The Final - HDĐT H I S C Tích C C 2015422 PDF

B Y T
HNG DN CHN ON V X TR
HI SC TCH CC
(Ban hnh km theo Quyt nh s 1493/Q-BYT ngy 22/4/2015
ca B trng B Y t)
H ni, 2015
Ch bin
PGS.TS. Nguyn Th Xuyn
ng Ch bin:
PGS.TS. Nguyn Gia Bnh
PGS.TS. Lng Ngc Khu
Ban bin son
PGS.TS. Nguyn Gia Bnh
PGS.TS. ng Quc Tun
PGS.TS. Nguyn Hng Sn
TS. Phm Th Ngc Tho
TS. Trn Qu Tng
TS. L c Nhn
TS. Trn Thanh Cng
TS. L Th Dim Tuyt
TS. Trn Hu Vinh
TS. o Xun C
TS. Nguyn Cng Tn
Ths. Bi Th Hng Giang
Ths. Nguyn ng Tun
Ths. Giang Thc Anh
Ths. Phm Th Thch
Ths. Bi Vn Cng
Ths. Mai Vn Cng
Ths. Ng minh Bin
Th k
Ths. Nguyn c Tin
TS. Nguyn Cng Tn
Ths. Nguyn ng Tun
Ths. Ng Th Bch H
Ths. Trng L Vn Ngc
MC LC
DANH MC CC T VIT TT
Chng I: H HP ............................................................................................................. 1
1. Chn on v x tr suy h hp cp ........................................................................1
2. Suy h hp nng do t mt b cp ca bnh phi tc nghn mn tnh .................8
3. Cn hen ph qun nng v nguy kch ...................................................................13
4. Hi chng suy h hp cp tin trin .....................................................................23
5. Trn kh mng phi bnh nhn th my ............................................................ 30
6. Vim phi nng do vi khun ti cng ng .......................................................... 34
7. Vim phi lin quan n th my .........................................................................42
8. Vim phi nng do vi rt cm A...........................................................................52
Chng II: TUN HON ................................................................................................. 59
9. Sc gim th tch mu ........................................................................................... 59
10. Sc tim .................................................................................................................65
11. Sc nhim khun ..................................................................................................73
12. Suy a tng do sc nhim khun ..........................................................................80
Chng III: TIU HA .................................................................................................... 88
13. Hi chng gan thn cp........................................................................................ 88
14. Suy gan cp ..........................................................................................................95
15. Vim ty cp nng .............................................................................................102
Chng IV: THN TIT NIU ..................................................................................... 111
16. Hi chng tiu c vn cp..................................................................................111
17. Suy thn cp .......................................................................................................116
Chng V: THN KINH ................................................................................................ 125
18. Cn nhc c nng ............................................................................................125
19. Hi chng Guillain-Barre .................................................................................132
20. Tng p lc ni s ..............................................................................................138
21. Chn on v x tr trng thi ng kinh...........................................................145
Chng VI: HUYT HC .............................................................................................. 152
22. Cc ri lon ng mu thng gp trong hi sc ..............................................152
Chng VII: SN KHOA ............................................................................................... 160
23. Hi chng HELLP .............................................................................................160
24. Sn git v tin sn git......................................................................................165
Chng VIII: NI TIT ................................................................................................. 173
25. Hn m tng p lc thm thu do i tho ng .............................................173
Chng IX: RI LON NC IN GII V THNG BNG KIM TOAN ..... 179
26. Tng kali mu .....................................................................................................179
27. H kali mu ........................................................................................................184
28. Tng natri mu ...................................................................................................188
29. H natri mu .......................................................................................................193
30. Cc ri lon thng bng kim toan.....................................................................200
31. Toan chuyn ha ....203
32. Kim chuyn ha ....206
33. Toan h hp ....209
34. Nhim kim h hp ....210
DANH MC T VIT TT
ALI
ALNS
ALT
ALTMTT
ALTT
ARDS
AST
BiPAP
BNP
BPTNMT
Tn thng phi cp (Acute Lung Injury-ALI)

p lc ni s(Intracranial pressure - ICP)
Alanine transaminase
p lc tnh mch trung tm (Central venous pressure- CVP)
p lc thm thu
Hi chng suy h hp cp tin trin(Acute respiratory distress
syndrome-ARDS)
Aspartate transaminase
p lc ng th dng vi hai mc p lc (Bilevel positive airway
pressure)
Yu t thi natri no-niu (Brain natriuretic peptide-BNP)
Bnh phi tc nghn mn tnh(Chronic Pulmonary Ostructive DiseaseCOPD)
CPAP
CPP
CT scan
CVVH
DIC
DNTB
ECMO
EPAP
ESBL
FiO2
GGT
HA
HATB
HATT
HATTr
HCGT
HPN
HPQ
IPAP
LDH
p lc ng th dng lin tc (Continuous positive airway pressure)

p lc ti mu no (Cranial perfusion pressure)
Chp ct lp vi tnh (Computed Tomography scanner)
Lc mu tnh mc-tnh mch lin tc (Continuous Veno-Venous
Hemofiltration)
ng mu ri rc trong lng mch (Disseminated Intravascular
Coagulation- DIC)
Dch ngoi t bo.
Trao i xy qua mng ngoi c th hay tim phi nhn to ti
ging(Extra Corporeal Membrane Oxygenation- ECMO)
p lc dng th th ra (Exspiratory positive airway pressure)
Men lactamase ph rng (Extended-Spectrum Beta-Lactamases)
Nng xy kh th vo (Fraction of inspired oxygen)
Gamma-glutamyl Transferase
Huyt p
Huyt p trung bnh
Huyt p tm thu
Huyt p tm trng
Hi chng gan thn
Huy ng ph nang
Hen ph qun
p lc dng th th vo (Inspiratory positive airway pressure)
Lactic acid dehydrogenase
MARS
MetHb
MRI
PaCO2
PaO2
PEEP
PEX
Pro BNP
SaO2
SGC
SpO2
TCV
TKMP
VTC
Lc mu hp ph phn t ti tun hon (Molecular Adsorbents

Recirculating System MARS)
Methemoglobin
Chp cng hng t ht nhn (Magnetic Resonance Imaging)
p lc ring phn CO2 trong mu ng mch (Partial pressure of
carbon dioxide in arterial blood)
p lc ring phn oxy trong mu ng mch (Partial pressure of
arterial oxygen)
p lc dng cui th th ra (Positive end exspiratory pressure)
Thay huyt tng (Plasma Exchange)
N-terminal pro B-type natriuretic peptide
bo ho xy mu ng mch (Saturation of arterial oxygen)
Suy gan cp
bo ho xy mu ngoi vi (Saturation of Peripheral Oxygen)
Tiu c vn
Trn kh mng phi
Vim ty cp
Chng I: H HP
CHN ON V X TR SUY H HP CP
1. I CNG
- Suy h hp c nh ngha l gim cp tnh chc nng thng kh ca b my
h hp hoc/v chc nng trao i kh ca phi.
- Suy h hp cp l nguyn nhn hng u bnh nhn phi nm ti cc khoa Hi
sc (60 70% ), trong trng hp nguy kch cn c x tr cp cu ngay lp tc ti
ch.
- Suy h hp cp c phn thnh ba nhm:
+ Suy h hp do gim oxy mu khi PaO2 di 60mmHg khi th kh phng.
+ Suy h hp do tng CO2 mu khi PaCO2 trn 50mmHg
+ Suy h hp th hn hp khi c km theo c gim PaO2 v tng PaCO2
2. NGUYN NHN
2.1. Thn kinh trung ng
- Thuc: an thn, gy ng, gy m.
- Trung tm iu ho h hp hnh no b tn thng: chn thng, bnh l
mch no, nhc gip.
- Ri lon h hp lin quan ti gic ng: ngng th khi ng trung ng, hi
chng gim thng kh do bo bu.
- Tng p lc ni s.
- Nhim trng h thn kinh trung ng.
- Hi chng gim thng kh v cn.
2.2. H thng thn kinh c
- Bnh l thn kinh c nguyn pht: hi chng Guillain Barr, nhc c, bi
lit, teo c, x ct bn teo c, vim a c.
- Thuc v ng c: ng c botulium, thuc tr su phospho hu c, cc thuc
c ch thn kinh c, aminoglycoside.
- Chn thng ct sng.
- Chn thng hoc mt chc nng thn kinh honh.
- Ri lon in gii: h Kali mu, tng Magi mu, h Phospho mu.
- Cc nguyn nhn khc: ph nim, mt mi, lit chu k.
2.3. Thnh ngc v c honh
- Mng sn di ng.
- Gy xng sn.
- G vo ct sng.
- C chng nhiu.
- Bo bu.
- Tng p lc bng.
2.4. Mng phi

- Trn kh mng phi.
- Trn dch mng phi.
- Dy dnh mng phi.
2.5. Cc tn thng nhu m phi
- Vim phi do cc nguyn nhn:vi rt, vi khun, nm, lao, k sinh trng.
- Bnh k phi do bnh h thng (sarcodoid, lupus ban h thng).
- Hi chng chy mu ph nang lan to.
- Ung th phi: nguyn pht v di cn.
- Chn thng phi do c hc hoc do sng n.
- Bng dng h hp.
2.6. ng dn kh
- ng h hp trn: m, d vt, ph hoc co tht thanh mn, nhim trng.
- Co tht ph qun doHen ph qun, phn v.
- t cp bnh phi tc nghn mn tnh (COPD).
2.7. Bnh l mch phi
- Tc ng mch phi do huyt khi, kh, nc i,..
- Bnh l mch phi: tng p lc ng mch phi nguyn pht,
2.8. Cc bnh l khc
- Ph phi cp do suy tim.
- Tng sn xut CO2: St, nhim trng,cng gip, co git, run c.
- Ng c cc cht gy Methemoglobin, ng c kh carbon oxit (CO).
- Thiu mu, tng nht ca mu.
3. TRIU CHNG
3.1. Triu chng lm sng
a) Hi tin s bnh: hen ph qun, COPD, bnh l tim mch...
b) c im lm sng:
- Nhp th tng nhanh hoc nhp th chm (so vi tui).
- Co ko c h hp: ting rt, kh th thanh qun, ran rt, co tht ph qun.
- Bin th yu (nhc c, mt c), th mnh (toan chuyn ha).
- Cch xut hin:
+ t ngt: d vt, trn kh mng phi.
+ Nhanh: Ph phi cp, hen ph qun, vim phi do vi-rt.
+ T t: u phi, trn dch mng phi, suy tim mt b...
- Cc triu chng pht hin nguyn nhn:
+ au ngc: trn kh mng phi, nhi mu phi, vim mng phi, nhi mu c
tim.
+ St: vim phi, vim ph qun...
+ Du hiu vim tc tnh mch chi di: nguy c gy tc ng mch phi
2
c) Thm khm: cn khm k v h hp, tim mch, thn kinh

- Thm khm k phi:
+ Ran m, ran rt.
+ Hi chng ba gim, ng c, tam chng ca trn kh mng phi.
+ Du hiu lit c honh
- Thm khm tim mch: du hiu v triu chng suy tim, bnh tim...
- Thm khm thn kinh: thc, triu chng lit c h hp...
3.2. Triu chng cn lm sng
- Kh mu ng mch: rt cn thit cho chn on xc nh suy h hp, phn
loi suy h hp v nh gi mc nng ca suy h hp.
4. CHN ON
4.1. Chn on xc nh
Da vo xt nghim kh mu ng mch:
- Suy h hp gim oxy khi PaO2 di 60mmHg khi th kh phng.
- Suy h hp tng CO2 khi PaCO2 trn 50mmHg.
4.2. Chn on nguyn nhn
a) XQ phi: rt c ngha trong nh hng chn on.
- Nhiu bnh l c biu hin triu chng trn X quang phi: Tn thng thm
nhim, ng c, xp phi, gin ph qun, gin ph nang,
- Mt s bnh l thng khng c triu chng X quang r: nhi mu phi, hen
ph qun, tc ng h hp trn, c ch h hp hoc lit h hp.
b) in tim: gip chn on mt s bnh tim v tm cc du hiu in tim ca bnh l
phi, cc ri lon nhp tim do suy h hp...
c) Cc xt nghim khc ty theo trng hp c th v tnh trng nng ca bnh nhn
c cho php khng:
- Cng thc mu.
- Siu m tim, in tim, Nt-ProBNP.
- Siu m tnh mch chi di, D-dimer.
- Chp thng kh ti mu phi, chp CT scan phi.
- Chp CT hoc cng hng t s no v/hoc ty sng.
- in c, chc dch no ty.
- Xt nghim phospho hu c, MetHb,
4.3. Chn on mc
Yu t
Xanh tm
Loi nng
++
Loi nguy kch

+++
V m hi
+++
Kh th
++
+++
Tng huyt p hoc tt

0
huyt p (tru mch)
+ (sp t vong)
Ri lon thc
+
giy gia, l ++
hn m +++
5. X TR
5.1. Nguyn tc x tr
iu tr suy h hp cp kt hp iu tr nguyn nhn gy suy h hp.
5.2. X tr ban u v vn chuyn cp cu
- Nhanh chng xc nh chn on suy h hp cp.
- nh gi nhanh cc nguyn nhn suy h hp cp cn can thip ngay:
+ D vt ng th: Lm th thut Hemlich y d vt ra ngoi.
+ Trn kh mng phi p lc: Ngay lp tc chc kim ln vo khoang lin sn
hai ng gia n. Sau vn chuyn n bnh vin dn lu mng phi v ht
dn lu kh mng phi.
+ Ngng th, lit h hp: Bp bng ambu v vn chuyn n bnh vin t
ng ni kh qun thng kh nhn to.
- X tr ban u suy h hp cp:
+ Khai thng ng th: ly d vt, ht m di.
+ C n bng cc nghim php: y trn nng cm, nng hm.
+ Canuyn Grudel hoc Mayo chng tt li.
+ T th nm nghing an ton nu c nguy c sc.
+ Bp bng mt n c oxy m bo thng kh.
+ t ni kh qun bp bng c oxy (nu c).
- t ng truyn tnh mch ngoi bin.
- Vn chuyn bnh nhn n trung tm cp cu v hi sc.
5.3. X tr ti bnh vin
5.3.1. X tr cp cu
- Ni soi ph qun ly d vt ng th.
- M mng phi bng ng ln ht dn lu kh mng phi p lc m.
- Ch nh t ni kh qun:
+ Tc nghn ng h hp trn.
+ Mt phn x bo v ng th.
4
+ Kh nng khc m gim nhiu hoc mt.

+ Thiu oxy mu nng khng p ng th oxy.
+ Cn thng kh nhn to xm nhp.
- Kim sot thng kh: Cc trng hp cn h tr thng kh
+ Gim thng kh:
Toan h hp vi pH < 7,25.
C nguy c gim thng kh hoc gim thng kh s tin trin nng
thm: PaCO2 tng dn; lit hoc mt c honh.
+ Thiu oxy mu nng km p ng vi th oxy.
5.3.2. xy liu php
a) Nguyn tc: Phi m bo xy mu (SpO2> 90%)
b) Cc dng c th:
- Canuyn mi: l dng c c dng xy thp 1 5 l/pht. Nng xy dao
ng t 24%-48%. Thch hp cho cc bnh nhn c mc suy h hp trung bnh,
bnh nhn COPD hoc cc nguyn nhn suy h hp khng c shunt hoc shunt trong
phi thp.
- Mt n xy: l dng c to dng thp 5-10 l/pht. Nng xy dao ng
35%- 60%. Thch hp cho cc bnh nhn suy h hp mc trung bnh do tn thng
mng ph nang mao mch (ALI, ARDS). Thn trng khi dng cho bnh nhn nn do
tng nguy c ht cht nn vo phi.
- Mt n khng th li: l dng c to dng xy thp 8-15 l/pht. Nng xy
cao dao ng mc cao 60%-100% ty thuc vo nhu cu dng ca bnh nhn v
kn ca mt n. Thch hp cho bnh nhn suy h hp mc nng do tn thng
mng ph nang mao mch (ph phi, ALI/ARDS). Thn trng khi dng cho bnh
nhn nn do tng nguy c ht cht nn vo phi.
- Mt n venturi: l dng c to xy dng cao, c th p ng c nhu cu
dng ca bnh nhn. Nng xy t 24%- 50%. u im l dng cho nhng bnh
nhn cn nng xy chnh xc
5.3.3. Thng kh nhn to (TKNT)
a) Thng kh nhn to khng xm nhp p lc dng: h tr thng kh cho bnh nhn
qua mt n (mi, mi ming)
- Ch nh:
+ Suy h hp do ph phi cp huyt ng, t cp ca COPD v hen ph qun.
+ Suy h hp nng c du hiu mt c: gng sc v tn s th trn 30/ph.
+ Toan h hp cp (pH < 7,25-7,30).
+ Tnh trng xy ho mu ti i (t l PaO2/FiO2 < 200).
- Chng ch nh:
+ Ngng th.
+ Tnh trng huyt ng khng n nh (tt huyt p hay nhi mu c tim
khng kim sot c).
5
+ Mt kh nng bo v ng th.
+ m di qu nhiu.
+ Vt v hay khng hp tc.
+ Tnh trng bnh nhn khng cho php t mt n hay khng bo m tnh
trng kn kht ca mt n.
b) Thng kh nhn to xm nhp: khi TKNT khng xm nhp c chng ch nh hoc
tht bi.
5.3.4. iu tr nguyn nhn
a) Thuc gin ph qun (kch thch beta 2- adrenergic; thuc khng cholinergic)
- Ch nh vi suy h hp do c co tht ph qun (COPD, hen ph qun)
- Nn u tin dng ng kh dung trc, nu khng p ng th chuyn sang
truyn tnh mch.
b) Corticoid: ch nh cho cc t cp ca hen ph qun, COPD.
c) Khng sinh: khi c du hiu ca nhim trng (vim phi, t cp COPD c bng
chng nhim khun).
d) Li tiu: suy tim huyt, ph phi cp huyt ng, qu ti th tch.
e) Chc dn lu dch v kh khi c trn dch v kh mng phi.
f) Thay huyt tng loi b khng th trong cc bnh t min gy lit h hp nh
nhc c, hi chng Guillain-Barre.
g) iu tr cc nguyn nhn ngoi khoa:
- Mng sn di ng: c nh xng sn bng th my hoc treo c nh.
- Chn p ty c: phu thut gii chn p.
h) Mt s nguyn nhn khng hi phc: x cng ct bn teo c,
6. TIN LNG V BIN CHNG
- Tin lng ph thuc vo nguyn nhn gy suy h hp cp.
- Suy h hp cp c th dn n tnh trng gim oxy mu tr hoc tng cac-bonic khng p ng iu tr.
7. PHNG BNH
iu tr cc bnh l nguyn nhn gy suy h hp cp:
- Suy tim.
- Bnh phi tc nghn mn tnh.
- D phng huyt khi tnh mch su chi di.
- iu tr khng sinh sm khi nghi ng vim phi do vi khun, iu tr thuc
khng virus khi nghi ng vim phi do virus.
Ti liu tham kho

1. Stone C.K., Humphries R.L.,(2008), Respiratory Distress, Current diagnosis &
treatment of emergency medicine. Mc Graw Hill Lange, Pp 181-90.
2. Mosby (2006), Rosen Emergency medicine: Concepts and Clinical Practice, 6th
edition.
3. Kaynar A.M., (2011), Respiratory Failure. www.Emedicine.com. Updated: April
13.
4. Darovic G.O. et al(2004), Hemodynamic monitoring, the second edition.
5. Kollef M.H. et al. (2008), The Washington Manual of Critical Care
6. Jean-Louis Vincent. et al (2010), Textbook of Critical care, the sixth edition.
SUY H HP NNG DO T MT B CP CA BNH PHI

TC NGHN MN TNH
1. I CNG
t mt b cp ca bnh phi tc nghn mn tnh (BPTNMT) l tnh trng
bnh giai on n nh chuyn sang nng ln nhanh khng p ng vi iu tr
thng thng hng ngy.
Suy h hp do t cp ca BPTNMT c th nng, thm ch nguy kch, nu
khng c x tr ng cch v kp thi.
2. NGUYN NHN
- Nhim trng ng h hp do vi khun hoc virus.
- iu tr hoc dng thuc khng ng cch, dng thuc ng, an thn.
- Xut hin mt bnh l khc: tc mch phi, suy tim, phu thut (nht l phu
thut bng, phu thut lng ngc).
- Cc ri lon chuyn ho: tng ng mu, gim kali.
- Cc nhim trng khc ( bng, no).
- nhim khng kh.
3. TRIU CHNG
3.1. Lm sng
- Ngi bnh c chn on BPTNMT trong tin s.
- Kh th tng ln so vi tnh trng hng ngy.
- Ho nhiu ln (c th ho khan hoc ho c m).
- m nhiu ln v tr nn c.
- Ngi bnh c th c st.
- Tm, th nhanh.
- Co ko c h hp ph (c c n chm, c lin sn, c bng).
- C th c run tay, v m hi,xanh tm.
- Huyt p tng, khi suy h hp nng, huyt p tt khi c suy h hp nguy kch.
- Nhp tim nhanh, nu hp tim chm dn l du hiu rt nng.
- Suy h hp nng c th c ri lon thc: kch thch,ng g hoc hn m.
- Nghe phi thng c nhiu ran (ran rt do tc nghn ph qun tng ln, ran m
hoc ran n do ng dch tit ph qun hoc do c tnh trng vim phi).
- Cc du hiu ca kh ph thng: lng ngc hnh thng, cc khoang lin sn
gin rng, xng sn nm ngang, tim p mi c, vng trc tim g trong).
3.2. Cn lm sng
- PaO2 gim di 60 mmHg, SpO2 gim < 90% , PaCO2 tng, pH gim.
- X quang phi: hnh nh ca bnh phi tc nghn mn tnh, c th thy m
m ca tn thng phi mi xut hin (vim phi).
8
- in tim c th cho thy hnh nh P ph, cc du hiu ca tng gnh tht

phi.
4. CHN ON
4.1. Chn on xc nh
- Tin s c chn on bnh phi tc nghn mn tnh, hoc ln vo vin
ny khm thy c cc du hiu ca BPTNMT.
- Kh th tng, ho tng, m nhiu ln v c.
- Cc du hiu ca suy h hp cp.
- Cc du hiu ca nhim trng ng h hp.
4.2. Chn on phn bit
- Lao phi.
- Trn kh mng phi ngi bnh BPTNMT.
- Cn hen ph qun.
- Cn hen tim do suy tim nng ln hoc nhi mu c tim mi.
- Xt nghim m tm vi khun gy bnh, vi rt cm khi c yu t dch t.
4.4. Chn on mc
Cc ch s
Nng
Nguy kch
Li ni
Tng t
Khng ni c
Tri gic
Ng g, ln ln
Hn m
Co ko c h hp
Rt nhiu
Th nghch thng
Tn s th/pht
25-35
Th chm, ngng th
Kh th
Lin tc
Lin tc
Mch/pht
>120
Chm, lon nhp
SpO2 %
87-85
< 85
PaO2 mmHg
40-50
<40
PaCO2 mmHg
55-65
> 65
pH mu
7.25-7.30
< 7.25
Ch : Ch cn c 2 tiu chun ca mc nng tr ln mt mc l .
5. X TR
5.1. Nguyn tc x tr
- X tr t cp BPTNMT mc nng bao gm: bo m oxy mu, dng
thuc gin ph qun, khai thng ng h hp (gii quyt tnh trng ng m),
dng khng sinh iu tr nhim khun h hp (thng l nguyn nhn dn n t mt
b cp ca BPTNMT) v iu tr cc bnh l km theo, iu tr d phng bin chng.
- Cho ngi bnh th oxy nu c th, lu lng oxy 1 - 2 lt/pht.
- Dng thuc cng bta-2 giao cm tc dng nhanh ti ch: kh dung qua mt
n 5 mg (salbutamol, terbutalin), hoc xt 2 - 4 nht/ln, c th nhc li 10 -15 pht
9
mt ln nu cha c hiu qu; phi hp vi thuc c ch ph giao cm tc dng nhanh

(ipratropium) kh dung hoc xt.
- Dng khng sinh nu c ch nh (xem phn 5.3.1.d).
- Chuyn ngi bnh i bnh vin: trn ng chuyn cn theo di tnh trng
h hp, tip tc dng thuc gin ph qun xt 10 -15 pht mt ln nu cn.
a) t cp bnh phi tc nghn mn tnh c suy h hp nng
- Oxy: th oxy qua gng knh oxy, gi SpO2 90% - 93%. Khng dng lu
lng oxy qu 2 lt/pht. Nu oxy mu tng ln nhanh, ngi bnh c th gim thng
kh, lm cho PaCO2 tng cao v nhim toan nng.
- Thuc gin ph qun
+ Dng thuc gin ph qun ti ch:
Thuc cng bta-2 giao cm, kh dung qua mt n 5 mg (salbutamol,
terbutalin), nhc li tu theo tnh trng ngi bnh, c th nhiu ln.
Thuc c ch ph giao cm: ipratropium (0,5 mg) kh dung qua mt n, nhc li
nu cn thit.
+ Dng thuc gin ph qun truyn tnh mch: thng dng thuc gin ph
qun ng tnh mch kt hp khi liu php kh dung km hiu qu:
Thuc cng bta-2 giao cm (salbutamol, terbutalin). Tc khi u
0,1g/kg/pht, iu chnh liu theo p ng ca ngi bnh (tng tc
truyn 5 - 10 pht/ln, mi ln 0,1g/kg/pht cho ti khi c p ng).
Nu kh dung v truyn tnh mch cc thuc cng bta-2 giao cm
khng hiu qu gin ph qun, c th dng aminophyline 0,24g pha
vi 100ml dch glucose 5%, truyn trong 30-60 pht, sau truyn duy
tr vi liu 0,5mg/kg/gi.
Trong trng hp dng ht cc thuc gin ph qun nh trn m vn
khng gii quyt c cn phi xem xt t ng ni kh qun, th cn
nhc dng thm adrenalin liu thp 0,01g/kg/pht iu chnh liu theo
p ng lm sng, nu xut hin lon nhp hoc huyt p tng ln th
ngng.
- Corticoid
+ Methylprednisolon 2mg/kg/24 gi tim tnh mch. Khi ngi bnh n nh s
chuyn sang ng ung.
+ Corticoid ch nn dng trong 10 - 14 ngy hn ch cc tc dng khng
mong mun.
- Khng sinh
+ Khng sinh c s dng khi nhim khun l nguyn nhn dn ti t cp
ca bnh phi tc nghn mn tnh.
+ Ch nh khng sinh khi c cc du hiu:
Kh th tng.
10
Lng m tng.
m m.
Hoc c 2 trong 3 du hiu trn, trong c du hiu m m.
+ La chn khng sinh da vo loi vi khun c kh nng gy t cp (theo
iu tra dch t hc v t l nhy cm vi khng sinh ca vi khun ).
- Nhim khun cng ng:
Cc vi khun cng ng gy nhim khun dn n t cp BPTNMT thng l
Haemophilus influenzae, Streptococcus pneumoniae, Moraxella catarrhalis.
Khng sinh nn la chn khi nhim khun cng ng l cephalosporin th h 3
hoc khng sinh nhm penicillin ph rng, kt hp vi khng sinh nhm
aminoglycosid hoc fluoroquinolone hoc Moxifloxacin. Nhm Marcrolid nu nghi
ng do Legionella hoc vi khun khng in hnh.
- Nhim khun bnh vin:
Nu nghi ng nhim khun bnh vin: dng khng sinh theo liu php xung
thang. Nu iu kin cho php nn la chn loi khng sinh ph rng v c tc dng
trn vi khun nghi ng gy bnh.
Loi vi khun thng gy nhim khun bnh vin v mc khng khng
sinh ca cc loi vi khun c th khc nhau mi c s iu tr v cn xc nh
da vo iu tra dch t c s .
- Th my:
+Thng kh khng xm nhp: nu khng c chng ch nh.
+ Thng kh xm nhp:(xem k thut th my ngi bnh c tn thng
phi).
b) t cp bnh phi tc nghn mn tnh c suy h hp nguy kch
Khi xut hin suy h hp cp nguy kch, ngi bnh cn c t ng ni kh
qun ngay c th tin hnh th my xm nhp.
- Bp bng qua mt n vi oxy 100%.
- t ng ni kh qun, th my.
- Ht m qua ni kh qun.
- Dng thuc gin ph qun truyn tnh mch (xem phn 5.3.1).
- Tim tnh mch corticoit (xem phn 5.3.1).
- Dng thuc khng sinh ng tnh mch (xem phn 5.3.1).
- Tin lng ngi bnh ph thuc: mc nng ca BPTNMT c, cc
bnh l km theo, mc nng ca nhim khun h hp, vic iu tr c kp thi hay
khng.
- Bin chng: cc bin chng cn ch l
+ Trn kh mng phi, y l bin chng nng v lm cho vic iu tr kh
khn thm nhiu. Pht hin trn kh mng phi trn ngi bnh BPTNMT thng kh
do cc du hiu vn c nh gin ph nang ca BPTNMT c th lm m cc triu
11
chng ca trn kh mng phi. Cn chup phi cp cu xac i nh trn kh mng phi
ngay khi: ngi bnh th nhanh ln t ngt, r ro ph nang giam km theo g vang ,
nht l khi gim mt bn lng ngc, tm, SpO2 tt nhanh, nu ang th may th xu t
hin th chng may va ap lc i nh ng th tng cao . X tr: dn lu mng phi tch
cc ngay.
+ Tc ng mch phi.
+ Vim phi bnh vin, vim phi lin quan th my.
+ Ph thuc my th nu ngi bnh phi th my ko di. Cn nh gi tnh
trng ngi bnh 2 - 3 ln mi ngy v tp cho ngi bnh b my ngay khi iu
kin.
7. PHNG BNH
- Theo di v iu tr tt cc ngi bnh b bnh phi tc nghn mn tnh.
- Trnh cc nguy c c th gy t cp.
- iu tr sm v tch cc cc bnh l mi xut hin ngi bnh bnh phi tc
nghn mn tnh.
Ti liu tham kho

1. Ng Qu Chu v cs (2011), Bnh phi tc nghn mn tnh, Trong: Bnh h hp
(Ch bin: Ng Qu Chu). Nxb Gio dc Vit Nam.
2. Calverley P.M.A. (2011),Chronic Obstructive Pulmonary Disease. In: Texbook
of Critical Care (Editors: Vincent J.L., Abraham E., Moore F.A., Kochanek P.M.,
Fink M.P.), Elsevier Saunders, 6th edition.
3. Global Initiative for Chronic Obstructive Lung Disease (2013),Management of
BPTNMT (Component 4: Manage Exacerbations), in: Global Strategy for
Diagnosis, Management, and Prevention of BPTNMT (Internet version, updated
2013).
4. Stoller J.K. (2010),Management of acute exacerbations of chronic obstructive
pulmonary disease. UpToDate online 18.3 [last updated:October 7, 2010],
Available in: http://www.uptodate.com.
5. Witt Ch.A., Kollef M.H. (2012): Acute exacerbations of chronic obstructive
pulmonary diseaseIn: The Washington Manual of Critical Care (Editors: Kollef
M. and Isakow W.), Lippincott Williams & Wilkins.
12
CN HEN PH QUN NNG V NGUY KCH

1. I CNG
Cn hen ph qun (HPQ) nng v nguy kch thng xut hin trn ngi bnh
HPQ khng c theo di v iu tr d phng ng hng dn, hoc khng c
iu tr tt khi xut hin cn HPQ cp.
Nhng ngi bnh d c nguy c b cn HPQ nng v nguy kch l nhng
ngi:
- C tin s c cn HPQ nng tng phi t ng ni kh qun, th my.
- Trong nm va qua phi vo nm vin hoc cp cu v cn HPQ.
- Thng dng corticoid ung, nht l nhng ngi bnh mi ngng ung
corticoid.
- Khng c dng corticoid ng ht.
- Thi gian gn y phi tng liu dng thuc cng bta-2 giao cm ng ht.
- C bnh l tm thn hoc c vn v tm l-x hi, k c dng thuc an
thn.
- Khng c theo di, iu tr bnh ng cch.
2. NGUYN NHN
Cng nh bnh HPQ ni chung, mt cn HPQ nng v nguy kch c th xut
hin khi c cc yu t khi pht. Theo "Hng dn chn on, iu tr hen ph
qun" ca b Y t (2009), cc yu t nguyn nhn gy cn hen l:
- D nguyn trong nh: mt bi nh, lng th (ch, mo, chut...), gin, nm,
mc, thuc men, ha cht, v.v...
- D nguyn ngoi nh: bi ng ph, phn hoa, nm mc, cc ha cht, cht
ln men, yu t nhim trng (ch yu l virus), hng khi cc loi.
- Nhim trng: ch yu l nhim virus.
- Cc yu t ngh nghip: than, bi bng, ho cht, v.v...
- Thuc l: Ht thuc ch ng v b ng.
- nhim mi trng khng kh: kh thi ca phung tin giao thng, cc loi
kh nhim, ho cht, v.v..
3. TRIU CHNG
3.1. Lm sng
- Cn HPQ nng c th xut hin v nng ln rt nhanh (trong vng 2 - 6 gi),
cng c th lc u ch l mt cn hen mc trung bnh, ko di v nng ln dn
dn.
- Cn hen in hnh vi kh th th th ra, co ko c h hp, c ting kh kh.
Nghe phi c ran rt.
13
- Cc triu chng c nng cng nh thc th v cn lm sng c th khc nhau

ty theo mc nng ca cn hen, v c trnh by trong bng mc 4.4. Chn
on mc nng ca cn hen.
3.2. Cn lm sng
- Lu lng nh th ra gim nng ( thng rt kh o hoc khng o c).
- Oxy mu gim (du hiu ny c th khng r nu ngi bnh c th
oxy). CO2 mu tng. Tng PaCO2 mu phn nh tnh trng gim thng kh ph nang,
du hiu khng c trong cc cn hen nh v trung bnh.
4. CHN ON
4.1. Chn on xc nh
Da vo xut hin cn HPQ in hnh vi cc du hiu nng hoc nguy kch.
4.2. Chn on phn bit
a) Cn hen tim: trn ngi bnh c bnh tim
- Tng huyt p.
- Nhi mu c tim cp.
- Bnh l van tim
b) Tnh trng tc nghn khu tr ng h hp
- Kh th thanh qun.
- Khi u, polyp kh qun, ph qun.
- D vt ng th.
c) Tnh trng tc nghn lan ta ng h hp
- Bnh phi tc nghn mn tnh.
- Vim tiu ph qun tc nghn.
- X ho kn.
- Gin ph qun.
Vn chn on nguyn nhn gy bnh hen v nguyn nhn khi pht cn
hen ni chung cha t ra khi x tr cp cu cn hen ph qun nng.
Vic tm nguyn nhn s c tin hnh khi ngi bnh n nh.
14
4.4. Chn on mc nng ca cn hen

nh gi mc nng nh ca cn hen
Theo "Hng dn chn on, iu tr hen ph qun" ca b Y t (2009)
Thng s
Nh
Trung bnh
Nng
Nguy kch
Kh th
Khi i b
Khi ni chuyn Khi ngh
Th ngp
n kh
T th
Kh nng ni
chuyn
Mc tnh
to
Nhp th
Co ko c h
hp ph v
hm trn
xng c
Kh kh
Mch/ pht
Mch nghch
thng
(mch o)
PEF sau
thuc dn
ph qun
khi u
% d on
hoc % tt
nht
PaO2 (th kh
tri) v/hoc
PaCO2
C th nm
c
Ni c c
cu
C th kch
thch
Tng
Thch ngi hn
Thng
khng c
Thng c
Ngi ci ngi
ra trc
Ch ni c
tng t
Kch thch, vt
v
Thng>
30/pht
Thng c
Trung bnh,
thng ch c
lc th ra
< 100
Khng
< 10mmHg
To
Thng to
100-120
C th c
10-25mmHg
> 120
Thng c
> 25 mmHg
Ch ni c
cm t
Thng kch
thch, vt v
Tng
Khng ni
c
L m hoc
l ln
Chm- ri
lon nhp th
Chuyn ng
ngc - bng
nghch
thng
Khng kh
kh
Nhp chm
C th khng
thy do mt
c h hp
< 60% d on
hoc tt nht
<100 lt/pht
thiu nin)
hoc p ng
ko di < 2 gi
> 80%
60-80%
Bnh thng
<45mmHg
Thng
khng cn
> 95%
> 60mmHg
< 45mmHg
< 60mmHg
C th tm ti
> 45mmHg; c
th suy h hp
< 90%
SaO2 hoc
91-95%
SpO2 % (th
kh tri)
Tng CO2 mu (gim thng kh) xy ra tr em nhanh hn thiu nin v ngi
ln
Phn loi da vo cc thng s trn, nhng khng nht thit phi c tt c, cn c
s nhn nh tng qut c quyt nh thch hp.
PEF: lu lng nh th ra.
15
a) nh gi cn HPQ l cn nng khi:

- C t 4 du hiu nng tr ln.
- p ng km vi iu tr bng thuc gin ph qun kh dung.
b) nh gi cn HPQ l nguy kch:
Khi c mt trong cc du hiu sau xut hin ngi bnh c cn HPQ nng:
- Ri lon thc.
- Ting r ro ph nang v ting ran rt gim hoc khng nghe thy (phi im
lng).
- H hp ngc bng nghch thng (kit sc c h hp).
- Tn s tim chm, huyt p tt.
- Th chm, cn ngng th.
5. X TR
5.1. Nguyn tc x tr
X tr cn HPQ nng i hi phi khn trng, tch cc, dng thuc ng
phng php (ng liu lng, ng ng dng).
X tr cn HPQ nng i hi phi phi hp b ba oxy - thuc gin ph qun corticoid.
a) Bo m oxy mu
Cn cho ngi bnh th oxy lu lng cao qua ng thng mi (gng knh oxy)
hoc mt n oxy. Nu ngi bnh vn gim oxy mu nng mc d dng oxy lu
lng cao cn ch nh th my.
b) Thuc gin ph qun
Thuc c la chn hng u l thuc cng 2 giao cm tc dng nhanh,
ng dng ti ch s c la chn u tin (thng dng kh dung, nu khng c
iu kin kh dung c th dng dng xt nh liu). Thuc c ch ph giao cm tc
dng nhanh cng thng c dng phi hp vi cng 2 giao cm. Theophyllin ch
c xem xt ch nh mt s ngi bnh p ng tt vi theophyllin v km p
ng vi cng 2 giao cm. Adrenalin c ch nh khi phi dng cc thuc trn vi
liu cao m khng c tc dng.
c) Corticoid
Corticoid ng ton thn c dng trong iu tr cn hen ph qun nng
di dng tim tnh mch.
- Dng ngay thuc cng bta-2 giao cm kh dung 5 mg trong 20 pht, nhc
li nu khng hiu qu.
- Hoc xt thuc cng bta-2 giao cm 2 - 4 pht, nhc li v tng s ln pht
xt (n 8 - 10 pht) nu khng hiu qu.
- Dng corticoid ung (prednisolon 5 mg x 6 - 8 vin) hoc tim tnh mch
(methylprednisolon 40 mg).
16
- Chuyn ngay ngi bnh n bnh vin. Trn ng vn chuyn: cho th oxy
6 - 8 lt/pht, tip tc xt thuc thuc cng bta-2 giao cm 10 - 15 pht/ln. Nn
dng bung m khi xt thuc thuc cng bta-2 giao cm.
Theo Ph lc 5 "Phc iu tr cn hen ph qun nng v nguy kch" ca
"Hng dn chn on, iu tr hen ph qun" ca b Y t (2009).
a) Phc iu tr cn hen ph qun nng
- Gi u tin
+ Th oxy qua mt n hoc gng knh oxy, duy tr SpO2> 90%.
+Thuc gin ph qun: cng 2 kh dung 5 mg/ 20 pht x 3 ln lin tip.
+ Corticoid: methylprednisolon tim tnh mch 40 - 80mg.
nh gi sau 1 gi, nu cha ct c cn hen ph qun nng
- Gi tip theo
Tip tc iu tr nh trn:
+ Thuc gin ph qun: cng 2 kh dung 5 mg trong 20 pht x 3 ln lin tip.
+ Corticoid: nu gi trc cha cho, tim tnh mch methylprednisolon 40 80mg.
Thm:
+ Ipratropium kh dung 0,5 mg.
+ Sulphat magie 2g truyn tnh mch trong 20 pht.
Nu cc du hiu nng cha mt i, tip tc iu tr
- Khong 6 12 gi tip theo
+ Thuc gin ph qun:
Thuc cng 2 kh dung lin tc 5 mg/ln (10 15 mg/gi)
Hoc thuc cng 2 truyn tnh mch lin tc: tc truyn khi u 0,1 0,15 g/kg/pht, tng tc truyn 5 pht/ln (tu theo p ng ca ngi bnh), mi
ln 0,1-0,15 g/kg/pht (c th n 4 mg/gi ngi ln).
Kt hp vi Ipratropium 0,5 mg kh dung 4 gi/ln.
+ Corticoid: methylprednisolon tim tnh mch (200-300 mg/24 gi, chia 4
ln).
* Xem xt ch nh:
-Theophylin (diaphylin)0,24 g tim tnh mch rt chm (20 pht) hoc pha
trong 100 dch ng trng truyn trong 20 pht.
- Th my.
Nu sau 6 - 12 gi cha c p ng tt:
Tip tc duy tr iu tr thuc nh trn, v xem xt ch nh dng adrenalin
- Xem xt ch nh th my
17
+ Nn bt u bng thng kh khng xm nhp nu cha xut hin cc ch nh

ca thng kh xm nhp.
+ Nu bnh nhn khng p ng, cn phi t ng ni kh qun v th my qua
ng ni kh qun.
Trong trng hp xut hin cc du hiu ca cn HPQ nguy kch: Trc khi t
ng NKQ dng adrenalin 0,3 - 0,5 mg tim di da, c th nhc li sau 5 10 pht
Ch nh t ng NKQ v th mykhi c xut hin bt k du hiu no sau y:
- Xut hin ri lon thc hoc bt k 1 du hiu no ca cn HPQ nguy kch..
- PaO2< 60 mmHg khi th oxy qua mt n c ti d tr.
- pH < 7,30, PaCO2> 50 mmHg.
- Tnh trng lm sng xu i nhanh.
- Ngi bnh mt, kit sc c h hp.
- Th my khng xm nhp khng c hiu qu.
Dng thuc an thn truyn tnh mch vi liu lng ngi bnh ng, nhng
khng c ch hot ng h hp ca ngi bnh (im Ramsay = 3).
Thi th my: khi ngi bnh ct c cn hen ph qun, xt nghim pH, PaCO2
v PaO2 bnh thng.
b)Phc iu tr cn hen ph qun nguy kch
- Bp bng qua mt n vi oxy 100%.
- Adrenalin 0,3 - 0,5 mg tim di da, c th nhc li sau 5 10 pht.
- t ng ni kh qun qua ming (ch : phi cho thuc an thn v/hoc thuc
gin c ngn m bo t ng ni kh qun thnh cng).
- Th my qua ng ni kh qun.
- Truyn tnh mch lin tc thuc gin ph qun:
+ Adrenalin truyn tc khi u 0,1 g/kg/pht, tng tc truyn 0,1
mg/kg/pht mi ln 2 - 3 pht/ln n khi c p ng ( c th thm 1-1,5 mg/h
ngi ln).
+ hoc thuc cng bta-2-giao cm truyn tc khi u 0,1 - 0,15
g/kg/pht, tng tc gp i sau 2 - 3 pht n khi c p ng.
Cc thuc khc: nh phc iu tr cn hen ph qun nng.
LU :
- Khng nht thit phi thc hin ng th t A-B-C-D nh trong phc . Nu
trc ngi bnh c x tr ng phc th p dng lun bc tip theo.
- Adrenalin c ch nh khi c cn hen nguy kch e da ngng tun hon,
hoc khi ngi bnh khng p ng vi iu tr thuc v th my.
- Khi dng thuc cng beta-2 liu cao cn ch b kali cho ngi bnh
trnh bin chng h kali mu./.
18

6.1. Tin lng
Tin trin ca cn hen ph qun nng ph thuc vo vic iu tr c c tin
hnh khn trng v ng phng php hay khng. Mt cn hen ph qun ko di c
th nng ln tr thnh nguy kch nu iu tr chm, nht l chm tr trong vic ch
nh th my hoc dng thuc khng liu.
Tin lng ca cn hen ph qun nng cng cn ph thuc vo s xut hin
cc bin chng.
6.2. Bin chng
- Trn kh mng phi/trung tht: c th xut hin t pht (thng khi ngi
bnh gng sc) hoc l bin chng ca th my.
- Nhim khun bnh vin.
- Ri lon nc-in gii (mt nc trong qu trnh gng sc h hp, h kali
mu do dng thuc cng giao cm liu cao).
7. PHNG BNH
- Theo di qun l hen v iu tr d phng hen ph qun ng hng dn.
- iu tr tch cc, ng phng php khi xut hin cn hen ph qun cp, c
bit l i vi cc ngi bnh c nguy c b cn hen ph qun nng.
- C gng trnh tip xc vi d nguyn gy cn hen ph qun.
19
S X TR CN HEN CP TRONG BNH VIN

(Ban hnh km theo Quyt nh s 4776 /Q-BYT ngy 04 thng 12 nm 2009 ca B
trng B Y t)
nh gi ban u: Khai thc tin s, khm lm sng (nghe phi, c h hp ph, nhp tim,
nhp th), o PEF hoc FEV1, SpO2, kh mu ng mch trong trng hp nng, v mt s
xt nghim khc tu vo hon cnh.
iu tr ban u:
- Th oxy cho n khi t SaO2 90% (95% tr em).
- Thuc kch thch 2 dng ht tc dng nhanh, thng dng kh dung c mt n lin tc trong 1
gi (cn nh c th dng xt 20 pht 1 ln trong 1 gi).
- Corticoid ton thn nu khng p ng nhanh hoc nu ngi bnh mi dng corticoid
ng ung, hoc cn hen nng.
- Chng ch nh dng thuc an thn trong iu tr ct cn hen.
nh gi mc nng nh:
- Khm lm sng, PEF, SpO2, kh mu, cc xt nghim khc nu cn.
Mc trung bnh:
-
PEF 60-80%.
Khm lm sng: triu chng
trung bnh c co ko c h
hp ph.
Thuc kch thch 2 dng
ht cho mi gi.
Xem xt dng corticoid.
Tip tc iu tr trong 1-3
gi vi iu kin l c ci
thin.
Mc nng:
- PEF<60%.
- Lm sng: triu chng nng khi ngh ngi, lng ngc
co rt.
- Tn s: ngi bnh c nguy c cao.
- Khng ci thin sau iu tr ban u.
- Thuc kch thch 2 cho mi gi, hoc lin tc thuc
khng ph giao cm dng ht.
- Th oxy.
- Corticoid ton thn (tim, truyn).
- Xem xt dng thuc kch thch 2 tim di da, tim bp,
tnh mch.
20
p ng tt:
-
p ng duy tr 60
pht sau iu tr.
Khm lm sng: bnh
thng.
PEF > 70%.
Khng suy h hp.
SaO2> 90% (>95%
tr em).
V nh:
-
p ng trung bnh
trong 1-2 gi:
-
Tin s: nguy c cao.

Khm lm sng: triu
chng nh hoc trung
bnh.
PEF 50% - 70%.
Khng ci thin thm
SaO2.
Lu li bnh vin:
Tip tc iu tr
thuc cng 2 ht.
Xem xt dng
corticoide dng vin.
Gio dc ngi bnh:
- iu tr ng.
- Xem li phc
iu tr.
- Theo di cht
ch.
p ng km trong 1
gi:
Thuc cng 2
ht khng ph
giao cm ht.
Corticoid ton
thn.
Th oxy.
Cn nhc dng
aminophylin tnh
mch.
Theo di PEF,
SaO2, mch.
Ci
thin
Tin s: nguy c cao.

Khm lm sng: triu
chng nng.
Ng g, co git
PEF > 30%.
PaCO2> 45 mmHg.
PaO2<60 mmHg.
Khoa hi sc tch cc:

-
Thuc cng 2 ht
khng ph giao cm.
Corticoid ton thn.
Th oxy.
Cn nhc dng
aminophylin tnh mch.
Xem xt dng thuc
cng 2 di da, tim
bp, tnh mch.
Ni kh qun v th my
nu cn.
Khng
ci thin
Chuyn hi sc tch cc:
V nh:
Nu khng ci thin.
Nu ct cn hen, PEF >70% n nh.
6-12 gi
iu tr thuc vin hoc ht.
21
Ti liu tham kho

1. B Y t (2009),Hng dn chn on v iu tr hen ngi ln(Ban hnh km
theo Quyt nh s 4776 /Q-BYT ngy 04 thng 12 nm 2009 ca B trng
B Y t).
2. Ng Qu Chu v cs (2011): Hen ph qun. Trong: Bnh h hp (Ch bin:
Ng Qu Chu). Nxb Gio dc Vit Nam.
3. Nguyn Th Kim Chung, ng Quc Tun, Nguyn Th D (2006), Nhn xt c
im lm sng v tnh hnh cp cu cn hen ph qun nguy kch ti bnh vin
Bch Mai trong thi gian t 2000 n 2005, Tp ch Y hc lm sng bnh vin
Bch Mai, 9: 47-50.
4. ng Quc Tun (2005),Nghin cu tc dng ca phng thc th my h
tr/iu khin v PEEP ngoi trong th my ngi bnh hen ph qun nng.
Lun n Tin s Y hc. Trng i hc Y H Ni.
5. Aysola R., Castro M. (2012),Status asthmaticus,In: The Washington Manual of
Critical Care (Editors: Kollef M. and Isakow W.), Lippincott Williams &
Wilkins.
6. Corbridge Th. C., Corbridge S.J. (2011),Severe Asthma Exacerbation. In:
Texbook of Critical Care (Editors: Vincent J.L., Abraham E., Moore F.A.,
Kochanek P.M., Fink M.P.), Elsevier Saunders, 6th edition.
7. Global Initiative for asthma (2013),Manage asthma exacerbations,In: Global
strategy for asthma management and prevention. Chapter 4: Asthma management
and prevention. GINA report Mar-13.
22
HI CHNG SUY H HP CP TIN TRIN
1. I CNG
Hi chng suy h hp cp tin trin (ARDS) c Ashbaugh v cng s m t
ln u tin nm 1967. L mt hi chng bnh l trong mng ph nang mao mch
ca phi b tn thng cp tnh do nhiu nguyn nhn khc nhau dn n tnh trng
suy h hp nng khng p ng vi th oxy liu cao.
Nm 1994, hi ngh ng thun u- M (AECC) a ra nh ngha v hi
chng suy h hp cp tin trin ARDS. T , c nhiu cng trnh nghin cu v
gi tr v tnh ng dng ca nh ngha ny trn lm sng. Nm 2011, hi ngh gm
cc chuyn gia hng u a ra nh ngha BERLIN v ARDS tp trung vo tnh
kh thi, tnh ng dng, gi tr, cng nh cc cch thc khch quan nh gi nh
ngha ny trn thc hnh. nh ngha BERLIN c gi tr tin lng tt hn v tp
trung vo mt s hn ch ca AECC nh cch thc loi tr ph phi huyt ng v
thm vo tiu chun thng kh pht.
nh ngha BERLIN ca ARDS ( 2012)
c tnh
Hi chng suy h hp tin trin
Thi gian
Trong vng 1 tun sau khi xut hin cc yu t nguy c hoc c
cc triu chng h hp mi xut hin, tin trin ti i.
Hnh nh X quang m m lan ta c 2 phi, khng th gii thch y bng trn
hoc CT
dch, xp phi hay khi u trong phi.
Ngun gc ca hin Hin tng suy h hp khng th gii thch y bng suy tim
tng ph ph nang
hay qu ti dch. C th nh gi bng siu m tim.
Oxy mu (*)
- Nh
- PaO2/FiO2t 200-300 vi PEEP hoc CPAP 5 cmH2O (**).
- Trung bnh
- PaO2/FIO2 t 100- 200 hoc vi PEEP 5 cmH2O.
- Nng
- PaO2/FiO2< 100 mmHg vi PEEP 5 cmH2O.
Ch :
*: nu cao t 1000 m tr ln, phi hiu chnh mc oxy ha mu theo cng
thc P/F* p sut / 760
**: mc PEEP ny c th cung cp bng cc phng php ca thng kh khng
xm nhp nhng ngi bnh c ARDS nh.
T l mc ARDS ty vao la tui, trung bnh khong 150 trn 100.000 ca bnh.
ARDS chim 10 - 15% s ngi bnh trong cc n v hi sc, trn 20% s ngi
bnh phi th my.
23
2. NGUYN NHN
2.1. Nguyn nhn ti phi
- Vim phi nng: l nguyn nhn thng gp nht, vim phi do vi khun (v
d nh: ph cu, lin cu, influenzae ...) hoc vim phi do virus (v d: cm A H5N1,
H1N1,H7N9,SARS...)
- Ngt nc: tn thng mng sufartan.
- Tro ngc dch d dy: thng gp ngi bnh hn m hoc say ru,
hoc c tng p lc ni s dch d dy gy ra tn thng phi trn din rng km xp
phi.
- Tim, ht heroin hay s dng cc loi thuc ma ty khc (cocain,
amphetamin).
- Chn thng lng ngc nng gy ng dp phi.
2.2. Nguyn nhn ngoi phi
- Nhim khun nng hoc sc nhim khun.
- Truyn mu s lng ln (>15 n v), c bit l mu ton phn.
- Vim ty cp nng.
- Suy thn cp.
- Bng nng ,c bit l bng h hp.
3. TRIU CHNG
3.1. Lm sng
- Thi gian xut hin nhanh, thng sau khi c tc nhn 6 72 gi c th n 7
ngy.
- Kh th, tm mi v u chi, th nhanh. Nghe phi c ran n lan ta.
- Nhp tim nhanh, th nhanh, v m hi.
- Co ko c h hp ph.
- au ngc, ho.
- Cc biu hin ca nguyn nhn gy hi chng suy h hp cp tin trin: st,
ri lon ng mu
3.2. Cn lm sng
- Xt nghim kh mu: PaO2 gim, thng c gim CO2 km theo (kim h
hp), tng chnh lch (gradient) oxy ng mch mao mch.
- Xquang phi: hnh nh thm nhim lan ta 2 phi.
24
Hnh 1. Hnh nh tn thng phi ngi bnh nhim cm A H1N1

- Hnh nh chp ct lp vi tnh ngc: tn thng thm nhim lan ta 2 phi.
Hnh 2. Hnh nh ct lp vi tnh ngc

4. CHN ON
4.1. Chn on xc nh theo nh ngha Berlin 2012
a) Lm sng
- Khi pht cp tnh.
- Ngi bnh th nhanh, tm mi u chi, co ko c h hp, khng p ng vi
dng xy liu cao.
- Nghe phi c th thy rale m, rale n.
- Khng c cc du hiu ca suy tim tri: khng tr tun hon, khng kh th
cn (m l kh th lin tc), p lc tnh mch trung tm <15cmH2O, p lc mao mch
phi bt 18mmHg. C th c nh gi bng siu m tim.
25
b) Cn lm sng
- Phim XQ ngc: dng thm nhim lan to c hai bn ph trng.
- Kh mu ng mch:
+ PaO2 gim nng thng < 60mmHg.
+ T l PaO2/FiO2 < 300 (vi PEEP hoc CPAP 5 cmH2O).
4.2. Chn on phn bit
a) Ph phi cp huyt ng
- Do suy tim tri cp hoc qu ti dch cp.
- Tn thng trn phim XQ dng cnh bm tin trin nhanh v thoi lui
nhanh.
b) Xut huyt ph nang lan ta
- Suy h hp cp c km theo mt mu nhanh.
- Ngi bnh ho ra m ln mu hoc soi ht ph qun c mu.
5. X TR
5.1. Nguyn tc chung
- Th my vi chin lc bo v phi.
- iu tr nguyn nhn.
5.2. X tr c th
Mc tiu cn t:
- Oxy mu: duy tr PaO2 55 80mmHg hoc o SpO2 l 88 - 95%.
- pH mu ng mch: 7,25 7,45
a)Th mykhng xm nhp (xem quy trnh k thut th my khng xm nhp).
b)Thng kh nhn to xm nhp
Khi c chng ch nh phng php khng xm nhp hoc p dng nhng
khng c kt qu.
- Phng thc th PCV.
+ t PC v PEEP sao cho tng p lc th vo di 30 cmH2O.
+iu chnh PC v PEEP sao cho t c cc mc ch nu trn.
- Phng thc VCV: t Vt lc u 8-10ml/kg, sau iu chnh da theo
Pplateau 30cmH2O, lu khng gim Vt < 5ml/kg.
* Ch :
t FiO2 v PEEP theo bng sau sao cho t mc tiu oxy ha mu
FiO2
0,3
0,4
0,5
0,6
0,7
0,8
0,9
PEEP
5-8
8-10
10
10-14
14
14-18
18-23
Ci t tn s th : 14 35 ln/pht sao cho m bo c thng kh pht (68 lt/pht).

- Phng thc APRV(Phng php thng kh x p ng th).
26
c) Nghim php huy ng ph nang:

Huy ng ph nang (HPN) l phng php s dng mc p lc cao m
cc ph nang khng c thng kh hoc thng kh km tham gia vo qu trnh trao i
kh. C 3 phng php
- Phng php huy ng ph nang CPAP 40/40: ngi bnh c th trn nn
mt p lc dng lin tc 40cmH2O trong mt khong thi gian 40 giy.
- Phng php huy ng ph nang CPAP 40/60: ngi bnh c th trn nn
mt p lc dng lin tc 40cmH2O trong mt khong thi gian 60 giy.
- Phng php huy ng ph nang bng thng kh kim sot p lc (PCV)kt
hp tng dn PEEP c chng minh hiu qu bng chp ct lp vi tnh.Tuy nhin
phng thc ny kh thc hin trn lm sng hn, bin chng v chn thng p lc,
h huyt p gp nhiu hn so vi phng thc HPN bng CPAP.
Ch :
Tm p lc m ph nang ti u.
Tm PEEP ti u:mc PEEP thp nht gi cho cc ph nang khng xp li.
Huy ng li ph nang v th my vi mc PEEP ti u.
d) An thn v gin c
- Dng an thn hoc dng phi hp thuc an thn v gin c sao cho ngi
bnh th theo my hon ton (im Ramsay t 4-5).
- Tuy nhin an thn gin c cn gim liu v dng ng lc khi bnh tin trin
tt ln cai th my kp thi v b my sm nht c th.
- Ca s an thn: hng ngy ngng an thn ngt qung.
e) m bo huyt ng v cn bng dch vo ra
- Cn ngi bnh hng ngy, nh gi cn bng dch vo ra, m bo cn bng
m hoc bng khng.
- Nu ngi bnh tng cn, cn bng dch dng, dng furocemide tim tnh
mch vi liu thch hp iu chnh kp thi ngi bnh tr v cn nng ban u.
- Duy tr p lc tnh mch trung tm t 6 n 8 cmH2O. p lc mao mch phi
bt 8-10mmHg (nu t catheter Swan ganz).
f) Cc bin php iu tr khc
- Kim sot glucose mu: Nu ng mu >10,0 mmol/l, lm xt nghim
ng mu mao mch ti ging 3 gi 1 ln v dng insulin t c mc ng
mu 6-10mmol/l.
- Liu php khng sinh chng nhim khun: Dng ngay khng sinh phng
php xung thang, sau iu chnh theo khng sinh (nu c).
- Trong trng hp vim phi do virus cm A (v d: H5N1): xem thm phc
iu tr vim phi do cm A.
- D phng tc mch: dng heparin liu d phng.
- D phng lot ng tiu ho: s dng 1 thuc c ch bm proton (v d
omeprazole).
27
- Bin php huy ng ph nang: tham kho qui trnh k thut huy ng ph
nang.
- m bo hemoglobin (>8 gam/lt).
- Albumin mu > 30 g/l.
- Thay i t th: ngi bnh nm nghing hoc nm sp (nu c iu kin)
6. TIN LNG V BIN CHNG: Ngi bnh ARDS c nguy c bin chng
cao.
- Bin chng lin quan n th my: chn thng p lc, vim phi
- Cc bin chng khc:
+ Lon thn.
+ Huyt khi tnh mch su.
+ Lot d dy thc qun.
+ Suy dinh dng.
+ Nhim khun catheter.
7. PHNG BNH
- Tch cc iu tr vim phi phng tin trin nng thnh ARDS.
- Cho ngi bnh nm u cao, c bit nhng ngi bnh c ri lon
thc.
Ti liu tham kho
1. Bi Vn Cng. (2012), nh gi hiu qu oxy ha mu ca bin php huy ng
ph nang bng phng php CPAP 40 cmH20 trong 40 giy ngi bnh suy h
hp cp tin trin, Lun vn thc s y hc chuyn nghnh Hi sc cp cu, Trng
i hc Y H ni.
2. L c Nhn. (2012), Nghin cu hiu qu ca chin lc m phi v chin
lc ARDS Network trong th myngi bnh suy h hp cp tin trin, Lun n
tin s y hc chuyn ngnh Hi sc cp cu, Trng i hc Y H ni.
3. Bastarache J.A., Ware L.B., Bernard G.R. (2013), Acute Lung Injury and Acute
Respiratory Distress Syndrome, Textbook of Critical Care. Sixth Edition. JeanLouis Vincent, Elsevier Sauders. 58, Pp. 388-97.
4. Bernard G.R., Artigas A, Brigham K.L. et al.(1994),The American-European
Consensus Conference on ARDS. Definitions, mechanisms, relevant outcomes,
and clinical trial coordination, Am J Respir Crit Care Med 149, Pp. 818-24.
5. Christie J., Lanken P. (2005), Acute Lung Injury and the Acute Respiratory
Distress Syndrome, Principles of critical care, Pp. 515-48.
6. Grasso S., Mascia L., Del Turco M. et al. (2002), Effects of recruiting maneuvers
in patient with acute respiratory distress syndrome ventilated with protective
ventilatory strategy Anesthesiology. 96, Pp. 795-802.
7. Hansen-Flaschen J., Siegel M.D. (2013), Acute respiratory distress syndrome:
Clinical features and diagnosis, Up to Date 2010. URL: http://www.uptodate.com/
28
8. Siegel M.D. (2013), Acute respiratory distress syndrome: Definition;

epidemiology; diagnosis; and etiology, Up to Date 2010. URL:
http://www.uptodate.com/
9. Special Communication. (2013), Acute Respiratory Distress Syndrome. JAMA:
307(23), Pp. 2526-33.
29
TRN KH MNG PHI BNH NHN TH MY
1. I CNG
Trn kh mng phi (TKMP) l mt bin chng rt nguy him ngi bnh
ang c th my.
Trn kh mng phi c th l bin chng nguy him ca th my do p lc
dng cao qu mc trong ph nang - bin chng ny c gi l "chn thng p lc.
Tnh hung ny c th xut hin khi c tnh trng "by kh" dn n cng phi (trong
cc bnh l gy tc nghn ph qun) hoc do tnh trng "phi nh" nh trong hi
chng suy h hp cp tin trin (ARDS). p lc cao nguyn ng th (p lc nh
ph nang) trong nhng tnh hung ny nu cao hn 30 cmH2O l du hiu bo hiu
nguy c chn thng p lc, nguy c s rt cao nu p lc cao nguyn ng th tng
trn 35 cmH2O.
2. NGUYN NHN
2.1. Chn thng p lc
Th my c th gy nn tnh trng tng qu mc p lc trong ph nang dn ti
v ph nang gy TKMP hoc trn kh trung tht.
Nhng ngi bnh c nhiu nguy c gp bin chng ny l:
- Ngi bnh c bnh l tc nghn ng h hp: cn hen ph qun nng, bnh
phi tc nghn mn tnh.
- Ngi bnh b ARDS.
- Cc trng hp khng phi cc bnh l trn nhng thng s my th c t
khng hp l, tng th tch lu thng qu mc, hoc bnh nhn chng my cng c
nguy c xut hin TKMP.
2.2. Bin chng ca cc th thut
Cc th thut nh t catheter tnh mch trung tm, sinh thit mng phi, sinh
thit phi, soi ph qun, p tim khi cp cu ngng tun hon u c nguy c gy
TKMP. Tai bin TKMP ny s nng hn v nguy him hn khi xut hin trn ngi
bnh th my.
2.3. Cc bnh l gy trn kh mng phi
Trn kh mng phi bnh nhn th my cng c th do nguyn nhn bnh l
nh: vim phi do t cu, lao, nhim cm A nng, hoc gin ph nang bnh nhn
COPD
3. TRIU CHNG
3.1. Lm sng
- Tnh trng kh th xut hin v tng ln nhanh chng.
- p lc nh ng th tng cao, ngi bnh chng my.
30
- Lng ngc mt bn cng, di ng km, khm thy gim hoc mt r ro ph

nang, g vang. Nu trn kh mng phi 2 bn s thy lng ngc c 2 bn cng v mt
r ro ph nang.
- C th pht hin thy trn kh di da km theo (trn kh di da bn ngc
cng bn vi trn kh mng phi, trn kh di da vng c nu ngi bnh b trn kh
trung tht).
- Ngi bnh tm, huyt p tng (suy h hp nng) hoc tt huyt p (suy h
hp nguy kch), nhp tim nhanh.
3.2. Cn lm sng
- Thiu oxy mu: SpO2 tt nhanh, xt nghim kh mu c PaO2, SaO2 gim.
- X quang phi cho php chn on trn kh mng phi, cn chp ti ging.
Tuy nhin nhiu trng hp din bin qu khn cp khng cho php i chn on
bng X quang.
4. CHN ON
4.1. Chn on xc nh
Da vo cc triu chng lm sng v X quang phi cp ti ging.
Lu trong trng hp trn kh mng phi rt nng, tin trin nhanh, chn
on c th ch da vo cc du hiu lm sng m khng cn ch chp X quang phi.
4.2. Chn on phn bit
Chn on phn bit vi cc nguyn nhn khc gy suy h hp nng ln nhanh
chng ngi bnh ang th my nh tc nghn ng th, trc trc my th, xp
phi,...
- Kim tra li cc thng s my th xem c nguy c TKMP do th my.
- X quang phi sau khi dn lu kh c th gip tm nguyn nhn.
4.4. Chn on mc
- Trn kh mng phi ngi bnh th my thng nng, nht l khi trn kh
do my th hay do bnh l phi ca ngi bnh.
- Trn kh mc nng l trn kh mng phi di p lc, gy suy h hp nng.
5. X TR
5.1. Nguyn tc x tr
- Dn lu mng phi ngay v trit vi ng dn lu c khu knh ln v
ht lin tc vi p lc m thch hp.
- iu chnh cc thng s ca my th gim nguy c trn kh mng phi tip
tc nng ln.
5.2. X tr c th
a) Dn lu mng phi
- Khi cc du hiu lm sng cho php ngh ti TKMP, cn chc thm d mng
phi ngay nu ngi bnh c suy h hp nng. Khi chc d mng phi cn c gi
tr chn on v khng th ch i chp X quang phi chn on.
31
- Cn nhanh chng m mng phi ti thiu, t 1 ng dn lu c khu knh

ln vo khoang mng phi ht dn lu kh lin tc.
- p lc m thng c iu chnh trong khong -20 n -30 cmH2O. Khi p
lc ht mnh (ln hn p lc nh ca my th y vo) v khu knh ng ln,
trn kh mng phi s ht dn. Ngc li, nu trn kh khng gim, thm ch tng ln
v xut hin trn kh di da, cn iu chnh p lc ht mnh hn, hoc xem xt thay
ng dn lu c khu knh ln hn.
- Khi mng phi ht kh, phi gin ra tt, tt my ht v theo di xem kh
cn tip tc ra khng. Rt ng dn lu nu sau 12 - 24 ting hon ton khng thy
xut hin du hiu kh trong mng phi (kh khng ra qua ng dn lu, X quang kim
tra thy mng phi khng cn kh).
(Xem thm Quy trnh k thut Dn lu kh mng phi cp cu).
b) t li cc thng s my th
- Gim th tch lu thng (Vt) n mc chp nhn c, gim mc PEEP hoc
b PEEP nu c th, gim lu lng nh dng th vo ca my th.
- Tng FiO2 gi SpO2 tha ng (c gng gi SpO2 t 92% tr ln).
- Nn cho ngi bnh th theo phng thc iu khin, khng nn dng h
tr/iu khin cho ngi bnh an thn ngi bnh th theo my. Dng thuc gin
c nu thuc an thn cha gip ngi bnh th hon ton theo my.
- iu chnh Vt gi cho p lc cao nguyn < 35 cmH2O.
c) Cc bin php khc
Trong trng hp dn lu mng phi khng gii quyt c trn kh mng phi
(khng ht kh) cn hi chn vi chuyn khoa H hp hoc Phu thut lng ngc xem
xt vic s dng cc bin php iu tr khc:
- Gy dnh mng phi.
- Phu thut ni soi mng phi.
- Phu thut m lng ngc.
d) Theo di
- Theo di ng dn lu mng phi:
+ Bo m ng lun thng tt, theo di tnh trng kh v dch ra qua ng dn
lu. Nu ng b tc cn tin hnh t li ngay.
+ Theo di pht hin tnh trng nhim khun ni t ng dn lu.
- Theo di tin trin ca TKMP: nu tnh trng khng tt ln phi xem xt li
vic t thng s my th v tnh trng ng dn lu. Tng p lc ht hoc thay ng
dn lu khc nu cn.
- Theo di tnh trng suy h hp: TKMP s lm tnh trng suy h hp ca ngi
bnh phc tp hn v lm tng nguy c t vong.
Tin lng TKMP ph thuc vo nguyn nhn gy TKMP, vic pht hin v
x tr sm hay mun, tnh trng h hp ca ngi bnh trc khi trn kh.
32
Bin chng ca trn kh mng phi:

- Tnh trng suy h hp nng thm.
- Tt huyt p
- C th ngng tun hon nu trn kh mng phi qu nng.
- Vim m mng phi do nhim khun trong qu trnh dn lu.
- cn mng phi
7. PHNG BNH
S dng phng thc gim thng kh ph nang (Vt 8 ml/kg hoc thp hn)
khi tin hnh th my cho cc ngi bnh c nguy c chn thng p lc.
Thng xuyn o auto-PEEP khi cho ngi bnh c auto-PEEP th my, iu
chnh my th v cc bin php iu tr bnh nguyn nhn auto-PEEP khng tng.
Thng xuyn o p lc cao nguyn ng th trong qu trnh th my, nht l
nhm ngi bnh c nguy c TKMP. Cn phi gi p lc cao nguyn ng th
<35 cmH2O, v tt nht l < 30 cmH2O. Nhiu nghin cu thy p lc cao nguyn
> 35 cmH2O l mt du hiu bo trc s xut hin ca TKMP ngi bnh th my.
iu chnh cc thng s my th p lc cao nguyn ng th lun trong mc
thch hp.
Ti liu tham kho
1. Ng Qu Chu v cs (2011), Trn kh mng phi. Trong: Bnh h hp (Ch
bin: Ng Qu Chu). Nxb Gio dc Vit Nam.
2. Bigatello L.M., Patroniti N., Sangalli F. (2001),Permissive hypercapnia, Current
Opinion in Critical Care. 7, Pp. 34-40.
3. Huggins G.T., Doelken P., Sahn S.A. (2011), Pleural disease and
pneumothorax. In: Texbook of Critical Care (Editors: Vincent J.L., Abraham E.,
Moore F.A., Kochanek P.M., Fink M.P.), Elsevier Saunders, 6th edition.
4. Hyzy R. C. (2010): Pulmonary barotrauma during mechanical ventilation, Up to
Date 2010. URL: http://www.uptodate.com/
5. Papiris S., Kotanidou A., Malagari K., Roussos Ch. (2002), Clinical review:
severe asthma, Crit Care 6, pp. 30-44.
33
VIM PHI NNG DO VI KHUN TI CNG NG

1. I CNG
nh ngha: l bnh l nhim khun ca nhu m phi, gy ra tnh trng vim
cc ph nang, tiu ph qun v t chc k ca phi, do cn nguyn vi khun, xy ra ti
cng ng.
Tn s th l mt trong cc du hiu quan trng nht nh gi tnh trng
nng ca bnh.
Cn nh gi y cc yu t tin lng nng nh hng x tr cho ph
hp.
2. NGUYN NHN
2.1. Phn loi theo chng vi khun gy bnh thng gp
a) Vi khun in hnh
- Cu khun gram dng: Streptococcus pneumoniae, Staphylococcus aureus,
Enterococcus faecalis, Enterococcus faecium.
- Song cu gram m: Moraxella catarrhalis.
- Trc khun gram m: Hemophillus influenzae, Klebsiella pneumoniae,
Enterobacteriacae, Pseudomonas aeruginosa, Escherichia coli.
b) Vi khun khng in hnh
- Legionella pneumophilia.
- Mycoplasma pneumoniae.
- Chlamydia pneumoniae, Chlamydia psittaci.
2.2. Theo c a ngi bnh
- Nghin ru: Streptococcus pneumoniae, vi khun gram m (Klebsiella
pneumoniae), vi khun k kh.
- V sinh rng ming km: vi khun k kh.
- ang c dch cm hot ng ti a phng: Streptococcus pneumonia,
Staphylococcus aureus, Streptococcus pyogenes, Hemophillus influenzae.
- Vng ang lu hnh dch hi chng h hp v sinh sn ln: Streptococcus
suis (lin cu ln).
- Tip xc vi gia cm, chim: Chlamydia psittaci (ngoi cn nguyn hay gp l
cm A, cm B).
- Bnh phi tc nghn mn tnh: Streptococcus pneumoniae, Hemophillus
influenzae, Moraxella catarrhalis, Legionella.
- Gin ph qun, x phi: Pseudomonas aeruginosa, Burkholderia cepacia,
Staphylococcus aureus.
- Vim phi bnh nhn ui nc ngt hoc ht phi bn t : Pseudomonas
pseudomallei ( cn gi l vi khun withmore )
- Ghp tng, suy thn: Legionella.
34
3. TRIU CHNG
3.1. Lm sng
- Ho.
- Kh th.
- St, c th rt run.
- Khc m c, s lng nhiu.
- au ngc tng khi ht vo.
- Khm phi: th nhanh, hi chng ng c, nghe c ran n, ran m, ting thi
ng ti vng tn thng.
- Cc triu chng nng: nhp tim nhanh, tm, co ko c h hp, ri lon thc,
ri lon huyt ng.
3.2. Cn lm sng
- X quang phi thng, nghing: hnh nh tn thng thm nhim mi thnh
m m trng hoc nhng nt m tp trung mt vng ca phi; c th thy hnh nh
trn dch hay trn kh mng phi.
- Cng thc mu: bch cu mu tng cao > 10G/l hoc < 4G/l.
- Xt nghim m:
+ Nhum soi: c th thy bch cu a nhn trung tnh, t bo biu m, vi
khun.
+ Cy nh danh vi khun gy bnh.
- Cy mu: 2 mu trc khi iu tr khng sinh.
- Xt nghim kh mu ng mch: nh gi tnh trng thng kh, oxy ha mu,
thng bng toan kim, lactat mu.
- Tng protein C phn ng (CRP), procalcitonin.
- Ni soi ph qun (nu cn): nh gi tn thng, ly bnh phm lm xt
nghim nui cy, m bnh hc, hoc phc v mc ch iu tr.
- Mt s xt nghim khc (ty theo kh nng sn c ca c s y t): huyt thanh
chn on Mycoplasma, Chlamydia; xt nghim nc tiu chn on nhim
Legionella.
4. CHN ON
4.1. Chn on xc nh:
- Vim phi mc phi ti cng ng:
+ Ngi bnh c cc triu chng lm sng v cn lm sng nh trnh by
phn 3.
+ c lm xt nghim nui cy vi khun trong vng 48 gi nhp vin, kt qu
xt nghim ln u tin dng tnh, v
+ Khng c cc yu t nguy c b vim phi lin quan n c s chm sc y t.
- Tiu chun chn on vim phi mc phi t cng ng mc nng, v
tiu chun nhp vin vo khoa Hi sc tch cc (khuyn co ca Hip hi cc bnh
nhim trng Hoa K-IDSA, v Hip hi lng ngc Hoa K-ATS nm 2007):
35
+ Tiu chun chnh:

Cn th my.
Sc nhim khun v cn dng thuc vn mch.
+ Tiu chun ph:
Tn s th 30 ln/pht.
T l PaO2 /FiO2 250.
Tn thng lan rng nhiu thy phi.
Tnh trng l ln, mt nh hng.
Tng ure mu (ure mu > 7mmol/L).
Gim bch cu do nhim trng (BC ht < 4000/mm3).
Gim tiu cu (s lng tiu cu < 100 000/mm3).
H thn nhit (nhit trung tm < 36oC).
Tt HA i hi phi tin hnh hi sc truyn dch tch cc.
Khi ngi bnh c t nht 1 tiu chun chnh hoc 3 tiu chun ph cn c
khuyn co nhp vin vo khoa Hi sc tch cc.V vy, vic theo di bnh nhn lin
tc pht hin sm nhng du hiu nng ln l quan trng nht.
4.2. Chn on phn bit
- Vim phi lin quan n cc c s chm sc y t.
- Vim phi khng do vi khun: do virut, nm, k sinh trng.
- Lao phi.
- Vim ph qun.
- Vim ng h hp trn.
- Nhi mu phi.
- Trn dch mng phi.
- Bnh l cc khi u phi-ph qun.
- Vim phi tng bch cu i toan.
- Bnh to u ht Wegener
- Cn hi bnh k v lm cc xt nghim cn thit c y thng tin v c
a ngi bnh (bnh phi mn tnh, suy thn, ghp tng, nghin ru, yu t dch
t). Lm cc xt nghim vi sinh gip phn lp vi khun gy bnh.
- Lu cc yu t nguy c gi nguyn nhn vim phi do trc khun m
xanh:
+ Bnh l lin quan n cu trc phi (gin ph qun, bnh phi tc nghn mn
tnh ).
+ Mi c iu tr khng sinh trong thi gian gn y.
+ Gn y c nm iu tr ni tr trong bnh vin.
+ Suy dinh dng.
+ iu tr corticoid di ngy, c a suy gim min dch.
36
4.4. Chn on mc nng

- Theo c a ngi bnh:
+ Tui > 75.
+ Bnh l km theo:
Cc khi u c tnh.
Suy h hp mn tnh.
Bnh l tim mch.
i tho ng.
Bnh l thn kinh (nh hng n c h hp hoc c tnh trng ri lon
nut).
Suy thn.
Ht thuc l, thuc lo nhiu nm.
Suy gim min dch.
Nghin ru.
Sau t nhim virut, hoc mi y c chn on v iu tr vim
phi.
- Cc triu chng ca tnh trng suy h hp nng:
+ Ri lon thc.
+ Nhp tim >110 ln/pht.
+ Nhit <350C hoc >400C.
+ Th nhanh > 30 ln/pht ngi ln ( tr em theo la tui).
+ Tm.
+ Thiu niu.
+ Huyt p < 90/60mmHg.
+ SaO2 < 90% hoc PaO2< 60mmHg.
- Vim phi nng gy nhim khun nng sc nhim khun: (xem Hng dn
chn on v x tr sc nhim khun).
5. X TR
5.1. Nguyn tc x tr
- iu tr khng sinh sm (trong vng 6 gi u sau khi nhp vin), ngay sau
khi ly bnh phm lm xt nghim (cy m, cy dch ph qun, cy mu)
- La chn khng sinh thch hp (da trn la tui, c a, mc nng ca
bnh), m bo dng khng sinh ng v liu.
- Vim phi nng do vi khun mc phi ti cng ng phi c iu tr v
theo di st ti khoa Hi sc.
- Ngi bnh c du hiu suy h hp nng v nguy kch cn c h tr th
my (khng xm nhp hoc xm nhp).
- Kt hp vi cc bin php truyn dch b nc v in gii, m bo dinh
dng v cc iu tr triu chng khc.
- Cn pht hin sm cc bin chng c cc bin php can thip kp thi.
37

- Cc trng hp vim phi nng do vi khun mc phi ti cng ng cn c
vn chuyn sm v an ton n cc khoa Hi sc cp cu c iu tr v theo di
st.
- Trc khi vn chuyn n khc khoa Hi sc hay cc bnh vin khc, phi
ch nh khng sinh theo kinh nghim liu u tin (da trn c a ngi bnh v
nh hng s b trn lm sng), v ghi r tn, liu khng sinh dng vo tm tt
bnh n chyn vin (hoc giy chuyn vin). Ngoi ra, cn nh gi mc suy h
hp ch nh oxy liu php, hoc thng kh h tr (xm nhp hoc khng xm nhp)
kp thi.
- Phi m bo mch, huyt p v tnh trng h hp n nh trong qu trnh vn
chuyn (dch truyn, oxy liu php hoc thng kh h tr).
a) iu tr khng sinh
- Khng c nguy c nhim trng do trc khun m xanh:
+ Cephalosporin th h 3 (ceftriaxon 1-2g/ngy; cefotaxim 1-2g mi 6-8gi)
kt hp vi fluoroquinolone khng ph cu (levofloxacin 500mg/ngy; gatifloxacin
400mg/ngy; moxifloxacin 400mg/ngy) hoc macrolid (azithromycin 500mg/ngy;
erythromycin 500mg mi 6gi; clarithromycin 500mg mi 12gi).
+ Hoc Betalactam + cht c ch men betalactamase (ampicillin/sulbactam 1,53g mi 6gi; amoxicillin/a.clavulanic) kt hp vi fluoroquinolone khng ph cu
hoc macrolid.
- Nguy c nhim trng do trc khun m xanh:
+ Betalactam khng trc khun m xanh kt hp vi aminoglycosid, kt hp
vi fluoroquinolone khng ph cu hoc macrolid.
+ Hoc Betalactam khng trc khun m xanh (cefepim 1-2g mi 12gi;
piperacillin/tazobactam; imipenem; meropenem) kt hp vi ciprofloxacin.
+ Nu nghi ng do cc cng vi khun sinh men betalactamase ph rng th
dng ngay nhm Carbapenem ( imipenem, meropenem..)
- Nu nghi ng nhim trng do Staphylococcus khng methicillin: thm
Vancomycin hoc Teicoplanin kt hp linezolid.
- Vim phi do ht hoc vim phi do vi khun k kh: betalactam + cht c ch
men betalactamase hoc clindamycin.
- vim phi do ht phi nc ngt hoc bn t : nhm Ceftazidim c th xem
xt kt hp vi Chloramphenicol, Doxycycline, Cotrimazole
Thi gian iu tr khng sinh:
+ Vim phi do cc vi khun in hnh thng gp: 7-10ngy
+ Do vi khun khng in hnh (Chlamydia, Legionella, Mycoplasma): 14
ngy.
+ Vim phi do trc khun m xanh: iu tr t nht 10-14 ngy.
38
+ Ngi bnh dng corticoid lu ngy cn ko di thi gian iu tr khng sinh

(14 ngy hoc lu hn).
b) Cc bin php hi sc
- iu tr suy h hp (xem thm Hng dn chn on v x tr Suy h hp
cp).
+ T th ngi bnh: u cao 30 - 45 (nu khng tt huyt p).
+ xy liu php: sao cho SpO2> 92% hoc PaO2> 65mmHg.
+ Th my khng xm nhp: khi xy liu php khng kt qu.
+ Th my xm nhp qua ng ni kh qun: khi ngi bnh suy h hp nng,
c chng ch nh hoc khng p ng vi th my khng xm nhp.
- Tnh trng nhim khun nng-sc nhim khun:
(xem Hng dn chn on v iu tr sc nhim khun)
- Cc bin php khc
+ Cn nhc soi ht ph qun nu c ch nh.
+ iu chnh cn bng dch vo ra v cc ri lon in gii.
+ Cc bin php vt l tr liu h hp.
+ Dinh dng cho ngi bnh.
+ Theo di st cc du hiu sinh tn.
+ iu tr phng huyt khi tnh mch su v vim lot d dy do stress.
6.1. Tin lng: tin lng nng khi
- Tui cao.
- Nhiu bnh l kt hp.
- C a nghin ru, suy gim min dch, s dng corticoid di ngy
- Vim phi nhiu thy.
- Tnh trng bnh nng ngay t u.
- p ng km hoc khng p ng sau 3 ngy iu tr.
- C bin chng nng: nhim trng huyt, sc nhim khun, ARDS
6.2. Bin chng
a) Bin chng ti phi
- Bnh c th lan rng ra hai hoc nhiu thy phi, ngi bnh kh th nhiu
hn, tm mi, mch nhanh, ngi bnh c th t vong trong tnh trng suy h hp, sc
nhim trng.
- Xp mt thu phi: do cc m c qunh gy tc ph qun.
- p xe phi: rt thng gp, do dng khng sinh mun, khng ng hoc
khng liu, ngi bnh st dai dng, khc nhiu m c m. Chp X quang phi c
th thy hnh nh p xe (hnh hang vi mc nc, mc hi).
b) Bin chng trong lng ngc
- Trn kh mng phi, trung tht: thng do nguyn nhn t cu.
39
- Trn dch mng phi: vim phi gy trn dch mng phi, dch vng chanh,
thng do ph cu khun.
- Trn m mng phi: ngi bnh st dai dng, chc d mng phi c m,
thng xy ra trong trng hp vim phi mng phi, hoc do chc d mng phi gy
bi nhim.
- Vim mng ngoi tim: triu chng au vng trc tim, nghe c ting c mng
tim, thng l vim mng ngoi tim c m.
c) Bin chng xa
- Vim ni tm mc cp tnh do ph cu: bin chng ny him gp, ngi bnh
c cn st rt run, lch to.
- Vim khp do ph cu: gp ngi tr tui, thng ch b mt khp sng, ,
nng, au.
- Vim mng no do ph cu: l bin chng him gp, dch no tu c bch cu
a nhn, glucose trong dch no ty gim, chn on vi sinh bng nhum soi v cy
dch no ty.
- Vim phc mc: thng gp tr em.
- Sc nhim trng: rt hay gp ngi bnh nghin ru.
7. PHNG BNH
- V sinh rng ming y .
- Tim phng vacxin cm v ph cu, c bit vi ngi bnh c c a suy
gim min dch, bnh l c tn thng cu trc phi.
- Ngi bnh mc cc bnh l ni khoa mn tnh nng hoc c nguy c suy
gim min dch cn c t vn k hoch tim phng cng nh bin php phng trnh
cc bnh ly qua ng h hp.
Ti liu tham kho
1. Nguyn Quc Anh, Ng Qu Chu. (2011), Vim phi nng do vi khun ti cng
ng, Hng dn chn on v iu tr bnh ni khoa, Nh xut bn Y hc, Tr
89-102.
2. Ng Qu Chu, Nguyn Thanh Thy. (2011), c im lm sng v vi khun
hc ca vim phi mc phi cng ng, Tp ch nghin cu y hc 73 (2). Trng
i hc Y H Ni.
3. V Vn nh, Nguyn Th D. (2000), Vim phi, Cm nang cp cu. Nh
xut bn Y hc, Tr. 149-53.
4. Nguyn Thanh Hi (2003). Nghin cu c im lm sng v vi khun hc ca
vim phi mc phi cng ng do vi khun hiu kh iu tr ti khoa h hp
bnh vin Bch Mai. Lun vn tt nghip bc s ni tr bnh vin. Trng i
hc Y H Ni.
5. Halm E.A., Teirstein A.S. (2002), Management of Community-Acquired
Pneumonia, New England Journal Medicine, Pp. 2039-45.
40
6. Kollef M.H., Isakow W. (2012), Community-Acquired Pneumonia, The

Washington Manual of Critical Care. second edition.
7. Niederman M.S. (2005), Community-Acquired Pneumonia, Texbook of Critical
Care, Pp. 647-61.
8. Slazados J.E. (2007), Pneumonia in Aldults. Saunders Manual of Critical Care,
Pp. 37-41.
9. Winshall J.S., Lederman R.J. (2006), Community-Acquired Pneumonia,
Tarascon Internal Medicin & Critical Care Pocketbook. Fourth Edition, Pp. 93-5
41
VIM PHI LIN QUAN N TH MY
1. I CNG
nh ngha: vim phi lin quan n th my (Ventilator Associated
Pneumonia - VAP), c nh ngha l nhim trng nhu m phi xy ra sau 48 gi k
t khi ngi bnh c th my (qua ng ni kh qun, hoc canuyn m kh qun),
ngi bnh khng trong thi k bnh ti thi im bt u c th my.
L bnh l nhim khun bnh vin rt thng gp trong khoa hi sc, vi t l
8-10% ngi bnh iu tr ti khoa hi sc, v 27% trong s ngi bnh c th
my. T l t vong khong 20-50% theo nhiu nghin cu, thm ch c th ti 70%
khi nhim cc vi khun a khng.
Lm tng t l t vong, ko di thi gian th my, thi gian nm vin v tng
chi ph iu tr.
2. NGUYN NHN V CC YU T NGUY C
2.1. Nguyn nhn
- Cc vi sinh vt gy bnh rt thay i ph thuc vo c im ngi bnh
trong tng khoa hi sc, phng tin chn on, thi gian nm vin cng nh thi
gian nm iu tr ti khoa hi sc, qui trnh kim sot nhim khunv cc chnh sch
s dng khng sinh ti n v .
- Cc nguyn nhn hay gp trong vim phi lin quan n th my sm (< 5
ngy): t cu nhy methicillin, Streptococcus pneumoniae, Hemophilus influenzae.
- Vim phi bnh vin mun ( 5 ngy): t cu khng methicillin,
P.aeruginosa, Acinetobacter baumannii, Klebciella pneumonia.Stenotrophomonas
maltophilia.
- Ngi bnh dng khng sinh trc : t cu khng methicillin,
P.aeruginosa, Acinetobacter baumannii v cc vi khun gram m a khng khc.
- Ngoi ra gn y nm l nguyn nhn rt ng ch gy vim phi bnh
vin, c bit nhng ngi bnh c c a suy gim min dch, s dng khng sinh
ph rng di ngy.
2.2. Cc yu t nguy c ca vim phi lin quan n th my
a) Yu t lin quan n ngi bnh
- Tui 60.
- Mc nng ca bnh.
- Suy tng.
- Dinh dng km hoc gim albumin mu.
- au bng thng v hoc c phu thut vng ngc.
- Hi chng suy h hp cp tin trin.
- Bnh phi mn tnh.
- Bnh l thn kinh c.
42
- Chn thng, bng.

- Hn m, suy gim thc.
- Ht phi lng th tch ln.
- C vi khun khu tr ng h hp trn.
- Vi khun khu tr d dy v pH dch v thp
- Vim xoang.
b) Yu t lin quan n cc bin php can thip
- Thi gian th my.
- t li ni kh qun.
- Thay i h thng dy th thng xuyn.
- t ng thng d dy.
- Theo di thng xuyn p lc ni s.
- Dng thuc an thn, gin c.
- Dng thuc khng H2, thuc khng acid.
- Truyn > 4 n v mu.
- T th u, nm nga.
- Vn chuyn ra ngoi khoa hi sc.
c) Cc yu t khc
Ma: ma thu, ma ng.
2.3. Yu t nguy c v cc vi sinh vt c bit
Vi sinh vt
Yu t nguy c
H. influenzae,
Bnh phi tc nghn mn tnh, vim phi lin quan n
Moraxella catarrhalis, th my t sm (xut hin sm < 5 ngy sau khi c
S. Pneumoniae
th my).
P. aeruginosa,
iu tr bng corticoid, suy dinh dng, bnh phi (gin
Acinetobacter
ph qun, x nang phi), vim phi lin quan n th
baumannii
my mun, c dng khng sinh trc .
T cu
Hn m, chn thng s no, phu thut thn kinh, i
tho ng, suy thn mn, cm.
Vi khun k kh
Ht phi.
Legionella
Ha tr liu, iu tr corticoid, bnh l c tnh, suy thn,
gim bch cu, ly nhim t h thng nc bnh vin.
Aspergillus
iu tr bng corticoid, thuc c t bo, bnh phi tc
nghn mn tnh.
Candida albicans
Suy gim min dch, thuc c t bo, s dng corticoid,
khng sinh ph rng di ngy, ngi bnh c lu cc ng
thng mch mu di ngy
Influenza
Ma ng, suy gim min dch, bnh l mn tnh tim
n, sng ni c dch cm lu hnh ...
Virus hp bo h hp
Suy gim min dch, bnh tim hoc phi mn tnh.
43
3. TRIU CHNG
3.1. Lm sng
Cc triu chng xut hin sau 48 gi k t khi c th my (qua ng ni kh
qun hoc qua canuyn m kh qun).
- Dch ph qun c m, c v s lng nhiu hn.
- St > 38C hoc < 35,5C.
- Nghe phi c ran bnh l.
3.2. Cn lm sng
- X quang c m thm nhim mi, tn ti dai dng, hoc thm nhim tin trin
thm sau 48 gi k t khi th my.
- Tng bch cu > 10G/l hoc gim bch cu < 4G/l.
- Procalcitonin tng cao > .0,125 ng/ml
- Cy dch ht ph qun >105 CFU/ml, hoc
- Cy dch ra ph qun ph nang > 104 CFU/ml, hoc
- Cy mu bnh phm chi ph qun c bo v > 103 CFU/ml.
- Gim oxy ha mu: nh gi da vo SpO2 ( bo ha oxy mch ny), hoc
ch s PaO2/FiO2 khi c kt qu kh mu ng mch.
4. CHN ON
4.1. Chn on xc nh
- Cc triu chng xut hin sau 48 gi k t khi c th my (qua ng ni kh
qun hoc qua canuyn m kh qun).
- X quang phi: tn thng mi hoc tin trin ko di trn 48 gi km theo 2
trong 3 du hiu sau:
+ Nhit > 38,3oC hoc < 35oC.
+ Bch cu > 10000/mm3, hoc < 4000/mm3.
+ Procalcitonin tng cao hn.
+ m c hoc thay i tnh cht m.
- Nui cy dch ph qun dng tnh.
4.2. Chn on phn bit
a) Vim phi mc phi ti cng ng
- Ngi bnh c kt qu cy vi sinh vt ln u (trong vng 48 gi u k t
khi nhp vin) dng tnh.
- Khng c cc yu t nguy c mc vim phi lin quan n chm sc y t.
b) Vim phi lin quan n c s chm sc y t.
Ngi bnh c kt qu cy vi sinh vt ln u (trong vng 48 gi u k t khi
nhp vin) dng tnh, v c km bt k mt trong s cc tiu chun sau:
- Ngi bnh c chuyn t mt c s chm sc y t khc.
- ang c lc mu, c vt thng hay c iu tr bng tim truyn nh
mt ngi bnh ngoi tr.
44
- Ngi bnh c nhp vin iu tr (thi gian iu tr t nht 3 ngy) trong

vng 90 ngy tr li y.
- C tnh trng suy gim min dch do bnh l nn, hoc do iu tr (nhim
HIV, dng corticoid ko di hoc ha tr liu).
c) Vim phi bnh vin khng lin quan n th my
- Ngi bnh c kt qu cy vi sinh vt ln u dng tnh (cy ti thi im
sau 48 gi k t khi vo vin).
- Ngi bnh khng hoc cha c th my.
Chn on nguyn nhn da trn cc yu t nguy c (qua hi bnh, lm cc xt
nghim cn thit), v lm y cc xt nghim vi sinh (gip phn lp vi khun gy
bnh).
5. X TR
5.1. Nguyn tc la chn khng sinh
- Xem xt k cc yu t sau la chn khng sinh thch hp:
+ C a ngi bnh, cc yu t nguy c v bnh l km theo.
+ Cc khng sinh dng trc .
+ Mc tn thng phi.
+ Dch t hc, mc nhy cm ca cc chng vi khun, hoc nm ti tng
khoa, bnh vin, iu ny rt quan trng v vi khun gy bnh v mc khng khng
sinh khng ging nhau gia cc khoa, bnh vin, v vy phi tin hnh nh k vic
iu tra dch t pht hin nguyn nhn, ng ly truyn, mc nhy cm vi thuc
khng sinh a ra quyt nh ph hp.
+ Vim phi bnh vin sm hay mun.
- Khng sinh la chn theo kinh nghim cn c cho sm (tt nht sau khi ly
cc bnh phm nh dch ph qun, mu lm xt nghim vi sinh), ng - liu, sau
iu chnh theo p ng lm sng v kt qu xt nghim vi sinh.
- Ngi bnh mc vim phi lin quan n th my thng ang c iu tr
ti cc c s Hi sc Cp cu. Trng hp ang c iu tr hoc chm sc di
ngy ti cc c s y t khc, ngi bnh cn c vn chuyn sm v an ton n cc
khoa Hi sc c iu tr v theo di st.
- Trc khi vn chuyn, cn ch nh sm khng sinh theo kinh nghim liu u
tin (da trn c a v nh hng s b trn lm sng). Ngoi ra, ngi bnh phi
c nh gi c th tnh trng h hp ch nh phng thc th my ph hp.
- Trong qu trnh vn chuyn phi m bo mch, huyt p v tnh trng h hp
n nh (dch truyn, thng kh vi my th vn chuyn chuyn dng hoc bp bng
qua ng ni kh qun/canuyn m kh qun). Tn, liu v thi gian s dng thuc
khng sinh phi c ghi y trong tm tt bnh n chuyn vin (hoc giy chuyn
vin).
45

a) Khng sinh iu tr vim phi bnh vin trong trng hp khng c nguy c nhim
vi khun a khng
- iu tr khng sinh kinh nghim vi: t cu nhy methicillin, Streptococcus
pneumoniae, Hemophilus influenzae, vi khun gram m ng rut nhy vi khng
sinh.
- La chn mt trong s cc khng sinh:
+ Ceftriaxone.
+ Quinolon (levofloxacin, moxifloxacin, ciprofloxacin).
+ Ampicillin/sulbactam, hoc ertapenem.
b) Vim phi lin quan n th my c nguy c nhim cc vi sinh vt a khng
- iu tr tp trung vo cc tc nhn: t cu khng methicillin, P. aeruginosa,
Acinetobacter, Klebsiella, Enterobacter, Serratia, Stenotrophonas, Burkhoderia
cepacia.
- La chn 1 loi khng sinh nhm A kt hp vi 1 khng sinh nhm B; cn
nhc thm nhm C hoc D, ty theo nh hng tc nhn gy bnh (nu vi khun sinh
ESBL: carbapenem kt hp vi fluoroquinolon).
- Nhm A:
+ Cephalosporin khng trc khun m xanh (cefepim, ceftazidim).
+ Carbapenem khng trc khun m xanh (imipenem, meropenem).
+ Betalactam c hot tnh c ch betalactamase (piperacillin/tazobactam).
- Nhm B:
+ Fluoroquinolon khng trc khun m xanh (ciprofloxacin, levofloxacin).
+ Aminoglycosid (amikacin, gentamycin, tobramycin).
- Nhm C (nu nghi ng t cu khng methicillin):
+ Linezolid.
+ Vancomycin.
+ Teicoplanin (cn nhc nu c nguy c khng vi vancomycin).
- Nhm D (nu nghi ng nhim nm):
+ Khi s dng khng sinh ph rng > 7 ngy, hoc c a suy gim min dch.
+ Thuc chng nm: Fluconazol, itraconazol. Nu khng th dng thuc
nhm Enchinocandin.
- Nu vim phi lin quan n th my mun: c nguy c hoc chc chn do
nhim vi khun gram m a khng: Colimycin kt hp vi carbapenem.
y l loi VAP mun ang ph bin nht Vit nam hin nay
- iu chnh liu theo kt qu vi sinh vt v p ng lm sng.
Ch :
Ngi bnh suy thn cn iu chnh theo mc lc cu thn, kt qu nh
lng khng sinh trong mu (nu c) v tnh trng ngi bnh.
46
c) Theo di v thi gian iu tr khng sinh

- Tin hnh iu tr theo kinh nghim da trn nh hng ban u, nh gi li
sau 48 72 gi, hay ti khi c kt qu nui cy vi sinh.
- Liu trnh khng sinh phi c xem xt li ti cc thi im sau 3 ngy, 5
ngy, 7 ngy iu tr. p ng tt: im CPIS (Clinical Pulmonary Infection Score)
gim, ci thin st, ci thin t l PaO2/FiO2, bch cu gim, procalcitonin gim, tnh
cht m m gim, tn thng trn phim X quang phi c ci thin.
- nh gi v theo di hng ngy v cc triu chng lm sng, xt nghim mu,
xt nghim vi sinh:
+ Triu chng lm sng ci thin nhanh, kt qu nui cy vi khun m tnh:
xem xt ngng khng sinh hoc rt ngn liu trnh khng sinh.
+ Khi c kt qu cy xc nh c vi khun gy bnh v cc triu chng
lm sng c ci thin: iu chnh phc khng sinh (liu php iu tr xung
thang) da trn kt qu vi sinh vt v nhy cm ca vi khun. Cn nhc lm li xt
nghim vi sinh nh k, c bng chng v hiu qu iu tr.
+ Khng thy c du hiu ci thin tnh trng nhim trng phi: loi tr cc
bin chng (v d: p xe, trn m mng phi) v cc nguyn nhn khc (k c
nguyn nhn nhim trng v khng nhim trng). Ngoi ra, phi nh gi li i vi
cc vi khun gy bnh khng khng sinh m phc khng sinh ban u khng bao
ph c, hoc nng khng sinh cha tha ng. Cn nhc lm li cc xt nghim
vi sinh nu cn thit.
- Thi gian iu tr ngn (khong 7-10 ngy): t cu, Hemophilus influenzae.
- Thi gian iu tr di (t nht 14 21 ngy):
+ Tn thng nhiu thy.
+ C a suy dinh dng.
+ C tn thng dng , dng khoang.
+ Vim phi c hoi t do vi khun gram m.
+ Kt qu nh danh vi khun: P. aeruginosa, Acinetobacter spp
6.1. Tin lng: nng nu ngi bnh c nguy c nhim cc vi sinh vt a khng
thuc
- Ngi bnh tng nhp vin >2 ngy trong vng 90 ngy gn y.
- Nm iu tr cc c s chm sc di ngy.
- Lc mu chu k trong vng 30 ngy.
- ang iu tr tim truyn ti nh.
- C ngi thn trong gia nh b nhim vi khun a khng.
- iu tr khng sinh trong vng 90 ngy gn y.
- Vim phi bnh vin mun ( 5 ngy).
- ang nm vin > 5 ngy (khng nht thit iu tr ti khoa Hi sc).
47
- ang iu tr ti bnh vin hoc mi trng khc c lu hnh vi khun c tnh

khng cao.
- Ngi bnh c bnh l suy gim min dch, hoc ang dng thuc gy suy gim
min dch.
6.2. Bin chng
-p xe phi.
-Hi chng suy h hp cp tin trin (ARDS - acute respiratory distress
syndrome).
-Vim m mng phi.
-Nhim trng huyt.
-Sc nhim khun.
7. D PHNG
7.1. Vim phi do ht phi
- u tin s dng th my khng xm nhp nu khng c chng ch nh.
- Rt ngn thi gian th my.
- Dng ng ht m kn v thay nh k.
- Ht m di thanh mn lin tc.
- T th na ngi (45).
- Trnh tnh trng t rt ng.
- Duy tr p lc bng chn (cuff) ti u.
- Trnh tnh trng cng gin d dy qu mc.
- Trnh thay ng ng dy th khng cn thit.
- Lm m bng HME (Heat and Moisture Exchangers).
- Trnh ng nc ng th.
- Trnh vn chuyn ngi bnh khi khng cn thit.
7.2. Vim phi do cc vi khun c tr (colonization) gy bnh
- Ra tay thng quy ng k thut v c hiu qu
- Tp hun v m bo s lng nhn vin, c bit l iu dng ch
cng tc chm sc v sinh rng ming, t th ngi bnh.
- Trnh s dng khng sinh khng cn thit.
- D phng lot d dy do stress.
- t ni kh qun ng ming.
- S dng khng sinh ngn ngy.
Ti liu tham kho

1. Nguyn Quc Anh, Ng Qu Chu. (2011), Vim phi lin quan n th
my, Hng dn chn on v iu tr bnh ni khoa. Nh xut bn Y hc,
Tr. 96-9.
48
2. Nguyn Ngc Quang (2011), Nghin cu tnh hnh v hiu qu iu tr vim

phi lin quan n th my. Lun vn tt nghip bc s ni tr bnh
vin.Trng i hc Y H Ni.
3. Bi Hng Giang (2013). Nghin cu c im vi khun v iu tr nhim
khun bnh vin ti khoa Hi sc tch cc, bnh vin Bch Mai nm 2012.
Lun vn tt nghip Thc s Y hc. Trng i hc Y H Ni.
4. Alp E, Voss A. (2006), Ventilator-associated pneumonia and infection
control, Annals of Clinical Microbiology and Antimicrobials, Pp. 5-7.
5. Antibiotic Essentials 2010. Physicians Press.
6. Australian Medicin Handbook. (2009), Anti-infectives.
7. Chastre J., Fagon J.Y. (2002), Ventilator-associated pneumonia, American
Journal of Respiratory and Critical Care Medicine, Vol 165 (7), Pp. 867-903.
8. Koenig S.M., Truwit J.D. (2006), Ventilator-associated pneumonia: Diagnosis,
treatment and prevention, Clinical Microbiology Review, Oct, Pp. 637-57.
9. Kollef M.H., Isakow W. (2012), Ventilator-associated pneumonia, The
Washington Manual of Critical Care. second edition.
10. Pelleg A.Y., Hooper D.C. (2010), Hospital Acquired- Infections due to gramnegative bacteria, New England Journal Medicine (362), Pp. 1804-13.
11. The Sanford Guide to Antimicrobial Therapy 2010.
12. Therapeutic Guidelines Antibiotic 2010, Respiratory tract infections:
pneumonia, version 14, Melbourne.
49
Du hiu lm sng nghi ng Vim phi

lin quan n th my.
Lm xt nghim m (nu ngi bnh st 38oC: cy mu):

Ni soi ph qun ly dch ra ph qun ph nang, hoc ly dch
bng phng php dng bn chi c bo v.
Nu khng tin hnh soi ph qun c: ly m ht qua ni kh
qun, hoc qua ng m kh qun.
Bt u khng sinh theo kinh nghim (da trn c a,

yu t nguy c, thi gian mc bnh).
Tip tc iu tr khng sinh theo kinh nghim trong vng

48 72 gi, hoc n khi c kt qu xt nghim vi sinh.
Cc triu chng thuyn gim

v kt qu cy m tnh.
Lm sng c ci thin hoc

cc triu chng n nh dn.
Cn nhc ngng khng sinh.
Liu php xung thang

da trn kt qu cy vi
sinh v khng sinh .
Tip tc ci thin triu chng.
Gii hn thi gian s dng khng

sinh trong vng 7-10 ngy, tr khi
xut hin nhim khun th pht
(iu tr 15 ngy trong trng hp
nhim trc khun m xanh, vi
khun a khng thuc, vi khun
sinh ESBL, hoc nm, hoc c
nhim trng ti pht).
Khng ci thin triu chng.
Loi tr kh nng
xut hin cc bin
chng (p xe, m
mng phi) v loi
tr cc nguyn nhn
khc khng do nhim
trng.
nh gi li kh
nng vi khun
khng li cc KS
ban u, hoc
nng khng
sinh trong phi
khng tha ng.
S tip cn v x tr vim phi lin quan n th my

50
Ph lc: Bng im CPIS - Clinical Pulmonary Infection Score

Tiu chun
o
Nhit
36,5 C v 38,5oC
38,5 oC v 38,9 oC
39oC v 36oC
Bch cu mu, 4000 v 11000
mm3
< 4000 hoc > 11000
< 4000 hoc > 11000 + bch cu on > 50%
Dch tit t Khng c
kh qun
Xut tit dch nhng khng c m
Xut tit dch c m
Oxy ha mu, >240 hoc ARDS (ARDS c nh ngha l PaO2/FiO2
PaO2/FiO2,
200, p lc mao mch phi bt 18mmHg, v tn
mmHg
thng cp tnh 2 bn phi)
240 v khng phi ARDS
X quang phi
Khng tn thng
Thm nhim phi lan ta (hoc m m)
Tn thng thm nhim khu tr
Tin trin ca Khng tin trin thm trn phim X quang
thm
nhim Tip tc tin trin trn phim X quang (sau khi loi tr
phi
suy tim xung huyt v ARDS)
Cy dch tit t m tnh
kh qun
Dng tnh
51
im
0
1
2
0
1
2
0
1
2
0
2
0
1
2
0
2
0
2
VIM PHI NNG DO VI RT CM A

1. I CNG
Vim phi nng l tn thng phi gy suy h hp tin trin nhanh cn nguyn
do cc virut cm A gy ra.
Din bin nng c lin quan mt s nhm ngi bnh nh:
+ Suy gim min dch: c thai hoc dng cc thuc c ch min dch
+ Ngi bnh thng tr tui, phn ln ang trong tui lao .
+ C nhiu bnh mn tnh phi hp.
Phn ln ngi bnh t vong v suy h hp do c tn thng phi nng hoc do
suy a ph tng, nhim khun bnh vin phi hp
C mt t l vi rt cm A khng vi oseltamivir.
iu tr kh khn v tn km v t l t vong cao.
2. NGUYN NHN
Thng gp do vi rt cm A (H5N1), cm A (H1N1), cm A (H3N2), cm A
(H7N9)
2.1. Vi rt cm A (H5N1).
- Cm A (H5N1) cn gi l cm gia cm v gy bnh cho gia cm v tryn bnh
sang ngi.
- Hay gy bnh cho la tui ang trong tui lao ng v cc ngi bnh c
suy gim suy gim min dch nh nghin ru, c thai
- Vi rt c c lc cao, khi xm nhp vo c th ngi gy tn thng qua 2 c
ch:
+ Trc tip: ti phi l vi rt nhn ln ti t bo ph bo II ca ph nang v
ph hy trc tip cc ph nang c tnh cht lan ta.
+ Gin tip l cc vi rt kch thch h thng bo v ca c th gy ra cc phn
ng vim qu mc(cc cn bo cytokine) v gy ra hi chng tn thng ph nang lan
ta (Diffuse Alveolar Damage - DAD ), lm mt kh nng trao i kh dn n thiu
oxy mu nng v ko di , tn thng suy a tng.
- Hay gp vng ng Nam nh Indonesia, Vit Nam
- T l t vong cao 60 -80%
2.2. Vi rt cm A (H1N1)
- L cm gy bnh trc tip cho ngi, mc ly lan ra cng ng nhanh
nhng c lc virut yu hn virut cm A (H5N1).
- Cc nguy c din bin nng: suy gim min dch, ph n c thai, tr em di
5 tui, c bnh tim mch mn tnh, bnh phi phi mn tnh, bo ph
- T l t vong thay i theo tng quc gia; 0,048% ti M v ti Anh l
0,026%.
- Nguyn nhn dn n t vong ch yu do suy h hp do pht hin v iu tr
mun, tn thng phi nng, suy a tng v nhim khun bnh vin.
52
2.3. Vi rt cm A H3N2
Cng c cc c im gy bnh tng t vi rt cm A H1N1.
2.4. Viruts cm A H7N9
Cc bo co ti Trung quc cng cho thy c im lm sng ca cm A H7N9
cng tng t nh cc loi cm khc, v t vong do iu tr mun (sau 6 ngy) suy h
hp cp nng, th my khng kt qu v suy a tng.
3. TRIU CHNG
3.1. Lm sng
- Biu hin hi chng cm chung: mt, st, au u, au hng, s mi, ho khan
- Biu hin suy h hp trn nn ngi bnh c biu hin hi chng cm, tuy
nhin din bin bnh khc nhau ty thuc vo tng cn nguyn gy bnh v xut hin
thm mt s triu chng ngoi ng h hp do vi rt cm A (H5N1).
a) Thi gian bnh: ty theo tng loi vi rt
- Do cm A (H5N1) thi gian bnh khong 1 tun sau khi tip xc vi gia cm
cht, m hoc b bnh.
- Do virut cm A (H1N1) thng t 1,5 n 3 ngy hoc lu hn.
- Do cm A ( H7N9) khong t 3-7 ngy
b) Thi gian ton pht
- Biu hin nhim cm chung nh; au rt hng, st, au u, au mnh my,
ho khan, chy mi , nu do cm A (H5N1)
- C th xut hin thm cc triu chng ca h thn kinh: l ln, nn bun nn,
ri lon c trn v hi chng no v mng no
- Cc triu chng v tiu ha nh vim d dy rut vi biu hin a chy, xut
huyt tiu ha
- H hp: au ngc, ho, kh th tng ln, suy h hp tin trin nhanh, th
nhanh, mch nhanh, SpO2 gim, tm mi u chi, khm phi nhiu ran n hoc thi
ng.
- C th tin trin suy a tng nh: suy h hp, tun hon, tng bilirubin ton
phn v trc tip, suy thn, gim tiu cu
3.2. Cn lm sng
- Cng thc mu:
+ Bch cu v tiu cu bnh thng hoc gim, t l bch cu a nhn trung tnh
cng gim, trng hp nng bch cu gim di 1000 t bo/ml.
+ Giai on sau c nhim khun th pht s lng bch cu tng cao.
- Tng t vi cc marker ch th vim khc nh CRP, procalcitolin trong gii
hn bnh thng, giai on c nhim khun th pht CRP v Procalcitolin s tng.
- X quang tim phi:
+ Tn thng thm nhim khu tr mt thy phi sau lan ta nhanh ra ton
b phi thm ch lan ta nhanh c hai phi (phi trng).
+ C th gp hnh nh trn dch hoc/v trn kh mng phi.
53
- Kh mu: biu hin in hnh gim oxy ha mu mc va n nng, t l

PaO2/FiO2 < 300, c th gp tng thng kh ph nang (PaCO2 gim < 35 mmHg)
giai on u do ngi bnh th nhanh, khi ngi bnh c suy h hp nng phi th
my vi PEEP cao thng c tng CO2 mu (> 45 mmHg) do gim thng kh ph
nang.
- Kt quxt nghim chn on nhanh cm A (+) vi dch t hu hoc dch ph
qun, vi cm A (H5N1) bt buc phi ly dch ht m su thng qua dch ht ph
qun hoc dch m sau khi c kh dung nc mui u trng 10%). Xt nghim
nhanh cho kt qu 15-30 pht, thng t l m tnh gi cao do vi rt t bin nhanh,
nn hin nay gi tr ca xt nghim chn on nhanh t ngha.
- PCR vi bnh phm m hoc dch ph qun chn on cm A (H5N1) hoc
cm A (H1N1) c nhy v c hiu cao nhng nhng cn thi gian t nht 1224 gi, c th tm thy vi rt cm A (H5N1) trong phn v dch no ty.
- Cy dch ph qun c th gp cc vi khun bi nhim nh Klebsiella
pneumonia, A. baumanii, Pseudomonas aeruginosa
- Cc xt nghim chn gip chn on suy a tng v theo di din bin suy a
tng.
4. CHN ON
4.1. Chn on xc nh: da vo
- Yu t dch t: ngi bnh c tin s tip xc vi gia cm m hoc cht nu
do cm A(H5N1) hoc tip xc vi ngi t vng dch tr v ( cm A H1N1, H7N9).
- Lm sng: biu hin 2 hi chng
+ Hi chng cm.
+ Hi chng suy h hp cp.
- Cn lm sng:
+ Cng thc mu bch cu v tiu cu bnh thng hoc gim, CRP v/hoc
procalcitonin trong gii hn bnh thng nu cha c bi nhim.
+ X quang tim phi: tn thng thm nhim khu tr mt bn phi hoc lan ta
hai phi.
+ Kh mu: gim oxy ha mu mc va n nng, t l PaO2/FiO2< 300.
+ PCR dch ph qun dng tnh vi vi rt cm A (H5N1) hoc A (H1N1).
4.2. Chn on phn bit
- Vi vim phi do vi khun nh ph cu, hemophilus influenza . thng c
bch cu tng, procalcitonin tng, cy bnh phm h hp c th pht hin cn nguyn
vi khun gy bnh.
- Vim phi nng do mt s nguyn nhn vi khun khng in hnh.
- Ly bnh phm ng h hp tt nht l m su nu ngi bnh t ng
ni kh qun.
54
- Nu ngi bnh cha t ng ni kh qun: ly myu cu ngi bnh khc

m (sau khi lm kh dung vi nc mui u trng) hoc ly qua dch ngoy
hng hoc dch t hu.
4.4. Chn on mc
Da theo mc tn thng phi v mc suy h hp chia ra cc mc (xem
bi suy h hp).
- Mc nng.
- Mc nguy kch.
5. X TR
5.1. Nguyn tc xr tr
- Cn pht hin sm v iu tr kp thi (dng thuc dit virut sm) cc trng
hp vim phi do cm c bit do cm A(H5N1).
- Cc trng hp nng cn c iu tr ti cc n v hi sc.
- Thc hin bin php cch ly trnh ly nhim.
- Cho ngi bnh vo khu vc cch ly tm thi.
- Dng ngay thuc dit vi rt Oseltamivir liu 300mg/ngy ung chia 2 ln nu
nghi ng do cm A (H5N1), liu 150mg/ngy chia 2 ln cho cc cm A khc.
- Dng methyprednisolone 1-2 mg/kg/ngy chia 2 ln tim tnh mch.
- Sau nhanh chng chuyn ngi bnh n cc n v hi sc.
a) Cc bin php cch li
- Thc hin quy trnh cch li ngi bnh v cc quy trnh v x l cht thi.
- Thc hin quy trnh kh khun cc dng c, trang thit b y t phc v chn
on, iu tr v chm sc ngi bnh trnh ly nhim.
b) iu tr c hiu
- Thuc khng virt: dng sm ngay khi c chn on hoc nghi ng nhim
cm. Tt nht trong vng 48-72 gi t khi pht bnh.
+ Cm A (H5N1): oseltamivir 300mg/ngy chia 2 ln, dng n khi xt nghim
dch ph qun m tnh.
+ Cm cm A (H1N1): oseltamivir 150mg/ngy, dng trong 7 ngy.
- Methylprednisolon 1-2mg/kg/ngy tim tnh mch chia 02 ln trong 03 05
ngy.
c) Cc bin php h tr
- H hp
+ Nm u cao 300, trng hp ngi bnh c sc cho ngi bnh nm u
thng.
+ Liu php oxy: mc tiu duy tr SpO2> 92% v PaO2> 60 mmHg.
+ Th my khng xm nhp: nu xy liu php khng kt qu.
55
+ Th my xm nhp qua ng ni kh qun: (xem qui trnh th my cho bnh

nhn ARDS).
+ Nu tht bi (PaO2/FiO2< 100) vi cc phng thc th my thng thng,
c th p dng cc bin php khc nh; th my tn s cao (HFO) hoc trao i oxy
ngoi c th (ECMO) nu c iu kin.
- Cc bin php h tr suy a tng
+ Tun hon: t catheter tnh mch trung tm, b dch duy tr ALTMTT 7-10
cmH2O (cao hn ngi bnh c th my), s dng thuc vn mch nu c huyt p
tt khi duy tr dch.
+ H tr suy a tng:
Lc mu vi qu lc c kh nng hp ph cytokine (nh qu lc PMX c cht
liu l polymycine B, hoc cc loi khc) cho n khi chc nng trao i kh ca phi
c ci thin (P/F 300) th ngng.
Lc mu lin tc tnh mch-tnh mch (CVVH) vi th tch dch thay th ln
(45 ml/kg/gi). Tiu chun ngng lc mu khi tin hnh cai th my hoc ch s oxy
ha mu 300, chuyn lc mu ngt qung nu c ch nh cho suy thn cp.
+ Duy tr hemoglobin 90 -100g/L bng truyn khi hng cu.
- iu tr ri lon ng mu (DIC) nu c: truyn cryo, khi tiu cu, thuc
chng ng ... nu c ch nh.
+ iu tr h tr suy gan nu c: truyn huyt tng ti, gan nhn to
(MARS) hoc thay huyt tng (PEX) nu c ch nh.
c) Cc iu tr khc
+ Khng sinh nu ngi bnh c nhim khun, ch s dng cc khng sinh
cho nhim khun bnh vin nu ngi bnh c nhim khun bnh vin (xem bi vim
phi bnh vin).
+ iu tr cc bin chng: nu ngi bnh c trn kh mng phi cn dn lu
kh v dch mng phi nu c trn kh, dch mng phi, cn ch ngi bnh c th
my xm nhp vi PEEP cao.
+ Corticoid: dng hydrocortisone 200 mg/ngy chia 4 ln tim tnh mch.
- D phng huyt khi tnh mch su bng cc bin php c hc hoc s dng
thuc chng ng heparin trng lng phn t thp vi liu d phng.
+ D phng lot tiu ha do stress s dng thuc bc nim mc nh sucrafate
1g x 2 ln lc i, hoc cc thuc c ch bm proton nh omeprazol, pantoprozol ...
+ Chm sc, nui dng, chng lot v phng nhim khun bnh vin.
+ Kim sot ng mu nu ngi bnh c tng ng mu.
+ Kim sot cn bng nc, in gii, thng bng kim toan.
- T l t vong khong 50% cc trng hp tn thng phi nngv iu tr
mun.
56
- Bnh din bin nng cc ngi bnh c c a suy gim min dch nh
mang thai, dng cc thuc c ch min dch ...
7. PHNG BNH
- Khng tip xc vi gia cm sng khi c dch.
- Khi c biu hin gia cm m cht phi bo c quan chc nng x l.
- Khi c biu hin nhim cm phi n khm ti cc c s y t ngay.
Ti liu tham kho
1. Hong-Ryang Kil, Jae-Ho Lee, Kyung-Yil Lee. et al. (2011), Early corticosteroid
treatment for severe pneumonia caused by 2009 H1N1 influenza virus, Crit Care
15, Pp. 413.
2. Koichiro Kudo, Nguyen Gia Binh. et al (2012), Clinical preparedness for severe
pneumonia with highly pathogenic avian influenza A (H5N1): Experiences with
cases in Vietnam, Resp Invest :http://dx.doi.org/10.1016/j.resinv.2012.08.005 .
3. Koichiro Kudo, Nguyen Gia Binh & et al (2012), Impact of Education and
Network for Avian Influenza H5N1 in Human: Knowledge, Clinical Practice, and
Motivation on Medical Providers in Vietnam, Plos one, Vol 7, Issue 1, e30384.
4. The Writing Committee of the WHO Consultation on Clinical Aspectsof Pandemic
(H1N1) 2009 Influenza (2009), Clinical Aspects of Pandemic 2009 Influenza A
(H1N1) Virus Infection, N.Engl J Med 2010;362:1708-19. Copyright 2010
Massachusetts Medical Society.
5. The Writing Committee of the World Health Organization (WHO) Consultation on
Human Influenza A/H5 (2009), Avian Influenza A (H5N1) Infection in Humans,
N Engl J Med 2005;353:1374-85. Copyright 2005 Massachusetts Medical
Society.
6. Hai-Nv Gao, Hong-Zhou Lu and et al. (2013), Clinical Findings in 111 Cases of
Influenza A (H7N9) Virus Infection, N Engl J Med; 368:2277-2285June 13,
2013DOI: 10.1056/NEJMoa1305584.
57
VIM PHI NNG

DO CM A
X tr ban u
- Cc bin php cch ly tm thi.
- m bo h hp bng oxy liu php hoc thng kh khng xm nhp hoc
bp bng mt n c oxy hoc th my.
- Dng Oseltamivir 300 mg/ngy ung chia 2 ln nu nghi ng nhim cm A
(H5N1), 150mg/ngy ung chia 2 ln nu nghi ng do cm A khc.
- Methylprednisolon 1-2 mg/kg/ngy chia 2 ln tim tnh mch.
X tr ti bnh vin
- Cch ly ngi bnh: a ngi bnh vo phng cch ly theo quy nh cch ly.
- iu tr c hiu: Tip tc dng thuc Oseltamivir vcorticoid.
- iu tr h tr h hp: ty theo tnh trng suy h hp ca ngi bnh p dng cc bc
liu php oxy, th my khng xm nhp hoc t ni kh qun th my theo chin lc
thng kh bo v phi (lu hn ch dng PEEP cao v nguy c trn kh mng phi).
- Lc mu hp ph cytokine.
- iu tr h tr cc tng suy nu c (xem bi suy a tng).
- S dng khng sinh iu tr cc nhim khun th pht (xem bi vim phi bnh vin).
S x tr vim phi nng do cm A
58
Chng II: TUN HON

SC GIM TH TCH MU
1. I CNG
Sc l mt hi chng lm sng xy ra do gim ti mu t chc dn ti thiu
oxy t chc v tn thng t bo.
Sc do gim th tch mu l hu qu ca tnh trng gim tin gnh do mt th
tch dch trong lng mch (c th do mt mu ton phn hoc ch mt dch hoc huyt
tng). Gim tin gnh s dn n gim cung lng tim v tng sc cn mch h
thng b tr cho tnh trng gim cung lng tim v duy tr ti mu cho nhng c
quan quan trng.
Nu pht hin v iu tr kp thi, bnh c th khng li di chng. Nu pht
hin mun v iu tr khng kp thi, tnh trng tt huyt p ko di dn ti suy a
tng v t vong.
2. NGUYN NHN
Nguyn nhn ca sc gim th tch chia lm hai nhm: sc gim th tch do mt
mu v sc gim th tch do mt nc.
2.1. Sc gim th tch do mt mu
- Chn thng: vt thng mch mu, v tng c, v xng chu
- Chy mu ng tiu ha: v gin tnh mch thc qun, lot d dy t trng,
hoc rut
- Chy mu qua ng h hp: ho ra mu nng.
- Bnh l mch mu: phnh bc tch ng mch, d dng ng tnh mch.
- Lin quan n thai sn: c thai ngoi t cung v, v hoc rch t cung, m
o, mt mu trong qu trnh sinh (k c phu thut ch ng).
2.2. Sc gim th tch do mt nc
- Tiu chy cp.
- Nn nhiu.
- i nhiu do i tho nht, tng p lc thm thu, dng thuc li tiu, hoc
truyn nhiu dch u trng ...
- Bng nng.
- Say nng, say nng.
- Mt nc vo khoang th ba: ngi bnh sau m, tc rut, vim ty cp, tiu
c vn cp
3. TRIU CHNG
3.1. Lm sng
a) Triu chng lm sng chung ca bnh cnh sc
- Mch nhanh, nh, kh bt, thng >120 ln/pht. Thi gian y mao mch
ko di ( > 2 giy).
59
- H huyt p: huyt p tm thu <90 mmHg (huyt p ng mch trung bnh

<65mmHg) hoc huyt p tm thu gim qu 40mmHg so vi mc huyt p nn ca
ngi bnh.
- Thiu niu hay v niu (nc tiu <0.5 ml/kg/gi) c th km theo cc triu
chng h huyt p t th, v m hi, kh cc mng nhy.
- Ri lon thc: chm chp, ln ln, kch thch hay hn m.
- Da lnh, ni vn tm.
- p lc tnh mch trung tm gim, p lc mao mch phi bt gim, cung lng
tim gim, sc cn mch h thng tng.
b) Nhng du hiu lm sng gi nguyn nhn ca sc gim th tch
- Ty nguyn nhn gy sc gim th tch, ngi bnh c th c cc triu chng
nh nn ra mu, i tiu phn en, nn, tiu chy, au bng.
- Pht hin cc du hiu ca chn thng hoc ngi bnh sau phu thut.
- Khm pht hin da kh, li kh, nim mc ming kh, tnh mch c xp, p
lc tnh mch trung tm gim. Ngi bnh c biu hin thiu mu nu sc mt mu.
3.2. Cn lm sng
- Lactate mu tng 3 mmol/l.
- Sc gim th tch do mt nc: Hematocit tng, Protein mu tng.
- Sc gim th tch do mt mu: hng cu gim, hemoglobin gim, hematocrit
gim,
- Ri lon nc in gii, thng bng kim toan.
- Xt nghim tm nguyn nhn: lipase, amylase tng trong vim ty cp. Tng
ng mu trong nhim toan x tn hoc tng thm thu. CK tng cao trong tiu c
vn cp.
4. CHN ON XC NH:
4.1.Chn on xc nh
a) Chn on sc gim th tch mu do mt mu
- Lm sng:
+ Mch nhanh, nh, huyt p h.
+ p lc tnh mch trung tm thp, tnh mc c xp.
+ Da nim mc nht nht, lnh.
+ Thiu niu, v niu.
+ Vt v, l , ri lon thc.
+ Cc du hiu gi nguyn nhn ca mt mu: xut huyt tiu ho, mt mu
do chn thng mch mu, v tng c, c thai ngoi t cung v...
- Cn lm sng: kt qu xt nghim thng chm
+ Lactate tng.
+ Xt nghim mu: hng cu gim, hematocrite gim.
b) Chn on sc gim th tch mu khng do mt mu
- Lm sng: C du hiu mt nc
60
+ Mch nhanh, huyt p h.

+ p lc tnh mch trung tm thp, tnh mc c xp.
+ Ngi bnh c cm gic kht nc.
+ Da kh, vo da (+), nim mc kh.
+ Triu chng ca bnh nguyn gy mt nc: nn hoc i ngoi nhiu ln.
- Cn lm sng:
+ C tnh trng c c mu: hng cu tng, hematocrit tng.
+ C th thy natri mu tng, ng mu tng...
4.2. Chn on phn bit
- Sc tim: c triu chng ca bnh l tim mch: au ngc, ri lon nhp tim,
thay i in tm , p lc tnh mch trung tm thng tng, p lc mao mch phi
bt tng, cung lng tim gim, sc cn mch h thng tng.
Nguyn nhn thng do:
+ Nhi mu c tim cp (do din tch b tn thng ln sc co bp ca c
tim gim nng hoc t hoc rch van tim ct c, v tim).
+ hoc lon nhp nhanh vi tn s tim > 150 ln /pht hoc chm < 40
ln/pht, hoc rung tht, xon nh, ).
+ Ngoi ra cn do phnh bc tch ng mch ch, nhi mu phi nng
- Sc nhim khun: st, c bng chng ca nhim khun, bch cu tng, p
lc mao mch phi bt gim, cung lng tim tng, sc cn mch h thng gim.
- Sc phn v: c tin s tip xc vi d nguyn, cng c phn gim th tch
tun hon (tng i). Chn on phn bit kh nu sc mun.
4.2. Chn on mc trong sc mt mu
Phn
Th tch
Huyt p
Mch
H hp
Thc
mu mt
(l/ph)
(ml)
I
750
Bnh thng
< 100
Bnh thng
Bnh thng
II
750-1500
III
1500- 2000
IV
>2000
Bnh thng
hoc gim t
Huyt p tm
thu < 90mmHg
Huyt p tm
thu < 70mmHg
5. X TR
5.1. Nguyn tc x tr
- m bo cung cp oxy.
- B dch v iu tr nguyn nhn.
- iu tr phi hp.
61
>100
Nhp th tng
Lo lng
>120
Kh th
>120
Suy h hp nng
Vt v
Kch thch
L m
Hn m

- Kim sot ng th.
- m bo thng kh.
- Bng p cm mu i vi cc vt thng h c chy mu.
- Hn ch gy thm cc tn thng (c nh ct sng c ngi bnh chn
thng nghi ng tn thng ct sng c..).
- t ng truyn ln v c nh chc, bt u truyn dch natriclorua 0,9%.
- Chuyn ngi bnh n c s y t cng nhanh cng tt, trong qu trnh vn
chuyn t bnh nhn t th nm u bng.
a) m bo cung cp oxy ti a cho ngi bnh
- Kim sot ng th.
- t ngi bnh t th nm u thp hai chn nng cao.
- Th oxy qua knh mi 4 -5 lt/pht hoc mt n 6-10 lt/pht.
- t ni kh qun nu ngi bnh c nguy c tro ngc vo phi hoc suy h
hp hoc ri lon thc.
- Nu ngi bnh c ch nh th my, cn trnh th my p lc dng cao.
b) B dch v kim sot nguyn nhn
- t 2 ng truyn tnh mch ngoi vi ln (kim lun kch thc 14 n 16G)
v/hoc t ng thng tnh mch trung tm, v o p lc tnh mch trung tm
(ALTMTT).
- Truyn tnh mch nhanh 1-2lt (i vi tr em 20ml/kg cn nng) natriclorua
0,9% hoc ringer lactate. Sau , tip tc truyn dch hay khi hng cu da vo p
lc tnh mch trung tm (ALTMTT) v huyt p trung bnh (HATB).
+ Nu ALTMTT< 8mmHg: truyn nhanh dch nhc li t nht 20ml/kg
natriclorua 0,9% hoc ringer lactate.
+ Nu ALTMTT 8mmHg v HATB < 60mmHg: dng thuc vn mch
noradrenalin hoc dopamine.
+ Nu ALTMTT 8mmHg v HATB 60mmHg: kt thc qu trnh b dch.
- Ngi bnh sc gim th tch do mt mu: trong khi ch i truyn mu c
th truyn dung dch HES hoc gelatin gi dch trong long mch
Nu c mu,truyn ngay khi hng cu m bo hemoglobin 8g/l. Trong
trng hp sc mt mu m chy mu ang tip din v khng c khi hng cu cng
nhm, c th truyn ngay 4 n v khi hng cu nhm O (truyn khi hng cu nhm
O, Rh (-) cho ph n la tui sinh ). Ngi bnh sc mt mu ang chy mu tip
din, mc tiu duy tr hemoglobin >8g/dl.
c) Kim sot ngun chy mu
- Bng p i vi vt thng m ang chy mu.
- M thm d pht hin v kim sot ngun chy mu t vt thng trong
bng, trong lng ngc.
62
- Chp mch, tm v tr chy mu v iu tr bng phng php nt mch i

vi mch ang chy mu.
- Ni soi d dy chn on nguyn nhn v cm mu khi ngi bnh b xut
huyt tiu ha cao.
d) Cc iu tr phi hp
- Truyn tiu cu, huyt tng ti ng lnh iu chnh chnh thch hp
thi gian Prothrombin, v aPTT m bo s lng tiu cu > 50.000/mm3.
- Truyn yu t VII: cn nhc khi ngi bnh c tnh trng chy mu lan ta
hay chy mu ang tip din khng th cm mu bng phu thut khi iu chnh
c cc yu t ng mu.
- Dng clorua canxi, clorua magie iu tr h canxi v magie do truyn ch
phm mu chng ng bng citrat.
- K thut lm m cho ngi bnh: chn p, chn nhit, n ta nhit
- Khng sinh: d phng v iu tr cc vt thng h nhim bn.
- Pht hin v iu tr cc bin chng lin quan n truyn ch phm mu: sc
phn v, tn thng phi cp lin quan n truyn mu.
6.1. Tin lng
- Nu sc gim th tch c chn on v iu tr kp thi, bnh c th khi
khng li di chng.
- Nu pht hin mun v iu tr khng kp thi, tnh trng tt huyt p ko di
dn ti suy a tng v t vong.
6.2. Bin chng
- Suy thn cp mi u l chc nng do gim ti mu thn, sau c th
chuyn thnh suy thn cp thc tn.
- Tn thng phi cp lin quan truyn mu nhiu trong iu tr sc mt mu.
- Suy tim do thiu oxy t chc, nhim toan mu, yu t c ch c tim.
- Tiu ha: vim lot d dy t trng chy mu, suy gan
7. PHNG BNH
Pht hin v iu tr cc nguyn nhn gy mt mu v mt nc sm.
Ti liu tham kho
1. Nguyn Quc Anh, Ng Qu Chu ch bin. (2011), Cp cu sc gim th tch,
Hng dn chn on v iu tr bnh ni khoa. Nh xut bn Y hc H ni, Pp.
60-62.
2. V Vn nh. (2003), Chn on sc gim th tch, Hi sc cp cu ton tp,
Nh xut bn Y hc, Tr 214.
3. Maier R.V. (2009), Approach to the patient with shock, Harrisons Principles of
internal medicine, Pp.1689.
4. Marin H.K. (2012), Hypovolemic Shock, The Washington manual of critical
care. Lippincott Williams & Wilkins, Pp. 4-7.
63
Bnh cnh lm sng sc

HA tm thu < 90 mmHg
HATB< 60 mmHg
N ng lactat mu 3 mmol/L
Mt cch ng thi
Kim sot ngun chy mu
Bng p i vi cc vt thng c nhn thy, bc l v kim sot
cn thn vt thng m v mch mu gy chy mu ni, bn vng
cao su hay t bng chn thc qun .i vi cc chy mu do v
dn tnh mch thc qun.
t ng truyn tnh mch (catheter TM trung tm khu knh

8, 5F hay 2 catheter TM ngoi bin khu knh 14G) truyn
nhanh dch/ cc ch phm mu
nh lng Hb mu
Tip tc hi sc dch
ng tnh mch v loi
tr cc nguyn nhn sc
khc phi hp (trn dch
mng ngoi tim gy p
tim cp, trn kh mng
phi, chn thng ty
sng, tc mch phi v vt
thng tim)
C kim sot c
ngun chy mu
khng?
Khng
Tip tc hi sc dch ng
tnh mch v xem xt nhng
bin php khc kim sot
chy mu. (VD: nt mch
cm mu)
9g/dL
Truyn khi
hng cu ti khi
nng Hb
9g/dL v iu
chnh cc bt
thng tiu cu
hay dng mu b
pht hin
Dng dch
NaCl 0,9%
hay Ringer
lactat
ALTMTT < 8 mmHg
o
ALTMTT
v HATB
ALTMTT 8 mmHg
HATB 60 mmHg
ALTMTT 8 mmHg
HATB<60mmHg
Kt thc qu trnh hi sc
S x tr sc gim th
64 tch mu
Truyn bolus
dch nhc li
t nht 20
mL/kg NaCl
0,9% hay
Ringer lactat
Dng thuc
vn mch
(Noradrenalin
hay Dopamin)
SC TIM
1. I CNG
- Sc tim l tnh trng gim cung lng tim khng p ng c nhu cu oxy
ca cc t chc trong c th.
- Chn on sc tim t ra sau khi loi tr cc sc khc: sc gim th tch,
sc phn v, sc nhim khun.
- Cc ri lon huyt ng c trng trong sc tim:
+ Cung lng tim gim vi ch s tim < 2,2 lt/pht/m2.
+ p lc tnh mch trung tm cao ( > 10 mmHg) v p lc mao mch phi bt
cao ( > 15mmHg).
+ Chnh lch oxy gia mu mao mch v mu tnh mch cao (DA-VO2 ln hn
0,55ml O2/lt) do ri lon trong sc tim l do tn thng chc nng tim khng phi do
ri lon ngoi vi.
- Trong iu tr sc tim: mt mt khn trng iu tr triu chng v hi sc
ton din, mt khc cn tm v gii quyt nguyn nhn sm nu c th c.
- Suy tim trong bnh cnh sc tim l vn lm sng ln bi v t l t vong
cao ln ti 30 90%. Tin lng ph thuc nhiu vo nguyn nhn gy ra sc tim v
kh nng can thip ca thy thuc.
- y l tnh trng cn c cp cu ti ch v vn chuyn bng xe t c trang
thit b cp cu ban u n khoa hi sc.
2. NGUYN NHN
2.1. Gim sc co bp c tim
- Thiu mu cc b c tim (c bit l nhi mu c tim cp).
- Bnh c tim do nhim khun (lin cu nhm B, bnh Chagas,), nhim vi rt
(enterovirus, adenovirus, HIV, vi rt vim gan C, parvovirus B19, vi rt Herpes, EBV,
CMV).
- Bnh c tim do min dch, do chuyn ha.
- Bnh c tim do nguyn nhn ni tit: cng hoc suy gip.
- Bnh c tim do ng c.
- Giai on cui ca bnh c tim gin hay bnh van tim.
2.2. Tng hu gnh (nguyn nhn tc nghn)
- Tc ng mch phi nng.
- Hp ng mch ch.
65
2.3. p tim cp do trn dch mng ngoi tim cp

2.4. Tn thng c hc ca tim
- H van ng mch ch, h van hai l cp.
- Thng vch lin tht.
2.5. Ri lon nhp tim: cn nhp nhanh, c bit l cn nhp nhanh tht hoc nhp qu
chm do bloc nh tht.
3. TRIU CHNG
- Huyt p tt: huyt p ti a di 90mmHg hoc gim so vi huyt p nn
trn 30mmHg ( ngi c tng huyt p).
- Da lnh ti, ni vn tm trn da, u chi tm lnh.
- Thiu niu hoc v niu, nc tiu < 0,5 ml/kg/gi.
- Cc du hiu tr tun hon ngoi vi (gan to, tnh mch c ni), xut hin ran
m phi.
- Ting tim bt thng: ty theo nguyn nhn gy ra sc tim, nhp tim nhanh,
ting T1 m, xut hin T3, T4, ting nga phi nu vim c tim cp do nhim c, vi
rt.
- Bnh l gy sc tim (ty theo nguyn nhn): ng c, chuyn ha, vim c
tim cp, bnh van tim cp, ri lon chc nng tht phi cp tnh.
- Thn kinh: thc ca bnh nhn gim.
3.2. Cn lm sng
- Lactat mu tng trn 1,5 mmol/l (phn nh tnh trng thiu oxy do gim ti
mu t chc). Toan chuyn ha v toan lactat khi lactat mu tng ko di t 2-4
mmol/l. Lactat mu trn 4 mmol/l trong cc trng hp nng.
- Thm d huyt ng: p lc tnh mch trung tm tng, p lc mao mch phi
bt tng (trn 15mmHg), cung lng tim gim, ch s tim gim di 2,2 lt/pht/m2.
4. CHN ON
4.1. Chn on xc nh
a) Chn on lm sng da vo cc tiu chun sau:
- Huyt p tm thu 90mmHg ko di hoc phi s dng thuc vn mch
duy tr huyt p tm thu 90mmHg hoc huyt p tm thu gim trn 30mmHg so vi
huyt p tm thu nn ca bnh nhn.
- C bng chng ca gim ti mu cc c quan (nc tiu di 30ml/gi hoc
chi lnh/v m hi hoc c bin i thc.
- Bng chng tng p lc y tht tri (ph phi)
b) Cc thng s thm d huyt ng:
- Ch s tim (CI) di 2,0 l/ph/m2 da khi khng s dng tr tim hoc di 2,2
l/ph/m2 da khi c s dng thuc tr tim.
66
4.2. Chn on phn bit

Chn on phn bit cc tnh trng sc da vo: tin s bnh, cc c im lm
sng v cn lm sng.
a) Sc nhim khun
- C tnh trng nhim khun km theo phi c thi gian xut hin ko di.
- p lc tnh mch trung tm gim, p lc mao mch phi bt gim.
- Ch s tim bnh thng hoc tng.
- Sc cn mch h thng v sc cn mch phi gim.
b) Sc gim th tch
- Hon cnh xut hin nhanh: a chy, nn nhiu, i nhiu hoc vim ty cp
nng.
c) Sc phn v
- Tnh hung xut hin thng kh t ngt lin quan n thuc hoc thc n.
- C th c cc du hiu khc ca d ng.nh da, sn, nga
a) Siu m tim: c th nh gi chc nng tht phi v tht tri v pht hin nguyn
nhn
- Hi chng p tim cp.
- Ri lon chc nng van hai l.
- Thng vch lin tht.
- Phnh tch ng mch ch on gn.
- Ri lon vn ng vng hoc ton b ca tht phi, tht tri.
- Tng p lc ng mch phi, o cc chnh p qua cc bnh l van tim cp
tnh.
b) in tim: c th c cc biu hin ca bnh tim nguyn nhn
c) Xquang ngc:
- Hnh nh ca bnh tim nguyn nhn.
- Hnh nh tng m cc nhnh mch phi.
- Phnh tch ng mch ch.
- Trn kh trung tht, trn kh mng phi p lc.
d) Cc xt nghim c hiu khc ty theo nguyn nhn gy sc tim
- Men tim, troponin, BNP, LDH, AST tng trong nhi mu c tim.
- Chp mch phi trong tc mch phi,
e) Cc xt nghim pht hin vi khun hay virus gy vim c tim cp
- Soi hoc cy dch/mu.
- PCR virus gy vim c tim.
f) Thng tim nh gi mch vnh
67
- nh gi ti mu mch vnh.
- C bin php ti ti mu sm khi c ch nh.
4.4. Chn on mc : Tiu chun ca ACC/AHA 2007
a) Tin sc
- p lc mao mch phi bt trn 15mmHg.
- Huyt p tm thu trn 100mmHg.
- Ch s tim di 2,5l/ph/m2 da.
b) Sc tim
- Huyt p tm thu di 90mmHg.
- Ch s tim di 2,5l/ph/m2 da.
c) Sc tim in hnh
- Ch s tim di 2 l/ph/m2 da.
5. X TR
5.1. Nguyn tc chung
- Giai on sm, h tr huyt ng phng nga cc ri lon v suy chc
nng c quan, thm ch phi gii quyt nguyn nhn gy sc tim nh ti ti mu
sm trong nhi mu c tim cp , to nhp cp cu trong trng hp nhp chm.
+ H tr chc nng tim: Tim phi nhn to ti ging ( ECMO), bm bng
ngc dng ng mch ch hoc thit b h tr tht tri.
+ Hi sc c bn: iu chnh cc ri lon do sc tim gy nn nh suy h hp,
suy thn...
- Giai on gii quyt nguyn nhn nhanh chng o ngc tnh trng sc
tim.
- Nhanh chng xc nh tnh trng sc tim ca bnh nhn, loi tr cc nguyn
nhn khc gy ra huyt p thp.
- Gim ti a cc gng sc: gim au, gim cng thng lo u.
- Thit lp ng truyn tnh mch.
- H tr th oxy (nu c).
- Lm in tim, xc nh chn on nhi mu c tim cp v xt ch nh dng
thuc tiu si huyt nu thi gian vn chuyn n trung tm can thip mch gn nht
trn 3 gi.
- Vn chuyn bnh nhn n cc trung tm cp cu v hi sc gn nht.
5.3.1. H tr thng kh
- Oxy liu php: h tr oxy nn c tin hnh ngay tng oxy vn chuyn v
phng nga tng p lc ng mch phi.
68
- Thng kh nhn to: u tin thng kh nhn to xm nhp khi bnh nhn sc
tim vi cc li ch: nhu cu oxy ca c h hp v gim hu gnh tht tri, ch nh
gm:
+ Bnh nhn kh th nhiu.
+ Gim oxy mu.
+ pH < 7,30.
5.3.2. Hi sc dch
- Hi sc dch gip ci thin vi tun hon v tng cung lng tim.
- Lng dch truyn rt kh xc nh bnh nhn sc tim:
+ V l thuyt, lng dch cho cung lng tim tng theo tin gnh.
+ V thc hnh, c nhiu phng php khc nhau bao gm: theo di v iu
chnh p lc tnh mch trung tm, p lc mao mch phi bt, bo ha oxy tnh mch
trung m v tnh mch trn; lm liu php truyn dch; theo di p ng iu tr nh
lu lng nc tiu, nng lactat mu,...
- La chn dch truyn:
+ Dch mui ng trng l la chn u tin vi u im d dung np v gi
thnh r.
+ Cc dung dch keo cng c s dng khi c thiu lng ln dch trong long
mch.
+ Dung dch albumin cng c s dng trong cc trng hp gim albumin
mu.
- Liu php truyn dch c th nhc li khi nghi ng bnh nhn thiu dch
bnh nhn sc tim.
5.3.3. Thuc vn mch v tr tim
- Dng thuc vn mch duy tr huyt p ti a trn 90mmhg (hoc huyt p
trung bnh trn 70mmHg). u tin dng noradrenalin hn dopamine v kh nng t gy
ri lon nhp bnh nhn sc tim.
- Dobutamin c ch nh trong cc trng hp sc tim do tn thng c tim.
+ Liu dng: bt u 5g/kg/ph.
+ Tng liu mi ln 2,5 5g/kg/ph ty theo p ng ca bnh nhn.
+ Liu ti a 20g/kg/ph.
- Thuc gin mch gip lm gim hu gnh dn n lm tng cung lng tim
v cng gip ci thin ti mu vi tun hon v chuyn ha t bo bnh nhn sc
tim. Tuy nhin, thuc gin mch c th lm tt huyt p v lm nng tnh trng gim
ti mu m nn cn c theo di st. Dn cht nitrates c ch nh trong cc
trng hp c thiu mu cc b c tim (nhi mu c tim, cn au tht ngc khng n
nh).
5.3.4. Cc bin php h tr c hc
- Tim phi nhn to (ECMO extracorporeal membrane oxygenation) ch lm
c cc n v chuyn su v c o to:
69
+ duy tr huyt ng nhn to thay th chc nng co bp ca c tim, to

iu kin cho c tim c ngh ngi hi phc.
+ Ch nh: sc tim do bnh l c tim, ( EF < 35 % cn cn nhc ch nh), do
tc mch phi nng hoc do ri lon dn truyn cha hi phc.
Bin php h tr tim phi nhn to t hiu qu cao trong cc bnh l c tim c
kh nng phc hi sau giai on sc.
- Bm bng ngc dng ng mch ch (IABC intraaortic balloon
counterpulsation).
+ lm gim hu gnh v tng ti mu mch vnh.
+ Ch nh trong sc tim do bnh l c tim, tc mch phi.
Cc nghin cu gn y cho thy, bin php bm bng ngc dng ng mch
ch khng t hiu qu r rang bnh nhn sc tim.
5.3.5. iu tr nguyn nhn c th
a) Nhi mu c tim
- Xt ch nh ti ti mu c tim (nong ng mch vnh, t gi hoc dng
thuc tiu si huyt hoc phu thut) sm trong 6 gi u khi nhi mu c tim cp gy
sc tim.
- Khng dng dn cht nitrat khi huyt p thp.
- Khng ch nh dng thuc nhm c ch bta giao cm.
b) Tc ng mch phi ln
- Duy tr n nh p lc tnh mch trung tm.
- Dng dobutamin v noradrenalin nng huyt p.
- Xt ch nh v chng ch nh dng thuc tiu si huyt.
c) p tim cp do trn dch mng ngoi tim
- Truyn dch gy tng p lc tnh mch trung tm (tng p lc y tht)
nhm chng li p lc p vo t mng ngoi tim.
- iu tr quan trng nht l dn lu dch mng ngoi tim v iu tr nguyn
nhn gy trn dch.
d) Sc do tn thng c hc ca tim: cn m cp cu gii quyt tn thng.
e) Sc do lon nhp tim
- iu tr lon nhp.
- Xem xt ch nh sc in khi cn nhp nhanh gy nn tt huyt p.
- Nhp chm: ch nh t my to nhp.
5.3.7. Mt s bin php khc
- Kim sot tt cc ri lon nhp tim km theo (nu c): sc in, t my to
nhp tm thi.
- iu chnh cc thng bng kim toan v cc ri lon in gii (tng/h
kali,magie,).
- Cho vitamin B1 nu nghi ng vim c tim do thiu vitamin B1, corticoid nu
nghi ng tn thng c tim do min dch.
70

- T l t vong trong bnh vin khong 48 74%, cc yu t tin lng t vong:
tui cao, tin s nhi mu c tim trc , du hiu lm sng khi c chn on (da
lnh m), v niu.
- Bin chng: suy a tng, sc tim khng hi phc,..
7. PHNG BNH
Ti ti mu mch vnh sm v thch hp cho vng nhi mu ng mch
bo tn ti a c tim v gim kch thc ca vng nhi mu.
Ti liu tham kho
1. Shabana A., Moustafa M., Menyar A.E., Thani H.A. (2013), Cardiogenic Shock
Complicating Myocardial Infarction: An Updated Review British Journal of
Medicine & Medical Research 3(3), Pp. 622-53.
2. Nguyn Ln Vit (2007), Thc hnh bnh tim mch, Nh xut bn Y hc.
3. Reynolds H.R. (2008), Cardiogenic Shock: Current Concepts and Improving
Outcomes, Circulation, 117: 686-697.
4. Sen M., Sakata Y., Shimizu M. et al. (2010), Trends in the management and
outcomes of cardiogenic shock complicating acute myocardial infarction, J Am
Coll Cardiol, 55 (10): 942.
5. Onsy Ayad, Ann Dietrich, Leslie Mihalov (2008), Extracorporeal membrane
oxygenation, Emerg Med Clin N Am, 26: 953 - 959
6. Pinsky M.R. (2003), Hemodynamic monitoring in the intensive care unit, Clin
Chest Med, 24:549-560.
7. Jean-Louis Vincent, Daniel De Backer (2013), Circulation shock, N Engl J Med,
369: 1726-34.
8. Tehrani S., Malik A., Hausenloy D.J. (2013), Review articles: Cardiogenic shock
and the ICU patient The Intensive Care Society - JICS, Volume 14, Number 3,
July 2013
71
Nghi ng sc tim
- Huyt p tm thu di 90mmHg.
- Du hiu gim cung lng tim (Thiu niu, gim thc, ph
phi).
nh gi ban u v n nh tnh trng bnh nhn

- Lm in tim: tm bng chng ca nhi mu c tim cp (ST chnh,
Block nhnh tri mi, nhi mu sau di).
- Oxy liu php/thng kh nhn to (khi c gim oxy mu).
- Nng huyt p (Nu huyt p tm thu di 90mmHg), mc tiu
huyt p trung bnh trn 65mmHg:
+ Dopamin 5-15ug/kg/ph hoc noradrenalin 1-20ug/ph.
+ Tt c cc bnh nhn ang dng vn mch cn t catheter tnh
mch trung tm v catheter ng mch.
ECG (-)
ECG (+)
Liu php ti ti mu ngay tc th
Tiu si huyt/bm bng

ngc dng ng mch ch
*Can thip mch vnh khi
khng c tiu si huyt
Can thip mch vnh

- Di 36 gi t khi khi pht nhi
mu c tim cp
- Trc 12-18 gi t khi khi pht
sc
*Khng c chn ch nh thuc chng
ng
* H tr tim (Bm bng ngc dng
ng mch ch)
- Ti ti mu mch vnh qua da
(Khi c nhi mu ng mch)
-
Siu m tim cp cu:

nh gi chc nng tht phi/tht tri, cc bin
chng c hc dn n sc tim (t ct c, thng thnh
tht)
t catheter ng mch phi theo di
Xc nh chc chn sc tim
Ch s tim (CI) < 2,2 l/ph/m2 da
p lc mao mch phi bt (PCWP) > 15mmHg
Khng c kh nng ti ti mu
Tip tc h tr cc thuc tr tim
- Dobutamin 2,5 10ug/pht
- Milrinone 0,375 0,75 ug/kg/pht
*Khng dng Mirinone khi c tt huyt p hoc suy thn
Hoc phu thut bc cu ni ch

vnh cp cu (bnh ba thn, tc
nhnh tri hoc khng th can thip
mch vnh qua da)
Sc tim tr
*Xt dng thit b h tr tht tri, ECMO, thay tim
S x tr sc tim
72
SC NHIM KHUN
1. I CNG
Sc nhim khun l giai on nng ca qu trnh din bin lin tc bt u t
p ng vim h thng do nhim khun, nhim khun nng, sc nhim khun v suy
a tng.
T l do sc nhim khun chim t 40 n 60%.
Vi khun xm nhp vo c th gy ra cc p ng vim h thng lm gii
phng cc cytokin gy vim, c s mt cn bng gia yu t gy vim v yu t khng
vim (yu t khng vim yu hn yu t gy vim) dn n gy tn thng c quan
th pht v to nn vng xon suy a tng.
2. NGUYN NHN
Do vi khun hoc nm t cc nhim khun xm nhp vo mu t:
- Da, m mm, c xng khp.
- ng tiu ha nh: vim rut, nhim khun ng mt, p xe gan.
- ng h hp: vim phi, p xe phi, vim ph qun, vim m mng phi...
- H tit niu nh: vim m b thn, m b thn ...
- H thn kinh: vim mng no m, p xe no ...
- Mt s nhim khun khc : nh vim ni tm mc cp v bn cp ...
3. TRIU CHNG
3.1. Lm sng
- Du hiu lm sng ca p ng vim h thng nh: xc nh khi c t 2 tiu
chun sau y tr ln.
+ St > 38oC hay h thn nhit < 36oC.
+ Nhp nhanh > 90 ck/pht.
+ Th nhanh, tn s > 20 ln/pht.
+ Tng s lng bch cu trn trn 10000/ml, hoc gim s lng bch cu
<4000/ml, hoc s lng bch cu non > 10%.
- Cc biu hin ca nhim khun nng:
+ Hi chng p ng vim h thng.
+ C nhim khun.
+ Ri lon chc nng c quan nh tng lactat mu 2 hoc thiu niu (th tch
nc tiu < 0,5 ml/kg/gi).
- Du hiu suy chc nng c quan:
+ Thn: thiu niu; s lng nc tiu gim dn v < 0,5 ml/kg/gi hoc v
niu.
+ Huyt p: tt h huyt p lin quan n nhim khun nng l HATT < 90
mmHg, hay HATB < 70 mmHg, hay HATT gim > 40 mmHg so vi tr s bnh
thng.
73
3.2. Cn lm sng
- Cc xt nghim cn lm sng xc nh nhim khun nh:
+ S lng bch cu tng (trn 10000/ml), tng t l a nhn trung tnh tng cao
trn gi tr bnh thng, hoc t l bch cu non > 10%.
+ Mu lng tng.
+ CRP tng trn 0,5 mg/dl.
+ Procalcitonin tng > 0,125 ng/ml.
- Xt nghim vi sinh xc nh cn nguyn gy nhim khun: cy mu mc vi
khun, virus, k sinh trng, nm.
- Gim ti mu t chc: tng lac tt mu ( 2 mmol/L).
- Du hiu cn lm sng ca ri lon, suy chc nng c quan nh:
+ Suy thn: tng ure v creatinin.
+ Suy h hp: t l PaO2/FiO2< 300, trng hp nng t l ny < 200.
+ Suy gan: tng ALT, AST, bilirubin mu, gim t l prothrombin mu ...
+ Gim s lng tiu cu, ri lon ng mu, ng mu ni mch ri rc...
+ Nhim toan chuyn ha, tng kali mu, tng ng mu.
4. CHN ON
4.1. Chn on xc nh khi c cc tiu chun sau
- Cc biu hin ca nhim khun nng.
- Ri lon chc nng c quan tin trin thnh suy chc nng c quan khng p
ng vi b dch v phi dng thuc vn mch.
4.2. Chn on phn bit
- Sc gim th tch: mt nc hoc mt mu, p lc tnh mch trung tm thp,
sc p ng tt vi b dch hoc mu.
- Sc tim do nhiu nguyn nhn; t mng ngoi tim, c tim vi nhiu tc nhn
nh chn p tim cp, vim c tim, nhi mu c tim..., vi c trng cung lng tim
gim nhiu.
- Sc phn v: thng lin quan n cc d nguyn vi cc biu hin qu mn.
- Tin hnh khm lm sng ton din cc c quan xc nh nhim khun.
- Phi hp cc bin php chn on hnh nh nh siu m, chp x quang, chp
ct lp vi tnh...
- Cy cc bnh phm nghi ng ca nhim khun nh; m, cht tit m di,
dch, m mng phi, mng tim, dch no ty, mu v nc tiu hay m hoc dch dn
lu p xe ....
4.4. Chn on mc
- C tin trin suy a tng l yu t tin lng nng.
- Lactat mu tng dn v tt huyt p khng p ng vi thuc vn mch l
biu hin nng ca sc.
74
5. X tr
5.1. Nguyn tc x tr
Nhanh chng, tch cc v mc tiu cn t trong vng 6 gi u:
- Duy tr p lc tnh mch trung tm (ALTMTT): 11 - 16 cmH2O
- Duy tr huyt p trung bnh 65 mmHg.
- Duy tr ScvO2 70% hoc SvO2 65%.
- Th tch nc tiu 0,5 ml/kg/gi.
m bo h hp v tun hon duy tr tnh mng cho ngi bnh bng cc
bin php:
- Lm nghim php truyn dch: truyn 1000 - 2000 ml dung dch natriclorua
0,9% hoc ringerlactat trong vng 1 n 2 gi u nhng ngi bnh tt huyt p do
nhim khun m bo huyt p trung bnh 65 mmHg.
- m bo h hp cho ngi bnh bng cc bin php oxy liu php (th oxy
knh, mt n n gin, mt n c ti ht li), th h thng p lc dng lin tc
(CPAP) c kt ni oxy h tr sao cho duy tr c SpO2 92%.
- S dng thuc vn mch (nu cn) nh noradrenalin hoc adrenalin ng
truyn tnh mch lin tc liu khi u 0,05 mcg/kg/pht m bo huyt p khi
nh gi tt huyt p ca ngi bnh khng do thiu dch.
a) Bi ph th tch dch
- Truyn dch sm v nhanh ngay khi c tt huyt p nhm mc ch b th
tch dch lng mch, tuy nhin cng trnh gy ph phi cp huyt ng do tha dch.
B 1000 ml dch tinh th (natri clorua 0,9% hoc ringer lactat) hoc 500 ml dung dch
cao phn t gelatin trong 30 pht, sau chnh theo p ng v nh gi lm sng.
- Lm nghim php truyn dch cho n khi t mc p lc tnh mch trung
tm mong mun, duy tr p lc trung tm 8-12 cmH2O, nu ngi bnh ang th my
duy tr CVP 12 15 cmH2O.
- Loi dch: dch tinh th NaCl 0,9%, hoc ringerlactat, nu truyn nhiu
dung dch tinh th nn truyn thm dung dch keo gelatin hoc albumin hn ch
thot mch.
- ng truyn: nu l ng ngoi vi phi ln hoc t 2-3 ng truyn,
nn t ng thng tnh mch trung tm b dch.
b) Dng vn mch
- Ch s dng thuc vn mch khi nh gi b dch.
- Noradrenalin l thuc s dng u tay vi liu khi u 0,05 g/kg/pht, tng
dn liu 0,05mcg/kg/pht mi 5 10 pht t huyt p trung bnh 65 mmHg.
- C th s dng dopamin nu khng c nhp nhanh hoc lon nhp hoc
adrenalin vi liu dopamin khi u 5 mcg/kg/gi tng dn 3-5 g/kg/gi mi 5-10
pht n khi t HA ch, ti a khng tng qu 20 g/kg/gi, vi adrenalin bt u
75
liu 0,05 g/kg/gi, tng dn 0,05 0,1 g/kg/pht n khi t HA ch, ti a khng
tng qu 5 g/kg/gi.
- Thuc tng co bp c tim: dobutamin khng s dng thng quy cho cc
ngi bnh nhim khun nng v sc nhim khun, ch s dng cho ngi bnh c ri
lon chc nng tht tri thng qua nh gi siu m tim hoc ng thng ng mch
phi.
Trng hp c ch nh, dng dobutamin vi liu khi u 3 g/kg/pht sau
theo di v tng dn mi ln 5 g/kg/pht, khng vt qu 20 g/kg/pht.
c) Chn on cn nguyn nhim khun v dng khng sinh
- p dng cc bin php lm sng kt hp xt nghim vi sinh v chn on
hnh nh xc nh nhim khun v cy mu trc khi dng khng sinh.
- Gii quyt nhim khun bng chc ht, dn lu hoc phu thut dn lu nu
c ch nh trn c s cn nhc gia li ch v nguy c cho bnh nhn.
- Dng khng sinh ng tnh mch cng sm cng tt, tt nht trong gi u
ngay sau khi c chn on nhim khun, lu dng khng sinh sau khi cy mu.
- Dng khng sinh ph rng theo liu php khng sinh kinh nghim v xung
thang trn c s da theo cc d liu nhy cm v khng khng sinh mi n v
hoc xem tham kho s dng khng sinh trong nhim khun nng v sc nhim khun
ca B Y t. Sau khi c kt qu vi khun v nhy cm cn la chn khng sinh
nhy cm c ph hp v ngm tt vo m c quan b nhim khun.
- Phi hp khng sinh trong cc trng hp:
+ Nu ngi bnh c gim bch cu phi phi hp khng sinh ph ti a ph
nhim khun (vi khun gram m, gram dng hay vi khun ni bo ...).
+ Nu nghi ng nhim trc khun m xanh, Acinetobacte baumanni cn phi
hp vi cc khng sinh nhy cm vi trc khun m xanh (Carbapenem kt hp
Colistin).
+ Nu nghi ng do cu khun ng rut phi hp thm khng sinh c nhy
cm vi cu khun ng rut nh: vancomycine, cubicin...
- Lu cc ngi bnh c suy thn, liu khng sinh phi da vo thanh
thi creatinin, liu u tin dng nh bnh thng khng cn chnh liu, ch chnh liu
t cc liu sau.
d) Dng corticoide
- Ch dng khi sc km p ng vi vn mch hoc cha ct c vn mch
sau 48 gi (khng dng thng quy) vi thuc c la chn hydrocortison liu 50
mg mi 6 gi tim tnh mch. Gim liu v ngng khi ngi bnh thot sc v ct
c thuc co mch.
- Lu c th lm nhim khun tin trin nng hn nu liu php khng sinh
kinh nghim khng ph hp v gy tng ng mu.
76
e) Kim sot ng mu
Kim sot ng mu mao mch bng insulin qua ng tim bp ngt qung
hoc ng truyn tnh mch, nu ng mu mao mch 11 mmol/l, mc tiu duy
tr ng mu t 7 - 9 mmol/l.
f) iu tr d phng cc bin chng
- D phng huyt khi tnh mch bng mt trong hai bin php sau:
+ Heparin trng lng phn t thp nh Enoxaparin 1 mg/kg tim di
da, gim liu khi ngi bnh c suy thn hoc fraxiparin.
+ S dng bao thay i p lc nh k 2 tay v 2 chn.
Thi gian d phng cho n khi bnh nhn ht cc yu t nguy c.
- Xut huyt tiu ha: dng thuc bng nim mc d dy nh sucalfate 2
gi/ngy chia 2 ung hoc bm qua d dy ... hoc cc thuc c ch bm proton nh
omeprazole liu 20 mg ung hoc tim tnh mch/ngy, pantoprazole, esomeprazole
liu 20-40mg ung hoc tim tnh mch, hoc cc thuc khng H2 nh ranitidin ..., lu
ng dng trong tng trng hp c th v tng tc thuc. Thi gian s dng khi
ht cc yu t nguy c v bnh n li theo ng ming.
g) Th my
- Mc tiu: SpO2> 92% hoc PaO2> 60 mmHg v pH > 7,15.
- Cc bin php:
+ Th my khng xm nhp vi CPAP hoc BiPAP nu ngi bnh tnh v
hp tc (xem bi th my khng xm nhp).
+ Th my xm nhp c s dng PEEP (nu khng c chng ch nh dng
PEEP) khi th my khng xm nhp tht bi hoc ngi bnh khng hp tc (xem k
thut th my cho ngi bnhARDS).
h) Lc mu lin tc
- Lc mu lin tc sm nht nu c th ngay sau khi c chn on sc nhim
khun v lu phi kim sot c nhim khun.
- Ch lc mu khi nng c huyt p tm thu > 90 mmHg (xem quy trnh
k thut lc mu lin tc bnh nhn sc nhim khun).
- Ngng lc mu lin tc khi ct c cc thuc co mch t nht 12 gi v
huyt p n nh v chuyn lc mu ngt qung nu cn ch nh.
i) Hng dn truyn mu v cc ch phm mu
- Khng truyn plasma ti ng lnh iu chnh cc bt thng trn xt
nghim khi khng c nguy c chy mu trn lm sng cng nh khng c k hoch
lm th thut.
- Ch truyn khi hng cu khi hemoglobin < 7g/l cc bnh nhn tr, vi cc
bnh nhn c nguy c gim oxy mu nh cao tui, nhi mu c tim, t qu no ...
nn suy tr nng hemoglobin 7 9 g/l.
- Truyn khi tiu cu (KTC) khi s lng tiu cu (SLTC) < 10.000/ml ngay
khi lm sng khng c nguy c chy mu. Truyn KTC khi SLTC < 20000/ml kt hp
77
c nguy c chy mu trn lm sng. a SLTC ln trn 50000/ml nu c k hoch

lm th thut hoc phu thut.
Tin lng sc nhim khun din bin nng khi c mt trong hai yu t sau:
- Tin trin suy a tng.
- Lactat tng dn v tt huyt p khng p ng vi thuc vn mch.
7. PHNG BNH:
Pht hin v x tr sm cc nhim khun.
Ti liu tham kho

1. Dellinger R.P., Carlet J.M. et al. (2008), Surviving sepsis campaign guidelines for
management of severe sepsis and septic sock, Crit Care Med 2012; 36:296-327.
2. Dellinger R.P., Levy M.M. et al. (2008), Surviving sepsis campaign: International
guidelines for management of severe sepsis and septic sock: 2012, Crit Care Med
41, Pp.580-637.
3. Jason Phua, Younsuck Koh and et al (2011), Management of severe sepsis in
patients admitted to Asian intensive care units: prospective cohort study, BMJ,
342: d3245.
4. Kollef M.H., Micek S.T. (2012), Severe septic and Septic shock, The
Washington Manual of Critical Care, 2rd Edition, Pp. 11-18.
5. Levy M.M., Fink M.P. et al. (2003), 2001SCCM/ESICM/ACCP/ATS/SIS
International Sepsis Definitions Conference, Intensive Care Med 29, Pp.530-8.
6. Schmidt G.A., Madel J. (2009), Management of severe sepsis and septic shock in
adults, Uptodate, destop 17.3
78
Chn on xc nh
sc nhim khun
X tr ban u
Nhanh chng m bo h hp v tun hon vn chuyn ngi
bnh ti bnh vin gn nht.
Liu php oxy hoc t ng NKQ bp bng oxy nu c iu kin.
Truyn dch nhanh 1000-2000ml trong 1-2 gi u nu nghi ng
tt huyt p do nhim khun v c th dng vn mch
(noradrenalin hoc adrenalin) nu nh gi ngi bnh khng c
thiu dch duy tr huyt p trung bnh 65 mmHg.
X tr ti bnh vin
Trong 06 gi u
- Tip tc m bo h hp bng liu php oxy hoc thng kh khng xm nhp hoc th
my xm nhp.
- Tip tc cc bin php m bo tun hon nh t ng tuyn tnh mch trung tm, b
dch, truyn khi hng cu, dng thuc vn mch khi ALTMTT duy tr 11-16 cmH2O
(cao hn BN c th my), dng thuc tng co bp c tim nu c ri lon chc nng tht
tri.
Mc tiu cn t: ALTMTT t 11 16 cmH2O,HATB > 65 mmHg, ScvO2 70%
hoc SvO2 65%. Th tch nc tiu 0,5 ml/kg/gi.
Trong cc gi tip theo
- Tin hnh cc bin php xc nh ngun nhim khun, cy mu v cc cc dch nghi ng
xc nh tc nhn gy bnh, ng thi dng khng sinh sm ngay gi u ti bnh vin.
Dng khng sinh ban u theo kinh nghim v xung thang. Dng khng sinh cho nhim
khun bnh vin a khng nu nghi ng do tc nhn vi khun bnh vin a khng.
- Tip tc cc bin php m bo tun hon: duy tr c p lc tnh mch trung tm 11-16
cmH2O, thuc vn mch, thuc tng co bp c tim nu c ri lon chc nng tht tri.
- Tip tc cc bin php m bo h hp bng cc bin php thng kh khng xm nhp
hoc th my xm nhp cho ngi bnh ARDS theo chin lc thng kh bo v phi mc
tiu SpO2 > 92% hoc PaO2 > 60 mmHg v pH > 7,15, p lc cao nguyn di 30
cmH2O.
- Dng hydrocortison 200 n 300mg/ngy chia 3-4 ln cho ngi bnh nghi ng c suy
thng thn hoc sc ko di.
- Lc mu lin tc cho ngi bnh sc nhim khun hoc lc mu ngt qung ko di ( 6
gi /24 gi) nu khng c iu kin vi th tch dch thay th 45ml/kg/gi.
- Kim sot ng mu bng Insulin tim ngt qung hoc truyn TM duy tr ng mu
mao mch 7-9 mmol/L
- D phng huyt khi tnh mch su bng heparin trng lng phn t thp hoc qun bao
p lc.
- D phng xut huyt tiu ha do stress.
S x tr sc nhim khun
79
SUY A TNG DO SC NHIM KHUN
1. I CNG
Suy a tng l tnh trng din bin cp tnh ca mt qu trnh bnh l c c cn
nguyn do nhim khun hoc khng do nhim khun trong c suy t nht hai tng
tr ln v tn ti t nht trong vng 24 gi.
Sc nhim khun l mt giai on nng ca qu trnh din bin lin tc bt u
t p ng vim h thng do nhim khun, nhim khun nng, sc nhim khun v
suy a tng.
Suy a tng m nguyn nhn c lin quan n nhim khun chim t l 60 81,5%. Trong tng s cc ca suy a tng
T vong do nguyn nhn nhim khun chim t l cao (cao gp 11 ln so vi
cc cn nguyn khc) trong t vong do sc nhim khun ti cc n v hi sc tch
cc chim t 40 n 60%.
C ch: cc tc nhn nhim khun (vi khun, virt hoc k sinh trng) gy ra
cc p ng vim h thng (SIRS) lm gii phng cc cytokin gy vim, c s mt
cn bng gia yu t gy vim v yu t khng vim (yu t khng vim yu hn yu
t gy vim) dn n gy t thng c quan th pht v to ln vng xon gy tn
thng a tng.
iu tr suy a tng l tn hp cc bin php tm v loi b cc nguyn nhn
gy suy a tng v thc hin cc bin php h tr cc tng suy. Trong khuyn co
quc t v iu tr nhim khun nng v sc nhim khun (Surviving Sepsis
Campaign) c thc hin lm gim tin trin thnh suy a tng v t l t vong do
nhim khun, khuyn co ny ang c p dng rng ri trn th gii.
2. NGUYN NHN
Do do nhim khun huyt l vi khun xm nhp vo mu t cc :
+ Nhim khun: da, m mm, c xng khp...
+ Cc nhim khun ng tiu ha nh: vim rut, nhim khun ng mt, p
xe ng mt, p xe gan, vim ty cp nng nhim khun...
+ Nhim khun ng h hp: vim phi, p xe phi, vim ph qun, vim m
mng phi...
+ Nhim khun h tit niu nh: vim m b thn, m b thn , bng
quang....
+ Nhim khun h thn kinh (vim mng no m, p xe no ...);
+ Mt s cc nhim khun hay gp khc nh vim ni tm mc cp v bn
cp...
80
3. TRIU CHNG
3.1. Lm sng:
- Du hiu lm sng ca p ng vim h thng nh: xc nh khi c t 2
tiu chun sau y tr ln
+ St > 38oC hay h thn nhit < 36oC.
+ Nhp nhanh > 90 ck/pht.
+ Th nhanh, tn s > 20 ln/pht.
+ Tng s lng bch cu trn trn 10000/ml, hoc gim s lng bch cu
<4000/ml, hoc s lng bch cu non > 10%.
- Cc biu hin ca nhim khun nng:
+ Hi chng p ng vim h thng.
+ C nhim khun.
+ Ri lon chc nng c quan nh tng lactat mu 2 hoc thiu niu (th tch
nc tiu < 0,5 ml/kg/gi).
- Du hiu suy a tng do nhim khun:
+ Trn nn ngi bnh nhim khun nng hoc sc nhim khun.
+ Thay i chc nng cc tng do ni mi thay i v khng th t cn bng
nu khng c can thip iu tr.
+ Cc tng suy v mc cc tng suy (theo bng im SOFA)
Bng im SOFA nh gi mc suy tng
im
> 400
400
300
> 150
150
< 20
20 32
Tim mch
Khng
HATB <
Tt HA
tt HA
70mmg
15
13 14
H hp
PaO2/FiO2
ng mu
Tiu cu (x 103/ml)
Gan
Bilirurin (mol/l)
Thn kinh
im Glasgow
200 vi h tr
100 vi h tr h
h hp
hp
100
50
20
33 101
102 204
> 204
Dopamin 5
Dopamin > 5 hoc
Dopamin > 15
hoc
Adre 0,1
hoc Adre > 0,1
Dobutamin
hoc Nora 0,1
hoc Nora > 0,1
10 12
69
<6
300 - 440
> 440
hoc
hoc
< 500ml/ ngy
< 200ml/ ngy
Thn
Creatinine (mol/l)
hoc
< 110
110 170
171 299
lu lng nc tiu
81
3.2. Cn lm sng
- Cc xt nghim cn lm sng xc nh nhim khun nh:
+ Xt nghim cng thc mu thy s lng bch cu tng (trn 10000/ml), t l
bch cu a nhn trung tnh tng cao trn gi tr bnh thng, hoc t l bch cu non >
10%.
+ CRP tng trn 0,5 mg/dl.
+ Procalcitonin tng > 0,125 ng/ml (bnh thng < 0,05)
- Xt nghim vi sinh xc nh tc nhn: cy mu mc vi khun, k sinh trng
(nm)...
- Gim ti mu t chc: tng lac tt mu ( 2 mmol/l).
- Du hiu cn lm sng ca ri lon, suy chc nng c quan nh:
+ Suy thn: tng ure v creatinin.> 130 mol/l.
+ Suy h hp: t l PaO2/FiO2 < 300, trng hp suy h hp nng t l ny <
200.
+ Suy gan: tng GOT, GPT, bilirubin mu, gim t l prothrombin mu...
+ Gim s lng tiu cu, ri lon ng mu, ng mu ni mch ri rc...
+ Nhim toan chuyn ha, tng kali mu.
- Xt nghim cn lm sng khi c suy tng: ch th hin 4 trong 6 tng, trong
2 tng huyt ng v thn kinh ch nh gi bng cc tiu ch lm sng.
+ Thn: tng ure v creatinin ty theo tng mc nng nh (xem bng im
SOFA).
+ H hp: t l PaO2/FiO2< 300%, ty theo tng mc (xem bng im
SOFA).
+ Tiu ha: Tng bilirubin ton phn so vi gi tr bnh thng, trong cc
mc tng ty theo mc nng nh (xem bng im SOFA).
+ Huyt hc: Gim s lng tiu cu di mc bnh thng, mc nng ty
theo s lng tiu cu gim (xem bng im SOFA).
4. CHN ON
4.1. Chn on xc nh: Khi c 02 tiu chun sau
- Nhim khun nng hoc sc nhim khun.
- Suy a tng: im SOFA 3 im, v tng t nht 01 im so vi lc vo vin
v t nht c hai tng suy v tn ti t nht trong vng 24 gi.
4.2. Chn on phn bit
Suy a tng do cc nguyn nhn khng do nhim khun: thng khng c bng
chng ca nhim khun.
Nguyn nhn suy a tng do nhim khun.
Cc bin php chn on nguyn nhn nhim khun (xem bi sc nhim khun)
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4.4. Chn on mc
- Khi c suy tng, im SOFA cng cao v xu th tng dn ngi bnh cng
nng
- S lng tng suy cng nhiu, t l t vong cng cao, ty tng nghin cu t l
t vong t 80 n 100% nu c suy 5 n 6 tng.
- Lactat mu tng dn v tt huyt p khng p ng vi thuc vn mch l
biu hin nng ca sc nng.
5. X TR
5.1. Nguyn tc x tr
- iu tr cn nguyn nhim khun: x l nhim khun v khng sinh.
- iu tr h tr cc tng suy.
- Nu sc nhim khun giai on din bin suy a tng: cn iu tr khn
trng. Mc tiu cn t c trong vng 6 gi u l:
+ Duy tr p lc tnh mch trung tm (ALTMTT) 8- 12 mmHg (11 16
cmH2O).
+ Duy tr huyt p trung bnh > 65 mmHg.
+ Duy tr ScvO2 70% hoc SvO2 65%.
+ Th tch nc tiu 0,5 ml/kg/gi.
Nhanh chng m bo h hp v tun hon duy tr tnh mng cho ngi
bnh bng cc bin php:
- Lm test truyn dch: truyn 1000 2000 ml dung dch natriclorua 0,9% hoc
ringerlactat trong vng 1 n 2 gi u nhng ngi bnh tt huyt p do nhim
khun m bo huyt p trung bnh 65 mmHg.
- m bo h hp cho ngi bnh bng cc bin php oxy liu php (th oxy
knh, mt n n gin, mt n c ti ht li), th h thng p lc dng lin tc
(CPAP) c kt ni oxy h tr, mc tiu duy tr SpO2 > 92%.
- S dng thuc vn mch nh noradrenalin hoc adrenalin ng truyn tnh
mch lin tc liu khi u 0,05 mcg/kg/pht m bo huyt p khi nh gi tt
huyt p ca ngi bnh khng do thiu dch.
5.3. Cc bin php c th
a) Bi ph th tch dch
- Truyn dch sm v nhanh ngay khi c tt huyt p nhm mc ch b th
tch dch lng mch tuy nhin cng trnh gy ph phi cp huyt ng do tha dch.
B 1000 ml dch tinh th (natri clorua 0,9% hoc ringer lactat) hoc 500 ml dung dch
cao phn t (khng phi l dung dch HEAS) nh dung dch gelatin hoc albumin 5%
trong 30 pht, sau chnh theo p ng v nh gi lm sng.
- Lm test truyn dch cho n khi t mc p lc tnh mch trung tm mong
mun, duy tr p lc trung tm 8-12 cmH2O cc bnh nhn khng th my v 12-15
cmH2O cc BN th my.
83
- Loi dch: dch tinh th Natri Clorua 0,9%, hoc Ringerlactat kt hp dung
dch gelatin hoc albumin trong trng hp truyn nhiu dung dch tinh th hn ch
thot mch.
- ng truyn: nu l ng ngoi vi phi ln hoc t 2-3 ng truyn,
nn t catheter tnh mch trung tm b dch trong trng hp c tt huyt p.
b) Dng vn mch
- Ch s dng thuc vn mch khi b dch (da vo CVP v huyt p).
- Noradrenalin l thuc s dng u tay vi liu khi u 0,05 mcg/kg/pht,
tng dn liu 0,05mcg/kg/pht mi 5 10 pht t huyt p trung bnh 65 mmHg.
- C th s dng Dopamin hoc Adrenalin nu khng c lon nhp hoc nhp
qu nhanh, vi liu Dopamin khi u 5 mcg/kg/gi tng dn 3-5 g/kg/gi mi 5-10
pht n khi t HA ch, ti a khng tng qu 20 g/kg/gi, vi Adrenalin bt u
liu 0,05 g/kg/gi, tng dn 0,05 0,1 g/kg/pht n khi t HA ch, ti a khng
tng qu 5 /kg/gi.
- Thuc tng co bp c tim: khng s dng thng quy vi CVP cao, ch dng
khi c ri lon chc nng tht tri qua nh gi siu m hoc ng thng ng mch
phi.
c) Chn on cn nguyn nhim khun v dng khng sinh
- Xc nh nhim khun (lm sng kt hp chn on hnh nh, visinh..) trc
khi dng khng sinh.
- Gii quyt nhim khun: u tin cc bin php t xm ln nh chc ht, dn
lu nu c th hoc nu tin khng c hoc tin lng kt qu hn ch th phu
thut.
- Dng khng sinh ng tnh mch cng sm cng tt, ngay sau khi cy mu,
trong gi u nu c th.
- Dng khng sinh ph rng theo liu php khng sinh kinh nghim (xem dn
s dng khng sinh trong sc nhim khun do B y t ban hnh hoc theo s liu tnh
hnh khng khng sinh ti mi n v nu c) v thc hin theo chin lc xung
thang nu c th c.
- Phi hp khng sinh trong cc trng hp:
+ Gim bch cu: phi phi hp khng sinh ph ti a ph nhim khun (vi
khun gram m, gram dng hay vi khun ni bo ...).kt hp thuc chng nm.
+ Nu nghi do trc khun m xanh, hoc A.baumanni cn phi hp vi cc
khng sinh nhy cm vi trc khun m xanh.hoc A.baumanii nh: carbapenem kt
hp colistin.
+ Nu nghi do cu khun ng rut phi hp thm vancomycine, cubicin...
- Khi c suy thn, liu khng sinh phi da vo thanh thi creatinin, liu u
tin dng nh bnh thng khng cn chnh liu, ch chnh liu t cc liu sau, nu c
lc mu nn chnh liu theo lc mu.( lc mu lin tc hay ngt qung).
84
d) Dng corticoide
- Ch dng khi sc km p ng vi vn mch hoc cha ct c vn mch
sau 48 gi (khng dng mt cch h thng), nn dng hydrocortison liu 50 mg mi 6
gi. Gim liu v ngng khi ngi bnh thot sc v ct c thuc co mch.
- Lu c th lm nhim khun tin trin nng hn nu liu php khng sinh
kinh nghim khng ph hp v gy tng ng mu.
e) Kim sot ng mu
Kim sot ng mu mao mch bng Insulin ngt qua ng tim ngt qung
hoc ng truyn tnh mch, nu ng mu mao mch 11 mmol/l, mc tiu duy
tr ng mu t 7 9 mmol/l.
f) iu tr d phng cc bin chng
- Huyt khi tnh mch bng mt trong hai bin php sau:
+ Heparin trng lng phn t thp nh Enoxaparin 1 mg/kg tim di da,
gim liu khi ngi bnh c suy thn.
+ S dng bao thay i p lc nh k 2 tay v 2 chn.
- Xut huyt tiu ha: dng thuc bng nim mc d dy nh sucalfate 2
gi/ngy chia 2 ung hoc bm qua d dy ... hoc cc thuc c ch bm proton nh
omeprazole, pantoprazole, esomeprazole ... hoc cc thuc khng H2 nh ranitidin ...,
lu ng dng trong tng trng hp c th v tng tc thuc.
g) Th my trong trng hp tn thng phi, suy h hp cp tin trin
- Mc tiu: SpO2> 92% hoc PaO2> 60 mmHg v pH > 7,15
- Cc bin php:
+ Th my khng xm nhp vi CPAP hoc BiPAP nu ngi bnh tnh v
hp tc (xem bi th my khng xm nhp).
+ Th my xm nhp c s dng PEEP (nu khng c chng ch nh dng
PEEP) khi th my khng xm nhp tht bi hoc ngi bnh khng hp tc (xem k
thut th my ngi bnh ARDS).
h) Lc mu lin tc
- Lc mu lin tc sm nht nu c th ngay sau khi c chn on sc nhim
khun v lu phi kim sot c nhim khun.
- Ch lc mu khi nng c huyt p tm thu > 90 mmHg(xem quy trnh
lc mu lin tc cho ngi bnh sc nhim khun).
- Ngng lc mu lin tc khi ct c cc thuc co mch t nht 12 gi v
huyt p n nh v chuyn lc mu ngt qung nu cn ch nh.
i) Hng dn truyn mu v cc ch phm mu
- Khng truyn plasma ti ng lnh iu chnh cc bt thng trn xt
nghim khi khng c nguy c chy mu trn lm sng cng nh khng c k hoch
lm th thut
85
- Ch truyn khi hng cu khi hemoglobin < 7g/l cc bnh nhn tr, vi cc
bnh nhn c nguy c gim oxy mu nh cao tui, nhi mu c tim, t qu no ...
nn suy tr nng hemoglobin 7 9 g/l.
- Truyn khi tiu cu (KTC) khi s lng tiu cu (SLTC) < 10.000/ml ngay
khi lm sng khng c nguy c chy mu. Truyn KTC khi SLTC < 20000/ml kt hp
c nguy c chy mu trn lm sng. a SLTC ln trn 50000/ml nu c k hoch
lm th thut hoc phu thut.
Tin lng sc nhim khun din bin nng khi c mt trong hai yu t sau:
- Tin trin suy a tng.
- Lac tat tng dn v tt huyt p khng p ng vi thuc vn mch.
7. PHNG BNH
- Pht hin v x tr sm cc nhim khun.
- Nu ngi bnh chuyn sang giai on nhim khun nng, sc nhim
khun cn tch cc iu tr ngn chn tin trin suy a tng.
Ti liu tham kho:
1. David J., Irvin M. (2001), Multiple organ dysfunction syndrome: a narrative
review, Canadian Journal of Anesthesia. 48, Pp. 502-9.
2. Dellinger R.P., Carlet J.M. & et al (2008), Surviving sepsis campaign guidelines
for management of severe sepsis and septic sock, Crit Care Med. 36, Pp. 296327.
3. Dellinger R.P., Levy M.M. & et al (2008), Surviving sepsis campaign:
International guidelines for management of severe sepsis and septic sock: 2012,
Crit Care Med. 41, pp. 580-637
4. George M.M. (1998),
Multiple organ system failure: Clinical expression,
pathogenesis, and therapy, Principles of critical care, McGRAW-HILL, Pp. 221-48.
5. Jason Phua, Younsuck Koh and et al. (2011), Management of severe sepsis in
patients admitted to Asian intensive care units: prospective cohort study, BMJ,
342:d3245.
6. Levy M.M., Fink M.P. & et al (2003), 2001SCCM/ESICM/ACCP/ATS/SIS
International Sepsis Definitions Conference, Intensive Care Med . 29, Pp. 530-8.
7. Schmidt G.A., Madel J. (2009), Management of severe sepsis and septic shock in
adults, Uptodate, destop 17.3
86
Chn on xc nh suy a tng

do sc nhim khun
X tr ban u
Nhanh chng m bo h hp v tun hon vn chuyn ngi bnh ti
bnh vin gn nht
Liu php oxy hoc t ng NKQ bp bng oxy nu c iu kin
Truyn dch nhanh 1000-2000ml trong 1-2 gi u nu nghi ng tt
huyt p do nhim khun v c th dng vn mch (noradrenalin hoc
adrenalin) nu nh gi ngi bnh khng c thiu dch duy tr huyt
p trung bnh 65 mmHg.
X tr ti bnh vin
X tr sc nhim khun nu cn (xem x tr sc nhim khun)
H tr cc tng suy bao gm:
- H hp: m bo h hp sao cho mc tiu t SpO2 > 92% hoc PaO2 > 60 mmHg v pH >
7,15 bng cc bin php th my theo chin lc bo v phi.
- Tun hon: cc bin php truyn dch, mu (khi hng cu) nu cn, s dng thuc vn mch
v thuc tng co bp c tim nu c ri lon chc nng tht tri nhm mc ch duy tr HATB
65 mmHg.
- Thn: lc mu lin tc vi th tch thay th 45ml/kg/gi nu c th, nu khng c iu kin lc
mu ngt qung ko di (6 gi/gi)
- Tiu ha: c th p dng cc bin php o thi bilirubin nh truyn dch tng thi bilirubin
trc tip hoc thay huyt tng loi b bilirubin nu cn khi m nng bilirubin qu cao >
250ol/L c nguy c gy hn m.
- Huyt hc: xem bi sc nhim khun
S chn on suy a tng do sc nhim khun
87
Chng III: TIU HA

HI CHNG GAN THN CP
1. I CNG
Hi chng gan thn (HCGT) l tnh trng suy gim chc nng thn cp tnh xy
ra trn ngi bnh b bnh gan cp hoc t cp bnh gan giai on cui, ch yu
gp ngi bnh x gan c trng tng p lc tnh mch ca, vim gan do ru, hoc
him gp hn nh khi u gan, vim gan ti cp do cc nguyn nhn khc nhau (vim
gan vi rt, x gan mt tin pht, vim gan nhim c, tn thng gan trong sc ..).
Theo nh ngha mi theo hi ngh ca Cu lc b c trng Quc t nm
2007, cng nh ca ADQI ln th 8, HCGT l mt hi chng c trng bi tnh trng
gim nng dng mu n thn do co tht ng mnh thn, dn ng mch ngoi vi do
tn thng gan nng tin trin. Mc d suy thn cp chc nng, nhng HCGT li c
tin lng rt xu, t l t vong cao v ghp gan l bin php duy nht c hiu qu tt.
2. NGUYN NHN
- Thng gp ngi bnh c biu hin x gan mn tnh.
- HCGT cc ngi bnh c tn thng gan cp tnh:
+ Vim gan do ru.
+ Vim gan nhim c do thuc, cc cht gy c.
+ Vim gan do vi rt.
+ Tn thng gan do sc (tim, nhim khun, phn v, gim th tch).
- Cc yu t thc y:
+ Nhim trng dch c chng
+ Mt dch do nn, a chy.
+ Gim albumin mu.
+ Tng th tch tun hon
3. TRIU CHNG
3.1. Lm sng
- Bnh gan cp tnh hoc t cp trn nn mt bnh gan mn tnh.
- Mt mi, chn n, ri lon tiu ha.
- Hi chng vng da : nc tiu vng, da v nim mc vng.
- Trn da c th c xut huyt do ri lon ng mu, sao mch, tun hon bng
h.
- Thn kinh: thc gim khi c biu hin no gan, du hiu ngoi thp ca x
gan.
- C th c nhim khun ton thn hoc nhim khun dch c chng.
- Du hiu mt nc, mt dch, sc (nu c nguyn nhn lin quan).
- Khai thc tin s nguyn nhn v cc t cp tnh ca bnh gan mn.
88
3.2. Cn lm sng
- Xt nghim nh gi chc nng thn: creatinin v ure huyt thanh, protein
niu v cc t bo nc tiu.
- Cc xt nghim in gii mu v nc tiu.
- Xt nghim nh gi suy t bo gan: AST, ALT, protein, albumin mu, GGT,
cc yu t ng mu, t bo mu ngoi vi.
- Chn on hnh nh: siu m, chp ct lp vi tnh nh gi nhu m, kch
thc ca gan, lch v h thng tnh mch ca, tnh mch trn gan
- Cc xt nghim tm nguyn nhn v cc yu t thc y xut hin HCGT:
+ Nhim trng ton thn.
+ Nhim trng c chng.
+ Vim gan do thuc, ng c gan cp.
4. CHN ON
4.1. Chn on xc nh: theo cu lc b c chng IAC 1996 v 2007, ADQI hi
ngh th gii thng nht ln 8.
a) Cc tiu chun chnh bao gm
- C bnh gan cp hoc mn tnh vi t suy gan cp tin trin km theo c
tng p lc tnh mch ca.
- Typ 1: tng creatinin mu trn 2,5 mg/dl (220 mol/l), triu chng khng
gim sau 48 gi iu tr bng li tiu v b th tch dch vi albumin 1g/kg/ngy. Tm
yu t thc y, thng tin trin vi ngy ti 2 tun, HCGT typ 1 thng nng hn
typ 2.
- Typ 2: c chng khng p ng vi thuc li tiu, chc nng thn bin i
t t, creatin mu 1,5 mg/dl (130 mol/l), din bin nh hn typ 1.
- Bt buc cn loi tr cc nguyn nhn gy ra suy thn cp khc nh: sc
nhim khun, sc gim th tch, s dng thuc c vi thn, si thn tit niu, hoi t
ng thn cp do nhim khun, tan mu, ng c thuc
b) Tiu chun ph
- Gim mc lc cu thn: v niu ( nc tiu < 100 ml/12 gi) hoc thiu niu
(nc tiu < 200 ml/12 gi).
- Protein niu < 500 mg/ngy.
- Hng cu niu < 50/vi trng
- Chc nng ng thn cn nguyn vn: ALTT niu > ALTT mu, Natri niu
<10 mEq/L.
- Natri mu < 130 mmol/l
4.2. Chn on phn bit
Suy thn cp trc thn ngi bnh x gan c trng do: gim th tch tun
hon thc s hoc gim dng mu ti thn do cc nguyn nhn khc nh dng thuc
h huyt p, ri lon vn mch trong thn (sc, nhim khun, phn ng vim SIRS qu
mc..).
89
4.3. Chn on nguyn nhn: gy ra HCGT (sng lc cc nguyn nhn trn).

4.4. Phn loi
a) Hi chng gan thn typ 1
- Tnh trng suy thn tin trin nhanh, tng nhanh creatinin huyt thanh, ngay t
u ln mc trn 220mol/L.
- Xut hin t pht, nhng thng sau cc yu t thc y, c bit l nhim
trng dch c trng, mt dch, tha th tch gim albumin...
- Tin lng ca HCGT typ 1 l rt ti, thi gian sng trung bnh 2 tun, t
vong gn 100% sau 3 thng.
b) Hi chng gan thn typ 2
- Tnh trng suy thn tin trin mc trung bnh, nng creatinin huyt
thanh tng t 150% tc khong 133 n 226mol/l.
- Thng tin trin t pht nhng cng c th xut hin sau cc yu t thc y.
Tnh trng c trng dai dng, khng p ng vi thuc li tiu.
- Tin lng sng thng ngn hn ngi bnh x gan khng c suy thn
nhng tt hn typ 1, c th sng ti 6 thng.
c) Hi chng gan thn typ 3 ( t gp)
Ngi bnh x gan c biu hin typ 1 hoc 2 trn nn bnh thn mn tnh.
d) Hi chng gan thn typ 4 (t gp).
Ngi bnh suy gan cp tnh c suy gim chc nng thn, gp khong 50%.
5. X TR
5.1. Nguyn tc x tr:
- Nhanh chng xc nh v iu tr yu t thc y: nhim trng, mt nc,
gim albumin mu, nhim trng dich c chng, ng c cp paracetamol.
- Cc bin php iu tr co mch h thng: Terlipressin dn cht ca
vasopressin.
- Cc bin php thay huyt tng (PEX), lc gan nhn to (MARS), hoc lc
mu lin tc (CVVH) kt hp vi thn nhn to cp ngt qung ty theo tnh trng lm
sng.
- iu tr nguyn nhn gy ra HCGT.
- Lm cu ni bn bn h thng tnh mch ca v tnh mch ch (TIPS): khi
c ch nh, vi mc ch gim p lc tnh mch ca.
- Ghp gan.
- X tr cc du hiu nng:
+ Suy thn cp: t ng thng tnh mch trung tm kim sot th tch nc
vo-ra, dng li tiu khi c thiu niu, v niu.
+Tng kali mu: nu kali mu > 6 mmol/l v hoc c ri lon nhp tim cn iu
tr cp cu (xem bi tng kali mu).
90
+ Ph phi cp, ph ton thn: ch nh thuc li tiu furosemid tim tnh mch
20-40 mg/ln, khng p ng cho ti 100-200 mg/ln, ti a 600-1000mg/ngy.
+ Hi chng no-gan: cn loi tr h ng huyt, duy tr truyn tnh mch
glucosa 10-20%, gii phng ng h hp, t canun mayo ming, trnh ng m,
nu c suy h hp, ri lon thc cn t ng ni kh qun bo v ng th,
phng thiu oxy.
+ Ph no, co git: bo v ng th, an thn ct cn git bng diazepam 10
mg tim bp hoc tnh mch (hoc midazolam 5 mg, phenobacbital 100 mg).
- Khi vn chuyn ngi bnh cn ch m bo v h hp, tun hon, ri lon
thc gy mt kh nng t bo v ng th, ri lon nhp tim.
a) Mc tiu
- iu tr tnh trng gin mch ni tng v co ng mch thn.
- Thuc iu tr triu chng v h tr cc chc nng gan vn ch nh duy tr
cc chc nng ca gan c bit trong thi gian ch c ghp gan.
- iu tr yu t thc y lm xut hin HCGT.
b) iu tr yu t thc y xut hin HCGT
- Nhim trng: vim ng h hp, nhim khun tit niu, vim c
+ Cy tm vi khun gy bnh, lm khng sinh .
+ Khng sinh theo nhim khun.
- Ph v tng dch c chng: thng i km vi c gim albumin mu.
+ Kim sot cn bng dch vo ra.
+ Dng thuc li tiu: furosemide, tim hoc ung, v hoc vi spironolacton.
+ Truyn albumin: albumin truyn 5%, 20%, a albumin mu v gi tr bnh
thng.
+ Chc tho dch c chng khi bng qu cng gy kh th, nh hng ti cc
du hiu c nng, xt nghm cc thnh phn trong dch c chng.
- Nhim trng dch c chng: d xy ra khi c chc dch c chng nhiu ln.
+ Cc triu chng nhim trng.
+ au bng.
+ Xt nghim dch c chng: bch cu a nhn, protein, soi, cy tm vi khun.
+ Khng sinh tnh mch: c tc dng vi vi khun Enterobacteriaceae,
S.pneumonia, Enterococci nh Cephalosporin th h 3, Piperacillin-tazobactam,
Ertapenem. Nu E.Coli c men ESBL (+) dng nhm Carbapenem c th kt hp vi
1 thuc nhm quinolon.
- Xut huyt tiu ha cao v thp: do tng p lc tnh mch ca, tnh mch ch.
Do gim cc yu t ng mu, do tiu cu gim.
+ Ni soi chn on nguyn nhn xut huyt tiu ha, can thip cm mu hoc
gim p lc tnh mch ca ty theo ch nh.
91
+ iu tr hi chng tng p lc tnh mch ca: thng tnh mch ca- ch trong
gan (TIPS) ty theo ch nh v kh nng tin hnh k thut.
+ nh gi cc yu t ng mu, b sung cc yu t ng mu (tiu cu,
plasma ti, si huyt).
+ Truyn mu theo mc mt mu, m bo Hb 9-11 g/lt.
c) Cc thuc dn mch thn: Prostaglandin, i khng Endothelin-1 c vai tr hot ha
cc ET-1 trong x gan. Kt qu cha r rng.
d) Cc thuc co mch h thng: s dng cc thuc co mch vasopressin phi lun kt
hp vi bi ph th tch tun hon.
- Terlipressin: dn cht ca vasopressi.
+ Terlipressin: ci thin chc nng thn ti 65%, ch nh HCGT typ 1.
+ Ci thin c tnh trng h natri mu do ha long.
+ Thi gian iu tr 7-14 ngy.
+ Liu dng: Terlipressin 0.5-2mg mi 4 gi tim tnh mch hoc truyn lin
tuc,
nu nng creatinin huyt thanh khng gim, tng liu ln 1mg, hoc 1,5mg,
hoc 2mg mi 4 gi cho ti khi nng creatinin huyt thanh gim.
+ Kt hp vi truyn albumin liu 1g/kg cn nng trong ngy u v sau liu
40g albumin mi ngy. iu tr n thun terlipressin khng c khuyn co.
+ Dng thuc khi nng creatinin huyt thanh khng gim 50% sau 7 ngy s
dng liu cao Terlipressin, hoc sau 3 ngy u iu tr.
+ C p ng: iu tr ko di n khi HCGT tt ln hoc ti a 14 ngy.
+ Tc dng ph: c th gy co mch, gy thiu mu v ri lon nhp tim.
- Cc iu tr thay th khc khi Terlipressin khng c tc dng:
+ Midodrine: thuc khng chn lc th th 1. Khi liu 2.5 7.5mg ng
ung chia 3 ln/ngy, tng dn t t ti liu 12.5mg/ ngy, kt hp vi Octreotide
khi liu 100mg tim di da, tng dn n 200mg/ngy, chia 2 ln v truyn
Albumin 40g/ngy. Tng liu sao cho tng huyt p ng mch trung bnh khong
15mmHg hoc a huyt p ng mch trung bnh ln khong 90mmHg. iu tr t
nht 20 ngy.
+ Octreotide (dn cht ca somatostatin)
+ Noradrenaline: liu 0.5 3mg/gi, tng dn cho ti khi nng huyt p ng
mch trung bnh thm 10-15 mmHg, kt hp vi albumin v furosemide cng c hiu
qu v an ton nh terlipressin ngi bnh HCGT.
- Vi HCGT typ 2: hin nay cha c bng chnh v s dng cc thuc co
mch.
- Cc p ng iu tr khi s dng thuc co mch
+ p ng hon ton: gim nng creatinin mu < 130mol/l.
+ Ti pht: li suy thn sau khi dng iu tr, creatinin mu >130mol/l.
92
+ p ng mt phn: gim nng creatinin huyt thanh 50% gi tr

creatinin ban u, nhng khng ti mc di 130mol/l.
+ Khng p ng: khng gim creatinin hoc gim < 50% gi tr creatinin ban
u nhng creatinine huyt thanh cui cng vn trn 130mol/l.
e) TIPS (cu ni bn bn h thng tnh mch ca v tnh mch ch): mi c t
nghin cu nh gi vai tr ca TIPS
- Ch nh: HCGT cp, dch c chng khng tr, ch ghp gan, c th ci thin
chc nng thn v c trng dai dng ngi bnh typ 2.
- Tc dng sau lm TIPS: lm gim p lc tnh mch ca, tng cung lng tim
v lm tng th tch tun hon trung tm, ci thin ti mu thn, tng mc lc cu
thn.
- Chng ch nh trn ngi bnh HCGT c tin s bnh no gan nng, c nng
bilirbin huyt thanh > 85mol/L, hoc Child-Pugh trn 12 im.
- Bin chng ca TIPS: hi chng no gan, nhim trng, hp ti v tr cu ni.
f) Cc bin php lc mu, lc gan nhn to
- Lc mu ngt qung hoc lc mu lin tc (IHD hay CVVH)
+ Ch nh khi: tha dch, tng gnh th tch dn n ph no, co git, ph phi
cp, hoc tng kali mu cp >6 mmol/lt hoc c ri lon trn in tim, toan chuyn
ha pH < 7,10.
+ Tai bin khi lc mu: chy mu nng, ri lon ng mu, tng huyt p.
- Thay huyt tng (PEX), lc gan vi hp ph phn t lin tc (MARS): ( xem
sch quy trnh k thut hi sc tch cc).
+ Ch nh: hi chng no gan giai on II vi NH3 mu tng cao, xt nghim
bilirubin ton phn > 250 mol/l, suy gim cc chc nng ca gan.
+ K thut c tin hnh hng ngy, ch cc ri lon ng mu v thuc
chng ng dung cho k thut ny.
+ Hiu qu tm thi trong giai on ch ghp gan.
5.3.7. Ghp gan
- Ghp gan l iu tr tt nht cho HCGT, c t l sng sau 3 nm khong 70%,
cho n nay vn l iu tr c hiu qu nht.
- Cn nhc ngi bnh c cc yu t nguy c, nghi ng xut hin HCGT typ
1.
- Tin lng tng ng vi ngi bnh trc khng b HCGT.
- HCGT typ 1: nu khng iu tr 80% c th t vong trong hai tun u, 20%
t vong trong 3 thng, tin lng ph thuc vo im MELD nh gi nng.
- HCGT typ 2: nu khng iu tr t vong trong 6 thng, nng lin quan ti
kh nng t vong ph thuc vo im MELD (di 20 im th tin lng sng 50%
sau 8 thng, trn 20 im th tin lng sng 50% sau 1 thng).
93
7. PHNG BNH
- D phng xut hin HCGT l rt quan trng trong thc hnh lm sng.
- Ngn chn hoc iu tr tch cc ngay khi c cc yu t thc y: nhim trng
dch c trng, xut huyt tiu ha, cc nhim trng khc trong c th.
- Bnh nhn x gan c dch c trng: ch xt nghim albumin mu, lun
duy tr trong gii hn bnh thng. Ch truyn b xung albumin cho bnh nhn c
nng bilirubin huyt thanh > 68.4mol/l hoc creatinin huyt thanh > 88.4mol/l.
- phng nhim trng : cho khng sinh Norfloxacine 400 mg/ngy cho ngi
bnh x gan c c chng m chc nng thn bt u thay i.
- Ch cc thuc c nguy c c vi thn nh: khng sinh nhm
aminoglycoside, thuc chng vim gim au khng steroid, thuc li tiu, thuc cn
quang c iot.
Ti liu tham kho
1. Nguyn t Anh, ng Quc Tun. (2012); Suy gan cp nng; Hi sc cp cu:
tip cn theo phc . (Bn ting Vit ca The Washington manual of critical
care). Nh xut bn khoa hc k thut. Trang 597-615.
2. Dhillon A. (2010), Hepatorenal syndrome, Textbook of Critical Care Sixth
Edition. Jean- Louis Vincent. Elsevier Sauders, Pp. 752-6.
3. European Association for the Study of the Liver. (2010), EASL clinical practice
guidelines on the management of ascites, spontaneous bacterial peritonitis, and
hepatorenal syndrome in cirrhosis,Journal of Hepatology. vol 53, Pp. 397-417.
4. Nadim M.K., Kellum J.A., Davenpor A. (2012), Hepatorenal syndrome: the 8 th
international consensus conference of the Acute Dialysis Quality Initiative (ADQI)
Group Critical Care (16):R23, Pp. 1-17.
94
SUY GAN CP
1. I CNG
Suy gan cp l tnh trng tn thng t bo gan mt cch t do nhiu nguyn
nhn khc nhau dn n bnh cnh lm sng cp tnh vi cc biu hin:vng da, ri
lon ng mu,bnh l no gan, suy a tng mt ngi trc c chc nng gan
bnh thng. T l t vong cao 50 - 90% nu khng c iu tr hp l hoc khng
c ghp gan.
2. NGUYN NHN
2.1. Nguyn nhn vi sinh vt
- Do cc virut vim gan A, B, C, E virut vim gan B l nguyn nhn ph bin
nht Vit Nam.
- Cc virut khc: Cytomegalovirus, Herpes, Epstein Barr, thy u.
- Vi khun: gp nhng bnh nhn nhim khun nng v sc nhim khun, t
l tn thng gan v suy gan cp ti 20 - 25%.
- K sinh trng: st rt, sn l gan, giun.
2.2. Do ng c
2.2.1 . Thuc
- Hay gp nht l Paracetamol k c vi liu iu tr thng thng bnh nhn
nghin ru, hoc c s dng cng vi cc thuc chuyn ha qua enzyme
Cytochrome 450 nh cc thuc chng co git.
- Cc thuc khc: Isoniazide, Rifampicin, thuc chng vim khng Steroid,
Sulphonamides, Phenytoin, Tetracycline, Allopurinol,Ketoconazole, IMAO...
- Ng c cc thuc ng y, c bit l cht bo qun thuc.
2.2.1. Cc loi nm mc
in hnh l nm Amianita phalloides.
2.2.3. Cc nguyn nhn khc
- Hi chng gan nhim m cp ph n c thai.
- Tc mch ln gan.
- Hi chng Reys.
3. TRIU CHNG
3.1. Lm sng
Bnh nhn suy gan cp thng c tin s khe mnh hoc khng c biu hin
tin s bnh l nng n trc . Bnh nhn khi pht vi triu chng: mt xu, bun
nn, chn n sau cc biu hin in hnh trn lm sng l:
- Vng da v nim mc tng nhanh, nc tiu sm mu.
- Cc triu chng do ri lon ng mu: chy mu di da, nim mc, xut
huyt tiu ha cao v thp, c th xut huyt no.
- Hi chng no gan biu hin nhiu mc v ty giai on:
95
+ I: Thay i trng thi tnh cm, gim tp trung ,ri lon gic ng.
+ II: L m, u m, hnh vi bt thng, ng x khng ph hp mt nh
hng, cn p ng vi li ni.
+ III: Ng g, khng p ng vi li ni, u m r ,tng phn x.
+ IV: Hn m, biu hin mt no, c th cn p ng vi kch thch au.
- Suy thn cp l bin chng xy ra sau suy gan cp.
- Nhim trng: hay gp vim phi, nhim trng tit niu, nhim khun huyt.
- Ngi bnh c th t vong trong bnh cnh suy a tng.
3.2. Cn lm sng
- Cc xt nghim sinh ha, huyt hc nh gi mc nng ca bnh nhn:
+ Tng bilirubin: nu tng > 250 mmol/l bnh nhn rt nng.
+ AST v ALT tng cao khi c tn thng t bo gan nng.
+ INR, NH3, PT, aPTT, yu t V, VII, VIII v fibrinogen.Thi gian
prothrombin PT ko di 1,5 l yu t xc nh bnh nng.
+ H ng mu, h natri mu, h mage mu ,kim h hp, toan chuyn ha.
+ Tng ure, creatinin mu.
- Chn on hnh nh:
+ Siu m bng, xc nh kch thc gan, loi tr cc bnh mn tnh khc gan...
+ Chp ct lp s xem tnh trng ph no, xut huyt no nu c.
- Cc xt nghim tm nguyn nhn
+ Ng c: ly nc tiu, mu xc nh v nh lng c cht (nh nng
paracetamol trong huyt thanh).
+ Huyt thanh chn on cc loi virut gy vim gan cp: vim gan A (IgM);
vim gan B (HBsAg, Anti HBC, HBV DNA...). Vim gan C(HCVAb,HCV-RNA),
Epstein Barr virt (IgM, IgG) Cytomegalovirus (IgG, IgM). PCR vi cc vi rt:
Herpes; Enterovirus, Adenovirus, Parovirus...
+ Khng th t min khi lm sng nghi ng vim gan t min.
4. CHN ON
4.1. Chn on xc nh
- Chn on suy gan cp trn lm sng cn kt hp y cc biu hin ca hi
chng suy chc nng gan cp tnh, hi chng no gan: mt mi, vng da, xut huyt,
du hiu thn kinh...
- Cc xt nghim sinh ha: tng bilirubin, NH3, AST, ALT thi gian
prothrombin ko di 1,5.
4.2. Chn on phn bit: suy gan cp cn phn bit vi:
- Ng c thuc an thn gy ng.
- H ng huyt.
- Hn m tng p lc thm thu.
- Tai bin mch mu no.
- Cc bnh l thn kinh khc.
96
- t cp trn mt bnh nhn c bnh gan mn tnh (do vim gan vi rt, x gan
ru, vim gan t min, bnh gan do ri lon chuyn ha...).
- Suy gan cp do ng c: xt nghim c cht trong mu nc tiu, dch d
dy, nh lng paracetamol trong huyt thanh.
- Suy gan cp nghi do vim gan virus: chn on huyt thanh: vim gan A
(IgM); vim gan B (HbsAg; Anti HBC,m nh lng HBV DNA)....
- Suy gan cp do cc nguyn nhn khc: bnh t min tm khng th t min,
bnh ri lon chuyn ha...
- Chn on hnh nh: siu m gan xc nh tc mch gan, gan teo trong cc
vim gan virus ti cp.
4.4. Phn loi mc
a) Phn chia theo Lucke v Mallory: chia lm 3 giai on
- Tin triu: l giai on cha c vng da.
- Giai on trung gian: nh du bng s xut hin ca vng da.
- Giai on cui biu hin ca bnh l no gan.
b) Phn loi lm sng kinh in: da vo khong thi gian t khi biu hin vng da
n khi xut hin bnh l no gan.
- Suy gan ti cp 7 ngy.
- Suy gan cp 8 - 28 ngy.
- Suy gan bn cp 5 - 12 tun.
c) Bnh l no gan chia lm 4 mc : rt hu ch trong tin lng, theo di v thi
x tr cho bnh nhn.
I: Hng phn hoc trm cm, ni nhu, hi ln, ri lon gic ng, run nh.
II: L m, u m, mt nh hng, run r.
III: Ng lm, nhng cn p ng, tng phn x, run thng xuyn.
IV: Hn m su, khng cn run.
5. X TR
5.1. Nguyn tc x tr
Khng c iu tr c hiu cho bnh suy gan cp, do vy cc bin php iu tr
bao gm:
- iu tr h tr gan, cc c quan b suy chc nng.
- iu tr cc bin chng trong khi ch i t bo gan hi phc hoc ch ghp
gan.
- Ngng tt c cc thuc ang ung, gy nn, ung 20 gam than hot nu nghi
ng ng c paracetamol.
- Truyn dung dch glucose 10% trnh h ng huyt
- Chuyn ngay n khoa hi sc tch cc, m bo t th an ton, h hp v
tun hon trn ng vn chuyn.
97

a) Cc bin php hi sc c bn
- Nm u cao 30o - 45o nu khng c tt huyt p, hn ch ti a vic s dng
thuc an thn.
- Hi sc h hp: t th an ton, cc bin php h tr h hp ty thuc tnh
trng h hp ca bnh nhn. Nu phi t ni kh qun th my, trnh dng PEEP qu
cao v lm tng p lc ni s.
- Hi sc tun hon: duy tr huyt p ca ngi bnh cao hn mc bnh thng
hoc huyt p nn m bo p lc ti mu no: s dng dch keo (albumin,
gelatin) m bo th tch tun hon, duy tr Hb 10g/dl. S dng thuc vn mch
noradrenalin duy tr huyt p nu huyt p cn thp khi b dch.
- iu tr chng ph no: bnh nhn suy gan cp giai on III v IV hu ht
c ph no. Cht no lin quan n ph no l nguyn nhn chnh ca t vong do suy
gan cp ngoi cc bin php m bo h hp, tun hon nh trn cn s dng cc bin
php:
+ Manitol 20% :0,5g/kg truyn tnh mch trong 15 pht lp li nu p lc thm
thu di 320 mosm/l.
+ Duy tr natri mu 145 - 155 mmol/l bng truyn dung dch mui natriclorua 3%.
+ Theo di v kim sot p lc ni s nu thc hin c k thut ny. Ch
nh khi bnh nhn giai on III, IV. m bo p lc ni s < 25mmHg v p lc
ti mu no 50 - 80mmHg.
+ Thuc an thn nn s dng Pentobarbital (3 - 5mg/kg liu ban u, sau
duy tr 1 - 3 mg/kg/gi). Ch nh khi bnh nhn kch thch ,co git v au.
- Cc bin php hi sc c bn khc
+ D phng chy mu ng tiu ha: s dng khng H2 liu cao: Ranitidin 1 3mg mi 8 gi (tnh mch) hoc c ch bm proton.
+ Theo di v iu chnh nc in gii, thng bng toan kim (Lu h natri
mu khng b nhanh v lm tng p lc ni s), cn bng dch vo ra.
+ Cung cp glucose bng truyn dung dch glucose 10% hoc 20%, truyn lin
tc v theo di ng mu theo gi, trnh h ng mu (lm tng t l t vong) cng
nh tng ng mu lm tng p lc ni s.
+ iu tr ri lon ng mu: truyn plasma ti, tiu cu, yu t ta khi c
xut huyt t pht hoc khi lm th thut xm ln m INR > 1,5 tiu cu < 50.000;
fibrinogen < 100mg/dl. Vitamin K 10mg tim tnh mch d phng.
+ Dinh dng cho bnh nhn suy gan cp u tin dinh dng ng ming,
m bo 35 - 40 Kcal/kg/ngy; 0,5 - 1g protein/kg/ngy.
+ S dng khng sinh:
Khng sinh dit khun ng rut chn lc Neomycine, Rifampicin
S dng khng sinh ton thn khi c bng chng nhim khun.
+ Thuc nhun trng: Sorbitol, Duphalac.
98
b) Cc bin php iu tr lc mu h tr gan ngoi c th

Cc bin php lc mu c tc dng loi b cc cht c sn sinh trong qu trnh
chuyn ha, nng gan v cc c quan trong lc ch i t bo gan hi phc hoc
ch i ghp gan.
- Lc mu lin tc tnh mch - tnh mch (CVVH) hoc thm tch CVVHD.
Ch nh: bnh nhn suy gan cp c suy thn cp.
- Thay huyt tng.: Thay huyt tng ch nh khi: Bilirubin > 250 mmol/l v/
hoc NH3> 150 /l v/ hoc PT > 100 giy, c bit nn thc hin sm khi trn lm
sng c biu hin hi chng no gan giai on I , II ( xem thm quy trnh k thut
thay huyt tng trong suy gan cp- Quy trnh k thut trong hi sc cp cu v
chng c B y t2014)
- Gan nhn to (liu php hp ph phn t ti tun hon MARS) dng h
tr chc nng kh c ca gan nh loi b cc sn phm chuyn ha c hi ha tan
trong nc cng nh cc cht gn kt vi protein bng h thng MARS ngoi c th,
qua huyt tng c lm sch trong khong thi gian ch i chc nng t bo
gan hi phc hoc phu thut ghp gan.( xem thm quy trnh k thut gan nhn to
trong suy gan cp- Quy trnh k thut trong hi sc cp cu v chng c B y t
2014)
c) iu tr theo nguyn nhn
- Ng c Paracetamol (v suy gan nhim c cp tnh khc): N-acetylcysteine
140mg/kg trng lng ngi bnh liu ban u gi, sau mi 4 gi mt liu 70 mg
/kg /ln (17 liu).
- Bnh l t min dch: corticoids.
- Thuc khng virus vi vim gan do vi rt.
- nh ch thai nghn (gan nhim m cp nng, hi chng HELLP ).
d) Ghp gan: cn lin h vi cc n v c th thc hin c ghp gan trong qu trnh
hi sc khi thy bnh nhn c ch nh ghp gan. Hin ti cc n v ghp gan trong
nc chn tiu chun theo King's Colllege Hospital i vi bnh nhn suy gan cp.
- Ch nh
Suy gan cp do ng c paracetamol
Suy gan cp do nguyn nhn khc
pH < 7,3 (khng ph thuc giai on
PT > 100 giy (khng ph thuc giai on
hn m); hoc: Hn m giai on III,
hn m) hoc 3/5 tiu chun sau:
IV; v PT > 100 giy v creatinin huyt + Tui < 10 tui hoc > 40 tui.
thanh > 300 mol/l.
+ Nguyn nhn vim gan non A non B,
vim gan do Halothane, phn ng thuc
khc.
+ Thi gian vng da ko di trc hn m >
7 ngy.
+ PT > 50 giy.
+ Bilirubin > 308 mmol/l.
99
- Chng ch nh: khng ch nh ghp gan nhng bnh nhn:

+ Nhim khun khng kim sot c.
+ Suy a tng.
+ Cht no.
Tin lng ph thuc vo nguyn nhn, tui v thi gian din tin bnh.
Tin lng tt khi nguyn nhn l ng c paracetamol v vim gan A, xu nht
trong vim gan non-A non-B v phn ng thuc c ng. Thi gian xut hin bnh
l no cng nh hng n tin lng. Suy gan ti cp c t l sng 35% v bn
cp ch cn 15%. Kt qu ghp gan cho suy gan cp ang c ci thin v hin
nay t c 65-75%.
7. PHNG BNH
- S dng thuc ng liu, liu
- Pht hin sm v iu tr tch cc cc ngi bnh vim gan do thuc, do
virus, vi khun v cc nguyn nhn khc
Ti liu tham kho
1. Nguyn Gia Bnh v CS (2013), Nghin cu ng dng mt s k thut lc mu
hin i trong cp cu, iu tr mt s bnh, ti khoa hc cp Nh nc.
2. V Vn nh (2000),Suy gan cp. Cm nang cp cu, Nh xut bn y hc,
Tr. 187-189.
3. Maxine A., Stephen J. (2013), Liver, biliary tract, & pancreas disorders,
Current Medical Diagnosis and Treatment, Pp. 662-800.
4. William M., Lee R. (2011), The management of Acute Liver Failure,
Hepatology: 11, Pp. 1-17.
100
Suy gan cp
X tr ban u v vn chuyn cp cu
- Ngng thuc ang ung, gy nn, ung 20g than hot + 20g
sorbitol (nu nghi ng ng c paracetamol).
- Truyn glucose 10%
- Vn chuyn n cc khoa hi sc tch cc, m bo h hp,
tun hon v t th an ton trn ng vn chuyn.
X tr ti bnh vin
Cc bin php hi sc
- Chng ph no
+ Theo di p lc s no (nu c iu kin)
+ Duy tr HA cao hn HA bnh thng,
m bo ti mu no.
+ Truyn manitol 0,5g/kg/6gi
+ Pentothal tnh mch nu c co git.
- Glucose 10 - 20% tnh mch lin tc
- B nc in gii
- Vitamin K1 10mg tnh mch
- Plasma ti, tiu cu truyn khi chy
mu hoc lm th thut.
- Thay huyt tng(PEX), gan nhn to
(MARS) thc hin khi c ch nh v
nhng n v hi sc c th thc hin
c cc k thut ny
iu tr theo
nguyn nhn
- Ng c Paracetamol
(v suy gan nhim c
cp tnh khc): Nacetylcysteine
140mg/kg trng lng
ngi bnh liu ban
u gi,sau mi 4
gi mt liu 70 mg /kg
/ln (17 liu).
- Bnh l t min dch:
corticoids.
- Thuc khng virus
vi vim gan do vi rt.
S x tr suy gan cp
101
Ghp gan
Thc hin
khi c ch
nh, ti
nhng ni
c th thc
hin k
thut
VIM TY CP NNG
1. I CNG
Vim ty cp (VTC) l mt qu trnh vim cp tnh ca ty, biu hin nhiu
mc khc nhau: mc nh ch cn nm vin ngn ngy, t bin chng. Mc
nng, bnh din bin phc tp, t l t vong cao 20-50%, trong bnh cnh suy a tng,
nhim trng.
Cc nghin cu gn y cho thy trong VTC c tng cao nng cc cytokin
trong mu IL6, IL8, TNF,thc y phn ng vim chnh l nguyn nhn dn n suy
a tng trong VTC. V vy iu tr sm l iu tr theo c ch bnh sinh khng cn ch
biu hin lm sng nh trc kia,t l t vong gim t 40-50% xung cn 10-15%.
2. NGUYN NHN
- Lm dng ru l nguyn nhn ph bin Vit nam.
- Nguyn nhn c hc:si mt,si ty , l nguyn nhn ng hng th 2.
- Do ri lon chuyn ha:
+ Tng tryglycerit mu l nguyn nhn ngy cng hay gp Vit nam.
+ Tng canxi mu: nh u tuyn gip, cng cn gip...
- Sau phu thut: nht l phu thut bng gn ty, quanh ty.
- Sau ni soi mt ty ngc dng (ERCP).
- Do chn thng, bm dp vng bng.
- Sau ghp tng: nh cc bin chng sau ghp gan, thn.
- Gan nhim m cp thi k c thai.
- Do nhim trng: quai b, vim gan virus, giun a.
- Do thuc: sulfonamide, 6MP, furosemide, ethanol, oestrogen...
- Bnh l t chc lin kt: lupus ban h thng, vim mao mch hoi t,
Schonlein Henock...
* Khng r nguyn nhn: 10% cc trng hp.
3. TRIU CHNG
Triu chng lm sng ca VTC xy ra ht sc cp tnh, t ngt, din bin
phc tp, c th c cc du hiu ngoi khoa xen ln, c bit trong VTC hoi t.
a) Triu chng c nng: Bao gm cc du hiu sau
- au bng: l du hiu ni bt nht, thng xut hin mt cch t ngt
vng thng v, c th lan ln ngc, ra hai mng sn hai bn, xin ra sau lng. au
lin tc, d di ko di nhiu gi, c th au khi pht sau khi n. Cng c khi khi
pht t nhin.
- Nn: a s ngi bnh c nn hoc bun nn, lc u nn ra thc n, sau
nn ra dch, nn xong c th au hoc khng.
102
- B trung i tin: do tnh trng lit rut c nng, ngi bnh khng trung tin,
khng i ngoi, bng trng v y tc kh chu.
- Kh th: do au, do trn dch mng bng, mng phi.
b) Triu chng ton thn
- St: thng c st nh, c th st cao v vim nhim ng mt do si, giun
hoc do hoi t ty rng.
- Mch, huyt p:
+ Vim ty cp th nh: tnh trng ton thn thng khng trm trng, ngi
bnh mt mi nhng tnh, mch, HA n nh, khng kh th.
+ Vim ty cp th nng: c th c tnh trng sc, v m hi, chn tay lnh, nht
nht, tinh thn chm chp, mch nhanh, HA tt, ngi bnh ht hong, kch ng hoc
ngc li nm l , mt mi, c nhng mng bm tm chn tay, thn th, th nhanh
nng.
c) Triu chng thc th
- Bng chng: bng chng u, c khi chng vng trn rn nhiu hn, g
vang do lit rut c nng, khng c quai rut ni, rn b nh trong tc rut c hc. Khi
bng c nhiu dch c th g c vng thp.
- Phn ng thnh bng: c th phn ng cc b hay ton b vng trn rn, xut hin
h sn bn phi khi nguyn nhn gy VTC l si mt.
- Mng cng trn rn: c th s thy mng cng vng thng v, c khi lan
sang hai vng di sn, ranh gii khng r, khng di ng, n au, cm gic ngay
di tu do hin tng hoi t m.
- im sn lng mt hay hai bn au: c hu ht cc ngi bnh VTC, im
au ny c Mayo-Robson v Korte m t t nm 1906, c Tn Tht Tng cho l
mt triu chng quan trng ca VTC.
- C triu chng vng da km gan to khi nguyn nhn lin quan vi ti mt to
do si, giun hoc si ng mt gy tnh trng mt hoc do vim gan.
- Trng hp nng (nht l trong VTC th hoi t) c th gp cc mng bm
tm di da hai bn mng sn (du hiu Grey Turner) hay quanh rn (du hiu
Cullen), y l du hiu rt c hiu, biu hin s chy mu vng ty v quanh ty.
a) Sinh ha
- Amylase mu tng > 3 ln bnh thng c 70% cc trng hp (tng sau 1 2 gi au, tng cao sau 24 gi v bnh thng sau 2 - 3 ngy).
- Lipase tng c gi tr chn on hn l tng amylase.
- CRP tng c ngha tin lng.
- Cytokine huyt thanh tng ( IL6, IL8, TNF..) xt nghim rt c gi tr . tuy
nhin xt nghim ny mi ch thc hin cc n v thc hin nghin cu.
b) Huyt hc
- Bch cu tng, trung tnh tng, Hematocrit tng do mu c c.
103
- Ri lon ng mu nhng ngi bnh nng. Thng hay c du hiu ca

ng mu ni qun ri rc ( DIC).
c) Chn on hnh nh
- Xquang bng.
+ Bng nhiu hi.
+ Cc quai rut gn ty gin.
- Siu m (khng thc hin c khi bng chng hi).
+ Ty to ton b hoc tng phn (u, thn hoc ui).
+ ng vin xung quanh ty khng r rng, mt khng u, gim m hoc
m vang hn hp.
+ C th c dch quanh ty v cc khoang trong bng.
- Ct lp vi tnh (CT scan) c gi tr nht trong chn on
+ Ty to ra hoc bnh thng.
+ B khng u, c th c hnh nh hoi t, cho bit mc tn thng
quanh ty v xa ty.
4. CHN ON
4.1. Chn on xc nh: chn on xc nh VTC theo tiu chun Atlanta sa i 2007.
a) Lm sng
au thng v t ngt, au d di, au xuyn ra sau lng km theo bun nn
v nn.
b) Cn lm sng
- Amylase v /hoc lipase mu tng cao trn 3 ln so vi gi tr bnh thng.
- Cytokine huyt thanh tng.
- Chn on hnh nh: c hnh nh in hnh ca VTC trn siu m hoc chp CT:
+Siu m: Ty to ton b hoc tng phn (u, thn hoc ui), ng vin
xung quanh ty khng r rng, mt echo khng u, gim m hoc m vang hn
hp, c th c dch quanh ty v cc khoang trong bng.
+ CT: Ty to ra hoc bnh thng, b khng u, c th c hnh nh hoi t,
cho bit mc tn thng quanh ty v xa ty.
4.2. Chn on phn bit
- Thng d dy: Ngi bnh c tin s d dy hay khng, au d di, bng co
cng, XQ c lim hi.
- Tc rut: au bng, nn, b trung i tin, XQ c mc nc, mc hi.
- Cn au bng gan:
+ C tam chng Charcot.
+ Siu m thy c si, u.
- Vim phc mc: c hi chng nhim khun, co cng ton bng, thm ti cng
Douglas au.
- Nhi mu mc treo (him): au d di t ngt, tng cn, c a ra mu,
m thm d mi bit c.
104
- Nhi mu c tim: au tht ngc, in tm c nhi mu c tim.

- Phnh tch ng mch ch bng : au bng, huyt p gia tay v chn chnh
lch nhiu, siu m hoc CT-scan bng c bm thuc cn quang s pht hin c.
4.3. Chn on mc ca VTC
C nhiu thang im c xy dng nh gi mc nng ,nh ca
VTC, cc thang im hay s dng l:
- Thang im APACHEII: ngi bnh c im APACHEII <8 l VTC
nh;ngi bnh c im APACHEII 8 l VTC nng.
- Thang im Ranson: nu ngi bnh c <3 yu t trong 11 yu t l VTC
nh;nu c 3 trong 11 yu t l vim ty cp nng, cng nhiu yu t th tnh trng
cng nng v tin lng cng xu.
- Thang im Glasgow (imrie): ngi bnh c < 3 yu t trong 8 yu t l VTC
nh; ngi bnh c 3 trong 8 yu t l vim ty cp nng, cng nhiu yu t tnh
trng cng nng v tin lng cng xu.
- Da vo chp ct lp vi tnh (thang im Balthazar sa i) (da theo mc
ph ty v mc hoi t), nu im Balthazar < 7 im l VTC nh v nu 7 im
l vim ty cp nng.
- Da vo p lc bng t bnh nhn VTC khng c tng p lc bng hoc
tng nhng I (< 21cm H2O) l VTC nh v bnh nhn tng p lc bng t II
tr ln ( 21 cm H2O) l VTC nng.
(cc thang im xin xem trong ph lc)
Chn on VTC nng theo tiu chun hip hi ty hc th gii 2007
* Giai on sm (tun u)
- VTC nng c nh ngha khi ngi bnh c hi chng p ng vim h
thng (SIRS) v/hoc pht trin thnh suy tng.
- Ngoi ra, nu ngi bnh VTC trn c a: suy thn, bnh l tim mch, suy
gim min dch u c coi l VTC nng.
* Giai on sau 1 tun
Sau 1 tun, VTC nng c nh ngha khi c suy t nht 1 tng v ko di trn
48 gi. Chn on suy tng da vo thang im Marshall chung cho ngi bnh vim
ty tt c cc khoa lm sng, iu tr. Vi ngi bnh nm HSTC cn s dng
thang im SOFA nh gi vo theo di suy tng.
(Suy tng c nh ngha khi im Marshall hoc im SOFA cho tng 2
im. Suy a tng c nh ngha khi c 2 tng suy ko di 48 gi).
5. X TR
5.1. Nguyn tc x tr
- Ngi bnh VTC nng cn c vo vin iu tr ti cc n v HSTC.
- Theo di v nh gi v tun hon, h hp, chc nng gan, thn, suy a tng
hn ch ti a cc bin chng do VTC gy nn.
- Nguyn tc iu tr: iu tr sm, tch cc v theo di cht ch.
105

- t 1-2 ng truyn ngoi vi c 14-16 G b dch 3-4 lt dch mui ng
trng, nu nn th t ng thng d dy dn lu.
- Gim au bng paracetamol 1g truyn tnh mch trong 15 pht.
- m bo h hp trn ng vn chuyn.
a) Cc bin php iu tr hi sc chung
- Hi sc tun hon:
+ Ngi bnh VTC nng thng mt mt lng dch rt ln ngay khi bt u nhp
vin, truyn mt lng dch khong 250-300 ml/gi trong 24 gi, nu nh tnh trng tun
hon ca ngi bnh cho php. Thc t lm sng trong 24 gi u ngi bnh cn b t
4-6 lt dch mui ng trng.
+ Ngi bnh VTC nng c bin chng, nn t ng truyn tnh mch trung
tm (TMTT) truyn dch, a thuc, nui dng v duy tr ALTMTT t 8-12 mmHg,
ALTMTT c th khng chnh xc khi c tng p lc bng.
+ Theo di v nh gi tun hon nn da vo cc du hiu ti mu : da m,
ht vn tm, theo di lng nc tiu tng gi m bo > 0,5ml/kg cn nng/gi.
+ Thuc vn mch ch nh khi nng c ALTMTT t 8-12 mmHg m HA
trung bnh cha t 65mmHg, thuc s dng l: noradrenalin, adrenalin. Liu thuc cn
thm d v nng dn m bo duy tr HA. Thuc tr tim dobutamin ch c s dng
khi c bng chng suy tim, liu lng ti a l 20g/kg cn nng/pht.
- Hi sc h hp
+ Cung cp oxy v bo ha oxy mu ng mch yu cu phi t trn 95%.
+ Trn dch mng phi, xp phi, vim y phi do dch vim, tng p lc bng,
ARDS l nhng yu t dn n tnh trng suy h hp nng ngi bnh VTC.
+ Cc bin php bao gm: th oxy knh mi, oxy mt n, th my khng xm nhp,
th my xm nhp c bit vi ARDS (chin lc thng kh bo v phi).
+ Chc tho v dn lu dch mng phi, dn lu dch ty gim tng p lc bng.
- Hi sc thn:
+ Bi ph dch sm ngay t u, m bo ti mu, hn ch qu trnh hnh
thnh suy thn cp thc tn.
+ Lc mu lin tc: p dng giai on sm trong 3 ngy u ca VTC nng,
l bin php c chng minh c th loi b cc cytokin v yu t gy vim, nh
c th ngn chn phn ng vim lm gim mc tn thng cc tng.
+ Nhng ngy sau nu c suy thn, huyt p n nh ch cn lc mu ngt
qung.
- Hi sc chng au: dng cc thuc tim tnh mch gim au khng phi steroid hoc
thuc gim au c cha opi. Trnh dng morphin v c th gy co tht c vng oddi.
- Khng sinh:
106
+ Khng dng khng sinh d phng thng quy cho ngi bnh VTC nng.
Ch nh khi c bng chng nhim khun r hoc c nguy c nhim khun cao (ty
hoi t nhiu, nghi ng p xe ty).
+ Cc nhm khng sinh thng c dng trong VTC c hoi t hoc nhim
khun l cephalosporin th h III, carbapenem, nhm quinolone, Metronidazol.
- Nui dng:
+ Nui dng ng tnh mch trong vng 24 - 48 gi u, sau cho ngi
bnh n sm qua ng ming, qua ng thng d dy vi s lng tng dn ty theo
kh nng dung np ca tng ngi bnh. Khi cho n li theo di cc triu chng au
vng thng v, bun nn v nn, tng p lc bng.
+ Trong 48-72 gi, ngi bnh khng nng lng qua ng tiu ha cn
kt hp nui dng tnh mch cho ngi bnh m bo nng lng 25-30kcal/kg
/24 gi.
+ u tin n qua ng thng cc cht lng, sau cho n c hn, khi ngi
bnh khng cn cc triu chng bun nn chuyn sang ch n qua ng ming.
+ Ch n c khuyn co: t l protid v glucid cao, cn t l lipid thp.
- Mt s bin php iu tr h tr khc
+Thuc lm gim tit dch tiu ha v c ch men ty: hin nay hay dng
sandostatin hay stilamin, cha c nghin cu no bo co hiu qu r rt trong vic
lm gim bin chng cng nh t l t vong ca VTC.
+ Thuc chng ng: s dng khi c bin chng ng mu ni mch ri rc do
tng ng mu v do hot ha c ch tiu si huyt.
+ Khng tit axit dch v: c th dng ngn nga lot, xut huyt tiu ho do
stress ng thi cng dng c ch tit dch ty v dch v.
b) Lc mu lin tc trong iu tr VTC
- Ch nh: Ngi bnh VTC nng n sm trong vng 72 gi u hoc c suy
a tng ngi bnh n mun.
- Phng php : Lc mu lin tc tnh mch tnh mch vi th tch thay th
ln 45 ml/kg th trng/gi.
c) Dn lu bng qua da
Ch nh khi:
- Cc t dch trong VTC thng nm trong hu cung mc ni, khoang trc
thn, lan dc theo rnh i trng xung h chu hoc nm sau phc mc. Cc ng
vo cn trnh i trng, rut non, gan, lch, thn ng thi gim thiu ti a nguy c
nhim trng v chy mu.
- Cc dch vng ui ty c th dn lu qua khoang trc thn tri, trnh i
trng xung pha sau. Tng t nh vy cc dch vng u ty c th dn lu qua
khoang trc thn phi.
107
Phng php:
- C th t dn lu bng qua da bng phng php Seldinger hoc bng
phng php Trocar ty theo kinh nghim v trang thit b sn c. i vi cc dch
hoi t c, dn lu khng ht cn thay dn lu c kch thc to hn.
- Dch ty vim c bit l dch ty hoi t thng kh c do dn lu tt
cc t dch ty vim cn la chn cc catheter c nhiu l bn v ng knh ti
thiu 12-14F. i vi t dch ln hoc nhiu t dch c th cn nhiu ng thng
hn.
- Rt dn lu bng khi: s lng dch t hn 30 ml/24 gi
d) Phu thut ngi bnh VTC khng do si
- M bng gim p:
+ Ch nh trong trng hp p lc bng tng cao 25mmHg,c triu chng ca
hi chng tng p lc bng m cc bin php hi sc trn khng t kt qu. Tuy nhin,
ch nh v thi im phu thut hin vn cn nhiu tranh ci c trong nc cng nh trn
th gii v nguy c nhim khun rt cao.
+ ng bng li cng sm cng tt thng sau 5-7 ngy khi ngi bnh bt u
hi phc. Cc bin chng qua m thnh bng: nhim trng bng, r, vim dnh, tch t
khoang dch trong bng.
- Mt s ch nh phu thut khc:
+ Chy mu cp trong bng do VTC hoi t n mn vo mch mu gy mt
mu trong bng cp nhiu (Ht < 25%, v kh nng truyn mu ti ch b hn ch)
cn phu thut cm mu cp cu.
+ p xe ty: cn phi m dn lu.
+ Nang gi ty: nhng nang ny c th t tiu, ch nh phu thut cho nhng nang
gi > 6cm v ko di > 6 tun. C th dn lu qua da vi cc nang nng, st thnh
bng, hoc qua d dy bng phng php ni soi nu dch nm cnh d dy (thnh cng
75% cc trng hp) cn li phi phu thut.
e) iu tr nguyn nhn gy VTC
- Vim ty cp do si, giun ng mt, ng ty.
- Cht hp ng mt do si hoc do u ti nm valter:
+ Ly si ng mt ra sm bng can thip iu tr ni soi (ERCP- Ct c
Oddi, s dng cc ng thng c bng hi km theo (Balloon Catheter) ly si trong
ng mt trong ngy th 2 hoc th 3 s lm gim bt mc nng ca VTC.
+ Ch nh phu thut ly si cp cu: thc hin khi khng can thip c k
thut ni soi ERCP hay tht bi v tnh trng nhim trng tc mt ngi bnh nng ln
m iu tr ni khoa khng c kt qu.
- Vim ty cp si ti mt: phu thut ni soi ct ti mt ch c p dng t
nht sau 3 tun, khi m VTC bnh phc, nu ct b ti mt sm th s lm tng
nguy c nhim trng.
108
- Vim ty cp do tng triglycerid:

+ Cn c iu tr cp cu tng t nh VTC do cc nguyn nhn khc; Cc bin
php nng bao gm nui dng, dch truyn tnh mch, thuc gim au nu cn thit
v cc bin php hi sc khc.
+ Thay huyt tng:
Bin php loi b trc tip cc lipoproteins bng thay huyt tng, ch nh khi
triglycerid mu >11mmol/l.
S dng mng lc kp (double filtration) hiu qu iu tr tt hn, nhanh hn.
+ Dng thuc gim triglycerid mu.
- Bin chng nguy him nht l suy a tng, l nguyn nhn t vong cao nht.
VTC nng cng c nhiu tng suy nguy c t vong s cng cao.
- Mt s bin chng ti ch khc nh : chy mu, p xe ty v nang gi ty.
7. PHNG BNH
- Hn ch ung ru,bia.
- Pht hin v iu tr si mt, si ty.
- Ngi bnh tng triglyceride cn iu tr thng xuyn v kim sot ch n hp
l.
Ti liu tham kho
1 Nguyn Gia Bnh v CS (2013), Nghin cu ng dng mt s k thut lc
mu hin i trong cp cu, iu tr mt s bnh, ti khoa hc cp Nh
nc.
2 V c nh, Tt Cng, Nguyn Gia Bnh (2011), "Nghin cu hiu qu
ca liu php lc mu lin tc trong vim ty cp nng, Tp ch Y hc thc
hnh, 783, tr. 35-38.
3 Pupelis G., Plaudis H., Grigane A., Zeiza K., Purmalis G. (2007), Continuous
veno venous haemofiltration in the treament of severe acute pancreatitis: 6
years experience", HPB, 9, pp. 295-301.
4 Rupjyoti T. et al. (2011), "Early management of severe acute pancreatitis",
Curr Gastroentorol Rep, 13, pp.123-30.
5 Santhi swaroop vege (2013), Treatment of acute pancreatitis,
[updated110.8.2013], UPL: http://www.uptodate.com/contents/treatment-ofacute pancreatitis
109
Vim ty cp nng
- t 1-2 ng truyn ngoi vi c 14-16 G b dch 2-3 lt dch
mui ng trng,nu nn th t ng thng d dy dn lu.
- Gim au bng paracetamol 1g truyn tnh mch trong 15 pht
- Vn chuyn n cc khoa hi sc tch cc, m bo h hp,
tun hon v t th an ton trn ng vn chuyn.
X tr ti bnh vin
Cc bin php hi sc ni khoa

- Tun hon: t ng truyn tnh mch
trung tm, truyn dch 250 - 300ml/24
gi (mui ng trng) 4 - 8 l/24 gi
u.
- H hp: cung cp oxy v bo ha oxy
ng mch > 95% (th oxy knh mi,
oxy mask, th my khng xm nhp,
xm nhp).
- Gim au: thuc gim au non steroid
hoc thuc gim au c cha Opi (khng
dng morphin).
- Khng sinh: khi c bng chng nhim
khun.
- Nui dng: tnh mch trong 24 - 48 gi
u, sau cho n ng ming s
lng tng dn.
- Thuc gim tit: khng tit acid dch v
(c ch bm proton); sandostatin hay
stilamin.
Cc bin php can

thip khc
- Lc mu lin tc: VTC
nng n sm trong
vng 72 gi u, tnh
mch - tnh mch, th
tch thay th ln
45ml/kg/gi.
- Dn lu bng qua da:
bng Seldinger hoc
trocar i vi cc
trng hp c t
dch trong bng c
ng vo di hng
dn ca siu m hoc
chp ct lp vi tnh.
S x tr vim tu cp nng
110
iu tr nguyn
nhn
- VTC do si: ni
soi ly si; phu
thut nu khng
thc hin c ni
soi.
- VTC do tng
triglycerid:
thay
huyt tng khi
triglycerid
11mmol/l; s dng
cc thuc lm gim
triglycerid.
Chng IV: THN TIT NIU

HI CHNG TIU C VN CP
1. I CNG
Tiu c vn (Rhabdomyolysis-TCV) l mt hi chng trong cc t bo c
vn b tn thng v hu hoi dn n gii phng mt lot cc cht trong t bo c
vo mu: kali, axit uric, myoglobin, axit lactic, cc enzym: creatine kinase (CK), AST,
ALT dn n ri lon nc in gii, toan chuyn ho, sc, tng kali mu, hi
chng khoang, ngoi ra myoglobin cn lm tc ng thn gy suy thn cp.
TCV c bit t nm 1941 sau trn nm bom Lun n, c Bywaters
v Beall m t vi tn gi hi chng vi lp.
2. NGUYN NHN
2.1. Nguyn nhn
- Nguyn nhn chn thng : chn thng nng, hi chng vi lp, in git,
bng nhit nng
- Nguyn nhn ni khoa:
+ Ng c ( ri, thuc an thn . strychnine, rimifon v cc cht gy co git
khc ,thuc ng, ).
+ Do thuc: cc thuc nhm statin, cocain, heroin, cc ma ty tng hp.
+ Hn m hoc bt ng lu (tai bin mch mu no..).
+ Co git ton thn nng v ko di hoc vn ng c qu mc.
+ Nc c : Rn cn, ong t,
+ Mt s loi nhim trng : un vn, vi khun, virus.
+ Thiu mu cc b cp tnh: tc ng mch cp tnh do chn p, do hi, do cc
mu ng sau cc k thut xm lm mch mu
- Mt s trng hp khc: tng, hoc h thn nhit ko di, gim kali mu,
gim natri mu, nhin toan xtn, hn m tng thm thu, vim da-c, suy gip, thiu
mt s men chuyn ha.
2.2. Cc yu t nguy c suy thn cp do tiu c vn cp
- Sc do chn thng nng.
- Huyt p tm thu < 90 mmHg.
- Creatine kinase (CK)> 15.000 n v /ml.
- Suy h hp cp.
- iu tr mun > 12 gi.
3. TRIU CHNG
3.1. Lm sng
- Triu chng c trng: mc v triu chng ty thuc vo nguyn nhn
+ au c, mc au c. Ch in hnh bnh nhn chn thng, cc bnh
nhn ni khoa thng t triu chng in hnh.
111
+ Nc tiu mu nu sau chuyn mu nu en.

+ Tng men CK (CK tng, t l CKMB/CK ton phn < 5% ).
- Cc triu chng khc: st, nhp tim nhanh, nn v bun nn, au bng. Ri
lon tm thn c th do nguyn nhn gy bnh (v d: chn thng, ng c, ri lon
in gii).
3.2. Cn lm sng
- Xt nghim CK mu trn1000 n v /ml, t l CKMB/CK <5%.
- Ur, creatinin tng.
- A xit uric, AST, ALT tng.
- Kh mu (thng thy toan chuyn ho : pH v HCO3- mu gim).
- in gii : Gim natri, canxi. Tng kali v phospho (ch : c th tng rt
nhanh kali dn ti ngng tun hon, cn lm xt nghim nhiu ln v theo di in tim
lin tc).
- Cc xt nghim khc phc v cho chn on nguyn nhn.
- Chn on hnh nh:ph thuc vo nguyn nhn gy ra tiu c vn cp.
4. CHN ON
4.1. Chn on xc nh
- C mt nguyn nhn gi dn n tnh trng TCV cp.
- Xt nghim gip chn on xc nh.
+ Men CK mu trn 1000 n v /ml (gp 5 ln bnh thng), t l CKMB/CK <5
+ Loi tr cc nguyn nhn khc : nhi mu c tim , nhi mu no.
+ C hemoglobin hoc myoglobin trong nc tiu, nc tiu mu nu.
4.2. Chn on phn bit
- Nhi mu c tim cp: lm sng c au ngc , c nhng thay i trn in tim:
ST chnh, sng Q . T l CKMB/CKton phn > 5%, troponin T tng trn 0,05 U/l,...
- Nhi mu no mi: CK tng, km theo cc du hiu thn kinh khu tr. C
hnh nh nhi mu no trn chp CT scan hoc MRI
- i mu v i ra hemoglobin.
- Bnh vim c t min.
- Huyt khi tnh mch su.
5. X TR
5.1. X tr chung
a) m bo cc bc hi sc cp cu ban u c bn
- A (Airway) m bo thng thong ng th.
- B (Breathing), m bo h hp.
- C (Circulation) m bo tun hon
b) nh gi tn thng
- nh gi cc tn thng.
- Lp k hoch x tr tm thi c bit lu ct sng c, s no
112
c) m bo khi lng dch truyn

- Cn bng dch vo ra, phng v iu tr cc ri lon in gii, toan kim.
- t catheter truyn dch
- Dch truyn: lu khi ngi bnh c CK > 5000 UI/L. Truyn dch ng
trng c pha kali, t nht 100-200 ml/gi, m bo nc tiu 200-250ml/gi. Theo
di kali, natri mu 2- 3 ln / ngy. Ch tng gnh th tch tha dch ngi bnh
cao tui, c tin s suy tim, bnh mch vnh cp hoc mn tnh.
- Bicarbonate: kim ha nc tiu, pH nc tiu khong 6,5. pH mu di 7,5
v HCO3 di 30 mmol/l. Ch phng h Canxi mu.
- Li tiu quai (furosemid 20 - 40 mg tnh mch mi ln) hoc manitol 1-2
g/kg/ngy, ch nh khi truyn dch v s lng nc tiu t hn nhiu so vi lng
dch a vo c th.
- iu tr cc ri lon in gii: h canxi mu, tng kali mu, tng axit uric, tng
phosphat mu.
d) iu tr nguyn nhn
- Xc nh nguyn nhn gy ra gii quyt nguyn nhn, ng thi xc nh
ngi bnh c nguy c suy thn cp hay khng?
- Nu c th iu tr ngay theo phc iu tr suy thn cp ngi bnh tiu
c vn cp.
5.2. iu tr suy thn cp, tng kali mu cp
- Nu suy thn cp (iu tr theo phc suy thn cp): cn bng nc in
gii, kim toan, m bo dinh dng.
- Lc mu khi c ch nh.
- Dng cc thuc cn iu chnh liu cho ph hp, theo mc lc cu thn.
5.3.iu tr hi chng khoang
- Khm nhiu ln, nh gi tin trin v mc tn thng ca cc du hiu
mch, thn kinh, phn mm
- Rch bao cn c gim p (fasciotomy): khi khng s c mch chi b
tn thng, ch trnh rch vo ng mch hoc cc dy thn kinh hn ch cc nguy
c nhim trng bao gi cng c.
- Ct ct nu khng bo tn c na.
6. BIN CHNG
- Ri lon nc (do nc tch t trong c), c th dn n sc do gim th tch
trong lng mch, v hi chng khoang.
- Ri lon in gii (h natri, can xi , tng kali, phospho).
- Toan chuyn ha.
- ng mu ri rc trong lng mch (DIC).
- Suy thn cp.
- Suy a tng.
113
7. PHNG BNH
- Phi ngh n tiu c vn cp nu ngi bnh nm lu, ng c nng hoc c
tng men CK hoc mu sc nc tiu sm mu.
- Nu nghi ng c th xy ra tiu c vn, tin hnh truyn dch y vi tc
1000-2000 ml/gi v cho thuc li tiu duy tr lng nc tiu 150 200ml/gi, iu tr cng sm cng tt.
Ti liu tham kho
1. Nguy n Gia Bnh (2003), c i m lm sng , sinh h c v i u tr suy th n
c p do tiu c vn c p . Lu n n ti n s y h c - Trng i h c Y H n i.
2. V Vn nh (2003), H i chng tiu c vn c p, H i sc c p cu ton t p.
Nh xu t b n y h c, Tr. 277.
3. V Vn nh (2003), Suy th n c p, H i sc c p cu ton t p. Nh xu t
b n y h c, Tr. 263.
4. Counselman. F.L, Lo B.M (2014). Rhadomyolysis Tintinallis Emergency
Medicine : A comprehensive study guide (Editor : Tintinalli J.E, Stapczynski
J.S, Ma O.J, Cline D.M, Cydulka R.K, Meckler G.D), The American College of
Emergency Physicians. 7th edition.
5. Alardin A.L.H., Varon J., Marik P.E. (2005), Bench-to-bedside review:
Rhabdomyolysis an overview for clinician, Crit Care. 9(2), Pp. 158169.
6. Bosch X., Poch E, Grau J. (2009), Rhabdomyolysis and Acute Kidney Injury,
N Engl J Med 361, Pp. 62-72.
7. Miller M.L. (2013),Causes of rhabdomyolysis. Uptodate.
8. Miller M.L. (2013), Clinical manifestations and diagnosis of
rhabdomyolysis. Uptodate
114
BN tiu c vn cpc nguy c suy thn
m bo h hp
t catheter o p lc tnh mch trung tm (ALTMTT)
Truyn NaCl 0,9%, cao phn t (mu nu cn)

Duy tr ALTMTT 8-10cm H2O
Thuc vn mch:Dobutamin, Dopamin, Noradrenalin

iu chnh sao cho huyt p tm thu > 90 mmHg
Nc tiu < 30ml/gi
Nc tiu > 50ml/gi
Lasix(400-200mg) bolus
sau tip tc 20-40mg IV
p ng
(nc tiu >
200ml/gi)
Tip tc cho
n khi ht yu
t nguy c
Manitol 20% 200ml

truyn TM 6gi/ln
Khng p
ng
Khng p
ng
Lc mu
khi c ch nh, ch
thn hi phc
Ngng manitol
chuyn sang lasix
Ch :
Chnh tc truyn theo ALTMTT
o ALTMTT sau mi gi quyt nh tc truyn.
Lc mu nhn to: cho n khi thn hi phc ( trung bnh khong 2-6 tun )
Phc iu tr suy thn cp do tiu c vn cp
115
p ng
(nc tiu >
200 ml/gi
Tip tc cho
n khi ht yu
t nguy c
SUY THN CP
1. I CNG
nh ngha: Suy thn cp l mt hi chng c biu hin bng s gim nhanh
ca mc lc cu thn vi th tch nc tiu < 0,5 ml/kg/gi ko di trn 6 gi, v c
nng creatinin huyt tng tng thm 0,5 mg/dl (44g/l) hoc trn 50% so vi gi
tr bnh thng (trn 130g/l) ngi trc chc nng thn bnh thng.
Hu qu: ng cc sn phm chuyn ho ca nit, ri lon cn bng nc,
in gii, axit-baz.
nh ngha mi: theo phn loi RIFLE
Phn mc
MLCT hoc Creatinin
Th tch nc tiu
RIFLE
hthanh
R- risk
Creatinin hth x 1,5 ln
< 0,5 ml/kg/gi trong 6 gi
Nguy c
hoc gim GFR> 25%
I- injury
Creatinin hth x 2 ln
Tn thng
hoc gim GFR> 50%
F- failure
Creatinin hth x3 ln
Suy
hoc gim GFR> 75%
hoc v niu trong 12 gi
L- loss
Mt ch/n thn hon ton > 4
Mt
tun
E-end-stade kidney Cn RRT di > 3 thng
disease
(Suy thn giai on cui >3
Giai on cui
thng)
GFR: mc lc cu thn; RRT: iu tr thay th thn
(Theo ADQI 2003 v theo KDIGO Clinical Practice Guideline for Acute Kidney
Injury 2012)
2. NGUYN NHN
2.1. Suy thn cp trc thn
a) Gim th tch tun hon
- Mt mu: chn thng, chy mu tiu ho, hoc chy mu khc.
- Mt dch trong lng mch: bng, vim phc mc, vim ty cp, tc rut, h
albumin mu, hi chng thn h, x gan, a chy, nn, ht dch tiu ho. Tiu c vn
cp.
- Mt qua thn: i ng toan xeton, tng p lc thm thu mu nh (s dng
manitol, tng natri mu), hoc gim kali mu, gim canxi mu.
- Mt qua da: mt m hi, bng nng, vn ng nng ko di (chy marathon
hay lm vic nng trong mi trng nhit cao), ri lon iu ho thn nhit (hi
chng tng thn nhit c tnh ), say nng say nng
- Gim th tch tun hon lin quan n gim cung lng tim : nhi mu c tim,
sc tim, trn dch mng tim c p tim, nhi mu phi, lon nhp tim.
116
b) Do mch thn
- Tc tnh mch mch thn.
- Co tht mch thn (dng thuc c ch men chuyn bnh nhn suy tim
huyt) hoc dng noradrenalin khi cha truyn dch ).
- Nhi mu ng mch thn.
- Hp ng mch thn.
- X va mch thn.
- Phnh tch ng mch ch bng.
c) Ri lon iu ho mch thn
- Nhim trng.
- Do prostaglandin hoc c ch men chuyn.
- Hi chng gan thn: c gin mch h thng dn n tt huyt p, thiu niu
do co tht mch thn cng vi ri lon chc nng gan nng. C ch bnh sinh cha r.
2.2. Suy thn cp ti thn
a) ng thn: ph bin nht gy suy thn cp.
- Thiu mu: do tnh trng suy thn trc thn nng v ko di.
- Do thuc: thuc khng sinh (aminoglycoside, cephalosporin, amphotericinB),
thuc cn quang c iode, kim loi nng, ho cht iu tr (cisplatin).
- Suy thn cp th pht sau nhim khun nng, iu tr mun: gim dng mu
ti thn gy tn thng thiu mu, mt kh nng t iu ho mch thn v co mch
thn.
- Tc ng thn do sn phm phn hu t t bo: hemoglobulin v myoglobulin
niu (tiu c vn, tan mu, tn thng c do nhit), myeloma, cc tinh th mui
oxalate, urat.
- Mang thai: sn git, chy mu t cung...
b) Vim thn k
- Nhim trng: vi khun (streptococcus, pneumococcus), virt (EBV, CMV,
HIV), nm, Mycoplasma.
- Thm nhim: lymphoma, sarcoidosis.
- Khng sinh: penicilin, rifampicin, vancomycin, quinolone, cephalosporin..,
acyclovir, ethambutol.
- Li tiu: thiazide, furosemide.
- Cc thuc khc: thuc chng vim gim au khng steroide, c ch men
chuyn, allopurinol.
c) Nguyn nhn do cu thn: bnh mch mu v mng y cu thn.
- Bnh khng th khng mng y cu thn: hi chng Goodpasture.
- Bnh l mch mu: vim mch Wegener, vim mch, tng huyt p c tnh.
- Do thuc: cyclosporin, amphotericin B, cisplatin ...
- Hi chng tan mu tng ure mu (HUS), hi chng tan mu gim tiu cu
(TTP).
117
2.3. Suy thn cp sau thn

- Tc ng thn: axt uric, canci oxalat, acyclovir, methotrexate, protein Bence
Jone trong bnh a u ty xng.
- Tc nghn ti thn: cc mu ng, si, hoi t nh.
- Tc niu qun: si niu qun, do chn p t ngoi vo v d u sau phc mc, u
t cung, u x tin lit tuyn, u niu o, bng quang, buc nhm niu qun trong m
...
- Tc niu o: co tht niu o, bnh l tuyn tin lit, khi u bng quang.
3.TRIU CHNG
3.1. Lm sng: in hnh tin trin qua 4 giai on.
a) Giai on 1:
24 gi u, mt, bun nn, nn, kh th, au ngc, nc tiu t dn, v niu.
Triu chng ca nguyn nhn gy ra suy thn cp nh ng c, nhim khun, mt
nc. iu tr kp thi v ng c th trnh tin trin sang giai on 2.
b) Giai on 2: ton pht vi cc triu chng nng v cc bin chng c th t vong.
- Ko di 1-6 tun, trung bnh sau 7-14 ngy ngi bnh s c nc tiu tr li.
- Thiu, v niu, ph. Tu theo th bnh m v thiu niu xut hin rt nhanh,
ng thi c triu chng tha dch nh ph phi, suy tim huyt.
- Ur, creatinin mu tng nhanh. Cc triu chng ca tng ure mu nh chy
mu ni tng, vim mng ngoi tim, biu hin ri lon no.
- Ri lon in gii, tng kali mu gy ra cc ri lon nhp tim nh sng T cao,
QT ngn, ngoi tm thu tht, rung tht, xon nh.
- Toan chuyn ho: pH, HCO3 mu gim, c khong trng anion. Ngi bnh
th su, gin mch, tt huyt p.
c) Giai on 3: i tr li, trung bnh 5-7 ngy
- C li nc tiu 200-300ml/24gi, lng nc tiu tng dn 4-5lt/24gi.
- Cc nguy c: mt nc do i nhiu, vn tng ur, kali mu, ri lon in gii
d) Giai on 4: hi phc, tu theo nguyn nhn ( 2-6 tun), trung bnh khong 4 tun.
3.2. Cn lm sng
- Nng creatinin huyt tng, ure huyt tng.tng
- Ri lon in gii mu. Toan chuyn ha pH gim, HCO3, d tr kim gim.
- Cc xt nghim khc nhm chn on phn bit, gi nguyn nhn:
+ Thiu mu, c mnh v hng cu: hi chng tan mu tng ure mu, tan mu
vi mch, vim ni tm mc, ng mu ni qun ri rc.
+ Canxi mu tng km theo suy thn cp: thng lin quan bnh c tnh ph
hy xng.
+ Men creatine kinase (CPK) tng > 6000 n v hoc c myoglobulin trong
nc tiu: tiu c vn.
+ Bt thng v in di min dch: gi nguyn nhn myeloma.
118
+ Xt nghim huyt thanh: khng th khng nhn (+), khng th khng mng
y cu thn (+), pANCA (+) nghi ng bnh l t min dch.
+ Tng bch cu a axit gi suy thn do vim thn k cp do d ng.
+ Suy chc nng gan: tm chng gan thn, suy tim huyt, nhim khun.
- Xt nghim nc tiu: protein, in gii, ure, creatinin, p lc thm thu niu.
- Nc tiu: nhiu hng cu, tr hng cu gi nguyn nhn vim tiu cu
thn, vim mch thn. Nhiu t bo m, tr bch cu gi vim thn k cp nhim
khun.
3.3. Cc xt nghim khc: gip tm nguyn nhn
- Chp Xquang bng: tm si, xc nh bng thn.
- Siu m bng, CT-scan bng: bnh l thn, mch thn, nc thn, hp
ng mch thn.
- Chp x hnh thn: nh gi ti mu thn v chc nng bi tit thn.
- MRI mch mu xc nh tc nghn ng mch, tnh mch thn.
- Sinh thit thn: ch nh khi
+ Suy thn cp ti thn: trng hp chn on cha r rng nh vim cu thn
cp, vim cu thn Lupus, bnh thn k cp tnh tin trin xu i sau khi loi tr
cc nguyn.
+ Chn on cha chc chn, da vo kt qu sinh thit thn gip cho iu tr
c hiu nh vim cu thn, bnh vim mch, HUS, TTP, vim thn k d ng.
4.CHN ON
4.1. Chn on xc nh
- Xt nghim creatinin huyt tng tng thm 0,5 mg/dl (44g/l) so vi
creatinin huyt tng trc b bnh hoc trn 50% so vi gi tr bnh thng.
- Th tch nc tiu: theo phn RIFLE vi th thiu niu (nc tiu< 200
ml/12 gi, hoc mc lc cu thn gim 50%), v niu (nc tiu < 100 ml/24 gi).
- Cc ch s khc: tng ur, toan chuyn ho, d tr kim gim, BE gim.
- C nguyn nhn hoc yu t nguy c cao gy suy thn cp.
4.2. Chn on phn bit
- Suy thn cp chc nng vi suy thn cp thc th (hoi t ng thn cp).
Ch s
Suy thn cp chc nng Suy thn cp thc th
thm thu nc tiu
> 500
< 400
(mosm/kg nc)
Na niu mmol/l
< 20
> 40
Creatinin niu/ Creatinin mu
> 40
< 20
Ch s o thi Natri (FEna)
< 1%
> 1%
Cn nc tiu
.Protein vt hoc (-)
.Tr ht +++,
.Bnh thng
.Tr HC, BC i toan
.Protein niu 1g/l
FENa = (UNa xPCr/PNa) x UCr) (100)
119
- t cp ca suy thn mn: tin s c bnh thn trc , thiu mu nng, ur,
creatinin huyt tng tng t trc, kch thc hai thn teo nh.
4.3. Chn on th
- Th v niu.
- Th thiu niu.
- Th bo tn nc tiu.
- Suy thn cp chc nng (suy thn c nng, suy thn cp trc thn) hay suy
thn cp thc th.
4.4. Chn on nguyn nhn: (tham kho phn 2)
5. IU TR
5.1. Nguyn tc x tr
- S b chn on c suy thn cp chc nng hay thc th c thi x
tr cp cu.
- X tr cp cu v cc du hiu e do tnh mng ngi bnh: tng kali mu,
ph phi cp, ph no co git, toan chuyn ha nng.
- X tr nguyn nhn gy ra suy thn cp: i hi chuyn khoa, cn kt hp vi
cc thm d cn lm sng.
5.2. X tr ban u v vn chuyn cp cu:
- Khi ph to, i t, kh th nhiu ngi bnh c tin s bnh thn phi n
ngay c s y t chuyn khoa, khng ngi bnh iu tr ti nh.
- Nm c cc bin php iu tr cp cu tng kali mu c ri lon nhp tim,
ph phi cp, ph no co git, toan chuyn ha nng gy try tim mch.
- Thn trng trong qu trnh vn chuyn ngi bnh c th t vong v tng kali
mu, suy h hp cp, try tim mch.
a) Suy thn cp chc nng
- X tr nguyn nhn:
+ Gim th tch tun hon trong lng mch: cm mu, truyn b th tch tun
hon (mt mu, truyn hng cu, cc ch phm mu) mt dch nh nn, a chay, say
nng (b dch ng trng truyn v ung). Mc tiu cn t duy tr ALTMTT 8-12
mmHg v huyt p trung bnh 65 mmHg.
+ Nu nguyn nhn gim huyt p do thuc (c ch men chuyn) , do cc thuc
c ch COX II, hoc cc thuc khng vim khng steroid (NSAIDs) v cc cht c
vi thn th dng thuc.
+ iu tr bnh chnh: xut huyt tiu ha, bng rng nng, vim phc mc,
vim ty cp, tc rut.
- Loi b cc thuc c vi thn v c kali, cc thuc gy gim dng mu ti
thn, trnh dng thuc cn quang.
- iu tr cc yu t gy mt b v cc cn nguyn mn tnh khc.
b) Suy thn cp thc tn
120
- Kim sot cn bng nc v m bo huyt ng:

+ th tch lng mch, theo di ALTMTT, du hiu ph nim mc, kt mc,
ph t chc k, tnh mch c ni, nghe phi, cn nng hng ngy, dch vo-ra.
+ Cn bng dch: dch ra= s lng tiu/24 gi + 0,5-0,6 ml/kg/gi ( mt qua
da, m hi khong 850-1000ml/ngy/70kg). St thm 10C, nc mt thm 13%.
+ Truyn cc loi dch c kh nng gi li trong lng mch, c bit khi c
gim albumim mu, c nhim khun nng, c ARDS.La chn dch truyn mui tinh
th hay dung dch albumin hoc dung dch keo ty theo tnh trng lm sng v nguyn
nhn.
+ Dch c la chn dng l NaCl 0,9% hoc albumin 5%: gip tng ti mu
t chc, gim tnh thm mch, gim ph (c bit khi c nhim khun).
+ Khi c ph khong k, khng nn truyn nhiu dch mui ng trng v
sau khi truyn th tch gi li trong lng mch c 20%, thi gian bn hu ngn 2030 pht.
+ Huyt p khng ln khi ALTMTT trn 8-12 mmHg, cn ch nh thuc vn
mch, norepinephrine truyn TM lin tc, liu 0,1 n 2 mcg/kg/pht.
- Kim sot thng bng kim toan, in gii:
+ Hn ch kali a vo v iu tr tng kali mu: iu tr khi kali mu > 5,5
mEq/l hoc c thay i trn in tm .
Kayexalate 30 gam/4-6 gi kt hp sorbitol 30gam : ung hoc tht gi.
Calciclorua 0,5-1gam tim TM chm , thi gian tc dng 30-60 pht.
Glucose 20%, 30% c insuline: truyn tnh mch, tc dng trong vi
gi.
Natribicarbonate 1,4% hoc 4,2%.
+ Toan chuyn ho: khi pH < 7,20 truyn NaHCO3 4,2% hoc 1,4% 250500ml.
+ Kim sot natri mu: h natri mu d i km tha th tch.
+ Kim sot canxi, photpho mu: gim canxi mu gp suy thn cp do tiu c
vn cp, tng photpho mu trong cc hi chng tiu hu khi u.
- Li tiu
+ Furosemide c th chuyn suy thn cp th v niu thnh th cn nc tiu:
lm gim s ti hp thu ch ng natri, lm tng dng chy ti ng thn.
Gip tr hon lc mu, khng lm gim tin lng nng v t l t vong.
Cch s dng: 10 ng (200mg) tim tnh mch 3 ln cch nhau 1gi
hoc truyn tnh mch duy tr 40 mg/gi.
Liu 600mg-1000mg/24gi khng p ng phi xt ch nh lc mu.
+ Manitol: l mt li niu thm thu, ch dng khi c tiu c vn cp.
Suy thn cp do tiu c vn, hi chng vi lp, c tc dng phng
ph n, sng v tc ng thn cp.
121
Thuc c dng cng dung dch bicarbonate v m bo truyn dch

vi ALTMTT 8-12 mmHg.
- Chng nhim khun
+ iu chnh liu khng sinh theo thanh thi creatinin, trnh thuc c tnh
vi thn.
+ Pht hin v kim sot nhim khun sm, trnh suy thn cp nng ln do
nhim khun khng kim sot c. Cy tm vi khun, lm khng sinh .
- X tr nguyn nhn: chn on nguyn nhn v phi hp gii quyt chuyn
khoa.
+ Nhim khun nng v/hoc sc nhim khun: xem bi sc nhim khun.
+ Hi chng gan thn cp (xem bi hi chng gan thn cp).
+ Bnh l cu thn cp t min dch v nhim trng: hi chng thn h, vim
cu thn cp, lupus ban h thng, bnh l mch mu.
+ Cc bnh l do tc nghn sau thn: hi chn chuyn khoa, can thip khi cn.
U x tin lit tuyn.
Si h thng thn tit niu.
Cc khi u, mu cc gy tc nghn, gy chn p.
- Ch nh ca cc bin php lc mu
+ Lc mu sm khi c 1 du hiu, ch nh bt buc khi c 2 du hiu
Khng p ng vi li tiu furosemide (liu nh trn).
Ur mu > 30mmol/l.
Kali mu > 6 mmol/l, tng nhanh, c ri lon nhp trn in tm .
Tng gnh th tch, ph to, ALTMTT tng, ph phi cp huyt ng.
Toan chuyn ho pH mu < 7,20.
Na+ mu >160 mmol/l hoc < 115 mmol/l.
+ Thm phn phc mc.
Ch nh lc mu nhng c s y t khng c my lc mu cp, hoc
khng ly c ng vo mch mu lc mu.
K thut: 1h/1 ln/1-3 lt dch thm phn qua ng thng lc mng bng,
lc lin tc 18-24h/ngy ty theo xt nghim. S dng dch lc mng
bng sn c.
+ Lc mu ngt qung
Cp cu cho cc ngi bnh nng c th ko di 4-5-6 gi/1 ln lc, tc
mu chm, tc siu lc chm, c th khng s dng thuc chng
ng.
Tn xut lc hng ngy hoc cch ngy, thn trng khi c huyt p tt.
Nn s dng dung dch lc c dch m bicarbonate, mng lc c
tng hp sinh hc cao.
122
+ Lc mu lin tc CVVH
u im: Loi b cc cht ho tan c phn t lng nh, trung bnh
(di 40.000 dalton) cng vi nc theo nguyn l i lu, khng ph
thuc nng . Hiu qu, dung np tt khi c km sc, suy tim, suy a
tng.
K thut: lc mu lin tc trong 18- 24 gi mi ngy, mu t c th ra,
c lc qua 1 mng lc c h s siu lc cao, kch thc l mng ln.
- Dinh dng
+ Cung cp nng lng 30-35kcal/kg/ngy vi suy thn cp khng c bin
chng.
+ Ngi bnh c nhim khun, suy a tng, tng nng lng tng ti 130%.
+ Suy thn cp khng bin chng: axt amin 0,65-1gam/kg/ngy, c lc mu
ngt qung, tng d ha cung cp axt amin 1,2-1,5gam/kg/ngy, lc mu lin tc
nhu cu axt amin ti 2,5gam/kg/ngy.
+ Tng lng nc qua mi ng cn tnh theo cn bng dch vo-ra.
+ Giai on v niu, thiu niu, hn ch nc, cc ch phm, thc n giu kali.
+ Cc quan im mi v ch dinh dng:
T l carbonhydrat trong khu phn n chim 50-80%.
Cung cp thm lipt, c bit cc axt bo thit yu, axt bo khng no.
Bnh nng: n qua ng thng d dy, phng nhim khun tiu ho.
- Bo tn chc nng cc c quan khc
+ iu tr d phng xut huyt tiu ho thuc khng a xt hoc c ch bm
proton.
+ Cc bin chng tim v phi c lin quan ti suy thn cp: ri lon nhp, ph
phi, nhim trng phi, tng huyt p, chy mu phi (vim cu thn cp tin trin).
+ Ri lon ng mu: gim tiu cu, DIC, gim fibrinogen.
+ Thiu mu, tan mu, gim erythropoietin c th xut hin trong giai on
u.
+ Bin chng thn kinh-c: giai on sm c th c tht iu, ng g, n,
kch thch hoc hn m, ch cc nguyn nhn nh ri lon in gii, tng ure mu.
- Cc yu t gp phn tin lng khng tt ca suy thn cp:
+ Tui cao, bnh mn tnh i km: i ng, suy gan mn, cao huyt p
+ Suy thn cp trong bnh cnh nhim khun, suy a tng, chn thng, hi
chng vi lp, sau m, creatinin mu > 3mg/dl.
+ Ngi bnh c nhiu yu t nguy c: ho cht, tiu c vn, thuc cn quang,
h huyt p do mi nguyn nhn, iu tr thuc c vi thn.
- Suy thn cp ti thn hay suy thn cp chc nng iu tr mun u c th dn
n t vong do cc bin chng cp tnh, ch c bit giai on v niu (tng K +
mu, toan ha nng, ph phi huyt ng).
123
7. PHNG BNH
- Chn on sm, pht hin cc yu t nguy c v d phng cng nh iu tr sm
v ng nguyn nhn gy ra suy thn cp.
- Ngi bnh cn c gio dc v c kin thc v cc bnh l mn tnh c nguy
c cao nh hng ti chc nng thn nh bnh i tho ng, cao huyt p, suy tim
mn, u x tin lit tuyn, t gip phng nga suy thn cho bn thn.
- Bit cc thuc c vi thn cng nh c ch gy suy thn ca n.
- D phng suy thn cp ngi bnh phu thut:
Yu t nguy c: ln tui, c bnh thn t trc, c bnh gan mn, suy tim
+ Phng suy thn cp: phi b dch, m bo huyt p trong phu thut.
- Phng trnh nguy c suy thn cp do cc thuc cn quang: xt nghim creatinin
mu trc chp, hi chn vi bc s chuyn khoa chn on hnh nh.
+ Truyn NaCl 0,9% 1ml/kg/h bt u 8 ting trc chp cn quang, Nacetylcystein 600mg x 2 ln/ngy, vo ngy trc v sau dng thuc cn quang.
+ Chn thuc cn quang nhm t nguy c gy suy thn: iodixanol (Visipaque)
- Phng STC do tiu hu khi u (lympho cp, ng th bch cu cp sau iu tr
ho cht).
+ Allopurinol 300-600mg/trc ngy dng ho cht
+ Truyn NaCl 0,9% 5000 ml/24h.
+ Kim ho nc tiu: truyn NaHCO3 100 mEq/m2/ngy, gi pH nc tiu
>7,00;
+ Tim tnh mch acetazolamide 1gam/m2 cng vi NaHCO3.
- Phng suy thn cp ngi bnh c tiu c vn cp.
Ti liu tham kho
1. Nguyn t Anh, ng Quc Tun. (2012); Tn thng thn cp; Hi sc cp
cu: tip cn theo phc . (Bn ting Vit ca The Washington manual of
critical care). Nh xut bn khoa hc k thut. Trang 557- 582.
2. V Vn nh. (2004); Suy thn cp; Hi sc cp cu ton tp; Nh xut bn y
hc; Trang 263-277.
3. Ronco C., Ricci Z., Bellomo R., Dintini V. (2013), Renal replacement therapy,
Textbook of critical care. sixth edition. jeanlouis Vincent. elsevier sauders.
chapter 115, Pp. 894-901.
4. Elhassan E.A., Schrier R.W. (2013), Acute kidney injury, textbook of critical
care. sixth edition. jeanlouis Vincent, elsevier sauders. chapter 114, Pp. 883-93.
5. Kellum J.A. and work group membership. (2012), Kdigo clinical practice
guideline for acute kidney injury vol 2-| supplements 2-| march.
124
Chng V: THN KINH

CN NHC C NNG
1. I CNG
Nhc c l do c th ngi bnh sinh ra khng th chng li th th
acetylcholine mng sau xi np dn n s vn ng ca c vn yu dn, c bit l
c h hp dn n suy h hp nng cn phi th my, s yu c c tnh cht ti pht
nu khng loi b c cn nguyn.
2. NGUYN NHN
- Thng do u hoc ph i tuyn c ngi trng thnh.
- Tuyn c c th sau xng c hoc lc ch.Mt s trng hp khng tm
thy u tuyn c.
- Cc nguyn nhn khc nhiu khi khng tm thy.
- Tnh trng nhc c nng ln thng l do:
+ t nhim khun h hp.
+ Sau phu thut.
+ Dng thuc khng liu, b thuc hoc qu liu thuc.
+ Mt s thuc lm tng mc yu c nh: aminoglycosides, erythromycin,
azithromycin, chn beta, procainamide, quinidine, magnesium...
3. TRIU CHNG
3.1. Lm sng
- Yu c m mt c th dn n sp mi, nhn i.
- C hm yu khi nhai lu (mt khi nhai).
- C hu hng yu to ra ni kh, nut kh,nguy c gy ra sc.
- C nng v c gp c thng b nh hng, to ra hi chng u gc
xung.
- Yu cc c chi, ch yu l yu cc gc chi.
- Yu cc c h hp l triu chng nng nht trong nhc c nng. Yu c h
hp dn n suy h hp e da tnh mng ngi bnh c gi l cn nhc c nng.
3.2. Cn lm sng
a) Th nghim ti ging: neostigmin (prostigmin)
- Tim neostigmin tnh mch chm: 1 mg + atropin 0,5 mg tnh mch.
- Sau tim 5-10 pht, thy cc c b yu c hi phc nhanh chng.
b) Cc xt nghim huyt thanh
- Khng th khng th th acetylcholin: dng tnh khong 80 -100% ngi.
Nng khng th khng tng quan vi mc nng ca bnh.
- Ngoi ra cn khng th khng c vn: 30-80%,khng th khng titin: 5095%.
125
c) Sinh l in c
- Nghim php kch thch thn kinh lp i lp li: c s gim bin b dn trong
4 - 5 kch thch u tin (suy gim p ng). Kt qu (+) nu bin gim trn 10%.
- in c cc si n l: c nhy cao, dng tnh chim trn 95%.
d) Chn on hnh nh.
- Chp ct lp vi tnh, hoc cng hng t lng ngc: xc nh c hnh thi
ca tuyn c cng nh mi tng quan ca n vi cc c quan khc trong trung tht.
Nhng i khi cng khng pht hin c.
4. CHN ON
4.1. Chn on xc nh
a) Lm sng
- Ngi bnh c yu c tng lc, yu tng ln khi vn ng, hi phc khi ngh.
- Thng c sp mi, c th c nhn i, nut kh, ni kh.
- Yu c h hp: th nhanh, nng, tm mi v u chi.
- Lm cc nghim php gng sc thy c yu i r rt.
b) Cn lm sng
- Th nghim prostigmin: (+).
- Nghim php kch thch thn kinh lp i lp li: (+).
- Kh mu ng mch: gim PaO2, tng PaCO2 do gim thng kh ph nang.
- Xquang phi: c th c hnh nh vim phi do sc, hoc xp phi.
- Ct lp vi tnh hoc cng hng t lng ngc: c th tm thy u tuyn c.
c) Cc du hiu nng
- Kh nut, nut sc.
- Lit c h hp gy suy h hp: th nhanh hoc chm, nng. gim SpO2, PaO2,
tng PaCO2.
- Do u hoc ph i tuyn c ngi trng thnh:
+ Chp ct lp vi tnh hoc cng hng t xc nh.
+ ng v phng x: khi nghi ng tuyn c lc ch.
- Nhng i khi khng r nguyn nhn.
4.3. Chn on phn bit
a) Nhc c mt
- Bnh l mt ca tuyn gip. Hi chng Kearns-Sayre.
- Bnh l thn kinh s vn ng v tn thng vng thn no.
b) Nhc c ton thn
- Mt mi ton thn: cm gic mt mi qu mc, khng phi l biu hin duy
nht.
- X cng ct bn teo c (Amyotrophic lateral sclerosis-ALS): bnh tin trin
ging nh nhc c. Tng phn x v du hiu Babinski, teo c v co cng cc b.
126
- Hi chng nhc c Lambert-Eaton (LEMS): tn thng khp ni thn kinhc thng lin quan vi bnh c tnh. in c c hin tng tng bin hot ng
ca c khi kch thch lin tc (p ng gia tng).
- Ng c botulism (ng c tht): n thc n b nhim Clostridium
botulinum. C triu chng hnh ty v c mt. Khong 50% ngi bnh c gin
ng t. Bnh tin trin nhanh. in c c hin tng tng bin hot ng ca c
khi kch thch lin tc (p ng gia tng) tng t nh trong LEMS.
- Nhc c do penicillamine: penicillamine kch thch c th to ra khng th
khng th th acetylcholin. Thng ht trong vng 3 - 12 thng sau ngng thuc.
- Vim a r v dy thn kinh: lit c tnh cht i xng, km theo t b. Trong
hi chng Guillain-Barre Dch no ty c protein tng > 0,5 g/l; t bo < 10 t
bo/mm3. in c c tn thng myelin hoc si trc hoc c hai.
- Bi lit: lit khng i xng, khng c ri lon cm gic km theo.
- Rn cp nia cn: lit vn ng, thng km theo ng t gin.
- H kali mu: khi nng Kali mu gim < 3 mEq/l. Hoc lit c c tnh cht
chu k (bnh Westphal ), hoc cng gip ...
- i ra porphyrin: xt nghim nc tiu c porphobilinogen.
- Vim tu lan ln: tn thng ty kiu khoanh (mt vn ng v cm gic).
4.4. Chn on mc : ca Osserman v Genkin ngi ln
a) Nhc cc c mt n thun: ch c cc c nhn cu b yu c.
b) Nhc c ton thn mc nh: ngoi nhc c mt, dn dn c cc triu chng
nhc c ton thn. Cha c triu chng nhc c h hp.
c) Nhc c ton thn mc trung bnh: nhc c ton thn nng hn. C triu
chng hnh cu no (kh nut, nut nghn, ni ngng). C th c yu nh cc c h
hp
d) Nhc c nng cp tnh: C lit c h hp. Thng c u tuyn c. T l t vong
cao.
e) Nhc c nng giai on mun: tin trin ko di trn 2 nm sau cc nhc c mt
hoc nhc c ton thn. Thng km theo u tuyn c. p ng rt km vi iu tr.
5. X TR
5.1. Nguyn tc x tr
- m bo duy tr chc nng sng.
- Cc bin php ci thin tnh trng yu c ca ngi bnh.
- Loi b nguyn nhn gy tnh trng yu c nng thm ngi bnh nhc c.
- Phu thut loi b tuyn c ngi bnh c u tuyn c.
- Nm u cao 30o - 45o.
- Th oxy knh hoc qua mt n. Khi c lit c h hp: t ng ni kh qun v
bp bng qua ng ni kh qun.
- t ng thng d dy, n qua ng thng khi c ri lon nut.
127
- Glucocorticoid: methylprednisolone80 mg/ngy chia 2 ln.

a) Cc x tr h tr
- H hp:
+ Lit c h hp gy suy h hp c n c th my h tr.
+ Nhc c nng: mt kh nng ho, th yu, khng nng c khuu tay hoc
u, mt kh nng ng. Cn nhp Khoa hi sc theo di, t ng ni kh qun v
th my xm nhp vi Vt cao ( 10- 12ml/kg) kt hp PEEP 5 cmH2O trnh xp
phi
- Tun hon: theo doi lin tuc mach , in tim, huyt ap phat hin va x tri
kp thi ri lon nhp, c bit l nhp chm, ri lon huyt ap nu co .
- D phong bin chng t c mch phi, tnh mch su : vn ng tr liu, dng
thuc heparin thng hoc trng lng phn t thp.
- D phong loet da dy v ng tiu ha : gim tit dch d dy (thuc khng
th th H2 hoc c ch bm proton) n qua ng thng sm.
- iu chi nh ri loan nc in giai, thng bng kim toan.
- am bao u ch dinh dng: 40 Kcalo/kg/ngy va ca c khoang cht.
b) X tr c hiu
- Thuc khang me n cholinesterase: c tc dng c ch men cholinesterase
duy tri nng acetylcholine xi nap t duy tr kh nng co c.
+ Cc thuc ng ung:
Tc dng chm v ko di nn c iu tr d phng: Pyridostigmin
(Mestinon),liu 60mg/ln ngy 4 - 6ln,tc dng nhanh (15-30 pht sau ung) v ko
di 3 - 4 gi. Ambenoiumchlorid (Mytelase), liu 5 25 mg/ln ngy 3-4 ln, tc dng
ko di hn pyridostigmin, kh iu chnh liu lng hn.
Tc dng ph: c hi chng muscarin nh au bng, a chy, tng tit nc bt,
co tht ph qun, nhp chmQu liu thuc: (thng vi liu > 120mg/3h/ln) lm
cho tnh trng yu c nng ln, kh phn bit vi tnh trng nng ln ca nhc c.
+ Cc thuc ng tim: neostigmin (prostigmin)
Tc dng nhanh nn c dng trong cp cu cn nhc c cp.
Liu: neotigmin 0,5 mg/ng tim bp hoc tnh mch chm.
Nn phi hp vi atropin tim bp trc khi tim neostigmin d phng tc
dng tng tit ca neostigmin hoc dng ngay trc cc ba n.
Ch : khi dng qu liu cc thuc khng cholinesterase c th gy cn cng
cholin. Triu chng ging cn nhc c nn c th gy nhm ln.
- Thuc c ch min dch: hiu qu chm, nhng ko di.
+ Glucocorticoid:
Thuc tim tnh mch: methylprednisolone 40mg/ng ngy 2 ng chia 2 ln
Thuc ung prednisolon: 5mg/ngy, tng dn 5mg/3 ngy, duy tr 60mg/ngy
hoc 120mg cch ngy.
128
+ Azathioprine (Imuran): liu khi u 0,5 mg/kg/ngy, liu duytr: tng dn

0,5mg/kg/ngy sau mi 2 tun t 2,2 mg/kg/ngy. Chng ch nh: ph n c thai
v cho con b.
+ Cyclosporine...thng c dng phi hp vi cc glucocorticoid:khi u
3mg/kg/ngy chia 2 ln, liu duy tr: tng liu sau vi tun, liu 6 mg/kg/ngy chia 2
ln. Chng ch nh tng huyt p, suy thn mn, ph n c thai.
- Truyn globulin min di ch:
+ C tc dng nhanh, nhng ch tm thi. Thng dng trong t cp. Ci
thin lm sang gp 50% - 90% ngi bnh nhng mc ap ng co khac nhau.
+ C ch tac dung: s bam vao vi tri c trng trn khang n guyn, lm gim s
iu ha san sinh ra khang th , lm thay i chc nng t bo lympho T .
+ Liu dng: tng liu 2 g/kg trong 2 - 5 ngy.
+ Tc dng ph: au u, bun nn, c khi c triu chng ging cm.
- Lc huyt tng: loi b bt t khng th, tnh trng bnh nhn c ci thin
nhanh chng sau mi ln lc, thng thng sau lc 3-5 ln l c th b c my th
+ Thay huyt tng: (xin xem quy trnh k thut thay huyt tng).
+ Lc kp (double filter): (xin xem quy trnh k thut lc kp).
+ Lc hp ph (hemoadsorption): (xin xem quy trnh k thut lc hp ph).
c) iu tr ngoi khoa
Khi bnh nhn c u tuyn c: phu thut ct b tuyn c nhm mc ch lm
gim to ra cc khng th t min khng th th acetylcholin.
d) Theo di
- Theo di st tnh trng h hp, mch, nhp tim, huyt p.
- Theo di SaO2, PaO2, PaCO2 mu ng mch.
- nh gi tnh trng c lc t chi v ri lon nut hng ngy.
- o th tch kh lu thng (Vt), p lc m ht vo ti a (NIP) hng ngy.
6.1. Tin lng
- Khng c yu t no d on liu ngi bnh ch biu hin mt tin trin
thnh nhc c ton thn.
- Tnh trng yu c ngy cng tin trin nng hn, c nhng t yu c cp.
6.2. Bin chng
- Vim phi do yu c hu hng. Xp phi
- Teo c.
- Gim kh nng lao ng.
7. PHNG BNH
- Dng thuc liu, khm kim tra nh k iu chnh liu thuc.
- Trnh nhim khun, c bit l nhim khun h hp.
- Trnh dung cc thuc lm tng tnh trng yu c.
- Phu thut tuyn c nu pht hin c u tuyn c.
129
Ti liu tham kho

1. Nguyn Quc Anh, Ng Qu Chu v CS. (2011), Cn nhc c nng, Hng
dn chn on v iu tr bnh ni khoa, Nh xut bn Y hc, Tr. 113-5.
2. Tt cng (1996), Hi sc iu tr cn nhc c nng gy suy h hp, Lun
n tin s y hc. Hc vin qun y.
3. V Vn nh (2003), Thay huyt tng bng my, Hi sc cp cu ton tp,
Nh xut bn y hc, Tr 621-30.
4. Nguyn Cng Tn, Nguyn Gia Bnh (2010), Bc u nh gi hiu qu ca
thay huyt tng trong trong iu tr cn nhc c nng ti khoa Hi sc tch cc
Bnh vin Bch mai Tp ch Y hc lm sng-Bnh vin Bch mai. Thng 8 (55)
Tr. 39-44.
5. Drachman D.B. (1994), Myasthenia Gravis, The New England Journal of
medicine, Vol 330 (25): 1797-1810.
6. Graves M., Katz J.S. (2004) Myasthenia gravis, Current treatment options in
neurology (6), Pp. 163-71.
7. Lisak R.B. (2003), Myasthenia Gravis, Sauders Manual of Critical care,
Sauders Pp. 304-306
8. Marinelli W.A., Leatherman J.W. (2005), Neuromuscular diseases leading to
respiratory failure, Principles of Critical Care 3rd edition, pp. 1025-36.
130
Cn nhc c nng
- Nm u cao 30o - 45o

- m bo h hp: th oxy
Khng
Suy h hp
C
- Th my: Vt cao (12ml/kg), PEEP 5 cmH2O.

- Cc yu t nng:
+ Tin trin nhanh
+ Mt kh nng ho
+ Ri lon nut, ni kh
- Theo doi v x tr ri loan nhi p, huyt ap.

- D phong tc mch: heparin enoxaparin, nadroparin
- D phong loet da dy : thuc bc nim mac da day , gim tit
dch, n qua ng thng sm.
- am bao dinh dng: 40 Kcalo/kg/ngy va cac khoang cht
X tr c hiu
Thuc khng men

cholinesterase
Ung
Pyridostigmin:
60mg x 4-6 ln/ngy
Ambenoiumchlorid:
5-25mg x 3-4 ln/ngy
Tim: cp cu
Neostigmin: TB, TM
0,5 mg x 3-4 ln ngy
Thuc c ch
min dch
Lc huyt tng:
S ln: 4-6 ln
Phu thut ct u
tuyn c
Truyn globulin min dch
0,4 g/kg/ngy x 5 ngy
Methylprednisolon80
mg/ngy.
Thay huyt tng:

Th tch thay th:
40 ml/kg
Azathioprine
2,2mg/kg/ngy
Lc hp ph:
Cyclosporine
6mg/ngy
Lc kp:
S x tr cn nhc c nng
131
HI CHNG GUILLAIN BARRE
1. I CNG
Trong hi chng Guillain -Barr l do c th sinh ra khang th chng lai cac
nguyn nhn nhim trng, ng thi cung chi nh cac khang th o tn cng va lam tn
thng myeline v/hoc si trc cua r v dy thn kinh ngo i bin. Biu hin la yu
c tin trin nhiu ni, bnh nng l khi co lit c h hp va ri loan th n kinh t ch.
2. NGUYN NHN
- Thng gp nht la Campylobacter jeuni, vi khun nay c trong vim da day .
- t gp hn: Cytomegalovirus, Epstein-barr virus v Mycoplasma pneumoniae.
- Sau dng vacxin:bi lit, cm, si, bch hu-ho ga-un vn....
3. Triu chng
3.1. Lm sng
Khong 1-3 tun trc co th co biu hin cua nhim vi rt nh ht hi , s
mi, chy nc mt, au hong, au moi bp c.
a) Giai oan khi phat
- Thng khng st.Ri loan cam giac nh kin bo ngon chi hay quanh mi.
- au moi nhiu ni tng ln.
b) Giai oan toan phat
- Yu c thng bt u chn, c th bt u cnh tay hoc c vng mt.
C d cm tay v chn b yu c
- Yu c mt, lit c hu hng.Yu c vn nhn.
- Yu c h hp cn phi th my h tr.
- Ri lon thn kinh t ng: nhp tim nhanh (hay gp nht), hoc nhp chm, b
tiu, huyt p thay i, tc rut, ra nhiu m hi.
- Cc triu chng t gp: ph gai th, git run c vng mt, gim thnh lc, du
hiu mng no, lit dy thanh m, thay i thc.
- C 90% bnh tin trin trong 2-4 tun t khi xut hin cc triu chng ban
u.
3.2. Cn lm sng
a) Dch no ty
- C s phn ly m- t bo: protein > 0,5g/lt, t bo < 10/mm3.
- C 80 - 90% ngi bnh tng protein dch no ty trong tun u ca bnh.
b) in c v dn truyn thn kinh
- Tn thng myelin: ko di thi gian tim tng ngn chi v sng F , gim tc
dn truyn cua cac dy thn kinh, nghn dn truyn do mt myelin tng on.
- Tn thng si trc: sng F c th mt, p ng vn ng v cm gic gim
hoc mt.
132
c) Cc xt nghim v min dch: khng th glycolipid nh: GQ1b. GM1, GD1a,

GalNac-GD1a, GD1b . GT1a. GD1b
4. CHN ON
4.1. Chn on xc nh (Theo tiu chun ca Ashbury v comblath nm 1990)
a) Lm sng
- Cc c im cn ngh n hi chng Guilain-Barr.
+ C s yu c tin trin dn dn ca c chn v tay.
+ C gim hoc mt phn x.
- Cc c im lm sng h tr thm cho chn on:
+ Tin trin nhiu ngy n 4 tun.
+ C tnh cht i xng ca cc du hiu.
+ Cc triu chng hay du hiu cm gic thng l nh.
+ Tn thng dy thn kinh s (tnh cht hai bn).
+ Bt u phc hi sau 2-4 tun sau khi ngng tin trin.
+ Ri lon chc nng thn kinh t ng.
+ Khng c st lc khi bnh.
b) Cn lm sng
- Dch no ty: Protein tng, t bo <10/mm3
- in c: dn truyn thn kinh chm hoc mt, tn thng myelin v/hoc si
trc
c) Cc du hiu nng
- Lit t chi c km theo lit hu hng: nut nghn, sc.
- C ri lon chc nng thn kinh t ng.
- C tnh trng suy h hp:
+ Lit c h hp: th nhanh hoc chm ( > 30 hoc < 10 ln/pht), nng.
+ Tm mi, u chi: tng PaCO2, gim PaO2.
+ Xquang phi: hnh nh vim phi do sc, xp phi.
- Thng gp nht la Campylobacter jeuni: tm vi khun nay trong dch da day.
- Cc nguyn nhn t gp : Cytomegalovirus, Epstein-barr virus v Mycoplasma
pneumoniae. Hoc ngi bnh trc c s dng mt s vacxin.
4.3. Chn on phn bit
- Vim mch thn kinh ngoi vi: vim mch tin trin nhanh, lm sng c th
ging Guillain-Barr vi yu c c tnh cht i xng.
- Bnh l ty sng cp: ln ct sng, vim ty ct ngang cp tnh. Phn x c
th b gim trong giai on cp tnh ca bnh ty sng. Ri lon cm gic kiu khoanh
ty.
- Cc bnh ca khp thn kinh-c: ng c, nhc c nng, hi chng
Lambert-Eaton. C tnh trng yu c cp tnh, khng c cc triu chng v cm gic.
133
- Bnh vim a c, bnh l c nng, bnh l thn kinh nng i khi ging
Guillain-Barr. Cc bnh ny biu hin nh tnh trng lit cp tnh.
- Hi chng Miller-Fisher: cn t qu no, bnh no Wernicke v vim no
vng thn no, nhng thng c thay i thc.
- Bi lit: lit khng i xng, khng c ri lon cm gic km theo.
- Rn cp nia cn: lit vn ng, thng km theo ng t gin.
- H kali mu: nng kali mu gim < 3,5 mEq/l.
- i ra porphyrin: xt nghim nc tiu c porphobilinogen.
- Vim tu lan ln: tn thng ty kiu khoanh (mt vn ng v cm gic).
- Tn thng tu do: vim mng nhn tu, chn p tu (lao, ung th, thot
v...).
- Hi chng ui nga: ch khi c biu hin lit hai chn.
- Bnh l thn kinh ngoi vi do ru, i tho ng...
4.4. Chn on th lm sng
a) Bnh a dy thn kinh hy myelin cp
- Mt phn x gn xng.
- S hi phc myelin thn kinh ngoi vi xy ra tng i nhanh.
b) Bnh thn kinh si truc vn ng cp
- Phn x gn xng i khi cn,dn truyn thn kinh cm gic bnh thng
- Lm sng v s phc hi khng ging nh th hy myelin cp.
c) Bnh thn kinh si truc vn ng va cam giac cp
- Si cm gic v vn ng b tn thng, hi phc chm v khng hon ton.
- C triu chng cm gic i km nhiu hn, lit xut hin nhanh va nng.
d) Hi chng Miller Fisher
- Gp khoang 5% cc trng hp GBS.
- Thng do nhim Campylobacter jejuni trc o.
- Lm sng in hnh: lit vn nhn, mt iu ha v mt phn x.
5. X TR
5.1. Nguyn tc x tr
- m bo duy tr chc nng sng, c bit khi c lit c h hp.
- iu tr ri lon nc v in gii.
- Tp vn ng hn ch bin chng do lit vn ng gy ra.
- Loi b nhanh cc khng th t min gy ra tn thng thn kinh ngoi vi.
- Th oxy knh hoc qua mt n. t ng ni kh qun v bp bng qua ng ni
kh qun khi c lit c h hp.
- t ng thng d dy, n qua ng thng khi c ri lon nut.Vitamin nhm B.
- Glucocorticoid: methylprednisolon 500mg/ngy x 5 ngy, sau gim liu
dn.
134

a) Cc x tr h tr
- H hp:
+ Khi c du hiu suy h hp cn th my h tr ngay.
+ Th oxy, nu khng kt qu chuyn sang th my xm nhp vi Vt cao
(12ml/kg) kt hp PEEP 5 cmH2O trnh xp phi .
+ Cc yu t nng nh: tin trin nhanh <7 ngy, mt kh nng ho, khng nng
c khuu tay hoc u, mt kh nng ng, phi nhp Khoa hi sc theo di, cn
t ni kh qun v th my sm.
- Tun hon: theo doi lin tc mch , in tim, huyt ap phat hin va x tri
kp thi ri lon nhp, c bit l nhp chm khi ht m, tt huyt ap.
- D phong thuyn t c ti nh mach su v t c mch phi: vn ng tr liu, dng
thuc chng ng heparin hoc heparin trng lng phn t thp.
- D phong loet da dy v ng tiu ha: gim tit dch d dy (thuc khng
th th H2, thuc c ch bm proton) n qua ng thng sm.
- iu chi nh ri loan nc in giai ,am bao dinh dng: 40 Kcalo/kg/ngy va
cc khong cht.
b) X tr c hiu
Mc ch: lm gim lng khng th khng myelin trong mu
- Corticoid:
+ Tc dng lm gim p ng min dch. Tuy nhin hiu qua khng nhiu.
+ Liu methylprednisolon 500mg/ngy x 5 ngy. Sau gim liu dn.
- Lc huyt tng:
+ Thay huyt tng: (xin xem quy trnh k thut thay huyt tng).
+ Lc kp (double filter): (xin xem quy trnh k thut lc)
+ Lc hp ph (hemoadsorption): (xin xem quy trnh k thut lc hp ph)
* Ch :
Thi gian lc cng sm cng tt: kh nng hi phc tt.
S ln lc v khong cch: hng ngy hoc cch ngy, 3-6 ln ty theo p
ng ,c th ti 15-16 ln. Nu sau 6 ln khng tin trin th ngng.
C nguy c d ng hoc sc phn v, ri lon ng mu, ri lon in gii,
nhim khun ti ch hoc nhim khun mu
- Truyn globulin min di ch: gi thnh iu tr cao.
+ Liu dung: 0,4 g/kg/ngy x 5 ngy.
+ Chng chi i nh: suy thn, d ng thuc.
c) Theo di
- nh gi hng ngy c lc t chi ,cc dy thn kinh s nh: ri lon nut
- Theo di st: h hp ( SpO2,PaO2, PaCO2, mch, nhp tim, huyt p.
- nh gi th tch kh lu thng (Vt), p lc m ht vo ti a (NIP) hng
ngy.
135

6.1. Tin lng
Khong 70% hi phc hon ton, k c lit c h hp cn phi th my h tr.
T l hi phc hon ton t 48 - 90% trong nm u , 60 - 88% trong nm th
hai.
Hi phuc kem n u> 60 tui, tin trin nhanh , in c tn thng si truc , th
my h tr di ngay.
6.2. Bin chng
Quan trong nht la suy h hp cp do lit c h hp , vim phi do hi t phai , xp
phi, thuyn tc mach phi.
Cc ri lan thn kinh t ng: ri loan nhi p tim , tng tit di ch ph quan phi ,
lit rut c nng, b tiu tin, vim ng tit niu, lot t
Di chng lit khng hi phc.
7. PHNG BNH
Phng trnh cc nhim khun, vi rt.
Khi c biu hin t b tay, chn, c lc yu cn phi i khm c chn
on v iu tr kp thi hn ch lit c tin trin v cc bin chng do lit c gy
ra.
Ti liu tham kho :
1. Nguyn Quc Anh, Ng Qu Chu v CS. (2011), Hi chng Guillain-Barr,
Hng dn chn on v iu tr bnh ni khoa, Nh xut bn Y hc, Tr. 130-2.
2. Nguyn Vn ng (2003), Cc bnh v hi chng thn kinh thng gp, Nh
xut bn y hc, Tr. 400 - 12.
3. V Vn nh (2003),Thay huyt tng bng my, Hi sc cp cu ton tp,
Nh xut bn y hc, Tr. 621- 30.
4. Nguyn Cng Tn. (2013), Nghin cu hiu qu ca phng php thay th huyt
tng trong cp cu hi chng Guillain-Barr, Lun n tin s y hc Vin
nghin cu khoa hc y dc lm sng 108.
5. Asbury A.K., Cornblath D.R. (1990), Assessment of current diagnostic criteria
for Guillain-Barr syndrome, Ann Neurol 27 Suppl, Pp. 21-4.
6. Lewis L.A. (2003), Guillain - Barr syndrome, Saunders Manual of Critical
care, Saunders, Pp. 307-10
7. Doorn P.A.V., Ruts L. (2008), Clinical features, pathogenesis, and treatment of
Guillain-Barr syndrome neurology, The Lancet Neurology 7, Pp. 939-50.
8. Marinelli W.A., Leatherman J.W. (2005), Neuromuscular diseases leading to
respiratory failure, Principles of Critical Care 3rd edition, Pp. 1025-36.
136
9.
H chng Guillain-Barr
- m bo h hp: th oxy
Khng
Suy h hp
C
- Th my: Vt cao (12ml/kg), PEEP 5 cmH2O.

- Cc yu t nng:
+ Tin trin nhanh < 7 ngy nhp vin
+ mt kh nng ho
+ Khng nng c khuu tay hoc u
- Theo doi v x tr ri loan nhi p, huyt ap.

- D phng tc mch: heparin enoxaparin, nadroparin
- D phong loet da dy : thuc bc nim mac da day , gim tit
dch, n qua ng thng sm.
- am bao dinh dng: 40 Kcalo/kg/ngy v cc khong cht
X tr c hiu
Methylprednisolon
500mg/ngy x 5 ngy.
Thay huyt tng:

Th tch thay th: 40
ml/kg, nguy c d ng
huyt tng
Lc huyt tng:
S ln: 4-6 ln, ti
a 15-16 ln
Truyn globulin min dch

0,4 g/kg/ngy x 5 ngy
Lc kp: rt t dch
thay th, khng c
nguy c d ng
S x tr hi chng GuillainBarr
137
Lc hp ph: khng cn
dch thay th, khng d
ng
TNG P LC NI S
1. I CNG
Tng p lc ni s (ALNS) c th gy ra ph no, thiu mu no, hoc tt no
rt nhanh gy t vong hoc tn thng khng hi phc, v vy cn phi c chn
on sm v x tr tch cc.
ngi trng thnh, th tch hp s khong 1500 ml gm (t chc no chim
80%, mu chim 10%, dch no tu chim 10%.
ALNS bnh thng l10 mmHg, tng ALNS khi p lc bn trong hp s ln
trn 15 mmHg.
p lc ti mu no (ALTMN) ln hn 60 mmHg: theo cng thc
ALTMN = HATB ALNS
(HATB: huyt p trung bnh)
2. NGUYN NHN
- Chn thng s no.
- Chy mu no: trong nhu m no, no tht, chy mu di nhn.
- Tc nhnh ln ng mch no: tc ng mch cnh trong, ng mch no
gia...
- U no.
- Nhim khun thn kinh: vim no, vim mng no, p xe no.
- No ng thy.
- Cc nguyn nhn c kh nng gy tng p lc ni s khc:
+ Tng CO2 mu; gim oxy mu.
+ Th my c s dng PEEP cao (p lc dng cui th th ra).
+ Tng thn nhit.
+ H natri mu.
+ Tnh trng co git.
3. TRIU CHNG
3.1. Lm sng
Tu vo ngi bnh tnh hay m m c nhng din bin bnh khc nhau.
a) Ngi bnh tnh
- Nhc u thng au tng dn ln, au c th lan to hoc khu tr.
- Nn: thng gp trong cc nguyn nhn h sau.
- Ri lon th gic: nhn i, thong m, gim th lc, soi y mt c ph gai.
- Ri lon thn kinh: ng g, l .
b) Ngi bnh hn m
- ang tnh t ngt hn m, hoc hn m su hn.
- C biu hin tng trng lc c.
- Ri lon thn kinh t ng (l du hiu nng):
+ Nhp tim nhanh hoc chm, tng huyt p hoc gim huyt p.
138
+ Ri lon h hp: th nhanh, su hoc Cheyne-Stockes.

+ Ri lon iu ho thn nhit: st cao.
- Du hiu tn thng do tt no:
+ Tt thu thi dng: lit dy III, ng t gin.
+ Tt thu hnh nhn tiu no: th nhanh hoc ngng th.
+ Tt no trung tm: biu hin tn thng t trn xung di.
3.2. Cn lm sng
- Xt nghim mu: c th xc nh nguyn nhn do h natri mu.
- Chp ct lp vi tinh (CT-scan) s no: c th thy
+ Ph no, cu trc no b x y, cu trc ng gia b thay i.
+ No tht gin: do tc nghn s lu thng ca dch no tu.
+ C th thy: chy mu no, thiu mu no, u no, p xe no...
- Cng hng t (MRI) s no: cho bit r hn v tn thng no.
- Chp ng mch no: xc nh c d dng mch no.
- Chc d tu sng: khi nghi ng vim mng no (ch cho dch no tu
chy ra t t).
4. CHN ON
4.1. Chn on xc nh
- au u ngy cng tng.
- Bun nn hoc nn.
- C th c ri lon thc km theo.
- Soi y mt: c ph gai th gic.
- CTscanner s no hoc chp cng hng t s no: c th xc nh c
nguyn nhn gy TALNS.
4.2. Chn on phn bit
- Hn m: hn m tng thm thu, toan xeton, h ng mu, hn m gan...
- Nhn m: cc bnh l thc th mt.
- au u: cc nguyn nhn do thn kinh ngoi bin, ri lon vn mch.
- Chn thng s no: CT scanner c th thy hnh nh chy mu no, tn
thng no do ng dp, v xng s.
- Chy mu no: CT scanner s no thy hnh nh chy mu trong nhu m no,
no tht, chy mu di nhn.
- U no: CT scanner hoc MRI s no cho thy v tr, kch thc, s lng khi
u.
- No ng thu: CT scanner v MRI c hnh nh no tht gin to lm cho cc
rnh cun no mt np nhn.
- Nhim khun thn kinh: Xt nghim dch no ty: protein tng km theo bch
cu tng (vim mng no m). vim mng no, p xe no.Dich no ty bnh thng
trong vim no....MRI c th thy hnh nh vim no, p xe no.
139
- Cc nguyn nhn c kh nng gy tng p lc ni s khc:

+ Tng CO2 mu; gim oxy mu: xt nghim kh mu.
+ Th my c s dng PEEP (p lc dng cui th th ra).
+ Tng thn nhit: nhit > 40oC, ko di lin tc.
+ H natri mu: xt nghm in gii cho thy [Na+] mu < 130 mmol/l.
+ Tnh trng co git: xt nghim sinh ha mu c CK mu tng cao.
5. X TR
5.1. Nguyn tc x tr
- Cn theo di p lc ni s lin tc duy tr p lc ti mu no.
- p dng cc bin php lm gim p lc ni s .
- Duy tr huyt p ca ngi bnh cao hn mc bnh thng hoc huyt p nn
m bo p lc ti mu no (Cranial Perfusion Pressure - CPP) t 65-75 mmHg.
- Duy tr p lc thm thu mu 295 to 305 mOsm/L.
- Hn ch ti a cc bin chng do tng p lc ni s gy ra.
- Loi b nguyn nhn gy tng p lc s no.
- Cho ngi bnh nm yn tnh nu ngi bnh tnh.
- u cao 30o - 45o nu khng c h huyt p.
- Cung cp oxy cho ngi bnh: th oxy knh.
- Duy tr huyt p cao hn huyt p nn ca ngi bnh.
+ H huyt p: truyn dch NaCl 0,9 %.
+ Tng huyt p: dng thuc h huyt p (chn knh canxi, c ch men
chuyn).
- Chng ph no: glucocorticoid khi c u no.
+ Methylprednisolon: 40 - 120 mg tim tnh mch, duy tr 40mg/6gi.
+ Dexamethasone: 8 mg tim bp hoc tnh mch, duy tr 4 mg/6gi.
- X tr tng thn nhit: paracetamol 0,5 gram bm qua xng hoc 1 gram
truyn tnh mch.
- Vn chuyn khi huyt p v h hp c m bo.
a) Ni khoa
- Chung
+ Cho ngi bnh nm yn tnh nu tnh.
+ u cao 30o - 45o.
+ iu chnh ri lon nc in gii.
+ iu tr tng thn nhit: paracetamol 0,5 gram bm qua ng thng d dy
hoc 1 gram truyn tnh mch.
+ Khng sinh: khi c du hiu nhim khun thn kinh cn phi s dng khng
sinh cng sm cng tt, la chn khng sinh d thm mng no, phi liu lng, vi
140
khun cn nhy cm vi khng sinh , thng dng 2 loi khng sinh kt hp, thuc
truyn tnh mch, iu chnh liu theo mc lc cu thn.
Cephalosporin th h 3: ceftazidime 2g/ 8 gi, cefotaxime 2g/ 4-6 gi,
ceftriaxone 2g/ 12 gi...
Cephalosporin th h 4: cefepime 2g/ 8 gi.
Nhm carbapenem: meropenem 2g/ 8 gi.
Chloramphenicol: 4g/ 6 gi.
Vancomycin 30-60 mg/kg/ngy chia 2-3ln. Thng kt hp vi 1 trong cc
khng sinh trn (khi cha c khng sinh ).
Ngi bnh suy gim min dch hoc trn 50 tui: cephalosporin + vancomycin
+ ampicillin 2g/ 4 gi.
+ Chng co git: (xem bi trng thi ng kinh)
+ Chng to bn: thuc nhun trng nh sorbitol, duphalac...
+ B tiu: t ng thng tiu.
- Hi sc bo h hp: cung cp oxy cho ngi bnh
+ Ngi bnh tnh: th oxy knh.
+ Ngi bnh hn m, ri lon h hp cn phi t ni kh qun v th my
(trnh s dng PEEP hoc dng PEEP thp 5 cm H2O), duy tr PaCO2 t 35 - 45
mmHg.
- Hi sc tun hon
* Cn ch : duy tr huyt p cao hn bnh thng hoc huyt p nn (HATT
140-180 mmHg, HATTr <120 mmHg) m bo p lc ti mu no (CPP: 65-75
mmHg).
+ Nu ngi bnh c h huyt p: cn t ng thng tnh mch trung tm 3
lng.
Truyn dch: da vo ALTMTT, khng truyn glucosa 5% v NaCl 0,45%
v lm tng p lc ni s do ph no tng ln.
HA vn khng t c yu cu: s dng dopamine truyn tnh mch.
+iu tr tng huyt p khi: HATT > 180 mmHg v/hoc HATTr > 120 mmHg
km theo suy thn.
Nu HATT > 230 mmHg v/hoc HATTr> 140 mmHg: nitroprussid truyn
TM: 0,1 - 0,5 g/kg/ph, ti a 10 g/kg/pht. Hoc nicardipine truyn TM: 5 15mg/gi.
Nu HATT 180 - 230 mmHg v/hoc HATTr 105 - 140 mmHg: ung chn
(labetalol) nu nhp tim khng chm < 60 ln/pht.
Nu HATT < 180 mmHg v/hoc HATTr< 105 mmHg: ung chn (nu nhp
tim khng chm < 60 ln /pht. Hoc c ch men chuyn: enalaprin 10mg/vin;
peridopril 5mg/vin. Li tiu furosemid tim tnh mch nu thuc h HA khng kt
qu.
- Chng ph no: gi p lc thm thu mu 295 - 305 mOsm/L.
141
+ Manitol ch dng khi c ph no: 0,5 - 1g/kg/6gi truyn tnh mch trong 30
pht; khng dng qu 3 ngy.
+ Dung dch mui u trng 7,5 - 10% 100 ml/ln c tc dng gim nhanh p
lc ni s, thi gian ti pht tng p lc ni s mun hn so vi manitol 20%, cho kt
qu tt ngi bnh b chn thng s no. Thi gian dng khng qu 3 ngy.
+ Thuc an thn truyn tnh mch
Thuc: phenobacbital hoc thiopental (100mg/gi), propofol (5 - 80
g/kg/pht).
Tc dng vi liu gy m: gim ph no, gim nhu cu s dng oxy
no, chng co git. Tc dng ph: hn m su hn, h huyt p. Cn theo di
st thc v huyt p.
+ Glucocorticoid: ch nh trong u no, p xe no.Khng dng khi c tng
huyt p.Thuc: Synacthen 1mg tim bp/ngy (tc dng tt trong u
no).Methylprednisolon: 40 - 120 mg tim tnh mch, duy tr
40mg/6gi.Dexamethasone: 8 mg tim bp hoc tnh mch, duy tr 4 mg/6gi.
b) Ngoi khoa:khi bit r nguyn nhn, iu tr ni khoa khng kt qu.
- No ng thu: m dn lu no tht.
- Khi mu t ln: ly khi mu t, gii quyt chy mu do v d dng.
- U no:
+ Khi u to: m ly khi u (thng kh khn).
+ Khi u nh 2 cm: x tr vi tia Gama
- p xe no: sau khi iu tr ni khoa n nh, p xe khu tr li.
- Chn thng s no c ng dp no nhiu: m b mt phn xng s vng
p dp ra ngoi gim p lc ni s.
c) Theo di p lc ni s
- Qua no tht: thng qua h thng dn lu no tht.
- Trong nhu m no: u nhn cm p lc c t vo trong nhu m no qua
mt l khoan nh xng s v c ni vi my theo di lin tc.
- Di mng nhn: u nhn cm p lc c t vo khoang di nhn qua
mt l khoan nh xng s v c ni vi my theo di lin tc.
- Ngoi mng cng: u nhn cm p lc c t vo khoang ngoi mng
cng qua mt l khoan nh xng s v c ni vi my theo di lin tc.
6.1. Tin lng
Tng p lc ni s ko di s c tn thng no kh hi phc, tin lng xu.
ngi bnh hn m do chn thng s no cho thy thi gian tng p lc ni
s cng ko di lin quan n tin lng cng xu.
142
6.2. Bin chng

Tng p lc ni s nu khng c x tr kp thi s to ra vng xon bnh l
lm cho p lc ni s ngy cng tng c th dn n co git, t qutn thng no
khng hi phc..
Tt no l bin chng nng, c th lm cho ngi bnh t vong nhanh chng.
7. PHNG BNH
Khi c du hiu ca au u, nhn m khng r nguyn nhn cn phi chp ct
lp s no loi tr nguyn nhn tng p lc ni s.
Khi c tng p lc ni s, ngi bnh cn phi c theo di st v x tr
nguyn nhn gy ra tng p lc ni s.
Ti liu tham kho:
1. Nguyn Quc Anh, Ng Qu Chu v CS. (2011), Tng p lc ni s,
Hng dn chn on v iu tr bnh ni khoa, Nh xut bn Y hc, Tr. 1279.
2. V Vn nh (2003),Chn on v x tr tng p lc ni s, Hi sc cp cu
ton tp, Nh xut bn y hc, Tr. 316-27.
3. Frank J.I., Rosengart A.J. (2005), Intracranial pressure: monitoring and
management, Principles of Critical Care 3rd edition, Pp. 1007-23.
4. Mauritz W., Steltzer H., Bauer P., Aghamanoukjan L.D., Metnitz P. (2008),
Monitoring of intracranial pressure in patients with severe traumatic brain
injury: an Austrian prospective multicenter study Intensive Care Med. Jul,
34(7), Pp. 1208-15.
5. Michael D.B. (2003), Intracranial Hypertension, Saunders Manual of Critical
care, SaunderSaunders, Pp. 293-297.
6. Kamel H., Navi B.B., Nakagawa .K. et al, (2011) Hypertonic saline versus
mannitol for the treatment of elevated intracranial pressure: a meta-analysis of
randomized clinical trials, Crit Care Med. 39, Pp. 554-9.
143
Tng pl c ni s
(Mc tiu: duy tr ALNS < 20 mmHg)
- Nm yn tnh nu tnh.
- u cao 30o - 45o.
- iu chnh ri lon nc in gii.
- iu tr tng thn nhit
- Khng sinh: khi c du hiu nhim khun
- Chng co git
Hi sc h hp
- Tnh: th oxy knh.
- Hn m, ri lon h hp:
TKNT (khng c PEEP), duy
tr PaCO2 30 - 40 mmHg.
Ngoi khoa
- No ng thy
- Khi mu t ln
- U no
- p xe no
- CTSN ng dp nhiu
Hi sc tun hon
Duy tr HA cao hn mc bnh
thng hoc HA nn (HATT
140-180 mmHg, HATTr <120
mmHg) m bo p lc ti
mu no (CPP: 65-75 mmHg)
Chng ph no
Duy tr ALTT mu
295-305 mOsm/L.
Manitol:
0,5-1g/kg/6gi
truyn TM trong 3 ngy.
H HA
- B dch theo ALTMTT
- Khng dng glucose, NaCl 0,45%
- Dopamin
NaCl: 7,5-10% x 100 ml/ln

truyn TM trong 3 ngy
Tng HA
- HATT > 230 mmHg v/hoc HATTr> 140 mmHg:
Nitroprussid TM: 0,1 - 10 g/kg/pht.
Nicardipine TM: 5 - 15mg/gi.
- HATT 180-230 mmHg v/hoc HATTr 105-140 mmHg:
Ung chn (labetalol) nu nhp tim > 60 ln/pht.
- HATT < 180 mmHg v/hoc HATTr< 105 mmHg:
Ung chn (nu nhp tim > 60 ln /pht.
c ch men chuyn: enalaprin, peridopril.
Furosemid TM nu thuc h HA khng kt qu.
Thiopental: 50-100 mg/gi,

Propofol: 5 - 80 g/kg/pht.
U no
Synacthen: 1mg tim bp.
Methylprednisolon: 40-120
mg tim TM, duy tr
40mg/6gi.
Dexamethasone: 8 mg TB,
TM, duy tr 4 mg/6gi.
S x tr tng p lc ni s
144
CHN ON V X TR TRNG THI NG KINH

1. I CNG
- L trng thi trong cc cn ng kinh xut hin lin tip lin nhau m trong
giai on gia cc cn vn tn ti cc triu chng thn kinh v/hoc ri lon thc;
hoc mt cn ng kinh ko di qu lu gy nn mt bnh cnh lm sng nng n.
- V thi gian ko di mt hot ng ng kinh t 30 pht tr ln vi cc triu
chng khc nhau do cc qu trnh gii phu, sinh l bnh v nguyn nhn rt a dng.
- Mt s tc gi a ra nh ngha ph hp cho lm sng hn:
+ Cn co git ko di trn 5 pht, hoc
+ C trn hoc bng 2 cn co git m gia cc cn khng c s phc hi hon
ton thc.
2. NGUYN NHN
2.1. Tn thng thn kinh trung ng cp tnh:
- Vim no hoc vim mng no.
+ Do vi khun: no m cu, lin cu, cm, t cu,
+ Do vi-rt: vi-rt herpes, vi-rt adeno,
+ Do nm: Cryptococcus, aspergillus,..
+ Do vi khun lao.
+ Do k sinh trng: u trng giun ln, sn no,
- Huyt khi tnh mch no:do nhim khun, do ri lon ng mu,
- Bnh l mch mu no:
+ Nhi mu no.
+ Xut huyt no.
+ Xut huyt di nhn.
- Tn thng no do chn thng.
- Bnh no do tng huyt p.
- Tn thng no do gim oxy v thiu mu:
+ Sau ngng tun hon.
+ Ngng th.
2.2. Tn thng thn kinh trung ng mn tnh
- Tin s tai bin mch mu no.
- U no.
2.3. Ri lon chuyn ha hoc ng c
- Qu liu thuc: amphetamine,
- Hi chng cai thuc (benzodiazepine, ru)
- Do cc thuc iu tr: betalactam, theophylline,
- Tng hoc h ng mu.
- Ri lon in gii: h natri mu hoc h canxi mu
145
- St cao tr em.
2.4. ng kinh
- Ngng t ngt hoc thay i liu thuc chng ng kinh.
- ng kinh tm thn.
3. TRIU CHNG
3.1.1. Tnh trng ng kinh ton th co git tng trng lc (tonico clonique)
- Cc cn ng kinh ton th ni tip nhau, khng phc hi thc gia cc
cn.
- i khi cn ng kinh ch biu hin kn o trn lm sng bng co git nh
mt.
- C th ch biu hin bng hn m.
3.1.2. Cn vng thc ko di hoc lin tip
- Thng biu hin bng tnh trng ln ln.
- C th c co git kn o mi mt.
- Nguy c di chng tr tu vnh vin nu cn ko di.
3.1.3. Tnh trng ng kinh mt phn
- Nhiu hnh thi.
- Cn co git ni tip nhau vi thiu st vn ng gia cc cn:
+ Ri lon li ni ko di.
+ Tnh trng ln ln.
- Nguy c c cc tn thng no khng hi phc.
- in no : xc nh chn on trng thi ng kinh v phn loi tn thng
trn h thng thn kinh trung ng.
- Cc chn on hnh nh v xt nghim khc: nh gi nguyn nhn v bin
chng ca trng thi ng kinh
4. CHN ON
4.1. Chn on xc nh
- Lm sng: co git ko di trn 30 pht hoc co git ko di trn 5 pht m
khng c hi phc thn kinh gia cc cn
- Cn lm sng: in no xc nh cc sng ng kinh ko di.
4.2.1. Chc dch no ty: Pht hin cc tnh trng vim mng no do vi khun, virus,
nm, lao, k sinh trng.
4.2.2. Chp cng hng t s no: xc nh huyt khi tnh mch, tn thng no do
thiu oxy, do h ng mu.
4.2.3. Chp CT s no: xc nh tn thng nhi mu no, xut huyt no, xut huyt
di nhn, cc chn thng s no, cc tn thng u no.
146
4.2.4. in no: Rt c gi tr chn on trng thi ng kinh m biu hin lm sng

khng r rng.
4.2.5. Cc xt nghim chn on nguyn nhn
- Tm amphetamin, ru, thuc ng,xt nghim mu v/hoc nc tiu.
- Cc ri lon in gii mu: h natri mu, h canxi mu.
5. X TR
5.1. Nguyn tc x tr
- m bo chc nng sng c bn: h hp, huyt ng, toan chuyn ha, thn
nhit, s cu cc chn thng.
- Ct ngay cc cn co git bng mi thuc c sn, cng nhanh cng tt.
5.2. Cc thuc ct cn co git
- Benzodiazepines:thuc ct cn co git u tay v tc dng ct cn co git
nhanh
Diazepam
(Valium)
Lorazepam
(Temesta)
Midazolam
(Hypnovel)
Thi gian tc Thi gian duy u im

Nhc im
dng sau tim tr tc dng
10-20s
< 20 pht
n nh nhit Phn b vo
phng
m m
2 pht
4-6h
< 1 pht
Ngn
C th truyn lin tc
trong tr trng thi ng
kinh tr
t nh hng tim mch
Clonazepam Nhanh
2-4h
(Rivotril)
- Phenytoin (hoc fosphenytoin) (Dyhydan, Dilantin)
+ Hiu qu (60 -80%) c bit vi cn ng kinh cc b v d phng ti pht
cn co git trong thi gian di.
+ Liu ti a: phenytoin n 50mg/pht, fosfenyltoin n 150mg/pht.
+ Tc dng ph: c ch tun hon v cn tim chm.
+ Chng ch nh: bnh tim mt b, ri lon dn truyn. Khng nn dng
ngi gi, bnh mch vnh.
- Barbiturat: Tc ng thng qua GABA receptor. Hai thuc trong nhm ny
hay c dng nht l Phenobarbital & Pentobarbital.
+ Phenobarbital:
Rt hiu qu, tim tnh mch tc dng sau 5 pht v tc dng ko di.
Nguy c: c ch thn kinh (tng ln khi phi hp vi benzodiazepam
+ Thiopental:
Tc dng nhanh, hiu qu; c dng nhiu ti cc khoa HSCC.
147
Nguy c: c ch TK, ngng th, tru mch, tn thng gan.

Liu dng: tn cng 3-5mg/kg sau 50mg/pht, duy tr 1-5mg/kg/gi.
- Propofol:
+ Thng dng khi iu tr trng thi ng kinh tr.
+ Tc dng nhanh, thi gian tc dng ngn. C th gy tt huyt p hoc c ch
h hp, him gp nhng nguy him l hi chng bao gm nhim toan chuyn ha, tiu
c vn, suy thn v ri lon chc nng tim.
- Mt s thuc khc:
+ Valproate (depakine): t kinh nghim dng ng tnh mch.
+ MgSO4: ch yu dng trong sn git, liu 2-4g/5 pht tnh mch sau
truyn 1g/gi trong 24 gi.
+ Lidocain tnh mch: t dng (hiu qu thong qua, tc dng ph nhiu).
+ Thuc gin c: khng phi l thuc chng ng kinh ch yu dng khng
ch cc hu qu ca cn git.
5.3. Cc bin php hi sc chung
5.3.1. m bo h hp
- t ni kh qun (bo v ng th, ht m).
- Th my ch kim sot.th tch nu hn m.
- Theo di SpO2 ( > 95% ) v kh mu ng mch.
5.3.2. m bo huyt ng
- Theo di nhp tim v huyt p.
- Nn t catheter tnh mch trung tm: m bo truyn dch, truyn thuc + o
p lc tnh mch trung tm.
- Nu tt huyt p: bi ph th tch, thuc vn mch, m bo thng kh, iu
chnh ri lon toan chuyn ho nng.
5.3.3. Toan chuyn ho
- Theo di kh mu ng mch.
- a s toan chuyn ho s t iu chnh sau khi kim sot c co git.
- NaHCO3 khi toan rt nng pH < 7,15.
- C th kt hp toan h hp, ch iu chnh li lu lng thong kh/pht.
5.3.4. Tng thn nhit
- Thng gp do bn thn co git gy ra, nguy c gy nng hn tn thng thn
kinh trung ng.
- Cn nhanh chng h thn nhit < 390C: chm lnh, thong gi, paracetamol
0,5g/ mi 4 gi.
5.3.5. Ph no
- Nm u cao 45 .
- Manitol truyn tnh mch nhanh trong 30 pht 0,5- 1 g/kg cn nng mi 4 6
gi
148
- Methylprednisolon 40mg tim tnh mch /6 -8 gi. Hoc Dexamethasone

trong vim mng no.
- Khng ch cn git.
5.3.6. Phng v iu tr tiu c vn
Truyn dch v cho i tiu nhiu (100 ml/gi) v thuc li tiu tnh mch nu
thy cn thit.
5.3.7. Ch s cu cc chn thng km theo: chn thng s no, chn thng
hm mt, gy xng
6.1. Tin lng
- T l t vong bnh nhn ln u xut hin trng thi ng kinh khong 20%,
thay i ty theo nguyn nhn khi pht.
- Nguyn nhn t vong lin quan ch yu n nhng ri lon do tnh trng co
git c ko di nh: tiu c vn, toan lactic, vim phi do ht, suy h hp
- Nguy c ti pht co git gp 1/3 s bnh nhn theo mt nghin cu theo di
dc 10 nm, v 10% bnh nhn c nhng di chng thn kinh.
6.2. Bin chng
- Khi c cn co git ko di trn 30-45 pht c th gy ra cc tn thng no
(nht l cu trc limbic nh hi hi m): no, di chng thn kinh, tr tu vnh vin.
- Ngoi ra, tnh trng ng kinh c th gy ra nhiu hu qu khc:
+ Chn thng: chn thng s no, trt khp vai, gy xng, ng dp tng.
+ Ri lon h hp: ng, vim phi do sc, toan h hp.
+ Ri lon huyt ng.
+ Toan chuyn ho.
+ Ri lon thn nhit, mt nc, tiu c vn.
7. PHNG BNH
- S dng thuc ng liu lng v khng ngng thuc t ngt.
- Trnh cc iu kin thun li gy cn co git, b tr cng vic v ngh nghip
hp l phng trnh cc tai nn th pht xy ra khi co git.
Ti liu tham kho
1. Stecker M.M. (2013), Status epilepticus in adults. Uptodate 21.2
2. Dhar R. (2008), Status epilepticus, The Washington manual of critical care,
the 2nd edition.
3. Shonrvon S. (2000), Handbooook of epilepsy treatment, Blackwell science.
4. Karine J., Khaled A., Hirsch L.J. (2010), Updates in the Management of Seizures
and Status Epilepticus in Critically Ill Patients., Comprehensive Epilepsy
Center, Columbia University, 7th floor, 710 West 168th Street, New York, NY
10032, USA.
5. Jean-Louis Vincent. et al (2010), Textbook of Critical care, the sixth edition.
149
Kim sot ban u trng thi ng kinh
- Kim sot v bo v ng th
- Theo di cc du hiu sng (SPO2, huyt p
v in tim)
- Xt nghim ng mu mao mch
- t ng truyn tnh mch
- Ly cc xt nghim: Cng thc mu, in
gii, can xi, chc nng gan/thn, c cht,
nng thuc chng ng kinh, kh mu ng
mch
iu tr thuc chng co git
- Xem xt cho thiamin (100mg) v glucose (50ml
glucose 20%) nu nghi ng do h ng huyt
- Lorazepam 4mg tim tnh mch, nhc li mi 2 4mg cho n liu ti a l 0,1mg/kg; v
- Phenytoin/fosphenytoin tim tnh mch liu 1820mg/kg; tc ti a 50mg/pht (phynetoin) hoc
150mg/pht (fosphenytoin)
Nu ngng co git
- Tip tc thm d chn on (CT s,
chc dich no ty)
- Xem xt lm in no nu ngi bnh
tnh v khng c co git
- Kim tra lieu phenytoin mu mi 1-2
gi/ln sau tim.
Nu co git tip din

- Thm 5-10mg phenytoin
- Xt cho thuc chng co git th hai
+ Valproat 20-40mg/kg tim tnh mch
trong 10 pht.
+ Levetiracetam 2g tim tnh mch
+ Phenobarbital 5mg/kg tim tnh
mch, liu ti a 20mg/kg trong 15 pht.
- Nu c du hiu gim oxy ha mu hoc
hn m (glasgow < 12 im t ng ni
kh qun v th my.
S x tr trng thi ng kinh
150
Trng thi ng kinh khng tr
Cn ng kinh tip din (lm sng hoc in no)

d dng hai thuc chng ng kinh
Kim sot chung

- t ng ni kh qun bo v
ng th
- Tip tc theo di in no
- Theo di cc du hiu huyt
ng
- Tip tc s dng cc thuc
chng ng kinh vi liu ti
a
- iu tr nguyn nhn
- Hi chn chuyn gia thn
kinh
Kim sot co git

- Dng thuc truyn tnh mch
kim sot (lm sng v in no):
midazolam
- C th tim nhanh liu np kim
sot co git
- iu chnh liu thuc truyn
kim sot cn git
Co git khng c kim sot

Tip tc co git d tng liu
thuc truyn, co git ngay sau khi
tim nhanh liu np hoc co git
sau khi gim liu thuc truyn
Co git c kim sot

- Tip tc truyn trong 24 gi kim
sot co git
- Theo di v pht hin cc bin
chng: nhim khun, ri lon huyt
ng,
- Sau 24 gi u gim liu dn v
theo di co git ti pht
Khng kim sot c co git

- Dng cc thuc chng co git
khc: propofol, pentobarbital
- Dng bin php h thn nhit.
- Thm thuc chng co git ng
ung
Co git c kim sot

- Theo di in no trong 12-24 gi
sau khi ngng truyn thuc chng co
git.
- Tip tc cc thuc chng co git
ng ung
S x tr trng thi ng kinh khng tr

151
Chng VI: HUYT HC

CC RI LON NG MU THNG GP TRONG HI SC
1. I CNG
Ri lon ng mu l mt vn thng gp ngi bnh nng trong khoa
Hi sc, do nhiu nguyn nhn v biu hin lm sng a dng. Mi nguyn nhn cn
phi c nhng bin php iu tr c hiu v h tr khc nhau. Trong nhng nm gn
y nhng hiu bit su hn v bnh nguyn v iu tr lm sng cc ri lon ng
mu gip ch cho vic chn on v xc nh chin lc iu tr ti u.
2. NGUYN NHN
- Nhim khun (52%): l yu t nguy c cao nht ca ri lon ng mu (gim
tiu cu do gim sinh, tng ph hy, tng tiu th ti lch, gim cc yu t ng mu).
- ng mu ri rc trong lng mch (DIC): chim 25%, l bin chng ca rt
nhiu bnh nguyn nh nhim khun, chn thng, cc bin chng sn khoa
- Mt mu nng (8%).
- Huyt khi vi mch (1%): ban huyt khi gim tiu cu tc mch
(thrombocytopenia thrombotic pupura - TTP ), hi chng tan mu tng ure huyt
(hemolytic uremic syndrome - HUS) l nhng bnh cnh him gp,
- Gim tiu cu do heparin (heparin induced thrombocytopenia - HIT), bnh
nhn trong hi sc thng phi dng heparin (trng lng phn t thp hoc khng
phn on) d phng huyt khi tnh mch su, lc mu
- Gim tiu cu do thuc (10%): quinine, iu tr ha cht, thuc chn knh
calci, cc thuc khc.
- Gim tiu cu do min dch (3%): hi chng khng phospholipid hoc Lupus
ban h thng
- Sau ghp ty xng (10%).
- Mang thai/ sau (21%).
- Cc ri lon khc: ung th (10%), tng huyt p c tnh
3. TRIU CHNG
3.1. Lm sng
- Bnh cnh lm sng a dng, t khng c triu chng n nhng bin chng
chy mu nguy him.
- Xut huyt di da v nim mc: dng chm, dng ban hay mng bm tm
- Chy mu nng: chy mu tiu ha, chy mu no.
- Thiu mu tan mu vi bnh l vi mch (microangiopathic hemolytic anemia).
- St.
- Ri lon thc.
- Biu hin lm sng ca bnh chnh.
152
3.2. Cn lm sng
- S lng tiu cu gim di 150.000 t bo/mm3.
- Xt nghim ng mu: nh lng sn phm ging ha ca fibrinogen (FDPs)
tng, D Dimer: tng cao, Antithrombin(AT): thp, Fibrinogen c th bnh thng do
c ch b tr trong giai on sm. Trng hp DIC nng lun thy gim fibrinogen
mu cn di 1 g/l.
- Mnh v hng cu.
- Xt nghim huyt ty , sinh thit ty xng tm nguyn nhn
- Cc xt nghim khc: ure, creatinin, MRI s no
4. CHN ON
4.1 Chn on xc nh: da vo lm sng v xt nghim.
- S lng tiu cu < 150000 /mm3.
- Prothrombin ko di, aPTT ko di, fibrinogen gim.
4.2. Chn on phn bit
- Gim tiu cu gi do dng chng ng khng y dn n tiu cu b vn
lm my m nhm, s dng khng th n dng abciximab tc ng trc tip vo th
th Gb IIb/IIIa.
- Chn on phn bit TTP/HUS vi DIC.
- Suy gan cp.
a) Gim tiu cu
Lm sng: bnh cnh a dng t khng triu chng n cc ban, chm xut
huyt di da v nng n nht l xut huyt nguy him (chy mu ni s, xut huyt
tiu ha)
Cn lm sng: tiu cu mu < 150000 /mm3.
- Gim tiu cu do heparin (Heparin induced thrombocytopenia : HIT)
+ Thng xy ra t ngy th 5 10 sau dng heparin.
+ da, hoi t v tr tim heparin, v cc triu chng ton thn nh st, kh
th, nhp tim nhanh do tim heparin liu bolus tnh mch.
+ Gim tiu cu: gim > 50% s lng tiu cu sau 5 10 ngy dng heparin
ln u tin.
+ S lng tiu cu thng < 100 G/l.
+ Khi lm sng c biu hin nghi ng v test huyt thanh tm khng th ph
thuc heparin (ELISA dng tnh).
- Gim tiu cu do nguyn nhn min dch.
+ L mt hi chng c trng bi:
Tiu cu giam di 100 G/l.
Tng mu tiu cu trong tuy xng.
i sng tiu cu ngn.
C khng th khng tiu cu trong huyt tng.
153
+ Cc nguyn nhn xc nh c nh:

Do b cc bnh nhim trng nng, nhim k sinh trng.
Cc bnh c lch to.
Cc bnh t min: ban ri rc, vim nt ng mch, vim a khp
dng thp.
Cc bnh v mu: suy ty xng, x ty, ung th mu, ung th hch,
ung th ni khc xm ln vo ty xng, thiu mu tiu huyt t min...
b) ng mu ni mch ri rc (DIC)
- Chn on DIC l mt chn on loi tr, khng mt xt nghim n c no
ngha khng nh chn on.
- Tiu chun chn on ng mu ni mch ri rc ca hip hi ng cm mu
quc t (International Society on Thrombosis and Haemostasis - ISTH) nm 2001 c
b sung bng cch tnh im da vo cc ch s theo bng sau.
Bng 1.1. Tiu chun chn on DIC theo ISTH 2001 c sa i
Ch s
im
S lng tiu cu
>100 G/l
0
D-Dimer so vi gii hn cao bnh

thng (du n tng tiu fibrin)
Thi gian prothrombin
Fibrinogen
50 - 100 G/l
< 50 G/l
< 2 ln
1
2
0
2 5 ln
> 5 ln
Ko di 3 giy
2
3
0
Ko di > 3 v 6 giy
Ko di > 6 giy
1 g/l
1
2
0
< 1 g/l
- Chn on DIC khi tng s im 5.

c) Ban huyt khi gim tiu cu tc mch/ hi chng tan mu tng ure
huyt(Thrombotic thrombocytopenic purpura- TTP/ Hemolytic uremic syndromeHUS).
- TTP l mt trong cc bnh l huyt khi tc vi mch. iu quan trng cn lu
l chng ch nh truyn khi tiu cu cho cc ngi bnh ny khi khng c tnh
trng chy mu e da.
- Nm tiu chun chn on ban huyt khi gim tiu cu tc mch:
+ Thiu mu tan mu vi bnh l vi mch.
+ Gim tiu cu.
+ Suy thn.
+ St.
+ Ri lon thc.
154
- Ch 40% trng hp gp y c nm chng trn.

- Thay huyt tng l mt trong nhng bin php c cho l c hiu qu nht
trong vic iu tr cu sng ngi bnh, ng thi cng l tiu chun chn on.
d) Cc nguyn nhn ko di thi gian ng mu.
Mt iu quan trng l xt nghim ng mu ton b, trong c Prothrombin
time (PT) v aPTT. Xt nghim l bin php nhanh chng, hu hiu nht theo di
cc yu t ng mu ti mt hoc nhiu thi im. Khi nng cc yu t ng mu
gim di 50% th cc xt nghim ng mu (PT, aPTT) s ko di.
Trong a s cc trng hp ti khoa Hi sc, gim cc yu t ng mu thng
l mc phi, do gim tng hp (suy gan, tn thng gan cp hoc mn, hoc thiu ht
vitamin K), mt qu nhiu (chn thng, mt mu nhiu) hoc tng tiu th. Ngoi
ra cn c s hin din ca cc khng th c ch lu hnh (nh trong bnh hemophilia)
Bng 1.2. Nguyn nhn ca gim cc yu t ng mu
Xt nghim
Nguyn nhn
Thiu ht yu t VII
PT ko di, aPTT
Thiu ht vitamin K mc nh
bnh thng
Suy gan nh
S dng liu thp thuc chng ng khng vitamin K
Thiu ht yu t VIII, IX hoc XI
PT bnh thng,
S dng heparin khng phn on
aPTT ko di
Khng th c ch v hoc khng th khng phospholipid
Thiu ht yu t XII hoc prekallikrein
Thiu ht yu t X, V hoc II
Thiu vitamin K nng
PT v aPTT ko di S dng thuc khng vitamin K
Thiu ht ton b yu t ng mu: suy gan, mt mu nng, tng
tiu th ( DIC)
- Lm sng v chn on
+ Biu hin lm sng ca bnh nguyn.
+ Cc du hiu chy mu, ty theo mc thiu ht cc yu t ng mu.
+ Xt nghim: gim cc yu t ng mu, thi gian ng mu ko di.
5. X TR
5.1. Nguyn tc x tr
- iu tr bnh nguyn l chnh.
- iu tr cc nguyn nhn ri lon ng mu.
- iu tr thay th v iu tr h tr.
5.2. X tr ban u
- Cm mu, n nh cc chc nng sng, bi ph th tch
- Nhanh chng chuyn ngi bnh n bnh vin iu kin iu tr.
155

a) Gim tiu cu
- Truyn tiu cu khi tiu cu < 10 G/l hoc 20 G/l c nhim trng hoc c
nguy c chy mu, hoc di 50 G/l cn tin hnh cc th thut, phu thut.
- Gim tiu cu do Heparin (HIT)
+ Ngng ngay heparin.
+ Dng cht c ch thrombin trc tip: lepirudin, argatropan v bivalirubin.
+ Khng c truyn tiu cu tr khi chy mu e da tnh mng.
+ Khi tiu cu > 100.000/l chng t bnh hi phc th b sung thm
warfarin v duy tr cht c ch thrombin trc tip cho n khi t c iu tr bng
warfarin.
b) ng mu ni mch ri rc
- iu tr thay th.
+ B sung ch phm mu: truyn huyt tng ti ng lnh 10 15ml/kg/24h
(tng ng 3 4 n v/ ngy, truyn 80 100 git/ pht ngay sau khi r ng).
+ Truyn yu t ta VIII khi c fibrinogen < 1 g/l.
+ Truyn tiu cu.
- Thuc chng ng.
+ Thuc chng ng c ch nh khi c D dimer tng cao, nghim php
ru dng tnh v thi gian DIC > 6 h.
+ Heparin trng lng phn t thp (enoxaparine): 1 mg/kg/12gi tim di
da. Duy tr anti Xa 0,5 1.
+ Ngng thuc chng ng khi : nghim php ru m tnh, D dimer gim v
tiu cu tng tr li.
- Thuc iu tr tiu si huyt.
+ Ch nh khi c biu hin tiu si huyt th pht tng cao, lm sng c chy
mu nng, fibrinogen tip tc gim, D dimer tng cao.
+ Transamin tim tnh mch 10 mg/kg x 2 4 ln/ ngy.
c) TTP/HUS
- Thay huyt tng (PEX) kt hp hoc truyn globulin min dch vi iu tr
h tr (hi sc tun hon, h hp, thn nhn to ).
- Thay huyt tng: c chng minh l bin php c hiu qu iu tr cu
sng ngi bnh. Phc iu tr TTP.
- Ch truyn khi tiu cu khi c chy mu nguy him.
156
Chn on
Bt u PEX hng
ngy viplasma
Nu khng thiu ht
ADAMTS 13 ( vd, c
suy thn cp, do thuc
hoc nghi ng c t
Shiga)
Khng dng corticoid
Tip tc PEX cho n
khi p ng
t cp ( gim tiu
cu ti din)
Bt u PEX hng
ngy, vi plasma
C chn on khc:
Ngng PEX
Nghi ng thiu ht
ADAMTS 13: bt u
iu tr corticois
p ng iu tr. Tiu cu >

150 G/l trong 2 ngy:
1.Ngng PEX.
2 Tip tc corticoid.
3. Lu ng truyn TMTT
Khng p ng hoc p
ng thong qua, c cc
bt thng thn kinh mi:
-Corticoid liu cao
-Rituximab
-PEX 2 ln/ngy
Tiu cu bnh thng trong

thi gian 1-2 tun.
1. Rt catheter TMTT.
2. Duy tr corticoid liu thp
Bnh thuyn gim: s lng tiu cu

bnhthng sau 30 ngy sau ln PEX cui
cng
Tipht:
PEX hng ngy
Corticoid
Rituximab
Phc thay huyt tng trong bnh TTP
157
TC tng, ci thin
triu chng thn kinh
PEX hng ngy
5.3.4. Ri lon ng mu do thiu ht cc yu t ng mu

- iu tr bnh chnh kt hp vi iu tr thay th cc yu t ng mu.
- iu tr thay th:
+ Vitamin K: tim ng tnh mch, di da, tim bp hoc ng ung.
+ Truyn plasma ti ng lnh 10 15 ml/ kg (4 -6 n v), yu t ta lnh
(giu fibrinogen) v tiu cu trong trng hp c chy mu hot ng.
Ty theo biu hin lm sng, v mc thay i cc yu t ng mu.
7. PHNG BNH
Pht hin v x tr kp thi nguyn nhn gy ri lon ng mu.
Ti liu tham kho
1. Coutre S. (2013), Heparin-induced thrombocytopenia. Uptodate.com
2. George J.N. (2010), How I treat patients with thrombotic thrombocytopenic
purpura, Blood. 116 (20).
3. Levi M and Opal S.M. (2006), Coagulation abnormalities in critically ill
patients, Crit Care. 10(4): 222.
4. Ritz E. (2003), Advance in the pathology, diagnosis, and the treatment of
thrombotic thrombocytopenic purpura
5. Rizoli S., Aird W.C. (2011), Coagulopathy, Texbook of critical care (Editors:
Vincent J.L., Abraham E., Moore F.A., Kochanek P.M., Fink M.P.), Elsevier
Saunders, 6th edition.
6. Rizoli S., Aird W.C. (2011), Thrombocytopenia, Texbook of critical
care(Editors: Vincent J.L., Abraham E., Moore F.A., Kochanek P.M., Fink M.P.),
Elsevier Saunders, 6th edition
7. Schroeder M.A. (2008), Acute management of the bleeding patient/
coagulopathy, The Washington manual of critical care (Editors: Kollef M.H.,
Bedient T.J., Isakow.W., Witt C.A.), Wolters Kluwer Lippincott Williams &
Wilkins, first edition.
158
Xt nghim cc yu t ng mu: PT, aPTT, TT v fibrinogen
ng mu bnh thng
Gim tiu cu
Nng fibrinogen bnh

thng
Tng LDH
Gim haptoglobin
C mnh v hng cu
Tn thng c quan ch
Ko di PT, aPTT v TT
Tng/gim fibrinogen
Tng D dimer
Tng sn phm ging
ha fibrinogen
C mnh v HC
Tn thng c quan
ch
Ko di PT
Ko di PT v aPTT
Ko di PT
Th nghim trn 50:50

Thiu ht
nhiu yu t
ph thuc
vitamin K
Hoc dng
wafarin
Ri lon
fibrinogen mu
Bnh gan
C cht c ch
thrombin
iu chnh c
Thiu ht mt yu t
n l
nh lng nng
cc yu t ng mu
TTP/HUS
Ri lon ng mu
do tiu th
Hi chn huyt hc
Thay huyt tng
Ch nh truyn khi
tiu cu khi c chy
mu
DIC
Vim mch
Ko di aPTT
Bi ph yu t thiu ht theo kinh

nghim
Vitamin K 5-10 mg ung hoc tim
TM
Truyn yu t ta lnh nu fibrinogen
< 100 mg/dl hoc nghi c vn bt
thng fibrinogen
Bi ph n khi nng
t 50 80%
Hi chn huyt hc
S tip cn ngi bnh ri lon ng mu
159
B ko di
C cht c ch
Sa cha bng nng

phospholipid
Cht chng
ng lupus
anticardiolipin
APLAS
Chng VII: SN KHOA

HI CHNG HELLP
1. I CNG
L mt bnh l sn khoa c trng bi cc biu hin: thiu mu do tan mu,
tng men gan v gim tiu cu xut hin vo na cui ca thi k c thai.
T l mc bnh l 2% - 12%, t l t vng ca m l 35%.
Do c nguy c gy t vong c m v thai, nn hi chng HELLP thc s l mt
cp cu cn c chn on v x tr cp cu ti cc n v sn khoa v hi sc cp cu.
Vit Nam cha c s liu chnh xc v t l mc hi chng HELLP.
2. NGUYN NHN
Nguyn nhn cha r rng, cn nhiu tranh ci. Tuy nhin a s cc tc gi u
nht tr bn cht ca HELLP l mt th lm sng c bit ca tin sn git.
3. TRIU CHNG
3.1. Lm sng
- Phn ln hi chng HELLP xut hin trn nn mt nhim c thai nghn (tin
sn git hoc sn git:
+ Ph.
+ Tng huyt p.
+ Thai > 20 tun.
+ Hi chng HELLP xut hin khong 4 - 12% ngi bnh tin sn git,
khong 30% cc trng hp HELLP xut hin cc tun u sau .
- Biu hin:
+ Cm gic kh chu (90%)
+ au thng v (65%)
+ Nhc u (31%): au nhiu, m mt, tnh trng d kch thch, tng phn x
+ Bun nn v nn.
- Ph, cao huyt p,vng da, xut huyt di da
- Sn git: trn nn tin sn git xut hin cc cn co git, biu hin thng tn
lin quan n h thn kinh trung ng.
3.2. Cn lm sng
- Tan mu: xy ra cc mao mch mu, do s vn chuyn ca cc t bo hng
cu trong lng cc mao mch mu b tn thng. Cc du hiu ca tan mu bao gm:
+ Mnh hng cu v, hng cu b bin dng trn tiu bn.
+ Bilirubin mu tng.
+ Haptoglobin tng.
+ LDH tng.
- Tng GOT, GPT: Nguyn nhn do thiu mu ti gan, c th dn ti nhi mu
gan, cc tn thng ny ct ngha triu chng au thng v, nn, bun nn hoc au
h sn phi, vng da.
160
- Gim tiu cu: Do tn thng vi mch ch yu l tn thng ni mch v co

tht mch. Hu qu ca serotonin v thromboxane A2 lm tng ngng kt tiu cu
trong lng mch.
4. CHN ON
4.1. Chn on xc nh:
Trn nn mt ngi bnh nhim c thai nghn (tin sn git, sn git) xut
hin tam chng:
- Tan mu:
+ Cc bt thng mu ngoi bin: mnh v hng cu, hng cu bin dng.
+ Bilirubin ton phn > 1,2 mg/dl.
+ LDH > 600 UI/l.
- Tng men gan: GPT > 70 UI/l.
- Gim tiu cu: s lng tiu cu < 100.000/ mm3.
4.2. Chn on phn bit
- Xut huyt gim tiu cu tc mch.
- ng mu ni qun ri rc.
- Hi chng c khng th khng Phospholipid.
- Tng huyt p c tnh.
- Thiu mu tan mu ure huyt cao.
- Vim gan vi rt.
- Nhim trng ng mt.
- Vim gan nhim c.
- Bnh gan thoi ha m cp tnh ngi c thai.
Bng chn on phn bit ca hi chng HELLP vi mt s bnh l
Du hiu
Thn kinh
Suy thn
Suy gan
Chy mu
ng
mu ni
HELLP
qun ri
rc
Xut huyt
gim tiu
cu tc
mch
Tan mu, Hi chng

Tng
ure huyt
khng
huyt p
cao
Phospholipid c tnh
+/+
+/-
+/+/+/+
++
+/-
++
+/-
++
-
+/+/+/+/Sy thai, tc
mch, lupus
+
+
++
++
Tng
huyt p
+
-
Tin s
+/-
+/-
Tiu cu gim
Howell di
Prothrombin
di
PDF
+
-
++
+
++
-
161
D - Dimer
VDRL
ANA
+
-
+
+
4.3. Phn loi, mc

- Theo phn loi hip hi sn ph khoa Hoa k nm 2000.
+ Hi chng HELLP 1 phn (c 1 hoc 2 du hiu bt thng).
+ Hi chng HELLP y : c nhiu bin chng cho m nn chm dt
thai k.
- Da trn s lng tiu cu:
+ I: < 50.000/ mm3.
+ II: 50.000 100.000/ mm3.
+ III: 100.000 150.000/ mm3.
5. X TR
5.1. Nguyn tc x tr
u tin cu m, la chn thi im thch hp xt nh ch thai nghn.
- Nu c co git:diazepam 10mg tim bp,cho ngi bnh nm nghing
tri,chun b mt ng truyn tnh mch,duy tri bng glucose 5% chy chm.
- Kim sot huyt p < 140/90 mmHg: ung Aldomet 250 mg 2-4 vin,
Nifedipine 10-20 mg,nu huyt p ti a trn 200 mm Hg c th nh di li 1-3
git Adalat,khi c th truyn nicardipin tnh mch 1-5 mg/gi theo p ng ca ngi
bnh.
- m bo h hp trn ng vn chuyn.
a) iu tr cho m
- H huyt p:
+ Nn khng ch huyt p < 150/90 mmHg, tt nht l h con s huyt p xung
khong 10 15% con s ban u trong mt vi gi u.
+ Nn dng thuc h p ng tnh mch c tc dng nhanh, ngn, d iu
chnh, thuc ung ung c gi dn thay th truyn tnh mch.
+ Thuc u tin: Nicardipin liu 1 5 mg/gi, gi dn thuc ung Nifedipine,
labetalol.
- Phng nga co git: Magie sunlfate liu bolus tnh mch 2 4g, sau duy tr
truyn tnh mch 1 2g/gi (thn trng khi suy thn).
- S dng cc ch phm mu:
+ Truyn mu ch nn khi Hematocrit < 25%, c bit lu khi m ly thai.
+ Truyn tiu cu: mc ch d phng chy mu khi cn can thip phu thut
hoc ch huy (truyn tiu cu khi tiu cu < 20.000/ml).
162
- Dch truyn: do tng tnh thm thnh mch nn th tch thng b gim (c c
mu) dn n cng Cathecholamin gy tng huyt p kh kim sot, gim ti mu
thn. Tuy nhin nu b dch nhiu th li c nguy c cao gy ph phi, nn phi theo
di lin tc ALTMTT v nc tiu.
+ Corticoid: cn nhiu tranh ci, tuy nhin c s dng cho mc ch lm
trng thnh phi ca thai nhi, gim mc tn thng gan.
+ Thay huyt tng (Plasma exchange - PEX): c ch nh trong trng hp
ngi bnh mc nng.
b) nh gi tnh trng thai nhi v quyt nh thi im chm dt thai k
Thi im chm dt thai k ty thuc vo tnh trng bnh ca m, p ng vi
iu tr ca m, tnh trng sc khe ca thai v s trng thnh ca thai.
- T l t vng m khong 10%, t l t vong con t 10% 60% ty thuc tnh
trng bnh ca m.
- 20% - 30% s b hi chng HELLP trong ln mang thai tip theo v 40% b
tin sn git trong nhng ln mang thai sau.
7. PHNG BNH
Qun l thai nghn tt, sm pht hin nhim c thai nghn iu tr kp thi,
cn lu cc trng hp c tin s nhim c thai nghn, mc hi chng HELLP
trong nhng ln mang thai trc.
Ti liu tham kho

1. V Vn nh (2000):Tin sn git v sn git. Cm nang cp cu, Nh xut
bn Y hc, Tr:529-532.
2. Abildgaard U., Heimdal K. (2013), Pathogenesis of the syndrome of
hemolysis, elevated liver enzymes, and low platelet count (HELLP): a review.
Eur J Obstet Gynecol Reprod Biol. 166, Pp.117.
3. Alan D., Lauren N. (2013), HELLP syndrome, Current therapy in Obstetrics
and Gymecology 11, Pp. 288 293.
4. Benedetto C., Marozio L., Tancredi A. et al. (2011), Biochemistry of HELLP
syndrome, Adv Clin Chem, Pp. 53-85.
5. Burwick R.M., Feinberg B.B. (2013), Eculizumab for the treatment of
preeclampsia/HELLP syndrome, Placenta. 34, Pp. 201.
163
Hi chng HELLP
- Diazepam 10mg tim bp nu co git, c th lp li sau 10 pht nu
cha ct c cn.
- Thuc h p aldomet 250mg x 2 - 4 vin; nifedipin 10 - 20mg. Nu
huyt p ti a 200mmHg, nh di li 2 - 3 git adalat/ln
- m bo h hp, tun hon v t th an ton trn ng vn chuyn.
X tr ti bnh vin
iu tr cho m
- H huyt p:
+ Duy tr huyt p < 150/90 mmHg
+ u tin nicardipin 1-5mg/gi (truyn tnh mch).
- Phng chng co git:
+ Diazepam 10 mg tnh mch hoc tim bp nu
ang co git.
+ Megie sunlfate 2 - 4g tnh mch, sau truyn
tnh mch duy tr 1 - 2 g/gi.
- Mu v cc ch phm mu
+ Truyn hng cu khi khi Hct < 25%, c bit
khi m ly thai.
+ Tiu cu khi can thip phu thut hoc ch
huy.
- Truyn NaCl 0,9% m bo th tch tun hon.
- Thay huyt tng khi ngi bnh mc nng.
nh gi tnh trng thai nhi v

quyt nh thi im chm dt
thai k
- Thi im chm dt thai k ty
thuc vo tnh trng bnh ca
m, p ng vi iu tr ca m,
tnh trng sc khe ca thai v
s trng thnh ca thai.
- Lu s dng thuc trng
thnh phi cho thai nhi.
S x tr hi chng HELLP
164
SN GIT V TIN SN GIT

1. I CNG
nh ngha: tin sn git v sn git l mt ri lon xy ra ph n c thai
c c trng bng tng huyt p v c protein niu, tnh trng in hnh xut hin
sau tun th 20 ca thai k. Ri lon ny cng c th gp ngay trong giai on sm
sau khi .
Tin sn git l mt bin chng sn khoa gp khong 12%- 22% cc ph n
mang thai v l mt trong nhng nguyn nhn trc tip gy ra t vong cho khong
17% ca m.
2. NGUYN NHN
- Khng c nguyn nhn r rng, nhng c lin quan ti mt s yu t nguy c
gy tin sn git v sn git ph n mang thai:
+ Sinh con ln u tin.
+ Tui m trn 35 tui hoc di 20 tui khi mang thai.
+ Tng huyt p mn tnh.
+ Bnh thn, bnh m lin kt.
+ Mang thai nhiu ln.
+ C tin s gia nh v sn git, tin sn git.
+ M bo ph, ht thuc l.
+ M c bnh l v mch mu (vim mch..).
+ i tho ng.
3. TRIU CHNG
3.1. Du hiu v triu chng sn git v tin sn git
a) Th nh tin sn git.
- Protein niu xut hin trn 300 mg/24 gi (+) hoc tng thm so vi protein
niu theo di trc y (2+ hoc 3+).
- Huyt p tm thu 140 mmHg, v hoc tm trng 90 mmHg.
- Triu chng co git c th xy ra trc, trong hoc sau khi sinh: t l ca sn
git trc 25%, trong 50%, sau 25%. Hu ht xut hin trong vng 48 gi
u.
- Ngoi ra c th c cc du hiu sau:
+ Tng phn x gn xng.
+ au u, chng mt, nhn m, hoa mt.
+ Thiu niu (nc tiu di 400ml/24 gi).
+ au vng thng v.
+ Ph phi.
- Xt nghim ha sinh: ure, SGOT, SGPT, acid, uric, bilirubin l cc cht tng
cao trong mu, trong khi tiu cu v Albumin huyt thanh ton phn gim.
165
b) Th nng tin sn git: khi c mt hoc nhiu biu hin sau:

- o huyt p tm thu 160 mmHg, hoc tm trng 110 mmHg (o t nht
2 ln, cch nhau 6 gi).
- C biu hin tn thng mt trong cc c quan ch:
+ Suy thn cp, chc nng thn xu i nhanh chng, c bit khi protein niu
3 gam/24 gi, hoc t ngt thiu niu, creatinin mu tng nhanh.
+ Thn kinh: au u, nhn m, m v tm thi, co git, chy mu no.
+ Thay i bt thng chc nng gan, t mu di bao gan, v gan.
+ Ph phi huyt ng (3% ngi bnh).
+ Tim: cn tng huyt p nguy kch, suy tim, ngng tun hon.
+ au bng thng v hoc mng sn phi: t dch, t mu di bao gan.
+ Tiu cu di 100.000/mm3, ng mu ni qun ri rc trong lng mch.
+ Hi chng HELLP c th biu hin (k c khng c protein niu).
+ C biu hin suy thai: a i, thiu i, khng o c khi siu m tim thai, rau
bong non, thai cht lu, chm pht trin.
c) Hi chng HELLP: mt th ca tin sn git.
- Tiu chun chn on hi chng HELLP bao gm:
+ Thiu mu: hematocrit gim.
+ Tan mu: tm thy mnh hng cu v trn tiu bn mu, tng bilirubin huyt
thanh, tng LDH.
+ Tng men gan: tng hot cc men SGOT, SGPT.
+ Gim s lng tiu cu l mt c trng ca hi chng HELLP.
d) Sn git: C cn git vi 4 giai on in hnh:
+ Giai on xm nhim: khong 30 giy n 1 pht. C nhng cn kch thch
vng mt, ming, m mt nhp nhy, nt mt nhn nhm, sau cn git lan xung 2
tay.
+ Giai on git cng: khong 3 giy. Ton thn co cng, cc c thanh qun v
h hp co tht li lm cho ngi bnh d ngt th v thiu oxy.
+ Giai on git gin cch: ko di khong 1 pht. Sau cn git cng cc c
ton thn v chi trn gin ra trong chc lt, ri lin tip nhng cn co git ton thn,
d cn vo li, ming si bt mp.
+ Giai on hn m: co git tha dn ri ngng. Ngi bnh i vo hn m.
+ Ty theo tnh trng nng nh ngi bnh c th hn m nh hoc hn m su.
+ Nh sau 5-7 pht ngi bnh s tnh li, nu hn m su, c th ko di vi
gi. C th km theo ng t gin, ri lon c vng i tiu tin khng t ch.
+ Nng c th t vong trong tnh trng hn m ko di.
- Km theo mt s du hiu tin sn git nng.
e) Cc biu hin lm sng, cn lm sng, chn on hnh nh c th gp l:
+ Suy chc nng gan v gim tiu cu xut hin trn nn tin sn git.
+ Mt s ngi bnh c th xut hin DIC.
166
+ au mng sn phi, t mu di bao gan, i khi gp bin chng v bao gan.

4. CHN ON
4.1. Chn on xc nh
- Protein niu > 300 mg/24 gi (1+) hoc nhiu hn (+++).
- Huyt p tm thu 140 mmHg, tm trng 90 mmHg, ngi bnh trc
khng tng huyt p.
- C th ph mt, chn.
- Th nng khi huyt p tm thu 160 mmHg, v hoc huyt p tm trng
110 mmHg.
- Thai ph c th mc t tun 20 n 6-12 tun sau sinh.
- C biu hin tn thng cc c quan khc nh: thiu niu, ph phi, au
mng sn phi, au u, nhn m, thay i chc nng gan, gim tiu cu, thai chm
pht trin.
- Sn git khi c co git (loi tr nguyn nhn khc).
- Chn on th bnh vi hi chng HELLP: tan mu thiu mu, gim tiu cu,
tng men gan.
4.2. Chn on phn bit
- au bng cp: chn thng bng, phnh tch ng mch ch bng, vim
rut tha cp, si ng mt, cn au qun mt.
- Suy tim huyt, ph phi huyt ng.
- Rau bong non.
- Xy thai sm.
- Tng huyt p nng.
- au u cp, au u do cn Migraine.
- Tc vi mch, gim tiu cu v ni ban di da (TTP).
- Cc bnh l mch mu no cp: tai bin mch no thong qua, t qu, xut
huyt di nhn, xut huyt di mng cng.
- Nhim c gip, cn cng gip trng.
- Ng c thuc, dn cht cng giao cm, Amphetamin, hi chng cai.
- Co git do ng kinh, khi u no.
- Ri lon chuyn ha.
4.2. Chn on th
- Tin sn git.
- Tin sn git nng
- Sn git.
- Hi chng HELLP.
4.3. Chn on bin chng
- Cc bin chng ca thai nhi c th xy ra nh
+ non, suy t cung rau cp tnh: do c hin tng nhi mu rau, rau bong
non dn n suy thai, thai cht lu.
167
+ Suy t cung rau mn tnh lm thai km pht trin.

+ a i.
- Cc bin chng ca m:
+ Co git, ph no.
+ Suy thn cp.
+ Ph v t mu di bao gan.
+ ng mu ni qun ri rc trong lng mch (DIC).
+ Gim tiu cu: c th n c hoc trong bnh cnh DIC.
+ Ph phi cp huyt ng.
+ Hi chng HELLP: c th gp khong 10%.
5. X TR
5.1. Nguyn tc x tr
- Pht hin yu t nguy c, gii thch ngi bnh v gia nh hiu bit v
bnh v cch iu tr, theo di v phng bin chng.
- Khi c triu chng d l th nh cn iu tr ti cc c s y t chuyn khoa v
c qun l, theo di thai v sn ph cht ch.
- i vi th nng c bin chng: cn cho ngi bnh nhp bnh vin v hi
chn cc chuyn khoa khi cn thit, theo di v iu tr ti cc phng hi sc sn khoa.
- i vi sn ph khi chuyn d hoc khi c du hiu nng, bin chng: tin
lng kp thi can thip phu thut bo tn tnh mng m, ly thai khi c ch nh.
5.2. X tr ban u v qun l thai nghn
- Sn ph c tin s tin sn git hoc sn git cn c theo di, qun l thai
theo k hoch c th ti cc phng khm thai khu vc vi cc trang thit b chuyn
khoa, cc xt nghim sinh ha, huyt hc, c phng tin cp cu v vn chuyn
cp cu.
- Sn ph c cc triu chng sn git, tin sn git phi c nm iu tr, d
kin sinh trong bnh vin c chuyn khoa sn, chuyn khoa hi sc, c phng phu
thut.
- Vn chuyn sn ph c chn on tin sn git, sn git ln tuyn cao hn:
phi m bo x tr cp cu ban u:
+ Ch chm sc, h l cp I.
+ Kim sot cn co git: Trc khi chuyn tim bp Diazepam 10mg x 1 ng,
sau tim bp chm Magnesi sulfat 15% 4g.
+ Kim sot h hp: t canun mayo phng cn vo li, th oxy m bo
SpO2> 92%, ht m khai thng ng h hp nu c biu hin tc nghn ng th.
+ Kim sot huyt p: duy tr HATT < 150 mmHg, hoc gim 10-15% trong
vi gi u.
+ Cp cu c bn ban u ti ch nu c cc bin chng hoc triu chng nng.
+ Sn ph c triu chng chy mu, suy thai phi hi chn v phi hp chuyn
khoa ngay.
168
5.3. X tr chuyn khoa: ti bnh vin tuyn tnh

a) Th nh ca tin sn git
- Thai thng hoc thai non nhng tnh trng thai nhi khng n nh, cc
biu hin ca th bnh tin trin dn n m c nguy c t vong cao:
+ Cho ng di khi phi pht trin (28 tun), cn cho thuc tng
trng thnh phi trc khi sinh.
+ Thai non tnh trng n nh: ngh ngi ti ging, iu tr bo tn, theo di
thai.
+ Thuc chng co git: magie sulfat 15% liu khi u 2-4gam tim tnh mch
tht chm vi tc 1gam/pht, hoc pha long trong dung dch glucose truyn tnh
mch chm. Sau tim bp su hoc tim, truyn tnh mch 1 gam mi gi. Phi
theo di phn x gn xng hng ngy, phng dng qu liu magnesi sulfat. Duy
tr 24 gi sau cn git cui cng.
b) Th nng ca tin sn git
- Mc tiu: phng sn git, kim sot huyt p, v cho hoc m ly thai.
- Tim truyn tnh mch Magie sulfat d phng co git: liu nh trn.
- H huyt p bng hydralazine, nitroglycerin, nicardipin loi truyn tnh mch
duy tr, liu truyn ph thuc vo huyt p o c v loi thuc sn c.
- Khi tnh trng ngi bnh n nh nn ly thai ra ngay.
c) Sn git
- Magie sulfat:
+ Ch nh: ngn nga sn git v c th gim nguy c t vong m. iu tr d
phng cho tt c thai ph tin sn git nng.
+ C ch tc dng ca magie sulfat: kch hot gin mch mu no, lm gim
thiu mu cc b bi s co tht mch mu no trong cn sn git. Magie sulfat l mt
thuc c ch canxi lm thay i dn truyn thn kinh c.
+ Phc khuyn co magie sulfat khi c co git nh sau:
Liu tn cng: 4- 6 gam tim tnh mch chm trong vng 15 n 20 pht
Duy tr 1-2 gam/gi truyn tnh mch lin tc.
Magie sulfat t tim tnh mch lc khi u giai on c triu chng, sau tip
tc trong sut qu trnh chuyn d v t nht 24 gi sau sinh.
+Sn ph c chc nng thn gim (thiu niu hoc creatinin 1,2 mg/dl), phi
gim liu magie sulphat, thm ch ngng s dng.
Nng iu tr ca magie sulphat trong huyt tng khong t 4-8 mg/dl (nu
xt nghim c).
+ Du hiu ng cmagie sulphat: bt u bng mt phn x gn xng bnh
ch, suy nhc, hoa mt, lon vn ngn. c ch h hp hoc ngng th c th xy ra
khi nng magie sulphat trong huyt tng > 14 mg/dl.
- H huyt p: (tham kho bng di y)
169
+ Thuc la chn: hydralazine, labentalol, nicardipin, nitroprusside c th cho

cc thuc chn knh calci khc.
+ Khi tng huyt p cp cu hoc bnh no tng huyt p cn truyn tnh mch
duy tr thuc mt trong cc thuc trn: dng nitroglycerin hoc nitroprusside,
nicardipin.
+ Mc tiu: huyt p 140-155/90-95 mmHg, hoc huyt p trung bnh 105-125
mmHg
- Corticoid: cho mc ch lm trng thnh phi ca thai nhi, gim mc tn
thng gan. Ch nh tui thai 28-34 tun, thuc s dng l:
Betamethason 12mg, tim bp 2 liu cch nhau 24 gi, hoc cho dexamethason
8 mg/ln, tim bp 3 ln cch nhau 8 gi.
Bng: tm tt cc thuc iu tr cao huyt p trong tin sn git

Thuc
Hydralazin
Labetalol
Nifedipin
Nicardipin
Natri
nitroprusside
Liu
5-10 mg TM hoc TB mi 15
pht cho n liu ti a l 20
mg TM hoc 30 mg TB
Truyn TM chm 20 mg (
mi 2 pht) cho n liu ti
a l 300 mg
10-20 mg ung mi 30 pht
cho n liu ti a l 50 mg
Tc dng khng mong mun

H huyt p, nhp tim nhanh, nh
trng ngc, nhc u, bng,
bun nn, nn, tiu chy, nc
H huyt p, chng mt, nhc
u, mt mi, trm cm, bun
nn, nn, co tht ph qun
Nhp tim nhanh, nhc u, nh
trng ngc, ph ngoi bin, trnh
dng chung vi Magne sulfate (h
huyt p)
Truyn TM vi tc Ph ngoi bin, nhp tim nhanh,
5mg/gi v tng 2,5 mg/gi nhc u
mi 5 pht cho n liu ti
a l 10mg/gi
Truyn TM vi tc l 0,20 H huyt p, bun nn, nn, tot
mcg/kg/ph, iu chnh dn m hi, cao huyt p di ngc
mi 5 pht, khng vt qu 4 (do khi pht tc dng nhanh
mcg/kg/ph
chng), tng p lc ni s
d) Ch nh ly thai khi c cc din bin nng hoc khi n nh

Cc triu chng biu hin din bin ang nng ln:
- Tng huyt p nng khng p ng iu tr ko di > 24 gi
- Suy thn khng p ng iu tr thuc li tiu.
- Ph phi cp huyt ng.
- Gim tiu cu kh kim sot, DIC.
- Ri lon chc nng gan, t mu bao gan, rch bao gan.
170
- Sn git vi cc biu hin thn kinh trung ng.

- Bong rau, a i, thiu i.
- Suy thai.
Trong qu trnh m ly thai m bo truyn tiu cu, cc yu t ng mu, hng
cu, ti thiu a tiu cu trn 50000/mm3, PT trn 50% giy, Hb trn 70g/lt. Lin
tc xt nghim theo di.
e) Hi chng HELLP
- Nhp vin theo di, lm cc xt nghim mi 12-24 gi/ln, phng gim
tiu cu nng, chy mu, thiu mu. iu tr hi sc kt hp theo di thai.
- Khi c du hiu din bin nng, e do t vong cho m cn c k hoch nh
ch hoc m ly thai ngay.
- Phi cho thuc tng trng phi cho thai nhi.
- Thay huyt tng (Plasma exchange - PEX): c ch nh trong trng hp
ngi bnh mc nng.
- Ni chung tin lng xu vi thai nh < 28 tun
f) Theo di m v thai
- Tin sn git xy ra sm trc tun th 34 thng tin lng nng, v trong
cc trng hp ny nguyn nhn c lin quan ti cc bt thng ca ng mch xon
t cung v d nh hng ti bnh rau. Tin lng khng tt cho thai nhi.
- T l ti pht kh cao 25-33%, nu c tng huyt p mn nguy c ti pht ca
tin sn git ln n 70%.
- D phng v iu tr khi xy ra tin sn git (sau iu tr n nh): aspirin
liu nh c tc dng d phng ti pht, calcium 1-2 gam/ngy.
- Theo di siu m dopper ng mch t cung: sc cn mch c tin lng.
- Theo di siu m tnh trng bnh rau, nc i.
- Theo di ng mu, cc men ca gan, chc nng thn, tiu cu, nc tiu
cho thai ph nh k.
- Thai chm pht trin, non, rau bong non, thai lu.
- Tin lng lu di cho cc sn ph sau sinh: tng huyt p, bnh c tim thiu
mu, t qu, tc tnh mch, i ng, tn thng thn mn, suy gip
- Kh nng ti pht cho nhng ln mang thai sau: 25-65% nu m c tin s
tin sn git, sn git nng v d xut hin sm trong qu trnh mang thai. Nguy c
ny ch khong 5% -7% nu ln mang thai trc b tin sn git nh. Trong khi
nguy c ch 1% cc thai ph thai ln mt c huyt p bnh thng.
7. PHNG BNH
- M phi c hiu bit v cc bin chng ni chung v cc triu chng ca tin
sn git, sn git ni ring trong tng thi k mang thai.
- Khm v qun l thai sm: theo di huyt p, nc tiu, triu chng ph
thng xuyn.
171
- Khm thai v siu m nh gi s pht trin ca thai c bit khi c tin s

tin sn git, sn git.
- Ch n ung, sinh hot ca ph n mang thai:
+ n nht.
+ Ung nc: 6-8 cc 200 ml/ngy.
+ Gim n rn, tht mui.
+ m bo thi gian ngh ngi.
+ Tp th dc ch cho ph n c thai.
+ cao chn nhiu ln mi ngy.
+ Khng ung ru, bia, cht c cafein.
Ti liu tham kho

1. B y t. (2010), Hng dn chn on, x tr cp cu tai bin sn khoa, Q s
5231/Q-BYT ngy 28 thng 12 nm 2010.
2. American College of Obstetricians and Gynecologists. (2002). Diagnosis and
management of preeclampsia and eclampsia: ACOG Practice Bulletin, Am J
Obstet Gynecol. Vol 99, Pp.159-67.
3. Baldisseri M.R. (2013), Hypertensive Disorders in Pregnancy, Textbook of
Critical Care Sixth Edition. Jean- Louis Vincent. Elsevier Sauders, Pp. 1181-6.
4. Hart T.D., Harris M.B. (2012), Preeclampsia Revisited, US Pharmacist. 37(9),
Pp.48-53.
5. Norwitz E.R., Repke J.T. (2013), Preeclampsia: Clinical features and diagnosis;
http://www.uptodate.com/contents/preeclampsia-clinical-features-and- diagnosis
172
Chng VIII: NI TIT

HN M TNG P LC THM THU DO I THO NG
1. I CNG
Hn m tng p lc thm thu (TALTT) v nhim toan ceton l hai bin chng
cp tnh e do n tnh mng bnh i tho ng. Bnh thng gp ngi trn
65 tui b i tho ng tp 2, b gim kh nng ung nc. Bnh c t l t vong
cao hn nhim toan ceton do i tho ng, gp khong 20-30%.
Tnh trng thiu ht insulin gy tng phn hy glucogen ti gan, tng tn to
glucose, gim s dng glucose ca t chc, dn ti tng nng ng huyt.
Tng ng huyt s gy tng bi niu do thm thu, hu qu l mt nc.
Tnh trng mt nc nhiu hn mt mui s lm TALTT mu. Khi p lc thm
thu tng > 320 mOsm/kg, nc t khong k v trong t bo trong c cc t bo
thn kinh trung ng b ko vo trong lng mch gy ra tnh trng hn m v mt
nc.
2. NGUYN NHN
Hn m TALTT gp ngi bnh i tho ng tp 2, km theo cc tnh
trng bnh l lm gim kh nng ung nc. Cc yu t nguy c bao gm:
- Nhim khun l nguyn nhn hay gp nht chim 57,1%. Ph bin nht l
vim phi, nhim khun tit niu, nhim khun huyt.
- Khng tun th ch iu tr tiu ng (hay i tho ng).
- Bnh i tho ng khng c chn on, thng b hn m tng TALTT
v khng pht hin c cc triu chng sm ca bnh.
- Cc bnh l km theo: tai bin mch no, nhi mu c tim cp, tng hoc
gim thn nhit, huyt khi mc treo
- Dng thuc li tiu, corticoid, ung ru.
3. TRIU CHNG
3.1. Lm sng
- Ri lon thc cc mc khc nhau t l m n hn m su.
- Du hiu mt nc nng: da kh, np vo da mt i chm, tnh mch c xp,
mch nhanh, huyt p tt, nc tiu t ...
- Cc biu hin lm sng ca cc nguyn nhn thun li: (nhim khun, tai bin
mch no, nhi mu c tim..).
3.2. Cn lm sng
- Tng ng huyt thng > 40 mmol/l.
- p lc thm thu mu > 320mOsm/l.
- Kh mu ng mch: pH > 7,3, bicarbonat > 15mmol/l.
- Khng c ceton niu hoc rt t.
- Natri mu thng tng > 145mmol/l.
173
4. CHN ON
4.1. Chn on xc nh
- Tng ng huyt thng > 33,3mmol/l.
- p lc thm thu mu >320mOsm/l.
- Tnh trng mt nc nng.
- pH mu > 7,30.
- Bicarbonat > 15mEq/l.
- C t ceton niu v khng c hoc t th ceton trong mu.
- Ri lon thc t l m n hn m.
4.2. Chn on phn bit
- Nhim toan ceton do i tho ng v hn m tng p lc thm thu
Toan ceton do i tho ng
Nh
Trung bnh
Nng
ng mu
(mmol/l)
pH mu ng mch
Bicarbonat (mEq/L)
Ceton niu
Ceton mu
p lc thm thu
(mOsm/kg)
Khong trng anion
Tnh trng thc
Hn m tng
p lc thm
thu
>33
> 14
>14
>14
7,25 - 7,30
15 18
+
+
Thay i
7,00 7,24
10 15
+
+
Thay i
<7,00
<10
+
+
Thay i
>7,30
>18
t
t
> 320
> 10
Tnh
> 12
Tnh
>12
Hn m
Thay i
Hn m
p lc thm thu c tnh = 2x[(natri (mmol/l)] + glucose (mmol/l)

Khong trng anion = (Na+) (Cl- + HCO3-)
- Tng thm thu ngi lc mng bng bng dung dch ng qu u trng.
- Hn m h ng huyt ngi i tho ng.
- Tng thm thu khng c tng ng huyt ngi ung qu nhiu ru.
4.3. Chn on nguyn nhn- nguyn nhn thun li.
- Nhim khun: vim phi, nhim khun tit niu
- Tai bin mch no.
- Nhi mu c tim.
- Sai lm trong iu tr (dng qu mc li tiu, manitol, corticoid).
5. X TR
5.1. Nguyn tc x tr
- Cp cu ban u A, B, C.
- B dch nhanh v .
- iu chnh in gii .
174
- Dng insulin kim sot ng mu.

- Chn on v iu tr nguyn nhn thun li gy TALTT (vim phi, nhim
khun tit niu...).
m bo h hp v tun hon khi vn chuyn, t ng truyn dch b sm
nhanh ti ch v trn ng vn chuyn.
a) B dch
- t ngay ng truyn tnh mch ln, sau t ng thng tnh mch trung
tm b dch (nu c th c).
- Bt u truyn 1 lt natriclorua 0,9%0 trong 1 gi, trong 2 gi. c tnh lng
nc thiu khong 8- 10 lt.
- Trong qu trnh b dch phi theo di st mch, huyt p, bo ha oxy,
nc tiu ca ngi bnh.
- Nu c gim th tch nng gy tt huyt p: truyn natriclorua 0,9% 1lt/ gi
cho n khi ht tnh trng h huyt p.
- Nu mt nc nh, tnh natri hiu chnh:
+ Na mu hiu chnh = natri mu o c + 1,6 mmol/l cho mi 5,6 mmol
glucose tng thm trn 5,6 mmol/l.
+ Nng natri bnh thng hoc tng: truyn natriclorua 0,45% 250500ml/gi ty vo tnh trng mt nc. Khi glucose mu gim xung khong 15- 16
mmol/l, truyn thm glucose 5% cng vi natriclorua 0,45%, tc truyn 150 250ml/gi.
+ Nng natri gim: truyn natriclorua 0,9% 250 - 500ml/gi ty vo tnh
trng mt nc. Khi glucose mu khong 15 mmol/l truyn thm glucose 5% vi
natriclorua 0,45% vi tc 150-250ml/gi.
b) Insulin
- Theo di ng mu mao mch 1 gi/ln, trong 3 gi u sau mi 3
gi/ln chnh liu insulin.
- Insulin 0,1n v/kg tim tnh mch sau truyn tnh mch lin tc 0,1 n
v/kg/gi.
- Nu glucose mu khng gim 3,0 mmol/l trong gi u tin c th tng gp
i liu insulin.
- Khi glucose mu t khong 15- 16mmol/l, gim insulin xung cn 0,02
0,05 n v/kg/gi. m bo glucose mu 11- 15 mmol/l cho n khi ngi bnh tnh.
c) B Kali
- Theo di in gii 6 gi/ln cho n khi ngi bnh n nh.
- Nu chc nng thn bnh thng (nc tiu 50ml/gi).
- Nu kali mu <3,5 mmol/l dng insulin v truyn tnh mch ( 1-2 gam/gi)
tng ng 20-30mmol kali/gi cho n khi nng kali mu > 3,5 mmol/l.
175
- Nu nng kali ban u t 3,5 5,3 mmol/l, b sung kali 20 - 30 mmol/l ca

dch truyn tnh mch m bo nng kali mu duy tr t 4 - 5mmol/l.
- Nu nng kali ban u > 5 mmol/l, khng b kali, kim tra kali mu mi 2
gi.
Khi ngi bnh n nh v c th n c chuyn sang tim insulin di da.
Tip tc truyn insulin tnh mch 1-2 gi sau khi tim insulin di da m bo
nng insulin trong mu.
d) iu tr nguyn nhn gy mt b
- Khng sinh nu c bng chng v nhim khun.
- Dng thuc d phng huyt khi tnh mch su.
- Bin chng do khng iu tr ng hn m tng p lc thm thu l tc mch
(tc mch mc treo, nhi mu c tim) v tiu c vn.
- B nc qu nhanh c th dn n suy h hp ngi ln v ph no tr
em, y l bin chng him gp nhng c th gy t vong tr em.
+ Triu chng ca ph no l au u, thay i thc, hoc l suy gim thc
t ngt sau khi c ci thin lc u. Nhp tim chm, tng huyt p, ph gai th.
+ iu tr bng manitol vi liu 1-2g/kg truyn tnh mch trong 30 pht v
dexamethasone tim tnh mch.
+ iu chnh tnh trng tng p lc thm thu mt cch t t c th trnh c
bin chng ny tr em.
7. PHNG BNH
- Ngi bnh i tho ng phi c theo di din bin bnh, s thay i
thc, kim tra ng mu mt cch cht ch v c h thng. Hng dn ch n
ung hp l, dng insulin theo ng ch nh ca thy thuc.
- Khm, pht hin v iu tr cc bnh l phi hp nh nhim trng, bnh l tim
mch.
Ti liu tham kho
1. Nguyn t Anh (2000), Hn m tng p lc thm thu do tiu ng. Cm
nang cp cu. Ch bin: V Vn nh. Nh xut bn Y hc H ni, Pp. 231-5.
2. Nguyn Quc Anh. Ng Qu Chu. (2011), Hn m tng p lc thm thu
ngi i tho ng. Hng dn chn on v iu tr bnh ni khoa, Nh xut
bn Y hc H ni, Pp.116-9.
3. Nguyn Khoa Diu Vn. (2012), i tho ng, Bnh hc ni khoa tp 2, Nh
xut bn Y hc H ni, Pp. 342-7.
4. Anthony S.F et al. (2009), Diabetic Ketoacidosis and Hyperosmolar Coma,
Harrisons manual of medicine, Pp. 100-102.
176
5. David A., Rometo., Marin H.K and Garry S.T. (2012), Diabetic Ketoacidosis and
Hyperosmolar Hyperglycemic State, The Washington manual of Critical Care,
Pp. 239-44.
6. Kruse J.A. (2003), Hyperosmolar Nonketotic Coma, Saunders Manual of
Critical Care, Pp.168-70.
177
nh gi tnh trng bnhu nhn, XN ng mu mao mch xc nh c tng ng mu.

Bt u truyn dch 1lt NaCl 0,9% trong 1 gi
- t ngay ng truyn tnh mch ln, sau t catheter tnh mch trung tm b dch (nu c th c)
- Tc truyn 1 lt natriclorua 0,9%0 trong 1 gi.
Truyn dch
Truyn TM insulin tc dng nhanh.

TD: Glucose mu mao mch 1 gi/ln
trong 3 gi u, sau 3 gi/ln
Tnh trng mt nc
Mt nc nng
Nu lng nc tiu >50 ml/gi
Mt nc trung bnh
NaCl 0,9% 1 lt/gi cho n

khi HA tr v bnh thng
Sc tim
Theo di M, HA,
SpO2, nc tiu
nh gi iu chnh Na+ mu
Tng Na+
Na+ bnh thng
NaCl 0,45% (250-500 ml/gi),

ph thuc tnh trng mt nc
Kali
Liu u: 0,1UI/kg
Duy tr: 0,1UI/kg/gi
K+ < 3,5 mmol/l
K+ > 5,3 mmol/l
Nu Glucose mu khng
gim i 3,0 mmol/l trong
gi u, c th tng liu
insulin ln gp i
Duy tr insulin
Thm Kali: 20-30
mmol/gi cho n
khi K+ > 3,5 mml/l
Theo di K+
mu 2gi/ln
H Na+
NaCl 0,9% (250-500

ml/gi), ph thuc tnh
trng mt nc
Khi Glucose mu t 15 mmol/l):

Truyn Glucose 5% v NaCl 0,45% tc
150-250 ml/gi
Khi Glucose mu t 15- 16 mmol/l):

Gim liu insulin xung cn 0,02-0,05 UI/kg/gi
Gi Glucose mu 11-15 mmol/l n khi bnh nhn
tnh
Xt nghim: ure, creatinin, Glucose, G mu 2-4 gi/ln n

khi tnh trng bnh nhn n nh. Khi bnh nhn n c chuyn
sang tim insulin di da. Truyn insulin cho ti 2 gi sau khi
tim inslulin di da mi u tin
S x tr hn m tng p lc thm thu mu do i tho ng
178
K+ = 3,5 - 5,3 mmol/l

Thm Kali: 20-30
mmol/lt dch duy
tr K+ : 4 - 5 mmol/l
Chng IX: RI LON NC IN GII V THNG BNG KIM TOAN

TNG KALI MU
1. I CNGc
Tng kali mu l 1 ri lon in gii thng gp trong khoa hi sc tch cc.C
th gy t vong nu khng c x tr kp thi.
Tng lng kali trong c th khong 3000 mEq (50-75mEq/kg). Tri ngc vi
Natri phn ln ngoi t bo. Kali 98% trong t bo. S khc bit trong phn b
gia 2 cation ny c iu chnh bi bm Na-K-ATPase mng t bo, bm vn
chuyn Natri ra ngoi t bo v a kali vo trong t bo vi t l 3:2.
Kali mu bnh thng t 3,5-5,0 mmol/l.
Tng khi kali > 5mmol/l.
2. NGUYN NHN THNG GP
2.1. Tng kali mu do tng a vo
- Truyn mu.c bit cc n v mu c lu tr lu.
- Truyn hoc ung kali: nu ngi bnh khng c cc yu t nguy c nh
gim bi tit aldosterol hoc bnh thn cp hoc mn tnh th tng kali mu do ung
khng phi l nguyn nhn chnh.
2.2. Tng kali mu do tng chuyn t trong t bo ra ngoi t bo
- Toan chuyn ha: tnh trng toan chuyn ha do toan lactic hoc toan ceton
dn n Kali t trong t bo i ra ngoi t bo. Khi pH mu gim 0,1 Kali mu s tng
0,5mmol/l.
- Do hy hoi t bo: bt k nguyn nhn no tng hy hoi t bo dn n gii
phng Kali trong t bo ra ngoi t bo nh tiu c vn, tan mu, bng, hi chng ly
gii khi u, sau tia x).
2.3. Tng kali mu do gim bi tit kali
C ba c ch chnh gy gim bi tit kali qua nc tiu: gim bi tit
aldosterol, gim p ng vi aldosterol, gim phn b Natri v nc ng ln xa
khi m gim dng mu n ng mch thn.
- Suy thn: suy thn cp v mn tnh c th c 1 hoc nhiu cc c ch trn v
l nguyn nhn ph bin gy tng Kali mu.
- Bnh l ng thn: toan ng thn typ IV.
- Suy thng thn.
2.4. Thuc
- Li tiu gi kali, c ch men chuyn, chng vim khng steroid,
succinylcholine
179
3. TRIU CHNG
3.1. Du hiu v triu chng
- Du hiu lm sng: khi c biu hin lm sng ngi bnh trong tnh
trng nguy kch nh: lon nhp nhanh, rung tht, ngng tun hon.
3.2. Cn lm sng
- Du hiu trn in tim
+ Nh: sng T cao nhn i xng, bin 2/3 sng R chuyn o trc tim
+ Va v nng: khong PR ko di, sng P dt, QRS gin rng, sng T v QRS
thnh mt, dn n ngng tim.
Hnh 1: Thay i in tim ngi bnh tng kali mu (kali mu >5mmol/l)

4. CHN ON
4.1. Chn on xc nh
Xt nghim kali mu > 5mmol/l.
4.2. Chn on phn bit vi gi tng kali mu
- Tan mu hoc thiu mu khi ly mu tnh mnh, xt nghim sai.
- Tng tiu cu (> 8 G/l) v tng bch cu.
180
4.3. Chn on mc tng kali mu

- Da vo tc tng kali mu v cc du hiu nng trn in tim.
- Tng kali mu mc va: sng T nhn v tng bin .
- Tng kali mu mc nng: khong PR v QRS ko di, chm dn truyn nh
tht, mt sng P, QRS dn rng, rung tht ri ngng tim.
5. X TR
5.1. Nguyn tc x tr: tng kali mu l cp cu, do vy thy thuc cn pht hin v
x tr kp thi.
a) Thuc tc dng tranh chp vi kali trn c tim: Calciclorua hoc Calci gluconate
tim tnh mch.
Calciclorua gip lm n nh mng t bo c tim, khng c tc dng lm gim
nng kali mu, cn phi kt hp vi cc bin php khc iu tr tng kali mu.
Liu t 0,5-2 g ty tng bnh nhn. Sau tim canxiclorua c tc dng ngay v thi
gian tc dng ko di 30-60 pht.
b) Thuc c tc dng vn chuyn kali t ngoi t bo vo trong t bo
- Insulin v glusoce:
+ Insulin c tc dng chuyn kali t ngoi vo trong t bo tuy nhin trnh
bin chng h ng huyt chng ta cn b sung thm glucose.
+ Hiu qu ca insulin bt u sau 10 n 20 pht, t nh sau 30 n 40 pht
v ko di 4 n 6 gi. hu ht ngi bnh nng kali mu gim 0,5-1,2 mmol/l.
- Natri bicarbonat:
+ Tng pH mu lm ion H+ gii phng vo mu nh mt phn ng m, gip
cho Kali di chuyn vo trong t bo lm gim kali mu. Thi gian bt u c tc dng
sau 6 gi. Khng nn s dng natri bicarbonat n c trong iu tr tng kali mu
cng nh cc ngi bnh toan chuyn ha va v nh. ( HCO3 - > 18 meq/l).
- Kch thch Beta 2 adrenergic (Albuterol): cng ging nh insulin, albuterol c
tc dng vn chuyn Kali mu vo trong t bo. Thi gian tc dng sau 10-15 pht v
ko di 3-6 gi.
c) Bin php o thi kali
- Li tiu quai (furocemid): c tc dng o thi kali qua nc tiu, tuy nhin
nhng ngi bnh suy thn nng chc nng o thi kali km, hiu qu iu tr h kali
mu ca li tiu km p ng.
- Nha trao i cation (kayexalate): kali lin kt vi nha trao i cation, gip
cho ngn nga kali hp thu qua rut vo mu, t kali s c o thi qua phn.
Thi gian c tc dng sau 1-2 gi v ko di 4-6 gi.
- Lc mu cp cu ngt qung: (thm tch mu hay cn gi l thn nhn to IHD) l bin php o thi Kali c hiu qu, nhanh c tc dng sau 30 pht ch nh
ngi bnh tng kali mu nng c biu hin trn in tim hoc trng hp tng kali
mu iu tr km p ng vi li tiu. Phng thc lc mu lin tc (CVVH) kt qu
chm hn.
181

- Nu nghi ng ngi bnh c tng kali mu m c nh hng n in tim,
calciclorua 0,5- 1g tim tnh mch trong 2-3 pht, c th lp li liu sau 5 pht.
a) C biu hin xt nghim v c ri lon trn in tim
- Calciclorua 0,5g tim tnh mch trong 2-3 pht. Nu in tim khng thay i
c th lp li liu sau 5 pht. Liu dng: t 0,5- 2-3 g, mi ln tim TM chm ng
0,5g, theo di thy phc b QRS hp li, sng T thp dn xung.
- Furosemid 40-60mg tim tnh mnh.
- Natribicarbonat 1,4%; 4,2%; 8,4%: truyn 45 mmol khi pH < 7,15
- Kayexalat (Resonium) ung 15-30gam vi 50 gam sorbitol.
- Dng 10 UI insulin nhanh + 50 - 100ml glucose 20% truyn trong 20 - 30
pht.
- Albuterol 10-20mg kh dung trong 15 pht hoc 0,5mg pha trong 100 ml
glucose 5% truyn tnh mch trong 15 pht.
- Lc mu cp cu ngay khi iu tr p ng km vi li tiu, hoc c v niu,
thiu niu, tha dch, kt hp tng kali mu nng, toan chuyn ha nng pH <7,10.
b) C biu hin xt nghim nhng khng c ri lon trn in tim
- Furosemid 40-60mg tim tnh mnh (xem bi suy thn cp).
- Kayexalat(resonium) ung 15-30gam vi 50 gam sorbitol.
- Lc mu cp cu khi iu tr p ng km vi li tiu.
c) Tm v iu tr nguyn nhn.
- Lu trong trng hp toan ceton v tng p lc thm thu do i tho ng
iu tr nguyn nhn l chnh.
Theo di
in tim lin tc trn monitor. Nu in tim khng thay i lm xt nghim
kali 2 gi/ln cho n khi tr v bnh thng. Nu c bin i trn in tim lm xt
nghim kali ngay.
6.1. Tin lng
- Ngi bnh tng kali mu tin lng nng, c th gy t vong.
6.2. Bin chng
- C th gy bin chng ngng tun hon v ri lon nhp tim. Do vy nhng
ngi bnh tng Kali mu cn c pht hin theo di v iu tr kp thi.
7. PHNG BNH
- Thay i ch n nhng ngi bnh c nguy c tng kali mu.
- Khng dng nhng thuc lm nng tnh trng tng kali mu.
- Ngi bnh chy thn nhn to chu k cn tun th ng lch chy thn.
182
Ti liu tham kho

6. Nguyn Quc Anh, Ng Qu Chu v CS. (2011), Tng kali mu, Hng dn
chn on v iu tr bnh ni khoa, Nh xut bn y hc, Tr. 145-6.
7. V Vn nh (2006), Tng kali mu, Cm nang cp cu, Nh xut bn y hc,
Tr. 219-22.
8. Usman A., Goldberg S. (2012), Electrolyte abnormalities, The washington
Manual of critical care, Lippincott William and Wilkins, Pp. 190-3.
9. Verive M.J. (2010), hyperkalemia, emedicine.medscape.com, eMedicine
Specialties > Pediatrics: Cardiac Disease and Critical Care Medicine > Critical
Care.
10. Zanotti S., Cavazzoni (2011), Hyperkalemia, Textbook of Critical Care, Pp. 567.
Kali >5 mmo/l
Khng c ri lon trn in tim
C ri lon trn in tim
-Calciclorua 1g tim tnh mch trong 2-3
- Furosemid 40-60mg tim
pht. C th lp li sau 5 pht.

- Furosemid 40-60mg tim tnh mnh.
-NaHCO3 truyn 45 mmol khi pH < 7,1
- Kayexalat(Resonium) ung 15-30gam
vi 50 gam sorbitol.
-10 UI insulin nhanh + 50-100ml glucose
20% truyn trong 30 pht.
-Albuterol 10-20mg kh dung trong 15
pht hoc 0,5mg pha trong 100 ml glucose
5% truyn tnh mch trong 15 pht.
-Lc mu cp cu khi iu tr p ng
km vi li tiu.
tnh mnh.
- Kayexalat( Resonium) ung
15-30gam vi 50 gam
sorbitol
- Lc mu cp cu khi iu
tr p ng km vi li tiu.
S x tr tng Kali mu
183
H KALI MU
1. 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 c a vo c th qua
ng n ung hoc ng truyn tnh mch, phn ln kali c d tr trong t bo
v sau c bi tit vo nc tiu. Do gim a kali vo hoc tng vn chuyn
kali vo trong t bo hoc hay gp hn l mt qua nc tiu, qua ng tiu ha hoc
qua m hi dn n gim nng kali mu.
Kali mu bnh thng 3,5-5mmo/l v h khi kali mu < 3,5mmol/l.
2. NGUYN NHN
2.1. Mt qua thn
- i nhiu do bt c nguyn nhn g.
- i tho ng khng kim sot c.
- H magie mu, h clo mu, tng calci mu.
- Toan ng thn typ I hoc typ II.
- HC Fanconi, HC Bartter.
2.2. Mt qua ng tiu ha
- Nn hoc mt do dn lu qua sonde d dy.
- Tiu chy (a chy).
- Dn lu mt, m thng hi trng, sau phu thut rut non.
- Tht tho hoc dng thuc nhun trng.
2.3. Do thuc
- Li tiu thi kali ( thiazid, furosemid).
- Insulin, Glucose, Natri bicarbonat.
- Cng Beta-adrenergic.
- Corticoid.
- Khng sinh: amphotericinB, aminoglycosides, penicillin, ampicillin,
rifampicin, ticarcillin, insulin.
- Kim mu.
- iu tr thiu ht vitamin B12 v acid folic.
2.4. Lng kali a vo khng
- Thiu n, nghin ru, ch n king.
2.5. Tha corticoid chuyn ha mui nc
- Cng aldosterol tin pht ( hi chng Conn), cng aldosterol th pht.
- Tng huyt p c tnh.
- Hi chng Cushing, ung th thn, u t bo cnh cu thn, ung nhiu cam
tho
184
2.6. Th lm sng c bit (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.
3. TRIU CHNG
3.1. Lm sng
- Yu c ( t chi,c h hp...), au c, co rt c, tiu c vn.
- Mch yu, ting tim nh c th c ting thi tm thu, c khi thong ngt
- Bng chng, gim nhu ng rut, to bn, nn, bun nn.
3.2. Cn lm sng
- Du hiu h kali mu trn in tim: thng a dng, c sng U, sng T dt,
ST chnh xung, QT ko di, du hiu nng trn in tim lon nhip tht (nhp nhanh
tht, xon nh).
- Xt nghim kali mu < 3,5 mmo/l.
- Xt nghim kali mu < 3,5 mmo/l.
Hnh 1. Biu hin c sng U trn in tim ngi bnh h kali mu
Hnh 2. Hnh nh xon nh ngi bnh h kali mu

4. CHN ON
4.1. Chn on xc nh
Xt nghim kali mu < 3,5 mmol/l.
4.2. Chn on mc
- Mc nh: h kali mu khng c triu chng lm sng v in tm .
- Mc va: h kali mu c th c chng bng, chut rt, in tm c
sng T dt, on ST chnh xung nhng khng c cc triu chng nng nh ri lon
nhp tim nng n, lit thn kinh c.
185
- Mc nng: h kalai mu c cc triu chng nng trn lm sng (ri lon

nhp tim hoc yu c, lit, hoc hi chng tiu c vn cp).
5. X TR
5.1. Nguyn tc x tr
- Mc tiu iu tr h kali mu ngn nga cc bin chng e da tnh mng ca
h kali mu (ri lon nhp tim, lit c, tiu c vn).
- Ngi bnh h kali mu nng kali 2,5 mmol/l (< 3 mmol/l nu ang dng
digoxin) v c triu chng lit c v du hiu trn in tim cn phi x tr ngay lp tc
kaliclorua 13-20 mmol/gi (1-1,5 g) truyn qua ng tnh mch.
- Tm v iu tr nguyn nhn h kali mu.
- Ngi bnh nghi ng h kali mu, cho ung kaliclorua 1-1,5 g.
a) Xt nghim kali 2,5 mmol/L (< 3 mmol/L nu ang dng digoxin)
- C triu chng lit c v du hiu nng trn in tim: Kaliclorua 13-20
mmol/gi (1 -1,5 g) tt nht truyn qua TMTT lin tc trong 3 gi, sau xt nghim
li ri quyt nh tip.
- Khng c triu chng nng hoc khng c triu chng: ung KCl 10- 15
mmol (1-1,5 g) mi 3 gi v /hoctruyn tnh mch KCl 10 mmol/gi.
b) Xt nghim 2.5 < kali <3.5 v khng c triu chng
- Ung hoc truyn tnh mch, KCl 10- 20 mmol (1-1,5 g) mi 6 gi.
* Theo di
- Trng hp h kali mu c bin i trn in tim, theo di in tim lin tc
trn my theo di cho n khi in tim tr v bnh thng.
- Theo di xt nghim kali mu. H kali mc nng 3 gi/ln, mc va 6
gi/ln, mc nh 24 gi/ln cho n khi kali mu tr v bnh thng.
* Ch
- Trnh truyn ng glucose ngi bnh h kali mu s gy tng bi tit
insulin lm gim kali mu.
- Nng kaliclorua pha khng qu 40mmol/l (3gram) nu dng ng truyn
ngoi bin (phi b qua ng ng thng tnh mch trung tm).
- Tc b kaliclorua khng qu 26 mmol/gi (2gram).
- pH tng 0,1 tng ng vi kali gim 0,4 mmol/l.
- 1 gram kaliclorua c 13,6 mmol.
6.1.Tin lng
Ngi bnh h kali mu tin lng nng c th gy gy t vong nu khng
c pht hin v x tr kp thi.
186
6.2. Bin chng

H kali mu gy bin chng nhp chm, gim sc bp c tim hoc nhp nhanh
xon nh, l mt trong nhng nguyn nhn ri lon nhp dn n ngng tim. Cp cu
ngng tun hon nhng bnh nhn ny m khng pht hin h kali mu s dn ti tht
bi.
Suy h hp do lit c h hp, thm ch lit t chi.
7. PHNG BNH
B kali ng ung vi nhng ngi c nguy c h kali mu. S dng thc
phm v hoa qu c nng kali cao nh: khoai ty, chui, cam v o.
Ti liu tham kho.

1. Nguyn Quc Anh, Ng Qu Chu. (2011), H kali mu, Hng dn chn on
v iu tr bnh ni khoa, Nh xut bn y hc, Tr. 147-9.
2. V Vn nh (2006), H kali mu, Cm nang cp cu, Nh xut bn y hc, Tr
215-18.
3. Society of Critical Care Medicine, Fundamental Critical Care support (Fourth
Edition), hypokalemia: 21-2, 12-3.
Manual of critical care, Lippincott William & Wilkins, Pp. 187-90.
5. Zanotti. S, Cavazzoni. (2011), Hypokalemia, Textbook of Critical Care, Pp. 579.
K<3.5mmol/l
K 2.5 mmol/L (<3 mmol/L nu

ang dng Digoxin)
C triu chng lit c v

du hiu nng trn in
tim.
KCl 20-30mmol/gitruyn
qua TMTT
2,5 < K <3.5

V khng c triu chng
Khng c triu chng nng

hoc khng c triu chng
Ung KCl 20-40 mmol mi 24 gi v/hoc truyn tnh mch

KCl 10mmol/h.
S x tr h kali mu
187
Ung hoc truyn tnh mch

KCl 20-40 mmol mi 4-6 h
TNG NATRI MU
1.I CNG
Natri ch yu khu vc ngoi t bo (140mmol/l, gp 7 ln so vi trong t
bo), n c vai tr quan trng duy tr cn bng thm thu v chu s iu ha ca
hormon thng thn.
Tng natri mu thng l do s mt cn bng gia lng nc a vo c th
v lng nc b o thi ra khi c th.
Tng natri mu km theo tng p lc thm thu.
Cc triu chng ngi gi thng kn o, ph thuc vo thi gian xut hin
tng natri mu.
2. NGUYN NHN
2.1 Tng natri mu c gim th tch (lng nc thiu ht > lng natri thiu ht)
Ngi bnh c mt c mui v nc nhng lng nc mt nhiu hn lng
mui. Nhng ngi bnh ny c du hiu thiu dch, tt huyt p khi ng, da kh,
nim mc kh, nhp tim nhanh.
a) Gim lng nc a vo c th
Lng nc a vo thiu hoc do c ch kht b tn thng (tn thng h
thng thn kinh trung ng).
b) Mt nc qua thn
- Li tiu (li tiu quai, thiazid, li tiu gi kali, li niu thm thu).
- Tng ng mu trong hn m tng p lc thm thu.
- Sau khi gii quyt tc nghn ng tit niu.
- Tiu nhiu trong giai on hi phc ca suy thn cp.
- i tho nht: do thn kinh trung ng hoc i tho nht ti thn.
c) Mt nc ngoi thn
- Mt qua ng tiu ha: nn, dn lu d dy, tiu chy (a chy). Dn lu
rut mt, mt dch qua l r.
- Mt qua da: do m hi, do bng, do vt thng h.
2.2. Tng natri mu c tng th tch (lng mui a vo nhiu hn lng nc a
vo)
Nguyn nhn ny khng thng gp ngi bnh tng natri mu, thng xy
ra ngi bnh a lng mui vo ln hn lng nc nh ngi bnh truyn natri
u trng hoc nhng ngi bnh c ri lon chuyn ha mui nc.
- Truyn mui u trng.
- Truyn natribicarbonat.
- Ung nhm mui.
- Tha corticoid chuyn ha mui nc (HC Cushing, HC Conn).
188
2.3. Tng natri mu c th tch mu bnh thng

Nhng ngi bnh mt nc nhng khng c thay i tng lng mui c th,
hn na mt nc n c khng hay gy ra tng natri mu. Tuy nhin nu ngi
bnh mt nc nhng khng c cung cp nc c th gy tng natri mu.
- Mt nc qua da: st, nng nng.
- Mt qua ng h hp.
3. TRIU CHNG
- Ton thn: kht, kh chu st.
- Thn kinh: yu c, l ln, m sng,co git, hn m, co cng, tng phn x.
- Tiu ha: bun nn v nn.
- Du hiu thay i th tch dch ngoi bo.
+ Tng natri mu do gim th tch (st cn, da nim mc kh, tnh mch c xp,
ALTMTT gim, nhp tim nhanh..).
+ Tng natri mu do tng th tch (tng cn, khng c du hiu thiu dch ngoi
bo, ph ngoi vi, tnh mch c ni, ALTMTT tng).
- Natri mu tng >145 mmol/l.
- ALTT mu tng.
- ALTT niu < 800 mOsm/kg ngi bnh thiu ADH.
- Na niu: thay i ph thuc vo nguyn nhn tng natri mu.
4. CHN ON
4.1. Chn on xc nh
- Xt nghim natri mu > 145 mmo/l.
Cc xt nghim cn lm chn on nguyn nhn:
- Hematocrit, protit mu (xc nh tng hay gim th tch ngoi t bo).
- Natri niu (xc nh mt natri qua thn hay ngoi thn), kali niu.
- p lc thm thu huyt tng, p lc thm thu niu.
4.3. Chn on mc : tng natri mu cp hay mn
- Tng natri mu cp tnh: thi gian xut hin 48 gi, thng triu chng s
nng n hn khi Natri mu trn 158 mEq/l, bnh nhn c ri lon tinh thn, kch thch,
vt v, i khi hn m, co git.
- Tng natri mu mn tnh: thi gian xut hin > 48 gi, natri ti mc 170-180
mEq/l nhng c th ch gy triu chng nh.
5. X TR
5.1. Nguyn tc x tr
- Tnh lng nc thiu ca ngi bnh.
- Tnh t l natri cn gim, trnh trng hp h natri mu qu nhanh.
- Chn dung dch thch hp h natri mu.
189
- Tm v iu tr nguyn nhn h natri mu.

a) Cng thc tnh lng nc thiu ca c th
- S dng khi c tng natri mu km gim th tch.
Lng nc thiu = Lng nc c th x ( Na mu / 140-1)
Trong :
Lng nc c th = Trng lng c th x 0,6 ( Nam)
Lng nc c th = Trng lng c th x 0,5 ( N)
- Nhc im ca cng thc trn chng ta khng tnh c lng nc mt qua
ng khc nh m hi, phn, hoc ng tiu. Do vy nhng ngi bnh tng natri
mu do mt nc qua thn hoc mt nc qua ng tiu ha (tiu chy, dn lu ti
mt, mt nc qua l r) cng thc trn c th s khng chnh xc.
- Ngi bnh thng lng nc mt qua ng m hi v phn 30ml/gi.
- nhng ngi bnh mt nc qua thn chng ta cn tnh thm lng
nc mt qua thn da vo cng thc sau.
Trong :
UV: th tch nc tiu (ml/ gi).
Una: nng na niu (mmol/l), Sna: nng natri mu (mmol/l).
Uk nng kali niu (mmol/l).
V d: ngi bnh nam 40 tui nng 60 kg, tng natri mu do mt nc qua ng
thn, natri mu 168mmol/l, natri niu 168mmol/l, kali niu 68mmol/l, tiu 100
ml/gi.
+ Lng nc thiu tnh theo cng thc: 6 lt, gim trong 48 gi tng ng
125ml/gi.
+ Lng nc mt qua m hi v phn : 30 ml/gi.
+ Lng nc mt qua nc tiu: 50 ml/gi.
Do vy lng nc thiu ht, cn b ngi bnh l: 205 ml/gi.
b) T l natri cn gim
- Ngi bnh tng natri cp (tng natri trong vng 24 gi) cn c iu chnh
nhanh chng bi v tng natri cp tnh dn n tn thng thn kinh khng hi phc
do hy myelin. nhng ngi bnh ny nn a natri mu gn mc bnh thng
trong vng 24 gi.
- Ngi bnh tng natri mu mn (tng natri mu trn 24 gi), cn iu chnh
natri mu khong 10 mEq trong 24 gi.
Cng thc iu chnh Natri
190
dch Natri
truynNatri
/ (Lng
c th+1)
Trong : NN=
l (sNa
mmol
mu
thaymu)
i khi
truynnc
1 lt dch
c) Chn dung dch thch hp
- iu tr tng natri mu c gim th tch: nn la chn dch mui 0,9% khi
phc lng nc thiu ht.
- iu tr tng natri mu ng tch: Nn dng natriclorua 0,45%.Nu mc lc
cu thn gim c th dng li tiu tng bi tit natri qua nc tiu.
- Tng natri mu c tng th tch: Nn s dng glucose 5% lm gim p lc
thm thu mu. Li tiu quai c th tng o thi natri qua thn.
- Trong trng hp tng natri mu nng v suy thn nng nn ch nh lc mu
ngt qung iu chnh natri mu.
- i tho nht trung ng b dung dch truyn c natri kt hp vi
desmopressin acetate (minirin).
- Nng natri trong 1 s loi dch.
+ Natriclorua 0,45 % c nng natri l 77 mmol/l.
+ Natriclorua 0,9 % c nng natri l 154 mmol/l.
+ Glucose 5% : nng natri l 0 mmo/l.
Ch
- Theo di in gii 6 gi /ln, p lc thm thu mu v niu 1 ln/ngy cho
n khi natri v bnh thng.
- p lc thm thu mu c tnh= 2 natri + glucose.
- Kim sot ng mu nu ng mu cao.
- Theo di st dch vo v dch ra ca ngi bnh.
5.3. Tm v iu tr nguyn nhn.
Tm v iu tr nguyn nhn gy tng natri mu.
6.TIN LNG V BIN CHNG
6.1.Tin lng
Nhng ngi bnh tng natri mu tin lng rt nng, do vy thy thuc cn
phi pht hin sm x tr kp thi.
6.2. Bin chng
Ngi bnh iu chnh h natri mu qu nhanh dn n tn thng no khng
hi phc do tn thng myelin.
7. PHNG BNH
Ngi gi d b tng natri mu do mt cm gic kht, cn t vn cho ngi nh
v ngi bnh cnh gic vi cc trng hp kht, nng, nng, mt nc.
Ti liu tham kho

1. Nguyn Quc Anh, Ng Qu Chu v CS. (2011), Tng natri mu, Hng dn
chn on v iu tr bnh ni khoa, Nh xut bn y hc, Tr. 140-1.
191
2. V Vn nh (2006), Tng natri mu, Cm nang cp cu, Nh xut bn y hc,

Tr. 211-14.
3. Kerry C., Fukagawa M., Kurokawa K. (2009), Hypernatremia, Current medical
diagnosis and Treatment, Pp. 771-2.
4. Kruse J.A. (2003), Hypernatremia, Saunder manual of critical care, Pp 124-128
5. Mcllwaine J.K., Corwin H.L. (2011), Hypernatremia, Textbook of Critical Care,
Pp. 53-4.
Manual of critical care, Lippincott William & Wilkins, Pp. 184-7.
Tng Natri mu (Natri > 145 mmo/l)

Bc 1
Tnh lng nc thiu
Lng nc thiu = Lng nc c th x ( Na mu / 140-1)
Bc 2
Tnh lng natri thay i trong 1 lt dch
N= ( Na dch truyn- Natri mu) / (Lng nc c th+1)

Bc 3
Chn loi dch b
Khng gim natri qu10 mEq trong 24 gi.

Chn loi dch ph hp b
S x tr tng natri mu
192
H NATRI MU
1. I CNG
H natri mu hay gp trong hi sc cp cu. Nng natri trong mu h gy
nn tnh trng gim p lc thm thu ngoi t bo, dn ti tha nc trong t bo do
nc di chuyn t ngoi vo trong t bo.
H natri mu phn nh tnh trng p lc thm thu ngoi t bo, khng phn
nh s thay i tng lng natri ton c th, do khng phi tt c cc trng hp
h natri mu u c th iu tr bng cung cp natri cho ngi bnh.
H natri mu mn tnh thng khng c triu chng. Triu chng thc th, nht
l triu chng ca ph no, thng xut hin ngi bnh h natri mu nng (di
125 mmol/l), xut hin nhanh (trong vng 48 gi).
2. NGUYN NHN
- Nu p lc thm thu niu < 100 mOsmol/l: do c th c cung cp qu
nhiu dch nhc trng (ung qu nhiu nc, ui nc ngt,).
- Nu p lc thm thu niu > 100 mOsmol/l: tm nguyn nhn da vo tnh
trng th tch dch ngoi t bo.
2.1. H natri mu km theo tng th tch ngoi t bo
H natri mu km theo ph, xt nghim c protit mu gim, hematocrit gim:
h natri mu km theo mui v nc ton th. Trong trng hp ny, tng lng
nc c th tng, tng lng natri c th tng nhng khng tng ng vi tng lng
nc.
- Natri niu < 20 mmol/l:
+ Suy tim.
+ Suy gan, x gan c chng.
+ Hi chng thn h.
- Natri niu > 20 mmol/l: suy thn cp hoc mn tnh.
2.2. H natri mu vi th tch ngoi t bo bnh thng
H natri mu, xt nghim c natri niu bnh thng, protit mu v hematocrit
gim nh: h natri mu do pha long.
- Hi chng tit ADH khng tha ng (tit qu mc):
+ p lc thm thu mu/niu > 1,5
+ Cc nguyn nhn thng gp ca hi chng ny l: hi chng cn ung th,
bnh l phi (vim phi, lao phi, th my, suy h hp cp), bnh l thn kinh trung
ng (tai bin mch mu no, chn thng s no, vim no...), do mt s thuc
(carbamazepin, thuc chng trm cm, thuc gim au gy nghin morphin v cc ch
phm, thuc chng lon thn, mt s thuc iu tr ung th).
- Suy gip, suy v thng thn.
- Dng li tiu thiazit.
193
2.3. H natri mu km theo gim th tch ngoi t bo

H natri mu km theo du hiu lm sng mt nc ngoi t bo, xt nghim c
protit mu tng, hematocrit tng: mt nc v natri vi mt natri nhiu hn mt nc.
- Mt natri qua thn: Natri niu > 20 mmol/l.
+ Do dng li tiu.
+ Suy thng thn.
+ Suy thn th cn nc tiu.
+ Giai on i nhiu ca hoi t ng thn cp.
+ Sau gii quyt tc nghn ng tit niu.
+ Bnh thn k.
- Mt natri ngoi thn: Natri niu < 20 mmol/l
+ Mt qua tiu ha: tiu chy, nn, d tiu ha, mt vo khoang th 3.
+ Mt qua da: mt m hi nhiu (say nng, say nng, vn ng th lc nng
trong mi trng kh nng), bng rng.
+ Tn thng c vn cp trong chn thng.
3. TRIU CHNG
3.1. Lm sng
Triu chng lm sng ca h natri mu khng c hiu, ph thuc vo mc
v tc gim nng natri mu.
Gim nng natri cp (thi gian hnh thnh trong vng di 2 ngy) c th c
cc du hiu lm sng ca tha nc trong t bo gy ph no:
- Ngi bnh s nc, chn n, bun nn, nn.
- Mt mi, au u, ln ln, u m, m sng, ri lon thc (c th hn m), h
natri mu nng c th c cc cn co git.
Khi gim nng natri mn vi thi gian hnh thnh ko di, cc triu chng
biu hin c th khng c hoc nh.
Ngoi ra, s xut hin cc triu chng ca ri lon nc km theo c gi tr
chn on nguyn nhn: tng th tch nc ngoi t bo (ph, c chng) hoc mt
nc ngoi t bo (gim cn; da kh, nhn nheo,...).
3.2. Cn lm sng
Natri mu < 135 mmol/lt, h natri mu nng khi Natri mu < 125 mmol/lt.
4. CHN ON
4.1. Chn on xc nh Da vo xt nghim
- Natri mu < 135 mmol/l v p lc thm thu huyt tng < 280 mOsmol/l.
- Cc triu chng lm sng ch c tnh cht gi v ni ln mc nng ca h
natri mu.
4.2. Chn on phn bit
H natri mu "gi" c th gp trong cc trng hp: tng lipit mu, tng protit
mu, tng ng mu, truyn mannitol.
194
Khi cn tnh "natri hiu chnh" theo cng thc:

Na hiu chnh = Na o c + [0,16 x (protit + lipit)(g/l)]
Na hiu chnh = Na o c + {[ng mu (mmol/l) - 5,6]/5,6} x 1,6
- p lc thm thu huyt tng > 290 mOsmol/l: tng ng mu, truyn
mannitol.
- p lc thm thu huyt tng 280 - 290 mOsmol/l: gi h natri mu (tng
protein mu, tng lipit mu).
Cc xt nghim cn lm chn on nguyn nhn:
- Hematocrit, protit mu (xc nh tng hay gim th tch ngoi t bo).
- Natri niu (xc nh mt natri qua thn hay ngoi thn).
- p lc thm thu huyt tng, p lc thm thu niu.
4.4. Chn on mc
- H natri mu c nh gi l nng khi Natri mu < 125 mmol/l v hoc c
triu chng thn kinh trung ng.
- Mc nng ph thuc vo thi gian cp hoc mn:
+ H Natri mu cp: khi thi gian xut hin 48 gi, biu hin tnh trng lm
sng nng.
+ H Natri mn: khi thi gian xut hin > 48 gi, biu hin lm sng nh hn.
5. X TR
iu tr phi theo nguyn nhn gy h natri mu. Trong qu trnh iu tr cn
theo di cht ch bilan nc vo-ra, cn ngi bnh hng ngy, xt nghim in gii
mu 3 - 6 gi/ln quyt nh vic iu tr.
5.1. iu tr theo nguyn nhn h natri mu
a) H natri mu km theo mui v nc ton th
- Hn ch nc (< 300 ml/ngy).
- Hn ch mui (ch n mi ngy ch cho 3 - 6 g natri chlorua).
- Dng li tiu thi nc v natri: furosemid 40 - 60 mg/ngy (c th dng
liu cao hn, ty theo p ng ca ngi bnh), ch b kali khi dng li tiu.
b) H natri mu vi th tch ngoi t bo bnh thng
- Ch yu l hn ch nc (500 ml nc/ngy).
- H natri mu do SIADH: c th cho thm li tiu quai, demeclocycline.
- H natri mu do dng thiazid: ngng thuc.
- H natri mu do suy gip, suy thng thn: iu tr hocmon.
- Nu h natri mu nng (Na < 125 mmol/l hoc c triu chng thn kinh trung
ng): truyn natri chlorua u trng (cch truyn xem phn 4.3). C th cho
furosemid (40 - 60 ml tim tnh mch) khi truyn natri chlorua.
c) H natri mu km theo gim th tch ngoi t bo
iu tr nguyn nhn song song vi iu chnh natri mu.
195
- Nu ngi bnh h natri mu khng c triu chng: cung cp natri chlorua

theo ng tiu ha.
- H natri mu bnh nhn tn thng c do chn thng th truyn dch
natriclo rua 0,9%.
- Nu h natri mu nng (Na < 125 mmol/l, c triu chng thn kinh trung
ng) hoc khi c ri lon tiu ha khng dng qua ng tiu ha c: truyn natri
chlorua u trng ng tnh mch.
5.2. iu chnh natri mu
a) Nguyn tc iu chnh
- Trong h natri mu khng c triu chng hoc xy ra mn tnh (> 2 ngy):
iu chnh natri mu tng ln khng qu 0,5 mmol/l trong 1 gi hoc 8- 12 mmol/l
trong 24 gi.
- Trong h natri mu cp tnh (< 2 ngy), h natri mu c km theo triu chng
thn kinh trung ng: iu chnh natri mu tng ln 2 - 3 mmol/l trong 2 gi u, sau
iu chnh tng ln khng qu 0,5 mmol/l trong 1 gi hoc 12 mmol/l trong 24 gi.
Cn lu l iu chnh nng natri mu ln qu nhanh c nguy c gy nn
tnh trng tiu myelin trung tm cu no, biu hin bi mt tnh trng lit mm, ri
lon vn ngn, ri lon thc, c th dn ti t vong.
b) Cch tnh lng natri chlorua cn b
Na cn b = Tng lng nc c th c tnh x (Na cn t - Na ngi bnh)
Trong :
Na cn b: lng natri cn b trong 1 thi gian nht nh.
Tng lng nc c th c tnh bng:
Nam: Cn nng (tnh theo kg) x 0,6
N: Cn nng (tnh theo kg) x 0,5
Na cn t: nng natri mu cn t c sau thi gian b natri.
Na ngi bnh: natri mu ca ngi bnh trc khi b natri.
c) Loi dung dch natri chlorua c la chn
- Truyn dung dch Natri chlorua 0,9% b c nc v natri.
- Khi c h natri mu nng: dng thm dung dch natri chlorua u trng
(dung dch 3% hoc 10%).
Ch : 1 g NaCl = 17 mmol Na+.
1 mmol Na+ = 0,06 g NaCl.
1000 ml dung dch natri chlorua ng trng 0,9% c 154 mmol Na+.
1000 ml dung dch natri chlorua 3% c 513 mmol Na+.
1000 ml dung dch lactat ringer c 130 mmol Na+ (+4 mmol K+).
d) Thay i nng natri huyt thanh khi truyn cho ngi bnh 1 lt dch c th c
c tnh bng cng thc Adrogue-Madias:
Na+ = [(Na+ + K+ dch truyn) - Na+ huyt thanh]/[Tng lng nc c th c tnh +1]
196

- Tin lng: ph thuc vo nguyn nhn gy h natri mu.
- Bin chng:
+ Bin chng ca h natri mu: tiu c vn, co git, tn thng thn kinh trung
ng do ph no.
+ Bin chng do iu tr: tng gnh th tch (truyn dch nhanh qu), tn
thng myelin (do iu chnh natri mu tng nhanh qu).
7. PHNG BNH
Theo di natri mu v tnh trng cn bng nc nhng ngi c nguy c h
natri mu iu chnh kp thi.
Ti liu tham kho
1. V Vn nh (2001) Ri lon nc in gii, Hi sc Cp cu, tp II, Nxb Y
hc.
2. Craig S. (2010):Hyponatremia. URL: http://emedicine.medscape.com/ article/
767624-overview
3. Service des Urgences-Smur, CH de Fontainebleau: Hyponatremie. URL:
http://samurgefontainebleau.free.fr/Files/hyponatremie.pdf
4. Sterne R.H. (2013): Hyponatremia. Up to date.
5. Tod S.R. (2011), Disorders of water balance, Texbook of Critical Care (Editors:
Vincent J.L., Abraham E., Moore F.A., Kochanek P.M., Fink M.P.), Elsevier
Saunders, 6th edition.
6. Usman A., Goldberg S. (2012): Electrolyte abnormalities, The Washington
Manual of Critical Care (Editors: Kollef M. and Isakow W.), Lippincott Williams
& Wilkins.
197
Natri mu < 135 mmol/l
o thm thu mu
Bnh thng
(280-290 mOsm/kg)
Thp
(< 280 mOsm/kg)
Gim Na mu gi
- Tng lipid mu
- Tng protid mu
nh gi tnh trng
th tch
Tng th tch mu
- Suy tim huyt
- X gan mt b
- Hi chng thn h
Gim th tch mu
Tng
(> 290 mOsm/kg)
Gim Na mu tng
thm thu huyt tng
- Tng ng mu
- Truyn dch u trng
Th tch mu bnh thng

- SIADH (ALTT niu
>100 mOsm/kg)
- Chng cung ung do
tm thn (ALTT niu
<100 mOsm/kg)
- Chng cung ung bia
- Suy gip
- Thiu cortisol
Xt nghim nng natri

niu
Natri niu > 20 mmol/l:

mt qua thn
- Dng li tiu (nht l
thiazide)
- Suy thng thn
- Bnh thn gy mt
mui/Hi chng mt
mui do no
Natri niu < 15 mmol/l:

mt ngoi thn
- Nn, a chy, l d
- Bng, mt m hi
- Vim tu, vim phc
mc
S chn on h natri mu
Theo: Usman A., Goldberg S. (2012) [6]
SIADH: hi chng tit ADH khng thch hp ALTT: p lc thm thu
198
Gim nng natri mu
C triu chng hoc xy ra

cp tnh (<2 ngy)
Khng c triu chng hoc

xy ra mn tnh (>2 ngy)
- iu tr nguyn nhn nn
- Hn ch nc
- Dng dch mui u trng (3%) iu chnh
gim nng natri mu vi tc iu chnh 1-2
mmol/lt/gi ti khi ht triu chng
- Tnh ton tc truyn v thnh phn dch
truyn bng phng trnh Adrogue-Madias (thay
i nng Na huyt thanh khi truyn 1 lt dch):
(Na+K trong dch truyn) - (Na huyt thanh)
- Khng cn phi iu chnh ngay

nu tnh trng gim Na mu nh
- iu tr nguyn nhn nn
- Hn ch nc
iu chnh vi tc khng
vt qu 0,5 mmol/gi hoc 12
mmol/ngy
(Tng lng nc trong c th) + 1

- Sau khi triu chng ci thin, iu chnh nng
Na huyt thanh vi tc khng qu 0,5
mmol/gi hoc 12 mmol/ngy
Cc biu hin lm sng

- Mc nng ca triu chng
ph thuc vo c mc v tc
gim Na mu
- Gim Na mu cp:
+ Na ~ 125 mmol/lt: bun nn,
kh chu; nu Na gim thp hn
na: au u, ng lm, l ln, u
m
+ Na < 115 mmol/lt: tnh trng
sng s, co git v hn m c th
xy ra
- Gim Na mu mn: cc c ch
thch ng c huy ng nhm
bo v th tch t bo v c xu
hng lm gim bt triu chng
biu hin.
S iu tr h natri mu
Theo: Usman A., Goldberg S. (2012): Electrolyte abnormalities. In: The Washington Manual of
Critical Care (Editors: Kollef M. and Isakow W.), Lippincott Williams & Wilkins. (Bn dch ting
Vit: Cc bt thng in gii, trong: Hi sc cp cu - Tip cn theo cc phc , Nxb Khoa hc k
thut, H Ni, 2012).
199
CC RI LON THNG BNG KIM TOAN
1. KHI NIM C BN
Nng ion H+ dch ngoi t bo (DNTB) c xc nh bi cn bng gia
PCO2 v HCO3. Mi tng quan c th hin:
H+ (neq/l) = 24 x (PCO2/ [HCO3])
Bnh thng: PCO2 40 mmHg, HCO3 24 mEq/l.
Nng H+ bnh thng mu ng mch l
[H+] = 24 x (40/ 24) = 40 nEq/l
Nng [H+] c biu th bng nanoequivalent. 1 nEq = 1 phn triu mEq.
pH l n v biu th H+ c tnh bng logarith m 10 ca H+ c tnh bng
neq. Thay i ca pH t l nghch vi thay i ca H+ (vi d pH gim th H+ tng).
Bnh thng pH t 7,35 7,45. Mc tiu l gi t l PCO2/ HCO3 hng nh
Bng 1 . Cc bin i tin pht v th pht ca acid base
Cc loi ri lon
Thay i tin pht
Cch b
Toan h hp
tng PCO2
tng HCO3
Kim h hp
gim PCO2
gim HCO3
Toan chuyn ho
gim HCO3
gim PCO2
Kim chuyn ho
tng HCO3
tng PCO2
Khi pH khu vc ngoi t bo c gi n nh th pH trong t bo cng c
gi n nh, khi c cc thay i tin pht ( u tin) ca PCO2 th HCO3 thay i theo
v ngc li.
Bnh thng CO2 c sn xut ra trong c th (khong 220 ml/ pht) tng
ng vi 15000 mmol acid carbonic / ngy. Trong khi nhng acid khng bay hi do
thn v rut sn di 500 mmol/ ngy. Bnh thng PaCO2 (khong 40 5mmHg)
c duy tr cn bng chnh xc bi thng kh ph nang v sn xut PaCO2.
Bng 2. Gi tr HCO3 cn t khi c ri lon toan - kim h hp
Thay i [HCO3- ] c d kin i vi cc ri lon toan kim do h hp
Ri lon
HCO3- ( mEq/l)
PaCO2 ( mmHg)
SBE ( mEq)
Toan h hp cp = [(PaCO240)/10] +24
> 45
=0
Toan h hp mn = [(PaCO240)/3] +24
> 45
=0.4 ( PaCO240)
Kim h hp cp = 24 -[(40 - PaCO2)/5] < 35
=0
Kim h hp mn = 24 -[(40 - PaCO2)/2] < 35
= 0.4x (PaCO2 40)
Trong cc ri lon toan kim h hp, thn b tr cho cc thay i ca PaCO2
bng cch lm tng nng bicarbonate (HCO3-) huyt tng trong nhim toan h
hp. Cc ri lon toan kim cp ch gy ra cc thay i nh trong nng bicarbonate
v h m t bo chim u th. B tr thn mn tnh xy ra trong vi ngy ti hng
tun v gy ra cc bin i ln hn trong nng bicarbonate huyt tng.
200
2. C CH BNH SINH
2.1. B tr theo c ch h hp
Thay i H+ trong mu s c cc receptor nhn cm ng mch cnh
trong, no ghi nhn. Khi c toan chuyn ho n s kch thch h thng h hp hot
ng tng ln v PaCO2 gim.
Kim chuyn ho khng kch thch h thng h hp hot ng, nh vy h hp
s gim v PaCO2 tng ln.
2.2. B qua c ch chuyn ho
Thn tham gia vo iu ho bng cch iu chnh ti hp thu HCO3 ng ln
gn. Toan h hp kch thch tng ti hp thu HCO3, kim h hp th s c ch ti hp
thu (HCO3 gim). Tuy nhin c ch b ca thn chm hn, thng bt u sau 6 12
gi v n nh sau vi ngy.
Bng 2. c lng thay i ca acid base
Thay i tin pht
Cc thay i b c tnh
Toan chuyn ho
PaCO2 = 1,5 x HCO3+(8 2)
Kim chuyn ho
PaCO2 = 0,7 x HCO3 + ( 21 2)
Toan h hp cp
pH =0,008 x (PaCO2 40)
Toan h hp mn
pH = 0,003 x ( PaCO2 40 )
Kim h hp cp
pH = 0.008 x ( 40 PaCO2)
Kim h hp mn
pH = 0,0017 x (40 PaCO2 )
3. CC QUI TC NH HNG PHN TCH
Ba thng s c bn: pH = 7,35 7,45
PaCO2 = 35 45 mmHg
HCO3 = 22 26 meq/l
Khi cc gi tr ny vt ra ngoi gii hn th u c coi l bt thng
3.1. Ri lon chuyn ho tin pht
Qui tc 1: ri lon toan kim c cho l do nguyn nhn chuyn ho nguyn pht khi
pH v PaCO2 thay i cng chiu.
v d: Toan chuyn ho nguyn pht: pH< 7,35 v PaCO2 gim.
Kim chuyn ho: pH > 7,45 v PaCO2 tng
Qui tc 2 : ri lon toan kim c cho l nguyn nhn h hp khi PaCO2 cao hn gi
tr c tnh th gi l toan h hp, nu thp hn th gi l kim h hp.
V vy khi xc nh l c toan chuyn ho nguyn pht, th tip theo c
tnh gi tr PaCO2 xem b bng h hp. Nu PaCO2 o c cao hn hoc thp hn
thi gi l c ri lon hn hp.
3.2. Ri lon h hp tin pht
Qui tc 3: ri lon acid base c cho l nguyn pht do h hp nu PaCO2 bt
thng v PaCO2 v pH thay i ngc chiu.
V d: Toan h hp nguyn pht nu PaCO2> 44 mmHg v pH gim.
201
Kim h hp nu PaCO2 < 36 v pH tng.

Qui tc 4: c lng thay i pH (s dng bng 2) xc nh ri lon h hp cp
hay mn tnh, v c toan chuyn ho thm vo hay khng?
Nn pH thay i 0,008 ln so vi thay i PaCO2 th c gi l cp tnh (khng
b). Nu thay i t 0,003 0,008 ln c gi l b mt phn. Nu thay i < 0,003
th c gi l mn tnh ( b hon ton) Nhng pH thay i > 0,008 ln so vi PCO2
thi c ri lon chuyn ho thm vo.
V d: PaCO2 o c l 50 mmHg
- Nu pH gim xung cn 7,32 th c gi l suy h hp cp v:
0,008 x ( 50 40 ) = 0,08 n v pH. 7,40 0,08 = 7,32
- Nu pH < 7,32 chng t c toan chuyn ho km theo.
- Nu pH t 7,33 7,37 ; gi l c b mt phn.
- Nu pH > 7,38 th gi l mn tnh.
3.3. Ri lon hn hp
Qui tc 5 : gi l hn hp khi PaCO2 bt thng m pH khng thay i hoc pH
bt thng m PaCO2 khng thay i.
V d: PaCO2: 50 mmHg v pH: 7,40 gi l toan h hp c b li bng kim
chuyn ho.
-Thng gp ngi bnh cp tnh v c th on bit trn cc tnh trng lm
sng.
- S nh gi k thut i b tr ca pH, PaCO2 v [ HCO3 ] l cn thit. Cn
thc hin o in gii mu v tnh cc khong trng anion. iu tr ri lon thng
bng toan kim phi hp l iu tr bnh chnh.
202
TOAN CHUYN HO
1. I CNG
nh ngha: toan chuyn ha l s gim [HCO3-], phn nh hoc l s li cc
acid c nh hoc l tnh trng mt kim.
p ng b tr l tng thng kh dn n gim PaCO2.
2. NGUYN NHN
2.1. Nhim toan khng tng khong trng anion (tng chlo mu hyperchloremic)
c th phn loi theo kali huyt thanh.
- Loi c kali mu cao hoc bnh thng:
+ Gim tit aldosterone.
+ Nhim toan ng thn loi tim truyn tnh mch.
+ Suy thn trung bnh (mc lc cu thn > 20 ml/pht).
+ a HCl vo v sau gim CO2.
- Loi c kali huyt thanh thp:
+ Mt qua d dy - rut do mt bicarbonat (a chy, niu qun phn nhnh, l
d mt hay ty).
+ Cc thuc c ch carbonic anhydrase.
+ Nhim toan do bnh ng thn xa v gn.
+ S gim bi tit acid ng thn.
2.2. Nhim toan c tng khong trng anion(anion gap)
- Toan ceton do tng ng huyt.
- Nhim toan lactic: hu qu ca sc, vim ty cp, ng c, suy gan cp
- Ng c thuc (methanol salicylat, ethylen glycol, paraldehyd).
- Toan ha ng thn.
3. TRIU CHNG
3.1. Lm sng: khng c hiu
- nh hng trn tim mch.
+ Gim sc co bp c tim, gim tnh dn truyn.
+ Gin ng mch.
+ Hi hp trng ngc, au ngc.
- nh hng trn h thn kinh.
+ c ch trung tm h hp.
+ Gim p ng ca thn kinh trung ng.
+ au u, hn m.
- nh hng n vic gn xy: gim gn xy vo Hb v gim 2,3 DPG (giai
on mun).
- nh hng n chuyn ha:
203
+ Ph hy protein.
+ Khng insulin.
+ Kch thch bi tit cathecholamin, PTH v aldosterol.
+ Mt cht khong xng.
+ Tng calci, kali v acid uric mu.
- nh hng trn tiu ha:nn, gim hp thu rut.
3.2. Cn lm sng
- Nng H+ trong mu tng v HCO3- gim.
- pH mu gim, hoc trong gii hn bnh thng (cn b).
- Cl- mu, Cl- nc tiu.
4. CHN ON
4.1. Chn on xc nh. Triu chng lm sng khng c hiu. Chn on xc nh
da vo xt nghim
- Nng H+ trong mu tng v HCO3- gim.
- pH mu gim, hoc trong gii hn bnh thng (cn b).
- Cl- mu, Cl- nc tiu.
a) Nhim toan khng tng khong trng anion (tng chlo mu hyperchloremic) c
th phn loi theo kali huyt thanh.
b) Nhim toan c tng khong trng anion
5. X TR
5.1. Nguyn tc x tr
- iu tr nguyn nhn. iu tr nhim toan phi lu thi gian din ra cc ri
lon thng bng kim toan.
- V d, nhim toan xe ton thng din ra trong thi gian ngn th bin php b
tr ti a bng h hp l an ton nht. Ngc li, i vi cc trng hp nhim toan
mn tnh (nh suy thn) cc iu tr nhm khi phc s chnh lch cc ion mnh
(Strong ion diffirence SID).
5.2. Cc bin php x tr
a) Natribicarbonate:dng natribicarbonate l n gin v hiu qu nht.
- Nu nh ch cn cho ung natribicarbonate 1g c 12 mmol natribicarbonate.
- pH < 7,20 cn phi b bicarbonate tnh mch c tnh theo cng thc:
[ HCO3 ] thiu = PKg x (0,4) x ([ HCO3 ]cn t - [ HCO3 ] o c)
Na s thiu ht tnh c c th b trong 3 - 4 gi nu khng c suy
tim nng. Cc loi dung dch natribicarbonate c dng 14%, 42% v 84%.
- Ring trong nhim toan xeton do i tho ng khng nn b bng
Bicacbonat, ch cn truyn dch nhanh o thi axit betahydroxybutyric v dng
insulin ng v kp thi l .
204
b) THAM:
- L mt cht nhn ion H +c ch nh khi nhim toan chuyn ha c tng
natri mu chng ch nh vi natribicarbonate. Tuy nhin, n c th gy c ch trung
tm h hp, h ng huyt v hoi t gan nng.
- iu tr nhim toan chuyn ha khng tng khong trng anion (tng chlo
mu).
c) Lc mu ngoi thn
Trong trng hp suy thn nhng c d ha mnh lm ure mu, creatinin hoc
kali mu tng nhanh v khng o thi c cc gc axit phi ch nh lc mu.
205
KIM CHUYN HO
1. I CNG:
Kim chuyn ha bn cht tng nng bicarbonate trong mu, thng gp
trn lm sng, nguyn nhn ch yu l mt ion H+ qua ng d dy hoc qua nc
tiu.
Mt ion H+ thng i km vi mt kali mu v h kali mu.
Nhng bnh nhn c chc nng thn bnh thng, lng bicarbonate c o
thi nhanh chng qua thn, v vy trng hp nhim kim ko di thng km theo
gim th tch, gim tun hon hiu dng, mt chlo mu, h kali mu v bt thng
chc nng thn
2. NGUYN NHN
- Mt axit clohydric qua d dy, thn, rut.
- a thm bicarbonate.
3. TRIU CHNG
3.1. Lm sng
- Triu chng tim mch: gim sc co bp c tim (lin quan n vn chuyn
++
Ca qua mng t bo), thay i dng mu ti mch vnh, ng c digoxin.
- Triu chng thn kinh c: tng trng lc c, co git do tn thng no.
- nh hng n chuyn ha: h kali mu, gim can xi mu, gim phosphat
mu, bt thng chc nng ca cc enzyme.
- nh hng n vn chuyn xy: tng kh nng gn oxy vo Hb v tng hot
tnh ca 2,3 DPG.
3.2. Cn lm sng
- Nng H+ trong mu gim v HCO3- tng.
- pH mu tng, hoc trong gii hn bnh thng (cn b).
4. Chn on
4.1. Chn on xc nh
V chn on, nn chia nguyn nhn gy nhim kim chuyn ho theo nng
clorua nc tiu l tin li. V ngc li iu ny c ngha iu tr v n quyt nh
c cho clorua iu tr nhim kim hay khng (nhim kim p ng v khng p
ng vi clorua).
a) Nhim kim p ng vi clorua
- C clorua niu di 10 mEq/l l loi thng gp nht trong nhim kim
chuyn ho.
- N thng km theo mt dch ngoi t bo (DNTB).
b) Nhim kim khng clorua
- Khi clorua nc tiu > 20 mEq/l.
206
- Rt t gp.
- Mt dch HCl trong d dy - rut (nn, ht d dy, u nang tuyn lng v tiu
chy nhiu clorua bm sinh).
- S dng li tiu v lm mt DNTB v h kali mu.
- Tnh trng sau tng CO2 do lun ti hp thu bicarbonat thn.
- Truyn nhiu kim hoc truyn mu nhiu ln (tng citrate) c th cn gy
nhim kim chuyn ho p ng clorua.
b) Nhim kim khng cloruakhi clorua
- Loi tr hi chng Bartter v mt magi, nhng ngi bnh ny ni chung c
tng huyt p v khng mt DNTB.
- Nhng nguyn nhn khc: gim tit aldosteron tin pht, hi chng Cushing,
hp ng mch thn, hi chng Lidde, tng calci mu, h kali mu nng.
5. X TR
- iu tr cc bnh chnh gy ra, b mt clorua c th dng vin NaCl, nu mt
DNTB r rt nn truyn mui tnh mch.
- Khi truyn nhiu dch, nu chc nng thn tt c th cho acetazolamide, l
mt thuc c ch men anhydrase carbonic lm tng o thi bicarbonat thn. Liu
thng dng l 250 - 500 mg ung hoc tim tnh mch 8 gi/ln.
- Nhim kim chuyn ho nng (pH > 7,55) vi cc triu chng lm sng r rt
nn iu tr bng liu php toan ho, c bit nu c chng ch nh a NaCl vo (v
c suy tim, suy thn). S lng acid a vo iu tr nhim kim c th c tnh
theo cng thc sau:
+ H+ thiu (mEq) = 0,5 x trng lng c th (kg) x [ HCO3 ] o c - HCO3 ]
mun c) 1/2 s thiu b trong 12 gi u tin, s cn li b trong 24 gi tip sau,
theo di tnh trng lm sng
+ C th lm gim HCl d dy bng cc cht i khng H2 ng ung hoc
truyn.
+ Cui cng l ngi bnh c suy thn c th dng thm phn mu iu tr
nhim kim.
207
b) Nhim kim khng cloruakhi clorua

iu tr
Bnh cnh
Cng
pht
tin Spironolactone c tc dng c ch ti hp thu natri

ng ln xa lm ci thin tnh trng kim, h kali
mu v tng huyt p
H ch mui v b ka li
Phu thut ct b khi u thng thn.
Cng thng thn th Thuc c ch men chuyn thng c hiu qu. iu
pht
tr cc nguyn nhn chnh nu c.
aldosterol
Hi chng Cushing
Hi chng Liddle
Hi chng Bartter
Dng corticoid ngoi sinh
Do tuyn yn tng tit qu mc ACTH: phu thut

hoc x tr
Do adenoma hoc carcinoma tuyn thng thn: ct u
Do tng tit ACTH th pht hoc lc ch: tm nguyn
nhn c tnh tin pht.
iu tr bng triamtere
Tin lng iu tr lu di thng khng tt. Li tiu
gi kali, b sung kali v thuc c ch men chuyn.
Ngng corticoid v ngay lp tc b sung kali
H kali hoc magie mu B sung in gii

nng
208
TOAN H HP
1. I CNG
Do gim o thi CO2 phi. Toan h hp l tnh trng tng PaCO2 mu

c hoc khng km theo tng HCO3, pH thng thp nhng c th gn nh
bnh thng.
Toan h hp c hai loi cp v mn tnh. Phn bit da vo mc tng
nng HCO3-.
2. NGUYN NHN
- c ch h thng thn kinh trung ng (thuc, nhim trng, tn thng no).
- Bnh thn kinh c (bnh c, hi chng Guillain Barre).
- Bnh phi: t cp BPTNMT, hen ph qun, bnh phi hn ch, vim phi
nng
3. TRIU CHNG
3.1. Lm sng
- Kch ng, hoa mt, ph gai th, nhc u, ng g, hn m.
- Tng huyt p, tim nhanh, suy tim v ri lon nhp tim.
3.2. Cn lm sng
- pH mu gim.
- PaCO2 tng.
- HCO3bnh thng hoc tng (ty vo tnh trng nhim toan h hp cp hay
mn).
4. CHN ON
o cc cht kh trong mu c pH gim v PaCO2 tng. HCO3 bnh thng hoc
tng.
5. X tr
- Nhm ci thin thng kh ph nang v bao gm thuc gin ph qun cho
ngi bnh hen ph qun, t cp BPTNMT hoc x l cc bnh l thn kinh c.
- Khng c khuyn co s dng natribicarbonate i vi nhim toan h hp.
209
NHIM KIM H HP
1. I CNG
Do o thi CO2 phi qu mc (tng thng kh).
2. NGUYN NHN
- Bnh l h thn kinh trung ng (u no, vim no mng no) hoc bt n
v tinh thn : tnh trng au n, vt v, khc lc , lo lng
- Gim oxy mu: sng vng cao, thiu mu nng.
- C thai.
- Cng gip, x gan.
- Thuc: salicylate, cathecholamin, progesteron.
- Cc bnh phi: vim phi, cc tn thng phi gy ra mt tng xng thng
kh v ti mu, tnh trng shunt phi.
- iu chnh qu nhanh nhim toan chuyn ho mn tnh cng c th dn n
nhim kim h hp v nhim toan h thn kinh c iu chnh chm v lu hn, lin
tc gy ra tng thng kh.
3. TRIU CHNG
- Chng mt, ri lon cm gic.
- Tetani, ngt, co git.
- Ri lon nhp tim.
4. CHN ON
- Bng o cc cht kh trong mu c tng pH v gim CO2, nn xc nh xem
c b thn khng, nu khng th l bnh phi hp.
- Bicarbonat huyt thanh khng xung di 15 mEq/l, tr phi c nhim toan
chuyn ho km theo.
5. X TR
- iu tr trc tip bnh chnh.
- iu tr cp cu thng khng cn thit tr phi pH > 7,50.
210
Ti liu tham kho

1. V Vn nh. (2003), Thng bng toan kim trong c th, Hi sc cp cu ton
tp, Nh xut bn y hc, Tr 35-41.
2. V Vn nh. (2003), Toan chuyn ha, Hi sc cp cu ton tp, Nh xut
bn y hc, Tr 41-43.
3. Bongard F.S. (2013), Acid base homeostasis and disorder, Current Diagnosis
and Treatment Critical care, Pp. 56-70
4. Chawia N., Koch M.J. (2012),Metabolic acid base disorders,The Washington
Manual of Critical Care (Editors: Kollef M. and Isakow W.), Lippincott Williams
& Wilkins. (Bn dch ting Vit: Cc ri lon toan kim, Hi sc cp cu Tip cn theo cc phc , Nxb Khoa hc k thut, H Ni, 2012).
5. Dubose T.D. (2010), Acidosis and alkalosis, Harrisons Pulmonary and Critical
care medicine, Pp. 410.
6. Dubose T.D., Daerhagh P. (2013), Metabolic Acidosis and Alkalosis, Texbook
of critical care. Sixth edition. Jean- Louis Vincent, Elsevier Sauders, Pp. 823-39
7. Emmett M. (2013), Approach to the adult with metabolic acidosis.
Uptodate.com
8. Labelle A. (2012),Respiratory acid base disorders,The Washington Manual of
Critical Care (Editors: Kollef M. and Isakow W.), Lippincott Williams &
Wilkins. (Bn dch ting Vit: Cc ri lon toan kim, Hi sc cp cu - Tip
cn theo cc phc , Nxb Khoa hc k thut, H Ni, 2012).
9. Marino P.L. (2007), Acid base disorder, The ICU book. Thirt edition, Pp. 53144.
211

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B Y T

Tn thng phi cp (Acute Lung Injury-ALI)

p lc ng th dng lin tc (Continuous positive airway pressure)

Lc mu hp ph phn t ti tun hon (Molecular Adsorbents

2.4. Mng phi

c) Thm khm: cn khm k v h hp, tim mch, thn kinh

Loi nguy kch

Tng huyt p hoc tt

+ Kh nng khc m gim nhiu hoc mt.

Ti liu tham kho

SUY H HP NNG DO T MT B CP CA BNH PHI

- in tim c th cho thy hnh nh P ph, cc du hiu ca tng gnh tht

mt ln nu cha c hiu qu; phi hp vi thuc c ch ph giao cm tc dng nhanh

Ti liu tham kho

CN HEN PH QUN NNG V NGUY KCH

- Cc triu chng c nng cng nh thc th v cn lm sng c th khc nhau

4.4. Chn on mc nng ca cn hen

a) nh gi cn HPQ l cn nng khi:

+ Nn bt u bng thng kh khng xm nhp nu cha xut hin cc ch nh

6. TIN LNG V BIN CHNG

S X TR CN HEN CP TRONG BNH VIN

Tin s: nguy c cao.

Tin s: nguy c cao.

Khoa hi sc tch cc:

Chuyn hi sc tch cc:

Nu ct cn hen, PEF >70% n nh.

iu tr thuc vin hoc ht.

Ti liu tham kho

HI CHNG SUY H HP CP TIN TRIN

Hnh 1. Hnh nh tn thng phi ngi bnh nhim cm A H1N1

Hnh 2. Hnh nh ct lp vi tnh ngc

Ci t tn s th : 14 35 ln/pht sao cho m bo c thng kh pht (68 lt/pht).

c) Nghim php huy ng ph nang:

8. Siegel M.D. (2013), Acute respiratory distress syndrome: Definition;

TRN KH MNG PHI BNH NHN TH MY

- Lng ngc mt bn cng, di ng km, khm thy gim hoc mt r ro ph

- Cn nhanh chng m mng phi ti thiu, t 1 ng dn lu c khu knh

Bin chng ca trn kh mng phi:

VIM PHI NNG DO VI KHUN TI CNG NG

+ Tiu chun chnh:

4.4. Chn on mc nng

5.2. X tr ban u v vn chuyn cp cu

+ Ngi bnh dng corticoid lu ngy cn ko di thi gian iu tr khng sinh

6. Kollef M.H., Isakow W. (2012), Community-Acquired Pneumonia, The

VIM PHI LIN QUAN N TH MY

- Chn thng, bng.

- Ngi bnh c nhp vin iu tr (thi gian iu tr t nht 3 ngy) trong

5.3. X tr ti bnh vin

c) Theo di v thi gian iu tr khng sinh

- ang iu tr ti bnh vin hoc mi trng khc c lu hnh vi khun c tnh

Ti liu tham kho

2. Nguyn Ngc Quang (2011), Nghin cu tnh hnh v hiu qu iu tr vim

Du hiu lm sng nghi ng Vim phi

Lm xt nghim m (nu ngi bnh st 38oC: cy mu):

Bt u khng sinh theo kinh nghim (da trn c a,

Tip tc iu tr khng sinh theo kinh nghim trong vng

Cc triu chng thuyn gim

Lm sng c ci thin hoc

Cn nhc ngng khng sinh.

Liu php xung thang

Tip tc ci thin triu chng.

Gii hn thi gian s dng khng

Khng ci thin triu chng.