B GIO DC V O TO TRƯờng đại học y hà nội B Y T TRNG MNH T NGHIÊN CứU NồNG Độ KẽM HUYếT THANH BệNH NHÂN NHIễM KHUẩN NặNG Từ THáNG ĐếN TUổI TạI KHOA CấP CứU CHốNG ĐộC BệNH VIệN NHI TRUNG ƯƠNG Chuyờn ngnh : Nhi Khoa Mó s : 60720135 LUN VN THC S Y HC Hng dn khoa hc: TS TRNG TH MAI HNG PGS.TS Lấ THANH HI H NI - 2015 LI CM N Trong quỏ trỡnh hc tp, nghiờn cu v hon thnh lun ny tụi ó nhn c rt nhiu s giỳp ca cỏc thy cụ, c quan, gia ỡnh, bn bố v ng nghip Tụi xin by t lũng kớnh trng v bit n sõu sc ti: - TS.BS Trng Th Mai Hng - Phú trng khoa Cp cu chng c Bnh vin Nhi Trung ng õy l ngi thy ó dỡu dt, giỳp v hng dn tụi sut quỏ trỡnh hc tp, nghiờn cu v hon thnh lun ny - Cỏc giỏo s, phú giỏo s, tin s hi ng thụng qua cng v hi ng chm lun tt nghip Cỏc thy cụ ó cho tụi nhiu ch dn v kinh nghim quớ bỏu bn lun hon thin hn Vi lũng bit n sõu sc, tụi xin chõn thnh cm n: - Cỏc thy cụ b mụn Nhi Trng i hc Y H Ni, ó tn tỡnh truyn t, trang b cho tụi nhng kin thc chuyờn mụn, giỳp tụi thc hin lun ny - Ban giỏm hiu, Phũng o to Sau i hc, Th vin v cỏc phũng ban ca Trng i hc Y H Ni - Ban Giỏm c, tập thể bác sĩ, nhân viên khoa Cp cu chng c, khoa Sinh húa Bệnh viện Nhi Trung ơng giúp đỡ, tạo điều kiện thuận lợi trình làm luận văn Tôi xin chân thành cảm ơn lónh o, nhõn viờn khoa Thn Lc mỏu Bnh vin Nhi Trung ng, c bit l TS.BS Nguyn Thu Hng trng khoa Thn Lc mỏu, PGS.TS Nguyn Th Qunh Hng ging viờn B mụn Nhi trng i hc Y H Ni ng h, động viên khuyến khích, to iu giỳp tụi hon thnh lun ny Cuối xin bày tỏ lòng biết ơn sâu sắc đến bố mẹ v ngi v ó luụn quan tâm, động viên, tạo điều kiện tốt cho hoàn thành luận văn Tụi xin trõn trng cm n! H Ni, ngy 15 thỏng nm 2015 Trng Mnh Tỳ LI CAM OAN Tụi l Trng Mnh Tỳ, Cao hc khúa 22, Trng i hc Y H Ni, chuyờn ngnh: Nhi khoa, xin cam oan õy l Lun bn thõn tụi trc tip thc hin di s hng dn ca TS.BS Trng Th Mai Hng 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, ó c xỏc nhn v chp nhn ca c s ni nghiờn cu Tụi xin hon ton chu trỏch nhim trc phỏp lut v nhng cam kt ny H Ni, ngy 16 thỏng 09 nm 2015 Ngi vit cam oan Trng Mnh Tỳ MC LC T VN Chng TNG QUAN 1.1 Tỡnh trng nhim trựng v nhim trựng nng 1.1.1 Cỏc khỏi nim 1.1.2 Nguyờn nhõn gõy tỡnh trng nhim trựng nng 1.1.3 Mt s yu t nguy c lm tng thờm tỡnh trng nhim trựng nng 10 1.1.4 Tiờu chun chn oỏn nhim khun v nhim khun nng [2] .13 1.1.5 Hu qu ca cỏc tỡnh trng nhim khun nng: 15 1.2 Nguyờn t km v tỡnh trng thiu km tr em 16 1.2.1 Vi nột v nguyờn t km 16 1.2.2 Chuyn húa v phõn b ca km c th 17 1.2.3 Km v vai trũ sinh hc ca km, nhu cu km hng ngy 17 1.2.2 Nguyờn nhõn thiu km v tỡnh trng tng km ngi 21 1.2.3 ỏnh giỏ tỡnh trng km 22 1.2.4 Tỡnh hỡnh thiu km hin trờn Th gii v Vit Nam 23 1.2.5 nh hng ca thiu km ti sc kho v bnh tt tr em [5] [31], [32] 27 1.2.6 Mt s yu t nguy c thiu km trờn cng ng: 28 1.3 Mi liờn quan gia tỡnh trng nhim khun nng v thiu km 30 1.3.1 nh hng ca tỡnh trng thiu km ti bnh cỏc tỡnh trng nhim khun nng 30 1.3.2 nh hng ca tỡnh trng nhim khun nng ti tỡnh trng thiu km .33 Chng 34 I TNG V PHNG PHP NGHIấN CU .34 2.1 i tng nghiờn cu 34 2.1.1 Tiờu chun la chn i tng nghiờn cu: 34 2.1.2 Tiờu chun loi tr 34 2.2 Thit k nghiờn cu 35 2.3 Phng phỏp chn mu 35 2.4 Phng phỏp thu thp s liu .35 2.4.1 Cụng c thu thp s liu: .35 2.4.2 Phng tin thu thp s liu 35 2.4.3 Quy trỡnh thu thp s liu 35 2.5 X lý v phõn tớch s liu .35 2.6 Bin s nghiờn cu, cỏc khỏi nim v tiờu chun ỏnh giỏ 36 2.6.1 Bin s nghiờn cu 36 2.6.2 Khỏi nim, o lng v tiờu chun ỏnh giỏ 39 2.6.3 nh lng nng km huyt 39 2.7 o c nghiờn cu .42 2.8 Cỏch hn ch sai s 42 Chng KT QU NGHIấN CU 44 3.1 c im v mu nghiờn cu .44 3.2 V nng km huyt bnh nhõn nhim trựng nng 51 3.3 Cỏc bin theo mc tiờu v cỏc yu t liờn quan n tỡnh trng thiu km bnh nhõn nhim trựng nng 53 Nhn xột: Cỏc bnh nhõn cú nhim trựng nng cú tỡnh trng viờm phi, tiờu chy cp v bnh mn tớnh kốm theo hoc ó mc cỏc bnh ny trc ú cú tỡnh trng thiu km mc nng chim t l cao nht 55 Nhn xột: Cú 1/41 bnh nhõn ng c chỡ nghiờn cu cú nng km huyt gim rt nng so vi nng km huyt trung bỡnh ca 40 bnh nhõn khụng bi ng c 55 Chng 61 BN LUN 61 4.1 Cỏc c im chung ca i tng nghiờn cu 61 4.1.1 V tui v gii .61 4.1.2 V a d .62 4.1.3 V cõn nng v tui thai lỳc sinh 62 4.1.4 V tin s cỏc bnh ó mc trc ú 62 4.1.5 V phõn b theo s ngy nm vin tuyn di ca i tng nghiờn cu 63 4.1.6 V trỡnh húa ca b m bnh nhõn 63 4.1.7 V phõn b theo ch n trc ú ca i tng nghiờn cu 63 4.1.8 V phõn b theo cỏc bin i xột nghim i tng nghiờn cu 63 4.1.9 V phõn b theo cỏc phng phỏp ó can thip tuyn di 64 4.1.10 V phõn b theo tỡnh trng ng c ca i tng nghiờn cu 64 4.2 V tỡnh trng thiu km i tng nghiờn cu 64 4.2.1 V cỏc mc thiu ht km i tng nghiờn cu 64 4.2.2 V nng km huyt trung bỡnh theo gii 66 4.2.3 V mc thiu km theo nhúm tui 67 4.3 V cỏc yu t liờn quan n nng km huyt bnh nhõn nhim trựng nng 69 4.3.1 Mi liờn quan gia nng km huyt v tỡnh trng nhim trựng nng .69 4.3.2 Mi liờn quan gia nng km huyt vi cõn nng lỳc sinh ca i tng nghiờn cu .72 4.3.3 Mi liờn quan gia nng km huyt v tỡnh trng suy dinh dng 73 4.3.4 Liờn quan gia nng km huyt vi trỡnh húa ca b m 76 4.3.5 Mi liờn quan gia nng km huyt v tỡnh trng mc cỏc bnh trc ú ca i tng nghiờn cu 77 4.3.6 Mi liờn quan gia tỡnh trng ng c chỡ v tỡnh trng thiu km 83 4.3.7 Liờn quan gia nng km huyt v cỏc thuc s dng trc ú ca i tng nghiờn cu .84 4.3.8 Liờn quan gia nng km huyt v thi gian nm vin tuyn di v thi gian iu tr ti bnh vin Nhi trung ng .85 4.3.9 Liờn quan gia nng km huyt v ch n trc ú ca i tng nghiờn cu 86 4.3.10 Liờn quan gia nng km huyt v bin i v bch cu mỏu .86 4.3.11 Liờn quan gia nng km huyt v tỡnh trng shock nhim trựng nhp vin ca i tng nghiờn cu 88 KT LUN 89 KIN NGH 91 TI LIU THAM KHO .1 DANH MC BNG Bng 1.1 Thc phm giu km (mg km/100g thc phm n c) 18 Bng 2.1 Phõn chia cỏc mc thiu km 42 Bng 3.1 Phõn b i tng nghiờn cu theo nhúm tui v gii 45 Bng 3.2 Phõn b i tng nghiờn cu theo a d sinh sng 45 Bng 3.3 Phõn b theo cõn nng sinh ca i tng nghiờn cu 45 Bng 3.4 Phõn b theo tin s mc cỏc bnh trc ú ca i tng nghiờn cu .47 Bng 3.5 Phõn b theo s ngy nm vin tuyn di ca i tng nghiờn cu .47 Bng 3.6 Phõn b theo trỡnh húa ca b m ca i tng nghiờn cu .48 Bng 3.7 Phõn b tỡnh theo trng dinh dng chung ca i tng nghiờn cu .48 Bng 3.8 Phõn b theo ch n trc ú ca i tng nghiờn cu 49 Bng 3.9 Phõn b theo cỏc bin i xột nghim sinh húa: Bch cu, CRP, lactate mỏu 49 Bng 3.10 Phõn b theo cỏc phng phỏp ó can thip bnh viờn tuyn di 49 Bng 3.11 Phõn b theo cỏc thuc bnh nhõn ng c trc lỳc vo vin 50 Bng 3.12 Phõn b mc thiu km vi tỡnh trng suy dinh dng 51 Bng 3.13 Cỏc mc thiu ht km i tng nghiờn cu 51 Bng 3.14 Nng km huyt trung bỡnh theo nhúm tui 51 Bng 3.15 Nng km huyt trung bỡnh theo gii 52 Bng 3.16 Liờn quan mc thiu km theo nhúm tui .53 Bng 3.17 Mi liờn quan gia nng km huyt v tỡnh trng suy dinh dng 54 Bng 3.18 Liờn quan gi nng km huyt vi trỡnh húa ca b m 54 Bng 3.19 Liờn quan gia nng km huyt vi tin s mc cỏc bnh trc ú ca i tng nghiờn cu 55 Bng 3.20 Liờn quan gia nng km huyt v tỡnh trng ng c chỡ ca i tng nghiờn cu 55 Bng 3.21 Liờn quan gia nng km huyt v cỏc phng phỏp can thip tuyn di .55 Nhn xột: nhúm bnh nhõn cú s dng khỏng sinh trc lỳc vo vin so vi nhúm bnh nhõn khụng dựng nng km huyt trung bỡnh khụng cú s thay i ỏng k Nhúm cú s dng nui dng tnh mch v corticoid trc ú cú nng km huyt trung bỡnh thp hn so vúi nhúm khụng dựng Nhúm bnh nhõn cú iu tr bng nuụi dng tnh mch v corticoid cú nng km huyt thp nht 56 Bng 3.22 Liờn quan gia nng km huyt thi gian nm vin tuyn di ca i tng nghiờn cu 57 Nhn xột: Nng km huyt nhúm bnh nhõn cú thi gian nm vin tuyn di t -14 ngy thp hn nhúm bnh nhõn cú thi gian nm vin di ngy 57 57 Nhn xột: Nhng bnh nhõn 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pp.3779-3781 105 Mumtaz A., Anees M et al (2011), Serum Zinc and Copper levels in nephrotic syndrome patients, Pak J Med Sci, 27(5), pp 1173-1176 106 Dwivedi J, Sarkar PD Study of oxidative stress, homocysteine, copper & zinc in nephrotic syndrome 107 Joshi A, Ratnu KS, Joshi KC, Vyas PC (1993) Trace elements in nephrotic syndrome and chronic renal failure Indian J Nephrol, 3:48-50 108 Teitiker T, Paydas S, Yuregir G, Sagliker Y (1993), Trace elements alteration in chronic hemodialysis patients with chronic renal failure and proteinuria, 6:33-5 109 Cogan MG (1982), Nephrotic syndrome West J Med, 136:411-7 110 Freeman RM, Richards CJ, Rames LK (1975), Zinc metabolism in aminonucleoside-induced nephroisis Am J Clin Nutr, 28:699-703 111 Boyett JE, Sullivan JF (1970), Distribution of protein bound zinc in normal and cirrhotic serum Metabolism, 19:148-57 112 Baqui AH, Zaman K, Persson LA, El Arifeen S, Yunus M, N Begum, en RE (2003), Weekly supplementation of iron and zinc and is related to the incidence of lower respiratory tract infection and diarrhea in infants in Bangladesh J Nutr, 133 (12), 4150-4157 113 Bose A, Coles CL, Gunavathi, John H, Moses P, Raghupathy P, Kirubakaran C, Black RE, Brooks WA, Santosham M (2006), Efficacy of zinc in the treatment of severe pneumonia in hospitalized children 38,3 C (1 Cú, Khụng) H thõn nhit < 36 C (1 Cú, Khụng) Nhp tim (1 Nhanh, Chm, Bỡnh thng) Th nhanh (1 Nhanh, Chm, Bỡnh thng) Thay i ý thc (1 Tnh tỏo, Li bỡ, Hụn mờ) Phự rừ hoc cõn bng dch dng (>20 ml/kg/24 gi) (1 Cú, Khụng) Tng glucose mỏu (1 Cú, Khụng) B Du hiu viờm (1 Cú, Khụng): Tng bch cu > 12000/àl Hoc gim bch cu < 4000/àl S lng bch cu bỡnh thng nhng t l bch cu non > 10% Protein C phn ng (CRP) > ln bỡnh thng Procalcitonin > ln bỡnh thng C Thay i huyt ng: Tt huyt ỏp (HA tõm thu < 90 mmhg, HA trung bỡnh < 70 mmhg, hoc HA tõm thu gim > 40 mmhg so vi bỡnh thng ca la tui ú) D Du hiu ri lon chc nng tng: Gim oxy mỏu ng mch (Pao2/fio2 < 300) Thiu niu cp (nc tiu < 0,5 ml/kg/gi ớt nhõt gi mc dự c bự dch) Tng creatinin > 0,5 mg/dl hoc 44,2 àmol/l Ri lon ụng mỏu (INR > 1,5 hoc aPTT > 60 giõy) Gim tiu cu (s lng < 100.000/àl) Bng chng (khụng nghe thy ting nhu ng rut) Tng bilirubin ton phn > mg/dl hoc 70 àmol/l E Du hiu gim ti mỏu t chc: Tng lactate mỏu (> mmol/l) Chm lm y mao mch (n ngún tay vo da nu da hng tr li>2 giõy) II Tiờu chun chn oỏn nhim khun nng - Nhim khun gõy tt HA - Tng lactate mỏu - Thiu niu (nc tiu < 0,5 ml/kg/gi) - Tn thng phi cp P/F < 250 nu khụng cú viờm phi - Tn thng phi cp P/F < 200 nu cú viờm phi kốm theo - Creatinin > 2.0 mg/dl (hoc 176,8 àmol/l) - Bilirubin > mg/dl (34,2 àmol/l) - Tiu cu < 100.000 àl - Ri lon ụng mỏu (INR > 1,5) - Cn lõm sng: BC CRP Lactat II TIN S THAI SN 10 Tr l th,/ 11 Cõn nng sinhgam 12 Tui thaitun III TIN S BNH 13 Cỏc bnh khỏc (1 Viờm phi, SDD, Bnh mn tớnh, Nhim trựng tỏi phỏt) 14 Ch nuụi dng trc ú (1 Sa m, n dm, Sa ngoi, Khỏc) 15 iu tr tuyn di trc ti Bnh vin nhi TW: Cú Khụng 16 Thi gian iu tr trc vo Bnh vin Nhi TW (Ghi c th) ngy 17 Cỏc phng phỏp ó can thip, cỏc thuc ó dựng (1 Th mỏy, khỏng sinh, Nuụi dng TM, Khỏc) V XẫT NGHIM NNG KM HUYT THANH 18 Km: 19 Kt qu iu tr: Khi Xin v T vong H Ni, ngy thỏngnm 2015 (iu tra viờn ký v ghi rừ h tờn) Trng Mnh Tỳ ... 34 2. 1 .2 Tiờu chun loi tr 34 2. 2 Thit k nghiờn cu 35 2. 3 Phng phỏp chn mu 35 2. 4 Phng phỏp thu thp s liu . 35 2. 4.1 Cụng c thu thp s liu: . 35 2. 4 .2 Phng... tỏch bộo Sa cụng thc 1 ,2 Lũng trng g Tht cu * Vai trũ sinh hc ca km: Km Tờn thc phm Km (mg) 20 0 1 42 110 70 13.4 4.7 3.8 3.7 2. 9 (100g) (mg) 15 11 3.8 2. 3 2. 2 2. 5 2. 4 2. 0 Rau mựi tu C ci Cựi... 35 2. 4.3 Quy trỡnh thu thp s liu 35 2. 5 X lý v phõn tớch s liu . 35 2. 6 Bin s nghiờn cu, cỏc khỏi nim v tiờu chun ỏnh giỏ 36 2. 6.1 Bin s nghiờn cu 36 2. 6 .2 Khỏi