HOI H U Y E T HOC - T R U Y E N MAU YN CONG HOA XA HOI C H U NGHIA V I E T NAM

Doc lap - TIT do - Hanh phue

So: A J /HH-TMVN ' '
V/v de xuat Huong dan su dung khang dong Ha Noi, ngay4^ thang 8 nam 2021
d benh nhan Covid-19 ngudi Ion

Ki'nh giri:
- B6 Y te;
- Tieu ban Dieu tri Covid-19.

Thirc hien y kien chi dao ciia PGS.TS. Nguyen Trudng Son - Thu trudng B6
Y te ve viec hoan thien "Hudng dan su dung khang dong d benh nhan Covid-19
ngudi Idn", sau khi tdng hop gdp y cua cac chuyen gia Huyet hoc - Truyen mau
trong ca nude. Hoi Huyet hoc - Truyen mau Viet Nam da hoan thien va xin dugc
bao cao Bg Y te (kem theo noi dung chi tiet).
Hoi Huylt hoc - Truyen mau Viet Nam kinh mong nhan dugc su chi dao ciia
Bg Y t l .
Xin tran trgng cam on!

Thong tin chi hit xin lien he: TS. Nguyh Hitu Chien, Truang phong KITTH, Vien Huyet
hoc - Truyin mau TW, DT: 0983.818.696.

Noi nhan: {K-oif^Uy^ TM. BANCHAP HANH HOI

- N h u tren; KT. C H U TICH
- Luu VP Hoi.
CHU TICH
 HOI H U Y E T H O C - T R U Y E N MAU VN CONG H O A X A HOI C H U NGHIA V I E T NAM
Boc lap - T y do - Hanh phuc

Hd Noi, ngay thang 8 nam 2021

HI/ONG DAN sty D V N G K H A N G D O N G 6 B E N H N H A N C O V I D - 1 9 NGlTcn L6N

(Kent theo cong van so: S /HH-TMVN, ngdy/fS thang 8 nam 2021)

1. Khi chu-a co xet nghiem:

CAN Liru Y sty D U N G THUOC CHONG DONG SOfM C H O NGlTCH B E N H , K H I C O 1 T R O N G C A C

DAU H I E U DUOT DAY:

Bang 1. Can cu" lam sang de sd dung chong dong cho
Sd dung chong dong lieu du phong
Khong sd dung chong dong
(theo bang 3)
+ Nguai benh khong co benh nen + Tinh trang lam sang d muc do vda
va tinh trang nhe (nhip tho < 20 (thd nhanh > 20 lan/phiit hoac Sp02 >
lin/phut, "Sp02 > 96% khi thd khi 93% khi thd khi trdi), nhu cau thd oxy
trdi) < 6 lit/ phut;
+ Ngudi benh cd benh nen (chu y beo
phi, tang huyet ap, tieu dudng, ung
thu, tien su huyet khdi, liet, hoac md
Idn trong vdng 3 thang...);
+ Ngudi > 60 tudi;
+ Phu nu cd thai (theo bang 5);
Diem Modified Improve =^ 2-3.
- Vdi ngudi benh FO dieu tri tai nha xin xem phu luc I .
- Thdi gian dung lieu du phong 7-10 ngay.
ngndi benh Covid-19
Sd dung chong dong lieu dieu tr|
(theo bang 3)
+ Ngudi benh tinh trang vda, nhu
cau thd oxy > 6 lit /phut;
+ Ngudi benh nang (nhip thd > 30
Ian/ phut, khd thd nang, hoac Sp02
< 93% khi thd khi trdi);
+ Diem Modified Improve > 4 (phu
luc 2).
1
 - Ngudi benh Covid-19 vua va nang nen dugc su dung chong dong cang sdm cang tot. Neu su dung thuoc chdng
dong theo lieu dieu tri thi thdi gian it nhat 2-6 tuan hoac cho tdi khi ngudi benh on dinh ve lam sang va xet nghiem;
r r •} y y r

Ngudi benh cd huyet khdi dugc chan doan bang hinh anh thi thdi gian dieu tri keo dai 3-6 thang theo khuyen cao
cua Hdi tim mach Viet Nam.
2. Khi ngudi benh da dirge lam xet nghiem;
DlTA V A O K E T Q U A C U A 1 T R O N G N H L T N G X E T N G H I E M T R O N G B A N G 02 D E Q U Y E T D I N H
DUNG LIEU CHONG DONG
Bang 2. Can cd xet nghiem de quyet dinh lieu chong dong
Lieu du phong (chinh lieu theo BMI Lieu dieu trj (chinh lieu theo BMI va
Can cd xet nghiem
va chdc nang than-bang 3) chdc nang than-bang 3)
CRP < 15 mg/L > 15 mg/L
Ferritin < l.OOOng/ml > l.OOOng/ml
r y

D dimer D dimer trong khoang tu > 2 den < 5 Ian > 5 Ian ngudng binh thudng;
ngudng binh thudng - Tang nhanh gap 2 Ian trong vdng 24-48h;
- Gap 2 binh thudng+ diem Improve = 2-3.
IL-6 15-40pg/ml > 40pg/ml
Bach can lympho > 0,8G/1 < 0,8G/1
Bach can trung tinh < lOG/1 > lOG/1
Huyet khoi dugc xac Khdng Cd
dinh bang chan doan
hinh anh

2
 - Limy:
+ Het sue than trong can nhac dung chong dong d nhung trudng hop cd nguy co chay mau vdi HAS-BLED
score > 3 (phu luc 3) hoac tieu cau giam nang < 25G/1 va/ hoac cd benh ly chay mau kem theo cung nhu cac chdng
chi dinh khac;
+ Vdi benh nhan cd tieu cau < 50G/1: Khdng dung UFH.
Bang 3: Khuyen cao dung chong dong d benh nhan covid-19 ngudi Idn (lua chon 1 trong cac loai sau,
uu tien dung lieu tang cudng trong du phong)
BMI va chuc Heparin standard LMWH Cac thuoc chong ddng khac
nang than (UFH) -
Lieu du B M I < 30kg/m2 va 5000U, hai lan/ngay *Lieu chuan: 40mg x 1 lan/ngay - Cd the lua chon 1 trong cac
phong CrCl>30ml/phut (TDD) loai chdng ddng khdc sau day
(Co the *Lieu tang cudng: de thay the heparin:
phoi hup 2 lan/ngay, cd the len tdi +Rivaroxaban 10-20mg,
them 0,5mg/kg, 2 ian/ngay±20%. udng 1 lan/ngay
aspirin B M I > 30kg/m2 va 7500U, hai *Lieu chuan: 40mg TDD, cd the +Apixaban 2,5mg, udng 2
neu khdng CrCl > 30ml/phut lan/ngay tang len 2 lan/ngay lan/ngay
CO tinh *Lieu tang cudng: +Dabigatran 220mg, udng 1
trang 2 lan/ngay, cd the len tdi lan/ngay
chdng chi 0,5mg/kg, 2 lan/ngay±20%.
dinh) cd the tang len 60mg, 2 lan/ngay
_ _ _
CrCl < 30ml/phut 7500U mdi 8-12h *Lieu chuan: 30mg x 1 lan/ngay + Dabigatran 75mg, udng 2
(TDD). lan/ngay
>
-f Rivaroxaban 15mg, udng 1
*Lieu tang cudng: 0,5mg/kg x i lan/ngay
lan/ngay (TDD) Khdng dung DOACs khi
C r C l < 15ml/phut
3
 BMI va chuc Heparin standard LMWH Cac thuoc chong dong khac
nang than (UFH)
Lieu dieu B M I < 30kg/m2 va Co the xem xet tiem *Khai dau bang Img/kg x 2 + Nhdm acecumarol,
tri (neu CrCl > 30ml/phut tmh mach 5000UI, lan/ngay (TDD) warfarin: DatINR2-3;
benh nhan sau do 250U/kg, Vdi benh nhan CrCl < 30ml/phut + Rivaroxaban 15mg, udng 2
dang dung TDD moi I2h. cd the khdi dau bang lieu lan/ngay;
aspirin can Chinh lieu sao cho lmg/kg±10%/ngay. + Dabigatran 150mg, uong 2
dirng dat antiXa 0,3- Lieu 1 lan/ngay khong ap dung lan/ngay;
0,7IU/ml. vdi benh nhan BMI > 30kg/m2 O berth nhan cao tudi, cd it
ngay)
va C r C l > 30ml/phut nhat 1 yeu td nguy ca chay
mau, dung lieu llOmg, udng,
B M I > 30kg/m2 va Khdi dau bang lieu 0,8mg/kg y

CrCI > 30ml/phut Hoac khdi dau vdi lieu 2 lan/ngay.

l,5mg/kg, TDD I lan/ngay. + Apixaban 5-lOmg, udng 2
lan/ngay;
+ Endoxaban 30mg -60mg,
r y

udng ngay 1 lan;

+ Warfarin: Dat INR 2-3.
Khdng dung DOACs khi
C r C l < 15ml/phut
CrCl < 30ml/phut Lieu dieu tri, co the Img/kg/ngay + Warfarin: Dat INR 2-3;
bolus sau do duy tri + Dabigatran 75mg, udng 2
theo anti Xa lan/ngay;
+ Rivaroxaban 15mg, udng 1
lan/ngay;
-HEndoxaban 30mg, udng
ngay 1 lan.
Khdng dung DOACs khi
CrCl < ISml/phiit
4
 - Trong dieu kien cho phep cua co sd, thuc hien cac xet nghiem theo doi nhu sau (tan suat xet nghiem tuy tinh
trang ngudi benh):
+ Tdng phan tich te bao mau ngoai vi;
+ PT, APTT, Fibrinogen, D-dimer, anti-Xa, FM, ROTEM.
- Khi dung UFH va L M W H lieu dieu tri can theo doi bang xet nghiem anti-Xa va can dat ngudng anti-Xa 0,3-
0,7 Ul/ml (khdng nen sir dung A P T T theo doi U F H do yeu td V I I I d benh nhan Covid-19 tang rdt cao, > 70% benh
nhan cd khang ddng noi sinh luu hanh va sai lech khi ngudi benh suy than). Lay man xet nghiem sau tiem 4h.
- Khdng khuyen cao theo doi anti-Xa vdi lieu UFH hay L M W H du phong, tuy nhien vdi ngudi benh cd ClCr <
30ml can kiem tra sau 10 lieu. Can nang < 50kg: theo doi sau tiem 10 lieu. Can nang > 120kg: theo doi sau tiem 3
lidu. Muc tieu anti Xa can dat: 0,l-0,4UI/ml.
- Neu cd tinh trang giam tieu cau do Heparin (HIT) can dung Heparin va dung chdng ddng khac thay the nhu
Agatroban, Fondaparinux hoac DOACs...
- Vdi benh nhan RRT hay ECMO can chinh lidu UHF theo bang 4.
Bang 4: Chinh lieu U F H theo anti Xa d benh nhan R R T hoac E C M O

Mirc anti-Xa (Ul/ml) Lieu dieu chinh Khuyen cao khac

<0,I Tang 400 Ul/h Cd the xem xet bolus 2000 U I
0,1-0,19 Tang 200 Ul/h
0,2-0,29 Tang 100 Ul/h
0,3-0,7 Khdng thay ddi
0,71-0,8 Giam 100 Ul/h Tam ngimg truyen trong 3 Op
0,81-1,7 Giam 200 Ul/h Tarn ngung truyen trong Ih
\ 1 -7 Giam 300 T IT/h Tam ngung truyen trong Ih
 Bang 5. Khuyen cao dung chong dong a phu nfr co thai mac Covid-19 (ngay khi mac covid 19)
Mnc D-dimer CrCl Chi djnh aspirin BMI < 40kg/m2 BMI > 40kg/m2
Mac covid-19 va/ CrCl > 30ml/phut Cd Enoxaparin 40mg Enoxaparin 40mg
hoac D-dimer TDD hang ngay TDD mdi 12h
< 7 l4n so voi nguong CrCl < 30ml/phut Cd Enoxaparin 30mg Enoxaparin 40mg
binh thudng: dung TDD hang ngay TDD hang ngay
X X
lieu dir phong chuan
7-10 lan: dung lieu dg CrCl > 30ml/phut Cd Enoxaparin 0,5mg/kg Enoxaparin 0,5mg/kg
phong tang cu-dng TDD mdi 12h TDD moi 12h
CrCl < 30ml/phut Cd Enoxaparin 0,5mg/kg Enoxaparin 0,5mg/kg
TDD moi 12h TDD moi 12h
> 10 lan hoac da cd CrCl > 30ml/phut Khdng Enoxaparin Img/kg Enoxaparin Img/kg
huyet khdi dugc chan TDD moi 12h TDD mdi 12h
doan bang hinh anh: CrCl < 30ml/phut Khdng Enoxaparin Img/kg Enoxaparin Img/kg
dung lieu dieu tri TDD moi 24h TDD moi 24h
Phu luc 1. Khuven cao dung chong ddng vdi benh nhan FO du dieu kien dieu tri tai nha
- Su dung thudc chdng ddng ducmg udng loai khdng can theo ddi bang xet nghiem (thdi gian 7 ngay), khi cd 1
trong nhung trudng hgp sau:
+ Benh nhan cd Sp02 < 95%, hoac nhip thd > 20 Idn/phut, hoac cam giac khd thd;
+ Cd benh ly nen (chu y beo phi, tang huyet ap, tieu dudng, ung thu, tien su huyet khdi, liet, hoac md Idn trong
vdng 3 thang...), nguy co huyet khdi trung binh cao (modified improve > 2);
+ > 60 tuoi.
- Su dung 1 trong cac loai chdng ddng sau:
-i-Rivaroxaban 10-20mg, udng 1 larfngay;
+ Apixaban 2,5mg, uong 2 lan/ngay;
+ Dabigatran 220mg, udng 1 lan/ngay.
- Vdi benh nhan dang su dung aspirin, van cd the tiep tuc dung phdi hgp.
6
 - Sau khi co cac xet nghiem ciia benh nhan, se dieu chinh lieu thuoc ca the hoa.
- Can ngung thuoc va bao ngay cho co sd y te khi thay cac dau hieu: bam tim dudi da, chay mau chan rang, tieu
mau, di ngoai ra mau tuoi hoac phan den...
Phu luc 2. Bang diem I M P R O V E cai tien (Modified IMPROVE) danh gia nguy co huyet khoi
Yeu to nguy co V T E Diem nguy co" V T E
Tien sii VTE 3
Benh ly tang dong da dugc chan doan (V Leiden, 2
Thieu PC, PS bam sinh, khang dong lupus)
Liet chi dudi 2
Benh ly ung thu (ngoai tru ung thu da khdng melanin) 2
trong vdng^S nam
Dang nam tai ICU/CCU 1
Bat ddng hoan toan > 1 ngay 1
Tudi > 60 1
Phu luc 3. Bang H A S - B L E E D S C O R E danh gia nguy co chay mau
Tieu chuan HAS-BLED Diem
Cao huyet ap 1
Bat thudng chuc nang Than /Gan I hoac 2
(1 diem cho mdi co quan)
Dot quy I
Chay mau 1
Chi sd INR khdng dn dinh 1
Tudi > 65 1
Thudc (aspirin. NSAID..) udng rugu 1 hoac 2
( I diem cho mdi phan)
Phu luc 4. Cong thoc tinh BMI
B M I (kg/m2) = Can nang (kg)/ [Chidu cao (m)^2

7
Tdi lieu tham khao:
1. Adam Cuker, Eric K Tseng, Robby Nieuwlaat et all. American Society of Hematology 2021 guideline on the
use of anticoagulation for thromboprophylaxis in patients with Covid-19. Blood advances, 9 february 2021,
vol 5, no 3
2. Alexander Godon, Charle Ambroise, Alexandre mansour et all. Prevention of thromboembolism and heamostasis monitoring
in patients with Covid-19: updated proposals (april 2021). From the French Working Group on perioperative heamostasis
(GIHP) and the French Society of Anaesthesia and intensive care (SFAR), april 2021.
3. The REMAP-CAP, ACTIV-4a, and ATTACC Investigators. Therapeutic anticoagulantion with heparin in noncritically ill
patient with covid-19. The New England Journal of Medicine, 4 august 2021.
4. The REMAP-CAP, ACTIV-4a, and ATTACC Investigators. Therapeutic anticoagulantion with heparin in critically ill
patient with covid-19. The New England Journal of Medicine, 4 august 2021.
5. Sotirios Bristogianis, Dwan Swan, Jecko Thachil. Thromboprophylaxis in covid-19- rationale and considarations. Advances
in biological regulation, July 2021.
6. YNHHS treatment guidance for hospitalized aldults with covid-19. Update 3/8/2021
7. CBagot, B Miles, G Chalmers, D McCarey, C Geddes. Prevention of thrombosis during RRT in COVID-19 +ve critical
patients \1, 30/10/20.

K T . C H U T I C H <2^i^^ff^

TSTBach Quoc Khanh