Y BAN NHN DN TP.

H CH MINH
S Y T TP. H CH MINH

LU CHN ON & X TR
BNH TAY CHN MING TR EM

THNG 06-2011
 NH NGHA CA LM SNG

C mt trong 2 tiu chun sau

Pht ban tay chn ming

Hoc: Lot ming

 BNH TAY CHN MING 4
- SUY H HP TUN HON NNG
C 1 trong cc tiu chun sau y:
Ngng th, th nc
Tm ti / SpO2 < 92%
Ph phi cp
Sc: C 1 trong cc tiu chun sau y:
Mch khng bt c, HA khng o c
Tt HA (HA tm thu):
Di 12 thng: < 70 mmHg
Trn 12 thng: < 80 mmHg

HA kp: Hiu p 25 mmHg

 X TR 4
Nm khoa cp cu / Hi sc tch cc
iu tr:
t ni kh qun gip th, thng s ban u:
Thng s Khng ph phi C ph phi
Ch th Kim sot p lc Kim sot p lc
(PC) (PC)
TS (ln / pht) I/E 20-40, 1/2 20-40, 1/2
IP (cm H2O) 10-12 10-15
VT (ml/kg) cn t 8-10 5-6
PEEP (cmH2O) 4-6 8-15
FiO2 (%) 40-60 60-100

c ch h hp bnh nhn th my
 X TR 4
Dobutamin 5g/kg/pht, tng dn 2-3 g/kg/pht mi 5-15 pht
cho n khi c hiu qu (ti a 20 g/kg/pht).

Nu c sc v khng c du hiu ph phi, suy tim (gallop, ran phi,

gan to, TMC ni)
thc hin Test dch truyn trong khi ch o ALTMT: NS/LR 5
mL/kg/15pht, theo di st du hiu ph phi v p ng quyt
nh iu tr tip (trang 12).

o ALTMT v x tr theo p ng lm sng v din tin ALTMT

 X TR 4
Phenobarbital 10-20mg/kg TTM chm trong 30 pht. (trang 15)

H st tch cc (trang 17)

-globulin khi HATB 50 mmHg: 1g/kg/ngy TTM chm trong 6-8 gi x 2

ngy (trang 15)

iu tr ri lon kim toan, in gii, h ng huyt

Nu khng p ng cc bin php trn, xem xt ch nh lc mu lin tc

hoc ECMO ( nhng c s y t c iu kin thc hin).

Khng sinh: Cefotaxime hay Ceftriaxone nu cha loi tr NKH v VMNM

Nu ph phi, khng sc v ALTMT > 10 cm H2O: Furosemide 1mg/kg/

ln TMC
 X TR 4
Theo di:
Sinh hiu:
M, HA v nhp tim, SpO2 mi 15-30 pht.
Nhit hu mn / 1-2 gi cho n khi N < 39oC

Theo di st trong 6 gi u, sau iu chnh theo p ng

lm sng.
Nc tiu mi 6-12 gi
ALTMT mi 1 gi cho n khi ra sc.
o HA ng mch xm ln.
 X TR 4
Xt nghim:
CTM, CRP, cy mu
ng huyt nhanh / 3 gi
Kh mu, lactate mu
Ion , ALT - AST, Ure - Creatinine
Troponin I, CK-MB, CPK
Pht hng / pht trc trng: PCR cy EV71
Xquang phi, siu m tim
Chc d tht lng xt nghim khi n nh
 BNH TAY CHN MING 3
SUY H HP, TUN HON
C 1 trong cc tiu chun sau:
Mch > 170 ln/pht (khi tr nm yn, khng st).
V m hi lnh ton thn hoc khu tr.
HA tng theo tui:

Di 1 tui: > 110 mmHg; T 1 - 2 tui: > 115 mmHg; Trn 2 tui: > 120 mmHg

Th nhanh theo tui

Gng chi / hn m (GCS < 10)
Th bt thng: C 1 trong cc du hiu sau:
Cn ngng th- - Th bng- Th nng
Rt lm ngc -Kh kh- Th rt thanh qun
 X TR 3
Nm khoa cp cu / hi sc tch cc

iu tr:

Nm u cao 15-30o

Th oxy cannula 1-3 lt / pht. Theo di p ng lm sng trong 30-60 pht, nu cn mt

trong cc biu hin sau th cn c ch h hp v t NKQ :

Th bt thng

Th nhanh > 70 ln / pht (tr nm yn, khng st)

Ri lon thn kinh thc vt: SpO2 dao ng, da xanh ti, v m hi, mch > 180 ln / pht (tr nm

yn, khng st)

Gng chi / Hn m (GCS < 10).

Phenobarbital 10-20mg/kg TTM chm trong 30 pht (trang 15).

-globulin 1g/kg/ngy TTM chm trong 6-8 gi x 2 ngy

 X TR 3
Dobutamin nh phn nu HA bnh thng v mch nhanh > 170 ln/pht.
Milrinone TTM 0,4g/kg/pht nu HA cao, trong 24-72 gi. Xem xt
ngng Milrinone nu:
HA tm thu n nh 100 - 110 mmHg
Ngng ngay Milrinone nu HA tm thu < 100 mmHg

H st tch cc (trang 17)

iu tr co git (nu c): Midazolam 0,15 mg/kg/ln hoc Diazepam 0,2-
0,3 mg/kg TMC, lp li sau 10 pht nu cn co git (ti a 3 ln).
Nui n tnh mch, hn ch dch 2/3 nhu cu + nc mt khng nhn bit.
Khng sinh: nu khng loi tr nhim khun huyt v VMNM
 X TR 3
Theo di:
Nhng tr cha c tiu chun t NKQ cn theo di cc du hiu sau:
Mch > 180 ln / pht
Yu lit chi
Cn git mnh nhiu sau truyn -globulin 12 gi
Nu c, cn theo di st mi 30-60 pht trong 6 gi u kp thi pht hin cc du
hiu cn t NKQ.
o HA ng mch xm ln / Monitor HA khng xm ln 1-2 gi.
Th kh mu, lactate mu v iu chnh .
Nhng bnh nhn cn li, theo di sinh hiu:
Tri gic, SpO2, HA v nhp tim / mi 1-2 gi
Nhit hu mn / 1-2 gi cho n khi N < 39oC
Theo di st trong 6 gi u, sau iu chnh theo p ng lm sng .
Xt nghim: Nh 4
 BNH TAY CHN MING 2B BIN CHNG
THN KINH NNG
C 1 trong 2 nhm triu chng sau:

Nhm 1: C mt trong cc du hiu sau:

Tht iu (run chi, run ngi, ngi khng vng, i long chong)

Rung git nhn cu, l

Yu chi (sc c < 4/5) hay lit mm cp.

Lit thn kinh s (nut sc, thay i ging ni, )

 BNH TAY CHN MING 2B BIN CHNG
THN KINH NNG
Nhm 2: Mt trong cc biu hin sau

Git mnh ghi nhn lc khm.

Bnh s c git mnh 2 ln / 30 pht

Bnh s c git mnh, km mt du hiu sau:

Ng g

Mch > 150 ln /pht (khi tr nm yn, khng st)

St cao kh h ( 39oC khng p ng vi thuc h st)

 X TR 2b
Nhp vin iu tr ni tr, nm phng cp cu
iu tr:
Nm u cao 15-30o, th oxy qua cannula 1-3 lt/pht (nhm 1)
Phenobarbital 10-20 mg/kg TTM chm trong 30 pht, lp li sau 6 gi nu
cn git mnh nhiu (tng liu: 30mg/kg/24 gi )
-globulin:
Nhm 1: 1g/kg/ngy TTM chm trong 6-8 gi. Sau 24 gi nu cn du hiu
2b: Dng liu th 2
Nhm 2: Khng ch nh -globulin thng qui. Nu triu chng khng gim
sau 6 gi iu tr bng Phenobarbital th cn ch nh -globulin. Sau 24 nh
gi li quyt nh liu th 2 nh nhm 1.
Khng sinh: Cefotaxim hay Ceftriaxon nu khng loi tr VMNM
 X TR 2b
Theo di:

Sinh hiu:
Tri gic, SpO2, HA, nhp tim, nhp th mi 1-3 gi trong 6 gi u.

Nu gim triu chng: theo di 4-6 gi.

Xt nghim

CTM, CRP

ng huyt nhanh

Chc d tht lng nu c st 38,5oC hoc khng loi tr VMNM

 BNH TAY CHN MING 2A BIN
CHNG THN KINH

C mt trong cc du hiu sau:

Bnh s c git mnh t (< 2 ln / 30 pht v khng
ghi nhn lc khm)

L , kh ng, quy khc v c, st trn 2 ngy

hay st > 39oC, nn i.
 X TR 2a

Nhp vin iu tr ni tr.

iu tr:
Phenobarbital: 5-7mg/kg/ngy (ung).

Hng dn thn nhn theo di du hiu chuyn

Theo di sinh hiu:

M, HA, NT, N, tri gic, SpO2 mi 8-12 gi.
 X TR 2a
Theo di

Nu c yu t nguy c din tin nng di y th cn theo di mi 4-6 gi, trong 24

gi u
Li b, st trn 3 ngy, st cao > 39oC

Bnh s c git mnh trong khong 24-72 gi

ng huyt > 160 mg% (8,9 mmol/L)

Bch cu tng > 16.000/mm3

Nn i nhiu

Xt nghim:
CTM

ng huyt nhanh
 BNH TAY CHN MING 1

Chn on:
Ch c pht ban TCM v / hoc lot ming

iu tr
ngoi tr (c iu kin theo di v ti khm)
Hng dn thn nhn theo di du hiu nng cn ti
khm ngay.
Ti khm mi ngy, cho n ngy th 8 ca bnh
 MC TIU IU TR CHUNG
Gi 0: Trong 15 pht u:
Kim sot ng th v n nh v h hp: trong gi u ( 4: ngay
lp tc).

Khi u thuc vn mch trong 15 pht ( tht s truyn cho bnh

nhn).

Bt u gi th nht (sau 60 pht tip nhn BN):

Hon thnh vic o v theo di HA ng mch xm ln (nu c ch
nh)

Hon thnh vic o v theo di ALTMT (nu c ch nh)

 MC TIU IU TR CHUNG
Bt u gi th 2 (sau 120 pht tip nhn BN):
HA n nh (khng cao, khng tt. Trng hp lc tip nhn BN c HA tt hay
khng o c, HA kp xem nh t mc tiu)

Kim sot c triu chng git mnh / co git / co gng.

n gi th 6:
Huyt ng hc n nh (M < 140 ln / pht, HA trong gii hn bnh thng ).

Kh mu n nh mc bnh thng

Lactate mu bnh thng

ng huyt n nh.

Sau 24 gi th my: Xem xt ch nh cai my th khi iu kin

TH MY
LU IU CHNH PaO2 TRONG TH MY
BTCM KHNG PH PHI
t thng s ban u:
FiO2 40-60%
PEEP 4-6 cmH2O
IP 10-15 cmH2O Gim FiO2 dn cho n tr s thp nht
m vn gi PaO2 > 70 mmHg
(+)
PaO2 > 70 mmHg (SaO2 > 92%)
(-)
Tng PEEP mi 2 cmH2O (ti a 10 cmH2O) (+)
cho n khi PaO2 > 70 mmHg
(-)
(+)
Tng IP mi 2cmH2O (-)(ti a 20 cmH2O) cho
n khi PaO2 > 70 mmHg
(-)
(+)
t I/E = 1/1,5 - 1/1 sao cho PaO2 > 70 mmHg
(-)
Tng FiO2 n 80% gi PaO2 60 mmHg hoc
SaO2 90%
(-)
Tng FiO2 n 100%
 Ci t thng s ban u
iu chnh IP t VT 8-10 ml/kg
p ng (-)
LU IU FiO2 mi 20% /5 pht ti a 60%
p ng (-)
CHNH PaO2
PEEP mi 2 cmH2O/5 pht ti a 10 cmH2O (*)
TRONG TH p ng (-)
MY BTCM FiO2 n 80%
C PH PHI p ng (-)
I/E = 1/1.5

p ng (-)
IP mi 2 cmH2O/5 pht ti a 20 cmH2O gi VT < 12ml/kg
(*)
p ng (-)
I/E = 1/1
p ng (-)
FiO2 mi 20%/15 pht 100%
p ng (-)
Th thut huy ng ph nang (m ph nang) hay HFO

(*) Nn BN xut hin sc: Chng sc theo lu chng sc

 HI SC SC
Thuc vn mch:

Dobutamin:
Ch nh:
ph phi

suy tim/sc tim

cao HA

nhp tim nhanh 170 l/pht

Dopamin, adrenaline, noradrenaline: sc nng khng p ng b dch + dobutamine

10-20g/kg/pht sau 1-2 gi.

Lu : khi truyn cc thuc vn mch nn mc monitor a thng s theo di lin tc

v o HAMXL
 HI SC SC
Thuc vn mch:

Milrinone:

Ch nh:

cao HA

suy tim khng km sc tim

nhp nhanh 170 ln / pht (tr nm yn, khng st)

Chng ch nh: huyt p < 100 mmHg

Liu: 0,4-0,5 g/kg/ph. Thi gian truyn trong 48-72 gi hoc ngng truyn nu HATT

n nh 100-110 mmHg.

Nu khng gim c huyt p, nhp tim: phi hp dobutamine.

 HI SC SC
Thuc vn mch:

Milrinone:
Cch s dng: ng mirinone 10mg/10ml (bit dc primacor hoc
novaplus) tnh liu lng theo cn nng pha vi dextrose 5% t
nng 50-100g/ml.

Tc dng ph: tt huyt p, ri lon nhp tim, nn, i, au bng, tn

thng gan, gim tiu cu, ha kali mu. Tc dng trn huyt ng c
th ko di 3-5 gi sau khi ngng thuc. Gim liu khi suy thn. Khng
dng chung vi furosemide v gy kt ta.
 HI SC SC
Dch truyn:

Nu bnh nhn c sc

o CVP v/hoc HA ng mch xm ln,

t sonde tiu,

siu m tim nh gi chc nng co bp c tim FS, EF.

Bi hon dch chng sc theo CVP v HA xm ln;

Dch truyn in gii (LR/NS) tc 5ml/kg/15pht.

Theo di ran phi, tnh mch c ni, nhp tim gallop, kch thc gan trnh qu ti dch gy

ph phi.

Duy tr hoc ngng dch ty tnh trng tng bnh nhn.

Tnh trng huyt ng thay i do ri lon iu ha thn kinh thc vt nn ngng dch truyn

ngay khi huyt ng va n nh, trnh truyn d dch gy ph no hoc ph phi do qu ti

dch.
 HI SC SC
Dch truyn:
nh gi sc cng nh hiu qu chng sc thng qua huyt ng (M, HA, CVP), ti mu c
quan (nc tiu, da nim, u chi, lactate, ScvO2, BE) mi 30 pht gi trong 6-12 gi u,
mi 1-2 gi trong 12-24 gi k. Mc tiu cn t HATT 100 mmHg, HATB 50-60 mmHg, CVP
6-15 cmH20, Lactate 2 mmol/L, ScvO2 70%

Nu p ng: duy tr dch 5-10 ml/kg/gi x 1-2 gi + dobutamine

Nu khng p ng: tip tc dch truyn 5 ml/kg/15pht + vn mch adrenaline 0,1-0,4

g/kg/ph.

Xt nghim kh mu ng mch, tnh mch trung ng (ScvO2), lactate mu mi 2-4 gi trong

24 gi u chng sc, 4-6 gi trong 24 gi k nhm pht hin tnh trng ti mu m km
can thip kp thi.
 Sc

0-5 pht t ni kh qun, thit lp ng truyn tnh mch mch hoc ty

xng, xt nghim mu, dobutamine 5g/kg/ph

Ph phi, suy tim (+)

(gallop, ran phi)

(-)
5-20
Test dch truyn: LR/NS 5ml/kg/15pht, o ALTMT, HAMXL, t Dobutamine 5-20
pht
thng tiu g/kg/pht

Du hiu ph (+)
phi, suy tim?

Khng
(-) p ng
(-) Sc ci thin (+) Duy tr dch 5-10
ml/kg/gi x 1gi, (+)
(-) dobutamine

Dch truyn 5ml/kg/15pht (lp li ti a 3 ln)

Dobutamine 7-10-15-20 g/kg/pht (+)
20-60 Mc tiu cn t:
pht CVP 6-14 cmH2O, HATT 100 mmHg, HATB 50-
(-) Khng p ng 60 mmHg,, ScvO2 70%, Lactate 2 mmol/L
sau 3 ln

Dch truyn 5 ml/kg/15 pht x 1 gi, Dobutamine 20 g/kg/pht,

phi hp Adrenaline 0,1-1 g/kg/pht hay Noradrenaline 0,1-1
g/kg/pht, di hng dn CVP, Huyt p ng mch xm ln
(HAMXL).
Xem xt ch nh cao phn t.
1 2 gi Tip tc theo di v iu tr h tr: h hp, tun hon, ri lon in
gii, chuyn ho, toan kim, ng mu, xem xt lc mu lin tc
 THUC S DNG TRONG IU TR BNH TAY
CHN MING
-Globulin
Ch nh:
BTCM 3
Bnh TCM 4: ch dng sau khi hi sc sc, khi HATB 50 mmHg.
BTCM 2b:
Nhm 1: 1g/kg/ngy TTM chm trong 6-8 gi. Sau 24 gi nu cn du hiu 2b: Dng
liu th 2.
Nhm 2: Khng ch nh -globulin thng qui. Nu triu chng khng gim sau 6-12 gi
iu tr bng Phenobarbital th cn ch nh -globulin.

Liu: 1g/kg/ngy TTM chm trong 6-8 gi x 2 ngy. i vi BTCM 2b, sau
24 gi nh gi li: nu triu chng gim (tng ng lm sng 2a) th
khng s dng liu 2
 THUC S DNG TRONG IU TR BNH TAY
CHN MING
An thn chng co git:

Phenobarbital:
Ch nh: T 2b

Liu lng: 10-20mg/kg TTM 30 pht, c th lp li sau 12 gi nu cn git

mnh nhiu. Tng liu 30mg/kg/ngy.

Diazepam:
Dng khi c co git hay c ch h hp trc t NKQ.

Liu lng: 0,2mg/kg TMC. C th lp li sau 10 pht nu cn co git, ti a 3

liu. Nhng bnh nhn cn co git sau th truyn tnh mch lin tc 0,1-
0,3mg/kg/gi.

Midazolam: s dng trong c ch h hp bnh nhn th my

 CC IU TR KHC
H st thng thng:
Paracetamol liu 10-15 mg/kg/ln (ung), lp li mi
4-6 gi khi cn.
Bnh nhn BTCM 3, 4: Paracetamol 10-15
mg/kg/ ln TTM chm trong 15 pht, lp li mi 4-6
gi khi cn.
Khng dng Aspirin
 CC IU TR KHC
H st tch cc
Ch nh: St cao lin tc 40oC, khng p ng vi h st thng thng.
Cch thc hin:
Lau mt h st tch cc.
Paracetamol 10-15 mg/kg/ ln TTM chm trong 15 pht.
Nu N vn cn > 39oC sau 1 gi s dng paracetamol TTM: kt hp Ibuprofen 10 mg/kg/ln
(ung hay qua sonde d dy). Khng s dng Ibuprofen nu c xut huyt tiu ha.
Ra d dy bng NaCl 0,9% lnh, kt hp tht tho NaCl 0,9% lnh: khi cn st > 40oC v
khng p ng vi Paracetamol + Ibuprofen.
Nu tht bi vi tt c cc bin php trn (thn nhit vn cn > 40oC sau 4-6 gi): Methyl
prednisone 10 mg/kg/ln TTM chm trong 30 pht x 2 ln / ngy. Theo di st HA khi truyn.
Thi gian s dng Methyl prednisolone: n khi kim sot c thn nhit, ti a 3 ngy.
 CC IU TR KHC
Lc mu lin tc:
Ch nh: C biu hin tn thng t nht 2 c quan sau:
Suy h hp nng: Cn th my FiO2 > 60%, IP > 25 cmH2O, PEEP > 10 cm H2O
Huyt ng khng n nh sau 3 gi hi sc
Ri lon ng mu (PT, aPTT > 1,5 chng)
Suy gan: ALT, AST > 100 U/L
Suy thn cp: Creatinine mu > 2 mg% (176,8 mmol/L)
Hn m su: GCS < 10

Qu ch nh: h thn nhit, ng t dn.

Nhng tnh hung nn xem xt ch nh lc mu:
Th my + hn m + st cao lin tc khng p ng vi bin php iu tr h st tch cc.
Th my + hn m + sc khng p ng vi cc bin php chng sc sau 2 gi.
Bnh nhn th my km bng chng tn thng tim: suy tim, troponin I (+)

Nn thc hin sm ngay sau khi t ni kh qun gip th hoc chng sc tm n

 CC IU TR KHC
Dinh dng: iu chnh in gii, toan kim, ng huyt:

H natri mu < 120 mmol/L: b natri u trng: NaCl 3% 6-10 ml/kg TTM
trong 1 gi. Duy tr dung dch in gii gi natri t 130-145 mmol/L

Toan chuyn ha: b bicarbonate 4,2% 1mmol/kg TTM khi HCO3- < 15
mmol/L hoc BE < - 5 mmol/L

H ng huyt: glucose 30% 2ml/kg TMC, duy tr dung dch ng 10% c

pha in gii.

Xt nghim kim tra: kh mu, ion , ng huyt / ng huyt nhanh

mi 4-6 gi iu chnh kp thi cc bt thng.