CC B MN NI TRNG I HC Y H NI

I U T R HC
o TP I

N H X U T BN Y HC

CC B MN NI TRNG I HC Y H NI

I U TR HC
o
TP I

N H X U T BN Y HC

MC LC

PHN I:

I CNG V l TR HC CP c u 25 27 30 32 34 35 36 39 40 42 45 47 49 50 52 53 54 55 56 57 59 60 61

PHN II:
Sc Sc phn v

Com hen ph qun nng Ho ra mu t cp cu bnh phi tc nghn mn tnh Cn nhp tim chm Com nhp tim nhanh Cn rung rh nhanh Ngng tun hon Cn au tht ngc Cn au tht ngc khng n nh Nhi mu c tim Phng tch ng mch ch Cn tng huyt p Nhn no tin trin Tai bin thiu mu no thong qua Xut huyt no mng no Vim ti mt cp Vim mt qun cp Vim tu cp X tr cp cu xut huyt tiu ho cao a chy cp nhim khun X tr ng c cp

PHN III

H HP 64
66

iu tr vim ph qun cp iu tr vim ph qun mn tnh iu tr gin ph qun iu tr cc bnh bi phi iu tr suy h hp cp iu tr suy h hp mn tnh iu tr hen ph qun iu tr trn kh mng phi iu tr trn dch mng phi do lao iu tr trn m mng phi iu tr p xe phi iu tr ung th phi Ni soi ph qun trong iu tr iu tr tm ph mn tnh Hi phc chc nng ca phi bng cc t th gip lu thng kh PHN IV ' TIU HO

70 72 76 79 . 83
86

89 93 95
100

104 107

Tro ngc d dy thc qun iu tr vim thc qun iu tr lot d dy t trng iu tr vim d dy cp tnh iu tr vim d dy mn tnh iu tr nhim khun cp ng tiu ho iu tr chng a chy mn tnh iu tr chng to bn iu tr bnh i trng c nng iu tr tr hu mn iu t bnh vim lot trc trng chy mu iu tr vim gan mn tnh iu tr p xe gan amip iu tr hn m gan iu tr p xe gan do vi khun

113 115 i'

122

C23) C2' (la ? 6 3 134 136 138 142 144 145 147

iu tr x gan iu tr ung th gan iu tr x gan mt tin pht iu tr si mt iu tr vim ti mt cp tnh iu tr vim ti mt mn tnh iu tr vim tu cp tnh iu tr vim tu mn tnh iu tr chng au trong tiu ho iu tr xut huyt tiu ho cao iu tr chng kh tiu iu tr giun sn ng tiu ho PHN V C - XUONG- KHP

148 151 153 157 160 162 164 167 169 172 ^75) 177

Thuc chng vim corticosteroid trong iu tr bnh khp Thuc chng vim khng steroid trong iu tr bnh khp Cc thuc chng thp khp tc dng chm iu tr bnh vim khp dng thp iu tr vim ct sng dnh khp iu tr thoi ho khp v ct sng iu tr chng long xng iu tr bnh gt iu tr cc bnh vim xng khp nhim khun iu tr luput ban h thng iu tr vim quanh khp vai iu tr bnh nhc c iu tr bnh x cng b ton th iu tr au tht lng iu tr vim khp mn tnh thiu nin

183 194 202 206 212 218 225 230 236 245 251 254 256 261 264

Phn II
CP CU

SC
V Vn nh
I. I CNG

Sc l tnh trng thiu ti mu t chc nguyn nhn tun hon c th cui cng dn n hi chng suy a ph tng. VI vy cn chn on sm iu tr sm. Sc c nhiu nguyn nhn, sc tim, sc nhim khun, sc phn v... Mi loi sc li c c im ring. Khi ang c sc khng nn vn chuyn bnh nhn. Lm sng Mt ti tm, tm cc u chi, trn da c nhng mng thm tm, n vo th nht i v chm tr li nh c. Da lnh, ngi lnh, v m hi. - Mch nhanh, huyt p h, kt v dao ng. C khi khng - Nhp th nhanh. - V niu: di 30 ml trong 3 gi u. in tim: Sng Tm hoc dt. on ST m cc chuyn o. p lc tnh mch trung tm: + m: Sc gim th tch mu, sc nhim khun. + Bnh thng hay tng Sc do tim (suy tim cp, p tim) Sc c suy thn, tng th tch mu.
II. X TR

cmch v HA.

1. Th oxy mi 2. t ngay catheter tnh mch trung tm, theo di p lc tnh mch trung tm (TMTT)

3. Truyn dch: Bt k loi dung dch ng trng no c di tay, tr dung dch u trng. - Tc truyn nhanh 500 - 1000 m, lc u truyn trong 15-30 pht. - Sc do tim hoc c suy thn: Truyn chm 5 - 7 git/pht duy tr ng vo tnh mch. - Khi lng: Da vo p lc TMTT v huyt p: + Huyt p h, p lc TMTT m: Tip tc truyn nhanh. + Huyt p 60 - 90 mmHg, p lc TMTT dng tin 7 cm H2O: Giam bt tc truyn. + Truyn mu nu c sc mt mu phi hp vi truyn dch. 4. t catheter vo bng quang theo s'lng nc tiu lm blan sc Ch nh dng thuc vn mch 5. Nu huyt p vn khng ln, p lc TMTT ln qu 7 - Gim bt lng truyn v dch Iruyn. - Cho vo ldung dch glucose 5% 500ml: Noradrenalin 1 - 2 mg' hoc dopamin 200 mg. .' Duy tr huyt p ti a xung quanh 100 mmHg. C th truyn nhiu ln. Nu vn khng c kt qu, truyn tnh mch: Dobutamin 5-10 mcg/kg/pht cui cng adrenalin 0,03 - 0,3 mcg/pht. Nu l s"c phn v phi dng ngay adrenalin ri mi truyn dch.
6 . H hp nhn to ngay nu c r lon h hp

7. Dng khng snh nu l s'c nhim khun

8 . Truyn natri bicarbonat nu pH di 7,2

9. Tim tnh mch - Heparin 10.000 .v nu c ng mu ri rc trong lng mch (fibrinogen gim, tiu cu gim, ethanol dng). Tim li 5000 .v sau 6 gi. EAC 4 - 8 g ngy 2 - 3 ln, ibrin 1 - 4 g ngy nu ch c lbrinogen gim.

10. Trong mi trng hp cn tm ngay nguyn nhn gii quyt sm p tim: tho dch mng ngoi tim - Chy mu: cm mu. - Sc phn v: Adrenalin, hydrocortison. - St rt c tnh: Artesunat tnh mch. C suy thn: Furosemid, c mng bng, thn nhn to. Nhim khun: khng sinh, corticoid.

III. THEO DI

1. Duy tr huyt p t a 1.1. Xung quanh 100 mmHg, p lc TMTT di 7 cm H2O ngi c huyt p trc kia bnh thng, th d 120/80 mmHg.
1.2 . ngi thng xuyn c tng huyt p phi duy tr con s huyt p bng 2/3 con s

c. Th d, nu huyt p c l 210/120 phi duy tr HA mc 150/90, 160/100mmHg. 1.3. ngi thng xuyn c h huyt p, bnh thng 90/60 phi duy tr khong 80/60mmHg. la tui 60, nu khng bit r s huyt p t trc phi a huyt p ln khong 145/90mmHg 2. Lng nc tiu phi t trn 50 m/g.

s c PHN V *
V Vn nh
I. I CNG

Sc phn v (SPV) c im: SPV l mt tai bin bt ng c th xy ra b't I lc no ngi ang dng thuc hoc thc n l v c th gy t vong, SPV phi c x tr ti ch. Chun b ti cp cu SPV l cn thit. Chn on Ngay sau khi tip xc vi d nguyn (thuc, thc n...) hoc mun hn, ximt hin: Chong vng, vt v, giy gia, c khi co git Tt huyt p, mch nhanh, tru mch, c th ngng tim i khi kh th kiu hen, kh th thanh qun (hay gp em) hoc xut huyt tiu ho C th mn nga, ban , my ay.

II. NGUYN TC

Phi x tr ngay ti ch Cho bnh nhn nm v ngng ngay thuc ang dng bng bt k ng no (tim, ung, bi, nh mt, mi) vi bt k loi thuc no (k c cc dung dch cao phn t hoc cc dn cht ca mu).

III. IU TRI

1. Adrenaln l thuc c bn chng sc phn v Adrenalin dung dch 1/1.000 ng lml=lmg, tim di da ngay sau khi xut hin sc phn v vi liu nh sau: + 0,5 - lmg ngi ln + Khng qu 0 ,3 mg em (pha long 1/10.000) Hoc adrenalin 0,01 mg/kg cho c tr em ln ngi ln. Tip tc tim adrenalin liu nh trn 10-15 phln cho n khi huyt p li bnh thng. m, u thp chn cao, theo di huyt p 10-15 pht/ln. Nm nghing nu c nn. ngi ln c th tim adrenlin dung dch 1/ 10.000 qua tnh mch i, bm qua ng ni kh qun hoc bm qua mng nhn gip, nu sc qu nng e do t vong. Liu lng mi ln tim: 0,3 - 0,5mg. 2. X tr suy h hp Thng thng sau khi tim adrenalin tnh trng suy h hp s ci thin ngay. Nu vn khng : Tu theo tnh hung v mc kh th c th s dng cc bin php sau y: - Thi ngt hoc bp bng Ambu nu c ngng th. Phi hp thi ngt v bp tim ngoi lng ngc nu c ngng tim. Nu SPV xy ra ti bnh vin: t ng ni kh qun, bp bng Ambu c oxy hoc thng kh nhn to. M kh qun nu c ph thanh mn. Truyn tnh mch chm: Salbutamol 0,02mg/kg/gi hoc terbutalin 0,2 microgam/kg/pht. Ti ch c th dng: Terbutalin 0,5mg, 1 ng di da ngi ln v 0,2ml/10kg tr em. Tim li sau 6-8 gi nu khng kh th. Xt hng terbutalin, salbutamol mi ln 4-5 nht bp, 4-5 ln trong ngy. 3. Thit lp mt ng truyn tnh mch adrenaln duy tr huyt p Bt u bng 0, microgam/kg/pht iu chnh tc theo huyt p. 4. Cc thuc khc Methylprednisolon lmg/kg/gi hoc hydrocortison hemisuccinat 5mg/kg/gi tim tnh mch hoc tim bp. Dng liu cao hn nu sc nng (gp 2-5 ln). Natri chlorua 0,9% 20ml/kg tr em, 1-2 lt ngi ln. Diphenhydramin lmg/kg tim bp hay tnh mch hoc promethazin 0,5mg/kg tim tnh mch.

5. iu tr phi hp Bng p chi pha n ch tim hoc ng vo ca nc c. C th tim adrenalin pha trn ch tim, chch. Ch : Liu adrenalin trung bnh cp cu bnh nhn sc phn v l 5-7 mg - Theo di bnh nhn t nht 24 gi sau khi tim nh mch i (v tnh mch to, nm pha trong ng mch i, d tm) Nu huyt p vn khng ln sau khi truyn dch v adrenalin th c th truyn thm huyt tng, albumin (hoc mu nu mt mu) hoc bt k dung dch cao phn t no sn c, nhng vn coi chng v cc dung dch ny cng c th gy sc phn v. iu dng c th s dng adrenalin di da theo phc khi y, bc s khng c mt. - Hi k tin s d ng v chun b hp thuc cp cu sc phn v trc khi dng l cn thit. a s cc chuyn gia y t trn th gii v trong nc khng cho test b l cn thit.

NI DUNG HP THUC CP c u CHNG s c PH V A. Cn c: 1. Adrenalin lmg=lml 2. Nc c't lOml : 2 ng : 2 ng

3. Bm, kim tim (dng 1 ln) lOml: 2 ci 4. Hydrocortison hemisuccinat lOOg hoc methylprednisolon (salbutamol 40mg hay depersolon 30mg): 2 ng 5. Phng tin kh khun (bng, bng, cn, 1 chun) B. Cc dng c khc, nn c cc phng iu tr - Bm xt salbutamol hoc terbutalin - Bng Ambu v mt n - ng ni kh qun - Than hot.

CN HEN PH QUN NNG

V Vn nh
I. I CNG

c im Cn hen ph qun nng l cn hen c co tht v tc cc ph qun nh. Kh bit din bin t cn hen ph qun thng sang cn hen ph qun nng. Nhng cn hen p h qun nng thng xy ra sau nhim khun, cm, b corticoid, dng an thn, gy m, d ng, cn khng hong tm l. Cn hi sc ti ch v trong lc vn chuyn bng t cp cu c trang b. Th nng: + + + + + + + + + + +
4-

Chn on Kh th, Rn rt (+++) Co ko c h hp. Mch o Tm Vt v, ht hong. V m hi Cung lng nh <120 ln/pht. Ni kh, ho kh. PaC 2 tng (n 24mm Hg). Tn s th > 30 ln/pht. Pa 2 gim (di 60mm Hg). Ri lon thc, khng ni c. Phi im lng, th chm <10 ln/pht. C cc cn ngng th.

Th nguy kch: + + +

Th nguy kch l th nng c thm mt hay nhiu du hiu nguy kch.

II. NGUYN T C CHUNG

Cn hen ph qun nng: Thuc trc th thut sau. Cn hen ph qun nguy kch: Th thut trc thuc sau.

III. IU TRI

Ti ch: Ventoin hoc Bricanyl: 0,5 mg 1 ng di da. Th cho ht kh dung: Ventolin hoc Bricanyl. Methylprednisolon; lmg/kh TM Th oxy mi, mt n. bnh nhn ngi theo t th thch hp. Trn t cp cu c trang b v khoa HSCC: Tip tc Oxy 4-10 1/pht qua mi hay mt n . t kim truyn tnh mch: Salbutamol l- 8 mg/gi hoc phi hp vi aminophyllin. N u khng v tru mch: Adrenalin 0,5mg/gi vi bm tim truyn tnh mch. Methylprednisolon lmg/kg tim tnh mch 4 gi/ln. Truyn dch: 3-4 1/24 gi. Phi t ng ni kh qun ngay, bp bng Ambu, th oxy 100%. Coi chng nguy c trn kh mng phi. Theo di: Ti ch: Sp 2. Trn t cp cu: Sp 2. Ti bnh vin: + + + o p lc kh trong mu. Chp phi. Tm nhim khun. Th nguy kch:

Nu bnh nhn c th th c, dng kh dung: Berotec, Bricanyl, Berodual, Ventolin 3-4 hi. Sau 15 pht xem kt qu.

HO RA MU
V Vn nh
I. I CNG

c im Din bin kh bit trc, cn c theo di ti bnh vin (t cp cu thng). Nu s lng mu ra nhiu, phi vn chuyn nhanh bng t cp cu c trang b. Mu c bt ra, sau mt cn ho, nguyn nhn c nhiu (phi ph qun, van tim, phng ng nh mch phi). Bin chng nguy him nht l ngt th do sc mu. i khi tru mch do mt nhiu mu.

Chn on -

II. X TR

1. Ti ch ng vin, gii thch cho bnh nhn v ngi nh bnh nhn Exacyl (acid tranexamic 500mg -1 vi n ho c u ng 1 ng lg), ng y u ng 2 n 4 l n. - .Uong diagepam 5mg

2. bnh vin Th oxy t kim truyn nh mch Nu mt nhiu mu: + Truyn mu ' + Pitressin (20v/ml) tc dng trong mt gi + Truyn tnh mch 0,2 - 0,4 v/pht tng dn n khi c p ng (nhng cng di 1 v/pht). + Terlipressin (Glypressin) l 1 mg, tc dng 4-6 gi. + Tim tnh mch lmg/4 gi, tng dn liu n 1,5 mg nu cn nng trn 50kg. Ch : Khng tim ra ngoi t chc di a. Tin hnh soi ph qun tm tn 'thng nu vn chv mu nhiu (st nh) + t ng ni kh qun bn kh qun lnh, hoc nu chy mu nhiu ln nhng s lng t hn, ni soi bng ng ni soi mm. + Tn thng lao c nay chy mu: Hch vi ho kch thch hoc nm. -

TRN KH MNG P H I TON B

V Vn nh
I. I CNG

c im: Xut hin t ngt Ngt th nhanh chng Cn dn lu nhanh trc khi chuyn vin. au ngc. Kh th Lng ngc bn n kh gin, di ng km. G trong, RRPN gim, rung thanh tng. Cc triu chng ca trn kh m ng phi (TKMP) nng (suy h hp, tru mch, bnh phi c trc)

Chn on: -

II. IU TR

Chc ht bng kim + + Ch nh: TKMP nh, khi cp cu cha kp hoc ni khng t c ng dn lu K thut: Chc lin sn 2 ng gia xng n, dng 1 bm tim to ht kh

+ u im: D thc hin, t bin chng + Nhc im: Lu lng nh, khng dn lu c Cn theo di ti pht - Dn lu mng phi: + Cc loi ng dn lu: Catheter, ng dn lu c nng kim loi. Chc thm d bng kim loi. Dng dao nhn rch da 3-5cm n ng nch gia, lin sn V hoc VI st b trn xng sn. Tip theo, dng ko tch cc th c lin sn. Chc thng l thnh ca mng phi, thy hi x ra. Lun ng thng dn lu vo mng phi, ni u ngoi ng thng vi mt ng ni ti mt bnh cha ri ti my h L + Ht dn lu mng phi lin tc, p c ht -25cmH2 Cch dn lu kh n gin: Ni ng dn lu vi mt ng thy tinh cm vo mt l dung dch st khun. Ct nc trong ng dn lu s l van mt chiu. t l nc thp cch m t ging t nht 30cm.

Theo di: + ng dn lu tc dng bm tim to ht. Nu khng c hiu qu th rt ng thng ra vi centimet.

T c p

c a b n h p h i t c n g h n m n t n h

(t cp BPTM)
V Vn nh
I. I CNG

c im t cp BPTM l mt suy h hp cp rt thng gp, d lm bnh nhn t vong - Mt b thng tin trin dn dn. - Nhng i khi t ngt do c bin chng (trn kh mng phi, ph qun ph vim) - Cn a bnh nhn ngay ti vin bng t cp cu c trang b, nu c bin chng. Chn on: Da vo lm sng l chnh Tin s bnh phi ph qun mn. Bnh nhn thng do nghin thuc lo, thuc l, Run tay, ng g, ri lon thc, v m hi, tng huyt p, nhp th trn 5 ln, h hp nghch thng, c th c gan to. Mng tay thng khum. Nguyn nhn thun li: Bi nhim, dng nhiu thuc ma tu, nhi mu phi. -

II X TR

1. Ti ch (ti nh) Theophyllin vin hoc aminophyllin 5mg/kg tnh mch chm. Cc thuc kch thch bta: kh dung, xt Kh dung: Tim di da: Bricanyl 1-2 ng 0,5mg di da, tim li sau 6-8 gi. Tin s hen ph qun r, khng c lot d dy tin trin, nh't thit phi dng methylprednisolon lmg/kg X 5 ngy. Bnh nhn nm lu b't ng: Fraxiparin 0,5ml/ngy Th oxy mi 1-2 1/pht Hoc bp bng Ambu c oxy Ventolin 2 hi X4/ngy Berodual 2 hi X3/ngy

2. Vn chuyn

3. Ti bnh vin Thng kh c hc khng thm nhp (vi PSV) bng mt n vi p lc h tr th vo 12-20 cm H 2O. Nu khng : Thng kh nhn to quy c trc sau t ng ni kh qun. Khng sinh: hoc: Amoxycillin + macrolid Amoxycillin + Auoroquinolon

Theo di: Huyt p thng tng, nu h l rt nng, mch nhanh 120 l nng (lc cha dng kch thch bta) Cc kh trong mu: Pa 2 gim, PaC 2 tng, G3H tng pH>7,35: m't b trung bnh pH < 7,3: ng ngi Chp X quang phi: Xc nh chn on v tm trn kh, vim phi, xp phi. in tim: dy tht phi, tht tri.
III. C C CH NH C B I T

C dy tht i: Digoxin, furosemid Nu c phi hp n kh mng phi: Dn lu trc ri h tr h hp sau nu cn. Khng dng thuc an thn nu khng thng kh nhn to. Ch ng thuc li tiu ung ngn ngy khi c ph to.

CN NHP TIM CHM

V Vn nh
I. I CNG

c im: Cn nhp tim chm (CNTC) c pht hin thng do ngt xu phi a i cp cu, (nhp di 40/ph). - Nguyn nhn thng do cng ph v, nhim virus ngi , nhi mu c tim ngi gi. Chn on: Lm sng: Mch chm 20-301/pht km theo Cn ngt xu, i khi co git (hi chng Stokes - Adams) Mch chm 30-401/pht. V m hi, mt mi nht nht, nn ma, mt nhoi: Ngh ti nhp chm xoang do cng ph v -

in tim c th thy: - Nhp chm xoang, bloc xoang nh. - Bloc nh tht cp 3. Ch tm cc du hiu nhi mu c tim. Nguyn nhn: ngi gi hay gp : Do nhi mu c tim. Ngi tr: thng gp do nhim virus. Ngoi ra cn gp nhng ngi b nhim c thuc chn bta.
II. X TR

Ti ch (ngt do cng ph v): - Cho bnh nhn nm, tim aopin 0,5 mg tnh mch Ti bnh vin Truyn tnh mch isuprel 0,2mg 5 ng trong dd glucose 5% 250ml , tc 0,5-5 microgam/ph. - Trong khi ch truyn thuc, nu nhp chm di 201/ph: m vo vng trc tim 60/ln/pht. - Glucagon lmg di da nu nhp tim chm do thuc chn bta, sau truyn tnh mch chm l-5mg. - Nu dng isuprel khng kt qu: + t my to nhp tim thi hoc vnh vin ty theo trng hp. + iu tr nhi mu c tim. -

CN NHP TIM NHANH

V Vn nh
I. I CNG

c im Gi l cn nhp tim nhanh (CNTN) khi tn s tim t ngt ln qu 120 ln/pht. CNTN phi c x tr ngay trnh ri lon huyt ng. CNTN c suy tim, sc hoc ngt phi c vn chuyn bng t c'p cu n khoa HSCC. Chn on: Hi k tin s: ngi tr: CNTN trn tht, do hp van hai l. ngi gi: CNTN trn tht do nhi mu c tim, suy mch vnh. Triu chng ch quan: Kh chu, trng ngc, v m hi, bun nn, kh th. Nghe tim: p nhanh, u hoc khng u (rung nh). -

Bt mch: Mch i khi chm hn nhp tim, khong 75 n 150 l/pht in tim: + + + + + QRS mnh < 0,10 s: CNTN trn tht. QRS rng > 0,12 s: CNTN tht hoc trn tht c bloc nhnh c nng. Nhp khng u: Rung nh. C th thy du hiu nhi mu c tim: hnh nh QS. Xon nh: Nhp khng u, QRS gin rng, cc t sng cao nhn vn quanh ng ng in ln trn v xung di.

III. X TR

1. Ti nh Tt nht l ghi c in tim. X tr nguyn nhn nu l CNTN xoang. Dng cc th nghim i giao cm: n nhn cu, xoa xoang cnh, ung nc lnh. ngi c tui: Trinitrin xt hay ngm di li. Nhp khng u (rung nh): Digoxin ung 0,4 mg 1 vin hoc tim tnh mch.

2. Ti bnh vin Ghi ngay in tim, theo di bng monitor, chun b my lm sc in. Ly mu xt nghim kali, CPK, CPKMB, kh trong mu,chp tim phi. Thit lp mt ng truyn tnh mch. Da trn in tim, x tr theo quy trnh di y:

Trn thV

Khng |u

1.
eu

I
Rung nh

I
n nhn cu tim adenosin 4mg TM

I-----------------

Khng ht nhuhg chm li Nhp sng p CNTN nh Cung ng nh CNTN b ni

Ht cn CNTN b ni (Bouveret)

(khng cho nu c hi chng W-P-W) Digoxin TM 0,4mg + Cordaron 200mg lv ung - An thn Nu ti pht: Flecaini dlOOmg Isoptin 120mg Sotalol 80-160mg Tenonnin lOOmg Khng khi Khi Cordaron 200mg Phng - Ngng cc cht kch thch

Sc in 50-75W/s

1. Thng l CNTNtht

Du hiu lm sng r

- Xylocain 50mg t.m hoc lOOmg tim bp sau 1500mg/24gi bng bm lim in - Hoc Coraron 30mg/kg ung 2. Nu in tim trc cn c bloc nhnh

Sc in 250-300W/s Nu khng ht

CNTN trn tht

I
x tr nh CNTN trn tht

CN RUNG NH NHANH (Cn nhp tim nhanh, lon nhp hon ton)
I. I CNG

c im: Cn rung nh nhanh (CRNN) phi c iu tr ti bnh vin v thng c r"i lon huyt ng: r lon thc, ngt, h huyt p, ph phi cp, au ngc. C th bin chng nhi mu phi, no. Nn vn chuyn bnh nhn trn t cp cu. Vit Nam, hay gp CRNN bnh nhn hp hai l, i khi c hi chng w .p .w , nhi mu c lim. Chn on: Khi u t ngt, thong ngt, trng ngc, au ngc, mch nhanh v khng u. in tim: + Cn nhp tim nhanh khng u. + QRS mnh, tn s 130 - 180.

+ Nu c bloc nhnh t trc, QRS c th gin rng. + Khng c sng p, ch thy sng rung nh nh ln tn nhn r D2,D3, VF v VI.
III. X TR

1. Ti ch Tim tnh mch chm digoxin 0,4 mg, furosemid 20 mg ngi hp van hai l. ngi khng c hp van hai l: Ngi cao tui: Tim digoxin 0,4 mg tnh mch chm. Xt hng lenitral (trinitrin) hoc ngm isosorbid diniat (Risordan) Tim Lasix (Furosemid) 20 mg tnh mch Ngi tui: Amiodaron 1 vin 200 mg nu khng c hp van hai l. digoxin 0,4 mg tnh mch chm nu c hp van hai l. 2. Ti bnh vin Lm ngay in tim kim a. Ung 1 vin amiodaron 200 mg. Tim tnh mch heparin 1 mg/kg, sau 5 mg/kg/24 gi truyn tnh mch. C th tim digoxin 0,4 mg ngi cao tui, hoc ngi tr hp van hai l. Phi hp: Furosemid, trinitrin, isosorbid dinitrat. Nu vn khng : sc in 250 - 300 w/s Cha nguyn nhn: Hp van hai l, cng gip trng, t cp bnh phi tc nghn mn tnh.

NGNG TUN HON

V Vn nh
I. i cng

c im: Ngng tun hon c nhiu nguyn nhn. Cn can thip sm khi mt no, ch c 3 pht hnh ng. ngi ln tui ang lm vic bnh thng t nhin ngng tun hon phi ngh ngay n NMCT. Chn on: Chn on ngay khi thy:
4-

Mt thc t ngt bnh nhn ang tnh. Bnh nhn t ngt ngng th.

+ M t mch bn hay mch cnh. + Cc du hiu khc. + Da nht nht do m t mu cp. + + Da tm ngt nu c suy h hp cp. Mu ngng chy khi ang phu thut ng mch hay chy mu ko di t vng m. + ng t gin to, c nh, mt phn x nh sng (mun). - Trnh mt thi gian vo cc ng tc nh: o huyt p, nghe tim, ghi in tim.
III. X TR

1. C c bin p h p cp cu ban u (hi sinh tim phi c bn hay cp cu giai on I) thng c p dng ngay khi pht hin ngng tim ch yu l p dng k thut hi phc chc nng sng c bn hay (ABC technics). / ./ . Kim sot iing th (Airway control = A) Cho nn nhn na u ra pha sau. Lm th thut Heimlich nu c d vt ng th. Mc sch m di v cc chl tit hng ming.

1.2. H trh hp (Breathing support = B) H hp nhn to ming - ming hay ming - mi: Thi 3 - 5 ci sau bt mch bn hay m ch cnh. Nu cn mch, tip tc thi ngt 12 ln/pht. Nu c iu kin c ih h tr h hp bng bng Ambu hoc t NKQ v bp bng qua NKQ. Lun n 2 ngn tay vo sn nhn trnh tro ngc dch v.

1.3. H tr tun hon (Circulation support = C) Cm mu nu bnh nhn c vt thng mch mu gy mt mu cp. nm u thp nu c tt huyt p nng. Nu khng c mch bn hay mch quay phi bp tim ngoi lng ngc. + + + + Bp tm 1/3 di xng c. Nu ch c 1 ngi cp cu: 15 ln bp tim ngoi lng ngc li thi ngt 2 ln. Bp tim vi tn s" 80 ln/pht. Nu c 2 ngi cp cu: 5 ln bp lim/ 1 ln thi ngt. Bp tim vi ln s" 60 ln/pht. Tin hnh ng thi hi sinh tim v phi ti khi tim bnh nhn p ir li.

2. Giai on II Hi sinh tim phi mt c s cp cu c trang b phng tin cn thit v c kp cp cu ihnh tho. Tip tc cng vic ca giai on I nu tim cha p li.

2.1. t mt ng truyn nh mch chc chn v ln a thuc v dch vo dng tun hon. Nu c iu kin c th t catheter nh mch trung tm 2.2. Bo m tnh trng cung cp oxy cho bnh nhn - Bp bng Ambu vi oxy 100% - Nhanh chng t NKQ sau thng kh nhn to qua NKQ 2.3. Thuc - Adrenalin: 0,5 - 1 mg tnh mch, tim nhc li nhiu ln nu cn. - Natri bicarbonat 1 mEq/kg tnh mch, nu cn tim li liu bng 1/2 i vi trng hp ngng tim lu. - Truyn mu khn cp nu c mt mu cp. 2.4. Ghi T v x l theo loi ngng tun hon Rung tht: + Chng rung tht bng nh sc in ngoi lng ngc cng 200 - 300 watsec. + Xylocain 1 - 2 mg/kg tnh mch sau duy tr 1 - 2mg/pht nu cn. + Kali chlorua truyn tnh mch khi nghi ng thiu kali bnh nhn ng c digitalis, hn m tng thm thu, dng li niu mnh. V tm thu: Calci chlorua tnh mch 0,5 - 1 g, c bit l khi c tng K mu. + Isuprel tnh mch 2 - 4 mcg/pht nu nghi mch chm gy ngng tim (pha 5 ng vo 125 ml glucose 5%). + t my to nhp ngoi kch thch qua catheter to nhp bung tim. + Xon nh: Isuprel truyn tnh mch, kali, magnesi truyn tnh mch.

CN AU THT NGC
V Vn nh
I. I CNG

c im: Cn au tht ngc l cn suy mch vnh cp thong qua, c th: - vn xy ra ngi ln tui, c bnh mch vnh r, khng c thay i triu chhg. - Mi xy ra ln u tin, cn chn on phn bit vi cn au tht ngc khng n nh. Chn on: Da vo lm sng v in tim.

1. Chn on lm sng ti ch ( nh hay ni lm vic) au t ngt sau lnh, gng sc, cm xc. au sau xng c, lan ln vai, xung cnh tay, ln hm. Ko di vi giy n vi pht. C nhiu cn lin tip. Khng kh th, mch, huyt p bnh thng. Dng trinitrin nhanh. au t nhin khng cn gng sc. au khng th c. Nhng dng trinitrin nhanh.

i khi lm sng khng in hnh:

2. Chn on in tm Cn in hnh: Trong cn, 50%, c thay i: T m hoc dt hay nhn, ST chnh mt s chuyn o. Bloc nh tht, bloc trong tht, ngoi tm thu tht. Ngoi cn: in tim bnh thng. Cn khng in hnh: Lm nghim php gng sc. 3. Hi sinh tim phi chuyn su Ch yu tm nguyn nhn x tr, duy tr cc kt qu t c giai on II, chng ngng tun hon ti pht. Suy ngh, tm kim nguyn nhn gy nghg tun hon v iu tr nguyn nhn. Hi sinh no: + + + + + + + Thng kh nhn to. Chng ph no. Chng tng p lc ni s. Duy tr huyt ng. iu chnh cc ri lon nc in gii, thng bng toan - kim. iu ho thn nhit. Nui dng...

H tr cc chc nng sng khc cha n nh sau cp cu ngng tun hon.

4. Kh no ngng cp cu 4.1. Thi gian ngng cp cu ph thuc Tinh ng bnh, nguyn nhn Din bin trong khi cp cu:

+ +

Thi gian pht hin ngng lun hon. Thi gian t khi ngng tun hon ti khi bt u cp cu.

4.2. Tin lng: 3 tnh hung xy ra Hi sinh tim phi c kt qu: Tim p li, h hp t nhin phc hi tuy vy vn c nguy c ngng tun hon ti pht v cn tip tc theo dih hp vduy tr huyt p. Ch tm v iu tr nguyn nhn. Mt no: - Cht no (hn m qu giai on) + Tim p i song bnh nhn hn m su, ng t gin to, tru mch, thng khng th t th c. + Xul hin i nht. + Co cng kiu mt no: 2 lay v 2 chn dui cng. + in no l ng thng. + Sau 24 h c th ngng cc bin php cp cu tch cc. Mt v no (hn m ko di) + Duy tr i sng thc vt trong nhiu thng, nhiu nm nu tip tc duy tr dinh dng cho bnh nhn. + Thng vnh vin khng phc hi tri gic hiu bit. Tim khng p li d cp cu ng quy cch: C th ngng cp cu sau 60 pht.
II. X TR

Ti ch: Trinitrin ngm hay phun hng, dng nhiu ln, cch nhau vi pht cho n ht cn au. Nu qu 30 m vn khng ht au, phi ngh n NMCT. - Sau cn au, c th dn mt tm nitriderm.

- Nm ngh. Nu cn vn tip tc, hoc cn aubt thng: Chuyn bnh vin cp ci bng t cp cu, nu huyt p n nh. C th dng morphin 2mg lnh mch. Phi iu tr ngay bng: + Trinitrin truyn tnh mch: 1 - 2 mg/h. + + Th oxy. Heparin truyn tnh mch.

Phng nga ti pht: - iu tr cc yu t nguy c: - Aspirin 100 - 250 mg ung. - Thuc chng cn au: Dng mt trong cc th thuc sau, mi ngy: + Tenormin 1 vin, hoc Secal 200mg X 1 - 2 V . + Seloken LP 200 mg 1 V '+ Tildiem 60 mg 1 V X41n hoc Isoptin 120 mg 1 VX 31n, Amlor 5 mg 1 V,

nifedipin 10 mg 1 V + + Vastarel 20 mg 1 V

31n. 31n

Dn cht nit: Risordan LP 40 - 60 mg.

X

Nu nghi ng c NMCT: X t nghim men CPK - MB, GOT. Nu nghi ng cn au tht ngc khng n nh: + + + in tim gng sc. Theo di bng Holter 24gi Chp mch vnh.

Chn on phn bit: Phng tch ng mch ch Vim ngoi tm mc Thot v honh Xt nghim khc: ng mu

CN AU THT NGC KHNG n NH

V Vn nh
I. I CNG

c im: Cn au tht ngc khng n nh c c im sinh bnh hc ging nhi mu c tim: Co tht mch vnh Tc mch vnh + + Khng hon ton: cn au khng n nh Hon ton: NMCT

V vy, l mt cp cu khn trng. Chn on:

2 c im:

Cn au tht ngc: au sau xng c, kiu au tht lan ln c, hm, tay, c tay.

Ht: sau ngng gng sc (di 15 pht) Sau dng trinitrin. Khng n nh: C nhiu mc nng khc nhau: 1. Cn au u tin sau gng sc 2. Cn au khi gng sc tng ln so vi trc, tip din nhiu ln, ch cn gng sc nh, dng initrin t nhy.

3. Cn au t pht khi u khng gng sc. 4. Cn au t pht ko di qu 10 pht nhng di 30 pht, khng khi khi dng trinitrin. Cn au tht ngc khng n nh tr thnh hi chng e do NMCT khi c cc c im: Nu l khi u: au t nhin, d di, ko di Nu l suy mch vnh mn tnh: au t nhin nhiu, ko di, cn au khc cn au tht ngc thng l.

II. X TR

1 . nh, hoc ti cho Triniin di li (hay Risordan 5 mg, 1 vin ngm hay initrin phun hng 1 hi). Nu huyt p ti a cao hn hay bng 100 mraHg. Nu ht cn:

Cho bnh nhn nm ngh Ung aspegic 300 mg hoc truyn tnh mch aspegic 250 mg. Sau dn mt ming nitriderm ngoi da. 2. Chuyn nhanh n trung tm HSCC nu Khi gng sc nh, cn au li d di hn nhng ln trc. Vn chuyn bng t cp cu thng. Cn au tht ngc u tin ko di km theo cc du hiu in tim thay i: chuyn bnh nhn bng t cp cu tim mch n trung tm HSCC.

3. Ti trung tm HSCC Chng Cn au: bng 3 loi thuc: + Dn cht nit: Risordan, hay trinitrin truyn tnh mch 1 - 2 mg/h hoc ngm 1 vin 0,15 mg cch nhau vi pht cho n khi ht au, nhng khng qu 20 vin/ngy. Thuc chn calci: Adalat 40 - 60 mg/ngy hoc Tildiem 240 mg/ngy. + Thuc chn bta: Tenormin 50 - 100 mg/ngy Heparin tnh mch 1000 n v/gi Aspegic tnh mch 250 mg/ngy

+ + + + -

Chng huyt khi v ngng t tiu cu:

Chp ng mch vnh ngay nu c hi chng e do hoc cn au mau ti pht. X tr cc nguyn nhn gy bnh: Thiu mu cp, nhim khun.

Cc xt nghim cn lm ngay in tim: + Thiu mu cp: Sng T m v cn i

NMCT: ST chnh ln

CPK tng nu NMCT CPK khng tng trong cn au tht ngc khng n nh m hng cu Chp phi: tm suy tim tri Siu m tim: Xem chc nng tim, tm bnh van tim (hp ng mch ch vi ho). Ch : - Sau cn au in tim c th bnh thng - Bun nn, nn ma, v m hi thng l du hiu ca NMCT bt u.
t

NHI MU C TIM
I

V Vn nh

I. I CNG

c im:

Nhi mu c tim (NMCT) l tnh trng tc hon ton mt hay nhiu nhnh ca ng mch vnh. Tc thng do mt mng x va ng mch, nhng cng c vai tr ca co tht mch. T l t vong rt cao. c n phi cp cu kp thi v ng quy cch. Chn on: Ti nh hoc ti ni lm vic: Ngh n NMCT khi c du hiu lm sng in hnh: Ngi trn 50 tui, thng c tng huyt p au tht ngc, ko di qu 20 pht, d di, t ngt Kh th V m hi Bun nn, nn Lm in lim: ST chnh ln > 1 mm t nht 2 chuyn o

Kp vn chuyn cp cu: - Cho ngm trinitrin: khng au khoa HSCC: Lm sng: au t ngt, sau xng c, co tht, ko di, trinitrin khng . Tin s c cn au tim. Mt ti nht, v m hi, ri lon tiu ho.

in tim: C ngha quyt nh. Lm in tim chn on (+)

ST chnh ln > 1 mm t nht 2 chuyn o: ST chnh ln, tn thng mi (sau vi gi), sng Q su (sau 24 gi), sng Pardee sau 4 - 5 ngy, sng T m ngay t u (tn thng thiu mu).
II. X TR

1. Ti ch hoc t nh Xc nh chn on bng in tim. o huyt p Nu huyt p bnh thng cho ngm trinitrin di li. Gi t cp cu chuyn khoa ( t cp cu c thit b cp cu v theo di tim mch). Nu ngm trinitrin khng au: Pha long 1 ng morphin 0,0lg trong 10 ml glucose 5%, c 3 pht tim mt ln 2 ml (2 mg) tnh mch cho n khi ht au. Aspegic 100 - 250 mg tim tnh mch hoc ung. Nu bun nn, h HA, nhp chm (thng c trong NMCT di): k cao hai chi di, tim atropin tnh mch 1/2 - 1 mg.

Khng tim bp, khng ri khi bnh nhn. 2. Kh xe cp cu tm mch n hoc nu c thit b ti ch t monitor theo di. Truyn ngay alteplase (Actilyse) 1 mg/kg tnh mch trong 90 pht, 2/3 liu trong na gi u. Cng lc truyn tnh mch heparin 25000 v/24 gi v aspegic 250 mg. Dng ng truyn khc nhau. Tim tnh mch chm Tenormin 5 mg.

(Chng ch nh nu: Mch di 50, huyt p di 100 mmHg, block nh tht cp 2, 3, tin s hen ph qun). iu tr phi hp: + + + Risordan, Lenitral truyn tnh mch (hoc ngm 15 - 30 mg) trong 500 ml glucose 5% truyn nh mch). Th oxy. Xylocain tnh mch 1 mg/kg sau 30 mg/kg/24 h nu c NTT tht trn 10%

Chp mch vnh, nong mch vnh, cu ni... nu c chng ch nh dng thuc tan cc mu ng. Lm in tim cho tt c bnh nhn c au tht ngc. Xt nghim: + + Men GOT, LDH, CPK MB ng mu

Theo di: -

+ + + 3. Th tc:

Cng thc mu Chp phi, tim Siu m

Ghi chp r rng bnh n C bc s i km Trang b dng c v thuc Nu c N T tim xkcain 1 mg/kg TM sau truyn 1 mg/ph Gim au bng triitrin, morphin. /

PHNG TCH NG MCH CH

V Vn nh
I. i cng

c im:

Phng tch ng mch ch l mt cp cu rt khn trng cn c can thip ngoi khoa sm trnh v vo mng ngoi tim hoc lm tc cc ng mch ln (ng mch ch, ng mch tng...). Phng tch ng mch ch xy ra do mt tn thng lt trong ng mch lm cho mu lt vo gia cc lt o ng mch ch ngc v bng, tch dn cc lt o lm cho tc dng mu hoc v ng mch (50% trong 48gi u). Tng huyt p v thai nghn thng l nguyn nhn gy phng tch ng mch ch. Lm sng: Khi u ln u tin au d di sau xng c lan xung di (khc vi NMCT, lan ln vai). C th thy: + + + + + + + Mt mch hoc yu mch mt bn. Huyt p hai chi trn chnh lch. H ng mch ch. C ting c mng ngoi tim. C tin s tng huyt p. C th c hi chng Marfan. Bin chng sc, v niu, p tim, trn mu mng phi.

+ Tai bin mch no.

II. x TR Ti ch: H ngay huyt p ti a xung di 110 bng: Adalat 10 mg ngm hoc Loxen 20 mg. Trn xe cp cu tim mch hoc khoa HSCC: Nu huyt p vn cao hoc bnh thng:

- Truyn triniin 0,5 - 2 mg/gi, tnh mch Hoc natri nitroprussiat 0,5 mcg/kg/ph Hoc Loxen 1 mg - 4 mg/h Nu c sc: t ng NKQ/thng kh nhn to, uyn dch cao phn t truyn adrenalin, dobutamin. Kim ho nc tiu: 1 mEq/kg natri bicarbonat truyn tnh mch.

- Xem xt phu thut sm nu phng tch ng mch ch on ln. Cc xt nghim cn lm ngay: in tim: Ngh ngay n phng tch ng mch ch nu c mt cn au ngc d di m in tim bnh thng. Chp phi: Quai ng mch ch gin rng i khi c n mu mng phi tri. Siu m: C gi cao, c bit l siu m Doppler mu CT Scan cng c gi tr cao. Cn nh: Nhm NMCT vi phng tch ng mch ch rt tai hi. Dng thuc chng ng khi c phng tch ng mch ch l mt sai lm.

CN TNG HUYT P
V Vn nh I. I CNG c im: Cn tng huyt p l tnh trng huyt p tng t ngt hn trc, ti a tng hn con s c 40 mmHg, s ti thiu thng cao hn 110 mmHg. - Mc cp cu lin quan ti cc bin chng ph tng: Thn kinh, tim mch, thn, phi... - Cn tng huyt p c bin chng cn phi c vn chuyn bng xe cp cu tim mch n trung tm cp cu. Chn on: o huyt p c 2 tay, 2 ln, bnh nhn nm nga, sau 10 pht ngh. -

Cn tng huyt p n thun: Huyt p tng t ngt (theo nh ngha) thng km theo cc du hiu c nng: Nhc u, hoa mt, chng mt. Cn tng huyt p c tnh: Cc biu hin hn m, co git, kh th (do ph phi cp, suy tim tri), cn au tht ngc... cn phi c x tr ngay. Soi y mt: Ph gai, ximt huyt vng mc in tim, chp phi, protein niu, t bo Do thuc: Ostrogen, thuc gy chn n, thuc co mch nh mi hoc mt (naphazolin), thuc khng vim, corticoid, cam tho, cc cht gy kim. Dou tu thng thn, u cn bch hch, hp ng mch thn.

Xt nghim -

Tm kim cc nguyn nhn thun li hoc gy bnh.

II. X TR 1. Ngi c tui, c cn tng huyt p cha c bin chng Khng cn nm vin: Ngm niedipin 5 mg di li (nang nc chc thng). Ngi c tui do ph phi cp: tim Lasix 20 mg X 2 ng nh mch, th oxy mi. Sau ung niedipin chm 10 mg 1 - 6 v/ngy. 2. Tng huyt p c bin chng Ti ch: Ngm mt vin niedipin 5 - 10 mg di li. Tim bp diazepam 10 mg nu c biu hin no v cho th Oxy. Trn t cp cu v khoa HSCC:

Nu vn tng huyt p, truyn tnh mch natrinitroprussiat (Niprid) tnh mch 3 mcg/kg/ph (0,5 - 8 ) hoc nicardipin truyn tnh mch (Loxen): 5 - 10 mg trong glucose 5%, tc 1 mg/h. C th truyn nhiu ln/ngy. iu tr duy tr bng cc loi thuc h p thng thng. Ch : TBMN, PPC (huyt p hi tng, khng qu 180) khng nn dng thuc h p.

NHN NO TIN TRIN

V Vn nh
I. I CNG

c im: Nhn no lin in t khi gy hn m, nhng nu c th rt nng. Kh hi phc hon ton. Nu c tng huyt p, phi thn trng khi dng thu"c h p Thuc chng ng c ch nh r nht nu c nguyn nhn tim. Thng c ph no hay gy tt no. Vn chuyn bng t cp cu thng nu bnh nhn tnh, th oxy ng mi. Lit na ngi t ngt hoc t l. Lit nng dn ln trong nhng gi sau Ko di qu 24 gi C d'u hiu ph no Hn m xut hin t t (nng ln) Nguyn nhn: X va ng mch, bnh van tim, bnh mu.

Chn on: -

III. X TR

Ti ch : Tim heparin 5000 v tnh mch nu l nguyn nhn tim - Nu c tc mch cnh, chuyn n khoa ngoi tim mch Ti bnh vin : A. CC BIN PHP CHNG : t ng NKQ, thng kh nhn to nu : Hn m, ph no, ri lon h hp Nui dng qua ng thng d y v tnh mch iu tr cc nguy c : Tng huyt p, i ng, va x ng mch, bnh tim c rung nh. B. CHNG NG : Heparin 50(X)v/12-24gi tnh mch trong 1-2 tun, liu cao gp i khi c bnh tim.

Khng dng nu : C bnh mu, lot d dy, suy gan, suy thn nng, du hiu tt no hoc tt hnh nhn, tng huyt p, tui cao.

c. CHNG KT T T l CU
Aspirin nu heparin c chng ch nh: Aspegic 250-500mg truyn tnh mch. D. CHNG PH NO Thng kh nhn to VT ln sao cho PaC 02 = 35mmHg MannitolJ0%-20% 200ml/4h tnh mch nu e da tt no C th dng urosemid. E. CHNG TNG HUYT p N c : Tenormin (Atenolol) lOOmg, nu huyt p trn 200mmHg c th dng nifedipin. Theo d i: CT Scan, tm nguyn nhn x va ng mch, bnh van tim.

TAI BIN THIU MU NO THONG QUA

V Vn nh
I. I CNG

c im: L mt cp cu thn kinh tin lng kh on: C th khi hon ton nhng cng c th tin ti nhn no. - Phi lp tc nm vin ngay, nu ti pht, c lit na ngi, c ting thi mch cnh hoc c lon nhp tim. Chn on: -

Lit na ngi t ngt, nhng din bin rt chm. Khi ngay sau 24 gi nhng d ti pht nng hn. Tin s: - c din bin tng t. - C bnh thiu mu c tm, bnh van tim, hay ri lon nhp tim. Yu t nguy c: Tng huyt p, ri lon chuyn ho m, i tho ng, nghin thuc l, ung thuc trnh thai. Khm: Thn kinh: Lit nh 1 chi + na mt, mt i sau 24gi. Khng nn, khng au u, khng ri lon thc. Nghe tim, in tim. Huyt p 2 chi n: C khi chnh lch. T b, m mt, mch cnh yu hoc khng p. Ri lon cm gic na ngi, c khi c ngi, bn manh cng bn, m tm thi hai bn: Thiu nng mch nn - ct sng.

II. x TR

1. Ti ch Nu HA cao trn 200 mmHg - Lasix 20 - 40 mg tnh mch Adalat chm 1 - 2 vin - A^pirin 300 mg ung hoc Ticlid 500 mg ung 2. Ti bnh vin Sau khi lm CT Scan, dng thuc chng ng (khng vitamin K). 3. Theo di CT Scan, chp ng mch no, siu m tim, ng mch cnh, Holter. Tm c a: i tho ng, tng hng cu, x va ng mch.

XUT HUYT NO - MNG NO

V Vn nh
\

I. I CNG

c im: - Xut huyt no - mng no (XHNMN) cn c nm vin cp cu. Mc khn trng ph thuc vo mc hn m v du hiu tng p ic ni s. Vn chuyn cp cu bng t c trang b. Nu ch c XHMN, phi chuyn n khoa phu thut thn kinh. Hi chng mng no: Nhc u d di, t ngt, ko di, lan xung km theo nn ma, s nh sng. Khm: cng gy, du hiu Kemig, Brudzinski. Ri lon thc: Thang im Glasgow t 15 n 3. Tim du hiu thn kinh, cc ri lon vn ng cm gic, ri lon ngn ng. i khi st 38 - 38.5c, tng HA.

Lm sng: Thng l r. -

II. X TR 1. Ti ch - t mt kim truyn tnh mch mt l dung dch NaCl 0,9% - Nu bnh nhn tnh: Dng thuc gim au Prodaalgan, Temgesic. - Truyn Loxen 1 mg/h tnh mch nu huyt p trn 160 - Chng co git: Diazepam.

2. Trong lc vn chuyn Nu c r lon thc: t ng NKQ 3. Ti khoa HSCC Nu c XHMN: Truyn nimodipin tnh mch 1 mg trong 1 gi bng bm tim in, sau 2 mg/gi (l 10 mg/50 ml). Chuyn bnh nhn n khoa phu thut thn kinh nu nghi ng c d dng mch mu no, can thip trong 3 ngy u. Nu t mu no, c tng p lc ni s e do tt no: c th can thip ngoi khoa. iu dng: Chm sc nui dng, chng lot, phng bin chng do nm lu.

VIM TI MT CP
V Vn nh
I. I CdNG

c im:

Thng l mt cp cu ni khoa, nhng nu c bin chng li phi can thip ngoi khoa sm. V vy nn theo di khoa ngoi. Chn on: Lm sng: au h sn phi, lan ra sau luhg, ln b vai phi, c th gy kh th. St trn di 38 Khm: - D'u hiu Murphy (+) - Ti mt t khi to. Cn chuyn bnh nhn n bnh vin: bng xe cp cu thng Chn on dng tnh da vo siu m.

II. X TR Bnh nhn khng c n. Hi phc nc in gii, cy mu. Truyn khng sinh: Claforan 1 g X 3 ln/ngy hoc Rocephin 1 g/ngy hoc quinolon phi hp vi amikacin. Chng au: paracetamol Nu trong vng 48 gi, khng (vn au, vn st) phi ct b ti mt (bng phu thut hay ni soi). Theo di: Vim phc mc thm mt. Thng, hoi th ti mt gy vim phc mc -

c n ch nh phu thut sm trc khi xy ra bin chng. Tng phosphatase kim, tng transaminase, tng bilirubin trn 85 mmol/L: ngh n si ng mt ch. Siu m ti mt: thng thy thnh ti mt dy, si hoc bn ti mt. CT Scan: T mu Lhu no ngh n d dng mch, t mu su, vng bao ong ngh n tng huyt p. Chc d nc no tu.

Theo di: -

Ch lm khi: 1. Scanner bnh thng m c c cng. 2. Nu khng c Scanner m cha loi tr c vim mng no 3. Chp ng mch no hoc lm cng hng t ht nhn MRI rt cn thit chn on. Ch : Gin ng t mt bn ngi XHMN m khng c hn m, khng c tn thng khu tr: Ngh n v phng ng mch on tn ca mch cnh cng bn. Khng lm h huyt p xung qu thp Khng dng thuc chn calci nu chy mu no nng.

VIM MT QUN CP
V Vn nh
I. I CNG

c im:

Vim mt qun c'p l mt nhim khun ng mt rt nng thng c nguyn nhn si ng mt ch. Vim mt qun cp phi c iu tr ti bnh vin dng khng sinh truyn nh mch v gim au. Thng c nguy c sc nhim khun, suy thn, cn phi phu thut. Chn on: Lm sng: 3 du hiu in hnh, cc du hiu xut hin ln lt: + + + au h sn phi St cao, i khi c rt run Vng da

Tin s: cn au gan; gan thng hi to. II. x TR

Sc nhim khun l bin chng ng s nht Siu m gan v ng mt c gi tr chn on ln: n g mt ch gin rng, c th thy si, giun. Bch cu tng cao, c khi gim. r mu thng tng. Bilirubin mu thng tng.

t catheter TMTT Hi phc nc v in gii Chng sc v nhim khun: Dopamin, dobutamin. Truyn khng sinh tnh mch: Cephalosporin + aminosid. Nu sau 24 gi khng st, phi can thip phu thut ly si v dn lu.

VIM TY CP
V Vn nh
I. i cng

c im: Cn c vn chuyn bng xe cp cu ti khoa HSCC v hay c tru mch v ri lon h hp. Cc biu hin lm sng ch c gi tr nh hng nghi ng vim ty cp, xt nghim cn lm sng c gi tr quyt nh chn on. 90% cn hi sc ni khoa, 10% phi phu thut v bin chng. Nguyn nhn: si mt ngi nghin ru thng gp nht.

Chn on: Lm sng: Ch nghi ng. c n phn bit vi nhi mu c tim thnh sau di.

au thng v d di, au xuyn ra sau lng, thng xy ra sau khi n no ru say, i khi c phn ng thnh bng nhng li khng st, i khi c cc vt tm, im sn tht lng au. Thm trc trng: bnh thng khng au. Thng c sc. Cn lm sng: Amylase mu tng t nht trn 4 ln bnh thng, nhng c th bnh thng. Amylase niu tng.

X quang:

Chp phi tm ARDS, n dch mng phi v loi tr vim phi. Chp bng khng chun b: C hnh nh tc rut do lit h sn tri. Siu m tu v ng mt loi tr vim ti mt. CT Scan c gi quyt nh.
II. X TR

1. Ti ch Nu c sc: t kim tnh mch ngoi bin, truyn dch, tim thuc gim au (Spason 1 ng, tim tnh mch). Vn chuyn sm n khoa HSCC.

2. Ti khoa HSCC t ng thng d dy, ht dch v. t catheter TMTT hi phc th tch mu. Truyn dch.

Ngy : Huyt tng 1500 ml + mu nu cn Glucose 5% 2500 ml + 10 g NaCl + 1 g CaC2 Natri bicarbonat 1,4% 1000 ml Cho thm kali chlorua 1 g/1 nu bnh nhn i c 1 lt. Ngy 2: Huyt tng 1000 ml + mu nu cn Glucose 5% 2000 ml + 8 g NaCl + 1 g C'dC2 Natribicarbonat 1,4% 500 ml + 4 g KC1 cho mi lt nc tiu. Ngy 3: Huyt tng 500 ml + mu nu cn Glucose 5% v natri bicarbonat 1,4% nh ngy 2. Cc ngy sau: Truyn dch theo yu cu da theo p lc TMTT v huyt p, nc tiu. Lng mu v huyt tng bng 10 - 2 0 % tng s' dch. Chng sc bng dopamin, dobutamin, noradrenalin. Gim au bng: Spason 3 - 4 ng/ngy nh mch. Visceralgin tnh mch theo yu cu Theo di cc bin chng: + p xe, XHTH, PPC, suy a ph tng, hoi t tu. + m trong phc mc: siu m, CT Scanner Phu thut: + Nu c bin chng bng: Thng, nhim khun... + Ct c trn Oddi bng ni soi ly si.

- Khng sinh Tip tc nui dng qua ng tnh mch khi amylase mu tr li bnh thng nhng cha c du hiu nhu ng rut.

x TR CP CU XUT HUYT TIU HO CAO

V Vn nh.
I. I CNG

c im:

Ximt huyt tiu ho cn c vn chuyn cp cu ngay ti khoa HSCC song song vi vic hi sc v truyn dch. 3 nguyn nhn thng gp l: - Lot d dy - t trng. - V gin tnh mch thc qun. - Tn thng d dy - t trng cp tnh nh't l do stress. Cn c ng soi mm tm nguyn nhn. Chn on: - Lm sng thng r nu thy nn mu, phn en. - Nu nghi ng: t ng thng d dy v thm trc trng. - c lng mc mt mu: H huyt p, sc. - Tm nguyn nhn qua hi bnh v thm khm: Ticn s lot d dy - t trng, nghin ru, khm gan, dng thuc hi d dy (aspirin, corticoid...).

II. X TR 1. Ti ch t mt kim tnh mch ngoi bin truyn 1 l dung dch mn NaCl 0,9%. 2. Ti xe cp cu Truyn mt loi dung dch cao phn t (Hemacel) duy Ir huyt p ti a l 100 mmHg. Nu huyt p gim: Bnh nhn nm u thp chn k ca (bng chic gi to), th oxy'6 - 8 lt qua mi. 3. Ti bnh vin Hi phc th tch tun hon bng uyn mu. Soi d dy l c bn, cn lm ngay bnh nhn khng c ri lon huyt ng. Nu c chy mu c th lm x ngay.

V gin tnh mch thc qun: Nu khng c ni soi gy x c, t mt 'ng thng Blake-More - Trong khi ch i: Tim tnh mch 1 - 2 mg Glypressin, 4 gi/ln nu khng c chng ch nh. Cc xt nghim cn lm ngay sau : - CTM, tiu cu, hematocrit, nhm mu - Rh, ng mu - o cc kh trong mu, ur, ng mu. Chng ch nh dng Glypressin: - Tuyt i: sc nhim khun, c thai. Tng i: Suy mch vnh, ri lon nhp tim, tng huyt p, khng c iu tr, suy tun hon no, hen ph qun, suy h hp, suythn, tuitrn 70. - Ra d dy ch thy nc trong cha loi tr cchy mu t trng. - Khng soi d dy nu ang sc.

Ch :

A CHY CP NHIM KHUAN

V Vn nh
I. I CNG

c im: Thng xy ra sau mt ba n c bit, nhiu kh nng d b nhim khun. a chy cp khng c bin chng nhng ko di qu 48 gi cn c vn chuyn trn t cp cu thng n bnh vin, a chy cp c bin chng phi c vn chuyn trn xe c ang b y t n bnh vin. Chn on: a chy tuy khng nhiu nhng c th gy sc nhim khun. a chy nh nc vo go lng rt nhiu: Ngh n t. Mi a chy cp cn c cy phn. Hai loi: + Do ngoi c t t cu, a chy xut hin ngay sau ba n khong 2 gi. Thng khng c s't.

+ Do vi khun Salmonella, shigella,... a chy sau khi n 6 - 12 gi. . - D gy sc nhim khun, cn cp cu ngay.

II. x TR Khng c bin chng sc nhim khun hoc sc mt nc mt mui'. C bin chng: + +
-

Ung Oresol: 1 - 2 lt H phc nc in gii qua ng tnh mch. Truyn dch da vo p lc TMTT: Ringer lactat
X

X tr nguyn nhn:

Salmonella, shigella: Ciproloxacin (Ciprobay 500 mg .Cha triu chng: Spason 80 mg ung 1 vin.

2 vin/ngy)

T: Doxycylin (Vibramycin): 0,100 g ngy u 2 vin, ngy sau 2 vin.

Imodium 2 mg ung 1 - 2 vin.

x TR NG C CP
V Vn nh
I. NGUYN TC X TR

1. Loi b cht c ra khi c th, cng sm cng tt, ngay ti ch. 2. Dng thuc chng c c hiu 3. Hi sc khi c biu hin nhim c. Lun bo m thng kh tt.
II. X TR

1. Loi tr cht c ra khi c th Ty theo ng xm nhp: Ra da, tc v mt. Chch da, ht mu nu l rn c cn. Qua ng tiu ha: + + + + Ung than hot 20g cho ngi ln, 5-10g'cho tr em, gy nn Tip theo ra d dy c than hot. Tuynhin,khng ra d dy nu ng c du ha, cc cht n mn. t "ng ni kh qun c, nu c hn m Dng thuc ty: Magie sulfat, natrisulat, sorbitol (5-30g)

Sau ra d dy tip tc ung than hot 5g-20g/2 gi cho n 120g ngi ln, 30g tr em.

2. Dng thuc chng c c hiu Cng sm cng tt. C 4 loi: 2.1. Gp cc chc nh: BAL (dimcrcaprol) gp kim loi nng, hydroxocobalamin gp CN, deserroxiamin gp Fc 2.2. iu tr thay th: Glucose u trng chng h ng huyt do insulin Vitamin K trong ng c dicoumarol hay aspirin Vitamin B 6 ong ng c INH 2.3. Trung ha cc cht c Huyt thanh chng nc rn Cc khng-th: Khng th khng digoxin Cc ha cht nh flumazenil lm mt tc dng ca diazepam.

2.4. i khng sinh l Atropin chng tc dng ca hi chng muscarin Phentolamin chng tc dng ca cc thuc ging giao cm. 3. Hi sc Hi sc khi c biu hin nhim c, nh hng n chc nng sng. C 7 iu cn ch : 3.1. Duy tr chc nng h hp Thng phi thng kh nhn to (TKNT) nu c hn m su, ri lon h hp TKNT iu khin nu c nguy c ngng th (rn h cn, ng c opi, thuc ng) TKNT vi p c dng lin tc, nu c tn thng phi Dng thuc h p ong ng c naphazolin, adrenalin, noradrenalin, aramin Dng thuc vn mch ong ng c cc thuc gin mch, lit hch. Dng xylocain trong ng c c u tu Tiu c vn do thuc chut Tu, ong t: Phi truyn nhiu dch phi hp furosemi'd c lng nc tiu 10 0 -200 ml/gi ngi ln. Suy thn cp thng gp trong ng c (mt c chm, cc, c nc, thy ngn): Dng furosemid v phi hp thn nhn to nu cn. Acetylcystein (Mucomyst) c tc dng tt trong ng c paracetamol Silymarin (Legalon) c tc dng trong ng c nm

3.2. Duy tr chc nng tun hon

3.3. Duy tr chc nng bi tit

3.4. Bo tn chc nng gan -

3.5. Bo tn chc nng to mu Thng gp tan mu ngi st rt dng primaquin Gim tiu cu do dng khng sinh

Ngng thuc l phng php c bn khng tn km. Truyn mu nu chy mu, uyn khi hng cu nu tan mu nng gy thiu mu. 3.6. Bo tn chc nng thn kinh Chng co git. Tuy nhin co git c th do h ng mu, thiu oxy no, ng c ru. Chng ri lon iu ha thn nhit.

3.7. Cui cng l chm sc, nui dng, chng lot Tm li: Khi thuc hay ch't c cha ng'm vo c th, rt cht c ra khi c th l c bn. Khi c chc nng sng b nh hng: Hi sc ngay ri mi dng cc bin php khc.

Phn III

H HP

VIM PH QUN CP
Bi Huy Ph
I. I CNG

Vim ph qun cp l tnh trng vim nhim nim mc ca ph qun ln v ph qun trung bnh.

Vim ph qun cp c th xy ra mi la tui nht l em v ngi gi. Bnh hay xy ra v ma lnh hoc ng xun. Yu t" thun li cho vim ph qun cp hay xy ra c th mt mi, lm vic cng thng, mi ng nhim c nhiu bi bn m thp. Vi khun gy bnh ch yu thng do lin cu nhm A, c v G, ph cu khun, t cu Meti s, Hemophilus influenzae. Lm sng: Triu chng chnh l ho v khc m, bnh bt u bng vim long ng h hp n ri xulng ng h hp di. Biu hin triu chng ca vim ng h hp trn: Th nh: Vim hng , c th chy nc mi, c khi c st. Th nng: Vim mi c m, vim xoang, vim amidan, vim tai gia. Biu hin triu chng ca vim ng h hp di: Th nh: Th nng: Ho khn ting, th kh kh, nghe phi c ran rt. Ngoi cc iu chng k trn bnh nhn c th kh th, c khi c du hiu co ko lng ngc, nhp th nhanh, mi tm ti nghe phi c ran rt, ran bt vng y phi hoc vng sau lng.

l. IU TR

iu tr nguyn nhn gy bnh l ch yu (khng sinh dit khun) ng thi cng phi iu tr triu chng na, c hai vn ny lin quan rt mt thit vi nhau. Mun dit khun tt cn phi lm khng sinh tm loi khng sinh no thch hp nht.

iu tr triu chng: Phi lm thng thong ng h hp, bng cch lm gim tit dch, ch'ng ph n, cho cc thuc long m, cho corticoid. Tu thecTcc th nng nh m c phng php iu tr thch hp. 1. Th nh Bnh nhn cn c ngh ngi.

Cho thuc st khun trc tip ng h hp. Locabiotal (kh dung) ngy xt 4 ln vo hng, khi xt phi ht su. Exomuc (Nacetyl Stein) ngi ln v tr em trn 7 tui ngy u"ng 3 gi chia lm 3 ln hoc Mucitux ngy ung t 3 n 4 vin. Sepsie (M - Php): Ngi ln ngy ngm 4 vin chia lm 4 ln. Ampicillin 500 mg ngy ung t 2 - 4 vin. 2. T h nng: (cn c khng sinh ) Phi iu tr phi hp khng sinh gia cc nhm (thng t hai nhm tr ln). Cho thuc khng histamin nh dimedron, histalong kt hp vi nhm corticoid loi ung hoc kh dung.

Erythromycin ( 500mg): Ngy ung 3 vin chia ba ln gia cc ba n tt nht l c cc ba n 45 pht ung vi na li nc. Cephalexin: Loi ung vin 500 mg ngy u"ng t 2 n 4 vin. Loi tim 1 g ngy c th dng t 2 g chia 2 ln (tim bp), nn th test trc khi tim (theo cc chuyn gia y t Vit Nam).

Prednisolon ngy cn 20 mg l c tc l ngy u"ng 4 vin chia 2 ln (ung sau khi n). Dimedron 10 mg ngy ung t 2 - 4 vin, mi ln ung 1 vin. Salbutamol 2 mg: ngy ung 2 vin chia 2 ln. Mucitux: ngy u"ng t 3 n 4 vin chia lm 3 n 4 ln. Ho long m: Ngy ug t 4 - 6 vin, mi ln 2 vin. Theophyllin 0,10 ngy ung 4 vin chia lm 2 ln (khi kh th mi dng).
III. PHNG BNH

Loi b cc yu t" kch thch nh thuc l, thuc lo, cc loi bi ca nhim mi trng xung quanh. Gi m c ngc v ma lnh. Tim vaccin chng virus v vi khun.

iu tr tt bnh nhn khi hon ton.

IU TR VIM PH QUN MN TNH

Phm Tl Ha M
. I CNG

Vim ph qun mn lnh l vim mn lnh nim mc ph qun do tng liu lng phan ng dn dn dn dn lc nghn ph qun gy ra mi lon h hp nng.
Lm sng:

Triu chng c nng: + + + Ho v klic m iheo quy nh ca T chc y l th gii: Tng s ln ho v khc m trong mi nm ! ha ihng v nh th t nht l hai nm. Triu chng kh th khi gng sc. C th st hoc khng s (i cp ih c si)

Triu chng ihe th: X quanII: Rn phi hai bn m. Chc nng thng kh h hp: FEV 1 (VEMS) nim khi c lc nghn.

Nihe phi Iihicu ran m ri rc c hai bn v c th c ran ngy v rt km theo.

II. IU TR

1. Nuyn tc Nhm iii quyt tc nihcn ph qun do 3 yu t": Tnn san xut cc cht tit dch (m) Ph n nim mc ph qun Mt phn no co thl c trn ph qun.

2. iu tr c th 2.1. Diu tr nguyn nhn B thuc l, ihuc lo, v sinh mi n ng ni lm vic, loi b cc nhim khun mi. xoang, hng, aniidan bng cch dng khng sinh hoc phu thul cc bnh . 2.2. Diu tr theo th bnh Khi cha c tc imhcn ph qun ch yu
+ + + Vn ng ir liu: lp b(fi. i b Th dc ir liu. Kh cng dng sinh.

Khi c tc nghn + Chng tng lit dch nhy nhm di bng cc ihuc long m, v rung, dn lu t th nm, ngi. Thuc long m: Dng mt trong nhng loi sau y:
+ + + + + + Bisolvon 0,02 g X2 v/ngy X5 ngy hoc + bcn/oat nairi 2 gam/ngy X5 ngy. Solmuxbroncho 0,2 g/ngy X 5 ngy Exomuc 2 gi/ngy X 5 ngy. Xiroiriatusic 10 ml/ngy X 5 ngy. Xiroatussin 10 ml/ngy X 5 ngy. Radipon 0,2 g X 4 vin/ngy X 5 ngy.

V rung v (Jn lu t th: V nh vo lng ngc mi ngy l nht 30 pht Dn lu t th nm, ngi (theo bi phc hi chc nng h hp). +
-

Chng ph n nim mc ph qun:

Coriicoi: Prednisolon 5 mg X 4v/ngy X 5 ngy

Sau 2 vin/ngy X 5 ngy ri ngng. Hoc hydrocoriison 125 mg X 1/2 l kh dung/ngy X 10 ngy Hoc depersolon 30 mg X 1 ng (tnh mch)/ngy X 5 ngy Hoc solumcdrol 4*mg x 1 ng (lnh mch) X 5 ngy. Hoc solucortel'80 mg X ng (lnh mch) X 5 ngy. Alpha ehymolrypsin 1 ng/ngy (tim bp) X 5 ngy Hoc dng 6 viOn/ngy chia 3 ln X 5 ngy Hoc danzcn 5 mg X 2 v/ngay X 5 ngy

Khng sinh chng vim: Tt nht chnkhng sinh no khngb d ng vi nim mc ph qun i nh dng nhm sulbueiam: Unasyn 0,75 g X 2 l/iiy lim hp hoc lim lnh mch.
+ Chng co tluli c inn phc#quan v tng phn ng nim mc ph quan. Thcophyllin 0.10 X 4 v/ngy X 7 ngy

Hoc nhm tUnolon: Oloxacin 200 mg X 2 vicn/ngy X 5 ngy.

Hoc - Thcophyllin chm 0,20 g X 2 v/ngy X 7 ngy

lh>c - Diaphyllin 0,48 g X 1 ng (lim tnh mch chm) Chng lng phaII n*z nim mc ph qun dng cc loi Ihue chng d ng Hismlong 10 m <! \ 1 v/ngy \ 5 ngy i cp ca vim ph qun mn iu ir nh th lc nghn. Khng sinh iheo khng sinh , nu khng c khng sinh th dng loi khng (J ni nim mc ph quan, dng loi lim liu cao.

2.3. iu tr triu chng Ho: Gim ho tecpincodein 0,20 g X 2 - 4 v/ngy St: H nhit paracetamol 0,5 g X 1 - 2 v/ngy au ngc: Gim auEfferal gan codein 2 vin/ney X 5 ngy An thn: Seduxen 5 mg X 1 vin/ngy 2.4. iu tr bin chng Gin ph nang: Tp th, thi vo l nc. Tm ph mn: iu tr thm v suy tim.
III. PHNG BNH

Khng ht thuc l, thuc lo. V sinh mi trng. Khi c nhim khun ng h hp n phi iu tch cc. Lp k hoch iu tr dch t hc, t m lp tp hun cho cn b x ph bin cho cng ng v tc hi ca vim ph qun mn tnh.

IU TR GIN PH QUN
Bi Huy Ph
I. I CNG Gin ph qun l gin lin tc, vnh vin khng hi phc ca mt hoc nhiu ph qun c ng knh trn 2 mm, do s ph hu ca t chc c, x chun, lp sn ca vch ph qun.

Thng ph qun b gin t th h th 4 n th h th 8 hoc 10. Lm sng -

Ton thn: a s bnh nhn khng c biu hin g, khng st nu khng c bi nhim, t gy st. - Triu chng c nng Khc m nhiu v bui sng (th t) khi lng m t 500 n 1000 ml ong 24 gi. m y nhy m c th c mi hi thi, lu thy c lng cn thnh ba lp, trn l dch nhy v bt, nu m b tc bnh nhn c th st cao ko di do nhim khun. - Ho ra mu: l gin ph qun th kh, ho ra mu ti pht nhiu ln v ko di trong nhiu nm, cn phi cy m tm BK v cc vi khun khc gy bnh. - Kh th: Thng kh th nh v kh th va.

Triu chng thc th: Khm phi nghe thy c ran m, ran ph qun vng ngc c tn thng, c khi khm thy hi chng ng c khi c xp phi. Cn lm sng: Chp phi: Chp phi bnh thng thng khng thy g, c th c rn phi m hoc thy tng m m l r nh hnh rut bnh m hay gp vng y phi. Chp p h qun cn quang: bng Lipiodol nu c gin ph qun ta c th thy ph qun b gin c dng: hnh ng, hnh ti, hnh t chim. Soi ph qun thy nim mc ph qun b vim, c ch b cht hp, pha di l ph qun gin, i khi thy c m chy mu. II. IU TR 1. iu tr ni khoa Dn lu m ph qun theo t th thch hp, v lng ngc c th ht ra ph qun bng huyt Ihanh mn ng trng 0,9% cho cc thuc long m nh:

Exomuc (N Acetyl cystein) mi gi c 200 mg N acetyl cystein, ngy ung l 3 n 4 gi, chia lm 3 n 4 ln. Benzoat natri ngy ung 30 ml chia lm ba ln. Terpin ngy ung t 4 n 6 vin chia lm 2 n 3 ln, hng ngy phi ung lng nc. Khng sinh phi iu tr theo khng sinh v phi hp khng sinh t 2 nhm tr ln. Erythromycin 0,25 g ngy ung t 4 vin n 8 vin. Augmentin 500 mg ngy ung 3 vin chia 3 ln. Oloxacin 400 mg ngy ung 2 vin chia 2 ln (ung sau khi n). Thi gian s dng khng sinh cc loi c th t 5 n 10 ngy. Nu bnh nhn trong tnh trng nhim khun cp tnh ta nn dng loi khng sinh tim nh: Cefuroxim (zinacef), ngy t 1,5 g n 3 g (tim bp) Ampicillin ngy t 2 g - 4 gi chia 2 n 4 ln. Thuc gin p h qun Theophyllin 0,10 g ngy ucng 4 vin chia 2 ln. Salbulamol ngy ung t 2 - 4 mg c ngha l ngy dng 1 - 2 vicn loi 2 mg. Thuc cm mu Post hypophyse (Hypantin 5 v), ngy c th dng t l - 8 ng trong 24 gi. Ngi ta c th kt hp vi cc thuc khc nh dicynon ansamin kt qu s tt hn.

2. iu tr ngoi khoa
Ho ra m u nhiu ln ko di iu tr ni khoa khng c nguy c thiu mu nghim trng.

Chng ch nh ngoi khoa khi c gin ph qun lan ta, c du hiu suy h hp mn, chc nng h hp gim di 50% (VC - FEV1). III. PHNG BNH -

iu tr sm v tt cc bnh v phi nhim khun cp tnh hoc mn tnh nh vim ph qun cp, vim ph qun mn tnh, p xe phi cp v mn tnh. Trnh tip xc vi bi v cc cht gy c hi vi phi.
Rn luyn thn th thng xuyn (th dc liu php, tp th dc bui sng v bui ti trc khi i ng).

IU TR CC BNH BI PH I
Bi Huy Ph I. I CNG Bnh bi phi bao gm cc bnh phi ngh nghip do ht vo phi cc bi khong cht, cn vim phi ngh nghip l tn thng phi do ht phi bi hu c.

Bnh bi phi gy x ha phi, gi l bnh bi phi c tnh, s lng bi t nhng x ha phi nhiu nh bnh phi -silic, bnh bi phi -abet, bi phi -beryli. Bnh bi phi do qu ti bi gi l bnh bi phi lnh tnh t gy x ha phi th du n h : bi than, bi thic, xi mng, baryt. Trong cc bnh bi phi hay gp nht l bnh bi phi -siic (silicose), bnh bi than (Entracose). Lm sng Bnh bi phi -silic (Silicosis). Bnh ny thng gp nhng ngi lm cc ngh tip xc vi bi nh th m, th c , th lm khun c, th lm thu tinh, th xay , th ri lm ng, gm. Thi gian tip xc bi trung bnh t 5 - 10 nm. Triu chng lm sng ca bnh thng ngho nn, c th c biu hin vim mi hng, vim ph qun. Khi bnh nng mi biu hin kh th tc ngc hoc au ngc. Nghe phi c th thy r ro ph nang gim, c ran m, ran ph qun, c khi c lao phi kt hp bnh cng nng thm. Cn lm sng X quang phi: C hnh nh vim x, rn phi m, c nhiu nt m nh, b r t rn phi ta xa dn xung quanh.

Chc nng h hp gim c ri lon thng kh hn ch v tc nghn v c + VEMS (FEVi) gim. Bnh nhn c tin s tip xc vi bi silic t 5 nm tr ln.
II. IU TR

1. iu tr bi nhim k c lao phi 2. iu tr cc bin chng nu c (ho ra mu do Sicome) Khi c t cp ca vim ph qun mn tnh phi dng khng sinh. Ampicillin 500 mg ngy ung t 2 n 6 vin. Erythromycin (Ery 500 mg) ngy dng t 2 vin n 6 vin. Mucitux ngy dng t 3 n 4 vin. Prednisolon 5 mg ngy c th dng t 20 mg l . Nu c bi nhim lao phi th phi dng cc thuc khng lao nh riampicin; pyrazynamid, ethambutol, rimibn (trc khi dng thuc lao nht l dng cng thc c rifampicin bt buc phi th transaminase xem c bnh thng khng). Thng bin chng ca bnh bi phi -silic l gy vim mi hng, vim ph qun mn tnh, kh ph thng. i khi c trn kh mng phi hoc suy h hp mn tnh, chnh v trnh hu qu gy suy h hp mn tnh phi tch cc iu tr cc bin chng km theo.

III. PHNG BNH

Cng nhn lm cc ngh tip xc vi bi phi eo khu trang, phi ch v sinh cng nghip, gi v sinh mi trng. Thng xuyn phi t chc kim a sc kho cho cng nhn (chp phim hng lot). C khi bi quy t li thnh si gy bnh si ph qun hay gy tn thng phi ging u (bi ca silic - Silicome). Silicome hay gy ho ra mu cn phi iu tr ngoi khoa. BNH BI PHI DO THAN Bnh bi phi do than hoc hn hp than v silic, bnh ny lnh tnh v cc mnh than nh khng ho tan c nn khng gy phn ng x. Bi than khng cn quang, nn trn phim X quang phi vn tng phi bnh thng tr hn hp bi than v silic th bnh c nguy c x phi. Bnh nhn thng khc ra m mu en, lng. Lao phi hay pht trin trn bnh nhn ny Hnh nh X quang bnh bi phi do bi than thng cho thy tn thng lan ta hch rn phi to ra, sau l cc nt nh ng knh t 1 - 10 mm, b xung quanh khng r nh bnh phi -silic.

v iu tr v phng bnh cng ging nh bnh phi -silic.

IU TR SUY H HAP

cp
Hong Hng Thi

I. I CNG

Suy h hp cp c biu hin bng s suy gim cp tnh ca qu trnh trao i kh do Ln thng c quan h hp cp tnh. Suy h hp cp xy ra khi: Pa 2 < 50 mmHg C phi hp hoc khng tng PaC 2 (PaC 2 >50 mmHg). Loi I: Pa 2 gim, PaC 2 bnh thng hoc gim. Loi II: Pa 2 gim, PaC 2 tng.

C 2 loi suy h hp cp:

Lm sng: C cc triu chng sau:

Tm.

Co ko cc c h hp. Tn s th nhanh, nng, c ri lon nhp th. R lon thc tin trin nhanh. C triu chng sc. Nghe phi: im lng. Xt nghim

Biu hin v thn kinh t l m ri hn m. pH mu < 7,3 HCO 3" bnh thng hoc hi tng. Nguyn nhn -

Do chn thng, nhim khun nng, nhim c, hi chng tro ngc Mendenson. Do bnh l tim mch: nhi mu phi, ph phi cp bnh nhn hp van hai l, r lon nhp tim. Bnh l c quan h hp: do tc nghn ng dn kh, do bnh l ca nhu m phi, do bnh l ca mng phi - thnh ngc.
Bnh l h thng thn kinh: vim d dy, a r thn kinh, ng c barbiiurie, tn thng no, mng no, chn thng ct sng c.

II. IU TR

1. Cp cu ti ch 1.1. Gii phng ng th y hm di xung.

t bnh nhn nm nghing v ml bn nh nn ht phi thc n. Nu do nhim c phi nhanh chng a bnh nhn ra khi vng c. Dng nghim php Heimlich loi b d vt hng (nu c) M kh qun cp nu bnh nhn c sc d vt hay co tht thanh qun. Bt ng bnh nhn ong trng hp chn thng (ct sng c chng hn).
p tim ngoi lng ngc - h hp h tr m ing - ming.

1.2. Bo m cho h thng tun hon hot ng hiu qu H hp vin tr bng bp bng qua mt n c oxy.

t mt ng truyn tnh mch c kim c ln cho php truyn cc thuc cp cu (tt nht l t catheter vo tnh mch trung tm). - S"c in i vi cc trng hp c r lon nhp gy cho tim bp khng hiu qu nh rung tht ngng tim. - Dn lu kh, dch trong khoang mng phi mng tim do chn thng. - t ni kh qun, m kh qun ong cc trng hp: + ' C ri lon h hp, c cn ngng th, xanh tm v tnh trng thn kinh u m tng dn. + n tc ph qun nhiu ( bnh nhn treo c t t).
+ Co tht p h qun nng, c tnh trng lit p h qun.

+ Hn m. + Bnh nhn c nn nhiu, sc d vt vo ph qun t ni kh qun ch c tin hnh sau khi + Bo m h hp h tr tt qua mt n c oxy. + tim atropin 1/4 mg 1 - 2 ng vo tnh mch. Sau khi t c ni kh qun + + + Ht ht dch ng trong ph qun Cho th oxy qua ni kh qun 4 - 6 lpht. Hoc bp bng qua ni kh qun, nu c my th, cho th my vi: Oxy 50 - 100%
Lu lng b o m 1 0 - 1 5 ml/kg

Tn s: 12 - 18 nhp/pht p lc ng th khng qu 40 mmHg.

2. X tr mt s' trng hp suy h hp 2.1. Cn hen ph qun Biu hin cn hen nng: 2.2. X tr Vt v giy gia kch thch. Co ko cc c h hp ph. Tn s th 35 nhp/pht Kh ni, kh ho. Tim nhanh 130 nhp/pht, mch nghch o. V m hi, tm. Peak - Flow < 120 lpht Sa2 < 90%

Ventolin 0,5 mg/ng 1 ng di da hoc Bricanyl 0,5 1 ng tim di da hoc tim tnh mch chm. Kh dung: Berotec, Ventolin 3 - 4 ln xt Bronchodual 2 xl ln ngy 2 - 3 ln. Nu khng c th dng Hydrocortisol hemisuccinat 4 mg/kg, 4 n 6 gi/1 ln. Bo m oxy 6 - 8 lpht. Nu triu chng lm sng nng hn, cho: Oxy 10 l 1 pht. Thuc gin ph qun ng ht kh dung bao gm: Ventolin 5 mg Huyt thanh mn 0,9%. 1 ml Kh dung bng oxy 8 1pht.

C th phi hp: Thuc qua ng tnh mch: Salbumol 1 - 8 ml/gi Glucose 5% 50 ml Tim qua bm in vo tnh mch d duy tr. Nu khng c th ng: - Adrenalin 0,5 - 1 mg/nh qua ng tim tnh mch bng bm in. Ch nh vi cn hen nng m cc thuc khc khng hiu qu. Lu : Bo m oxy vi lu lng 6 - 8 lt/pht.
Hydrocortison 4 mg/kg truyn tnh mch t 4 n 6 gil ln.

3. Trong vim ph qun tc nghn mn tnh 3.1. Biu hin lm sng 3.2. iu tr a. Khng sinh

Kch thch vt v Tng huyt p - v m hi Tn s th 35 ln/ 1 pht. o ngc nhp h hp Xanh tm ton thn tng dn

Erythromycin (Penglobe), hoc Clamoxyl. Amocicilin + acid Clavulamic (Augmentin) liu lng 1 g/1 ln 2 ln/ngy. Oflocef vi liu tng t.
Erythromycin c th gy kch ng nim mc d dy, gy nn v bun nn.

Lu bnh nhn d ng vi Blactamin khi dng Augmentin, Clamoxyl phi thn ng.
Dung dch mn ngt ng trng

Cn bng nc in gii lm long m v dinh dng

-

Dung dch Ringer lactat

Bo m 2 n 3 lngy Thuc gin ph qun Theophyllin chm. Armophylin 10 mg/kg chia 2 ln/ngy Thuc kch thch... giao cm Bricanyl 0,5 mg 1 ng di da Ventolin mi ln 2 xt - ngy 3 - 4 ln.
Corticoid

Hydrocortison hemisuccinat (Solucocte, Solumedrol 1 mg/kg/ngy tim tnh mch chm. Cn thn khi dng vi bnh nhn c cao huyt p. C tin s lot d dy t trng. bnh nhn c i tho ng hoc c lao phi km theo.

Chng ng: Fraxiparin (Zovenox, Fragmin) 2500 l/in 2 ln/ngy tim di da.

Oxy liu php 4 n 6 lpht qua mt n hoc qua sonde kiu gng knh. Nu bnh nhn vn Irong tnh trng nng: + + + + + t ni kh qun sau khi cho th oxy. t ng truyn tnh mch. Th my qua ni kh qun c oxy 8 ml/kg. Tn s th 12 n 15 ln/1 pht. p lc ng th 12 - 20 cm nc. Bm bicarbonat 14%0 10 -15 mi vo ni kh qun ri ht cc dch tit ng.

IU TR SUY H HAP

m n t n h
Phm Ha M

I. I CNG
Suy h hp mn tnh l chc nng ca b my h hp b suy gim mt cch l t do tn thng cu trc hoc thc th ca b my h hp. Bn cht ca suy h hp l do r lon trao i kh oxy v carbonic dn n nng C 2 v O 2 khng bnh thng biu hin sm nh't l mu, mun nh't l t chc. Lm sng

a. Lm sng biu hin kh thiu oxy r rt Tn s th tng Tm (do tng hng cu nhng hng cu khng c bo ha oxy methemoglobulin tng). Tn s" tim nhanh. Triu chng no: Thiu oxy nh: thong qun, nhc u; thiu oxy nng: ph no, hn m lc m PaCCb tng (80 mmHg). + + +
-

b. Cn lm sng Da vo triu chng ca nguyn nhn gy nn. Da vo phn tch kh ca mu Pa 2 gim, PaC 2 tng. Da vo o chc nng thng kh h hp.

Chn on sm khi cha c biu hin ri lon kh ca mu v chc nng thng kh h hp th lm nghim php gng sc. Nu nghim php gng sc bnh thng th khng phi l suy h h'p.

II. IU TRI

1. Nguyn tc iu tr iu tr bnh c s l nguyn nhn gy ra suy h hp. Liu php oxy. Lm thng thong ng th. Tp th iu tr bng thuc Th my iu tr suy tim iu tr thng bng kim - toan.

2. iu tr c th 2.1. iu tr nguyn nhn gy suy h hp mn nh vim ph qun mn tnh, hen ph qun, gin ph qun, lao phi.v.v... 2.2. Liu php oxy: Th oxy ngt qung qua sonde mi tt nht l th oxy 30 - 40%, qua l nc lm m, lu lng th l 1 lpht.

Khng c th oxy 100% v nguy him gy c ch trung tm h hp, mt khc lm kh nim mc ph qun dn n kh khc m, m b ng li ph qun gy tc nghn ph qun cng ngy cng tng. Thi gian th oxy ph thuc vo p lc oxy ca mu ng mch, khi Pa 2 t c 70 - 80 mmHg th ngng. Tct hn ht l th ngt qung hoc duy tr vi lng oxy t, nu ngng th oxy c th gy gim thng kh ph nang.

Tt hn ht nn sn xut bnh oxy vi nng 30 - 40%. Hoc th khng kh trong mt phng th qua sonde mi 1 pht th 2 - 3 lt khng kh th tng ng vi nng oxy 40 - 50% l thch hp. 2.3. Lm thng thong ng th bng cch: - Bnh nhn t khc m hoc v rung.
- Ht m di qua ng thng, qua mi, qua ng ni kh qun, qua m kh qun.

2.4. Tp th: Tt nht theo phng php phc hi chc nng. 5. Thuc u tr Khng sinh chng bi nhim, tt nh't theo khng sinh v tu thuc vo nguyn nhn gy bnh, nn cho khng sinh loi tim v d:

Petcef 1 g X 2 l/ngy tim tnh mch, tim trong 10 ngy, c n phi hp vi metronidazol 2 gam/ngy nh git tnh mch.

Thuc gin c trn ph qun:

Diaphyllin 0,48 g X 1 ng (tim tnh mch rl chm ticm 5 ngy) hoc Berotec (Spray bm). Mi ngy bm 3 ln, bm nh vy trong 5 ngy. Nhm chng vim v chng d ng:
Prednisolon 5 mg X 4 v/ngy trong 10 ngy sau gim xung 2 vin/ngy X 10 ngy ri ngng.

Hoc Solumerol 40 mg X 2 l/ngy nh git tnh mch trong 5 ngy.

Hoc xolucortef 80 mg X 1 l/ngy dng Irong 5 ngy.

m c v dnh th dng cc Ihuc long ni, v rung dn lu t th.

Thuc long m: Bisolvon 0,20 g X 4 v/ngy X 5 ngy. HocSolmuxbroncho 0,20 g X 2 vin/ngy X 5 ngy HoeXirolriatunic 10 ml/ ngy X 5 ngy

Hoc xir aiussin 10 ml/ngy X 5 ngy. Trong ng hp gim thng kh ph nang th dng thuc kch thch trung lm h hp nh:

Lobckin 0,10 g X 2 vin/ngy Calein 0.10 g X 2 viC'ii/ngv

Thuc an ihn gim ho:

Khng c cho morphin v c ch trung tm h hp, Ihuc an thn nhanh nh Seduxen loi tim, garcnal l chng ch nh.
Tt nh cho loi chng d ng gy ng nhxiro phenecgan 3 % X 10 ml/ngy X5 ngy.

2.6. Chng toan h hp Biearbonat 14 c /cc.

Cng thc tnh lng dch hicarhonal 14%0 truyn nh sau: Lng dch: 1 ml X 8 X Ung lng c th X s"m ca kim d. V(J:Trngngc ihca bnh nhn no l 50 kg, sm ca kim d l -10 th lng dch bicarbonal 14c /cc cn iruyn l:
1 ml X 1,8 X 50 X 10 = 90 ml

ChoirispulTcr:

(Tris - Hydroxymelhyl - aminomelhan) Vil tt: THAM 2.7. Nu bnh nhn suy tim th iu tr nh suy tim Thuc li liu c ch men anhydrasc carbonic nh Diamox, Aldacton dng khi c tr CO 2. Liu dng: 10 mg/kg/ngy cho lng i 3 - 4 ngy. Digilalis khng dng kli suy lim mt h Trong suy tim m b th liu php in iii nh hng n ihni! bng kim-loun.

Ngng thuc li licu khi pH mu < 7,30 -

2.8. Th ox\ qua my Ch nh: Nhim loan h hp m b

PuCCb: 55 - 60 mmHg

Bl buc phi c xt nghim kh mu mi c th my Chng ch nh: + Thiu oxy mu nhng PuCCb bnh ihng, nu th my trong ng hp ny l v ch v nguy him v th my lm cho PaCCb gim di mc hnh thng gy kim mu. + Chng chi' nh trong nhng bnh phi mn lnh nh vim ph qun mn lnh m PaC 2 = 50 mmHg.

+ Chng ch nh khi khng c xi nghim kh mu. + Chng ch nh trong trng hp th my PaC 2 tng ln. 2.9. Theo di bnh nhn thng xuyn o kh mu ng mch, cn bng kim-toan, o in tim, chp phi c phi hin kp ihi i cp ca suy h hp mn tnh.
III. PHNG BNH SUY H HP MN iu tr sm nhng bnh ctf s nh: Vicm ph qun mn tnh, hen ph qun, gin ph qun, lao phi.v.v... nguyn nhn dn n suy h hp mn tnh.

IU TR HEN PH QUN
Phm Th Ha M
I. I CNG

Hen ph qun gm bu qu trnh Tc nghn ph qun hi phc ngu nhin hoc do iu ir. Vim nhim ng h hp.

Tng phn ng nim mc ph qun vi nhng cht v yu l kch thch thng qua c ch min dch (phn ng khng nguyn v khng th IgE).

Chn on:
Hi tin s d ng v han ihn v gia nh.

Triu chng c nng: Kh th tng cn, kh ih chm, kh th ra c tnh ch chu k lin quan n ma, n ihay i ihi lil. n cc ch lip xc.
iriu chng bi) n c hi hi, nga mi. c h y nc mi. c th SI hoc

khni si, ho khan hoc c m.

Triu chng thc th:

Nhn: Co ko cc c h hp S: Rung thanh bnh thng G: Trong hn bnh thng khi ln cn, ngoi cn th bnh thng. Nghe: Nhiu ran ngy + rt v c th c ran m. Triu chng cn lm sng: + + + + + Xquang phi: Phi sng hn bnh thng c 2 bn, c th c rn phi m. Test: D nguyn dng tnh mt hoc nhiu loi IgE khng c hiu: Tng ln IgE c hiu: Xut hin c o chc nng h hp: VEMS (F.EV1) gim.

II. IU TR HEN PH QUN

1. Nguyn tc iu tri 1.1. i vi ct cn hen: iu tr theo mc ca cn hen nhm gii quyt ba qu nh. Chng co tht ph qun. Chng vim v tit dch Gim tnh mn cm ca nim mc ph qun.

1.2. i vi iu tr bnh hen (phng cn hen) -

iu tr c hiu bng cch iu gii mn cm c hiu v cch li ngun d nguyn.

Phng cn hen bng cc thuc zaiten, (Intal).

Ngn nga cc yu t v cht kch thch cng nh nguyn nhn thun li khc.

1.3. iu tr bin chng 2. iu tr c th 2.1. Ct cn hen: Tt c cc mc : nh, trung bnh, nng,c tnh phi dng cc loi gin c trn ph qun, khng sinh, long m, chng d ng. a. Cn hen nh:
+ Theophyllin 0,10 g X 4 v/ngy X 10 ngy (hoc ht cn th ngng)*hoc Theophyllin chm 0,20 g X 2v/ngy X 10 ngy.

+
+

Thuc chng d ng: Histalong 10 mg X 1 v/ngy X 5 ngy

Khng sinh ung: nasyn 1500 mg X 3 vin/ngy X 10 ngy hoc amoxicillin 0,5 g X 3 vin/ngy X 10 ngy

b. Cn hen trung bnh: Diaphyllin 0,48 g X 1 ng (tim lnh mch chm) mi ngy tim khi no ct cn th ngng.

Phi hp vi Salbutamol (Spray) mi ngy bm 2 - 3 ln mi 1 ln bm tng ng vi 5 mg. Bm khi no ct cn th ngng, hoc Berotec (Spray) 2 - 3 ln bm/ngy. Hoc Berodual (Spray) 2 - 3 in bm/ngy. Khng sinh: ng tim hoc ung v d:
Oloxacin 200 mg X 2 v/ngy X 5 ngy

hoc Petcef 1 g/ngy X 5 ngy (tim tnh mch hoc bp).

Hyrocortison 125 mg 1/2 ng/ngy X 10 ngy, hoc Prenisolon 5 mg X 4 - 6 v/ngy X 5 ngy. Sau h xung 2 - 4 v/ngy X 5 ngy, sau h xung 1 - 2 v/ngy X 5 ngy ri ngng thuc. Histalong 10 mg X 1 v/ngy X 5 ngy hoc xo phenecgan 3% X 10 m g/ngy X 5 ngy
h o c z a d ite n 1 m g X 1 v i n /n g y X 5 n g y .

c. Cn hen nng: Salbutamol truyn nh git tnh mch 0,1 mg/kg n n g /1 pht hoc adrenalin truyn tnh mch 0,05 mg/kg/ 1 pht hoc 1 mg tim di da/ngy, c t cn th ngng. Diaphyllin 0,48 g X 1 ng nh git tnh mch trong 20 pht sau duy 0,72 - 0,96 g nh git ong 24 gi. Depersolon 30 mg 4 - 6 gi khng thay bng solumedrol 40 mg X 2 ng/ngy nh git tnh mch hoc Solucortef 80 mg X 1 - 2 ng nh git tnh mch/ngy khi no ct th ngng. (C th nh git tnh mch trong 5 ngy).

Nu iu kin tch cc bnh nhn t din bin nguy kch tc l chuyn thnh cn hen c tnh th iu tr nh sau: Khng sinh tim liu cao v ko di 10 ngy.

d. Nkanh chng gii phng ng th bng cch m kh qun, ht m di th Oxy 40% qua my th nhn to. V M _ Thuc iu tr gin c trn ph qun nh iu tr cn hen nng. Khng sinh tim liu cao v ko di 10 ngy. Phi hp vi cc phng php iu tr hen ca y hc c truyn nh bm huyt, chm cu, thu chm.v.v...

2.2. iu tr phng cn hen (iu tr bnh hen) iu tr gii mn cm c hiu i vi d nguyn m bnh nhn y b d ng v d: d ng vi bi nh th dng bi nh iu tr hoc cc loi phn hoa

th dng loi iu tr thi gian iu tr ko di 3 nm, mi nm iu tr trong 3 thng lin tc, mi thng tim 4 mi vo di da nh vy l mi tun tim 1 mi. Chn 3 thng trong nm m t ln cn hen v d: ma h t ln cn hen hoc khng ln cn hen th chn 3 thng ca ma h iu tr.

v liu lng: T thp n cao. Tun th 1: Tim 1/10 ml; tun th 2: 2/10 ml.v.v... cho n 1 ml th khng tng n na m c tim 1 ml cho nhng tun tip theo. v nng : Nm u tin nng thng thp nht, nm th 2 nng cao hn, nm th 3 nng cao nht. (Sn xut Bencard (Anh) sn th t nng trn l thuc). Cch li ngun d nguyn nh bi nh, bi cng nghip, bi ng ph, cc bi phn hoa, cc loi thc n, cc lng sc vt.v.v... Histamin pha long 1/10.000 (kh dung). Gamma globulin 2 ml/1 tun X 3 tun tim bp Thuc phng cn: Dinatrium Cromoglycat (Intal) - Vin con nhng: Dng c ht vo ph qun - Dng nc cho vo my kh dung - Bnh xt (spray) Liu lng: 0,04 g X 3 - 4 V con nhng/ ngy ht lin tc 3 - 4 thng nu th ht n 3 nm l ti a. Di dng spray: Ngy bm 2 - 3 ln vi thi gian nh trn. 2.3. iu tr nguyn nhn khc gy cn hen
-

Intal c 3 dng:

C t b u x t c u n g , u n a n g b u n g tr n g , p o ly p r u t.

iu tr vim gan, x gan, vim ng mt, ti mt. Ni tit: ngi mn kinh Overtin 1 mg/ngy lin tc ong 1 thng hoc 3 thng ri ngng 6 thng li tip tc.

Vitamin E 1v/ngy lin tc trong 3 thng, ngi cho con b ln cn hen th cai b. Ri lon tm thn: Dng thuc c hiu tm thn. Hen do gng sc: Cho ch lm vic nh. Hen do dng nhm thuc chng vim khng steroid th ngng ung thuc .

2.4. iu tr bin chng: Gin ph nang: Tp th. Tm ph mn: iu tr suy tim.

III. PHNG BNH

Xem mc iu tr phng cn hen, ngoi ra nn i ni , i vng, i ngh nu ngh v ni l yu t gy d ng. Nu do kh hu, m th nn i ni c tr.

IU TR TRN KH MNG P H I
Hong Hng Thi
I. I CNG

Trn kh mng phi l biu hin bnh l do s xut hin bt thng trong khoang mng phi mt lng kh t hoc nhiu do bnh lca l thnh hoc l tng hoc do iu tr. Tu theo lng kh nhiu hay t m ta c 2 loi trn kh Trn kh mng phi khu tr Trn kh mng phi t do hay ton b. Trn kh mng phi ng Trn kh mng phi m Trn kh mng phi c supap hay c van Cc bnh phi mn tnh hay cc bnh cp tnh (vim phi cp do t cu) Sau gng sc, hoc do ngh nghip.

Ngi ta cn phn ra 3 loi trn kh da theo p lc ca khoang mng phi:

Yu t thun li:

Chn on: Bnh nhn biu hin suy h hp v suy tun hon cp. C tam chng Galiard bn bnh C hnh nh X quang in hnh (phi sng, khoang lin sn gin rng, nhu m phi co v rn phi, tim b y qua bn i din. Chc ht c kh khoang mng phi.

II. IU TR 1. Trn kh mng ph t pht v cn

1.1. Trn kh mng phi ng Ngh ngi ti ging theo t th Fowler Gim au, an thn bng Aspirin 500 mg 2 - 4 vin/ngy ung sau n. Ngi ta c th dng:

Chng ch nh bnh nhn c tin s hn, tn thng d dy t trng. ParacetamoK Efferalgan ) 500 mg 2 ln/ngy mi ln 1 vin. Thn trng: i vi bnh nhrt su gan he cho:

Seduxen,diazepam 5 mg 1 vin/ngy Khng cho ong trng hp trn kh bnh nhn b suy h hp mn tnh. Ngng thuc l - thuc lo. Hn ch cc hot ng gng sc v th lc.

1.2. Trn kh mng phi m Phc hi thnh ngc (nu do chn thng thng thnh ngc). t catheter khoang mng phi v ht lin tc vi p lc m, hoc ht bng bm quay vi kim ln (17 hoc 18G). Theo di mch huyt p ca bnh nhn v du hiu ton thn nh gi kt qu. Sau 48 gi ht lin tc, chp phi thng nh gi kt qu.

1.3. Trn kh mng phi c van hay c supap. y l loi cp cu cn phi x tr khn trng Tim atropin 1/4 mg/ ng X 2 ng tim di da. Gy t vng ngc bn tn thng, v tr khoang lin sn II v dng kim ln 14 G hay 16 G chc ht qua my lin tc hoc bng bm quay, p lc (nu qua my ht) l -15 cm H 2O.

ni khng c my ht th n vi kim chc ht bng 1 si dy truyn huyt thanh, u kia cho vo 1 bnh ng nc mui 9%0, nhtig su 10-15 cm. Kim tra qua X quang nu phi n ra kh khn c th soi ph qun tm tn thng ph qun thng vi khoang mng phi.

C th soi mng phi tm nguyn nhn v khc phc l thng l tng ca mng phi. 2. Trn kh mng phi ti pht Sau khi ht kh khoang mng phi nhiu ln m khng kt qu. Ngi ta p dng mt trong cc phng php sau: 2.1. Bm vo khoang mng phi b bnh Teaxyclin 1 g X 1

Natri cloma 9 %0 X 20 ml Streptomycin 1 g X 10 l

Natri clorua 9 %0 X 20 ml

Th phn ng vi streptomycin trc khi bm vo khoang mng phi. Mu t mn (mu ca bnh nhn, 20 ml n 40 ml bm qua ng thng dn lu khoang mng phi b bnh. t bnh nhn nm nghing v bn phi b bnh ri ht qua my vi p lc m 15 cm nc.

Yu cu: Phi bo m khu v khun tuyt i. Lu : Trong th trn kh mng phi m do thng l tng ca mng phi vi l thng ln (do v hang lao, p xe phi v vo khoang mng phi) khi ht, khi cn duy tr p lc m thp 5 - 10 cm nc. Trnh ht vi p lc ln c th gy ra hin tng ngt v suy h hp cp do my ht ko phn th tch kh lng ph qun ca phi lnh (hin tng n cp kh).Bnh nhn c th t vong nu thi gian ht ko di
khng c th e o d i.'

3. iu tr ngoi khoa 3.1. Trn mu trn kh mng phi do chn thng Phc hi l thng, thnh ngc. Dn lu mu khoang mng phi. Dn lu kh ng thi. Soi ph qun tm ph qun tn thng thng vi khoang mng phi. Dng sonde c bng u nt ph qun b tn thng. Ht kh v m, gii phng khoang mng phi.

3.2. Trn kh, trn m do p xe hoc hang lao vd vo khoang mng phi

3.3. Trn kh mng phi ti pht Soi mng phi. Tht hoc ct cc chm ph nang gin qua ni soi mng phi.

4. iu tr nguyn nhn 4.1. Do nhim khun 4.2. Do lao Cho cc thuc chng lao vi phc iu tr 6 thng 2 thng u vi 4 loi: - Streptomicin 1 g/ngy tim bp - Pirazynamid 15 mg/kg/ngy - Rifampicin 10 mg/kg/ngy - Rimin 5 - 1 0 mg/kg/ngy 4 thng sau: Vi 2 th thuc rifampicin v rimifon. Lu : phng tc dng ph ca Streptomycin Nu c: triu chng ca hi chng tin nh C biu hin thn (nc tiu t, ph phi ngng thuc). Nu c biu hin chn n, nc tiu vng sm, cng mc mt vng phi ngng rimibn v riampicin. Cho khng sinh ton thn bng ng tim hoc ng ung da vo khng sinh t kt qu cy mu, m.

4.3. Do p xe phi v vo khoang mng phi gy trn kh - trn dch mng phi - Dn lu kh v m - Ra khoang mng phi hng ngy bng dung dch natri clorua 9%0 . 500 ml 1000 ml cho n khi dch trong. - Cho cc thuc tiu fibrin vo khoang mng phi nh a chymotrypsin 5 mg/ ng 1 ng/ngy - Hng dn bnh nhn tp th h tr chng dy dnh mng phi.

IU TR TRN DCH MNG PH I DO LAO

Phm Th Ha M
I. I CNG

Trn dch mng phi do lao l s tit dch gia l tng v l thnh do phn ng min dch khng nguyn khng th hoc vi khun ao tn thng vim trc tip mng mao mch ca l tng mng phi. Lm sng + Khm:

Hi chng 3 gim, trung tht b y (tim b y) lin sn gin rng, xng sn nm ngang, ing ngc d cao. Xquang: Hnh nh m u, ranh gii gia sng v m'l mt ng cong Damoiseau, tim b y sang bn lnh, khoang lin sn gin rng, xng sn nm ngang. + Siu m: Thy hnh nh trn dch. + Chc d: c dch Triu c h n g khng nh chc chn do lao nu + Tim thy BK m hoc dch. + Tun thy t bo bn lin, khng l Langhans dch hoc sinh thit mng phi. + Xquang: Nhn thy hnh nh tn thng lao. Thc t nhng triu chng ny thng gp 5% so vi cc trng hp trn dch do lao. V vy cn da vo triu chng sau: Triu chng ngh nhiu n trn dch mng phi do lao: Thng mu vng chanh (t gp: mu, m). T bo dch mng phi: i b phn l lympho bo. Mantoux (+) +

s lng BC bnh thng, a nhn trung tnhbnh thng nhng lympho bo tng. Tc mu lng tng cao: gi th nht > 30 mm gi th hai > 40 mm Gp nhiu ngi tr tui St nh, va v chiu v m. iu tr th thuc chng lao: khi

II. IU TR

1. Nguyn tc iu tr iu tr ha tr liu chng lao phi c t nht 3 loi phi hp, trong ba loi cn c mt loi dit vi khun lao. Bt buc phi hp thuc chng vim v gim phn ng min dch bng corticoid, a chymotrypsin. Chc tho dch mng phi, bm (X chymotrypsin hoc depersolon, hoc septomycin vo mng phi sau khi tho dch. iu tr tn cng 2 thng, duy tr 4 thng, theo di hai nm.

2. iu tr c th 2.1. Cc loi thuc chng lao, ng dng, liu lngy tc dng ph xem bng sau y: Tn thuc ng dng Liu lng cho 1 ngy 5 mg/kg cn nng ung 1 ln 10 mg/kg cn nng ung 1 ln 20 - 25 mg/kg 1 g/ngy Tc dng ph

1. INH (Phtyson) dit VK lao Ung 1 ln vo bui sng 2. Riampicin (Rimactan Ung c tubocin dit VK) khi n Ung 3. Ethambutol 4. Streptomycin Tim bp (c che VK lao) Ung 5. Astionamid (Rigenicid) (c ch) 6 . Prothionamid: c ch, VK Ung lao (Tebeorm) 7. Cycloserin c ch VK lao Ung
8 . Kanamycin

9. Acid paraaminosalysyl (P.A. S). 10. Pyrazinamid 11. Viomycin (Viocin) 12. Thiosemicarbason (Thiacetazon)

Tim bp ung hoc tim T/M hoc nh git l,5 - 2 g Ung Tim bp 1g 0,1 - 0,15g Ung

Vim thn kinh, c vi gan Suy gan: vng mt, vng da, nn, bun nn, d ng nh hng th lc nh hng c tai tin nh gy ic 0,75 g (u'ng phi hp Nn, bun nn, suy gan thuc khc) 0,75 g (ung phi hp Nn, bun nn, suy gan vi thuc khc) Ri lon h thn kinh 0,75 g - 1 g trung ng c c tai 1g Ri lon d dy rut 8 - 24 g

Tn thng gan, thn, khp c thn (suy thn) Vim da, suy gan, ri lon d dy

2.2. Phc iu tr theo Boston (M) u tin iu tr cao nht: Trng hp 1 + Xt nghim BK (+) trong qun th khng thuc cao 2HRZE (hoc S)/4 RH 2HRZE (hoc S)/4 R3H3 2HRZE (hoc S )/6 HT 2HRZE (hoc S )/6 HE 6H3R3Z3E3 (hoc S) + Xt nghim BK (+) trong qun th khng thuc thp 2HRZ/4RH hoc nh trn Trng hp 2: BK pht phin knh (-) cy (+) (ging trng hp 1) Trng hp 3: Kt qu cy, pht u m tnh, Xquang phi bt thng. u tin iu tr trung bnh: iu tr nh trng hp mt nhng chm dt iu tr sau 4 thng. Ch thch k hiu: K hiu: 2HRZE/4RH: Ch: Con s 2: tn cng 2 thng Con s' 4: duy tr 4 thng H: INH R: Riampicin Z: Pyrazinamid E: Ethambutol K hiu: 6H3R3Z3E3: Tn cng 6 thng mi loi cch 3 ngy-ung 1 ln. 2.3. Thuc chng vim v chng d ng (gim min dch) Corticoid: Ch dng khi xt nghim BK m tnh nn dng ngay t ngy u khi b trn dch mng phi
Prednisolon Sau : 5 mg X 4 - 6 v/ngy X 10 ngy (ung) 2 - 4 v/ngy X 10 ngy, sau : 1 - 2 v/ngy X 10 ngy

ri ngng ung
a c h y m o t r y p s i n 1 l t i m b p / n g y X 1 0 n g y

hoc 6 vin/ngy X 10 ngy

2.4. Chc tho dch mng phi (bt buc phi chc tho) Lng dch t: Cch 3 ngy chc 1 ln Lng dch trung bnh: Cch 1 ngy chc 1 ln. Lng dch nhiu: Ngy no cng chc tho sau khi chc tho bm vo mng phi.

(Xchym otrypsin X 1 ng hoc prednisolon 30 mg X 1 ng

' hoc streptomycin 1 g X 1 ng 2.5. iu tr triu chng au ngc: Dng thuc gim au nhm khng steroid V d: Efferal gan codein 2 v/ngy X 5 ngy Seduxen 5 mg X 1 v/ngy X 5 ngy St: H nhit bng: paracetam ol 0,5 X 2 v/ngy Kh th: Chc tho dch 2.6. iu tr bin chng: Dy dnh mng phi: Nu dy dnh t: Tp th theo phc hi chc nng Dy dnh nhiu: Phu thut
III. PHNG BN H

Sau khi iu tr ht dch cn theo di 2 nm bng chp phim nh k 1 thng hoc 2 thng 1 ln. Hng dn v theo di cch s dng thuc phng lao.

IU TR TRN M MNG P H I
Hong Hng Thi
I. I CNG

Trn m mng phi l m t th n dch mng phi m chc ht xc nh c dch c hoc m v i th v trn vi th thy c mt ca bch cu a nhn thoi ha (loi tr trng hp trn m m nguyn nhn do lao thng khng thy c tp khun). Tn thng gii phu bnh l Qua 3 giai on: Giai on lan ta Giai on dnh Giai on ng kn. Vim nhim cn mng phi (p xe phi, p xe di honh) Nhm khun trc tip: Chn thng, chc d b bi nhim, th thut ngoi khoa Nhim khun vng k cn: Trung tht, thnh ngc, vim phc mc

v nguyn nhn: Thng do 3 nguyn nhn. -

Lm sng v cn lm sng

Hi chng nhim khun Hi chng ti phi Cc nhim khun ngoi phi: Nhim khun rng ming, nhim khun mt, ngoi da. X quang, c hnh nh trn dch mng phi. Cng thc mu c bch cu tng, mu lng tng.
Dch mng phi c, mi thi.

Xt nghim dch c xc bch cu a nhn thoi ha, c vi khun gy bnh nh Krebsiellea hoc proteus, t cu, ph cu... Cy mu c khi dng tnh (l cu - ph cu) trong mt s trng hp.

V. IU TR 1. iu tr ton thn 1.1. Thit lp li cn bng nc, in gii v dinh dng

Natri clorua 9% 1000 ml/ngy Glucose5% 1000 ml/ngy Nh git nh mch. Cc dung dch cao phn t:

Hemacel 500 ml/1 chai. Intralipid loi 10%, 20% loi 250 ml/chai Moriamin 500 ml/1 chai nh git tnh mch tun t 1 n 2 chai. Cc vitamin: Phc hp vitamin nhm B.

Becozym (phc hp vitamin B 1, B2, B6 v PP), tim bp ngy 2 ng (sng, chiu). 1.2. iu chnh lng ng huyt n nh bnh nhn i ng da vo kt qu ng mu v ng niu hng ngy. Cho insulin (nhanh hoc chm, tim di da. Trc cc ba n 30 pht i vi th ph thuc insulin. iu chnh lng sulamid chng i tho ng i vi th khng ph thuc insulin. Oxy liu php vi bnh nhn trn m s lng nhiu, tnh trng nhim khun nng 2 - 3 lt/pht th ngt qung. V sinh thn th, rng ming hng ngy. Thay cc sonde dn lu bng quang, ng ni kh qun (nu c) thng xuyn, ngm trong dung dch Cidex nh nhim khun cho.

2. iu tr khng sinh Nguyn tc Cho khng sinh sm, liu cao Cho phi hp khng sinh. Da vo khng sinh .

2,1. Khng sinh thng c s dng nhiu nht l Penicillin G 20 triu n v Glucose 5% 500 ml Nh git tnh mch 30 gipht phi hp vi: Gentamicin 80 mg 2 ng/ngy tim bp cch nhau 8 gi. Flagyl (Klion, Metronidazol).

Vin 0,25 dng 4 vin/ngy chia 2 ln. L: 500 mg dng 2 l/ngy, uyn tnh mch 20 gipht. Lu : Bnh nhn c tin s d ng nn thn trng vi nhm p-lactam . Theo di chc nng thn khi s dng nhm aminosid nh gentamicin, kanamycin. Nu bnh nhn c tin s d ng v khng dung np vi nhm p-lactam c th cho: + + + Erythromycin 0,25 dng 8 vin/ngy chia lm 4 ln cch nhau t 4 n 6 gi. Gentamicin 80 mg dng 2 ng/ngy tim bp cch nhau 8 gi mt ln Flagyl (Klon, Metronidazol): Vin 0,25 4 n 6 vin/ngy chia 2 ln. L 500 mg 2 l nh git tnh mch. Thi gian dng thng t 1 tun n 10 ngy. Lu : vi Erythromycin c th gy kch ng nim mc d dy, gy bun nn v nn. 0

Trong nhng nm gn y do s khng khng sinh ca vi khun ngy cng tng nht l ni nhm (3-lactam xut hin nhiu th h khng sinh mi nh nhm Cephalosporin, quinolon, hoc i vi nhm p-lactam xut hin nhm thuc mi c gn vi acid clavulanic c ch men P-lactamase ca vi khun v d nh thuc Augmentin (CIBLOR). Augmentin (CIBLCOR): Amocicilin + acid clavulanic Dng vin nn 500 mg 3 vin/ngy chia 3 ln. Dng tim 1 g/l 2 l/ngy tim tnh mch. Cch nhau 6 gi.

Hoc nh git tnh mch pha trong 250 ml glucose ng trng truyn chm 4 n 6 gi. Zeclar 2 vin/ngy cch nhau 8 gi. Pyostacin 500 mg/vin 6 vin chia 2 ln ung cch nhau 6 gi/ 1 ln.
Cephalosporin

i vi cu khun Gram dng + T cu + Lin cu + E.coli + P.Mabilis + Klebsiella

C th dng cephalosporin th h I hoc II: - Cephaloridin (CEPORINE) 1 n 2 g tim tnh mch 2 ln/ngy - Cephalotin (KEFLIN) l 1 g ngy 2 l tim bp hoc tnh mch cch nhau 6 gi. - Cephalotin (EFALOJECT) l 1 g ngy 2 gam tim nh mch chm chia 2 ln. - Cephalotin (KEFZOL) l lg ngy tim 2 g chia 2 ln tim tnh mch. Dng thuc vin ung: Ceaclor, Ceadroxil (Oraceal) vin 500 mg ngy 2 n 4 vin chia 2 ln ung Phi hp vi: - Metronidazol 500 mg/I, 2 l/ngy nh git nh mch. - Gentamicin 80 mg 2 ng/ngy tim bp. - Nu nguyn nhn do vi khun k kh: Cephalosporin th h in (Cebis, Claran Fortum), tim bp ngy 2g cch nhau 6 gi. Hoc quinolon (PeAacin, Cyproloxacin) 400 mg/1 ng Glucose5% 250 ml "Nh git tnh mch20 - 30 git/pht Phi hp vi: Meonidazol 500 mg 2 l. Nh git nh mch 20 git/pht - Vi nhim khun bnh vin, c th s dng: Piperacillin, imipenem, 5 - nitro - imidazol 2.2. iu tr ti ch Dn lu kn khoang mng phi.

Ra mng phi bng huyt thanh mn 9 %c 500 ml n 1000 ml/ngy cho n khi dch ra trong. + Hyase (men Hyaluronidase) 5 n v/ ng 1 - 2 ng/1 ln. + Men tiu brin: a chymotrypsin 5 mg/ng ngy 1 ng, cho trong 1 tun.

3. iu tr ngoi khoa Ch nh: iu tr ni khoa m cn mng phi vn cn. Soi mng phi lau ra cn mng phi. Bc mng phi gii phng phi. Ct phi vng p xe phi mn tnh.

IU TR P XE PHI
Nguyn Vn Thnh
I. I CNG

Lm sng

L hin tng nung m nhu m phi, khng do lao, li mt hay nhiu hang tn to sau khi m thot ra ngoi qua ng dn kh. C trng hp m khng thot qua ng dn kh. C trng hp m khng thot ra ngoi v ng dn kh b bt li, to nn trn hnh nh mt m m u ging nh u phi. Trng hp ny gi l p xe phi th gin. Vic chn on phi da vo chc ht qua thnh ngc. p xe phi din bin qua 3 giai on: Giai on vim: v lm sng v Xquang ging nh vim phi. Giai on nung m v c m St cao Hi th hi c m, cn xt nghim v vi khun, nm, amip qua soi trc tip hoc nui cy.

X quang: C mt hoc nhiu vi mc nc, mc hi nhu m Cc ny c th hnh trn hoc bu dc, b vin dy. Khi m khng thot ra ngoi trn Xquang nhu m phi c m m u ging nh u phi m ta gi l th gi u Cc xt nghim khc: Hng cu thng khng thay i, bch cu tng, mu lng cao. Giai on lui bnh vi cc tiu chun sau: Ht st, hi th khng hi, khng c m, X quang tr li bnh thng hoc li nhng vt x, cng thc mu, tc mu lng bnh thng. Bnh nu c iu sm, ng cch c th khi hon ton sau vi tun hoc vi thng. Nu sau ba thng bnh khng khi, gi l p xe phi mn tnh, cn phi phu thut. II. IU TR p xe phi l mt bnh c tnh cht ni ngoi khoa nh ni trn. 1. iu tr ni khoa Vic s dng khng sinh rt cn thit d b't k nguyn nhn g. Nn dng khng sinh theo kt qu khng sinh . iu cn ch l s ngm thuc vo cc t chc ph thuc vo tng loi thuc.

Theo kinh nghim, thuc ngm vo cc ph tng ti a thng l cc loi macrolid (erythromycin, Oleandomycin, pamyn), cc loi cyclin v chloramphenicol. Ngoi ra c th dng cc loi p- lactam (Penicillin, Cephalosporin), aminosid (Kanamycin, Gentamicin). Nu dng thy t hiu qu phi tng liu. Cn phi hp khng sinh c tc dng h tr v nh cc thuc tng tc. Trnh hin tng khng thuc - iu tr khng sinh bao vy hoc phng nga l khng hp l v rt nguy him. Cng cn ch n c tnh ca thuc - Thuc no gy c nhiu u khng c dng. Khng sinh c th dng ng ton thn (tim bp, tnh mch, ung) hoc a vo p xe sau khi chc ht m. Nu m c, bm a chymotrypsin, ht ri bm khng sinh thch hp vo m. Trng hp do amip: Khng sinh phi hp vi dehydro emetin l phng php rt tt. 2. Dn lu m Thi gian c m cn c dn lu - M ra c cng nhiu cng tt ( 2 cch) - Dn lu theo t th thch hp, c th phi hp vi v rung lng ngc. Chc kim vo m ht.

3. Ngoi khoa Ch s dng khi p xe tr thnh mn tnh (n 3 thng iu tr ni khoa khng kt qu) hoc p xe ti pht hoc c di chng gy bi nhim do aspegillus hoc do u, do gin ph qun khu tr. Ngoi khoa nhm bc tch m.

IU TR NG TH PH I
Nguyn Vn Thnh
I. I CNG

C 4 phng php iu tr: Min dch, ni khoa, tia x, phu thut. Ngy nay ngi ta cn dng phng php iu tr bng tia laser lnh, ct cc mnh ung th ko ra ngoi qua ng soi. Cc phng php trn c s dng tu theo tnh cht m bnh hc ca khi u. v m bnh hc i th c 4 loi: + +
+

dng biu b dng tuyn

khng bit ha t bo nh

khng bit ha t bo to.

Ngoi ra cn phi tnh n giai on da trn h thng phn lo i. theo TNM. 1. T = Tumor (khi u) Tis: u nm di nim mc ph qun Tx: u nm nim mc ph qun, nhimg khng nhn thy c v tr khi soi ph qun. T I : u c ng knh 3 cm. T2: u c ng knh 3 cm hoc nu u ph qun gc thng cch ng ba chc kh ph qun trn 2 cm. xm nhp vo l tng mng plii.R lon thng kh mt thu. T3: B't k ng knh bao nhiu nhng xm nhp vo thnh ngc, l thnh mng phi, mng phi trung tht hoc cch carena di 2 cm, gy ri lon thng kh mt phi. T4: u xm nhp vo ung tht (tim, cc mch mu n, kh qun, thc qun, t sng, carena, trn dch mng phi).

2. N : Node (hch ngoi bin) N0: khng c hch ngoi bin Ni: C hch quanh ph qun hay rn phi cng bn N2: Hch ng ba chc kh - ph qun (carena) hoc hch trung tht cng bn. N 3: Hch trung tht v/hoc hch bn i din, v/hoc hch thng n.

3. M = Metastasis (di cn)

M0: khng thy c di cn xa

- Mi: c i cn xa Da vo TNM, ta chia giai on nh sau: Tis + Giai on 0 No + Giai on 1 + Giai on 2 + Giai on 3A Ti
T2 No No

Mo Mo Mo Mo Mo Mo Mo Mo

Ti
T2

Ni Ni
N2 N2 No, N i, N2

Ti
T2
T3

+ Giai on 3B N 2 ,N 3 Mo t4 Mi Cc loi T Cc loi N + Giai on 4 Da vo m bnh hc v TNM. Ta s s dng cc phng php iu tr khc nhau: tia x, ni khoa hay phu thut. II. IU TR 1. iu tr bng phng php min dch Ngi ta thy cc loi ung th ph qun bt k giai on no cng c tnh cht gim min dch. Hin nay vi bnh AIDS, tuy cha c cng trnh no nghin cu s lin quan gia ung th phi v AIDS. Nhiig theo Lo-Gerfo, ung th ph qun hu nh mang khng nguyn c hiu. iu cho php ta s dng phng php iu tr bng min dch. C hai cch: 1.1. Min dch th ng: Dng huyt tng hay mu ngi b ung th phi ang lc bnh ti ri tim cho ngi b ung th phi. 1.2. Min dch ch ng - Khng c hiu: Dng BCG: Ly 2 ml hn hp BCG (1 ml cha 75.000 vi khun sng lm kh) bi ln da sau khi rch da - rch da vi din tch khong 5cm2 - Mi tun 1 ln. C th lm trong nhiu tun (6 - 8 tun). c hiu: Tng hp cc bnh nhn b ung th phi khc nhau - Ly t bo ung th ca cc bnh nhn y tim cho bnh nhn cn iu tr. 6 mi u phi x l bng formon. Nhng mi sau phi x l bng tia cc tm (V) hay tia X.

2. iu tr bng tia x (Telecobalt, Betatron) Liu: 40 - 70 Grays/1 khi u. Thng s dng iu tr ung th dng biu b. Khng dng khi khi u qu ln ( 5 cm) v d gy hoi t hoc chy mu. C th p dng phng php ny trc khi m. 3. iu tr ni khoa v nguyn tc phi a ha tr liu (Polychimis therapie). Sau y l cc thuc chnh: 3.1. Thuc chng phn bo: Hu hoi nucleoprotein gm 4 loi chnh: Dn ximt p Chloro Ethylamin gm: + Methyl bis Chlore thylamin (Caryolysine) + Chloro - ethylamine Dexoxy - Mannitol (Degranol). + Acid Chloro - Ethylamino - Phenylbutyric (Chloraminophene) + Cyclophosphamid (Endoxan) + Chloroamino - phenyl - alamin (Sarcolysine) Dn xut ca Ethylin - Imin gm: + Triethylene - Melamin (TEM) + Thio Ethylen Phosphoramid (Thiotepa) + Ethylen - Imino - Benzoquinon (E39). Estres Disulonic: + Dimethyl Sulfonyloxy Butan (Misulban) + Dimethyl - Sulfonyl Mannitol (Myleran) Dn xut ca Methyl Hydrazin + Procarbazym + Natulan. 3.2. Thuc chng chuyn ha C tc dng c ch tng hp acid nucleic Gm c: Khng Folic Acid amino phteoryl glutamic (Aminopterin) Acid methyl - phteoyl glutamic (Methotrexat)

Cht i khng Adenin Mercapto - 6 - Purin (Purinethol) Cht i khng ca Thymin Fluoro - 5 - racyl (5 F.U).

3.3. Khng sinh chng ung th L nhng ch't ly t vi sinh vt, gm c: Azoserin, actinomycin D, milomycin c , ruochromonycin (5278 R.P), bleomycin. Desacetyl methyl colchicin (Demecolcin) Desacetyl thio colchicin (Thio Colcizan) Alcaloid ca cy da cn (Pervenche) + + Vincaleucoblastin Vincaleucorislin (Vincristin, Leucoristin).

3.4. Cn c cc cht sau (Poisons Fusoriaux) -

Khi dng ha cht phi theo di cng thc mu. Liu lng dng phi thay i c tc dng ti a ti t bo ung th v khng c i vi t bo bnh thng. Nu dng gin on: Dng mt loi trong thi gian ngn (10 ngy) - Khi cn phi iu tr tip c th thay th loi thuc khc. i vi ha tr liu, dng phng php a ha, phi dng phng php gin on -Mi t cch nhau t 15 ngy n 01 thng. sau y l m hnh iu tr ha cht: Dng thucTc chng phn bo, tc dng n ADN t bo, hu hoi nhn v nhim sc th: + Mannomustin (Degranoi): 50 mg + glucose 5% truyn nh git tnh mch/ngy. Truyn 20 ngy lin.

C tc dng i vi ung th khng bit ha. + Cyclophosphamid: 200 mg/ngy - ung hoc tim tnh mch, nh git tnh mch. 5 F.: 0,75 - 1 g + glucosc 5% iruyn nh git tnh mch. Khng sinh chng ung th Bleomycin 15 mg/ng y m nh m ch ho c nh gi t tnh m ch. Th i gian: 15 - 20 ng y. 4. iu tr bng phu thut Cn phi da vo phn chia giai on theo h thng TNM. Ngoi ra cn da vo thm d chc nng h hp v phng in thng kh ring r (Examen separe des poumons); Kh mu, thng tim phi.v.v... Khng m kh c: u lan trn n kh qun. Tc hon ton tnh mch ch trn. Di cn hch ngoi bin. Lit thn kinh honh qut ngc.

Hch thng n Trn dch mng phi.

Phu thut c th: Ct phi rng (ct mt phi v ly cc hch xung quanh). Ct phi Ct thu phi M lng ngc thm d.

Di y l bng tm tt v iu tr ung th phi 5. Ch nh v chng ch nh v iu tr ung th phi Tnh ch't ca K Ch nh Chng ch nh

K dng biu b hay K dng tuyn

A. Phu thut Bnh nhn di 70 tui

- K khng bit ha - 70 tui - Suy mn - C suy h hp + FEV1 1200 ml + Tiffeneau 55% + Ri lon thng kh bn din - p lc ng mch phi 40 mmHg - C hch trung tht, xm nhp vo mng phi, xng sn - Di cn xa: chng ch nh tuyt i

K khng bit ha B. Dng tia x Suy mn, bi nhim, ri lon to huyt, u

qu ln, c di cn vo mng phi thc

qun hoc cc ni khc - Khi khng c ch nh m hoc dng tia c. iu tr bng ha cht - Dng cc phng php trn khng kt qu

- Suy mn - C Ti lon c quan to huyt

NI SOI PH QUN TRONG IU TR

Hong Hng Thi Ni soi ph qun l mt k thut xem xt bn trong ca kh ph qun nh mt ng soi bng kim loi (ng cng)v ng bng cht do c dy dn sng bng si thu tinh quang hc (ng mm). K thut ni soi ph qun c Gustave Killian thc hin ln u tin nm 1897 gp mt mnh xng ln ph qun gc phi ca mt bnh nhn b sc thc n. Ngay ngy u th k 20, k thut ny c Chevalier - Jackson p dng bng ng cng. Gn 70 nm sau, IKEDA (Nht Bn) ch to ra ng soi mm (nm 1967).

Ni soi ph qun d l ng cng hay ng mm u c xem nh k thul quan ng trong lm sng chn on bnh l phi - ph qun. Ngi ta chia ra 2 lnh vc trong ni soi: Ni soi chn on Ni soi iu tr

v phng tin tuy c khc nhau, nhng chng c tn trng theo tng bc ca qu irnh soi
I. CHUN B BNH NHN

Gii thch cho bnh nhn, mc ch ca th thut. Tin hnh tin t bng atropin 1/4 mg 2 ng tim di da: - Seduxen 10 mg 1 ng (nu khng c chng ch nh) tim bp. Gy l ti ch hu hng thanh qun bng Liocain 5% Gy m ton thn nu phi gp d vt v cuc soi ko di.

II. PHNG TIN SOI

1. ng soi cng

Dng ng kim loi kiu Chevaliei - Jackson, kch thc vi ngi ln thng l ng c ng knh 8 - 9 - 1 0 mm, di 45 - 48 cm. Ngun sng c truyn qua dy mm bng si thu linh vi ngun sng lnh. y l 2 b phn c bn cn cho mt cuc soi bng ng cng. Ngoi ra cn c: r My ht p lc m ht cc dch tit ph qun. H thng dn kh oxy v dy dn.

Cc phng tin ly bnh phm (km sinh thit, kim chc ht, chi chi ph qun, dung dch ra ph qun v cc lam knh). Cc thuc v phng tin chng chong.

2. ng soi mm L ng soi c cu to bi cc si thu tinh mm dn sng bng ngun sng halogen hay xenon mt u ca ng C ng di lm 2

ng knh ng soi c nhiu loi tu theo hng sn xut, thng t 3,5mm 4,5mm - 5,5mm - 6 mm Tu theo i tng nam hay n, vc dng m chn ng cho ph hp. Ngun sng lnh v h thng dn sng bng si Ihu tinh. Mn hnh, camera. Cc phng tin ly bnh phm xt nghim t bo v t chc hc bao gm: + + + Km sinh thit mm cc kiu v cc c. Kim chc ht mm phn kim loi thng l 1 - 1,3 cm. Lam knh, ng ng dch lm xt nghim

III. NI SOI CHN ON

1. Mc ch Da trn s bin i bt thng ca nim mc kh, ph qun, cc tn thng lot si, chy mu trn i th quan st c phi hp vi phn tch cc mu bnh phm thu c trong qu trnh soi nh sinh thit chc ht tn thng bng kim, dch ht ph qun a ra chn on xc nh v phng din t bo hc, t chc hc v vi khun hc. 2. Ch nh nhng bnh nhn trn lm sng v X quang nghi ng c u phi - ph qun (k c u lnh hay u c) Ho ra mu cha r nguyn nhn Ho ko di, ho khan iu tr khng kt qu Nghi ng c l r ph qun Hen ph qun v bnh phi tc nghn mn tnh.

3. Chng ch nh Bnh nhn yu khng chu ng c cuc soi Bnh nhn khng hp tc vi thy thuc trong soi C r"i lon v cm mu, ng mu C tn thng ct sng c (vi ng soi cng l chng ch nh tuyt i) C biu hin bnh l ca h thng tim mch (ri lon nhp, ri lon dn truyn, bnh c tim, nh nhi mu c tim)

IV. NI SOI IU TR

1. Mc ch Thng qua th thut ni soi ly d vt ph qun, gii phng cc trng ngi ca ng th do u, so, polyp ca kh ph qun, cc cht dch n tc ph qun. 2. Ch nh Cc bnh nhn c triu chng sc d vt kh -ph qun Cc bnh nhn c triu chng ca u trong lng ph qun gy bt tc ng th. Cc tn thng so li gy hp sau t ni kh qun, m kh qun. n tc mu, mi do p xe phi v vo ph qun, ng dch nhy vmu sau t ni kh qun trong gy m. a khng sinh vo iu tr ti ch cc tn thng vim nhim. Gy tc p h qun chn lc trong trng hp ho mu nng, hoc trn kh mng phi ti pht.

3. Cc k thut c s dng trong ni soi iu tr 3.1. Ly d vt p h qun Thng dng ng soi cng v c ng soi ln c th quan stv ly d vt d dng, i khi cng s dng ng mm vi cc d vt nh hn. 3.2. K thut laser Laser l ch vit tt ca cm t ting anh: (Light Amplipication by Stimulated emission of Radiation) C 2 p dng ca laser trong iu tr: Photoradiation (s dng nh sng do laser pht ra iu tr) Phng php ny c 2 bc: + + Bc : a vo tnh mch ca bnh nhn mt lng hematoporphyrin lm cho t chc u d nhy cm vi nh sng. Bc 2: t ln trn khi u ngun laser vi bc sng 630nanomet.

Cc t bo u, di tc dng ca cc gc t do do laser to ra gy c vi t bo u, khi u s b hu. Phng php ny c p dng cho cc khi u nh. 3.3. Phng php ct bng laser Dng ngun laser c u pht tia hng ngoi km hng cho ngun laser i ng hng. Di tc ng ca ngun nng lng cao do laser to ra ct cc khi u li vo trong lng ph qun. T chc u di tc dng ca laser s bin thnh khi v hi nc v vy phi c my ht dn lu khi v nc cng cc cht dch nhy ph qun.

Bin chng: vo khong 5 - 10%: Bng, chy mu, thng kh ph qun.

3.4. p lnh cryotherapie) p dng ln u tin nm 1975. Ngun lnh l nit lng nhit - 70 Thi gian p 10 - 15 pht ti khi u K thut ny c s dng i vi cc u ph qun gn, kh qun, lm ng cc t bo u, khi u hoi t v c thi ra ngoi khi ho. Tia x chn lc (endobrachiotherapie) Ngi ta a qua ng soi vo t chc u mt dy dn c gn mt ngun phng x. Liu u tin 50 giy. Ngun phng x hay s dng l ridium 192 v cho p ti u 10 - 15 pht sau rt sonde ra. K thut ny c p dng cho cc u kh ph qun gn.

3.6. ENDOPROTHESE y l phng php mi c p dng vo nhng nm 70. Bng cch a vo trong kh ph qun mt ng bng cht do, cng, gi cho lng kh ph qun thng thong, trnh s xm ln ca t chc si hay t chc u vo lng kh, ph qun. Ch nh: Cc so li kh ph qun sau khi c sa bng laser hay p lnh. Cc khi u si c tnh c loi b v ch i phng php iu tr khc (ha cht hay tia x) trong khi th trng bnh nhn cn tt.

3.7. Ra p h qun (lavage) K thut ny c Ramirez p dng u tin nhng bnh nhn b protein ph nang. Thng s dng ng mm Lng dch ra t 5 n 10 lt mi ln. + + + + Cc nhim khun m ph qun p xe phi v vo ph qun Hi chng tro ngc Menenson Hen ph qun c n tc dch nhy cc ph qun.

Ch nh:

IU TR TM PH MN TNH (TPMT)
Nguyn Vn Thnh
I. I CNG

Tm ph mn tnh l ng hp ph i thl phi do tng p lc ng mch phi gy nn bi nhng bnh lm tn thng chc nng hoc cu trc ca phi nh cc bnh ph qun, phi, mch mu, bin dng lng ngc. nh ngha ny loi tr cc bnh ca tim gy nn suy tht phi, ph i tht phi. Lm sng Bnh tin trin kh lu, nhng cng v sau bnh cng nng thm. giai on u, kh th nh, ho, khc m. giai on tng p lc ng mch phi: Kh th khi gng sc, mng tay khum, tm mi v cc u chi, Pa 2 gim n 70 mmHg, in tm : Sng p nhn, Xquang phi thy cung ng mch phi phnh, o p lc ng mch phi tng trn 30 mmHg. giai on suy tht phi: Kh th, gan to v au tnh mch c ni, phn hi gan tnh mch c dng tnh, ph, mt li, mng tip hp , ti t. Tim nhp nhanh, c khi c lon nhp hon ton, mm tim p di mi c (du hiu Hartzer dng tnh), ting thi tm thu - mi c (h van ba l c nng), thi tm trng van ng mch phi, h ng mch phi c nng) ong t cp c th nghe thy ting nga phi. p lc tnh mch ngoi bin tng (trn 25 cm H2O) Xquang: hnh tim to, cung ng mch phi ni. in tm : sng p phi, trc in tim lch phi, dy tht phi, mm tim quay sau, bloc nhnh phi khng hon ton Kh mu: Pa 2 gim < 70 mmHg PaCC>2,tng > 50 mmHg Sa 2 gim di 75% pH mu ng mch < 7,2

Nguyn nhn C nhiu. y ch nu mt s" nguyn nhn chnh: Bnh ng h hp v nhu m phi Vim ph" qun mn tnh tc nghn, hen ph qun, x phi k, lao phi th x, bi phi, gin ph qun, bnh sarcoid, bnh cht to keo, c bit trong bnh x cng b. Bin dng lng ngc: G, vo g ct sng, ct nhiu xng sn, dy dnh mng phi, bo bu. Mch mu: Tng p lc tin pht ng mch phi,vim mch, tc mch phi tin pht hoc do cc mu. nt

quanh

II. IU TRI V PHNG BNH

1. Ch n ung v ngh ng Nhng ngi b bnh phi - ph qun mn tnh, khi xut hin kh th nn lm vic nh, khng lm vic nng qu sc, ngh ngi thch hp. Khi c du hiu suy tim phi cn ngh vic hon ton. Ch n t mui. 2. Khng sinh trong cc t bi nhim s dng khng sinh rt quan trng C th s dng: Penicillin, amoxillin, chloramphenicol. Nn dng di ngy, vi liu cao. Thi gian s dng 2 tun l di dng tim, ung hoc kh dung. Nhiu tc gi ch trng dng khng sinh ngoi t bi nhim phng nga nhim khun, nht l vo ma lnh. 3. Corticoid Rt tt trong iu tr t cp: - Prednison 5 mg - ngy 30 mg, ung - Hydrocortison 25 mg. Kh dung. C th pha ln vi Penicillin. - Depersolon 30 mg, tim tnh mch. Corticoid va c tc dng chng vim, chng d ng, va lm gim tit dch ng th. 4. Cc thuc lm gin p h qun Rt tt trong trng hp do hen ph qun, vim ph qun mn tnh tc nghn. C th s dng cc loi sau: 4.1. Cht i khng giao cm beta 2: Theo cch ht vo c th dng my xng c nh liu (Metered nebulizer) Thuc: Metaproterenol, terbutalin (Bricanyi) hoc Ventolin. Mi ln bm bp hai nht v ht vo mnh. Ngy c th bm vi ba ln. 4.2. Cht i khng cholnergic nh Ipatropium bromid c th lm gim tc nghn ng dn kh. Trong t c'p tc dng ca thuc c b hn ch. 4.3. Budesond (Pulmicort, Rhinocort) di dng ht c nh liu cng c tc dng tt. 4.4. Theophyllin: c dng i vi bnh nhn p ng km vi thuc lm gin ph qun bng cch ht vo. Nn tim tnh mch chm (20 pht) Th d aminophyllin cha 80%, theophyllin vi liu tn cng l 6 mg/kg. Sau gim dn v duy tr vi liu lng 0,6 mg/kg/gi.

Nng theophyllin trong huyt thanh phi c theo di v phi t t 10 - 20 mg/1. Vi liu cao c th gy bun nn, nn, a lng, lon nhp nh. Tuy nhin vi liu thp cng c th gy nhim c m khng c bt k du hiu bo c no. 4.5. Oxy liu php Kt qu rt tt khi s dng oxy lin tc (Ann, Intein Med 1980). Cn cho th lin tc khi Pa 2 di 55 mmHg hoc Sa2 di 88 %, hoc Pa 2 t 55 - 59 mmHg, hematocrit trn 55% Oxy liu php c th ci thin kh nng chu ng bnh nhn b h oxy khi gng sc hoc vo ban m khi ang ng. Bin php ny gip lm gim lon nhp tim v lm tm ph mn tnh chm pht trin. Ngy nay ngi ta s dng my chit sut oxy t khng kh (Concentrateur 02) ch cn cm my vo ngun in, iu chnh liu lng th v ht th qua mt canuyn t vo hai l mi. My loi ny thng dng cho c nhn ti nh ring. 4.6. Thuc li tiu v tr tm Dng cc thuc c ch men anhydrase carbonic nhDiamox, Lasilix: 10 mg/kg. C th dng Aldacton, thuc ny khng lm gim kali mu. nh ch thuc li tiu khi pH mu di 7,30. Cc thuc glucosid tr tim ch s dng khi suy tim cn b vi liu thp - khng dng khi suy tim mt b. 4.7. Cc thuc gy ng nh Morphin, Phenobartital, hoc valium (Diazepam) d bt k di hnh thc s dng no cng u chng ch nh. 4.8. Phc hi chc nng h hp Gio dc cch tp luyn (tp th) nhiu nc vic gio dc ny c trin khai qua mt trung tm (Kinesitherapie) nm trong mt vin hoc mt bnh vin ln v bnh h hp v phi c ngi hng dn (Moniteur) Bng phng php ny c th ci thin s chu ng ca bnh nhn khi gng sc, gy cm gic d chu, yu cuc sng. Bn cnh cn gio dc v khuyn bnh nhn b thuc lo, thuc l, nh ni c nhiu bi, khi. nc ta vn nhim mi trng do khi, bi qu ln. y l vic m b Cng ngh v Mi trng cn quan tm. Hin nay nh my xi mng Hi Phng phi di chuyn n mt a im khc. Cc nc pht trin v c nn cng nghip cao, nh my thng t ngoi vi thnh ph ng dn trnh nhim mi trng. 4.9. iu tr c th theo nguyn nhn - ngi bo bu, n ch gim cn - ngi bin dng lng ngc: Tp th, chng bi nhim. - Do tc mch phi, ngh ngi tuyt i, ch n rt t mui, thuc chng ng (heparin) hoc khng Vitamin K (Sintrom).

HI PHC CHC NNG CA P H I BNG CC T TH GIP LU THNG KH

Bi Huy Ph

T th 1: Thu trn thng, cung phi trn. Bnh nhn ngi thng ngi v hi nghing v pha sau, sau hi nghing v pha c, ri sang hai bn, tu theo vng cn lu thng.

T th 2: Cc thu bn phi v bn tri thng, cung phi trc. Bnh nhn nm nga.

T th 3: Thu trn thng, cung phi pha sau. Bnh nhn nm nghing v bn tri, na thn bn phi nghing v pha trc to mt gc 45. t mt ci gi di khuu tay tri v di ngc tri.

T th 4: Thy n tri, cung phi pha sau. Bnh nhn nm nghing v bn phi, na ngi bn i ng v pha trc to mt gc 45. t mt ci gi di khuu tay phi v ngc phi .

T th 5. Cc thu trn phi v tri, cung phi pha sau Bnh nhn nm sp, di c chn mt chic gi gip cho c th th gin.

T th 6 . Thu trn bn tri, phn di, cc cung phi pha n v di.

Bnh nhn nm nga, hi nghing v bn phi to ml gc 45. Lng c m mt chic g t gia tri ra t di vai tri li hng tri. u ging pha chn c nng cao in 12 cm.

T th 7. Thu gia bn phi, cc cung phi, trung tht v gian tht. Bnh nhn nm nga, hi nghing v bn tri gc khong 45. Lng c m mt chic g t di t di vai phi xung ti hng phi. u ging pha chn

Bnh nhn nm nga, u ging pha t chn c nng cao khong 18 cm.

T th 9. Thu phi, cung phi pha trc. Bnh nhn nm nga, thn hi nghing v bn tri. u ging pha t chn c nng cao khong 18 cm.

T th 10. Thu di phi, cung phi pha di bn cnh. Bnh nhn nm nghing bn tri. Mt chic g t di xng sn tri v xng hng. Lng c m mt chic gi t gia tri ra t di vai tri ti hng tri. u ging pha t chn c nng cao khong 18 cm.

C N

V/

T th 11. Cc thy di bn phi v tri, cung phi di ng sau. t th ny c th s dng 3 phng php. Nhng d phng php no th gc m ngc bnh nhn to vi phng nm ngang cng l' 45. (a) Bnh nhn nm sp, u ging pha t chn c k cao ln 25 cm. (b) C th dng mt ci khung nghing kiu nh ci g h nga dng ca. Cc chn khung c ng nghing 45 so vi sn, sau ph mt tm thm ln khung. (c) Bnh nhn nm sp mp ging hoc bn, sao cho phn thn trn dc vi sn nh mt gc 45. Thn trn v u ta vo mt ci gh hoc ta ln sn nh thng qua cng tay t vo mt ci gi, u t ln hai bn tay an vo nhau.

T th 12. Thu di tri, cung phi di bn cnh. Bnh nhn nm nghing v bn phi, mt chic g k di xng sn cu"i v xng hng phi. u ging ni t chn c k cao ln khong 18cm.

T th 13. Thu di tri, cung phi di, gia ng trc. Bnh nhn nm nga, thn mnh hi nghing v bn phi. u ging pha t chn c k cao ln chng 18cm.

TIU HA TRO NGC D DY - THC QUN

Nguvn Khnh Trch I. I CNG Tro ngc d dy thc qun l hin tng tro ngc dch v t d dy ln thc qun, c khi ln tn ming m ngi bnh thng khng c. Nu s tro ngc khng ln n ming th ngi bnh d b qua khng nhn thy, ch n khi c hu qu vim thc qun mi bit. Hu q ca hin tng tro ngc ny l gy vim thc qun v lot thc qun, c hai hu qu ny u c th gy hp thc qun. C ch gy ra tro ngc l do gim trng lc c vng di thc qun. Nguyn nhn gy gim trng lc c vng ny cho n nay ngi ta mi bit c l do mt s thuc v thc n. II. IU TR Phi gii quyt cc v'n sau y: - Lm tng trng lc c vng di thc qun. - Gim bt p lc trong d dy. - Gim bt p lc trong bng. - D phng hu qu ca tro ngc l vim v lot thc qun. gii quyt 4 vn trn y, cn s dng my bin php sau y: 1. C h n ung Mi ba n khng nn n qu nhiu, nn n lm nhiu ba, 4 - 5 ba mi ngy, mi ba n t mt. Khng nn n cht lng, nn n c, kh. Sau khi n khng nn nm nhiu, ngi th ci ra pha trc... nm ng t th u dc cao. B hn mt s thc n lm gim trng lc c vng: S-c-la, thuc , c ph, cht m, nc khong c hi, cc ung c hi. n chm, nhai nt, k, trnh nuct hi vo d dy.

2. Cc thuc c tc dng lm tng trng lc c vng di thc qun v tiu ho co bp d dy Cisaprid (Prepulsid) vin 10 mg. Liu lng: 2 - 4 vin/ngy chia nhiu ln ( 3 - 4 ln) trong ngy, ung trc khi n v ucng trc khi i ng. Mtoclopramid (Primperan) vin 10 mg, ng 10 mg hoc siro. Liu lng: ngi ln: l-3v/ngy chia nhiu ln ( 2 - 3 ln) ong ngy, trc khi n. Tr em: bng na liu ngi ln, c th dng ng hu mn bng cc vin n vi liu lng 0,5 mg/kg cho tr trn 20 kg. Dompridn (Motilium) vin 10 mg. Liu lng: 3 - 6 vin/ngy, ung trc khi n, chia 3 ln trong ngy. i vi tr em: Nn dng loi nh dch vi iu 1,25 - 2,5 mg/kg/ngy. 3. Cc thuc chng bi tit dch v v to mng bc, chng acid Chng H2, c ch bm proton... Gastropulgit, Smecta, Gel de polysilan... (xem bi iu tr lot d dy - t ng)

Ring i vi nh mi nn dng: /GelopectoseD lOOg, mi ci tha c ph cha 2g. Liu lng: 2 tha c ph/ngy sau khi n. 4. Cc thuc to mng ngn d dy - thc qun Gaviscon: Vin, nh dch, sau mi ba n ung 1 - 2 vin, nn nh cn nhai tht k vin thuc. Topaal: Vin, nh dch. Liu lng cch dng nh trn. 5. Lm gim p lc bng To bn, chng bng y hi, tht cht dy lng... l nhng yu t lm tng p lc bng, cn hn ch. 6. Khng c dng mt s' thuc lm gim trng lc c vng di thc qun C rt nhiu thuc, nhng thng dng mt s loi: esogen, progesteron, anticholinergic, barbituric, c ch calci, diazepam, theophyllin. 7. Phu thut Ch phu thut khi iu tr ni khoa khng khi v khi c bin chng nng n.

 IU TR VIM TH C QUN
o Vn Long
I. I CNG

Vim thc qun l mt thut ng dng ch tnh trng vim thc qun. Nguyn nhn thng gp l 1. Tro ngc: l nguyn nhn ch yu gy vim thc qun. i a s l do tro ngc acid clohydric v men pepsin t d dy vo thc qun, m t s t do dch m t v tu tro ngc d dy ri ln thc qun. 2. Cc cht n mn: Acid, kim. 3. Thuc: Aspirin, doxycyclin, quinidin. 4. Phng x 5. Nm Candida albicans. Triu chng: Tu nguyn nhn khc nhau, nhtig lm sng u c tru chthg chung l: au vi tnh cht nng, rt bng sau xng c, nng hn bnh nhn c kh nut, m t s trng hp c th nn, sc nc, ng m ing, nc. II. IU TR 1. Nguyn tc Giai on u iu tr ni khoa v ch nh thuc tu theo nguyn nhn gy vim thc qun. Khi hp thc qun c th phi hp vi iu tr ngoi khoa.

2. tr c th 2.1. iu tr vim thc qun do tro ngc 2.1.1. Ni khoa C h n ung sinh hot Khng nm ngay sau khi n. Trc khi i ng 2 - 3 gi khng n. Hn c h n m t s" loi thc n c m, bc h, scla, cc loi gia v, c ph v cc loi thc n c acid nh c chua. Khng mc qun o cht. Nu c th, k cao chn ging pha u ln khong 10 cm. Trnh dng thuc gy gim p lc c tht hoc cc thuc c ch p giao cm, thuc chn knh calci, theophyllin, diazepam, cc thuc khng vim khng thuc nhm steroid hoc steroid.

Thuc Cc thuc c ch th th H2: c ch ko di bi tit dch v ban m, d ung v kh an ton. + + + + Cimetidin (Tagamet): 1200 - 1600 mg/ngy. Ranitidin (Zantac, Azantac): 300 mg/ngy. Famotidin (Pepcid, Pepcidin): 40 mg/ngy. Nizatidin (Acid): 300 mg/ngy.

Cc thuc ong nhm ny gm: (dng mt trong cc thuc sau y)

Ko di 6 - 1 2 tun. Cc thuc c ch bm proton: Ngn chn bi tit acid HC1 bng vic c ch p ng men K+/H+ ATPase i vi vic bm ion H+ ca t bo vin vo ong lng d dy. Nhm ny bao gm: + + + Omeprazol (Mopral, Prilosec, Losec): vin 20 mg; 1-2 vin/ngy. Lansoprazol (Lanzor): vin 30 mg; 1-2 vin/ngy. Pantoprazol (Pantoloc): vin 40 mg; 1 vin/ngy.

Dng lin tc 8 tun. Thuc chng tro ngc: Nhm thuc ny lm tng co bp ca thc qun lm gim thi gian tc ng ca acid v pepsin thc qun, tng p lc ng ca c tht tm v, tng kh nng tng thc n ca d dy. Nhm ny c cc thuc: + + + Metoclopramid (Reglan, Primperan): vin 10 mg, 1-2 vin/ngy. Bethanecol clorid (recholin): vin 10 mg, 1-4 vin/ngy. Cisaprid (Prepulsid ): vin 10 mg; 1-3 vin/ngy.

Dng t 4-12 tun Alginat (Gaviscon, Topaal): 1 vin sau mi ba n v 1 vin trc khi i ng, dng trong 4 tun. Thuc bo v nim mc: Thuc lin kt vi pepsin, mui mt v ph in vng nim mc thc qun b vim. Loi c coi l tt nht hin nay l sucralat (Carafat) lg/vin hoc dng gel, 4 ln/ngy, trc mi ba n 30 pht ung lg v trc khi i ng ucng lg.

2.7.2. Ngoi khoa Lm gim tro ngc bng cc to ra mt np van gip thc n i mt chiu t thc qun xung d dy. Phu thut c ch nh khi khng p ng vi iu tr ni khoa, chy mu cp hoc hp thc qun. 2.2. iu tr vim thc qun do cc nguyn nhn khc Vim thc qun do virus: Khng c iu tr c hiu, thng t khi, c th dng cc thuc chng virus nh: Vidarabin, hoc acyclovir. Vim thc qun do nm: Cc thuc thng dng l:

+ + + -

Amphotericin: Tim tnh mch bt u t 0,25mg/kg tng dn ln 1mg/kg dng trong 6 - 1 2 tun. Ketoconazol (Nizoral): v i n nn dng 200 - 400mg/ngy, trong 10- 12 tun. Flucanazol (Dilucal): Vin ung dng 100- 200mg/ngy, trong 8 tun.

Vim thc qun do thuc: Khng c iu tr c hiu, a s" khi sau khi dng thuc. C th ng thm cc thuc chng tro ngc.

IU TR LOT D DY T TRNG
Nguyn Khnh Trch I. I CNG iu tr lot d dy t trng trong vi thp k gn y c nhiu tin b ng k v lm o ln chin lc iu tr c in trc y ch yu l: iu tr ngoi khoa bng ct d dy loi tr lot. Chin lc iu tr hin nay coi iu tr ni khoa l chnh, nu khng khi mi phi phu thut ct d dy. Do m ct d dy iu tr ot gim kh nhiu, ti 80 - 90% so vi trc y, S d c nhng tin b ln nhvyl nh: Pht hin vi khun Hlicobacter pylori c vai tr quan trng trong nguyn nhn gy lot. Hiu bit mi v c ch bi tit HC1. Tm ra nhiu thuc mi rt c hiu qu lm gim bi tit HC1 cng nh lm tng yu t bo v nim mc d dy.

II. NGUYN TC CHUNG 1. iu tr ni khoa trc (d lot to, chy mu...) mt cch tch cc, y v ng cch, kin tr. Nu khng c kt qu mi phi phu thut. 2. Nu phi phu thut, nn ct dy thn kinh ph v trc, ct d dy su.
III. C C TH UC IU TR L O T

1. Cc thuc tc dng n thn no Metocloprami: Primperan vin 10 mg, 3 - 4 v/ngy. Sulpiri: Dogmatil, vin 50 mg, 3 - 4 v/ngy. 2. Cc thuc c ch bi tiet HC1 c ch c quan th cm muscari M i: Pyrenzepin, Gastrozepin: Tc dng mnh hn atropin nhhg cng c nhng bin chng nhatropin..

Liu lng, cch dng: 100-150mg/ngy, chia nhiu ln trng ngy, phi dng trc khi n 30 pht Thuc chng H 2: c ch c quan th cm vi histamin ca t bo thnh. Thuc thuc nhm ny n nay c ti 5 th h:

Cimetidin, ranitidin, nizatidin, roxatidin v amotidin. Thuc cng mi cng t c hn m tc dng li mnh hn, ko di hn t ti pht hn. Cimitidin, (Tagamet): lg/ngy.30 ngy, ung nhiu ln trong ngy, trong c 1 ln ung bui ti trc khi i ng. Thuc c c tnh vi gan v thn do phi theo di transaminase v creatinin trong khi dng. T l ti pht sau 1 ' nm l 90%-100% Famotiin (Servipep, Pepdin...) vin 20 mg

Liu lng cch dng: 40mg/ngy. 4 tun, ung 1 ln vo bui ti c khi i ng. T l ti pht t hn nhiu so vi cimetidin. Thuc c ch bm Proton: c ch hot ng ca men ATPase do K+ khng vo trong t bo c, v H+ khng ra ngoi t bo to nn HC1. Do HC1 khng c hnh thnh. Lansoprazol: Lanzor, Ogast: vin 20 mg Omeprazol: Mopral, Lomac, Losec, Prilosec... vin 20 mg. Liu lng, cch dng: 20 mg/ngy. 4 - 8 tun. 40 mg/ngy. 2 - 4 tun ung 1 ln vo bui ti trc khi i ng. Prostaglandin Ei, E 2: chng c hai tc dng: Chng bi tit HC1. Tng tit nhy v bicarbonat

Liu lng, cch dng: Misoprostol (Cytotec, Dimixen) 800 |ig/ngy. 4 tun. Enprotil: 70 ng/ngy Tc dng ph: a chy, chng mt, y bng. Ph n trong tui sinh cn dng thn trng. 3. Thue trung ho acid Trung ho H+ ca HC1, a dch v ln trn 3 lm cho HC1 b loi b, khng cn hot ng. Cc thuc thuc nhm ny u l mui ca nhm v magie: carbonat, phosphat, trisilicat, hydroxyt. Cc bit dc c rt nhiu: Maalox, Gelox, Polysilanegel, Gastrogel, Gasopulgite, Phosphalugel... Liu lng cch dng: liu lng tu theo tng bit dc, cn ung nhiu ln trong ngy, ung sau khi n 30pht - 1 gi duy tr dch v lun lun trn 3 - 3,5. Tc dng ph: a chy, si thn, kim ho mu.

4. Thuc to mng bc Gn vi protein hoc cht nhy ca nim mc d dy to thnh mng che ch nim mc d dy, nht l che ch cho lot. C rt nhiu loi thuc: Kaolin, Smecta, Gelpolysilan Actapulgit, Gasopulgit Bismuth: Subcitrat bismuth (Trymo) Tripotasium dicitrat bismuth sucralfat Liu lng: 480 mg/ngy, chia nhiu ln, ung trc khi n. Thuc dit Hlicobacterpylori: Ngoi cc thuc c ch bm proton, mui bismuth, c Tt nhiu khng sinh c tc dng dit HP, nhtig mt s khng sinh sau y c tc dng nht: Tetracyclin, amoxicillin, claritromycin v metronidazol.
IV. P DNG TH C T

Cn c chn on lot bng ni soi hoc t nh't bng X quang. nh gi kt qu cng bng ni soi hoc X quang d dy. 1. iu tr khi lot ang tin trin C th dng mt trong cc loi thuc chng bi tit HC1, thuc chng acid, thuc to mng bc trn y vi liu tn cng khng nht thit phi phi hp 2 - 3 loi thuc, m c th dng mt loi ring r, cng c kt qu. Khng nht thit phi dng cc thuc mi nht, t tin nht mi c kt qu. Cc thuc chng bi tit HC1, cng nh cc thuc chng acid thuc to mng bc c tc dng lin so gn tng t nhau, nu c dng ng cch, y . Thuc phi hp: Thuc dit HP. Ch n ung: Khng ung ru, thuc l, c ph trnh cc cht kch thch gia v, ht tiu, t, dlm... Dogmatil, Primperan

2. Kh lot lnh so C ngi cho rng khng cn iu tr duy tr, khi no lot ti pht s iu li. C ngi ch trng phi tip tc iu tr duy tr. C th dng: thuc c ch th th H 2, c ch bm proton nhng liu lng v cch dng gim 1/3 hoc 1/4 so vi liu tn cng. Thuc to mng bc nh,Gastropulgit, Phosphalugel, Gel de polysilan... cng vi liu lng gim bng 1/3 hoc 1/4 so vi liu tn cng. Thi gian iu tr duy tr tu theo tng ngi t 6 thng n vi nm. 3. iu tr lot chy m u Nn dng cc thuc c ch th th H 2 hoc c ch bm proton loi tim, trong 2 - 3 ngy u khi mu ang chy, khi mu cm th dng thuc ung.

120
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K i m tra 3

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K i m tra 4 e

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K i m tra 5 e

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LOT HNH T TRNG iu tr le Kim tra l e

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iu tr 3e

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IU TR VIM D DY CP TNH
Phm Th Thu H
I. I CNG

Nguyn nhn gy vim d dy cp tnh thng gp: Do ung ru mnh Do thuc chng vim khng steroid, (Aspirin, Alnalgyl, poxicam, dicloenac, phenylbutazol, Pred nisolon,...) Vim d dy cp trong ng c ton thn: Ng c thuc tr su, ng c kim loi nng, ur mu cao... Vim d dy cp do vi khun Helicobacter pylori.

Vim d dy cp thong qua hoc ko di mt s" ngy vi biu hin lm sng: Chn n, bun nn, nn, au vng thng v, ccm gic nng rt, cn co, m ch vng thng v, c trng hp nn ra mu. Hnh nh nim mc d dy qua ni soi: Nim mc rc, ph n, c th c cc chm xut huyt ri rc trn nim mc. II. IU TR 1. Nguyn tc Ct cc nguyn nhn gy bnh k trn nu c. Dng cc thuc iu tr triu chng Tit tr Helicobacter pylori, nu c nhim

2. Dng thuc cha cc triu chng Thuc chng co tht, chng nn. + + Atropin, Belladon Metoclopramid - HC1 (Primperan) Vin nn lOmg - Liu dng 1/2 - 1 vin/1 ln ng lml - lOmg (30-40 mg/ngy - tim TM, tim bp) + Alverincitrate (Spasmavrin) Vin nn 40 mg ngy dng 2 - 6 vin. Thuc bng b, bo v nim mc d dy thuc nhm thuc ca mui nhm v magnesium, tt nht nn dng di dng keo (gel) + Phosphalugel 12,38 gam - dng gi

Liu lng 1 - 2 gi/2 - 3 ln/ngy ung sau khi n + + + Sucrate gel ng gi 5 ml Liu lng 1 - 2 gi/2 ln/ngy ung trc khi n 1 gi Polisilarie gel 15 gam ng gi Gel de polysilan
L iu lng 1 - 2 g i/2 l n n g y

Nhm thuc c ch bi tit dch v. C th dng thuc ca nhm c ch th th H 2 t bo thnh ca nim mc d dy, hoc thuc c c h bm proton ATPase. + + Cimetidin, ranitidin, famotidin, nizatidin Omeprazo , lansoprazol, Pantoprazol

Cc thuc bc ph riim mc, cc thuc ny gn vi protein, hoc cht nhy nim mc d dy to thnh mng che ch cho nim mc. + + + Gasopigite, Smecta Colloidal Bismith Subcitrat (CBS) Tripotasium Diciat Bismuth (TDB) (Bit dc: Trymo. pylocid, Denol)

Thuc kch thch sn xut cht nhy v duy tr s ti inh ca nim mc d , dy, ci thin tun hon ca nim mc. * 4 + Teprennon (bit dc Selbex, Dimixen) Vin nn 50 mg, liu dng 100 mg - 150 mg/ngy. iu chnh liu lng theo la tui v mc trm triirg ca triu chng,

Cc thuc tit tr Helicobacter pylori (xem bi vim d dy mn tnh) Truyn dch v truyn mu nu c xut huyt tiu ho, gy tnh trng thiu mu (xem bi iu tr chng chy mu tiu ho cao)

l TR TNH VIM D DY MN
Phm Th Thu H I. I CNG Vim d dy mn tnh thng do nhiu nguyn nhn, trn cng mt bnh nhn c th c s phi hp ca vi nguyn nhn. Cc nguyn nhn gy vim d dy mn lnh c k n nh sau: Nhim c do ru Do cc thuc chng vim khng steroid, thuc corticoid

- Vim d dy mn tnh do dch mt tro ngc. - Vim d dy mn tnh do vi khun Helcobacter pylori - Vai tr c hi ca thc n, ca ho cht, thiu dinh dng. - Yu t ni tit: Bnh suy gip trng, bnh Addison. - Yu t t min dch. Cc nguyn nhn k trn y thng phi tc ng trong mt thi gian di mi c th gy nn tn thng mn tnh cho nim mc d dy. Chn on vim d dy mn tnh ch yu da trn kt qu ni soi d dy t trng, sinh thit nim mc xt nghim m bnh hc xc nh, chn on, phn loi, nh gi mc tin trin ca bnh, vim long, vim xc,vim chy mu, vim teo, vim ph i). Dch v thay i t v toan n thiu toan v a toan. II. IU TR 1. Nguyn tc Loi tr cc nguyn nhn gy bnh va liu n nu c. Dit tr vi khun Heicobacter pylori nu c. Dng cc thuc kch thch sn xut cht nhy,duytr s ti sinh nim mc, ci thin tun hon nim mc. - iu triu chng cn tnh n chc nng bi tit dch d dy, lng acid clohydric (v toan, thiu toan, tng toan). Giai on bnh n nh hay t tin trin.

2. iu tr c th 2.1. Ch n ng trong t tin trin - Cn trnh tuyt i cc thc n gy kch thch nim mc d dy. Ru, bia, thuc-l, thc n c nhiu gia v cay chua. Khng nn ung nc ngt c nhiii hi. - Nn n nhiu ba trong ngy, mi ba khng nn n qu no. - Nn dng nc khong loi c nhiu Ca++ 2.2. Dng thuc trong t tin trin - Nhm thuc bo v, bc ph nim mc d dy + Nhm thuc mui bismuth. Cc tinh th ca mui ny kt hp vi glycoprotein ca nim mc v dch d dy, cng c hng ro bo v nim mc chng khuych tn ngc H+, kch thch tng tit prostaglandin E2 Colloidal Bismuth Subciat (CBS) Tripotasium Dicitrat Bismith (TDB) Bit dc: Trymo. Pylocid, Denol. 125 mg, 120 mg vin nn ngy ung 2 - 4 vin ung na gi trc n.

Nhm thuc ca mui nhm v magnesium. Gastropulgit gi 3 gam ngy ung 2 - 4 gi pha ong nc ung trc hoc sau n. Maalox vin nn 1 - 2 vin ngm, nhai/2 - 3 ln ong ngy. Phosphalugel gi 12,38 g ung 1 - 2 gi/ 2 - 3 ln trong ngy sau khi n.

Nhm thuc iu chnh chc nng vn ng d y + + Thuc an thn: Seduxen, Rotunda, Stinox Nhm thuc chng co tht, gim au Spasmaverin vin nn 40 mg, 2 - 6 vin/ngy Spasfon vin bc ng, vin t di li 2 - 6 vin/ngy. Metoclopramid HC1 (Primperan) vin nn, 1 - 2 vin/ngy Drotaverine HC1 (No - spa) vin nn 40 mg, 3 - 6 vin/ngy Nhm thuc lm tng bi tit nhy, ti sinh nim mc ci thin tun hon ca nim mc d dy Teprennon (Selbex. Dimixen) Vin nn 50 mg, 1 - 3 vin/ngy iu chnh liu lng theo la tui v mc tn thng Nhm thuc tit tr vi khun Helicobacter pylori + Phi hp 2 hoc 3 khng sinh dit HP
Amoxycillin 1 - l,5g/ngy chia 2 - 3 ln dng trong 7 - 1 0 ngy

Metromidazol lg/ngy chia 2 ln ong 7 - 1 0 ngy Tetracyclin lg/ngy chia 2 ln trong 7 - 1 0 ngy Tinidazol lg/ ngy chia 2 ln trong 7 - 1 0 ngy. + Phi hp 2 khng sinh vi mui bismuth
Amoxycillin + metronidazol + Trymo.

hoc Gastostat gm 3 thuc khng sinh Tetracyclin HC + metronidazol + tripotassium dicitrate bismuth Nu vi khun Helicobacter pylori khng thuc, c th thay bng tinidazol (bit dc Fasigyn), hoc clarythromycin (Klagid) + Phi hp 2 thuc khng sinh vi mt thuc c ch bi tit acid Amoxycillin + metronidazol + thuc c ch th cm H2 Amoxycillin + metronidazol + thuc c ch bm proton. Nhm thuc iu chnh h tr tiu ho d dy - rut + Nu gim toan dch v: c th cho ung dch d dy 1 tha canh/3 ln/ngy cng vi ba n. Dung dch acid clohydric 1%, 50ml/3 ln/ngy sau khi n. + + Nu dch v nhiu tng toan: dng cc thuc trung ho acid, hoc c ch bi tit aci (xem bi iu tr lot d dy t trng). Vitamin B 1 - B6 - B9 - Vitamin c .

IU TR NHIM KHUAN CAP

n g t i u

HO

ng Kim Oanh I. I CNG C nhiu loi vi khun gy bnh khc nhau gy ra nhng tn thng rut. Nhng vi khun ny tn cng trc tip nim mc rut, hoc gin tip thng qua cc ni c t" hay ngoi c t" m chng gii phng ra. Bnh cnh lm sng t nhiu khc nhau tu theo loi vi khun gy bnh, nhng triu chng chung ni bt l a lng, Ti lon nhu ng rut. Phn ln cc trng hp a chy cp nhim khun c iu tr ngoi tr ti nh v ch cn iu tr triu chng l . iu tr ni tr ti bnh vin dnh cho nhng trng hp a chy nng, c ri lon nc v in gii nhiu. Khng sinh ng rut ch dng ong mt s" trng hp c bit. II. IU TRI TRIU CHNG 1. X tr ti nh Ch v sinh n ung: + + Ngng ung sa (nht l nhng ngi thiu men lactase), v cc loi ung c cha cafein. n cc loi thc n c cha nhiu in gii, nht l kali nh nc cam ti, chui...

Chng m't nc v in gii: Cho bnh nhn ung cc loi dung dch c cha in gii v mui khong (v d nh mui Oresol). S" lng dch ung nhiu hay t tu thuc vo tnh trng kht v s lng nc mt qua phn, nc tiu, cht nn. Thuc chng co tht:
Spasmaverin:2 vin X 2 ln/ngy

Buscopan: 2 vin X 2 ln/ngy Thuc chng nn: Primperan: 2 vin X 2 ln/ngy 2. iu tr ti bnh vin 2.1. p dng cho nhng trng hp Khng dung np c thuc qua ng tiu ho (do nn), buc phi dng thuc qua ng tnh mch hoc ng tim. Nhng bnh nhn c ri lon nc v in gii nng, tt huyt p. /

2.2. C th Bi ph nc: Kim sot lng dch cn b bng p lc tnh mch trung tm (ALTMTT). nhng c s iu tr khng c iu kin o ALTMTT, c th tnh lng dch cn b bng mt trong hai cch sau: - Nu bit trng lng c th ca bnh nhn trc khi b bnh: Lng nc = TLCT bnh thng - TLCT hin ti. (TLCT: trng lng c th tnh theo kg) Nu khng bit trng lng c th ca bnh nhn trc khi b bnh: Lng nc = Lng nc mt (qua phn, nc tiu, ch't nn) + 500 ml/24 gi (lng nc m't qua da, hi th bnh nhn khng st).

Thnh phn dch cn b l: Glucose 5% c pha insulin (5 n v insulin cho 500 ml) v NaCl 0,9%. Bi ph in gii: Tu theo in gii , tuy nhin phi ch ng hng u n tnh ng h kali mu v n c th gy ra nhng ri lon nhp tim nguy him. -

B kali: Khi K mu < 3mmol/l Nu bnh nhn khng nn: n thc n c cha nhiu K, ung K (lg KC1 cho 13 mmol K) Truyn tnh mch: cho bnh nhn nn nhiu hoc thiu K nhiu. Lng K cn b = (K mu bnh thng - K bnh nhn) X 0,6 TLCT (TLCT: trng lng c th tnh bng kg) Trong mi lt dch truyn c th cho 50 -70 mmolK. Tc truyn: 4 - 8 mmol/ gi

B natri: + Lng N cn b = ( 140 - Na mu ca bnh nhn) X 0,6 TLCL (TLCT: trng lng c th tnh bng kg) + Dung dch truyn l NaCl 0,9%.

Cc thuc chng co tht v chng nn: nu trn, c th dng cc loi thuc tim nu bnh nhn nn nhiu hoc dng thuc qua ng ung t kt qu.

III. KHNG SINH NG RUT 1. Ch nh Hu ht cc trng hp a chy cp nhim khun ch cn iu tr triu chng l , khng cn dng khng sinh. Khng sinh ng rut ch cho trong nhng trng hp tht cn thit sau y: - a chy nng, c ln m u mi trong phn. - iu tri triu chng tch cc, nhiig-sau 48 gi khng c kt qu. - a chy nhim khun nhng vng ang c dch. - C a suy gim sc khng tr s sinh hoc ngi gi tnh trng suy dinh dng, ang mc cc bnh gy suy gim min dch, cc bnh c tnh, bnh van tim.

2. Nguyn tc Dng cc loi khng sinh tu theo tng loi vi khun gy bnh, tt nh't l da vo kt qu cy phn v khng sinh . C th: Escherichia Coli (E.coli): Ampicillin: lg x2 ln/ngy. hoc Cotrimoxazol (Bactrim) 480 mg: 2 vin/ln X2 ln/ngy. Campylobacter jejuni: Erythromycin: lg X 2 in/ngy X 7 ngy. Salmonella non typh (ph thng hn): Ampicillin hoc amoxicillin: lg X2 ln/ngy X 10 -15 ngy. hoc thiamphenicol (Thiophenicol) 250 mg: 4 vin X2 ln/ngy X10- 15 ngy
hoc Cotrimaxazol 480 mg: 2 vin X 2 ln/ngy X 10 - 15 ngy.

Shigella dysenteria (l trc trng): c th dng mt trong nhng loi khng sinh sau
Ampicillin: 2g/ngy X 4 ngy.

Cotrimaxazol 480: 2 vin/ngy X 2 ln/ngy. Ciproloxacin (Cilox*) 500mg X2 ln/ngy Norloxacine (Noroxin): 400mg X2 ln/ngy. Yersinia enterocolitica: Doxycyclin (Doxy): ,Nu bnh nhn nng > 60 kg: 200 mg/ln/ngy. Nu bnh nhn nng < 60 kg Ngy u: 200mg/ln/ngy. Nhng ngy sau: 100 mg/ln/ngy. hoc: Coimoxazol Ciproloxacin, Norloxacin. - Vibro cholerae (t): tetracyclin 40mg/kg/ngy, chia lm 4 ln X 2 ngy - Clostridium difficile (gy bnh vim i trng gi mng, thng xut hin sau khi dng khng sinh, chn on xc nh bng pht hin c t" ca vi khun trong phn hoc mnh sinh thit nim mc i trng): Th nh: Metronidazol (Flagyl) 500 mg X 3 ln/ngy X 7- 10 ngy. Th nng: Vancomycn 500mg X 4 ln/ngy X 7 - 10 ngy. - Cc thuc chng virus + Cc virus gy tn thng rut non: Rota virus hoc virus Norwalk, khng c thuc iu tr c hiu. + Cc vi rus gy tn thng i trng: Herpes simplex: Acyclovir (Zovirax) 20 mg/kg/ngy, chia lm 4 ln, dng thuc iu tr c hiu.

Cytomegalovirus (CMV): Ganciclovir (Cymevan ) Liu tn cng: 5 mg/kg/truyn tnh mch trong 1 gi, sau 12 gi truyn nhc li mt liu tng t. iu tr trong vng 14-21 ngy. IV. IU TR D PHNG 1. V sinh n ung Gio dc v sinh n ung cho ton dn.

Khng Tt c

nthc n i thiu hoc b nhim bn do cc loi cn trng nh rui, kin... cc n, nc ung phi c nu chn.

2. Dng thuc d phng i tng: Nhng ngi thng xuyn phi i cng tc nhng vng khc nhau, thng n nhng thc n d b nhim khun. Thuc: Doxycyclin Cotrimoxazol Ciproloxacin Cch dng: Dng thuc 3 -5 ngy trc khi thay i mi trng sng v n ung.

Nhng ngi c c a nhim khun ng tiu ho. -

IU TR CHNG A CHY MN TNH

Nguyn Khnh Trch I. I CNG Tiu ho bnh thng l s phi hp hot ng ca 4 yu t: Hp thu ca rut, s tiu ho thc n trong ng tiu ho, s bi tit cc dch tiu ho, v nhu ng ca rut. Khi c s mt cn bng gia cc yu t trn s dn n a chy. Nguyn nhn dn n a chy c rt nhiu. Do phm vi bi ny ch ni n iu tr triu chng a chy v phng nhng hu qu ca*n, m khng ni n iu tr nguyn nhn, ngha l lm th no cm c a chy. Khi iu tr chng a chy ko di phi phn bit hai loi a chy: a chy thc s v a chy gi. a chy gi hay gp ngi to bn, xen k vi to bn c nhng t a chy, nhng ngi c khi u i trng cng c th a chy gi di dng i ngoi ra cht nhy phn nt. Nu ta tm cch cm a chy nhng ngi a chy gi s lm tng to bn, nh vy s lm tng a chy ch khng cm c a chy.

II. NGUYN TC 1. Nh trn ni, a chy mn tnh thng do 4 c ch gy ra. Do phi tm cch iu ho cc c ch . Tuy nhin khng phi bt c a chy mn tnh no cng u do c 4 c ch gy ra, m thng ch c mt hoc hai c ch m thi. Do , phi xem c ch no l chnh gy ra a chy m icu ho c ch . 2. Vic s dng khng sinh cn thn trng, Khc vi a chy cp tnh phn ln do vi khun hoc virus gy ra, trong a chy mn lnh, nguyn nhn do vi khun t gp, nu c cng ch l nguyn nhn ph. Nu s dng khng sinh khng ng, tiu dit ht cc loi vi khun ng rut th li lm cho a chy nng ln. 3. Trong iu tr a chy cp tnh, vic bi ph nc v in gii l rt cn thit v cp bch, phi thc hin ngay. Trong a chy mn tnh, bnh nhn c thi gian t thch nghi, nn vic bi ph nc v in gii khng phi l cp bch, trng hp nng., Vic bi ph nc v in gii ong trng hp ny ch yu l nui dng. 4. Ch n king thch hp l rt quan trng. C nhiu ng hp ch cn ch n thch hp cng cm a. III. IU TR C TH 1. Cc thuc lm chm nhu ng rut: Phn ln l cc thuc c ngun gc opium:
1 Paregoric (cn opium benzoic 50%)

Ngi ln 1 - 2 tha canh mi ngy Tr em: Tu theo tui, t 30 thng tr ln t 1/4 n 4 tha c ph mi ngy. - Aco din 10 mg (Codethyllin acodin v codein), Terpincodein 5 mg, Tercodin dung dch mi ci tha canh cha 15 mg codein l nhng thuc gim ho long m nhng cng c tc dng cm a chy. Khi dng thuc ny cn ch :
Ch c tc dng vi a chy nh v va. Khng dng cho tr em di 8 tui.

Liu lng: Ngi ln 30 - 40 mg/ngy Tr em trn 8 tui: bng na liu ngi ln.
Loperamid HC1 v tropin (Imodium ) vin 2 mg. Ngoi tc dng lm chm nhu ng rut n cn c lc dng chng bi tit lm gim khi lng phn. Imodium c tc dng tt vi a chy nng, nhiu ln trong ngy. Diphenoxylat v atropin (diarscd) vin 2,5 mg diphonoxylat v ,02 mg atropin.

Liu lng: Thay i t 1 - 6 vin/ngy tu theo mc nng nh ca a chy.

-

Liu lng: t 1 - 8 vin/ngy tu theo mc nng nh ca bnh. Tr em trn 30 thng bng 1/2 liu ngi ln.

Chng ch nh: Thuc c atropin nn c chng ch nh trong trng hp c glaucome v to tin lit tuyn. 2. Cc thuc bng b v lm sn nim mc ng tiu ha t st (Actapulgit , Smecta...) 2 - 4 gi/ngy Polyvidon , polyrolidon (Bolinan) vin 2 g 2 - 4 vin/ngy Gelotanin: gi 0,5 ngi ln 4 - 8 gi/ngy Tr em 1/2 gi n 3 gi/ngy. Geopectose: Ch dng cho tr nh hoc mi sinh, 1 ci tha sp mi ngy (tng ng 7 g) l i non, nc sc bp i cng c nhiu tanin c th dng c. 3. T it khun ru t: dng cc thuc l nh n nng Berberin, Guanidan, Biseptol, Intetrix, 5 metronidazol. Cc sn phm cha sacharomyces boulardi v lacto bacillus: Ultraleure, Bolor (Sace boulardi) Lacteol, Bactisubtil, Antibio. 4. Bi ph nc v in gii Khi cn thit mi phi truyn tnh mch, nu khng dng qua ng ung cng . Cn ch ba in gii chnh: Na, Ca v K. Cc cht dch: mui ng trng 0,9%. - ng glucose 5% 5. C h' n ung: Trong ihi gian i a chy cn n king: Gia v, rau hoa qu, ung c hi, sa bo, m Nn n: Cho, cm vi tht ln nc, tht b, nc rau luc Ngoi thi gian a chy: T bn thn ngi bnh tm ra thc n thch hp v thc n khng thch hp trnh.

IU TR CHNG TO BN
Nguyn Khnh Trch 1. I CNG To bn c rt nhiu nguyn nhn: Nguycn nhn ti b my tiu ha v ngoi b my tiu ha, do thi quen v ngh nghip, hoc khng c nguyn nhn g r rt. Nu khng c nguyn nhn r rt, gi l bnh to bn hoc to bn tin pht, nu c nguyn nhn do mt bnh khc a n, gi l to bn triu chng. C ch gy ra to bn: + Ri lon vn ng i trng: Tng hoc gim. i trng c nhim v y phn t trn xung. Nu nhu ng ca i trng tng hoc gim, hoc b cn tr bi mt khi u u dn n hu qu phn b gi li lu i trng. + Ri lon vn ng trc trng v hu mn: Gim trc ng v i trng Sigma, tng hu mn. Khi iu tr to bn cn bit r to bn do c ch no. Nu do nguyn nhn i trng th cn dng cc thuc iu ha nhu ng i trng, nu nguyn nhn trc trng th dng thuc ti ch. II. CC THUC CHNG TO BN C nhiu loi: X . Cc thuc gy kch thch Tc dng vo nim mc i trng gy tng bi tit nc v in gii. Hot cht gy kch thch thng l: Acid riconoleic, dioctyl sulosuccinat Na, danon, phenolphtalein, sene... Bit dc c rt nhiu: Boldolaxin, Fructin Vichy, Coraga... 2. Cc thuc thm thu C tc dng ko nc t trong thnh rut vo lng rut, ng thi hn ch ti a qu trnh hp thu nc. Hot cht chnh thng l cc mui sulat, phosphat ca Mg hoc Na, mt s loi ng. Bit dc cng c rt nhiu. S dng cc loi mui cn thn trng v tc dng mnh v hay gy to bn tr li sau khi ngng thuc. Bit dc c nhiu: Lactulosc, Duphalac, Sorbitol, Sorbostyl... 3. Cc thuc lm trn Hot cht chnh l vaselin hoc paraphin bit dc: Lansoyl, Transitol... Vit Nam c gc. Si x v mucilage: Mt s si x c tc dng ngm nc v n ra lm cho phn mm v tng khi lng phn, lm cho i Irng tng phn d dng hn. Bit dc c nhiu: Actison, Celluson, Natuvit, Igol, cm go, Karaya stercula. Cc thuc trn t c nht.

4. Cc on kal, calci, natr Nhu ng ca rut, nht l ca i trng chu nh hng nhiu ca cc in gii trn. Nc sui knh g rt tt. 5. Cc thuc dng ng hu mn Hot cht l cc cht kch thch hoc cc cht sinh hi nh trn nhng dng ng hu mn. Bit dc: Microlax, Ducolax, Rectobanbilin... III. P DNG THC T 1. Khng dng thuc Cc bin php khng cn dng thuc c p dng trc d l to bn do i trng hay do trc trng. Cc bin php bao gm: Ch n: Giu cht x, thc n nhiu nc, Ung nhiu nc: Ti thiu mi ngy ung 1,5 lt. Trnh n cc cht gy to bn: i, qu nhiu cht b.

Luyn tp: Massage bng kt hp tp i ngoi ng gi. Thay i thi quen: Nm nhiu hoc ngi nhiu bng nhng bin php trn nu khng c kt qu mi dng thuc. 2. Dng thuc Nn nh rng cc loi thuc chng to bn t nhiu u gy c nh't l i vi gan v thn. Lm dng s gy bnh gi l bnh ca thuc nhun trng (melanose) gy a chy hoc sau khi ngng thuc th li to bn ngay. Cn bit hai loi to bn: Do i trng hay do trc trng. Nu do trc trng nn dng thuc qua trc trng. Nu do i trng nn dng thuc ton thn qua ng ung. Trong trng hp khng bit do ti u, nn dng thuc qua ng trc trng trc. Trong trng hp phi dng thuc ung, nn dng thuc t c trc theo th t: Si thc n thc vt v mucilage, thuc c du, thuc thm thu v thuc kch thch. C th dng cc thuc thm thu hoc kch thch trc trong vi ba ngy u c tc dng ngay, sau dng cc thuc khc. Mun c tc dng ko di nn dng cc in gii kali, calci v natri. l iu tr nn, khng c hi v p dng cho mi loi to bn. Liu lng i vi kali trung bnh 2 g/ngy, vi calci 1 g/ngy. Nc sui knh g rt tt i vi to bn.

IU TR BNH I TRNG c NNG ( Hi chng rut d kch thch)

Nguyn Khnh Trch I. I CNG Bnh i trng c nng r't hay gp trong lm sng. Bnh nhn thng hay b au bng v r lon phn, nhhg khng c tn thng thc th i trng. Ngoi au bng v r"i lon phn cn thcm cc triu chng khc nh i ngoi ngy nhiu ln, chng bng y hi. Ngi ta cho rng bnh i ng c nng l mt tnh trng ri lon vn ng i trng (tng hoc gim) dn n i chy hoc to bn, i trng qu mn cm, bnh c lin quan cht ch n tnh trng tinh thn, cho nn ngi ta cn gi bnh ny l mt bnh tm th. II. IU TR 1. C h n ung: Quan ng nht n king: Nhng thc n khng thch hp nh sa, tm, cua, c. Bnh nhn phi t tm nhng thc n thch hp. - Nhng thc n sinh hi nhiu v kh tiu nh khoai ty, sn. - Nhng thc n kch thch: Ru, c ph, gia v. - Hoa qu kh tiu, c nhiu ng: cam, qut, soi, mt. - Thc n nhiu si x: Khng king hn nhtig khng n qu nhiu. - Thc n nhiu ng: bnh ngt... - Cc U()ng c hi: coca, 7 up.... - Khng nn n qu nhiu mt lc - Cc thc n lu, bo qun khng tt. - Cc thc n sng. 2. Luyn tp: Rt cn thit, phi kin tr, cng phu. Luyn i ngoi ngy mt ln bui sng. Massage bng bui sng gy cm gic i ngoi. Luyn tp th gin, kh cng: Rt c hiu qu i vi trng hp bnh tm th.

3. iu tr triu chng Chng au: Phloroglucinol (Spason) Vin 80mg: 4 - 6 vin/ngy

vin t di li 80 mg: 2 - 3 vin/ngy ng tim 40 mg 1 - 3 ng/ngy Trimebutin (Debridat) vin 100 mg M ebeverin (Duspatalin) vin 100 mg

Hai thuc ny khng nhng c tc dng gim au m cn c tc dng vi cc triu chng khc nh y bng chng hi, ri lon vn ng i trng... Liu lng, cch dng: 3 - 4 v/ngy chia nhiu ln, ung trc khi n. Chng to bn: Gasopax: 1 tha c ph
X

3 ln/ngy, trc khi n

Mucinium, mucipulgite: xem thm bi to bn.

Cm a chy: Cc thuc lm chm nhu ng rut v gy mng bc (xem bi a chy) Chng chng bng y hi: Debridat, Duspatalin Motilium: vin 10 mg X 3 - 4 v/ngy Carbophos, than hot Gartralgin: 3 vin/ngy

Dit khun rut: Khi c a chy, cn thn trng, khng nn lm dng (xem bi a chy).

4. Tm l liu php Cng gp phn lm gim cc triu chng, c n gii thch cho bnh nhn bit r bnh khng nguy him, rt t nh hng n sc kho bnh nhn yn tm, c th chung sng ho bnh vi n. 5. Thay i mi trng sng M t s sui nc nng c kh nng lm du nhng ri lon c nng rut, c th i ngh ngi ti , hoc tm bin, hoc ni c kh hu mt m d chu.

IU TR TR HU MN
Nguyn Khnh Trch I. I CNG T l mt bnh ph bin, do gin tnh mch ng hu mn trong hoc ngoi c tht, cng ging nh gin tnh mch chn hoc ni khc. NhiAig gin tnh mch tri c lin quan ch yu n yu t gia nh v bm sinh. Cn gin tnh mch chi thng l do c hc. Hu qu ca tr l chy mu v sa nim mc trc trng. II. IU TRI NI KHOA 1. Tr khng bin chng 1.1. Trong cn cp tnh: Khi ang chy mu. Dng cc thuc lm bn thnh mch v rng thm tnh ca thnh mch. l: Yu t' p hay rutin 1 Flavonoid I Vit Nam c nhiu Ginkobiloba Ngoi nhng hot cht chnh trn y, trong cc bit dc ngi ta cn thm cc ch't ph nhheparin, phenylbutazon, cc thuc gy t gim au. Dng bo ch: Vin nang ung, vin n t hu mn v dng nc. Ch nh iu tr: Tri I, II, III ang chy mu. Bit dc: Ginkor procto, Ginkor fort: 3 -4 v/ngy trong 7 ngy, ung hoc vin n t hu mn. Dalon 500: ang cn cp tnh: 6 v/ngy trong 4 ngy, sau 4v/ngy. Ngoi cn: 2 v/ngy Midy (vin n) 2 v/ngy nht hu mn sng v chiu ti. C th dng thuc m midy bi vo hu mn thay cho vin n. Preparation H veinotonic (Diosmin) vin 300 mg 4 - 6 vin/ngy Preparation: vin n, thuc m: t hu mn 2 ln/ngy (sng, ti). Cc thuc ph: Proctolog, Titanorein Tim x: Theo phng php c in ca Benoaude mc ch gy x tn gc bi tri. Ch nh: Tr I, II, III Ch't gy x: - Quinin ure - Du phenol 5% - Cn tuyt i polidocanol - Dung dch mui u trng.

Kt qu: Vi III ch lm cm chy mu, bi tri t khi nh li. Vi I, II c th lm bi tr nh li hoc bin m't. Dng in cao tn p ti ch: Dng in ny lm tng dn dn nhit ti ch gy ng mu trong su v x ha bi tr, khng au. Vi cng 14-18mA phi mt 8 - 1 0 pht. Phi lm nhiu ln. Kt qu: Lm cm chy mu ngay, lm nh bi tr nhimg vi tr in t l nh bi tr thp Tht bi tr bng vng cao su: Dng mt dng c c bit c lp sn vng cao su, kp hoc ht bi tr ln ri y vng cao su vo chn bi tri. Mi bi tri chi cn tht 1 ln l ht. i vi tr III th phng php ny khng thc hin c. Thuc y hc c truyn: Bi thuc cm mu: C tc dng cii mu tt khng km cc thuc ty, nhng khng lm nh bi . Thuc bi lm rng tr: C th lm rng tri, nhng c nhc im gy au v bin chng hp hu mn. 1.2. Ngoi cn cp tnh Chng to bn: Ch n nhiu x, nhiu hoa qu, thuc chng to. King n cc cht kch thch: t, ht tiu, ru. Ch lm vic: Trnh ngi nhiu, ng nhiu Khi i ngoi: khng rn nhiu Khng dng giy hoc vt cng chi, nn ra bng nc sch. Trnh nhim khun tiu ha: a chy, l., nu c phi iu tr ngay. Vim hu mn: Gy au, chy nc, nga. Nn dng cc loi thuc trn nhng di dng vin n, thuc m, c th phi hp vi Proctolog, Titanorein. Huyt khi: iu tr nh n, thm cc thuc gim au ng u"ng: Aspirin, Efferagan codein... Heparin ti ch, chymotrypsin nu khng c kt qu thi phi m rch ly huyt khi. Sa trc trng: Ngoi cc thuc trn, cn kt hp cc bin php khc: + + + Ngm hu mn nc nng hng ngy chng ph n. M khi sa cn y ngay vo. Tp vn ng c nng hu mn.

2. Tr c bin chng

Phu thut: Ch nh: + Tr III: iu tr ni khoa tri III ch c th cm mu, rt t trng hp bi t nh li. + Tr c bin chng: Chy mu ko di, iu tr ni khoa khng kt qu Chy mu nng Huyt khi Nght tn

IU TR BNH VIM LOT I TRC TRNG CHY MU

ng Kim Oanh I. I CNG Bnh vim lot i trc trng chy mu (VLTTCM) thng gp ngi tr. Bnh tin trin mn tnh vi tn thng lun gp trc trng. Tn thng i trng vi mc khc nhau tu theo tng bnh nhn v nhng t tin trin ca bnh. Nguyn nhn bnh cha r. Bnh cnh lm sng v tn thng gii phu bnh c nhiu c im ging bnh Crohn. T l t vong ca bnh h ng k t 30 nm nay nh nhng tin b ca iu tr ni khoa v ch nh ngoi khoa ng n. II. IU TR NI KHOA 1. Ch n Ni chung khng cn n king cht ch, ch n king ch t ra cho mt s trng hp. nhng bnh nhn thiu men lactase: Hn ch ung sa v n nhng thc n c cha nhiu sa. i vi th tn thng i trng tri, hoc ton b i trng: Ch n hn ch cht x v ch't b. Ch n qua ng tnh mch l cn thit cho nhng bnh nhn suy dinh dng hoc suy nhc nng.

2. Thuc iu tr triu chng Bi ph nc v in gii, c bit l kali (khi thiu kali c nguy c gy phnh gin i ng nhim c). Thiu mu: Dng cc ch phm cha st. Nhng trng hp tn thng nng n i trng, c nguy c bi nhim: Cho khng sinh ph rng (ampicillin, metronidazol). Cc thucc chng a chy, cc dn xut ca thuc phin, cc thuc anticholinergic chng ch nh dng cho nhng t tin trin nng ca vim i trng tri hoc vim i trng ton b v c nguy c gy phnh i ng nhim c.

3. Thuc chng vim 3.1. Cortcosteroid 3.1.1. Tc dng chng vim thng qua c ch: c ch men phospholipase, do ngn cn s gii phng acid arachidonic t phospholipid v lm gim s xm nhp bch cu ht vo ni tn thng nim mc rut. 3.1.2. Ch nh: vi t tin trin nng ca vim ton b i ng: Prednisolon: 100 mg (hoc mt liu tng ng cc ch phm khc), truyn tnh mch trong 24 gi X 10 -14 ngy. Nu khng c mt ci thin tt no trn lm sng, cn ch nh phu thut ct i trng ton b. Nu cc triu chng lm sng thuyn gim: 60 - 100 mg prednisolon/ung/ngy. Sau gim dn liu tu theo din bin ca lm sng. - i vi th tin trin trung bnh: 40 - 60 mg prednisolon ung/ngy (ung mt ln vo bui sng). Sau gim dn liu: c 5 - 7 ngy gim 5 mg, gim dn cho n khi lui bnh th ngng hn. Nu bnh nhn c khng corticoid, ngha l i hi phi dng thuc trn 3 thng, cn phi cn nhc n iu tr ngoi khoa. i vi t tin trin nh ca th vim i ng tri hoc th vim lot trc ng chy mu:

Tht thuc vo hu mn (bui ti): 20 - 40 mg prednisolon phosphat (hoc betamethazon). Gn y c nhiu loi corticoid, prednisolon mi ng tht nh: Budesonid, Beclamethason..., sau khi c tc dng c tip ln nim mc rut, thuc s c o thi qua gan, do c thm hiu qu ton thn. Nu tht thuc vo hu mn cha hiu qu, th c th phun cc thuc chng vim dng bt vo hu mn. 3.2. Sufazalazn (SAS) v cc dn xut ca n Thnh phn gm 5 amino - salicylic (5 - ASA) gn vi sulfapyridin qua cu ni N-N. Nh men azo - redutase ca cc vi khun sng i trng, sulfazalazin s tch thnh 5-ASA v sulapyridin. 3.2.L SAS - Tc dng: iu tr t Lin trin nh ca vim i ng i v vim trc trng - i trng sigma. c bit c vai tr gim t ti pht ca bnh, tc dng ny ph thuc vo liu dng duy tr hng ngy: 1 g/ngy ti pht 33% 2 g/ngy ti pht 14% 4 g/ngy ti pht 9%

Tc dng ph nhiu v mc ph thuc vo liu lng thuc: y tc thng v, bun nn, au u, suy yu tinh trng dn n v sinh... Tc dng ph khc him gp hn: M n nga, gim bch cu ht, thiu mu, tan mu, cc bnh phi... Cc tc dng ph ny l d thnh phn sulamid ca thuc gy ra. Chnh 5 - ASA c tc dng chng vim l ch yu, cn sulfapyridin c t tc dng hn trong khi li gy ra nhiu tc dng ph, chnh v th ngy nay 5-ASA c s dng thay th cho sulfazalazin. C ch ca 5-ASA: c ch men lipoxygenase, ngn cn s gii phng cht leucotriene t i thc bo v bch cu a nhn trung tnh, ngn cn s gn ca cc gc t do. Cch dng: .

3.2.2. 5 - ASA: -

Tn cng: Pentase 1 g X 3 - 4 ln/ngy X 4 - 8 tun. Th tin trin nh, trung bnh: 1 g X 2 ln/ngy Duy Ui: 0,5 g X 3 ln/ngy Th tn thng i trng tri hoc trc trng: Dng vin n t hu mn 1 nang/ngy X 2 tun, nu cn c th nhc li 2 tun na. t tc dng ph nn c th dng liu cao v ko di. Tc dng ph: M n nga.

4. Cc thuc khc Azathiopyrin (Imuran): C tc dng tt i vi mt s th nng ca bnh. Khi phi hp vi corticoid s gim liu dng ca corticoid, do gim c tc dng ph ca thuc ny. Cyclosporin A: Ch nh dng cho nhng bnh nhn iu tr corticoid khng c kt qu, do trnh c can thip ngoi khoa trong mt thi gian nht nh. Liu lng: Truyn tnh mch 4 mg/kg/ngy. 5. iu tr th phnh i trng nhim c (megacolon toxic) Phi c iu tr tch cc ti bnh vin. Dinh dng bng ng tnh mch, bi ph nc - in gii, c bit kali. Ht dch d dy lin tc. Khng sinh ton thn, loi ph rng. Corticoid truyn tnh mch vi liu cao: 100 mg X 2 ln/24 gi. Theo di sau 72 gi: Nu khng c ci thin triu chng lm sng, cn hnh nh gin i trng trn phim chp khng chun b, cn ch nh ct i trng ton b.

III. THEO DI BNH 1. Mc ch Pht hin sm ung th i - trc ng (tn sut xy ra cao nhng bnh nhn vim lot i trc trng chy mu). Pht hin sm ung th nhng bnh nhn ct i trng bn phn hoc ton b.

2. Cch theo d Soi i trng ton b v nh k 6 thng/mt ln. i vi th tn thng ton b i trng: Soi i trng nh k k t nm th 8 ca bnh. i vi th tn thng i trng tri: Sau 15 nm bnh tin trin, phi soi i trng nh k. Soi i trng v sinh thit nhiu mnh nhiu v tr khc nhau pht hin t bo ung th hoc s lon sn rut. Nu ln sinh thit sau tn thng lon sn nng hn ln trc, th cn ch nh ngoi khoa. Mt s nghin cu gn y cho thy: Nu iu tr phi hp vi acid folic (SAS lm gim s hp thu ca thuc ny) s gim nguy c lon sn i trng. Liu dng: 2 mg/ngy.

IV. IU TR NGOI KHOA 1. Ch nh 1.1. Ch nh cp cu: Chim 5,5% Phnh i ng nhim c. Vim i trng lan ta, nng n. Bin chng cp tnh ngoi i trng: thrombose Tc rut Chy mu tiu ha t, cp tnh Thng i, trc ng.

1.2. iu tr ni khoa khng kt qu: 70% - Cht lng sng khng m bo: Cuc sng lun b nh hng ca nhng t tin trin hoc do nhng tc dng ph ca thuc. Ph thuc corticoi: Phi drig corlicoid liu cao ( 20 mg/ngy, trong thi gian 6 thng). Ti pht li sau khi ngng thuc Chy mu mn tnh, ti i ti li nhiu ln gy thiu mu. Gy st nhiu do mt dinh dng ko di.

1.3. Phng nga ung th - Bnh tin trin ko di 10 nm - Soi i trng v sinh thit c lon sn rut ( ni trn). 2. Cc phng php Tu thuc vo v tr tn thng m c cc phng php tng ng. - Ct ton b i trng, a trc trng ra thnh bnglm hu mnnhn to. - Ct i trng, ni hi trng - hu mn. - Ct i Irng, ni hi - trc trng. - Ct ton b i - trc trng, a hi trng ra thnh bng lm hu mn nhn to.

IU TR VIM GAN MN TINH

Nguyn Khnh Trch I. I CNG Vim gan mn tnh l mt bnh thng gp, hu qu cui cng l x gan. Vim gan mn tnh c hai loi chnh: Vim gan mn tnh n nh hay dai dng v vim gan mn tnh tin trin hay tn cng. Vim gan mn tnh tin trin cng c hai loi chnh: Do virus Do t min Triu chng ca vim gan mn tnh tin trin ph thuc vo trong t hay ngoi t tin trin: Trong t: st, vng da, au nh vng gan, ri lon tiu ha, au khp, da sm, sao mch, gan to, ph... Ngoi t: Ch l ri lon tiu ha, da sm, trng c, m ay. II. IU TR 1. Vim gan mn tnh n nh: Khng c thuc c hiu. Ch n: Quan trng nht, cn b ru, bia, king m, tng cng cht ng, protid, thay m ng vt bng m thc vt. n ung y calo, vitamin: 200 g protid/ngy 300 - 400g glucid v 20 - 30 g lipid mi ngy. Hn ch dng cc thuc c hi i vi gan: Mt s thuc to bn, cha tng huyt p, i tho ng, mt s thuc gim au, an thn... Thuc tr gan li mt: Thc s khng cn thit, trong mt s' t trng hp c th dng thuc li mt, thuc kch thch n ung: Antichaud, Sulfarlem, Hepadial... v mt s thuc tr gan: Legalon, Rigaton... Khng cn ngh ngi hon ton, ngi bnh vn c th lao ng bnh thng.

2. Vim gan mn tnh tin trin -

Ch n ung: Ging nh trn. Ch sinh hot: Trong t tin trin phi ngh ngi hon ton ti ging. Ngoi t c th lao ng nh, gim cng lao ng, trnh gng sc.
Hn ch s dng cc thuc iu tr cc bnh khc nh: Thuc gim au chng vim, thuc an thn, khng sinh.v.v... S dng kim tim ring, k c kim chm cu... Trnh cc bnh nhim khun, virus: n ung hp v sinh khng b a chy, trnh cc bui lin hoan tp th, n ung ti nh hng khch sn, trnh tip xc ni ng ngi, hn ch i ra ph nu khng tht cn thit...

Thuc iu tr: Ty theo vim gan virus hay vim gan t min. Vim gan virus (HBsAg+): Khng c thuc c hiu tiu dit virus vim gan. Ngi ta c th dng mt s thuc sau y, nhimg kt qu rt hn ch. Thuc chng virus: Vidarabin, Zovirax, Retrovir: Khng c kt qu. Intereron (Intron...) loi a i, a. c nghin cu nhiu nh't, nhuhg kt qu tht thng, ti a khng vt qu 50% trng hp. - Transaminase tng rt cao. - Sinh thit gan c hoi t t bo gan.
- Cc din bin lm sng trn 6 thng. - HBsAg (+) '

Ch nh:

Liu dng: 3 - 5 triu n v/1 ln/ mi tun 3 ln t nht trong 6 thng. Hoc 5 triu n v/ngy, hoc 10 triu n v/ln, mi tun 3 ln dng trong 4 thng. Ngi ta c th phi hp interferon v thuc khng sinh chng virus, kt qu c cao hn mt cht. Vim gan t min (HBsAg-) Corticoid: C th s dng ring r hay phi hp vi cc thuc gim min dch khc. S dng ring r: Prednisolon: 60 mg/ngy ri 40 mg, 30 mg/ngy mi liu nh vy dng trong 1 tun, liu duy tr l 20 mg/ngy dng cho n khi cc triu chng lm sng v xt nghim tr v bnh thng. S dng phi hp vi thuc gim min dch khc: 30 mg/ngy ri 20 mg/ngy/15 mg/ngy/mi liu dng 1 tun, liu duy tr l 10 mg/ngy. Thuc gim min dch: C nhiu, nhng c hai loi hin c s dng nhiu nht l : Azathioprin: 50 mg/ngy hoc 1,5 mg/kg/ngy dng cho n khi triu chng lm sng hoc xt nghim tr v bnh thng, hoc n khi gim bch cu. Ciclosporin (Sandimum) gn y mi s dng v cha c dng ph bin. Cc thuc li mt v tr gan: Nh i vi vim gan n nh.

Nguyn Khnh Trch I. I CNG Trong nhng nm gn y iu tr p xe gan do amp c nhiu tin b ng k, lm o ln chin lc iu tr t mt bnh iu tr Gh yu bng phu Ihut tr thnh mt bnh iu tr ch yu bng ni khoa. l nh: - S ra i cc my siu m chn on. - Cc thuc chng amip mi c hiu qu - S hiu bi mi: Giai on vim gan thc t khng ctrong lm sng, khi c biu hin u tin l giai on p xe ri.
II. NGUYN TC IU TR

1. Pht hin sm, iu tr sm. 2. iu tr ni khoa trc, nu khng kt qu mi phu thut. Nu phi m, vn phi dng thuc trit . 3. iu tr trit , tiu dit amp gan v c rut d phng ti pht.
III. CC BIN PHP IU TR

1.

Dng thuc chng amp n thun

1.1. Ch nh: o p xe khng qu ln (khng l) chung quanh 10 cm. Bnh nhn n sm: Khng qu l thng. Trc y theo quy nh ca th gii khi p xe di 6 cm th dng thuc trc, hin nay quy nh ny c m rng hn, c nhng trng hp p xe trn 10 cm dng thuc chng amip vn c th khi. l.2.Thuc nhm nitroimidazol (Klion, agyl...) c th tim hoc ung loi ung: Flagentyl (Senidazol).l,5 g/ngy X5 ngy/u'ng. Fasigyne (Tinidazol) 1,5 - 2 g/ngy X3 - 4 ngy/ ung. Flagyl, Kion: 1,5 g/ngy X8 ngy hoc 2 g/ngy X5 mg ngy/ung. Omidazol lg - 1,5 g/ngy X 3 ngy. - Dehydroemetin: 1 - 2 mg/kg /ngy hoc 0,08 g/ngy X 8 - 10 ngy. Nhiu nc khng cn dng thuc ny na. - Chloroquin (Nivaquin) 0,4 g/ngy X 8 - 10 ngy. Chloroquin bao gi cng dng sau cng. Thng dng lo nitroimidazol ng ung tnc, khng ung c mi phi dng loi tim. Khng nht thit phi dng c

hai loi nitroimidazol v dehydroemetin. Cng thc dng thuc: nitroimidazol (ulng, nu khng ung c th tim) - Thuc dit amip rut (k c kn): Intetrix: vin 300 mg 4 vin/ngy X 10 ngy. 2. Chc ht m phi hp dng thuc chng amp Ch nh: - p xe qu to trn 12 cm - n mun trn 2 thng - Dng thuc nitroimidazol khng kt qu Cch chc: Chc m Chc qua soi bng: Hin r't t dng Chc di s hng dn ca siu m: Tt nht v chnh xc nh't. S ln chc: Ch nh: .Khi c bin chng v (tr v vo phi, khng nh't thit phi m) Do bin chng p xe qu to (khng l) thnh mng, v tr nguy him (gan tri, li xung mt di gan.) Khi iu tr nh trn m khng kt qu. a s ch chc 1 ln, nhiu nht ch nn chc 5 ln cch nhau 5 -7 ngy. 3. M dn lu phi hp dng thuc

IU TR HN M GAN
Nguyn Khnh Trch
I. I CNG

Hn m gan hay cn gi bnh no do gan tuy khng gp nhiu trong lm sng, nhng n l hu qu nng n ca suy gan, hu ht u dn n t vong. S d nh vy l v c ch sinh bnh hc ca n cha c chng minh r rng. Trong nhng nm gn y c nhiu gi thuyt c a ra nhng cha gi thuyt no c sc thuyt phc nht. D gi thuyt no i na, cho n nay trong iu tr vn ly vic loi tr NH3 khi mu ngi bnh l chnh.
li. IU TR THEO c C H TNG NHa MU

Ngn chn ngun NH3 trong i trng ngm vo mu:

Ra rut: Ra bng nc thng, nu khng c chy mu tiu ha, nu c chy mu tiu ha th ra nh sau: Dung dch mannitol: 40 gam, KC1: lgam, NaCl: lgam pha vo 1 lt nc, ra 4 - 5 lt.

Lactulosc (Duphalac) 40 - 60 g/ngy n lm gim pH ca phn < 6 do ngn cn cc vi khun ln men NH 3 hot ng. Khng sinh ng rut: Neomycin 4 - 6 g/ngy Tetracyclin 1 -1 ,5 g/ngy Vancomycin 1 -1 ,5 g/ngy Metronidazol 1 -1 ,5 g/ngy Lactobacitlus acidophil

Cc acid amin tng chuyn ha v o thi NH 3 Glutarsin, Valin, leucin, isoleucin, acid glutamic, arginin, glutamat Na, hoc Ca, Mg... Trong omicetil v arginin l quan trng hn c. Ta c th dng:

Omicetil: l 2 g - 1 - 51/ngy, tim hoc truyn tnh mch. Eucol: 0,5 g/kg/ngy, tng ng 3 - 4 l/ngy Morihepamin ti 250 ml - 2 - 3 ti /ngy Benzoat Na: Lm tng o thi NH3 qua thn, ung 3 - 6 g/ngy. Ch n ung: Gim lng protcin a vo c th, nhng vn phi m bo calo: 1600 - 2500 Kcal/ngy/ lng m mi ngy ch nn 40 - 80 g. Gim m ng vt, thay bng m thc vt. Nn dng protein t sa. Hi sc chung: Hi sc tim mch, h hp nu cn. iu chnh ri lon nc in gii v pH mu: Gim K, Na v nhim kim chuyn ha. - Khng c dng cc thuc gim au, an thn, thuc ng, morphin, li .tiu mnh. iu tr ngoi khoa: p dng cho th mn tnh. Buc ming n ch ca. M thng hai u ca i, trng v ni manh trng vi i trng. Ni rut cui vo trc trng. -

III. IU TR THEO GI TH U YT C C CHT DAN t r u y n t h n k in h t r u n g

g ia n

Acid.amin phn nhnh gim, acid.amin thm tng lm cho cc cht dn truyn thn kinh trurig gian b gim trong no, cc cht dn uyn gi hiu thay vo . - Levodopa (L-dopa) dopamin, hay cht cnh tranh ca dopamin l bromocriptin. L -dopa: 2 - 4 g/ngy (ung) Bromocriptin: 15-25 mg/kg/ngy (ung) Dung dch giu acid.amin chia nhnh (valin, leucin, isoleucin...) ngho acid amin thm (phcnylalanin, tyrosin...).

IV. IU TR TH EO GI T H U Y T c QUAN TH CM BEN ZO D IA ZEPA M

Flumazenil (Anexad)

Phm Th Thu H
I. I CNG

p xe gan do vi khun t gp hn do amp, vi khun ti gan bng ng mt, mu, xy ra nhng bnh nhn b si mt, giun chui ng mt, nhim khun huyt... Vi khun gy bnh gm: T cu, lin cu, E. coli, Proeus, Enerobacter, Enterococcus /aecais, Clostridium Yersinia, Klebsiella, Haemophius influenzae... Chn on da n hnh nh siu m: Nhiu trng gim m kch thc khc nhau, chc ht m mu vng, xanh, c mi thi, nui cy m c vi khun mc. Ap xe gan do vi khun thng nng.
II. IU TR

1. Nguyn tc - Tham kho khng sinh , chn khng sinh thch hp. - Phi hp khng sinh hoc dng khng sinh ph rng, khuych tn tt trong mu c thi tr qua gan mt, nn dng liu cao. - Chng s"c nu c, chng au. - Chc ht m p xe nu ln hn 5 cm. 2. Cc thuc iu tr Chng s"c nu c + Th oxy, tr tim mch. + + Dng thuc nng huyt p: Dopamin Ni tit t thng thn:vDepersolon ng tim, 30 mg - tim tnh mch hoc trn vi dch truyn nh git tnh mch, s" lng tu theo tnh trng bnh, c th dng t 100 - 200 mg/ngy.

+ Truyn dch duy tr huyl p. TI nht dng dung dch Ringer lactat natri clorua 0,9% Dng khng sinh: Nn phi hp khng sinh dit vi khun gram m v gram dng. C th dng mt irong cc loi khng sinh sau: + Penicillin G liu cao 5 - 10 - 15 triu/ngy, truyn nh git tnh mch. + nasyn (Sulbactam + Ampicilin) 1,5 - 10 g/ngy, tim bp hoc tim tnh mch. + Augmentin (Amoxicillin + acid clavulanic) ung lg - 2 g/ngy, truyn tnh mch 500 mg/ngy. (Clabran, Cetriaxon, Ceolaxin, Ceftazidim)

+ Cephalosporin 1 - 6 g/ngy.

+ Nhm Quinolon Ciproloxacin, Peloxacin, PeAacin, Pelox ng tim 100 mg - 200 mg - 400 mg tim tnh mch 1 g/ngy. Oloxacin (olocet) l truyn tnh mch 200 mg. Phi hp vi nhm Nitroimidazol (Metronidazol, Secnidazol, Omidazol, tinidazol) bng ng ung hoc truyn tnh mch. Hoc phi hp vi Colimycin (Colistin) ng tim 500.000 n v tim bp) - Nu bnh nhn c suy thn; khng nn dng cc thuc c hi, cho thn nh: Gentamicin, Cetazidim, Ceotaxin. Thuc gim au, gim co tht Nu c vng da (khng do tc mi) Spasfon, Spasmaverin, Visceralgin. Thuc li mt: Chophyton, artiso, Sorbitol. Nu p xe gan ln hn 5 cm, nn chc ht m p xe di hng dn ca siu m. p xe gan do vi khun l bnh nng, tu theo tng bnh nhn c th iu tr theo triu chng: + ' St cao: Dng thuc h nhit: Paracetamol(Efferalgan.) + + B li nc v in gii da trn in gii v p lc nh mch trung tm. Nng cao th trng ca bnh nhn: Ch dinh dng, hoa qu m bo ing vitamin hng ngy.

nh gi khi bnh: Gan nh li, p xe mt dn trn siu m, ht st.

IU TR X GAN
o Vn Long
I. CNG

X gan l mt bnh thng gp. v mt gii phu, bnh c c trng bi qu trnh x ha lan ta v s hnh thnh cc ht u inh (nodules) trong gan. Nguyn nhn gy bnh c nhiu nhng ch yu l do virus vim gan v ru, v lm sng, ngi ta chia s pht trin ca bnh ra lm hai giai on: Giai on cn b (giai on u): Kh pht hin do cc triu chng khng in hnh. Bnh nhn thng tc nh h sn phi, n ung chm tiu, gin cc mao mch di da, gan mp m b sn, mt chc. Chn on xc nh ch yu da vo soi bng v sinh thit gan.

Giai on m't b (giai on mun): Triu chng lm sng th hin r: + + Hi chng tng p lc tnh mch ca: c trng t do, tun hon bng h ca ch, gin tnh mch thc qun, gin tnh mch c trng, lch to. Hi chng suy t bo gan: Gy st, vng da, ph, gin mch trn da, xut huyt di a, gan nu to th c mt cng hoc chc. Cc xt nghim chc nng gan b ri lon.

II. IU TR

Mt s im cn lu ong iu tr x gan X gan l mt bnh khng th cha khi, nhng nu c iu tr ng bnh nhn c th sng lu di. Giai on cn b iu tr bng ch n ung, sinh hot, hn ch s dng thuc v cc cht c hi cho gan. Giai on mt b ch yu l iu tr ngn nga bin chng.

1. Ch ngh ngi, n ung Trnh lao ng nng, khi bnh tin in cn c ngh ngi tuyt i. Khng dng bia ru. Hn ch mui, m trong khu phn n. Khi c ph, c trng cn n nht hon ton. m bo cung cp nng lng cho ngi bnh (2000 - 3000 kcal/ngy). Trong protid dng khong 1 g/kg/cn nng 1 ngy. n nhiu hoa qu, rau ti v chng cung cp vitamin v kali.

2. iu tr tng p c tnh mch ca 2.1. iu tr xut huyt do v nh mch thc qun Cm mu bng thuc lm gim p lc tnh mch ca. + Vasopressin: Tim tnh mch 10 - 30 n v, c th nhc li sau 30 pht hoc tt hn l truyn trong dung dch dextran 0,2 - 0,8 n v/pht. Ch thuc c tc dng ph l: Co ng mch, gim natri mu v gy suy tim nn khng dng liu cao v ko di. Glypressin: L mt cht ging vasopressin nhng c tc dng ko di hn. Liu dng 2 mg tim tnh mch. C th nhc li sau 6 gi. Somatostatin: truyn trong dung dch ng trng 4 p.g/pht. Nitroglycerin (Lenitral): Vin 2,5 mg; ung 2 - 4 vin/ngy ng thng Linton: Ch yu dng trong cc trng hp gin tnh mch d dy gy chy mu. ng thng Sengstaken - Blackmore: Ch yu dng chn ong cc ng hp chy mu do gin tnh mch thc qun.

+ + + + +

Cm mu bng ng thng c bng chn: C 2 loi ng Ihng dng.

cm mu bng tim thuc gy x ha qua ni soi: Qua ng soi mm, ngoi vic chn on cn c th cm mu bng cc cht gy x ha tnh mch nh: Tetradecyl suat, ethanolamin, polydocanol. Mi mi tim khong 1 ,5 -3 ml, ti a c th ln ti 20 - 30 ml cho mt ln tim v soi tim nhc li sau 2 - 4 ngy.

2.2. iu tr d phng xut huyt Dng thuc + Ch yu dng propranolon lm gim p lc tnh mch ca. Liu thng dng l 20 - 60 mg, c 6 gi ung 1 ln. c n chnh liu sao cho nhp tim gim xung 25%. Thuc c th dng ko di trong nhiu nm. Isosorbit nitrat (Imdur) 60 mg X 1-2 vin/ngy.

To mt ng thng trong gan ni h thng tnh mch ca vi h thng tnh mch gan. Phu thut to cc shunt vi h thng tnh mch ca: Ni tnh mch ca vi tnh mch ch di, ni h tnh mch mc treo trng trn vi tnh mch ch, ni tnh mch lch vi tnh mch thn.

3. iu tr c trng Hn ch n mc t*i thiu lng mui a vo c th ( 2 g/ngy) t thc n, t thuc v dch truyn. Nhng trng hp c trng nng c th chc tho dch c trng. Li tiu: m bo bnh nhn i tiu t 1,5 - 2 lngy v c chia lm 3 bc. + + + Bt u bng spironolacton: 50 mg/ngy, nng dn ln 200 - 300 mg/ngy. Nu vn i tiu t, phi hp vi urosemid (Lasix) vin 40 mg; nng dn ln t 1 - 4 vin/ngy. Nu vn cha t yu cu, phi hp vi hydrochlothiazid 25 - 50 mg/ngy.

Truyn m: Huyt tng ti, Human albumin 20% v cc dung dch m giu albumin khc. Mt s phng php iu tr c trng c bit khc. + Truyn li dch c trng cho bnh nhn. + To shunt Leveen bng cch t mt ng polyethylen dn dch c ng t bng vo tnh mch ch di.

4. Mt s' thuc u tr khc Dng thuc chng x ha: D-penicillamin, colchicin (trong thc t t c kt qu) Dng cc vitamin nht l vitamin nhm B liu cao, khng cn thm mui khong. Trong t tin trin ca bnh c th dng: Legalon, nissel, citrarginin, dynamisan. Prednisolon: Liu va phi (30 mg/ngy) cho cc trng hp x gan do r v x gan mt. Trng hp x gan mt c th cho thm: Acid ursodeoxycholic, 10 mg/kg/ngy.

o Vn Long
I. I CNG

L loi ung th thng gp nc ta, tin lng xu, nhng nu c pht hin sm, iu tr ng c th ko di i sng cho bnh nhn. v chn on, khi c cc du hiu lm sng, bnh giai on mun. Pht hin ung th gan sm ch yu da vo kim tra nh k bng siu m v nh lng AFP tt c cc i tng c nguy c cao nh: X gan, vim gan mn, ngi mang virus vim gan B, c , ngi nghin ru hoc b cc bnh gan mn tnh khc. Khi nghi ng, cc bin php thm d b sung c th c ch nh tip nh: Chp ct lp vi tnh, chp hin hnh gan bng cng hng t, chc ht di s hng dn ca siu m xt nghim t bo v m bnh hc. v iu tr: Hin c nhiu phng php iu tr ung th gan. Vic la chn cch iu tr cho tng bnh nhn c th phi da vo: Giai on bnh ( ln ca u, s lng u, di cn...) Bn cht m bnh hc ca khi u Chc nng gan (c km theo x gan hay khng) Th trng bnh nhn

II. IU TR NI KHOA

1. iu tr bng ha cht 1.1. Cc thuc C nhiu loi, nhng 4 thuc sau y c coi l c tc dng tng tt, c ng n c hoc phi hp vi nhau. Doxorubicin (Adreamicin): Thuc gn vi ADNgy cn tr tng hp DNA v ARN. Fluoro uracil: Thuc c ch chuyn ha gy cn tr tng hp ADN v ARN. Mitomycin - C: Lm cn tr s phn bo do gn vi ADN. Vi nng cao c ch tng hp ARN v protein t bo. Mitoxatron (Novantron): L thu"c chng ung th, kh tt vi ung th gan. C ch tc dng cha r.

1.2. Cch dng v liu lig Truyn tnh mch: Thuc c pha ong dung dch ng trng. Doxorubicin: 60 mg/m2 da, c 3 tun nhc li mt ln hoc 30 mg/m2 da truyn lin tc trong 3 ngy, sau 4 tun nhc li. Nhng bnh nhn c vng da phi gim liu. Tng liu khng vt qu 550 mg. Fluorouracil: 12 mg/kg/ng y X4 ng y (t ng li u m t ng y kh ng v t qu 800 m N u b nh nh n chu c, c c ng y th 6, th 8, th 10, v th 12 truy n 6 Nh c l i m i th ng m t l n k t ng y d ng thu c cu i c ng. Mitomycin - C: 20 mg/m2 da, nhc li sau 6 - 8 tun. Mitoxanon (Novatron): 12 mg/m2 da. Dng lin tc trong 21 ngy. Truyn vo ng mch: Thng qua mt catheter c t vo nhnh ng mch gan nui khi u vi mc ch tp ung nng thuc cao trong khi u. Truyn vo ng mch gan thuc c trn trong du Lipiodol: Khi vo gan, lipiodol c cc t bo Kuffer v h bch mch ca t chc gan lnh lc i nhanh chng. Nhng t chc ung th khng c t bo Kuffer v bch mch nn Lipiodol cng ha cht nm li sau 2 - 3 tun. Tim thng thuc vo khi u: L phng php ang c nghin cu. Di s hng dn ca siu m, ngi ta chc kim vo khi u ri tim 5 Fluorouracil v thng kt hp vi lm hoi t ng bng cn.

1.3. Theo di tc dng ph Khi dng cn theo di tc dng ph ca thuc: Gim bch cu, tiu cu, bun nn, a chy, rng tc... 2. iu tr bng cch gy tc mch Qua catheter lm tc nhnh ng mch nui khi u lm cho m ung th b hoi t. Cc loi thng dng gy tc mch: Gelarm v Gelatin. 3. Phng x: c 2 phng php Chiu x: Tng liu c th ln ti 3000 Rads. Ch yu p dng cho u lympho gan. Liu php phng x la chn: + + Dng khng th khng feritin a dng c gn phng x ph hu khi u. Dng khng th n dng khng AFP gn phng x.

4. Ph hu khi u gan bng cn tuyt bng acid acetc hoc bng laser L phng php iu tr thay th phu thut c nhiu trin vng i vi cc u gan b. 5. iu tr bng cch nng cao sc khng ca c th: Truyn gamma globulin. 6. iu tr triu chng - Gim au: Efferalgan codcin, temgesis, Dolacgan, morphin. iu tr c trng: n nht, li tiu, chc tho dch, truyn m.

III. IU TR NGOI KHOA

C 3 phng php 1. Tht ng mch gan: Hin t dng. Ch yu p dng cho cc trng hp b chy mu khng cm c do v nhn ung th m khng c kh nng ct b u. 2. Ct b mt phn gan: Ch nh trong cc trng hp u khu tr mt vng gan v chc nng gan cn tng tt. 3. Ghp gan: p dng cc nc tin tin. Ch yu cho cc trng hp ung th gan xut hin trn mt gan x nng hoc c mt s khi trong gan nhng cha c di cn.
IV. THEO DI K T QU IU TR

Kt qu iu tr c coi l tt khi V lm sng: Bnh nhn au hoc m't au, tng cn, gan nh li. v xt nghim: nh lng AFP gim, trn siu'm, hoc chp ct lp thy khi u b hoi t hoc nh li.

V. D PHNG Tim vacxin phng virus vim gan B: Cho tr em v nhng ngi c nguy c ly nhim cao v y c coi l nguyn nhn ch yu gy ung th gan nc ta. Kim tra nh k 3 thng mt ln bng siu m v nh lng AFP cho cc i tng c nguy c mc bnh cao.

IU TR BNH x GAN MT TIN PHT

ng Kim Oanh I. I CNG X gan mt tin pht (XGMTP) l mt bnh gy ra bi s ph hu dn dn cc ng mt trong gan, dn ti mt v cui cng l x gan. Nguyn nhn gy bnh cn cha r rng, nhiu tc gi c cp ti cc yu t di truyn, min dch v nhim khun, v lm sng: ngoi cc triu chng ca x gan cn ni bt cc triu chng mt (nga, vng da...) v nhng r lon do gim hp thu cc vitamin tan trong du (a chy m, long xng...). Mc ch iu tr nhm: Ci thin chc nng gan v hn ch tn thng x tin trin. iu tr triu chng ca x gan. - . iu chnh nhng ri lon do thiu ht vitamin tan trong du.

II. IU TR NI KHOA

1. Cc thuc ci thin chc nng gan 1.1. Acid ursodesoxycholic: 1.1.1. C s iu tr ca thuc: Trong bnh XGMTP cc ng mt trong gan dn dn b ph hu dn ti s tch t cc acid mt ni sinh trong t bo gan. Khi nng cc acid mt ni sinh tng cao trong t bo gan s gy ra mt, gy c i vi t bo gan, hnh thnh qu nh x ha (lbrose) v x gan pht trin. Acid ursodeoxycholic l mt loi acid mt rt i nc, khng c i vi t bo gan. Sau khi a vo c th, acid ny s kt hp vi taurin hoc glycin v thnh mt acid mt c tnh tri: c ngha l n c kh nng cnh anh vi acid mt ni sinh hng ro nim mc rut, lm gim s ti hp thu tch cc acid mt ni sinh nim mc rut v do lm gim t l acid mt ni sinh (acid chenodesoxycholic'v acid cholic) trong phc hp acid mt tun hon. Tc dng ca thuc c pht huy nu dng thuc trong mt thi gian di.

1.1.2. Vai tr ca thuc Thay i c tin lng ca bnh, ci thin cc triu chng lm sng; sinh ha v t chc hc ca bnh. Nu bnh nhn c iu tr giai on tin lm sng (ngha l ch c thay i v sinh ha) kt qu tt nht. t tc dng hn giai on sau. Khng c kt qu giai on cui ca bnh.

1.1.3. Liu lng 10 - 15 mg/kg/ngy, chia lm 2 ln: Sng v ti. C th: Ursolvan 200 mg 1 vin/sng v 2 vin/t. - Ch : + + + Cn thn ng nhng bnh nhn c vng da nhiu (bilirubin >200 |imol/l) nhng bnh nhn c triu chng nga, liu lng ca thuc bt du l 200 mg; sau tng dn dn liu. Nu phi hp vi cholestyramin (Questran), thuc s b gim tc dng do thuc s gn vi cholestyramin v o thi ra ngoi.

1.2. Cc thuc khc Mt s thuc c kh nng ci thin chc nng gan, nhng v phi dng thuc trong mt thi gian rt di nn phi cn nhc gia hiu qu ca thuc vi tc dng ph nng n do dng thuc ko di gy ra. Mt s thuc khc c th nghim li trn lm sng, v thy rng khng c tc dng.

1.2.1. Corticosteroid Tc dng: Gim vng da, gim phosphatase kim, gim transaminase v ci thin nhng thay i t chc hc gan. Tc dng ph: Lm m ng thm triu chng long xng ca bnh. Khuyn co: Nn dng thn trng.

1.2.2. Aiathioprin: Quan nim trc kia: C lm thay i t l t vong ca bnh. Kt lun ca cc nghin cu mi: Khng lm thay i triu chng lm sng, sinh hc v tin trin ca bnh, do ngy nay khng dng thuc ny iu tr. '

1.2.3. Chlorambucil: -

Tc dng: Ci thin c mt s" thng s" sinh ha v gim bt tn thng t chc hc gan, c bit nhng tn thng xung quanh khong ca. Khng th dng trong thi gian di v tc dng ph nng n ca thuc, c bit l gy gim sinh tu.

1.2.4. Colchicin: Tc dng: Ci thin c mt s xt nghim sinh ha, nhng khng lm thay i cc triu chng lm sng v t chc hc. Thuc khng c, c th dng ko di. Liu lng: 0,6 mg X 2 ln/ngy

1.2.5. Cyclosporin A: Tc dng: Gim cc triu chng lm sng v sinh ha. Cc triu chng v t chc hc thay i khng ng k. Khng an ton khi dng thuc ko di do c nhng tc dng ph nguy him, nht l gy c i vi thn v gy tng huyt p.

2. iu tr tru chng 2.1. Chng a chy m v long xng (do gim hp thu cc vitamin tan trong du): - B sung vitamin A, D, K, E bng ng tim v calci, magncsium... - Tm nng. 2.2. Chng nga (do mt) - Cholestyramin (Questran): gi 4 g 1 gi X 3 ln/ngy Ch : Khi dng phi hp vi acid mt s lm gim hiu qu ca acid mt. Gim s hp thu cc yu t ng mu rut nn phi kim a t l prothrombin. - Lc huyt tng (plasmaphrse): Tch cc thnh phn hu hnh ca mu ra khi huyt tng, sau truyn li cc thnh phn hu hnh vo mu.

2.3. Cc triu chng ca x gan: iu tr ging nh bnh x gan khc (xem bi iu bnh x gan).
III. GHP GAN

1. Khi no cn phi ghp: Khi c cc triu chng ca x gan mt b: c trng, ph, v gin tnh mch thc qun... T l bilirubin trong mu > 150 jimol/l T l albumin trong mu < 30 g/1

- 'T l prothrombin gim 2. Tin lng sau ghp gan: Ghp gan nhng bnh nhn XGMTP ctin lng tt hn nhng bnh nhn x gan sau vim gan virus hoc x gando ru: 78%sng sau 2 nm, 70% sau 5 nm. Bnh c th ti pht sau khi ghp gan, nhng khng c hoc c t triu chng. Ch c 25% trng hp cn ghp li.

IU TR SI MT
Nguyn Khnh Trch I. I CNG Si mt l mt bnh ph bin nc ta. cu to bi si gm 3 loi: Cholesterol: Thng gp nht Bilirubin: t gp hn Carbonat calci: t gp nht. Trong thc t t khi gp loi si mt thnh phn m thng c hai hoc ba thnh phn C ch to nn si cholesterol l do mt t mui mt lm cho cholesterol b kt ta v thnh si. II. IU TR 1. iu tr triu chng 1.1. Chng au: Dng cc thuc chng co tht, tu theo mc au m c th dng: - Debridat, Duspatalin. - Atropin, Papaverin. - Viscralgine fort - Spason. Cc thuc chng au khc: Voltaren, Dolargan... Nn phi hp thuc gin mch: Nitroglycerin... 1.2. Chng nhim khun (nu c) cc vi khun thng l gram (m): E. Coli, Enterocococ, Proteuss. Cc khng sinh thng dng: Ceobis, Ciprobay Pelacin Colistin Gentamicin Penicillin NitroimidazoI: Meomidazol, Klion, Flagentyl... 1.3. Thuc li mt Khi c triu chng mt ( mt to, vng d a...) th khng nn dng: Artichaud (chophyton, ch artichaud, cao lng,:..) Sorbito Sularlem

2. Thuc lm tan si l cc acid mt, c tc dng lm gim bo ha ca cholesterol, lm cholesterol khng kt ta c, lm si nh dn v bin mt. Ch nh: Ch dng iu tr si ti mt thi vi iu kin: si nh di 1 cm, cha b calci ho, chc nng ti mt cn tt. Bnh nhn khng th m, hoc dt khot khng mun m. phng ti pht sau m.

Thuc: Chenodesoxycholic (Chenodex vin 250 mg, Chenar vin 200 mg, Chenolk, Chenolite vin 250 mg) Liu lng: 12-15 mg/kg/ngy, phi dng lin tc 6 thng l t nh't, trung bnh 18 - 24 thng, c khi ti 3 nm. Kt qu 50 - 70% mt si, s cn ii si nh li. Usodesoxycholic (Delursan vi 250 mg, rsolvan mg...) t bin chng hn. Liu lng 8 - 1 2 mg/kg/ngy ko di hng nm. Kt qu 70 - 80%. Cc thuc trn c th gy nn bin chng: a chy Transaminase mu cao. Cc thuc lm gim m mu: Lipavion, lipanthyl, lopid.Moristerol, Essenlial... Ch n: Gim nng lng: 2000 cal/ngy, gim m mu: n t m, thay m ng vt bng m thc vt, nn dng nc sui kim, ch nhn trn, artichaud ihay cho nc ung. 3. Ly si qua ni soi y l mt phng php tt nht ong iu si mt, c nhiu ngi bnh hoan nghnh, n thay th hn cho ml i phu thut m, li nhanh chng, rt ngn ngy iu tr nm vin, th thul ch ko di trung binh 60 pht, bin chng v l l t vong thp hn nhiu. Ch nh: Si ng mt ch, ng gan. si ti mt hoc ng ti mt khng c ch nh p dng k thut ny. Si to, nh, nhiu t, trong ng mt ch hay ng gan. vin 200mg, Destolite 150 thi gianiu trcng phi

Giun chui ng mt ln qu cao khng xung c na. vi sn l gan, v mt l thuyt th c th ly sn qua ng ni soi, nhng Irong thc t cha ai lm v cn nhiu vn phi bn bc. Si ti.phi sau m. Ngi gi khng chu ni phu thui.

Kt qu 93 -97% ly c si.

Bin chng: Chy mu khi ct c trn, thng ng m t ch do ct c trn qu su, vim ty, vim ng mt, tr bin chng vim ty l hay gp, cn nhng bin chng khc rt t gp. N u chy mu Ih cm mu ngay khi ang ni soi v sau tip tc ly si, nu thng th phi gi m ngay. Cc bin chng khc t khi sau mt vi ngy, k c vim ty. T l t vong chung 0,5 - 1,3%. 4. Ph si trong c th C th tn si trong c th bng nhiu cch: Siu m, thu in, laser v c hc. 4.1. Trong khi lm ERCP Nu gp phi trng hp si qu to, c th ph si ngay bng chnh ci r ly si, dng mt dng c c bit xit cht ci r li lm v vin si ra, sau tip tc ko si ra. Nhng cng c trng hp vin si qu cng khng bp v ra c, th phi a n chiu laser, hoc mt dng in vo nhng tia la in do dng in pht ra s lm v nhng vin si rt cng ra v tip tc ko si ra ngoi. Nu qu nhiu si m ly bng r hoc bng hi khng ht c, ngi ta phi t mt ng thng di vo ng m t truyn dch vo nhng ngy sau ph si bng siu m. 4.2. Ni soi ng m t qua gan To mt con ng qua gan vo ng mt, qua ng ny a mt trocat vo ng mt, ri qua trocat ny ngi la a mt n soi ng m m vo ng m t qua ngi ta li c th tin hnh ph si bng thu in hoc laser nh trn. 5. Ph si ngoi c th : p dng cho si ti mt Phng php ny cng c nhiu bnh nhn a thch v khng phi m, t au, nhng c nhc im l phi ph nhiu ln, t nht cng l 2 ln vi si nh, hng chc ln vi si ln, si ln m cng qu cng khng ph c si, c th ti pht. Nguyn l ca phng php l a mt sng siu m p vo ng vin si to nn mt p lc rt ln hng ngn atmosphe trn vin si, do lm v vin si. i vi si ng mt: C th a sng siu m p vo ngay si trong gan nhng c nhiu kh khn v t khi ph c. Do phi a mt ng thng vo qua ng ni soi nh trn m t ri mi dng sng siu m p ngoi c th a vo ng ch c si. 6. M ct ti mt qua ni soi p dng cho si ti mi. y l mt phng php iu tr si ti m t c hiu qu nht hin nay, v khng phi m bng, t bin chng v gn nh khng c di chng, t l t vong rt thp so vi m bng, n c u im hn phng php ph si ngoi c Ih l trit khng ti pht. v nguyn tc th c si ti ml c th ct ti m t qua ni soi, nhng khi no th m ,trng hp no th ct ti mt qua ni soi, cng cn nhiu kin khc nhau.

- Ch nh + Si khng triu chng: Tu theo s lng si, kch thc si, tui tc m ch nh ha khng ch nh. + Si c triu chng: C ch nh m ni soi. Chng ch nh: Ti mt b vim dnh nhiu vi cc tng ln cn. 7. Phu thut ly si: si ti mt hay ng mt. Khi cc bin php trn khng c kt qu, hoc khng c iu kin thc hin cc bin php iu tr trn y. Ngy nay, phu thut m bng ly si ngy cng hn ch, nh't l si ti mt.

IU TR VIM TI MT CP TNH
Phm Th Thu H I. I CNG Vim ti mt cp tnh l bin chng thng gp ca si mt. Hnh thi tn thng ca ti mt t nh n nng: ph, xung huyt, lot nim mc ti mt, hoi th, thng li mt, vim nhim quanh ti mt. Nguyn nhn gy vim ti mt cp: - Do tc nghn ng dn mt - Do giun chui ln ng mt vo ti mt gy vim ti mt do nhim khun. Vi khun thng gp Escherichia Coi, Proteus, clostrdum Yersinia, t cu, lin cu ecals... - Nguyn nhn t gp hn do d ng, ho cht, c ch't... Triu chng chnh: au t ngt vng ti mt, st cao rt run, nn, bun nn, r lon tiu ho. Trng hp nng biu hin tnh trng ton thn nhim khun nhim c: cn lm sicu m gan mt hoc soi bng xc nh chn on. II. IU TR 1. Nguyn tc - Chng nhim khun - Chng co tht ti mt - Phu thut ct b ti mt khi vim ti mt hoi th, vim phc mc, vim ti mt do v. - iu tr triu chng

2. iu tr ni khoa - ' Ngh ngi tuyt i. C h n ung: Thc n d tiu, gim m, cho, Nu st cao, nn ma + Ringer lactat + + NaCI 0,9% Glucose 5% - 20% sa, sp

Cn b ph nc v in gii:

s lng dch truyn tt nht da trn in gii v p lc tnh mch trung tm Chng nhim khun. Nn dng khng sinh, c thi tr qua gan mt, khuych tn tt trong mu. + + Ampicilin: 500 mg - (lg - 2g/ngy) tim bp, truyn tnh mch Pelacin: Vin 400 mg, ng tim 400 mg Liu dng 400 mg - 800 mg/ngy + Gentamicin: ng tim 40 mg, 80 mg. Tim bp hoc tim truyn tnh mch Liu: + Cephalosporin Cebis ho tan lg trong 10 ml nc ct Tim tnh mch chm 3 - 5 pht, hoc ho trong dung dch NaCl 0,9% truyn tnh mch + Metronidazol tim truyn tnh mch 500 mg trong 50 ml sinh Tu theo tnh trng nhim khun ca bnh nhn. C th dng mt khng hoc phi hp 2 - 3 loi khng sinh ca cc nhm. Chng co tht ti mt, chng au + + Spasfon: Dng vin, dng t di li, dng tim Alverine citrate (Spasmaverin)

Tim 4ml - liu dng 1 - 2 ng tim nh mch ct cn au sau 1 5 -3 0 pht. vin nn 40 mg C th dng 3 - 9 vin/ ngy + Buscopan Vin nn 10 mg, ng tim 20 mg ong 1 ml Liu dng 20 - 40 mg/ngy + Visceralgin Vin nn, ng tim 5 ml

Liu dng 2 - 6 vin/ngy, tim bp 1/2 - 2 "ng/ngy. Trong khi iu tr ni khoa cn theo di, pht hin kp thi nhng bin chng cn can thip ngoi khoa 3. iu tr ngoi khoa Phu thut cp cu + + + Vim ti mt cp th hoi t Vim ti mt cp c vim phc mc Thng ti mt

Phu thut ti mt theo k hoch

Trong vim ti mt to thnh m qunh m iu tr ni khoa khng c kt qu C th m theo ng m bng, hoc m ct ti mt qua ni soi.

IU TR VIM TI MT MN TNH
Phm Th Thu H I. I CNG Vim ti mt mn tnh l vim nhim ti mt c ngun gc ch yu do vi khun, i khi xut hin th pht trong si mt, k sinh trng ng mt hoc r lon vn ng ng mt Vi khun gy vim ti mt mn tnh Vi khun rut: E. Coi, Enterobacter, Clostridum Yersinia, Kebsiella, Proteus... T cu, liu cu Vim gan vus, sn l gan

Nu ch do vi khun cha gy vim mn tnh m cn nguyn nhn do tc mt v mt s yu t" tc ng ln thnh ti mt: Do ri lon ch n ung, do ri lon thnh phn mt, do men ty kch thch, do chn thng ca si mt... ' . Vim ti mt mn tnh lm cho ti mt nhn nheo, thnh ti mt dy ln v x ho lm mt chc nng bnh thng ca ti mt. Trong mt s ng hp nng t vim ti mt c th lan ra vim ng mt, xut hin cc pxe nh, hoi t v lot gy thng ti mt

II. IU TR Tu theo giai on vim ti mt mn tnh tin trin hoc n nh 1. Nguyn tc Chng vim nhim (ong t tin trin ca bnh) Gim co tht ti mt Ci thin dng chy mt, lu thng dch ti mt Nng cao phn ng min dch, tng sc khng ca c th.

2. u tr ni khoa C h n ung: Nn n thc n d tiu ho, gim thc n cnhiu m, tht rn hun khi, gim thc n c nhiu gia v cay chua,. Nn n thnh nhiu ba khi ang c t tin trin. Chng vim nhim trong t tin trin: Bnh nhn c st, au vng ti mt + + + + Trimthoprim, Sulam thoxazol (Bicepton) Vin nn 480 mg - c th dng 2 - 6 vin/ngy. Bacterim 480 mg - liu dng 480 mg/lOkg/ngy Chia 2 ln trong ba n, nu nng c th dng liu gp 2 ln Gentamicin 80 mg tim bp ngy 1 - 2 ng Cephalosporin th h 3 Tu theo mc nhim khun c th dng mt hoc phi hp hai khng sinh Chng co tht ti mt v ng mt, gim au + + + Papaverin vin nn 40 mg Liu dng: 2 - 4 vin/ngy Spasn: vin nn 160 mg - Liu dng 2 - 6 vin/ngy Tim bp, tim nh mch 1 - 3 ng/ngy Spasmaverin Vin nn 40 mg Liu dng 1 - 2 vin/3 ln/ngy + + Nitroglycerin vin ngm di li Visceralgin. Vin nn, ng tim 5ml

Khng sinh nn dng loi khng sinh c hp thu rut thi tr qua ng mt.

Liu lng ung 2 - 6 vin/ngy Tim bp 1/2 - 2 ng/ngy - Ci thin lu thng mt + Lm gim trng lc ng mt t ng thng t trng ht dch mt ong trng hp vim ti mt khng do si.

Thuc li m t (trng hp khng c tc mt thp). Nn ng cc thuc li mt va phi, khng nn dng cc thuc gy co tht mnh ti mt Chophyton 1 - 2 vin/3 ln/ngy Actiso di dng vin, cao, ng ung.

Cc loi vitamin nhm B v c . (

3. iu tr ngoi khoa Vim ti mt hoi t Tc ti mt Ti mt ho x, bin dng mt chc nng bnh thng, c nhiu t vim nhim.

- Si ti mt C th phu thut bng ng m bng nht l trong trng hp cp: Vim ti mt hoi t, tc ti mt. C th phu thut ti mt qua ni soi, rt ngn c thi gian iu tr sau phu thut 4. Phng bnh Trnh n thc n c nhiu cholesterol bo ho thc n nhiu m, cn cn i khu phn thc n. iu tr kp thi vim ti mt cp, si ti mt.

IU TR VIM TY CP TNH
Phm Th Thu H I. I CNG Vim ty cp tnh l tnh trng vim cp tnh ty gy ra ph n xung huyt hoi t v c th chy mu ty Nguyn nhn thng gp Si mt, giun chui ng mt, si ty. Nghin ru. Ngi bo n qu mc tht, m. Lot t trng n su vo ty. Mt s nhim khun ti cc c quan trong bng: Vim rut tha, vim ti mt... Chn thng ty do va chm. Ni soi chp mt ngc dng, sau phu thut bng.

- Cc nguyn nhn cha r. Bnh khi pht t ngt, au vng thng v d di tng cn lan ra sau lng v mn sn i, nn ma, bng chng hi. Trng hp nng c th sc. Chn on da vo s tng cao amylase, lipase trong mu, siu m thy ty to gim echo, c th c cc khi dch trong bng.

II. IU TR 1. Nguyn tc Chng sc nu c c ch s tit dch ty, lm mt hot tnh ca dch ty bi tit. Bi ph nc v in gii m bo nhu cu v nng lng cho ngi bnh. Chng vim nhim. iu tr triu chng.

2. iu tr c th 2.1. iu tr ni khoa: Phi iu tr sm v theo di cht ch. Vim ty cp c s"c: cn chng sc + Th oxy, tr tim mch. + H huyt p: cho cc thuc nng huyt p Dopamin 200 mg + glucose 5% truyn nh git tnh mch liu 5 - 1 0 mg/kg/pht lc u, sau iu chnh a huyt p ln. Noradrenalin + Truyn tnh mch cc loi dch 2 - 4 lingy S lng dch truyn tu theo tng bnh nhn, s lng dch truyn da trn p lc tnh mch trung tm. Renger Lactat NaCl 0,9% Huyt thanh albumin ngi Truyn mu khi c hin tng chy mu + Depersolon 30 mg (1 - 4 ng tim tnh mch) + Chng au: Visceralgine fork tim bp - Vim ty cp khng c sc + Nhn n tuyt i + t ng thng d dy ht dch lin tc + iu chnh th dch, cn bng in gii Renger lactat 500 -1000 ml truyn nh git tnh mch NaC10,9% Glucose 5% Nu gim calci nhiu cho calci gluconat 10% - (10 - 20 ml) trong dch truyn, gim kali mu: cho kali clorua 20% (cho 2 - 3 g/ngy pha trong dch truyn) + Cho thuc c ch bi tit dch ty Cimetidin tim TM hoc trn dch truyn 600 mg - 1000 mg/ngy Somatostatin tng hp

Osotid actat (Sandostatin) Liu dng 0,1 mg tim di da, ngy tim t 0,1 - 0,3 mg chia 2 - 3 ln Somatostatin (Stilamin) ng tim 250^g v 3mg l peptid vng tng hp cu trc ging somatostatin t nhin. Liu dng 250|ig tim tnh mch chm 3 - 5 pht hoc dng 3 mg + NaCl 0,9% 1000 ml tim uyn nh git tnh mch trong 12 gi (3,5 ng/kg/1 gi) + Cho thuc gim au Atropin 1/4 mg tim di da t 1 mg - 2 mg chia 3 - 4 ln trong ngy Visceralgin vin nn, ng tim 5 mi Liu dng: ung 2 - 6 vin/ngy Tim bp, tim tnh mch 1/2 - 2 ng/ngy Khng nn dng morphin v gy co tht mnh c oddi + Cho thuc khng sinh Ampicillin 500 mg ng tim bp truyn tnh mch Gentamicin 80 mg ng tim bp Claforan, Ceobis, Rocephin tu theo tnh trng nhim khun nng hay nh ca bnh nhn cho liu lng v phi hp khng sinh. + Dng cc thuc khng enzym, lm mt hot tnh ca cc men ty bi tit. Contry kal 10000 - 15000 ATC tim tnh mch chm/ngy Trasylol (Zymofren) 25000 - 50000 KIE ho v i dung dch Levulose 5% ti m truy n nh gi t hh m ch/ng y c th gi m li u d n theo s l ng amylase, lipase trong m u. + + Nu c tn thng thn phi hp: Chng suy thn c trng hp phi chy thn nhn to (xem bi iu tr suy thn cp) m bo dinh dng bng ng tim truyn trong suct thi gian nhn n: bng truyq glucose, acid amin, vitamin...

Ch cho n li khi ht triu chng lm sng, s" lng amylase v lipase mu tr v gn bnh thng, ch n t thc n nh t m m, d tiu ho cho bnh nhn thch nghi, sau tng dn khi lng v cht lng thc n. 2.2. iu tr ngoi khoa: Ch phu thut nhng trng hp sau: Vim ty cp tnh do chn thng trong nhng ngy u dnlu. M thm d khi cha chc chn vim ty cp, nghi ng bnh ngoi khoa khc. M si mt, ct ti mt, m c tht Oddi khi vim ty cp do tc nghn. Nang gi ty ln, sau 6 thng vim ty cp khng mt i - do v hoc pxe ho. ngi bo, tui trung nin khng nn ung ru. n ung khng nn qu lm dng trong ba n qu nhiu tht m. iu tr tch cc bnh l si mt, giun chui ng mt, lot d dy t ng.

2.3. Phng bnh vim ty cp

IU TR VIM TY MN TNH
Phm Th Thu H I. I CNG Vim ty mn tnh l s ph hu, x ho nhu m ty, tn thng lan to hoc khu thnh tng , calci ho lan to gy x, si ty hoc calci ho khu tr ng Wsung lm hp lng cc ng ty, to u nang gi ty dn n suy gim chc nng ni tit v ngoi tit ca ty Nguyn nhn gy vim ty mn tnh - Vai tr suy dinh dng ko di gy vim ty calci ho Do ru Vim ty mn tnh th pht do tc nghn ng ty sau chn thng, phu thut, khi u p lm gin v gy x ho mnh quanh ng ty. Vim ng mt, si mt, vim cht c Oddi... Vim lot t ng Vim ty mn tnh do di truyn. Biu hin lm sng chnh: au bng vng thng v lan ra sau lng, gy st, phn lng c m cha tiu ht, c 50% bnh nhn c i tho ng. Thm d chc nng ty ngoi tit b ri lon, mt s trng hp c c ri lon chc nng ni tit II. IU TR 1. Nguyn tc Vim ty mn c cn cp tnh iu tr nh vim ty cp. Dng thuc thay th chc nng ty b suy gim iu tr triu chng. Phu thut khi c tc nghn ng mt ty

2. iu tr ni khoa N u c cn cp tnh ca vim ty m n (iu tr xem bi iu tr vim ty cp tnh) C h n ung

+ K hng ung ru.

Khu phn 'n: Gim cht bo, tng cng ch't m v ng. Nn dng cc cht bo c nhiu triglycerid d c hp thu mc d thiu men ty nh: du vng, du u tng, du lc...

m bo dinh dng mi ngy t 2000 - 2500 calo. - Thuc ung c cha enzym ca ty gip cc qu trnh tiu ho bnh thng. Cc thuc c cha amylase, lipase, trypsin nh: Panzynor, Pestal, Pancreatan, Panthicone - F Liu dng da trn tnh ng lm sng, thng dng 3 - 6 vin/ngy cng vi ba n v cc enzym ty ch c hiu lc mi trng kim. C th phi hp vi bicarbonat Na, 1 - 3 gam trong mi ba n. Nu c suy chc nng ni tit gy i tho ng. Dng insulin theo phng php d liu chn liu iu tr thch hp. Khng nn hn ch bng ch n v bnh nhn vim ty mn tnh tnh trng dinh dng km. Thuc iu tr triu chng: + Thuc gim au: Tu theo mc au dng liu

Efferalgan C: Liu dng 0,5 g - 1 g/2 - 3 ln/ngy Paracetamol, codein phosphat, (Efferalgan Codein) Liu dng: 0,5 g - 1 g/1 - 3 ln/ngy Aspirin Liu dng 0,5 g - 1 g/1 - 2 ln/ngy Khi dng thuc gim au n cn ch n bnh l d dy t ng, nn cho ung thuc sau khi n, hoc cho cc thuc bc ph nim mc trc ri mi dng thuc gim au Visceralgin khi bnh nhn au nhiu, Khng nn cho thuc gim au c morphin + Nu c nang gi ty nh hn 2 cm nn theo di trn siu m, nu nang to ra hoc bin chng c th phu thut

2. iu tr ngoi khoa C si ty, si mt gy tc mt, tc ng ty, m dn lu ng mt, ng ty, ly si mt, si ty. Bnh nhn au bng nhiu, iu tn ni khoa khng c kt qu, c th phu thut chng au n hch v h thn kinh giao cm, thn kinh tng Nang ty ln c th m dn lu.

Nguyn Khnh Trch I. I CNG au l mt triu chng thng gp trong cc bnh ca b my tiu ho. C ch gy au c th do: - . Gin t ngt ng tiu ho Ngc li do co tht qu mnh (ch yu) Do thn kinh giao cm b chn p kch thch

Trong mi c ch gy au u c vai tr ca co tht cc mch mu gy ra thiu mu cc b, s thiu mu ny c t nhiu cng gp phn gy ra au.

II. CC THUC CHNG c o THAT y l c ch chnh gy ra au trong nhiu bnh ca b my tiu ho.
Thuc thuc nhm ny c 3 loi chnh: 1. Nhm chng chon (hoc nhm c i lc vi thn kinh: anticholinergic hay neurtrope) Trong nhm ny c 2 phn nhm: Nhm chng th th muscarid: i din l atropin v belladon - ngoi tc dng gim au cn c tc dng lm gim bi tit, c th gy mt s" tc dng ph nh gy kh ming, gin ng t, gy kh i... Nhm gy lit hch hoc chng nicotin: ch c hai bit dc hay c dng: Ttrathylammonium v Hxamthionium. V d: probanthino Chng ch nh ca hai nhm thuc ny l tin lit tuyn, glaucom

2. Nhm i lc c hoc nhm khng chng choin Musculotrope hoc cn gi anticholinergic chng c tc dng trn cc c n hoc n cc m ri Auerbach m khng thng qua vai tr trung gian ca h thng thn kinh t ch (systeme nerveuse autonome...) i din cho nhm ny l papaverin, rt tic l tc dng ca papaverin ln co bp ca rut rt yu nn khng c dng n ch c tc dng i vi co tht ca ng mt. 3. Nhm hn hp Phi hp mt cht chng au mnh l noramidopyrin vi cc thuc thuc nhm i thn kinh hoc vi c hai nn nh noramdopyrin c th gy tc dng khng mong mun thm ch c th gy t vong, tuy rt him. Mt s thuc chng co tht thng thng c trn th trng Vit Nam:

Nhm i thn kinh:

Atropin Buscopan Diaspasmyl Librax Prantal Priamid Probanthin Spasmocarbin Viscralgin

Nhm i c:

Debridat Duspatalin Mtospasmyl Spasfon No-spa

Nhm hn hp:

Algobuscopan Avaortan Baralgin Viscralgine forte.

Cc thuc trn c th phi hp vi nitroglycerin ngm di li s lm tng tc dng chng au v tc dng nhanh hn. III. CC THUC CHNG AU KHNG THUC NHM CHNG COTHAT Thng c dng trong cc trng hp au khng do co tht nh au do cc khi u, au nh khng r nguyn nhn... 1. Nhm khng c morphin - Nhm paracetamol: - Nhm salicylat: - Nhm fnoprofne: - Nhm ibuprofne: - Nhm ktoprofne: - Nhm tiaprofne: - Nhm diclonac: - Nhm poxicam: - Nhm fenoxicam: Efferalgan, Dafalgan, Prodafalgan. Aspirin, Aspirin 8 Nalgsie. Oralen, Ibupron Profenid Burgam,Tiafen. Voltaren, Xenid. Felden. Tilcotil.

2. Nhm gim au ph hp vi morphin nh - Nhm c codein - Phi hp vi paracetamol: Efferalgan codein Dafalgan codein, Panadol codein.

3. Nhm hn hp thuc gim au v morphn Timgesic . Nubain 4. Nhm morphn Moscontin Skenan Dolosal Fortal II. CCH DNG THUC 1. au khng do co tht Tu theo mc au m dng cc loi thuc khc nhau. C th chia 3 mc khc nhu: Mc 1: au nh, dng cc thuc gim au n thun, nhtig a s cc thuc ny thng hay gy vim, chy mu tiu ho ( paracetamol) nn phi theo di cc bin chng ny. Mc 2: au va: Dng cc thuc gim au c phi hp codein hoc dexopropoxyphen Mc 3: au nng: Dng cc loi thuc l morphin. 2. au do co tht Mc 1: Ch dng cc thuc chng co tht Mc 2: Dng cc thuc chng co tht, nu khng c th phi hp vi cc loi thuc chng au gim vim nh Voltaren tim. Mc 3: Dng cc thuc chng co tht nu khng c kt qu th dng cc thuc thuc nhm morphin nh Dolosal, Fortal, nhng khng nn ng morphin, morphin lm tng co tht ng mt, lm gim mnh co bp ng tiu ho.

Nguyn Khnh Trch I. I CNG Chy mu tiu ho cao l t rut u tr ln n thc qun, hay ni mt cch khc l chy mu t cc b phn nm trn mc treo i trng ngang bao gm phn u ca rut u, t trng, gan mt, d dy, v thc qun. Nguyn nhn gy chy mu rt phc tp, iu tr phi ph hp vi tng nguyn nhn. II. NGUYN TC 1. Phi tm mi cch b s lng mu mt cng sm cng tt. 2. Phi sm tm ra nguyn nhn gy chy mu, cng sm cng tt. ng thi cng l cm mu cng sm cng tt. 3. iu tr thch hp theo tng nguyn nhn. III. IU TR CHUNG 1. B i s' lng mu mt Tt nht l truyn mu ton phn. Khng nhng b li s mu m cn gip cho sm hnh thnh cc mu ng. Ngi ta c th dng thm hemocaprol ung (1 0 -4 0 ml) gip hnh thnh sm cc mu ng ny. Nu khng c mu th c th dng cc ch't thay th mu nh: Huyt tng. Dung dch albumin. Gelafundin.

Nu khng c cc cht n ta c th dng huyt thanh nh huyt thanh mn, glucose ng trng ringger lactat hoc cc dung dch nh alvesin, cavaplasma, nutrisol... S lng dch truyn nhiu hay t tu theo lng mu chy, tn s mch, con s" huyt p ng mch. Nu c chong phi chng chong: Nng huyt p bng clopamin, th oxy, m... 2. Sm tm nguyn nhn da vo Lm sng, Chp X quang d dy: Cng sm cng tt. Ni soi d dy t trng: Quan trng nht.

Siu m gan mt: Chp mch mu nu cn. Trong khi tin hnh ni soi cp cu tm nguyn nhn c th tin hnh ng thi cc bin php cm mu qua ni soi.

3. iu tr theo tng nguyn nhn Do lot d dy t trng, ung th d dy. - Cm mu qua ni soi: + t bng in, laser + Tim dung dch adrenalin 1/10.000, hoc polidocanol + + + + Kp bng kp kim loi Cimetidin: 1 g/ngy, nh git tnh mch. Losec tim: 40 mg/ngy: Tim tnh mch hoc truyn nh git tnh mch. Dng trong 3 ngy u, sau dng thuc ung. Mopral ung, nu khng c thuc tim - 40 mg/ngy. Thuc chng bi tit HC1 ng tim:

Do polyp d dy: t cung polyp bng in Ct polyp cp cu.

Do v tnh mch thc qun h gin: Tim x tnh mch bng polidocanol hoc histoacryl (nu gin tnh mch d dy). - t sonde cm mu: Sonde Linton, Blacke - More, sonde Bertrand michel. Cc thuc lm gim p lc tnh mch ca: + + + Sandostatin: Tc dng khng r rng, kt qu tri ngc nhau tu theo tc gi. Do t dng. Stilamin (Somatostatin) c tc dng gim p lc tnh mch ca tt hn. Dng ng 3mg pha vi dung dch mui ng trng truyn tnh mch 12 gi. Vasopressin: 0,4 /pht, truyn tnh mch, duy tr liu, hiu qu 12 - 24 gi sau gim liu.

+ Terlipressin (Glypressin) c tc dng tt hn vasopressin. liu lng: <50 kg: 1 mg >70 kg: 2 mg tim tnh mch, c 4 gi 1 liu nh trn. Khng c dng qu 5 ngy. C th dng cc thuc trn phi hp vi nitroglycerin tc dng c tng hn v nhanh hn. Cc thuc gim bi tit HC1: Nh trong lot d dy t trng. Cn phng hn m gan: Xem bi iu tr hn m gan.

Chy mu ng mt: Truyn mu v theo di, nu c nguy c e da tnh mng bnh nhn cn gi m, hoc chy mu ko di trn 7 ngy khng cm cng nn gi m.

4. C h n Trong khi ang chy mu, n ch lng nh nc cho, sa, nc tht, nc hoa qu... n nhiu ba, khng nn bnh nhn i. Khi chy mu cm, cho n c dn tr li. 5. Theo di mu cm chy hay cha t sonde vo d dy Theo di mch huyt p 1 gi, 2 gi, 3 gi mt ln tu theo tin lng v mc chy mu. o huyt p tnh mch ung tm Xt nghim cng thc mu, nh lng huyt sc t", o hematocrit 4 gi 1 ln hoc lm hng ngy.

6. iu tr ngoi khoa - Chy mu nng m khng c mu hoc cc cht thay th mu. - Ni soi thy mu pht thnh tia mch m khng c kp kim loi cm mu. iu tr ni tch cc v ng cch trong 24 gi m mu vn tip tc chy. Tin s chy mu nhiu ln: Khng nn ch n lc cm chy mu mi gi m.

IV. P DNG THC T 1. Ti nh Nm u th'p, b't ng trn ging. - t ng polyten vo tnh mch truyn dch. - Nu c chong th chng chong: Th oxy, thuc nng huyt p. Sau chuyn n bnh vin.

2. Ti bnh vin - Nm u th'p, bt ng n ging. - t ng polyten vo tnh mch, nu xp mch th t catether vo tnh mch di n, tnh mch cnh. - Truyn mu hoc cht thay th mu. Nu c chong th chng chong: Th oxy, nng huyt p, m. Thm khm lm sng k hn. Xt nghim mu: CTM, Hb, hematocrit Chun b cho bnh nhn ni soi hoc chp X quang d dy. t ng thng d dy, hoc ng thng Blacke - More, ng thng Linton.

IU TR CHNG KH TIU (Dyspepsia)

Phm Th Thu H I. I CNG Chng kh tiu l triu chng r lon chc nng ca b my tiu ho ch yu d dy, nhtig khng tm thy tn thng thc th d dy, c ch gy chng kh tiu kh phc tp c th do ri lon chc nng vn ng ca d dy v km s iu ph'i vn ng co bp gia d dy v t trng lm tng nhu ng ngc chiu, hoc gim nhu ng gy ng thc n trong d dy lm gim s nhy cm ca nim mc d dy, gim chc nng bo v nim mc d dy. Triu chng chnh ca bnh: y bng, nng bng, au tc bng, nng rt bng sau khi n, nng hn c th gy bun nn hoc nn xy ra tng t hoc thng xuyn. II. IU TR 1. C h n Trnh cc thc n ung d kch thch nh: Ru, bia, nc ung c hi, thuc l. n iu theo thi gian ba n trong ngy khng nn n cc thc n kh tiu: thc n nhiu m, tht rn, hun khi, rau qu c nhiu cht x: da, c. Khi n nn nhai k, n chm.

2. Ch thuc men Dng cc thuc lm tng nhanh s vn chuyn thc n t d dy xung mt v iu phi vn ng hang v - t trng. C th dng mt trong cc loi thuc sau: + Domperidone maleate (Motilium - M) l loi thuc khng c tc dng n trung tm thn kinh trung ng ch c tc dng n thn kinh ngoi bin lm bnh thng ho v iu phi nng lc vn ng ca d dy t trng bng cch khng th th dopanim ti ng tiu ho vin 10 mg. T 20 - 60 mg/ngy iu tr 1 t t 7 n 10 ngy. + Cisapride (Prepulsid) tng cng iu ph'i c nng vn ng y ti ca d dy - rut gip chng li s tr v tro ngc dch tiu ho. Prepulsid, khng c tnh ch't khng dopamin v khng kch thch th th cholin nn khng c tc dng ph Vin 5 mg, hn dch ung 1 mg/1 ml

Tu thuc mc bnh nng nh 1 5 -4 0 mg/ngy chia lm 2 - 4 ln trc ba n, trc khi rig. + Metoclopramid HC1 (Primperan) tc dng qua t chc li thn no. Vin 10 mg, ng 10 mg/2 ml tim bp hoc tim tnh meh Dung dch ung Liu lng 1 -3 vin/ngy, ung 1 - 2 mung c ph/ 2 ln Tim 10-20 mg/ngy Khng nn dng thuc bnh nhn c xut huyt d dy rut. Cc thuc chng acid v bc ph nim mc d dy. Khng nn dng cc thuc chng acid mnh. Nn dng cc thuc trung ho H+ ca acid chlohydric lm cho HC1 khng cn hot ng. Cc thuc thuc nhm ca mui aluminium v magnesium Gastropulgit ngy 2 - 4 gi chia 2 ln trc khi n 1 gi. Maalox vin nn ngy 2 - 4 vin nhai ngm/ngy, sau khi n Huyn dch: 1 mung canh/ 2 ln/ngy sau khi n. Polycilane gel ngy ung 2 - 4 gi/2 ln/ngy Phosphalu gel ngy ung 2 - 4 gi/2 ln/ngy. Cc thuc h tr s tiu ho d dy rut bao gm ccvitamin,men tiu ho v tinh cht ty tang. Khng nn dng thuc ny ko div nh hng n s bi tit dch tiu ho. .

Vin nang Neopeptin ngy ung 1 - 2 vin chia 1 - 2 ln. Panthicone - F ngy ung t 1 - 2 vin chia 1 - 2 ln. Zymoplex vin nang 4 - 6 vin/ngy chia 2 - 3 ln.

IU TR GIUN SN NG TIU HA
Nguyn Khnh Trch I. I CNG Bi ny ch ni n cc loi giun sn ng tiu ha m khng ni n iu tr cc loi k sinh vt ca gan v ng mt. Giun sn ng tiu ha l hay gp nht trong nhim KSV tiu ha, c ti 70% dn s mc bnh giun sn, thng nhim nhiu loi giun cng mt lc. S dng thuc giun sn cn ch mt s" vn sau y : 1. Cc thuc chng giun sn t nhiu c c tnh, nht l vi gan thn v tim. Cc thuc mi hin nay t c hn, nhhg khng phi hon ton khng c, do khng nn dng ba bi. 2. Nn dng thuc c tc dng vi nhiu loi giun sn. 3. Cn th phn trc v sau khi ung thuc. Nu khng sch giun th nn ty ii, nhng phi lu thi gian ngh thuc gia 2 ln. 4. Cn thn trng vi tr em nh, ph n c thai, ngi gi, ngi mc bnh gan, thn, tim mch. 5. a s" cc thuc hin nay khng cn dng kt hp vi thuc ty v nhn n. Nu cn phi dng thuc ty th phi dng ng lc. Trong v sau khi dng thuc 12 gi khng c ung ru, bia. II. GII THIU CC LOI THUC 1. Piperan: Bit dc Antepar (pip hydrate) sop ng l 125 ml, 5 ml = 0,33 g pip hydrate. Piperazin c itra t: sirop, l 150 ml. Piperazin vin 0,25 g hoc vin n Vermiuge: gm piprazindrate v bromure Na. c tnh: Thuc c hp th rut non, o thi qua nc tiu. C ch tc dng: Gy lit k sinh vt. Tc dng: Giun a (+) giun kim (+++) Chng ch nh: Suy gan thn, ng kinh. Tc dng ph: Nn, co git, git c, chng mt. Liu lng, cch dng: u n g bui sng, lc i:

Cch 1: 50 mg/kg/ngy 1 - 6 tui: > 12 tui: 1 tha c ph so/ ngy 3 tha c ph siro/ ngy 7 - 1 2 tui: 2 tha c ph siro/ ngy Giun kim: Dng 2 t, mi t 7 ngy, cch nhau 1 5 -2 0 Giun a: Dng 1 t 3 - 5 ngy Cch 2: Giun a: Ngi ln: 75 mg/kg/ngy trong 2 ngy - ti a 4 ngy Tr em: 150 mg/kg/ngy c th dng li sau 2 ngy. Giun kim: Ngi ln: 75 mg/kg/ngy trong 7 ngy, liu ti a 4 g/ngy. Tr em: 150 mg/kg/ngy Trong 7 ngy, c th dng li sau 2 tun. Cch 3: dng piperazin vin. Giun kim: Trn 10 tui: 5 - 1 0 tui: -1 -5 tui: Di 1 tui Trn 10 tui: Di 10 tui: 6 v/ngy chia 2 ln, sng v chiu dng trong 2 ngy. 4 v/ngy trong 2 ngy, chia 2 ln (sng v chiu). 2 v/ngy trong 2 ngy, chia 2 ln (sng v chiu) 0,05 g/kg/ngy 1 vin sng, 1 vin chiu. 1/2 vin sng, 1/2 vin chiu.

Piperazin vin n: B sung cho piperazin vin.

C th dng li sau 1 5 -2 0 ngy. Giun a: Dng nh trn, nhtig ch dng 1 ngy, khng cn dng vin n b sung. 2. p y ran tel: bit c Helmintox Combantrine vin 125 mg, vin 250 mg, nh dch 750 mg c tnh: Rt t hp thu rut, 50% o thi qua phn, 1% o thi qua nc tiu. C ch tc dng: Lm lit KSV Tc dng: giun kim (+++), giun a (+++) Giun m necator Tc dng ph: Nn, r lon tiu ho, co git, git c, chng mt, nhc u. Chng ch nh tng i: suy gan, c thai. Cch dng, liu lng: Trung bnh 10 mg/kg/ngy, ung 1 ln giun a, giun kim: Di 75 kg 6 vin hoc 6 tha c ph. Ngi ln: Trn 75 kg 8 vin hoc 8 tha c ph. i vi giun kim cn ng li sau 2 - 3 tun.

Giun mc:

Nh dng nh trn. Nng, loi giun m necator dng liu gp 2 trong 2 - 3 ngy, hoc dng 20 mg/kg/ngy trong 2, 3 ngy (d ancylostoma t ng)

3. Levamisol: Bit dc: Ketrax vin 40 mg sop 40 mg/5 ml Decaris: vin 50 - 150 mg Hacaris vin 40 - 150 mg Solaskil vin 30 - 150 mg c tnh: Hp thu c qua nim mc rut, o thi qua phn v nc tiu. Tc dng: Giun a +++, giun mc hay giun m necator ++ Tc dng ph: Nn, bun nn, au u, h bch cu. Cch dng, liu lng: Giun a: Ngi ln: 2,5 mg/kg/ngy hoc 150 mg/ngy ung 1 ln sau khi n bui sng. C th dng li sau 2 tun. Tr em 2,5 - 3 mg/kg/ngy Giun mc: Cch 1: Dng nh trn Cch 2: Ngi ln 300 mg/ngy X 1- 2 ngy. Tr em: 6 mg/ngy X 1 - 2 ngy C th dng li sau 2 tun. 4. ThabendazoI (hoc tiabendazole) Bit dc: Mintezol vin 500 mg, sop 100 mg/5 ml Tc dng: Giun a (-H-), giun mc, giun m necator (++), giun ln (Strongyloid) (++) Liu lng, cch dng: Giun a, giun mc: Ngi ln 2,5 mg/kg/ngy ong 2 ngy. Ti a dng 3 ngy. Tr em: 5 mg/kg/ngy, trong 2 ngy. Ti a 3 ngy. Mebendazol Bit dc: Vermox, Fugacar vin 100 mg sirop 20 mg/ml l 30 ml. Tc dng: Giun a (+++), giun mc, giun m necator (+++), giun kim (++) Tc dng ph: Chng bng, a chy. Cch dng, liu lng: Giun a, giun mc, giun m necator: Ngi ln, tr em 10 kg
100 mg X 2 ln/ngy dng ng 3 ngy.

Giun kim: Ngi ln, tr em 7 kg. 100 mg X 1 ln trong ngy, ch dng 1 ngy. 5. Flubendazol: bit dc: Fluvermad vin 100 mg, nh dch 600 mg/30 ml (1 tha c ph = 100 mg). c tnh: Rt t hp thu qua rut, o thi qua phn.

C ch tc dng: c ch men hp thu thc n ca KSV Tc dng: Giun kim, giun a, giun tc, giun mc Chng ch nh: C thai Cch dng, liu lng: Ngi ln, tr em liu ging nhau, khng cn nhn i, khng cn ty, ung vi nc hoc nhai khi n. Giun kim: 1 vin hoc 1 tha c ph, ung 1 ln ong 1 ngy. C th dng li sau 1 5 -2 0 ngy. Giun a, giun mc, giun tc: 1 vin hoc 1 tha c ph, ung bui chiu, ung trong 3 ngy. 6. Albendazol Bit dc: Zentel vin 200 mg. nh dch 400 mg/20 ml. c tnh: Hp thu hon ton qua rut, o thi hon ton qua nc tiu. m cao nh't trong mu 2gi30 sau khi ung. i sng bn hu l 8gi30 C ch tc dng: c ch k sinh vt hp thu glucose Tc dng: Giun kim, giun a, giun mc, giun tc (trichiuris, trichiura) giun ln, sn dy. Chng c nh: C thai Cch dng, liu lng: Ngi ln, tr em > 2 tui. Liu lng ging nhau. Giun kim, giun a, giun mc, giun tc: 400 mg/ngy mi ln = 2 vin hoc 200 ml nh dch) ung 1 ln. Giun ln, sn dy: 400 mg/ngy X 3 ngy iu tr giun kim cho tr 2 tui: 100 mg/ngy ung 1 ln hai ngy sau ng li. 7. Niclosamid: Bit dc Yomesan vin 500 mg Tredemin vin 500 mg c tnh: Khng hp thu qua rut. C ch tc dng: Ngn chn chu trnh cytric ca qu trnh chuyn ho hydrocarben ca sn, lm sn cht. Tc dng: Ch yu vi sn dy b, sn dy ln (bothiocphal). Chng ch nh tng i: C thai Cch dng, liu lng: Chiu hm trc n nh v nhn i n khi ung thuc 24 gi sau khi ung thuc khng c ung riu, bia. Phi nhai k vin thuc. 3 gi sau khi ung vin cui cng mi c ung v n. Sn ln (sn ln, sn b, sn l) Ngi ln, tr em 7 tui: Bui sng nhn i, nhai 2 vin, 1 gi sau nhai 2 vin. Tr em 2 - 7 tui: bng 1/2 liu n.

Tr em 2 tui bng 1/4 liu n. Hoc tnh theo cn nng: Trn 35 kg: 1,5 g 10 - 35 kg: 1 g Sn d nh nain (hymenoepsis nana) phi dng 7 ngy. Ngi ln, tr em 7 tui Ngy th n h t: Nhai 4 vin 6 ngy tip theo: Mi ngy nhai 2 vin, cui ba n Tr em 2 - 7 tui: bng 1/2 liu trn. 2 tui: bng 1/4 liu trn. Nn ung nhiu nc hoa qu lm sch cht nhy che ph con sn. 8. Prazquantel, Bit dc: Bilicid vin 60 mg C ch tc dng: 0,4 ig/ml lm sn co li, ri lit, v ca sn b nhng l hng. Thuc c th ngm vo mu 1 - 3 gi sau m ti a, i sng bn hu l 1 lg 3 0 \ Thuc o thi ch yu qua thn (80%). Tc dng: Bilhaizios: sehistosomia hematobium, interculatam,japonicum, mansoni. Distomatose: Chlonorchis sinensis, paragonimus Westermani. Trong thc t cn dng iu tr sn ln, kn sn ln (da, ni tng...) tuy trong y vn khng ni n. Chng ch nh: Kn sn mt. Tng tc: Dexamethason lm gim nng thuc. Cch dng, liu lng: Khng nhai vin thuc, ung vi nc, sau l n cm. Nu ung nhiu ln th khong cch gia 2 ln khng c di 4 gi v khng c qu 6 gi. Schistosome: 40 mg/kg u"ng 1 ln, trong 1 ngy (hemat, mansonie, interculat). Schistosomia japonicum: 60 mg/kg ung 1 ln hoc 2 ln (mi ln 30 mg/kg) trong 1 ngy. Chlonorchis senensis, opisthorcis vivenini: 25 mg/kg/ln ung 3 ln trong 1 ngy. Paragonimus west: ung nh trn nhtig phi ung 2 ngy. Ch : Ph n c thai trong 3 thng u khng nn dng, mc thuc khng c vi thai v khng gy dng, thn trng th vn khng nn dng. Ph n ang cho con b vn c th dng c vi iu kin con khng b m ong khi dng ihuc v 72 gi sau khi ung vin cui cng.

BNG TM TT Giun a: Giun mc: Giun kim: Giun ln: Giun tc: Sn l gan: Levamisol, albendazol, pyrantel, mebendazol , thiabendazol, piperazin. albendazol, mebendazo, levamisol, pyrantel, thiabendazol. Piperazin, flubendazol, mebendazol, pyrantel, albendazol. Mebendazol, albendazol, thiabendazol Mebendazol, flubendazol, sebendazol Dehydroemetin, albendazol, praziquantel. niclosamil, praziquantel, albendazol niclosamid Praziquantel, thiabendazoI Praziquantel, Oxamniquine (vansil)

Sn dy (ln v b) Hypmenolepsis nana Botriocephale u ng sn ln

Sn mng (Schistosoma)

Phn V C XNG KHP

THUC CHNG VIM CORTICOSTEROID TRONG IU TR BNH KHP
Trn Ngc n Nguyn Vnh Ngc I. I CNG Nm 1935 Kendall phn lp tinh cht v thng thn. n nm 1948 Cortison c tng hp v s dng rng ri n lm sng. Cc hormon v thng thn l cc corticosteroid, gm ba nhm l glucocorticoid (c tc dng chng vim) v mineralocorticoid (c tc dng chuyn ho nc v in gii lm gi nc) v androgen (ni tit t" sinh dc nam testosteron). Trong lm sng ngi ta s dng cc glucocorticoid tng hp c tc dng chng vim mnh v t tc dng ph trn chuyn ho nc v in gii hn. II. PHN LOI SINH HO CA CC GLCOCORTICOID TNG HP, LIN QUAN GIA CU TRC V HOT TNH CHNG VIM Cc glucocorticoid tng hp u l dn xut t nhn steroid c 17 phn t carbon. Chng c phn loi theo cu trc sinh ho, chnh cu trc ny quyt nh thi gian bn hu, tnh cht chng vim v c cc tc dng ph. 1. Cortison L glucocorticoid u tin c tng hp nm 1944. Thuc c tc dng chng vim nhng cng c hot tnh gi nc ca mineralocorticoid. 2. Hydrocortison L dn xut ca cortison, c hydroxyl ho C u . Thuc c thi gian bn hu trong huyt tng khong 2 gi, thi gian bn hu sinh hc t 8 - 12 gi. Tc dng chng vim gp 1,5 ln cortison, nhng vn cn nhiu hot tnh chuyn ho khong. Thi gian km hm tuyn yn ngn (24-36 gi). 3. Cc dn xut "delta" Chng c thm mt lin kt kp gia carbon 1 v 2 so vi cortison v hydrocortison. Tng ng vi cortison l delta-cortison hay prednison (Cortancyl, Beviprid..). Tng ng

vi hydrocortison l delta - hydrocortison hay prednisolon (Hydrocortancyl, Solupre...). Prednison v prednisolon c thi gian bn hu v hot tnh chng vim cao (tng ng l 2 v 4 ln) v hot tnh chuyn ho khong gim (bng 0,8 ln) so vi hydrocortison. S km hm tuyn yn cng ngn hn. 4. Cc dn xult luo ho, methyl ho, hydroxyl ho ca prcdnison v prednisolon Cc dn xut ny c fluo ho C6 v C9 hay hydroxyl ho C6 hay c 16: Methylprednisolon (Betalon) hay methylprednisolon (Merol) l dn xut methyl ho ca prednison v prednisolon. Paramethason (Dilar), betamethason (Bennesol, Celesten, Diprosten), dexameihason (Decadron, Dectancyl) l cc dn cht fluo ho v methyl ho ca prednisoon. Cortivazol (Diastcr, Atim)...

Cc thuc ny, theo th t trnh by c cc c trng sau: Thi gian bn hu huyt tng v sinh hc cng di, hot tnh chng vim cng cao, hot tnh chuyn ho khong cng gim, thi gian km hm Luyn yn cng di. Tuy nhin, d c ih lng kh nng chng vim, khng c mt cch thc no c th trnh c cc hu qu ni tit chuyn ho, thm ch c Ih gy t vong ca corticoid. V d so snh vi hydrocortison: Methylprednisolon c tnh cht chng vim gp 5 ln, tc dng gi nc gim i mt na v thi gian km hm Luyn yn ngn. Betamethason c tnh cht chng vim mnh gp 25 ln, t gi nc hn 10 ln v thi gian km hm tuyn yn ln hn 48 gi. Cortivazol c tc dng chng vim mnh hn 60 ln, tc dng gi nc gim 10 ln v km hm luyn yn rt lu. Cortison v cc dn xut Cortison Delta cortison (Prednison) fluo, methyl hydroxyl ha Hydrocortison (O H C n) Delta hydrocortison (Prednisolon) Cc dn xut

III. CC TC DNG Dc L 1. Tc dng sinh l v c ch Cc tc dng sinh l ny u c th tr thnh tai bin trong qu trnh iu tr. 1.1. Tc dng trn chuyn ho protd Gim chuyn acid amin vo t bo v tng d ho protid, acid amin tun hon lng v bilan m tnh. Hu qu l teo c, gim khung protein ca xng v gy mm xng. 1.2. Tc dng trn chuyn ho glucid Cc glucocorticoid c tc dng tng ng ho glucid do: Tng hot ng ca cc men tn to glycogen nh glucose -6-phosphatase, fructose 1,6 -diphosphatase, carboxykinase... Chuyn acid amin tng trong tun hon do d ho protid thnh glucid. Lm gim tit insulin, tng tit glucagon.

Tt c cc c ch trn dn n hu qu l tng ng huyt. 1.3. Tc dng trn chuyn ho lipid Cc glucocorticoid gy phn b li lipid ong c th, tp trung nhiu m mt, c, vai, bng, gc chi. 1.4. Tc dng trn chuyn ho phosphocalci Thuc nhm ny lm gim hp thu calci rut do i khng vi vitamin D v tng thi calci qua thn. Do , bilan calci m tnh, calci mu gim, gy cng ph gip trng, tng tit hormon cn gip (PTH), calci s c ko t xng ra, gy tiu xng. Thuc cn gy gim ti hp thu phospho ng thn. 1.5 Tc dng trn chuyn ho nc v in gii Thuc c mt s tc dng ging nh aldosteron nhtig km v mc : Tng ti hp thu Na+ ng ln xa, km theo nc, nn c th gy ph v tng huyt p. Tng thi tr K+ v H+, dn ti kim huyt v gim K+ mu.

1.6. Tc dng trn h thng tim mch Do tc dng gi Na+ do gi nc, lm th tch mu tng. Mt khc, c s co mch, do thnh mch tng nhy cm vi cc yu t" co mch ni sinh (renin, cathecholamin, vasopressin). Hu qu l gy tng huyt p, suy tim mt b. 1.7. Tc dng trn h hg tiu ho Do gim tng hp prostaglandin E l, E2 v mucin l nhng yu t tham gia vo c ch iu ho bi xut v bo v d dy - t trng m cc glucocorticoid c th gy cc tai bin v tiu ho: T vim nim mc, lot, n cc tai bin nng, c th gy t vong nh chy mu, thng d dy - t trng v vim tu.

1.8. Tc dng trn h thn kinh trung ng Kch thch, gy sng khoi, bn chn, mt ng hoc co git, trm cm do nh hng ca s trao i nc-in gii ca dch ngoi t bo. 1.9. Tc dng trn khu no - tuyn yn Cc glucocorticoid c ch sn xut pro-opiomalanocortin - ch't tin thn chung ca ACTH, P-lipotropin, v p-endorphin, dn ti gim lng ACTH, do m teo v thng thn. 2. Cc tc dng chnh c dng trong iu tr Trn c s cc tc dng sinh l nu trn, c 3 loi tc dng ca glucocorticoid c p dng ong iu tr l chng vim, chng d ng v c ch min dch. Tuy nhin, cc tc dng ny ch t c khi nng thuc ong mu cao hn nng sinh l. l nguyn nhn d dn n cc tai bin trong iu . Thc t, c ch ca cc glucocorticoid rt phc tp v chng c nhiu tc dng ln mt t bo ch, v li c nhiu t bo ch chu tc dng ng thi. 2.1. Tc dng chng vim Glucocorticoid tc dng trn nhiu giai on khc nhau ca qu trnh vim, khng ph thuc vo nguyn nhn gy vim. y l l do lm thuc c s dng rng ri trn lm sng, i khi qu lm dng. C ch chng vim ca cc corticoi tng hp nh sau: 2.1.1. C nh trn cc th th c hiu trong t bo Do c c tnh ho tan, cc corticoid d dng qua c mng ca tng bo. Ti bo tng, n c c nh trn th th c hiu sau khi tch ra t mt protein c gi l HSP 90 (Heat Shock Protein) m n lin kt ti . Nh vy, s to thnh phc hp corticoid - th th c hiu din ra sau khi s di chuyn ca n vo trong nhn. n lt mnh, phc hp ny c nh trn cc v tr chnh xc ca ADN nhn v dn n hoc l tng, hoc gim hot tnh ca gen ln cn. Trong s cc protein c tng hp di tc dng ca s iu ho ny, mt s" c tc dng chng vim ca glucocorticoid v chng c m ho cc thc phn ng sinh hc nhm sn xu't ra cc trung gian vim. 2.7.2. Tng hp lipocortn Cc lipocortin (macrocortin, lipomodulin, renocortin) l cc protein tn ti trng thi bnh thng trong a s t bo. S hot ho, s tng hp v gii phng chng bi corticoid gy ra nhiu hiu qu chng vim. Ngi ta chng minh c hot ng khng phospholipase A2 ca cc lipocortin lm gim cc cht trung gian ho hc gy vim chnh. hiu chnh xc hn tc dng ca lipocortin, cn thit phi m t cc iTin tng trong ni bo c ngun gc phn ng vim: Tt c cc phn ng vim c bt u bng s chuyn ho phospholipid mng thnh acid arachidonic di tc dng ca phospholipase A2. n lt mnh, acid arachidonic sinh ra prostaglandin (theo con ng cyclooxygenase) v thnh leucotrien (theo con

ng lipooxygenase). Cc cht ny tham gia mnh m vo qu trnh vim. Cc prostaglandin tc ng ng trn thnh phn mch mu ca qu trnh vim bng cch gy nn hin tng gin mch v tng tnh thm thnh mao mch. Chng khng tc ng vo cc i thc bo, song dng nh c tc ng km hm i vi chc nng ca lympho bo (sn xut lymphokin) Leucotrien l cht ho hc c bit mnh, cng tham gia vo giai on t bo ca vim. Chng tng tc trn hot ng ca cc i thc bo v gii phng ra cc men. Do hot tnh khng phospholipase A2, cc lipocortin c th c ch to.acid arachidonic, c tc dng gim tng hp v gii phng prostaglandin, leucotrien, do lm ngng qu trnh vim. 2.1.3. c chphospholipase A 2 Corticoid c ch mnh m s sn xut cc cht trung gian ca qu trnh vim bng cch ngn chn, c th l khng c hiu, hot ng ca phospholipase A2. Hiu qu ny c th l khng trc tip, song xy ra do s tng hp lipocortin. Dng nh vai ca cht ny l ngn cn s tng tc gia phospholipid mng v phospholipase.
P H O S P H O L IP ID M N G G L C O C O R TIC O ID

A C ID A R A C H ID O N IC

Phospholipase A2 Lipocortin

S 2
C ch tc dri ca glucocorticoid v thuc chng vim khng steroid trong tn hp prostuglamiin, cht c vai tr chnh trong c ch vim. LOX: Lipo-oxygenase; COX: Cyclo-oxygenase.

Tm li: Kh nng chng vim mnh m ca corticoid l kt qu ca s ct t hin tng vim: Ngay t ngun g"c vim Vi s c ch ton b cc cht trung gian ho hc ca vim c pht sinh t acid arachidonic.

2.1.4. Hot tnh chng vim t chc Cc corticoid phn ng mnh v nhanh ngay t giai on khi pht ca qu trnh vim t chc. Vi giai on mao mch: Chng sa cha s gin mch v tng tnh thm mao mch ti vng tn thng. Do vy, chng khng li cc biu hin lm sng ca phn ng vim sm vn rt d di mt cch tuyt vi, l s ph v au.

giai on t bo: Nhiu hin tng cnh tranh nhm ct t qu trnh t duy tr ca phn ng vim: - c ch mnh s di chuyn bch cu v vim. - Lm gim hot ng thc bo ca i thc bo, ca bch cu a nhn, gim sn xut cc cytokin. - O Y i nh mng tiu th ca bch cu a nhn v i thc bo, do c ch gii phng cc men tiu protein, cc ion superoxyd (cc gc t do), lm gim hot tnh ca cc yu t ho hng ng, cc cht hot ho ca plasminogen, collagenase, elastase... - Giai on cui, cc corticoid tc ng ln s tng sinh ca nguyn bo x, do , ln s tng hp cc si collagen v mucopolysacharid. Do vychng c ch li c bit trong qu trnh tng sinh mn tnh v x ho. Tm li: Cc corticoid biu hin mt trng hot ng c khuych i c bit, chng tng tc nht trn 3 giai on ca qu trnh vim, vn c ngun gc dc l. Vi sc khng vim mnh m, corticoid lm gim nhanh chng s hn ch chc nng hoc ci thin tin lng c th e do cuc sng ca bnh nhn. 2.2. Tc dng khc ca cortcoid Cc corticoid thng c s dng iu tr ch yu nh tc dng chngvim, song trn thc t, chng cn chng d ng v c ch min dch. 2.2.1. Tc dng chng d ng Cc phn hg d ng xy ra do s gn ca cc IgE hot ho trn cc receptor c hiu dng bo (mastocyte) v bch cu kim tnh di tc dng ca d nguyn. S gn cc Ig^ ny hot ho phospholipase c , cht ny tch phosphatidyl-inositoldiphosphat mng t bo thnh diacyl-glycerol v inositoltriphosphat. Hai cht ny ng vai tr "ngi truyn tin th hai", lm cc ht bo tng ca t bo gii phng cc cht trung gian ha hc ca phn hg d hg: Histamin, serotonin... Bng cch c ch phospholipase c , cc glucocorticoid phong to gii phng trung gian ha hc ca phn ng d ng. Nh vy, IgE gn trn dng bo nhng khng hot ho c nhhg t bo . Do glucocorticoid l nhng cht chng d ng mnh. 2.2.2. Tc dng c ch min dch Glucocorticoid tc dng ch yu trn min dch t bo, t nh hng n min dch th dch, thng qua c ch: c ch tng sinh cc t bo lympho T do lm gim sn xut interleukin 1 (t i thc bo) v interleukin 2 (t T4).

Gim hot tnh gy c t bo ca cc lympho T (T8) v cc t bo NK (natural killer: T bo dit t nhin) do c ch sn xut interleukin 2 v intereron . Do c ch sn xut TNF v c intereron, glucocorticoid lm suy gim hot tnh dit khun, gy c t bo v nhn dng khng nguyn ca i thc bo.

Mt s tc dng ny cng ng thi l tc dng chng vim. Tc dng c ch min dch th hin khi ng liu cao (1-2 mg/kg/ngy prednisolon hay tng ng). Do c ch tng sinh, glucocorticoid c tc dng tt trong iu tr bnh lxmi th lympho, bnh Hodgkin. IV. DC NG HC: TM QUAN TRNG CA VIC Hiu BIT CC YU T SINH L, BNH L V IU TR 1. Dc ng hc Ph thuc vo s hp thu, phn phi, chuyn dng sinh hc v s thi tr ca thuc. - Hp th: Glucocorticoid c hp th qua cc ng: Ung, tim bp, tnh mch, hoc thm qua da. Liu duy nht 10 mg prednison ng u"ng c hp th hn 70% rut. S hp th cc corticoid ng tim ph thuc vo tng ch phm: Thm nhm C 21 lm tng tnh tan trong nc v tnh hp th (hydrocortison hemisuccinat), trong khi triamcinolon acetanid c hp th rt chm (nhiu tun). S hp th khc nhau gii thch rng tim bp hydrocortison acetat khng cho php t c nng huyt tng ong trng hp cp cu, c bit trng hp suy thng thn cp. Phn phi: Thuc c phn phi ton th. Tuy nhin mc thay i tu thuc theo ng dng v ho tan ca sn phm. Trong ng hp tim ni khp th chi c 5-10% thuc b khuych tn. Chuyn dng sinh hc: a s cc glucocorticoid hot ng m khng chuyn dng. Tuy nhin prednison v cortison cn gn thm mt OH v tr C 11 gan chuyn thnh prednisolon v cortisol c hot tnh. Thi tr: Cc glucocorticoid tng hp ch yu c thi tr bng ng thn.

2. Cc thay i sinh l, dc ng hc theo thi gian Vai tr ca tui: Thi gian bn hu tr em thp hn ngi ln, nht l do cc men. Cc thay i sinh l, dc ng hc theo thi gian: Thuc lin kt vi protein theo nhp ngy m, ban m nhiu hn ban ngy. Do hiu qu c ch di i ln nht khi ung thuc vo ban m. Sinh kh dng khng b thay i bi thc n, tuy nhin n lm x dch ng cong nng huyt tng trong vng 2 gi.

3. Cc thay i bnh l Gim albumin mu: L nguyn nhn tng tc dng ph (do tng thnh phn thuc trng thi jt do). c nhng cng b" v cc bnh nhn c h albumin mu r't d b hi chng gi Cushing. Vi cc bnh nhn b bnh gan: c bit nhng bnh nhn x gan nng, c s gim chuyn ho t prednison sang prednisolon. cc bnh nhn b bnh ng rut: nh huyt tng i khi gim song khng phi l km hp thu thc s. Tuy nhin, s gim sinh kh dng i khi gp, c th lin quan ti hoc s gim albumin mu hoc s s dng vin hp th rut.

V. CH NH TRONG CC BNH KHP 1. ng ton thn - Cc ch nh chnh l: Cc bnh h thng (collagenose), c bit khi c biu hin ni tng, vim khp dng thp giai on tin trin, thp khp cp c tn thng tim. Corticoid ch s dng nh thuc u tay ong bnh Horton v gi vim a khp gc chi, vim mch v bnh h thng nng. Thng hn l ngi ta ch dng corticoid sau khi dng thuc chng vim khng c hiu qu trong bnh h thng hay cc bnh khp vim (vim khp dng thp, thp khp vy nn hay him hn trong vim ct sng dnh khp v vim khp phn ng...). Corticoid cng c dng trong trng hp m khng nn s dng thuc chng vim khng steroid, v d ngi gi c lot d dy. C mt s" ch nh c bit dng corticoid liu thp, ong thi gian ngn: Vim quanh khp vai vi ho th tng au gi gy xng, gt hay ti pht, au thn kinh to m cc bin php iu tr ni khoa khc tht bi.

2. ng ti ch Vim khp mn tnh khng do nhim khun Trn dch khp gi khng do nhim khun, kn mng hot dch Vim mng hot dch th lng nt v sc t. Mt s trng hp thoi ho khp Vim quanh khp vai Vim cc khp lin mm sau ct sng. Vim gn
n h v t h n t r n g

VI. CHNG CHl

1. Chng ch nh Lot d dy t trng. i tho ng.

Tng huyt p. Lao cu hoc ang tin trin. Bnh nhim khun, virus, k sinh trng ang tin trin. c thu tinh th. Ph r c thai: Khi tht cn mi cho Tr em: Cho khi tht cn thit. Liu dng 1/2 mg/kg/24gi l nh hng n s pht in ca tr. Ngi c tui: Thng gy ri lon iu ho ng.

2. C a c bit

VII. CCH THC S DNG 1. Nguyn tc dng thuc Dng thuc khi c chn on chnh xc. Dng trong thi gian cn thit. Gim liu ngay khi c th. Theo di thng xuyn. Phng nga bin chng.

2. Theo thi gian iu tr Corticoid c th s dng theo phc iu tr ngn ngy hay di ngy. 2.1. Corticoid iu tr ngn ngy (trong vi ngy, thng hn 15 ngy) Thng dng liu cao, bng nhiu ng: ng, tim truyn tnh mch. C 3 phc iu tr. 2.1.1. Bolus hay fla sh t Pulse therapy (dng mt lng ln ong 1 thi gian ngn) p dng phc iu tr ca cc nh thn hc, s dng 1 gr methyl-prednisolon chng li phn ng thi li mnh ghp. K thut ny c s dng iu tr cc th nng ca cc bnh h. thng v mt s bnh khp vim khc, c bit l vim khp dng thp vi mc ch chn ng phn ng vim ong mt thi gian ng k do tc dng chng vim v c ch min dch ca cortison. Truyn tnh mch 750 mg - 1 gr methyl-prednisolon pha trong 250-500ml dung dch mui sinh l hay glucose ng trng trong 2-3 gi, dng mt liu duy nht hay 1 ln/ngy trong 2-3 ngy. Sau liu ny, gi tip bng ng ung vi liu tng ng prednisolon 1,5-2 mg/kg/24h. Ch nh trong trng hp c bit, phi theo di bnh nhn nghim ngt. 2.1.2. Corticod tn cng (assaut cortisonique) Dng tng liu 240 mg methyl-prednisolon, gim liu dn trong 6 ngy (60 mg/ngy trong 2 ngy, 40 mg/ngy trong 2 ngy tip theo, 20 mg/ngy trong 2 ngy cui). Liu ny cng c tc dng tng t liu bolus 1 gr hay nhiu hn v t tc dng ph hn. Ngoi ng truyn tnh mch c th tim bp do c th iu tr ti nh. Phc ny cho php kim sot c bnh vim khp dng thp trong 6-10 tun, cho cc thuc iu c bn pht huy tc dng.

2.1.3. Corticoid dng ngn ngy bng ng ung Tt vi bnh nhn ngoi tr, c th dng prednisolon 60 mg/ngy. 2.2. Crticoid iu tr lu di Thng dng ng ung, ung mt ln trong ngy vo ba n bui sng (8 gi sng) gim thiu nguy c c ch trc di i-yn-thng thn. Tuy nhin, tu theo tng bnh m c th chia nh liu theo cch thc khc nhau th mi c hiu qu. V d i vi bnh Still ngi ln, khi liu ban u cao, thng c chia nh, thm ch c th chia lm 5-6 ln trong ngy. Vi liu cao c th ung 2/3 liu vo bui sng v 1/3 liu cn li vo bui chiu. Cn bt u bng liu cao sau gim dn n liu thp nht c hiu qu. iu tr vi liu tn cng 10-15 mg prednison hay 1 mg/kg/ngy tu theo mc v loi bnh, trong vi tun. Sau khi c hiu qu th h' liu dn dn theo kiu bc thang cho ti liu duy tr. - c n c gng gim liu tip bng cch kt hp dng thm mt thuc chng vim khng steroid hay s dng liu gp i nhng cho cch ngy. V d mi ngy ung 1 vin th chuyn thnh cch mt ngy ung 2 vin mt ln, ngy sau ngh khng ung. vi nhng tnh ng stress th c th tng tm thi liu corticoid. Cch dng thuc: Khi corticoid dng lu di phi thn ng khi dng thuc, sau khi bnh n nh, c n thit phi dng test synacthen nh gi p ng ca tuyn thng thn. o nng cortisol mu trc v 60 pht sau khi tim tnh mch 1 ng 0,25 mg synacthen. Bnh thng nng cortisol c bn phi > 300 nmol/1 v phi tng ti thiu gp i pht th 60. Nu 2 s" ny bnh thng th c th dng thuc. Nu cortisol c s bnh thng nhng p ng km vi synacthen th cn dng corticoid khi b stress. Nu hai s" ny u gim th phi dng thuc h tr (hydrocortison 10 mg 2 ln/ngy (sng v ti).

3. Cc ng dng ng ung: S dng cc dng thuc vin nh cortison (25 mg), prednison (5 mg), prednisolon (5 mg), methylprednisolon (4mg), iamcinolon (4 mg), betamethason (0,75 mg), dexamethason (0,5mg). ng tim bp hay tim tnh mch: Ch dng trong trng hp tht cn thit. Dng cc thuc nh hemisuccinat hydrocortison, solumedrol... ng tim bp hin nay hu nh khng c s dng trong khp hc v cc tc dng ti ch kh nghim trng (teo c, nguy c nhim khun). ng ti ch (tim trong hay cnh khp, tim ngoi mng cng, tim vo trong 'ng sng): Phi c bc s chuyn khoa ch nh v tun th v khun cht ch. C c ch phm nh Hydrocortancyl, Depomedrol, Disprospan..., thng c ch nh trong au tht ltig cp, au thn kinh to, tn thng vim vi khp (phi loi tr nguyn nhn nhim khun), hi chng ng hm, tn thng bao khp (vim quanh khp vai).

4. Liu dng (tnh theo prednsoon) Liu thp: 5-10 mg/24h, trung bnh: 20-30 mg/24h, liu cao: 60-120 mg/24h (1-2 mg/kg/24h). i vi cc bnh thp khp,' thng cho liu 0,5 mg/kg/24h, sau gim liu 10% mi tun. T liu 15 mg tr i, gim 1 mg/tun. ng ko di khng qu 5-10 mg/24h.

VIII. CC TC DNG PH 1. Tiu ho: Lot d dy t ng (chy mu, thng), vim tu. 2. Mt: c thu tinh th sau di bao, tng nhn p. 3. Da: Trng c, to da, ban v t mu, mt, chm lin so, vt rn da. 4. Ni tit: Hi chng Cushing (bo mt v thn), chm pht trin tr em. 5. Chuyn ho: Tng ng mu, i tho ng nhim toan ceton, hn m tng p lc thm thu, gi nc, mt kali. c bit cc ri lon chuyn ho ng rt d xut hin ngi ln tui. 6. Tim mch: Tng huyt p, suy tim mt b. 7. Thn kinh - tm thn: Kch thch hoc trm cm. 8. Nhim khun v gim m in dch: Tng nguy c nhim khun, khi pht nhim khun tim tng. 9. C quan vn ng: Long xng, hoi t u xng, bnh l v c (yu c, nhc c). 10. Tai bin do dng thuc: Cn suy thng thn cp, t ti pht bnh khp do dng khng ng cch. IX. THEO DI MT BNH NHN C IU TR CORTICOID Vic theo di c mc ch nh gi hiu qu iu tr, iu chnh liu cho ph hp tu theo kt qu t c v pht hin cc bin chng (nhim khun, ri lon tm thn khi dng corticoid liu cao, i tho ng, hi chng Cushing do thuc, tng huyt p...). Theo di v lm sng: Huyt p, ng cong biu cn nng, ng cong nhit , khm mt. Theo di v xt nghim: in gii (c bit l kali mu), ng mu khi i. C h n: C h n nht: Liu cng cao, cng thc hin nghim ngt. Hn ch ng hp thu nhanh (ng, bnh ngt). C h iu tr b sung: Thm 1-2 gam kali clorua hoc 2-4 vin kaleorid '600 mg mi ngy, dng cc thuc bo v nim mc d dy v phi ung cch xa lc ung prednisoloiiy. dng thm benzodiazepin trong trng hp mt ng, vitamin D (Dedrogyl: 10 git) v 1 gam calci mi ngy chng long xng do thuc. C h ny phi c thc hin khi liu prednisolon mi ngy vt qu 10 mg, v cng phi c thc hin nghim ngt khi liu cng cao.

THUC CHNG VIM KHNG STEROID (CVKS) TRONG IU TR BNH KHP

Trn Ngc n Nguyn Vnh Ngc I. I CNG Thuc CVKS l cc thuc c hot tnh chng vim v khng cha nhn steroid, hin ang c s dng rng ri trong iu tr cc bnh khp. Danh t thuc CVKS ln u tin c s dng cho phenylbutazol vo nm 1949, ba nm sau khi pht hin ra tnh cht chng vim ca glucocorticoid. Nhm ny ngy nay bao gm rt nhiu cc dn ch't c thnh phn ho hc khc nhau, song cch thc tc dng ca chng rt gn nhau: Ch yu l c ch cc cht trung gian ho hc gy vim, nht l prostaglandin iu ny l gii phn ln cc hiu qu ca thuc, song cng gii thch tc dng ph ca nhm thuc CVKS. a s cc thuc trong nhm cng c tc dng h nhit v gim au. Cc thuc CVKS ch lm gim cc triu chng vim m khng loi tr c cc nguyn nhn gy vim. Chng cng khng lm thay i tin trin ca qu trnh bnh l chnh. II. CH NH V CHNG CH INH 1. Ch nh trong khp hc Bnh khp cp tnh: Thp khp cp, gt cp, au tht lng cp, au thn kinh to Bnh khp mn tnh: Vim khp dng thp, vim ct sng dnh khp, vim khp mn tnh thiu nin, vim khp phn ng, thp khp vy nn... H khp v ct sng. Cc bnh to keo (luput ban h thng...). Vim quanh khp do thp: Vim gn c, vim bao khp, vim quanh khp vai (hi chng vai - cnh tay)

2. Ch nh khc iu tr au sau hu phu, chn thng th thao, au na u, cn au qun thn, au qun mt. Cc ri lon tai - mi - hng, vim hng - hu, nh rng. Vim tnh mch huyt khi Cc ri lon v ph khoa, au sau , au sau khi t vng trnh thai, au bng kinh nguyn pht.

i vi em: Vim, st c lin quan n nhim khun ng h hp, gim au do cc nguyn nhn khc nhau: au sau khi phu thut, au do tn thng c xng, au do chn thng m mm...

3. Chng ch nh Chng ch nh tuyt i: - Bnh l chy mu. Mn cm vi thuc trong tin s. Lot d dy t trng c hoc ang tin trin. Suy gan va n nng. Ph n c thai v cho con b. Nhim khun ang tin trin. Hen ph qun.

Chng ch nh tng i:

III. TC DNG CHNH V c CH CA THUC CVKS Cc tc dng chnh l chng vim, gim au, h st v chng ngng tp tiu cu. Tc dng chng vim c gii thch bi cc c ch sau: Thuc CVKS c ch hot tnh men cyclooxygenase (COX) lm gim tng hp prostaglandin l cht ung gian ho hc ca cc phn ng vim, c ch to kinin. Mt s" thuc CVKS cn c ch c men lypo-oxygenase (LOX). Thuc cng lm bn vng mng lysosome ca i thc bo do gim gii phng cc men tiu th v cc ion superoxyd. Ngoi ra thuc cn c ch di chuyn bch cu, c ch s kt hp khng nguyn khng th. Cc thuc CVKS c tc dng gim au trong qu trnh vim do lm gim tnh cm th ca cc u dy thn kinh cm gic, p ng vi au nh v khu tr, khng gy ng, khng gy nghin. Thuc c tc dng h st do c ch cc prostaglandin gy st, lm tng qu trnh thi nhit m khng tc dng trn nguyn nhn gy st. Thuc CVKS ch h st n ngi b st m khng gy h nhit ngi bnh thng. Tc dng chng ngimg tp tiu cu lin quan n c ch men thromboxan, synthetase, lm gim tng hp thromboxan A2 l cht lm ng vn tiu cu. IV. DC NG HC Mi thuc CVKS u c tnh acid yu, pH t 2-5. Chng c hp thu d dng qua ng tiu ho, t nng ti a huyt tng t 30-90 pht v thm nhp vi nng cao vo trong t chc vim. Thuc lin kt vi protein huyt tng rt mnh (90%) do y cc thuc khc ra dng t do, lm tng c tnh ca cc thuc (sulfamid h ng huyt, khng vitamin K, methotrexat...). Do vy, phi gim liu thuc cc nhm ny khi dng cng vi thuc CVKS. Thuc c d ho gan (tr salisylic), thi qua thn di dng cn hot tnh. Cc thuc CVKS c thi tr khc nhau: Thuc no c pH cng thp th thi gian bn hu cng ngn. Thi gian bn hu dch khp chm hn

huyt tng, c thuc c thi tr rt chm. Mt s thuc nh aspirin, dn cht ca propionic c thi gian bn hu trong huyt tng t 1-2 gi, do vy cn cho thuc nhiu ln trong ngy. C thuc c thi gian bn hu di ti vi ngy (oxicam, pyrazol) th ch cn cho 1 ln/ngy. V. NGUYN TC s DNG THUC CVKS Bt u bng loi thuc c t tc dng ph nht. Cn phi th nhiu loi thuc chn thuc c tc dng nht do mi bnh nhn c p ng thuc v dung np thuc ring. Dng liu ti thiu c hiu qu, khng vt liu ti a. Thn trng vi cc bnh nhn c tin s d dy, d ng, suygan, suy thn, ngi gi, ph n c thai. Phi theo di cc tai bin: D dy, gan, thn, mu, d ng. Ch cc tc dng tng h ca thuc CVKS vi cc thuc khc. Khng kt hp cc thuc CVKS vi nhau, v khng lm tng hiu qu m ch tng tc dng ph.

VI. XP LOI NHM THUC 1. Theo thnh phn ho hc c 7 nhm thuc CVKS Nhm salicyle, nhm pyrazole, nhm indol, nhm propyonic, nhm anthranilic, nhm oxicam v nhm khc, trong c dn xut ca aryl acetic acid. 2. Theo thi gian bn hu cc thuc CVKS chia thnh hai nhm Nhm I c thi gian bn hu ngn (< 6 gi) v nhm II c thi gian bn hu di (>12 gi). Cc thuc thuc nhm I l Proenid, ibuproen, Voltaren, indometacin. Cc thuc nhm II l phenylbutazon, Felden, Tilcotil, Mobic. 3. Theo kh nng c ch chn lc men c o x C 2 nhm CVKS: Thuc c ch c o x khng chn lc (cc thuc CVKS c) v thuc c chCOX-2 c chn lc: Mobic (c), Lodin SR (Anh), Celebrex (M). Trong c th c hai loi cyclooxygenase (COX) khc nhau c gi l COX-1 v COX-2 m vic tm ra chng dn n s pht trin ca mt h thuc CVKS mi. Men COX-1 xc tc qu trnh sn xut prostagandin c tc dng bo v v mt sinh l, cn men COX-2 c to ra do phn ng vim (cm ng bnh l) sn xut cc dng prostaglandin gy vim. Cc thuc CVKS khng chn lc (thuc CVKS c) c ch ng thi cc men COX-1 v COX-2, cc thuc CVKS c chn lc th ch c ch COX-2 c tc dng kim sot c cc trng hp vim v au, cn c ch COX-1 li gy nhng tc dng ph n thn v ng tiu ho. Cc thuc CVKS c c h COX-2 chn lc c tc ng c ch s hnh thnh cc prostaglandin v TXA2 c to ra do phn ng vim, ng thi cng c ch cc cht trung gian gy vim khc nh superoxid, cc yu t" hot ho tiu cu, m etalloprotease, histamin..., cn tc dng c ch ln COX-1 l ti thiu, do lm gim thiu tc dng ph trn thn v ng tiu ho.

VII. MT S THUC CVKS CHNH 1. Aspirin c dng t 100 nm nay. Trong nhiu nm thuc c dng nh mt thuc CVKS chnh. Nhuhg t khong 20 nm nay n bt u nhng ch cho cc thuc CVKS khc do c nhiu tc dng ph trn ng tiu ho, huyt hc (ng mu), thnh gic, d ng. Mt s nh nghin cu hin nay c xu hng khng xp aspirin vo nhm thuc CVKS. Aspirin ch c tnh cht chng vim t liu ln hn 3 g/ngy, liu ny, tc dng ph trn ng tiu ho rt thng gp. Aspirin c tnh cht gim au v h st ngi ln vi liu t 0,3 - 1 g/ngy. Aspirin c tc dng chng ngng tp tiu cu vi liu 0,3 g/ngy. Vi bt k dng s dng no th liu dng ca aspirin cng nh nhau:

i vi ngi ln: 1- g/ngy, vi tr em: Liu thng thng t 25-50mg/kg/ngy. 2. Phenylbutazon y l thuc CVKS c cu trc ho hc tng t nh amidopyrin, tc dng rt mnh, nhiig do c nhiu tc dng ph c bit l huyt hc (thiu mu, suy tu, gim bch cu ht, gim tiu cu) nn hin nay hu nh khng c s dng na. 3. Indometacn Indometcin c a vo s dng nm 1965 c ch nh kh rng ri trong cc bnh l khp v ngoi khp v tc dng chng vim kh, gi r. l thuc CVKSD c thi gian bn hu ngn (4-5 gi) do vy phi ung 3-4 ln/ngy vi tng liu ti a l 200 mg/ngy (vin 25, 50,75 mg). Thuc hp thu nhanh qua ng tiu ho, c th thm qua rau thai. Tuy nhin do c mt s tc dng ph khc, ngoi nhng chng ch nh chung ca thuc CVKS, khng ch nh thuc ny khi c hen ph qun, hi chng tin nh. 4. Ibuproen L thuc CVKS thuc nhm arylpropionic acid, hp th nhanh qua ng ung, c thi gian bn hu ngn (1,7 gi). Thuc dng kh an ton. Liu dng 400-1200 mg/ngy ch c tc dng gim au l chnh. Liu iu tr vim khp dng thp t 2400-3600 mg/ngy. Cn liu cao 4800 mg/ngy c th dng iu tr gt cp. 5. Dcofenac (Voltaren) c dng rng ri chu u cng nh Vit Nam. Thuc c hiu qu trong vim khp dng thp, vim ct sng dnh khp, cn gt cp tnh, thoi ho, thp ngoi khp v vim au sau chn thng, sau phu thut, au bng kinh v vim phn ph, cn migraine, cn au qun thn v au qun mt (tim bp) v iu tr h tr trong nhim khun Tai-mi-hng nng. Thuc c hp thu nhanh, hon ton qua ng tiu ho, c thi gian bn hu ngn (1,25 gi). Do vy c th dng tng liu 75-200 mg/ngy chia thnh 2-4 ln. Bit dc tiu biu l Voltaren, c nhiu dng thuc phong ph la chn v c th dng c cho tr em ln hn 1 tui (ng tim 75 mg, vin nn khng acid d dy 25mg, 50 mg, vin phng thch chm SR 75 mg, 100 mg. dng to dc 50 mg).

Nhm Salicyl

Tn chung Aspirin Acetylsalicylat de lysin Bnorilat Difunisal

Bitdc

Liu 24h 0,5-4g 0,5-4 g 1-4 g 0,25-1,5 g 100-500 mg

Trnh by Vin: 500 mg Gi: 500-1000; ng 1000 mg gi: 1 g vin: 250 mg Vin: 100, thuc n: 250 mg (< 1 tun) Vin:25, 50, lOOmg ng: 75 mg vin: 75 mg Vin: 100, 200;thuc n : 200 mg

Aspegic Salipran Dolobis Butazolidin

Pyrazol

Phenylbutazon

Dn xu'tacid indol-acetic

Indomethacin

75-150 mg Inocid Chrono-indocid 75-150 mg Athrocin Nalgesic Cebuti 100 Brufen 400 Profenid Bi-profenid ProfenidLP 200-400 mg 1

Suindac Proprionic Fenoprofen Flurbiprofen Ibuprofen ' Ketoprofen

300-1200mg Vin: 300 mg 100-300 mg Vin: 100 mg

400-1200mg Vin: 400 mg, thuc n: 500 mg 50-300 mg Vin: 50; 150; 200mg thuc n: 100; ng: 50; 100 mg Vin nn: 200 mg

Naproxen Anthranilic Oxicams Cc nhm khc Acid niAumic Piroxicam Tenoxicam Diclofnac

Naprosyn Apranax Nifluril Felden Tilcotil Vltaren Voltaren SR

250-1000mg Vin nang: 250; 500 275-100 mg vin nn: 275; 550mg 250-1000 mg vin nn: 250 mg 20-40 mg 20 mg 50-150 mg vin, ng 20 mg vin: 25;50; thuc n: 100 mg; ng 75 mg vin: 75; 100 mg vin nn: 100; 200mg vin: 7,5 mg

Etodolac Meloxicam

Lodin Mobic

400 mg 7,5-15 mg

6. Piroxicam (Felden) Vin nang 10-20 mg, ng tim bp 20 mg. Thuc c tc dng gim au nhanh v ko di, nhanh chng ci thin tnh trng vn ng khp, c dung np tt, tin li do ch cn ung 1 ln ong ngy. 7. Meloxicam (Mobc) , Thuc Mobic ' l thuc c ch chn lc i vi COX-2. Thuc c ch nh trong vim khp dng thp, vim ct sng dnh khp, thoi ho khp vi liu dng 7,5mg hay 15 mg/ngy (vin nn 7,5 mg, ng tim 15mg) 8. Tenoxicam (Tilcotil) Vin, thuc n, ng tim bp c hm lng 20 mg. Thuc ch nh trong nhng trng hp cp tnh (dng tim, ung) c bit gt cp rt hiu qu. Vi cc bnh l mn tnh nh vim khp dng thp, thuc c th gim thi gian cng khp bui sng v c an ton cao. 9. Naproxen sodium (Apranax) Dng iu tr gim cc cn au t nh n trung bnh, cp hay mn ca cc bnh c xng khp, vim m mm v gt cp. C tc dng gim au kh nhanh. Liu khuyn co: 2 vin 275 mg, tip theo 1 vin 275 mg cch 8 gi ung 1 vin (ti a 5 vin 275 mg/ngy). 10. Ketoproen (Profenid, Bi-profend, Profenid LP) L thuc c s dng ng thi vi ibuproen. Thuc hp thu nhanh v hon ton qua ng tiu ho. Thuc thng dng vi liu lng 100-300 mg/ngy, c hiu qu trong iu tr vim khp dng thp, vim ct sng dnh khp, cn gt cp, vim khp mn tnh thiu nin. Tc dng ph hay gp nht l trn ng tiu ho trn, tng t nh cc thuc CVKS khc. 11. Anthranlic (NiAuril) c s dng iu tr vim khp dng thp, thoi ho khp, gt, vim ct sng dnh khp. Cc tc dng ph ln tiu ho v da thng hay gp (co tht rut, a chy gp trong 25% cc trng hp v mn nga trong 16% cc trng hp). VIII. CC TC DNG PH 1. Tc dng ph trn ng tiu ho Thng gp nht l cc tc dng ph nh nh bun nn, cm gic chn n, au thng v, a chy, to bn. C th gp cc bin chng nng n nh lot d dy (thng b cong ln) - t trng, thng ng tiu ho l hu qu ca s c ch mt s prostaglandin (Pr E l) c tc dng bo v cht nhy ca d dy cng nh do tc dng trc tip ca thuc ln nim mc d dy, xut huyt tiu h do thuc lm gim ngng tp tiu cu.

B't c thuc CVKS no cng c th gy tc dng ph ny. Mt s c a d bin chng tiu ho do CVKS: Tin s lot c, ngi nghin ru, ngi c tui, bnh nhn dng thuc chng ng. Thuc cng thng lm tng transam inase khi s dng lu di. c n ngng dng thuc khi transam inase tng gp 3 bnh thng. Him xy ra bin chng nng nh: V im gan gy vng da do c ch m in dch d ng, tin trin thun li sau khi ngng thuc. 2. I vi c quan to mu C tc dng c t bo gy gim bch cu, suy tu (pyrazole) v ri lon ng mu (aspirin) do tc dng c ch ngng tp tiu cu ca thuc. 3. i vi thn - Thuc gy vim thn k cp c hay khng km theo hi chng thn h dng nh do nguyn nhn min dch - d ng. - C th gy suy thn cp chc nng do cc prostaglandin gy gin mch thn duy th tch lc qua thn b c ch. Do vy, suy thn chc nng gp cc bnh nhn c xu hng gim th tch mu: Suy thn, hi chng thn h, x gan mt b, dng thuc li tiu, suy tim, c bit nu cc bnh nhn ny l ngi c tui. Ni chung, thiu niu v tng cratinin c th tr li bnh thng sau khi ngng CVKS, mt s t trng hp phi lc ngoi thn, song s phc hi khng li di chng. 4. i vi thn knh au u, chng mt (Indocid), gim liu hoc ngng thuc c th mt triu chng ny, tai v gim ngng nghe do aspirin qu liu. 5. Trn da - nim mc Khi dng moi CVKS c th gp ban, nga... cn hi chng Lyell (bng nc thng b do nhim c nng), c th thy khi dng oxycam, song him gp. 6. Tc dng ph khc Lm tnh ng nhim khun nng thm, gy c thai ngi t vng: Gp mi thuc CVKS. Nhim fluo (Niluril). Tng huyt p do gi nc, mui (pyrazole). Mt s" tai bin d ng khc gp ngi nhy cm, hay gp khi dng aspirin. IX. TNG TC THUC 1. Thuc chng ng Thuc CVKS lm tng tc dng ca cc thuc chng ng (c bit l khng vitamin K, dn xul ca coumarin: Tromexane, Sintrom) do tc dng chng ngng tp tiu cu v lm tng thnh phn t do ca thuc chng ng trong huyt ing; iu dn ti nguy c xu't huyt; v vy nn trnh kt hp hai loi thuc ny. Khi vic kt hp l bt buc th nn chn thuc CVKS loi propionic v thuc chng ng l dn xut ca phenindion (Pindion).
/

2. Thuc chng tiu ng Cc thuc CVKS (salicyle, pyrazole) lm tng tc dng ca thuc chng tiu ng (sulamid h ng huyt l dn xut ca sulfonylure: Daonyl, Diamicron...). Do vy c nguy c h ng huyt v hn m do h ng huyt. 3. Thuc CVKS lm gim tc dng ca cc thuc chn bta giao cm, thuc gin mch, li tu Khi dng thuc CVKS cng vi cc thuc k trn c th c nguy c gy cn tng huyt p, do phi tng liu cc thuc k trn duy tr kt qu h p, nhimg nu ngng dng thuc CVKS th li c nguy c tt p t ngt do cc thuc trn tr nn qu liu. 4. Thuc khng acid Hai thuc ny cn dng cch nhau, thuc CVKS dng sau ba n, cn thuc khng acid dng 1-2 gi sau ba n. X. NG DNG - Thng dng ng ung, tt vi mi trng hp. Cc ng kKc ch dng ong nhng trng hp c bit. - Tim: Trng hp cp tnh v au nhiu (au r thn kinh cp, t vim a khp cp), dng khng qu 5 ngy. - ng t hu mn: Tt i vi cc trng hp vim khp mn tnh do thuc lm gim au ban m v gim thi gian cng khp bui sng. Song dng ko di c th gy vim c trng. - Bi ngoi: t tai bin, tt i vi u c v chn thng. C th dng mt trong cc thuc sau: Voltaren etulgel, Rheumon gel, Gelden, Proenid gel. niluril cream... XI. C A C BIT - Ph n c thai v cho con b: Ti cn thit th cho corticoid. - Tr con: Aspirn: Di 100 mg/kg/ngy, indocid 2,5 mg/kg/ ngy, voltaren 2 mg/kg/ngy, naprosyn 10 mg/kg/ngy. - Ngi ln tui: Trnh dng loi thi chm v "chm" c th c nhiu bin chng thn hn. XII. CC BIN PHP LM HN CH CC TC DNG PH CA THUC CVKS TRN NG TIU HO Nhm hn ch tc dng ph hay gp nht l lot d dy t trng. C th ung thuc chng toan, bc nim mc km theo, vo gia cc ba n (sau n 1-2 gi). C th dng mt trong cc thuc sau: - Gastropulgit ngy 2 gi, chia 2 ln, pha vo nc. - Maalox ngy 2 vin, nhai hoc ngm, chia 2 ln. - Nu dng amotidin 40 mg, th mi ti ung 1 vin trc khi ng. - Hoc dng cht ng ng ca prostaglandin El: Misoprostol (Cytotex): 200 mg/vin, 4 vin/24h, sau cc ba n v trc khi i ng.

CC THUC CHNG THP k h p

tc dng chm
Trn Ngc n

Trong iu tr mt s bnh thp khp, cc thuc chng vim gim au khng steroid v corticosteroid c tc dng lm gim nhanh song c tnh ch't nht thi cc triu chng ca bnh, trong khi nhng thuc chng thp tc dng chm li c th phn no lm thay i qu trnh t nhin ca bnh, lm chm li s tin trin v c th khng ch cc triu chng ca bnh mt cch tng i lu di. Nhng thuc ny c th l nhng thuc c ch min dch hoc nhng thuc chng vim tc dng chm. Thi gian pht huy tc dng sm nh't cng phi 3-4 tun (i vi methotrexat) v thng phi sau 2-6 thng. 1. Methotrexat - Methotrexat l mt thuc k h n g acid lic (khng chuyn ho), c tc dng c ch men dihydrofolat reductase, dn n c ch tng hp tetraolat trong qu trnh tng hp ADN ca t bo. Trong cc bnh l thp khp n c s dng nh mt thuc c ch min dch v chng vim tc dng chm. Methoexat ni chung dung np tt v thng pht huy tc dng sau 2-4 tun iu tr, so vi thi gian 2-6 thng khi dng nhng thuc khc nh mui vng, penicillamin v nhng thuc chng s't rt. Ch nh: Methotrexat l thuc c la chn iu tr cho nhng bnh nhn vim khp dng thp nng, khng p ng vi iu tr bng thuc CVKS; bnh vim khp vy nn nng. Chng ch nh: C thai, cc bnh l ca gan, phi v huyt hc, suy thn nng, nghin ru, phi hp vi cc thuc khng folic khc. Liu lng: Trong iu tr cc bnh khp, ngi ta s dng methoexat liu th'p v ko di. Liu ban u thng dng l 7,5 mg methotrexat ung mi tun (nn chia u lm 3 ln ung cch nhau 12 gi); nu khng thy p ng sau 6-8 tun iu tr c th tng liu ml ln 2,5 mg sau mi 2 tun, cho ti liu ti a 15 mg/tun hoc cho ti khi cc triu chng lm sng c ci thin. Tc dng ph: + + Thng gp nht l kch thch d dy v vim d dy. Vim phi k l mt tc dng ph nng, e do tnh mng v thng c gii quyt bng vic ngng thuc v cho corticosteroid. Nn chp phim tim phi 3-6 thng mt ln: ' c tnh vi gan: Biu hin bng tng cc men gan, x ho gan v x gan l mt tc dng ph quan trng khc ca methoexat, rt may tc dng

' +

ph ny him gp, ch vo khong 1/1.000 bnh nhn sau 5 nm dng thuc. i tho ng, bo ph, v c bnh thn l nhng yu t" lm tng nguy c c tnh gan. c n theo di chc nng gan, men gan sau 4-8 tun iu tr, cng vi xt nghim cng thc mu, creatinin v albumin mu. Ung ru nhiu lm tng nguy c c tnh vi gan, do khuyn bnh nhn khng nn ung ru. Sinh thit gan nn c tin hnh sau mi t dng 4g methotrexat. Gim chng khng c th t bo tu do c ch tu xng v nhim khun l nhng bin quan trng khc. Nn nh phi hp methotrexat vi cc thuc folat khc chng hn trimethoprim - sulfamethoxazol bi v iu gy ra gim ton b cc t bo mu.

Tc dng ca methotrexat, k c c tnh vi gan c th hn ch bng cch dng thm 1 mg folat mi ngy hoc dng leucovorin calcium (2,5-5 mg 24h sau mi ln dng methotrexat). 2. Cc thuc chng st rt Chloroquin v hydroxychloroquin l thuc chng st rt thuc nhm 4-aminoquinolin, c s dng iu tr ko di bnh vim khp dng thp, cc bnh to keo v thnh thong c dng trong vim khp mn tnh thiu nin. Thi gian pht huy tc dng chm sau 3-6 thng, i khi lu hn. u im ca chloroquin v hydroxychloroquin l c tnh tng i thp, vi liu thp (200-400 mg/ngy) gn nh khng thy c tc dng ph. Chng ch nh: Bnh l vng mc, cc bnh mu, vim khp vy nn v ph n c thai khng nn dng. Liu lng 200-400 mg mi ngy. Tc dng ph ch yu l nhng tn thng vng mc, c bit l vim vng mc hc t gy mt th lc, rt may tc dng ph ny him gp khi dng thuc vi liu thp. Nn khm mt 2 nm mt ln cho nhng bnh nhn phi dng thuc ko di. Nhng tc dng ph khc gm bnh 1 1 c vn cng nh c tim v nhng ri lon ny thng hi phc khi ngng thuc. Thuc c th lm cho tn thng da ong vim khp vy nn nng ln.

3. Mui vng (chrysotherapy) Mui vng l mt thuc chng vim tc dng chm c s dng sm nht trong iu tr vim khp dng thp (t nhng nm 1920). Khong 60% bnh nhn p ng vi iu tr mui vng, mc d thuc t khi lm lui bnh hon ton. C ch tc dng cn cha r. 3.1. Ch nh: Vim khp dng thp khng p ng y vi bin php iu t thng thng, vim khp dng th'p nng c bo mn (erosion), bnh vim khp vy nn. 3.2. Chng ch nh Tin s ng c vi mui vng, ri lon ng k chc nng to mu, chc nng gan, thn.

3.3. La chn ch phm C 2 dng mui vng: Dng tim bp (Sodium thiomalat, aurothioglucose) v dng ung (Auranon). Thng hay s dng dng tim bp v n c hiu qu cao hn dng ung. 3.4. Liu lng - Bt u dng vi liu thm d 10 mg mui vng tim bp, trong tun u lin, v liu 25 mg trong tun th hai, nu bnh nhn dung np tt duy tr 50 mg mi tun v sau tip tc (c th ko di ti 20 tun) tr khi tc dng ph xut hin. - Nu khng c p ng sau khi dng 800 mg, nn ngng thuc. Nu p ng tt, cho ti tng liu 1 g, sau tip tc dng vi liu 50 mg, hai tun mt ln, nu vn p ng tt, tip tc dng chu k 3 tun v sau l 4 tun mt ln. i vi dng ung: Auranofin 3 mg, 2 ln mi ngy, cho n khi tc dng hoc xut hin c tnh. Cn ch l cc triu chng ti khp c th xu i sau khi dng liu mui vng u tin v thng l tm thi, khng nn cn c vo ngng thuc. Nhng bnh nhn nh vy c th p ng tt vi thuc nu tip tc iu tr. Khong 1/3 bnh nhn (thay i t 4-50%) c cc phn ng ph vi mui vng. Biu hin ca nhim c tng t biu hin ca ng c cc kim loi nng khc (asenic). Nhng tc dng ph ch yu gm vim da (t mc nh n c vy v nga), vim d dy - rut (a chy, au bng, bun nn), gim bch cu trung tnh, thiu mu bt sn tu, protein niu v nhng phn ng dng nitrit (c bit i vi mui vng thionialat). Auron ung t gy tc dng ph hn mui vng tim bp v thng gp l a chy. ngn chn v gim bt mc nng ca nhng tc dng ph, khng nn dng mui vng cho bt k bnh nhn no c nhng chng ch nh c lit k trn. Nn xt nghim cng thc mu v nc tiu nh k. Nu ximt hin cc tc dng ph, nn ngng thuc ngay. Ng c nng c th i hi phi dng corticosteroid, nu vn khng c p ng vi corticosteroid, c th phi s dng penicillamin hoc dimercaprol (BAL), nhng thuc c tc dng i khng (chelating) vi mui vng (tuy nhin nhng thuc ny cng phi dng mt cch thn trng).

3.5. Tc dng ph -

4. Sulfasalazin Sulfasalazin (salazopyrine) l ch phm kt hp gia sulfapyridin v acid aminosalicylic, c c tnh chng vim v c th c tc dng c ch min dch (tc dng c ch min dch cha r rng).

Thuc c ch nh trong iu tr vim khp dng thp, vim ct sng dnh khp, vim khp mn tnh thiu nin v mt s bnh l khp do cc bnh ng rut (vim lot i trc trng, bnh Crohn). - Chng ch nh: Tng nhy cm vi sulfamid hoc salicylat, thiu men G6PD. Sulfasalazin thng c cho bt u vi liu 0,5 g mi ngy sau mi tun tng ln 0,5 g t ti liu trung bnh khong 2 g mi ngy. Tc dng ph: au u, bun nn, au bng, ngoi ra c th c cc biu hin ca tnh trng tng nhy cm vi thuc (pht ban, st, gim bch cu ht, c tnh vi gan v thiu m u bt sn). Nhng tc dng ph, c bit l gim bch cu on v tiu cu, xut hin 10-25% bnh nhn, v 2-5% mc nng. Bnh nhn dng sulfasalazin nn theo di cng thc mu thng xuyn.

6. Pencilamin (D-penciamin) Penicilamin c bn cht ho hc l dimethyl cystein, c th c s dng cho bnh nhn vim khp dng thp nng, bnh vn lin tc tin trin mc d dng nhng thuc k trn, n cng c tc dng vi nhng tn thng da trong x cng b ton th. C ch tc dng cha r. Tc dng ph: C ti mt na s bnh nhn c tc dng ph nh lot ming, mt v gic, st, pht ban, gim tiu cu, gim bch cu v thiu mu bt sn tu, protein niu v hi chng thn h. Thuc c th gy ra mt s bnh l ca phc hp min dch nh nhc c, luput ban h thng, vim tuyn gip, vim da c, hi chng Goodpasture. Chng ch nh: Luput, nhc c, bnh l gan, thn nng, ph n c thai. Liu lng v cch dng: Trong iu tr vim khp dng thp nn bt u bng liu nh: 250 mg mi ngy, tng liu 125 mg sau 2-3 thng t ti liu ti a 0,75-lg/ngy. Pnicilamin c cho gia cc ba n tng kh nng hp th.

7. Cc thuc c ch mn dch khc Nhng thuc c ch min dch nh cyclophosphamid, azathioprin, chrorambucil, cyclosporin t nhiu nm nay c s dng iu tr mt s bnh h thng, bnh Behet, mt s bnh l vim mch mu v mt s" bnh t min khc. Thuc thng c ch nh trong nhng trng hp bnh nng, khng p ng vi iu tr bng corticosteroid v nhng thuc lm thay i bnh khc. Do nhng tc dng ph nng n ong c tc dng c c h m in dch gy bin chng nhim khun, nn thuc t c s dng rng ri. Ch nn dng nhng thuc ny di s hng dn ca nhng thy thuc chuyn khoa v c kinh nghim vi nhng tc dng ph ca chng. Tc dng ph: c ch tu xng (gy bin chng nhim khun, gim tiu cu, thiu mu), c tnh ng tiu ho (vim d dy, a chy, bun nn v nn); vim phi k, vim bng quang chy mu... Azathioprin: Liu ban u thng dng l 1 mg/kg, tng ln t t, nu cn thit c th ti liu ti a 2,5 - 3mg/kg.

Cyclophosphamid: Thng bt u vi liu 1,0-1,5 mg/kg, ung hng ngy vo bui sng, c th tng liu dn ti liu li a 2,5-3, 0 mg/kg/ngy. Cng c th dng thuc ng nh mch. Chlorambucil: Dng ng ung, vi liu 0,05-0,2 mg/kg/ngy.

IU TR BNH VIM KHP DNG THAP

Trn Ngc n Vim khp dng thp l mt bnh khp mn tnh thng gp ph n, tui trung nin, tn thng gii phu ch yu l tnh trng vim khng c hiu ca mng hot dch khp do cc ri lon v min dch m nguyn nhn cha c xc nh, bnh nhn din bin ko di nhiu nm, dn n dnh v bin dng khp.
I. CHN ON

Chn on bnh VKDT da vo tiu chun ARA 1987, Chn on xc nh khi c 4 ong 7 tiu chun sau: 1. C du hiu cng khp bui sng ko di trn 60 pht. 2. Sng, au 3 trong s14 v tr khp (ngn tay gn, bn ngn, c tay, khuu, gi, c
c h n , n g n c h n X 2 b n p h i v t r i = 1 4 ).

3. Sng, au 1 trong 3 v tr khp ngn tay gn, bn ngn tay, c tay. 4. Sng au i xng. 5. C ni ht di da in hnh. 6. C tn thng c hiu trn phim chp X quang. 7. Phn ng tm yu t dng thp dng tnh, (phn ng Waller Rose, Gamma latex). T't c cc du hiu lm sng phi c thi gian ko di trn 6 tun. nh gi mc tin trin ca bnh VKDT ngi ta da vo cc ch s v lm sng, xt nghim v X quang, theo quy nh bnh c chia lm 4 giai on theo th t l giai on I, II, III, IV. v th bnh, ngi ta.phn bit 4 th thng gp th nng, th nh, th tin trin nhanh, th tin trin chm.
II. IU TR

1. Nguyn tc chung 1.1. Do cha bit c nguyn nhn gy bnh nn vic iu tr nhm gii quyt iu chng, lm chm s tin trin ca bnh, hn ch cc bin chng v di chng, gip cho ngi bnh c mt cuc sng d chu hn. Do mc ch ca vic iu tr l: (a) Chng vim, gim au. (b) Bo tn chc nng vn ng, hn

ch cc di chng xu. (c) Nu c bin dng v dnh khp th sa cha nhng tn thng ny, ci thin chc nng vn ng, phc hi kh nng lao ng. 1.2. V bnh nhn VKDT c tin trin ko di nhiu nm nn iu tr i hi bnh nhn v thy thuc phi kin tr, lu di v lin tc, phi c thng xuyn theo di v kim tra. 1.3. Phi kt hp nhiu phng php: Ni khoa, vt l, ngoi khoa, y hc c truyn, phc hi chc nng, ti gio dc lao ng v ngh nghip, phi kt hp gia iu tr ni tr, ngoi tr, iu dng v ti nh. 2. Cc phng php iu tr 2.1. S dng thuc gim au Gim au thng: Gm cc thuc: Paracetamol (Acetaminophen), codein, dexopropociphen. Gim au gy nghin: Morphin, Pethidin.

2.2. Cc thuc chng vim khng steroid (NSAID) Thuc u tin c s dng iu tr l aspirin (1848). Sau l phenylbutazon (1949), ngy nay nhng thuc chng vim c a vo lm sng ngy cng nhiu i hi ngi thy thuc phi la chn thuc tu theo mc bnh v kh nng p ng ca tng bnh nhn. Cc thuc CVKS c chia ra 2 nhm l cc thuc tc dng nhanh (thng trong thi gian 4 n 6 gi) v cc thuc tc dng ko di (trn 12 gi). Da vo c ch tc dng c hay khng c nh hng n nim mc ng tiu ho, chia thnh thuc COX-1 (c nh hng) v COX-2 (t nh hng). 2.3. Nhm thuc corticosterod Vic s dng corticosteroid iu tr bnh VKDT l mt bc tin to ln ong y hc, tuy nhin sau gn 50 nm theo di v nh gi, vic dng thuc phi c cn nhc cn thn v phi c theo di cht ch trnh nhng tai bin nhiu khi rt nguy him ca thuc. 2.4. Nhng thuc chng thp tc dng chm (slow acting antirheumatic drugs-SAARDs) hay l nhm thuc chng thp lm thay i bnh l (disease modifying antirheumatic drugs-DMARDs) gm mt s" thuc c s dng trong thi gian di, (nhiu thng, nhiu nm) mi thy tc dng, phn ln khng gii thch c c ch lc dng. 2.5. Cc thuc c ch'min dch v cc phng php ang c th nghim Cyclophosphamid, chlorambucil, cyclosporin A c ch nh iu tr nhng trng hp nng, khng p ng vi thuc khc, c th cho nhng kt qu tt. Da vo nhng hiu bit v min dch trong bnh VKDT gn y ngi ta nghin cu cc thuc tc. ng vo cc thnh phn m in dch iu tr nh khng th n dng khng yu t TNF a , khng cytokin, khng t bo T... v c mt s" kt qu.

Vi mc lch loi tr cc globulin min dch lu hnh ong mu ngi ta th dng phng php lc huyt tng (plasmaphrse) iu tr cho nhng trng hp nng, bc u c mt s kt qu. Ngi ta dng phng php lim mt s cht vo khp nhm ph hu mng hot dch, sau s t ti to li v m t i phn ng vim, tim acid osmic, cc ng v phng x... v c gi chung l phng php "ti to mng hot dch ni khoa" (synoviorthse). 2.6. Vt l liu php v phc hi chc nng Vn vn ng v c nh: Nguyn tc chung trong iu tr cc bnh khp mn tnh l phi tng cng vn ng, vn ng mi t th, mi ng tc...c th luyn tp th ng vi s tr gip ca thy thuc, hoc ch ng c hng dn...nhm chng dnh khp, chng bin dng, tng cng dinh dng, phc hi v duy tr cc chc nng vn ng ca khp, trong nhng t bnh tin trin cp tnh th c nh trong mt thi gian ngn v c nh t th c nng. Cc phng php iu tr vt l: Tu theo tnh trng tin trin v'giai on bnh nhn m ch nh phng php nh ng tay tc ng, xoa bp, nn chnh, dng nhit, dng sng, ti x, dng nc, in dn thuc, kch thch in... tt c u nhm mc ch chng vim, chng dnh v bin dng, phc hi chc nng vn ng. Dng nc sui khong: Vic s dng sui khong iu tr v phc hi chc nng cho cc bnh khp m n tnh t lu c tin hnh nhiu nc v c kt qu tt. Nc ta c rt nhiu sui khong c pht hin, trong c nhng sui c nhiu tc dng cha bnh, nhng cho n nay cha c khai thc (sui nc nng M Lm-Tuyn Quang, Quang Hanh - Qung Ninh; Vnh Ho...), Ni chung sui khong va c tc dng vt l, tc dng ho hc, va c tc dng tm l trong iu tr, nn ch nh cho nhng trng hp bnh khp tng i n nh, cn cng c v phc hi chc nng.

2.7. Cc phng php ngoi khoa Trong bnh VKDT phu thut c ch nh trong hai trng hp l chnh hnh phc hi chc nng v iu tr ti ch. Phng php ct b mng hot dch ti ch, c tin hnh khp gi v mt s" khp ln, ngi ta m ct b ton b mng hot dch khp, sau mt thi gian mng hot dch li mc ti to li y nh c, nhng tnh trng vim gim rt nhiu c khi gim hn. Th thut ny c ch nh khi bnh ch khu tr mt vi khp ln m vi cc phng php iu tr khng mang
li k t q u . ;

Phu thut chnh hnh khp khi c dnh, bin dng lm gim, hoc l mt i chc nng vn ng ca khp, cc th thut thng dng l m ct xng, gt u xng, to hm khp, chnh trc, bc tch x,dnh, gii phng.gn c, hoc ch ng lm dnh khp t th chc nng chng au v trnh dnh t nhin vi t th xu, sau phu thut cn luyn tp phc hi chc nng.

Thay khp nhn to: Trong vi chc nm gn y, ngi ta ch to c nhiu loi khp nhn to bng kim li, bng cht do, cng vi nhng cht hn dnh trung tnh (xi mng); vic thay th cc khp b tn thng nng, mt kh nng phc hi c tin hnh thng xuyn v mang li nhiu kt qu, khp nhn to gip cho nhng bnh nhn tn ph c kh nng tr li hot ng v sinh hot c. Khp nhn to c dng hin nay l khp hng (bng kim loi v cht do), khp gi (kim loi), c chn (kim loi), khp vai (kim loi), khuu (kim loi), khp ngn tay (cht do).

2.8. Y hc c truyn Quan nim c truyn v bnh VKDT c coi l chng "bnh li", c ngha l kh huyt khng lu thng b tc nghn, cc phng php iu tr u nhm gip cho thng s tc nghn ny, bao gm chm cu, n huyt, chch l, xoa bp, cc thuc lm lu thng kh huyt (c hot, ngu tt, d, qu chi, m tin....) hoc cc bi thuc c truyn nh c hot tang k sinh, qu chi, thc dc chi mu. Mt s ru xoa bp, cao dn chng vim. Cc cy thuc nam nh c hy thim, cy xu h, l lt, vi voi, c gai leo... cc cao c ngun gc ng vt nh cao xng h, d, kh, gu, nga.... cao ton tnh trn, rn, sng hu nai... Ni chung cc phng php v thuc YHCT ch c tc dng tr gip thm trong qu trnh iu tr, hin cha c bi thuc hoc phng php no c tc dng c tr bnh VKDT.
III. P DNG THC T

1. Giai on I, th nh, tin trin chm Chng vim gim au bng: Aspirin 0.5g X 4-6 ln trong ngy, hoc mt trong cc thuc CVKS sau: Indomethacin 25 mg X 2-6 v/ngy
B ruen 200 mg X 4-6 v/ngy

Diclophenac 50 mg X 2-3 v/ngy Thuc chng thp tc dng ko di: Chloroquin (Nivaquin, Delagyl) 0,30g X lv/ngy. Tim corticosteroid ti ch nu c ch nh. iu tr vt l, luyn tp, kt hp y hc c truyn.

2. Giai on I, tin trin nhanh Chng vim bng: Corticosteroid ng ton thn liu trung bnh lc u ri gim dn

Prednisolon 5 mg X 8 v/ngy, gim dn mi ngy lmg, cui cng duy mi ngy t 5-7 mg prednisolon. Chng thp tc dng ko di bng: Salazopyrin 0,5g X 2-6 v/ ngy, hoc chloroquin 0,3g X 1 v/ngy. Cc thuc phi hp khc: Vitamin nhm B, chng thiu mu, d phng long xng (do dng thuc corticosterod ko di) bng calci, vitamin D. Vt l tr liu, YHCT phi hp.

3. Giai on n , tin trin chm Chng vim bng mt ong cc thuc thuc nhm CVKS nh:
Diclophenac 50 mg X 2-3 v/ngy

Proenid 50 mg X 2 nang /ngy Piroxicam 20 mg X 1 v/ngy Tenoxicam 20 mg X 1 v/ngy. Chng thp tc dng ko di bng Salazopyrin hay chloroquin. Cc iu tr h tr v phi hp nh trn.

4. Ga on II, tin trin nhanh, th nng Chng vim bng corticosteroid ton thn: Depersolon (Mazipredon) 30 mg X 2-3 ml truyn nh git chm trong 250 ml d/d glucose 5%, hoc methylprednisolon 125mg truyn nh trn. Sau 7-10 ngy chuyn sang thuc ung liu trung bnh ri gim dn dn: 50 mg prednisolon.. ri duy tr 5-7 mg/ngy Chng thp vi: Methotrexat 2,5 mg X 3-5 v/1 tun 1 ln, hoc Salazopyrin 0.5g X 4-6 v/ngy, hoc mui vng, D penicillamin, c ch min dch. Tim thuc ti ch vi corticosteroid. Vt l tr liu, YHCT, iu tr h tr....

5. Giai on III, tin trin nhanh, nng, c bu hin ni tng Chng vim bng corticosteroid ton thn liu cao methyl prednisolon, depersolon, hydrocortison hemisuccinat... truyn tnh mch, nu cn thit c th dng phng php liu ti cao (bolus, pulse) vi 700-1200 mg methylprednisolon /500ml glucose 5% truyn tnh mch trong 2 gi mi In/ngy X 3 ngy, sau duy tr bng liu 5-7 mg prednisolon/ngy. Chng thp bng methotrexat hoc Salazopyrin hoc cyclosporin A, c ch
m i n d c h v .v .

Tim thuc ti ch. Vt l tr liu, phc hi chc nng, iu h tr. Khi n nh iu sui khong t 1-3 thng. Phu thut chnh hnh.

6. Giai on III, rv tin trin chm, hoc n nh Chng au, gim vim bng aspirin 0,5g X 2-4 v/ngy, hoc in dom ethacin 25 mg X 2-4 V /n g y , h o c B ru en 200 mg X 2-4 v /n g y , hoc Piroxicam 20 mg X 1 v/ngy. Thuc chng thp bng chloroquin 0,3g hoc Salazopyrin 1,0-1, 5g/ngy. Vt l tr liu, phc hi chc nng, YHCT... iu tr sui khong.

Phu thut chnh hnh. Hun luyn, ti gio dc ngh nghip.

7. Cc th c bit - Bnh nhn c lot d dy, hnh t trng: Dng thuc chng vim nhm COX2 (Meloxicam), thuc t nh hng n nim mc tiu ho (Brufen), dng thm cc thuc bo v nim mc (Phosphalugel, Galtropulgit), Cc thuc iu tr lot (Cimetidin, Omeprazole...). Kt hp y hc c truyn. - Bnh nhn c suy thn, suy gan: Chng' vim bng corticosteroid, chcmg thp bng methotrexat, iu tr ti ch.

IU TR VIM CT SNG DNH KHP (Nhm bnh l ct sng)

Trn Ngc n Nguyn Th Ngc Lan
I. I CNG

Vim ct sng dnh khp (VCSDK) l mt trong s cc bnh khp vim thng gp nht. Bnh thng gp nam gii, tr tui. Tn thng cc khp gc chi (hng, gi, c chn), xng, ct sng v khp cng chu 2 bn v c mi lin quan vi HLA B27 cao (90%). Hin nay, bnh c xp vo nhm bnh l ct sng (BLCS), hay cn gi l nhm bnh khp huyt thanh m tnh, bao gm mt s bnh c c trng bi s kt hp gia hi chng cng chu ct sng, hi chng khp ngoi bin, hi chng bao gn v hi chng ngoi khp cc mc khc nhau, c yu t thun li l c a di truyn chung (cc trng hp c nh gia nh v mi lin quan ca nhm bnh ny vi khng nguyn HLA B27). T nm 1985, tc gi Amor B ngh cc tiu chun chn on nhm BLCS ni chung v coi cc bnh trong nhm l di nhm, khng nh't thit phi chn on ring (tiu chun Amor - 1991). Tuy nhin hin nay vn cn nhiu nc s dng tiu chun New York 1968 phn lp ring bnh VCSDK. Vit Nam, do th khp ngoi bin ni bt, nn tiu chun n khng ph hp, chn on thng da vo cc tiu chun sau: Nam gii, tr tui, siig au khp hng, gi hoc c chn 2 bn, au ct sng tht lng v vim khp cng chu 2 bn giai on 3 hoc 4. Trn c a gen c sn, bnh khi pht di nh hng ca mt s yu t mi trng bn ngoi. c th l vi khun (Klebsiella pneuumoniae, Yersnia enterocolitica...), nc ta, c th l Chlamyia Trachomatis. Tn thng c bn l vim cc im bm tn ca gn, dy chng hocca bao khp bm n xng, tin trin thnh x v xng ho nhiu hn l ph hu. iu ny gii thch phn ln cc triu chng nht l ct sng. Vic iu tr ch yu l iu tr triu chng, phc hi chc nng, hng dn cch thc sinh hot, chng ti nhim khun. Triu chng lm sng v cn lm sng - Ti khp: Tn thng trc: Cc khp g"c chi (hng, gi, c chn), i xng, ct sng v khp cng chu 2 bn. au kiu vim tin trin. - Ngoi khp: Vim im bm tn (thng gp nht gn Achille v cn gan chn), vim mng b o trc cp tnh, vim ni tm mc. - Xt nghim mu: C hi chng vim, nhm khng nguyn HLAB27 (+). - X quang: Vim khp cng chu hai bn, i xng. Ct sng c hnh nh cu

xng (hnh "cy tre") do dy chng b ct ho, cc khp ngoi bicn thng ch c hp khe khp, him khi c hu khp. Bnh mn tnh tin trin thnh tng i, gy au CSTL kiu vim v vim cc khp ngoi vi, c p ng vi thuc chng vim khng steroid (CVKS). Di chng gy tn ph nng l dnh ct sng, dnh khp hng v g. Vi khp hng, i khi phi lm khp gi.

II. IU TR 1. Nguyn tc Ch yu l iu ir triu chng trong cc t vim cp tnh, v trnh nhim khun tdi pht. Hng dn cch thc sinh hot, nh hng ngh nghip cho bnh nhn. Vi cc khp c di chng, c th iu tr chnh hnh.

2. iu tr ni khoa iu tr ni khoa bao gm: iu tr bng thuc (CVKS, gim au, gin c. thuc chng thp khp tc dng chm, iu tr ti ch). 2.1. Thuc chng vim khng steroid (CVKS): (xem thm bi thuc CVKS). 2.1.1. Nguyn tc Thuc CVKS l nn tng ca iu tr ni khoa trong bnh VCSDK. Thuc ci thin ng k cc triu chng au, gim vn ng. Ch nh trong cc t tin trin. Ht au nn ngng thuc. Khi ti pht s tin hnh iu tr li. 2.1.2. La chn loi CVKS Lu khng kt hp cc loi CVKS vi nhau v ch lm tng tc dng ph m khng tng hiu qu. C th dng bt k loi CVKS no, song trnh dng phenylbutazon hoc oxyphenylbutazon do cc nguy c thiu mu do suy tu tim lng, c th gy t vong. Ch dng phenylbutazon khi cc thuc CVKS khc khng c hiu qu, liu khng qu 500 mg/ngy (trung bnh 200-300 mg/ngy). Nu la chn CVKS da vo nhp iu au ca tng bnh nhn v dc ng hc ca thuc. Nu mt bnh nhn thc gic vo 4 gi sng v au, cho 1 thuc CVKS c thi gian hn hy di v ihi chm vo bui ti v mt loi thi nhanh vo bui sng, v d: 1 vin Voltaren SR 75 mg trc khi ng v vicn Voitaren 50 mg ban ngy, chia 2 ln. 2.1.3. Chn liu Do VCSDK c mt s u th hn VKDT (irc hn, l iu tr kt hp...) nen c ih dng liu CVKS cao hn. Tuy nhin cng phi tun theo nguyn tc d t liu thp nhi n liu c hiu qu. V d: - DicIofenac: Tim bp trong giai on cp ngy 1 ng 75 mg trong 3 ngy, c th thm 1 vicn ung hoc to dc bui ti. Sau giai on cp c th cho

dng vin 50 mg/ngy 2 - 3 vin, chia 2 - 3 ln. Piroxicam: Tim bp trong giai on cp ngy 1 ng 20 mg trong 3 - 5 ngy. Sau duy tr ngy 1 vin 20 mg.

2. .4. iu tr kt hp Cc tc dng ph v d dy - rut l kinh in, gy hu qu chy mu ng tiu ha, c th hn ch bng cch s dng 1 s thuc sau: Gastropulgit ngy 2 gi, chia 2, sau n 1 - 2 gi. Cytotex: (ng ng ca Prostaglandin E1 - misoprostol) 200/mg/24h, 2 vin chia 2 ln sau n. Famotidin: 40 mg trc khi i ng ung 1 vin.

2.2. Thuc gim au Nhm thuc gim au ng vai tr quan trng trong iu tr CVSDK, cng nh cc bnh khp khc. Nhm ny t c vi d dy v thn hn cc thuc CVKS. Cch dng nhm thuc ny tun theo s bc thang ca OMS. 2.3. Thuc gin c Trong VCSDK, do thng c hin tng co cc c km theo, nn cho cc thuc gin c, c tc dng rt tt. c bii, cc thuc gin c hin nay c loi tc dng trn thn kinh irung ng, khng gy ng, li c tnh ch't gim au nn tng hiu qu vi bnh. C th dng mt trong cc thucc sau: Myonal: 50 mg/vin, 3 vin/ngy, chia 3 ln. Coltramyl: 4 mg/vin, 2 vin/ngy, chia 2 ln. Mydocalm: 50 mg/vin, 4 vin/ngy, chia 2 ln. Decontractyl: 250 mg/vin, 4-6 vin/n"y, chia 2-3 ln.

2.4. Thuc chng thp khp tc dng chm Salazosulfapyridin (Salazopyrin): T 1 - 3 gam mi ngy, trong 3-6 thng. Kt qu v dung np tt khng ch vi VCSDK (c bit th khp ngoi bin) m cn vi cc hnh khc trong nhm nh vim khp phn ng v vi cc biu hin ngoi khp ca nhm bnh ny nh vy nn, vim mng b o. Ngoi ra, thuc cn c th phng nga cc t vim mng b o trc cp, mt triu chng ngoi khp ca nhm bnh BLCS. 2.5. Mt s phng php iu tr ni khoa khc 2.5. . Thuc corticod ng ton thn: Ni chung khng c ch nh. Song vi mt s him cc trng hp, khi bnh khng p ng vi cc thuc CVKS, k c pheny!butazon hoc oxyphenylbutazon, hoc trng hp c mt s chng ch nh tm thi nh tn ihng ng tiu ho, c th cho corticoid liu thp, khng vt qu 10 mg/ngy. Mt s trng hp c th ch nh phng php iu tr "t sng" (bolus corticoid): Methylprednisolon liu 15 mg/kg pha

trong 240 ml dung dch NaCl 9 %c, truyn ong 3 gi, 3 ngy lin tc, tuy nhin kt qu cn c nhiu kin tri ngc. Ring vim mng mt c ch nh corticoid ng ton thn v tim hu nhn cu. ng ni khp: c ch nh ngay khi bnh khu tr. Cc v tr thng gp ct sng nh khp cng chu, khp lin mu sau, khp sn - ct sng, c n, sn - c; cc khp ngoi bin v gt. Ni chung hn ch vi khp hng. Cch dng nh vi cc ng tim ni khp khc: Vi hydrocortison acetat: Mi t 2 - 3 mi tim cch nhau 5 - 7 ngy. Khng vt qu 4 mi tim mi t. Vi cc ch phm "chm (Triamcinolon Hexacetonid, Betamethason...): 1 mi, hoc nu 2 mi th cch nhau 6 - 8 tun trong mt t. Khng tim qu 2 t/nm. Lu : Phi tin hnh tim trong iu kin v khun tuyt i.

2.5.2. Khng sinh c ch nh trong t tin irin ca vim khp phn ng hoc khi vn tn li nhim khun sau khi khi pht vim khp. Nu iu tr khng sinh ngn ngy thng khng lm thay i tin trin ca vim khp phn ng sau nhim Chlamyia, th ngc li, t khng sinh di ngy c th lm cho t vim khp rt ngn li. c bit, iu tr khng sinh vi cc nguyn nhn gy vim khp c th phng nga c cc t vim khp phn ng. Thng p ng tt vi th ngoi bin. C th ch nh: Doxycyclin (Vibramycin): 200 mg/ngy, ung 1 ln, ong 1 thng. Hoc teiracyelin: 1 gam/ngy, chia 2 ln, trong 1 ihng in.

2.5.3. Ct b mng hot dch bng ho cht Thng dng osmic tim ti khp. Ch nh vi khp gi d thc hin hn c. t hiu qu cao. 2.5.4. Chiu x Trc y, radium - 224 c dng iu trVCSDK,song cnguy c c thu tinh th v ung th cao. Do hin khng dng. 3. Phc hi chc nng 3.1. Mc ch Duy tr chc nng ct sng v khp, gio dc bnh nhn cc phng php v sinh v p ng vi tnh irng tn thng chc nng. 3.2. Mt s trng hp c th t c dc tht thuyn gim hoc tin irin va phi: Xoa bp, vt l tr liu, dng nc, bii dng sui khong liu php, rt hiu qu vi triu chng au. Th liu php, vn ng ct sng chng g on lng v cng ct sng lng, tng hot ng ca c cnh CI sng.

t tin trin cp tnh: Cc phng php ny gi v tr khim ln. Ch yu nhm mc ch gim au v ho tn khp t th c nng. Phi gim cng

 tp luyn. Nn nm sp trnh dnh khp hng t th gp. Trng hp t thuyn gim bnh nhn dnh khp: Vn ng C I sng, tp cc ng tc tr h hp, c bit tp th bng, trnh dnh ct sng lng, c bit tp di nc, trong b bi, h bi. Khi c g on ct sng lng, c th phi eo tht lng kiu Swain.

4. iu tr ngoi khoa iu tr ngoi khoa c ch nh khi cc phng php iu khc khng c kt qu. Di y l mt s' ch nh c th: Khp hng: Thay chm hoc thay khp ton phn mang li kt qu tt, song c nguy c b ri phn c nh chm do tc ng hot ng mnh ngi tr. Ct sng: Hin him ch nh chnh hnh ct sng bng phng php sa li cc t sng.

5. Mt s' vn cn quan m 5.1. v p h m b c s Phi nm vng cc ihng tin v bnh nhn nh sau: 5.1.1. Tin lng Phi bit nh gi cc yu t cho php tin lng lu di ca bnh nhn ngay t lc khi bnh, v tng thng l thanh nin tr tui, cha nh hng ngh nghip, cn trnh cho bnh nhn nhng lo lng khng ng c. 5.1.2. Mt s rc ri c th gp trong iu tr Ch yu cc kh khn ny l do cc tai bin ca thuc CVKS. Thy thuc phi gii thch r s cn thit ca ch nh thuc trong thi gian au v la chn thuc thch hp. Mt khc, thng bo trc cho bnh nhn mt s bin chng c th xy ra, v cch theo di, x tr n gin (ngng thuc, khm li tc th...) 5. .3. Phng nga di chng Bnh nhn phi bit r nguy c lu di ca bnh v li ch ca phc hi chc nng. Ngoi ra, phi bit r nguy c v triu chng ca vim mng b o n khm bc s nhn khoa kp thi, trnh bin chng dnh mng mt. 5.2. v pha bnh nhn: phi tun theo mt s quy tc sng sau 5.2. . Hot ng th lc Trong giai on tin trin cp tnh: Bnh nhn phi ngh ngi, ngng hoi ng th thao v hot ng th lc nng. Mc tu thuc tng bnh nhn c th. Tuy nhin, ngh ngi khng c ngha l sut ngy nm trn ging (s gy dnh khp v long xng). Ng 7 - 8 gi mi m l . Nn c nhng khong thi gian ngh ngi ngn vo ban ngy, trnh mt qu sc. Tuy phi ngng hot ng th thao. Hoc gim cng tp luyn, song nn duy tr cc bi tp th dc hng ngy, nht l cc ng tc ct sng.

Vi cng vic hng ngy: Nu cng vic hng ngy buc b n h nhn phi ng ko di, th y l yu t' khng tt i vi tin lng lu di. Tuy nhin khng phi bt c bnh nhn no cung phi i ngh. Thy thuc s phi hng dn cho bnh nhn cc cch thc ph hp. Ch gi lng thng c khi cn phi ci hoc khi ngi. a ngc ra trc duy tr t th lng ngc. Ng trn nm cng, gi u phi thp, khng n gi di khp hng v khp gi.

5.2.2. Phc hi chc nng Cc ng tc i vi ct scng rt quan trng. Tp luyn cc bi gin ct sng song song vi cc ng tc h h'p, ngay t khi c cc du hiu thay i t th hoc dnh khp nh nht. ng tc n gin nht l gi ct sng tht lng t th dui bng cch nm di trn sn mi ngy 20 pht (c th va c bo hoc xcm ti vi hoc th gin). Hng nm phi c kim tra li pht hin v chnh l kp thi cc t th x'u. 5.2.3. Ch th dc th thao Cc mn cho php bnh nhn VCSDK l bi, bn cung, cc tr chi c dng vt (cu lng, tennis) trong khi nn trnh cc mn bng chy, gn, ch . Bi li r't c ch do kch thch vn ng ca lng ngc, ct sng, vai v hng. p nc rt tt vi khp hng. Tuy nhin, nu bnh nhn b hn ch vn ng khp vai, th nn trnh cc ng tc a mnh tay ra sau. 5.2.4. Ch v sinh - dinh dng Khng cn thit mt ch n ung c bit no. Tuy nhin, theo c ch bnh sinh, mt s vi khun ng tiu ho hoc Chlamydia vi ng sinh c, c coi l yu t" khi pht bnh, do nn trnh mc phi cc loi bnh trn v n mc th phi iu tr trit .

IU TR THOI HO KHP V CT SNG (H khp v ct sng)

Trrt Ngc n Nguyn Th Ngc Lan I. I CNG Thoi ho khp v ct sng (THK - CS) l mt bnh khp thng gp nht ngi c tui, m tn thng gii phu bnh l sn khp - a m. y l nguyn nhn gy au v gim vn ng 52% s ngi trn 35 tui, 80% nhng ngi n 70 tui. C hai loi thoi ho (TH): nguyn pht v th pht. THK - c s thng th pht sau chn thng, chuyn ho, vim khp hoc d dng, lch trc xng khp, ct sng. Chn on THK - c s da vo cc du hiu lm sng v X quang. iu tr nhm mc ch gim au cho bnh nhn v duy tr chc nng vn ng, la chn mt chng trnh iu tr c bit cho mi bnh nhn phi da trcn hon cnh c th ca bnh nhn . Cc phng thc iu tr ch yu l iu tr triu chng, bao gm: Vt l tr liu, iu tr ni v ngoi khoa. Lm sng - Thoi ho khp ngoi vi + Thng tn thng cc khp chu lc hoc hot ng nhiu: Hng, gi, cc khp bn tay, bn chn. + au khp kiu c hc. Cng khp bui sng ko di t 15 - 30 pht, (du hiu ph g khp). + Khp thng sng, c th do trn dch hay c ni cc u xng (gai xng). C th thy bin dng khp. + Hnh nh X quang in hnh: Hp khe khp, gai xng, x xng di sn, v xp cc din di sn. Trong giai on lin trin: C th thy cc hc di sn. Cc xt nghim sinh ha v mu u bnh thng, dch khp ngho t bo. Thoi ho CI sng (THCS): + THCS c 2 th nh khu: TH cc cu c ca a m, (gi l TH a m), v TH sn ca cc khp lin mm sau, gi l THK lin mm sau, ni chung thng c s kl hp c 2 tn thng. Tinh trng TH gia tng bi cc yu t nh chn thng, vi chn thng; cc ri lon chuyn ho ca cc a m (ealci ho sn khp, alcapton niu), cc r lon pht trin (bnh Scheuermann) hoc cc yu t bm sinh hay mc phi khc gy sai lch t ih ct sng: G, vo, ct sng qu lm, cng t sng t nhin hoc mc phi.

Biu hin lm sng: au ct sng (thng gp on ct siig thc lng, c), hoc cc triu chng au dy thn kinh, chn p cc ng mch t sng, hn hu c p tu biu hin bng yu c, hi chng thp, i li kh khn.. X quang: Hp khe a m, gai xng, hp l lin hp.

+ II. IU TR

1. iu tr ni khoa /./. Vt l tr liu Mc ch: Trnh cho khp b qu ti bi vn ng v trng lng. Nn dng nng, can chng mt hoc hai bcn i vi cc THK chi di. Ch vn gim trng lng vi cc bnh nhn bo ph. Sa cha cc bin dng, lch trc khp v ct sng. Vt l tr liu c tc dng gim au tt. vi mc ch cha t th xu v duy dinh dng c cnh khp, iu tr cc au gn v C kt hp: Thng ch nh xoa bp v cc bin php dng nhit. Liu php sui khong, bn c hiu qu cao. Vi ngh nghip ca bnh nhn, nu c th tm cc bin php cho bnh nhn thch nghi vi iu kin lm vic, trn nguyn tc lm cho khp tn thng khng b qu ti. Tp luyn: Vi cc khp ngoi vi: C th tp cc bi lp nh chy b khi khp cha c tn thng X quang (khe khp cn bnh thng). i b hoc p xe p ti ch l cc bin php tp luyn tt. Vi ct sng l hc cch gi cc t ih ng.

1.2. Thuc iu tr triu chng tc dng nhanh 1.2.1. Thuc gim au Nhm thuc gim au ng mt vai Ir quan trng trong iu tr THK - c s , cng nh cc bnh kihp khc. Nhm ny t c vi d dy v Ihn hn cc thuc chng vim khng steroid (CVKS). Cch dng nhm thuc ny tun theo s bc thang ca OMS: Khi u: Paraeetamol: Ni chung c s dung np ll ngi ln tui. Liu 500 mg, c 4 gi ml ln. Thm d trong 2-3 ngy, nu khng t hiu qu c th tng liu. Khng vt qu 3g/24h. Nu bnh nhn vn au. chuyn sang bc 2 ca s : Paracetamol + codein (ETeralgan codein) hoc Di - antalvic. Ngy 2 - 4 vicn, chia 2 - 4 ln cho cc thuc ny trong thi gian ngn, sau li chuyn sang dng paracetamol.

/.2.2. Thuc chn vim khng steroid (CVKS): (xem thm bi thuc CVKS). Trong THK lun c hin tng vim mng hot dch km theo lnguyn nhn gy au. do , thuc CVKS c tdc dng i vi triu chngau: Mt khc CVKS c c tc dng gim au.

La chn CVKS: Mt s cng trnh nghin cu lu rng c mt s CVKS c tc dng tt trn sn khp (acid thiafnic...) mt s li c hi, lm cho THK nng ln (indomethacin), song cha c khng nh. Aspirin l thuc thng c s dng nht. Cc loi CVKS c thi gian bn hu nhanh thng tt hn Io chm. Cc loi CVKS c gn mnh vi 95% albumin ca huyt tng d c nguy c tng tc vi cc thuc khc (c im ca ngi ln tui l ng thi mc nhiu bnh). Ch nh phi thn trng cc trng hp c suy thn, lim v gan. Liu tu theo tnh trng lm sng p ng ca bnh nhn: Bnh nhn d chu v trong gii hn dung- np c. Ni chung, liu CVKS dng cho ngi ln tui thng bt u bng liu thp hn liu vn dng cho ngi ln thng thng. V d: + + + Dicloenac: vin 50 mg ngy 2 vin, chia 2 ln. Ibuprofen: 200 mg/vin, ngy 2 - 4 vin. Pyroxicam: 20 mg/vin, ngy 1 vin.

Pht hin cc tc dng ph: Trng hp dng ko di, phi pht hin cc tc dng bng xt nghim: C 6 - 8 ihng lm mt ln cng thc mu (pht hin gim bch cu), chc nng thn v cc men gan. Cc tc dng ph v d dy - rut l kinh in, gy hu qu chy mu ng tiu ho. C th hn ch bng cc cch s dng ng ng ca prostaglandin E l, misoprostol (bit dc Cytotex) 400 mg/24h. Ngoi ra, nn s dng cc thuc CVKS dng ng ngoi da, bi ti ch au ngy 2 - 3 ln: cc loi gel (Vollaren - Emugel, Proenid, Gelden...) cc loi cao dn (cao trng sn, salonpas), cc loi du xoa ti ch.... cng c tc dng gim au ng k m khng gy cc tc dng ph nh dng ng ton thn.

1.2.3. Thuc corticoid ng ton thn: Chng ch nh ng ni khp: Rt hiu qu i vi cc triu chng c nng ca THK: Vi hydrocortison acetat: Mi t 2 - 3 mi tim cch nhau 5 - 7 ngy, khng vt qu 4 mi tim mi t. Vi ch phm "chm" (Triamcinolon Hexacetonid): mi mi. cch nhau 6-8 lun. Khng tim qu 2 t/nm. LU : Phi tin hnh tim trong iu kin v khun tuyt .

1.2.4. Thuc iu tr triu chng c dn chm Gii thiu mt s thuc:

y l mt nhm ihuc iu Ir mi, khng t hiu qu tc th m sau mi thi gian di (trung bnh 2 ihng), v hiu qu ny c duy Ir c sau khi ngng iu ir (sau vi tun n 2 - 3 thng). Dung np ihuc tt, dng nh khng c tc dng ph. Nhm ny gm mt s loi c lc dng kch Ihch t bo sn, tng tng hp proteoglycan, c ch cc men... hoc thay i cht nhy (dch khp nhn to). Di y l bng gii thiu mt s ihuc Ihuc nhm ny.

Thnh phn Chondroitin sulfat (Ch-s) Chondroitin sulfat (Ch-s) Diacerhein hoc diacetylrhein S.adenosyl-L-methionin (SAM) Superoxy dismutas Acid hyaluronic (AH)

Bt dc Chondrosulf Structum

Liu
3 v i n /2 4 h X 2 th n g ( u n g )

4 - 6 vin/24h, t nh't 1 thng (ung) 100 mg/24h (ung) t nht 1 thng 1200 mg/24h X 1 - 2 thng (ung)

Orgotein Hyalagan 20 mg/ng/tun X 5 tun. Tim ni khp.

S lc v c ch ca mt s thuc chng THK tc dng chm: ' Chondroitin sulphat (Structum, Chondrosulf): c ch mt s' men tiu sn, nht l men metalloprotease. Diacetylrin hoc diacerhin l mt phn t mi thuc nhm anthraquinon, c tc dng c ch sn xut interleukin-1 v mt s" men thoi ho sn. Thuc khng lm gim t l prostaglndin nn khng gy tn hi d dy. S-adnosyl - methionin (SAM) l mt ch't, kch thch s tng sinh cc t bo sn v lm tng tng hp proteoglycan. Sulat glucosamin l mt amino - saccharid thuc v cc glycosaminoglycan (GAG): c ch men tiu protein. Acid hyaluronic (AH) di dng hyaluronate de sodium, l mt thuc c tim vo trong khp. Thuc hot ng bi 3 c ch: Bao ph v bi trn b mt sn khp, ngn cn s mt proteoglycan bi cc khun sn gin tip lm tng cng ch tit AH t do, t nhin hoc hyaluro ho bi cc t bo mng hot dch. Trong khp TH, nng AH (0,8 - 2 mg/ml) t hn khp bnh thng (2,5 - 3,5 mg/ml) v ng lng phn t ca AH b gim (0,5 - 4 mega Dalton, trong khi bnh thng: 4-5 mega dalton. Tim AH c trng lng phn t cao vo ni khp b TH s to ra c mt " nht b sung" ihc s. Cc ch phm c th nghim v s dng Nht, , c c trng lng phn t t 500 - 900 mega Dalton. Hin nay, ngi ta c xu hng tm cc loi AH tim c trng lng phn t Tt cao: Nhiu triu n v Dalton. Orgotein hoc superoxyd dismutase: c ch to cc gc superoxyd t do hu hoi t chc. c dng ng tim ni khp.

1.2.5. Thuc bo v sn khp Theo nh ngha ca Hip hi thp khp quc t (ILAR), thuc bo v sn khp l thuc iu tr d phng, lm chm tn thng sn khp b thoi ho ngi, hoc thm ch lm lnh tn thng . Trong thc t, cha c loi thuc no xng ng vi tn gi ny. 2. iu tr ngoi khoa 2. 1. iu tr ngoi khoa Cc phng php: Chm li khp, gt gia xng (osteotomy), lm cng khp, thay mt phn hoc ton b khp. Trong , gt gia xng c bit tt sa cha cc khp b lch trc nh khp gi vo vo trong hoc cong ra ngoi. au c th c ci thin khi t th tt lm cho sn khp tt hn. Ch nh: Cc trng hp hn ch chc nng nhiu, hoc au khp khng p ng vi phng thc iu tr ni khoa. Ch nh: Tn thng trn X quang t tin trin v au nhiu. Phng php: Thng qua ni soi ra khp, ly b cc phn mm trong khp, gt gia b mt khng u ca sn. Trn b mt ca sn b thoi ho c th c iu tr bng cch mi nhn cc mu sn ghp, trong sn c duy tr do c nhng vo cc vng xng c ti mu. Nh vy b mt sn b thoi ho c ph bi sn chc nng. Nu khng, qu trnh sn b tr ra c th gy cng khp. Ch nh: Cc THK tin trin, c hiu qu r vi triu chng au v vn ng ca khp. Thng ch nh vi khp hng v khp gi. Vi khp vai, khuu, c tay, v khp bn ngn ci, cng c ch nh song kt qu khng c chc chn. Bin chng: Nhim khun, vim tc nh mch, tc mch phi, tn thng dy thn kinh, hoc cc bin chng do bn thn khp gi: Mm hoc gy xng.

2.2. iu tr di ni soi khp -

2.3. Thay khp gi -

2.4. iu tr ngoi khoa d phng Khi c mt t th xu hoc lch trc s gy THK th pht. C th sa bng cch can thip ngoi khoa: Gt gia xng chy trong lch trc khp gi, sa cha li cc thiu sn khp hng bm sinh. 3. Ch nh c th 3.1. Giai on khi pht Bo v khp bng cc bin php v sinh v gim s qu ti vi khp. Phng nga t ih x'u v itT tr au bng xoa bp vt l, chm cu... Chng au ti ch v ton thn bng cc thuc CVKS ng ton thn, m ch yu l aspirin tu theo mc au ca bnh nhn.

Cc thuc chng TH tc dng chm nu c iu kin. Ch nh tim ni khp corticoid nu c t au nhiu.

3.2. Giai on tin trin L THK gy au thng xuyn v gy gim chc nng nng, i hi phi iu tr bng mt thuc chng vim mnh hn: CVKS: C th dng: Ibuprofen hoc diclofenac liu hng ngy ph thuc vo mc au v s dung np. Tim corticoid ni khp. iu tr vt l phi trnh cc ng tc qu mnh (l yu t khi pht t lin trin), ch nn gii hn cc bin php lm gim au. Ngm v tp cc ng tc trong nc sui khong, p bn c hiu qu tt. Cc bin php ny c th trnh cho bnh nhn phi ng nhiu thuc v ci thin c chc nng ca khp.

3.3. Ch nh i vi mt s trng hp c bit 3.3. . Cc khp bn tay Ngm nc nng, b paraphin v trnh lm nng cc chn thng lin tip l cc bin php tt vi cc khp .bn tay. Gim au v CVKS thng c s dng. C th lim ti ch ni khp hoc cnh khp steroid c bit tt khi ch c 1 - 2 khp c biu hin triu chng. THK bn ngn tay ci ch p ng tm thi vi tim ti ch stcroid. C th phi np c' nh. Nu cc bin php trn khng c kt qu, c th lm cng khp. 3.3.2. Khp hng THK hng i hi phi trnh cho khp phi chu lc, c cc bi tp vn ng thch hp. Gim au v CVKS thng c ch nh. C th gim bt cc stress bng cch dng nng, hoc gy chng. Thay khp hng thng c ch nh khi bnh nhn giai on lin trin. 3.3.3. Khp gi cng cn phi dng cc phng php vt l tr liu i vi vn ng khp v lm mnh c t u i, irnh cho khp b qu ti v dng cc thuc gim au, CVKS. Dng nng chng i din vi khp bnh c th cho kt qu tt. Trong t cp, c th ch nh lim steroid ti khp, song khng nn lm dng. Thay lon b khp gi s lm gim au v ci thin vn ng. 3.3.4. Hi chng au ct sng cp do TH Thng him gp. Vic iu bao gm: Ngh ngi, gim au v CVKS. Xoa bp, bm huyi, chiu hng ngoi, p paraphin.... gp phn lm gim au do cc co tht c. 3.3.5. Hi chng au ct sn mn lnh Mc ch: Gim au bng cch gim hoc thch nghi vi cc hot ng sinh l, th thao v nghe nghip.

Trnh dng cc thuc gim au v CVKS ko di. Cc bin php ko gin ct sng c hoc ct sng tht lng cho kt qu kh lng, cn thn trng khi ko, c bit vi ct sng c. eo mt ai ym tht lng c nh (lombostat) lm cho cc au ct sng mn tnh do TH c ci thin r, c bit trng hp c trt t sng hoc hp ng'sng, hay trong cc trng hp m ngh nghip i hi phi gng sc. Vt l tr liu trong iu kin tt c th lm gim au, c bit cho php bnh nhn thch nghi c vi cc thi quen mi trong sinh hot hng ngy thch hp vi tnh trng tn thng. p bn, tm nhit v.v l cc bin php b sung c ch.
t

3.3.6. au ct sng do THK lin mu sau Tim corticoid ti khp au c kt qu tt, song mun tim vo khp chnh xc, phi tim di mn tng sng. 3.3.7. Hi chng r do TH

au thn kinh to do hp ng sng

Vi th thng thng: Ngoi thuc gim au v CVKS. tim corticoid ngoi hoc trong mng cng lm ci thin cc triu chng chc nng mt cch r rng v nhanh chng. Ngoi ra, phi sa cha li cc bt thng v t th ct sng: Sa ct sng qu lm bng cc ng tc tp c lng-bng t th g. Dng mt ai ym tht lng c nh vng ny tng cng kt qu trn. Vi th nng: C ch nh ngoi khoa: Tu theo s gim vn ng chc nng, cc du hiu thn kinhTtnh trng chung v tui tc ca bnh nhn. Mc ch: L lm gim chn p nh m mt ng pha sau: c t b cung sau ca t sng vi hp ng s"ng trung lm v ct b c cung sau km mt phn t sng vi hp ng sng bn, nu c ln thng a m nng phi ct c a m. Lm cng khp ch c ch nh khi c trt t sng sau m hoc trng hp au tht lng nhiu. Kt qu tt vi trng hp au r thn kinh v chng au cch hi. i vi au lng, kt qu km hn nhiu. au thn kinh i b: iu tr ph thuc vo nguyn nhn (tng t nh au thn kinh to). iu tr ni khoa phi lu di hn. Cc ri lon vn ng do di chng lin quan ti s teo c t u ihng gp v cn phi tp luyn tch cc. Ch nh ngoi khoa ging nh au thn kinh to. au thn kinh c - cnh tay: Vi th thng Ihng: Kt hp ngh ngi vi cc thuc gim au, CVKS, gin c, an thn v np c" nh, lm thnh mt vng eo c lc ban ngy. Thng dng loi vng np c m nl c C114, hoc vng nha c th iu chnh cao, loi vng Schrantz, c C156. Nn ng t th na ngi, c c nh, tay c k gi cao. Cc ng tc licn quan n ct sng c ch c thc hin bi mt bc s c kinh nghim, vi s cn nhc k cng cc yu t (tui, bin chng thn kinh....), nu khng s lm tn thng nng thm hoc gy gia tng cc bin chng ihn kinh.

Th tng au: Ngoi cc ihuc gim au mnh, cn phi dng corlicoid ton ihn, liu 0,5 mg/kg/24h irong khong 1 tun, kt hp vi bt ng bng vng c la trcn xng chm v cm (loi C159). Th bn cp mn tnh: C th ko gin ct sng c, song phi rt thn trng nh phn trn ni. Khi di chuyn bng xe t, khi vn ng cc ng tc trong ngh nghip hoc ni tr, nn eo vng np c. Liu php nc khong thng tt i vi au c mn tnh. iu tr ngoi khoa c ch nh vi mt s him cc trng hp au thn kinh c - cnh lay, l cc th tin trin ko di qu 6 thng d iu tr ni khoa ng cch v eo np vng c, th tng au khng li iu tr, th au m tin trin nng dn ln bi cc ri lon Ihn kinh: Lit kiu r, p tu. K thui can thip nhm gii phng r: c t b a, ct b gai xng c hoc khng km iheo lm cng khp.

IU TR CHNG LONG XNG

Trn Ngc n

I. I CNG Long xng l mt bnh c c trng bi khi lng xng thp v s suy gim vi cu trc ca m xng, lm xng tr nn gin v d gy. Tu iheo nguyn nhn, long xng c chia lm 2 loi: lin pht v th pht. Long xng tin phi gm long xng tp I (long xng sau mn kinh) v long xng tp II (long xng lui gi). Long xng th pht do nhiu nguyn nhn khc nhau: Bnh v hi chng Cushing, cng cn gip trng, s dng corlcostcroid, bt ng ko di, a L I lu xng, cc bnh gan Ihn mn tnh... Lm sng Biu hin lm sng ca long xng xut hin mun. Nhng triu chng ch . yu gm au C I sng cp hoc mn lnh, g v d gy xng. Nhng cn au cp lnh thng xut hin t ngt, t nhin hoc sau nhng ng tc bt thng ca CI sng, bnh nhn c ih khng i li c irong vng vi ngy n vi tun. au lng c ih m , ko di, vi nhng c im ca au c hc, thng xut hin sau vi ln au lng cp. Km iheo au lng c th c bin dng ct sng (g) v gim chiu cao. Ngi bnh rl d b gy xng, c bit l gy xp cc i sng khng do chn thng, gy cng lay kiu Poutcau Collcs v gy c xng i. Cn lm sng Trong lng xng lin phi lc mu lng, calci mu, phospho mu. phosphulase kim bnh Ihng, calci niu hnh ihng hoc gim.

X quang: Xng tng thu quang t mc nh n nng, thn t sng c th bin dng hnh chm, hnh thu knh lm hoc xp hon ton, v cc xng di mng, c th thy hnh nh ct ho, vi ho mt s" dy chng, sn sn, thnh ng mch chu. Cc phng php o khi lng xng (o hp th photon, chp ct lp vi lnh...) l nhng thm d nhy v chnh xccho php nh gi mc gim st khi lng cht xng v lin on gy xng.

II. IU TR 1. Nhng hin php chung Trong nhng t au cp tnh, s dng nhng thuc gim au (nhm chng vim gim au khng stcroid hoc ml thuc gim au khc), ngh ngi ti ging. Ngoi cc i au cn duy ir cc hot ng th lc v th dc hp l, thng xuyn, trnh bl ng ko di. Ch n m ho calci, proiein, cc viiamin. Ch sinh hoi an lon, Irnh ng v irnh mi sang chn khc.

2. Cc thuc iu tr long xng

2. . C a lc i

Calci l mi eh'l khong rt cn ihit trong vic hnh ihnh, phi irin v duy tr lnh vng chc ca m xng. Thuc va c lc dng d phng va l ihuc iu tr cho bnh nhn long xng, re lin, dung np lt, nn s dng cho tl c cc bnh nhn b long xng cng nh mt s i tng c nguy c long xng cao, nh l ml hin php b sung trong ch dinh dng. Liu dng iu tr long xng khong 1000 - 1500 mg calci nguyn t" mi ngy. C nhiu loi mui calci. hay dng nh't l calci carbonat (vi hm lng calci nguyC'n l chim 40%). Tc dng ph: MI s" l bnh nhn c ih c r lon licu ho {v hi. chm tiu), to bn, khng nn dng cho bnh nhn si ihn.

2.2. Calcitonin: Miacalc, calcilar, calsyn, cibuculcinc.... Calcitonin l mt polypeplid c 32 aci amin, c til hi l bo c ca luyn gip, cc ch' phm c ngun nc t c hi, ln hoc loi tng hp ging culcilonin ngi imnw calclonin c hi c tc dng mnh v kodi hn cc loi khc. Trong iu tr long xng, ihue c lc dng c ch qu irnh hu xng do tc dng c ch irc lip ircn hu ct bo v giam au. Tc dng gim au (c th c liC '11 quan n s hi lil ca cc cndorphin ni sinh) thnii xu hin sm irong tun u lin dng Ihuc. Caciionin nn ch nh cho nhng bnh nhn long xng c iriu chng, c bii l nhng ngi c au lng do xp ln cc t sng.

Liu lng: 50 - 100 n v mi ngy, tim bp, di da hoc xt qua ng mi hng, dng hng ngy hoc cch ngy, nn dng tng i khong 7 - 1 0 ngy mi thng. Tc dng ph: Hay gp nht l biu hin nng bng mt (xut hin ngay sau khi dng thuc v thng qua nhanh khng cn phi x tr g), ngoi ra c th c bun nn, nn hoc d ng.

2.3. Liu php Hormon thay th Oestrogen c tc dng trc tip trn t bo xng, c ch qu trnh hu xng. Vic s dng oestrogen nhng ph n mn kinh nh mt liu php hormon thay Ih l mt bin php c hiu qu nht trong d phng v iu tr long xng sau mn kinh. Rt nhiu nghin cu ch ra rng vic dng oestrogen d phng cho nhng ph n sau mn kinh, ngay c khi mn kinh nhiu nm s c tc dng lm gim ng k nguy c gy xng tui 70 - 75. Trc y thng dng oestrogen n thun dng ung hoc tim bp, sau mt thi gian di thy xui hin nhiu tai bin (ung th ni mc t cung, ung th v...); trnh hin tng ny ngi ta kt hp oestrogen vi progestcron. Hin nay c 2 loi thuc c dng irnh c cc tai bin k n: Tibolon (Livial) c tc dng ging nh oestrogen, progesteron v androgen, vin 2,5mg, mi ngy ung 1 vin, ung ko di nhiu thng. Raloxiten (Evista) c tc dng ging nh oesogen nhng khng c tnh cht ni tit, vin 60mg mi ngy ung 1 vin, ung nhiu Ihng. Khng dng phng php hormon thay Ih vi nhng bnh nhn c ung ih v, qu sn ni mc t cung, vim tc tnh mch, cn au thl ngc.

2.4. Vitamin D v cc cht chuyn ht ca vitamin D Vitamin D v 1,25 dihydroxyvitamin D (calcitriol) c tc dng iu tr long xng nhng bnh nhn c Ihiu hi vitamin D, gim hp thu calci rul, c bit l mi s ngi gi v ph n sau mn kinh. Liu lng: 800 - 1000 n v viiamin D mi ngy, hoc 0,50 - 0,75 microgam calcilriol (roculiru) mi ngy. Thuc c nguy c lm lng calci mu v nc tiu, cn theo di nng calci mu v nc tiu nh k khi dng thuc.

2.5. Cc thuc bisphospionat C tc dng c ch qud trnh hu xng. Cc thuc thng dng l: Alendronat (Fosamax) vicn lOmg, mi ngy ung 1 vicn trong nhiu Lhng. Etidronat (Didronel) vin 400mg' mi ngy ung 1 vicn t 2-3 thng khi dng 2 Ihuctc ny phi ung nhiu nc, xa ba n v phi hp vi calci v viiamin D. Pamidronai (Aredia) ng 30mg, lOml truyn lnh mch chm pha vi 250ml dung dch glucosc 5% hay NaCl 0,9% (15-20mg/2 gi), ch nh trong long xng do bnh Kahler hay di cn ung th gy hy xng.

Tc dng ph: Nn, a chy thong qua. Chng ch nh: Gy xng, nhuyn xng, suy thn nng.

2.6. Cc cht tng ng ho (durabolin, decadurabulin, testosteron...) Durabolin (Nandrolon phenylpropionat) v Decadurabolin (Nandrolon Decanoat) c tc dng tng cng ng ha, dinh dng, tng qu trnh tng hp khung protein ca xng. Durabolin ng 25mg tim bp 1 tun 1 ln. Decadurabolin ng 50mg lim bp su 3 lun 1 ln chng ch nh trong nhng trng hp ung th tuyn lin lit v ung th v ( nam gii). Teslosteron c vai tr quan trng trong s phi trin v duy tr khi lng xng nam gii ging nh oestrogen n. S thiu ht testosteron l mt nguyn nhn thng thng ca long xng nam gii v vic s dng thuc ny l thch hp i vi nhng nam gii b long xng do thiu nng sinh dc. Nhng thuc tng ng ho c tc dng lm tng qu trnh ng ho irong khi c rt t nhng c tnh androgen nh i vi lestosteron t nhin. Testosteron undecanoat (Andriol nang 40mg, ung 1 nang/ngy ung l 10-15 ngy trong thng. Thuc c tc dng lm tng khi lng cht xng do kch thch qu trnh to xng v lm tng khi lng c. Tc dng ph ch yu l c th gy nam tnh ho (irng c rm lng, thay i ging ni). Do nhng tc dng ph ny m nhng dn cht ca androgen I c s dng rng ri iu ir ko di cho bnh nhn long xng.

2.7. Mui Puor Tc dng kch thch qu Irnh to xng, c th lm tng khi lng ch't xng. Liu lng: Mui NaF 50 - 75 mg mi ngy, phi hp vi calci. Do thuc lm gim lnh n hi ca xng cho nn c th gy thay i cu trc xng, lm gim tnh vng chc ca b xng, ch nn ch nh nh mi bin phdp iu tr h trong mt s t irng hp long xng nng. Tc dng ph: Bun nn. nn, a chy, au bng, au xng, au khp, nhuyn xng. Chng ch nh: Suy ihn, gy xng, nhuyn xng.

2.8. Mt s'bin php khc Hormon luyn cn gip (PTH) l cht gy hu xng, tuy nhin vi liu ihp v s dng ngt qung n li c coi l c tc dng kch thch to xng v gn > cng bt u c dng nh mt thuc iu tr long xng. 3. iu tr mt s" th b long xng 3.1. Long xng sau mn kinh Cc hin php iu nn c bt u sm nhng ph n sau mn kinh c biu hin xp, ln cc i sng ngay c khi hin tng bin dng t sng cn mc nh hoc c khi lng xng thp khi o khi lng xng.

S dng calci cho tt c cc bnh nhn. C th dng thm vitamin D hoc cc ch't chuyn ho ca n nu c hin tng gim hp th calci (biu hin l calci nc tiu <100 mg/24h).

- Cc bin php tp luyn th lc rt quan trng. - Nn s dng liu php hormon thay th, ngay c khi bnh nhn mn kinh nhiu nm. - Dng calcitonin khi c chng ch nh vi hormon thay th khng dung np oestrogen, hoc trong nhng trng hp c long xng nng (xp ln t sng). C th dng Biphosphonat ong nhng trng hp ny. 3.2. Long xiig tui gi - Hormon thay th hoc calcitonin t c tc dng, mc d c th dng calcitonin khi bnh nhn c au nhiu do xp ln cc l sng. - S dng calci cho lt c bnh nhn. - Xem xt s dng thm vitamin D hoc cc ch phm ca n nu c nhng bng chng ca ihiu ht vitamin D (gim nng 1,25 dihydroxy vitamin D, hoc gim hp thu calci rut). - C th dng Biphosphonat hay thuc tng ng ha. - iu quan trng l cn p dng cc bin php an ton trongsinh hothng ngy, trnh ng v trnh mi sang chn khc d rt nh. 3.3. Long xng do glucocorticid Nu c th, nn ngrng cortcosteroid hoc chn loi thuc c thi gian tc dng ngn vi liu lng thuc thp nh't c hiu qu. Duy tr ti cc hoi ng th lc v tp luyn trong qu trnh iu tr. S dng calei cho Lt c cc bnh nhn. C th dng li liu thiazid (v d hypothiazid) hn ch tnh trng mt calci qua thn. Xem xt liu php hormon thay th cho nhng ph n sau mnkinh phidng corticosteroid ko di hoc cc ch phm ca androgen cho nhng bnh nhn nam c biu hin suy gim testosteron mu do dng corticosteroid.

Trn Ngc n

I. I CNG Gt l mt bnh ri lon chuyn ho, do s tng bt thng lng acid uric trong c th. c tnlig u tin ca bnh l nhng cn vim khp cp ti pht, thng mt khp sau l tnh trng vim khp bin dng mn tnh. Tng acid uric mu c th bm sinh (v d hi chng Lesch - Nyhan) hoc nguyn pht (do tng tng hp purin ni sinh v thng c tnh cht gia nh) hoc th pht (do tng cng thoi ging purin hoc gim thi ir acid uric qua thn), n thc t ch yu gp bnh gt nguyn pht. Bnh ch yu gp nam gii, tui trn 30. Biu hin lm sng c th din bin qua 4 giai on: (1) giai on tng acid uric mu khng iu chng, (2) nhng cn vim khp cp, (3) giai on gia cc cn cp v (4) giai on vim khp mn tnh. Lm sng - Gt cp tnh: Triu chng c irng ca bnh l nhng cn vim khp cp khi pht t ngt, d di, thng vo ban m, hay gp nht l vim khp bn ngn chn ci, song cng c th xut hin nhng v tr khc ca bn chn, c chn v khp gi, rt t p chi trn. Khp vim sng, nng, da cng bng, v rt au. Vim khp ko di trong vi ngy ti mt tun ri khi song hay ti pht, p ng nhanh vi colchicin hoc cc thuc chng vim gim au khng steroid. Gt mn tnh: + Vim a khp mn tnh cc khp nh v nh, i xng, c th dn n bin dng. + Ni cc u cc (ht tophi) vnh tai, quanh khp, di da, i khi ht tophi b v thot ra tinh th urat mu trng ging nh phn. + C Ih ln thng Ihn nh vim thn k, si tit niu, suy thn cp v mn tnh. Cn lm sng - Acid uric mu thng tng (> 420|imol/1 nam v 380|imol/1 n). - Acid uric trong nc tiu 24 gi c th tng hoc gim. - Chc dch khp hoc cc hl tophi c th thy cc tinh th sodium urai (hnh kim. nm trong hoc ngoi bch cu on trung tnh). - Chp X quang khp c th thy nhng vng khuyt xng (trong gt mn tnh). - Xt nghim chc nng, siu m v X quang thn nu nghi ng c tn thng thn.

l. IU TR

1. Nguyn tc iu tr Chng vim khp trong cc cn cp. D phng nhilg cn vim khp cp ti pht. H acid uric mu (bng ch n, thuc gim tng hp hoc tng o thi acid uric). Khng bao gi bt u iu tr ng thi c vim khp cp v iu tr lng acid uric mu. c n phi tch bit, iu tr vim khp cp trc v sau khi tang tnh trng vim khp ht hoc thuyn gim mi bt u dng cc . thuc h acid uric mu.

2. iu tr c th 2.1. iu tr gt cp tnh 2.1.1. Colchicin Colchicin l mt alcaoid c chit xut t cy eholchicum autumnale, c dng ln u tin vo nm 1820. Loi cy ny c dng iu tr bnh gt cp t rt sm, khong th k th su. T lu thuc c coi l mt Ihuc c ir trong iu tr gt. c ch nh trong cn gt cp d phng cn c'p v ngoi ra n cn c s dng nh mt test ihm d trong chn on. Tuy nhin, hin nay do s ra i ca nhiu loi thuc chng vim khng sleroid mi v do nhng tc dng ph c th c ca thuc m colehiein khng cn c coi l thuc la chn duy nht iu tr gt cp. - Colchicin rt c hiu qu irong iu tr gt cp, c bit khi thuc c s dng sm trong vng 1 2 -2 4 gi u ca bnh v thng c tc dng lm gim cc triu chng trong vng 6-12 gi sau khi dng thuc. - Cch ng: Trong cn gt cp c Ih dng colchicin ung, theo 2 cch sau: Cch th nht: + + + Ngy u in: ung 3 mg, chia 3 ln sng - tra - ti. Ngy ih hai v ngy Ih ba: ung 2 mg, chia 2 ln sng- ti. T ngy ih ur: dng 1 mg mi ngy cho ti khi ht vim khp. ng 0,5 - 0,6 mg mi ln, 2 gi mt ln cho n khi au gim hoc ximt hin cc tc dng ph ca ihuc (bun nn, hoc a chy) th ngng li, tng liu khng nn qu 4 - 6 mg trong 24 gi. + Cn gim licu colchicin nhng ngi gi, bnh nhn suy gan hoc suy thn. + Colchicin tnh mch: C th dng colchicin ng tnh mch'khi khng th dng c bng ng ung, (liu ban u 1-2 mg pha trong 1 0 -2 0 ml dung dch mui sinh l, tim tnh mch chm trong 3-5 pht), tuy nhicn o nhng tc dng ph nng nn ng tim rt t c s dng. -

Cch th hai:

+ Tc dng ph: Bun nn, nn, a chy, au bng, mn nga, pht ban, st cao. Khi s dng ko di c th c hin tng c ch tu xng, vim dy thn kinh ngoi vi, rng tc, ri lon kinh nguyt... 2.1.2. Cc thuc chng vim gim au khng steroid Cc thuc chng vim gim au khng steroid cng c tc dng rat tt trong iu cn gt cp. Khi khng c colchicin hoc bnh nhn khng dung np colchicin, c th dng mt trong cc thuc chng vim gim au khng steroid v d: + Dicloenac (Voltaren) 75 mg X 1 -2 ng, tim bp trong 2-3 ngy, sau ung 100 mg mi ngy. + Ketoproen (Proenid) 100 mg X 1-2 ng, tim bp trong 2-3 ngy, sau ung 100 - 200 mg mi ngy + Piroxicam (Felden) 75 mg X 1 ng, tim bp trong 2 - 3 ngy sau ung 20 mg/ngy. Chng ch nh dng cc thuc chng vim khng steroid gm: Lot d dy t trng ang(tin trin, suy thn, tin s d ng vi nhng thuc ny.

2.1.3. Corticosleroid Corticosteroid thng c tc dng gim nhanh cc triu chng trong cc t cp ca gt, v vy n cng c s dng iu tr gt cp mt s bnh nhn, song cn hn ch s dng v ch nn dng ngn ngy cho nhng bnh nhn b gt cp m khng th ung colchicin hoc cc thuc chng vim gim au khng steroid (chng hn: methylprednisolon 40 mg/ngy, gim liu dn v ngng trong 7 ngy hoc ng ung nh prednisolon 40 -60 mg/ngy, gim liu dn v ngng trong 7 ngy). Vi bnh nhn ch c vim 1 khp m cc thuc ng ton thn t tc dng c th tim thuc coiticosleroid ti khp, tuy nhin cn thn irng v ht sc hn ch.

2.1.4. Thuc gim au Khi bnh nhn c au nhiu, au d di, c th dng thm cc thuc gim au trc khi cc thuc c hiu pht huy tc dng. Thng dng paracetamol hoc paracetamol-codein, meperidin, trnh dng aspirin. 2.1.5. Ngh ngi Bnh nhn nn ngh ngi ti ging trong cn gt cp v tip tc t nhl 24 gi sau khi lui, i li sm c th im cho cn ti pht, nn dng thm cc thuc an thn. 2.2. iu tr gia cc cn cp (iu tr d phng cn gt cp) iu tr trong giai on khng c triu chng (hay giai on.sau cn gt cp) nhm hn ch ti thiu s lng ng urat trong cc t chc, phng nga tnh trng vim khp mn tnh c tophi v lm gim kh nng ti pht v gim mc nng ca nhng cn ti pht.

2.2. . Ch n, ung, sinh hot King ru v cc th kch thch: t, c ph. Hn ch nhng thc n cha nhiu purin: Ph tng ng vt (lng, im, gan, tit canh), mt s loi tht nh th rng, thl ch, c, tm, cua, rau dn, cc loi u. C th ung bia, n trng, sa, hoa qu, cc loi tht khc (di 100 g proiein mi ngy). Ung nhiu nc hng ngy,-nn duy tr lng nc tiu t nht l 2 lt mi ngy, tt nht dng cc loi khong kim. Trnh lm vic qu sc, trnh lnh, Irnh n ung qu mc. Trnh dng nhng thuc gy tng acic urid mu: Thiazid v cc thuc li tiu quai, aspirin, acid nicotinic, pyraznami v mt s thuc khc.

2.2.2. Colchicin

Trong giai on khng c triu chng gia cc cn cp (hay giai on sau cn gt cp), s dng colchicin khng phi vi tc dng chng vim m l d phng. Mc ch dng colchicin d phng gm:

(1) Dng thuc ngn chn nhng cn gt c'p ti pht. Thuc khng nh hng n nng acid uric mu song c tc dng lm gim tn sut ca nhng cn gt cp; (2) Khi bt u s dng nhng thuc lm tng o thi acid uric hoc alopurinol, colchicin s c tc dng ngn chn nhng cn gt cp c th xut hin do c s thay i l ngt nng acid uric huyt thanh. Liu dng 0,5 - 1 mg mi ngy. Thi gian s dng tu thuc tng bnh nhn. Vi nhng bnh nhn b gt c'p ln u, c kh nng khng ch ti nng acid uric mu, gim c cn nng, t c nguy c ti phi th khng cn thit phi dng colchicin ko di. Tri li vi nhng bnh nhn ln tui hn, c km theo suy thn nh i hi phi dng thuc li tiu, nhng ngi c tin s b nhiu cn gt cp nen s dng colchicin ko di. Nhn chung, sau 6 - 8 tun khi nng acid uric mu tr v bnh thng v khng c cn ti pht c th ngng colehin.

2.2.3. Cc thuc h acid uric mu: Cc thuc h acid uric mu c nhiu loi, tc ng vo nhng khu khc nhau trong qu trnh tng hp, chuyn ho v thi tr ca acid uric mu trong c th. Tu iheo c ch tc dng c Ih chia lm cc nhm sau (xem bng): + + + Thuc lm tng thi acid uric qua thn (probenecid, sunfipyrazon, zoxazolamin, benziodaron, benzbromaron...). Thuc lm gim tng hp acid uric (ailopurinol, oxypurinol, tisopurin). Thuc lm tiu acid uric trong mu (urate oxydase).

Trn thc t, ch yu dng cc thuc tng o thi acid uric: Probenecid, sunlnpyrazon v allopurinol. La chn mt trong 2 loi thuc ny da vo mt s yu t nh: Nguyn nhn v mc ca tng acid uric mu, tnh trng suy thn v si thn, s c mt ca tophi..., song ch yu l cn c vo mc bi tit acid uric'trong nc tiu 24 gi. Nu acid uric nc tiu <500mg/ngy, chng t c hin tng gim bi tit acid uric, khi ch nh dng cc thuc lm tng o thi. Nu acid uric trong nc tiu 24 gi trn 800 mg, chng t c hin tng tng tng hp acid uric, nn dng allopurinol. Trong mi s t trng hp c th ng thi s dng 2 loi thuc ny. Mt s' thuc iu tr h acid uric mu Nhm Tn thuc c ch Allopurinol tng hp Tisopurin Bit dc Zyloric Xan turic Thiopurinol Tng o thi Probenecid Benzbromaron Benemid Dsuric Hn hp Allopurinol + Benzbromaron D sa tura Tiu acd uric Urate - oxydase ricozym Trnh by Vin nn 100, 200, 300 mg; nang 100 mg vin 100 mg Vicn 500 mg; vin 100 mg 100 mg + 25 mg ng 1000 UI, IM, IV Liu lng 100 - 300 mg; Chng ch inh C thai Cho con b Thn trng trong suy thn, suy gan Tng ural niu Si thn Suy thn Tng urat niu Si thn Suy thn C ihai D ng Thiu G6PD

00 - 400 mg 500- 1500mg; 100 - 200 mg 1 - 2 nang lOOOUI/ngy X 12 ngy

Thuc trig thi acid uric:

Nhng thuc ny c tc dng ngn cn s ti hp thu ca urat ng thn, do lm lng o thi urat qua thn, lm h acid uric mu v tng nng acid uric Irong nc tiu. Thuc khng c tc dng nhng bnh nhn suy thn (creatinin huyt ihanh trn 2 mg%). C nhiu loi thuc, song thng dng 2 loi sau: Probenecid: Liu ban u ung 0,5g mi ngy, tng dn ti liu l-2g/ngy, hoc Sulfnpyrazon: Bt u vi liu 100 mg/ngy, tng dn ti liu 200 - 400 mg/ngy.

Ch nhng tc dng ph: Hin tng lng nhy cm vi thuc, biu hin hng si, phi ban xut hin khong 5% bnh nhn v khong 10% c nhng tc dng ph ng Liu ho.

Thn trng khi dng cc thuc lng o thi: Khng dng thuc cho nhng bnh nhn suy ihn, tin s si thn. Nn duy tr lng nc tiu thng xuyn trcn 2000 ml/24 gi hn ch ti ihiu s lng ng acid uric ng tit niu nn dng thm cc thuc gy kim ho nc tiu hn ch hn na s lng ng ny (duy tr pH niu trn 6,0). Salycylat liu thp khng li tc dng ca nhng thuc lm tng o thi. Allopurinol: Allopurinol l mt ch't c ch men xanthine oxidase, ngn cn s tng hp acid uric t hypoxanthin v xanthin, do vy c tc dng h thp nng acid uric c trong mu v nc tiu. Ch nh cho nhng bnh nhn gt c tng tng hp acid uric, gt mn tnh c tophi, bnh nhn khng p ng vi cc thuc tng o thi acid uric v nhng bnh nhn gt c si thn. Liu lng: Ph thuc vo nng acid uric mu. Thng bt u cho allopurinol 100 mg/ngy trong vng mt tun, sau c th tng liu nu nng acid uric mu cn cao. Liu thng dng 200 - 300mg/ngy. Thn trng khi dng thuc cho nhng bnh nhn c suy thn. Khng nn dng thuc cho nhng bnh nhn c tng acid uric mu khng triu chng. Thuc c th lm khi pht cn gt cp (do lm h acid uric mu t ngt). Allopurinol lm tng tc dng ca azathioprin, do vy nn trnh dng allopurinol cho bnh nhn ang dng azathioprin hoc khi bt buc phi dng ng thi 2 thu"c ny, phi gim liu azathioprin. Tc dng ph: Khong 5% bnh nhn c biu hin tng nhy cm vi allopurinol (ni ban sn nga v c Lh tin trin n hoi t da, nhim c nng, thm ch gy l vong). Khi phi hp allopurinol vi ampicillin c th lm tng kh nng b pht ban. Vim mch mu, vim gan l nhng bin chng him gp khc.

2.3. iu tr gt mn tnh H acid uric mu bng cch thay i ch n ung v .dng cc thuc ging phn iu tr d phng cc cn gl cp, khng dng cc thuc thi acid uric, nn dng allopurinol. Khi c tn thng thn, trong iu tr cn ch ti nhng chng nhim khun, cao huyi p, si thn v suy thn tim tng. Cc ht tophi c th nh i hoc bin mt khi c iu tr vi allopurinol. Nhng ht tophi ln v nh hng nhiu ti chc nng vn ng, thm m c th phu thulci b. -

Nn ng colchicin 1 mg mi ngy d phng nhng cn cp trong khi dng cc thuc h aeid uric mu. C th dng Ihm cc thuc chng vim khng steroid liu thp cho nhng bnh nhn c tinh irng vim khp cn lin trin.

IU TR CC BNH VIM XNG KHP NHIM KHUN

Trn Ngc n Nguyn Th Ngc Lan Vim xng khp nhim khun l biu hin xng khp lin quan n mt vim nhim gy nn bi mt vi khun, virus, k sinh vt, nm. c th ch l vim khp n thun hoc vim tu xng (ci lu vim). i vi vim khp nhim khun (VKNK), c th chia thnh 2 nhm: Nhm I VKNK l c mt ca vi khun trong khp hoc i qua khp v nhm II thp khp sau nhim khun, trong ngi ta khng chng minh c tn ti ca vi khun ti khp, m ch iin quan n mt nhim khun xa. nhm th 2 ny, bao gm cc vim khp phn ng, khi pht irn mt c a i truyn c bit. Thc ra nhiu khi rt kh phn nh mt VKNK thuc nhm no, song vic nh nhm v mt l thuyt t ra vn mc ch iu tr khng sinh: Nhm I cn khng sinh tr liu dit vi khun, cn nhm II khng cn thit dng khng sinh, m dng ihuc chng vim l chnh, nu cho khng sinh th ch l mc ch phng nga s tc ng lip theo ca vi khun. Ct tu vim l tnh trng nhim khun xng, do vi khuh lao, vi khun thng hoc nm. C ih dn n hoi t biu hin bng s c mt ca cc mu xng cht. Di y l mt s nhim khun xng khp thng gp.
I. VIM KHP NHIM KHUAN d o VI KHUAN t h n g

Trong s cc vim khp do vi khun thng, c ti 65 - 85% s" trng hp l do cc vi khun gram dng (tr lu cu) gy nn, bao gm t cu vng (ch yu qua nhim khun da), cc lin cu ( vim hu hng, nhim rng), s trng hp do vi khun gram m chim 10 - 15%, gm coli, pseudomonas, serratia (do nhim khun rut mn tnh, vim ng mt mn lnh, nhim khun lit niu)... Ch c di 5% s trng hp l do nhim vi khun i v k kh kt hp, v 5% do nhim khun mycobacteria v nm. Trn thc t th bt c loi no cng c th gy nhim khun khp. Mt s" c a to thun li cho VKNK: Mt s" bnh l (ung th, bnh mu. a L I lu xng, nghin ru nng, x gan, i ng), cc ri lon min dch mc phi (iu tr ho ir liu, iu min dch, corticoid liu php, lupul ban h thng, AIDS), thiu ht bm sinh cc yu t chng nhim khun (gim hoc v gammaglobulin mu, thiu ht b ihc bm sinh, bt thng ca bch cu on, ihc bo, bnh huyt cu l"). Ngoi ra c mt s' nguyn nhn ti ch: Tim tnh mch, i catheter (khng v khun cathelcr lu ngy), hoc cc yu l' ti khp nh: Vim khp dng thp, khp gi, gl, calci ho sn khp, bnh khp do thn kinh...

Triu chng ton thn: Thng ni bl vi st cao, km rt run. Hi chng nhim khun r. Mt s ln cc trng hp, VKNK nm trong bnh cnh nhim khun mu. Triu ch ng ti khp: Thng tn thng mt khp. Vim a khp r'l him, thng xu't hin cc c a c bit (suy gim min dch nng), vi cc d'u hiu vim ti khp r: R'l au, nng , vn ng khp gim r rt. C cnh khp teo nhanh. Thng c hch gc chi c khp tn thng. X nghim dch khp: Rl quan ng chn on v phn lp vi khun: dch thng c, s lng t bo tng, c th trn 50.000 t bo/mm3 (trn 90% bch cu on trung tnh) v s c mt ca bch cu thoi ho l du hiu rt quan irng khng nh mi VKNK do vi khun thng. Nhum soi trc tip, cy dch c ih thy vi khun. Cy mu: Thng dng tnh Chp khp tn hng: Hp ton b khe khp, cc hc xng v hu xng' l du hiu c trng ca vim khp nhim khun (mun).

B. NGUYN TC CHUNG Mc ch ca iu tr l loi b vi khun, bo ln chc nng vn ng, ngn cn s hu hoi khp, chng li pht hoc thnh mn tnh. iu tr bao gm 3 phng thc chnh: Khng sinh, bt ng v dn lu.

c. PHNG PHP IU TR 1. Khng sinh /./. Nguyn tc chn khng sinh Vic la chn khng sinh phi p ng cc im sau: - Khng sinh thch hp vi vi khun, lc u da vo s phn on nguyn nhn, sau tu theo khng sinh v nghin cu kh nng dit khun. Kt hp 2 khng sinh tng hp. ng dng: Khi u cho khng sinh ng tim trong khong 2 tun, sau thay bng ng ung. Khng cn thit tim khng sinh ti khp v khng sinh khuych ln ri tt vo dch khp. - Theo di hiu qu iu tr: Nu c iu kin, theo di bng cch o kh nng dit khun ca dch khp l l tng. Thng thng theo di bng tc mu lng. Nu dng CRP th ti hn v CRP nhy hn tc mu lng. - Thi gian iu tr lu theo lng trng hp, ni chung t 6-8 tun Irong trng hp dicn bin tt. Trcn thc l, khng sinh Ir liu phi c bt u cng sm cng tt, trc khi c kt qu khng sinh . Lc ny, vic la chn khng sinh s da trn s d on -

vi khun gy bnh nh iriu chng bnh, tnh hung khi bnh, ng vo ca vi khun... Nu khng, c th dng khng sinh c ph rng chng c c t cu ln vi khun gram m nh cc nhm cephalospon hoc loi penicillin khng nhy cm vi men penicillinase kt hp vi nhm aminosid. 1.2. Mt s gi trong vic dng khng sinh i vi nhim khun do cu: Thng cc bnh nhn ny c nguy c b nhim cc chng khng li vi men penicillinase, nh't l trong trng hp nhim khun bnh vin, nn khi u c th chn cc khng sinh sau: + + + Natcilin: 100 - 150 mg/kg/24h, chia lm 4 ln truyn tnh mch. Cephalothin: 100 mg/kg/24h v vancomycin 30 mg/kg/24h. Penicillin G: C th dng nu nhy cm, liu 20 Iriu n v mi ngy, chia lm 4 ln, ng tnh mch.

Nu bnh nhn b nhim cc chng khng li vi penicillin hoc d ng vi penicillin th phi chn khng sinh khc. Thi gian iu Ir khng sinh t 2-4 tun, lc u ticm tnh mch, sau thay hng ng ung, khi khng sinh c p ng. C th nh gi p ng ca thuc khng sinh bng cch theo di lm sng: Cui tun u tin, cc du hiu vim phi c ci thin. Nu khp tip tc sng, lng dch khp tip tc tng v c m mc d chc ht nhiu ln, thm ch hi hng ngy, ton trng ca bnh nhn km i, th cn thit phi xem xt vn thay khng sinh. Trng hp ct tu vim cc xng di hoc cc t sng do t cu, cn phi duy ir khng sinh ko di, i khi n vi thng. a s" cc irng hp khi chuyn sang dng khng sinh ng ung, (c th iu tr ngoi tr) t kt qu tt. i vi nhim khun do lin cu: a s" cc lin cu c bit l nhm A v B, nhy cm vi penicillin. Tuy nhin mt s" chng vi khun ng rut nh Streptococus tecalis v s.ecium li khng li vi mt s khng sinh. i vi cc vi khun khng thuc tng i ny c th ng ampicillin ng tnh mch, liu cao, 8 - 1 0 gam/24h, chia nh iu, hoc truyn tnh mch 1 0 -2 0 triu n v penillin G mi ngy. Kt hp streptomicin: 1 g mi ngy chia 2 ln (tim bp) hoc gentamicin 120 - 240 mg mt ngy, chia 2 - 3 ln tim bp hoc lnh mch.

Ngo i ra, c th cho thc m vancomycin 2,0 g/ng y chia 2 l n nh m t kh ng sinh xen k . Thi gian s dng khng sinh phai m bo t 2 - 4 tun, ni chung tu theo p ng ca tng trng hp. Di vi nhim khun gram m: Nu nghi ng VKNK do vi khun giam m. th khng sinh la chn s l nhm uminogycosid nh gentamicin, liu 5 mg/kg/24h chia 3 ln truyn tnh mch. Nu nhim pseudomonas aeruginosa, c th thm caihenicilin 400 mg/24h. Trung bnh, cn 4-6 tun iu ir.

2. Bt ng Cc khp tn thn" cn phi c b^t ng t th C nng bng cc np. Nh vy vn cho phcp chc d c dch khp. Ring i vi khp hng cn phi c

dng c ko nn. Triu chng au li khp trong VKNK lm bnh nhn gi khp t Ih gp, do dn n cng khp. V vy, vic cho thuc gim au kt hp l mt hin php chng dnh khp. Ngoi ra, ngay khi qu trnh vim bt u thuyn gim, cn phi sm vn ng khp (ch ng v th ng). 3. Dn lu 3.1. Chc ht dch khp Khp cn phi c chc tho u n. u tin chc mi ngy mt ln, sau c 2 ngy mt ln. Theo di lng t bo ca dch chc d, cho ti khi tin trin tt. Thng sau 7 - 1 0 ngy, nu lh'y ch khp vn ti pht nhanh, s lng t bo dch lng, hoc khi xut hin hin tng vch ho (bm dch vo c, song khng Iho hi ra c). hoc vi khun lc ny vn tn li trong khp, th nn ngng chc ht dch khp xem xt ch nh m dn ,lu khp. 3.2. Dn lii khp ngoi khoa khp gi, nu c iu kin, ch cn dng ni soi khp ra l . Ch nh dn lu khp ngoi kha khi chc d khng t hiu qu, hoc nu du hiu vim ti ch qu nng, irn dch m c chng t qu trnh p xe thc s, cn thit phai m dn lu lc th. M dn lu vi khp hng phi c ch nh sm, v y l khp kh choe d. 3.3. Diu tr cc trng hp c bit Cc vim khp sau nhim khun: c n b sung ihem cc thuc chng vim. Cc nhim khun khp gi: Thng kt hp khng sinh c hoc khng km Iheo dn lu ngoi khoa. Trng hp nhim khun khp gi. khng sinh phi ko di. Ni chung Ihng phi ly b khp gi, nht l khi khp b bong ra. C th phai i li mt khp khc vi cht xi mng c cha khng sinh. Th VKNK rt lin irin: Cc VKNK vi khi u c hu xng lun khng li vi iu tr, cn ihit m phu thut ct b xng cht. Trng hp hu hoi khp nghim trng, c thc phi gy cng khp t th c nng.

II. VIM K H P DO LA O

A. LM SNG V XT NGHIM Triu chng ton luln: Hi chng nhim khun mn lnh: st nh (thng v chiu), gy sl, mi mi, chn n... Lao xng khp ihng xut hin sau lao cc c quan khc nn c th c cc iriu chng ca nhim lao cc c quan khc nh ho ra mu (lao phi), irn dch cc mng (lao cc mng), hch to, c bii hach dc c c n chm... Ldo khp ngoi \'i: Thng ln ihng ml khp vi tnh chl vim bn cp: au va phai, khp suig r, giam vn ng khp, ICO c nhanh. Xl nghim dch khp I gi chn on. Him khi tm thy trc khun Koch khi soi. Phai cy dch khp ircn mi trns Loewenstein. Sinh ihit mng hot dch: C th ihy naim lao in hnh, hoc nui cy mnh sinh thit cho l ml xt

nghim c gi tr cho php chn.on song ch c thc hin cc c s y t ln. X quang quy c: Hp khe khp ton b, c th ttmy vng hu xng v c 2 u xng trn v di, y l du hiu gi chn on. Lao ct sng (bnh Pott): Thng tn thng cc t sng lng - thl lng, vi tnh cht: au khu tr mt im ti v tr tn thng, c th thy im ny g ln, hoc g ct sng (mun). i khi c th Ihy dch b u chy ra theo l r cnh ct sng hoc chy xung cc c, xung mng, c tht lng chu pha bn... C th c du hiu thn kinh do p tu (mun v nng). Khi c p tu th phi iu ir ngoi khoa kt hp, X quang quy c Ihy hnh nh hu xng trc thn t sng v a m. Chc d ti t sng hoc a m tn thng: Cho php ly bnh phm lm xt nghim t chc hc nhm pht hin tn thng do vi khun lao (cht hoi t b u, t bo khng l, l bo bn lin). l mt xt nghim c gi xc nhn chn on. Ni chung hn hu mi tm thy trc khun lao. Nu c iu kin, bnh phm c nui cy trn mi trng Loewenstein cho php chn on xc nh.

B. IU TR NI KHOA LAO XNG KHP 1. iu tr lao bng thuc 1.1. Gii thiu mt s khng sinh hng lao Di y l mt s thuc khng sinh chng lao Ihng c dng, liu v mi s c tnh chnh ca chng. Thuc chng lao Liu mi ngy (ngi ln) 300 mg 600 mg 0,75 - 1 g 1,5-2 g 15 mg/kg 12g lg lg 150 mg lg 1g 1g c tnh chnh

Isonia/.id Riampicin Slreptomycin Pyra/inamid Elhambutol P-Aminosalieylie acid Elhionamid Cyloserin Thioacetazon Kanamycin Capreomycin Viomycin

Vim gan, bnh thn kinh ngoi bin, s't do thuc Vicm gan, hi chng ging nh nhim influenza, gim tiu cu ic, m't iu ho tin dinh, suy thn Vim gan, tng acid uric mu Vim th thn kinh (rt him gp) a chy, vim gan, phn ng tng nhy cm Vim gan Trm cm, thay i nhn cch, tm ihn co git Vim da bong vy, vim gan ic, suy thn, r lon tin nh (him) ic, mt iu ho lin nh, suy thn ic. m't iu ho tin nh, suy thn

Vic la chn thu()c v cc dng kt hp, tu theo iu kin c th m quyi nh (da vo tnh trng kinh l, iu kin y t, iu kin qun l theo di bnh nhn, mc tn thng c th).

Ti Vit Nam, t nm 1999, cng ihc sau y c chnh thc p dng trn lon quc, i vi c lao phi hoc ngoi phi, trong c lao xng khp. 1.2. Cc cng thc iu tr lao c p dng ti Vit Nam Cng thc iu r lao m i: Lao mi l cc bnh nhn c pht hin nhim lao ln u, cha dng thuc chng lao bao gi hoc mi c iu tr thupc chng lao di 1 thng, p dng cng thc sau: 2SHRZ/6HE Tc l trong 2 thng u dng 4 khng sinh phi hp: Streptomycin (S), isoniazid (H). riampicin (R), pyrazinamid (Z), 6 thng sau dng hai loi thuc l isoniazid v elhambutol (E) hng ngy. - Cng thc iu tr li: 2 SHRZE/1 HRZE/5HR3E3
-

Cng thc trn c ngha l trong 2 thng u dng 5 khng sinh phi hp: Streptomycin, isoniazi. rmpicn, pyrazinamid v ethambutol thng th 3 (1 ihng tip theo) dng 4 loi thuc H, R. z, E (b streptomycin) hng ngy 5 thng tip theo dng 3 ngy mi tun vi 3 loi H, R, E. Cng thc iu li c ch nh trong cc trng hp: iu tr ln u tht hi, li pht, iu tr li sau b iu tr. - Cng thc iu r lau tr em: 2HRE/4 HR Hng thng dng 3 khng sinh phi hp: H, R, z, 4 ihng tip theo dng 2 loi H, R mi ngy. Liu thuc chng lao: Trong cc cng thc trn, cc thuc khng sinh c dng liu sau: Liu ti u ca cc thuc chlng lao thit yu
(Gii h n c ghi trong n g o c n)

Tn thuc

Liu dng hng ngy

(m g/kg)

Liu cch qung 2 ln/tun 3 ln/tun

(m g/kg) (m g/kg)

Isonia/.id (H) R i l a m p i n (R) Pyra/.inamid (Z) S trcp iom ycin (S) E lham butol (E)

5(4-6)

10(8- 12) 10(8- 12) 35 (30 - 40) 15 (12- 18) 30 (25- 35)

15(13- 17) '10(8- 12) 50 (40 - 60) 15(12- 18) 45 (40 - 50)

10(8- 12) 25 (20-30) 15 (12- 18) 15(25 - 20)

2. Cc bin php khc 2.1. Bt ng khp: l vic khng th thiu giai on u ca bnh. 2.2. Chc d, dn lu khp: Ngc li, dn lu khp li khng cn thit: Nu chc d lin tip hoc dn lu ngoi s c nguy c to thnh l r. 2.3. Ngoi khoa: Ring i vi ct sng, khi c p tu th phi ch nh iu tr ngoi khoa. i vi pxe lnh cnh ct sng th khng cn dn lu nu c khng sinh kt hp, tr khi pxe qu ln. III. THP KHP DO LU CU L nguyn nhn thng gp nht ca vim mt hoc vi khp ngi tr, nht l ph n, chim 1 - 3% cc nhim khun lu cu. ng vo thng l ng sinh dc. A. LM SNG V XT NGHIM Khi pht nhanh chng v t ngt vi st cao rt run. Thng tn thng 1 - 2 khp, vi triu chng ti khp r: au nhiu, sng v lun km trn dch. Tn thng gn-mng hot dch rt gi , tn thng da c gi tr chn on cao. Phn lp c vi khun cc mu dch khp, dch ti cng sinh dc.dch m hu mn hay khi cy mu cho php chn on.

B. IU TR 1. Khng sinh a s cc lu cu vn nhy cm vi penicillin G, vi liu 10 triu n v/ngy, truyn tnh mch trong t nht 10 ngy. Nu bnh nhn khng penicillin, c th dng erythromycin 2 g/ngy, chia 4 ln, truyn tnh mch hoc ceoxitin 100 mg/kg/24h chia 4 ln. Ampicillin hoc nhm quinolon cng c hiu qu. Ni chung,a s cc bnh nhn p ng nhanh, khp ht vicm ong 1 - 2 tun l. 2. Cc bin php iu tr khc' Kt hp vi cc thuc chng vim khng steroid s rt ngn qu trnh tin trin. Trng hp vim mt khp nhim khun, phi ko di tr liu, c n bt ng, thm ch phi dn lu nu trn dch. Khng c qun kim tra bn tnh ca bnh nhn v phi iu tr c hai ngi nu c nhim lu cu.

IV. THP KHP DO LINCU NGI LN Tng ng vi thp khp cp tr em. y l mt v dinhnh ca vim khp sau nhim khun. A. LM. SNG V XT NGHIM Bnh nhn thng xul hin khong 30 tui, c 2 gii,70% cthy cc t vim hng trc. i vim khp thng km theo st. Vim a khp, i xng, hoc mt vi khp vi tnh cht vim r. Thng khng c tnh ch't di chuyn. Hay ti pht khi c t vim hng mi. Cng c cc du hiu ngoi da, l cc ban vng. Tn thng tim ch gp 15%, t khi li i chng van tim. Khng gp ma vn ngi ln. Hi chng vim mu v dch khp r. Khng phn lp c lin cu trong dch khp. Him khi phn lp c hng. Cc khng th khng lin cu tng (ASLO...), hiu gi tng nhong t thp khp cp tr m.

B. IU TR

1. Khng sinh: C th dng mi trong cc khng sinh sau: - Penicillin G lim bp 4 iriu n v/ngy. - Cc penicillin nhy cm vi lin cu ng ung: v d nh ampicillin (Totapen 2 -3 g/24h hoc clamoxyl 1,5 g/24h). - Erylhromycin 1,5 g/24h: Nu d ng vi penicillin. 2. Cc thuc chng vim Thng dng aspirin 3 - 4 g/24h, trong 6 tun, ri gim dn liu (0,5 g/tun) irnh hin tng vng bnh. 'Corticoid i khi cn thit, vi liu ban u 1/2 mg/kg/24h. c ch nh trong ih khng li aspirin hoc c cc biu hin tim. Dng trong vng 6 tun, sau , c mi tun, 1 vin Coriancyl 5 mg hng ngy c thay Ih bng 1 vin aspirin irnh vng bnh. 3. Diu tr d phng iu tr d phng nhm mc ch Irnh ti pht. C th dng: - Oracillin 1 Lriu n v/vicn, mi ngy ung 1 vin trong vng 1 nm, hoc t nht ong ma lnh. - Hoc pcnicillin ben/.athin 1.20(X(X)0 n v tim bp, c 3 - 4 tun tim mt mi. - Bin php d phng tt nht l mi khi c vim hng phi c iu tr penicillin.
*

V. CT TU VIM Ct tu vicm c th do vi khun thng hoc irc khun lao. vi khun giang mai, nm. C th cp hoc mn lnh. Thng gp nhl l cl tu vicm do vi khun sinh m (thng do t cu vng). A. TRIU CHNG LM SNG V XT NGHIM Ct tu vim cp: Do vi khun sinh m thng gp tr em v thanh nicn, khu ir u xng di. Khi pht t ngi vcp tnhvi hi chngnhim khun r. au ti u xng di mt cch d di. cy mu thng phn lp c vi khun gy bnh. X quang giai on cp khng thy g, c th c lng c nh trn chp nhp nhy . Ct tu vim mn tnh sau giai on cp. Bnh nhn lip lc au luy c gim hn giai on cp. sl, nh hng ton irng. X quang cho thy tn Ihng phn di xng, c xng cht, phn ng dy mng xng, hu sn khp cnh ln ihng.

B.ITR 1. Khng sinh Vic chn khng sinh thch hp lrC vn c s phn lp vi khun. Nu cy mu rr lnh, c th phi choc d sinh Ihit ln Ihng phn lp vi khun. Phi lii chn cc khng sinh c kh nng khuych ln lt vo xng nh: Penicillin G licu cao, penieillin M, ccphalosporn cc th h, synerigistin (c hit l pristinamycin). lincomycin, clintlamycin, riampicin, acid fusidic, 5 lluorocyiosin, melronidazol, luoroquinolon. Kc hp 2 khng sinh lng hp, truyn tnh mch Irong 2 - 3 tun u. Sau dng lip ng ung, nu hp thu ihuc qua ng liu ho t nng thch hp c th c ch vi khun. Thi gian iu tr lu tng trng hp, song l nht 1 ihng i vi ci tu vim cp v 3 - 6 ihng V i'fi th mn lnh. 2. Cc bin php iu tr kt hp Bt dng: ti ng hng np irong cc mn l u, cho n khi cc triu chng ti ch bin ml. No vt phu thut: c ch nh nu c mnh xng cht hoc ng hp iu ir ni khoa tht bi, c bit Irong trng hp cl lu vim mn tnh.

IU TR LUPUT BAN H THNG

Trn Ngc n Nguvn Vnh Ngc I. I CNG y l mt bnh l min hay gp nhl, c tn thng nhiu ni tng, du hiu lm sng rt phong ph, nguyn nhn cha r, trong cc m v t bo b tn ihng do lng ng cc khng th bnh l v cc phc hp min dch. a s" bnh nhn l n, chim 90%, la tui sinh . Chn on xc nh da vo 11 tiu chun ARA 1982: Ban hnh cnh bm ml. Ban dng a thn, mt. Nhy cm vi nh nng. Lot ming hoc mi hng. Vim a khp khng c hnh bo mntrn Xquang. Vim mng tim hoc mng phi. Tn thng thn: Protein niu trn 500mg/24h, hoc c hng cu, hemoglobin, hi hoc c hi chng thn h. Tn thng Ihn kinh - tm ihn khng do cc nguyn nhn khc. R lon v mu: Thiu mu huyt tn c tng hng cu li, gim hch cu di 4000/mm'\ gim tiu cu di l()0.000/mm'\ Ri lon v min dch: T bo LE, khng th khng ADN hoc khng Sm. BW dng tnh ko di trn 6 ihng, TPI dng tnh (cnh xon khun). Khng th khng nhn dng tnh bng phng php min dch hunh quang. Chn on xc nh khi c t 4 tiu chun ir len.

Tin lng khde nhau ly iheo mc tn Ihng cc tng. Nguycn nhn l vong ml ml do lin quan n bnh, ihng l tai bin mch no, vim no mng no, suy thn giai on cui, mi khc c ih lin quan n iu tr: Nhi mu c lim. bnh mu c tnh, ung th. Cc bin chng nhim khun lin quan n c hai loi irn, trong t vong do suy thn v nhim khun chim a s. II. IU TR LUPUT BAN H THNG I. Nguyn tc chung v cch thc tin hnh iu tr Qu irnh icu tr c th chia lm 2 phn: Nguyn tc iu tr p dng cho bnh mn tnh (phni cc i lin irin) v iu tr cc t tin irin.

Trc khi quyt nh iu tr, vic nh gi cc tn thng, mc nng nh ca bnh, cc bnh km theo rt quan trng. Vic nh gi mc hot ng v mc trm trng ca bnh quyt nh bin php iu tr. Phng cc t tin trin: c p dng trong giai on lui bnh. Cc bin php phng v: Trnh nh nng trc tip, cn thn khi dng cc loi thuc d gy mn cm, nht l khng sinh, phng nhim khun (bnh nhn luput c nguy c nhim khun cao. c bil trong trng hp c suy thn, bt Ihng van tim, phi dng liu cao corticoid hay cc thuc c ch min dch khc...) trong mt s" trng hp c th tim vacxin phng bnh,cn phi ch kim sot thai nghn trn bnh nhn luput v c bit thn trng khi dng thuc v bnh nng ln trong thi k mang thai v c nguy c sy thai cao. Khi bnh khng hot ng cn m bo ti a chc nng cc c quan, trnh dng thuc c ch min dch.

2. Dc ng hc cc thuc iu tr luput ban h thng Hin nay cha c thuc iu tr c hiu. Thng hay s dng cc thuc c ch vim hay Ihuc can Ihip vo chc nng min dch. Cng cn phi cn nhc nh gi c nhng tc dng khng mong mun ca cc ihuc ny (tng huyt p, nhim khun, long xng...). Do vy vic iu tr hao gm cc thuc sau: Thuc chng vim khng sleroid: Mi Ihuc trong nhm ny Corticoid: Liu ty mc nng nh ca bnh, cho php ci thin tin lng bnh ng k. Cc thuc chng st rt tng hp: c coi l thuc iu tr c bn ca bnh. Thuc c ch min dch: Ch nh trong cc th nng Cc thuc khc (danazol, globulin min dch, dapson...)

2.1. Salcylat v cc thuc chng vim khng steroid c s dng vi cc th trung bnh c sl, au khp hoc vim khp, au c khng c vim c r rt, t c xu hng vim cc mng. Trnh dng thuc CVKS khi c tn ihng thn (nguy c i mu, tng crcalinin mu). Trong trng hp bl buc phi dng, cn theo di st chc nng thn, c n ch rng ibuproen c th gy vim mng no v khun. Indometacin c hiu qu c bit lt vi triu chng au xng do hoi t. Trnh ch nh nhm pyra/olc trn bnh nhn Iuput do c nhicu tc dng ph rt nng n. 2.2. Thuc chng st rt tng hp (CSRTH) Cc nhm thuc: hao gm 4-aminoquinolin (hydroxychloroquin v chloroquin) v dn xut ca 9 - aminocridin (quinacrin). MI s thuc CSRTH thng dng Chloroquin: vin 0,lg; 0,2g. Liu dng 0,2g/ngy Quinacrin: vin lOOmg, 1-2 vicn/ngy Nivaquin: vin 100, 30()mg. Dng liu 4mg/kg/ngy Plaquenil (Hydroxychloroquin): Vin 200mg, liu dng 2 vin/ngy (hoc 5-7mg/kg/ngy). Plavoquin: vin 200mg. dng liu 1 vin/ngy.

Ch nh: Cc th bnh c tn thng da nh ban dng a, nhy cm vi nh sng (do thuc lm gim s th'm ca tia cc tm v ngn cn tnh hot ha nh sng ca ADN). Triu chng khp v cc tng ca luput: C th dng CSRTH n c hoc kt hp vi thuc CVKS. Nu ngng thuc CSRTH t ngi s c nguy c bnh vng ln. Cch dng: Thng bt u bng plaquenil vi liu 400mg/ngy chia 2 ln. Sau l thng nu khng c tc dng c th tng liu n 600mg/ngy hoc Ihcm lOOmg Quinacrin. S kl hp ny khng lm lng c tnh vi mt nhng c th lm da c mu vng. Trnh kt hp Nivaquin vi Flavoquin do lm tng c vi l chc li ca mt. Khi khng ch c bnh, cn gim liu dn ( c 3-6 ihng th gim 1/4 liu). Duy ir liu plaquenil 200 hoc 400mg/tun. Theo di tc dng ph: Ni chung Ihuc dung np tt. Tuy nhin c th gp vim vng mc mt khng phc hi, thng gp nhiu hn vi chloroquin v phi kim tra ih lc, th trng, soi y mt u n 6 ihng ml ln. Khi c tn thng mt th phi ngng thuc ngay. Vig Ihuc vo bui chiu hoc trc khi ng c ih trnh c cc triu chng ph liu ha nh nn, bun nn. Thuc cng c th gy nhim c Ihn kinh trung ng (au u, thay i cm xc, lm thn). Do vy nn ngng thuc bnh nhn lupul c biu hin tm thn kinh. Thn irng dng thuc trn bnh nhn c suy gim G6PD (glucose-6-phosphat dchyrogenasc) hoc ln thng gan.

2.3. Corticosteroid Ch nh: Dng lng li trong cc irng hp luput c st, vim da, c, khp, ln thng ni tng (vim thanh mc, vim c tim. vim phi, vim thn, thiu mu huyl tn, gim tiu cu, triu chng tinh thn kinh), hay c chl chng ng liiput lim hnh. Cch dng: + Trong ng hp c sl, au khp, triu chng th tng khi cn c Ih cho liu thp (di 15mg prcdnisoon hoc lhu"c tng ng mi ngy), iu duy nht hoc c th cho cch ngy.

+ Trng hp vim c, tn thng nhiu ni tng, hoc thiu mu nng (do tan mu hay giam tiu cu) cn cho liu hng ngy va phi, t 15-5()mg hoc liu cao (ln hn 50mg), lc u c th chia liu u cho c ngy, nh'i l khi bnh nhn qu yu. Khi bnh thuyn gim cn gim liu chm, chuyn sang liu duy nht khi t c liu ihp. + Tn thng thn lupuL, hoc cc ln thng ni lng nng n khi' (ln thng phi, no mng no, gim liu cu...) khng p ng vi corlicoi ng ung c ch nh dng Bolus (pulse iherapy): Truyn metbylprednisolon (Solumerol) liu 500 - lOOOmg pha trong 250ml

dung dch mui sinh l, 1 ln trong ngy, lin 3 ngy lin tip, sau cho duy tr bng corticoid ng ung 30-40mg prednison. Trong ng hp vim thn do luput c th dng corticoid liu cao trn 1 mg/kg/ngy prednisolon hoc ch phm tng ng/ngy v cn phi c bit ch iu ir tng huyt p c th km theo. ng dng: C th bi ti ch khi c ban , ban dng a. Thng dng ng ung loi corticoid c thi gian tc dng ngn nh prenison, prednisolon hay methylprednisolon v d thay i liu, t tch ly do t tc dng ph hn corticoid c thi gian tc dng di (examethason). ng lim ch s dng trong nhng trng hp nng, cp Liu dng: vi th nh dng liu thp <20mg/24h (<0,5mg/kg/24h). ng 1 ln duy nht vo bui sng. i vi th trung bnh hoc nng hn: Dng liu lmg/kg/24h ng ung hay tim tnh mch. Khi bnh c kim sot cn gim liu corticoid. nhng ngi c nguy c bnh ti pht cn dng liu duy tr thp nhl c th. Liu <15mg/24h ung 1 ln vo bui sng khng gy c ch trc di i tuyn yn - thng thn.

2.4. Thuc c c h m in dch (CMD) Ch nh: Trong vim thn luput (ci ihin triu chng thn, st v cho php gim liu corticoid) hoc cc trng hp khng p ng vi corticoid. Cc loi thuc CMD: Azathioprin (murel) vin nn 50mg. Liu dng 2-3mg/kg/ngy. C kt qu tt trong vim thn luput v gp phn lm gim liu corticoid trong cc th khc. Azathioprin t c nht, tuy nhin thuc cng c nhng tc dng ph nh gy c ty xng (gim bch cu, thiu mu), tng nguy c gy ung Ih, c bit ung th nguyn pht ca m u (gp 4 n so vi ngi khng dng). Do vy cn kim tra cng thc mu thng xuyn chnh liu. Cyclophosphamid (Endoxan) vin nn 50mg. Liu l-2m g/kg/ngy ung lin tc n khi kim soi c bnh th ngng. C th dng bolus cyclophosphamid vi liu 10-15mg/kg (hoc 0,5-lg/m 2 c th) truyn tnh mch, 4 tun truyn mt ln. Dng ng ny c hiu qu nhanh hn, t c vi bng quang hn song lc dng ph vi ty xng c th nng hn. Sau vi thng tr liu nu bnh c khng ch th c th.ngng iu tr. C th dng cyclophosphamid n c hoc kt hp vi liu thp azathioprin (0,5 - 1m g/kg/ngy). Cyclophosphamid c hiu qu nhl song cng c nhl. Thuc c nhiu tc dng ph: Huyl hc, suy bung trng, v linh trng nu iu tr ko di, vim bng quang chy mu, x hng quang, ung th bng quang. Do cn lm cng Ihc mu v iu chnh liu da vo s" lng hch cu, tiu cu, hematocrit v kim tra nc tiu, soi bng quang tm nhng thay i c tnh. C th lm giam tc

dng ph l rng tc khi truyn cycophosphamid bng cch chm vo u trong thi gian truyn thuc. - Chlorambucil (Chloraminophen) vin nn 2,5mg. Liu 0,l-0,25mg/kg/ngy. - Methotrexat: Vin nn 2,5mg, ng 5 v 20mg. Liu 7,5 - 15mg/tun (liu duy nh't). C th c dng iun phin vi thuc chng sl rt tng hp hay vi liu thp prednisolon. Ch nh trong vim khp, ban , st ong Iuput. cn gim liu trn bnh nhn c suy thn.

Cyclosporin A: t dng trong luput v c tc dng ph lm tng huyt p v gy c trc tip vi thn.

2.5. Mt s'phng php khc Lc huyt tng: Thay 3-4 lt huyt tng ca bnh nhn mi tun bng huyt ing hay sn phm thay th. Cng c ih ch lc t bo lympho mu. Cc phng php ny c th ct t qu trnh min dch v lm bnh thuyn gim. Truyn gammaglobulin tnh mch: 0,5g/kg/24h trong 4-5 'ngy. Ch nh trong gim tiu cu khng p ng vi corticoid, luput thiu thnh phn C2 ca b th, sy thai c yu t chng ng lu hnh, hoc mt s trng hp vim cu thn tng sinh khng li corticoid v thuc c ch min dch. Diamino-diphenylsulon (Dapson): iu tr cc tn thng da luput bn cp, phng nc v nhng tn thng su ca luput. Liu bt u 50mg/ngy, tng dn n liu li a 150mg/ngy. Danazol (androgen c lm yu i): C tc dng ong iu tr gim tiu cu luput. C ch hoi ng cha r, c th lin quan n vic thay i chc nng min dch v l bo li ni m. Thuc chng ch nh trong trng hp c thai, cho con b, chy mu m o. Thn ng khi c tn thng gan thn. 3. iu tr c th LPHT 3.1. Diu tr theo th - i' vi th lnh tnh: L th khng c tn thng cc ni tng e do n tnh mng. Cc thuc ch nh bao gm: CVKS v chng s"t rt tng hp. giai on tin'trin, ch nh thm corticoid liu nh (10 - 20mg/24h), ngn ngy. - i vi th nng: L th c ln ihng cc tng quan trng, thng l thn. , S dng corticoid liu cao: 1-2mg/kg/24h. Khi bnh c kim sot, gim liu 10% mi tun. n khi l 20mg/24h th gim chm hn. C th dng liu g'p i cch ngy. Kt hp vi thuc chng st rt tng hp. Trong trng hp bnh nng va c th u"ng hng ngy azathioprin 1,5-2,5 mg/kg/24h. Khi bnh nng, e da tnh mng hoc c xu hng lng tn thng c quan cn dng liu cao corticoid phi hp vi thuc c t bo. Cng c th dng phi hp corlicoid vi cycophosphamid. Nu tt ln trong 4-12 tun th cn gim liu corlcoid nu c th. Nu khng cn phi phi hp vi cc bin php iu tr khc (lc huyt tng, dng cyclosporin A...).

Trng hp ln thng ni tng c da l vong, dng bolus (pulse therapy) vi methyiprednisolon. Sau duy tr tip bng liu 30-40 mg prednison. Liu php trn thng tt vi tn thng thn, song l kt qu vi tn thng tm thn kinh. Khi khng ch c bnh, gim dn liu corticoid. Thng kt hp dng ihuc chng st rt tng hp. Cng c th dng bolus cyclophosphamid 10-20 mg/kg/24h truyn tnh mch 3-4 tun mt ln hoc dng ng ung ] ,5-2,5 mg/kg/24h. iu tr kt hp: ty theo tng trng hp c th m s dng cc Ihuc khng sinh, chng ng,- h p, an thn kinh... C th ghp thn khi ln ihng thn gy suy thn khng hi phc.

3.2. Diu tr LPBHT theo triu chng St: C th dng mt trong cc loi Ihuc: Aspirin, CVKS, corticoid. au khp: Ty theo mc au c ih dng ml trong cc thuc sau: Aspirin, CVKS. CSRTH. Nu c biu hin vim khp r th c th dng ihm corticoid. Ban da: Dng corticoid ngoi da. u tin l hydrocortison ti ch, sau dng ch phm cha iluo kl hp vi CSRTH. Vim mng phi, mng ngoi lim: p ng tt vi thuc CVKS hay corticid Tn thng phi: Dng corticoid Tng huyt p: Dng cc ihuc li tiu, chn beta giao cm, c ch mcn chuyn hay cc thuc khc. Gim tiu cu. thiu mu huyt tn: Dng corticoid, truyn gammaglobulin, s dng thuc c ch min dch. Nu cn Ihit c th ct lch. Tn thng ihn: Dng eorticoid, ihm ch bolus corticoid. Nu khng hiu qu c th s dng ihuc c ch min dch (bolus tnh mch). Tn thng ihn kinh irung ng: C th dng corticoid hoc thuc c ch min dch. Cn migren: Propranolol.

3.3. Diu tr kt hp v mt s'tnh hung c bit

Long xng do dng cortieoid: Cc bnh nhn Juput hay dng corticoid liu cao ko di nn hay c bin chng long xng, c bit l irn bnh nhn n c tui. C th lm gim lc dng ny bng cch cho calci hng ngy ( lg/ngy) v vitamin D. c n theo di calci mu v niu trnh bin chng si thn I

Hoi t v khun u trn xng i: Cng gp trong luput, c bit ircn bnh nhn c vim mao mch v/ hoc hi chng Raynaud v dng corticoid ko di. Pht hin sm s lm gim nguy c phi phu thut chnh hnh. Cc bnh C do corticoid: Cung hay gp, c ih phng nga bng cc hi luyn lp c chi. Trnh cc ch phm corticoid cha Fluo cng nga c bin chng ny.

Luput BHT phi phu thut: Nu bnh nhn ang dng corticoid trc , th liu thuc corticoid vn phi c duy tr trong lc phu thut. Lc thng dng ng lnh mch trong lc gy m v tip tc duy tr ong khi m vi liu 200-300mg hydrocortison hoc 50-60mg methylprednisolon. Sau vi ngy, khi dng c ng ung, c th quay li liu trc khi m m khng cn phi gi liu cao. Luput v thai nghn: Thai nghn lm nng thm bnh luput (c bit l nng thm tn thng thn) v d gy sy thai, non, thai cht lu. V vy ch khuyn mt ph n mc bnh luput c thai trong cc iu kin sau: Phi khng c cc du hiu tin trin bnh v lm sng v cn lm sng trong 6 thng lin trc . Tt nht l sinh thit thn. Nu c vim cu thn mng tng sinh th khng nn c thai. Nu bnh nhn c cc khng th c bit nh khng th khng ng lu hnh th c nhiu nguy c sy thai, cn nu c khng th anti-SSA th c nguy c bloc nh tht bm sinh bo thai.

Trong khi c thai phi theo di nh l thai nghn c nhiu nguy c. Nu bnh nhn ang dng corticoid phi theo di iu l v lng liu do thai nghn.'Nu bnh nhn khng dng corticoid th trong 3 thng cui phi cho corticoid liu 0,5mg/kg/24h, hoc trong irng hp sy thai hay no thai. Sau khng nn gim liu corticoid trong vi thng v khng nn cho con b. Vn trnh thai: Khng nn dng dng c t cung v c nguy c nhim khun. Nn dng thuc trnh thai liu cc ihp. Chng ch nh dng thu"c trnh thai irong trng hp tin s c huyt khi, khng th chng ng lu hnh hoc phn ng BW dng tnh gi. Ngoi ra ty theo lng trng hp c th m phi iu tr cc thuc chng ng, h p, an thn kinh... Nu bnh nhn c vim thn giai on cui, cn c k hoch chy thn nhn to hay ghp thn.

IU TR VIM QUANH KHP VAI (VQKV)

Trn Ngc n Nguyn Vnh Ngc I. I CNG L hnh l ca cc cu trc cnh khp (gn. ti thanh mc, bao khp) m khng c ln thng chnh khp vai. c biu hin lm sng l au v hn ch vn ng khp vai. xc nh chn on, c bit l xc nh cc tn thng thc th ca phn mm quanh khp vai. ngoi cc du hiu lm sng, cn lin hnh chp siu m (vi u d > 7,5m Htz) vng khp vai. Trong ml s" nng hp cn chp khp vai cn quang hay cng hng l hl nhn pht hin l gn, co tht bao khp.

VQKV n thun (au vai n ihun): C bn cht l vicm gn c Ircn gai, ml irong cc gn quay ngn hay gn ca b di c nh u. Xul hin thng sau 40 lui. khng c nguyn nhn chnh xc, hay sau lnh, vn ng mnh. Khm thy c im au chi di mm cng vai hoc ngay pha trc mm cng vai (tng ng vi v tr gn tn thng). Bnh khi t nhin sau vi tun n vi thng, c th li pht. Tin trin c th dn n t m cc gn quay ngn. Trong mt s trng hp au vng khp vai do cc bnh l ngoi khp vai gy nn au do phn x (ung th v, 1 1 phi, nhi mu c lim...), cn ch lm iu ir kp thi. VQKV do l gn (au vai gi lil):. ngi tr lui ihng xy ra do l rch m gn c quay khp vai sau tp ih Ihao, mt chn thng hoc gng sc. ngi sau 50 tui thng xy ra t gn b di c nh u, sau mi vn ng sai i th, chn Ihng hoc gng sc trn c s mt m gn c quay b ihoi ha. VQKV cp (au vai cp): C ln ihng gii phu bnh l vim bao thanh dch di c della do cc hl calci ha gn c di chuyn v v vo ti Ihanh dch. Bnh c Ih khi t nhin sau vi ngy hoc vi tun, luy nhin trong nhiu trng hp vn phi iu tr ni khoa. VQKV th nghn tc (Cng khp vai, au do lon dng khp vai, hi chng vai tay): L triu chng ca vim co tht bao khp dy cng dn n gim vn ng khp cho - xng cnh tay. Nguyn nhn do ri lon thn kinh dinh dng lan la ca bao khp, xng, c. mch mu v da to ncn bnh cnh au do lon dng thn kinh phn x chi trn, v lm sng khi u c au vai Iheo kiu c hc, sau hn ch vn ng ch ng v th ng khp vai mi ng tc, ch yu l dng v xoay ngoi.

II. IU TR 1. Cc phng php iu tr iu ir ni khoa: Dng cc ihuc gim au, chng vim, gim au khng stcroid, corticoid, Ihuc chng co iht c. Phong b v ticm thuc li ch: Novocain, hydrocortison. c l t phn x bng phong h giao cm c, chm cu theo cc huyt. iu ir ngoi khoa: Ty lng th bnh c ih phu thut ni rng khe di mm cng vai hng cch to hnh mm cng vai, cl dy chng cng vai qu, sa li m gn c quay, khu li gn t. Vi l tr liu v phc hi chc nng: Dng cc phng php vi l nh chm nng, chy lia hng ngoi, sng ngn, kch ihch in. Xoa bp, kco gin v luyn lp. rt quan irng iu ir vim quanh khp vai.

2. iu tr tng th 2.1. Tl (fii thiin Trong t cp cn cho gn tn Ihng c ngh ngi. Ngng cc hot ng th thao, ngh nghip c th gy nn vicm gn trong mt vi tun. Tuy nhin au khp vai mn tnh, sau khi khp vai n nh cn ti luyn tp chng li s nh cao ca chm xng cnh tay khi nhc cnh tay ln. iu ir ti ch: Chm lnh bng . xoa kem chng vim (Vollarel Emulgen, Niilugel, Procnid Gcl, Gendcl...), ticm corticoid cnh gn. Ch : nu tim trc tip vo gn c th gy t gn. Tim ti a 3 ln, mi ln nn lim cch nhau 10 ngy, cn s dng loi thuc corticoid nhanh v khng tluo ha. Cn ngng lim nu tim 2 ln u m khng c kt qu. Dng thuc gim au: Aspirin, paracelamol, ElTcralgan eodein, Di-anialvic... C th dng cc thuc gim au chng vim khng sieroid ng ung, t hu mn, tim bp. Ap dng cc bin php vi l ir liu: p bn, sns ngn, in phn ihuc, siu m, dng dng in c tn s" Irung bnh gim au.

2.2. Gi lit khp vai (do t rch m gn cqnayy xc nh bng siu m) iu tr ni khoa: Bt ng tm Ihi, khp vai i ih dng. Dng thuc chng vicm khng sieroid. Nn trnh tim li ch v c th lm hoi t gn lng 10n. Phc hi chc nng bao gm nhil tr liu, vn ng liu php tch cc. iu ir ngoi khoa: M khu li gn l, thng p dng cho ngi irc. ngi gi, do ln thng thoi ha c nhng gn ln'cn nciTch iu tr nsoi khoa khi iu ir ni khoa ihl bi. Ring t gn b di c nh u khng c ch nh m, ir trng hp c bil.

2.3. tau vai cp: xc nh bng chp xquang, siu m pht hin tnh trng lng dng ccilci) Cho khp au c ngh ngi (bng cho hl ng), chm . Dni Ihuc chng vim khng steroid liu cao trong vi ngy. Dng coriicoid lim li ch cng c hiu qu. Trong a s irng hp dng corticoid ng ung (prednisolon 20-30mg/ngy) trong 3-4 ngy, ri gim dn liu v ngng hn. iu ir ngoi khoa: C Ihc chc ht dch cha ealci hay ni soi ht, cl mnh ealci ha. Nu ti phi nhiu ln ih cn phu ihut no calci. i khi cn ki hp vi cl dy chng cng vai - qu v ci phn nc mm cng vai. 2.4. Cn khp vai B nh thn khi l nhicn sau 6 ihng - 2 nm, c ihc rt ngn thi gian nh iu tr.

iu tr ni khoa bao gm s dng thuc chng vim gim au khng steroid, cc thuc gin c. iu tr au do lon dng bng cc thuc chn beta giao cm, calcitonin. p dng l liu php sau khi ht au, nhit tr liu cng c tc dng nht nh. Nu khng c kt qu th c th dng corticoid ng tim ni khp hoc ng ton thn. C th dng corticoid ng ung liu trung bnh (15-20 mg/ngy) trong 5-7 ngy sau gim dn liu 1-2 mg/ngy cho n khi ngng hn. Thi gian iu tr khong 3 tun. C th tim corticoid ni khp 3-6 ln trong mt t iu tr, vi khong cch gia cc ln tim l 5 ngy. Phc hi chc nng: Vn ng th ng nh nhng, cc bi tp t th, vn ng ch ng c s gip . Khi tnh irng bnh bt u c ci thin, bnh nhn cn vn ng tng dn, tp c ng cnh tay trong nhiu ngy. a tay thng ra trc, sang ngang, qunh tay ra sau vai. iu tr ngoi khoa: MI s tc gi ngh bin php chng co rt bao thanh dch bng cch tim ml s" lng ln dch vo bao thanh dch, sau lm cc ng tc vn ng khp vai hay lm th thut m bao khp trc bng ni soi.

IU TR BNH NHC c
Trn Ngc An I. I CNG L mt bnh do ri lon dn uyn h thn kinh c, biu hin bng du hiu h c vn chng gim c lc khi vn ng (chng mi v mi nhiu), nguyn nhn ch yu ca bnh l o cc th th tip nhn acetylcholin ca khp ni thn kinh c b c ch bi cc khng th khng ih th t sinh (t min dch), bnh c nhiu mi lin quan n bnh l min dch v tuyn Ihymus. Ngy nay do bit c c ch sinh bnh nn iu tr mang li nhiu kt qu. Bnh thng gp n, tui tr, nhng c th gp cc i tng khc. Triu chng lm sng gm c: Sp mi tng c, cc c vn mi nhanh v tng dn khi vn ng (nhn i, nhai, nut, ni. cm nm, i li. Cc du hiu ny gim hoc ht sau khi ung hoc tim prostigmin (chng li men cholinesterase). Bnh c th tin trin nng dn lit lan n cc c h hp gy t vong nhanh chng.

II. IU TR 1. Cc thuc v phng php iu tr /./. Thuc chng men cholinesterase: Prosiigmin v cc ch phm, ung hoc tim mang li lc dng nhanh chng v r rt, do thuc chng li men cholinesterasc ncn tng cng tc dng ca acetylcholin trn khp thn kinh c, da vo tc ng ny ngi ta

s dng thuc lm test xc nh chn on. Prostigmin (Neostigmin methylsulit ng 0,5mg, ng 2,5mg), tim bp hoc di da, cch 3-4 gi tim 1 ng 0,5mg, nu nng c th tng liu, nn phi hp vi atropin l/4mg trnh cctc dng khng mong mun ca thuc; ncostigmin bromid vin 15mg, ung cch 4 gi mi ln 1 vin pyridostigmin bromid (Mcstinon) vin 60mg, ung nhiu ln cch nhau 4 gi, mi n khng qu 120mg ambenonium chlorid (Mytelase) vin lOmg edrophonium chlorid (Tcnsilon) ng lml = lOmg tim TM trong trng hp cp cu. Ch khi s dng cc thuc chng cholinesierase phi theo di tnh trng qu liu gy hi chng nhim muscarin (tiu chy, tng tit, au bng, nn...). 1.2. Cortcosteroid c s dng theo c ch c ch min dch, liu trung bnh thng mang li kt qu. Lc u cho 15 - 25mg prednisolon/ngy, sau tng dn nhng khng qu 50mg/ngy, ko di 2-3 thng, theo di tin trin v cc tc dng ph ca thuc iu chnh liu lng. Nn dng thm ACTH (Synacthen lmg) tim bp mi mn 1 ln gim liu prednisolon. .3. Cc thuc c ch min dch thng dng l azathioprin, cyclosporin, cycophosphami. c th kt hp vi corticosteroid. Azathioprin lc u ung 50mg/ngy sau tng liu dn nhng khng qu 2m/kg/ngy, ung ko di t 3 n 6 thng, iu chnh liu da vo kh nng chu ng v p ng ca lng bnh nhn. Cyclosporin c tc dng ing t nh azathioprin ung vi liu 4-5mg/kg/ngy. Ch dng cyclophosphamid khi cc ihuc n khng c kt qu. 1.4. Lc huyt tng, tim globuln min dch tnh mch: Da vo c ch bnh sinh ca bnh nhc c, ngi la lin hnh k thut lc huyt tng (bng dng c lc c bii) nhm loi ir cc phc hp khng nguyn - khng ih (thng l nhng phn l c trng lng ln). Phng php ny mang li mt s kt qu. Cng vi mc ch lm thay i Ihnh phn cc globulin trong huyt tng, ngi ta cho truyn tnh mch immunoglobulin 400mg/kg/ngy, trong vi ngy, tng liu khng qu 2g/kg. 1.5. Ct b tuyn thymiis: Nhiu cng unh nghin cu nhn thy c li 75% ngi mc bnh nhc c c cu irc tuyn thymus khng bnh thng (hoc ph i, hoc u c tnh), nu lin hnh ct b thymus th cc iu chng nhc c gim r ri hoc khi hn. xc nh tnh irng thymus phi lin hnh chp CT scanner. hoc MRI, nu thy c bt thng Ih nn m ct b ngay, nu hnh nh bnh Ihng ih iu tr ni khoa l 2-3 thng, nu khng kt qu th ncn ch nh m, sau phu thul lip tc iu l cng c ni khoa. 2. p dng thc t 2.1. Nhc c mc nh (ch c cc du hiu mt v mt): Prostigmin 0,50mg + atropin l/4mg ticm bp thl, nhiu ln trong ngy, ty mc nng nh ca bnh (c ih s dng thuc ung dng vin). Chp thymus (MRI hay CT), nu thy ph i hay khi II, ch nh cl b Ihymus.* Nu hnh nh bnh thng, iu tr vi eorticosieroid, sau 2-3 thng khng c kt qua, dng cc ihuc c ch min dch.

2.2. Nhc c mc trung bnh (mt, mt, c, gy, tay...): Prostigmin cho ging nh trn, dng corticosteroid liu cao lin tc, tm u hiu ph i v u ca thymus, nu c th phu thut ct b, theo di cht ch trc, trong v sau phu thut cc 'u hiu nng bnh (nhc c h hp, ri lon in gii, cn qu liu Prostigmin), sau phu thut vn duy tr iu tr cc thuc trn.
2.3. Nhc c nng (ton thn, c h hp) bnh nhn trong tnh trng cp cu, t vong nhanh chng do suy h hp, ri lon in gii, theo di c s hi sc cp cu, h tr h hp tch cc, iu chnh nc v in gii, ch kali, natri v calci. Prostigmin ng tnh mch, corticosteroid liu cao, nn xt kh nng ct b thymus sm. Sau phu thut tip tc iu ir cc thuc c ch min dch, prostigmin, theo di cht ch. Nu khng phu thut c, s dng phng php lc huyt tng, c ch min dch, chiu x vo vng sau c. Ni chung cn iu tr lu di, theo di cht ch. Khi s dng Prostigmin liu cao cn phng tinh trng nhim c anticholinesterasc (ging nhim c ln hu c), kp thi gim liu v cho atropin.

IU TR BNH x CNG B TON THE (XCBTT)

Trn Ngc n Nguyn Vnh Ngc I. I CNG X cng b ton th (XCBTT) c Ih gp khp mi ni n th gii, l bnh ihng gp th hai trong s cc bnh h thng. l mt bnh ton th ca m lin kt (collagenose), c ri lon a h thng c trng bi nhng tn thng da, mch mu v ni tng, ch yu l thc qun, phi, tim, v thn. Bnh dng nhc bit ti t thi Hippocrate v ln u c Curzio m t nm 1753. Hin nay ngi ta dng tiu chun ca ARA 1980 chn on XCBTT, bao gm: Tiu chun chnh: X da vng gc (gc chi, gc ngn, thn, c, mt) Tiu chun ph: X da u ngn (tay, chn) So ngn tay hoc vt lot u ngn tay X phi vng y

Chn on dng lnh khi c tiu chun chnh hoc 2 tiu chun ph: Tin lng vn t ra xu hn i vi chng tc ngi da en, nam gii, bnh nhn c tui. Trong hu ht cc trng hp, t vong xy ra do suy thn, suy lim hay suy h hp. Cc ung ih v, phi c Ih xy ra th pht bnh nhn XCBTT.

|. IU TR

Cha c iu tr no' t ra c hiu qu. Khng c thuc hay mt tp hp thuc no c kh nng lm ngng tin trin bnh. Ch c thuc lm ko di thi gian sng v nng cao chl lng cuc sng. Trong rt nhiu ihuc c ngh, ch c D-penicilliimin, thuc chn calci v c ch men chuyn l l ra c hiu qu nhl. Cc thuc c s dng iu tr gm: D-penicillamin ung liu tng dn ko di nhiu ihng. Corticosteroid: ng liu trung bnh, sau duy tr liu Ihp khi c triu chng khp, c, phi. iu tr hi chng Raynaud: Dng thuc chn calci. reserpin... iu ir triu chng khi c tn thng cc ni tng (thn, tim, phi, liu ha, nhim khun...). Gi v sinh, chm sc da, u ngn, iu tr sui khong.

1. iu tr ton thn . . D-peniciamin (bit dc l Trolovol) L ihue duy nhi c khuyn dng hin nay. Thuc c th lm gim dy ca da'v phng nga cc ln Ihng ni tng, v c ch, tc dng ca thuc l c ch nhm aldchyd irong phn t collagcn trng thnh. Tuy nhin D-penicillamin cng lm tng lun chuyn coilasen khng ho lan do ct t cc cu disuld v c ch sinh tng hp collagen. Thuc cng c lc dng c ch min dch. Liu dng: Bt u bng liu ung 250mg/ngy trong 2-3 thng (vin 125mg, 250mg), tng n liu li a, l n 750-1250 mg/ngy trong 12-24 thng. Nu t hiu qu, khng c cc hiu hin a, s gim chm liu cho n khi t liu duy tr 250mg/ngy. Tc dng ph: Xy ra Irong khong 30-40% cc trng hp, bao gm: sl, chn n, nn. phi han, h hch cu, liu cu, ihiu mu do suy ty. hi chng thn h, nhe c nng. Do vy 1/4 bnh nhn phi ngng thuc. Cc lc dng khc, c bit nh kh chu v d dy, rui, SL phi ban s t gp hn nu dng ihuc theo kiu "i nh, i chm". Phi iheo di lng bch cu, tiu cu irong mu v protein niu. 1.2. Corticoid c dni vi mc dch gim min dch, song kt qu khng r rng. Thuc c hiu qua vi phn ng vim khp, c v phi, vim mng ngoi tim cp song khng c hiu qua vi cc ln thng ni lng v tin lng chung ca hnh. Khi xul hin ln ihng phi c yu l vim r rt c phdt hin qua ni soi ph qun v phn lch ra phc qun ph nang ngi la c ih dng conicoid liu cao (60-80 mg prednisolon/ngy chia nhiu ln) irong thi gian ngn. Thuc cng gp phn ci thin lnh irng lng p lc ng mch phi nu dng sm v kl hp vi Ihuc chn knh calci. Vi liu 30-40ni prednisolon/ngy chia nhiu ln. thuc c tc dng lm gim r ri cc biu hin vim, ph nhng khng c lc dng ircn qu irnh x ha. Nhn chun nn irdnh dni coriicoid i vi dng x ha da v c kh nng gy tn Ihng ihn m hiu qua ca Ihuc ihe ra C IIS khng r rt.

1.3. Interferon gamma lin hp L cht c ch sn xu't collagen bi cc nguyn bo x ca da bnh thng v da x cng. C hiu qu i vi cc triu chng da, khp, thc qun (kh nut) v thn. Thuc khng c tc dng ph ln v hin ang tip lc c nghin cu. .4. Colchicin: Dng liu l-2mg/ngy, c tc dng c ch tch ly collagen do c ch chuyn tin collagen thnh collagen in vitro, c ih qua c ch giao thoa gia vn chuyn vi ng v s to tin collagen l nguyn bo x. Ni chung hiu qu khng r rng, ch c hiu qu vi triu chng da khi dng trong thi gian di. Thuc c dung np ll hn so vi D-pcnicillamin. 7.5. Cc thuc c ch min dch: Cyclophosphamid c th ci thin triu chng vim phi k nng mc d gy nhiu lc dng ph. Cn chlorambucil t ra khng c hiu qu. 1.6. Thuc chng ngng tp tiu cu: Cc sn phm sinh hc ca tiu cu tc dng ln thnh mch. Aspirin liu thp c ch thromboxan 2 (ch'l gy co mch v ngng tp liu cu mnh). C th dng dipyryamol liu 200-4000mg/24 gi, chia nhiu ln ong ngy. 1.7. Ngi ta cng th dng mt s cc thuc khc nh viiamin E, du thc vt (Piascledine), EDTA hoc salazopirin, iod. tinh cht gip trng, song hiu qu cha r l ng. Vic s dng yu t ng mu XIII (Fibrogammin) lm da mm nhng thuc ch c dng theo ng tim. Thuc Keianserin c ch serotonin cng c th c tc dng nht nh. Ngoi ra ngi ta cn s dng cc phng php iu tr vi l lm mm da, phc hi chc nng vn ng, c bit l iu tr sui khong (nc nng). 2. iu tr triu chng 2. /. Diu tr hi chng Raynaud 2.1. . Cc bin php chung: c n khuyn bnh nhn mc m, i gng tay, tt chn trong ma lnh, trnh stress, khng dng cc thuc nhamphetamin, crgotamin, chn heta giao cni. Bnh nhn XCBTT vn c Ih dng thuc trnh thai cha ocstrogen v progesteron. Bnh nhn cn c h tr tm l (Ihgin, t luyn tp, dy bnh nhn t lm tng nhit da bng c ch iu ha ngc). Vi cc t kch pht tha, mc nh Ih ch cn cc hin php trn y l . Cn khi cc iriu chng tr nn thng xuyn, nng, c bit khi c r lon dinh dng t chc hay lot th phi dng thm thuc vi mc tiu gin c trn mch mu, lm tng cng tun hon. 2.7.2. Cc huc iu tr hi chng Raynaud: Ty theo tng bnh nhn, dng mi trong cc loi thuc sau y: -

Thuc c ch Alpha giao cm: Prazosin, reserpin, apha-methylopa, iuanetidin, phcntolamin, phenoxyben/.amin, nicergolin, tolazolin. Thuc chn calci: Diltiazem, Niedipin, verapamin Thuc i khng vi serotonin: Ketanserin
P rostag lan d in : PG E i,P G E 2 ,P G l2 (pro stacyclin)

Cc thuc khc: Trinitrin bi da, Stanozolol, Dazoxiben, thyrocalcitonin, Iiothyronin, indapamid. griseofulvin, ioxsuprin

Thuc chn giao cm alpha nh prazosin c tc dng tt nhng kh dung np. Do vy thuc cn dng liu thp ri tng dn liu nh cc tc dng ph (mch nhanh, h huyt p t th ng). Reserpin ng ung vi liu 0,l-0,5mg/ngy. Trong trng hp lot da ngn tay, thuc c th dng ng tim chm ni ng mch vo ng mch cnh tay hay ng mch quay vi liu 0,5 - lm g ha tan trong dung dch mui ng trng trong nhiu pht. Thuc c ch serotonin (Kctanserin) c tc dng c ch cm ih quan vi serotonin typ 2 c tc dng lm gim co tht mch v gim ngng kt tiu cu, gy ra bi serotonin. Thuc c tc dng tng ng vi chn calci nhng t gy tc dng ph hn (chng mt, tng cn). Vic s dng thuc chn calci l mt bc t ph mi irong iu tr hi chng Raynaud. Trong thi tit lnh c th dng nifedipin (Adalat) 10 hoc 20mg 3-4ln/ngy (trung bnh 30-60 mg/ngy). Nu niledipin khng dung np c th chuyn sang dng diltiazem (Tiidiem) 3-4 vin/ngy. Trng hp hi chng Raynaud nng c hoi t cc ngn tay c th truyn dung dch dextran trng lng phn t thp (Rheomacrodex). Truyn prostacyclin - PG2 (Iloprost) hay prostaglandin Ei (PGEi) vi liu 6-10 ng/kg/pht trong 2 h hay licn tc trong 1-3 ngy gy gin mch, c ch tiu cu c tc dng lm lnh vt lot u ngn, hiu qu c th ko di trong nhiu tun. Cng c th phong b hch sao hay phong b ngoi mng cng (tc dng nhanh nhng khng ko di). M nioglycerin (Trinitrin, kem lenitral 2%)'hay m prostaglandin E2 (PGE2) c bi ngoi da, trn cc ngn tay t ra c hiu qu ti ch. Mt phng php mi gy gin mch ngn tay l gy cng gip bng cch dng sodium liothyronin (Triiodolhyronin) 15ig hng ngy. Kt hp Triiodothyronin v reserpin t ra c hiu qu nht. 2.1.3. Phc tham kho iu r hi chng Raynaud Tn sut v mc trm trng Gi iu tr ca t co ma ch 1. t him hay mc trung bnh Cc bin php bo v, ngng ht thuc, khng cn dng thuc 2. t thng xuyn nhng khng Cc bin php bo v v chn calci c loan dng 3. t thng xuyn c lon dng Bin php bo v, chn calci hoc reserpin ng ung, nhng cha c lot m liothyronin 4. t thng xuyn c lot au PGE| truyn tnh mch, reserpin iruycn ni ng mch sau dng chn calci; hoc reserpin kt hp vi liothyronin

3. vi tn thng da Kh da c th gim nu trnh tip xc vi x phng v bi thuc m. Bnh nhn cn tp th dc thng xuyn duy tr mm do ca chi, ngn v nhy cm ca da. Xoa bp da'vi ln irong ngy cng c tc dng tt. Trnh lm da b chn ihng v d gy lot. Cc vl lot da phi c chm sc cn thn bng thuc ra st khun hay ct lc ngoi khoa. Cc vt lot b nhim khun phi c iu tr hng cc thuc khng sinh, cng c th kt hp vi thuc dit khun ti ch. 4. Caci ha di da Dng colchicin lmg/ngy c tc dng gim vim ti ch, gim au v lot da. 5. Vim x da c iu tr nh vim da c, gm cortcoid liu cao, cc Lhucc c ch min dch nh a/athioprin, cyclophosphamid, methotrexat. 6. i vi triu chng tiu ha 6.1. Tro ngc thc qun: n nhiu ba nh, thuc chng acid ung vo gia cc ba n, k u cao khi nm. Trnh n mun ban m. Khng nm trong vi gi sau khi n, trnh c ph, ch, socla v cc cht ny gy gim c lc c trn vng ihp ca thc qun. Thuc: Chng acid: Cimetidin, Ranitidin, Famotidin, Omeprasol (20-40 mg/ngy) c hiu qu rt tt. Khng sinh ph rng nh nhm cyclin c tc dng chng li s tng sinh vi khun: Tetracylin 0,5 X4 ln/ngy.

6.2. Nut kh: phi nhai k thc n v y thc n xung bng cch nut vi nc. C ih dng thuc chng acid (ranitidin, omeprasol), ketanseri. 6.3. Hi chng km hp thu: Thng do gim vn ng t trng v do vi khun. C th dng khng sinh nhm cyclin theo t. Nu khng c tc dng th c th chuyn sang cc khng sinh khc nh erythromycin, metronidazol. Octreotid, ng ng cua somatostatin cng c tc dng trong mt s irng hp tng sinh v khun v gi tc. Khuyn bnh nhn n ihc n mm v ung cc thuc nhun trng i vi to bn do tn thng rut. 7. Vim c c'p Thng p ng vi glucocorlicod, thuc khng ch nh trong cc trng hp XCBTT khng c tn thng c. 8. au khp
Asprn v cc thuc chng vim khng Sleroid, vt l tr liu, tim ti khp, ghp khp gi i vi cc khp b hy hoi nhiu nh khp g, hng. Dng prednisolon 5mg/ngy ung cch ngy gp phn ci thin ton trng v au khp.

9. X phi X phi ong XCBTT l khng hi phc. iu u ch yu l triu chng v iu tr bin chng. Nhim khun phi iu tr bng khng sinh. Thiu oxy th cn phi cho th oxy nng thp. Vai tr ca glucocorticoid trong phng nga tin trin ca tn thng t chc k phi khng r rng. 10. Tn thng thn do mch mu (cn rno-vasculaire) Pht hin sm cc tn thng thn ng vai tr quan trng trong vic bo tn chc nng thn. Cn tin trin nhanh chng, c th gy t vong, thng c km theo tng huyt p. Do a s" bnh nhn c tng renin nn cc thuc c ch men chuyn c tc dng bnh n v bo tn chc nng thn nh mt thuc h p tt. Cc thuc thng dng l: Captopril (37,5 - 75mg/ngy), enalaprin, lisinopril, peridopril. Chng c tc dng tt trong tng huyt p, t tn Ihng thn cp, tng p lc ng mch phi, suy tim. Thn nhnto c th ch nh ong trng hp tn thng thn tin trin.
I

11. Tn thng tim: i hi phi theo di cn thn vic dng digitalis v thuc li tiu. Trn dch mng ngoi tim c th p ng vi thuc li tiu. Trnh li tiu qu mc v c th lm gim hiu qu ca th tch huyt tng, gim th tch tng mu ca tim v lm tn thng thn. Cc thuc c ch calci lm ci thin cung lng tim.

IU TR AU THAT l n g (TL)
Trn Ngc An Nguyn Vnh Ngc I. I CNG Vng tht lng c gii hn trn bi b di xng sn 12, hai bn bi khi c thng cnh ct sng v pha di l xng chu. TL l mt hi chng rt thng gp. T l TL ni chung xy ra trong cuc i chim 60-90% dn s. Vit Nam TL chim 2% trong nhn dn v ln ti 17% nhng ngi trn 60 tui. Nh nhng phng php chn on hin i Scanner, cng hng t ht nhn...) vic xc nh nguyn nhn TL, iu tr v phng bnh c nhiu tin b. Nguyn nhn TL rt phong ph v a dng. i a s cc trng hp khng tm thy nguyn nhn. Ch c 10% cc trng hp l tm thy cn nguyn bnh: Cc nguyn nhn thng gp l tn thng ct sng tht lng (trng thi cng ct sng v t th xu, thoi ha ct sng thl lng, thoi ha a m, vicm t sng do nhim khun, di cn ung th...) v cc nguyn nhn khc trong bng gy au tht lng (lol d dy t trng, bnh l gan mt, thn til niu, sinh dc...).

au tht lng thng hu qu ca t th ng v ngi sai lch lu ngy trong sinh hot v lm vic. Khi trng lng ca cth to lc nn lch Irn cc t xng sng v gy sc cng ko qu nhiu trn a m, khp t sng, dy chng v cc bp c xung quanh. Theo din bin ca bnh, c 3 th lm sng TL: cp, bn cp, v mn tnh. Trong au thn kinh la c xp vo nhm bn cp. Nguyn nhn ca au thn kinh ta ch yu l do thot v a m (90%). II IU TR AU THAT 1. Nguyn tc Lun lun c gng pht hin c nguyn nhn ca bnh iu tr. Nu TL do cc nguyn nhn trong bng th iu tr nguyn nhn gy bnh ng thi s cha khi c TL. i vi cc nguyn nhn tn thng thc th ct sng (chn thng, d dng, vim t sng a m, u t sng nguyn pht hay th pht...) th cc bin php ni huy ngoi khoa thch hp l rt cn thit. iu tr TL ch yu l ni khoa bo tn. cn vn dung linh hot cc bin php ngh ngi, dng thuc, tm l, vt l tr liu v phc hi chc nng. Phu thut ch c ch nh trong mi s rt t cc trng hp.
l ng

2. iu tr ni khoa 2.1. Ngh ngi: Bnh nhn cn ngh ngi v bt ng khi au nhiu. Ch cn 2-7 ngy ngh ngi ti ging v dng mt vi thuc gim au thng thng th gii quyt c a s cc trng hp TL cp. Bnh nhn cn nm n ging phng v cng. Nu au nhiu c th nm co chn li hay nm sp. Khi c nguy c ln v di lch ct sng (lao, vim, ung ih...) c th c nh bng bt, ai np, ym, o chnh hnh tht liig. 2.2. Vn ng: Ch nh khi giai on TL cp qua. Vn ng, tp th dc u n gip bnh nhn nhanh chng li vi cuc sng bnh thng. trnh ti trng qu mc ln ct sng bnh nhn c th eo ai lng. Th dc liu php v bi c bit cn ihit vi bnh nhn b vim ct sng dnh khp hay h ct sng mc nh. 2.3. Vt l tr liu: C tc dng tt trong nhiu trng hp, tuy nhin khng c ch nh trong cc trng hp TL do nhim khun, ung th, long xng. C th dng cc bin php sau: Chm nng, chiu tia hng ngoi, sng ngn, t trng, in dn thuc... Xoa bp, chm cu n huyt Thao tc ct sng: Lm gin cc mm sng v dch chuyn phn a m b li ir li v tr bnh thng. C kt qu tt khi tin hnh irong 1-3 lun u au tht lng. Mi t lm 2-5 ln. Chng ch nh khi nghi c vim, ung th, long xng nng. ' Ko gin ct sng bng dng c ch nh cho li hoc thot v a m. Liu php tm cl, tdm bn v p bn, tm nhit, tm sui khong, liu

Cc thuc gim au rat a dng: Aspirin, paracetamol, Efferalgan codein, Di-antalvic... Cc thuc chng vim gim au khng steroid: Diclofenac, pyroxicam, meloxicam... C th dng dng thuc bi ngoi da nh cc loi gel cha diofenac, niAuril, pyroxicam hoc mt gu, cn xoa bp, cao xoa cc loi... Nu c co cng c th dng mt trong cc thuc gin c nh Decontractyl, Mydocalm, Myonal, Coltramyl... Trong mt s cc trng hp c Ih tim ngoi mng cng (ch yu vi au thn kinh ta) hoc tim cnh ct sng corticoid. Khi c h a m nng c th tim thuc lm tiu a m bng chymopapain (c kt qu tt trong 75% cc trng hp, tng ng phu thut ct cung sau hay ct b a m). Mt s" trng hp c bit c th c ch nh dng corticoid ng ton thn vi liu cao (c th t ti 50-60mg pre dnisolon/ngy trong 4-5 ngy).

3. iu tr ngoi khoa Cn c cn nhc k trc khi phu thut. Ch nh ngoi khoa hn ch trong mt s ng hp. - Cc bnh gy chn p ty, ui nga (lao, vim m, chn thng...) c cc triu chng ri lon trc trng, bng quang. Trong trng hp ny cn m cp cu gii phng p. - Phu thut lm cng, c nh khi c nguy c ln t sng, g vo nhiu, TL mn tnh. - Phu thut iu tr thot v a m: M ct cung sau, m ly nhn thot v. III. PHNG BNH i vi TL do ngh nghip th cn ci thin iu kin lm vic, hn ch cc sang chn v tinh thn, chn thng do lao ng. Mt khc cn duy tr ch tp luyn th dc th thao thng xuyn nng cao ih lc. Bo m t th ng khi ng, ngi, mang vc hay nhc vt nng c ngha r't quan trng. Cn ng trn t th thng, khng li vai, g lng. nh khom U Tng khi ngi c v vit lu nn ngi gn bn vit, gh ngi khng qu cao hoc bn vit khng nn qu ihp. Nu phi ngi lu nn thng xuyn ng ln v lm cc ng tc th c gia gi. Khi ngi trn gh bo m gc ca khp hng bng vi gc u gi, bn chn t phng Irn sn nh v khung xng chu ta vo sn gh gi cho phn c th t hng tr ln c thng. Khi mang vc vt nng hy cho sc nng ca vl chia u c hai bn c th. Khng bao gi mang vt nng mt bn ngi. Trnh mang nng trong thi gian di. Khi mun nhc mt vt nng ln nn co i, gp gi, i chn gp li va phi nhirtig vn gi lng thng. Nn ng ln bng cch thng hai chn. Khng nn gi thng hai chn v ci cong ngi xung khi nhc vt nng. Lau chi nh ca cng s d dng v thoi mi hn nu ta trn hai tay v u gi. Vn c ngha quan Irng l phi c ch n ung sinh hot hp l, gim cn vi nhng ngi bo ph, irnh nhng cng thng qu mc v tm l (c th l nhng yu t"gy TL v lm irm ng bnh).

IU TR VIM KHP MN TNH THIU NIN

(VIM KHP THIU NIN T PHT - JIA)
_ , . I. I CNG Trn Ngc n Nguyn Vn Hng 5

Vim khp mn tnh thiu nin (VKMTTN) l mt trong nhng bnh thng gp nht ong cc bnh khp nhi khoa (ch sau thp khp cp), n mc nhiu hn nam vi t l x'p x 2/1. La tui hay mc bnh l t 6-7 tui v 12-15 tui, mt s" trng hp thy r yu t gia nh. Nguyn nhn ca VKMTTN cha r. 1. Tn gi v phn loi Bnh c nhiu tn gi khc nhau. Trc y bnh c gi l vim khp dng thp thiu nin, hoc vim khp mn tnh thiu nin, ngy nay tn gi ca bnh dn c thay th l vim khp thiu nin t pht hoc vim khp thiu nin, v cch phn loi bnh cng c nhiu thay i. Cc tc gi M phn loi da vo bnh cnh lm sng chia lm 3 th: Th a khp, th vi khp, th c biu hin h thng. c vic phn loi da vo iu chng lm sng v xt nghim min dch, c chia lm 7 th: Vim khp h thng, vim a khp c yu t dng thp (RF) dng tnh, vim a khp c RF m tnh, vim vi khp, vim t chc quanh khp kt hp vi vim khp, vim khp vy nn. Vit Nam, bnh c chia lm 4 th nh sau: Th bt u cp c biu hin ni tng, th a khp mn tnh, th ct sng, th mt khp hay vi khp. C mt s im khc bit trong cch iu tr mi th ny. 2. Tiu chun chn on Tr em di 16 tui. Vim mt hoc nhiu khp c sng hoc trn dch khp hoc c biu hin hai hoc nhiu hn trong s cc du hiu sau: Hn ch vn ng, cng khp hoc au khi vn ng, nng. Thi gian ko di > 6 tun

II. IU TR A. NGUYN TC CHUNG So vi iu tr cc bnh khp mn tnh ngi ln, i vi tr em c mt s" im cn lu : Cn quan tm n cc hot ng tm sinh l ca cc chu, v bnh gy hn ch vn ng ko di (th a khp), a b tch khi cc mi trng gia nh v x hi, d c nhng ri lon v mt tm l v tnh cm.

a tr cn c khuyn khch ng vin c c mt cuc sng cng gn vi i sng bnh thng ca tr nh cng tt. Hu ht cc a u c th n ng hc bnh thng v nh vy c c nhng c hi pht trin v mt x hi, tm l v tri thc. Nhng s pht trin ny l ht sc quan trng. Quan tm n vic hc hnh, phc hi chc nng, ti gio dc v chnh hnh, cn nhc k khi s dng cc thuc, ht sc hn ch cc thuc nh hng n s pht trin ca tr em (ni tit t, thuc c ch min dch, thuc nh hng n c quan to mu...) Tr cn c ngh ngi y v ng tt.
B. C TH

1. iu tr bng thuc C 3 nhm thuc c s dng trong iu tr VKMTTN: Nhm gim au, nhm chng vim v nhm thuc thuc hng th hai c tc dng trn h thng min dch v trc tip trn khp. Trong nhm ny c cc thuc chng thp khp tc dng chm v cc thuc c t bo. i vi tng th c cc thuc c u tin la chn nhm em li hiu qu iu tr tt nht. a. Thuc gim au chng vim khng steroid - Aspirin l'thuc n gin v hiu qu nht trong iu tr VKMTTN. N cng l thuc tng i r tin v an ton trong liu trnh iu tr di ngy. Liu c tc dng chng vim t 70-90 mg/kg/ngy ph thuc vo tui v cn nng. Liu cao dung np tt nht tr c cn nng di 25 kg. Nn dng thuc bn ln trong ngy vo cc ba n v bui ti trc ng km ung sa hn ch cc bin chng ng li-u ha. Nng aspirin trong huyt thanh thch hp vo khong 20-25mg/dl, khng nn vt qu 30mg/dl, c o 2 gi sau liu bui sng. nhng bnh nhn c biu hin h thng c th kh t c liu iu tr nhng nu tng liu ln trn lOOmg/kg th thng gy ra ng c; Nu bt buc phi iu tr liu cao th nn gim dn ti liu duy tr khi triu chng h thng gim i. Ngy nay ngi ta dng aspegic (salicylat lysin) liu lng ing ng nhaspirin. Tc ng ph aspirin gm ng c salicylat, tai, tan chuyn ha, kch thch d dy, hen ph qun. Khng nn dng aspirin cng vi metholrexat v c th gy ra cc tn thng gan tim tng, trong thi gian b nhim virus v khng c hiu qu iu . Nu tr khng p ng vi aspirin sau thi gian iu tr ti a l 3 thng hoc p ng vi iu tr khng r rng th c th dng mt s thuc gim au chng vim khng stcroid khc. Hu ht cc thuc gim au chng vim khng steroid mi u cha c tha nhn dng cho tr em. Tuy nhin c mt s thuc sau nm trong nhm thuc c dng rng ri cho tr em di 14 tui. Ibuprocn 35mg/kg/ngy chia 4 ln. Indomethacin vin 25 mg, 2-4 vin/ngy. Dicloenac vin 25-50mg, liu 50-100mg/ngy.

i vi tr em trn 14 tui th vic dng thuc gim au chng vim khng sleroid c d hn, c th dng mt trong cc thuc thuc nhm ny ngoi cc thuc k trn. Khong 50-70% tr c kt qu iu tr tt i vi ihuc gim au chng vim khng sterod n thun. Thi gian iu tr nn ko di l 12-24 thng sau khi tt c cc biu hn lm sng ca bnh ht. b. Cc thuc iu tr tng cng Khi tr khng p ng vi thuc gim au chng vim khng steroid n thun hoc p ng km th c th dng thm mt s loi thuc sau nhm tng cng hiu qu iu tr. Thuc chng st rt tng hp: Hydroxychloroquin l mt thuc h tr tt iu nhng tr ln b VKMTTN. Liu bt u t 5-7 mg/kg/ngy (<600mg) v tng tbi gian iu tr ca t iu tr ban u khng nn ko di qu 2 nm. c n phi khm mt cho tr trc iu tr v 4 thng mt ln trong thi gian iu tr. Phi ngng thuc nu nh c bt k du hiu nghi ng no v bnh vng mc. C th gp lng ng gic mc v l mt du hiu cn phi gim liu ihuc. Nn ch tr di 7 tui kh nh gi nh hng mt khi dng chloroquin v kh kim tra kh nng th lc v mu sc ca tr. Sulfasalazin dng c kt qu v tng i an ton. Hiu qu iu tr t c sau 6-8 tun. Liu duy tr cho tr em t 40-60 mg/kg/ngy chia lm 3-4 ln, ung vo ba n hoc vi sa. Sau t iu tr u tin, liu duy u gim ' dn ti khong 25mg/kg/ngy ko di duy tr hiu qu. Thuc c th gy ra cc triu chng nhim c cao bao gm r lon v d y rut, lot ming, vim da bao gm c hi chng Steves Johnson, suy tuy xng. Khng nn s dng sulfasalazin cho tr s sinh, tr c lin s mn cm vi sul, salicylat, suy gan, suy thn hoc vi cc chng ch nh c th nh r lon chuyn ha porphyrin, thiu men G6-PD. Tetracyclin (dng cho tr >14 tui) dng chng cc nhim khun tim tng ng tit niu sinh dc. Liu dng l 25-50mg/kg/ngy, chia lm 2-4 ln. Thuc c th gy cc tc dng ph trn ng liu ha: Nng rut, y bng, a chy, bun nn hoc nn; trn da gy lng ng sc t" da; nhim c cho gan, thn. D-penicilamin c ch nh ing t nh mui vng. Hai thuc ny khng c iu tr kt hp. Liu lng duy tr l lOmg/kg/ngy (< 750 mg/ngy), ung bui sng khi i. Liu trn t c sau 3 t iu tr liu tng dn t 8 n 12 tun, vi liu ban u l 3mg/kg. Kim Ira cng Ihc mu, phn lch nc tiu hng tun v xl nghim sinh ha 6 tun mt ln. Cc tc dng ph quan trng ca Ihuc gm luput do thu"c, vicm da, gim tiu cu v prolein niu. Nhng bnh nhn b nhim c do dng mui vng cng c nguy c tng t nh khi dng D-pcnicilamin Glucocorticoid: C th c kt qu i vi nhng ung hp VKMTTN khng p ng vi cc bin php iu tr ho tn khc. Thuc thng c kt hp vi mt thuc gim au chng vim khng sleroid hoc mt thuc

iu tr thp khp khc. iu tr corticoid ti ch ch gii hn 1 hoc 2 khp lin tc b vim tin trin nhng tr c p ng tt vi iu tr bo tn. Prednisolon l thuc thng c s dng. Vi trng hp c cc triu chng h ihng khng kim sot c cng vi gim vn ng ca khp ng k, c th dng liu duy nh't bui sng t 0,1-lmg/kg/ngy (<40mg) hoc chia liu nh nhng bnh nhn nng hn. Khi t c kt qu iu tr, nn gim liu dn v sau ngng hn. S dng corticoid thm ch liu cao khng lm rt ngn thi gian b bnh, phng cc bin chng ngoi khp hay lm thay i tin lng cui cng ca bnh. Vi nhng trng hp c biu hin m sng nng, c th dng corticoid ng iruyn lnh mch vi liu t 10-30mg/kg/ln theo nhiu cch khc nhau, c th t I ln duy nh. cho ti 3 ln vo cc ngy khc nhau. Vic dng corticoid ng truyn nh trn c th mang li hiu qu chng vim tc th ng thi lm hn ch cc bin chng do dng corticoid ko di. Tuy nhin cn lu dng corticoid ng truyn liu cao c th gy cc bin chng nng n v cht ngi nh ri lon nc, in "ii, lon nhp tim. Do cn theo di lin tc trong khi truyn v mt vi gi sau . Ngoi ra, cn c th gp cc bin chng khc khi s dng corticoid nh chm pht trin ngay c vi liu 3-5mg/ngy, hi chng cushing... Thuc c ch min dch: Ch nn s dng trong cc trng hp iu tr c tnh cht nghin cu, vi nhng trng hp bnh nng e da n tnh mng, nhng trng hp bnh li pht, tin trin lin tc. Cc thuc thng dng l azathioprin, cyclophosphamid, chlorambucil v mcthoexat. Bin chng thng gp khi dng thuc ny gm gim bch cu, suy ty xng.

Methotrexat ch nh trong trng hp bnh c tn thng nhiu khp nng, khng p ng vi iu tr di ngy bng cc thuc khc bao gm cc thuc chng thp khp tc dng ko di. Thuc c dng mi tun mt ln khi i, irc n sng 60 pht. Liu bt u l lOmg/m c th/tun, cn kim tra cng thc mu 2 tun mt ln v transaminase huyt ihanh hng thng. Trng hp gy c ca ihuc bao gm suy ty xng, loct ng liu ha, a chy, au u, vim phi k cp, rng tc, vim da, x gan. 2. Vt l tr iu v hng nghip Vic duy tr chc nng v phng cc bin dng khp l rt quan trng trong lon b qu trnh iu tr VKMTTN. Phng php ny c bit thch hp vi cc bnh nhn ngay ban u phi nm Li ging hoc ngi xe y do qu trnh tin trin ca bnh hoc do au. Trong giai on vim cp c th p dng mt s ng tc vn ng nh sau khi c tm nng. Nhit c th lm gim cng khp, au v chun h cho trc cc bi lp. Yu c, teo c, gim kha nng chu ng v co cng c l nhng triu chng ca VKMTTN c th dn n tn ph. Tp luyn duy tr ti a c lc, kh nng vn ng v chc nng ca khp l rt cn thit. K hoch tp luyn cn c thc hin hi chnh bn thn bnh nhn vi s hng dn ca thy Ihuc, s gip ca gia nh v nh nng v phi c coi l mt phn ca nhng hot ng bnh ihng trong cuc sng hng ngy ca ir.

Lun quan tm n nhng t th ng ngay t khi bnh mi c chn on. C th dng nhng dng c tr gip nh np chi, vng c mm... Cn phi c s cn bng gia qu trnh luyn tp v ngh ngi ban m hoc ban ngy sau gi hc. Hu ht cc tr u c kh nng t vn ng tt, him khi phi khuyn khch. Nhng hot ng vui chi bnh thng nn c khuyn khch v ch cc hot ng khng cn thit i hi vn ng qu mc gy ra s t nn ln cc khp chu li ang b vim nh cc hot ng th thao mnh, in kinh cn c hn ch. 3. Phu thut chnh hnh Phu thut ct'mng hot dch khng c tc dng vi trng hp bnh ko di tuy nhin c th c ch i vi nhng a tr c la chn cn thn nhm gii phng cc khp c gim vn ng c tnh cht c gii lin quan n dy mng hot dch, lm gim au. Nn trnh cc phu thut khp m v vic phc hi vn ng ca khp sau phu thut tr nh thng l rt kh. Phu thut gn c th c ch nh nhm gim nguy c b t gn hoc trong trng hp vim dnh bao gn, ngn lay c sng. Thay th ton b khp, c bit l khp hng thng ch c tin hnh sau khi s pht in ca xng dng li. 4. Gio dc v t vn cho ngi bnh v gia nh V tin lng ca VKMTTN r't kh quan, cho nn nu c th cho cc bc cha m v tr hiu bit v bnh v hp tc iu tr. c n ginh thi gian v sc lc gii thch cho h nm c din bin ca bnh v kt qu c th mong i ca iu tr. Vic gio dc cng nn thc hin ng Ihi. c n yu cu cha m ca tr vit ra cc vn lin quan n bnh v nhng cu hi cn gii p v mang theo mi ln n khm bnh c th x l kp ihi. 5. C h dinh dng Cng l mt vn quan ng ong qu trnh iu ko di ca VKMTTN. cn cung cp y cc ch't dinh dng, cc yu t vi lng, cc vitamin trong khu phn n ca tr. Ch n qu nh pht trin ca tr v mt s bin chng c th gp nh long xng. c . P DNG THC 1. Th ni tng Corticoid: prednisolon l,5-2mg/kg/ngy, liu ln cng 3-5 ngy ri gim dn liu. Nu tnh trng nng c th cho truyn tnh mch depersolon hoc methylprednisolon). C th dng cc thuc c ch min dch, methotrexat. 2. Th vim a khp m n tnh: Aspirin hoc cc thuc gim au chng vim khng steroid, Salazopyrin. 3. Th vim ct sng dnh khp Cc thuc gim au chng vim khng steroid. Salazopyrin hay tetracyclin.
t

4. Th mt vi khp Aspirin, thuc gim au chng vim khng steroid. Tim steroid vo khp Ct b mng hot dch nu iu tr ni khoa qua 6 thng khng kt qu hoc s dng phng php ti to mng hot dch bng ha cht.