VIỆn nghiên cứu khoa học y dưỢc lâm sàng 108 nguyễn văn tuyến nghiên cứU ĐẶC ĐIỂm lâm sàNG, CẬn lâm sàng và chỉ ĐỊnh thông khí CƠ HỌC

INTRODUCTION

Intracerebral hemorrhagic patients requiring mechanical ventilation has specific features. There are many studies of Intracerebral hemorrhage in general but not many studies of stroke patients requiring mechanical ventilation.

Therefore, we studied the thesis "Studying clinical, paraclinical features and indications for mechanical ventilation in moderate and large supratentorial intracerebral hemorrhage”.

Objectives:

3. 
   Assess clinical, paraclinical features in patients with moderate and large supratentorial itracerebral hemorrhage requiring mechanical ventilation.
   
4. 
   Determine some features related to indications for mechanical ventilation in patients with moderate and large supratentorial itracerebral hemorrhage requiring mechanical ventilation.
   

• 
  Assess clinical and paraclinical features in patients with moderate and large supratentorial itracerebral hemorrhage requiring mechanical ventilation in order to provide experienced michanical ventilation in stroke patients for doctors.
  
• 
  Determine features related to indications for mechanical ventilation in patients with moderate and large supratentorial itracerebral hemorrhage requiring mechanical ventilation. These features should be considered to indicate mechanical ventilation in Intracerebral hemorrhagic patients.
  

The reseach consists of 124 pages: 2 pages of introduction, 35 page of overview, 16 pages of subjects and methods, 31 pages of research results, 37 pages of discussion, 2 pages of conclusions and 1 page of suggesion.

The reserch consist of 119 references, including 52 Vietnamese documents and materials in English 67

Chapter 1 - OVERVIEW

4. 
   Consequences of increased intracranial pressure in patients with acute intracerebral hemorrhage
   According to the formula:
   

Increased intracranial pressure can lead to brain ischemia because of decreased cerebral perfusion pressure. In addition, increased intracranial pressure can cause brain herniation.

5. 
   The role of CO2 in the management of increased intracranial pressure
   CO₂ plays a role in the regulation of cerebral blood flow: Increased CO₂ is due to cerebral vasodilation and increased cerebral blood flow. In contrast, reduction of CO₂ lead to vasoconstriction and reduction of cerebral blood flow; therefore, intracranial pressure is reduced.
   

6. 
   Indications for mechanical ventilation in stroke patients.
   

• 
  According to David L. McDonagh and Cecil O. Borel
  

6. 
   Deterioration of consciousness (Glasgow < 10 )
   
7. 
   Injured brain affects the ability to control respiration
   
8. 
   Posterior fossa lesions due to the inability of protect the airway
   
9. 
   Respiratory failure in patients with Guillain – Barres, Myasthemia gravis...
   
10. 
    Pulmonary complications: aspiration pneumonitis, atelectasis..
    

• 
  According to Rahul Nanchal and Ahmed J. Khan
  

4. 
   Acute injured brain due to loss of airway protective reflexes.
   
5. 
   Acute respiratory failure: Septic shock, neuromuscular diseases, ARDS...
   
6. 
   In anticipation of the clinical worsening, threatening respiratory failure, inability to protect the airway.
   

• 
  Acording to Eelco F.M. Wijdicks
  

4. 
   Acute injured brain due to loss of airway protective reflexes.
   
5. 
   Acute neuromuscular respiratory failure: hội chứng Guillain-Barré syndrome, Myasthemia gravis...
   
6. 
   Respiratory failure in patients with previous lung desease such as: acute pulmonary edema, aspiration pneumonitis.
   

• 
  Acording to Ellen Deibert and Michael N. Diringer.
  

6. 
   Coma (Glasgow coma scale ≤ 8).
   
7. 
   Inability to clean throat, phlegm widely.
   
8. 
   Loss of cough reflex, vomitive reflex.
   
9. 
   Airway obtruction due to paralysis of the muscles in the throat.
   
10. 
    Acute respiratory failure.
    

According to Hoang Khanh, studying prognostic factors in stroke ischemic patients confirmed the volume of infaction correlated very closely with Glasgow coma scale. Nguyen Van Thong at al also found that the hematoma volume correlated very closely with Glasgow coma scale and respiratory disorders. Therefore, hematoma and infaction volume also could be a factor for deciding to intubate ... This issue needs to be studied further.

Patients with acute moderate and large supratentorial itracerebral hemorrhage (first 72 hours), divided into two groups, the group of patients with mechanical ventilation and the others without mechanical ventilation. The studying Patients were inpatients of the Stroke center - Central Military Hospital 108 from january 2008 to March 2012.

Including patients with acute moderate and large supratentorial itracerebral hemorrhage: Confirmed diagnosis based on the definition of intracerebral hemorrhage of the World Health Organization (1989). Intracerebral hemorhage was diagnosed by computed tomography scan of brain. The hematoma located above the tentorium. Hematoma volume was calculated by the formula of Broderick: hematoma volume is moderate from 30 to 60 cm3, large over 60 cm3, arrive at the hospital before 72 hours from the onset.

Exclusion criteria: Intracerebral hemorrhage due to traumatic brain injury, bleeding in the cerebral infarction, bleeding in cerebral tumor, subarachnoid hemorrhage, intracerebral hemorrhagic patients with severe deseases such as liver failure, renal failure, coagulation disorders...

A prospective, observational, follow-up study.

Sample size is determined by formula:

p: estimated ratio, the rate of hemorrhage patients requiring mechanical ventilation estimates 20%. ε: relative error. Z _1-α/2² = 1,96, p = 0.2, ε = 20%, we have n = 196.

In our study, the number of study patients was 230 patients.

Research Contents: All study patients were followed up within 30 days from hospital arrival. The patients were divided into two groups: the group with mechanical ventilation and the others without mechanical ventilation. Indications for mechanical ventilation when at least including one of the following criteria: The Glasgow coma score ≤ 8, acute respiratory failure, loss of protective airway reflexes.

Study the clinical and paraclinical characteristics: the statistical clinical and paraclinical characteristics were compared between the two groups: the group with mechanical ventilation and the others without mechanical ventilation to highlight special clinical and paraclinical characteristics of the group of patients with mechanical ventilation. Study the relative factors to indications for mechanical ventilation: a comparison between two groups: the group with mechanical ventilation and the others without mechanical ventilation. Univariate analysis and multivariate logistic regresion analyses were performed to determine relative factors to indications for mechanical ventilation.

2.4.

AUC = 0,68

• 
  Deterioration of oconsciousness in the group of mechanical ventilation: Glasgow coma score ≤ 8 (55,22%), Glasgow coma score 9-12 (42.53%), Glasgow coma score 13-15 (2.23%). Numbers of patients with GCS ≤ 8 was higher than in the other studies. According to Nguyen Minh Hien The proportion of patients with a Glasgow coma score (GCS) 3-5 was 6.3%, GCS 6-9 was 26.5%, GCS 10-14 was 39.1%, consciousness was 26.6%. Claude J. Hemphill III found that the proportion of patients with GCS 3-5 was 22%, GCS 5-12 was 30%, GCS 13-15 was 47%.
  
• 
  Assessment of muscle strength by Henry scale: In the mechanical ventilation group, 0 point of muscle strength hand account for 77.61%, whereas in non-mechanical ventilation group, it account for only 45.83%. It is reasonable because the patient requing mechanical ventilation with large hematoma or at strategic locations, not only affects respiratory function but also affects motor function.
  
• 
  Assessment of severity by intracranial hemorrhagic score (ICH score): In the group of mechanical ventilation, 3 and 4 ICH score account for mainly (57.46% and 11.19%). In the group of non-mechanical ventilation, 1 and 2 ICH score account for mainly (34.37% and 50.00%). The differences between the two groups were statistically significant for ICH score (P <0.001). As we know, the ICH score was a worse prognostic factor, the higher the score the more severe the disease. According to Hempill JC et al, the first 30-days mortality in intracranial hemorrhagic patients with 1,2,3,4 and 5 ICH score were respective 13%, 26%, 72%, 97% and 100%.
  
• 
  Assessment of severity by NIHSS: Mean NIHSS score at admission in mechanical ventilation group was 22.54 ± 5.91 points, in the others group was 15.08 ± 4.87 points. Similar to ICH score, NIHSS scale has prognostic value, the higher NIHSS score the more severe the disease and the ability of patients requiring mechanical ventilation is higher.
  

• 
  The 30-days mortality in patients requiring mechanical ventilation in our study was 47%. According to Tran Thanh Hung and Vu Anh Nhi, the mortality of stroke patients requiring mechanical ventilation was 63.7%. Thorsten Steiner at al studied 124 stroke patients requiring mechanical ventilation, the mortality is 52%. Bushnell at al studied 131 stroke patients underwent mechanical ventilation, the 30-days mortality was 51%.
  
• 
  Assessment of rehabilitation by Modified Rankin scale: In the group of mechanical ventilation, modified Rankin score 5 and 6 points were in most cases (71.63%). The group of non-mechanical ventilation, 3 and 4 modified Rankin score are mainly (88.54%). Thus, patients requiring mechanical ventilation had poor outcome, high mortality.