CHONG

Tp.HCM

BS Bi Xun Phc
B mn Ni- HYD

MUC TIEU HOC TAP

1. nh ngha.
2. Sinh ly benh.
3. Nguyn nhn v phn loi.
4. Bien chng.
5. Chan oan.
6. X tr.

I. nh ngha:

Chong l tnh trng ti mu cung

cp cc cht dinh dng cn thit
cho cc m v cc c quan khng .
Hu qu cui cng l ri lon chc
nng mng t bo, ri lon chuyn ho
t bo v cht t bo.

II. Sinh l bnh:

c im ca chong l gim ti mu m
h thng, mt cn bng cung-cu oxy
ca m, thiu oxy cho m (hypoxia).
Tn thng t bo trong chong: ri lon
chc nng bm ion ca mng t bo,
ph ni bo, r r cc thnh phn ni bo
vo gian bo, mt iu ho pH ni bo.

Ri lon h thng:
Thay i PH mu.
Ri lon chc nng ni mc.
Kch hot h thng vim v khng vim ca
c th.
Chong ko di s dn n cht t bo, suy a
c quan v t vong. Do cn nhn bit
chong sm v iu tr kp thi.

Chong giai on 1: Chong cn b.

Tt huyt p c th do gim cung lng tim hoc
dn mch ngoi vi.
Cc c ch b tr c khi kch nhm phc hi
p lc ng mch v ti mu cho cc c
quan quan trng nh no, tim.
Triu chng kh nhn bit. Nu pht hin v iu
tr kp thi th nhiu trng hp qua khi.
Nhp tim nhanh, huyt p bnh thng hoc gim
nh, hiu p gim, co mch ngoi bin nh,
bt rt.

Chong giai on 2: Chong mt b.

Tnh trng gim ti mu cc c quan:
No: ri lon tri gic.
Thn: thiu niu.
Tim: thiu mu c tim.
Bnh nhn c y triu chng ca chong:
Mch nhanh, nh, kh bt.
Huyt p tt.
Th nhanh
Co mch ngoi bin, tm u chi, v m hi.

Chong giai on 3:
Chong khng hi phc.

Gim ti mu m ko di
thay i chc nng mng t bo,
kt tp t bo mu trong vi tun
hon nghn mao mch tn
thng t bo.
Huyt p gim nng gim ti
mu cc c quan sng cn
vng xon bnh l suy sp tun
hon suy a c quan.

Multiple Organ System Failure

(MOSF)
Hoai t ong than cap.
Hoai t niem mac ng tieu hoa.
Ton thng te bao noi mac mach mau RL
tnh tham mang mao mach mat dch va
protein ni mch gim th tch tun hon v gim HA.
Ton thng te bao noi mac mach mau DIC.
oc to cua vi khuan phan ng vi bach
cau polypeptides gian mach gim HA.
Giam ti mau c tim gim co bp c tim gim
cung lng tim v gim HA.
Te bao b huy hoai choang khong hoi
phuc.

III. Nguyn nhn v Phn loi:

Ti mu cho cc c quan ph thuc vo:

1/ Tim bm.
2/ Trng lc mch mu.
3/ Th tch tun hon.
4/ S thng sut ca ng dn mu.

Ti mu c quan tht bi khi:

1/ Tim suy: chong tim.
2/ Gim hoc mt trng lc mch mu:
chong nhim trng, chong phn v.
3/ Gim th tch tun hon: chong gim th
tch.
4/ Tc nghn dng mu: thuyn tc ng
mch phi, hp van hai l kht.

Do chong c xp thnh 4 nhm:

1/ Chong tim.
2/ Chong phn phi.
3/ Chong gim th tch.
4/ Chong do tc nghn mch mu ngoi tim.

1. Chong gim th tch:

L loi chong thng gp nht.

Chong gim th tch l do gim s lng
dch ni mch tuyt i (thng t ngt) so
vi dung tch ca h mch mu, lm gim
lng mu v tht phi cung lng tim
gim.
Khi th tch ni mch gim 10%: HA gim
nh, gim cung lng tim nh.
Khi th tch ni mch gim 20%: HA gim
va, gim cung lng tim va.

Khi th tch ni mch gim 40%: HA gim

nng, gim cung lng tim nng.
Nu tnh trng ny ko di vi gi th t
vong gn nh chc chn d hi sc tch
cc.
Bnh nhn c bnh l tim mch, h hp,
thn, no i km th tnh trng chong
cn nng n hn.

Nguyn nhn:

Mt mu: chy mu, xut huyt ni.

Mt nc - in gii:
ng tiu ho: tiu chy, nn i.
ng thn: tiu nhiu.
Qua tn thng b mt c th: bng.
Thot dch vo ngn th ba: c chng,
tc rut.

Lm sng:

C bnh NN gy mt mu, mt nc.

Gim ti mu cc c quan
Du mt nc: mt trng, da kh, mi li
kh, vo da(+), TM c xp, nhn cu mm
Du mt mu: da xanh, nim nht
CVP gim, ALMP bt gim.
CTM:

Hct gim khi mt mu.

Hct tng khi mt nc lm c c mu.
BC bnh thng.

2. Chong tim:
Nguyn nhn: 2 nhm
a. Nhi mu c tim cp:
Khi s lng c tim hoi t 25-40% s
lm sc co bp c tim gim nng.
Chong cn c th do cc bin chng c
hc: thng vch lin tht, h van hai l
cp, v tim.

b. Khng do Nhi mu c tim:

Bnh van tim nng: hp kht van M ch.

Bnh mng ngoi tim co tht.
Bnh c tim tc nghn.
Vim c tim.
Ri lon nhp tim.

Lm sng chong tim do NMCT cp:

Tt HA (HA trung bnh < 60 mmHg).

Gim cung lng tim (Ch s tim < 2
l/pht/m2).
Tng p lc M phi bt (PAOP > 18
mmHg).
Tng sc cn ngoi bin.
Gim ti mu cc c quan: thiu niu,
ri lon tri gic...

3. Chong do phn phi dch:

Khng lc mch mu gim nng, vt qu s b tr
ca tnh trng tng cung lng tim.
a. Chong nhim trng:
Thng do nhim trng gram m: E.coli, Klebsiella,
Enterobacter, Pseudomonas.
Bat ky o nhiem trung nao cung co
the gay ra chong NT: viem ai be
than, viem phoi, viem phuc mac,
viem ng mat, viem mo te bao,
viem mang nao, cac loai ap xe..

SINH LY BENH
O nhiem
trung
Tang sinh va lan rong
cua vi khuan
Hoat hoa he thong khang
c cua ky chu
Phong thch hoa chat
trung gian
Anh hng cac c
quan
Chong nhim

Cc giai on ca chong nhim trng:

Chong NT c 3 kiu huyt ng hc:

Chong m = G 1
Chong lnh = G 2
MOSF = G 3
Ranh gii gia cc giai on khng r rng.
Cn chn on sm.

Lam
sang:
NH
NGHA (consensus, critical care medicine 2001 )
SIRS-Systemic Inflammatory Response Syndrome:
t nhat co 2 trong 5 tieu chuan:
* Tan so tim > 90l/ph
* Nhp th > 20/ph hay PaCO2 < 32 mmHg (hay can
phai th TKNT)
* Tang hay giam than nhiet (T > 38C hay < 36C)
* Tang hay giam BC ( > 12000/mm3 hay < 4000/
mm3) hay co >10% dang cha trng thanh.
* Cac ch iem sinh hoc cua viem: C-reactive
protein, Interleukin-6, D-dimer

Lam
sang:
Sepsis : SIRS + chac chan hay nghi ng
do nhiem trung.
Severe sepsis: sepsis + suy 1 hay nhieu
c quan + giam HA hay giam ti mau
(= nhiem toan lactic, thieu nieu va
roi loan y thc).
Septic Shock: Severe sepsis + Tut HA keo
dai khong ap ng vi bu dch ma
phai can dung thuoc van mach.

b. Chong phn v:
Phn v (Anaphylaxis):
L phn ng d ng cp tnh, ton thn, mc
t nh n rt nng v t vong.
Bn cht l phn ng min dch, ph thuc vo
s thnh lp IgE, l 1 globulin min dch chu
trch nhim cc phn ng d ng.
Phn ng dng phn v (Anaphylactoid
reaction):
Khng qua trung gian IgE.
Lm sng khng phn bit c vi phn v.
iu tr ging phn v.

C che benh sinh cua choang

phan ve

Lm sng:
Triu chng thng xy ra nhanh sau khi tip
xc vi d nguyn.

Da: nga, ni m ay, ph mch.

H hp: kh th, th rt (ph thanh qun), kh
kh (co tht ph qun).
Tun hon: mch nhanh, tt HA, ri lon tri gic.
Tiu ho: bun nn, nn, au bng, tiu chy.

T vong thng do suy h hp, tt HA.

4. Chong do tc nghn mch mu ln:

Chn p tim cp
Trn kh mng phi p lc.
U nhy nh tri.
Thuyn tc phi din rng (do huyt khi, kh,
nc i...

Chong kt hp:
Nhiu c ch chong trn cng 1 bnh nhn.
V d: chong NT + Chong gim th tch...

IV. Bin chng:

1. DIC: ng mu ni mch lan to

L bin chng thng gp trong chong, c

bit l chong nhim trng gram m. Khi c
HC ny th t l t vong rt cao.
L tnh trng ng mu ni mch v tiu
fibrin xy ra ng thi.
Biu hin lm sng l tnh trng xut huyt.
Gy hoi t v thn, tn thng cc c
quan, tiu hao yu t ng mu, gp phn
gy chong phi.

2. ARDS: Hoi chng nguy

ngap ho hap cap

Cn gi l chong phi.
L bin chng thng gp ca chong,
c bit l chong nhim trng.
Lm sng: ph phi cp khng do tim.
Suy h hp cp gim oxy mu nng.
Km p ng vi iu tr oxy.
X quang: thm nhim phi lan rng.

3. Suy than cap:

L bin chng thng gp ca chong.

Nguyn nhn chnh l do gim ti mu
thn trong tnh trng tt huyt p.
Lm sng:
Thiu niu, v niu.
Ur, creatinin mu tng.

4. Bin chng trn gan, tim, no:

Gan: tn thng gan cp.

Lm sng: tng men gan, tng bilirubin...
Tim: nu huyt p gim nng (< 60 mmHg),
toan mu nng s gy gim co bp c tim
cung lng tim gim.
No: khi huyt p gim nng, toan mu nng,
gim oxy mu, h ng huyt... bnh nhn
s bt rt, vt v, l m, l ln, hn m.

V. Chn on:
1. Lm sng:

Mch nhanh, nh, kh bt.

Huyt p tt (HA tm thu < 90 mmHg), kp.
Co mch ngoi bin: da lnh, rn m hi;
u chi, mi, tai lnh, tm; thi gian y
mao mch ko di > 2 giy.
Th nhanh.
Thiu niu (V nc tiu < 25 ml/gi).
Triu chng ca bnh nguyn nhn. Cn
hi k bnh s, tin cn.

2. Cn lm sng- Th thut:
Gip chn on nguyn nhn, chn on
phn bit, nh gi tnh trng chong.

Cng thc mu. XN ng mu nu nghi ng

c DIC.
Chc nng gan, thn, ion , kh mu M.
o Lactate mu tnh mch.
X quang tim phi, ECG.
Cy tm vi trng trong m, mu, nc tiu.
Siu m tim, men tim...

2. Cn lm sng- Th thut:

o p lc tnh mch trung tm gip nh gi

th tch tun hon.
o HA ng mch xm ln gip nh gi HA
chnh xc.
p lc M phi bt tng trong chong tim.
t sonde tiu theo di lng nc tiu.
t sonde mi- d dy.

VI. X tr:
Cc bin php chung:
iu tr chong ti Khoa Sn sc c bit (ICU).
Th oxy.
Th my khi cn.
B th tch tun hon.
Dng thuc vn mch.
iu chnh ri lon in gii, kim-toan...
Theo di: DHST (M, HA, T0, Nhp th, Sp02), lng
nc tiu, CVP, HA M xm ln.

Nang tuan hoan- Goals of

therapy
Reasonable goals for initial resuscitation includeMuc tieu hoi sc trong 6 gi au:

Central venous pressure 8 to 12 mmHg

Mean arterial pressure 65 mmHg
Urine output 0.5 mL per kg per hour
Central venous or mixed venous oxygen
saturation 70 percent.

Thuoc van mach: cac loai

thu the
Cac loai thu the giao cam:
1: nam chu yeu thanh mach. Kch thch cac thu the nay
gay co c trn thanh mach, tang huyet ap.

2: nam tien synap co tac dung ieu hoa ngc am tnh .

Kch thch cac thu the nay c che giai phong noradrenaline.

1: nam chu yeu tim va c trn thanh ruot. Kch thch thu
the nay gay tang co bop c tim, tang nhp tim va gian c
trn thanh ruot.

2: thng thay phe quan, t cung, c trn thanh mach.

Kch thch 2 gay gian mach va gian phe quan.

Thuoc van mach: cac loai

thu the
Cac thu the dopaminergic:
Cac loai thu the nay co than kinh trung ng (ni dopamine la
mot chat dan truyen than kinh quan trong).
ngoai vi cac thu the dopaminergic co :
D1: mach mau ngoai bien, mach than, mach mac treo. Kch thch cac
thu the nay gay dan mach.
D2: tien synap, co tac dung c che phong thch hoa chat trung gian.

Cac thu the vasopressine:.

V1 nam c trn thanh mach, co tac dung gay co mach.
V2 nam ong gop, co tac dung tai hap thu nc.
V3 nam tuyen yen co tac dung gay tang tiet ACTH.

1. Chong gim th tch:

iu tr ch yu l bi hon th tch tun
hon v iu tr nguyn nhn.

Dch truyn:
NaCl 0.9%, Lactate Ringer.
Dung dch cao phn t (Dextran...).
Chong mt mu: truyn mu.
Tc truyn:
BN khng suy tim sung huyt: c th bolus 500 ml
dch, sau iu chnh tc tu theo HA, CVP, tnh
trng ti mu c quan.
ng truyn: ng tnh mch ngoi bin, kim ln.
Th tch b: tu thuc lng dch mt v p ng BN.

2. Chong phn phi:

a. Chong nhim trng:

Bi hon dch.
Thuc vn mch: Khi b dch hoc gn
(CVP bnh thng hoc hi cao) m HA khng ln,
tnh trng ti mu c quan khng ci thin.
Dopamin:
Liu thp (2-3 g/kg/p): tc dng Dopaminergic gy
dn mch thn.
Liu trung bnh (4-5 g/kg/p): tc dng ln th th
1 lm tng co bp c tim, tng cung lng tim.
Liu cao (> 10 g/kg/p): tc dng ln th th gy
co mch, tng huyt p.

Noradrenaline: tc dng v 1.
L thuc gy co mch mnh, dng khi HA
gim nng, hay khi dng Dopamin khng c
p ng.
Liu: 2-20 g/p
Gii quyt tnh trng nhim trng:
Khng sinh.
Phu thut khi c ch nh.

b. Chong phn v:
ADRENALINE: Thuoc hang au trong
ieu tr phan ve.

Giup on nh huyet ong, dan phe quan, ngan

phong thch hoa chat trung gian them t te bao mast.
Lieu: 0.3- 0.5 ml Adrenaline 1/1000 (tre em: 0.01 ml/Kg) IM,
SC.
Tiem bap (vung ui trc- ben) tot hn tiem di da
Lap lai moi 10-15 phut khi can.
BN nang (co trieu chng ho hap nang hay co tut
huyet ap):
Adrenaline IV 0.1mg (1ml dung dch 1/10.000) moi 5 phut.
BN tut huyet ap keo dai: Adrenaline truyen tnh mach
lieu khi au 1-4 g/phut va tang lieu dan e at
HA thch hp.

3. Chong do tc nghn mch mu ln:

Cn tm ra nguyn nhn gii quyt, v iu tr ni

khoa t mang li kt qu.
Trn dch mng ngoi tim:
Truyn dch tng sc y tm tht.
Chc tho mng ngoi tim.
Thuyn tc phi din rng:
Truyn dch.
Thuc vn mch (Dopamin, Noradrenalin)
nng HA ln tm thi.
Thuc tiu si huyt, phu thut ly huyt khi.

4. Chong tim:

Th oxy. Th my khi cn.

Truyn dch cn thn. Trnh thiu dch hay
d dch.
Thuc tng co bp c tim, thuc vn mch:
Dopamin, Dobutamin.
Dng c h tr tun hon: t bng di
nghch trong M ch gip gim cng ca tim
v ti mu mch vnh tt hn.
iu tr trit : thng M vnh, phu thut
bt cu M vnh, thay van tim, thay tim.