Nhu cầu chăm sóc tích cực sau điều trị tái thông trong nhồi máu não cấp=The need for intensive care after recanalization in acute ischemic stroke

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Tác giả: Thị Xuân Hiền Huỳnh, Anh Tài Nguyễn, Văn Nhật Trần

Ngôn ngữ: vie

Ký hiệu phân loại:

Thông tin xuất bản: Tạp chí Y học Việt Nam (Tổng hội Y học Việt Nam), 2024

Mô tả vật lý: tr.412-421

Bộ sưu tập: Báo, Tạp chí

ID: 477922

Thêm vào giỏ

After the recanalization of occluded arteries in acute ischemic stroke (AIS), patients require intensive neurologic monitoring in ICU or a dedicated stroke sciences unit for at least 24 hours to follow the progress, detect and control complications, treated comorbid medical diseases … need to be followed up in ICU for at least 24 hours(1). This study aims to clarify this issue and help to stratify these patients. Subiect and methods: this was a describe and retrospective study, which was peformed in the intensive care unit of stroke at Cho Ray Hospital from January 2016 to December 2017. All acute ischemic stroke who had received intravenous tPA (windows <
4.5 hours) and/or intra-arterial embolectomy (windows <
6 hours) were included. We collected demographic data (age, gender), other risks of stroke: hypertension, hyperlipidemia, diabetes, smoking status, atrial fibrillation, disease coronary arteries, other cardiovascular diseases (ventricular dysfunction, valvular disease, ventricular septal ...), history of stroke
and the status of stroke such as: NIHSS score, physiological parameters before and after the recanalized treatment (blood pressure, blood sugar, creatinine, site of ischemic lesion, recanalized method). Data on critical care treatment after recanalization such as: (1) blood pressure control by intravenous drugs or vasomotor drugs
(2) manage the symptomatic intracranial hemorrhage with fresh frozen plasma, cryoprecipitate and/or platelets
(3) control blood glucose by insulin
(4) monitor and manage arrhythmias
(5) monitor and manage the respiratory failure (endotracheal intubation with and without ventilator ventilation)
(6) manage the increased intracranial pressure, cerebral edema by internal medicine and surgical methods (such as open skull decompression) were collected for analysis. Result: 70 AIS were treated with recanalization and followed-up in the intensive care unit of stroke. 26 patients (37.5%) had need for critical care treatments and 44 patients (62.9%) did not need for such treatments. The common critical care treatments were: intracerebral hemorrhage 37%, severe cerebral edema and increased intracranial pressure 23%, cardial arrhythmia 23%, arterial hypertension 08%, hyperglycemia 06% and low blood pressure 03%. The main differences in the two groups that need or didn’t need for critical care treatments are heart rate, blood pressure and NIHSS score after recanalization. The ROC curve (Receiver Operating Characteristic) is used to find variable that can estimate the need for critical care treatments after recanalization. The NIHSS score after intervention is the most valuable variable with the area under the curve being 0.76. Conclusion: The severity of AIS after recanalization that is assessed by the NIHSS score is a predictor of the need for critical care treatments. Based on the true positive rate against the false positive rate for the different possible cutpoints of NIHSS score after recanalization, we can stratify patients who need for critical care treatments in accordance with our unit.Sau can thiệp điều trị tái thông nhồi máu não cấp (NMN), bệnh nhân (BN) cần được theo dỏi sát diễn tiến bệnh, phát hiện sớm và kiểm soát các biến chứng, điều trị các bệnh nội khoa đi kèm… tại các đơn vị chăm sóc tích cực thần kinh ít nhất 24 giờ(1). Nghiên cứu này nhằm làm rõ hơn vấn đề này và giúp phân tầng bệnh nhân. Đối tượng và phương pháp: Mô tả, hồi cứu, thực hiện tại khu vực Hồi sức tích cực đột quị (HSTCĐQ) bệnh viện Chợ rẫy (BVCR) từ tháng 1/2016 - 12/2017 các BN NMN cấp được điều trị tái thông bằng thuốc tiêu sợi huyết (tpA) với cửa sổ điều trị <
4,5 giờ, lấy huyết khối bằng dụng cụ với cửa sổ điều trị <
06 giờ, và kết hợp cả hai phương pháp trên. Bệnh nhân được thu thập các dữ liệu về nhân khẩu học (tuổi, giới tính), các biến số về nguy cơ đột quỵ (tăng huyết áp, rối loạn lipid máu, đái tháo đường, tình trạng hút thuốc lá, rung nhĩ, bệnh mạch vành, các bệnh lý tim mạch khác (rối loạn chức năng tâm thất, bệnh van tim, thông liên nhĩ…), tiền sử đột quỵ và các dữ liệu liên quan NMN lần này (điểm NIHSS, các thông số sinh lý trước và sau tái thông động mạch (huyết áp, glucose máu, creatinine, vị trí NMN, phương thức can thiệp). Các dữ liệu về can thiệp sau điều trị tái thông: (1) kiểm soát huyết áp bằng thuốc hạ huyết áp đường tĩnh mạch hoặc các thuốc vận mạch
(2) Kiểm soát tình trạng chảy máu não bằng huyết tương tươi đông lạnh, kết tủa lạnh và/hoặc tiểu cầu đậm đặc
(3) kiểm soát glucose máu bằng insulin qua bơm tiêm điện
(4) theo dõi và kiểm soát các tình trạng loạn nhịp tim
(5) theo doxi và kiểm soát tình trạng suy hô hấp cần đặt nội khí quản với các liệu pháp oxy có và không hổ trợ thông khí bằng máy thở
(6) kiểm soát tình trạng tăng áp lực nội sọ, phù não bằng các phương pháp nội khoa và ngoại khoa (mở sọ giải ép) được thu thập để phân tích. Kết quả: 70 bệnh nhân NMN cấp được điều trị bằng các phương pháp tái thông và theo dõi sau can thiệp tại khu Hồi sức tích cực đột quỵ (HSTCĐQ). 26 (37,5%) BN có các can thiệp tích cực và 44 (62,9%) BN không cần các can thiệp này. Các can thiệp hồi sức sau điều trị tái thông thường gặp: chảy máu não (CMN) 37%, phù não nặng và tăng áp lực nội sọ (TALNS) 23%, Loạn nhịp tim 23%, tăng huyết áp 08%, tăng glucose máu 06% và tụt huyết áp 03%. Khác biệt chính ở 02 nhóm là điểm NIHSS sau can thiệp và tình trạng mạch, huyết áp. Đường cong ROC được sử dụng để xem xét khả năng cần hồi sức sau điều trị tái thông cho các biến số có sự khác biệt và ghi nhận: điểm NIHSS sau can thiệp là biến số có giá trị nhất với diện tích dưới đường cong là 0,76. Kết luận: Độ nặng của NMN ngay sau điều trị tái thông đánh giá bằng thang điểm NIHSS là yếu tố dự đoán nhu cầu cần can thiệp hồi sức sau đó. Dựa vào độ nhạy và độ đặc hiệu, các cơ sở điều trị có thể chọn lựa điểm cắt mức điểm NIHSS sau can thiệp để phân tầng BN có nguy cơ cần hồi sức tích cực phù hợp điều kiện cơ sở của mình.

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