PHAC DO DIEU TRI KHOA CAP CUU

["Chlamydia \u1ede b\u1ec7nh nh\u00e2n vi\u00eam ph\u1ed5i do c\u00fam (A ho\u1eb7c B) ngo\u1ea1i tr\u00fa ho\u1eb7c n\u1ed9i tr\u00fa pneumoniae) \u0111\u1ec1u c\u00f3 ch\u1ec9 \u0111\u1ecbnh d\u00f9ng thu\u1ed1c kh\u00e1ng virus, d\u00f9ng trong 48h \u0111\u1ea7u sau khi c\u00f3 tri\u1ec7u ch\u1ee9ng. Vi\u00eam ph\u1ed5i do Thu\u1ed1c: Oslertamivir 75mg x 2 vi\u00ean\/ng\u00e0y u\u1ed1ng chia 2 l\u1ea7n. Tr\u01b0\u1eddng virus c\u00fam h\u1ee3p n\u1eb7ng c\u00f3 th\u1ec3 d\u00f9ng li\u1ec1u g\u1ea5p \u0111\u00f4i. N\u00ean d\u00f9ng kh\u00e1ng sinh \u0111i k\u00e8m li\u1ec7u ph\u00e1p kh\u00e1ng virus v\u00ec b\u1ed9i nhi\u1ec5m vi khu\u1ea9n sau \u0111\u00f3 s\u1ebd l\u00e0m n\u1eb7ng h\u01a1n t\u00ecnh tr\u1ea1ng vi\u00eam ph\u1ed5i. S. aureus l\u00e0 vi khu\u1ea9n th\u01b0\u1eddng g\u1eb7p \u1edf b\u1ec7nh nh\u00e2n vi\u00eam ph\u1ed5i do c\u00fam, ti\u1ebfp \u0111\u1ebfn l\u00e0 H. influenza, Streptococcus nh\u00f3m A H\u01b0\u1edbng d\u1eabn x\u1eed tr\u00ed khi \u0111\u00e1p \u1ee9ng k\u00e9m v\u1edbi \u0111i\u1ec1u tr\u1ecb 6. D\u1ef1 ph\u00f2ng: - \u0110i\u1ec1u tr\u1ecb tri\u1ec7t \u0111\u1ec3 c\u00e1c \u1ed5 nhi\u1ec5m khu\u1ea9n v\u00f9ng tai m\u0169i h\u1ecdng, r\u0103ng mi\u1ec7ng, qu\u1ea3n l\u00fd tri\u1ec7t \u0111\u1ec3 c\u00e1c b\u1ec7nh l\u00fd n\u1ec1n c\u1ee7a b\u1ec7nh nh\u00e2n. - Gi\u1eef \u1ea5m c\u1ed5 ng\u1ef1c trong m\u00f9a l\u1ea1nh, lo\u1ea1i b\u1ecf k\u00edch th\u00edch c\u00f3 h\u1ea1i: r\u01b0\u1ee3u bia, thu\u1ed1c l\u00e1 - Ti\u00eam ph\u00f2ng c\u00fam 1 n\u0103m\/l\u1ea7n \u1edf ng\u01b0\u1eddi > 50 tu\u1ed5i, ch\u1ec9 \u0111\u1ecbnh \u1edf ng\u01a3\u1eddi m\u1eafc b\u1ec7nh l\u00fd tim ph\u1ed5i m\u1ea1n t\u00ednh, \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng, suy th\u1eadn n\u1eb7ng, suy gi\u1ea3m mi\u1ec5n d\u1ecbch. - Ti\u00eam ph\u00f2ng ph\u1ebf c\u1ea7u: 5 n\u0103m\/l\u1ea7n khi ti\u00eam l\u1ea7n \u0111\u1ea7u d\u01b0\u1edbi 65 tu\u1ed5i, n\u1ebfu l\u1ea7n \u0111\u1ea7u ti\u00eam > 65 tu\u1ed5i th\u00ec kh\u00f4ng c\u1ea7n nh\u1eafc l\u1ea1i, ch\u1ec9 \u0111\u1ecbnh \u1edf ng\u01b0\u1eddi m\u1eafc b\u1ec7nh tim ph\u1ed5i m\u1ea1n, \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng, nghi\u1ec7n r\u01b0\u1ee3u, b\u1ec7nh gan m\u1ea1n t\u00ednh, d\u00f2 d\u1ecbch n\u00e3o t\u1ee7y, c\u1eaft l\u00e1ch, suy gi\u1ea3m mi\u1ec5n d\u1ecbch. - T\u01b0 v\u1ea5n cai thu\u1ed1c l\u00e1 v\u1edbi chi\u1ebfn l\u01b0\u1ee3c t\u01b0 v\u1ea5n ng\u1eafn 5A (H\u1ecfi \u2013 Khuy\u00ean \u2013 \u0110\u00e1nh gi\u00e1 \u2013 H\u1ed7 tr\u1ee3 - S\u1eafp x\u1ebfp) ho\u1eb7c t\u01b0 v\u1ea5n s\u00e2u. 97","VI\u00caM PH\u1ed4I B\u1ec6NH VI\u1ec6N I. \u0110\u1ecaNH NGH\u0128A - Vi\u00eam ph\u1ed5i b\u1ec7nh vi\u1ec7n (VPBV) l\u00e0 vi\u00eam ph\u1ed5i xu\u1ea5t hi\u1ec7n sau khi v\u00e0o vi\u1ec7n 48 gi\u1edd m\u00e0 kh\u00f4ng c\u00f3 bi\u1ec3u hi\u1ec7n ho\u1eb7c \u1ee7 b\u1ec7nh t\u1ea1i th\u1eddi \u0111i\u1ec3m nh\u1eadp vi\u1ec7n, \u0111\u01b0\u1ee3c ph\u00e2n th\u00e0nh VPBV - kh\u1edfi ph\u00e1t s\u1edbm, khi th\u1eddi \u0111i\u1ec3m xu\u1ea5t hi\u1ec7n vi\u00eam ph\u1ed5i <5 ng\u00e0y sau nh\u1eadp vi\u1ec7n v\u00e0 kh\u1edfi ph\u00e1t mu\u1ed9n, khi th\u1eddi \u0111i\u1ec3m xu\u1ea5t hi\u1ec7n vi\u00eam ph\u1ed5i >5 ng\u00e0y sau nh\u1eadp vi\u1ec7n. VPBV \u0111\u01b0\u1ee3c \u0111\u1eb7c tr\u01b0ng b\u1edfi t\u0103ng nguy c\u01a1 ti\u1ebfp x\u00fac v\u1edbi c\u00e1c vi khu\u1ea9n \u0111a kh\u00e1ng thu\u1ed1c c\u0169ng nh\u01b0 c\u00e1c vi khu\u1ea9n gram \u00e2m. YTNC cao ti\u1ebfp x\u00fac v\u1edbi c\u00e1c vi khu\u1ea9n n\u00e0y g\u1ed3m: + \u0110i\u1ec1u tr\u1ecb kh\u00e1ng sinh trong v\u00f2ng 10 ng\u00e0y k\u1ec3 t\u1eeb khi nhi\u1ec5m tr\u00f9ng \u1edf b\u1ec7nh vi\u1ec7n + Th\u1eddi gian n\u1eb1m vi\u1ec7n t\u1eeb 5 ng\u00e0y tr\u1edf l\u00ean + T\u1ea7n su\u1ea5t cao c\u1ee7a kh\u00e1ng kh\u00e1ng sinh \u0111\u00f3 trong c\u1ed9ng \u0111\u1ed3ng \u0111\u1ecba ph\u01b0\u01a1ng ho\u1eb7c trong c\u00e1c \u0111\u01a1n v\u1ecb b\u1ec7nh vi\u1ec7n \u0111\u00f3 + B\u1ec7nh nh\u00e2n \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb \u1ee9c ch\u1ebf mi\u1ec5n d\u1ecbch, c\u00f3 b\u1ec7nh l\u00fd l\u00e0m suy gi\u1ea3m mi\u1ec5n d\u1ecbch + S\u1ef1 hi\u1ec7n di\u1ec7n c\u1ee7a c\u00e1c YTNC ti\u1ebfp x\u00fac v\u1edbi vi khu\u1ea9n \u0111a kh\u00e1ng - Vi\u00eam ph\u1ed5i li\u00ean quan \u0111\u1ebfn th\u1edf m\u00e1y: l\u00e0 m\u1ed9t d\u1ea1ng c\u1ee7a vi\u00eam ph\u1ed5i b\u1ec7nh vi\u1ec7n \u0111\u01b0\u1ee3c \u0111\u1ecbnh ngh\u0129a l\u00e0 vi\u00eam ph\u1ed5i xu\u1ea5t hi\u1ec7n sau khi \u0111\u1eb7t NKQ 48 gi\u1edd ho\u1eb7c trong v\u00f2ng 48 gi\u1edd sau r\u00fat \u1ed1ng NKQ. YTNC cao ti\u1ebfp x\u00fac v\u1edbi vi khu\u1ea9n \u0111a kh\u00e1ng. Vi\u00eam ph\u1ed5i th\u1edf m\u00e1y x\u1ea3y ra tr\u00ean 10-20% b\u1ec7nh nh\u00e2n th\u1edf m\u00e1y tr\u00ean 48 gi\u1edd Khi b\u1ec7nh nh\u00e2n \u0111ang n\u1eb1m vi\u1ec7n, b\u1ec7nh nh\u00e2n \u0111ang \u1edf m\u1ed9t nguy c\u01a1 cao c\u1ee7a b\u1ec7nh vi\u00eam ph\u1ed5i, \u0111\u1eb7c bi\u1ec7t l\u00e0 n\u1ebfu b\u1ec7nh nh\u00e2n \u0111ang th\u1edf m\u00e1y, sau ph\u1eabu thu\u1eadt ng\u1ef1c b\u1ee5ng, trong m\u1ed9t \u0111\u01a1n v\u1ecb ch\u0103m s\u00f3c \u0111\u1eb7c bi\u1ec7t ho\u1eb7c khi c\u00f3 h\u1ec7 th\u1ed1ng mi\u1ec5n d\u1ecbch suy y\u1ebfu. \u0110\u00e2y l\u00e0 lo\u1ea1i vi\u00eam ph\u1ed5i \u0111\u1eb7c bi\u1ec7t nghi\u00eam tr\u1ecdng, nh\u1ea5t l\u00e0 cho nh\u1eefng ng\u01b0\u1eddi tr\u00ean 70 tu\u1ed5i, tr\u1ebb em v\u00e0 nh\u1eefng ng\u01b0\u1eddi c\u00f3 b\u1ec7nh ph\u1ed5i t\u1eafc ngh\u1ebdn m\u1ea1n t\u00ednh (COPD) ho\u1eb7c HIV\/AIDS II. NGUY\u00caN NH\u00c2N 1. Tr\u00ean th\u1ebf gi\u1edbi: B\u00e1o c\u00e1o CDC 2009-2010, c\u00e1c vi khu\u1ea9n th\u01b0\u1eddng g\u1eb7p l\u00e0 Staphylococcus aureus (24.1%), Pseudomonas aeruginosa (16.6%), Klebsiella species (10.1%), Acinetobacter baumanii (6.6%) 2. \u1ede Vi\u1ec7t Nam: C\u00e1c nghi\u00ean c\u1ee9u t\u1ea1i khoa H\u1ed3i s\u1ee9c t\u00edch c\u1ef1c c\u1ee7a BV B\u1ea1ch Mai v\u00e0 Bv Ch\u1ee3 R\u1eaby nh\u1eadn th\u1ea5y t\u00e1c nh\u00e2n g\u00e2y VPBV v\u00e0 VP li\u00ean quan th\u1edf m\u00e1y th\u01b0\u1eddng g\u1eb7p l\u00e0 c\u00e1c vi khu\u1ea9n Gram \u00e2m. T\u00e1c nh\u00e2n g\u00e2y VPBV th\u01b0\u1eddng g\u1eb7p \u1edf BV B\u1ea1ch Mai v\u00e0 BV Ch\u1ee3 R\u1eaby Vi khu\u1ea9n BV B\u1ea1ch Mai BV Ch\u1ee3 R\u1eaby Acinetobacter baumannii 2011 2013 2015 61% Pseudomonas aeruginosa 11,7% 59% 56,7% 66,2% 7% 8,5% 8,8% 98","T Klebsiella pneumoniae 17% 11,1% 11,8% 10,4% 0% 4,1% 0% 0% \u00e1 Stecnotrophomonas 1% 1,4% 0% 5,2% maltophilia 3% 6,4% 2,9% 11,7% 1% 2,7% 0% Esncherichia coli 0% Stahphylococcus aureus \u00e2 Strneptococcus pneumoniae N\u1ea5gm 13% 0% 11,7% 0% \u00e2 y VP li\u00ean quan th\u1edf m\u00e1y th\u01b0\u1eddng g\u1eb7p \u1edf BV B\u1ea1ch Mai v\u00e0 BV Ch\u1ee3 R\u1eaby Vi khu\u1ea9n BV Nh\u00e2n BV C\u1ea5p c\u1ee9u B\u1ec7nh vi\u1ec7n BV Th\u1ed1ng d\u00e2n Gia Tr\u01b0ng L\u00e2m Nh\u1ea5t Acinetobacter baumannii V\u01b0\u01a1ng \u0110\u1ed3ng Pseudomonas aeruginosa \u0110\u1ecbnh 18,5% Klebsiellaspp 32,3% 29,3% Enterobacter 27,7% Staphylococcus aureus Escherichia coli 25% 7,7% 14,7% 38,1% Proteus mirabilis Stenotrophomonas 33,3% 13,8% 24% 28,2% maltophilia 0% 0% 5,3% 3,7% 0% 15,4% 14,7% 13,2% 8,3% 9,7% 9,3% 3,7% 0% 0% 1,3% 0% 2,8% 0% 0% 0% III. Y\u1ebeU T\u1ed0 NGUY C\u01a0 1. C\u00e1c y\u1ebfu t\u1ed1 thu\u1ed9c v\u1ec1 ng\u01b0\u1eddi b\u1ec7nh: + Tr\u1ebb s\u01a1 sinh, ng\u01b0\u1eddi gi\u00e0 tr\u00ean 65 tu\u1ed5i, ng\u01b0\u1eddi b\u00e9o ph\u00ec, ng\u01b0\u1eddi b\u1ec7nh ph\u1eabu thu\u1eadt b\u1ee5ng, ng\u1ef1c, \u0111\u1ea7u v\u00e0 c\u1ed5, ng\u01b0\u1eddi b\u1ec7nh c\u00f3 b\u1ec7nh l\u00fd n\u1eb7ng k\u00e8m theo nh\u01b0 c\u00f3 r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng ph\u1ed5i nh\u01b0 b\u1ec7nh ph\u1ed5i t\u1eafc ngh\u1ebdn m\u00e3n t\u00ednh, b\u1ea5t th\u01b0\u1eddng l\u1ed3ng ng\u1ef1c, ch\u1ee9c n\u0103ng ph\u1ed5i b\u1ea5t th\u01b0\u1eddng, suy gi\u1ea3m mi\u1ec5n d\u1ecbch, m\u1ea5t ph\u1ea3n x\u1ea1 ho nu\u1ed1t. Ng\u01b0\u1eddi b\u1ec7nh h\u00f4n m\u00ea, kh\u00f3 nu\u1ed1t do b\u1ec7nh l\u00fd h\u1ec7 th\u1ea7n kinh ho\u1eb7c th\u1ef1c qu\u1ea3n l\u00e0m t\u0103ng nguy c\u01a1 vi\u00eam ph\u1ed5i h\u00edt + C\u00e1c y\u1ebfu t\u1ed1 l\u00e0m gia t\u0103ng s\u1ef1 x\u00e2m nh\u1eadp v\u00e0 \u0111\u1ecbnh c\u01b0 c\u1ee7a vi khu\u1ea9n (colonization). \u1ede ng\u01b0\u1eddi kh\u1ecfe m\u1ea1nh, t\u1ebf b\u00e0o bi\u1ec3u m\u00f4 ni\u00eam m\u1ea1c mi\u1ec7ng \u0111\u01b0\u1ee3c ph\u1ee7 m\u1ed9t l\u1edbp fibronectin ng\u0103n ch\u1eb7n s\u1ef1 b\u00e1m d\u00ednh c\u1ee7a vi khu\u1ea9n gram \u00e2m, l\u1edbp b\u1ea3o v\u1ec7 n\u00e0y b\u1ecb m\u1ea5t \u0111i trong nh\u1eefng tr\u01b0\u1eddng h\u1ee3p b\u1ec7nh n\u1eb7ng l\u00e0m cho vi khu\u1ea9n gram \u00e2m b\u00e1m d\u00ednh v\u00e0o bi\u1ec3u m\u00f4 v\u00f9ng h\u1ea7u h\u1ecdng nhi\u1ec1u h\u01a1n. Do \u0111\u00f3 vi khu\u1ea9n th\u01b0\u1eddng tr\u00fa \u1edf v\u00f9ng h\u1ea7u h\u1ecdng \u1edf ng\u01b0\u1eddi l\u1edbn kh\u1ecfe m\u1ea1nh l\u00e0 vi khu\u1ea9n y\u1ebfm kh\u00ed v\u00e0 li\u00ean c\u1ea7u tan m\u00e1u \uf061 (Streptococci \uf061-hemolytic), ng\u01b0\u1ee3c l\u1ea1i v\u00f9ng h\u1ea7u h\u1ecdng c\u1ee7a c\u00e1c ng\u01b0\u1eddi b\u1ec7nh nh\u1eadp vi\u1ec7n th\u01b0\u1eddng b\u1ecb c\u00e1c vi khu\u1ea9n Gram \u00e2m hi\u1ebfu kh\u00ed \u0111\u01b0\u1eddng ru\u1ed9t c\u01b0 tr\u00fa. 99","2. C\u00e1c y\u1ebfu t\u1ed1 do can thi\u1ec7p y t\u1ebf: + \u0110\u1eb7t n\u1ed9i kh\u00ed qu\u1ea3n ho\u1eb7c m\u1edf kh\u00ed qu\u1ea3n. + \u0110\u1eb7t \u1ed1ng th\u00f4ng m\u0169i d\u1ea1 d\u00e0y: \u1ed1ng th\u00f4ng l\u00e0m gia t\u0103ng vi sinh v\u1eadt k\u00fd sinh \u1edf v\u00f9ng m\u0169i, h\u1ea7u, g\u00e2y tr\u00e0o ng\u01b0\u1ee3c d\u1ecbch d\u1ea1 d\u00e0y, vi khu\u1ea9n t\u1eeb d\u1ea1 d\u00e0y theo \u0111\u01b0\u1eddng \u1ed1ng \u0111\u1ebfn \u0111\u01b0\u1eddng h\u00f4 h\u1ea5p tr\u00ean. + C\u00e1c \u0111i\u1ec1u ki\u1ec7n t\u1ea1o thu\u1eadn l\u1ee3i cho qu\u00e1 tr\u00ecnh tr\u00e0o ng\u01b0\u1ee3c ho\u1eb7c vi\u00eam ph\u1ed5i do h\u00edt s\u1eb7c: nh\u01b0 \u0111\u1eb7t n\u1ed9i kh\u00ed qu\u1ea3n, \u0111\u1eb7t \u1ed1ng th\u00f4ng d\u1ea1 d\u00e0y, t\u01b0 th\u1ebf n\u1eb1m ng\u1eeda + C\u00e1c b\u1ec7nh l\u00fd c\u1ea7n th\u1edf m\u00e1y k\u00e9o d\u00e0i: l\u00e0m t\u0103ng nguy c\u01a1 ti\u1ebfp x\u00fac v\u1edbi c\u00e1c d\u1ee5ng c\u1ee5 b\u1ecb nhi\u1ec5m khu\u1ea9n, b\u00e0n tay c\u1ee7a NVYT b\u1ecb nhi\u1ec5m b\u1ea9n. Ng\u01b0\u1eddi b\u1ec7nh th\u1edf m\u00e1y b\u1ecb m\u1ea5t c\u00e1c c\u01a1 ch\u1ebf b\u1ea3o v\u1ec7 b\u00ecnh th\u01b0\u1eddng do \u1ed1ng n\u1ed9i kh\u00ed qu\u1ea3n ng\u0103n c\u1ea3n c\u01a1 ch\u1ebf b\u1ea3o v\u1ec7 b\u00ecnh th\u01b0\u1eddng c\u1ee7a c\u01a1 th\u1ec3 v\u00e0 l\u00e0 n\u01a1i vi khu\u1ea9n \u0111\u1ebfn c\u01b0 tr\u00fa v\u00e0 ph\u00e1t tri\u1ec3n, ngo\u00e0i ra vi khu\u1ea9n ph\u00e1t tri\u1ec3n t\u1eeb ch\u1ea5t ti\u1ebft \u1ee9 \u0111\u1ecdng ph\u00eda tr\u00ean b\u00f3ng c\u1ee7a \u1ed1ng n\u1ed9i kh\u00ed qu\u1ea3n \u0111i v\u00e0o kh\u00ed qu\u1ea3n. L\u00f2ng \u1ed1ng n\u1ed9i kh\u00ed qu\u1ea3n b\u1ecb ph\u1ee7 l\u1edbp m\u00e0ng sinh h\u1ecdc c\u0169ng l\u00e0 y\u1ebfu t\u1ed1 l\u00e0m gia t\u0103ng nhi\u1ec5m khu\u1ea9n. Ng\u01b0\u1eddi b\u1ec7nh th\u1edf m\u00e1y c\u00f3 nguy c\u01a1 vi\u00eam ph\u1ed5i g\u1ea5p t\u1eeb 6 \u2013 1 l\u1ea7n so v\u1edbi ng\u01b0\u1eddi b\u1ec7nh kh\u00f4ng th\u1edf m\u00e1y. + C\u00e1c y\u1ebfu t\u1ed1 c\u1ea3n tr\u1edf qu\u00e1 tr\u00ecnh kh\u1ea1c \u0111\u1eddm: nh\u01b0 c\u00e1c ph\u1eabu thu\u1eadt v\u00f9ng \u0111\u1ea7u, c\u1ed5, ng\u1ef1c, b\u1ee5ng, b\u1ea5t \u0111\u1ed9ng do ch\u1ea5n th\u01b0\u01a1ng ho\u1eb7c b\u1ec7nh, d\u00f9ng thu\u1ed1c an th\u1ea7n hay h\u00f4n m\u00ea. + Ng\u01b0\u1eddi b\u1ec7nh \u0111\u01b0\u1ee3c d\u00f9ng thu\u1ed1c kh\u00e1ng acid d\u1ea1 d\u00e0y \u0111\u1ec3 d\u1ef1 ph\u00f2ng xu\u1ea5t huy\u1ebft ti\u00eau h\u00f3a do stress c\u00f3 nguy c\u01a1 VPBV cao h\u01a1n ng\u01b0\u1eddi b\u1ec7nh \u0111\u01b0\u1ee3c d\u1ef1 ph\u00f2ng b\u1eb1ng sucralfate. pH acid d\u1ea1 d\u00e0y c\u00f3 t\u00e1c d\u1ee5ng di\u1ec7t vi khu\u1ea9n \u0111\u01b0\u1ee3c nu\u1ed1t v\u00e0o c\u00f9ng v\u1edbi th\u1ee9c \u0103n v\u00e0 n\u01b0\u1edbc b\u1ecdt, duy tr\u00ec m\u00f4i tr\u01b0\u1eddng v\u00f4 khu\u1ea9n \u1edf \u0111\u01b0\u1eddng ti\u00eau h\u00f3a tr\u00ean. Khi \u0111\u1ed9 acid c\u1ee7a d\u1ecbch d\u1ea1 d\u00e0y b\u1ecb gi\u1ea3m do d\u00f9ng thu\u1ed1c kh\u00e1ng acid, \u1ee9c ch\u1ebf H2, \u1ee9c ch\u1ebf b\u01a1m ion H ho\u1eb7c nu\u00f4i \u0103n qua \u1ed1ng th\u00f4ng, vi khu\u1ea9n nu\u1ed1t v\u00e0o ph\u00e1t tri\u1ec3n trong d\u1ea1 d\u00e0y v\u00e0 l\u00e0 ngu\u1ed3n d\u1ef1 tr\u1eef vi khu\u1ea9n g\u00e2y vi\u00eam ph\u1ed5i khi c\u00f3 t\u00ecnh tr\u1ea1ng tr\u00e0o ng\u01b0\u1ee3c. Nu\u00f4i \u0103n qua \u0111\u01b0\u1eddng ti\u00eau h\u00f3a c\u00f3 th\u1ec3 g\u00e2y l\u00e2y ch\u00e9o vi khu\u1ea9n th\u00f4ng qua qu\u00e1 tr\u00ecnh chu\u1ea9n b\u1ecb dung d\u1ecbch nu\u00f4i \u0103n v\u00e0 l\u00e0m cho pH d\u1ea1 d\u00e0y t\u0103ng l\u00ean, ngo\u00e0i ra s\u1ef1 tr\u00e0o ng\u01b0\u1ee3c v\u00e0 vi\u00eam ph\u1ed5i h\u00edt d\u1ec5 x\u1ea3y ra khi d\u1ea1 d\u00e0y gia t\u0103ng v\u1ec1 th\u1ec3 t\u00edch v\u00e0 \u00e1p l\u1ef1c. 3. C\u00e1c y\u1ebfu t\u1ed1 m\u00f4i tr\u01b0\u1eddng, d\u1ee5ng c\u1ee5: + L\u00e2y truy\u1ec1n c\u00e1c vi khu\u1ea9n g\u00e2y VPBV nh\u01b0 tr\u1ef1c khu\u1ea9n Gram \u00e2m v\u00e0 t\u1ee5 c\u1ea7u qua b\u00e0n tay c\u1ee7a NVYT b\u1ecb nhi\u1ec5m b\u1ea9n th\u00f4ng qua c\u00e1c thao t\u00e1c nh\u01b0 h\u00fat \u0111\u1eddm, c\u1ea7m v\u00e0o d\u00e2y m\u00e1y th\u1edf, v\u00e0o \u1ed1ng n\u1ed9i kh\u00ed qu\u1ea3n. V\u00ec th\u1ebf NVYT ph\u1ea3i tuy\u1ec7t \u0111\u1ed1i ch\u00fa \u00fd \u0111\u1ebfn v\u1ea5n \u0111\u1ec1 r\u1eeda tay, mang g\u0103ng khi ch\u0103m s\u00f3c ng\u01b0\u1eddi b\u1ec7nh, \u0111\u1eb7c bi\u1ec7t t\u1ea1i c\u00e1c khoa\/\u0111\u01a1n v\u1ecb HSTC. L\u00e2y truy\u1ec1n c\u00e1c vi sinh v\u1eadt g\u00e2y VPBV qua d\u1ee5ng c\u1ee5 kh\u00f4ng \u0111\u01b0\u1ee3c kh\u1eed t\u1ecb\u1ec7t khu\u1ea9n \u0111\u00fang quy c\u00e1ch L\u00e2y truy\u1ec1n c\u00e1c vi sinh v\u1eadt g\u00e2y VPBV qua m\u00f4i tr\u01b0\u1eddng kh\u00f4ng kh\u00ed, qua b\u1ec1 m\u1eb7t b\u1ecb nhi\u1ec5m. IV. CH\u1ea8N \u0110O\u00c1N 1. Ch\u1ea5n \u0111o\u00e1n x\u00e1c \u0111\u1ecbnh Ti\u00eau chu\u1ea9n 1: Vi\u00eam ph\u1ed5i x\u00e1c \u0111\u1ecbnh tr\u00ean l\u00e2m s\u00e0ng Ti\u00eau chu\u1ea9n 2: Vi\u00eam ph\u1ed5i do nh\u01b0ng vi khu\u1ea9n th\u01b0\u1eddng g\u1eb7p Ti\u00eau chu\u1ea9n 3: Vi\u00eam ph\u1ed5i tr\u00ean nh\u01b0ng ng\u01b0\u1eddi b\u1ec7nh suy gi\u1ea3m mi\u1ec5n d\u1ecbch Vi\u00eam ph\u1ed5i x\u00e1c \u0111\u1ecbnh tr\u00ean l\u00e2m s\u00e0ng L\u00c2M S\u00c0NG XQUANG C\u00f3 \u00edt nh\u1ea5t m\u1ed9t trong c\u00e1c tri\u1ec7u ch\u1ee9ng sau: Hai hay nhi\u1ec1u phim Xquang ph\u1ed5i c\u00f3 \u00edt nh\u1ea5t - S\u1ed1t (>38 C) m\u00e0 kh\u00f4ng c\u00f3 nguy\u00ean m\u1ed9t trong c\u00e1c d\u1ea5u hi\u1ec7u sau: nh\u00e2n n\u00e0o kh\u00e1c - Th\u00e2m nhi\u1ec5m m\u1edbi hay ti\u1ebfn tri\u1ec3n v\u00e0 k\u00e9o - BC gi\u1ea3m (< 4.000\/mm3) ho\u1eb7c t\u0103ng d\u00e0i (>12.000 mm3) - \u0110\u00f4ng \u0111\u1eb7c - Ng\u01b0\u1eddi l\u1edbn > 70 tu\u1ed5i c\u00f3 thay \u0111\u1ed5i tri 100","gi\u00e1c m\u00e0 kh\u00f4ng c\u00f3 nguy\u00ean nh\u00e2n n\u00e0o - T\u1ea1o hang kh\u00e1c - Tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i - Ch\u00fa \u00fd: n\u1ebfu ng\u01b0\u1eddi b\u1ec7nh kh\u00f4ng c\u00f3 suy V\u00e0 gi\u1ea3m mi\u1ec5n d\u1ecbch, ch\u1ec9 c\u1ea7n c\u00f3 thay \u0111\u1ed5i \u00cdt nh\u1ea5t trong c\u00e1c tri\u1ec7u ch\u1ee9ng sau: tr\u00ean XQuang l\u00e0 c\u00f3 th\u1ec3 ch\u1ea9n \u0111o\u00e1n - Xu\u1ea5t hi\u1ec7n \u0111\u1eddm m\u1ee7 hay thay \u0111\u1ed5i t\u00ednh ch\u1ea5t c\u1ee7a \u0111\u00e0m hay t\u0103ng b\u00e0i ti\u1ebft hay gia t\u0103ng nhu c\u1ea7u c\u1ea7n h\u00fat \u0111\u1eddm - Xu\u1ea5t hi\u1ec7n ho ho\u1eb7c ho t\u0103ng l\u00ean, ho\u1eb7c kh\u00f3 th\u1edf ho\u1eb7c th\u1edf nhanh - C\u00f3 rales - Kh\u00ed m\u00e1u x\u1ea5u \u0111i ( v\u00ed d\u1ee5 PaO2\/FiO2 < 241) t\u0103ng nhu c\u1ea7u Oxygen ho\u1eb7c t\u0103ng nhu c\u1ea7u m\u00e1y th\u1edf Vi\u00eam ph\u1ed5i do nh\u1eefng vi khu\u1ea9n th\u01b0\u1eddng g\u1eb7p L\u00c2M S\u00c0NG XQUANG VI SINH C\u00f3 \u00edt nh\u1ea5t m\u1ed9t trong c\u00e1c tri\u1ec7u Hai hay nhi\u1ec1u C\u00f3 \u00edt nh\u1ea5t m\u1ed9t trong c\u00e1c k\u1ebft ch\u1ee9ng sau: phim Xquang qu\u1ea3 sau : - S\u1ed1t (>38 C) m\u00e0 kh\u00f4ng ph\u1ed5i c\u00f3 \u00edt nh\u1ea5t c\u00f3 nguy\u00ean nh\u00e2n n\u00e0o kh\u00e1c m\u1ed9t trong c\u00e1c - C\u1ea5y m\u00e1u d\u01b0\u01a1ng t\u00ednh kh\u00f4ng li\u00ean quan \u0111\u1ebfn c\u00e1c - BC gi\u1ea3m (< d\u1ea5u hi\u1ec7u sau: ngu\u1ed3n nhi\u1ec5m khu\u1ea9n kh\u00e1c 4.000\/mm3) ho\u1eb7c t\u0103ng - C\u1ea5y d\u1ecbch m\u00e0ng ph\u1ed5i (>12.000 mm3) - Th\u00e2m d\u01b0\u01a1ng t\u00ednh nhi\u1ec5m m\u1edbi - C\u1ea5y \u0111\u1ecbnh l\u01b0\u1ee3ng d\u01b0\u01a1ng - Ng\u01b0\u1eddi l\u1edbn > 70 tu\u1ed5i c\u00f3 hay ti\u1ebfn t\u00ednh b\u1eb1ng ph\u01b0\u01a1ng ph\u00e1p l\u1ea5y thay \u0111\u1ed5i tri gi\u00e1c m\u00e0 kh\u00f4ng tri\u1ec3n v\u00e0 k\u00e9o \u0111\u1eddm qua r\u1eeda ph\u1ebf nang hay c\u00f3 nguy\u00ean nh\u00e2n n\u00e0o kh\u00e1c ch\u1ea3i c\u00f3 b\u1ea3o v\u1ec7 d\u00e0i - Soi t\u01b0\u01a1i tr\u1ef1c ti\u1ebfp V\u00e0 - \u0110\u00f4ng \u0111\u1eb7c (nhu\u1ed9m Gram) c\u00f3 > 5% t\u1ebf - T\u1ea1o hang b\u00e0o t\u1eed r\u1eeda ph\u1ebf nang c\u00f3 ch\u1ee9a \u00cdt nh\u1ea5t trong c\u00e1c tri\u1ec7u ch\u1ee9ng - Tr\u00e0n d\u1ecbch vi khu\u1ea9n n\u1ed9i b\u00e0o sau: m\u00e0ng ph\u1ed5i M\u00f4 h\u1ecdc c\u00f3 \u00edt nh\u1ea5t 1 trong c\u00e1c - Xu\u1ea5t hi\u1ec7n \u0111\u1eddm m\u1ee7 hay Ch\u00fa \u00fd: n\u1ebfu thay \u0111\u1ed5i t\u00ednh ch\u1ea5t c\u1ee7a \u0111\u00e0m ng\u01b0\u1eddi b\u1ec7nh tri\u1ec7u ch\u1ee9ng vi\u00eam ph\u1ed5i hay t\u0103ng b\u00e0i ti\u1ebft hay gia kh\u00f4ng c\u00f3 b\u1ec7nh t\u0103ng nhu c\u1ea7u c\u1ea7n h\u00fat \u0111\u1eddm ph\u1ed5i ho\u1eb7c b\u1ec7nh - T\u1ea1o abces, hang hay \u0111\u00f4ng \u0111\u1eb7c c\u00f3 t\u00edch t\u1ee5 bach c\u1ea7u - Xu\u1ea5t hi\u1ec7n ho ho\u1eb7c ho tim \u0111i k\u00e8m \u0111a nh\u00e2n trung t\u00ednh trong ti\u1ec3u t\u0103ng l\u00ean, ho\u1eb7c kh\u00f3 th\u1edf ph\u1ebf qu\u1ea3n ho\u1eb7c th\u1edf nhanh (COPD, suy - C\u1ea5y nhu m\u00f4 ph\u1ed5i \u0111\u1ecbnh tim), ch\u1ec9 c\u1ea7n l\u01b0\u1ee3ng d\u01b0\u01a1ng t\u00ednh - C\u00f3 rales m\u1ed9t XQuang - B\u1eb1ng ch\u1ee9ng x\u00e2m l\u1ea5n - Kh\u00ed m\u00e1u x\u1ea5u \u0111i ( v\u00ed d\u1ee5 nhu m\u00f4 ph\u1ed5i do n\u1ea5m fungal PaO2\/FiO2 < 241) t\u0103ng thay \u0111\u1ed5i l\u00e0 c\u00f3 hyphae ho\u1eb7c pseudohyphae nhu c\u1ea7u Oxygen ho\u1eb7c t\u0103ng th\u1ec3 ch\u1ea9n \u0111o\u00e1n nhu c\u1ea7u m\u00e1y th\u1edf Vi\u00eam ph\u1ed5i do virus, Legionella v\u00e0 nh\u1eefng vi khu\u1ea9n kh\u00e1c L\u00c2M S\u00c0NG XQUANG VI SINH C\u00f3 \u00edt nh\u1ea5t m\u1ed9t trong c\u00e1c tri\u1ec7u Hai hay nhi\u1ec1u C\u00f3 \u00edt nh\u1ea5t m\u1ed9t trong c\u00e1c k\u1ebft ch\u1ee9ng sau: phim Xquang qu\u1ea3 sau : 101","- S\u1ed1t (>38 C) m\u00e0 kh\u00f4ng ph\u1ed5i c\u00f3 \u00edt nh\u1ea5t - C\u1ea5y d\u01b0\u01a1ng t\u00ednh v\u1edbi c\u00f3 nguy\u00ean nh\u00e2n n\u00e0o kh\u00e1c virus ho\u1eb7c Chlamydia t\u1eeb d\u1ecbch m\u1ed9t trong c\u00e1c ti\u1ebft h\u00f4 h\u1ea5p - BC gi\u1ea3m (< 4.000\/mm3) ho\u1eb7c t\u0103ng d\u1ea5u hi\u1ec7u sau: - Ph\u00e1t hi\u1ec7n d\u01b0\u01a1ng t\u00ednh (>12.000 mm3) v\u1edbi kh\u00e1ng nguy\u00ean virus hay - Th\u00e2m kh\u00e1ng th\u1ec3 t\u1eeb d\u1ecbch ti\u1ebft h\u00f4 h\u1ea5p - Ng\u01b0\u1eddi l\u1edbn > 70 tu\u1ed5i c\u00f3 nhi\u1ec5m m\u1edbi (v\u00ed d\u1ee5 EIA. FAMA, shell vial thay \u0111\u1ed5i tri gi\u00e1c m\u00e0 kh\u00f4ng hay ti\u1ebfn c\u00f3 nguy\u00ean nh\u00e2n n\u00e0o kh\u00e1c tri\u1ec3n v\u00e0 k\u00e9o assay, PCR) V\u00e0 d\u00e0i - \u0110\u00f4ng \u0111\u1eb7c \u00cdt nh\u1ea5t trong c\u00e1c tri\u1ec7u ch\u1ee9ng - T\u1ea1o hang sau: - Tr\u00e0n d\u1ecbch - Xu\u1ea5t hi\u1ec7n \u0111\u1eddm m\u1ee7 hay m\u00e0ng ph\u1ed5i thay \u0111\u1ed5i t\u00ednh ch\u1ea5t c\u1ee7a \u0111\u00e0m Ch\u00fa \u00fd: n\u1ebfu hay t\u0103ng b\u00e0i ti\u1ebft hay gia t\u0103ng nhu c\u1ea7u c\u1ea7n h\u00fat \u0111\u1eddm ng\u01b0\u1eddi b\u1ec7nh - Xu\u1ea5t hi\u1ec7n ho ho\u1eb7c ho kh\u00f4ng c\u00f3 b\u1ec7nh t\u0103ng l\u00ean, ho\u1eb7c kh\u00f3 th\u1edf ho\u1eb7c th\u1edf nhanh ph\u1ed5i ho\u1eb7c b\u1ec7nh - C\u00f3 rales tim \u0111i k\u00e8m - Kh\u00ed m\u00e1u x\u1ea5u \u0111i ( v\u00ed d\u1ee5 PaO2\/FiO2 < 241) t\u0103ng (COPD, suy nhu c\u1ea7u Oxygen ho\u1eb7c t\u0103ng nhu c\u1ea7u m\u00e1y th\u1edf tim), ch\u1ec9 c\u1ea7n m\u1ed9t XQuang thay \u0111\u1ed5i l\u00e0 c\u00f3 th\u1ec3 ch\u1ea9n \u0111o\u00e1n Vi\u00eam ph\u1ed5i tr\u00ean nh\u1eefng ng\u01b0\u1eddi b\u1ec7nh suy gi\u1ea3m mi\u1ec5n d\u1ecbch L\u00c2M S\u00c0NG XQUANG VI SINH \u00cdt nh\u1ea5t 1 trong c\u00e1c tri\u1ec7u \u2265 1 phim Xquang ph\u1ed5i c\u00f3 \u00cdt nh\u1ea5t m\u1ed9t trong c\u00e1c tri\u1ec7u ch\u1ee9ng sau tr\u00ean ng\u01b0\u1eddi \u00edt nh\u1ea5t m\u1ed9t trong c\u00e1c d\u1ea5u ch\u1ee9ng sau: b\u1ec7nh suy gi\u1ea3m mi\u1ec5n d\u1ecbch: hi\u1ec7u sau : \u2022 S\u1ed1t (> 380C ) m\u00e0 kh\u00f4ng \u2022 Th\u00e2m nhi\u1ec5m m\u1edbi hay \u2022 C\u1ea5y m\u00e1u v\u00e0 \u0111\u1eddm d\u01b0\u01a1ng ti\u1ebfn tri\u1ec3n v\u00e0 k\u00e9o d\u00e0i t\u00ednh v\u1edbi Candida spp c\u00f3 nguy\u00ean nh\u00e2n n\u00e0o kh\u00e1c \u2022 \u0110\u00f4ng \u0111\u1eb7c \u2022 Ng\u01b0\u1eddi l\u1edbn > 70 tu\u1ed5i c\u00f3 \u2022 T\u1ea1o hang \u2022 B\u1eb1ng ch\u1ee9ng n\u1ea5m hay thay \u0111\u1ed5i tri gi\u00e1c m\u00e0 \u2022 Tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i Pneumocytis carinii t\u1eeb b\u1ec7nh ph\u1ea9m \u0111\u01b0\u1eddng h\u00f4 h\u1ea5p kh\u00f4ng c\u00f3 nguy\u00ean nh\u00e2n d\u01b0\u1edbi nh\u01b0 r\u1eeda ph\u1ebf nang hay ch\u1ea3i c\u00f3 b\u1ea3o v\u1ec7 qua m\u1ed9t n\u00e0o kh\u00e1c trong c\u00e1c ph\u01b0\u01a1ng ph\u00e1p \u2022 Xu\u1ea5t hi\u1ec7n \u0111\u1eddm m\u1ee7 hay thay \u0111\u1ed5i t\u00ednh ch\u1ea5t c\u1ee7a sau: \u0111\u00e0m hay t\u0103ng b\u00e0i ti\u1ebft hay - Soi tr\u1ef1c ti\u1ebfp gia t\u0103ng nhu c\u1ea7u c\u1ea7n h\u00fat - C\u1ea5y n\u1ea5m d\u01b0\u01a1ng \u0111\u1eddm t\u00ednh \u2022 Xu\u1ea5t hi\u1ec7n ho ho\u1eb7c ho t\u0103ng l\u00ean, ho\u1eb7c kh\u00f3 th\u1edf ho\u1eb7c th\u1edf nhanh \u2022 C\u00f3 rales \u2022 Kh\u00ed m\u00e1u x\u1ea5u \u0111i (v\u00ed d\u1ee5 PaO2 \/FiO2 102","2. Ch\u1ea9n \u0111o\u00e1n nguy\u00ean nh\u00e2n: - D\u1ef1a v\u00e0o c\u1ea5y b\u00e1n \u0111\u1ecbnh l\u01b0\u1ee3ng b\u1ec7nh ph\u1ea9m kh\u00f4ng x\u00e2m nh\u1eadp - C\u00e1c t\u00e1c nh\u00e2n g\u00e2y VPBV th\u01b0\u1eddng g\u1eb7p l\u00e0 Acinetobacter baumanii, Pseudomonas aeruginosa, Klebsiella pneumoniae, Escherichia coli, Staphylococcus aureus - Nguy c\u01a1 nhi\u1ec5m vi khu\u1ea9n \u0111a kh\u00e1ng trong VPBV: \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh t\u0129nh m\u1ea1ch trong v\u00f2ng 90 ng\u00e0y tr\u01b0\u1edbc \u0111\u00f3 - Nguy c\u01a1 nhi\u1ec5m vi khu\u1ea9n \u0111a kh\u00e1ng trong VP li\u00ean quan th\u1edf m\u00e1y: o \u0110i\u1ec1u tr\u1ecb kh\u00e1ng sinh t\u0129nh m\u1ea1ch trong v\u00f2ng 90 ng\u00e0y tr\u01b0\u1edbc \u0111\u00f3 o S\u1ed1c nhi\u1ec5m khu\u1ea9n t\u1ea1i th\u1eddi \u0111i\u1ec3m ch\u1ea9n \u0111o\u00e1n vi\u00eam ph\u1ed5i li\u00ean quan th\u1edf m\u00e1y o N\u1eb1m vi\u1ec7n qu\u00e1 5 ng\u00e0y o L\u1ecdc m\u00e1u c\u1ea5p c\u1ee9u 3. Ch\u1ea9n \u0111o\u00e1n m\u1ee9c \u0111\u1ed9 n\u1eb7ng: - VPBV m\u1ee9c \u0111\u1ed9 n\u1eb7ng: c\u00f3 suy h\u00f4 h\u1ea5p v\u00e0\/ho\u1eb7c t\u1ee5t huy\u1ebft \u00e1p - VP li\u00ean quan th\u1edf m\u00e1y m\u1ee9c \u0111\u1ed9 n\u1eb7ng: PaO2\/FiO2 gi\u1ea3m n\u1eb7ng v\u00e0\/ho\u1eb7c t\u1ee5t huy\u1ebft \u00e1p - B\u1ec7nh nh\u00e2n c\u00f3 nhi\u1ec5m khu\u1ea9n huy\u1ebft ho\u1eb7c vi\u00eam ph\u1ed5i do vi khu\u1ea9n \u0111a kh\u00e1ng - B\u1ec7nh nh\u00e2n c\u00f3 c\u00e1c b\u1ec7nh l\u00ed n\u1eb7ng kh\u00e1c \u0111i k\u00e8m theo V. \u0110I\u1ec0U TR\u1eca 1. Nguy\u00ean t\u1eafc: - \u0110i\u1ec1u tr\u1ecb kh\u00e1ng sinh c\u00e0ng s\u1edbm c\u00e0ng t\u1ed1t, trong v\u00f2ng 1 gi\u1edd \u0111\u1ea7u n\u1ebfu c\u00f3 k\u00e8m s\u1ed1c nhi\u1ec5m khu\u1ea9n. Khi ngh\u0129 \u0111\u1ebfn VPBV, khuy\u1ebfn c\u00e1o hi\u1ec7n n\u00e0y l\u00e0 d\u1ef1a v\u00e0o ti\u00eau chu\u1ea9n l\u00e2m s\u00e0ng \u0111\u01a1n thu\u1ea7n, h\u01a1n l\u00e0 d\u1ef1a v\u00e0o thay \u0111\u1ed5i n\u1ed3ng \u0111\u1ed9 procalcitonin\/CRP k\u1ebft h\u1ee3p v\u1edbi ti\u00eau chu\u1ea9n l\u00e2m s\u00e0ng \u0111\u1ec3 quy\u1ebft \u0111\u1ecbnh kh\u00e1ng sinh ban \u0111\u1ea7u. - \u0110i\u1ec1u tr\u1ecb kh\u00e1ng sinh ban \u0111\u1ea7u theo kinh nghi\u1ec7m: o Kh\u00e1ng sinh \u0111\u01b0\u1ee3c ch\u1ecdn ph\u1ea3i bao ph\u1ee7 \u0111\u01b0\u1ee3c c\u00e1c vi khu\u1ea9n c\u00f3 kh\u1ea3 n\u0103ng l\u00e0 t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh o L\u1ef1a ch\u1ecdn kh\u00e1ng sinh ban \u0111\u1ea7u c\u0169ng c\u1ea7n d\u1ef1a v\u00e0o m\u1ee9c \u0111\u1ed9 n\u1eb7ng c\u1ee7a vi\u00eam ph\u1ed5i v\u00e0 nguy c\u01a1 nhi\u1ec5m vi khu\u1ea9n \u0111a kh\u00e1ng o Li\u1ec1u l\u01b0\u1ee3ng v\u00e0 c\u00e1ch d\u00f9ng thu\u1ed1c ph\u1ea3i tu\u00e2n th\u1ee7 nguy\u00ean t\u1eafc d\u01b0\u1ee3c l\u1ef1c v\u00e0 d\u01b0\u1ee3c \u0111\u1ed9ng h\u1ecdc c\u1ee7a kh\u00e1ng sinh \u0111\u01b0\u1ee3c d\u00f9ng - \u0110i\u1ec1u ch\u1ec9nh kh\u00e1ng sinh khi c\u00f3 k\u1ebft qu\u1ea3 x\u00e9t nghi\u1ec7m vi khu\u1ea9n v\u00e0 kh\u00e1ng sinh \u0111\u1ed3: o \u0110\u00e1nh gi\u00e1 hi\u1ec7u qu\u1ea3 \u0111i\u1ec1u tr\u1ecb ban \u0111\u1ea7u sau 48-72 gi\u1edd o N\u1ebfu b\u1ec7nh nh\u00e2n \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb v\u00e0 kh\u00e1ng sinh ban \u0111\u1ea7u ph\u00f9 h\u1ee3p v\u1edbi kh\u00e1ng sinh \u0111\u1ed3 th\u00ec gi\u1eef nguy\u00ean kh\u00e1ng sinh \u0111ang \u0111i\u1ec1u tr\u1ecb v\u00e0 xem x\u00e9t xu\u1ed1ng thang kh\u00e1ng sinh. L\u01b0u \u00fd: \u0111\u00e1p \u1ee9ng l\u00e2m s\u00e0ng c\u00f3 \u00fd ngh\u0129a quan tr\u1ecdng o N\u1ebfu b\u1ec7nh nh\u00e2n kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb m\u1eb7c d\u00f9 kh\u00e1ng sinh \u0111ang d\u00f9ng ph\u00f9 h\u1ee3p v\u1edbi k\u1ebft qu\u1ea3 kh\u00e1ng sinh \u0111\u1ed3, c\u1ea7n l\u00e0m l\u1ea1i x\u00e9t nghi\u1ec7m vi sinh, t\u00ecm \u1ed5 di b\u1ec7nh ho\u1eb7c 1 nguy\u00ean nh\u00e2n g\u00e2y s\u1ed1t kh\u00e1c (n\u1ea5m...) - Th\u1eddi gian d\u00f9ng kh\u00e1ng sinh o Th\u00f4ng th\u01b0\u1eddng l\u00e0 7 ng\u00e0y. C\u00f3 th\u1ec3 k\u00e9o d\u00e0i \u0111\u1ebfn 15-21 ng\u00e0y t\u00f9y lo\u1ea1i vi khu\u1ea9n g\u00e2y b\u1ec7nh v\u00e0 c\u01a1 \u0111\u1ecba b\u1ec7nh nh\u00e2n o Quy\u1ebft \u0111\u1ecbnh ng\u1eebng kh\u00e1ng sinh d\u1ef1a v\u00e0o l\u00e2m s\u00e0ng v\u00e0 k\u1ebft qu\u1ea3 x\u00e9t nghi\u1ec7m procalcitonin, n\u1ed3ng \u0111\u1ed9 procalcitonin \u0111\u01b0\u1ee3c khuy\u1ebfn c\u00e1o \u0111\u1ec3 xem x\u00e9t ng\u1eebng kh\u00e1ng sinh l\u00e0 0.25 \u2013 0.5 ng\/l\u00edt 2. \u0110i\u1ec1u tr\u1ecb kh\u00e1ng sinh ban \u0111\u1ea7u theo kinh nghi\u1ec7m: 103","Vi\u00eam ph\u1ed5i b\u1ec7nh vi\u1ec7n kh\u00f4ng Vi\u00eam ph\u1ed5i b\u1ec7nh vi\u1ec7n Vi\u00eam ph\u1ed5i b\u1ec7nh vi\u1ec7n kh\u00f4ng ph\u1ea3i ph\u1ea3i m\u1ee9c \u0111\u1ed9 n\u1eb7ng v\u00e0 kh\u00f4ng Vi\u00eam ph\u1ed5i b\u1ec7nh vi\u1ec7n m\u1ee9c \u0111\u1ed9 m\u1ee9c \u0111\u1ed9 n\u1eb7ng nh\u01b0ng c\u00f3 nguy c\u01a1 c\u00f3 nguy c\u01a1 nhi\u1ec5m vi khu\u1ea9n n\u1eb7ng ho\u1eb7c c\u00f3 nguy c\u01a1 nhi\u1ec5m vi nhi\u1ec5m Staphylococcus aureus \u0111a kh\u00e1ng khu\u1ea9n \u0111a kh\u00e1ng kh\u00e1ng methicillin M\u1ed9t trong nh\u1eefng l\u1ef1a ch\u1ecdn Hai trong c\u00e1c l\u1ef1a ch\u1ecdn sau, M\u1ed9t trong nh\u1eefng l\u1ef1a ch\u1ecdn sau sau tr\u00e1nh d\u00f9ng 2 beta lactam + Piperacillin-tazobactam 4,5g + Piperacillin-tazobactam 4,5g + Piperacillin-tazobactam 4,5g TTM trong 3 gi\u1edd, m\u1ed7i 6 gi\u1edd TTM trong 3 gi\u1edd, m\u1ed7i 6 gi\u1edd TTM trong 3 gi\u1edd, m\u1ed7i 6 gi\u1edd HO\u1eb6C HO\u1eb6C HO\u1eb6C + Cefepime 2g TTM trong 3 + Cefepime ho\u1eb7c Ceftazidime 2g + Cefepime 2g TTM trong 3 gi\u1edd, gi\u1edd, m\u1ed7i 8 gi\u1edd TTM trong 3 gi\u1edd, m\u1ed7i 8 gi\u1edd m\u1ed7i 8 gi\u1edd HO\u1eb6C + Levofloxacin + Levofloxacin + Levofloxacin - 750 mg TTM m\u1ed7i 24 - 750 mg TTM m\u1ed7i 24 gi\u1edd - 750 mg TTM m\u1ed7i 24 gi\u1edd gi\u1edd - Ho\u1eb7c 500mg TTM m\u1ed7i 12 - Ho\u1eb7c 500mg TTM m\u1ed7i 12 gi\u1edd - Ho\u1eb7c 500mg TTM m\u1ed7i gi\u1edd trong nhi\u1ec5m khu\u1ea9n n\u1eb7ng 12 gi\u1edd trong nhi\u1ec5m khu\u1ea9n + Ciprofloxacin 400mg TTM m\u1ed7i trong nhi\u1ec5m khu\u1ea9n n\u1eb7ng n\u1eb7ng + Ciprofloxacin 400mg TTM m\u1ed7i 8 8 gi\u1edd gi\u1edd HO\u1eb6C HO\u1eb6C HO\u1eb6C + Imipenem 500 mg TTM + Imipenem 500 mg TTM trong 3 + Imipenem 500 mg TTM trong 3 trong 3 gi\u1edd m\u1ed7i 6 gi\u1edd gi\u1edd m\u1ed7i 6 gi\u1edd gi\u1edd m\u1ed7i 6 gi\u1edd + Meropenem 1g TTM trong 4 gi\u1edd + Meropenem 1g TTM trong 4 + Meropenem 1g TTM trong 4 m\u1ed7i 8 gi\u1edd gi\u1edd m\u1ed7i 8 gi\u1edd gi\u1edd m\u1ed7i 8 gi\u1edd + Doripenem 0,5 \u2013 1g TTM trong 4 + Doripenem 0,5 \u2013 1g TTM trong gi\u1edd m\u1ed7i 8 gi\u1edd 4 gi\u1edd m\u1ed7i 8 gi\u1edd HO\u1eb6C HO\u1eb6C + Amikacin 15-20 mg\/kg TTM Aztreonam 2g TTM m\u1ed7i 8 gi\u1edd m\u1ed7i 24 gi\u1edd + Gentamycin 5-7 mg\/kg TTM m\u1ed7i 24 gi\u1edd + Tobramycin 5-7 mg\/kg TTM m\u1ed7i 24 gi\u1edd HO\u1eb6C Aztreonam 2g TTM m\u1ed7i 8 gi\u1edd Xem x\u00e9t k\u1ebft h\u1ee3p K\u1ebft h\u1ee3p + Vancomycin 15-20 mg\/kg TTM + Vancomycin 15-20 mg\/kg TTM trong 1-2 gi\u1edd, m\u1ed7i 8-12 gi\u1edd trong 1-2 gi\u1edd, m\u1ed7i 8-12 gi\u1edd 104","(C\u00f3 th\u1ec3 d\u00f9ng li\u1ec1u n\u1ea1p 25-30 (C\u00f3 th\u1ec3 d\u00f9ng li\u1ec1u n\u1ea1p 25-30 mg\/kg mg\/kg 1 l\u1ea7n v\u1edbi nh\u1eefng tr\u01b0\u1eddng h\u1ee3p 1 l\u1ea7n v\u1edbi nh\u1eefng tr\u01b0\u1eddng h\u1ee3p n\u1eb7ng) n\u1eb7ng) HO\u1eb6C HO\u1eb6C + Teicoplanin Li\u1ec1u n\u1ea1p: 6 mg\/kg\/12 gi\u1edd TTM + Teicoplanin trong 30 ph\u00fat \u2013 1 gi\u1edd. Truy\u1ec1n 3 li\u1ec1u Li\u1ec1u n\u1ea1p: 6 mg\/kg\/12 gi\u1edd TTM Li\u1ec1u duy tr\u00ec: 6 mg\/kg\/24 gi\u1edd trong 30 ph\u00fat \u2013 1 gi\u1edd. Truy\u1ec1n 3 (400mg) TTM trong 30 ph\u00fat- 1 gi\u1edd li\u1ec1u Li\u1ec1u duy tr\u00ec: 6 mg\/kg\/24 gi\u1edd HO\u1eb6C (400mg) TTM trong 30 ph\u00fat- 1 gi\u1edd HO\u1eb6C Linezolide 600 mg TTM m\u1ed7i 12 Linezolide 600 mg TTM m\u1ed7i 12 gi\u1edd gi\u1edd Vi\u00eam ph\u1ed5i li\u00ean quan th\u1edf m\u00e1y Kh\u00e1ng sinh t\u00e1c d\u1ee5ng tr\u00ean vi Kh\u00e1ng sinh t\u00e1c d\u1ee5ng tr\u00ean vi Kh\u00e1ng sinh t\u00e1c d\u1ee5ng tr\u00ean vi khu\u1ea9n Gram d\u01b0\u01a1ng - khu\u1ea9n Gram \u00e2m, khu\u1ea9n Gram \u00e2m, Staphylococcus aureus Pseudomonas aeruginosa \u2013 Pseudomonas aeruginosa \u2013 Nh\u00f3m kh\u00f4ng ph\u1ea3i beta kh\u00e1ng methicillin Nh\u00f3m beta lactam lactam Nh\u00f3m Glycopeptides: C\u00e1c penicillin kh\u00e1ng C\u00e1c fluoroquinolone: Pseudomonas aeruginosa: + Levofloxacin + Vancomycin 15-20 mg\/kg Piperacillin-tazobactam 4,5g TTM trong 1-2 gi\u1edd, m\u1ed7i 8-12 TTM trong 3 gi\u1edd, m\u1ed7i 6 gi\u1edd - 750 mg TTM m\u1ed7i 24 gi\u1edd gi\u1edd (C\u00f3 th\u1ec3 d\u00f9ng li\u1ec1u n\u1ea1p 25-30 HO\u1eb6C - Ho\u1eb7c 500mg TTM mg\/kg 1 l\u1ea7n v\u1edbi nh\u1eefng tr\u01b0\u1eddng m\u1ed7i 12 gi\u1edd trong nhi\u1ec5m h\u1ee3p n\u1eb7ng) khu\u1ea9n n\u1eb7ng HO\u1eb6C + Ciprofloxacin 400mg TTM m\u1ed7i 8 gi\u1edd + Teicoplanin Li\u1ec1u n\u1ea1p: 6 mg\/kg\/12 gi\u1edd HO\u1eb6C TTM trong 30 ph\u00fat \u2013 1 gi\u1edd. Truy\u1ec1n 3 li\u1ec1u Li\u1ec1u duy tr\u00ec: 6 mg\/kg\/24 gi\u1edd (400mg) TTM trong 30 ph\u00fat- 1 gi\u1edd HO\u1eb6C Oxazolidinones: C\u00e1c cephalosporin: C\u00e1c aminoglycoside: Linezolide 600 mg TTM m\u1ed7i 12 gi\u1edd + Cefepime 2g TTM trong 3 + Amikacin 15-20 mg\/kg gi\u1edd, m\u1ed7i 8 gi\u1edd TTM m\u1ed7i 24 gi\u1edd + Ceftazidime 2g TTM trong + Gentamycin 5-7 mg\/kg 3 gi\u1edd, m\u1ed7i 8 gi\u1edd TTM m\u1ed7i 24 gi\u1edd + Tobramycin 5-7 mg\/kg 105","HO\u1eb6C TTM m\u1ed7i 24 gi\u1edd HO\u1eb6C C\u00e1c carbapenem: C\u00e1c polymyxin: + Imipenem 500 mg TTM + Colistin trong 3 gi\u1edd m\u1ed7i 6 gi\u1edd Li\u1ec1u n\u1ea1p: 5 mg\/kg x 1 l\u1ea7n Li\u1ec1u duy tr\u00ec: 2,5 mg\/kg x (1,5 + Meropenem 1g TTM trong x \u0110\u1ed9 thanh th\u1ea3i creatinin + 4 gi\u1edd m\u1ed7i 8 gi\u1edd 30) TTM m\u1ed7i 12 gi\u1edd + Doripenem 0,5 \u2013 1g TTM trong 4 gi\u1edd m\u1ed7i 8 gi\u1edd + Polymyxin B 2,5-3 mg\/kg\/ng\u00e0y chia 2 l\u1ea7n TTM HO\u1eb6C C\u00e1c monobactam: Aztreonam 2g TTM m\u1ed7i 8 gi\u1edd VI. D\u1ef0 PH\u00d2NG 1. V\u1ec7 sinh tay tr\u01b0\u1edbc v\u00e0 sau khi ti\u1ebfp x\u00fac ng\u01b0\u1eddi b\u1ec7nh v\u00e0 b\u1ea5t k\u1ef3 d\u1ee5ng c\u1ee5 h\u00f4 h\u1ea5p \u0111ang s\u1eed d\u1ee5ng cho ng\u01b0\u1eddi b\u1ec7nh 2. V\u1ec7 sinh r\u0103ng mi\u1ec7ng b\u1eb1ng b\u00e0n ch\u1ea3i ng\u00e0y l\u1ea7n ho\u1eb7c b\u1eb1ng g\u1ea1c m\u1ed7i 4 gi\u1edd l\u1ea7n b\u1eb1ng dung d\u1ecbch kh\u1eed khu\u1ea9n 3. R\u00fat c\u00e1c \u1ed1ng n\u1ed9i kh\u00ed qu\u1ea3n, \u1ed1ng m\u1edf kh\u00ed qu\u1ea3n, \u1ed1ng nu\u00f4i \u0103n, cai m\u00e1y th\u1edf c\u00e0ng s\u1edbm c\u00e0ng t\u1ed1t khi c\u00f3 ch \u0111\u1ecbnh 4. N\u1eb1m \u0111\u1ea7u cao 30 -45O n\u1ebfu kh\u00f4ng c\u00f3 ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh 5. N\u00ean s\u1eed d\u1ee5ng d\u1ee5ng c\u1ee5 ch\u0103m s\u00f3c h\u00f4 h\u1ea5p d\u00f9ng m\u1ed9t l\u1ea7n ho\u1eb7c ti\u1ec7t khu\u1ea9n kh\u1eed khu\u1ea9n m\u1ee9c \u0111\u1ed9 cao c\u00e1c d\u1ee5ng c\u1ee5 s\u1eed d\u1ee5ng l\u1ea1i 6. \u0110\u1ed5 n\u01b0\u1edbc t\u1ed3n l\u01b0u trong \u1ed1ng d\u00e2y m\u00e1y th\u1edf, b\u1eaby n\u01b0\u1edbc th\u01b0\u1eddng xuy\u00ean 7. D\u00e2y th\u1edf ph\u1ea3i \u0111\u1ec3 \u1edf v\u1ecb tr\u00ed th\u1ea5p h\u01a1n ph\u1ea7n tr\u00ean c\u1ee7a \u1ed1ng n\u1ed9i kh\u00ed qu\u1ea3n. 8. Th\u01b0\u1eddng xuy\u00ean ki\u1ec3m tra t\u00ecnh tr\u1ea1ng \u1ee9 \u0111\u1ecdng c\u1ee7a d\u1ea1 d\u00e0y tr\u01b0\u1edbc khi cho \u0103n qua \u1ed1ng 9. Gi\u00e1m s\u00e1t v\u00e0 ph\u1ea3n h\u1ed3i ca VPBV 106","L\u01afU \u0110\u1ed2 \u0110I\u1ec0U TR\u1eca NHI\u1ec4M CETON DO T\u0102NG \u0110\u01af\u1edcNG HUY\u1ebeT \u0110i\u1ec1u tr\u1ecb nhi\u1ec5m ceton do t\u0103ng \u0111\u01b0\u1eddng huy\u1ebft g\u1ed3m : \u25aa B\u00f9 n\u01b0\u1edbc v\u00e0 \u0111i\u1ec7n gi\u1ea3i \u25aa Insulin \u25aa B\u00f9 kali \u25aa B\u00f9 bicarbonat \u25aa \u0110i\u1ec1u tr\u1ecb c\u00e1c y\u1ebfu t\u1ed1 th\u00fac \u0111\u1ea9y v\u00e0 \u0111i\u1ec1u tr\u1ecb h\u1ed7 tr\u1ee3 1. B\u00f9 n\u01b0\u1edbc v\u00e0 \u0111i\u1ec7n gi\u1ea3i: D\u1ecbch truy\u1ec1n NaCl 0.9% 1L\/gi\u1edd \u0111\u1ea7u Ki\u1ec3m tra t\u00ecnh trang m\u1ea5t n\u01b0\u1edbc S\u1ed1c gi\u1ea3m th\u1ec3 t\u00edch H\u1ea1 HA nh\u1eb9 S\u1ed1c tim NaCl 0.9% (1L\/h) v\u00e0 T\u00ednh Na+ m\u00e1u \u0111\u1ec3 \u0111i\u1ec1u ch\u1ec9nh Theo d\u00f5i t\u00ecnh t\u1ea1ng \/ho\u1eb7c dd cao ph\u00e2n t\u1eed huy\u1ebft \u0111\u1ed9ng Truy\u1ec1n NaCl 0.45% Truy\u1ec1n NaCl 0.9% (4 \u2013 14 ml\/kg\/h) t\u00f9y m\u1ea5t n\u01b0\u1edbc (4 \u2013 14 ml\/kg\/h) t\u00f9y m\u1ea5t n\u01b0\u1edbc Khi Glucose trong m\u00e1u kho\u1ea3ng 250 mg\/dl Chuy\u1ec3n sang G5% v\u1edbi NaCl 0.45%, t\u1ed1c \u0111\u1ed9 160 \u2013 250ml\/h v\u00e0 Insulin TTM (0.05 \u2013 0.1 U\/kg\/h), duy tr\u00ec \u0110H 150 \u2013 200 mg\/dl 107","2. Insulin: Insulin Insulin nhanh bolus 10 \u2013 20 UI, sau \u0111\u00f3 TTM 0.1 UI\/kg\/h T\u0103ng g\u1ea5p \u0111\u00f4i li\u1ec1u Insulin n\u1ebfu \u0110H kh\u00f4ng gi\u1ea3m \u0111\u01b0\u1ee3c 50 \u2013 70 mg\/dl trong gi\u1edd \u0111\u1ea7u Khi Glucose m\u00e1u <250 mg\/dl Insulin TTM (0.05 \u2013 0.1 UI\/kg\/h) + G5% duy tr\u00ec \u0110H 150 \u2013 200 mg\/dl Ceton \u00e2m t\u00ednh, \u0103n u\u1ed1ng \u0111\u01b0\u1ee3c c\u00f3 th\u1ec3 chuy\u1ec3n sang Insulin TDD 3. B\u00f9 Kali: Kali m\u00e1u <3.3 mEq\/L 3.3 \u2013 5.5 mEq\/L >5.5 mEq\/L Truy\u1ec1n K+ 40 \u2013 50 Cho 20 \u2013 30 mEq\/L d\u1ecbch Kh\u00f4ng b\u00f9 K+, ki\u1ec3m mEq\/L tr\u01b0\u1edbc khi d\u00f9ng truy\u1ec1n TM. tra K+ m\u1ed7i 2 gi\u1edd Insulin. Gi\u1eef K+ \u1edf m\u1ee9c 4 \u2013 5 Th\u01b0\u1eddng tr\u00ec ho\u00e3n d\u00f9ng mEq\/L Insulin kho\u1ea3ng 60 -90 ph\u00fat cho \u0111\u1ebfn khi m\u1ee9c K+ \u0111\u01b0\u1ee3c b\u00f9 \u0111\u1ea7y \u0111\u1ee7 108","4. B\u00f9 Bicarbonate: \u0110\u00e1nh gi\u00e1 nhu c\u1ea7u Bicarbonate pH < 6.9 pH 6.9 \u2013 7.0 pH >7.0 NaHCO3 1.4% 400ml, NaHCO3 1.4% 200ml, Kh\u00f4ng b\u00f9 HCO3 TTM 200ml\/h TTM 200ml\/h v\u00ec gia t\u0103ng nguy c\u01a1 ki\u1ec1m chuy\u1ec3n h\u00f3a v\u00e0 g\u00e2y lo\u1ea1n nh\u1ecbp L\u1eb7p l\u1ea1i NaHCO3 m\u1ed7i 2h cho \u0111\u1ebfn khi pH > 7.0 Theo d\u00f5i K+ 5. \u0110i\u1ec1u tr\u1ecb c\u00e1c y\u1ebfu t\u1ed1 th\u00fac \u0111\u1ea9y v\u00e0 \u0111i\u1ec1u tr\u1ecb h\u1ed7 tr\u1ee3: N\u1ebfu nghi ng\u1edd c\u00f3 nhi\u1ec5m tr\u00f9ng th\u00ec d\u00f9ng ngay kh\u00e1ng sinh. Theo d\u00f5i m\u1ea1ch, nhi\u1ec7t, huy\u1ebft \u00e1p, nh\u1ecbp th\u1edf, n\u01b0\u1edbc ti\u1ec3u.... Theo d\u00f5i glucose m\u00e1u mao m\u1ea1ch m\u1ed7i 30-60p trong 4 gi\u1edd \u0111\u1ea7u, sau \u0111\u00f3 m\u1ed7i 2 gi\u1edd. Theo d\u00f5i \u0111i\u1ec7n gi\u1ea3i \u0111\u1ed3 m\u00e1u m\u1ed7i 2 gi\u1edd cho \u0111\u1ebfn khi \u1ed5n \u0111\u1ecbnh, sau \u0111\u00f3 m\u1ed7i 4 gi\u1edd T\u00e0i li\u1ec7u tham kh\u1ea3o: Ph\u00e1c \u0111\u1ed3 \u0111i\u1ec1u tr\u1ecb N\u1ed9i khoa 2013 \u2013 B\u1ec7nh vi\u1ec7n Ch\u1ee3 R\u1eaby 109","H\u1ea0 \u0110\u01af\u1edcNG HUY\u1ebeT I.\/ \u0110\u1ea0I C\u01af\u01a0NG Tri\u1ec7u ch\u1ee9ng h\u1ea1 glucose m\u00e1u th\u01b0\u1eddng x\u1ea3y ra khi l\u01b0\u1ee3ng glucose huy\u1ebft t\u01b0\u01a1ng c\u00f2n kho\u1ea3ng 2,7-3,3 mmol\/l. N\u1ebfu glucose huy\u1ebft t\u01b0\u01a1ng l\u00fac \u0111\u00f3i < 2,8 mmol\/l (50 mg\/dl) l\u00e0 h\u1ea1 glucose m\u00e1u n\u1eb7ng, c\u00f2n khi l\u01b0\u1ee3ng glucose m\u00e1u < 3,9 mmol\/l (< 70 mg\/dl) \u0111\u00e3 b\u1eaft \u0111\u1ea7u \u0111\u01b0\u1ee3c xem l\u00e0 c\u00f3 h\u1ea1 glucose m\u00e1u. II.\/ CH\u1ea8N \u0110O\u00c1N 1. Ch\u1ea9n \u0111o\u00e1n x\u00e1c \u0111\u1ecbnh ph\u1ea3i d\u1ef1a v\u00e0o x\u00e9t nghi\u1ec7m sinh h\u00f3a : Sinh ho\u00e1: Khi n\u1ed3ng \u0111\u1ed9 glucose m\u00e1u < 2,8mmol\/l (50 mg\/dl) l\u00e0 h\u1ea1 glucose m\u00e1u n\u1eb7ng, c\u00f2n khi glucose m\u00e1u <3,9mmol\/l (< 70mg\/dl) \u0111\u00e3 b\u1eaft \u0111\u1ea7u \u0111\u01b0\u1ee3c xem l\u00e0 c\u00f3 h\u1ea1 glucose m\u00e1u (h\u1ea1 glucose m\u00e1u sinh h\u00f3a). 2. L\u00e2m s\u00e0ng: C\u00f3 nhi\u1ec1u m\u1ee9c \u0111\u1ed9. 2.1. M\u1ee9c \u0111\u1ed9 nh\u1eb9 : Th\u01b0\u1eddng l\u00e0 c\u00e1c tri\u1ec7u ch\u1ee9ng v\u00e3 m\u1ed3 h\u00f4i, run ch\u00e2n tay v\u00e0 \u0111\u00f3i. \u0110\u00e2y l\u00e0 tri\u1ec7u ch\u1ee9ng c\u1ee7a h\u1ec7 th\u1ea7n kinh t\u1ef1 ch\u1ee7. C\u00e1c tri\u1ec7u ch\u1ee9ng n\u00e0y s\u1ebd m\u1ea5t \u0111i kho\u1ea3ng 10 -15 ph\u00fat sau khi \u0103n, u\u1ed1ng 10 \u2013 15 gram carbohydrate. \u1ede m\u1ee9c \u0111\u1ed9 n\u00e0y ng\u01b0\u1eddi b\u1ec7nh c\u00f3 kh\u1ea3 n\u0103ng t\u1ef1 \u0111i\u1ec1u tr\u1ecb \u0111\u01b0\u1ee3c. 2.2. M\u1ee9c \u0111\u1ed9 trung b\u00ecnh : \u1ede m\u1ee9c \u0111\u1ed9 n\u00e0y, c\u00f3 c\u00e1c tri\u1ec7u ch\u1ee9ng l\u00e2m s\u00e0ng do \u0111\u00e1p \u1ee9ng c\u1ee7a h\u1ec7 th\u1ed1ng th\u1ea7n kinh t\u1ef1 ch\u1ee7 v\u00e0 c\u1ee7a h\u1ec7 th\u1ea7n kinh trung \u01b0\u01a1ng v\u1edbi gi\u1ea3m l\u01b0\u1ee3ng glucose \u1edf m\u00f4 nh\u01b0: \u0111au \u0111\u1ea7u, thay \u0111\u1ed5i h\u00e0nh vi, d\u1ec5 b\u1ecb k\u00edch th\u00edch, gi\u1ea3m kh\u1ea3 n\u0103ng ch\u00fa \u00fd, ng\u1ee7 g\u00e0. Th\u00f4ng th\u01b0\u1eddng ng\u01b0\u1eddi b\u1ec7nh kh\u00f4ng \u0111\u1ee7 t\u1ec9nh t\u00e1o \u0111\u1ec3 k\u1ebft h\u1ee3p \u0111i\u1ec1u tr\u1ecb v\u1edbi th\u1ea7y thu\u1ed1c. Th\u1eddi gian ph\u1ee5c h\u1ed3i s\u1ebd l\u00e2u h\u01a1n. N\u1ebfu kh\u00f4ng can thi\u1ec7p k\u1ecbp th\u1eddi, ng\u01b0\u1eddi b\u1ec7nh c\u0169ng mau ch\u00f3ng chuy\u1ec3n sang m\u1ee9c n\u1eb7ng. 2.3. M\u1ee9c \u0111\u1ed9 n\u1eb7ng :L\u00fac n\u00e0y l\u01b0\u1ee3ng glucose m\u00e1u h\u1ea1 r\u1ea5t th\u1ea5p. Bi\u1ec3u hi\u1ec7n l\u00e2m s\u00e0ng b\u1eb1ng h\u00f4n m\u00ea, m\u1ea5t c\u1ea3m gi\u00e1c ho\u1eb7c nh\u1eefng c\u01a1n co gi\u1eadt. C\u1ea5p c\u1ee9u l\u00fac n\u00e0y c\u1ea7n truy\u1ec1n glucose t\u0129nh m\u1ea1ch v\u00e0\/ho\u1eb7c glucagon (ti\u00eam b\u1eafp ho\u1eb7c ti\u00eam d\u01b0\u1edbi da). 2.4. H\u1ea1 glucose m\u00e1u ti\u1ec1m t\u00e0ng hay h\u1ea1 glucose m\u00e1u kh\u00f4ng tri\u1ec7u ch\u1ee9ng : Tr\u01b0\u1edbc \u0111\u00e2y ng\u01b0\u1eddi ta cho r\u1eb1ng h\u1ea1 glucose m\u00e1u kh\u00f4ng c\u00f3 tri\u1ec7u ch\u1ee9ng c\u1ea3nh b\u00e1o - hay h\u1ea1 glucose m\u00e1u ti\u1ec1m t\u00e0ng - l\u00e0 r\u1ea5t hi\u1ebfm. Th\u1eadt ra tai bi\u1ebfn n\u00e0y r\u1ea5t hay g\u1eb7p, nh\u1ea5t l\u00e0 \u1edf nh\u1eefng ng\u01b0\u1eddi b\u1ec7nh \u0111\u01b0\u1ee3c \u00e1p d\u1ee5ng ph\u01b0\u01a1ng ph\u00e1p tr\u1ecb li\u1ec7u t\u00edch c\u1ef1c. Nh\u1eefng ng\u01b0\u1eddi c\u00f3 c\u01a1n h\u1ea1 glucose m\u00e1u kh\u00f4ng tri\u1ec7u ch\u1ee9ng l\u1eb7p l\u1ea1i nhi\u1ec1u l\u1ea7n s\u1ebd g\u00e2y ra nh\u1eefng t\u00e1c h\u1ea1i: L\u00e0m \\\"c\u00f9n\\\" \u0111i c\u01a1 ch\u1ebf ho\u1ea1t \u0111\u1ed9ng c\u1ee7a h\u1ec7 th\u1ed1ng hormon ng\u0103n ch\u1eb7n h\u1ea1 glucose m\u00e1u. H\u1ea1 th\u1ea5p ng\u01b0\u1ee1ng \\\"b\u00e1o \u0111\u1ed9ng\\\" v\u1ec1 nguy c\u01a1 h\u1ea1 glucose m\u00e1u c\u1ee7a c\u01a1 th\u1ec3. \u0110\u1ec3 ch\u1ea9n \u0111o\u00e1n x\u00e1c \u0111\u1ecbnh ng\u01b0\u1eddi b\u1ec7nh c\u1ea7n \u0111\u1ecbnh l\u01b0\u1ee3ng glucose m\u00e1u, khi l\u01b0\u1ee3ng glucose m\u00e1u <3,1mmol\/l (< 55mg\/dl) \u0111\u00e3 b\u1eaft \u0111\u1ea7u \u0111\u01b0\u1ee3c xem l\u00e0 c\u00f3 h\u1ea1 glucose m\u00e1u ti\u1ec1m t\u00e0ng tr\u00ean l\u00e2m s\u00e0ng, l\u00fac n\u00e0y \u0111\u00e3 c\u1ea7n \u0111\u1ebfn s\u1ef1 can thi\u1ec7p c\u1ee7a c\u00e1c nh\u00e0 chuy\u00ean m\u00f4n c\u00f3 kinh nghi\u1ec7m. Khi \u0111\u00e3 c\u00f3 h\u1ea1 glucose m\u00e1u kh\u00f4ng tri\u1ec7u ch\u1ee9ng, kh\u00f4ng n\u00ean \u0111i\u1ec1u khi\u1ec3n ph\u01b0\u01a1ng ti\u1ec7n giao th\u00f4ng, kh\u00f4ng n\u00ean ti\u1ebfp t\u1ee5c luy\u1ec7n t\u1eadp... III. \u0110I\u1ec0U TR\u1eca C\u01a0N H\u1ea0 \u0110\u01af\u1edcNG HUY\u1ebeT 1. Th\u1ec3 nh\u1eb9 : Ch\u1ec9 c\u1ea7n 10-15g carbohydrate u\u1ed1ng l\u00e0 glucose m\u00e1u nhanh ch\u00f3ng tr\u1edf l\u1ea1i b\u00ecnh th\u01b0\u1eddng (u\u1ed1ng \u0111\u01b0\u1eddng, n\u01b0\u1edbc \u0111\u01b0\u1eddng). C\u1ea7n nh\u1edb, kh\u00f4ng d\u00f9ng socola v\u00e0 kem \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb h\u1ea1 glucose m\u00e1u c\u1ea5p. Tr\u01b0\u1eddng h\u1ee3p ng\u01b0\u1eddi b\u1ec7nh \u0111ang \u0111i tr\u00ean \u0111\u01b0\u1eddng, ho\u1eb7c ng\u01b0\u1eddi b\u1ec7nh \u0111ang \u0111i\u1ec1u khi\u1ec3n ph\u01b0\u01a1ng ti\u1ec7n giao th\u00f4ng, c\u00f3 d\u1ea5u hi\u1ec7u h\u1ea1 glucose m\u00e1u, t\u1ed1t nh\u1ea5t l\u00e0 n\u00ean d\u1eebng l\u1ea1i 10 - 15 ph\u00fat \u0111\u1ee3i khi glucose m\u00e1u tr\u1edf l\u1ea1i b\u00ecnh th\u01b0\u1eddng h\u00e3y ti\u1ebfp t\u1ee5c c\u00f4ng vi\u1ec7c. 2. Th\u1ec3 trung b\u00ecnh: C\u00f3 th\u1ec3 d\u00f9ng \u0111\u01b0\u1eddng u\u1ed1ng \u0111\u1ec3 can thi\u1ec7p, nh\u01b0ng c\u1ea7n th\u1eddi gian d\u00e0i h\u01a1n v\u00e0 li\u1ec1u d\u00f9ng l\u1edbn h\u01a1n \u0111\u1ec3 glucose m\u00e1u tr\u1edf l\u1ea1i b\u00ecnh th\u01b0\u1eddng. C\u00f3 th\u1ec3 d\u00f9ng glucagon ti\u00eam b\u1eafp ho\u1eb7c d\u01b0\u1edbi da k\u1ebft h\u1ee3p v\u1edbi u\u1ed1ng carbohydrat (\u0111\u01b0\u1eddng, n\u01b0\u1edbc \u0111\u01b0\u1eddng). 3. H\u1ea1 glucose m\u00e1u n\u1eb7ng : Do ng\u01b0\u1eddi b\u1ec7nh m\u1ea5t \u00fd th\u1ee9c n\u00ean kh\u00f4ng c\u00f3 kh\u1ea3 n\u0103ng nu\u1ed1t, v\u00ec th\u1ebf cho u\u1ed1ng c\u00f3 th\u1ec3 s\u1ebd b\u1ecb s\u1eb7c v\u00e0o \u0111\u01b0\u1eddng th\u1edf. Nh\u1eefng ng\u01b0\u1eddi b\u1ec7nh n\u00e0y bu\u1ed9c ph\u1ea3i ti\u00eam b\u1eafp ho\u1eb7c ti\u00eam d\u01b0\u1edbi da glucagon v\u00e0 ti\u00eam t\u0129nh m\u1ea1ch glucose \u01b0u tr\u01b0\u01a1ng v\u00e0 sau \u0111\u00f3 ti\u1ebfp t\u1ee5c truy\u1ec1n t\u0129nh m\u1ea1ch glucose. Th\u00f4ng th\u01b0\u1eddng t\u00ecnh tr\u1ea1ng l\u00e2m s\u00e0ng s\u1ebd kh\u00e1 l\u00ean sau 10 - 15 ph\u00fat ti\u00eam glucagon v\u00e0 1 - 5 ph\u00fat sau truy\u1ec1n glucose. N\u1ebfu h\u1ea1 glucose m\u00e1u \u0111\u00e3 l\u00e2u v\u00e0 m\u1ee9c \u0111\u01b0\u1eddng trong m\u00e1u qu\u00e1 th\u1ea5p, vi\u1ec7c ph\u1ee5c h\u1ed3i t\u00e2m th\u1ea7n c\u00f3 th\u1ec3 l\u00e2u h\u01a1n (trong nhi\u1ec1u gi\u1edd). 110","Trong tr\u01b0\u1eddng h\u1ee3p n\u00e0y c\u00f3 truy\u1ec1n \u0111\u01b0\u1eddng n\u1eefa hay kh\u00f4ng l\u00e0 tu\u1ef3 thu\u1ed9c v\u00e0o h\u00e0m l\u01b0\u1ee3ng glucose trong m\u00e1u. N\u1ebfu h\u1ea1 glucose m\u00e1u c\u00f3 tri\u1ec7u ch\u1ee9ng th\u1ea7n kinh, giai \u0111o\u1ea1n sau c\u00f3 th\u1ec3 c\u00f3 \u0111au \u0111\u1ea7u, tr\u1ea1ng th\u00e1i u m\u00ea, m\u1ea5t tr\u00ed nh\u1edb v\u00e0 n\u00f4n m\u1eeda. Tr\u01b0\u1eddng h\u1ee3p n\u00e0y c\u00f3 th\u1ec3 d\u00f9ng thu\u1ed1c an th\u1ea7n \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb tri\u1ec7u ch\u1ee9ng. Sau khi qua giai \u0111o\u1ea1n c\u1ea5p c\u1ee9u, ng\u01b0\u1eddi b\u1ec7nh n\u00ean \u0111\u1ec1 ph\u00f2ng b\u1eb1ng c\u00e1ch ho\u1eb7c l\u00e0 t\u0103ng ch\u1ebf \u0111\u1ed9 \u0103n ho\u1eb7c \u0103n b\u1eefa \u0103n ph\u1ee5 (t\u1ef7 l\u1ec7 ~10% t\u1ed5ng s\u1ed1 calo trong ng\u00e0y). Glucose qua \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch : L\u00e0 ph\u01b0\u01a1ng ph\u00e1p \u0111i\u1ec1u tr\u1ecb c\u01a1 b\u1ea3n nh\u1ea5t n\u1ebfu c\u00f3 s\u1eb5n nh\u00e2n vi\u00ean y t\u1ebf ph\u1ee5c v\u1ee5. Trong tr\u01b0\u1eddng h\u1ee3p h\u1ea1 glucose m\u00e1u n\u1eb7ng, glucose ti\u00eam t\u0129nh m\u1ea1ch ph\u1ed1i h\u1ee3p v\u1edbi glucagon \u0111\u01b0\u1ee3c xem l\u00e0 ph\u01b0\u01a1ng ph\u00e1p c\u1ea5p c\u1ee9u ho\u00e0n h\u1ea3o nh\u1ea5t. H\u1ea1n ch\u1ebf c\u1ee7a ph\u01b0\u01a1ng ph\u00e1p n\u00e0y l\u00e0 ph\u1ea3i c\u00f3 nh\u00e2n vi\u00ean y t\u1ebf. Th\u01b0\u1eddng khi b\u1eaft \u0111\u1ea7u c\u1ea5p c\u1ee9u ng\u01b0\u1eddi ta th\u01b0\u1eddng d\u00f9ng: \u2022 10 - 25g (trong dung d\u1ecbch Dextrose 50%, ho\u1eb7c glucose 50%). \u2022 50 - 100ml dung d\u1ecbch glucose 30%. Th\u1eddi gian \u0111\u1ec3 ti\u1ebfn h\u00e0nh c\u1ea5p c\u1ee9u ban \u0111\u1ea7u t\u1eeb 1-3 ph\u00fat. C\u1ea5p c\u1ee9u ban \u0111\u1ea7u ti\u00eam glucose v\u00e0o \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch sau \u0111\u00f3 s\u1ebd ti\u1ebfp t\u1ee5c duy tr\u00ec \u0111\u01b0\u1eddng truy\u1ec1n t\u0129nh m\u1ea1ch. Li\u1ec1u c\u1ea5p c\u1ee9u ti\u1ebfp theo ph\u1ee5 thu\u1ed9c \u0111\u00e1p \u1ee9ng c\u1ee7a ng\u01b0\u1eddi b\u1ec7nh. Th\u00f4ng th\u01b0\u1eddng, ng\u01b0\u1eddi ta cho glucose \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch v\u1edbi li\u1ec1u 5\u201310g\/gi\u1edd. Glucose s\u1ebd \u0111\u01b0\u1ee3c ti\u1ebfp t\u1ee5c truy\u1ec1n cho \u0111\u1ebfn khi ng\u01b0\u1eddi b\u1ec7nh h\u1ed3i ph\u1ee5c ho\u00e0n to\u00e0n v\u00e0 c\u00f3 kh\u1ea3 n\u0103ng t\u1ef1 \u0103n, u\u1ed1ng \u0111\u01b0\u1ee3c. IV.\/ PH\u00d2NG V\u00c0 CH\u1ed0NG H\u1ea0 \u0110\u01af\u1edcNG HUY\u1ebeT \u0110\u1ec3 ph\u00f2ng ch\u1ed1ng c\u01a1n h\u1ea1 glucose m\u00e1u c\u00f3 hi\u1ec7u qu\u1ea3, vi\u1ec7c c\u1ea7n l\u00e0m l\u00e0 t\u00ecm hi\u1ec3u nh\u1eefng nguy\u00ean nh\u00e2n c\u00f3 th\u1ec3 g\u00e2y ra h\u1ea1 glucose m\u00e1u. 1. C\u00e1c nguy\u00ean nh\u00e2n hay g\u1eb7p c\u1ee7a h\u1ea1 glucose m\u00e1u 1.1. Nh\u1eefng nguy\u00ean nh\u00e2n c\u00f3 li\u00ean quan \u0111\u1ebfn s\u1eed d\u1ee5ng insulin \u2022 Do qu\u00e1 li\u1ec1u. \u2022 Th\u1eddi gian ti\u00eam kh\u00f4ng ph\u00f9 h\u1ee3p v\u1edbi b\u1eefa \u0103n ho\u1eb7c lo\u1ea1i insulin d\u00f9ng kh\u00f4ng ph\u00f9 h\u1ee3p. \u2022 Li\u1ec7u ph\u00e1p \u0111i\u1ec1u tr\u1ecb t\u0103ng c\u01b0\u1eddng b\u1eb1ng insulin. \u2022 Th\u1ea5t th\u01b0\u1eddng h\u1ea5p thu c\u1ee7a insulin t\u1ea1i n\u01a1i ti\u00eam. \u2022 H\u1ea5p thu nhanh h\u01a1n n\u1ebfu ti\u00eam \u1edf v\u00f9ng hay v\u1eadn \u0111\u1ed9ng. \u2022 V\u1ecb tr\u00ed ti\u00eam c\u00f3 v\u1ea5n \u0111\u1ec1: teo l\u1edbp m\u1ee1 d\u01b0\u1edbi da ho\u1eb7c lo\u1ea1n d\u01b0\u1ee1ng v\u00f9ng ti\u00eam... \u2022 S\u1eed d\u1ee5ng nhi\u1ec1u insulin tinh khi\u1ebft ho\u1eb7c \u0111\u1ed5i t\u1eeb d\u1ea1ng t\u1ed5ng h\u1ee3p sang c\u00e1c d\u1ea1ng insulin tr\u1ed9n ho\u1eb7c insulin ng\u01b0\u1eddi l\u00e0m thay \u0111\u1ed5i t\u1ed1c \u0111\u1ed9 h\u1ea5p thu. 1.2. Ch\u1ebf \u0111\u1ed9 dinh d\u01b0\u1ee1ng \u2022 \u0102n \u00edt. B\u1eefa \u0103n kh\u00f4ng \u0111\u1ee7 l\u01b0\u1ee3ng carbohydrate so v\u1edbi li\u1ec1u insulin. \u2022 Th\u1eddi gian gi\u1eefa c\u00e1c b\u1eefa \u0103n ch\u01b0a ph\u00f9 h\u1ee3p. 1.3. Luy\u1ec7n t\u1eadp Kh\u00f4ng c\u00f3 k\u1ebf ho\u1ea1ch, ho\u1eb7c m\u1ee9c \u0111\u1ed9 v\u00e0 th\u1eddi gian luy\u1ec7n t\u1eadp kh\u00f4ng ph\u00f9 h\u1ee3p. 1.4. U\u1ed1ng r\u01b0\u1ee3u v\u00e0 s\u1eed d\u1ee5ng ph\u1ed1i h\u1ee3p v\u1edbi m\u1ed9t s\u1ed1 thu\u1ed1c \u2022 Kh\u1ea3 n\u0103ng t\u00e2n t\u1ea1o \u0111\u01b0\u1eddng t\u1ea1i gan b\u1ecb suy gi\u1ea3m khi u\u1ed1ng r\u01b0\u1ee3u. C\u00e1c nguy\u00ean nh\u00e2n g\u00e2y h\u1ea1 glucose m\u00e1u hay g\u1eb7p nh\u1ea5t l\u00e0 nh\u1eefng sai s\u00f3t trong ch\u1ec9 \u0111\u1ecbnh li\u1ec1u l\u01b0\u1ee3ng insulin, l\u1ecbch tr\u00ecnh c\u00e1c m\u0169i ti\u00eam, s\u1ef1 ph\u00e2n b\u1ed1 c\u00e1c b\u1eefa \u0103n kh\u00f4ng ph\u00f9 h\u1ee3p, \u0111\u00e2y l\u00e0 nh\u1eefng nguy\u00ean nh\u00e2n ch\u00ednh g\u00e2y ra h\u1ea1 glucose m\u00e1u. 1.5. C\u00e1c nguy\u00ean nh\u00e2n kh\u00e1c Ng\u01b0\u1eddi ta c\u0169ng \u0111\u00e3 ghi nh\u1eadn nh\u1eefng l\u00fd do t\u01b0\u1edfng nh\u01b0 hi\u1ebfm g\u1eb7p kh\u00e1c; v\u00ed d\u1ee5: \u2022 Ng\u1ee7 mu\u1ed9n h\u01a1n l\u1ec7 th\u01b0\u1eddng c\u0169ng l\u00e0 m\u1ed1i nguy hi\u1ec3m ti\u1ec1m t\u00e0ng cho ng\u01b0\u1eddi b\u1ec7nh, v\u00ec n\u00f3 l\u00e0m v\u1ee1 th\u1ebf c\u00e2n b\u1eb1ng gi\u1eefa th\u1eddi gian ti\u00eam insulin v\u00e0 vi\u1ec7c thu nh\u1eadn th\u1ee9c \u0103n c\u1ee7a c\u01a1 th\u1ec3. \u2022 Nhi\u1ec1u tr\u01b0\u1eddng h\u1ee3p h\u1ea1 glucose m\u00e1u n\u1eb7ng, th\u1eadm ch\u00ed t\u1eed vong, x\u1ea3y ra sau c\u00e1c b\u1eefa ti\u1ec7c do ng\u01b0\u1eddi b\u1ec7nh u\u1ed1ng nhi\u1ec1u r\u01b0\u1ee3u, ho\u1eb7c sau khi c\u00f3 t\u0103ng ho\u1ea1t \u0111\u1ed9ng \u0111\u1ed9t ng\u1ed9t m\u00e0 kh\u00f4ng gi\u1ea3m li\u1ec1u thu\u1ed1c ho\u1eb7c kh\u00f4ng c\u00f3 ch\u1ebf \u0111\u1ed9 b\u00f9 \u0111\u1eafp cho \u0111\u1ee7 s\u1ed1 n\u0103ng l\u01b0\u1ee3ng b\u1ecb ti\u00eau hao. 2. C\u00e1c y\u1ebfu t\u1ed1 li\u00ean quan \u0111\u1ebfn ph\u00f2ng c\u01a1n h\u1ea1 glucose m\u00e1u: M\u1ed9t ch\u1ebf \u0111\u1ed9 \u0111i\u1ec1u tr\u1ecb ph\u00f9 h\u1ee3p bao g\u1ed3m ch\u1ebf \u0111\u1ed9 \u0103n, ch\u1ebf \u0111\u1ed9 ngh\u1ec9 ng\u01a1i, ch\u1ebf \u0111\u1ed9 ti\u00eam thu\u1ed1c, ch\u1ebf \u0111\u1ed9 luy\u1ec7n t\u1eadp ph\u00f9 h\u1ee3p, l\u00e0 bi\u1ec7n ph\u00e1p ph\u00f2ng ch\u1ed1ng h\u1eefu hi\u1ec7u nh\u1ea5t. 2.1. Gi\u1ea5c ng\u1ee7 : \u0110\u1ec3 \u0111\u1ea3m b\u1ea3o an to\u00e0n, ng\u01b0\u1eddi ta th\u01b0\u1eddng ti\u00eam insulin b\u00e1n ch\u1eadm v\u00e0o bu\u1ed5i t\u1ed1i. V\u1edbi li\u1ec1u d\u1ef1 t\u00ednh th\u00f4ng th\u01b0\u1eddng ng\u01b0\u1eddi b\u1ec7nh c\u00f3 th\u1ec3 ng\u1ee7 th\u00eam 30-60 ph\u00fat. Nh\u01b0ng n\u1ebfu ng\u01b0\u1eddi b\u1ec7nh ng\u1ee7 th\u00eam tr\u00ean 1 gi\u1edd ph\u1ea3i b\u1ed5 sung n\u0103ng l\u01b0\u1ee3ng ho\u1eb7c \u0111\u1ed5i li\u1ec1u insulin. V\u00ed d\u1ee5 n\u1ebfu ng\u01b0\u1eddi b\u1ec7nh \u0111\u1ecbnh ng\u1ee7 th\u00eam tr\u00ean 60 ph\u00fat, c\u00f3 th\u1ec3 gi\u1ea3m 10-15% li\u1ec1u insulin b\u00e1n ch\u1eadm ho\u1eb7c ch\u1eadm c\u1ee7a m\u0169i ti\u00eam t\u1ed1i h\u00f4m tr\u01b0\u1edbc. C\u0169ng c\u00f3 th\u1ec3 ng\u01b0\u1eddi 111","b\u1ec7nh v\u1eabn s\u1eed d\u1ee5ng thu\u1ed1c \u0111\u00fang li\u1ec1u l\u01b0\u1ee3ng, nh\u01b0ng \u0111\u01b0\u1ee3c \u0111\u00e1nh th\u1ee9c d\u1eady \u0111\u00fang gi\u1edd, l\u00e0m test ki\u1ec3m tra glucose m\u00e1u, \u0103n s\u00e1ng, ti\u00eam m\u0169i insulin bu\u1ed5i s\u00e1ng r\u1ed3i l\u1ea1i ng\u1ee7 ti\u1ebfp. 2.2. Ch\u1ebf \u0111\u1ed9 luy\u1ec7n t\u1eadp: Luy\u1ec7n t\u1eadp l\u00e0m t\u0103ng s\u1ef1 h\u1ea5p thu, t\u0103ng nh\u1ea1y c\u1ea3m c\u1ee7a insulin \u1edf m\u00f4 \u0111\u00edch. \u0110i\u1ec1u quan tr\u1ecdng \u0111\u1ec3 tr\u00e1nh h\u1ea1 glucose m\u00e1u khi luy\u1ec7n t\u1eadp l\u00e0 ng\u01b0\u1eddi b\u1ec7nh ph\u1ea3i c\u00f3 ngu\u1ed3n carbohydrate b\u1ed5 sung k\u1ecbp th\u1eddi, nhanh ch\u00f3ng. Tr\u01b0\u1eddng h\u1ee3p \u0111ang luy\u1ec7n t\u1eadp m\u00e0 c\u00f3 d\u1ea5u hi\u1ec7u h\u1ea1 glucose m\u00e1u ph\u1ea3i ng\u1eebng t\u1eadp ngay. N\u1ebfu h\u1ea1 glucose m\u00e1u x\u1ea3y ra sau khi t\u1eadp, ph\u1ea3i c\u00f3 b\u1eefa \u0103n ph\u1ee5 tr\u01b0\u1edbc khi t\u1eadp. \u0110\u1ec3 tr\u00e1nh h\u1ea1 glucose m\u00e1u khi luy\u1ec7n t\u1eadp ng\u01b0\u1eddi ta c\u00f2n khuy\u00ean n\u00ean gi\u1ea3m li\u1ec1u insulin. \u0110\u00e2y l\u00e0 bi\u1ec7n ph\u00e1p d\u1ef1 ph\u00f2ng kh\u00f4ng t\u0103ng n\u0103ng l\u01b0\u1ee3ng, th\u01b0\u1eddng \u00e1p d\u1ee5ng cho nh\u1eefng \u0111\u1ed1i t\u01b0\u1ee3ng kh\u00f4ng mu\u1ed1n t\u0103ng c\u00e2n. 3. Gi\u00e1o d\u1ee5c, h\u01b0\u1edbng d\u1eabn ng\u01b0\u1eddi b\u1ec7nh t\u1ef1 theo d\u00f5i, \u0111i\u1ec1u ch\u1ec9nh ch\u1ebf \u0111\u1ed9 \u0111i\u1ec1u tr\u1ecb : \u0110\u1ec3 ng\u01b0\u1eddi b\u1ec7nh hi\u1ec3u v\u00e0 t\u1ef1 theo d\u00f5i b\u1ec7nh lu\u00f4n l\u00e0 m\u1ee5c \u0111\u00edch quan tr\u1ecdng nh\u1ea5t c\u1ee7a c\u00f4ng t\u00e1c gi\u00e1o d\u1ee5c s\u1ee9c kho\u1ebb c\u1ed9ng \u0111\u1ed3ng. Vi\u1ec7c t\u1ef1 theo d\u00f5i glucose m\u00e1u ph\u1ea3i \u0111\u01b0\u1ee3c gi\u00e1o d\u1ee5c cho t\u1ea5t c\u1ea3 ng\u01b0\u1eddi b\u1ec7nh \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng, k\u1ec3 c\u1ea3 ng\u01b0\u1eddi ch\u01b0a c\u00f3 \u0111i\u1ec1u ki\u1ec7n s\u1eed d\u1ee5ng m\u00e1y theo d\u00f5i \u0111\u01b0\u1eddng huy\u1ebft. T\u00e0i li\u1ec7u tham kh\u1ea3o: H\u01b0\u1edbng d\u1eabn Ch\u1ea9n \u0111o\u00e1n v\u00e0 \u0111i\u1ec1u tr\u1ecb b\u1ec7nh N\u1ed9i ti\u1ebft \u2013 Chuy\u1ec3n ho\u00e1 2014 B\u1ed9 Y t\u1ebf 112","C\u1eacP NH\u1eacT CH\u1ea8N \u0110O\u00c1N, \u0110I\u1ec0U TR\u1eca S\u1ed0T XU\u1ea4T HUY\u1ebeT DENGUE I. \u0110\u1ea0I C\u01af\u01a0NG S\u1ed1t xu\u1ea5t huy\u1ebft Dengue l\u00e0 b\u1ec7nh truy\u1ec1n nhi\u1ec5m g\u00e2y d\u1ecbch do vi r\u00fat Dengue g\u00e2y n\u00ean. Vi r\u00fat Dengue c\u00f3 4 t\u00fdp huy\u1ebft thanh l\u00e0 DEN-1, DEN-2, DEN-3 v\u00e0 DEN-4. Vi r\u00fat truy\u1ec1n t\u1eeb ng\u01b0\u1eddi b\u1ec7nh sang ng\u01b0\u1eddi l\u00e0nh do mu\u1ed7i \u0111\u1ed1t. Mu\u1ed7i Aedes aegypti l\u00e0 c\u00f4n tr\u00f9ng trung gian truy\u1ec1n b\u1ec7nh ch\u1ee7 y\u1ebfu. B\u1ec7nh x\u1ea3y ra quanh n\u0103m, th\u01b0\u1eddng gia t\u0103ng v\u00e0o m\u00f9a m\u01b0a. B\u1ec7nh g\u1eb7p \u1edf c\u1ea3 tr\u1ebb em v\u00e0 ng\u01b0\u1eddi l\u1edbn. \u0110\u1eb7c \u0111i\u1ec3m c\u1ee7a s\u1ed1t xu\u1ea5t huy\u1ebft Dengue l\u00e0 s\u1ed1t, xu\u1ea5t huy\u1ebft v\u00e0 tho\u00e1t huy\u1ebft t\u01b0\u01a1ng, c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn s\u1ed1c gi\u1ea3m th\u1ec3 t\u00edch tu\u1ea7n ho\u00e0n, r\u1ed1i lo\u1ea1n \u0111\u00f4ng m\u00e1u, suy t\u1ea1ng, n\u1ebfu kh\u00f4ng \u0111\u01b0\u1ee3c ch\u1ea9n \u0111o\u00e1n s\u1edbm v\u00e0 x\u1eed tr\u00ed k\u1ecbp th\u1eddi d\u1ec5 d\u1eabn \u0111\u1ebfn t\u1eed vong. II. DI\u1ec4N BI\u1ebeN L\u00c2M S\u00c0NG B\u1ec6NH S\u1ed0T XU\u1ea4T HUY\u1ebeT DENGUE B\u1ec7nh s\u1ed1t xu\u1ea5t huy\u1ebft Dengue c\u00f3 bi\u1ec3u hi\u1ec7n l\u00e2m s\u00e0ng \u0111a d\u1ea1ng, di\u1ec5n bi\u1ebfn nhanh ch\u00f3ng t\u1eeb nh\u1eb9 \u0111\u1ebfn n\u1eb7ng. B\u1ec7nh th\u01b0\u1eddng kh\u1edfi ph\u00e1t \u0111\u1ed9t ng\u1ed9t v\u00e0 di\u1ec5n bi\u1ebfn qua ba giai \u0111o\u1ea1n: giai \u0111o\u1ea1n s\u1ed1t, giai \u0111o\u1ea1n nguy hi\u1ec3m v\u00e0 giai \u0111o\u1ea1n h\u1ed3i ph\u1ee5c. Ph\u00e1t hi\u1ec7n s\u1edbm b\u1ec7nh v\u00e0 hi\u1ec3u r\u00f5 nh\u1eefng v\u1ea5n \u0111\u1ec1 l\u00e2m s\u00e0ng trong t\u1eebng giai \u0111o\u1ea1n c\u1ee7a b\u1ec7nh gi\u00fap ch\u1ea9n \u0111o\u00e1n s\u1edbm, \u0111i\u1ec1u tr\u1ecb \u0111\u00fang v\u00e0 k\u1ecbp th\u1eddi, nh\u1eb1m c\u1ee9u s\u1ed1ng ng\u01b0\u1eddi b\u1ec7nh. 1. Giai \u0111o\u1ea1n s\u1ed1t 1.1. L\u00e2m s\u00e0ng - S\u1ed1t cao \u0111\u1ed9t ng\u1ed9t, li\u00ean t\u1ee5c. - Nh\u1ee9c \u0111\u1ea7u, ch\u00e1n \u0103n, bu\u1ed3n n\u00f4n. - Da xung huy\u1ebft. - \u0110au c\u01a1, \u0111au kh\u1edbp, nh\u1ee9c hai h\u1ed1 m\u1eaft. - Nghi\u1ec7m ph\u00e1p d\u00e2y th\u1eaft d\u01b0\u01a1ng t\u00ednh. - Th\u01b0\u1eddng c\u00f3 ch\u1ea5m xu\u1ea5t huy\u1ebft \u1edf d\u01b0\u1edbi da, ch\u1ea3y m\u00e1u ch\u00e2n r\u0103ng ho\u1eb7c ch\u1ea3y m\u00e1u m\u0169i. 1.2. C\u1eadn l\u00e2m s\u00e0ng - Hematocrit (Hct) b\u00ecnh th\u01b0\u1eddng. - S\u1ed1 l\u01b0\u1ee3ng ti\u1ec3u c\u1ea7u b\u00ecnh th\u01b0\u1eddng ho\u1eb7c gi\u1ea3m d\u1ea7n (nh\u01b0ng c\u00f2n tr\u00ean 100.000\/mm3). - S\u1ed1 l\u01b0\u1ee3ng b\u1ea1ch c\u1ea7u th\u01b0\u1eddng gi\u1ea3m. 2. Giai \u0111o\u1ea1n nguy hi\u1ec3m: Th\u01b0\u1eddng v\u00e0o ng\u00e0y th\u1ee9 3-7 c\u1ee7a b\u1ec7nh 2.1. L\u00e2m s\u00e0ng a) Ng\u01b0\u1eddi b\u1ec7nh c\u00f3 th\u1ec3 c\u00f2n s\u1ed1t ho\u1eb7c \u0111\u00e3 gi\u1ea3m s\u1ed1t. b) C\u00f3 th\u1ec3 c\u00f3 c\u00e1c bi\u1ec3u hi\u1ec7n sau: - \u0110au b\u1ee5ng nhi\u1ec1u: \u0111au b\u1ee5ng nhi\u1ec1u v\u00e0 li\u00ean t\u1ee5c ho\u1eb7c t\u0103ng c\u1ea3m gi\u00e1c \u0111au nh\u1ea5t l\u00e0 \u1edf v\u00f9ng gan. - V\u1eadt v\u00e3, l\u1eeb \u0111\u1eeb, li b\u00ec. - Gan to > 2cm d\u01b0\u1edbi b\u1edd s\u01b0\u1eddn, c\u00f3 th\u1ec3 \u0111au. - N\u00f4n \u00f3i. - Bi\u1ec3u hi\u1ec7n tho\u00e1t huy\u1ebft t\u01b0\u01a1ng do t\u0103ng t\u00ednh th\u1ea5m th\u00e0nh m\u1ea1ch (th\u01b0\u1eddng k\u00e9o d\u00e0i 24-48 gi\u1edd). + Tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i, m\u00f4 k\u1ebd (c\u00f3 th\u1ec3 g\u00e2y suy h\u00f4 h\u1ea5p), m\u00e0ng b\u1ee5ng, ph\u00f9 n\u1ec1 mi m\u1eaft. + N\u1ebfu tho\u00e1t huy\u1ebft t\u01b0\u01a1ng nhi\u1ec1u s\u1ebd d\u1eabn \u0111\u1ebfn s\u1ed1c v\u1edbi c\u00e1c bi\u1ec3u hi\u1ec7n v\u1eadt v\u00e3, b\u1ee9t r\u1ee9t ho\u1eb7c li b\u00ec, l\u1ea1nh \u0111\u1ea7u chi, m\u1ea1ch nhanh nh\u1ecf, huy\u1ebft \u00e1p k\u1eb9t (hi\u1ec7u s\u1ed1 huy\u1ebft \u00e1p t\u1ed1i \u0111a v\u00e0 t\u1ed1i thi\u1ec3u \u2264 20mmHg ho\u1eb7c t\u1ee5t huy\u1ebft \u00e1p, kh\u00f4ng \u0111o \u0111\u01b0\u1ee3c huy\u1ebft \u00e1p, m\u1ea1ch kh\u00f4ng b\u1eaft \u0111\u01b0\u1ee3c, da l\u1ea1nh, n\u1ed5i v\u00e2n t\u00edm (s\u1ed1c n\u1eb7ng), ti\u1ec3u \u00edt. - Xu\u1ea5t huy\u1ebft. + Xu\u1ea5t huy\u1ebft d\u01b0\u1edbi da: N\u1ed1t xu\u1ea5t huy\u1ebft r\u1ea3i r\u00e1c ho\u1eb7c ch\u1ea5m xu\u1ea5t huy\u1ebft th\u01b0\u1eddng \u1edf m\u1eb7t tr\u01b0\u1edbc hai c\u1eb3ng ch\u00e2n v\u00e0 m\u1eb7t trong hai c\u00e1nh tay, b\u1ee5ng, \u0111\u00f9i, m\u1ea1n s\u01b0\u1eddn ho\u1eb7c m\u1ea3ng b\u1ea7m t\u00edm. + Xu\u1ea5t huy\u1ebft ni\u00eam m\u1ea1c nh\u01b0 ch\u1ea3y m\u00e1u ch\u00e2n r\u0103ng, ch\u1ea3y m\u00e1u m\u0169i, n\u00f4n ra m\u00e1u, ti\u00eau ph\u00e2n \u0111en ho\u1eb7c m\u00e1u, xu\u1ea5t huy\u1ebft \u00e2m \u0111\u1ea1o ho\u1eb7c ti\u1ec3u m\u00e1u. + Xu\u1ea5t huy\u1ebft n\u1eb7ng: ch\u1ea3y m\u00e1u m\u0169i n\u1eb7ng (c\u1ea7n nh\u00e9t b\u1ea5c ho\u1eb7c g\u1ea1c c\u1ea7m m\u00e1u), xu\u1ea5t huy\u1ebft \u00e2m \u0111\u1ea1o n\u1eb7ng, xu\u1ea5t huy\u1ebft trong c\u01a1 v\u00e0 ph\u1ea7n m\u1ec1m, xu\u1ea5t huy\u1ebft \u0111\u01b0\u1eddng ti\u00eau h\u00f3a v\u00e0 n\u1ed9i t\u1ea1ng (ph\u1ed5i, n\u00e3o, gan, l\u00e1ch, th\u1eadn), th\u01b0\u1eddng k\u00e8m theo t\u00ecnh tr\u1ea1ng s\u1ed1c, gi\u1ea3m ti\u1ec3u c\u1ea7u, thi\u1ebfu oxy m\u00f4 v\u00e0 toan chuy\u1ec3n h\u00f3a c\u00f3 th\u1ec3 d\u1eabn \u0111\u1ebfn suy \u0111a ph\u1ee7 t\u1ea1ng v\u00e0 \u0111\u00f4ng m\u00e1u n\u1ed9i m\u1ea1ch n\u1eb7ng. Xu\u1ea5t huy\u1ebft n\u1eb7ng c\u0169ng c\u00f3 th\u1ec3 x\u1ea3y ra \u1edf ng\u01b0\u1eddi b\u1ec7nh d\u00f9ng c\u00e1c thu\u1ed1c kh\u00e1ng vi\u00eam nh\u01b0 acetylsalicylic acid (aspirin), ibuprofen ho\u1eb7c d\u00f9ng corticoid, ti\u1ec1n s\u1eed lo\u00e9t d\u1ea1 d\u00e0y-t\u00e1 tr\u00e0ng, vi\u00eam gan m\u1ea1n. 113","- M\u1ed9t s\u1ed1 tr\u01b0\u1eddng h\u1ee3p n\u1eb7ng c\u00f3 th\u1ec3 c\u00f3 bi\u1ec3u hi\u1ec7n suy t\u1ea1ng nh\u01b0 t\u1ed5n th\u01b0\u01a1ng gan n\u1eb7ng\/suy gan, th\u1eadn, tim, ph\u1ed5i, n\u00e3o. Nh\u1eefng bi\u1ec3u hi\u1ec7n n\u1eb7ng n\u00e0y c\u00f3 th\u1ec3 x\u1ea3y ra \u1edf ng\u01b0\u1eddi b\u1ec7nh c\u00f3 ho\u1eb7c kh\u00f4ng c\u00f3 s\u1ed1c do tho\u00e1t huy\u1ebft t\u01b0\u01a1ng. + T\u1ed5n th\u01b0\u01a1ng gan n\u1eb7ng\/suy gan c\u1ea5p, men gan AST, ALT \u2265 1000U\/L. + T\u1ed5n th\u01b0\u01a1ng\/suy th\u1eadn c\u1ea5p. + R\u1ed1i lo\u1ea1n tri gi\u00e1c (s\u1ed1t xu\u1ea5t huy\u1ebft Dengue th\u1ec3 n\u00e3o). + Vi\u00eam c\u01a1 tim, suy tim, ho\u1eb7c suy ch\u1ee9c n\u0103ng c\u00e1c c\u01a1 quan kh\u00e1c. 2.2. C\u1eadn l\u00e2m s\u00e0ng - C\u00f4 \u0111\u1eb7c m\u00e1u khi Hematocrit t\u0103ng > 20% so v\u1edbi gi\u00e1 tr\u1ecb ban \u0111\u1ea7u c\u1ee7a ng\u01b0\u1eddi b\u1ec7nh ho\u1eb7c so v\u1edbi gi\u00e1 tr\u1ecb trung b\u00ecnh c\u1ee7a d\u00e2n s\u1ed1 \u1edf c\u00f9ng l\u1ee9a tu\u1ed5i. V\u00ed d\u1ee5: Hct ban \u0111\u1ea7u l\u00e0 35%, SXHD c\u00f3 t\u00ecnh tr\u1ea1ng c\u00f4 \u0111\u1eb7c m\u00e1u khi Hct hi\u1ec7n t\u1ea1i \u0111o \u0111\u01b0\u1ee3c l\u00e0 42% (t\u0103ng 20% so v\u1edbi ban \u0111\u1ea7u). - S\u1ed1 l\u01b0\u1ee3ng ti\u1ec3u c\u1ea7u gi\u1ea3m (<100.000\/mm3) - AST, ALT th\u01b0\u1eddng t\u0103ng. - Tr\u01b0\u1eddng h\u1ee3p n\u1eb7ng c\u00f3 th\u1ec3 c\u00f3 r\u1ed1i lo\u1ea1n \u0111\u00f4ng m\u00e1u. - Si\u00eau \u00e2m ho\u1eb7c X quang c\u00f3 th\u1ec3 ph\u00e1t hi\u1ec7n tr\u00e0n d\u1ecbch m\u00e0ng b\u1ee5ng, m\u00e0ng ph\u1ed5i. 3. Giai \u0111o\u1ea1n h\u1ed3i ph\u1ee5c: Th\u01b0\u1eddng v\u00e0o ng\u00e0y th\u1ee9 7-10 c\u1ee7a b\u1ec7nh 3.1. L\u00e2m s\u00e0ng - Ng\u01b0\u1eddi b\u1ec7nh h\u1ebft s\u1ed1t, to\u00e0n tr\u1ea1ng t\u1ed1t l\u00ean, th\u00e8m \u0103n, huy\u1ebft \u0111\u1ed9ng \u1ed5n \u0111\u1ecbnh v\u00e0 ti\u1ec3u nhi\u1ec1u. - C\u00f3 th\u1ec3 ph\u00e1t ban h\u1ed3i ph\u1ee5c ho\u1eb7c ng\u1ee9a ngo\u00e0i da. - C\u00f3 th\u1ec3 c\u00f3 nh\u1ecbp tim ch\u1eadm, kh\u00f4ng \u0111\u1ec1u, c\u00f3 th\u1ec3 c\u00f3 suy h\u00f4 h\u1ea5p do qu\u00e1 t\u1ea3i d\u1ecbch truy\u1ec1n. 3.2. C\u1eadn l\u00e2m s\u00e0ng - Hematocrit tr\u1edf v\u1ec1 b\u00ecnh th\u01b0\u1eddng ho\u1eb7c c\u00f3 th\u1ec3 th\u1ea5p h\u01a1n do hi\u1ec7n t\u01b0\u1ee3ng pha lo\u00e3ng m\u00e1u khi d\u1ecbch \u0111\u01b0\u1ee3c t\u00e1i h\u1ea5p thu tr\u1edf l\u1ea1i. - S\u1ed1 l\u01b0\u1ee3ng b\u1ea1ch c\u1ea7u m\u00e1u th\u01b0\u1eddng t\u0103ng l\u00ean s\u1edbm sau giai \u0111o\u1ea1n h\u1ea1 s\u1ed1t. - S\u1ed1 l\u01b0\u1ee3ng ti\u1ec3u c\u1ea7u d\u1ea7n tr\u1edf v\u1ec1 b\u00ecnh th\u01b0\u1eddng, mu\u1ed9n h\u01a1n so v\u1edbi s\u1ed1 l\u01b0\u1ee3ng b\u1ea1ch c\u1ea7u. - AST, ALT c\u00f3 khuynh h\u01b0\u1edbng gi\u1ea3m. III. CH\u1ea8N \u0110O\u00c1N V\u00c0 PH\u00c2N \u0110\u1ed8 1. B\u1ec7nh s\u1ed1t xu\u1ea5t huy\u1ebft Dengue \u0111\u01b0\u1ee3c chia l\u00e0m 3 m\u1ee9c \u0111\u1ed9 (theo T\u1ed5 ch\u1ee9c Y t\u1ebf th\u1ebf gi\u1edbi n\u0103m 2009) - S\u1ed1t xu\u1ea5t huy\u1ebft Dengue. - S\u1ed1t xu\u1ea5t huy\u1ebft Dengue c\u00f3 d\u1ea5u hi\u1ec7u c\u1ea3nh b\u00e1o. - S\u1ed1t xu\u1ea5t huy\u1ebft Dengue n\u1eb7ng. Ph\u1ee5 l\u1ee5c 2: Ph\u00e2n \u0111\u1ed9 s\u1ed1t xu\u1ea5t huy\u1ebft Dengue. L\u01b0u \u00fd: Trong qu\u00e1 tr\u00ecnh di\u1ec5n bi\u1ebfn, b\u1ec7nh c\u00f3 th\u1ec3 chuy\u1ec3n t\u1eeb m\u1ee9c \u0111\u1ed9 nh\u1eb9 sang m\u1ee9c \u0111\u1ed9 n\u1eb7ng, v\u00ec v\u1eady khi th\u0103m kh\u00e1m c\u1ea7n ph\u00e2n \u0111\u1ed9 l\u00e2m s\u00e0ng \u0111\u1ec3 ti\u00ean l\u01b0\u1ee3ng b\u1ec7nh v\u00e0 c\u00f3 k\u1ebf ho\u1ea1ch x\u1eed tr\u00ed th\u00edch h\u1ee3p. 2. Ch\u1ea9n \u0111o\u00e1n c\u0103n nguy\u00ean vi r\u00fat Dengue 2.1. X\u00e9t nghi\u1ec7m huy\u1ebft thanh - X\u00e9t nghi\u1ec7m nhanh: t\u00ecm kh\u00e1ng nguy\u00ean NS1 - X\u00e9t nghi\u1ec7m ELISA: t\u00ecm kh\u00e1ng th\u1ec3 IgM, IgG t\u1eeb ng\u00e0y th\u1ee9 5 c\u1ee7a b\u1ec7nh. 2.2. X\u00e9t nghi\u1ec7m PCR, ph\u00e2n l\u1eadp vi r\u00fat: l\u1ea5y m\u00e1u trong giai \u0111o\u1ea1n s\u1ed1t (th\u1ef1c hi\u1ec7n \u1edf c\u00e1c c\u01a1 s\u1edf x\u00e9t nghi\u1ec7m c\u00f3 \u0111i\u1ec1u ki\u1ec7n). 3. Ch\u1ea9n \u0111o\u00e1n ph\u00e2n bi\u1ec7t - S\u1ed1t ph\u00e1t ban do vi r\u00fat. - Tay ch\u00e2n mi\u1ec7ng. - S\u1ed1t m\u00f2. - S\u1ed1t r\u00e9t. - Nhi\u1ec5m khu\u1ea9n huy\u1ebft do li\u00ean c\u1ea7u l\u1ee3n, n\u00e3o m\u00f4 c\u1ea7u, vi khu\u1ea9n gram \u00e2m, ... - S\u1ed1c nhi\u1ec5m khu\u1ea9n. - C\u00e1c b\u1ec7nh m\u00e1u. - B\u1ec7nh l\u00fd \u1ed5 b\u1ee5ng c\u1ea5p,... IV. \u0110I\u1ec0U TR\u1eca A. \u0110i\u1ec1u tr\u1ecb s\u1ed1t xu\u1ea5t huy\u1ebft Dengue 114","Ph\u1ea7n l\u1edbn c\u00e1c tr\u01b0\u1eddng h\u1ee3p \u0111\u1ec1u \u0111\u01b0\u1ee3c \u0111i\u1ec1u tr\u1ecb ngo\u1ea1i tr\u00fa v\u00e0 theo d\u00f5i t\u1ea1i y t\u1ebf c\u01a1 s\u1edf, ch\u1ee7 y\u1ebfu l\u00e0 \u0111i\u1ec1u tr\u1ecb tri\u1ec7u ch\u1ee9ng v\u00e0 ph\u1ea3i theo d\u00f5i ch\u1eb7t ch\u1ebd ph\u00e1t hi\u1ec7n s\u1edbm s\u1ed1c x\u1ea3y ra \u0111\u1ec3 x\u1eed tr\u00ed k\u1ecbp th\u1eddi. * Xem x\u00e9t ch\u1ec9 \u0111\u1ecbnh nh\u1eadp vi\u1ec7n trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p sau - S\u1ed1ng m\u1ed9t m\u00ecnh. - Nh\u00e0 xa c\u01a1 s\u1edf y t\u1ebf, kh\u00f4ng th\u1ec3 nh\u1eadp vi\u1ec7n k\u1ecbp th\u1eddi khi b\u1ec7nh tr\u1edf n\u1eb7ng. - Gia \u0111\u00ecnh kh\u00f4ng c\u00f3 kh\u1ea3 n\u0103ng theo d\u00f5i s\u00e1t. - Tr\u1ebb nh\u0169 nhi. - D\u01b0 c\u00e2n, b\u00e9o ph\u00ec. - Ph\u1ee5 n\u1eef c\u00f3 thai. - Ng\u01b0\u1eddi l\u1edbn tu\u1ed5i (\u226560 tu\u1ed5i). - B\u1ec7nh m\u1ea1n t\u00ednh \u0111i k\u00e8m (th\u1eadn, tim, gan, hen, COPD k\u00e9m ki\u1ec3m so\u00e1t, \u0111\u00e1i th\u00e1o \u0111\u01b0\u1eddng, thi\u1ebfu m\u00e1u tan m\u00e1u...). 1. \u0110i\u1ec1u tr\u1ecb tri\u1ec7u ch\u1ee9ng - N\u1ebfu s\u1ed1t cao \u2265 38,5\u00b0C, cho thu\u1ed1c h\u1ea1 nhi\u1ec7t, n\u1edbi l\u1ecfng qu\u1ea7n \u00e1o v\u00e0 lau m\u00e1t b\u1eb1ng n\u01b0\u1edbc \u1ea5m. - Thu\u1ed1c h\u1ea1 nhi\u1ec7t ch\u1ec9 \u0111\u01b0\u1ee3c d\u00f9ng l\u00e0 paracetamol \u0111\u01a1n ch\u1ea5t, li\u1ec1u d\u00f9ng t\u1eeb 10-15mg\/kg c\u00e2n n\u1eb7ng\/l\u1ea7n, c\u00e1ch nhau m\u1ed7i 4-6 gi\u1edd. - Ch\u00fa \u00fd: + T\u1ed5ng li\u1ec1u paracetamol kh\u00f4ng qu\u00e1 60mg\/kg c\u00e2n n\u1eb7ng\/24 gi\u1edd. + Kh\u00f4ng d\u00f9ng aspirin (acetylsalicylic acid), analgin, ibuprofen \u0111\u1ec3 \u0111i\u1ec1u tr\u1ecb v\u00ec c\u00f3 th\u1ec3 g\u00e2y xu\u1ea5t huy\u1ebft, toan m\u00e1u. 2. B\u00f9 d\u1ecbch s\u1edbm b\u1eb1ng \u0111\u01b0\u1eddng u\u1ed1ng: Khuy\u1ebfn kh\u00edch ng\u01b0\u1eddi b\u1ec7nh u\u1ed1ng nhi\u1ec1u n\u01b0\u1edbc oresol ho\u1eb7c n\u01b0\u1edbc tr\u00e1i c\u00e2y (n\u01b0\u1edbc d\u1eeba, cam, chanh, ...) ho\u1eb7c n\u01b0\u1edbc ch\u00e1o lo\u00e3ng v\u1edbi mu\u1ed1i. - Kh\u00f4ng \u0103n u\u1ed1ng nh\u1eefng th\u1ef1c ph\u1ea9m c\u00f3 m\u00e0u n\u00e2u ho\u1eb7c \u0111\u1ecf nh\u01b0 x\u00e1 x\u1ecb, s\u00f4 c\u00f4 la,... - L\u01b0\u1ee3ng d\u1ecbch khuy\u1ebfn c\u00e1o: u\u1ed1ng theo nhu c\u1ea7u c\u01a1 b\u1ea3n, khuy\u1ebfn kh\u00edch u\u1ed1ng nhi\u1ec1u. 3. Theo d\u00f5i a) T\u00e1i kh\u00e1m v\u00e0 l\u00e0m x\u00e9t nghi\u1ec7m h\u00e0ng ng\u00e0y. N\u1ebfu xu\u1ea5t hi\u1ec7n d\u1ea5u hi\u1ec7u c\u1ea3nh b\u00e1o cho nh\u1eadp vi\u1ec7n \u0111i\u1ec1u tr\u1ecb. b) Ng\u01b0\u1eddi b\u1ec7nh \u0111\u1ebfn kh\u00e1m l\u1ea1i ngay khi c\u00f3 m\u1ed9t trong c\u00e1c d\u1ea5u hi\u1ec7u sau - Ng\u01b0\u1eddi b\u1ec7nh th\u1ea5y kh\u00f3 ch\u1ecbu h\u01a1n m\u1eb7c d\u00f9 s\u1ed1t gi\u1ea3m ho\u1eb7c h\u1ebft s\u1ed1t. - Kh\u00f4ng \u0103n, u\u1ed1ng \u0111\u01b0\u1ee3c. - N\u00f4n \u00f3i nhi\u1ec1u. - \u0110au b\u1ee5ng nhi\u1ec1u. - Tay ch\u00e2n l\u1ea1nh, \u1ea9m. - M\u1ec7t l\u1ea3, b\u1ee9t r\u1ee9t. - Ch\u1ea3y m\u00e1u m\u0169i, mi\u1ec7ng ho\u1eb7c xu\u1ea5t huy\u1ebft \u00e2m \u0111\u1ea1o. - Kh\u00f4ng ti\u1ec3u tr\u00ean 6 gi\u1edd. - Bi\u1ec3u hi\u1ec7n h\u00e0nh vi thay \u0111\u1ed5i nh\u01b0 l\u00fa l\u1eabn, t\u0103ng k\u00edch th\u00edch, v\u1eadt v\u00e3 ho\u1eb7c li b\u00ec. B. \u0110i\u1ec1u tr\u1ecb s\u1ed1t xu\u1ea5t huy\u1ebft Dengue c\u00f3 d\u1ea5u hi\u1ec7u c\u1ea3nh b\u00e1o 1. \u0110i\u1ec1u tr\u1ecb s\u1ed1t xu\u1ea5t huy\u1ebft Dengue c\u00f3 d\u1ea5u hi\u1ec7u c\u1ea3nh b\u00e1o: ng\u01b0\u1eddi b\u1ec7nh \u0111\u01b0\u1ee3c cho nh\u1eadp vi\u1ec7n \u0111i\u1ec1u tr\u1ecb. 1.1. \u0110i\u1ec1u tr\u1ecb tri\u1ec7u ch\u1ee9ng: h\u1ea1 s\u1ed1t 1.2. B\u00f9 d\u1ecbch s\u1edbm b\u1eb1ng \u0111\u01b0\u1eddng u\u1ed1ng n\u1ebfu b\u1ec7nh nh\u00e2n c\u00f2n kh\u1ea3 n\u0103ng u\u1ed1ng \u0111\u01b0\u1ee3c. 1.3. Theo d\u00f5i m\u1ea1ch, HA, nh\u1eefng d\u1ea5u hi\u1ec7u c\u1ea3nh b\u00e1o, l\u01b0\u1ee3ng d\u1ecbch \u0111\u01b0a v\u00e0o, n\u01b0\u1edbc ti\u1ec3u v\u00e0 Hct m\u1ed7i 4-6 gi\u1edd. 1.4. Ch\u1ec9 \u0111\u1ecbnh truy\u1ec1n d\u1ecbch: xem x\u00e9t truy\u1ec1n d\u1ecbch khi ng\u01b0\u1eddi b\u1ec7nh n\u00f4n nhi\u1ec1u, kh\u00f4ng u\u1ed1ng \u0111\u01b0\u1ee3c v\u00e0 Hct cao ho\u1eb7c c\u00f3 d\u1ea5u m\u1ea5t n\u01b0\u1edbc. 1.5. Ph\u01b0\u01a1ng th\u1ee9c truy\u1ec1n d\u1ecbch Truy\u1ec1n Ringer lactate, Ringer acetate ho\u1eb7c NaCl 0,9% 6ml\/kg\/gi\u1edd trong 1-2 gi\u1edd, sau \u0111\u00f3 3ml\/kg\/gi\u1edd trong 2-4 gi\u1edd. Theo d\u00f5i l\u00e2m s\u00e0ng, Hct m\u1ed7i 2-4 gi\u1edd. Trong qu\u00e1 tr\u00ecnh theo d\u00f5i: - N\u1ebfu m\u1ea1ch, HA \u1ed5n \u0111\u1ecbnh, Hct gi\u1ea3m, n\u01b0\u1edbc ti\u1ec3u \u2265 0,5-1ml\/kg\/gi\u1edd, gi\u1ea3m t\u1ed1c \u0111\u1ed9 truy\u1ec1n Ringer lactate, Ringer acetate ho\u1eb7c NaCl 0,9% 1,5ml\/kg\/gi\u1edd trong 6-18 gi\u1edd. N\u1ebfu l\u00e2m s\u00e0ng ti\u1ebfp t\u1ee5c c\u1ea3i thi\u1ec7n, c\u00f3 th\u1ec3 ng\u01b0ng d\u1ecbch sau 12-24 gi\u1edd. - N\u1ebfu b\u1ec7nh nh\u00e2n c\u00f3 bi\u1ec3u hi\u1ec7n s\u1ed1c (m\u1ea1ch nhanh, nh\u1eb9, kh\u00f3 b\u1eaft, huy\u1ebft \u00e1p k\u1eb9t, t\u1ee5t, kh\u00f3 \u0111o v\u00e0 Hct t\u0103ng): truy\u1ec1n d\u1ecbch ch\u1ed1ng s\u1ed1c nh\u01b0 ph\u00e1c \u0111\u1ed3 \u0111i\u1ec1u tr\u1ecb s\u1ed1c SXHD \u1edf ng\u01b0\u1eddi l\u1edbn v\u1edbi li\u1ec1u ch\u1ed1ng s\u1ed1c \u0111\u1ea7u ti\u00ean l\u00e0 cao ph\u00e2n t\u1eed 10-15ml\/kg\/gi\u1edd. Ch\u00fa \u00fd \u0111i\u1ec1u tr\u1ecb toan h\u00f3a m\u00e1u, xu\u1ea5t huy\u1ebft, h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft, h\u1ea1 calci huy\u1ebft n\u1ebfu c\u00f3. C. \u0110i\u1ec1u tr\u1ecb s\u1ed1t xu\u1ea5t huy\u1ebft Dengue n\u1eb7ng: ng\u01b0\u1eddi b\u1ec7nh ph\u1ea3i \u0111\u01b0\u1ee3c nh\u1eadp vi\u1ec7n \u0111i\u1ec1u tr\u1ecb c\u1ea5p c\u1ee9u. 115","C. \u0110i\u1ec1u tr\u1ecb s\u1ed1t xu\u1ea5t huy\u1ebft Dengue n\u1eb7ng Ng\u01b0\u1eddi b\u1ec7nh ph\u1ea3i \u0111\u01b0\u1ee3c nh\u1eadp vi\u1ec7n \u0111i\u1ec1u tr\u1ecb c\u1ea5p c\u1ee9u. C.1. \u0110i\u1ec1u tr\u1ecb s\u1ed1c s\u1ed1t xu\u1ea5t huy\u1ebft Dengue, s\u1ed1c s\u1ed1t xu\u1ea5t huy\u1ebft Dengue n\u1eb7ng C.1.1. Th\u1edf oxy qua g\u1ecdng m\u0169i 1-6 l\u00edt\/ph\u00fat khi SpO2 < 95%. C.1.2. B\u00f9 d\u1ecbch nhanh theo ph\u00e1c \u0111\u1ed3. S\u01a1 \u0111\u1ed3 truy\u1ec1n d\u1ecbch trong s\u1ed1c s\u1ed1t xu\u1ea5t huy\u1ebft Dengue \u1edf ng\u01b0\u1eddi l\u1edbn. Trong 1 gi\u1edd \u0111\u1ea7u, ph\u1ea3i thay th\u1ebf nhanh ch\u00f3ng l\u01b0\u1ee3ng huy\u1ebft t\u01b0\u01a1ng m\u1ea5t \u0111i b\u1eb1ng Ringer lactate ho\u1eb7c NaCl 0,9% 15ml\/kg\/gi\u1edd sau \u0111\u00f3 \u0111\u00e1nh gi\u00e1 l\u1ea1i l\u00e2m s\u00e0ng, Hct. a) N\u1ebfu c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng (m\u1ea1ch gi\u1ea3m, HA b\u00ecnh th\u01b0\u1eddng, h\u1ebft k\u1eb9t) - Ti\u1ebfp t\u1ee5c truy\u1ec1n Ringer lactate ho\u1eb7c NaCl 0,9% t\u1ed1c \u0111\u1ed9 10ml\/kg\/gi\u1edd x 2 gi\u1edd. N\u1ebfu ng\u01b0\u1eddi b\u1ec7nh c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng v\u00e0 hematocrit gi\u1ea3m, gi\u1ea3m t\u1ed1c \u0111\u1ed9 Ringer lactate ho\u1eb7c NaCl 0,9% 6ml\/kg\/gi\u1edd trong 2 gi\u1edd, sau \u0111\u00f3 3ml\/kg\/gi\u1edd trong 5-7 gi\u1edd, sau \u0111\u00f3 1,5ml\/kg\/gi\u1edd trong 12 gi\u1edd. Ng\u01b0ng d\u1ecbch truy\u1ec1n n\u1ebfu l\u00e2m s\u00e0ng \u1ed5n \u0111\u1ecbnh. b) N\u1ebfu kh\u00f4ng c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng (m\u1ea1ch nhanh, nh\u1eb9, HA c\u00f2n t\u1ee5t, k\u1eb9t hi\u1ec7u \u00e1p < 20mmHg) b.1) N\u1ebfu hematocrit gi\u1ea3m > 20% hematocrit l\u00fac v\u00e0o s\u1ed1c, ho\u1eb7c hematocrit < 35%: x\u1eed tr\u00ed nh\u01b0 xu\u1ea5t huy\u1ebft n\u1eb7ng. b.2) N\u1ebfu hematocrit t\u0103ng, kh\u00f4ng \u0111\u1ed5i, ho\u1eb7c gi\u1ea3m < 20% hematocrit l\u00fac v\u00e0o s\u1ed1c: chuy\u1ec3n sang truy\u1ec1n cao ph\u00e2n t\u1eed (CPT) 10-15ml\/kg\/gi\u1edd trong 1 gi\u1edd: + N\u1ebfu c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng: ti\u1ebfp t\u1ee5c Ringer lactate ho\u1eb7c NaCl 0,9% t\u1ed1c \u0111\u1ed9 10ml\/kg\/gi\u1edd trong 2 gi\u1edd, sau \u0111\u00f3 6ml\/kg\/gi\u1edd trong 2 gi\u1edd, sau \u0111\u00f3 3ml\/kg\/gi\u1edd trong 5-7 gi\u1edd, sau \u0111\u00f3 1,5ml\/kg\/gi\u1edd trong 12 gi\u1edd. \u0110\u00e1nh gi\u00e1 l\u00e2m s\u00e0ng, Hematocrit sau m\u1ed7i l\u1ea7n chuy\u1ec3n t\u1ed1c \u0111\u1ed9 truy\u1ec1n. Xem x\u00e9t ng\u01b0ng d\u1ecbch truy\u1ec1n sau 24-48 gi\u1edd n\u1ebfu l\u00e2m s\u00e0ng \u1ed5n \u0111\u1ecbnh. + N\u1ebfu kh\u00f4ng c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng: \u0111\u00e1nh gi\u00e1 l\u1ea1i Hematocrit nh\u01b0 tr\u00ean, ch\u00fa \u00fd li\u1ec1u CPT l\u1eb7p l\u1ea1i l\u1ea7n 2 l\u00e0 10ml\/kg\/gi\u1edd. N\u1ebfu v\u1eabn kh\u00f4ng c\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng: x\u1eed tr\u00ed nh\u01b0 s\u1ed1c SXHD kh\u00f4ng \u0111\u00e1p \u1ee9ng d\u1ecbch truy\u1ec1n. L\u01b0u \u00fd: - T\u1ea5t c\u1ea3 s\u1ef1 thay \u0111\u1ed5i t\u1ed1c \u0111\u1ed9 truy\u1ec1n ph\u1ea3i d\u1ef1a v\u00e0o m\u1ea1ch, huy\u1ebft \u00e1p, l\u01b0\u1ee3ng b\u00e0i ti\u1ebft n\u01b0\u1edbc ti\u1ec3u, t\u00ecnh tr\u1ea1ng tim ph\u1ed5i, hematocrit m\u1ed7i 1 ho\u1eb7c 2 gi\u1edd m\u1ed9t l\u1ea7n v\u00e0 CVP ho\u1eb7c c\u00e1c ch\u1ec9 s\u1ed1 \u0111\u00e1nh gi\u00e1 huy\u1ebft \u0111\u1ed9ng h\u1ecdc kh\u00e1c (n\u1ebfu c\u00f3). - Hematocrit n\u1ec1n \u1edf nam 15-40 tu\u1ed5i l\u00e0 43%, \u1edf n\u1eef 15-40 tu\u1ed5i l\u00e0 38%. - Trong tr\u01b0\u1eddng h\u1ee3p t\u1ed5n th\u01b0\u01a1ng gan, ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh s\u1eed d\u1ee5ng LR ch\u1ec9 c\u00f3 t\u00ednh t\u01b0\u01a1ng \u0111\u1ed1i. - Tr\u01b0\u1eddng h\u1ee3p t\u00e1i s\u1ed1c (t\u00ecnh tr\u1ea1ng s\u1ed1c tr\u1edf l\u1ea1i sau khi huy\u1ebft \u0111\u1ed9ng \u1ed5n \u0111\u1ecbnh h\u01a1n 6 gi\u1edd) c\u1ea7n \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1 hematocrit nh\u01b0 tr\u00ean \u0111\u1ec3 x\u1eed l\u00fd truy\u1ec1n d\u1ecbch. Tuy nhi\u00ean th\u1eddi gian truy\u1ec1n d\u1ecbch c\u00f3 th\u1ec3 ng\u1eafn h\u01a1n t\u00f9y v\u00e0o th\u1eddi \u0111i\u1ec3m t\u00e1i s\u1ed1c, l\u00e2m s\u00e0ng v\u00e0 di\u1ec5n ti\u1ebfn hematocrit. - C\u00e2n n\u1eb7ng (CN) ch\u1ed1ng s\u1ed1c \u1edf ng\u01b0\u1eddi l\u1edbn \u0111\u01b0\u1ee3c t\u00ednh nh\u01b0 sau + T\u00ednh c\u00e2n n\u1eb7ng l\u00fd t\u01b0\u1edfng (kg) \u2022 N\u1eef: 45,5 + 0,91 x (chi\u1ec1u cao(cm) - 152,4) \u2022 Nam: 50,0 + 0,91 x (chi\u1ec1u cao(cm) - 152,4) + So s\u00e1nh c\u00e2n n\u1eb7ng l\u00fd t\u01b0\u1edfng v\u00e0 c\u00e2n n\u1eb7ng th\u1ef1c t\u1ebf \u2022 N\u1ebfu CN th\u1ef1c < CN l\u00fd t\u01b0\u1edfng \u2192 Ch\u1ecdn CN th\u1ef1c \u2022 N\u1ebfu CN th\u1ef1c t\u1eeb 100% - 120% CN l\u00fd t\u01b0\u1edfng -> Ch\u1ecdn CN l\u00fd t\u01b0\u1edfng \u2022 N\u1ebfu CN th\u1ef1c > 120% CN l\u00fd t\u01b0\u1edfng \u2192 Ch\u1ecdn CN hi\u1ec7u ch\u1ec9nh + C\u00e2n n\u1eb7ng hi\u1ec7u ch\u1ec9nh = CN l\u00fd t\u01b0\u1edfng + 0,4 x (CN th\u1ef1c - CN l\u00fd t\u01b0\u1edfng) C.1.2. \u0110i\u1ec1u tr\u1ecb t\u00e1i s\u1ed1c S\u1eed d\u1ee5ng cao ph\u00e2n t\u1eed \u0111\u1ec3 ch\u1ed1ng s\u1ed1c, li\u1ec1u t\u1eeb 10-15ml\/kg\/gi\u1edd, sau \u0111\u00f3: n\u1ebfu huy\u1ebft \u0111\u1ed9ng c\u1ea3i thi\u1ec7n, chuy\u1ec3n sang Ringer lactate ho\u1eb7c NaCl 0,9% t\u1ed1c \u0111\u1ed9 10ml\/kg\/gi\u1edd x 1 gi\u1edd, sau \u0111\u00f3 gi\u1ea3m li\u1ec1u c\u00f2n 6ml\/kg\/gi\u1edd, sau \u0111\u00f3 3ml\/kg\/gi\u1edd, sau \u0111\u00f3 1,5ml\/kg\/gi\u1edd. L\u01b0u \u00fd th\u1eddi gian duy tr\u00ec c\u00e1c li\u1ec1u tr\u00ean c\u00f3 th\u1ec3 gi\u1ea3m t\u00f9y thu\u1ed9c v\u00e0o l\u00e2m s\u00e0ng, di\u1ec5n ti\u1ebfn Hct v\u00e0 giai \u0111o\u1ea1n s\u1ed1c. C.1.3. \u0110i\u1ec1u tr\u1ecb xu\u1ea5t huy\u1ebft n\u1eb7ng - C\u00e1c bi\u1ec3u hi\u1ec7n ho\u1eb7c g\u1ee3i \u00fd xu\u1ea5t huy\u1ebft n\u1eb7ng tr\u00ean b\u1ec7nh nh\u00e2n SXHD: + Hi\u1ec7n di\u1ec7n ch\u1ea3y m\u00e1u ti\u1ebfn tri\u1ec3n, ch\u1ea3y m\u00e1u nhi\u1ec1u k\u00e8m huy\u1ebft \u0111\u1ed9ng kh\u00f4ng \u1ed5n \u0111\u1ecbnh. + Huy\u1ebft \u0111\u1ed9ng kh\u00f4ng \u1ed5n \u0111i k\u00e8m hematocrit gi\u1ea3m nhanh (>20%) khi truy\u1ec1n d\u1ecbch ch\u1ed1ng s\u1ed1c. + S\u1ed1c kh\u00f4ng c\u1ea3i thi\u1ec7n sau khi truy\u1ec1n d\u1ecbch nhanh 40-60ml\/kg. + Hematocrit th\u1ea5p khi v\u00e0o s\u1ed1c. 116","+ Toan chuy\u1ec3n h\u00f3a k\u00e9o d\u00e0i ho\u1eb7c ti\u1ebfn tri\u1ec3n x\u1ea5u m\u1eb7c d\u00f9 huy\u1ebft \u00e1p t\u00e2m thu b\u00ecnh th\u01b0\u1eddng, \u0111\u1eb7c bi\u1ec7t khi c\u00f3 \u0111au b\u1ee5ng, ch\u01b0\u1edbng b\u1ee5ng. - Ch\u1ec9 \u0111\u1ecbnh truy\u1ec1n m\u00e1u, ch\u1ebf ph\u1ea9m m\u00e1u: Xem Ph\u1ee5 l\u1ee5c 15: H\u01b0\u1edbng d\u1eabn x\u1eed tr\u00ed s\u1ed1c SXHD th\u1ec3 xu\u1ea5t huy\u1ebft n\u1eb7ng v\u00e0 ch\u1ec9 \u0111\u1ecbnh truy\u1ec1n m\u00e1u, ch\u1ebf ph\u1ea9m m\u00e1u. C.2.4. \u0110i\u1ec1u tr\u1ecb suy t\u1ea1ng n\u1eb7ng a) T\u1ed5n th\u01b0\u01a1ng gan n\u1eb7ng, suy gan c\u1ea5p - Tr\u00e1nh d\u00f9ng c\u00e1c thu\u1ed1c g\u00e2y t\u1ed5n th\u01b0\u01a1ng gan. - \u0110i\u1ec1u tr\u1ecb h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft, r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i n\u1ebfu c\u00f3. - \u0110i\u1ec1u ch\u1ec9nh r\u1ed1i lo\u1ea1n \u0111\u00f4ng m\u00e1u theo ch\u1ec9 \u0111\u1ecbnh - Kh\u00e1ng sinh khi nghi ng\u1edd nhi\u1ec5m khu\u1ea9n. - \u0110i\u1ec1u tr\u1ecb b\u1ec7nh l\u00fd n\u00e3o gan + Lactulose. + Th\u1ee5t th\u00e1o. + Kh\u00e1ng sinh: metronidazol ho\u1eb7c rifaximin. b) T\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p - Ch\u1ea9n \u0111o\u00e1n t\u1ed5n th\u01b0\u01a1ng th\u1eadn c\u1ea5p theo ti\u00eau chu\u1ea9n KDIGO 2012: khi c\u00f3 01 trong c\u00e1c ti\u00eau chu\u1ea9n sau: + Creatinine m\u00e1u t\u0103ng \u2265 0,3 mg% (26,5 umol\/L) trong 48 gi\u1edd. + Creatinine m\u00e1u t\u0103ng \u2265 1,5 l\u1ea7n gi\u00e1 tr\u1ecb n\u1ec1n ho\u1eb7c trong 07 ng\u00e0y tr\u01b0\u1edbc \u0111\u00f3. + N\u01b0\u1edbc ti\u1ec3u < 0,5ml\/kg\/gi\u1edd trong 06 gi\u1edd. - \u0110i\u1ec1u tr\u1ecb: + Ch\u1ed1ng s\u1ed1c n\u1ebfu c\u00f3. + C\u00e2n b\u1eb1ng d\u1ecbch xu\u1ea5t - nh\u1eadp. + Tr\u00e1nh thu\u1ed1c g\u00e2y t\u1ed5n th\u01b0\u01a1ng th\u1eadn. + Xem x\u00e9t ch\u1ec9 \u0111\u1ecbnh \u0111i\u1ec1u tr\u1ecb thay th\u1ebf th\u1eadn trong c\u00e1c tr\u01b0\u1eddng h\u1ee3p: \u2022 Qu\u00e1 t\u1ea3i tu\u1ea7n ho\u00e0n m\u1ee9c \u0111\u1ed9 n\u1eb7ng kh\u00f4ng \u0111\u00e1p \u1ee9ng v\u1edbi \u0111i\u1ec1u tr\u1ecb n\u1ed9i khoa. \u2022 Toan chuy\u1ec3n ho\u00e1 m\u00e1u m\u1ea5t b\u00f9 k\u00e8m theo r\u1ed1i lo\u1ea1n huy\u1ebft \u0111\u1ed9ng. \u2022 T\u0103ng Kali m\u00e1u n\u1eb7ng kh\u00f4ng \u0111\u00e1p \u1ee9ng \u0111i\u1ec1u tr\u1ecb n\u1ed9i khoa. \u2022 C\u1ea7n truy\u1ec1n m\u00e1u v\u00e0 c\u00e1c ch\u1ebf ph\u1ea9m m\u00e1u nh\u01b0ng b\u1ec7nh nh\u00e2n c\u00f3 nguy c\u01a1 ph\u00f9 ph\u1ed5i cao. c) S\u1ed1t xu\u1ea5t huy\u1ebft Dengue th\u1ec3 n\u00e3o - Ch\u1ea9n \u0111o\u00e1n: r\u1ed1i lo\u1ea1n tri gi\u00e1c, co gi\u1eadt ho\u1eb7c c\u00f3 d\u1ea5u th\u1ea7n kinh khu tr\u00fa, lo\u1ea1i tr\u1eeb c\u00e1c nguy\u00ean nh\u00e2n kh\u00e1c: h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft, r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i, ki\u1ec1m toan, gi\u1ea3m oxy m\u00e1u n\u1eb7ng, xu\u1ea5t huy\u1ebft n\u00e3o, m\u00e0ng n\u00e3o, vi\u00eam n\u00e3o, m\u00e0ng n\u00e3o do nguy\u00ean nh\u00e2n kh\u00e1c. - \u0110i\u1ec1u tr\u1ecb: + \u0110\u1ea7u cao 30\u00b0. + Th\u1edf oxy n\u1ebfu c\u00f3 gi\u1ea3m oxy m\u00e1u. + \u0110\u1eb7t n\u1ed9i kh\u00ed qu\u1ea3n b\u1ea3o v\u1ec7 \u0111\u01b0\u1eddng th\u1edf c\u00e1c tr\u01b0\u1eddng h\u1ee3p m\u00ea s\u00e2u. + Ch\u1ed1ng co gi\u1eadt (n\u1ebfu c\u00f3). + \u0110i\u1ec1u tr\u1ecb h\u1ea1 \u0111\u01b0\u1eddng huy\u1ebft, r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i, ki\u1ec1m toan (n\u1ebfu c\u00f3). + H\u1ea1 s\u1ed1t (n\u1ebfu c\u00f3). d) Vi\u00eam c\u01a1 tim, suy tim - Ch\u1ea9n \u0111o\u00e1n: \u0111au ng\u1ef1c, kh\u00f3 th\u1edf, tim nhanh, s\u1ed1c, t\u0103ng men tim, thay \u0111\u1ed5i \u0111i\u1ec7n t\u00e2m \u0111\u1ed3, h\u00ecnh \u1ea3nh h\u1ecdc (si\u00eau \u00e2m, xquang). - \u0110i\u1ec1u tr\u1ecb: + \u0110o CVP ho\u1eb7c c\u00e1c bi\u1ec7n ph\u00e1p \u0111\u00e1nh gi\u00e1 huy\u1ebft \u0111\u1ed9ng kh\u00e1c \u0111\u1ec3 h\u1ed7 tr\u1ee3 \u0111i\u1ec1u ch\u1ec9nh huy\u1ebft \u0111\u1ed9ng n\u1ebfu c\u00f3 r\u1ed1i lo\u1ea1n. + S\u1eed d\u1ee5ng v\u1eadn m\u1ea1ch noradrenalin, dobutamin, dopamine, adrenalin. + Xem x\u00e9t ch\u1ec9 \u0111\u1ecbnh ECMO. D. C\u00e1c v\u1ea5n \u0111\u1ec1 kh\u00e1c 1. Nu\u00f4i d\u01b0\u1ee1ng ng\u01b0\u1eddi b\u1ec7nh s\u1ed1t xu\u1ea5t huy\u1ebft Dengue. 2. Ch\u0103m s\u00f3c v\u00e0 theo d\u00f5i ng\u01b0\u1eddi b\u1ec7nh s\u1ed1c - Gi\u1eef \u1ea5m. - Khi \u0111ang c\u00f3 s\u1ed1c c\u1ea7n theo d\u00f5i m\u1ea1ch, huy\u1ebft \u00e1p, nh\u1ecbp th\u1edf t\u1eeb 15-30 ph\u00fat\/l\u1ea7n (\u1edf tr\u1ebb em); 30-60 ph\u00fat\/l\u1ea7n \u1edf ng\u01b0\u1eddi l\u1edbn. 117","- \u0110o hematocrit sau 1 gi\u1edd b\u00f9 d\u1ecbch ch\u1ed1ng s\u1ed1c v\u00e0 sau \u0111\u00f3 m\u1ed7i 1-2 gi\u1edd 1 l\u1ea7n, trong 6 gi\u1edd \u0111\u1ea7u c\u1ee7a s\u1ed1c. Sau \u0111\u00f3 4 gi\u1edd 1 l\u1ea7n cho \u0111\u1ebfn khi s\u1ed1c \u1ed5n \u0111\u1ecbnh. - Ghi nh\u1eadn l\u01b0\u1ee3ng n\u01b0\u1edbc xu\u1ea5t v\u00e0 nh\u1eadp trong 24 gi\u1edd. - \u0110o l\u01b0\u1ee3ng n\u01b0\u1edbc ti\u1ec3u. - Theo d\u00f5i t\u00ecnh tr\u1ea1ng tho\u00e1t d\u1ecbch v\u00e0o m\u00e0ng b\u1ee5ng, m\u00e0ng ph\u1ed5i, m\u00e0ng tim. - X\u00e9t nghi\u1ec7m lactate m\u00e1u, \u0111\u01b0\u1eddng huy\u1ebft, \u0111i\u1ec7n gi\u1ea3i \u0111\u1ed3. - X\u00e9t nghi\u1ec7m kh\u00ed m\u00e1u \u0111\u1ed9ng m\u1ea1ch khi c\u00f3 suy h\u00f4 h\u1ea5p, t\u00e1i s\u1ed1c, s\u1ed1c k\u00e9o d\u00e0i, t\u1ed5n th\u01b0\u01a1ng gan n\u1eb7ng\/suy gan. Ph\u1ee5 l\u1ee5c 18: C\u00e1c d\u1ea5u hi\u1ec7u c\u1ea7n theo d\u00f5i khi h\u1ed3i s\u1ee9c s\u1ed1c SXHD. 3. Ti\u00eau chu\u1ea9n cho ng\u01b0\u1eddi b\u1ec7nh xu\u1ea5t vi\u1ec7n - H\u1ebft s\u1ed1t \u00edt nh\u1ea5t 2 ng\u00e0y. - T\u1ec9nh t\u00e1o. - \u0102n u\u1ed1ng \u0111\u01b0\u1ee3c. - M\u1ea1ch, huy\u1ebft \u00e1p b\u00ecnh th\u01b0\u1eddng. - Kh\u00f4ng kh\u00f3 th\u1edf ho\u1eb7c suy h\u00f4 h\u1ea5p do tr\u00e0n d\u1ecbch m\u00e0ng b\u1ee5ng hay m\u00e0ng ph\u1ed5i. - Kh\u00f4ng xu\u1ea5t huy\u1ebft ti\u1ebfn tri\u1ec3n. - AST, ALT <400 U\/L. - Hct tr\u1edf v\u1ec1 b\u00ecnh th\u01b0\u1eddng v\u00e0 s\u1ed1 l\u01b0\u1ee3ng ti\u1ec3u c\u1ea7u khuynh h\u01b0\u1edbng h\u1ed3i ph\u1ee5c > 50.000\/mm3. 4. Ph\u00f2ng b\u1ec7nh - Th\u1ef1c hi\u1ec7n c\u00f4ng t\u00e1c gi\u00e1m s\u00e1t, ph\u00f2ng ch\u1ed1ng s\u1ed1t xu\u1ea5t huy\u1ebft Dengue theo quy \u0111\u1ecbnh c\u1ee7a B\u1ed9 Y t\u1ebf. - V\u1eafc xin ph\u00f2ng b\u1ec7nh \u0111ang ti\u1ebfp t\u1ee5c \u0111\u01b0\u1ee3c \u0111\u00e1nh gi\u00e1. - Bi\u1ec7n ph\u00e1p ph\u00f2ng b\u1ec7nh ch\u1ee7 y\u1ebfu l\u00e0 ki\u1ec3m so\u00e1t c\u00f4n tr\u00f9ng trung gian truy\u1ec1n b\u1ec7nh nh\u01b0 tr\u00e1nh mu\u1ed7i \u0111\u1ed1t, di\u1ec7t b\u1ecd g\u1eady (lo\u0103ng qu\u0103ng), di\u1ec7t mu\u1ed7i tr\u01b0\u1edfng th\u00e0nh, v\u1ec7 sinh m\u00f4i tr\u01b0\u1eddng lo\u1ea1i b\u1ecf \u1ed5 ch\u1ee9a n\u01b0\u1edbc \u0111\u1ecdng. 118","C\u00c1C GIAI \u0110O\u1ea0N L\u00c2M S\u00c0NG C\u1ee6A S\u1ed0T XU\u1ea4T HUY\u1ebeT DENGUE (Ban h\u00e0nh k\u00e8m theo Quy\u1ebft \u0111\u1ecbnh s\u1ed1 3705\/Q\u0110-BYT ng\u00e0y 22 th\u00e1ng 8 n\u0103m 2019 c\u1ee7a B\u1ed9 tr\u01b0\u1edfng B\u1ed9 Y t\u1ebf) PH\u00c2N \u0110\u1ed8 S\u1ed0T XU\u1ea4T HUY\u1ebeT DENGUE (Ban h\u00e0nh k\u00e8m theo Quy\u1ebft \u0111\u1ecbnh s\u1ed1 3705\/Q\u0110-BYT ng\u00e0y 22 th\u00e1ng 8 n\u0103m 2019 c\u1ee7a B\u1ed9 tr\u01b0\u1edfng B\u1ed9 Y t\u1ebf) Ph\u00e2n \u0111\u1ed9 SXHD SXHD c\u00f3 d\u1ea5u hi\u1ec7u c\u1ea3nh SXHD n\u1eb7ng b\u00e1o S\u1ed1ng\/\u0111i \u0111\u1ebfn v\u00f9ng c\u00f3 d\u1ecbch. \u00cdt nh\u1ea5t 1 trong c\u00e1c d\u1ea5u hi\u1ec7u \u00cdt nh\u1ea5t 1 trong c\u00e1c d\u1ea5u S\u1ed1t \u2264 7 ng\u00e0y v\u00e0 c\u00f3 2 trong sau hi\u1ec7u sau c\u00e1c d\u1ea5u hi\u1ec7u sau: - V\u1eadt v\u00e3, l\u1eeb \u0111\u1eeb, li b\u00ec. 1. Tho\u00e1t huy\u1ebft t\u01b0\u01a1ng - Bu\u1ed3n n\u00f4n, n\u00f4n. - \u0110au b\u1ee5ng nhi\u1ec1u v\u00e0 li\u00ean t\u1ee5c n\u1eb7ng d\u1eabn t\u1edbi - Ph\u00e1t ban. ho\u1eb7c t\u0103ng c\u1ea3m gi\u00e1c \u0111au - S\u1ed1c SXHD, s\u1ed1c SXHD - \u0110au c\u01a1, \u0111au kh\u1edbp, nh\u1ee9c v\u00f9ng gan. n\u1eb7ng. hai h\u1ed1 m\u1eaft. - N\u00f4n \u00f3i nhi\u1ec1u \u2265 3 l\u1ea7n\/1 gi\u1edd - \u1ee8 d\u1ecbch, bi\u1ec3u hi\u1ec7n suy h\u00f4 - Xu\u1ea5t huy\u1ebft da ho\u1eb7c d\u1ea5u ho\u1eb7c \u2265 4 l\u1ea7n\/6 gi\u1edd. h\u1ea5p. hi\u1ec7u d\u00e2y th\u1eaft (+). - Xu\u1ea5t huy\u1ebft ni\u00eam m\u1ea1c: 2. Xu\u1ea5t huy\u1ebft n\u1eb7ng Tri\u1ec7u ch\u1ee9ng - Hct b\u00ecnh th\u01b0\u1eddng ho\u1eb7c ch\u1ea3y m\u00e1u ch\u00e2n r\u0103ng, m\u0169i, 3. Suy c\u00e1c t\u1ea1ng l\u00e2m s\u00e0ng, c\u1eadn t\u0103ng. - B\u1ea1ch c\u1ea7u b\u00ecnh th\u01b0\u1eddng n\u00f4n ra m\u00e1u, ti\u00eau ph\u00e2n \u0111en - Gan: AST ho\u1eb7c ALT \u2265 l\u00e2m s\u00e0ng ho\u1eb7c gi\u1ea3m. ho\u1eb7c c\u00f3 m\u00e1u, xu\u1ea5t huy\u1ebft \u00e2m 1000U\/L. \u0111\u1ea1o ho\u1eb7c ti\u1ec3u m\u00e1u. - Th\u1ea7n kinh trung \u01b0\u01a1ng: r\u1ed1i - Ti\u1ec3u c\u1ea7u b\u00ecnh th\u01b0\u1eddng - Gan to > 2cm d\u01b0\u1edbi b\u1edd lo\u1ea1n \u00fd th\u1ee9c. ho\u1eb7c gi\u1ea3m. s\u01b0\u1eddn. - Tim v\u00e0 c\u00e1c c\u01a1 quan kh\u00e1c. - Ti\u1ec3u \u00edt. - Hct t\u0103ng k\u00e8m ti\u1ec3u c\u1ea7u gi\u1ea3m nhanh. - AST\/ALT \u2265 400U\/L*. - Tr\u00e0n d\u1ecbch m\u00e0ng ph\u1ed5i, m\u00e0ng b\u1ee5ng tr\u00ean si\u00eau \u00e2m ho\u1eb7c Xquang *. 119","* N\u1ebfu c\u00f3 \u0111i\u1ec1u ki\u1ec7n th\u1ef1c hi\u1ec7n S\u01a0 \u0110\u1ed2 PH\u00c2N NH\u00d3M \u0110I\u1ec0U TR\u1eca NG\u01af\u1edcI B\u1ec6NH S\u1ed0T XU\u1ea4T HUY\u1ebeT DENGUE (Ban h\u00e0nh k\u00e8m theo Quy\u1ebft \u0111\u1ecbnh s\u1ed1 3705\/Q\u0110-BYT ng\u00e0y 22 th\u00e1ng 8 n\u0103m 2019 c\u1ee7a BYT) 120","C\u1ea3i thi\u1ec7n l\u00e2m s\u00e0ng: m\u1ea1ch gi\u1ea3m, HA b\u00ecnh th\u01b0\u1eddng, hi\u1ec7u \u00e1p > 20mmHg M: m\u1ea1ch, HA: Huy\u1ebft \u00e1p, CPT: Cao ph\u00e2n t\u1eed (Dextran ho\u1eb7c HES 200\/0,5), RL: Ringer lactate 121","S\u01a0 \u0110\u1ed2 X\u1eec TR\u00cd SXHD C\u00d3 D\u1ea4U HI\u1ec6U C\u1ea2NH B\u00c1O \u1ede NG\u01af\u1edcI L\u1edaN (Ban h\u00e0nh k\u00e8m theo Quy\u1ebft \u0111\u1ecbnh s\u1ed1 3705\/Q\u0110-BYT ng\u00e0y 22 th\u00e1ng 8 n\u0103m 2019 c\u1ee7a B\u1ed9 tr\u01b0\u1edfng B\u1ed9 Y t\u1ebf) CPT: cao ph\u00e2n t\u1eed, RL: Ringer lactate 122","S\u01a0 \u00d0\u1ed2 TRUY\u1ec0N D\u1ecaCH TR\u1eccNG S\u1ed0C S\u1ed0T XU\u1ea4T HUY\u1ebeT DENGUE \u1ede NG\u01af\u1edcI L\u1edaN (Ban h\u00e0nh k\u00e8m theo Quy\u1ebft \u00f0\u1ecbnh s\u1ed1 3705\/Q\u00d0-BYT ng\u00e0y 22 th\u00e1ng 8 n\u00e3m 2019 c\u1ee7a B\u1ed9 tr\u01b0\u1edfng B\u1ed9 Y t\u1ebf) 123","M\u1eaaU GI\u1ea4Y T\u00d3M T\u1eaeT \u00d0I\u1ec0U TR\u1eca S\u1ed0T XU\u1ea4T HUY\u1ebeT DENGUE K\u00c8M THEO GI\u1ea4Y CHUY\u1ec2N TUY\u1ebeN (Ban h\u00e0nh k\u00e8m theo Quy\u1ebft \u00f0\u1ecbnh s\u1ed1 3705\/Q\u00d0-BYT ng\u00e0y 22 th\u00e1ng 8 n\u00e3m 2019 c\u1ee7a B\u1ed9 tr\u00fd\u1edfng B\u1ed9 Y t\u1ebf) GI\u1ea4Y T\u00d3M T\u1eaeT \u00d0I\u1ec0U TR\u1eca S\u1ed0T XU\u1ea4T HUY\u1ebeT DENGUE H\u1ecd t\u00ean b\u1ec7nh nh\u00e2n: \u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026\u2026 L\u00e2m s\u00e0ng X\u00e9t nghi\u1ec7m X\u1eed tr\u00ed Ng\u00e0y M\u1ea1ch HA Nh\u1ecbp N\u00fd\u1edbc SpO2 CVP Hct Lactate Kh\u00e1c H\u1ed7 D\u1ecbch M\u00e1u, gi\u1edd (1\/ph) (mmHg) th\u1edf ti\u1ec3u (%) (cmH2O) (%) (mmol\/L) (ghi tr\u1ee3 truy\u1ec1n thu\u1ed1c r\u00f5) h\u00f4 (Lo\u1ea1i, (1\/ph) (ml) h\u1ea5p t\u1ed1c \u00f0\u1ed9) - Gi\u1ea5y chuy\u1ec3n tuy\u1ebfn b\u1ec7nh vi\u1ec7n s\u1eed d\u1ee5ng m\u1eabu theo quy \u00f0\u1ecbnh hi\u1ec7n h\u00e0nh - \u00d0\u00e1nh d\u1ea5u \u201c\u00d6\u201d n\u1ebfu kh\u00f4ng c\u00f3 th\u00f4ng tin T\u00c0I LI\u1ec6U THAM KH\u1ea2O: - H\u01af\u1edaNG D\u1eaaN CH\u1ea8N \u0110O\u00c1N, \u0110I\u1ec0U TR\u1eca S\u1ed0T XU\u1ea4T HUY\u1ebeT DENGUE (Ban h\u00e0nh k\u00e8m theo Quy\u1ebft \u0111\u1ecbnh s\u1ed1 3705\/Q\u0110-BYT ng\u00e0y 22 th\u00e1ng 8 n\u0103m 2019 c\u1ee7a B\u1ed9 tr\u01b0\u1edfng B\u1ed9 Y t\u1ebf) 124","CH\u1ea8N \u0110O\u00c1N V\u00c0 X\u1eec TR\u00cd TR\u1ea0NG TH\u00c1I \u0110\u1ed8NG KINH 1. \u0110\u1ea0I C\u01af\u01a0NG - L\u00e0 tr\u1ea1ng th\u00e1i trong \u0111\u00f3 c\u00e1c c\u01a1n \u0111\u1ed9ng kinh xu\u1ea5t hi\u1ec7n li\u00ean ti\u1ebfp li\u1ec1n nhau m\u00e0 trong giai \u0111o\u1ea1n gi\u1eefa c\u00e1c c\u01a1n v\u1eabn t\u1ed3n t\u1ea1i c\u00e1c tri\u1ec7u ch\u1ee9ng th\u1ea7n kinh v\u00e0\/ho\u1eb7c r\u1ed1i lo\u1ea1n \u00fd th\u1ee9c; ho\u1eb7c m\u1ed9t c\u01a1n \u0111\u1ed9ng kinh k\u00e9o d\u00e0i qu\u00e1 l\u00e2u g\u00e2y n\u00ean m\u1ed9t b\u1ec7nh c\u1ea3nh l\u00e2m s\u00e0ng n\u1eb7ng n\u1ec1. - V\u1ec1 th\u1eddi gian k\u00e9o d\u00e0i m\u1ed9t ho\u1ea1t \u0111\u1ed9ng \u0111\u1ed9ng kinh t\u1eeb 30 ph\u00fat tr\u1edf l\u00ean v\u1edbi c\u00e1c tri\u1ec7u ch\u1ee9ng kh\u00e1c nhau do c\u00e1c qu\u00e1 tr\u00ecnh gi\u1ea3i ph\u1eabu, sinh l\u00fd b\u1ec7nh v\u00e0 nguy\u00ean nh\u00e2n r\u1ea5t \u0111a d\u1ea1ng. - M\u1ed9t s\u1ed1 t\u00e1c gi\u1ea3 \u0111\u01b0a ra \u0111\u1ecbnh ngh\u0129a ph\u00f9 h\u1ee3p cho l\u00e2m s\u00e0ng h\u01a1n: + C\u01a1n co gi\u1eadt k\u00e9o d\u00e0i tr\u00ean 5 ph\u00fat, ho\u1eb7c + C\u00f3 tr\u00ean ho\u1eb7c b\u1eb1ng 2 c\u01a1n co gi\u1eadt m\u00e0 gi\u1eefa c\u00e1c c\u01a1n kh\u00f4ng c\u00f3 s\u1ef1 ph\u1ee5c h\u1ed3i ho\u00e0n to\u00e0n \u00fd th\u1ee9c. 2. NGUY\u00caN NH\u00c2N 2.1. T\u1ed5n th\u01b0\u01a1ng th\u1ea7n kinh trung \u01b0\u01a1ng c\u1ea5p t\u00ednh: - Vi\u00eam n\u00e3o ho\u1eb7c vi\u00eam m\u00e0ng n\u00e3o. + Do vi khu\u1ea9n: n\u00e3o m\u00f4 c\u1ea7u, li\u00ean c\u1ea7u, c\u00fam, t\u1ee5 c\u1ea7u,\u2026 + Do vi-r\u00fat: vi-r\u00fat herpes, vi-r\u00fat adeno,\u2026 + Do n\u1ea5m: Cryptococcus, aspergillus,.. + Do vi khu\u1ea9n lao. + Do k\u00ed sinh tr\u00f9ng: \u1ea5u tr\u00f9ng giun l\u01b0\u01a1n, s\u00e1n n\u00e3o,\u2026 - Huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch n\u00e3o:do nhi\u1ec5m khu\u1ea9n, do r\u1ed1i lo\u1ea1n \u0111\u00f4ng m\u00e1u,\u2026 - B\u1ec7nh l\u00ed m\u1ea1ch m\u00e1u n\u00e3o: + Nh\u1ed3i m\u00e1u n\u00e3o. + Xu\u1ea5t huy\u1ebft n\u00e3o. + Xu\u1ea5t huy\u1ebft d\u01b0\u1edbi nh\u1ec7n. - T\u1ed5n th\u01b0\u01a1ng n\u00e3o do ch\u1ea5n th\u01b0\u01a1ng. - B\u1ec7nh n\u00e3o do t\u0103ng huy\u1ebft \u00e1p. - T\u1ed5n th\u01b0\u01a1ng n\u00e3o do gi\u1ea3m oxy v\u00e0 thi\u1ebfu m\u00e1u: + Sau ng\u1eebng tu\u1ea7n ho\u00e0n. + Ng\u1eebng th\u1edf. 2.2. T\u1ed5n th\u01b0\u01a1ng th\u1ea7n kinh trung \u01a3\u01a1ng m\u1ea1n t\u00ednh - Ti\u1ec1n s\u1eed tai bi\u1ebfn m\u1ea1ch m\u00e1u n\u00e3o. - U n\u00e3o. 2.3. R\u1ed1i lo\u1ea1n chuy\u1ec3n h\u00f3a ho\u1eb7c ng\u1ed9 \u0111\u1ed9c - Qu\u00e1 li\u1ec1u thu\u1ed1c: amphetamine,\u2026 - H\u1ed9i ch\u1ee9ng cai thu\u1ed1c (benzodiazepine, r\u01b0\u1ee3u) - Do c\u00e1c thu\u1ed1c \u0111i\u1ec1u tr\u1ecb: betalactam, theophylline, - T\u0103ng ho\u1eb7c h\u1ea1 \u0111\u01b0\u1eddng m\u00e1u. - R\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i: h\u1ea1 natri m\u00e1u ho\u1eb7c h\u1ea1 canxi m\u00e1u - S\u1ed1t cao \u1edf tr\u1ebb em. 2.4. \u0110\u1ed9ng kinh - Ng\u1eebng \u0111\u1ed9t ng\u1ed9t ho\u1eb7c thay \u0111\u1ed5i li\u1ec1u thu\u1ed1c ch\u1ed1ng \u0111\u1ed9ng kinh. - \u0110\u1ed9ng kinh t\u00e2m th\u1ea7n. 3. TRI\u1ec6U CH\u1ee8NG 3.1. Tri\u1ec7u ch\u1ee9ng l\u00e2m s\u00e0ng 3.1.1. T\u00ecnh tr\u1ea1ng \u0111\u1ed9ng kinh to\u00e0n th\u1ec3 co gi\u1eadt \u2013 t\u0103ng tr\u01b0\u01a1ng l\u1ef1c (tonico \u2013 clonique) - C\u00e1c c\u01a1n \u0111\u1ed9ng kinh to\u00e0n th\u1ec3 n\u1ed1i ti\u1ebfp nhau, kh\u00f4ng ph\u1ee5c h\u1ed3i \u00fd th\u1ee9c gi\u1eefa c\u00e1c c\u01a1n. - \u0110\u00f4i khi c\u01a1n \u0111\u1ed9ng kinh ch\u1ec9 bi\u1ec3u hi\u1ec7n k\u00edn \u0111\u00e1o tr\u00ean l\u00e2m s\u00e0ng b\u1eb1ng co gi\u1eadt nh\u1eb9 \u1edf m\u1eb7t. - C\u00f3 th\u1ec3 ch\u1ec9 bi\u1ec3u hi\u1ec7n b\u1eb1ng h\u00f4n m\u00ea. 3.1.2. C\u01a1n v\u1eafng \u00fd th\u1ee9c k\u00e9o d\u00e0i ho\u1eb7c li\u00ean ti\u1ebfp - Th\u01b0\u1eddng bi\u1ec3u hi\u1ec7n b\u1eb1ng t\u00ecnh tr\u1ea1ng l\u1eabn l\u1ed9n. - C\u00f3 th\u1ec3 c\u00f3 co gi\u1eadt k\u00edn \u0111\u00e1o mi m\u1eaft. - Nguy c\u01a1 di ch\u1ee9ng tr\u00ed tu\u1ec7 v\u0129nh vi\u1ec5n n\u1ebfu c\u01a1n k\u00e9o d\u00e0i. 3.1.3. T\u00ecnh tr\u1ea1ng \u0111\u1ed9ng kinh m\u1ed9t ph\u1ea7n 125","- Nhi\u1ec1u h\u00ecnh th\u00e1i. - C\u01a1n co gi\u1eadt n\u1ed1i ti\u1ebfp nhau v\u1edbi thi\u1ebfu s\u00f3t v\u1eadn \u0111\u1ed9ng gi\u1eefa c\u00e1c c\u01a1n: + R\u1ed1i lo\u1ea1n l\u1eddi n\u00f3i k\u00e9o d\u00e0i. + T\u00ecnh tr\u1ea1ng l\u1eabn l\u1ed9n. - Nguy c\u01a1 c\u00f3 c\u00e1c t\u1ed5n th\u01b0\u01a1ng n\u00e3o kh\u00f4ng h\u1ed3i ph\u1ee5c. 3.2. Tri\u1ec7u ch\u1ee9ng c\u1eadn l\u00e2m s\u00e0ng - \u0110i\u1ec7n n\u00e3o \u0111\u1ed3: x\u00e1c \u0111\u1ecbnh ch\u1ea9n \u0111o\u00e1n tr\u1ea1ng th\u00e1i \u0111\u1ed9ng kinh v\u00e0 ph\u00e2n lo\u1ea1i t\u1ed5n th\u01b0\u01a1ng tr\u00ean h\u1ec7 th\u1ed1ng th\u1ea7n kinh trung \u01b0\u01a1ng. - C\u00e1c ch\u1ea9n \u0111o\u00e1n h\u00ecnh \u1ea3nh v\u00e0 x\u00e9t nghi\u1ec7m kh\u00e1c: \u0111\u00e1nh gi\u00e1 nguy\u00ean nh\u00e2n v\u00e0 bi\u1ebfn ch\u1ee9ng c\u1ee7a tr\u1ea1ng th\u00e1i \u0111\u1ed9ng kinh 4. CH\u1ea8N \u0110O\u00c1N 4.1. Ch\u1ea9n \u0111o\u00e1n x\u00e1c \u0111\u1ecbnh - L\u00e2m s\u00e0ng: co gi\u1eadt k\u00e9o d\u00e0i tr\u00ean 30 ph\u00fat ho\u1eb7c co gi\u1eadt k\u00e9o d\u00e0i tr\u00ean 5 ph\u00fat m\u00e0 kh\u00f4ng c\u00f3 h\u1ed3i ph\u1ee5c th\u1ea7n kinh gi\u1eefa c\u00e1c c\u01a1n - C\u1eadn l\u00e2m s\u00e0ng: \u0110i\u1ec7n n\u00e3o x\u00e1c \u0111\u1ecbnh c\u00e1c s\u00f3ng \u0111\u1ed9ng kinh k\u00e9o d\u00e0i. 4.2. Ch\u1ea9n \u0111o\u00e1n nguy\u00ean nh\u00e2n 4.2.1. Ch\u1ecdc d\u1ecbch n\u00e3o t\u1ee7y: Ph\u00e1t hi\u1ec7n c\u00e1c t\u00ecnh tr\u1ea1ng vi\u00eam m\u00e0ng n\u00e3o do vi khu\u1ea9n, virus, n\u1ea5m, lao, k\u00ed sinh tr\u00f9ng. 4.2.2. Ch\u1ee5p c\u1ed9ng h\u01b0\u1edfng t\u1eeb s\u1ecd n\u00e3o: x\u00e1c \u0111\u1ecbnh huy\u1ebft kh\u1ed1i t\u0129nh m\u1ea1ch, t\u1ed5n th\u01b0\u01a1ng n\u00e3o do thi\u1ebfu oxy, do h\u1ea1 \u0111\u01b0\u1eddng m\u00e1u. 4.2.3. Ch\u1ee5p CT s\u1ecd n\u00e3o: x\u00e1c \u0111\u1ecbnh t\u1ed5n th\u01b0\u01a1ng nh\u1ed3i m\u00e1u n\u00e3o, xu\u1ea5t huy\u1ebft n\u00e3o, xu\u1ea5t huy\u1ebft d\u01b0\u1edbi nh\u1ec7n, c\u00e1c ch\u1ea5n th\u01b0\u01a1ng s\u1ecd n\u00e3o, c\u00e1c t\u1ed5n th\u01b0\u01a1ng u n\u00e3o. 4.2.4. \u0110i\u1ec7n n\u00e3o: R\u1ea5t c\u00f3 gi\u00e1 tr\u1ecb ch\u1ea9n \u0111o\u00e1n tr\u1ea1ng th\u00e1i \u0111\u1ed9ng kinh m\u00e0 bi\u1ec3u hi\u1ec7n l\u00e2m s\u00e0ng kh\u00f4ng r\u00f5 r\u00e0ng. 4.2.5. C\u00e1c x\u00e9t nghi\u1ec7m ch\u1ea9n \u0111o\u00e1n nguy\u00ean nh\u00e2n - T\u00ecm amphetamin, r\u01b0\u1ee3u, thu\u1ed1c ng\u1ee7,\u2026x\u00e9t nghi\u1ec7m m\u00e1u v\u00e0\/ho\u1eb7c n\u01b0\u1edbc ti\u1ec3u. - C\u00e1c r\u1ed1i lo\u1ea1n \u0111i\u1ec7n gi\u1ea3i m\u00e1u: h\u1ea1 natri m\u00e1u, h\u1ea1 canxi m\u00e1u. 5. X\u1eec TR\u00cd 5.1. Nguy\u00ean t\u1eafc x\u1eed tr\u00ed - \u0110\u1ea3m b\u1ea3o ch\u1ee9c n\u0103ng s\u1ed1ng c\u01a1 b\u1ea3n: h\u00f4 h\u1ea5p, huy\u1ebft \u0111\u1ed9ng, toan chuy\u1ec3n h\u00f3a, th\u00e2n nhi\u1ec7t, s\u01a1 c\u1ee9u c\u00e1c ch\u1ea5n th\u01b0\u01a1ng. - C\u1eaft ngay c\u00e1c c\u01a1n co gi\u1eadt b\u1eb1ng m\u1ecdi thu\u1ed1c c\u00f3 s\u1eb5n, c\u00e0ng nhanh c\u00e0ng t\u1ed1t. 5.2. C\u00e1c thu\u1ed1c c\u1eaft c\u01a1n co gi\u1eadt - Benzodiazepines:thu\u1ed1c c\u1eaft c\u01a1n co gi\u1eadt \u0111\u1ea7u tay v\u00ec t\u00e1c d\u1ee5ng c\u1eaft c\u01a1n co gi\u1eadt nhanh Th\u1eddi gian t\u00e1c Th\u1eddi gian duy \u01afu \u0111i\u1ec3m Nh\u01b0\u1ee3c d\u1ee5ng sau ti\u00eam tr\u00ec t\u00e1c d\u1ee5ng \u0111i\u1ec3m Diazepam \u1ed4n \u0111\u1ecbnh \u1edf nhi\u1ec7t \u0111\u1ed9 (Valium) 10-20s <20 ph\u00fat ph\u00f2ng Ph\u00e2n b\u1ed1 v\u00e0o m\u00f4 m\u1ee1 Lorazepam 2 ph\u00fat 4-6h (Temesta) < 1 ph\u00fat Ng\u1eafn C\u00f3 th\u1ec3 truy\u1ec1n li\u00ean t\u1ee5c Midazolam trong \u0111i\u1ec1u tr\u1ecb tr\u1ea1ng th\u00e1i (Hypnovel) \u0111\u1ed9ng kinh tr\u01a1 \u00cdt \u1ea3nh h\u01b0\u1edfng tim m\u1ea1ch Clonazepam Nhanh 2-4h (Rivotril) - Phenytoin (ho\u1eb7c fosphenytoin) (Dyhydan, Dilantin) + Hi\u1ec7u qu\u1ea3 (60 -80%) \u0111\u1eb7c bi\u1ec7t v\u1edbi c\u01a1n \u0111\u1ed9ng kinh c\u1ee5c b\u1ed9 v\u00e0 d\u1ef1 ph\u00f2ng t\u00e1i ph\u00e1t c\u01a1n co gi\u1eadt trong th\u1eddi gian d\u00e0i. + Li\u1ec1u t\u1ed1i \u0111a: phenytoin \u0111\u1ebfn 50mg\/ph\u00fat, fosfenyltoin \u0111\u1ebfn 150mg\/ph\u00fat. + T\u00e1c d\u1ee5ng ph\u1ee5: \u1ee9c ch\u1ebf tu\u1ea7n ho\u00e0n v\u00e0 c\u1ea7n ti\u00eam ch\u1eadm. + Ch\u1ed1ng ch\u1ec9 \u0111\u1ecbnh: b\u1ec7nh tim m\u1ea5t b\u00f9, r\u1ed1i lo\u1ea1n d\u1eabn truy\u1ec1n. Kh\u00f4ng n\u00ean d\u00f9ng \u1edf ng\u01b0\u1eddi gi\u00e0, b\u1ec7nh m\u1ea1ch v\u00e0nh. 126","- Barbiturat: T\u00e1c \u0111\u1ed9ng th\u00f4ng qua GABA receptor. Hai thu\u1ed1c trong nh\u00f3m n\u00e0y hay \u0111\u01b0\u1ee3c d\u00f9ng nh\u1ea5t l\u00e0 Phenobarbital & Pentobarbital. + Phenobarbital: \u00b7 R\u1ea5t hi\u1ec7u qu\u1ea3, ti\u00eam t\u0129nh m\u1ea1ch t\u00e1c d\u1ee5ng sau 5 ph\u00fat v\u00e0 t\u00e1c d\u1ee5ng k\u00e9o d\u00e0i. \u00b7 Nguy c\u01a1: \u1ee9c ch\u1ebf th\u1ea7n kinh (t\u0103ng l\u00ean khi ph\u1ed1i h\u1ee3p v\u1edbi benzodiazepam + Thiopental: \u00b7 T\u00e1c d\u1ee5ng nhanh, hi\u1ec7u qu\u1ea3; \u0111\u01b0\u1ee3c d\u00f9ng nhi\u1ec1u t\u1ea1i c\u00e1c khoa HSCC.\u00b7 Nguy c\u01a1: \u1ee9c ch\u1ebf TK, ng\u1eebng th\u1edf, tru\u1ef5 m\u1ea1ch, t\u1ed5n th\u01b0\u01a1ng gan. \u00b7 Li\u1ec1u d\u00f9ng: t\u1ea5n c\u00f4ng 3-5mg\/kg sau \u0111\u00f3 50mg\/ph\u00fat, duy tr\u00ec 1-5mg\/kg\/gi\u1edd. - Propofol: + Th\u01b0\u1eddng d\u00f9ng khi \u0111i\u1ec1u tr\u1ecb tr\u1ea1ng th\u00e1i \u0111\u1ed9ng kinh tr\u01a1. + T\u00e1c d\u1ee5ng nhanh, th\u1eddi gian t\u00e1c d\u1ee5ng ng\u1eafn. C\u00f3 th\u1ec3 g\u00e2y t\u1ee5t huy\u1ebft \u00e1p ho\u1eb7c \u1ee9c ch\u1ebf h\u00f4 h\u1ea5p, hi\u1ebfm g\u1eb7p nh\u01b0ng nguy hi\u1ec3m l\u00e0 h\u1ed9i ch\u1ee9ng bao g\u1ed3m nhi\u1ec5m toan chuy\u1ec3n h\u00f3a, ti\u00eau c\u01a1 v\u00e2n, suy th\u1eadn v\u00e0 r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng tim. - M\u1ed9t s\u1ed1 thu\u1ed1c kh\u00e1c: + Valproate (depakine): \u00edt kinh nghi\u1ec7m d\u00f9ng \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch. + MgSO4: ch\u1ee7 y\u1ebfu d\u00f9ng trong s\u1ea3n gi\u1eadt, li\u1ec1u 2-4g\/5 ph\u00fat t\u0129nh m\u1ea1ch sau \u0111\u00f3 truy\u1ec1n 1g\/gi\u1edd trong 24 gi\u1edd. + Lidocain t\u0129nh m\u1ea1ch: \u00edt d\u00f9ng (hi\u1ec7u qu\u1ea3 tho\u00e1ng qua, t\u00e1c d\u1ee5ng ph\u1ee5 nhi\u1ec1u). + Thu\u1ed1c gi\u00e3n c\u01a1: kh\u00f4ng ph\u1ea3i l\u00e0 thu\u1ed1c ch\u1ed1ng \u0111\u1ed9ng kinh ch\u1ee7 y\u1ebfu d\u00f9ng \u0111\u1ec3 kh\u1ed1ng ch\u1ebf c\u00e1c h\u1eadu qu\u1ea3 c\u1ee7a c\u01a1n gi\u1eadt. 5.3. C\u00e1c bi\u1ec7n ph\u00e1p h\u1ed3i s\u1ee9c chung 5.3.1. \u0110\u1ea3m b\u1ea3o h\u00f4 h\u1ea5p - \u0110\u1eb7t n\u1ed9i kh\u00ed qu\u1ea3n (b\u1ea3o v\u1ec7 \u0111\u01b0\u1eddng th\u1edf, h\u00fat \u0111\u1eddm). - Th\u1edf m\u00e1y ch\u1ebf \u0111\u1ed9 ki\u1ec3m so\u00e1t.th\u1ec3 t\u00edch n\u1ebfu h\u00f4n m\u00ea. - Theo d\u00f5i SpO2 ( > 95% ) v\u00e0 kh\u00ed m\u00e1u \u0111\u1ed9ng m\u1ea1ch. 5.3.2. \u0110\u1ea3m b\u1ea3o huy\u1ebft \u0111\u1ed9ng - Theo d\u00f5i nh\u1ecbp tim v\u00e0 huy\u1ebft \u00e1p. - N\u00ean \u0111\u1eb7t catheter t\u0129nh m\u1ea1ch trung t\u00e2m: \u0111\u1ea3m b\u1ea3o truy\u1ec1n d\u1ecbch, truy\u1ec1n thu\u1ed1c + \u0111o \u00e1p l\u1ef1c t\u0129nh m\u1ea1ch trung t\u00e2m. - N\u1ebfu t\u1ee5t huy\u1ebft \u00e1p: b\u1ed3i ph\u1ee5 th\u1ec3 t\u00edch, thu\u1ed1c v\u1eadn m\u1ea1ch, \u0111\u1ea3m b\u1ea3o th\u00f4ng kh\u00ed, \u0111i\u1ec1u ch\u1ec9nh r\u1ed1i lo\u1ea1n toan chuy\u1ec3n ho\u00e1 n\u1eb7ng. 5.3.3. Toan chuy\u1ec3n ho\u00e1 - Theo d\u00f5i kh\u00ed m\u00e1u \u0111\u1ed9ng m\u1ea1ch. - \u0110a s\u1ed1 toan chuy\u1ec3n ho\u00e1 s\u1ebd t\u1ef1 \u0111i\u1ec1u ch\u1ec9nh sau khi \u0111\u00e3 ki\u1ec3m so\u00e1t \u0111\u01b0\u1ee3c co gi\u1eadt. - NaHCO3 khi toan r\u1ea5t n\u1eb7ng pH < 7,15. - C\u00f3 th\u1ec3 k\u1ebft h\u1ee3p toan h\u00f4 h\u1ea5p, ch\u00fa \u00fd \u0111i\u1ec1u ch\u1ec9nh l\u1ea1i l\u01b0u l\u01b0\u1ee3ng thong kh\u00ed\/ph\u00fat. 5.3.4. T\u0103ng th\u00e2n nhi\u1ec7t - Th\u01b0\u1eddng g\u1eb7p do b\u1ea3n th\u00e2n co gi\u1eadt g\u00e2y ra, nguy c\u01a1 g\u00e2y n\u1eb7ng h\u01a1n t\u1ed5n th\u01b0\u01a1ng th\u1ea7n kinh trung \u01b0\u01a1ng. - C\u1ea7n nhanh ch\u00f3ng h\u1ea1 th\u00e2n nhi\u1ec7t < 390 C: ch\u01b0\u1eddm l\u1ea1nh, tho\u00e1ng gi\u00f3, paracetamol 0,5g\/ m\u1ed7i 4 gi\u1edd. 5.3.5. Ph\u00f9 n\u00e3o - N\u1eb1m \u0111\u1ea7u cao 45 \u0111\u1ed9. - Manitol truy\u1ec1n t\u0129nh m\u1ea1ch nhanh trong 30 ph\u00fat 0,5- 1 g\/kg c\u00e2n n\u1eb7ng m\u1ed7i 4 \u2013 6 gi\u1edd 148- Methylprednisolon 40mg ti\u00eam t\u0129nh m\u1ea1ch \/6 -8 gi\u1edd. Ho\u1eb7c Dexamethasone trong vi\u00eam m\u00e0ng n\u00e3o. - Kh\u1ed1ng ch\u1ebf c\u01a1n gi\u1eadt. 5.3.6. Ph\u00f2ng v\u00e0 \u0111i\u1ec1u tr\u1ecb ti\u00eau c\u01a1 v\u00e2n Truy\u1ec1n d\u1ecbch v\u00e0 cho \u0111i ti\u1ec3u nhi\u1ec1u (100 ml\/gi\u1edd) v\u00e0 thu\u1ed1c l\u1ee3i ti\u1ec3u t\u0129nh m\u1ea1ch n\u1ebfu th\u1ea5y c\u1ea7n thi\u1ebft. 5.3.7. Ch\u00fa \u00fd s\u01a1 c\u1ee9u c\u00e1c ch\u1ea5n th\u01b0\u01a1ng k\u00e8m theo: ch\u1ea5n th\u01b0\u01a1ng s\u1ecd n\u00e3o, ch\u1ea5n th\u01b0\u01a1ng h\u00e0m m\u1eb7t, g\u00e3y x\u01b0\u01a1ng\u2026 6. TI\u00caN L\u01af\u1ee2NG V\u00c0 BI\u1ebeN CH\u1ee8NG 127","6.1. Ti\u00ean l\u01b0\u1ee3ng - T\u1ec9 l\u1ec7 t\u1eed vong \u1edf b\u1ec7nh nh\u00e2n l\u1ea7n \u0111\u1ea7u xu\u1ea5t hi\u1ec7n tr\u1ea1ng th\u00e1i \u0111\u1ed9ng kinh kho\u1ea3ng 20%, thay \u0111\u1ed5i t\u00f9y theo nguy\u00ean nh\u00e2n kh\u1edfi ph\u00e1t. - Nguy\u00ean nh\u00e2n t\u1eed vong li\u00ean quan ch\u1ee7 y\u1ebfu \u0111\u1ebfn nh\u1eefng r\u1ed1i lo\u1ea1n do t\u00ecnh tr\u1ea1ng co gi\u1eadt c\u01a1 k\u00e9o d\u00e0i nh\u01b0: ti\u00eau c\u01a1 v\u00e2n, toan lactic, vi\u00eam ph\u1ed5i do h\u00edt, suy h\u00f4 h\u1ea5p\u2026 - Nguy c\u01a1 t\u00e1i ph\u00e1t co gi\u1eadt g\u1eb7p \u1edf 1\/3 s\u1ed1 b\u1ec7nh nh\u00e2n theo m\u1ed9t nghi\u00ean c\u1ee9u theo d\u00f5i d\u1ecdc 10 n\u0103m, v\u00e0 10% b\u1ec7nh nh\u00e2n c\u00f3 nh\u1eefng di ch\u1ee9ng th\u1ea7n kinh. 6.2. Bi\u1ebfn ch\u1ee9ng - Khi c\u00f3 c\u01a1n co gi\u1eadt k\u00e9o d\u00e0i tr\u00ean 30-45 ph\u00fat c\u00f3 th\u1ec3 g\u00e2y ra c\u00e1c t\u1ed5n th\u01b0\u01a1ng n\u00e3o (nh\u1ea5t l\u00e0 c\u1ea5u tr\u00fac limbic nh\u01b0 h\u1ed3i h\u1ea3i m\u00e3): n\u00e3o, di ch\u1ee9ng th\u1ea7n kinh, tr\u00ed tu\u1ec7 v\u0129nh vi\u1ec5n. - Ngo\u00e0i ra, t\u00ecnh tr\u1ea1ng \u0111\u1ed9ng kinh c\u00f3 th\u1ec3 g\u00e2y ra nhi\u1ec1u h\u1eadu qu\u1ea3 kh\u00e1c: + Ch\u1ea5n th\u01b0\u01a1ng: ch\u1ea5n th\u01b0\u01a1ng s\u1ecd n\u00e3o, tr\u1eadt kh\u1edbp vai, g\u00e3y x\u01b0\u01a1ng, \u0111\u1ee5ng d\u1eadp t\u1ea1ng. + R\u1ed1i lo\u1ea1n h\u00f4 h\u1ea5p: \u1ee9 \u0111\u1ecdng, vi\u00eam ph\u1ed5i do s\u1eb7c, toan h\u00f4 h\u1ea5p. + R\u1ed1i lo\u1ea1n huy\u1ebft \u0111\u1ed9ng. + Toan chuy\u1ec3n ho\u00e1. + R\u1ed1i lo\u1ea1n th\u00e2n nhi\u1ec7t, m\u1ea5t n\u01b0\u1edbc, ti\u00eau c\u01a1 v\u00e2n. 7. PH\u00d2NG B\u1ec6NH - S\u1eed d\u1ee5ng thu\u1ed1c \u0111\u00fang li\u1ec1u l\u01b0\u1ee3ng v\u00e0 kh\u00f4ng ng\u1eebng thu\u1ed1c \u0111\u1ed9t ng\u1ed9t. - Tr\u00e1nh c\u00e1c \u0111i\u1ec1u ki\u1ec7n thu\u1eadn l\u1ee3i g\u00e2y c\u01a1n co gi\u1eadt, b\u1ed1 tr\u00ed c\u00f4ng vi\u1ec7c v\u00e0 ngh\u1ec1 nghi\u1ec7p h\u1ee3p l\u00fd \u0111\u1ec3 ph\u00f2ng tr\u00e1nh c\u00e1c tai n\u1ea1n th\u1ee9 ph\u00e1t x\u1ea3y ra khi co gi\u1eadt. T\u00e0i li\u1ec7u tham kh\u1ea3o B\u1ed8 Y T\u1ebe 2015 Quy\u1ebft \u0111\u1ecbnh 4193\/Q\u0110-BYT ng\u00e0y 22\/04\/2015 c\u1ee7a B\u1ed9 Y t\u1ebf 128","NHI\u1ec4M KHU\u1ea8N HUY\u1ebeT V\u00c0 S\u1ed0C NHI\u1ec4M KHU\u1ea8N 1. \u0110\u1ea0I C\u01af\u01a0NG Nhi\u1ec5m khu\u1ea9n huy\u1ebft l\u00e0 m\u1ed9t b\u1ec7nh nhi\u1ec5m khu\u1ea9n c\u1ea5p t\u00ednh, g\u00e2y ra do vi khu\u1ea9n l\u01b0u h\u00e0nh trong m\u00e1u g\u00e2y ra c\u00e1c tri\u1ec7u ch\u1ee9ng l\u00e2m s\u00e0ng \u0111a d\u1ea1ng, suy \u0111a t\u1ea1ng, s\u1ed1c nhi\u1ec5m khu\u1ea9n v\u1edbi t\u1ec9 l\u1ec7 t\u1eed vong r\u1ea5t cao (t\u1eeb 20 - 50%), trong \u0111\u00f3 s\u1ed1c nhi\u1ec5m khu\u1ea9n l\u00e0 bi\u1ec3u hi\u1ec7n n\u1eb7ng c\u1ee7a nhi\u1ec5m khu\u1ea9n huy\u1ebft. C\u00e1c y\u1ebfu t\u1ed1 nguy c\u01a1: Ng\u01b0\u1eddi gi\u00e0, tr\u1ebb s\u01a1 sinh\/\u0111\u1ebb non. Ng\u01b0\u1eddi s\u1eed d\u1ee5ng thu\u1ed1c \u1ee9c ch\u1ebf mi\u1ec5n d\u1ecbch, nh\u01b0 s\u1eed d\u1ee5ng corticoid k\u00e9o d\u00e0i, c\u00e1c thu\u1ed1c ch\u1ed1ng th\u1ea3i gh\u00e9p, ho\u1eb7c \u0111ang \u0111i\u1ec1u tr\u1ecb h\u00f3a ch\u1ea5t v\u00e0 tia x\u1ea1. Ng\u01b0\u1eddi b\u1ec7nh c\u00f3 b\u1ec7nh l\u00fd m\u1ea1n t\u00ednh, nh\u01b0 ti\u1ec3u \u0111\u01b0\u1eddng, HIV\/AIDS, x\u01a1 gan, b\u1ec7nh van tim v\u00e0 tim b\u1ea9m sinh, b\u1ec7nh ph\u1ed5i m\u1ea1n t\u00ednh, suy th\u1eadn m\u1ea1n t\u00ednh. Ng\u01b0\u1eddi b\u1ec7nh c\u1eaft l\u00e1ch, nghi\u1ec7n r\u01b0\u1ee3u, c\u00f3 b\u1ec7nh m\u00e1u \u00e1c t\u00ednh, gi\u1ea3m b\u1ea1ch c\u1ea7u h\u1ea1t. Ng\u01b0\u1eddi b\u1ec7nh c\u00f3 \u0111\u1eb7t c\u00e1c thi\u1ebft b\u1ecb ho\u1eb7c d\u1ee5ng c\u1ee5 x\u00e2m nh\u1eadp nh\u01b0 \u0111inh n\u1ed9i t\u1ee7y, catheter, \u0111\u1eb7t \u1ed1ng n\u1ed9i kh\u00ed qu\u1ea3n\u2026 2. NGUY\u00caN NH\u00c2N Nhi\u1ec5m khu\u1ea9n huy\u1ebft do vi khu\u1ea9n x\u00e2m nh\u1eadp tr\u1ef1c ti\u1ebfp v\u00e0o m\u00e1u ho\u1eb7c t\u1eeb c\u00e1c \u1ed5 nhi\u1ec5m khu\u1ea9n \u1edf m\u00f4 v\u00e0 c\u01a1 quan nh\u01b0: da, m\u00f4 m\u1ec1m, c\u01a1, x\u01b0\u01a1ng kh\u1edbp, h\u00f4 h\u1ea5p, ti\u00eau h\u00f3a\u2026 C\u00e1c vi khu\u1ea9n th\u01b0\u1eddng g\u00e2y nhi\u1ec5m khu\u1ea9n huy\u1ebft: M\u1ed9t s\u1ed1 vi khu\u1ea9n Gram-\u00e2m g\u00e2y nhi\u1ec5m khu\u1ea9n huy\u1ebft th\u01b0\u1eddng g\u1eb7p: Vi khu\u1ea9n Gram-\u00e2m \u0111\u01b0\u1eddng ru\u1ed9t h\u1ecd Enterobacteriacae: bao g\u1ed3m Salmonella, Escherichia coli, Klebsiella, Serratia, v\u00e0 c\u00e1c vi khu\u1ea9n Enterobacter\u2026; Pseudomonas aeruginosa; Burkholderia pseudomallei. M\u1ed9t s\u1ed1 vi khu\u1ea9n Gram-d\u01b0\u01a1ng g\u00e2y b\u1ec7nh th\u01b0\u1eddng g\u1eb7p: Streptococcus pneumoniae, Staphylococcus aureus, Streptococcus suis\u2026 C\u00e1c vi khu\u1ea9n k\u1ecb kh\u00ed th\u01b0\u1eddng g\u1eb7p: Clostridium perfringens v\u00e0 Bacteroides fragilis. 3. TRI\u1ec6U CH\u1ee8NG - CH\u1ea8N \u0110O\u00c1N 3.1. Nhi\u1ec5m khu\u1ea9n huy\u1ebft Ch\u1ea9n \u0111o\u00e1n d\u1ef1a tr\u00ean tri\u1ec7u ch\u1ee9ng l\u00e2m s\u00e0ng v\u00e0 ch\u1ea9n \u0111o\u00e1n x\u00e1c \u0111\u1ecbnh d\u1ef1a tr\u00ean k\u1ebft qu\u1ea3 c\u1ea5y m\u00e1u. a) L\u00e2m s\u00e0ng S\u1ed1t v\u00e0 c\u00e1c tri\u1ec7u ch\u1ee9ng to\u00e0n th\u00e2n. S\u1ed1t l\u00e0 tri\u1ec7u ch\u1ee9ng r\u1ea5t th\u01b0\u1eddng g\u1eb7p, c\u00f3 th\u1ec3 k\u00e8m theo r\u00e9t run ho\u1eb7c kh\u00f4ng. Trong nh\u1eefng tr\u01b0\u1eddng h\u1ee3p n\u1eb7ng, ng\u01b0\u1eddi b\u1ec7nh c\u00f3 th\u1ec3 h\u1ea1 th\u00e2n nhi\u1ec7t. Nh\u1ecbp tim nhanh, th\u1edf nhanh, c\u00f3 th\u1ec3 thay \u0111\u1ed5i t\u00ecnh tr\u1ea1ng \u00fd th\u1ee9c. Ph\u00f9, gan l\u00e1ch to. Tri\u1ec7u ch\u1ee9ng \u1ed5 nhi\u1ec5m khu\u1ea9n kh\u1edfi \u0111i\u1ec3m: Nhi\u1ec5m khu\u1ea9n ti\u00eau h\u00f3a: \u00c1p xe gan, vi\u00eam t\u00fai m\u1eadt, vi\u00eam ru\u1ed9t, vi\u00eam \u0111\u1ea1i tr\u00e0ng, th\u1ee7ng ru\u1ed9t hay c\u00e1c \u1ed5 \u00e1p xe kh\u00e1c. Nhi\u1ec5m khu\u1ea9n sinh d\u1ee5c ti\u1ebft ni\u1ec7u: Vi\u00eam \u0111\u00e0i b\u1ec3 th\u1eadn, \u00e1p xe th\u1eadn, s\u1ecfi th\u1eadn c\u00f3 bi\u1ebfn ch\u1ee9ng, \u00e1p xe tuy\u1ebfn ti\u1ec1n li\u1ec7t. Nhi\u1ec5m khu\u1ea9n v\u00f9ng ti\u1ec3u khung: Vi\u00eam ph\u00fac m\u1ea1c v\u00f9ng ti\u1ec3u khung, \u00e1p xe bu\u1ed3ng tr\u1ee9ng-v\u00f2i tr\u1ee9ng. Nhi\u1ec5m khu\u1ea9n h\u00f4 h\u1ea5p d\u01b0\u1edbi: Vi\u00eam ph\u1ed5i, vi\u00eam m\u1ee7 m\u00e0ng ph\u1ed5i, \u00e1p xe ph\u1ed5i\u2026 Nhi\u1ec5m khu\u1ea9n m\u1ea1ch m\u00e1u do c\u00e1c \u0111\u01b0\u1eddng truy\u1ec1n t\u0129nh m\u1ea1ch, c\u00e1c catheter m\u1ea1ch m\u00e1u, thi\u1ebft b\u1ecb nh\u00e2n t\u1ea1o nhi\u1ec5m khu\u1ea9n. Nhi\u1ec5m khu\u1ea9n tim m\u1ea1ch: Vi\u00eam n\u1ed9i t\u00e2m m\u1ea1c nhi\u1ec5m khu\u1ea9n, \u00e1p xe c\u01a1 tim, \u00e1p xe c\u1ea1nh van tim. C\u00e1c nhi\u1ec5m khu\u1ea9n da v\u00e0 ni\u00eam m\u1ea1c. Tri\u1ec7u ch\u1ee9ng r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng c\u01a1 quan: Suy gan, suy th\u1eadn\u2026 Bi\u1ebfn ch\u1ee9ng: S\u1ed1c nhi\u1ec5m khu\u1ea9n, suy \u0111a t\u1ea1ng. b) X\u00e9t nghi\u1ec7m C\u1ea5y m\u00e1u d\u01b0\u01a1ng t\u00ednh l\u00e0 ti\u00eau chu\u1ea9n v\u00e0ng \u0111\u1ec3 ch\u1ea9n \u0111o\u00e1n nhi\u1ec5m khu\u1ea9n huy\u1ebft. Tuy nhi\u00ean, c\u1ea7n l\u01b0u \u00fd l\u00e0 k\u1ebft qu\u1ea3 c\u1ea5y m\u00e1u \u00e2m t\u00ednh c\u0169ng kh\u00f4ng lo\u1ea1i tr\u1eeb \u0111\u01b0\u1ee3c nhi\u1ec5m khu\u1ea9n huy\u1ebft, c\u00f3 kho\u1ea3ng 60% nhi\u1ec5m khu\u1ea9n huy\u1ebft c\u00f3 k\u1ebft qu\u1ea3 c\u1ea5y m\u00e1u \u00e2m t\u00ednh. 129","N\u00ean c\u1ea5y m\u00e1u 02 l\u1ea7n (\u0111\u1ed1i v\u1edbi c\u1ea3 nu\u00f4i c\u1ea5y hi\u1ebfu kh\u00ed v\u00e0 k\u1ef5 kh\u00ed) tr\u01b0\u1edbc khi \u0111i\u1ec1u tr\u1ecb kh\u00e1ng sinh v\u1edbi th\u1ec3 t\u00edch m\u00e1u t\u1ed1i thi\u1ec3u l\u00e0 10 ml\/m\u1eabu. Tuy nhi\u00ean tr\u00e1nh \u0111\u1ec3 vi\u1ec7c l\u1ea5y b\u1ec7nh ph\u1ea9m tr\u00ec ho\u00e3n vi\u1ec7c s\u1eed d\u1ee5ng kh\u00e1ng sinh > 45 ph\u00fat. N\u1ebfu l\u1ea5y 2 m\u1eabu m\u00e1u \u0111\u1ed3ng th\u1eddi th\u00ec c\u1ea7n l\u1ea5y \u1edf 2 v\u1ecb tr\u00ed kh\u00e1c nhau. Trong tr\u01b0\u1eddng h\u1ee3p c\u00f3 catheter m\u1ea1ch m\u00e1u \u0111\u00e3 \u0111\u1eb7t qu\u00e1 48 gi\u1edd, c\u1ea7n l\u1ea5y \u00edt nh\u1ea5t m\u1ed9t m\u1eabu b\u1ec7nh ph\u1ea9m qua catheter n\u00e0y. X\u00e9t nghi\u1ec7m huy\u1ebft h\u1ecdc: S\u1ed1 l\u01b0\u1ee3ng b\u1ea1ch c\u1ea7u m\u00e1u ngo\u1ea1i vi > 12 G\/l ho\u1eb7c < 4 G\/l ho\u1eb7c t\u1ec9 l\u1ec7 b\u1ea1ch c\u1ea7u non > 10%, gi\u1ea3m ti\u1ec3u c\u1ea7u (< 100 G\/L), r\u1ed1i lo\u1ea1n \u0111\u00f4ng m\u00e1u (INR > 1.5 ho\u1eb7c aPTT > 60 gi\u00e2y). X\u00e9t nghi\u1ec7m sinh h\u00f3a: Gi\u1ea3m oxy m\u00e1u \u0111\u1ed9ng m\u1ea1ch: PaO2\/FIO2 < 300, creatinin t\u0103ng, t\u0103ng bilirubin m\u00e1u, t\u0103ng men gan, protein ph\u1ea3n \u1ee9ng C (CRP) th\u01b0\u1eddng > 150 mg\/l, t\u0103ng procalcitonin > 1,5 ng\/ml. C\u00e1c x\u00e9t nghi\u1ec7m kh\u00e1c \u0111\u00e1nh gi\u00e1 t\u1ed5n th\u01b0\u01a1ng c\u01a1 quan theo v\u1ecb tr\u00ed nhi\u1ec5m khu\u1ea9n kh\u1edfi \u0111i\u1ec3m nh\u01b0 x\u00e9t nghi\u1ec7m d\u1ecbch n\u00e3o t\u1ee7y, t\u1ed5ng ph\u00e2n t\u00edch n\u01b0\u1edbc ti\u1ec3u, X-quang ng\u1ef1c, si\u00eau \u00e2m\u2026 3.2. S\u1ed1c nhi\u1ec5m khu\u1ea9n Ch\u1ea9n \u0111o\u00e1n x\u00e1c \u0111\u1ecbnh khi c\u00f3 ti\u00eau chu\u1ea9n sau: Nhi\u1ec5m khu\u1ea9n n\u1eb7ng, r\u1ed1i lo\u1ea1n ch\u1ee9c n\u0103ng c\u00e1c c\u01a1 quan. T\u1ee5t huy\u1ebft \u00e1p (HA t\u00e2m thu < 90 mmHg, HA trung b\u00ecnh < 70 mmHg, HA t\u00e2m thu gi\u1ea3m > 40 mmHg ho\u1eb7c huy\u1ebft \u00e1p gi\u1ea3m d\u01b0\u1edbi 2 l\u1ea7n \u0111\u1ed9 l\u1ec7ch chu\u1ea9n so v\u1edbi gi\u00e1 tr\u1ecb b\u00ecnh th\u01b0\u1eddng c\u1ee7a l\u1ee9a tu\u1ed5i \u0111\u00f3) v\u00e0 kh\u00f4ng h\u1ed3i ph\u1ee5c khi b\u00f9 \u0111\u1ee7 d\u1ecbch ho\u1eb7c c\u1ea7n ph\u1ea3i d\u00f9ng thu\u1ed1c v\u1eadn m\u1ea1ch. 4. \u0110I\u1ec0U TR\u1eca 4.1. \u0110i\u1ec1u tr\u1ecb kh\u00e1ng sinh 4.1.1. Nguy\u00ean t\u1eafc \u0110i\u1ec1u tr\u1ecb s\u1edbm ngay trong gi\u1edd \u0111\u1ea7u khi ngh\u0129 \u0111\u1ebfn nhi\u1ec5m khu\u1ea9n huy\u1ebft v\u00e0 s\u1ed1c nhi\u1ec5m khu\u1ea9n sau khi \u0111\u00e3 c\u1ea5y m\u00e1u. S\u1eed d\u1ee5ng li\u1ec7u ph\u00e1p kinh nghi\u1ec7m theo chi\u1ebfn l\u01b0\u1ee3c xu\u1ed1ng thang, kh\u00e1ng sinh ph\u1ed5 r\u1ed9ng bao ph\u1ee7 \u0111\u01b0\u1ee3c t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh (ph\u1ed1i h\u1ee3p kh\u00e1ng sinh n\u1ebfu c\u1ea7n), kh\u00e1ng sinh th\u1ea5m t\u1ed1t v\u00e0o t\u1ed5 ch\u1ee9c b\u1ecb b\u1ec7nh v\u00e0 s\u1eed d\u1ee5ng kh\u00e1ng sinh theo kh\u00e1ng sinh \u0111\u1ed3 theo h\u01b0\u1edbng kh\u00e1ng sinh ph\u1ed5 h\u1eb9p nh\u1ea1y c\u1ea3m v\u1edbi vi khu\u1ea9n g\u00e2y b\u1ec7nh. \u01afu ti\u00ean s\u1eed d\u1ee5ng kh\u00e1ng sinh \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch. 4.1.2. Li\u1ec7u ph\u00e1p kh\u00e1ng sinh theo kinh nghi\u1ec7m a) \u0110\u1ed1i v\u1edbi c\u00e1c ng\u01b0\u1eddi b\u1ec7nh ch\u01b0a x\u00e1c \u0111\u1ecbnh \u0111\u01b0\u1ee3c \u1ed5 nhi\u1ec5m khu\u1ea9n tr\u01b0\u1edbc \u0111\u00f3 tr\u00ean l\u00e2m s\u00e0ng v\u00e0 kh\u00f4ng c\u00f3 nguy c\u01a1 nhi\u1ec5m khu\u1ea9n b\u1ec7nh vi\u1ec7n V\u1edbi ng\u01b0\u1eddi b\u1ec7nh c\u00f3 \u0111\u00e1p \u1ee9ng mi\u1ec5n d\u1ecbch b\u00ecnh th\u01b0\u1eddng: T\u00f9y thu\u1ed9c v\u00e0o th\u00f4ng tin vi khu\u1ea9n v\u00e0 nh\u1ea1y c\u1ea3m kh\u00e1ng sinh t\u00f9y t\u1eebng \u0111\u01a1n v\u1ecb c\u00f3 th\u1ec3 l\u1ef1a ch\u1ecdn sau \u0111\u00e2y S\u1eed d\u1ee5ng kh\u00e1ng sinh ph\u1ed5 r\u1ed9ng \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch s\u1edbm ngay trong gi\u1edd \u0111\u1ea7u: Ph\u1ed1i h\u1ee3p m\u1ed9t kh\u00e1ng sinh nh\u00f3m penicilin ph\u1ed5 r\u1ed9ng (piperacilin-tazobactam) ho\u1eb7c cephalosporin th\u1ebf h\u1ec7 ba (ceftriaxon, cefotaxim, ceftazidim, cefoperazol...) ho\u1eb7c th\u1ebf h\u1ec7 b\u1ed1n (cefepim, cefpirom) ph\u1ed1i h\u1ee3p v\u1edbi m\u1ed9t kh\u00e1ng sinh nh\u00f3m quinolon (ciprofloxacin, levofloxacin ho\u1eb7c moxifloxacin) ho\u1eb7c v\u1edbi m\u1ed9t kh\u00e1ng sinh nh\u00f3m aminoglycosid (amikacin, neltimicin...) N\u1ebfu nghi ng\u1edd t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh l\u00e0 S. aureus (t\u1ee5 c\u1ea7u v\u00e0ng), c\u00e2n nh\u1eafc s\u1eed d\u1ee5ng c\u00e1c kh\u00e1ng sinh ch\u1ed1ng t\u1ee5 c\u1ea7u nh\u01b0 oxacilin, cloxacilin, cefazolin (khi nghi ng\u1edd nhi\u1ec5m t\u1ee5 c\u1ea7u v\u00e0ng nh\u1ea1y methicilin, MSSA) ho\u1eb7c vancomycin, teicoplanin ho\u1eb7c daptomycin (\u0111\u1ed1i v\u1edbi tr\u01b0\u1eddng h\u1ee3p nghi nhi\u1ec5m t\u1ee5 c\u1ea7u kh\u00e1ng methicilin, MRSA). N\u1ebfu nghi ng\u1edd t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh l\u00e0 vi khu\u1ea9n k\u1ef5 kh\u00ed, c\u00e2n nh\u1eafc s\u1eed d\u1ee5ng metronidazol. V\u1edbi c\u00e1c ng\u01b0\u1eddi b\u1ec7nh c\u00f3 gi\u1ea3m b\u1ea1ch c\u1ea7u h\u1ea1t, suy gi\u1ea3m mi\u1ec5n d\u1ecbch. C\u1ea7n d\u00f9ng kh\u00e1ng sinh ph\u1ed5 r\u1ed9ng \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch n\u1ebfu s\u1ed1 l\u01b0\u1ee3ng b\u1ea1ch c\u1ea7u h\u1ea1t < 0,5 x 109 \/L ho\u1eb7c d\u1ef1 \u0111o\u00e1n s\u1ebd gi\u1ea3m < 0,5 x 109 \/L \u1edf c\u00e1c ng\u01b0\u1eddi b\u1ec7nh c\u00f3 s\u1ed1 l\u01b0\u1ee3ng b\u1ea1ch c\u1ea7u h\u1ea1t < 1 x 109 \/L. Ph\u1ed1i h\u1ee3p m\u1ed9t kh\u00e1ng sinh nh\u00f3m carbapenem (ertapenem, imipenem-cilastatin, doripenem, meropenem) ho\u1eb7c kh\u00e1ng sinh nh\u00f3m penicilin ph\u1ed5 r\u1ed9ng (piperacilin tazobactam) v\u1edbi m\u1ed9t kh\u00e1ng sinh nh\u00f3m quinolon (ciprofloxacin, levofloxacin ho\u1eb7c 130","moxifloxacin) ho\u1eb7c v\u1edbi m\u1ed9t kh\u00e1ng sinh nh\u00f3m aminoglycosid (amikacin, neltimicin). T\u00f9y theo \u0111i\u1ec1u ki\u1ec7n c\u1ee7a c\u01a1 s\u1edf \u0111i\u1ec1u tr\u1ecb, c\u00f3 th\u1ec3 s\u1eed d\u1ee5ng li\u1ec7u ph\u00e1p kh\u00e1ng sinh theo kinh nghi\u1ec7m nh\u01b0 ph\u1ea7n a, m\u1ee5c 4.1.2. N\u1ebfu ng\u01b0\u1eddi b\u1ec7nh v\u1eabn s\u1ed1t k\u00e9o d\u00e0i t\u1edbi 96 gi\u1edd khi \u0111\u00e3 d\u00f9ng li\u1ec7u ph\u00e1p kh\u00e1ng sinh kinh nghi\u1ec7m ban \u0111\u1ea7u, c\u1ea7n t\u00ecm ki\u1ebfm c\u00e1c nguy\u00ean nh\u00e2n nhi\u1ec5m khu\u1ea9n b\u1ec7nh vi\u1ec7n v\u00e0 c\u00e2n nh\u1eafc b\u1ed5 sung thu\u1ed1c kh\u00e1ng n\u1ea5m ph\u00f9 h\u1ee3p. b) \u0110\u1ed1i v\u1edbi c\u00e1c ng\u01b0\u1eddi b\u1ec7nh ch\u01b0a x\u00e1c \u0111\u1ecbnh \u0111\u01b0\u1ee3c \u1ed5 nhi\u1ec5m khu\u1ea9n kh\u1edfi \u0111i\u1ec3m nh\u01b0ng c\u00f3 y\u1ebfu t\u1ed1 nguy c\u01a1 nhi\u1ec5m khu\u1ea9n b\u1ec7nh vi\u1ec7n C\u1ea7n d\u1ef1a v\u00e0o th\u00f4ng tin vi khu\u1ea9n h\u1ecdc v\u00e0 nh\u1ea1y c\u1ea3m kh\u00e1ng sinh c\u1ee7a t\u1eebng b\u1ec7nh vi\u1ec7n \u0111\u1ec3 l\u1ef1a ch\u1ecdn kh\u00e1ng sinh kinh nghi\u1ec7m cho ph\u00f9 h\u1ee3p: C\u00f3 th\u1ec3 ph\u1ed1i h\u1ee3p m\u1ed9t kh\u00e1ng sinh c\u00f3 t\u00e1c d\u1ee5ng ch\u1ed1ng P. aeruginosa nh\u00f3m carbapenem (imipenem-cilastatin, doripenem, meropenem) ho\u1eb7c kh\u00e1ng sinh nh\u00f3m penicilin ph\u1ed5 r\u1ed9ng nh\u01b0 piperacilin-tazobactam v\u1edbi m\u1ed9t kh\u00e1ng sinh nh\u00f3m quinolon (ciprofloxacin, levofloxacin ho\u1eb7c moxifloxacin) ho\u1eb7c v\u1edbi m\u1ed9t kh\u00e1ng sinh nh\u00f3m aminoglycosid (amikacin, neltimicin) ho\u1eb7c v\u1edbi fosfomycin. Ch\u00fa \u00fd c\u1ea7n ch\u1ec9nh li\u1ec1u c\u00e1c kh\u00e1ng sinh theo \u0111\u1ed9 thanh th\u1ea3i creatinin. N\u1ebfu nghi ng\u1edd t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh l\u00e0 S. aureus (t\u1ee5 c\u1ea7u v\u00e0ng) kh\u00e1ng methicilin (MRSA), c\u1ea7n c\u00e2n nh\u1eafc s\u1eed d\u1ee5ng th\u00eam vancomycin, teicoplanin ho\u1eb7c daptomycin. N\u1ebfu nghi ng\u1edd t\u00e1c nh\u00e2n vi khu\u1ea9n Gram-\u00e2m \u0111a kh\u00e1ng (kh\u00e1ng carbapenem): Ph\u1ed1i h\u1ee3p kh\u00e1ng sinh nh\u00f3m carbapenem c\u00f3 t\u00e1c d\u1ee5ng ch\u1ed1ng A. baumanii v\u00e0\/ho\u1eb7c kh\u00e1ng sinh nh\u00f3m penicilin ph\u1ed5 r\u1ed9ng ph\u1ed1i h\u1ee3p v\u1edbi c\u00e1c ch\u1ea5t \u1ee9c ch\u1ebf beta-lactamase (piperacilin tazobactam ho\u1eb7c ampicilin-sulbactam) v\u1edbi colistin \u0111\u1ec3 t\u0103ng t\u00e1c d\u1ee5ng hi\u1ec7p \u0111\u1ed3ng. c) \u0110\u1ed1i v\u1edbi c\u00e1c ng\u01b0\u1eddi b\u1ec7nh c\u00f3 \u1ed5 nhi\u1ec5m khu\u1ea9n ch\u1ec9 \u0111i\u1ec3m Khi ch\u01b0a x\u00e1c \u0111\u1ecbnh \u0111\u01b0\u1ee3c c\u0103n nguy\u00ean g\u00e2y b\u1ec7nh, c\u1ea7n s\u1eed d\u1ee5ng kh\u00e1ng sinh theo kinh nghi\u1ec7m. Khi c\u00f3 k\u1ebft qu\u1ea3 nu\u00f4i c\u1ea5y, chuy\u1ec3n d\u00f9ng kh\u00e1ng sinh ph\u1ed5 h\u1eb9p nh\u1ea1y c\u1ea3m v\u1edbi vi khu\u1ea9n g\u00e2y b\u1ec7nh khi c\u00f3 k\u1ebft qu\u1ea3 c\u1ea5y vi khu\u1ea9n v\u00e0 kh\u00e1ng sinh \u0111\u1ed3. C\u1ea7n ch\u1ec9nh li\u1ec1u kh\u00e1ng sinh theo \u0111\u1ed9 thanh th\u1ea3i creatinin \u1edf c\u00e1c ng\u01b0\u1eddi b\u1ec7nh c\u00f3 suy th\u1eadn. Nhi\u1ec5m khu\u1ea9n \u0111\u01b0\u1eddng m\u1eadt hay ti\u00eau h\u00f3a: Nhi\u1ec5m khu\u1ea9n gan m\u1eadt: K. pneumoniae l\u00e0 vi khu\u1ea9n ch\u00ednh g\u00e2y nhi\u1ec5m khu\u1ea9n huy\u1ebft v\u00e0 \u00e1p xe gan \u1edf Vi\u1ec7t Nam. S\u1eed d\u1ee5ng kh\u00e1ng sinh nh\u00f3m cepalosporin th\u1ebf h\u1ec7 3 ho\u1eb7c 4, ho\u1eb7c carbapenem (n\u1ebfu ng\u01b0\u1eddi b\u1ec7nh c\u00f3 nguy c\u01a1 nhi\u1ec5m vi khu\u1ea9n sinh beta-lactamase ph\u1ed5 r\u1ed9ng \u2013 ESBL) ph\u1ed1i h\u1ee3p v\u1edbi m\u1ed9t kh\u00e1ng sinh nh\u00f3m aminoglycosid (amikacin, neltimicin) ho\u1eb7c metronidazol khi nghi ng\u1edd vi khu\u1ea9n k\u1ef5 kh\u00ed. Nhi\u1ec5m khu\u1ea9n \u1ed1ng ti\u00eau h\u00f3a: S\u1eed d\u1ee5ng kh\u00e1ng sinh nh\u00f3m cepalosporin th\u1ebf h\u1ec7 3 ho\u1eb7c 4, ho\u1eb7c carbapenem ho\u1eb7c quinolon (ciprofloxacin) ph\u1ed1i h\u1ee3p v\u1edbi metronidazol (khi nghi ng\u1edd vi khu\u1ea9n k\u1ef5 kh\u00ed). Nhi\u1ec5m khu\u1ea9n \u0111\u01b0\u1eddng h\u00f4 h\u1ea5p: Xem th\u00eam b\u00e0i Vi\u00eam ph\u1ed5i m\u1eafc ph\u1ea3i \u1edf c\u1ed9ng \u0111\u1ed3ng v\u00e0 Vi\u00eam ph\u1ed5i li\u00ean quan \u0111\u1ebfn th\u1edf m\u00e1y. Nhi\u1ec5m khu\u1ea9n tim m\u1ea1ch: Xem th\u00eam b\u00e0i Vi\u00eam n\u1ed9i t\u00e2m m\u1ea1c nhi\u1ec5m khu\u1ea9n. N\u1ebfu nghi ng\u1edd t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh l\u00e0 S. aureus (t\u1ee5 c\u1ea7u v\u00e0ng), c\u00e2n nh\u1eafc s\u1eed d\u1ee5ng c\u00e1c kh\u00e1ng sinh ch\u1ed1ng t\u1ee5 c\u1ea7u nh\u01b0 oxacilin, cloxacilin, cefazolin (\u0111\u1ed1i v\u1edbi t\u1ee5 c\u1ea7u v\u00e0ng nh\u1ea1y methicilin, MSSA) ho\u1eb7c vancomycin, teicoplanin, daptomycin (\u0111\u1ed1i v\u1edbi tr\u01b0\u1eddng h\u1ee3p t\u1ee5 c\u1ea7u kh\u00e1ng methicilin, MRSA) \u0111\u01b0\u1eddng t\u0129nh m\u1ea1ch. Nhi\u1ec5m khu\u1ea9n li\u00ean quan \u0111\u1ebfn c\u00e1c d\u1ee5ng c\u1ee5 m\u1ea1ch m\u00e1u: Xem th\u00eam ph\u1ea7n nhi\u1ec5m khu\u1ea9n c\u00f3 y\u1ebfu t\u1ed1 nguy c\u01a1 nhi\u1ec5m khu\u1ea9n b\u1ec7nh vi\u1ec7n. N\u1ebfu nghi ng\u1edd do t\u1ee5 c\u1ea7u v\u00e0ng kh\u00e1ng methicilin (MRSA), c\u1ea7n d\u00f9ng vancomycin, linezolid, teicoplanin ho\u1eb7c daptomycin. Nhi\u1ec5m khu\u1ea9n sinh d\u1ee5c \u1edf n\u1eef gi\u1edbi: D\u00f9ng ceftriaxon t\u0129nh m\u1ea1ch 1gam h\u00e0ng ng\u00e0y ph\u1ed1i h\u1ee3p v\u1edbi azithromycin t\u0129nh m\u1ea1ch 500mg h\u00e0ng ng\u00e0y v\u00e0 metronidazol 1g\/ng\u00e0y. N\u1ebfu nghi ng\u1edd c\u00f3 li\u00ean quan \u0111\u1ebfn nhi\u1ec5m khu\u1ea9n b\u1ec7nh vi\u1ec7n d\u00f9ng kh\u00e1ng sinh nh\u00f3m carbapenem (imipenemcilastatin, meropenem) ho\u1eb7c piperacilin- tazobactam ph\u1ed1i h\u1ee3p v\u1edbi azithromycin v\u00e0 metronidazol, n\u1ebfu nghi ng\u1edd do vi khu\u1ea9n \u0111a kh\u00e1ng thu\u1ed1c ph\u1ed1i h\u1ee3p colistin. Nhi\u1ec5m khu\u1ea9n da: Tham kh\u1ea3o ph\u1ea7n s\u1eed d\u1ee5ng kh\u00e1ng sinh cho nhi\u1ec5m khu\u1ea9n da v\u00e0 m\u00f4 m\u1ec1m. N\u1ebfu nghi ng\u1edd t\u00e1c nh\u00e2n g\u00e2y b\u1ec7nh l\u00e0 S. aureus (t\u1ee5 c\u1ea7u v\u00e0ng), c\u00e2n nh\u1eafc s\u1eed d\u1ee5ng c\u00e1c kh\u00e1ng sinh ch\u1ed1ng t\u1ee5 c\u1ea7u nh\u01b0 oxacilin, cloxacilin, cefazolin (\u0111\u1ed1i v\u1edbi t\u1ee5 c\u1ea7u v\u00e0ng nh\u1ea1y methicilin, MSSA) 131","ho\u1eb7c vancomycin, teicoplanin ho\u1eb7c daptomycin (\u0111\u1ed1i v\u1edbi tr\u01b0\u1eddng h\u1ee3p t\u1ee5 c\u1ea7u kh\u00e1ng methicilin, MRSA). \u0110\u1ed1i nh\u1eefng ng\u01b0\u1eddi b\u1ec7nh t\u1ed5n th\u01b0\u01a1ng da (v\u00ed d\u1ee5 do b\u1ecfng), c\u1ea7n c\u00e2n nh\u1eafc nguy c\u01a1 nhi\u1ec5m khu\u1ea9n b\u1ec7nh vi\u1ec7n v\u00e0 s\u1eed d\u1ee5ng c\u00e1c kh\u00e1ng sinh c\u00f3 t\u00e1c d\u1ee5ng di\u1ec7t P. aeruginosa. 4.1.3. L\u1ef1a ch\u1ecdn kh\u00e1ng sinh d\u1ef1a theo th\u00f4ng tin vi khu\u1ea9n g\u00e2y b\u1ec7nh Kh\u00e1ng sinh \u0111\u01b0\u1ee3c l\u1ef1a ch\u1ecdn d\u1ef1a tr\u00ean th\u00f4ng tin v\u1ec1 vi khu\u1ea9n g\u00e2y b\u1ec7nh \u0111\u01b0\u1ee3c th\u1ec3 hi\u1ec7n trong B\u1ea3ng II.10. B\u1ea3ng II.10. L\u1ef1a ch\u1ecdn kh\u00e1ng sinh theo kinh nghi\u1ec7m Vi khu\u1ea9n Kh\u00e1ng sinh l\u1ef1a ch\u1ecdn Kh\u00e1ng sinh thay th\u1ebf Vi khu\u1ea9n Gram \u00e2m 400mg x2 \u0111\u1ebfn 3 l\u1ea7n\/ ng\u00e0y, t\u1ed1i \u0111a C\u00e1c kh\u00e1ng sinh cephalosporin \u0111\u01b0\u1eddng ru\u1ed9t h\u1ecd kh\u00f4ng qu\u00e1 1200mg\/ng\u00e0y, truy\u1ec1n th\u1ebf h\u1ec7 3 v\u00e0 4 kh\u00e1c Enterbacteriaceae TM C\u00e1c kh\u00e1ng sinh nh\u00f3m (kh\u00f4ng sinh ESBL) +Ceftriaxone 2g\/ l\u1ea7n, ti\u00eam t\u0129nh fluronquinolon m\u1ea1ch ch\u1eadm m\u1ed7i 12 gi\u1edd\/l\u1ea7n Vi khu\u1ea9n Gram \u00e2m Ertapenem 1g\/l\u1ea7n\/ ng\u00e0y, truy\u1ec1n Imipenem- cilastatin 500mg\/l\u1ea7n \u0111\u01b0\u1eddng ru\u1ed9t h\u1ecd TM trong 3-4 gi\u1edd truy\u1ec1n TM m\u1ed7i 6 gi\u1edd\/l\u1ea7n Meropenem 1g\/l\u1ea7n, truy\u1ec1n TM 8 Enterobacteriacea gi\u1edd\/l\u1ea7n Doripenem 500mg\/l\u1ea7n, truy\u1ec1n (sinh ESBL) TM 8 gi\u1edd\/l\u1ea7n Pseudomonas Ceftazidime 2 g\/l\u1ea7n, ti\u00eam TM Ciprofloxacin x 400- 1200 aeruginosa ch\u1eadm m\u1ed7i 8 gi\u1edd\/l\u1ea7n Cefepim 2 g\/l\u1ea7n, ti\u00eam TM ch\u1eadm mg\/ng\u00e0y m\u1ed7i 8 gi\u1edd\/l\u1ea7n Piperacillin - tazobactam 4.5g\/l\u1ea7n Imipenem-cilastatin 1g\/l\u1ea7n, ti\u00eam TM ch\u1eadm m\u1ed7i 6 gi\u1edd\/l\u1ea7n truy\u1ec1n TM m\u1ed7i 6-8 gi\u1edd\/l\u1ea7n Meropenem 1g\/l\u1ea7n, TM m\u1ed7i 8 gi\u1edd\/l\u1ea7n Burkhlderia Ceftazidim 2g\/l\u1ea7n, ti\u00eam TMC m\u1ed7i Imipenem-cilastatin 1g\/l\u1ea7n, pseudomallei 8 gi\u1edd\/l\u1ea7n truy\u1ec1n TM m\u1ed7i 8 gi\u1edd\/l\u1ea7n Meropenem 1g\/l\u1ea7n, TM m\u1ed7i 8 gi\u1edd\/l\u1ea7n Streptococcus Ceftriaxone 2g\/l\u1ea7n, ti\u00eam TMC 12 Levofloxacin 750mg\/ng\u00e0y pneumoniae gi\u1edd\/l\u1ea7n Vancomycin 1g\/l\u1ea7n, TTM c\u00e1ch Cefotaxime 2g\/l\u1ea7n ti\u00eam TMC 6 12 gi\u1edd\/l\u1ea7n gi\u1edd\/l\u1ea7n Staphylococcus Oxacilin 100-200 mg\/kg\/ng\u00e0y Vancomycin 1g\/l\u1ea7n, TTM c\u00e1ch aureus (nh\u1ea1y chia ti\u00eam TMC c\u00e1ch 6 gi\u1edd\/l\u1ea7n 12 gi\u1edd\/l\u1ea7n Methicilin) Staphylococcus Vancomycin 1g\/l\u1ea7n, TTM c\u00e1ch Daptomycin 4-6mg\/kg\/ng\u00e0y aureus (kh\u00e1ng 12 gi\u1edd\/l\u1ea7n Methicilin) Streptococcus suis Ampicilin 2g\/l\u1ea7n, ti\u00eam TM m\u1ed7i 6 Ceftriaxone 2g\/l\u1ea7n ti\u00eam TM 12 gi\u1edd\/l\u1ea7n. Tr\u1ebb em 200-250 gi\u1edd\/l\u1ea7n. Tr\u1ebb em 100mg\/kg\/ng\u00e0y mg\/kg\/ng\u00e0y Clostridium Penicilin 3-4 tri\u1ec7u \u0111\u01a1n v\u1ecb ti\u00eam Clindamycin truy\u1ec1n TM 6-9 perfringens TM c\u00e1ch 4 gi\u1edd\/l\u1ea7n g\/ng\u00e0y chia li\u1ec1u c\u00e1ch 8 gi\u1edd\/l\u1ea7n Metronidazole truy\u1ec1n TM li\u1ec1u t\u1ea5n c\u00f4ng 15mg\/kg sau \u0111\u00f3 s\u1eed d\u1ee5ng li\u1ec1u duy tr\u00ec 7,5mg\/kg trong 1 gi\u1edd c\u00e1ch m\u1ed7i 6 gi\u1edd\/l\u1ea7n Bacteroides fragilis Metronidazole truy\u1ec1n TM li\u1ec1u t\u1ea5n c\u00f4ng 15mg\/kg sau \u0111\u00f3 s\u1eed d\u1ee5ng li\u1ec1u duy tr\u00ec 7,5mg\/kg trong 1 gi\u1edd c\u00e1ch m\u1ed7i 6 gi\u1edd\/l\u1ea7n 4.1.4. C\u00e1ch d\u00f9ng c\u1ee5 th\u1ec3 c\u00e1c lo\u1ea1i kh\u00e1ng sinh 132","Li\u1ec1u d\u00f9ng v\u00e0 c\u00e1ch d\u00f9ng c\u1ee7a m\u1ed9t s\u1ed1 kh\u00e1ng sinh \u0111\u01b0\u1ee3c th\u1ec3 hi\u1ec7n trong B\u1ea3ng II.11. B\u1ea3ng II.11. Li\u1ec1u d\u00f9ng - c\u00e1ch d\u00f9ng c\u1ee7a m\u1ed9t s\u1ed1 kh\u00e1ng sinh Lo\u1ea1i kh\u00e1ng sinh C\u00e1ch s\u1eed d\u1ee5ng Ceftriaxone 1-2g x1 l\u1ea7n\/ng\u00e0y, t\u1ed1i \u0111a 4g\/ng\u00e0y Cefepim 1-2g m\u1ed7i 12h, t\u1ed1i \u0111a 6g\/ng\u00e0y. Nhi\u1ec5m khu\u1ea9n \u0111e d\u1ecda t\u00ednh m\u1ea1ng: 2g m\u1ed7i 8-12h Ceftazidim 1-2g m\u1ed7i 8-12h Ampicilin- sulbactam 1,5-3g m\u1ed7i 6h, \u0111\u01b0\u1eddng TM Ertapenem 1g x 1 l\u1ea7n\/ng\u00e0y truy\u1ec1n TM trong 3-4h Imipenem 0,5g- 1g m\u1ed7i 6h, t\u1ed1i \u0111a 4g\/ng\u00e0y, truy\u1ec1n TM trong 3-4h Meropenem 1g m\u1ed7i 8h, t\u1ed1i \u0111a 2g m\u1ed7i 8h, \u0111\u01b0\u1eddng TM Piperacilin- tazobactam 4,5g m\u1ed7i 8h, truy\u1ec1n TM Levofloxacin 500-750 mg\/ng\u00e0y, truy\u1ec1n TM Moxifloxacin 400mg\/ ng\u00e0y, truy\u1ec1n TM Ciprofloxacin 400mg x2 \u0111\u1ebfn 3 l\u1ea7n\/ng\u00e0y, t\u1ed1i \u0111a kh\u00f4ng qu\u00e1 1200mg\/ng\u00e0y, truy\u1ec1n TM Amikacin 16-24 mg\/kg x 1 l\u1ea7n\/ng\u00e0y, truy\u1ec1n TM Tobramycin 4-7mg\/kg x1 l\u1ea7n\/ng\u00e0y, truy\u1ec1n TM Gentamycin 4-7mg\/kg x1 l\u1ea7n\/ng\u00e0y, truy\u1ec1n TM Linezolid 600mg x1 l\u1ea7n\/ng\u00e0y * Li\u1ec1u d\u00f9ng c\u00f3 th\u1ec3 thay \u0111\u1ed5i t\u00f9y theo k\u1ebft qu\u1ea3 theo d\u00f5i n\u1ed3ng \u0111\u1ed9 thu\u1ed1c trong m\u00e1u (TDM)123 4.2. X\u1eed tr\u00ed \u1ed5 nhi\u1ec5m khu\u1ea9n kh\u1edfi \u0111i\u1ec3m D\u1eabn l\u01b0u \u1ed5 \u00e1p xe, d\u1eabn l\u01b0u m\u00e0ng ph\u1ed5i, m\u00e0ng tim, d\u1eabn l\u01b0u t\u00fai m\u1eadt, l\u1ea5y s\u1ecfi \u0111\u01b0\u1eddng m\u1eadt khi c\u00f3 t\u1eafc m\u1eadt\u2026 R\u00fat c\u00e1c d\u1ee5ng c\u1ee5\/thi\u1ebft b\u1ecb y khoa l\u00e0 \u0111\u01b0\u1eddng v\u00e0o c\u1ee7a nhi\u1ec5m khu\u1ea9n n\u1ebfu c\u00f3 ch\u1ec9 \u0111\u1ecbnh. 4.3. \u0110i\u1ec1u tr\u1ecb h\u1ed7 tr\u1ee3 v\u00e0 h\u1ed3i s\u1ee9c \u0110\u1ec1 ph\u00f2ng v\u00e0 \u0111i\u1ec1u tr\u1ecb s\u1ed1c nhi\u1ec5m khu\u1ea9n. \u0110\u1ea3m b\u1ea3o h\u00f4 h\u1ea5p: \u0110\u1ea3m b\u1ea3o th\u00f4ng kh\u00ed, th\u1edf oxy, \u0111\u1eb7t \u1ed1ng n\u1ed9i kh\u00ed qu\u1ea3n v\u00e0 th\u00f4ng kh\u00ed nh\u00e2n t\u1ea1o khi c\u1ea7n thi\u1ebft. \u0110i\u1ec1u ch\u1ec9nh c\u00e2n b\u1eb1ng n\u01b0\u1edbc, \u0111i\u1ec7n gi\u1ea3i v\u00e0 th\u0103ng b\u1eb1ng ki\u1ec1m toan. \u0110i\u1ec1u tr\u1ecb suy th\u1eadn: Truy\u1ec1n \u0111\u1ee7 d\u1ecbch, l\u1ee3i ti\u1ec3u. L\u1ecdc m\u00e1u li\u00ean t\u1ee5c khi c\u00f3 ch\u1ec9 \u0111\u1ecbnh. \u0110i\u1ec1u tr\u1ecb xu\u1ea5t huy\u1ebft v\u00e0 \u0111\u00f4ng m\u00e1u r\u1ea3i r\u00e1c trong l\u00f2ng m\u1ea1ch. H\u1ea1 s\u1ed1t, dinh d\u01b0\u1ee1ng n\u00e2ng cao th\u1ec3 tr\u1ea1ng. Ch\u0103m s\u00f3c v\u1ec7 sinh, ch\u1ed1ng lo\u00e9t. T\u00c0I LI\u1ec6U THAM KH\u1ea2O Quy\u1ebft \u0111\u1ecbnh 708\/Q\u0110-BYT ng\u00e0y 05\/07\/2022 c\u1ee7a B\u1ed9 Y t\u1ebf 133"]