MUC LUC

MUC LUC......................................................................................................................................1
AI CNG V HA DC - DC LI................................................................................2
AI CNG V DC NG HOC.......................................................................................5
AI CNG V DC LC HOC........................................................................................10
THUC GIM AU THC TH............................................................................................19
THUC GIM AU - HA ST - KHANG VIM KHNG STEROID (NSAID)..............28
THUC IU TR BNH GOUT............................................................................................41
THUC KICH THICH THN KINH TRUNG NG.........................................................45
THUC M V THUC TIN M.........................................................................................50
THUC T..................................................................................................................................59
THUC CHNG D NG TNG HP (THUC KHANG HISTAMIN H1)....................64
THUC CHA HO V HEN PH QUN..............................................................................71
THUC IU TR TIU CHY..............................................................................................78
THUC NHUN TRNG..........................................................................................................85
THUC CHA VIM LOT DA DY TA TRNG..............................................................92
THUC PHA DUNG DCH TIM TRUYN V CAC CH PHM THAY TH
HUYT TNG.......................................................................................................................100
THUC AN THN, GY NG, CHNG CO GIT............................................................108
THUC TAC DUNG LN QUA TRNH NG MAU........................................................116
A. THUC CM MAU......................................................................................................116
B. THUC CHNG NG MAU....................................................................................122
C. THUC TIU FIBRIN..................................................................................................126
THUC CHNG THIU MAU..............................................................................................128
VITAMIN...................................................................................................................................134
THUC TIM MACH................................................................................................................150
A. THUC TR THIU MAU TIM CC B...................................................................150
B. THUC TR TNG HUYT AP..................................................................................155
C. THUC LI TIU........................................................................................................160
D. THUC IU TR SUY TIM MN TNH..................................................................166
E. THUC TR RI LON LIPID HUYT.....................................................................172
TI LIU THAM KHO.........................................................................................................175
 AI CNG V HA DC - DC LI

MUC TIU HOC TP

Trinh bay c cac khai nim v thuc, quan nim v cach dng thuc phng
bnh, cha bnh cho ngi.
Trinh bay c ni dung, mc tiu, v tr ca mn hc.
Nu c cac khai nim c bn v Ha dc Dc l hc va mi lin quan
vi cac mn hc khac.

NI DUNG
1. AI CNG V HA DC DC LI
1.1. Khi nim v thuc
Thuc la nhng cht hay hp cht c ngun gc t thc vt, ng vt,
khoang vt, sinh hc hay tng hp ha hc c bao ch dng cho ngi
nhm mc ch phng bnh, chn oan bnh, cha bnh hoc dng hi phc,
iu chnh cac chc phn ca c th, lam gim cm giac mt b phn hay toan
thn, lam nh hng n qua trinh sinh , lam thay i hinh dang c th.
1.2. Quan nim v dng thuc
o Thuc ng vai tr quan trng trong phng va cha bnh.
o Thuc khng phi la phng tin duy nht gii quyt bnh.
o Khi cn dng thuc cha bnh phi la chn k nhng loi thuc c hiu
vi bnh, t gy c hi cho c th, phi s dng thuc hp l, an toan.
1.3. nh ngha mn hc
Ha dc Dc l hc la mn hc nghin cu v cac hp cht ha hc dng lam
thuc va tac dng ca thuc trong c th ap dng trong cng tac phng bnh, cha
bnh cho ngi.
1.4. Ni dung mn hc
Ni dung mn hc gm hai phn: Ha dc hc va Dc l hc.
o Phn Ha dc s nghin cu v cng thc ha hc, tnh cht l ha, mi lin
quan gia cu trc ha hc va tac dng dc l ca cac hp cht dng lam thuc.

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 o Phn Dc l s nghin cu tac dng ca thuc trn c th ap dng trong
cng tac phng bnh, cha bnh.
2. KHAI NIM V DC LI HOC
Dc l hc la mn hc nghin cu v s tac ng gia thuc va c th. Khi thuc
vao c th, thuc c c th tip nhn nh th nao va c th a phn ng ra sao di
tac dng ca thuc. S tac ng qua li gia thuc va c th a gip dc l hc c
chia thanh hai phn ro rt:
o Dc ng hoc: Nghin cu v s tip nhn ca c th i vi thuc. la
ng hc ca s hp thu, phn b chuyn ha va thi tr. Cac kin thc v dc ng
hc gip cho vic dng thuc hp l hiu qu (ng a thuc vao c th, liu dng
trong mt ln, liu dng trong ngay va trong t iu tr).
o Dc lc hoc: Nghin cu v s tac ng ca thuc i vi c th sinh vt.
Thuc c th tac ng trn cac t chc, c quan hoc h thng ca c th theo cac c
ch khac nhau cho hiu qu iu tr (iu chnh c qua trinh sinh l bnh thanh
qua trinh sinh l) hoc th hin cac tac dng khng mong mun.
3. V TRI MN HOC
Ha dc - Dc l hc la mn hc tch hp, lin quan mt thit vi nhng mn y
dc khac: ha hc, dc liu, bao ch, qun l dc, sinh ha, gii phu sinh l, sinh
l bnh, vi sinh, min dch, iu tr hc, t chc hc Ha dc - Dc l hc lun
da trn nhng thanh tu mi nht ca cac nganh khoa hc c lin quan ngay cang
hiu su v c ch phn t ca thuc, gip cho vic nghin cu sn xut cac thuc mi
ngay cang c tnh c hiu, khng ngng nng cao hiu qu iu tr.
4. MUC TIU MN HOC
Muc tiu cua mn Ha dc - Dc li hoc la ngi hoc sau khi hoc xong c th:
o Trinh bay va gii thch c c ch tac dng, ap dng iu tr
ca cac thuc i din trong tng nhm.
o Phn tch c tac dng khng mong mun va c tnh ca
thuc bit cach phng va x tr.
o K c cac n thuc ng nguyn tc, ng chuyn mn,
ng phap l.
Ngi thy thuc lun nh rng:
o Khng c thuc nao v hi.

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 o Ch dng khi tht cn, ht sc tranh lm dng thuc.
o Khng phi thuc t tin lun lun la thuc tt nht.
o Trong qua trinh hanh ngh, phi lun lun hc hoi nm c
cac kin thc dc l ca cac thuc mi hoc nhng hiu bit mi, nhng ap dng mi
ca cac thuc cu.
5. PHNG PHAP HOC TP MN HOC
Mun hc tp mn Ha dc Dc l t kt qu tt phi cn c vao mc tiu hc
tp ca tng bai c kin thc chung v thuc:
o Tn thuc
o Cng thc ha hc
o Tnh cht l, ha hc
o Tac dng, tac dng ph ca thuc
o Dc ng hc
o Ch nh, chng ch nh
o Cach dng, liu lng
o c tnh, cach gii c (nu c)
o Bo qun

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 AI CNG V DC NG HOC

MUC TIU HOC TP

Nu c cac khai nim c bn v bn qua trinh dc ng hc trong c th.
Trinh bay c c im ca tng qua trinh hp thu, phn b, chuyn ha va
thi tr thuc trong c th ngi.

NI DUNG
Dc ng hc nghin cu cac qua trinh chuyn vn ca thuc t lc c hp thu
vao c th cho n khi b thi tr hoan toan. Cac qua trinh la: S hp thu, s phn
b, s chuyn ha, s thi tr.
Cac qua trinh dc ng hc:
1. S HP THU
Hp thu la s vn chuyn thuc t ni dng thuc (ung, tim) vao mau ri i
khp c th, ti ni tac dng. Ngoi tr ng tim tnh mch, trong qua trinh hp thu
vao vng tun hoan, mt phn thuc s b pha hu do cac enzym ca ng tiu ha,
ca t bao rut va c bit la gan, ni c ai lc vi nhiu thuc. Phn thuc b pha
hu trc khi vao vng tun hoan c gi la "first pass metabolism" (chuyn ha do
hp thu hay chuyn ha qua gan ln th nht vi thng la ung thuc), phn vao c
tun hoan mi phat huy tac dng dc l, c gi la sinh kh dung (bioavailability)
ca thuc.
Cac ng a thuc vao c th va s hp thu thuc:
1.1. QUA NG TIU HA
ng tiu ha tnh t nim mc ming n hu mn. Tr loi thuc t di li
va thuc dng qua ng trc trang, cn li thuc dng qua ng ung s tri qua t
u n cui ng tiu ha va s c hp thu vi mc khac nhau cac phn khac
nhau ca ng tiu ha.

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 u im la d dng vi la ng hp thu t nhin. Nhc im la b cac enzym tiu
ha pha hu hoc thuc to phc vi thc n lam chm hp thu. i khi thuc kch
thch nim mc tiu ha gy vim lot.
1.1.1. Hp thu qua nim mac ming
Nim mc ming c bit la vng di li c h thng mao mch phong ph nn
thuc c hp thu nhanh, vao thng vng tun hoan chung khng qua gan, tranh c
nguy c b pha hy bi dch tiu ha va chuyn ha ln u gan.
1.1.2. Hp thu qua nim mac da day
d day h thng mao mch t hn nhiu so vi rut non, pH dch d day li rt
thp (1 3) nn ni chung ch nhng thuc c bn cht la acid yu (thuc ng
barbituric, cac salicylat), mt s thuc c h s phn b lipid/nc cao mi c
hp thu qua nim mc d day.
1.1.3. Hp thu qua nim mac rut non
Nim mc rut non la ni hp thu tt nht trong s cac nim mc ng tiu ha va
hu ht cac thuc c hp thu y vi c mt s c im sau:
Din tch tip xc ln.
H thng mao mch phong ph.
Gii pH t acid nhe n kim nhe thch hp hp thu cac nhm thuc c tnh kim
hoc acid khac nhau.
1.1.4. Hp thu qua nim mac rut gia
S hp thu thuc qua nim mc rut gia km hn nhiu so vi nim mc rut non
vi din tch tip xc nho hn. Chc nng ch yu ca nim mc rut gia la hp thu
nc, Na+, Cl, K+ va mt s cht khoang. Ngoai ra mt s cht tan trong lipid cung
c hp thu ti y.
c bit phn cui ca rut gia (trc trang) c kh nng hp thu thuc tt hn vi c
h thng tnh mch phong ph. Tnh mch trc trang di va tnh mch trc trang gia
(nm 2/3 di ca trc trang) mau v tnh mch ch di ri v tim khng qua
gan. Nh vy khi dng thuc qua ng trc trang ty theo thuc nm phn nao ca
trc trang ma n c th vao thng tnh mch ch di khng qua gan hoc qua gan.
1.2. NGOI NG TIU HA
1.2.1. Hp thu qua ng tim di da, tim tnh mach, tim bp tht

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 Khi tim di da hoc tim bp tht thuc hp thu nhanh hn hoan toan hn so vi
ng ung va t nguy c ri ro hn so vi ng tim tnh mch. Tim di da thuc
hp thu chm hn va au hn so vi tim bp tht.
Tim tnh mch la a thng thuc vao mau nn thuc hp thu hoan toan. Khi cn
a mt lng ln dung dch thuc vao c th ngi ta tim truyn nho git tnh
mch.
Cn ch khng tim tnh mch cac hn dch, cac dung dch du, cac cht gy kt
ta protein huyt tng va ni chung cac cht khng ng tan vi mau vi c th gy
tc mch, cung khng tim tnh mch cac cht gy tan mau c i vi tim.
1.2.2. Hp thu qua ng h hp
Phi c cu to t cac ph qun, tiu ph qun va ph nang. Cac ph nang va cac
ng dn kh c mng mao mch phong ph bao quanh. c bit b mt tip xc ca
ph nang rt ln nn thun li cho vic trao i kh va hp thu thuc. Phi la ni hp
thu thch hp i vi cac cht kh va cac cht long bay hi. Cac cht rn cung dng
qua ng h hp di dng kh dung iu tr vim nhim ng h hp va ct cn
hen.
1.2.3. Hp thu qua da
t thuc c th thm qua c da lanh. Cac thuc dng ngoai (thuc m, thuc xoa
bp, cao dan) c tac dng nng ti ch sat khun, chng nm, gim au. Tuy nhin,
khi da b tn thng, vim nhim, bong... thuc c th c hp thu. Mt s cht c
d tan trong m c th thm qua da gy c toan thn. Da tr s sinh va tr nho, c lp
sng mong manh, tnh thm mnh, kh nng hp thu tt hn va d b kch ng cho nn
cn thn trng khi s dng, hn ch din tch bi thuc.
1.2.4. Cc ng khc: gy t ty sng, tim vao mang khp, nim mc mui.
2. S PHN B
Sau khi c hp thu vao mau thuc c th tn ti di dng t do, mt phn lin
kt vi protein huyt tng hoc mt s t bao mau, ngoai ra mt s t thuc c th b
phn hy ngay trong mau. T mau thuc c vn chuyn n cac t chc khac nhau
ca c th.
dng lin kt thuc khng c tac dng ch dng t do mi c tac dng. Gia
hai dng t do va dng lin kt lun mt cn bng ng. Dng lin kt gia thuc vi
protein huyt tng c th coi la mt phn d tr ca thuc trong c th.

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 Thuc dng t do trong huyt tng s i qua thanh mao mch n cac t
chc. Mt s t chc c c im ring v cu trc nn s phn b thuc y c
nhng nt khac bit cn phi tnh n trn thc t lm sang.
Phn b thuc vao nao va dich nao tuy: Binh thng ngi trng thanh thuc
kh thm qua mao mch vao nao hoc dch nao ty vi chng c bo v bi lp
hang rao mau nao hoc hang rao mau dch nao ty. Tuy nhin nhng cht tan
trong du m c th thm qua cac hang rao nay vao nao hoc dch nao ty. Khi t
chc thn kinh trung ng b vim, hang rao bo v b tn thng, mt s thuc (cac
khang sinh) c th vao nao d dang hn. tr s sinh do ham lng myelin t chc
thn kinh cn thp nn thuc cung d dang xm nhp vao nao hn.
Phn b thuc qua rau thai: Thuc cung nh cac cht dinh dng t me vao mau
thai nhi phi qua hang rao rau thai. Hang rao rau thai rt mong, din tch trao i
ln, lu lng mau cao va c nhiu cht vn chuyn nn c nhiu thuc t me qua rau
thai vao thai nhi. Vi vy trong thi ki mang thai ngi me cn thn trng dng thuc
tranh nh hng xu n thai nhi.
3. S CHUYN HA
Chuyn ha hay cn gi la sinh chuyn ha i vi thuc la qua trinh bin i ca
thuc trong c th di nh hng ca cac enzym to nn nhng cht t nhiu khac vi
cht me, c gi la cht chuyn ha. Tr mt s t thuc sau khi vao c th khng b
bin i c thi tr nguyn ven nh cac cht v c, strychnin, khang sinh nhm
aminoglycosid cn phn ln cac thuc u b chuyn ha trc khi thi tr. Bn
cht ca qua trinh chuyn ha thuc la qua trinh bin i thuc trong c th t khng
phn cc thanh phn cc hoc phn cc yu thanh phn cc mnh d ao thi.
Anh hng ca chuyn ha i vi tac dng sinh hc va c tnh ca thuc:
o Ni chung, phn ln cac thuc qua chuyn ha s gim hoc mt c tnh,
gim hoc mt tac dng. Mt khac qua chuyn ha thuc d dang b thi tr cho nn
qua trinh chuyn ha thuc cn c cho la qua trinh kh c ca c th i vi
thuc.
o Mt s qua chuyn ha, cht chuyn ha vn cn gi c tac dng dc l
nh cht me nhng mc c th thay i t nhiu. Mt s thuc sau khi chuyn ha
mi c tac dng hay c trng hp mt s thuc sau khi chuyn ha li tng c tnh.

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 Chuyn ha thuc c th xy ra cac t chc khac nhau nh thn, phi, lach,
maunhng ch yu xy ra gan. Cac phn ng chuyn ha thuc xy ra gan c s
tham gia ca cac enzym khac nhau. Do nhng yu t nh hng n qua trinh sinh
tng hp hoc c ch enzym gan s nh hng n chuyn ha thuc.
Cm ng enzym: La hin tng tng cng mc enzym chuyn ha thuc di
nh hng ca mt cht c gi la cht gy cm ng enzym. Kt qu ca cm ng
enzym la tng cng sinh tng hp enzym gan nn lam tng chuyn ha, rt ngn thi
gian ban thi ca thuc do nh hng n tac dng ca thuc:
o Phn ln cac trng hp sau khi chuyn ha thuc b gim hoc mt tac
dng nn trong nhng trng hp nay cm ng enzym lam gim hoc lam mt tac
dng ca thuc.
o i vi mt s thuc sau khi chuyn ha mi c tac dng hoc tng c tnh
thi cm ng enzym lam tng tac dng hoc tng c tnh ca thuc.
o Mt s thuc sau khi dng nhc i nhc li mt s ln s gy cm ng
enzym chuyn ha ca chnh n. la hin tng quen thuc do cm ng enzym nh
phenyltoin, meprobamat
c ch enzym: Bn cnh nhng cht gy cm ng enzym cn c nhng cht gy c
ch enzym lam gim qua trinh chuyn ha thuc dn n tng tac dng hoc tng c
tnh ca thuc. c ch enzym gan ch yu la do gim qua trinh tng hp enzym gan
hoc do tng phn hy enzym, do tranh chp v tr lin kt ca enzym lam mt hot
tnh ca enzym.
4. S THI TR
Qua trinh bai tit dn n s gim nng thuc trong c th. Thng thng s
chuyn ha cung dn n lam gim nng c hiu lc ca thuc. Do trong nhiu
trng hp ngi ta thng kt hp khai nim bai tit va chuyn ha bng thut ng
chung la thi tr.
Tt c cac ng thi tr thuc u la ng t nhin nh thi tr qua: da, thn,
m hi, h hp, tiu haNi chung cac cht tan trong nc thi tr qua thn, cac
cht khng tan trong nc ma dng qua ng ung thi tr qua phn. Cac cht kh
cac cht long bay hi thi tr qua cac ph nang. Mt thuc c th thi tr qua nhiu
ng khac nhau nhng thng thng mi thuc c ng thi tr ch yu ca minh
ty thuc vao cu trc ha hc, tnh cht l ha ca thuc, dng bao ch va ng

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dng. Thi tr qua thn la ng thi tr quan trng nht, khong 90% thuc thi tr
qua ng nay.

AI CNG V DC LC HOC

MUC TIU HOC TP

Nu c khai nim c bn v dc lc hc.
Trinh bay c cac c ch tac dng ca thuc
K c cac yu t nh hng n tac dng ca thuc.

NI DUNG
Dc lc hc nghin cu tac dng ca thuc ln c th sng, gii thch c ch ca
cac tac dng sinh ha va sinh l ca thuc. Phn tch cang y c cac tac dng,
cang cung cp c nhng c s cho vic dng thuc hp l trong iu tr.
1. C CH TAC DUNG CA THUC
1.1. RECEPTOR
Trong iu tr kt qu tac dng ca thuc c th hin trn mt c th nguyn
ven. Tuy nhin v tr tac dng ca thuc thng ch la mt s thanh phn ca t bao.
Nhng thanh phn ca t bao c kh nng lin kt chn lc vi thuc hoc cht ni
sinh (hormon, cac cht trung gian ha hc) to nn ap ng sinh hc c gi la
receptor.
1.2. CAC C CH TAC DUNG CA THUC
1.2.1. Tc dung cua thuc thng qua receptor
Thuc tac dng trc tip trn cac receptor ca cac cht ni sinh (hormon, cht dn
truyn thn kinh): nhiu thuc tac dng trn cac receptor sinh l va thng mang tnh
c hiu. Nu tac dng ca thuc ln receptor ging vi cht ni sinh, gi la cht ng
vn hay cht chu vn (agonists), nh pilocarpin trn receptor M - cholinergic. Nu
thuc gn vao receptor, khng gy tac dng ging cht ni sinh, trai li, ngn cn cht
ni sinh gn vao receptor, gy tac dng c ch cht ng vn, c gi la cht i

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khng (antagonists), nh D - tubocurarin tranh chp vi acetylcholin ti receptor N ca
c vn.
Ngoai receptor t bao, cac receptor ca thuc cn la:
Cac enzym chuyn ha hoc iu ha cac qua trinh sinh ha c th b thuc c ch
hoc hot ha:
Thuc c ch enzym: captopril c ch enzym chuyn angiotensin I khng hot tnh
thanh angiotensin II c hot tnh dng cha cao huyt ap; cac thuc chng vim phi
steroid c ch cyclooxygenase, lam gim tng hp prostaglandin nn c tac dng h
st, chng vim; thuc tr tim digitalis c ch Na+ - K+ ATPase...
Thuc hot ha enzym: cac yu t vi lng nh Mg2+, Cu2+, Zn2+ hot ha nhiu
enzym protein kinase, phosphokinase tac dng ln nhiu qua trinh chuyn ha ca t
bao.
Cac ion: thuc gn vao cac knh ion, lam thay i s vn chuyn ion qua mang t
bao. Novocain cn tr Na + nhp vao t bao thn kinh, ngn cn kh cc nn c tac
dng gy t; benzodiazepin lam tng nhp Cl- vao t bao, gy an thn.
1.2.2. Tc dung cua thuc khng qua receptor
Mt s thuc c tac dng khng phi do kt hp vi receptor.
Thuc c tc dung do tinh cht l ha, khng c hiu:
Cac mui cha cac ion kh hp thu qua mang sinh hc nh MgSO 4, khi ung s
ko nc thanh rut vao lng rut va gi nc trong lng rut nn c tac dng ty;
khi tim vao tnh mch s ko nc t gian bao vao mau nn c dng cha ph nao.
Mannitol dng liu tng i cao, lam tng ap lc thm thu trong huyt tng.
Khi lc qua cu thn, khng b tai hp thu ng thn, lam tng ap lc thm thu trong
ng thn, c tac dng li niu.
Cac base yu lam trung ha dch v acid dng cha lot d day nh hydroxyd
nhm, magnesi oxyd.
Thuc c cu trc tng t nh nhng cht sinh ha bnh thng, c th thm
nhp vao cac thanh phn cu trc ca t bao, lam thay i chc phn ca t bao. Thuc
ging purin, ging pyrimidin nhp vao acid nucleic, dng chng ung th, chng virus.
Sulfamid gn ging paraamino benzoic acid (PABA), lam vi khun dng "nhm",
khng phat trin c.
2. CAC CACH TAC DUNG CA THUC

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 Khi vao c th, thuc c th c 4 cach tac dng sau:
2.1. TAC DUNG TAI CH V TON THN
Tac dng ti ch la tac dng ngay ti ni thuc tip xc, khi thuc cha c hp
thu vao mau: thuc sat khun ngoai da, thuc lam sn nim mc (tanin), thuc bc
nim mc ng tiu ha (kaolin, hydroxyd nhm).
Tac dng toan thn la tac dng xy ra sau khi thuc a c hp thu vao mau qua
ng h hp, ng tiu ha hay ng tim: thuc m, thuc tr tim, thuc li niu.
Nh vy, tac dng toan thn khng c ngha la thuc tac dng khp c th ma ch la
thuc a vao mau "i" khp c th.
2.2. TAC DUNG CHINH V TAC DUNG PHU
Tac dng chnh la tac dng iu tr. Ngoai tac dng iu tr, thuc c th cn
gy nhiu tac dng khac, khng c ngha trong iu tr, c gi la tac dng khng
mong mun, tac dng dng ngoi (adverse drug reactions ADR). Cac tac dng
ngoi c th ch gy kh chu cho ngi dng (chng mt, bun nn, mt ng), gi
la tac dng ph; nhng cung c th gy phn ng c hi (ngay vi liu iu tr) nh
xut huyt tiu ha, gim bch cu, tt huyt ap th ng...
Th d: aspirin la thuc h st, gim au, chng vim (tac dng chnh), nhng gy
chy mau tiu ha (tac dng c hi). Nifedipin, thuc chen knh calci dng iu tr
tng huyt ap (tac dng chnh), nhng c th gy nhc u, nhp tim nhanh (tac dng
ph), ph chn, tng enzym gan, tt huyt ap (tac dng c hi).
Trong iu tr, thng phi hp thuc lam tng tac dng chnh va gim tac dng
khng mong mun. Th d ung thuc chen giao cm cng vi nifedipin s lam gim
c tac dng lam tng nhp tim, nhc u ca nifedipin. Cung c th thay i ng
dng thuc nh dng thuc t hu mn tranh tac dng kh ung, gy bun nn.
2.3. TAC DUNG HI PHUC V KHNG HI PHUC
Tac dng hi phc: sau tac dng, thuc b thi tr, chc phn ca c quan li tr v
binh thng. Th d sau gy m phu thut, ngi bnh li c trng thai binh
thng, tnh tao.
Tac dng khng hi phc: thuc lam mt hoan toan chc phn ca t bao, c quan.
Th d: thuc chng ung th dit t bao ung th, bo v t bao lanh; thuc sat khun
bi ngoai da dit vi khun nhng khng nh hng n da; khang sinh cloramphenicol
c tai bin gy suy ty xng.

12
2.4. TAC DUNG CHON LOC
Tac dng chn lc la tac dng iu tr xy ra sm nht, ro rt nht trn mt c quan
nht nh trong c th. Th d aspirin ung liu 1 2 g/ ngay c tac dng h st va
gim au, ung liu 4 - 6 g/ ngay c c tac dng chng vim; digitalis gn vao tim,
nao, gan, thn... nhng vi liu iu tr, ch c tac dng trn tim; albuterol
(salbutamol) kch thch chn lc receptor 2 adrenergic...Thuc c tac dng chn lc
lam cho vic iu tr tr nn d dang hn, hiu qu hn, tranh c nhiu tac dng
khng mong mun.
2.5. TAC DUNG HIP NG V TAC DUNG I KHANG
Khi phi hp hai thuc hay nhiu thuc vi nhau trong iu tr thi cac thuc nay s
nh hng n tc , cng , thi gian tac dng va c th xy ra :
Tac dng i khang: lam gim tac dng ln nhau.
Tac dng hip ng: tng cng tac dng ln nhau.
3. NHNG YU T NH HNG N TAC DUNG CA THUC
3.1. CU TRUC CA THUC
Thay i cu trc lam thay i dc lc hc cua thuc
Mt s thay i nho v cu trc ha hc (hinh dang phn t ca thuc) cung c th
gy ra nhng thay i ln v tac dng. Nh vy vic tng hp cac thuc mi thng
nhm:
Lam tng tc dung iu tri va gim tc dung khng mong mun: Khi thm F vao v
tr 9 va CH3 vao v tr 16 ca corticoid (hormon vo thng thn), ta c betametason
c tac dng chng vim gp 25 ln va khng c tac dng gi Na+ nh corticoid.
Lam thay i tc dung dc l: thay i cu trc ca isoniazid (thuc chng lao), ta
c iproniazid, c tac dng chng trm cm, do gn vao receptor hoan toan khac.
Thay i cu trc thuc lam thay i dc ng hc cua thuc
Khi cu trc ca thuc thay i, lam tnh cht l ha ca thuc thay i, nh hng
n s ha tan ca thuc trong nc hoc trong lipid, nh hng n s gn thuc vao
protein, ion ha ca thuc va tnh vng bn ca thuc. Mt s v d:
Dopamin khng qua c hang rao mau nao, nhng L - dopamin (Levodopa), cht
tin thn ca dopamin thi qua c.
Estradiol thin nhin khng ung c vi b chuyn ha mnh gan. Dn xut
ethinyl estradiol (- C CH gn v tr 17) rt t b chuyn ha nn ung c.

13
 Qua y ta c th nhn thy rng, khi thuc gn vao receptor gy hiu lc,
khng phi toan b phn t thuc ma ch c nhng nhm chc phn gn vao receptor.
Khi thay i cu trc ca nhm hoc vng chc phn, dc lc hc ca thuc s thay
i. Cn khi thay i cu trc ngoai vng chc phn, c th thay i dc ng hc
ca thuc.
3.2. DANG THUC
T 1 dc cht, cac nha bao ch c th a ra th trng nhiu loi bit dc
(dng thuc) khac nhau, c sinh kh dng khac nhau do c nh hng khac nhau
ti hiu qu iu tr.
Trang thi cua dc cht
tan nho: thuc cang mn, din tip xc cang tng, hp thu thuc cang nhanh.
Dng v nh hinh va dng tinh th: thuc rn dng v nh hinh d tan, d hp
thu.
T dc
Ta dc khng phi ch la "cht n" bao gi thuc ma cn nh hng n
ha tan, khuch tan...ca thuc. Khi thay calci sulfat (thch cao, ta dc c in) bng
lactose dp vin diphenylhydantoin, a gy hang lot ng c diphenylhydantoin
do lng thuc c hp thu nhiu hn (c, 1968). Nguyn nhn la ta dc calci
sulfat ch ng vai tr mt khung mang, khng tiu va xp, lam dc cht c gii
phng t t trong ng tiu ha. Cn lactose li lam dc cht d tan, nn c hp thu
nhanh trong thi gian ngn.
K thut bao ch va dang thuc
K thut bao ch la mt yu t khng km phn quan trng c tac ng trc tip
n sinh kh dng ca thuc, c th kim soat c s gii phng dc cht va v tr
thuc gii phng (gii phng ti ch). Vi vy n thng c cac nha sn xut gi
b mt. Hin c rt nhiu dng thuc khac nhau c sn xut theo cac k thut khac
nhau sao cho:
- Hot tnh ca thuc c vng bn.
- Dc cht c gii phng vi tc n nh.
- Dc cht c gii phng ti ni cn tac ng (gii phng ti ch, targetting
medication).
- Thuc c sinh kh dng cao.

14
 3.3. NGI DNG THUC
c im v tui
3.3.1.1. Tr em:
"Tr em khng phi la ngi ln thu nho li", ngha la khng phi ch gim liu
thuc ca ngi ln thi thanh liu ca tr em, ma tr em cn c nhng c im ring
ca s phat trin, la:
- S gn thuc vao protein huyt tng cn t, mt khac, mt phn protein huyt
tng cn gn bilirubin, d b thuc y ra, gy ng c bilirubin.
- H enzym chuyn ha thuc cha phat trin.
- H thi tr thuc cha phat trin.
- H thn kinh cha phat trin, myelin cn t, hang rao mau - nao cha bo v
nn thuc d thm qua va t bao thn kinh cn d nhy cm (nh vi morphin).
- T bao cha nhiu nc, khng chu c thuc gy mt nc.
- Mi m va c quan ang phat trin, ht sc thn trng khi dng cac loi hormon.
3.3.1.2. Ngi cao tui
Ngi cao tui cung c nhng c im ring cn lu :
- Cac h enzym u km hot ng vi a "lao ha".
- Cac t bao t gi nc nn cung khng chu c thuc gy mt nc.
- Ngi cao tui thng mc nhiu bnh (cao huyt ap, x va mch, thp khp,
tiu ng...) nn phi dng nhiu thuc mt lc. Cn rt ch tng tac thuc khi k
n.
c im v gii
Nhin chung, khng c s khac bit v tac dng va liu lng ca thuc gia nam
va n. Tuy nhin, vi n gii, cn ch n 3 thi k:
3.3.1.1. Thi k c kinh nguyt
Khng cm hn thuc. Nu phi dng thuc dai ngay, c tng t ngng thuc thi
nn sp xp vao lc c kinh.
3.3.1.2. Thi k c thai
Trong 3 thang u, thuc d gy d tt bm sinh, to ra quai thai. Trong 3 thang
gia thuc c th nh hng xu n s phat trin ca bao thai, n chc phn phat
trin ca cac c quan. Trong 3 thang cui, thuc c th gy xy thai, non.

15
 Vi vy, khi cn ch nh thuc cho ph n c thai, cn cn nhc tht k gia li ch
cho ngi me va mc nguy hi cho bao thai. Ni chung, trong 3 thang u, tuyt i
tranh dng mi loi thuc.
i vi ngi me, khi c thai, lng nc gi li trong c th tng, th tch mau
tng, ham lng protein huyt tng c th gim, lng lipid c th tng... lam nh
hng n ng hc ca thuc.
3.3.1.3. Thi k cho con b
Rt nhiu thuc khi dng cho ngi me s thi tr qua sa va nh vy c th gy
c hi cho con. Cac nghin cu v cac loi thuc nay ni chung cn cha c y
, do tt nht la ch nn dng nhng loi thuc tht cn thit cho me. Tuyt i
khng dng nhng thuc c cha thuc phin va dn xut ca thuc phin (thuc ho,
codein) vi thuc thi tr qua sa va trung tm h hp ca tr rt nhy cm, c th b
ngng th.
Khng dng cac loi corticoid (lam suy thng thn tr), cac khang giap trng tng
hp va iod (gy ri lon tuyn giap), cloramphenicol va thuc phi hp
sulfamethoxazol + trimethoprim (Co - trimoxazol) vi c th gy suy tu xng. Cn
rt thn trng khi dng cac thuc c ch thn kinh trung ng (meprobamat,
diazepam), thuc chng ng kinh, u gy m mang va li bi cho tr.
3.4. THC N
Ni chung thuc hp thu ng tiu ha tt nht lc i, ty theo s thay i
pH dch v d day ma tc hp thu thuc cung c s thay i. Ch n thiu
lipid, protein s lam chm chuyn ha mt s thuc gan. Mt s thuc b gim tac
dng hoc gim hp thu do thc n: ampicillin, amoxicillin. Mt s thuc tng hp thu
nh thc n: Hypothiazid, B6. Mt s thuc khng b nh hng bi thc n:
glucocorticoid. Vi vy cn c bin phap thch hp trong la chn thc n hay nc
ung trong qua trinh dng thuc nhm tng kh nng hp thu thuc va tranh tac hi
trong s dng thuc.
4. NHNG TRANG THAI TAC DUNG C BIT CA THUC
Trong qua trinh s dng thuc, ngoai tac dng iu tr, i khi cn gp nhng tac
dng "khng mong mun" do s phn ng khac nhau ca tng ca th vi thuc.
4.1. PHN NG C HAI CA THUC (ADVERSE DRUG REACTIONS -
ADR)

16
 "Mt phn ng c hi ca thuc la mt phn ng c hi, khng nh c trc
va xut hin liu lng thng dng cho ngi " (nh ngha ca Chng trinh
giam sat thuc quc t - WHO).
ADR la tn gi chung cho mi triu chng bt thng xy ra khi dng thuc ng
liu. C th ch la nhng triu chng rt nhe nh nhc u, bun nn... cho n nhng
triu chng rt nng dn n t vong nh sc, phn v, suy tu xng. Tu theo nc
va tu theo tac gi, ADR c th xy ra khong 8 - 30% s ngi dng thuc.
4.2. PHN NG D NG
D ng thuc cung la 1 ADR. Do thuc la 1 protein l (insulin, thyroxin ly t sc
vt), la a peptid, polysaccharid c phn t lng cao, mang tnh khang nguyn. Tuy
nhin, nhng thuc c phn t lng thp hoc chnh sn phm chuyn ha ca n
cung c th gy d ng.
Cac phn ng d ng thuc khng lin quan n liu lng thuc dng, s ln dng
va thng c d ng cho. Vi vy cn hoi tin s d ng ca bnh nhn trc khi dng
thuc. Vi nhng thuc hay gy d ng (penicilin, lidocain,.. ) khi dng phi c sn
thuc va phng tin cp cu (adrenalin). Sc phn v c th xy ra do ng dng
thuc khac nhau: Vitamin B1 dng tim tnh mch c th gy sc cht ngi, trong khi
dng ung khng gy phn ng nay.
4.3. TAI BIN THUC DO RI LOAN DI TRUYN
Thng la do thiu enzym bm sinh, mang tnh di truyn trong gia inh hay chng
tc. Ngi thiu enzym glucose 6 phosphat deshydrogenase (G6PD) hoc
glutathion reductase d b thiu mau tan mau khi dng primaquin, quinin, sulfamid,
nitrofuran...tai bin thng xy ra nam va thng gp trn ngi da en.
Ngi thiu enzym methemoglobin reductase la nhng ngi d hp t (khong
1% dn s). Khi dng thuc st rt (primaquin), thuc khang sinh, sat khun
(cloramphenicol, sulfon, nitrofurantoin), thuc h st (phenazol, paracetamol) rt d b
methemoglobin.
Ngi thiu acetyl transferase s chm acetyl ha mt s thuc nh hydralazin,
isoniazid, phenelzin... nn d b nhim c cac thuc nay.
Hin tng c ng (idiosyncrasy) la nhy cm ca nhn bm sinh vi thuc
chnh la s thiu ht di truyn 1 enzym nao .
4.4. QUEN THUC (DUNG NAP THUC)

17
 Quen thuc la s ap ng vi thuc yu hn hn so vi ngi binh thng dng
cng liu. Liu iu tr tr thanh khng c tac dng, i hoi ngay cang phi tng liu
cao hn. Quen thuc c th xy ra t nhin ngay t ln u dng thuc do thuc t
c hp thu, hoc b chuyn ha nhanh, hoc c th km mn cm vi thuc, trng
hp nay thng la do nguyn nhn di truyn. Thng gp quen thuc do mc phi sau
mt thi gian dng thuc, i hoi phi tng dn liu.
4.5. NGHIN THUC (L THUC THUC)
Nghin thuc la mt trng thai c bit lam cho ngi nghin ph thuc c v tm
l va th cht vao thuc vi cac c im sau:
o Thm thung manh lit nn xoay s mi cach c thuc dng, k c hanh
vi phm phap.
o C khuynh hng tng liu.
o Thuc lam thay i tm l va th cht theo hng xu: ni iu, li lao
ng, bn thu, thiu o c... gy hi cho bn thn va xa hi.
o Khi cai thuc s b thuc "vt" hay ln cn "i thuc" : vt va, ln ln, d
cm, va m hi, tiu chy... Nu li dng thuc cn "vt" s ht ngay.
o Nhng thuc gy nghin u c tac dng ln thn kinh trung ng gy sng
khoai lng lng, o nh, o giac ("ph" thuc) hoc trng thai hng phn mnh (thuc
lc), c gi chung la "ma ty": morphin va cac cht loi thuc phin (heroin,
pethidin, methadon), cocain, cn sa (cannabis, marijuana), metamphetamin, ectasy...

18
 THUC GIM AU THC TH

MUC TIU HOC TP

Trinh bay c khai nim, phn loi, c im ca thuc gim au thc
th.
Nu c tnh cht, dc ng hc, tac dng, ch nh, chng ch nh,
cach dng, bo qun cac thuc.
Trinh bay c nguyn tc s dng cac thuc.

NI DUNG
1. AI CNG
1.1.KHAI NIM
- Thuc gim au thc th la thuc gim au opioid c hiu lc vi cac cn au
su rng nh au ni tng do c ch chn lc trn trung tm au.
- Ngoai tac dng gim au nhm thuc nay cn c tac dng gy sng khoai, an
thn, gy ng, c ch trung tm h hp va d gy nghin.
- Thuc gim au thc th c vai tr rt quan trng trong iu tr vi au n la mt
trong nhng nguyn nhn c th dn n ri lon trm trng cac hot ng v tm sinh
l ca bnh nhn, biu hin ro nht la sc va choang khi b chn thng thc th.
1.2. PHN LOAI THUC
1.2.1. Phn loai theo ngun gc
- Alcaloid ca nha thuc phin va cac dn cht t morphin.
- Nhm opioat tng hp, ban tng hp t morphin nh Pethidin, Dimethyl
pethidin, Phenopethidin, Fentanyl, Dextropropoxyphen.. tac dng mnh hn
Morphin nhiu ln.
1.2.2. Phn loai theo tc dung giam au
- Gim au opioid nhe: Codein, Dextropropoxyphen.
- Gim au opioid mnh: Morphin, Pethidin, Fetanyl.
1.3. C CH TAC DUNG

19
 Morphin va cac thuc cng loi tac ng trn cac receptor , tn cng si thn
kinh hng tm ti sng sau ca ty sng gy c ch s tit cht P la cht trung gian
ha hc c vai tr quan trng trong s dn truyn cm giac au. Do , nhng cht
opioid lam mt cm giac au.
1.4. C IM CHUNG
Cac thuc gim au thc th khng c s dng rng rai bi chng c nhng c
im sau:
- Ngoai tac dng c ch mnh trn trung tm au, phn ln cac thuc nhm nay
cn gy c ch mnh trn mt s trung tm khac ca h TKTW ngay t liu iu tr,
trc ht la gy c ch h hp nn d gy tai bin, nht la vi ngi gia yu, ph n
ang mang thai, tr em nho hn 5 tui.
- C c tnh cao va d gy nghin.
- Tac dng phc tp dc l phc tp: gy trng thai khoan khoai, tng tr tng
tng, mt bun ru, mt cm giac s hai lam cho ngi a dng rt kh bo va lun
mun dng li thuc. Khi a nghin thi rt kh cai thuc, khi thiu thuc thng gy
hin tng vt va, au n
Vi nhng c im trn thuc phi c qun l cht ch theo quy ch tranh
cac t nn xu cho xa hi.
1.5. PHAM VI S DUNG:
- La nhm thuc c tac dng gim au mnh nhng cha phi la thuc gim au l
tng vi chng c nhiu tac dng ph nguy him (gy nghin, c ch h hp) nn
thng ch dng trong cac cn au nng ni tng nh: ung th giai on cui, soi
thn, soi mt, chn thng, au sau phu thut, phong nng, lam thuc tin m trong
ngoi
- Khi dng phi chp hanh ng quy nh s dng, bo qun, qun l phn phi
thuc gy nghin tranh lm dng thuc hoc s dng thuc vao mc ch phi y
hc.
2. MT S THUC GIM AU THC TH
2.1. MORPHIN
2.1.1. Ngun gc:
- La Alcaloid c trong nha ca vo qu cy Thuc phin.
- Dng dng mui Hydroclorid.

20
2.1.2. Tnh cht:
- Tinh th hinh kim nho, mm, mau trng hay ng thanh khi vung.
- Khng mi, v ng, d tan trong nc, kh tan trong Ethanol, khng tan trong
Cloroform, tan trong dung dch kim.
2.1.3. Dc ng hc:
- Hp thu: ng ung km hn tim, phi sau 30 - 60 pht mi t nng ti a.
- Phn b: vao cac t chc, qua c hang rao mau nao, nhau thai.
- Chuyn ha: ch yu gan, mt t thn.
- Thi tr: qua thn ( 90 % ), mt t qua mt, phn, m hi, sa, nc bt.
2.1.4. Tc dng:
- Trn h thn kinh trung ng
Tac ng thay i ty theo liu dng:
Liu thp 1 3 mg: gy khoan khoai, gia tng tr tng tng, cho cm giac ph
du thoat tc, lam kh ng, nn ma.
Liu iu tr 1 3 cg: Gim au va gy bun ng.
Liu cao hn: Gy ng va c th lam hn m.
- Trn h h hp
Liu thp: lam tng nhp h hp.
Liu cao hn: Suy h hp, lam trung tm h hp gim nhy cm vi CO2.
Liu c: c ch hoan toan trung tm h hp.
Ngoai ra morphin cn c ch trung tm ho (km codein).
- Trn h tun hoan
Liu c: suy yu c tim, h huyt ap, dan n mch mau da.
- Trn h tiu ha
Gy bun nn, i ma, tng trng lc c d day va rut, gim s tit dch tiu ha
va chm nhu ng rut.
- Tc ng khc
Khang li tiu, co ng t, gim thn nhit.
2.1.5. Tc dng ph:
- Liu iu tr: gy nghin, c ch trung tm h hp.
- Liu cao: gy m, mt tri giac, lit hoan toan trung tm h hp.
- Thuc cn gy bun nn, tao bn, b tiu.

21
 *
Do thuc gy cm giac khoan khoai nn thng c s lm dng thuc, khi s
dng lp li s gy tinh trng dung np, s dung np xy ra sau 2 -3 tun s dung
thng xuyn liu iu tr. i km vi s dung np la s l thuc thn th, khi khng
tip tc dng thuc na s xut hin hi chng cai thuc: chy nc mui, nc mt,
tng thn nhit, dan ng t, i ma, tiu chy, yu c, run, ri lon tun hoan - h hp
va c th dn n t vong.
2.1.6. Ch nh:
- Cac cn au ni tng d di, cp tnh: ung th giai on cui, soi mt, soi thn,
au hu phu, un van.
- Sc, choang do chn thng hay sau khi .
- Phi hp lam thuc tin m.
2.1.7. Chng ch nh:
- Tn thng u.
- Nghi vim rut tha va vim mang bng cp.
- Tr em nho hn 5 tui.
- Suy h hp, hen ph qun n thun, ph phi cp th nng.
- Bnh gan, thn man tnh, ng c ru, ng c cac Barbituric va cac thuc c
ch h hp.
2.1.8. Cch dng, liu lng:
Dng thuc - ham lng:
- Sir Morphin 0.05 %, chai 100 ml.
- ng dung dch tim 0.01g / 1 ml.
- Vin 10, 30, 50, 100 mg morphin sulfat
Liu dng:
- Liu gim au: 1 3 cg ty bnh nhn. Liu ti a: ung, tim di da 0.02g /ln,
0.05 g/24 gi.
- Liu thm d khi u: 5 10 mg/ln, cach quang 4 gi.
- Ngi trn 60 tui va suy gan dng liu nho hn va cach quang xa hn.
*
Lu : i vi bnh nhn au nhiu (au do ung th) khi dng morphin hoc cac
thuc gim au thc th khac rt t nguy c gy c ch h hp (do tac ng au a lam
gim qua trinh c ch). Liu dng cn c vao ap ng ca bnh nhn, c th dng liu
cao so vi liu thng dng. Khng c gii hn ti a.

22
2.1.9. Bo qun:
- Nguyn cht: thuc gy nghin, tranh anh sang, chng m, tranh cac cht Oxy
ha.
- Thanh phm: thuc gy nghin, tranh anh sang, tranh va chm.
2.2. PETHIDIN
BD: Pethidol*, Dolargan*, Dolosal*, Lidol*.
2.2.1. Tnh cht:
- Tinh th khng mau hay bt kt tinh trng, khng mi, v chua va ng.
- Rt d tan trong nc, d tan trong Ethanol, Cloroform, khng tan trong Ether,
Benzen.
2.2.2. Tc dng:
- Tac dng xut hin nhanh, thi gian tac dng tng i ngn. Sau khi ung 15
pht, pethidin a c tac dng gim au mc d khng mnh bng morphin (km 7- 10
ln). t gy nn, t gy gim tiu tin, khng gy tao bn, khng gim ho. Pethidin
cung gy an thn, lam du, c ch h hp va gy nghin nh morphin.
- Pethidin lam gim huyt ap, nht la t th ng.
- Khi dng qua ng tnh mch, pethidin lam tng lu lng tim, lam tim p
nhanh, do c th nguy him cho ngi b bnh tim.
- ng mt, thuc lam co tht c oddi, vi vy khi au ng mt phi dng
thm atropin.
2.2.3. Tc dng ph:
- Pethidin t c hn morphin. Thng gp: Bun nn, nn, kh ming, tao bn.
- Him gp cac tac dng khng mong mun trn thn kinh trung ng nh bun
ng, suy gim h hp, ngt.
- Nghin xut hin trong iu tr t 1 2 tun.
2.2.4. Ch nh va chng ch nh
- Nh morphin: gim au, tin m.
2.2.5. Cch dng, liu lng:
Dng thuc - ham lng:
- Vin 0.025 g.
- ng dung dch tim 0.10 g / 2ml.
- Ung: 2 - 3 ln, mi ln 0.05 g.

23
Liu lng
- Tim bp, tim di da: 0.05 - 0.10 g/ln/ngay.
- Cp cu: c th tim tnh mch chm 0.10 g pha trong 20 ml thuc tim truyn
Natri clorid 0.9 %.
* Liu ti a: ung, tim di da 0.10 g/ln, 0.25 g/ngay.
2.2.6. Bo qun:
Thuc gy nghin, tranh anh sang
2.3. FENTANYL
BD: Duragesic*, Submimaze*, Fentanest*, Leptanal*
2.3.1. Tc dng
Fentanyl gim au mnh gp 100 ln morphin, tac dng nhanh (khong 3 - 5 pht
sau khi tim tnh mch) va ko dai 1 - 2 gi.
2.3.2. Tc dng ph
- Toan thn: chng mt, ng l m, l ln, o giac, ra m hi, o bng mt, sng
khoai.
- Tiu ha: bun nn, nn, tao bn, co tht ti mt, kh ming.
- Tun hoan: chm nhp tim, h huyt ap thoang qua, anh trng ngc, lon nhp.
- H hp: th nhanh, suy h hp, ngt th.
- C xng: co cng c bao gm c lng ngc, git rung
- Mt: co ng t
2.3.3. Ch nh
- Gim au trong phu thut.
- Phi hp vi droperidol gim au, an thn
- Phi hp trong gy m.
2.3.4. Chng ch nh
- Cac trng hp au nhe (c th dng cac thuc gim au khac nh
acetaminophen).
- Nhc c
- Thn trng trong cac trng hp: bnh phi mn tnh, chn thng s nao va tng
ap lc s nao, bnh tim, trm cm, ph n c thai.
- Fentanyl c ch nh i vi ph n cho con b, mc d thuc c mt trong
sa me nhng vi liu iu tr fentanyl khng nh hng n tr ang b.

24
2.3.5. Tng tc thuc
- Cac thuc c ch thn kinh trung ng nh ru, thuc ng, thuc m,
phenothiazin... lam tng tac dng gim au ca fentanyl.
- Fentanyl lam gim hp thu ca mt s thuc nh metoclopamid, mexiletin... khi
dng phi hp.
- Huyt ap gim mnh khi phi hp fentanyl vi thuc c ch - adrenergic va thuc
chen knh calci.
2.3.6. Cch dng liu lng
Dng thuc
ng tim 100g/2ml, 500 g/10ml.
ng tim phi hp cha 50 g fentanyl va 25mg droperidol.
Liu lng
Dng cho tin m: 50 - 100 g, c th tim bp 30 - 60 pht trc khi gy m.
H tr gy m: Liu thay i ty theo tiu phu, trung phu hoc i phu. Thng
khi u 1 20 g/kg, tim li 50 - 100 g ty theo nhu cu cach nhau 20 pht.
Gim au trong phu thut: 0,07 - 1,4 g/ kg th trng, c th nhc li trong 1 - 2
gi nu cn.
2.3.7. Bo qun
Thuc gy nghin, tranh anh sang.
2.4. METHADON
BD: Dolophin*, Amidone*, Phenadon*
2.4.1 . Tc dng
Methadon c tac dng tng t morphin nhng nhanh hn va ko dai hn, t gy
tao bn. Gy gim au mnh hn pethidin. D gy bun nn va nn.
2.4.2. Tc dng ph
Tac dng khng mong mun va c tnh ging nh morphin. Khi dng ko dai,
methadon c th lam ra nhiu m hi, tng bch cu lympho, tng nng prolactin,
albumin va globulin trong mau.
2.4.3. Ch nh
Trn lm sang, methadon c dng gim au va cai nghin morphin, heroin.
Liu lng: ung mi ln 2,5 mg, ngay 2 - 3 ln, tu thuc mc au va phn
ng ca bnh nhn.

25
2.5. PROPOXYPHEN
2.5.1. Tc dng
Tac dng gim au km: liu 90 - 120 mg propoxyphen hydroclorid theo ng
ung, c tac dng gim au tng t 60 mg codein hoc 60 mg aspirin.
2.5.2. Tc dng ph
C th gy c ch h hp, co git, hoang tng, o giac, c vi tim... khi dng.
2.5.3. Ch nh
Dng gim au nhe va trung binh. Propoxyphen thng c phi hp vi
aspirin hoc acetaminophen.
3. THUC I KHANG VI OPIOID
Nalorphin, Naloxon, Naltrexon
Cac cht nay i lp c cac tac dng do morphin gy ra, ch yu la nhng du hiu
c ch nh gim au, c ch h hp, an thn, sng khoai. Thi gian tac dng ni
chung ngn hn morphin.
Nalorphin khng c dng trn lm sang vi c ch h hp, lam chm nhp tim, co
ng t, sng khoai.
3.1. NALOXON (NALONE, NARCAN, NARCANTI)
3.1.1. Tc dng
- ngi a dng liu ln opioid, naloxon i khang phn ln nhng tac dng
khng mong mun ca opioid nh c ch h hp, an thn, gy ng...
- Khi dng, naloxon c th gy ra hi chng thiu thuc sm ngi nghin
opioid, tuy vy dng liu cao s ngn chn c triu chng suy h hp trong hi
chng nay.
3.1.2. Tc dng ph
- Tim mch: tng huyt ap (c khi gim huyt ap), nhp tim nhanh, lon nhp tht.
- Thn kinh trung ng: mt ng, kch thch, lo u.
- Tiu ha: bun nn, nn.
- Nhin m, ban o ngoai da.
3.1.3. p dng iu tr
- Naloxon c dng iu tr ng c cp cac opiat va opioid, cai nghin opioid
Phi ht sc thn trng khi dng naloxon cho ngi c bnh tim mch, ph n c thai
va cho con b.

26
 - Liu lng; ngi ln: 0,4 - 2 mg, tim tnh mch , 2 -3 pht tim nhc li nu
cn. Tng liu 10 mg.
- Vi thi gian tac dng ca naloxon rt ngn (60 - 90 pht) nn cn truyn lin tc
naloxon khi bnh nhn ng c opium nng.
3.2. NALTREXON
i khang vi opioid mnh hn naloxon, thng dng ng ung. Naltrexon
c dng cai nghin opioid (ung 100 mg/ngay), cai nghin ru (phi hp vi
disulfiram).
4. NGUYN TC S DUNG THUC GIM AU
4.1. CHON THUC
Thuc gim au ch iu tr triu chng, thuc c th che lp cac du hiu ca bnh
trong khi bnh vn tin trin nn phi ht sc cn nhc khi s dng thuc gim au.
Khi la chn thuc cn ch n cng va bn cht ca au. T chc Y t Th gii
khuyn cao nn ung thuc theo bc thang gim au:
- Bc 1 (au nhe): dng thuc gim au khng phi opioid nh paracetamol, thuc
chng vim khng phi steroid.
- Bc 2 (au va): phi hp thuc loi opioid yu (codein, oxycodon,
propoxyphen) vi paracetamol, thuc khang vim khng steroid (NSIAD) hoc thuc
gim au h tr.
- Bc 3 (au nng): dng thuc gim au loi opioid mnh: morphin,
hydromorphon, methadon... phi hp vi thuc chng vim khng steroid.
5.2. NG DNG THUC
Thng thng nn dng ng ung. Tuy nhin, trong cac cn au nng, cp tnh
hoc sau phu thut ln... phi dng ngay cac thuc gim au mnh loi opioid qua
ng tim tranh sc va nh hng xu ca au n tin trin ca bnh .

27
 THUC GIM AU - HA ST - KHANG VIM
KHNG STEROID (NSAID)

MUC TIU
Trinh bay c nh ngha, phn loi, tac dng ca cac thuc gim au h st
khang vim khng steroid.
Nu c tnh cht, tac dng, tac dng ph, ch nh, chng ch nh, cach
dng, liu dng ca mt s thuc gim au h st khang vim khng steroid
thng dng.
Trinh bay c mt s nguyn tc chung khi s dng cac thuc gim au h
st khang vim khng steroid.

NI DUNG
1. AI CNG
1.1. NH NGHIA
Thuc gim au h st la nhng dc phm c hiu lc gim au gii hn trong
cac chng au nhe va trung binh nh au u, au rng, au dy thn kinh. Ngoai hiu
lc gim au cac thuc nay c th c hiu lc h st va khang vim.
1.2. PHN LOAI
Theo tac dng thuc gim au h st khang vim khng steroid c chia
thanh cac nhm sau:
Thuc giam au ha st khng vim:
o Nhm acid salicylic: Aspirin (acid acetylsalicylic), Methylsalicylat.
o Nhm indol: Indomethacin, Sulindac, Etodolac
o Nhm pyrazolon: Phenylbutazon.
o Nhm acid propionic: Ibuprofen, Naproxen, Ketoprofen.
o Nhm acid phenylacetic: Diclofenac.
o Nhm acid enolic (nhm oxicam): Meloxicam, Piroxicam, Tenoxicam.
o Nhm acid phenamic: Acid mefenamic, Acid meclofenamic.
o Nhm acid heteroarylacetic: Tolmetin, Ketorolac.
o Nhm coxib: Celecoxib.
28
 o Nhm sulfonanilid: Nimesulid.
Thuc giam au ha st
o Nhm Para - aminophenol: Paracetamol (acetaminophen), Phenacetin
Thuc giam au thun ty
o Nhm acid floctafenic: Floctafenin
1.3. TAC DUNG DC LY
1.3.1. TC DUNG HA ST
Cac cht gy st ngoi lai (vi khun, c t vi khun) xm nhp vao c th gy
st do lam tng qua trinh sinh nhit (rung c, tng h hp, tng chuyn ha) va gim
qua trinh thi nhit (co mch da). Cac thuc h st tac ng ln trung tm iu ha
thn nhit vng di i lam tng qua trinh thi nhit (gian mch ngoi bin, ra m
hi), c ch qua trinh sinh nhit lp li thng bng cho trung tm iu nhit vng
di i.
Vi liu iu tr, nhm thuc nay ch gy h st ngi c st (do bt ki nguyn
nhn nao) khng c tac dng trn ngi thng. Thuc h st ch c tac dng cha
triu chng, sau khi thuc b thi tr, st s tr li.
1.3.2. TC DUNG GIAM AU
Ch c tac dng vi cac chng au nhe, khu tr. Tac dng tt vi cac chng au
do vim (au khp, vim c, vim dy thn kinh, au rng, au sau m). Khac vi
thuc gim au nhm opioid, cac thuc nay khng c tac dng vi au ni tng, khng
gy ng, khng gy c ch h hp, khng gy khoan khoai va khng gy nghin. i
vi mt s chng au sau m, CVKS c th c tac dng gim au mnh hn c
morphin vi m a gy ra vim.
Cac thuc gim au h st khang vim lam gim tnh cm th ca cac ngn
dy cm giac vi cac cht gy au ca phn ng vim nh bradykinin, histamin,
serotonin
1.3.3. TC DUNG KHNG VIM
Cac thuc gim au h st khang vim c tac dng trn hu ht cac loi vim
khng k n nguyn nhn, theo cac c ch sau:
c ch c hi phc cyclooxygenase (COX), ngn cn sinh tng hp
prostaglandin (PG) la cht trung gian ha hc ca phn ng vim.

29
 Lam vng bn mang lysosom (th tiu bao): vim, trong qua trinh thc bao,
cac i thc bao lam gii phng cac enzym ca lysosom (hydrolase, aldolase,
phosphatase acid, colagenase, elastase...) lam tng thm qua trinh vim. Do lam vng
bn mang lysosom, cac gim au h st khang vim lam ngn cn gii phng cac
enzym phn gii, c ch qua trinh vim.
Ngoai ra c th cn c thm mt s c ch khac nh i khang vi cac cht trung
gian hoa hc ca vim do tranh chp vi c cht ca enzym, c ch di chuyn bch
cu ti vim, c ch phn ng khang nguyn khang th.
1.3.4. TC DUNG CHNG KT TP TIU CU
Cac thuc gim au h st khang vin khng steroid, c bit la aspirin liu
thp (70 325mg/ngay) ang c quan tm dng trong cac bnh tim mch vi tac
dng ngn kt tp tiu cu phng, chng huyt khi nghn mch.
1.4. TAC DUNG KHNG MONG MUN
o Trn tiu hoa: Kch ng, au thng v, nng hn c th gy lot d day ta
trang, xut huyt tiu ha.
o Trn mu: Ko dai thi gian chy mau, mt mau khng nhin thy qua phn,
tng nguy c chy mau.
o Trn thn: Gim lng mau qua thn, gim sc lc cu thn, gim thi dn n
nc d dn ti tng huyt ap, tng K mau va vim thn k.
o Trn h hp: Gy cn hen gi trn ngi khng b hen hoc lam tng cac cn
hen ngi b hen ph qun.
o Vi phu n mang thai 3 thang u thai ki thuc gy d tt thai nhi, 3 thang
cui thai k d gy cac ri lon phi, ko dai thi gian mang thai, lam chm
chuyn d.
o Ngoai ra co th gp mn cam: ban da, m ay, sc qua mn.
2. CAC NHM THUC
2.1. NHM ACID SALICYLIC: ASPIRIN, METHYLSALICYLAT.
ASPIRIN
Tnh cht
Tinh th hinh kim, khng mau hay bt kt tinh trng, thong mi Acid Acetic, v chua.
Kh tan trong nc, d tan trong ethanol, dung dch kim. Khi gp m d phn hy
thanh Acid Salicylic va Acid Acetic.

30
Tc dng
Liu cao ( > 4g/ngay) c tac dng chng vim. Liu trung binh (500 mg/ln) c tac
dng h st va gim au trong vng 1 - 4 gi. Liu thp (70 325mg/ngay) c tac
dng chng kt tp tiu cu va ko dai thi gian ng mau.
Ch nh
o Gim au trong cac trng hp au nhe va va: au u, au c, au do vim
khp, au rng, au bng kinh
o H st do cac nguyn nhn gy st tr st xut huyt va st do cac loi virus
khac, khng dng h st cho tr em di 12 tui.
o Khang vim trong cac dng thp khp cp, vim khp do vy nn, vim c.
o D phng th phat nhi mau c tim va t quy.
Tc dng khng mong mun
o Mc d cac dn xut salicylic u t c, d ung, nhng dng lu c th gy
hi chng salicyle (salicylisme): bun nn, tai, ic, nhc u, l ln.
o c ng: ph, m ay, mn, ph Quincke, hen.
o Nhim c vi liu trn 10g. Liu cht i vi ngi ln khong 20g.
o Xem thm 1.4
Chng ch nh
o Lot d day ta trang, xut huyt tiu ha.
o Mn cm.
o Hen suyn.
o Ri lon ng mau, tng d chy mau.
o Bnh gan thn nng.
o Ph n c thai.
Ch phm liu dng
o Vin nn aspirin 0,5g (bit dc: Acesal, Aspro, Polopyrin).
o Aspirin pH8: vin nn cha 0,5 g aspirin, c bao bng cht khang vi dch
v, nhng tan trong dch rut, t thuc c hp thu vao mau. Nng ti a
trong mau t c sau 7 gi, thi gian ban thi dai hn aspirin binh thng, do
gim c s ln ung thuc trong ngay, rt tin li cho cac trng hp iu tr
ko dai.

31
o Lysin acetyl salicylat (Aspgic): la dng mui ha tan, mi l tng ng vi
0,5g aspirin. Tim tnh mch hoc tim bp 1 - 4 l/ngay.
o Liu: H st gim au: 0,5 2g/ngay. Chng vim: 3 6g/ngay. D phng
huyt khi: 100 150mg/ngay dng hang ngay hoc cach ngay.
METHYLSALICYLATE
Dung dch khng mau, mi hc lu, d dang thm qua da nn ch dng xoa bp gim
au ti ch: dng gel, cao dan Salonpas.

2.2. NHM PARA AMINOPHENOL

PARACETAMOL
Tnh cht
Bt kt tinh trng c anh hng, khng mi, v ng nhe, tan trong nc, ethanol, va
cac dung dch hydroxyd kim.
Tc dng
Paracetamol c cng va thi gian tac dng tng t nh aspirin v gim au va h
st, khng c tac dng chng vim. liu iu tr thuc t nh hng trn h tim
mch, h hp, khng gy kch ng tiu ha, khng nh hng trn s ng mau va c
th s dng c cho ph n mang thai, cho con b.
Ch nh
o Gim au, h st. C th thay th cho aspirin khi khng dng c thuc nay.
o Gim cac cn au ngoi vi t nhe n trung binh, h st do mi nguyn nhn.
o C th phi hp vi cac thuc gim au khac:
Alaxan: paracetamol + ibuprofen.
Di altavic: paracetamol + dextropropoxyphen.
Efferalgan codein: paracetamol + codein.
Panadol extra: paracetamol + caffein.
Decolgen: paracetamol + phenylpropanolamine + chlorpheniramine.
Tc dng khng mong mun
o Ni chung thuc dung np tt, t tac dng khng mong mun, i khi gp cac
phn ng d ng (nh ban da, may ay, st do thuc), bun nn, ri lon to mau.

32
o Nu dng liu cao ko dai ( > 4g/ngay) gy tn thng hoi t t bao gan do
mt lng ln paracetamol b chuyn thanh N acetyl parabenzoquinonimin, cht
nay s phn ng vi nhm SH ca protein gan va gy hoi t t bao gan.
Chng ch nh
o Qua mn vi paracetamol.
o Thiu men G6PD.
o Bnh gan nng.
o Phi hp vi cac thuc gy c vi gan nh isoniazid, rifampicin, phenytoin
o Khng ung ru trong thi gian dng thuc.
Ch phm Liu dng
Ch phm
Hin c rt nhiu bit dc cha paracetamol vi tn gi rt khac nhau ( Efferalgan,
Panadol, Dafalgan, Tylenol) di dng:
Vin nn, vin nang, vin si 100mg 325mg 500mg 650mg.
Ta dc 80mg 150mg 300mg 600mg.
Thuc bt 80mg 150mg.
Thuc tim:
Propacetamol (Pro dafalgan) l thuc bt 1g + dung mi, pha ngay trc khi dng.
La tin cht ca paracetamol s phng thch t t paracetamol trong c th, 1g
propacetamol = 0,5g paracetamol. Dng gim au trong cac trng hp cp cu hay
phu thut. Liu dng 1 2g/ln, cach 4 6 gi. Khng dng qua 8g/ngay.
Paracetamol dng tim truyn (Perfalgan) 10mg/ml chai 100ml. Liu 1g Perfalgan c
tac dng tng ng sinh hc vi 2g pro dafalgan, ketorolac 30mg, diclofenac
75mg tim bp, morphin 10mg tim bp.
Liu dng
Liu thng thng ngi ln: 325 1000 mg/ngay. Khng dng qua 4g/ngay.
Tr em: 10mg/kg/ln x 3 4 ln/ngay (40 480 mg/ngay). Khng dng qua 5 ln mi
ngay.

2.3. NHM INDOL: INDOMETHACIN, SULINDAC, ETODOLAC.

INDOMETHACIN
Tc dng

33
Chng vim mnh hn phenylbutazon 20 ln, hn hydrocortison 4 ln. Khng dng h
st n thun vi nhiu c tnh. Gim acid uric tt.
Ch nh
o iu tr cac bnh v vim xng khp nh: Vim xng khp, h khp, thp
khp ct sng, vim nhiu khp mn tnh tin trin, au lng, vim dy thn kinh...
o iu tr bnh gt.
Tc dng khng mong mun
o Tng t cac thuc trong nhm thng gp nht la kch ng tiu ha lot d
day, nhc u vng tran.
o Ngoai ra cn gp gim bch cu, gim tiu cu.
Liu dng
Indomethacin (Indocid, Indocin): vin nn hoc vin nang 25mg. Thuc n 50 -
100mg. Mi ngay ung 50 - 150 mg chia lam nhiu ln.
SULINDAC
Tc dng
Trn thc nghim, tac dng dc l ca sulindac bng 1/2 indometacin; trn thc t
lm sang, tac dng chng vim va gim au ca sulindac tng t aspirin. T l va
mc c tnh km indometacin.
Liu dng
Sulindac (Arthrocin, Artribid, Clinoril) vin 150 va 200 mg; mi ngay ung 1 - 2
vin, liu ti a 400mg/ngay, la liu tng ng vi 4g aspirin hoc 125 mg
indometacin.
ETODOLAC
Etodolac (Lodine, Etolac, Febret, Dolchis): ung 200 - 400 mg mi 6 8 gi. Khng
dng qua 1200mg/ngay.

2.4. NHM PYRAZOLON

PHENYLBUTAZON.
Ch dng phenylbutazon cho vim cng khp va vim a khp mn tnh tin trin
khi cac thuc khang vim khng steroid khac khng cn tac dng va phi theo doi cht
ch cac tac dng khng mong mun ca thuc.

34
 c tnh thng gp va nng: lot d day d dng ng tim, gi Natri gy ph,
tng huyt ap, gim bch cu, suy ty, phn ng d ng.
Bit dc: Apo-Phenylbutazon.
Liu dng: Ngay u ung 200mg chia lam 2 ln ung trong hoc sau ba n, tng
dn liu ti 600 mg/ngay. Tu theo tinh trng bnh va sc chu ng ca ngi bnh,
c th gi liu trong 4 - 5 ngay, sau gim xung liu duy tri 100 - 200 mg. Ni
chung, mt t thuc khng qua 15 ngay, sau ngh 4 - 5 ngay mi dng. Liu 600
mg c tac dng thi tr acid uric tt, lam gim st va gim vim nhanh trong cac cn
cp tnh ca bnh gt.

2.5. NHM ACID PROPIONIC: IBUPROFEN, NAPROXEN, KETOPROFEN.

Tc dng
Liu thp c tac dng gim au; liu cao hn chng vim; tac dng h st km nn t
dng lam thuc h st n thun; tac dng chng kt tp tiu cu yu hn aspirin.
Tc dng khng mong mun
Tng t cac thuc khac trong nhm nhng nhe hn. Ngoai ra thuc nhm nay c th
gy gim th lc, thay i nhn cm mau sc, gim bch cu ht, vim mang nao v
khun, c bit c s mn cm cho vi aspirin.
Ch nh
o Gim au nhe va va trong cac bnh: thng kinh, nhc u, au rng.
o Dng n c hoc phi hp vi thuc gim au gy ng gim bt liu dng
ca nhm thuc nay.
o Tr vim khp dng thp, vim xng khp, vim c
Ch phm va liu dng
IBUPROFEN
Bit dc: Brufen, Mofen
Vin nn 100, 150, 200, 300 va 400 mg, vin nang 200 mg, thuc n 500 mg.
Vim khp: thng dng 1,2 - 1,8g/ngay, chia lam 4 ln. C th tng liu nhng khng
vt qua 3,2g/ ngay. Sau 1 - 2 tun cn gim xung liu thp nht c tac dng (0,6 -
1,2g/ ngay).
Gim au: ung 400 mg/ ln, cach 4 - 6 gi/ ln.
Tr em: 20mg/kg/ngay chia 4 ln.

35
NAPROXEN
Bit dc: Naprosyn, Apranax
Vin 125 250 375 500 mg. Ung 500 1000 mg/ngay. D dung np nn thng
c dng nh ibuprofen.

KETOPROFEN
Bit dc: Profenid
Dng vin nang, vin tac dng ko dai, vin bao tan trong rut. Ung 100 300
mg/ngay.
Trong s cac thuc khang vim khng steroid, ketoprofen la thuc c tac dng gim
au ngoi bin va trung ng do thuc thm qua c hang rao mau nao va t c
nng tac dng ti trung tm nhn cm va dn truyn au ty sng va trn ty
sng. Ti cac trung tm nay thuc lam gim gii phng cac cht trung gian gy au
(cht P, glutamat). Do c tac dng trung ng, ketoprofen c th dng theo ng tim
bp, tim tnh mch 100 200 mg/ngay. Ch nh cho gim au sau m, nht la trong
chnh hinh va m ng niu.

2.6. NHM ACID PHENYLACETIC: DICLOFENAC.

DICLOFENAC
Tc dng
Gim au va chng vim mnh hn indomethacin.
Ch nh
Trong vim khp mn, thoai ha khp cp va mn. Cn dng gim au trong vim c,
au sau m, au do kinh nguyt, au do soi thn, vim dy thn kinh
Tc dng ph
Tng t cac thuc trong nhm, c th lam tng aminotransferase gan gp 3 ln nhng
hi phc c, tac dng ph trn ng tiu ha thp hn indomethacin va aspirin,
thuc cung gy mt bch cu ht nhng nhe hn phenylbutazon.
Ch phm va liu dng
Diclofenac (Voltaren) dng vin 50 75 100mg (dng bao tan trong rut), thuc
tim, dng gel thoa ngoai da, dng nho mt. Ung 100 150 mg/ ngay.

36
2.7. NHM ACID ENOLIC (NHM OXICAM): MELOXICAM, PIROXICAM,
TENOXICAM.
Tc dng: La nhm thuc khang vim mi, c nhiu u im
o Tac dng chng vim mnh vi ngoai tac dng c ch COX cn c ch
proteoglycanase va collagenase ca m sn, liu iu tr ch bng 1/6 so vi cac
thuc th h trc. Tac dng gim au xut hin nhanh, na gi sau khi ung. So
vi aspirin tac dng h st km, ch yu dng gim au, chng vim.
o Thi gian ban thi dai (2 3 ngay) cho php dng liu duy nht trong 24 gi.
Vi t1/2 qua dai, d c nguy c tch lu thuc.
o D thm vao t chc bao khp b vim, t thm vao cac m khac va vao thn
kinh, gim c nhiu tai bin. Cac tai bin thng nhe va t l thp hn so vi
cac khang vim khng steroid khac, ngay c khi dng thuc ko dai ti 6 thang.
Ch nh: trong cac vim cp va mn: vim khp dng thp, vim xng khp, thoai
hao khp, vim ct sng dnh khp, bnh gt, cac bnh c xng cp, chn thng
trong th thao, au hu phu
Tc dng khng mong mun: tng t cac khang vim khng steroid khac.
Ch phm va liu dng
PIROXICAM
Bit dc: Felden, Gelden
Vin nang 10 mg, 20 mg; ng tim 20 mg/1ml. Ung 10 - 40 mg/ngay.
TENOXICAM
Bit dc: Tilcotil, Tenox
Vin nn 20 mg, ng tim 20 mg/1ml. Ung 10 - 20mg/ngay
MELOXICAM
Bit dc: Mobic.
Vin nn 7,5 mg va 15 mg; ng tim 15mg/1,5ml. Liu 7,5 15mg/ ngay.

2.8. NHM COXIB

CELECOXIB
Coxib la nhom thuc mi c a vao s dng co nhng c im sau:
o c ch u tin trn COX - 2 nn tac dng chng vim mnh, c ch COX - 1
yu nn cac tac dng ph v tiu ha, mau, thn, cn hen... gim i rt ro rt.

37
o Thi gian ban thi dai, khong 20 gi cho nn ch cn ung mi ngay 1 ln.
o Hp thu d dang qua ng tiu ha, d thm vao cac m va dch bao khp nn
c nng cao trong m vim, ch nh tt cho vim xng khp va vim khp
dng thp.
Ch nh: iu tr cp tnh va dai hn cac chng vim xng khp, gim au trong cac
cn au cp nh au rng, au hu phu.
Tc dng khng mong mun: Tng t cac khang vim khng steroid khac, tac dng
trn ng tiu ha gim nhng tac dng khng mong mun trn tim mch hay gp
hn.
Ch phm:
Celecoxib (Celebrex)
Vin nang 100 200mg. Liu thng dng 100 mg 2 ln/ ngay. Trong thp khp c
th tng liu ti 200 mg 2 ln/ ngay.
2.9. NHM ACID HETEROARYLACETIC: TOLMETIN, KETOROLAC.
TOLMETIN
Bit dc: Tolectin
Tac dng chng vim, gim au va h st tng t aspirin nhng d dung np hn.
Thuc c gi li trong bao hot dch ti 8 gi sau 1 liu duy nht. Tac dng chng
vim, gim au liu 0,8 - 1,6g/ ngay, tng ng vi aspirin 4 - 4,5g/ ngay hoc
indometacin 100 - 150 mg/ ngay. Liu ti a la 2g/ ngay chia lam 3 - 4 ln.
KETOROLAC
Bit dc: Ketogesic, Ketorol, Acular.
La thuc c tac dng gim au mnh hn chng vim.
Ch nh gim au ngn hn, di 5 ngay nh au sau m, au cp tnh. Khng
dng cho au trong sn khoa, au nhe va au mn tnh.
Liu ung 5 - 30 mg/ ngay; tim bp 30 - 60 mg/ ngay; tim tnh mch 15 30 mg/
ngay.

2.10. NHM ACID PHENAMIC: ACID MEFENAMIC, ACID

MECLOFENAMIC.
ACID MEFENAMIC
Bit dc: Nifluril, Mefenacid, Ponstel.

38
Dng vin nang 250mg, vin nn 500mg, vin n 500mg, hn dch ung 50mg/5ml
va kem bi 3%. Liu dng: ung 250 500 mg/ln x 2 3 ln/ngay (ti a 1,5g/ngay)
hoc 1 vin n vao bui ti. Ch yu dng gim au du, au rng, au dy thn
kinh, au chn thng, au sau phu thut hoc au bng kinh.
ACID MECLOFENAMIC
Bit dc: Meclomen.
Dng vin nang 50 va 100mg. Liu dng: ngi ln 200 300 mg/ngay, chia 2 3
ln. Ch yu dng iu tr vim khp dng thp, au xng khp, vim xng khp
ph n.

2.11. NHM SULFONANILID

NIMESULID.
La thuc khang vim, gim au c ch u tin trn COX 2, t gy tac dng khng
mong mun trn ng tiu ha.
Ch phm: Nimesulid (Mesulid) vin nn 100ng, mi ngay ung 1 2 vin. Mi y
TCYTTG a thng bao va ngay 14/08/2007 cc Qun l Dc Vit Nam a cnh bao
v tac dng gy sc phn v, nga phat ban, kh th ca thuc. Singapore va Ireland
a thng bao ngng ng k thuc nay.

2.12. NHM ACID FLOCTAFENIC

FLOCTAFENIN
Tc dng: Floctafenin c tac dng gim au n thun, khng c tac dng h st va
khng khang vim. Tac dng gim au mnh hn aspirin.
Ch nh: gim cac cn au cp va mn tnh mc nhe trung binh.
Tc dng khng mong mun: cm giac kin b, nng rat mt va chi, ng o toan
thn, km nga, may ay, ph mch, kh th dng hen, ngt xu, tt huyt ap co th
try mchCac tai bin nay him nhng nghim trng.
Thn trng:
o Khng dng chung vi cac thuc chen beta vi lam gim c ch b tr ti tim va
lam nng thm h huyt ap, ng thi tng nguy c sc phn v.
o Tr em di 15 tui.
o Ph n c thai va cho con b.

39
Ch phm: Floctafenin (Idarac) vin 200mg. Liu trung binh dng ung 400
800mg/ngay. Ti a 1200mg/ngay.

3. MT S NGUYN TC CHUNG KHI S DUNG THUC

GIM AU KHANG VIM HA ST KHNG STEROID
o Vic chn thuc tu thuc vao ca th. C ngi chu ng c thuc nay
nhng khng chu ng c thuc khac.
o Ung trong hoc sau ba n tranh kch ng d day.
o Khng ch nh cho bnh nhn c tin s lot d day. Trong trng hp tht cn
thit, phi dng cng vi cac cht bo v nim mc d day.
o Ch nh thn trng i vi bnh nhn vim thn, suy gan, c c a d ng, cao
huyt ap.
o Khi iu tr ko dai, cn kim tra c nh k (2 tun mt ln) cng thc mau,
chc phn thn.
o Nu dng liu cao tn cng, ch nn ko dai 5 - 7 ngay. Nhanh chng tim
c liu thp nht c tac dng iu tr tranh c tai bin.
o Ch khi dng phi hp thuc:
Khng dng phi hp cac khang vim khng steroid vi nhau vi lam tng c
tnh ca nhau.
Khng dng cac khang vim khng steroid cng vi thuc chng ng mau loi
khang vitamin K (dicumarol, warfarin), sulfamid h ng huyt,
diphenylhydantoin, vi cac khang vim khng steroid s y cac thuc nay ra
khoi ni d tr (protein huyt tng), lam tng tac dng va c tnh cac thuc
nay. Nu vn cn phi hp thi gim liu cac thuc .
Cac khang vim khng steroid c th lam gim tac dng mt s thuc do lam
tng giang ha hoc i khang ti ni tac dng nh meprobamat, androgen, li
tiu furosemid.

40
 THUC IU TR BNH GOUT

MUC TIU
1. Trinh bay c nguyn nhn gy ra bnh Gout.
2. Trinh bay c nguyn tc iu tr bnh Gout.
3. Nu c tn, c ch tac ng ca cac thuc dng trong iu tr bnh Gout.
1. AI CNG
1.1. S lc v bnh Gout
Gout la mt dng vim khp vi s tch t ca cac tinh th natri urat hinh kim ti
cac khp va cac dch bao khp.
Gout c mt c im la c mc cao ca acid uric trong mau va nc tiu.
Gout chia lam hai dng cp tnh va man tnh.
Cac cn vim cp ca Gout cung c bn c trng c bn ca mt phn ng vim
la sng, nng, o, au, c bit la au d di. Nu khng iu tr thi cn Gout cp
cung c th t khoi nhng s li tai din va thi gian gia cac cn bc phat s ngay
cang ngn i, cac cn au s ngay cang trm trng va ko dai hn.
1.2. Nguyn nhn
Nguyn nhn gy nn bnh Gout la do s ri lon chuyn ha acid uric lam tng
lng acid uric trong mau.
Acid uric to thanh giai on cui trong qua trinh chuyn ha cac base purin
(adenine va guanine).
Trong huyt tng, pH sinh l, c n 98% acid uric hin din di dng natri
urat. Acid uric khng c phn hy ngi va 80% acid uric c thi tr qua thn
va 20% qua rut, cn li mt phn rt nho qua m hi (<1%). pH nc tiu nh hng
rt ln n s ha tan acid uric, do vy pH cang cao cang thun li cho vic thi acid
uric qua ng niu va ngc li.
S gia tng nng acid uric huyt c th la do s tng tng hp acid uric, gim
thi tr acid uric hoc c th do c 2 yu t.
Do , hai yu t chnh la tng acid uric la tng sn xut acid uric (ch n giau
purin, hin tng tng pha hy t bao trong bnh ac tnh hay chn thng, thuc c t

41
bao dng tr ung th) ; gim bai tit acid uric (yu thn, mt s thuc nh aspirin,
vitamin C, thuc li tiu, cyclosporine, ru)
2. NGUYN TC IU TR BNH GOUT
2.1. Khng ch cc t vim Gout cp: Cang nhanh cang tt
Thuc s dng:
Colchicin.
Khang vim khng steroid: Diclofenac, Naproxen.
Khang vim steroid: Prednisolon, Metylprednisolon.
2.2. Lam ha va duy tr acid uric mu mc cho php
a. Chng tng hp acid uric
ng ngoi sinh: Hn ch cac thc n cha nhiu purin nh tim, gan,
c
ng ni sinh: Gim tng hp acid uric bng cach c ch xanthin
oxydase : Allopurinol (Zyloric).
b. Tng thi acid uric khoi c th: Probenecid, Sulfinpyrazon, kim ha nc tiu
(n nhiu rau xanh, hoc thuc nh NaHCO3, Acetazolamide).
2.3. Kim sot tt cc bnh km theo:
Gim cn nng.
Thay i thi quen sng va sinh hot gim cac yu t nguy c.
Kim soat cac bnh l km theo: Cao huyt ap, tiu ng, ri lon
lipid.
3. MT S THUC IU TR BNH GOUT
3.1. Colchicin
Colchicin la mt alkaloid c c t nhiu loai Colchicum.
Tc dung dc l: Colchicin c tac dng khang vim yu, c chng minh
th. Trong pha khi u ca cn Gout, tac ng ca n c bit mnh. Colchicin tac
ng ln bch cu a nhn lam gim kh nng xuyn mch , kh nng thc bao va
nht la kh nng phng thch enzyme lysosom trc khi thc bao. Tac ng c bit
nay, khac vi tac ng ca cac thuc NSAIDs, ch yu trn bch cu n nhn, i
thc bao va bch cu ht, lam ngn chn chu k vim do tch t cac tinh th acid uric
va natri urat.
Ch nh:
42
 Cn Gout cp: cng hiu c bit trong 95% trng hp.
Phng nga cn Gout cp tnh nhng ngi bnh Gout man tnh.
Bnh khp vi tinh th gi Gout (do lng ng trong khp
hydroxyapamit, hoc nhng tinh th pyrophosphate natri).
Tc dung phu:
Tiu ha: tiu chy, bun nn, him khi nn ma. y la nhng du hiu
bao trc s qua liu. Gim liu hoc dng iu tr, cac triu chng bin mt.
Cac nguy c v mau: Gim bch cu, bch cu ht.
Chng v tinh trng (c th phc hi khi dng iu tr).
Ni may ay, phat ban dng si.
Chng ch nh:
Tuyt i: Ph n c thai.
Tng i: Suy gan nng, suy thn nng, suy tim, ri lon tiu ha.
Dang dng: Colchicin c dng ch yu bng ng ung (vin 1mg) hoc
phi hp 1mg Colchicin vi 50 mg tiemonium iodide, 15 mg Phenobarbital va 12,5
mg bt opium (Colchimax).
Liu dng: Khi u iu tr cn Gout cp tnh va liu tn cng 3 hoc 4 mg
ngay u tin (1 mg khong cach 2 gi); 2 ngay tip theo gim liu cn 2 mg, tip theo
1 mg trong 10 ngay.
3.2. Allopurinol
Tc dung dc l: Vao c th, Allopurinol c chuyn ha ch yu thanh
oxypurinol, c hai cht nay c cu trc tng ng vi base purin, ngn chn s to
thanh acid uric bng cach c ch tng tranh men xanthin oxydase.
Ch nh: Tng acid uric huyt nguyn phat va th phat. Tng acid uric huyt
do dng thuc sau x tr, sau khi dng thuc li tiu, thuc kim ham s phat trin ca
t bao.
Bnh Gout vi cac cn thng xy ra, do gia tng sinh tng hp acid uric.
Tc dung phu:
Tiu ha: au thng v, bun nn, tiu chy.
Cac biu hin trn da: c th xut hin bt k lc nao trong sut qua
trinh iu tr cac triu chng phat ban nga ngay, eczema. Khi xut hin cac triu
chng nay phi ngng ngay vic iu tr.
43
 Thn kinh: suy nhc, au u, chng mt, kh ng c th xut hin lc
bt u iu tr.
Cac ri lon v mau: c th gy gim bch cu, hi phc khi ngng iu
tr.
Chng ch nh:
Tuyt i: D ng vi Allopurinol, ph n mang thai va cho con b.
Tng i: Kt hp vi vidarabin, kt hp vi Penicillin nhm A
(Ampicillin va cac cht tng ng).
Thn trng: Khng bao gi bt u vic iu tr bng Allopurinol i vi con
Gout cp tnh. nhng bnh nhn Gout, Colchicin (1mg/24h) phi c kt hp mt
cach c h thng tranh khi phat cn Gout cp tnh.
Trong tt ca cc trng hp, Allopurinol phai c s dung sau ba n.
Dang dng: Vin nang 100mg hoc vin nn 100mg, 200mg, 300mg.

44
 THUC KICH THICH THN KINH
TRUNG NG

MUC TIU HOC TP

Trinh bay c khai nim, cach phn loi thuc kch thch thn kinh trung
ng.
Nu c ngun gc, tnh cht, tac dng, ch nh, chng ch nh, cach
dng, liu lng va bo qun cac thuc.

NI DUNG
1. AI CNG
1.1. KHAI NIM: Thuc kch thch thn kinh trung ng la thuc c tac dng lam
tng hng phn trn h thn kinh trung ng (vo nao, hanh ty, ty sng).
1.2. PHN LOAI THUC: C 3 loi.
- Thuc c tac dng u tin trn ty sng: Strychnin.
- Thuc c tac dng u tin trn hanh ty: Long nao, Niketamid.
- Thuc c tac dng u tin trn vo nao: Cafein, Theobromin.
S phn loi nay ch c tnh cht tng i vi thuc tac dng trn thn kinh trung
ng u nh hng ti nhiu b phn, nhiu vng ca h thn kinh.
2. CAC THUC
2.1. STRYCHNIN SULFAT
Ngun gc:
La Alcaloid chnh trong ht cy Ma tin, dng dng mui Sulfat.
Tnh cht:
- Tinh th hinh kim, khng mau hay bt kt tinh trng.
- Khng mi, v ng.
- D tan trong nc si, tan c trong nc lnh va Ethanol, t tan trong
Cloroform, khng tan trong Ether.
Tc dung:
- Kch thch TKTW u tin trn ty sng, tng cng cac c quan cm giac.

45
 - Kch thch phn x, tng dn truyn thn kinh c, tng hot ng va dinh dng
c.
- Kch thch tiu ha va tng tit dch v.
Tc dung phu:
Dng liu cao, thuc c th gy ng c do thn kinh b kch thch qua mnh va c
th t vong do ngng h hp.
Ch nh:
- Nhc c, lit dng, ai dm.
- n ung kh tiu do lit nhe rut, tao bn.
- Gii c thuc ng loi Barbituric.
Chng ch nh:
Cao huyt ap, x cng mch, vim gan, thn, Basedow, ng kinh.
Dang thuc - ham lng:
- Dung dch ung 0.1%.
- ng dung dch tim 1 mg / 1 ml.
- Dng vin nn phi hp vi Vitamin B 1 ( Strychnan - B 1 ).
Cch dng, liu lng:
- Ung: 1mg/ln, 3mg/24 gi
- Tim di da: 1 mg / ln, 2mg/24 gi.Trng hp c bit c th tim ti 10
mg/ngay, theo liu tng dn.
* Liu ti a:
- Ung: 6 mg / ln, 18 mg / ngay.
- Tim di da: 2 mg / ln, 10mg / ngay.
Bao quan:
- Nguyn cht: thuc c bng A, tranh anh sang.
- Thanh phm: gim c A, tranh anh sang, tranh va chm.
2.2. NIKETHAMID
BD: Cardiamid*, Coramine*, Eucoran*.
Tnh cht:
- Long, sanh nh du, khng mau hay hi vang, mi c bit, v hi ng km theo
cm giac nng.
- 22 - 24oC d kt tinh thanh khi tan trong nc va Ethanol.

46
 Tc dung
- Kch thch TKTW u tin trn hanh ty, c bit trn trung tm h hp va tun
hoan lam tng hot ng ca cac c quan nay: lam tng nhp tim, tng sc co bp
ca tim, tng nhe huyt ap, lam nhp th nhanh va su do kch thch trung tm h
hp va do kch thch th th ha hc xoang ng mch c.
- Khng c tac dng trc tip trn tim va mch mau.
Ch nh
- Try tim mch, suy tun hoan va h hp do nhiu nguyn nhn: ng c thuc
m, thuc ng, oxyd carbon.
- Ng c thuc m, thuc ng, Morphin, Oxyd carbon, Cyanid.
- Phi hp cha suy tim gia 2 t dng digitalis.
Tc dung phu
Liu cao c th gy cn co git rung do kch thch toan b thn kinh trung ng.
Chng ch nh
Mn cm vi thuc, cao huyt ap, ng kinh, ph n c thai.
Dang thuc
Vin coramin glucose 0,125/1,5g; dung dch 25% dng l 5ml dng ung hoc
ng tim 1ml.
Liu dng
- Dung dch ung 25% X XX git/ln x 2 3 ln/ngay; hoc 4 6 vin/ngay.
- Tim di da, tim bp 1 ng/ln x 1 3 ln/24 gi.
Liu ti a 0,5 g/ln; 1g/24 gi.
Bao quan:
Kn, kh, thoang mat, tranh anh sang, tranh va chm.
2.3. CAFEIN
Tnh cht
- Cafein la mt alkaloid c trong ht Ca ph, la va bp Ch. Tinh th Cafein hinh
kim mt, dnh vao nhau xp nh bng hoc bt kt tinh trng, khng mi, v rt
ng.
- Cafein trong khng kh kh d b vn nat thanh bt va mt nc kt tinh, un
nng s thng hoa.
Tc dung

47
 - Trn vo nao: lam tng qua trinh hng phn vo nao, tng cng nhn cm ca
cac giac quan, tr tu minh mn, gim mt moi, gim bun ng. Nu dng lin tc
va ko dai thi sau giai on hng phn la giai on c ch, mt moi. Vi liu cao
tac dng trn toan b h thn kinh. Liu c gy cn co git.
- Trn h tim mch: vi liu nho lam nhp tim p chm, liu cao lam tng nhp tim
va tng sc co bp c tim, gy dan mch da, tim, nao.
- Trn h hp: kch thch trung tm h hp hanh nao lam tng nhp va bin h
hp.
- Trn thn: lam dan mch thn va c tac dng li niu (km hn Theophylin va
Theobromin do tng lc cu thn, gim tai hp thu ng thn). Tuy nhin tac
dng nay khng mnh s dng trn lm sang.
- Trn d day: tng tit dch v, tng tit acid dch v.
- Trn c trn: lam dan nhiu c trn nh c trn mch mau, rut, phi, c bit la
c trn kh qun.
- Trn c vn: lam tng trng lc va kh nng hot ng ca c vn.
Ch nh
- Mt s trng hp try tim mch, suy cp trung khu h hp, co tht mch nao.
- Mt moi v tm thn va th lc, nhc u.
- Nhim c thuc m gy c ch thn kinh trung ng.
Chng ch nh
Bnh cao huyt ap, chng kh ng hoc mt ng, x cng ng mch.
Dang thuc
ng tim cafein natri benzoat: 0,07g/1ml.
Liu dng
- Tim di da: 1 3 ng/ln, dng 1 3 ln/ngay.
- Khng dng cafein cho bnh nhn cao huyt ap, tn thng tim mch.
2.3. MT S THUC KHAC
LONG NO
Long nao c trong tinh du ca cy Long nao.
Bt kt tinh ca Long nao khng mau, th cht hi do, s mn tay, c th ct c
bng dao, mi mnh c bit, v cay hi ng nhng d chu. Long nao t tan trong

48
nc, d tan trong Ethanol, du bo. Long nao d thng hoa nhit thng, khi un
nng s thng hoa hoan toan, khng b Carbon ha.
Long nao c tac dng kch thch TKTW, c bit trn trung tm h hp va vn
mch. Dng ngoai, Long nao c tac dng gim au, sat trng ngoai da.
Long nao c ch nh cho tr tim va h hp khi b ngt, Phi hp cha suy tim
gia 2 t dng Digitalin.
Du xoa cha Long nao c tac dng gim au, tiu vim.
THEOBROMINE
Theobromine va caffeine la mt loi hp cht nh nhau, ch khac la caffeine c
nhiu nhm methyl hn (mt nguyn t carbon va 3 nguyn t hydro).
Tac dng ngn chn cn ho ko dai hiu qu gp 3 ln so vi codeine
Khng gy ra cac tac dng ph c hi cho tim mch va h thn kinh, chng hn
nh tinh trng u oi, ng l m.

49
 THUC M V THUC TIN M

MUC TIU
Trinh bay c c im tac dng va cac tiu chun ca thuc m.
Nu c cach phn loi va cac tai bin thng gp khi dng thuc m.
Nu c cac tac dng ca thuc tin m.
Trinh bay c tnh cht, tac dng, tac dng ph, ch nh, chng ch nh va
bo qun cac thuc m thng dng.

NI DUNG
1. AI CNG
1.1. NH NGHIA
Thuc m la thuc c ch c hi phc h thn kinh trung ng khi dng liu iu
tr. Thuc m c tac dng lam mt thc, cm giac va phn x ma khng lam xao trn
cac chc nng h hp va tun hoan.
Thuc m c ch thn kinh trung ng theo th t: vo nao, di vo, tu sng lam
mt thc, c ch thn kinh vn ng, nu ngng a thuc thi tac dng c ch s
ht, cac chc nng c hi phc, bnh nhn s tnh dn, nu tip tc a thm thuc
m vao c th s gy lit hanh tu dn n t vong.
1.2. C IM TAC DUNG CA THUC M
Khi thuc m c hp th vao mau s ln lt biu hin tac dng bng cac du
hiu nh an thn, suy gim thc, dan c vn ng, mt dn phn x, v cm tm
thi.
Thi gian gy m thay i ph thuc vao hai yu t: Mc nhy cm ca neuron
thn kinh va liu lng.
Nu dng thuc qua liu thi trung tm h hp va tun hoan b c ch c th dn
n t vong.
1.3. TIU CHUN THUC M LI TNG
o Khi m nhanh, hi phc nhanh.
o D chnh liu.

50
 o C tac dng dan c vn ng.
o Khng nh hng n tun hoan va h hp.
o Khng c, khng gy tac dng ph.
o Khng gy chay n, gia thanh h.
Trn thc t khng c loi thuc m nao ap ng c cac yu cu trn. Do vy
hn ch nhc im ca cac thuc m, ngi ta thng s dng phi hp cac thuc
m hay thuc tin m trong phu thut.
1.4. PHN LOAI THUC M
Cn c ng a thuc vao c th ma thuc m c chia lam hai loi:
1.4.1. Thuc m dng ng h hp
c im
o Thng th long, d bay hi hoc th kh.
o a vao c th qua ng h hp.
o Hp thu nhanh, d s dng, d chnh liu.
o ao thi qua phi, nn khi tai bin xy ra, d loi tr.
Mt s thuc m ng h hp
o Ether etylic, Halothan, Enfluran, Nitrogen protoxid.
1.4.2. Thuc m dng ng chch
c im
o Th rn tan trong nc.
o a vao c th bng ng tim chch thng la tnh mch.
o Tac dng gy m nhanh, thi gian gy m ngn.
o t c tac dng gim au va dan c.
o D gy ngng h hp va kh chnh liu lng thuc.
Mt s thuc m ng chch
o Thiopental, ketamin, fentanyl, etomidat, propofol.
1.5. TAI BIN KHI DNG THUC M
Khi s dng thuc m c th gp cac tai bin tc thi hay chm tr trn h hp, tim
mch, tiu hoa, gan, thn.
o Trn h hp: co tht thanh qun, tng tit dch ng h hp, ngt do ngng
h hp phn x (eter).

51
 o Trn tim mch: Ngt do ngng tim phn x, rung tm tht, h huyt ap, sc.
o Trn tiu hoa: i ma, lam nghn ng h hp.
o Tn thng gan (Halothan), Tn thng thn (Methoxyfluran).
1.6. THUC TIN M
1.6.1. Muc ch
Thuc tin m c dng trc khi gy m nhm mc ch:
o Lam du va lam gim s lo lng ca bnh nhn.
o Phng nga cac tai bin ca thuc m.
o Tng tac dng va gim liu cac thuc gy m, gim tac dng ph.
1.6.2. Cc thuc tin m thng dng
o Thuc an thn: Diazepam, midazolam, droperidon.
o Thuc lit i giao cm: Atropin, scopolamin.
o Thuc gim au: Morphin, fentanyl.
o Thuc dan c: succinylcholin.

2. CAC THUC M THNG DUNG

2.1. THUC M NG H HP
2.1.1. ETHER ETHYLIC
Diethyl ether, Ether m
Tnh cht
Cht long trong sut, linh ng, khng mau, mi c trng, v ngt nng bay hi
nhanh, d bt la. Hn hp hi vi khng kh d n khi ma sat. B oxy hoa di tac
dng ca anh sang, khng kh m to ra peroxyde. Ether tan trong 12 phn nc,
tan torng ethanol, benzen, cloroform, cac du bo va tinh du. Ether la dung mi
hoa tan c nhiu cht nh tinh du, cht bo hc n.
T trng d25oC = 0,713 0,716.
Nhit si = 340 C 350C
Tc dung
Tac dng gy m tng i chm, tac dng hi phc ko dai. Dng ether gy m
c u im la gii hn an toan rng, t nh hng n tim nhng c nhc im d
chay n, nng gy chay n tng ng vi nng gy m nn vic s dng
ether b hn ch.

52
 Tc dung phu
Tng tit dch h hp, kh th.
Bun nn, i ma, gim nhu ng rut thi k hu phu.
Ch nh
Dng gy m cho phu thut nho hay nn xng gay thng phi hp vi
Thiopental Natri, N2O.
Chng ch nh
Phu thut trn 90 pht.
Dng dao in m.
Cch dng liu dng
Dng dng: Cht long ng chai 100ml 150 ml.
Cch dng liu dng: Mi ln gy m dng 60 -150 ml, nu dng phi hp vi
cac thuc m khac thi lng ether c th gim t 1/3 n 1/2.
Bao quan
Nhit mat (< 150C), tranh anh sang, theo doi hn dng.
2.1.2. HALOTHAN
Fluothan, Narcotan.
Tnh cht
Cht long, bay hi, khng mau, mi cloroform, v ngt li cm giac nng,
khng chay, khng n. t tan torng nc, tan trong ethanol, ether, cloroform, ra anh
sang b bin cht dn thanh cac acid bay hi.
Tc dung
Tac dng gy m mnh hn ether khong 4 ln, tac dng gim au va an thn km.
So vi thuc m khac Halothan c u im la khng gy chay n, khng gy kch
ng, tac dng m du va tnh nhanh (< 1 gi).
Tc dung phu
Lon nhp tim thoang qua, h huyt ap.
Vim gan hoi t thng gp ngi ln tui hay s dng lp li.
Dan t cung.
Gim oxy huyt, suy h hp..
Ch nh

53
 Gy m trong phu thut, cn phi hp vi thuc gim au, thuc dan c. Nn phi
hp vi thuc tin m nh atropin.
Chng ch nh
Gy m trong sn khoa (cn thit gim liu).
Tin s st hay vang da khng ro nguyn nhn.
Suy tim, gan, thn.
H huyt ap.
Lp li Halothan di 3 thang.
Cch dng Liu dng
Dng dng: Cht long ng l 125 250 ml.
Cch dng Liu dng:
Khi m:
Ngi ln: dng hn hp vi N2O va Oxy, nng 2 3%.
Tr em: dng hn hp vi N2O va Oxy, nng 1,5 2%.
Duy tri: Gy m cho ngi ln va tr em liu 0,5 1%.
Bao quan
Nhit di 250C va tranh anh sang.
2.1.3. ENFLURAN
Ethrane
Tnh cht
Cht long bay hi, linh ng, khng chay n, kh tan trong nc, tan trong ethanol,
eter.
Tc dung
Gy m mnh, dan c tt, t gy lon nhp tim, bun nn, i ma
Tc dung phu
Liu cao gy suy tun hoan va h hp.
ng kinh (c bit khi gim CO2 huyt).
Dan c trn t cung.
Ch nh
Thay th Halothan khi khng mun dng lp li thuc nay, hin nay enfluran c
s dng rt ph bin.
Cch dng Liu dng

54
 Khi m: Dng chung vi O2 hay hn hp O2 va N2O, bt u vi nng 0,5%.
Sau tng dn ln mi ln 0,5% mi hai hay ba nhp th cho ti khi t nng
ti a 4%.
Duy tr m: 0,5 2%.
Tnh gic: Khi chm dt gii phu a v nng 0,5%. Sau ngng khi bt u
ng da.
Bao quan
Ni mat va tranh anh sang.
2.1.4 NITROGEN OXYD (N2O)
Nitrogen protoxyd
Tnh cht
Cht kh, khng mau, khng mi, khng chay n, tan nhiu trpng lipid, ethanol,
ether, t tan trong nc, d b phn hu nhit cao. N 2O c gi la kh ci vi
to cm giac d chu, nhe nhang va hng phn trong giai on kch thch.
Tc dung
Tac dng gy m yu, khng gy dan c. Nng gy m hoan toan la 90% khng
kh ht vao, a n tinh trng gy thiu oxygen gy chng thanh bi nn N 2O thch
hp cho phu thut ngn.
Tc dung phu
Bun nn, i ma hu phu.
Thanh bi.
Ch nh
Mun gy m hoan toan phi phi hp vi thuc m khac nh Halothan, isofluran,
ether, thiopental Na
Dng mt minh gim au va trong giai on u ca chuyn d.
Cch dng Liu dng
Nng gy m 40% O2 + 50% N2O, N2O c ao thi nhanh sau 1 2 pht khi
ngng s dng.
Bao quan
ng trong binh thp sn xanh, bo qun nhit mat.
2.2. THUC M DNG NG CHICH
2.2.1. THIOPENTAL NATRI

55
Pentotal, Thiopenton Natri, Nesdonal
Tnh cht
Bt kt tinh mau trng hoc mau vang nht anh xanh, ht nc mnh, c mi kh
chu. Thiopental Natri tan trong nc, ethanol, khng tan torng dung mi hu c.
Dung dch trong nc c pH kim, lu b phn hu va kt ta. Kh CO 2 cung
lam kt ta dung dch, do vy ch pha khi dng.
Tc dung
Tac dng nhanh (1 pht), thi gian tac dng ngn, hi tnh 20 30 pht sau mt
liu tim tnh mch. Do lam gim chuyn hoa va s dng oxygen nao nn khng
lam tng ap sut hp s, hay dng cho bnh nhn ph nao.
Tc dung phu
Suy h hp, co tht thanh ph qun.
Suy tim, lon nhp tim, h huyt ap.
Bun ng ko dai.
Ch nh
Dng mt minh trong phu thut ngn hn.
Khi m hu khi phat tac dng nhanh, sau mi dng n thuc m khac ko
dai tac dng.
Chng ch nh
Mn cm
Ri lon chuyn hoa porphyrin (mt myelin si thn kinh s va ngoi bin gy
e do tnh mng).
Hen ph qun.
Tr di 7 tui va ngi gia > 60 tui.
Cch dng Liu dng
Dng dng: Thuc tim bt 0,5 g hoc 1 g Thiopental natri vi 30 mg
natrihydrocarbonat khan km 1 ng nc ct pha tim.
Cch dng liu dng:
Ngi ln
Khi m: 3 5 mg/kg
Duy tri m: tim liu tng dn co n tng liu 0,75 mg 1 g (gy m 40 60
pht).

56
 Tr em:
4 5 mg/kg, tng liu 0,1 0,5 g.
Bao quan
Tranh anh sang.
2.2.2. KETAMINE
Ketalar, Ketalest
Tnh cht
Tinh th kt tinh trong pentan ether, tan trong nc.
Tc dung
Tac dng gy m nhanh gim au mnh (ko dai 40 pht).
Tc dung phu
Mt nh hng, o giac, c gic m mnh m, c th khc phc bng thuc tin
m diazepam.
Tng nhp tim, tng huyt ap (xy ra giai on u khi m).
Tng lu lng nao va tng ap sut ni s (dng chung diazepam, midazolam s
gim tac dng nay)..
i ma, m hi, ban o da, run ry.
Suy h hap tm thi nht la khi chch tnh mch nhanh va liu cao.
Ch nh
Gy m: Cac phu thut ngn, cac phu thut sn khoa, bnh nhn b sc (do lam
tng huyt ap va kch thch tim), cac phu thut cp cu.
Gim au: thay bng vt bong cho tr em.
Chng ch nh
Mn cm
Suy tim nng, cao huyt ap.
Tin s tai bin mch mau nao.
Cch dng Liu dng
Dng dng: ng chai 500mg/100ml.
Liu dng:
Khi m: tim tnh mch 1 4,5 mg/kg/60 hoc tim bp 6,5 13 mg/kg.
Duy tri m: liu khi m va nhc li khi cn.

57
 Nu dng ng tim truyn tnh mch thi hoa tan 500 mg ketamin trong 500 ml
dung dch tim truyn NaCl hay glucose ng trng:
Khi m: Truyn 2 5 mg/kg hoc 120 150 git/pht.
Duy tri m: Tu thuc vao tng bnh nhn.
Bao quan
Tranh anh sang.
2.2.3. PROPOFOL
Diprivan
Tc dung
Gy m tng t thiopental nhng hi tnh nhanh hn, c cm giac tt hn sau
phu thut so vi cac thuc m ng tnh mch khac.
Tc dung phu
Suy h hp.
Gim huyt ap (do gim sc cn ngoi bin).
Ch nh
Dng mt minh gy m trong phu thut ngn thch hp i vi bnh nhn khng
cn nm vin.
Phi hp thuc m ng h hp trong phu thut ko dai.
Cch dng Liu dng
Khi m 1,5 3 mg/kg tnh mch.
Bao quan
Tranh anh sang.

58
 THUC T

MUC TIU
Trinh bay c c ch tac dng, tiu chun, phn loi va c tnh ca thuc t.
Trinh bay c tnh cht, tac dng, tac dng ph, ch nh, chng ch nh, liu
dng va bo qun cac thuc t thng dng.

NI DUNG
1. AI CNG
1.1. NH NGHIA
Thuc t la thuc c ch chuyn bit va tm thi lung xung ng thn kinh t
ngoi bin ln trung ng lam tm mt cm giac, c bit la cm giac au ni thuc
tip xc.
1.2. C CH TAC DUNG
Thuc t c ch knh Na+ trn mang t bao nn ngn chn s kh cc, vi vy lung
thn kinh khng th dn truyn.
1.3. TIU CHUN CA MT THUC T LY TNG
o liu iu tr c tnh hoan toan thp.
o Khi u tac dng phi nhanh, thi gian tac dng dai.
o Tan trong nc va n nh trong dung dch.
o Khng b phn hu bi nhit trong lc tit trng.
o Phi c hiu lc khi tim chch hoc khi t trn nim mc.
o Tac ng gy t phi hi phc hoan toan.
1.4. PHN LOAI THUC T

59
C nhiu cach phn loi, nhng thng da vao cach dng ca thuc t phn
loi:
Gy t b mt: t thuc t trn nim mc, vt phong, vt thng gim au,
nga.
Gy t tim thm: Tim thuc trc tip vao ni cn gy t.
Gy t dn truyn: La tim thuc gn thn nron, to thanh mt vng t xung
quanh khu vc au.
Gy t tuy sng: Thuc t c tim vao im ngoai mang cng hay vao khoang
di mang nhn phong b cac r thn kinh ca ty sng.
1.4.1. Thuc gy t theo ng tim: Procain, Tetracain, Lidocain, Mepivacain.
Thi gian tac ng ca thuc t ph thuc vao thi gian duy tri s tip xc ca
thuc vi thn kinh khu vc gy t. ko dai thi gian gy t phi phi hp vi
cac thuc co mch (adrenalin, nor adrenaline 1/200000 hoc 5 microgam/ml
mau). Khng nn chch thuc t c cha cht co mch vao trong da, m, u chi,
u dng vt vi s co mch c th gy hoi t vng .
1.4.2. Thuc gy t b mt: Cocain, benzocain, ethyl cloride.
c im:
o Thuc c c tnh cao, kh thm nhp vao cac t chc va phn ln khng tan
trong nc. (Mt s thuc t tan trong nc nhng cung c dng gy t b
mt nh Lidocain, Tetracain).
o Tac dng gy t khng su nhng ko dai.
o K thut gy t la phun hoc bi trn da, nim mc bng cac dng bao ch thch
hp nh thuc m, gel, thuc phun (spray).
2. CAC THUC GY T THNG DUNG
2.1. PROCAIN
Novocain, Syncain
Tnh cht
Tinh th khng mau hoc bt kt tinh trng, khng mi, v hi ng sau gy cm
giac t li. D tan trong nc, tan trong ethanol, kh tan trong cloroform, khng
tan trong ether.
Tc dung

60
Tac dng gy t: Do hp th chm qua nim mc nn gy t b mt rt yu, hp thu
d dang khi dng ng tim chch.
Tac dng trn tim: Chng rung tim do lam n nh mang t bao, nhng b thu
phn rt nhanh trong c th nn s dng dng amid la procainamid tr rung tim.
Tc dung phu
D ng (c bit la sc phn v c th t vong nn hin nay gii hn s dng).
Khang Sulfamide
Liu c gy run ry, co git, suy nhc h thn kinh trung ng.
Ch nh
Gy t: Gim au khi b bong gn, sai khp, chn thng.
Chng lao suy: procain HCl 2% ngn chn qua trinh lao hoa va tng kh nng dinh
dng c th ngi gia.
Lam chm hp thu penicilline.
Chng ch nh
Mn cm.
Phi hp vi sulfamide khang khun.
Cch dng liu dng
Gy t tim thm: dng dung dch 0,25 5%.
Gy t dn truyn: dng dung dch 0,5 2%.
Gy t tu sng: dng dung dch 5 10%.
Khng dng gy t b mt.
Liu dng tu tng trng hp.
Bao quan
Dung dch procain 4% bo qun c B, tranh anh sang, tranh m.
Dung dch procain < 4% bo qun gim c B.
2.2. LIDOCAIN
Solcain, Xylocain
Tnh cht
Bt kt tinh trng, khng mi, v ng nhe, nng chy 79 0C, d tan trong nc,
tan trong cloroform, ethanol, khng tan trong ether.
Dc ng hc

61
Hp thu: Lidocain hp thu km khi ung, hp thu tt khi bi trn da, nim mc nn
c tac dng gy t b mt. Mc hp thu ph thuc vao liu lng ca thuc va
mc phn b quanh mch mau ni tim.
Thuc qua c hang rao nhau thai va mang nao. Hp thu tng i nhanh qua
ng tim chch. Khi c phi hp vi adrenaline, hiu lc t ko dai gp 2 3
ln.
Tc dung
Lidocain c tac dng nhanh, mnh va ko dai hn procain. La thuc t b mt dn
truyn tt, rt thng dng hin nay. Thuc cn c tac dng chng lon nhp khi
tim tnh mch.
Tc dung phu
Liu cao gy chng mt, bun ng, d cm, hn m, co git.
Qua liu cht do rung tm tht hoc ngng tim.
Ch nh
Gy t tim thm, gy t b mt, gy t ngoai mang cng.
Chng lon nhp.
Chng ch nh
Mn cm
Cao huyt ap, block nh tht.
Nhim khun nng, tr em di 30 thang tui.
Cch dng Liu dng
Gy t tim thm: dung dch 0,5 1%.
Gy t vng va ngoai mang cng: dung dch 1,5%.
Gy t b mt: dng xt (spray) 1 1,5%.
Chng lon nhp: Tim tnh mch 1 1,5 mg/kg, 5 pht sau dng thm liu th hai
bng liu trn.
Bao quan
Tranh anh sang, chng m.
2.3. ETHYLCLORIDE
Monocloroethane - kelene
Tnh cht

62
Cht kh trn 120C, di 120C va ap sut nn thch hp ch phm tr thanh cht
long, khng mau, linh ng, c mi ging ether, v bong, d bay hi. Nhit si
12 130C, t tan trong nc, tan nhiu trong ethanol, ether. Khi chay ch phm cho
ngn la hi xanh, toa khi. Th hi ethyl cloride d chay, to hn hp n vi
khng kh.
Tc dung
C tac dng gy m nhng khng dng vi d chay n, thng dng gy t b
mt do bay hi nhanh, khi bi trn da s lam b mt da gim nhit nhanh nn
mt cm giac au.
Ch nh
Gy t ni b chn thng gim au, gy t trong tiu phu (chch nht), gim
au khi b au dy thn kinh hay au tht ngc.
Cch dng Liu dng
Phun trc tip ln b mt da cn gy t, di dng long ng l 20 ml.
Bao quan
L 20 ml c khoa, bo qun nhit mat, tranh anh sang.
S lng ln bo qun trong kho chay n, c bin cm la.

63
 THUC CHNG D NG TNG HP
(THUC KHANG HISTAMIN H1)

MUC TIU HOC TP

Trinh bay c khai nim c bn v d ng.
Trinh bay c c ch tac dng, cach phn loi cac thuc chng d ng tng
hp.
Trinh bay c tnh cht, tac dng, ch nh, chng ch nh, nguyn tc s
dng cac thuc chng d ng tng hp.
NI DUNG
1. AI CNG
1.1 KHAI NIM PHN NG D NG
D ng la trng thai phn ng khac thng ca c th khi tip xc vi mt d
nguyn (khang nguyn) ln th hai va cac ln sau. D ng din tin theo 3 giai on:
Giai on 1: la giai on mn cm k t khi d nguyn xm nhp vao c th. D
nguyn s kch thch c th tng hp khang th IgE, cac khang th IgE n gn trn t
bao mastocyte nh cac receptor c hiu.
Giai on 2: la giai on sinh hoa bnh, khi d nguyn ln th hai xm nhp vao c
th, d nguyn nay s kt hp vi khang th IgE a gn sn trn mang t bao
mastocyte. S kt hp nay lam t bao masotcyte v ra va gii phng cac cht trung
gian hoa hc nh: histamin, serotonin, leucotrien, bradykinin, cht phn ng chm ca
phn v SRSA (Slow reacting substance of anaphylaxis).

64
 Giai on 3: Giai on sinh l bnh, cac cht trung gian hoa hc trn n cac c
quan ch nh ph qun, da, tim mch, mui hnggy nn bnh cnh lm sang ca d
ng: hen suyn, s mui, nga, m ay, ph quincke, sc phn v.
Cht trung gian hoa hc quan trng ca phn ng d ng la Histamin.
D nguyn c th la thc n, cy co, m phm, ha cht, thucD ng c th xy
ra nhe, nhanh khoi nn d b bo qua, nhng cung c khi d di dn n t vong.
1.2 HISTAMIN V VAI TR SINH BNH
Histamin la mt trong nhng cht sinh hc trung gian gi vai tr quan trng trong
sc phn v va phn ng d ng. Ni tch tr chnh histamin trong cac m la t bao
mastocyte, trong mau la bch cu a kim. Nh vy histamin c nhiu trong cac m
cha nhiu mastocyte nh: da, nim mc ph qun, nim mc rut.
Khi b d ng hoc c tac ng ca cac yu t khac nh: lnh, tn thng t bao,
hoa cht thi cac t bao cha histamin b kch thch gii phng ra histamin dng t
do. Chnh histamin dng t do gn vao th th histamin (H1) gy triu chng d ng.
Th th phn ng vi histamin gm hai loi: th th H2 nm thanh d day, th
th H1 nm thanh mch mau (nht la cac mch mau nho) va c trn kh ph qun,
rut, t cungTrn th th H1, histamin gy dan c trn mch mau nht la cac mch
mau nho, lam tng tnh thm mao mch gy thoat dch, ph n, sung huyt; gy co tht
c trn ca kh ph qun, ca ng tiu ha, c trn ng tit niu. Ngoai ra histamin
cn c tac dng trn cac tuyn lam tng tit nc bt, nc mt, dch v, dch ty
1.3 THUC KHANG HISTAMIN H1 (THUC CHNG D NG TNG HP)
1.3.1. nh ngha:
Cac thuc c tac dng chng li tac ng ca histamin trn th th H1 gi la thuc
khang histamin H1 hoc thuc chng d ng tng hp, cac thuc nay u c tac dng
chng li nhng biu hin lm sang do d ng gy ra.
1.3.2. C ch:
Thuc khang histamin H1 i khang cnh tranh vi histamin ti th th H1 y
histamin ra khoi th th va phat huy tac dng chng li tac ng gy d ng ca
histamin. Trng hp lng histamin sinh ra qua nhiu so vi thuc, thi thuc s b
y ra khoi th th, khi thuc s khng phat huy c tac dng. Nh vy cac thuc
chng d ng tng hp ch c tac dng cha triu chng, khng cha c nguyn

65
nhn gy bnh. Vi vy mun cha d ng c hiu qu phi dng thuc khang histamin
sm va duy tri tng i dai ngay phi hp vi loi bo nguyn nhn gy d ng.
1.3.3. Cu trc:
a s cac thuc chng d ng u c cng thc tng t nhau, gn ging dng cu
to ca Histamin. Cng thc chung c biu din nh sau:

Trong cng thc trn phn ethylamino la rt quan trng, tt c cac thuc chng d
ng u c cha phn nay.
X = C, O, lin kt C O hoc khng c.
R la gc hydrocarbon thm hay d vng. R1 va R2 la cac gc th alkyl.
1.3.4. Ch nh chung ca thuc khng histamin tng hp
Chng d ng (ch thun tu cha triu chng): vim mui d ng, d ng da, nga
do cn trng cn.
Chng nn, chng say tau xe (cinnarizine, dimehydrinat, promethazine,
diphenhydramin).
Chng ho, phi hp vi thuc ho lam tng tac dng chng ho (promethazine,
alimemazine, oxomemazine)
Hi chng au na u (cinnarizine).
Lam thuc tin m (promethazine, cyclizin).
Phi hp vi thuc gim au, thuc ng, thuc gy t (vi chng lam tng tac dng
ca nhng thuc nay).
1.3.5. Tc dng khng mong mun
Ch yu gp nhm thuc khang H1 c in.
c ch thn kinh: an thn, gy ng, gim phn x, mt.
Tac dng khang tit cholinergic: kh ming, tao bn, ri lon iu tit mt, kh
tiu tin.
Lam tng tac dng ca ru va cac thuc c ch thn kinh trung ng.
Gy h huyt ap th ng. Mn cm vi thuc.
1.3.6. Chng ch nh
Ngi mang thai, thi ki cho con b.
U x tin lit tuyn.

66
 Nhc c, tng nhan ap.
1.3.7. Nguyn tc s dng thuc chng d ng
m bo hiu qu trong iu tr va tranh cac tai bin khi dng thuc chng d
ng cn tun th theo cac nguyn tc sau:
Dng thuc sm.
Khng c nhai.
Khng tim di da, hn ch tim tnh mch, nu cn tim bp su.
Thuc km theo tac dng h huyt ap nn cn nm ngh sau khi ung
(promethazine).
Mt s thuc gy bun ng khng nn dng khi cn s tp trung va ch (vn
hanh may, lai tau xe).
Trong iu tr cn phi hp vi loi bo nguyn nhn gy ra d ng, khng nn da
hoan toan vao thuc.
2. CAC THUC CHNG D NG THNG DUNG
Theo thi gian thuc ra i va li im, thuc c chia lam ba th h:
Th h 1: Clorpheniramin, Alimemazin, Oxomemazin, Dexclorpheniramin,
Diphenhydramin, Dimenhydrinat, Hydroxyzin, Promethazin, Doxylamin,
Cyclyzin, Cinnarizin(cn gi la cac thuc khang histamin c in). Thuc thuc
th h 1 c hai bt li la thi gian tac dng ngn va c tac dng ph trn h thn
kinh trung ng (gy an thn, bun ng)

Promethazin (Pipolphen, Diprazin, Phenergan)

Tc dng: Chng d ng mnh, gim au, gy ng.
Ch nh: Cha d ng do mi nguyn nhn vi ca biu hin nh: ni m ay, mn
nga, ph n, ho, phn ng do dng thucThuc cn c dng cho trng hp:
tm thn ri lon, mt ng va lam thuc tin m trong ngoi khoa.
Chng ch nh: Ngi ang iu khin may mc, phng tin giao thng, ang
dng IMAO.
Thn trng: Khng dng thuc qua ng tim di da.
Khi dng thuc nn nm ngh (nht la sau khi tim) vi lam h huyt ap.
Tc dng ph: Kh ming, tao bn, chng mt, nn nao, bun ng, ng ga ban
ngay, khi tim gy h huyt ap th ng.

67
Cch dng, liu lng:
Ung, tim bp su, tim tnh mch chm.
Ngi ln:
Ung 0.025 g/ln; 1-3 ln/24h.
Tim bp 0.025 0.05 g/ln; 1 2 ln/24h.
Tim tnh mch (ch ap dng trong ngoi khoa): 0.025g
Tr em: ty theo la tui c th dng t 0.025 g 0.05 g/24h.
Dng thuc: Vin bao 0.015g; 0.025g, ng tim: 0.05g/2ml, siro 1%o.

Diphenhydramin (Nautamine, Benadryl, Allergan)

Tc dng: chng d ng (km promethazine), chng co tht, an thn va gy ng.
Ch nh: d ng do mi nguyn nhn, say tau xe, say sng, nn ma khi c thai,
mt ng, hi chng Parkinson.
Chng ch nh: Tim di da, ngi ang iu khin may mc, phng tin giao
thng, ang dng IMAO.
Tc dng khng mong mun: kh ming, chng mt, bun ng, ng ga ban ngay,
h huyt ap th ng nhng khi ngng thuc s ht.
Cch dng, liu lng:
Ung, tim bp, tim truyn nho git tnh mch.
Liu lng:
Ung 25 50mg/ln; 1 3 ln/ngay.
Tim bp: 0.01 0.02g/ln; 1-2 ln/24h.
Tim truyn nho git tnh mch: 20mg 50mg (ha tan trong dung dch NaCl
9o)
Dng thuc: vin nn, nang 10mg, 25mg; ng tim 10mg/ml; cn nho git
12,5mg/5ml.

Chlorpheniramin (Clortrimeton, Clorphenamin, Allergy)

Tc dng: chng d ng mnh hn promethazin, gy ng.
Ch nh: D ng do mi nguyn nhn: s mui, ngt mui do co tht, ph Quincke,
vim kt mc do d ng, m ay.

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 Chng ch nh: Ngi ang iu khin may mc, phng tin giao thng, ang
dng IMAO.
Tc dng ph: Bun ng, nng u, ng ga, kh ming, chng mt, tao bn.
Cch dng, liu lng:
Ngi ln:
Ung 4 16 mg/ngay; chia lam 3 4 ln..
Tim bp 10 20mg/ln, tim 1- 2 ln trong ngay.
Tr em:
Ung 0.3mg/kg th trng/ngay chia lam 3 4 ln.
Dng thuc: Vin nn 2mg, 4mg, 6mg; siro 0.5mg/5ml. ng tim 1ml c cha
5mg, 10mg.

Th h 2: Loratadin, Certirizin, Acrivastin.

Astemizol va Terfenadin gy lon nhp nn hin nay khng s dng.
Th h mi nay khc phc c 2 bt li ca th h 1. Nh c cu trc thn nc
nn khng xm nhp qua c h thn kinh trung ng va thi gian tac dng dai
nn ch cn dng mt ln trong ngay.

Certirizine (Zyrtec)
Ch nh: Vim mui d ng theo ma, vim mui d ng quanh nm & m ay t
phat mn tnh nh ht hi, s mui, xut tit vng mui sau, o mt & chy nc
mt, nga & phat ban.
Tc dng ph: Nhc u, bun ng, mt moi, kh ming, chng mt, bun nn.
Chng ch nh: Mn cm
Dng thuc:
Vin nn d b 10 mg.
Dung dch ung 1 mg/1 ml : l 75 ml.
Dung dch ung 10 mg/1 ml : l 10 ml.
Liu dng:
Ngi ln va tr em trn 12 tui: 10 mg/ngay ung mt ln duy nht.
Dng dung dch ung:
< 6 tui : 5 mg mi ngay.

69
 6-12 tui : 10 mg mi ngay.

Loratadine (Claritin)
Ch nh:
Vim mui d ng nh : Ht hi, s mui va nga.
Vim kt mc d ng nh : Nga mt va nng mt.
Triu chng ca m ay va cac ri lon d ng da.
Tc dng ph: mt moi, nhc u, bun ng, kh ming, ri lon tiu ha.
Chng ch nh: Qua mn vi thanh phn thuc. Tr < 6 tui.
Dng thuc - Liu dng:
Vin nn 10mg.
Ngi ln va tr em > 12 tui: 10mg/ln/24h.

Th h 3: Fexofenadine, Desloratadin, Levocertirizin, Tecasmizol.

Th h nay gm nhng thuc la ng dng hoc la cht chuyn hoa ca cac thuc
thuc th h 2. Cac thuc nay khng gy tac dng ph trn h thn kinh (so vi th
h 1), trn tim mch (so vi th h 2), thi gian tac dng ko dai, c tnh khang
vim nhe nn tr vim mui d ng kha tt.

Fexofenadine (Telfast)
Ch nh: Cha triu chng do vim mui d ng, d ng ngoai da, m ay.
Dng thuc - Liu dng:
Vin nn 60, 120mg.
Ngi ln va tr em > 12 tui: 60mg x 2 ln/ngay. Khng dng tr em < 12 tui.
Tc dng ph: Dung np tt c th gp nhc u, bun nn, l , kh tiu, mt
moi.
Thn trng: C thai va cho con b, tr di 12 tui.

Levocetirizine (Xyzal)
Ch nh:
iu tr cac trng hp d ng: vim mui d ng theo ma, vim mui d ng mn
tnh, ht hi, chy nc mui, nga mui, chy nc mt, mt o, may ay mn tnh.
70
 Chng ch nh:
Qua mn vi thanh phn thuc hoc dn xut piperazine, Suy thn nng c ClCr <
10 mL/pht.
Tc dng ph:
Kh ming, au u, vim mui, vim hu hng, mt ng, au bng, nhc na u.
Dng thuc Liu dng:
Vin nn 5mg. Ngi ln & tr > 6 tui: 5 mg/ngay.

THUC CHA HO V HEN PH QUN

MUC TIU HOC TP

Trinh bay s lc c im ca cac bnh ho, hen.
Phn loi c cac thuc iu tr ho, hen theo c ch tac dng.
Trinh bay c tnh cht, tac dng, ch nh, tac dng ph, chng ch nh, cach
dng cac thuc cha ho, hen thng dng.

NI DUNG BI HOC
1. THUC TR HO LONG M
1.1. AI CNG
Ho la phn x t v sinh l quan trng ca c th nhm tng ra ngoai d vt, cac
cht nhy, am dai do nim mc ng h hp tit ra.
Ho la mt trong nhng triu chng ca mt s bnh vim nhim ng h hp nh
nhim lnh, vim hng, vim ph qun, vim phi; mt s trng hp la do hi lu d
day thc qun hoc do thuc tr liu
Ho nhiu s gy tn thng cac mao qun, mt ng, mt moi va c th gy kh
th. Trong trng hp cn dng thuc lam gim cac cn ho hay cac thuc gip tng
xut am dai ra ngoai mt cach d dang. Cac thuc cha ho ch c tac dng cha triu
71
chng nh gim ho, long am, sat trng ng h hp nn cn phi phi hp vi
thuc cha nguyn nhn.
C ch ca mt phn x ho bao gm 3 thanh phn:
Dy thn kinh dn truyn kch thch ho vi cac th th ho phn b t thanh
qun cho n ph qun, mang dn truyn n trung tm ho.
Trung tm ho.
Dy thn kinh vn ng i dn cac c lin sn va c hoanh.
C hai dng ho: Ho khan va ho c am.
1.2. PHN LOAI CAC THUC TR HO LONG M
1.2.1. Thuc giam ho ngoai bin
Thuc lam gim s nhy cm ca cac th th ho ngoi bin.
EUCALYPTUS (Eucalyptin: vin nang mm, siro)
Tinh cht: Thanh phn chnh la eucalyptol (cineol) c tnh gim ho nhe va sat
trng, thng phi hp vi codein tng hiu qu tr ho (Eucalyptin).
Ch inh: Ho do kch ng, ho khan.
Chng ch inh: Suy h hp, hen suyn.
Liu dng:
Trn 15 tui dng 2 3 vin nang mm/ngay vi dng siro dng 3 4 mung,
5ml/mung, 4 ln mi ngay.
Tr em t 5 tui tr ln ch ung t 1/2 mung cho n 1 mung, 3 4 ln/ngay.
Mt s thuc khac: Benzonatat, bc ha (menthol), lidocain, bupivacain gy t cac
thn kinh gy phn x ho.
1.2.2. Thuc giam ho trung ng
Thuc c ch trc tip trung tm ho hanh ty.
CODEIN (Neo codion, Terpin Gonnon, Acopin)
Tinh cht: Tinh th khng mau, hoc bt kt tinh mau trng, khng mi, d tan
trong cloroform va ethanol 96%. Kh tan trong nc. Tan trong nc si va ether.
Tc dung: Lam gim ho do c ch trung tm ho, lam m c kh tng xut m.
Ch inh : Ho khan gy mt ng, cac chng au nhe va va.
Tc dung khng mong mun: tao bn, bun ng, hoa mt, lam am c kh tng ra
ngoai, dng lu dai c th gy dung np va l thuc thuc.

72
 Chng ch inh : Mn cm, hen suyn, suy h hp, bnh gan, tr em di 5 tui,
ph n c thai va cho con b.
Liu dng:
Ngi ln : 10 50 mg chia 3 ln/ngay.
Tr em t 5 tui: 5 15 mg/ngay.
DEXTROMETHORPHAN (Thorphan, Atussin, Decolsin)
Tinh cht: Bt kt tinh gn nh trng, d tan trong ethanol 96%, hi tan trong
nc, khng tan trong ether.
Tc dung: c ch trung tm ho tng t codein, t phn ng ph va t trm trng
nh codein, gy bun ng nhe, khng gy nghin thuc, t gy tao bn so vi
codein.
Ch inh: Ho khan do cm cm, cm lnh, vim ph qun.
Liu dng:
Ngi ln: 10 30 mg/ngay. Ti a 120mg/ngay.
Tr em 6 12 tui : 5 15 mg/ngay. Ti a 60mg/ngay.
PHOLCODIN (Biocalyptol, Hexapneumin)
Tc dung: Nh codein nhng t gy suy h hp hn, khng c tac dng gim au,
khng gy nghin.
Ch inh: Cac cn ho do kch ng, ho khan.
Liu dng:
Ngi ln: 60 120 mg/ngay.
Tr em t 5 45 mg/ngay ty tui.
CAC THUC KHANG HISTAMIN H1 CHNG HO
Alimemazin (Theralene, Allerlene), Oxomemazin (Toplexil), Promethazine
(Rhinathiol Promethazine, Pilpolphen), Diphenhydramin (Benadryl, Nautamin)
1.2.3. Thuc long am tiu am
a) Thuc long am
La nhng thuc lam tng long (tng thanh phn nc) ca dch tit nim mc
ng h hp do gip cho vic loi tr am d dang hn va gim cac kch thch ho.
Cac thuc c tac dng long am: Guaicol, guaifenesin, natri benzoat, terpin
hydrate, amoni acetat Thng dng dng ung va phi hp vi cac thuc ho. Tuy
nhin hiu qu ca thuc nay khng cao.

73
b) Thuc tiu am
La thuc lam gim sanh ca dch tit ng h hp bng cach ct t cac lin
kt gia cac phn t glycoprotein (thanh phn chnh ca am) lam cho dch nhy loang
ra.
Thuc c s dng trong cac trng hp vim ph qun phi, vim kh ph
qun cp va man tnh.
Thn trng tac dng ph: Bnh nhn c tin s lot d day ta trang, tin s hen,
ph n c thai, cho con b. S dng liu cao c th gy au d day, bun nn, tiu
chy, d ng trn da.
Ch phm liu dng:
Ambroxol (Muxol, Mucosolvan): Ngi ln: 60 90 mg/ngay. Tr em: 15 45
mg/ngay.
Bromhexin (Bisolvon): Ngi ln: 8mg x 3 ln/ngay. Tr em: 4 8 mg/ngay.
Acetylcystein (Mucomyst, Acemuc, Exomuc): dng ung 200 mg x 3 ln/ngay. Cn
dng lam thuc gii c khi qua liu paracetamol.
2. THUC IU TR HEN PH QUN
2.1. AI CNG
Hen ph qun v mt lm sang c nh ngha la hi chng tt nghn ng h
hp c tnh thun nghch va tai din. Cn hen c c trng bi cac triu chng nh
kh th, kh kh, mt nhc km theo ri lon xut tit am dai. Cac triu chng nay
c th ko dai t 5 10 pht, c khi hang gi hay c ngay khng dt. Sau cac cn
kh th s gim dn va ht hn, bnh nhn c th tr li trng thai binh thng.
V mt sinh l bnh c th xem hen suyn la mt bnh vim mn tnh ng h
hp c s hot ha cac t bao bch cu, i thc bao, dng bao, lympho baolam
gii phng ra cac cht trung gian ha hc (histamin, leucotrien, prostaglandin,
protease, cytokin, PAF) tham gia vao phn ng vim va co tht ph qun, trong
c vai tr quan trng ca leucotrien trong bnh chng hen.
Cn hen c th do d ng (bi, phn hoa, lng vu, thc phm) hoc khng do d
ng (nhim khun, ri lon ni tit, gng sc, dng thuc khang vim NSAID).
2.2. THUC TR LIU HEN PH QUN
2.2.1. Nguyn tc
Da vao hai nguyn tc chnh

74
 Tr liu khang vim
Tr liu bng cac thuc lam dan ph qun
2.2.2. Thuc dn ph quan
SALBUTAMOL (Sultamol, Volmax, Ventoline)
Tinh cht: Salbutamol sulfat la cht bt kt tinh mau trng, v hi ng, tan t trong
nc, tan trong ethanol, kh tan trong ether.
Tc dung:
Lam dan ph qun, tac dng nhanh (sau 3 5 pht), ngn hn (thi gian tac dng 4
6 gi).
Dng kh dung c ch gii phng histamin va leucotrien khoi dng bao phi,
tng kh nng chng vim ca corticoid kh dung.
Ch inh:
Ct cn hen cp tnh, tt nghn ng h hp, vim ph qun.
Tc dung phu:
Dng ung va tim c th gy tim p nhanh, run ry, au u, hi hp, gim kali
huyt, tng glucose huyt, lon nhp tim.
Dng nhiu ln s c hin tng quen thuc, bnh nhn c xu hng phi tng
liu.
Chng ch inh:
Cng tuyn giap, bnh tim mch, tng huyt ap, lon nhp tim, ai thao
ng, ang iu tr bng MAOI.
Liu dng:
Cn hen cp: Ht nh liu mi ln 100 - 200 g (1- 2 xt), ti a 3 - 4 ln/ ngay.
Hoc: tim bp hoc tim di da mi ln 500 g, nhc li sau mi 4 gi nu cn.
Cn hen cp nghim trng: Dung dch kh dung 2,5 5 mg, ti a 4 ln/ ngay hoc
tim tnh mch chm 250 g, dng nhc li nu cn.
phng cn hen do gng sc: ht 100 - 200 g (1- 2 xt) truc khi vn ng 15
30 pht, hoc ung 2 - 4 mg trc khi vn ng 2 gi.
Salmeterol, formoterol tac dng chm, ko dai c hiu qu lam dan ph qun sau
30 pht va ko dai 12 gi, c dng trong iu tr d phng cn hen m.
THEOPHYLINE (Theostat, Nuelin SA).

75
 Ch yu dng theophylin gii phng chm iu tr d phng va kim soat hen
v m. Trong cn hen nng, theophylin c dng phi hp vi cac thuc cng 2
hoc corticoid lam tng tac dng gian ph qun.
Tac dng ph: nhp tim nhanh, lon nhp, bn chn, bun nn, nn, au u, mt
ng, run; co git la du hiu xac nh trng thai qua liu.
Chng ch nh: Lot d day - ta trang tin trin, ri lon chuyn ha porphyrin,
ng kinh khng kim soat c.
Liu dng:
Hen mn tnh: Vin theophylin gii phng chm (Theostat, Nuelin SA): mi ln
ung 200 400 mg, cach 12 gi ung 1 ln.
Hen ban m: Aminophylin: Ung 100 300 mg, ngay 3 4 ln, sau ba n. Tim
tnh mch chm vi liu khi u 5 mg/kg trong 20 pht, sau tip tc vi liu 500
700 g/kg/gi.
IPRATROPIUM (Atrovent)
Thng ch c phi hp s dng khi cac thuc SABA (cng 2 tac dng ngn)
khng mnh hoc c tac dng ph nng gim liu SABA. Ipratropium cung c
tac dng tt trong iu tr bnh phi tc nghn mn tnh, vim ph qun man tnh.
Tac dng ph: kh ming, bun nn, tao bn, au u, tng nhan ap.
Thn trng: Tng nhan ap, phi i tuyn tin lit va tc nghn dng chy ra t bang
quang, c thai va cho con b.
Liu dng:
Ht nh liu: mi ln 20 - 40 g (1 - 2 xt), 3-4 ln/ ngay.
Berodual (ipratropium bromid + fenoterol): mi ln xt c 20 g ipratropium va 50
g fenoterol. Liu thng thng 1 - 2 xt/ ln, ngay 3 ln.
2.2.3. Thuc khng vim glucocorticoide
Tac dng chng vim, gim ph n, gim bai tit dch nhy vao lng ph qun va
lam gim cac phn ng d ng, ngn phn ng min dch.
Ch phm:
Dng dang xng ht: Beclometason dipropionat, Budesonid va Fluticason propionat.
Dng ht c tac dng tt iu tr d phng hen khi ngi bnh phi dng cng 2
nhiu hn 3 ln/tun. Tac dng khng mong mun ti ch thng gp khi dng dng
ht la nhim nm Candida ming hng, khn ting va ho.

76
 Beclometason dipropionat (Becotide): kh dung nh liu mi ln 100 - 400 g,
2 ln/ ngay, sau iu chnh theo ap ng ca ngi bnh.
Budesonid (Pulmicort): ht mi ln 200 g, 2 ln/ ngay.
Formoterol va Budesonid (Symbicort) vi cac ham lng formoterol/ budesonid
mi ln xt la 4,5 g/ 80 g; 4,5g/ 160 g; 9g/ 320g. Ngi ln va tr em trn 12
tui: mi ln 1 - 2 nhat xt, ngay 2 ln. iu tr duy tri: 1 ln xt/ ngay.
Fluticason propionat (Flixonase): ht nh liu mi ln 100 - 250 g, 2 ln/ ngay.
Tr em 4 - 16 tui: mi ln 50 - 100 g, 2 ln/ ngay.
Salmeterol va Fluticason propionat (Seretide) vi cac ham lng
salmeterol/fluticason propionat mi ln xt la 25 g/ 50 g; 25 g/ 125 g; 25 g/ 250
g. Ngi ln va tr em trn 12 tui: mi ln 2 nhat xt, ngay 2 ln.
Dng toan thn: Tr cn hen cp nng hoc kim soat hen mn tnh nng.
Hen nng cp tnh: ngi ln ung prednisolon 40 - 50 mg/ ngay, t nht trong 5
ngay. Tr em 1- 2 mg/ kg/ ngay, trong 3 ngay, sau iu chnh liu theo ap ng ca
ngi bnh, hoc tim tnh mch hydrocortison 400 mg/ ngay, chia lam 4 ln.
Hen mn tnh nng khng ap ng y vi cac thuc chng hen khac, ht GC
liu cao phi hp vi ung GC mi ngay mt ln vao bui sang. Tim liu thp nht
kim soat c triu chng.

77
 THUC IU TR TIU CHY

MUC TIU HOC TP

Trinh bay c nguyn nhn va c ch gy tiu chy.
Phn loi c cac nhm thuc dng trong iu tr tiu chy.

78
 Trinh bay c tnh cht, tac dng, tac dng ph, ch nh, chng ch nh, liu
lng cach dng ca tng thuc.

NI DUNG
1. BNH TIU CHY
Tiu chy thng c nh ngha la i cu phn long hoc te nc trn 3 ln trong
24 gi. Trn lm sang thng chia ra hai loi tiu chy cp va man tnh.
Tiu chy cp thng do:
o Nhim vi khun: Enterotoxigenic, Escherichia coli,
Shigella, Campilobacter jejuni, Vibrio cholerae 01, Salmonella (non-typhoid),
Enteropathogenic, Escherichiae coli, Cryptosporidium.
o Virus: Rotavirus
o K sinh trng ng rut: Amip (Entamoeba histolytica),
Giardia Lamblia.
o Nhim c: cac kim loi nng (Hg, As, Ag), cac loi
nm c, cac thuc bo v thc vt ln vao thc n hoc cac cht c sinh ra t
thc phm bo qun km.
o D ng d day rut.
o Lm dng thuc nhun trang.
o Dng khang sinh ko dai.
Tiu chy mn tnh thng do:
o Tn thng thc th c hiu thanh rut: khi u i
trang, khi u lympho rut non, vim rut, lao rut, vim lot i trc trang
chy mau.
o Tn thng rut gy ri lon qua trinh tiu ha va hp
thu: b ct on d day, vim ty, tt mt, thiu men tiu ha mt loi thc n
nao ph bin nht la thiu men tiu ha sa (lactase).
o Bnh cac c quan khac: suy dinh dng, nhim c giap,
suy thng thn, toan mau, ri lon hot ng thn kinh
o Lon khun rut: dng khang sinh ng ung ko dai.
Sinh l hp thu rut

79
Binh thng nc va in gii c hp thu nhung mao va c bai tit cac hm
tuyn ca lin bao rut, iu to ra lung trao i hai chiu ca nc va in gii
gia lng rut va mau. Bt k s thay i nao ca lung trao i nay u gy ra gim
hp thu hoc tng bai tit lam tng khi lng dch xung rut gia. Nu lng dch
nay vt qua kh nng hp thu ca rut gia thi tiu chy s xy ra dn n mt dch va
cac cht in gii.
C 4 c ch chnh dn n tiu chy:
o Tiu chy do tng ap sut thm thu trong lng rut.
o Tiu chy do tng tit dch.
o Tiu chy do ri lon nhu ng rut.
o Tiu chy do tn thng nim mc rut.
2. THUC IU TR TIU CHY
2.1. THUC KHANG NHU NG RUT
LOPERAMID (IMODIUM)
Tc dung
Lam chm nhu ng rut nn lam chm cac cht di chuyn trong rut vi vy ko dai
thi gian hp thu nc va cac cht in gii nn tng c ca khi phn. c ch
nhu ng rut nhanh chng (1 gi) va ko dai.
Ch nh
Tiu chy cp khng chuyn bit, tiu chy man tnh ngi ln.
Tc dung phu
au bng, chng mt, bun ng, kh ming, bun nn, i ma, tc rut do lit.
Chng ch nh
Mn cm, tr em di 2 tui, tiu chy do nhim khun, tn thng gan, hi chng ly,
trng bng, vim i trang nng.
Liu dng
Dng thuc: vin nn, vin nang 2mg, 4mg, dung dch 1mg/5ml
Ngi ln: khi u 4mg, sau 2mg mi ln i long. Ti a 16mg/ngay. Khng dng
qua 5 ngay trong tiu chy cp.
Tr em: khng dng thng qui trong tiu chy cp. Ch dng cho tr em trn 6 tui
khi tht cn thit. Mi ln ung 2 mg, ngay 2 - 3 ln tu theo tui. Ngng thuc nu
thy khng c kt qu sau 48 gi.

80
2.2. THUC HP PHU
Hp ph c t, vi khun, thuc, dch tiu ha, kh. Thuc hp ph ch cha triu
chng vi liu ln dng ngay sau khi tiu chy, khng tac dng vi loi tiu chy cp
nng. Thuc nay khng c vi khng hp thu qua tun hoan nhng hiu qu cha c
chng minh.
2.2.1. Kaolin, Pectin
Tc dung
Kaolin va pectin ng vai tr cht hp ph vi khun, c t va cac cht kch thch khac
trn lp nim mc rut, pectin lam gim pH trong lng rut va lam gim au trn nim
mc kch thch.
c dng lam gim cac cn tiu chy cp tnh t khi dng iu tr tiu chy mn tuy
nhin c th s dng lam gim tm thi cac cn tiu chy man tnh cho n khi
nguyn nhn gy bnh a c xac nh va vic iu tr dt khoac a bt u.
Tc dung phu: tao bn.
Liu dng
Dng phi hp kaolin vi pectin: Kaopectate
Ngi ln: 1,2 1,5 g sau mi ln i long (ti a 9g/ngay).
2.2.2. Dioctahedral smectite (Smecta)
Tc dung
Bao ph nim mc d day rut, lam tng kh nng khang ca lp dch nhy i
vi cac tac nhn kch thch nim mc rut.
Ch nh: tiu chy cp va mn ngi ln va tr em.
Tc dung phu: tao bn (him gp).
Liu dng
Dng thuc: gi cha 3g hot cht dng bt pha thanh dung dch ung.
Tr em: Di mt tui 1 gi mi ngay.
T 1 n 2 tui: 1 n 2 gi mi ngay.
Trn 2 tui: 2 n 3 gi mi ngay.
Thuc c th hoa trong binh nc 50 ml, chia ra ung trong ngay hay trn u vao
thc n st: bt, thc n nghin.
Ngi ln: Trung binh 3 gi mi ngay, hoa trong na ly nc.

81
Trong tiu chy cp tnh, thng thng liu dng hang ngay c th tng gp i khi
khi u iu tr.
2.2.3. Attapulgite
Tc dung
To mang bo v nim mc rut, hp ph cac c t ca vi khun, cac kh trong rut,
c tac dng cm mau ti ch, lam gim mt nc.
Ch nh
Tiu chy trong trng hp bnh i trang cp va mn c km tng nhu ng rut.
Chng ch nh: Khng nn s dng thuc cho nhng bnh nhn c thng tn hep
ng tiu ha, tr em tiu chy cp.
Thn trng
Khng nn s dng thuc nu c st hoc tr di 3 tui.
Nn thn trng vi bnh nhn trn 60 tui vi hay gp tinh trng mt nc va tao bn
nhm tui nay.
Ngng s dng thuc khi xut hin tao bn, chng bng hoc tc rut.
Liu lng va cch dng
Dng vin nn 650 mg attapulgite va 50 mg pectin (NEO ENTROSTOP)
> 12 tui: 2 vin sau mi ln i tiu. Khng qua 12 vin/ngay.
6 - 12 tui: 1 vin sau mi ln i tiu. Khng qua 6 vin/ngay.
Dng bt pha hn dch ung va ng trc trang: hp 30 gi, hp 60 gi, gi 3g.
Ngi ln: 2 n 3 gi/ngay (pha trong na ly nc, thng trc ba n).
Tr em: liu lng ty thuc vao trng lng ca tr, trung binh tr:
di 10 kg: 1 gi/ngay.
trn 10 kg: 2 gi/ngay.
2.3. VI KHUN V NM
2.3.1. Lactobacillus acidophilus
Binh thng, cac vi khun cng sinh trong lng rut c s cn bng gia vi khun hu
saccharose va cac vi khun hu protein. Mt s cht tn cng vao vi khun hu
saccharose nh ru, stress, nhim khun, khang sinh a gy ra s mt cn bng, lam
tng vi khun hu protein, dn n ri lon tiu ha (tiu chy, tao bn, trng bng).

82
Lactobacillus acidophilus c tac dng lp li thng bng vi khun cng sinh trong
rut, kch thch vi khun hu saccharose phat trin, kch thch min dch khng c
hiu ca nim mc rut (tng tng hp IgA) va dit khun.
Ch nh: cac tiu chy do lon khun rut.
Ch phm: Antibio gi bt 1g cha 100 triu vi khun sng.
Ngi ln ung mi ln 1gi, ngay 3 ln. Tr em ung mi ngay 1- 2 gi.
2.3.2. Saccharomyces boulardii
La nm men c tac dng tng hp vitamin nhm B, kim khun, dit Candida albicans,
kch thch min dch khng c hiu.
Ch nh: d phng va iu tr tiu chy do dng khang sinh, tiu chy cp.
Vi nm men la cac t bao sng nn khng c trn vao nc hay thc n nng qua
lnh hoc c ru. Khng dng cng vi cac thuc chng nm.
Ch phm: Ultra - levure, vin nang cha Saccharomyces boulardii ng kh 56,5mg.
Mi ln ung 1 vin, ngay 4 ln.
2.4. THUC UNG B NC V IN GII (ORS, ORESOL)
2.4.1. Thanh phn dung dch ORS
Thanh phn g/l Nng mmol/l
Natri clorua 3,5 Na+ 90
Cl- 80
Trisodiumcitrate, dihydrate 2,9* Citrate 10**
Kali clorua 1,5 K+ 20
Glucose (anhydros) 20,0g Glucose 111

* Hoc Natri bicarbonate 2,5g.

** Hoc bicarbonate 30 mmol.
Nc ha tan: 1gi/ 1 lt.
2.4.2. Tc dung
Thanh phn ca ORS thch hp vi bnh nhn b tiu chy do t hay cac loi tiu chy
khac. Cng thc ORS ph hp b dch hiu qu trong trng hp mt nc u
trng hay nhc trng. Tuy nhin dung dch ORS khng lam gim khi lng phn,
s ln i tiu chy hay thi gian tiu chy. ORS n thun bng ng ung c th
phc hi c 95% cac trng hp tiu chy mt nc trung binh.

83
2.4.3. Ch nh
Phng va iu tr mt nc va in gii mc nhe va va.
2.4.4. Chng ch nh
Gim niu hoc v niu do gim chc nng thn. Mt nc nng (phi truyn tnh
mch dung dch Ringer lactat). Nn nhiu va ko dai, tc rut, lit rut.
2.4.5. Tc dung khng mong mun
Nn nhe, tng natri mau, suy tim do b nc qua mc.
2.4.6. Liu dng
Mt nc nhe: ung 50 ml/kg trong 4 - 6 gi u.
Mt ncva: ung 100 ml/ kg trong 4 - 6 gi u. Sau iu chnh theo mc
khat va ap ng vi iu tr.
Cn tip tc cho tr b me hoc n ung binh thng. C th cho ung nc trng
gia cac ln ung ORS tranh tng natri mau. Lng ORS cho tr ung sau mi ln
i ngoai:
> 24 thang : 50 - 100 ml.
2 - 10 tui : 100 - 200 ml.
> 10 tui : Ung ty thch.
Tip tc cho ung cho n khi ht tiu chy.
Khi khng c sn oresol th c th dng 1 trong cc dung dich sau:
Nc mui ng: 1 mung ca ph mui, 8 mung ng trong 1 lt nc. C th vt
thm qu chanh.
Nc chao mui: Go 50g, mui n 1 mung, nc 1 lt. un nh thanh chao.
Nc da mui: Mui n 1 mung cho 1 lt nc da non dng b nc nh oresol.
2.5. B NC V IN GII QUA NG TRUYN TINH MACH
Cn thit i vi cac trng hp mt nc nng (khi lng nc mt > 10% trng
lng c th), b li khi lng tun hoan mt cach nhanh chng va iu tr shock.
Tng s dch truyn trong 24 gi s bao gm trng lng c th b hao ht va nhu cu
nc binh thng mi ngay.
Dung dch tt nht: Ringer lactat.
Cac loi dch dng c: Dung dch mui sinh l, dung dch Darrow pha loang .
iu tr bnh nhn mt nc nng:
Ngi ln truyn ti thiu 2 lt/ngay.

84
Tr em 80 120 ml/kg: truyn tnh mch dung dch Ringer lactat 100 ml/kg, chia s
lng va thi gian nh sau:
Tui Lc u cho 30 ml/kg trong Sau truyn 70ml/kg trong
Tr nho < 12 thang 1 gi 5 gi
Tr ln hn 30 pht 2 gi 30 pht
Ngay khi bnh nhn c th ung c, cho ung 5 ml/kg/gi dung dch ORS.
2.6. THUC KHANG TIT
ACETORPHAN (RACECADOTRIL)
Tc dung
Racecadotril chng xut tit rut lam gim mt nc va cht in gii, c ch nh
trong bnh iu tr bnh tiu chy cp.
Khng lam gim nhu ng rut, do khng gy tao bn sau iu tr.
Dng kt hp vi ORS (Oresol) s gim nhanh triu chng tiu chy va rt ngn thi
gian iu tr.
Ch nh
iu tr bnh tiu chy cp.
Tc dung phu
Thng gp: st, bun ng, nn, bun nn.
Rt him: ban o, da ni mn, m ay.
Chng ch nh
Bnh nhn nhy cm vi racecadotril hoc bt c thanh phn nao ca thuc.
Liu lng va cch dng
Dng thuc: Vin nn 100mg, gi cho tr em 10mg, 30mg.
Ngi ln va tr > 15 tui: mi ln ung 1 vin 100mg x 3 ln/ngay, tt nht ung
trc ba n.
Tr em: 1 9 thang tui (di 9 kg): 1 gi 10mg/liu; 9 30 thang tui (9 13 kg): 2
gi 10mg/liu. 30 thang 9 tui (13 27 kg): 1 gi 30mg/liu; trn 9 tui (> 27 kg): 2
gi 30mg/liu. Ngay u tin khi u 1 liu x 4 ln/ngay. Nhng ngay sau: 3
liu/ngay, ti a 7 ngay.

THUC NHUN TRNG

85
MUC TIU
Trinh bay c cach phn loi, c ch tac dng ca cac thuc nhun trang.
Nu c tnh cht, ch nh, chng ch nh, tac dng ph va cach dng cac
thuc nhun trang.

NI DUNG BI HOC
1. TAO BN
Tao bn la tinh trng gim s ln i tin (di 3 ln/tun), phn cng, gim s
lng phn hay cm giac tng phn khng hoan toan.
Nguyn nhn: la hu qu ca mt s bnh l, ch sinh hot, n ung hay do
thuc. Hu ht trng hp tao bn (90%) xy ra do ch n ung va sinh hot, phn
cn li do tac ng ca mt s thuc va ch c mt t l rt nho do nguyn nhn bnh
l.
Do ch sinh hot, n ung: Ung t nc, t vn ng, l nhu cu i i
tin.
Do thuc: Antacid c cha Al 3+, khang cholin, thuc lit hch, st, resin,
thuc opioid, thuc chng trm cm loi 3 vng, thuc c ch Ca, thuc ch
vn adrenergic, lm dng thuc nhun trang
Do bnh h thn kinh nh: Parkinson, tn thng ct sng, x cng ri
rac, trm cm, ri lon n ungbnh h tiu hoa nh: tt nghn, tt nt
hu mn do ri lon chuyn hoa nh: thiu nng giap, canxi mau cao, ri
lon hormon sinh dc n
2. THUC NHUN TRNG
Thuc nhun trang c dng iu tr tao bn do lam gia tng va lam d dang
s bai xut phn bng cach gia tng nhu ng rut va/hoc lam mm cht cha trong
rut.
Phn loi:
Thuc nhun trang c hc.
Thuc nhun trang thm thu.
Thuc nhun trang kch thch.
Thuc nhun trang lam mm phn.
Thuc nhun trang lam trn.
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2.1. Thuc nhun trang c hc (nhun trang tao khi)
Tnh cht
La dn cht ca cellulose hay cac polysaccharide.
Khng b thu phn bi men tiu hoa va khng c hp thu toan thn.
C ch tc dng
Cac thuc nay trng n trong nc to mt khi gel lam mm phn, lam tng th
tch cac cht khng hp thu khi lng phn tng ln kch thch nhu ng rut.
Cac thuc nay khi u tac dng chm (1 3 ngay).
Ch nh
Tr cac trng hp n gin ca tao bn, c bit la tao bn do ch n ngho
cht x hoc cht long.
Tc dng ph
Thuc tng i an toan, t c tac dng ph, c th gp: y hi, trung tin, trng
bng, tt nghn rut va thc qun c th xy ra nu nh khng ung nc. Phi
ung vi nhiu nc tranh tao bn ngc li (t nht la 240 ml nc cho 1 liu
thuc).
Chng ch nh
Hep rut, dnh rut
Ch phm, liu lng
Methylcellulose (Citrucel)
Ngi ln: 1 2g x 1 3/ngay.
Tr em: 0,5g x 1 3/ngay.
Polycarbophil (Mitrolan, fibrall, fibercon,)
Ngi ln: 1g x 1 - 4/ngay.
Tr em: 0,5g x 1 3/ngay.
Psyllium (Metamucil, konsyl, fiberal)
Ngi ln 3,5 7g x 1 3/ngay. Tr em liu ngi ln x 1 3 ln/ngay.
2.2. Thuc nhun trang thm thu
Tnh cht
La cac polyalcohol, glycerin, lactulose hay cac mui hoa tan (mui magie, natri).
C ch tc dng

87
 Cac thuc nay lam tng ap sut thm thu trong lng rut nn ko nc vao lng
rut lam trn, mm phn va lam tng s cng phng tng nhu ng rut.
Tac dng nhun trang rt nhanh (ngoi tr lactulose) ch phm trc trang nh
thuc n, dng tht khi phat tac dng trong 15 30 pht, dng ung khong 4 gi.
Ch phm
MUI NHUN TRNG
Mui magie: magie sulfat, magie citrat (mui Epson).
Mui natri: natri sulfat (Celloid, Fynon salt), natri tartrat (Meral).
Ch inh:
Tht thao rut nhanh kham chn oan bnh ng rut, gii c, loi tr giun
san qua hu mn.
Tr tao bn.
Chng ch inh:
Tin s suy thn
Ngi tng huyt ap, suy tim sung huyt.
Liu lng:
ng dng Ngi ln Tr em
Magie sulfat ung 10 - 30g 2 - 5 tui: 2,5 - 5g; 6 - 11 tui: 5 - 10g
Magie citrat ung 10 - 25g 2 - 5 tui: 3 - 6g; 6 - 11 tui: 6 - 12g

GLYCERIN
Cch dng:
c t trc tip vao trong kt trang bng cach bm tht hoc vin t va khng
hp thu toan thn. S dng thuc n 3g, khi u tac dng di 30 pht. Thuc nay
rt an toan (i khi gy kch ng hu mn), c dng theo cach ngt quang, ph hp
cho tr em.
Liu lng:
Trn 12 tui: 3g; di 6 tui: 1 2g; 6 12 tui: 2 3g.
LACTULOSE
(DUPHALAC, CEPHALAC)
Tinh cht, tc dung:

88
 Khng hp thu, b vi khun trong kt trang phn gii thanh cac acid mch ngn.
Cac acid nay c tac dng thm thu lam tng khi lng phn va kch thch nhu ng
rut.
Tc dung phu:
y bng, chut rt vng bng, nn, tiu chy, gim K huyt.
Cch dng, liu lng:
Tao bn: Ngi ln: 15 30 ml, 1 ln/ngay, c th tng n 60 ml. Tr em 5 10
tui: 10ml x 2 ln/ngay.
Bnh nao gan: 30 45 ml x 3 4 ln/ngay.
C th s dng cho ph n mang thai, cho con b, tr s sinh.
MACROGOL
(FORLAX)
Tinh cht, tc dung:
Lam mm phn va kch thch nhu ng rut. Phat huy tac dng nhun trang t 24
48 gi.
D dung np vi khng gy trng bng, y hi, khng nh hng chc nng tim,
gan, thn va khng lam thay i hp thu rut.
Chng ch inh:
Vim rut, nghn rut, au bng cha ro nguyn nhn, khng s dng lu dai.
Tng tc:
Cn tr hp thu cac thuc khac.
Liu dng:
Macrogol (Forlax): bt ung 10g/gi, ung 2 gi/ngay.
SORBITOL
Tc dung
Tng tit dch mt, dch tuy va nhun mt; kch thch nhu ng rut.
Ch inh
Chng chm tiu, y bng, tao bn.
Chng ch inh
Cac bnh thc th vim rut non, vim lot i - trc trang, bnh Crohn va hi
chng tc hay ban tc, au bng cha ro nguyn nhn.
Thn trong

89
 Khng dng trong nhng trng hp tc ng dn mt.
ngi bnh i trang kch thch tranh dng sorbitol khi i va nn gim liu.
Khng nn dng lu dai thuc nhun trang.
Tranh tim thuc nu c tt rut do nguyn nhn c hc.
Tc dung phu
C th b tiu chy hay au bng.
Cch dng, liu lng
iu tr triu chng kh tiu, dng thuc trc ba n:
Ngi ln 1- 3 gi (5g)/ngay.
iu tr tao bn:
Ngi ln dng 1 gi vao lc i, trong bui sang.
Tr em dng 1/2 liu ngi ln.
Ung trc ba n 10 pht.
2.3. Thuc nhun trang kch thch
C ch:
Kch thch u mt thn kinh ca nim mc kt trang lam tng nhu ng rut.
Tc dung:
Ung hiu qu nhun trang xy ra sau 6 12 gi, dng ng trc trang hiu qu
nhanh sau 15 pht 2 gi.
Tc dung phu:
Co cng c bng, bun nn, ri lon cn bng nc in gii.
Dng ng trc trang gy kch ng va c cm giac nng rat.
Nc tiu mau hng (phenoltalein).
Chng ch inh:
Vim kt trang, au bng khng ro nguyn nhn.
Ph n c thai, cho con b.
Khng dng lin tc 1 tun.
Ch phm, liu lng:
ng dng Ngi ln Tr em
Bisacodyl Ung 5 - 15mg > 3 tui: 0,3 mg/kg
Bisacodyl Trc trang 10 mg < 2 tui: 5mg; 2 - 11 tui: 5 - 10mg
Phenolphtalein Ung 30 - 270mg 6 - 11 tui: 30 - 60 mg; 2 - 5 tui: 15 - 30mg

2.4. Thuc nhun trang lam trn

90
 Du khoang la thuc nhun trang lam trn chnh hin nay ang s dng.
Tc dung:
Lam trn phn va nim mc rut, ngn cn tai hp thu nc t nim mc rut.
Lng cht long trong phn tng lam tng nhu ng rut.
Khi u tac dng t 1 3 ngay.
Ch inh:
Tr tao bn va lam cho phn mm trn nhng ngi bnh cn hn ch s cng
thng do i tin nh: bnh tim mch, bnh mch mau nao.
Tr chng phn ng cht.
Ngn tn thng m tr hoc ngn kch ng ch nt hu mn.
Tc dung phu:
Vim phi lipid.
Gy r hu mn, nga va kh chu quanh hu mn.
Tng tc thuc:
Gim hp thu cac vitamin tan trong du, thuc tranh thai, cac coumarin.
Cn tr hot tnh khang khun ca sulfamide.
Liu lng:
Ung: > 12 tui: 15 45 ml; 6 11 tui: 5 15 ml.
Trc trang: > 12 tui: 120 ml; 6 11 tui: 30 60 ml.
2.5. Thuc nhun trang lam mm
Tc dung:
Lam tng kh nng tng tac gia nc, cht bo va cac cht x ca phn cho
php nc va cht bo thm qua phn do thuc c tac dng lam m va lam mm
phn d ao thi hn.
Ch inh:
Lam mm phn trn nhng bnh nhn cn tranh b cng thng trong qua trinh
chuyn ng ca rut (va mi nhi mau c tim hay va mi phu thut).
Tht thao rut lam sch trc khi chp X quang vng bng.
Tc dung phu:
Cm giac ng, tiu chy, bun nn, au tht vng bng nhe thoang qua.
Ch phm, liu lng:
Docusat natri (Colace, Doxinate), docusat canxi (Surfak), docusat kali (Dialose).

91
Phng nga tao bn: Ngi ln: 360mg/ngay. Tr em: 150 mg/ngay.
Liu dng tht thao trc trang: 50 120mg.
Mi liu ung t nht 240ml nc.

92
 THUC CHA VIM LOT DA DY TA TRNG

MUC TIU HOC TP

Trinh bay c nguyn nhn bnh sinh va cac yu t thc y a n lot d
day ta trang.
Trinh bay c cach phn loi cac thuc da trn c ch tac dng.
Trinh bay c tnh cht, tac dng, ch nh, chng ch nh, tac dng ph, cach
dng va liu lng thuc thng dng trong iu tr.
Trinh bay c nhng im cn lu khi s dng thuc.

NI DUNG
1. NGUYN NHN BNH SINH VIM LOT DA DY TA TRNG
D day hot ng c binh thng nh s cn bng gia hai qua trinh: Qua trinh
hy hoi nim mc va qua trinh bo v nim mc. Khi c s mt cn bng gia hai qua
trinh nay ma trong qua trinh hy hoi chim u th hn dn n lam tn hi hoc
lam mt cht liu nim mc d day gy vim lot d day ta trang (VLDDTT)
Qua trinh hy hoi nim mc: la qua trinh to bi cac yu t c kh nng n mn,
hy hoi nim mc d day ta trang:
o la acid hydrocloric (HCl) va pepsin trong dch
v. tiu ha thc n, d day tit dch v gm cac men tiu ha (ch yu la pepsin);
cac cht v c (HCl, cac ion Na+, Mg2+, K+, SO42-); cht nhy va yu t ni ti. Song
chnh HCl va pepsin li la yu t n mn nim mc d day.
o la s nhim vi khun Helicobacter pylori (Hp).
o la nhng cht t ngoai a vao nh: ru, thuc
khang vim khng steroid (NSAID), cac steroid, s cng thng (stress), cng ph
giao cmcung lam tng tit dch v.
Qua trinh bo v nim mc: la qua trinh to bi cac yu t c kh nng bo v nim
mc d day ta trang:
o la cht nhy va Natri bicarbonat (NaHCO 3) c
t bao tit nhy nm ri rac trn khp nim mc d day tit ra.

93
 o la prostaglandin do c th tit ra c tnh bo v
nim mc bng cach kch thch t bao nhy sn sinh ra cht nhy va NaHCO 3.
2. CAC THUC DNG TRONG IU TR VIM LOT DA DY TA
TRNG
C th chia thuc dng trong iu tr VLDDTT thanh hai nhm ln:
o Nhm tac ng vao qua trinh hy hoi tac dng
theo c ch lam hn ch qua trinh bai tit dch v.
o Nhm tac ng vao qua trinh bo v tac dng theo
c ch tng cng yu t bo v.
2.1 Nhom tc ng vao s bai tit acid dch v
2.1.1. Thuc khng acid (Antacid)
Thng la cac hp cht v c c tnh base yu c kh nng trung ha acid dch v
nng pH d day ln xp x 4. Thuc hin nay ang c dng la nhm hydroxyde
(Al(OH)3), magnesi hydroxyde (Mg(OH)2) hoc cac mui nhm, magnesi dng
phosphat, carbonat, trisilicat.
Dc ng hc
Cac antacid cha Al3+, Mg2+ c hp thu rt t nn c tac dng ti ch.
C ch tc dng
Trung ha acid dch v, c ch hot tnh pepsin, lam sn se va chng lot nim mc
d day ta trang.
Tac dng ct cn au va gim triu chng nhanh nhng ngn (15-30 pht), nn
phi dng nhiu ln trong ngay.
Ch nh
Vim lot d day ta trang.
Hi chng trao ngc d day thc qun.
Gim cac triu chng nh: chua, au rat d day, chng kh tiu, y bng.
Tc dng ph
Ch phm cha Al3+ gy tao bn, gim phosphat huyt gy nhuyn xng.
Ch phm cha Mg2+ dng lu c th gy tiu chy, tng Mg2+ huyt.
Chng ch nh thn trng
i tng c nguy c mt nc, ngn rut, ngi ln tui, suy thn nng.
Ch phm

94
Trong thc t thng dng ch phm kt hp

MAALOX
Vin nn cha 0.4g Al(OH)3 + 0.4g Mg(OH)2. Ngm hoc nhai 1-2 vin, 1h sau
ba n hoc khi kh chu, lc au.
GASTROPULGITE
Gi bt ung c 2.5g attapulgite + 0.5g gel kh nhm hydroxyde va magnesi
carbonat. Liu dng 2-4g/ngay.
PHOSPHALUGEL
Gi 100g c cha 13g nhm phosphat dng keo. Ung 1-2 gi/ln x 2-3 ln/ngay.
Mt s iu lu khi s dng antacid
Nn ung cac antacid 1- 2 gi sau khi n thi tac dng ko dai hn (3- 4 gi) va
mt ln trc khi ng. S dng lc bng i ch c tac dng trung ha ngn ngi
(15-30 pht).
Al(OH)3 dng lu gy tao bn, cn Mg(OH)2 c tac dng nhun trang nn
thng dng phi hp (Maalox, Stomafar). Nhiu antacid cn phi hp thm
simethicon c tac dng chng y hi (Maalox plus, Simelox).
Cac antacid lam gim hp thu cac thuc khac khi dng chung vi vy cn ung
cach xa cac thuc khac t nht la 2 gi.
Dng cac thuc c cha Al3+ lu dai (tr nhm phosphat) lam gim lng
phosphat trong mau d gy nhuyn xng. Cn n ch nhiu protid va phosphat
va khng dng chung vi sucralfat.
2.1.2 Thuc khng th th H2
Gm: cimetidin, ranitidin, famotidin, nizatidin. Cu to c mt d vng 5 cnh va 1
mch nhanh ( CH2 S CH2 CH2 R).
Dc ng hc
Hp thu nhanh va hoan toan qua ng tiu ha.
Chuyn ha qua gan. Thi tr qua thn.
Qua c dch nao ty, nhau thai va sa me.
C ch tc dng
c ch khng cho Histamin gn vao th th H2 trn mang t bao vin do c ch
t bao vin d day tit ra HCl, lam gim tit c s lng va nng HCl ca dch

95
v. Kh nng gim tit dch v tng dn: cimetidin < ranitidin # nizatidin <
famotidin.
Ch nh
Vim lot d day ta trang.
Hi chng tng tit acid do cac khi u gy tng tit gastrin tuyn ty.
Hi chng trao ngc d day thc qun.
Tc dng khng mong mun
Thuc dng tng i an toan, t c bin chng. C th gp cac triu chng nh
ban o ngoai da, tiu chy, tao bn, chng mt, au u, au c.
Cac tac dng ph thng gp vi cimetidin, cac thuc khac t gy tac dng ph, t
thy nht la vi nizatidin. Ranitidin c th gy vim gan nhng thuc loi him cn
famotidin i lc gy nhc u.
Vi cimetidin c th gp cac tac dng ph sau:
Trn TKTW: M sng, ln c bit vi ngi cao tui.
Trn ni tit: khang androgen va tng tit prolactin.
Lon th tng mau: gim nhiu loi t bao mau, thiu mau bt sn.
Trn gan: mt c hi phc, vim gan.
Tng tc thuc
Tng tac vi cac thuc chuyn ha qua enzym Cyt P450 gan do cimetidin c
ch ro rt emzym nay. Rantidin rt t c ch Cyt P450. Famotidin va nizatidin gn
nh khng c ch enzym nay.
Chng ch nh
Ph n c thai, cho con b.
Ngi suy gan, suy thn.
Ch phm
Cimetidin (Tagamet) 400mg x 2/ngay.
Ranitidin (Zantac) 150mg x 2/ngay, mnh gp 5-10 ln cimetidin.
Famotidin (Pepcid, Quamatel) 20mg x 2/ngay, mnh gp 20-30 ln cimetidin.
Nizatidin (Nizaxid, Axid) 150mg x 2/ngay, tng ng ranitidin.
Mt s lu khi s dng
Hin nay c xu hng dng liu duy nht mt ln vao ban m.
Tranh dng chung vi cac antacid nn cach nhau t nht 2 gi.

96
 Do c ch tit acid nn lam gim hp thu mt s thuc cn mi trng acid tan
ra, hu ht thuc khang H2 (tr famotidin) c ch alcol dehydrogenase cn thn trng
cho ngi nghin ru.
2.1.3 Thuc c ch bm proton
Gm: omeprazol, lansoprazol, pantoprazol, rabeprazol, esomeprazol. Cac cht nay
la dn xut benzimidazol, s dng dng tin dc khng c hot tnh va tr thanh
dng c hot tnh ti pH = 5.
Dc ng hc
Hp thu nhanh qua ng tiu ha, b phn hy mi trng acid nn c bao
tan rut. Chuyn ha qua gan, thi tr qua thn khong 80%.
C ch tc dng
c ch bm proton bng cach kt dnh lam bt hot enzyme nn c ch bai tit
HCl t bn trong t bao vin ra d day.
Thuc c ch c hiu va khng hi phc bm proton nn cho tac dng nhanh va
hiu qu hn cac thuc khac.
Ch nh
Vim lot d day ta trang tin trin hay cac trng hp lot ma dng khang H 2
khng hiu qu.
Hi chng tng tit acid do cac khi u gy tng tit gastrin tuyn ty.
Hi chng trao ngc d day thc qun.
Tr lot do Hp (phi hp vi khang sinh).
Tc dng ph
Nhin chung thuc dung np tt. C th gy:
Ri lon tiu ha: bun nn, tao bn hay tiu chy.
Chng mt, nhc u, ng ga (t gp).
Tng tc thuc
Omeprazol c ch cyt P450 nn c th nh hng n cac thuc khac chuyn ha
qua enzyme nay.
Chng ch nh
Mn cm vi thuc.
Lot d day ac tnh.
Thn trng: ph n c thai, cho con b.

97
 Ch Phm
Omeprazol (Losec, Mopral) 20 - 40mg/ngay.
Lansoprazol (Lanzor) 15 - 30mg/ngay.
Pantoprazol (Pantoloc) 40 - 80mg/ngay.
Rabeprazol (Pariet) 10 -2 0mg/ngay.
Esomeprazol (Nexium) 20 - 40mg/ngay.
Ung trc n 30 pht.
Phc iu tr nhim Helicobacter pylori
Helicobacter pylori la xon khun gram (-) c tr lot d day ta trang, lam tn
thng cac t bao nim mc va thoai ha lp dch nhy bo v nim mc. Ch 3
thuc gm c ch tit acid (hay dng c ch bm proton) phi hp vi
Clarithromycin va amoxicillin (hoc metronidazol) s dng 7 - 14 ngay dung np
tt va t t l loi tr Hp cao.
Thi gian
Ch loi tr HP Liu dng Ghi ch
(ngay)
Clarithromycin 500mg x 2/ngay Sau thi gian tit tr HP phi
Amoxicillin 1g x 2/ngay 7-14 ngay iu tr duy tri khang tit acid
c ch bm proton 2/ngay vi liu phn na trong thi
Clarithromycin 500mg x 2/ngay
gian 3 tun i vi lot ta
Metronidazol 500mg x 2/ngay 7-14 ngay trang hoc 5-7 tun i vi
c ch bm proton 2/ngay
lot d day.

Liu dng c ch bm proton: omeprazol 20mg, esomeprazol 20mg, lansoprazol

30mg, rabeprazol 20mg, pantoprazol 40mg.
2.2 Nhom tc ng vao qu trnh bao v nim mac da day
2.2.1 Sucralfat (Aluminium sucrose sulfat)
Bit dc: Ulcar, Sucrafar.
Cng thc C12H6O11 [SO3Al(OH)5+]8.H2O
Tnh cht
La mt phc hp ca ng sucrose vi sulfat va nhm, rt t c hp thu qua
ng tiu ha.
C ch tc dng
To hang rao che ch, bo v nim mc d day.

98
 Kch thch sn sinh prostaglandin c tac dng bo v nim mc d day.
c ch trc tip pepsin.
Ch nh
Lot d day ta trang.
Lam gim hoc ngn nga lot do thuc chng vim khng steroid.
Trao ngc d day thc qun.
Tc dng khng mong mun
Tao bn, kh ming.
Tng tc thuc
Lam gim sinh kh dng ca cac thuc dng ng ung, gn vi phosphat va
protein thc n nn ung lc bng i.
Tranh ung chung vi cac thuc khang acid.
Ch phm
Ulcar, Carafate, Sucrafar dng ung vin nn 1g x 4/ngay (ung 1h trc mi ba
n va trc khi i ng) trong 4-8 tun. Do c nhiu thuc lam lanh vt lot hiu qu
hn nn ngay nay t dng thuc nay.
2.2.2 Cc Prostaglandin
C ch tc dng
Kch thch t bao nhy tit cht nhy va bicarbonat.
Duy tri lu lng mau n nim mc d day.
Kch thch tng sinh t bao nim mc d day.
Gim sn xut histamin nn gim tit acid.
Ch nh
Vim lot ng tiu ha.
Phng nga lot do phi dng NSAID dai hn.
Tc dng ph
au bng, tiu chy, chut rt, co tht t cung.
Chng ch nh
Ph n c thai.
Ch phm
Misoprostol (cytotec) 200g/ln x 4 ln/ngay, ung lc no tranh tiu chy.

99
 Do misoprostol c mt s c tnh li thm dng nhiu ln nn hin nay tr
VLDDTT do NSAID thi dng c ch bm proton hiu qu va d dung np hn.
2.3 Thuc dng h tr
Trong iu tr VLDDTT, ngoai cac thuc k trn ngi bnh cn c th c ch
nh dng thm:
Thuc chng co tht: Drotaverin (No-spa), Buscopan gip gim au nhanh.
Thuc an thn: chng stress la yu t lam mt s cn bng gia qua trinh hy
hoi va qua trinh bo v (stress lam tng tit acid dch v). Thuc c dng: Sulpiride
(Dogmatil), diazepam (Seduxen).

100
THUC PHA DUNG DCH TIM TRUYN V CAC CH
PHM THAY TH HUYT TNG

MUC TIU HOC TP

Nu c vai tr ca nc trong c th; nh ngha, phn loi dung dch
tim truyn va cac ch phm thay th huyt tng.
Trinh bay c tnh cht, tac dng, ch nh, chng ch nh, cach dng, liu
dng, bo qun dung dch tim truyn va cac ch phm thay th huyt tng.

NI DUNG
1. AI CNG
1.1 VAI TR CA NC TRONG C TH
Nc chim 70% trng lng c th, c phn b 50% trong cac t bao va 20%
ngoai t bao (5% huyt tng, 15% khong gian bao). Nc la mi trng cho cac
hp cht ha hc c trong c th tn ti va thc hin vai tr ca chng, tham gia ao
thi cac cht cn ba ca cac qua trinh chuyn ha trong c th.
Khi c th b tiu chy, mt mau s lam mt nhiu nc, gy ra nhng ri lon sinh l.
Khi , cn phi s dng cac dch truyn b nc, cung cp dinh dng, b sung
cht in gii. la mt trong nhng bin phap hu hiu trc tin lp li thng
bng cho c th.
1.2 DUNG DCH TIM TRUYN
1.2.1 nh ngha
Dung dch tim truyn la nhng dung dch thuc v khun, khng c ch nhit t, dng
tim vi khi lng ln vao c th, phn ln c truyn nho git vao tnh mch.
1.2.2 Phn loai
Cn c vao mc ch iu tr, c th chia cac thuc tim truyn thanh 4 loi sau:
- Dung dch b nc, cht in gii: dung dch Natri clorid (0.9%, 3%, 10%, 30%),
Kali clorid 2%, Ringer lactat
- Dung dch chng toan huyt: dung dch Natri hydrocarbonat 1.4%...
- Dung dch cung cp cht dinh dng cho c th: dung dch Glucose 5%, Glucose u
trng (20%, 30%, 40%), Moriamin, Alvesin, Nutrisol, Evasol, Cavaplasmal,
Intralipid

101
- Dung dch thay th huyt tng duy tri huyt ap, chng try tim mch: Dextran,
Subtosan, Plasma.
1.2.3 Nhng lu khi s dung dung dch tim truyn
Khi dng dung dch tim truyn, bnh nhn c th b shock.
Nguyn nhn: c th do
- Cht lng thuc
- Dy truyn dch
- Tc truyn
- C a mn cm
hn ch tai bin nay, khi s dng cn lu :
- Kim tra thuc, nhan, hn dng va cht lng thuc
- Chai c nt a chm kim thi khng c dng
- Loi u trng ch tim tnh mch
- Khi s dng cn cach thy chai thuc n 37-38oC (Plasma, Subtosan)
- Theo doi bnh nhn sut thi gian truyn dch phat hin va x l kp thi nu b
shock.

2. MT S THUC V CH PHM THNG DNG

2.1 NATRI CLORID - NaCl
2.1.1 Tnh cht
Tinh th hinh lp phng khng mau hoc bt kt tinh trng, khng mi, v mn, d
ht m chy nc, rt d tan trong nc va glycerin, hi tan trong ethanol.
2.1.2 Tc dung
La thanh phn c bn trong cac cht in gii ca c th, c bit la trong mau; c vai
tr quan trng trong vic iu chnh qua trinh thm thu va khuych tan cac cht trong
c th. Ngoai ra, dng ngoai c tac dng sat khun.
2.1.3 Ch nh
- Pha dung dch tim truyn b nc va cht in gii khi c th b mt mau, mt
nc nhiu do chn thng, phu thut, tiu chy, nn, tc rut, lit rut cp.
- Pha dung dch lau ra vt thng, vt lot, sc ming khi b vim hng,
2.1.4 Chng ch nh
- Ngi b ph n, cao huyt ap.

102
- Dung dch u trng khng tim bp va di da.
2.1.5 Liu dng
Tim di da, tim tnh mch, tim truyn nho git tnh mch, ung, dng ngoai ty
theo mc ch iu tr.
- Trng hp mt mau, mt nc: 200-500ml dung dch 0.9%, tim di da hoc
truyn nho git tnh mch.
- Trng hp gim Natri huyt, tc rut cp, lit rut sau phu thut: 10-20ml dung
dch 10%, tim tnh mch chm, sau vai gi thi lp li liu nh trn.
- Dng ngoai sc ming, ra vt thng: dung dch 2-4%.
2.1.6 Bao quan
Trong chai l hoc ti PE c han kn, ni kh rao, chng m.

2.2 KALI CLORID - KCl

2.2.1 Tnh cht
Bt kt tinh hoc tinh th khng mau, khng mi, v mn chat, d tan trong nc, kh
tan trong ethanol.
2.2.2 Tc dung
Cung cp K+ cn cho hin tng co c va chc nng mang t bao, tng thi tr NaCl
va gip li tiu.
Ngoai ra, cn c tac dng i khang vi Ca2+ va cac glycoside tim.
2.2.3 Ch nh
- Phng va iu tr cac trng hp c th b thiu ht Kali (thch hp nu c km gim
Clo huyt) nh: nhc c, h huyt ap, ri lon c tim, tiu chy, mt moi, chut rt.
- Thay th mui n trong ch n nht lam gim lng Natri.
2.2.4 Chng ch nh
Suy thn cp mn km tiu t, bnh Addison (suy vo thng thn mn), toan huyt do
ai thao ng.
2.2.5 Liu dng
Ngi ln: ung 2-12g/ngay, chia lam 3-4 ln, vao cac ba n.
Tim tnh mch hoc tim truyn tnh mch chm trong trng hp cp cu do h Kali
huyt, liu lng theo ch nh ca bac s iu tr.
2.2.6 Thn trng

103
- Theo doi kim tra h tim mch, nh lng Kali huyt trong khi dng thuc.
- Phi dng rt thn trng i vi bnh nhn c tn thng c tim.
2.2.7 Bao quan
ng trong chai l nt kn, ni kh rao, chng m.

2.3 DUNG DCH RINGER LACTAT

2.3.1 Thanh phn
La dung dch a cht in gii. Trong 1000ml dung dch c:
Natri clorid 6g
Calci clorid 0.4g
Kali clorid 0.4g
Natri lactat 3.1g
Nc v 1000ml
2.3.2 Tc dung
- m bo s tai cn bng nc va cac cht in gii.
- Gp phn iu ha s cn bng acid-base trong huyt tng do ion lactat
(CH3CHOHCOO-) chuyn ha nhanh thanh HCO3-.
2.3.3 Ch nh
B nc va cac cht in gii trong cac trng hp: tiu chy, bong nng, nht la
trong va sau phu thut.
2.3.4 Liu dng
- Ngi ln: 500-1000ml, truyn nho git tnh mch.
- Tr s sinh nng t 2-10kg: khong 125ml, truyn tnh mch.
- Tr em nng 11-40kg: 350ml, truyn tnh mch.
2.3.5 Bao quan
ni mat, kim tra cht lng va theo doi hn dng.

2.4 NATRI HYDROCARBONAT - NaHCO3

Tn khac: Natribicarbonat
2.4.1 Tnh cht
Bt kt tinh trng, khng mi, v mn hi nng, tan trong nc, khng tan trong
ethanol 96o, dung dch c phn ng kim nhe.

104
2.4.2 Tc dung
Dung dch 1.4% la mt cht kim ha cung cp cac ion Na + va HCO3-, gp phn iu
ha cn bng acid-base ca huyt tng.
- Liu > 2g, ung sau ba n: gip trung ha acid dch v.
- Liu < 2g, ung trc ba n: lam tng tit dch v.
2.4.3 Ch nh va liu dng
- Chng toan huyt trong ai thao ng hoc do ng c thuc, thc n: 500-1000ml
dung dch 1.4%, truyn nho git tnh mch chm.
- iu tr chng kh tiu do thiu acid dch v: 0,5-1,5g/ln, 1 - 2 ln/ngay, ung trc
ba n.
2.4.4 Chng ch nh
Cac trng hp nhim kim chuyn ha, nhim kim h hp, tng Natri huyt, suy
tim, ph, cao huyt ap, tn thng thn va ang dng thuc li tiu gy nhim kim
(Spironolacton)
2.4.5 Tc dung phu
- Ung: gy y bng do gii phng CO2.
- Tim truyn tnh mch: gy nhim kim ha (nu dng ko dai).
2.4.6 Thn trng
Cn c bit ch n kh nng gim Kali huyt. C nguy c tng Natri huyt d dn
n nguy c ph phi.
2.4.7 Bao quan
ng trong chai l nt kn, ni mat, tranh anh sang, tng ky vi acid. Hn dng
thng la 2 nm.

2.5 GLUCOSE
Tn khac: D-glucose, Dextrose
2.5.1 Tnh cht
Tinh th khng mau hay bt kt tinh trng, khng mi, v ngt mat, d tan trong nc,
kh tan trong ethanol, khng tan trong ether.
Cu trc phn t c cha nhm aldehyd nn c tnh kh, khi b t chay c mi thm
ca ng chay.
2.5.2 Tc dung

105
- Cung cp nng lng cho c th duy tri s sng: 1g glucose cho 4kcal.
- Tng kh nng chng c gan khi c th b nhim c, nhim khun.
- C tac dng li tiu nhe.
2.5.3 Ch nh
- Tr lc c th khi b mt mau, mt nc, try tim mch, nhim c, nhim khun.
- Bnh v ng tiu ha khng n ung c.
- Phi hp vi xanh methylen gii c Cyanid.
2.5.4 Chng ch nh
Khng tim bp va di da cac dung dch glucose 10%, 20%, 30%.
2.5.5 Liu dng
Ung, tim, tim truyn. Liu lng ty theo tng trng hp.
- Mt mau, mt nc nhiu, try tim mch, nhim khun, ng c Cyanid: 200-500ml
dung dch glucose 5%, truyn tnh mch.
- Ng c thuc (thuc m, thuc ng, asen, insulin,), nhim khun cp, vim gan,
x gan: 20-100ml dung dch glucose 20%, 30%/ln, tim tnh mch chm.
2.5.6 Bao quan
ng trong chai l nt kn hoc ti PE, ni kh rao, thoang mat.

2.6 ALVESIN
2.6.1 Thanh phn
Alvesin c ng chai 500ml. Thanh phn c 8 amino acid thit yu (Alanin,
Leucin, Iso- Leucin, Lysin, Methionin, Phenylalanin, Threonin, Tryptophan) va cac
amino acid khac (Glycin, Arginin, Histidin, Acid Aspastic, Acid Glutamic), Sorbitol va
mt s mui khoang (Na+, K+, Mg2+, CH3COO-, Cl-),
2.6.2 Tc dung
Cung cp acid amin va mt s ion cn thit cho c th.
2.6.3 Ch nh
C th thiu ht protein do ri lon hp thu hoc nhu cu cao, tr em suy dinh dng.
2.6.4 Chng ch nh
Kali huyt tng, suy thn nng.
2.6.5 Liu dng
- Ngi ln: 500ml/ngay, truyn nho git tnh mch chm.

106
- Tr em: 25-50ml/kg/ngay.
- Tr s sinh: 100ml/ngay.
2.6.6 Bao quan
ni mat, tranh anh sang, theo doi hn dng.

2.7 DEXTRAN
Tn khac: Rheomacrodex, Plasmodex, Dextraven
2.7.1 Ngun gc
Dextran la mt polysaccarid c phn t lng ln t 40.000-70.000 n v carbon,
c iu ch t ng saccarose nh hot ng ca mt s loai vi khun nh
Leuconostoc mesenteroides hoc Leuconostoc dextrannicum.
Dextran dng trong y hc gm 2 loi:
- Dextran c phn t lng 70.000 n v carbon.
- Dextran c phn t lng 40.000 n v carbon.
2.7.2 Tnh cht
Bt trng, xp nhe, khng mi, khng v; tan c trong nc, nht la nc nng (70
-800) to thanh dung dch trong sut hoc hi c, c nht cao, khng tan trong
ethanol.
2.7.3 Tc dung
Do c nht cao nn c tac dng duy tri ap lc ng mch, m bo cho s lu
thng tun hoan, khng c tac dng dinh dng.
2.7.4 Ch nh
Thay th huyt tng trong cac trng hp mt mau nhiu do: sinh , phu thut, tai
nn, xut huyt nng, bong nng,
2.7.5 Chng ch nh
Cao huyt ap do thn, xut huyt nao, suy tim, vim thn.
2.7.6 Liu dng
- Ngi ln: 500-1500ml dung dch 6% hoc 10%, truyn nho git tnh mch chm
(khng qua 60 git/pht).
- Tr em: 10-20ml/kg/ngay.
2.7.7 Thn trng

107
Nu thy dung dch Dextran b c thi c th un nng, thy dung dch trong thi vn
dng c.
2.7.8 Bao quan
ng trong chai l nt kn, ni mat (10-20oC).

2.8 HUYT TNG KH

Tn khac: Normal Human Plasma, Plasma sec.
2.8.1 Ngun gc
Plasma sec c ch to t huyt tng ngi bng cach sy chn khng hay c lnh
trong iu kin tuyt i v khun vi dung dch glucose (nhm tranh phn hy
protein va tng tan). C thanh phn tng t thanh phn ca mau ngi tr huyt
cu.
2.8.2 Tnh cht
Kt tinh dng mnh mau trng nga hoc vang nht, tan trong nc, dung dch khng
trong.
2.8.3 Tc dung
Thay th huyt tng ca c th.
2.8.4 Ch nh
Cp cu khi mt mau nhiu do phu thut, tai nn, shock do chn thng, bong, bnh
nhn b gim protein huyt.
2.8.5 Chng ch nh
Vim mang trong tim, vim nghn tnh mch, vim thn cp, xut huyt nao.
2.8.6 Liu dng
Tim tnh mch, truyn nho git tnh mch. Liu lng theo ch nh ca bac s.
Dng thuc: bt ng kh, ng chai 500ml, c km theo mt chai nc ct ha tan
khi dng.
2.8.7 Tc dung phu
Gy d ng nhe, mn cm.
2.8.8 Bao quan
ng trong chai l nt kn, ni mat (khng qua 25oC), chng m, tranh anh sang.

108
 THUC AN THN, GY NG, CHNG CO GIT

MUC TIU
Trinh bay c khai nim va cach phn loi thuc an thn, gy ng, chng co
git.
Nu c cach s dng mt s thuc an thn, gy ng, chng co git thng
dng.

NI DUNG
1. KHAI NIM
Thuc ngu la thuc c ch thn kinh trung ng, to ra trng thai bun ng va a
dn n gic ng tng t gic ng sinh l.
Thuc an thn la thuc lam gim kch thch thn kinh trung ng, lam gim qua
trinh hng phn vo nao. Da vao mc va phm vi tac dng c th chia thuc an
thn ra lam hai nhm:
Thuc an thn chu yu (thuc lit thn, thuc an thn mnh) c tac dng lam gim
kch thch xc cm, lam mt cm giac lo u, cng thng, lam gim thc hoang tng,
o giac va cac hi chng thn kinh khac c dng iu tr cac chng lon tm
thn, cac cn hng cm.
Thuc an thn th yu (thuc an thn nhe) c tac dng lam gim s xc cm va hi
hp, lam gim cm giac lo u, bn chn va cng thng thn kinh.
Trn thc t, tac dng ca thuc an thn va thuc ng rt kh phn nh ro rang vi
phn ln cac thuc ng khi dng liu nho c tac dng an thn va ngc li mt s
thuc an thn khi dng liu cao li c tac dng gy ng.
Thuc chng co git la thuc c tac dng ngn nga cac trng thai co git trong
cn ng kinh hoc cn co cng bnh un van. a s cac thuc chng co git u c
tac dng gy ng.
Ni chung cac thuc an thn, gy ng, chng co git u la nhng thuc cha triu
chng khi s dng phi phi hp vi thuc cha nguyn nhn va khng dng thuc
trong thi gian dai tranh hin tng quen thuc, lm dng thuc. Phi qun l thuc
cht ch tranh s dng vao nhng mc ch phi y hc.

109
 Lu : Nu nh gic ng t nhin la qua trinh b p, hi phc va i mi thi gic
ng do thuc la qua trinh kt qu do c th phi tin hanh chng c. Gic ng t
nhin bo tn nng lng, cn gic ng do thuc tiu ph nng lng. Sau gic ng t
nhin, cac c bp khoe hn, ch c tng cng; cn sau gic ng do thuc, cac c
yu va run, ch b cn mn i.
2. CAC NHM THUC
2.1. Thuc thuc dn xut Barbituric
Thuc nhm nay c tac dng an thn, gy ng va chng co git. Ty theo cu trc
ma c s khac nhau v cng tac dng, thi gian tac dng va thm ch c tac dng.
Mt s thuc cn c tac dng gy m.
Da vao thi gian tac dng chia cac barbiturat thanh 4 nhm
Nhom thuc Thi gian tc dung Thuc in hnh
Tac dng dai 8 - 12 gi Phenobarbital, barbital, butabarbital
Tac dng trung binh 4 -8 gi Amobarbital, pentobarbital, heptabarbital
Tac dng ngn 1 - 3 gi Hexobarbital, secobarbital
Tac dng rt ngn 1/2 - 1 gi Thiopental, thiobarbital

2.2. Thuc thuc dn xut Benzodiazepin

Cac dn xut Benzodiazepin u c tac dng an thn, gy ng nhng do cng
tac ng ca chng khac nhau nn tin s dng c th chia thanh:
Cac thuc ch yu dng an thn: Diazepam, alprazolam, clodiazepoxid,
clonazepam, lorazepam, oxazepam.
Cac thuc ch yu dng gy ng: Flurazepam, temazepam, triazolam, sutrazepam,
flunitrazepam, midazolam, estazolam.
2.3. Nhom khc:
Sulpiride (Dogmatil), Clopromazin (Largactil), Meprobamat (Andaxin), thuc t
tho mc nh: binh vi (rotundin), lc tin (vin an thn lc tin), vng nem (mimosa),
sen vng (sevona), tm sen, tao nhn
3. MT S THUC AN THN, GY NG, CHNG CO GIT THNG
DUNG
3.1. PHENOBARBITAL (Gardenal, Luminal)
Tc dung

110
 Trn thn kinh: c ch thn kinh trung ng nn c tac dng an thn, gy ng hoc
gy m (ty theo loi barbiturat, liu lng, cach dng).
Lam dan c, chng co git (i khang vi tac dng co git ca strychnin,
pentetrazon), chng ng kinh cn ln.
Trn h hp: c ch trung tm h hp hanh nao nn lam gim bin va tn s
cac nhp th.
Trn tun hoan: liu gy m lam gim lu lng tim, h huyt ap. Liu c: c ch
tim.
Tc dung phu
Dng lu gy quen thuc hoc nghin thuc, u oi, nhc u, mt iu ha ng
tac, huyt ap gim, ni mn.
Vi liu gp 5 10 ln liu gy ng s gy ng c: mt dn phn x, ng t dan,
dan mch da, thn nhit h, gim huyt ap ng mch, nhp th chm va nng, tm
xanh sau hn m ri cht do lit h hp, try tim mch, v niu, ph nao.
Ch nh
Cac trng thai mt ng nng.
Bnh ng kinh (cn ln) hoc cac chng co git (do un van, ng c strychnin,
)
Dng trong tin m.
Cn au tht ngc, nhc na u, ri lon thn kinh thc vt.
Chng ch nh
Suy h hp, suy gan nng.
Mn cm vi thuc.
Dang thuc
Vin 10mg, 50mg, 100mg. ng tim 40mg, 200mg.
Liu dng
iu tr mt ng: ung 100 200 mg/ln vao bui ti (30 pht trc khi ng).
Lam thuc an thn: 10 30 mg/ln x 2 3 ln/24 gi.
iu tr ng kinh: bt u 50 mg/ln x 2 3 ln/ngay, sau tng dn liu cho n
khi ct cn. (nhng khng qua 0,6g/ngay). Sau gim liu dn.
Liu ti a ngi ln: 300 mg/ln; 600mg/24 gi.
Ch

111
 Trong thi gian dng thuc khng lai xe ung ru.
Trong iu tr ng kinh khng ngng thuc t ngt.
Cn nhc k khi dng cho ngi c thai.
La thuc c dng t sat, khng c k qua 3 ngay cho ngi mt ng.
3.2. DIAZEPAM (Seduxen, Valium, Faustan)
Tc dung
Ch yu la an thn, chng lo u, lam d ng.
Chng co git va lam dan c.
Tng cng tac dng ca ru, thuc ng.
Tc dung phu
Khi nng trong mau cao hn liu an thn, t ti liu gy ng c th gp u oi,
ng tac khng chnh xac, l ln, ming kh ng, gim tr nh. C th gy d ng
ngoai da, ri lon kinh nguyt.
Ch nh
Cac trng hp lo u, hi hp, kh ng do cng thng.
ng kinh th nhe, sn git, un van.
Cac bnh v tim mch (tng huyt ap, ri lon mch vanh).
Gy m hi sc (lo u trc khi m, kch ng sau m).
Chng ch nh
Nhc c (do tac dng c ch thn kinh va dan c).
Suy h hp, suy gan.
Ph n c thai trong ba thang u, ang cho con b.
D ng vi cac dn cht benzodiazepin.
Dang thuc
Thuc ung: vin nn: 2 mg, 5 mg, 10 mg; vin nang: 2 mg, 5 mg, 10 mg.
Thuc tim: ng tim 5mg/1ml, 10 mg/2 ml, l 50 mg/10 ml.
Thuc trc trang: Vin n 5 mg, 10 mg; dng ng tht hu mn 5 mg, 10 mg.
Cch dng, liu lng
Ung, tim bp, tim tnh mch, t hu mn.
Khi lo lng, kh ng: 5 20 mg/ngay chia 3 4 ln.
ng kinh: tim tnh mch 10mg/ln chia 1 2 ln/ngay.
Bnh un van: tim tnh mch 20 30 mg/24 gi chia 2 8 ln/ngay.

112
Ch
Dng ng ch nh (ch dng khi tht cn thit).
King ru trong thi gian dng thuc.
Tranh dng cho ngi lai xe hoc ang vn hanh may mc.
3.3. MEPROBAMAT (Andaxin)
Tc dung
c ch thn kinh trung ng: an thn mnh nh barbiturat nhng tac dng ngn
hn.
Ko dai tac dng ca thuc m, thuc ng.
Chng co git, lam mm c (dan c trung ng).
Tc dung phu
t c nhng i khi cung gy tai bin
Vim da o do d ng, ri lon tiu ha, gim bch cu a nhn.
Dng liu cao c th chng mt, chy mau mao mch di da.
Nhim c vi liu 4 - 5 g, hn m, try tim mch, try h hp.
Ch nh
An thn chng cac trng thai cng thng thn kinh, bn chn, lo u, mt ng.
ng kinh cn nho.
Dng chun b trc khi m lam cho ngi bnh bt lo lng, s hai.
iu tr suy nhc thn kinh.
Lam dan c trong cac chng co tht.
Chng ch nh
D ng vi thuc, thiu nng phi, suy h hp, ph n cho con b.
Dang thuc
Vin 200 mg, 400 mg.
Cch dng va liu lng
Ngi ln ung 400 mg/ngay x 2 4 ln/ngay.
3.4. CLOPROMAZINE (Aminazin, Largactil)
Tc dung
Trn thn kinh trung ng: c tac dng c ch lam gim cm xc, gim sang kin,
gim o giac, thao cung, vt va, chm phn ng vi cac kch thch bn ngoai va gy
bun ng.

113
 Trn thn kinh thc vt: c ch do lam lit hch va gim hot ng thn kinh giao
cm, ph giao cm (dan ng t, gim tit dch v, gim tit nc bt, m hi), lam
h thn nhit.
Khang histamin va khang serotonin.
Trn tun hoan: gy dan mch, h huyt ap (do hy giao cm).
Chng nn do c ch trung tm nn
Tng cng tac dng ca thuc ng, thuc t, thuc m, thuc gim au loi
morphin.
Ch nh
Do c nhiu tac dng a dng, clopromazin c dng nhiu khoa:
Khoa tm thn: lon thn kinh, tm thn phn lit, cac trng thai kch ng, thao
cung, hoang tng, o giac, cn co git.
Khoa sn: sn git (ch thuc qua c rau thai).
Khoa gy m: tin m, gy m h th nhit, h huyt ap.
Khoa ni: chng nn, chng au, an thn, chng rung tim.
Khoa da liu: chng nga.
Chng ch nh
Vim gan vang da, h huyt ap, bnh c quan to mau, bnh tng nhan ap, x cng
ng mch, hn m do ru, thuc ng
Tc dung khng mong mun
Gy bun ng, mt moi, km theo c cac ng tac khng ch ng ca li, mt
ham, ban tay.
Trm cm, kh ming, tao bn, ri lon kinh nguyt, suy gim tinh dc, mn o
ngoai da, gim bch cu, h huyt ap th ng.
Dang thuc
Vin 0,025;0,05; 0,1g, ng tim 0,025 0,05 g/2ml.
Cch dng, liu lng
Ung 0,025 0,05g/ ln 2 4 ln/ ngay.
Tim bp 0,025 0,05g/ ln 2 3 ln/ ngay.
Tim tnh mch t dng ch dng trong ngoi khoa va cn ng kinh cp: 0,025g
pha trong 10 25 ml dung dch glucose 5% hoc dung dch Natricloride 0,9%.
Liu ti a:

114
 Ung, tim bp: 0,15 g/ln; 0,5 g/24 gi.
Tim tnh mch 0,05 g/ln; 0,2 g/24 gi.
3.5. SULPIRIDE (Dogmatil)
Tc dung
Thuc c tac dng an thn kinh, gii c ch, chng trm cm.
Ch nh
Ngi lon tm thn, thn kinh phn lit trng thai c ch, o giac, hoang tng,
trm ut, lanh cm.
Chng nn (mnh hn clopromazin).
Phi hp cha vim lot d day ta trang (ci thin lu lng mau nim mc d
day, tng trng lc c hang v).
Thn trng
Bnh nhn a bit hay nghi ng b u ty thng thn (gy cn tng huyt ap).
Dng cng vi ru gy tt huyt ap.
Ngi c ng kinh (vi lam gim ngng ng kinh).
Nu c st cao, phi ngng iu tr, vi du hiu nay c th la mt trong nhng yu
t ca "hi chng ac tnh ca thuc lon thn kinh".
Tc dung phu
Tit sa, tng cn, n ha tuyn v, bt lc hay lanh cm, v kinh, phn ng ngoi
thap, h huyt ap t th; chng lon vn ng mun, an thn, ng gt.
Dang thuc
Vin nn 50 mg, 200 mg.
Dung dch ung 25mg/ml l 200ml.
ng tim 100mg/ml.
Cch dng, liu lng
ng ung.
Lon thn, tm thn phn lit: 0,3 0,6 g/24 gi.
Chng o giac, hoang tng: 0,6 1,2 g/24 gi.
Tr em: dung dch ung 5 10 mg/kg/ngay.
Lot d day ta trang: 150 mg/ngay x 4 6 tun.
Tim bp: bnh tm thn cp 0,2 0,6g/ngay x 2 ln.
3.6. ROTUNDIN (Stilux, Rotunda)

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Ch nh
An thn gy ng liu thp.
Gim au, h st liu cao hn.
H tr ct cn nghin ma tu.
Chng ch nh
Qua mn vi thanh phn ca thuc
Liu lng
Ngi ln
Cac trng hp lo u, cng thng, mt ng: ung 1 - 2 vin trc khi i ng.
au trong cac bnh ng tiu hoa, au khi c kinh, au vng kn sau khi sinh, au
u, st: ung 2 - 4 vin chia 2 ln mi ngay, c th dng ti 8 vin mi ngay.
Tr em trn 1 tui: 1/2 - 1 vin mi ngay.

116
 THUC TAC DUNG LN QUA TRNH NG MAU

MUC TIU
Trinh bay c khai nim v thuc cm mau, s ng mau, c ch ng mau.
Nu c tnh cht, tac dng, cng dng, chng ch nh, liu dng, bo qun
mt s thuc cm mau va chng ng mau thng dng
NI DUNG
A. THUC CM MAU
1. AI CNG
1.1. THUC CM MAU
Thuc cm mau la nhng thuc c tac dng ngn cn hoc hn ch s chy mau ra
khoi thanh mch khi thanh mch b tn thng.
1.2. KHAI NIM V S NG MAU
ng mau la mt qua trinh mau chuyn t th long thanh th c do chuyn
fibrinogen thanh fibrin khng ha tan va cac si fibrin nay b trng hp to thanh
mng li giam gi cac thanh phn ca mau lam mau ng li.
Binh thng mau chy trong lng mch khng ng la do trong mau c nhng cht
chng ng, mt khac do thanh mch nhn tim co bp y mau chy ng u lin
tc. Khi mau chy ra khoi c th hoc chm vao vt th rap s ng li sau 2 4 pht.
ng mau la hin tng t bo v ca c th khi c chy mau. Khi c ch ng mau
b ri lon thi xy ra hi chng chy mau nhe hoc nng.
1.3. C CH NG MAU
Binh thng trong mau va trong cac m c cac cht gy ng va cht chng ng,
nhng cac cht gy ng dng tin cht, khng c hot tnh. Khi mch mau b tn
thng s xy ra cac phn ng sinh hc lin tip lam hot ha cac yu t ng mau
theo kiu dy chuyn lam cho mau ng li.
Qua trinh ng mau xy ra qua 3 giai on :
- Giai on to thanh phc hp prothrombinase (1).
- Giai on to thanh thrombin (2).
- Giai on to thanh fibrin (3). Fibrin khng tan kim huyt cu trong mng li
day c, dn dn co tht li, lam cho mau ng.

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 Thrombokinase

S tm tt qua trinh ng mau

2. CAC THUC CM MAU

2.1. CALCI CLORID
Tnh cht
Tinh th khng mau, khng mi, v chat, hi ng, d ht m, d tan trong nc,
khi tan lam dung dch mat lnh, d tan trong cn 950.
Tc dung
Ca2+ cn hot ha cac yu t VIII, IX va X chuyn prothrombin sang
thrombin.
Cung cp calci cho c th.
Ch nh
Cm mau: chy mau cam, ho ra mau, xut huyt di da, chy mau d day
Chng co git do h calci huyt.
Tr em chm mc rng, chm ln, ngi c thai, cho con b.
Chng ch nh

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 Tim di da, tim bp (gy hoi t), tng calci huyt, tng calci niu, soi mt, soi
thn, bnh nhn ang dng Digitalis.
Liu dng
Ung 2 - 4g mi ngay, dng cach quang tng thi k 3 - 4 ngay, ri ngh. Tim tnh
mch cho nhng trng hp chy mau: 20ml dung dch 5%. Thuc tim ra ngoai tnh
mch s gy lot ch tim.
Ch
Tranh dng liu cao cho ngi suy thn, thng xuyn kim tra calci huyt, calci
niu dng liu thch hp.
Bao quan
Ni kh mat, chng m, chng nng.
2.2 VITAMIN K (K: KOAGULATION - NG MAU).
Ngun cung cp
C 3 ngun cung cp vitamin K:
o Vitamin K1 (phytonadion, phulloquinon) c ngun
gc thc vt.
o Vitamin K2 (menaquinon) do vi khun gram m
ng rut tng hp.
o Vitamin K3 (menadion) va K4 (Menadion natri
diphosphat) ngun gc tng hp.
Tnh cht
Vitamin K1 dng long sanh, trong sut, mau vang ti, gn nh khng mi. Khng
tan trong nc, tan trong du va cac dung mi hu c nh cn, ether, benzen,
cloroform. B phn hy bi anh sang va cac cht kim. Ring vitamin K3 dng mui
natribisulfit hoc mui tetra natri tan trong nc vao c th b chuyn ha thanh
vitamin K2 c hot tnh nn K3 c tac dng chm.
Dc ng hc
Vitamin K tan trong du, khi hp thu cn c mt ca acid mt. Loi tan trong du
thng qua h bch huyt vao mau, cn dng tan trong nc hp thu i trc tip vao
mau. Sau hp thu vitamin K1 tp trung nhiu gan va b chuyn ha nhanh thanh cht
c cc thi ra ngoai theo phn va nc tiu.
Tc dung

119
 Vitamin K gip cho gan tng hp cac yu t ng mau nh prothrombin (II), VII,
IX va X.
C ch
Binh thng, cac yu t II, VII, IX va X dng tin cht. Khi c mt vitamin K
vi vai tr cofactor cn thit cho enzym microsom gan xc tac chuyn cac tin cht
thanh cac cht c hot tnh.
Du hiu cua s thiu hut
Nhu cu hang ngay khong 1 g/kg. Khi thiu ht s xut hin bm mau di da,
chy mau ng tiu ha, rng ming, ai ra mau, chy mau trong s, ko dai thi
gian ng mau.
Ch nh
o Thiu vitamin K do nhiu nguyn nhn khac nhau.
o Chun b phu thut ( phng chy mau trong va
sau phu thut ). Nhng trng hp nay phi dng thuc trc 2 - 3 ngay.
o Gim prothrombin mau
o Gii c khi dng qua liu cac thuc chng ng
mau (coumarin, warfarin, heparin).
c tnh
o Mc d c phm vi iu tr rng, nhng c th gp
thiu mau tan mau va cht do vang da tan mau tr di 30 thang tui dng
vitamin K3
o Vitamin K3 cn gy kch ng da, ng h hp, gy
ai albumin, gy nn va c th gy tan mau ngi thiu G6PD.
Ch phm - Liu dng
Vitamin K1 (Phytonadion, Phylloquinon, Phytomenadion): vin nn 5mg, ng tim
2mg/ml, 10mg/ml. Ty theo ch nh ma s dng vi liu khac nhau. Trung binh 10
20 mg/ngay.
Menadion (Vitamin K3): vin nn 5mg, ng tim 2mg/ml. Menadion natri
diphosphat (Vitamin K4).Vin nn 5mg, ng tim 2mg/ml. Ung tim di da, tim
bp, tim tnh mch. Liu trung binh 15 20mg/ngay.
iu tr gim prothrombin huyt nng: tim bp 50 100mg/ngay.
2.3. ERGOMETRIN MALEAT

120
Tc dung
C tac dng trc tip ln c trn t cung, lam co bp t cung, co mch.
Ch nh
Phng va iu tr chy mau sau do t cung.
Phng bng huyt trong va sau no thai.
Tc dung phu
Tng huyt ap, nu tim nhiu ln va lin tip vao c t cung c th gy hoi t.
Chng ch nh
Cao huyt ap, suy gan thn nng.
Liu dng
Bit dc: Ergonovin, Ergobazin
Tim tnh mch 1 ng (1ml: 0,2mg)/ngay.
Tim bp 1 3 ng/ngay. Hn hu c th tim 1 ng vao thanh hoc c t cung.
Liu ti a: 0,5 mg/ln, 1 mg/ngay.
Ch
Phi chc chn rau thai a ra ht mi c tim thuc.
Bao quan
Thuc hng thn, tranh anh sang, chng m.
2.4. ERGOTAMIN TARTRAT
Tc dung
Co c t cung nh ergometrin nhng ko dai hn, co tht mch mao nao.
Ch nh
Cm mau trong sn khoa nh ergometrin.
iu tr au na u (do s dan cac mch mau nao gy ra cn au).
Chng ch nh
Nh ergometrin, suy tun hoan ngoi vi, bnh mch vanh, x va mch, c thai.
Liu dng
Bit dc: Ergotartrat, Rigetamin.
Ung 1 6mg/ngay, tim di da hoc tim bp 1 2 ng (0,2 0,5mg), khng
qua 7 ngay.
Bao quan
Thuc hng thn, chng m, tranh anh sang.

121
2.5 OXYTOCIN
Ngun gc
La hormon do thy sau tuyn yn tit ra hoc tng hp.
Tc dung
Gy co bp t cung gip thai ra nhanh, rua thia bong nhanh, t cung co hi li
nhanh va cm mau.
Ch nh
Gy chuyn d trong trng hp cn ly thai ra ma cha c chuyn d (v i sm,
thai cht lu, pha thai).
H tr chuyn d trong trng hp cn co t cung yu va tha.
Phng va iu tr bng huyt sau do t cung, t cung co hi khng tt sau ,
sau m ly thai.
Tai bin
Dng qua liu gy cn co mnh thai thiu oxy b ngt, v t cung, ng c thuc.
Chng ch nh
Chuyn d t cung da v, thai ngang, hep khung chu.
Thn trng
Ngi cao huyt ap, nhiu ln, sinh i hay sinh ba, ngi th tht thng, a m
t cung ly thai.
Liu dng
Bit dc: Pitocin, Syntocinon
Cm mau: tim bp 5 10 UI hoc tim vao c t cung 2 5UI.
Thc : Truyn tnh mch chm 5UI/500 ml glucose 5%. C th dng 30 UI/ngay.
2.6. CAC THUC KHAC
2.6.1. COAGULEN
La tinh cht mau toan phn, c bit c tinh cht ca tiu cu. Dng trong ngoi
khoa ngi bnh a chy mau va trong nhng trng thai chy mau (ban chy mau, i
ngoai ra mau v.v...).
Ung 1 - 5 ng mi ngay (ng 20ml). Hemocoagulen: ng tim 5ml. Trng hp
nng, c th tim ti 4 ng mi ngay.
2.6.2. CARBAZOCHROM (ADRENOXYL)

122
 Lam tng sc khang mao mch, gim tnh thm thanh mch, nn lam gim thi
gian chy mau. Tac dng sau khi tim 6 - 24 gi (tim bp 1,5 - 4,5 mg mi ngay hoc
ung 10 - 30 mg mi ngay).
Cha chy mau do gin mao mch hoc phng chy mau sau phu thut to hinh,
tai mui hng, ct bo tuyn tin lit.
2.6.3. ETHAMSYLAT V DOBESILAT CALCI
Lam tng sc khang mao mch, gim tnh thm thanh mch. Dng phng chy
mau cp trong phu thut to hinh, tai mui hng, ct bo tuyn tin lit, rong kinh.
Mi ngay tim bp 250 - 500mg hoc ung 750 - 1500mg.
2.6.7. VITAMIN P (FLAVONOID, RUTOSID RUTIN V DN XUT)
Rutosid va dn xut ngun gc thc vt c hot tnh vitamin P u gim tnh thm
thanh mch va lam tng sc khang mao mch Ung 20 - 40mg mi ngay, cha gin
mao mch va tng tnh an hi mch mau.

B. THUC CHNG NG MAU

Trn lm sang hay dng ba nhm thuc sau:
Thuc c ch s tng hp ca cac yu t ng mau gan (yu t II, VII, IX,
X): dn xut coumarin.
Thuc c ch tac dng ca cac yu t ng mau: heparin.
Thuc chng kt tp tiu cu: aspirin, dipyridamol, ticlopidin, clopidogel.
1. DN XUT CA COUMARIN
Warfarin, Acenocoumarol, Dicoumarol.
Dc ng hc
Hp thu nhanh qua ng tiu ha. Thuc c th i qua rau thai, qua sa.
Tc dung
Thuc khang vitamin K.
Ch nh
Phng hoc cha bnh tc nghn mch nh: vim tnh mch, tc mch phi, nhi
mau c tim.
c tnh
Dng liu cao, ko dai gy ri lon thm phn mao mch, xut huyt, rt nguy
him bnh nhn lot d day ta trang, chn thng, cao huyt ap.

123
 D ng, rng tc, vim gan, thn, tng bch cu a acid, nhng li gim hoc
mt bch cu ht, nc tiu o mau da cam.
Nng thuc trong rau thai va tr em b me cao c th gy xut huyt cho
thai nhi va tr b me. Nu ung thuc vao 3 thang u thai k c th gy cho tr s
sinh mt s d thng mui, mt, xng.
Khi qua liu hoc ng c dn xut coumarin dng vitamin K iu tr.
Chng ch nh
Ph n c thai, cho con b; cao huyt ap, vim ty cp; lot d day - ta trang tin
trin; tai bin mch mau nao va tng chy mau.
Tng tc thuc
Thuc lam gim hp thu coumarin qua ng tiu ha
Thuc lam tng pH d day, thuc nhun trang, thuc khang cholinergic, du
parafin, than hot, cholestyramin (to phc vi couramin).
Thuc y coumarin ra khi protein - huyt tng
Clofibrat, phenylbutazon, sulfa mid, tolbutamid, salicylat, acid ethacrynic
Thuc c ch chuyn ha coumarin microsom gan
Allopurinol, chloramphenicol, cimetidin, diazepam, metronidazol, phenylbutazon,
sulfinpyrazon, thuc chng trm cm loi ba vng.
Thuc cm ng enzym microsom gan lam tng chuyn ha coumarin
Barbiturat, rifampicin
Liu lng - cch dng
Tac dng chng ng ph thuc vao tng ca th. Trong qua trinh iu tr bng dn
xut coumarin phi gim liu dn va cn theo doi thi gian Quick, thi gian Howell
chnh liu nhm duy tri t l prothrombin khong 20% so vi binh thng. Sau khi
dng 36 - 48 gi lam xt nghim anh gia tac dng, chn liu duy tri ph hp. Giai
on iu tr duy tri c sau 2 tun cho xt nghim 1 ln.
Dicoumarol: liu cho ngi ln: 2 3 ngay u 0,05 0,1g/ln x (2 3) ln/ngay.
Nhng ngay sau: 0,15 0,2g/ln/ngay. Sau duy tri 0,05 0,1g/ngay. Ti a
0,1g/ln; 0,3/ngay.
Acenocoumarol (Sintrom): vin nn 4mg. Ung 2 12mg/ngay.
Warfarin natri (Coumadin): vin nn 2mg; 2,5mg; 5mg; 7,5mg; 10mg. Ung 2
6mg/ngay, dng 5 6 ngay. Ty theo t l prothrombin gi liu duy tri 2 5 mg/ngay.

124
2. HEPARIN
Dc ng hc
Ung khng hp thu va b phn hu ng tiu ha. Do vy, phi tim di da,
tim tnh mch, khng tim bp, khng i qua rau thai. Thi gian ban thi ph thuc
vao liu lng. Liu cao va ngi suy gan, thn thi thi gian ban thi ca thuc dai.
Tc dung
Chng ng mau.
Chng kt tp tiu cu.
H lipoprotein mau c bit la triglycerid. Tac dng nay xut hin nhng liu
thp hn liu c tac dng chng ng mau. C hin tng tng lipoprotein hi ng
(rebound) khi ngng heparin.
C ch chng ng mu
Binh thng antithrombin III trong huyt tng phn ng chm chp vi thrombin
va cac yu t ng mau IX, X, XI, XII a hot ha lam mt tac dng ca cac yu t
nay. Khi c mt heparin, heparin to phc vi antithrombin III. Phc hp heparin -
antithrombin III thc y nhanh phn ng gia antithrombin va thrombin;
antithrombin vi cac yu t IX, X, XI va XII. Hu qu cac yu t chng ng a t
hot ha mt hiu lc nhanh, mt kh nng chuyn fibrinogen thanh fibrin.
Ch nh
Phng va cha cac bnh tt nghn mch do huyt khi, nh vim tnh mch huyt
khi, tt mch phi, nghn mch sau m, nhi mau (heparin c dng trong 1 2
tun sau nhi mau c tim). Do tac dng nhanh nn heparin c dng ngay sau khi
bt u iu tr khi c tt mch.
Thuc dng c cho ngi mang thai va ph n cho con b.
Tc dung khng mong mun
Chy mau, gim tiu cu, triu chng nay thng xut hin sau khi tim heparin 7
14 ngay va hi phc sau khi ngng thuc.
D ng, nhc u , nn, gy nt au, hoi t gn nu tim di da dai ngay. Dng
ko dai vi liu trn 15000 n v/ngay gy loang xng.
Tng AST, ALT.
Chng ch nh
Tng a chy mau; lot d day - ta trang tin trin; vt thng.

125
 Gim chc nng gan, thn; c th suy nhc, vim ni tm mc, nhim trng, lao
tin trin.
Ch phm va liu dng
Heparin trong lng phn t thp (1000 10000 DA.
Enoxaparin (Lovenox): ng 20mg/0,2ml, ng 40mg/0,2ml. Phng bnh: tim di
da 1mg/kg/ln x 2 ln/ngay. iu tr: tim di da 1mg/kg/ln x 2 ln/ngay.
Dalteparin (Fragmin): ng 2500 IU/0,2ml; 5000 IU/0,2ml; 10000IU/ml. Phng
bnh: tim di da 100UI/kg x 2 ln/ngay, hoc truyn tnh mch 15 000 IU/24 gi.
iu tr: tim di da 100UI/kg x 2 ln/ngay, hoc truyn tnh mch 15000 IU/24 gi.
Nadroparin (Fraxiparin): ng 0,2; 0,3; 0,4; 0,6; 0,8; 1 ml (1ml cha 25000IU).
Phng bnh: tim di da 5000 7500 IU/ln/ngay. iu tr: Tim di da 225 IU/ln
x 2 ln/ngay, hoc truyn tnh mch 1000 IU/24 gi.
Heparin phn t lng cao (10000 30000 DA)
Natri heparin: l 5ml cha 25000IU
Calci heparin: ng 1ml cha 1000; 5000; 10000; 20000; 25000 IU.
Thng truyn tnh mch liu u 3000 5000 IU, sau truyn 400 500
IU/kg/24 gi. 4 - 6 gi sau khi bt u truyn xt nghim kim tra tinh hinh ng mau.
Liu tip theo cn c vao kt qu xt nghim trn.
Khi qua liu phi ngng heparin ngay va tim tnh mch chm protamin sulfat
trung ha vi tc 50 n v/pht. 1 mg protamin sulfat trung ha c 100 n v
heparin.
3. THUC CHNG KT DINH TIU CU
S kt dnh tiu cu la yu t to ra mng x va ng mnh va gy nn tc mch.
Hin c mt s thuc chng kt dnh tiu cu c s dng trn lm sang phng
va iu tr huyt khi nh: thuc chng vim phi steroid (aspirin), dipyridamol,
ticlopidin, clopidogrel.
3.1. ASPIRIN (ACID ACETYLSALICYLIC)
Ngoai tac dng h st, gim au, chng vim, aspirin cn c tac dng chng ng
vn tiu cu (do c ch 90% cyclooxygenase ca tiu cu), lam n nh mang tiu cu
hn ch s gii phng ADP va phospholipid nn gim s kt dnh tiu cu va tng thi
gian chy mau.

126
 Ch nh: dng aspirin trong d phng va iu tr huyt khi ng - tnh mch vi
liu thp t 75 - 160mg/ngay.
Chng ch nh va tac dng khng mong mun (xem bai thuc h st, gim au va
chng vim).
3.2. DIPYRIDAMOL (PERSANTIN, PERIDAMOL, CURANTYL)
Va c tac dng gian mch vanh, va c tac dng chng ng vn tiu cu.
Ch nh: thuc c phi hp vi warfarin trong phng huyt khi bnh nhn
thay van tim nhn to.
Liu dng: vin 25; 75 mg. Ung 75 150 mg/ngay chia 2 ln.
3.3. TICLOPIDIN (TICLID)
Tac dng ngn cn s kt dnh tiu cu va ko dai thi gian chy mau.
Thuc c dng phng huyt khi bnh nhn b bnh tn thng mch nao
hoc mch vanh vi liu 250 - 500mg/ngay. Khi dng c th gp mt s tac dng
khng mong mun: chy mau, bun nn, a chy, gim bch cu trung tnh. Khng
dng thuc cho tr em.
3.4. CLOPIDOGREL (PLAVIX)
Thuc c tac dng chng kt tp tiu cu vi liu thng dng ung 75mg/ngay.

C. THUC TIU FIBRIN

Cac thuc nay lam tiu fibrin gip cho cc mau ng mi hinh thanh c th tan tr
li, nh vy s tranh c tc nghn mch.
c ch nh cho cac trng hp tc ng mch cp chn, tay; huyt khi mch
vanh cp; nhi mau c tim; nghn mch phi th nng; huyt khi tnh mch su; vim
m, ng mau mang phi hoc cac khp xng hay cac hch (dng streptokinase ti
ch); bm vao ng dn lu m tranh tc (streptokinase).
Chng ch nh: Sau khi phu thut cha qua 8 ngay; mi hoc sy thai cha
qua 4 ngay; cao huyt ap nghim trng, qua trinh cm mau bt thng; c a d ng;
mi dng streptokinase cha qua 6 thang; mi b bnh do lin cu; c thai (thuc
khng qua rau thai, nhng phng bong rau sm); chy mau ng tiu ha nng
trong vng 3 thang; tin s tai bin mch mau nao; vim mang ngoai tim cp; phu
thut ng mch ch; vim ty cp; bnh gan nng.
1. UROKINASE (ABBOKINASE)

127
 Thuc ch c tim tnh mch, khi u 1.000 - 4.500 n v/kg th trng, sau
duy tri 4.400 n v/gi. Thuc hu nh khng c tnh khang nguyn, khng b trung
ha bi khang th, nhng c th gy st.
2. STREPTOKINASE ( SK, STREPTASE)
Khi u tim tnh mch 500.000 n v trong 30 pht, sau mi gi tim
100.000 150.000 n v va dng trong 24 - 48 gi lin. Trong nhi mau c tim c th
truyn tnh mch 1500000 n v trong 60 pht.
C th ha tan 20.000 - 100.000 n v vao 5 - 20ml nc mui sinh l tim
thng vao ti m sau 6 - 24 gi ht ra.
Trong qua trinh dng thuc c th gp mt s tac dng khng mong mun: chy
mau, d ng hay gp vao ngay th 8, nn sau khi dng thuc 8 ngay, cn phi chuyn
sang dng thuc khac.
3. ALTEPLASE
Trong nhi mau c tim cp tim tnh mch 15 mg sau truyn tnh mch 50 mg
trong 30 pht va trong 60 pht tip theo truyn 35 mg (tng liu truyn trong 90 pht
khng vt qua 100 mg).

128
 THUC CHNG THIU MAU

MUC TIU HOC TP

Trinh bay c khai nim, nguyn nhn thiu mau.
Nu c tnh cht, tac dng, ch nh, cach dng, liu lng, bo qun cac
thuc chng thiu mau.

NI DUNG
1. AI CNG

1.1. Khi nim:

Thiu mau la tinh trng gim s lng hng cu hoc huyt sc t hoc hematocrit
di mc binh thng so vi ngi cng tui, cng gii kho mnh.

i vi nam gii c coi la thiu mau khi s lng hng cu di 4 triu hoc
hemoglobin di 12g/100 ml hoc hematocrit di 36%.

i vi n gii c coi la thiu mau khi: s lng hng cu di 3,5 triu hoc
hemoglobin di 10g/100 ml hoc hematocrit di 30%.

1.2. Nguyn nhn gy thiu mu:

a. Do gim sinh hng cu: Thiu st, thiu B12, suy ty, thiu erythropoietin.

b. Do tan mu: Bt thng v mang hng cu (hng cu hinh trn, hinh bu dc);
ri lon cu to Hb (Thalasemia, thiu mau hng cu hinh lim); ri lon men hng
cu (thiu mau tan mau do thiu G6PD); truyn nhm nhm mau, thiu mau tan mau
t min, bnh st rt, nhim cac cht dc gy v hng cu (phenol, benzen, quinin,
sulfamide)

129
 c. Do chy mu: Chy mau cp trong chn thng, phu thut, xut huyt ni tng
nng. Chy mau mn tnh trong cac trng hp lot d day ta trang, tr, nhim giun
mc, giun tc, rong kinh

1.3. Phn loai thiu mu:

Da trn th tch trung binh hng cu:

a. Thiu mau hng cu to: thng do thiu vitamin B12 hay axit folic. Gp
nhng bnh nhn b ri lon tiu ha lam c th khng hp thu c vitamin B12 hoc
do b ct on d day dn n thiu yu t ni ti cn hp thu vitamin B12.

b. Thiu mau hng cu nho: a s loi nay la do thiu cht st. Gp bnh nhn b
mt mau kinh din (mi ngay mt mt t mau nhng r r nhiu nm nh trong bnh
tr, ung th d day, ung th trc trang, u x t cung, lot d day ta trang), b bnh v
d day, rut lam gim kh nng hp thu st rut.

c. Thiu mau hng cu binh thng, chia lam ba nhm:

- Thiu mau do thiu nng c quan to huyt trung ng: suy tu, x tu.

- Thiu mau do hu hoi qua mc hng cu ngoi bin: cac bnh thiu mau tan
mau c th do: st rt, st vang da c ai ra huyt sc t, nhim khun, nhim c
(H2S va chi), huyt sc t bt thng trong mau.

- Thiu mau do mt nhiu mau trong chn thng

2. CAC THUC CHA THIU MAU THNG DUNG

2.1. ST

Vai tr va nhu cu st ca c th

C th ngi ln cha khong 3 - 5 gam st, trong phn ln c trong hng cu

(1,5 3 gam), phn cn li c trong sc t c (myoglobin), mt s enzym
(xanthinoxidase, - glycerophosphatoxidase) va d tr trong mt s m nh gan, lach,
ty xng. Thanh phn c bn chim 1/3 trng lng hng cu la huyt sc t
(hemoglobin). Huyt sc t mang oxy i khp c th nui sng cac t bao va vn
chuyn kh cacbonic thi ra ngoai nhm ap ng i sng ca con ngi. St la mt
thanh phn cu thanh nhn Heme ca huyt sc t trc tip gn kt vi oxy gip vn
chuyn oxy n cac c quan.

130
 ngi binh thng, nhu cu st hang ngay khong 0,5 - 1 mg trong 24 gi. Ph
n giai on c kinh nguyt nhu cu st cao hn khong 1 - 2 mg, khi c thai, cho con
b nhu cu st khong 5 - 6 mg trong 24 gi.

ng hc ca st trong c th

Ngun cung cp: ch yu t thc n c ngun gc ng vt va thc vt: gan, tim,

trng, tht nc, gia u, hoa qu.

St trong thc n (dng Fe2+ hoc Fe3+) vao c th chuyn thanh dng st hp thu
c la dng Fe2+ nh tac dng ca acid dch v. Mt s cht nh: phosphat, acid
nucleic, acid phytic, tanin, tetracyclin cn tr hp thu st. Vitamin C va protein cha
nhm - SH lam d hp thu st.

Trong mau: st kt hp vi transferin (la protein vn chuyn st trong mau) va

c a n cac m nh tu xng, c mt phn dng d tr cn mt phn to
ra hng cu va cac enzym.

St c thi tr qua phn, m hi va nc tiu.

Ch nh

Thiu mau nhc sc do thiu st: do chy mau, rong kinh, bnh nhn b st rt,
nhim giun mc, tr

Ngi mang thai, thi ki cho con b khi thiu mau do thiu st.

Tc dng ph:

ng ung: kch ng ng tiu ha, lm ging, bun nn, nn, tao bn.

ng tim: au ti ch tim, au u, bun nn, nn, st, shock kiu phn v.

Chng ch nh:

Lot d day- rut, chng kh tiu, tng d chy mau.

Cch dng, liu lng:

Ch phm ung: st (II) sulfat (Ferrosi sulfat, Feospan), st (II) oxalat (Feroxalat),
st fumarat, st gluconat (Cerrovon, Fergon, Gluconat ferreux). Dng kt hp st vi
acid folic, vitamin C, hn hp vitamin B (Iberet).

131
 Ch phm dng tim: st dextran (Imferon) va st sucrose (Venofer) dng tim
chm tnh mch hoc truyn tnh mch. Khi dng cn phi th vi liu thp trc
phng phn ng phn v.

Ngi ln liu trung binh 2 - 3 mg/kg cn nng tng ng 200 mg/ngay.

Tr nho liu trung binh 5 mg/kg cn nng/ ngay.

Ph n c thai hoc cho con b liu trung binh 4 - 6 mg/ kg cn nng/ ngay.

2. VITAMIN B12

Vai tr va nhu cu:

Vitamin B12 cn thit cho s cu to va phat trin ca hng cu, gip cho s phn
chia va tai to t bao ca t chc (c bit la t bao thn kinh). Tham gia tng hp
protid, chuyn ha lipid, gip c th trng thanh va bo v c th, chng nhim c,
nhim khun.

Nhu cu hang ngay i vi ngi ln khong 2g.

Dc ng hc

Ngun cung cp vitamin B12 nhiu nht la gan, tht, ca, trng. Trong thc vt
khng c vitamin B12. Trong c th mt s vi khun rut tng hp mt lng nho
vitamin B12 nhng khng cung cp cho c th.

Trong thc n vitamin B12 c dch v va protease gii phng ra khoi cac lin kt
vi protein va c gn vi yu t ni ti do t bao nim mc d day bai tit ra. Phc
hp vitamin B12 - yu t ni ti c hp thu ti nim mc hng trang va c chuyn
vao mau. Vitamin B12 tch tr nhiu gan (90%), phn cn li thn kinh trung
ng, tim va nhau thai. Vitamin B12 c thi tr qua phn, nc tiu. Vi c chu k
gan rut, cho nn c trng hp sau ct d day 3 - 4 nm mi c biu hin thiu
vitamin B12.

Ch nh

Thiu mau u sc hng cu to, thiu mau sau khi m, sinh , ct bo d day.

Vim, au dy thn kinh.

Phi hp vi cac vitamin khac khi c th suy nhc, suy dinh dng, tr em chm
ln, nhim khun, nhim c.

Tc dng khng mong mun

132
 C th gy d ng nh sc, may ay, nga, o da i khi rt nng.

Chng ch nh

Thiu mau cha ro nguyn nhn.

Ung th ang tin trin.

Mn cm vi thuc.

Cch dng liu lng

Cyanocobalamin (Residol) ng dung dch tim: 30,100, 500 va 1000 microgam.

Hydroxocobalamin (Codroxomin) ng tim ham lng t 50 5000 microgam,

dng vin 200, 500, 1000 microgam.

Ngoai ra c nhiu ch phm dng phi hp vi vitamin B1, B6 (Neuramin, H

5000) hoc acid folic, st, calci gluconat.

Cch dng, liu lng:

- Thiu mau ac tnh: tim bp 200 microgam/ln, cach 1 ngay tim 1 ln, t tim
10 - 20 ngay.

- Vim, au dy thn kinh: tim bp 500 - 1000 micro gam/1ln/1 tun, thng
dng phi hp vi vitamin B1, B6.

- Hydroxo 5000: cach 2 - 3 ngay tim bp 1 ng 250 microgam (khi thiu mau ),
tim bp 1 ng 5000 microgam, t tim 6 - 12 ngay (au dy thn kinh).

* Lu : Tranh dng Vitamin B12 ng IV vi b ao thi nhanh va c th gy sc

phn v, tt nht la IM, i vi trng hp nhe, u tin ng ung.

3. ACID FOLIC (VITAMIN B9)

Vai tr va nhu cu

Tham gia vao qua trinh tng hp acid nucleic nhng nguyn hng cu va qua
trinh tng hp cac amino acid. Acid folic la cht khng th thiu cho vic to hng cu
binh thng, khi thiu acid folic gy thiu mau nguyn hng cu khng l.

Nhu cu hang ngay vi ngi ln 180 200 microgam, vi ph n c thai cn

khong 400 microgam.

Ngun gc

133
 Acid folic khng ch c nhiu trong tht, ca, trng, gan, men bia ma cn c trong
rau xanh, hoa qu nhng rt d b phn hy trong qua trinh ch bin. Khi nu chn thc
n, c bit la rau xanh 90% acid folic b phn hy.

Ch nh

Chng thiu mau nguyn hng cu to khng c du hiu tn thng thn kinh,
thiu mau tan mau.

Phng va iu tr thiu ht acid folic khi mang thai, cho con b, do mt s thuc
khang acid folic (methotrexat, trimethoprim, pyrimethamin), thuc chng ng kinh
hydantoin, thuc lam hn ch hp thu va d tr acid folic trong m va trong mau
(thuc ung tranh thai).

Gim bch cu, chng mt bch cu ht.

Tc dng khng mong mun

Dung np tt, c th gp nga, ni ban, may ay hoc ri lon tiu ha.

Chng ch nh

Dng n thun cho cac trng hp thiu mau ac tnh.

Dng thuc - ham lng

Bit dc: Foldine vin 0,4mg, 0,8mg, 1 mg, 5 mg.

ng tim 2,5 va 5 mg/ml, tim di da, tim bp hoc tim tnh mch.

Cch dng, liu lng

Thiu mau hng cu to:

Ngi ln va tr em > 1 tui: 5mg/24h.

Tr em di 1 tui: 500 microgam/kg/24h.

B sung cho ph n mang thai: 200 400 microgam/24h.

134
 VITAMIN

MUC TIU
Nu c nh ngha, phn loi, vai tr sinh hc, bnh l do tha thiu vitamin
va nh hng ca vitamin n cac thuc dng chung.
Ngun gc, tnh cht, tac dng, dc ng hc, triu chng tha - thiu, ch
nh, cach dng, liu dng va bo qun cac vitamin thng dng.

NI DUNG
1. AI CNG
1.1. NH NGHIA
Vitamin la nhng cht hu c ma phn ln c th khng tng hp c.
Vitamin tac ng vi mt lng nho m bo s sinh trng va hot ng
binh thng ca c th.
Phn bit vitamin vi:
Cht khoang: cht dinh dng tac dng nho nhng la
cht v c.
Lipid, glucid, protid: cht hu c nhng tac dng vi
lng ln.
1.2. PHN LOAI
Cn c vao tnh tan, ngi ta phn vitamin ra thanh hai nhm:
Vitamin tan trong nc: vitamin nhm B va C.

135
 Vitamin tan trong du: A, D, E, K.
1.3. VAI TR SINH HOC
Vitamin tac dng nh mt coenzym (vitamin nhm B) gp phn vao nhiu
phn ng ca enzym chuyn ha cac cht glucid, lipid, protid thanh nng
lng cn thit cho hot ng t bao.
V d:
Vitamin B1 tham gia chuyn ha hydrocarbon.
Vitamin B2 tham gia chuyn ha protid, lipid.
Vitamin tac ng chng oxy ha: vitamin A, C, E.
Vitamin tac ng nh mt hormon: vitamin A, D.
1.4. NGUYN NHN V HU QU THIU VITAMIN
1.4.1. Nguyn nhn
Dinh dng
Thc phm km cht lng.
Bo qun khng ng, ch bin.
n king.
Ri lon hp thu
Lot, ct d day.
Bnh gan, ty, mt.
Nghin ru.
Cung cp khng nhu cu
Ph n c thai, nui con b.
Tui dy thi.
Bnh nhn sau m dy.
Nguyn nhn khac
Dng khang sinh, sulfamid dai ngay.
Tr s sinh: thiu vitamin K.
Thuc nhun trang, du khoang, antacid cn tr hp thu vitamin A.
1.4.2. Hu qua
Mt s bnh gy ra do thiu vitamin
Thiu vitamin A: tr chm ln, quang ga, kh mt.
Thiu vitamin B1: t ph.
136
 Thiu vitamin C: chy mau chn rng.
Thiu vitamin D: ci xng.
1.5. NGUYN NHN V HU QU THA VITAMIN
1.5.1. Nguyn nhn
Lm dng vitamin di dng thuc.
n ung: t gp vi c th c c ch t iu chnh trong qua trinh hp thu qua ng
tiu ha.
1.5.2. Hu qua
Ni chung tha vitamin tan trong nc thng khng gy hu qu vi chng thi
nhanh qua thn, nhng mt vitamin tan trong du (A, D) khi dng tha c th gy
bnh l nguy him:
Tha vitamin A: c gan, tng ap lc ni s, da kh,
rng tc.
Tha vitamin D: tng huyt ap, tng calci huyt, soi
thn.
1.6. NH HNG CA VITAMIN N TAC DUNG CA THUC KHAC
Vitamin B3 dng chung thuc h huyt ap (c ch adrenergic): gy h
huyt ap th ng.
Vitamin B6 dng chung levodopa: mt hot tnh levodopa.
Vitamin C dng chung penicillin, ampicillin, erythromycin: gim hot tnh;
dng chung alcaloid: tng thi tr.
Vitamin D dng chung digitalis: lon nhp tim.
Vitamin K dng chung chng ng mau (dicoumarol): gim tac dng.
2. CAC VITAMIN TAN TRONG DU
2.1. VITAMIN A (RETINOL)
Arovit, Avibon
2.1.1. Ngun gc
ng vt (retinol): du gan ca thu, b, sa, lng o trng.
Thc vt (tin vitamin A carotene): ca rt, ca chua, gc, bu, b
2.1.2. Tnh cht
Tinh th mau hi vang, d b oxy ha, bn vi acid, kim va nhit.
2.1.3. Tc dung
137
 To sc t th giac nhin trong ti.
Bit ha va duy tri biu m.
Gip phat trin xng, phat trin phi thai, tng trng tr em.
Tng cng chc nng min dch va gim nhim khun.
2.1.4. Dc ng hc
Hp thu: tt qua ng ung cng vi du m trong thc n nh mui mt.
Phn b: tch luy phn ln gan (90%), 5% vao mau.
Thi tr: thn mt.
2.1.5. Triu chng thiu
Quang ga, kh kt mc, vt bitot trn cng mc, tng sng ha nang lng.
2.1.6. Triu chng tha
Ng c cp
Xy ra khi dng vitamin A theo liu sau:
Ngi ln: liu duy nht 1.500.000 IU.
Tr em: Liu duy nht 300.000 IU.
Triu chng: chng mt, bun nn, ban o, da trc vy.
Ng c mn
Xy ra khi dng liu:
Ngi ln: 25.000 100.000 IU trong thi gian dai.
Triu chng: au xng, rng tc, tng ap lc ni s, gan lach to.
2.1.7. Ch nh
Thiu vitamin A: quang ga, kh mt.
Bnh v da: trng ca, vy nn.
Ung th va cac bnh nhim trng.
2.1.8. Cch dng liu dng
Dng dng
Vin nang, bao 5.000 IU, 50.000 IU.
Hn dch ung 150.000 IU/ml.
ng tim 100.000 IU/ml.
Kem bi xoa.
Cach dng liu dng

138
Ty theo bnh, cng thiu vitamin A va theo tui.
Ung, tim bp: ngi ln va tr em > 8 tui: 5.000 10.000 IU/ngay x vai tun
Tr < 8 tui: 2.000 5.000 IU/ngay x vai tun.
2.2. VITAMIN D (CALCIFEROL)
Aldevit, Vitasterol, Vigantol.
2.2.1. Ngun gc
Ni sinh: 7dehydrocholesterol (tin vitamin D/da) UV
cholecalciferol
(D3).
T nhin: du gan ca thu, m ng vt, b, sa, lng o trng (D3).
Tng hp: t ergosterol c trong nm, men bia.
Ergoterol UV
Ergocalciferol (D2).
V hot tnh khng c s khac bit gia D2 va D3.
2.2.2. Tnh cht
Tinh th hinh kim, khng mau, khng mi, khng v, khng tan trong nc, tan
trong dung mi hu c, du, cht bo. B phn hy bi anh sang, acid.
2.2.3. Tc dung
Vitamin D2, D3 c hydroxyl ha ti gan, thn thanh Calcitriol la dng c hot
tnh:
Tng Ca2+ huyt (tng calci rut, huy ng Calci t xng vao mau, tai
hp thu calci va phosphat).
Tac ng trn xng, biu bi va t bao bit ha (tng thanh lp xng, bit
ha biu bi, c ch tng sinh va cm ng bit ha t bao ac tnh).
2.2.4. Dc ng hc
Hp thu: tt qua mang rut.
Phn b: Tch tr ch yu m m va c.
Thi tr: ch yu qua phn.
2.2.5. Triu chng thiu
Tr em: ci xng (xng bin dng), c km phat trin.
Ngi ln: nhuyn xng.
2.2.6. Triu chng tha
Liu gy tha: 50000 IU/ngay trong vai thang.

139
 Triu chng: Calci huyt cao, tiu nhiu, mt nc, lo u, nn ma, nu ko
dai calci lng ng m mm gy soi thn, tng huyt ap.
X tr:
Ngng vitamin D va Calci.
Ung nhiu nc.
Dng thm furosemide, corticoid.
2.2.7. Ch nh
Phng va tr bnh ci xng tr em.
Tr nhuyn xng ngi ln.
Nhc nng tuyn cn giap.
H calci huyt.
2.2.8. Chng ch nh
Tng Ca2+ huyt.
Mn cm.
Bnh cp gan, thn.
2.2.9. Cch dng liu dng
1 IU = 0,025 g D3 hay
1 g D3 = 40 IU.
Dng dng
Vin bao 500 IU, vin nang 500 1000 IU.
Dung dch du 10000 IU/ml, 500000IU/ml.
Cach dng liu dng
D phng ci xng
Dng hang ngay: 1200 IU/tr em, 400 2000 IU/ngi ln.
400 600 IU/ph n c thai, nui con b.
Dng nh ki 6 thang: 200000 IU la xu hng chn la.
iu tr ci xng, loang xng:
4000 8000 IIU/tr em trong ba tun.
4000 20000 IU/ngi ln n khi khoi bnh.
iu tr co git:
Dng liu phng ci xng va cn kt hp thm mui calci.

140
2.3. VITAMIN E (TOCOFEROL)
Ephynal, Tocomin, Aquasol E.
2.3.1. Ngun gc
C nhiu trong du ht thc vt (m, lc, u nanh, hng dng)
Ngoai ra cn c torng gan b, lng o trng, cy xanh.
2.3.2. Tnh cht
Cht long sanh nh du, mau hi vang, khng mi v, khng tan trong nc, tan
trong du va cac dung mi hu c. B hy hoi nhanh chng bi tia cc tm, d b
oxy ha. Bn vi acid, kim, chu nhit n 400C.
2.3.3. Tc dung
Chng oxy ha, bo v mang t bao khoi s tn cng ca gc t do nhm tranh
thanh lp sn phm c ca s oxy ha.
2.3.4. Dc ng hc
Hp thu: tt qua rut.
Phn b: Khp cac m, kh qua nhau thai, tch tr ch yu gan va m m.
Thi tr: qua phn.
2.3.5. Triu chng thiu
Thn kinh va c: yu c, tht iu, rung git nhan cu, mt cm giac au va
xc giac.
Tr non: Thiu mau tiu huyt, chy mau tm tht.
2.3.6. Triu chng tha
Vitamin E t c nht trong cac viatmin tan trong du.
Liu 300 3200 mg/ngay: ri lon tiu ha, suy nhc, mt moi.
Liu 200 270 mg/ngay x thi gian dai: cn d tr vitamin A, c ch hp
thu va tac dng ca vitamin K.
Liu rt cao 1,3 1,8 g/ngay: ri lon tiu ha, gim chc nng sinh dc,
gim creatinin.
2.3.7. Ch nh
iu tr va d phng thiu vitamin E.
Dng ti ch lam m da va ngn tac dng ca tia UV.
Phng sy thai, v sinh, thiu nng to tinh trng.

141
 Ri lon kinh nguyt, tin man kinh.
Cn th.
Tr thiu mau tiu huyt va chy mau tm tht tr non.
2.3.8. Chng ch nh
Tim tnh mch gy c gan, thn, phi, h to mau.
2.3.9. Cch dng liu dng
Dng dng
Vin bao, nang: 100, 200, 400, 500 mg.
ng tim 500 mg/ml.
Cach dng liu dng
Ung 100 500 mg/ngay
Tim bp: 1 2 mg/kg.
2.4. VITAMIN K (Xem bai thuc cm mu).
3. CAC VITAMIN TAN TRONG NC
3.1. VITAMIN B1 (Thiamin)
Bevitin, Benerva
3.1.1. Ngun gc
Thin nhin: ng vt: tht heo, gan, thn, lng o trng.
Thc vt: mm la, men bia, cam go.
Ni sinh: Vi sinh vt trong rut tng hp
Tng hp: t nm 1936.
3.1.2. Tnh cht
Bt kt tinh trng hoc hi vang, mi thm men, v hi ng. D tan trong nc va
d mt tac dng bi nhit.
3.1.3. Tc dung
Tham gia chuyn ha carbonhydrate.
Tng tng hp acetylcholin cn cho dn truyn thn kinh.
3.1.4. Dc ng hc
Hp thu: tt qua ng tiu ha.
Phn b: m c va m thn kinh.
Thi tr: Thn.

142
3.1.5. Triu chng thiu
Nhe: chan n, vp b, d cm, d b kch thch.
Nng: nh hng n tim mch (beri beri t) hoc thn kinh (beri beri
kh).
Beri Beri t: suy tim cung lng cao va ph (ph phi, ph ngoi bin)
xy ra i tng hot ng th lc nng va n nhiu glucid.
Beri Beri kh: au, mt phn x, vim thn kinh, lit, teo c, m sng xy
ra i tng t hot ng va n t glucid.
3.1.6. Ch nh
Cha bnh Beri Beri
Phng thiu vitamin B1.
au nhc, au lng, au thn kinh hng, au thn kinh sinh ba.
3.1.7. Chng ch nh
Tim IV ( sc ngng h hp va ngng tim).
3.1.8. Cch dng liu dng
Dng dng
Vin nn, bao: 50, 100, 250mg.
ng tim 100, 200mg/ml.
Cach dng liu dng
Phng bnh: 50 100mg/ngay.
Tr bnh:
Ung: 250 500 mg/ngay.
Tim bp 100mg/ngay.
au nhiu dng liu cao: 500 1000 mg/ngay.
3.2. VITAMIN B2 (RIBOFLAVIN, VACTOFLAVIN)
Beflavin
3.2.1. Ngun gc
Thin nhin: cam, sa, sn phm t sa, men bia, tht, lng trng trng.
Ni sinh: vi sinh vt rut tng hp nhiu hn thc n a vao.
Tng hp: 1935.
Vitamin B2 d tr gan, tim, thn nn c th t thiu B2.
3.2.2. Tnh cht
143
Bt tinh th mau vang cam, v ng, kh tan trong nc va dung mi hu c,
khng b phn hy bi nhit va oxygen nhng d hong ngoai anh sang va mi
trng kim.
3.2.3. Tc dung
Tham gia chuyn ha glucid, lipid va protid.
Dinh dng da va nim mc.
3.2.4. Dc ng hc
Hp thu: tt qua rut.
Phn b: tch tr tim, gan, thn.
Thi tr: nc tiu va phn.
3.2.5. Triu chng thiu
Ri lon tiu ha.
Cng t kt mc, vim giac mc.
Vim li, lot mi, vim da tng tit ba nhn.
Thiu mau.
3.2.6. Ch nh
Dng trong tn thng mt, da, nim mc.
Thng phi hp vi vitamin B1, B3.
3.2.7. Liu dng
Dng dng
Vin nn 1mg, 5mg, 10mg.
ng tim 10mg.
Thuc nho mt 0,01 0,1%.
Cach dng liu dng
Ung: 5 30 mg/ngay.
Tim bp: 3 5 mg/ngay.
Nho mt: 1 git/ln x 2 3 ln/ngay.
3.3. VITAMIN B3 (NIACIN, VITAMIN PP)
Nicobion
Niacin la tn chung gi acid nicotinic va dn xut cu acid nicotinic
(nicotinamid).

144
 Acid nicotinic: c nhiu trong du thc vt.
Nicotinamid: c nhiu trong ng vt.
3.3.1. Ngun gc
Thin nhin: Gan, thn, tht, ca, ngu cc, men bia, rau xanh, ht u.
Ni sinh:
Vi sinh vt trong rut.
Trong m: Tryptophan B6
Niacin
3.3.2. Tnh cht
Tinh th hinh kim, khng mau, v ng, mi c trng, tan trong nc va ethanol,
khng b phn hy khi un nu.
3.3.3. Tc dung
La coenzym xc tac phn ng oxy ha kh trong h hp t bao.
Tham gia chuyn ha glucid, lipid, protid.
Acid nicotinic lam gim LDL va tng HDL, lam dan mch ngoi bin.
3.3.4. Dc ng hc
Hp thu: d dang qua ng ung.
Phn b: Trong tt c cac m, d tr gan.
Thi tr: thn.
3.3.5. Triu chng thiu
Nhe: chan n, suy nhc, au hng, vim li, vim hng.
Nng: bnh Pellagra vi 3 du hiu c trng:
Vim da: kiu i xng sm da, da kh, trc vy.
Tiu chy: C th nng lam teo nhung mao rut.
Sa st tr tu: Ln, nh km, o giac, tm thn.
3.3.6. Ch nh
Tr bnh pellagra.
Phng thiu niacin.
Ri lon tiu ha, ri lon thn kinh.
Acid noctinic liu cao (500mg/ln x 3 4 ln/ngay) tr chng tng lipid
huyt, tng cholesterol huyt, x ng mch.
3.3.7. Ch

145
 Acid nicotinic liu cao gy dan mch ngoi bin lam da o bng, kch thch
d day, nga.
Khc phc: Bt u liu thp, tng liu t t, ung sau ba n, ung 325 mg
aspirin 30 pht trc khi ung niacin (gim prostagladin).
3.3.8. Cch dng liu dng
Niacin c tnh bn n v NE, 1 NE = 1mg Niacin.
Dng dng
Vin nn, nang: 50mg, 500mg.
ng tim 100mg/ml.
Cn ngt 50mg/5ml.
Cach dng liu dng
Phng bnh ung: 50 200 mg/ngay.
Tr bnh: Ung 200 500 mg/ngay.
Tim bp, tim tnh mch chm: 500 mg chia liu nho.
Tr em: 1/3 1/2 liu dng ngi ln.
3.4. VITAMIN B5 (ACID PANTHOTHENIC)
Bepanthene
3.4.1. Ngun gc
C nhiu torng lng o trng, thn, gan, tht b, men bia, bp ci.
3.4.2. Tnh cht
Cht long, nht, mau vang, ht m. S dng ch yu dng mui calci la tinh th c
v ngt tan trong nc.
3.4.3. Tc dung
La thanh phn cu to ca coenzym A gip tn to glucid, phn hy acid
bo, tng hp steroid, hormon vo thng thn.
Sn sinh m biu bi, gip lanh seo
n nh hot tnh protein.
3.4.4. Dc ng hc
Hp thu: tt qua tiu ha.
Phn b: Trong cac m, khng b phn hy trong c th.
Thi tr: thn.

146
3.4.5. Triu chng thiu
Thoai ha thn kinh c va thiu nng vo thng thn: mt moi, nhc u, ri lon
gic ng, bun nn, i, au bng, y hi, co tht c.
3.4.6. Ch nh
Ri lon dinh dng mng chn, mng tay, rng tc.
Co git thi ki mang thai.
3.4.7. Cch dng liu dng
Vin nn 25 545 mg (dng penthothenat calci).
ng tim 500 mg.
Cach dng liu dng
Ung
Ngi ln: 100 400 mg/ngay.
Tr em 100 150 mg/ngay.
Tim bp, tim tnh mch: 50 1000mg/ngay x 3 ln/tun x 6 tun.
3.5. VITAMIN B6 (PYRIDOXIN)
Besivit, Becilan
3.5.1. Ngun gc
Tht ga, gan, thn, ca trng, ngu cc, rau ci va trai cy.
3.5.2. Tnh cht
Tinh th trng, v ng, tan trong nc va cn. Bn vi nhit, nhy cm vi tia UV
va s oxy ha, vi th vitamin B6 cn bo qun tranh anh sang (chai mau nu).
3.5.3. Tc dung
Tham gia chuyn ha protid.
Tham gia chuyn ha tryptophan B6
acid nicotinic.
Tham gia tng hp heme.
Tham gia qua trinh chuyn ha nao, nh hng n hot ng ca h thn
kinh.
3.5.4. Dc ng hc
Hp thu: tt qua ng ung.
Phn b: phn ln khp c th.
Thi tr: thn.
3.5.5. Triu chng thiu
147
Nh
Da: vim da tng tit ba nhn, vim li, kh nt mi.
Thn kinh: suy nhc, d b kch thch.
Nng
Vim thn kinh ngoi bin, thiu mau, co git.
3.5.6. Ch nh
Phng va iu tr thiu B6.
Ngn nga cac ri lon h thn kinh do mt s thuc gy ra nh
isoniazid
Co git, thiu mau, chng nn.
3.5.7. Ch
Khng nn phi hp vi levodopa.
Qua liu (2 10g): bn chn v m, mt iu ha, vng v, t cng tay
chn khi ngng thuc triu chng nay ht.
3.5.8. Cch dng liu dng
Dng dng
Vin nn 10, 50, 100, 250mg.
ng tim 100mg/ml, 250mg/ml.
Cach dng liu dng
Ung, tim bp, tim tnh mch: 50 250 mg/ngay, cung c khi cn n 600
mg/ngay.
3.6. VITAMIN B8 (BIOTIN VITAMIN H)
3.6.1. Ngun gc
Thin nhin: gan b, sa b, ca, lng o trng, khoai ty, chui.
Ni sinh: vi khun rut tng hp.
Tng hp: nm 1994.
3.6.2. Tnh cht
Cht kt tinh ha tan nhiu trong nc, bn vi oxy, H 2SO4 va nhit nhng b phn
gii bi H2O2, nc brom, HCl, NaOH.
3.6.3. Tc dung
Tham gia chuyn ha lipid, glucid va acid amin.
Dinh dng da va nim mc.
148
3.6.4. Triu chng thiu
Da: vim da, vim li, au c, tuyn m da bai tit nhiu m.
Tc: rng tc.
3.6.5. Ch nh
Tr bnh ngoai da: tng tit ba nhn, kh bong da, mn trng ca.
Vim li, ri lon tiu ha, rng tc.
3.6.6. Cch dng liu dng
Dng dng
Vin nn 5 mg.
ng tim 5mg/ml.
Cach dng liu dng
Ngi ln
Ung: 2 4 vin/ngay.
Tim bp: 1 4 ng/ngay.
Tr em
Ung: 1 2 vin/ngay.
Tim bp: 1 ng/ngay.
Dng n 40mg/ngay khng thy tac dng ph.
3.6.7. Ch
n lng trng trng trong thi gian dai gy thiu biotin (avidin trong lng trng +
biotin to thanh phc hp gy cn tr hp thu B8).
3.7. VITAMIN B9 (Xem bai thuc thiu mu).
3.8. VITAMIN B12 (Xem bai thuc thiu mu).
3.9. VITAMIN C (AICD ASCORBIT)
Upsa C, Laroscorbin, C 1000
3.9.1. Ngun gc
C trong hu ht rau ci ti, trai cy xanh chua, c t trong tht.
Tng hp ha hc nm 1993.
3.9.2. Tnh cht
Tinh th khng mau hoc bt kt tinh trng, v chua, d tan trong nc. D b phn
hy nhit, anh sang, O2, kim loi nng va cac cht oxy ha.
3.9.3. Tc dung

149
 Cht chng oxy ha mnh.
Tng hp collagen, proteoglycan to m lin kt trong xng, rng va
ni m mch mau.
Chuyn ha lipid, glucid va protid.
Ngn thanh lp nitrosamin.
Tham gia chuyn ha Fe, acid folic va methemoglobin.
Tng hp khang th.
3.9.4. Dc ng hc
Hp thu: tt qua nim mc rut.
Phn b: cac m, c bit tuyn yn, thng thn, gan, c bp, nao va bch
cu.
Thi tr: thn.
3.9.5. Triu chng thiu
Giai on u: bnh scorbut (xut huyt di da, khp xng va chn rng,
vt bm tht, sng nu rng, rng d rng, vt thng chm ln seo).
Giai on cui: ph, gim tiu, chy mau nao ri cht.
3.9.6. Triu chng tha
Liu < 1g/ngay: an toan.
Liu > 1g/ngay: gy cac tac hi sau:
Kch thch d day, y hi, tiu chy (ung).
Suy thn nng, tch t oxalat thn, lon nhp tim (tim).
Tan mau ngi thiu men G6PD.
3.9.7. Ch nh
Tr bnh scorbut
Phng thiu viamin C.
Tng sc khang cho c th.
3.9.8. Chng ch nh
Tim 1g/ngay.
Thiu men G6PD
Soi thn.
3.9.9. Cch dng liu dng

150
 Dng dng
Vin nn, nang, si bt: 50mg n 1000mg.
ng tim 100, 500, 1000mg.
Cach dng liu dng
Phng nga: ung, tim bp: 100mg/ngay.
iu tr: Ung, tim bp: 500 1000mg/ngay.

THUC TIM MACH

MUC TIU HOC TP

Trinh bay c cach phn loi, c im tac dng ca tng nhm thuc
cha bnh tim mch.
Nu c ngun gc, tnh cht dc ng hc, ch nh, chng ch nh, tac
dng ph, cach dng, liu lng va cach bo qun cac thuc.

NI DUNG BI HOC
Thuc cha bnh tim mch gm c:

151
 Thuc tr thiu mau tim cc b.
Thuc tr tng huyt ap.
Thuc li tiu.
Thuc tr suy tim mn.
Thuc tr tng lipid huyt.

A. THUC TR THIU MAU TIM CUC B

Thiu mau tim cc b khi cung cp oxy ca mch vanh khng ap ng nhu cu oxy
ca c tim. Bnh thiu mau tim cc b t nhe n nng theo th t sau:
au tht ngc: Th hin bng cac cn au ko dai vai
giy n vai pht, nu cn au qua 15 20 pht phi nghi ng c nhi mau c
tim.
Nhi mu c tim: La s ngng t ngt cung cp mau
cho mt vng c tim do nghn hoan toan hay gn nh hoan toan mch vanh. S
nghn nay ko dai n mc thiu mau tim cc b, tn thng va hoi t m tim
c th khng hi phc.
1. NHM NITRAT
Gm Nitroglycerin (Lenitral), Isosorbid dinitrate (Risordan), Isosorbid mononitrate
(Imdur)
1.1. TINH CHT
Nitroglycerin la cht long, sanh, khng mau rt t tan trong nc, tan trong ethanol,
eter, cloroform, d n khi va chm mnh.
1.2. TAC DUNG DC LY
Dan ng mch, tnh mch toan thn trong dan tnh
mch la ch yu. Mc dan mch ca nitrat theo th t sau: dan tnh mch >
ng mch > mao mch.
Dan c trn kh ph qun, ng tiu hoa, niu sinh
dc, ng mt.
1.3. DC NG HOC
D hp thu qua ng tiu hoa, khng bn trong dch v, c chuyn hoa qua gan
ln u nn sinh kh dng ng ung thp, vi vy thng bao ch dng ngm di
li. Nitroglycerin t di li t Cmax sau 4 pht, t1/2 khong 3 pht. Isosorbit

152
dinitrat t di li t C max sau 6 pht, t1/2 khong 45 pht; cht chuyn hoa la
isosorbit mononitrat vn cn hot tnh vi t 1/2 khong 2 5 gi. Isosorbit mononitrat
hp thu tng t nhng khng chu s chuyn hoa qua gan ln u nn hiu lc ko
dai hn. ao thi qua thn la ch yu.
1.4. CH NH
Thuc u bng iu tr au tht ngc mi th, ct
cn nhanh chng.
Phng nga au tht ngc do stress hay gng sc.
Nhi mau c tim.
Suy tim huyt mn
Ph phi cp.
1.5. TAC DUNG KHNG MONG MUN
Nhc u (do dan mch nao), o bng mt ( do dan
mch ngoi vi).
H huyt ap t th, tng nhan ap.
Nhp tim nhanh phn x va tng co bp c tim c th
lam tng nghch l nhu cu oxy ca c tim (him gp).
Khi s dng liu cao va thi gian ko dai gy: dung np
thuc ( hn ch hin tng nay thng dng cach quang 8 12 gi) va l thuc
thuc (do khng ngng nitrat t ngt sau khi a s dng mt thi gian dai).
Nng cao trong mau c th gy Met Hb.
1.6. THN TRONG
Try tim mch, huyt ap ti a di 90 mmHg.
Tng ap lc ni s, tng nhan ap.
Bnh c tim tc nghn.
Phi nhp vin nu ngm 3 vin nitrat cach nhau 5 pht
ma vn khng gim au tht ngc vi la du hiu nhi mau c tim cp.
1.7. CH PHM LIU DNG

Tn thuc ng dng Liu S ln/ngay

153
Nitroglycerin Vin ngm di li 0,15-0,6 mg Theo nhu cu
(Glycerin trinitrate Dng xt
Nitrobid, Nitrostat, Vin gii phng chm 0,4 mg Theo nhu cu
Nitrodur, Natispray, M bi 2,5 - 9,0 mg Mi 6-12 gi
Nitromit...) Ming dan
Dng tim truyn TM 1,25 5 cm Mi 4-8 gi
2,5 - 15 mg Mi 24 gi
5-400mg/pht Truyn lin tc

Isosorbide dinitrate Vin ngm di li 2,5 - 10 mg Mi 2 - 3 gi

(Isosorbid, Lenitral, Vin nhai
Sorbitrate) Vin ung Vin chm 5 - 10 mg Mi 2 - 3 gi
10 - 40 mg Mi 6 gi
40 80 mg Mi 8 - 12 gi

Isosorbid mononitrate Vin ngm di li 10 - 40 mg Mi 12 gi

(Imdur, Ismo) Vin chm
60 mg Mi 24 gi

Erythrityl tetranitrate Vin ngm 5 - 10 mg Theo nhu cu

(Cardilate) Vin ung 10 mg Mi 8 gi

2. BLOCKER
Propranolol, Atenolol, Metoprolol, Bisoprolol, Carvedilol, Nebivolol, Nadolol.
2.1. DC NG HOC
Hu ht cac - blockers hp thu tt qua ng ung (tr atenolol, nadolol).
Propranolol chu tac dng qua gan ln u nn sinh kh dng thp. c phn phi
nhanh chng vao c th. Cac thuc u qua c nhau thai va sa me.
2.2. TAC DUNG
Lam chm nhp tim, gim sc co bp c tim gim cng nng tim gim s
dng oxy ca c tim.
Tng cung cp mau cho vng c tim b thiu mau.
2.3. CH NH
iu tr au tht ngc do gng sc.
Phng nga cn au tht ngc.

154
 Thuc quan trng iu tr trong va sau nhi mau c tim.
Tng huyt ap.
Suy tim mn vi 4 thuc chen sau: metoprolol, bisoprolol, carvedilol, nebivolol.
Lon nhp, cng giap (propranolol)
2.4. TAC DUNG PHU
Mt moi, mt ng, au na u, trm cm hoc kch thch.
Nhp tim chm, bloc nh tht.
Che y phn ng bao hiu s h ng huyt, dng lu dai c th gy khang
insulin.
Chen khng chn lc gy co tht ph qun gy cn hen ph qun.
Ri lon tun hoan ngoi vi.
C th gy lit dng.
Tng LDL, triglyceride, gim HDL.
Ngng thuc t ngt gy hin tng di ngc.
2.5. CHNG CH NH
au tht ngc Prinzmetal.
Suy tim vi EF < 35%, tuy nhin hin nay mt s thuc chen (metoprolol,
bisoprolol, carvedilol, nebivolol) s dng liu thp iu tr suy tim mn mc nhe va
va ci thin c tinh trng suy tim.
Nhp chm (di 60 ln/pht), block nh tht 2, 3.
Huyt ap ti a < 90 mmHg
Hen suyn, COPD.
Hi chng Raynaud, ri lon tun hoan ngoi vi.
C a d h glucose mau
Ph n mang thai, cho con b, ngi suy gan thn.
2.6. CH PHM LIU DNG
Propranolol (Inderal): 40 80 mg/ngay.
Nadolol (Corgard): 40 80 mg/ngay. Ti a 320mg/ngay.
Metoprolol (Betaloc): 50 100 mg/ngay. Ti a 200 mg/ngay.
Atenolol (Tenormin): 50 100 mg/ngay.
Bisoprolol (Concor): 2,5 5 mg/ngay. Ti a 10 mg/ngay.
3. CHN KNH CALCI

155
 Diltiazem (Cardiazem, Altiazem)
Verapamil (Calan, Isoptin)
Nifedipine (Adalat, Timol, Procardia)
Amlodipine (Amlor, Norvasc)
Felodipine (Plendil)
Lacidipine (Lacipil, caldine)
Tc dung chng au tht ngc:
Trn tim: Gim nhu cu s dng oxy ca c tim (tac dng chnh). Phn phi li
mau c li cho vng ni tm mc.
Trn mch: Dan mch vanh tng cung cp oxy cho c tim.
(Xem thm bai thuc tr tng huyt p).
4. THUC TAC NG TRN CHUYN HA NNG LNG T BO
TRIMETAZIDINE (VASTAREL)
C ch tc dung
c ch hot tnh men 3 Ketoacyl CoA Thiolase (3 KAT) chuyn sn xut
ATP sang con ng oxy ha glucose cn t oxy hn sn xut ATP c hiu nng
hn trn 1 phn t oxy thch hp trong tinh trng oxy ang b gim cung cp do
thiu mau cc b c tim.
Bo v t bao c tim khi b thiu mau, ko thi gian chu ng thiu oxy ca c
tim.
Lam gim s cn au tht ngc, gim s lng nitrat dng hang ngay ct
cn au va tng kh nng gng sc.
Ch nh
Thuc iu tr c bn chng cn au tht ngc
Tc dung phu
Gy ri on tiu ha nhe, an thn, bun ng
Chng ch nh
Mn cm
Ph n c thai cho con b
Ngi mc hi chng Parkinson, c cac triu chng ri lon vn ng.
Ch phm liu dng
Trimetazindine: Vastarel 20 mg: ung 1 vin x 3 ln/ngay;

156
 Vastarel MR 35 mg: ung 1 vin x 2 ln/ngay.

B. THUC TR TNG HUYT AP

1. PHN LOAI TNG HUYT AP
Tng huyt ap nguyn phat cn gi la tng huyt ap v cn vi nguyn nhn tng huyt
ap khng c bit. Loi tng huyt ap nay chim 90% dn s tng huyt ap.
Tng huyt ap th phat la hu qu ca mt s bnh nh suy thn, suy timLoi tng
huyt ap nay chim 10% dn s tng huyt ap.
BNG PHN LOAI TNG HUYT AP CA NGI LN

Phn Loai HA tm thu (mmHg) HA tm trng (mmHg)

Binh thng < 120 < 80
Huyt ap cao
Tin tng HA 120 139 80 - 89
Giai on 1 140 159 90 - 99
Giai on 2 160 100

2. PHN LOAI THUC TR TNG HUYT AP

Da theo c ch tac dng c cac nhm:
Thuc li tiu: thi natri va nc nn lam gim th
tch tun hoan.
Nhm thiazide.
Thuc li tiu quai.
Thuc hu giao cam
Tac dng trung ng: methyldopa, clonidine.
Thuc lit hch: trimethaphan.
Thuc phong to nron: guanethidine, reserpin.
Thuc chen : propranolol, metoprolol, atenolol, bisoprolol
Thuc hu : prazosin, phenoxybenzamine.
Thuc dn mach trc tip
Dan ng mch: hydralazine, minoxidil, diazoxide.
Dan ng va tnh mch: nitropruside.
Thuc chn knh Calci
Nifedipine, amlodipine, felodipine, nicardipin, lacidipine, verapamil, diltiazem
Thuc c ch men chuyn

157
 Captopril, enalapril, peridopril, ramipril, lisinopril
Thuc i khng tai thu th angiotensin
Losartan, irbesartan, candesartan, valsartan, telmisartan
3. MT S THUC TR TNG HUYT AP
3.1. THUC CHN KNH CALCI
Tc dung
Trn mch: Dan mch ngoi vi, ch yu dan ng mch, lam gim sc cn
ngoi bin gim huyt ap. Dan mch vanh lam tng ti mau, tng cung cp
oxy cho vng c tim b thiu. (Nifedipine, amlodipine, felodipine, nicardipin,
lacidipine).
Trn tim: Gim dn truyn, gim nhp tim va gim co bp c tim.
gim nhu cu oxy c li cho bnh nhn tim thiu mau cc b.
(Verapamil, Diltiazem).
Ch nh
Tr tng huyt ap.
iu tr cn au tht ngc th n nh.
Verapamil, diltiazem c ch nh trong nhp tim nhanh.
Tc dung phu
Tac dng nhe, khng cn ngng iu tr: cn nng bng, nhc u, chng mt,
hi hp, phn x nhp tim nhanh (do phn x gian mch nn dng cng vi thuc
chen giao cm), kh ming, bun nn, tao bn (ro nht vi verapamil nht la
ngi gia), ph chi di. (Gp vi cac thuc tac ng u th trn mch mau).
Tac dng nng hn, him gp lin quan n tac dng iu tr do c ch qua
mnh knh Ca: mt moi, tim p chm, nghn nh tht, suy tim nng hn. (Vi cac
thuc tac ng u th trn tim).
Chng ch nh
Hep ng mch ch nng, huyt ap thp < 100 mmHg.
Nhp chm (< 50 nhp/pht), suy tim mt b, bloc nh tht, bloc xoang nh.
Thn trng trong suy gan, ngi mang thai va thi k cho con b.
Ch phm
Nifedipine (Adalat) vin nn 10, 20, 40 mg; tac dng nhanh, ngn. Dng Adalat
LA 30mg, Adalat LP 20mg tac dng ko dai. Ung 20 60 mg/ngay.

158
 Amlodipine (Amlor) vin nang 5mg, ung 5 10 mg/ngay.
Felodipine (Plendil) vin nn 2,5; 5; 10 mg tac dng ko dai. Liu khi u 2,5
mg. Thng dng 5 10 mg/ln/ngay.
Lacidipine (Lacipil) vin nn 2;4 mg. Khi u 2mg/ngay. Ti a 6mg/ngay.
Diltiazem (Deltazen LP 300mg; Dilrene 300mg, tac dng ko dai) ung 120
360 mg/ngay. Diltiazem (Tildizem) vin nn 30mg, 60mg, tac dng nhanh, ngn.
Verapamil (Isoptine) vin nn 40 80 120 mg, tac dng nhanh, ngn; Isoptine
LP, vin nn 240mg; Arpamil LP, vin nang 240mg, tac dng ko dai. Ung: 120
240 mg/ngay.
3.2. THUC C CH MEN CHUYN
C ch tc dung
Men chuyn xc tac cho qua trinh to angiotensin II la mt cht gy co mch va
gi mui va nc li trong c th (thng qua aldosteron). c ch men chuyn lam
gim sn sinh angiotensin II dan mch, thi mui nc h huyt ap.
Trn mch: Dan mch, gim phi i, tng tnh an hi va ci thin chc nng
mch mau.
Trn tim: Gim phi i va x hoa tm tht.
Ch nh
Tng huyt ap. Thuc c dng trong nhiu trng hp tng huyt ap c tn
thng c quan ch (tn thng thn, tiu ng).
Suy tim mn.
Bnh mch vanh.
Tc dung khng mong mun
H huyt ap: thng gp liu u tin.
Ho khan.
Ph mch.
Tng K mau.
D ng, phat ban, thay i v giac (captopril).
Chng ch nh
Hep ng mch thn.
Hep ng mch ch nng.
Ph n mang thai va cho con b.

159
 Tin s ph quincke
Thn trng: Trong suy thn (khng dng khi K mau > 5,5 mmol/l hoc h s
thanh thi creatinin < 30ml/pht hoc creatinin mau > 265 mol/l); ngi tiu
ng b mt nc va cung lng tim thp.
Ch phm liu lng
Captopril (Lopril) 25 - 50 mg; ung 25 150 mg/ngay.
Enalapril (Renitec) 5 - 20 mg; ung 5 20 mg/ngay.
Perindopril (Coversyl 4, 8 mg); ung 4 8 mg/ngay.
(Coversyl 5, 10 mg); ung 5 10 mg/ngay.
Ramipril (Triatec) 2,5 5mg; ung 2,5 10 mg/ngay.
Lisinopril (Zestril) 5 20 mg; ung 10 40 mg/ngay.
3.3. CHN THU TH ANGIOTENSIN II (AT II)
Tc dung:
Cac cht chen th th AT1 ngn cn Angiotensin II lin kt vi cac th th lam
mt hiu lc ca hormon nay dan mch, gim sc cn ngoi vi h huyt ap.
Ch nh
Thay th CMC iu tr tng huyt ap, suy tim mn, bnh mch vanh khi
khng dung np vi CMC.
Tc dung phu
Gim huyt ap lc u (t gp)
Chng mt, ri lon tiu ha nhe.
Tng nhe K huyt va enzym gan.
Chng ch nh
Mn cm.
Hep ng mch thn.
Suy gan, tc ng mt.
Khng dng cho ph n c thai, cho con b.
Ch phm
Losartan (Cozaar), Valsartan (Diovan), Candesartan (Atacand), Irbesartan
(Aprovel), Telmisartan (Micardis)
LIU DNG MT S THUC NHM C CH MEN CHUYN V I
KHANG THU TH AT II

160
3.4. CHN THU TH - ADRENERGIC
Tac dng lam gim huyt ap do gim cung lng tim, gim tit renin.
iu tr tng huyt ap nhe va va.
Ch phm: propranolol, metoprolol, atenolol, bisoprolol
3.5. METHYLDOPA
Ch nh
iu tr tng huyt ap. Thuc khng nh hng ti chc nng thn va tim, c
tac dng ngay c vi nhng ngi suy thn.
Dng tr tng huyt ap cho ngi ang mang thai, suy thn, suy tim trai.
Thn trng
Nn nh ki kim tra hng cu, bch cu, chc nng gan.
Khng nn lai xe hay ng may khi ang dng thuc.
Khng nn dng khi ang cho con b vi thuc bai tit qua sa me.
Tc dung khng mong mun
Gi mui, nc gy ph.
H huyt ap t th ng.
Trm cm , lit dng.
Vim gan, thiu mau tan mau.
Hi chng gi Parkinson, tng prolactin huyt.
Gy nhc u, chng mt, bun ng, kh ming, bun nn, tiu chy.

161
 Chng ch nh
Bnh gan: Vim gan, x gan tin trin.
Trng thai trm cm ro; Thiu mau tan mau.
Cch dng, liu lng
Dng thuc: vin nn 125mg, 250mg, 500mg.
Ngi ln: t 0,25 2 g/ngay; chia 2 4 ln, ti a la 3g/ngay.
Ngi cao tui: ti a 2g/ngay; chia 2 4 ln.

C. THUC LI TIU
Thuc li tiu gm nhng hp cht c tac dng lam tng bai tit nc tiu qua ng
niu. Nhng thuc lam tng sc lc ca cu thn c tac dng li tiu yu. Cac thuc
lam gim tai hp thu ng thn c tac dng li tiu mnh hn.
1. NHC LAI SINH LY THN
Mi thn gm 1 triu n v thn (nephron). Mi n v thn gm c cu thn va
ng thn (ng un gn, quai Henle, ng un xa va ng thu). Qua trinh to thanh nc
tiu xy ra ti n v thn, gm c:
Qua trinh lc cu thn.
Qua trinh tai hp thu ng thn.
Dch lc u tin qua cu thn vao ng thn c thanh phn gn tng t huyt
tng, khac la khng c nhng thanh phn phn t ln (protein, lipid, ng, t bao
mau).
Khi qua ng thn, nc va mt s cht c tai hp thu hoc thi tr nn thanh
phn ca nc tiu c thay i:
Ti ng un gn: Na+ c tai hp thu ko theo
nc cn bng ap sut thm thu.
Ti quai Henle: H thng vn chuyn Na +, K+, 2Cl-
t lng ng thn vao dch k gy tai hp thu Na +. Mg2+ va Ca2+ cung c tai hp
thu ti y.
Ti ng un xa: Tai hp thu ch ng Na + va Cl-
nh cht vn chuyn Na+, Cl-. Ca2+ c tai hp thu di s kim soat ca PTH.
Ti ng thu: Di s kim soat ca aldosteron, Na +
va K+ c trao i tai hp Na+ va thi tr K+/H+. Nc c tai hp thu th
ng nh ap sut thm thu ca dch k di s kim soat ca ADH.
162
2. CAC NHM THUC LI TIU
Theo mc ch iu tr c th chia thuc li tiu thanh ba nhm ln:
Thuc li tiu gim K+ mau.
Thuc li tiu gi K+ mau.
Thuc li tiu thm thu
2.1. NHM LI TIU GIM K+ MAU
2.1.1. Thuc c ch enzyme carbonic anhydrase (CA)
ACETAZOLAMIDE (Diamox)
Tnh cht
o Bt kt tinh mau trng, khng mi, khng v, rt t
tan trong nc va ethanol.
o Hp thu d dang qua ng tiu ha, khng b
chuyn hoa, phn phi cao n nhng m c nhiu CA nh hng cu, vo thn.
ao thi hoan toan qua thn sau 24h.
C ch tc dung
o
ng ln gn, trong t bao ng thn, CA c tac dng lam gii
phng ion H+ vao lng ng thn theo phn ng sau:
o
H2O + CO2 H2CO3 HCO3- + H+
o
H+ s bai xut vao ng thn va trao i vi Na+ c tai hp thu.
o
Khi enzyme CA b c ch, s bai tit H+ b gim, s trao i gia Na+
va H+ khng xy ra. Vi vy Na+ khng c tai hp thu nn thi tr ra ngoai
ko theo nc gy li tiu.
o
Thn kinh trung ng va mt cung c CA, phong to CA lam gim
sn xut dch nao tu va gim tit thu dch.
Ch nh
o iu tr tng nhan ap.
o iu tr nhim kim chuyn ha.
o Kim hoa nc tiu gip thi tr mt s cht: Acid uric, Aspirin
o iu tr ng kinh.
Tc dung khng mong mun
o Gy toan hoa mau, gim K mau.

163
 o Soi thn do tng phosphat niu va canxi niu.
o Ri lon thn kinh trung ng (nht la ngi b x gan), c th gy
hi chng nao gan.
o Qua mn: st, phat ban, tn thng thn ging sulfamide.
Chng ch nh
o X gan va suy gan.
o Bnh tim phi mn c suy h hp va tng CO2 mau.
o Ngi c soi tit niu
o Mn cm vi sulfamide, ph n mang thai.
Ch phm - Liu dng
o Dng thuc: Thuc tim 500 mg/5 ml; Vin nn 125 mg, 250 mg.
o Liu dng:
Dng ung: Liu li tiu 250 500 mg/ngay dng mt ln.
Tr tng nhan ap mn 250 1000mg/ngay, chia mi liu 250mg.
Dng tim 500mg bt pha tim.
o Thuc cng nhm: Methazolamide (Neptazane), Dichlophenamide
(Daranide).
2.1.2 Thuc li tiu quai
FUROSEMIDE (Lasilix, Lasix)
Tnh cht
o Bt kt tinh mau trng, khng mi, khng v, gn
nh khng tan trong nc, tan t trong ethanol va eter, tan nhiu trong dung
dch hydroxyde kim.
o Hp thu nhanh, xut hin tac dng nhanh 3 5 pht
sau khi IV, thi gian tac dng 4 -6 h. Thi tr qua thn, mt phn qua mt.
C ch tc dung
o c ch tai hp thu Na+ nhanh ln quai Henle lam
tng thi tr Na+ ko theo nc gy li tiu. Tac dng li tiu nhanh, mnh,
thi gian tac dng ngn.
o Gian mch thn, tng lu lng mau qua thn.

164
 o Gian tnh mch, gim mau phi, gim ap sut
tht trai.
Ch nh
o Cp cu trong ph phi cp, cn tng huyt ap.
o Suy tim trai cp tnh va suy tim mn tnh c ph tr
vi cac thuc li tiu khac.
o Ph toan thn trong cac bnh v gan, thn.
o Suy thn ure huyt cao, tng canxi huyt cp tnh.
Tc dung khng mong mun
o ao thi nhanh, mnh nc va cac cht in gii
nn gy mt moi, chut rt, tin hn m gan, h huyt ap th ng.
o Ri lon in gii: gim Kali, Natri, Canxi, Maggie,
H+, nhim kim
o Ri lon chuyn hoa: tng acid uric huyt, ng
huyt, cholesterol huyt.
o D ng: ni mn, au c, khp.
o c i vi dy thn kinh s VIII (chng mt, tai,
c th gy ic)
o Ri lon to mau, ri lon tiu ha, ri lon chc
nng gan thn.
Chng ch nh
o Mn cm, d ng vi sulfamide.
o X gan, bnh nao gan, bnh gt
o Gim kali mau, gim th tch mau.
o Ph n mang thai.
Thn trng
Ngi phi i tuyn tin lit, kh tiu tin, ph n c thai 3 thang cui hay ang
cho con b, dng ng thi vi aminoglycoside va cac digitalis lam tng c tnh ca
cac thuc nay.
Ch phm liu dng

165
 o Furosemide (lasilix, trofurit, lasix) vin 20mg,
40mg, 80mg; ng 20mg/2ml.
o Ung 20 80mg/ngay; tim bp, tim tnh mch 1
2 ng/ln/ngay.
2.1.3 Li tiu thiazide
HYDROCHLOROTHIAZIDE HCTZ (Hypothiazide)
Tnh cht
o Bt kt tinh mau trng, khng mi, khng tan trong
nc, kh tan trong ethanol, d tan trong aceton va dung dch hydroxyde.
o Hp thu tt qua ng ung, tac dng ko dai 6
12h. Qua c nhau thai va sa me. Thi tr qua thn va cnh tranh bai tit vi
acid uric, lam gim bai xut acid uric.
C ch tc dung
o c ch tai hp thu Na+ on u ng ln xa. Tac
dng li tiu trung binh nhng ko dai hn so vi li tiu quai.
o Thuc cn c tac dng dan mch do c ch ti ch
tac dng ca cac cht co mch (vasopressin, nor - adrenalin ).
Ch nh
o Tng huyt ap (thng phi hp)
o Dng n thun trong suy tim nhe va va, phi hp
vi li tiu quai trong suy tim nng.
o Ph do cac bnh tim, gan, thn va nhim c thai
nghn.
o Tng Ca niu khng ro nguyn nhn.
Tc dung khng mong mun
o Ri lon in gii: dng lu gim Na, K, Mg huyt;
tng Ca huyt dn n mt moi, nhc u, bun nn, chut rt, nhim kim.
o Ri lon chuyn hoa: tng acid uric huyt, glucose
huyt, cholesterol huyt.
o C th gy d ng ngoai da
Chng ch nh

166
 o Trng thai gim K mau
o Bnh nhn ang iu tr bng cac ch phm
digitalis.
o Bnh gt.
o Suy gan thn.
o D ng vi sulfamide.
Ch phm - liu lng
o Hydroclorothiazide (HCTZ): vin nn 25 mg, 100
mg. Ung 50 - 100mg/ngay.
o Clorothiazide (Diurilix): vin 500mg. Ung 0,5 1
g/ngay chia 2 ln.
o Triclomethiazide (Triazid, Trichlorex): 2 8
mg/ln/ngay.
o Indapamide (Natrilix SR): vin nn 1,5mg. Ung 1
vin/ngay.
o Chlorthalidon (Hygroton): vin 100mg. Ung 1 2
vin/ngay.
2.2 Nhom li tiu gi K mu
SPIRONOLACTON (Aldacton, Verospiron)
Tnh cht
Hp thu d dang qua ng ung, tac dng xut hin chm (sau khi ung 2 4 h)
va ko dai 48 72 gi. Qua c nhau thai va sa me. Thi tr qua thn, phn. Thi
gian ban thi 12 24h.
C ch tc dung
C tac dng i khang vi aldosterone ti ng ln xa, lam tng ao thi natri va
nc va phi. Tac dng li tiu yu.
Ch nh
o Phi hp vi cac thuc li tiu gim K mau iu
tr suy tim mn, x gan, tng huyt ap, bnh thn.
o Tng Aldosteron nguyn phat hoc th phat.
Tc dung khng mong mun

167
 o Tng K huyt, nhim acid chuyn hoa.
o Ri lon tiu hoa, mt moi, ng ga, ni mn da.
o Gy hin tng v to nam gii, thiu nng sinh
dc, ri lon kinh nguyt.
Chng ch nh
Suy thn mn, suy gan, lot d day ta trang, tng K huyt, nhim acid chuyn
hoa, thn trng vi ngi mang thai, cho con b.
Ch phm - liu lng
o Spironolacton (aldacton, verospiron): vin nn
25mg, 50mg, 100mg. Ung 50 100mg/ngay chia 2 ln.
o Amiloride (modamide): vin 2,5mg; 5mg. Ung 5
20 mg/ngay.
o Triamterene (dyazide, teriamteril): vin nang 50mg,
75mg, 100mg. Ung 50 200 mg/ngay.
2.3 Nhom li tiu thm thu
MANITOL
Tc dung
o Manitol c lc t do qua cu thn, t hp thu qua
ng thn lam tng ap lc thm thu ng thn nn ko nc vao lng ng gy
li niu.
o Thuc lam gim ap lc ni s trong tng ap lc ni
s.
Ch nh
o Tng li tiu thi c.
o Duy tri chc nng to nc tiu trong trng hp
suy thn cp, hoi t ng thn, thiu niu sau m, sau chn thng
o Lam gim ph nao, tr tng nhan ap.
Chng ch nh
o Suy tim sung huyt.
o Xut huyt nao.
o Mt nc trong t bao.

168
 Thn trng
o Khi truyn cn theo doi cht ch cn bng dch va
in gii.
o Thuc c th che lp du hiu gim th tch tun
hoan.
o Khng c truyn manitol cng vi mau toan
phn.
o Khng c tim cach khac ngoai tim tnh mch,
gy tiu chy nu dng ng ung.
Tc dung khng mong mun
o H natri huyt gy: nhc u, bun nn, nn.
o C th gy ph phi cp ngi suy tim hoc ang
b sung huyt phi.
Cch dng, liu lng
o Phng suy thn cp: truyn dung dch t 50 100 g
trong dung dch 5 15%.
o Gii c: truyn tnh mch 200 mg/kg th trng vi
dung dch 15% hoc 25%.
o Gim ap lc ni s: truyn tnh mch t 1 2 g/kg
th trng vi dung dch 5% hoc 20% va iu chnh cho ph hp.
o Vi ngi cao tui phi lam test cn thn chn
liu thch hp.
o Dng thuc: Chai dch truyn 100 ml, 250 ml, 500
ml cha dung dch 5%, 10%, 20%, 25%.

D. THUC IU TR SUY TIM MAN TINH

1. BNH SUY TIM
Suy tim la trng thai bnh l trong cung lng tim khng ap ng i vi nhu
cu ca c th v mt oxy trong mi tinh hung sinh hot ca bnh nhn.
Suy tim la hu qu ca bt c ri lon chc nng hay cu trc nao ca tim lam suy
gim kh nng nhn (suy tim tm trng) va tng mau (suy tim tm thu) ca tm tht
ap ng c nhng nhu cu chuyn ha ca t chc.

169
 Cc nguyn nhn gy suy tim: Tng huyt ap, bnh mch vanh, bnh c tim dan n,
bnh van tim.
Cc yu t lam nng suy tim:
o S khng tun th iu tr (thuc, dinh dng)
o Cac yu t huyt ng
o S dng thuc khng ph hp (Th d: Khang vim, c ch calci...)
o Thiu mau cc b c tim hay nhi mau c tim
o Bnh h thng (thiu mau, tuyn giap, nhim trng)
o Thuyn tc phi
Bng phn suy tim
Phn loai mc suy tim theo NYHA
Biu hin
I Bnh nhn c bnh tim nhng khng c triu chng c nng nao, vn sinh hot va
hot ng th lc gn nh binh thng
II Cac triu chng c nng ch xut hin khi gng sc nhiu. Bnh nhn b gim nhe
cac hot ng v th lc.
III Cac triu chng c nng xut hin k c khi gng sc rt t, lam hn ch nhiu cac
hot ng th lc.
IV Cac triu chng c nng tn ti mt cach thng xuyn, k c lc bnh nhn ngh
ngi khng lam gi c

Phn loai mc suy tim trn lm sang

Biu hin
I Bnh nhn c kh th nhe nhng gan cha s thy
II Bnh nhn c kh th va, gan to di b sn phi vai cm
III Bnh nhn c kh th nhiu, gan to gn sat rn, khi c iu tr c th nho li
IV Bnh nhn kh th thng xuyn, gan lun to nhiu mc d a c iu tr

2. CAC THUC IU TR SUY TIM MAN

2.1. MUC TIU
o Gim triu chng c nng va ci thin kh nng vn ng
o Ngn chn tin trin
o Ko dai i sng
2.2. CAC NHM THUC IU TR
o c ch men chuyn: Captopril, Enalapril, Perindopril, Lisinopril, Ramipril,
Quinapril.

170
o Chen th th : Bisoprolol, Metoprolol, Carvedilol, Nebivolol.
o Chen th th angiotensin II: Irbesartan, Losartan, Candesartan, Telmisartan,
Valsartan.
o Nitrat: Nitroglycerin, ISMN, ISDN.
o Li tiu: Furosemide, Indapamide, HCTZ.
o Thuc khang aldosteron: Spironolacton
o Thuc tng co bp c tim: Digitalis, Dopamin, Dobutamin, Amrinon, Milronen.
o Thuc chng lon nhp, thuc khang ng.
2.3. CAC GLYCOSIDE TIM (DIGITALIS)
Digitoxin, Digoxin, Ouabain.
Cac thuc nay c 3 c im chung:
o Tt c u c ngun gc t thc vt.
o Cu trc gn ging nhau: Phn ng gn vi phn
genin qua lin kt glycoside.
o C cng c ch tac dng.
2.3.1. Dc ng hc
o Hp thu:
Ung: Digitoxin, Digoxin. Tim: Ouabain
o Phn b:
Gn nhiu vao m, c bit m tim, gan, phi, thn. Khi nng K huyt cao, cac
glycoside t gn vao tim va ngc li.
o Chuyn hoa:
Cac glycosid tim c chuyn ha gan tr Ouabain khng b chuyn ha.
o Thi tr:
Digitoxin va digoxin thi tr qua thn va gan. Ouabain khng b chuyn hoa, thi
tr qua thn dng cn hot tnh.
So sanh c ng hc ca mt s glycosid tim
Digitoxin Digoxin Ouabain
Hp thu qua tiu ha 100% 80% 0
Gn vao protein huyt tng 90% 50% 0
Phn hy gan +++ + 0
Thi tr Chm Nhanh Rt nhanh
Thi gian tac dng 48 - 60 gi 12 - 24 gi 12 gi
Lu li trong c th 14 - 28 ngay 7 ngay 1 - 2 gi
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2.3.2. Tc dung
o Tng sc co bp c tim, tng trng lc c tim.
o Gim nhp tim, gim tnh t ng va kch thch dn
truyn, ko dai thi k tr.
2.3.3. Ch nh
o Suy tim cung lng thp c bit khi c rung nh
nhanh.
o Lon nhp: rung nh, cung ng nh.
2.3.4. Tc dung phu
o Ri lon nhp tim: Ngoi tm thu, nhp nhanh nh.
o Ri lon dn truyn: Nhp chm, bloc nh tht, bloc
xoang nh
o Ri lon tiu ha: chan n, bun nn, nn ma, tiu
chy, au bng
o Ri lon thn kinh: chng mt, nhc u, mt ng,
o giac, ln
o Ri lon th giac: gim th lc, lon sc
2.3.5. Chng ch nh
o Nhp chm (di 60 ln/pht).
o Bloc nh tht cp II, cp III.
o Nhp nhanh tm tht, rung tht.
o Ngoi tm thu.
o Vim c tim cp.
o Bnh c tim tc nghn.
o Hi chng Wolff - Parkinson White.
o Thn trng trong trng hp Ca 2+ mau cao, K+ mau
thp.
2.3.6. Ch phm liu dng
Vi thuc c tch lu nn phi dng liu gim dn va ngt quang.
Digitoxin (Crysfodigin)

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 Vin 0,1mg; ng 0,1 mg. Mi ln ung 1 2 vin, 2 3 ln/ngay trong 3 ngay
lin.
Digoxin (Lanoxin)
Vin nn 0,25mg; dung dch ung 0,5mg/2ml.
Liu tn cng 0,5 1 mg/ngay, chia lam nhiu ln.
Liu duy tri 0,125 - 0,25 mg/ngay.
Ouabain
Tac dng xut hin nhanh (5 10 pht sau khi tim tnh mch, tac dng ti a
sau khong 1h) va thi tr nhanh, c th dng khi nhp tim chm.
Ch nh thay th cac digitalis khi bnh nhn khng chu thuc hoc km hiu
qu, cp cu suy tim cp vi tac dng nhanh.
Trong khi dng digitalis vi liu iu tr, mun chuyn sang dng Ouabain, cn
ngng thuc t nht 3 ngay.
Liu tim tnh mch 0,25 1 mg/ngay. Vi thuc thi nhanh nn c th tim
hang ngay nu dng liu 0,25 mg.
2.4. THUC TR TIM KHNG PHI DIGITALIS
2.4.1. Adrenalin
o Tc dng
Kch thch tim p tr li khi b ngng tim, lam co mch ngoi vi nhanh.
Tng nhp tim lam dan va tng lu lng mch vanh, mch nao, mch phi.
Co mch ngoi vi nn c tac dng nng huyt ap.
Lam dan c trn ph qun ngi b hen (nhng b mt tac dng rt nhanh
nhng ln dng sau).
Trn tiu ha: lam dan c trn b may tiu ha nhng lam co cac c vng.
Trn chuyn ha: tng phn hy glycogen gan lam tng glucose mau, tng chuyn
ha c bn.
o Ch nh
Cp cu shock phn v: choang, ngt, try tim mch, h huyt ap.
Cp cu ngng tim t ngt (tr ngng tim do rung tht).
iu tr hen ph qun, d ng.
Phi hp vi thuc t tng tac dng t.
p ti ch dung dch 1% cm mau nim mc, tr vim mui.

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o Tc dng ph
Trng thai lo u, hi hp, chng mt, nhc u, kh ng, lon nhp ngi c bnh
tim.
o Chng ch nh
Tim ngng p ngi b in git c triu chng rung tm tht.
Cng chc nng tuyn giap.
Cao huyt ap, x va ng mch, suy tim nng.
ai thao ng ngi gia va tr em.
o Dng thuc
ng 1mg/1ml adrenalin hydroclorid.
o Liu dng
Tim di da hay bp tht: 0,5 1 ml dung dch 1 hoc truyn tnh mch 1 4
mg/24 gi pha trong dung dch NaCl 9 hay glucose 5%.
Liu ti a 10mg/24 gi.
Ch : khng c tim thng adrenalin vao tnh mch khi khng pha loang vi
huyt thanh (vi gy tng huyt ap c th ngng tim).
2.4.2. Isoprenalin
o Ch nh
Sc c h huyt ap.
Ngng tim kt hp vi xoa bp tim ngoai lng ngc.
o Tc dng khng mong mun va c tnh
H huyt ap, lon nhp, au vng trc tim, nhi mau c tim.
Khng dng cng cac thuc m nh cyclopropan, flouthan, lam tng c tnh vi
tim.
o Ch phm
Isoprenalin clohydrate (Isuprel)
Isoprenalin sulfat (Aleudrin)
ng 1ml = 0,2 mg.
Truyn tnh mch 2 6 ng trong 250 500 ml huyt thanh ngt ng trng
khng c base. Khi ngng tim tim 2 ng vao tim.
2.4.3. Dopamin
o Tc dng

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 Kch thch thn kinh giao cm lam tng tit adrenalin.
Liu thp c tac dng dan mch vanh, mch ni tng c bit la mch thn, lam
tng tc lc ca cu thn.
Liu trung binh lam tng nhp tim va sc co bp c tim.
Liu cao gy co mch va tng huyt ap.
o Tc dng ph
Khi dng liu cao c th gy bun nn, au u, tng huyt ap, anh trng ngc
(do kch thch mnh h giao cm).
o Ch nh
Chng shock do nhi mau c tim, chn thng, nhim khun huyt, c bit la
shock km theo gim th tch mau hoc v niu.
o Dng thuc
ng tim 40, 80, 160 mg/ml dng tim hoc truyn tnh mch (ch : phi b
th tch mau trc khi tim).
o Liu dng
Bt u liu thp 2 5 g/kg/pht va tng dn n khi t c liu 10, 15 hay 20
g/kg/pht. Cui t iu tr cn gim liu dn mi 30 pht/ln. Khng pha loang
vi dung dch kim.

E. THUC TR RI LOAN LIPID HUYT

1. PHN LOAI MC LIPID HUYT

Thanh phn lipid Mong mun Gii han Nguy c cao

< 5,2 mmol/l 5,2-6,2 mmol/l > 6,2 mmol/l
Cholesterol
(200mg/dl) (200-239 mg/dl) (240mg/dl)
< 2,3mmol/l 2,3-4,5mmol/l 4,5-11,3mmol/l
Triglycerid
(200mg/dl) (200-400mg/dl) (400-1.000mg/dl)
Lipoprotein t trng < 3,4 mmol/l 3,4-4,1mmol/l
> 160mg/dl
thp (LDLc) (130mg/dl) (130-159mg/dl)
Lipoprotein t trng > 1,5mmol/l < 0,9mmol/l
cao (HDLc) (60mg/dl) (35mg/dl)

2. MT S THUC TR RI LOAN LIPID HUYT

2.1. NHM ACID FIBRIC
Gemfibrozil, Fenofibrat.

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 Tc dung
Gim lng triglyceride t 20 30%, gim LDL khong 10 15% va lam tng
HDL khong 10%.
C hiu qu tt trn bnh nhn cao triglyceride km cao cholesterol.
Ch nh
Tr ri lon lipid huyt ch yu do tng triglycerid, VLDL huyt.
Tc dung khng mong mun
Thng gp nht la gy ri lon tiu hoa: bun nn, tiu chy, au bng. Cac
tac dng ph khac nh: au u, mt moi, chng mt, rng tc, ni mn, m ay
thnh thong xy ra.
au c, vim c, teo c.
Tng nhe men gan, gim bch cu, thiu nng tinh dc.
Chng ch nh
Suy gan, suy thn nng.
Ngi ang mang thai.
Soi mt, tin s bnh ti mt.
Tr em di 10 tui.
Ch phm liu dng
Gemfibrozil (Lopid) vin nang 300mg, vin nn 600mg. Liu thng dng la
600mg, 2 ln/ngay, ung 30 pht trc ba n sang va ti.
Fenofibrat (Lipanthyl) vin nang 100mg, 300mg. Liu thng dng la
300mg/ngay. Fenofirat cn c hiu qu trn bnh nhn cao lipid huyt km theo
bnh gout.
2.2. NHM STATIN
Atorvastatin, Simvastatin, Rosuvastatin, Lovastatin, Pravastatin.
Tc dung
Lam gim lipid mau do c ch sinh tng hp cholesterol gan va tng thu nhn
LDL vao trong t bao.
Ty theo liu Statin lam gim LDL t 20 60%, gim triglyceride t 10 40%,
tng HDL t 5 15%.
Ch tr liu bng statin cung lam gim t l t vong do bnh mch vanh,
gim nguy c cac bin c tim mch.

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 Ch nh
Ri lon lipid huyt ch yu do tng cholesterol, LDL huyt.
D phng cac tai bin mch vanh, nhi mau c tim, x va ng mch.
Tc dung khng mong mun
Hay gp ri lon tiu ha: au bng, y hi, tao bn. Nhc u, chng mt,
nga, ni mn, tng men gan thnh thong xy ra.
Tng men gan gp 3 ln so vi binh thng phi ngng dng thuc. Nn kim
tra khi bt u iu tr va nh k mi 6 - 12 tun vao nm u dng thuc va mi
3 6 thang trong sut thi ki tr liu bng statin.
au c, yu c c th dn n vim c/ly gii c vn; suy thn cp tnh him
xy ra nhng rt nguy him n tnh mng.
Chng ch nh
Mn cm vi thuc.
Ph n mang thai va cho con b, tr di 18 tui.
Suy gan, thn, tng enzym gan.
Ch phm va liu dng
Atorvastatin (Lipitor) vin nn 10; 20mg.
Liu khi u 10mg/ngay sau c th tng ti a 80mg/ngay.
Simvastatin (Zocor) vin nn 5; 10; 20mg.
Liu khi u 5 10 mg/ngay vao bui ti. Ti a 80mg/ngay.
Lovastatin (Mevacor) vin nn 10; 20mg.
Liu khi u 10 20mg/ngay vao bui n ti. Ti a 80mg/ngay. Thay i liu
mi 4 tun.
Rosuvastatin (Crestor) vin nn 5;10;20;40 mg
Liu khi u 5 - 10mg/ngay. C th tng liu ln 20mg/ngay sau 4 tun nu cha
kim soat. Ti a 40mg/ngay.
Pravastatin (Elisor) vin nn 10mg
Liu trung binh t 10 20mg/ngay.
Fluvastatin (Lescol) vin nn 10mg, 40mg.
Liu trung binh t 10 80mg/ngay

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 TI LIU THAM KHO

Gio trnh Dc trung hoc Ha dc Dc L, Trng Trung cp Kinh t - K
thut Quang Trung, 2006.

Mai Tt T, Vu Th Trm (2007), Dc l hoc tp 1 & 2, Nha xut bn Y hc.

ao Vn Phan (2010), Dc l hoc tp 1 & 2, Nha xut bn Y hc.

Trn Th Thu Hng (2006), Dc lc hoc, Nha xut bn Phng ng.

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