NH HNG CA CAN THIP DD BNH NHI CTNT TI BV NHI NG 2

NH HNG CA CAN THIP DD BNH NHI STM CTNT TI BV NHI NG 2Nguyn Th Thu Hu, Hong Th Dim ThyKHOA DINH DNG BV N2HU 5/2014NHM NGHIN CUNguyn Th Thu Hu: bc s, khoa DD, BV Nhi ng 2

Phm Th Mnh, Nguyn Hong Nht Hoa, L Th Kha Nguyn: KSDD, khoa DD

Man Th nh Ti, Nguyn Ngc Thy Dung, Phm Vn Hu, ng Th Tuyn: nhn vin cp dng, khoa DD

L Th Hng Hnh, Nguyn Hu Lc, Trng Th nh, Phm Th Li: KTV dinh dng, khoa DD

Hong Th Dim Thy,Hong Ngc Qu , Nguyn Khoa Th Bnh Minh: bc s, khoa Thn-ni tit, BV Nhi ng 2

T VN Tnh trng dinh dng ca BN STM trc CTNT: yu t c lp nh hng tin lng v bnh tt v t vong

can thip DD: t vong, tin lng / ngi ln

tr em: c th ang pht trin, nhu cu E cao tuy nhin thc v bnh tt v tun th iu tr km hn khng tun th tt ch n bnh l

tnh trng suy dinh dng cng caoT VN Trc y:p dng lng m rt thp (theo phc ngi ln) kh tun th v khng hp khu v.Nhi ng 2: theo phc ca Php v B Mc chuyn ha cng nh nhu cu dinh dng c s khc nhau hay khng gia ngi chu u v ngi Vit nam?TI BV NHI NG 2Tui chiu caoTheo AFSSALng protein khuyn ngh an ton1-6 thng1.2-2.2 g/ kghoc 10g /ngy2-2.2 g / kg6-12 thng1-1.1 g/kghoc 10g /ngy1.9-2 g / kgGFR < 10ml/phtGFR =10-30 ml/phtGFR= 31-60 ml/pht13 thng- 3 tui12g130-160 %170-180 %200 %4-6 tui15-18g7-9 tui20-24g10-12 tui27-32 g130-140 %150 %170-180 %13-15 tui38-43 g ( n)47g (nam)Trong lc thn nhn to: protid cung cp bng GFR 10-30 ml/ pht.Trong thm phn phc mc: protid cung cp bng GFR 10-30 ml/ pht + 3-5g /ngy ( b lng mt trong dch lc)

MC TIU NGHIN CUMc tiu tng qut:nh gi nh hng ca can thip DD n tnh trng DD v mc hi lng v ch n cho BN STM c CTNT ti BV Nhi ng 2.Mc tiu chuyn bit:So snh s pht trin th cht ca tr trc v sau can thip DDSo snh mc thiu mu ca tr trc v sau can thip DDnh gi mc hi lng v ch n STM ti bv N 2 trc v trong chng trnh can thip DD

PHNG PHP NGHIN CUThit k nghin cu: can thip

i tng nghin cu: tt c bnh nhn STM CTNT/N 2Tiu chun nhn bnh: bnh nhn STM c CTNT/BV N 2Tiu chun lai tr: khng 3 thng thc hin sut n ti BV

Phng php chn bnh C mu: ly trn

Cc bc tin hnh:Chn bnh.nh gi tnh trng dinh dng v mc hi lng, mc tun th v ch n trc can thip: thi im chn vo NC v trc NC 3 thng, nu thi gian chy thn cha 3 thng th ly thi im khi bt u c chy thn nh k.Thit k ch n theo phc dinh dng STM nh gi tnh trng dinh dng sau can thip: thi gian 3 thng hoc n khi kt thc nghin cu.

PHNG PHP NGHIN CUThit k ch n theo phc dinh dng STM

nng lng v Protein theo tui chiu cao Na theo cn nng thc t Hn ch Kali, dch nhp

BN c cung cp 2 phn n min ph trong ngy chy thn:ba nh trong vng 1h sau khi bt u chy thn v ba chnh sau sut chy thn chim tng s 2/3 lng protein, 2/3 lng Na v nhu cu nng lng/ngy.

Cc ba n cn li c tnh ton v hng dn thn nhn v bnh nhn t thc hin

PHNG PHP NGHIN CUThu thp v x l s liu:Dng phiu kho st: hi trc tip bnh nhn, s dng h s bnh n.Ngi ly s liu: bs dinh dng, k s dinh dngS liu c m ha, nhp v x l bng phn mm SPSS 16.0 for Window

Vn y c: m boTheo phc ca bnh vin, ch nh theo ng yu cu theo di iu trCung cp sut n min ph t ngun ti tr ca mnh thng qunng thun ca thn nhn v bnh nhnThng qua Hi ng Y c v NCKH ca bnh vin.

KT QU NGHIN CUV BN LUN

9/2011-1/2012: c tt c 31 bnh nhi suy thn mn (STM) giai on cui c chy thn nhn to (CTNT) ti bnh vin Nhi ng 2 (N 2)

chng ti loi ra 2 trng hp: 1 c ghp thn1 b d ng dch lc phi chuyn sang thm phn phc mc (TPPM).KT QU NGHIN CU 1. c im BN khi bt u NCGii tnh: nam 20(69%) , n 9 (31%) , t l nam/n = 2,2

Tui: 5-10 tui 8 (27,6%), >10 tui (72,4%)

Ni c tr: TPHCM 5 (17,2%), min ng NB 4(13,8%), min Ty NM 11(37,9%) Nam TB 6 (20,7%), Ty nguyn 3 (10,3%)

KT QU NGHIN CU 1. c im BN khi bt u NCTrung bnhMin- MaxThi gian pht hin bnh thn39,9 35,2 thng1-156 thngThi gian chy thn NT21,6 20,2 thng0- 72 thngUre mu (bnh thng 0,1-0,45 g/l)2,19 0,521,43-3,77Creatinin mu (bnh thng 2,3-10 mg/l)100,97 29,851,3-161,4GFR (ml/1,73m2 da/ngy)0,72 0,2 0,45 - 1,18 khm v tham vn ch n suy thn mn28/29 (96,6%)KT QU NGHIN CU 1. c im BN khi bt u NCKT QU NGHIN CU 1. c im BN khi bt u NCKT QU NGHIN CU 1. c im BN khi bt u NCKT QU NGHIN CU 1. c im BN khi bt u NCTrung bnhMin- Max% Cn nng chun (theo tui chiu cao)90,4 11,9 %70,4 -115 %Suy dinh dng cp: (CN/CN nn c theo chiu cao 1,5 g/l14/24 (58,3%)Bng 3a: Cc tr s sinh ha lc nhn vo nghin cu

KT QU NGHIN CU 1. c im BN khi bt u NCBiu 5: Tnh trng tng cholesterol mu khi nhn vo NC: n= 25

KT QU NGHIN CU 1. c im BN khi bt u NCBiu 6: Tnh trng gim albumin mu khi nhn vo nghin cu (%)

KT QU NGHIN CU 1. c im BN khi bt u NCCanxi mu ( bnh thng 2,2-2,9 mEq/l)2,4 0,212,1 2,88Kali mu (bnh thng 3,5-5 mEq/l)4,52 1,053-7,5Tng Kali mu (> 5 mEq/l)11/29 (37,9%)Natri mu133,3 3,5126-139Magne mu( bnh thng 25-40 mg/l)25,8 4,418-37H magne muNng < 18: 3,6% (1/28)TB 18-25: 50% (14/28)Phosphor mu (bnh thng 40-70 mg/l)83,1 25,545-141Tng phosphor mu( > 70 mg/l)60,7% (17/28)Bicarbonate (bnh thng 24-29 mEq/l)18,9 5,29-27,7Cn b sung bicarbonate ( HCO3 < 24)80% (12/15)Bng 3b: Cc tr s sinh ha lc nhn vo nghin cu (phn ion )

KT QU NGHIN CU 1. c im BN khi bt u NCLng sa: trung bnh 154,6 102,5 ml/ngy (0-400ml)

KT QU NGHIN CU 1. c im BN khi bt u NCCh s kho stTrung bnhMin-MaxFe huyt thanh78,8 35,840,4-177,8Gim Fe huyt thanh < 50 20,8% (5/24)Ferritin (mc tiu > 800 ng/ml)731,9 543,750-2245Gim d tr Fe 66,7% (18/27) bo ha Fe huyt thanh TSAT (>20%)23,4 13,69,9-56,7Gim bo ha Fe huyt thanh66,7 % (18/27)B sung st ( ung hoc tnh mch) 31% (9/29)MCV85,1 4,6 67,8-91,7T bo mu nh MCV 11 g/dl)10,8 2,26-15,9Thiu mu (Hb 50% ba n) 58,6%, km (25-50% s ba) 17,2% khng tun th hay n t do 13,8%.

So vi trc can thip, ch HDDD: n t do 26%KT LUNNC29 BN STM giai on cui CTNT/BV N 2 nm 2011-2012:

T l SDD mn v cp u cao: SDD cp 31% v da SDD cp 10,34%.

T l thiu mu Fe: 50% , gim Fe, Ferritin, gim TSAT kh ph bin: ln lt 20,8%, 66,7% v 66,7%

RL m mu cao: 58,3% c TG cao > 1,5g/l, 20% c cholesterol mu cao > 2,4g/l

Gim Albumin mu < 3g/dl : 6,9%, 3-3,5g/dl :41,1%

khm v tham vn ch n suy thn mn 96, 6%.

Mc tun th ch n iu tr cha cao.

CHA, tng kali mu, tng phosphor mu, gim magne, gim bicarbonate kh ph bin.KT LUNSau 3 thng cung cp min ph sut n v sa trong v sau sut chy thn:

S khc bit c ngha thng k cc ch s cn nng, chiu cao, vng cnh tay, m mu, cholesterol mu, canxi mu, magne mu, phosphor mu.

Albumin mu, bicarbonate c xu hng tt hn. Phosphor mu, kali mu, ure mu c xu hng tng .

ci thin thiu mu: ci thin Hemoglobin, Fe huyt thanh, TSAT, MCV.

KT LUNSut n v sa cung cp trong v ngay sau sut CTNT c t l hi lng ci thin hn trong sut CTNT hi lng 65,5% sau CTNT 72,1% sa 82,2% so vi ch n STM ti bnh vin (26%)

Mc tun th ch n iu tr thp: 48,3% n t do khi ch c khm v hng dn dinh dng, khi c cung cp sut n v cho thc n nhng ba cn li l 13,8%.

KIN NGHCn tng cng dinh dng ph hp hn cho BN STM CTNT: cn nhc gia lng m, nng lng a vo pht trin th cht v nguy c tng ure huyt.

Cn iu tr thiu mu, tng kali mu, tng phosphor mu, h HCO3 tch cc hn.

Cn s hp tc cht ch v thng xuyn hn gia bc s iu tr v khoa dinh dng t c hiu qu iu tr tt nht cho bnh nhi.

Nu c kh nng, nn cung cp cc sut n ng ch nh min ph, c tham kho kin ca bnh nhi tng cng mc tun th.TI LIU THAM KHO1. Hong Ngc Qu. Dc im cc trng hp suy thn mn c chy thn nhn to ti bnh vin Nhi ng 2. Lun n bc s chuyn khoa 2. i hc Y dc thnh ph H Ch Minh. 2007.2. Nguyn Th Hoa. Ch n trong mt s loi bnh l. Phc iu tr N1 2009. Tr 698-7113 . Nguyn Th Thu Hu. Ch n bnh l. Phc iu tr BV N2 2008.4. Capelli JP., Kushner H., Camiscioli TC., Chen SM & Torres MA. (1994). Effect of intradialytic parenteral nutrition on mortality rates in end-stage renal disease care. Am. J. Kidney Dis. 23: 8088165. Dittique en nephrology pdiatrique, Hpital Necker Enfants Malades, Paris, 20076. KDOQI Clinical Practice Guideline for Nutrition in Children with CKD: 2008 Update. Amerian Journal of Kidney Diseases. Vol 53(3,2).March 20097. Kopple JD. Pathophysiology of protein-energy wasting in chronic renal failure. J Nutr, 1999; 129 (1S Suppl): 247S-251S8. Mc Custer, CANUSA Study, Kidney Int 1996, 50: S56-619. Oksa H, Ahonen K, Pasternack A, Marnela KM: Malnutrition in hemodialysis patients. Scand J Urol Nephrol 25:157-161, 199110. Srivaths PR. Nutrition aspects in children receiving maintenance hemodialysis: impact on outcome. Pediatr Nephro. 2009; 24(5): 951-7XIN CHN THNH CM N!