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Mc tiu
1. K c nhng thuc chnh thng
dng trong qu trnh gy m v hi
sc.
2. S dng ng cc thuc thng dng
trong gy m v hi sc.
3. Phi hp thuc ng cch tng hiu
qu v hn ch tc dng ph.
1. Thuc tin m
Mc ch:
An tm, an thn, bt lo u.
Lm qun
Lm gim nn i, gim co tht.
C tnh gy ng.
Nhm Benzodiazepin
- Gm: Midazolam, Diazepam, Lorazepam.
- u im ca thuc nhm Benzodiazepin: t
gy tc dng ph, t c ch h hp v nht l
chng t gy try tim mch
Nhm Benzodiazepin
1.1. Tc dng:
H TKTW: Gy an thn, gy ng, gy qun,
chng co git, gy dn c
H tim mch: gy dn mch v gim cung
lng tim nh. Nhp tim thng khng thay
i.
H hp: lm gim tn s th v th tch
thng lu ty theo liu dng. c ch h
hp nu dng km vi nhm thuc phin
Nhm Benzodiazepin
1.2. Tc dng ph:
Tng tc thuc: Dng Benzodiazepin trn
BN ng kinh ang iu tr vi Valproat c
th gy ln cn tm thn cp.
C thai v sinh : thuc c th gy d tt
cho bo thai nh st mi, ch vm nu
dng trong ba thng u thai k. Thuc qua
nhau c th gy suy h hp tr s sinh.
Nhm Benzodiazepin
a. Midazolam: Hypnovel
- Tc dng ngn, tan trong nc, khng c cht
t dc, thuc c tc dng gy qun mnh
nht v ko di
- Tin m: Liu dng 0,5 - 1 mg TM/mt ln
Nhm Benzodiazepin
b. Diazepam: Valium, Seduxen
- Thuc c s dng trong GMHS rt sm,
c tnh kch thch tnh mch, gy au ni
chch v c th gy d ng, ngay c gy sc
qu mn.
- Tin m: Liu dng 05 - 10 mg ung khong
0,5 - 1 gi trc m.
Atropin
Liu tin m 0,01 0,02 mg/kg TB hay
TM
Atropin dng thn trng ngi b tng
nhn p gc ng, ph i tuyn tin lit
hay hp c bng quang
Scopolamin
- Tc dng chng tit nc bt mnh hn
Atropin v c tc dng nhiu hn trn h
thn kinh trung ng so vi Atropin.
- Liu dng lm sng thng gy bun ng v
qun, c th km bt rt, ni sng, nht l
i vi ngi gi.
- Scopolamin cn nga say tu xe. Nn thn
trng hay trnh dng cho ngi gi, tng
nhn p.
MORPHIN
- Gim au hiu qu trn mi loi au: au ni
tng, au do chn thng, gim au v gim
lo u trong nhi mu c tim.
- Morphin lm dn tnh mch nn rt tt
iu tr ph phi cp do suy tim tri cp v
lm gim cm gic kh th.
- Liu dng:
Morphin tim tnh mch liu 0,05 - 0,1mg/kg,
nn chn liu nh t 1 - 2 mg/ln, hay tim
bp 0,1 - 0,2 mg/kg
Fentanyl
- Fentanyl l thuc phin tng hp, tan trong
m nhiu hn Morphin, mnh gn 100 ln
hn Morphin.
- Thi gian tim phc nhanh hn: 3 - 5 pht,
tnh n nh huyt ng tt hn v c ch h
hp mnh hn.
- Liu cao Fentanyl tim tnh mch nhanh c
th gy cng c thnh ngc. Fentanyl gy
nga mt v ton thn.
Fentanyl
Liu dng:
Gy m: liu dng 1- 2 mcg/kg bnh nhn t
th, cuc m ngn khong 30 - 40 pht; liu
dng 5 - 10 mcg/kg phu thut ln, c th my
Fentanyl 10 - 25 mcg pha chung vi thuc t ti
ch Bupivacain trong t ty sng lm tng tc
dng t v ko di thi gian tc dng ca thuc
t.
Cho Fentanyl vo khoang NMC qua catheter
liu 0,3 mcg/kg/gi hay cho tng liu 50 - 100
mcg/ln.
Remifentanil
- Remifentanil l thuc phin c tc dng
ngn nht hin nay, thng thi gian tc
dng khong 3 5 pht nn thuc dng
truyn tnh mch, do b thy phn bi men
esterase trong mu v m;
- Remifentanil (0,3 - 0,4 mcg/kg/pht TM) vi
Propofol (75 mcg/kg/pht TM).
Sufentanil
- Sufentanil l thuc phin tng hp mnh
nht hin nay
- Tc dng tng t nh Fentanyl nhng thi
gian tc dng ngn hn v t b tch t thuc
so vi Fentanyl.
- Dng duy tr trong gy m cn bng,
Sufentanil cho tng liu 0,1 - 0,2 mcg/kg
TM hay truyn tnh mch lin tc 0,2 - 1
mcg/kg/gi.
THUOC ME LY TNG
1.Tnh me nhanh, lam quen.
2.Khong tang ap suat noi so, me nhanh
em, khong kch thch.
3.Huyet ong on nh.
4.Thong kh de dang.
5.De s dung, on nh trong dung dch.
6.Dung nap tot tnh mach, khong au
7.t phong thch Histamine, phan ng phu,
qua man.
8.Nhng chat chuyen hoa t tac dung, t
tch tu.
Khong co thuoc me n thuan " LY
TNG ".
4.2. Ketamin
C ch tc dng cha r, nhng c tc dng
i khng ti th th N-methyl-D-aspartat
(NMDA).
Thuc chuyn ha ti gan, thnh nhiu cht
chuyn ha trong vi cht c hot tnh.
Thi gian tc dng: 1 pht
Thi gian tc dng: 10 - 20 pht.
Liu: 2 3 mg/kg TMC
4.2. Ketamin
a. Tc dng:
TKTW: Ketamin lm tng LL mu no, CH
no v tng ALNS. Ketamin l thuc gy
m phn ly, c tnh gy qun v gim au.
TM: Ketamin lm tng tn s tim, tng HA
M h thng v M phi do phng thch
catecholamin ni sinh.
HH: t c ch h hp.
4.2. Ketamin
a. Tc dng ph:
Ketamin gy tng tit nc bt
Ketamin gy vt v, bt rt trong lc tnh
m, gy o gic v c mng trong v sau m
Lm tng ALNS nn khng dng BN CTSN
hay tng ALNS
Tr em t b o gic hn ngi ln.
Khng nn dng Ketamin cho BN c RL tm
thn.
Gy run c khi c kch thch. Lm tng
trng lc c.
4.3. Propofol
- Dng khi m v duy tr m,
- Chn la cho BN m v trong
ngy v: tnh m nhanh, cht lng
khi tnh m tt, khng b ngy
ngt khi tnh m, t b bun nn v
t nn i sau gy m
- Liu khi m 2 3 mg/kg,
- Thi gian tc dng: 30 45s
- Thi gian tc dng: 5 - 10 pht
4.3. Propofol
a. Tc dng:
TKTW: Liu cao, gy mt tri gic, liu thp gy an
thn nhng bnh nhn vn tnh to. Gim CH no,
gim LL mu no v gim ALNS.
TM: Gy tt huyt p do dn mch v gim cung
lng tim. Gim nhp tim
HH: Propofol c ch phn x thanh qun, kh qun
nn t b co tht thanh qun khi t ng ni kh qun,
nn rt thun li khi t mask thanh qun.
C th truyn tnh mch lin tc duy tr m.
4.3. Propofol
b. Tc dng ph:
- BN thng b au ni tim thuc
- Dng nh tng gip vi khun pht trin nn
phi ch gi v trng khi ly thuc, v b
ng thuc m khng dng sau khong 6
gi trnh b nhim khun.
4.4. Etomidat
Etomidat l cht Imidazol c tnh
gy m, gy ng, c dng
khi m.
Thi gian tc dng : 30 giy
Thi gian tc dng: 4 - 6 pht.
Etomidat c chuyn ha ti gan
v men esterase trong mu thnh
cht chuyn ha khng c hot tnh
4.4. Etomidat
a. Tc dng:
- TKTW: Gim CH no, LL mu no v gim
ALNS. Etomidat c tc dng chng ng kinh
nhng gy thay i sng in no gip nh v
c ng kinh.
- TM: t thay i nhp tim, huyt p v cung lng
tim
- HH: c ch h hp ngng th thong qua.
- Khng gy phng thch histamin v t b phn
ng d ng nn l thuc c chn cho bnh
nhn b tng phn ng ng th.
4.4. Etomidat
b. Tc dng ph:
- au ni tim
- Run git c v c ng ngoi thp
- Bun nn v i thng xy ra sau m,
nhiu hn cc thuc m khc.
- Kch thch tnh mch gy au ni chch.
- Etomidat c ch tuyn thng thn tit
Cortisol trong 24 gi, nn khng dng liu
lp li hay truyn tnh mch ko di.
c. Liu dng : Khi m: Liu 0,3 0,4 mg/kg.
DC NG HC
THN KINH TW
TIM MCH
H HP
THIOPENTAL
- Gim TT oxy
- Gim LL mu
- Gim ALNS
- Co tht TQ, KQ
- V kh LT:
KETAMIN
- Tng LL mu
- Tng ALNS
- Gim au
- Dn PQ
- Tng tit
PROPOFOL
- Gim LL mu
- Gim ALNS
- M mt sm
- Tn s: Gim
- V kh LT:
- Gim KT PQ
ETOMIDATE
- Gim LL mu
- Gim ALNS
- Tnh nhanh
- Tn s: Tng
- V kh LT:
- Khng gy co
tht PQ
CH NH CHNG CH NH
CH NH
THIOPENTAL
KETAMIN
PROPOFOL
ETOMIDATE
CHNG C
LIU LNG
- Gm ton din
- BN CTSN
- Hi sc
- Sn khoa
- D ng barbituric
- KHTH , suy tim
- Hen PQ
- Suy gan thn
3 5 mg/kg
- Sc, bng
- Th thut gy au, phi
hp t vng
2 3 mg/kg
- BN ngoi tr
- Khi m, duy tr m
- Phi hp t vng
- ng kinh cha n
- Gim KHTH
- RL lipid
2 3 mg/kg
- Ct b ng kinh
- Bnh l TM
- Sn khoa
- ng kinh
- Suy thng thn
- Suy gan
5. Duy tr m: Thuc m h hp
Nhm Halogen:
- Halothan
- Isofluran
- Sevofluran
5.1. Halothan
- Thuc m h hp, khng mu, c mi
5.2. Halothan
a. Tc dng:
- TKTW: Tng LL mu no v tng ALNS
- TM: gy tt huyt p, gy lon nhp tim,
thng l nhp tim chm v nhp nt
- HH: Halothan gy th nhanh, nng. Gy dn
ph qun v lm gim phn x hu v thanh
qun
5.2. Halothan
a. Tc dng:
- Dn c trn v c vn, k c c t cung lm
chy mu nhiu khi m bt con.
- Gim LL mu thn, gim lc cu thn v
lng nc tiu do tt huyt p v gim
cung lng tim.
- Gim LL mu qua gan do gim cung lng
tim.
5.2. Halothan
b. Tc dng ph:
Gy khi pht st cao c tnh.
Gy vim gan do Halothan, tng i
him, t l khong 1:35.000 trng hp
v c th gy hoi t gan khi gy m
lin tip nhiu ln trong mt thi gian
ngn.
5.2. ISOFLURAN
- Isofluran l thuc m bc hi, khng mu, c
mi hi nng cay, gy kch thch ng h
hp nn t c dng khi m.
- Duy tr m thng nng 2 - 3% phi
hp vi dng kh (O2) hay hn hp N2O v
O2.
- Tnh m nhanh, t phn ng ca thuc m
nn Isofluran c dng trong gy m BN
ngoi tr hay v trong ngy
5.2. ISOFLURAN
Tc dng:
- TKTW: t nh hng trn LL mu no v
ALNS nng thp
- TM: Gy tt huyt p t l vi nng thuc
m do dn mch ngoi vi. Mch tng i
n nh hoc tng nhanh nh
- HH: Gy c ch h hp nh, nhng t gy
th nhanh.
5.2. ISOFLURAN
Tc dng:
- C tc dng dn c tt, tng tc dng ca
thuc dn c khng kh cc v gy dn c
t cung.
- Isofluran gy gim lu lng mu qua gan,
nhng s cung cp dng kh cho t bo
gan c duy tr
5.3. SEVOFLURAN
- Sevofluran c mi d chu, khng kch thch
ng h hp nn c chn dng lm thuc
khi m ng h hp hiu qu, nhanh v m
du cho c tr em v ngi ln.
- Cht Sevofluran l thuc m h hp yu hn
cht Isofluran, nhng nh ha tan trong mu
thp nn thuc cho tc dng nhanh, rt d dng
v khi m nhanh, d iu chnh thay i m
v c thi gian tnh m nhanh.
- Hin nay c gi kh cao.
5.3. SEVOFLURAN
a. Tc dng:
- TKTW: Tng LL mu no v ALNS nh Isofluran.
Lm gim chuyn ha no.
- TM: c ch co bp c tim rt nh. Gim nh sc
cn ngoi vi v t gy h HA M v t gy mch
nhanh. Sevofluran lm gim s tiu th oxy c
tim, gim sc cn mch vnh nhng khng gy
n cp mu ng mch vnh.
- HH: Sevofluran gy c ch h hp v gy dn n
ph qun nh Isofluran
5.3. SEVOFLURAN
a. Tc dng:
- Thn kinh - c: dn c va BN chu ng
c th thut t ng NKQ tr em sau khi m
bng ng h hp, c th lm khi pht cn st
cao c tnh, nhng t l thp hn so vi Halothan.
- Gan: Gim LL mu TM ca nhng tng LL mu
M gan nn duy tr c LL mu qua gan v cung
cp dng kh cho gan.
- Thn: lm gim nh LL mu qua thn. Cht chuyn
ha l gc ion fluor t do gy h hi ng thn
5.3. SEVOFLURAN
b. Tc dng ph:
- Khong 5% Sevofluran c chuyn ha ti
gan bng men P450 to ra ion fluor t do gy
c cho thn.
- Thuc m h hp Sevofluran b hp thu v
bin i bi vi Soda hay Baralym thnh
cht vinyl ether, hay hp cht A, hp cht
ny c c tnh cao cho chc nng thn, chc
nng gan v thn kinh no b
TC DNG CA THUC M H HP
TN
H
ME
Halothan
Isoflurane
Cha
m
Trung
bnh
TKTW
- LLMN:
- ALNS:
- LLMN:
t
- ALNS:
t
HO
HAP
TIM MACH
Nhp
tim
HA
TB
Dan
MV
- c
che
- Dan
PQ
- Tang
TS
Gia
Cham
m
Khon
g
- c
che
- Dan
PQ
- Giam
TS
Nhanh
Gia
m
ang
ke
Tc dng ca thuc m h hp
DAN C GAN
THAN
- LL mau:
Giam
Halothan
Isoflurane
Trung bnh
Giam
mau
LL
- Giam
mau
LL - LL mau:
Giam
- o loc:
Giam
Nhieu
Van duy - o loc:
tr oxy gan
Giam
- Giam
mau TM
LL
- LL mau:
6. THUC DN C
- Thuc dn c, hay nn gi ng hn l
thuc ngn chn s dn truyn thn
kinh c (Neuromuscular Blocking
Drugs), l nhng thuc khi dng cho
bnh nhn, n s lm mm c vn, cn
c trn v c tim n khng c tc dng
6. THUC DN C
C 2 cch chia thuc dn c:
- Dn c kh cc (Suxamethonium) v dn c
khng kh cc (Vecuronium, Rocuronium,
Atracurium)
- Dn c ngn (Suxamethonium) , dn c
trung bnh (Vecuronium, Rocuronium,
Atracurium) v dn c di.
6.1. Suxamethonium
Tc dng ph:
au c sau m.
Tng ion kali mu
Gy d ng nh ni m ay, nga v nng nht l
sc phn v.
Gy nhp tim chm v lon nhp
Tng nhn p v tng p lc ni s
Tng p lc trong d dy
Co cng thong qua c hm khi t ni kh qun
Tng t l st cao c tnh.
6.1. Suxamethonium
- Liu khong 1 - 1,5 mg/kg, tim tnh
mch, s gy run c v tip theo gy
lit c trong vng 45 - 60 giy, v ko
di khong 5 - 7 pht
- Ch nh:
+ BN tin lng t ni kh qun kh
+ M cp cu BN c d dy y
6.2. Thuc dn c kh cc
6.2.2. Rocuronium: (EsmeronR)
- Liu 0,6 mg/kg, Liu cao t NKQ nhanh
- Thi gian tc dng: 90 giy
- Thi gian tc dng: 30 - 45 pht
- Thuc thi nguyn dng qua thn v gan,
nn thi gian tc dng s ko di nu suy
gan suy thn.
6.2. Thuc dn c kh cc
6.2.3. Atracurium:
- Liu 0,5 mg/kg
- Thi gian tc dng 2 - 2,5 pht,
- Thi gian tc dng khong 20 - 25 pht.
- y l thuc c chn cho bnh nhn suy
thn, suy gan
- Thuc khng c tc dng tim mch trc tip,
nhng c th phng thch histamin, gy ni m
ay v da quanh ni chch, tt huyt p nh
.
KT LUN
Gy m hi sc l chuyn khoa thng
dng nhng thuc mi, thuc c.
Thuc c dng trong Gy m Hi sc
rt a dng, a chng loi.
Nm tht vng nhng tnh cht ca mi
loi thuc s dng cho ng.
Tun th nhng nguyn tc khi s dng
thuc nht l nhng thuc mi.
n
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Th
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k
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