HNG DN CHN ON, IU TR ST XUT HUYT DENGUE

(Ban hnh km theo Quyt nh s: 458/Q-BYT ngy 16 thng 02 nm 2011 ca B trng B Y t) I. I CNG - St xut huyt Dengue l bnh truyn nhim gy dch do virus Dengue gy nn. Virus Dengue c 4 type huyt thanh l: DEN 1, DEN 2, DEN 3, DEN 4. Virus truyn t ngi bnh sang ngi lnh do mui t. Mui Aedes aegypti l cn trng trung gian truyn bnh ch yu - Bnh xy ra quanh nm, thng gia tng vo ma ma. Bnh gp c tr em v ngi ln. c im ca st xut huyt Dengue l st, xut huyt v thot huyt tng, c th dn n shock gim th tch, ri lon ng mu, suy tng, nu khng c chn on v x tr kp thi d dn n t vong

II. DIN TIN LM SNG BNH ST XUT HUYT DENGUE Bnh st xut huyt Dengue c din tin lm sng a dng, din tin nhanh chng t nh n nng. Bnh thng khi pht t ngt v din tin qua 3 giai on: giai on st, giai on nguy him v giai on hi phc. Pht hin sm bnh v hiu r vn lm sng trong tng giai on bnh gip chn on sm, iu tr ng v kp thi, nhm cu sng ngi bnh 1. Giai on st: 1.1. Lm sng: - St cao t ngt, lin tc - Nhc u, chn n, bun nn - Da sung huyt - au c, au khp, nhc 2 h mt - Nghim php dy tht dng tnh - Thng c chm xut huyt di da, chy mu chn rng hoc chy mu cam 1.2. Cn lm sng: - Dung tch hng cu (Hematocrit) bnh thng - S lng tiu cu bnh thng hoc gim dn (nhng vn trn 100.000/mm3)

- S lng bch cu thng gim 2. Giai on nguy him: 2.1. Lm sng: a) Ngi bnh c th cn st hoc gim st b) C th c cc biu hin sau: - Biu hin thot huyt tng do tng tnh thm thnh mch (thng ko di 24 48 gi): + Trn dch mng phi, m k, mng bng, n mi mt, gan to, c th au + Nu thot huyt tng nhiu s dn n sc vi cc biu hin vt v, bt rt hoc li b, lnh dn u chi, da lnh m, mch nhanh nh, huyt p kt (hiu p ti a v ti thiu 20mmHg), tt huyt p hoc khng o c huyt p, tiu t - Xut huyt: + Xut huyt di da: Nt xut huyt ri rc hoc chm xut huyt thng mt trc hai cng chn v mt trong 2 cnh tay, bng, i, mng sn hoc mng bm tm + Xut huyt nim mc: chy mu mi, li, tiu ra mu. Kinh nguyt ko di hoc xut hin kinh sm hn k hn + Xut huyt ni tng nh tiu ha, phi v no l biu hin nng c) Mt s trng hp nng c th biu hin suy tng nh vim gan nng, vim no, vim c tim. Nhng du hiu nng ny c th xy ra mt s ngi bnh khng c du hiu thot huyt tng r hoc khng sc 2.2. Cn lm sng: - Hematocrit tng so vi gi tr ban u ca ngi bnh hoc so vi gi tr trung bnh ca dn s cng la tui - S lng tiu cu gim di 100.000/mm3 (<100G/L) - Enzym AST, ALT thng tng - Trong trng hp nng c th c ri lon ng mu - Siu m hoc Xquang c th pht hin trn dch mng bng, mng phi 3. Giai on hi phc: 3.1 Lm sng:

Sau 24 48 gi ca giai on nguy him, c hin tng ti hp thu dn dn dch t m k v bn trong lng mch. Giai on ny ko di 48 72 gi - Ngi bnh ht st, ton trng tt ln, thm n, huyt ng n nh v tiu nhiu - C th nhp tim chm v thay i v in tm - Trong giai on ny nu truyn dch qu mc c th gy ra ph phi hoc suy tim 3.2 Cn lm sng: - Hematocrit tr v bnh thng hoc c th thp hn do hin tng pha long mu khi dch c ti hp thu tr li - S lng bch cu thng tng ln sm sau giai on h st - S lng tiu cu dn tr v bnh thng, mun hn so vi s lng bch cu

III. CHN ON 1. Bnh St xut huyt Dengue c chia lm 3 mc (Theo t chc y t th gii 2009): - St xut huyt Dengue - St xut huyt Dengue c du hiu cnh bo - St xut huyt Dengue nng Ph lc 2: Cc mc St xut huyt Dengue a) Lm sng: St cao t ngt lin tc t 2 -7 ngy v c t nht 2 trong cc du hiu sau: - Biu hin xut huyt, c th nh nghim php dy tht dng tnh, chm xut huyt di da, chy mu chn rng hay chy mu cam 1. SXH Dengue: - Nhc u, chn n, bun nn - Da sung huyt, pht ban - au c, au khp, nhc 2 h mt b) Cn lm sng: - Hematocrit bnh thng (khng c biu hin c c mu) hoc tng

- S lng tiu cu bnh thng hoc hi gim - S lng bch cu thng gim a) Lm sng: St cao t ngt lin tc t 2 -7 ngy v c t nht 2 trong cc du hiu sau: - Biu hin xut huyt, c th nh nghim php dy tht dng tnh, chm xut huyt di da, chy mu chn rng hay chy mu cam - Nhc u, chn n, bun nn - Da sung huyt, pht ban - au c, au khp, nhc 2 h mt KM THEO CC DU HIU CNH BO SAU: 2. SXH Dengue c du hiu cnh bo - Vt v, l , li b - au bng vng gan hoc n au vng gan - Ganto > 2cm - Nn nhiu - Xut huyt nim mc - Tiu t - Xt nghim mu: Hematocrit tng cao Tiu cu gim nhanh chng Nu ngi bnh c du hiu cnh bo trn phi theo di st mch, huyt p, s lng nc tiu, lm xt nghim hematocrit, tiu cu v c ch nh truyn dch kp thi Khi ngi bnh c mt trong cc biu hin sau: 3. SXH Dengue nng - Thot huyt tng nng dn n sc gim th tch (Sc SXH Dengue), dch khoang mng phi v bng nhiu - Xut huyt nng - Suy tng a) Sc SXH Dengue: - Suy tun hon cp, thng xy ra vo ngy th 3 7 ca

bnh, biu hin bi cc triu chng nh vt v, bu rt hoc li b, lnh u chi, da lnh m, mch nhanh nh, huyt p kt, hoc tt huyt p hoc khng o c huyt p, tiu t - Sc SXH Dengue c chia ra lm 2 mc iu tr b dch: Sc SXH Dengue: c du hiu suy tun hon, mch nhanh nh, huyt p kt hoc tt, km theo cc triu chng nh da lnh, m, bt rt hoc vt v, li b Sc SXH Dengue nng: sc nng, mch nh kh bt, huyt p khng o c Trong qu trnh din bin bnh c th chuyn t mc nh sang mc nng, v vy thm khm cn phn lm sng tin lng bnh v c kt qu x tr thch hp b) Xut huyt nng: - Chy mu cam nng (cn nht gc vch mi), rong kinh nng, xut huyt trong c v phn mm, xut huyt ng tiu ha v ni tng, thng km theo tnh trng sc nng, gim tiu cu, thiu oxy m v toan chuyn ha c th dn n suy a ph tng v ng mu ni mch nng - Xut huyt nng cng c th xy ra ngi bnh dng thuc khng vim nh acetylsalicylic acid (Aspirin), ibuprofen hoc corticoid, tin s lot d dy t trng, vim gan mn c) Suy tng nng - Suy gan cp men gan AST, ALT 1.000U/L - Suy thn cp - Ri lon tri gic (SXH th no) - Vim c tim, suy tim hoc suy chc nng cc c quan khc 2. Chn on cn nguyn virus Dengue: 2.1. Xt nghim huyt thanh: - Xt nghim nhanh Tm khng nguyn NS1 trong 5 ngy u ca bnh Tm khng th IgM t ngy th 5 tr i - Xt nghim ELISA: Tm khng th IgM: t ngy th 5 ca bnh
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 Tm khng th IgG: Ly mu 2 ln cch nhau 1 tun tm c lc khng th (gp 4 ln) 2.2. Xt nghim PCR, phn lp virus: ly mu trong giai on st 3. Chn on phn bit: - St pht ban do virus - St m - St rt - Nhim khun huyt do lin cu ln, no m cu, VK gram m... - Sc nhim khun - Cc bnh v mu - Bnh l bng cp...

IV. IU TR 1. iu tr SXH Dengue: Phn ln cc trng hp c iu tr ngoi tr v theo di ti y t c s, ch yu l iu tr triu chng v phi theo di cht ch, pht hin sm sc xy ra v iu tr kp thi a) iu tr triu chng: - Nu st cao 39C, cho thuc h nhit, ni lng qun o, lau mt bng nc m - Thuc h nhit ch c dng l paracetamol n cht, liu dng 10 15mg/kg cn nng/ ln cch nhau mi 4 -6 gi Ch : Tng liu paracetamol khng qu 60mg/kg cn nng/24h Khng dng aspirin (acetylsalicylic acid), analgin, ibuprofen iu tr v c th gy xut huyt, toan mu b) B dch sm bng ng ung: khuyn khch ngi bnh ung nhiu nc Oresol hoc nc un si ngui, nc tri cy (nc da, cam, chanh) hoc nc ho long vi mui 2. iu tr SXH Dengue c du hiu cnh bo: - Ngi bnh cho nhp vin iu tr - Ch nh truyn dch:

 Nn xem xt truyn dch nu ngi bnh khng ung c, nn nhiu, c du hiu mt nc, l , hematocrit tng cao, mc d huyt p vn n nh Dch truyn bao gm: Ringer lactate, NaCL 0.9% Ph lc 4: S truyn dch trong SXH Dengue c du hiu cnh bo SXH Dengue cnh bo c ch nh truyn dch Truyn TM ban u (Ringer lactate hoc NaCl 0.9% 6 7ml/kg cn nng/ gi truyn trong 1 3 gi

CI THIN Hct gim, mch HA n nh, tiu nhiu

KHNG CI THIN Hct tng, mch nhanh, HA h hoc kt, tiu t

Gim lng truyn TM 5ml/kg cn nng/ gi Truyn trong 1- 2 gi

Ch nh truyn CPT 15 -20 ml/kg cn nng/ gi (theo Sc SXH Dengue)*

CI THIN Gim lng truyn TM 3ml/kg cn nng/ gi Truyn trong 1- 2 gi

Ch thch: HCT: hematocrit HA: huyt p TM: Tnh mch CPT: cao phn t

TIP TC CI THIN

Ngng truyn TM khi mch, HA n nh, bi niu tt Thng khng qu 24 48 gi Ch : ngi bnh 15 tui c th xem xt ngng truyn dch khi ht nn, n ung c SXH Dengue trn c a c bit nh ph n mang thai, tr nh nhi, ngi bo ph, ngi cao tui, c cc bnh ly i km nh T, vim phi, hen ph qun, bnh tim, bnh gan, bnh thn ngi sng 1 mnh hoc nh xa c s y t nn xem xt cho nhp vin theo di iu tr 3. iu tr sc SXH Dengue nng: ngi bnh phi c nhp vin iu tr cp cu

3.1 iu tr Sc SXH Dengue: a) Sc SXH Dengue: - Cn chun b cc dch truyn sau: Ringer lactate Dung dch mn ng trng NaCl 0.9% Dung dch cao phn t: Dextran 40 hoc 70, hydroxyethyl starch (HES) - Cch thc truyn: Phi thay th nhanh chng lng huyt tng mt i bng dung dch Ringer lactate hoc NaCl 0.9%, truyn TM nhanh 15 20ml/kg cn nng/ gi nh gi tnh trng ngi bnh sau 1 gi, sau 2 gi truyn phi nh gi li tnh trng Hct Nu sau 1 gi ngi bnh ra khi tnh trng sc, huyt p ht kt, mch quay r v tr v bnh thng, chi m, nc tiu nhiu hn th gim tc truyn xung 10ml/kg cn nng/gi truyn trong 1 2 gi. Sau gim dn tc truyn xung 7,5ml/kg cn nng/ gi truyn trong 1 2 gi, 5ml/kg cn nng/ gi truyn trong 4 -5 gi v 3ml/kg cn nng/ gi ty theo p ng lm sng v hematocrit Nu sau 1 gi truyn dch m tnh trng sc khng ci thin (mch nhanh, huyt p tt hay kt, tiu vn t) th phi thay th dch truyn bng dung dch cao phn t 15 20ml/kg cn nng/gi truyn trong 1 gi sau nh gi li: Nu sc ci thin HCT gim, th gim tc truyn CPT xung 10ml/kg cn nng/gi truyn trong 1 2 gi. Sau nu sc tip tc ci thin v HCT gim th tc truyn CPT xung 7,5ml/kg cn nng/gi ri n 5ml/kg cn nng/gi truyn trong 2 -3 gi Theo di tnh trng ngi bnh, nu n nh th chuyn truyn TM dung dch in gii Nu sc vn ch ci thin, th o p lc TM trung ng (CVP) quyt nh cch thc x tr Nu sc vn cha ci thin m Hct gim xung nhanh (mc d cn trn 35%) th cn phi thm khm pht hin xut huyt ni tng v xem xt ch nh truyn mu. Tc truyn mu 10ml/kg cn nng/gi Ch : Tt c s thay i tc truyn phi da vo mch, huyt p, lng bi tit nc tiu, tnh trng tim, phi, Hct 1 hoc 2 gi 1 ln v CVP

Ph lc 5: S truyn dch trong SXH Dengue tr em Sc Mch nhanh, HA kt, nc tiu gim, vt v, l m Tuyn TM ban u NaCl 0.9% hoc RL Tc 15 20ml/kg cn nng/gi Truyn trong 1 gi Ci thin Truyn NaCl 0.9% hoc RL Tc 10ml/kg/gi Truyn 1 2 gi Ci thin Truyn NaCl 0.9% hoc RL Tc 7,5ml/kg/gi Truyn 1 2 gi Ci thin Truyn NaCl 0.9% hoc RL Tc 5ml/kg/gi Truyn 4 - 5 gi Ci thin Truyn NaCl 0.9% hoc RL Tc 3 ml/kg/gi Truyn 4 - 6 gi Ngng truyn khi HA, mch, Hct bnh thng, tiu nhiu Khng ci thin HA h hoc kt, mch nhanh, lng nc tiu gim, Hct tng cao CPT 15 20ml/kg/gi Truyn trong 1 gi Tc 5ml/kg/gi Truyn 1 Khng ci thin 2 gi

Ci thin

CPT 10ml/kg/gi CPT 10ml/kg/gi Tc 7,5ml/kg/gi o CVP Truyn 1 2 gi T

Ci thin

Khng ci thin

CPT 7,5-5ml/kg/gi hoc NaCl 0.9%, RL 10-7,5ml/kg/gi Truyn 2 3 gi (ty tnh hnh ngi bnh)

Hct gim d cn trn 35%. Truyn mu 10ml/kg/gi

Hct tng Tip tc truyn CPT

Ci thin CPT: cao phn t CVP: p lc TM trung tm RL: Ringer lactate

Ph lc 2: Cc mc SXH Dengue SXH Dengue Cc du hiu cnh bo SXH Dengue nng

Khng c du hiu cnh bo

C cc du hiu cnh bo

1. Thot HT nng 2. XH nng 3. Suy cc tng

C th mc SXH Dengue: Sng/du lch n vng c dch. St v c 2 trong cc du hiu sau: Bun nn, nn Pht ban au mi ngi Du hiu dy tht (+) H bch cu Bt k cc du hiu cnh bo no

Cc du hiu cnh bo * au bng hoc tng c/gic au Nn ko di C biu hin dch Xut huyt nim mc Mt l, bn chn Gan to >2cm Xt nghim : tng Hct i km vi h tiu cu

1. Thot huyt tng nng dn ti: Sc (hi chng sc Dengue) dch, biu hin suy h hp 2. Xut huyt nng: c nh gi trn lm sng 3. Suy cc tng: Gan: AST hoc ALT 1000UI/ml Thn kinh trung ng: Ri lon thc Tim v cc c quan khc

XN khng nh nhim Dengue (quan trng khi khng c cc du hiu thot huyt tng)

* i hi theo di cht ch v iu tr kp thi

b) Sc SXH Dengue nng: Trng hp ngi bnh vo vin trong tnh trng sc nng (mch quay khng bt c, huyt p khng o c (HA=0) th phi x l rt khn trng - ngi bnh nm u thp - Th oxy - Truyn dch: + i vi ngi bnh di 15 tui: Lc u dng bm tim to bm trc tip vo tnh mch Ringer lactate hoc dung dch mn ng trng vi tc 20ml/kg cn nng trong vng 15 pht. Sau nh gi li ngi bnh, c kh nng xy ra:

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 Nu mch r, huyt p ht kt, cho dung dch cao phn t 10ml/kg cn nng/ gi v x tr tip theo nh SXH Dengue cn b Nu mch nhanh, huyt p cn kt hoc huyt p h: Truyn dung dch cao phn t 15 20ml/kg cn nng/gi, sao x tr nh: Nu sau 1 gi truyn dch m tnh trng sc khng ci thin (mch nhanh, huyt p tt hay kt, tiu vn t) th phi thay th dch truyn bng dung dch cao phn t 15 20ml/kg cn nng/gi truyn trong 1 gi sau nh gi li: Nu sc ci thin HCT gim, th gim tc truyn CPT xung 10ml/kg cn nng/gi truyn trong 1 2 gi. Sau nu sc tip tc ci thin v HCT gim th tc truyn CPT xung 7,5ml/kg cn nng/gi ri n 5ml/kg cn nng/gi truyn trong 2 -3 gi Theo di tnh trng ngi bnh, nu n nh th chuyn truyn TM dung dch in gii Nu sc vn ch ci thin, th o p lc TM trung ng (CVP) quyt nh cch thc x tr Nu sc vn cha ci thin m Hct gim xung nhanh (mc d cn trn 35%) th cn phi thm khm pht hin xut huyt ni tng v xem xt ch nh truyn mu. Tc truyn mu 10ml/kg cn nng/gi Nu mch, huyt p vn khng o c: Bm tnh mch trc tip dung dch cao phn t 20ml/kg cn nng/15 pht. Nn o CVP c phng hng x tr. Nu o huyt p v mch r, th truyn dch cao phn t 15 20ml/kg cn nng/gi, sau x tr: Nu sau 1 gi truyn dch m tnh trng sc khng ci thin (mch nhanh, huyt p tt hay kt, tiu vn t) th phi thay th dch truyn bng dung dch cao phn t 15 20ml/kg cn nng/gi truyn trong 1 gi sau nh gi li: Nu sc ci thin HCT gim, th gim tc truyn CPT xung 10ml/kg cn nng/gi truyn trong 1 2 gi. Sau nu sc tip tc ci thin v HCT gim th tc truyn CPT xung 7,5ml/kg cn nng/gi ri n 5ml/kg cn nng/gi truyn trong 2 -3 gi Theo di tnh trng ngi bnh, nu n nh th chuyn truyn TM dung dch in gii Nu sc vn ch ci thin, th o p lc TM trung ng (CVP) quyt nh cch thc x tr Nu sc vn cha ci thin m Hct gim xung nhanh (mc d cn trn 35%) th cn phi thm khm pht hin xut huyt ni tng v xem xt ch nh truyn mu. Tc truyn mu 10ml/kg cn nng/gi

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Ph lc 6: S truyn dch trong sc xut huyt Dengue nng tr em SC Mch khng bt c, HA = 0 Bm trc tip RL hoc NaCl 0,9% 20ml/kg cn nng/15 pht

Mch r, HA ht kt CPT 10ml/kg/gi Truyn trong gi X tr nh sc xut huyt Dengue (ph lc 4) Ch thch: CPT: cao phn t HA: huyt p RL: Ringer lactate

HA kt hoc h CPT 15 20ml/kg/gi Truyn trong 1 gi

Mch khng bt c, HA = 0 Bm CPT 20ml/kg/15 pht. o CVP Khi o c HA, ly c mch

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+ i vi ngi bnh > = 15 tui: truyn dch theo ph lc 7 Ph lc 7: S chng sc SXH Dengue ngi ln SC

Ci thin LR 10ml/kg/1 gi Ci thin LR 6ml/kg gi 3 v 4 (1) Ci thin LR 3ml/kg gi 5-12 (2) Ci thin LR 1,5ml/kg/gi 1324 (3) Ngng truyn HA, mch, Hct gim, nc tiu bnh thng, tiu nhiu L/R 15ml/kg trong 1 gi

L/R 15ml/kg trong 1 gi

Khng ci thin CPT 10ml/kg trong 1 gi Khng ci thin ln 2 Sau CPT ln 1 sau LR (1), (2) hoc (3) CPT 10ml/kg trong 1 gi + o CVP v Hct CVP thp (<50cm H 2O)

CVP (>12cm H2O) Hct khng i Vn mch Duy tr tc dch truyn trc khi dng CPT l RL (1), (2) hay (3)

Hct cn 35% (**) truyn mu Hct hoc khng i LR theo CVP

Ch thch: RL: dung dch Lactate Ringer HA: huyt p, M: mch Hct: hematocrit CPT: cao phn t Hai ln dng CPT iu tr ti sc c th lin nhau hoc cch nhau bi cc giai on truyn LR (1), (2), (3) (*) Tng ng III, IV theo hng dn SXH nm 2009 (**) Truyn mu khi M tng, HA kt hoc thp, chi mt, mc d Hct 35%, xut huyt hoc cha xut huyt trn lm sng

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*NHNG LU KHI TRUYN DCH: - Ngng truyn dch tnh mch khi huyt p v mch tr v bnh thng, tiu nhiu. Ni chung khng cn thit b dch na sau khi ht sc 24 gi - Cn ch n s ti hp thu huyt tng t ngoi lng mch tr li lng mch (biu hin bng huyt p, mch bnh thng v Hct gim). Cn theo di triu chng ph phi cp nu cn tip tc truyn dch. Khi c hin tng b dch qu ti gy suy tim hoc ph phi cp cn phi dng li tiu nh furosemid 0,5 1mg/kg cn nng/ 1 ln dng (tnh mch). Trong trng hp sau khi sc hi phc m huyt p kt nhng chi m mch chm r, tiu nhiu th khng truyn dch, nhng vn lu kim tnh mch, theo di ti phng cp cu - i vi ngi bnh n trong tnh trng sc, c chng sc t tuyn trc th iu tr nh mt trng hp khng ci thin (ti sc). Cn lu n s lng dch c truyn t tuyn trc tnh ton lng dch sp a vo. - Nu ngi bnh ngi ln c biu hin ti sc, ch dng CPT khng qu 1.000ml i vi Dextran 40 v khng qu 500ml i vi Dextran 70. Nu din tin khng thun li nn tin hnh: + o CVP b dch theo CVP hoc dng vn mch nu CVP qu cao + Theo di st mch, huyt p, nhp th, nim mc, tm xut huyt ni ch nh truyn mu kp thi + Thn trng khi tin hnh th thut ti cc v tr kh cm mu nh tnh mch c, tnh mch di n - Nu huyt p kt, nht l sau 1 thi gian tr li bnh thng cn phn bit cc nguyn nhn sau: + H ng huyt + Ti sc do khng b cp lng dch tip tc thot mch + Xut huyt ni + Qu ti do truyn dch hoc do ti hp thu - Khi iu tr sc cn phi ch n iu chnh ri lon in gii v thng bng kim toan: h natri mu thng xy ra hu ht cc trng hp sc nng ko di v i khi c toan chuyn ha. Do cn phi xc nh mc ri lon in gii v nu c iu kin th o cc kh trong mu ngi bnh sc nng v ngi bnh sc khng p ng nhanh chng vi iu tr 3.2. iu tr xut huyt nng: a) Truyn mu v cc ch phm ca mu: - Khi ngi bnh c sc cn phi tin hnh xc nh nhm mu truyn mu khi cn - Truyn khi hng cu hoc mu ton phn: + Sau khi b dch nhng sc vn khng ci thin Hct gim xung nhanh (mc d cn trn 35%) + Xut huyt nng b) Truyn tiu cu:

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- Khi s lng tiu cu xung nhanh di 50.000/mm3 km theo xut huyt nng - Nu s lng tiu cu di 5.000/mm3 mc d cha c xut huyt c th truyn tiu cu ty tng trng hp c th c) Truyn plasma ti, ta lnh: Xem xt truyn khi ngi bnh c ri lon ng mu dn n xut huyt nng 3.3. iu tr suy tng nng: a) Tn thng gan, suy gan cp: - H tr h hp: th oxy nu tht bi th NCPAP, xem xt t bi kh qun th my sm nu ngi bnh c sc ko di - H tr tun hon: + Nu c sc: chng sc bng NaCl 0,9% hoc dng dung dch CPT, khng dng Lactate Ringer + Nu khng sc: b dch in gii theo nhu cu hoc 2/3 nhu cu khi ngi bnh c ri lon tri gic - Kim sot h ng huyt: Gi ng huyt 80 120mg%, tim tnh mch chm 1 2ml/kg glucose 30% v duy tr glucose 10 12,5% khi truyn qua tnh mch ngoi bin hoc glucose 15 30% qua tnh mch trung ng (lu c pha dung dch in gii) - iu chnh in gii: + H natri mu: Natri mu <120mmmol/L km ri lon tri gic: b NaCl 3% 6 10ml/kg truyn tnh mch trong 1 gi Natri mu 120 -125mmol/L khng hoc km ri lon tri gic: b NaCl 3% 6 10ml/kg truyn tnh mch trong 2 3 gi + H Kali mu: b ng tnh mch qua dung dch pha hoc ng ung - iu chnh ri lon thng bng toian kim: toan chuyn ha: b bicarbonate 1 2mEq/kg tim mch chm (TMC) - iu chnh ri lon ng mu/ xut huyt tiu ha: + Huyt tng ng lnh 10 15ml/kg: XHTH + ri lon ng mu + Kt ta lnh 1v/6kg: XHTH + fibrinogen < 1g/L + Tiu cu m c: XHTH + s lng tiu cu < 50.000/mm3 + Vitamin K1: 1mg/kg/ngy (ti a 10mg) TMC x 3 ngy - iu tr phng nga XHTH: Ranitidine 2mg/kg x 3 ln/ngy hoc omeprazole 1mg/kg x 1 2 ln/ngy - Ri lon tri gic/ co git: + Chng ph no: mannitol 20% 2,5ml/kg/30 pht x 3 4 ln/ngy + Chng co git: diazepam 0,2 0,3mg/kg TMC hoc mdazolam 0,1 0,2mg/kg TMC. Chng ch nh: phenolbarbital + Gim amoniac mu: tht tho bng nc mui sinh l, lactulose, metronidazole, neomycin (gavage) - Khng sinh ton thn ph rng. Trnh dng cc khng sinh chuyn ha qua gan chng hn nh perfloxacine, ceftrixone - Khng dng paracetamol liu cao v gy c tnh cho gan
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- Lu : iu tr h tr tn thng gan cn lu chng sc tch cc nu c, h tr sm nu sc khng ci thin, theo di in gii , ng huyt nhanh, kh mu ng mch, amoniac mu, lactat mu, ng mu ton b mi 4 6 gi iu chnh kp thi cc bt thng nu c b) Suy thn cp: iu tr bo tn v chy thn nhn to khi c ch nh v huyt ng n nh. Lc mu lin tc nu c biu hin suy a tng i km hoc suy thn cp huyt ng khng n nh. Ch nh chy thn nhn to trong st xut huyt suy thn cp - Ri lon in gii kim toan m khng p ng iu tr ni khoa: + Tng kali mu nng > 7mEq/L + Ri lon Natri mu ang tin trin([Na] > 160 hay < 115 mmol/L) + Toan ha mu nng khng ci thin vi b Bicarbonate (pH<7,1) - Hi chng ur huyt cao: Ri lon tri gic, xut huyt tiu ha, ur mu > 200mg% hoc creatinine tr nh > 1,5mg% v tr ln > 2mg% 3.4. Qu ti dch khng p ng iu tr ni khoa: - Suy tim huyt, cao huyt p - Ph phi cp - ch nh lc mu lin tc trong st xut huyt: khi c hi chng suy a tng km suy thn cp hoc suy thn cp c huyt ng khng n nh 3.5. SXH Dengue th no, ri lon tri gic, co git: - H tr h hp: th oxy, nu tht bi CPAP p lc thp 4 6cm H 2O, nu tht bi th my - Bo m tun hon: nu c sc th iu tr theo phc chng sc, v da vo CVP - Chng c git - Chng ph no - H st - H tr gan nu c tn thng - iu chnh ri lon nc in gii, kim toan - Bo m chm sc v dinh dng - Phc hi chc nng sm 3.6. Vim c tim, suy tim: vn mch dopamine, dobutamine o CVP nh gi th tch tun hon 4. Th oxy: tt c cc ngi bnh c sc cn th oxy gng knh 5. S dng cc thuc vn mch: - Khi sc ko di, cn phi o CVP quyt nh thi v x tr - Nu truyn dch y m huyt p vn cha ln v p lc tnh mch trung ng ln 10cm nc th truyn tnh mch: + Dopamin, liu lng 5 6mcg/kg cn nng/pht + Nu dng Dopamine liu 10mcg/kg vn nng/pht m huyt p vn cha ln th nn phi hp dobutamin 5 10mcg/kg cn nng/pht 6. Cc bin php iu tr khc:

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- Khi c trn dch mng bng, mng phi, kh th, SpO2 gim xung di 92% nn cho ngi bnh th NCPAP trc. Nu khng ci thin mi xem xt ch nh chc ht gim bt dch mng bng, mng phi 7. Chm sc v theo di ngi bnh sc: - Gi m - Khi ang c sc cn theo di mch, huyt p, nhp th 15 30 pht/ln - o HCT c 1 2 gi 1 ln trong 6 gi u ca sc. Sau 4 gi 1 ln co n khi sc n nh - Ghi lng nc xut v nhp trong 24 gi - o lng nc tiu - Theo di tnh trng thot dch vo mng bng, mng phi, mng tim 8. Tiu chun cho ngi bnh xut vin: - Ht st 2 ngy, tnh to - Mch, huyt p bnh thng - S lng tiu cu > 50.000/mm3 9. Phng bnh: - Thc hin cng tc gim st, phng chng SXH Dengue theo quy nh ca b y t - Hin cha c vaccin phng bnh - Bin php phng bnh ch yu l kim sot cn trng trung gian truyn bnh nh trnh mui t, dit b gy (lng qung), dit mui trng thnh, v sinh mi trng loi b cha nc ng Ph lc 1: Cc giai on LS ca SXH Dengue S ngy b bnh Nhit
Ti hp thu dch

Cc yu t nguy c

Mt dch

Shock xut huyt Suy cc tng

Thay i v xt nghim

Ti lng VR

Huyt thanh v virus hc

IgM/IgG

Cc giai on ca Dengue:

St

Nguy him

Hi phc

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Ph lc 3: S phn nhm iu tr ngi bnh SXH Dengue Chn on s b ca LS SXH Dengue: Sng / i ti vng dch t. st v c t nht 2 trong s cc tiu chun sau: Chn n v bun nn Sung huyt da au u, au ngi C 1 trong cc du hiu cnh bo Nghim php dy tht (+) Gim bch cu Cc du hiu cnh bo: Vt v, l , li b au bng vng gan hoc n au vng gan Gan to >2cm Nn nhiu Xut huyt nim mc Tiu t Xt nghim mu: o HCT tng cao o Tiu cu gim nhanh chng C 1. Thot huyt tng nng dn ti Sc dch, biu hin h hp 2. XGH nng: c nh gi bng LS Khng SXH Dengue c du hiu cnh bo Nhp vin iu tr C SXH Dengue nng

Khng C bnh l nh ngi mang thai, tr nh, ngi gi, T, suy thn Sng 1 mnh, sng xa bnh vin C Khng SXH Dengue C th cho v nh

Vo khoa hi sc tch cc

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Ph lc 8: Pht hin v x tr iu tr SXH Dngue tuyn c s khi c dch Cn nghi ng dch SXH Dengue trong cng ng khi thy nhiu ngi b st cao t ngt cha r nguyn nhn, st ko di t 2 7 ngy, ng thi km cc biu hin xut huyt nh chy mu cam, chy mu li, xut huyt di da, i mu, nn mu, rong kinh hoc c vt bm tm ni tim chch Cng nghi ng khi thy nhng trng hp st m khng p ng iu tr c hiu vi cc bnh vim hng, vim phi, st rt hoc c ngi bnh t vong trong vng 1 tun sau khi st km theo xut huyt cha r nguyn nhn I. Ti cc trm y t phng x: 1. Khi ngi bnh n khm: C cc triu chng nh st cao t ngt, au ngi, chn n, mt mi, du hiu dy tht (+) a) Nu ngi bnh tnh to, gan khng to, mch, huyt p bnh thng, tiu nhiu, chn tay m th iu tr ngoi tr, cho ung nc un si ngui hoc ung nc tri cy (cam, chanh, da) nu st 39C th lau mt, ung paracetamol Ngi bnh c khm li mi ngy cho n khi ht st 2 ngy. Nu khng c iu kin xt nghim Hct v tiu cu th nn chuyn tuyn. Khng truyn dch khi cha c ch nh b) Khi ngi bnh c cc triu chng nh l , vt v, chn tay lnh, da m, tiu t, nn nhiu, huyt p kt hoc huyt p tt, gan to, xut huyt - Nu trm y t x khng c y bc s v khng c iu kin truyn tnh mch th tch cc b nc bng ng ung v chuyn gp n bnh vin gn nht iu tr - Nu trm y t x c y bc s v c iu kin truyn tnh mch th truyn ngay dung dch Ringer lactate vi tc 15 20ml/kg cn nng/gi, ri chuyn ngi bnh n bnh vin gn nht iu tr trong iu kin an ton (tip tc b dch trong lc chuyn ngi bnh, c nhn vin y t h tr) - Nu ngi bnh n khm m khng o c huyt p (HA = 0), mch nhanh, nh kh bt, phi bm trc tip vo TM dung dch mn ngt ng trng hoc Ringer lactate cho n khi mch bt c r ri chuyn gp n bnh vin iu tr 2. Nhim v ca cc cn b y t x phng cn phi: - Ph bin cho nhn dn v cc triu chng nghi ngi SXH Dengue nh st cao t ngt, mt mi, chn n, nhc u, c biu hin xut huyt da hay nim mc, gia nh nn a ngi bnh i khm ti cc trm y t theo di iu tr - Ph bin cho nhn dn bit cch chm sc ngi bnh SXH Dengue iu tr ngoi tr ti gia nh nh cho tr n bnh thng, cho ung

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nhiu nc tri cy, bit cch pha oresol ung (1 gi pha vi 1 lt nc un si ngui) khi st cao 39C bit cch lau mt hoc cho ung paracetamol do y t x cho n Cm dng Aprisin (acetyl salicylic acid), analgin, ibuprofen iu tr v c th gy xut huyt, toan mu - Hng dn cho gia nh ngi nh bit cc triu chng nng ca SXH Dngue v cn a ngy ngi bnh n khm ti trm y t x nh ang st m nhit gim t ngt, chn tay lnh, bt rt, vt v, hoc li b, da m, v nhiu m hi, nn i nhiu, au bng nhiu, tiu t v c cc biu hin xut huyt nng - Thc hin quy ch thng tin, bo co bnh truyn nhim theo quy nh ca b y t II. Ti bnh vin qun, huyn v tnh: 1. T chc phng v iu tr ring cho ngi bnh SXH Dengue v phng iu tr cho ngi bnh c sc 2. Chun b y cc dch truyn cn thit nh: - Ringer lactate - NaCl 0,9% - Dextran 40 hoc 70, hydroxyethyl starch - Mu ti v ch phm mu - Cc dng cc nh my o huyt p tr em, ngi ln, cc thit b o CVP 3. C phng lm cc xt nghim cn thit ti thiu nh: - My o Hct - Knh hin vi v dng c m hng cu, bch cu, tiu cu - Phng sinh ha ca bnh vin phi c c cht lm in gin 4. Vn chn lc ngi bnh iu tr: a) Ti phng khm ca bnh vin - Theo di iu tr ngoi tr hoc cho nhp vin ngi bnh SXH Dengue nu ngi bnh xa bnh vin - Theo di hng ngy HA, mch, nhit ,nc tiu, tnh trng xut huyt, Hct, tiu cu - Cho nhp vin ngay v tin hnh iu tr khn trng khi ngi bnh n khm c hi chng sc Dengue b) Ti phng iu tr - Nu ngi bnh SXH Dengue c du hiu cnh bo v khng ung c th truyn dch theo s hng dn - Nu ngi bnh c sc SXH Dengue th tin hnh iu tr khn trng theo hng dn

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TNH CN NNG TRUYN DCH SXH D CN BO PH

NGHI D CN / BO PH Cn nng thc t (CN) o chiu cao (CC) Tnh BMI = CN/CC2 BMI / TUI ( > 85th)

TNH BMI MC 75th

CN NNG = BMI (75th) x chiu cao2 (Truyn dch)

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