phc khoa noi tong hop 2014
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phác đồTRANSCRIPT
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S Y T AN GIANG
BNH VIN KKVTNH
PHC IU TR
KHOA NI TNG HP
2013-2014
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MC LC
IU TR VIM D DY CP ........................................................................................ 3
IU TR HELICOBACTER PYLORI .............................................................................. 5
IU TR LOT D DY-T TRNG ........................................................................... 8
IU TR XUT HUYT TIU HA ............................................................................ 11
VIM TY CP ............................................................................................................... 16
IU TR X GAN .......................................................................................................... 21
NG KINH ..................................................................................................................... 27
NHI MU NO.............................................................................................................. 32
XUT HUYT NO ........................................................................................................ 36
CN THIU MU NO CC B THONG QUA ....................................................... 40
XUT HUYT KHOANG DI NHN ........................................................................ 42
LIT VII NGOI BIN .................................................................................................... 44
H KALI MU ................................................................................................................. 46
TNG KALI MU (Hyperkalemie) ................................................................................. 49
H NATRI MU .............................................................................................................. 53
VIM KHP DNG THP (VKDT) ............................................................................... 55
VIM KHP DNG THP (VKDT) ............................................................................... 56
X TR CC PHN NG DO TRUYN MU V CH PHM MU ...................... 63
SUY GIP ......................................................................................................................... 67
BNH BASEDOW ............................................................................................................ 70
HN M H NG HUYT ....................................................................................... 75
NHIM TRNG TIU...................................................................................................... 77
SUY THN MN ............................................................................................................. 82
HI CHNG THN H .................................................................................................. 86
BIN CHNG CP I THO NG ...................................................................... 93
VIM PH QUN CP ................................................................................................... 99
VIM PHI CNG NG ............................................................................................ 104
BNH PHI TC NGHN MN TNH ........................................................................ 109
HEN PH QUN ............................................................................................................ 118
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IU TR VIM D DY CP
I. NGUYN NHN:
Stress.
Ru, Thuc Aspirin, NSAID
Acid mt, men ty.
Ung cht n mn: acid mnh (thng hang v d b vim mnh), kim mnh
(thng thc qun d b tn thng nng)
Nhim khun: Helicobacter pylori, lin cu khun, t cu khun, chng
Proteus, Escherichia coli, Cytomegalovirus
II. CHN ON:
1. Lm sng:
au thng v lc n hay sau n, n khng ngon, kh tiu, bun i, i, nng
rt thng v.
au c tnh cht chu k, theo ma trong nm
2. Cn lm sng:
Ni soi d dy: sung huyt, vt trt v trong mt vi trng hp lot nng
hoc su y hoc thn d dy.
Clo test (+) nu c nhim Hp
III. IU TR:
1. Ch n:
+ Chia lm nhiu ln trong ngy, n t
+ Thc n mm d tiu, t m. Sa ung tt v c kh nng trung ha acid
nhanh .
2. iu tr h tr (khi cn):
+ Bi hon dch v cc yu cu in gii.
+ Loi b tc nhn gy bnh: Ngng ru, bia, ct Stress
+ Ung cht n mn: khng ra d dy, ch yu dng thuc bng nim mc.
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+ Ngng cc thuc gim au, khng vim: non-steroid, steroid, aspirin
+ iu tr Helicobacter Pylori nu c nhim.
Thuc iu tr triu chng:
a. Nhm c ch tit dch v:
iu tr lin tc 4 tun
Dng dng tim trong giai on vim cp xut huyt, au d di, khi
n chuyn sang dng ung, ung trc n.
Dng mt trong cc thuc sau:
Anti H2:
Ranitidine (Zantac, Histac vin 0.15g, ng 0.05g), liu 1 ng x 2-3
ln/ngy; 1 vin 2 ln/ngy.
c ch bm proton (PPI):
Omeprazole : Liu: 20-40 mg/ngy
Pantoprazole 40mg : 1 vin 2 ln/ngy
Esomeprazole 20mg 1 x 2 ln/ ngy
b. Thuc che ch v bo v nim mc:
Gastropulgit, Phosphalugel, Pepsan 1 gi 3 ln/ngy ung sau n 1 gi.
c. Chng co tht, chng nn:
Metoclopramide (Primperan 0.01g) 1 ng 3 tim mch, tim bp
Spasmaverin 40mg: 2-6 vin/ngy.
d. Thuc kch thch to nhy v duy tr s ti sinh nim mc d dy:
Cc thuc trn iu chnh liu lng v thi gian theo mc trm trng ca
bnh.
3. Ch nh ngoi khoa:
Khi c bin chng xut huyt tiu ha iu tr ni khoa tht bi
Khi c bin chng thng (thng do ung cht n mn).
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IU TR HELICOBACTER PYLORI
I. AI CNG
H.P la mt loai xon khun thuc ho Campylobacter
H.P la yu t bnh sinh chinh trong loet d dy t trng, ung th d dy t trng
c xp vo loi vi trng kh tiu dit, ly qua ng tiu hoa.
II. CHN OAN
Test xm ln (da trn ni soi d dy t trng):
CLO test: test urease nhanh (kt qu sau 1 gi)
III. CH NH IU TR
Loet d dy, loet t trng
Vim d dy man type B hoat ng
Sau ct d dy vi ung th
Tin cn gia inh co ngi bi ung th d dy va lun bi nhim H.P
Mt s BN co hi chng d dy khng loet
IV. IU TR
1. Nguyn tc:
+ c ch toan tt
+ Khng sinh dng ng ung va thuc it bi pha huy bi acid, nn ung
sau n
+ Phi dng t nht 2 loi khng sinh tr ln c tc dng hip ng, khng
bao gi phi hp Tetracylline vi Clarithromycine (hoi t gan)
Thi gian iu tri: 7-14 ngy
Khng tinh liu thuc theo mg/kg tr tre em
Nu iu tri 1 phc khng u liu lng hoc thi gian thi khi
iu tri lai co th dung phac cu nhng keo di thi gian iu tr
2. Cac nhom khang sinh dung tit tr H.P
Nhm Macrolide: Clarithromycin 0,5g x 2 ln/ngy
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Amoxicilline 1g x 2 ln/ngy
Nhm Tetracilline: 1g x 2 ln/ngy
Nhm Imidazole: Metronidazole 0,5 x 2 ln/ngy v
Tinidazole 0,5 x 2 ln/ngy
Nhm Quinolone: Levofloxacine 0,5g x 2 ln/ngy
3. Cac phac iu tr tit tr H. pylori hin nay:
o PPI + Amox + Clari, (t l thnh cng >95%) hoc
o PPI + Amox + Metro, (t l tht bi cao)
o PPI + Clari + Tini, (t l thnh cng # 90%)
o PPI + Tini + Tetra, (t l thnh cng >85%)
o PPI/ RBC + Levofloxacin + Tini (phc khng thuc)
PPI: Omeprazole 20mg x 2 ln/ ngy, hoc
Rabeprazole 10mg x 2 ln/ ngy. hoc
Esomeprazol 20mg x 2 ln/ngy
RBC: Ranitidin + Bismuth subcitrat (bit dc Albis)
Tt c 5 phc trn c th phi hp thm Bismuth tng hiu qu
4. Tac dng ph: Cn au tng, ng ming, kh ng, tiu chay x tri:
Smecta
5. Vn khang thuc
khng nguyn pht ca H. pylori: Metronidazole 47-86%,
Amoxicillin 69%, Clarithromycin 20% .
khng th pht ca H. pylori: nhm d gy khng: Metronidazole,
Clarithromycin. Nhm t gy khng: Amoxicillin, Tetracycline,
Bismuth.
Khng cheo trong cng mt ho D iu tri tht bai nu dung khang
sinh cung nhom vi khang sinh BN thng dung iu tri bnh khac
Khi tht bi vi 1 cng thc: chn 1 cng thc khc nhm hoc thm
bismuth.
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Khi tht bi vi c hai phac , cn thit tin hnh cy va lm khng sinh
Tiu chun chn oan H.P khang thuc: iu tri u thuc, u liu va thi
gian ma cac XN chn oan vn (+) sau t iu tr (ngoi tr cc phng
php tm khng th vi khng th cn tn tai sau khi a tit tr thanh cng)
Theo doi
Nhng trng hp loet d dy hoc loet co bin chng cn kim tra va anh
gi kt qu bng ni soi d dy t trng
Dng mt trong cac phng phap chn oan H.P ngoai tr cc phng php
tm khng th (trong mu, nc bt, nc tiu)
Ti pht H.P: nhim cung mt chung loai trc (thng nhim trong vong 6
thng) Khi iu tri phai i phac mi.
+ C 3 trng hp:
Dit cha sch
Khng thuc
Ti nhim sm
Ti nhim H.P: qua theo doi co s hin din tr lai cua H.P cung chung hoc
khc chng trc, sau khi iu tri tit tr thanh cng (nhim sau 24 thng
c xem la tai nhim thc s) c th dng li phc cu khi iu tr H.P
Phong nga:
+ Gi v sinh n ung: khng n hang quan, hng rong
+ Thay i thoi quen n chung: n chung dia, ung chung ly
+ D phong ly nhim bng vaccine (ang nghin cu).
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IU TR LOT D DY-T TRNG
I. I CNG:
Loet d dy t trng l bnh ph bin, chim 10% dn s, nam > n
C ch bnh sinh la do mt cn bng gia qua trinh bao v v ph hy
Nguyn nhn thng gp: ru, thuc, stress va H.P (80% loet d dy, 95-
100% lot t trng)
Bin chng loet d dy: xut huyt tiu ho, hp mn v, thng, ung th trn
nn loet ( c vai tr ca H. pylori )
II. CHN OAN
1. Lm sang:
Thng au thng v m hoc c nhng cn au d di bng pht theo chu
k, theo cac yu t tac ng vao nh ru, thuc, stress, thc n...
Ngoi ra cn c cc v tr au bt thng khc nh: di c hoanh lan ln trn,
vng tm v, d lm vi cac bnh ly tim mach; sau lng lan ln trn d lm
bnh ly ct sng, thn
2. Cn lm sang:
Ni soi da day ta trang: gip anh gia vi tri va hinh dang loet, sinh thit v
lm CLO test
III. IU TR
A. NI KHOA
1. Ch n ung ngh ngi:
n nhiu ba nho, n nhe, n long, ba n cui nn trc ng 3 gi,
gim cht beo trnh hot ha acid mt.
Trnh cc yu t lm tn thng da day: ru bia, thuc l, thuc khang
vim...
Lm vic mt cch khoa hc, trnh thc khuya, ngh ng gi.
2. Cac nhom thuc iu tri :
a. Nhm Antacid: Phosphalugel, Gastropulgit
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Liu lng va cach dung:
Ung 1-2 gi/ln, sau 3 ba n chnh 30 pht , nu au vo ban m ung
thm trc ng.
Trng hp nng bnh nhn cn trung ha acid lin tc c th dng 6 8
ln/ngy.
Thi gian iu tr: 4 8 tun va nn phi hp vi anti H2
b. Nhm c ch H2 Receptor: Thi gian iu tr 4 8 tun.
Ranitidine (vin 150mg, 300mg; ng 50mg) liu 150 300mg/24gi,
chia 2 ln hoc 1 ln trc ng.
c. Nhm thuc c ch bm proton (PPI ): Thi gian iu tr 4 8 tun.
Omeprazole ( 20mg/vin) liu 40mg/ngy
Pantoprazole (vin 20, 40mg) liu 40mg/ngy
Rabeprazole (vin 15, 30mg) liu 30mg/ngy
Esomeprazole (20mg/vin) liu 40mg/ngy.
d. Nhm thuc bo v nim mc d dy:
Cac phac thng dung:
1. Anti H2 + Antacid / Nhm bo v nim mc
2. PPI (c ch bm Proton)
3. PPI + Nhm bo v nim mc
Khi c vi trng H.P thi iu tr theo phc dit H.P
Ni soi can thip: khi c bin chng
Cm mau: tim cm mu, kp
B. NGOI KHOA
1. Ch nh loet d dy:
+ Loet khng tr hoc loet ti pht
+ Cc bin chng ca bnh loet d dy XHTH , thng, hp mn v, ung
th
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+ BN ln tui co loet to d dy va loet khng lanh sau 3 thng
iu tri
2. Ch nh loet ta trang:
+ Loet ti pht sau thi gian iu tr duy tri < 2 nm
+ Loet ti pht trn BN c tin s xut huyt c theo doi cht ch
sau iu tri ni
+ Loet ti pht sau 2 t iu tri ni khoa kem 3 yu t sau: Chy mu
a khu thung BN ln tui, loet x chai, loet mt sau
+ Loet ti pht trn BN khng tun th iu tr
IV. THEO DOI
+ Nu H.P (-): Cn ni soi d dy t trng kim tra sau 1 t iu tri
nikhoa
+ Nu H.P (+): Cn ni soi d dy t trng kim tra sau ngng iu tri 2 tun.
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IU TR XUT HUYT TIU HA
I. NH NGHA:
Xut huyt tiu ha (XHTH) l tnh trng mu thot ra khi lng mch chy
vo ng tiu ha v c thi ra ngoi bng cch nn ra mu hoc tiu ra
phn c mu.
II. CHN ON:
1. Xc nh c XHTH :
Nn ra mu
Tiu phn en
Tiu ra mu
Mc XHTH:
Nh Trung bnh Nng
Lng mu mt 30%Vtun hon
(>1500mL)
Du hiu sinh tn
-Mch
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-Nc tiu binh thng Gim Thiu niu, v niu
Cn lm sng
-Hct >30% 20-30% < 20%
-Hng cu >3 triu/mm3 2-3 triu/mm3 < 2triu/mm3
-CVP binh thng gim 2-3 cmH2O
gim >5 cmH2O
-Bun, creatinin binh thng c th tng nh tng
-Kh mu ng mch
binh thng binh thng toan chuyn ha
2. Xc nh xut huyt cn tin trin hay khng?
a. Cn din tin:
Tip tc i mu, tiu ra mu, Nhu ng rut tng (binh thng 10-20
ln/pht)
Mch, HA thay i theo chiu hng xu (mch tng, HA kp tt)
Hct, HC gim dn d c truyn mu
Chn on xc nh da vo ni soi
b. Ti pht xut huyt:
BN n nh vi gi hoc vi ngy t nhin i mu, tiu mu hoc c cc
du hiu khc ca XHTH.
c. Tm ngng xut huyt:
Khi hi sc thy mch, HA ci thin n nh, da nim hng tr li,
lng nc tiu tng.
XHTH n nh khi theo di 5 ngy khng thy xut huyt tr li.
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III. IU TR:
1. Hi sc ni khoa: Bi hon th tch, khi lng tun hon cng sm cng
tt:
Thnh lp 2 ng truyn TM ngoi bin ln, c nh ng truyn
bng cc dung dch ng trng nh: Natriclorua 0.9%, Glucose 5%...
Khng dng cc dung dch u trng.
Cho BN nm u bng, ni yn tinh, thong mt, nu c du hiu thiu
oxy th O2 5 L/pht
Lm cc XN c bn cn thit: CTM, nhm mu, ng mu, chc nng
gan thn.
Phn loi mc XHTH (da vo cc tiu chun trn)
XHTH mc nh: sau khi x tr dch truyn, tip tc theo doi, chn
on v iu tr nguyn nhn.
XHTH mc trung binh:
B dch bng lng mu mt nn dng dch mn ng trng/ngt ng
trng 1/1 hoc 2/1 nn u tin dung dch mn trc.
Nu huyt ng n nh theo doi tip v chn on, iu tr nguyn
nhn.
Nu XHTH mc nng:
B th tch tun hon bng mu v dch vi t l mu / dch l .
Truyn dch: huyt tng, dch cao phn t, dch ng trng, albumin.
Truyn n khi:
Mch, HA n nh, BN ra khi tinh trng chong, ht du thiu Oxy no.
Hct> 25%, hng cu >2,5triu/mm3
Vi ngi ln tui v c bnh l tim mch nn nng Hct >30%, hng cu
>3 triu/mm3
2. Cac bin phap chm soc chung:
a. Theo doi : ty theo mc v din tin XHTH
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o Khi c sc: M-HA/15-30pht, Hct-HC/4-6gi
o t CVP: nu cn theo doi st CVP bnh nhn
o Sonde tiu nu cn.
b. Ch n:
c. Din tin bnh
o XHTH din tin : nhn n, nui n bng ng tinh mch
o XHTH ngng n lng, mm, c.
3. iu tr theo nguyn nhn:
1. XHTH do lot d dy t trng:
a. Ni soi d dy t trng: nn lm sm trong 24gi u.
Gip xc nh v tr, tnh trng chy mu; Chch cm mu.
b. iu tr ni khoa: s dng trong nhng thuc sau
c ch bm proton H+ (PPI):
Omeprazole 80mg TMC trong 5 pht liu u, sau 40mg/12gi tim
TMC cho n khi ngng xut huyt.
Pantoprazole 20mg/ng: 40mg TMC liu u, sau 20mg/ 8 gi
trong 3-5 ngy, theo di triu chng xut huyt cho n khi n nh.
Esomeprazole ( 40mg/ng):
Liu u: 80mg tim truyn tnh mch trong 30 pht
Sau 40mg /8gi trong 3-5 ngy
Anti H2 vi Antacid
Anti H2 : Ranitidin 50mg TMC mi 6 gi
Antacid: dng gel liu 15-20ml/1-2gi. Chng ch nh: suy thn, x gan.
c. Ch nh phu thut:
Chy mu nhiu i hi truyn mu nhiu >5 n v/24 gi
Chy mu t e da t vong ngay lp tc
Chy mu ti pht sau iu tr ni khoa tch cc ng phng php, khng
kt qu.
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2. XHTH do v dn TM thc qun:
a. t sonde Blackemore .
b. Ni soi :
+ Chch x
+ Tht bi TM dn bng vng cao su
c. iu tr bng thuc
+ Sandostatin: ng 50mcg, 100mcg
+ Liu 50-100 mcg bolus, duy tr 25-50 mcg/gi
+ Vitamin K 10mg/ngy tim bp
+ Truyn tiu cu: nu TC
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VIM TY CP I. I CNG:
VTC l mt bnh cp cu vi bnh cnh au bng cp:
+ Khong 10%-15% trng hp VTC c din tin nng l c th t vong.
+ VTC l do s vim cp ca m ty v m xung quanh ty do kh nng hot
ha ca men ty (c bit l Trypsin)
II. CHN ON:
A. Lm sng:
- au bng l triu chng thng gp nht , gn 95% trng hp au vng
thng v, quanh rn, h sn tri, lan sau lng
- Bun nn,i : gp trong 85% trng hp, khng gim au sau nn
- Khong 60% bnh nhn VTC st nh do vim ng mt hoc vim ty hoi
t
- Khong 40% bnh nhn c nhp tim nhanh, h huyt p
- Bng chng, n au
- Nhu ng rut gim hoc mt
Cc du hiu khc: trn dch mng phi thng bn tri, vng da nh, vt xut
huyt di da sn lng tri (du Turner Grey).
Quanh rn ( du Cullen) l du hiu ca xut huyt sau phc mc
B. Cn lm sng:
- Amylase mu, lipase mu, CTM, ng huyt, BUN, URE, Creatinin, Ion ,
LDH, AST, ALT, CRP
- XQ bng ng khng sa son: Pht hin si ty, trn dch mng phi, quai
rut canh gc.
- S bng: Ty ph n tng kch thc, hoi t m ty, si, giun
- CT Scan bng cn quang: Ty hnh nh tn thng nhu m, mc hoi t,
m dch quanh ty.
III. CHN ON XC NH:
Chn on VTC thng c chp nhn khi c 2 trong 3 tiu chun sau:
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1. au bng cp kiu ty
2. Amylase mu hoc Lipase mu 3 gi tr binh thng
3. Hnh nh in hnh VTC trn CTScan
IV. NGUYN NHN VTC:
Nguyn nhn thng gp:
- Si ng mt ch, si ti mt
- Giun chui ng mt ch, ng ty
- Ru
- Tng triglyceride mu
- C thai
Nguyn nhn him gp:
- U ty
- Thuc: Thiazid
- Chn thng ty
- Cng cn gip (tng Ca2+)
- Bnh t min
- 20-25% khng r nguyn nhn
V. IU TR:
1. iu tr chung:
- Nhn n, nui n bng ng tinh mch, theo di din tin bnh
- t ng thng mui d dy, lu ng gim nn, gim trng bng
- Theo di du hiu sinh tn, mch, huyt p, nhit , nc tiu, SpO2
- Cung cp cho bnh nhn qua ng tinh mch, m bo nc, in
gii, nng lng (dung dch mui, ng.) thng ti thiu 2 lt/ngy,Lactat
Ringer/glucose
- Gim au: nn dng thuc gim au t nh n nng, thng dng
paracetamol, nu khng gim au c th dng morphin.
- Gim co tht:
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+ Buscopan 20g: 20mg x 3ln/ngy TM/TB
+ No-spa 40mg: 4mg x 3ln/ngy TM/TB
- Gim tit:
+ Ranitidin 50mg: 2-3ln/ngy TM/TB
+ PPI : omeprazol 40mg: 1-2ln/ngy TM, Pantoprazol .
Hoc dng thm
+ Sandostatin 100mg x 3ln/ngy (TM/TDP)
+ Primperan 10mg x 2-3 ln/ngy (TM/TB)
- Khi bnh nhn n c qua ng ming cn theo th t: nc ng, cho
ng, cm nho ri cm binh thng
- Ch : nn king sa, m, cht bo.
2. iu tr bin chng:
a) Nhim trng:
Trong vim ty cp hoi t: Imipenem 0,5g x 3ln/ngy dng trong 7- 10 ngy
C th dng thm:
ceftriaxon 1-2g/24gi (TM)
ceftazidim: 1-2g/8-12 gi (TM)
Meropenem 1-3g/ ngy
Nu nghi ng c k kh:
Metronidazol 500mg truyn tinh mch trong 1 gi/6-8 gi.
b) Phng v iu tr sc:
- Truyn dch lng nhiu: (4-6lt/ngy) trong nhng ngy u
- iu chnh nc, in gii, thng bng kim toan,h Ca2+ ,Mg2+
-iu tr nguyn nhn gy sc: nhim trng, nhim c, xut huyt
- S dng thuc vn mch nu cn
c) Can thip ngoi khoa:
- Khi nghi ng trong chun on, khi khng loi c bnh ngoi khoa
- C cc bin chng ngoi khoa: xut huyt, hoi t, p xe ty, vim phc mc
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- iu tr si mt kt hp
- Tht bi trong iu tr ni khoa tch cc m khng ci thin c tnh trng
bnh
3. Cc yu t tin lng nng vim ty cp
* Tiu chun Ranson:
Lc nhp vin Qua 48 gi theo di
- Tui >55
- Bch cu > 16.000/mm3
- Glycemia > 10 mmol/l
- LDH > 350 UI/l
- AST > 250 UI/l
- Ur huyt > 3 mmol/l
- Pa O2 < 60 mmHg
- Calcemia 10%
- HCO3 gim > 4 mmol/l
- Thot dch m k > 6l
Nu c t 3 yu t tr ln l VTC nng
* Cc yu t nguy c ca vim ty cp nng
- Tui > 60
- Beo phi, BMI 30
- C km bnh khc
* Cc ch im ca VTC nng trong vng 24 gi u sau nhp vin (ch s
im BISAP)
1/ Hi chng p ng vim ton thn
2/ Ri lon tri gic
3/ Ur mu > 25 mg%
4/ Tui >60
5/ Trn dch mng phi
Nu: BISAP 3, nguy c xut hin suy a c quan tng 7-12 ln.
+ Suy c quan:
- Tim mch: HA tm thu 130 ln/pht
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- H hp: paO2 < 60mmHg
- Creatinin >2mg%
* Cc yu t n c khc khi nhp vin c lin quan vi tin trin nng ca
vim ty cp bao gm:
- HCT >44%
- Bo ph
- CRP > 150mg%
- Albumin mu < 2,5mg%
- Calci mu
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IU TR X GAN
X gan l mt tin trnh to m x lan ta gan, bin i cu trc bnh thng
ca gan thnh cu trc dng nt bt thng.
I. CHN ON:
Tin cn nghin ru, vim gan siu vi B,C,vng da nim.
Cc hi chng: Tng p lc tinh mch ca, suy t bo gan.
Xt nghim chc nng gan:Tiu cu gim, TQ ko di, Albumin mu
gim(A/G
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Albumin(g%) >=35g/l 28-34g/l 17s(=8: X gan mt b.
II. IU TR:
1. iu tr nguyn nhn:
+ X gan do ru: Ngng ru.
+ X gan trn bnh nhn vim gan siu vi B,C: Thuc dit siu vi s ci
thin tnh trng x gan.
+ X gan mt nguyn pht: Ch dng thuc ci thin chc nng gan nu
x gan cn b, khng hiu qu x gan mt b.
o Ursolvan 0,2g liu 10-15mg/kg/ngy( chia sng-ti), s dng thi gian di.
o Khng phi hp Questran(Cholestyramin) v thuc s b gim tc dng.
+ X gan mt th pht: Xt ch nh gii quyt tc mt ngoi gan bng
phu thut hoc qua ni soi nu c th c.
+ X gan tim: iu tr bnh tim c bn.
2. iu tr c bn v triu chng x gan:
Bin php chung:
+ Nghi ngi.
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+ Trnh s dng cc loi thuc, cc loi ha cht gy c cho gan, ngng ung
ru.
+ Ch n:
o Gim m, b sung y vitamin v cc khong cht cn thit. n nhiu rau,
trnh to bn.
o ng ty thuc vo tr s ng huyt ca bnh nhn.
o m: Nn chn m thc vt
o Nhu cu m 1g/kg/ngy
o Nu da hn m gan: Ch n gim m 0,5-0,7g/kg/ngy.
iu tr bng bng:
Bc 1:
+ Hn ch mui: 2g (hoc 88 mmol) Na+/ngy.
+ Nn ch nh cho tt c bnh nhn x gan c bng bng nhiu.
+ Gio dc bnh nhn lm tng tun th iu tr.
+ Ch n king mui n thun ch gii quyt bng bng khong 10%
s bnh nhn.
+ Hn ch nc thng khng cn thit.
+ Nu bnh nhn b gim Na do pha long (
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Khi u 100mg liu duy nht ung sau n sng sau tng dn 100mg
mi 7-10 ngy cho n khi t mc gim cn mong mun, liu ti a c
th dng: 400mg/ ngy.
Tc dng ph: tng Kali mu, v to (gynecomatia).
Amiloride: 5-10 mg/ngy, ung.
Li tiu quai Furosemide:
Liu khi u 20-40mg sau tng dn n 160mg/ngy.
Hoc bt u 40mg/ngy phi hp vi spironolactone theo t l 100/40
Bumetanide 0,5 2mg/ngy vi spironolactone.
Nn theo di st du hiu mt nc, ri lon in gii, vp b, bnh no gan,
suy thn.
Gim cn nng
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Khi khng p ng vi Spironolactone 400mg/ngy v Furosemide
160mg/ngy.
Bng bng khng tr l du hiu tin lng thi gian sng cn
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Truyn tiu cu khi tiu cu
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NG KINH I. I CNG:
Cn co git (seizure) c nh nghi l tnh trng bnh l no, c trng
bi s phng lc qu mc, ng b v tm thi ca mt nhm cc neuron trong
no; biu hin lm sng tng ng vi vng no b kch thch. Bnh ng kinh
(epilepsy) c c trng bi cc cn ng kinh ti pht. Thng thng mt bnh
nhn c chn on l ng kinh khi c t nht hai cn ng kinh t khi pht
cch nhau ti thiu 24 gi, nu h ch c mt cn duy nht thi cha th gi l ng
kinh.
Trng hp bnh nhn c cc cn ng kinh trong khun kh bnh l cp
tnh (Vim no, nhim c cp, ri loi chuyn ha) thi khng c gi l bnh
ng kinh. T l dn s b ng kinh khong 1% - 2%.
II. CHN ON:
1. Tiu chun chn oan:
Chn on da vo hi bnh s cn thn, khm thn kinh v lm mt s xt
nghim, chp hnh no b chn on. Khi hi bnh s ngi thy thuc s hi
khi no cn ng kinh bt u, m t chi tit nhng bin c khi cn ng kinh xy
ra, tin cn sc khe ca bnh nhn v gia inh.
Cn lm sng: Chp ct lp in ton (CT Scan) s cho thng tin chi tit v
cu trc binh thng ca no, nhng bt thng cu trc nh mu t, nang, u , m
so m lin quan n ng kinh. Chp cng hng t (MRI) ngoi thng tin
nhn c nh chp CT scan, MRI no cn pht hin cc d dng bm sinh, x
cng thy thi dng. o in no gip nhn bit c hot ng in bt
thng trong no m sinh ra cn ng kinh. N cung gip nhn bit v tr, nng
v loi cn ng kinh.
2. Chn oan nguyn nhn:
Khong 60% - 75% cc trng hp khng r nguyn nhn ca ng kinh. Cc
nguyn nhn sau c th pht hin: Tn thng no trong bo thai, chn thng lc
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sinh (do thiu oxygen), ng c, nhim trng h thn kinh trung ng, chn thng
u, u no, tai bin mch mu no
3. Chn on phn bit:
Co git do nguyn nhn tm l: Ngt; Migraine; h ng huyt; bnh no do
bin dng; cn thiu mu no thong qua; ri lon tin inh; ri lon trong gic
ng; cn qun ton b tm thi; ri lon vn ng; co tht na mt; cn hong lon;
tc dng ph ca thuc v c cht.
4. Phn loi ng kinh:
Theo Hip Hi Chng ng Kinh Quc T nm 1981.
4.1. ng kinh cc b:
a. ng kinh cc b n gin: Triu chng vn ng, cm gic, gic quan
hay tm thn v tr gic khng b nh hng.
b. ng kinh cc b phc tp: Tr gic b nh hng, c th khi u l
ng kinh cc b n gin sau mt thc hay mt thc ngay.
c. ng kinh cc b n gin hay phc tp ton th ha.
4.2. ng kinh ton th:
Cn vng thc; Cn vng khng in hinh; Cn git c; Cn co git; Cn
co cng; Cn mt trng lc; Cn co cng - co git.
4.3. ng kinh khng phn loi:
Gm cc cn m d liu lm sng khng cho php phn loi vo 2 loi trn
nh hi chng West, hi chng Lennox - Gastaut.
III IU TR:
1. Nguyn tc iu tr:
1. iu tr cc cn K, khng iu tr theo in no .
2. Bt u liu thp, tng dn.
3. n tr liu u tin.
4. Tng liu thuc theo hiu qu lm sng, c tnh.
5. Theo di nng thuc (Phenyltoin, Phenobarbital, carbamazepin).
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6. Kt hp thuc khi cn v thch hp cc thuc c c ch khc nhau (VD:
VPA, & LTG/TPM), trnh kt hp cc thuc c cng c ch (VD: CBZ+PHT,
BZP+PB), trnh kt hp cc thuc cnh tranh dc l (VD: VPA & CBZ/PHT).
7. Ngng TCK t t c bit BZP v PB.
2. iu tr c hiu:
2.1. Nu c nguyn nhn:
iu tr nguyn nhn v iu tr ng kinh
2.2. Nu khng c nguyn nhn hoc nguyn nhn khng iu tr c:
iu tr chng ng kinh.
* Mt s gi s dng thuc chng K cho cc th lm sng:
1. K ton th nguyn pht: VPA; CBZ, LTG hay TPM; PHT, PB.
2. K cc b hay K khng xc nh c: CBZ; VPA. LTG hay TPM;
PHT, PB.
3. K vng thc tr nh: VPA hay ESM; LTG; VPA+LTG/ESM.
4. K vng thc thiu nin: VPA; LTG; VPA+LTG/ESM.
5. Cc cn cc b:
a. V cn (Cc cn K c tnh gia inh lnh tnh): ? Khng iu tr; CBZ
hay VPA; VPA+LTG.
b. Triu chng (K thy thi dng, K thy chm): CBZ; VPA, TPM,
LTG; PHT, PB.
6. Cc cn K hn hp (Git c):
a. V cn (Khng co cng): VPA; VPA+LTG; + BZP, ESM; + PNT.
b. Triu chng (Vi co cng): VPA; VPA+LTG hay TPM; +BZP; PHT, PB,
VGB; + PNL.
Cc t vit tc: Carbamazeoine, VPA: Valproic acid, PHT: Phebytoin, PB:
Phenobarbital, LTG: Lamotrigine, TPM: Topiramate, ESM: Ethosuximide, BZP:
Benzodiazepine.
Cc thuc c th lm nng cn ng kinh.
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- Carbamazepine: Cn vng thc, git c, co cng co git ton th.
- Vigabatrin: Cn vng thc, git c.
- Benzodiazepines: Cn vng thc, trng thi co cng.
- Barbiturates: Cn vng thc
- Gabapentin: Git c
- Phenytoin: ? cn vng thc, co cng co git ton th (c tnh)
- Lamotrigine: SMEI
- Tiagabine: Trng thi K.
Cc tc dng ph c hiu/c d:
- Carbamazepine: Ni ban, hi chng Stevens-Johnson, gim bch cu, gim
natri mu.
- Valproate: Tng cn, rng tc, vim ty, suy gan.
- Phenobarbitone: Ni ban.
- Clonazepam: Tng tit
- Phenytoin: Ni ban, bnh huyt thanh, rm lng, tng sn li, xp xng.
- Lamotrigine: Ni ban, HC Sgren, qu mn nng.
- Vigabatrin: Tng cn, bnh vng mc, lon thn.
- Topiramate: Si thn, tng cn, toan mu.
2.3. Phu thut ng kinh:
Phu thut nhm ly b vng no gy ra ng kinh, lm gin on th chai.
Ch nh trong cc trng hp: C nguyn nhn tn thng no: U no, p - xe
no; ng kinh cc b, ng kinh khng tr i vi cc phng php iu tr ni
khoa (>2 loi thuc ph hp). Hin din t nht l 02 nm; ng kinh gy tr ngi
ln trong sinh hot hng ngy, hc tp, lm vic v quan h x hi ca ngi bnh.
2.4. Phng phap t my kch thch thn kinh X:
Phng php ny cung hiu qu trong mt s trng hp ng kinh khng tr
vi thuc.
3. iu tr h tr:
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Ch n sinh ceton: n theo thc n chn sn vi nhiu m, t cht bt v
m. Phng php ny thng c p dng tr em t 1-8 tui.
III THEO DI V TI KHM:
Quan trng l phi gio dc bnh nhn, gia inh v nhng ngi lin quan v
tnh trng bnh l ng kinh, kh nng p ng thuc, tc dng ph v nhng nguy
him m bnh nhn c th gp phi do bnh l, do qu trnh s dng thuc v thi
gian s dng thuc. Thi gian theo doi ban u v ti khm: Mi 2 tun trong 02
thng u (nh gi p ng thuc, tc dng ph, iu chnh liu thuc). Khi n
nh c th theo di mi 1 - 2 thng.
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NHI MU NO I. I CNG:
Nhi mu no v cn thong thiu mu no c cng mt c ch bnh sinh v
phn dit da trn khong thi gian no b thiu mu nui, thi gian ny gy
hoi t m no trong nhi mu no v ngn hi phc hon ton trong cn
thong thiu mu no.
II. CHN ON:
1. Tiu chun chn oan:
1.1. Triu chng:
Khi pht t ngt. C th nhc u lc khi pht; thnh thong xy ra trong
lc ng. thc c th gim thiu nu NMN din rng, hai bn cu hoc thn no.
C th c tin cn cc cn thong thiu mu no. C th c cc triu chng do x
va mch mu (Bnh tim, bnh ng mch ngoi bin) hoc cc bnh nn (Tng
huyt p, i tho ng).
1.2. Cc du chng:
Hnh nh gim m ph hp lm sng trn CT scan hoc MRI, loi tr
xut huyt no, loi tr tn thng cu tng ng trn lm sng (C th gy ng
kinh v gi nhi mu no).
2. Chn oan nguyn nhn:
2.1. X va cc mch mu ln v trung bnh:
Tng lipid mu, tng huyt p, tiu ng, tng homocystein mu, x tr. Bc
tch ng mch, lon sn si c, bnh moyamoya, sarcoidois, vim mch do nm
v lao, vim mch do varicella zoster, hi chng vim mch h thng, vim mch
h thn kinh trung ng cng bn.
2.2. Bnh mch mu nh:
Lipohyaliosis, x va ng mch. Nhim trng (Giang mai, lao,
cryptococcus), vim mch.
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2.3. Thuyn tc t tim:
Tng huyt p, bnh c tim, rung nhi, bnh van tim, huyt khi nhi tri, huyt
khi thnh tht sau nhi mu c tim, vim ni tm mc nhim trng, khng do vi
trng (Ung th, hi chng antiphospholipid), u nhy nhi tri.
2.4. Tnh trng tng ng:
Thuc nga thai, thai k v hu sn, hi chng antiphospholipid, bnh hng
cu lim, ung th, a hng cu thc s, TTP, DIC, tng ng di truyn.
2.5. Do thuc:
Cht gy co mch, vim mch, lon nhp tim, vim ni tm mc, phnh mch
dng nm, tim truyn cc cht gy nhim hoc to huyt khi.
2.6. CADASIL
(Bnh mch mu no di truyn tri nhim sc th) thng vi nhi mu di
v v bnh no cht trng, bnh fabry, hi chng Sneddon, MELAS (Bnh no ty
th vi nhim acid lactic mu v t qu tng t).
3. Chn oan phn bit:
Cc dng bnh mch mu no khc:
- Xut huyt no, xut huyt di nhn, huyt khi tinh mch ni s.
- Lit sau cn ng kinh (Lit Todd).
- Lit trong Migraine.
- H ng huyt
- Khi chon ch ni s.
- Ri loi chuyn dng.
III. IU TR:
1. Nguyn tc iu tr:
- Ti thng mch mu phc hi ti mu no.
- m bo ti mu no hn ch ti pht sm.
- Phc hi chc nng v phng nga ti pht.
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2. iu tr c hiu:
2.1. Thuc tiu huyt khi ng tnh mch:
Cho bnh nhn t qu, thiu mu no trong vng 3-4, 5 gi sau khi pht, c
khim khuyt thn kinh ng k, khng qu nh cung khng qu nng (NIHSS t
5-25 im), khng c xut huyt v khng c cc chng ch nh khc. Actilyse
liu 0,6-0,9mg/kg, ti a 90mg, liu u 10% blous TM, cn li TTM trong 60
pht.
2.2. Thuc tiu huyt khi ng ng mch:
Khi t qu thiu mu no trong vng 3-6 gi t lc khi pht, rtPA, bm
trc tip vo cc huyt khi gy tc tinh mch.
3. iu tr h tr:
3.1. m bo ng th thng thoang, thng kh y , v tun hon n
nh:
Oxy qua sonde mui: 2-4l/p, khi SpO2
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- iu tr st v n nh ng huyt: Gi ng huyt
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XUT HUYT NO I. I CNG:
Xut huyt no (XHN) l tnh trng chy mu vo trong nhu m no hoc no
tht do v ng mch, tinh mch hoc cu trc mch mu khc. Cn phn bit
XHN tin pht (V mch mu) v nhi mu no (NMN) chuyn dng xut huyt
(Bt u t tc nghn mch mu) vi nguyn nhn v iu tr hon ton khc nhau.
T l XHN thay i t 10 n 20 trng hp trn 100.000 dn v gia tng theo tui.
Mt s dn tc, c bit l Nht Bn c t l cao 50-55 cho mi 100.000. T l
XHN theo tui tng theo cp s nhn v t l nam nhiu hn n.
II. CHN ON V NH GI:
1. Tiu chun chn oan:
- Bnh cn lm sng hng n t qu no.
- Hnh nh hc (Thng dng CT scan) xc nh XHN:
+ Khim khuyt thn kinh do XHN phn nh v tr chy mu ban u v
tnh trng ph n phi hp. Ngoi ra, co git, nn ma, nhc u, v gim thc l
triu chng ph bin. Suy gim thc gp trong khong 50% bnh nhn XHN.
Chp CT scan s no ghi nhn tng m xc nh XHN, c th ghi nhn no
ng thy sm v mu trong no tht. Th tch khi mu t gi tr tin lng.
+ Chp mch no : Gip pht hin sang thng mch mu; nn c
thc hin nhng bnh nhn tr (65), v tr XHN gi do tng huyt p (Hch nn,
i th, cu no, tiu no, thy), hoc nhiu XHN v no.
- Do thuc (Heparin hoc Coumadin; Cocaine).
- Do d ng mch mu no (Phnh mch, d dng ng - tinh mch, cavernous
angioma).
- Do huyt khi tinh mch no.
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- U no.
- Chn thng u.
- Cc bnh l ng cm mu.
3. anh gia ban u:
- Hi bnh s v khm: Tm cc du hiu chn thng. nh gi im GCS
v phn x thn no (Nu hn m) hoc im NIHSS nu BN cn tnh. Kim tra
huyt p, bo ha oxy, tnh trng thng kh.
- Chp CT scanner s no (Lp li nu chuyn t BV khc n xem tin
trin): Xc nh ni chy mu, hiu ng chon ch v tnh trng no ng thy.
Kim tra CTM, ng mu v c cht nc tiu. ECG: Loi tr NMCT.
III. IU TR:
1. Nguyn tc iu tr:
- Hn ch lan rng tn thng.
- Bo m ti mu no.
- Phng nga bin chng.
- Phc hi chc nng.
- Phng nga ti pht.
2. iu tr c hiu:
- Ngn chn s chy mu tip din bng cch iu chnh cc ri lon ng
mu v tiu cu (nu c): PTT v APTT keo di nn c iu chnh ngay bng
plasma ti ng lnh (2-6 n v), vitamin K tim di da hoc tinh mch khi c
INR ko di (Mc tiu INR
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tui) c GCS 9-12 hoc XHN thy ln c GCS gim tin trin; Chn la: BN
TALNS khng vi iu tr ni khoa; M s gii p sm mt s BN chn la.
- Tm nguyn nhn gy chy mu v iu tr nguyn nhn.
3. iu tr h tr:
- Gi p lc ti mu no (CPP)>70 hoc p lc M trung binh (MAP)>70
BN c TALNS. Nu c TALNS, cn gi MAP>80. Theo di HA lin tc.
- Cc bin php iu tr TALNS gm:
+ Tng thng kh c kim sot (Mc ch PaCO2 28-32; ch s dng trong
thi gian ngn).
+ Mannitol v/hoc dung dch mui u trng (NaCl 3% truyn ng tinh
mch ln). Khng nn dng mannitol thng qui.
+ Gim au v an thn.
+ Dn lu no tht c kim sot.
+ Gy m, h thn nhit nh (34-36 ) trong cc TH khng p ng.
+ Nn s dng dung dch ng trng hi sc vi mc ch duy tri tinh
trng bnh th tch. Nu cn thit, s dng thuc vn mch m bo huyt p
trung bnh v p lc ti mu no mong mun.
+ Theo doi cc CLS nh in gii , CTM, tnh trng ng mu v nng
thuc,
+ Duy tri H bng insulin t glucose 120-160mg%. S dng Insulin
truyn nu glucose>180mg% 02 ln kim tra lin tip.
+ Duy tri natri mu binh thng tr khi c ch nh khc (Nu TALNS
hoc ph no gy hiu ng chon ch lm nng thm tnh trng thn kinh: Cn
nhc s dng Natri u trng).
+ Duy tr thn nhit binh thng. iu tr st v cc nguyn nhn gy st.
IV. THEO DI V TI KHM:
- Ti khm mi tun trong thng u, sau mi 2 tun, khi tnh trng n
nh ti khm mi thng.
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- Khm lm sng, nh gi bng thang im NIHSS, ch s Barthel, v thang
im Rankin iu chnh.
- m bo kim sot huyt p, kim sot ng huyt, iu chnh cc yu t
nguy c.
- Phi hp thuc c ch men chuyn v li tiu indapamid.
- Tp vt l tr liu v ti nhp cng ng.
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CN THIU MU NO CC B THONG QUA
I. i Cng:
Cn thiu mu no cc b thong qua c c trng bng cc thiu ht thn
kinh khu tr tn ti trong thi gian di 24 gi
II. Lm Sng:
A. Triu chng:
Bnh khi pht t ngt,khng bo trc
Hi phc nhanh trong vng vi pht
Cc triu chng lm sng hi phc hon ton trong vng 24 gi
+ Nu cn thiu mu no cc b thong qua: thuc h thng ng mch cnh
Triu chng thng gp l yu v nng tay, chn na ngi, ri lon cm gic,
ni kh, mt th lc ca mt
+ Nu cn thiu mu no cc b thong qua: thuc h thng ng mch t
sng-thn nn, triu chng c th phc tp hn nh: chng mt, long chong,
nhin i, kh nut, nhn m, yu v ri lon cm gic mt bn hoc 2 bn.
B. Cn lm sng:
- CTscan s : xut huyt no,u no
- MRIs: pht hin tn thng c kch thc nh
- Siu m xuyn s: o tc dng mu ni s
- Chp ng mch: l phng php quan trng xem xt h thng mch mu.
- CTM, Ion ,Creatinin, AST,ALT,Lipide mu,TPTNT,ECG
III. Nguyn Nhn:
- X va ng mch
- Cc bnh tim gy thuyn tc :Thp tim,hp van 2 l,suy tim,rung nhi,u nhy
nhi,van tim nhn to
- Nguyn nhn khc: vim ng mch t bo khng l,Lupus h thng,a
hng cu
IV. iu Tr:
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Nhm nga t qu: b ht thuc l nu bnh nhn ht thuc, h huyt p nu
bnh nhn tng huyt p, kim sat ng huyt nhng bnh nhn T,iu
chnh ri lon lipide mu.
Thuc asprin162- 325mg/ngy hoc cloprdogel: 75mg/ngy.
Cc thuc chng kt tp tiu cu dng trong thi gian di
Khi khm tnh mch mu hp >70% nn phu thut.
Ti liu tham kho
1. Phc iu tri BVK Trung tm An Giang
2. Chn on v iu tr y hc hin i 2008
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XUT HUYT KHOANG DI NHN
I. I CNG
Xut huyt di nhn l tnh trng mu chy vo trong khoang di nhn
ha ln vi dch no ty v khi chc d dch no ty thy c mu khng ng c
03 ng nghim thi c chn on chc chn l xut huyt di nhn. Theo thng
k khong 15 n 20% cc tai bin mch mu no l xut huyt no, v 50% cc
trng hp xut huyt no l xut huyt di nhn. Hu ht cc trng hp xut
huyt di nhn ngi tr u lin quan n v phnh mch mu no
II. CHN ON
au u d di, tng ln tng giy, cm gic nh v u, au lan ta khp
u, bun nn v nn, co git, s nh sng, ri lon thc, du mng no (+), lit
dy III, lit na ngi
Cn lm sng: CT u, cng thc mu, ure, creatine, ion , AST, ALT,
lipid mu, CRP, tng phn tch nc tiu, ECG,
Phn lm sng theo Hunt v Hess
1: Khng c triu chng hay au u nh
2: au u t va n nng, cng gy, lit vn nhn
3: L m, l ln, du thn kinh nh v nh
4: Trng thi sng s, hn m, lit na ngi, ri lon thn kinh thc vt
5: Hn m su v dui cng mt no
Phn Fisher trn CT u
1: CT binh thng
2: Mu lan ta trong khoang di nhn c dy < 1mm
3: Mu cc hoc mu lan ta c dy > 1mm
4: Mu t trong nhu m no hoc no tht m khng c xut huyt di nhn
lan ta
Chn on (+): Lm sng au u + CT xut huyt nhi nhn
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Phn bit: Vim mng no; Xuyt huyt tiu no; au ct sng c cp; Migraine;
Huyt khi tinh mch ni s; No ng thy cp.
II. IU TR
1. Nguyn tc iu tr:
Can thip ngoi khoa sm khi lm sng cho php
Phng nga bin chng
Phc hi chc nng
2. iu tr h tr:
Nm ngh ti gng
Truyn dch: Natri clorua 9, 500ml 2-3 lt/24 gi
Chng to bn: Forlax 2 gi/ngy hoc Duphalac 2 gi/ngy
Gim au: Paracetamol truyn tinh mch hoc ung
An thn bng Seduxen ng ung hoc tinh mch ty tnh trng lm sng
Seduxen 5mg, 01 vin ung ti
Seduxen 10mg, 01 ng tinh mch trong vng 2 pht khi bnh nhn kch
thch, liu ti a 40mg/ngy
Duy tr huyt p tm thu t 120-150mmHg bng c ch knh canxi:
Amlodipin 5mg 1 x 2 vin/ngy, c ch men chuyn: perindopril 5mg 01
vin/ngy.
3. Chng co tht mch mu no
Nimodipine 30mg, 1-2 vin/ngy trong 21 ngy hoc nimodipine truyn tinh mch
mch liu khi u 1mg (5ml) truyn tinh mch trong vng 1 gi trong vng 2 gi
nu huyt p n nh tng ln 2mg (10ml) truyn tinh mch/gi trong vng 01 tun
sau chuyn sang ng ung ko di trong 21 ngy
Khi tnh trng lm sng cho php chuyn tuyn trn can thip ni mch.
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LIT VII NGOI BIN
I. I CNG
Lit dy thn kinh s VII ngoi bin l mt tn thng cp tnh, thng t
gii hn lin quan n ch mt dy thn kinh mt (thn kinh s VII). Cho n nay
vn cha xc nh c nguyn nhn ca lit VII ngoi bin. Mt s yu t c
cho l c th gy ra Lit VII ngoi bin
Herpes simplex virus type 1 (HSV-1) c xc nh trong a s cc trng
hp
Herpes Zoster
Nhim HIV cp tnh
Bnh Lyme
Vim tai gia cp hoc mn tnh
Bnh c
Khi u vng mt: u tuyn nc bt,
II. CHN ON
Chn on bnh ch yu da vo lm sng. Bnh thng xy ra t ngt khi
di tu xe hoc thng sau ng dy pht hin
Khun mt mt cn xng: M hoc mt cc np nhn t nhin nh np nhn
trn, rnh mui m. Ming v nhn trung b ko v bn lnh (khi nhe rng s
mt cn xng cng ro hn)
Mt bn lit khng nhm kn (du Charles Bell (+))
Cm gic t mt bn mt
Mt v gic 2/3 trc li
Kh mt hoc chy nc mt
III. IU TR:
Khng c iu tr c hiu
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Corticoid (Prednisolone): 20mg-60mg/ ngy chia lm 2-3 ln/ ngy (c th
n 80mg/ngy) duy tr 1-2 tun, gim liu khi lm sng ci thin. Nn cho
trong vng 72 gi sau khi khi pht
Khng virus nh: Acylovir 200mg x 5 ln/ngy t 7 n 10 ngy
Kt hp khng virus v corticoid 1000mg/ngy x 5 ngy kt hp
prednisolone 60mg/ngy x 5 ngy sau 30mg/ngy x 3 ngy sau
10mg/ngy x 2 ngy
Vitamin nhm B (B1, B6, B12): 1 vin x 2 ung/ngy x 7 ngy
Chm sc mt: nn eo knh rm chng gi bi, ra mt thng xuyn bng
nc mt nhn to, nc mui sinh l hay Cloramphenicol 0,4 %
Vt l tr liu: Cc bi tp trn khun mt c th lm gim thi gian phc hi
hoc di chng
Phng php khc: Hiu qu ca chm cu cn ang c xem xt
IV. THEO DI V TI KHM
Ti khm mi 2 tun u, sau c th ti mi thng mt ln
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H KALI MU
I. I CNG
- H kali mu l mt ri lon in gii thng gp trong khoa hi sc tch
cc. C th gy t vong nu khng c x tr kp thi.
- Kali mu binh thng t 3,5 5,0 mmol/l.
- H kali khi < 3,5 mmol/l.
II. CHN ON
1. Chn oan xac nh
Du hiu h kali mu trn lm sng :
+ Yu c (t chi, c h hp...), au c, co rt c.
+ Lon nhp tim.
+ Bng trng, gim nhu ng rut, to bn, nn, bun nn.
Du hiu h kali mu trn ECG : c sng U, sng T dt, ST chnh xung,
QT ko di. Du hiu nng trn ECG : lon nhp tht (nhp nhanh tht,
xon nh).
Xt nghim kali mu < 3,5 mmol/l.
2. Chn oan mc
- Mc nh : 2,5mmol/l < kali < 3,5mmol/l. Khng c triu chng.
- Mc va : kali < 2,5mmol/l (< 3mmol/l nu ang dng digoxin). Khng
c yu c v khng c du hiu nng trn ECG.
- Mc nng : kali < 2,5mmol/l (< 3mmol/l nu ang dng digoxin). C
yu c hoc c du hiu nng trn ECG.
3. Nguyn nhn thng gp
- Mt qua thn :
+ Tiu nhiu do bt c nguyn nhn g.
+ i tho ng khng kim sot c.
+ H magnesi mu, h clo mu, tng calci mu.
+ Toan ng thn typ 1 hoc typ 2.
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+ Hi chng Fanconi, hi chng Bartter.
- Mt qua ng tiu ha:
+ Nn hoc mt do dn lu qua ng thng d dy.
+ Tiu chy.
+ Dn lu mt, m thng hi trng, sau phu thut rut non.
+ Tht tho hoc dng thuc nhun trng.
- Do thuc:
+ Li tiu thi kali.
+ Insulin, glucose, natri bicarbonate.
+ Cng beta-andrenergic.
+ Corticoid.
+ Khng sinh: aminoglycosid, penicillin, ampiciilin, rifampicin, ticarcillin.
+ Kim mu.
+ iu tr thiu ht vitamin B12 v acid folic.
- Lng kali a vo khng : thiu n, nghin ru, ch n king.
- Tha corticoid chuyn ha mui nc:
+ Cng aldosteron tin pht (hi chng Conn), cng aldosteron th pht.
+ Tng huyt p c tnh.
+ Hi chng Cushing, ung th thn, u t bo cnh cu thn, ung nhiu cam
tho,
Lit chu k Westphal th h kali mu nguyn pht
- Thng gp la tui nh n < 30 tui.
- Din bin t vi gi n 1 tun hay gp vo bui sng, ti pht nhiu ln.
- Yu c t nh n nng.
III. IU TR
B kali mu:
1. Kali 2,5mmol/l (< 3mmol/l nu ang dung digoxin):
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+ C triu chng lit c hoc du hiu trn ECG: KCL 20-30mmol/gi
truyn qua TM Trung tm.
+ Khng c yu c v khng c du hiu nng trn ECG: Ung KCL 20-
40mmol mi 2-4 gi v/hoc truyn tinh mch KCL 10mmol/gi.
2. 2,5mmol/l < kali < 3,5mmol/l: Ung hoc truyn tinh mch KCL 20-
40mmol mi 4-6 gi.
Theo di
- Trng hp h kali mu c bin i trn ECG, theo di ECG lien tc trn
my theo doi cho n khi ECG tr v binh thng.
- Theo di xt nghim kali mu. H kali mu mc nng 3 gi/ln, mc
va 6 gi/ln, mc nh 24 gi/ln cho n khi kali mu tr v binh thng.
Ch
- Trnh truyn ng glucose bnh nhn h kali mu s gy tng bi tit
insulin lm gim kali mu.
- Nng kali clorid pha khng qu 40mmol/l (3g) nu dng ng truyn
ngoi bin (phi b qua ng catheter tinh mch trung tm).
- Tc b kali clorid khng qu 40mmol/gi (3g).
- pH tng 0,1 tng ng vi kali gim 0,4mmol/l.
- 1g kali clorid c 13,6g mmol.
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TNG KALI MU (Hyperkalemie)
I. NH NGHA:
Tng Kali mu l mt cp cu ni khoa bnh nhn c th t vong nhanh chng
nu khng cp cu kp thi. y l bnh l thng gp chim 10% bnh nhn
ni tr. Tng Kali mu khi Kali huyt thanh > 5.5 mmol/L ( binh thng 3.5
5.5 mmol/L).
II. CHN ON:
1. Triu chng:
Thng c triu chng khi Kali huyt thanh > 6.5 mmol/L.
- Triu chng thn kinh c: mt mi, nh trng ngc, d cm, yu c, lit c,
gim hoc mt phn x, lit hng ln.
- Triu chng tim: nhp chm c th dn n v tm thu, ko di dn truyn
nhi tht dn n bloc hon ton v rung tht.
Thay i ECG tng ng mc tng Kali huyt thanh:
+ Kali huyt thanh 5.5-6 mmol/L: Sng T cao nhn- i xng- hp y
(T>2/3R t V3- V6), khong QT ngn li.
+ Kali huyt thanh 6-7 mmol/L: khong PR ko di, QRS dn rng.
+ Kali huyt thanh 7-7.5 mmol/L: sng P dt, QRS dn rng hn na.
+ Kali huyt thanh > 8 mmol/L: xut hin sng hnh Sin 2 pha, phc b
QRS dn rng trn ln sng T, bo trc ngng tim sp xy ra.
Bin i v in tim thy r khi pH mu gim, Na+ mu gim, Ca++ mu gim.
2. Cn lm sng:
- o ECG.
- in gii .
- Chc nng thn: ur, creatinin ( nng kali phi c xt nghim vi chc
nng thn v nhng bnh nhn suy thn c kh nng dung np vi kali cao
hn).
3. Nguyn nhn:
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- Gim bi tit qua thn: suy thn cp, suy thn mn, H/C Addison, H/C gim
Renin, bnh thn tc nghn.
- Ti phn phi kali t dch ni bo ra ngoi bo:
+ Toan huyt.
+ Qu liu Digitalis, thiu insulin ( tng ng huyt), dng nhiu dung dch
Glucose u trng, Mannitol.
- Ngoi sinh: ung, truyn Kali, truyn mu, truyn PNC K+ liu cao (1 triu
n v PNC cha 1.7 mEq kali).
- Ni sinh do hy hoi m: tn huyt, ly gii c vn, xut huyt tiu ha, i
phu, chn thng do chn ep).
- Tng kali gi:
+ Kali phng thch t cc mu mu b ng c tng bch cu > 105/ul hoc
tng tiu cu > 106/ul.
+ Tn huyt do ly mu bng kim nh, mu mu lu, buc garrot ko di
v sit qu cht.
- Thuc: li tiu tit kim kali, c ch men chuyn, c ch th th
angiotensin, NSAID
III. IU TR:
Cn iu tr cp cu khi kali mu > 6-7 mmol/l hoc ECG c du hiu tng kali
mu. Theo di st kali mu v ECG lin tc.
1. Mc tiu:
- Bo v tim trnh tc dng ca tng kali trn dn truyn tim (dng Calcium).
- Chuyn kali t ngoi bo vo ni bo (dng Sodium bicarbonate, Insulin+
Glucose, Beta 2 receptor).
- Gim tng lng kali trong c th (renins trao i cation, thm phn).
2. Nguyn tc:
- Nu kali mu 5.5-6 mmol/l: iu chnh ch n, khng a thm kali vo
c th, tng thi kali qua ng tiu v ng tiu ha.
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- Nu kali mu 6-6.5 mmol/l: s dng thm cc thuc gim kali mu, chun b
lc mu.
- Nu kali mu 6.5 mmol/l: lc mu cp cu.
3. Phng php:
a. Dng thuc:
+ Canxi gluconate 10% 10 ml (1g) tim TMC trong 2-5 pht. Nu khng p
ng; ( ECG khng thay i) c th lp li liu th 2 sau 5- 10 pht.
Ch : Canxi bt u tc dng trong vi pht v ko di khong 1 gi. Khng
tim canxi qua ng truyn bicarbonate trnh kt ta nn dng canxi trc
khi dng NaHCO3.
+ Natri bicarbonate 8.4% (150 mmol/l) pha 3 ng trong 1000ml Glucose 5%
truyn TM hoc 50-100 mmol tim TMC > 5 pht bt u tc dng trong
15 pht v ko di 1-2 gi. C th lp li sau 15- 30 pht nu ECG cn bt
thng.
Ch : tng natri mu v qu ti tun hon khi dng lng ln NaHCO3.
+ Insulin pha Glucose : 10 UI Insulin Actrapid + 50 ml Glucose 50% (25g) >
5 pht, p ng trong 30-60 pht.
+ Li tiu Furosemide 40 mg TM
+ ng vn 2 adrenergic: Salbutamol 10-20 mg PKD hay 0.5 mg TM c p
ng sau 30 pht, kali mu gim 0.5-1 mmol/l, hiu qu ko di 2-4 gi.
+ Renin trao i cation.
b. Chy thn nhn to: Ch nh khi
- Kali mu 6.5 mmol/l hoc
- Hnh nh ECG khng bin mt sau khi iu tr ni khoa.
c. Cc bin php hn ch tng kali mau:
- Khng n thc n giu kali: chui, thc phm kh, thc phm ng hp, hoa
qu kh, nc qu ngm
- Khng s dng thuc c kali: Kali clorua, Kaleorid, Penicillin potasium
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- Ct lc loi b cc hoi t, m, nhim khun.
- Nu c chy mu ng tiu ha cn loi nhanh mu ra khi ng tiu ha.
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H NATRI MU
I. I CNG:
- H natri mu xy ra khi natri mu gim di 135 mEq/L.
- y l loi ri lon in gii thng gp nht cc bnh nhn ni tr.
II. CHN ON: (Xem thm s chn on v iu tr)
1. Biu hin lm sng:
Hu ht cc triu chng lm sng ca h natri mu l do tnh trng gia tng
th tch dch ni bo a ti ph no. a s bnh nhn ch b h natri mu nh vi
cc triu chng khng ng k. Mc nng ca cc triu chng ty thuc vo
mc v tc h natri.
H natri cp ( 290mOsm/L):
Glucose v mannitol l cc cht ha tan c p lc thm thu cao s keo nc vo
lng mch gy ra h natri mu do pha long. Mi 100mg/dl ng huyt tng ln
s lm natri mu gim 1,6 - 2,4 mEq/L.
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- H natri mu vi p lc thm thu mu binh thng (ALTTm 275-290
mOsm/L): Cn gi l h natri mu gi xy ra khi c s gia tng lipid hay protein
huytt tng.
- H natri mu vi p lc thm thu mu thp (ALTTm < 275 mOsm/L): H
Na/mu tht s biu hin bng s gia tng dch t do tng i so vi Na trong
dch ngoi bo.
III. IU TR: (Xem thm s chn on v iu tr)
iu tr h natri mu cn phi xc nh: (1) tc iu chnh; (2) can thip thch
hp; (3) bnh l nn.
Trong h natri mu cp (< 2 ngy) hay khi c triu chng thn kinh, tc tng
natri mu c th n 1-2mEq/l mi gi cho ti khi triu chng ci thin, sau
khng qu 0,5 mEq/l mi gi, v khng qu 10-20 mEq/L trong 24 gi.
Natri u trng ch nn dng cho bnh nhn c triu chng nng (Hn m, co
git)
Trong nhng gi u tin, nn o ion mi 2-4 gi/ln m bo [Na+] mu
khng tng ln qu nhanh.
Trn lm sng c th tnh tc b natri nh sau:
- Cng thc Adrogue - Madias c tnh s thay i natri mu ([Na+]) khi truyn 1 lt dch
[Na+] = ([Na+ dch truyn] + [K+ dch truyn] - [Na+ mu]) / (0,6 x cn nng BN + 1)
- V d: Bnh nhn nm 80kg, [Na+] mu 103 mEq/l, m, c ch nh b natri u trng.
1 lt Natrichlorua 3% c th tng 10 mEq/l natri mu
[Na+] = (513 - 103) / (0,6 x 80 + 1) = 10 mEq/L
Cn tng [Na+] mu 2 mEq/L/gi cho ti khi triu chng ci thin Tc b dch natrichlorua 3% = 2 mEq/L/gi:
10 mEq/L/l = 0,2/gi cn b 200ml dch natri 3% mi gi
Trnh tng [Na+] mu > 10-12 mEq/L khng b qu 1 lt dch natri 3%.
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S CHN ON V IU TR H NATRI MU
[Na] <
13mmol/l
ALTTm
> 290mOsm/l 275 -
290mOsm/l
< 275mOsm/l
ng mu
manitol
protein mu
lipid mu
H natri mu
tht s
ALTTnt
>
100mOsm/l
<
100mOsm/l ECV Bnh ung
nhiu
Tng Bnh thng Gim
[Na] niu
[Na] niu >
20mEq/l
[Na] niu
20mEq
/l
X gan
Suy tim
HC thn
h
Suy
thn
Khi u bng Furosemide BN khng c triu chng Furosemide + rt thn trng NaCl 3% BN c
triu chng
SIADH
Suy thng
thn
Suy gip
Thiu cortisol
Tng hot tnh
ADH do thuc
Furosemide + NaCl 3% BN c triu chng B NaCl 9% BN cha c triu chng
20mEq
/l
Mt Na ngoi
thn: tiu
chy, i
Bnh no mt mui
Bnh thn mt
mui
Dng li
tiu
Nhc
aldosteron
B NaCl 3% nu BN
c triu chng
B NaCl 9% nu BN
cha c triu chng
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VIM KHP DNG THP (VKDT)
I. NH NGHA
Vim khp dng thp l mt bnh t min kh in hnh ngi, di dng
vim mn tnh nhiu khp ngoi bin vi biu hin kh c trng : sng,
au khp, cng khp bui sng v i xng hai bn. Ngoi ra ngi bnh
cn c cc biu hin ton thn (mt mi, xanh xao, st, st cn,) v tn
thng cc c quan khc.
Bnh VKDT l bnh mang tnh x hi v t l mc bnh cao, bnh din bin
ko di, hu qu dn n tn ph.
II. CHN ON
1) Chn on xc nh theo tiu chun ca Vin Thp Khp hc M (ARA)
nm 1987:
- Cng khp ( ti khp v quanh khp ) bui sng, ko di ti thiu 1
gi trc khi ci thin ti a.
- Vim ti thiu 3 nhm khp: sng phn mm hay trn dch ti thiu 3
nhm khp trong s 14 nhm sau (k c 2 bn) khp ngn tay gn,
khp bn ngn tay, khp c tay, khp khuu, khp gi, khp c chn
v khp bn ngn chn (do thy thuc xc nh).
- Vim cc khp bn tay: sng ti thiu mt nhm trong s cc khp:
c tay, khp ngn gn, khp bn ngn.
- Vim khp i xng: ring khp ngn gn, khp bn ngn tay, khp
bn ngn chn i xng tng i.
- Ht di da: (5-10%) trn nn xng, pha mt dui ca khp,
quanh khp (do thy thuc xc nh).
- Yu t dng thp trong huyt thanh (+) 65-75%, thng xut hin
mun, sau 6 thng 1 nm.
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- Du hiu Xquang: thng xut hin t nm th 2. Nhng du hiu
in hnh ca VKDT trn phim thng bn tay v c tay thy hnh bo
mn xng, hp khe khp, mt vi hnh di.
Chn oan xac nh khi c 4 tiu chun tr ln, tiu chun t 1 n 4 tn
ti t nht > 6 tun.
2) Tiu chun ca Hi Thp khp hc Hoa K v Lin on chng Thp
khp Chu u 2010 (ACR/EULAR 2010 American College of
Rheumatology / European League Against Rhumatism). Tiu chun ny c
th p dng trong trng hp bnh giai on sm, cc khp vim < 6 tun
v th t khp. Tuy nhin cn lun theo doi nh gi li chn on vi nhiu
trng hp y cung c th l biu hin sm ca mt bnh l khp khc
khng phi vim khp dng thp.
i tng l cc bnh nhn
- C t nht 1 khp c xc nh vim mng hot dch trn lm sng.
- Vim mng hot dch khp khng do cc bnh l khc
- Biu hin im
A. Biu hin ti khp
1 khp ln 0
210 khp ln 1
13 khp nh (c hoc khng c biu hin ti cc khp ln) 2
410 khp nh (c hoc khng c biu hin ti cc khp ln) 3
>10 khp (t nht phi c 1 khp nh) 5
B. Huyt thanh (t nht phi lm mt xt nghim)
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RF m tnh v Anti CCP m tnh 0
RF dng tnh thp* hoc Anti CCP dng tnh thp* 2
RF dng tnh cao* hoc Anti CCP dng tnh cao* 3
C. Cc yu t phn ng pha cp (cn t nht mt xt nghim)
CRP bnh thng v Tc lng mu bnh thng 0
CRP tng hoc Tc lng mu tng 1
D. Thi gian biu hin cc triu chng
< 6 tun 0
6 tun 1
Chn oan xac nh: khi s im 6/10
* Dng tnh thp khi 3 ln gii hn cao ca bnh thng
* Dng tnh cao khi > 3 ln gii hn cao ca bnh thng
III. IU TR
1) Nguyn tc
iu tr ton din, tch cc, di hn v theo doi thng xuyn.
Cc thuc iu tr c bn hay cn gi l nhm thuc DMARDs ( Disease
modifying antirheumatic drugs ) kinh in ( methotrexat, sulfasalazine,
hydroxychloroquine...) c vai tr quan trng trong vic n nh bnh v cn
iu tr ko di.
Cc thuc sinh hc cn c gi l DMARDs sinh hc ( khng TNFa, khng
Interleukin 6, khng lympho B) c ch nh i vi th khng iu tr vi
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DMARDs kinh in, th nng hoc tin lng nng. Khi ch nh cc thuc
sinh hc, cn c kin ca cc bc si chuyn khoa C Xng Khp v thc
hin ng quy trinh ( lm cc xet nghim tm sot lao, vim gan ( virus B,
C), chc nng gan thn...)
2) iu tr triu chng:
a) Khng vim nonsteroid: dng mt trong s cc thuc sau:
- Diclofenac: 75mg x 2 ln/ngy (TB) x 3-7 ngy, sau 50-75mg x 2
ln/ngy ung.
- Meloxicam: 15mg/ngy TB hoc ung.
- Celecoxib: 100-200mg/ngy ung.
Nu sau 1-3 tun s dng thuc m khng y li c t tin trin
thi i thuc hoc chuyn sang dng corticosteroide.
b) Corticosteroide:
- Th va: Methylprednisolone 16-32mg/ngy ung lc 8 gi sng, sau
n.
- Th nng: Methylprednisolone 40mg/ngy TM gim dn v ngng khi
iu tr c bn c hiu lc ( sau 3-6 thng ).
- Th tin trin cp tnh nng, e da tnh mng Methylprednisolone
500-1000mg TTM 30-45 pht/ngy x 3 ngy lin tc ri tr v liu
1mg/kg/ngy sau gim liu dn.
Liu trnh c th lp li mi thng nu cn.
- iu tr di hn khi cn: Methylprednisolone 16-20mg/ngy lc 8 gi
sang, sau gim dn liu v duy tr 5-7,5mg lc 8 gi sng hng
ngy.
3) iu tr c bn: dng thuc c th lm chm hoc ngng tin trin
ca bnh
a) Hydroxycloroquin
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- Liu dng: 200mg x 2 ln/ngy x 6 thng, sau tip tc 200mg/ngy
nu c hiu qu.
- Tc dng ph: ri lon tiu ha, xm da, c gic mc, vim vng
mc cn kim tra mt mi 3 thng.
b) Methotrexate (MTX)
- Liu dng: khi u liu 10mg mi tun.
Ty theo p ng m duy tr t 7,5-15mg ung/tun, ti a 20mg.
- Chng ch nh: qu mn vi thuc, suy thn, suy gan nng, suy ty,
nghin ru, c thai, cho con b, ang nhim trng, lot ming, lot
ng tiu ha, v niu, gim tinh trng, ri lon kinh nguyt, tng
men gan, vim phi, nhim c thn kinh, da, xm da, nga, rng
tc.
c) Hoc Sulfasalazin (SSZ) : khi u 500mg/ngy, tang 500mg mi
tun, duy tr liu 1g x 2 ln/ngy.
d) Hoc kt hp MTX vi SSZ v/hoc Hydroxycloroquin nu
n tr liu khng hiu qu.
e) Th nng khng tr vi thuc lm chm hoc ngng tin trin
ca bnh c in ( 6 thang ) cn kt hp vi cc thuc sinh
hc:
- MTX + thuc khng Interleukin 6: MTX 10-15mg mi tun +
Tocolizumab 4-8mg/kg, tng ng 200-400mg truyn TM mi
thng 1 ln.
- MTX + thuc khng TNF: MTX 10-15mg mi tun + Etanercept
50mg TDD mi tun 1 ln hoc MTX 10-15mg mi tun + Inflicimab
2-3mg/kg truyn TM mi 4-8 tun.
- MTX + khng lympho B: MTX 10-15mg mi tun + Rituximab 0,5-
1g x 2 ln, cch 2 tun truyn TM, c th nhc li 1 hoc 2 liu trnh
mi nm.
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f) Tim khp Methylprednisolone axetat 20-40-80mg/khp (nh-
va-ln).
Ch nh: khi cn 1-2 khp khng p ng vi iu tr ton thn, ti
a 3 ln/nm cho 1 khp, cn phi hp calcium 1,5g/ngy v vitamin
D 400-800UI/ngy.
4) Cc bin php h tr:
- Ch n ung dinh dng: tng cng cht m, vitamin v khong
cht (calcium, phospho, magne,)
- Tp vn ng:
Trong t vim cp: khp t th c nng, trnh k, n gy cng
khp t th sai.
Tp ngay khi gim vim, tng dn, nhiu ln trong ngy c th ng
v ch ng theo ng cc chc nng sinh l ca khp.
- Vt l tr liu, phu thut chng dnh, thay khp nhn to khi khp
gim chc nng nng.
- Ni soi ra khp: ch nh khi vim mt vi khp ko di kh kim
sot.
TM TT PHC IU TR VKDT TI VIT NAM
Kt hp ng thi 3 nhm thuc di y:
1. Thuc chng vim:
- Corticoid liu cao, ngn ngy, sau gim liu dn ( thng khong 1-2
thng ).
- Hoc thuc chng vim khng steroid.
2. Thuc gim au: Paracetamol hoc cc ch phm kt hp khc.
3. Thuc chng thp khp tc dng chm:
- Hydroxychloroquin hoc chloroquin ( i vi th nh ).
- MTX + chloroquin c la chn hng u.
- Salazopyrin ch nh khi khng dung np MTX.
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- MTX + chloroquin + salazopyrin.
- MTX + cyclosporine A.
- Rituximab.
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X TR CC PHN NG DO TRUYN MU V CH PHM MU
I. CC PHN NG DO TRUYN HNG CU:
1. Cc phn ng min dch:
Phn ng d ng:
Do c cc d ng nguyn trong huyt tng. Bnh nhn ni m ay trong
hoc sau khi truyn mu.
X tr:
- Tm ngng truyn mu.
- Antihistamin: Chlorpheniramin 4mg/1 vin (ung) hoc Pipolphene 50mg
ng TB mi 4-6 gi.
Tn huyt cp:
Do truyn nhm nhm mu h ABO, chim t l 1/200.000-1/1.000.000.
- Lm sng: n lnh, kh th, au lng, au ngc xy ra ngay bt u
truyn. Khm bnh nhn st, nhp tim nhanh, tt HA, thiu niu hoc v
niu.
X tr:
- Ngng ngay truyn mu.
- Kim tra cc ch phm mu v thng tin bnh nhn
- Bo cho ngn hng mu.
- Xt nghim: nhm mu, khng th bt thng, Hb niu, ng mu ton b,
fibrinogen, D- Dimer, LDH, Bilirubin, haptoglobin.
- Truyn dch duy tri nc tiu > 1ml/kg/gi, c th dng li tiu
Furosemide v/hoc Manitol.
Tn huyt mun:
Thng xy ra t 2-14 ngy sau truyn mu do bnh nhn c khng th khng
vi khng nguyn ca hng cu ngi cho cc nhm mu ph. Bnh nhn
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thng c du hiu gim Hb m khng gii thch c, c bng chng tn
huyt va Coombs trc tip (+).
iu tr nng hu ht bnh nhn hi phc.
St khng tn huyt:
T l 1% thng gp bnh nhn truyn mu nhiu ln hoc ph n mang thai
nhiu ln. St xy ra trong hoc sau truyn mu. Do c khng th khng vi
bch cu hoc do cc cytokin c trong thnh phn mu c truyn.
- iu tr: Paracetamol 500mg (ung) 1 vin/4 gi.
- Phng nga: Truyn hng cu lng HCL c km b lc bch cu.
2. Tn thng phi do truyn mu (TRALI: Transfusion Related Acute Lung
Injury):
- Lm sng l hi chng suy h hp cp: kh th, tt HA, st, XQ c hnh nh
thm nhim 2 phi trong 1-8 gi sau truyn mu m khng c bng chng
suy tim hay qu ti.
- iu tr ch yu khoa sn sc c bit ICU.
3. st:
- Mt n v HCL 200ml cha 200- 250mg st ( 1ml mu c 1mg st). Do
truyn mu lu di gy st trong cc i thc bo ca h vng ni m gy
st gan, tim, cc tuyn ni tit dn n suy a c quan.
- iu tr thi st:
+ Desferal 0,5g 5 ng+ 10ml nc ct tim di da lin tc trong 8
gi/ngy x 5 ngy (dng my thi st) sau chuyn sang ng ung.
+ Deferiprone (Kelfer, Depron) liu 75mg/Kg/ngy cho n khi Ferritin tr
v binh thng.
+ Deferasirox (Exjade) 20mg/kg/ngy ung.
4. Bnh mnh ghp chng ch (GVHD: Transfusion Associated greft versus
host disease).
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- Cc lymphocyte ca ngi cho hot ng chng li cc t chc ca ngi
nhn.
- Lm sng: ni mn da, st, gim 3 dng t bo mu v hi chng d dy-
rut xut hin sau truyn 4-10 ngy.
- Tin lng hu ht t vong.
- Phng nga: chiu x cc ch phm mu bt hot cc lymphocyte ca
ngi cho.
5. Tai bin do truyn mu vi khi lng ln:
- Qu ti tun hon (c bit bnh nhn suy tim, suy thn)
- H thn nhit.
- Ri lon ng mu.
- Nhim c citrate + kim chuyn ha.
- H canxi mu.
- Tng kali mu.
- Ban xut huyt sau truyn mu thng xy ra sau truyn mu 7-10 ngy.
6. Cc tai bin khc:
- Nhim siu vi: HIV, HBV, HCV, giang mai, st rt, CMV, Parvovirus
B19
- Nhim trng: st, n lnh, tt huyt p trong hoc ngay sau truyn mu.
II. CC BIN CHNG DO TRUYN TIU CU:
1. Sc nhim trng: Cc ch phm tiu cu d c nguy c nhim trng hn
hng cu v bo qun nhit phng, cc vi trng thng gp:
Staphylococcus aureus, Klebsiella pneumonia, Serratia marcescens v
Staphylococcus epidermidis.
- Hin cha c phng php no xc nh cc ch phm b nhim trng.
- Cn lu cc bnh nhn b st sau truyn tiu cu 6 gi.
2. Khng tng s lng tiu cu:
- S lng tiu cu tng t hn d on hay gim.
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- C ch: do ngi nhn c d khng th khng HLA
- nh gi hiu qu truyn tiu cu ngi ta kho st SLTC trc v sau
truyn tiu cu 10- 60 pht. S gia tng s lng tiu cu (CCI)< 5000
truyn tiu cu khng hiu qu.
CCI = ( SLTC sau truyn SLTC trc truyn) x din tch c th / SLTC c
truyn.
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SUY GIP
I. I CNG
- Suy gip mt tnh trng bnh l gy ra do bt k bt thng no v cu trc
v chc nng c th dn n s tng hp khng hormon gip trng.
- y l mt bnh l thng gp, c bit l ph n vi t l mc vo
khong 20% (so vi 0,1% nam).
II. NGUYN NHN
a) Nguyn pht: Chim 95% trng hp.
- Vim gip Hashimoto: l bnh l t min, ch yu gp n, tng theo tui.
- Do iu tr:
+ Phu thut tuyn gip.
+ iu tr iod ng v phng x.
+ Dng thuc khng gip tng hp qu liu.
- Vim tuyn gip bn cp.
- Thiu men tng hp hormon gip bm sinh.
b) Th pht:
- U tuyn yn.
- Phu thut tuyn yn.
- Hi chng Sheehan (hoi t tuyn yn do mt mu sau ).
- Ri lon chc nng
+ Nguyn nhn khc: Do khng ngoi vi vi tc dng hormon gip c bt
thng th th i vi T4 t no.
III. CHN ON
A. Lm sng:
1/ TC da nim: Mt trn nh mt trng, mi mt ph, nht l mi di, biu l
cm xc, da kh, ging khn, tc d rng.
2/ Triu chng gim chuyn ha: S lnh, thn nhit gim, tng cn d n
ung km, to bn, gim tr nh.
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3/ Triu chng tim mch: Nhp tim chm < 60l/p, huyt p thp, c th trn
dch mng tim, tim p yu, ting tim nghe m, nh.
4/ Triu chng ni tit:
- Bu c to hay khng to.
- Ri lon kinh nguyt.
B. Cn lm sng:
- TSH tng hoc binh thng, FT4, FT3 gim.
- CTM: Thiu mu, hng cu binh thng hoc to.
- in gii .
- Cholesterol, Triglyerid tng.
- Siu m tuyn gip.
- Siu m tim, ECG.
- FNA (Fine needle Aspiration).
IV. IU TR:
- Nu trng hp suy gip do dng thuc khng gip th phc hi sau khi
ngng thuc.
- iu tr bng hormon thay th sut i.
Cc thuc hin nay:
Levothyrox: 50g, 100g.
Berlthyrox: 100g.
Liu dng:
+ Ngi trng thnh, khe mnh khng bnh l mch vnh 75 100mg/ngy.
+ Bnh nhn >60 tui v c bnh mch vnh: 12,5mg/ngy, tng liu t t
12,5mg/mi 2 3 tun.
V. V. THEO DI:
- nh lng (TSH, FT4, FT3): 3 6 tun cho n khi tr v binh thng.
- Nhp tim.
- Cn nng.
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- Lipid mu
Ti liu tham kho:
1/ Ni tit hc i cng 2007.
2/ Ni tit hc trong thc hnh lm sng 2012.
3/ Phc iu tr Bch Mai, 115, Ch Ry.
4/ Chn an v iu tr y hc hin i 2008.
5/ The Washington manual 2012
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BNH BASEDOW
I. I CNG:
Bnh Basedow cn c tn gi khc bnh Graves, bnh bu gip li mt:
- L nguyn nhn gy cng gip hay gp.
- L mt bnh t min ,c tnh gia inh.
- Bnh thng gp n, tui 20-50, n: nam= 7 : 1.
- Bnh thng biu hin:
+ Hi chng cng gip.
+ Bu gip lan ta.
+ Ph nim trc xng chy.
+ Li mt.
II. CHN ON:
A. Lm sng:
1/ Hi chng cng gip:
a/ Ri lon iu ha thn nhit: s nng, thch thi tit lnh, tm nhiu ln,
tng tit m hi.
b/ Biu hin tim mch: Hi hp, nh trng ngc, nhp tim nhanh, ting tim
mnh, m thi tim thu lin sn 2-3 b tri xng c, huyt p tm thu cao.
c/ Biu hin thn kinh: bn chn, lo lng, d xc ng, ni nhiu, kh ng,
run u ngn tay, tn s cao, u, bin nh.
d/ Biu hin c: yu c, teo c, du gh u (+) (c t u i), lit chu k
do h kali mu.
e/ Biu hin tiu ha: tng nhu ng rut, tiu chy.
f/ Thay i cn nng: n nhiu, st cn nhanh.
Cc triu chng khc: Sm da, rng tc, kht nhiu, ung nhiu, tiu nhiu.
2/ Li mt: Li mt mt bn hay 2 bn, chy nc mt, chi mt, cm gic
cm, co c mi trn (du Dalrymple, lidlag, von Graefe).
Tn thng phn mm quanh hc mt.
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Tn thng c vn nhn
Tn thng thn kinh th gic
3/ Phu nim trc xng chy:
- Thng i xng 2 bn, vng cng chn i khi lan xung mu chn.
- Ph cng
- Tn thng mu vng nu hoc tm.
4/ Bu gip: Bu gip lan ta, bu c tnh cht ca bu mch, s c run
miu, nghe c m thi.
II. CN LM SNG:
- TSH gim, FT4, FT3 tng.
- Cholesterol, Triglyceride mu gim.
- Cng thc mu: a hng cu gi, thiu mu thiu sc.
- Ion : c th h Kali mu.
- S tuyn gip: TG to, lan ta, tng lu lng mu n m TG.
- X hnh tuyn gip (I131, I123, T99m).
III. CHN ON NGUYN NHN KHC GY CNG GIP:
1/ Bu (n hoc a) nhn c gip:
- Hi chng cng gip.
- Khng li mt.
- X hnh c nhng vng tng bt x xen ln gim bt x.
- Siu m tuyn gip: c nhiu nhn
2/ Cng giap do iu tr:
- Do dng qu liu Hormon gip hay qu ti iod.
- Khng biu hin mt.
- tp trung Iod phng x tuyn gip thp.
- Iod mu, niu tng.
3/ Cng gip do vim tuyn gip:
- St, au nhiu ti tuyn gip.
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- Hi chng cng gip thong qua, khi trong vi tun, vi thng (< 2 thng).
- Cn lm sng: tc mu lng (VS) tng, CRP tng, TSH gim.
4/ Cng gip do u tuyn yn: rt him gp.
5/ Nguyn nhn khc:
- Thai trng.
- Ung th gip.
IV. IU TR BASEDOW:
1/ iu tr ni khoa:
a/ Thuc c ch : Nhm gim triu chng ca cng gip nh nhp nhanh,
m hi,hi hp.
Propranolol: 40 120mg/ngy ung 3 4 ln/ngy.
Atenolol 50mg: 25-50mg/ngy.
Chng ch nh: Hen ph qun, suy tim, bloc nh tht.
b/ Thuc khng gip tng hp:
- iu tr tn cng 6-8 tun, duy tr 18-24 thng.
- C 2 nhm thuc.
+ Thiamazone (Carbimazol, Thyrozol): 5mg, 10mg.
Liu tn cng: 15-30mg/ngy, ung 1 2 ln/ngy, ung sau n.
Chnh liu khi bnh nhn v bnh gip.
Liu duy tr: 5-10mg/ngy.
+ PTU (Propythiouracil): 50mg.
Liu tn cng: 200-400mg/ngy, ung 2-3 ln/ngy, ung sau n.
Chnh liu khi bnh nhn v bnh gip.
Liu duy tr: 50-100mg/ngy.
Tc dng ph:
D ng, au c, au khp, gim bch cu ht, vim gan, vng da, tc rut.
c/ Corticoidl:
- Ngn chn tit hormon tuyn gip.
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- c ch chuyn T4 T3 ngoi vi.
Ch nh: Trong cc trng hp cng gip nng, cn bo gip, sa son tin
phu: Dexamethason 2mg ung hoc tim mch mi 6 gi.
d/ iod v c:
- Iod liu cao nh hng qa trnh chuyn ha ca Iod hu c trong TG.
- Iod v c ngn cn chnh n vo tuyn gip.
- Iod liu cao c ch s phng thch hormon ra khi tuyn gip.
Cc dng thuc: dung dch glugol 1%, 5%, SSKI.
Liu dng:
Lugol 1%: 20-60 git chia ung 3 ln/ngy.
Lugol 5%: 9-15 git chia ung 3 ln/ngy.
SSKI: 2-4 git chia ung 2 ln/ngy.
Ch nh: cng gip nng, cn bo gip, sa son tin phu, d ng thuc
khng gip tng hp.
e/ An thn, ngh ngi.
2/ iu tr ngoi khoa:
Ch nh:
- Nghi ng ung th tuyn gip.
- BN t chi iu tr phng x.
- Ph n c thai khng dung np khng gip tng hp.
Bao gi cung iu tr ni khoa trc m, gim nguy c cng gip.
3/ iu tr Iod131:
Ch nh: Bnh nhn ln tui, suy tim, tng trng gy, ti pht sau iu tr ni
khoa hoc ngoi khoa.
Chng ch nh: Ph n c thai, cho con b.
4/ iu tr Basedow trn ph n c thai:
Thuc u tin c chn.
PTU: 50g.
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Liu s dng: 150g/ngy dng 3 4 tun.
Duy tr nng T4 trn mc binh thng, sau gim liu 50g/ngy v
ngng hn qu 3 thai k.
Ti liu tham kho:
1/ Ni tit hc i cng 2007.
2/ Phc iu tr BV 115.
3/ Ni tit hc trong thc hnh lm sng 2012.
4/ Chn on v iu tr Y hc hin i 2008.
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HN M H NG HUYT
I. i Cng:
HH l mt ri lon sinh ha m chng ta cn xc nh ro cn nguyn.
Thng thng khi mc ng huyt gim di 70mg% ngi ta coi l c h
ng huyt, nhng triu chng thng xy ra khi ng huyt di 45-
50mg%
II. Chn oan:
Hi chng HH khng nh khi c tam chng Wipple
1. Cc hi chng ca HH
Thn kinh t ng Thn kinh trung ng
- Trng ngc
- Run
- m hi
- Tim p nhanh
- Lo lng
- Cm thy i cn co
- Co git
- Ln ln
- Mt thc
- Hn m
+ Nng huyt tng thp (45-50mg%)
+ Triu chng ht khi ung hoc chch ng a glucose huyt v
mc binh thng
III. Nguyn Nhn:
A. HH khi i:
HH do thuc: Bnh nhn T ang dng sulfonylurea hoc insulin qu
liu Ngai ra cn c thuc gy HH nh: Aspirin,CMC,
quinin,Propranolol,quinolon.
HH do ru: Nghin ru lu ngy s lm gim d tr NAD gan ,cht
ny cn thit cho s tn sinh ng->d b HH khi i
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Bu t bo ty: l mt bnh him c th cha c, tui trung bnh 47,n
nhiu hn nam,thng xy ra sng sm,tra sau khi nhn i,hat ng nhiu.
Bnh l gan mt: HH ch gp bnh nhn b gan giai on cui, bnh nhn
c y triu chng ca suy gan.
Mt s nguyn nhn khc:
T khng th khng insulin
B. HH sau n:
Cn gi l HH chc nng:xy ra trn bnh nhn phu thut d dy,do
thc n xung rut nhanh->Glucose huyt tng->tng insulin->chang
vng,chng mt, m hi
IV. iu Tr:
+ Nu bnh nhn cn tinh c triu chng giao cm nh nh: m hi, chn
tay lnh, i .Cho ung nc ng, 01 ly sa, n mt ming bnh
+ Nu bnh nhn bnh nng hn: l m,co git ,hn m.
iu tr :Tim thng tinh mch(bolus) 40ml glucose 30%-50%
Sau duy tri glucose 5%,10%
Glucagon(ng 1mg): Tim TM,TB,TDD 1-2mg c th lp li 10-20
pht. Khng s dng glucagon i tng nghin ru
Hydrocortison (100mg/l): liu 100mg/4gi trong 12gi u khi nghi ng
c ph no
Ti liu tham kho:
2) Phc iu tr BVBK trung tm An Giang
3) Ni tit hc trong thc hnh lm sng 2012
5) Khuyn co v i tho ng 2009
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NHIM TRNG TIU
I. NH NGHA
Nhim trng tiu l hu qu hoc xm nhp ca cc vi sinh vt vo nc tiu
v m ca bt c thnh phn no thuc h thng tit niu.
II. CHN ON
1. TRIU CHNG LM SNG
- Hi chng nhim trng.
- Cc ri lon i tiu: tiu gt, tiu but, tiu gp, tiu lt nht.
- Thay i tnh cht nc tiu: tiu c, tiu mu.
- au hng lng, au hoc nng vng h v, au vng hi m.
2. CN LM SNG
- Cng thc mu, urea, creatinine, CRP, cy mu.
- Tng phn tch nc tiu ( dipstick ):
Leucocyte Esterase (+)
Nitrite test (nitrate reductase/vi khun) (+)
- Hnh nh hc: Siu m, chp X quang h niu (KUB, UIV).
- Cy nc tiu: 105 khm/ml ch mt loi vi khun.
CHN ON: 2 trong 3 du hiu sau
+ Lm sng.
+ TPTNT: Leucocyte Esterase (+), Nitrite test (nitrate reductase/vi
khun) (+).
+ Cy nc tiu: 105 khm/ml ch mt loi vi khun.
3. NGUYN NHN: Cc yu t thun li:
- ang thng tiu lu hoc thng tiu ngt qung.
- Th tch tn ng > 100ml trong bng quang sau khi tiu.
- Tc nghn c bng quang do si hoc do nguyn nhn khc.
- Tt tro ngc bng quang niu qun hoc sau phu thut.
- Suy thn ti thn.
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- Sau ghp thn.
- i tho ng.
- Suy gim min dch.
- Nhim trng tiu do cc vi khun t gp hoc khng thuc.
Vi khun gy nhim trng tiu: 75% - 90% do Escherichia coli,
5% - 15% do Staphylococcus saprophyticus, phn cn li l Enterococci,
Klebsiella, Proteus mirabilis.
III. IU TR: theo tng nguyn nhn
1. Vim bng quang cp:
- Yu t chn on: tiu gt, lt nht, st (+)
- Nn cy nc tiu trc khi iu tr.
- Khng sinh ban u: nhm Quinolone, Cephalosporin ( II, III).
+ Augmentin 625mg/vin 1 vin x 3 ung/ngy
1g/l x 2 (TB, hoc TM)/ngy.
+ Ciprofloxacin: 500mg/vin 1 vin x 2 ung/ngy
200mg/chai (100ml): 1 chai x 2 truyn tinh mch/ngy.
+ Levofloxacin: 500mg/vin 1 vin ung/ngy
500mg/chai (100ml) truyn tinh mch/ngy.
+ Cefuroxim: 500mg/vin 1 vin x 2 ung/ngy
750mg/l x 3 (TB hoc TM)/ngy.
+ Ceftriaxon 1gr/l 1 l x 2(TB hoc TM)/ngy.
+ Cefoperazone 1gr/l 1 l x 2(TB hoc TM)/ngy.
+ Ceftazidim 1gr/l 1 l x 2(TB hoc TM)/ngy.
- Thi gian iu tr: 5 7 ngy.
- Nu khng p ng iu tr theo khng sinh .
2. Vim i b thn cp:
- Yu t chn on: st, n lnh, au hng lng, ri lon i tiu ().
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- Nn cy nc tiu trc khi iu tr.
- Cy mu khi c 2/4 tiu chun p ng vim ton thn, hoc HA tm thu
< 90mmHg hoc gim > 40mmHg.
- Khng sinh ban u: nhm Quinolone, Cephalosporin (II,III)
+ Ciprofloxacin: 500mg/vin 1 vin x 2 ung/ngy
200mg/chai (100ml): 1 chai x 2 truyn TM/ngy.
+ Levofloxacin: 500mg/vin 1 vin ung/ngy
500mg/chai (100ml) truyn tinh mch/ngy.
+ Cefuroxim: 500mg/vin 1 vin x 2 ung/ngy
750mg/l x 3 (TB hoc TM)/ngy.
+ Ceftriaxon (1gr/l): 1 l x 2(TB hoc TM)/ngy.
+ Cefoperazone (1gr/l): 1 l x 2(TB hoc TM)/ngy.
+ Ceftazidim (1gr/l): 1 l x 2(TB hoc TM)/ngy.
- Thi gian iu tr: 10 - 14 ngy.
- Nu khng p ng iu tr theo khng sinh .
3. Nhim trng tiu/thai k:
- Nn cy nc tiu trc iu tr
- Khng sinh ban u: Cephalosporin (II,III)
+ Cefuroxim: (500mg/vin): 1 vin x 2 ung/ngy
750mg/l x 3 (TB hoc TM)/ngy.
+ Ceftriaxon (1gr/l): 1 l x 2(TB hoc TM)/ngy.
+ Cefoperazone (1gr/l): 1 l x 2(TB hoc TM)/ngy.
+ Ceftazidim (1gr/l 1): l x 2(TB hoc TM)/ngy.
- Thi gian iu tr: Vim i b thn cp 10-14 ngy. Vim bang quang
cp 7-10 ngy.
- Nu khng p ng iu tr theo khng sinh .
4. Nhim trng tiu/ ai thao ng:
- Lun phi cy nc tiu trc v sau iu tr.
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- Khng sinh ban u: Fluoroquinolone, Cephalosporin (II,III). Nu bnh
nhn c biu hin nhim trng nng phi cy mu v kt hp khng sinh
dit c Pseudomonas: Imipenem, Ticarcillin/a.Clavulanic.
+ Imipenem (1gr/l) 1 l x 2(TB hoc TM)/ngy, ti a 4g/ngy.
+ Ticarcillin/a.Clavulanic 200mg (Timentin) 1,6 3,2gr mi 6-8 gi.
5. Vim tin lit tuyn cp:
- Yu t chn on: st, n lnh, tiu gt, lt nht, au di tht lng v
hi m, thm trc trng tin lit tuyn rt to v au.
- Nn cy nc tiu trc v sau iu tr.
- Khng nn xoa nn tin lit tuyn xt nghim.
- B nc, in gii, gim au.
- Thuc:
+ Ciprofloxacin: 500mg/vin 1 vin x 2 ung/ngy
200mg/chai(100ml): 1 chai x 2 truyn TM/ngy.
+ Levofloxacin: 500mg/vin 1 vin ung/ngy
500mg/chai (100ml) truyn TM/ngy.
- Thi gian iu tr 4 tun. Nu khng p ng iu tr theo khng sinh
.
1. Nguyn tc iu tr
- Chn la khng sinh da trn: tnh nhy cm ca vi trng, sc khng
ca bnh nhn, khng sinh thi c qua thn, t c nht, r tin.
- Hu ht khng sinh tp trung cao trong m thn nhng ch c
Tetracycline, Trimethoprim-Sulfamethoxazone, Fluoroquinolone n
c tin lit tuyn.
2. Cac phac : Khng sinh theo kinh nghim s dng trong iu tr nhim
trng tiu.
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Bnh iu tr theo kinh nghim Ghi ch
Vim bng
quang
TMP-SMX
Nitr0mg bid
Cprofloxacin 250mg bid
Norfloxacine 400mg bid
Chn khng sinh
da vo s nhy
cm ti ch
Trnh dng TMP-
SMX ngi ln
tui
C thai Nitrifurantoin 100mg bid
Cephalexin 250-500mg qid
Cefuroximeacetil 250mg qid
iu tr tt c NTT
khng triu chng
thai k
NTT c bin
chng
Nh-trung bnh: FQ th h 2
Nng: Cefepime 2g IV q12h hoc
Cephalosporin th h 3 hoc
Carbapenem th h 3 hoc Carbapenem
hoc Piperacilline-tazobactam
C th thm Vancomycon nu nhum
Gram c cu trng Gram
iu tr 10-14 ngy
Nm ng
niu
Candida albicans: fluconazole
100-200mg PO qdx5d
Bnh nng hoc nm khc:
AmphotericinB x 5d
Rt catheter
Vim i b
thn
Ngoi tr: FQ th h 2
Nhp vin: FQ th h 2 hoc
Aminoglycoside hoc
Ampicillin-sulbactam 1-2gIV q6
gi hoc cephalosporin 1g IV q8gi
hoc Ceftriaxone 1g IV q24gi
hoc Piperacillin 4g IV q8gi
iu tr n khi ht
st 48 gi chuyn
qua ung 14
ngy Khng dng
FQ cho ph n c
thai
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SUY THN MN
I. NH NGHA :
Suy thn mn l mt hi chng lm sng v sinh ha tin trin qua nhiu nm,
nhiu thng, hu qu dn n x ha cc nephron v gim dn cc chc nng ca
thn nh : o thi cc sn phm chuyn ha, thng bng kim toan, duy tr cn
bng nc in gii v chc nng ni tit.
II. CHN ON :
1. Lm sng :
Ph ti i ti li nhiu ln, thiu niu hoc v niu.
Hi chng thiu mu
Tng huyt p
Xut huyt di da
Tin cn : bnh l thn, si tit niu
2. Cn lm sng :
Xt nghim mu : ure, creatinine, ion , TPTNT : tr HC, BC, m niu.
Siu m bng : pht hin thn teo nh, si ng tit niu
Chp KUB : pht hin si ng tit niu.
Chp UIV : rt nguy him, ch c nghia khi nghi ng si ng tit niu.
3. Nguyn nhn:
i tho ng, tng huyt p, vim cu thn, bnh thn do nhim trng hoc tc
nghn
III. PHN SUY THN MN :
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* phn theo khuyn co ca K/D.
IV. IU TR :
1. iu tr nguyn nhn : gii quyt nguyn nhn suy thn mn nu c th
2. Ch n ung :
- Ch n king mui ch p dng khi c ph, tng huyt p, suy tim
(NaCL 2 4g/24h).
- Cn bng nc : ty thuc tnh trng kht, hn ch nc khi
Na+/mu gim: Nc nhp = lng nc tiu /24h + 500ml
- B sung kim: cn gi kim = 20 24 mmol/l
- Ch n m : P = 0,4 - 0,8g/kg/ngy
(Chy TNT = 0,8 1,2g/kg/ngy)
Tng nng lng 35 40 Kcalo/ngy
- Hn ch thc n c cha phosphat : sa, phomat
- B sung canxi
3. iu tr ri lon in gii :
a) Tng kali mu : K+> 5.5mmol/l
+ Hn ch a kali vo qua thc n v cc thuc c cha kali.
Biu hin lm sng : yu, lit c, nhp tim chm, lon nhp tim hoc ngng
tim.
- ECG : T cao, nhn, i xng, c th phi hp PR ko di, QRS dn rng,
ST chnh ln hoc chnh xung.
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+ Bicarbonat truyn TM : 1.4%, 4.2%, 8.4%.
b) K+ > 6.5mmol/l ch nh lc mu cp cu
4. iu tr toan mu : Bicarbonate, gi HCO3- = 18 24 mmol/l
5. Tng huyt p :
Mc tiu :
+ HA < 130/80 mmHg
+ Nguy c cao HA < 125/75 mmHg
( m niu > 1g/24h hoc i tho ng )
Thuc h p : Thuc li tiu (Furosemide); c ch men chuyn;
c ch th th Angiotensin II; c ch (Daxazocine);
c ch TKTW (Aldomet); c ch (Bisoprolol(Cocor), Atenolol); c
ch canxi (Nifedipine, amlodipin,Adalate LA).
6. iu tr ri lon lipid mu :
Khuyn co h Cholesterol Total < 5.0 mmol/l
Nhm thuc an ton Statin : Gemifroril, statine
7. iu tr thiu mu :
- Nguyn nhn thiu mu : mt mu, thiu Erythropoietine, gim i sng
hng cu, thiu st.
- Xut hin thiu mu khi GFR < 30ml/pht, i vi i tho ng GFR <
45ml/pht.
- Mc tiu iu tr :
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+ B st (Ferritin > 200ng/ml)
+ Hb : 10 12g/dl
+ Thuc Erythropoietine : 50 150 UI/kg tim di da hoc tinh mch chm
2 3 ln/tun
8. Long xng :
Xut hin khi GFR < 30 40ml/pht.
- Hn ch thc n c phosphat
- S dng Rocalt