cng Phu thut lng ngc Basedow

BASEDOW

Gii phu tuyn gip

Chn on SM: Basedow bu gip lan to . giai on(bnh gip hoc
nhim c gip mc (nh, trung bnh, nng) phu thut ct gn hon ton
tuyn gip ngy th.

Cu hi:
1. Bin lun chn on?
2. Chn on phn bit vi nhng bnh no?
3. K n cho bnh nhn Basedow c nhim c gip mc trung bnh?
4. Ch nh iu tr ngoi khoa Basedow?
5. iu tr cho chun b m Basedow?

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 cng Phu thut lng ngc Basedow

6. Cc k thut ct gn hon ton tuyn gip?

7. Tai bin bin chng sau m Basedow: nguyn nhn, triu chng pht hin
v cch x tr?

* N: Bnh Basedow l tnh trng tng sinh lan to ton b tuyn gip + tit nhiu
hormon gy nn nhim c ni sinh
* Tn khc: Bnh Grav, bnh bu lan to nhim c, bnh bu gip li mt
Cu 1. Bin lun chn on:
1. Chn on Basedow:
* Hc thay i hnh thi tuyn gip:
- Bg to lan to 2 thu, mt , ranh gii r hay khng, mt nhn hay khng nhn
- S c rung miu?
- Nghe c TTTT ?
* Hc ri lon iu chnh trc di i - tuyn yn-tuyn gip:
- Mt li, cc du hiu Moebius, Dh Dalrymple, Dh Von Graefe?
- Run tay: bin nh
- Thay i tnh tnh
- NP hm Werner(-): Cch lm: Sau khi o iod ti tuyn gip thy tng cao cho
bnh nhn ung T3 o li nu gim trn 25-50% l NP (+). Trong bnh
Basedow Np m tnh do c s ri lon iu chnh trc tuyn yn- tuyn gip.
* Hc nhim c gip:
- Mch nhanh(c lc ngh)
- n ung nhiu n
- 0hng vn gy st nhanh( gim ..cn/..thng?)
- CHCS tng cao(bnh thng 10)
- XN nng hormon gip:
+ T3, T4, fT3, fT4: tng
+ TSH gim
2. Chn on :

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- I: S thy bu khi bnh nhn nut

- II: Nhn v s u thy r nhng vng c cha thay i
- III: Bu li hn ra khi vng c chim mt din tch rng trc c
- IV: Bu to ln qu xng c lm thay i hnh dng vng c
- V: Bu rt to bin dng hon ton vng c
3. Chn on mc nhim c gip:

Mch CHCS St cn
Nh <100 20-30 <10% c th
Va 100-120 30-60 10-20%
Nng >120 >60 >20%

4. Tiu chun chn on bnh gip:

- ct thuc khng gip tng hp t nht 7 ngy
- Mch < 90l/pht
- CHCS < 20%
- Bnh nhn ln cn n ng tt, tinh thn n nh, yn tm mun c m
- Cc XN trong gii hn bnh thng(tg lm XN <20ngy)
Cu 2. Chn on phn bit Basedow vi nhng bnh no? Bin lun?
1. Bu c th nhn(Bnh Plummer):
* Ging:
- Bu gip to
- Hc nhim c gip
* Khc :
- Bu gip th nhn c ranh gii r mt chc
- Triu chng tim mch tin trin nhanh v nng
- Khng c li mt
- Chp x hnh tuyn gip c hnh nh mt nhn nng trn nn nhu m xung
quanh gim hp thu iod

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 cng Phu thut lng ngc Basedow

2. Suy nhc thn kinh:

* Ging : cng c cc triu chng run tay, mch nhanh, d kch thch, gy st
* Khc:
- Mch nhanh khng n nh, lc ngh v yn tnh mch bnh thng
- n ung t khng thy ngon
- Cc XN nh gi chc nng tuyn gip trong gii hn bnh thng(Hy nu cc
XN nh gi chc nng tuyn gip?)
3. Lao phi: trng hp bnh nhn Basedow st cn nhanh cn chn on phn
bit vi lao phi. Trong lao c:
- n lnh
- St v chiu ra m hi ban m
- XQ: Hnh nh tn thng lao
- XN: AFB, Mantoux
- XN chc nng tuyn gip bnh thng
Cu 3. K n iu tr ni khoa cho bnh nhn c chn on sau: Basedow bu
gip to lan toa III nhim c gip mc trung bnh
1. PTU 50mg 8vin (S-C)
2. Propranolon 40mg 1vin
3. ATP 20mg 2vin(S-C)
4. Seduxen 5mg 1vin(ti)
5. Prednisolon 5mg 4vin(ung 8h sng sau n)
6. Vicap * 1vin
Cu 4. Ch nh iu tr phu thut bnh Basedow?
- iu tr ni khoa c bn t nht 3-6 thng kt qu khng n nh hoc khng
khi
- Bu ln gy chn p, bu chm trong lng ngc
- C cc bin chng tim mch, chn p:
+ Chn p kh ph qun : kh th
+ Chn p thanh qun: kh nut, nghn

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 cng Phu thut lng ngc Basedow

+ Chn p mch mu: xut hin tun hon bng h c

+ Chn p thn kinh qut ngc: khn ting, th rt, kh th
- Bnh nhn khng dng c thuc khng gip tng hp do b cc tc dng ph
ca thuc hoc ang c thai
- Khng c iu kin iu tr ni khoa
- Ch nh m i vi mt s th bnh c th:
+ Basedow tr em: c th c C m v kt qu khi bnh cao v kh bn vng
( kin cho rng PT c th nh hng n s pht trin ni tit ni ring v ton
b c th ni chng n nay vn cha c c s c chng minh chc chn)
+ Ph n c thai :
i vi ph n c thai dng thuc khng gip v iot phng x u b chng ch
nh do iu tr ngoi khoa c tnh n.
Chun b m bng cc thuc iot, mui lithium, bnh nhn b nhim c gip nng
th c th dng mt liu nh thuc khng gip tng hp 3 thng u cvu thi k
thai nghn
Tham kho: < 3thng ph thai m; > 3thng iu tr ni khoa xong
m
+ Ngi gi : thng c ch inh iu tr bng iot phng x nht l v cc bnh
nhn ny thng c km theo cc ri lon nng v tim mch. Hin nay vi tin b
gy m.. c th ch nh m i vi ngi gi v ngi gi cc mch mu thng b
x ho v gim kh nng ti mu tuyn gip nn kh thc hin iu tr bng iot
phng x
- Basedow + nhc c: Khng c m Basedow nu cha iu tr n nh
nhc c. Nhng phi iu tr ni khoa Basedow n nh n bnh gip m
ct tuyn c iu tr nhc c Sau khi bnh nhc c n nh mi nghin
cu phu thut iu tr Basedow
- Basedow c li mt:
+ Basedow c li mt nh v va tin trin chm th khng c CC m ct gn
hon ton TG

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 cng Phu thut lng ngc Basedow

+ Nu bnh nhn c li mt nng tin trin nhanh th thn trng khi C m v sau
m c mt s trng hp tnh trng li mt tin trin c tnh din bin nhanh v rt
nng
- Baswdow c km i tho ng: Ni chung khng c chng ch nh m
- Basedow ti pht sau m: Thng gp nhiu kh khn, t l tai bin trong m
v bin chng sau m cao hn m ln u do s dnh nhiu
Cu 5. iu tr chun b m?
1. Mc ch:
- iu tr cho bnh nhn t c tnh trng bnh gip, n nh cc ri lon ton
thn khc
- Lm cho bu gip gim ti mu v chc li nhm gip cho phu thut c
thun li
- iu tr ni khoa bng cc thuc khng gip tng hp n giai on bnh gip
th gim dn liu v phi ct thuc trc m 7 ngy
2. Cc thuc:
- Thuc khng gip tng hp : dng n khi bnh nhn bt u xut hin tnh
trng bnh gip th gim dn v ct hn trc m 7-10 ngy
- Iod: Lugol 2-3% dng khi bnh nhn gim thuc khng gip tng hp v
tng liu dn ln t liu cao nht trc m vi ngy mc ch lm chc
tuyn gip hn ch chy mu
- Corticoid: dng trc m di dng ung chng suy thng thn
- Chn bta: Propranolon, khng nn lm dng v c th lm nh gi khng
ng tnh trng bnh gip trc khi m (lm mch chm)
- Cc thuc khc: an thn, sinh t, trn tnh, tr tim mch
- Chun b tt v tm l: gii thch cho bnh nhn yn tm, tin tng vo kt qu
iu tr
3. Cc thuc khng gip tng hp:c 2 nhm
- Nhm thiouracil: PTU(propythiouracil),MTU(methylthiouracil)
- Nhm imidazol: methimazole

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 cng Phu thut lng ngc Basedow

C ch : ngn cn s tng hp hormon gip nhiu khu:

- Ngn cn s iod hu c ho tc s gn iod vi thyroglobulin
- Ngn cn s hnh thnh v kt hp ca monoiodotyrosin v diiodotyrosin
- Tc dng ngoi tuyn gip: ngn cn tc dng chuyn T4 thnh T3 , c th c
ch min dch
Tc dng khng gip ca nhm imidzol mnh hn nhm thiouracil 7-15 ln nhng
gy d ng nhiu hn
Tc dng ph ca thuc khng gip tng hp:
- D ng: vo ngy 7-10 sau khi bt u iu tr; x l gim liu v dng khng
histamin
- Gim bch cu: trc dng thuc cn kim tra CT bch cu v trong cng gip
cha iu tr c th c gim bch cu l mt du hiu ca bnh. Khi BC <4.109/l
hoc BC a N <45% th ngng dng thuc
- Ri lon tiu ho: t gp
CC dng thuc KGTH:
- Bu gip lc ch
- Nhim c ph n c thai hoc cho con b
- Suy gan suy thn nng
- Bnh l d dy t trng
Ch nh dng iot:
- Basedow mc nh
- Cn cng gip cp: chng li s phng thch hormon gip vo mu
- Chun b cho phu thut tuyn gip: 2 tun trc v 1 tun sau phu thut, tc
dng gim ti mu v bt chy mu lc m, lm m gip chc li
- Bnh nhn c bnh l gan
- C bnh tim km theo cn h nhanh nng hormon gip
4. Thuc chn beta: gim nhp tim m khng gy h huyt p, cn gim nng
T3 do c ch s chuyn T4 thnh T3 ngoi vi
Tc dng ph:

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