B GIO DC V O TO B Y T TRNG I HC Y H NI PHM NG THUN NHậN XéT HIệU QUả PHáC Đồ CHốNG ĐÔNG BằNG HEPARIN TRONG Kỹ THUậT TIM PHổI NH ÂN TạO TạI GIƯờNG (ECMO) CủA KHOA HồI SứC TíCH CựC BệNH VIệN BạCH MAI LUN VN THC S Y HC H NI 2016 B GIO DC V O TO B Y T TRNG I HC Y H NI PHM NG THUN NHậN XéT HIệU QUả PHáC Đồ CHốNG ĐÔNG BằNG HEPARIN TRONG Kỹ THUậT TIM PHổI NH ÂN TạO TạI GIƯờNG (ECMO) CủA KHOA HồI SứC TíCH CựC BệNH VIệN BạCH MAI Chuyờn ngnh: Hi sc cp cu Mó s: 60720122 LUN VN THC S Y HC Ngi hng dn khoa hc: TS o Xuõn C TS Nguyn Tun Tựng H NI 2016 LI CM N Trong sut thi gian hc tp, ngun ng lc tụi luụn c gng chớnh l nhng tỡnh cm quý giỏ m tụi nhn c t Thy cụ, gia ỡnh v bn bố T nhng tỡnh cm chõn thnh nht, tụi xin gi li cm n n TS o Xuõn C, TS Nguyn Tun Tựng - nhng ngi Thy ó hng dn tụi nhng bc i u tiờn trờn ng nghiờn cu khoa hc; ngi luụn tn tỡnh ch bo, ng viờn, khớch l tụi sut quỏ trỡnh hc v nghiờn cu Vi tt c s kớnh trng, tụi xin gi li cm n n GS Nguyn Gia Bỡnh, PGS.TS ng Quc Tun, TS Lờ Th Dim Tuyt, TS Nguyn Cụng Tn v cỏc Thy cụ Khoa Hi sc tớch cc Bnh vin Bch Mai nhng ngi Thy ó dỡu dt, dy d v truyn cho tụi nhng kin thc chuyờn mụn quý giỏ Tụi xin by t lũng bit n sõu sc i vi PGS.TS Nguyn t Anh v cỏc Thy cụ B mụn Hi sc cp cu trng i hc Y H Ni - nhng ngi Thy ó truyn cho tụi kin thc, s say mờ nghiờn cu v lũng yờu ngh cụng vic ging dy Tụi xin gi li cm n chõn thnh n th cỏn b nhõn viờn Khoa Hi sc tớch cc, Khoa Cp cu, Trung tõm Chng c Bnh vin Bch Mai ó giỳp tụi rt nhiu quỏ trỡnh hc v thc hin ti Tụi xin cm n tt c cỏc Thy cụ, cỏc anh ch B mụn Hi sc cp cu v Khoa Hi sc tớch cc Bnh vin a khoa Thỏi Bỡnh - ni tụi cụng tỏc ó luụn ng viờn v to iu kin tt nht tụi hon thnh tt nhim v Tụi xin by t lũng bit n ti gia ỡnh, bn bố - nhng ngi thõn thit luụn ng viờn, c v v ng hnh cựng tụi sut thi gian qua Tụi xin chõn thnh cm n! Phm ng Thun LI CAM OAN Tụi l Phm ng Thun, hc viờn cao hc khúa 23 - Trng i hc Y H Ni, chuyờn ngnh Hi sc cp cu, xin cam oan: õy l lun bn thõn tụi trc tip thc hin di s hng dn ca TS o Xuõn C v TS Nguyn Tun Tựng Cụng trỡnh ny khụng trựng lp vi bt k nghiờn cu no khỏc ó c cụng b ti Vit Nam Cỏc s liu v thụng tin nghiờn cu l hon ton chớnh xỏc, trung thc v khỏch quan Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, thỏng 11 nm 2016 Tỏc gi Phm ng Thun DANH MC CH VIT TT ACT : Activated Clotting Time - Thi gian ụng mỏu hot húa ARDS : Acute Respiratory Ditress Syndrome (Hi chng suy hụ hp cp tin trin) APTT : Activated Partial Thromboplastin Time (Thi gian thromboplastin tng phn hot húa) APACHE : Acute Physiology And Chronic Health Evaluation (ỏnh giỏ tỡnh trng bnh mn tớnh v bnh lý cp tớnh) DIC : Disseminated Intravascular Coagulation (ụng mỏu ri rỏc lũng mch) ECMO : Extracorporeal Membrane Oxygenation (Trao i oxy qua mng) FiO2 : Inspired Oxygen Fraction Nng oxy khớ th vo HSTC : Hi sc tớch cc NMCT : Nhi mỏu c tim PaCO2 : Arterial Partial Pressure of Carbon Dioxide (p lc riờng phn CO2 mỏu ng mch) PaO2 : Arterial Partial Pressure of Oxygen (p lc riờng phn O2 mỏu ng mch) PT : Prothrombin Time Thi gian prothrombin rAPTT : Rate Activated Partial Thromboplastin Time - APTT bnh/chng SOFA : Sequential Organ Failure Assessment TB : Trung bỡnh VA : Veno-Arterial (Tnh mch- ng mch) VCT : Viờm c tim VV : Veno-Venous (Tnh mch-tnh mch) MC LC DANH MC BNG DANH MC BIU T VN K thut tim phi nhõn to - Extracorporeal Membrane Oxygenation (ECMO) l k thut c ci tin t mỏy tun hon ngoi c th phu thut tim h c im ca k thut ECMO l mỏu c ly t cỏc tnh mch ln thụng qua mt bm li tõm a mỏu n mt mng trao i oxy, mỏu sau trao i oxy s c tr v c th Ph thuc vo ng vo mch mỏu l tnh mch - tnh mch (VV-ECMO) hay tnh mch - ng mch (VA-ECMO) m ECMO dựng h tr chc nng tim, chc nng phi hay c hai [1],[2],[3] Quỏ trỡnh iu tr ECMO thng kộo di nờn nguy c tc mng trao i oxy l rt cao Khi phi thay mng s rt nguy him, cú th nh hng n tớnh mng ca bnh nhõn Vỡ vy s dng thuc chng ụng ECMO l ht sc quan trng nhm kộo di tui th ca mng Tuy nhiờn vi bnh cnh ca bnh nhõn ECMO cú rt nhiu ri lon nht l nhng ri lon v ụng mỏu thỡ vic s dng thuc chng ụng l rt khú khn, ũi hi phi trỡ mt s cõn bng tinh t gia vic phũng nga huyt v trỏnh bin chng chy mỏu [4],[5] Thuc chng ụng c hu ht cỏc trung tõm s dng quỏ trỡnh chy ECMO l heparin khụng phõn on nhng s dng v theo dừi heparin ECMO cũn nhiu tranh cói Hin cha cú phỏc thng nht, mi trung tõm thỡ phỏc s dng heparin li khỏc Dn n t l bin chng chy mỏu dựng heparin cũn cao (41% - 60%), nh hng n tớnh mng, thi gian v hiu qu iu tr ca bnh nhõn [6],[7],[8],[9] ó cú nhiu phỏc s dng heparin quỏ trỡnh chy ECMO c nghiờn cu, th nghim v s dng, mi phỏc cú nhng u nhc im 10 nht nh Tuy nhiờn khụng cú phỏc no l ti u cho tt c cỏc trng hp [10],[11] Khoa Hi sc tớch cc Bnh vin Bch Mai hin ang ỏp dng phỏc chng ụng s dng heparin khụng phõn on iu chnh theo thi gian thromboplastin tng phn hot húa (APTT) Tuy nhiờn cha cú nghiờn cu no ỏnh giỏ hiu qu ca phỏc ny Vỡ vy chỳng tụi thc hin ti ny nhm mc tiờu: Nhn xột hiu qu phỏc chng ụng bng heparin khụng phõn on k thut tim phi nhõn to ti ging (ECMO) ca Khoa Hi sc tớch cc Bnh vin Bch Mai Nhn xột mt s tỏc dng khụng mong mun s dng heparin theo phỏc trờn 79 KIN NGH T kt qu nghiờn cu chỳng tụi cú nhng kin ngh sau: Nờn trỡ ớch iu tr ca APPT mc 40-50s Cn b sung xột nghim ụng mỏu nhanh ti ging theo dừi v iu chnh liu heparin 80 TI LIU THAM KHO Hsu K H, Chi N H, Yu H Y et al (2011) Extracorporeal membranous oxygenation support for acute fulminant myocarditis: analysis of a single center's experience Eur J Cardiothorac Surg, 40(3), 682-688 Fabio N P (2014) ECMO-Extracorporeal Life Support in Adults, Pringer, Italia, 3-77 Maslach H A, Bratton S L (2013) Extracorporeal membrane oxygenation for pediatric respiratory failure: History, development and current status World J Crit Care Med, 2(4), 29-39 Buck M L (2005) Control of Coagulation during Extracorporeal Membrane Oxygenation J Pediatr Pharmacol Ther, 10(1), 26-35 Esper S A, Levy J H, Waters J H et al (2014) Extracorporeal membrane oxygenation in the adult: a review of anticoagulation monitoring and transfusion Anesth Analg, 118(4), 731-743 Oliver W C (2009) Anticoagulation and coagulation management for ECMO Semin Cardiothorac Vasc Anesth, 13(3), 154-175 Bembea M M, Annich G, Rycus P et al (2013) Variability in anticoagulation management of patients on extracorporeal membrane oxygenation: an international survey Pediatr Crit Care Med, 14(2), 77-84 Aubron C, DePuydt J, Belon F et al (2016) Predictive factors of bleeding events in adults undergoing extracorporeal membrane oxygenation Ann Intensive Care, 6(1), 97 Guodong G, Lin L, Qiang H et al (2015) Outcome of extracorporeal membrane oxygenation support for adult patients in Fuwai Hospital during the last 10 years: treatment strategy and risk factors Zhonghua Wei Zhong Bing Ji Jiu Yi Xue, 27(12), 959-964 10 Weingart C, Lubnow M, Philipp A et al (2015) Comparison of Coagulation Parameters, Anticoagulation, and Need for Transfusion in Patients on Interventional Lung Assist or Veno-Venou Extracorporeal Membrane Oxygenation Artif Organs, 6(2), 10-20 11 Conrad S A, Rycus P T, Dalton H (2005) Extracorporeal Life Support Registry Report 2004 ASAIO J, 51(1), 4-10 12 Kohler K, Valchanov K, Nias G et al (2013) ECMO cannula review Perfusion, 28(2), 114-124 13 Ash S R (2007) Fluid mechanics and clinical success of central venous catheters for dialysis-answers to simple but persisting problems Semin Dial, 20(3), 237-256 14 Koster A, Weng Y, Bottcher W et al (2007) Successful use of bivalirudin as anticoagulant for ECMO in a patient with acute HIT Ann Thorac Surg, 83(5), 1865-1867 15 Ranucci M, Ballotta A, Kandil H et al (2011) Bivalirudin-based versus conventional heparin anticoagulation for postcardiotomy extracorporeal membrane oxygenation Crit Care, 15(6), 275 16 Phm Th Minh c, Trnh Bnh Dy, Phựng Xuõn Bỡnh v cng s (2006) Sinh lý cm mỏu v ụng mỏu Sinh Lý Hc, Nh xut bn Y hc, H Ni, 1, 143-150 17 Cung Th Tý (2004) C ch ụng cm mỏu v cỏc xột nghim thm dũ Bi ging huyt hc truyn mỏu, Nh xut bn Y hc, H Ni, 236-242 18 Phựng Xuõn Bỡnh (2004) Sinh lý cm mỏu v ụng mỏu Sinh lý hc Nh xut bn y hc, H Ni, 141-156 19 Nguyn Anh Trớ (2002) Sinh lý quỏ trỡnh ụng mỏu v tiờu fibrin ụng mỏu ng dng lõm sng, Nh xut bn Y hc, H Ni, 40-81 20 Spiess B D, Vocelka C, Cochran R P et al (1998) Heparin-coated bypass circuits (Carmeda) suppress the release of tissue plasminogen activator during normothermic coronary artery bypass graft surgery J Cardiothorac Vasc Anesth, 12(3), 299-304 21 Velthuis H, Baufreton C, Jansen P G et al (1997) Heparin coating of extracorporeal circuits inhibits contact activation during cardiac operations J Thorac Cardiovasc Surg, 114(1), 117-122 22 Gikakis N, Khan M M, Hiramatsu Y et al (1996) Effect of factor Xa inhibitors on thrombin formation and complement and neutrophil activation during in vitro extracorporeal circulation Circulation, 94(9), 341-346 23 De Somer F, Van Belleghem Y, Caes F et al (2002) Tissue factor as the main activator of the coagulation system during cardiopulmonary bypass J Thorac Cardiovasc Surg, 123(5), 951-958 24 Albes J M, Stohr I M, Kaluza M et al (2003) Physiological coagulation can be maintained in extracorporeal circulation by means of shed blood separation and coating J Thorac Cardiovasc Surg, 126(5), 1504-1512 25 Aldea G S, Soltow L O, Chandler W L et al (2002) Limitation of thrombin generation, platelet activation, and inflammation by elimination of cardiotomy suction in patients undergoing coronary artery bypass grafting treated with heparin-bonded circuits J Thorac Cardiovasc Surg, 123(4), 742-755 26 Hoffman M, Monroe D M (2001) A cell-based model of hemostasis Thromb Haemost, 85(6), 958-965 27 Skinner S C, Hirschl R B, Bartlett R H (2006) Extracorporeal life support Semin Pediatr Surg, 15(4), 242-250 28 Oudemans H M, Wester J P, de Pont A C et al (2006) Anticoagulation strategies in continuous renal replacement therapy: can the choice be evidence based? Intensive Care Med, 32(2), 188-202 29 Spinler S A, Wittkowsky A K, Nutescu E A et al (2005) Anticoagulation monitoring part 2: Unfractionated heparin and low-molecular-weight heparin Ann Pharmacother, 39(7-8), 1275-1285 30 Abramson S, Niles J L (1999) Anticoagulation in continuous renal replacement therapy Curr Opin Nephrol Hypertens, 8(6), 701-707 31 Schetz M (2001) Anticoagulation for continuous renal replacement therapy Curr Opin Anaesthesiol, 14(2), 143-149 32 Opatrny K, Polanska K, Krouzecky A et al (2002) The effect of heparin rinse on the biocompatibility of continuous veno-venous hemodiafiltration Int J Artif Organs, 25(6), 520-528 33 Marmur M, Renee P (2009) The Methodology of the Activated Clotting Time (ACT) and the Activated Partial Thromboplastin Time (aPTT) J Invasive Cardiol, 21(12), 64-653 34 Trung Phn (2009) K thut xột nghim huyt hc v truyn mỏu ng dng lõm sng, Nh xut bn Y hc, H Ni 35 Bermudez C A, Rocha R V, Sappington P L et al (2010) Initial experience with single cannulation for venovenous extracorporeal oxygenation in adults Ann Thorac Surg, 90(3), 991-995 36 Biancofiore G, Esposito M, Bindi L et al (2003) Regional filter heparinization for continuous veno-venous hemofiltration in liver transplant recipients Minerva Anestesiol, 69(6), 527-534 37 Arepally G M, Ortel T L (2006) Clinical practice Heparin-induced thrombocytopenia N Engl J Med, 355(8), 809-817 38 Sakr Y (2015) What's new about heparin-induced thrombocytopenia type II Intensive Care Med, 41(10), 1824-1827 39 Linkins L A, Dans A L, Moores L K et al (2012) Treatment and prevention of heparin-induced thrombocytopenia: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Chest, 141(2), 495-530 40 Laverdure F, Louvain-Quintard V, Kortchinsky T et al (2016) PF4heparin antibodies during ECMO: incidence, course, and outcomes Intensive Care Med, 42(6), 1082-1083 41 Strickland R, Frantzis P, Buttery J (2009) Royal Adelaide Hospital General ICU ECMO Guidelines, 42 Protti A, L'Acqua C, Panigada M (2016) The delicate balance between pro-(risk of thrombosis) and anti-(risk of bleeding) coagulation during extracorporeal membrane oxygenation Ann Transl Med, 4(7), 139 43 Symons J M, McMahon M W, Karamlou T et al (2013) Continuous renal replacement therapy with an automated monitor is superior to a free-flow system during extracorporeal life support Pediatr Crit Care Med, 14(9), 404-408 44 Hirsh J, O'Donnell M, Weitz J I (2005) New anticoagulants Blood, 105(2), 453-463 45 Hirsh J, O'Donnell M, Eikelboom J W (2007) Beyond unfractionated heparin and warfarin: current and future advances Circulation, 116(5), 552-560 46 Pollak U, Yacobobich J, Tamary H et al (2011) Heparin-induced thrombocytopenia and extracorporeal membrane oxygenation: a case report and review of the literature J Extra Corpor Technol, 43(1), 5-12 47 Young G, Yonekawa K E, Nakagawa P et al (2004) Argatroban as an alternative to heparin in extracorporeal membrane oxygenation circuits Perfusion, 19(5), 283-288 48 Panigada M, Iapichino G, L'Acqua C et al (2016) Prevalence of "FlatLine" Thromboelastography During Extracorporeal Membrane Oxygenation for Respiratory Failure in Adults ASAIO J, 62(3), 302-309 49 Chang X, Li X, Guo Z et al (2016) Analysis of complications in 61 extracorporeal membrane oxygenation cases Zhonghua Wai Ke Za Zhi, 54(5), 384-388 50 Lubnow M, Philipp A, Foltan M et al (2014) Technical complications during veno-venous extracorporeal membrane oxygenation and their relevance predicting a system-exchange retrospective analysis of 265 cases PLoS One, 9(12), e112316 51 Nguyn Th Xuyờn, Nguyn Anh Trớ, Lng Ngc Khuờ v cng s (2015) ụng mỏu ri rỏc lũng mch Hng dn chn oỏn v iu tr mt s bnh lý huyt hc, B y t, H Ni, 139-141 52 Smith A, Hardison D, Bridges B et al (2013) Red blood cell transfusion volume and mortality among patients receiving extracorporeal membrane oxygenation Perfusion, 28(1), 54-60 53 Lamb K M, Cowan S W, Evans N et al (2013) Successful management of bleeding complications in patients supported with extracorporeal membrane oxygenation with primary respiratory failure Perfusion, 28(2), 125-131 54 Iwashita Y, Yukimitsu M, Matsuduki M et al (2015) Use of a fixed, body weight-unadjusted loading dose of unfractionated heparin for extracorporeal cardiopulmonary resuscitation J Intensive Care, 3(1), 33 55 Lorusso R, Centofanti P, Gelsomino S et al (2016) Venoarterial Extracorporeal Membrane Oxygenation for Acute Fulminant Myocarditis in Adult Patients: A 5-Year Multi-Institutional Experience Ann Thorac Surg, 101(3), 919-926 56 Huang L, Liu Y W, Li T et al (2016) Effect and related factors of extracorporeal cardiopulmonary resuscitation combined with emergent percutaneous coronary intervention on cardiac arrest patients due to acute myocardial infarction Zhonghua Xin Xue Guan Bing Za Zhi, 44(7), 570-576 57 Sakamoto S, Taniguchi N, Nakajima S et al (2012) Extracorporeal life support for cardiogenic shock or cardiac arrest due to acute coronary syndrome Ann Thorac Surg, 94(1), 1-7 58 Unai S, Tanaka D, Ruggiero N et al (2016) Acute Myocardial Infarction Complicated by Cardiogenic Shock: An Algorithm-Based Extracorporeal Membrane Oxygenation Program Can Improve Clinical Outcomes Artif Organs, 40(3), 261-269 59 Krueger K, Schmutz A, Zieger B et al (2016) Venovenous Extracorporeal Membrane Oxygenation With Prophylactic Subcutaneous Anticoagulation Only: An Observational Study in More Than 60 Patients Artificial Organs, 30(2), 12 60 Dornia C, Philipp A, Bauer S et al (2015) D-dimers Are a Predictor of Clot Volume Inside Membrane Oxygenators During Extracorporeal Membrane Oxygenation Artif Organs, (9), 782-787 61 Glick D, Dzierba A L, Abrams D et al (2015) Clinically suspected heparin-induced thrombocytopenia during extracorporeal membrane oxygenation J Crit Care, 30(6), 1190-1194 62 Dornia C, Philipp A, Bauer S et al (2014) Analysis of thrombotic deposits in extracorporeal membrane oxygenators by multidetector computed tomography ASAIO J, 60(6), 652-656 63 Extracorporeal Life Support Organization (2013) Guidelines for Adult Respiratory Failure Version 1.3, 64 Yeo H J, Kim D H, Jeon D et al (2015) Low-dose heparin during extracorporeal membrane oxygenation treatment in adults Intensive Care Med, 41(11), 2020-2021 65 Malfertheiner M V, Philipp A, Lubnow M et al (2016) Hemostatic Changes During Extracorporeal Membrane Oxygenation: A Prospective Randomized Clinical Trial Comparing Three Different Extracorporeal Membrane Oxygenation Systems Crit Care Med, 44(4), 747-754 66 Panigada M, Artoni A, Passamonti S M et al (2016) Hemostasis changes during veno-venous extracorporeal membrane oxygenation for respiratory support in adults Minerva Anestesiol, 82(2), 170-179 67 Yie K, Chon S H v Na C Y (2016) Activated clotting time test alone is inadequate to optimize therapeutic heparin dosage adjustment during post-cardiopulmonary resuscitational extracorporeal membrane oxygenation (e-CPR) Perfusion, 31(4), 307-315 68 Rastan A J, Lachmann N, Walther T et al (2006) Autopsy findings in patients on postcardiotomy extracorporeal membrane oxygenation (ECMO) Int J Artif Organs, 29(12), 1121-1131 69 Esper S A, Bermudez C, Dueweke E J et al (2015) Extracorporeal membrane oxygenation support in acute coronary syndromes complicated by cardiogenic shock Catheter Cardiovasc Interv, 86(1), 45-50 70 Dickey L A, Butler T J, Bergmann T M et al (1994) Selective heparinization of the extracorporeal membrane oxygenation circuit using continuous infusions of protamine and heparin in a short-term pig model Perfusion, 9(5), 327-333 71 Kasirajan V, Smedira N G, McCarthy J F et al (1999) Risk factors for intracranial hemorrhage in adults on extracorporeal membrane oxygenation Eur J Cardiothorac Surg, 15(4), 508-514 72 Ang A L, Teo D, Lim C H et al (2009) Blood transfusion requirements and independent predictors of increased transfusion requirements among adult patients on extracorporeal membrane oxygenation - a single centre experience Vox Sang, 96(1), 34-43 BNH N NGHIấN CU I Hnh chớnh H v tờn: Tui: Gii: Mó bnh ỏn: Ngh nghip Ni : S in thoi liờn lc Ngy vo vin: ./ / Ngy vo ICU: ./ / Mó lu tr: Thnh th Nụng thụn Min nỳi Ngy vin: / / Ngy chuyn khoa (tuyn di) / / S ngy nm vin: S ngy nm ti ICU: II Chuyờn mụn Chn oỏn: Lý chy ECMO Viờm c tim bc sc tim Nhi mỏu c tim bc sc tim ARDS K thut ECMO V-A ECMO V-V ECMO Loi mỏy v mng lc Terumo Marque Mc nng vo ICU APACHE II: SOFA: Thuc chng ụng ang s dng: Tin s bnh: Ngng tun hon trc vo ECMO: Cú Khụng ng thụng ECMO - Phng phỏp t ng thụng: M mch mỏu - Kớch thc ng thụng VA-ECMO: ng mch: - Kớch thc ng thụng VV-ECMO: Tnh mch vo: - Kớch thc catheter tỏi ti mỏu ng mch: Seldinger Tnh mch: Tnh mch ra: 10 Theo dừi ụng mỏu, liu heparin v bin chng - Heparin mi dõy qu: Ngy s 1(ngy ) Cõn nng: Kg Vo ECMO Sau 6h Sau 12h Sau 18h Sau 24h PT INR APTT APTT(bnh/chng) Fibrinogen D-dimer Nghim phỏp ru Von-Kaulla HC Hb Hct TC Nhúm nguy c chy mỏu Bolus Heparin (UI/l-UI/kg) D/trỡ Heparin (UI/h-UI/kg/h) Heparin iu chnh (UI/h) iu chnh heparin sau XN Bin chng chy mỏu X trớ Truyn hng cu (ml) Truyn tiu cu (n v) Truyn Plasma (ml) Truyn cryo (n v) Protamine sulfate (UI/h) Tc mng/ PaO2 CI/ Vũng quay Ngy s (ngy ) Sau 6h PT Cõn nng: Kg Sau 12h Sau 18h Sau 24h INR APTT APTT(bnh/chng) Fibrinogen D-dimer Nghim phỏp ru Von-Kaulla HC Hb Hct TC Bolus Heparin (UI/l-UI/kg) D/trỡ Heparin (UI/h-UI/kg/h) Heparin iu chnh (UI/h) iu chnh heparin sau XN Bin chng chy mỏu X trớ Truyn hng cu (ml) Truyn tiu cu (n v) Truyn Plasma (ml) Truyn cryo (n v) Protamine sulfate (UI/h) Tc mng/ PaO2 CI/ Vũng quay 11 Cỏc xột nghim khỏc Trc ECMO Ure Creatinin BilTP/Bil TT GOT/GPT CK/CKMB LDH TroponinT ProBNP S/õ tim EF Ngy Ngy Ngy Ngy Ngy Ngy 12 Kt qu S mng lc ECMO Yu8Thi gian chy ECMO Mng 1: ngy vo .ngy kt lý kt Mng 2: ngy vo ngy kt.lý kt S ngy ngng ECMO Kt qu cui cựng Sng Nguyờn nhõn t vong: t vong Xin v ... I HC Y H NI PHM NG THUN NHậN XéT HIệU QUả PHáC Đồ CHốNG ĐÔNG BằNG HEPARIN TRONG Kỹ THUậT TIM PHổI NH ÂN TạO TạI GIƯờNG (ECMO) CủA KHOA HồI SứC TíCH CựC BệNH VIệN BạCH MAI Chuyờn ngnh: Hi sc cp... hiu qu phỏc chng ụng bng heparin khụng phõn on k thut tim phi nhõn to ti ging (ECMO) ca Khoa Hi sc tớch cc Bnh vin Bch Mai Nhn xột mt s tỏc dng khụng mong mun s dng heparin theo phỏc trờn 11... trung tõm u s dng heparin khụng phõn on chng ụng ECMO [6], [7] 1.3.1 Heparin khụng phõn on 1.3.1.1 Ngun gc - Heparin c phõn lp nm 1916 bi McLean - Heparin c sn xut t t bo Mast - Heparin l mt mucopolysaccharid