Benh Hoc Noi Khoa

enh hoc noi khoa Jo Joai 7am
1

Ioi noi daa
)aat hat ta nha caa can tai /iea de hoc tot mon 7oi chanq toi coq danh
maq /ai cac /ai ome+oint + handoat caa cac thaq cac co caa o mon 7oi J
V0 )) Jw )ai /iea naq ch nham mac dich hoc ta hi thaonq mai Iaa
hanh noi /o
)ham qia /ien oan
Jo Joai 7am
Iam oi Jq
Ja )hi Jai aonq
0a Ie winh
7qaqen 0an Jien
o winh hi
Muc luc: Trang
1. Bach cau cap..............................................................................................3
2. Bach cau man dong tuy.............................................................................6
3. Lymphoma..................................................................................................8
4. Bach cau man dong Lympho...................................................................12
5. Suy tuy......................................................................................................14
6. Benh huyet sac to ...................................................................................17
7. Ch nh truyen mau ................................................................................22
8. Tai bien truyen mau.................................................................................26
9. Choang......................................................................................................32
10. Tang huyet ap..........................................................................................47
11. Tam phe man...........................................................................................51
12. Viem noi tam mac nhiem trung..............................................................55
13. Viem mang ngoai tim..............................................................................60
14. X tr phu phoi cap..................................................................................65
15. Thieu mau c tim.....................................................................................70
16. COPD.......................................................................................................77
17. K phoi.......................................................................................................84
18. Hen phe quan...........................................................................................92
19. Suy than cap ..........................................................................................109
20. Suy than man.........................................................................................114
21. Nhiem trung tieu ...................................................................................121
22. Chan oan x gan..................................................................................133
23. Helicobacter Pylori................................................................................138
24. Chan oan viem ai trang man ............................................................142
25. Viem gan................................................................................................153
26. Ngo oc Phospho hu c.......................................................................158

2

HUYET HOC

HUYET HOC

3

BENH BACH CAU CAP
"5 C5 5x,ae %qC "a "a

/ // /.\ I\ I||.\ | /.\ |/ |

////\/ \//
enh /ach caa ac tinh {Ieakemia) /a 1 /enh e maa co a tanq inh qaa do caa
te /ao maa chaa han hoa hoac han hoa kem dan toi ta onq mot cach nhanh
chonq nea kho nq die a t+i haa hiea

TE BAD MAU GDC A NANG
TE BAD MAU GDC
CUA CAC DDNG TB MAU CDN
TE BAD MAU GDC
CUA DDNG LYMPHD
TB TIEN THAN CUA
DDNG BC THE TUY &
DDNG BC DN NHAN
TIEN NGUYEN
HDNG CAU
NGUYEN MAU
TIEU CAU
HDNG CAU

TIEU CAU
NGUYEN BAD
LYMPHD

TIEN LYMPHD
BAD

LYMPHD BAD

Tb T & Tb B

NGUYEN
BC DN
NHAN

TIEN BC
DN NHAN

BC DN
NHAN

NGUYEN
TUY BAD

TIEN TUY
BAD

TUY BAD

HAU TUY
BAD

4

/// |/\ /./ |/\/ /.
Phan loai FAB :
Bach cau cap nguyen bao limpho (ALL) ky hieu la L, gom 3 loai :
L1 : te bao ac tnh nguyen bao limpho nho ong dang.
L2 : te bao ac tnh : te bao nguyen bao, limpho trng thanh, to hn, a dang.
L3 : te bao giong te bao Burkitt.
Dong te bao limpho nhuom PAS (+)

Bach cau cap khong lien quan en dong nguyen bao limpho : ky hieu la M (dong
tuy)
Mo : Bach cau cha biet hoa
M1 : Nguyen tuy bao cha trng thanh
M2 : Nguyen tuy bao a trng thanh
M3 : Tien tuy bao
M4 : hon hp nguyen tuy bao + nguyen bach cau n nhan
M5 : Nguyen bach cau n nhan
M6 : Nguyen tuy bao va tien nguyen hong cau
M7 : Nguyen tuy bao va nguyen mau tieu cau.
Te bao dong tuy nhuom sudan Black (+)

/! \|/\ \/\
ho den naq an chaa /iet nqaqen nhan chinh rac
ea tc tbaaa /c|:
- Nhiem phong xa
- Nhiem hoa chat benzen, thuoc ieu tr ung th, thuoc diet sau ray.
- Roi loan nhiem sac the : Benh Down t le benh bach cau cap cao gap 20 lan so
vi bnh thng. Roi loan nhiem sac the (14, 18)
- Nhiem sieu vi nhat la RNA virus - HTLV1
! I|//| /|\ / \
Rat thaq doi Bach cau cap dong limpho va Bach cau cap dong tuy co nhieu
trieu chng tng t nhau.
Benh co the khi phat ot ngot vi sot cao, thieu mau, xuat huyet hoac co the
xay ra t t vi trieu chng thieu mau, sot nhe, chay mau chan rang , l mieng.
Thieu mau : xuat hien t t va nang dan len.
Sot la trieu chng thng gap nhat vi bieu hien tat ca kieu sot. Rat co the
co kem 1 o nhiem trung rang mieng, l loet mieng, nu rang.
Xuat huyet : Thng la xuat huyet da - niem, oi khi co xuat huyet nao, mang
nao, phoi.
Bien oi he vong noi mo :

5

Hach to, hach kch thc trung bnh, oi xng, di ong, khong day, phan ln
la hach ngoai bien co, hay toan than.
Gan co the to.
Lach to.
au nhc xng khp.
Tham nhiem he than kinh trung ng. Benh nhan co the nhc au, oi, loi mat,
mu, yeu liet chi, ton thng than kinh so.
Tham nhiem u bu vao da, mat, xng
!/ \ / \
ha qea /a conq thac maa a taq do
Cong thc mau
Ib|ea maa ang sac, ang bao do giam san xuat.
6|am t|ea caa
0acb caa co the bnh thng, co the giam va co the tang
Co the tm thay bacb caa ac t|ab trong phet mau ngoai bien
Tuy o
Ibacaq qaa saa te bac
va te bac ac t|ab taaq ttea 30%
Acid uric mau tang cao do huy nhieu te bao ac tnh.
Nhiem sac the : 90% thay co bat thng nhiem sac the vi nhieu loai khac nhau
!/// /\ /.\
Chan oan xac nh :
Da vao benh canh lam sang
Can lam sang : Cong thc mau
Tuy o : Blast/tuy ln hn 30%.
Chan oan phan biet :
Phan ng gia bach cau : tang bach cau gia va trng thanh do tnh trang nhiem
trung tuy b kch ong manh.
Qua trnh phuc hoi sau suy tuy th thay co tang sinh bach cau au dong.
/' |//\ /|\
Neu khong ieu tr benh nhan se chet trong 1-3 thang v cac bien chng.
Xuat huyet nang : nao, ng tieu hoa.
tre bach cau nao, phoi.
Nhiem trung, choang nhiem trung
Suy kiet
' /| I. I//\ /|.\
Tuoi cang cao tien lng cang xau
So lng bach cau : cang tang cang xau
Dong tuy tien lng xau hn dong limpho
6

Roi loan nhiem sac the cac roi loan kieu t (9 ; 22) (-5 , -7) co the tien lng xau.
So c quan b ton thng cang nhieu th tien lng cang nang.

B
B
A
A
C
C
H
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C
C
A
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U
U
M
M
A
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N
N

(
(
C
C
H
H
R
R
O
O
N
N
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C
L
L
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K
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M
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C C5 5 5 5x x, ,a a e e % %q qC C " " a a " " a a
/ //\/ \//
enh /ach caa man /a
wot /enh /q ac tinh e maa
)anq inh qaa do caa /ach caa da han hoa nhiea
ien tien toi ta onq n nh ha an nq q c ch ha a m m h ho on n / /e e n nh h / /a a c ch h c ca a a a c ca a
// |/\ /./ |/\/ /.
o o m m 3 3 / /o oa a i i c ch hi in nh h
o Benh bach cau man dong tuy (chronic myeloid leukemia :CML ) Thng gap
VN.
o Benh bach cau man dong lympho (chronic lymphoid leukemia CLL)- Phng tay.
o Benh bach cau man dong bach cau n nhan
(chronic myelomonocytic leukemia CMML ) Hiem gap
/// \|/\ \/\
hinh rac chaa +o
e e a a t to o t th ha aa a n n / /o o i i
o Tia xa
o Bom nguyen t
o Roi loan nhiem sac the
o Yeu to gia nh: CLL tang gap 16 lan neu trong gia nh co ngi mac benh
nay
/! |/\/ |/ | \ /.\ I|
Dien tien qua 2 giai oan :
o Giai oan kinh nien
o Giai oan chuyen cap

6) iai doan kinh nien
1. Lam sang
- Khi phat am tham
- Met moi, da hi xanh , an khong ngon , nang ha sn trai
- Lach to o 3 , o 4.
7

2. Can lam sang
)w
-hcaq caa: bnh thng hoac giam nhe. Thieu mau ang sac ang bao
0acb caa tang rat cao t 100.000 -500.000/mm
3
hien dien ay u cac giai oan
cua BC hat ( phet mau nh phet tuy) chan oan xac nh.
I|ea caa bnh thng hoac tang
)aq do
Tuy rat giau te bao.
Co ay u tat ca cac giai oan cua BC dong tuy.
Dong hong cau bnh thng
Dong tieu cau tang
Nhiem sac the: Co NST Philadelphia (Ph) NST 22 bat thng .T(9,22), lam
NST 22 ngan lai.Cho noisinh ra 1 gen sinh ung th (ABL BCR). 90% Bn
co NST Ph : Tien lng tot

3. Chan oan
o Lach to
o CTM : Bc tang cao , co ay u cac giai oan cua dong tuy
o Tuy rat giau te bao
o Co NST Ph
o Keo dai t 2- 4 nam

) iai doan chaqen ca
Sot khong giai thch c, sut can , au khp
Gan to
Thieu mau
Xuat huyet (do giam TC)
Khong ap ng vi thuoc ieu tr trc ay
CTM :HC giam nang, BC tang cao , TC giam
Tuy o: nguyen tuy bao + tien tuy bao >25%

) ien tien a tien /aonq
BN thng song t 2 4 nam, ty le song con sau 5 nam la 52-63%
BN t vong do benh chuyen cap
Hau het cac BN eu chuyen qua giai oan chuyen cap. Bieu hien :thieu mau ,
lach to khong ieu tr c, tuy o nh mot bach cau cap.
NST Ph van ton tai trong giai oan chuyen cap va xuat hien them nhieu Roi
loan NST nh 3nst 8 ( trisomie 8 ), 3nst 19, 1nst 17

8

) iea t+i
iai doan kinh nien
1.Hydroxyurea(hydrea) Vien 500mg.
- c che tong hp AND giam sinh san BC+ cac TB khac (da niem).
-
Lieu t 1-6 g /ngay tuy theo so lng bach cau. ieu chnh sao cho Bc t
10.000-20.000. Ngng thuoc khi BC <5000 m
3 .
- Hydroxyurea khong lam thay oi ty le NST Ph
-
Theo doi CTM / w.

- Phu: l loet da niem sau 1 tg s dung
2. Interferon (Roferon )
- Lieu 5.000.000 v TDD x 3 ngay trong tuan . Dung trong 1 nam
- Interferon lam giam ty le NST Ph. . Interferon keo dai them 3 nam . Nhng BN
mat NST Ph co i song dai nhat .
3. Gleevec : c che phc hp ABL-BCR qua c che c che men ATP cua phc hp
nay.
Lieu :400mg -800mg /ngay .
Dung t 3-9 thang
4.Ghep tuy:
- BN <55 tuoi
- c thc hien trong giai oan kinh nien.
- Trong vong 1 nam ke t ngay chan oan .
iai doan chaqen ca
- ieu tr nh bach cau cap
- -Hoa tr Aracytine lieu cao:Aracytine 3g/m
2
moi 12 gi x 10 ngay

L
L
I
I
M
M
P
P
H
H
O
O
M
M
(
(
L
L
Y
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M
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P
P
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M
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A
)
)
C5 5x,ae %qC "a "a
/ //\/ \//
Iqmhoma /a danh ta de ch cac /enh /q ac tinh co nqaon qoc ta te /ao
/qmho
? naq co the raat hat ta hach /ach haqet hoac cac mo /ach haqet o +aot
/ach amqqda/e hoac ta /at ca co qaan nao
// |/\ /./ |/\/ /.
Gom 2 nhom
o Benh Hodgkin
o Limphoma khong Hodgkin
lympho T, limpho B
9

/// \|/\ \/\
Virus Epstein Barr
Virus HTL V1
Vi khuan Helicobacter pylori
Dung thuoc c che mien dch
Tia xa
Hoa tr ung th
Roi loan nhiem sac the t(8,22), 14q marker
/! / \
1 Joi cha nq hach to
o Hach co the xuat hien bat c ni nao trong c the
o Hach to ,luc au rieng le, sau thanh am, mat o chac ,t di ong
o Hach khong oi xng
2)haq doi tonq t+anq
o Sot cao, khong lien tuc , hoac sot co chu ky(Sot Pel-Epstein)
o o mo hoi ve em
o Xanh xao
o Sut can (>10% trong lng c the trong vong 6 thang)
o Nga thng gap trong benh Hodgkin
3ac thaq doi khac t+onq co the
o au nhc xng
o Gan to, lach to
o Tran dch mang phoi
o Ton thng da:noi man o , cham.
oi khi /enh nhan ch co 1 khoi a /at kq t+onq co the inh thiet moi chan doan daoc
Iqmhoma
! \ / \
1 inh thet la xet nghiem quan trong nhat
Ket qua GPBL:
- Hodgkin
- Lymphoma khong Hodgkin
)han /oai /enh Jodqkin theo R{

wo hoc )an raat {%)
)q 1 Iqmho /ao chiem aa the
)q 2 anq ro not
)q 3 Jon ho te /ao
)q 7qheo /qmho /ao
5 - 10%
30 - 60%
20 - 0%
5 - 10%
10

)han /oai /qmhoma theo WF
o ac tnh thap:
Limphom lympho bao nho
Dang nang te bao nho co kha
Dang nang loai hon hp te bao nho co kha va te bao ln
o ac tnh trung gian :
Dang nang loai te bao to
Dang lan toa loai te bao nho co kha
Dang lan toa loai hon hp te bao ln te bao nho
Dang lan toa te bao ln, te bao nhan co kha, nhan khong kha
o ac tnh cao:
Loai te bao to, nguyen bao mien dch
Loai nguyen bao lympho
Loai te bao nho khong kha.
2)w:
Hong cau giam thng gap trong benh Hodgkin hn la cac limphom
khong Hodgkin.
Bach cau tang nhat la bach cau a acid cac benh nhan co trieu chng
nga.
Tieu cau giai oan au tang hoac bnh thng, ve sau giam.
LDH (Lactate Dehydrogenase)
- Bnh thng < 200 v / L.
- Khi LDH tang co gia tr tien lng xau.
- LDH phan anh khoi lng bu va toc o tang trng cua bu
3ac )et nqhiem can thiet khac
X quang phoi
Sieu am bung
CT scan ngc bung e tm hach, c quan b ton thng.
Tuy o
Xa hnh xng neu co au xng.
MRI neu nghi ng co ton thng mang tuy
Chc nang gan , than , tim ,ng huyet....

)han qiai doan theo 6nn 6+/o+

iai doan 0i t+i ton thaonq
iai doan / wot nho m hach { / )
wot co qaan haq mot i t+i nqoai hach { IE )
11

iai doan //

Jai haq nhiea nhom hach o mot /en co hoanh
{//)
wot nhom hach a mot i t+i nqoai hach o
mot /en co hoanh { II E )
iai doan /// 7hiea nho m hach o hai /e n co hoanh {///)
a 1 i t+i nqoai hach { III E )
hoac /ach to { III S )

iai doan /! Ian toa kha noi {/!)

Moi giai oan con phan ra giai oan A hoac B:
A: Khong trieu chng
B: Co 1 trong 3 trieu chng : sot , o mo hoi, sut can

)aoi

< = 60t hoac >60 taoi

iai doan

/// hoac /// /!
0i t+i nqoai hach 01 hoac >=2
)inh t+anq /enh nhan 01 hoac >=2
IJ inh thaonq hoac tanq

)han /oai nqaq co

)ha 0-1 qea to
)+anq /inh 2-3
ao -5

h o tien /aonq qaoc te (IPI)
nte+nationa/ +oqnotic inder
12

!/ ///| I|/
Giai oan I va II A : hoa tr 4 t va sau o xa tr cung co .
Giai oan III va IV : hoa tr 8 t . Neu sau khi hoa ma van con hach th xa tr
tiep tuc.

BENH BACH CAU MAN DONG LYMPHO
"5.C5. 5x,ae %qC "a "a
I. GII THIU
- Bnh bch cu mn dng lympho l s tng sinh c tnh ca t bo lympho B.
- Nguyn nhn cha r, c th do tip xc vi ho cht dng trong nng
nghip, cht c mu da cam
- Bt thng v nhim sc th:
- 50 80% bnh nhn c bt thng v nhim sc th.
- Thng thng l mt 13q (55%), 3 nhim sc th 12q, mt nhnh 11q, mt
17q.
- Bnh nhn bnh bch cu mn dng lynpho c tin lng tt khi ch c 13q;
tin lng xu khi c 17q v 11q
II. LM SNG
Hu ht bnh nhn khng c triu chng g vo lc khi pht. Nhiu khi bnh
nhn cm gic yu, mt mi, st, v m hi, st cn.
i khi bnh nhn c km nhim trng, nhim siu vi, thiu mu tn huyt t
min, xut huyt gim tiu cu.
Mt s bnh nhn c hch to v lch to.
Khm lm sng.
Hch to: kch thc t nh n ln.
Lch to.
Gan to.
III. CN LM SNG.
- S lng t bo lympho trong mu 5000/mm
3

- 30% bnh nhn bnh bch cu mn dng lympho c thiu mu v gim tiu cu
khi bnh din tin nng.
- Mt s bnh nhn Coomb test (+). 10 25% bnh nhn c thiu mu tn huyt
t min.
- 15 20% bnh nhn c gim tiu cu.
- Gim gamma globulin mu.
- Tu : tng s lng t bo tu v s lng t bo lympho tng > 30%.
- LDH, microglobulin, acid urique tng.
III. CHN ON.
Da theo tiu chun chn on ca Vin Ung th quc gia v Nhm lm vic:

13

1. Tng t bo lympho mu ngoi bin 5000/mm
3
, t bo lympho trng thnh
m khng tm thy nguyn nhn no khc.
2. 30% t bo lympho trong tu xng. S lng t bo c th tu bnh thng
hay tng.
3. Qun th t bo B n dng c th c CD5, CD22, C1 v CD20.
IV. CHN ON PHN BIT.
- Bnh bch cu cp dng lympho
- Ung th hch
V. XP GIAI ON
)heo R6

)heo 7{)

VI. IU TR
Giai on sm ca bnh: thng khng iu tr v bnh tin lng tt v iu tr kt qu
cng khng thay i.
- Ch theo di.
B. Ch nh iu tr
1. Bnh c triu chng st, lnh run, v m hi, st cn.
2. Thm nhim tu xng: thiu mu, gim tiu cu.

14

3. Lch to.
4. Hch to > 10cm.
5. Thiu mu tn huyt t min, gim tiu cu do min dch.
6. Thng b nhim trng.
7. Tng nhanh s lng t bo lympho.
C. Phc iu tr.
1. Fludarabine: 25mg/m2 , tim tnh mch N1 N5. Lp li 6 chu k vi mi chu k
28 ngy.
T l p ng cao v thi gian sng khng bnh di hn nhng khng c
ngha ko di i sng hn nhng phc khc.
2. CAP.
- Cyclophosphaminde.
- Doxorubicine ( Adriamycine).
- Prednisone.
3. CHOP.
- Cyclophosphamide.
- Doxorubicine.
- Vincristine.
- Prednisone.
4. Khng th n dng.
ALEMTUZUMAB ( Campath 1H)
L anti-CD52.
CD 52 c hn 95% t bo B, T trng thnh.
Liu 30mg tim mch 3 ln/ tun. Ti a 12 18 tun.

SUY TUY
C5 5x,ae %:J "a "a
/ //\/ \//
aq taq /a a aq qiam chac nanq tao maa caa taq raonq
iea hien /a qiam J )
)aq raonq nqheo te /ao mo taq daoc thaq /a nq mo mo tham nhiem te
/ao /qmho te /ao don nhan taonq /ao
// /// I/ /.
Tan suat 2-5 /1.000.000 dan
Cac Benh xuat hien nhieu ni tren the gii
nc phng ong :Trung quoc , nhat ban , Thai lan , An o co tan suat cao
gap 2-5 lan so vi chau Au va chau My.
/// |/\ /./
Phan loai theo benh hoc :
- Suy tuy that s
15

- Suy tuy tieu hao: co s xam lan cua te bao ung th, nang lao.
Phan loai theo dien tien benh
-Suy tuy cap : Xay ra trong vai ngay
-Suy tuy man : benh khi phat am tham , vai thang tr len
/! /\/ / |/\/
o che /enh inh
Ton thng te bao mau goc
Ton thng moi trng tuy xng
Ton thng yeu to tang trng cua te bao mau
c che mien dch cua tuy xng qua c che MD dch the hoac MD qua
trung gian te bao
! \|/\ \/\
1am inh
1.1 Thieu mau Fanconi: di truyen tren NST lan
LS :Da co om mau cafe , d dang xng quay va ngon cai, d dang tim , than
CLS:tuy ngheo te bao, NST rat de gay.
ieu tr Androgen co the cai thien tnh trang suy tuy
1.2 Benh loan san sng bam sinh: bat thng mong ,da niem, suy tuy
2 wac hai
- -Hoa chat:thuoc tr sau,Benzen va cac san pham co cha benzen
- Thuoc:muoi vang, Penicillamine, Phenylbutazone, sulfonamide,
carbamazepine, chloramphenicol, acetazolamide
- Thuoc ieu tr ung th: Cyclophosphamide, busulfan, daunorubicin
- Tia xa
- Nhiem trung:sieu vi viem gan , EBV
- Thai ky
- Benh collagen
!/ / \
Khi phat thng am , t t:chong mat met moi ,xanh xao, kem tap trung, kho th khi
gang sc.
Toan phat
-Trieu chng lien quan en dong HC nh thieu mau, dong BC nh nhiem trung, dong TC
nh xuat huyet.
-BN khong co bien oi ve he vong noi mo, khong au nhc xng khp, khong sut can ,
khong sot neu khong nhiem trung
!// \ / \
1.CTM:
HC +, BC +,TC +:giam 3 dong mau.
Thieu mau ang sac HC to, Hb +, HC mang +
BC giam nhat la BC hat giam
16

TC giam
2.TUY O :tuy ngheo te bao, dong HC nhan va BC hat giam,mau TC bien mat.Tuy
chu yeu la TB lympho, tng bao, ai thc bao.
3.SINH THIET TUY thay cac o tao mau giam nang, ch co to chc m, te bao
lympho, tng bao, te bao n nhan

V du CTM cua 1 BN suy tuy
HC :2 T/L
Hb : 6,2 g%
Hct: 22%
MCV :110 fL
MCH :31 pg
MCHC :310 g/L
BC :9 G/L
(N:13%, L :66% , E: 0%, B:0%, M:21%)
TC :5 G/L
HCL :0,1%
!/// /\ /.\
1.Chan oan xac nh da vao LS va CLS
2.Chan oan phan biet
- Roi loan sinh tuy: Giam 3 dong mau ngoai vi,tuy ngheo te bao, Blast trong tuy
tang sinh nhng cha u tieu chuan chan oan ung th mau.
- Suy tuy tieu hao:co te bao ac tnh trong tuy.
- X tuy:LS , CLS giong nh suy tuy, Sinh thiet tuy co nhieu mo x.

anh qia mac do aq taq

/' ///| I|/
1.ieu tr nguyen nhan
2.ieu tr ho tr
-Truyen HC khi Hb< 8g%.Tui mau phai qua tia xa va nen co loc BC.

J manq hat ) I te /ao taq
7he <1% <25 / <100 / <30 /
)+anq /inh <1% <15 / <20 / ) taoma a
<25%
7anq <05% <05 / <20 / ) taoma a
<25%
Rat nanq <05% <02 / <20 / ) taoma a
<25%
17

- Truyen TC khi TC < 20G/L ,hoac khi co xuat huyet tren LS. S dung epsilon
aminocaproic acid 4-12 g/ngay co the han che xuat huyet.
- Kch thch BC :GM-CSF, G-CSF
- Dung khang sinh khi co dau hieu sot hoac nhiem trung ngay sau khi cay mau,
cay am
3. ieu tr ac hieu.
a.c che mien dch
- Anti-lymphocyte globulin(ALG), hoac Anti-thymocyte Globulin(ATG)
-Cyclosporine A (Neoral):thuoc c chemien dch tren te bao T. Lieu 3-7 mg/Kg. T 4-
6 thang
-Corticoide: Methylprednisolone
nen ket hp 3 loai thuoc tren se lam tang ty le thanh cong .
b. Androgen
Nandrolone decanoate (durabolin 50mg )3-5 mg /kg / tuan (tiem bap )
Testosterone enathate 250 mg , lieu 200- 600mg /tuan
c.Ghep tuy
o Ch nh cho nhng ngi di 45 tuoi
o BN khong c truyen mau ap ng tot hn BN c truyen mau.
o Ghep tuy ap ng tot t 75%-85% BN cha c truyen mau,55%-65% a c
truyen mau.
' /| /|
Sau 8 nam ieu tr c che mien dch , BN co the co 1 trong nhng van e sau :
- Tiep tuc thieu mau, va giam TC
- Suy tuy van con
- Tieu Hb kch phat ve em
- Benh ung th mau
- HC roi loan sinh tuy

BENH HUYET SAC TO
C5 5x,ae %qC "a "a
/ //\/ \//
enh haqet ac to /a /enh caa J/
// /\/ I.\ /.| /|
1 phan t Hb gom 1 Heme va 4 chuoi globin. Heme giong nhau tat ca cac Hb,
cac globin th khac nhau.
Chuoi Globin gom cac axit amin. Cac chuoi globin khac nhau la do trat t sap xep
cac aa khac nhau hoac do so lng aa khac nhau.
18

Chuoi gom 141 aa
Chuoi , , gom 146 aa
/// |/\/ / /I /|.\ /|
Gene cau truc bao am trat t cac aa, ot bien gene cau truc lam cho aa nay thay
the bang 1 aa khac.
VD:Hb S, Hb C, Hb D, Hb E,
- Hb S: 22 6 glu----> valine
- Hb M:ot bien ngay v tr histidine
Iam anq
Khi thieu oxy HC co HbS se bien thanh hnh liem, mat tnh mem deo va gay tac
mach.
Tan huyet man , HC song 10-15 ngay.
Bn de b tac mach: nao (me) ,chi (loet chan ), bung (au bung ), ngc (au ngc )
Hb M :BN b xanh tm do HC khong gan oxy
Bn vang da , vang mat, thieu mau , gan to ,lach to
CLS : HC hnh liem
ien di Hb Hb S , hoac Hb C,
/! |/\/ / . /|.\ /|
Gene ieu hoa ieu hoa tong hp cac chuoi Hb.
Khi ot bien gene ieu hoa th thay oi toan bo chuoi globin nay bang chuoi
globin khac.
Thay oi 1 chuoi globin goi la benh Thalassemia
Thalassemia co the xay ra moi la tuoi:phoi, thai, sau sinh

THALASSEMIA
C: 5x,ae %:J "a "a
/ //\/ \//
Ia mt nhom /enh di t+aqen e a tonq ho caa 1 hoac nhie a chaoi q/o/in

Jhi mat can /anq tonq ho chaoi q/o/in e to nq ho J/ khonq hiea qaa a nh
haonq de n a a n raat honq caathiea ma a a tan haqet
// /// I/ /.
thalassemia :
Chau Phi
a Trung Hai
Trung ong
ong Nam A
19

thalassemia
a trung hai
Trung ong
An o
Pakistan
ong nam a
Trung quoc
Nam nc Nga
/// /\/ /
Phan t Hemoglobine (Hb) gom Heme va globine
1 phan t Hb gom 2 oi globin
Gene sinh chuoi nam tren nhiem sac the 16, co 2 gene
Gene sinh chuoi nam tren nhiem sac the 11, co 1 gene

/! /./ /|
Phoi:3 thang au thai ky
Hb Gower 2:(
2
2
)
Hb Gower 1(
2

2
)
Hb Porland (
2

2
)
Thai :6 thang sau thai ky
Hb F(
2
2
)

Ngi trng thanh
Hb A (
2
2
) :96%
HbA 2 (
2
2
) : 2,5-3%
Hb F(
2
2
) :1%
! /\ |/ \/| | I////
thalassemia
+
thalassemia: thieu chuoi
o
thalassemia: mat chuoi

thalassemia : do mat 1- 4 gene
- Neu mat 1 gene: -
- Neu mat 2 gene:- -
- Do o Bn mat gene : - / - hoac /--, hoac
- - / - - , -- / --
Thalassemia: thieu chuoi : khong anh hng en thai va ngui trng thanh v rat
t.
Thalassemia :ch anh hung en i song bao thai
20

!/ /\/ / |/\/
thalassemia
Khong tong hp chuoi gay ra hong cau nho nhc sac , tang Hb A
2
hoac
Hb F
thalassemia
San xuat qua nhieu chuoi ---->
4
(Hb Bart s)
San xuat qua nhieu chuoi ------> 4 (Hb H)
Hau qua :
Thieu mau nang
Thieu oxy mo gay tang san xuat eythropoietine ---> banh trng tuy xng
gay bien dang hop so lam de b nhiem trung tai ,mui,xoang.., gay xng benh ly.
Lach to
D sat , ong sat cac tuyen noi tiet: tieu ng, suy giap, suy tuyen
yen , suy tim
!// / \
thalassemia major (the nang)
ong hp t
Thieu mau rat nang sau khi sinh va ngay cang nang dan
Thng Hb <7 g%
Khong c truyen mau ay u be se cham phat trien, au to, bien dang
xng mat, gan lach to, sam da, loet chan, kiet sc, thng xuyen nhiem trung ,
thieu acide folic, gay xng.
Truyen mau u be se phat trien bnh thng cho en khi co dau hieu sat.
thalassemia the trung gian
Khong trieu chng hoac nhe ,khong phu thuoc vao nhu cau truyen mau
Hb thng 7-10 g%
thalassemia the nhe
Thng khong bieu hien lam sang , ch khi xet nghiem mau mi nhan biet
qua hong cau nho nhc sac (MCV+ MCH +)

thalassemia
Ngi bnh thng /
Ngi mang benh tm an -/
thalassemia that s -/- , - -/
Mat 2 gene thng khong co bieu hien lam sang ,ch co thay oi ve huyet
hoc M CV+ MCH +
ien di Hb co Hb Bart s vi nhiei mc o khac nhau.
Mat 3 gen (- -/ -) : Hb H, HC nhc sac nang . Thieu mau tan huyet t
trung bnh en nang. Tan huyet nhieu, lach to , Hb H(
4
)

Mat 4 gene (--/--) Hb Bart :thai thoai hoa nc

21

!/// I// I/. / /. \|.
Thng khong the song c khi moi trng ngoai t cung
Be chet trong bung me, hoac chet luc sanh , be phu toan than , da xanh ,gan lach to.
Me b nhiem oc vi tan suat cao luc sanh
T thiet :tao mau ngoai tuy o at
/' \ / \
thalassemia the nang
- Thieu mau nang ; Hb 2-3g%
- MCV+, MCH +
- Phet mau ngoai bien :Hc a kch thc, a hnh dang, HC nhc sac , HC hnh
bia, HC nhieu hnh dang khac nhau.HC nhan nhieu , HC li tang
- Ferritine tang cao
- ien di Hb: giam Hb A, tang Hb A 2, hoac Hb F
thalassemia the nhe
- Hb :9-11g%
- HC nho , nhc sac,MCV :50-70 fl, MCH :20-22pg
- MCV co gia tr tam soat benh nhan Thalassemie
- ien di Hb cho chan oan xac nh
thalassemia
- HC nho nhc sac
- HC mang tang
- ien di Hb thay Hb Bart hoac Hb H

CTM ngi thalassemia:
HC :3,8T/L
Hct 24%
Hb 7g/L
MCV : 63fl
MCH:18,4pg
MCHC:342g/L
RDW :18%
' \|./ \ /\/ |/\/ |:|:--: ()
Luc sinh ien di Hb co 1-2% Hb Bart
Phan tch bang o gene la cach giup chan oan ngi mang mam benh
thalassemia
Can thiet e tham van tien sanh
'/ I//\ /|.\
Thng song keo dai khoang 15 tuoi
i song co the keo dai them neu thai sat tot
22

Ghep tuy co the cha lanh benh
thalassemia the trung gian
Neu thai sat tot co the song en 40 tuoi
Co the co bien chng tieu ng, suy tim.
'// /| |/.\
Trc sanh theo doi me
Neu me la ngi mang gene Thalassemia th theo doi cha. Neu ca cha va
me eu mang gene Thalassemia thi xet nghiem mau bao thai ,
Lay mau banh nhau tuan 9-10,va phan tach DNA
'/// ///| I|/
Quan trong nhat la tre em: chan oan sm cac benh nhiem trung nh
nhiem trung ho hap, rang, xoang.
Cung cap acid folic
Truyen mau nang Hb > 10g%, truyen HC moi 6-8 tuan
Thai sat khi co dau sat (Ferritin >500 ng/L, sat huyet thanh > 350g/ dl
Thuoc: Deferosamine (Desferal 500mg ).
Co the dung 1-2g/ ngay, truyen lien tuc di da hoac tnh mach 12gi
S dung them vitamine C 50 -100mg/ngay
Cat lach khi co dau hieu cng lach

CH NH TRUYEN MAU
": C: 5x,ae %qC "a "a
7qaqen tac t+aqe n maa
Truyen mau ch la mot phan cua ieu tr
S can thiet cua truyen mau co the giam en mc toi thieu nh nhng ieu sau:
1. D phong , chan oan va ieu tr sm cac trng hp thieu mau , nguyen
nhan thieu mau ( VD :cung cap sat , vitamine ). Truyen HCL ch can thiet
neu hau qua cua thieu mau tram trong
2. ieu chnh lai tnh trang thieu mau trc khi phau thuat
3. Dung dung dch tinh the (NaCl, Lactate Ringer ), dung dch keo khi mat mau
cap.
4. Dung phng phap mo tot nhat e giam thieu mat mau
5. Ngng thuoc chong ong , thuoc c che ngng tap tieu cau trc mo.
6. Han che xet nghiem mau nhat la tre em
7. Truyen mau hoan hoi
8. Dung cac thuoc Erythopoietin kch thch san xuat HC

23

h dinh t+aqen maa
1. Boi hoan the tch tuan hoan
2. Boi hoan kha nang van chuyen oxy cho mo
3. Boi hoan thanh phan thieu cua mau
4. Khi dung thuoc hoa tr co anh hng en tuy xng th truyen mau hoi sc
cho BN
anq danh qia 7 can t+aqen maa
1. Bn co cai thien khong neu c truyen mau?
2. Lam sao cam c mau mat ?
3. Co phng phap ieu tr nao khac trc khi truyen mau :Oxy , truyen dch

4. LS nao, CLS nao quyet nh truyen mau
5. Li va hai cua truyen mau ,cai nao nhieu hn ?
6. Nguy c lay nhiem cac benh HIV, Viem gan , giang mai, nhiem trung
7. Co y kien nao khac neu khong truyen mau vao luc nay
8. Co BS theo doi Bn va biet x tr tai bien truyen mau khong?
9. Toi co ghi nhng ly do truyen mau vao benh an va phieu xin mau khong?
10. Cuoi cung neu con nghi ng th t hoi:neu la mnh hoac con mnh th mnh
co chap nhan truyen mau khong
wac do mat maa ca
1. Mat mau nhe: < 500 ml mau
M, HA Bnh thng , BN tnh tiep xuc tot
2. Mat mau trung bnh: 500 1000 ml
M: 100 120l/p , HA >90mmHg
BN met, l m, nc tieu giam.
3. Mat mau mc o nang: >1000 ml mau
BN choang . M>120 hoac khong bat c ,
HA < 8cmHg co the =0. Thieu nieu hoac vo nieu
o che /a t+a t+onq thiea maa ca
1.Tang the tch huyet tng
2. Tang cung lng tim
3.Tang hoat ong he giao cam :co mach ngoai bien ch d tr mau nao, tim ,
than
4.Tang thong kh
5. Thay oi ng cong phan ly oxy
6.Thay oi hormon (Tang tiet ADH, Aldosterone, erythropoietine, steroide cua
tuyen thng than , tang tiet Adrenalin, Nor adrenaline)
7.Tang tong hp protein huyet tng
h dinh t+aqe n ma a khi thie a maa ca
1. Thieu mau cap mc o nang
2. Thieu mau cap mc o trung bnh nhng van con chay mau hoac con tan huyet

24

h dinh t+aqe n ma a khi thie a maa man
1. Thng khong can thiet truyen mau BN thieu mau man
2.Ch truyen mau cho nhng BN thieu mau nang khong bu tr
3. BN thieu mau man , ln tuoi thng co suy tim i kem, neu can truyen mau
ch can 1 n v HCL va phai dung furosemide i kem
4. Ch can nang Hb len e cai thien lam sang , khong nang len u nh bnh
thng.
5.Khi Hb >7 g% th khong can truyen mau
an ham maa
1.San pham cua mau phai sang loc an toan. Ngay ca mau co chat lng cao
truyen mau van co rat nhieu nguy c. Mau chat lng kem, truyen mau co rat
nhieu nguy hiem.
2.Neu mau khong c xet nghiem trc th khong c s dung mau nay.
3.Moi n v mau phai c dan nhan he ABO , Rh, ngay lay mau , ngay het han ,
loai mau, chat chong ong.
he ha m maa
1. Mau toan phan:
- 1n v mau toan phan co 250ml, bao gom: 200ml mau va 50 ml chat chong ong.
- Hb: 12g%
- Hct : 35-45%
- Khong co tieu cau , khong co yeu to ong mau
- D tr nhiet o 2-6 o C
- Truyen mauphai c tien hanh trong 30 phut t khi lay ra khoi tu lanh.
Ch nh
- Nhng trng hp mat mau cap co tut HA
- Nhng ni can truyen mau nhng khong co HC lang
Chu y :
- Khong c cho bat c thuoc g vao mau
- Tui mau phai c s dung trong vong 4 gi t khi bat au truyen mau
- Truyen 1 n v mau nang Hct them 1-1,5 %,
- nang Hb them t 0,3-0,5 g%
2.Hong cau lang
1 n v hong cau lang co 150 ml hong cau , khong co huyet tng.
-Nong o Hb 20 g%
-Hct :55-75 %
-D tr :2-6 o
-Ch nh: Bu lng HC cho BN thieu mau.
Dung BN thieu mau ma co suy tim

3. HC ra
Dung HC lang va ra bang nc muoi sinh ly.

25

Ch nh :
Thieu mau tan huyet t mien
Tre s sinh
4. Tieu cau am ac
Lay t tui mau cua ngi cho. The tch 50 ml, co 55. 10 9 tieu cau
1 n v tieu cau am ac khi truyen cho BN nang them 5000 con /mm3
2 n v mau tao c 1 n v tieu cau
D tr 20-24 o C , vi may lac lien tuc
5. Kit tieu cau
The tch 150-300 ml , co t 150-500.10 9 TC
khi truyen 1 kit TC se nang them cho BN t 40.000 -70.000 /mm3
Kt TC c lay t 1ngi cho mau vi may tach tieu cau ac biet.
Kt TC c d tr nhiet o t 20-24 o C , vi may lac lien tuc
6.Huyet tng ti ong lanh
Huyet tng ti ong lanh c lay trong vong 6 gi sau khi rut mau va c
d tr nhiet o am 25 o C
Thanh phan :
Cac yeu to ong mau
Khang the (Ig)
Huyet tng
Yeu to VIII
D tr nhiet o nho hn 25 o trong vong 1 nam. Trc khi s dung, phai
c xa ong trong nc co nhiet o t 30-37 o , nhiet o khong qa 37 o v se
huy cac yeu to ong mau va cac protein.. Khi huyet tng ti tan th d tr
nhiet o 2-6 o C
Ch nh :Suy gan
Qua lieu thuoc Antivitamine K
Thieu cac yeu to ong mau
ong mau noi mach lan toa
Lieu lng :15 ml/kg
7.Ket tua lanh
Tach t huyet tng ti ong lanh
Cha ham lng yeu to VIII va fibrinogen cua ngi cho
1 khoi yeu to VIII.
Ch nh :
Thieu yeu to VIII
Benh Von Willebrand
Thieu yeu to XIII
- Dung trong vong 6 gi sau khi ra ong

26

T
T
A
A
I
I
B
B
I
I
E
E
N
N
T
T
R
R
U
U
Y
Y
E
E
N
N
M
M
A
A
U
U
C5 5x,ae %qC "a "a
/ \/. |
He ABO : Bao gom 4 nhom mau goi ten theo khang nguyen tren be mat hong cau

He Rh ( He Rhesus )
Rh (+) : co khang nguyen D tren be mat hong cau
Rh (-) : khong co khang nguyen D tren be mat hong cau.
// \|/\ I I||/\ |
* at /aoc hai taonq ho he 60 a he Rh

-Mau nhom nao th nhan mau nhom o.

- Khi khong co u mau truyen th la chon nh sau:
Nhom O: ch nhan mau nhom O.
Nhom A: Nhan c mau nhom A va O.
Nhom B: Nhan c mau nhom B va O.
Nhom AB: Nhan c mau nhom AB, B, A va O.

Cc nhm mu c bn
C 4 nhm mu chnh
Nhm mu O chim t l 43%
Nhm mu A chim t l 30%
Nhm mu B chim t l 20%
Nhm mu AB chim t l 7%

Nhm Rhesus:
Nhm Rhesus (+) chim t l 99,6%
Nhm Rhesus (-) chim t l 0,4%
Nhm mu him l nhm mu AB v nhm mu Rh (-)
m bo an tan v min dch khi truyn mu :
Tt nht nn truyn theo ng nhm mu ca bnh nhn.

Trong trng hp truyn mu khc nhm th phi truyn theo s ABO

27

Nhom mau Rh: Nhom mau Rh(-) khong c nhan mau Rh(+).

/// I/ |//\ I||/\ | |
1 )an haqet noi mach ca.
- C che:
Khang the trong huyet tng benh nhan lam v hong cau truyen vao.
Vi the tch 10 50ml mau khong tng hp cung co the gay phan ng tram trong va co
the gay t vong.
Nguyen nhan:
a. Truyen nham nhom mau he ABO.
Co the la do:
* Viet sai t yeu cau lay mau truyen.
* Lan lon mau mau nh nhom mau vi benh nhan khac.
* Ghi sai ten benh nhan.
* Khong kiem tra ay u ten benh nhan, mau.

b. Khang the khac nh he Kidd Kell, Duffy cung gay ra tan huyet noi mach
cap.
Lam sang :

Xay ra vai phut sau khi truyen mau, oi khi cha het 10ml mau au tien.

au nhc khap ngi , au lng d doi , vat va bt rt , sot cao lanh run , da tai ,
truy tim mach , hon me va t vong .

oi vi benh nhan ang c mo co trieu chng chay mau vet mo du a c
cam mau can than.
Can lam sang :
* Lay mau em ly tam thay huyet tng co mau o.
* Hb (+) trong nc tieu.
Cach x tr :
Ngng ngay chai mau ang truyen.
Kiem tra lai nhom mau cua BN va cua chai mau
ieu tr cap cu tru tim mach va cap cu ngng ho hap tuan hoan, neu
co.
Tai bien truyen nham nhom mau rat nguy hiem , BN co the t vong neu
khong x ly kp thi . BN thng t vong do thieu oxy nao hoac suy than cap.

D phong:
Dan nhan vao tui mau.
Viet ten benh nhan chnh xac vao phieu lanh mau.
Viet ten benh nhan chnh xac vao chai mau gi len ngan hang mau.
28

Phai xuong tan ging benh nhan e nh nhom mau.
Luon luon phai lam phan ng cheo tai ging.
2 )+aqe n maa nhie m i t+anq a choanq nhie m t+anq
Mau b nhiem trung do:
- Nhiem trung t da cua ngi cho mau, thng la do Staphylococus.
- Vi trung co trong mau cua benh nhan, thng la Yersinia.
- Nhiem trung trong qua trnh che tao cac san pham mau.
- Tui ng mau b h, rach.
- Ra ong tui plasma trong nc b nhiem trung.
Lam sang:
Sot cao, lanh run, tut HA xay ra sau vai gi truyen mau.

ieu tr:
Hoi sc cap cu va s dung khang sinh.
3 aa tai taan hoan
Qua tai tuan hoan co the gay suy tim cap va phu phoi.

Qua tai tuan hoan co the xay ra khi:
- Truyen mau qua nhieu.
- Truyen mau qua nhanh.
- Suy than, suy tim.
D phong:
nhng benh nhan thieu mau man nang can truyen mau th truyen HC lang va
phai dung thuoc li tieu, theo doi sat tnh trang phoi cua benh nhan, truyen mau toc
o cham.
)ha n a nq ha n e . .
Hiem gap.
Co the xay ra khi truyen plasma ti ong lanh va truyen nhanh.
- C che: Cytokin trong huyet tng co the gay ra co that phe quan va co that mach
mau.
- Lam sang: Xay ra vai phut sau khi truyen mau, co bieu hien truy tim mach va suy
ho hap.

Phan ng phan ve co the gay t vong neu khong cap cu kp thi.
5 )on thaonq hoi ca
Thng la do huyet tng cua ngi cho co khang the chong lai BC cua ngi nhan.
Lam sang:
Suy chc nang ho hap nhanh chong xay ra t 1 4 gi sau khi truyen mau.
X quang phoi: hnh anh m ca 2 phoi
/! I/ |//\ I||/\ | ' | /.
1 )ha n a nq tan haqet mao n do t+aqen maa
29

Lam sang:
Bieu hien xuat hien t 5 10 ngay sau truyen mau vi sot, thieu mau, vang
da, tieu Hb.
Benh canh rat nang e doa tnh mang, co the choang, suy than va DIC.
ieu tr:
Giong nh tan huyet noi mach. Phong nga suy than.
Kiem tra lai nhom mau, Coombs test, Bilirubin mau.
D phong: Truyen ung mau tng hp.
2 an raat haqet aa t+aqen maa
Hiem gap, nhng la bien chng gay t vong neu truyen HC va TC.
Do KT chong lai trc tiep KN ac hieu cua TC ngi nhan.
Lam sang:
Xuat huyet rat nang, giam TC t 5 10 ngay sau truyen mau.
ieu tr:
- Corticoid.
- IgG : lieu 0,4g/Kg x 5 ngay.
So lng TC thng hoi phuc sau 2 4 tuan.
D phong: Truyen ung mau tng hp.
3 enh kq cha chonq at qhe
Hiem gap va la bien chng co the gay t vong.
Thng xay ra benh nhan ghep tuy, suy giam miem dch.
Truyen mau nhng benh nhan tng hp mien dch: mau cua ngi cho tng
hp mo (HLA) vi ngi nhan.
Lam sang:
Xay ra t ngay 10 ngay 12 sau truyen mau. Sot, phat ban, da bong vay, tieu
chay, viem gan, giam 3 dong mau ngoai bien.
ieu tr:
Benh thng dan en t vong.
ieu tr nang , khong co ieu tr ac hieu.
D phong:
Xa tia gamma nhng che pham mau e ngan s sinh san cua te bao Lympho.
aa tai at
Lam sang: Suy a c quan, ac biet la tim va gan.
ieu tr: Desferrioxamine dung e lam giam tch tu sat.
Muc tieu giam Ferritin < 2000mg/L.
5 Iaq nhiem cac /enh t+aqen nhiem
Cac benh truyen nhiem co the lay qua ng truyen mau la: HIV1 va HIV2, HTLV1
va HTLV2, Viem gan B va C, Giang mai, Sot ret, Cytomegalovirus, Parovirus B12,
Brucellosis, Epstein Barr, Toxoplasmosis, Tang BC n nhan nhiem khuan va benh
Lyme.

30

Nhng benh truyen nhiem co the xay ra vai tuan hay vai thang sau truyen mau, do
o benh ket hp vi truyen mau co the b bo quen.
6 )+aqe n maa o /aonq /on
Truyen mau so lng ln c nh ngha la thay the 1 khoi lng mau bang hay
ln hn the tch mau toan phan trong vong 24 gi.
( Ngi ln: 70ml/Kg, Tre em : 80 90ml/Kg)
Ch nh truyen mau so lng ln va truyen dch lam tang nhng bien chng sau:
a. Toan hoa mau.
b. Tang Kali mau.
c. Ngo oc Citrate va ha Can-xi mau.

31

TIM MACH
32

CHOANG
"5.C5 "-xs, 2xa, C.
/ | I//|
1 )+inh /aq daoc dinh nqhia choanq
2 )ha n tich daoc 3 qiai doan inh /q /e nh caa choanq
3 )+inh /aq a ha n tich dao c nhom nqaqen nhan caa choanq
)+inh /aq daoc 6 /ien chanq caa choanq
5 )+inh /aq a han tich 5 t+iea chanq danq de chan doan choanq
6 )+inh /aq chi tiet cach ra t+i /oai choanq

// //\/ \//
nh ngha choang mot cach chi tiet :

hoanq /a haa qaa caa tinh t+anq qiam taoi maa cac co qaan a cac mo den
mot mac do toi han nao do a/hoac cac mo do khonq co kha nanq de a danq
cac chat dinh daonq can thiet

iem chanq nhat t+onq tat ca cac /oai choanq /a aq i taan hoan
{mic+oci+ca/ato+q ina[[iciencq) Jaa qaa caoi canq caa choanq /a +oi /oan
chac nanq manq te /ao +oi /oan chaqen hoa te /ao a chet te /ao

/// /\/ / |/\/ ! // /.\ | /.\
3 giai oan:
Choang giai oan I hay la choang con bu

Choang giai oan II hay la choang mat bu

Choang giai oan III hay la choang khong hoi phuc
hoanq qiai doan
qiai doan daa caa choanq

Tnh trang tut huyet ap co the la do giam cung lng tim hoac do dan mach ngoai
vi.

S giam cung lng tim va ap lc ong mach a khi kch c che bu tr

33

giai oan nay cac dau hieu va trieu chng ve tnh trang suy sup huyet ong rat
kho nhan ra.

Neu c chan oan sm giai oan nay va ieu tr tch cc ngay th nhieu trng
hp choang co the qua c
hoanq o qiai doan
ac co che /a t+a daoc kich hoat o qiai doan de daq t+i haqet a a taoi
maa mo khonq con da ac de /a t+a cho cac +oi /oan haqet donq.

* Benh nhan bat au co tnh trang giam ti mau cac c quan : roi loan tri giac
(giam ti mau nao), giam lng nc tieu (giam ti mau than), thieu mau c tim
(giam lu lng mach vanh).

* Benh nhan co ay u cac dau hieu va trieu chng cua choang : tut huyet ap,
nhp tim nhanh, th nhanh, mach nho, yeu, kho bat, tm au chi, co mach ngoai
bien, va mo hoi.

* Can phai ieu tr tch cc, nhanh chong e phuc hoi cung lng tim va s ti
mau cho cac c quan e choang khong i vao giai oan khong hoi phuc.
hoanq khonq hoi hac
iam taoi maa cho cac mo nanq ne a keo dai thaq doi chac nanq manq te
/ao ket ta cac te /ao maa t+onq he i taan hoan a nqhen tac o cac mao
mach )inh t+a nq co mach keo dai /am ton thaonq cac te /ao

Huyet ap tiep tuc giam nang ne en mc o lam giam luon s ti mau
cac c quan song con va vong xoan benh ly ve s suy sup tuan hoan xay ra, va
cuoi cung la tnh trang suy sup co tnh chat he thong nhieu c quan (multiple
organ system failure)
wa/ti/e o+qan qtem [ai/a+e
* Hoai t ong than cap
* Ton thng hoai t niem mac ng tieu hoa
* Ton thng te bao noi mac mach mau.
* oc to cua vi trung phan ng vi te bao bach cau giai phong cac polypeptides
gay dan mach giam huyet ap nang ne hn.
* Giam ti mau c tim.
* Ton thng te bao noi mach mao mach roi loan tnh tham thau mang mao
mach mat dch va protein noi mach giam the tch mau va giam huyet ap.
Cuoi cung th te bao b huy hoai do cac thanh phan ben trong te bao b ton thng. ay
la tnh trang choang khong hoi phuc c du co ieu tr tch cc i na.
34

Tren lam sang: cac giai oan cua chong khong the hien tach bach.

Khong co dau hieu nao ch iem rang choang van con hoi phuc hay a qua G bat
hoi phuc

=> )hai chan doan canq om canq tot
/! \|/\ \/\ /.\ |/\ /./ ! / /// | I|\
/./ /.\
Ti mau cho cac c quan phu thuoc vao :
. Tim bm.
. Trng lc mach mau.
. Lng mau trong long mach.
. S thong suot cua ong dan mau.
Ti mau c quan that bai khi
. Tim suy : Choang tim.
. Giam hoac mat trng lc mach mau : Choang nhiem trung.
Choang phan ve.
. Giam lng mau trong long mach : Choang giam the tch.
. Tac nghen dong mau :
Thuyen tac ong mach phoi.
Hep van hai la kht.
4 nhom nguyen nhan choang
Choang tim.
Choang the tch.
Choang do phan phoi dch.
Choang do tac nghen mach mau
6) hoanq qiam the tich
Choang giam the tch la do s giam so lng dch noi mach tuyet oi va thng la
ot ngot so vi dung tch cua he mach mau giam lng mau ve that phai.

Cac nguyen nhan gay ra choang giam the tch : Mat mau hoac mat dch va chat
ien giai.

Mat mau : xuat huyet noi, chay mau.
Mat dch va chat ien giai
+ Qua ng tieu hoa : tieu chay, non
+ Qua ng than : tieu nhieu
+ Qua s ton thng be mat c the : bong
+ Thoat dch vao ngan th ba cua c the
35

) hoanq tim
Nhom do nhoi mau c tim cap gay ra : Choang tim do nhoi mau c tim cap la do so
lng c tim b hoai t kha nhieu cho nen sc co bop cua c tim giam han .
Choang tim do nhoi mau c tim cap con co the xay ra do tnh trang ton thng c
hoc cua tim nh : thung vach lien that, h van 2 la cap, v thanh t do cua tam
that.
Choang tim do nhoi mau c tim cap thng co:
* Tut huyet ap (huyet ap trung bnh < 60mmHg)
* Giam cung lng tim (ch so tim < 2 l/phut/m2)
* Tang ap lc ong mach phoi bt (PAOP > 18mmHg)
* Tang sc can ngoai bien
* Giam ti mau cac c quan : giam lng nc tieu, thay oi tri giac
Nhom choang tim khong phai do nhoi mau c tim :
+ Benh van tim nang : hep van ong mach chu kht
+ Benh mang ngoai tim co that
+ Benh c tim tac nghen
+ Viem c tim
+ Roi loan nhp tim
+ ..

) hoanq do han hoi dich
Choang do khang lc mach mau b giam qua mc, vt qua s bu tr cua tnh
trang tang cung lng tim.
Hai dang chu yeu cua loai choang nay la choang phan ve va choang nhiem trung.

1) hoanq nhie m t+anq
*Chiem khoang 1% so benh nhan nhap vien.
* T le t vong cua choang nhiem trung la 30-80%.
* Choang nhiem trung thng la hau qua cua nhiem trung gram am. 4% benh
nhan nhiem trung huyet nhiem trung gram am se vao choang nhiem trung: E. coli,
Klebsiella, Enterobacter va Pseudomonas.
* oi tng gia, tieu ng, suy dinh dng, nghien ru, benh ung th, benh suy
giam mien dch hay b choang nhiem trung hn ngi bnh thng.
* Choang nhiem trung xay ra la do co s phong thch vao he tuan hoan cac chat
trung gian hoa hoc. S phong thch nay la do vi trung gram am va cac san pham
cua chung (nh noi oc to : endotoxine chang han) gay ra.

Choang nhiem trung co the co 3 kieu huyet ong hoc : choang am, choang lanh va
tnh trang suy sup he thong a c quan (multiple organ system failure = MOSF).

36

+ Giai oan sm: dan mach tao ra benh canh choang am (warm shock) : sot, nhp
tim nhanh, tang cung lng tim.
+ Giai oan sau: giam cung lng tim tut huyet ap nang ne, toan mau, giam oxy
mau va hypoxia: choang lanh (cold shock)
+ Giai oan cuoi cua choang nhiem trung la benh canh MOSF : roi loan chc nang
tim mach, phoi, than.

hoanq 7)-inh /q /enh
)on thaonq cac tanq
+ Phoi : tang khang lc TMP; thay oi tnh tham, SDRA, bat thng V/Q.
+ Cac c quan khac: than, gan, tieu hoa, nao, tao maudo giam TTTH, noi oc
to,cytokine.
+ Tren CH: tang CH cuoi cung can kiet d tr E va a en chuyen hoa k kh.
+ Neu vong xoan benh ly trong choang NT khong c cat, choang se khong hoi phuc,
MOF va TV nhanh.

Hypovolemie absolue
(giam TTTH tuyet oi)
Vasoplegie et hyporeactivite
vasculaire aux agents vaso
constricteurs
(Liet mach va giam ap ng
mach mau vi tac nhan co
mach)
Dysfonction
cardiaque
(Suy bm tim)
Dysfonction endotheliale
(RLCN noi mo)
Heterogeneite de la
microcirculation
(RLCN vi tuan hoan)
SDMV
(HC suy a phu tang)
Anomalies de la
Circulation pulmonaire
(Bat thng tuan hoan phoi)
37

O nhiem trung:
Viem phoi
Nhiem trung ng mat
Nhiem trung ng tieu
Viem mang nao
Viem mo te bao
Viem phuc mac
Ap xe
...
Tang sinh va lan rong cua vi khuan:
* Cac chat do VK tao ra (exotoxins)
- TSST -1 (Toxic shock syndrome toxin -1)
- Toxin A
* Cac thanh phan cau truc cua VK:
- Endotoxin
- Teichoic acid antigens
Hoat hoa he thong khang c cua ky chu:
* Cac thanh phan trong huyet tng
* Te bao n nhan
O nhiem trung
Tang sinh va lan rong cua vi khuan
Hoat hoa he thong khang c cua ky chu
Phong thch hoa chat trung gian
Anh hng cac c quan
SEPTIC SHOCK
38

* ai thc bao
* Te bao noi mac.
Phong thch hoa chat trung gian

anh haonq /en cac co qaan

- Chat chuyen hoa cua acid
arachidonic:
*Cyclooxygenase:prostaglandi
ng
* Lipoxygenase: leucotrienes
- Bo the: C5a
- He ong mau
- Kinins: bradykinin
- Endorfins
He mach mau:
* Gian mach
* Co mach
* RL chc nang
te bao noi mac
* Ket dnh bach
cau
C tim
* c che
* Gian tim
Cac c quan
(phoi, than, gan, nao)
* Roi loan chc nang
* Khiem khuyet
chuyen hoa
SEPTIC SHOCK
- Cytokins
* Tumor
necrosis factors.
* Interleukins
* Interferons
- Yeu to hoat
hoa tieu cau.
* Nitro oxide
* Goc t do
oxygen
39

SEPTIC SHOCK

2) hoanq han e
+ Phan ve la mot phan ng d ng he thong, xay ra nhanh va qua trung gian IgE.
Phan ng phan ve (Anaphylactoid reations) la phan ng d ng (Anaphylaxis) qua
trung gian tng bao.

+ Choang phan ve co the la phan ng d ng hoac co the la phan ng phan ve.

+ Tnh trang choang thng xay ra rat nhanh sau khi tiep xuc vi d nguyen. Cac
trieu chng thng gap la : nga, noi me ay, phu mach, suy ho hap (do phu, co
that thanh quan, co that phe quan), tut huyet ap, au bung va tieu chay. T vong
thng la do b nghen ng ho hap, th en la do tut huyet ap.

) hoanq do tac nqhen mach maa /on
* Loai choang nay co the xep vao loai choang tim. Ban chat chnh cua choang nay
khong co lien quan en tnh trang noi tai cua c tim va phai c tach rieng ra nh
la mot chan oan rieng biet vi choang tim.

* Cac nguyen nhan gay ra choang nay la :
Chen ep tim cap: tnh trang nay thng do chan thng, nhiem trung, ung
th, v tim. Neu tch tu dch trong khoang mang tim xay ra nhanh th ch can
100-200 ml la a gay ra chen ep tim cap va choang.
Tran kh mang phoi ap lc (tension pneumothorax)
U nhay nh trai.
Thuyen tac phoi dien rong do huyet khoi, kh, nc oi, u bu.
Boc tach ong mach chu gay nghen tac ong mach chu.
! |//\ /|\ | /.\
1onq maa noi mach /an toa
* ong mau noi mach lan toa la mot hoi chng thng co trong benh canh
choang, ac biet la cac loai choang nhiem trung gram am.
* Khi a co hoi chng nay xuat hien th t le t vong rat cao.
* Mau chot lam sang cua ong mau noi mach lan toa la tnh trang ong mau
noi mach va tieu fibrine xay ra ong thi trong c the.

Hoi phuc
Tut HA khong
hoi phuc
Suy a c quan
40

* Bieu hien lam sang noi bat la tnh trang xuat huyet (do tieu hao qua nhieu
yeu to ong mau)
* Hoi chng nay gay ra hoai t vo than, ton thng do thieu mau en cac c
quan, tieu hao yeu to ong mau, chay mau va co the gop phan tao ra choang phoi.
2Jo i cha nq nqaq nqa ho ha o nqaoi
Hoi chng nay trc ay co ten la choang phoi (shock lung).
* Hoi chng nguy ngap ho hap cap ngi ln thng la bien chng cua choang
nhiem trung va choang tim.
* Benh canh lam sang la :
Giam oxy mau tram trong, khong ap ng vi ieu tr oxy.
Phu phoi cap
Tham nhiem phoi lan rong
3aq tha n ca
La bien chng thng gap.

* Bien chng nay xay ra khong phu thuoc vao nguyen nhan gay ra choang,
nguyen nhan chnh gay ra suy than cap la thieu mau en ti mau than trong tnh
trang tut huyet ap cua choang.

* Bieu hien lam sang chnh la thieu nieu hoac vo nieu, BUN tang, creatinine tang.
an
Khi choang nang va keo dai, gan cung b anh hng nhng t co bieu hien lam
sang. Cac chc nang gan nh : chuyen hoa ng, tong hp enzyme, giai oc cua
gan eu b roi loan
5)im
Tim la c quan song con , c ti mau kha tot trong tnh trang choang.

* Nhng neu huyet ap ha nhieu ( 60 mmHg) va toan mau nang th se giam co bop
c tim cung lng tim giam
67ao
ay cung la mot c quan c ti mau tot trong giai oan au cua choang.

* Khi choang nang : huyet ap tut 50 mmHg, toan mau nang, giam O2, giam
ng huyet th benh nhan vat va, l m, lu lan va co the hon me

!/ /\ /.\
* Co mach ngoai bien : da lanh, rn mo hoi, au chi - moi - tai : lanh tm, an len
mong tay thay lt i va cham o tr lai (chng to s tai lam ay mao mach b
giam nhieu)

41

* Nhp tim nhanh (tr trng hp nhp cham nghch ao gap trong choang do mat
mau nhieu). Mach nho, nhanh, kho bat.
* Th nhanh
* Tut huyet ap (HA tam thu < 90 mmHg) hoac huyet ap tut va kep. oi khi khong
o huyet ap bang may o huyet ap co tui hi.
* Thieu nieu : (nc tieu < 25 ml/gi)
han doan choanq /a chan doan /am anq

* Huyet ap la trieu chng c chu y nhieu nhat va de c nhan nh.

* Tuy nhien, khong c ch da vao trieu chng la huyet ap tut e ma chan oan
xac nh choang. Neu co them huyet ap kep th co gia tr chan oan hn. Tot nhat
la co u benh canh nh tren.

* Chu y la co tnh trang cng giao cam phan xa bu tr cho tnh trang tut huyet ap
cho nen huyet ap khong ha nhieu. Co the chan oan xac nh choang khi huyet ap
con cao hn 80 mmHg neu co u cac dau hieu thieu mau ti cho cac c quan.
ac ret nqhiem a tha thaat can thac hien
Muc ch: chan oan phan biet cac loai choang, chan oan nguyen nhan gay
choang va anh gia tnh trang choang.
* o huyet ap ong mach trc tiep
* Trong choang tim co the o ap lc ong mach phoi, ap lc ong mach phoi bt
* ECG e phat hien nhoi mau c tim cap.
* Sieu am tim
* Xa hnh phoi trong nhoi mau phoi.
* Xet nghiem ve ong mau
* Kh mau ong mach nhieu lan
* at sonde mui-da day
* Xet nghiem nhom mau, phan ng cheo khi nghi co xuat huyet.
* Chc nang than, ien giai o.
* Cong thc mau trong trng hp nhiem trung.
* Cay dch c the trong benh canh nhiem trung.
* at sonde tieu theo doi lng nc tieu.
!// '| I|/ /.\
iea t+i tai /|
iea t+i taq theo nqaqen nha n qaq choanq
iea t+i tinh t+anq hock tai /|
Tai ICU: phat hien va ieu chnh HA, nhp tim, co bop c tim, oxy, chuyen hoa
- Theo doi sat HA, cac catheter M.
- Bu u the tch tuan hoan.
42

- Dung thuoc van mach.
- Dung thuoc tang co bop c tim.
- Cung cap u oxy.
- Thong kh c hoc neu can.

Monitoring tnh trang BN
* ECG lien tuc.
* Ho hap lien tuc.
* HA, nhp tim.
* Tri giac.
* Lng nc tieu.
* HAM he thong, M phoi trc tiep khi co ch nh
* Cac KQ ve tnh trang chuyen hoa, kh mau

-> Can thu nhan lien tuc e ieu chnh ieu tr thch hp
1hoanq qiam the tich
A)Boi hoan the tch :
Bu loai dch thng co nhat : NaCl 0,9%, tam dung Dextrose 5% hay Lactate
Ringer cung c. Dung dch keo cung khong co tac dung tot hn NaCl 0,9%.

Toc o bu dch : neu benh nhan khong co suy tim xung huyet th co the bolus 500
ml dch au va ngay sau o tuy theo ap lc tnh mach trung tam, huyet ap va tnh
trang ti mau cac c quan ma ieu chnh toc o dch.

ng bu dch : tot nhat la ng tnh mach ngoai bien nhng phai truyen qua kim
ln hoac catheter co lo ln.

Khi choang la do mat mau th ngay sau 500ml dch au tien neu co c mau cung
nhom e truyen th tot, neu khong th co the dung loai mau an toan khong can th
phan ng cheo.

So lng dch bu : phu thuoc vao lng dch mat va tnh hnh cai thien huyet ong
cua benh nhan.
B) Giai quyet nguyen nhan gay ra giam the tch :
Quan trong nhat la trng hp choang do mat mau : phai tm ra ni gay mat mau
va can thiep ngoai khoa neu can.

Cac tnh trang mat dch khac cung phai c tm ra e ieu tr triet e.
C) Dung tui hi chong choang (pneumatic antishock garment).
Tui hi quan chi di, bung va c tao ap lc 15-40 mmHg se lam tang
sc can ngoai bien va tam thi duy tr c s bu dch cho cac loai choang giam
43

the tch, choang do tac nghen mach mau ln va choang do phan phoi. Chong ch
nh dung bien phap nay cho choang tim.
2hoa nq nhiem t+a nq
A)Boi hoan dch : ieu tr nh phan boi hoan dch trong choang giam the tch (d
nhien la khong dung mau). Chu y la trng hp nay chung ta khong nen dung
dung dch Lactate.
B)Dung cac thuoc van mach
oi khi khong can dung en, vi ieu tr bu dch choang nhiem trung co the on
nh.
a so cac trng hp th thuoc van mach c s dung en.

+ Thi iem cho thuoc van mach : khi lng dch bu a gan u hoac u (ap lc
tnh mach trung tam a bnh thng hoac hi cao) ma huyet ap cua benh nhan
khong len c hoac tnh trang ti mau cho cac c quan khong cai thien.

+ Mot so y kien mi: dung van mach sm, ngay khi bat au truyen dch e co HA
ngay
Cac loai thuoc dung :
Dopamine : la loai thuoc van mach hang au trong choang nhiem
trung. Tac dung phu thuoc vao lieu lng.

Lieu thap : 2-3 g/kg/p : dopamine tac dung len thu the Dopaminergic
va chu yeu la gay dan mach than, ruot.

Lieu trung bnh : 4-5g/kg/p : tac dung len thu the 1 c tim lam tang co
bop c tim tang cung lng tim.

Vi lieu cao : > 10g/kg/p : tac dung len thu the ngoai bien co
mach tang huyet ap.
Noradrenaline : la loai thuoc tac ong len ca thu the (tang co bop c
tim, dan mach) va thu the (co mach ngoai bien) nhng chu yeu la len .

Thuoc nay c s dung khi huyet ap tut qua nang, khi Dopamine khong
nang c huyet ap. Tac dung cua Noradrenaline cung phu thuoc vao lieu lng
va v vay can c theo doi va chnh lieu theo huyet ap cua benh nhan.
C) Giai quyet nhiem trung :
Cho khang sinh
Phau thuat giai quyet o nhiem trung
3hoa nq ha n e
A)Thuoc :

44

* Adrenaline 1%o : 0,3 - 0,5 ml tiem di da va co the lap lai moi 20 phut. 0,3 -
0,5 ml phun di li.

* Adrenaline 1%o, 3ml tiem vao tnh mach ui, tnh mach canh trong, cho vao ong
noi kh quan.
* Neu can phai tiem nhieu lan th co the dung ng truyen tnh mach va chnh
lieu theo huyet ap benh nhan.

B)at noi kh quan neu benh nhan co trieu chng cua suy ho hap. Khi can thiet co
the phai m kh quan.

C)Bu dch : 500 ml bolus va sau o truyen tnh mach theo huyet ap va nc tieu
cua benh nhan.
hoanq do tac nqhen mach maa /on
Nguyen tac ieu tr la phai xac nh ra nguyen nhan gay choang e giai quyet, v
ieu tr noi khoa t em lai ket qua.

+ Tran dch mang ngoai tim : truyen dch e lam tang sc o ay tam that va choc
thao mang ngoai tim. oi khi ch can thao 100-200 ml la a giai quyet c tnh
trang choang.

+ Thuyen tac phoi dien rong :Truyen dch va dung cac thuoc van mach (Dopamin,
Noradrenaline e tam thi nang huyet ap e co thi gian ieu tr manh hn bang
phau thuat lay huyet khoi hoac dung cac loai thuoc tieu si huyet.
5hoanq tim
Cac bien phap chung :
* Oxy
* Thong kh c hoc : at noi kh quan - th may giup giam cong th.
* Chu y tnh trang dch : khong d qua e b phu phoi, khong thieu qua e giam co
bop c tim.
* Dung cu ho tr tuan hoan : at bong doi nghch trong ong mach chu giup giam
cong cua tim va giup ti mau mach vanh tot hn.
* Chuan b ieu tr triet e : thong ong mach vanh, phau thuat bat cau ong mach
ieu tr bang thuoc :
Chu yeu cho cac tnh trang giam sc co bop c tim dan en choang. Thuoc dung la
cac loai tang co bop c tim va van mach. Thuoc dan mach khong c dung cho
choang tim tr khi benh nhan a c ieu tr on nh huyet ap roi.

Thuoc tang co bop c dung au tien la Dopamine (tham khao lieu lng phan
choang do phan phoi dch). Khi huyet ap on nh hn co the dung Dobutamine .

45

!/// ///| I|/ /.\ / . /|| / \
- anh gia BN nhanh chong va toan dien
- Hoi benh s that ky, ung, va tham kham t m, khan trng.
- Xac nh ngay tut HA?, gia thuyet ve nguyen nhan.
Th x ly nham vao nguyen nhan nen neu thay co 1 chut g o co lien quan.
- Bao am u TTTH. Chnh theo nhu cau ac biet cua rieng tng benh nhan
Neu khong co bat tng ong gia chc nang tim P va T: da PVC. Lu y
en courbe PVC hn la tr so tuyet oi cua PVC. PVC muc tieu ? 10-12 cm
H2O!
Neu co roi loan chc nang tim T hoac P: catheter MP ? (Connors AF et al,
JAMA 1996 276 pp889-897
- Tch cc bang moi cach duy tr ha. ha muc tieu? HATB trc choang, neu biet;
hoac khoang 100 mg Hg. Muc tieu nay nen c ieu chnh tuy theo ac thu rieng
cua tng benh nhan.
- Khong can phai ch i cho en khi viec bu dch khong ap ng th mi s dung
thuoc. Ngay sau khi bat au HS bu dch tch cc, neu HA thap, s dung hau nh
ngay lap tc vasopressor +/- inotrope (+) lieu tng oi cao
TMTT, SE hay perfuser.
1a dich
Loai dch: Mau ( neu Hb < 10 mg), dch keo (neu Albumin <2 gr%) va dch tinh
the thng cho tat ca BN
ng truyen: TM ln, tot nhat la TMTW.
So lng: 1-2 lt/ 30 phut au.
Bu dch cho en khi CVP = 10 -12 cmH2O
*Co khi ch bu u dch la HA cai thien roi.
2iea t+i kha nq inh
Cay mau, dch cua o nhiem
ieu tr tch cc, manh.
KS pho rong diet ca Gr(-) va Gr(+)
KS diet khuan, lieu toi a, ng tnh mach.
Chon KS theo kinh nghiem: o nhiem ban au, tnh hnh khang thuoc cua tng
vung. Chu y VK yem kh BN NT trong o bung, ap xe, viem phoi ht.
NT t catheter nen dung Vancomycine.
BN neutropenic nen dung: Vanco+Genta+Metro hoac Ceftazidime+Genta.
3)haoc an mach a tanq co /o co tim
* Thi iem dung: Khi a bu u dch ma HA cha cai thien.
* Thuoc: Dopamine (3-20 mcg/Kg/phut). Theo doi HA lien tuc e ieu chnh lieu.
* Khi khong ap ng vi Dopa th co the dung Norepinephrine.
* BN can lieu cao Nor th dung them Dopa lieu thap e tang mau en than.
* Co the dung them Dobutamine e cai thien co bop c tim.

46

Choang NT- S dung V +/-I (+)

* S dung thuoc V +/- thuoc I (+) IVP lien tuc vi toc o chnh xac. (SE hay
transfusor).

* Tac dung I (+) co vai tro quan trong (lam tang CLT) khi ma qua tim a qua
hyperkinetic phase trong choang NT va bat au suy.

* Phai phong tranh viec s dung qua mc thuoc V v co the lam mat tac ong I (+).

LU Y DUNG THUOC INOTROPE
- Neu bu dch khong /ng, phai phoi hp ngay vi V +/- Inotrope (+)(tut HA dai dang co
the do dan mach tram trong hoac do suy tim hoac phoi hp ca 2)
- Thuoc: NAD, AD, dopamine, dobutamine,
- Dopamine va la V () va la I (+) () va re nen van c chuong s dung. - 1 so tai
lieu cho thay t/d thu the dopaminergic cua dopamine co the gay hai. Mac dau thuoc co
the gay tang LL mau tang nhng lai lam giam LL mau ti niem mac (lien quan t/d ) va
gay hai, moi lien quan LS cua van e nay ang con c xem xet. (Giraud GD &
MacCannell KL, J Pharm Exp Ther 1984 230 pp214-20 ; Pawlik W et al, Ref 79 of Meier-
Hellmann & Reinhart 1995)
Dobutamine la I (+) manh () nhng khong co t/d V. Dobutamine n oc du vi lieu 20-
30 g/kg/phut cung khong at c yeu cau ti mau c quan.
- NAD la V manh () nhng t/d I (+) lai t. Nhieu tac gia chon lam thuoc au tay do thuoc
nham vao hien tng SLB quan trong gian mach
(A Rational Approach to Use of Inotropes-J van Schalkwyk-2000).

Dobutamine + dopamine hay dobutamine + NAD.

Dobutamine + NAD > dobutamine + AD (Crit Care Med 1997 25 pp399-404 ], as
do Levy et al [Intens Care Med 1997 23 pp282-7).
Vasopressine (ADH) a cho thay rat hu hieu trong ieu tr choang nhiem trung.
BN choang NT khang tr cho thay co giam hormone nay.
Vasopressine lieu thap, lieu a nong o vasopressine mau tr ve bnh
thng giup choang khang tr co the ap ng vi trng lc giao cam noi
sinh hay vi thuoc adrenergic a vao.
S dung vasopressine phoi hp vi thuoc I (+) (dobutamine) hien nay la phoi hp ang
c a chuong e ho tr HH trong SS

oi vi Adrenaline, 1 thuoc tang co bop c tim hu hieu, re, lieu bat au thng la
0,05-0,1 g/kg/ph. Neu khong ap ng sau 5 phut se TANG LIEU LEN GAP OI
cho en khi at c HA muc tieu!

47

CAN TNH EN VIEC BOLUS TM TNG LIEU NHO e co ngay HA.
benh nhan 70kg, co the pha 1 mg AD/20ml. Bolus TM 0,5-1ml va theo doi ap
ng.
* CHNH LIEU THEO TNH HUONG LS. Khong rap khuon theo khuyen cao!

* Khi a at HA muc tieu, can DUY TR MC HUYET AP NAY VA LIEN TUC
ANH GIA LAI.

* Lu y en chc nang cac c quan, va quan trong nhat, nham en benh ly nen
gay nen tnh trang mat ieu hoa tim mach cap tnh nay.
* CAI THUOC CANG SM CANG TOT KHI CO THE C.
Hien tng down-regulation cac thu the beta.
Co the nen th va cai thuoc ngay khi co bang chng chuyen hoa a c cai
thien ang ke (lactat, bicarbonat, pH).

Khong c e tai dien tnh trang mat c che t ieu hoa, tc khong c e cho
HA giam qua mc di mc HA muc tieu! Khong giam toc o truyen thuoc qua nhanh

/' |/I /|\
hoanq /a mot tinh t+anq do nhiea nqaqen nha n qaq +a co chanq dac diem
/am anq /a tinh t+anq tat haqet a qiam taoi maa toi cho cac co qaan

0iec chan doan can thac hie n nhanh danq chinh rac a iec diea t+i can
khan t+aonq danq dan moi co the t+a nh daoc +oi ao tinh t+a nq choanq
khonq hoi hac moi co the daa /enh nha n +a khoi tinh t+a nq choanq

TNG HUYT P
NGUYN NHN SINH BNH HC - BIN
CHNG
7,:.:: qax 7,-: W-a
MC TIU
1. Trnh by sinh bnh hc THA
2. Lit k nguyn nhn tha v c ch
3. Trnh by bin chng THA
I CNG
Tn sut bnh THA vo khong 18-20% dn s
T l kim sot THA tt < 30%
48

95% THA khng r nguyn nhn (THA v cn, THA nguyn pht) : bnh yu t

THA DO THUC
Thuc cam tho
Cam tho (reglisse carbenoxolon hay glycyrrhiza) thuc h Capilionace, lm
dng nhiu s gy ng c glycyrrhiza dn n tng aldosterone
Triu chng LS bao gm : THA, h kali huyt thanh
Thuc Corticoide
S dng ko di hay dng liu cao s gy THA do s mui v nuc
Thuc nga thai Estroprogesterone
C ch cha r, mt s gi thuyt a ra gi mui nc ca Progesterone v
s tng chuyn Renin thnh Angiotensin ca Oestrogen
5% ph n dng thuc c THA
Cn thn dng thuc cho BN c c a THA, bo ph, c bnh l thn
Khi dng thuc nn theo di huyt p nh k

THA DO HP EO MC
7% cc bnh tim bm sinh
C ch THA do cn ngi c hc, tng sc cn mch mu
49

LS: BN tr, THA chi trn, HA chi di thp, mch bn gim hay mt, thi tm thu
LS
3
tri, nghe r lng, gia ct sng, vng b vai
CLS: hnh khuyt ba di xng sn 3->6 trn Xquang lng ngc thng
SA tim, Scanner, MRI vng ngc, chp cn quang h, mch ch
BC ca hp eo MC: ST, v MC, VNTM bn cp, xut huyt no
iu tr ch yu l phu thut

THA DO THN
Bnh nhu m thn
+ Thn a nang
+ Thn nc
+ Vim cu thn cp
+ Vim cu thn mn
+ Lao thn
+ K thn (carcinome, sarcome, u wilm)
+ Hi chng Kimmelstiel-wilson
+ Vim quanh thn, p xe quanh thn
+ Chn thng thn
C ch THA do nhu m thn
+ S gim ti mu nhu m thn do tn thng vim v x cc mch nh dn n s
gia tng lng Renin
Bnh ng tit niu
Cc nguyn nhn gy tc nghn : si niu, u bu chn bn ngoi
C ch cha r
Bnh mch mu thn
Bnh thng gp, c th iu tr phu thut c
Hp M thn di 2 dng :
Hp M thn do x va, chim 2/3 cc trng hp
Hp M thn do di san si c, chim 1/3 cc trng hp
Cc xt nghim chn on : Siu m Doppler thn
Xquang h niu
Chp M thn
C ch : gim ti mu m thn lm hot ho h RAA

THA DO BNH NI TIT
Cng gip
Nhc gip
Cng tuyn cn gip
Hi chng Cushing
U ty thng thn
U v thng thn (hi chng Conn), cng aldosterone nguyn pht
To u chi

THA DO NGUYN NHN KHC

THA v thai k
- Chim 5% cc trng hp c thai
50

- THA trc khi c thai: THA c pht hin trc tun l 20 thai k
- THA trong thai k: THA c chn on sau tun 20 thai k
- THA 24 gi sau sanh
- Theo WHO, THA trong thai k : HATT 140mmHg hay HATTr 90mmHg
hay HATT> 25mmHg hoc 15mmHg so vi HA trong 3 thng u ca thai k
+ Bnh to keo : vim nt quanh M, lupus
+ THA trong phng : chim 25% cas, c ch cha r
+ Cc bnh l v no nh : u no, u tiu no, hi chng Guilain Barr, vim mng no
+ Sau phu thut ln : phu thut v no, phu thut lng ngc

II :
M x ho va phi,
tng phn quang v p vo
cc TM ti ch bt cho

III
Ph, xut tit v xut
huyt : cc M co tht nhiu v
x ho (si dy bc)

IV
Ph gai th ... xut tit v
xut huyt lan rng

I (theo Keith, Wagener v
Barker) :
Cc M vng mc hp nh tng
i so vi cc tnh mch
51

TAM PHE MAN
":. C:. "a ", "a Wxs,
/ // |.\
Chng tam phe: ln that P th phat do bat thng cua phoi, long ngc , thong kh phoi
hay tuan hoan -> suy that P.
Tam phe va suy that P :
Cap (thuyen tac MP)
Man (benh phoi tac nghen man nang, on nh)
Cap/man (BPTN man + nhiem trung + oxy mau)

Tam phe man
_ Day dan that P
_ Nguyen nhan
_ C che : tang ap MP

// /. '|I ///\

- 45t: a so
- Nam > N (hut thuoc)
- 20% suy tim nhap vien : suy tim P do tam phe
- > benh phoi TNMT -> tam phe : (5-10% benh tim ngi ln My)
- Kh phe thung
Viem PQ man

/// \|/\ \/\

1. BENH MACH MAU PHOI
2. BENH HO HAP :
TAC NGHEN
HAN CHE
Benh mach mau phoi
- Thuyen tac phoi tai phat
- Tang ap MP nguyen phat
- Benh mach mau do thuoc
- Benh mach mau chat tao keo
Benh ho hap
- Tac nghen:
50% trng hp tam
phe My
52

VPQ man va kh phe thung
Hen phe quan man
- Han che :
1. Noi tai : x phoi mo ke, cat phoi
2. Ngoai lai:
Beo ph, nhc giap, benh than kinh c
Veo cot song, tac nghen ng ho hap tren, ngi vung nui cao
Hoi chng ngng th luc ngu
Giam thong kh phe nang nguyen phat hay vo can (ondines curse)

/! . // /\/ |/\/
Tang ap MP -> TPM
P MP trung bnh = (CLT x sc can mach phoi) + P TMP.

2 loai nguyen do : nguyen do c the
nguyen do co that mach
Nguyen do c the : MP va cac nhanh b tat nghen hay x cng
Nguyen do co that mach (hoi phuc ) : giam oxy mau, toan mau.
^ P phe nang, ^ P mo ke phoi -> ep mao quan -> ^ sc can.

NGUYEN DO PHU
- ^ ap lc tnh mach phoi.
- ^ o nhay mau do a hong cau, phan ng mien dch cua BC, ket dnh tieu cau.
- ^ cung lng tim : gang sc, nhp tim nhanh.
- ^ lu lng mau phoi : luong thong T -> P.
- Thong noi gia MP hay TMP va M phe quan.
Tam that T
Dan va suy (cung cap oxy khong u).
R = K l / r
4

R: Sc can mach phoi
K : Hang so
: o nht mau
r : Ban knh mach mau

! /\/ |/\/ | I |//

53

Benh phoi man
Mang mau phoi
Hep co that ong mach phoi
O
2
a HC va
o nht
ap MP
Day va dan that P
Suy tim P
Toan huyet va
CO
2
Benh phoi man
Mang mau phoi
Hep co that ong mach phoi
O
2
a HC va
o nht
ap MP
Day va dan that P
Suy tim P
Toan huyet va
CO
2

S O COURNAND

SUY HO HAP DO DAN PHE NANG
DAN THAT PHAI
SUY TIM P
HEP VA CO THAT MP THIEU OXY MAU ONG MACH
^ pMP
TANG HONG CAU
TANG THE TCH
PH AI THAT PHAI TANG LU LNG TIM
54

!/ I|//| /|\ / \ !| \
3 giai oan
A. giai oan au
- VPQ man co boi nhiem, cha tang ap lc ong mach phoi
- Boi nhiem PQ -> viem dan phe nang, VPQ man
Giai oan bat au anh hng that p
1. Lam sang
- Kho th (gang sc)
- Xanh tm
- Ngon tay dui trong
- That P ln kn ao : Harzer +, nga phi P, T2 manh
2. XQ phoi
- MP ln
- That P ln kn ao
3. ECG
P phe ( P
I
dep P cao nhon D
II
, D
III
, avF)
Truc P : 80-90
0
Dau hieu C
I
(lead I sign): P dep, QRS, T bien o thap.
Truc QRS 110
0

Day that P: R cao (V
1
), S sau V
5
, V
6

Hnh anh gia nhoi mau c tim: R nho V
1
V
2
V
3
.
BLOCK nhanh P khong hoan toan

4. Huyet ong hoc
o P mp ^ (> 30 mmHg)
o P mao mach bnh thng
o P cuoi tam trng cua nh P, that P bnh thng khi cha suy tim P
5. Xet nghiem khac
o bao hoa oxy giam
P co2 ong mach tang
D tr kiem tang
Hct tang (> 55%)
Sieu am tim
C. Giai oan suy that P
1. Lam sang:
Kho th- xanh tm-TMC noi, gan to, phu
Kham tim: that P ln, nga phi P, SS h 3 la, SD h MP
2. Xquang: MP dan to, ap manh, that P ln
3. ECG: dau day that P ro, nhp xoang, loan nhp
4. Sieu am tim:
Hn ch trong vic nh gi a s cc th tng p MP

55

Du hiu tng p MP :
- M van MP chm
- Khc gia tm thu
- RVPET/ET tng.
- Sng a dt hay mt.
ng knh tht P th tm trng, chiu dy vch tht P.
p lc MP tm thu (Doppler)
Siu m tim qua thc qun khi siu m thnh ngc b hn ch.
5.Chp cng hng t
o khi lng tht phi, b dy vch, th tch bung tht v phn sut tng mu
6.Thng tim : o p sut mch mu phi, khng lc mch mu phi
7.Sinh thit phi
!// /\ /.\
A. +
- Tang ap MP do benh phoi hay co lien quan en ho hap
- Dau day that P suy tim P

B. phan biet
- Benh tim mac phai
- Benh tim bam sinh
C. nguyen nhan

VIEM NOI TAM MAC NHIEM TRUNG
" ": :. . q q a a x x 7 7, ,- - : : W W- -a a
/ | I//|
Trnh bay cac vi trung gay VNTM va lien he vi ng xam nhap cua chung
Mo ta trieu chng lam sang va can lam sang cua VNTM ban cap
Chan oan xac nh VNTM
// // |.\
Lch s
1761 Morgagni mo ta benh canh t vong au tien cua VNTMNT
1824 - 1835 Bouillaud at ten cho benh canh nay la VNTM
1883 W. Osler mo ta cac dau hieu lam sang cua VNTM ban cap
VNTM nhiem trung la benh do s lan tran vi khuan t nhng o sui nhiem trung t
noi mac tim hay noi mac ong mach
Co nhieu cach phan loai :
- VNTM cap , ban cp
- VNTM van t nhien , nhan tao, c a nghien ma tuy
Trc khi co khang sinh t vong 100%
56

1940 lan au tien ieu tr VNTM thanh cong bang Penicillin
Ty le t vong cao va ieu tr ton kem
Tien lng: phu thuoc:
- oc lc vi khuan
- C a benh nhan
- Sang thng tim c ban
- Thi gian phat hien
/// I \/\ |/\/
1.Lien cau khuan (streptococcus): 50% VNTM
Streptococcus Viridan: VNTM ban cap
Lien cau khuan khac: S. Mutan, S. Sanguis, S.Minor, S. Salivavirus, S. Mileri
Streptococcus nhom D (Theo PL Lancefield):
- Enterococcus: S. Faecalis, S. Faecium, tang sinh mon, khang Penicillin
- Non Enterococcus: S. Bovis, ruot, thng gay VNTM sau PT K ai
trang, con nhay Penicillin
Streptococcus nhom B: VNTM cap, t cung, c a sc e khang kem nh cac
benh ac tnh.
2.Tu cau (Staphylococcus): 30% VNTM
S. Aureus: VNTM cap, thng t ngoai da, at Sonde benh vien, chch ma tuy.
Khang Penicillin
S. Epidermidis, S. Albus: VNTM ban cap, c a co dung cu nhan tao (van nhan
tao)
3.Cac tac nhan khac
Nam: Candida Albican (chch ma tuy) va Aspergilus (van nhan tao)
Sui thng ln, gay thuyen tac nhieu ni
Nhom vi khuan song trong te bao: Chlamydia, Mycolasma, Listeria, Legionella,
Burnetii kho nuoi cay
Vi khuan Gram (-) khac:
- Nhom HACEK: Haemoplilus, Actino baciluss, Cardiobacterium,
Eikenella, Kingella. Vung hau hong kho nuoi cay
- S. Pneumonia, E. Coli, Klebsiella, Pseudomonas, Enterobacter
/! /\/ / |/\/
S hnh thanh cac mang sui nhiem khuan tai noi mac tim
Ton thng noi mac
S hnh thanh huyet khoi si huyet tieu cau : huyet khoi vo trung
Du khuan huyet: huyet khoi hu trung
Cac khang the ket dnh
Hau qua cua s hien dien mang sui nhiem khuan
Tai tim
- Thung van, rach van
- t day chang
57

- Abces vong van, vach lien that, c tim, xoang valsava
- Tac lo van (sui ln, at biet VNTM do nam)
Ngoai tim
- Thuyen tac va abces cac mo ngoai vi
- Phnh mach v
- Phc hp MD cac sang thng mien dch
! // |/| |/\/
Cac sang thng c ban trong VNTM
Sui
Loet
Sui + Loet
ai the
Sui: nhng hat nho, nh tren van hay vach tim nh bong cai. Hong xam nhat
Loet: thng ba van, nong hay sau. Loet sau gay thung van, vach lien that
Cac ton thng van tim, abces c that, vong van
Tac mach, abces c quan khac, sang thng MDch
Vi the
Vi khuan, bach cau, tieu cau, si huyet va cac mo hoai t

/ \ !\I\I |\ | (BENH OSLER)

Bang chng xam nhap vi khuan:
- Trieu chng thng khi phat am tham sau thi gian xam nhap cua vi khuan (vai
tuan - vai thang)
- Vi khuan co the xam nhap t:
Da
Vung rang ham mat - hau hong
ng nieu sinh duc
ng tieu hoa
Do nhan vien y te: cac thu thuat
T cac vet chch khong vo trung ngi chch ma tuy
!/ / \
1. Hoi chng nhiem trung
Sot: - Thng gap
- Hang nh
- Co the khong sot
Trieu chng kem theo:
- Chan an
- Met moi
- Sut can
58

- au c
- Xanh xao
2. Cac dau hieu tai tim
- Co the nghe cac am thoi co t trc do sang thng tim co san
- S xuat hien cac am thoi mi do h van (2 la hay MC), s thay oi ot ngot ve
cng o va am sac tieng thoi cu: co gia tr gi y chan oan VNTM
- Suy tim cap do thung van hay vach tim
- t gap bien chng loan nhp
3. Cac dau hieu ngoai tim
Da niem:
- Xuat huyet dang cham chi, di mong, ket mac mat
- Ngon tay dui trong, xuat hien tre gap 25% trng hp
- Not Osler
- Sang thng Janeway
Lach to: 30-40% trng hp, mem va au
Tieu mau ai the hay vi the
Tac mach nao, phnh mach, co the gay abces nao, XH nao
Roth spot, hiem co mu ot ngot do tac M vong mac
Dau tac mach ngoai vi
!// \ / \
1. Cay mau
- (+) cao: 85-95%
- Benh ban cap, cha co T , cay mau 3 lan trong 3-6 gi va bat au T.
- Neu benh cap, cay 3 mau cach 30 phut , khi ong KS khong cham hn 2 gi
- Neu a dung KS, nen ngng KS 24-48 gi va sau o cay mau
2. Sieu am tim :
- Phat hien sui > 2mm
- anh gia cac ton thng c ban va phat hien ton thng mi
- Phat hien cac bien chng
- anh gia chc nang that trai
3. Xet nghiem bo sung
Cong thc mau, toc o lang mau
Tong phan tch nc tieu
Mien dch
X quang long ngc
ien tam o
Soi ay mat
!/// /\ /.\
- Nen ngh en VNTM tat ca benh nhan co sang thng tim co bieu hien sot ma
cha xac nh c o nhiem
- Chan oan VNTM co the da theo tieu chuan Duke (1994) nh sau:
59

+ Co 2 tieu chuan chnh
+ Co 1 tieu chuan chnh + 3 tieu chuan phu
+ 5 tieu chuan phu
1. Tieu chuan chnh
Cay mau
- Phan lap c : S. Viridans, S. Bovis, HACEK, Staphylococcus,
Enterococcus qua 2 mau cay, hoac
- Phan lap VK phu hp gay VNTM 2 mau cay cach nhau tren 12 gi, hoac
- Phan lap c cung 1 loai VK tren ca 3 mau cay rieng biet (mau au va
cuoi cach nhau t nhat 1gi)
Sieu am
- Mang sui di ong, hoac
- Ap xe, hoac
- Mi phat hien co h van nhan tao hay van t nhien
2. Tieu chuan phu
a. Co benh tim de gay VNTM, hoac nghien ma tuy
b. Sot 38C
c. Thuyen tac M ln, nhoi mau phoi nhiem trung, phnh mach, XH noi so,
XH niem mac mat, ton thng Janeway
d. Viem vi cau than, not Osler, Roth- spot, yeu to thap
e. Cay mau (+) nhng khong u cac tieu chuan chnh, hoac bang chng huyet
thanh (+) vi cac loai VK thng gay VNTM
f. Sieu am phu hp VNTM, nhng khong u tieu chuan chnh
- Chan oan phan biet:
+ Thap khp cap
+ Benh ac tnh ve mau
+ Benh Lupus
+ U nhay nh trai
+ Cac nhiem trung phoi, ng nieu, ng sinh duc
- Loai tr VNTM:
+ Co chan oan khac
+ Cac trieu chng mat i sau ieu tr khang sinh 4 ngay
+ Khong co bang chng VNTM khi phau thuat hay mo t thi
- Nghi ng VNTM
Khong u tieu chuan C xac nh, nhng khong the loai tr
/' |/I /|\
Benh nang , tien lng t vong con cao, ieu tr ton kem.
Canh giac benh VNTM, khi ng trc benh canh sot phoi hp benh tim mach.
Kham nh ky ve rang ham mat cho cac benh nhan co benh tim
D phong khang sinh cho cac benh nhan co nguy c VNTM trc khi tien hanh
cac phau thuat.

60

Bao am vo trung khi lam thu thuat.

VIEM MANG NGOAI TIM
":. C:. "a ", "a Wxs,
/ // |.\
MNT : - La thanh
- La tang
- Dch MNT : 15 50 ml
Chc nang MNT :
- Ngan s dan ot ngot buong tim
- Giup o ay nh th tam thu that
- Ngan di lech
- Giam s co xat gia tim va cac to chc lan can
- Cham s lan rong cua nhiem trung
// // |/| |/\/
Viem MNT kho : MNT xung huyet , BC a nhan tu lai, tiet fibrin
Viem MNT tran dch : MNT viem , tiet dch nhieu
Viem MNT co that : MNT viem , day dnh , co that .
/// |/\ /./
A. Phan loai lam sang
B . Phan loai nguyen nhan
A. PHAN LOAI THEO LAM SANG
1. VMNT cap ( < 6 tuan )
- Tiet Fibrine
- Tran dch ( thanh dch hay co mau )
2.VMNT ban cap ( 6 tuan 6 thang )
- Tran dch - Co that
- Co that
3. VMNT man ( > 6 thang ) :
- Co that
- Tran dch
- Day dnh ( khong co that )
B. PHAN LOAI THEO NGUYEN NHAN
1. VMNT nhiem trung :
Sieu vi ( Coxsackie A va B , Echovirus , Adenovirus , quai b , viem gan ,
HIV )
Vi trung sinh mu ( Staphylococcus , Streptococcus ..)
VT lao
Nam ( Candida , Histoplasmosis , Coccidioidomycosis

61

Nhiem trung khac : giang mai , ky sinh trung , nguyen sinh ong vat
2. VMNT khong nhiem trung :
Nhoi mau c tim cap
Tang ure mau
U tan sinh:
* U nguyen phat ( lanh , ac )
* U di can ( K phoi , K vu , Lymphoma )
_ Chan thng ( xuyen thau thanh ngc )
_ VMNT vo can cap
_ Sau tia xa
Suy giap
Cholesterol
Tran dch bach huyet
Phnh MC boc tach
Sot a trung Hai co tnh cach gia nh
VMNT co tnh gia nh ( chng lun Mulibrey )
Sarcoidosis
3. VMNT lien he phan ng qua man hay t mien :
_ Thap tim
_ Benh mach mau chat tao keo
Lupus , VKDT , viem cng cot song , x cng b
_ Thuoc : (Procainamide , Hydralazine , Dilantin , Isoniazide, Doxorubicine ,
Minoxidil , thuoc khang ong ..)
_ Sau ton thng tim :
* Sau nhoi mau c tim ( H/C Dressler )
* Sau m mang ngoai tim
* Sau chan thng tim
/! !// \ \./ I/ |
au ngc
Tieng co mang tim
Thay oi ECG
TDMT vi chen ep tim
Mach ngch
1. au ngc
Khong hang nh
Thng (+): VMNT nhiem trung cap, cac the lien he phan ng qua man hay t
mien
Thng (-): VMNT do , sau tia xa, u tan sinh hay do ure mau cao
Tnh chat
au kieu au mang phoi
au kieu au thieu mau c tim
Giam: ngoi day, cui ra trc
62

V tr: gia ngc( sau xng c , trc tim T) ,lan en lng va c thang
2. Tieng co mang tim
Quan trong nhat
3 thanh phan/ chu chuyen tim
Ro khi ngoi, nghieng ra trc, ap manh ong nghe, th TR
Tam thi, mat trong vai gi, tai xuat hien ke tiep
3. ECG
+ Viem MNT cap ( khong tran dch lng ln )
Bieu hien nhng thay oi th phat cua viem cap lp di thng tam mac
ST tan toa (2 hay 3 T chuan, V2 -> V6)
ST (ch aVR, thnh thoang V1)
QRS khong thay oi, hoac ien the
ST ve ang ien (sau vai ngay)
T ao ngc
oan PQ : lien quan nh
+ TDMNT lng ln:
+ QRS giam ien the, song T det .
+ NTT nh, rung nh thnh thoang (+)
4. Tran dch mang ngoai tim
a. Trieu chng lam sang:
C nang: Nang ngc, chen ep cac c quan
Lam sang
Mom tim: kho s
Tieng tim m
Co mang tim mat, hay con nghe ro
Ewarts sign
Gan to , TMC noi
b. Can lam sang
+ X quang: To, Bau nc hoac bnh thng hay gan bnh thng
ng m MNT
Bong tim ap yeu
+ Sieu am:
Khoang trong echo (+)
TD lng ln: tim du a t do trong khoang MNT
Nang: mc o chuyen ong thay oi, ket hp so le ien the
Chen ep tim: HV: that P tang , that T , lo m van 2 la .
oi khi that P , chuyen ong vao trong cuoi tam trng cua vach t do that P, nh P

+ Chan oan dch MNT hay day mang tim:
Thong tim Chup cat lp ien toan
Quang tam mach MRI

63

+ Choc do dch, MNT:
Dieulafoy, Marfan

5. Chen ep tim
Dch MNT -> tac nghen dong mau o ve that
Lng dch t # 200ml, nhieu # > 2000ml
Nguyen nhan:
3 nguyen nhan thng gap :
Benh tan sinh
VMNT vo can
Tang ure mau
Chen ep tim nang cap :
Giam P ong mach
Tang P tnh mach
Tieng tim m
Chen ep tim phat trien dan
Lam sang giong suy tim : kho th , gan huyet , tang p TM co
Vung uc trc tim rong . Mach nghch ( +)
X Quang :
- Phoi tng oi sang
- Tim ap yeu . Bong tim ln hay bnh thng

ECG : QRS giam ien the .
So le ien the cua P , QRS T hay ch cua QRS
Nhp cham ot ngot + phan ly ien c ep tim cap do v tim

Sieu am tim : That P giam ng knh . Co chuyen ong vao trong cuoi tam trng
cua vach t do that P nh P
6. Mach nghch
Dau quan trong trong chen ep tim
Giam HATT ong mach th HV >10mmHg
1/3 Bn VMNT co that
Mach nghch co the gap trong nhieu benh khac
! !// \ \./ I/ . I/I \
1. ai cng
VMNT cap tiet fibrine hay fibrine thanh dch, TDMNT man

ieu tr mo hat

Tac nghen khoang MNT

64

Co that, seo cng bao quanh tim

Can tr o day that
2. Nguyen nhan
3. Sinh ly benh
CLT giam
P cuoi tam trng 2 that tang, p trung bnh nh, TMP, tnh mach he thong
tang
4. Trieu chng lam sang va can lam sang
a). C nang:
Met, yeu
Kho th
Phu
b). Kham
TM co noi, Kussmaul (+), Mach nghch (+)
Tim
Kch thc bnh thng (1/2 cases)
Tieng tim xa xam
Paricardial knock
Mom kho xac nh
Gan to, roi loan chc nang gan, bang bung, lach ln
c). Can lam sang
ECG: ien the thap, T det hay (-) lan toa
P mitrale (+) (nhp xoang)
Rung nh (1/3 case)
X quang: bong tim bnh thng, ln nhe; bien o ap giam. MNT ong voi
Sieu am: MNT voi, day
Cong hng t: chan oan MNT chnh xac hn
5. Chan oan
1. Chan oan (+)

2. Chan oan #:
Tam phe man
Hep 3 la, hep 2 la
Benh c tim han che

65

X TR PHU PHOI CAP
C: 7,xye 7xa "xa A
/ //\/ \//
Phu phoi cap (PPC) la tnh trang thoat dch vao long phe nang t mao mach phoi
PPC xay ra khi ap lc mao mach phoi vt qua ap lc giup keo nc vao ben
trong long mach mau (bao gom ap lc keo huyet tng va ap lc thuy tnh mo ke). Ban
au dch ong mo ke phoi, sau o tran ngap vao trong long phe nang va gay roi loan
chc nang trao oi kh. Nguyen nhan chnh cua s gia tang ap lc mao mach phoi la tnh
trang suy tim trai va khi co tat nghen dong mau chay qua van 2 la (hep van 2 la hay u
nhay nh trai).
// /\/ // |/\/
1. Khi benh nhan b suy tim, ap lc tnh mach phoi tang dan en s mau
he thong mach mau phoi vi cac thay oi sau:
- Tang khang lc ng th nho
- Giam o an hoi phoi
- Tang dan lu he bach huyet, ieu nay nham duy tr mot the tch dch hang
nh ben ngoai mach mau
Bieu hien lam sang la benh nhan th nhanh hay kho th nhe
2. Khi mc o suy tim nang hn, ap lc trong long mao mach tang va dch
thoat ra khoi long mach mau dan en phu mo ke. Bieu hien lam sang la mc o kho
th tang them va bat au co roi loan trao oi kh.
giai oan nay ta co the thay thay oi tren X quang long ngc: ng Kerley B va b
cac mach mau m i. Ve mat giai phau ta thay cho tiep noi cac te bao noi mac mao
mach phoi rong ra dan en s thoat dch vao mo ke
3. Khi ap lc trong long mach tang them: phu phe nang.
Cho tiep noi cac te bao lot trong long phe nang b h ra khien dch tran vao phe nang (
cha hong cau va cac ai phan t ). Nh vay trong cn phu phoi cap, ta thay co 2 hien
tng quan trong:
Gay, v mang phe nang mao mach
Dch phu ne tran ngap phe nang va ng ho hap
Lam sang:
Ran am 2 ben phoi
Khac ra bot hong
Lo lang, vat va, toat mo hoi am a, kho th d doi
Can lam sang:
M lan toa 2 phe trng nhat la 2 ron phoi
Roi loan trao oi kh: giam oxy mau
Dien tien: toan mau, tang than kh mau va ngng th
Tnh trang thoat dch ra khoi long mach mo ta tren tuen theo nh luat Starling
ve s trao oi dch gia mao mach va mo ke:
66

S tch tu dch
[( ) ( )]
c if pl if lymph
K P P Q
=

K: he so dan thuy lc (ty le vi dien tch mang)
P
c
: ap lc trong long mao mach
P
if
: ap lc mo ke
pl
: ap lc keo huyet tng
if
: ap lc keo mo ke
Q
lymph
: lu lng dch bach huyet
: he so cua ai phan t

Ap lc di chuyen dch ra khoi mach mau: P
c
va
if

Ap lc di chuyen dch vao lai long mach mau: tong cua P
if
va
pl

// \|/\ \/\
Nguyen nhan c chia theo c che mat can bang cac lc theo nh luat starling gom co:
A-Tang ap lc mao mach phoi
1.Tang ap lc mao mach phoi ma khong kem suy that trai (vd: benh hep van 2 la)
2.Tang ap lc tnh mach phoi th phat sau suy that trai (cao huyet ap, benh van 2
la, van ong mach chu, benh mach vanh, roi loan nhp tim)
3. Tang ap lc mao mach phoi do tang ap lc ong mach phoi (phu phoi do ti
mau qua mc)
B-Giam ap lc keo huyet tng: giam albumin mau
C-Tang ap lc am mo ke: rut kh vi ap lc am ln trong trng hp tran kh mang
phoi)
Ngoai ra con cac nguyen nhan khac nh tang tnh tham thanh mach (hoi chng suy
ho hap cap ngi ln) xay ra trong cac benh canh nh viem phoi, ht phai kh oc,
choang
/// I|//| /|\ / \ ! \ / \
A/ C nang:
PPC thng xay ra ban em (sau khi ngu) hoac sau khi gang sc. Benh nhan thay
kho th d oi, ho tng cn ru ri, khac ra bot hong. Benh nhan kho th phai ngoi, tm
tai, chi lanh, am.
B/ Thc the:
Ran am, ngay, rt dang len t ay phoi len nh phoi
Mach nhanh( co khi khong eu: rung nh)
Tim co tieng gallop
Huyet ap thay oi ( co khi cao: cn cao HA, co khi thap: hep van 2 la, suy tim
nang)
C/ Xquang: tham nhiem m, b khong ro, quanh ron phoi 2 ben, ng Kerley B.

67

D/ Cac xet nghiem khac: giup theo doi va ieu tr cn PPC gom co: ECG, ion o, BUN,
Creatinin, CTM, kh mau ong mach (lam nhieu lan), men tim. Sieu am tim ac biet quan
trong v co the xac nh benh tim can ban (benh van tim, thieu mau cuc bo c tim, benh
c tim nguyen phat) va anh gia c mc o tram trong (phan suat tong mau EF).
Ta nen s dung sieu am tim trong giai oan cap cu khi ap ng vi ieu tr co ve cham
hoac khi co nghi ng bien chng c hoc cua nhoi mau c tim.

/! /\ /.\ |/\ |//I
Hen phe quan, benh phoi tac nghen man tnh, viem phoi, cac nguyen nhan gay suy
ho hap
Phu phoi khong do nguyen nhan tim mach: ton thng phe nang do thuoc, hoi
chng suy ho hap cap ngi ln- ARDS (Acute respiratory distress syndrome)
! ///| I|/ |/| |/./ |
PPC la mot cap cu noi khoa do o can x tr nhanh, manh. Cac bien phap ieu tr gom
co:
- Can truy tm va loai bo cac yeu to lam nang suy tim
- ieu tr cap cu khong ac hieu: thay thuoc can tien hanh ong loat cac
bien phap sau:
1. ieu tr nang ban au:
- Cho benh nhan th oxy: th oxy qua sonde hoac qua mask 6-8 L/phut, muc
tieu PaO2 > 60mmHg. Ch nh thong kh c hoc (th may) khi benh nhan b
tang than kh trong mau hoac khi oxy mau khong tang len sau khi dung cac
bien phap khac.
Phu phe nang ngan can s khuech tan oxy giam oxy mau ong mach.
Cho benh nhan th oxy vi ap lc dng giup: tang ap lc long phe nang,
giam tham dch t mao mach phoi, giam lng mau tnh mach o ve phoi,
giam ap lc mao mach phoi.
- at benh nhan t the ngoi, chan thong xuong giam mau tnh mach tr
ve.
- Thiet lap mot ng truyen tnh mach.
2. ieu tr bang thuoc:
- Morphine sulphate 2-5 mg (TM), lap lai nhieu lan moi 10-25 phut cho en
khi co hieu qua.
Giam lo au, giam kch thch giao cam co mach cac tieu ong mach va tnh
mach ( dan tnh mach)
Chu y can co san Naloxone va dung no khi co suy ho hap do morphine
- Furosemide: thuoc li tieu manh, co tac dung tot nhat trong cac trng hp
suy tim man co d the tch tuan hoan, tuy nhien thuoc cung co hieu qua
trong bc au ieu tr PPC. Lieu khi au t 20-40 mg (TM) trong vai
phut, va co the tang lieu tuy theo ap ng cua benh nhan en 200 mg la
lieu toi a cho cac lan dung sau o. ay la thuoc li tieu quai chch tnh
68

mach co tac dung li tieu nhanh, lam giam the tch tuan hoan giam phu
phoi
Ngoai ra furosemide con co tac dung lam giam mau tnh mach ve tim
giam phu phoi ( tac dung sm sau vai phut, trc ca tac dung gay li tieu)
Tuy nhien viec s dung thuoc nen than trong, ngi thay thuoc can anh gia
xem benh nhan co tnh trang d nc hay muoi trong c the hay khong.

- Nitroglycerine: tac dung dan tnh mach, tang tac dung cua furosemide.
Dung ng truyen tnh mach khi HA tam thu > 105 mmHg, lieu khi au
10 g/ phut, o lai HA sau 30 phut, sau o tang dan len tuy theo ap ng
lam sang va HA benh nhan. Thuoc co the dung ngam di li vi lieu 0,2-
0,8 mg moi 5 phut. lieu ln hn 300-400 g/phut, tac dung tot cua thuoc
khong tang them. Do kha nang lam giam tien tai va hau tai nhanh nen
thuoc co vai tro quan trong trong x tr PPC benh nhan khong b choang
tim

- Nitroprusside sodium (IV) lieu 20 30 g/phut co tac dung giam hau tai
dung khi benh nhan co HA tam thu > 100 mmHg. S dung trong nhng
trng hp PPC do h van cap hoac tang HA. Nen theo doi huyet ong
bang cac at catheter theo doi ap lc phoi va ap lc ong mach.

- Cac thuoc lam tang sc co bop c tim: khi a cho thuoc dan mach va li
tieu ma theo doi thay viec ieu tr co ve khong hieu qua, nhat la khi a
dung ti furosemide lieu cao, ta co the dung them cac thuoc kch thch giao
cam. Thuoc c dung khi benh nhan khong b ha HA la dobutamine. Muc
ch s dung la lam tang sc co bop c tim. Trong trng hp benh nhan b
ha HA ( HA tam thu < 80 85 mmHg hay HA trung bnh < 60 mmHg), cac
thuoc ch lam tang sc co bop c tim n thuan nh dobutamine t khi c
dung n oc. Trong trng hp nay phai dung thuoc va co tnh van mach
va va tang co bop c tim nh dopamine. Khi au bang lieu thap: 2,5 5
g/ kg/ phut e th xem ap n gcu3a benh nhan. Sau o tang lieu dan
nhng khong nen qua 10 g/ kg/phut oi vi dopamine va 15 g/ kg/ phut
oi vi dobutamine. lieu nay tac dung kch thch beta at mc toi a va
bat au co tac dung kch thch alpha giao cam gay tang sc can ngoai bien
khong co li cho s co bop c tim. Dopamine 5-10 g/ kg/phut khi co giam
HA. Dobutamine 2,5 5 g/ kg/phut.

- Digoxin 0,75 1 mg TM cham trong 15 phut benh nhan suy tim tam thu
cha dung c digoxin

- 1 vai trng hp co the dung aminophylline 240 mg (TM) tac dung giam co
that phe quan, tang ti mau ti than, tang thai Natri, tang sc co bop c tim
69

- Neu cac bien phap tren khong co hieu qua garrot 3 chi luan phien (hien
nay t lam)
3. Chay than nhan tao va sieu loc: co the co hieu qua nhat la cac benh nhan co
roi loan chc nang than va khang thuoc li tieu
4. Thong tim phai (catheter Swan-ganz): nen lam khi benh nhan khong ap ng
nhanh vi ieu tr. Thong tim phai o c cac tr so huyet ong trung tam va cung
lng tim giup ta co the phan biet c PPC do nguyen nhan tim mach hay khong
do tim mach
5. ieu chnh cac yeu to lam nang suy tim:
- tang HA nang
- Nhoi mau c tim cap - TMCT (nhat la khi co h 2 la kem theo)
- H van cap
- Roi loan nhp nhanh (rung nh) hay nhp cham
- Qua tai tuan hoan khi benh nhan co suy tim trai
- Thuoc lam giam co bop c tim ( thuoc c che thu the beta)
- Gang sc qua mc.

Sau khi ieu tr cap cu va xac nh cung nh loai bo cac yeu to lam nang ta can
chan oan xac nh benh tim c ban gay PPC ( neu cha ro chan oan)
Sau khi benh nhan on nh chien thuat lau dai nga PPC tai phat (co the can phau
thuat)
Viec ieu tr thanh cong PPC thng ch at c khi ieu chnh c cac benh l
c ban

!/ |/I /|\
PPC la mot cap cu noi khoa do suy tim trai tram trong hoac do co s can tr mau
t nh trai xuong that trai (hep van 2 la). Thai o x tr can nhanh chong, thay thuoc phai
theo doi sat dien tien cua benh nhan va s dung ong thi cac bien phap dung thuoc
cung nh khong dung thuoc. Song hanh vi viec ieu tr PPC, can tm va loai bo cac yeu
to thuc ay suy tim nang len cung nh xac nh ro benh ly c ban cua benh nhan e co
ke hoach ieu tr nga PPC tai phat.

70

BENH MACH VANH
CAC THE BENH AU THAT NGC (TN)
: 7,xye Wxy Cx,
| I//|
- Hieu moi lien he sinh ly benh noi tai thong suot gia x va M vanh , benh
mach vanh , suy vanh tc thieu nang vanh , thieu mau cuc bo c tim va benh danh tap
hp Benh tim thieu mau cuc bo (BTTMCB) trong o bao gom ca nhoi mau c tim
(NMCT) va cac the TN
- Tien hanh c quy trnh hoi benh va tham kham benh nhan TN , chan oan
phan biet c TN on nh , TN khong on nh , TN bien thai .
T KHOA : BTTMCB , BMV , can can cung cau , TMCB c tim tham lang , NMCT ,
TN on nh , TN bien thai , nghiem phap gang sc , nghiem phap stress .

/ // |.\
1 Cac benh danh :
- Benh tim thieu mau cuc bo (BTTMCB) IHD la benh danh c WHO chnh
thc khuyen cao .
- o la benh mach vanh (BMV) , cu the la thanh mach vanh b thng ton (>90%
do x va M) . (Than MV nao , nhanh MV nao b nh the se khong hoan thanh tot chc
nang tot chc nang chuyen mau , tc suy vanh hoac thieu nang vanh) . Hau qua la
tng vung nho (cuc bo) cua c tim tng ng (von do nhanh MV o phu trach ti mau)
se b giam cung cap mau mang oxi khi tnh va nhat la khi hoat ong , vung c tim ay b
TMCB (ischemia) . TMCB tng vung c tim la cot loi he trong nhat cua benh tim nay nen
ten goi chnh thong phai la BTTMCB.
- S thc BTTMCB la mot benh danh tap hp,bao gom hn chuc the LS. Trong o
2 benh danh quen thuoc nhat la NMCT va TN .

2 Xep loai cac the benh trong BTTMCB : gom nhieu the LS
The LS TN thc ra gom 3 the khac nhau :
- TN on nh (TNO)
- TN khong on nh (TNKO)
- TN bien thai vi cn co that MV ln be mat , do Prinzmetal xac lap t 1959 .
Ngoai ra con co 2 the ac biet khac :
- Hoi chng X : cung cn co that M nhng khong phai MV ln nh trong TN
bien thai , ma cac nhanh type B xuyen be day c tim
- TMCB c tim tham lang : tham lang vi ngha la hoan toan khong au cho nen
khong xep vao 3 the TN ke tren , nhng cung la cn TMCB c tim nh vay . Ghi
ro c nhng t 5 7 phut (cung co the lau hn) oan ST chenh xuong tren ien
tim Holter 24 gi , hoac tren ien tim nghiem phap gang sc .
71

5 the benh ke tren la cac the benh chc nang . Ben canh chung co cac the benh
co ton thng thc the la hoai t : NMCT ,cung gom nhieu the :
- NMCT co ST chenh len
- NMCT khong co ST chenh len
- NMCT tham lang .
Ngay nay , trong 5 the chc nang neu tren , tach tieng TNKO , con lai 4 goi la
BTTMCB man . Mi xac lap lai nhom BTTMCB cap goi la Hoi chng vanh cap bao
gom 4 the benh :
- NMCT co ST chenh len
- NMCT khong co ST chenh len
- TN khong on nh
- ot t do MV
Ngoai ra BTTMCB con 2 the ac biet :
- Loan nhp tim do MV
- Suy tim do MV (nh vay bao gom het c dien BN co benh MV ke ca nhng ai
cha bao gi trai qua NMCT hay TN bao gi .
3 Sinh ly benh :
- Can can cung cau :
ieu ma SLB nhan manh trc tien chnh la TMCB c tim , tc la s ti mau tai 1 vung
c tim thoang b thieu hut .Trong tng thi gian ngan ay , s thieu hut xay ra v mat thang
bang can can cung cau ve oxi : cung < cau .
- Cac bien oi rieng trong NMCT : Thieu oxi mo (hypoxia , anoxia) tuyet oi hoac
keo dai tai mot vung c tim lam cho no hoai t la do MV tng ng a b tac hoan toan
trong vong 4 gi ke t luc khi phat cn au (thay 95% BN b NMCT)
S tac nghen o thng do huyet khoi mi sinh . Huyet khoi nay lien quan en hien
tng viem tai cho , gay bien chng cua mang x va : ran , nt , v , gay roi t ri vo
mang x va vi ket von tieu cau xung quanh tao ra mot huyet khoi trang , roi them ca
hong cau va huyet cau khac quan trong t huyet tao thanh huyet khoi o hoan chnh ,
hon hp . Cuc thuyen tac di ong theo dong mau ti oan MV hep hn lam gi no lai .
Thng co them vai tro cua cn co that manh chon ung nhng khu vc MV b x va
va/hoac b huyet khoi . oi khi con co xuat huyet nhng tan mach pha di mang x va
, oi no len , lam hep them long ong mach .

Ghi chu: Tien trien cua vung hoai t:
Xuat hien 3 vung gan nh ong tam va long vao nhau tnh t ngoai vao la vung
TMCB , ton thng , hoai t
Ba vung nay phat trien lien tuc , va la qua trnh thuan nghch (tr hoai t , no ch
se x hoa ma thoi)v du TMCB lien tuc quay tr lai mo bnh thng hay ngc lai chuyen
thanh ton thng ; Ton thng th lap tc hoac quay tr lai TMCB , hoac chet ngay (hoai
t) .Ca ba vung o , khi khi phat trien eu t lp c tim sat noi tam mac tien ti lp c
tim sat thng tam mac . Gi th nhat co the bat au hoai t , e se tr nen xuyen
thanhthng gi th 6
72

Vung hoai t va vung TMCB bao quanh se gay ra : (1) tr ngai co bop lam giam
chung cung lng tam that (Suy tim) ; (2) gay bat on inh ien hoc (Loan nhp tim nh
nhp nhanh tren that , rung that) hoac tr ngai dan truyen xung ong ien (block) ; (3)
gay toan huyet chuyen hoa do sinh nhieu acid lactic trong hoan canh yem kh
Vung hoai t nay co bieu hien roi loan chuyen ong vung (giam ong , bat ong ,
loan ong) , co the b bien chng c hoc (mong , phnh , v, thung) , co the tao huyet khoi
mat trong thanh that , neu bt rase thanh thuyen tac trong ai tuan hoan (nao , mac treo ,
chi di )

// /\ /.\ I// |/\/ /| I/I \|
1 TN ON NH :
- La the benh kinh ien tc la a c mo ta t lau nhat , cung la the thng gap
nhat .
- La TN gang sc : xay ra nhng cn au khi gang sc va neu ngh th het . Neu
ien hnh , cn au nh bop nghet hoac e nang sau xng c , lan len ay co , ham di
, vai trai hoac ra sau lng vung gian ba , co the xuong thng v nhng thng mo ta
ve cac au ngc kieu MV
- Ngng gang sc cho phep : Cn au dng nh khong xay ra neu gang sc
nho hn mot ngng cho phep nhat nh , vt ngng o la b cn au (moi BN
thng t biet rat ro).
- Goi la on nh v ngng gang sc cho phep thng kha on nh trong nhieu
nam (nen cung goi la TN man)
1.1 Tam quan trong cua viec hoi benh :
- Hoi benh t m va theo mot quy trnh chat che ve cac ac iem cua moi cn au :
tnh chat , v tr , hng lan , o dai , cac hoan canh gay ra hoac cham dt cn au . V du
: mot BN TN on nh co the thu thap : au co tnh chat nang/e ep/nghet (nh
khong th c)/nghen (nhng khong ra c) ; BN khong ro iem cu the nao au
ma noi au pha trong sau xng c ; lan tan co , ham di , vai hoac canh tay , keo dai 2
5 phut , sinh ra do gang sc hoac cang thang au oc ; giam va het nh ngh tnh hoac
ngam di li Trinitrin (tac dung dan tnh mach , giam tien tai )
- oi khi co the kem theo mot so trieu chng cua than kinh t chu nh toat mo hoi,
buon oi , oi , hoi hop , trong ngc , kho th , chong mat .
- Cung nh hoi benh e tham khao ve benh s , tien can va cac yeu to nguy c .
1.2 Chan oan con da vao tham kham : bao gom :
- Tham kham LS va CLS (sinh hoa , X Quang ) chi tiet con giup tm s lan rong
cua XVM nhng vung khac (nao , than , cac chi di , ong mach chu , ) , giup xet
them ve nhng yeu to nguy c XVM (v du tong ke lipid e ieu chnh neu can ).
- ECG :
+ Kho lam kp trong cn au , nhng rat co gia tr chan oan . V du : co ST chenh
(hoac T vanh hoac loan nhp tim)

73

+ Ngoai cn au lai co the co san t trc nhng thay oi ST , T , tham ch ca QS ,
nhng chang ai dien cho cn au nay cua the benh TN ; ngc lai mot ECG ngoai cn
ma bnh thng rat hay gap vay chang the loai tr chan oan .
- SA tim 2 chieu Doppler :
+ Xet roi loan chuyen ong vung
+ Day that trai , h van van tim chc nang .
+ Tang ap ong mach phoi
+ Phan suat tong mau EF bnh thng 55% hay a giam < 40% (V du :
mot BN TN ro ma EF < 50% th o la ch nh quy cho can thiep nong MV hay phau
thuat bac cau chu vanh)
- Mot tham kham ay u nhieu khi con can :
a) ien tim Holter (mang theo ngi , ghi 24 gi)
b) ien tim cua nghiem phap gang sc (NPGS):
Xe ap hoac tham di ong (neu khong co CC nh suy tim , hep van ong
mach chu) , ch sc gang ti mc lam tang tan so tim en 85% cua mc toi a
d kien cua la tuoi .
Nghiem phap gang sc (+):
- Da oan ST nhenh : ST mi chenh len hoac chenh xuong > 2mm
nhieu ao trnh hoac ngay khi au NPGS . Cang ro NPGS (+) khi ST
chenh o lau tr ve ang ien sau NPGS .
- Cung da vao khong the gang sc hn 2 phut , ha HA , dau hieu suy
tim .
c) Cac nghiem phap stress (NP stress) khac . NPGS va neu cung la NP
stress , lai co NP stress dc ly . Tang cong tai cho tim (tc tang cau oxi) , thay v
bang gang sc the lc th ay la bang thuoc : v du tiem TM Dipyridamol hoac
Adenosin , hoac truyen TM lieu cao Dobutamin . Con viec ghi nhan ket qua co the
thong qua cac bien oi cua ECG , SA tim , hoac cua xa hnh tim .
d) Chup MV :
Chup MV tng phan (ch cu goi la can quang) a tr thanh c ban cho hau het BN
benh mach vanh tren the gii v nay a kha an toan (tai bien nang va t vong ch 0,1
0,2%) . Va v kha nang ln:
- Ch nh chup MV cho nhng trng hp ket qua NP stress bat thng ro ,
nhng BN ieu tr ung , ay u van khong , cung nh nhom nguy c
cao khac (v du TNKO khang tr , TN sau NMCT )
- Xac nh o bt hep long MV , xep ra c nhom BN bt hep > 70%
(ng knh long M) tc hep nang e xet tiep ch nh can thiep .
- Noi chung khong chup MV ch e biet ma a san sang nong MV hay phau
bac cau , e xac nh v tr phai can thiep , so cho va mc o can thiep .
- Loai tr benh MV cho ngi mang trieu chng b nham lan .
2 TN BIEN THAI :
- Co mot so ac iem : cn au ngau phat , keo dai hn , co the ch xuat hien khi
i ti mot a iem nhat nh , hoac vao gi nhat nh tham ch na em ve sang .
74

- Neu lam c ECG trong cn au , thay oan ST chenh len (nh trong NMCT
vay , nhng ch thoang qua mi phut cung cn au) , neu dung thuoc dan MV v du oi
khang Calci / cac nitrat th oan ST lap tc tr ve ang ien va co the kem loan nhp tim
- Men CPK vas troponin T khong tang .
- Ve c the benh , MV co the co hoac khong co mang x va .
- Hiem khi tien trien thanh NMCT hoac ot t .
3 TN KHONG ON NH :
Ban chat :80% co huyet khoi mi sinh mang x va cua MV . o chnh la cai
nen c the benh va sinh ly benh an pha di the benh TN khong on nh (TNKO)

LS :
+ Theo doi LS thay TNKO thng von la mot TN gang sc co ngng gang
sc cho phep, ma BN t biet ro, bong mat tnh on nh , c sut thap tng nac , tham ch
ti mc co cn au mc gang the lc toi thieu . Trong o noi ro s nang len , tang len
dan (crescendo) ve 1 , 2 hoac ca 3 mat : tan so xay cn , o dai cn , cng o au (ma
nguyen do cua au crescendo cung chnh la do huyet khoi ang sinh ra va ang ln
them nh a neu tren )
+ TNKO con bao gom TN vi cn au ngc b lan au tien hoac sau bao nam
lui benh khong co cn au bong lan au bung tai phat (denovo)
+ Hoac von la mot TN gang sc bong chuyen thanh au ngc ca khi ngh tnh :
goi la cap tnh neu ang dien ra t 48 gi , goi la ban cap neu t 48 gi cha co cn mi .

CLS :
+ ECG : ang cn au oan ST thng chenh xuong [hoac khong chenh len
hoac nh trong NMCT khong ST ma NMCT nay thng cung khong Q]
+ Cac chat anh dau tim (nhat la Troponin T) khong tang

Tien trien :
+ Neu TNKO khong c ieu tr th mot t le cao (10 20%) tien trien
thanh NMCT (v huyet khoi mi sinh la c s e TNKO de chuyen thanh NMCT )
+ Bi vay co nhng TNKO goi la :
Hoi chng tien NMCT
Hoi chng doa NMCT
Hoi chng trung gian
+ c ieu tr , so chuyen sang NMCT ha xuong con 5 7%

Chan oan phan biet :
+ Can ac biet phan biet t au va tng nac (theo quy trnh chan oan va
x tr tng nac HCVC) vi hai the benh sau :
NMCT khong ST (da vao co tang Troponin)
NMCT kinh ien (co ong hoc ECG (ca ST , T , Q) ong hoc chat
anh dau tim , o dai cn au thng vt 20 30 phut)
75

+ Vi TN Prinzmetal(ST nhng ve bnh thng sau 15 phut cua cn au)
+ Viem mang ngoai tim cap (co SA tim)
+ Boc tach ong mach chu (SA qua thc quan , CT xoan oc )
+ Thuyen tac ong mach phoi
+ Ngoai ra cung phan biet vi au ngc d do nhng benh ly trong long
ngc nhng ngoai he tim mach : viem sun c sn (hoi chng Tietze), au khp ba
canh tay , viem day than kinh gian sn (kham doc b di xng sn , hoi chng re
than kinh ngc , benh Zona (Herpes Zoster) vung ngc
+ Cap cu ngoai khoa vung bung : loet da day ta trang , viem da day , soi
mat , thc quan trao ngc hoac co that .
+ Nhng kieu au trc ngc cua roi loan than kinh t chu hoac au do suy
nhc than kinh-tuan hoan (neuro-circulatry asthenia) , hoac au do tam ly (psychogenic)
thng ngan hn mot giay hoac lai rat keo dai , khong thanh cn , khong kem bien oi
ECG . Mot quy tac : ch c ghi chan oan nay sau khi a loai tr kha nang cac benh ly
khac .

76

HO HAP

77

BENH PHOI TAC NGHEN
MAN TNH
CHRONIC OBSTRUCTIVE PULMONARY DISEASE- COPD
7,:.": "-a 1a 7,-:
NOI DUNG
I. NH NGHA
II. SINH BENH HOC
III. SINH LY BENH
IV. LAM SANG
V. CAN LAM SANG
/ //\/ \//
0) enh daonq ho ha nho dac t+anq /oi tac nqhe n tho nq khi { do 0)w
haq J))) a tac nqhen na q thao nq tie n t+ien co the tanq da anq caa daonq ho
ha a co hac hoi mot han
+ anq )ink a[[e+ { J)) /a cha qea )
+ anq /ae //oate+ { 0)w /a cha qea )

Ton thng PQ Pha huy thanh
va tieu PQ phe nang
Co that PQ N.trung N.trung ho hap
Tang tiet nhay (thnh thoang)

Tac nghen co hoi phuc
tieu PQ va PQ nho
Ton thng lien N.trung lien tuc
tuc va tai i hay tai i tai lai
tai lai(t.la)

VPQM KPT
Pha huy thanh N.trung lien tuc
phe nang & tai phat
Ton thng lien tuc
& tai i tai lai

VPQM & KPT
78

// // |/| |/\/
1. ng ho hap ln:
+ Niem mac PQ: tang TB va Lympho T / ngi hut thuoc la.
+ TB n nhan vi cytokins TNF-alpha va IL-1.
+ Neutroplil ket hp vi am mu, giai phong elastase va cathepsin G --> ly
giai protein va gay bai tiet rat manh.
2. ng ho hap nho :
+ Viem ,x hoa va day thanh PQ tang SCT
+ C.san TB ai , tang TB n nhan va TB tiet nhay,
+ Ph ai c trn hep long PQ + phu ne va tham nhiem TB.( tai cau truc
ng th )
+ Giam surfactant tang SCBM hep hay xep ng th.
+ Mat cho dnh cac tieu PQ gay xoan va hep ng th / COPD.
+ Tch tu TB viem n nhan PQ tan pha huy si an hoi tieu PQ ho
hap, ong phe nang xoan van va cht hep PQ
3. Nhu mo phoi :
+ KPT : gian bat hoi phuc tui phe nang + pha huy cac thanh cua no
+ 2 dang KPT :
(1) KPT trung tam tieu thuy ( centro- lobular emphysema).
(2) KPT toan tieu thuy( panlobular emphysema) .

Sinh benh hoc

/// |/\/ /\/ .|/
1. BNH SINH CUA VIEM PHE QUAN MAN:

Thay
oi cau
truc
Roi loan
he nhay
long

Viem ng th
Anh
hng
toan
than

ng th b han che
79

a.S suy yeu lp tru long:
+ Ht chat oc hai giam CN lp b.mo tru long.
+ Thuoc la : gay tch tu TB viem trong phoi :
TB tang 10 lan va c hoat hoa GP chat hoa ng ong loi keo BC hat vao n.mac ho
hap.
+ BC hat c hoat hoa :
+ GP TGHH tang sinh tuyen di n.mac va TB ai; tang SX am
nhay va co that PQ
+ GP protease va chat oxy hoa ton thng bieu mo
+ Giam c.nang lp tru long ton thng thc the va c che tai tao ngay
cang giam dan
b.Nhiem trung:
+ Do mat c.nang cua lp tru long va s c tru cua VK.
+ S giam IgA / ng ho hap tao ieu kien cho VK c tru . Mot so VK tan
cong IgA con lai bang men Protease.
+ Virus va mycoplasma gay oc bo may tru long tao ieu kien c tru cua
VK gay bnh.
+ e phan biet s c tru va nhiem trung cua vi khuan can da vao lam
sang, tm khang the va anh gia qua trnh bnh di khang sinh ieu tr
c.Tac nghen ng th
+ Do viem day lp niem mac va ong am nht ng ho hap nho.
+ Mot so trng hp co tang ap ng khong ac hieu cua PQ oi vi cac
kch thch va gay co that PQ.
+ S tang ap ng co the bam sinh hay mac phai.

TAI CAU TRUC NG TH :
- Tang sinh mo em & di niem mac ( phu, lang ong proteoglycan , collagen)
- Tang vi mach PQ
- Tang kch thc & so lng tuyen niem mac
- Tang khoi lng c trn ( ph ai va tang san )
d.Cac bien chng :
- KPT trung tam tieu thuy:
Do pha huy trc tiep cau truc phoi bi cac chat oxy hoa ( co nhieu trong thuoc la ) hoac
bat hoat cac chat c che protease ( ac biet alpha 1 Pi ) bi cac chat oxy hoa nay gay
thieu alpha 1 Pi .
+ 90% pha huy nhu mo phoi do cac protease ( a so la elastase ) t
Neutrophile, TB. ngi hut thuoc nong o elastase tang gap 10 lan .
+ S mat can bang protease- anti protease se dan en KPT.
- Tang ap MP :
+ Do giam tong dien tch cua m/m phoi va giam oxy mau
+ Mc o tang ap phu thuoc vao s pha huy dng m/m va giam
thong kh phe nang gay giam O2 phe nang va gay co mach.
80

+ S thuyen giam ap lc MP bi oxy ho tr cho gia thuyet co mach
e.Giai oan cuoi

A) Elastin phoi :
- La thanh phan chanh cua si an hoi, va chat em ngoai bao
- Trong 1 so BN COPD , tang elastin peptides trong mau va nc tieu co le
do pha huy elastin trong phoi
B) Cac te bao viem va cac proteinases trong phoi:
+ Neutrophil:Chc nang cua alpha 1-AT la c che elastase cua Neutro
Proteinases cua Neutro co the tham gia vao s ieu hoa ap ng viem qua s kch thch
hay hoat hoa cac cytokins.
+ Monocytes: Cac proteases c STH bi cac tien than Monocytes trong
xng va GP nhanh chong bi cac te bao lu hanh.
+ ai thc bao:
- Tao cac YT thuc ay s pha huy chat em ngoai bao va cac YT to
bao ve chong lai s pha huy chat em => co vai tro phc tap trong bnh sinh KPT.
- TB phe nang co kha nang thoai bien elastin bang men ly giai
protein nh Macrophage cystein proteinases, Macrophage matrix metalloproteinases

+ ac trng bi suy tim, suy ho hap.
+ Suy tim phai
+ Suy ho hap toan phan vi tang PaCO2 va giam PaO2 va tam phe man mat bu.
81

KPT DO THIEU ALPHA 1- AT:
+ PiZ phenotyp la thng nhat (95%).PiSZ, Pi nul-nul , Pi nul-Z.
+ Nhng ngi PiZ co alpha 1-AT = 15% bnh thng.
+ Thuoc la thuc ay nhanh bnh ly. 1 ngi hut thuoc la vi PiZ co trieu chng #
40 tuoi, 15 nam sm hn ngi PiZ khong hut thuoc.
+ Gay KPT toan tieu thuy, chu yeu ay phoi.
Cac ch nh truy tm giam alpha 1-AT :
+ VPQM tac nghen ngi khong bao gi hut thuoc la
+ GPQ nhat la khong co yeu to nguy c ro ret
+ khi phat sm COPD mc o va hay nang tuoi 50
+ KPT chu yeu 2 ay
+ Phat trien hen phe quan khong dt, ac biet BN < 50t
+ Tien can gia nh co giam alpha 1-AT hay COPD trc 50t
+ X gan ma khong co yeu to nguy c ro rang.
/! /\/ / |/\/
1. Tac nghen thong kh :
+ Giam FEV 1 va FEV1/ FVC %
+ Lu lng ht vao toi a bt ( maximal inspiratory flow : MIF)
+ Giam lu lng th ra gang sc do hep hay tac nghen co nh va s khong on
nh cua ng ho hap trong luc th ra gang sc.
+ Giam lc an hoi va tang sc can ng th (SCT ) lam giam lu lng th ra
toi a ( maximal expiratory flow : MEF )
2. Thong kh khong ong nhat va mat can bang thong kh ti mau:
S mat can oi V/Q : a xay ra trong g au cua COPD
3. S kh ( hyperinflation)-Kh b nhot ( air-trapping )
+ Tang the tch can (Residual Volume:RV) va %RV/TLC.
+ Tang TLC
+ Khi V kh trong long ngc tang qua mc thong kh het hieu qua va tang
cong th, ca 2 kho th.
+ S kh ay c hoanh det xuong , tao ra mot so tac dung khong co li trong ho
hap
4. kho th:
+ Khi FEV1 60%: kho th . 1 so BN COPD khong kho th ke ca khi FEV1 giam
nhieu.
+ C che kho th / COPD rat phc tap va cha c hieu ro.

82

! / \
1.Viem phe quan man:
+ Ho khac am nhay trong, thay oi mau sac va tang so lng khi nhiem trung
+ Kho th : gang sc , co that PQ
+ Kham LS: bnh thng ,tam phe
2. Kh phe thung :
+ Ho , am t dan
+ Kho th khi gang sc
+ Kham LS: long ngc hnh thung
!/ \ / \
1.o chc nang ho hap
+ Giup chan oan xac nh tac nghen va mc o tac nghen
+ TD dien tien,
+ Kiem tra ieu tr
+ Tien lng
PHAN CHIA GIAI OAN COPD

Mc o
Tieu chuan chan oan
I: Nhe
Thng ( nhng khong luon luon ) ho khac am keo dai,
FEV1/FVC < 70% , FEV1 > 80%
II: Trung bnh
Trieu chng xau hn vi kho th nhat la khi gang sc ,
FEV1/FVC < 70% , 50% <FEV1 < 80%
III : Nang
Trieu chng nang, kho th ro , FEV1/FVC < 70%,
30% < FEV1 < 50%
IV : Rat nang
Trieu chng tram trong , FEV1/ FVC < 70% va FEV1 < 30%
hay FEV1< 50% kem theo suy ho hap hay suy tim phai.

Time (seconds)

Vol
L
i
t
e
r
s
Th ra
--- ng th rong, phoi n tot
ng th rong, phoi n kem .
ng th hep, phoi n tot
-..- ng th hep, phoi n kem
83

2. XN hnh anh :
* X quang :
+ VPQM : XQ khong giup chan oan VPQM ma e loai tr cac bnh gay ho keo
dai khac , cac bnh i kem ( KPQ) va bien chng ( MP to , tim to )
+ KPT : long ngc hnh thung , phe trng tang sang , MP to.
* ECHO : giup phat hien that phai to, tang ap MP
3.XN sinh hoa :
+ o IgA, IgG, IgM e phat hien h/c giam KT
+ o alpha 1- AT
+ KMM : giup theo doi dien tien va mc o suy ho hap
4. Vi trung hoc :
Nhuom gram va cay. Hemophillus influenzae va Streptococcus pneumonae la 2 VK
thng gap nhat. VK khac : Moraxella catharrhalis, P. aerusinosa, Sthaphylococcus...
5. Noi soi PQ: Giup loai tr cac bnh co TC giong hay i kem : KPQ , lao , do hach lao
vao PQ , d vat.

T KCH PHAT BPTNMT: NH NGHA
t kch phat BPTNMT la mot tnh huong xay ra trong dien bien t nhien cua
benh ac trng bi s thay oi cac trieu chng can ban cua benh nhan nh kho th,ho
am khac nhng dien bien thng ngay, khi phat cap tnh va co the oi hoi s thay
oi thuoc men thng ngay tren benh nhan co BPTNMT

1. T KCH PHAT COPD
Tieu chuan chnh (so vi luc ban au)
- Ho va am tang
- Tang am mu
- Kho th tang
Tieu chuan phu:
- Th kho khe
- au hong
- Ho va cac trieu chng cua cam lanh thong thng nh nghet hoac chay nc mui

2.YEU TO CO THE LAM THAY OI NGNG XUAT HIEN T CAP KCH
PHAT COPD
Cac yeu to ben trong:
Suy chc nang phoi
ang hut thuoc
Phan ng qua mc cua phe quan
Tang tiet dch nhay keo dai
Suy giam cac c che bao ve
Cac yeu to khong ac hieu: cang ln tuoi, cac benh khac kem theo

84

Cac yeu to ben ngoai:
Loai vi khuan
Nhiet o moi trng thap hn
O nhiem khong kh
Tr lieu COPD on nh va t
kch phat COPD

Phan loi t kch phat COPD

U
U
N
N
G
G
T
T
H
H
P
P
H
H
O
O
I
I
7,:.":."-a 1a 7,-:
T KHOA :
- Ung th phoi lung cancer
- Ung th bieu mo phe quan : bronchial carcinoma
- Ung th te bao nho : small cell carcinoma
- Ung th khong phai te bao nho :non-small cell carcinoma.
- Ung th te bao ln : large cell carcinoma
- Ung th te bao gai ( tb vay ): squamous cell carcinoma
- Ung th te bao tuyen : adeno carcinoma
Nhm Nh

Va phi

Trm trng
Triu chng quan
trng*
1 trong 3
Loi 3
2 trong 3
Loi 2
Ca 3
Loi 1
Tui Bt k Bt k Thng > 65
Chc nng phi ban
u
Bnh thng Gim nh - trung bnh
FEV1 > 50% d on
FEV1 < 50% d
on
Cn kch pht

< 4 lan / nm > 4lan / nm
Bnh cng mc

Khong khong Ro rang
Tc nhn gy bnh
ng h

hp

Virus (t gii
han, lanh tnh)
H. influenzae
M. catarrhalis

S. pneumoniae
Hemophilus spp.
Nhim vi rt trc
nhim vi khun

H. influenzae
M. atarrhalis

S. neumoniae
H.parainfluenzae
Gram m
Pseudomonas
thng gp VK tit
b-lactamase

* lng m tng, m tng,
kh th tng.
85

//// I/ /. |\ I/| |/./
au TK XX, K phoi la mot benh hiem. 1912, t le K phoi nguyen phat My va
Tay Au la < 0.5% .
K phoi 0.5% moi nam, thanh th > nong thon ( 1.2 2 ).
Ngay nay la nguyen nhan t vong hang au nam .
T le n ngay cang . cac nc ang phat trien,
// \|/\ \/\ ! ///| |//\ I/|\ /./ : :
A. THUOC LA VA UNG TH PHOI :
Thuoc la la nguyen nhan noi bat cua K phoi
Cac yeu to nguy c phat trien K phi ngi hut thuoc la :
- Thi gian hut ,So ieu thuoc hut (pack year : so goi /ngay x nam hut ),Loai
thuoc hut ,Tuoi bat au hut
- Hut thuoc cang nho tuoi, nguy c K phoi cang cao.
- Hut thuoc la va an m nhieu co nguy c phat trien K phoi.
- An rau ti va trai cay lam t le K phoi ngi hut thuoc. Tra co the c che
s sinh ung do TD cua cac chat chong oxy hoa cua mot so polyphenols trong
tra xanh.
Mot so chat sinh ung th trong khoi thuoc la : Carcinogenic polycyclic hydrocarbons
gay K TB gai, Tobaco specific N nitrosamines (TSNH) gay K TB tuyn loai gam
nham . Tac dung gay K tai cho cua Nitrosamine yeu, khi c hoat hoa no bien thanh 1
chat sinh ung manh.

B. YEU TO NOI SINH CUA UNG TH PHOI :
< 20% ngi hut thuoc la nhieu phat trien K.
K phoi thng xay ra trong gia nh
Chuyen hoa thuoc ha ap Debrisoquine c kiem soat bi gene t than .
Ngi hut thuoc co chat chuyen hoa manh co nguy c hn ngi co chat chuyen
hoa t hay trung bnh .
Kha nang hoat hoa sinh ung th khac nhau moi ngi , Cac chat chuyen hoa nh
Aryl hydrocarbon hydroxylase, debrisoquine hydroxylation va glutathion s
transferase : chat anh dau ve gene cua K phoi.
a so BN, yeu to ngoai sinh quan trong hn.

C. ANH HNG VE GIONG :
- K TB tuyen / n > nam,ac biet n khong hut thuoc (50 80%).
- Phoi cua n nhay hn nam trong viec phat trien K phoi do thuoc la (1,9 lan).
- Yeu to hormone gi mot vai tro trong K phoi. N.cu : lieu phap thay the
Estrogen lam nguy c K TB tuyen .

D. CAC YEU TO KHAC LIEN QUAN EN UNG TH PHOI :
1. Khoi thuoc trong moi trng :
86

Khoi thuoc la yeu to sinh ung quan trong nhat trong K phoi.
Khoi thuoc thu ong cha tat ca cac chat sinh ung.
Khoi thuoc phu (side stream) khong qua au loc cha chat sinh ung 100 lan hn
khoi thuoc hut.
20 30% K ngi khong hut thuoc co the do tiep xuc yeu to moi trng.
2.O nhiem khong kh :
ot nhien lieu hoa thach hydrocarbon a vong. Khoi xe, chat thai ong c
diesel, bot cay,chat thai cong nghiep
Cong nhan tiep xuc san pham ot chay nhien lieu co t le K phoi cao.
Cong nhan tiep xuc khoi than co nguy c K 50% cao hn sau 20 nam tiep xuc.
3.Kinh te xa hoi :
Co tng quan nghch gia K phoi va tnh trang kinh te xa hoi .Do hut thuoc,
nghe nghiep, tiep xuc vi chat o nhiem
4.Radon :
San pham cua Uranium co the gay K phoi. Ket hp Radon va hut thuoc gia nguy
c theo cap so nhan.
5.Asbestos :
Cong nhan ong tau va lam viec vi cac chat cach nhiet , co nguy c b
Mesothelioma ac tnh cua mang phoi va phuc mac.
Asbestos gay cac mang x hoa mang phoi va x hoa mo ke. Khi hut thuoc la,
nguy c K phoi cc ky cao.
Tiep xuc Asbestos cung co nguy c cao b K phoi.
6.Yeu to nghe nghiep khac :
Tiep xuc vi Arsenic, bischloromethyl ether, chloromethyl methyl ether,
chlorrmium, nickel, polycyclic aromatic hydrocarbon (hydrocarbon thm a vong),
vinylchloride, chat phong xa ion hoa.
7.Bnh phoi a co trc :
K phoi cao hn BN lao , VPQM, Silicosis...
Khoi thuoc gay viem x hoa, day niem mac va tieu PQ ho hap, ph ai tuyen
nhay, san va loan san ng ho hap ln. Bien oi chc nang va cau truc keo
dai cong vi tiep xuc cac chat sinh ung trong khoi thuoc K phoi.
/// // |/| |/\/
V tr : P > T, thuy tren > di. 55% trung tam, 34% ngoai bien , 11% khong
xac nh v K lan tran .
Theo loai K :
K te bao gai ( te bao vay ) : ( squamous cell carcinoma , epidermoid
carcinoma ):35- 60% , trung tam, lien quan ti thuoc la, nam > n, phat trien cham, co
khuynh hng hoai t trung tam (10%)
K te bao nho ( small cell carcinoma):15-25%, phat trien rat nhanh, di can
hach va mau sm, thng a di can vao thi iem phat hien bnh ( hach ron va trung that,
gan , nao, khp , thng than , tuy, giap, tinh hoan ...), phan ln PQ trung tam sau o
lan toa khap ni
87

K te bao tuyen ( Adenocarcinoma ):15-25%,a so ngoai bien,di can sm
ac biet he TKTW.
Carcinom te bao ln ( large cell carcinoma ): 5-10%
Khong phan loai c ( unclassified carcinoma ):
KPQ khong phai t mot loai TB ong nhat, ma co nhieu loai.
Phan loai TB phu thuoc loai TB chiem u the.
S phan loai ung th te bao nho va khong phai te bao nho co y nghia ve mat ieu tr.
/! / \
1. Ho:
La dau hieu au tien thng nhat (35 75%).
Mot trieu chng ho n oc hiem khi giup ch .
S thay oi tnh chat ho la quan trong.
2. Kho th
26 60 % do u phat trien va xam lan (TDMP, xep, viem phoi sau cho
tac nghen, tac ho hap tren, TKMP, khung xng).
Kho th cung thng do bnh ong thi nh COPD.
3.au ngc
20 45% do xam lan trc tiep hay di can vao cac cau truc nhay cam
trong long ngc (mang phoi thanh, thanh ngc) gay au kieu mang phoi
cach quang hay lien tuc.
Mot so BN au m ho, khong khu tru ro, lien tuc vi khoi u trung tam
xam lan trung that va cac TK quanh mach mau va quanh PQ.
4. Ho mau
Bieu hien n oc trong 5 10% , 50% la trieu chng au tien. ien
hnh la ho am vay mau do hoai t khu tru va viem mach mau trong
khoi u. BN ho mau
XQ bnh thng c phat hien qua noi soi la 3%.
Ho ra mau tren BN hut thuoc > 40 tuoi la dau hieu bao ong. Ho ra mau
nang do u te bao gai trung tam, tao hang ln, xam lan trc tiep vao
mach mau PQ phoi.
5.Kho khe :
5 18% la tr/chng au tien, thng kem ho do xam lan trung that hay hach
e TK quat ngc gay liet day thanh
6. Trieu chng ngoai long ngc
Do di can : au xng, trieu chng TK trung ng (nhc au, buon non,
non) au lng do di can xng hay chen ep re TK, au bung do di can tuyen thng than
va / hay gan.
7. Toan than
Tuoi co anh hng ang ke en tr/chng LS. K BN < 40tuoi co o ac tnh
cao hn ngi gia
Sut can : co y ngha khi 5% trong lng, do tram cam, bieng an, roi loan
chuyen hoa, cong th, au va ho.
88

8. Khong trieu chng:
5 15% khong co trieu chng luc . X quang phat hien tnh c khi kham
nh ky.
! |/\/ \/ / \
1.Ton thng trung that :
Khoang 40% trng hp trung that b xam lan trc tiep hay do hach di can HC
tnh mach chu tren.
Hach to co the gay tac bach huyet, gay TDMP hay xam lan bach huyet lan toa.
2.Viem phoi tac nghen va xep phoi :
BN co the sot, run, ho am, am vay mau.
Chup X quang hang loat co the thay tham nhiem man, tai phat hay hoi phuc
cham. Tham nhiem man cung co the do chnh K phe quan phe nang.
1 / 4 trng hp hoi chng thuy gia do K phoi va 14% trng hp viem
phoi man do VK co 1 K phoi can ban.
Trieu chng LS phu thuoc vao toc o gay tac nghen, mot so BN hoan toan
khong trieu chng, mot so khac kho th .
3.Tran dch mang phoi :
Gay ho, au ngc va oi khi khong trieu chng.
TB K bat au mang phoi tang qua xam lan va thuyen tac MP xoang
MP MP thanh.
Dch thanh t, t huyet hay mau ai the ,dch tiet trong a so trng hp ,
Co TB K trong dch la giai oan III B va co tien lng kem.
oi khi dch do viem phoi hay xep phoi.
4.Pancoast tumor : u cc nh phoi.
HARE mo ta 1838 , TOBIAS va PANCOAST 1932.
au canh tay, vai, hoi chng Horner s va teo cac c nho cua ban tay do
xam lan am roi canh tay, hach giao cam .au luc au khu tru vai sau lan
xuong canh tay doc theo xng tru do to thng re C8 va T1
Trieu chng ho hap thng am tnh.
X quang : Khoi u nh phoi hay bong m co the bo sot. MRI la phng phap
chon la do tnh chat tai tao hnh anh theo chieu ngang va doc.
Phan ln u Pancoast s tumor la K KTBN nhng cung do K TBN hay di can
t c quan ngoai phoi
5.Broncho alveolar carcinoma ( Carcinoma PQ PN) :
U co khuynh hng phat trien doc theo thanh phe nang t cac pneumocyte
type 2 hay te bao tieu PQ khong co vi nhung mao (te bao clara).
X quang : tham nhiem lan toa hay ong ac phe nang gii han ro hay dang
li not.
K PQ- PN thng c phan loai la K khong phai te bao nho nhng thng
di can xa, ac biet dang tham nhiem lan toa.
6.Ap xe phoi do ung th :
- ac biet loai K TBG, co 1 hang b nham nh .
89

- Trieu chng gi y K : Ho mau dai dang, khong sot, khong BC, v tr X
quang vung khong phu thuoc vi t tham nhiem xung quanh.
!/ /\ /.\
1.Te bao hoc am :
- c dung e nam 1887, o nhay 20 77%. T le cao hn vi K trung tam, thuy
di, u ln.
- 5 mau am ti sang sm vi BN ho sau.
- Ngoai t le (+) thap, te bao hoc am thieu gia tr v tr.
- Giup ch /BN t choi cac ky thuat xam lan hay co nguy c nh bnh ong thi,
bnh tim thieu mau, COPD nang.
2.X quang :
X quang thong thng :
12 30% K phoi b bo sot, o ac hieu thap.
Dau hieu nghi ng cao la xep toan bo phoi .
So sanh phim hien tai va phim trc giup anh gia BN.
a so u thuy tren , ben (P) > (T) va cac phan thuy trc.
CT scan :
Hnh anh ro rang hn va cac cau truc lan can, giup anh gia nhng u ngoai PQ
CT scan co the gi y K , khong phan biet lanh ac
MRI:
Co vai thuan li hn CT . MRI co ch trong cac u nh phoi
PET: Positron emission tomography* vi fluoro 2 deoxyglucose la phng tien tham
sat co li hoat ong chuyen hoa cao cua K phoi e chng minh u nguyen phat va di can.

Nhieu ky thuat hnh anh khac, bao gom sieu am, soi XQ, chup PQ, chup TM chu tren,
nh n, cheo, phim nam nghieng, oi khi co li e tra li nhng van e lien quan en
K phoi va cac bien chng trong long ngc.

* positron emission tomography : (positron = a positive electron, or positively charged
particle emitted from neutron-deficient radioactive nuclei = hat ien tch dng phong
thch

3.Noi soi phe quan ong soi mem:
- La 1 ky thuat quan trong,an toan, bien chng thap, BN de chap nhan, t le
cao.
- Ra, chai, sinh thiet. Choc hut xuyen PQ danh cho u tham nhiem sau di niem
mac hay gay chen ep PQ. T le khi co ho tr cua soi XQ (C arm / biplanar
fluoroscopy), ra PQ PN.
- T le 90% / u noi PQ trung tam, 50 60% u ngoai bien.
- Cac thuoc huynh quang tap trung nhieu vung ac tnh hn vung khong ac tnh
giup sinh thiet chnh xac hn.
4.Sinh thiet xuyen ngc bang kim :
90

Thch hp cho cac u ngoai bien.KQ phu thuoc vao kch thc : 15% oi vi
u < 2 cm ; 50% oi vi u 2 3 cm.
Thong nhat gia ket qua te bao hoc va mo hoc t 60 90%.
Thch hp cho BN khong dung nap hay t choi soi PQ va BN khong the mo
c nhng can mo hoc trc khi xa tr.
Am tnh gia 30% . Ket qua (+) gia 1 3 %.
5.Thu thuat m ngc :oi khi can thiet.
Noi soi mang phoi giup va khoi u, TDMP.
Noi soi trung that, m trung that
Sinh thiet hach trc c scalene co the giup ch cho .
6.Sinh thiet v tr di can :
oi vi khoi u nguyen phat nho va khong tiep can c oi vi noi soi PQ hay
choc hut xuyen ngc nhng co bang chng LS cua di can xa.
Can mo hoc e K TBN va K KTBN, giup hoa tr hay xa tr.
7. Tumor marker:
Trong KPQ, cho ti nay , CEA, SCC-A, NSE co y nghia lam sang.
Ket hp nhieu Tumormarker se tang mc o ac hieu khi chan oan.
CEA (carcino embryonic antigen): nhay 50-60%/ K khong phai TB nho, 40-50%
/ K TB nho.
SCC-A ( squamous cell carcinoma antigen): nhay 53%/ Squa.carc., 46%/
Adenoma
CEA + SCC-A : nhay 75%/ Adenoma, 80%/ Squa.carc.
NSE( neurospecific enolase ): co y nghia / K TB nho
+Limited Disease : nhay 60%
+ Extensive Disease : nhay 80%.
+ Giam nhanh sau 72 gi hoa tr.
+ Thch hp trong ang gia tai phat
8.Chc nang ho hap :
- au ngc, TDMP nhieu, xep phoi, yeu c ho hap, liet TK hoanh gay roi loan han
che. Tac PQ ln co the tao hnh anh ng bieu dien lu lng the tch 2 pha ac trng.
- DLCO do vi thuyen tac do u hay di can hach bach huyet va noi tac do xep
phoi, viem phoi sau cho tac nghen hay K PQ phe nang lan toa.
9.Xet nghiem can lam sang thng qui :
- Thieu mau, Ca++ mau, phosphatase alkaline thng ket hp vi bnh lan toa.
- Cac dau hieu hiem khac nh D.I.C , phan ng gia bach cau, Eosinophil ,
Lactic acidosis.
10.Chan oan lam sang khong co sinh thiet :
Mot t BN t choi lam bat ky ky thuat nao va mot so bnh nang hay bnh ong thi
co rat nhieu nguy c khi sinh thiet.
Nhng trng hp khong (+) nay can xem xet can than LS va X quang e am
bao rang khong bo qua 1 thay the co the c.

91

!// |/\ // // /.\ (I/\)
T
0
: Khong co bang chng cua u nguyen phat
T
X
: Te bao K dng tnh trong am, nhng khong co ton thng tren X quang
hoac noi soi phe quan
T
IS :
Carcinoma in situ
T
1
: U 3 cm va khong co bang chng xam lan gan ti PQ thuy khi soi PQ
T
2
: U > 3 cm hay bat ky kch thc nhng xam lan mang phoi tang hay co xep
phoi, viem phoi sau cho tac lan en vung ron phoi. Khi soi PQ, xam lan u ch PQ thuy
hay U phe quan goc cach carina 2 cm. Moi xep phoi hay viem phoi tac nghen khong
anh hng tren toan bo phoi.
T
3
: U bat ky kch thc xam lan thanh ngc, mang phoi trung that, c hoanh, mang
ngoai tim ma khong anh hng tim, mach mau ln, KQ, thc quan, cot song hay U phe
quan goc cach carina < 2 cm nhng cha xam lan carina.Xep toan bo phoi
T
4
: U xam lan trung that (tim, mach mau ln, kh quan, thc quan, cot song, carina)
tran dch mang phoi ac tnh cung ben (te bao K hien dien trong dch mang phoi)

Hach (N)
N
0
: Khong co di can hach vung
N
1
: Di can hach quanh phe quan, hach ron phoi cung ben bao gom xam lan trc
tiep
N
2
: Di can hach trung that cung ben, hoac hach di carina
N
3
: Di can hach trung that oi ben, hach ron oi ben ; hach thng on, c thang
cung ben hay oi ben
Di can (M)
M
0
: Khong co di can
M
1
: Co di can
Carcinoma an : T
x
N
0
M
0

Giai oan 0 : T is N
0

Giai oan 1: T
1
N
0
M
0
, T
2
N
0
M
0

Giai oan 2 : T
1
N
1
M
0
, T
2
N
1
M
0

Giai oan 3a :T
3
N
0
M
0
, T
3
N
1
M
0
, T
1-3
N
2
M
0

Giai oan 3b : Bat ky T N
3
M
0
, T
4
Bat ky N M
0

Giai oan 4 : Bat ky T Bat ky N M
1

K TE BAO NHO
LIMITED DISEASE:
- Cha xam lan thanh ngc, kem theo:
. Hach ron, thng on cung ben
. Hach trung that cung ben va oi ben
- Xep phoi
- Liet TK quat ngc , TK hoanh
92

- TDMP t, khong co TB K / DMP
EXTENSIVE DISEASE:
- Xam lan thanh ngc
- Hach ron, thng on oi ben
- TDMP ac tnh
- Lymphangiosis carcinomatosa
- H/C tnh mach chu tren
- Di can phoi oi ben
- Di can xa.
!/// ///| I|/
Ung th khong phai te bao nho :
- Cisplatin ( carboplatin ) + Docetaxel ( Paclitaxel )
- Docetaxel n thuan
- Gemcitabine n thuan hay phoi hp Cisplatin ( Carboplatin )
- Etoposide + Cisplatin ( Carboplatin )
Ung th te bao nho :
- Cisplatin ( Carboplatin ) + Docetaxel ( Paclitaxel )
- Gemcitabine + Cisplatin ( Carboplatin )
- Cisplatin ( Carboplatin ) + Etoposide
- Cyclophosphamide + Doxorubicine + Etoposide ( CAE )
- Cyclophosphamide + Doxorubicine + vincristine ( CAV )

HEN PHE QUAN
".e :. 7,xye ", "- 7x
// |.\
Hen phe quan la tnh trang xao tron ng ho hap man tnh vi ac iem la co
nhng cn kho th kch phat cap tnh tng t. Mc o kho th thay oi tuy theo mc o
tac nghen cap tnh cua cay phe quan. Cac cn kho th co the giam mot cach t phat hoac
nh ieu tr. Trieu chng lam sang co the ien hnh vi nhng cn kho th kem ran rt lan
toa phoi vao th th ra hoac ch la nhng cn ho dai dang ve sang. Ve can nguyen cua
Hen phe quan ngoai yeu to d ng - viem con nhieu ieu cha sang to, v vay viec ieu
tr tan goc Hen phe quan hien nay con la van e nan giai.
/ '|I /.
- Xuat o Hen phe quan thay oi tuy theo tng vung, tuy theo la tuoi , Xuat o
hen phe quan ngi ln con co nhieu y kien cha thong nhat :
- Tren the gii : 2% - 6% dan so.
- tuoi nho en luc day th xuat o benh phai nam > 2 lan so vi phai n.

93

- tuoi thanh nien - giai oan sm cua tuoi trung nien : phai n > so vi phai
nam.
- tuoi gia: xuat o hen nam co ve troi hn la n, ie na co le lien quan
nhieu e hut thuoc.
// \ \|/\
Cac yeu to thuc ay cn boc phat va tan tr cn hen nang them :
1. Cac d ng nguyen :
Yeu to d ng c ghi nhan kha cao tre con b Hen phe quan # 90% trng hp,
con ngi ln # 50%. Cac d ng nguyen co the gap la :
Phan hoa, hoa co, nam moc, long, vay, phan, nc tieu cua cac gia suc cho, meo,
bui nha va cac loai con mat bot Dermatophagoides Pteronyssimus [Chau Au], D.
Farinae [My], D, Pteronyssimus va Glyciphagus Domesticus [Viet Nam] nhiet o t 22-
26
o
C,

am o # 55% . Con gian.
+ Hen phe quan do d ng phan hoa, bong, co : cn hen xay ra theo mua [seasonal
asthma], co kem cac trieu chng viem mat, viem mui.
+ Hen phe quan do d ng nam moc : cn hen xay ra theo mua, khong co kem cac
trieu chng viem mat, viem mui.
Cac loai nam moc gay d ng c ghi nhan la Alternaria, Stemphylium,
Aspergillus. Thng phat trien trong ieu kien moi trng am thap, co nhieu bui giay ,
bui go, may lam am khong kh, may ieu hoa khong kh , cay coi trong trong nha, thung
rac, tham chui chan, tranh anh treo tren tng, ging co em.
Nam moc trong nha thng gap la Alternaria. cac vung thieu anh sang, am t,
thieu thong kh la ni thuan li cho nam phat trien. cac nha co x dung may lam am
khong kh, may lanh, may nong cung la ni thuan li cho nam moc moc,. Tuy vay hien
nay ngi ta cha co thiet b o lng ang tin cay nong o nam moc trong nha.. Cac
nam moc trong nha thng gap la Penicilium, Aspergillus, Alternaria, Cladosporium,
Candida.
Nam moc ngoai vn co the gap la Alternaria, Cladosporium. Xay ra theomua
x on i thng vao mua am, khonhb vao he, trong khi o x khac th vao mua am
t nh mua thu co ma em.
Hen do d ng nam Aspergillus khong phai hiem gap, thng xay ra ngi ln
hn tre em.
+ Hen phe quan do cac d ng nguyen co t nguon suc vat, th # 25% trng hp co
test phan ng da dng tnh vi cac d ng nguyen th nghiem. oi vi d ng suc vat
nuoi trong nha nh meo, cho thng do d ng nguyen protein co trong phan, nc tieu
dnh tren long cua chung (khong do nc mieng), oi khi d ng nguyen co t cac loai
gam nham nuoi trong nha nh soc, chuot lang, tho
+ Thc pham : Trng, sa, tht bo, ca bien dau tay, bot m, chocolate.

94

Mac du ngi ln b hen phe quan co test tm d ng nguyen da dng tnh , nhng
cha chac la khi kiem tra xac nh cac d ng nguyen nay bang test kch thch phe quan
vi chung lai co ap ng dng tnh.
+ Thuoc men :
ien hnh la d ng khang sinh nhom PNC,
Cac thuoc khang viem khong cha corticoides nh Aspirine, dichlophenac,
ibuprophen.Xuat o hen do d ng Aspirin ngi ln kho xac nh , tuy vay theo
thong ke xuat o vao khoang 8-20% . Nhat la nhom ngi co viem xoang mui man
tnh, polyp mui, tuy thuoc steroid th xuat o o vao khoang 30-40%. D ng Aspirin
thng co phan ng d ng cheo vi NSAIDs, nhng hiem khi co tac dung phan ng cheo
oi vi mhom acetaminophen. tre con, xuat o hen do nhay cam vi Aspirin a c
xac nh, nhng xuat o co ve thap hn so vi ngi ln. ngi ln hen do nhay cam
vi aspirin thng gap n nhieu hn nam.
Cac chat co cha sulfites:
Cac chat co cha sulfites dang bisulfite hay metabisulfites muoi natri hay muoi
kali trong cac khang sinh hay chat chong oxyhoa nham gi mau hay bao quan thuoc ,
thc pham. Mot so trng hp Bn tang nhay cam vi cac chat nay co the b len cn co
thac phe quan nang ne, Cac nguon thc pham co cha sulfite la trai cay phi kho, ru
vang, mot vai loai bia. Trong thuoc men ngi ta ghi nhan mot so thuoc dan phe quan co
cha sulfite nh isoetharine, hoac la cac che pham cua corticosteroid. Do o Hoa Ky
viec x dung chat phu gia sulfite b nghiem cam bi FAD(food and drug administration).
Cac chat phu gia trong gia v nh monosodium glutamate ( bot ngot)
Hut thuoc chu ong : lam tang nguy c benh hen do nghe nghiep. Tyu nhien hien
nay van con t d kien chng to hut thuoc chu ong la yeu to nguy c gay hen PQ.

2. Nhiem trung :
Ngi ta nhan thay mot so tre nho b viem ng ho hap trong thi ky nhu nhi
do virus nh : Respiratory syncytial virus [ tre nho], Rhinovirus [ tre i hoc va ngi
gia], Influenzae, parainfluenza Neu chung co nhng cn kho th vi ran rt keo dai dai
dang, th de co tnh trang tang tnh kch ng cay phe quan tuoi trng thanh. ac biet
nhiem trung Chlamydia pneumonia tuoi nho c gi y co ong vai tro trong s phat
trien thanh hen ve sau .
Boi nhiem vi trung phoi benh nhan b Hen phe quan thng lam cho Hen phe
quan tr nen nang kho ieu tr , e doa tnh mang.

3. O nhiem khong kh :
Cac bui trong khong kh nh sng mu, bui do cac nha may thai ra, bui xang, khoi
thuoc la la nhng tac nhan quan trong kch thch cn Hen phe quan xuat hien benh
nhan co tien can Hen phe quan.

95

4. S thay oi thi tiet :
Khi thi tiet khong on nh nh la cac thi ky giao mua nong lanh, nang ma cn
Hen phe quan co the xuat hien. C che cua anh hng nay cha c hieu ro.
5. Yeu to than kinh tam ly :
benh nhan Hen phe quan cac sang chan tam ly co the gay ra cn hen. Co le anh
hng tam ly gay co that phe quan qua he than kinh t ong.
6. $ trao ngc dch v - da day len thc quan kh quan :
Thng xay ra luc benh nhan i nam, gay ra nhng cn kho th ve em.
7. Tang hoat ong the lc :
Cn hen co the xay ra sau vai phut bat au hoat ong the lc nang hoac luc gan
ket thuc buoi luyen tap. Cn kho th keo dai khoang 20' - 30' hoi phuc hoan toan trong
vong 90'.
Hau het cac trng hp BN b hen phe quan co tng\h trang tac nghen ng ho
hap khi tang hoat ong the lc. Cng o cua cac trieu chng lien quan en loai hoat
ong the lc ngi benh thc hien . Trong cac loai o th chay ua la loai hnh hoat ong
the lc co tem nang khi phat cn hen nhieu nhat.
8. Do nghe nghiep :
Do tiep xuc lien tuc dai ngay vi cac d ng nguyen ac biet tren c a d ng
tiem an, cac trieu chng Hen phe quan xay ra oi khi khong ien hnh. Cn hen thng
xay ra khi gan ket thuc mot ngay lam viec, giam benh thng xay ra cuoi tuan khi ngh
viec hoac ngh phep.
Cac d ng nguyen t nghe nghiep:
9. Yeu to noi tiet :
Co mot so trng hp benh nhan Hen phe quan phai n hay len cn hen khi gan
co kinh hoac khi s dung thuoc nga thai. Co le trong cac trng hp nay s thay oi can
can muoi nc trong c the lam anh hng en tnh co that c trn phe quan Ngi ta
nhan thay dng nh Hen phe quan co ve nang hn mot so trng hp thai ky, dng
nh cac cn kho th kch phat thng xay ra t thang th t cua thai ky tr i. Co trng
hp co thai khong thai oi mc o nang cua hen phe quan.
/// . // |/\/ /\/ //\ |// |\
Cac iem then chot can lu y trong hen PQ:
1. hen PQ la xao tron man tnh cua ng ho hap vi cac t kch phat cua benh,
2. Phan ng viem mam tnh kem ton thng va sa cha lp bieu mo phe quan tai
cau truc cay PQ.
3. Phan ng ng viem, tai cau truc cay PQ, S chi phoi cua TK kh ao gay cac
cn hen kch phat va tac nghen ng dan kh thng xuyen.
4. Hep kh ao do cac nguyen nhan Co that c trnPQ, phu ne niem mac PQ, cac lc
co keo nhu mo phoi tac ong, dch tiet trong long PQ.
96

5. Cac cn hen kch phat thng xay ra khi co nhiem trung ng ho hap, tiep xuc
vi d ng nguyen trong khong kh hay trong nghe nghiep.
6. Suy hohap trong cn hen kch phat thng la hau qua cua s tac nghen kh ao, roi
loan gia thong kh va ti mau, moi c ho hap.
PHAN NG VIEM TRONG HEN :
3 hien tng sau ay ghi nhan c trong cn Hen phe quan :
1. Tiet dien cua phe quan b hep lai : Do c trn phe quan b co that, do phu ne
niem mac phe quan, tang tiet chat nhay trong long phe quan.
2. Co that cac c ho hap do phan xa than kinh : ac biet la cac c hoanh, c ngc.
3. Dan PN cap tnh : v phe quan co that lai lam han che thong kh t PN ra ngoai
th th ra.
Cac c che gay ra cac hien tng ke tren cha c hieu biet ay u, tuy nhien co
the tom tat nh sau :
A. C che mien dch viem kh ao trong hen :
- Mien dch dch the thong qua cac lymphocyte B tao ra cac immunoglobulin .
- Mien dch te bao thong qua cac lymphocyte T.
Trong Lymphocyte T co 2 di nhom LT h1 vaLTh2
LTh1: tiet IL-2, IL-3, GM-CSF, IFN, TNF.
LTh2 tiet IL-3, GM-CSF, IL-4, IL-5 , IL-9, IL13.
IL-2 co tac dungf kch thch s tang sinh TB lymphocyte T
IFN Co tac dung c che hoat ong cua lymphocyte B va tong hp IgE
GM-CSF : granulocyte macrophage colony stimulating factor : co tac dung lam
hoat hoa cac TB dong hat va ai thc bao.
IL-4 co vai tro trung tam trong sinh benh hoc cua hen PQ. No thuc ay lymphocyte
B mi tong hp khang the IgE. LymphocyteB c ieu hoa bi Lymphocyte T c che
va bi IFN cua LTh1. Nhng BN hen PQ co tnh trang thieu hut Lymphocyte T c
che va do roi loan mien dch nen giam lymphocyteTh1 do o IgE c san xuat ao at khi
c theBN b man cam vi d ng nguyen ac hieu b tai tiep xuc vi KN nay. Khang the
IgE se ket hp vi khang nguyen achieu tao thanh phc hp khang nguyen - khang the
bam len be mat cac TB ch : dng bao. Kch hoat dung bao tao ra cac hoa chat trung
gian gay D ng nhanh - xay ra sau khi benh nhan tiep xuc vi d ng nguyen la khang
nguyen [ bat au trong vong 10 phut sau khi ht phai d ng nguyen , at mc toi a trong
vong 30 phut, t xuong cn trong vong 1-3 gi]. Cac hoa chat trung gian c tao ra
trong phan ng mien dch nhanh c ghi nhan la :Histamin, serotonine, tryptopase,
kalikreine
mot so benh nhan sau khi ap ng nhanh xay ra, ng th van con hep dai
dang , chc nang ho hap khong tr ve giatr c ban hoac sau o 3-4 gi cn hen tr lai
va at en mc o toi a trong vai gi sau o oi khi keo dai ti 24 gi. ap ng kieu
nay la ap ng muon cua hen, Thng ket hp vi tnh tang ap ng cua ng th oi
97

vi methacholine hay histamine, tnh trang tang tnh kch ng vi ng th co the keo
dai dai dang vai tuan en vai thang. Cac hoa chat trung gian trong ap ng muon c
ghi nhan la cac Leukotrienes LT C4, LTD4, LT E4, cac Prostaglandins D2 va
thromboxane A2. Gay co that, phu ne, tang tiet chat nhay cay phe quan, gay tang tnh
tham thanh mach.
B.C che than kinh :
Neu ch rieng yeu to d ng th oi khi khong the giai thch c mot so trng
hp hen phe quan. Ngay nay ngi ta chu y en vai tro than kinh the dch trong hen phe
quan.
+ He giao cam : Phoi nhan TK giao cam chu yeu qua chuoi hach sao, sau o chi
phoi tren cay phe quan, ca va receptor eu co c trn phe quan.
Khi 2 receptor b kch thch se gay ra dan c phe quan, mach mau phoi, lam cho
cac ion va nc trao oi qua lai cac mang TB ng th, kch thch tiet ra chat nhay.
Ngc lai khi c che adrenergic receptors trong ng th se gay ra co that phe
quan.
+ He cholinergic : Qua TK X chi phoi cac phe quan ln en cac phe quan nho. Khi
b kch thch gay ra co that ng th, tang tiet chat nhay cac TB hnh ai hoac te bao
tuyen va dan mach mau phoi.
+ Cac neuron khong thuoc he giao cam nhng co anh hng len trng lc c trn
phe quan, cac chat dan truyen TK cua he thong nay la : Vasoactive intestinal peptide,
peptide histidine isoleucine, peptide histidine methionine va chat P. Vai tro chnh xac cua
he thong nay cha sang to.
C. Yeu to di truyen :
Tren lam sang t lau ngi ta ghi nhan xuat o hen phe quan tre em sinh oi
cung trng cao hn la tre em sinh oi khac trng. Nguy c hen phe quan tre em co ca
cha va me b hen phe quan cao hn la tre em co cha hoac me b hen phe quan, tng t
nhom tre va ke tren co nguy c hen phe quan cao hn cac tre em co cha va me manh
khoe. Theo cac nghien cu cua Hopkins Cooksin ghi Hen phe quan lien quan en yeu to
di truyen, lien quan en nhiem sac the 11q, ong nhiem sac the, mang tnh troi. Neu me
hoac cha b benh d ng th nguy c tang d ng con cai khoang 30%, neu ca hai cha me
b benh th nguy c nay tang len 50%.
/! /\/ / |/\/ /. | //\ |
1. Tat nghen ng th : gay kho th cac mc o khac nhau, ho: do cac HCTG kch
thch TK cam giac cua kh ao.Tang PaCO2, giam PaO2 gay kch thch ho hap
lam tang thong kh PN.
2. Hepkh ao cap tnh do tac dung cua cacHCTG nh a noi tren. DO cac
neuropeptide cua TK thng tam tac ong tai cho, do acetylcholine t TK ly tam
cua si hau hach tietra.
3. Cac PQ b anh hng co kch thc 2- 5 mm, cac PN cung co b anh hng viem.
98

4. Hau qua :
+ Tang khang lc ng th , dong kh th ra toi a giam cac the tch phoi.
+ ng th ngoai bien b hep lai nen ong thetch cao hn bnh thng gay
tang residual volume long ngc cang phong, Bn th vi long ngc kh , the tch
phoi tang hn bnh thng ( hyperinflation ) nham
keo ng knh cac PQkhong xep lai moi c ho hap, tang cong ho hap. Suy ho
hap cap.
! // |/| |/\/
cac benh nhan chet do hen phe quan nghien cu giai phau benh ve ai the
ngi ta ghi nhan c cac iem sau ay :
- Phoi cang phong.
- Co mot so tieu phan thuy b xep.
- Long cac phe quan trung bnh, tieu phe quan b bt tat bi cac cuc am
- Niem mac phe quan phu ne xung huyet, mc o nang hn thanh phe quan day
len.
Di knh hien vi :
- Niem mac phe quan co s tham nhiem cac TB viem : TB ai toan, tng bao,
lymphocyte loai phenotype H2.
- Mc o nang hn co s tang sinh cac TB tiet nhay, te bao hnh ai b d san, lp
bieu mo phe quan b tan pha tng vung, co hien tng ph ai lp c trn phe quan, va
ong collagen lp di niem mac phe quan.
Trong am co nhieu TB bieu mo thoai hoa. TB ai toan, cac cum TB bieu mo
ng th vi cac long chuyen ng th, tinh the Charcot Leyden.
!/ I|//| /|\ / \
A.Cn hen phe quan ien hnh :
Mo ta cn hen phe quan ien hnh xay ra Bn ngi ln tre tuoi
Cn kho th cua hen phe quan thng xay ra vao ban em. Benh nhan hay co tien
trieu nh nang ngc, nga mat mui, ho khan sau o xuat hien cn kho th.
Benh nhan phai ngoi ty tay vao thanh ging, ha mieng th, giai oan au kho th
cham th th th ra, tieng th on ao en noi nhng ngi ng gan benh nhan co the
nghe c tieng rt th th ra, tinh than bt rt, da am mo hoi.
Kham phoi rung thanh con bnh thng, go vang r rao phe nang giam nhe, co ran
rt ngay khap 2 phe trng.
Dien tien cua cn : Cn kho th co the keo dai vai phut en vai gi. Cn nang hay
nhe tuy thuoc vao tnh trang sc khoe tong quat cua benh nhan.
Luc gan het cn benh nhan thng khac ra c am nhieu bot trang trong, quanh,
sau o bt kho th va ngu lai c.
99

B. Cn hen ac tnh :
Cn hen phe quan ac tnh thng xay ra cac benh nhan b boi nhiem ng ho
hap, co s dung corticosteroide nhieu ngay trc o, thieu nc, d ng thuoc, tran kh
mang phoi, xep phoi
Trieu chng lam sang cua hen phe quan phu thuoc vao mc o tac nghen cua cay
phe quan.
Ho hap : Tan so th > 30lan/ phut, benh nhan phai ngoi th, khong muon noi hoac
khong the no c, khong ho ;khac c. Long ngc cang phong, luc au cac c ho hap
phu con co keo manh ve sau bien o th giam dan long ngc khong con di ong, cac
tieng ran luc au on ao che mat ca tieng tim va ve sau tieng ran giam dan va bien mat.
Tim mach : Nhp tim > 120 lan/phut, co the co mach nghch > 15mmHg, HA giai
oan au tang ve sau giam. Tim co tieng nga phi phai, Hardzer + gan co the hi ln.
Tri giac : Roi loan cac mc o khac nhau : s hai, kch ong, day dua, la het, l
m en hon me .
!// \ / \
Trong cn hen phe quan :
+ am : co TB bieu mo phe quan bong ra, tnh the Charcot Leyden, vong xoan
Curschmann, the Creola cac TB ai toan thoai hoa, neu co boi nhiem phoi : co TB TB
h bien.
+ Mau :BC : co khi khong tang ve so lng
Neu BC mau > 15.000/mm3 la do nhiem trung phoi, nhng co khi khong phai, ma
co the Stress cua cn hen phe quan lam tang BC, hoac la benh nhan co s dung
Epinephrine trc o.
+ X quang phoi : muc ch tm cac sang thng phoi tan tr cn hen keo dai kho
ieu tr nh la hnh anh viem phoi, xep phoi, gay xng sn, tran kh hay tran dch mang
phoi hay trung that.
+ ECG : Thay oi tren ECG thng xay ra trong cn hen nang.
Nhp nhanh, truc lech phai, t the tim xoay theo chieu kim ong ho, co P phe, ph
ai that phai. Song T, ST thay oi bat thng.

+ Chc nang ho hap :
Mc o nhe trung bnh nang
FEV1 % GTD <80- 71 % 70 - 45 % <50%
PF %GTD >=80 % >=60% <50%

100

Phan tch kh mau trong ong mach : oi vi cn hen nhe cha can XN nay :

Mc o PaO
2
[mmHg] PaCO
2
[mmHg]
Bnh thng > 80 < 40
Cn hen bat au nang < 70 Bnh thng
Cn hen nang < 65 > 40

+ Test anh gia mc o ap ng cua cay phe quan oi vi cac thuoc dan phe quan
Benh nhan c tham do CNHH do FEV1 lan 1 trc khi th kh dung thuoc dan phe
quan nh Salbutamol, sau o 15 o lai CNHH cho benh nhan nay : neu tr so FEV1 lan
2 cao hn lan 1 # 15% th chc nang ho hap cua benh nhan co cai thien oi vi thuoc
c test.
*. Ngoai ra co mot so xet nghiem co the thc hien e giup chan oan hen phe
quan neu benh nhan khong co trieu chng hen phe quan ien hnh nhng benh s nghi
ng en hen phe quan.
a/. Kch thch cay phe quan bang nghiem phap gang sc :
Benh nhan c o FEV1 trc va sau nghiem phap gang sc nh ap xe ap co
lc can, chay bo tai cho . Neu FEV1 sau khi gang sc < 15% th chan oan +.
b/. Th thach tnh kch thch cua cay phe quan oi vi mot so chat hoa hoc nh :
metacholine, histamine, nc + khong kh lanh hoac mot so d nguyen. Nghiem phap nay
rat nguy hiem v co nguy c xay ra shock phan ve hoac co that phe quan nang ne cac
benh nhan b hen phe quan cha c chan oan, do o ch nen thc hien trong cac Benh
vien vi phng tien chong shock san sang.
Benh nhan c o FEV1 trc va sau test 15 , 30, 6h. 8h. Gia tr FEVI lan sau
thap hn lan au > 15% : test +.
c/. Cac test da : nh dan, kheu da, rach da, tiem trong da cac d ng nguyen nghi
ng : neu test + cung cha chac la benh nhan b hen phe quan do cac chat gay d da .

101

!/// |/\ /./ | /. \\ | //\ |// |\
Viec phan loai nay ch co y ngha trong viec ieu tr va quan ly hen phe quan.
Trng hp cn hen phe quan kch phat viec o nang nhe cua cn hen se da vao trieu
chng lam sang Bn ang co.
/' /\ /.\ |/\ |//I
Khong phai tat ca cac trng hp benh nhan kho th co ran rt phoi eu b Hen phe
quan. Do o can chan oan phan biet hen vi cac benh thng gap sau ay.
BAC Hnh anh lam sang trc khi ieu tr
I. tng luc < 1 lan /tuan.
Cac cn kch phat ngan( vai gi- vai ngay).
Trieu chng hen ve em< 2 cn trong thang.
Gia cac cn khong co trieu chnh lam sang. FEV1 :
BT
+ PEF hay FEV1 >/= 80% GTD
+ thay oi <20%
II. dai dang, nhe Cac trieu chng >/= 1 lan trong tuannhng t hn 1 lan
moi ngay.
Cac cn co the lam xao tron hoat ong va giac ngu.
Trieu chng hen ve em> 2 cn trong thang
+ PEF hay FEV1 >/= 80% GTD
+ thay oi t 20% -30%.
III. dai dang, trung bnh Cac trieu chngco hang ngay.
Cac cn kch phat lam xao tron hoat ong va giac ngu.
Cn hen ve em > 1 cn moi tuan.
Phai x dung thuoc dan phe quan agonist tac dung
ngan moi ngay.
+ PEF hay FEV1 >60% - < 80% GTD
+ thay oi > 30%.
IV. dai dang, nang Cac trieu chng xay ra thng xuyen lien tuc.
Cac cn kch phat thng xuyen.
Cn hen ve em thng xuyen.
Cac hoat ong hang ngay b han che bi cn hen
+ PEF hay FEV1 < 60% GTD
+ thay oi > 30%.
102

1/. D vat ng th
2/. Viem nap thanh quan cap
3/. Hoi chng tang thong kh
4/. Cac khoi u vung thanh kh quan ln
5/ Viem phe quan man tnh type B
6/. Cn hen tim
' |//\ /|\
1/. Bien chng cap tnh :
Xep phoi do tat am, tran kh mang phoi. Suy ho hap cap e doa tnh mang.
Nhoi mau c tim, phu phoi cap : cac bien chng tim mach cap thng lam ty le t
vong cac benh nhan nay tang cao hn the hen n thuan.
2/. Bien chng man tnh : hiem gap
Suy ho hap man, tam phe man.

CHAN OAN HEN PHE QUAN:
Chan oan hen phe quan ngi ln va tre em > 5 tuoi
Da vao: tm cac dau hieu cua hen, gom co:
Benh s:
+ Co cn kho th vi tieng th kho khe tai phat tng t, nang ngc, hi th ngan,
hay la ho
+ Cac trieu chng xau i theo mua, khi co cac d nguyen trong khong kh hay khi
van ong the lc
+ Cac trieu chng xuat hien hay nang hn vao luc khuya khien benh nhan phai
thc giac
+ Benh nhan co viem mui d ng hay viem da d ng
+ Trong gia nh co ngi than thiet ruot tht b hen, d ng, viem xoang, viem mui
d ng
Kham lam sang ng ho hap tren, long ngc, da:
+ Long ngc cang phong
+ Tieng ran rt trong luc th bnh thng hay th th ra keo dai
+ Chay nc mat, nc mui, viem ket mac, viem xoang d ng, polyp mui
+ Viem da d ng, cham
Thiet lap chan oan HEN da vao:
1. Benh s trc ay hay va hien tai co trieu chng tac nghen ng th theo tng
t. Neu BN khong co trieu chng tac nghen thi iem ngi thay thuoc tham
kham cung cha chac loai tr c Hen.

103

2. Tm bang chng tac nghen ng th trong cn kho th da tren xet nghiem chc
nang ho hap FEV1<80% gia tr d oan, FEV1/FVC < 65%.
3. Tm bang chng cua ap ng cua cay phe quan oi vi thuoc dan phe quan nhom
kch thch 2 . FEV1 tang len sau test thuoc >= 12% hay t nhat 200ml sau khi ht
terbutaline. Hay PFR tang15 %
4. Chan oan loai tr cac nguyen nhan khac gay kho th kho khe.

Xet nghiem bo sung gup tm yeu to tan tr cn hen khi phat va phan biet hen vi mot
so benh ly ho hap co the gap: XQUANG tim phoi thng quy, ien giai o mau,
Xet nghiem anh gia mc o nang nhe cua cn hen: FEVi, kh mau ong mach..
Cac xet nghiem truy tm d ng nguyen nghi ng gay hen khong thc hien trong luc cac
cn hen kch phat.

'/ ///| I|/
CAC THUOC X DUNG TRONG IEU TR HEN PHE QUAN:
IEU TR
A/. ieu tr d phong :
Benh nhan co gang tranh tiep xuc cac d ng nguyen neu a biet c loa nao,
can phai quan tam en cac yeu to thuc ay cn hen kch phat, co bien phap lam sach moi
trng song, tap th e s dung cac c ho hap co hieu qua.
* Phat hien kp thi va theo doi sat tnh trang benh theo chng trnh phong chong
hen phe quan :
Can co s hp tac tot gia cac thay thuoc c s vi benh nhan, giup cho ngi
benh hieu c benh cua mnh mac phai e ho khong xem thng benh, biet cach tranh
tiep xuc vi d nguyen gay hen neu co the c, biet cach s dung cac thuoc giai man
cam hoac thuoc dan phe quan ung cach va ung ch nh.
Hng dan benh nhan cac x dung may o lu lng nh e t theo doi ien bien
cn hen trong thi ky cac cn kch phat thng xay ra e x dung thuoc dan phe quan
loai cat cn kho th xay ra.
* Cac phng phap giai man cam bang thuoc :
Hieu qua ieu tr ch co khi biet chac chan benh nhan b hen do d ng nguyen
nao, viec ieu tr can keo dai nhieu nam, no la con dao 2 li, co the gay shock phan ve.
Cac thuoc giam d ng loai antihistamin khong ngan nga cn hen xuat hien.
B/. ieu tr nga cn hen kch phat:
Ngay nay ngi ta co xu hng chon cac thuoc kch thch giao cam lam
thuoc dan phe quan hang au, cac dang thuoc khi dung lieu nh san, phun sng bang
may, uong, chch di da, tiem bap, truyen tnh mach c ch nh tuy theo tnh trang
lam sang cua benh nhan.

104

ieu tr duy tr hen theo bac : ngi ln
Bac Thuoc hang ngay ieu tr khac
Intermittent
Asthma I.
khong can
Mild persistent
asthma II
Ht glucocorticosteroid
( 500g BDP hay tng
ng)

Theophylline phong thchcham
hay Cromone
Hay : Leukotriene modifier.
Bac III
(200-1.000g BDP hay tng
ng)
+ 2 (+) dang ht tac dung
keo dai

+ Ht glucocorticosteroid
(500- 1.000g BDP hay
tngng) + theophylline
phong thch cham
hoac
(500-1.000gBDP hay
tngng) + 2 (+) dang uong
tac dung keo dai, phong thch
cham
hoac
(1.000g BDP hay tng ng)
hay
(500-1.000gBDP hay tng
ng)+ leukotriene modifier

105

Bac IV
Severe persistent asthma
(1.000 g BDP hay tng
ng)+ 2 (+) dang ht,
tac dung keo dai .
kem vi 1 thuoc sau ay:
+Theophylline tac dung keo
dai.
+LTs modifier
+ Glucocorticosteroid uong
+ 2 (+) uong, tac dung
keo dai

Chu y khi hen a kiemsoat c can duy trche o ieu tr nh vay t nhat 3 thang
sau o anh gia laibaccua hen e ieu tr giam bac nhammuc ch tm lieu duy tr toi u
cho BN

CAC THUOC X DUNG TRONG IEU TR HEN PHE QUAN:
A.THUOC KCH THCH GIAO CAM:
Cac thuoc adrenergic ket hp vi cac receptors nam tren be mat cac te baogay
kch thch ca receptor ( gay co mach,liet ruot, co bop c trn t cung,co that phe quan,
nhat la trong trng hp co c che adrenergic). Khi kch thch 1 adrenergic gay kch
thch tim mach. Khi 2 adrenergic kch thch gay dan c trn phe quan, c trn t cung.
Dan mach . Mat khac 2 adrenergic kch thch se c che phong thch ra histamine t
tng bao, c che s tao khang the t cac te bao lympho, va c che s phong thch ra cac
enzymes t cac bach ca a nhan trung tnh. Kch thch 2 adrenergic se gay tang s bai
tiet nc t cac te bao tiet nhay kch thch s thanh loc cua cac te bao co long chuyen
tren niem mac phe quan.
S kch thch cac 2 adrenergic receptor gay hoat hoa enzyme adenyl cyclase,
ma chung co tac dung chuyen oi adenosine triphosphate (ATP) thanh adenosine
monophosphate vong ( AMPc). Sau o AMPc se tac ong nh mot thong tin th hai tao ra
s phosphoryl hoa cac protein noi bao gay bien oi trong te bao. S gia tang AMPc lam
gia tang ket hp calcium trong noi bao vao mang te bao, vao he vong noi mo, gay ra
giam myoplasmic calcium nh vay lam dan c.
Cac thuoc kch thch giao cam dung ieu tr hen phe quan gom co:
Thuoc tac dung ngan: 4- 6 gi :
Epinephrine: kch thch ca va adrenergic, tac dung adrenergic troi hn.
Trong mot so trng hp cn hen kch phat nghi ng dophan ng d ng Epinephrine la
thuoc chon la au tien. Hau het tac dung phu cua thuoc do tac dung tren va 1
106

adrenergic gay tang nhp tim, tang huyet ap, co mach, roi loan nhp tim , ve mat ly
thuyet gay co that phe quan
Thuoc kch thch 2 adrenergic tac dung ngan: 3- 6 gi
1. Terbutalin sulfate la loai kch thch chuyen biet tren 2 adrenergic co tac dung
dan phe quan tng ng vi epinephrine trong ieu tr cn hen cap hay cn hen on
nh. Tac dung phu la gay run tay, tang nhp tim.
Dang thuoc: vien 5mg., ong- phun kh dung:5mg, ong tiem di da 0,5mg, ong lieu nh
san:250g/lieu xt/200lieu.
2. Salbutamol:vien 2mg, 4mg. Ong- phun kh dung; 2,5 mg- 5mg, dang kh dung
lieu nh san; 100g/lieu/200lieu, dang vien ht lieu nh san.lieu truyen tnh mach : 4-25
g/ phut vi ieu kien theo doi sat tnh trang tim mach cua BN
Cac thuoc tac dung keo dai 8- 12gi:
1. Formoterol: co tac dung dan phe quan manh hn Salbutamol 5-15 lan, thi gian
tac dung keo dai #12 gi. Dang vien ht 12g/lieu.
2. Salmeterol: thi gian tac dung keo dai #12 gi. Thuoc thng c dung trong
ieu tr cn hen xay ra ban em, hay d phong hen do tang hoat ong the lc.
B. THUOC CORTICOSTEROIDS.
Tac dung cua thuoc gom co(1) anh hng len s tong hp va phong thch
histamine,chuyen hoa acid arachidonic. (2)dan mach va giam tnh tham mach mau, (3)
anh hng len sdo lng va chc nang bach cau vaeosinophil, (4) lam ben vng mang
lysosome, (5) giam kch thch cholinergic,(7) tang ap ng oi vi catecholamine( ke ca
phuc hoi mat o receptor, (7) tang s thanh loc cua cac te bao tiet nhay co long
chuyen.
Tac dung khang viem cua corticosteroidsco the la do ssan xuat ra cac protein noi
bao nh lipocortin- loai protein nay co kha nang c che phospholipase A loai enzyme
mang tebao gay pha v phospholipid cua mang thanh arachidonoic acid va cac hoa chat
trung gian gay viem. Trong cac che pham co cha corticosteroid loai tac dung toan than ,
neu chon hydrocortison lam c s anh ga tiem nang khang viem, khi so sanh tiem nang
khang viem cua cac che pham cha corticoids vi nhau , ngi ta co ghi nhan nh sau:
Hydrocorisone co tiem nang khang viem la 1, tac dung phu la gi muoi, nc, khong tot
cho cac BN hen. Prednisone co tiem nang khang viem la 4, can gan chuyen hoa thanh
dang hoat ong .Tiem nang khang viem cua Methylprednisilone bang 5, t co tac dung
gi muoi nhat, nen thng c chon trong ieu tr cn hen kch phat cap ng uong
hay chch, thi gian ban huy cua thuoc t 2-3 gi, thi gian ban huy sinh hoa # 18- 36 gi
. Dexamethasone co tiem nang khang viem la 25-30, khong co tac dung gi muoi.
Nhng co nhieu tac dung phu. Khi au tac dung cua thuoc corticoid sau khi cho uong
hay chch thng cham # 6-12 gi. Tren lam sang thng BN co cai thien trieu chng tac
nghen mot cach ang ke sau khi cho thuoc , hien tng nay c giai thch la co le thuoc
lam tang mat o cua receptor, lam gia tang ap ng vi thuoc dan phe quan vi kch
thch 2 giao cam.
107

Lieu Methylprednisolone cha thong nhat : thay oi t 60mg en 125 mg x 4 lan/ ngay.
Hydrocortisone: 1000mg/ ngay.
C. ANTICHOLINERGIC:
Khong c chon lam thuoc dan phe quan au tay trong ieu tr cat cn hen phe quan
kch phat, Tac dung toi a at c sau khi cho thuoc khoang90 phut en 2 gi. Keo dai
tac dung >6 gi.
D. THEOPHYLLINE VA CAC CHE PHAM CO XANTHINE:
Gan ay ngi ta ban ve c che tac ong cua nhom thuoc nay lien quan en c
che c che phan ng viem cua ng th BN hen. nong o cao thuoc c che s
phong thch Histamine t tng bao, basophil, nong o ieu tr thuoc co ong gay c
che hoat ong cua bach cau a nhan trung tnh, lam ben vng cac te bao viem khac e
khong phong thch ra cac hoa chat trung gian.
Thuoc co tac dung cai thien s van chuyen bat thng cua te bao tiet nhay, kch
thch trung tam ho hap, tang inotrop va chronotrop cua tim, dan mach phoi, li tieu nhe,,
tang ap ng thong kh oi vi giam thieu oxy mau. Tac dung phu cua thuoc gom co kch
thch than kinh trung ng gay kch ong, co giat ong kinh, kch ng da day gay non oi,
tieu chay,kch thch tim mach gay nhp nhanh xoang, ngoai tam thu that, rung nh.
Nong o ieu tr cho phep: 10 20 m/ml huyet thanh.
Lieu Aminophylline: truyen tnh mach:
Tan cong: 5,6 mg/kg ( truyen trong 20 phut)
Duy tr:
Tre em <18 tuoi 1mg/kg/ gi
Ngi ln hut thuoc la <50 tuoi 0,9 mg/ kg/ gi
Ngi ln khong hut thuoc la < 50 tuoi 0,5 mg/ kg/ gi
Ngi ln >50 tuoi 0,4 mg/ kg/ gi
COPD nhiem sieu vi cap 0,6 0,7mg/ kg/ gi
Suy tim huyet 0,35 0,68mg/ kg/ gi
Roi loan chc nang gan 0,25 0,45mg/ kg/ gi
TAI LIEU THAM KHAO
1. Benh hoc noi khoa 1982 Bo mon noi Trng ai hoc Y Dc TP. Ho Ch
Minh.
2. David Spearlman, C. Warren Bierman 1988 Asthma [Bronchial Asthma].
In Allergic Disease from in fancy to adulthood, 2
nd
edition.
W. B. Saunders Company. pp 546 570.
3. Jeffrey M. Drazen 1992 Asthma.
In Cecil Textbook of 19
th
edition.
WB. Saunders Company. pp 381 386.
4. Robert K. Bush. William W. Busse 1988 Treatment of Asthma.
108

THAN
109

SUY THN CP
C: q7 99 7,xye ", 7,-: Z.
I. NH NGHA
STC: tnh trng suy gim lc cu thn t ngt (vi gi n vi ngy) -> ng
cc sn phm azot mu, RL nc- in gii -kim toan
Chim 5% cc trng hp nhp vin, 30% nm khoa sn sc c bit
Chc nng thn hi phc gn nh han tan
Vic chn on xc nh nguyn nhn trc thn, ti thn, sau thn rt quan trng
-> iu tr sm, trnh suy thn khng hi phc
II. CHN ON STC
Creatinin mu tng t nht 0,5mg% (44,2 mol/L) hoc gim GFR 50% so vi tr s
ban u
T/C LS: tiu t < 400ml/N, v niu < 100 ml/N
50% dng khng thiu niu
Phn bit:
Mt s thuc ngn bi tit creatinin OT: cephalosporin, bactrim
BUN tng: XHTH, d ha m tng, dng corticoid
Ngc li, creatinin khng tng cao nhng c suy thn do gy, suy kit -> tnh
thanh lc creatinin
Suy thn cp: thut ng ch tt c cc trng hp suy thn do nguyn nhn
trc thn, ti thn, sau thn
Hai t ng thn cp: ch nhng trng hp suy thn cp ti thn do c cht
v thiu mu nui thn

III. NGUYN NHN V C CH BNH SINH SUY THN CP
1. TRC THN: gim ti mu thn (55 -60%)
- NN thng gp nht, do gim ti mu thn, khng tn thng thc th ti
nhu m thn
- CN thn nhanh chng hi phc khi ti lp lu lng mu n thn
- Tuy nhin khi gim ti mu thn nng n v ko di s gy tn thng ti
thn -> hai t ng thn cp. V th vic bi han nc- in gii sm s ngn
chn c tin trin n suy thn cp .

+ C ch gim ti mu thn (55 -60%)
- Khi th tch lu thng hiu qu gam s gy gim HA, kch thch p cm th
quan M cnh v tim -> kch thch h giao cm v h renin- angiotensin-
aldosterone, phng thch hormon khng li niu ADH
- Norepinephrine, angiotensin II v ADH tng -> duy tr huyt p, ti mu
tim v no
110

- Khi thiu mu nh, c ch b tr ti ch : dn tiu M n, tng tng hp
cht lm dn mch thn nh prostaglandine , nitric oxide (NO), kinin
- Khi thiu mu nng, c ch b tr khng hiu qu -> suy thn cp

+ Nguyn nhn
1. Gim V mu lu thng: mt mu, mt nc (nn i , tiu chy, dn lu
dch sau m), tiu nhiu (dng li tiu, i tho ng)
2. Gim P bm tim: suy tim, RL nhp tim, chn p tim, h HA, chong
3. Ti phn b dch trong c th: phng, vim ty cp, HCTH
4. Thay i sc khng mch mu tan thn v thn:
- Dn mch ngoi vi: nhim trng, thuc h p
- Co mch thn: thuc chng vim NSAID, cyclosporin, adrenaline
- Hi chng gan thn

2. STC TI THN: 20-40%. Do tn thng ti nhu m thn.
2.1 Bnh cu thn: vim cu thn cp
2.2 Bnh MM thn
- Bnh MM ln: thuyn tc M-TM thn do huyt khi, chn p, phnh bc tch
M thn
- Bnh MM nh: vim MM thn, lupus , nhim c thai nghn, THA c tnh,
HC tn huyt ure huyt
2.3 Bnh ng thn: hai t ng thn cp
- Do thiu mu: cc NN gy STC trc thn ko di lm tn thng thn
- Do c cht: cht cn quang, KS, thuc iu tr ung th, acid uric, ly gii c
vn (myoglobin), tn huyt (Hb), a u ty
2.4 Vim m k thn:
- D ng: KS, chng vim non-steroid, captopril
- Nhim trng: vim i b thn cp, siu vi
- Thm nhim m k thn:lymphoma, leucemia, sarcoidose
2.5.Thi ghp
- 75% hai t ng thn cp do thiu mu ti thn, c cht
3. STC SAU THN: 5-10%, do tc nghn
- Niu qun 2 bn b tc nghn do si, mu cc,u t cung xm ln, x ha sau phc
mc
- C bng quang - niu o: si, u, cc mu, bng quang TK, ph i TLT
- Niu o: hp niu o, hp bao da qui u
= a s trng hp STC trc thn v hoi t OT cp (do thiu mu, c cht)

IV TRIU CHNG LM SNG STC:
STC do hoi t ng thn cp gm 3 giai an: khi pht, duy tr (thiu niu, v niu),
hi phc (a niu)
111

A. G KHI PHT :
- Ko di vi gi- vi ngy
- LS: Biu hin tnh trng gim ti mu thn: chong, tt HA, suy tim, mt mu mt
nc
- Vic pht hin v iu tr sm, ci thin tnh trng ti mu thn s ngn chn
c hoi t OT

B. G THIU NIU (G DUY TR):
- Tip theo g khi pht, khi tn thng thc th ch m thn
- Ko di 1-2 tun. Nu qu thiu niu ko di
> 4 tun phi ngh n hoi t v thn, vim cu thn hoc vim MM thn
- LS: thiu niu # 150 ml/N, khng b v niu hon ton
+ Bin chng G thiu niu
Thn khng cn kh nng o thi nc v cht ha tan -> bin chng. Mc
nng ca bin chng ty thuc mc suy thn, s thoi ha m ca BN
1. Tng th tch dch ngai bo: do gim bi tit nc qua thn khi thiu niu, v
niu, thng km theo truyn dch qu ti.
- Ion : natri mu gim do pha long, nu gim nng < 120mEq/L s gy ph
no, co git.
- Tng azot mu: BUN tng, creatinin tng. Nu ly gii c vn hoc dp nt c
creatinin tng nhanh > 2mg%/N
- LS: ph, tng cn, ran m phi, TM c ni, nng gy suy tim, ph phi cp
2. RL in gii
- Tng K/mu
- Giai an thiu niu, K/mu tng 0,5 mEq/L/ ngy, c th tng nhanh 1-2
mEq/gi
- Tng K/ mu nh < 6 mEq/L: khng biu hin LS
- Tng K/mu nng hn gy thay i ECG: sng T cao nhn, PR ko di,
sng P dt, QRS dn rng, lan nhp tim nh bloc nh tht, nhanh tht,
rung tht, v tm thu
- Tng phosphat mu: thng tng t, tng nhiu (10-20mg%) khi tn huyt, ly
gii c vn
- Gim canxi mu: thng gim nh, khng triu chng
- Gim natri mu, nu nng < 120 mEq/L c th gy co git, hn m.
3. Thiu mu: thng nh
C ch: gim sn xut erythropoietin, tn huyt, xut huyt. RL ng mu do
gim tiu cu, RL CN tiu cu, RL yu t ng mu
4. Toan chuyn ha:
- Mi ngy thn thi 50-100 mMol acid khng bay hi, lm HCO3
-
+ 1-2
mEq/L/N
- Toan mu nng hn khi km theo nhim trng, nhim acid lactic, nhim ceton
mu
112

5. Biu hin RL thng bng kim toan
+ Toan mu chuyn ha:
- thi H
+
NH
3
+ H
+
--> NH
4

- ti to v hp thu HCO
3
-

O
2
H
2
CO
3
CO
2
H
3
HCO
pH

+ Nhp th Kussmaul
6. Nhim trng
- BC thng gp ca hoi t ng thn cp, chim t l 50-90%. 75% gy t
vong.
- Do gim sc khng c th v VK xm nhp qua ng tim truyn, thng
tiu, my th.
7. BC tim mch: lan nhp, nhi mu c tim, ph phi cp do hu qu qu ti tun
han, toan chuyn ha, tng K/mu
8. BC tiu ha: XHTH gp trong 10-30%. NN: let do stress d dy
3 nguyn nhn thng gy t vong trong g thiu niu: ph phi cp, tng kali mu,
toan ha mu nng

C. GIAI ON HI PHC (A NIU):
- LS: Lng NT gia tng mi ngy, ngy sau gp i ngy trc
- Do a niu thm thu, tng bi tit cc cht tch t trong g thiu niu:
nc,mui, cht ha tan, tc dng ca thuc li tiu
- T bo ng thn phc hi, ti to -> CN thn hi phc dn, ci thin trong 3-12
thng. Tuy nhin c 2/3 BN gim GFR 20-40% so vi bnh thng. Mt s BN
tin trin dn n suy thn g cui
V. XN CN LM SNG SUY THN CP
1. BUN, creatinin mu
2. Tng phn tch nc tiu: m, ng. Cn lng NT: hng cu, tr hng cu, bch
cu, tr bch cu, tinh th, cc tr trong, tr m, tr t bo gip chn an nguyn
nhn suy thn cp. Tr rng gip chn an xc nh suy thn mn
3. Siu m h niu: si, tc nghn ng tiu lai tr STC sau thn. Xc nh kch
thc thn, ranh gii v -ty thn gip phn bit STC v suy thn mn
113

4. Chp X-quang KUB: tm si cn quang h niu
5. Siu m Doppler, MRI kho st M- TM thn
6. Ion mu
7. D tr kim (RA), pH mu
8. Cc XN nh gi BC tim mch: X-quang phi, ECG, siu m tim
VI. Chn an suy thn cp
+ Cc bc tip cn mt BN suy thn cp
1. Chn on xc nh STC: BUN, creatinin tng mi ngy
2. Chn on phn bit STC v Suy thn mn
3. Chn on phn bit STC trc thn, ti thn v sau thn
4. Cui cng chn an xc nh nguyn nhn gy suy thn cp v tm yu t thc
y
+ Chn on phn bit Suy Thn cp-mn

SUY THN CP SUY THN MN
Lm sng bnh cnh cp tnh
BUN, creatinin /N
SA : Thn to, ph n. V ty phn
bit r
Khng thiu mu hoc thiu mu
nh ( xut huyt, tn huyt )
XN TPTNT : bnh thng ( nu
suy thn trc thn )
Tin cn bnh thn hoc creatinin
mu tng > 3 thng
SA : thn teo nh < 80-100 mm,
v ty khng phn bit r
RL d trng xng
Thiu mu ng sc ng bo
TPTNT : cn lng : t bo, tr
rng

+ Cc ch s quan trng gip phn bit STC trc thn v ti thn
STC trc thn STC ti thn
FE Na <1% >1%
Natri niu ( mEq/l ) <20 >40
Creatinin niu /Cre mu >40 <20
P thm thu nc tiu ( mOsm/kg) >500 #300
BUN/Creatinin mu >20 <10-15

FE Na (Fraction Excretion of sodium): phn sut thi Na

114

VII. TIN LNG SUY THN CP
- T l sng 50%. T vong thng do km bnh l nng, suy a c quan: suy h
hp, suy gan, nhim trng
- 10% bn tin trin dn -> suy thn mn cn thn nhn to
VIII. PHNG NGA SUY THN CP
1. Trnh tnh trng gim ti mu thn :
B dch, mu y nhng bn sau phu thut, i ma, tiu chy -> khm LS
k, TD HA, cn nng, nc tiu, lm XN.
H HA t th: HA gim 10mmHg, M tng 10l/ph -> thiu nc
Ch thuc li tiu, thuc h HA
2. Dng thuc thn trng nhng bn c nguy c STC: T, ln tui, bo ph, suy tim,
bnh thn sn c. Khng nn s dng thuc c thn trn nhm bn nguy c ny. Nu
buc phi s dng -> p dng cc bin php phng nga STC

SUY THN MN
C: q7 99 7,xye ", 7,-: Z.

I. NH NGHA
Bnh thn mn tnh: tn thng thn (bt thng xt nghim, hnh nh hc thn)
hoc GFR < 60 ml/ph/1.73 m
2
da ko di hn 3 thng (DOQI 2003)
STM: gim dn v khng hi phc chc nng thn
o thi sn phm chuyn ha, c cht
Duy tr cn bng nc, in gii
Chc nng ni tit

II. NGUYN NHN: 4 nhm chnh
1. Bnh cu thn: 35-40%
+ BCT nguyn pht
+ BCT th pht: VGSV, T, thoi ha dng bt, K...
2. Bnh ng thn m k: 35%
+ Do nhim trng
+ c cht: ni sinh, ngoi sinh
+ Do tc nghn, tro ngc
3. Bnh l MM thn (10%): THA, hp M thn
4. Bnh thn bm sinh: Thn a nang, thn c nht, HC Alport
III. SINH L BNH
n v hot ng thn: nephron
Bricker: khi nephron b tn thng nephron lnh mnh ph i, tng lc
+ 80% nephron b tn thng: thi k b tr
+ > 90% nephron tn thng : suy thn ni bt
115

C s kt hp CN gia cu thn- ng thn
Gia tng p lc mu cc nephron cn li x chai cu thn tin trin suy thn
g cui
IV.TRIU CHNG LM SNG V CN LM SNG
A. LM SNG
Hi chng ure huyt tng, tr/c r khi GFR < 15ml/ph
1. Biu hin TK-c :
TK trung ng: tp trung, mt ng, ng g, m
Kch thch TK: nc ct, vp b, co git
TK ngoi bin: RL vn ng, cm gic
2. Biu hin tiu ha:
a. Sm: chn n, nc ct bun nn, l lot nim mc
b. Mun: Vim lot d dy, rut ty, XHTH...
Ure NH3: hi th khai, vim lot ng tiu ha
3. Biu hin tim mch
- THA: mui nc, tng tit renin
Yu t thc y suy thn
- Suy tim: mui nc, THA, BMV
Thiu mu lm suy tim nng thm
- Ph phi cp: Bin chng gy t vong
- Vim mng ngoi tim: Lng ng ca, a. uric
- Trn dch mng tim
4. Biu hin huyt hc
1. Thiu mu
Tr/chng hng nh, khi Cre > 2 mg%.
Tng ng mc suy thn
ng sc ng bo, HC mng gim
Hct: 18-20%
C ch: gim sn xut erythropoietin, tn huyt, ure tng c ch ty xng, gim
nguyn liu
1. RL ng mu
2. Nhim trng
5. RL nc in gii
C th bi tit cht ha tan 600 mosmol/L/N, P thm thu NT 300 mosmol/kg tiu
2 lt/N
BT: P thm thu NT 40 -1.200 mosmol/kg
# tiu 15 L( pha long) 0,5 L/N (c c)
Bnh l: P thm thu NT 250-350 mosmol/Kg
d b thiu nc hay ng c nc.
Ion : Na ; K, P, Mg ; Ca
6. Biu hin RL thng bng kim toan
Toan mu chuyn ha:
+ thi H
+
NH3 + H
+
--> NH4
+
ti to v hp thu HCO3
-
pH = HCO3
H2CO3 (CO 2+ H2O)

116

Nhp th Kussmaul

7. RL d trng xng
au xng, gy xng bnh l, ci xng
Tin trin chm
C ch gim Canxi: thn SX 1,25 (OH) D3
P tng cng tuyn cn gip canxi mu
8. RL ni tit chuyn ha
ng huyt gim
H thn nhit
Ni tit: bt lc, v kinh, v sinh, cng cn gip th pht
Da: Xm da, vt co gi, mui sng, bm mu, ban xut huyt

B. CN LM SNG
1. XN nh gi CN thn
BUN (10-20mg%), creatinin (0,8-1,2 mg%)
2. XN chn on nguyn nhn v bin chng
+ Tng phn tch nc tiu
+ m niu /24 gi
+ D tr kim, Kh mu M
+ CTM
+ Siu m h niu, KUB, UIV
+ Ion mu
+ in tm
+ XQ lng ngc
+ Sinh thit thn
V. (+) SUY THN
LS: hi chng ur huyt cao
Creatinine mu
(140 - tui) x cn nng (kg) Hoc (140 - tui) x cn nng (Kg)
72 x creatinin mu (mg%) 81 x creatinin mu (mol/l)

Creatinin mu (mg%) = creatinin mu mol/l x 0,01125

Cc yu t chn on suy thn mn tnh :
1. TPTNT : tr rng
2. Thiu mu
3. SA thn teo < 80mm, mt ranh gii v ty
4. Ri lon d trng xng
5. Dung np tt vi hi chng ur huyt cao
6. Tin cn bnh l thn, creatinin mu tng ko di > 3 thng
7. Creatinin mu tng cao n nh
8. Din tin iu tr
VI. CHN ON NGUYN NHN
1. Bnh cu thn
LS : Ph THA - Tiu t
Ccr =
117

CLS: TPTNT: tiu m thng > 3g/l, tr hng cu
Sinh thit thn
2. Bnh ng thn m k
LS: tiu nhiu, tiu m, khng ph, khng THA
CLS: TPNT : tiu m 1 2 g/l
ng niu (+), ng huyt bnh thng
T trng nc tiu gim 1.000
Tr bch cu
Tin cn nhim trng tiu ti pht, tiu c, tiu m
Si thn, bnh thn tc nghn, tro ngc
Dng thuc : gim au
Gout , Kahler
3.Bnh thn di truyn -> siu m
Thn a nang
Hi chng Alport
Thn c nht
4. Bnh l mch mu thn
- C triu chng THA
- Bnh l: hp M thn, vim nt quanh ng mch, tng huyt p

VII. CHN ON GIAI ON

C Cr re ea at ti in ni in n C Cc cr r
m mg g % %
G Gi i m m d d t tr r t th h n n < < 1 1, ,5 5 > > 5 50 0 m ml l
S Su uy y t th h n n n nh h 2 2 3 30 0- -5 50 0
S Su uy y t th h n n t tr ru un ng g b b n nh h 4 4 1 10 0- -3 30 0
S Su uy y t th h n n n n n ng g 8 8 < < 1 10 0
118

Phn loi bnh thn mn tnh theo DOQI 2003

VIII. TC TIN TRIN SUY THN
Ty thuc nguyn nhn gy STM, vic iu tr, cc yu t thc y suy thn tin trin
+ STM do BCT tin trin tng i nhanh
+ Cc bnh OTMK tin trin chm hn
+ Cc BL mch mu thn c th gy suy thn rt nhanh, c bit THA c tnh.
T: GFR 10-12 ml/ph/nm STM g cui 3-5 nm
THA: GFR 2 ml/ph/nm STM g cui: 35-40 nm
BCT: STM g cui 5-10 nm

IX. TM YU T THC Y SUY THN
1. Tng hoc tt Huyt p
2. Mt nc - in gii
3. Nhim trng
4. Thuc c thn : Aminoglycosid, thuc cn quang
5. Thuc gim au, c ch men chuyn
119

6. Tiu m
7. Tng lipid mu
X. TIP CN BN STM
1. Khai thc bnh s:
Khai thc Tr/C c nng ca HC ure huyt tng
Tin cn c nhn: ph ti i ti li
Tiu mu, tiu m, THA
Cn au qun thn, nhim trng tiu, tiu si
Tin cn gia nh: bnh thn a nang
2. Khm lm sng:
Tm tr/c ph kn o, thiu mu, HA cao, da kh...
XI. NH GI BIN CHNG SUY THN MN CN IU TR
1. Tiu ha
2. Thn kinh : TK trung ng
TK ngoi bin
3. Tim mch : - THA
- Suy tim
- Vim mng ngoi tim , Chn p tim
- Ri lon nhp tim
4. Huyt hc :
Thiu mu (ng sc, ng bo, tng ng mc suy thn, hng nh)
Nhim trng
Xut huyt -> CTM, pht mu NB
5. Ri lon in gii
Ion mu : - Na, Ca : gim
- K, Phospho, Magne : tng
6. Thng bng Kim toan : toan ho mu -> RA gim (BT 25 meq/L)

XII. IU TR
A. Bo tn
1. Tng huyt p : mc tiu HA <120/70 mmHg
Li tiu : Furosemide 40mg 1-2vin (u)
Furosemide 20mg 1-2 ng (TM)
Creatinin > 2,5mg% : Thiazide khng hiu qu
Khng Aldosteron : CC
CMC : dng khi creatinin mu < 3mg%
CC : creatinin mu 3,4 4 mg%
Captopril 25mg 1v x 2-3 (u)
Enaplapril 5-10mg (Renitec) 1-2v (u)
Lisinoptil 5-10mg 1-2v ngy
c ch Canxi
Dihydropyridin : Nifedipin 20mg 1 x 2v ngy
Amlodipin 5mg 1-2v ngy
Diltiazem 30 mg 1 v
Verapamil 40mg, 80 mg
c ch
Atenolol 50mg 1v-2 ngy: gim liu
120

Metoprolol 50mg 1-2v ngy
Bisoprolol 5mg
Tc dng thn kinh trung ng : metyldopa
Aldomet 0,25g 1v x 2 ln/ngy
Dn mch trc tip : Hydralazin 25mg 1v x 2 ngy
Minoxidil 5 mg 1v x 2 ngy

2. Suy tim
- Digoxin: thn trng v d ng c
- Li tiu
- Dn mch
- Nitrat : Lenitral 2,5 mg 1v x 2 ngy
3. Thiu mu: mc tiu Hct 33-36%, Hb 11-12g/dL
- Erythropoietin 2000 v 1ng TDD x 2-3 ln/tun
B/c iu tr : THA: ng kinh Tc mch
- Sulfat st 1v ngy (thiu st chc nng)
- Ch nh truyn mu : - Hct 15-16%
- Suy tim , BMV truyn sm hn
4. Ri lon in gii
Tng Kali mu : - Nh 5-6 mEq/l
- TB: 6-7 mEq/l
- Nng > 7 mEq/l
ECG: P xp, sng T cao nhn i xng, QRS dn rng, LN tht
1- Calciclorua 0,5g 1ng TM
2- Natribicarbonat 4,2% ; 5% 100ml (60 mEq) TTM XL g/ph
3-Insulin R 5-10 v, pha trong Glucoza 30% 100ml TTM XLg/ph
4- Ventolin phun kh dung
5- Kayexalat 15g 1gi x 2-3 ln/ngy
C th km Sorbitol 5g 1gi x 2-3 ln/ngy
Gim canxi mu
- Calcigluconat, calcicarbonat 0,5g 1v -2 v x 2 ln/ ngy
- Rocaltrol (calcitriol) 0,25 g 1v x 2 ln/ ngy
Theo di nng canxi mu, trnh tng canxi mu
Tng phosphat mu : dng cht gn kt phosphat
- [Al(OH)3] :Rocgel, Alumina 15ml x 2-3 ngy
- Canxicarbonat: 1-2 g/ngy

5. Toan ho mu
Duy tr RA 18- 20 mEq/l , trung bnh liu 0,5 mEq/kg/N
Cng thc : HCO3
-
b = (HCO3
-
bt HCO3
-
bn) x o,3 x Cn nng
Natribicarbonat 5g (c 60meq HCO3
-
) gi x 2 ln/ngy

B.Ch nh chy thn nhn to
1. Creatinin < 10 ml/pht
2. Bnh cnh no do ur huyt cao
3. Vim mng ngoi tim
4. Tng Kali mu khng p ng iu tr ni khoa
121

5. Toan ho mu nng
6. Ph phi cp

NHIM TRNG TIU

C: 7,xye "y A

MC TIU BI GING
1. Nu c cc nh ngha v nhim trng tiu.
2. Nu v phn tch c:
Cc c ch bo v ng tiu.
Cc yu t nguy c gy NTT.
Cc tc nhn gy bnh thng gp
ng vo ca cc tc nhn gy bnh.
3. Nu v phn tch c cc triu chng lm sng v bnh cnh lm sng ca NTT.
4. Nu v phn tch c cc xt nghim cn lm sng
Xt nghim nc tiu: soi nc tiu, dipstick.
Cy nc tiu: ch nh, phng php ly nc tiu, bin lun kt qu.
Xt nghim hnh nh, cy mu.
5. Bin lun c chn on NTT da vo triu chng lm sng, bch cu trong
nc tiu v tm vi khun trong nc tiu.
6. Nu v phn tch c cc nguyn nhn tiu gt do nhim trng ph n.
7. Nu v phn tch c cc bin chng ca NTT.

NHIM TRNG TIU (NTT) l hu qu gy ra bi s xm nhp ca cc vi sinh vt vo
nc tiu v cc m ca bt c thnh phn no thuc h thng tit niu t l niu o n
v thn. Cc vi sinh vt gy NTT c th l vi khun, vi rt, vi nm v ksinh trng. Cng vi
cc nhim trng h hp v tiu ho, NTT l mt trong cc nnhim trng thng gp nht
trong v ngoi bnh vin. Vn v tin lng, x tr tu thuc rt nhiu vo vic chn
on ng v tr ca NTT, cc yu t thun li v c a ca bnh nhn.
Trong bi ging ny, khng cp n cc trng hp NTT c bit do lao, k sinh trng.

I. CC NH NGHA.
1. NTT TRN: nhim trng ti thn.
2. NTT DI: bao gm cc nhim trng bng quang, tin lit tuyn v niu o.
3. TIU VI KHUN C NGHA : l tiu ra c s lngvi khun xc nh
c NTT v loi tr kh nng dy nhim. Nu dng phng php cy nc tiu gia dng th
ngng chn on tiu vi khun c ngha l 10
5
khm vi khun/ml nc tiu, vi ch
duy nht mt loi vi khun.
4. NTT TIU KHNG TRIU CHNG: NTT khng c cc triu chng nh tiu
gt tiu lt nht, au hng lng.
5. NTT TI NHIM: l NTT tr li do mt loi vi khun khc vi vi khun ca ln
NTT trc.
6. NTT TI PHT:l NTT tr li do cng mt loi vi khun ca ln NTT trc.
ph n, thng ti pht trong vng 14 ngy sau iu tr, n ng thi gian ny c th di
hn nu nhim cn tn ti trong tin lit tuyn.
122

7. HI CHNG NIU O CP: bao gm cc triu chng tiu gt, tiu lt nht v
mt tiu nhng khng km tiu vi khun c ngha.
8. VIM BNG QUANG: nhim trng bng quang.
9. VIM NIU O: nhim trng niu o.
10. VIM TIN LIT TUYN: nhim trng tin lit tuyn.
11. VIM I B THN CP: (hoc vim thn b thn cp) l hi chng lm sng
gm st, n lnh, au lng do NTT ti ch m v i b thn.
12. VIM I B THN MN: (hoc vim thn b thn mn) l tnh trng vim
tin trin ti ng hn m k do NTT ti pht hoc ti nhim nhiu ln, thng xy ra trn c
a mt bnh nhn tc nghn hoc bnh thn k mn tnh (do tng acid uric mu, do lm
dng thuc gim au, do gim kali mu).
13. NTT PHC TP: l NTT xy ra trn c a c cc yu t lm phc tp vn
tin lng v x tr nh: tc nghn ng tiu (do si, u, nang), bt thng gi phu ca
ng tiu, ri lon chc nng bng quang, ngoi vt trong ng tiu (thng tiu), thai k,
ghp thn, cc bnh l ri lon min dch (i tho ng, iu tr corticoide ko di).
14. NTT KHNG PHC TP: NTT trn c a khng c cc vn nu trn.

II.DCH T HC.
Tn sut NTT thay i theo phi tnh v tui.
Ph n c t l NTT cao hn n ng v tng trong giai on c quan h tnh dc.
Tui gi c t l NTT cao c hai phi. Sau 60 tui, t l NTT nam l 4%, n l
10%.
V phng din vi khun hc, cc vi khun COLIFORM thng gp nht.

III.C CH BNH SINH.
1.CC C CH BO V NG TIU CHNG NHIM TRNG.
Bnh thng ng tiu lun trong tnh trng v trng ngoi tr mt t vi khun
Staphylococci v Diphtheroid c tr niu o ngoi. Cc c ch bo v NTT gm:
1.1-NC TIU: c th c ch s pht trin ca vi khun nh p lc thm thu cao,
nng urea v acid hu c cao, pH acid, c protein Tamm Horsfall c ch kh nng bm
dnh ca vi khun, c khng th v lun lu thng t cao xung thp y vi khun ra ngoi.
1.2-M O: cc vi khun Lactobacillus c tr nim mc m o ca ph n lm
gim nguy c dy nhim cc vi khun ng rut. Nhng ph n thng xuyn NTT lun
c nim mc m o v niu o d b vi khun ng rut bm dnh hn ( s dng mng
trnh thai v thuc dit tinh trng)
1.3-BNG QUANG: kh nng tng xut nc tiu ca bng quang gip thi vi
khun ra ngoi trong khi lp MUCIN bao ph nim mc cn tr s bm dnh ca vi khun.
1.4-NIU QUN :nhu ng niu qun to iu kin cho dng nc tiu t thn
xung bng quang. Cc vi khun gy bnh tit 1 yu t lm gim nhu ng niu qun to
iu kin cho nhim trng ngc dng t bng quang ln thn gy vim i b thn. Ngoi
ra, van niu qun-bng quang l hnh ro ngn chn NTT ngc dng.
1.5-THN: vng v thn khng nhim trng tt hn vng tu, c th do vng
tu c nng amoniac cao, thm thu cao, lu lng mu v nng oxy thp lm cn
tr c ch min dch t bo v th dch.
1.6-CC P NG MIN DCH: ch c vai tr gii hn trong c ch bo v

123

2.CC YU T NGUY C CA NTT.
2.1-TUI GI: Ngi gi sng trong cng ng c tn sut NTT khng triu chng
khong 10-20% (tn sut ny trong bnh vin khong 30%).
- Bng quang b gim kh nng tng xut nc tiu khi nm lu hoc do cc bnh
thn kinh.
- Ph i tin lit tuyn n ng.
- Gim tit protein Tamm Horsfall.
- Tin lit tuyn gim tit cc yu t dit khun.Tng kh nng dy nhim cc vi
khun ng rut vo m o sau tui mn kinh.
2.2-PHI: ph n c nhiu nguy c NTT hn n ng do niu o ngn hn, c bit
khi c quan h tnh dc.
2.3-THAI K: tn xut NTT khng triu chng ph n c thai l 6%. Nu khng iu
tr s c khong 30% NTT khng triu chng tr thnh NTT c triu chng lm sy thai v
sanh non. Do cc yu t ni tit v gii phu hc lm chng nc niu qun v ng
nc tiu.
2.4-NGHN TC NG TIU: gy ng nc tiu. Nguyn nhn c th do si, u,
nang, d tt, so x ho ti thn...si l nguyn nhn thng gp nht. Mt yu t kch thch
nim mc ng tiu lm tng kh nng bm dnh ca vi khun. c bit, si STRUVITE,
c thnh lp bi cc vi khun gy NTT tit men urease, l yu t gy NTT rt kh iu tr
v d ti pht nu cha phu thut ly ht si. Cc vi khun tit men urease: Proteus
mirabilis, Ureaplasma urealytium, Klebsiella pneumoniae, Pseudomonas aeruginosa,
Providencia, Staphylococcus.
2.5-CC TH THUT: ni soi, thng tiu...
- Sau mt ln thng tiu: nguy c NTT 1-2% (cao hn bnh nhn ph i tin lit
tuyn).
- Thng tiu lu vi ng thng u m (open indwelling catheter): 90% trng hp
s bi NTT trong 4 ngy, l tin cho vim i b thn cp v nhim trng huyt t ng
tiu.
2.6-BNG QUANG THN KINH: ri lon chc nng bng quang hoc lit bng quang
lm ng nc tiu mn tnh kt hp vi nguy c do thng tiu lu s gy NTT.
2.7-BNH L SUY GIM MIN DCH:
Cc bnh i tho ng, s dng corticoide ko di, AIDS,...

3.TC NHN GY BNH.
3.1-ESCHERICHIA COLI: thng gp nht v vi khun ny xut pht t ng rut va
c nhiu yu t c lc c bit d gy NTT hn cc vi khun khc. Chnh nh cc yu t
ny ma E.Coli c th gy NTT trn ngi lnh trong khi cc vi khun khc cn nhiu yu t
thun li ti ng tiu (v d: tc nghn, thng tiu...) mi c th gy bnh. Cc yu t c
lc ca E,Coli:
- Khng nguyn v K: c ch kh nng thc bo ca bch cu ti ch m thn.
- Khng nguyn O: gy phn ng vim v cc triu chng ca nhim trng tiu ng
thi cn tc ng ln c trn lm gim nhu ng ng tiu, gy ng nc tiu.
- Cc cu trc ngoi t bo PILI hay FIBRIAE: lm tng kh nng bm dnh ca vi
khun vo nim mc ng tiu.
- HEMOLYSIN l nhm polypeptid c t bo.
3.2-T L CC VI KHUN GY NTT NGOI BNH VIN:
85% do E.Coli, 15% do proteus, Klebsiella v Staphylococcus saprophyticus.
3.3-T L CC VI KHUN GY NTT TRONG BNH VIN:
124

50% do E.Coli, 50% do Klebsiella, Enterobacter, Citrobacter, Serratia, Pseudomonas
aeroginosa, Providencia, Enterococcus, Staphylococcus epidermidis v cc vi nm nh
Candida, Cryptococcus neoformans.
Cc bnh nhn nm vin cng lu th t l NTT do E.Coli v Proteus cng gim, ngc li
t l NTT do serratia hoc Pseudomonas cng tng. Nu bnh nhn c t thng tiu lu
hoc c c a suy gim min dch, cn c nguy c NTT do cc vi khun ym kh cng nh
cc vi nm.
3.4-VIM NIU O LY QUA QUAN H TNH DC: do Chlamydia trachomatis,
Neisseria gonorrhea.
3.5-CC K SINH TRNG & CC VI RUT; cng c th l tc nhn gy NTT.
Adenovirus, sn gy vim bng quang xut huyt, Herpes gy vim niu o cp.
4.NG VO CA TC NHN GY BNH:
4.1-NG NGC DNG: thng gp nht, thng do cc vi khun hiu kh gram
m ng rut xm nhp ngc dng qua niu o vo bng quang sau khi di tr t hu
mn.
4.2-NG TH DCH:
4.2.1-NG MU: him hn, thng xy ra trn cc bnh nhn c sn tn thng
ti thn, c th gp trong
- Nhim trng huyt do Staphylococcus.
- Nhim trng Candida ton thn.
- Vim ni tm mc nhim trng.
- Lao, thng hn.
4.2.2-NG BCH HUYT: cha chng minh r rng.
4.3-NG VO T NNHNG C QUAN KHC: d ng tiu qua da, vo m
o, vp i trng trc sau g cng gy NTT.

IV.TRIU CHNG LM SNG V CN LM SNG.
1.LM SNG.
Cc NTT c triu chng c th biu hin bng:
- Hi chng niu o cp; gm tiu lt nht, mt tiu v tiu gt.
- au trn xng mu.
- Tiu c, i khi tiu mu.
- St km n lnh.
- au gc sn lng hc vng hng.
Cc NTT di thng c hi chng niu o cp. cc NTT trn thng c st, n lnh v
au lng. Tuy vy, trong thc t, cc triu chng lm sng khng phi lc no cng phn
nh trung thc v tr NTT v mc trm trng ca NTT.

2.CN LM SNG.
2.1-XT NGHIM NC TIU: ly nc tiu gia dng sau khi ra sch vng
quanh l tiu lm gim kh nng dy nhim bch cu v vi khun t m o hoc t bn
ngoi vo bnh phm.
2.1.1-SOI NC TIU KHNG LI TM: nhum Gram, xem di quang
trng (QT) knh du. 90% trng hp tiu vi khun c ngha s c 1 vi khun/QT.
2.1.2-SOI NC TIU SAU LI TM: ly tm 10 ml nc tiu trong ng
nghim hnh chp trong 5 pht vi tc 2500 vng/pht. Sau soi 3-4 git cn lng di
QT x 40 (che bt nh sng). Kt qu hu ht cc trng hp tiu vi khun c ngha chn
on u tm c vi khun trn QT40.
125

NTT tht s hay ch l do dy nhim (khong 95% bnh nhn tiu bch cu tht s b NTT).
2.1.3-QUE NHNG DIPSTICK:
- Que nhng pht hin men leucocyte esterase ca bch cu: lecocyte esterase l men
cha trong cc ht ca bch cu a nhn trung tnh s tc dng ln cht ch ti mu ca que
lm cht ny chuyn sang mu xanh lam (sau 1-2 pht). Xt nghim ny r tin, chuyn
bit rt cao 94-98%.
- Que nhng pht hin vi khun trong nc tiu (NITRITE TEST): ming m c
tm amin ca que s chuyn mu hng khi tip xc vi nitrite trong nc tiu (sau 1 pht).
Nitrite l mt sn phm t nitrate trong nc tiu di tc dng ca men nitrate reductase
ca vi khun. nn s dng nc tiu sng sm xt nghim v cc vi khun cn t nht 4
n 6 gi bin nitrate thnh nitrite. Kt qu m tnh gi nu nng nitrate thp do n t
nitrate, dng thuc li tiu, hoc do nnhim trng bi cc vi khun khng c men nitrate
reductase (v d: Staphylococcus sp, Enterococcus sp, Pseudomonas sp). Do , mc d
chuyn bit ca test rt cao 92-100% nhng nhy ch 35-85%.
Cc xt nghim s dng Dipstick ny cho kt qu nhanh v r tin, d thc hin ti phng
khm. Do , nn dng quyt nh xem c nn thc hin tip theo cc xt nghim t
tin khc hay khng (v d: cy nc tiu). ch dng cc xt nghim ny khi c triu chng
lm sng gi b NTT v khng c s dng tm sot NTT khng triu chng.
2.1.4-CY NC TIU + KHNG SINH : l xt nghim quyt nh
chn on NTT va gip chn la khng sinh ph hp.
a-Ch nh cy nc tiu:
- C triu chng c nng v thc th ca NTT.
- Theo di kt qu iu tr ca NTT.
- Khi rt thng tiu lu.
- Tm sot NTT khng triu chng ph n c thai.
- Trc khi tin hnh cc th thut trn bnh nhn c bnh thn tc nghn.
Lu : hai ch nh u tin khng cn thc hin ph n tr khng mang thai v b NTT
ln u.
b-Phng php ly nc tiu: lm gim kh nng ly nhim t ngoi vo.
- Ly nc tiu gia dng: sau khi ra sch b ph sinh dc ngoi bng nc hoc
dung dch mui sinh l, tiu b i khong 200 ml, sau tiu tip vo mt vt cha v
trng.
- Ly nuc tiu bng thng tiu ( 1 ln) hoc chc ht bng kim v trng qua bng
quang trn xng mu: thng ch dng nghin cu trn cc bnh nhn khng tiu c
hoc nghi ng b NTT do vi khun ym kh.
- Ly nctiu bng cch chc ht kim v trng qua h thng ng thng tiu kn
(close catheter drainage system): trn cc bnh nhn ang t thng tiu lu.
- Ly nc tiu trc v sau khi xoa nn tin lit tuyn: chn on tiu vi khun
t tin lit tuyn.
c-Bin lun kt qu cy nuc tiu:
S lng vi khun c ngha chn on NTT tu thuc vo phng php ly nc tiu,
cc triu chng lm sng v cn lm sng khc km theo (v d: tiu m, tiu bch cu).
Cy nc tiu bng cch ly nc tiu gia dng l phng php c thc hin nhiu nht
trong bnh vin. vi phng php ny, Kass ngh ngng chn on NTT thc s khi
s khm vi khun 10
5
/ml vi ch duy nht mt loi vi khun (nu 2 loi vi khun kh
nng dy nhim > 90%). y l tiu chun kinh in chn on c NTT thc s v c
chuyn bit rt cao(>98%) nhng li c nhy rt km (ch khong 50%), do nu ly
nc tiu bng cc phng php o m v trng hn (v d : thng tiu) hoc tuy bnh
126

nhn c xt nghim nc tiu gia dng nhng li c cc triu chng lm sng ca NTT
r rng hoc c cc yu t thun li ca NTT th chn on c th chp nhn c vi cc
ngng thp hn. V d:

Phng php
ly nc tiu
Tiu chun vi khun c ngha chn on NTT

Gia dng
N c triu chng lm sng: 10
2
khm
COLIFORM/ml hoc 10
5
khm khng phi
COLIFORM/ml.
Nam c triu chng lm sng: 10
3
khm vi
khun/ml.
Khng c triu chng lm sng: 10
5
khm vi
khun/ml cng mt loi vi khun qua 2 ln cy lin
tip.
Chc ht bng quang > 1 khm vi khun/ml
Thng tiu 10
2
khm vi khun/ml

Ch cc yu t kt qu cy nc tiu (-): nc tiu long qu, acid qu, c khng sinh,
dy thuc st khun, NTT do cc vi khun khng pht trin trn mi trng cy thng
thng (lao, Chlamydia, virut).
2.2-CY MU: nn cy mu cc bnh nhn NTT nhp vin c st n lnh (vim i b
thn cp, vim tiu lit tuyn cp).
2.3-HNH NH HC:
Siu m, CT scan, CHP H NIU CN QUANG
- Dng tm cc yu t nguy c ca NTT: si,u thn, u bng quang, thn chng
nc, d tt bm sinh (nang thn, tro ngc).
- Dng chn on cc bin chng NTT: pxe thn hoc quanh thn, hoi t gai
thn, x ho thn do vim mn
2.3.1-Nn tin hnh siu m bng hoc X quang bng khng sa son cc bnh
nhn:
+ NTT ln u n ng.
+ NTT phc tp hoc c nhim trng huyt.
+ Nghi ng c bnh thn tc nghn hoc si thn.
- Tiu mu + NTT.
2.3.2- gim nguy c b suy thn cp, nn trnh chp cn quang niu tnh mch khi
NTT c creatinie mu>1,5mg/dl, i tho ng, mt nc nng hoc >60 tui.

2.4-XT NGHIM CHC NNG THN, CNG THC MU; nn tin hnh trn tt c
cc bnh nhn NTT nhp vin cn tnh ton liu lng khng sinh cho ph hp chc
nng thn.

3.CC BNH CNH LM SNG CA NTT:
3.1-VIM BNG QUANG CP: tiu gt, lt nht h v trn xng mu, tiu nhiu
bch cu, t bo m, i khi tiu mu i th (vim bng quang xut huyt).
3.2-VIM NIU O CP: hi chng niu o cp km tiu c u dng. Vi
khun thng gp ly qua quan h tnh dc: Chlamydia trachomatis, Neisseria gonorrea hay
Herpes simplex.

127

3.3-VIM TIN LIT TUYN CP: t ngt st cao, lnh run, au vng di tht
lng, tiu gt, kh v au tc vng gn hu mn. Thm trc trng: tin lit tuyn sng to,
rt au. Cy nc tiu gia dng thng ch c 10
3
khm/ml. vi khun thng gp: trc
khun gram m ng rut, Staphylococcus, Enterococcus. Cy mu c th dng tnh.
3.4-VIM TIN LIT TUYN MN: bnh cnh gm NTT ti pht thng xuyn
vi triu chng au vng gn hu mn, tiu m. Vim tin lit tuyn mn thng khng
ch khu tr tin lit tuyn m lun kt hp vi vim vng ng t niu o-sinh dc,
thng c x ho v hp niu o.
3.5-VIM I B THN CP: trng hp in hnh, bnh nhn t ngt st cao
39-40
0
C km lnh run, au gc sn lng hoc vng hng cng bn. Tiu gt c th xy ra
trc vi ngy v i km vi cc triu chng trn.
3.6-VIM I B THN MN: bnh tin trin dn n suy thn mn. Siu m
thy hai thn teo nh khng ng u. i b thn bin dng trn phim X-quang c cn
quang. Cc bnh nhn thng c sn mt bnh thn tc nghn.
3.7-NTT KHNG TRIU CHNG: chn on khi cy nc tiu gia dng 2 ln
lin tip 10
5
khm/ml c cng mt loi vi khun/cch 24 gi.
3.8-NTT TRN BNH NHN BNG QUANG THN KINH: cc bnh nhn
thng t thng tiu lu, NTT rt kh iu tr, thi gian t thng tiu lu cc vi khun
khng nhiu loi khng sinh hn, bnh nhn thng t vong trong bnh cnh nhim trng
huyt nng.
3.9-NTT TRN BNH NHN I THO NG: cc bnh nhn i tho
ng c tn sut NTT khng triu chng cao gp 4 ln ngi bnh thng. NTT trn bnh
nhn i tho ng c triu chng ngho nn nhng d c nhiu bin chng nng.
3.10-NTT DO VI NM: CANDIDA thng gp nht. Thng gp bnh nhn
c t thng tiu lu.

V.CHN ON.
1.CHN ON XC NH.
1.1-CC TNH HUNG PHT HIN: cc bnh nhn n khm v cc triu chng
lm sng r rt hoc v tiu c tiu m. mt s trng hp n khm v au qun thn do
si hoc tiu kh v ph i tin lit tuyn Sau pht hin c NTT. Nn ch ng tm
sot NTT khng triu chng trn ph n c thai, sau khi tt thng tiu lu, bng quang thn
kinh.
1.2-TIU CHUN CHN ON NTT:
Trung tm kim sot v phng bnh (M) CDC: Centers For Disease Control And
Prevention

NHIM TRNG TIU C TRIU CHNG
C 1 trong cc tiu chun sau:
Tc 1: 1 trong cc tc st > 38/tiu lt nht/tiu gt/au h v + cy nt 10
5
/ml 2 loi vk.

Tc 2: 2 trong cc tc st > 38/tiu lt nht/tiu gt/ au h v + 1 trong cc yu t:
a/Leucocite esterase (+) hoc nitrite (+)
b/BC>3/QT40
c/Nhum gram c vk
d/Cy nt qua thng 2 ln > 10
2
/ml 1 loi vk
e/Cy nt 1 ln< 10
5
/ml 1 loi vk (sau iu tr)

128

TIU VK KHNG TRIU CHNG
C 1 trong cc tiu chun sau:
Tc 1: c thng tiu 7 ngy (do thng tiu): khng c cc triu chng st > 38/tiu
lt nht/tiu gt/au h v
+ cy nt 10
5
/ml 2 loi vk

Tc 2: khng c thng tiu 7 ngy (khng do thng tiu): khng c cc triu chng st >
38/tiu lt nht/tiu gt/au h v
+ cy nt 2 ln 10
5
/ml cng 1 loi vk

NHIM TRNG TIU TRN
C 1 trong cc tiu chun
Tc 1: phn lp c vk t dch ca nhim (khng phi nt)
Tc 2; pht hin c p xe hoc bng chng nhim trng qua khm trc tip, phu thut,
m hc
Tc 3: khi c 2 yu t
T > 38/tiu gp/au khu tr ti nhim
+ 1 trong cc yu t sau
- Tiu m hoc cy nt 10
5
/ml
- Kt qu nhum GRAM +
- Dn lu m t nhim +
- Xc inh nhim qua hnh nh hc (S, CT, MRI)

TIU CANDIDA KHNG TRIU CHNG
Bnh nhn thng tiu > 10
2
/ml
Bnh nhn khng thng tiu 10
4
/ml

NHIM TRNG TIU DO CANDIDA: cc tiu chun trn + cc tiu chun lm sng
ca (CDC)
NHIM CANDIDA NG TIU TRN: tng t cc tiu chun nhim trng tiu trn
(CDC)

2.CHN ON PHN BIT.

2.1-Phn bit cc nguyn nhn gy tiu gt khng do NTT: chn thng niu sinh
dc, kch thch niu o, d ng, vim m o.
2.2-Phn bit cc nguyn nhn gy tiu gt do nhim trng thng gp ph n
nh vim bng quang cp, vim niu o, vim m o theo hng sau

Vi khun Tiu m Tiu
mu
Cy NT
(khm/ml)
Triu chng LS
VIM
BNG
QUANG
Escherichia coli,
Staphylococcus
saprophyticus,
Proteus sp,
Klebsiella
Thng gp C th
gp
10
2
n 10
5
Khi pht t
ngt, nhiu
triu chng
(tiu gt, lt
nht, mt tiu
khng nhn
c) au h v
129

VIM
NIU
O

Chlamydia
trachomatis,
Neisseria
gonorrheae,
Herpes simplex

Thng gp

Him
gp

<10
2

Khi pht t t,
triu chng
nh, c huyt
trng hoc chy
mu m o
(do vim c t
cung), au di
tht lng, c
bn tnh mi,
c sang thng,
herpes m h
m o.
VIM M
O
Candida sp,
Trichomonas
vaginalis
Him gp Him
gp
< 10
2
C huyt trng,
hi, nga, au
khi giao hp,
tiu gt l
niu o, khng
tiu lt nht,
khng mt tiu,
khm c vim
m h m o.

2.3-Phn bit cc nguyn nhn gy au lng: au qun thn, bnh c xng khp.
2.4-Phn bit cc nguyn nhn gy tiu BC, tr BC, vim cu thn, vim thn k.
2.5-Phn bit NTT phc tp va NTT khng phc tp.

VI. BIN CHNG
1.NHIM TRNG HUYT T NG TIU (urosepsis): Cy mu thng gp cc
vi khun gram m ng rut, thng xy ra trn bnh nhn
- c thc hin cc th thut trn ng tiu.
- p xe thn.
- C bnh thn tc nghn hoc suy gim min dch.
Cc triu chng ca nhim trng huyt thng che lp cc triu chng ti ng tiu. st
km lnh run, ri lon tri gic, th nhanh. Chong v t vong s khng trnh khi nu
khng c pht hin v iu tr kp thi.

2.P XE THN V P XE QUANH THN: st n lnh, ri lon tiu ho, au lng.
Rung thn (+). Cn theo di bin chng ny trc 1 trng hp vim i b thn cp khng
p ng vi iu tr ph hp >72 gi.
2.1-p-xe thn: c th l hu qu ca vim i b thn cp, 50% trng hp vi khun
t ng mu n (S. aureus). Siu m, CT-scan gip chn on.
2.2-p xe quanh thn: thng do p xe trong thn v. Siu m, CT- scan gip chn
on.

130

3.HOI T GAI THN: thng xy ra trn c a i tho ng, vim thn k mn,
bnh hng cu hnh lim, sau ghp thn. l hu qu ca vim i b thn cp trn nn thn
b thiu mu cc b. Gai hn b hoi t trc ra c th tm thy trong nc tiu. Bnh cnh
lm sng ging vim i b thn cp nhng khng p ng vi iu tr v din tin n suy
thn cp. Chn on : siu m, chp cn quang i b thn ngc dng.

4.VIM BNG QUANG SINH HI V VIM I B THN SINH HI: bin
chng hu nh ch xy ra trn bnh nhn i tho ng. Vim i b thn cp sinh hi c
hoi t ch m v sinh hi tch t trong thn hoc quanh thn.Cc vi khun thng gp;
E.Coli, Klebsiella, Aerobacter va Proteus.
Bnh cnh lm sng ging vim i b thn cp nng, khng p ng vi iu tr.
Siu m hoc CT-scan pht hi trong hoc quanh thn. Cy mu thng (+). Vim bng
quang sinh hi him gp hn. Siu m, CT-scan: c hi trong thnh bng quang hoc trong
bng quang. Vi khun gy bnh: E.Coli, Clostridium perfringens.

VII. IU TR V PHNG BNH:
1.KHI NO CN IU TR NTT:
Nhim trng tiu c triu chng: iu tr khng sinh
Nhim trng tiu khng triu chng:
Khng iu tr khng sinh cc bnh nhn:
- Thng tiu lu
- i tho ng
- Bng quang thn kinh
Ch iu tr nu c nguy c bng pht nhim trng nh hng xu tin lng, t vong:
- Gim bch cu ht
- Suy gim min dch
- C thai
- Khi phu thut h niu hoc t cc b phn gi
- Bnh nhn mang cc b phn gi (khp, tim mch) hoc ghp tng.

2.MC TIU IU TR
- Dng khng sinh dit vi khun v gim bt cc triu chng.
- Ngn nga cc tn thng thn v kh nng lan rng ca nhim trng.

3.NGUYN TC IU TR NTT
Gii quyt tc nghn
Bo m khng thiu niu
Chn khng sinh hp l: E.coli hoc theo kt qu khng sinh
iu tr thi gian
Gii quyt ng thng tiu

4. PHNG BNH:
NGOI BNH VIN
iu tr cc yu t nguy c
TRONG BNH VIN
- Hn ch cht ch cc ch nh v thi gian t thng tiu lu
- Nn thng tiu ngt qung
131

- Cn c khoa chng nhim khun trong bnh vin v hot ng phi - hiu
qu, thng xuyn
- Bt buc phi ra tay mi khi sn sc bnh nhn
- Nghim cm tnh trng mang gng tay thng xuyn m khng thay gng
khi sn sc cc bnh nhn
.
Phng nga cho cc bnh nhn ang c thng tiu
1.Phi s dng h thng thng tiu kn (closed systems)
2.Xt li ch nh t thng tiu lu mi ngy
3.Cch ly cc bnh nhn ang thng tiu c tiu vi khun
4.Khng nn thay thng tiu mt cch thng quy, c th lu thng di hn n3
thng !
5.Thay thng tiu ngay khi h thng khng cn bo m KN !
6.Bo m v trng cht ch khi t thng v khi ly mu nc tiu xt nghim
7.Dng ng thng mm v nh nht
8.Bi trn gel lignocaine loi dng 1 ln
9.Ra hng ngy bnh nhn vi x bng
10.Trnh dnh phn vo ng thng
11.Trnh ko cng hoc lm st ng thng
12.C nh ng thng tht tt
13.Ti dn lu phi lun thp hn bnh nhn
14.Ti dn lu khng c chm t
15.Thay ti mi tun hoc mi khi thay thng tiu mi

LY MU NC TIU XT NGHIM QUA THNG TIU

1-Ra tay bng dung dch st khun
2-Kp pha di ch ly mu
3-St trng ch ly mu bng cn 70
0

5-Ht 5-10ml nc tiu
6-ng nc tiu trong l v trng
7-St trng ch ly mu bng cn 70
0

8-Tho kp
9-Xt nghim ngay <2 gi

132

TIU HA

133

CHN ON X GAN
1- ", %y Cx,
MC TIU
- Trnh bay nguyen nhan gay x gan
- Trnh bay trieu chng lam sang x gan
- Trnh bay thay oi ve xet nghiem mau & sinh hoa trong x gan
I. I CNG
Gan: thc hin nhiu chc nng sng
Tch tr vitamin, mui khong
Sn xut cc protein cn thit
Sn xut cc yu t ng mu
Chuyn ho cc cht
Sn xut cc cht chng nhim trng, loi b vi khun khi dng mu
Vim gan: gan b vim, sng phng
Vim gan mn: vim gan > 6 thng
X ha: m so thay th t bo gan cht
X gan: to so nng khp gan
Suy gan: gan b tn thng nhiu, khng th thc hin cc chc nng
X gan: bnh gan mn tnh
T bo gan b thoi ho, hoi t
Thay th bi nhng t bo gan tn sinh & cc di x Cu
trc tiu thy gan b thay i thnh nhng nt tn sinh ,khng c chc nng gan
II. PHN LOI
- X gan nt nh
- X gan nt to
- X gan th hn hp
1. X gan nt nh: Vch u, dy, tng sinh nt < 3mm
Nghin ru
Suy dinh dng
Thm nhim st
mt
Tc tnh mch gan
2. X gan nt to
Vch & cc nt to nh khc nhau
Cc tiu thu nt > 3 mm
Nhiu so x ho khong ca
Tn sinh cc t bo ln nhn ln
Gm:
- XG do VGSV B, C
- Thiu 1-antitrypsin
- XG mt nguyn pht
3. X gan th hn hp
X gan nt nh + X gan nt to
XG nt nh XG nt to
134

III. BNH HC
i th
B mt khng u
Nhiu nt vng
Gan to do nhiu nt tng sinh
Gan teo nh giai on cui
Tiu chun chn on x gan
Nt tn sinh
X ho (tch t m x to tiu thu gi)
Cu trc gan bt thng
T bo gan bt thng: Tinh th ho, lon sn, tng sn
IV. NGUYN NHN
- Vim gan siu vi B Delta; C
- Ru
- mt:
XG mt nguyn pht
XG mt th pht
Vim ng mt x ho nguyn pht
- Chuyn ho:
Thiu 1-antitrypsin
Thm nhim st (Heamochromatosis)
Thm nhim ng (Wilson)
Glycogenosis IV
Galactose mu
Tyrosinosis bm sinh
- Mch mu:
Bnh tc nghn tnh mch
Hi chng Budd-Chiari
X gan tim
Vim mng ngoi tim co tht
- Ri lon min dch:
Vim gan t min
- Suy dinh dng
- Nhim trng:
Giang mai s sinh x gan
Sn mng: trng gy phn ng m x khong ca
St rt X gan ?
SR & XG SDD & VGSV ?

- Sang thng dng ht:
Brucellosis
Lao
Sarcoidosis x ho, khong ca tng sinh dng nt
- X gan cn nguyn n
V. TIP CN BN X GAN
1. PHN HNH CHNH : Ch cc c im lin quan bnh

135

Ngh nghip
Tui: thng ln tui
Gii: nam > n
Gia nh
2.TIN S
Vng da
Vim gan
S dng thuc
Truyn mu
Nghin ru
Bnh di truyn gia nh
3. LM SNG
Hi chng suy t bo gan
Hi chng tng p tnh mch ca
4. TRIU CHNG
A. TRIU CHNG C NNG
Mt mi
St cn
Bing n
Tiu chy
Teo c
Ph chn
St
Vng da:
T bo gan suy chc nng
i sng hng cu
Bng bng
Xut huyt: Chy mu cam, li
Xut huyt da
Xut huyt tiu ho
Gim kh nng tnh dc
B. TRIU CHNG THC TH
Tng trng: gy
St
Vng da
Tng sc t
Ban xut huyt
To tuyn mang tai
Ngn tay di trng
Mng trng (Terrys nail)
Lng bn tay son
Bn tay co kiu Dupuytren
Ph chn
Lim mng xanh da tri (Wilson)
Sao mch: c ngc, cnh tay, lng bn tay

136

N ho tuyn v nam
Thay i phn b lng
Teo tinh hon
Khm bng
Bng bng
Tun hon bng h
Lch to
Gan to, gan teo
Thay i v thn kinh
Trng thi tinh thn
Run vy
L m
Hn m
5. CN LM SNG
Huyt hc:
- Hng cu (thiu folate)
- i sng HC
- Haemoglobin
- Bch cu
- Tiu cu
- Cc yu t ng mu:
- Gan tng hp I (fibrinogen), II (Prothrombin),V, VII, IX, X
- T: VII ngn nht, X, IX
- V khng ph thuc vit K
- Vit K 10 mg
TQ ci thin t nht 30% / 24 gi
Sinh ho mu:
Bilirubin TP, TT > GT
Phosphatase kim
Transaminase , bnh thng
ng huyt tng
Albumin ( 65% Pr, t: 3 tun)
T l Alb/Glo < 1
in di Globulin: -Glo
XGM: 2-Glo, -Glo
Glo min dch:
IgA : X gan ru (Laennec)
IgM : X gan mt tin pht
IgG : Vim gan t min
Nu bng bng: XN dch bng, dch thm:
Rivalta ()
Protein DMB < 2,5 g/dL
Alb HT Alb DMB > 1,1
Khng th khng c trn
Khng th khng nhn
Khng th khng ti lp th
137

HBsAg, anti-HCV
St, Ferritin, Ceruloplasmin, Cu
-Fetoprotein
Ni soi:
Dn tnh mch thc qun
Dn tnh mch trc trng
Siu m & CT scan
Gan nh
Gan teo
Cu trc nt
Sinh thit gan: Tiu chun vng
EEG nu c bt thng tri gic
Phn loi theo Child

Phn loi Child-Pugh-Turcotte

A B C
Bilirubin mu < 2 mg% 2-3 > 3
Albumin mu > 3,5 g% 3-3,5 < 3
Bng bng khng
d
kim sot
kh
kim sot
Ri lon
thn kinh
khng nh Hn m
Dinh dng rt tt tt km
1 2 3
Bnh no gan khng 1-2 3-4
Bng bng khng nh trung bnh
Bilirubin mu < 2 mg% 2 - 3 > 3
Albumin mu > 3,5 g% 2,8 - 3,5 < 2,8
TQ ko di < 4 4-6 > 6
Hoc INR < 1,7 1,7 - 2,3 > 2,3
XG mt Bili < 4 4-10 > 10
138

VI. BIN CHNG
XHTH do v TM thc qun dn
Vim phc mc nhim khun nguyn pht
Hi chng gan thn
Hn m gan
Ung th ho
Bng bng
VII. IU TR
X gan: bnh e do i sng
Khng c tr liu no cha lnh x gan hoc phc hi m so gan
iu tr nhm ngn nga hoc lm chm tn thng gan
iu tr nguyn nhn, nu c
Trnh cc cht lm tn thng gan
iu tr nng :
Nhu cu dinh dng
Hng dn ch n
iu tr bng bng
iu tr bin chng
Ghp gan

HELICOBACTER PYLORI
C: "-a 7.ex %.e
/ /I !\ //
- 1900-1980: ghi nhan le te co s hien dien cua 1 xoan khuan: Campylobacter
pylori
- 1983: Warren va Marshall xac nh Helicobacter pylori
- Xac nh c tnh chat ac biet cua H.pylori (men, oc to, nguyen nhan sinh
benh)
- H.p la nguyen nhan quan trong cua: Viem, loet da day ta trang, ung th da day.

- Ch co acid thng khong u gay loet da day ta trang
- Helicobacter pylori la yeu to nguyen nhan quan trong trong benh viem da day,
loet da day ta trang va ung th da day
Acid + H.pylory

Acid + NSAIDS

Acid + Others
Ulcer
139

- H.pylori la nguyen nhan cua tren 80% trng hp viem da day
- H.pylori la yeu to benh sinh chnh trong loet da day ta trang
- Nhiem H.pylori co the lam tang nguy c ung th da day
// / I/\/ | /|
1.Tit men urease:
Ure + H
2
O NH
3
+ H
2
CO
3
(CO
2
+H
2
O)
Hu qu:NH3 tng tn thng nim mc d dy
HCO3- tng pH tng tng tit gastrin, tc ng ln t bo thnh
tng tit HCL lot
2.Tit mt s men khc:( catalase, oxylase, glucopolypeptidase)
Ct cu ni, lin kt H+
Ph hu lp cht nhy
Xm nhp d dng vo nim mc d dy,gn vo t bo, ph hu nim mc,
tn thng xut hin
3.Tit ra cc c t tb:
Gy tn thng t bo sinh lot mnh
Gy phn ng oxy ho mnh trong neutrophil lm tn thng m, lot d dy
t trng
Gii thch: lot thng gp d dyn nm phn ng b cong nh,vng
tin mn v v phn t trng cch mn v 3cm do mch mu ni ny c ng
knh nh v di di tc ng ca cc yu t kch thch thn kinh v dch th,
co tht nhiu hn tn thng nhiu hn
4.Hp v mi trng HCL:
pH:3-4.5: sao chp gen
pH<2: vn tn ti nhng khng sao chp gen
pH>7:ngng hot ng hon ton, khng sao chp gen, chuyn t hnh xon
sang hnh cu,khng trt khng xoay chuyn, l thi im thn li cho
khng sinh tc dng
5.Hp v nhm mu:Hp d gn kt ln b mt khng nguyn Tewish. Khng nguyn
ny c trn biu m nim mc dd,c trng cho cu to cho nhm mu O-> nhim Hp trn
nhm mu O cao gp 1.5-2 ln so vi nhm mu khc
6.Hp vi khng sinh:
c xp vo loi kh tiu dit v:
Vi 1 khng sinh,thnh cng 20-30%
Vi 2 khng sinh,th cng 40-60%
Nu phi hp c ch toan tt vi trn hai loi khng sinh >90%
Nu a pH >7 th khng sinh mi t hiu qu
7.Hp vi lot v K:
Hp chuyn sn nim mc DD TT, to iu kin nh v Hp t trng sinh
sinh lot
H.pylori chia lm 3 nhm chnh:khng c, c va (sinh lot, vim) c
mnh (gy ung th)
Loi c mnh gy o ln cu trc gen d dy gy lon sn v d sn:
To u MALT
To Adenocarcinoma

140

III. S PHT TRIN CA CHUYN SN D DY, VIM T
TRNG V LOT T TRNG

IV. C CH BNH SINH UNG TH D DY

Nhim H.pylori
Vim d dy do H.pylori
Chuyn sn d dy t trng
Gastrin ^
Somatostatin +
Tng tit acid
Nhim sang
Vim t trng
Lot t trng
1 s yu t khc
Tn thng hng ro nim mc
Bnh thng
Vim nng d dy
Vim teo d dy
D sn rut non
D sn rut gi
Lon sn
Carcinoma
Nacl
Tng
trng
Vi
khun
pH cao
H.pylori
NO, cht
gy t bin
?
141

V. HPYLORI, VIM D DY V BNH L

VI. HU QU NHIM H.PYLORI
Khng c du hiu lm sng
Lot hnh t trng
Lot d dy
Vim d dy v t trng
Bnh c tnh d dy:
Adenocarcinoma
Lymphoma (U MALT: Mucosa Associated Lymphoid Tissue)
Ri lon tiu ha mn tnh ( Dyspepsia, hi chng vim i trng mn)

VII.CC PHNG PHP CHN ON HP
1. Test xm ln da trn ni soi
Test Urease nhanh: (CLO test: campylobacter pylori like organ test)
Ur + cht ch th (mu vng) + mu sinh thit c HP tm hng
iu kin:
Ngng khng sinh > 4 tun
Khng dng thuc c ch H2, bm proton > 2 tun
10
5
copies/ml
Vng sinh thit c HP
Nui cy v phn lp vi khun
Xt nghim hin vi trc tip
Gii phu bnh
DNA probes/ PCR
C th
Vim d
dy mn th
hot ng
Ch yu
hang v
Vim d dy vng
hang v/thn v, ch
yu thn v
Vim d dy
mn th teo
(trung v,
thn v)
Lymphoma
Ung th d
dy
Lot d
dy
Lot t
trng
Vim d
dy mn th
khng hot
ng
Khng trnh khi Vim d
dy cp
142

2. Test khng xm ln
Test hi th C13/14 urea
iu kin:
- Nhn i tuyt i (khng n, ung nc) > 8h
- Ngng khng sinh > 4 tun
- Khng dng thuc c ch toan > 2 tun
Chng ch nh :
- Tr em < 4 tui
- Thai ph, cho con b
- Ln thi trc cch nay < 6 thng (/v C14)
- Tip xc tia x ( Xquang, CT-Scan) trong thi gian gn 3-6
thng (/v C14)
Huyt thanh hc (IgG, IgA)
PCR trong mu nc bt v phn

VIII. CH NH TIT TR HP:
Lot d dy
Lot t trng
Vim d dy mn tnh type B hot ng
U MALT, lymphoma
Bt thng d dy trn i th v vi th
Sau phu thut v K d dy v c bng chng nhim HP
RLTH khng lot v bnh nhn yu cu
Ch nh dng thuc NSAID
Tin cn gia nh c K v lun nhim HP

CHAN OAN VIEM AI TRANG MAN
C5. 1- ", %y Cx,
MUC TIEU
Trnh bay cac nguyen nhan VTM
Trnh bay the lam sang VT lao
Trnh bay the lam sang cua VT do amibe
Trnh bay the lam sang cua viem loet ai trang
Trnh bay the lam sang cua benh ly ai trang chc nang
/ // |.\
- VTM la tnh trang ton thng man tnh ai trang do nhieu nguyen nhan.
- Can phan biet vi K ai trang la benh ly can can thiep phau thuat.
// \|/\ \/\
1. Nhiem trung:
VK: lao, Sal., Shigella, Yersinia,
KST: Amibe, G. lambia, Bilharzia,
143

Nam: Candida, Cryptococcus ,
Sieu vi : Cytomegalovirus, Herpes simplex, HIV
2. Khong ro can nguyen:
Viem loet ai trang (viem trc trang-ai trang xuat huyet)
Benh Crohn
- Trong 2 the benh nay, mot so yeu to co lien quan en benh nh thuoc la, thuoc
nga thai uong, yeu to gia nh.
- Hai giai oan co xuat o benh cao la 15-30 tuoi va 60-80 tuoi.
Tan suat benh nam/n la 1/1 trong viem loet ai trang ; 1,1-1,8/1 trong benh
Crohn.
3. Nguyen nhan khac:
VT gia mac (pseudomembranous colitis)
VT do viem tui tha ai trang
VT do xa tr : trieu chng thng xay ra cap trong vong 1-2 tuan sau
khi bat au xa tr, tieu chay nhay mau, mot ran, neu ruot non b anh
hng thng tieu chay; trieu chng tre thng gap la kem hap thu, sut
can, hep, tac, do ruot- bang quang, am ao hoac thanh bung.
VT vi the
VT do thieu mau cuc bo thng gap ngi ln tuoi co phnh M chu
bung hoac co tnh trang tang ong, benh tim nang, benh ly mach mau (d dang
mach mau, x m ong mach) : ot ngot co cn au quan vung bung 1/4 di T,
tieu mau o ti.
/// // |/| |/\/
1. ai the:
Niem mac: sung huyet, x hoa, mang gia.
Cac to chc mo hat.
Tui tha ai trang.
Do tieu hoa.
2. Vi the:
Ton thng khong ac hieu: ch thay tnh trang viem nhng khong ket
luan c nguyen nhan.
Ton thng ac hieu: lao, amibe,
/! I|//| /|\
1. Lam sang :
au bung : doc theo khung ai trang, thng au nhieu vung ai trang
sigma, hai ho chau, tren ron. au kieu co that, quan, tng cn.
144

Roi loan i tieu : bon, tieu chay n oc hoac xen ke.
Phan bat thng : ve so lng, o ac long, hoac co s hien dien cua nhng
chat bat thng nh nhay, mau, Khao sat phan co the phat hien c ky
sinh trung, vi khuan, vi nam, hong cau, bach cau,
Mot ran, mot i cau : ai trang de b kch thch do ton thng phan thap.
Bieu hien toan than ngoai ng tieu hoa : sot, au khp, au c, viem gan,
...
Kham lam sang :
+ Trieu chng tuy nguyen nhan
+ Khoi u HC P (u lao / u amibe)
Tham trc trang : la thu thuat can thc hien trong moi trng hp viem ai
trang.
2. Can lam sang :
Khao sat phan: KST, vi khuan, vi nam, hong cau, bach cau,
Chup X quang ai trang can quang vi ky thuat oi quang kep kho bo
sot ton thng.
Noi soi ai trang - sinh thiet : giup chan oan xac nh c nguyen
nhan
Tham do tuy theo nguyen nhan
! I// / \
1. VIEM AI TRANG DO LAO (LAO HOI MANH TRANG)
a. TNGB: M. tuberculosis, co the la lao nguyen phat hay th phat
b. TCLS:
- Hoi chng nhiem lao chung
- Trieu chng nhiem lao tai cho:
Tieu chay, phan nhay, mau (hiem)
Khoi u lao ho chau P, chac, phang, khong au.
au bung am , au quan go cuc
H/C ban tac (dau hieu Koenig : khoi go noi han lean, BN rat au, nghe
ro tieng hi di chuyen trong ruot, va co cam giac nh hi thhoa1t ra c
qua lo hep, khoi xep dan va BN bt au), hoac tac ruot,
c. CLS:
- Phan: nhuom, cay, BK.
Tm BK trong phan thng khong co gia tr quyet nh v neu co ton thng
phoi, BK co the do BN nuot vao t am qua ng tieu hoa, qua phan.

145

XQ khung ai trang: Manh trang day cng, hoi trang cho hep cho phnh
(dau hieu Stieling)
- NST & sinh thiet : tm te bao ien hnh cua lao.
- Cac xet nghiem tham do nhiem lao toan than, lao phoi hp,
d. Bien chng: tac, thung, do, lao mang bung, lao hach o bung
2.VIEM AI TRANG DO AMIBE
a. TNGB:
- Nhiem E. histolytica qua ng mieng manh trang, T len, T
- L cap tai phat, tai nhiem, l man.
b. TCLS:
- au quan bung tng cn.
- Mot ran, mac i tieu nhat la ton thng manh trang, T .
- Tieu nhieu lan, phan t, nhay mau ; neu keo dai, tai phat nhieu, BN
se i cau thng xuyen.
- Sot: do boi nhiem vi trung.
c. CLS:
- Phan: a-mip the hoat ong, ken; HC, BC
- NST: ton thng hnh dau an ngon tay.
- LB: vet loet tao anh loi dang co chai.
- Huyet thanh chan oan amibe : tm khang the khang amibe bang pp
mien dch hoc.
d. Bien chng:
- Abces gan : phat hien sm, tien lng tot.
- Di can xa : Abces nao
- U amibe
- Thung
- Xuat huyet
- Long ruot
3. VIEM TRC TRANG - AI TRANG XUAT HUYET
- La tnh trang viem niem mac trc trang va ai trang. Trc trang luon luon b ton
thng, hien tng viem se tiep tuc lan rong en cac phan con lai cua ai trang.
- 40-50% trng hp gii han trc trang va T .
- 30-40% : ton thng lan khoi T nhng khong anh hng en toan bo T
- 20% toan bo T b ton thng.
a. TCLS:
au bung: am , co cn d doi doc khung ai trang, ro nhat vung ai trang di
ong nh ho chau, tren ron, au sau tieu.
146

Tieu phan lan mau : thng xay ra trong em va hoac sau khi an,mc o i
tieu phu thuoc vao t cap cua benh nhng hau heat luc nao cung co mau, co
luc tieu toan mau khong co phan.
Mot ran.
Bieu hien toan than: viem khp, gan nhiem m, VG man the hoat ong, viem
ng mat x hoa nguyen phat, hong ban dang nut, viem ket mac, viem
than,
Tham trc trang : BN rat au, gang dnh mau
b. CLS:
XQ bung KSS : trong viem nhe. Co the mat cac nep va ruot ngan lai. Trng
hp viem nang do bat c nguyen nhan nao : T co the gian. Neu co dau hieu
nay i kem vi sot, BC va au bung nhieu, co the BN b bien chng phnh
T nhiem oc.
XQ khung ai trang : khong nen thc hien khi BN ang trong tnh trang cap
tnh. Chuan b ruot trc khi soi hoac chup T bang dd ien giai tot hn la
thut ra.
- Giai oan au: .
- Tuy nhien, chup oi quang kep thng phat hien ton thng dang hat
lan toa niem mac.
- Mat nep, phu ne niem mac, loet, gia polyp la cac dau hieu tre. oi khi
thay 1 vung b teo hep do x hoa, can phan biet vi K T.
NST - sinh thiet
Khao sat mien dch d ng :

Viem loet ai
trang
Benh Crohn
pANCA 60-70 % 5-10%
ASCA 10-15% 60-70%
T khang the khang TB
dang ly bieu mo T
39% 30%
Khang the khang T 36% 13%
Khang the khang TB nang
tuyen tuy
4% 31%

147

- pANCA ( perinuclear antineutrophil cytoplasmic antibody ) : KT khang
bao tng cua BC a nhan trung tnh. Con gap trong viem toan bo ai
trang , viem tui hau moan nhan tao hoi trang va viem ng mat x
hoa.
- ASCA : KT khang Saccharomyces cerevisiae . 5% BN khong b viem
loet ai trang va benh Crohn co ASCA (+)
c. Bien chng:
- Cap : xuat huyet nang, toxic megacolon ( phnh T nhiem oc ): T mat
trng lc va dan, thung ( t gap hn so vi benh Crohn ), tac ruot ,
- Lau dai : tai phat
K hoa: 5% sau 10 nam (P)>(T); 10% sau 10-20 nam; 50% sau 35 nam
4. BENH CROHN ( Viem ai trang mo hat , viem ruot tng vung )
Ton thng tat ca cac lp cua thanh ruot va co the xay ra tng vung suot ong tieu
hoa, nhng thng vung hoi manh trang.
- 30-40% trng hp ton thng ruot non n thuan.
- 40-55% : ton thng ruot non va ruot gia.
- 15-25% : ton thng ruot gia n thuan.
a. Khong ro nguyen nhan
b. TCLS:
au bung: am thng HCP khong sau khi i tieu.
Tieu chay : phan lan mau, toan mau: hiem.
Sut can :10-20% trng hp.
Sot
khoi u HCP.
Ton thng hau mon-trc trang: # l
Bieu hien ngoai ong tieu hoa: giong VLT
c. CLS:
X
Q
bung KSS: trong viem nhe.Co the thay mat nep, hep long T.
X
Q
T can quang: phu ne, hep do x hoa, do phan anh ban chat cua benh.
+ Ton thng thng oan cuoi hoi trang va s hien dien cua
nhng vung ton thng khong lien tuc hoac co kem ton thng
ruot non giup ngh nhieu en benh Crohn hn la VLT.
+ Can phan biet vi lao ai trang cung co hnh anh ton thng hoi
manh trang.
X
Q
ng tieu hoa tren, ruot non
Noi soi T va sinh thiet

148

Noi soi ng tieu hoa tren giup phan biet benh Crohn ta trang va benh
loet da day ta trang.
Khao sat mien dch d ng (a trnh bay muc VLT )
d. Bien chng:
- Hep, tac ruot.
- Do tieu hoa
- Thung
- Viem phuc mac
- Kem hap thu
- Phnh ai trang nhiem oc
- Ung th hoa (hiem)
- Bien chng do ieu tr: phau thuat, nuoi an dai ngay bang ng tiem
truyen, thuoc c che mien dch,
5. VIEM AI TRANG GIA MAC
a. Sinh benh hoc:
o S dung KS dai ngay (Lincomycin)
o S dung Bismuth, thuy ngan,
o Chan thng tam ly (stress)
b. TCLS:
o au bung: thng vung thap nh ho chau trai
o Tieu chay, sot
c. CLS:
o X
Q
T: viem khong ac hieu
o Noi soi: mang gia
o Cay phan: trong moi trng k kh phan lap c Clostridium difficile
6. VIEM TUI THA
Benh tui thathng gap cac nc phng Tay, t le benh tang theo tuoi.
Khoang 30% dan so toi 60 va khoang 80% dan so tuoi 80 b benh tui tha T.
Khoang 90% benh tui tha T khong trieu chng.
a. Sinh benh hoc:
Che o an t chat x gay tao bon.
Do cac iem yeu cua thanh T.
Theo tuoi : < 40 tuoi : < 10%
> 60 tuoi : > 25%
b. TCLS:
au HC T, au bung di cap
Sot
149

Tieu chay phan nhay, mau
Dau phuc mac viem khu tru
S: khoi abces hoac am quanh
Nhu ong ruot hoac
Tham trc trang : giup nh v o abces, khoi viem,
c. CLS
CTM : BC , CTBC chuyen trai (ien hnh)
Hct-Hb : co mau
TPTNT : co the co BC va HC .Mot bien chng hiem gap cua viem
tui tha la do BQ-T: tieu kh, nc tieu co BC (+++), VK, phan
X
Q
bung KSS: ca 2 t the nam nga va thang, s hien dien cua mc
nc hi gi y liet ruot, tac ruot. Co hi t do trong o bung chng to tui tha
b thung.
Sieu am bung : phat hien khoi viem, abces; giup vi cac benh
khac.
Noi soi ai trang : thc hien neu khong nghi ng thung.Tuy nhien tot
nhat nen i cho en khi cac trieu chng giam sau khi qua t viem phuc
mac roi mi thc hien.
X
Q
ai trang can quang : tot nhat nen i cho en khi qua t viem
phuc mac khu tru mi thc hien.
au bung di cap, sot & Bach cau/ tui tha ai trang viem tui
tha
d.Bien chng:
Xuat huyet tui tha : la 1 trong nhng nguyen nhan gay XHTH di
ngi ln tuoi.
Abces
Ro tieu hoa
Thung viem phuc mac
X hoa teo hep
!/ /\ /.\ ' //\/
1. Chan oan xac nh :
a. TCLS:
au bung
Roi loan thoi quen i cau
Phan bat thng
Cac trieu chng gi y nguyen nhan
150

b. CLS:
Khao sat phan
X quang ai trang
Noi soi ai trang
Tham do theo nguyen nhan
2. Chan oan phan biet:
a. Ung th ai trang :
C a > 50 tuoi
Tien can gia nh: K ai trc trang, polyp
Che o an: nhieu beo, t x
TCLS: mau/ phan, thay oi thoi quen i tieu( giam kch c khuon phan
neu ton thng T trai hoac long ruot b chit hep), BN co the than
phien bon hoac tieu chay ; co the s thay u T phai.
Trieu chng khac nh : thieu mau, sut can, bieng an, gay yeu,
Tham do can lam sang sm :
- X quang ai trang : hnh khuyet khong eu, hoac hep khong
eu.
- Noi soi ai trang - sinh thiet : Noi soi phat hien u dang sui,
dang tham nhiem lam hep long ruot, hoac dang loet, de chay mau
khi va cham. Sinh thiet tm TB ac tnh.
b. Benh ly ai trang chc nang :
-Cac ten goi khac :
- Hoi chng ruot kch thch
- Hoi chng ai trang kch thch
- Hoi chng ruot co that
- Viem ai trang co that
- Viem niem mac ai trang
- Benh ly ruot do tam than kinh
- C a: n, 30-50 tuoi
- Yeu to tam ly, than kinh,
- TCLS:
+ au quan bung, sau khi i cau
+ Tao bon hoac Tieu chay. Mot so BN tao bon man tnh xen ke tieu
chay cap. Mot so Bn ch b tieu chay.
+ Nhu ong ruot nhieu vao buoi sang hoac suot ngay, nhng hiem khi
gay kho chu khien Bn thc giac vao ban em.
+ Phan: nhay, khong mau tr khi Bn b tr do tnh c.
151

+ hi, trao ngc DD-TQ, kho tieu:
- CLS: khong ton thng thc the
c. Hoi chng kem hap thu :
- Tien s cat da day-ruot, viem tuy man, .
- Tieu chay man: suy dinh dng, thieu mau, thieu vit B, C, D,
- CLS :
- Phan: am > 1,5 g/l; m > 3,5 g/l
- Schilling test ( uong B12 anh dau : th nghiem chc nang tuy): o lng
s bai tiet B
12
anh dau a uong rong nc tieu 24 gi thieu yeu
to noi tai IF : gap trong thieu mau ac tnh, teo da day.
- Cho IF +
B12
anh gia chc nang : hoi trang, tuy
- X
Q
ruot non: mat hnh rang ca do nhung mao ruot b pha huy.
- Sinh thiet niem mac ruot non

!// \|/\ I ///| I|/
A. Cac bien phap chung:
o Tiet che an uong: tranh cac chat kch thch niem mac ai trang (chat beo,
rau song,)
o ieu chnh tnh trang i tieu
o ieu tr ho tr: an than
thuoc ieu hoa van ong ng ruot
B. ieu tr theo nguyen nhan :
1. Viem loet T :
+ ieu tr noi khoa :
a. Aminosalicylate : nhe, trung bnh
b. Glucocorticoids : trung bnh, nang Aminosalicylate
Khong dung trong giai oan duy tr
Lieu Prednisone 20-40 mg
Hydrocorti sone 50-100 mg tiem mach moi 6 gi
Methyprednisolone 20-40 mg tiem mach moi 12 gi
Cat T : ch nh trong trng hp s dung > 15 mg
prednisone moi ngay trong nhieu thang
c. c che mien dch :
- Azathioprine
- 6-mercaptopurine : 1.5 mg/kg/ngay (u)
- Cyclosporine tnh mach : VLT khong ap ng ieu tr
152

- Cac thuoc c che mien dch mi :
- Tacrolimus c che tac ong giong Cyclosporine
- Mycophosphate mofeil c che tong h p purine trong
lymphocyte, gian oan s bien oi monophosphate inosine thanh
monophosphate guanine (GMP) giam GMP giam s hnh
thanh KT t cac TB B b kch joat5. Lieu : 15 mg/kg/ngay chia 2
lan.
- Thalidomide c che TB monocyte san xuat TNF, hieu qua trong
cac trng hp e khang glucocorticoid
d. Thuoc khang cholinergic & chong tieu chay :
- Td: au bung va tieu chay
- CC : VLT nang.
+ Che o an: dinh dng ay u
+ Cn bung phat, phnh T nhiem oc :
Cn bung phat 15-10%, tieu chay nang, au bung.
Xuat huyet,giam albumin mau, sot,
Nhiem trung, roi loan ien giai,mat nc
Phnh T nhiem oc (toxic megacolon) 1-2%
a. Hut dch da day& nuoi an ng tnh mach
b. RLG, bu nc.
c. Khang sinh ng TM pho rong.
d. Glucocorticoids TM : hydrocortisone 100mg moi 6h
e. Cat T : khong ap ng sau 48h
f. Khong dung khang cholinergic & chong tieu chay
+ Ung th hoa : 10%,10-20 nam,(T) < (P)
Noi soi T + sinh thiet : sau 8-10 nam

2. Benh Crohn :
a. Thuoc hong tieu chay
b. Sulfasalazine
c. Cac che pham 5-ASA
d. Glucocorticoids : nang
e. c he MD : azathioprine, 6-mercaptopurine
f. Metronidazole :
- S dung trong cac trng hp khong dung nap Sulfasalazine, hoac khong
ap ng cac thuoc
- Lieu : 250 mg x 4 lan/ngay
153

- Hieu qua # Sulfasalazine
g. Dinh dng ay u
h. Nuoi an ng TM

KET LUAN
Viem ai trang man Viet Nam:
- Nguyen nhan thng gap: nhiem trung amibe, lao,
- can loai tr sm ung th ai trang

VIEM GAN
": Cx. Wxx W-a,
Ca. ,.a, :ee :ay

/ //\/ \// 0iem qan /a tinh t+a nq iem o nha mo qan qom te /ao qan a
mo ke o nhiea tac nhan qaq +a ien tien /am a nq a diea t+i +at khac nhaa ta q
theo nqaqen nhan
a < 6 thanq
wan >6 thanq
//. /\ /.\ ' //\/
A. LAM SANG
Trieu chng lam sang rat m ho, cac bieu hien gi y viem gan nh vang da, au
HSP ch xay ra 25% trng hp. Con a so th khong co trieu chng lam sang, ch phat
hien tnh c qua men gan tang. Trieu chng lam sang khong giup phan biet the loai,
nguyen nhan gay viem gan.
1. Viem gan cap: Hoi chng cap qua 4 giai oan ( mo ta theo VG B)
+ U benh :
T khi tiep xuc vi tac nhan gay benh ti khi xuat hien trieu
chng au tien.
Vai tuan en vai thang tuy vao so lng virus xam nhap va c
a benh nhan.
Hoan toan khong co trieu chng
Ch biet la co yeu to tiep xuc a xac nh (NVYT, kim am)
+ Tien vang da:
Keo dai khoang 1 tuan.
Sot nhe khong kem lanh run, met moi, au nhc khap ngi
giong cam cum.
154

An uong kem
oi khi au HSP
Tieu vang sam ( dau hieu cham dt thi k tien vang da)
+ Vang da:
Vang da tang, vang mat , tieu vang sam tang, phan bac mau ,
nga . Khi vang da xuat hien th sot giam hoac het
Buon non, non.
Roi loan dung nap m ( ngan m, kho tieu)
BN van con sot, met moi, suy nhc tram trong, sut can
Gan 2-3 cm di b sn, trn, lang, mem, tu, au tc.
Lach co the hi to
Sao mach thoang qua
Vang da keo dai 2-6 tuan
Trong giai oan cap co the xuat hien viem gan bung phat ( fulminant hepatitis):
Viem gan dien tien nhanh, nang, vang da sam hn, hon me gan, xuat huyet tieu hoa =>
t vong. Tuy thuoc thi gian chia lam 3 loai: viem gan bung phat toi cap (< 2 tuan), viem
gan bung phat cap tnh (4 - 6 tuan), viem gan bung phat ban cap (> 8 tuan). Neu qua
c giai oan bung phat se hoan toan bnh thng. Neu khong qua c => chet do suy
gan, t trng hp dien tien ti viem gan man.

+ Thi ky hoi phuc:
Vang da giam
Tieu nhieu
Cam giac khoe hn
Met moi co the keo dai vai tuan en vai thang
Roi loan tieu hoa giam dan hoac het.
2.Viem gan man:
Co the tiep theo sau viem gan cap neu trieu chng keo dai
tren 6 thang
Met moi, suy nhc, an uong kem
Roi loan tieu hoa: khong tieu, ay bung, tieu chay
Kham co the khong phat hien trieu chng g ac biet, ch ghi
nhan bat thng qua xet nghiem men gan tang
- a so thng khong co trieu chng ien hnh giai oan viem gan cap, neu co
trieu chng cua viem gan cap thng khoi benh. Benh dien tien am tham x gan K
- Phat hien ch tnh c khi xet nghiem thay men gan tang tren 6 thang.
- Mot so trng hp VGM nhat la VGSV B co nhng t bung phat: men gan tang
cao ot ngot, xuat hien cac trieu chng cua viem gan cap nh vang da sam, au HSP. Co
the xuat hien trieu chng mat bu ve chc nang gan: hon me gan, roi loan ong mau co
the t vong. De lam viem gan cap.
- Nhng t bung phat thuc ay viem gan nang hn de dan en x gan hoac k gan.
VG B tien trien qua K gan khong can giai oan x gan, khac VG C.
155

B. CAN LAM SANG
1. Xet nghiem anh gia viem gan:
Men gan ( AST va ALT : <40 UI/L )
Co the tang > 1000 trong viem gan cap hay t bung phat cua viem gan man
- Viem gan man khong bung phat: men gan tang t: 100 - 200 UI/L
- Viem gan sieu vi : ALT tang nhieu hn AST
- Viem gan do ru : ALT tang t hn
- Viem gan man co tien trien x hoa: ALT tang t hn AST
LDH :5 - 30 UI/L, tang trong viem gan do thuoc
Bilirubin : tang khi co vang da , chu yeu la lien hp.
PK: < 85 UI/L, tang khi co tac mat , Wilson giai oan bung phat
GT ( < 30 U/L) tang trong viem gan do ru, gan nhiem m, thuoc
acetaminophen (paracetamol), phenyltoin
ien di : bnh thng trong g cap, viem gan man co tien trien x hoa:
albumin giam va globulin tang
ong mau , roi loan nhe hoac roi loan nang trong viem gan bung phat,
vang da keo dai
Sinh thiet gan : khong bat buoc thc hien trong giai oan cap tr trng hp
kho chan oan hoac can tm nguyen nhan . oi vi VGM, sinh thiet co vai tro
quan trong hn v anh gia mc o ton thng gan , phan biet x gan giai oan
sm
Chan oan hnh anh: sieu am , CT Scan, Fibroscan : chan oan phan biet
viem gan cap man, chan oan tac mat
Cap : to, Echo kem(en)
Man : teo, echo day, sang, b khong eu

2.Xet nghiem tm nguyen nhan
a) Viem gan virut
- 0iem qan 6
Anti HAV: IgM (+) trong giai oan cap, sau 6 thang giam dan, xac nh giai oan cap.
IgG xuat hien ong thi trong giai oan cap, ton tai keo dai sau khoi benh, dung ieu tra
dch te hoc, khong co y ngha la viem gan man
Viem gan cap t khoi, khong bao gi chuyen sang giai oan man tnh

- 0iem qan
HbsAg: (+) benh nhan ang co hien dien virut trong c the ,khi co anti
HBs (+) th HBsAg(-) a co khang the mien nhiem oi vi virut B , co
kha nang bao ve c the
HBcAg: khong hien dien trong mau, ch co trong te bao gan, do o tm
gian tiep qua Anti HBc. Khang the nay khong la khang the bao ve ma ch
chng nhan benh nhan a tng nhiem virut viem gan B. IgM (+) trong giai
oan cap, IgG (+) trong giai oan man.
156

HBeAg: (+) de lay cho ngi khac, de tien trien
Anti HBe(+): c the a khong che c virut han che lay nhiem,
viem gan on nh hn
HBV-DNA: cho ket qua nh tnh, nh lng
Cho biet so lng virut /ml mau , copies/ml (>10^5 copies/ml viem gan
ang ang tien trien va co ch inh ieu tr )
- 0iem qan
Anti HCV (+) : co nhiem, khong biet ang benh hay het, muon biet lam HCV-RNA
- 0iem qan { : anti HDV, anti HEV
- {0 w0 anti EBV, anti CMV
b) Viem gan t mien
ANA hay gap trong Lupus. Neu viem gan co ANA (+) viem gan type 1 , ap
ng eu tr corticoid
Anti LKM ( khang the khang tieu the gan than) type 2, khong ap ng ieu
tr corticoid
SMA
AMA (antimitochondria): X gan mat nguyen phat
Nong o khang the > 1/80 + IgG tang mi co gia tr chan oan
c) Benh Wilson
La benh di truyen theo NST13. Cu hap thu t thc an, qua gan, gan thai Cu d qua
mat, gi lai 1 lung t cho c the hoat ong. Trong viem gan , Ceruloplastin giam nen
khong van chuyen c Cu
nh lng Ceruloplastin trong mau (< 20-40 mg/ml).
nh lng Cu trong nc tieu (< 40 g/24 h ): tang
d) Hemochromatosis
Fe huyet thanh: 80-180 g%, tang
Ferritin ( < 300 ng/ml), tang
o bao hoa transferin < 45%, tang
/// /\ /.\ |/\ |//I
Vang da trc gan? Tai gan? Sau gan?
/! /\ /.\ \|/\ \/\
1) Do vi khuan, KST : nhiem trung huyet, Leptospira, thng han, sot ret,
chistosoma, san mang, san la gan
- Sot nhiem trung, BC tang 12.000- 15.000
- Vang da, men gan tang
- Cay mau (+)
- Huyet thanh chan oan: Martin pent (Leptospira), Widal (thng han)
2) Viem gan virut:
Viem gan A, E : ch gay viem gan cap, co the toi cap => t vong. Khong
gay viem gan man. Lay qua ng an uong.
157

B, C, D, E : lay mau, da niem, quan he tnh duc, me ->con luc sinh. Co the :
cap man x gan, K gan
Hoan toan da vao huyet thanh hoc, khong co da hieu gi y
3) Viem gan do ru :
- Co the tien trien t viem gan thoai hoa m viem gan man x gan do
ru
- AST tang chu yeu, GGT tang, MCV tang (do thieu acid folic)
- Chan oan da vao tien can uong ru nhieu trong nhieu nam va loai tr
cac nguyen nhan gay viem gan khac
4) Viem gan do thoai hoa m ( gan nhiem m) :
- Tnh trang tch tu m trong gan co the gay viem gan hoac khong.
- Hay gap BN beo ph, T tip 2, roi loan lipid mau ac biet la tang
Triglyceride, dung corticoid, thuoc nga thai lau ngay.
- Men gan tang, GGT tang cao
- Chan oan :
+ Sieu am: gan to , echo day, sang
+ Chan oan xac nh bang sinh thiet gan ( khong bao m nam trong
te bao gan ay nhan len : te bao nhan)
5) Viem gan do thuoc: la chan oan ngoai tr
Tien can s dung thuoc: khang lao, Tetracyclin, Paracetamol, Aminodaron,
nga thai
Benh nhan t on khi ngng thuoc
Nang: gay t vong, viem gan toi cap do hoai t te te bao gan cap
6) Viem gan do oc chat:
Tien can co tiep xuc chat oc: CCl4, phospho vo c, nam oc
7) Viem gan t miem:
- Khong co benh canh ac biet
- Da vao khang the t mien ( >1/80 )
- Ig G tang nhieu
- ien di Globulin: tang nhieu
8) Wilson:
Ton thng gan_ than_than kinh
Thng bieu hien than kinh trc, co roi loan ngoai thap
Vong Kayser-Flusher: vong xanh tren mi mat
Xet nghiem: Ceruloplasmin
9) Hemochromatosis:
Suy gan, tim, ai thao ng, sam da
Xet nghiem nh tren
Xet ngiem ot bien gen C282Y (VN : cha lam c , NN: thng qui)

158

NGO OC THUOC PHOSPHO HU C
C: "-a 7.ex %.e
/ // |.\
Gom 3 nhom chnh:
- Nhom Parathion Methyl: Baladon Methyl
- Nhom Malathion: Wofatox
- Nhom Diazinon: Basudin, Azinon
Nhng nhom nay ang c s dung Viet Nam. Ngoai ta con co khoang 35 nhom khac
cung loai phospho hu c nh: Dimethoat, Dichlorovos
// /. I/\/
Ngam de dang qua ng tieu hoa, ho hap, qua da va niem mac.
Thuy phan nhanh trong moi trng kiem va ben vng trong moi trng acid.
V vay khi ngo oc qua ng tieu hoa hap thu nhanh.
Lieu t vong cua nhom Parathion:
Ngi ln: 4 mg/kg

Tre em: 1 mg/kg
oc tnh tng loai co khac nhau nhng tac dung oc vi c the giong nhau do co
chat khang men cholinesteraza.
/// . // |/\/ /\/
Acetylcholin la chat hoa hoc trung gian co cac hau hach than kinh (Nron hau hach)
cua:
He than kinh giao cam: i vao tuyen ngoai tiet.
He than kinh pho giao cam
He than kinh van ong c
He than kinh trung ng
Khi phospho vao mau co tac dung c che men Acetyl Cholinesteraza la men tham gia
qua trnh thuy phan acetylcholin.
Hau qua: Acetylcholin khong b thuy phan se tch tu lai cac vung hau hach Synap than
kinh gay nen nhng xung ong tha lien tuc.
Men Acetyl Cholinesteraza thuy phan Acetylcholin cac Synap than kinh c, than
kinh giao cam, than kinh trung ng, tren hong cau va cac tuyen ngoai tiet c goi la
Acetyl Cholinesteraza that hoac Cholinesteraza hong cau Cholinesteraza ac hieu.
Men Butyrocholinesteraza: co trong huyet tng va cac to chc khong phai he
thong than kinh tham gia thuy phan 1 so ln ester trong huyet tng va khong co tac dung
len Acetyl Cholin va cac thu the cua he than kinh giao cam trung ng. V vay con goi
Butyrocholinesteraza la Cholinesteraza huyet tng hoac Cholinesteraza gia hoac
Cholinesteraza khong ac hieu.

159

V co kha nang c che men Acetyl Cholinesteraza nen tren lam sang bieu hien 3
hoi chng:
Hoi chng Muscarin (M)
Hoi chng Nicotin (N)
Hoi chng than kinh trung ng (TKT)

o do co che

Jhi hoho haa co ao co the

Tch tu tai cac Synap than kinh

)hoho ao co the
c chuyen hoa ngay thanh chat trung gian paraoxone rat oc ( manh gap
1000 lan phospho hu c)
Chuyen hoa ty lap the trong gan bi 2 men oxydaza va dehydroxydaza
Khi a chuyen hoa co kha nang c che men Neurotoxicesterase lam roi loan he
thong tieu the co chc nang oxy hoa cac thuoc gan => lam tang oc tnh cua
phospho.
Khi a tao ra paraoxone, chat nay gan ket chat vi men Cholinesteraza thanh
phc hp ben vng, sau o thai ra ngoai di dang Para-Nitrophenol.
Phospho hu c chuyen hoa gan phc hp (Paraoxone +
Cholinesteraza) Para-Nitrophenol ( nc tieu)
Paraoxone co the c gi lai mo m.
Phospho hu c con niem mac ruot se a dan vao mau trong nhng ngay sau
nen benh nhan co the tr nang ngay th hai, th ba.
Hoat tnh cua men Cholinesteraza huyet tng ( butyrocholinesteraza) c
phuc hoi 100% trong 10 ngay.
Cholinesteraza hong cau c phuc hoi trong 1 thang.
Men Cholinesteraza huyet tng phuc hoi tng ng vi s phuc hoi tren lam
sang
V vay thng nh lng Cholinesteraza huyet tng e theo doi lam sang.

Cholinesteraza
Acetylcholin
+ H2O
Acid Acetic + Cholin
Phospho hu c + Cholinesteraza
Tao thanh phc hp c che ben vng
c che
Acetylcholin Acid Acetic + Cholin
160

/! I|//| /|\ / \ \ / \
1. Tac dung len he M (Muscarinic) ( HC Muscarine)
- ong t co nho nh au inh ghim.
- Tang tiet dch cac hoc t nhien: nc, nc mat, nc mui, am nht, tang
tiet dch tieu hoa
- Tang tiet mo hoi.
- Roi loan tri giac.
- Tang nhu ong ruot lam au bung oi ma, tieu chay
- Co that kh phe quan: kho th, nhieu ran ong
- Giam huyet ap, roi loan dan truyen tim

2. Tac ong len he N (Nicotin) (HC Nicotinic)
- Lam ru ri
- Rung giat cac tam c van: c mat, c ngc, c ui, c canh tay
- Yeu cac c va sau o cac c gan nh liet
- Loan nhp tim, rung that.

3. Tac ong len he than kinh trung ng
- c che ho hap, co giat, hon me
- c che trung tam van mach gay suy tuan hoan cap phu phoi cap: dan en t
vong rat nhanh.

4. Bieu hien cua ngo oc cap nhanh hay cham tuy vao ng xam nhap:
- ng tieu hoa sau 30 phut , bieu hien au tien la au bung, oi ma, tieu chay
- ng ho hap sau 30 phut 1 gi, bieu hien au tien la kho th, nghet th,
tang tiet am nht.
- ng da, niem mac: 2 3 gi, bieu hien rung c, tang tiet mo hoi

5.Can lam sang:
- nh lng men Cholinesteraza trong huyet tng giam
- Tm phospho hu c trong chat oi, phan.
- Tm para-nitrophenol trong nc tieu.

! /\/ / | /. \. /.:
Nhe : HC Muscarinic, men Cholinesteraza huyet tng giam 30%
Va: HC M + HC Nicotinic, men Cholinesteraza huyet tng giam 50%
Nang: HC M + HC N + HC TKT, men Cholinesteraza huyet tng giam 70%

Suy ho hap cap thng la nguyen nhan that bai trong ieu tr hay gap nhat v theo s o
sau:

161

Joac danh qia theo cac tiea chaan aa
Biet chac chan benh nhan nay uong nhieu, nong o thuoc am ac
en sau 12 gi
Men Cholinesteraza giam rat thap
Co liet c ho hap hoac suy ho hap
Roi loan nhp tim truy mach
!/ '| I|/
1. Loai chat oc ra khoi c the
- Ra da day: la phng phap bat buoc neu ngo oc qua ng uong. Ra that
sach en khi nc trong khong con mui phospho hu c. Lng nc ra co khi len ti 30
40 lt
- Sau khi ra sach, bm qua sonde dau Paraffine 200 ml

- C che: dau Paraffine co trong lng phan t ln khong hap thu qua ng tieu
hoa nhng co tac dung hoa tan Phospho hu c con gan tren niem mac va ao thai theo
phan ra ngoai.
- Uong than hoat tan 20g/ moi 2h. Tong lieu 100 120g/ 24h
- Cho thuoc so manh.
- Ra da, tam, goi au, thay quan ao neu qua da.
- Tang thong kh th
Chu y: neu benh nhan hon me: dung tube Levin ra da day va phai at noi kh quan
trc ra. Neu benh nhan tnh, dung ong Faucher
2. Dung Atropin lieu cao:
7ea nqhi nqo lam test Atropin: tiem TM cham Atropin 2 3 mg, neu khong phai
ngo oc Phospho hu c se co dau no Atropin ngng va i tm oc chat khac
7qo doc that a: anh gia tnh trang ngo oc:
Nhe: Atropin 1 2 mg/ moi 15 TM cham
Trung bnh: Atropin 2 3 mg/ 15 TM cham
Co that kh phe quan
Tang tiet am nht
(Muscarin)
Liet c ho hap
Trung ng va ngoai bien
( Nicotin)
c che TKT
c che ho hap, co giat,
hon me (TKT)
Suy ho hap
Nhiem oc phoi
162

Nang: Atropin 4 8 mg/ 15 TM cham
Tiem en khi co dau hieu ngam no Atropin bieu hien ong t dan > 4mm, da kho,
nong, o. Mach nhanh > 100 lan/ph. Benh nhan sang het dau rung giat c, het xuat tiet,
phoi trong, khong tieu chay, mat kho, mien kho, xuat hien cau bang quang.
Luc nay phai keo dai them lieu no Atropin t 1 2h na, sau o giam lieu vi nguyen
tac: giam lieu ang ieu tr va anh gia lai sau moi 4 6h e giam lieu tiep.
Atropin ch la thuoc co tac dung len hoi chng Muscarin va hoi chng than kinh trung
ng, khong co ket qua vi hoi chng Nicotin v vay tnh trang liet ho hap van co the xay
ra.
Dung Atropin lieu cao lam tang nhu cau tieu thu oxy cua te bao va c tim phai
am bao cung cap Oxy ay u. Cu the:
Thong kh hut am nht
Oxy ho tr
Co suy ho hap th may
3. Dung thuoc oi khang: Nhom Oxime
Nh: - Paralidoxime
- Obidoxime
- PAM (2-pyridin Aldoxin Methylchloride hay iodide)
C che tac dung: hoat hoa men Cholinesteraza bang cach gan ket nhom Oxime
vao paraoxone thanh hp chat khong oc tach khoi Cholinesteraza sau o thai ra bang
ng nieu.
Nhom Oxime khong trung hoa c cac loai chat oc thuoc nhom Carbamate mac
du Carbamate la chat khang Cholinesteraza (khong thuoc nhom Phospho hu c)
Cach s dung:
Nhom Paralidoxime (Contrathion hay Paracontrathion)

Tan cong: Ngi ln 25 50mg/kg tiem TM 5 10
Tre em: 20 50mg/kg TM cham 5 10
Duy tr: lieu 10 20mg/kg/24h
PAM:
Lieu trung bnh: 0,5 1g, tiem TM cham 5 10 phut, khong c tiem qua nhanh
co the gay truy mach
Nang: 1 2g
Sau o duy tr: 0,2 0,5g truyen TM cham, moi 8h nhac lai 1 lan
Tre em: 20 40mg/kg
Dung:
- Cang sm cang tot.
- Khi co thuoc oi khang phai giam lieu Atropin vi lieu nh s dung
- Benh nang thng t ngay th 2 en ngay th 5
- Nen toi thieu dung 5 ngay au tien, co the dung keo dai 7 10 ngay
- Tac dung phu: nhc au, hoa mat, chong mat, buon non, mach nhanh.

163

4. Cac bien phap phoi hp
Bu nc va ien giai cho u (chu y bu lng nc mat do tang tiet dch, dan
mach)
Hut am nht + th oxy
Chong co giat bang diazepam
5 ngay au: nuoi dng BN bang ng TM
ieu tr tch cc trong 10 ngay au tien va theo doi s phuc hoi men
Cholinesteraza huyet tng
5. Giai oan on nh:
anh gia: lieu 0,5 mg/6h khong thay dau no Atropin hoac dau ngo oc Phospho
hu c cho uong nc ng
Tuyet oi: khong an m, dau, chat beo, trng, sa trong vong 1 thang.

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