BNH C V SYNAP THN KINH - C

MC TIU 1. Trnh by triu chng hc bnh c v cn lm sng trong bnh c. 2. Hiu c phn loi bnh c. 3. Trnh by chn on v iu tr bnh lit chu k. 4. Hiu c sinh bnh hc v phn nhm ca bnh synap thn kinh - c 5. Trnh by chn on v phng php iu tr bnh nhc c. NI DUNG 1. BNH C 1.1. i cng Bnh c l nhng tnh trng bnh l c cc triu chng do ri lon chc nng ca c, m trn lm sng v xt nghim khng tm thy bng chng ca cn nguyn tm l hay hin tng mt phn b thn kinh. 1.2. Triu chng hc bnh c - Yu c: Thng yu cc c gc chi (vai, i, mng). Yu c thng tng tin t t, lin tc. Yu c khng thay i trong ngy hoc trong thi gian ngn, nu c th c th ngh ti lit chu k. - Teo c. - Hin tng tng trng lc c: gim kh nng th gin c, sau ngh ko di th co c kh khn, v khi co c th th gin kh khn v chm. - Co v cng cc c. - Vp b. - Ch c mt s t bnh c c au c, au c khng phi l triu chng ni tri ca bnh c. - Khng t b, khng ri lon cm gic. - Khng du hiu thp. - Khng co git b c. - Phn x gn xng c th gim hoc mt trong giai on bnh nng, ri lon phn x cng khng phi l c trng ca bnh c. 1.3. Cn lm sng - nh lng enzyme huyt thanh: Enzyme Creatine Kinase (CK) huyt thanh tng cao. CK huyt thanh tng cao thng trong bnh c, bnh tim, CK cng c th tng trong st nhim virus, chn thng, hot ng th lc, v nu CK bnh thng cng cha loi tr bnh c c. Cc enzyme huyt thanh khc nh SGOT, SGPT, Lactat dehydrogenase (LDH) cng tng. - Myoglobin trong mu v nc tiu: cn nghi bnh c do chuyn ha v c hoi t c.

- Chn on in: tc d dn truyn ca dy thn kinh bnh thng, in c kim c hnh nh bnh c. - Sinh thit c: hnh nh bnh c. - Xt nghim gen chn on sm bnh, l xt nghim quyt nh chn on. 1.4. Phn loi bnh c 1.4.1. Cc bnh lon dng c: - Lon dng c Duchene v Becker. - Lon dng c Emery Dreifuss. - Lon dng c vng ai chi. - Lon dng c th mt b vai cnh tay. - Cc lon dng c khc: th mt, mt hu, ngoi vi. 1.4.2. Cc bnh c tng trng lc c: - Cc bnh lon dng - tng trng lc c. - Tng trng lc c bm sinh. 1.4.3. Cc bnh c bm sinh: - Bnh c c si. - Bnh li trung tm. - Bnh c do tiu qun c. - Cc bnh c do ty lp th. 1.4.4. Cc bnh c do vim: - Vim a c. - Vim c v da. - Vim c th vi. - Bnh c trong AIDS. - Bnh c do giun xon, toxoplasma 1.4.5. Cc bnh c do cn nguyn khc: - Bnh c do ru. - Bnh c do thuc: nhm statins, corticoids, clofibrate - Bnh c do bnh ni tit: cng gip, nhc gip, thiu nng tuyn yn, cng hoc thiu nng thng thn. - Bnh c do chuyn ha: McArdle (thiu phosphorylase ca c bm sinh), bnh lit chu k. BNH LIT CHU K: * Lit chu k h Kali mu: - Di truyn tri theo nhim sc th thng. - a s khi pht trc 16 tui. - Yu t khi pht cn lit: n nhiu bt hoc ng, vn ng th lc nhiu gy mt mi, cc yu t cm xc, nhim lnh. - Bnh nhn thng ng dy vi cm gic yu lit tay chn, cn thng ko di vi pht ti vi gi.

- Thng ch c cc c t chi v c thn mnh b yu lit, gc chi b nng hn ngn chi. Cc c mt, c vn nhn, c hu hng, c honh, cc c trn rt t khi b nh hng. - Trong cn phn x gn xng v phn x da gim hoc mt. - Phn x ring c mt trong cn. - Khng ri lon cm gic. - Trong cn lit nng kali huyt thanh gim. - ECG: sng T dt, c sng u. - in c trong cn lit biu hin gim hoc khng c in th ca cc n v vn ng. Ngoi cn lit, khng c bt thng v in c. - iu tr ct cn bng ung Kali chlorua liu 0,25 mEq/kg cn nng. Sau 1-2 gi nu khng c hiu qu th truyn tnh mch 0,05 0,1 mEq//kg cn nng. Trnh dng dch truyn c Glucose hay Natri Chlorua. iu tr d phng bng ch n ung cc thc n nhiu kali v t mui Na, ch n t bt ng, trnh n mt lc qu nhiu, trnh lu ngoi tri lnh. C th d phng bng KCl 510g/ngy, hoc Acetazolamide. * Lit chu k tng Kali mu: - Di truyn tri theo nhim sc th thng. - Khi pht tui s sinh hoc nhi ng. - Cn thng xut hin sau khi bnh nhn vn ng th lc, ang ngi ngh ngi c 1 lc. - u tin lit bn chn, ri lan dn ln ton thn. Cc c thuc dy thn kinh s no t b, cc c h hp khng b nh hng. - Phn x gn xng gim hoc mt trong cn. - Cn ko di 15 60 pht, him khi ko di vi ngy, khi ht cn c th yu c thm 1 2 ngy. - Kali mu thng tng > 5 6 mmol/l. Natri mu gim. - ECG: sng T cao. - Dn truyn thn kinh bnh thng. - iu tr: khi cn ko di v nng: tim tnh mch 1 -2 g Calcium gluconate. Nu sau vi pht khng kt qu th truyn Glucose (c th km Insulin) iu tr duy tr bng Hydrochlorothiazide 0,5g/ngy nhm duy tr nng Kali mu < 5 mEq/l. * Lit chu k Kali mu bnh thng: bnh rt him, lm sng ging cn lit chu k tng kali mu nhng nng kali mu bnh thng. 2. BNH SYNAP THN KINH - C Bnh l ca synap thn kinh c cn gi l bnh l ca chuyn tip thn kinh c (disorsers of neuromuscular transmission), c th chia thnh hai phn nhm: - Nhm bnh l ca mng trc synap thn kinh c gm hi chng nhc c, ng c tht do nhim c t Botulism, lit c do ve t
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- Nhm bnh l ca mng sau synap thn kinh c gm bnh nhc c, chng nhc c do cc hp cht kiu Curare

Bnh l ca synap thn kinh c c biu hin chung l yu mi c, yu sc c thng phn b khng u, khng theo mt nh khu thn kinh no, mc yu c c bit thay i lin quan vn ng. BNH NHC C 2.1. i cng - Bnh nhc c (Myasthenia gravis) l bnh ca mng sau synap thn kinh c, l mt bnh t min do cc khng th khng th th acetylcholine (AchR), hoc khng th khng li tyrosine kinase ca th th c hiu ca c (MuSK) gy ra, do lm suy gim dn truyn thn kinh c. - T l mc bnh mi dao ng trong khong 1-9/1 triu, trong khi t l mc bnh chung l 25-142/1 triu. - T l mc bnh mi ph n hi cao hn so vi nam gii. - T l khi pht bnh cao nht ph n l la tui 20-24 v 70-75 tui, nam gii l 30-34 v 70-74 tui. 2.2. Sinh bnh hc - Ti synap thn kinh c, cc khe synap th cp b bin mt hoc b rng ra mt cch bt thng, tr nn tha hn, khe synap s cp cng b

rng ra. S lng cc th th acetylcholine mng sau synap b gim st r rt, do gim hiu lc dn truyn thn kinh c gy ra tnh trng yu c. - Ngi ta tm thy khng th khng protein ca th th acetylcholine khong 80 - 90% bnh nhn nhc c ton thn v 60 - 70% bnh nhn nhc c th mt. Cc khng th khng th th acetylcholine ny lm suy gim chc nng th th acetylcholine bng cch: phong ta khng cho cc phn t acetylcholine gn vo vi th th acetylcholine, lm tng tc thoi ha ca cc th th acetylcholine ln cao gp 2-3 ln, v qua trung gian b th gy ph hy cu trc cc np gp ca mng sau synap lm gim s lng th th acetylcholine. - Khong 10 20% s bnh nhn khng c khng th khng th th acetylcholine, ngi ta vn tm thy nhng khng th kiu khc gn kt vo tn cng synap, ngoi v tr ca cc th cm th acetylcholine. - Bnh c lin quan vi tuyn c, khong 70% bnh nhn nhc c c tng sn tuyn c, v 10% c u tuyn c. Tuyn c c cc t bo thng b trnh din th th acetylcholine, ngoi ra tuyn c cha cc lympho B c hiu vi th th acetylcholine v cc tng bo tham gia to khng th khng th th acetylcholine. - Bnh i khi lin quan vi cc bnh t min khc: cng gip, vim a khp dng thp, lupus ban , vim a c... 2.3. Lm sng - Khi pht bnh c th cp tnh, bn cp, hoc t t. - Yu t khi pht: stress, bnh nhim trng, sau phu thut, thai k, thuc phong b thn kinh c, i khi khng c yu t no c tm thy. - Yu c dao ng trong ngy, tng khi c hot ng gng sc v phc hi khi ngh ngi. Yu c khng ph hp vi bt k nh khu thn kinh no. - Triu chng thng gp l yu c mt vi biu hin sp mi hoc lit vn nhn. Biu hin sp mi (50-90% bnh nhn) c th khng i xng hai bn. Khm pht hin sp mi do nhc c bng cch: cho bnh nhn nhn ngc ln mt im c nh trn cao trong 2 pht, mi trn mt bn mt s t t sp xung. Yu cc c vn nhn biu hin bng cc t nhn i (15% bnh nhn). - Khong 1/3 bnh nhn biu hin yu c nhai, c hu hng. Bnh nhn kh nut v b mi hm khi nhai, ba n d b ngt qung do khng nhai c v nut nghn tng dn, ging ni kh nghe v ni ging mi. - Khong 20-30% bnh nhn c yu c gc chi hoc c vng c, yu c c khin cho bnh nhn kh gi c c thng v c r xung. - Cng c mt s t (khong 3%) b yu c ngn chi nhiu hn. - i khi bnh nhn c biu hin suy h hp do yu c honh v cc c h hp ph khi bnh tin trin nng.
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- Din tin ca bnh nhc c rt khc nhau, c bnh nhn yu c tin trin v lan rng ra rt nhanh, c bnh nhn ch yu khu tr mt nhm c ko di nhiu thng. Din tin thng ti i ti li. Khi nng, bnh nhn c th t vong do suy h hp. - Cn nhc c (myasthenic crisis): l tnh trng nhc c tng tin nhanh chng gy lit t chi km suy h hp. Cc du hiu bo ng cn nhc c l: bnh nhn bn chn, s hi, tot m hi, ni lp ging mi, nut kh, yu c c, suy h hp, kh th, th nng, c hin tng c ng nghch o ca thnh bng v ngc khi h hp, gim dung tch sng. - Phn loi lm sng bnh nhn b nhc c (theo tiu chun ca Osserman) Nhm I: Nhc c th mt n thun, t l 15 20% tng s bnh nhn. Nhm IIA: Nhc c ton thn nh, tin trin chm chp, khng c cn nhc c, c p ng vi thuc, t l 30%. Nhm IIB: Nhc c ton thn mc trung bnh, nh hng nng ti h c xng v h c thuc hnh no, nhng khng c cn nhc c, c p ng vi thuc nhng khng y , t l 25%. Nhm III: Nhc c bng n cp tnh, cc triu chng nng pht trin nhanh chng vi cn suy h hp, p ng vi thuc km, t l u tuyn c cao, t l t vong cao, t l 15%. Nhm IV: Nhc c nng v mun giai on v sau, triu chng ging nhm III, nhng tin trin t I sang IV mt hn 2 nm, t l 10%. Thng thi gian chuyn tip t mt giai on ny sang mt giai on khc l khong 18 thng. 2.4. Cc test chn on v cn lm sng 2.4.1. Cc test chn on: test th bng thuc khng acetylcholinesterase lm tng tm thi th th acetylcholine trong tip hp thn kinh c. Edrophonium (tensilon test): - Test c xem l dng tnh khi triu chng nhc c thoi lui sau khi tim thuc, p ng ny ch ko di 4-5 pht. - Tng liu thuc thc hin l 10mg/1ml edrophonium, u tin tim tnh mch 2mg edrophonium nh l liu kim tra, nu sau 45 60 giy khng c p ng th tim TM 3mg edrophonium liu tip theo, nu p ng vn cha r rng sau 3 pht, tim TM tip 5mg cn li. - Edrophonium c th gy rung tht v ngng tim, phi theo di mch v huyt p ca bnh nhn, v chun b sn thuc atropine trung ha tc dng khng cholinergic ca edrophonium, phi thc hin test trong bnh vin hoc ni c iu kin cp cu. Neostigmin test: - Neostigmine (prostigmine) 1-1,5mg tim bp hoc 0,5mg tim tnh mch cho kt qu thuyn gim biu hin nhc c sau 10-15 pht, ko di 2-3 gi.
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2.4.2. Hnh nh hc: CTScan hoc MRI ngc v trung tht: ph i hoc khi u tuyn c, tng sn cc nang lympho ty tuyn. 2.4.3. Xt nghim tm khng th - Khng th khng th th acetylcholine c khong 80-90% th ton thn, th mt th 60-70%. - MuSK (muscle-specific receptor tyrosine kinase) l khng th c trong khong 1/3 bnh nhn khng c khng th khng th th acetylcholine. - Cc khng th khng c vn (antistriatal muscle antibody) thy 30% bnh nhn ngi ln nhc c v 80% bnh nhn c u tuyn c. - Cc khng th khng nhn (ANAs) v cc test chc nng tuyn gip c th bt thng nhng bnh nhn b cc bnh t min kt hp khc. 2.4.4. Chn on in (in c): vai tr quan trng trong chn on bnh nhc c. - Thc hin chui kch thch lp li lin tip trn 3 nhm c (c m ci, c thang hoc c delta, c vng mi): thc hin mt chui 10 kch thch vi tn s 3Hz, o bin ca sng co c, so snh co c th 4 5 vi co c u tin ca chui. Khi c suy gim > 10% v c thy t nht 2 c, th chc chn c nhc c. - Phng php in c si n c c tng hin tng bn chn ca si c. 2.4.5. Xt nghim chc nng tuyn gip. 2.4.6. o chc nng h hp Theo di chc nng h hp cho tt c bnh nhn nhc c ton thn nng hoc khi nghi c suy h hp. o p lc th ra ti a, p lc ht vo ti a, v dung tch sng. Khi dung tch sng < 10 15 ml/kg th phi t ni kh qun. 2.5. iu tr iu tr nhc c bao gm vic p dng v phi hp cc phng thc iu tr khc nhau bng thuc c ch acetylcholinesterase, corticosteroids, thuc c ch min dch, thay huyt tng, immunoglobuline tim mch, v phu thut ct b tuyn c. La chn phng php iu tr ph hp ty thuc vo giai on v mc nng ca nhc c, lin quan u tuyn c, tui ca bnh nhn, v cc bnh km theo. t c hiu qu ti u trong iu tr, cn x tr tt cc ri lon khc i km nh nhim trng, ri lon nc in gii, v trnh s dng cc thuc c th lm bnh nhc c nng thm. Cc thuc khng c dng trong bnh nhc c v c th lm bnh nhc c tr nng hn: mt s khng sinh: polymyxin, nhm aminoglycoside, tetracycline, lincomycine, clindamycin, nhm quinolone; cc thuc c tnh gin c: benzodiazepine, thuc gin c trong gy m; botulinium toxin; phenytoin, procainamide, quinine, quinidine, lithium, thuc c ch bta, verapamil, diltiazem, cc mui Magne.
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2.5.1. Thuc c ch acetylcholinesterase: - iu tr ci thin triu chng bng cch gia tng lng acetylcholine trong khe synap b tr. - Dng n c trong nhc c nh khng km u tuyn c, hoc nhc c th mt. - Pyridostigmine bromide (Mestinon, vin 60mg): Liu khi u: ngi ln l 30-60mg, mi 6 gi 1 ln; tr em l 1mg/kg. Tng dn liu ty theo nhu cu, nhm kim sot c cc triu chng ca nhc c, v trnh cc tc dng ph. a s ngi ln thng cn dng liu trong khong 60-120mg, mi 4-6 gi 1 ln. - Neostigmine (Prostigmine): ung 7,5 15 mg, mi 4 6 gi mt ln. - Pyridostigmine phng thch t t (Mestinon Timespan, vin 180mg): thng c dng 1 vin vo ban m trc khi ng cho cc trng hp triu chng nhc c tr nng khi bnh nhn thc gic lc sng sm. - Tc dng ph cholinergic do tch t acetylcholin khi dng thuc c ch acetylcholinesterase: bun nn, nn i, au qun bng, tiu chy, v m hi, tng tit nc bt, tng tit dch ph qun, co ng t, nhp tim chm. - Cn Cholinergic do qu liu thuc c ch acetylcholiesterase: yu c tin trin nhanh km vi cc biu hin ca tc dng ph cholinergic. - Cn phn bit cn cholinergic do thuc vi cn nhc c, ta dng tensilon test, nu yu c c ci thin r, chng t thuc cha liu, ngc li nu yu c tng ln hoc khng thay i th nguy c cn cholinergic. X tr cn cholinergic bng cch ngng thuc c ch acetylcholinesterase, dng thuc khng cholinergic (atropine). 2.5.2. Corticosteroid - Corticosteroid c ch nh trong cc trng hp: nhc c ton thn t trung bnh n nng, tht bi khi iu tr thuc c ch acetylcholinesterase hoc bnh nhn khng dung np c thuc c ch acetylcholinesterase, chun b bnh nhn trc phu thut ct b tuyn c, triu chng khng thoi lui sau m ct b tuyn c, nhc c th mt khi tnh trng nhn i gy kh chu cho bnh nhn. - C hai chin lc dng prednisone cho bnh nhn nhc c: dng liu cao tn cng mnh ngay t lc bt u, hoc khi u liu thp v tng t t. - Corticosteroid liu cao vi prednisone 1-1,5mg/kg/ngy trong 2 tun, ri chuyn sang dng cch nht (ngy ung, ngy ngh). Duy tr liu cao prednisone cho ti khi sc c bnh thng tr li, hoc khi sc c ci thin mc n nh r rt. Sau , gim dn liu prednisone, gim 5mg mi 2-3 tun cho n mc 20mg ung cch nht. Vo lc ny, c th gim n 2mg mi 4 tun, tuy nhin liu thp ny bnh nhn c th b ti pht. Phc dng liu cao ny c th lm tr nng cc triu chng nhc c trong vng 5 ngy n 2 tun u tin sau khi bt u corticosteroid liu
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php, do nn cho bnh nhn nhp vin iu tr ni tr khi bt u dng corticosteroid liu cao. - Corticosteroid liu thp vi prednisone theo liu khi u l 1520mg/ngy v tng dn 5mg mi 2-4 ngy. Phc dng liu ban u thp sau tng dn c u im l khng to ra cc tnh trng tr nng triu chng nhc c nh phc dng liu cao ngay t u. Tuy nhin khng thun li vi nhng bnh nhn nng v hiu qu iu tr xut hin chm, phi sau 6-7 tun iu tr, v phi duy tr iu tr t nht l 3 thng lin tc trc khi ngng thuc. - Lu cc tc dng ph v thn trng khi dng corticosteroid. Cn loi tr lao phi trc khi dng thuc. B sung Calcium (1g/ngy) v vitamin D (400-800UI/ngy) d phng long xng do steroid. D phng lot d dy t trng bng thuc c ch th th histamin H2. Ch n t mui, t carbohydrat v giu protein. Theo di huyt p, kim tra nh k mt pht hin c thy tinh th hoc glaucom. Xt nghim kim tra nh k ng huyt v kali mu, nu c h kali mu cn b sung kali cho bnh nhn. 2.5.3. Thuc c ch min dch - Dng cho bnh nhn b nhc c trung bnh hoc nng khng c kim sot tt bng prednisone v mestinon. - Azathioprine (Imurel vin 50mg): liu 50mg/ngy cho ngi ln, v tng dn ln c 50mg mi tun, cho n tng liu 2-3 mg/kg/ngy. Thuc chm c cng hiu (6 thng hoc lu hn). Phn ng ph: st, au bng, bun nn, nn, bing n, gim bch cu, c tnh gan. Cc phn ng ph au bng, nn, bing n c th xy ra trong vi tun u tin dng thuc v bin mt trong vi ngy sau khi ngng thuc. Cn theo di cng thc mu ton b v xt nghim chc nng gan hng tun, cho n khi bnh nhn t c liu azathioprine n nh, sau theo di 3 thng 1 ln. Nu s lng bch cu gim di 4000/mm3 th gim liu thuc. Tm ngng thuc nu bch cu gim n 2500/mm3, hay men gan tng cao gp 2 ln. Chng gim bch cu c th xut hin rt sm ngay trong 1 tun u dng thuc, hoc rt mun sau 2 nm dng thuc. Chng h bch cu c th ht i trong vng 1 thng, v sau c th dng li azathioprine cho bnh nhn khng b ti pht h bch cu nng. Thuc thng c c tnh gan trong vi thng u, v c th mt vi thng mi ht triu chng. i khi c th dng li azathioprine thnh cng cho bnh nhn sau khi xt nghim chc nng gan tr v mc c bn v khng ti pht ri lon chc nng gan. - Cyclosporine (Sandimmun, vin 25 v 100mg): c ch cc phn ng min dch ph thuc t bo T nguyn pht, dng cho bnh nhn khng vi prednisone v azathioprine.
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Thuc c cng hiu nhanh hn (khong 2-3 thng) so vi azathioprine. Liu khi u 3-4 mg/kg/ngy, chia lm 2 ln, v tng dn liu cho n 6 mg/kg/ngy nu cn. Tc dng ph: au u, tng huyt p, c thn, ri lon chc nng gan, bnh no, ng kinh, rm lng. - Mycophenolate mofetil (Cellcept, vin 250 v 500mg): l thuc c ch min dch mi, c ch pht trin lympho B v T, bng cch phong b tng hp purine ch trong cc lympho. Thuc c hiu qu thuyn gim bnh sm ngay vo khong 2 tun, thng nht l vo khong 3 thng u sau khi bt u dng thuc, nhng hiu qu thc s c th chm khong 12 thng. Liu khi u 0,5g x 2 ln/ngy, tng liu dn vi 500mg mi thng, cho n liu 1g x 2 ln/ngy. Bnh nhn suy thn liu khng c qu 1g/ngy. Thuc khng c c tnh vi thn hay gan. Tc dng ph ch yu l tiu chy, bun nn, ph ngoi vi, st, gim bch cu. 2.5.4. Immunoglobulin tnh mch (Humaglobulin 2,5g, GammaIV 5g) - Thng dng cho cn nhc c nguy kch, hoc tng sc c trc khi phu thut ct tuyn c, hoc nhng bnh nhn khng vi tr liu c ch min dch, hoc phi hp vi prednisone nhm mc ch hn ch dng nhiu steroid. - Liu: 0,4g/kg/ngy x 5 ngy. - Tc dng ph: au u, au c, st, rt run, nn, shock phn v, suy thn. - Cn kim tra nng IgA cho tt c bnh nhn trc khi iu tr, v nng IgA thp c th c nguy c phn v. - Cn kim tra chc nng thn v nguy c b suy thn do immunoglobulin tnh mch gy ra. - Trnh dng cho bnh nhn b tng ng mu v c bnh tim mch do va x r rt. 2.5.5. Thay huyt tng - Ch nh cho cn nhc c nguy kch, bnh nhn b yu c mc trung bnh trc khi m ct b tuyn c nhm tng ti a sc c sau m. - Cch thc hin l thay 2-3 lt huyt tng, 3 ln trong 1 tun, cho n khi sc c c tin b r rt, t nht l 5-6 ln thay ton b. - Thay huyt tng c hiu qu ngay sau 24 gi, c th c thuyn gim sau 2-4 ln thay. - Trong vng 1 tun sau khi thay huyt tng, cc t khng th gy bnh tng dn tr li, v vy vn cn cho bnh nhn dng thuc c ch min dch 2.5.6. Ct b tuyn c - Ch nh cho bnh nhn b u tuyn c trong la tui t lc dy th n 55 tui..
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- Vai tr trn nhc c khng c u tuyn c cn cha r, nhng y l mt chn la tt lm tng kh nng thuyn gim bnh. - p ng ca bnh i vi phng php iu tr phu thut ny ch xut hin nhiu thng sau m, v ch t mc ti a sau 3 nm. iu tr cn nhc c - Cn nhc c l tnh trng nhc c tng tin nhanh chng gy suy h hp. - Bnh nhn cn c iu tr ti n v sn sc c bit v h tr h hp. - Dng thuc c ch acetylcholinesterase ng tim tnh mch vi liu Pyridostigmin 1-3 mg hoc Neostigmin 0,5-1 mg, nu khng ci thin cn c ch nh t ni kh qun v th my. - Trong khi thng kh h tr, duy tr thuc c ch acetylcholinesterase truyn tnh mch lin tc: Neostigmin liu 0,15-0,5 mg/gi, tng liu s dng 16-20 mg/ngy. - Nu khng kim sot c cn nhc c trong 24 gi cn iu tr bng thay huyt tng v Immunoglobulin. - Khi iu tr cn nhc c n nh, tnh trng suy h hp ci thin c th b my th. TI LIU THAM KHO 1. Nguyn Hu Cng (2006), Thn Kinh Hc, NXB i Hc Quc Gia TP HCM, tr. 41-55. 2. L Minh (2002), Bnh nhc c. 3. Greenberg D.A, Aminoff M.J, Simon R.P (2002), Clinical Neurology, 5th edition, Lange Medical Books/McGraw-Hill, p. 183-193. 4. Martin A.Samuels (2004), Manual of Neurologic Therapeutics, 7th edition, Lippincott Williams and Wilkins, p. 260-266. 5. Richard T. Johnson, John W. Griffin, Justin C. McArthur (2006), Current Therapy in Neurologic Disease, 7th edition, Mosby Inc, p.387-392.

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