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IU TR

PHC IU TR CHUN ( nguyn tc iu tr+cc nhm thuc s dng ,


c nhng thuc g+ cch s dng cc nhm + tng tc ca cc thuc trong
nhm )
THUC ( nhm no ,c ch, ch nh chnh, cch dng, TDKMM, tng tc)
1.COPD( thiu nguyn tc iu tr, cch s dng, tng tc)

I. NH NGHA
Bnh phi tc nghn mn tnh (BPTNMT) l mt bnh biu hin bi s gii hn lu lng kh, s gii
hn ny khng hi phc hon ton. S gii hn lu lng kh thng xy ra t t v phi hp vi mt s
p ng vim bt thng ca phi i vi cc ht c hay kh. BPTNMT bao gm vim ph qun mn
v kh ph thng.
Bao gm vim ph qun mn, kh ph thng v hen ph qun khng hi phc.
S chn on BPTNMT cn c vo triu chng ho, khc m, kh th v hay l c
tin s tip xc vi cc yu t nguy c. S chn on c xc nh bng ph dung
k. sau khi dng thuc gin ph qun m FEV1 < 80% so vi tr s d on phi
hp vi FEV1/FVC < 70%

II. NHNG YU T NGUY C


1. Nhng yu t k ch
1.1. Gnes: Yu t di truyn ng lu nht l thiu ht bm sinh 1 antitrypsine. S pht trin sm v
nhanh kh ph thng ton tiu thu
1.2. S tng p ng ph qun
1.2. S tng trng phi: lin h vi qu trnh xy ra trong giai on mang thai, cn nng lc sinh v s
tip xc vi mi trng trong thi k thiu nin.
2. Nhng yu t tip xc
2.1. Ht thuc l
2.2. Bi v cht ho hc ngh nghip
2.3. nhim mi trng trong v ngoi nh:
2.4. Nhim khun: nhim trng h hp thi k thiu nin c th gy BPTNMT
thi k trng thnh.

III. C CH SINH BNH


1. Vim v cc yu t nguy c ca BPTNMT
S lin quan gia ht thuc l v vim c nghin cu rt nhiu. Thuc l kch hot i thc bo v
t bo thng b sn xut ra TNF v mt s cht trung gian gy vim nh IL8 v ILB4.
2. Mt qun bnh gia proteinase v antiproteinase
Thiu 1 antitrypsine l mt cht c ch mt s proteine thuyt thanh nh neutrophile elastase lm gia
tng nguy c gy kh ph thng; elastin l mt thnh phn chnh ca thnh ph bo b hu bi
neutrophile elastase. S mt qun bnh gia proteinase v antiproteinase ni sinh c th gy nn s ph
hu phi v c th xy ra do s suy gim hot tnh ca antiproteinase do stress oxy ho, do thuc l v c
th do nhng yu t nguy c khc ca BPTNMT.
3. Nhng stress oxy ho
Trong BPTNMT c mt s mt qun bnh r rng cht oxy ha v cht chng oxy
ha, trong ch yu l cc cht oxy ha, l hydrogen peroxide (H2O2) v nitric
oxide (NO). Nhng stress oxy ha ngoi vic gy tn thng trc tip phi cn gp
phn vo s mt qun bnh proteinase - antiproteinase Nhng cht oxy ha cng

xc tin vim. Cui cng nhng stress oxy ha c th gp phn lm hp ng h


hp.
IV . Gii phu bnh:
- ng th trung tm: c cc t bo vim thm nhim b mt biu m,
lm tng tit cht nhy.
- ng th ngoi vi: qu trnh vim mn tnh gy tn thng v ti cu trc
li thnh ph qun, to thnh so lm hp lng v gy tc dng th c nh.
V.t bng pht ca BPTNMT
* Ngi ta coi l BP: khi BN b nhim khun phi, ph qun, lm tng kh th, lm
cho tnh trng BN xu i. a s BN b BP t giai on III v giai on IV.
BP BPTNMT
* Chn on BP: cn c vo mt trong cc du hiu sau : Tng s lng m ,
tng m c c m, tng kh th. C 3 mc ca BP: Nh, trung bnh,
nng.
* Nguyn nhn gy ra BP :
- Do nhim trng: L nguyn nhn ch yu, chim 80%.
- Khng do nhim trng: L nguyn nhn th yu.

VI. Triu chng lm sng:


- Triu chng c nng : ch yu l ho, khc m, kh th.
- Triu chng thc th :
Khm thc th t c gi tr trong chn on BPTNMT. Nhng triu chng thng gp l
+ Tm trung tm.
+ Cc khong gian sn nm ngang, lng ngc hnh thng.
+ Du hiu Hoover (dt 1/2 c honh phi hp vi s thu li vo trong nghch l ca y lng ngc
trong k ht vo).
+ Tn s th lc ngh > 20 ln / pht, nhp th nng.
+ Bnh nhn th ra vi mi mm li vi mc ch lm chm li lung kh th ra c th lm vi phi
c hiu qu hn.
+ Nghe phi m ph bo gim, c ran wheezing.
3. Nhng tt v nhng xt nghim b sung cho chn on BPTNMT
i vi nhng bnh nhn c chn on BPTNMT giai on II v III, nhng tt v nhng xt nghim
sau y c th c s dng:
3.1. nh gi gim chc nng h hp bng ph dung k: o FEV1 v FEV1/FVC.
3.2. Tt hi phc ph qun sau khi kh dung thuc gin ph qun
+ Nhng bnh nhn khng s dng thuc gin ph qun kh dung tc dng ngn trc 6 gi, thuc
ng vn 2 tc dng di trc 12 gi hay theophylline thi chm trc 24 gi.
+ o FEV1 trc khi s dng thuc gin ph qun.
o FEV1 li 3 - 45 pht sau khi dng thuc gin ph qun
3.3.Kh mu: nhng bnh nhn b BPTNMT lu nh gi tm ph mn.

3.4. Chp phim lng ngc: cho thy kh ph thng.

1.2.1. iu tr giai on n nh:


- Mc tiu iu tr: Ngn cn v kim sot cc triu chng, gim mc v tn s
BP, ci thin cht lng cuc sng ca bnh nhn.
- Phc iu tr: Theo 5 giai on.
1.2.2. iu tr BP:
* Mc tiu iu tr: Gii quyt nhim khun h hp, iu tr cc triu chng v
cc bin chng: tm ph mn, suy h hp, trn kh mng phi .
* Phc iu tr :
- Chng nhim khun ph qun.
- iu tr tc nghn ng th: gin ph qun, chng vim , long m.
- iu tr thiu oxy.

1. Thuc khng sinh:


1.1. Nguyn tc s dng khng sinh.
1.1.2. Nhm - lactam (cc penicilin v cephalosporin).
1.1.3. Nhm Aminnosid (hay aminoglycosid).
1.1.4. Nhm Lincosamid.
1.1.5. Nhm Quinolon.
1.2. Thuc gin ph qun:
1.2.1. Nhm ch vn 2 adrenergic.
1.2.2. Nhm Xanthin.
1.2.3. Nhm khng cholinergic.
1.3. Thuc Corticoid (corticosteroid).
1.4. Thuc long m.

STT

Kiu phi hp

KS + gin ph qun

KS + gin ph qun + long m

KS + gin ph qun + corticoid

KS + gin ph qun + corticoid + long m

Kiu phi hp

S lng BN

T l

KS n c

18

10,

Ampicillin/Sulbactam

3,3

Cephalosporin th h II

1,1

Cephalosporin th h III

10

5,6

Phi hp hai KS

143

80,

- lactam + aminosid

102

57,

Lincosamid + aminosid

20

11,

- lactam + quinolon

21

11,

Phi hp ba KS

16

9,0

- lactam + aminosid + quinolon

14

7,9

Lincosamid + aminosid + quinolon

1,1

Tng s

177

100

Nhm KS

- lactam

Bit d
dc

Dng thuc,
hm lng
lng

Cephalexin

Cephalexin

Vin 500 mg

Cefuroxim

Tafurex

750mg/l

Cefotaxim

Claforan

1g/l

Cefoperazon

Medocef

1g/l

Tn gc

Cch
dng

Tn gc

Ton
thn

Prednisolon

Metylprednisolo
n
Succinat
Mazipredone

Dng thuc,
hm lng
lng

Tn
xut s
dng

T l

Prednisolon

Vin 5mg

36

16,59

Medrol

Vin 4mg

21

9,68

Solumedrol

Bt pha tim
40mg/l

23

10,60

Depersolon

ng tim

2,30

72

33,18

26

11,98

Bit dc
dc

(%)

30 mg/ml
Ti ch

Budesonid

Pulmicort

Kh dung, ng
0,5 mg/2 ml

Fluticason
propionat

Flixotide

Kh dung, ng

Fluticason +

Seretide

Thuc xt
25,50mcg/liu

1,84

217

100

0,5 mg/2 ml

Salmeterol
Tng s

Cc thuc ph tr.
STT

Cc nhm thuc

Tn thuc

Tim mch

Ouabain, digoxin, dopamin, nitroglycerin

ng tiu ho

Cimetidin, omeprazol, n s 12, nhm +


magnesi hydroxyd.

H st, gim au

Paracetamol, paracetamol/codein

Li tiu, b Kali

Furocemid, spironolacton, kaliroid

Tng cng
cng chc nng gan,
mt

Diphenyldimethyl-dicarboxylat, arginin

Thn kinh

Piracetam, cerebrolysin

H huyt p

Amlodipin, nifedipin, perindopril

B nc,
nc, in gii, acid amin

Glucose 5%, NaCl 0,9%, ringerlactat


ringerlactat

B, vitamin

Vitamin nhm B, C, AD, khong cht.

2. TNG HUYT P
2.1 nguyn tc T

2.1.1 nh gi THA theo mc nguy c ca T chc y t Th Gii v Hi tng


huyt p Th Gii (ISH) nm 2003, 2007. nh gi cc yu t nh hng n tin
lng, bao gm:
Yu t nguy c ca bnh tim mch: - Mc huyt p tm thu v tm trng (13). - Nam > 55tui. - N > 65 tui. - Ht thuc l. - Cholesterol ton phn > 250mg
%. - Tiu ng. - Tin s gia nh b bnh tim. + Yu t khc nh hng xu tin
lng: - HDL-C gim. -LDL-C tng. -Albumine niu vi th bnh nhn tiu ng.
-Ri lon dung np Glucose. -Bo ph. -Li sng tnh ti. -Fibrinogene mu tng.
-Nhm kinh t x hi cao. -Nhm dn tc nguy c cao. - Vng a l nguy c cao.
+ Tn thng c quan ch
+ Tnh trng lm sng i km
2.1.2Phn loi nguy c gip tin lng bnh

i vi tng huyt p nguy c thp v trung bnh cn theo di thi gian ri nh


gi li huyt p v yu t nguy c, p dng cc bin php khng dng thuc. i
vi nhm nguy c cao v rt cao cn iu tr thuc ngay phi hp vi cc bin php
khng dng thuc.

p dng phc iu tr theo c nhn

C 3 cch la chn thuc iu tr ban u (nu khng c chng ch nh ca cc thuc ny):


- La chn th nht: vi ngi tng huyt p (THA) cha c bin chng, dng thuc li tiu, thuc chn th th beta giao cm.
- La chn th hai: ch nh bt buc vi ngi i tho ng tp 2, c protein niu, chn thuc c ch men chuyn. i vi ngi c
suy tim chn thuc c ch men chuyn, thuc li tiu. Trng hp THA tm thu n c, u tin dng thuc li tiu, thuc chn knh
calci loi dihydropyridin tc dng ko di. Ngi c nhi mu c tim dng thuc chn beta giao cm.
- La chn th ba l cc ch nh c bit cho cc loi thuc sau: thuc c ch men chuyn, thuc c ch th th angiotensin II, thuc
chn th th alpha giao cm, thuc chn th th beta giao cm, thuc chn c th th alpha - beta giao cm, thuc chn knh calci,
thuc li tiu. Nn bt u vi loi thuc tc dng ko di, liu duy nht trong ngy, liu thp, iu chnh liu t kt qu, c th
kt hp vi liu thp cc thuc khc. Nu vn cha t c ch iu tr THA m thuc khng p ng hoc c tc dng ph th cn
thay nhm thuc khc. Nu thuc ch p ng mt phn, nhng dung np tt th thm thuc nhm khc (u tin thuc li tiu nu
cha dng).
Tuy vo tng ngi bnh v mc tng huyt p thy thuc c th la chn thuc dng cho ph hp. V d: au ngc, chn thuc
chn beta giao cm, thuc chn knh calci; Rung nh chn thuc chn beta gia cm, chn knh calci (tr nhm dihydropyridin); i
tho ng tp 1 v 2 c protein niu chn thuc c ch men chuyn (u tin), chn knh calci, li tiu liu thp; C ri lon m mu
chn thuc chn beta giao cm (loi khng chn lc)...

* iu tr cn tng huyt p cp tnh Cn phi dng loi h huyt p bng ng


tnh mch nh:

- Nitroprussiate de Na (Nipride) chuyn tnh mch liu 0,5-2mg/pht (10mg/gi)


c chn dng trong hu ht cn tng huyt p. Tc dng ph: ng c
Thiocyanate.
- Nitroglycerine chuyn tnh mch dng bnh nhn c suy vnh cp khi khng
chng ch nh, liu 5 - 10mg/pht.
- Labetalol (Trandate) loi c ch c anpha v bta giao cm, dng tt nhng
bnh nhn nhi mu c tim cp, chuyn tnh mch 1-2mg/pht.
- Anpha Methyldopa hay clonidine chuyn tnh mch.
- Cc loi c ch men chuyn: Captopril 25mg ngm di li.
- Thng phi hp thm Lasix chch tnh mch.
2.1.Thuc li tiu
Thiazid v ging thiazid
Li tiu quai
Khng Aldosteron
2.2Thuc tc ng ln thn kinh giao cm
ng vn giao cm trung ng
Chn giao cm
2.3Thuc gin mch
Nhm thuc gin mch trc tip
Chn dng Calci
c ch men chuyn dng Angiotensin
c ch th th AT1 ca Angiotensin II

Tn thuc (INN)

Bit dc

Dng bo ch

Thuc li tiu

Lasix

Vin nn 40 mg

Furocemid

Furocemid

ng tim 20mg

Indapamide

Natrilix

Vin nn 40mg

Hydroclothiazid
Hydroclothiazid

Hypothiazid

Vin nn SR 1,5mg
Vin nn 25 mg

Khng Aldosteron

Aldacton

Vin nn 25mg

Spironolacton

Verospiron

Vin nn 25mg

c ch men chuyn

Captopril

Vin ngm di li

Captopril

Ednyd

Vin nn 5mg

Enalapril

Coversyl

Vin nn 10mg

Perindopril

Vin nn 5mg

sinopril

Zestril

Vin nn 10mg

Imidapril

Tanatril

Vin nn 5mg
Vin nn 40 mg
Vin nn 5mg

ng vn giao cm
trung ng

Aldomet

Vin nn 250 mg

Chn giao cm

Betaloc

Vin nn 50mg

Metoprolol

Concor

Vin nn 25 mg

Bisoprolol

Propranolol

Vin nn 5mg

Methyldopa

Propranolol

Vin nn 40 mg

Chn dng calci

Amlodipin

Vin nn 5mg

Amlodipin

Amlor

Vin nn 5mg

Lacidipin

Normodipin

Vin nn 5mg

Nifedipin

Lacipin

Vin nn 2mg

Andalat

Dung dch nh git

Andalat

Vin nn SR 25mg

Micardis

Vin nn 40 mg

c ch th th AT1
Telmisartan

Cc phi hp thuc c tng tc

Mc

c ch men chuyn + Spironolacton

Nng

Antacid + c ch men chuyn

Va

Chn giao cm + Glyclazid

Va

c ch men chuyn + NSAIDs

Va

Chn giao cm + NSAIDs

Va

Li tiu + NSAIDs

Va

Chn giao cm + Diazepam

Va

Phi hp thuc sai:


Phi hp thuc h p cng nhm
Chn dng Calci + Chn dng Calci:
*
Amlodipin* + Nifedipin
Li tiu + Li tiu:
*
*
Indapamid + Furocemid
*
*
Furocemid + Hypothiazid

3. CO XUONG KHOP (nguyn tc iu tr, c nhng thuc g, cch s dng)

1.2.2. Cc nhm thuc chnh iu tr bnh l c xng khp


1.2.2.1. Nhm thuc chng vim khp c tc dng iu bin bnh (Disease-Modifying
Anti-Rheumatic Drugs DMARD)
c im chung ca nhm thuc ny l c tc dng chng vim khng c hiu,
gim au, thuyn gim tin trin bt li ca bnh, gim protein C phn ng, ci thin cc
xt nghim cn lm sng v yu t dng thp v lm chm qu trnh bo mn xng .
DMARD c khuyn co iu tr sm ngay khi c chn on vim

khp dng thp . Mt s thuc thuc nhm ny bao gm: thuc chng st
rt tng hp (cloroquin, hydrocloroquinolon), methotrexat, cc thuc c ch min dch
(azathioprin, leflunomid, cyclosporin, cyclophosphamid, sulfasalazin) v mt s thuc
khc nh mui vng, penicilamin
Methotrexat l DMARD hng u c ch nh vi vim khp dng thp v vy
nn. Methotrexat l mt thuc khng chuyn ha, c ch sinh tng hp DNA . Ngoi
ra, methotrexat cn c hiu qu chng vim v c ch min dch . Tc dng khng
mong mun ch yu ca methotrexat l lot ming, suy gim chc nng gan, tn thng
ng tiu ha
Cc thuc c ch min dch c chng minh c hiu qu trong iu tr vim
khp dng thp, tuy nhin, hiu qu ca cc thuc ny khng vt tri hn methotrexat
v cc tc nhn sinh hc. Nhm ny c ch nh trong cc trng hp iu tr tht bi
hoc chng ch nh vi methotrexat .
1.2.2.2. Nhm cc tc nhn sinh hc
Cc tc nhn sinh hc sinh hc gy c ch hoc tng tc vi chc nng ca cc
cytokin hot ng trong c ch bnh sinh ca vim khp dng thp, in hnh l cc
thuc khng TNF (Tumor Necrosis Factor), bao gm: etanercept th th typ 2 ca TNF
gn vi khng th IgG, infliximab khng th n dng khng TNF, adalimumab
khng th y khng TNF, abatacept cht c ch t bo T .Cc tc nhn
sinh hc c ch nh trong cc trng hp vim khp dng thp nng, khng vi cc
thuc iu tr thng thng khc, thng kt hp vi methotrexat. Tc dng khng mong
mun ng ngi nht l lao v cc nhim khun c hi
1.2.2.3. Nhm thuc chng vim
Nhm glucocorticoid c hiu qu chng vim lin quan n c ch min dch.
Nguyn tc s dng corticoid l dng liu tn cng, ngn ngy trnh hy khp v trnh l
thuc thuc. n khi t hiu qu, gim liu dn dn, thay th bng NSAID.
Nhm NSAID c ch nh ngay t u hoc sau khi iu tr bng glucocorticoid
c hiu qu. C th dng NSAID ko di khi cn triu chng vim hoc ngng khi
kim sot c tnh trng vim .
Colchicin c tc dng chng vim, gim au nhanh trong vng 48 gi, c ch
nh trong cn gt cp hoc t cp ca gt mn. Colchicin cn l mt test quan trng
gip chn on gt
1.2.2.4. Nhm thuc gim au
Thuc gim au c chia lm hai nhm l gim au trung ng v gim au
ngoi vi. Ngoi ra. mt s nhm thuc khc cng c s dng gim au, bao gm
thuc chng ng kinh, thuc chng trm cm v thuc an thn kinh
Cc thuc gim au trung ng c ch nh trong cc trng hp au mc
nng v va khi nhm thuc gim au ngoi vi khng hiu lc. Cc thuc thuc nhm
ny thng km theo tc dng gy ng v gy nghin. Da trn mc gim au, nhm
ny c phn thnh hai phn nhm l gim au mnh (morphin, fentanyl, methadon)
v gim au trung bnh (codein, tramadol, propoxyphen, detropropoxyphen...). Tc dng
khng mong mun ca cc thuc gim au trung ng bao gm: to bn, bun nn, nn
(khng ph thuc vo liu); c ch h hp v gy nghin (ph thuc liu v thi gian
iu tr)
Cc thuc gim au ngoi vi c ch nh trong cc trng hp au cm th t
nh n va. Cc thuc thuc nhm ny thng c thm tc dng chng vim (tr

paracetamol) v h st. Mc c ch chn lc i vi COX 1 hoc COX 2 ca mi


NSAID cho bit kh nng gy ra tc dng khng mong mun. Cc thuc c ch khng
chn lc c nguy c gy ra cc tc dng khng mong mun nh lot d dy t trng, suy
thn v chy mu nhiu hn, trong khi cc thuc c ch chn lc COX 2 c nguy c
gp tc dng khng mong mun t hn
Mi NSAID c mt mc liu gim au gii hn, khi tng n mc ti a cho
php m vn khng tc dng th phi phi hp thm thuc. Kiu phi hp ph bin
nht l cc nhm thuc gim au vi nhau nhng khng c phi hp hai thuc c cng
kiu ADR nh nhau. Khi NSAID khng gim au, nn phi hp thm nhm thuc
gim au trung ng trung bnh nh codein, dextropropoxyphen... nu phi hp vn
khng gim au tha ng, phi phi hp thm 1 thuc gim au opiat. Ngi bnh au
ko di thng c iu tr thm nhm thuc chng trm cm
1.2.2.5. Cc thuc iu tr h tr
Hai nhm thuc iu tr h tr c s dng ph bin trong cc bnh l CXK l
nhm thuc c ch bm proton v khng sinh. Nhm thuc c ch bm proton c s
dng vi mc ch hn ch tc dng khng mong mun ca glucocorticoid khi s dng
di ngy. Khng sinh c ch nh trong t tin trin ca vim khp phn ng hoc khi
vn tn ti nhim trng sau khi khi pht vim khp

1.Glucocorticoid: methylprednisolon
2.Thuc c ch bm proton: rabeprazol, omeprazol, esomeprazol
3.Nhm NSAID: meloxicam, paracetamol, celecoxib, diclofenac, piroxicam
4.Thuc gim au trung ng: tramadol
5.Vitamin v khong cht: vitamin C, vitamin K
6.Khng sinh v chng k sinh trng: cefepim, ciprofloxacin, levofloxacin,
cefoperazon, cefuroxim, clindamycin, metronidazol
7.Thuc iu tr gt: colchicin
8.Nhm DMARD: methotrexat
9.Thuc gin c: eperison, tolperison
10.Thuc iu tr thoi ha khp v long xng: diacerin, glucosamin, acid
zoledronic
11.Hormon: calcitonin
12.Thuc iu tr tng huyt p (nhm c ch men chuyn, nhm c ch AT1, nhm
chn knh canxi): nifedipin, amlodipin, telmisartan, enalapril
13.Thuc hng tm thn, an thn kinh (nhm benzodiazepin, nhm chng trm cm
ba vng): diazepam, pregabalin, amitriptylin
14.Thuc iu tr i tho ng : insulin, gliclazid

15.Thuc khng histamin H1: fexofenadin


16.Thuc tc dng ln h mu : cilostazol
17.Thuc iu tr ri lon lipid mu: atorvastatin
18.Thuc cp cu: adrenalin
19.Thuc li tiu quai: furosemid
20.Thuc tc dng trn ng h hp: ambroxol
21.Thuc chng nn: metoclopramid

allopurinol (thuc iu tr gt); cloroquin (thuc DMARD).


Ph lc 2 thuc c xng khp
4. NHI MU NO(nguyn tc iu tr, c nhng thuc g)
4.1 Cc nhm thuc s dng
1 Bo v thn kinh
2 Khng sinh
3 Vitamin- khong cht
4 D phng lot d dy
5 Chng ngng tp tiu cu
6 H lipid mu

7 H huyt p
8 Tr tim mch
9 An thn
10 Chng ng
11 H st - gim au
12 H ng huyt

NMN cp l mt bnh cnh lm sng phc tp, nghim trng. iu tr ni khoa NMN cp bao gm 3 vn
chnh l x l cp cu iu tr cc nguyn nhn v yu t nguy c v phng v iu tr cc bin
chng
-

Vit Nam hin nay, vic s dng thuc tiu si huyt cho bnh nhn NMN cp cn mang tnh
nghin cu, th nghim ch mt s t cc bnh vin ln
thuc chng ng ch c cn nhc s dng trong cc trng hp c bit nh bnh nhn NMN
cp-do-huyt-khi-t-tim (rung nh, nhi mu c tim, bnh van tim gi...) hoc c nguy c cao b
huyt khi tnh mch su v tc mch phi [4]. Trong thc t ti khoa phng, thuc CNTTC c
ch nh cho hu ht cc bnh nhn NMN cpkhng-do-huyt-khi-t-tim. Trong khi, cc bnh
nhn c ch nh dng thuc chng ng,khong phn na l cc bnh nhn vi NMN-cngun-gc-huyt-khi-t-tim khng hoc ckm lit ngi; cc trng hp khc thng c lit,
xt nghim hnh nh thy tc ng mch chi di, tc ng mch no hoc c hi chng tng tiu
cu... Hai thuc CNTTC c s dng gm aspirin v clopidogrel; hai thuc chng ng c
s dng gm enoxaparin v acenocoumarol.
Cc thuc BVTK c s dng ph bin trong nghin cu bao gm piracetam, cao Ginkgo
biloba v glutathion, cholin alfoscerat, cerebrolysin v citicolin. Ti Vit Nam, cc thuc
BVTK ni trn cng a v ang c s dng cc tuyn. Nhn xt bc u thy an ton
ca cc loi u cao, cha thy trng hp no b tai bin do thuc, nhiu trng hp cho kt qu
tt nn cc thuc BVTK vn c ch nh dng song song vi vic tip tc nghin cu
Tng huyt p thng xy ra trong giai on nhi mu no cp (khong 60% cc bnh nhn t
qu cp c huyt p tm thu > 160 mmHg). L do ca vic dng thuc h huyt p bao gm
lm gim ph no, phng s ph hy mch mu v cn t qu ti pht sm. Tuy nhin, iu tr
qu mc tng huyt p c th gy hi bi v lm gim ti mu n vng thiu mu, c th tng
kch thc vng NMN. Khuyn co ca AHA/ASA nm 2007 - M [1] v ca chu u 2008 l:
cn dng thuc h p trn bnh nhn NMN c huyt p >220/120mmHg v i vi cc bnh nhn
b cc bnh l i km nh suy thn cp, ph phi cp tnh, suy tim hoc hi chng mch vnh cp
cn iu tr tch cc huyt p. Thuc h huyt p nn c s dng li trong vng 24 gi cho cc
bnh nhn b THA t trc v c trng thi thn kinh n nh tr khi c chng ch nh khc. Bn
nhm thuc h huyt p c s dng iu tr tng huyt p c s dng trong nghin cu bao
gm nhm chn th th angiotensin, nhm li tiu, nhm chn knh canxi v nhm c ch
men chuyn.
C quan im cho rng, thuc i khng histamin 2 hoc thuc c ch bm proton c
khuyn dng dng cho tt c cc bnh nhn phng bin chng lot/vim d dy
T l bnh nhn s dng khng sinh kh cao (85,1%). Thc t, cc khng sinh c s dng trn
bnh nhn NMN cp a s c ch nh iu tr bin chng nhim khun sm l vim phi, t
ph bin hn l iu tr nhim khun ng niu, lot da do t v mt s t trng hp
iu tr cc nhim khun khc nh vim mng tim, nhim khun huyt, nhim khun mt iu
ny ph hp vi dch t cc bin chng nhim khun trn bnh nhnTBMMN. Cc xt nghim
nh danh vi khun, khng sinh khng c tin hnh thng xuyn m ch tin hnh trn cc
bnh nhn nng nh nghi ng c nhim khun huyt. Do , trong thc hnh lm sng iu tr
khng sinh ch yu theo kinh nghim ti bnh vin thng s dng nhm khng sinh ph rng
nh aminoglycosid, nhm penicilin ph rng (ampicilin, amoxcilin), nhm cephalosporin
(c bit nhm cephalosporin th h 2-3-4), quinolon vi mc tiu iu tr bao vy. Phi hp
khng sinh (ch yu l phi hp nhm cephalosporin v nhm aminoglycosid hoc phi hp
cephalosporin + quinolon) thng c ch nh trn bnh nhn nhim khun nng, bnh nhn
th my, t sonde, c suy thn cp, bnh nhn ln tui...

4.2 Cc tng tc mc nng thng l cc phi hp tng c tnh trn thn (furosemid +
aminoglycosid), lm tng nng kali mu (phi hp KCl, thuc li tiu gi kali spirolacton, thuc c
ch men chuyn, thuc chn th th angotensin II), lm tng nguy c xut huyt (phi hp nhm chng
ng, nhm CNTTC), gim tc dng ca clopidogrel (clopidogrel + nhm c ch bm proton)...