trin ca cỏc phu thut trờn tim kớn (to shunt ng mch di ũn - ng mch phi iu tr tim bm sinh cú tớm ca Blalock, khõu ct ng ng mch ca Gross,) hay trờn tim cũn p (tỏch van hai lỏ, iu tr viờm mng ngoi tim co tht,) Thi gian phu thut giai on ny b hn ch v hụ hp h tr chng li trn khớ mng phi m mng phi sau phu thut cha gii quyt c Lch s phỏt trin ca ngnh gõy mờ hi sc lnh vc ny gn lin vi s phỏt trin ca ngnh ngoi khoa Vn quan trng nht gõy mờ phu thut tim vi THNCT l phi loi b c cỏc kớch thớch trờn h thn kinh giao cm lm tng huyt ỏp, tng nhp tim, co mch ngoi vi, gi li cỏc catecholamine ni sinh cho giai on sau m Phu thut tim m bt u thc hin thnh cụng trờn ngi vo nm 1953 Nm 1955 Gorden Murray ó thc hin thay van ng mch ch ng loi trờn ngi Nm 1960, ln u tiờn Starr v Edward ghộp thnh cụng van c hc vo v trớ van hai lỏ Van lng Starr-Edward T ú n nay, k thut sa cha trờn van tim khụng ngng c ci tin v s lng bnh nhõn c phu thut van tim cng ngy cng nhiu lờn Hng nm, Phỏp cú hn 10.000 bnh nhõn [39] v M cú hn 60.000 bnh nhõn [33], c thay van tim nhõn to Ti Bnh vin Tim H ni nm hot ng ó phu thut hn 6000 ca vi tim phi nhõn to, ú hn 50% trng hp bnh nhõn c phu thut trờn van tim Tớnh ti thỏng nm 2011 ó phu thut c 1000 ca vi hn 400 ca phu thut trờn van tim Da trờn nhng nghiờn cu v dc ng hc v nh hng lờn h tim mch ca cỏc thuc gõy mờ m khuynh hng gim liu cỏc thuc gim au dũng h morphin i, cựng vic phi hp vi nhúm benzodiazepin hoc cỏc thuc mờ ng hụ hp h halogen 2],[3],[7 1.1.2 Mỏy tun hon ngoi c th 1.1.2.1 Lch s Phu thut tim m vi THNCT ln u tiờn c ỏp dng trờn ngi vo thỏng nm 1951 bi Clarence Dennis v cng s Minnesota nhng tht bi, bnh nhõn t vong Ca m thnh cụng u tiờn trờn ngi vi THNCT l vo thỏng nm 1953 John Gibbon thc hin ti Philadelphia, S mỏy THNCT Mỏy THNCT Sau mt lot cỏc nghiờn cu v vũng tun hon, v bm, mng trao i oxy, chng ụng mỏu bi heparin (do Mac Lean tỡm nm 1916), trung ho heparin bng protamine sulphat (do Chargaff v Olson tỡm nm 1937) V Vit Nam, c GS Tụn Thõt Tựng ó bt u phu thut tim vi mỏy tun hon ngoi c th nm 1965, ca m u vỏ thụng liờn nh tin hnh thnh cụng ti Bnh vin hu ngh Vit nam- Cng hũa dõn ch c t nn múng cho s phỏt trin ca gõy mờ hi sc tim mch núi riờng v ngnh phu thut tim mch núi chung 1.1.2.2 Nguyờn lý mỏy THNCT Mỏy tun hon ngoi c th (THNCT) - Nú m bo trỡ tun hon mỏu v trao i ụxy ton b c th tim v phi tm thi ngng hot ng [2],[19] Nhm bo v c tim bng vic s dng dung dch gõy lit tim (cardioplegie) cú nng kali cao lm tim ngng p, to mt phu trng khụng cha mỏu cho cỏc sa cha tim Nhng k thut ny cho n nayvn cũn c ỏp dng, nhiờn cng ó cú nhiu ci tin gim bt cỏc tai bin ca THNCT 19],[23 THNCT gõy thay i ln v sinh lý: Thay i tớnh mch p v kiu dũng chy ca mỏu; mỏu tip xỳc vi b mt khụng sinh lý v lc ma sỏt gõy ging xộ (shear stress); ỏp ng quỏ mnh ca c th vi stress 1.2 Lu lng tim v phng phỏp chớnh thm dũ huyt ng 1.2.1 Lu lng tim[8],[13] 1.2.1.1 Khỏi nim Hot ng ca tim th hin bng lu lng tim (Cardiac Output : CO) l s lng mỏu m tim tng trung bỡnh mi phỳt, nú l kt qu tỏc ng phi hp ca yu t: tin gỏnh, sc co búp c tim, hu gỏnh v tn s tim p phỳt Lu lng tim khỏc mi ngi, lu lng tim ngi 80 kg v ngi 40 kg khỏc Do vy trờn lõm sng ta thng s dng ch s tim Ch s tim (CI = CO/BSA): lu lng mỏu tng phỳt trờn mt n v din tớch da, l mt cỏch biu th khỏc ca lu lng tim [10] Ch s ny khụng ph thuc vúc dỏng to, nh, nng nh ca bnh nhõn nờn d so sỏnh trờn lõm sng 1.2.1.2 Cỏc yu t quyt nh LLT Bn yu t quyt nh lu lng tim l : * Tin ti (preload) Tin ti th hin tỡnh trng lm y tht, trờn lõm sng ngi ta thng dựng t tin ti ch th tớch tõm tht cui thỡ tõm trng Theo lut Frank Starling chiu di ny cng tng sc co búp c tim cng tng, nhng ch n mt gii hn no ú, qua gii hn ny thỡ lc co c s gim Ta cú th lng giỏ tin ti qua Catherte Swan-Ganz hoc bng siờu õm tim * Hu ti Hu ti c nh ngha l gỏnh nng chng li s co c tõm tht Nh vy tng mỏu vo ng mch, sc cn ca c tht phi vt c sc cn ny Hu ti cng ln thỡ c tim co búp cng khú khn nờn d dn ti suy tõm tht Hu ti ph thuc vo sc n hi ca ng mch, sc cn mch h thng Sc cn mch h thng hay cũn gi l sc cn ngoi biờn, nú khụng i din cho hu ti vỡ nú khụng tớnh ti yu t ni ti ca qu tim, nhiờn thng dựng trờn lõm sng Sc cn ngoi biờn ph thuc vo b trớ cu trỳc ca h mch mỏu, trng lc ca tiu ng mch v quỏnh ca mỏu Cụng thc tớnh : SVR ( MAP MRA ) ì80 CO * Sc co c tim Sc co c tim l c im ni ti ca c tim, mt sc co c thay i thỡ hiu sut lm vic, th tớch tng mỏu ca c tim gim dự tin gỏnh hoc hu gỏnh khụng thay i Trờn ngi v sỳc vt thc nghim vic ỏnh giỏ khú khn + o phõn xut tng mỏu Bng k thut siờu õm hay ht nhõn ngy ngi ta cú th o c th tớch tõm trng (EDV) v th tớch cui tõm thu (ESV) t ú tớnh c phõn xut tng mỏu (EF) EF= (EDV- ESV)/ EDV = SV / EDV +Cỏc yu t nh hng ti sc co c tim Yu t kớch thớch -Hot ng ca h thn kinh giao cm, b kớch thớch h giao cm tit Noradrenalin lm tng sc co búp c tim - Catecholamine tng : Khi b gim th tớch tun hon hay thiu mỏu, tuyn thng thn tit catecholamine lm tng co búp c tim - Cỏc thuc tr tim Yu t c ch - Thiu oxy, toan húa -Thuc c ch Ca+2, Quinidin - Thuc mờ h Halogen, bacbituric * Tn s tim Khi tn s tim thay i lm thay i lu lng tim (LLT = th tớch tng mỏu ì tn s tim) õy l cỏch ỏp ng ca c th vi nhu cu tng chuyn húa ca c th Tn s tim ph thuc tỡnh trng kh cc ca t bo to nhp (nỳt xoang, nỳt nh tht) di tỏc ng ca thn kinh t ng Tuy nhiờn tn s tim quỏ nhanh 150 200 ln/phỳt thỡ lu lng tim li gim, vỡ tim p nhanh lm thi gian y tht thi k tõm trng ngn li Do ú lm th tớch y tõm tht gim nờn lu lng tim gim Mt khỏc thi gian tõm trng ngn li thỡ lu lng vnh gim nờn s cung cp oxy cho c tim gim lm sc co c tim gim t ú lm gim lu lng tim nh lut Frank- Starling nh lut Frank- Starling l nh lut v mi quan h gia mt bờn l tin ti vi mt bờn l th tớch nhỏt búp v lc tng mỏu tõm tht to (th hin qua ỏp lc tõm tht thi gian co ng th tớch) Khi tin ti tng thỡ lc tng mỏu tõm tht to v th tớch nhỏt búp cựng tng Mi liờn h ny c biu din qua mt ng cong gi l ng cong FrankStaling ng vi nhng kh nng co búp ca c tim khỏc ta s cú nhng ng cong khỏc 1.2.2 Catheter Swan-Ganz[50] Catheter Swan-Ganz l mt loi catheter cú cn quang, nhiu ng, c trang b mt búng bm c u xa Catheter ny c t vo ng mch phi ca bnh nhõn, u ngoi c ni vi mt h thng o chuyờn bit Vic t mt catheter vo ng mch phi l k thut hay c s dng gõy mờ v hi sc tim mch Nm 1953, Lategola v Rahn ó a nhng kinh nghim u tiờn t mt catheter cú búng vo ng mch phi ca chú, cho phộp o ỏp lc ng mch phi, qua ú xỏc nh ỏp lc ti mao mch phi Tuy nhiờn phi i cho n nm 1970, hai nh phỏt minh Jeremy Swan v William Ganz ( trung tõm y t Cedars-Sinai) mi a loi catheter mang tờn Swan-Ganz s dng trờn ngi 50 Ch nh t catheter Swan-Ganz - Nhi mỏu c tim cp cú bin chng sc tim, suy tõm tht nng - Tỡnh trng sc : Sc tim, sc nhim trựng, sc gim th tớch cựng suy gim chc nng tht trỏi - Thuyờn tc phi rng gõy ri lon huyt ng - Suy hụ hp cp kốm suy gim chc nng tht trỏi v ri lon huyt ng - M tim, cú suy tim hoc tng ỏp lc ng mch phi - Bnh nhõn cú theo dừi v iu tr bng búng bm ni ng mch ch - Theo dừi v sau m (khụng phi m tim) bnh nhõn suy tim nng, tựy ch nh ca bỏc s gõy mờ Nú cho phộp o ỏp lc nh phi, ỏp lc ng mch phi, ỏp lc mao mch phi bớt Ta o ỏp lc mao mch phi bớt bng cỏch bm cng búng u catheter u catheter ó nm mt nhỏnh ng mch phi Khi ú búng s bớt mt nhỏnh ca ng mch phi, v ỏp lc o c t l u ca catheter Swan- Ganz l ỏp lc ca ct mỏu v nh trỏi Bỡnh thng ỏp lc mao mch phi bớt tng ng ỏp lc nh trỏi - o chớnh xỏc ỏp lc ng mch phi, qua ú xỏc nh ỏp lc lm y ca tim trỏi Vic o ny cú th thc hin theo cỏch nhc li hoc theo dừi liờn tc K thut khụng quỏ phc tp, cú th thc hin ti phũng m v ti ging bnh nhõn v phũng hi sc 10 TI LIU THAM KHO I Trong nc: Phm T Dng: Thuc Tim Mch Nh xut bn y hoc 2000.tr :315-338 Nguyn Quc Kớnh: Gõy mờ m tim Bi ging gõy mờ hi sc Tp II Nh xut bn y hoc 2002.tr:102-120 Hong Anh Khụi, Nguyn Vn Chng, Nguyn Th Quý: Rỳt NKQ sm ti phũng m sau m thụng liờn nh Bỏo cỏo khoa hc - 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Vol 44, No 4: 281-286 53 53 Tarr T.J., Moore N.A., Frazer R.S., Shearer E.S., Desmond M.J.: Haemodynamic effect and comparison of enoximone, dobutamine and dopamine following mitral valve surgery Eur J Anaesthesiol Suppl 1993; 8: 15-24 54 Van Trigt P , S.T.L., Pasque M.K., Peyton R.B., Pellom G.L., Wechsler A.S., (1984) The comparative effect of dopamine and dobutamine on ventricular mechanics affter coronary arteru bypass grafting: a pressurce dimension analysis Ciculation, 70(suppl 1)tr 112-117 54 Bnh vin Tim H Ni PHIU NGHIấN CU 2011 Phũng m Bs: Trn Hựng H Tờn BN: Tui: Gii: Nam/N a chin thoi Chiu caocm Cõn nng :.Kg NYHA Din tớch da.m2 Mó bnh ỏn Ngy vo vin: / / 2011 Ngy m: / / 2011 Chn oỏn: Cỏch phu thut: Tin s ECG:.RCT: Siờu õm tim Trc m Dd : PAPs : Nh trỏi: Ds : EF : Khỏc: Dd : PAPs : Nh trỏi: Ds : EF : Khỏc: Thg PT: Thg CEC: Nc tiu: Ngy Thg Kp MC: Thg H tr CEC: Sau m Theo dừi m: Thi gian theo dừi hu phu: Thi gian th mỏy: gi Thi gian nm iu tr hi sc: ngy Thi gian dựng Dob:gi Thi gian nm vin:.ngy 55 Ngy ml ml THEO DếI HUYT NG Trc Sau1h Sau 6h Sau12h Sau24h Sau48h Dob Dob Dob Dob Dob Dob Ts tim (HR) MAP CVP CO CI SV PAP PAPo Sc cn Phi(PVR) Sc cn HThng(SVR) Liu Dob Tr tim khỏc Thuc khỏc 56 Cn lõm sng Trc m Sau v hi sc Hng cu Bch cu Hematocrite Hemoglobine Tiu cu Ure Creatinine ng huyt Albumine Proteine Bilirubin : TP TT GT GOT GPT CK CK-MB Prothrombine APTT INR Fibrinogen Trc R da Trc Dob pH PCO2 PO2 HCO3 BE 57 SM Ngy SM Ngy S Y T Bnh vin Tim H Ni DANH SCH BNH NHN NGHIấN CU STT H tờn bnh nhõn Tui Gii Ngy m Mó bnh ỏn Nguyn Vn D 50 Nam 24/3/11 0341 Phm Tin T 61 Nam 20/4/11 0561 Ngụ Th L 34 N 21/4/11 0572 Trnh Th Hng G 40 N 20/4/11 0541 Nguyn Th 25 N 21/4/11 0584 Trn Thin M 62 N 26/4/11 0565 Cao Minh 23 Nam 28/4/11 0648 Nguyn Vn C 61 Nam 05/5/11 0703 Phm Vn 53 Nam 09/5/11 0710 10 Nguyn Vn T 51 Nam 23/5/11 0860 11 inh Th O 35 N 24/5/11 0832 12 Ngụ nh T 29 N 24/5/11 0830 13 Phựng Th T 54 N 12/5/11 0786 14 Nguyn Th L 44 N 13/5/11 0784 15 Cn Th H 29 N 31/5/11 0894 16 Nguyn Th B 55 N 03/6/11 0881 17 Nguyn Th C 51 N 02/6/11 0908 18 Trn Th D 56 N 06/6/11 0958 19 Lờ Th Nh B 54 N 20/6/11 1041 20 Hong Th T 31 N 21/6/11 1064 21 Nguyn Phựng T 44 Nam 24/6/11 1114 22 Triu Kim H 46 Nam 22/6/11 1036 58 23 ng Th T 51 N 28/6/11 1075 24 Nguyn Th T 55 N 15/6/11 1030 25 Nguyn Vn K 54 Nam 20/6/11 1012 26 Khng Quyt T 27 Nam 22/6/11 1044 27 Phm Vn N 26 Nam 07/7/11 1233 28 Hong Th 44 N 08/7/11 1172 29 Nguyn Vn K 31 Nam 14/7/11 1281 30 Nguyn Thi T 40 N 21/7/11 1319 31 Nguyn ỡnh T 55 Nam 26/7/11 1360 32 Ch Vn T 44 Nam 15/8/11 1491 33 Hong Vn V 49 Nam 12/8/11 1488 34 Nguyn c L 43 Nam 16/8/11 1547 59 CC CH VIT TT TRONG LUN VN BSA : Din tớch c th CI : Cardiac Index- Ch s tim CO : Cardiac output- Lu lng tim CVP : Central venous pressure- p lc tnh mch trung tõm Dd : Kớch thc tht trỏi EF : Phõn xut tng mỏu ca tht trỏi HR : Heart rate- Tn s tim MAP : Mean arterial pressure- p lc ng mch trung bỡnh MPAP : Mean pulmolary artery pressure p lc ng mch phi trung bỡnh SVR : Systemic vascular resitance - Sc cn h thng PVR : Pulmonary vascular resitance PAPs : p lc ng mch phi tõm thu PCWP : Mean capillary wedge pressure- p lc ng mch phi bớt THNCT : Tun hon ngoi c th TCBCT : Tng co búp c tim 60 - Sc cn phi MC LC Trang T VN .1 Chng I: TNG QUAN TI LIU 1.1 Lch s gõy mờ - hi sc phu thut tim vi THNCT 1.1.1 Lch s gõy mờ- hi sc .4 1.1.2 Mỏy tun hon ngoi c th 1.1.2.1 Lch s 1.1.2.2 Nguyờn lý mỏy THNCT 1.2 Lu lng tim v phng phỏp chớnh thm dũ huyt ng 1.2.1 Lu lng tim 1.2.1.1 Khỏi nim 1.2.1.2 Cỏc yu t quyt nh LLT .7 1.2.2 Catheter Swan-Ganz 1.3 Mt s ch s huyt ng hc khỏc v phng tin theo dừi chỳng gõy mờ- hi sc tim mch 12 1.3.1 Huyt ỏp ng mch 12 1.3.2 p lc tnh mch trung tõm 13 1.4 Gim lu lng tim v suy tim 13 1.4.1 Hi chng gim lu lng tim 13 1.4.2 Suy tim .14 1.5 Thuc tr tim sau phu thut tim 16 1.5.1 Tiờu chun la chn thuc tr tim sau phu thut 16 1.5.2 Dobutamine 17 Chng II: I TNG V PHNG PHP NGHIấN CU .19 2.1 i tng nghiờn cu 19 2.1.1 Tiờu chun chn bnh nhõn 19 2.1.2 Tiờu chun loi tr 19 2.2 Phng phỏp nghiờn cu .19 2.2.1 Thit k nghiờn cu 19 2.2.2.Phng tin nghiờn cu 20 2.2.3 Tin hnh nghiờn cu .20 2.2.4 Thu thp kt qu .24 61 2.3 Phng phỏp x lý thng kờ 25 CHNG III: KT QU NGHIấN CU 26 3.1 c im chung ca cỏc bnh nhõn trc phu thut 26 3.1.1 c im bnh nhõn 26 3.1.2 Phõn suy tim theo NYHA 27 3.1.3 in tõm 27 3.1.4 Phõn sut tng mỏu trc m 28 3.2 c im phu thut 29 3.2.1 Phõn loi bnh nhõn phu thut .29 3.2.2 c im gõy mờ - THNCT 29 3.3 Kt qu iu tr 30 CHNG IV: BN LUN .35 4.1 Mt s c im chung 35 4.1.1 im v tui v gii 35 4.1.2 c im hỡnh thỏi v tỡnh trng suy tim 35 4.2 Duy trỡ huyt ng n nh giai on chu phu 36 4.2.1 X trớ gõy mờ giai on trc chy THNCT 37 4.2.2 X trớ gõy mờ quỏ trỡnh THNCT 37 4.2.3 Chun b ngng THNCT 37 4.3 ỏnh giỏ hiu qu ci thin huyt ng ca dobutamin .38 4.4 Tỏc dng bt li ca dobutamin 42 4.4.1 Bt li trờn nhp tim 42 4.4.2 Thiu mỏu c tim chu phu .43 4.5 Rỳt ni khớ qun trờn bnh nhõn m van tim .44 KT LUN 46 KIN NGH .47 TI LIU THAM KHO 48 62