H Ni - 2002

H Ni - 2002
Hi sc cp cu
gio trnh ging dy ca hc vin qun y

b mn hi
schi sc
b mn

Hc vin qun yHc vin qun y

hc vin qun y
B mn Hi sc cp cu

hi sc cp cu
gio trnh ging dy ca hc vin qun y

Nh xut bn qun i nhn dn

H Ni - 2002

Li gii thiu
huyn ngnh Hi sc cp cu ngy nay v ang pht trin
Cmnh
trn th gii cng nh Vit Nam. Nh tin b ca chuyn
ngnh Hi sc cp cu thc y, hu thun cho cc chuyn
ngnh ngoi khoa, ni khoa, c hc, truyn nhim, sn khoa, nhi
khoa... v chuyn khoa k thut cao nh ghp cc c quan.
B mn Hi sc cp cu - Hc vin Qun y mi thnh lp do vy
nhu cu v gio trnh, ti liu tham kho chuyn ngnh l vn
mang tnh cp thit.
Gio trnh do TS: Tt Cng ch bin cng gio vin trong B
mn Hi sc cp cu - Hc vin Qun y kt hp vi mt s chuyn
vin HSCC trong Qun i v b mn HSCC ca trng i hc y
khoa - H Ni bin son.
Tp gio trnh Hi sc cp cu gm 6 chng: tun hon - h hp thn - ni tit - ri lon nc in gii, cn bng kim toan - ng c cp,
trong c nhng vn mi nh: hi chng suy h hp cp tin trin
(ARDS), ghp thn, tch huyt tng v cht no vv... Cc bi vit u
cp nht kin thc mi, c bn v h thng. Gio trnh ny ginh cho
sinh vin y khoa, cn b sau i hc, c bit cho bc s chuyn ngnh
HSCC hc tp v tham kho.
Xin trn trng gii thiu vi bn c cun gio trnh Hi sc
cp cu v mong nhn c kin qu bu ng gp gio trnh
tip tc c hon thin.
Chng ti chn thnh cm n cc tc gi cng s hp tc gip
ca ban bin tp, nh xut bn, nh in v cc bn ng nghip cun
sch n vi bn c.
Gim c Hc Vin Qun Y

Thiu tng GS.TS. Phm Gia Khnh

Li ni u
nhng thp k qua v c bit nhng nm gn y chuyn
T rong
ngnh HSCC pht trin mnh m c v phng tin hin i
cng nh k thut chuyn ngnh. Ngoi trung tm Hi sc cp
cu chung cn c nhng n v cp cu hi sc chuyn su v
mch vnh, h hp, thn kinh s no, ng c vv...
Vai tr ca cp cu l cc k quan trng v tip cn bnh
nhn ngay t u vi mi loi tai nn, bnh l cp tnh e do
n chc phn sng ca c th. Nu khng cp cu ban u
tt th nhiu trng hp t vong trc khi vo vin. Cp cu
sm ng k thut, hi sc tt v phi hp vi cc chuyn khoa
iu tr ton din s tr li cuc sng v sc kho hon ho cho
ngi bnh.
Gio trnh Hi sc cp cu gm 19 bi cp nhng
vn thit yu trong cp cu - Hi sc c bn, h thng, hin
i cp nht vi nhiu ti liu tham kho t nm 1998 n nm
2001 s gip ch cho sinh vin y khoa v cc cn b sau i
hc hc tp v tham kho.
Mc d cc tc gi ht sc c gng, song cun sch
khng trnh khi nhng thiu st. Rt mong bn c gp kin
gio trnh c b sung v hon chnh trong ln in sau.

Cc tc gi

Gio trnh - hi sc cp cu
Gio trnh ging dy ca hc vin qun y
Mc lc
Trang
Chng I: Tun hon
- Hi sinh tim phi no.
- Thuc vn mch v cng tim dng trong Hi sc cp cu.
- Sc chn thng.
- Sc nhim khun.
- Cht no.
Chng II: H hp
- Suy h hp cp.
- Ph phi cp.
- Suy h hp cp tin trin (ARDS).
- Nhim khun phi ph qun bnh vin trong khoa Hi sc cp cu.
Chng III: Thn
- Suy thn cp.
- Ghp tng-ghp thn. Theo di v iu tr sau ghp.
Chng IV: Ni tit
- Cp cu v iu tr cn nhim c Hormon gip kch pht sau phu thut.
- Cp cu v iu tr cn nhc c nng gy suy h hp cp.
- Tch huyt tng (Plasmapheresis).
Chng V: Ri lon nc in gii, cn bng kim toan
- iu chnh nc - in gii.
- Cn bng kim toan.
Chng VI: Ng c cp
- Nguyn tc cp cu iu tr ng c cp.
- Cp cu iu tr mt s ng c cp thng gp.
Chng VII: Chn thng s no nng
- Theo di v iu tr cc bnh nhn chn thng s no.
- Ti liu tham kho

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214

Chng I

Tun hon
hi sinh tim - phi - no
(Cardiopulmonary - cerebral resuscitation)
Tt Cng
L Nam Hng

1. i cng.
Ngng tim - phi (cardiopulmonary arrest) l hu qu cui cng ca rt nhiu
nguyn nhn v bnh l khc nhau v thng dn n t vong. Ngng tim - phi
c th xy ra t ngt mi ni trong v ngoi bnh vin, thm ch ngay trong
phng m, phng hi sc.
Cp cu ngng tim - phi phi rt khn trng ng k thut, trch nhim v
kin tr vi mt phc ph hp mi c th cu sng bnh nhn. Theo bo co
ca hi gy m Th gii (WFSA) nm 1988 th gn 50% bnh nhn ngng tim phi c cp cu lm cho tim p li song mt na trong s ny cht mc d
c a vo bnh vin. S cn li b tn thng no dn ti t vong l t 10 n
30%. Nh vy ch khong di 10% s bnh nhn ngng tim phi c th c
cp cu v iu tr thnh cng khi ra vin. Chnh v vy m phi hi sinh tim phi - no (CPCR) mi c th tr bnh nhn v cuc sng bnh thng c.
Trong nhng nm gn y Hip hi tim mch Hoa K (AHA), Hi hi sc Chu
u (ERC)- u ban quc t v hi sinh (ILCOR)- Hi gy m th gii (WFSA)
thng nht a ra phc cp cu ngng tim - phi (tp ch gy m th gii s 101999) v tp ch quc t v iu tr tch cc nm 1999; 2000 v s ma xun nm
2001 hng dn phc cp cu hi sinh tim - phi - no, lm ti liu c bn cho
iu tr v ging dy hin nay: bao gm 3 phn khng th tch ri l:
- Hi sc tim - phi c bn (basic life support): vi 3 bc a-b-c.
- H tr cc chc nng sng bng bin php tin tin hay hi sc tim - phi
chuyn su (advanced life support).
- Duy tr cc chc nng sng v hi sinh no cng vi iu tr ton din
(prolonged life support).

2 . Nguyn nhn ngng tim - phi.

* Nguyn nhn do tim:

- Bnh thiu mu c tim.

- Tc mch vnh cp.
- Cc bnh c tim.
- Vim c tim.
- Chn thng tim chn p tim cp.
- Kch thch trc tip vo tim.
* Nguyn nhn tun hon:
- Thiu khi lng tun hon cp.
- Tc mch phi (do kh, do cc nghn).
- C ch phn x dy ph v.
* Nguyn nhn h hp:
- Trn kh mng phi nng.
- Thiu oxy cp (thng gy ra v tm thu): d vt, tc ng th.
- u thn.
* Nguyn nhn ri lon chuyn ho:
- Ri lon chuyn ho kali.
- Tng canxi mu cp.
- Tng catecholamin cp.
- H thn nhit.
* Nguyn nhn do thuc, nhim c:
- Tc ng trc tip ca thuc gy ngng tim.
- Do tc dng ph ca thuc.
* Nguyn nhn khc:
- in git.
- ui nc.

3. hi sinh tim - phi - no:

3.1. Hi sc tim phi c bn:

Mc ch: L nhanh chng phc hi li tun hon v h hp hu hiu chng
li qu trnh bnh l c bn thiu oxy, bo v no, ng thi pht hin v gii
quyt nguyn nhn gy ra ngng tim - phi.
Phng php hi sc tim - phi c bn, mc d c mt s thay i theo tng
nc, song n c chun ho v c ging dy ph cp cho cc nhn vin
cp cu cng nh cho cng ng.
Cc ng tc cp cu c bn nhm mc ch duy tr s thng sut ca ng
th, bo m thng kh phi v tun hon c hiu qu m khng cn n nhng
phng tin no, hoc ch cn 1 canule ming hng hoc 1 mt n (masque) n
gin.

3.1.1. Chn on ngng tim - phi:

Chn on xc nh ngng tim - phi khi khng bt c mch cnh (hoc
mch bn), mt thc, ngng th hoc th ngp; da xm, tm ti, mu khng
chy hoc mu en trn vt m l cc bin php b xung, khng dng ng nghe
tim xc nh ngng tim phi v mt thi gian v kh xc nh.
Gi cp cu: gi to ngi n h tr v gi i cp cu cng nhanh cng tt.

3.1.2. K thut thc hin cc ng tc cp cu c bn:

t bnh nhn nm nga trn nn cng.
C 3 ng tc phi lm: A (Airway: ng th), B (Breathing: h hp), C
(Circulation: tun hon). Cc ng tc ny c ni n t 30 nm nay trong
cc khuyn co ca Hi tim mch Hoa K.
3.1.2.1. Gii phng ng th:
Nga nh u, y xng hm di ra trc v nng cm bnh nhn ln. Nu
nghi ng c chn thng ct sng c th ko hm di mt cch thn trng trnh
lm tng thng tn tu c.
3.1.2.2. Thng kh:
Thi ming - ming hoc ming - mi hoc bp bng qua mt n (masque).
Thi chm trong 1,5 - 2 giy, sau ch 3 - 4 giy cho khng kh thot ra
hon ton trc khi thi tip trnh hi vo lm cng d dy.
Trong khi thi tm ngng p tim ngoi lng ngc.
Th tch mi ln thi l 800 - 1200ml ngi ln (10 - 15ml/kg).
Cho n nay khng c bng chng no cho thy HIV c th ly qua nc bt
n thun. Tuy nhin s ly lan cc bnh khc c th xy ra nn c th dng cc
phng tin bo v (sng hoc masque dng 1 ln) tuy nhin khi dng cc
phng tin ny th hiu qu ca thng kh nhn to c th b gim i.
3.1.2.3. Tun hon (circulation):
p tim ngoi lng ngc vi mt tn s nhanh 80 - 100l/pht v s tng quan
gia p v gin l 50%. im p c xc nh l 1/3 di chnh gia xng c,
lc p mnh lm xng c ln xung l tng l 3 - 5 cm. Khi ngng tim phi do rung tht xy ra v khng c sn my ph rung, ngi ta c th th thay
th bng bin php c in "m vo xng c" nhng hiu qu l rt hn ch.
Nu ch c mt ngi thc hin vic cp cu hi sinh th nn thc hin 15 ln
p tim, ri dng li thi chm 2 - 3 ln. Cn khi c hai ngi th c 5 ln p tim 1
ln thi ngt. cn nh k kim tra tnh hiu qu ca ng tc cp cu v mc
thit lp li tun hon ca bnh nhn c 2 - 3 pht/ln. Trong trng hp c tc
nghn c hc hon ton ng th do d vt ri vo kh o trn, phi thc hin
nghim php Heimlich.
* Sinh l hc ca vic p tim ngoi lng ngc:

Tun hon ca mu trong c th bnh nhn khi hi sinh tim - phi ch yu

c gii thch bi 2 thuyt, i din cho 2 cch nhn nhn khc nhau v tc dng
ca lc p trc tip ln lng ngc.
+ Thuyt bm tim:
y l thuyt kinh in, c nu ra t nm 1960 bi Kowenhoven. Theo
thuyt ny, sc p trc tip ln tim gia ct sng v xng c s to ra tun
hon mu trong c th, ngha l khi p tim, cc van tim s ng li, cn trong th
tm trng nh lng ngc gin ra th ng lm tim cng gin v cc van 2 l v 3
l t ng m ra nh bnh thng.
Trong nhiu nm, vic gii thch ny c coi l tho ng, nhng nhng
nghin cu v siu m tim hoc l quay phim ng mch ngi ta thy cc van
tim khng cn hot ng hiu lc trong p tim ngoi lng ngc. Vic ng m
ca n khng cn u n v ng nhp vi p tim. Do vy kt qu ca tun hon
mu trong p tim ngoi lng ngc cn ph thuc vo nhiu yu t khc na.
+ Thuyt bm lng ngc:
Thuyt ny ngi ta khng tha nhn sc p trc tip ln tim l tc nhn ch
yu to nn tun hon mu, m c ch chnh l do thay i p lc trong lng
ngc. Tim v cc mch mu ca phi trong khi p c vai tr nh mt ng dn
th ng, ton b th tch tim v cc mch mu phi to nn mt b cha mu.
Khi p tim th p lc trong lng ngc tng lm dn p mu chuyn ng xui
chiu trong h thng ng dn th ng . Mu khng th pht ngc vo cc
tnh mch ln c l do c cc van tnh mch sinh l ca tnh mch ch trn v
tnh mch ch di. T rt nhiu nhn xt thc nghim v lm sng khng
nh l thuyt ny v t gia nhng nm 80 ca th k 20 n c mi ngi
chp nhn.
+ B sung c 2 l thuyt trn:
Thuyt v bm tim v bm lng ngc dng nh l tri ngc nhng li b
sung cho nhau. Nhiu cng trnh thc nghim ch ra rng, khi thc hin hi
sinh tim phi s c mt hoc nhiu c ch cng tham gia. Trn m hnh thc
nghim ngng tim ln, ngi ta thy nu tng lc p th c ch p trc tip ln
tim cng tr nn r rng hn. Ngc li khi s dng lc p thp th tun hon ch
yu da vo c ch bm lng ngc. Halperin v cng s s dng siu m tim trn
ch cho thy nh hng ca chu k h hp ln hot ng ca van hai l, nu
lc p ng vo cui th th ra van 2 l s ng v ngc li n m khi p tim
ng th ht vo. Paradis v cng s o chnh lch p lc gia cc bung
tim, ng mch cnh gc v ng mch cnh trong, trong qu trnh hi sinh tng
hp ko di. Cc ng nhn thy rng: ch yu c ch bm lng ngc to nn
dng mu tun hon trong cc mch mu, ngoi ra lc p trc tip vo tim cng
kt hp to nn tun hon mu. iu ny minh ha rt tt cho kh nng phi
hp ca 2 l thuyt trn trong thc hnh lm sng p tim ngoi lng ngc.
* Hiu qu ca p tim ngoi lng ngc:
Hiu qu ca p tim ngoi lng ngc thng l rt hn ch so vi lu lng
tim ca tun hon t nhin. Theo cc m hnh thc nghim trn ng vt hoc

nghin cu ngi th hiu qu huyt ng khi p tim ngoi lng ngc l rt thay
i. p tim ngoi lng ngc rt ng cng ch t 20 - 30% lu lng bnh thng
ca tim, do gim rt nghim trng tun hon cc c quan, c bit l tun
hon vnh (y l iu ct yu to nn s hi phc ca hot ng tim) hoc l
tun hon no (iu quyt nh c bn cho tin lng v thn kinh). nh ca p
lc ng mch khi p tim ngoi lng ngc him khi vt qu 70mmHg. Nh vy
tun hon ca p tim ngoi lng ngc l khng , mong manh v khng th snh
c vi b p c hiu qu ca tun hon t nhin. Da trn cc l lun ny
c rt nhiu ci tin k thut c xut nhm ci thin hiu lc ca hi sinh
tim - phi.
* Cc th nghim ca p tim ngoi lng ngc:
+ Tng lc v tn s p tim chun:
Trn thc nghim, lu lng tim c ci thin bi s tng lc p. ngi lc
p tt nht l lm lng ngc ln xung c t 4 - 5 cm. Ngc li tc
dng ca tng tn s p tim th t hiu qu hn: tn s trn 120l/pht khng lm
ci thin lu lng tim. Ni chung tn s p c quy nh khong 80 - 100l/pht
s m bo lu lng tim tt nht v cho 2 t l cn xng gia thi gian p v
gin l khong 50%.
+ p tim bng dng c:
c gng ci thin k thut v tn s u n ca p tim ngoi lng ngc,
ngi ta ch ra nhiu thit b p tim. Ni ting nht l Thumper c cu to
vi 1 piston hi do p lc ca bnh oxy cung cp. Lc p v nng lng ngc c
to ra nh piston v c th iu chnh ln ca piston ny d dng. My c
ci t chng trnh c 5 ln p s c thi gian tng xng cho 2 ln thi
vo chm ca my th. Tn s p 80 - 90l/pht. Mc d vy hiu qu lm sng
ca kiu my ny ch t c i vi mt vi loi bnh nhn. My t ra rt hu
ch cho nhng trng hp phi hi sinh tim phi ko di v trong cc m hnh
thc nghim.
+ p tim v thi ng nhp:
K thut c a ra sau nhng nm 1980, ngi ta tin hnh thi kh vo
trong phi cng lc vi p lng ngc, bng cch lm tng p lc trong lng
ngc. Thc nghim trn ng vt cho thy k thut ny lm tng lu lng mu
no. Trn lm sng, k thut ny i hi bnh nhn phi c t ni kh qun
(NKQ) v thng kh phi nhn to bng my. Tuy nhin theo Kirsher khi p dng
phng thc ny cho nhng bnh nhn c hi sinh ngoi bnh vin khng thy
c ci thin thi gian sng d. Trn thc t n l c s ngi ta chp nhn hin
tng khng ng nhp gia my th v p tim ngoi lng ngc.
+ p bng ngt qung:
K thut ny p bng phi hp khi gin lng ngc trong p tim ngoi lng
ngc nhm mc ch lm tng dng mu tnh mch tr v v cng lc lm
tng p lc quai ng mch ch, u tin tun hon khu vc na trn ca c th.
p bng ngt qung c p dng trn ngi bi Sack v cng s trong cc
trng hp hi sc ngng tim t ngt bnh vin. Cc tc gi thy s ci
thin ng k tin lng ca bnh nhn. Tuy nhin phi ghi nhn rng, trn lm

sng k thut ny kh thc hin bi v n cn t nht l 3 ngi cp cu v phi

phi hp ht sc hi ho. N bt buc cc bnh nhn phi c t NKQ v
thng kh nhn to trnh nguy c ht vo ph qun cc cht nn tro ngc.
- p v nng tch cc:
l th nghim mi nht ci thin p tim ngoi lng ngc, n s dng
mt gic ht c t trn ngc p tim ngoi lng ngc. N cho php sau khi
p ngi cp cu s ko gic ht nng ch ng lng ngc nn nhn ln. Th
nng tch cc ny tng ng vi th tm trng ca tim, do lm tng y
mu vo cc bung tht nh tng dng mu tnh mch tr v v lm tng lu
lng tim ln p tip theo. Cohen v cng s quan st cc bnh nhn ngng
tim - phi ko di bng siu m v thy c tng lu lng tim, tng kch thc
cc bung tht v nh phi trong th nng tch cc lng ngc. Vic tng lu lng
tim ny i km vi tng ng k p lc ng mch ngoi vi. Cc kt qu thc
nghim tng t ch cho thy phng php ny cn gy tng hiu qu thng
kh do c ng tch cc lng ngc th gin th ng. Tuy nhin, trc khi ph
bin vic s dng k thut ny cn c cc kt qu thm d v ci thin t l cu
sng cng nh tc dng trn tun hon ngoi vi, no v c tim. i vi ngi gy
th khng thc hin c v khng gn c gic ht.
+ o hi sinh tim phi:
l mt loi o hi c bm phng ngt qung tng hi,nh vy s to ra
hin tng tng ngt qung p lc trong lng ngc, nh p lc ca quai ng
mch ch v p lc ti mu mch vnh s cao hn so vi p tim ngoi lng
ngc. K thut ny c thc hin trn ng vt t nhiu nm nhng cha c
p dng rng ri trn ngi, hiu qu ca n i vi kh nng cu sng bnh
nhn phi tip tc c xc nh.
3.1.2.4. Bp tim trong lng ngc:
Bp tim trong lng ngc lm tng t l cu sng vi chc nng no tt hn,
nht l trong phng m, trong bnh vin, thm ch bp tim trc tip ti 2,5 gi
sau ngng tim m vn cu sng c bnh nhn. Bp tim trc tip lm tng p
lc ti mu no v tun hon vnh hn so vi p tim ngoi lng ngc. V th d
lm cho tim p li nhanh hn v cho php quan st trc tip tnh trng tim, d
cho thuc, dch truyn v c th lm sc in trc tip. Ngoi ra m ngc p tim
cn cho php cm mu trong ngc, kp mch mu tm thi khi cp cu, trong
cc trng hp ngng tim - phi do tn thng cc mch mu ln.
* Ch nh:
Ngng tun hon trong bi cnh:4
- m ngc sn trong khi m.
- Nghi ng chy mu trong lng ngc.
- Chy mu ln trong bng cn phi m ngc cp ng mch ch ngc
thp v bp tim.
- Tc mch phi ln .
- Ngng tim do h thn nhit (m ngc cho php lm m tim trc tip).

- Khng th p tim ngoi lng ngc (bin dng lng ngc hoc kh ph
thng nng).
- p tim ngoi lng ngc 5-10 pht m khng kt qu th tu theo kinh
nghim v iu kin ca tng ni, tng thy thuc m quyt nh cho hp l.
* K thut:
t NKQ th my p lc dng ngt qung (IPPV) hoc vi PEEP (p lc
dng cui th th ra). Rch da khoang lin sn 4 hoc 5 bn tri, ct c lin
sn bng ko Mayor (trnh b mch thn kinh lin sn), m rng lin sn.
Bp tim ngay khng cn m mng ngoi tim, bp khong 1ln/giy. Ngi thy
thuc ng bn tri bnh nhn, t bn tay bn tri pha sau tht tri, tay kia
pha trc tht phi, trong khi bp tim trnh bp tm nh, nu khng nhn r tm
tht th c th m mng ngoi tim bp, c th tim trc tip adrenalin vo
bung tht tri, nu cn c th kh rung tht bng 2 in cc trong qua gc tm
HTM 9%0, (1cc t sau tim ngay tht tri v in cc kia t tht phi), sc
in bt u bng 0,5 J/kg (cng c th nh sc ngoi lng ngc khi m lng
ngc). Trong trng hp tc mch phi th m ngc bp tim c th lm thot
c cc nghn.

3.2. Hi sc tim - phi chuyn su:

Mc ch l thit lp trong khong thi gian ngn nht tun hon t nhin c
hiu qu, khc phc ti a hu qu thiu oxy ca tim, no. Khc vi hi sc tim
phi c bn, hi sc tim - phi chuyn su ch c thc hin vi kp hi sc
c o to chuyn khoa v s dng tt cc k thut hi sc hin i. N gii
quyt tt nht mi lin quan cht ch ph thuc ln nhau gia h hp v tun
hon. Sau y l cc k thut u tay v c xp di dng cng thc thc hnh.

3.2.1. Ph rung tht sm:

Cn ghi in tim 1 o trnh bit ngng tun hon trng thi v tm thu,
rung tht hay l phn ly in c.
Rung tht l ngun gc ca a s cc trng hp ngng tim - phi t ngt
ngoi bnh vin ngi ln, cho nn ph rung tht l vic lm u tin v c hiu
qu nht ca hi sc tim - phi chuyn su. Vic u tin ph rung tht sm s ci
thin quan trng tin lng cp cu, do hin nay cc nhn vin cp cu hi sc
c trang b my ph rung bn t ng.
Mc ch ca vic ph rung l kh cc mt lng ng k cc t bo c tim
cho php lp li mt hot ng in phi hp ng b ca c tim. Nu s
dng mt nng lng qu thp s khng t hiu qu v ngc li, mt nng
lng qu mnh c th lm tn thng c tim cng nh l lm mt c may c th
hi phc tr li hot ng ca tim. V th nn bt u ph rung vi mt ngun
in nng tng i thp ri tng dn. Bt u t 200J ri nhc li mt ln 200J
na, nu khng kt qu tip tc tng ln 300J ri 360J. Mun t c hiu lc
ph rung phi thc hin k thut chun xc. Hai bn in cc phi c t ng:

thng thng l di n phi v nch tri hoc vng mm tim. Kch thc in
cc phi ln t 8 - 12cm2 v c ph mt lp kem dn in, phi p cht din
in cc vo mt da ca bnh nhn khi nh sc. Nu cc iu kin ny khng
c tn trng th in tr lng ngc s tng ln ng k lm gim hiu qu iu
tr ca sc in v gy bng da ti ch. Khi nh sc phi tho dy in tim t
bnh nhn ni vi my. m bo an ton, ngi nh sc phi i gng cch
in v ng trn bc g v khng chm vo ging bnh nhn.

3.2.2. t ni kh qun:
t ni kh qun l phng php kim sot ng th hu hiu nht trong cp
cu ngng tim - phi. N cho php va bo v ng th va h hp nhn to vi
mt nng oxy cao. C th dng ng ni kh qun cho adrenaline trong
trng hp khn cp cng c th dng masque thanh qun thng kh nhn to
nu ngi cp cu khng quen t NKQ hoc khng c dng c.

3.2.3. Thng kh nhn to:

C th thng kh nhn to bng 1 bng cao su ni vi ni kh qun hoc bng
my th t ng. Nu dng my th th chnh tn s th 12 ln/pht v th tch
lu thng 10ml/kg. Nu bnh nhn c ng NKQ th khng bt buc phi xen k
p tim ngoi lng ngc vi th my th bm kh vo.

3.2.4. Dng thuc cp cu:

3.2.4.1. Adrenaline:
Adrenaline l thuc c bn ca hi sc chuyn su, ch yu l nh tc dng
. adrenergic khi phc kh nng co bp ca c tim, do ci thin tnh hiu qu
ca p tim ngoi lng ngc. N lm tng p lc tin tm trng quai ng mch
ch, l yu t quyt nh n tun hon vnh. Adrenalin lm ci thin lu lng
mu no bng phn phi dng mu ng mch cnh gc u tin cho ng mch
cnh trong. Nh vy, ch n gin p tim ngoi lng ngc tt kt hp vi tim
adrenaline s c hiu qu hn so vi cc k thut phc tp khc nu trn.
Kinh in, vi ngi ln liu adrenaline l 1mg nhc li c 3pht/ln. Gn y,
mt vi cng trnh ngh s dng liu adrenaline cao hn. Brunette v cng
s tin hnh thc nghim trn ch kt lun rng, dng liu ln adrenaline ngay
t u cho php lp li tun hon t nhin nhanh hn, huyt ng tt hn v thi
gian sng d cao hn. Gonzalez v cng s s dng liu cao adrenaline trong cp
cu ngng tim - phi khng cn p ng vi cc iu tr thng thng ngoi
bnh vin, thy c tng p lc ng mch ng k khi p tim ngoi lng ngc vi
liu adrenaline 5mg tnh mch.
Do vy hng dn hin nay (nm 2000) ca Hi tim mch M v Hi hi sc
Chu u l dng liu u tin 1mg, c sau 3-5 pht nhc li 3 ln m khng hiu
qu c th dng liu 3mg/1ln v cng nhc li sau 3 pht.
ng dng: ng tnh mch l ng c chn la u tin. Nu bnh
nhn c sn 1 ng tnh mch trung tm th dng ng ny v thuc s vo

tun hon nhanh nht. Nu khng c sn ng tnh mch trung tm th nn t

mt ng tnh mch ngoi vi, v s nhanh hn v t nguy him hn (adrenalin
liu 1mg hoc 3mg pha long trong 20ml huyt thanh mn 9%o tim tnh mch,
trong khi tim cn nng cao chi th ni tim thuc ln v cho dch chy nhanh ln
nu tim qua dy truyn dch t sn y nhanh thuc v tun hon chung).
C th dng ng ni kh qun nu khng t ng truyn tnh mch c
ngay. Khi phi dng liu cao hn gp 2 ln liu tim tnh mch, pha vo 5ml
NaCl 0,9%. Sau khi bm thuc vo ng NKQ phi bp bng 2 nhp y thuc
vo su. C th bm thuc qua 1 dy ht a qua ng NKQ n tn ch chia 2
ph qun gc. Nng nh adrenaline trong mu khi dng ng ni kh qun
thp hn, chm hn v ko di hn so vi dng ng tnh mch. V th khng
nn bm vo ng ni kh qan lp li nhiu ln. Vn cn nhiu iu bn ci v
hiu qu ca adrenaline bm vo ng ni kh qun v nng adrenaline ngm
vo trong mu khng n nh v c th rt thp.
Cc thuc vn mch khc: hin nay khng c mt lun c no ng h vic
thay th adrenaline bng 1 thuc vn mch khc. Cc thuc co mch c tnh kch
thch alpha n thun (nor adrenaline) khng cho kt qu tt hn adrenaline trong
cc nghin cu lm sng. Trong iu tr v tm thu ngi ta cng khng dng
isoprnaline v l 1 thuc c kch thch beta n thun.
3.2.4.2. Cc thuc kim ho:
Vn s dng cc thuc kim ho trong cp cu ngng tim - phi cn
nhiu quan im tri ngc. Hin nay cc xt nghim phn tch cn bng axit baz rt hon thin, cho bit tnh trng cn bng axit - baz trong iu kin tun
hon bnh thng, nhng n s khng phn nh ng cn bng axit - baz ca t
chc v nht l trong t bo khi c ngng tun hon. Ngi ta thy rng trong
khi cc kh mu ng mch l bnh thng hoc thm ch th hin mt nhim
kim h hp th c th vn tn ti mt nhim toan vi trng thi u thn mnh
trong mu tnh mch. iu ny c gii thch bi tch t CO2 trong cc m
ngoi vi m nguyn do l lu lng tim gim, lm mu khng th vn chuyn
CO2 v tun hon phi, kt qu l nhim toan h hp hoc hn hp. Nhim toan
t chc, c bit l c tim cn cao hn so vi toan mu tnh mch o c.
Vic iu chnh tnh trng nhim toan ny bng bicacbonat l khng c c s
sinh l bnh chc chn m ch khi tun hon mu hu hiu c khi phc to
iu kin o thi nhanh v nhiu CO2 th cn bng axit - baz s c b p n
nh. Nhim toan mt mc nht nh cha phi l c hi lm ti c th v
cha cn can thip hi sc. N khng lm thay i tin lng sng v cng
khng cn tr vic ph rung tht thnh cng hoc nh hng n hot tnh ca
adrenaline. Ngc li, qu ti bicacbonat c nhiu nguy him hn (v nhim kim
lm chuyn dch ng cong phn ly oxyhemoglobin dn ti nhim toan ni bo,
nht l trong t bo no v c tim, gy ra tng thm thu v tng Natri mu v
cui cng lm bt hot adrenaline) v vy khng nn iu chnh qu mc tnh
trng nhim toan trong ngng tim - phi.

Cc thuc kim ho khc nh THAM (tri - hydroxymethyl - aminomethane),

carbicarb hoc tribonate c sn sinh hoc khng sn sinh CO2, khng c u
chung hn bicacbonat c trong thc nghim cng nh trn lm sng.
Hi hi sc cp cu Chu u chp nhn mt quan im d dt sau: khi
khng c bng chng v mt nhim toan r rng tn ti trc lc ngng tim phi th khng cn s dng bicacbonat, cn trong trng hp ngng tim ko di
qu 15 pht hoc khi phn tch kh mu ng mch v tnh mch thy r mt pH
mu ng mch thp hn 7,1 v BE < -10, th ch nh dng liu bicacbonat
(50ml 8,4%) nhng khng vt qu 1mEq/kg v nhc li 1/2 liu trn sau 10 pht
trong sut thi gian hi sinh tng hp. Liu cao hn, ngc li khng c hiu qu
v cn nguy him. Cc thuc kim ho c dng tt nht l sau khi tim t
p li v iu chnh theo xt nghim cn bng axt - baz.
3.2.4.3. Thuc chng lon nhp:
Cc thuc chng lon nhp dng iu tr rung tht khng sc in khng phi
bao gi cng hu hiu v khng phi l khng c tc dng ph.
Lidocaine l thuc thng c dng v n lm tng ngng ph rung nhng
hiu qu ca n cha hon ton c chng minh. Sau khi ph rung tht bi v
dng adrenaline, dng lidocaine 1,5mg/kg tim tnh mch v c th tim nhc li
nu cn, sau duy tr gi git tnh mch liu 4 mg/1pht trong 30 pht sau
gim xung 2 mg/1pht trong 2 gi ri 1 mg/1pht tip theo.
Brtylium tosylate (brtylate) liu 5mg/kg tim tnh mch ch nh trong
trng hp tht bi vi lidocaine, nhng hiu qu ca n cng cha c chng
minh v thuc ny c nhiu tc dng ph ng k trn huyt ng.
3.2.4.4. Atropin:
L thuc c hiu lc trong trng hp v tm thu hoc nhp rt chm (dng
phi hp vi adrenaline), liu dng l 1 - 3mg tim tnh mch (tng liu l
0,05mg/kg).
3.2.4.5. Calcium:
Dng calcium l v ch v thm ch c hi; ch dng khi c gim calcium
mu trc hoc ng c thuc i khng calcium hoc c tng kali mu > 6
mmol/l th cho 10 ml canxiclorua 10% tim chm tnh mch.
3.2.4.6. Magnesium sulphat:
Ch s dng khi h kali mu v cho10 ml dung dch magnesium sulphat 50%
tim chm tnh mch.
3.2.4.7. Amiodaron (cordaron):
L thuc chn knh kali c tc dng chng rung tht, d phng rung tht, v
dng trong khi ngng tim. Dng liu 900 mg amiodaron pha trong 1000 ml HTN
5% gi git tnh mch trung tm trong 24 gi. Trong trng hp khn cp c th
dng ngay liu u 300mg tim chm tnh mch ngoi bin trong thi gian t 5
pht n 15 pht v tip theo dng liu nh trn.
3.2.4.8. To nhp tim:

Ch nh ca to nhp tm thi l nhp tim chm khng p ng vi thuc.

To nhp tm thi trong khi cp cu v tm thu, d c thc hin tht sm cng
khng c hiu qu.
3.2.4.9. Khi phc khi lng tun hon (KLTH):
Vic phc hi khi lng tun hon rt cn thit trong trng hp c gim
khi lng tun hon mt cch r rng, nht l ngng tim do gim th tch mu
lu thng . Qu ti KLTH khng lm ci thin lu lng tim trong p tim ngoi
lng ngc. Vic truyn dch khng hon ton l c hi nhng phi thn trng v
chng mc. Dch truyn thng c s dng nht l huyt thanh mn ng
trng (hoc ringerlactat), liu truyn va phi < 500ml. Nn trnh dng dung
dch glucose nht l glucose u trng v tc dng c hi gy tng ng mu,
toan chuyn ho, c th s dng glucose 5% trong cp cu.

3.3. Hi sinh no - duy tr s sng lu di (prolonged life

support):
+ Sau ngng tim ko di s xut hin hi chng no sau hi sinh (the cerebral
postresuscitation syndrome) gm 8 ri lon cn phi d phng iu tr:
- Thiu nng lng ATP.
- Suy yu bm ion ( do ph trong t bo ).
- Toan ho t chc .
- Gim ti mu (do gim oxy).
- Nhim c thn kinh gc t bo.
- Cc gc t do tng sinh.
- Phn ng ph n t chc .
- Ri lon cc c quan ngoi no ( nhim c cc tng do thiu oxy ) .
+ Cc bc tin hnh nh sau:
- Sau khi tim p li cn gi huyt p tng nh sau duy tr huyt p bnh
thng (huyt p trung bnh 90-100mmHg) bng dch truyn, thuc co mch
hoc gin mch.
- Thng kh phi nhn to lin tc.
- Duy tr CO2 mu bnh thng hoc gim nh (tng thng kh va phi:
PaCO2 = 30-35mmHg).
- Cho tng oxy t: PaO2 100mmHg.
- Duy tr pH ng mch 7,3 - 7,5 bng NaHCO3.
- Bt ng bnh nhn nu giy qu bng diazepam, bacbituric, mocphin.
- Chng co git (diazepam, phenytoin).
- Duy tr Hematocrite, in gii, ng mu, p lc thm thu bnh thng
- Corticoid cho liu thp
- Duy tr thn nhit 34-350C ngay sau khi cp cu trong thi gian 12 gi. (H
thn nhit lm gim gc t do, gim nhim c ni sinh, tng d tr ATP, lm
cn bng vn chuyn ion qua mng, lm gim tiu th oxy).

- iu tr tch cc cho tt c cc tng khc.

- t u t th hi cao, tr mnh thng xuyn.
C nhiu bin php iu tr chng li hin tng thiu mu no. ngi,
khng c mt th thuc no c dng trong lc ngng tim phi cho php ci
thin tnh trng thn kinh. Cc bacbituric (c bit l penthotal) b loi b t
khi cng b cc kt qu ca th nghim hi sc no (Brain Resuscitation Clinical
Trial), v khng c s ci thin thi gian sng d.
Mi y cc cht c ch canxi tr thnh mc tiu thc nghim ca nhiu
trung tm vi nhng kt qu y ha hn. Nimodipine c s dng trn ngi
trong ngng tim phi ngoi bnh vin, cc kt qu s b l kh quan. N ci thin
c thi gian sng d ca cc trng hp c rung tht m vic cp cu b mun.
Tun hon ngoi c th (CEC) cng c ngh nhm hn ch tc dng ti
qun mu no. Martin v cng s tin hnh CEC trn ch b rung tht v nhn
xt nh tun hon ngoi c th, vic ph rung tr nn d dng hn nhiu v tin
lng tt hn hn so vi hi sc kinh in. Rt tic vic p dng trn ngi trc
mt ch gii hn mt vi trung tm ngoi khoa tim mch.
Phi nh rng ch c tnh khn trng, hiu qu ca hi sc ngng tim phi
c bn s m bo tt nht cho tin lng thn kinh. Sau khi lp li tun hon t
pht th vic iu tr triu chng s trnh c ph no trm trng. Cn phi n
nh huyt ng sm, c bit trnh tt huyt p ng mch (nguyn nhn ch
yu gy thiu mu no) cng nh cc hin tng tng ng mu, tng thm
thu, tng thn nhit v co git.... l cc ngun gc lm trm trng thm cc
tn thng thn kinh ca no.

3.4. Theo di trong cp cu ngng tim phi:

3.4.1. Theo di trong khoa hi sc hoc phng m:

1 bnh nhn ang c theo di bng phng php xm nhp (invasive)
c th da vo huyt p do trc tip trong ng mch nh gi hiu qu ca
ETNLN. Tuy nhin, huyt p ch l 1 trong cc thnh phn xc nh p lc
ti mu mch vnh. Ti mu vnh l ch s quyt nh tin lng v hiu
qu ca hi sc.

3.4.2. Theo di khoa khng chuyn su hoc ngoi bnh

vin:
Nu ngng tim xy ra 1 ngi khng c theo di, v d ngoi bnh vin
cn nh gi cc d kin n gin bng phng php khng xm nhp (non invasive). l s mch trong khi p tim ngoi lng ngc (ETNLN), quan st
trng thi bnh nhn v o in tim cng sm cng tt. o CO2 trong kh th ra
(capnomtrie) l phng tin theo di b sung duy nht hu ch trong trng hp
ny. Do CO2 ng m v h tnh mch trong lc ngng tim, khi tim p li s

c hin tng tng thi CO2 lng ln. Trong khi cp cu ngng tun hon lng
CO2 th ra gip nh gi hiu qu ca ETNLN. Trong trng hp ny o CO2
cui th th ra (ET CO2) c th c gi tr tin lng v cc bnh nhn sng st c
ET CO2 cao hn mt cch c ngha thng k so vi nhng ngi t vong. Tuy
nhin, theo di CO2 trong kh th ra c th gp nhiu vn : N b nh hng
bi bicacbonate tim tnh mch v bi nhng thay i ca thng kh nhn to.
Ngoi ra, ngi ta cng nhn thy khi dng adrenaline liu cao th ET CO2 gim
xung.

3.5. Khi no ngng hi sc tim - phi:

Khng c quy nh chnh xc no v vic ngng cp cu ngng tim - phi,
tuy nhin cn da vo cc yu t sau:

3.5.1. Thi gian ngng tun hon:

Ngi ta chng minh tin lng tu thuc vo phc hi tun hon t pht
nhanh hay chm. Tuy nhin, thi gian ngng tun hon rt kh xc nh nu
khng c nhn chng.

3.5.2. Tnh trng thn kinh ca bnh nhn trong qu trnh hi

sc:
Khng nn da vo ngng hi sc sm. Gin ng t 2 bn khng nht
thit l du hiu ca tn thng no khng hi phc v khng c da vo du
hiu ny nn ch hoc ngng cp cu.

3.5.3. Tnh trng sinh l v tin cn ca bnh nhn:

Thng khng r v kh xc nh lc cp cu.

3.5.4. Cc khuyn co hin nay:

a s cc khuyn co cho rng ch nn ngng hi sc nu bnh nhn vn v
tm thu d hi sc cp cu trn 30 pht v tt c cc bin php hi sc u
c thc hin v thc hin ng. Tuy nhin, iu ny khng p dng cho cc
trng hp c yu t bo v no lc ngng tim. l trng hp h thn nhit
hoc ng c thuc ng bacbituric; khi phi tip tc ko di cc n lc hi sc
v vn c th thnh cng. Quyt nh ngng hi sc l 1 hnh vi y khoa do bc s
trc tip cp cu bnh nhn chu trch nhim.
4. T chc v c im ca cp cu ngng tim-phi tu theo ni xy ra.

4.1. Ngoi bnh vin:

Tin lng ca ngng tim ngoi bnh vin tu thuc ch yu vo thi gian t
lc ngng tim n lc phc hi tun hon t nhin. V vy cp cu cng sm th
tin lng cng tt.

4.1.1. Cc mt xch ca vic cu sng bnh nhn hay dy

truyn cp cu:
Gn y nhiu nghin cu cho thy c nhng iu kin nu c thc hin
sm s ci thin c tin lng. Cc iu kin ny to nn 4 mt xch ca 1 ''dy
truyn cp cu". Nu " dy truyn cp cu " din tin hon ton ng th c th
cu sng c trn 30% cc trng hp rung tht xy ra ngoi bnh vin.
+ Mt xch u tin l bo ng sm: bo ng nhanh nht cho cc i cp
cu. Bo ng nhanh v chnh xc l mt yu t c bn ginh thng li v thi
gian. Bo ng sm khng nhng cho php cc i cp cu ti nhanh m cn
mang n cc phng tin cp cu ban u ngay lp tc ph hp vi tnh hnh.
+ Mt xch th hai l nh nhng ngi c mt ti ch tin hnh cp cu.
Nhiu cng trnh cho thy tin lng ngng tim - phi s tt hn nu hi sc
c bn c tin hnh sm trc khi i cp cu ti. Tuy nhin iu ny i hi
phi c cng tc o to rng ri trong qun chng nhn dn nh thc hin
mt vi ni trn th gii. Cht lng ca vic o to ny thng l hn ch, nht
l vi kiu o to t xa. ci thin tnh hnh c hai gii php c ngh
mi y:
- o to cho chnh nhng ngi c nguy c v gia nh h: V d nh o
to cho cc gia nh bnh nhn b bnh mch vnh, c bit l i vi cc
bnh nhn c tin s rung tht v thm ch dy cho h bit cch ph rung
vi my t ng.
- Hng dn k thut hi sinh tim - phi c bn qua in thoi: Seattle v
Culey Eisenderg chun b sn cc ng in thoi ring, n cho php ngi trc
in thoi ca trung tm cp cu hng dn cho ngi gi n thc hnh ng
tc cp cu.
+ Mt xch th 3 l ph rung sm. Tin lng ca rung tht trc ht gn lin
vi s ph rung nhanh chng. T nhiu nghin cu thc nghim v lm sng vo
gia nhng nm 80 chng minh r iu ny. V vy cc nc Anh - M
ngi ta trang b cc my ph rung cho cc nhn vin cp cu c th can thip
ngay ti ch. Nh cng ngh pht trin, ngy nay c cc my ph rung c kh
nng t nhn bit rung tht: cc nhn vin cp cu s gn cc in cc trung gian
vo bnh nhn, my s t phn tch nhp tim v ph rung khi pht hin c rung
tht (my t ng hon ton), hoc ph rung do nhn vin cp cu trc tip s
dng (my bn t ng).

T , k thut ny c a vo p dng nhiu nc v em li thnh

cng ng k. Php vic p dng thng bo in tim qua in thoi cho bc s
v tin hnh ch o t xa k thut ph rung ang c xem xt v trong tng lai
cc my ph rung t ng c th s c trang b cho cc i cp cu.
+ Mt xch th 4, mt xch cui cng l hi sc chuyn su. Khng nn nh
gi qu cao mt xch ny bi v nu khng c mt kt qu hi sc hon ho trc
th khi bnh nhn n c vi k thut hi sc chuyn khoa qu mun.
Nhng cng khng nh gi thp n bi v trong trng hp rung tht c ph
rung thnh cng, s ti rung tht sm l rt thng gp, hn na tnh trng tim
mch c n nh sm s lun lun l iu cn thit cho mt tin lng kh
quan v bn vng.

4.1.2. Ngng tim - phi cc bnh nhn trong bnh vin:

Khi ngng tim phi xy ra t ngt mt khoa trong bnh vin khng c
theo di t trc th vic cp cu cng tng t nh ngoi bnh vin. Do vy
bnh vin cn t chc 1i cp cu c ng trang b my ph rung cng nh l
cc dng c khc cn thit cho hi sc chuyn khoa. Cc i ny s nhanh chng
n cp cu cc khoa ngay khi xy ra ngng tim - phi.
Vic cp cu ngng tim - phi trn mt bnh nhn ang c theo di v
thng kh nhn to s c nhng c im ring, trong trng hp ny, ngng tim
phi c th xy ra ngay khi t ni kh qun do phn x dy X, ri lon nhp tht,
t ng sai v tr. Ngng tim c th xy ra t ngt sau 1 bin chng huyt ng
i km tnh trng gim khi lng mu lu hnh hoc gin mch cp, tc dng
bt li ca cc loi thuc gy m, phm sai lm trong khi s dng cc kh gy m
bay hi, trn kh mng phi ln bnh nhn th my, nhng trc trc ca my
th, tc ng NKQ sau nhiu gi thng kh... Hi sc ngng tim phi bnh nhn
ang c thng kh cn thay i ngay tnh hiu qu ca thng kh. Nu lng
ngc khng phng ln, phi ngh ti mt trc trc hoc mt in my th v phi
thng kh ngay bng bp bng vi oxy nguyn cht. Nu my th m bo hon
ton tt cn ngh n tc ng ni kh qun hoc tt ng, trong trng hp ny
phi rt ng ngay lp tc v thng kh cho bnh nhn bng masque vi xy v t
li ng NKQ. Trng hp ng nm ng v lu thng tt phi ngh ti trn kh
mng phi, nht l khi bnh nhn ang th my c PEEP hoc vi p lc cao.
Trong trng hp ny cn phi chc ht kh mng phi bng bm tim trc khi
dn lu. Nu cc chn on trn u b loi tr th nn ngh n mt co tht
ph qun nghim trng.
5. cp cu mt s tnh hung ngng tim - phi c bit.

5.1. T chc cp cu ngng tim - phi:

Vi mc tiu chn on nhanh, p dng ngay v ng cc ng tc c bn
ca hi sc, nhanh chng a nn nhn n cc c s chuyn khoa hoc gi in,

i cp cu c trang b ti cp cu ti ch nn cc nc pht trin ngi ta

tin hnh cc phng php sau y:
- Gio dc cho ton th nhn dn qua cc lp o to ngn hn cc c quan,
trng hc, cc t chc x hi ... v cc kin thc chn on nhanh v ngng tim
- phi v cc ng tc cn thit phi lm khi gp nn nhn ngng tim - phi.
- T chc cc nhm cp cu lu ng kiu nh SAMU ca Php. Hoc cp
cu 05 H Ni, thnh ph H Ch Minh.
- T chc h thng bo ng cp cu nhanh v c hiu qu thng xuyn qua
in thoi.
- Cc bnh vin phi lun c mt nhm thng trc l cc bc s, y t hi sc
c trang b c th ngay lp tc ng cu hoc tip nhn cc bnh nhn b
ngng tim - phi cc khoa phng khc hoc t ngoi vo.

5.2. Ngng tim - phi trong chn thng:

Ngng tim - phi trong a chn thng thng kh hi sc v cn ch n
mt s im c bit sau y:
- B khi lng tun hon cng nhanh cng tt bng HTM 9%o, ringerlactat,
dch keo, mu, hai chn cao hoc mc qun chng sc.
- Nu c chn p trong lng ngc (trn kh, mu mng tim, mng phi) cn
phi c chc ht v dn lu ngay.
- Nu tn thng ty sng cao gy cng ph giao cm cn iu tr bng
atropin liu cao.
- Nu ngng tim - phi do tng kali cao t ngt vi toan chuyn ho do b
gip nt cc chi th hoc hi chng vi lp cn cho bicarbonat sm, v cho
canxichlorua.

5.3. Ngng tim - phi do ng c:

Nu ngng tim - phi c lin quan vi c ch h hp do dng cc thuc ng
bacbiturate, benzodiazepine hay cc thuc h morphine th ch cn hi sc
chuyn khoa theo kinh in l . Nhng nu c nhim c tim mch th cn c
iu tr c hiu hn. Tuy nhin trong mi trng hp h hp vi oxy 100% cng
hn ch c c tnh ca nhiu loi thuc.

5.3.1. Nhng im c bit ca ngng tim - phi do ng c:

* Ngng tim: - Tim atropine liu cao nu ng c photpho hu c.
- Tim thuc i khng nu ng c cyanuare (bng hydroxocobalamin)
hoc nu ng c bi cht c ch canxi hoc cc cht gn canxi (bng truyn
mui canxi).

* Nu c rung tht hoc nhp nhanh tht c tun hon khng hiu qu: iu tr
bng sc in, tim lidocaine hoc diphenyl hydantoine (ng c digitalis) nhng
cn cnh gic khng c nhm: rung tht vi xon nh; nhp nhanh tht vi
nhp nhanh trn tht c QRS gin rng.
* Nu c xon nh: iu tr yu t gy xon nh (h canxi mu, h kali
mu); tim magi; lm tng nhp tim bng my to nhp tim hn l bng
isoprenaline.

5.3.2. iu tr tip sau:

* Nu vn cn cc ri lon dn truyn:
- Nhp chm tim: tim atropin.
- Nghn nh - tht (bloc A-V): my to nhp tim hoc dng isoprenaline.
- Ri lon dn truyn trong tht vi QRS gin rng > 0,12 giy: tim mui
natri u trng (lactate hoc bicarbonate).
- Khong QT ko di l tin triu ca cn xon nh: iu tr h canxi mu
hoc h kali mu.
* Nu ri lon tnh kch thch ca c tim:
- Lidocaine trong trng hp ngoi tm thu tht a dng a hoc cn nhp
nhanh tht.
- Dng betabloquants (thuc c ch beta adrenergic) phng ti pht ca
nhp nhanh tht c lin quan vi hi chng tng adrenergic.
* iu tr suy tim: bng cch cho truyn thuc tng sc co bp c tim:
adrenaline, dopamine, dobutamine bng bm tim in.

5.4. Ngng tim ph n c thai:

Nhng ng tc c bn ca hi sc vn gi nguyn nh vi bnh nhn khc.
c bit vic dng adrenaline vn c ch nh nh bnh thng mc d c nguy
c lm co mch mu ca t cung-rau. Cn ch mt s im sau:
* Khi tin hnh p tim ngoi lng ngc phi k cao vng mng sn hoc
mng bn phi ca nn nhn y t cung sang pha bn tri v lm tng mu
tnh mch tr v.
* Nu nh thai c nhiu kh nng sng st phi chun b tin hnh m ly
thai cp cu trong khi vic hi sc tim - phi cn cha c hiu qu. Vic m ly
thai, nhanh trong vng 4-5 pht sau khi ngng tim s ci thin c hi sng st
ca c m v thai nhi. Nu cp cu tt sau khi m ngng tim ti 20 pht th thai
nhi vn c th sng st khng c di chng.

5.5. Ngng tim - phi do in git:

5.5.1. Nguyn nhn gy ngng tim:
* Ch yu l do rung tht nhng i khi ngng tim ngay (v tm thu).
* Thiu oxy ch yu do co cng cc c h hp.

5.5.2. Cc im c bit khi cp cu:

* Ngi cp cu trnh khng b cng ko vo tai nn in, phi trnh tip
xc vi ngun in, ct in, gi ngi chuyn mn v in nu l in cao th.
Tm mi cch a nn nhn ta khi ngun in cng nhanh cng tt.
* u tin ph rung tim mt cch h thng ngay lp tc.
* C nh ct sng phi c lm mt cch h thng v n c th gy v ng
cao hoc do co c qu mnh.
* m bo b dch ng tnh mch v cho bicarbonat nu chy bng do in
vo su ( ging hi chng vi lp hoc dp nt t chc ln).

5.6. Ngng tim - phi do cht ui:

* Ngi cp cu khng nn mo him khi c cu nn nhn di nc, cn
c phao hoc thuyn cu tr. Phi tin hnh cc ng tc s cu c bn d cho
bnh nhn b chm xung nc lu v thng c h nhit
* Cn c nh ct sng nu nghi c tn thng tu c do ng trc khi cht ui.
* Lng nc nm trong ng th thng t v nhanh chng b hp thu vo
h tun hon, do vy khng nn dc ngc nn nhn hoc ht ph qun lu i
khi gy nguy him, tuy nhin cn ht nc trong d dy, trnh gy cn tr
hot ng ca c honh.
* Sau khi hi phc c hot ng t ng ca tim c hiu qu, cho th
my vi p lc dng cui th th ra (PEEP) chng ph phi do tn thng.
* Cn phn bit cht ui nc ngt vi cht ui nc mn:
+ Trong cht ui nc ngt thng gy tha khi lng tun hon, tn
thng lp surfactant ca phi v cc ph nang c th xp gy tng hiu ng
shunt trong phi.
+ Cht ui nc mn thng thiu khi lng tun hon nhng cc ph nang
b lp y nc v xp phi gy tng hiu ng shunt trong phi.
Nhng hu qu chung vn l ph phi v thiu oxy do tn thng ph nang.

5.7. Ngng tim - phi nhit thp:

- Trc tin cn phi bit chn on ngng tim - phi trong iu kin tt nhit
nghim trng v bt u hi sc ngay khi nghi ng v hot ng ca tim kh
nhn bit do co mch.
- Ngng tim - phi nhit thp c c im: tt nhit lm tng kh
nng chu ng ca no vi thiu oxy (15 pht 25oC, 30 pht 20oC, 60 pht
15oC ).

- Tn s p tim ngoi lng ngc v thng kh nhn to phi gim i mt phn

t trong trng hp nhit tt < 28oC.
- Nu c rung tht th cn lm sc in. Tuy nhin rung tht th tr vi sc
in ngoi nu thn nhit di 30oC. Khi mt s tc gi cho rng c th dng
bretylium cho kt qu tt.
- Trc mt trng hp ngng tim - phi c tt nhit nghim trng cn
si m t trong (th kh m, ra mng phi hoc mng bng bng nc m 4042oC), c th m lng ngc bp tim trc tip v lm m tim trc tip. Vic p
dng tun hon ngoi c th cho php nng ti a 10-15oC/gi v n cn c ch
trnh phi p tim ko di, ngoi ra cn h tr c tun hon cho c th.

Bng 1 : cp cu ngng tim phi

(Theo cc khuyn co ca Hi Hi sc Chu u- European
ResuscitationCouncil).
C phn ng? Bng li v/hoc
vn ng.

Bo v, theo di v nh gi li
1 cch nh k.
Ku gi gip nu cn.

Khng
Th c hiu qu:
H hon gi ngi

+ Hnh ng A:

gip .
- Cho nm nghing t th an ton.
Gi (hoc nh gi) ngi gip.

Khng thy th c hiu qu,

Bt c mch:
Gii phng ng th.

+ Hnh ng B.

nh gi h hp.

- Thi h hp nhn to 10 ci/pht,

Kim tra mch.

(ming - ming).
- Gi (hoc nh gi) ngi gip.
- Tip tc h hp nhn to
ming - ming.

Khng bt c mch:
+ Hnh ng C:
- Gi (hoc nh gi) ngi gip.
- Bt u p tim ngoi lng ngc
(ETNLN).

Bng 2: Quy trnh iu tr rung tht v nhp nhanh tht

ng tc cp cu c bn:
ETNLN + h hp nhn to (1)

(1) Ch tm ngng cc ng tc
cp cu c bn trong thi gian
tht ngn kim tra mch, sc
in hoc thc hin cc k thut
hi sc khc

Sc in cho n 3 ci: 200J (2 ln)

300J, 360J

(2) Mch? Nhp? Nu rung tht

c thay th bng phn ly in
c hoc v tm thu th chuyn
sang quy trnh tng ng.

Mch? Nhp ? (2)

Tip tc cc ng tc cp cu c bn

(3) Nu tht bi c th tng liu

adrenaline ln 3 - 5 mg tnh
mch/3 pht 1 ln
(4) C th lp li lidocaine mi 5
pht
n tng liu 3 mg/kg. Nu tht
bi c th dng cc thuc
chng lon nhp khc
(5) Bicarbonate c ch nh tuyt
i trong trng hp c tng kali
mu hoc toan
huyt

c
t
trc,
bicarbonate c th c li khi
ngng tim ko di > 15 pht.
Sau liu u 1mmol/kg tim lp
li 0,5 mmol/kg mi 10 pht

t ni kh qun- t ng truyn tnh

mch

Adrenaline tnh mch 1mg/3pht (3)

Mch? Nhp ? (2)

Tip tc cc ng tc cp cu c bn

Sc in 360J n 3 ln nu cn
Mch? Nhp ? (2)
Tip tc cc ng tc cp cu c bn

Lidocaine tnh mch 1,5 mg/kg (4)

Sc in 360J n 3 ln nu cn
Mch? Nhp ? (2)
Tip tc cc ng tc cp cu c bn
Bicacbonate tnh mch 1 mmol/kg (5)

Bng 3: Quy trnh cp cu v tm thu.

Cc ng tc cp cu c bn:

(!)

ETNLN+ h hp nhn to (1)

Ch ngng cc ng tc cp cu
c bn trong thi gian tht ngn
kim tra mch, sc in hoc
thc hin cc th thut hi sc
khc.

Loi tr rung tht: kim tra li

(2) Nu nghi ng th sc in.

in cc, dy cp... (2)

t ni kh qun, t ng
truyn tnh mch

(3) Nu tht bi c th tng liu

adrenaline ng
tnh mch
5mg /3 pht.
(4)

Nu v tm thu c thay th bi
1 bnh cnh khc chuyn sang
quy trnh tng ng.

Adrenaline ng tnh mch

3mg /3 pht (3)

(5) C ch nh tuyt i trong trng

hp c tng kali huyt hoc toan
huyt c t trc. Bicarbonate
c th c li khi ngng tim ko di
(>15 pht). Sau liu u 1
mmol/kg tim lp li 0,5 mmol/kg
mi 10 pht.

Mch? Nhp ? (4)

Tip tc cc ng tc cp cu c bn

Bicarbonate 1mmol/kg tnh mch (5)

Mch? Nhp ? (4)

Tip tc cc ng tc cp cu c bn

Bng 4: Quy trnh cp cu cc lon nhp khng c mch khc (1)

Cc ng tc cp cu c bn:
ETNLN + h hp nhn to (2)

(1) Cc lon nhp khng c mch

(2)

t ni kh qun - t ng truyn
tnh mch

Xem xt gii quyt ngay nguyn

nhn sau: (3)
* Gim khi lng tun hon.
* Trn kh mng phi c p lc.
* Chn p tim.
* Ng c thuc c ch co bp c tim.
* Tng kali mu, toan huyt.
* Tc mch phi, nhi mu c tim rng.
* H thn nhit

(3)

(4)
(5)
(6)

Adrenaline 1mg/3 pht tim tnh mch (4)

Mch? Nhp ? (5)

Tip tc cc ng tc cp cu c bn

Atropine nu nhp chm:

1 mg tim tnh mch (6)

Mch? Nhp ?
Tip tc cc ng tc cp cu c bn

Bicarbonate 1 mmol/kg tnh mch

Mch? Nhp ?
Tip tc cc ng tc cp cu c bn

(7)

khc gm: phn ly in c,

lon nhp chm, nhp t tht
sau sc in ph rung.
Cc ng tc cp cu c bn
ch c tm ngng trong thi
gian tht ngn kim tra
mch, sc in hoc thc hin
cc th thut hi sc khc.
Gim khi lng tun hon: b
dch, trn kh mng phi c p
lc: chc ht ph mc gim
p; ng c thuc c ch co
bp c tim; iu tr sc tim,
tng kali mu, toan huyt:
bicarbonate; tc mch phi,
nhi mu c tim: nong mch
vnh, thuc tiu si huyt,
chng h thn nhit.
Nu tht bi tng liu
adrenaline ln 3 - 5 mg 1 ln /
mi 3 pht.
Nu xut hin v tm thu hoc
rung tht th chuyn sang quy
trnh tng ng

Thuc vn mch v cng tim

dng trong hi sc cp cu
Trn Duy Anh

1. Cc th th adrenergic ca h thng tim mch.

Cc thuc tim mch s iu chnh hot ng ca tim, mch, kh ph qun v
trng lc c trn ca ng tiu ho thng qua cc h th cm adrenergic. C 3
nhm th cm th h adrenergic.
+ - adrenergic (1 v 2).
+ - adrenergic (1 v 2).
+ dopaminenergic.
Cc cathecholamine c nhng i lc kt gn khc nhau vi cc th cm th h
adrenergic.
Bng 1:
Cc amine
giao cm

Epinephrine
(adrenalin)
Norepinephri
ne
(levophed)

Liu tim tnh

mch thng
thng

Hiu qu trn h th
cm adrenergic

Nguy c
gy lon
nhp

0,5 - 1mg
1 - 200g/pht

+
+ +

++
+ ++

++ +
+++

2 - 80g/pht

+ ++

++

++

1 - 2g/kg/pht
2 - 10g/kg/pht
10 - 30g/kg/pht

+ (*)
++
+ +
+ ++

+
++
+ ++
+ +

Dobutamine
(dobutrex)

2 - 30g/kg/pht

+
++
+ ++
+

Isoprotereno

2 - 10g/pht

+ ++

+ ++

2 - 15g/kg/pht

0 (**)

+ +

Dopamine
(intropin)

l
(isuprel)
Marinone
(inocar)

(*) Tng dng mu thn.

(**) phosphodiesterase inhibitor-cht c ch men phosphodiesteraza.

Cc th cm th 1 c vng sau xinp ca tim, cc nron thn kinh v cc
c trn mch mu. Kch thch cc receptor 1 mch mu s dn ti co mch.
Cc th cm 1 c tim lm tng va sc co bp c tim v chm nhp tim. Hiu
lc tc dng ca cc thuc nhm adrenergic trn 1 - receptor theo th t tng
dn: phenylephrine, norepinephrine v epinephrine.
Cc receptor trn xinp 2 iu chnh trng lc mch mu cc mch mu
ln v to thnh mt c ch iu chnh i khng vi tc dng ca cc 1 receptor. Khi nhng 2 - receptor b kch thch n s hn ch tch ly
norepinephrine. h thng thn kinh trung ng, s kch thch cc 2 - receptor
s c ch cung phn x vn mch dn ti gin mch ngoi vi. Cc receptor 2 sau
xinp cng c th gy co cc tiu ng mch v tnh mch.
Kch thch cc 1 - receptor lm tng nhp tim v tng sc co bp c tim. Kch
thch 2 - receptor s lm gin mch, gin c trn ph qun, niu qun v ng tiu
ho. 2 -receptor cng hot ho chuyn ho m, phn hu glycogen v a ion
kali vo trong t bo gy gim kali mu. Hiu qu ny c th ng vai tr quan
trng trong iu tr lon nhp tim khi c thiu mu c tim v c th gii thch cho
hiu qu u vit ca nhm c ch d phng cc bin chng cp v th pht
sau nhi mu c tim. Kch thch cc th cm th 2 - adrenergic dn n gim
renin-mt cht b c ch bi liu cao cc thuc c ch . ng mch vnh c c 2
loi th cm th v - adrenergic.
Dopamine liu thp s kch thch h th cm dopaminergic gy ra gin mch
mu thn v mc treo rut, nhng trng lc ca tnh mch li tng ln nh kch
thch h - adrenergic. nng cao hn, nhng tc dng u th trn adrenergic ca dopamine s gy co cc mch mu thn v mc treo rut.
Nhng nghin cu sinh ho t bo cho thy l cc th cm th - adrenergic
chim u th nhng ng mch vnh c kch thc ln bao ngoi tim, cn
nhng th cm th - adrenergic chim u th nhng ng mch vnh nh.
Kch thch cc -receptor (v d bng cc tc nhn ging nh norepinephrine
hoc dopamin hoc do kch thch h thn kinh giao cm) s gy ra co tht mch
vnh. Co tht mch vnh thng thng b khng ch ngay bi cc yu t chuyn
ho ti ch nh adenosin-mt cht c sinh ra trong qu trnh hot ng ca
tim. nhng bnh nhn c cc bnh mch vnh, s co tht ng mch vnh do
mt tc nhn kch thch no c th b tng ln v thng xut hin nhng p
ng tri ngc do tn thng ni mc. V vy cc cathecholamine c hot tnh
ging - adrenergic cn c s dng mt cch thn trng nhng bnh nhn
c nhng bnh l thiu mu c tim cp. Nhng th cm th 2 sau xinp c th
gi v tr trung gian c bit quan trng i vi co tht mch vnh. Cc thuc
nhm chn dng Ca++ lm gim s co mch qua trung gian th th 2, iu ny
gii thch cho tc dng chng co tht mch vnh ca chng. Kch thch cc th
th -adrenergic thng gy gin mch vnh.

Trng lc ca h adrenergic (giao cm) l cn bng vi h ph giao cm v

c iu chnh bi h thn kinh ny. H thn kinh giao cm v ph giao cm c
nh hng trc tip ti chc nng in sinh l v co bp ca mch vnh. Ngoi ra
cn mt s c ch khc gy co gin bt thng ca mch vnh:
+. S mt cn bng gia nhng sn phm trung gian hot ho ca tiu cu nh
thromboxane A2 v prostacyclin.
+. Ri lon chc nng ca t bo ni mc dn ti p ng nghch thng vi
kch thch gin mch bnh thng.
+. Mt nhng cht gin mch nh yu t gii phng t t bo ni mc.
2. Nhng thuc lm tng sc co bp c tim v tr-ng lc mch mu.

2.1. Norepinephrine:
*C ch tc dng:
Norepinephrine l 1 cathecholamin c chit xut t t nhin, n ch khc
vi epinephrine bi khng c nhm methyl amine cui cng. Epinephrine v
norepinephrine gn ging nhau v kh nng kch thch cc th th 1 - adrenergic
(trn tim), nhng hiu qu kch thch trn th th 1 v 2 - adrenergic l rt khc
nhau. Norepinephrine l cht ch vn ca th cm th m rt t nh hng trn
th th 2. Norepinephrine lm tng tnh co bp c tim do tc dng trn th cm
th 1 - adrenergic. Tc dng ca n trn th th dn ti co ng mch v tnh
mch. Tc dng tng sc co bp c tim (inotrope (+)) ca norepinephrine
c ng dng trong iu tr cc trng hp shock nng. Cn lu tc dng gy
tng sc cn mch mu ca norepinephrine c th s lm mt tc dng inotrope
(+) ca n. Norepinephrine lm tng huyt p do tng sc cn mch mu h
thng nhng c th khng ci thin hoc thm ch lm gim cung lng tim. V
norepinephrine lm tng nhu cu O2 c tim cho nn c th lm tng thiu mu c
tim, c bit do kch thch cc th cm th mch vnh nn c th gy ra co
tht mch vnh nhng bnh nhn c bnh thiu mu c tim. Norepinephrine
c s dng nh 1 bin php cui cng trong cp cu ni khoa.
* Ch nh:
Thuc c dng trong iu tr tt huyt p nng m cc amin giao cm khc
khng cn hiu lc. norepinephrine c tc dng tt hn nhng trng hp c
sc cn ngoi vi thp. Tt huyt p v sc cn ngoi bin thp him gp trong
nhi mu c tim cp (NMCTC) nhng li thng gp trong shock nhim trng v
shock c c ch thn kinh. Vic s dng norepinephrine cn c xem nh 1 bin
php tm thi. Bi v kt qa iu tr ph thuc khng ch n thun l nng c
huyt p m cn i hi phi iu chnh cc bt thng khc km theo trong
trng thi shock.
* Liu lng:

Norepinephrine bitartrate USP c ng trong nhng ng 4ml; mi ml cha

1mg norepinephrine nguyn cht v 2mg norepinephrine bitartrate. Cn trn n
vi 250ml dung dch dextrose 5% hoc mui ng trng c c m
16g/ml. Phi truyn norepinephrine qua 1 catheter tnh mch trung tm gim
ti a nguy c truyn ra ngoi tnh mch (xem phn ch ). Liu truyn ban u
thng dng l 0,5 - 1g/pht. Sau chnh tc truyn t c tc dng
mong mun l duy tr huyt p va (tiu chun hp l l huyt p tm thu t
nht 90mmHg) vi liu nh nht c th c. Liu trung bnh ngi ln l 212g/pht. Nhng bnh nhn shock nng c th cn liu ln ti 30g/pht.
Norepinephrine phi c truyn qua bm tim in m bo tc dng
chnh xc. Vic s dng thuc ny phi c xem nh mt bin php tm thi,
cn gim liu hoc ngng truyn cng sm cng tt v chuyn sang dng mt
loi amin giao cm khc, cn gim liu norepinephrine t t trnh tt huyt p
t ngt, nng.
* Ch :
Cc bin php o huyt p ngoi bin trong shock thng l khng chnh xc
do hin tng co cc mch mu ngoi vi, cho nn theo di lin tc huyt p ng
mch trc tip l cn thit xc nh chnh xc mc huyt p ng mch ca
bnh nhn. Nu huyt p o trc tip v huyt p o gin tip bng ti hi l nh
nhau th ngng theo di huyt p o trc tip.
Khi khng dng phng php theo di huyt p ng mch trc tip na th cn
theo di huyt p c 5 pht 1 ln bng ti hi hoc bng doppler trong sut qu trnh
iu chnh liu thuc. bnh nhn c iu tr bng thuc vn mch
norepinephrine cn c theo di cc ch s huyt ng nh gi nhng thay i
ca cung lng tim, p lc ng mch phi bt v sc cn ng mch ngoi bin.
Norepinephrine lm tng nhu cu O2 c tim m khng km theo tng b tr
lu lng mu vnh. N c th c hi bnh nhn thiu mu c tim hay l nhi
mu. norepinephrine c th gy kch thch gy lon nhp c bit nhng bnh
nhn c gim th tch mu lu hnh v nhng bnh nhn c vng c tim lnh cn
t. Tt huyt p do gim th tch mu l chng ch nh dng norepinephrine, tr
khi n l mt phng php tm thi duy tr ti mu vnh v no cho ti khi
vic b dch c thc hin. Hin tng thot mch ca norepinephrine c th s
gy ra hoi t t chc (do thiu mu cc b) v hin tng ni da g. Nu s
thot mch xut hin, tim phentolamin (5 - 10mg ho vi 10 - 15ml dung dch
mui ng trng) vo vng chng li tc dng co mch ca
norepinephrine v gim ti a hin tng hoi t.

2.2. Dopamin:
* C ch tc dng:

Dopamin hydrochloride l cht ho hc tin thn ca norepinephrine kch

thch h dopaminergic, cc th cm th 1 hay adrnergic tu thuc vo liu
lng khc nhau ca thuc. Dopamin cng kch thch vic gii phng
norepinephrine. Dopamin liu thp (1-2 g/kg/pht) kch thch cc th th
dopaminegic gy gin mch mc treo, thn, no, nhng lm tng trng lc tnh
mch do kch thch th th - adrenegic ca tnh mch. S lng nc tiu c th
tng nhng tn s tim, huyt p thng l khng i. Vi liu 2-10g/kg/pht
dopamin kch thch th cm th 1 v - adrenergic. Kch thch th th 1 adrenergic lm tng cung lng tim v i khng 1 phn vi th th adrenergic gy co mch. N rt c tc dng trong tng cung lng tim v km
tng rt t sc cn ngoi bin.
liu trn 2,5/kg/pht dopamin lm tng trng lc tnh mch v p lc
tnh mch trung tm. Liu trn 10g/kg/pht tc dng trn th th - adrenergic
ca dopamin chim u th, n gy ra co ng mch thn, mc treo, ng mch
ngoi bin, sc cn ng mch phi v xa hn na l tng tin gnh. Liu trn
20g/kg/pht gy ra hiu qu huyt ng tng t nh ca norepinephrine. p
ng ca c th vi dopamin so vi cc thuc vn mch khc l rt khc bit, do
phi chnh liu thuc da vo hiu qu huyt ng. Dopamin lm tng cng c
tim khng km tng lu lng ti mu vnh b tr, s mt cn bng gia cung
v cu O2 ny c th gy ra thiu mu c tim cp.
* Ch nh:
Ch nh dng dopamin l tt huyt p nng khng km gim th tch mu
lu hnh (tt huyt p nng l huyt p ng mch tm thu di 90mmHg km
theo cc triu chng gim ti mu m: thiu niu, hay nhng thay i thc).
Dopamin nn s dng vi liu thp nht c th duy tr mt mc ti mu
cho cc c quan sng quan trng (no, tim, gan, thn...). Tng sc cn mch mu,
huyt phi hay tng tin ti l nhng chng ch nh ca dng dopamin. Trong
nhng trng hp ny dopamin cn dng liu thp (1-2g/kg/pht) lm tng
ti mu thn. Vic iu tr bng dopamin thng dnh cho nhng bnh nhn c
tt huyt p xut hin cng vi nhp chm hay sau khi ti lp tun hon t pht
cc trng hp ngng tim - phi. C th phi hp norepinephrine vi dopamin
nu liu dopamin vt 20 g/kg/pht. Theo Gonzalez vic kt hp dopamin v
epinephrin khng sinh ra mt tc dng vn mch hip ng no cc bnh
nhn ngng tim - phi. Mt nghin cu mi y s dng m hnh trn bnh nhn
ngng tim - phi chng t rng dopamin t hiu qu hn epinephrin trong tc
dng ci thin huyt ng ca qu trnh hi sc. iu quan trng cn nh rng
nhng tc dng trn th th - adrenergic ca dopamin d liu thp cng lm
tng p lc ng mch phi bt v c th gy ra hay lm nng ln tnh trng
huyt phi mc d n c lm tng cung lng tim. Cc thuc gin mch (nh
nitroglycerin, nitroprusside) c th c dng phi hp lm gim tin gnh,
tng cung lng tim bng cch i khng vi tc dng tng sc cn ng mch
v tnh mch ca dopamin. S kt hp dopamin v nitroprusside cho ta hiu qu
huyt ng tng t nh dobutamin.
* Liu lng:

Dopamin ch c dng bng ng tnh mch. Trn 1 hoc 2 ng

(200mg/ng) dopamin trong 250ml dextrose5%. Thu c dung dch c nng
800 hoc 1600g/ml. Tc truyn ban u l 1-5g/kg/pht. C th tng tc
truyn cho ti khi ci thin c huyt p, lng nc tiu v cc du hiu ca
tng ti mu cc c quan. Liu thng dng l 5-20g/kg/pht. gim ti
thiu cc tc dng ph, cn dng dopamin liu thp nht c th cho php m
vn t c s ci thin huyt ng. Phi dng dopamin qua bm tim in
m bo chnh xc liu lng thuc. nhng bnh nhn c bnh thiu mu c
tim hay suy tim huyt, vic theo di huyt ng l quan trng s dng
dopamin chnh xc. Theo di huyt ng phi c thit lp trc hay cng sm
cng tt sau khi bt u iu tr bng dopamin. Khi cn gim liu dopamin phi
gim t t trnh tt huyt p t ngt.
* Ch :
Dopamin s lm tng tn s tim v c th gy ra hay lm nng thm nhng
lon nhp trn tht. Ngoi ra d liu thp nh hng gy co ng mch v tnh
mch ca dopamin c th lm nng ln tnh trng huyt phi v thay i cung
lng tim. i khi nhng nh hng ny c th buc phi gim liu hoc ngng
truyn. Mc d c nhng ci thin v huyt ng. Nhng do tng nhu cu 02 c
tim v tng to cc sn phm lactat ca c tim, cho nn cn lu l cung lng
mu vnh tng b tr khng vi vic tng cng ca tim khi p ng vi liu
cao dopamin. S mt cn bng gia cung v cu ny gy ra hoc lm nng
thm tnh trng thiu mu c tim.
Bun nn, nn l nhng tc dng ph thng gp ca dopamin, dopamin c
th gy ra hoi t da, ni da g khi truyn n vo tnh mch ngoi vi. Khc ph
tc dng ph ny ca dopamin cng lm ging nh vi norepinephrine.
Dopamin khng c cho vo cc dch truyn cha natricacbonat hoc cc
dch truyn mang tnh cht kim v n b lm bt hot pH kim. Tuy nhin phn
ng ny din ra chm dopamin v cc dch kim khc (aminophylin,
phenytain, natribicacbonat...) c th truyn trong mt thi gian ngn qua cng
mt catheter tnh mch.

2.3. Dobutamin:
* C ch tc dng:
Dobutamin l mt amin giao cm tng hp, n c tc dng tng sc co bp c
tim bng cch kch thch cc th th 1 v 1 - adrenergic trn c tim. Dobutamin
c kch thch cc th th 1 - adrenergic ngoi bin nhng do n b i khng bi
tc dng kch thch th th 2 - adrenergic mnh hn, dn ti p ng gin mch
nh. Dobutamin lm tng cung lng tim v gim sc khng mch mu ngoi
bin. liu thng thng (2 - 20g/kg/pht) dobutamin t c xu hng gy nhp
nhanh hn dopamin hoc isoproterenol. D sao i na liu cao hn dobutamin
vn gy ra p ng nhp nhanh. Dobutamin lm tng ti mu thn v mc treo

nh lm tng cung lng tim. N khng th gy ra gin trc tip mch thn v
mc treo qua cc th th dopaminenergic. D sao tc dng tng lng nc tiu
v ti mu thn l nh nhau gia dopamin v dobutamin. Tng ti mu thn
th pht sau tng cung lng tim l mt du hiu rt quan trng nh gi chc
nng thn. Hiu qu huyt ng ca dobutamin tng ng vi vic dng phi
hp dopamin vi mt thuc gin mch nh nitroprusside. Dobutamin lm tng
cung lng tim, gim p lc ng mch phi bt v sc cn ngoi bin .
Nhng u im ca dobutamin v huyt ng v tc dng gii phng
norepinephrine ni sinh s dn ti gim ti thiu nhu cu O2 c tim v to ra mt
cn bng c li gia cung v cu v O2 ca c tim so vi norepinephrine v
dopamin. Tc dng inotrope(+) cng khng c ci thin do tng ti mu vnh.
V nhng l do trn dobutamin khng lm tng kch thc nhi mu hoc khng
gy lon nhp tim. Tn s tim c th gim khi huyt ng ci thin. nh gi
p ng lm sng vi dobutamin cn theo di huyt ng trung ng trc tip.
Ngi ta dng kt hp hai thuc dopamin v dobutamin vi nhau liu trung
bnh (7,5g/kg/pht) duy tr huyt p ng mch v hn ch tc dng gy tng
p lc ng mch phi bt v tnh trng huyt phi ca dopamin n c. S kt
hp dopamin v dobutamin trong iu tr s ci thin ng k huyt ng nhng
n khng lm thay i t l sng st bnh nhn shock tim.
* Ch nh:
- Dobutamin rt hu ch trong iu tr cc trng hp huyt phi v cung
lng tim thp cng nh l cc bnh nhn c tt huyt p km huyt phi v ri
lon chc nng tht tri m khng dng c cc thuc gin mch.
- Dobutamin c chn iu tr suy tim c ri lon huyt ng nng
bnh nhn nhi mu c tim cp (NMCTC).
- Dobutamin cng c th c dng ci thin cng tht tri bnh nhn
shock nhim trng.
* Liu lng:
Dobutamin c th c hiu qu liu thp ( 0,5g/kg/pht) liu thng thng l
2-20g/kg/pht. Dobutamin lm tng tn s tim > 10% so vi ban u, l iu
cn trnh bnh nhn c bnh l ng mch vnh. Trn 2 ng (ti 4 ng)
dobutamin (250mg/ng) vo 250ml dextrose 5% hoc dung dch mui ng trng.
Phi truyn dobutamin qua bm tim in m bo tc dng chnh xc.
* Ch :
Dobutamin c th gy ra nhp nhanh, lon nhp v huyt p dao ng. N c
th gy thiu mu c tim nht l khi xut hin tng nhp tim. Cc tc dng ph
khc gm: au u, bun nn, run c v h kali mu

2.4. Isoproterenol:
* C ch tc dng:

Isoproterenol hydrochloride l mt amin giao cm tng hp c tc dng chn

lc gn hon ton trn th th - adrenergic. Cc c tnh inotrope (+) v iu
nhp ca n thng lm tng cung lng tim mc d n lm gim huyt p trung
bnh do gin h tnh mch ngoi vi v tng dung tch lng tnh mch.
Isoproterenol lm tng ng k nhu cu O2 c tim v c th gy ra hay lm nng
thm thiu mu c tim. Cc thuc tng sc co bp c tim mi (dobutamin,
amrinone) thay th isoproterenol trn thc t lm sng hin nay.
* Ch nh:
Isoproterenol c dng kim sot huyt ng tm thi trong trng hp
c nhp chm nng. Hin nay ch nh chnh l iu tr nhp chm. Tuy nhin
trong cc trng hp c nhp tim chm lc u nn s dng atropin, to nhp,
dopamin v epinephrine trc khi dng isoproterenol (my to nhp in t gp
phn kim sot tt hn isoproterenol m khng km theo tng tiu th O2 c tim
v nguy c lon nhp nhanh). To nhp tim nn dng thay cho isoproterenol cng
sm cng tt sau khi isoproterenol c ch nh nh mt bin php tm thi.
Khi s dng isoproterenol vi mc ch h tr nhp c th lm thiu mu c tim
v tt huyt p. Trong iu tr ngng tim khng nn dng isoproterenol.
* Liu lng:
Liu h tr nhp tim thng nh, khng ln hn 10g/pht l . Liu bt u
l 2g/pht, chnh liu t t cho ti khi tn s tim khong 60 ln/pht l c. Ho
1mg isoproterenol trong 250ml dextrose 5% s c dung dch nng 4g/ml phi
truyn n bng mt bm truyn dch m bo tc truyn chnh xc.
* Ch :
Do isoproterenol lm tng nhu cu O2 c tim nn trnh dng khi c bnh l
thiu mu c tim. c tnh iu nhp ca n c th gy ra lon nhp nng nh:
nhp nhanh tht, rung tht. N c th lm nng ln cc lon nhp nhanh do ng
c digital v c th gy h kali mu.

2.5. Amrinone:
* C ch tc dng:
Amrinone l thuc tng sc bp c tim tc dng nhanh c th dng ng
tnh mch. Amrinone l mt thuc c ch phosphodiesterase. Hiu qu ca
amrinone trn huyt ng tng t nh dobutamin. liu 2 - 15g/kg/pht n
lm tng cung lng tim, gim sc cn ngoi bin v tin gnh. Liu cao hn n
gy nhp nhanh ging nh dobutamin. amrinone c th lm thiu mu c tim
nng thm v cn thn trng khi s dng thuc ny cho cc bnh nhn b bnh
thiu mu c tim. Vic theo di lin tc cc ch s huyt ng trung ng l rt
cn thit cho vic iu chnh liu chnh xc khi bt u iu tr bng amrinone.
* Ch nh:
Cn cn nhc vic s dng amrinone nhng bnh nhn suy tim huyt nng
khng tr vi cc thuc li tiu, gin mch v cc thuc vn mch thng thng.

* Liu lng:
Amrinone c thi gian bn hu di (4 - 6gi). C th s dng liu ln bt u
t 0,75mg/kg. Do tc dng gim hu gnh ca amrinone l trc tip t l vi liu
v tc truyn nn liu khi u thng khng vt qu 1mg/kg, liu ny c
th truyn trong 2 - 5 pht, nhng tt hn l truyn 10 - 15 pht gim ti thiu
nguy c tt huyt p bnh nhn c ri lon chc nng tht tri nng v huyt p
ang mc gii hn. Tip theo l liu duy tr bt u truyn tc 2 5g/kg/pht v chnh liu 10 - 15g/kg/pht theo s p ng ca huyt ng.
Do tm quan trng ca tnh tng k ho hc amrinone lactat khng c ho
trc tip vo cc loi dch dextrose trc khi truyn. Nhng vn c th truyn n
qua mt catheter tnh mch cng vi dung dch dextrose. truyn tnh mch
lin tc, cn phi pha amrinone vo natriclorua 0,45% hoc 0,9% vi nng 1 3mg/ml. Nn dng amrinone qua mt bm truyn dch chnh liu chnh xc.
* Ch :
+ Amrinone c th gy ra hoc lm xu i tnh trng thiu mu c tim. Theo
di lin tc huyt ng trung ng l quan trng v nhng thay i cc ch s
huyt ng trung ng c th xut hin khng ng thi vi nhng bin i ca
huyt p v tn s tim. gim ti thiu tc dng ph ca amrinone, nn dng
liu thp nht c th t c hiu qu mong mun. Amrinone c th gy ra gim
tiu cu (khong 2 - 3% trng hp dng thuc) do n lm gim thi gian sng
ca tiu cu. Tc dng khng mong mun ny xut hin trong vng 48 - 72 gi
sau bt u iu tr. Gim tiu cu thng l him khi i km chy mu v n
mt i khi ngng thuc. Mc gim tiu cu ph thuc vo liu thuc. Cc tc
dng ph khc gm: ri lon tiu ho, au c, st, ri lon chc nng gan v kch
thch tm tht. Trong phn t amrinone c cha metabisulfit nn chng ch nh
dng n bnh nhn d ng vi cc bisulfit.
+ Nguyn tc gim liu cc thuc vn mch:
Khi gim liu cc thuc vn mch c tc dng inotrope (+) nn gim t t v
c theo di cht ch v nhng thuc ny tc ng ln vic kim sot thn kinh-th
dch i vi huyt p v th tch tun hon. ng thi cn phi m bo b sung
y lng dch trong lng mch trnh tt huyt p sau khi gim liu.

2.6. Cc glycozit cng tim (digital glycosides):

* C ch tc dng:
Digital glycosides c s dng trong nhiu thp k iu tr cc ri lon
tim. Digoxin l mt dng ca digital glycosides hin ang c s dng rng ri
trn thc t lm sng.
Digoxin c kh nng lm tng sc co bp c tim v kim sot p ng tht
trong rung, cung nh. C ch tc dng tng sc co bp c tim ca digitalis l c
ch Na+ - K+ ATPase mng t bo. Tc dng ny lm thay i dng Ca++ v tng
nng Ca++ h li ni bo, nh lm tng tnh co bp. Tc dng inotrope

(+) ca digitalis khng ph thuc vo vic gii phng cc cathecholamin v

khng b nh hng bi vic chn cc th th adrenergic. Digitalis gy co
mch vnh v mch mc treo.
Digitalis c tc dng trc v gin tip trn nt xoang v nt nh - tht. N lm
gim bt mt cch trc tip v gin tip (bng cch tng trng lc ph giao cm)
dn truyn xung ng qua nt nh - tht nhng lm tng tn s dn truyn trong
nh. Liu digitalis ph thuc vo ng dng v mc ch iu tr. Liu cao
thng c ch nh kim sot p ng ca tht trong rung nh hn l lm
tng tnh co bp.
Ng c digitalis thng gp khi nng ca n trong huyt tng cao,
nhng ng c cng c th xut hin ngay c khi nng digitalis huyt thanh
thp. Ngc li c th nng thuc trong huyt thanh cao nhng li khng xut
hin triu chng ng c bi v c tnh ca n ph thuc vo lng thuc c
trong c tim ch khng phi trong tun hon mu.
* Ch nh:
Digitalis gip vic kim sot p ng tht trong rung nh hay trong cung nh
v n c th chuyn nhp nhanh kch pht trn tht thnh nhp xoang bnh thng.
bnh nhn c ri lon chc nng tht tri n c th chuyn cung tht thnh
rung tht. digoxin c th c ch nh trng hp ri lon nhp trn tht nu
bnh nhn c huyt ng n nh m khng i hi sc in o nhp cp cu.
Tc dng tng sc co bp c tim ca digoxin dng ung khng mnh bng loi
tim tnh mch v cng c hn. Digitalis t c vai tr trong iu tr suy tim
huyt cp. Cc nghin cu lm sng ch ra rng cc digitalis c hiu qu huyt
ng tt trong iu tr suy tim huyt mn tnh.
* Liu lng:
Digoxin c th dng bng ng ung hay tnh mch. Dng digoxin tnh
mch c th trnh c cc vn hp th qua d dy, rut v thi gian bt u
c tc dng cng nh thi gian t tc dng nh nhanh hn ng ung. Sau
dng ng tnh mch tc dng iu nhp v c ch dn truyn ca digoxin xut
hin trong vng 5 - 30 pht, t tc dng nh trong vng 1,5 - 3 gi. Tc dng
inotrope (+) xut hin sau p ng in sinh l ca n.
Trong cc trng hp khng phi cp cu, vic iu tr c th bt u bng
ng ung. Do thi gian bn hu tng i di ca digoxin (36gi) nn dng
bt u bng liu 10 - 15g/kg ni chung l mang li hiu qu iu tr vi nguy
c ng c ti thiu. Liu duy tr ph thuc chiu cao cn nng ca c th v
chc nng thn.
* Ch :
Ng c digitalis l mt vn thng gp v nguy him xut hin vi tn
xut thay i t 7-20%. Thc t c th gp bt c loi lon nhp no trong ng
c digitalis, thng gp nht l ngoi tm thu nh, tht, ngoi tm thu tht nhp
i v nhp nhanh tht. Nhp b ni nhanh dn, nhp b ni nhanh, nhp nh
nhanh kch pht vi bloc nh-tht 2/1, bloc nh - tht cao t gp hn nhng li

l c trng cho cc trng hp qu liu digitalis. Nhng biu hin khc ngoi
tim ca ng c digitalis gm chn n, bun nn, nn ma, a chy, ri lon th
lc, thay i thc (mt mi, bn chn, lon thn). Ng c thng xut hin
nhng bnh nhn c h K+, Mg++, Ca++ mu.
Khi nghi ng ng c digitalis, cn ngng thuc v nh lng nng thuc
trong huyt thanh, khi nng thuc bnh thng trong mu l loi tr ng c.
Nhng bnh nhn c nng digitalis trn 2,5ng/ml c nguy c ng c cao hn.
Vic iu chnh K+ mu l quan trng, mc K+ huyt thanh cn tng cho ti khi
n v bnh thng. iu chnh K+ mu cn thn trng bnh nhn c bloc v n
c th nng ln do truyn kali. Cc phng php iu tr b tr bao gm lidocain,
phenytoin hay propranolol kim sot lon nhp tht v trn tht. C th phi
tin hnh t mt to nhp tm thi iu tr bloc A-V nng. Cc cathecholamin
l chng ch nh tng i cho nhng trng hp lon nhp tht nng v n c
th lm bnh nng ln.
Thc hin sc in o nhp cho nhng bnh nhn lon nhp do ng c
digitalis rt nguy him v c th gy lon nhp tht cht ngi, nu bt buc phi
lm cho bnh nhn ng c digitalis c lon nhp gy ri lon huyt ng nng
e do tnh mng, th nn bt u vi mc nng lng thp 10 - 20J. D sao th
o nhp thng an ton hn nhng bnh nhn c nng digitalis huyt tng
thp hn 2ng/ml.
Khng th khng digoxin c chn dng cho trng hp qu liu nng v
ng c digoxin khng cn p ng vi iu tr. Qu liu nng digoxin c th
gy ra tng K+ mu, co tht mch mc treo, thiu mu hoc nhi mu mc treo,
co tht mch vnh. Cc thuc quinidin, verapamin v aminodaron lm gim s
o thi digoxin, nhng bnh nhn c iu tr nhng thuc ny phi gim
liu digoxin 50% trnh tng tc tng c tnh.
3. Cc thuc gin mch.

3.1. Sodium nitroprusside:

* C ch tc dng:
Sodium nitroprusside l mt cht gin mch ngoi bin mnh vi hiu qu
trn c trn c tnh mch v ng mch. Tc dng xut hin ngay lp tc v
ht ngay lp tc sau ngng truyn. Nitroprusside b chuyn ho ti hng cu
thnh hydrocyanic v tip tc chuyn thnh thiocyanate gan ri c bi tit
qua thn. Ri lon chc nng gan - thn c th nh hng ti s thanh thi thuc
v ng cc cht chuyn ho ca n nh: cyanate v thiocyanide.
Nitroprusside c dng trong iu tr cp cu tng huyt p v suy tim.
Nitroprusside lm gim huyt p do lm gim sc cn ng mch ngoi bin v
lm tng kh nng gin ca tnh mch. Khi c suy tim, nitroprusside thng lm
tng cung lng tim bng cch gim sc cn mch mu v tng th tch tng

mu, mc tng thng tim duy tr mt cung lng bng hay di mt

cht ch s trc iu tr. Nhp nhanh do nitroprusside gy ra bnh nhn suy tim
tri chng t l p lc y mu khng . S ci thin huyt ng trong trng
hp c suy tht tri hoc tng huyt p c th c ngha c bit vi nhng bnh
nhn c bnh thiu mu c tim . Nitroprussit lm gim cng c tim v v vy lm
tnh trng thiu mu c tim bt i. Tuy nhin mt vi thng bo cho rng
nitroprusside c th lm gim ti mu vnh vng c tim thiu mu, iu ny
s nh hng n mt phn hay ton b tc dng ci thin cng c tim. Rt nhiu
nghin cu xc nhn s ci thin chc nng tht tri, ti mu m, cung lng
tim v tnh trng lm sng nhng bnh nhn c hi chng cung lng tim nh
v sc cn mch mu ngoi bin cao. Nitroprussit c xu hng lm gim p lc
ng mch phi bt nhiu hn dobutamin, do tc dng gin tnh mch v lm
tng co gin tht tri mnh hn.
* Ch nh:
Nitroprussit l thuc dng ng tnh mch cho trng hp tng huyt p
kch pht hoc khi cn lm gim lp tc sc cn ngoi vi. N gy gim huyt p
nhanh, d iu chnh v thng dung np tt. Tc dng ca n c th nhanh
chng o ngc c (nu cn) bng cch n gin l ngng truyn.
Nitroprussit cng rt hu ch trong iu tr bnh nhn suy tht tri cp. C th
dng n trong suy tim c huyt phi cp tnh m vic dng li tiu khng c
kt qu. Trong trng hp ny kt hp gia dopamin v nitroprussit thng hiu
qu hn mt thuc n c, s kt hp thuc nh th cng tng t nh tc dng
ca dobutamin nhng r hn.
* Liu lng:
Pha 50-100mg nitroprussit (sau khi trn bt kh vi 2 - 3ml dextrose) vo
250ml bt k loi dextrose no hoc natriclorua 0,9% v truyn tnh mch lin
tc. Dung dch phi c bc kn trong v nhm hay kim loi phn quang
trnh b phn hu thuc khi tip xc vi nh sng. Dung dch thuc mi pha c
mu nu m nhng khng c thay i v tnh nng cu thuc. Dung dch
nitroprussit lu s phn ng vi nhng mc khc nhau to thnh cc sn
phm c mu m, nu n xut hin phi ngng truyn ngay. Cn s dng dung
dch nitroprussit ngay sau khi pha. Tc truyn lc khi u 0,1g/kg/pht, sau
iu chnh liu theo tc dng mong mun. Theo di huyt ng lin tc l rt
cn thit chnh liu chnh xc khi iu tr suy tim huyt. Liu iu tr trung
bnh 0,5 - 8g/kg/pht. Nitroprussit phi c truyn bng bm truyn dch
m bo tc truyn chnh xc
* Ch :
Khi suy tim huyt nht thit phi theo di lin tc cc ch s huyt ng
trung ng chnh liu thuc an ton v chnh xc theo mc ch s dng, phi
theo di lin tc huyt p ng mch h thng. Phn ng tt huyt p l thng
gp nht, khi s dng nitroprussit n c th gy thiu mu c tim, nhi mu c
tim t qy, c th xut hin gim O2 mu v ri lon t s thng kh/ dng mu

phi (V/Q). Nhng bnh nhn ln tui v nhng bnh nhn c thiu khi lng
mu lu hnh s nhy cm hn vi thuc v cn gim liu thp hn. Nitroprussit
c th gy gim cung lng mu vnh v lm nng ln thiu mu c tim mc d
n lm gim cng c tim. trng hp suy tim huyt dng nitroglycerin tnh
mch c nh hng trn huyt ng tng t nh nitroprussit nhng n li ci
thin tnh trng thiu mu c tim, v vy bnh nhn c bnh mch vnh ngi ta
thch dng nitroglycerin hn.
Nitroprussit c chuyn ho qua gan thnh thiocyanat. Ng c thiocyanat
khi dng nitroprussit t gp, tr trng hp dng liu ln (>3g/kg/pht) truyn
ko di (2- 3ngy) hoc nhng bnh suy thn. Phi theo di nng thiocyanat
trong cc trng hp dng liu cao, ko di hoc c suy thn. Nu nng
thiocyanat trong mu nh hn10mg/100ml th vn tip tc dng c. Cc triu
chng ca ng c thiocyanat gm tai, nhn m, thay i thc, bun nn, au
bng, tng phn x, ng kinh. Ng c cyanide l mt bin chng him gp
ngay c bnh nhn c suy gan.

3.2. Nitroglycerin:
* C ch tc dng:
Nitroglycerin lm gin c trn mch mu bng cch gn vo cc th th c
hiu v to thnh cc cu disulfite. Cc loi thuc nitrat s khc nhau c bn
thi gian tc dng, tnh nng, ng dng thuc. Nitrat c rt nhiu bit dc
trn lm sng nhng y ch bn ti hai dng tnh mch v di li, thng
c dng iu tr cn au tht ngc, nhi mu c tim cp v suy tht tri.
Nitroglycerin rt hiu qu trong iu tr cn au tht ngc. Tc dng ny
thng xut hin sau 1 - 2 pht v c th ko di ti 10 pht. Trc y s p ng
ny c coi nh 1 test chn on lm sng ca cn au tht ngc, song c th b
nhm vi cc trng hp khc (co tht thc qun cng c p ng vi nitrat nh
vy). Nitrat lm gim au ngc do gy gin c trn ca h tnh mch, n cn tr
dng mu tr v ca tnh mch v gim p lc trong thnh c tim, gim cng tht
tri v p lc thnh tht, ci thin ti mu di ni tm mc. Nitroglycerin cng
lm gin cc ng mch vnh c ng knh ln, chng co tht mch vnh v tng
tun hon bng h ti vng c tim thiu mu. Tc dng ny rt quan trng khi
thiu mu c tim do ri lon vn mch ca mch vnh. Nitroglycerin di li lm
gim p lc y tht tri m khng lm gim nhiu sc cn ngoi bin
bnh nhn suy tim huyt, nitroglycerin lm gim p lc y tht tri
v gim sc cn ngoi bin. Gim th tch bung tht v trng lc thnh tht tm
thu s lm gim nhu cu O2 c tim v gim thiu mu c tim. Tc dng r nht l
tng cung lng tim. Nitroglycerin dng ng tnh mch lm gim tin gnh
nhiu hn v t gim sc cn ngoi bin so vi nitroprusside. Nitroglycerin
thng khng lm tng tn s tim khi tin gnh .
* Ch nh:

Nitroglycerin di li c chn trong iu tr cn au ngc. N c hiu

qu i vi cn au ngc khi ngh cng nh khi gng sc. i vi au ngc, liu
dng l 1 vin (0,3 - 0,4mg) di li. C th 2 ln cch nhau 5 pht. Trng hp
cn gim au ngc cp, nitroglycerin c th dng di dng bnh xt, n chuyn
c 0,4mg nitroglycerin mi ln xt vo di nim mc ming. Dng m bi
ngoi da c th dng cho c trng hp cp v mn. Bi mt lp m nitroglycerin
2% vo vng da 3 x 6cm. Nitroglycerin dng dn khng c dng trong cp
cu.
Vi cn au ngc khng n nh v nhi mu c tim, nitroglycerin tnh mch
c a chung hn mc d dng ung cng c tc dng gim tn s cn au
ngc khng n nh nhng thi gian bt u tc dng ca n mun hn. bnh
nhn co tht mch vnh (cn au kiu prinzmetal) thng p ng tt vi
nitroglycerin di li.
Nitroglycerin tnh mch c chn cho iu tr cp cu suy tim huyt c
bit bnh c bnh thiu mu c tim. Nitroglycerin tnh mch v nitroprusside
c cng tc dng huyt ng (gim sc cn ng mch v tng kh nng gin
tnh mch). Nitroglycerin tim tnh mch c tc dng trn ng mch nhng yu
hn nitroprusside. Nitroglycerin tnh mch c th gim din tch nhi mu khi
iu tr nhi mu c tim c km suy tim huyt. N cng hn ch s lan rng
ca nhi mu. Ngi ta khng nh rng: dng nitroglycerin mt cch
thng qui s hn ch din tch nhi mu.
Nitroglycerin thng c dng vi thuc tiu ng v aspirin bnh nhn
nhi mu c tim cp. N lm gim co tht mch v tr mng x va v c tc
dng hip ng chng ngng kt tiu cu vi aspirin. Cc s liu nghin cu mi
y ch ra rng: nitroglycerin tnh mch c th i khng vi tc dng ca
heparin v lm thay i p ng ca yu t hot ho plasminogen t chc
(alteplase). bnh nhn iu tr bng nitroglycerin tnh mch c hin tng gim
p ng chng ng vi heparin.
Khi dng nitroglycerin bnh nhn nhi mu c tim c th gy tt huyt p,
gim ti mu ng mch vnh v lm nng thm tnh trng thiu mu c tim.
Nhng nu ch gim 10% (hay t hn) s huyt p ban u c xem nh l an
ton bnh nhn c bnh l ng mch vnh.
* Liu lng:
Khi dng di li: liu bt u 0,3 - 0,4mg, c th nhc li c mi 5 pht
cho ti tng liu 3 vin nu cn au ngc khng gim. Thuc ung t hiu qu v
n b bt hot ti gan.
Nitroglycerin tnh mch: c th dng liu ln t u (bolus) hay truyn tnh
mch lin tc. Khi u bng liu 12,5 - 25 g tim tnh mch, trc khi truyn
tnh mch lin tc (200 - 400g/ml) vi tc 10 - 20g/1pht. Tng dn tc
truyn 5 - 10g/1pht c mi 5 - 10 pht cho ti khi t c hiu qu huyt
ng cng nh p ng lm sng mong mun (v d nh gim sc cn ngoi bin
hoc gim p lc y tht tri, au ngc). Hu ht bnh nhn p ng vi
tc 50 - 200g/pht l liu thp nht c th dng. Tu tng bnh nhn c th

dng ti liu 500g/pht. Hiu qu dc l ca n ph thuc vo th tch trong

lng mch v liu lng. Nu th tch mu lu hnh gim s gim hiu qu ca
thuc v tng nguy c tt huyt p. Phi dng n qua mt bm tim truyn dch
m bo chnh xc liu lng v gim ti a nguy c tt huyt p.
Cn lu l nitroglycerin rt d gy ra s nhn thuc, cng tng liu cng
tng hin tng nhn thuc. Nn s dng liu ngt qung vi nhng thi gian
ngh thuc s gim c hin tng nhn thuc ny.
* Ch :
au u l hu qu hay gp khi iu tr bng nitroglycerin. Tt huyt p gy ra
bun nn, chong vng, mt mi hoc ngt. Cc triu chng trn thng nng ln
khi bnh nhn t th ng. Phi hng dn bnh nhn nm hay ngi v nn dng
liu nh nht nu c th. Nn chn cao khi c tt huyt p. nhng bnh nhn
dng ko di nitroglycerin th s thch nghi vi tt huyt p v au u. Tt huyt
p l tc dng ph nng nht ca nitroglycerin, c bit khi c bnh l tc ng
mch. Cch iu tr tt nht cc trng hp tt huyt p l gim hay ngng nitrat
v b xung dch truyn. Nu c nhp chm km theo tt huyt p (phn x ph giao
cm) nn iu tr bng atropin, ngng thuc v truyn dch. Phi theo di huyt
ng khi truyn nhanh nitroglycerin m hiu qu an ton. N c th gy ra
methemoglobin v ri lon t s thng kh/ dng mu (V/Q) gy gim O2 mu.
4. Cc thuc chn beta (propranolol, esmolol, atenolol, metoprolol):
* C ch tc dng:
Cc thuc chn lm mt tc dng ca cc cathecholamin tun hon trong
mu do mt kh nng gn kt vo cc th th adrenergic ca n. Propranolol,
metoprolol, atenolol v esmolol c th dng ng tnh mch. Propranolol
hydroclorid l mt thuc chn khng chn lc (tc dng trn c receptor 1 v
2) khng km hot tnh giao cm ni sinh. Do n l thuc chn khng chn
lc nn c tc dng trn c tim (c ch sc co bp c tim v chm nhp tim) v
phi (co tht ph qun). Propranolol c cng nhn l thuc iu tr nhp nhanh
tht v rung tht khng tr vi cc thuc iu tr lon nhp khc gy ra do thiu
mu c tim.
Metoprolol, atenolol v esmolol l cc thuc chn 1 chn lc. liu thp
(<200mg/ ngy i vi metoprolol v <300g/kg/pht i vi esmolol cc thuc
ny c xu hng c ch hu ht cc th th 1. liu cao metoprolol v esmolol
mt tc dng chn lc 1 ca chng. Chn s lm gim tn s tim, huyt p, sc
co bp ca c tim v tiu th oxy c tim. Nhng tc dng ny c ng dng
trong iu tr cn au tht ngc v bnh tng huyt p. Chn c th gip kim
sot c lon nhp m nguyn nhn do s kch thch ca cc cathecholamin (rt
c th do tc dng i khng 2 gy h K+ mu).
Chn cng rt hu ch khi gim p ng tht trong rung nh, cung nh v
nhp nhanh kch pht trn tht v n lm gim dn truyn qua nt nh tht. Mt

vi chn (propranolol) c tc dng nh quinidin trn mng t bo c tim v trn

in th hot ng ca tim, iu lm d dng cho hiu qu chng lon nhp
ca chng.
Cc thuc chn c th lm gim creatine kinase - yu t xc nh kch
thc nhi mu bnh nhn nhi mu c tim cp v c th ngn nga ti nhi
mu khi n c ch nh cng vi cc thuc tiu cc mu ng. Thuc chn
c th bo v thiu mu c tim do tc ng mch vnh bng cch gim tiu th
oxy c tim v c ch oxy ho lipid trong qu trnh ti ti mu.
Nhng hiu qu ca c ch chn lc cc v tr ca th th do cc thuc chn
ph thuc khng hon ton vo s lng cc th th v nng cathecholamin
tun hon trong mu.
Tim tnh mch propranolol v metoprolol to ra p ng thuc ko di 6 -8
gi. Esmolol c chuyn ho rt nhanh do ester ho bo tng ca hng cu.
Thi gian bn hu n gn 9 pht (trung bnh 5 - 23 pht) v thi gian tc dng
ca n gn 15 - 20 pht. Tnh chn lc tng i th th 1 ca esmolol v tc
dng nhanh ca n to ra mt mc rt an ton bnh nhn nng, nhng thuc
c gi thnh cao.
* Ch nh:
Ch nh chnh ca cc thuc chn trong cp cu tim mch l iu tr rung
tht v nhp nhanh tht ti pht nhiu ln hay nhp nhanh kch pht trn tht
khng p ng vi cc phng php iu tr khc. Cc chn hu ht l c hiu
qu khi cc lon nhp ny gy ra do s kch thch qu mc ca th th adrenergic hay do thiu mu c tim. Chng rt hu ch trong trng hp tng
huyt p v nhp nhanh nu chc nng tht tri khng b gim nhiu.
Vic s dng thuc chn sau nhng triu chng u tin ca nhi mu c
tim cp gim kch thc nhi mu hoc t l cht cn l vn ang c
bn ci. Atenolol, metoprolol v propranolol lm gim ng k tn xut ca rung
tht trong NMCTC m khng c tiu ng. Chn cng c th rt c tc dng
bnh nhn iu tr bng tiu ng, khi c s dng 4 gi sau liu php tiu
ng th n c th lm gim t l ti nhi mu nh v thiu mu ti pht. bnh
nhn iu tr bng thuc tiu ng chn , c th lm gim t l cht v NMCT
ti pht nu n c dng trong vng 2 gi sau nhng triu chng u tin. D
sao i na th nhng tc dng ny ch c quan st thy nhm bnh nhn t
nguy c. Tm li hin ti cha c th a ra mt khuyn co v vic dng thuc
chn mt cch thng qui bnh nhn iu tr bng thuc tiu ng.
C bng chng thuyt phc l dng thuc chn ko di c th gim t l
cht sau NMCTC. Nu khng c chng ch nh th cc thuc chn c
khuyn co nh mt phng php iu tr phng nga t t sau NMCTC. Cn
nh gi cn thn chc nng tht tri v nhng yu t bnh l i km khi mun
dng thuc chn cp cu hay ngn nga lu di sau NMCTC.
* Liu lng:

Cc thuc chn ng tnh mch cn c truyn chm v theo di thng

xuyn cn thn huyt p, in tm v p ng lm sng. Liu c khuyn
co ca atenolol l 5mg tnh mch trong 5 pht; i 10 pht sau nu bnh
nhn dung np tt th bt u ng ung vi liu 50mg; sau liu ung l
50mg x 2ln hng ngy.
Metoprolol ng tnh mch c dng vi liu 5mg trong 2 - 5pht v nhc
li sau mi 5 pht n khi t c tng liu l 15mg. ng ung c bt u
sau liu 50mg 2 ln/ngy trong t nht 24 gi v c tng ti 100mg x 2
ln/ngy.
Propranolol c th dng ng tnh mch liu 1 - 3mg trong 2 - 5 pht
(khng vt qu 1mg/pht). Liu ny c th c lp li sau 2 pht cho ti khi
t c tng liu 0,1mg/kg. Liu duy tr ung l 180 - 320mg/ngy chia 2 ln.
Esmolol c tc dng nhanh v thi gian tc dng ngn, n c dng cho
trng hp cn tc dng ngn, lc ban u kim sot tn s tht bnh nhn
c nhp nhanh trn tht bin i. N t nng tc dng trong 30 pht. Vic
kim sot tn s cng t c trc thi gian ny, lc c th chnh tc
truyn hoc ngng li. Esmolol c ng trong ng 2,5g, trc khi truyn phi
pha n ti khi t c nng ti a 10mg/ml. Cch pha l cho 2,5g esmolol
vo trong 250ml dch. Bt u pha truyn esmolol vi liu ln 250 500g/kg/pht v duy tr tip theo vi liu 25 - 50g/kg/pht cho 4 pht. C mi
khong 5-10 pht th chnh liu 1 ln t liu 25 - 50g/kg/pht cho n liu ti a
l 300g/kg/pht.
* Ch :
Tc dng khng mong mun chnh ca thuc chn l gy tt huyt p, suy
tim huyt v co tht ph qun. S dng thn trng cho nhng bnh nhn nng
khi ang dng cc thuc kch thch th th - adrenergic. Khng nn dng n
khi m chc nng tim suy gim v nhng trng hp sau ngng tim.
Suy tim huyt do thuc chn gy ra c th iu tr bng li tiu v gin
mch, nhng thng phi dng thm cc thuc vn mch. bnh nhn c bnh l
mn cm ca ng h hp, thuc chn c th gy co tht ph qun nng, thm
ch t vong. Khi co tht ph qun xut hin c th iu tr bng aminophylin v
cc amin giao cm. Chng ch nh dng thuc chn trong trng hp bnh
nhn b bloc nh - tht hoc nhp chm nng. Atropin c th khi phc nhp tim b
chm do chn gy ra. Nu nhp chm khng p ng vi atropin th cn xem
xt phng php to nhp qua da, hoc truyn dopamin hay epinephrin.
Isoproterenol c xem nh l gii php cui cng.
Cc tc dng khng mong mun s nng thm khi n c kt hp vi cc
thuc khc c tc dng tng t (nh chn dng Ca++, cc thuc chng tng
huyt p, cc thuc chng lon nhp).

sc chn thng
L Xun Thc

1. i c-ng:

1.1. Vi nt lch s pht trin ca sc chn thng:

Danh t sc (shock) ln u tin c Francois Le Dran m t nm 1737. V sau
nhiu tc gi b thi gian nghin cu gii thch tnh trng phn ng bnh l ny.
Nhiu danh t c a ra ch tnh trng bnh l ny nh ting la tinh gi l
torpor, stupor; ting c l wundschrek, traumatischer, torpor; ting Php l choc,
secousse; ting Anh l shock... Ni chung trong vng 100 nm u s hiu bit v
bnh l ca sc cn th s nn cch iu tr cng n gin t thu c kt qu.
Giai on mi trong lch s pht trin ca sc l t nm 1853 - 1856. Trong
thi k ny xy ra cuc chin tranh Crime v c bit l cuc phng th ca cc
chin s qun i Nga hong bo v pho i Sevastopon chng li qun i
ng minh Anh, Php. Trong thi gian ny s lng thng binh xy ra kh ln.
Cc thy thuc lc ny trn thc t nhn thy rt nhiu hnh thi khc nhau
ca sc chn thng. Mt thy thuc c nhiu kinh nghim nghin cu v sc
trong giai on ny l Pirogov A.I. Qua thc t quan st tnh trng bnh nhn ng
m t tnh trng lm sng ca cc bnh nhn b sc tng i in hnh. Khi
m cc t thi cht v sc Pirogov nhn thy c s phn b mu khng u
trong cc c quan ni tng, tim trng rng, trong khi cc mch mu ln c
s lng mu cha tng i nhiu hoc ngc li. Phng php iu tr lc ny
l cho thng binh ung ru vang mnh, si m bnh nhn, tim thuc gim
au. Pirogov cng nu ra l khng nn phu thut nhng bnh nhn m tnh trng
sc cha c iu tr tt.
Nm 1867 Jorden ra vic chn on sc bng cch o huyt p ng mch
v ng tin hnh cc thc nghim v sc u tin trn sc vt. Nhng thuyt
v sc cng dn c hnh thnh.
+ Thuyt thn kinh: Thuyt ny c mt s tc gi ra (Pirogov, Cooper,
Bilroth, Crile ...) v gii thch do tn thng ti ch cc c quan th cm th ca
h thn kinh b kch thch. Cc lung thn kinh c dn ln h thn kinh trung
ng gy nn tnh trng kch thch h thn kinh ni tit, to nn mt tnh trng
phn ng bo v b tr ban u nh co mch, phn phi li mu tun hon, lp li
p lc thm thu, iu chnh li ri lon nc v in gii khoang ngoi t bo,
duy tr p lc thu tnh trong mch mu a huyt p ng mch tr li bnh
thng. Giai on ny c gi l giai on sc tin pht hay sc cng. Khi cc
phn ng ca h thn kinh b kit qu, cc phn ng b tr khng cn duy tr
c na th sc chuyn sang giai on sc nhc. Ph hp vi thuyt ny, ngi

ta thy nhiu chin s b mt mi, thn kinh cng thng v chin u, hay lo s,
cm xc qu mnh thng b sc nng khi b thng. Cc thuc gim au, thuc
an thn, thuc m, hoc thuc lit thn kinh c th ngn chn hoc hn ch c
qu trnh sc pht trin. Nhiu tn thng h thn kinh c pht hin trn
nhng bnh nhn cht do sc. Nhng c hin tng khng ph hp l: gy t
hoc gy m khng loi b c sc chn thng.
+ Thuyt tc m ca Porter (1917): Tc gi da trn thc nghim tim m
vo mch mu no ca th thy xut hin tnh trng phn ng nh sc. Trn thc
t ch c mt s thng binh b gip nt xng di c th gy ra tc m cn i
a s ngi ta khng nhn thy nh vy.
+ Thuyt nhim c do Quenu xng (1918) : Tc gi cho sc l do s
tch lu c t t cc cht hu hoi ca t bo. ng chng minh bng nhng nhn
xt nhng bnh nhn sau khi tho gar. Thuyt ny khng gii thch c cc
tnh trng sc khc ngoi hnh thi sc m Bywaters m t trong nhng nm
1940 - 1941 c gi l hi chng Crush (Crush Syndrome).
+ Thuyt chu k ca Moon: V khng th gii thch c tt c cc hin
tng ca sc theo mt c ch thng nht nn Moon a ra mt thuyt gi l
chu k Moon. Theo Moon chu k ny c 4 giai on. C th tm tt sau:
- Giai on 1: Suy tun hon c th xut hin sau mt nguyn nhn nhim
c thn kinh hay mt mu.
- Giai on 2: Sc c b do cc phn x bo v nh tit cc cathecholamine
t tu thng thn, tng tit cc corticoide, co lch.
- Giai on 3: Sc mt b. Cc mch mu khng cn trng lc, tun hon
suy sp dn ti thiu xy cc t bo v t chc.
- Giai on 4: Vng lun qun xut hin cui cng. Thiu xy lm gii phng
cc cht c, tc ng ln h thn kinh v mao mch, lm cho cc ri lon ca
suy tun hon nng ln, c bit mao mch mt trng lc, dch trong lng mao
mch s xut ra ngoi.
Thuyt ny c nhiu im cn ang trong giai on gi thuyt, tuy nhin n
c th gii thch nhiu s kin lm sng. Qua cho thy sc l th bnh l c
bit, sc khng phi l n thun, m n xen k ln nhau v c th do nhiu
nguyn nhn gy nn.
+ Thuyt suy sp tun hon: khi b chn thng hay mt mu th c th c
phn ng b tr bo v nh co mch, lm cho khi lng tun hon ph hp vi
th tch cha cc mch mu. Tuy nhin cc phn ng tc th ny khng th ko
di. Sc hay l s suy sp tun hon s xut hin khi c th mt kh nng b tr.
Nguyn nhn g gy ra s suy sp tun hon . C 3 nguyn nhn c ra:
- Tng thm thu ca mao mch: Tc nhn chn thng s lm thay i
tnh thm thu ca mch mu lt cc phn t c trng lng cao m bnh
thng khng thot ra ngoi mch mu c (th d nh albumin, thot ra ngoi
thnh mch s lm gim p lc keo trong lng mch, do nc s khng c
gi trong mch mu, lm khi lng mu tun hon b thiu ht). Tnh trng ny
gp trong sc bng. Truyn mu v dch c th khi phc li khi lng mu

tun hon nhng khng lm hi phc sc thm ca thnh mch c. Tuy nhin
trong nhiu trng hp sc ngi ta khng thy ph n do thot dch.
- Do mt dch ti ch b thng (Domoon v Blalock xut): Mu v huyt
tng thot ra ngoi ti ch b thng lm gim khi lng mu tun hon. Sc
s qua 3 giai on:
. Sc tin pht: xy ra ngay sau khi b chn thng. H thn kinh ni tit b
kch thch gy co mch.
. Giai on b tr.
. Giai on sc tht (mt b): Khi c ch b tr mt kh nng hot ng, khi
lng mu tun hon s b thiu ht v tun hon s suy sp. Sc do mt dch ti
ni b thng hay gp trong khi b thng, sau m, bng v.v... Do mt dch lm
khi lng mu tun hon gim st dn ti sc. Tuy nhin c nhng trng hp
mt mu khng nhiu m bnh nhn vn b sc.
- Do ri lon s phn phi mu trong h tun hon: Mu c phn phi
ng cc mch mu ln hoc h tnh mch ca.
Tm tt, nhng l do trn y gii thch s suy sp tun hon gy ra sc cng
khng th gii thch mt cch tho ng mi trng hp.
+ Thuyt v bnh mao mch hay l s ri lon vi tun hon do Lang xut
(1945): Trc nhng chn thng c gii mnh hoc mt mu c th c phn ng
t v co mch mu duy tr mc huyt p bnh thng. Phn ng ny xy ra
giai on u ca sc. Do co mch nn qu trnh thiu xy mao mch xy ra
trc tin. Thiu xy nn qu trnh chuyn ho cht b ri lon. Cc cht c do
chuyn ha s lm cc mao mch b nhim c, gin ra v lit. Huyt tng thot
ra ngoi v lm khi lng mu tun hon cng gim v mu b c c. Thuyt
ny v sau c Laborit v Huguenard pht trin (1954). Cc tc gi ny cho sc
trc tin gy ra bi qu trnh ri lon tun hon ngoi vi v c s tham gia trc
tip hoc gin tip ca h thn kinh giao cm adrenalin. Trc nhng kch thch
au c th phn ng tit ra catecholamine gy co tht cc mch mu nh v lm
qu trnh thiu xy t bo xut hin. V vy 2 tc gi trn ra vic iu tr
sc trc tin nn dung dch cocktail litique (thuc phong b thn kinh, gim au
v khng histamin tng hp) hn ch cc kch thch ca sc v bo v c th.
Trn y ni s qua lch s pht trin ca sc v nhng thuyt nu ra
gii thch tnh trng bnh l phc tp ny, nhng cha c thuyt no c th gii
thch y qu trnh phn ng bnh l ny. Trn thc t cc yu t gy ra sc l
phi hp (mt mu, dch, nhim c...). Nhng tng trng hp c th c yu
t gy bnh tri hn ln nh hi chng vi lp th yu t nhim c l ch yu,
khi b thng hoc bng th yu t mt mu, mt dch l chnh... Cho nn tu
tng trng hp c th cn phi phn tch v ra bin php iu tr cho thch
hp. Nhng phi nh rng d t hay nhiu cc yu t trn c phi hp vi nhau.
Cho nn iu tr sc chn thng l phi iu tr tng hp.

1.2. nh ngha:
Sc chn thng l tnh trng phn ng bnh l phc tp c tnh cht giai
on ca c th m tnh trng ny gy ra bi nhng chn thng c gii mnh v
mt mu. Tnh trng phn ng bnh l ny biu hin nhng ri lon chc nng
cc c quan ca c th (tun hon, thn kinh, h hp, ni tit, tiu ho v chuyn
ho). Trong nhng ri lon ny quan trng nht l ri lon vi tun hon v
chuyn ho cht.
2. C ch bnh sinh:
Trc nhng chn thng v mt mu c th c phn ng bo v nh tim p
nhanh, mch mu co li, mu ho long, th tng... Trong cc phn ng thch
nghi ny c 2 hin tng cn ch l qu trnh co tht cc mch mu nh v hin
tng ho long mu. Qu trnh ho long mu xy ra ngay sau khi b chy mu
cp nhng s hi phc hon ton th tch huyt tng b mt thng phi sau mt
thi gian 24 - 48 gi. Qu trnh co tht cc mch mu nh do phn ng ca h
thn kinh giao cm nhanh hn. Cc catecholamine c tit ra lm cc mch mu
co li gi huyt p khi tt. Ngi ta gi giai on ny l giai on sc cng.
Hin tng co tht cc mch mu nh s lm mu khng qua h thng mao mch
c m qua cc shunt ni ng - tnh mch tr v tim m bo khi lng
mu cung cp cho cc c quan quan trng nh tim, no. Hin tng ny gi l
hin tng thiu xy t chc v t bo xy ra trm trng do co tht cc mao
mch. Tnh trng thiu xy ny cng tng khi s mt mu cng ln v c km
theo ri lon thng kh. Do thiu xy nn qu trnh chuyn ho b d dang.
Nhng sn phm ca qu trnh chuyn ho d dang ny nh a.lactic, a.puruvic,
ferritin, histamin... tng ln s dn ti tnh trng toan v lm nhim c thnh
mch, lm cc mao mch b lit v gin ra. Lc ny huyt p tt v sc chuyn
sang giai on nhc (sc nhc). Bnh nhn nm trong tnh trng c ch. Nu
khng c iu tr th tnh trng ny c th ko di ti cht.
Khi cc mao mch b lit v gin ra s lm mu ng h mao mch, huyt
tng s thm ra ngoi lm mu b c li v cc hng cu s dnh vo nhau. Hin
tng ng mu ri rc trong lng mch xy ra. giai on ny vic iu tr sc
rt kh khn, ngi ta gi giai on ny l giai on sc khng hi phc. Hin
tng ho long mu (hemodilution) xy ra r rng nhng trng hp mt mu
hn nhng trng hp b chn thng n thun. sc chn thng, hin tng
phn ng bnh l xy ra phc tp hn v n bao gm c mt mu v chn thng.
Qua s phn tch c ch bnh sinh trn cho thy: lc u yu t gy bnh
ng vai tr quan trng l mt mu v chn thng, nhng cng v sau th tc
nhn gy bnh ch yu li l nhng yu t khng c hiu (nhng sn phm ca
qu trnh chuyn ho do thiu xy) ngy cng tng v gi vai tr quan trng.
Mun ngn chn nhng yu t khng c hiu trn cn phi iu tr sm,
mun vic iu tr s rt kh khn. Chnh nhng yu t khng c hiu ny s
gy ra nhim c h vi tun hon, ng thi n s gy hng lot cc ri lon bnh

 h thn kinh, gan, phi, thn, tiu ho... Nhng ri lon ny s dn ti qu trnh
t vong ca bnh nhn.
3. Phn loi sc chn th-ng:
+ Theo nguyn nhn:
- Sc thn kinh phn x.
- Sc mt mu.
- Sc nhim c v.v...
+ Theo thi gian xut hin:
- Sc tin pht.
- Sc th pht.
+ Da vo din bin lm sng:
- Sc cng.
- Sc nhc.
- Sc hi phc v khng hi phc.

3.1. Sc cng:
Bnh nhn trong tnh trng phn ng kch thch, mch nhanh huyt p tng,
th tng... Theo nhiu tc gi nhn thy sc cng thng xy ra trong vng 10 30 pht u. T l thng gp khong 8 - 12% (Sraiber M.G). C ngi cho sc
cng xy ra hu ht cc thng binh nhng mc phn ng c khc nhau,
i khi yu qu nn tng nh khng c (Petrov).

3.2. Sc nhc:
H thn kinh trung ng b c ch nn cc phn ng ton thn cng trong tnh
trng suy gim. Sc nhc chia ra cc mc sau:
+ 1: HA = 90 - 100 mmHg.
Mch = 90 - 100 mmHg.
H thn kinh trung ng b c ch nh, cc phn x gim.
+ 2: HA = 80 - 90 mmHg.
Mch 110 - 120/pht.
Da xanh, th nng. Thn kinh trong tnh trng c ch.
+ 3: HA = 60 - 70 mmHg.
Mch = trn 120/pht.
Da xanh nht, c ch nng thn kinh, tri thc l m.
+ Tnh trng tn cng: l tnh trng nng, trm trng, gy ra bi nhiu nguyn
nhn nh gip nt c v xng, chy mu cp, bng, ngt th, ng c... Mc d
nguyn nhn khc nhau nhng biu hin lm sng ging nhau. Tnh trng tn
cng c chia ra:

- Tin hp hi: Tri thc b ri lon, khng ly c huyt p. Mch ch s

thy cc ng mch ln (bn, c), th nng v nhanh.
- Hp hi: Tri thc khng cn, mch v huyt p ch khng ly c ngoi
vi. Ri lon h hp nng, th ngp c.
- Cht lm sng: Ngng tim, ngng th thi gian ko di khong 5 pht, nu
khng iu tr s chuyn sang cht sinh vt.

3.3. Sc hi phc v khng hi phc:

Vn ny rt quan trng. Nu qu trnh thiu xy ko di s gy nhng tn
thng khng hi phc, th hin trc tin no, sau tt c cc c quan
khc. Qu trnh ny ph thuc vo vic cung cp mu. Nu huyt p h thp
mc 60 - 70 mmHg ko di c th dn ti tnh trng sc khng hi phc. Theo
nghin cu ca Vasaze (1966): nu huyt p mc 40 mmHg trong vng trn 2
gi, v HA mc 60 mmHg trong vng 7 gi th sc s chuyn sang giai on
khng hi phc. Nu huyt p h thp, thm ch khng o c nhng c iu
tr a ngay huyt p tr li ngng lc bnh thng ca thn trong thi gian
ngn th c th tnh trng sc khng hi phc s khng xy ra.
Thc t qu trnh bin i khng hi phc th ngoi huyt p ra n cn ph
thuc c vo tnh trng tn thng ca cc c quan quan trng na. nh gi
qu trnh sc hi phc hay khng cn phi cn c vo tnh trng lm sng v tnh
trng c th tn thng tng bnh nhn mt.
4. Triu chng lm sng:
Trc y Pirogov miu t:
"Nn nhn mt tay hoc mt chn b gip nt trm cp cu, khng ku ca,
khng van ni, khng c ng v khng i hi g. Thn th gi lnh, mt nht
nht nh mt xc cht, mt khng c ng v nhn v ni xa xm, mch nh si
ch v rt yu. Hi nn nhn khng tr li hoc tr li th thm ch cho mnh
nghe thy. H hp chm, vt thng v da hu nh mt cm gic, nhng nu c
si thn kinh ln li ra ngoi b kch thch th nn nhn phn ng bng s co nh
nhng cc c tng ng. Tnh trng ny ko di vi gi hoc cho ti khi cht".
Thc t nhn xt ca Pirogov cho ti nay vn cn gi tr.

4.1. Triu chng thn kinh:

Bnh nhn trong tnh trng kch thch (lc u), sau chuyn sang giai on c
ch nhng tri thc vn cn. Phn x gim.

4.2. Ton thn:

Da xanh xao, c th c vt ph xm da. Nhit gim, da lnh. Chy m hi.

4.3. Tun hon:

Tim nhp nhanh, mch nhanh nh c khi khng ly c. Huyt p ng
mch v huyt p tnh mch trung ng gim.

4.4. H hp:
Th nhanh dn ti tnh trng gim CO2, v sau th nhanh nng.

4.5. Tit niu:

Lng nc tiu gim. Theo di lng nc tiu c th cho bit tin lng
ca bnh nhn. Bnh thng lng nc tiu bi tit 1 - 1,5ml trong 1 pht.
Nguyn nhn gy gim niu l do co tht mch mu thn, tng tit yu t chng
li tiu ca thu sau tuyn yn (ADH), do HA thp v mt mu, ri lon chc
nng ng thn do lng ng myoglobine trong iu kin toan mu v nhng sn
phm hu hoi nhng t chc gip nt.

4.6. Sinh ho:

Toan chuyn ho, kali mu tng.
5. iu tr sc chn th-ng.
Qu trnh sc l mt qu trnh bnh l phc tp, kt qu iu tr ph thuc
vo thi gian iu tr sm hay mun, iu tr cng sm kt qu thu c cng
cao. Do , nguyn tc u tin trong iu tr sc l phi iu tr sm v
phng sc. Nguyn tc th hai l phi iu tr ton din c phn bit v khng
dp khun. Qu trnh iu tr phi tp trung vo gii quyt my khu sau:

5.1. Chng nhng ri lon v pha h thn kinh:

+ S dng cc thuc gim au:
C th dng mt trong cc thuc mocphin, pantopon, dolargan, fentanyl... cho
tt c cc trng hp tn thng c gii. ng tim truyn l ng tnh mch,

khng nn tim bp, hoc tim di da v tun hon ngoi vi nhng bnh nhn
sc b suy gim nn vic hp th thuc vo mu chm hoc km. Phi ch cc
thuc gim au gy ra tc dng ph l c ch h hp cho nn khi c ri lon h
hp th chm hoc chn thng s no th tim thuc phi thn trng. Trc khi
tim thuc gim au phi khm v pht hin cho c cc tn thng ni tng ,
nu khng phi ghi r tim thuc g v thi gian tim tuyn sau da trn c
s c thi phn on hp l.
+ Gim au ton thn:
Dng thuc m hoc thuc ng cho nhng trng hp c tn thng c gii
hoc bng nng. Phng php ny c tc dng chng sc tt nhng phi m bo
thng kh cho tt. Vi quan im ny cc nc tin tin thng s dng khi
N2O v xy cho bnh nhn th. Khi c iu kin cho t ni kh qun kt hp vi
gin c v tin hnh h hp nhn to.
+ Phong b novocain:
Tin hnh phng b novocain cho tt c cc loi tn thng c gii, bng v
ni t gar. C th tin hnh ngay ni xy ra tai nn nu nh iu kin cho
php. Phng php tin hnh c th phong b ni gy, phong b thn, dy thn
kinh, t ngoi bao cng hoc cnh ct sng...
+ C nh chc nhng ni b gy xng hoc nhng chi b tn thng phn
mm rng. Vn chuyn nn nh nhng.
+ Cho ung ru: C ngi cho ru tc dng kch thch h thn kinh giai
on sc nhc. Mt s cho ru c tc dng gim au. Hin nay vn ny
cng cn bn ci v tc dng gim au ca n t nhng khi t chy n cn phi
lng xy ln.
+ S dng thuc c ch thn kinh v thuc phong b hch trong sc: Phng
php iu tr ny c Bigelow v Laborit tin hnh t lu. Cc tc gi cho sc
gy ra ri lon vi tun hon trc tin. Cc mch mu nh co tht li do phn x
v do lng catecholamine tng tit. Cc tc gi ch trng dng dung dch
cocktail litique. Mt s tc gi khc (Guber, Vinogradov, Diachenko) trn thc
nghim v lm sng cng khng nh tc dng chng sc ca cc thuc phong b
hch v c ch thn kinh. L do l n c tc dng c ch thn kinh, gim kch
thch nn gim bt tiu hao nng lng, chng nhng lung xung ng i xung
gy ra nhng ri lon cc c quan pha di. Nhng c mt iu bt li trong
trng hp ny l n gy h huyt p. Do khi huyt p mc gii hn
(ngng thn) th phi thn trng khi dng phng php trn. Vinogrdov dng
phng php phong b hch khng h huyt p chng sc cng thu c mt
s kt qu tt nhng bnh nhn sc nng. Tc gi dng mt thuc co mch nh
mesaton, hoc noradrenalin 2 - 3 mg + HTN 5% 250ml nh git tnh mch duy
tr huyt p cho bnh nhn, ng thi dng mt thuc phong b hch nh
pentamin 60 - 100mg hoc benzohexonie 40 - 60mg. i vi phng php ng
min ca Laborit dng dung dch cocktail litique chng ch nh cho cc trng
hp sau:

- Huyt p h di mc gii hn.

- Cn chy mu.
- Cha chn on tn thng chnh xc v c th gy ra tnh trng nguy kch
lm cho chn on km chnh xc.
Dung dch cocktail litique gm: Dolargan 100mg
Pipolphen 50mg
+ Nc ct va 10ml.
Aminazin 25mg
Mi ln tim 2 ml dung dch ny.

5. 2. Chng ri lon tun hon:

+ Lm ngng chy mu: C th dng bng p, gar, kp mch mu t hoc
m cp cu cm mu. Bin php lm ngng chy mu rt quan trng, khng
th a bnh nhn ra khi tnh trng sc khi cha cm mu c.
+ B xung li lng mu mt: Trong sc chn thng vn mt mu ng
mt vai tr rt quan trng. C ngi cho rng sc chn thng thc cht l sc
"mt mu". Do vic hi phc li lng mu mt c mt ngha quyt nh.
Khi mt mu s dn ti hng lot cc thay i bnh l. Nu hi phc li lng
mu mt nhanh th c th trnh c nhng ri lon bnh l trn. Trn th
nghim cng nh trn lm sng ngi ta thy: khi mu mt t 10 - 25% khi
lng mu tun hon ch gy ra tnh trng h huyt p t v ngn, khng gy ra
nhng ri lon nng v huyt ng. Nu lng mu mt trn 25% s gy ra
nhng ri lon nng v huyt ng c th dn ti t vong nu nh khng c
iu tr kp thi. Vic chn on khi lng mu mt l bao nhiu c mt ngha
rt quan trng. C nhiu bin php da vo nh gi lng mu mt nh:
da vo huyt p ng mch, tn s mch p, ch s sc, t trng mu, huyt p
tnh mch trung tm c th cho bit s b lng mu mt. Nhng chnh xc hn
vn l do trc tip th tch mu mt bng phng php ho long cht mu xanh
Evans hoc cht ng v phng x.
Lin quan gia ch s sc v lng mu mt:
Tnh trng BN

Ch s sc (mch p/pht
trn HA ti a mmHg)

Mu mt

1. Bnh thng

60/120 = 0,5

2. Sc 1 - 2

100/100 = 1

20 - 30%

3. Sc mc 3

120/80 = 1,5

30 - 50%

Lin quan gia t trng mu, hematocrit, hemoglobin vi lng mu mt.

Lng mu mt

T trng

Hemoglobin

Hematocrit

- 500 ml

1,057 - 1,054

65 - 62%

44 - 40%

- 1000 ml

1,053 - 1,050

61 - 53%

38 - 32

- 1500 ml

1,049 - 1,044

53 - 38

30 - 23

Trn 1500ml

< 1,044

< 38

< 23

Khi xc nh c lng mu mt th tin hnh truyn mu v dch thay

th mu. Nguyn tc b li mu mt phi m bo ch s hematocrit t 30%.
Vi ch s ho long mu nh trn mi m bo tun hon hot ng bnh thng
khng c nhng ri lon nng v huyt ng. Mt khc cn lm cho vi tun hon
hot ng tt. Tc truyn da vo huyt p ng mch v huyt p tnh mch
trung tm trnh tnh trng b qu nhanh gy ph phi cp.
- Cc cht thay th mu hin nay c dng l:
Dextran 70 (phn t = 60.000 - 75.000) dung dch 6%, plasmadex, macrodex,
polyglukin. Ngoi tc dng thay th mu cc cht ny cn c tc dng chng
ng vn tiu cu v hng cu. Khng c truyn qua 2.000ml v c th gy ri
lon ng mu.
Dextran 40, rheomacrodex (phn t 40000) dung dch 10% c tc dng ht
nc t gian bo vo lng mch lm tng th tch mu tun hon (tc dng ngn
v thi qua thn nhanh).
Haemacel, gelafundyl, polyvinilpirolidon, periston, subtosan.
Ringer lactat.
Ngoi ra cn c th dng cc huyt thanh mn, ngt, cc dung dch m thy
phn, huyt tng kh...
- V ng truyn dch: ch yu bng ng tnh mch.
+ Vn bm mu vo ng ng mch: hin nay t dng v n c nhiu
kh khn v bin chng, phi c bc l ng mch, bm mu di p lc, gy ri
lon lu thng mch mu v c th gy thrombose. Kt qu thu c cng khng
r rng lm, v vy hin nay ngi ta truyn mu ch yu qua ng tnh mch
ln. Khi cn thit c th t hai dy truyn dch qua 2 tnh mch.
+ Xoa p tim: tin hnh khi c hin tng ngng tim (xem iu tr cht lm
sng). Phi tin hnh ngay khi pht hin ngng tim, khng c lu qu 5
pht. Phng php tin hnh xoa p tim trong lng ngc (trc tip) nu nh lng
ngc m, hoc ngoi lng ngc (gin tip) tit kim c thi gian v kt qu
thu c cng tt khng km phng php xoa p trc tip.
+ Ph rung tht: khi c hin tng rung tht phi tin hnh ph rung bng in.
+ Dng thuc duy tr trng lc ca mch mu: y l mt vn kh phc
tp. Trong giai on u ca sc c hin tng co mch l ch yu, giai on ny
ch yu l b li dch v mu, giai on ny mt s c ch trng cho thuc
gin mch cng vi b dch. Nu huyt p h thp di ngng thn th song
song vi truyn dch c th cho thm thuc co mch. Thuc co mch thng
dng l noradrenalin, aramin, dopamin... Phi ch khng c lm dng v

dng thuc co mch nhiu c th gy qu trnh thiu xy t bo do co mch, lm

qu trnh sc cng nng hn.

5.3. iu tr suy h hp ngoi:

Suy h hp ngoi trong sc thng xy ra. Nguyn nhn c nhiu nh tc do
m ri, mu trn vo ng th, tt li lm che lp thanh mn, gip nt lng
ngc, trn kh ph mc, tn thng trung tm h hp...
Nguyn tc iu tr l phi tm nguyn nhn, loi b nguyn nhn. Mt khc
phi tu tnh hnh c th m ra bin php iu tr cho thch hp.
+ Th xy: Phi ch ti my im sau:
Trc khi cho th xy phi lm thng ng th bng cch ht sch m di,
mu, ly ht d vt gy cn tr ng h hp, lc cho th xy mi c tc dng.
nhng bnh nhn th nng, c ri lon h hp nng nu dng xy cho th
qua mi th t c tc dng. Tt nht l t ng ni kh qun v tin hnh h hp
nhn to bng kh tri cng tt. Khng nn dng xy 100% tin hnh h hp
nhn to ko di v c th dn ti tnh trng ng c xy. Hp l nht l cho th
xy + kh tri (m bo xy 60 %).
+ H hp nhn to: L bin php rt cn thit trong vic iu tr sc. Tu theo
mc v iu kin m c th dng nhng phng php t n gin nh thi
ngt "mm vo mm" hoc "mm vo mi", thi qua ng hnh ch S, c th dng
ambu th, b th, th qua mt n hoc qua ng ni kh qun. nhng ni c iu
kin ta c th cho th my. Nu dng my tin hnh h hp nhn to ngi ta
thng kt hp cho thm thuc m N2O + xy gim au v thuc gin c nu
cn tin hnh h hp cho d dng.
+ Vn t ni kh qun v m kh qun: Thng khi cp cu nhanh
chng suy h hp nu c iu kin th t ni kh qun. Nhng xt thy qu trnh
h hp nhn to phi ko di, bnh nhn khng th t th c sau 24 gi, cn
ht m di lu di th c ch nh m kh qun. mt s bnh nhn b chn
thng s no nng, hn m ngi ta thng tin hnh m kh qun sm. Tt
nhin chm sc h l nhng bnh nhn ny kh phc tp.
+ H nhn to: nhng bnh nhn b hn m th phn x ho yu, m di
nhiu ngoi vic ht sch m di cn c th dng my kch thch gy ho tng
m di ra hoc sau khi ho th li tip tc ht sch m di.
+ phng v iu tr ph phi: Ngoi cc bin php chung nh cho bnh
nhn th xy, phong b thn kinh ph v, cho khng sinh, tr tim... ngi ta
khuyn cho th xy qua cn lm gim qu trnh tng tit bt trong ph nang,
cho th xy di p lc lm qu trnh khuych tn xy qua ph nang tt hn.
Dng thuc li tiu lasilix hoc manitol.

+ Vn dng thuc kch thch h hp: Phi thn trng v n lm cho qu

trnh thiu xy no tng ln do thuc kch thch no. Lobelin khng c dng
trong sc.

5.4. iu tr ri lon v ni tit:

Trong sc chn thng, ri lon ch yu ca h thn kinh ni tit l khu
tuyn yn v thng thn l quan trng nht, cho nn ngi ta ch trng iu
chnh ri lon ny bng cho corticoide (cortisol, cortancyl, prednisolon). Tc
dng ch yu ca n l tng cng sc chng ca c th, chng ph n,ngoi
ra n cn c tc dng iu chnh li thng bng kali. Kinh nghim ca mt s tc
gi cho rng tc dng ca corticoide trong nhng ri lon cp tnh v huyt ng
v h hp km hn trong qu trnh nhim c nhim trng. S dng ACTH t tc
dng hn cortisol. Vn ny cng cn mu thun v trn thc t thc nghim
mt s tc gi thy nhng bnh nhn b sc th lng hocmon ca tuyn thng
thn tng hn bnh thng ch khng phi suy gim. Tuy vy, trn thc t ngi
ta dng corticoide thy tc dng ca n trong chng sc rt tt, lm chm qu
trnh chuyn sang sc khng hi phc.
Liu iu tr c ngi ch trng cho cortisol 100mg trong 2 - 3 ngy. Cng
c ngi ch trng cho liu cao mt ln 25 - 50mg/kg (Veghelyi, 1966).
Khi s dng phi theo di in gii v m trong huyt tng khi dng
nhiu ngy.

5.5. iu tr ri lon chuyn ho trong sc:

+ Chng trng thi toan: C th dng bicarbonat Na, lactat Na hoc THAM
(trihydroxy methyllamino metan). Da trn thiu ht kim d (BE) ngi ta tnh
c lng kim thiu nh sau:
Tng s lng kim thiu bng trng lng (kg) x 0,3 x (-BE).
Bicacbonat - Na 8,4% x 1ml = 1mEq kim.
Lactat - Na 11% x 1 ml
= 1mEq kim.
THAM 3,6 x 1 ml
= 0,3 mEq kim.
Th d: nu tng s lng kim thiu l 90 mEq th kim phi dng l 90ml
bicacbonat Na 8,4% hoc 90ml dung dch lactat Na 11%, nu dng THAM 3,6%
phi mt 300ml.
+ Chng hin tng tng kali mu: cho clorua calci hoc cho thm Na. Cng
c th truyn dung dch glucoza + insulin to ra nng lng y kali vo t
bo. Kim tra lng kali trong huyt tng.
+ Truyn m, Plasma khi thy thiu m, cho vitamin nhm C v nhm B.
+ m bo ch hp l v nhit , khng nng hoc lnh qu. Nu
thng binh b lnh qu th cn m cho thng binh, nhng khng nn chm
nng qu gy gin mch c th dn ti s try mch.

5.6. Chng nhim trng:

Trong sc chn thng nn dng khng sinh ngay t u phng v
chng nhim trng. C th dng loi thng dng nh penicillin, gentamycin...
phng un vn nn dng thuc SAT cho tt c cc thng binh b tn
thng c gii (nu khng thuc ta phi cho cc thng binh c vt thng
bn trc). Bnh nhn cha c tim cn ghi r tuyn sau tim.
phng hoi th sinh hi cn cho thuc chng hoi th.
6. Vn can thip phu thut trong sc.
Tt c cc thng binh b sc c th chia ra lm 3 nhm:

6.1. Nhm 1:
thip phu thut l ch nh sng cn i vi thng binh. Nhm ny gm
cc bnh nhn ang chy mu, ngt th do nhng nguyn nhn bn trong lng
ngc, mu t trong no, gip nt cc ni tng trong bng. nhm ny cn phi
nhanh chng dng cc bin php hi sc tng hp chng sc cho thng binh. S
dng phng php v cm hin i, m bo thng kh tt cho thng binh ng
thi tin hnh m gii quyt nguyn nhn, yu cu m phi nhanh v gii quyt
nhng ci cp thit ti thiu.

6.2. Nhm 2:
L nhm thng binh cn can thip phu thut nhng c th tr hon c
bng cch cho thuc khng sinh phng nhim trng, iu tr hi sc a bnh
nhn ra khi tnh trng sc ri mi m. Thuc nhm ny gm ct lc x tr vt
thng phn mm, nn gy xng...

6.3. Nhm 3:
L nhm bnh nhn qu nng khng c ch nh phu thut, gm nhng
thng binh b gip no nng, v nhiu ph tng, tnh trng tn cng khng lm
g c hoc cc thng binh nh ch cn iu tr sc cho tt.
7. nh gi th-ng binh ra khi tnh trng sc.
Ta phi cn c vo cc ch s sau:
- Huyt p c n nh khng?
- Mch c ny khng, tn s c nhanh khng?
- Tri thc bnh nhn c tnh khng, cm gic ch quan th no?

- Da chn tay c m khng, cc tnh mch c ni khng?

- Lng nc tiu c bnh thng khng?
- Ch s huyt ng v mu (hng cu, hematocrit, hemoglobin) tr li bnh
thng cha?
- Ch s in gii, toan kim bnh thng cha?
Ch khi no cc ch s trn tr li bnh thng th mi c th kt lun thng
binh ra khi tnh trng sc.

Sc nhim khun
Trn Duy Anh

Sc nhim khun (SNK) l mt loi sc nng v phc tp m trong s

nhim khun l yu t khi pht dn n mt lot cc phn ng rt phong ph v
min dch v ni mi ca c th, gy ri lon nng chc nng ca nhiu c quan
h thng, c bit l h tun hon lm gim ti mu v cung cp oxy cho m
t chc.
1. Dch t v mt s thut ng.
SNK l nguyn nhn gy t vong thng gp nht ti cc khoa hi sc (n
ng hng thc 13 ca cc nguyn nhn gy t vong M). Hng nm c
400000 trng hp nhim trng mu v 200000 trng hp sc nhim khun xy
ra cc nc Ty u. T l t vong do sc nhim khun dao ng t 20-80%. T
nm 1979-1987 t l nhim khun mu M tng thm 1,39% ngha l t
73,6 trng hp/100000 bnh nhn ln ti 175,9 trng hp/100000 bnh nhn,
t l ny tng chung cho mi la tui nhng tp trung nhiu nht tui trn
65. C mt s yu t c th gp phn lm tng t l sc nhim trng: liu php c
ch min dch tr bnh c tnh; ghp tng; tiu ng; suy thn; cc th thut y
hc xm nhp (lun catheter, thay van tim, clip mch mu, th my...) .
V thut ng, theo Hi lng ngc v Hi hi sc M thng nht cng nhn
cc khi nim sau:
+ Hi chng phn ng vim nhim ton thn (systemic inflammatory
response syndrome - SIRS): c xc nh khi tn ti hai hoc nhiu hn cc du
hiu sau:
- St hoc thn nhit thp.
- Nhp nhanh tim.
- Th nhanh.
- S thay i s lng bch cu.

Hi chng SIRS c th khi pht do b nhim trng hoc khng phi do

nhim trng nh chn thng hoc vim ty hoi t.
+ Nhim khun mu (sepsis) l phn ng vim nhim ton thn (SIRS) m
nguyn nhn l do nhim khun.
+ Sc nhim khun (septic shock) l nhim khun mu (sepsis) mc nng
c km tt huyt p ng mch ko di (vi mc p lc tm thu < 90mmHg) mc
d c b dch tha ng.
+ Sc ni c t (endotoxic shock) l mt hi chng xy ra cc ng vt
thc nghim sau khi a mt s lng ln cht lipopolysaccaride (LPS,
endotoxin) vo mu. N l mt thnh phn cu trc mng t bo ca cc vi
khun gram (-).
+ Nhim ni c t mu (endotoxemia) l ch s tn ti ca cht ni c t
(endotoxin) trong mu cc bnh nhn b nhim khun mu (sepsis) v sc
nhim khun (septic shock) .
+ Cn lu thut ng vng khun huyt (septicemia) hin nay khng c
dng na cc nc Anh, M v Ty u v khi nim ny rt m h v khng
chnh xc.

2. Vi khun hc:
SNK c th do nhiu loi vi khun gy ra, cc trc khun gram (-) thng gp
hn c (70%), nhng SNK nng li thng do vi khun gram (+). Ngi ta hu
nh khng gp trng thi sc gy ra do nhim vi rt.
Gram (+) (30%)

Gram (-) (70%)

Staphylococcus

Escherichia coli

Streptococcus

Klebsiella

Pneumococcus

Enterobacter

Clostridium perfringeus

Pseudomonas

Clostridium tetani...

Proteus...

3. Sinh l bnh.
Khi u ca nhim khun xut hin s tng sinh vi khun, tip theo chng
di chuyn vo trong mu, ri tip tc khu tr v tng sinh nhiu v tr khc
nhau, gii phng c t vo mu tun hon. Cc cht ny bao gm nhiu thnh
phn cu trc ca vi khun, chng kch thch gii phng cc cht trung gian ni
sinh (mediator) t cc tin cht c trong huyt tng hoc trong cc t bo

(monocyte, i thc bo, t bo ni mc, BC a nhn trung tnh v cc t bo

khc). Cc cht trung gian ny c tc dng sinh l rt ng k i vi tim mch
v cc c quan khc.
3.1. Suy chc nng co bp c tim:
Hin nay ngi ta c bng chng r rng khng nh trong SNK hot
ng co bp ca c tim b c ch nng, thm ch ngay c khi lu lng mu bnh
thng hoc tng th chc nng tht tri vn b suy sp. Cng sinh ra t c
mt th tch tng mu xc nh ca tim b gim v c th hin trn lm sng
bng tr s huyt p ng mch trung bnh (HAMTB), tuy nhin cng tim cn
ph thuc vo huyt p ng mch (hu gnh) v tin gnh, m c 2 yu t ny
u b gim trong SNK v vy HAMTB khng phi l mt ch s trung thnh
nh gi sc co bp c tim. Mt ch s cho php nh gi tt hn v suy chc
nng c tim l phn sut tng mu (EF- t l phn trm ca th tch cui tm
trng c tng i mi nhp bp ca tim). Gim phn sut tng mu xy ra
trong 24- 48 gi u ca nhim khun mu. Ngoi ra suy chc nng c tim cn
biu hin tng th tch cui tm trng v cui tm thu; tng nhp tim v lu
lng tim.
C ch ca hin tng c ch c tim trong sc nhim trng rt phc tp.
Mt s nh nghin cu cho rng chc nng c tim b suy yu do hin tng
gim dng mu qua mch vnh dn n thiu mu c tim, nhng mt s nghin
cu gn y chng minh c lu lng dng mu vnh v s tiu th oxy
c tim hon ton khng b gim i cc bnh nhn sc nhim khun. Mt gi
thuyt th 2 l s c ch c tim do tc dng trc tip hoc gin tip ca mt
hoc nhiu cht trung gian c trong mu. c nhng s liu nghin cu rt c
gi tr khng nh gi thuyt ny (khi ly huyt thanh ca bnh nhn giai
on SNK c vi t bo c ca chut thy chiu di v s hot ng ca cc
t bo ny b gim i).

3.2. Cc cht trung gian gy suy yu c tim:

Tim ni c t vi khun (Lypopolysacharid mng vi khun Gram m) cho
ng vt dn n bnh cnh sc ni c t vi tt huyt p v suy chc nng cc
c quan. bnh nhn b SNK Gram m chc chn c ni c t lu hnh trong
mu v gy c ch c tim, gin tm tht.... Tuy nhin khi SNK gy ra bi cc vi
khun Gram (+) (khng c ni c t) cng xut hin cc biu hin lm sng
ging nh do vi khun Gram (-). Nh vy phi c mt cht lu hnh trong mu
ng mt vai tr SLB quan trng i vi hin tng suy chc nng c tim trong
SNK, n gy ra gim EF v gim tin gnh, gim ti mu cc c quan t chc.
Hin nay xc nh cc cht trung gian l: TNF , nhm Cytokines, v cc

Leukotriene. Chng ng mt vai tr quan trng gy suy gim kh nng co bp

ca c tim cc bnh nhn SNK.

3.3. Ri lon trng lc h mch ngoi vi:

Khc vi nhiu loi sc khc, sc khng mch mu ngoi vi b gim i
trong a s trng hp SNK. y l yu t c trng quan trng gy tt huyt
p ng mch v gp phn lm tng t l t vong cc bnh nhn b SNK.
Mt s ti liu chng minh sc cn h thng mch ngoi vi thp trong
nhim khun huyt v SNK l do nhiu cht trung gian gy gin mch c
gii phng vo mu nh prostacyclin(PGI2), bradykinin, IL1, TNF , v c
bit l nitric oxide (NO).
Dng nh vic gii phng nitric oxide l nguyn do chnh ca hin tng
gin mch trong SNK. Nitric oxide l mt cht kh c gc t do vi hot tnh cao.
Nitric oxide c ngun gc t axit amine arginine theo con ng hot ha ca
mt loi enzym c gi l nitric oxide synthase.
Gi thuyt ny da trn 3 l do:
Th nht l ngi ta tm thy mt lng cao cc cht nitrite v nitrate (l
nhng sn phm chuyn ha cui cng ca nitric oxide) trong mu cc bnh nhn
b SNK.
Th hai l trn thc nghim ng vt b SNK tnh trng tt huyt p ng
mch v gin h mch ngoi vi c th c phc hi nh iu tr bng cc thuc
c ch cnh tranh chng s tng hp nitric oxide; Th ba l cht gy c ch tng
hp nitric oxide lm gim lng endotoxin v cc cytokines cc t bo c
trn mch mu trong ng nghim.
C ch tc ng ca nitric oxide gy gin c trn mch mu l: s m knh
+
K ca ATP- hot ha, hot ha vng guanylate trong cc t bo c trn mch
mu; s gii phng calcitonin- mt cht gy gin mch nhanh; lm gim kh
nng p ng ca mch mu vi cc cht gy co mch thuc h thn kinh giao
cm. Ni to ra cc nitric oxide l cc t bo ni mc v c bit l t bo c trn
ca mch mu.
S gim kh nng phn ng vi noradrenalin ca h thng mch mu trong
SNK c th cn do hu qu ca tng sinh cc cht chuyn ha axit arachidonic,
gim s lng cc th cm th , gim nng ion canxi trong cc t bo c,
tng tng hp IL1... Nhng cht ny cng vi ni c t s kch thch tng hp
NO v gy gin c trn mch mu.

Hot tnh trng lc mch s c khi phc sau khi tim cc cht c ch
tng hp NO v n c tc dng mnh hn l kch thch cc th cm th giao
cm. NO l mt cht trung gian quan trng trong SNK. NO c tng hp bi
enzym calcium v NADPH, ph thuc vo s c mt ca chng trong cc t
bo ni mc, no, hch giao cm v tiu cu. NO cng c sn xut bi mt
enzym khc trong t bo i thc bo, bch cu a nhn t bo Kupffer v cc
t bo gan. Mt vi cht kch thch min dch nh ni c t hoc cytokin s
kch thch enzym ny.
CMP
C trn mch mu

GTP

Gin c

sGCa

Xanh methylene
sGCi
NO

NO ht

NO

NO

NO- EDRF
Cofactor
NADP
T bo ni mc

Citruline +

Ca++
Calmoduline
NADPH2
FAD,FMN
BH4

LNMMA

NO- Synthase
L- arginine
Antagoniste

Hnh 1: Tc dng ca NO trn c trn mch mu.

Vic s dng cc cht c ch men nitric oxide synthase hoc guanilate

cyclase c th s hi phc c huyt p trong cc mu thc nghim v trn cc
bnh nhn sc nhim khun. Tuy vy da trn nhng kt qu nghin cu ng
vt, cc loi thuc c ch tng hp NO c th gy tc dng bt li v c th n
gy ra hin tng co mch qu mc dn n thiu mu cc c quan ni tng hoc
nhng hu qu khc (nh nghn cc vi mch mu). chng minh cho iu ny
ngi ta s dng 300mg/kg cht c ch tng hp NO (LNMMA) chut b
nhim khun mu s dn n s suy sp nhanh hn v r hn ca HAM so vi
nhm khng c dng cht ny. Tri li nu ch dng liu 30mg/kg th li d
phng c tt huyt p ca sc nhim khun. Cc kt qu ny ni ln rng vic
gii phng NO to nn mt vai tr bo v c th trong SNK nhm chng li phn

ng co mch qu mc, gip duy tr tnh ton vn ca mch mu di tc ng

ca ni c t, lm gim shunt phi, ci thin s trao i kh do gin cc mao
mch phi, lm tng tnh phn ng ca mch mu vi cc thuc co mch... Nh
vy mt nng NO no s l cn thit duy tr s ti mu cc c quan
trong nhim khun mu.
Tm li gin mch ton thn trong SNK l do mt cht trung gian cha kha
nitric oxide. Ni c t v mt s cytokin kch thch tng hp NO ni sinh t t
bo ni mc (endothelial devide relaxing factor-EDRF) v cc t bo c trn
mch mu.
* Tn thng thn:
Thiu niu v tng ure mu l du hiu ph bin trn lm sng SNK. C ti
50% s bnh nhn SNK b suy thn cp. Ri lon chc nng thn l hu qa ca
gim dng mu thn v tng qu mc hot tnh h thn kinh giao cm dn n co
tht cc mch mu thn.
* Tn thng ng tiu ha:
Trong m hnh nghin cu kinh in sc ngoi c t trn ch, i ngoi ra
mu l mt c trng ca hi chng. ngi du hiu ny t thy, ch c cc triu
chng lit rut, bun nn, nn v thng xut hin s thay i chc nng hng
ro bo v ca ng tiu ha. Trong sc nhim khun dng mu qua mc treo rut
b gim ti 50% do tc ng ca cc cht trung gian nh sulfidopeptide,
leucotriens, cc cht c gc lipid lm co cc mch mu mc treo rut.
* Tn thng gan:
Vng da thng xut hin cc bnh nhn SNK, nhng ri lon chc nng
cc t bo gan cng do tc ng ca cc cht trung gian, c bit l s gii phng
cc nitric oxide t LPS-stimulated ca cc t bo Kupffer.
* Ri lan h thng ng mu:
Ko di thi gian prothrombin (PT), thi gian thromboplastin (PTT), gim
tiu cu, hi chng ng mu ri rc trong lng mch l nhng du hiu rt
thng gp cc bnh nhn SNK. S kch hot h thng ng-chy mu trong
SNK ph thuc vo cc yu t bnh l ni sinh nh: yu t t chc (tissue factor)
s hot ha cc yu t VII thnh yu t VIIa. Phc b VIIa + yu t t chc s
hot ha yu t X Xa v n tip tc chuyn prothrombin thrombin.
* Ri lon h thn kinh trung ng:
H TKTW thng b nh hng xu trong sc nhim khun, xut hin cc ri
lon tm thn hoc trng thi l m v nng hn l hn m.

3.4. Cc cht trung gian ha hc (mediator) ca cc tnh trng

nhim khun nng v sc nhim khun:

3.4.1. B th (C3a v C5a phng nhim c- anaphylatoxine):

- Hot ha cc bch cu a nhn, i thc bo v cc tiu cu.
- Gin mch, huy ng cc bch cu a nhn trong ty xng.
- Tc dng c t bo trc tip trn cc t bo ni mc.

3.4.2.Gii phng 3-phosphocholin :

+ Prostanoid (con ng oxygenase):
- Co mch (PGF2), gin mch (PGI2, PGE2), st (PGE2), c ch ngng tp
tiu cu (PGI2), d ha protein.
- TXA2 (thromboxane): co mch, ngng tp tiu cu, tng p ng mch phi;
c t bo trn cc t bo ni m.
+ Leucotrien (con ng lipo-oxygenase):
- LTB4: ngng tp tiu cu v bch cu a nhn.
- LTC4, LTD4, LTE4: tc dng inotrope (-), co mch nht l cc tnh mch,
tng p M phi, co tht ph qun, gim compliance phi, tc dng c t bo
trn cc t bo ni mc, gii phng histamin.
+ PAF (ng chuyn axetyl):
- Tc dng inotrope (-) v iu nhp (-). Co mch thn v mch ni tng (-).
- Tng p M phi, co tht ph qun, gim compliance phi.
- Tng tnh thm mao mch.
- Ngng tp tiu cu v bch cu a nhn.

3.4.3. H thng tip xc (kininogene trng lng phn t cao, tin kalikrine,
yu t XI, yu t XII):
- c hot ha bi LPS ca vi khun, mng nn mch mu, mng ca t
cu.
- Gii phng bradykinin (gin mch, ri lon tnh thm thnh mch)
- Hot ha b th v h thng ng mu.
3.4.4. Enzym ca lysosom v cc gc t do (phng thch t oxy):
- Peroxyt ha cc lipid ca mng t bo.
- Tc dng c vi cc t bo ni m.

3.4.5. Catcholamin:
- Co mch ton thn, m c tht tin mao mch v tng sc khng sau mao
mch (to thun li cho thot huyt tng).

- Inotrope (+) v iu nhp (+).

3.4.6. Angiotensin:
- Co ng mch.

3.4.7. Vasopressin:
- Co ng mch.
- Tc dng inotrope (-).
- Ngng tp tiu cu, hot ha yu t VIII.

3.4.8. Histamin, serotonin:

- Gin mch, nht l tnh mch
- c t bo vi t bo ni mc (tng tnh thm mao mch)
- Block cc th th H2.
3.4.9. Peptid opioid ni sinh (endorphin, enkphalin):
- Suy sp cc phn ng cathecholamin ban u.
- Gim au.
3.4.10. MDF (myocardial depressant factor):
- Tc dng inotrope (-).

3.4.11. Endothelium-derived relaxing factor EDRF (NO):

- Gin mch.

3.4.12. Endothline-1:
- Co mch.
3.4.13. Adhsin (phn t to thun li cho s thm nhp ca t bo trn cc
ni mc mch mu):
Adhsin tc ng vo c tht sau mao mch: ELAM-1, ICAM-1, VCAM-1.
3.4.14. Cc cytokin:
+ TNF:
- TNF c tit ngay t 45-60 pht u ca sc nhim khun, nh ch tit
pht 90. S tit nhc i nhc li nhiu ln.
- Kch thch cc monocyte.
- Tc ng trn cc t bo ni mc: CIVD, tng hp cc yu t ha hc trn
cc bch cu a nhn, to iu kin thm nhp ca cc bch cu a nhn kch
thch sn xut IL1, IL6, PAF.
- To thun li cho: s thm nhp ca cc bch cu bng vic cng hng vi
IL1, tnh thc bo ca chng, gii phng cc gc t do v cc enzym tiu th
lysozim
- Kch thch tng hp prostaglandin E2 (tng thn nhit) v cc cht khc
c gii phng t a.a rachidonic, gii phng TSH, GH, glycogen.
- Gim in th mng t bo c (to thun li cho ph trong t bo).

- Hot ha yu t XII, to thun li cho tiu si huyt.

- To thun li cho tng sinh cc nguyn bo si.
- Gin mch (do tng NO) gim p ng ng mch vi noradrenalin.
- Thiu mu ng tiu ha, thng thn v ng thn.
- Tng tnh thm mao mch.
- Tng phn hy (turn-over) cc axit bo t do (tng triglyxerit) mu
- c ch co rt ca cc t bo c.
- Hot ha lymphocyt T v B.
- Tng tng hp cc protein ca h thng vim.
+ Interleukin 1 (IL1 v ):
- IL1 c tit sau TNF v trc IL6, n ng vai tr quan trng trong kch
thch cc t bo lympho v mono.
- Tng sn sinh TNF v s nhy cm ca t chc m n tc ng (tc dng
cng hng gia 2 cytokin ny).
- c dng c t bo trn t bo ni mc; chng ng mu do c ch cht hot
ha plasminogen.
- Kch thch tng sinh cc t bo c trn, gim kh nng p ng vi kch
thch h anpha adrenergic (do tng NO).
- To thun li cho s xm nhp bch cu a nhn ln cc t bo ni mc.
- Hot ha phospholipaza A2: tng hp prostaglandin v thromboxant A2.
- Tng sn xut cc bch cu dng ty v di chuyn n vo mu.
- Kch thch lympho T v sn xut IL2,4,5,6,8.
- Kch thch lympho B.
- Kch thch phng thch cc GB (dn xut ca oxy v enzym trn protein).
- To thun li cho BC a nhn xm nhp.
- Tng tnh thm mao mch.
- Tng thn nhit, tng hp protein vim ACTH, cortisol.
- Gin mch v gim p ng thnh ng mch vi noradrenalin.
- Kch thch cc men tiu lipid.
- Kch thch sn sinh insulin.
- Kch thch hot ng cc i thc bo.
- Tng sn xut cc gc oxy ha t do.
+ Interleukin 2 (IL2):
- Tng hot ng ca GB.
- Tng tnh thm mao mch.
- Tc dng inotrope (-).
- Hot ha v kch thch lympho.
- Dn n gii phng TNF .
+ Interleukin 4 (IL4):
- To thun li cho xm nhp ca cc lympho vo ni mc
- To thun li cho vic trnh din khng nguyn.

- To thun li cho vic gii phng cc gc t do oxy ha.

+ Interleukin 6 (IL6):
Ni c t ca vi khun dn n (trc tip hoc thng qua trung gian ca
TNF hoc TL1) tng hp IL6:
- Kch thch lympho khu vc nhim khun.
- Sn xut protein gy vim, st.
- Huy ng cc t bo ty.
- Gim sn xut cytokin do s gim nhy cm ca i thc bo.
- Hot ha lympho B v T.
+ Iterleukin 8 (IL8):
- c tit ra do TNF v IL1.
- Hot ha cc bch cu, co tht ph qun.
+ Interferon :
- Sn phm lympho T4,T8 v t bo vi khun vi s c mt ca IL1 v IL2
khi p ng vi khng nguyn ngun gc VK hoc virt.
- Tng cng tc dng v sn xut TNF .
- To thun li cho vic trnh din khng nguyn vi phc b ph hp t chc
typ 1 v typ 2.
+Yu t kch thch i thc bo hch n dng (Granulocyte Macrophage
Clony Stimulating Factor-GMCSF) v yu t kch thch i thc bo n dng
(Macrophage Clony Stimulating Factor-MCSF):
Hot ha cc bch cu a nhn v i thc bo (sn xut TNF v IL1)
Bng II: Cc t bo tham gia vo sinh l bnh ca cc tnh trng nhim khun
nng v sc nhim khun.
T bo

a nhn

Hot ha hoc mt hot ha

bi

Gii phng ra

Prostaglandin, gc t do
C3a , C5a , TNF , LTB4 , oxy ha, PAF-leucotrien,
men lysosom phn hy
PAF , IL1
protein, histamin,IL1 , IL8
.

Tiu cu

prostaglandin,
PAF, TNF, TXA2, C3a, C5a, PAF,
leucotrien,
TXA2,
Leucotrien (LTB4)
Vasopressine, yu t XII , histamin, serotonin.
IL2.

Mastocyte

C 3a , C 5a

i thc bo
T bo NK

Cc vi sinh vt (vi khun, vi TNF , IL1 , IL2 , IL6 , IL8

rut, nm, k sinh trng) phc PAF

Histamin, prostanoid v
leucotrien, TNF.

(Naturalkiller)
Lympho T

T bo
mc

b khng nguyn-khng th Prostaglandin

axit Tiochoique (gram +) leucotrien.
C3a, C5a , IL2 , IL1 , TNF

S xm nhp ca vi khun IL1 , IL2 , IL3 , IL4 , IL6 ,

IL8,
TNF , IL1 , IL6 , IL8
inteferon , TNF , PAF.
ni a nhn c hot ha, Gc Sn phm chuyn ha
t do oxy ha, Enzym tiu ca a.arachidone,yu t
Protein
ca
Lysosom, XII,PAF
Leucotrien,TNF
, IL1 , IL6 , IL8,TNF .
PAF,Kinin,Histamin, IL1

Nguyn bo C3a , C5a , TNF , IL1, PAF

si v t bo
c trn

IL1 , IL6 , IL8.

4. Lm sng v chn on sc nhim khun:

Nhng triu chng v hi chng c th tn ti trong sc nhim trng:
+ Hi chng nhim khun: st cao (380C), cn rt run, hoc h thn nhit
(35,50C), s lng bch cu tng v chuyn tri. Cn lu : nu bch cu khng
tng cng khng c ngha loi tr SNK, gim bch cu cng c th gp trong
mt vi ngy u ca SNK.
+ Ri lon h hp: th nhanh, thiu oxy mu, kim h hp.
+ Ri lon tun hon: nhp nhanh, tt huyt p ng mch, ri lon vi tun
hon da ni vn , lon nhp tim.
+ Suy a tng:
- Suy thn cp: thiu-v niu, ure, creatinine mu tng.
- Suy chc nng gan: vng da, tng bilirubin mu khng c tc ng dn
mt, ri lon ng - chy mu.
- Ri lon thn kinh: kch thch vt v, co git, thc l m hoc hn m.
- Hi chng ARDS, hi chng ri lon ng mu.
Cc bnh nhn SNK khng thng xuyn c y cc triu chng kinh
in. Nu c iu kin nn t catheter Swan-ganz c th gip cho chn on.
Chn on SNK c khng nh thm nh s c mt ca hin tng tng huyt
ng (hyperhemodinamic), nu ch s SVRI thp nn t chn on SNK, cn
SVRI cao th hng n cc th sc khc.
Cy mu nn lm u n nhng trng hp c nghi ng SNK. nhng
bnh nhn cha c iu tr, cy mu c t l mc vi khun l 100% khi cy 3
ln. Ch : v lng vi khun trong mu thp nn mi ln cy mu cn ly t nht
10ml mu (thm ch 20-30ml). Mc d c nhng ngh khng c cy mu
qua cc catheter t sn trong cc tnh mch, nhng hin nay ngi ta cho php

ly mu nh vy (vi nhy 96% v c hiu 98%). Cc bc qui nh cy

mu nh sau:
. Ngng truyn cc loi dch.
. St trng ni ly mu bng povidone iodine (betadin), sau l cn 70o; 3ml
mu u tin phi b i.
Cy nc tiu v cc cht dch tit khc cng nn lm khi c ch nh.
5. iu tr sc nhim khun.

5.1. Liu php truyn dch:

Tt c cc bnh nhn shock nhim khun u phi c truyn dch. Khi
lng dch truyn vo khng th d on trc c, n s c quyt nh da
trn mc HAM, cung lng tim, p lc y cc bung tht, ch s vn
chuyn oxy, lng nc tiu, p lc ng mch phi bt (PAWP).
Trong SNK s thiu ht khi lng dch trong lng mch khng ln nh
trong mt s loi sc khc, v vy lng dch truyn cng khng nhiu: 15002000ml/24h. m bo mc cn thit cho tin gnh, cn gi ALM phi bt
(Pulmonary Artery Wedge Pressure) xp x 12mmHg l cho p ng ti a chc
nng tim cc bnh nhn SNK (p lc ng mch phi bt cn c theo di
tt c cc bnh nhn SNK). Cn lu trong mt s trng hp PAWP c th phn
nh khng ng gi tr thc ca tin gnh (th tch cui tm trng tht tri) do
tc ng ca mt s yu t: thay i trng lc c tim, th my, PEEP.
Vic la chn dch truyn cho cc bnh nhn SNK vn cn nhiu tranh lun,
cha c mt ti liu no khng nh s u th gia 2 loi dch tinh th v dch
keo, nhng chc chn l khi bnh nhn c thiu mu (Ht < 30%, HST <100g/l)th
truyn thm mu l bt buc. Cc dung dch tinh th (HTM 9%0, ringerlactat) sau
khi a vo lng mch d dng b thot ra khong gian bo gy ph khe k m
nguy hi nht l ph phi. Cc dng dch keo c p lc thm thu ln
(hydroxyethyl starch, dextran, albumin) s lu li trong lng mch lu hn. Theo
Haupt trong nhng trng hp c gim KLMLH nng km theo cc du hiu
ca shock v chuyn ha ym kh th vic dng cc dung dch keo s lm tng th
tch trong lng mch nhanh v lu hn, v vy n c u th hn dch tinh th.
Vic khi phc khi lng tun hon c thc hin bng truyn lp li nhiu ln
t 5-7ml/kg trong vng 30 pht c dung dch tinh th v dch keo (theo t l 2/14/1) cho ti khi h c nhp tim, tng HAM, c nc tiu, cc p lc khc tr
v bnh thng). Vic truyn dch phi t 2 mc ch: khi phc mt tin gnh
l tng v gim thiu nhng nh hng xu i chc nng phi.
Kinh nghim cho thy vic s dng cc thuc vn mch cc i tng c
tin gnh thp (cha c b dch) lun dn n nhp tim nhanh rt nguy
him, hiu qu khi phc huyt ng rt km v nguy c ngng tim. V vy vic
u tin phi lm l khi phc khi lng tun hon tht .

5.2. Khng sinh:

S dng khng sinh theo kinh nghim ngay khi cha c kt qu cy trng l
mt vic lm cn thit trong iu tr SNK. Rt t trng hp ch kt qu cy mu
vi bt u liu php khng sinh.
C s la chn chnh xc cc nhm khng sinh cn s dng l:
- D on c nhim trng nguyn pht v chng vi khun gy bnh.
- Tnh hnh khng khng sinh ca loi vi khun gy nhim trng v s
khng khng sinh trong tng bnh vin.
- Cc s liu v dch t hc mi nht ca bnh vin, ch n cc loi c
nhiu kh nng gy nhim trng bnh vin nh P.aeruginosa, enterobacter hoc
t cu vng khng methicillin.
Nn nh l cc bnh nhn khng c s dng khng sinh hp l c mt tin
lng ti hn cc bnh nhn c dng khng sinh hp l. Liu php phi hp
khng sinh thng c chn trong iu tr SNK giai on sm vi kiu phi
hp khi u n gin sau s thay i khi c kt qu cy mu v khng sinh
. Phi hp khng sinh cho kt qu tt hn dng n c vi iu kin m bo
nguyn tc: to c ph khng sinh rng; cn tr hoc ngn c hin tng
khng khng sinh; cc thuc c tc dng hip ng.
Nh vy s phi hp tt l chn mt khng sinh nhm amynoglycoside vi
mt khng sinh chng c men -lactamaza (cefalosporines, methicillin,
vancomycin). Nu nhim trng nguyn pht l trong bng: amynoglycoside
+ methronidazol hoc clindamycin. Nu l vi khun gram (+): vancomycin.
Nhm amynoglycoside c ph dit khun rng, chng c cc vi khun
gram (-), nhng n li c nguy c gy tn thng thn, hin nay c mt s loi
khng sinh mi nh imipenem (tienam), fluoroquinolone, axepim (cefepim) c
hiu qu dit khun rt tt.

5.3. Nhng bin php chng nhim khun khc:

h tr cho liu php khng sinh, nhng bin php loi b cc nhim
trng khu tr trong c th ng mt vai tr cc k quan trng. Nhiu trng hp
SNK sau khi chch, rch, dn lu, cc m, p xe... tnh trng bnh nhn c
ci thin rt nhanh. Bt k mt dng c y t no c a vo trong c th u c
th tr thnh ngun nhim khun: catheter, my to nhp trong, thng i... phi
rt b chng khi c nghi ng.

5.4. La chn hp l cc thuc vn mch:

Sau khi truyn dch khi phc khi lng tun hon m khng nng c
huyt p v lng bi tit nc tiu th cn phi s dng cc thuc vn mch hoc

cng tim khi phc huyt ng. Bnh sinh c bn ca sc l s kt hp ca

tt huyt p ng mch km theo gim ti mu cc m t chc. V vy vn
quan trng ca khi phc tun hon trong sc ni chung v SNK ni ring phi
t 2 mc ch ng thi: nng huyt p v ci thin ti mu t chc. Nu ch
gii hn phng din tim mch (tc l ch a HAM v gii hn bnh thng
bng cch dng cc thuc co mch n thun m khng tng c ch s tim
(cardiac index - CI) v tng cung cp oxy cho t chc th s khng em li bt c
mt ch li g cho bnh nhn. Ngi ta thy rng cc gi tr trn mc bnh thng
ca CI (4,5 lt/pht/m2), vn chuyn oxy: TO2 ( 550-600ml/pht/m2) v lng
tiu th oxy: VO2 (150-170ml/pht/m2) cho mt tin lng rt tt bnh nhn
SNK. Vic ci thin lng bi niu l mt du hiu nh gi dng mu n cc
m c khi phc.
t c tc dng inotrope (+) v iu tr suy tim trong SNK th
dobutamin c nhiu u im. N c hot tnh inotrope (+) mnh hn dopamine.
Nhng dobutamin t tc dng trn sc khng h mch, v vy trong nhng trng
hp suy tim l ch yu (CI <4,5l/pht/m2) th nn dng dobutamine.
Dopexamine (dopacard) l mt cathecholamine mi c ch nh iu tr cc
trng hp sc c gim ch s tim v tng sc khng mch phi hoc tng sc
khng mch mu h thng. Dopexamine lm tng sc co bp c tim v gim
ng k sc khng mch h thng, thuc cn c dng cho cc trng hp gim
ch s tim trong khi HAM vn cn duy tr.
Dopamine l thuc vn mch c nhiu bc s lm sng s dng trong SNK.
liu thp (1,5g/kg/pht) n c tc dng inotrope (+) v gy gin ng mch
thn iu ny c li cho vic ci thin chc nng tim. liu cao (>
15g/kg/pht) n kch thch h -adrenergic gy tng HAM. Mt s tc gi
cho rng s dng dopamine vi liu cao nh vy s khng thch hp trong SNK
v t l tht bi cao, nn thay bng noradrenalin.
i vi th sc nng ca SNK (CI 4,5 l/pht/m2) l mt ch nh tt cho
vic s dng noradrenalin, liu thng thng dao ng trong khong 11,5mcg/kg/pht. Nhng cng c th ti 5-7mcg/kg/pht. iu chnh liu gi
mc HAMTB > 80mmHg.
Khi ch s CI < 4,5l/pht/m2 th c ch nh dng dopamin hoc dobutamin
(5-15-20 mcg/kg/pht). Nu CI tng nhng HAMTB < 80 mmHg th cho php
phi hp vi noradrenalin. Trong trng hp tht bi c th kt hp adrenalin
hoc thm ch isuprel.
Trong trng hp nghi ng, u tin s dng noradrenalin hoc phi hp vi
dobutamin. Dng noradrenalin n c hoc kt hp cho php bnh thng ha
cc ri lon huyt ng 90-95% bnh nhn. Tuy nhin noradrenalin c th c
mt vi tc dng xu trn ng mch v dng mu thn,dn ti thiu niu.
khc phc cn a CI gii hn bnh thng hoc cao.
Sau khi n nh huyt ng 18-24h bt u cho cai dn cc thuc vn mch
(i khi phi ko di ti 15 ngy).
Tm li, cng thc la chn thuc vn mch nh sau:
* Ch s tim CI 4,5l/pht/m2 : noradrenalin.

* Ch s tim CI < 4,5l/pht/m2 : dobutamin hoc dopamin (+ noradrenalin nu

sc cn mch mu ngoi vi < 1000 dyn.giy/cm5.m2 hay HAMTB < 80mmHg).
* Trong nhng trng hp nghi ng: bt u bng noradrenalin.
Tin gnh l tng

Khng

Truyn dch

IC 4,5l/pht/m2. Sc cn ngoi vi
1100dyn. giy/cm5.m2

C
Noradrenalin
.
.

Khng
Dobutamine
Dopamine
Noradrenalin

Bnh n nh:
HAMTB 80mmHg
CI
> 4,5lt/pht/m2
DO2
> 550 ml/pht/m2
hoc
> 0,7ml/kg

Khng

Theo di iu tr tip tc

5.5. iu tr c ch hot ng ca cc cytokine :

5.5.1. Khng th n dng khng TNF :

Hin nay nhiu nc ngi ta a ra mt s thuc c tc dng chng li cc
phn ng min dch - vim vo thc t iu tr SNK. y l mt hng iu tr
mi y ha hn, nhng cng cha phi ht tranh ci do kt qu thu c rt
khc nhau.
Khng th khng TNF c bn cht l IgG. mt s nghin cu thy s
dung np tuyt vi ca cc khng th ny v mt vi tc dng tt trn HAM,

cng tht tri, ci thin t l sng... nhng cn phi ch i kt qu nghin cu

trn ngi.

5.5.2. Cc thuc khng TNF khc:

Bn cnh khng th n dng khng TNF cn rt nhiu cc cht khc c
tc dng c ch s gii phng v tng hp TNF nh: IL4, IL10, corticoide,
PGE2, chloroquine, ethanol ...

5.5.3. iu tr c ch hot tnh IL1 (interleukin 1):

IL1 c tit ra t nhiu t bo v c nhiu s tng ng vi TNF . IL1
ng vai tr quan trng trong qu trnh tin trin ca nhim khun mu. Nng
IL1 cao ngay t gi th 3-4 sau khi xut hin ni c t v n lu li lu hn rt
nhiu so vi TNF . V l thuyt cc cht c ch hot tnh IL1 s rt c ch trong
iu tr nhim khun mu v SNK. C mt protein t nhin c gi l IL1- c
ch l sn phm ca monocyte c vai tr c ch s c nh ca IL1 trn cc th
cm th mng, ngn chn s hot ha t bo, gim sn xut TNF ,IL1, IL6,
NO, phc hi HAM, tng ch s tim, ci thin t l sng. Gn y n cn c
gi l IL1- i khng th cm th (IL1-receptor antagoniste hay IL1-ra).

5.5.4. iu tr c ch hot tnh cc cytokin khc (IL4, IL6, IL8):

Do tm quan trng ca cc cytokin trong bnh sinh SNK nn nhng bin
php dng cc khng th khng IL4,6,8... c nghin cu trn m hnh thc
nghim. Nhn chung nhng sn phm ny l c hiu qu, cho php khc phc
tnh trng tt HAM, gim tnh thm thnh mch.

5.5.5. iu tr khng ni c t:
Cc vi khun gram (-) l nguyn nhn thng gp ca SNK. Ni c t l mt
thnh phn ca vi khun, n c kh nng hot ha mt chui cc phn ng bnh
l phc tp, kch thch i thc bo gii phng TNF , IL1,2,4,6,8... v cc cht
trung gian khc, tc ng trc tip trn chui b th v h thng ng mu.
S dng cc khng ni c t nh centoxin (HA-1A), khng th E5, cho thy
gim c t l t vong cc bnh nhn SNK. Tuy nhin cha bng chng
thuyt phc cho vic p dng rng ri trn lm sng.

5.6. iu tr suy th:

Trong nhiu trng hp cn phi tin hnh thng kh phi nhn to kt hp
vi liu php oxy duy tr cc thnh phn kh mu gii hn bnh thng. Ch
nh tuyt i tin hnh thng kh nhn to l: PaO2 thp hn 60-70 mmHg.
Nn dng phng thc thng kh h tr c PEEP hoc CPAP.

5.7. iu tr ngoi khoa nhim khun trong c th:

y l bin php iu tr rt cn thit v khng c lng qun, v thiu n th
cc bin php trn s khng t kt qu trong iu tr sc nhim khun. Nhng
bin php iu tr ngoi khoa nhm loi b cc vi khun (mn, nht, cc

khoang cha dch m trong c th...) ngun gc gy ra sc nhim khun. Trong

nhng trng hp c biu hin vim phc mc m, vim m bung t cung,
nhim trng ng mt do tc mt c hc... cn ch nh can thip ngoi khoa
sm ngay sau khi bnh nhn thot sc (m bng, no t cung). Nhng m ri
rc di da hoc trong c cng cn c chch rch trit v cy khun cc dch
m ny, lm khng sinh .

5.8. iu tr suy thn:

Sau khi b khi lng tun hon v huyt p ng mch c duy tr tt
m mc bi xut nc tiu < 30ml/1gi th c ch nh dng thuc li tiu lasilix
(liu 40- 80 mg/24 gi) duy tr lng nc tiu > 30ml/1gi. Khi cn c th
tng liu lasilix ti a ti 1000mg/24 gi. Lc mu ngoi c th ch s dng khi
liu php dng lasilix khng kt qu v bnh nhn thot sc, huyt p ng
mch n nh.

5.9. iu tr ri lon chuyn ha toan - kim:

m bo thng kh tt v dng dung dch natribicacbonat 4,8%. B sung
cc cht in gii ch cc ion Ca++, K+ v Na+.

5.10. Nui dng qua ng tiu ha:

Cn c tin hnh sm ngay khi bnh nhn thot khi trng thi sc .

5.11. Corticosteroide:
Mc d c nhng kin tranh lun v vic s dng corticosteroide. Bn
cnh nhng quan im ng h vic dng thuc ny thm ch vi liu cao
prednisolon 15- 30mg/kg iu tr sc nhim trng. Song cng nn nh
corticosteroide l con dao hai li: gy c ch min dch v hin tng thc
bo, xut huyt tiu ha...
Nhng nghin cu gn y i n kt lun l vi nhng liu iu tr bnh
thng corticosteroide s khng cho mt li ch g cc bnh nhn sc nhim
khun m c th cn c hi, bi vy liu cao corticosteroide khng nn dng
iu tr bnh l ny.

5.12. S dng heparin:

Trong sc nhim khun lun c nguy c xut hin hi chng ng mu ri
rc trong lng mch (disseminated intravascular coagulation). Cho nn khi c y
cc tiu chun chn on c hi chng ng mu ri rc cn dng ngay
heparin vi liu 100 n v/kg tim tnh mch sau duy tr liu heparin 10- 40
n v/kg/h truyn lin tc vo tnh mch bng bm tim in trong 24 gi.

Cht no
Tt Cng

1. i c-ng.

1.1. Th no l cht:
Cht l hin tng sinh hc chm dt cuc sng khi c ngng tun hon mu
v tip theo l chm dt cc hot ng sng hoc ngng cc hot ng phi hp
cu ton b c th.
Khi mt c th cht th cc m v cc c quan khc nhau ca c th
khng cng cht mt lc m c th tip tc sng trong nhng khong thi
gian khc nhau.
Qu trnh cht c th din bin t giai on hp hi, th ngp (gasping), sau
chuyn sang cht lm sng (clinical death) ri dn n cht sinh vt chm dt
cuc sng (biological death). Khi bnh nhn hp hi hoc cht lm sng (ngng
tim - phi) m c cp cu tt th c th qua khi.

1.2. Th no l cht no (brain death):

Vo nhng nm 60 ca th k XX khi nim cht no c a ra. Cht no
l tnh trng no b tn thng khng hi phc v nng n mc chc nng h hp,
tim mch khng cn gi c na khi cht no. Ri lon chuyn ho v cc chc
nng ca no hon ton v phng cu cha, mc d vn tn ti hot ng t pht
ca tim song tin trin xu dn dn n suy sp tun hon ri dn n ngng tim
vnh vin (cht sinh vt). Tuy nhin thi gian cht no di hay ngn cn ph thuc
vo chm sc v iu tr c tch cc hay khng. Song d c hi sc tt th ngi
cht no cng ch tn ti ti a l 5-6 ngy, trung bnh t 2- 4 ngy. Ngi ta c th
ly cc tng ghp bnh nhn cht no v thi gian ly tng cng sm cng tt,
song tt nht l trong vng 24 gi k t khi chn on cht no.
2. Tiu chun chn on cht no.
T nm 1960 vi tiu chun chn on ca trng i hc HaRvard (Hoa K)
n nay c rt nhiu hi tho Quc T v cht no. Vit Nam gn y cng
c nhiu nghin cu cht no Bnh Vin 103, bnh vin Vit c, BV Bch
Mai v cui nm 2000 thng nht a tiu chun chn on cht no nh sau:

2.1. Tn thng no rt nng khng cn kh nng hi phc:

Tr nhng trng hp hn m do nhim c, ri lon chuyn ho, ri lon ni
tit, h thn nhit di 32oC, nhng nn nhn b rn c thn kinh cn (cng b
mt mi phn x, ng t gin) v tr em di 6 tui.

2.2. C cc tiu chun lm sng sau:

- Hn m su: Glasgow 3 im.
- ng t gin trn 4mm.
- Phn x ng t vi nh sng (-).
- Phn x gic mc mt (-).
- Phn x ho (-): dng dy ht a vo tn ch phn chia ph qun gc khng
cn phn x ho.
- Nghim php mt bp b (-).
- Nghim php kch thch tin nh bng nc lnh (-).
- Mt kh nng t th vnh vin (phi th my) (nghim php ngng th
dng tnh (+)).

2.3. Tiu chun thi gian:

T khi bnh nhn c cc tiu chun trn bnh nhn phi c khm t nht
4 gi/1ln; nu sau 16 gi m cc tiu chun trn khng thay i mi c chn
on cht no.

2.4. Tiu chun khc:

- Ghi in no khng bt buc (nu c), lm t nht 2 ln nu thy in no
"im lng" th thi gian theo di ch cn sau 6 gi c th chn on cht no.
- Siu m doppler xuyn s khng bt buc (nu c), lm t nht 2 ln m
khng thy c sng mch cc ng mch no th thi gian theo di cng ch
cn 6 gi c th chn on cht no.
- Bng tiu chun trn phi c hi ng t nht 3 bc s chuyn khoa: hi
sc cp cu - bc s ni thn kinh - bc s phu thut thn kinh, t chuyn khoa
cp I, thc s tr ln c tp hun v cht no v do ban gim c bnh vin ph
duyt: ba bc s ny khm c lp v xc nhn l bnh nhn cht no. (Cc bc s
tham gia ghp tng khng c vo hi ng).
- Ch c chn on cht no cc bnh vin c khoa hi sc cp cu t nht
l c my th v my phn tch kh mu.

3. Qui trnh khm trn lm sng.

3.1. Xc nh bnh nhn hn m su, thang im Glasgow=3, cn

c vo:
- Bnh nhn khng p ng m mt vi mi kch thch.
- Bnh nhn khng p ng ngn ng (ni, ku, rn) vi cc kch thch.
- Bnh nhn khng p ng vn ng vi cc kch thch v khng c cc vn
ng t ng, khng c cn co cng, dui cng hoc co git.

3.2. Khm phn x ng t vi nh sng v o kch thc ng

t:
Tt n v ng kn ca bung bnh, dng n pin nh (2 pin 1,5V) chiu
vung gc vo ng t, nu hon ton khng c p ng co ng t th kt lun
phn x m tnh (-). Khi dng thc o ng t hoc thc nha trong, c
khc mm o ng knh ng t. Khm tng bn, phi khm t nht 3 ln v
ghi kt qu khm c th vo bnh trnh theo di.

3.3. Khm phn x gic mc:

Dng bng kh, v nh u, chm mnh vo gic mc khng thy p ng
chp mt (khng c biu hin co c vng mi) th khi kt lun phn x m tnh
(-). Phi khm c hai bn, phi khm t nht 3 ln xc nh chc chn.

3.4. Lm nghim phpmt bp b:

t bnh nhn nm nga, quan st thy hai nhn cu ng yn (bt ng),
xoay u bnh nhn nghing ht mc sang mt bn, khng thy nhn cu xoay
sang bn i din cht no, sau li xoay u bnh nhn sang bn kia cng
khng thy xoay nhn cu. Tip theo nga c v gp c bnh nhn ht mc cng
khng thy xoay nhn cu xung di hoc ln trn th kt lun: du hiu mt
bp b m tnh (-).
Cn khm t nht 3 ln v quan st t m (khng lm nghim php ny khi
bnh nhn tn thng ct sng c).

3.5. Lm nghim php kch thch tin nh bng nc lnh:

t bnh nhn nm nga, k u cao khong 300 , dng bm tim ng 50ml
nc mi tan, ni vi mt on ng dn bm nh vo ng tai ngoi ca bnh
nhn, quan st hai nhn cu ca bnh nhn khng thy a hoc git v bn bm
nc lnh (nhn cu vn ng yn). Lm tng t tai bn kia, nu thy nhn
cu ng yn th kt lun nghim php m tnh (-).
Phi lm t nht 3 ln, cch nhau t nht 5 pht xc nh cho chc chn.

3.6. Nghim php ngng th:

3.6.1. Chun b bnh nhn:

+ Bnh nhn hn m su, c th my vi theo ch thng kh nhn to
iu khin c 5% kh CO2 v 95% kh oxy (O2).
+ Huyt p c duy tr bng thuc v b dch, huyt p tm thu trn
90mmHg, lng nc tiu trn 50-60ml/gi, pH mu 7,44.
+ Ht m di.
+ o cc kh trong mu:
- Nu PaCO2 bnh thng (36mmHg- 40mmHg) th tin hnh lm nghim
php ngng th.
- Nu PaCO2 di 36mmHg th cn gim bt th tch v tn s th my
a PaCO2 ln mc bnh thng.
+ Nu PaCO2 tng trn 40mmHg th cn tng thng kh (tng tn s th
my hoc tng th tch thng kh) a PaCO2 v bnh thng ri mi lm
nghim php ngng th.

3.6.2. Tin hnh lm nghim php ngng th:

+ Cp oxy 100% qua ng ni kh qun 6lt/pht.
+ Tho ri my th khi bnh nhn trong thi gian 5 pht.
+ Sau , ly mu xt nghim PaCO2.
- Nu bnh nhn th tr li: nghim php m tnh (-) bnh nhn cha cht no.
- Nu bnh nhn khng th tr li, PaCO2 bng hoc trn 50mmHg
(6,65KPa): nghim php ngng th dng tnh (+) bnh nhn cht no.
+ Cho th my tr li.
+ Lm li nghim php trn sau 2 gi.

3.7. nh gi mc ri lon thc theo thang im glasgow:

p ng
m mt

p ng
li ni

- M mt t nhin
- M mt khi gi
- M mt khi kch thch au
- Khng m mt khi kch thch au

4 im
3 im
2 im
1 im

- Tr li ng cu hi
- Tr li chm chp mt nh hng
- Tr li khng ph hp vi cu hi
- Li ni v ngha
- Khng cn p ng li ni

5 im
4 im
3 im
2 im
1 im

- Thc hin vn ng ng theo yu cu

p ng
- p ng vn ng ph hp kch thch
au
vn
ng
- p ng vn ng khng ph hp kch
thch au
- Co cng kiu mt v no
- Dui cng kiu mt no
- Khng p ng khi kch thch au
Cng

6 im
5 im
4 im
3 im
2 im
1 im

15 im

Chng II

H hp
Suy h hp cp

Mai Xun Hin

1. Nhc li mt s im c bn v sinh l h hp.

1.1. S cn bng gia h hp v tun hon:

Tnh hng nh ca t s thng kh ph nang (VA) v tun hon ca dng
mu qua phi (Q) cc vng khc nhau ca phi c ngha c bit. T l ny
ngi kho khi th bnh thng khong 0,8-1,0 (thng kh ph nang: 4-6 lt/pht,
lu lng mu qua mao mch phi: 5-6 lt/ pht). Trong iu kin cn bng thng
kh th lng O2 trong khng kh th vo v lng CO2 o thi ra t phi trn
mt n v thi gian bng lng O2 t ph nang vo mao mch v CO2 t mu
vo ph nang. Lng O2 ph nang khuch tn vo mu v CO2 t mu vo ph
nang t l thun vi lng mu chy qua mao mch ca ph nang .
Nhng vng phi c t s VA/Q thp th paO2 s thp hn v paCO2 s cao
hn, ngc li vng phi c t s VA/Q cao hn gi tr trung bnh th paO2 s ln
hn v paCO2 thp hn gi tr trung bnh.
vng phi c t s VA/Q khc nhau th c s khc nhau v thnh phn
khng kh ph nang v s trao i kh vi mu.

1.2. S khuch tn ph nang - mao mch:

Kh nng khuch tn kh ca phi rt ln, cho nn p lc ring phn cc kh
gia khng kh ph nang v mu mao mao mch phi khng khc nhau l bao.
Hiu s p lc ring phn CO2 (pCO2) ph nang v mu mao ng mch

ngi kho lc bnh thng bng 0. Vi p lc ring phn O2 (pO2) hiu s ny l

3-6 mmHg. S khuch tn kh t ph nang vo mao mch ph thuc vo:
+ S chnh lch p lc ring phn ca cc kh hai mi trng kh v mu.
+ Thi gian tip xc gia hai mi trng.
+ T s khuch tn ca cc kh:
Kh cacbonic (CO2) c ho tan 20 ln, mnh hn so vi oxy nn ri lon
khuch tn ca CO2 t hn, tr khi suy th nng. S o thi CO2 ph thuc hon
ton vo thng kh ph nang.
+ Thnh ph nang:
Thnh ph nang dy khong 0,26 -2,5 micromet (gm c ni mc: 200 400 , mng c s: 1100 -1600 , mng ph nang: 400 -650 ).
+ Din tch h hp v s lng mao mch chy qua ph nang:
Trng hp x phi, ph phi, gin ph nang th c s ri lon khuch tn
cc kh.

1.3. S vn chuyn O2 v CO2 trong mu:

Vic vn chuyn xy t phi n cc t chc c thc hin nh s kt hp
c hi phc gia O2 v Hb : Hb + O2 = HbO2.
S kt hp ny theo quy nh oxy ho c lp vi mi h thng men. S cn
bng gia hai th kh oxy (cn gi l mt oxy) v oxy ho ca Hb thay i theo
p lc ring phn ca oxy trong mu, nhng ch trong phm vi mt mc no ,
d paO2 tng, HbO2 cng vn ch 100%. ng biu din s kt hp
oxyhemglobin theo paO2 l ng cong hnh ch S. S d c ng cong ny l
do cu trc v thnh phn c bit ca hemoglobin.
Khi n cc t chc, paO2 y thp vo khong 40 mmHg, oxyhemoglobin
s b tch i, oxy s chy vo t bo.
S tch ri ny ph thuc vo nhiu yu t nh pH, pCO2, nhit ; v nh
c th c th iu chnh s cung cp oxy cho cc t chc tu theo nhu cu chuyn
ho ca t bo.
Cc c ch vn chuyn ca CO2 gm c:
- CO2 kt hp vi cc cht m ca huyt tng thnh cc dn xut ccbamin.
- CO2 ho tan trong huyt tng v phn ng vi nc theo phng trnh:
CO2 + H2O

H2CO3

H+ + HCO3-. Cc ion H+ -c gii phng, s -c m.

- CO2 khuch tn trong hng cu v cng c vn chuyn theo hng cu

di 3 dng: ho tan, cachemoglobin, kt hp vi nc thnh axt cacbonic
(H2CO3) di tc dng ca anhydraza cacbonic.
1.4. Thng bng kim toan:
Axit l cht cung cp protein hay ion H +, baz l cht nhn protein hay ion
+
H . Gi cn bng kim toan ngoi t bo, ph thuc cn bn vo s hot ng v
hiu lc ca 3 h thng: m, h hp v thn. Cc h thng m chnh ca huyt
tng gm c:

CO3 H SO4 H proteinat

,
,
CO3 H 2 SO4 H 2 protein

Phng trnh Henderson - Hasselbach cho php tnh:

[HCO ]; pK = 6,10, [HCO ] = 20 ; pH = 7,49

pH = pK + log

H 2CO3

H 2CO3

1.5. iu ho h hp:
C s cn bng gia tip thu O2 cng nh o thi CO2 phi vi s tiu th
O2 v sn xut CO2 t bo. C ch thch ng h hp theo nhu cu ngoi vi c
thc hin bi mt h thng iu ho phc tp c mc ch gi cc p lc ring
phn ca oxy v kh cacbonic trong nhng gii hn cht hp, mc d chuyn ho
c thay i.
C 2 h thng iu ho h hp : thn kinh v th dch. Trong h thng th
dch, vai tr ca CO2 l ch yu. Mi khi paCO2 tng 2,5 mmHg th thng kh c
s c th tng gp i v ngc li. S gim O2 tc ng km nht so vi hai yu
t pH v CO2 v n phi qua cun ( glomus) ca ng mch cnh v quai ng
mch ch.
Cc h thng iu chnh h hp rt d b c ch bi cc thuc dng trong tin
m, trong gy m nh mocphin, dolargan, thiopental.
nhng ngi b suy th kinh din, h thng iu ho h hp b hng, pCO2
tng ln v s gi mc cao hn. Cc trung tm h hp s quen dn vi u thn
do yu t kch thch h hp do tng CO2 s li vo hng th yu nhng ch
cho yu t thiu oxy. Trong cn suy th cp, pCO2 s tng vt v s c tc dng
c ch h hp. S d bnh nhn cn th c l do thiu oxy.

1.6. Mng cng ca phi (Surfactant pulmonery):

Mng cng ca phi l mt mng mng khong 50 lt bn trong ph nang
v nm c bit nhng vng tip xc gia nhiu ph nang. N c cc t bo
ph nang c bit to nn v mt hn hp lipit- protit, trong c nhiu lexithin.
Mng cng ny c hnh thnh t lc cn bo thai (tun th 20). Nhim v ca
n l lm cho cc ph nang khng b xp, do gim c nng lng h hp.

1.7. Thm d chc nng th:

Trn thc t lm sng ch cn thm d cc chc nng chnh sau y:
+ Dung tch sng: CV 75% so vi l thuyt l bnh thng, VC < 85%: c
hn ch h hp, VC < 50%: hn ch rt nng.
+ Ch s Tiffeneau hay l-ng kh th ra ti a trong 1 giy. Bnh th-ng Tiffeneau
75%, nu Tiffeneau < 75% : c nghn h hp , nu < 50%: nghn rt nng.

+ Compliance: thay i th tch h hp tng ng vi s thay i ca p lc.

C = v/q (bnh thng C = 0,1301 cmH2O ).

Compliance cng b th h hp cng kh. Compliance gim th lng ngc,

phi b x cng, ph, mt mng cng.
+ p lc ring phn ca O2 trong mu ng mch (paO2 ): bnh thng paO2
95 mmHg. Nu paO2 < 90 mmHg th c s thiu oxy.
+ p lc ring phn ca CO2 trong mu ng mch (paCO2): bnh thng
paCO2 = 40 4 mmHg. Nu paCO2 > 44 mmHg s c u thn, c nhc thn khi
paCO2 < 36 mmHg.
+ pH mu ng mch: bnh thng pH = 7,40 0,04, nu pH < 7,36 s c
toan. Nu pH >7,44 s c s nhim kim.
+ Kim d BE (base excess ): bnh thng mu ng mch trung tnh, BE =
2 mEq/l. Nu BE > + 2mEq/l th c s nhim kim. Nu BE< - 2mEq/l th c s
nhim toan.
+ Kim chun SB (standard bicacbonat): bnh thng SB = 23,5 mEq/l.
RA (reseroe alcaline) d tr kim: bnh thng RA = 27 mEq/l.
+ Kim m BB (buffer base): bnh thng BB =45mEq/l.
Cc kt qu sinh l trn y c ghi trn biu ca Davenport tin
chn on v theo di bnh.
2. sinh l bnh ca suy h hp.

2.1. nh ngha suy h hp:

Suy h hp cp l tnh trng b my h hp khng cung cp xy cho t
chc t bo v loi tr kh Carbonic ra khi c th qua phi.
Thiu oxy mu km theo hoc khng km theo tng CO2 mu. Thiu oxy
mu n thun khng c ngha l nh hn thiu oxy mu c km theo tng CO2
mu, c khi li nng hn nh trong hi chng suy h hp cp tin trin (ARDS:
acute respiratory distress syndrome).

2.2. Sinh l bnh:

H hp phm vi phi ph thuc vo nhiu yu t:
- Thng kh ph nang: bng thng kh ton b tr i th tch khong cht
(VA= VT-DS). ngi bnh thng VA=2,5 l.
- Tun hon ca dng mu trong phi: Q= 3,5 l. Tun hon ny ph thuc vo
cung lng tim.
- Kh nng khuych tn kh qua mng ph nang - mao mch.
Suy h hp c th xy ra do ri lon mt trong ba yu t trn, hoc phi hp
cc yu t trn.
mt s bnh phi nht nh, c th c nhiu c ch gy suy h hp cp.
Ngc li, c nhiu bnh ch c mt c ch chung. Th d vim ph qun phi c
th va gy ri lon thng kh va gy bloc ph nang - mao mch. Bi lit, hi

chng Guillain-Barre, nhc c, rn h cn, chng porphyrre cp, c ch gy suy

h hp l do lit c h hp.
2.2.1. Ri lon thng kh:
Ri lon thng kh l c ch thng gp nht trong suy h hp cp. Gii quyt
c ch nyl mt nhim v cp bch ca ngi lm cp cu.
+ S gim thng kh ph nang ton b: Th-ng do tn th-ng trung -ng hay cc c,
rt t gp cc tr-ng hp b bnh lng ngc v phi, ch tr tr-ng hp ngoai l
nhng hon cnh c bit nh- tc -ng th cp tnh, trn dch, trn kh ln mng
phi hai bn, gy nhiu s-n... Biu hin nhng triu chng sau:

- Lm sng : xanh tm, v m hi, nhp th tng hoc gim.

- Xt nghim : paCO2 tng v paO2 gim.
+ Gim thng kh ph nang khu tr : c nhiu nguyn nhn gy gim thng
kh ph nang khu tr :
- Vim phi : ti mu tng nhng thng kh mt vng vim phi, VA/Q
di 0,8 (tc dng on mch), paO2 s gim.
- Xp phi : ti mu bnh thng nhng thng kh mt vng b xp. VA/Q
di 0.8; paO2 gim.
- Gin ph nang : VA gim, Q bnh thng. VA/Q cng gim.
Trong cc tr-ng hp ny, paCO2 vn bnh th-ng v khuych tn nhanh qua vng ph
nang khng hoc t b th-ng tn, paCO2 c th b gim v tng thng kh.

2.2.2 Ri lon thng kh - ti mu :

Ri lon thng kh - ti mu thng gp trong cc t cp ca vim ph
qun mn :
- C vng gim c VA ln Q.
- C vng gim VA nhng Q vn bnh thng.
- C vng VA vn bnh thng nhng Q mt.
Cui cng paCO2 v paO2 gim nh trng hp gim thng kh ph nang
ton b.
2.2.3 Ri lon khuych tn:
in hnh l tnh trng bloc ph nang - mao mch, c xc nh bng xt
nghim: paO2 gim, paCO2 vn bnh thng v CO2 khuych tn nhanh gp 25 ln
O2 qua mng ph nang mao mch. Nhng c khi tnh trng tc m li km theo
gim thng kh ph nang lm cho paCO2 tng.
Bloc ph nang - mao mch l c ch c bn trong ARDS v ph phi cp tn
thng.

2.3. Cc loi suy th th-ng gp trong ni, ngoi khoa:

2.3.1 Suy th do tn thng ngoi phi:
- Do tn thng cc trung tm h hp: ng c bi cc thuc bacbituric,
thuc phin (mocphin, dolargan), chn thng s no hay u no c ph no, chn
p trung tm h hp...
Lc u ch c gim thng kh n thun, v sau c thm n tc m ri, dch
d dy tro ngc. Suy th c th biu hin t ngt bi ngng th hoc cng c
th tin trin rt m . Trong chn thng s no, c khi bnh nhn th nhanh
(khi b kch thch), cng c lc bnh nhn qun th. Xt nghim mu trn nhng
bnh nhn ny, lc u c thiu xy v nhc thn nhng v sau c th c nhim
toan hn hp.
- Do tn thng ty: chn thng, vt thng vo tu, bnh bi lit. Din bin
cng ging nh trn.
- Do tn thng thn kinh ngoi vi hay thn kinh c: cc bnh vim thn
kinh (polynevrite, polyradiculo - nvrite), cc bnh ca c (myasthnie), do thuc
gin c, hoc mt s thuc khng sinh.
- Do tn th-ng lng ngc: ni khoa, c cc bnh un vn, nhim c do strychnin
vi co cng, co git ton thn gy p lng ngc. ngoi khoa, cc chn th-ng lng
ngc lm gy nhiu s-n, in hnh l mng s-n di ng, c trn kh ph mc, c
h hp o chiu. y c gim h hp cng vi tc m ri, bnh nhn b thiu
xy v -u thn nng, suy th rt d chuyn sang khng hi phc.

- Hi chng Pickwick v hn m do thiu nng gip trng: Hi chng

Pickwick hay gim thng kh ph nang trn mt ngi bo ph l mt v d mi
v suy th m nguyn nhn ngoi phi. Bnh cnh ni bt l mt ngi bo ph,
lun lun ng gt, tm ti, th theo kiu Cheyne Stokes, c tm ph mn. Cc th
tch h hp, thng kh gng sc ti a gim, compliance gim, sc lm vic ca
h hp tng. Trong mu, paO2 gim, paCO2 tng. Hi chng gim h hp ngi
b thiu nng gip trng cng tng t.
2.3.2 Cc suy th c nguyn nhn phi:
+ Cc ri lon khuch tn:
- X phi lan to: Trn lm sng, kh th l du hiu ni bt, thng rt nng
v lc u ch xy ra khi gng sc, nhng v sau s tr thnh lin tc. Th nhanh
u v nng. Bnh nhn gy cm, au vng ngc, c th c ngn tay di trng.
Chn on da vo tin s, ngh nghip, lm sng, Xquang v kt qu th mu,
paO2 thp, paCO2 bnh thng. Cc ri lon trn y c iu chnh khi bnh
nhn c th nhiu xy.
Hn ch nn mao mch phi (nhu m phi): c gim thi gian tip xc gia
kh v mu, do cn bng kh ph nang v mu khng thc hin c, a
n thiu xy. Trn lm sng, bnh nhn kh th, c nhng cn au kiu co tht

ng mch vnh, ho v suy nhc, c khi b khi huyt, X.quang : hnh tim to,
cung gia ng mch phi cng. Thng tim c tng p lc trong ng mch phi.
- Sunt trong phi: bnh thng vn c mt phn rt t mu tnh mch chy trc
tip vo ng mch m khng c xy ho. Sunt sinh l ny xy ra nhiu ni:
gia tnh mch ph qun v tnh mch phi, gia ng mch phi v tnh mch
phi, gia cc tnh mch Thibsius vo tim tri. Trong mt vi hon cnh c
bit, sunt trong phi c th rt ln v dn ti gim bo ho xy ngoi vi trong
khi paCO2 vn bnh thng hoc gim. Mun chn on, cho bnh nhn th xy,
mc d bo ho xy ln ti 100%, paO2 vn thp.
+ Cc ri lon cn bng h hp - tun hon:
- Vim ph qun mn tnh: -ng h hp b nghn, c th c vim ph qun phi, p
xe, tc ph qun ln v b, xp phi. Bnh nhn khng cn hiu lc h hp,Tiffeneau
gim rt nhiu. Thng kh gng sc ti a gim, th tch kh cn tng.

t suy h hp cp ca COPD, hen c tnh

- Gin ph nang.
- Hen ph qun.
- ng tc m ri trong ngoi khoa.
- ARDS: c bn ci nhiu trong nhng nm gn y. Trn nhng bnh nhn
b sc chn thng khng c lin quan n ngc v phi, trong nhng ngy sau,
xut hin kh th, nhp th nhanh dn, i hi xy vi nng ngy cng cao.
Trn phim X.quang c nhng m m ri rc hai phi, lc u ring l, v sau
dy c v lm phi m ton b.
Th mu, paO2 gim nhiu, paCO2 lc u gim hoc bnh thng, v sau
tng. Compliance gim. Cui cng, bnh nhn cht.
V sinh bnh l, c nhiu gi thuyt. Xt nghim bnh l gii phu c: ph
k, ng mu trong lng mch, vim ph qun nh, vim ph nang, apxe nh cc
phn thu phi, tc m ri.
3. Triu chng.

3.1. Lm sng:
3.1.1. Kh th :
Thiu oxy mu km theo tng hay khng tng paCO2 cng u gy kh th.
+ Nhp th : c th tng trn 32 ln/pht, thng c co ko c h hp ph nh
trong vim ph qun phi. C th gim di 12 ln /pht, khng c co ko do lit
h hp nguyn nhn trung ng nh trong ng c bacbituric. Phi ch nh th
my ngay v nhp th s chm dn.
+ Bin h hp:
- Gim trong vim ph qun phi, rn h cn, bi lit, hi chng Guillai- Barre.

- Tng trong hi chng ARDS, tc mch phi.

3.1.2. Xanh tm:
+ mi v u chi ngn. Khi Hb kh trn 5g/100 ml, SaO2 di 85g/l. Cc
u chi vn nng, khc vi sc.
+ Khng c xanh tm nu thiu mu.
+ Khng c xanh tm m ta, v m hi nu tng PaCO2 nhiu nh trong
t cp ca vim ph qun mn. Thng c km theo ngn tay di trng.
3.1.3. Ri lon tim mch:
+ Nhp : thng nhp nhanh xoang hay cn nhp nhanh ( flutter, rung nh
nhanh hoc cn nhp nhanh b ni ). Rung tht thng l biu hin cui cng.
+ Huyt p tng hoc h: giai on u huyt p th-ng tng cao, giai on sau h dn,
phi can thip ngay (bp bng, t ng ni kh qun, ht m, th my).

+ Ngng tim do thiu oxy nng hoc tng paCO2 qa mc cn cp cu ngay.

C th phc hi nhanh nu can thip trc 5 pht.
3.1.4. Ri lon thn kinh v thc:
No tiu th 1/5 s oxy ton c th. V vy no chu hu qu sm nht tnh
trng thiu oxy v tng CO2 mu.
- Ri lon thn kinh: giy da, ln ln, mt phn x gn xng.
- Ri lon thc : li b, l , hn m.
3.1.5. Khm phi:
+ Trong suy h hp nguyn nhn ng c, thn kinh: nhiu rn m, i khi
thy xp phi.
+ Lit h hp:
- Lit c gian s-n: lng ngc xp khi th vo, c honh vn di ng bnh th-ng

- Lit mn hu: mt phn x nut v ng m di, d ht phi m di v

dch v.
- Lit h hp th-ng dn n xp phi ( cn ch nh m kh qun v th my).

- Trn kh mng phi d pht hin khi mi vo vin nhng d b st khi bnh
nhn ang th my. Hay xy ra trong qu trnh th my hoc sau khi t catheter
di n.
- Vim ph qun phi vng sau phi hay gp nhng bnh nhn suy h hp
nm lu, khng c dn lu t th v thay i t th. Vim ph qun phi bnh
vin thng gp bnh nhn thng kh nhn to ko di, chim t l 15-20%.

3.2. Xt nghim:
3.2.1. Chp phi:

Cn chp phi ngay ti ging bnh cho tt c bnh nhn suy h hp cp. Tuy
nhin kh c th chp in cho mt bnh nhn th nhanh, nm trn ging hoc
mt bnh nhn hn m do ng c bacbituric ang th my. Kinh nghim chp
phi ca chng ti nh sau: cho bnh nhn th my c tng thng kh v oxy
100% hoc bp bng qua mt n trong 20 pht bo ho oxy s tng ln nhanh
chng, nhp th s chm li hoc ngng hn trong vi pht. Chp phi, ngay c
vi my chp na sng, vn c th thc hin c.
3.2.2. Xt nghim cc kh trong mu:
-SaO2 ( bo ho oxy trong mu ng mch): bnh thng bng 95-97%.
SaO2 di 85% l c tm.
- PaO2 (p lc oxy trong mu ng mch): bnh thng ngi tui thanh
nin l 95-96 mmHg, ngi trn 60 tui l 78mmHg. Trong suy h hp cp,
paO2 gim xung di 40 mmHg (8kPa).
- PaCO2 (p lc CO2 trong mu ng mch): bnh thng bng 40mmHg, c
th ln ti 80mmHg (10,7 kPa) trong suy h hp cp hay hn na. PaCO2 tng
trong gim thng kh ph nang.
Xt nghim cc kh trong mu cho php phn loi suy h hp cp ra lm hai
nhm chnh:
- Nhm 1: gim oxy mu khng c tng CO2
PaCO2 gim xung di 40 mmHg (8 kPa).
PaCO2 bnh thng, hoc h thng km theo: kim h hp do tng thng kh
ph nang, hay toan chuyn ho do tng axit lactic.
Th d: ARDS, sc.
- Nhm 2 : gim thng kh ph nang.
PaO2 gim.
PaCO2 tng.
Thng km theo nhim toan h hp hoc nhim toan hn hp (phi hp vi
tng axit lactic mu).
Th d: lit h hp, vim ph qun phi tc nghn.
Nhm 1 ch c gim oxy mu khng c ngha tin lng nh hn nhm 2.
Trong hi chng suy h hp cp tin trin ARDS, oxy ch khuych tn qua vch
ph nang vng lnh, nn th oxy vi FiO2 = 1 nhiu khi cng khng a PaO2
tr li bnh thng.
4. Chn on:
Chn on suy h hp cp thng l d, l mt chn on lm sng. Xc
nh th loi suy h hp cp c th kh khn hn v phi da vo xt nghim, c
bit l xt nghim kh mu l tiu chun chnh chn on xc nh. Cch gii
quyt tt nht l xc nh nguyn nhn ri t tm ra c ch sinh bnh quyt
nh thi x tr. Chn on phn bit cng rt quan trng trnh vic x tr
khng ng.

- Tng khng kh ( khng phi l kh th) c trong toan chuyn ho, ng c

aspirin, tn thng thn no. C trng hp suy thn c m kh qun.
- Nhp th Cheyne-Stokes hay gp trong cc trng hp khc khng phi l
suy h hp nh: suy tim, suy thn, tai bin mch mu no. i khi gp trong ng
c opi ( y c ch nh th my).
- Xanh tm v kh th c th do trn dch mng tim gy p tim, thiu vitamin
B1 (thng mt phn x gn xng).
Bnh no do suy h hp cp c th nhm vi vim no c suy h hp cp. St rt
c tnh li th-ng c bin chng phi lm bnh nng thm (th-ng b b qua).

5. Phn chia giai on.

Suy h hp cp l mt cp cu thng gp nht, cn phi can thip ngay.
Trong thc t, c th phn chia suy h hp cp ra lm 2 loi:
- Loi nng: can thip bng thuc l ch yu, c th gii quyt c bng
thuc hoc mt s th thut khng ng k.
- Loi nguy kch: phi can thip ngay bng cc th thut sau mi dng
thuc hoc phi s dng song song (t ng ni kh qun, bp bng, th my...)
Bng phn loi suy h hp theo triu chng lm sng
Loi nng

Loi nguy kch

Xanh tm

++

+++

V m hi

+++

++

+++

Sp t vong

Vt v, kch thch

Giy da, l ,hn

m

Kh th
Tng HA hoc
Tt HA (tru
mch)
Ri lon thc

6. X tr.
Cc bin php hi sc h hp cn phi c thc hin ngay lp tc, cng khn
trng th kh nng cu sng bnh nhn cng nhiu.

6.1. Dn l-u mng phi:

C ch nh trong cc hi chng trn kh mng phi, trn kh trung tht v
trong trn mu, trn dch mng phi. Thc t lm sng cho thy: dng kim chc
ht trn kh mng phi khng c kt qu. Phi dn lu khong lin sn 2
ng gia n vi ng bng cao su hoc cht do, c ng knh 0,3 - 0,5mm,

dn lu kn, mt chiu, v khun v c p lc ht khong 20 - 35mmHg (nu l

trn kh). Trong trng hp trn kh ln khng c phng tin dn lu th phi
chc bng kim Petrob ci tin chuyn v c s cp cu.
Trng hp v, rch ph qun, c trn kh mng phi ln, dn lu khng c
hiu qu th phi cp tc can thip phu thut v t ng Carlens hoc ni ph
qun m.
D l trn kh mng phi nhng bnh nhn ni khoa, vn phi dn l-u mng phi.

Nu c trn kh trung tht, nhiu khi vi dn lu mng phi cng , nhng

cng c khi phi dn lu trung tht, i vo khong gia kh qun v xng c.
Dn lu mng phi cng c th c ch nh d phng trn nhng bnh nhn b
gy nhiu sn, b mng sn di ng, trc khi c gy m ni kh qun hay
th my.
Trn mu, trn dch mng phi phi dn lu bng ng argyl gian sn 8 ,9
ng nch gia.
Rt ng dn lu trong vng 48 gi hoc 72 gi sau khi ht kh hoc dch.

6.2. Khai thng -ng dn kh:

Khai thng ng dn kh l vic u tin phi lm, phi xem xt khng
nhng cho cc bnh nhn c suy h hp cp m cho tt c cc bnh nhn cp cu
ngay t giy pht u tin tip xc. Tu theo nguyn nhn v mc , c th p
dng cc th thut sau y:
+ Mc mm, mi, hng, lau sch, ht sch t, ct, bn, thc n, mu v.v...
+ Trong trng hp c d vt ng th phi lm nghim php Heimlich
tng d vt ra ngoi.
+ Dn lu t th ht m di qua ming, t canuyn Guedel hay Mayo
nng li, t u tht nga ra ng sau hoc ko li ra ngoi khi li b tt in
hnh trong cc chn thng hm mt.
+ Lun dy polyten qua khe sn gip nhn. Trn nhng bnh nhn b tc m
di nhiu m ht khng kp v khng ht, c th lun mt dy polyten qua mng
gip nhn vo kh qun vo a su xung carina kch thch ho tng m ri
ra ngoi v qua bm thuc long m, khng sinh vo ng h hp. Phng
php ny n gin v rt nhiu trng hp, ch sau 24 - 48 gi, 2 phi c
thng sut; sau c th rt b dy. Nh phng php ny, nhiu bnh nhn
trnh c m kh qun.
+ Ht m di, mu m trong kh - ph qun. C 2 cch ht:
- Ht m: bnh nhn ngi n ra ng trc hoc nm nga, h mm, th
li. Mt tay thy thuc cm gc ko li bnh nhn ra trc, tay kia cm ng
ht a xung gc li vo thanh qun, kh qun v ht. Khi ng ht vo ng
ng h hp, bnh nhn s ho mnh v khng ni c. Ch ht nhanh v ch
ht khi ko ng ra, khi b ngt cp.

- Ht c n soi hoc dng n soi thanh qun: nng tiu thit, l thanh
qun, a ng ht vo su trong kh - ph qun v ht. Hoc dng ng soi kh ph qun v ht (bronchoscopie aspiration).
Phng php soi ht : t bnh nhn ngi theo t th Fowler hoc ngi thng
tu theo mc suy th. Phi gy t bng xylocain 2%. Trng hp bnh nhn
cn tnh to th phi cho bnh nhn an thn bng valium hoc ng min nh,
cng nh i vi bnh nhn suy th nng th phi lm h hp vin tr trong khi
soi. Soi trc tip c thun li l thy r cc tn thng bn trong ng h hp,
c th ht sch m di, mu, m tt c cc nhnh ph qun. Tuy nhin i hi
phi c k thut, phng tin v kinh nghim
t ni kh qun, m kh qun l cc th thut c bn nht khai thng
ng dn kh.

6.3. M kh qun:
+ C ch nh khi:
- C tr ngi ng h hp trn m cc phng php trn y khng gii
quyt c, v d co tht thanh qun, ph n thanh qun, vim lot thanh qun
(bch hu), vt thng thanh - kh qun.
- Bnh nhn phi th my di ngy.
- Khi cn gim khong cht tng thng kh ph nang.
K thut m kh qun cng lm theo kinh in, tuy nhin phi lm ng k
thut trnh bin chng sau m nh : hp kh qun, chy mu v hoi t thnh
kh qun.
+ Trong sn sc bnh nhn m kh qun, cn c bit ch :
- Kim tra xem ng c b y ra trc hoc ra sau hay sang bn lm nghn h
hp v vim lot kh qun.
- Bo m v trng tuyt i trong sn sc nh: bnh nhn c cch ly vo
ni v trng, cc thy thuc sn sc phi i m, mang khu trang v mi ln ht
trong ng Krishaberg hoc Sjoberg trong ng h hp, phi ra tay st trng v
mang gng tay; dy ht cng phi bo m v trng.
Tuy ch cc bin php ni trn, mt s ln bnh nhn vn b nhim
khun. Nhiu trng hp sau ngy th 2 b nhim tp khun, n ngy th 5,
th 7 c t cu vng (S. aureus) hoc trc khun m xanh (P. aeruginosa).

6.4. t ni kh qun:
t ni kh qun c ch nh ging m kh qun. C 2 phng php t ni
kh qun:
- Qua ming.
- Qua mi.
Phng php t ni kh qun qua ming d t v nhanh, nhng phi dng
n soi thanh qun, bnh nhn c th cn ng v kh v sinh rng ming. t qua

mi c th lm m khng cn n soi, c th lu hn. Nhc im ca phng

php ny l gy lot, chy mu mi, sn sc kh hn v d b tc ng hn.
Nh t ni kh qun, mt s bnh nhn khng phi m kh qun, trnh c
cc bin chng do phng php ny gy nn. Tuy nhin d gy ph thanh qun,
do a s cc tc gi ch trng m kh qun ngay trong ngy u, nu bit
trc cn phi th my di ngy.

6.5. H tr h hp, h hp nhn to:

Phng php ny c thc hin trn nhng bnh nhn b gim thng kh.
+ Trc khi lm h hp nhn to, ch :
- t thng d dy, phng tro ngc.
- M thng mng phi, nu c nguy c trn kh, trn mu mng phi.
- t ni kh qun hoc m kh qun vi ng Sjoberg.
+ C nhiu phng php h hp nhn to. Cc phng php thng lm l:
- Thi ngt: c lm trong s cu ngoi bnh vin, ti ni xy ra tai nn.
So vi phng php nhn to bng tay trc y (Sylvester, Safar ...) thi ngt tt
hn nhiu v:
. a vo nn nhn nhiu xy nht.
. C th lm bt k u, ai lm cng c.
Kt qu cho thy phng php ny tuy n gin, nhng c hiu lc, v
cu c nhiu bnh nhn b ngng tim, ngng th, nh thi ngt kt hp vi p
tim ngoi lng ngc kp thi rt ngn c thi gian thiu xy no, lm
cho v no c hi phc hon ton.
Hin nay, c nhiu loi ng hnh ch S, nhiu loi mt n bng cao su, cht
do, qua c th h hi cho bnh nhn phng c bin chng ly bnh
truyn nhim. Cc loi bng ambu thay cho thi ngt. y mun lm h
hp nhn to c kt qu, phi p masque tht st vo mi v mm bnh nhn v
phi t u bnh nhn tht nga ra ng sau.
Bng: Hiu qu ca phng php thi ngt.
S Lng Thng Oxy Lng CO2
ln
trong
kh
kh
trong
xy
th/p lu ml/pht khi
pht kh th
ht thng
vo
th
vo
Nn
0
0
0
0
0
0
nhn
khng
th
Ngi 12
>
>
20%
>
0,03%
lm
1.000 12.000
2400ml
hi
sc

CO2
trong
ph
nang

Ghi ch

> 5%

< 5%

Khi th
gng sc
nng
xy trong
kh th ra
l 18% cao

Nn
nhn
c
thi
ngt

12

1000 12.000

18%

2160

< 5%

hn bnh
thng16
%
So vi
5%
ngi bnh
thng,
nn nhn
c mt
lng oxy
a vo
cao hn
> 5%

Ngi 16
500
8000 20% 1600
0
bnh
thn
g
- Th my (ventilation mecanique): c ch nh khi c phng php h tr
h hp thng thng khng c kt qu.
Thng kh nhn to gm: Thng kh nhn to xm nhp v thng kh nhn to
khng xm nhp.
C 2 loi my th:
. Th theo p lc.
. Th theo th tch.
My th theo p lc ly nng lng t cc bu oxy hoc kh tri nn di p
lc. Mt h thng van c ng v m tu theo p lc trong phi bnh nhn
a kh t bu xy vo my, vo bnh nhn (khi p lc trong phi bnh nhn ln
cao mt mc tnh trc) hoc kho li khng kh vo my v bnh nhn
th ra. in hnh ca cc loi my ny l Bennelt, Newport, Servo...
My th theo th tch chy nh mt c in lm quay mt ti xp ng v m
theo chu k v th tch tnh trc. Khi ti xp ln hay xung s rt kh hoc
y kh vo phi bnh nhn. My Engstrom, my P05, P06... thuc loi ny.
i vi tr em c bit cc tr s sinh v ang b, phi c nhng loi my
c bit c p lc thp v khong cht b, nh my Losco (H Lan), Engstrom
(mu tr em).
Trc khi chy my phi:
Kim tra xem ng c in c chy tt khng, cc van, ti xp, dy dn kh,
ng ni v.v... c kn khng ?
Tnh cc thng s h hp, da theo biu Radford hoc ca Engstrom
Herzog. Thng thng th tch kh lu thng t 10-12 ml/ kg, T l xy trong
khi th vo (FiO2) l 40% - 60% hoc 80%.
Nn cho bnh nhn cc thuc ng min hoc an thn khi t ng ni kh
qun hoc m kh qun.
Khi cho bnh nhn th my phi kim tra xem lng ngc bnh nhn c ln
xung theo nhp th ca my, xem bnh nhn c thch ng vi my hay khng

Cn theo di tnh trng chung, mch, huyt p ca bnh nhn v c bit l phi
lm cc xt nghim v kh mu: pH, paCO2 trong mu ng mch iu chnh
cc thng s h hp cho ng. Nu bnh nhn th chng my v sau khi kim
tra thy mi vic chun b lm tt, ng h hp c thng sut th phi:
- Tng thng kh gy nhc thn.
- Cho cc thuc ng min nh dolargan, mocphin.
- Cho thuc gin c (bt c d).
Vic theo di v sn sc bnh nhn th my kh hn nhiu so vi m kh
qun, trong ny phi c bit ch :
- Chng nhim trng.
- Lm m kh th vo.
Mun nh vy, phi ch st trng my th, phi gi v trng tuyt i trong
cng tc sn sc bnh nhn, lp thm mi nhn to Toremaln hoc dng kh dung
(arosol) hay cho nh git dung dch khng sinh, long m vo ng h hp.

6.6. Oxy liu php:

Ch cho bnh nhn th khi thiu xy, trng hp va thiu xy va u thn
th phi lm bnh nhn th tt, tng ht CO2 tha ra ngoi ri mi cho th xy.
Cc phng php th oxy thng dng l:
- Th oxy qua thng t mi.
- Th qua mt n.
- Th oxy trong lu hoc lng p.
- Th oxy cao p.
Mi phng php c nhng u im, nhc im v ch nh ring ca n. V
d: th oxy qua mt n c ch nh trong trng hp c ph phi, trong cc
phi t (wet lung); th oxy cao p th c ch nh trong cc trng hp thiu oxy
rt nng m cc phng php khc khng gii quyt c.
Cho bnh nhn th xy s nng c p lc ring phn ca xy trong mu
ng mch ca bnh nhn, nhng cng c th gy mt s bin chng nh m mt
( tr s sinh), au xng, d b vim phi.

6.7. Ra ph qun:
L mt th thut d lm v c hiu qu. Tuy nhin cn phi chun b tt bnh
nhn (th oxy 100% t nht 20 pht trc). Bm qua ng ni kh qun 20-30ml
nc ct, lun ng thng ht mm, t ra l hai c (to v nh) ht theo nhiu t
th. Thnh thong cho bnh nhn th oxy hoc bp bng. Thi gian khng ko
di qu 4 pht. Cn ch theo di mch, huyt p v tnh trng ton thn. C th
ra ph qun nhiu ln trong ngy. Trong cn hen ph qun c tnh, ra ph qun
qua ng ni kh qun, th thut c bn kt hp vi vic th my.
Ra ph qun kt hp vi tm qut vng ngc, kch thch ho l cc bin php
tch cc lm cho long m.

6.8. Chng nhim toan:

Truyn nh git cc dung dch kim nh natribicacbonat hay tham. Trong suy
th, bnh nhn c toan h hp n thun hoc toan hn hp. Ri lon kim toan
s dn ti ri lon tun hon, ri lon bi tit thn v.v. Do vic s dng cc
dung dch kim l cn thit. Liu lng natribicacbonat hay THAM c tnh
theo kt qu kim d (BE) v trng lng c th ca bnh nhn (ml dung dch
HNaCO3 7,4% = [BE] x 0,6 x P) hoc (ml Tham 0,3M = [BE] x P), nhng thng
thng c th cho 75ml natri bicacbonat 8,4% hoc 450ml THAM 0,3M.

6.9. Cc thuc kch thch h hp:

+ Cc thuc kch thch h hp nh: almitrin (vectarion), niketamit, lobelin,
diamox, micoren v.v.. kch thch trung tm h hp, lm cho bnh nhn th su,
th nhanh hn, nhng cnglm tng nhu cu xy ca bnh nhn, ch c ch
nh sau khi ng h hp ca bnh nhn c thng sut v bnh nhn phi
c th oxy. Cc thuc ny c tc dng tt trn nhng bnh nhn b suy th mn
tnh, c t suy th cp. Trng hp cc trung tm h hp b c ch bi cc thuc
bacbituric, cc thuc nh mocphin, dolargan th c th dng cc thuc i khng
nh bemegride, nalocphin.
+ Cc thuc dng trong hi sc h hp:
- Aminophylin (diaphylin), salbutamol, terbutalin c tc dng tt trong cn
hen ph qun. Cc thuc ny cn ho long trong 500ml glucoza 5% hoc 10%
truyn nh git tnh mch. Khng nn tim tnh mch nhanh c th gy cn nhp
nhanh (trn tht, rung tht).
- Corticoit ch c tc dng trong mt s cp cu cn hen ph qun, ph thanh
qun, ph phi cp tn thng, hi chng Mendelson.
- Cc thuc long m c dng rng ri trong hi sc h hp nh:
mucomyst, mucosolvan ...
Gi tr ca cc thuc trong hi sc h hp, nu c tc dng th ch l h tr,
quan trng nht vn l cc th thut c tin hnh kp thi, thch hp, c trnh t
nht nh.

6.10. S dng cc khng sinh c hot lc mnh:

Suy th v nhim khun ng h hp thng gn lin vi nhau. Suy th gy
nhim khun v nhim khun gy suy th. iu tr nhim khun phi ph qun
tt nht l cc khng sinh nhm cephalosporin th h th 3 kt hp vi nhm
aminosit hoc nhm quinolon th h 2.

ph phi cp

Mai Xun Hin

1. t vn :
+ Ph phi cp l hi chng suy h hp cp gy ra bi s thm tit dch t
mch mu vo ph nang t gy ngt th.
+ Ph phi cp l mt cp cu rt thng gp, chn on khng kh, nhng
i khi b nhm ln.
X tr kh khn v:
- Nguyn nhn gy ph phi cp ca cc bnh nhn rt khc nhau.
- Bnh xut hin bt k ni no.
2. Sinh bnh hc.
+ Mng ph nang mao mch c cu to bng:
- Cc mao mch gm cc t bo ni mc.
- Khong k gm t chc lin kt, cc i thc bo v cc t bo x non.
Khong k ny tip ni vi khong k quanh cc tiu kh qun tn, c cha cc
bch mch v pha trung tht.
- Lp thng b ph nang tip ni lp thng b ph qun bao gm lp t bo
type I v t bo type II.
+ Mt dng chy lin tc gm c nc, cc ion v cht dng keo vn chuyn
trong khong k theo nh lut Starling.
+ Bnh thng dng chy t mao mch phi vo khong k ri vo bch mch
bng 20ml/gi. Cc bch mch c th dn lu gp 10 ln.
+ Tnh trng ng nc trong phi din bin theo 3 giai on:
- Giai on 1: dng chy tng nhng dn lu bch mch cng tng.
- Giai on 2: ph k.
Kh nng dn lu qua bch mch b vt qu, nc v cc cht dng keo
tch ly trong khoang quanh ph qun, khong k dy dn ln.
- Giai on 3: ph ph nang, bt u xut hin ph nang nh, sau n cc
ph nang ln.
Hu qu:
Ph nang b trn ngp nc lm ri lon b my thng kh lm gim dung
tch cn chc nng, gim gin n v tng sc cn ng dn kh nh ( ph
qun nh). Cng h hp tng ln v shunt trong phi xut hin dn n gim oxy
mu.

Ph phi cp lm tng tit adrenaline gy ra tng huyt p, nhp tim nhanh,

ri lon nhp, to iu kin xut hin thiu mu c tim, lm suy tim tri v lm
nng thm ph phi cp .
3. Chn on.

3.1. Chn on xc nh:

Thng l d, ni chung ch cn da vo triu chng lm sng: khi u l
t ngt ho, kh th, nhp th nhanh, nng, lm cho bnh nhn phi ht hong
bt ngi dy th v ku gi cp cu.
n khi bnh ton pht th bnh nhn khc bt hng, nghe phi hai bn c
nhiu rn m nh ht hai y (ging nh rn n th th vo hoc cui th th
ra). i khi c th nghe c rn ngy nu c du hiu tc nghn m.
Ph phi cp bnh nhn cp cu nm lit ging kh chn on nu khng
theo di cht ch. Khng c rn m nh nc triu dng. Nghe phi pha trc
khng thy g c bit, ch c SaO2 gim r rt.
o SaO2 trc khi cho th oxy rt c gi tr chn on nhanh trc khi
cho bnh nhn chp X- quang phi: SaO2 rt thp chng t c tnh trng thiu
oxy trm trng.
Chp X. quang phi cho thy:
- Giai on 1: Cha r, nhng c th thy ng mch phi ni to, rn phi
m. Tuy nhin cc triu chng lm sng nh kh th, ho bt u xut hin.
- Giai on 2: Ph k, phi thng m nh ging nh vim phi k.
- Giai on 3: Ph ph nang: phi trng hnh cnh bm. Gc sn honh c
th cn sng (ph phi cp tn thng), c th m (ph phi cp huyt ng).

3.2. Chn on phn bit:

+ t cp ca bnh phi, ph qun tc nghn mn tnh: i khi cng kh phn bit.

+ Tc mch phi bnh nhn hp van 2 l hay tm ph mn. Tc mch phi

bnh nhn hp 2 l l tc mch nh nhiu nhnh. X-quang phi: rn phi m
nhng nhu m phi c th sng.

3.3. Phn loi theo c ch bnh sinh:

3.3.1. Ph phi cp do:
+ Tng p lc vi mch phi:
- Tim.
- Tc tnh mch phi.
+ Thn kinh:

- Chn thng s no.

- Xut huyt no - mng no.
- Tng p lc ni s.
- Cn ng kinh lin tc.
3.3.2. Ph phi cp c p lc ng mch phi bnh thng:
+ Tn thng phi trc tip :
- Nhim khun phi do vi khun, virus, k sinh trng.
- Ht phi ho cht c, hi c.
- Ngt nc.
- Tc mch do nc i, do m.
- Chn thng phi.
+ Tn thng phi gin tip:
- Nhim khun nng, nhim khun huyt.
- Vim ty cp.
- a chn thng.
- ng mu ri rc trong lng mch (truyn mu nhm nhm, sc
nhim khun).
- Bnh bch cu cp cp.
+ Phi hp c 2 loi, c ch phc tp:
- Ph phi cp do cao.
- Dn lu kh mng phi vi p lc qu nhanh.
- Tc ng dn kh.
- Qu liu heroine.
- Suy thn cp, sn git.
- Tun hon ngoi c th.
- Truyn mu trong bnh bch cu cp.
- Thuc chut Tu.
Phn bit hai loi ph phi cp huyt ng v tn thng
Ph phi cp nguyn nhn Ph phi cp khng do tim (tn
do tim (huyt ng)
thng)
Bnh tim mch
Khng c
Nga phi
Khng c
Tnh mch c ni, ph chi
Khng c
Cn tng huyt p
Khng c
in tim thay i
Nhp xoang nhanh
XQ: rn phi m phi hnh Phi m, trng, phi hnh cnh

cnh bm
Gc sn honh m

bm
Gc sn honh sng

Cn tng huyt p c th l nguyn nhn hay hu qu ca ph phi cp do tim.

4. X tr.

4.1. T- th:
- Ngi thng, thng chn trong ph phi cp huyt ng
- Na nm, na ngi trong ph phi cp tn thng.
Bnh nhn c cao huyt p nn t gar t chi (gar tnh mch). C 30 pht
li ni gar. Khi xy ra qu cp tnh cn trch mu cho bnh nhn. Trc khi trch
mu cn tim vo tnh mch bnh nhn 5.000-10.000 n v heparin. Lng mu
trch khong 200-400 ml. Khng c ch nh trch mu cho cc bnh nhn b ph
phi cp nhiu ln.

4.2. Oxy liu php:

+ Oxy liu php tu theo mc :
- Th oxy qua mi 6 -8 l/pht. Cho th oxy qua cn 70% v 10% dung dch
silicon lm tan bt trong ph nang. Khi bt v dch trong ph nang nhiu th
phi tin hnh ht dch. Nu bnh nhn hn m nn t ng ni kh qun v ht
sch dch t ph qun.
- Mt n oxy .
- Mt n BIPAP.
- Thng kh nhn to xm nhp (c t ng ni kh qun) sau khi tim
midazolam, etomidat vi BIPAP hay PEEP (positive end expiratory pressure)
nh.
- Khi c bt hng th phi thng kh nhn to xm nhp.
- Thng kh nhn to vi p lc dng ngt qung IPPV (Intermittent positive
pressure ventilation) cn c tc dng lm gim tun hon tr v.
+ Khi vn chuyn: Thng kh nhn to khng xm nhp vi phng thc
thng kh nhn to p lc h tr + PEEP + trigger l bin php tt nht.
+ bnh vin :
- Ph phi cp huyt ng: nu bnh nhn vn cn nng th thng kh nhn
to xm nhp, p lc h tr + PEEP nh (5cm H2O) + trigger l bin php c bn
i vi ph phi cp huyt ng.
- Ph phi cp tn thng: thng kh nhn to xm nhp p lc h tr +
PEEP (5cm H20) cho ALI hoc cao hn cho ARDS vi th tch kh lu thng
thp v tng thn cho php t c PaO2 trn 60 mmHg hoc SpO2 trn 90%
l phng thc c bn cho ph phi cp tn thng.

4.3. Cc thuc:
u phi dng qua ng tim tnh mch hoc xt v thi gian khng cho
php ko di.
* u bng l cc dn cht nit: cc dn cht nit hin nay thay th hn
morphin (morphin ch dng gim au trong nhi mu c tim, tc mch phi
ngoi ra morphin cn c tc dng ph c ch h hp). Do vy nn dng trinitrin
hay isosorbide dinitrat. Cc cht ny lm pht sinh ra NO lm gin mch v
chng kt t tiu cu.
ng xt : 2 - 4 ln bm.
ng tnh mch, phi truyn lin tc: Trinitrin 0,5-5 mg/gi. Isosorbid
dinitrat phi dng liu gp i. Tc dng ca isosorbid di hn (vng bn hu
1gi). Phi dng cc dng c truyn bng polyethylen hay polypropylen khng
dng loi polyvinyl. Do cc dn cht nitr c th lm h huyt p nn thng phi
phi hp vi dobutamin nu c tru mch.
+ Nitroprussiat natri i khi phi s dng nu c tng huyt p bnh nhn
nhi mu c tim hoc bnh nhn nhi mu c tim c tng huyt p m dng
thng kh nhn to khng kt qu.
- Liu lng bt u bng 0,5 microgam/kg/pht.
- Nitroprussiat chuyn ho thnh thiocyanate v vy liu cao c th gy ng
c cyanua, phi dng n hydroxocobalamin (vitamine B12).
+ Thuc li tiu : furosemid c tc dng gin mch trc khi lm li tiu.
Liu lng 1-2 ng tim tnh mch nhng nu suy tim c gim chc nng tm
trng th khng c li.

Suy h hp cp tin trin (ARDS)

V Vn nh
Nguyn Th D
1. Lch s.
Hi chng suy h hp cp tin trin ngi ln (adult respiratory distress
syndrome - ARDS) ln u tin c miu t bi Ashbaugh nm 1969. T rt
nhiu ti liu v hi chng ny ct ngha c ch sinh bnh v tm cc phng
php x tr. Sau ny ngi ta thy cc tr s sinh b bnh mng trong cng c
ARDS, ri ln lt cc tr em ln cng c hi chng ny, nn vn gi l ARDS
(acute respiration distress syndrome). ARDS tht s l mt suy h hp cp
(SHHC) rt nng gy t vong cao bnh nhn trc y c phi lnh v khng c
suy tim tri.
Trc Ashbaugh, i a s cc trng hp SHHC do gim thng kh ph nang
c gii quyt mt cch hiu qu bng phng php th my vi p lc
dng ngt qung IPPV kinh in. C mt s t cc trng hp SHHC li gy t
vong rt cao mc d c th my vi oxy liu cao (FiO2 = 0,6). Ngi ta cho
rng l tnh trng thiu oxy mu tr c l do thiu men no , t d men
G6PD. Ngi ta nhn thy tnh trng thiu oxy mu tr ny khng h p ng vi
oxy cao p, tun hon ngoi c th.
Nu tng FiO2 ln n 1 (oxy 100%) th mi u tnh trng suy h hp c kh
ln, nhng vi ngy sau th bnh cng nng hn. L do l oxy 100% cng lm tn
thng mng ph nang - mao mch, gy tc hi ln lp surfactant. Nm 1969,
ashbaugh ln u tin cng b phng php h hp nhn to (HHNT) bng p
lc dng lin tc iu tr ARDS c kt qu tt. 10 nm sau, Zapol tht bi
khi dng tun hon ngoi c th iu tr ARDS. Nhng hiu bit v nguyn
nhn v c ch sinh bnh s gip cho chn on v x tr ng n ARDS
2. Nguyn nhn.
Nguyn nhn gy ra ARDS v cc danh t ch tnh trng ca phi trong
mt s bnh c th gy ra ARDS ngy cng nhiu.
- Phi ngt nc, phi sc, ph phi cp, tn thng phi nhim c, phi
nhim khun, bnh mng trong, suy h hp cp tin trin, vim phi do ht
phi dch v ... Cc tnh trng phi trn u dn n bloc ph nang - mao mch
lm cn tr s khuych tn kh, mc d s thng kh vo vn bnh thng
(ng dn kh vo lng ngc bnh thng).Cc c ch dn n bloc ph nang
mao mch c nhiu.

3. C ch sinh bnh.
Phi bnh nhn ARDS gm 3 phn r rt : vng lnh, vng ng vin c,
vng bnh.

3.1. Vng lnh:

vng ny gin n ca phi vn bnh thng. gin n c hiu
compliance spcifique C/CRF ca phi c ARDS vn bnh thng, chng t phi
ny c gim gin n song song vi gim th tch phi. Nh vy trong ARDS
phi hnh nh c th tch nh li, nhng c n hi bnh thng.

3.2. Vng ng vin -c:

Trong ARDS, mt vng khng nh cc ph nang ba phi xp xung cng
vi cc ph qun nh. Vng ny nu c ng vin bng PEEP s hot ng
nh vng bnh thng.

3.3. Vng bnh:

+ Gii phu bnh :
Tu theo tin trin nhanh hoc chm m c th thy :
- Phi , nng, kiu can ho.
- Phi xm, nh v x ho.
Xt nghim vi th ca vng ny cho thy mng ph nang - mao mch b tn
thng nhiu lp khc nhau, t lng ph nang ra ngoi.
- Mng surfactant (l lp bao ph trong ph nang) b tn th-ng u tin, thay vo
l lp mng trong khng c tc dng h hp, li hn ch s khuych tn kh.

- Lp thng b gm 2 lt ph bo mng v ph bo ht cng b ph hu.

- Lp k b ph n cha y fibrin v albumin.
- Lp ni mc mao mch c nhiu mch mu b tc cha nhiu fibrin.
Ngoi ra, lng ph nang cng cha nhiu fibrin, albumin.
+ V mt sinh l bnh :
- Tn thng mng ph nang mao mch gy ph vch ph nang lm gim
n hi phi.
- Cc mao mch phi tn thng cho protein thot ra ngoi t chc k do
tng tnh thm, fibrin v cc t bo ng li lm mng ph nang dy ln v x
ho nhanh chng.
Nu khi, tng lai vng phi bnh cng b e da v mt chc nng.
+ V mt th dch :
Ngi ta thng thy gim p lc keo huyt tng, h protein mu, to iu
kin cho s thot dch t mao mch ph nang ra ngoi (Guyton). Tuy nhin cng
trnh nghin cu ca John P. Kohler (Chicago) ng trong Critical care medicine.
Vol 9, 2, 1981 cho rng: nhim khun gy ri lon chc nng phi nhng ri lon

ny khng lin quan n hin tng gim p lc theo th dch. Tim albumin
m c cho sc vt thc nghim cng khng ngn nga c ARDS.
Cc nghin cu gn y cng cho thy bloc ph nang - mao mch l hu qu
ca mt tnh trng tng tit nc trong phi vo khong k, lin quan n nhiu
c ch :
- Hot ho h thng b th.
- Tng chuyn ho axit arachidonic phng thch t cc mng photpholipid
trong phi (xem bng dc y).
C ch ny ct ngha v sao phi dng cocticoit trong ARDS v albumin truyn tnh
mch khng c tc dng r rng, mc d c h protein mu trong ARDS.

C ch bnh sinh ArdS

Tc nhn gy bnh

Tiu cu, dng bo,

ng hot ha b th --------------------------------------- t bo ni mc
C5a

Axit arachidonic

Kt t bch cu trong phi

Lipoxygenaza

Cyclooxygenaza

Men tiu t bo

Lencotrien
C4-D4

Cyclooxygenza
PGG2-PGH2

Cc c
cht gc oxy

Tn thng t
bo ni mc

SRS-A
Co tht ph qun

Tng thm tnh

mao mch phi
Tng nc trong phi

TXA2 Prostacyclin
PCI2
Tng p lc
mao mch phi

Kt t t bo

Cng giao cm

Ch thch:
SRS-A : Stow reacting substanee of arattaneee of artaphylaxia.
PGG2 - PGH2 : Prostagiandin (G2 - H2).
TXA2 Thromboxan A2.

4. Triu chng.

4.1. Lm sng:
4.1.1. Tnh cht xut hin:
ARDS xut hin 1 - 3 ngy sau mt nguyn nhn ti phi hoc ton thn.
+ Ti phi: ngt nc, ht phi dch v, nc i, vim ph qun phi, nhi mu
phi, tc mch phi do nc i, hi ngt ...
+ Ton thn: hn m i tho ng, suy thn cp, vim ty cp, vim no,
ph no, xut huyt no, sc nhim khun, bng do chn thng, cm, st xut
huyt, ng c cp.
4.1.2. Du hiu ca suy h hp cp tin trin:
ARDS tin trin theo 4 giai on:
+ Giai on 1 : l giai on tip theo chn thng hoc bnh chnh. Mc d
phi c tn thng nhng nghe phi vn cha c rn v X quang phi vn
sng. C tng thng kh gy kim h hp.
+ Giai on 2: 1 - 3 ngy sau. V lm sng ch c hi kh th (th nhanh),
lng ngc cn di dng tt. V xt nghim : PaCO2 tng, PaO2 hi gim v shunt
trong phi Qs/Qt tng.
+ Giai on 3: Kh th v xanh tm, kiu ph phi cp tn thng.
. Nhp th mi lc mt nhanh, km theo xanh tm v m hi.
. Khm phi: lng ngc bt u di ng km, rn m v rn n ri rc hai
phi.

. Ri lon thc l hu qu ca suy h hp cp.

+ Giai on 4: gim PaO2, tng PaCO2 , toan chuyn ho, cui cng gy ra
hn m v suy c tim do thiu oxy khng hi phc.

4.2. Xt nghim:
+ SaO2 v PaO2 rt thp mc d bnh nhn th oxy qua mi hoc th my
IPPV vi FiO2 cao (0,6 - 1).
+ PaCO2 bnh thng hoc hi gim, i khi tng cao nu cc tn thng phi
qu ln.
+ p lc keo huyt tng gim.

4.3. Chp phi:

+ Hai phi m, kiu phi trng, phi hnh cnh bm, hnh m ri rc, nhng
hai nh v cc gc sn honh vn cn sng.
+ C th thy hnh nh cc tn thng phi hp hoc l nguyn nhn ca
ARDS : vim phi khi, ph qun, ph vim.

5. Chn on.

5.1. Chn on quyt nh:

5.1.1. Ngh n ARDS khi thy:
+ Bnh nhn c nguy c b ARDS nh : ngt nc, hn m (nghi ht phi
dch v), vim phi khi, cm c tnh ...
+ Du hiu lm sng ca mt trnh trng SHHC tin trin.
5.1.2. Chc chn l ARDS nu:
+ Xt nghim SaO2 v PaO2 rt thp mc d th oxy hoc th my IPPV.
+ Chp phi : hai phi m u hoc ri rc hnh bng gn.

5.2. Chn on phn bit : Cn loi tr :

+ Trn dch hoc trn kh mng phi.
+ Trn dch mng tim.
+ Suy tim tri cp.
+ Vim phi lan to.
6. Cc hu qu sinh l.

6.1. Gim gin n v th tch phi:

Trong ARDS, mng surfactant b ph hu lm xp cc ph nang nhiu ni.
Th tch phi b thu hp. Dung tch cn chc nng b gim nng. ng dn khi
b ng li, khi th ra cn vng ra phi khng c trao i kh.

6.2. Ri lon trao i kh:

Mt iu ng s trong ARDS l phi khng cn kh nng duy tr PaO2
mc sinh l mc d FiO2 c tng cao n nhim c.
C 3 c ch gy gim PaO2:
+ Ti mu vng ph nang km thng kh. Nc trong phi pht trin t
khong k n ch phn thnh nhnh ca cc ph qun trn ph nang lm hp
ng dn kh nh. T l VA/Q gim vng xung quanh tn thng.
+ Ti mu vng ph nang khng c thng kh (shunt tht).
Bnh thng shunt sinh l chim khong 3 - 5 cung lng tim, do shunt ng
- tnh mch nh v h tun hon ph qun v Thebesius. Trong ARDS shunt ny
tng n 60 - 70% cung lng tim, mt phn do cc shunt sn c m ra, nhng
phn ln l do ti mu vng khng c thng kh.
+ Ri lon khuych tn : bn cnh hin tng mng ph nang dy ln, li c
gim th tch mu mao mch v gim tc tun hon phi.
Tin l-ng cng nng nu PaO2 khng thay i mc d tng FiO2 ln n 1.

6.3. Tng th gng sc:

T l khong cht trn th tch lu thng (VD/VT) tng do cc mao mch b
tc nhiu ni. Bnh nhn phi c gng sc th, cui cng s kit sc v suy
h hp.
7. Tin trin v tin l-ng.
Nu khng c iu tr ng quy cch, chc chn bnh s dn n t vong
nhanh chng vi gi n vi ngy.
- Ri lon thc dn n hn m do thiu oxy no.
- Mch nhanh dn, huyt p h ri try mch.
- Nu bnh nhn qua khi, tin lng xa vn cn d dt; bnh nhn c th b
x phi, suy h hp mn, tm ph mn.
- T l t vong chung t 50 - 75% theo cc tc gi.
8. X tr.

8.1. Th PEEP:
8.1.1. C ch tc dng:
Theo ashbaugh (1969) v Suter (1975): vic s dng phng php th my h
hp nhn to vi p lc dng lin tc CPPV hay PEEP em li nhiu kt qu
tt, cu sng thm c mt s bnh nhn SHHC. Phng thc th my vi p
lc dng ngt qung IPPV hay ZEEP thm ch oxy cao p, tim - phi nhn to
cng khng gii quyt c.
- PEEP c tc dng ng vin c cc ph nang vng ba phi b xp do nh
hng ca ARDS, t c dng n trong sinh l h hp bnh thng.
- PEEP li cn lm cho cc ph nang lnh lun lun n ra c hai th h hp.
Kt qu l PEEP lm tng dung tch cn chc nng FRC, lm gim t l shunt
trong phi v do lm cho s oxy ho mu ng mch tt hn. Trn thc
nghim ch cn 15 sec l FRC tng ln v ch ra 22 sec sau khi ngng PEEP l
FRC xung. Khi dng PEEP ch cn cho bnh nhn th vi FiO2 = 0,4
8.1.2. Cch lm PEEP:
Trn bt k mt my h hp nhn to no, ngi ta cng c th lm c mt
van PEEP gy lc cn cho kh th ra. Mc PEEP l mc gy lc cn :
n cui th th ra p lc cn li trong ng dn th ra l mc PEEP, c th
nhn thy p lc k ni vi ng dn th ra.
C th t to ly van PEEP bng cch ni l ngoi ng dn th ra vi mt ng
cht do ng knh 1 cm2, u ngoi cm vo mt l nc to hoc mt x nc.
Chiu su ca ct nc l mc ca PEEP tnh ra cmH2O

8.1.3. Mc PEEP:
Cc cng trnh ca nhiu tc gi u cho rng mc PEEP c kt qu bt
u t 5 cmH20 v c th t kt qu tt nht t 15 - 20 cmH20, Suter (1975) cn
a ln n 30 - 40 cmH20 (super PEEP). Vi PEEP cao nh vy, mu s c
oxy ho tt nhng phi cu cha bng dopamin hay dobutamin truyn tnh mch
sau khi truyn dch y .
Vi tng bnh nhn, ngi ta c th tm thy PEEP ti u p ng vi
oxy ho mu tt v tnh trng huyt ng cn bng. Cch lm : a dn PEEP
ln 5 cm mt ln, ghi huyt p, mch, lm xt nghim PaO2, PaCO2.
David Rose California trong Critic care medicine, 1981, Vol 9, No2 thc
nghim ARDS trn ln a ra nhng kt lun sau y :
- Dng PEEP c th mau chng phc hi th tch phi FRC (dung tch cn
chc nng) c n nh ch vi PEEP bng 5 cmH20, nhng PaO2 ch tr li bnh
thng khi FRC tng gp i, do PEEP a ln n 20 cm2. Nu t nhin ngng
PEEP, th FRC v PaO2 s xung rt nhanh. V vy tc gi khuyn khng nn
bnh nhn ra khi my qu lu
8.1.4. Cch tin hnh:
Bnh nhn nm nga, t th Fowler c t ng ni kh qun hoc canun
m kh qun c bng chn.
- Huyt p phi c duy tr bnh thng. Nu huyt p thp phi truyn
plasma hoc albumin.
- Lng FiO2 = 0,4 khng cn cao hn. l u im ca CPPV so vi
IPPV.
- Bt u bng PEEP 5 cmH2O lm xt nghim ngay nu c iu kin, 15
pht sau a ln 10 cmH2O, c nh vy a ln n 15 ri 20 cmH2O. i chiu
cc kt qu kh trong mu, mch, huyt p v sc mt bnh nhn.
Trong khi s dng PEEP cn ch :
- Ht m, tm qut, vn ng tr liu, xoa bp.
- Theo di k pht hin sm cc bin chng : trn kh mng phi, trung
tht, di da.
8.1.5. Theo di v iu tr cng c:
Sau vi ba ngy, nu tin trin tt bnh nhn s tnh, hng ho, mch huyt p
n nh.
Vic nghin cu b my cn thn trng hn so vi cc SHHC khc v nn s
dng cc bin php trung gian nh h hp t nhin vi p lc dng lin tc
CPAP hay h hp nhn to bt buc ngt qung IMV, SIMV (c 2 - 4 nhp th
bnh thng li c mt nhp th bt buc ca my).
8.2. Thng kh nhn to vi p lc dng v tn s cao (High frequency
positive pressure ventilation HFPPV):

Phng php ny trnh c cc p lc cao trong lng ngc vi tn s cao v

thng kh pht thp. Ngi ta s dng mt my h hp nhn to c bit to nn
mt tn s th t 60 - 100 ln/pht v mt th tch lu thng nh. My c khong
cht rt nh, y ch cn PEEP thp.
8.3. Tun ton ngoi c th bng my oxy ho qua mng (extracorporal
membrane oxygenator ECMO):
Dng bypass tnh - ng mch gim bt tun hon phi v shunt phi tri, cn mng oxy ho mu th khc ph s gim oxy mu ng mch v tng
CO2 mu. Ngoi ra phi vn c thng kh bng p lc thp v vi oxy nng
thp. Phng php ny qu mi kt lun c tc dng, nhng chc chn
gii quyt trc mt c cc ARDS rt nng. Tin lng xa ca cc bnh nhn
ny cha r rng c tt hn khng.
8.4. Thng kh nhn to vi p lc dng c hai th v tn s thp kt
hp vi my dng mng lc CO2 ra khi c th (Low frequency positive

pressure ventilation (LFPPV) with extracorporal CO2 removal ECCO2R):

Ngi ta thnh cng trong vic cu cha mt s bnh nhn b ARDS nng
bng cch dng mt bypass tnh - tnh mch cho mu qua mt mng rng ca
phi nhn to cho my chy vi tc chm lc ra CO2, duy tr tnh trng
PaCO2 bnh thng. p lc dng tnh trong ph nang ch cn thp, tn s th thp
v p lc y vo thp lm cho phng thc d chu hn IPPV.

8.5. Cc bin php x tr khc:

8.5.1. Vn truyn dch ARDS: v thc cht l mt ph phi cp tn

thng. V vy nu khng cn b nc th cng khng nn truyn dch qu nhanh

v nhiu. Tnh trng tng tnh thm mao mch c trong ARDS v gim protein
mu c th l nhng nguyn nhn thun li cho PPC huyt ng xut hin. Ni
chung khng nn truyn dch v cho n ung qu 1 lt ri mt ngy.
8.5.2. Cocticoit: cocticoit l thuc bt buc phi c. C tc gi cho liu
lng rt cao, c tc gi li dng liu thp. i vi thc t Vit Nam dng liu
thp l ng hn c. Liu lng ngh : Methyl prednisolone 30 mg/6h. Nn
ko di t ra l 2 tun, nhng c th gim dn bt liu.
8.5.3. Khng sinh : Khng sinh cng l cn thit trnh bi nhim lm
nng thm ARDS.

Nhim khun phi - ph qun bnh vin

Trong khoa hi sc cp cu

Mai Xun Hin

1. i c-ng.
+ nh ngha: Nhim khun phi - ph qun bnh vin l mt nhim khun
ng h hp di, pht trin bnh nhn sau khi vo vin t 2 ngy tr ln. Qu
trnh nhim khun ny khng c giai on nung bnh hoc khi pht trc khi
vo vin.
+ Trong cc th nhim khun bnh vin th nhim khun tit niu (40 50%), nhim khun vt thng (25 - 30%), nhim khun phi - ph qun (1520%), nhng t l t vong ca nhim khun phi ph qun cao hn. Din bin
nhim khun phi ph qun bnh vin thm lng v c coi l "k git ngi
du mt" thng b coi nh trong cc khoa Hi sc cp cu trong nhng nm
qua.
2. Tnh hnh nhim khun phi ph qun bnh vin trong cc
khoa hi sc cp cu.
Trong y vn t l nhim khun phi ph qun bnh vin chim 0,5% tng s
bnh nhn nm vin. Trong khoa Hi sc cp cu t l nhim khun tng ln 7 20%, cao nht t 17-20%, thng gp bnh nhn thng kh nhn to.
Nhim khun phi ph qun bnh vin bnh nhn c t ng ni kh qun
cao gp 4 ln so vi bnh nhn khng t ng, nguy c nhim khun cn cao hn
na i vi bnh nhn m kh qun.
Nhim khun phi ph qun bnh vin bnh nhn suy h hp tin trin cp
tnh (ARDS) l 30% v t l t vong 60%.
3. Cn nguyn vi khun gy NKPPQ bnh vin trong khoa hi sc
cp cu.
Mc d c rt nhiu kh khn trong vic xc nh chnh xc cn nguyn vi
khun gy nhim khun phi ph qun bnh vin bnh nhn thng kh nhn to,
song hu ht cc nghin cu v vn ny nhn thy trc khun gram m l cn
nguyn chnh gy nn nhim khun phi ph qun bnh vin.

Trc khun gram m chim 60% trong P.aeruginosa (34%), acinetobacter

(14%) v cc vi khun ng rut chim 32%. Cu khun gram dng gy bnh
chim t l 40%, trong t cu chim (54%) v lin cu (35%).
Nhng vi khun him gp hoc kh xc nh nh legionella pneumophila,
mycoplasma pneumoniae. Mt s loi vi sinh vt gy bnh xut hin nhng
bnh nhn b c ch min dch nh aspergillus fumigatus, candida,
pneumocystis carinii.
Vit Nam mt cng trnh nghin cu v cn nguyn vi khun gy nhim
khun phi ph qun bnh vin bnh nhn thng kh nhn to cho thy trc
khun gram m chim 59,7% trong gm P.aeruginosa 14,2%. Klebsiella spp
4,0%. Trc khun gram dng chim 29,3% trong gm S.aureus 18,2%,
S.epidermidis 8,7%; St. pneumoniae 2,4%. Vi khun khc chim 11,0% (Mai
Xun Hin 1996).
4. C ch bnh sinh NKPPQ bnh vin bnh nhn trong khoa
hi sc cp cu.
+ C 2 ngun gy NKPPQ bnh vin bnh nhn trong khoa hi sc cp cu l:

- Do ht vi khun t ng h hp trn vo phi.

- Th pht sau nhim khun huyt (vim tc tnh mch, nhim khun tit
niu, nhim khun t cc dy catheter lun tnh mch).
+ Ba bc chnh trong bnh sinh hc ca NKPPQ bnh vin:
- S pht trin vi khun mi -hng:
S pht trin vi khun mi - hng do trc khun gram m a kh gia tng
mt cch t cc bnh nhn nm vin, cc bnh nhn mc bnh mn tnh v
bnh nhn trc dng nhiu khng sinh.
Nhng yu t lm tng s pht trin vi khun gram m -ng th trn l: Bnh pht
trin nng hn, nm vin di ngy, suy mn, giai on sau m, tui cao...

Vi khun pht trin ng h hp c ngun gc t ng tiu ho v mi

trng xung quanh.
ng tiu ho ng vai tr ch yu trong vic truyn bnh vo ng h hp.
Ngun vi khun khng nhng c trong rut ca bnh nhn m c ngay trong
d dy. Nhng nm gn y nhiu cng trnh nghin cu chng minh d dy
l ti cha nhiu mm bnh. axit d dy b gim do dng cc thuc c tnh
cht kim iu tr lot d dy, t trng hoc d phng xut huyt tiu ho cng
to iu kin cho vi khun pht trin trong ng tiu ho.

Qu trnh tro ngc a vi khun t d dy xm nhp vo ng h hp.

Vic t ng xng mi - d dy nui dng bnh nhn ko di l nguy c
nhim khun phi ph qun do s di chuyn vi khun t d dy ln mi - hng.
Vic s dng khng sinh khng hp l lm ri lon s pht trin bnh
thng ca vi khun, to ra mt chng vi khun khng thuc, trong khi li
gim tp khun bnh thng ng th trn.
Ngun vi khun t bn ngoi -a vo phi nh- khng kh b nhim, ly truyn qua
bn tay ca nhn vin y t, cc dng c y t khng -c tit khun th-ng xuyn. -ng
ly truyn qua my th cng th-ng gp nu my th khng -c kh trng sau khi s
dng v thay n-c gi m trong h thng my.

Qu trnh pht trin vi khun nim mc biu m ng h hp gm 3 yu t

tham gia:
. Pili ca vi khun.
. Th cm ca biu m (fibronectin trn b mt t bo).
. Protease trong nc bt.
Fibronectin bao ph t bo nim mc c vai tr bo v chng li s kt dnh
trc khun gram m vo t bo. Khi protease tng trong nc bt s dn n mt
fibronectin b mt t bo mi - hng, t tng kh nng dnh kt v pht trin
ca trc khun gram m nim mc ng h hp trn. Ngun gc ca protease
l s tiu hu bch cu a nhn trung tnh trong dch kh ph qun.Biu m
ng h hp trn b tn thng l yu t thun li cho s pht trin ca vi
khun.
- Cc yu t lm tng kh nng ht vi khun vo phi:
Nhng bnh nhn b ri lon thc, sau cn co git, t qi, sau gy m ton
thn, ri lon c ch nut, ng thng mi d dy l cc yu t lm tng kh nng
ht vi khun vo phi.
ng ni kh qun c bng chn khng th ngn cn hon ton vi khun
xung phi. Qu trnh ht dch kh ph qun khng tun theo nguyn tc v
khun gp phn a vi khun xung phi.
Vic m kh qun v t ng m kh qun ko di l nguy c lm tng kh
nng nhim khun.
- Ri lon c ch bo v t nhin ca ng th:
Bnh nhn nhim khun phi ph qun phi t ng ni kh qun hoc m kh
qun lm mt kh nng lc v dit vi khun t nhin ca -ng h hp trn.

Vic t ng c bng chn hoc m kh qun gy ch xt ph v nim mc

bnh thng ca kh qun, do lm ri lon chc nng ca thm nhy rung mao,
i thc bo ph nang... Cc yu t lm gim kh nng bo v t nhin ca
ng th.
Bnh nhn c iu tr trong khoa hi sc cp cu l nhng bnh nng,
khng vn ng, thiu dinh dng ... Nhng yu t lm ri lon chc nng ca
cc c quan, c bit l qu trnh chuyn ho, cc qu trnh chng c v kh
nng min dch c th.
Cc bnh nhn chn thng nng, sau m ln ... cc chc nng min dch b
c ch. y l nhng nguy c dn n s pht trin nhim khun phi ph qun
bnh vin.

s c ch bnh sinh ca nkppq bnh vin

(Macfarlane J.T. 1995)

Bnh nhn nm
vin

Khng sinh ph
rng

- Bnh nhn nm lu, suy

kit c th
- Dng c (dy ht, xng
mi, d dy)
- Gim thc (do dng
thuc hoc bnh thn

Khun lc gram m mi hng >

50%
Tro ngc d dy - thc
qun
Ht phi cht tit mi hng

Gim phn x ho (sau

gy m, do au, do thuc

Nhim khun qua my th

hoc my kh dung
Gim cht nhy KPQ v
cht bo v phi
i vo trc tip ng h
hp di (ng NKQ, m

Lan truyn mm bnh theo ng mu t cc bnh xa (tc mch,

nhim khun bng, nhim khun dy catheter

5. Chn on nhim khun phi ph qun bnh vin trong khoa hi

sc cp cu:
Do tnh cht trm trng ca nhim khun phi ph qun bnh vin, vic xc nh
bnh phi c tin hnh cng sm cng tt v cn tm c vi khun gy bnh.
Trn lm sng, cn lm sng cc du hiu thng gp nh: st, bch cu tng
cao, c hnh nh X-quang phi nghi ng v dch kh ph qun c nhy m. Tuy
nhin cc du hiu trn c th thy nhiu bnh phi khc khng do nhim
khun nh: ph phi, nhi mu phi, xp phi, chy mu trong ph nang, chn
thng phi cng nh trong nhim khun phi ph qun . V vy, chn on
chnh xc phi ly dch kh ph qun nui cy tm vi khun gy bnh.
Cc bnh phm ly t kh qun hoc t m rt hay b nhim tp khun mi
hng ch yu l trc khun gram m. V vy, khng th xc nh c chnh xc
nguyn nhn gy bnh.
Cc bin php khc ly bnh phm cy khun nh: chc ht qua khe
sn gip - nhn (Pecora D.V.1962), chc ht phi xuyn thnh ngc (Thomas
H.M. 1920). Tuy vy, hai bin php ny khng thc hin c bnh nhn thng
kh v t ng ni kh qun hoc m kh qun v d gy trn kh mng phi
do p lc trong mng phi cao.
Bin php thch hp nht v c hiu qu cao l k thut chi c bo v
(protected specimen brush) qua ng soi ph qun si mm (Wimberley N.W.
1982). K thut ny c nhy, c hiu cao, cho gi tr chn on trn 90%.
Kt qu xt nghim dng tnh khi xc nh t nht mt loi vi khun gy bnh
vi s lng trn 104 vi khun/ml dch ph qun. V tr ly bnh phm tt nht l
khu vc c nghi ng tn thng trn X-quang phi.
Tm li, vic chn on nhim khun phi ph qun bnh vin da trn 5 tiu
chun ca Macfalene J.T (1995) nh sau:
- St
- Dch KPQ c nhy m
- S lng bch cu trong mu ngoi vi tng cao.
- Chp X-quang phi c bng m vim phi hoc vim ph qun hoc vim t
chc k mi xut hin.
- Khi pht NKPPQ sau khi vo vin t 2 ngy tr ln.
Ngoi 5 tiu chun trn chn on quyt nh cn phi ly bnh phm
xc nh vi khun gy bnh. Trong trng hp cy vi khun m tnh hoc khng
c iu kin xc nh vi khun nhng c y triu chng nh trn th vic

chn on nhim khun phi ph qun bnh vin vn c t ra c bin php

iu tr kp thi.
6. iu tr nhim khun phi ph qun bnh vin.
+ iu tr nhim khun phi ph qun bnh vin gp nhiu kh khn v:
- Mc khng khng sinh ca cc chng gy nhim khun phi ph qun
bnh vin mc cao.
- Bnh nhn b nhim khun phi ph qun bnh vin thng l nhng bnh
nhn nng, phi hp nhiu bnh km theo, khng th b gim st.
+ Nguyn tc iu tr phi phi hp hai bin php sau:
- iu tr khng sinh ton thn.
- iu tr khng sinh ti ch.

6.1. iu tr NKPPQ bng khng sinh ton thn:

Nguyn tc iu tr l s dng khng sinh ph rng v phi hp khng sinh.
Trong nhng trng hp cha c tiu chun chn on cho php phn bit gia
nhim khun ng th vi nhim khu su trong phi th nhng bnh nhn
thng kh nhn to c nghi ng nhim khun phi ph qun u phi c iu
tr khng sinh . Tuy nhin cn ch nhng khng sinh c c tnh cao i vi c
th v nu s dng khng hp l s to nn mt dng vi khun khng thuc.
Bin php iu tr theo kinh nghim c th tin hnh trc khi xc nh c
cc chng vi khun gy bnh c bit cc bnh nhn c suy gim min dch,
nhim khun huyt hoc trong tnh trng suy th nng. La chn khng sinh theo
bin php ny cn phi cn c vo tnh cht dch t hc ca nhim khun phi
ph qun bnh vin, cn c vo tnh trng nhim khun phi hp cc bnh l c
sn ca bnh nhn.
S dng khng sinh theo nguyn tc phi hp khng sinh c tc dng hp
ng nh nhm beta-lactamin vi nhm aminosid. Khi iu tr mt t khng
sinh m khng c hiu qu th phi ngh n P.aeruginosa v S.aureus khng
vi meticilin. V vy nn dng phi hp 3 loi khng sinh nh: vancomycin,
cefalosporin th h 3 (ceftazidim, rocefin, fortum) v mt khng sinh nhm
aminosid (amiklin, amikacin) hoc khng sinh mi nh axepim,tienam trong khi
ch i kt qu cy khun.
Sau khi xc nh c vi khun gy bnh, vic s dng khng sinh phi theo
khng sinh v theo nguyn tc phi hp. Thi gian iu tr ang c bn ci.
C mt s tc gi khuyn iu tr 1 thng hoc di hn. Thc t t khi iu tr
khng sinh ngoi ng ung t 15 - 20 ngy.

Ngy nay vic s dng khng sinh cephalosporin th h 3 rt hiu qu vi

phn ln vi khun gram m. Phc thch hp l cephotaxim hay ceftazidim kt
hp hoc khng kt hp vi mt khng sinh nhm aminosid nh amiklin,
amikacin, gentamycin
Nu bnh nhn c nghi ng nhim P.aeruginosa th phi s dng phc :
cefazidin hay azlocilin, tiakacilin, piperacilin phi hp hoc khng phi hp vi
khng sinh nhm aminosid. C th thay th phc trn bng mt khng sinh
mi c hiu qu nh imipenem hoc aztreonam, axepim. Khng sinh nhm
quinnolon th h 2 nh ciprobay, oflocet... c hiu qu cao trong iu tr nhim
khun phi ph qun bnh vin.
Theo Gantz N.M. (1997) phc iu tr vim phi bnh vin nh sau:
(I) Cefalosporin th h 3 + aminoglycosid.
(II) Penixillin ph rng + aminoglycosid th d:
Ticarcillin-clavulanic acid hoc piperacillin-tazobactam + aminoglycosid.
(III) Imipenem + aminoglycosid.
(IV) Cipro hoc aztreonam + clindamycin.

6.2. Ph-ng php s dng khng sinh ti ch iu tr nhim

khun phi ph qun bnh vin:
+ Kh dung: s dng khng sinh nhm aminozit nh : amikacin, gentamycin.
Vi phng php kh dung c 70,69 3,4 % lng thuc vo c ng th,
phn cn li dnh vo thnh ng my th v theo khng kh ra ngoi.
+ Bm khng sinh vo kh ph qun: s dng phng php ny, tt c liu
thuc c a vo kh ph qun v xm nhp vo vng thp ca phi b tn
thng. Nng khng sinh trong dch tit ph qun, phi cao hn nng c
ch ti thiu (MIC) i vi vi khun gy bnh.
Thc hin bm khng vo kh qun theo 2 phng php: bm cch qung
hoc lin tc
Bm khng sinh vo kh ph qun cch qung 5ln/ngy mi ln t 3-5ml
dung dch khng sinh. Thng dng khng sinh nhm aminozit nh: amikacin,
gentamixin...
Cch bm: lun dy catheter vo trong kh ph qun ri tin hnh bm thuc.
t bnh nhn nghing tri hoc nghing phi hng dung dch khng sinh
chy vo bn phi b tn thng.

- Bm khng sinh vo kh qun lin tc thng qua dy catheter lun vo kh

ph qun. Bm thuc lin tc c thc hin bng bm tim in.
7. d phng nhim khun phi ph qun bnh vin trong khoa
hi sc cp cu:
D phng nhim khun phi ph qun bnh vin trong khoa Hi sc cp cu
bao gm s phi hp cc bin php, t chc k thut v iu tr. Mt mt phi
hn ch s pht trin vi khun gy bnh ng h hp, mt khc tng cng cc
c ch bo v, nng cao sc khng ca bnh nhn.
Bin php hng u l ci thin v sinh mi trng bnh vin, phng iu tr,
ra tay trc khi tip xc vi bnh nhn, v sinh v kh trng cc dng c h hp.
m bo v trng khi ht dch kh qun.
Khng s dng ko di hoc hn ch s dng cc dng c ng h hp
khng cn thit (ng ni kh qun, m kh qun hoc ng thng mi - d dy...).
i vi my th phi kh khun ng ng dn kh, thay nc trong h thng
lm m sau khi thng kh nhn to trnh ly nhim gia cc bnh nhn.
Tng cng vn ng sm, c bit cc bnh nhn sau phu thut, nm vin
lu. phng n tc m trong kh qun, ng ni kh qun, ng m kh qun
bng bin php bm ra kh ph qun, v p vng ngc, kch thch phn x ho.
Nng cao th trng bnh nhn bng cc bin php nui dng qua ng tiu
ho nhm duy tr cc chc nng ca cc c quan, c bit l chuyn ho, cc qu
trnh chng c v tng cng kh nng min dch ca c th.
S dng liu php khng sinh ti ch nh: kh dung, bm dung dch khng
sinh vo kh ph qun c tc dng d phng v iu tr nhim khun phi ph
qun bnh vin.

Chng III

Thn
suy thn cp

Tt C-ng
1. i c-ng.
Suy thn cp l hi chng suy chc nng thn t ngt cp tnh do nhiu
nguyn nhn gy nn.
+ Khi b suy thn cp, bnh nhn s thiu niu, v niu, nit phiprotein mu
(ure, creatinin...) tng dn, cng tng nhanh cng b nng, km theo ri lon
nc, in gii v thng bng kim toan, nu khng iu tr kp thi th bnh
nhn s cht do kali mu tng, ph phi cp, hi chng ure mu cao hoc t
vong do bnh chnh gy nn suy thn cp. n nay, mc d c nhng phng
tin hi sc tch cc ( nh lc mu ngoi thn), t l t vong vn cn rt cao.
Tuy nhin, nu c iu tr kp thi v chnh xc, nhiu trng hp, chc nng
thn c th c hi phc hon ton hoc gn hon ton, bnh nhn c th tr
li cuc sng bnh thng.
+ Theo Anderson R.J. v Schrier R.W. (1988): Hoa K hng nm c 5%
bnh nhn nm vin do suy thn cp, trong bnh nhn ngoi khoa v phu
thut chim 60%, bnh nhn ni khoa chim 40%, sn ph chim 1-2%.
2. C ch bnh sinh.
C 4 c ch c xut :
+ Tc c gii ng thn do tr niu trong lng ng v ph n t chc k chn
p bn ngoi.
+ Co tiu ng mch thn, gy thiu mu thn cp tnh .
+ Khuch tn tr li dch lc ng thn do hoi t ng thn cp.
+ Gim tnh thm qua mng mao qun cu thn.

C ch c nu sm nht l gi thuyt v tc ng thn trong suy thn cp

ca Ponfick E.(1875). Qua thc nghim v truyn mu, tc gi nhn thy rng
chnh cc huyt cu t (do tan hng cu) v cc t bo bong khi mng y, t li
trong lng ng, lm tc ng thn gy thiu niu ,v niu . Sau ny, Pexter J.T.
(1945), Bohle A., Von Gise H., Mackensen- Haen S. (1981) chng minh thm
rng: trong suy thn cp c hin tng ph n t chc k thn. Chnh s ph n
k thn chn p t ngoi vo gy tc nghn ng thn v mao qun thn, lm
gim dng mu thn ln dch lc qua ng thn, dn n thiu niu , v niu.
C ch th hai l gi thuyt ca Borst M. (1917) v co mch thn. Gi thuyt
v sau c Oken O.E. b sung (1917) v thut ng bnh thn vn mch
(vasomotor nephropathy) xut hin. Cc tc gi cho rng, do s co mch thn m
dng mu qua thn b gim lm gim mc lc cu thn, gy thiu niu, v niu.
Nhiu cng trnh sau tip tc xc nhn s gim dng mu qua thn v mc lc
cu thn trong suy thn cp. Cho n nay, co mch thn gy thiu mu thn cp
vn l mt trong nhng c ch c nhiu bng chng l gii bnh sinh ca suy
thn cp.
C ch th ba l gi thuyt khuch tn tr li ca Dum J.S. (1924). Tc gi
cho rng, do tn thng cc t bo biu m cu cc ng thn nn dch lc cu
thn b khuych tn khng chn lc t ng thn tr vo t chc k thn v cc
mao qun quanh ng thn, dn n thiu niu, v niu trong suy thn cp. Gi
thuyt ny c b sung nhiu trong chin tranh Th Gii th II. c bit l cc
cng trnh ca Bealt (1941), ca Bywaters (1942) v suy thn cp trong hi chng
sp hm, v niu sau chn thng, hi chng chn p hay hi chng vi lp. Sau
mt s tc gi khc tip tc nghin cu tn thng thn trong hi chng sp
hm, bng, truyn nhm mu ... v a ra thut ng bnh h thn cui nephron
(lower nephron nephrosis) hay suy thn cp do tn thng phn thp hay phn
cui ca nephron ( n v chc nng ca thn ). Tn thng m bnh hc ng k thn cp hoc hoi t ng - k thn cp c cng nhn trong bnh hc
thn, nhng khi nim c ch khuych tn tr li ca dch ng thn th vn cn
nhiu tranh lun. Nhiu kin cho l trong suy thn cp , do ng thn b tn
thng nng,khng c dch lc qua th khng cn khuych tn tr li. Nh vy,
hin tng khuych tn ch c th c c mt s m hnh thc nghim v mt
s nephron ca thn bnh trn ngi. D sao, hin tng khuych tn tr li n
nay vn c xem l mt c ch bnh sinh suy thn cp.
Da vo cc cng trnh ca Atick N.Q., Weltervelt F.B. v Peach M. (1975)
v s tn thng cc chn li ca biu m trong ranh gii mng y mao qun
cu thn, mt s tc gi a thm gi thuyt thay i tnh thm ca mng y
mao qun cu thn gii thch s gim mc lc cu thn trong suy thn cp.
Qua cc nghin cu v tnh thm qua mng, Klaus Thurau,June Mason v
Gerhard Gstraunthaler (1985) cho rng: s gim mc lc cu thn trong suy thn
cp c th do thay i tnh thm qua mng hoc tn thng vng l lc hoc do
c hai.

C nhiu tc nhn gy suy thn cp, d cng c nhiu cch phn loi.
Trong nhng nm 70, c 2 cch phn loi:
+ Cc tc gi Legrain M., Suc J.M., Durand D., Lebon P., Tonthat H. (1977)
chia thnh 4 nhm:
- Suy thn cp do ri lon huyt ng hc thn.
- Suy thn cp c gii do tc ng bi niu.
- Suy thn cp do vim ng , k thn cp, hoi t ng thn .
- Suy thn cp do cc bnh khc: vim cu thn cp, vim thn - b thn cp,
bnh mch thn cp.
+ Miller T. (1978), v Espinel C., Gregory A. (1980) chia suy thn thnh 5
nhm :
- Tng nit mu trc thn .
- Hoi t ng thn cp c thiu, v niu.
- Hoi t ng thn cp khng thiu, v niu.
- Tc ng dn niu.
- Kiu phn loi ny tuy chi tit hn nhng khng bao gm mt s nguyn
nhn khc (v d tc mch thn, vim thn b thn cp, vim cu thn cp).
Trong nhng nm 80, a s cc tc gi phn loi suy thn cp thnh 3 nhm
ln : suy thn cp trc thn (suy thn cp chc nng); suy thn cp ti thn; suy
thn cp sau thn.
3. Nguyn nhn gy suy thn cp:
Hin nay cc tc gi thng nht chia lm 4 nhm sau:
3.1. Suy thn cp trc thn (cn gi l suy thn cp chc nng):
Do gim p lc lc cu thn, gy ra bi:
+ Sc gim khi lng tun hon, tt huyt p do mt mu nng; mt nc,
mt mui nhiu do a chy, nn, tc rut, r tiu ho; dng thuc li tiu mnh
ko di ( furosemid, acid ethacrynic); bng rng mt nhiu huyt tng.
+ Sc tim do nhi mu c tim cp tnh, suy tim nng, ph phi cp, v tim, p
tim, nghn tc ng mch phi.
+ X gan c trng nng, c trng hnh thnh nhanh lm gim th tch mu,
cng vi thuc li tiu mnh v chy mu ng tiu ho.
+ Suy thng thn cp tnh.
+ Sc nhim khun: nhim khun huyt, nhim khun ng mt, nhim
khun t cung ...
+ Sc phn v.

3.2. Suy thn cp ti thn (c tn thng nhu m thn thc th):

Do hoi t ng thn cp:
+ Do suy thn cp trc thn (suy thn cp chc nng) khng c iu tr
dn n suy thn cp thc tn, hoi t ng thn cp.

+ Do hu huyt trong bng nng, truyn nhm nhm mu, nhim khun ym
kh, st rt chng falciparum gy vng da, tan mu, huyt cu t niu, do thiu
men 6-GPD ca hng cu, nhim c cc kim loi nng, carbon tetrachlorua, cht
cn quang c iod, cc cht khng vim khng steroid, khng sinh (aminozid,
quinolon...).
+ Do ng mu ri rc ni mch (CIVD).
+ Do gip nt c (hi chng vi lp, chn thng...), do hu c vn
(rhabdomyolyse) khng lin quan n chn thng gy myoglobin niu.

3.3. Suy thn cp sau thn:

Cn gi l suy thn cp do tc nghn c gii c th cn tr trn ng bi
niu c hai bn hay mt bn m bn kia b hng khng bi tit, hoc ch c mt
thn (bm sinh hoc b ct 1 thn t trc). V tr cn tr thng di i b
thn, niu qun. Nguyn nhn thng do si tit niu, do chn p bi khi u
bng, h chu, do niu qun b gp trong sa thn, b chn p bi mt ng mch
thn bt thng, bi phng ng mch ch bng, x ho sau phc mc, ung th
tin lit tuyn , si hoc ung th bng quang, cng c th do tht nhm niu qun
trong m ct hon ton t cung.
+ Suy thn cp do vim thn k cp tnh:
- Do nhim khun mu m xut pht t nhim khun ng tit niu; trong
k thn c nhiu bch cu trung tnh, cc vi p xe, c mt s cu trc nephron b
ph hu.
- Do nhim c thuc nh colistin, glafenin, aminosid dng liu cao... hoc
do nhim c d ng thuc nh i vi methicillin, ampicillin, rifampicin,
allopurinol, thuc chng vim khng steroid...
+ Suy thn cp do vim cu thn cp tnh :
- Vim cu thn cp tnh ngoi mao mch: Th ny c c im l tng sinh
t bo lp y khoang nc tiu cu thn to nn hnh nh li lim. Cc t bo
tng sinh ny c ngun gc t cun mao mch hay t bao Bowman, ngoi ra cn
c i thc bo v bch cu a nhn trung tnh. Xt nghim min dch hunh
quang thy c lng ng IgG v C3 thnh ht hoc vt di thnh mao mch.
Mc nng nh ca bnh ph thuc vo s lng cu thn b thng tn v vo
mc tn thng ca cu thn
Vim cu thn cp ngoi mao mch gp trong:
. Hi chng Goodpasture gm vim cu thn ngoi mao mch, tn thng
phi, ho ra mu, lng ng IgG thnh di trn mng nn mao mch cu thn v
mao mch ph nang.
. Vim cu thn trong bnh Berger thy c lng ng IgA v phc hp min
dch gia cc mao mch cu thn.
- Vim cu thn cp tnh trong mao mch: tng sinh t bo ch trong ni
mao mch, khoang nc tiu vn bnh thng hay ch c tha tht vi m nh t
bo, thng gp do nhim lin cu khun .

- Bnh thn do mch mu gy suy thn cp tnh nh huyt khi hay nghn tc
ng mch thn ngi c mt thn, huyt khi tnh mch thn , bnh vi mch
gy huyt khi, hay trong x mch thn c tnh .
- Cn mt th vim cu thn c bit na l vim cu thn tin trin nhanh
c gi l vim cu thn bn cp gy suy thn nng ln rt nhanh. V vi th
thy c hnh nh li lim trong khoang nc tiu, trong cc li lim c cc t
bo vim, i thc bo v c cc t bo ca bao Bowmann, c cc hoi t cha
fibrin. Tin lng cng nng khi c nhiu li lim v hnh nh x ho v c cc
thng tn ng thn v k thn.

3.4. Suy thn cp do ct thn:

Do sau ct 1 thn gy phn x ngng bi tit nc tiu ca thn cn li song
th ny nh hn d hi phc, c trng hp ch cn lc mu bng thn nhn to
bnh nhn c nc tiu tr li bnh thng.
4. Tn th-ng m bnh hc.
Tu theo nguyn nhn gy bnh, tn thng m bnh hc c th khc nhau:
+ Suy thn cp do ng c: tn thng in hnh l thoi ho v hoi t biu
m ng ln gn. Cc thuc khng sinh thng ch gy ph n v thoi ha hc
t bo ng ln gn, nng hn, c hoi t t bo.
+ Suy thn cp do thiu mu thn: v thn nht mu, tu thn sung huyt.
Tn thng ng thn thng l thoi ho v hoi t t bo ri rc ng thn, mt
dim bn chi,khng phn bit c ng ln gn vi ng ln xa.
+ Suy thn cp do truyn nhm mu: thn to, phn tu thn mu thm hn
phn v.Tn thng vi th ging nh trong thn thiu mu, ng thn c lng ng
tr sc t.
Trong suy thn cp do nhim c thn, do thiu mu thn: ng ln xa v ng
gp thng cha y tr trong v tr ht, t chc k ph n, c xm nhp t bo
vim. Khoang Bawmann gin rng cha nhiu cht liu hnh ht. Mao qun cu
thn b xp, c th c huyt khi mn.
Suy thn cp, giai on hi phc nhiu trng hp s ti to biu m ng thn
khng hon ton, t chc k b x ho mt phn. Khi , chc nng cng khng
c hi phc hon tan, kh nng c c nc tiu gim ko di.
5. Triu chng lm sng v cn lm sng.
Suy thn cp thng din bin qua 4 giai on. Cc triu chng lm sng biu
hin khc nhau tu theo giai on ca bnh. Triu chng ch yu l thiu niu v niu.

5.1. Giai on khi u:

L giai on tn cng ca tc nhn gy bnh dn n suy thn cp.

Din bin ca giai on ny di ngn khc nhau tu theo tng loi nguyn
nhn gy suy thn cp. bnh nhn thn b nhim c v niu c th xut hin
trong 24 gi u. bnh nhn sc khi huyt p tm thu gim xung di 70
mmHg s c thiu niu.

5.2. Giai on thiu niu - v niu:

L giai on ton pht ca bnh, thiu niu , v niu c th ko di 1-2 ngy,
cho n vi tun.. V niu do hoi t ng thn, trung bnh sau 7-14 ngy bnh
nhn c nc tiu tr li. Chng ti gp bnh nhn v niu 22 ngy phi chy
thn nhn to 12 ln mi kt qu. V niu do si ng tit niu c th ko di
trn 7 tun l. Cc triu chng lm sng, cn lm sng trong giai on ny ch
yu l :
+ Lng nc tiu: Phi thng tiu theo di s lng nc tiu gi.
- Thiu niu khi nc tiu t 12-20ml trong 1 gi (t 300-500ml/24 gi).
- V niu khi nc tiu < 12ml/gi (<300ml/24 gi).
+ Nit phi protein mu: tng cao dn.
Trong thc hnh lm sng, ch nh lng ure, creatin mu l . Ure chim
phn ln (80%) lng phi protein ton phn trong mu.
Khi b suy thn cp, ure, creatin mu tng cao dn, tng cng nhanh th bnh
cng nng. Ure mu tng qu 50 mg/100ml mi ngy th tin lng xu, phi lc
mu ngoi thn mi c th cu sng c bnh nhn. Tuy nhin, ure mu khng
phn nh chnh xc chc nng thn suy, v ure mu tng cao cn ph thuc vo
ch n nhiu protit hoc nhim khun, xut huyt tiu ho, c hoi t...
Creatinin mu l sn phm chuyn ho cui cng ca creatin c lc qua cu
thn ra thng nc tiu, khng b ti hp thu v bi tit thm ng thn, creatinin
cng t ph thuc vo ch n, nn phn nh chc nng thn suy chnh xc hn
ure. Mc lc cu thn cng gim th creatinin mu cng cao. Cho nn cn xt
nghim v theo di c ure v creatinin mu hng ngy.
+ Ri lon nc, in gii v toan kim mu:
- Ph: Tu theo lng nc a vo khi bnh nhn bt u thiu niu-v
niu. Nu cho ung qu nhiu nc, truyn qu nhiu th s gy ph, ph phi
cp, trn dch a mng, natri mu gim, c th gy t vong.
- Kali mu tng cao dn: y l triu chng nguy kch nht trong ri lon
in gii ca bnh nhn suy thn cp, d dn n t vong do rung tht ngng tim.
bnh nhn khng c nhiu bin chng, kali trung bnh tng 0,5 mmol/lt mi
ngy. Vi bnh nhn chn thng nng, nhim khun, c bm dp t mu, hoi
t th kali c th tng 1mmol/lt mi ngy.Kali mu cng tng nhanh, bnh cng
nng. Chn on nhanh nht l theo di in tim v kali mu 5,5mmol/lt tr ln
lm thay i in tim. Biu hin sm l sng T cao nhn, i xng, r nht l
chuyn o trc tim. T V1-V5, khi sng T vt qu 2/3 sng R th c coi l
T cao. Sau QR s gin rng,P-R ko di. Nu nng hn na s xut hin rung
tht, nhp t tht v ngng tim.

- Natri v canxi mu thng gim, canxi mu gim s dn n nguy c tng

kali mu.
- Toan huyt: khng trnh khi nhim toan chuyn ho do tch t cc axt khi c thiu
niu - v niu. Bicacbonat mu s gim 1-2 mmol/lt mi ngy. Kim d- gim, khong
trng anion tng [Na+ - (HCO3- + Cl- )], pH mu gim. Bnh nhn s b ri lon nhp
th, th nhanh, su, nhp th Kussmaul v rt d gy t vong.

+ V tim mch: ri lon v tim mch trong suy thn cp thng xut hin khi
K+ mu tng cao. C th c suy tim cp. Suy tim thng do hu qu nc v ri
lon in gii. Huyt p c tng nhng thng ch tng va. Khi huyt p tng
cao, thng gp do vim cu thn cp. Nu huyt p tm trng tng qu
130mmHg (c km theo nhc u, m mt, c th suy sp nhanh, thiu niu v
niu ) th c th l suy thn cp do cao huyt p c tnh.
+ Thiu mu: xut hin sm, nhng khng nng, th tch khi hng cu
(hematocrite) c th gim, cn 30% vo tun th 2. Nu thiu mu nng, c th
do nguyn nhn khc.
+ Hi chng ure mu cao: cui cng, nu khng t vong do nguyn nhn ca
suy thn cp, do cc bin chng, th hi chng ure mu cao s xut hin y ;
kh th, nn, bun nn, xut huyt, co git, hn m, ... T vong khng trnh khi
nu khng lc mu ngoi thn kp thi.
Chn on phn bit gia suy thn cp chc nng v suy thn cp c tn
thng thc th: C th da vo mt s ch tiu sinh ho mu v nc tiu
phn bit cc trng hp suy thn cp trc thn hay cn gi suy thn cp chc
nng hoc chuyn thnh suy thn cp thc tn c hoi t ng thn cp nh
sau:
Ch s theo di

- Natri niu( mmol/lt )

- Natri niu/ kali niu
- Phn s thi Natri(%) =
Una/Pna
100
Ucr/Pcre
- Nng thm thu niu
(mosm/kgH2O)
- Thm thu niu/ thm
thu mu
- Ure niu/ure mu

Suy thn cp chc

nng suy thn cp
trc thn)

Suy thn cp thc

th
(hoi t ng thn
cp )

Di 20
Di 1
Di 1

Trn 40
Trn 1
Trn 3

Trn 400
Trn 1
Trn 10
Trn 30

Di 400
Gn bng 1
Di 10
Di 20

- Creatinin niu/creatinin
mu
U: nng trong nc tiu. P: nng trong huyt tng.

5.3. Giai on a niu:

L-ng n-c tiu tng dn l du hiu khi u cho s hi phc chc nng thn. Giai on
ny n-c tiu tng dn khong 2 lt mi ngy. C tr-ng hp l-ng n-c tiu 4-6 lt mi
ngy, thm ch n-c tiu 8 lt/ ngy. N-c tiu nhiu hay t cn ph thuc vo l-ng
n-c -a vo c th v tu nguyn nhn gy bnh. a niu th-ng ko di t 5-7 ngy.
Tuy nhin, nhiu tr-ng hp sau thng th hai, k t ngy c n-c tiu tr li, l-ng n-c
tiu vn cn trn 2 lt mi ngy; ko di nht l suy thn cp do bng. Sau nhng
ngy u c n-c tiu tr li, l-ng n-c tiu tng nhiu, ure niu, creatinin niu tng
dn; ure mu, creatinin mu gim dn; mc lc cu thn tng. Bnh nhn s chuyn
sang giai on hi phc.

5.4. Giai on hi phc:

i vi cc bnh nhn suy thn cp c hoi t ng thn n thun, t bin
chng, trung bnh sau mt thng lng ure mu, creatinin mu gim v tr li
bnh thng.Sc kho bnh nhn dn dn hi phc, a s c th tr li cuc sng
bnh thng. C 20-30% bnh nhn c mc lc cu thn gim ko di v kh
nng c c ti a thng gim lu di.
6. Tin l-ng.
Tin lng ca suy thn cp thng ph thuc vo ba yu t sau:
+ Tc nhn gy bnh: Sau bng nng, t trng hp hi phc; sau m v chn
thng: hi phc 60%; do nguyn nhn ni khoa: hi phc 30%; do nguyn nhn
sn khoa: hi phc 10-15%.
+ iu kin x l ban u: x l mun, t l t vong s cao. Trong chin tranh
Th Gii th II, do vn chuyn bnh nhn n cc trung tm tuyn trn thng b
chm nn t vong rt cao: 90%. Trong chin tranh Triu Tin: t vong 53%.
+ Bin php x l: nu bnh nhn c x l kp thi, va iu tr nguyn
nhn va iu tr triu chng, c bit l lc mng bng hay lc mu bng thn
nhn to kt hp iu tr tch cc ton din th s c tin lng tt.
7. iu tr d phng.
Suy thn cp l hu qu ca nhiu nguyn nhn gy ra, chnh v th cn phi
theo di nc tiu v chc nng thn cng nh iu tr d phng suy thn cp.
Khi c nhng nguyn nhn nu trn (mc 3): chng mt nc, mt mu cp,
khng tt huyt p ti a di 70mmHg ko di. Chng nhim khun iu tr
sc bng kp thi ... Ngoi ra cn phng cc tc nhn c th gy suy thn cp.

8. iu tr.
Nguyn tc chung khi iu tr suy thn cp : khn trng tp trung phng
tin, iu tr ph hp vi tng giai on tin trin ca bnh; ch cng tc h l
ngay t u v c th phi iu tr ko di hng thng.

8.1. Giai on khi u:

Cn loi b cc tc nhn gy bnh nh-: cm mu- b dch - chng sc - chng nhim
khun, duy tr huyt p tm thu trn 80mmHg; loi b c cht; m ly si (ty theo
th trng bnh nhn m ch nh m ly ngay hoc ch n lc hi phc) c th
dn l-u b thn ti thiu hoc chc dn l-u n-c tiu i b thn qua da.

8.2. Giai on ton pht:

Giai on thiu niu-v niu, ure, creatinin mu tng,...ph a mng, e do
ph phi cp do vy cn phi iu tr ng, ton din:
+ Cn bng nc: i vi bnh nhn c du hiu mt nc,cn b dch.
Tt nht l da vo p lc tnh mch trung tm. i vi bnh nhn khng c biu
hin mt nc phi phng ph, ph phi cp do ung nc hoc truyn dch
qu nhiu. Cn bo m cn bng m, ngha l nc vo t hn ra. Cn phi o
chnh xc lng nc a vo v lng nc thi ra.Khi tnh ton b nc, cn
ch : lng nc do nn, a chy, nc tiu; lng nc do m hi, hi th
(khong 600ml/24 gi nhit bnh thng vi ngi nng 50kg), lng nc
ni sinh do chuyn ho khong 300ml/24 gi.
+ in gii v kim toan: iu chnh theo in gii mu, quan trng nht
l hn ch lng kali mu tng (v d gy ngng tim). Do , khng dng cc loi
thuc, dch c kali; loi b cc hoi t, chng nhim khun; king cc thc n
giu kali nh rau qu. Nu kali mu tng, cho dung dch kim natribicacbonat
loi 4,2% (1ml c 0,5 mEq HCO3- hoc 8,4% 1ml c 1mEq HCO3-). Ung nha
resin trao i ion rt bt kali mu qua ng tiu ho (resonium ung 30g/24
gi). Lc mu ngoi thn l bin php tt nht h kali mu bng chy thn
nhn to hoc lc mng bng.
+ Hn ch nit phi protein mu tng: phi cung cp nhiu calo (35-40
kcal/kg/ ngy) bng gluxit v lipit m bo nhu cu nng lng , ng thi
hn ch c s phn gii protein ca c th, do hn ch c s tng ure
mu. Cn dng nhiu thc phm giu gluxit, t protein nh khoai lang,sn,min
dong, ng, mt,b, m ,du ch bin thc n. Bt dng go, ch nn cho
100g/24 gi. Khi cn, truyn thm dung dch glucoza u trng (30-40%) tng
thm calo. Lng protit hn ch khng qu 0,5g/kg cn nng mi ngy. Phi
chn cc protit c gi tr sinh hc cao cha nhiu axit amin c bn cn thit nh
trng, sa, tht nc. Cho vitamin. Loi b cc hoi t, xut huyt, nhim
khun l nhng bin php quan trng hn ch tng ure mu,...

+ Gy bi niu: dng li tiu furosemide l tt nht.Trc khi dng phi bo

m huyt p tm thu trn 80mmHg v c th nc, duy tr huyt p tnh
mch trung tm 8cm H2O.
- Truyn 500ml dung dch glucose u trng 20% hoc 30% c pha insulin (1
n v cho 5 gam glucose h kali mu tm thi).
- Cch dng furocemid: c nhiu cch dng gy li tiu, theo Hamburgeur
c th dng 3gr lasix trong 24 gi. Theo chng ti nn dng lasix (test lasix) nh
sau. (Ch t ng thng tiu theo di nc tiu gi).
Gi th

Lasix (mg)

40

60

80

100

120

140

160

180

- Nu c nc tiu th iu chnh lasix t lng nc tiu khong

1ml/kg/1 gi.
- Nu sau 8 gi m bnh nhn vn v niu th tu ch nh cho chy thn nhn
to hoc lc mng bng.
- C th dng dung dch manitol 20% liu 3-5ml/kg th trng truyn tnh
mch nhanh trong 20 pht. Nu thn khng p ng th ngng hn v malitol
20% c th gy hoi t thm thu biu m ng thn.
+ Lc mu ngoi thn: khi cc bin php iu tr bo tn ni khoa khng hiu
qu th phi lc mu ngoi thn bng thn nhn to, hoc lc mu qua mng
bng. Ch nh: ure mu 250mg/100ml tr ln (cng tng nhanh cng phi tin
hnh lc mu). Kali mu trn 6,5mmol/lt hoc khi bnh nhn c ph phi cp do
v niu, lc mu rt nhanh nc.
Ngoi bin php trn, trong khi iu tr giai on ton pht cn ch n
iu tr nguyn nhn

8.3. Giai on a niu:

Trong giai on ny, bnh nhn bt u c nc tiu tr li nhng chc nng
ca thn cha c phc hi ngay. Trong nhng ngy u, tuy nc tiu nhiu
nhng ure niu, kali niu vn thp. Bnh nhn vn c kh nng t vong do hi
chng ure mu cao. Bi vy, cn tip tc hn ch protit v kali; b dch v in
gii phng i tiu nhiu gy mt nc, ri lon in gii. Lng dch s
dng tu theo lng nc tiu v th trng bnh nhn; ch tng protit trong ch
dinh dng khi ure mu gim n mc an ton.

8.4. Giai an hi phc:

Giai on ny phi iu tr ton din nhm phc hi sc kho bnh nhn v
to iu kin cha khi cc tc nhn gy bnh. Quan trng nht l ch dinh
dng, m bo calo, vitamin, tng dn lng protit. Tip tc cha bnh
chnh v bin chng nu c .

Tm li, suy thn l hi chng lm sng gy ra do nhiu nguyn nhn cp

tnh.Biu hin c trng l thiu niu- v niu do thoi ho v hoi t t bo ng
thn, ure v creatin mu tng cao, t l t vong cao. Bnh nhn c th cht do ph
phi cp do kali mu v hi chng ure mu cao, hoc bnh chnh v nhim
khun. Tuy nhin, nu iu tr kp thi v chnh xc th chc nng thn c th
c hi phc hon ton hoc gn hon ton. Do , cn huy ng mi phng
tin v kh nng nh lc mu ngoi thn tp trung cu cha bnh nhn.

ghp tng - ghp thn

theo di v iu tr sau ghp

Tt C-ng
1. t vn .
Ghp m v c quan l mt can thip sinh hc nhn to. l mt thnh tu
quan trng ca y sinh hc trong th k XX v l mt hng pht trin ca y sinh
hc th k XXI, m mt trin vng mi trong vic thay th cc tng b suy giai
on cui hoc b thng tn khng cn kh nng hi phc. Nh nhng tin b
v khoa hc, cng ngh trong na cui th k XX, c bit l min dch hc ghp
(transplantation immunology) v cc chuyn ngnh gy m, hi sc, phu thut
mch mu, cc thuc c ch min dch, cc k thut chn on, theo di chc
nng cc tng, cc k thut ra v bo qun tng c ly ghp... Ngnh ghp
tng hin nay (organ transplatation) thc hin hng nm trn th gii hn
30.000 trng hp ghp tng. Hoa K l mt nc tin hnh ghp tng vi s
lng ln nht, mi nm ghp khong 8.000 thn, hn 3000gan, hn 2000 tim v
hn 500 phi. Php cng l nc ghp tng nhiu mi nm khong trn 2000
thn, 600 gan, 600 tim, 100 phi, 80 tim - phi, 80 ty...
Ngnh ghp tng Th Gii ngy cng t c nhng thnh tu mi nh ghp
tng tr nh, tr s sinh, ngi gi. C th ghp nhiu tng cng mt lc:
ghp tim - phi, ghp thn - ty, ghp gan - d dy - rut. C th tin hnh nhiu
ln ghp tng mt ngi (2 - 3 ln). Vic dng ngun tng cho l ng vt cng
ang c nghin cu vi nhng tin b mi v sinh hc phn t, min dch v di
truyn phn t, cng ngh gen... m mt trin vng mi v ngun cho tng.
Kt qu ca ghp tng ngy cng kh quan. Thi gian sng sau ghp c
ko di hn 30 nm vi thn, 20 nm vi tim, gan. Cht lng cuc sng ca
ngi ghp tng c phc hi, kh nng lao ng, tham gia cng tc x hi, sinh

hot gia nh (ly v, chng, sinh con...) u c th thc hin tt sau ghp tng
ni chung v ghp thn ni ring.
2. Lch s ghp thn.
2.1. Trn Th gii:

Vic nghin cu thn c cc nh khoa hc y hc nghin cu t th k

XX. Nm 1902, U11mann E. ghp thn t thn ch thnh cng.
- Nm 1906, Fabolay M (Php) ghp thn ln, d cho ngi nhng tht bi.
- Nm 1911, Alexis Carrel (Php) tin hnh ghp thn t thn ngi thnh
cng (gii thng Nobel nm 1912).
- Nm 1936 ,Voronoi Iu (Kiep - Nga) tin hnh ghp thn ng loi t
thn t thi c nhm mu "O" nhng tht bi. Bnh nhn v niu v cht 48h sau
ghp.
- Mi cho n nm 1951, Rene Kuss, Charles Dubost Pari, Marceau Sarrelle
Stradbourg tin hnh ghp thn t thi song cng tht bi.
- Nm 1952, Jean Hamburger bc s ni khoa cng bc s Louis Michon
chuyn khoa tit niu Bnh vin Necker - Paris tin hnh ghp thn sng (m
cho con trai), song cu b ch sng c 3 tun sau ghp.
- Nm 1954, Murray J. v cng s ghp thn ng loi mt cp sinh i
khc trng thnh cng v s dng chiu tia X cho ngi nhn. Bnh nhn sng 25
nm v cht nm 1979 v bnh tim.
- Thng 6-1954, Jean Hamburger v cng s tin hnh ghp thn cho mt
cp anh em sinh i cng trng v bnh nhn sng 26 nm sau ghp, sau cht
v ung th bng quang.
- Nm 1962, Jean Hamburger tin hnh chn cp cho v nhn bng th
nghim tng hp m (histocompatibility). Hai tc gi Caln R v Murray J. s
dng ajathioprine chng thi ghp, cn Gobwin s dng glucocorti steroide
(prednison) chng thi ghp. Cng ti Php, mt ca ghp cng loi (allograft)
c tin hnh nm 1962 v hin nay bnh nhn vn sng, ng ta hin l ngh s
Quc hi Php. y l ca ghp thn sng lu nht trn Th Gii.
- Nm 1966, Kismegen N. ng dng nghim php cho (cross match).
- Nm 1967, Starjl T. s dng globulin khng lympho bo.
- Nm 1972, Borel F. v cng s iu ch ra cyclosporine v nm 1978 c
s dng ln u tin trn lm sng d phng v iu tr thi ghp tng.
- Nm 1981, Cosin A. v cng s s dng khng th n clon OKT3 trong
iu tr thi ghp cp sau ghp.
- n nm 1993 ti Anh c 62% bnh nhn b suy thn mn giai on cui
c sng nh thn ghp. Italia l 28%, Php l 41%.
- Cho n nm 1997 c 381.901 bnh nhn c ghp thn trn ton Th
Gii (RFM WOOD - Transplantation in the 21th century - 1998).

2.2. Vit Nam:

Nc ta cng tin hnh vic ghp thn thc nghim t thp k 70 v
thc hin trng hp ghp thn u tin trn ngi vo ngy 4/6/1992. Hin nay
c 3 c s lm sng thc hin ghp thn: Bnh vin 103 (Hc vin Qun y), Bnh
vin Ch Ry v Bnh vin Vit c (B Y t).
Trong thp k 90, ngnh min dch hc nc ta c xy dng v pht
trin, nhu cu ghp thn c t ra, ban ch o ghp thn kt hp qun - dn y
c thnh lp (nm 1990, mt i ng ng b c c sang Cu Ba hc ghp
thn v mi chuyn gia Cu Ba sang kho st d n ghp thn). c s gip
ca Hng Sandoz, Gio s Chu Su Lee (i Loan) c mi sang cng i
ng cn b khoa hc qun - dn y tin hnh ghp thn cho trng hp u tin
vo ngy 04 - 6 - 1992 ti Bnh vin 103.
- Nm 1996 thnh lp Hi ng t- vn chuyn mn ghp thn thuc B Y t.

- Nm 1998, xy dng chnh thc d n ghp thn thuc B Y t, cho ti

ngy 31/12/2000 thc hin ghp thn cho 32 trng hp (13 trng hp ti
Bnh vin 103 - Hc vin Qun y, 17 trng hp ti Bnh vin Ch Ry - thnh
ph H Ch Minh, 2 trng hp ti Bnh vin Vit c - H Ni).
3. Nhu cu ghp thn.
Hin nay nhu cu ghp thn rt ln. Hoa K, hng nm c khong 100
ngi/1 triu dn b suy thn mn giai on cui v trong s c khong 20.000
bnh nhn c nhu cu c ghp thn. cc nc Chu u c khong 50 - 80
ngi trong s 1 triu dn b suy thn mn giai on cui. S bnh nhn suy thn
mn giai on cui c nhu cu ghp thn Nht l khong 15.000 ngi, i
Loan l 500 ngi, Thi Lan gn 1000 ngi, nc ta cha c s liu ton
quc v tng s bnh nhn suy thn mn giai on cui nhng theo s liu ca
Bnh vin Trung ng c Khoa thn nhn to th c 100 bnh nhn b bnh thn
c khong 30 ngi giai on cui. Vi bnh nhn b suy thn mn giai on
cui c 2 bin php iu tr c bn gi l liu php iu tr thay th thn (Renal
Replaement Therapy - RRT) l lc mu chu k bng thn nhn to, lc mng
bng v ghp thn.
4. Nguyn tc ghp tng v ghp thn.

4.1. Cc kiu ghp:

C 2 loi:
4.1.1. Ghp ph hp (tng hp):
M tng ghp tng hp v m hc vi c th nhn, khng xy ra hin tng
thi ghp. Gm 2 nhm:

- Ghp t thn (autograft) : m ly t ch ny ghp sang ch khc trn cng

c th.
- Ghp ng loi cng gen (isogenic, homograft): sinh i cng trng.
4.1.2. Ghp khng ph hp:
M tng ghp khng tng hp vi m c th nhn, lun xy ra hin tng
thi ghp. Gm hai phn nhm:
+ Ghp ng loi khc gen (allogenic homograft, allograft): m ghp c
trao i gia hai c th trong cng mt loi nhng khng ging nhau v di
truyn. Trn thc t lm sng, tr ghp ng loi cng gen (sinh i cng trng)
cn hu ht cc trng hp ghp, m ghp u c ngun gc khc gen cng loi.
+ Ghp d loi (xenograft, heterograft) c chia lm hai nhm:
- Ghp gia cc loi rt gn nhau (closery related) nh gia cc ging chut
vi nhau, ghp gia ngi vi ngi gi l ghp d loi tng ng (concordant
xenotransplantation).
- Ghp gia cc loi rt khc bit nhau (distantly related species) nh gia
ch v mo, gia ln v ngi c gi l ghp d loi d ng (discordant
xenotransplantation).

4.2. Cc khng nguyn ghp:

Trn cc c th nhn ghp c p ng min dch bnh thng th vic m
ghp sng hoc b thi b c quyt nh bi cc protein (do cc gen nm trong
phc hp gen ph hp t chc chnh m ho). Cc protein ny c gi l khng
nguyn ghp hoc khng nguyn ph hp t chc. C cc khng nguyn ghp vi
tnh sinh min dch mnh, l h thng HLA - khng nguyn ph hp t chc
chnh ngi (human leucocyte antigene), cn chut nht trng l h thng H 2. Cc gen kim sot h thng HLA c nh v trn nhim sc th 6 v cc gen
kim sot h thng H-2 c nh v trn nhim sc th 17.
Cc khng nguyn trong h thng HLA v h thng H-2 c chia thnh 2
lp: lp I v lp II.
- Lp I: cc khng nguyn ny gm 2 chui polypeptid. Chui th nht l
chui , c m ho bi cc gen HLA ngi hoc phc hp gen H-2 chut
nht. Chui th hai bn cht l 2 microglobulin do mt gen nm trn nhim sc
th khc m ho. Cc khng nguyn lp mt c mt trn hu ht cc t bo c
nhn ngi. Lp I gm HLA-A, HLA - B, HLA - C (v gn y thm HLA -E).
chut nht, lp I gm H-2K, H-2D, H-2L. Cc khng nguyn lp I hot ng
nh nhng n v nhn dng. Chng quyt nh tnh c hiu trong vic tn cng
Lymph bo T gy c t bo (Tc) chng cc t bo nhim virus, t bo ung th,
t bo khc alen cng loi.
- Lp II: cc khng nguyn lp II cng gm 2 chui polypeptyid: chui v
chui . C hai chui u c m ho bi cc gen nm trong h thng gen HLA
(vng D) hoc h thng H-2 (vng 1). Cc khng nguyn lp hai ch xut hin

trn cc t bo tham gia vo p ng min dch (t bo gii thiu khng nguyn

lympho bo B, t bo biu m trong tuyn v cc lympho bo T hot ho). C rt
nhiu bng chng cho thy yu t kch thch gy ra hot ho cc p ng thi b
m ghp chnh l cc khng nguyn lp II c trong bn thn m ghp hoc cc
khng nguyn lp II trn bch cu ln trong m ghp. Cc khng nguyn lp II
cng c tc dng khi ng phn ng m ghp chng tc ch (graft versus host
reaction) trong nhng bnh nhn nhn tu xng ghp t mt c th khc gen
cng loi.
Ngoi vic hot ng nh mt khng nguyn ghp, cc khng nguyn lp II
cn kch thch s tng sinh cc lympho T khc gen cng loi trong phn ng nui
lympho hn hp v cn tham gia vo s gii hn trong qu trnh tng tc gia
cc t bo gii thiu khng nguyn v cc t bo T phn ng vi khng nguyn.
Chng cng gii hn s tng tc gia t bo B trong qu trnh to khng th.

4.3. Thi ghp (graft rejection):

Hin tng thi ghp c nhn bit t rt lu:
- Cui th k XIX v u th k XX cc nh khoa hc khi ghp da ng loi,
da d loi thy cc mnh da ny b thi.
- Nm 1901, Lexe E. m t hin tng thi da ng loi.
- Nm 1924, Holman E. thy ln ghp th hai da ng loi, mnh da b thi
nhanh hn so vi ln I.
- Nm 1932, Gorez P.A phn bit ghp gia ng vt thun chng ca mt
dng (ghp da ph hp) vi ghp gia cc ng vt khng thun chng (ghp da
khng ph hp). T pht hin nhng khng nguyn kch thch s p ng
min dch ghp.
- Nm 1944 - 1960, Medawar P.B v cng s nghin cu p ng min dch
ghp ng loi (allograft response), hin tng tng p ng min dch ghp
ng loi nhng ln ghp sau, hin tng kch thch dung np th ng vi cc
t bo l, hin tng p ng min dch do cc lympho bo T.
- Nhng nm 1948 - 1951, Sneel G.D v cng s pht hin cc gen tng hp
m (histocompatibility gennes).
- Nm 1958, Jean Dausset pht hin h thng khng nguyn bch cu (human
leucocyte antigens - HLA).
Cc nh khoa hc nh v vng HLA trong khu 21 nhnh ngn ca
nhim sc th th 6 ngi, khng nguyn tng hp m (histocompatibility
genes) gi vai tr quyt nh trong thi ghp.
4.3.1. C ch thi ghp trong ghp ng loi khng ph hp:
+ Cc khng nguyn HLA - A, HLA - B, HLA - C, HLA - D ca tng cho
(donor) khi pht hin tng p ng min dch ghp.
+ Cc t bo lympho Tc (cytotoxic T lymphocytes) ca ngi nhn (recipient)
pht hin cc khng nguyn lp I (HLA -A, HLA - B, HLA - C) ca tng cho.

Cc t bo lympho Th (helper T lymphocytes) ca ngi nhn pht hin cc

khng nguyn lp II (HLA - DR, HLA - DQ, HLA - DP) ca tng cho. Cc
lympho Th cn tr gip cho cc hot ng ca cc t bo lympho B.
+ Cc t bo lympho B ca ngi nhn (c s tr gip ca lympho Th) tit
ra IgG, IgM, cc khng th khng HLA - A, HLA - B, HLA - C, HLA - D ca
tng cho.
+ Nh th s thi ghp xy ra t nhng khng nguyn ca tng ghp khng
ph hp ngi cho v p ng ghp (vi tng l) ca c th ngi nhn gm
cc yu t t bo: lympho bo T (gm Tk, Th, Tc), lympho bo B, cc yu t th
dch: IgG, IgM v cc khng th tng ghp...
4.3.2. C ch thi ghp trong ghp d loi:
Xut hin phn ng ghp d loi, ngoi cc yu t t bo v cc yu t th
dch nu trn cn xut hin cc khng th t nhin c hnh thnh sn trong
tng c th (ca ngi nhn) {preformed natural antibodies - PNAb} chng tc
ng vi h thng protein b th (complement protein system - CPS). Cc protein
ny bnh thng c chc nng iu ho trong c th nay tr thnh cc protein b
th "ao ph" (killer complement protein) hu cc tng d loi ngay lp tc hoc
vi gi sau ghp.
4.3.3. Phn loi cc thi ghp theo thi gian xut hin:
+ iu khng ai mong mun sau khi ghp l phn ng thi b m ghp do
chnh c th nhn. Phn ng ny c th xy ra sm hoc mun tu thuc vo:
+ Mc khng ph hp khng nguyn gia c th cho v c th nhn.
- Vic c th nhn c mn cm trc vi cc khng nguyn ph hp t chc
ca c th cho hay khng.
- Dng thuc c ch p ng min dch ca c th nhn.
+ Ngi ta phn loi cc phn ng thi b m ghp da vo thi gian c
tnh t lc ghp cho n khi c biu hin thi b gm:
- Thi b ghp ti cp (hyperacute graft rejection).
- Thi ghp nhanh (accelerate acute graft rejection).
- Thi ghp cp (acute graft rejection).
- Thi ghp mn (chronic graft rejection).
4.3.4. Thi ghp ti cp:
Phn ng ti cp xut hin vi pht hoc vi gi sau khi ghp. Phn ng ti cp xy ra
sau khi c th nhn c sn khng th chng cc khng nguyn HLA c lp I v lp II c
trong cc t bo ni mc cc mch mu tng ghp ca c th cho. Cc khng th -c
to ra l do c th nhn -c truyn mu trong c bch cu mang cc khng nguyn
ph hp t chc, chnh cc khng nguyn ny kch thch c th nhn to ra khng
th. S xut hin khng th cn c th l do sinh hoc c ghp ln tr-c nh-ng
tht bi s to ra trng thi tin mn cm cao ng-i nhn. Mt v d ca phn ng ti
cp tc th l tr-ng hp ghp thn hoc tim t c th c nhm mu A sang c th c

nhm mu O (bnh th-ng c th nhn ny c sn khng th khng nhm mu A) cc

c quan ghp b loi b nhanh n ni ch-a kp c cc mch mu tn to. Bi vy cn
phi kim tra xem c th nhn c sn cc khng th chng cc khng nguyn ca c th
cho hay khng. Ch c lm nh- vy mi trnh -c phn ng thi b ti cp tc th.

Khi b thi ghp ti cp, tng ghp mm nhn, tm. Hnh nh vi th thy mch
mu b vim cp, thnh mch y bch cu a nhn, lng cc vi mch b tc do
cc huyt khi tiu cu. Khi buc phi ly b tng ghp b hu do thi ghp
ti cp.
4.3.5. Thi ghp cp nhanh:
Cc phn ng thi b cp nhanh din ra trong vi ngy u sau ghp. Do c
hai yu t t bo v th dch ca c th ngi nhn phn ng cp vi cc khng
nguyn c tng ghp. M ghp b thm nhim bi lympho bo v bch cu
trung tnh v vim thnh mch hoi t. Cc nghin cu trn cc m hnh ng vt
chng minh rng cc phn ng ny l do cc lympho bo ch khng phi
khng th gy ra. C th ngn nga phn ng ny bng cch dng huyt thanh
khng lympho bo hoc khng thymo bo (anti lymphocyte globulin - ALG hoc
anti thymocyte globulin - ATG).
4.3.6. Thi ghp cp:
Thi ghp cp c th xy ra trong 3 thng u sau ghp ngay c nhng bnh
nhn c iu tr bng cc thuc c ch min dch. C 2 c ch tham gia:
- Mt l cc p ng min dch qua trung gian t bo gy ra tn thng tng
ghp. Trong ghp thn, bnh nhn i t, c khi ch st nh 37, 10C - 37, 20C; tng
cn c th t 0,5 - 3kg/24h, thn ghp au, to ra; xt nghim ure v creatinin
huyt thanh tng hn trc; c protein niu. Nu sinh thit thn ghp thy c
thm nhim rt nhiu t bo n nhn xung quanh mao mch, ph v teo biu m
ng thn; cu thn bnh thng. S dng corticoid liu cao c th lm gim cc
phn ng ny.
- Hai l cc khng th mi do c th nhn sinh ra chng li cc khng
nguyn c th cho, cc khng nguyn ny lm suy thn ghp. Sau ghp, thn
ghp hot ng bnh thng sau bt u c i t v suy thn. Hnh nh vi
th khi sinh thit thn cho thy tc cc mao mch, lng ng fibrin, hoi t ng
thn.
4.3.7. Thi ghp mn:
Phn ng thi b mn thng xut hin t thng th t sau ghp, c bit c
khi xut hin vo thng th 3 sau ghp v thng kt hp vi s gim dn chc
nng ca m ghp. Trong ghp thn biu hin chnh ca thi ghp mn tnh l c
protein niu, cao huyt p; ure v creatinin mu tng hn trc. Kt qu xt
nghim m hc cho thy c tng sinh mng trong v hp ng mch. Nhng thay
i ny xut hin bi phn ng vim min dch mn tnh, chng li t bo ni m
mao mch v gy ngng t tiu cu ln fibrin. Trong m ngng tp c c khng
th v b th. C p ng min dch qua trung gian t bo ln khng th u tham

gia vo phn ng thi b m ghp mn tnh, trong c c s tham gia ca cc

lympho bo Tc, cc lymphokin gy c do t bo lympho k, hiu qu ADCC (gy
c t bo do t bo ph thuc khng th - antibody dependent cellular
cytotoxicity).
5. Cc bin php chng thi b m ghp.
i vi ghp tng, vic quan trng nht l gi cho tng ghp khng b thi b.
Do trc khi ghp phi lm cc xt nghim: th khng nguyn, nh tp m,
xc nh mn cm trc ghp, dng cc thuc c ch min dch trong v sau
khi ghp.

5.1. Th khng nguyn:

Vic th khng nguyn ph hp gia t chc c th cho v c th nhn l mt
bin php quan trng ci thin thi gian sng d ca c quan ghp. Cng trnh
tng kt gn y ca Festenstein trn 1300 bnh nhn c ghp thn t nm
1969 lm sng t iu ny. Khng c bnh nhn no iu tr bng cyclosporin.
Cc bnh nhn c chia thnh 3 nhm theo mc ph hp vi khng nguyn
lp I. Nu ph hp 2 khng nguyn HLA - A v 2 khng nguyn HLA - B th
mang li kt qu tt nht. Ch ph hp hai khng nguyn HLA - A hoc ch ph
hp 2 khng nguyn HLA - A v mt khng nguyn HLA - B th kt qu ghp s
km hn. Kt qu km hn na khi ch ph hp mt khng nguyn. S ph hp
cc khng nguyn HLA - B c ngha quan trng hn cho vic ghp thnh cng.
Mc d cn t cng trnh ni v lin quan gia s ph hp ca cc khng nguyn
lp II vi thi gian sng d ca m ghp, nhng chc chn l s ph hp cc
khng nguyn lp II s lm tng kt qu ghp r rt.
- Ngi cho v ngi nhn phi ph hp v nhm mu (nhm mu ABO), y
l mt bc c bn ngn cn phn ng thi b m ghp ti cp.
- Cc khng nguyn Lewis cng nh hng n kt qu ghp thn v hnh
nh chng c nh hng thm vo khi khng c s ph hp ca cc khng
nguyn lp I v lp II. Nh vy cc khng nguyn khc nhau c tnh sinh min
dch khc nhau trong vic kch thch sinh ra hin tng thi b m ghp v nu
khng ph hp mc cao d cho cc khng nguyn l yu th vn gy
nguy hi cho m ghp. Cc khng nguyn Rh khng thy gy nh hng n thi
gian sng ca m ghp.
5.1.1. HLA (human leucocyte antygene) l g ?
HLA l khng nguyn b mt c trn t bo lympho ca ngi (trn b mt
lympho bo cn c nhiu khng nguyn khc).
HLA c trn b mt bch cu v c hu ht trn t bo c nhn, ngi ch
hng cu khng c HLA (hng cu li vn c HLA).
Chnh HLA gy ra hin tng thi b mnh ghp.
5.1.2. Phn lp HLA:
5.1.2.1. Lp I (class I): gm 3 nhm:

- HLA - A c 25 khng nguyn khc nhau.

- HLA - B c 56 khng nguyn khc nhau.
- HLA - C c 12 khng nguyn khc nhau.
S phn chia s lng khng nguyn ny tu thuc vo T chc y t Th Gii
c 5 nm hp 1 ln thng nht danh php v HLA v b sung HLA mi.
HLA - AW : y ch W l Workshop (hi ngh) c ngha l tnh c hiu
ca khng nguyn cha c xc nh m ch Workshop tip theo khng nh
li.
+ Lp II (class II): rt phc tp.
Trc nm 1980 gi l HLA - D nhng ch c 1 nhm D. Sau nm 1980 v
cho n by gi ngi ta thy c nhiu nhm D: HLA - DR, HLA - DP, HLA DQ, HLA - DX. Ch R vit tt ca ch Related (lin quan), sau ngi ta tm ra
nhng nhm khc v ly tn l DP, DQ, DX.v.v...
+ S khc nhau gia lp I v lp II:
- Khc nhau v di truyn: hai lp ny c m ho v locus gen khc nhau
song u nm cng trn nhim sc th 6.
- T bo lp I c trong tt c cc c quan ghp: t bo biu m mch mu
nh, c bit t bo m mch mu cu thn v c nhiu nht t bo bch tuc
(dendritic cell). T bo ny c nhim v by khng nguyn.
- T bo lp II nm lympho B, khng c trong t bo lympho T tr khi
lympho T c hot ho.

5.2. Cross match (th cho):

Phng php th cho (hay cho) tin hnh nh sau:
- Ly huyt thanh ngi nhn trn vi lympho bo ngi cho (c lympho B
v T) xem trong huyt thanh ngi nhn c khng th chng t bo lympho
ngi cho hay khng. Phng php ny phi lm 3 nhit khc nhau: 40C,
200C, 370C.
- Ly huyt thanh ngi nhn trn vi lympho bo B ca ngi cho cng
0
4 C, 200C, 370C. Nhng ngi c khng th ngng kt t lnh phn ng ch xy
ra nhit thp (40C) m khng ngng kt nhit cao 370C th vn c th
ghp c nhng khi ghp phi lm "nng" qu thn ln 370C.
Cross match m tnh mi c ghp.
Cross match dng tnh th ch ghp khi phn ng dng tnh 40C vi t bo
B v khi ghp phi lm "nng" qu thn ln nh trn. Cn nu phn ng dng
tnh vi t bo T th khng c ghp.

5.3. Xc nh tnh trng tin mn cm tr-c ghp (c tc gi gi l

tnh trng tin min dch):
Ly huyt thanh ngi nhn trn vi lympho bo bt k ca ln lt t
ngi th nht n ngi th 20 bnh thng. Nu huyt thanh ngi nhn git
cht t bo lympho ca 5 ngi bt k c ngha l dng tnh 25% th khng c

ch nh ghp. Nu tin mn cm dng tnh 20% (git cht t bo lympho ca 4

ngi bt k) th phi cn nhc cn thn trc ghp. Cn dng tnh t 15% n
m tnh th c ch nh ghp.
Tm li v phng din min dch trc ghp xc nh nu s ph hp HLA
ca ngi cho v ngi nhn cng cao th kh nng thi ghp cng t (trng hp
ghp anh em sinh i cng trng l ph hp HLA hon ton). Phi xc nh cross
match m tnh v tin mn cm phi di 15% mi c ch nh ghp.

5.4. S dng cc thuc c ch min dch:

Trong ghp thn ngi ta dng corticosteroid (prednison hay methyl
prednison) v azathiopin natri, tin hnh iu tr t vi ngy trc ghp hoc ngay
khi ghp. ng thi bnh nhn cng c iu tr bng globulin khng lympho
bo vo lc tin hnh ghp.
Nhng nhiu cng trnh ch ra rng globulin khng lympho bo t ra t
hiu qu v mt s nhm nghin cu v ghp a dng khng th n clon chng
mt s qun th lympho bo T c hiu.
iu tr bng cyclosporin A l phng php quan trng nht trong ghp hin
nay. Loi thuc ny c tc dng a nng trn h thng min dch, n c th gn
vo lympho bo v ngn cn khng nguyn hoc cc mitogen hot ho invitro
lympho bo. N cng c tc dng c ch i thc bo sn xut interleukin I v c
ch lympho bo T sn xut interleukin II. Nhng cha chc chn rng cc hiu
qa invitro trn y ca cyclosporin tham gia vo c ch lm gim p ng min
dch invitro hay khng.
Tuy nhina cyclosporin c th gy c cho thn, gan v thn kinh trung ng.
Cc tn thng do tc dng c c th hi phc khi ngng thuc hoc gim liu.
Khi s dng cc thuc c ch min dch, cng cn bit cc tc dng bt li
ca n. Cc thuc c ch min dch c tc dng lm gim phn ng thi b m
ghp, nhng thuc cng lm c th tr nn nhy cm vi nhim trng do cc vi
khun c hi gy ra. Ngoi ra cc c th nhn ghp c s dng thuc c ch min
dch cn d b cc bnh c tnh. Hoover v Fraumini tng kt 6297 trng hp
ghp thn v nhn thy nguy c mc u lympho tng 35 ln. Nguy c ny biu
hin r rt ngay trong nm u sau khi ghp. Nguy c tng mc ung th m v da
cng th hin r rt. Ngy nay c nhiu thuc c ch min dch mi ang c s
dng (mc 7).
6. Chn on v iu tr phn ng thi b m ghp.

6.1. Chn on:

Triu chng lm sng v chc nng phn ng thi b m ghp thay i tu
thuc vo c quan ghp. Bnh nhn thng c st v mt mi. C quan ghp
thng b ph n v mt trng lc. nh gi ch yu bng cc xt nghim ho
sinh v chc nng. Phi chn on phn bit gia phn ng thi b v nhim
trng. Gn y ngi ta s dng cc k thut chn on "mnh m" hn bao gm
c vic lm sinh thit m ghp c c kt lun v phn ng thi b m ghp.

6.2. iu tr:
Mc ch ln nht ca vic iu tr l lm gim cng tn cng ca cc c
ch min dch vo cc c quan hoc m ghp. Cc steroid c hiu qu nhanh
chng v r rt trong vic lm gim phn ng thi b (ti 60 - 70% cc trng
hp giai on thi b cp). Thng tim tnh mch chm methylprednisolon
liu cao (pulsse therapy) c th tim 1g/ 1 ngy trong 3 ngy lin hoc 500 mg x
2 ngy u sau c 2 ngy gim 1/2 liu. Thng th sau tim bnh nhn ht
cc triu chng thi b, c bit l ht st v d chu ngay (ch nn cho thuc
chng acid d dy, c ch th th H2 trong thi gian pulse therapy). Gn y
ngi ta nhn thy tim methylprednisolon vi liu nh hn (2 - 4mg/kg/ngy)
cng c hiu qu tng t.
C th phi hp cc steroid vi globulin khng lympho bo. S phi hp ny
c hiu qu cao nht vi cc trng hp phn ng thi b c s tham gia ca p
ng min dch qua trung gian t bo. Gn y ngi ta s dng cc khng th n
clon c ngun gc chut nht trng chng li cc qun th lympho bo T, cc
khng th ny gy gim s lng lympho bo T (CD3+). Khi tim, chc nng ca
m ghp c ci thin sau 2 - 7 ngy.
Vic iu tr cc cn thi b cp thng c kt qu. Nhng ngc li cha c
phng php iu tr c hiu i vi cc trng hp ghp thn khc gen cng
loi m c phn ng thi b ti cp hoc mn tnh. Vic ngn nga thi ghp mn
tt c bnh nhn c ghp khc gen cng loi bng duy tr cc thuc c ch
min dch trong sut thi gian sng sau ghp. C th dng phc 2 thuc:
cyclosporin A (sandimun, neorale) phi hp vi prednisolon hoc imuran
(imurel) phi hp vi prednisolon. Hoc phc 3 thuc: cyclosporin A phi hp
vi prednisolon v imuran hoc cellcept.
Liu duy tr vi cc thuc nh- sau: cyclosporin A, 3 - 4 mg/kg/ngy ung chia 2 ln trong
ngy - mi ln cch nhau 12 gi; imuran 1 - 2mg/kg/ngy; prednisolon 5 - 10mg/kg/ngy
{nn dng c liu ung mt ln sau n sng s t b c ch trc d-i i - tuyn yn th-ng thn (hypothalamus - pituitary - adrenal)}, [Grant: 1965, Fleighen: 1967,
Ackerman: 1988, PDR - 53 Edition: 1999].

Dng imuran hoc cellcept trong phc iu tr phi theo di bch cu trong
mu. Nu bch cu h di 4,0 x 103 phi ngng thuc, sau 1 - 2 tun bch cu s
tr v bnh thng v c th dng tip thuc nhng phi gim liu.
Khi dng thuc cn phi nh lng nng cyclosporin trong huyt thanh
tng hay gim liu sao cho t nng ti thiu 100 - 200 nanogam trong 1ml
huyt thanh (ng/ml) vi phng php min dch phng x (radio immuno assay RIA) hoc 400 - 800ng/ml trong mu ton phn vi phng php sc k lng cao
p (high pressure liquid chromatography - HPLC). Hin nay theo di nh lng
nng T2 trong huyt khng ung thuc sau 2 gi - duy tr 6 thng u
1.700mg/ml (1,7microgam/ml). 6 thng sau 1.200mg/ml - Sau 1nm khong 8001000mg/ml.

7. Cc thuc c ch min dch chng thi ghp.

7.1. Cc loi thuc hin c:

- Azathioprine sodium (imuran).
- Cyclosporin A (sandimmun, neoral).
- Corticossteroid (methylprednisolone, prednisolone).
- Orthoclone OKT3 (monoclonal - CD3).
- FK - 506 (tacrolimus, prograf).
- Rapamycin.
- Mizoribine.
- Mycophenolate mofetil (cellcept).
- Deoxypergualin (DSG).
- Leflumide.
- Brequinar.

7.2. C ch chng thi ghp ca cc thuc c ch min dch:

- Phong to, km s nhn dng m tng ghp khng ph hp.
- Phong to, km s chuyn cc tn hiu ca cc t bo T (blockage of T cell
communication).
- Km ch cc qu trnh nhn bn t bo lympho (cell replication processes),
c ch s trng thnh cc bch cu, c ch qu trnh tng hp DNA cc bch
cu v lympho bo, c ch tc dng cc cytokin do cc lympho bo tit ra.
8. Cc b-c chun b tin hnh cho ghp thn.
Ghp thn cng nh ghp tng i hi phi phi hp nhiu chuyn ngnh:
thn hc, min dch hc, m phi hc, thn nhn to, phu thut thc nghim,
ngoi khoa (ngoi chung, ngoi mch mu, tit niu) gy m, hi sc, sinh ho,
ho nghim, huyt hc - truyn mu - chn on hnh nh, chn on chc nng;
tm l y hc, dc hc...
Chnh v vy vic chun b bnh nhn trc ghp nht l vi ngi cho thn l
ngi sng l rt quan trng.

8.1. Chn cp ghp:

Ngi cho v ngi nhn.
8.1.1. Ngi cho:
Ngun cho thn hin nay l ngi sng v ngi cht:
+ Ngi sng (Living donor) gm:
- Cng huyt thng gia nh (living related donor).
- Khng cng huyt thng gia nh (living non related donor).
+ Ngi cht (cadaver donor) gm:
- Cht no (brain death)
- Tim khng cn p (non - heart beating donor).

Ngi cho phi c nhm mu ph hp, khng c bnh ly truyn, bnh h

thng, bnh ung th... hai thn phi c chc nng tt v gii phu bnh thng, v
min dch hc v cc xt nghim cho php ghp v tng hp m (tng hp v
h thng DLA, th cho, tin mn cm). Vi ngi cho sng phi lm test tm l
h t nguyn d l c quan h huyt thng. Vi ngi cho l cht th cng
phi c t nguyn hoc gia nh h chp nhn. nhiu nc trn th gii
lm th cho ph tng t nguyn khi cht no c th xin ph tng m khng
phi xin kin ngi thn na.
8.1.2. Ngi nhn:
c ch nh cho tt c cc bnh nhn suy thn mn giai on cui hoc mt
thn phi chy thn nhn to hoc lc mng bng chu k. Tui t 6 thng n 64
tui - c bit c th cao hn 70 tui.
Chng ch nh ghp thn cho ngi c bnh sau: bnh l c tnh, suy tim
khng hi phc, suy h hp mn tnh, bnh gan ang pht trin, bnh mch mu
(mch vnh, mch no hoc ngoi bin), d dng ng tit niu bm sinh nng,
nhim khun mn tnh khng p ng vi iu tr, AIDS, ri lon ng mu
nng, bnh tm thn, nghin ru nng v.v...
Vic tuyn chn ngi cho v ngi nhn phi rt cht ch. Hin nay c
khong 50 ch tiu chn cp ghp.

8.2. Phu thut ly thn - ra thn v ghp thn:

8.2.1. Ly thn:
Phi ly mt qu thn vi mt cung mch bo m : tnh mch v ng
mch thn di v khng lm tn thng gii phu thnh mch. on niu
qun c ly ht chiu di v khng lm tn thng khi phu tch v bc tch
trnh gy hoi t sau ny.
Khi ly thn cn c bit ch th phu tch b mch c bit l tnh mch
thn nht l cc nhnh bn trnh lm rch hoc sang chn, tn thng.
Khng c s nn vo qu thn trong khi ly thn phng tn thng nhu
m thn. Sau khi ly thn xong qu thn phi c "ra sch".
8.2.2. Ra thn:
Mc ch ra thn: lm sch ht hng cu, bch cu v lm thng sch cc
ng mch v nhu m thn ghp. Ra thn bng dung dch euro - Collin c
lnh 40C, u vo l ng mch thn; ra n khi qu thn trng ht v nc ra
tnh mch thn trong hon ton (ch khi ra thn khng lm tn thng mch
mu, cung thn v nhu m thn).

8.3. Ghp thn:

V tr thn ghp: h chu phi hoc tri.
Ghp thn c 3 th quan trng:
- Ni tnh mch thn vi tnh mch chu trong theo kiu tn-bn hoc tn-tn

- Ni ng mch thn vi ng mch chu trong theo kiu tn-bn hoc tn-tn.

Kim tra hnh thi v chc nng thn ghp sau khi ni xong mch mu
(mu nui, nhu m thn v nc tiu ra u niu qun).
- Trng niu qun vo bng quang.
Trong qu trnh ghp thn ch cng tc gy m hi sc, c bit ch
lng dch truyn vo, thuc li niu, thuc c ch min dch, thuc gin mch...

8.4. iu tr sau ghp:

Sau m bnh nhn phi c nm ti khoa sn sc c bit (ICU), theo di v
h hp, tim mch, huyt p ng mch, huyt p tnh mch trung tm, lng dch
vo, ra hng gi, theo di s lng, cht lng nc tiu, m bo lng dch
truyn vo so vi lng nc tiu l 0,8 - 1ml dch vo/1ml nc tiu. Dch
truyn vo l glucose 5% v huyt thanh mn 0,45%; 0,9% v ringer.
Trong thi gian 3 thng u sau ghp thn, c bit l tun u, thng u l
thi gian c nhiu bin chng sau m v c cc t thi ghp cp. Thc hin
dng thuc c ch min dch, cha huyt p cao, chng bnh nhim khun,
nhim nm, nhim virut, cha cc bnh bt pht, theo di v phng cc tc dng
ph ca thuc c ch min dch...

8.5. Theo di sau ghp thn lu di:

Bnh nhn ghp thn phi c theo di sut i sau ghp: nh k 1 - 2
thng phi c kim tra ure, creatinin, cng thc hng cu, bch cu, SGOT,
SGPT, axit uric, glucose trong mu v protein nc tiu.
Cn nng v huyt p phi c theo di hng ngy duy tr ch n
khng tng cn v dng thuc duy tr huyt p cho ph hp.
Bnh nhn phi c theo di nng thuc c ch min dch v iu chnh
liu sao cho ph hp vi tng c th ngi bnh; theo di cc bin chng nhim
khun, tim mch, ung th sau ghp, bin chng do dng corticoide v cc thuc
c ch min dch ko di.
Ghp thn - ghp tng l k thut y sinh hc cao, i hi nhiu chuyn ngnh,
tn km v phi theo di lu di, lin tc vi ch dng thuc hp l, nht l
thuc c ch min dch. Do vy ngi bnh sau ghp phi c thy thuc
chuyn khoa qun l v theo di cht ch.

Chng iv

Ni tit
cp cu v iu tr cn nhim c
hormon gip kch pht sau phu thut

T V Kh-ng
1. i c-ng.
Vit Nam, phu thut ct gn hon ton tuyn gip iu tr bnh basedow
cng nh cc phu thut khc trn tuyn gip c tin hnh thng xuyn ti
cc trung tm ngoi khoa. iu tr ngoi khoa t kt qu 85 - 90%, song vn gp
mt s bin chng giai on sm sau phu thut, trong cn nhim c
hormon gip kch pht (NHKP) sau m lun l vn thi s, nht l v chn
on, iu tr, d phng v n l mt trong cc nguyn nhn gy t vong sau m.
Cn NHKP l bin chng nng thng gp 3 ngy u sau m cng nh
bin chng nng bnh basedow m nguyn nhn ca c ch bnh sinh cn
nhiu im cn phi c lm sng t.
Vic chn on cn NHKP sau m ch yu da vo bnh cnh lm sng
nhng ngy u sau m, sau kt hp vi xt nghim nng T3, T4, FT4 b
sung cho vic chn on v tin lng iu tr. Chn on nhanh, chnh xc v
iu tr v ng th mi hn ch t l t vong.
2. Nguyn nhn v c ch bnh sinh.
+ C ch bnh sinh ca cn NHKP l ri lon qu nhanh h thng thn kinh
trung ng, tip theo l tng hot tnh chc nng ca tuyn gip, tng tit hormon
gip vo mu a n ri lon chuyn ho lipid trong gan, suy chc nng v
thng thn.
+ Vi cn NHKP sau m tuyn gip xy ra l do chn thng tuyn gip
trong lc m kt hp vi s kch thch thn kinh ngoi bin gy nn.
Cho n nay cc tc gi a ra hai gi thuyt chnh:
+ Mt l, do s tng t ngt hormon tuyn gip vo h thng tun hon. V
d nh sau iu tr ngoi khoa bnh nhn b cng gip.

+ Hai l, s tng t ngt nng hormon gip t do t t bo ca c th khi

kh nng gn protein huyt thanh ca hormon gip b gim ng k nh trong
nhim khun phi, ri lon chuyn ho trong i tho ng.
3. Chn on cn NHKP sau m.

3.1. Lm sng:
Cn NHKP c th xy ra t t trong mt vi ngy hoc xy ra rt nhanh ch
trong mt vi gi sau m. Triu chng lm sng rt rm r, cc triu chng chnh
ca tnh trng nhim c hormon gip biu hin nh sau:
+ St cao 39 - 400C, da nng m.
+ Lun trng thi hng phn, khng ng, c th c lon thn cp.
+ Ngi bnh v lc, mt l.
+ V m hi.
+ Tng xung huyt ngoi da.
+ Bnh nhn bun nn, nn, nu nng c a lng.
+ Nhp tim nhanh trn 100 ln/ pht, c th c nhp nhanh kch pht trn tht,
trn 200 ln/pht hoc lon nhp, ngoi tm thu, suy tim cp.
+ Huyt p c th cao hoc thp nu nng.
+ Nhiu trng hp c vng da.
Nu khng c chn on sm, nhanh, iu tr tch cc, kp thi th t l t
vong ti 75%, ngi ln tui ti 100%. T vong thng xy ra vo 2 ngy u
ca cn NHKP.

3.2. Xt nghim cn lm sng:

+ Cc phng php chn on invitro vi bnh tuyn gip ni chung v bnh
basedow ni ring phn ln l cc phng php min dch phng x RIA (Radio
Immuno Assay) nhm ch yu xc nh nng thyroxin (T4) v triiodothyronin
(T3). Nng T3, T4 tu thuc vo k thut xt nghim ca labo. Ch s bnh
thng ca ngi Vit Nam theo mt s tc gi:
- L c Trnh, Lng Tn Thnh, Phm Khu v CS (1995):
T3 = 1,5 2,8nmol/l (trung bnh 2 nmol/l).
T4 = 65 140nmol/l (trung bnh 100 nmol/l).
- V nh Vinh (1996):
T3 = 1,59 2,77nmol/l, T4 = 38,46 89,74 nmol/l.
+ chn on bnh cng chc nng tuyn gip theo phng php invitro,
u tin cn xc nh T4 t do (free thyroxin). Nu T4 t do (FT4) tng cao c th
chn on bnh cng gip trng.
+ Vic chn on cn NHKP sau m da vo lm sng l chnh; hormon
tuyn gip c gi tr chn on cao c bit l s khng bnh thng ca FT4, T3.

+ Theo tc gi Richard S. Bernua, David V. Becker (1995) th nng T3 v

T4 thng tng cao trong bnh cng gip. Trong cn NHKP th nng T4, T3
c th khng tng cao lm hoc c mc khc nhau t giai on u ca cn
bo gip. Nhng FT4 th tng cao trong cn NHKP, vn ny thay i tu theo
kh nng gn protein huyt thanh v Hormon gip.
4. iu tr cn NHKP sau m.
Cn NHKP sau m l mt cp cu cn c theo di st sau m pht
hin sm, chn on nhanh chng v iu tr kp thi ti trung tm hi sc cp
cu c iu kin trang b.
Sau y l nguyn tc iu tr cn NHKP:
- Chng qu trnh tiu hao nng lng v sinh nhit.
- An thn v gim au.
- Chng ri lon v tun hon.
- Chng suy h hp cp.
- Corticoid liu php.
- iu chnh ri lon nc, in gii v thng bng kim toan.
- Nui dng tt, m bo t nht 2500 - 3000 Kcalo/24 gi.
- Phng bi nhim.
- Phng nga cn ti pht.
- Lm gim lng hormon gip trong mu: plasmapheresis.

4.1. Qu trnh chng tiu hao nng l-ng v sinh nhit:

4.1.1. Dng thuc khng gip trng tng hp:
Nhm mc ch: lm gim sn xut hormon tuyn gip v c ch qu trnh
chuyn T4 thnh T3 .
+ Dng PTU vi liu 200mg/ln (qua ng ung hoc ng sonde d dy)
v c 4 gi cho lp li, tng liu l 1200mg/24 h.
+ Methimazol: liu 30mg/ln, c 6 gi cho qua ng ung hoc qua sonde
d dy mt ln.
+ Hoc dng MTU liu 600 - 1000mg/ngy, chia u c 6 gi ung 1 ln.
Hoc dng mercazolin liu 60 - 100mg/ngy sang ngy th 2 cho liu 30 - 60 mg.
4.1.2. S dng mui iod:
+ Dng iod iu tr bnh tuyn gip c s dng t lu, nhng cc tc
gi s dng ca iod trn tuyn gip cha tht hiu ht, c mt s kin cho rng:
- c ch tm thi qu trnh gn hu c trong tng hp hormon gip (c ch
tng hp hormon tuyn gip).
- Gim s bi tit hormon gip vo mu, do vy lm gim nng T3, T4
trong mu.

+ Cc mui iod c s dng l dung dch lugol 1% vi liu 10 git x 3

ln/ngy, c th dng liu 20 x 30 git x 3 ln/ngy. Hoc dung dch iodua kali 3
git/ln x 3 ln/ngy
4.1.3. H thn nhit:
+ Chm lnh ton thn bng cc ti nc hoc my h thn nhit, duy tr
nhit di 380C.
+ Dng cc thuc h nhit : khi chm lnh hoc my h thn nhit khng
c kt qu.
+ Dng thuc ng min, an thn: seduxen tim bp tht hoc tnh mch l tt
nht v lm gim chuyn ho.

4.2. Chng ri lon tun hon:

bnh nhn b cn NHKP sau m th c nhp nhanh kch pht trn tht
hoc lon nhp, rung nh, suy tim cung lng cao. Nu cn NHKP nng th tt
huyt p.
+ S dng cc thuc glucozit cng tim c tc dng nhanh nh uabain,
isolanide.
+ Cc thuc c ch . adrenergic nh inderal, propranolon... cc thuc ny c
tc dng c ch qu trnh bin i t T4 sang T3.
- Cc thuc c ch lm gim nhp tim, run tay, ra m hi, gim tnh trng
hng phn, kch thch v di tc dng ca cc thuc ny nhanh chng ht cc
tri chng nhim c gip.
- Chng ch nh ca thuc bnh nhn c suy tim nng, c ri lon dn
truyn trong tim, hen ph qun.
- D phng c th dng thuc c ch ngay lp tc trong trng hp c nghi
ng cn NHKP (theo tc gi Luton. J.P, Vidal Trecan. G v CS: 1984).
+ B sung khi lng mu mt: truyn mu khi s lng hng cu di 3
triu/1mm3, Hb < 100gr/l v Hct < 30%.

4.3. Phng chng suy h hp:

Chc nng h hp phi c theo di cht ch bng cc ch tiu lm sng v
xt nghim (xt nghim kh mu) d phng v chn on, iu tr kp thi suy
h hp cp xy ra nht l trong trng hp cn NHKP mc nng c suy h
hp cp.
+ m bo lu thng ng th tt:
- Ht m di.
- Th oxy.
- Kh dung: khng sinh + chymotrypsin + corticoid.
- L liu php.

+ Nu trng hp ng m di nhiu, ph n thanh qun nng hoc chy

mu vt m gy chn p kh qun th c ch nh t ni kh qun hoc m kh
qun v thng kh phi nhn to.

4.4. Crorticoid liu php:

+ Mc ch iu tr suy chc nng thng thn cp v c ch chuyn i
T4 thnh T3.
+ Dng metylprednisolon liu cao 200 300mg/ngy hoc hydrococtison
hemisuccinat 300 - 600mg/ngy cho vo dch truyn nh git lin tc hoc c 6
8h mt ln tim tnh mch hoc bp tht, nu cha, c hiu qu liu thuc trn c
th tng.
Sang ngy th 2 liu corticoid gim v tim bp tht prednisolon 30 - 50mg x
3 ln/ngy.
Nu c HAM tt thp c th cho DOCA (5mg) tim bp tht 1 2 ln/
ngy.
- C th cho dexamethasone 2 mg mi 6 gi (Davis V.Becker v CS, 1995).
Ch : cho cimetidine hoc zantac v maalox khi dng corticoid.
4.5. iu chnh nc - in gii v thng bng kim toan:
+ Chng mt nc: truyn dung dch natri clorua 9%o hoc glucose 5%.
glucose 10%.
- Lng nc a vo da theo p lc tnh mch trung ng ca bnh nhn
(thng phi t catheter tnh mch di n, cnh su theo di).
- Tnh lng nc vo - ra trong 24h b kp thi. Thng b 2500ml 3000ml/24h.
+ iu chnh in gii v thng bng kim - toan da vo xt nghim in
gii v kh mu, c th xt nghim 1 - 2 ln/ngy v da vo kt qu thc t bnh
nhn iu chnh kp thi.
iu chnh in gii: ch s thiu ht can xi sau phu thut tuyn gip (s
thiu ht ny c th l nguyn nhn thun li lm xut hin cn NHKP sau
m).
4.6. iu tr nhim khun v gii quyt cc nguyn nhn xut hin cn
NHKP:

Dng khng sinh d phng v iu tr nhim khun vt m sau phu thut:

+ Dng khng sinh ph rng v liu cao.
+ Kt hp vi gii quyt nguyn nhn nh bin chng chy mu sau m (cn
m li ly mu cc v cm mu vt m nu xy ra bin chng ny).

4.7. m bo nui d-ng tt:

+ Bnh nhn sau phu thut ct gn hon ton tuyn gip iu tr bnh Basedow
v nht l bnh nhn bin chng cn NHKP sau m th b tiu tn nhiu nng l-ng

do st cao, do nhim khun, do tng chuyn ho ca hormon gip. Do vy, vic nui
d-ng bnh nhn tt gp phn lm cho cn NHKP qua khi.

+ Vic nui dng m bo t nht 2500 - 3000 Kcalo/24h:

- ng tnh mch.
- Qua sonde d dy: bm sa, sp v bm thuc.
- Cc loi sinh t nhm B, C.

4.8. Tch bt huyt t-ng (plasmapheresis):

Trn c s iu tr tch cc, tnh trng bnh nhn s tt hn ln sau 24 - 30
gi. Khi thn nhit gim, ht a lng v nn. Song iu tr ht c tt c cc
triu chng ri lon chuyn ho cn phi tip tc iu tr 7 - 10 ngy.
- Nu 24 - 48 h iu tr m khng c kt qu r rt th vn tch huyt
tng phi c t ra.
- Tch huyt tng ci thin nhanh chng v iu tr khi bnh. Nh vy,
n chng minh rng c kh nng lm gim nhanh chng nng hormon gip
trng v t c li ch lm sng i vi bnh nhn.
5. D phng cn NHKP sau m.
+ d phng bin chng cn NHKP sau m Basedow th vn ct li l
phi ngn chn cc yu t thun li v nguyn nhn gy ra n.
+ Mc ch h thp t l cc bin chng cn NHKP th phi kt hp tt cc
yu t:
- Chn ch nh m ng.
- iu tr ni khoa trc m tt.
- Ci tin k thut m.
- Phng php v cm.
- Vn hi sc sau m.
phng cn NHKP c th xy ra sau khi m, ch c tin hnh phu
thut khi bnh nhn c iu tr ht cc triu chng nhim c hormon gip
(tnh trng bnh gip).
+ Mt khc iu tr cho tuyn gip chc li, chng chy mu trong m v
hn ch bin chng chy mu sau m, phn no ngn chn cn NHKP c th
xy ra 2 - 3 tun trc khi m cho iu tr phi hp:
- Dung dch Lugol 1%: 30 - 50 git, 2 - 3 ln trong ngy, ko di 10 - 15 ngy.

- Khi c gim chc nng v thng thn th dng prednisolon 10 - 30mg/ngy

hoc hydrocortison 25 - 30 mg/ngy cho 2 - 3 tun trc khi phu thut.

cp cu v iu tr
cn nhc c nng gy suy h hp cp

Tt C-ng
1. i c-ng.
Bnh nhc c (myasthenia gravis) l mt bnh t min dch nn cn gi l
bnh nhc c t min. Ngy nay, ngi ta xc nh trong huyt thanh ca
bnh nhn b bnh nhc c c t khng th chng cc th cm th tip nhn
acetylcholin mng sau xi np thn kinh - c, lm mt kh nng dn truyn thn
kinh, lm c khng co c v gy ra hin tng nhc c.
Bnh nhc c c Thomas Willis pht hin t nm 1792 nhng n nm
1901 nh thn kinh hc Herman Oppenhiem xc nh bnh nhc c v nhim
c Cura c nhng triu chng ging nhau. Ngy nay rt nhiu cng trnh nghin
cu tm hiu su bnh nhc c c v sinh l bnh, triu chng v phng
php iu tr, c bit l cp cu iu tr cn nhc c nng gy suy h hp cp
gp phn iu tr thnh cng loi bnh l phc tp ny.
Bnh nhc c c mi chng tc, c hai gii nhng n mc bnh nhiu hn
nam, t l 3/2. C 2/3 s bnh nhn n mc bnh nng dn tui di 40, cn
2/3 s bnh nhn nam bnh nng dn tui trn 40. T l mc bnh t 1/10.000
n 1/20.000 dn.

2. Sinh l bnh nh-c c.

2.1. Gii phu sinh l dn truyn thn kinh c bnh th-ng v trong
bnh nh-c c:
Dy thn kinh vn ng n c vn chia ra lm nhiu nhnh nh, mi nhnh
li mt c vn. Ti ch tip gip vi si thn kinh, mng c lm vo, dy ln v
hnh thnh nhiu np gp. Ngay trn nh nhng np gp ny tp trung rt nhiu
th cm th (receptor) nhy cm vi axetylcholin. u tn cng ca si thn kinh
nm ng vo pha ca np gp, khong cch gia u tn cng ca dy thn
kinh v mng c khong chng 200 - 500Angstron (A0) to thnh v tr tip hp
thn kinh - c, gi l xi - np thn kinh - c.
u tn cng si thn kinh vn ng c nhiu ty lp th v nhiu bng nh
cha ho cht l axetylcholin (Ach). Cc bng nh ny gi l quan ta. Mi quan ta cha khong 10.000 phn t axetylcholin. Bnh thng khi c ngh ch c mt
hai bng v ra, phng thch 1 - 2 quan ta, v th Ach, qua xi np qu t khng
gy kh cc c xi np, song cng gy nn nhng xung rt nh m ch c vi in
cc t ti ch mi ghi li c, l nhng in th nh tn cng (miniature
end place potential) vit tt l MEPP. Khi kch thch hay khi c xung ng ti
u tn cng ca dy thn kinh, lng Ach, t 150 n 200 quan ta c phng
thch ra cng mt lc v kt hp vi th cm th Ach, cc th cm ny lun tp
trung dy c ti cc nh ca cc np gp sau xinp (Post synaptic folds). ng
thi cc knh (chanels) trong th cm th tip nhn Ach, c m ra lm tng tnh
thm ca mng t bo ch ion Na+ t ngoi vo, ion K+ t trong ra gy nn hin
tng kh cc to nn mt in th hot ng lan truyn dc theo si lm co c.
Trong khi th th tip nhn Ach, nm ngay trn nh cc np gp ca xinap th ngay
bn di np gp l ch sn xut ra men cholinesteraza tiu hu Ach. V th ngay
sau khi gy ra kh cc th phn ln Ach, b men cholinesteraza tiu hy ch cn mt
phn rt nh khuych tn ngc tr li mt on thn kinh dng li.
Trong bnh nhc c, s thiu ht c bn l gim s lng th cm th Ach,
ti mng sau xinap (Post synaptic muscle membrance). Hn na nhng np gp
sau xi np b dn phng ra hoc b mng i. Hu qu l gim dn truyn thn
kinh c. V th cho d lng Ach c phng thch bnh thng nhng ch sinh
ra in th nh tn cng (MEPP). in th ny qu nh khng gy ra co c
dn ti nhc c (Randall. R. Long Intensine care 1999, Tp 2, trang 2122).
S xi np thn kinh c bnh thng (A) v trong bnh nhc c (B)
Daniel. B. Drachman - 6/1994

2.2. T khng th trong bnh nh-c c:

Bnh thng biu m, t bo lympho v t bo dng c tuyn c cha
mt cht c thnh phn ging nh th cm th tip nhn Ach. Khi b nhim c
hay nhim virut, c th c th b ri lon min dch do cc thnh phn trn c
th "b nhm" nh mt th th tip nhn Ach v c coi l "khng nguyn" . Vi
s nhm ln y, tuyn c sinh ra khng th chng li cht c coi l "khng
nguyn" ni trn, ng thi chng li cc th cm th tip nhn axetylcholin.
chnh l cc "t khng th", ngha l khng th chng li cht vn l thnh phn
bnh thng ca c th.
p ng min dch u tin v duy tr nh th no trong bnh nhc c vn
cha c hiu bit y . Tuy nhin tuyn c c ng vai tr trong qu trnh
ny. Tuyn c khng bnh thng trong 78% s bnh nhn nhc c. Trong c
65% bnh nhn c tuyn c b tng sn (hyper - plasiae) vi xut hin cc trung tm
mm (germing center) v 10% bnh nhn c u tuyn c (thymomas).
Cng trnh nghin cu ca U.A. Besinger cho thy nhng trng hp nhc
c nng v va c s i i gia tng t khng th v mc nng ca bnh trn
lm sng. nhng trng hp nh th khng nh vy. P.Osserman theo di trong
5 nm lin thy c mi lin quan cht ch gia hiu gi t khng th v din
bin lm sng, ngha l hiu gi tng khi bnh nng ln v gim khi bnh thoi
lui. Ngoi ra cn thy hiu gi t khng th cao bnh nhn c u tuyn c.
Nh vy trong bnh nhc c t min, t khng th khng th cm tip nhn
acetylcholin c l ng vai tr quan trng nht. C ch tc dng ca t khng th
ny trn th cm th acetylcholin l: gy dung gii mng sau xinp, lm hng cc
th cm th acetylcholin, tranh ch nh mt ho cht (curare) hay c ch s phn
ng no nm rt gn cho nn gy cn tr acetylcholin kt hp vi cc th
cm th ging nh c ch cc cht c ch men.

Cng c th do s kt hp vi cc nhm phn ng ca th cm th

acetylcholin, hay ca mt v tr k cn nn c ch cc l thot ion lm s kh
cc khng xy ra c. Gi thuyt ny ang c cc nh sinh hc phn t
nghin cu chng minh.

2.3. Cc t khng th khc:

Trong ph ca bnh t min th bnh nhc c t min thuc vo nhm c
hiu c quan ngha l t khng th ch chng ring mt c quan m thi. Nhng
cng nh cc bnh t min khc, bnh nhn nhc c ngi ta cn pht hin
thm mt s t khng th khc nh t khng th chng nhn, chng ty lp th,
khng th khng gip. Nhng t khng th ny cng c th gy nn nhng ri
lon ti cc c quan tng ng. Hay gp nht l ri lon tuyn gip.
3. c im lm sng v phn loi bnh nh-c c.

3.1. c im lm sng ca bnh nh-c c:

+ c im lm sng ca bnh nhc c l: tnh trng yu c t pht lc c,
lc khng ca cc c vn ng theo mun,c bit c trng hp t khi.
+ Tnh trng nhc c thng tng ln khi vn ng v gim mt phn khi
ngh ngi.
+ Cc c hay b tn thng nht l: c vn nhn ngoi, c nng mi, c hu
hng, c nhai, cc c chi th v c h hp. Do cc triu chng thng xut
hin l: sp mi, nhn i, nhai mi, kh nut, yu chn tay, lm vic chng mi
v kh th tu theo giai on bnh. David Grob nghin cu trn 1487 bnh nhn
nhc c thy c cc triu chng biu hiu nh sau:
- Sp mi
: 25%
- Nhn i
: 41%
- Ni ngng
: 16%
- Nut kh
: 10%
- Yu chi trn
: 7%
- Yu chi di
: 13%
- Yu ton thn
: 11%
+ Cc c b nhc : nng mi mt: 58%, c vn nhn: 54%, c nhai: 32%, c
khp mi: 71%, c mt 63%, c nut: 24%, c li: 33%, c vai v c chi trn:
72%, c bn v ngn tay: 68%, c chi di: 75%, c ton th: 11%
+ c im ca bnh nhc c l: s c b nhc v mc nhc c thay
i trn tng bnh nhn.
Khi tnh trng nhc c nng ln nht l nhc c h hp lm cho bnh nhn
th yu khng ho khc c dn n thng kh khng m bo, bnh nhn vt v,
tm, cm gic nh cht ui trn cn. l cn nhc c. Cn nhc c l mc
pht trin nng nht ca bnh, i hi phi c cp cu kp thi, khi c suy

h hp phi thng kh nhn to v kt hp iu tr ton din mi hy vng qua

khi, trng hp cp cu mun, iu tr khng ng c th t vong.

3.2. Phn loi bnh nh-c c:

+ Perlo - Osserman 1979 chia mc bnh nhc c lm 5 giai on:
- Giai on I: nhc c khu tr mt.
- Giai on IIA: nhc c nh hn, hnh thnh dn h c ngoi vi, cha c
ri lon nut v h hp.
- Giai on IIB: nhc c nng hn, c ri lon nut, ni kh song cha c
ri lon h hp.
- Giai on III: nhc c nng, cp tnh, c bit l cc c h hp, sm c ri
lon h hp.
- Giai on IV: nhc c nng nh giai on III d xut hin suy h hp cp
trm trng.
+ H.J.H.G. Oostehuis ci tin phn loi ca P.Osserman v chia thnh 5
mc nhm pht hin rt sm bnh nhc c:
- O : khng c triu chng, bnh nhn lm vic bnh thng, ch mt nh
v mi mt s nhm c ring bit, nhng dng thuc khng cholinesteza th kh
hn, phn ng in c dng tnh.
- 1: ch c triu chng mt, sp mi.
- 2: yu c nh.
- 3: yu c ton thn va hoc c ri lon chc nng h hp nh v va.
- 4: yu c ton thn hoc c ri lon chc nng h hp nng.
4. iu tr cn nh-c c nng gy suy h hp cp.
Bin chng nng nht ca bnh nhc c l cn nhc c nng gy suy h
hp cp. Cn nhc c l tnh trng yu c honh, c lin sn, c h hp, c hu
hng trm trng dn ti suy h hp cp, nguy him n tnh mng nu khng
c cp cu kp thi. Cn nhc c nng thng xy ra khi c tng chuyn ho
qu mc, nhim khun hoc iu tr qu nhiu thuc khng men cholinesteraza.
Cc thuc khng men cholinesteraza c tc dng ph lm tng xut tit
ng kh o, bnh nhn nhc c li ho khc km, ng m di gy thiu
xy, lm tin cho cn nhc c nng gy suy h hp cp trc m
(W.C.Edward: 1987).
Hn th na dng liu cao thuc khng men cholinesteraza c th gy cn
cng cholin lm tr cc th cm th tip nhn axetylcholin v lc thuc
khng cn tc dng na. Biu hin ca cn cng cholin ging ht cn nhc c,
bnh nhn nh tnh trng cht ui trn cn, vt v, tm ngt, y m di trong
kh o, trong mi, ming, nu khng cp cu kp thi c th t vong.
Khoa Hi sc cp cu - Bnh vin 103 c 5 bnh nhn t bnh vin khc gi
n do cn nhc c nng gy suy h hp cp. Cc bnh nhn ny c m kh
qun, TKNT (thng kh nhn to) v dng protigmin ti 8 - 10 ng (mi ng

1/2mg)/ngy. Song bnh nhn khng thot khi cn nhc c v bnh nhn c c
cn nhc c ln cn cng cholin. Bnh nhn c ngng thuc khng men
cholinesterza v iu tr theo phc : TKNT + tch b huyt tng + corticoide +
Khng sinh, c 5 bnh nhn u n nh. Sau c 5 bnh nhn c m ct b
tuyn c, sau m din bin bnh thng. Bnh nhn ch nm khoa hi sc 3 - 4
ngy ri chuyn khoa v ra vin.

4.1. Tiu chun chn on lm sng cn nh-c c nng gy suy h

hp cp:
Chn on cn nhc c nng gy suy h hp cp thc cht l chn on suy
h hp cp. Song suy h hp cp ny l suy h hp trn bnh nhn nhc c, va
lit c h hp va c tc nghn ng th do tng tit ng m di nn suy h
hp xy ra rt nhanh v nng, nu khng x tr kp thi s nguy him n tnh
mng. chn on suy h hp cp mc no cn phi xt nghim kh mu,
o PaO2, PaCO2 v.v... Song nhng bnh nhn c cn nhc c nng gy suy h
hp cp thng biu hin lm sng rt trm trng v va suy h hp cp va
nhc c nng, do cn phi c chn on v x tr ngay trc khi c kt qu
xt nghim kh mu. C khi khng kp i kt qu xt nghim phi ht m
di, t ni kh qun cho TKNT ngay. Suy h hp cp do cn nhc c nng gy
ra c mt s c im lm sng nh sau:
- Bnh nhn kh th do nhc c h hp, lng ngc di ng km c 2 th h
hp, v m hi nhiu, nht l trn, mt , tm quanh mi v u chi, vt v,
ging nh hnh nh cht ui trn cn.
- Tng tit m di nhiu, phi ht lin tc 3 n 5 pht 1 ln. Nghe phi: r
ro ph nang gim c 2 bn.
- Dung dch sng (DTS) di 1.000ml.
- Nghim php prostigmin dng tnh. Nghim php dng tnh khi: tim 1
ng prostigmin 1/2 mg vo bp tht, sau 10 - 15 pht bnh nhn d th hn nhng
li ti pht ngay cn nhc c gy kh th, tng tit m di nhiu hn. tr em
dng liu test: 0,04mg/kg trng lng c th.

4.2. iu tr cn nh-c c nng gy suy h hp cp:

iu tr cn nhc c nng gy suy h hp cp phi ton din, va phi iu
tr suy h hp cp va phi iu tr tnh trng nhc c nng, va phi d phng,
iu tr nhim khun, nui dng v cc bin php iu tr tch cc khc.
Do khi bnh nhn c cn nhc c gy suy h hp cp nht thit phi nm
trung tm hi sc cp cu vi nhn vin v bc s c kinh nghim trong vic
iu tr suy h hp v nhc c.
Do vy phc iu tr cn nhc c nng p dng thnh cng trong
nhiu nm qua ti khoa hi sc cp cu - Bnh vin 103 nh sau:
TKNT + loi bt huyt tng + corticoide + khng sinh + nui dng.
4.2.1. Thng kh nhn to:

Khi bnh nhn b suy h hp cp do cn nhc c nng gy ra cn phi ht

sch m di trong ming sau p Mask, bp bng cho n khi bnh nhn
hng tr li, thc tr li, ht vt v lc mi t ni kh qun v cho TKNT
bng my. Thng cho th my vi ch Volum Control tn s 14 - 16
ln/pht; p lc dng ngt qung IPPV hoc PEEP + 5cmH2O; Vt = 10 - 12
ml/kg th trng. c im suy h hp cp trong cn nhc c nng l: mc d
bnh nhn cn c nhp t th song khi lp my th, bnh nhn th theo my
ngay, khng bao gi c nhp th chng my. Bnh nhn nm yn v dng nh l
tho mn vi my th m t cn kn chn loi my th no ngay c my th PO2,
PO5, PO6 cng ph hp v hiu qu.
4.2.2. M kh qun:
Khi bnh nhn phi TKNT qua ng ni kh qun n ngy th 3 m vn cha
t th c th c ch nh m kh qun. M kh qun trn bnh nhn c sn ng
ni kh qun c li l bnh nhn vn c TKNT bng bp bng trong sut thi
gian m kh qun. Vic m kh qun gip cho d ht, d bm ra kh qun do vy
hn ch c ng gy tc m di ng th, hn na qua l m kh qun
c th soi ht bng ng cng hoc ng mm ph qun gc phi tri d dng m
cc bin php ht m khc khng t hiu qu mong mun.
M kh qun cn gim -c khong cht sinh l nn bnh nhn t th d hn, thun li
cho vic "cai" th my. Tuy nhin m kh qun d gy nhim khun ph qun phi.
d phng bnh nhn phi -c ht m di nh k vi catheter cht do, mm, v
khun, ht su vo ph qun gc. Tr-c khi ht, bm 3 - 5 ml dung dch natri
bicarbonat 1,25% hoc HTM 0,9% lm long cc cht tit trong kh ph qun.
c im sau khi ht xong phi bp bng bng tay (ambu) phng chng xp phi.
T.R.Makarenko (1989) cho rng hin t-ng xp phi ny th-ng xut hin nhng
bnh nhn thng kh nhn to n iu bng my ko di v tc gi gp 3 tr-ng hp
xp phi trn 8 bnh nhn phi TKNT.

Hng ngy cn cho bnh nhn nm nghing phi, nghing tri t 3 - 4 ln, v
p vng lng bnh nhn c th t ho khc, d phng bin chng xp phi.
4.2.3. Tch bt huyt tng trong iu tr cn nhc c nng gy suy h hp
cp:
Cho n nay vn t khng th trong bnh nh-c c vn -c y vn th gii bn
lun si ni. Ni n bnh nh-c c khng th khng cp n vn t khng
th. Cc t khng th gy hin t-ng tiu mng sau xinap thn kinh - c, tng tc
thoi ho cc th cm th tip nhn axetylcholin v gy cn tr tc dng ca axetylcholin
vo cc th cm th ny. Ng-i ta tm thy trong huyt thanh ca hn 90% bnh
nhn nh-c c c t khng th khng th cm tip nhn axetylcholin. Do gn vi cc
globulin min dch (IgG1, IgG2, IgG4) nn cc th cm th b km v cht l-ng, gim

v s l-ng, c khi ch cn li 20 - 30%, cui cng gy ri lon dn truyn ti xi-np thn

kinh - c dn n tnh trng nh-c c.

Canada ngay t nm1982 thnh lp nhm nghin cu tch bt huyt

tng (the Canadian a Pheresis Study Group) gi tt l CASG. Ring nm1987,
nhm ny tch bt huyt tng 5.907 ln cho 700 bnh nhn b mc hn 22
bnh khc nhau trong 60% l bnh thn kinh m ch yu l cn nhc c
nng v hi chng Guillain - Barre phi thng kh nhn to t kt qu tt, hin
nay CASG ang tip tc nghin cu tc dng iu tr ca phng php ny.
Cho n nay cc tc gi vn thng nht l dng my tch t bo (cell
separator) tch ring huyt tng v khi hng cu, sau loi b huyt tng
v truyn li khi hng cu cho bnh nhn. Do c kh khn v my, t nm 1987
khoa Hi sc cp cu phi hp vi khoa Huyt hc truyn mu - Bnh vin 103
tm ra phng php n gin, an ton, t tn km m vn t hiu qu iu tr.
Phng php c tin hnh nh sau: ly 300 - 400 ml mu ton phn ca
bnh nhn c cn nhc c nng chng ng bng CPD sau cho ly tm lnh
ri ht loi b huyt tng trong h thng kn v khun, khi hng cu cn li
pha vi huyt thanh mn 0,9% truyn tr cho bnh nhn.
Tch bt huyt tng c lm hng ngy hay cch nht, khi lng huyt
tng tch b trung bnh mt bnh nhn t 20 - 30ml/kg trng lng c th.
Ngay sau khi ly mu tch b huyt tng, bnh nhn c truyn mt lng
huyt thanh ngt 5% tng ng vi lng mu ly ra. Trong t iu tr tch
bt huyt tng, bnh nhn c truyn dung dch m hoc plasma ti. Sau t
iu tr tch bt huyt tng bnh nhn c truyn 250ml mu cng nhm.
Trung bnh mt t iu tr tch bt huyt tng c th lm lin tc 6 - 8 ln,
ti a 10 - 12 ln. Nh c phng php tch bt huyt tng trong phc iu
tr cn nhc c nng gy suy h hp cp rt ngn thi gian th my, ngy
nm vin v nng cao hiu qu iu tr.
4.2.4. Corticoide v cc thuc c ch min dch:
* Corticoide:
Corticoide l mt trong nhng thuc thit yu dng iu tr cc bnh t
min cng nh trong lnh vc ghp c quan. Trong bnh nhc c, corticoide
ng mt vai tr quan trng trong iu tr. Ngoi ra khi ct tuyn c c th dn
ti suy trc di i - tuyn yn - thng thn. Bnh thng s suy gim ny c
c th t b tr, nhng khi tri qua gy m v phu thut mc d khng dng
cura th stress ny cng lm cho trc mt b v thc y cn nhc c kch
pht. Corticoide c s dng iu tr mt b ny rt hiu qu. Chnh v th
khi b cn nhc c nng nht thit phi dng corticoide vi liu cao:
Depersolon 120 - 180mg hoc methyl prednisolon 120 - 160 mg tim tnh
mch chm 1 ln vo bui sng trong ngy, dng lin tc t 6 - 8 ngy sau
gim liu dn v duy tr liu prednisolon 10 - 20 mg ung 1 ln sau n sng.

 hn ch tc dng ph ca corticoide trn ng tiu ho cn cho bnh nhn

ung hoc bm qua ng thng d dy.
Cc thuc bo v nim mc ng tiu ho (maalox, mylanta...) thuc c ch
th th H2 (cimetidine, ranitidin...).
J. Tanaka (1994) ch trng dng corticoide liu cao tn cng (pulse therapy)
500mg tim tnh mch 1 ln/ngy trong 3 ngy iu tr cn nhc c nng t
kt qu tt.
H.Azarnoff (1978) s dng corticoide liu cao trong v ngay sau m cho
32 bnh nhn tui t 14 - 62 trong c 12 bnh nhn b nhc c giai on IIB
v 20 bnh nhn nhc c giai on III. Cc bnh nhn u c dng liu
100mg prednisolon hng ngy trong 1 thng trc m. Trong m tc gi dng
nh sau:
Cho 200mg prednisolon 1 gi trc tin m sau tim 200mg prednisolon
ln th 2 khi m c 1 gi v sau cho 100mg prednisolon ln th 3 v sau c
1 gi li cho 20mg prednisolon t tng liu l 1 gam. Sau m bnh nhn
nm khoa hi sc trung bnh l 20 gi, khng c bnh nhn no b suy h hp
hoc bin chng phi. Thi gian nm vin trung bnh l 6 ngy, khng c bin
chng vt m.
G.Genkins (1987) a ra 10 li khuyn co v s dng corticoide bnh
nhn nh sau:
+ Khi c triu chng ca cn nhc c gy suy h hp cp phi dng liu cao
corticoide.
+ Thuc c c tnh 30% s bnh nhn d iu tr trong thi gian ngn hay di.

+ iu tr corticoide ring l hay phi hp vi tch bt huyt tng hoc vi

azathioprin hay vi thuc khng men cholinesteraza u t hiu qu cao.
+ S dng corticoide t khi lm cho bnh thuyn gim vnh vin.
+ Khi c cn nhc c nng trc hoc sau m th s dng corticoide bng
ng tnh mch rt c hiu qu. i khi tht bi th phi phi hp vi cc bin
php iu tr khc.
+ Nhng bnh nhn s dng corticoide ko di c th lm tng yu c do
xut hin bnh c do corticoide.
+ iu tr corticoide trc m ko di c th lm bnh nng ln trong m
hoc sau m.
+ S dng phi hp corticoide vi gama globulin c th lm gim liu
corticoide m vn t kt qu tt ng thi gim c c tnh ca corticoide.
+ Trong hi sc cn nhc c nng sau m c th dng corticoide ring l
hoc phi hp vi tch bt huyt tng t kt qu tt.
+ Cha c biu hin r rng v tnh u vit ca mt loi corticoide no.
* Azathiopin:
Azathiopin c tc dng u th vi t bo T v tc dng ny vi bnh nhc c
l lm gim sn xut khng th khng th cm th axetylcholin. Thuc c

dng trn bnh nhn nhc c khi corticoide b chng ch nh, hoc khi bnh
nhn km p ng cvi corticoide hoc vi mc ch gim liu corticoide.
Azathiopin l thuc c ch min dch rt sm iu tr bnh nhc c t
nhng nm 70. Tuy nhin thuc cng c hn ch do tc dng ph ca thuc nh:
st, bun phin, au c, gim bch cu. Ngoi ra tc dng iu tr ca thuc lc
u rt chm i hi phi hng thng, c khi ti 1 nm mi c kt qu, cho nn
khi c cn nhc c thuc t tc dng tc th.
* Cyclosporin A:
Cyclosporin A (sandimmum, neoral) l loi thuc c ch min dch mnh,
ln u tin c s dng (1980) iu tr bnh nhc c trn thc nghim v
ngy nay c s dng trn lm sng. Cyclosporin A c ch sn xut
interleukin - 2 ca t bo T h tr (T helper), tc dng ca cyclosporin A cng
tng t nh azathiopin, nhng nhanh hn, thng s dng trong vng 1 - 2
thng. Tc dng ph ca thuc gy c vi thn v gy tng huyt p. Khi s
dng phi theo di cht ch, nh lng nng thuc trong huyt thanh bnh
nhn v duy tr nng ti thiu t hiu qu iu tr t 100 - 200 nanogam/ml.
* Globulin min dch:
Cho n nay ngi ta vn cha bit c ch tc dng ca globulin min dch
song ngi ta ch bit l thuc khng tc dng trn s lng khng th khng th
cm th axetylcholin. Ch nh iu tr globulin min dch cng ging nh ch
nh tch bt huyt tng. Thuc lm ci thin nhanh chng tnh trng bnh, nht
l bnh giai on nng, cng nh khi c cn nhc c xy ra. Liu s dng
glubulin min dch l 400mg/kg/ngy v dng trong 5 ngy. Sau khi tim
globulin min dch lm ci thin bnh l 73% v thng t ngy th 3 tr
i, tc dng ca thuc l tm thi nhng c th dng thuc ko di hng thng
hoc dng xen k trong qu trnh bnh nhc c nng dai dng. Thuc c tc
dng ph xy ra di 10%: au u, dch, cng c khi gy suy thn. Tuy nhin
thuc rt t nn cn t c s dng.
4.2.5. Khng sinh v d phng nhim khun.
G.Genkin S (1987), D.B.Drachman (1994): a ra kin rt quan trng l:
nhim khun nh c th thc y cn nhc c ln, hn na bnh nhn li phi
dng corticoide ko di, thm ch liu cao bnh nhn c cn nhc c nng suy
h hp, phi m kh qun, th my li cng c nguy c nhim khun nht l
nhim khun phi ph qun bnh vin. Do d phng nhim khun l rt quan
trng, bnh nhn phi c nm bung ring, st khun khng kh bung bnh
bng tia cc tm, nu c th th qun o, vi tri ging c hp tit trng. Nhn
vin y t tun th nghim ngt quy tc v khun, trnh ly cho. Cc thao tc ht,
chm sc bnh nhn phi m bo v khun nh: eo khu trang, ra tay trc
khi ht, dng dng c v khun khng c dng tay cm dy ht.v.v... Mi
bnh nhn c b ht ring, b ht gm 3 l trong l 2 ng thuc st khun
(cidex 2%, rivanol 1% hoc furacillin 1%) cn l 1 v 3 ng HTM 0,9%. Khi
ht xong dy ht phi c ngm vo l 2 - thuc st khun, trc khi ht cho
bnh nhn, phi ht qua l th 3 HTM 0,9%. Phi thay dy ht 2 - 3 ln trong

ngy. Hin nay c b dy ht kn o m bo v khun m 1 - 2 ngy mi

phi thay dy ht 1 ln. Thay nng trong Krishaberg 1 -2 ln/ngy, thay c
Krishaberg hoc ng Shoberg hng ngy.
Vic s dng khng sinh cho bnh nhn c cn nhc c l bt buc, thng
cho bnh nhn khng sinh nhm cephalosporin th h th 3 khong 2g/24 gi v
tu theo khng sinh m s dng cho hp l.
Cc thuc gy tng cn nhc c v c tc dng gn ging cura (cura like)
cn chng ch nh l:
- Khng sinh: nhm aminoglucoside (kanamicin, gentamicin, streptomycin,
netromycin), lincocin, clindamycin, colistin, polymycin B, neomicin, tobramycin,
trimethoprim, sulfamethoxazole.
- Thuc gin c, bloc thn kinh c, succinylcholin, norcuron (vecuronium),
pavulon (pancuronium), tracrium, benzodiazepim, cura, flaxedil.
- Thuc chng lon nhp, cao huyt p: lidocain, quinidine, procainamide,
beta - blockers, calxium - blockers.
- Chng tm thn: lithium, phenothiazine, thuc chng trm cm (anti
depressan).
- Thuc nhm opi, khng histamin, khng cholinergic.
4.2.6. Nui dng v iu tr ton din:
Bnh nhn nhc c thng n ung km trong mt thi gian di do khng n
c v khng n , vic nui dng qua ng thng d dy thng kh m
bo, do nn nui dng bnh nhn bng 2 ng: ng tnh mch v ng
tiu ho m bo 40 - 50 Kcall/1kg cn nng/24h. Thc n ng tiu ho c
th dng vivonex - ten, ensure song cn ch pha cho ng, m bo 1ml sa c
1Kcalo, trnh pha c thm thu cao gy a lng v ch khng dng nc
si m dng nc m (khong 400C) khng gy ph hy protein trong sn
phm nui dng. Trong nui dng ng tnh mch cn cho liu protein 1,2 1,5g/1kg/24h vi tc 0,1g/1kg/1h nh git tnh mch, nh vy 1 chai m 50g
Protein s nh git khong 10 gi cho bnh nhn khong 50kg. Dung dch lipid
(lipofundin, intralipid...) cng vi liu 1g cho 1kg/24h v tc l 0,1g/kg/1h.
c im ca cn nh-c c nng ch yu l nh-c c h hp gy suy h cp cp
cn a s cc c t chi vn t-ng i bnh th-ng nn bnh nhn vn co chn tay
-c, thm ch c th t ht m di trong ming, do cc bnh nhn ny
th-ng t b lot im t, tuy nhin c th cho bnh nhn nm m n-c, thay
i t- th ngy 2 - 3 ln, v p vng l-ng trnh ng gy vim phi, xoa bp l
liu php trnh vim tc tnh mch. Hng ngy lau ng-i t 1 - 2 ln nht l v sinh
rng ming, mi, b phn sinh dc... gp phn iu tr ton din cho bnh nhn.

Bnh nhc c ni chung, cn nhc c nng gy suy h hp cp ni ring

cn phi c iu tr ng phng php cng phu v kin tr mi c th tr bnh
nhn v vi cuc sng bnh thng.

Tch huyt tng (PLASMAPHERESIS)

Tt C-ng
1. Lch s.
u th k XX khi cha tm ra cht chng ng thch hp, phng php tr
mu thng dng l ly mu ri loi b fibrin (defibrinated blood) do Fleig
xng (1902). Phng thc ly mu ny gy nguy him cho ngi nhn mu v
mu thu c gm hng cu, huyt thanh v nhiu loi t bo do k thut tch
fibrin gy ra. trnh nguy c ny, Hendon (1902) thc nghim ly mt lng
mu th theo phng php trn sau tch b huyt tng, truyn tr li khi
hng cu cho chnh th v th hi phc hon ton. Trong thc nghim ny
Hendon ln u tin s dng phng php tch huyt tng (THT) v nhng con
th thc nghim ch mt huyt tng m khng mt hng cu.
Nm 1910, Fleig dng phng php tch huyt tng loi b nhng c t
lu hnh trong huyt tng bnh nhn suy thn tng u r mu v lm ci thin
tm thi tnh trng lm sng ca bnh ny.
Nm 1914, Abel v cng s lp li ph-ng php ny trn ng-i v ln u tin thut ng
plasmapheresis ra i ch ph-ng php ly b huyt t-ng v truyn tr li khi
hng cu cho ng-i cho (donor). Song trong nhiu nm ph-ng php ny b lng qun do
kh khn v k thut v ch-a tm -c mc ch s dng.

Trong vng 20 nm gn y nht l vo nhng nm ca thp k 80, phng

php ny c pht trin mnh m.
Nm 1978, Pressel, Petets (Bnh vin Necker - Paris) s dng phng php
THT iu tr cho 44 bnh nhn b thn mn, lupus ban t kt qu tt.
Nm 1981, Hugon, Gabky dng phng php tch bt huyt tng iu tr
cn nhim c thyroxin kch pht trong bnh Basedow.
Nm 1970, Penching cng b 94 trng hp tch bt huyt tng loi b
t khng th trong iu tr bnh nhc c.
Marcelo, R. olarte, Richard, Lewis Columbia tin hnh 350 ln tch bt
cho 21 bnh nhn nhc c t nm 1978 n nm 1980 t kt qu tt.
Nm 1986, Thorlacius, Lefvert v cng s trng i hc Bergon Norway
tin hnh i huyt tng (plasma exchange) cho 6 bnh nhn b nhc c v
sau 1 tun iu tr bnh nhn ci thin r rt v triu chng lm sng.

Nm 1988, cc tc gi Nht Bn: Jgoichi, Noda; tc gi Trung Quc: Guixs. YE cng cng
b thnh cng trong iu tr bnh nh-c c bng loi b huyt t-ng.

T nm 1987, ti Bnh vin 103, khoa Hi sc phi hp cng khoa Truyn mu, khoa
Phu thut lng ngc, ln u tin trong n-c p dng ph-ng php tch huyt t-ng
v i huyt t-ng iu tr bnh nh-c c, c bit cn nh-c c nng gy
suy h hp t kt qu rt tt (99% bnh nhn thot khi cn nh-c c t th bnh
th-ng).

T nm 1994, Drachman bo co kt qu rt tt ca phng php tch bt

huyt tng iu tr cn nhc c nng.
Thng 2/2001, Stegmayr .B. khoa thn bnh vin Umea - Thy in
dng phng php chuyn i huyt tng iu tr cho 100 bnh nhn c
chng suy a tng (MODS) nhim khun nng km theo suy thn cp t t l
sng st 66%, so vi nhm chng ch t 44%. c bit iu tr cho 56 bnh
nhn b sc nhim khun nng t l sng st l 80%.
2. Ph-ng php v k thut.
Theo nh ngha ca T chc y t Th Gii tch huyt tng l th thut
ly mu an ton phn ca ngi cho hoc ngi bnh v tch ring thnh phn
ca mu theo phng php lin tc hoc gin on. K thut ny i hi phi
truyn tr li khi hng cu cho ngi cho huyt tng hoc ngi bnh.

2.1. Ph-ng php:

C 2 phng php tch hay b huyt tng (plasmapheresis) v i huyt
tng (plasma exchange):
+ Tch huyt tng (THT) l phng php ly mt lng huyt tng di
500ml v tr li khi hng cu cho bnh nhn.
+ i huyt tng (HT) l phng php tch huyt tng, song s lng
huyt tng ly b ln hn 500ml v bnh nhn c b xung lng huyt tng
ly i bng dung dch protein hoc plasma ti tng ng.

2.2. K thut:
C 3 k thut tch huyt tng :
+ K thut 1: Ly mu cho vo ti cht do hoc cho vo chai cha ACD
hoc CPD sau ly tm bng my ly tm. Sau ht b huyt tng v truyn
tr khi hng cu cho ngi bnh, phng php ny l thuc vo thi gian ly tm
hoc lng. ngi Vit Nam s lng mu ton phn ly ra ch di 500ml.
+ K thut 2: Tch huyt tng bng my tch t bo (cell separetor). My c
th tch ring huyt tng, hng cu, bch cu , tiu cu qua h thng t ng.
Huyt tng c tch ring v loi b, cc thnh phn khc c truyn li cho

ngi bnh. Phng php ny c th tch 500 ml huyt tng trong 32 pht
(Rork: 1980).
K thut 3: Tch huyt tng bng phng php siu lc (hemofiltration
plasmapheresis).
S dng mng siu lc ch cho huyt tng i qua v gi cc t bo li.
Phng php ny do Hael v cng s xut nm 1983 v mt gi tch c 500
ml huyt tng.
nhng c s khng c mng siu lc, khng c my tch t bo v cng
khng c my ly tm lnh c th dng phng php sau:
Ly mu tng bnh nhn, c th ly mu ton phn t 350 ml n 500ml cho
vo chai cha ACD hoc CPD sau lc nh, cho vo t lnh 4oC hoc 6 oC, sau
4-5 gi khi khi hng cu lng ht, ht v khun ht s khi lng huyt
tng, cho huyt thanh mn 9%o tng ng khi lng huyt tng ly i v
truyn tr li cho bnh nhn.
Phng php ny tin hnh ngy1/ln hoc 2 ngy 1/ln. C th tin hnh t 4
n 20 ln tch huyt tng tu mc ch v ch nh iu tr.
Sau 4 - 5 ln loi bt huyt tng c th truyn thm 150ml mu ton phn
cng nhm cho bnh nhn.
3. Ch nh.
Phng php tch huyt tng c ch nh chnh sau:
+ Bnh l thn kinh:
- Nhc c (Myasthenia gravis).
- Vim a r thn kinh (Guillain - Barre).
- Cc bnh l thn kinh khc.
+ Bnh v mu:
- Leucose.
- Hemophyllia.
+ Bnh thp khp v mch mu:
- Lupus ban .
- Hi chng Raynaud.
- Bnh Schoenlein Henoch.
- Vim a khp v bnh khp khc.
+ Bnh l tn thng gan (hepatic failure):
+ Nhim c.
+ Bnh chuyn ho v ni tit:
- Tng cholesteron mu.

- Cn nhim c thyroxin kch pht.

+ Ung th.
+ Bnh suy thn mn.
+ Loi thi sau ghp thn.
+ Nhim khun mu, sc nhim khun.
+ Hi chng suy a tng.
4. Nhng thay i trong qu trnh iu tr bng tch huyt t-ng.
Mi ln tch huyt t-ng ly ra khong 400 ml n 500 ml mu ton phn, khi
ch-a kp truyn tr khi hng cu th vic ly mu nh- trn c nguy hi g
khng?

4.1. Huyt ng:

Loutit v cng s, Ganrilov v cng s (1982) thy: vic ly di 500 ml mu
khng gy thay i no v huyt ng mc d khng truyn tr li bt k dung
dch g. Trong nhng bnh nhn ca Bnh vin 103 tin hnh cng khng thy
thay i g v huyt ng, k c bnh nhn ang thng kh phi nhn to bng
my th. Ch s huyt p v mch khng thay i g gia trc, trong v sau khi
ly mu tch huyt tng.
Trong trng hp ly mu di 500 ml th c th phn ng b tr tc th.
Dch t khoang ngoi bo chuyn vo mch mu vi tc 40 ml n 100 ml
mt gi (Genetet: 1978) hoc 150 ml mt gi (Moore: 1967). Bnh thng c
28% n 30% lng nc ton b c th nm ngoi t bo. Trong ch c 8%
n 10% nm trong lng mch. Do phn ng ca c th s p ng bng tng
tc dch chuyn s lng dch t khong k vo lng mch ln ti 1500 ml.
Mt s biu hin c th gp khi ly mu ton phn nh: chng mt, nhc u,
cc biu hin ny thong qua khng gy nguy hi g cho ngi bnh.
Khi truyn li khi hng cu c cho thm huyt thanh mn 9%o cng c th gy nn
phn ng vi dung dch ny. H. Horberg (1981) trong 205 ln tch huyt t-ng iu
tr gp 27 tr-ng hp (13%) bin chng trong phn ng d ng gp 1 (0,48%), try
tim mch 3 (1,46%), rt run 18 (8,78%), h canxi mu 3 (1,46%), st 2 (0,97%). V vy tc
gi khuyn nu hematocit ca bnh nhn d-i 30% th ch -c tch mt l-ng huyt
t-ng khng qu 300 ml . Khi thi tit lnh c th lm m mu truyn li (ti 36-37oC)
trnh hin t-ng rt run. Cn khi xy ra phn ng dung dch mn 9%o th x tr nhsc huyt thanh thng th-ng.

4.2. T bo:
S lng bch cu v tiu cu t b nh hng bi tch huyt tng. Kliman
v cng s (1964) thy tiu cu c mt trong huyt tng c tch ra, nhng s
lng tiu cu ch gim khi tch lng ln huyt tng (tch ti 5lt huyt tng
giu tiu cu trong 1 tun). Song ngay c trong trng hp ny th tiu cu cng
tr li gi tr bnh thng sau 3 ngy.

4.3. Protein ton phn v albumin:

Vn t ra trong tch huyt tng l mt protein. Nu mi ln tch 500 ml
huyt tng s mt i 30 n 40 gram protein. Ngay trong thi gian tin hnh
tch huyt tng th 30% lng protein b ly i s c b xung t d tr ngoi
lng mch.
Kliman (1964) nghin cu ngi cho huyt tng thy: ngi cho 1000 ml
huyt tng mt ngy, trong 5 ngy lin khong 5lt, trong 1tun s c nng
proteine huyt thanh gim khong 10 gram trong 1lt v tr li gi tr ban u sau
2 n 4 tun. Do tc gi khuyn khng nn ly qu 750 ml huyt tng/ trong
1ngy ng vi vic mt 40 n 50 gram protein.
Lng albumin lu hnh chim 40% albumin ton b c th. Bi vy khi
gim albumin trong lng mch s c b tr t d tr ngoi lng mch v tng
tng hp albumin. Bnh thng d ho albumin vi tc 0,2 gram trn 1kg th
trng trong mt ngy tc l khong 10 gram trong mt ngy. Sau mt ln tch
500 ml huyt tng mt 15 n 20 gram albumin . Lng albumin ny c b
mt phn ngay trong 24 gi u t khoang ngoi mch v c th s tng tng hp
albumin vi tc 0,3 gram cho 1kg trng lng c th trong mt ngy sau 3
n 4 ngy hi phc hon ton lng albumin mt.
Schultze v Hereman (1966) thy tc tng hp albumin tng 12gram trong mt ngy
cn bng vi vic mt albumin 30 gram trong 1 tun. Nu tch huyt t-ng 1 lt trong 1
tun , c th s tng hp 50% l-ng albumin duy tr cn bng v nng albumin
huyt thanh lun trong gii hn bnh th-ng (Hansen: 1977).

4.4. Yu t min dch:

IgG trong lng mch chim 42% n 44% tng lng IgG ton th. Thi gian
bn hu l 23 ngy, t l d ho 7% n 8%, ng vi 2 gram IgG trong mt ngy.
Tch huyt tng 4-5 lt lm gim nng IgG cn 35% so vi gi tr ban u
(Keller va urbamark 1978). ngi cho 1000 ml huyt tng trong 5 ngy lin
thy nng protein huyt thanh hi phc sau 2-4 tun, nhng nng IgG cha
hi phc hon ton sau 4 n 13 tun.
IgM trong lng mch chim 80% tng lng IgM ca c th, d ho hng
ngy 15 n 18% (Brown v Cooper: 1975), v vy nng IgM thng gim
thp v chm phc hi.Tuy nhin cc gi tr lun gii hn bnh thng.

IgA ch c 49% trong lng mch v t l d ho hng ngy ln ti 33%

(Tomassi: 1965), v vy t xy ra gim nng IgA trong tch huyt tng.

4.5. Cc yu t ng mu:
Hu ht cc yu t ng mu u c i sng ngn v khi phc hon ton,
nhanh chng sau tch huyt tng. Flaum (1979) thy nhng ngi chuyn i
4lt huyt tng trong mt gi th c nng yu t V, VII, VIII, IX, X,
fibrinogen v cc XN ng mu (thi gian prothrombin, thi gian thromboplastin,
thi gian thrombin.. .) u trong gii hn bnh thng v tr v gi tr ban u
trong 24 gi sau .
5. Mt s phc iu tr bng ph-ng php tch huyt t-ng.

5.1. iu tr suy thn mn:

Deten, Pussel v cng s (1978) tch 4 lt huyt t-ng cch nht v truyn tr li
albumin do trung tm quc t sn xut, bnh nhn -c phi hp iu tr vi
prednisolon 60 mg trong mt ngy + cyclophosphamit 3mg/kg/ ngy + azathioprin
1mg/kg/ngy . Vi phc trn tc gi t kt qu tt vi 24 bnh nhn b bnh
thn vi bnh khng th chng mng y (anti membran basale glomerulaire), 20
bnh nhn b vim cu thn v 6 bnh nhn b luput ban ri rc.

5.2. iu tr cn nhim c thyroxin kch pht:

Nm 1981, a. Gabky, Hugon, Martis v cng s cng b dng phng php
tch huyt tng iu tr cn cng gip cho bnh nhn basedow sau m, mc
d trc bnh nhn c iu tr bng thuc c ch beta 80 mg/ngy, benzin thiuracil 300 mg/ngy, lugol 60 git/ngy, hydrocortison 600 mg/ngy khng kt
qu. Bnh nhn c tch 4 lt huyt tng trong 5 gi v b li bng albumin
4%. Bnh nhn tr li bnh thng, xt nghim thy T4 t 189 nanomol/ml gim
xung cn 49 nanomol/ml sau khi tch huyt tng.

5.3. iu tr bnh nhn nh-c c:

+ T nm 1970, ngi ta pht hin vic ly b t khng th iu tr
bnh, l khng th chng th cm th acetylcholin. Penching cng b 94
trng hp tch huyt tng iu tr bnh nhc c. Marcedo, R.loarte,
Richord t nm 1978 n nm 1980 tin hnh 350 ln tch huyt tng cho 21
bnh nhn nhc c vi ch nh sau:
- Cn nhc c kch pht.
- Chun b trc m.
- Nhc c phi dng thuc min dch v cocticoit lu ngy liu cao vi mc
ch gim liu thuc.

+ i vi bnh nhn nhc c c th dng tch huyt tng theo phc sau:
- Tch hoc i huyt tng n thun.
- Tch huyt tng + cocticoit.
+ Vi nhng bnh nhn c cn nhc c nng gy suy h hp th p dng
phc sau:
Tch huyt tng + cocticoit + th my + khng sinh + iu tr tch cc
Cocticoit c th dng: depersolon 120 mg - 150 mg trong 24 gi hoc methyl
prednisolon 120mg - 160 mg/ 24 gi.