CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM PHAN V: GAY ME HOI SOC CHO PHAU THUAT TIM
THEO DOI VA SLf DUNG THUOC TRONG HOI sQC N G Q N G TIM
Nguydn Tat Dung, Le Quang Thiifu, Huj^nh Van Minh
Bai nay cung cap mot cai nhin khai quat ve cac ky thuat theo doi va sir dung thuoc frong va sau khi hoi siic ngimg tuan hoan ho hap.
I. THEO DOI NGAY TRiSOC, TRONG VA SAU KHI NGU'NG TIM
Danh gia benh nhan trong khi hoi sue ngirng tim Hien nay, khong co tieu chuan lam sang nao dang tin cay de danh gia sir huu hieu ciia hoi siic ngimg tim.
Chi CO nong do CO2 cuoi thi tha ra dugc diing nhu mot chi diem cho cung lugng tim sinh ra nha ep tim va co thi la mot dau hieu som ctia sir hoi phuc tuin hoan binh thudng ciia benh nhan.
I I . DANH GIA HUYET DONG L Ap lire tiroi mau vanh (CPP) Ap lire tudi mau vanh la hieu so giira ap lire dong mach chu voi ap lire nhT phai trong thi tam truang. Ap lire tuoi mau vanh tuong quan voi ca luu lugng mau ca tim lan sir hoi phuc tuan hoan binh thudng ciia benh nhan. Tri s6 CPP> 15 mmHg bao truoe mot sir hoi phuc tuin hoan binh thucmg. Tren sue vat thi nghiem, tri so CPP tang tuong quan vai
tang ty le song, tang luu luong mau vanh i va gia tang su hoi phuc tuan hoan binh!
thucmg. Khi theo doi huyet ap dong mach : xam nhap trong hoi siic ngirng tim, thiy ; thuoc nen co gang nang ap lire dong mach \ chu tam truong len de dat dugc mgt ap j lire tuoi mau vanh toi uu. Neu cho tri s6 | ap lire nhT phai tam truong la 10 mmHg j thi ly tudng nhat la nen nang ap lire dong \ mach chu tam truong len it nhat la 30 mm \ Hg dl duy tri mot CPP > 20 mm Hg khi j hoi sue. Tuy nhien, viec theo doi ap lire i nhu vay khong de thuc hien neu benh \ nhan bi ngirng tim 6 ben ngoai benh vien. ^
2. Bat mach Thay thuoc thudng co | gang bat mach de danh gia sir hiiu hieu \ ctia viec hoi sue ngirng tuan hoan ho hap. j Trong tat ca cac nghien cuu, gia tri lam • sang ciia viec kiem tra mach dap trong!
qua trinh hoi sue ngirng tim chua dugc khang dinh. Vi tTnh mach chO dual khong • CO van nen luc ep tim luong mau dpi|
ngugc tro lai vao he thdng tTnh mach, tran;
vao tTnh mach diii, lam nhim tuong lai dong mach diii nay. Sir niy cua dong;
mach canh trong khi h6i siic ngimg tim;
khong danh gia dugc luu lugng mau vanh, tuoi mau ca tim va Uiai mau nao co tit'
hay khong. 1
Y HOC VIET NAM SO DAC BIET — THANG 11 /2010
./v yv'
I I I . DANH GIA VE HO HAP
L Khi mau dong mach Trong mot loat cac trudng hop nghien cuu ngudi ta thay rang khi mau dong mach trong khi ngirng tim khong phai la mot chi didm dang tin cay cho mirc do tram trong ciia thieu oxy mo, uu than va mtic do nhiem toan tai mo. Vi vay, khong the diing thong so nay de theo doi khi ngimg tim va trong khi hoi siic ngirng tuan hoan ho hip ca trong va ngoai benh vien.
2. Theo doi do bao hoa oxy mau Trong khi ngirng tim thi chirc nang theo doi bao hoa oxy cua may khong tot boi vi luu lugng mau khong den du tirng mach mau ngoai bien. May theo doi do bao hoa oxy trong mau dugc diing kha pho bien a cac phong cap cuu va phong hoi siic de theo doi nhiing benh nhan nang vi day la each don gian de theo doi lien tuc bao hoa oxy trong mau. Tuy nhien, tri so bao hoa oxy mau binh thucmg bieu hien tren monitoring khong dam bao chac chan la viec mang oxy den he thong ia dii vi no khong tinh dugc sue chua oxy toan bg (bao gom oxy gan vai Hemoglobin va oxy hoa tan trong mau) va khong tinh dugc cung lugng tim.
Ap lire oxy tai mo thuang khong dugc danh gia trong khi hoi sire ngirng tim nhung no co the cung cap mot ca che dk danh gia tuoi mau mo boi vi ap lire oxy xuyen kit mac giam nhanh khi ngimg tim va tro \e duong can ban khi da co phuc h6i lai tuin hoan binh thucmg cua benh nhan.
3. Theo doi nong do khi carbonic CO2 cuoi ky thff ra
Day la mot phuong phap khong xam nhap, rat an toan va hieu qua de danh gia cung lugng tim khi hoi sue ngimg tuan hoan ho hap va co the la mot dau hieu ban dau cua su hoi phuc lai tuan hoan binh thuang. Khi bi ngimg tim, CO2 tiep tue dugc tao ra khap ca the. Yeu to chinh de xac dinh sir bai tiet CO2 la toe do cua no tir cac nai san xuat CO2 o phan ngoai bien vao den phoi. O tinh trang luu lugng mau thap trong khi hoi sue ngirng tuan hoan ho hap, thong khi phe nang tuong doi cao hon so voi luu luong mau, vi vay nong do CO2 cuoi ky tha ra se bi thap. Neu thong khi kha hang dinh thi su thay doi nong do CO2 cuoi ky tho ra se phan anh sy thay doi cua cung lugng tim.
Trong mot loat 8 truang hgp benh nhan dugc hoi sue thanh eong sau ngimg tim nguai ta thay rang nong do CO2 cuoi ky tha ra cao hon han so voi nhirng benh nhan bi that bai. Do nong do CO2 cGng co the dugc sir dung nhu mpt dau hieu som cho su hoi phue lai tuan hoan binh thuong cua benh nhan.
Trong mgt loat 744 benh nhan nguoi lon ngirng tim co dat ngi khi quan, neu nong do CO2 cuoi ky tho ra <10 mm Hg thi CO tien lugng xau, ngay ca khi dugc hoi sire tich eirc. Tuy nhien, trong 4 nghien ciru khac da cho thay khong co sir khac biet ve ty le hoi phuc va ty le song sot 6 nhiing nguai co nong do CO2 ban dau <10mmHg so voi nhom c6 nong do CO2 cuoi ky tha ra cao hon; c6 5 benh nhan da co sir hoi phuc tuan hoan binh thuong (1 benh nhan song sot den khi
CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM
xuit vien) mac dii nong do CO2 ban dau duoi lOmmHg.
Tom lai, theo doi ndng do CO2 cu6i ky tho ra trong ngimg tim co the hiiu ich nhu mgt phuong phap khong xam nhap dk danh gia cung lugng tim trong hoi sue ngimg tuan hoan ho hap. Can nghien cuu hon nua ve tinh hiru dung cua nong do CO2 cu6i thi tha ra trong viee quyet dinh tilp tuc dieu tri tan cong hoac ngung khong hoi siic ntta.
d nhirng benh nhan da co su hoi phuc tuin hoan binh thudng, viec theo doi nong do CO2 lien tuc hay ngat quang c6 the dam bao dugc rang ong ngi khi quan van con nam trong khi quan. Nong do CO2 CO the huong dan viec thong khi nhan tao cho benh nhan, dac biet khi no tuong quan vol PaC02 trong khi mau dgng mach.
IV. THUOC VAN MACH HO TRQ TUAN HOAN
Thuoc van mach c6 the cho ngay truac, trong va sau khi ngirng tim de h6 trg cung lugng tim, dac biet luu lugng mau den nao va tun.
Co the chgn thuoc de cai thien tan so tim (tac dung chronotropic), eai thien co bop ca tim (tac dung inotropic) hoac huyet ap (tac dung co maeh), hoac de giam hau ganh (tac dung gian mach). Tuy nhien, nhieu thuoc van maeh khong c6 tac dung chgn lgc, co the lam tang hoae lam giam tan so tim va hau ganh, tang nguy CO roi loan nhip tim va thieu mau ca tim vi tao ra sy mat can bang giira cung va cau oxy doi vol co tim. Liic do thieu mau CO tim CO the lam giam chire nang tim.
Ngoai ra, co vai thuoc anh huong d^n ' ehuyen hoa nhu tang glueo mau, lactat' mau.
Khong CO con so eu the ve toe do' chuyen thuoe vi a nhimg benh nhan h6i' sue luon co sy thay doi ve dugc luc hoc' (moi lien quan giira lieu thuoc vai n6ng' do ciia no) va duge dong hgc (m6i lien quan giira nong do thuoc va tac dung ciia!
no). Cac thuoc van mach phai dugc chinh' lieu eu the ngay tai giuong benh dl dam I bao tac dung mong muon va han che tac • dung phu. Ngudi su dung phai biet n6ng do thudc dang diing va sy tuong hgp vol
eac thudc da va dang cho. ^ Ndi chung khdng nen trdn cac thuoc \
van mach vdi natri bicarbonate hoac cac i dung dich kiem khac trong ciing ducmg j truyen tTnh mach vi thude bi bat hoat ddng trong mdi trudng kiem.
Noradrenalin va cac loai catecholamine hoat hda thy the a adrenergic cd the gay i hoai tii md neu thudc chuyen khdng diing ? vao trong ldng mach mau. Neu phat hien]
sdm thi cd the tiem tai chd 5-10 mg^
phentolamine hda vdi 10-15 ml nuoc' mudi smh ly de ngan ngira vimg md tai do bj*
hoai tii. 1*
•^:
w < -5
Adrenalin Day la thudc lya chgn dau|
tien trong hdi siic ngimg tuan hoan hoj hap. Nd cQng diing trong nhirng truongj hgp can trg tim va van mach. Chang han, adrenalin la thudc dugc coi la nhdm lib]
trong dieu tri eham nhip tim khi diin^
atropin that bai va liic ehua dat dugc ma)l tao nhip tim. Adrenalin cGng dugc diin^
trong trudng hgp bi sde phan ve khdng 6ri
Y HOC VIET NAM SO DAC BIET-THANG 11/2010
'dinh huyet ddng hoac cd co thit phi
I quan. - , i
Khi cham nhip tim va ha huyit ap thi truyin adrenalin Img hda trong 500 ml tnuac mudi sinh ly hoac glucose 5%, lilu :,ban dau d ngudi ldn la Imcg/ phiit rdi rl chinh lieu cho thich hgp, cd thi dat din i lilu 2-10 meg/ phiit. Chii y ring, day chi :^la lieu dung eho nhirng trudng hgp
;: khong ngimg tim, tiic la chi dung cho
!i cham nhip tim va ha huyit ap.
6 ngudi ldn, khi ngirng tim thi tiem j tinh mach adrenalin Img mdi 3-5 phiit.
• Lieu cao hon cd the diing de dieu tri qua lieu thudc iic che p hoac uc che kenh : canxi. Neu khdng cd dudng truyen thi : cho adrenalin vao ndi khi quan vdi lieu 2-
! 2,5 mg.
I Vasopressin Day la mdt thudc co mach ngoai vi khdng thude nhdm adrenergic, gay co mach vanh va mach [ than. Trong ngirng tim, tac dyng cua
vasopressin khdng khac vdi adrenalin nen 1 lieu 40 dan vj tiem tTnh mach cd the thay the lieu thii 1 va thii 2 ciia adrenalin.
Giong nhu adrenalin, vasopressin cGng dugc diing trude va sau ngirng tim. Nd dugc dimg de dieu trj trong sde gian mach nhu sde nhiem triing khi cac thudc trg tim va van mach khac khdng cai thien duge huyet ddng benh nhan.
Noradrenalin Noradrenalin la thudc trg tim va co maeh. Khi diing noradrenalin, cung lugng tim cd the tang hoac giam tiiy thuoc vao sue can mach, chiic nSng ctia thit trai va dap iing phan
xa (thdng qua thy the ap lye d ddng mach chu va ddng mach canh).
Noradrenalin thudng lam co maeh mac treo va mach mau than, nhung trong sde nhiem triing thi nd lai cai thien luu lugng mau than va lugng nude tieu. Nd cd the hieu qua khi dieu tri cho benh nhan bi ha huyet ap qua thap (nghTa la huyit ap tdi da <70 mmHg) va siic can mach ngoai vi thap nhung dieu tri bang eae thudc van mach khac nhu Dopamin, Phenylephrine hoac Methoxamine khdng hieu qua.
Chdng chi dinh tuong ddi dimg noradrenalin cho nhiing benh nhan bj giam the tich tuan hoan. Thude lam tang nhu cau oxy ca tim vi vay phai can than khi diing eho benh nhan bj benh tim thieu mau cyc bd. Nhu da ndi tren, noradrenalin gay hoai tii tai chd khi truyen thudc khdng dung trong ldng mach mau. Lieu Noradrenalin khdi dau la 0,5-1 mcg/phiit va chinh lieu dan de ed dap iing thich hgp.
Dopamine Day la mdt chat gidng catecholamine kieh thieh ca thy the a lan p. Ngoai ra, cdn cd mdt sd thy the dac hieu ciia dopamine la DA| va DA2 dopamingernic. Ve mat sinh ly, dopamine kieh thieh tim thdng qua ca hai loai thy the a va p. Ve mat dugc ly, dopamine la thudc ddng van vdi thy the adrenergic va thy the dopamine ngoai bien. Miic do tae dyng tiiy thudc vao lieu dung. Trong hdi siic, dopamine thudng dugc dimg de dieu tri ha huyet ap, dac biet neu benh nhan bi cham nhjp tim va khi da ed hdi phye tuan hoan binh thudng sau ngimg tim. Neu van cdn ha huyet ap du da bii du dich, ngudi
CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM
1
ta kit hgp dopamine vdi adrenaline hoae Lieu thudng diing la 2- j noradrenaline dl lam tang cung lugng tim 20meg/kg/phut. Tuy nhien cd mdt gioi j va ca ap lye tudi mau ddng mach. Ngudi han rdng ve dap img thudc cho tirng benh j ta khuyen nen diing lieu thap dopamine nhan dang dieu tri tai phdng hdi siic tang i dk duy tri luu lugng mau than va eai thien cudng. Benh nhan ldn tudi giam dap iing i chiic nang than, nhung thye te nhieu dang ke ddi vdi dobutamine. C) lilu >20 i nghien eiiu gin day eho thiy lieu trinh meg/kg/phut, thudc lam tang tin sd tim i dilu tri lilu thip nhu vay khdng cd lgi ich len >10% nen ed the lam nang len tinh j gi ca. trang thieu mau cyc bd ea tim. Cd M \ Lilu dopamine thudng diflig la 2-20 dung lieu cao >40meg/kg/phut nhung J mcg/kg/phiit, lilu cao> 10-20 meg/kg gay thudng gay ra tae dyng phy la lam nhjp !
eo mach he thdng va mach mau tang va tim nhanh len va ha huyet ap. ]
lam giam tudi mau tang d mdt sd benh 'i nhan. Cac thuoc gian mach inodilators
Inamrinone (trude day ggi la i Dobutamine: Dobutamine amrinone) va Milrinone la nhirng chat lie | hydrocloride la mdt catecholamine tdng che phosphodiesterase III nen cd tac dung i hgp va la mdt thudc trg tim manh khi tang co bdp tim va gian mach. Cac thuoe \ dilu trj suy tim tam thu nang. nay thudng diing phdi hgp cac \ Dobutamine ed dugc ddng hgc phiic tap catecholamine de dieu trj suy tim nang, j vi cac ddng phan khac nhau ed tac dyng sde tim, va cac dang sde khac khdng dap j khac nhau. Ddng phan (+) la mdt chat ting vdi lieu trinh dieu trj dan doc { ddng van manh vdi thy the p- adrenergic, catecholamine. Can theo ddi ky huyet \ trong khi dd ddng phan (-) la chat ddng ddng. Chdng chi djnh dung cac thudc nay j van eho ai- adrenegic. Tac dyng gian cho nhirng benh nhan bj benh hep van tim |
maeh vdi thy the P2- adrenergic cua ddng gay giam cung lugng tim. \ phan (+) can bang vdi tac dyng co mach Ngay nay, ngudi ta thudng diing ;
do tac ddng len a- adrenegie thudng dan milrinone vi thdi gian ban huy ngin hon J
den sy lam giam it nhieu sire can mach he va it gay giam tieu eau. J
thdng. Dobutamine cd tac dyng cd lgi la :' lam giam ap lye lam day that trai. Ngoai Canxi Mac dii canxi ddng vai tro i
tac dyng tryc tiep tang co bdp ca tim, nd quan trgng trong eo bdp ca tim va tao i cdn lam tang hon nira the tieh tdng mau xung dan truyen, cac nghien ciiu hdi ciiu | do gian mach ngoai bien phan xa (thdng va tien ciiu khdng thay cd lgi ich gi khi i qua thy the ap lye) lam giam hau ganh diing canxi trong hdi siic ngirng tim. Hon j that nen huyet ap ddng maeh khdng thay nua, miie canxi trong mau eao do biii ddi hoac cd the giam du eung lugng tim canxi cd the gay hai cho benh nhan. Vi ly i tang. do dd, khdng nen eho canxi thudng quyj .;.; ; de hd trg tuan hoan trong hdi sire ngirng;
Y HOC VI ET NAM so DAC BIET — THANG 11 /2010
tim. Khi tang kali mau, giam canxi ion huyit ap. Ha huyet ap do nitrate dap iing hoa (khi truyen mau nhilu) hoac khi bj rit tdt vdi lieu phap bii dich. Bien chiing ngo ddc thudc iic che canxi thi diing chii yeu do tiem nitroglycerin la nhjp tim canxi cd the cd lgi. Ly tudng nhit la djnh nhanh, cham nhjp tim dao nghjch, nhiic lugng ndng do canxi ion hda trude khi dau va giam dxy mau do mat can bing cho canxi vi d benh nhan nang d phdng thdng khi/ tudi mau tai phdi. Nen trach hoi siic ndng do canxi toan phan khdng dimg nitroglycerin cho nhiing benh nhan tuong duong vdi ndng do canxi ion hda. bj nhip tim cham, nhjp tim nhanh qua
Digitalis Hien nay, ngudi ta da it diing digitalis nhu la mdt thudc tang co bop ca tim trong cap ciiu tim mach.
Digitalis la giam tan sd that d mdt sd benh nhan bj rung nhT va flutter nhT do lam cham dan truyen qua mit nhT that.
Thudc de gay ngd ddc, dac biet khi benh nhan bj thieu hyt kali. Ngd dde digitalis CO the gay loan nhjp tim nang ne va ngirng tim. Cd the diing khang the dae hieu digoxin de dieu trj ngd dde nang (Digibind, Digitalis antidote BM)
miic hoae khi dimg chat ire ehe phosphodiesterase de dieu trj rdi loan cuong duong trong vdng 24- 48 gid.
Truyen lien tye nitroglycerin 50 mg hoac 100 mg trong 250 ml dung djch glucose 5% hoac natri clorua 0,9% vdi tdc do 10- 20 meg/ phiit, tang dan 5- 10 meg/ phiit mdi 5- 10 phut cho den khi dat dugc ket qua huyet ddng mong mudn.
Lieu thap 30- 40 meg/ phiit gay gian tTnh maeh. Lieu cao > 150 meg/ phiit lam gian ddng mach. Dimg lien tyc tren 24 gid thi tac dyng thudc bj giam din.
Nitroglycerin Cac thudc nitrate cd tac dung gian mach. Nitroglycerin la thudc lya chgn dau tien de dieu trj nhiing con dau that ngye nghi ngd thieu mau cyc bo CO tim. Tiem tTnh mach nitroglycerin cung la mdt trong nhirng phuong each hiru hieu dieu trj suy tim sung huyet dii nguyen nhan nao di niia. Nd ciing cd lgi trong dieu trj cap ciiu con cao huyet ap, dSc biet neu do qua tai the tich. Tac dyng gian mach cua nitroglycerin qua trung gian sy san sinh NO ndi md mach mau tai eho, dac biet d he thdng tTnh mach. Tac dung hiru hieu nhat d nhirng benh nhan tang thi tieh ndi mach. Thieu hyt the tich tuin hoan che lip tac dyng huyet ddng cd lgi ciia nitroglyccerin va tang nguy ca ha
Natri nitroprusside Day la mdt thudc gian mach ngoai bien tryc tiep, tac dyng nhanh va manh, rat hiiu ich trong dieu trj suy tim nang va trong cap ciiu eon tang huyet ap. Tac dyng gian tTnh mach tryc tiep cua nd gay giam ap lye lam day that phai va trai. Anh hudng den lugng mau tTnh mach trd ve (tien ganh) phy thudc vao the tich ndi mach. C) nhieu benh nhan, cung lugng tim cai thien sau khi giam hau ganh do diing nitroprusside cd nghTa la luu lugng mau tTnh mach trd ve eiing phai tang nhung sy tang nay xay ra d miic ap lye cudi thi tam truang thap hon, dieu nay lam giam sung huyet phdi lam giam the tich va ap lye that trai. Gian tieu ddng mach lam giam siic can ddng
CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM
mach ngoai bien (hau ganh) nen lam tang sy lam rong tim thi tam thu vdi thi tich va siic ep len thanh tam that trai giam va giam tieu thy dxy co tim. Khi bj thieu hyt thi tich tuin hoan, nitroprusside ed the gay tyt huyit ap vdi nhjp tim nhanh phan xa. Theo ddi huyet ap xam nhap rat hiru ich trong khi dieu trj bang nitroprusside.
Mac dii nitroprusside cd the cd lgi trong dilu trj tang ap phdi, nd lai dao ngugc sy co mach phdi do thieu dxy d nhirng benh nhan bi benh phdi(viem phdi, suy hd hip cap tien trien d ngudi ldn).
Dao ngugc tac dyng co mach phdi nhu vay cd the lam tang them cac dudng shunt trong phdi nen se lam thieu dxy mau tram trgng hon. Bien chimg chii yeu klii diing nitroprusside la tyt huyet ap. Ddi khi gay nhiic dau, budn ndn, ndn va eac con eo that d byng.
Nitroprusside chuyen hda nhanh thanh cyanide. Chat nay duge khir dde tai gan va than thanh thioeyanate. Cyanide Cling duge chuyen hda bang each tao ra mdt phiic hgp vdi vitamin B12.
Thioeyanate dugc thai ra d than. Benh nhan bj suy gan, suy than hoac khi dimg nitroprusside vdi lieu > 3 meg/ kg/ phiit trong hon 72 gid cd the tich luy cyanide hoac thioeyanate. Vi vay, can theo doi ky eac dau hieu nhiem dde cyanide hoac thioeyanate (toan chuyin hda). Khi ndng do thioeyanate vugt qua 12 mg% thi bilu hien trieu chiing nhiem ddc nhu lu lin, co giat. Dieu trj tinh trang tang cyanide hoac thioeyanate la ngimg ngay nitroprusside.
Neu benh nhan da ed trieu chiing nhilm ddc thi diing natri nitrite va natri thiosulfate.
Khi truyen nitroprusside thi phai hoc toan bd he thdng bam tiem va day truyin de tranh bdc Id thudc vdi anh sang. Hoa 50 mg hoac 100 mg nitroprusside trong 250 ml glucose 5% . Lilu dimg 0,1- 5 meg/ kg/ phut. Cd the den lilu 10 meg/
kg/ phiit.
Truyen dich tinh mach It cd tai lieu hudng dan truyen djch trong hdi siic ngimg tim. Bii djch nhieu trong hdi siic ngimg tim ed the lam tang ap lye nhT phai tuong ddi so vdi ap lye dgng mach chu, dieu nay cd anh hudng bat lgi gay giam ap lye tudi mau vanh. Trong thii nghiem d ehd, bom djch vao tTnh mach hoac vao trong ddng mach chu.eiing khdng iam tang ap lye tudi mau vanh khi hdi siic ngimg tim.
Neu ngimg tim lien quan den mat djeh qua miic thi se cd dau hieu sde giam the tieh tuan hoan tien trien den kieu ngimg tim hoat ddng dien vd mach (PEA). Trong tinh hudng nay nen bdi phu djch cho du. Tren siie vat thi nghiem, viec dieu trj hoat ddng dien vd mach bang boi phy djeh td ra hieu qua nhung each dieu trj nay van chua dugc nghien ciiu tren ngudi. Sau khi bi rung that, truyen dung djch mudi uu truong cd the cai thien ty le sdng cdn so vdi truyen dung djch muoi sinh ly. Tuy nhien, can phai nghien ciiu them viee sir dyng dung djch mudi im truang trong hdi siic cho benh nhan. Nen tranh diing cac djch cd chiia glucose trong hdi siic ngirng tim neu benh nhan khdng bj ha dudng huyet.
Y HOC VIET NAM SO DAC BIET — THANG 11/2010
Natri bicarbonate Tinh trang nhilm toan tai md va toan mau sinh ra khi ngimg tim va khi hdi sue la nhihig tiln trinh dong hgc do mat luu lugng mau trong khi ngimg tim va ha thip luu lugng mau trong khi hdi sue ngimg tim. Cac tiln trinh nay bj anh hudng bdi thdi gian ngimg tim, cung lugng tim, siic chiira dxy dgng mach trong khi hdi siie. Hdi phye siic chiia dxy bang thdng khi nhan tao diy du vdi dxy, hd trg tudi mau md, hd trg cung lugng tim d mdt miic nao dd bing ky thuat ep tim diing thi se hdi phye lai chiic nang tuan hoan binh thudng va se duy tri dugc can bang toan kiem trong ngimg tim.
Khdng cd nghien ciiu nao tan thanh viec dieu trj bang dung djch dem trong ngimg tim. Tren siic vat thi nghiem, bicarbonate khdng cai thien kha nang mng that hoac thay ddi ty le sdng cdn khi bj ngimg tim sau rung that. Dung bicarbonate trong hdi siic ngimg tim cd nhilu tae dyng phy. Bicarbonate lam han ehl tudi mau vanh do lam giam siic can mach he thdng. Nd cd thi gay kiem ngoai bao lam cho dudng cong bao hda oxyhemoglobin bj chuyen djch di va ue ehl sy phdng thich dxy. Nd cd the lam tang ndng do natri mau va vi vay lam tang ap lye thim thiu. Nd tao ra qua nhilu carbonic, khi nay khuech tan vao eg tim va tl bao nao va cd the gdp phan gay ra toan ndi bao. Nd cd thi thiie diy tinh trang toan d tTnh mach trung tam nen bit hoat cac thudc catecholamin khi eho dong thdi.
Trong vai tinh hudng hdi sire dac biet (benh nhan bj toan ehuyin hda tir trude.
tang kali mau, qua lieu thudc chdng tram cam ba vdng), dung bicarbonate lai td ra cd lgi. Natri bicarbonate khdng phai la thude dau tay khi hdi siic ngirng tim. Neu ein dung thi cho lieu ban dau ImEq/kg.
Neu dugc thi nen djnh lugng bicarbonate hoac tinh toan mire kiem thieu theo ket qua khi mau trude khi cho bicarbonate.
De giam thieu nguy ea kiem mau do dieu tri khdng diing each thi khdng nen bu hoan toan lugng kiem thieu vira duge tinh toan. Nhiing chat dem khdng tao ra CO2 (Carbicarb, THAM, Tribonat) giam thieu dugc cac tae dyng phy khi dung bicarbonate nhu tao ra qua nhieu CO2, tang ap lye tham thau, tang natri mau, ha dudng huyet, nhiem toan ndi bao, nhiem toan ea tim. Tuy nhien, ngudi ta van cdn thieu kinh nghiem ve sir dyng bicarbonate trong hdi siic ngirng tim.
Thuoc loi tieu Furosemide la mdt thudc lgi tieu manh lam can hap thu natri d dng lugn gan, dng lugn xa va quai Henle. Nd khdng ed tac dyng tryc tiep tren maeh mau nhung lai lam giam siic can mach mau phdi va tTnh maeh do kieh thich tao ra prostaglandin va vi vay rat hiru ich trong dieu trj phii phdi. Tac dyng vao mach mau xay ra trong 5 phiit nhung tac dyng lgi tieu thi cham hon. Mac dii nd duge dung trong suy than cap de kich thich tang luu lugng nudc tieu, khdng cd nghien eiiu nao iing hd cho chi djnh diing thudc nhu vay, tham chi ed vai nghien ciiu cdn ghi nhan viee diing lgi tieu lien quan den sy tang ty le tir vong. Lieu ban dau la 0,5- 1 mg/kg tiem tTnh mach cham.
CHUYEN DE: PHAU THUAT TIM MACH VA LONG NGUC VIET NAM
Cae thudc lgi tilu "quai Henle" mdi cin phai ep tim diing vdi tin sd thich hgp nhu Torsemide, Bumetanide deu cd tac chd ngyc nd trd lai sau mdi lin ep tim, ddng va tae dyng phy tuong ty tranh thdng khi qua miie, giam thilu Furosemide. Nhiing benh nhan khdng dap khoang thdi gian nghi giira cae lin ep tim.
ling vdi lieu cao thudc lgi tieu quai Henle Ndng do CO2 thd ra la mdt chi dilm tit thi nen phdi hgp vdi thudc lgi tieu tac cho cung lugng tim dugc tao nen khi ep dyng d dng lugn gan hg thiazide tim. Theo ddi bao hda dxy mau lien tuc (chlorothiazide, metolazone). Khi phdi tren may khdng giiip ich gi trong khi hii hgp thudc nhu vay can phai theo ddi ky siic ngimg tim nhung nen diing nd cho ket qua dien giai dd huyet thanh de tranh nhung benh nhan cd nguy ca cao dl dam giam kah mau qua miic. bao dxy hda mau diy dii. Khdng cd thudc
nao cd the cai thien nguyen ven vl thin V. KET LUAN kinh sau khi ngirng tim. Cin phai cd cae Duy tri ap lye tudi mau vanh dii se phuong tien tdt hon dl theo doi hieu qua lam tang ty le sdng sau hdi sue ngimg cua viec hdi siic ngimg tim.
tim. Mudn vay, ngudi thuc hanh cap ciiu
