THUYEN TAC PHOI(PULMONARY EMBOLISM ; VENOUS THROMBOEMBOLISM; ACUTE PULMONARY THROMBOEMBOLISM Hoa Ky : 500000- 600000/ nam 150000- 200000/ nam Tan suat t vong : 1/1000 dan- Tang gap 2 moi 10 tuoi

PGS- TS PHAM NGUYEN VINHVIEN TIM TP. HCM

SINH LY BENHVirchow (1856): - Ton thng khu tru thanh mach - Tnh trang tang ong - tre tuan hoanTnh trang tang ong (td: Protein S, Protein C, Anti Thrombin III)Cac tnh trang mac phai co the lam nang huyet khoi TMHau qua sinh ly benh cua thuyen tac phoi THUYEN TAC PHOI

CAC TNH TRANG TANG ONG PHOI HP VI HUYET KHOI TNH MACHTnh trang tang ong Nghien cu Nhan xet

Bien chung di the yeu to VBertina Ridker Thay the Arginine 506 cua yeu to V bang Glutamine ; dan en yeu to V khang c s bat hoat cua Protein C hoat hoa (yeu to V Leiden)Khang vi Protein C hoat hoa ZollerBoi canh phan t a dang oi vi s oi khang Protein C hoat hoaBien chung di the Protein C Allaart Phoi hp vi s khiem khuyet Protein C Khiem khuyet Protein S Gladson Protein S la ong yeu to cua Protein C

TL: Heart Disease, WB Saunders Co 6th 2001, p.1886

THUYEN TAC PHOI

CAC TNH TRANG TANG ONG PHOI HP VI HUYET KHOI TNH MACHTnh trang tang ong Nghien cu Nhan xet

Khiem khuyet Antithrombin III HirshDi truyen troi tren nhiem sac the thng (autosome)Khiem khuyet Plasminogen Hach-WunderleChc nang Plasminogen hien dien van bnh thngKhang the khang Phospholipid Hughes Bao gom khang the anticardiolipin va chat khang ong Lupus.Gia tang nong o yeu to VIII KosterNguy c huyet khoi TM tang gap 5 lan. Nguy c cao hn benh nhan co them yeu to V > 1500 n v/l

TL: Heart Disease, WB Saunders Co, 6th 2001, p.1886THUYEN TAC PHOI

TAN SUAT VE S KHIEM KHUYET CAC PROTEIN ONG MAU CO IEN, XAY RA BENH NHAN CO HUYET KHOI TNH MACHBat thngGladsonHeijboerMalm(N = 141) (%) (N = 277) (%)(N = 439) (%)

Protein C 4 3 2Protein S 5 2 2 Antithrombin 3 1 1 Plasminogen 2 1 0,5THUYEN TAC PHOI

CAC TNH TRANG MAC PHAI CO THE LAM NANG HUYET KHOI TM + Phau thuat/Bat ong/Chan thng + Beo ph + Tuoi cao + Thuoc vien nga thai/Thai ky/ Hau san + Ung th (oi khi la adenocarcinoma tiem an) va hoa tr ung th + TBMMN/Ton thng tuy song + Catheter trung tam at lau

THUYEN TAC PHOI

SINH LY BENH CUA ROI LOAN CHC NANG THAT PHAI/THUYEN TAC PHOIThuyen tac phoiNghen c hocYeu to than kinh the dch ap lc MP hau tai TP sc cang thanh mach nhu cau O2 TPDan/roi loan chc nang TPThieu mau cuc bo TP Cung lng TP vach lien that phong ve TT cung cap O2 TP tien tai TT Cung lng TT ti mau he thong ti mau he thongHa HA ti mau MVTHUYEN TAC PHOITL :Heart Disease, WB Saunders Co 5th, 1997 MP : ong mach phoi TP : That phaiTT : That trai

BIEU HIEN LAM SANGTan suat trieu chng c nang va thc the cua 327 benh nhan TTPTC/CNTan suat (%) TC/TT Tan suat (%)- au ngc 88- Ho hap > 16 lan/phut92 Kieu mang phoi 74 Khong kieu mang phoi 14- Kho th 84- Ran58- Lo s59- T2 (P2)53- Ho53- Mach > 100/ph44- Khai huyet30- Sot > 37o8 C43- Mo hoi27- Viem tnh mach32- Ngat13- Tieng nga phi34- Phu24- Am thoi23- Tm tai19TL: Am J Med 62: 355-360, 1977THUYEN TAC PHOI

BIEU HIEN LAM SANGTan suat trieu chng cua 117 benh nhan TTP troc o khong co benh tim phoi TC/CNTan suat % TC/TTTan suat (%)- Kho th73- Th nhanh (>20 lan/phut) 70- au ngc 66- Ran51kieu mang phoi- Ho37- Tim nhanh (>100/ph)30- Phu cang chan28- T424- au cang chan26- T2 (P2)23- Khai huyet13- Bieu hien lam sang cua11huyet khoi TM sau- Hoi hop10- Toat mo hoi11- Th rt9- Sot > 38o5 C7- au giong cn 4- Dau Homans4 au that ngc- Dau nang that phai4- T3 3- Tieng co mang phoi3- Tm tai1TL: Chest 100: 598, 1991

THUYEN TAC PHOI

TRIEU CHNG C NANG VA THC THE 2454 BENH NHANTHUYEN TAC PHOI TRONG N/C ICOPER (INTERNATIONAL COOPERATIVE PULMONARY EMBOLISM REGISTRY)Trieu chng %Kho th82Th nhanh > 20/ph60Tim nhanh > 100/ph40au ngc49Ho20Ngat14Khai huyet7

TL: Lancet 353 : 1386,1999THUYEN TAC PHOI

BIEU HIEN LAM SANGSau hoi chng cua Thuyen tac phoi cap (1)Hoi chng Bieu hien Roi loan ieu tr chc nang TPO atKho th, ngat, tm,co Heparin va thuoc ha HA keo dai ; nghen tan cuc mau hoac > 50% M phoi can thiep c hocVa en nhieu HA bnh thng ; > 30% co- nt- ton thng xa ky phoi

t en vaHA bnh thngkhongHeparin

Nhoi mau phoi au ngc kieu mang phoi; hiem Heparin va khang khai huyet ; tieng co mang viem khong Steroid phoi ; hnh anh ac phoi ; thuyen tac ngoai vi

TL: Atlas of Heart Disease ; Current Medicine 1995. Vol III, p 7.1- 7.112

THUYEN TAC PHOI

BIEU HIEN LAM SANG Sau hoi chng cua Thuyen tac phoi cap (2)Hoi chng Bieu hien Roi loan ieu tr chc nang TP

Thuyen tacThuyen tac he thong hiemthay oingc dong ot ngot (TD : TBMMN)

Thuyen tacThng gap nhat : kh, m, hiemnang khong do manh bu, nc oihuyet khoi

TL: Atlas of Heart Disease ; Current Medicine 1995. Vol III, p 7.1- 7.12 THUYEN TAC PHOI

CHAN OANLam sang: khong ac hieu

CLS: - ECG - Sieu am mach mau, sieu am tim - Xa ky phoi - nh lng D- dimer trong huyet tng - CT xoan oc - anh cong hng t - chup mach mau phoi (tieu chuan vang)THUYEN TAC PHOI

CHAN OANTieu si huyet noi sinh va s phong thch D-dimerHoat hoa(chat thoai bien cua Fibrinogen)(Tieu si huyet)(noi cheo chat thoai bien cua Fibrinogen co cha D-dimer)THUYEN TAC PHOITL: N. Engl J Med 1998; 339: 93-104

CHAN OANBIEU HIEN T CUA THUYEN TAC PHOIBloc nhanh phai hoan toan hay khong hoan toanS DI va aVL > 1,5 mmVung chuyen tiep lech ve V5Qs DIII va aVF, nhng khong co DIITruc QRS > 90o hoac truc khong xac nhien the thap chuyen ao chiSong T ao DIII va aVF hoac V1-V4

TL: Am J Cardiol 73: 298,1994

THUYEN TAC PHOI

CHAN OANBieu hien tren Xquang ngc cua Thuyen tac phoiDau hieuTan suat %Bnh thng15 - 30Bat thng - C hoanh nho cao mot ben25 26 - Bong m Nhoi mau10 Xuat huyet50 - Tran dch mang phoi40 50 - Dan MP15 20 - Xep phoi20 - Giam ti mau phoi khu tru15 50TL: Mayo Clinic Practice of Cardiology Mosby 1996, p. 1837- 1851

THUYEN TAC PHOI

CHAN OAN : SIEU AM TNH MACH VA O KH MAU ONG MACHSieu am TM : tm huyet khoi TM sau (50%) (TM khong e bep c)

Kh mau M : khong giup chan oanTHUYEN TAC PHOI

CHAN OANDAU HIEU SIEU AM CUA THUYEN TAC PHOIThay trc tiep cuc mau ong (hiem)Dan that phai*Giam ong that phai (ngoai tr mom tim)Van ong bat thng vach lien thatH van 3 laDan MPMat dau hieu xep TMC vao ky ht vao

* Dan TP : ng knh TP cuoi tam trng > 30 mm hoac ty le ng knh TP/TT > 1 mat cat 4 buong

THUYEN TAC PHOI

CHAN OAN : CT XOAN OC VA ANH HNG CONG T o nhay cam va o ac hieu ca 2 : tng ngNghien cu(tham khao) So benh nhan o nhay cam o ac hieuHelical CT (CT xoan oc)Goodman (66)2080*92*63+89+Remy-Jardin (67)729086Van Rossum (70)1249798Sostman (64)287397Remy-Jardin (68)4210096Van Rossum (71)459597Electron-beam CTTeigen (75)606597Teigen (69)259580

TL: Textbook of Cardiovascular Medicine Lippincott Raven 1998, p.735THUYEN TAC PHOI

QUI TRNH CHAN OAN THUYEN TAC PHOI TAI BRIGHAM AND WOMENS HOSPITALXquang ngc/trac nghiem nhanh D-Dimer ELISAAm nghiemDngNgng- Xa ky phoi hoac- CT xoan oc ngcBnh thng/gan bnh thngTrung gianKha nang mac benh caongngSieu amieu trAm nghiemDng nghiemChup MPieu trTHUYEN TAC PHOITL : Heart Disease, WB Saunders Co 6th 2001, p.1896

QUI TRNH CHAN OAN THUYEN TAC PHOI TRONG IEU KIEN HIEN NAY VNBenh s - kham thc the - ECG- Xquang ngc- Sieu am tim+ D-dimer ELISA- Sieu am mach mauKhongnghi ng co (ch 1/4 TN)ngngieu trChup MPTHUYEN TAC PHOI

CAC BENH CAN PHAN BIET VI THUYEN TAC PHOIViem phoi hoac Viem phe quanSuyent nang cua benh phoi man tac nghenNhoi mau c timPhu phoiBoc tach ong mach chuChen timUng th phoiTang ap MP tien phatGay xung snTran kh mang phoiViem khp sun snTrang thai lo langau c xng ngcTHUYEN TAC PHOI

IEU TRieu tr bang khang ong (Heparin, Khang Vit K, Dextran)

Thuoc tan cuc mau

ieu tr phong nga bang mang loc TMC diTHUYEN TAC PHOI

IEU TRLng nh nguy cTTP nhe hay va ;chc nang TP bnh thngHuyet ap thap va/hoac giam ong that phaiCh dung khang ongKhang ongThuoc tan cuc mauCan thiep c hocLoc trong TMC diG bo cuc mau thuyen tac * Catheter * Phau thuatTTP : thuyen tac phoiTMC : Tnh mach chuTP : That phaiTHUYEN TAC PHOI

IEU TR BANG KHANG ONGBang ch dan cua Raschke giup s dung Heparin theo can nangS thay oi Lieu lng heparinLieu Heparin au tien 80 v/kg/bolus, sau o 18 v/kg/giaPTT < 35 giay (< 1,2 x chng) 80 v/kg/bolus sau o tang lieu TTM 4v/kg/giaPTT 35 45 giay (1,2 1,5 x chng) 40 v/kg/bolus, sau o tang lieu TTM 2 v/kg/giaPTT 46 70 giay (1,5 2,3x chng) khong thay oiaPTT 71 90 giay (2,3 3 x chng) giam TTM 2 v/kg/giaPTT > 90 giay (> 3x chng) ngng TTM 1 gi ; sau giam TTM 3 v/kg/gi

TL: Ann Intern Med 119: 874,1993THUYEN TAC PHOI

HNG DAN S DUNG THUOC KHANG ONG (1)Lieu bolus Heparin5000 v TM

Lieu duy tr au tien32 000v TTM/24 gi hoac 17 000 v Tdd moi 12 gi chnh lieu sau lieu au vao gi th 12

Chnh lieu heparin moi 6 gi theo bang ch dan. Duy tr aPTT mc ieu tr

Khi au s dung Warfarin 10 mg (hoac khang Vit K khac) vao gi 24 va 10 mg na vao ngay ke tiep

Thi gian trung lap gia Heparin va Warfarin t nhat la 4 ngay

THUYEN TAC PHOI

HNG DAN S DUNG THUOC KHANG ONG (2)Th thi gian Prothrombine (PT) moi ngay, chnh lieu Warfarin e gi INR khoang 2-3

S dung Heparin t nhat 5 ngay, ch ngng khi INR trong mc ieu tr t nhat 2 ngay lien tiep

Tiep tuc s dung Warfarin trong 3 thang, th PT moi ngay ti mc ieu tr, sau o 3 lan trong tuan le au tien, 2 lan moi tuan trong 2 tuan ke tiep ; khi lieu ieu tr a on nh, th moi 2 tuan

Trc ieu tr, o nong o hemoglobin, tieu cau, PT va aPTT. em tieu cau moi ngay cho ti khi ngng Heparin TL: Circulation 93: 2212-2245, 1996THUYEN TAC PHOI

HEPARIN TRONG LNG PHAN T THAP (LMWH)TRONG IEU TR HUYET KHOI TM SAU VA TTP1998 FDA ong y :

Benh lyKhang ongHuyet khoi TM- Enoxaparin 1mg/kg/12h/ sau khong kem TTP t nhat 5 ngay- Warfarin t ngay 1 (INR: 2-3)Huyet khoi TM sau- Cung lieu lng kem TTP Enoxaprin hoac Enoxaparin 1,5mg/kg/12h

THUYEN TAC PHOI

IEU TR KHANG ONG BANG DEXTRANDextran : ngan chan ket dnh HC, tieu cau va ket cum bach cauCh nh : benh nhan co nguy c xuat huyet giam tieu cau do HeparinLieu trac nghiem : 20ml Dextran 40 TTMLieu duy tr : Dextran 40, 20ml/gi/ 5 ngayUong kem khang Vit KTHUYEN TAC PHOI

IEU TR KHANG ONG BANG THUOC KHANG VIT KNgan chan hoat hoa yeu to II, VII, IX, X

Tac dung tang ong vao 3-5 ngay au ieu tr/ benh nhan ang trong tnh trang tao huyet khoi (Protein C va S )

Dung khang Vit K ngay ngay au Heparin hoac DextranTHUYEN TAC PHOI

CH NH AT MANG LOC TMC DI1. Benh nhan Thuyen tac phoi, nhng chong ch nh dung thuoc khang ong. a. ang xuat huyet (TD : XHTH) b. E ngai xuat huyet nang (TD : sau giai phau so) c. ang b bien chng cua thuoc khang ong (TD : giam tieu cau do Heparin) d. D tru hoa tr lieu tch cc ung th (co kha nang giam bach cau va tieu cau)2. That bai cua khang ong du a ieu tr u (TD : Thuyen tac phoi tai phat)3. Phong nga cho benh nhan nguy c cao a. Huyet khoi TM tien trien hoac lan rong b. Phoi hp vi g bo cuc mau ong thuyen tac bang catheter hay bang phau thuat c. Tang ap MP nang hay tam phe

THUYEN TAC PHOI

MANG LOC KIEU TO CHIM CUA BIRD (BIRD/S NEST FILTER)TL : Goldhaber SZ, Atlas of Heart Disease Philadelphia, Current Medicine 1995, Vol III, p. 12.1 - 12.14THUYEN TAC PHOI

CH NH THUOC TAN CUC MAU TRONG IEU TR THUYEN TAC PHOIHa HA do Thuyen tac phoiGiam oxy mau nangKhiem khuyet ti mau > 1 thuy phoiRoi loan chc nang that phai do Thuyen tac phoiHuyet khoi TM sau lan rong

TL: Textbook of Cardiovascular Medicine Lippincott- Raven 1998, p.727-744THUYEN TAC PHOI

LIEU LNG THUOC TAN CUC MAU S DUNG TRONG IEU TR THUYEN TAC PHOI CAPStreptokinaseLieu tan cong 250.000 v/TTM 30 phut ; sau o 100.000 v/gi/24 gi*Urokinase2000 v/lb TM (lieu tan cong trong 10 phut). Sau o 2000 /lb/gi t 12-24 gitPA (Alteplase Actilyse )- 100 mg TM/2gi

TL: Textbook of Cardiovascular Medicine Lippincott- Raven 1998, p.727-744

THUYEN TAC PHOI

CHONG CH NH S DUNG THUOC TAN CUC MAU TRONG IEU TR THUYEN TAC PHOI CAPTuyet oiBu nao hoac ot qu xuat huyetMi b chan thng au hay phau thuat auXuat huyet noi ang b hay mi bTng oiGiam tieu cau hay benh ve ong mauTHA nang khong kiem soat cang hoi sc tim phoiPhau thuat hoac sinh thiet trong vong 10 ngay trc

THUYEN TAC PHOI

PHONG NGA HUYET KHOI TM SAU VA THUYEN TAC PHOI (1)Trng hpCach phong nga

Phau thuat tong quat Heparin khong phan oan, 5000 v x 2-3 lan/ngay Enoxaparin, 40mg/ngay/Tdd Dalteparin, 2500 hoac 5000 v/ngay/Tdd Nadroparin, 3100 v/ng/Tdd; co hay khong kem v ep

Thay hoan toan Warfarin (gi INR 2,5) khp hang Ep bang kh tng luc Enoxaparin, 30 mg x 2/ngay/Tdd Danaparoid 750 v x 2/ngay/TddTL: N. Engl. J Med 1998; 339: 93-104

THUYEN TAC PHOI

PHONG NGA HUYET KHOI TM SAU VA THUYEN TAC PHOI (2)Trng hpCach phong ngaThay hoan toan khp goiEnoxaparin, 30 mg x 2/ngay/TddArdeparin, 50 mg x 2/ngay/Tdd

Phau thuat than kinhV ep va ep bang kh tng luc ; kem hay khong kem Heparin khong phan oan 5000 v x 2/ngayChan thng (ngoai so)Enoxaparin 30 mg x 2/ngay/Tdd

Phau thuat long ngcV ep, ep bang kh tng luc va Heparin khong phan oan 5000 v x 3/ngayTL: N. Engl. J Med 1998; 339: 93-104THUYEN TAC PHOI

PHONG NGA HUYET KHOI TM SAU VA THUYEN TAC PHOI (3) Trng hpCach phong ngaPhau thuat bac cau MVV ep, kem hay khong kem Heparin khong khong bien chng phan oan 5000 v x 2-3/ngay

Benh noi khoa tong quatV ep, ep bang kh tng luc hoac Heparin can nhap vien khong phan oan 5000 v x 2-3/ngay

Benh nhan nam trong san soc V ep, ep bang kh tng luc, kem hay khong tch cc kem Heparin khong phan oan 5000 v x 2-3/ngay

Thai kyDalteparin 5000 v/ngay TddEnoxaparin 40 mg/ngay TddTL: N. Engl. J Med 1998; 339: 93-104

THUYEN TAC PHOI