THUC THNG DNG GMHS

Ths. Trn Th cm Nhung

L/O/G/O

Mc tiu
1. K c nhng thuc chnh thng
dng trong qu trnh gy m v hi
sc.
2. S dng ng cc thuc thng dng
trong gy m v hi sc.
3. Phi hp thuc ng cch tng hiu
qu v hn ch tc dng ph.

1. Thuc tin m
Mc ch:
An tm, an thn, bt lo u.
Lm qun
Lm gim nn i, gim co tht.
C tnh gy ng.

Nhm Benzodiazepin
- Gm: Midazolam, Diazepam, Lorazepam.
- u im ca thuc nhm Benzodiazepin: t
gy tc dng ph, t c ch h hp v nht l
chng t gy try tim mch

Nhm Benzodiazepin
1.1. Tc dng:
H TKTW: Gy an thn, gy ng, gy qun,
chng co git, gy dn c
H tim mch: gy dn mch v gim cung
lng tim nh. Nhp tim thng khng thay
i.
H hp: lm gim tn s th v th tch
thng lu ty theo liu dng. c ch h
hp nu dng km vi nhm thuc phin

Nhm Benzodiazepin
1.2. Tc dng ph:
Tng tc thuc: Dng Benzodiazepin trn
BN ng kinh ang iu tr vi Valproat c
th gy ln cn tm thn cp.
C thai v sinh : thuc c th gy d tt
cho bo thai nh st mi, ch vm nu
dng trong ba thng u thai k. Thuc qua
nhau c th gy suy h hp tr s sinh.

Nhm Benzodiazepin
a. Midazolam: Hypnovel
- Tc dng ngn, tan trong nc, khng c cht
t dc, thuc c tc dng gy qun mnh
nht v ko di
- Tin m: Liu dng 0,5 - 1 mg TM/mt ln

Nhm Benzodiazepin
b. Diazepam: Valium, Seduxen
- Thuc c s dng trong GMHS rt sm,
c tnh kch thch tnh mch, gy au ni
chch v c th gy d ng, ngay c gy sc
qu mn.
- Tin m: Liu dng 05 - 10 mg ung khong
0,5 - 1 gi trc m.

2. Thuc khng i giao cm:

Atropin, Scopolamin
2.1.Tc dng:
- Tng nhp tim: dng nga nhp tim chm do
phn x i giao cm
- H hp: c ch tit m nht, dn ph qun
gy gim sc cn ng th
- TKTW: gy vt v, bt rt, o gic.
- Mt: dn ng t v mt iu tit
- H niu - sinh dc: gim trng lc niu o
v bng quang do dn c trn gy b tiu.
- Chng tit: nc bt, gim p lc co tht thc
qun di.

Atropin
Liu tin m 0,01 0,02 mg/kg TB hay
TM
Atropin dng thn trng ngi b tng
nhn p gc ng, ph i tuyn tin lit
hay hp c bng quang

Scopolamin
- Tc dng chng tit nc bt mnh hn
Atropin v c tc dng nhiu hn trn h
thn kinh trung ng so vi Atropin.
- Liu dng lm sng thng gy bun ng v
qun, c th km bt rt, ni sng, nht l
i vi ngi gi.
- Scopolamin cn nga say tu xe. Nn thn
trng hay trnh dng cho ngi gi, tng
nhn p.

3. THUC GiM AU H MORPHIN

- L nhng thuc gim au rt mnh, thng c
dng trong GMHS hay gim au sau m.
- Thuc c tc dng ng vn (agonist) hay i
vn (antagonist) trn nhng th th
morphiniques no v sng sau ty sng.
- Kch thch cc th th (mu), th th (kappa)
v th th (delta) bng thuc ng vn n
thun s cho tc dng:
+ Th th , : Gim au, c ch h hp
+ Th th : Sng khoi, gy nghin
+ Th th : An thn

3. THUC GiM AU H MORPHIN

- Phn loi theo:
+ Thuc ng vn n thun: Morphin,
Pethidin, Fentanyl, Sufentanil, Alfentanil v
Remifentanil.
+ Thuc ng vn mt phn/i vn:
Buprenorphin, Nalbuphin, Tramadol.
+ Thuc i vn n thun: Naloxon.

3. THUC GiM AU H MORPHIN

gim au ca cc thuc phin c nh
nh sau:
- gim au ca Morphin # 1
- gim au ca Meperidin # 1/10
- gim au ca Fentanyl # 100
- gim au ca Remifentanil # 100
- gim au ca Sufentanil # 1000

3. THUC GiM AU H MORPHIN

3.1. H thn kinh trung ng:
- Gy an thn t, gim au ty theo liu, gy
sng khoi.
- Liu cao c th gy qun v mt tri gic.
3.2. H tim mch:
- t thay i sc co bp c tim, ngoi tr thuc
Meperidin l cht gy c ch c tim trc tip.
- Gim nh sc cn mch mu ngoi vi.
- Lm chm nhp tim ty theo liu, ngoi tr
Meperidin gy tng nhp tim
- Tnh n nh tim mch cao

3. THUC GiM AU H MORPHIN

3.3. H h hp:
Gy c ch h hp ty thuc liu dng. Ban
u, thuc gy gim tn s th, liu cao, s
gim th tch kh thng lu.
C th gy ngng th do c ch h hp hay
co cng c thnh ngc. Cc thuc phin,
c bit l Fentanyl, Sufentanil, Alfentanil
gy co cng c thnh ngc lm ngi bnh
th kh, cng nh h hp iu khin kh
khn.
c ch phn x ho ty theo liu.

3. THUC GiM AU H MORPHIN

3.4. H tiu ha:
- Lm chm thi gian lm trng d dy v
gy to bn do gim nhu ng.
- Tng trng lc c vng lm co tht ng
mt gy cn au qun mt v b tiu.
- Bun nn v nn i do kch thch trung tm nn.

3.5. Tc dng ph khc:

- Nga da: iu tr vi Naloxon.
- Gy nghin v dung np thuc:

MORPHIN
- Gim au hiu qu trn mi loi au: au ni
tng, au do chn thng, gim au v gim
lo u trong nhi mu c tim.
- Morphin lm dn tnh mch nn rt tt
iu tr ph phi cp do suy tim tri cp v
lm gim cm gic kh th.
- Liu dng:
Morphin tim tnh mch liu 0,05 - 0,1mg/kg,
nn chn liu nh t 1 - 2 mg/ln, hay tim
bp 0,1 - 0,2 mg/kg

Fentanyl
- Fentanyl l thuc phin tng hp, tan trong
m nhiu hn Morphin, mnh gn 100 ln
hn Morphin.
- Thi gian tim phc nhanh hn: 3 - 5 pht,
tnh n nh huyt ng tt hn v c ch h
hp mnh hn.
- Liu cao Fentanyl tim tnh mch nhanh c
th gy cng c thnh ngc. Fentanyl gy
nga mt v ton thn.

Fentanyl
Liu dng:
Gy m: liu dng 1- 2 mcg/kg bnh nhn t
th, cuc m ngn khong 30 - 40 pht; liu
dng 5 - 10 mcg/kg phu thut ln, c th my
Fentanyl 10 - 25 mcg pha chung vi thuc t ti
ch Bupivacain trong t ty sng lm tng tc
dng t v ko di thi gian tc dng ca thuc
t.
Cho Fentanyl vo khoang NMC qua catheter
liu 0,3 mcg/kg/gi hay cho tng liu 50 - 100
mcg/ln.

Meperidin (Pethidin, Dolargan)

- Liu 1 - 2 mg/kg (TB), 0,5 mg/kg (TMC).
- Thuc c thi gian tc dng ngn hn
Morphin v gy bun nn, nn i, gy tt
huyt p nhiu hn Morphin do phng thch
Histamin
- Meperidin liu 25 - 50 mg TM thng rt
hiu qu iu tr chng lnh run trong hay
sau khi phu thut

Remifentanil
- Remifentanil l thuc phin c tc dng
ngn nht hin nay, thng thi gian tc
dng khong 3 5 pht nn thuc dng
truyn tnh mch, do b thy phn bi men
esterase trong mu v m;
- Remifentanil (0,3 - 0,4 mcg/kg/pht TM) vi
Propofol (75 mcg/kg/pht TM).

Sufentanil
- Sufentanil l thuc phin tng hp mnh
nht hin nay
- Tc dng tng t nh Fentanyl nhng thi
gian tc dng ngn hn v t b tch t thuc
so vi Fentanyl.
- Dng duy tr trong gy m cn bng,
Sufentanil cho tng liu 0,1 - 0,2 mcg/kg
TM hay truyn tnh mch lin tc 0,2 - 1
mcg/kg/gi.

4. THUC DNG KHI M

- Thuc khi m, thuc dn u l nhng
thuc khi dng gip cho ngi bnh i vo
gic ng m i, m du hn, trnh cho bnh
nhn phi i qua thi k II kch ng v kh
chu cho ngi bnh

4. THUC M TNH MCH

Cc thuc m tnh mch dng :
+ Khi m,
+ Lm cc th thut ngn: ph rung tim,
+ iu tr cn ng kinh khng p ng
vi cc thuc chng ng kinh khc,
+ Gy m tnh mch hon ton
+ An thn khi th my.

THUOC ME LY TNG
1.Tnh me nhanh, lam quen.
2.Khong tang ap suat noi so, me nhanh
em, khong kch thch.
3.Huyet ong on nh.
4.Thong kh de dang.
5.De s dung, on nh trong dung dch.
6.Dung nap tot tnh mach, khong au
7.t phong thch Histamine, phan ng phu,
qua man.
8.Nhng chat chuyen hoa t tac dung, t
tch tu.
Khong co thuoc me n thuan " LY
TNG ".

4.1. Sodium thiopenton:

(Thiopental, Nesdonal)
- Thiopental l thuc barbituric c s dng
sm nht trong GMHS v hin nay vn cn
c s dng, nht l trong gy m phu
thut TKSN
- Thi gian tc dng: 30 - 45 giy
- Thi gian tc dng:
5 - 10 pht

4.1. Sodium thiopenton

a. Tc dng:
- TKTW: Thiopental l thuc chng ng kinh
rt mnh, v nhanh. Lm gim CH no,
gim LL mu no v gim ALNS. C tc
dng bo v no.
- TM: Gy tt huyt p do c ch c tim v
dn tnh mch v tng nhp tim
- H hp: Lm gim tn s th v th tch kh
thng lu. Ngng th thng xy ra
khong 30 - 90 giy sau liu gy ng.

4.1. Sodium thiopenton

b. Tc dng ph:
- Thuc gy au ni tim do kch thch tnh
mch.
- Gy hoi t m nu tim ra ngoi TM.
- Nu tim nhm vo M gy au nhc d
di v hoi t tay do tnh kim cao ca dung
dch thuc ny
c. Liu dng:
- Khi m: Liu 3 - 5 mg/kg

4.2. Ketamin
C ch tc dng cha r, nhng c tc dng
i khng ti th th N-methyl-D-aspartat
(NMDA).
Thuc chuyn ha ti gan, thnh nhiu cht
chuyn ha trong vi cht c hot tnh.
Thi gian tc dng: 1 pht
Thi gian tc dng: 10 - 20 pht.
Liu: 2 3 mg/kg TMC

4.2. Ketamin
a. Tc dng:
TKTW: Ketamin lm tng LL mu no, CH
no v tng ALNS. Ketamin l thuc gy
m phn ly, c tnh gy qun v gim au.
TM: Ketamin lm tng tn s tim, tng HA
M h thng v M phi do phng thch
catecholamin ni sinh.
HH: t c ch h hp.

4.2. Ketamin
a. Tc dng ph:
Ketamin gy tng tit nc bt
Ketamin gy vt v, bt rt trong lc tnh
m, gy o gic v c mng trong v sau m
Lm tng ALNS nn khng dng BN CTSN
hay tng ALNS
Tr em t b o gic hn ngi ln.
Khng nn dng Ketamin cho BN c RL tm
thn.
Gy run c khi c kch thch. Lm tng
trng lc c.

4.3. Propofol
- Dng khi m v duy tr m,
- Chn la cho BN m v trong
ngy v: tnh m nhanh, cht lng
khi tnh m tt, khng b ngy
ngt khi tnh m, t b bun nn v
t nn i sau gy m
- Liu khi m 2 3 mg/kg,
- Thi gian tc dng: 30 45s
- Thi gian tc dng: 5 - 10 pht

4.3. Propofol
a. Tc dng:
TKTW: Liu cao, gy mt tri gic, liu thp gy an
thn nhng bnh nhn vn tnh to. Gim CH no,
gim LL mu no v gim ALNS.
TM: Gy tt huyt p do dn mch v gim cung
lng tim. Gim nhp tim
HH: Propofol c ch phn x thanh qun, kh qun
nn t b co tht thanh qun khi t ng ni kh qun,
nn rt thun li khi t mask thanh qun.
C th truyn tnh mch lin tc duy tr m.

4.3. Propofol
b. Tc dng ph:
- BN thng b au ni tim thuc
- Dng nh tng gip vi khun pht trin nn
phi ch gi v trng khi ly thuc, v b
ng thuc m khng dng sau khong 6
gi trnh b nhim khun.

4.4. Etomidat
Etomidat l cht Imidazol c tnh
gy m, gy ng, c dng
khi m.
Thi gian tc dng : 30 giy
Thi gian tc dng: 4 - 6 pht.
Etomidat c chuyn ha ti gan
v men esterase trong mu thnh
cht chuyn ha khng c hot tnh

4.4. Etomidat
a. Tc dng:
- TKTW: Gim CH no, LL mu no v gim
ALNS. Etomidat c tc dng chng ng kinh
nhng gy thay i sng in no gip nh v
c ng kinh.
- TM: t thay i nhp tim, huyt p v cung lng
tim
- HH: c ch h hp ngng th thong qua.
- Khng gy phng thch histamin v t b phn
ng d ng nn l thuc c chn cho bnh
nhn b tng phn ng ng th.

4.4. Etomidat
b. Tc dng ph:
- au ni tim
- Run git c v c ng ngoi thp
- Bun nn v i thng xy ra sau m,
nhiu hn cc thuc m khc.
- Kch thch tnh mch gy au ni chch.
- Etomidat c ch tuyn thng thn tit
Cortisol trong 24 gi, nn khng dng liu
lp li hay truyn tnh mch ko di.
c. Liu dng : Khi m: Liu 0,3 0,4 mg/kg.

DC NG HC
THN KINH TW

TIM MCH

H HP

THIOPENTAL

- Gim TT oxy
- Gim LL mu
- Gim ALNS

- Tng nhp tim

- Gim HA
- n cp mu MV

- Co tht TQ, KQ
- V kh LT:

KETAMIN

- Tng LL mu
- Tng ALNS
- Gim au

- Tng nhp tim

- Tng LL tim, sc cn
nn tng HA

- Dn PQ
- Tng tit

PROPOFOL

- Gim LL mu
- Gim ALNS
- M mt sm

- Gim nhp tim

- Gim HA
- t nh hng MV

- Tn s: Gim
- V kh LT:
- Gim KT PQ

ETOMIDATE

- Gim LL mu
- Gim ALNS
- Tnh nhanh

- Nhp tim: tng t

- Huyt ng n nh

- Tn s: Tng
- V kh LT:
- Khng gy co
tht PQ

CH NH CHNG CH NH
CH NH

THIOPENTAL

KETAMIN

PROPOFOL

ETOMIDATE

CHNG C

LIU LNG

- Gm ton din
- BN CTSN
- Hi sc
- Sn khoa

- D ng barbituric
- KHTH , suy tim
- Hen PQ
- Suy gan thn

3 5 mg/kg

- Sc, bng
- Th thut gy au, phi
hp t vng

-TBMMN, Tng ALNS

- THA, MV, NMCT
- Tin SG, Sn git

2 3 mg/kg

- BN ngoi tr
- Khi m, duy tr m
- Phi hp t vng

- ng kinh cha n
- Gim KHTH
- RL lipid

2 3 mg/kg

- Ct b ng kinh
- Bnh l TM
- Sn khoa

- ng kinh
- Suy thng thn
- Suy gan

0,3 0,4 mg/kg

5. Duy tr m: Thuc m h hp
Nhm Halogen:
- Halothan
- Isofluran
- Sevofluran

5.1. Halothan
- Thuc m h hp, khng mu, c mi

thm nh mi tri to chn, v ngt, t

gy kch thch ng h hp nn c th
dng khi m, nht l tr em.
- Khi m nng 2 - 3%, duy tr m
vi nng 0,5 - 1,5.

5.2. Halothan
a. Tc dng:
- TKTW: Tng LL mu no v tng ALNS
- TM: gy tt huyt p, gy lon nhp tim,
thng l nhp tim chm v nhp nt
- HH: Halothan gy th nhanh, nng. Gy dn
ph qun v lm gim phn x hu v thanh
qun

5.2. Halothan
a. Tc dng:
- Dn c trn v c vn, k c c t cung lm
chy mu nhiu khi m bt con.
- Gim LL mu thn, gim lc cu thn v
lng nc tiu do tt huyt p v gim
cung lng tim.
- Gim LL mu qua gan do gim cung lng
tim.

5.2. Halothan
b. Tc dng ph:
Gy khi pht st cao c tnh.
Gy vim gan do Halothan, tng i
him, t l khong 1:35.000 trng hp
v c th gy hoi t gan khi gy m
lin tip nhiu ln trong mt thi gian
ngn.

5.2. ISOFLURAN
- Isofluran l thuc m bc hi, khng mu, c
mi hi nng cay, gy kch thch ng h
hp nn t c dng khi m.
- Duy tr m thng nng 2 - 3% phi
hp vi dng kh (O2) hay hn hp N2O v
O2.
- Tnh m nhanh, t phn ng ca thuc m
nn Isofluran c dng trong gy m BN
ngoi tr hay v trong ngy

5.2. ISOFLURAN
Tc dng:
- TKTW: t nh hng trn LL mu no v
ALNS nng thp
- TM: Gy tt huyt p t l vi nng thuc
m do dn mch ngoi vi. Mch tng i
n nh hoc tng nhanh nh
- HH: Gy c ch h hp nh, nhng t gy
th nhanh.

5.2. ISOFLURAN
Tc dng:
- C tc dng dn c tt, tng tc dng ca
thuc dn c khng kh cc v gy dn c
t cung.
- Isofluran gy gim lu lng mu qua gan,
nhng s cung cp dng kh cho t bo
gan c duy tr

5.3. SEVOFLURAN
- Sevofluran c mi d chu, khng kch thch
ng h hp nn c chn dng lm thuc
khi m ng h hp hiu qu, nhanh v m
du cho c tr em v ngi ln.
- Cht Sevofluran l thuc m h hp yu hn
cht Isofluran, nhng nh ha tan trong mu
thp nn thuc cho tc dng nhanh, rt d dng
v khi m nhanh, d iu chnh thay i m
v c thi gian tnh m nhanh.
- Hin nay c gi kh cao.

5.3. SEVOFLURAN
a. Tc dng:
- TKTW: Tng LL mu no v ALNS nh Isofluran.
Lm gim chuyn ha no.
- TM: c ch co bp c tim rt nh. Gim nh sc
cn ngoi vi v t gy h HA M v t gy mch
nhanh. Sevofluran lm gim s tiu th oxy c
tim, gim sc cn mch vnh nhng khng gy
n cp mu ng mch vnh.
- HH: Sevofluran gy c ch h hp v gy dn n
ph qun nh Isofluran

5.3. SEVOFLURAN
a. Tc dng:
- Thn kinh - c: dn c va BN chu ng
c th thut t ng NKQ tr em sau khi m
bng ng h hp, c th lm khi pht cn st
cao c tnh, nhng t l thp hn so vi Halothan.
- Gan: Gim LL mu TM ca nhng tng LL mu
M gan nn duy tr c LL mu qua gan v cung
cp dng kh cho gan.
- Thn: lm gim nh LL mu qua thn. Cht chuyn
ha l gc ion fluor t do gy h hi ng thn

5.3. SEVOFLURAN
b. Tc dng ph:
- Khong 5% Sevofluran c chuyn ha ti
gan bng men P450 to ra ion fluor t do gy
c cho thn.
- Thuc m h hp Sevofluran b hp thu v
bin i bi vi Soda hay Baralym thnh
cht vinyl ether, hay hp cht A, hp cht
ny c c tnh cao cho chc nng thn, chc
nng gan v thn kinh no b

TC DNG CA THUC M H HP
TN
H
ME

Halothan

Isoflurane

Cha
m

Trung
bnh

TKTW

- LLMN:
- ALNS:

- LLMN:
t
- ALNS:
t

HO
HAP

TIM MACH

Nhp
tim

HA
TB

Dan
MV

- c
che
- Dan
PQ
- Tang
TS

Gia
Cham
m

Khon
g

- c
che
- Dan
PQ
- Giam
TS

Nhanh

Gia
m

ang
ke

Tc dng ca thuc m h hp
DAN C GAN

THAN
- LL mau:
Giam

Halothan

Isoflurane

Trung bnh

Giam
mau

LL

- Giam
mau

LL - LL mau:
Giam

- o loc:
Giam

Nhieu
Van duy - o loc:
tr oxy gan
Giam
- Giam
mau TM

LL

- LL mau:

6. THUC DN C
- Thuc dn c, hay nn gi ng hn l
thuc ngn chn s dn truyn thn
kinh c (Neuromuscular Blocking
Drugs), l nhng thuc khi dng cho
bnh nhn, n s lm mm c vn, cn
c trn v c tim n khng c tc dng

6. THUC DN C
C 2 cch chia thuc dn c:
- Dn c kh cc (Suxamethonium) v dn c
khng kh cc (Vecuronium, Rocuronium,
Atracurium)
- Dn c ngn (Suxamethonium) , dn c
trung bnh (Vecuronium, Rocuronium,
Atracurium) v dn c di.

6.1. Suxamethonium
Tc dng ph:
au c sau m.
Tng ion kali mu
Gy d ng nh ni m ay, nga v nng nht l
sc phn v.
Gy nhp tim chm v lon nhp
Tng nhn p v tng p lc ni s
Tng p lc trong d dy
Co cng thong qua c hm khi t ni kh qun
Tng t l st cao c tnh.

6.1. Suxamethonium
- Liu khong 1 - 1,5 mg/kg, tim tnh
mch, s gy run c v tip theo gy
lit c trong vng 45 - 60 giy, v ko
di khong 5 - 7 pht
- Ch nh:
+ BN tin lng t ni kh qun kh
+ M cp cu BN c d dy y

6.2. Thuc dn c khng kh cc

6.2.1. Vecuronium: (NorcuronR)
- Liu t ni kh qun l 0,08 - 0,1 mg/kg,
lp liu - liu ban u
- Thi gian tc dng: 3 pht,
- Thi gian tc dng: 30 45 pht.
- Duy tr truyn tnh mch lin tc 1 2mcg/kg/pht.
- Vecuronium thi qua thn 30%, phn cn li
qua gan

6.2. Thuc dn c kh cc
6.2.2. Rocuronium: (EsmeronR)
- Liu 0,6 mg/kg, Liu cao t NKQ nhanh
- Thi gian tc dng: 90 giy
- Thi gian tc dng: 30 - 45 pht
- Thuc thi nguyn dng qua thn v gan,
nn thi gian tc dng s ko di nu suy
gan suy thn.

6.2. Thuc dn c kh cc
6.2.3. Atracurium:
- Liu 0,5 mg/kg
- Thi gian tc dng 2 - 2,5 pht,
- Thi gian tc dng khong 20 - 25 pht.
- y l thuc c chn cho bnh nhn suy
thn, suy gan
- Thuc khng c tc dng tim mch trc tip,
nhng c th phng thch histamin, gy ni m
ay v da quanh ni chch, tt huyt p nh
.

6. THUC HA GII: Prostigmin

Sau mt thi gian nht nh thuc dn c s
ht tc dng v ngi bnh s t th li hiu
qu;
Khi cuc m kt thc nhng thi gian tc
dng thuc dn c vn cn, ngi gy m c
th dng thuc Prostigmin ha gii
Liu: 0,02 0,04 mg/kg ha gii thuc
dn c v pha Atropin liu 0,01 0,02 mg/kg
cng lc

KT LUN
Gy m hi sc l chuyn khoa thng
dng nhng thuc mi, thuc c.
Thuc c dng trong Gy m Hi sc
rt a dng, a chng loi.
Nm tht vng nhng tnh cht ca mi
loi thuc s dng cho ng.
Tun th nhng nguyn tc khi s dng
thuc nht l nhng thuc mi.

n
a
Th

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